By Samaiya Mushtaq
Soon after I started residency in psychiatry, the movie Spotlight was released, about The Boston Globe’s investigation and groundbreaking story on sexual abuse within the Catholic Church. I remember thinking then how the seed of psychiatric illness for so many of my patients was planted the same: childhood and adolescent trauma. The parent who beat me. The uncle who molested me. The clergy who took advantage of me. Often, the ones who had the responsibility to protect also had the power to do the most harm. The second injury was that when young, those abused couldn’t really ever tell anyone, particularly when it was the person whom they would tell that was perpetrating the abuse. And that was the very worst part: that their ability to trust was left totally shattered.
Now as I end residency, the most rewarding part of my job as a psychiatrist is my role as a therapist, treating patients primarily using psychodynamic (insight-oriented) therapy. It is joyful work in which I can examine some of these old hurts with people in order to help them live a more meaningful and satisfying life. When I reflect on what makes my work safe for me and my patients, it boils down to these three key precepts:
- Acknowledgment of the inherent power dynamics. Over the years, I have become very aware of the one-sided intimacy of the therapeutic relationship. It demands a lot of vulnerability from my patients to entrust me with the most private aspects of their lives. Simply knowing that guides how I phrase my questions and the balance I strike between supporting and challenging my patients. Which leads to…
- Awareness of and respect for boundaries. In training to be a therapist, I was taught about the transference (the patient’s feelings towards the therapist) and countertransference (the therapist’s feelings towards the patient). Sometimes, the transference is erotic. Sometimes, the countertransference involves frustration. To be aware of that in real time is critical in maintaining a healthy therapeutic relationship. Clear boundaries are the kindest thing we can do to protect both our patients and ourselves as therapists while preserving a healthy clinical relationship. Boundaries around after-hours communication, meeting in a dedicated therapy space, holiday gifts, or physical touch when a patient wants a hug can all be discussed. Which is further protected by…
- Oversight and accountability to third parties. I spent several hundred dollars and months obtaining licensure from the Texas Medical Board, which tracks malpractice against healthcare providers. I am regularly evaluated by my peers and faculty at the medical center where I am employed. And for every hour of therapy, I conduct as a trainee, I have a half-hour of supervision with senior providers with whom I discuss my cases. All these pieces create both a regulatory climate and a rich learning environment for my own growth as a therapist. This can go on even after residency when psychiatrists participate in continuing education to maintain licensure and or seek the counsel of mentors.
I can’t imagine practicing therapy safely and effectively without these guidelines, and so for a long time, it has disturbed me that the realm of spiritual counseling does not share some of these safeguards. As it is now, imams are often the first point of contact for our community members (1) when congregants are in the throes of marital discord or divorce, suffering internal spiritual turmoil, and even when decompensating from psychiatric illness. Whether they elect to be or not, they are also in the position of acting as counselors during these experiences of their congregants’ with potentially no codified set of ethics to guide them.
To put imams in this position of responsibility untethered hurts everyone, including imams, many who work for little pay and often no benefits. Without clear professional guidelines when it comes to spiritual counseling, both our imams and community members are left vulnerable and face dire consequences. It’s no wonder then that you’ve got fertile ground for situations such as, according to a pending lawsuit in Irving, Texas, an imam completely traumatizing a congregant through exploiting his access as a spiritual counselor (2). The organization investigating this case reported that, in the wake of this nightmare, the mosque dealing with the fallout stopped providing counseling on their premises and began outsourcing counseling into the community through referrals and funds (3).
Imam As Counselors
That was one mosque in one city. As it stands now within our greater community, however, we have not yet refined the role of imams-as-counselors, and trying to get to the roots of the problems within that role is an uphill battle. There is still little acknowledgment of the inherent power dynamic of an imam’s privilege in our society. Mention of #MeToo in Muslim spaces or the real threats to women at the hands of powerful men is quickly met with anger and conspiracy theories about an all-powerful Western machine designed to brainwash Muslim women through a feminist-but-secretly-Islamophobic agenda.
Our celebrity shaykh culture has run away with us, to the point where individuals pay hundreds of dollars to get a selfie with scholars and communities and give them carte blanche to speak to anyone and everyone on anything and everything from fiqh to racial injustice; even when they are not fully learned in either. We place no boundaries on their scope. And finally, we have little oversight regulating our imams and few governing bodies that communicate internally. When we do have nascent organizations that try to provide accountability, we tear them down or question their funding and motives.
This isn’t where we have to be, though. This is an opportunity for us to collectively examine the necessary role of imams in our lives and what we expect it to look like. We have to honestly ask ourselves how much more we are willing to risk putting imams and congregants in unsafe situations when we know this risk can be mitigated. Can we decide that now is the time when: men can acknowledge their privilege over women? When spiritual leaders acknowledge their power over their congregants? When the older generation can acknowledge their influence over young people? When a central body requires an imam to have the training to counsel people? When mosques are willing to enforce this? When mental health professionals provide supervision for imams to discuss their challenging cases? When imams can be taught about transference/countertransference and learn how to navigate those complexities? When mosques enforce boundaries during counseling on how you meet people, where you meet people, how often you meet people, to the exclusion of any kind of relationship outside of the counseling one? When imams are accountable to God as well as His creation?
The most egregious wrong is the inaction of our society in situations that call for anything but. As we turn the corner in providing resources for and destigmatizing mental health care, I hope we can combat willful ignorance within the domain of spiritual counseling, because, with free reign, no boundaries, and zero accountability, this isn’t the last time “counseling” will be trauma in disguise.
- A study conducted by this writer found that almost 70% of individuals in Nashville, Tennessee’s Muslim community would seek mental health care from imams. http://www.medicineandreligion.com/bringing-psychiatry-into-the-mosque-analysis-of-a-community-psycho-education-intervention.html
Samaiya Mushtaq, MD is a resident psychiatrist based in Dallas, Texas. She teaches workshops on wellness and conducts research on help-seeking populations.