Mental illness and Muslims interface in unique circumstances. In the Singapore Mental Health Study (SMHS 2016) completed in 2018, researchers from the Institute of Mental Health (IMH) has found that those of Malay ethnicity has higher odds of OCD (Obsessive Compulsive Disorder). (For the convenience of this article, Malay ethnicity has been taken as representative of the local Muslim community.)

The SMHS went on to state the “higher odds of OCD are difficult to explain and needs further research to elucidate the underlying cause(s)”.

Those familiar with OCD would know that this mental health condition consists of two components – obsessions and compulsions. Persons with OCD may have varying obsessions and compulsions.

According to Dr Elna Yadin, an authority from the International OCD Foundation who visits Singapore occasionally for consults, the  main anxious obsession  of a person with OCD is the desire not to become “a bad person”. As for compulsions, some of its more typical forms involve maintaining cleanliness and acts of washing.

When these dots are connected, it becomes understandable if one tries to hypoth esise how OCD interfaces with Muslims.

OCD: AN OBSESSION WITH PIETY?
Given the  emphasis oflslamic teachings on cleanlin ess as an indicator of one’s faith , members of the Muslim communit y may run the risk of turning cleanliness into an unhealthy obsession.

It is indeed important for the Muslim to perform acts of ritual purification such as taking ablution and compulsory baths properly, in order to perfect his acts of worship. However, overzealousness masked by attempts to attain absolute perfection during such acts of ritual washing may land such a Muslim in a psychological trap and throw him into a spiral of compulsive behaviours.

Such persons then become preoccupied with washing and keep repeating their ablution, sometimes to the point of missing their prayers entirely.

Unfortunately, this is sometimes compounded by extreme fear-mongering about the perils of not taking proper ablution, by unwitting yet well-meaning religious teachers and elders. Anecdotally, it is not uncommon in religious settings to hear about the ‘punishments’ to be suffered by one who is lackadaisical in washing after himself after using the restroom to pass bodily waste.

It is then drilled into the psyche that one’s ritual worship will be invalidated, and that he would be tortured in the grave due to a lack of proper hygiene when using the toilet.

While such teachings are essential, there may be a greater need to mediate such messages when they are delivered on public platforms.

It is true that maintaining cleanliness is part of a Muslim’s faith, and this article does not seek to deny this religious injunction. However, when it is internalised by an unwitting layman without nurturance and guidance, it may become problematic. In striving to perfect one’s faith, such a Muslim may end up obsessing irrationally about cleanliness and miss the higher objectives of the religion instead.

The Need to Prevent OCD in Religious Practice
The SMHS found that OCD has the highest 12-month prevalence among mental disorders at 2.9%. Statistically, this means that for every 50 persons in the street, at least one person would have had a diagnosis of OCD within the past r 2 months. In fact, the data for Muslims may be even more startling as Malays have a 12-month prevalence of OCD of 4.3°/o. For data visualisation’s sake, this could mean that at least one out of every 2 5 Malays may be experiencing clinical OCD. Imagine how many persons in any given mosque at a Friday congregation actually suffers from OCD?

Leaders in the community must be concerned about this 25th person, for if he has an existing schema that renders him psychologically more  vulnerable, this person may tum innocent intentions into obsessions, and innocent rituals into compulsions, at the expense of his mental health. It becomes more worrying when one considers that persons with OCD have been shown to delay seeking professional help the longest (II years). Are members of the Muslim community then able to distinguish the difference between ‘piety’ and OCD in their religious practices? Does this indicate that more psychoeducation for OCD is needed in the Muslim community?

While these questions fester in our minds, we should also call for a more nuanced delivery of Islamic teachings with regard to ritualistic practices, especially as religious rituals inevitably become associated with the accumulation of ‘merits’ and ‘demerits’ – a significant phenomenon because of its attributed role in determining where one ends up in the afterlife.

Solutions can be found within the vast Islamic scholarship on this matter. Therefore, adopting a moderate approach in Islamic teachings cannot be overemphasised here, accompanied by critical thinking skills to help individual Muslims contextualise and accommodate or adapt their daily rituals accordingly without jeopardising their mental health.

DEPRESSION
Not far behind OCD in terms of prevalence, is depression. While Malays (again by extension, Muslims) had  the lowest lifetime prevalence of Major Depressive Disorder at 4.9°/o, Malays were still second highest for r 2-month prevalence at 2.9°/o. It must be noted that while not every person who feels depressed receives a diagnosis of major depressive disorder, there are many variants of depressive symptoms which are equally disruptive to daily functioning.

Even without manifesting as a fullblown episode of clinical depression, it is possible for one to experience acute stress, adjustment difficulties, grief and complicated grief, or simply one of the many symptoms of depression such as loss of appetite, poor sleep, irritability, low mood, suicidality and so forth. These presentations could eventually lead to depression, or may possibly exist in isolation without ever meeting the clinical criteria for depression.

Although  the rates of prevalence for mental illness for Malays were not flagged in the SMHS, there are still potential risk areas which may be of interest to helping professionals, and the community at large. Specifically, these risk areas pertain to relationship difficulties.

The Relational Dimension of Depression
The causes of depression are multidimensional and the onset of depression may be caused by biological factors, environmental factors, or both. Extrapolating from some of the evidence­ based psychotherapy treatments for depression, we will find that such ‘environmental factors’ which contribute to depression may have developed out of difficult couple and interpersonal relationships.

This poses some questions for the Muslim community because anecdotally, the community is more communal, connected and family-oriented (read: interpersonal relationships) and where the prevalence of marriage and divorce (read: couple relationships) is relatively higher. Certainly, it will be a huge leap to suggest that members of the Muslim community are therefore at higher risk of developing depression. There is simply no data to support such a correlation. Furthermore, despite ranking second highest for 12-month prevalence, Malays still ranked lowest in terms of lifetime prevalence for depression.

One hypothesis is that perhaps somewhere after an acute 12-month period, Malays (and Muslims) find a way to overcome depressive symptoms, or simply ‘manage to get by’. Possibly, this could either be due to the communal and social support that the tight-knit community lends to its members, or in spite of this tight-knit community. The latter might suggest that the Muslim community is resilient and can buttress against chronic depression.

Yet, given the literature on ‘disability days’ due to depression, paired with its

‘economic burden’, it still behooves helping professionals, and the wider community, to be able to detect signs and symptoms of this illness. The social impact of depression is such that one person with depression in the community remains one too many.

Depression, Marriage & Divorce
Another question then lingers: If we cannot definitively conclude that difficult interpersonal relationships lead to depression, can we say the reverse instead i.e. that it is depression that leads to difficult interpersonal relationships? Could this then finally explain the pervasive marital difficulties in the Muslim community, and even in society at large?

These questions run the risk of oversimplifying both depression and couple conflict, yet it seems intuitive to do so. Adopting a systemic mental model, depression may possibly correlate with numerous other contributing factors to couple conflict such as unemployment, financial difficulties, marital/parenting role adjustment, addiction, sexual dysfunction and more.

Systemically, this implies that marriage preparation programmes and divorce counselling programmes in the community may need to include some form of awareness with regard to the impact of mental health on marriage, and  marriage on mental health.

 A NOT-SO-FINAL WORD
These reflections are a cumulation of the author’s professional practice experiences in the social and mental health sectors, and have been crystallised by the ethnic breakdown of data in the SMHS 2016. The role of mental health cannot be neglected in social and community development, and this can only be achieved with relentless advocacy.

Dots of social problems, health problems and their respective solutions keep interconnecting, even as more dots continue to appear in our highly developed society. The impact on the Malay, and Muslim, community is significant. While some of the ideas that have been suggested in this article remain moot for now, it is hoped that they may spark ideas for research and uncover new social and mental health solutions for the future. ⬛

Sufian Hanafi is a  senior  social worker and counsellor who has been providing counselling , psychotherapy and psychoeducation for individuals, couples , families and groups for more than a decade. He has worked in both the health and social services sectors, specifically in outpatient children and adolescent mental health. inpatient and community adult mental health, specialised services and mandatory pre-divorce counselling programmes for inter-ethnic and blended families. He currently runs a private practice, Just Guidance Counselling & Psychotherapy.