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Religions 2011, 2(3), 330-344; https://doi.org/10.3390/rel2030330

Article
The Spiritual Approach to Group Psychotherapy Treatment of Psychotraumatized Persons in Post-War Bosnia and Herzegovina
1
Department of Psychiatry, University Clinical Centre Tuzla, School of Medicine on University of Tuzla, 75000 Tuzla, Bosnia and Herzegovina
2
Department of Neurology, University Clinical Centre Tuzla, School of Medicine on University of Tuzla, 75000 Tuzla, Bosnia and Herzegovina
3
SEPT at Weller Wing, Bedford Hospital Bedford, Bedfordshire, MK42 9DJ, UK
*
Author to whom correspondence should be addressed.
Received: 1 April 2011; in revised form: 4 July 2011 / Accepted: 20 July 2011 / Published: 28 July 2011

Abstract

: Psychological trauma and post-traumatic stress disorder (PTSD) may have an intensive negative impact on a patient's spiritual beliefs or his/her belief in God; this effect may diminish the social and professional skills of many survivors. In the same time researches showed that religion plays a coping role among patients with medical and mental health illnesses. During the war in Bosnia-Herzegovina (1992-1995) the whole population, regardless of age, gender, nationality or profession, suffered severely. During the pre-war period in communistic Yugoslavia religious believes altered with atheistic public life styles. Additionally, war traumatization had a negative impact on spirituality and religious beliefs. In the series of case reports we intended to describe and assess the impact of a session of group psychotherapy, with spiritual topics and content, which was offered to patients who needed to reestablish religious beliefs. The patients who come to the Psychiatry Clinic because of trauma-induced mental health problems and who we are interested in strengthening their spirituality met each other in the group regardless of their religious or spiritual conviction. We described the conceptualization and development of such a group and present some self-reported views of clients who took part in these groups. The supportive and empathetic presence of such group in the community helps to prevent withdrawal and isolation, alienation and deviation of traumatized persons. The presence of such group facilitates the rehabilitation process of the victims, allowing them to understand that people are available to them in certain critical moments, to help, to offer protection or to console. Groups like this one, offer long term social and spiritual support to extremely severely traumatized victims.
Keywords:
spirituality; group psychotherapy; psycho-traumatized; Bosnia and Herzegovina

Introduction

The terms religion and spirituality must be defined because of their ambiguous meanings that may impact on the understanding of this article. According to Koening (2009), religion is generally agreed on and involves beliefs, practices, and rituals that are sacred. Additionally, he defined sacred as that which relates to the numinous or God, and in Eastern religious traditions, to Ultimate truth to Reality. Religion may also involve beliefs about spirits, angels, or demons and usually religions have specific beliefs about life after death and rules to guide life within a social group. Religion is often organized and practiced within a community, but can also be practiced alone and privately [1]. On the other hand, spirituality is considered more personal, something people define for themselves that is largely free of the rules, regulations, and responsibilities associated with religion. There are more and more individuals categorized as spiritual-but-not-religious. They deny any connection at all with religion and understand spirituality entirely in individualistic, secular terms. Koening emphasized that a spiritual person was considered earlier as someone with whom the spirit of God dwelt, often referring to the clergy. In the Second Vatican Council, spirituality replaced terms of ascetical and mystical theology. While in the Greek's definition of spirituality, the word spiritual was used to distinguish humanity from non-rational creation, throughout Western history spiritual and/or spirituality has been distinctly religious. Eastern religions adopted this term much later, and then spiritual people were a subset of religious people whose lives and lifestyles reflected the teachings of their faith tradition [1].

Due to the difficulties in finding appropriate measuring instruments to assess spirituality Koenig proposed that spirituality be defined in terms of religion [2], where religion is a multidimensional construct not limited to institutional forms of religion. Thus he either referred to religion or used the terms religion and spirituality synonymously [1].

From time immemorial, religion has had an educational role and an outstanding influence on the population [3]. From the beginning, many people tried to overcome illness by the use of religious rituals and mystical experiences to attempt to reestablish the body and spiritual equilibrium and harmony in search of the most valuable treasure: health [4]. However, religion is frequently ignored within the clinical domain. Systematic research published in the mental health literature to date does not support the argument that religious involvement usually has adverse effects on mental health. On the contrary, religion is recognized as a common important coping mechanism among patients with medical and mental illness [1]. Interest in the relationship between spirituality and health is growing and there is extensive research in the medical and psychiatric literature on the physical and psychological benefits of religious and spiritual practice and beliefs [1,5]. Religious beliefs and practices have long been linked to hysteria, neurosis, and psychotic delusions. However, recent studies have identified another side of religion that may serve as a psychological and social resource for coping with stress. Religious beliefs provide a sense of meaning and purpose during difficult life circumstances that assist with psychological integration. Unlike many other coping resources, religion is available to anyone at any time, regardless of financial, social, physical, or mental circumstances [1]. Prayer is an integral component of the spiritual life of mankind. Prayer allows people to express themselves during crisis and emotional turmoil. It can serve as an important source of personal strength and as a foundation for self-resilience during times of adversity. Holistic nurses may use prayer with patients to positively influence their ability to cope with anxiety related to their illness [6]. Using MEDLINE, limited to the English language and the reference lists of randomized controlled trials, Townsend et al. (2002) assessed the impact of religion on health outcomes via systematic, critical review of the medical literature published from 1966 to 1999. They used the Canadian Medical Association Journal's guidelines for systematic review of medical literature to evaluate each manuscript. Randomized controlled trials showed that Islamic-based psychotherapy speeds recovery from anxiety and depression in Muslims [7].

However, intensive physical or psychological traumas can devastate the human psyche and leave the traumatized personality in ruin [8]. The events which represent an integral part of wars, natural catastrophes and similar situations may cause much pain and suffering to the survivors which overwhelms their psychophysical capacities. This can lead to a collapse of internal defense mechanisms and the appearance of psychical complains which leads to disorder in a previously normal life [9]. Extreme trauma, after the devastation of the human psyche leaving the human personality in ruins, can bring complete disorder into religious beliefs and spirituality, which are integral parts of human existence [8]. Mental health professionals are increasingly aware of the need to incorporate the patient's religious and spiritual beliefs into mental health assessments and treatment plans [10]. On the other side, Koenig (2009) reviewed studies examining the relationship between religion and mental health in five areas and emphasized that religious involvement is related to better coping with stress and less depression, suicide, anxiety, and substance abuse, while among patients who suffer from psychotic disorders religion played more of a positive than a negative role in the lives and treatment of these patients [1]. Therefore, faced with the reality of the entire tragedy and insecurity of human existence on Earth today, all mental health professionals and clergy need to understand the influence of psycho-trauma and post-traumatic stress disorder (PTSD) on human spirituality and personality [11,12]. The written resources bear witness that the first organized institution for complex mental healthcare on the territory of Bosnia and Herzegovina has been Hajjy Sinan's tekke in Sarajevo. In regard to its stirring history, which is not primary goal of the investigation in this paper, there is no material existing today about how it was organized in terms of admissions, accommodation, and treatment and dismissing of mentally ill persons during that time. From the existing written resources it is clear that there existed an organized institutional approach to the mental health problem, even much wider and deeper than is expected within a hospital framework. Besides complex skilled works, sheikhs (spiritual guides) of Sinan's tekke occupied themselves with other works too, such as curing and similar activities [13]. In regard to tekke as an institution for definite mental healthcare for mentally ill individuals, Cerić and others mentioned its existence at The First Physician Congress in Bosnia and Herzegovina in 1977, in Sarajevo, giving reflection about mentally ill persons, not about the mental healthcare system. ”The status of mentally ill persons was especially difficult, because for their treatment there were not any institutions almost until 1640, when in so-called Sinan's tekke in Sarajevo there was organized some sort of shelter for mentally ill persons, and only for Islamic believers“ [14].

In this paper we present our positive experiences acquired by the introduction of spiritual and religious parameters into everyday practice and particularly into group psychotherapy, in the treatment of psycho-traumatized clients in the Psychiatry Clinic in Tuzla, after the war in Bosnia and Herzegovina (1992-1995).

Between April 1992 and December 1995 a war occurred in Bosnia and Herzegovina (BH) which caused tremendous destruction and poverty and affected the whole population [15]. Out of the 4.3 million population of prewar BH, 40% were Muslims, 30% were Serbs who belonged to the Orthodox Church, and 18% were Croat Catholics. The figures after the war show that in Bosnia and Herzegovina 242000 people were killed, 175000 were wounded and 1.3 million made into refugees [16]. After the war, which caused so many cases of trauma, stress and sufferings to the whole population, common people and professionals have had to deal with many issues which can only be understood in terms of the state of the public mental health [17-19], as well as the ongoing reform and development of mental health care [18]. The mental health of the average citizen of Bosnia and Herzegovina, regardless of age, gender, nationality or profession, is seriously damaged [14,15,20-22].

Everyday prayers establish and revive the belief from which courage, sincerity, resoluteness, purity of heart and soul, moral standing, and all other positive characteristics of a person originate, so such prayer is the best way to help an individual to adapt his/her behavior to his own ideals [23] In his research, carried out as part of his Master thesis, Pajević (1999) was interested in the influence of Islamic daily routine (five daily prayers) on psychological stability in adults. He studied a sample of 100 soldiers of the BH Army who had experienced different traumas during the recent war in Bosnia and Herzegovina (1992-1995). In the experimental group there were 50 Muslim soldiers who had kept their prayers every day continually during the war, and in the control group there were 50 Muslim soldiers who did not pray at all. It was found that regular practicing of five daily prayers made the will and the ability of self-control stronger, that it induced the tendency for self-perfection and for modeling one's own personality, for acquiring new knowledge and its practical application. Those individuals, who regularly practiced five daily prayers, distinguished themselves by a more correct and more explicit life orientation, with better and stronger character, with more constructive identity, stability and pragmatism. He found that a religious lifestyle has a positive influence on mental health and human individual stability, so it represents one very efficient way of achieving higher resistance to different stressful factors in everyday life and particularly in extraordinary, catastrophic situations like war [9,24]. Religiosity strengthens psychological stability in humans [25], and provides more successful strategies to cope with the various stress factors that war veterans face. It also increases the readiness of soldiers for battle, making them more willing to confront all the hardships brought about by war activities and destruction [26].

Many scientists admit that the specific forms of religious engagement are associated with better functioning, which is then ascertained by various measurements of mental health [27]. The role of spiritually oriented group psychotherapy, led by the principles of psychotherapy guidelines of the group leader, with equal participation of all members, helps in the discovery of the healing role of religion. The elements of Spiritual care in group psychotherapy include:

  • Sitting in a circle as a purposeful approach to creative and structured work and enjoyment in the essence of our very existence;

  • Feeling safe and secure; being treated with respect and preserve dignity and be allowed to develop the feeling of belonging, of being valued and trusted;

  • Having time to express feelings to other members in the group with a sympathetic, open ear; Opportunities and encouragement for emotions to grow and develop, and helping patients to draw their own conclusions from their experience and from the disease;

  • Receiving permission and encouragement to develop a relationship with God or with the Absolute (however the person conceives what is sacred), the time, place, and space for prayer and privacy, education in spiritual matters and encouragement in deepening faith, the feeling of universal connection and perhaps also forgiveness [28].

Stable groups like this can represent the first line in a protective response for trauma victims. The supportive and emphatic presence of these groups can help by preventing the traumatized person from withdrawing into isolation, alienation or deviation. Such a structured existence can facilitate rehabilitation from traumatic events, allowing victims to realize that people are available in critical moments, to help, to take care or to console. Groups like these offer ongoing social and spiritual support for severe trauma victims [24]. This can help in the discovery of the healing role of religion [29]. This illustrates the effect of patience and the role of endorphins in pain relief and stabilization [30].

We aimed to describe and assess the impact of group psychotherapy sessions, with spiritual topics and content, whichwere offered to psychotraumatized patients who—on an assessment of needs—were found to have a spiritual inclination. Due to negative impacts of war traumatization on spirituality and religious beliefs, this treatment was targeted to reestablish religious beliefs of the involved patients and to improve overall outcomes of the clinical treatments.

Clinical Environment as Room for Spiritual Recovery

We first here discuss the rationale which led us to the development of a specific psychotherapeutic group in which spiritual values were discussed. We later discuss the environment, or therapeutic milieu, in which the group takes place and the structure of the group, including how clients were recruited and how the group was organized as compared to an ordinary psychotherapeutic group. It is worthy of note that the request for the development of the group came from the patients themselves.

Regarding our clinical experiences, the incidence of PTSD and trauma related disorders are seriously increasing. The majority of our clients, who we treated during the war and in the post-war period, were soldiers of the Bosnia-Herzegovina Army (AR BH) and Croat's Defense Council (HVO), their family members, as well as civil war victims, and among them particularly refugees, displaced persons, adolescents and children. These included Bosnians with the Muslim cultural-spiritual and historical background, and the Croats of Catholic faith, the Serbs of Orthodox faith and the members of all three ethnicities who considered themselves atheists. All Bosnia and Herzegovina citizens belonged to some culturally-historical background based on religious traditions before the communist regime in the former Yugoslavia (1945-1991). Parents of the actual population were raised in the spirit of religious manner and tradition. After religion behaviors were condemned and expelled from public life and school programs, the postwar generation had double standards in regards to religious and spiritual values. On one hand, a the secret home environment, which remained as religious because of keeping religious customs and obligations, and on the other hand the public life where interpersonal relationships were displayed in an atheistic manner in public communications. Before the war, after Yugoslav president Tito passed away, communism and atheism weakened, and all national groups began to seek their particular values in the return to own religious believes, behavior and gathering. After the war a new religious group emerged within Bosnia and Herzegovina, known as Jehovah's Witnesses, who were recruited from the members of all three ethnicities, but mainly from the atheists. All of them show a certain level of spirituality, regardless of whether they practice it in daily or weekly routines, or just as passive consumers of the contents offered in different media programs or in the community. During different clinical procedures which we developed in our clinic after the war, a significant number of our clients showed an open desire for conversation about the spiritual perspectives of life; the meaning of death and the symbolism of life sacrifice of their close family members, as well as of the spiritual meaning of the sacrifice of those who had lost their own body parts, properties, social status and social relations. Very often during the individual, family or group psychotherapy sessions there appeared tendencies toward spiritual and more often religious explanations of life, and the hereafter. Our clients, particularly those from Bosniac ethnicity, expressed a need to keep a daily rhythm of obligatory prayers. In the Islamic religion every believer is required to perform five daily prayers at defined times. Before these prayers the ritual washing of certain body parts is also required (ablution). In our clinical experiences with traumatized clients and those who are suffering from PTSD, we have noted that a daily program of religious activities was clinically helpful. Religious clients participate voluntarily by making a free choice of how to spend their 24 hours in clinic. To support this choice, we arranged that there should be, within the clinical environment, one room dedicated to spiritual psychotherapy, which was also the same room which was set aside for performing prayer. The inpatients experienced this facility with pleasure, because it completed their 24 hours stay in the clinic, and particularly facilitated the healing of their mental disorders and disturbances.

Since the day hospital patients often demanded clarifications based upon the domain of spiritual dimensions regarding their experiences and the conditions and situations they survived and were obliged to remain, it became clear that these domains needed to be incorporated into the group psychotherapy which was being offered. Initially, the group leader resisted such an introduction, trying to maintain the classical structure of a group with a cognitive psychotherapy approach. Furthermore, a certain number of patients who declared themselves as atheists expressed the opinion that: “…religions were guilty for the breakout of war in BH”, so they rejected any possibility of opening any discussion about the suggested spiritual issues.

Since we observed the need of the patients who showed a spiritual inclination, to discuss these issues, it was decided to offer them for a term an extra session of group psychotherapy which had primarily spiritual topics and contents. The session was held only once a week with open access and the clients did not need a specialist's referrals. The sessions lasted 60 min., from 13:15 to 14:15 every Thursday, and took place in this manner for over two years. The patients sat in a circle as in every other session. The number of clients varied from 20 to 30. There were 20 permanent clients and the rest changed throughout the running of the program. All who happened to be in the day clinic or those who were inpatients in the Psychiatry Clinic met regardless of their religious or spiritual orientation. Those who completed their course of treatment and were discharged but continued to receive outpatient treatment, along with citizens (who heard about the group from their friends or relatives) also came to the Psychiatry Clinic for these sessions. We observed that after such sessions the clients are less anxious, less depressed, have better communication skills, while symptoms of avoidance and hyper-arousal symptoms become decreased in intensity. After finishing their prayer, the clients continued with the work in the group therapy of spiritual sessions where all the team members collaborated. In such open sessions, the therapeutic team, which was well trained in using religious faith as a part of the whole therapy, gave answers about religious obligations and its value in achieving mental wellbeing. Sessions of such groups provide for an increase of the participants' interest in their daily spiritual program, and can teach them how to use their time in a constructive way and choose some recreational activities which bring satisfaction, as a foundation for the reconstruction of their behavior for a therapeutic purpose [31].

Case Presentations

Here we present some data regarding patients' trauma experiences, mental health sufferings, recovery outcomes and satisfaction with the group. Data were collected using individual interviews and standardized psychological tests performed by clinical psychologist employed in our clinic. Data about reflections on spiritual group experiences were collected by action research methods, whereby we asked our clients to write down their own impressions of the group and how introduction of religious issues in the group affected their lives. We believe that this data demonstrates the positive effect that the group has had on patients' mental state and ability to cope with difficulties.

Mrs. S. J. Worker, 47 years old, married, mother of two grown-up sons: She was born out of wedlock from a father and mother who are Serbs-orthodox. Her father did not admit her, her mother had left her in an orphanage where she had grown up, and met her husband who was an orphan too but he was a Muslim. During the war her husband and older son were engaged in the Bosnia-Herzegovina Army. Son was wounded. Both sons witnessed the massacre that happened in Tuzla downtown “Kapija-Gate” on 25 May 1995 where only one shell hit the crowd of adolescents gathered to celebrate the traditional “Day of Youth” the birthday of President Tito, which was celebrated in the whole Yugoslavia before this war. At the certain moment of 8:55 p.m., 71 girls, boys and children aged from three to 26 years were brutally killed and about one hundred were wounded [32]. When she heard the shell detonation, she thought that her sons could be victims, after that she watched TV and was horrified with the massacre that could be seen. She was shocked until her sons returned in bloody shirts, because they helped in collecting parts of dead bodies. From that period she suffered chronic PTSD, Persisting Depressive disorder, high blood hypertension. She visited her family physician regularly on a monthly basis and use antidepressants, anxiolitics, antihypertensive drugs, but without significant improvement of symptoms. Finally she was referred to the Department of Psychiatry where she was treated in Day hospital and included in the spiritual group. After two months she recovered significantly and she continued with spiritual groups as an outpatient. During a year of spiritual group psychotherapy she became stabilized with no PTSD symptoms, without depression, with controlled blood pressure with low doses of antihypertensive drugs. Asked to reflect on her impressions of the spiritual group psychotherapy she stated: “For the first time I speak openly among these people without the feeling that my problems will cause a nuisance to everyone. I don't feel weak here, but rather think that everyone carries his own burden and that we all require some kind of help. Some time ago I used to think that religion was something that rather belonged to elderly people, but now I know that we're all able to find it within ourselves and that we're all capable of living it in our own ways.”

Miss. A.M. Administrator, 31 years old, single, has no child: Originally Croat-Catholic, has older sister, older brother and both parents died. During war as an employee in the Clinical hospital Tuzla she helped many times to nurse wounded civilians and soldiers when there were needs for additional staff. She saw numerous crippled, injured and dying young individuals. She witnessed the gradual death of her mother; she still has difficulties missing her mother as a friend. Father was alcoholic, who died in orthopedic clinic after he fractured his hip in the bathroom in a drinking state. It is difficult for to come to terms with not having had an easy life with her father, she suffered with her mother, sister and brother as kids and later until her father's death. Her sister misused marijuana, and her brother often behaved crudely toward her. In his behavior she recognized her father's behavior. Whenever she witnessed violence, to street kids without parental care with bad behavior, to alcoholics and old helpless persons, she suffered PTSD symptoms, became depressed and could not be functional in her job. She was referred to Day hospital, and she was included in the spiritual group. She was active in group settings; she spoke about her series of traumatic experiences in childhood, adolescence and during the war. She successfully understood the psychological side of her problems, she was oriented positively to peaceful settlement of her suffering. She successfully understood her behavior was learned from her helpless mother in the marriage with violent father. She recovered significantly. Asked to give impressions about her experiences in the spiritual group settings, she stated: “I used this kind of therapy only on two occasions, and I already feel its positive effects. I communicate much more easily with people around me and I am much clearer in the expression of my attitudes. I don't have much opportunity to join in conversations of this kind (my house mates don't practice their faith and moreover, talk about these matters does not occur). After these therapy sessions, I feel that deep inside me, I experience the suppressed feeling of belonging to a large group of people (‘believers’).”

Mrs. N.S. Worker, 45 years old, divorced, has no child: She survived loss of her father because of war, she is a displaced person with two brothers and mother. She was married to a taxi driver who was violent and they divorced after four years of his violent behavior. She is suffering from chronic back pain, as a 15 years girl she was raped by her neighbor ten years older than her. She never told her parents. About her impressions of psychotherapy in spiritual groups she stated: “I am a chronic patient with a neurological disorder and even with the therapy I use, my condition did not get any better, so I committed myself to the faith, and in the performance of my daily prayers I found peace. Nevertheless, I still have episodes of nervousness, discontent, insomnia, and bursts of tears (depression). My biggest problem is that I don't really know how to find out for myself the right solution at the right time. My coming to the sessions of ‘spirituality and humanism’ enables me to discard negative energy and wrong thinking and bad decision making. In the presence of the group leader, I am able to discard that negative energy and to absorb a positive one. I feel relaxed, I am in a good mood, and I feel that I am not under pressure. My desire to talk about these things in this company of people frees me from problems that put pressure on my body too.”

Mrs. Sh. P. Shopkeeper, 46 years old, she has two grown up daughters; one daughter is married and has a child: “Contact with the group has sparked a warm presence of light, as at the end of a long and dark tunnel; it is very pleasant to be there. I met people with similar difficulties and my medical status changed for the better. My dark tunnel is now enlightened and I don't use any sedatives anymore, instead I cure my soul with firm belief in The Most High, the God. I am aware, that it is only He who can help me now and I pray for His guidance and help. I am certain that He will never abandon me or betray me. His are not ways of corruption and I believe in Destiny and in the Bounty of The Most High, the Lord. The state of my soul is much better now as well as my physical state. I will continue with this spiritual therapy, although I'm being retired with God's help, I think that this is my spiritual filling up, my inspiration, my stimulation and I am happy now, my Life is not a ‘dark tunnel’ anymore, but rather a ‘lit crystal hall’.”

Mrs. R.B. Shopkeeper, 53 years old widow, remarried, has no children: Operated on after an extra uterine pregnancy; she looks after two young children of her second husband. During the war she lost her father, one brother, another brother was injured; she was forcedly expelled from her home. She had chronic PTSD, headache, and back pain; she was overweight and suffered from blood hypertension. She was referred to Day hospital, where she was included in spiritual group psychotherapy. After two months she recovered significantly and continued with group psychotherapy for an additional year as an outpatient. Her recovery became stable. About her impressions in these groups she stated: “This group has given me back my lost confidence, self-respect, and the strength I need to cope with entirely different and new experiences in my life. This group is a school for my future. With this I feel stronger for my present and future life. It gives me strength and fills me with positive energy. I use what I have learned within my capacities and every session adds strength and gives me back my peace.”

Mr. M. S. an active Army officer, 43 years old, married, father of three young children: During the war he witnessed massacre of young people in the Tuzla downtown [32], and a massacre that happened in the military camp, when only one shell killed almost a hundred soldiers who were lined up in the morning on the runway in front of military barracks. M.S. collected remains of bodies in both tragedies. He was wounded in his head and his left knee with shrapnel. He was hospitalized because of vertigo, nausea, back pain, nightmares, and severe intrusive thoughts that prevented him from being functional in his duties. He was included in the spiritual psychotherapy groups and contributed well during sessions. After one month of inpatient care he continued to be active in spiritual groups the next year as an outpatient. He recovered significantly, he organized an association of war veterans who were treated for PTSD, and became its president, and did a lot on destigmatization of war veterans who suffered from PTSD. He stated: “By visiting these sessions, I have gradually recovered my strength and desire to fight for my life and have become aware of how much my wife and kids need me. Every hour spent with the group has left a deep imprint, and with God's help has given me a great strength to cope with my difficulties, war nightmares that have haunted me by night, to feel my body parts as they were really mine, since they were heavily injured in the conflict, with a desire to recover, as much as it is possible in my case. The leader of the group has helped me to make one great decision, to give up smoking, a vice difficult to get rid of, but now I feel like I've never smoked before.”

Mrs. R.S. Shopkeeper, 51 year old, married, mother of two grown up daughters: Her elder daughter is married and has two sons, she emigrated to the USA with her family four years ago. She survived the first attack on 15 May 1992 in Tuzla, when war broke out—in front of the building where she has an apartment. Her husband is violent; jealous and he often blames and tortures her. Her father died after stroke at our clinic, consequently she is afraid of injections, because her father died after intramuscular injection of analgesic. While she was talking her face, neck and across her chest became red and itchy, with intense erythematous swelling, which indicates neurovegetative reaction to trauma. After Day hospital treatment she continued with spiritual group settings for an additional year. She recovered, retired and divorced. About spiritual group impressions she stated: “A large number of people of all faiths take part in these sessions. This is practically the only place where I feel comfortable and well. In these sessions I have learned so much about things that I have not known until now, and which help me to cope with my problems.”

Discussion

Religion has been found to be a significant protective factor against many types of maladaptive adjustment outcomes among adolescent samples [29] and war veterans [33]. By identifying the ways in which religion may exert a positive impact on individuals, mental health professionals can design interventions which have the potential to help improve the quality of life for these persons [34].

Clinical studies maintain the statement emphasized in DSM III and DSM IV, that extreme trauma influences the “important fields of functioning” of many survivors [35,36]. Psychological trauma and PTSD can have a severe negative impact on spiritual faith or faith in God by decreasing social and professional skills. Because of the effects of psycho trauma and PTSD effects, the faith of the traumatized person collapses. Therefore, the spiritual sense of binding, confidence and order of that person become “scattered” as well as defeated, because the trauma experience of an individual deranges his psychological dimensions. The same experience influences the individual's systems of faith and spirituality, which are fundamental for the meaning of life for this individual. When an individual's faith is overthrown, a believer falls into an exhausted state of existential crisis. In our clinical work with the survivors of (an) some early childhood trauma or different traumas in the adult period, we are very often faced with males and females who are suspicious and dubious regarding belief in God. They question aloud, expressing guilt, and asking why they are “punished so cruelly”. They usually consider themselves innocent and the victims of “God's injustice”, which they are not ready to accept [24], or they ask themselves: “God, why did this happen to me?” [37]. The traumatized experience the feeling of being cast away from both human and God's care and protection, thus losing these fundamental supports for normal human existence. As a result, they feel spiritually abandoned and completely alone. This leads to a situation where all relationships, whether the most intimate family bonds or the most abstract communication in the community and religion become colored with the feeling of alienation and disconnection [8]. Psychotherapists are more likely to be relevant when they appreciate the fact that many clients have religious values and commitments. Greater awareness of religion and religious values in the lives of their clients may aid clinicians' efforts to provide more accurate assessments and effective treatment plans. The “Ethical Principles of Psychologists and Code of Conduct” of the American Psychological Association's (1992) are used as a framework to examine many of the ethical issues relevant for the psychologists' work with religious clients. These guidelines also provide suggestions for clinicians as to how to obtain the skills needed to offer competent assessments and interventions with religiously committed clients [38]. During the process of treating their clients, psychotherapists should “discover patients' religion”, even if they say that they are not religious. In this way they could help them to alter their life views, which is necessary for good treatment outcomes [39]. Recent changes in the assessment and treatment guidelines in the USA have resulted in corresponding curricular changes, with at least 16 USA psychiatric residency programs now offering formal training in religious and spiritual issues. Currently, most Canadian programs offer minimal instruction on issues pertaining to the interface of religion, spirituality, and psychiatry. Grabovac and Ganesan (2003) proposed that a lecture series focusing on religious and spiritual issues is needed to address this apparent gap in the curricula across the country. Therefore, they propose a 10-session lecture series and outline its content. They believe that including this lecture series in core curricula will introduce residents in psychiatric wards to religious and spiritual issues, as they pertain to clinical practice [10]. This, therefore, means that psychotherapists and priests, in the Muslim faith imams, work together with other community mental health workers [40]. It would also be necessary to establish and maintain environmental conditions in which traumatized persons are enabled to reflect again, to revalue and to change their presumptions about spirituality and beliefs. In addition, it may be necessary to revive certain religious values, ritual practices, belief systems and traditions [31], along with common efforts and constructive and open collaboration. Such developments may provide chances for trauma victims and survivors to experience an added dimension to their treatment, and to develop a new perspective in life [24].

In his research, Levin (2002) suggests that a relationship with a God filled with Love can make a positive impact on psychological distress. So a person's relationship with the God can present a significant personal resource of consolation regarding the emotional consequences of poor health and other distressing living circumstances, as well as religious guidance in tackling difficult circumstances [41]. A true religious affiliation surely represents a positive factor for the protection of mental health and some experts in mental health have had no doubt about this for a very long time [42,43].

The believers who practice their daily religious rituals, dedicated to achieve, as much as possible, the inner peaceful state of mind, can be expected to achieve the following:

The creation of conviction that personal fate is determined by personal actions, this then ensures the feeling of safety against tragedy;

The creation and strengthening of conviction that a person is being protected by the true and eternal Power which then offers a chance to a person to establish a relationship with God;

Some convictions regarding their contemplation about death; they are likely to feel more secure with a promise of eternal life;

A healthy religious perspective offers a person the possibility to cope with guilt by offering the mechanisms for repentance;

It offers a transcendental shelter from the crude realities of daily life [44].

Evidence supports the idea that a framework utilizing a religious perspective in assessment and treatments is indeed helpful. The relationship between religious variables and mental health can depend on cognitive–behavioral mechanisms. Understanding in this area can encourage clinicians to further consider the ways in which religious variables can be utilized in therapy. It is clear that there is need for further efforts incorporating religious and spiritual factors into the clinical arena [4].

There is good evidence in the existing literature, that surviving intensive traumas can devastate the human psyche and have traumatic effects on personality. Wars, natural catastrophes and similar situations cause much pain and suffering to the survivors and can lead to a collapse of internal defense mechanisms and the appearance of psychological complains which disorder normal life. Nowadays it is very important that professional helpers of trauma victims are ready to develop an integral and holistic model based on a multidisciplinary approach, including all relevant resources in the assessment and healing of psycho trauma and PTSD consequences; indeed an eclectic approach, utilizing all positive experiences in human practice are valuable. Following the needs of our psycho-traumatized clients in clinical treatment in postwar Bosnia and Herzegovina we have found that it is very helpful to involve spiritual issues in the process of healing.

It is known that Islamic behavior principals are multilaterally beneficial when applied in the everyday life of believers; therefore, the use of daily Muslim routine incorporated in therapy facilitates the process of healing of mental dysfunction. The five obligatory daily prayers play a focal role, if they are practiced constantly either individually or in a group. To realize a holistic approach in the community based mental healthcare it is very important to educate religious professionals in a psychotherapeutic approach, so that they can be included as professional helpers in a therapeutic team and get ready to meet the sophisticated spiritual needs of traumatized believers. This can strongly help in the process of spiritual healing of PTSD and other different mental disorders related to psycho trauma. Professional and personal development in terms of spiritual attitudes, values and skills can be nurtured by encouraging the language and practice of spirituality and religiosity in mental healthcare.

Practically also, an adequate room, which provides a quiet space encouraging contemplative spiritual and religious activities, is useful. Spiritual skills can be taught by directly educating mental healthcare workers through official curricula, and directly in the doctor-patient relationship.

Conclusions

Group psychotherapy is very useful for achieving higher spiritual and religious awareness as a therapeutic tool for clients, and in building up better personal, trustworthy relationships between professionals and patients, which is a very important aspect of good mental healthcare practice. We believe that our group psychotherapy described above has had a positive effect on the mental health and lives of the patients who have participated in it. Further research about effects of spirituality and religiosity and its' influence on mental health improvement of traumatized individuals in individual and group psychotherapy settings is needed.

Acknowledgments

The authors are grateful to all individuals and institutions that helped in the development of a better and more modern mental healthcare and on the promotion of mental health in the post-war Bosnia-Herzegovina. Special thanks to Azur Salihović for the help and support that he provided in finalizing this paper, we are thankful to Gordana Rajter who improved the language of this paper. Particular thanks go to our patients who were willing to give their impressions about their experiences in such an approach to their mental health problems.

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