Islamically Integrated Chair-Work for Bereaved Muslims

This study explores the effectiveness of the Islamically Integrated chair-work techniques for unfinished business in patients with prolonged grief. Grief is characterized by intense emotional suffering, a yearning or longing for the deceased, a sense of shock or shock at the loss, and difficulty in moving on after the loss. The loss of a loved one is an unavoidable, universal life experience, although it is also one of the most stressful. Mourning individuals often become accustomed to the death of a loved one over time, but a small yet significant number of people subsequently experience serious psychological problems. Individuals who have experienced the loss of a loved one have a higher risk of developing psychopathology in the first year after bereavement, including an increased risk of self-harm and a higher risk of suicide. This group is also susceptible to a high degree of morbidity and mortality.

Studies over the last few decades suggest that many grieving individuals experience persistent difficulties associated with bereavement that exceeds the expected social, cultural, or religious expectations. With the publication of the DSM-5-TR (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision), the term Prolonged Grief Disorder (PGD) has been coined for those experiencing grief after the loss of a loved one, lasting longer than 12 months for adults or 6 months for children, and causes significant impairment. An estimated 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder. Among children and adolescents who have lost a loved one, approximately 5%-10% will experience depression, posttraumatic stress disorder (PTSD), and/or prolonged grief disorder following the bereavement. Although only a minority of grievers suffer from some psychological problems, misdiagnoses have been common because there was no specific diagnosis for grief in the past.

One of the most important risk factors for severe PGD is unfinished business, which indicates incomplete, unexpressed, or unresolved relational issues with the deceased. It was found that 43% of bereaved individuals exhibit some degree of unfinished business. Higher levels of unfinished business are associated with higher levels of psychological problems and unhealthy ways of expressing grief. In the context of the Traditional Islamically Integrated Psychotherapy (TIIP) framework, unfinished business is conceptualized as an emotionally-charged problem. Through the emotional processing of unfinished business during TIIP psychotherapy sessions, suffering patients are able to find a resolution to their emotional problems, which leads to the replacement of maladaptive emotions with more adaptive ones, need fulfillment, and the creation of new meanings for unresolved conflicts. Indeed, making sense of one's loss is associated with a healthier grieving process. Therefore, meaning-oriented techniques are more effective in grief therapy. Furthermore, the results of a systematic literature review show that the expression of grief is directly influenced by spirituality, religious beliefs, and practices. Yet, there is no intervention program specifically designed for grieving Muslims that is faith-based. From an Islamic perspective, death is seen as a natural part of the human lifecycle, including the soul's transfer from this world to the after-world.

In order to better explain the mourning process, a number of theories have been put forth in Western literature. Nevertheless, they largely ignore socio-cultural variations outside of the bereavement of white people in Europe or North America. Although it is known that religion and belief have a very important role in the mourning experience, there are no intervention programs specifically tailored for grieving Muslims that utilize a faith-based approach reported in the literature. This study aims to develop and explore the utility of an Islamically integrated chair-work intervention to help resolve unfinished business for Muslims who have experienced prolonged grief. A randomized, non-concurrent, multiple baseline design is planned for the proposed study to use Islamically integrated chair-work intervention using five phases: (1) baseline phase, (2) empathic attunement phase, (3) TIIP -Traditional Islamically Integrated Psychotherapy- chair-work intervention phase, (4) cognitive consolidation & spiritually behavioral activation phase, and (5) follow-up phase (1 month post). The protocol will be implemented on a weekly basis through 50-minute, face-to-face individual psychotherapy sessions, totaling seven sessions.

In this study, the multiple-baseline design comprises five phases, with the initial phase designated as the baseline. Notably, the duration of this baseline phase will be randomly varied among participants. This random allocation to baseline periods of different lengths facilitates the evaluation of whether symptom changes are specifically associated with the application of the intervention. Participants will be randomly assigned to one of three baseline lengths-2, 4, or 6 weeks-allowing for varied observation periods before the intervention commences. During the baseline phase, participants will complete the primary outcome measurement. This study will demonstrate the utilization of the Islamically integrated chair-work in assisting bereaved Muslims facing numerous psychological, physiological, social, and economic risks to resolve the unfinished business on account of their prolonged grief. The Islamic integration of the chair-work intervention incorporates insights from early Islamic thinkers with psychological counseling and cultural and religious elements.

Early Islamic scholars such as Al-Kindi, Abu Bekir al-Razi, and Ibn Sina had conceptualized grief and sorrow and provided strategies to cope with the emotional struggles following the loss of a loved one. The investigators have integrated certain therapeutic methods from early Islamic scholars to address the challenges of grief after a loss. Al-Kindi begins by defining sorrow and offering guidance for those suffering from grief. His definition emphasizes sorrow arising from losing a loved object, conceptualized as "loss," and also from unfulfilled desires, conceptualized as "missing out." Al-Kindi's concept of "loss" resonates with the empathic attunement process in the Islamically integrated psychotherapy protocol. The 'missing out' forms the basic framework of unfinished business after loss. The investigators integrated the concept of "grief meditation" chair-work intervention to resolve unfinished business tension from al-Razi's advice to imagine the scenarios of loss. Finally, a phase of cognitive consolidation and spiritually behavioral activation draws influence from Ibn Sina's teachings. He posited that due to the obscurity of death, individuals struggle to establish a healthy relationship with the concept of death. For the final part of the protocol, patients search for meaning from the loss with the therapist, then transform cognitive and emotional schemas and devise behavioral plans based on newly acquired perspectives and emotions. The importance of the study stems from an Islamically integrated interventional method of providing closure to individuals experiencing prolonged grief that is otherwise not available in the literature.

Inclusion criteria

• Loss of a loved one 6 months to 5 years ago,
• Grieving for unresolved tension for a loved one (24 or more points on the Unfinished Business in Bereavement Scale),
• Religiously adherent adults (according to self report)

Exclusion criteria

• Imminent suicide risk or self-harm,
• Current substance or alcohol dependence,
• Past or current psychotic disorders or bipolar disorder;
• Currently receiving any form of psychotherapy