Chronic pain is a complex condition that pervades the existential alongside the physical and psychological. The existential framework with which a patient views chronic pain and suffering must therefore be considered. During the chronic pain patient’s journey, an initial experience of grief and a sense of loss may give way to sustained change and existential benefit. For the Muslim, chronic pain provides an opportunity for reassessment, reconnection with their spiritual tradition and realignment with fitrah (divine disposition). It is a stimulus for jihad annafs (struggle of the soul) and may facilitate the soul’s development as such, allowing for the development of character and virtues centred in existential fulfilment and informed wisdom. This commentary is informed by personal reflection during an elective placement with a chronic pain team.
“…He does not break His believing servant except to mend him”– Ibn Al Qayyim1p.14
Chronic pain is “a major source of suffering”2. Individuals with chronic pain show an increased association with mental health disorders and a reduced quality of life3. This association is bidirectional4and partially illustrated by the collective consideration of the biopsychosocial model, pain cycle5 and depictions of grief6. Chronic pain patients will seek r be referred for medical, psychological, and alternative therapies. However, these models and treatments may not sufficiently account for the existential impact upon the individual7. The “transformative potential” of chronic pain as a “gift” facilitating spiritual development has been documented8 and warrants consideration in the treatment of chronic pain. When considering the most ‘healing’ resolution for the chronic pain patient, the framework within which they view ‘suffering’ must be understood. For the Muslim patient, this requires an appreciation of the Islamic philosophical and theological context9.
The field of modern Islamic psychology has provided Islamic models for clinicians to utilise when treating the Muslim individual10,11. Rothman and Coyle’s framework for an Islamic psychotherapy represents a major contribution to the field12,13. The authors establish an academically rigorous model of the soul and self- development integral to the Islamic faith. This provides a suitable model within which to consider the ‘role’ chronic pain may serve in an Islamic context. This commentary will be informed by personal reflection undertaken during a three-week elective period with a chronic pain team. Explicit reflection, guided by Rolfe et al’s reflective framework of ‘What? So what? Now what?’14, will be shared to illustrate key concepts.
The Soul in Islam
Rothman and Coyle outline “distinct foundational elements of an Islamic conception of the soul”13p.1735; nature of the soul; structure of the soul; stages of the soul; and development of the soul.
- Nature of the soul
The salient feature relating to the nature of the soul is fitrah, divine disposition,Fitrah is the internal compass that guides the individual to seek truth and meaning, in the form of the Divine. This fundamental need for alignment with God and objective truth is instilled in all and represents an incorruptible deep-rooted knowledge of God within the human being. For the Muslim, alignment with fitrah is the means to contentment and realisation of human potential.
2. Structure of the soul
Rothman and Coyle consider the soul to be quadripartite (nafs, qalb, aql, ruh) with a “dynamic interplay”13p.1742 between components. The nafs correlates most readily to the ‘self’ or ‘ego’ of contemporary Western philosophy. It is considered to be a temporal manifestation, related to faculties of impulse and desire. The qalb, ‘heart’, refers to place where “consciousness resides”13p.1736. Its semantic roots in the verb “to turn” indicate the qalb’s capacity to turn towards and away from truth and contentment. This etymology also outlines the heart’s ‘obligation’ to apprehend the flux of states both within and outside the human being15. The aql, an aspect that ‘intellects’, signifies the rational faculty of the soul and the target of cognitive therapies (Fig re 1)12. Though consensus regarding its dominion over ther components of the soul vary in the Islamic tradition, Rothman and Coyle illustrate its role in regulation and discipline of the nafs12. The ruh, unique to the Islamic context, describes that part of the soul which is considered the ‘spirit’ – unchanging, pure and with “direct access”13p.1736 to the Divine.
3. Stages of the soul
In order to maintain alignment with the fitrah, a constant engagement with the soul’s components is required. Through ‘struggle’, one is able to raise the state of their soul and inhabit a place of greater spiritual liberation and presence (Figure 2). The Qur’an outlines three stages from which Rothman and Coyle build their model. The lowest station, nafs al ammarah, ‘the soul that commands’ details the individual who lives solely in relation to the desires of the ego. This unchecked stage is characterised by hedonistic priority and ghafla, the forgetfulness of God. Nafs al lawwama, ‘the self-reproaching soul’, is the ext stage and involves the resistance of desire and selfish tendencies and a struggle towards the moral and altruistic. The term ‘lawwama’ denotes the emphatic form and signifies the presence of guilt and remorse one feels, from their actions and intentions if not in line with their fitrah. The final station, nafs al mutmainah, ‘the soul at rest’ is an ideal stage representing the highest potential of the soul.
Fig1: – The Iceberg Model of Islamic Psychotherapy12
4. Development of the Soul
For the Muslim, the purpose of life is centred upon self- development or “to uncover the fitrah by purifying the nafs”13p.1737. However, while Islam suggests the ideal fulfilment of human potential is in the Prophetic exemplar, it does not dictate a minimum standard for all to achieve. Rather, each individual is tasked with self- progression and ultimately rewarded for their intention and effort.
Rothman and Coyle explain thattazkiyatan nafs, ‘purification of the soul’, here the ruh shines without infraction, is an ideal for those reaching the stage of nafs al mutmainah. Conversely jihad annafs, the ‘struggle of the soul’, is more applicable to the common person, seeking to gain and consolidate their hold upon nafs al lawwama (Figure 2). This struggle, aided by religious obligations and Prophetic teachings, is a distinctly constructive and not destructive process within Islam. Shortcomings and inclinations are deemed to be ‘part of the process’, normal and transient as one progresses, rather than inherently evil or “fissures of the psyche”13p.1739. Within this struggle, Islamic philosophy also identified the value of ‘virtue ethics’ in tahdhib al akhlaq, the reformation of character, referring to muhlikatandmunjiyatas ‘vices’ and ‘virtues’ respectively (Figure 2).
Fig 2 : An Islamic Model of the Soul13
Suffering in Islam
Victor Frankl’s assertion that the individual’s “primary motivational force”16p.104 is the “search for meaning”16p.105, to which difficult and painful circumstances play a significant role, presents a helpful concept with which to begin to understand the place of suffering in Islam.
Islam suggests that the material world, dunya, while perfect in the execution of its function, is inherently imperfect in that it is “an abode of stress, despondency, tribulation and strife” (Imam al-Junayd as quoted by Sidi Ahmad Zarruq as quoted by Hamza Yusuf)17. To this end, Sidi Ahmad Zarruq, a fifteenth century scholar, notes (as quoted by Hamza Yusuf) “to seek perfection in existence based on its foundation of imperfection is vanity”17. So, the individual’s existence within the temporal is characterised by the search for meaning (realignment with fitrah) and realisation of human potential (through jihad annafs), aided by trials and tribulations.
Suffering is thus not only beneficial but an expected and necessary component to human life. This view is exemplified further by the following Qur’anic verses:
“And We will surely test you with something of fear and hunger and a loss of wealth and lives and fruits but give good tidings to the patient. Who, when disaster strikes them, say, “Indeed we belong to Allah, and indeed to Him we will return. Those are the ones upon whom are blessings from their Lord and mercy. And it is those who are the [rightly] guided”18
“Do the people think that they will be left to say, “We believe” and they will not be tried?”19
The Muslim therefore reconciles suffering as part of divine omnipotence, Omnibenevolence and justice while taking comfort from the following hadith, Prophetic teaching:
“How wondrous is the affair of the believers; verily, all of their affair is good. And that is for no one except the believers. When they are given a blessing, they are grateful, and it [the blessing] was good for them. And if they are afflicted with anything harmful [calamities, diseases, loss of wealth], they show patience. And therefore, it was better for them.”20
Accordingly, Izz al-Din ibn Abd al-Salam, a twelfth century jurist, outlines seventeen distinct benefits from trials which include aspects of self-actualisation (realising the individual’s place in reality), emotional and spiritual transformation (becoming and being patient, forgiving and grateful) and contentment21. Hence, the Islamic view of suffering sees the appropriate engagement with the self during tribulation as a facilitator of self-improvement and existential grounding.
The Role of Chronic Pain
- A Means of Reassessment
It is arguable that not all trials in life are equivalent in the impact they may have and the growth they may instil thereafter. In Surah Yunus, the ‘chapter regarding Jonah’, the Qur’an outlines a common human response to difficulty:
“Whenever someone is touched by hardship, they cry out to Us, whether lying on their side, sitting, or standing. But when We relieve their hardship, they return to their old ways as if they had never cried to Us to remove any hardship!”22
Here, the Qur’an highlights the nature of trials in reconnecting the individual with their fitrah and Creator, but laments those who do so transiently and without appropriate reflection. In contrast, the unrelenting reality of chronic pain may predispose the human being to an active engagement with the immediate situation and consequentially their existential reality.
Due to the troubling existential weight they experience, the chronic pain sufferer is forced to ‘slow down’ and navigate the moral and spiritual. They must consider the manner in which they operate and the axioms, including allowances therein, which dictate their current spiritual state. Thus, the patient’s chronic pain can serve as a means of spiritual awakening. An awakening, according to Ayad, in reference to Imam al Harawy’sManazil al- Sa’irin, ‘Stations of the Wayfarer’, that sees the individual recognise their “blessings, misdeeds and time’s passage”23.
The above is mirrored within Rothman and Coyle’s conceptualisation of an Islamic psychotherapy, where reactions to traumatic experiences create “dysfunctional patterns”12p.207. In this framework, the chronic pain sufferer experiences an emotional stimulus which causes an “imbalance”12p.207 and disrupts one’s alignment with their fitrah. It is through careful consideration of this emotional “blockage”12p.207, utilising aspects of the rational faculty (aql) in prescribed therapy (cognitive behavioural therapy) or outside of formal medicine, that the individual reconciles their immediate feelings and concerns. This healing process opens up further existential questions as they continue to engage with their reality and undertake jihad annafs.
In subsequent reflection, the human being will no doubt encounter issues of objective meaning and individual action. The initial separation from what had been considered to be ‘meaningful’ may cause a grief reaction, as normality and the foundations upon which they act have been removed. They may indeed be uncomfortable with their previous disposition and seek to better themselves while gaining a sense of moral awareness and presence, as outlined by nafs al lawwama. For the Muslim, this must be considered part of the opportunity presented to them in the trial of chronic pain, as Al- Ghazali, an 11th century theologian, is quoted as saying:
“If God wishes good for a believer, He gives them an awareness of their deficiencies.”24
In Frank’s consideration of narrative and phronesis25, practical wisdom, in medicine, he suggests that those experiencing chronic distress fall into one of three patient journeys. The first is ‘chaotic’ and characterised by denial and a failure of responsible agency. The second is ‘restitutive’ and normalises illness while seeking to restore a return of function to the previous ‘normal’. The third, akin to the ideas aforementioned, is the ‘quest’ narrative, where the individual begins to see their plight as the potential source of insight and guidance. The lessons of this quest are universal and applicable to the ‘healthy’ who do not “realise their own suffering” 25p.214. For Frank, this journey leads to an individual who lives in a more considered manner, learning to live with their fears and stressors (such as illness and mortality). Having benefitted from the experience of chronic pain, these persons will cease to “think about the story and start to think with it” 25p.214. Existential liberation is here begotten of physical and material contrition.
These notions are outlined by three consultations I had with a 60-year-old patient who suffered from chronic regional pain syndrome, following multiple operations on their right hand. They explained that initially they felt a great deal of anger and envy, before then attempting to ‘ignore’ their condition and ‘do the things they wanted to do’. They further articulated that over time they learnt to ‘not be defined by their pain’ and have ‘meaning beyond their physical condition’, noting they were ‘learning to value all the things that truly matter’ with ‘fresh eyes’ and ‘grounding’. Though this patient mentioned they began their patient journey with no religious background, they outlined how their renewed appreciation for life had come through a ‘spiritual le s as much as a psychological one’. These conversations further illustrate the immense potential for inner development, the form it may take and the need for such discussion in the clinician’s dialogue with chronic pain patients.
While the overall direction f inner movement is towards alignment with the fitrah and sees the individual’s positive development, it ought to be recognised that this is not a linear nor straightforward process of progression. Rather, by the human being’s very nature, there will be flux between states of the nafs, iman (faith) and even the narrative with which patients understand their condition.
This constant struggle is encapsulated by jihad annafs and should be considered ‘normal’ and ‘expected’ for the individual, especially in the view of the clinician and close company who may be prone to frustration given the perceived ‘instability’ of the pain sufferer. This struggle is attritive and cumulative without tangible measure at times and this can present a great deal of concern for the patient.
2. A Facilitator of Contentment and Virtue
As the human being partakes in jihad annafs, they begin to enter a more considered state of living, or sulooq. Here, the individual undertakes ‘self-negotiation’ and learns to ‘unwrap’ the ‘gift of pain’8. his gift, initially understood as “disappointment, sadness or indifference”8p.11, becomes “hope, gratitude…or healing”8p.11 as “self-sympathy becomes self- empathy”6p.14. Islamic literature suggests that at such a point multiple interdependent concepts such as tawakkul (divine reliance) andmuhasaba(self-analysis) become part of the individual’s habit, allowing them to not only develop a sense of sabr(patience)and shukr(gratitude)but move beyond this more passive notion into an active rida(contentment)and shahid (divine testament).
When considering Rothman and Coyle’s work, such an attitude is developed as the chronic pain sufferer begins to solidify their hold on the stage of nafs al lawwama and align with their fitrah. Here, a sense of contentment and trust in divine decree replaces the transient happiness rooted in hedonism and materialism. Nathan Kollar states that “meaning…liberates the human being from the present situation. It allows behaviour to be guided by many factors beyond the immediate environment”26p.18 and this exemplifies the development of the chronic pain patient from initial grief to ‘attitudinal values’27, where new concepts specific to their situation allow for coping, to self-actualisation, where truly altruistic virtues develop beyond the sufferer’s own circumstance.
My interactions with a 68-year-old patient, undergoing laser therapy after decades of hip and back pain, illustrate this poignantly. Our first two conversations were dominated by talk of ‘positive coping mechanisms’ such as ‘cognitive reframing’ and the stoic attitude they had developed. However, by the third consultation they had begun to feel that there was a ‘glass ceiling’ in this approach and that they were learning lessons that would ‘unravel’ deeper changes and allow them to be ‘present in a different away’. This particular patient began to show remorse for the manner in which their ‘coping’ had excluded their partner from their healing and expressed a renewed desire to recognise the value of their partner. The most striking part of this patient’s journey was the fundamental role ‘the other’ had in their reflection. They explained that the balance between individual reflection and time with clinicians, loved ones and other pain sufferers had allowed them to holistically consider their situation and recognise common humanity, thus becoming more empathetic.
This patient’s experience echoes Hovey’s sentiment that the lessons chronic pain may bring must be uncovered by the individual but with the help of others8. Hovey goes further and refers to Riess’ notion that empathy, developed in this relationship-dependant reflection, is self-perpetuating in that it “leads to…renewal of vital human capacity”28p.76. Hence, the chronic pain sufferer is able to not only behave with empathetic altruism through the lessons of their own trial, but when they have achieved their self-actualised state that they are able to do so authentically and to the existential benefit of both the recipient and donor.
The search for meaning is a fundamental process in the chronic pain sufferer’s journey both as a patient and as an individual29. Rothman and Coyle’s model provides a helpful framework with which to begin to understand how questions of meaning, arising from the experience of chronic pain, may affect the Muslim’s sense of self. In this context, chronic pain may provide the opportunity for spiritual reawakening and inner development. Further, from an Islamic perspective, the chronic pain patient may uncover and consolidate a responsible agency within a wider perspective of objective meaning founded upon an acceptance of life’s events being beyond their control and t ere being divinely ordained benefit in all happenings. In such a case, the individual has benefitted from the ‘quest’ of chronic pain and identified their place within the larger ‘quest narrative’ of life, which Islam asserts.
If Muslim patients are to undertake healing rather than solely receive treatment, it is imperative that space to explore such themes and struggles are afforded to them, particularly by medical professionals. Such space must be founded upon the perspective that at the point of discharge, unlike many other conditions, the end of clinical dialogue is not the end of the sufferer’s journey; rather it is a moment that must be prepared for so that it is a moment of realisation and liberation that grants existential independence, allowing them to live more fully and be present.
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- Qur’an 2:155-157
- Qur’an 29:2
- Sahih Muslim 2999
- ‘Izz al-Din ibn ‘Abd al-Salam, Al-Fitanwa’l- balayawa’l-miḥanwa’l-razaya (1992) Beirut, Lebanon: Dar al-Fikr al-Muʻaṣir
- Qur’an 10:12
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