Jinn and mental health: looking at jinn possession in modern psychiatric practice

This article focuses on jinn possession and mental illness in Islam. After discussing spirit possession generally and its classification in DSM-5, we present an overview of several studies examining the role of jinn in mental distress in Muslims in the UK. A case study which exemplifies jinn possession is presented and the clinical implications of the findings are discussed. We argue for collaborative working relationships between Islamic religious professionals and mental health professionals. Finally, we discuss potential areas for future research.

spirits as the cause of illness and misfortune (pathogenic possession). 1 In executive possession the afflicted individual acts as though their identity has been displaced by that of the possessing spirit, whereas in the pathogenic type, possession by a spirit is an explanation for abnormal behaviour while the identity of the supposed afflicted individual remains intact. In the latter type, spirit possession is merely incidental to the psychopathology rather than a cardinal symptom.

Spirit possession and mental illness
Being possessed by demons or evil spirits is one of the oldest ways of accounting for bodily and mental disorders. The idea that spirit possession and mental illness are related has a long historical legacy. Throughout history mental illness has been attributed to demonic possession; the oldest references to demonic possession derive from the Sumerians, who believed that all diseases of the body and mind were caused by 'sickness demons' called gidim or gid-dim. The Gospels report Jesus regularly exorcising evil spirits. During the middle ages of Europe, possession (and witchcraft) was considered as one of several causes of mental illness. Astrological theories prevailed during this period of history, in addition to the humoral theories of medicine. In addition, distinctions were made between eccentricity, madness and religious visions and revelations. A large number of the alleged witches and possessed persons who were burned had probably had mental disorders. 5 Although this article focuses on jinn and mental illness among contemporary British Muslims, it is important to note that this close affinity between spirit possession and mental illness is not unique to Islam and similar beliefs are held in Hinduism, Buddhism and Judaism. [6][7][8] Among contemporary Evangelical Christians, demonic possession is considered to be one possible cause of mental illness, with those displaying symptoms of possession being subject to deliverance. It is recognised that a certain percentage of psychotic and less severely disturbed individuals attribute their symptoms to the devil. 9 Spirit possession in the DSM-5 In many non-Western cultures the most important dissociative disorders involve trance/possession. Although the DSM-IV acknowledges the existence of dissociative trance and possession disorders, simply named dissociative trance disorder, it asks for further studies to assess its clinical utility in the DSM-5. Possession and possession trance are listed under the diagnosis dissociative disorder not otherwise specified. The DSM-IV-TR definition includes 'possession trance, a single or episodic alteration in the state of consciousness characterized by the replacement of customary sense of personal identity by a new identity. This is attributed to the influence of a spirit, power, deity, or other person'. 10 Possessed individuals sometimes exhibit symptoms similar to those associated with mental illnesses such as psychosis, hysteria, mania, Tourette syndrome, epilepsy, schizophrenia or dissociative identity disorder; this includes involuntary or uncensored behaviour. Since possession is not normative in Western cultures, it is the cultural context which determines the distinction between psychosis and the spiritual. Spirit possession is a culturally specific way of displaying symptoms of psychosis, dissociation, social anxiety, etc. and is a fairly global idiom of distress. That is, whereas a person with psychosis in the West may believe he is being controlled by a computer, a member of a community that believes in spirit possession may believe his body to be taken over by a demon.
Cardeñ a et al 11 argue that the diagnostic criteria for possession states are a nosological imperative for DSM-5 in order to facilitate recognition of these disorders by mental health professionals, to encourage programmatic research on them, and to help devise culturally sensitive ways of treating them. It has been proposed that DSM-5 should include social impairment in dissociative identity disorder to help differentiate normative cultural experience from psychopathology. It is further proposed that dissociative trance disorder, a diagnosis present in DSM-IV, will be merged with dissociative identity disorder for DSM-5. The mention of possession is intended to make dissociative identity disorder a more globally acceptable diagnosis, replacing dissociative trance disorder and possession in the DSM-IV. The recently published DSM-5 makes possession part of dissociative identity disorder and then provides for possession to not be considered a disorder if it is 'a normal part of a broadly accepted cultural or religious practice'. 12

Jinn and misfortune in Islam
Islamic texts discuss various classes of beings that populate the universe: jinn (spirits), shaytaan (satanic beings), marrid (demons), bhut (evil spirits) and farista (angels). The origin of the jinn is rooted in pre-Islamic Arab societies, even prior to the arrival of Judaism and Christianity in the Arab peninsula. Pagan Arabs would refer to jinn as demon-like creatures, considering them to be lower in ranking than angels, or even lesser deities. The word jinn derives from the Arabic root Jann which conveys the idea of protecting, shielding, concealing or veiling. Jinn are one of the creations of Allah. The basic difference between a human being and jinn lies in the substance they are made of. According to the Qur'an the jinn are made of a 'smokeless and scorching fire' and they have the physical property of weight. Like human beings, they exhibit moral and mortal attributes. The jinn can be good, evil or neutrally benevolent. They live and die. Among jinn, there are also believers and non-believers. Typically, they are held to attack individuals who are weak of will, lack self-confidence, struggle for self-identity and acceptance by others, or are greedy for more and more pleasures of this earthly existence and desire power and control. Individuals can protect themselves from jinn through keeping their obligations to Islam (prayer, fasting, enjoining right and forbidding wrong), and prayer from reading the Qur'an and Sunnah -the traditions of the Prophet. [13][14][15] Most Islamic scholars accept the possibility that jinn can possess people. Some scholars, however, disagree and assert that jinn can only influence mankind and cannot literally take up physical space within a human's body -that is, they cannot possess individuals. Both groups, however, would concur that there are clear criteria which need to be applied before concluding that a jinn has had a role in an individual's situation, whether through possession or influence. Various passages in the Qur'an and Hadith (the collective body of traditions relating to Muhammad and his companions) support the idea that jinn can cause erratic behaviour in one's words, deeds and movements: 'Those who eat Ribaa will not stand [on the Day of Resurrection] except like the standing of a person beaten by shaytaan [Satan] leading him to insanity' (Al-Baqarah, Qur'an, 2: 275).
Attribution of misfortune to malevolent forces including jinn, witchcraft and the evil eye is widely described in the anthropological literature on Islam. 4,[16][17][18][19] This includes mental disorder which is often treated by exorcism of jinn spirits. 3,14,20,21 Jinn are frequently held to cause both madness ( janun) and epilepsy, ideas which go back to pre-Islamic Arabia. For many Islamic communities in the UK, particularly South Asian Muslims, a belief in the malevolent effects of possession is tied to persistence in demand for traditional healers to resolve treatment issues associated with spirit possession and the evil eye. [22][23][24][25] Studies exploring jinn possession There have been a few studies documenting the relationships between jinn possession and mental illness among contemporary Muslims. El-Islam 26 reported that symptoms such as morbid fears, forgetfulness and lack of energy are commonly attributed to jinn in the Arab world. In relation to jinn possession in the UK, Dein et al 21 interviewed 20 members of the east London Bangladeshi community aged 18-80, including students, shopkeepers, restaurant workers, elderly day centre attendees and imams (10 male, 10 female). The interviewer was a White British anthropologist and psychiatrist who regularly visited the community between the years 2005 and 2008 alongside a Sylheti speaking interpreter, who was also present at the interviews. Participants were recruited through a snowballing technique. That study asked about the causes of misfortune generally, and more specifically about the role of jinn and witchcraft in this process. The researcher (S.D.) also spent time as a participant observer at the East London Mosque, documenting prayer and ritual, interviewing an exorcist, and attending meetings held by imams discussing the relation between spirit possession and mental health. Additionally, he collated adverts in newspapers for traditional healers to examine the types of problems they dealt with. 21 The study found beliefs in jinn, the evil eye and witchcraft to be prevalent in this sample, especially among older and less educated Bangladeshi individuals. A study of beliefs related to jinn possession comparing Bangladeshi Muslims in Dhaka and in Leicester revealed similar education-related effects, namely a higher prevalence among women who were less educated. 27 Thus, as Dein et al have argued, 21 Western education may diminish the prevalence of beliefs concerning jinn possession, although they are not totally eradicated. In Dein et al's study, 21 frequent resort was made to traditional healers in the context of physical and mental illnesses, particularly when jinn possession or witchcraft was suspected. Faith healers typically employed a range of religious interventions to treat affliction by jinn, of which the most widely used were ruqyah (seeking refuge with Allah by reciting certain verses from the Qur'an), a dhikr (remembrance and invocation of Allah), and reciting the Qur'an over water and instructing the individuals to drink it afterwards. Alternatively, they may recite the Qur'an over water and blow into it, then they tell the sick person to wash with this water.
A second semi-structured interview study looked at understandings of mental illness and care pathways among a sample of 30 Bangladeshi mental health service users and 30 of their carers attending a day centre in Tower Hamlets, an east London borough. The service users had all received psychiatric help and had been diagnosed with a range of conditions: schizophrenia, depression, bipolar disorder and anxiety. Although family members frequently held jinn possession and witchcraft responsible for their illnesses, the service users and carers themselves were often sceptical about these explanations and frequently invoked 'Western' psychological explanations such as stress and marital discord instead. Most had, however, consulted traditional healers at some stage in their illness. Almost unanimously all reported the efficacy of reading the Qur'an and prayer in helping them cope with their illnesses. Most expressed satisfaction in relation to their professional psychiatric treatment. 28 Khalifa et al 29 examined Muslims' beliefs about jinn, black magic and the evil eye in Leicester, UK. Using a selfreport questionnaire they asked their sample of 111 individuals aged over 18 years whether they believed affliction by these supernatural entities could cause physical or mental health problems and also whether doctors, religious leaders or both should treat this. The majority of the sample believed in the existence of jinn, black magic and the evil eye, and approximately half of them stated that these could cause physical and mental health problems and maintained that these problems should be treated by both doctors and religious figures. 29 Here we present a case study which exemplifies the relation between jinn possession and mental illness. Details have been changed to preserve anonymity.

Case study: jinn possession
Ayesha is a 50-year-old legal secretary. She was born in Pakistan and has lived in London for the past 20 years. She and her husband Jamil attended an Islamic healer, a raqi (person who performs ruqyah). Ayesha recounted the following story.
Over several months, her husband had become increasingly withdrawn, slept poorly and was tearful and agitated following problems at work. Small irrelevant matters started to bother him, consuming much of his energy and time and significantly affecting the marital relationship; at times he became violent towards his wife. Very soon he started to have nightmares which used to wake him up after midnight; he used to dream of strange creatures of all sizes and shapes and at times felt as if somebody was choking him by sitting on his chest; he would wake up screaming in perspiration. The couple had been married for 30 years and had four children together. Before his troubles began, Jamil had been an outgoing and optimistic man from a religious and well-to-do family, with a memorable childhood wherein he excelled in all fields.
Ayesha became convinced that this was a spiritual problem. Following months of prayer, Allah revealed to her in a dream Namaze istekhara (the special guidance prayer) that Jamil's problems had something to do with Satan and jinn. She remarked that her husband had become agitated and developed jerking movements after reading the Qur'an, a sign of jinn possession. At the same time, her twin sons started crying after midnight for no reason and screaming inconsolably. It so happened that an Islamic scholar advised her to recite particular verses of the holy Qur'an and then to blow them in a mug of water and instructed the entire family to drink from it for 7 days, as he felt that the symptoms could be the mischief of the jinn in the house, which could be creating mischief at night as well.
Following consultation with their general practitioner her husband was prescribed a course of paroxetine. He improved only slightly, and it was after this that Ayesha took him along to the raqi who confirmed jinn possession and the malevolent influence of witchcraft perpetrated by his cousin in Pakistan. He recommended that Jamil ingested olive oil. Through reciting verses of the Qur'an to him the spirit revealed himself and finally, after some time, agreed to leave him. This procedure was repeated several times. Both Ayesha and Jamil reported subsequent improvement in his mental state.
This case study illustrates several features. From a Western psychiatric perspective, the patient experiences an anxiety state or depressive disorder. His symptoms have been attributed to jinn possession. From an Islamic perspective, his anger caused by hearing recitation of the Qur'an reinforces a diagnosis of jinn possession. The recitation of Qur'anic verses (ruqyah) and ingestion of olive oil are typical treatments for possession by jinn spirits.

Clinical implications
This article has examined the relationship between jinn possession and mental illness among British Muslims. Resort to traditional explanations of mental illness appears to be commonplace among some groups of Muslims in the UK. More work is needed to establish the contexts in which jinn are invoked at times of illness and more information is required about the backgrounds of those who deploy such explanations.

SPECIAL ARTICLES
Dein & Illaiee Jinn and mental health a. Ruqyah (plural: ruqa) derives from the past-tense verb raqa. It consists of words said or written in the form of dua or dhikr for the purpose of protection or cure. It is sometimes accompanied by other actions, such as blowing or wiping over the thing which it is applied to. 'It should be done by reciting the words of Allah, may He be exalted, or His names and attributes, and in Arabic or in a language the meaning of which is understood, and with the belief that ruqyah has no effect in and of itself; rather it is only effective by the will of Allah, may He be exalted.' 14 The findings of empirical studies on jinn and mental health cited in this article have significant clinical implications. Mental health professionals should be aware of the explanatory models adopted by their patients and there is a need for these professionals to collaborate with imams in the provision of holistic mental healthcare which incorporates biological, psychological and spiritual factors. Whereas mental health professionals can teach imams to recognise mental illness, Islamic religious professionals can in turn educate health professionals about the importance of religious factors in psychiatric disorders. Clinicians must be careful to distinguish between culturally sanctioned belief in spirit possession and obvious psychotic symptoms lest the patient be treated unnecessarily with antipsychotics. On the other hand, clinicians must exercise caution and not assume that all unusual beliefs in a patient from an unfamiliar culture are culturally sanctioned lest psychosis goes undetected and untreated. Members of the patient's own religious community should be consulted in relation to these issues. Furthermore, it is important to distinguish spirit possession as an altered state with the replacement of identity from psychopathological conditions that include the individual's belief that the disorder is caused by a spirit or in which beliefs about spirits are part of a larger condition. We emphasise the importance of embracing the service user's rationale of illness for them to accept medication. Embracing complimentary treatment options such as ruqya will help engagement, concordance and possibly enhance the service user's well-being.
Future work in this area should involve psychological, biological and anthropological approaches to ascertain the psychological predispositions to dissociate, be suggestible/ have unusual experiences, their neurological correlates and the ways in which sociocultural factors shape them. Furthermore, as Cardeñ a et al ask, 11 it is worth exploring whether people with dysfunctional possession experienced more trauma and attachment problems (both predisposing factors to dissociation) than those with controlled organised possession. Another issue is why some people become more easily possessed than others. There are several further questions for future research. In what ways do rituals heal those who are perceived to be possessed by spirits and to what extent are such rituals efficacious? Of particular importance are phenomenological comparisons of specific forms of psychopathology such as schizophrenia and diverse forms of spirit possession with a specific focus on agency which is disturbed in both instances.