Introduction

Psychotherapy is a Western practice of healing mental illness. Well-known methods such as cognitive behavioral therapy, family therapy, and hypnotherapy are being taught and practiced by mental health professionals throughout Southeast Asia, given their training in Western psychology. However, the application of Western psychological approaches to mental health are seen as foreign to many indigenous communities in Southeast Asian countries where spirituality is frequently used as a means of coping with mental illness or psychological distress. Studies in the United States have shown that integrating spirituality into psychological approaches of therapy can lead to deeper benefits with respect to therapeutic outcomes (D’Souza 2007). However, will the same be applicable in a cross-cultural setting?

To answer this question, this paper aims to explore religious and spiritual aspects of healing within the psychotherapeutic context in the overseas Chinese population in the Malaysian setting. We believe that there are unique religious resources suitable for the local people, as Malaysia is a highly religious country with a myriad of religions that can be found in both institutional form and in folklore practices. However, due to the cultural differences between Southeast Asians and Westerners, current religious therapies promoted in the West might be limited in the Malaysian setting, since the clients we work with in this community are more family-oriented, lean toward spiritual explanations of mental problems, and blend the official religion with folk practices. We chose to address the Chinese population in Malaysia in this paper, as this is the second-largest ethnic group in the country and has a rich religious tradition. Hence, we call for a therapeutic approach that respects and values the religious tradition of the clients and is sensitive to their languages. We will use case studies to locate major themes concerning the explicit use of religious resources in psychotherapy with religious clients. In the first part of this paper we will introduce the socio-political background of the Chinese in Malaysia and their major religious tenets. From there we will highlight a tradition-sensitive therapeutic approach as the framework for conceptualizing the four clinical cases conducted among Chinese in Malaysia. Lastly, the limits of this approach will be discussed to prevent potential risks and to maximize the strengths.

Socio-political background of the Chinese in Malaysia

Malaysia is a predominantly Muslim nation, with significant numbers of Christians, Buddhists, Hindus, Taoists, Sikhs, and other minority religions such as Jainism and Baha’i. Many religious festivals, such as the Birthday of Prophet Muhammad, Diwali, Wesak, Good Friday, Christmas, and Hari Raya Aidilfitri (Eid ul-Fitr), are recognized as public holidays by the Malaysian government. These festivals are usually celebrated in public with courtesy visits and exchanges of good wishes between ethnic groups and believers of different religions. For the most part, this religious diversity is well accepted, and religious practices play a key role within each community. Spiritual practice is prevalent in Malaysia, with studies showing that religion and spirituality play a major role in community and family life in different racial groups (Husain et al. 2008).

This creates a distinct religious atmosphere among ethnic Chinese in Malaysia as compared to the Chinese in Mainland China. The Chinese in Malaysia range from first-generation to sixth-generation immigrants who have settled in Malaysia since the end of the 19th century. The biggest wave of immigration occurred at the end of Ching Dynasty, as many Chinese in coastal cities relocated themselves to Southeast Asian countries like Malaysia as traders and labourers. Hence, the recent immigrants identify more strongly with their Chinese lineage compared to those who have assimilated to Malay culture over the past several generations (Tan et al. 2005).

In addition, most of the ethnic Chinese in Malaysia have not been exposed to the Cultural Revolution in China or to other political/economic movements that happened after China was liberated in 1911. Marxism and materialism are not as popular and widespread among the Chinese in Malaysia as they are in Mainland China, as Communism has been viewed as a negative element by the Malay government (Lee and Tan 2000). Based on the different degrees of assimilation to the Malaysian culture, Chinese in this country could be roughly divided into three major groups: those who are assimilated to Western worldviews due to an English education, those who strongly identify with their Chinese cultural roots and receive private Chinese education through an independent education system, and those who identify strongly with Malay national identity due to generations of assimilation.

Though Chinese are not encouraged to hold political power in Malaysia due to their “non-Bumiputera” (non-indigenous) status, Chinese in Malaysia generally hold economic power in Malaysia and value education and achievement in order to hold their own in social competition with other racial groups. In the past 20 years, many Chinese in Malaysia have been encouraged by their parents to pursue higher education overseas, due to “unfair” government policies towards minority groups, and this has resulted in many “international families” in recent years. In terms of psychological sensitivity, mental illness is still a taboo in this community, and family support is a crucial factor in recovery.

Major religions among the Chinese community in Malaysia

Though Malaysia endorses Islam as its national religion, the constitution asserts that all citizens should have the freedom to choose their own religion and to follow spiritual practices in their daily lives. Every citizen’s Identity Card indicates their religious belief. Religious practices are widely accepted and tolerated in the country, although there have been some subtle, isolated conflicts between members of different religious groups lately, such as incidents of church burning and of blasphemy in a mosque. Hence, religion is a significant aspect of people’s lives, and many Chinese retain their religious tradition while adopting some local practices through assimilation and acculturation. For example, at weddings, some Chinese Christians will have formal services in a church and still have a “tea ceremony” at home to pay respect to the elderly.

In public, Chinese in Malaysia adhere to a wide variety of different religious beliefs, mainly Taoism, Buddhism, and Christianity. There is also a minority presence of Chinese Muslims. In Malaysia, Chinese who are Muslim converts and live the Malay lifestyle are constitutionally considered as Malay. The different Chinese religious groups tend to adopt their own viewpoint and interpretation of the problem of mental illness. Each group also has its own solution that it offers to believers who suffer from mental illness. These are summarized in Table 1.

Table 1 Comparison between the tenets of three major religions practiced among Chinese in Malaysia
Full size table

Chinese Taoist perspectives on mental illness

Taoist philosophy is based on the ideas of transcendence of self and society, dynamic interaction with nature, integration with nature and people, and the pursuit of infinite equilibrium which stresses the balance of opposites—yin and yang (Kam 2004). Philosophically, the Taoist perspective on mental health relies on the attainment of the above-mentioned qualities, while mental illness is viewed as a result of the violation of or distancing from the ideology of Taoism.

Generally, practitioners of Taoism worship their ancestors and perform certain rituals on a daily basis. This is done by burning joss sticks and serving their ancestors food and flowers, which is a sign of respect for and remembrance of their ancestors. Part of the ritual entails seeking protection from these ancestors. People who face obstacles or illnesses in life are thought not to be worshiping their ancestors, thereby removing themselves from the protection of their ancestors.

Although these rituals, to secular eyes, might seem “superstitious,” Taoist followers attach communal and collective meanings to them that are consistent with Chinese values. Clarke (2000) suggests that these attached meanings are generated both by the individuals themselves and by society at large. Thus, people from different religions may still practice the ritualized actions, bringing with them their own meanings. The rituals then become a means of enhancing family togetherness and creating bonds, rather than being only part of a religious ceremony.

Many Taoists also believe in a spirit that controls the mind and body. It is believed that if a person’s spirit is low in energy, one is susceptible to illness and harm. The causes of illness are viewed as the possession of evil spirits or as an imbalance in life energy. In such situations, the family of the affected person will pray to the shen (a collective name for various gods/deities) in the temple. They will plead to their sifu (the shaman that serves as a medium between the spiritual realm and the human realm) to seek out the reason for their ailments. Rituals are then carried out to treat the affected person. The results of such treatments are mixed (Haque 2008). In the words of Heinze (1997), “the services rendered by these experts tend to restructure their client’s psyche,” and they even “complement and support the other social systems of their society” (p. 110). This method is popular among the Chinese in Malaysia and is in line with Chinese society—and it is generally more affordable than seeking medical treatments (Haque 2008).

Furthermore, those who come from a Taoist family expect their descendants to carry on the practice of ancestor worship and inherit the family shrine. This is particularly evident among CIM, where converting to other religions is greatly discouraged within Taoist families. If an individual chooses to become a Christian, the parents put much pressure on their child, seeing him/her as “betraying” the family line. The son, who is supposed to carry on the family name, has the filial duty and obligation to maintain the tradition. He would cause much grief by not obeying the family “rules” of upholding the religious tradition of his community. Thus, freedom of religion is limited by this Chinese value of filial piety, which can be difficult for a Westerner to comprehend.

Chinese Buddhist perspectives on mental illness

Followers of Buddhism believe in ye-zhang (業障) or karma (the consequence of one’s past actions) that influences the destiny of people. Problems and illnesses (including mental illnesses) with which persons suffer can sometimes be attributed to ye-zhang, especially if the problems cannot be resolved with conventional solutions. Buddhist ways of influencing ye-zhang are to perform meritorious behaviour (which is equal to kind behaviour) and practice Buddhist teachings, especially in accordance with the Noble Eightfold Path. Buddhist teachings are based on the core ideology of “not indulging in any unwholesome behaviours, upholding of virtuous behaviour, and the self-purification of the mind” (Kumar, 2002).

In the context of Chinese Buddhism in Malaysia, when devotees have problems that cannot be solved they often seek teachings from monks or nuns. Usually, devotees will be taught the ideology of ye-zhang, which attributes part of the presenting problem to the reactions from a past life, and they will learn how to influence the ye-zhang. Buddhists seek to calm their minds and relieve painful emotions through reciting sutras, engaging in repentance, and developing compassionate thoughts and behavior, as well as through meditation. These methods can be practiced individually or in a group to help purify the mind, increase concentration, and be aware of oneself and one’s environment, thus allowing one to attain wisdom. Sometimes, if devotees invite a monk/nun to chant for them for blessing and merits, they will pay a certain amount of money to the monk or nun’s organization for the services. On Wesak day (celebrating the birth, enlightenment and passing of the Buddha), it is common for the whole family to go to the temple to give offerings and ask for blessings from the monks or nuns. Parents will usually ask their children to pray for good education, while they themselves may pray for achievement and financial prosperity. The temples also perform cremations and keep the remains of CIM Buddhists at a cemetery, which serves a function for family reunions and services. They also have “Sunday school” services for the younger generation and special services for the adults. This phenomenon is different from the Buddhism practiced in the West, where the practice is more individualized and less centered in the family.

Chinese Christian perspectives on mental illness

Chinese Christians believe in God as Creator of the universe and of life. A Christian’s life is devoted to the glorification and the enjoyment of God, as described in the Bible. They seek forgiveness and grace from God as a means of seeking a personal relationship with God and an eternal life in heaven. When Christians encounter problems in life, most often it is seen as a test from God to strengthen their faith. The problem of suffering has been discussed at length (theodicy, or the theology of suffering). Christians believe that God has knowledge of all events that happen and that they happen only through God’s good will. God may use illness as a means to teach patience, perseverance, and trust and to build character.

The Christian life centers around a redemptive relationship with Jesus Christ. A redemptive worldview in counselling helps a person draw grace and mercy from God for his/her sins (Malony and Augsburger 2007). It also inspires a person to help another to restore hope and wholeness. Redemption helps to establish a healthy sense of self as it often helps to restructure the broken part of the shattered life into a healthier self (McMinn 1996). However, in many Asian settings, the idea of sin is equivalent to shame. For example, Chinese churches in Malaysia celebrate “Mother’s Day” annually in church by honoring all the mothers through their children’s presence. The pastor usually emphasizes the fourth commandment—“Honor your father and your mother, so that your days may be long in the land that the Lord your God is giving you”—as the primary interpersonal commandment. Salvation of the whole family is seen as equal to personal redemption. Since Christianity is still seen as a “Western product” by many CIMs, it is usually difficult for a first-generation CIM Christian to go through the “coming out” process with their non-believing family. This may in itself create much guilt and shame within individuals.

On the other hand, Chinese Christian groups often offer strong social support within their circle because Christianity stresses communal relationships, and this value is exemplified in the Chinese community in Malaysia. Often the support group plays a caring role, offering simple counselling, emotional support, and living assistance to those in need. They function similar to a “clan” which retains its own dialect, cultural practices (such as weddings and funerals), and family lineage. This is particularly evident in rural areas where the church community takes the lead in education and the hospital system. When the problem is too complex for the communal group, it can be referred to the pastor. Usually, a pastor offers prayer, biblical advice, and exhortation to the congregation as guidance for their life.

The relationship of ethnic identity to religion among Chinese in Malaysia

While religions define many individuals’ values, belief systems, and sense of being, in many Asian countries like Malaysia, religion is also part of community life and ethical regulations. In the Chinese culture, religion is seen as a family heritage that is to be kept, inherited, and extended. Hence we often hear of such terms as “born Christian,” “born Buddhist,” or “traditional Taoist” to describe a person’s religious identity among Chinese in Malaysia. To change religion would mean changing one’s family identity and lineage, which could be seen as a lack of filial piety and dishonoring of one’s ancestors. This is drastically different from many Western cultures, where religion is seen as a private and individual choice or preference. In contrast, religion in Asia has been deeply rooted in traditional practices such as festivals, story-telling, moral guidance, grieving rituals, and developmental transitions. Hence religion provides a sense of tradition, cultural roots, and history to many Asian individuals.

To summarize, the intertwined relationship of ethnic identities and religion among the Chinese in Malaysia has resulted in three distinctive social phenomena observed by the authors: 1) a blend of religion, folklore and superstitious practices, especially in life or death events; 2) filial loyalty to the family’s religious tradition such that changing religion would mean abandoning family practices; and 3) beliefs that disturbance in the spiritual realm, such as demonic possession, causes mental illness. Even though there are many spiritual psychologies or religious psychotherapies that are well established in the West, if we do not take into consideration these three distinctive cultural aspects of Chinese Malaysian religion, importing a set model of Western therapy would be insensitive and even intrusive on CIM value systems.

The need to integrate religious traditions within psychotherapy

The American Psychological Association’s (APA) “Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations” (1993) appealed to psychologists to “respect clients’ religious and/or spiritual beliefs and values, including attributions and taboos, since they affect world view, psychosocial functioning, and expressions of distress” (p. 46). As such, exploring religious and spiritual values with clients may facilitate further insights and personal meanings that may bring about or even add to therapeutic benefits in the psychotherapy session. Another example provided by these guidelines is the incorporation of traditional healers (e.g., shamans, curanderos, espiritistas) while working with minority communities. In fact, before the advent of the practice of modern psychology in Asia, many persons with psychological disorders were referred to indigenous healers or spiritual leaders for advice and treatment. It is believed that consultation with and/or inclusion of religious/spiritual leaders/practitioners relevant to the client’s cultural and belief systems will increase the effectiveness of the treatment (Yeh et al. 2004).

Since the endorsement by the APA of the inclusion of spirituality and religion in mental health practices, American psychologists have widely accepted the integration of spiritual approaches in psychotherapy. In the past, many Western psychologists mainly focused on the “implicit” nature of religion or spirituality, which focuses on the individual’s self-enhancement. Religion has been documented to bring about cognitive and behavioral changes, with answers to the existential quest and self-fulfillment (Peterson and Seligman 2004; Gall et al. 2005; D’Souza 2007). However, as described above, religion in Asia is deeply rooted in the “explicit” nature of religion, such as festivals, story-telling, moral guidance, grieving rituals, and rites of passage. Religion provides a sense of tradition, cultural rootedness, and history for many Asian individuals. Hence we should include the traditional and cultural dimension as therapeutic resources for Asians, especially in this case for the Chinese in Malaysia. It would not be wise just to import the findings from the West and assume that we should use the same model of integration in Malaysia.

Reviewing the history of integration between psychotherapy and religion, Nelson (2009) proposed a continuous dialogue between psychology and religion that will be beneficial for both parties. One of these integration efforts is known as “tradition-sensitive psychotherapy” (Dueck and Reimer 2003). Alvin Dueck and Kevin Reimer criticize the uncritical exportation of the liberal tradition in Western psychology because it may invalidate, suppress, or even replace localized meanings that are central to the mental health of indigenous peoples. The primary value of the “tradition-sensitive psychotherapy” model, in contrast, is to enrich the client’s tradition without imposing the beliefs of the therapist’s particular tradition. Therapists must be aware of their own particularity; failure to acknowledge the differences between the values of the therapist and of the client may foster or repress the cultural identity and values of the clients. Nelson (2009) further supports this notion by suggesting that religion can be a binding force that elicits an alliance between the therapist and client. Furthermore, we also suggest that religion should not be taken as just another facet of the client but rather should be seen as a key source of information regarding the client’s psychological being. The spiritual assessment could serve as the first step in deciding what seems appropriate and critical for the therapists to address at the outset of therapy.

For the tradition-sensitive clinician, the telos of the therapeutic encounter is embedded within the history of the client’s tradition, which is consistent with his/her community. The therapist will utilize both the shared meanings (thin) and affirm the particular, prioritized virtues (thick) of the client. Hence, in the following section we stress that the clinician’s knowledge and awareness of religious traditions (thickness) can have an effect on the diagnosis, treatment, and rehabilitation of Chinese clients in Malaysia.

Case examples of the tradition-sensitive approach to psychotherapy among Chinese in Malaysia

The definitions of “psychotherapy” are as diverse as there are schools of therapy. In this paper, we define psychotherapy in terms of several major components: (1) an intentional helping relationship between (2) a trained psychotherapist (3) and help-seeking from a client or patient (4) that aims to promote wellbeing in the latter through the application of psychological insights, skills, theories, and corrective experiences. In the following section, we will introduce the presenting problems and course of treatment of four clinical cases gathered from the both authors’ clinical practice which attempt to integrate religion into the process of therapy. Through a thorough thematic analysis (Taylor and Bogdan 1984) of these narratives, we will then conceptualize a psychotherapeutic approach that is sensitive to the client’s tradition and explicitly utilizes the client’s religious background in the therapeutic process.

  1. Case 1

    Use of religious rituals (prayer) and scriptures

T is a 20 year-old female of Chinese descent living in Malaysia who requested to see a Christian therapist because of her personal religious beliefs. She stated that she would like the therapist to use cognitive-behavioral therapy to counteract the “lies” planted in her head. She had seen a counselor before but did not find it helpful as the counselor did not share the same belief system. T emphasized that faith has been a very important part of her life since her conversion to Christianity three years earlier, and thus the therapist had her permission to discuss religion explicitly in her therapy.

During the initial phase of therapy, T was very open in disclosing the history of her relationships which had led to her current emotional turmoil. She had struggled with setting physical boundaries in her previous relationships with men. She expressed a deep sense of guilt and shame for “seducing” her ex-boyfriend so that he would engage in sexual activities with her, yet she enjoyed the pleasure of being touched and “wanted” the relationship. She ended her last relationship with a Christian boyfriend because she had “betrayed his trust” by crossing the “boundary” with another male friend. She was “remorseful” and decided as penance to remain “abstinent” from any romantic relationship for a year. At a spiritual retreat, a spiritual director told her that her childhood has greatly affected her concept of “love.” She was aware of her dysfunctional belief that “love was conditional and inconsistent,” yet she harbored much unresolved anger towards her father.

T revealed that her father was an artist who had not had a stable income ever since T was a young child. When she was young, her mother had to go to work overseas for a low-paying job in order to support the family financially. T was always resented her father’s incompetency, which had caused her separation from her mother. Moreover, when she was six years-old, T discovered that her father enjoyed watching pornographic videos. She was very confused about the sexual content and adult pictures she had seen in her home, but her father always assured her that it was “normal for adults to watch” pornography. She denied being sexually violated while she was young, but she felt averse towards her father’s affectionate gestures. She felt conflicted because the Bible taught her to “honor the parents’ wishes,” yet she was resentful towards her father for all the emotional damage he had caused her. During her teenage years, T experimented with sexual activities with both sexes and found herself “trapped” in a repetitive pattern. She acknowledged that “sex is just a way to numb [her] pain.”

As a fairly intelligent, high-functioning, attractive, soft-spoken, and sensitive young woman, T used therapy to “confess” her deepest and darkest secret. She was often tearful when talking about her struggle to be a “perfect daughter” in God’s eyes and her confusion over certain biblical verses. She imposed on herself a very rigid set of religious mandates, such as “I should not have anger towards my parents” and “I should glorify God with my good deeds.” When the first author explored this further, T identified her core belief as “I am not loveable,” and hence she needed to “please others” in order to be loved. Once an overtly sexually active person, T compensated by removing herself from any sexual pleasure and by battling with her desire to be wanted.

In therapy sessions, the therapist explicitly discussed T’s religious beliefs, using biblical verses (e.g., glorifying God with an honest heart) and metaphors (e.g., Jesus also feels angry) to challenge T’s rigid “do’s and don’ts” in terms of her relationships with her father and her ex-boyfriend. In light of T’s conflict concerning her obligations as a Chinese daughter, the therapist tended to normalize her sense of duty to her father. For instance, the therapist normalized T’s inner conflict of wanting to “honor” the father as a faithful daughter while harboring negative feelings towards him. The therapist also offered the opportunity for T to use prayer in therapy. T found that being prayed for by the therapist was a way of receiving a blessing. Gradually, the therapist invited T to participate in prayer at the end of the session, where T was encouraged to pray for herself. This gave the therapist a chance to assess T’s spirituality, as well as to empower T to take charge of her own healing process. T was also motivated to continue attending spiritual retreats and talking with spiritual mentors. She actively sought support in her Christian fellowship group and expanded her circle of friends as a way to overcome her break-up with her boyfriend. After four sessions, T expressed that she had found sufficient resources in her community and that a retreat had been helpful. As sex is a taboo subject in many Malaysian Chinese communities, T found the trust built in the therapeutic relationship had removed her shame in talking about her sexual longings and behaviors.

  1. Case 2

    Accepting the spiritual realm and religious practices in order to maintain filial piety

P is a 23 year-old female of Chinese descent. She was referred to the first author by her lecturer because of her “fear of death.” She reported having night terrors, including screaming and murmuring in her sleep, without her conscious awareness. Her roommate brought this to her attention and hoped she would seek help for it.

During the intake interview, P revealed that while battling with terminal cancer her mother had committed suicide two years ago by hanging herself. Since the diagnosis of cancer, P’s mother had become depressed, and soon her mental functioning deteriorated. There were some suicidal gestures, threats, and attempts during her mother’s final phase of life. P had saved her mother from these attempts several times, but eventually she failed. P recalled that her last interaction with her mother was fairly negative, and she never had a chance to resolve the conflict with her before her mother’s suicide.

The funeral practice for her mother involved traditional Chinese folk religious rituals (semi-Taoism), where she had to stay next to her mother’s shrine for 49 days. During these nights, she often heard noises of things moving outside of her room, and her relatives told her that the souls of people who committed suicide would not rest and would come back in other animal forms (e.g., a moth, cat, etc.). P was very threatened by the appearance of unusual phenomena in her environment, and it was during this time that her night terrors first occurred.

Before seeking help, P had sought various “cures” that were consistent with her religious and cultural beliefs. She felt a strong need to know where her mother was after her passing, and so a relative introduced her to a shaman. However, she feared facing her mother through the spiritual medium. Furthermore, the shaman ended up becoming sexually exploitative. She also sought counselling with a local counsellor for “stress management.” Though the treatment lasted for 20 sessions, she did not find it especially helpful and paid a high price for it.

After moving to the city for her college education, she occasionally complained about having interpersonal conflicts with schoolmates who seemed to “take her for granted” and “were overly dependent” on her for help. She felt as though she was not being “appreciated” for all her contributions and voluntary efforts for her friends. Once when she tried to confront a friend, she was shut down by her friend’s verbal threat—“I would not forgive you even if I ended up in a coffin.” This statement repeatedly intruded into P’s thoughts and bothered her emotionally. Finally she entered into therapy to deal with this ordeal in her interpersonal relationship.

At the beginning of therapy, the first author reframed P’s “fear of death” as “unresolved grief over her mother’s death.” The therapist accepted her attitude towards the spiritual realm and the practice of folk rituals without judgment. The therapist also built a safe environment for her to explore the underlying issues of guilt, anger, grief, and apprehension after seeing the shaman. Later, P told the therapist that she would like to challenge herself to view a video recording of her mother. Since her mother’s death, she had not had the courage to view the recording, nor did she have the desire to delete it. Knowing that it was anxiety-provoking for P to face her mother’s image directly, the therapist prepared P so as to reduce her anxiety about direct exposure to a vivid image of her mother. When P was asked to imagine a pleasant and safe place (sanctuary) where she could find peace, P imagined herself “kneeling in front of a KuanYin (Goddess of Mercy) inside a temple.” This inspired the therapist to integrate the elements of her beliefs into the therapy, knowing that P’s faith played a significant part in her coping and relief from guilt. P also reported that she was learning more about Buddhism, so the therapist validated her pursuit of spirituality and explored with her the Taoist and Buddhist resources in her community.

During the Chinese New Year, P went to a Buddhist temple and consulted a nun there about her mother’s whereabouts. The nun gave her the advice that her mother had already passed on and she would not return in an aggressive or revengeful form. The only thing P could do was to continue to do “good deeds” and be self-disciplined in her practice of Buddhism (such as changing to a vegetarian diet). After the talk with the nun, P felt some relief and decided to follow the suggestions of the nun. Religious practice gave P a means of “self-redemption,” and P was able to recall more positive memories of her mother in therapy. Eventually P was able to view the recording of her mother together with the therapist. Following the exposure to the recording, the therapist “invited her mother” into the therapy room using the empty-chair technique, since P had been longing for such a “ritual” with the shaman. The therapist is not a shaman or a psychic medium, but similar functions can be performed by connecting clients to someone they have lost through death and with whom they have unresolved issues. Through the facilitation of the therapist, P finally found closure and forgiveness through her confession to the “mother” in the room. Her night terrors have since disappeared, and she has regained her sense of confidence in setting boundaries with her friends.

  1. Case 3

    Use of religious resources in finding social identity

Q is a 35 year-old childless woman who was divorced and depressed when she started therapy. Q was working as a clerk at a small law firm. She complained of frequent irrational demands from her boss, which led to her inability to complete the work required of her and to her being regularly scolded by her boss as well as the firm’s customers. She persevered in her job fearing that in the current economic crisis it would be difficult for her to find another job. Also, she had been a housewife for 10 years until her husband had left her six months earlier after finding out about her affair with another man. Although she had ended the relationship immediately after that and begged for her husband to stay in the marriage, he was determined to move on and filed for divorce. Since she did not receive any alimony from her ex-husband, she had to re-enter the workplace.

Q reported being depressed by her current predicament because she hated her job but needed it to support herself as well as her mother. She tended to blame herself for the divorce and for bringing shame to her family. She also experienced discrimination at her workplace after people found out about her marital status. Once her boss made a general statement that “divorce is a selfish act” in front of her and other colleagues. Since then, she became isolated at work and anxious whenever talking to her boss. When asked if she was spiritual or religious, she stated that she grew up in a conservative Chinese church. On exploring her spiritual beliefs and her guilt further, Q reported that she perceived that her trials and suffering came from her personal failure as a divorced woman. She said that she has been a bad person and did not think that her church community would accept her.

In therapy, Q was encouraged to reflect on the strengths of her community. Q’s understanding of this increased her tendency to be thankful for whatever she had, including her health, her mother, and her ability to withstand a cranky boss as well as unappreciative customers. She reappraised these stressful situations as opportunities to be gracious and compassionate rather than as spiritual punishment for a moral failure.

Nevertheless, despite her efforts to reaffirm her faith, Q had difficulties accepting her own anger and frustration, which often resulted in guilt for not being a “good enough person” and in harbouring ill-will and negative feelings towards others. The therapist tried to normalize Q’s repression of anger in the Chinese context and affirmed her strength for wanting to keep peace and harmony with everyone. Q was also validated for her effort and sense of responsibility towards her mother as a filial daughter since she was willing to “sacrifice” her own happiness to obtain financial support for her aging mother. From this point on she was better able to forgive herself as well as others and to contemplate the meaning of her suffering in a more communal context. Eventually, Q decided to quit her job, realizing that the stress she was going through was unnecessary and that her mother did not need a “depressed daughter.” She figured she would find more meaning being a volunteer at a children’s tutoring center and exploring a career as a freelance writer, given her degree in English literature. When she was able to overcome her shame as a divorcee, she gradually reached out to her church’s women’s group and to the pastor’s wife. The church’s young adult group, which mainly consisted of CIM, also helped her find a new job as a newspaper editor. Every weekend she joined the church’s outreach program giving free lessons to children from poor families. Through choosing a path that was self-giving to her community, Q gradually found a new support system among her friends and family.

  1. Case 4

    Buddhist and folklore practices in atonement

A 46 year-old professional female, M, was referred by her psychiatrist for follow-up treatment for depression. She had been on anti-depressant medication for two years prior to her visit to the second author. At the initial presentation, the client appeared to attribute her depression to being a constant worrier and to her being exhausted by her multiple roles as a mother, wife, daughter, specialist, deputy head of department, and “minister of finance” for her family as well as her extended family. Through some thought restructuring via Buddhist teachings on mindfulness and compassion, M was able to appreciate the positive sides of herself and her husband more.

After building a trusting relationship in the therapeutic relationship, M eventually disclosed to the second author (her therapist) a traumatic and painful memory in her past. She shared that she had been coerced by her husband to abort a child as they were not financially ready for another child at that time. Furthermore, one of their three children had a congenital physical disability. At that time she was conflicted because her Buddhist tradition views abortion as a form of murder. However, she was convinced by her husband that the fetus had not yet developed a mind and it was safe to abort. She reluctantly went ahead with the procedure. Since then she had harbored anxiety about the dead fetus coming back to haunt her. At the time when M broke down in the session and recounted her abortion, she believed that her depression was due to the influence of her aborted baby, as a punishment, which was a folk belief blended with her Buddhist background.

While the second author was discussing her guilt for the abortion from the spiritual lens, M felt strongly that she needed to go through some form of religious ritual for atonement so that she could confidently be free from her “punishment.” The second author agreed with this idea. Therefore, M sought help from a Buddhist nun who was known to have insight in seeking atonement. She proceeded to carry out the tasks advised by the nun, which included travelling to the north to seek another master of the Thai Buddhist tradition. Prayers and some rituals were carried out whereby she made financial and symbolic offerings and asked for forgiveness, bid her dead child goodbye, and wished it well. After this ceremony for closure, the weight of M’s guilt over her abortion was significantly lifted. She is currently in remission from depression after two years of intermittent therapy and a continued spiritual practice of meditation and reading of Buddhist texts.

Construction of themes and theory

Through an ethnographic approach and thematic analysis (Taylor and Bogdan 1984) of these four cases, we looked for some common religious and spiritual interventions that the clients found helpful. The themes developed are not necessary linear, but could be seen as an evolving process.

Exploring the client’s religious beliefs and spiritual reality

The practice of exploring the client’s religious beliefs and spiritual reality is evident in all four cases, as both the clients and therapists explicitly agreed to talk about religion in the therapy sessions. The therapist must have an open mind to addressing “supernatural phenomena” described by the clients and not deem them as superstition or dismiss them due to lack of scientific evidence. This ties back to the argument we made earlier on that, among CIM, it is very common to believe that emotional disturbance is caused by a disturbance in the spiritual realm. The separation between death and life is not as definite as in the West, due to Taoist beliefs (see cases 2 and 4). Hence it proved helpful to explore each client’s belief system around spiritual reality and to view it from their religious background. The therapist can adopt a learner’s approach by asking the client to inform them about the elaborate rituals needed for atonement, as well as what practices are deemed acceptable in their community.

Affirming the client’s religious resources and social obligations

In all the above cases, each client’s mental illness was closely related to their “deviation” from the social norms for CIM—having an abortion, divorce, premarital sex, and rebellious actions towards parents. Their guilt and shame had their roots in their religious and cultural beliefs regarding their social roles. Hence, it was helpful to them when the therapists acknowledged and normalized their social responsibilities without judgment as well as searched for positive resources and strengths in their religious beliefs. As filial piety is a significant mandate among CIM, the understanding of the therapist of the dynamic between parents and children was a key factor in addressing their emotional turmoil which stemmed from “self punishment.”

Returning to the client’s basic religious teachings and rituals

After acknowledging and affirming the client’s cultural and religious background, the therapists normally utilized the basic doctrines and teachings in that client’s religious worldview. To understanding a client’s religiosity and spirituality, we normally asked these questions: “What would bring release from your feeling of guilt?” “Who would be a trustworthy religious leader that can help you?” “Do you have certain scriptures that you find helpful?” “Do you regularly participate in any religious activities?” Since both of the authors have some basic knowledge of Christian and Buddhist teachings, we also drew upon our religious backgrounds for words of wisdom if we needed to challenge a client’s rigidity on certain doctrines and teachings. Clients usually found it helpful when their self-punishing thoughts were “counteracted” by words of mercy, compassion, and grace from their religious texts. Explicit rituals were also performed in therapy sessions with Case 1 (prayer) and outside of therapy sessions with the rest of the cases.

Expanding religious support from family and community

Because the culture of the Chinese in Malaysia is collectivistic in nature, it was crucial to assist all our clients above to expand their support groups, especially if they were religious. Many CIM choose certain religious identities either due to family tradition or through the influence of friends. Hence it was not difficult for our clients to find support within their religious circles. However, in some cases there were issues of shame and guilt (Cases 1 and 3) which could be worked through in individual therapy. Therapists who are sensitive to the client’s religious background can guide them through the process of selecting religious leaders or indigenous healers with discernment, as not all shamans are experienced or credible. Sometimes therapists may also seek consultation from peers who are more familiar with a particular religious community in order to ensure the safety of the client.

Personal growth and healing in the client’s relationships

Usually when clients start to gain new insights and to build meaningful friendships, we take this as a sign of the effectiveness of our therapeutic approach. As we have reviewed before, the main three religions among CIM—Buddhism, Taoism, and Christianity—all believe in human flourishing in a collective way. In all four cases we described how the clients either sought reconciliation with family members who had passed away (Cases 2 and 4) or fulfilment of social duties (Cases 1 and 3). There were certain aspects of personal growth in our clients, especially in their relationships with significant others. Even the acknowledgement of the spiritual realm was a symbolic representation of the client’s relationships with the departed. If this process remained unfinished, we would go back to other elements of religious therapy to continue exploring further the religious undertone in the client’s suffering. Given these four examples, it can be said that therapists who are able to facilitate the explicit use of religion in therapy can provide empowerment for cognitive and emotional changes in their clients. Hence these themes could be intertwined, parallel, or layered. They are principles or guidance for religious therapy among CIM, rather than a skill set or stages in therapy.

Discussion

Benefits of addressing religious traditions in therapy

From a values-based practice, viewing psychological disorders from a more spiritual and communal perspective may reduce the stigma of mental illness. This is possible because a person’s or a family’s response to the illness by seeking spiritual or religious approaches to treatment is socially more acceptable than seeking psychiatric care. When a person’s disorder is seen as manageable by spiritual or religious means, it takes away the idea of the disordered person being a “psychiatric patient.” This approach moves away from the biomedical model of mental disorder that is usually advocated in Western health care. In addition, it is more congruent with a collectivist society such as ethnic Chinese in Malaysia, who tend to value traditional and natural ways of healing.

Within the Asian context, the religio-spiritual approach to illness management seems to be more acceptable than the medically oriented psychopathology model, especially for culture-bound syndromes (Sue and Sue 2007). This is particularly appropriate for Chinese in Malaysia who commonly believe in a spiritual realm and its effect on psychological wellbeing. As such, focus on explicit religious rituals or spiritual development can play a significant part in healing, while reducing the stigma that is associated with mental illness. This approach also allows room for traditional wisdom and for healers to mentor the clients in their recovery. As seen in the cases of pastoral counseling and visits to Buddhist monks or nuns for various consultations, people do benefit from these consultations and suggested practices of generosity, prayers, rituals, meditations, lifestyle changes, and other methods of treatment, either indigenous or religious in nature (Russinova et al. 2002; Swinton 2001). This research has recently been supported by Meeks and Jeste (2009), who suggest that spiritual wisdom aids neurobiological processes in managing mental functioning and ultimately, mental health.

Finally, by incorporating religious rituals in the treatment plan, we address the physical and somatic aspects of mental illness, which is highly congruent with the Asian context. Scientific studies related to extending religious and spiritual practices in managing mental health, such as mindfulness-based stress reduction, have shown these practices to be effective in treating mental health issues (Irving et al. 2009) and even physical health, such as through meditation.

However, given the destigmatization that comes with using religious means of treatment for mental health, seeking religion as a quick way out or as an excuse to not seek help from mental health professionals can be detrimental. This will be further elaborated in the following section.

Caveats regarding explicit integration of religion in therapy

In some cases, the use of religion in treatment, such as the destigmatization of mental illness by the use of spiritual or religious terminology, may in itself become a barrier to help. For instance, one of the authors had a client who is a 54 year-old Chinese man with post-traumatic stress after an armed robbery who refused medical treatment but sought spiritual remedies because of his belief that the robbers cast a spell on him. He became acutely anhedonic and anorexic with suicidal tendencies. Despite being nonreligious, he had a sudden obsession with demonic possession and charms. He had visited a wide range of religious healers, such as a Malay bomoh, Footnote 1 a Chinese sinseh, Footnote 2 a Buddhist monk, and a Christian pastor, in order to exorcise what he thought were evil spirits residing in him and making him depressed. It turned out that none of the religious healers believed that he was possessed and referred him instead for psychiatric help. So this man kept jumping from one healer to another. In this particular case, religious or spiritual intervention became a disguise for deeper psychological issues and became a barrier for this client from seeking psychiatric help. As a result, his family became more distressed.

Another way that religious psychotherapy might be detrimental is when it reinforces the client’s existing rigid and dogmatic perception of religious rules which lead to self-punishment. This type of coping may bring about more anxiety and guilt in dealing with thoughts and behaviours that bring distress. It could also reinforce taboos within the religious community and thus create shame. Hence, using religion in therapy should be more fluid and flexible, with a focus on virtues such as compassion, forgiveness, and mercy rather than reinforcing the obsession with fear or guilt within the clients.

Suggestions for the future

Given that no therapy is value-free, the therapist’s personal biases need to be kept in check so as to avoid the potential imposition of religious beliefs on the client. This could be achieved by promoting multicultural training and indigenous psychotherapy in graduate school curricula. In a highly religious country like Malaysia, Rafidah Aga and Noh (2008) have raised several issues and challenges facing therapists in using religious resources and have offered guidelines for working with clients who are spiritually and religiously inclined. These include awareness of professional boundaries on religious issues, listening carefully for the spiritual needs of the client, and avoiding any arguments over doctrinal differences. Therapeutic processes and goals need to be the focus of therapy rather than religious goals.

The authors also recognize the need to carry out further research into the efficacy of integrated psychotherapy in the Malaysian setting, challenging the common notion that religion and counseling or therapy should be treated as separate issues (see See et al. 2009) We must also acknowledge that there is no “one size fits all” cookbook recipe for psychotherapy with Chinese clients of different religions. Therapists need to be sensitive to each client’s uniqueness and to adapt the principles of religious therapy in a dynamic and organic process. A holistic view of assessment and intervention needs to be considered, taking into consideration variables such as education, family dynamics, social context, and personal meanings.

In conclusion, the Chinese in Malaysia is a unique population that has inherited three major religion traditions that exist both in the West and the East. Through a socio-political lens, we have discussed the influences of Southeast Asian culture on their religious practices. CIM often see religious identity as part of familial identity, believe in the existence of the spiritual realm, and have less differentiation between folk practices and religious rituals. In view of their distinctiveness in religiosity, we adopted a tradition-sensitive therapy as the context of healing. Through a thematic analysis of four cases of CIM clients, we identified five major principles that improve the therapy for religious clients: 1) exploring the client’s religious beliefs and spiritual realm: 2) affirming the client’s religious resources and social duties; 3) returning to the client’s basic religious teachings and rituals; 4) expanding religious support from the client’s family and community; and 5) personal growth and healing in the client’s relationships. However, just as in other kinds of therapeutic orientations, our approach needs to take into consideration the fact that the concept of mental illness is still not widely recognized and accepted in Malaysia. Hence some religious clients who really need psychiatric treatment have not received timely help due to their belief in a spiritual explanation for their illness.

In the future, we hope there will be increased and ongoing dialogue between mental health professionals, faith communities, religious institutions, and indigenous traditional healers. We hope that our experiences and reflections will not only benefit the Chinese community in Malaysia, but also Chinese in other parts of the world as well. Western psychologists may also widen the scope of their psychological practices in their own multicultural societies by being aware of and knowledgeable about the tradition-sensitive approach to helping religious clients.