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Guide XIII-231

Khushu' (humble presence in prayer)

A 35 · L 49 · M 1619 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Sunni teaching on khushu' as set out in Abu Hamid al-Ghazali's Ihya' 'Ulum al-Din (the chapters on the inner dimensions of prayer, in the abridgement by Abd el Salam Haroun translated by Ahmad A. Zidan); the juristic position summarised in Mufti Muhammad Shafi's Ma'arif al-Qur'an on Qur'an 2:45; and practical Shafi'i guidance from Shaykh Amjad Rasheed (Qibla.com, translated by Faraz Rabbani). Clinical material follows Ahmed & Yousaf (2025), Awad (2017, Yaqeen Institute), the International OCD Foundation and the Traditional Islamically Integrated Psychotherapy (TIIP) curriculum of the Khalil Center. [source: Ghazali, trans. Zidan; Rasheed via IslamQA; quran.com Ma'arif al-Qur'an; Ahmed & Yousaf 2025]

Khushu' is not a technique or a therapy. In Islamic teaching it is the quality of humble, reverent presence with which the five daily ritual prayers (salah) are meant to be performed. The Qur'an praises "the believers, who are reverent in their prayers" (23:1-2, as translated in the Rasheed answer) and says prayer is hard "except for those who are humbly submissive" (2:45, quran.com). Ma'arif al-Qur'an defines it as an inner calm and humility arising from awareness of God's greatness and one's own smallness; outward bowing of the head without inner humility does not count, as in the report that the Caliph Umar told a man that "humbleness of heart is in the heart." [source: quran.com, Ma'arif al-Qur'an on 2:45]

How change happens, as the tradition holds it: al-Ghazali teaches that distraction in prayer has external causes (sights, sounds) and internal causes (worldly concerns, desires, rooted in love of this world). The worshipper removes external causes, prepares the heart before the opening takbir, attends to the meaning of each word and posture, and over time disciplines the lower self (nafs) so that fewer attachments pull at attention. As this happens the inner qualities of prayer deepen. In the tradition's terms the aim is closeness to God, not symptom relief. [source: Ghazali, trans. Zidan] For the psychotherapist, khushu' matters in three ways: (a) a devout client may want help with attention, calm or meaning in prayer, which can be supported client-led within spiritually integrated psychotherapy; (b) distress about a lack of khushu' may be ordinary spiritual struggle, depression, or scrupulosity (waswasa, religious OCD); (c) prayer can be a coping resource and a source of perspective. [source: Ahmed & Yousaf 2025; Awad 2017; IOCDF] The therapist is not a religious authority on khushu' and does not teach it as a spiritual director; rulings and spiritual guidance belong to the client's imam, scholar or shaykh. [synthesis]

2. Framework

The tradition does not set out therapy phases or session numbers for khushu'. It is cultivated within each of the five daily prayers and over a lifetime. No source gives session counts or durations for clinical work on it; any figures would be [synthesis] and are not given here.

A. Within a single prayer, as al-Ghazali presents it [source: Ghazali, trans. Zidan; Rasheed via IslamQA]

  • Before prayer (preparation). Goal: arrive with an emptied, attentive heart. Hearing the call to prayer recalls the summons of the Day of Resurrection; purification (wudu) moves from place and clothes to body and then the inner self through repentance; the place is chosen and cleared of distractions; worldly concerns are set aside, for example by brief remembrance of God (dhikr) or Qur'an recitation.
  • Entering prayer. Goal: align heart with action. Facing the qibla is matched by turning the heart toward God; the intention (niyya) is a resolve to obey sincerely; the takbir ("Allahu akbar") should be true in the heart, not only on the tongue.
  • Within prayer. Goal: sustain presence and understanding through standing, recitation, bowing (ruku'), prostration (sujud), sitting and the testimony (tashahhud), each with its inner meaning; when the mind wanders, return.
  • Closing. Goal: gratitude and seriousness. The salam is said with thanks for completing the prayer, and al-Ghazali advises imagining this may be one's last prayer.

B. Over time (cultivation). Al-Ghazali describes gentle calming of the mind as enough when desires are weak, and addressing the root (attachments and desires of the lower self) when distraction is strong and recurrent. He describes six inner qualities that deepen in sequence: awareness or presence of heart, understanding, reverence, awe, hope and shame (in Arabic commonly hudur al-qalb, tafahhum, ta'zim, hayba, raja', haya' [uncertain: Arabic terms not verified in the translation used]). [source: Ghazali, trans. Zidan]

C. Psychotherapist's work alongside (clinical frame) [synthesis, drawing on the CFI, TIIP curriculum, Awad 2017, IOCDF]

  1. Assessment and consent. Goal: understand what prayer and khushu' mean to the client, why it is raised now, and whether the client wants it in therapy. Move on when the client has said explicitly that they want prayer-related work and has named their tradition and preferred authority.
  2. Formulation. Goal: distinguish ordinary spiritual striving, low mood or anxiety affecting attention, trauma-related responses in prayer, scrupulosity, and adverse contemplative experiences. Move on when the presenting problem is clear enough to choose a pathway.
  3. Intervention pathway. Either (a) client-led integration of khushu' practices as an attention, meaning and coping resource; or (b) treatment of scrupulosity with exposure and response prevention (ERP) or cognitive approaches in consultation with the client's religious authority; or (c) trauma-sensitive or adverse-effect management. Pathways can run together.
  4. Collaboration. With the client's written consent, liaise with imam, scholar, chaplain or shaykh for rulings and spiritual guidance.
  5. Review and ending. Goal: the client's own sense of prayer is restored or improved, with no new compulsive rituals; relapse plan for scrupulosity. End or step down when goals are met.

3. Guiding principles

  • Khushu' is inward. Outward signs without inner humility do not count, and deliberately displaying signs of khushu' is called self-delusion in Ma'arif al-Qur'an (citing al-Qurtubi). Practical meaning: never coach visible behaviours of piety; work only with the client's inner experience as they describe it. [source: quran.com, Ma'arif al-Qur'an]
  • Validity and reward are different questions. Ma'arif al-Qur'an reports that the four imams and most jurists require only the sincere intention at the opening takbir; distraction during the rest loses reward for that part but does not make the prayer abandoned. It also reports that some early figures held prayer without khushu' to be invalid. Practical meaning: a client who repeats prayers because of distraction needs a ruling from their own scholar, not the therapist; the majority position can be named as something to check with that scholar. [source: quran.com, Ma'arif al-Qur'an]
  • Passing thoughts are not sins. Awad (2017) cites the hadith (al-Bukhari 6664; Muslim 127) that God forgives what crosses the mind of the community as long as it is not acted on or spoken. Practical meaning: intrusive thoughts in prayer are normal and are not evidence of bad faith; useful in scrupulosity work, ideally endorsed by the imam. [source: Awad 2017]
  • Remove external causes first, then internal ones. Al-Ghazali treats the environment as the easy fix and attachments as the root. Practical meaning: start with practical setting changes before deeper work. [source: Ghazali, trans. Zidan]
  • Understanding feeds presence. Knowing what one recites is both a classical remedy and a facilitator reported by worshippers. Practical meaning: support the client to learn meanings through their own teachers and resources. [source: Ghazali, trans. Zidan; Ahmed & Yousaf 2025]
  • Hope balances awe and shame. Al-Ghazali pairs fear of God with hope for mercy, and Ma'arif al-Qur'an reports his hope that God accepts the distracted worshipper who intended worship. Practical meaning: with depressed or scrupulous clients, notice whether shame is crowding out hope and raise this, citing the tradition's own balance, with the client's imam. [source: Ghazali, trans. Zidan; quran.com]
  • Client-led, with consent, in the client's own tradition and language. Practical meaning: the client chooses whether prayer enters therapy, which school or teacher they follow, and the words used. [source: TIIP curriculum (consent not detailed there); synthesis]
  • The therapist is not the religious authority. Awad (2017) describes clinicians deferring to religious guidance as they would to a psychiatrist on medical questions. Practical meaning: refer rulings out, keep clinical work in. [source: Awad 2017]
  • Religious practice must not become a compulsion. Awad (2017) warns that spiritual remedies should not become compulsive and that the plan should change if the client is distressed when unable to perform them. Practical meaning: monitor every added practice for checking, repeating or reassurance-seeking. [source: Awad 2017]
  • Uncertainty is compatible with faith. The IOCDF article states that "there can be no certainty or perfection in our religious practices." Practical meaning: the aim of scrupulosity treatment is tolerating doubt while continuing valued worship. [source: IOCDF]
  • Not a treatment for physical illness. Practical meaning: health claims about prayer are attributed to their sources, not offered as treatment. [synthesis]
  • Watch for adverse experiences. Contemplative practices can bring anxiety, depression and other difficulties, including in people with no prior history. Practical meaning: ask about them; do not assume prayer-based work is risk-free. [source: Farias et al. 2020, Acta Psychiatrica Scandinavica; Lindahl et al. 2017, PLOS ONE]

4. Intervention inventory

Part A gives the practices for khushu' as the tradition openly teaches them, in paraphrase. They are the client's religious practices. The therapist does not prescribe them; when a consenting client wants to work on them, the therapist helps the client apply what their own teachers teach and checks how it is going. Part B gives the psychotherapist's own clinical work. Ritual details (what to recite, how to perform wudu, postures and their rulings) belong to the client's school and teachers and are not given here.

Part A. Traditional practices for khushu'

A1. Preparing the heart before prayer

  • Purpose / when: Al-Ghazali's remedy for internal distraction: before the takbir, remember the Hereafter and empty the heart of worldly cares. Shaykh Amjad Rasheed advises setting worries aside beforehand, for example by brief dhikr or Qur'an recitation. Useful when the client arrives at prayer rushed or preoccupied. [source: Ghazali, trans. Zidan; Rasheed via IslamQA]
  • Steps (as taught, paraphrased): (1) On hearing the call to prayer, treat it as a summons and begin to turn inward. (2) Use purification as a transition: outwardly washing, inwardly repenting and resolving. (3) Before starting, spend a short time in remembrance of God or recitation to settle. (4) Deliberately put aside the task or worry that was occupying the mind.
  • Therapist's role: Ask what the client already does before prayer and what their teachers recommend; help the client plan a realistic transition (for example, ending a work task a few minutes earlier) [synthesis].
  • Example language (illustrative): "What helps you arrive at prayer, rather than just get to it? Is there something your teachers suggest doing first that you'd like to try this week?"
  • Watch for: Preparation growing into a ritual that must be done perfectly before prayer can begin, or delaying prayer until the mind feels "clear enough" (scrupulosity signs, see B4). Working: the client reports starting prayer less hurried, without added anxiety.

A2. Arranging the setting (external causes)

  • Purpose / when: Al-Ghazali's remedy for external distraction; first-line when distraction is mainly from surroundings. [source: Ghazali, trans. Zidan; Rasheed via IslamQA]
  • Steps (as taught, paraphrased): (1) Choose a quiet place away from worldly talk. (2) Pray near a wall or in a small room. (3) Avoid patterned or decorated prayer mats and ornamented spaces. (4) Lower the gaze. (5) Cover or remove distracting objects; al-Ghazali cites the Prophet's instruction to cover cooking pots in a room of prayer, and reports that the Prophet removed an ornamented cloak that had distracted him.
  • Therapist's role: Problem-solve practical barriers (shared housing, children, workplace prayer space, phone notifications) with the client [synthesis].
  • Example language (illustrative): "Where do you usually pray, and what tends to catch your attention there? What's one change that would be easy to make?"
  • Watch for: Environment changes becoming rigid preconditions ("I can't pray unless..."). Working: fewer environmental interruptions reported, prayer still performed on time in imperfect settings.

A3. Recalling before whom one stands

  • Purpose / when: The central orientation of khushu': remembering that one stands before God, who knows what is hidden; al-Ghazali links standing upright and the bowed head to humility before God. [source: Rasheed via IslamQA, citing Ibn Hajar's al-Tuhfa; Ghazali, trans. Zidan]
  • Steps (as taught, paraphrased): At the start of prayer and when attention returns, bring to mind the One being addressed, as the client's tradition describes God, and let posture express humility.
  • Therapist's role: Explore the client's image of God. For some clients this orientation brings calm; for others (harsh religious upbringing, religious trauma, scrupulosity) it brings fear. Do not reshape the client's theology; note the effect and, if the client wishes, involve their imam or teacher [synthesis].
  • Example language (illustrative): "When you think of standing before God in prayer, what do you feel in that moment? Comfort, fear, something else?"
  • Watch for: Terror, intrusive blasphemous thoughts, or flashbacks to punitive figures. Working: the client describes a sense of presence or connection that they value.

A4. Understanding the words (tafahhum)

  • Purpose / when: Al-Ghazali names understanding as the second quality and a barrier to distraction; he describes reciters who move only the tongue, those who attend to meaning, and those whose tongue expresses inner understanding. Worshippers in Ahmed & Yousaf (2025) named difficulty understanding or memorising Arabic as a barrier and understanding recitations as a facilitator. [source: Ghazali, trans. Zidan; Ahmed & Yousaf 2025]
  • Steps (as taught, paraphrased): (1) Learn the meanings of what is recited in prayer through the client's own teachers or resources. (2) Recite slowly, attending to meaning. (3) Reflect on the meaning of each phrase as it is said.
  • Therapist's role: Support goal-setting and follow-through; refer content questions to teachers. Questions about using another language inside prayer are juristic and go to the client's scholar [uncertain: rulings not verified].
  • Example language (illustrative): "Which part of the prayer feels most like just words to you? Would learning its meaning with your teacher be something you'd want to set as a goal?"
  • Watch for: Re-reciting to "get the meaning right" or checking pronunciation repeatedly (IOCDF lists repeating verses until every letter feels right as a scrupulosity sign). Working: the client reports words feeling more meaningful, without repeating.

A5. Inner meanings of each act of prayer

  • Purpose / when: Al-Ghazali gives an inner meaning for each part of the prayer, so that body and heart move together. Useful when prayer feels mechanical. [source: Ghazali, trans. Zidan]
  • Content (paraphrased): facing the qibla = turning the heart from everything else to God; takbir = holding nothing in the heart greater than God; opening supplication = guarding against seeking people's approval; ruku' = renewing submission and humility, with hope for mercy; sujud = the highest submission, returning the self to its origin, where mercy flows to lowliness; tashahhud = renewing the testimony and covenant and greeting the Prophet and the righteous; salam = gratitude for completing the prayer.
  • Steps: The client chooses one act per period to bring meaning to, as their teachers advise; Ahmed & Yousaf's participants reported feeling closest to God in sujud.
  • Example language (illustrative): "Is there one moment in the prayer where you feel most present? What happens for you there?"
  • Watch for: Self-monitoring of every movement turning into checking; bodily discomfort or trauma reactions in prostration (see B6). Working: the client describes specific moments of the prayer as alive or meaningful.

A6. Cultivating the six inner qualities

  • Purpose / when: Al-Ghazali's six qualities: awareness (presence of heart), understanding, reverence, awe, hope and shame. They are cultivated, not forced. [source: Ghazali, trans. Zidan]
  • Steps (as taught, paraphrased): Reflection outside prayer on God's greatness (reverence, awe), mercy (hope), and one's own shortcomings (shame), so that these states are more available within prayer.
  • Therapist's role: Notice the balance. Al-Ghazali pairs awe with hope; for a depressed or scrupulous client, "shame" may already be overwhelming. Invite the client to explore what their tradition says about hope and mercy, and consult their teacher if they wish [synthesis].
  • Example language (illustrative): "You mentioned feeling a lot of shame in prayer. In what you've been taught, where does hope come in?"
  • Watch for: Shame becoming self-punishment (IOCDF names self-shaming as a mental compulsion). Working: a mix of reverence and hope reported, not only fear.

A7. Returning from distraction

  • Purpose / when: Wandering thoughts are expected. Participants in Ahmed & Yousaf (2025) described repeatedly redirecting attention; al-Ghazali advises gentle calming when desires are weak. Awad (2017) cites the report in Sahih Muslim in which the Prophet advised a companion troubled by distraction in prayer to seek refuge in God and spit lightly to the left three times. [source: Ahmed & Yousaf 2025; Ghazali, trans. Zidan; Awad 2017]
  • Steps (as taught, paraphrased): Notice the wandering, return attention to the words and meaning, and, as the client's tradition teaches, seek refuge in God from the distraction. Continue the prayer rather than restarting it, subject to the client's scholar's ruling.
  • Example language (illustrative): "When your mind drifts in prayer, what do you do next? What does your tradition say about simply coming back?"
  • Watch for: Restarting prayers, counting distractions, or harsh self-judgement after each one (scrupulosity, B4). Working: return becomes quick and gentle; no restarts.

A8. Addressing the root (discipline of the lower self)

  • Purpose / when: Al-Ghazali calls this the root cure when distraction is strong: loosening attachments that keep pulling the mind (he gives the example of a companion who gave away a garden that had distracted him). It is a long-term spiritual project taught by scholars and Sufi teachers. [source: Ghazali, trans. Zidan]
  • Therapist's role: Do not prescribe renunciation or austerities. If the client wants to, explore which preoccupations repeatedly intrude in prayer; these often point to clinically relevant worries (debt, conflict, grief) that can be worked on in therapy. Spiritual disciplines go to the client's teacher [synthesis].
  • Example language (illustrative): "Which thoughts come back most often during prayer? Sometimes they show us what most needs attention outside it."
  • Watch for: Pressure to give up possessions, relationships or treatment to achieve purity; a teacher demanding this is a red flag (B7). Working: recurring preoccupations get addressed and intrude less.

A9. Closing the prayer

  • Purpose / when: Al-Ghazali advises saying the salam with gratitude and imagining this may be one's last prayer. [source: Ghazali, trans. Zidan]
  • Therapist's role: For anxious, suicidal or grieving clients, the "last prayer" theme may stir distress or intrusive thoughts about death; ask how it lands and screen for risk if needed [synthesis].
  • Example language (illustrative): "How do you usually end your prayer? How do you feel in the minutes after?"
  • Watch for: Post-prayer checking of whether the prayer "counted" (IOCDF: replaying memory to confirm prayers were done perfectly). Working: the client leaves prayer settled and moves on.

Part B. The psychotherapist's work

B1. Spiritual assessment with the Cultural Formulation Interview

  • Purpose / when: At intake or whenever prayer comes up. The DSM-5-TR Cultural Formulation Interview (CFI) has 16 questions across the cultural definition of the problem, perceived causes, stressors and supports, cultural identity, self-coping, past help-seeking, barriers, current preferences and the clinician-patient relationship. Religion and spirituality appear as a possible cause, as a support, and as a source of help, with a linked Religion and Spirituality supplementary module. [source: APA CFI form] (The manual titles the module on spirituality, religion and moral traditions [uncertain: module title and content not verified].)
  • Steps: (1) Use the CFI core questions in your own words; do not reproduce or modify the form beyond what its terms allow. (2) Ask whether the client prays, what prayer means to them, and whether the difficulty touches prayer. (3) Ask about the client's school or tradition and whom they consult for religious guidance. (4) Ask whether they want prayer to be part of therapy. (5) Record their own words (khushu', presence, waswasa) [synthesis on steps 2–5].
  • Example language (illustrative): "Some people find their faith is part of the problem, part of the help, or both. How is it for you? Is prayer something you'd like us to talk about here?"
  • Watch for: Assuming religiosity from appearance or name; a client agreeing out of politeness. Working: the client's explanatory model, supports and preferences are clear and written into the formulation.

B2. Client-led integration within spiritually integrated psychotherapy

  • Purpose / when: For a consenting Muslim client who wants their prayer life supported in therapy. Ahmed & Yousaf (2025) suggest therapists could introduce mindfulness-based approaches within a salah-related or religious frame and note prayer as a source of emotional support and perspective. Traditional Islamically Integrated Psychotherapy (TIIP), developed at the Khalil Center by Keshavarzi and colleagues, integrates Islamic concepts and spiritual (ruhani) interventions including muraqabah (contemplative watchfulness) and dhikr into clinical care. [source: Ahmed & Yousaf 2025; Khalil Center TIIP curriculum] TIIP's detailed procedures for prayer are not set out here [uncertain: not verified].
  • Steps [synthesis]: (1) Confirm consent and record it. (2) Agree a specific, client-defined goal (for example, "feel less rushed in the evening prayer"). (3) Ask what the client's tradition and teachers already offer (A1–A9) and which the client wants to try. (4) Link to therapy skills the client already has (noticing and returning attention, slowing down, planning). (5) Review weekly: what helped, what made it harder, any new worries or rituals. (6) Keep the client's language; do not translate their prayer into psychological jargon unless they welcome it.
  • Example language (illustrative): "You said you'd like your prayers to feel less like a race. Shall we look at what gets in the way, and what you already know from your own tradition that helps?"
  • Watch for: The therapist steering the content of worship; the client feeling judged on piety; prayer becoming homework that is "failed". Working: the client reports prayer as more meaningful or calming in their own terms, and owns the plan.

B3. Bridging from secular mindfulness (cross-reference Domains II and VII)

  • Purpose / when: Clients in mindfulness-based programmes (MBSR, MBCT, MSC, CFT; Domain II) or contemplative and spiritually integrated psychotherapy (Domain VII) who ask how this relates to their prayer, or who decline secular meditation on religious grounds. Ahmed & Yousaf (2025) found that participants spontaneously linked mindfulness with salah, naming ghafla (heedlessness) as its opposite, and listed breath focus and visualising holy sites among their own facilitators. [source: Ahmed & Yousaf 2025]
  • Steps [synthesis]: (1) Ask how the client views secular meditation in light of their faith. (2) Note the overlap: noticing wandering attention and returning. (3) Name the difference: khushu' is directed toward God with reverence, not neutral non-judgemental awareness; let the client decide whether and how the skills transfer. (4) Never present secular mindfulness as a replacement for prayer or prayer as a mindfulness exercise.
  • Example language (illustrative): "Some of what we practise here, noticing the mind drift and coming back, may feel familiar from prayer. Others feel it's quite different. How does it seem to you?"
  • Watch for: The client feeling their worship has been secularised or co-opted. Working: the client uses attention skills in ways consistent with their faith.

B4. Scrupulosity and waswasa around khushu'

  • Purpose / when: When worry about lack of khushu', distraction, intention or correct recitation leads to repeating prayers or wudu, reassurance-seeking, avoidance of prayer or intense self-shaming. The IOCDF lists repeating prayers until they feel complete or error-free, repeating verses until every letter feels right, repeating wudu, asking scholars for reassurance, replaying memory to check prayers and self-shaming. Awad (2017) distinguishes everyday waswasa (intrusive thoughts everyone has) from overwhelming waswas al-qahri, which may meet DSM criteria for OCD, and warns not to attribute depression, panic or psychosis to waswasa. [source: IOCDF; Awad 2017]
  • Steps: (1) Assess obsessions, compulsions (including mental checking and reassurance-seeking), time taken and impairment. (2) Psychoeducation: OCD attaches to what matters most; doubt is the core; the aim is to live with uncertainty while continuing worship. (3) With consent, consult the client's imam or scholar on rulings relevant to exposures, for example the principle Awad reports that doubt does not remove certainty, and the majority juristic view reported in Ma'arif al-Qur'an that distraction does not invalidate prayer. (4) Build a hierarchy of exposures that stay within Islamic law but provoke doubt; the IOCDF gives the example of performing only the required parts of wudu without checking that every area was covered. (5) Response prevention: shorten wudu, stop restarting prayers, stop reassurance-seeking from scholars and family, reduce mental review. (6) Awad's question journal: the client writes religious questions down and brings them to a scheduled weekly appointment with the imam rather than calling between times. (7) Cognitive or ACT work where ERP is not available or acceptable, explained carefully so the client does not think acceptance means endorsing blasphemy. (8) Relapse prevention and periodic check-ins. [source: IOCDF; Awad 2017; quran.com Ma'arif al-Qur'an] Keshavarzi, Khan and Syed (2020) describe an Islamically integrated treatment of scrupulosity, and TIIP has a waswasa workbook [uncertain: contents not verified].
  • Exposure safety and consent: explain the rationale, get explicit consent for each exposure, agree the imam's role, start low on the hierarchy, and stop or adjust if the client becomes unsafe, severely depressed or suicidal [synthesis]. Prescribing is outside this guide; coordinate with the client's doctor.
  • Example language (illustrative): "Your imam has said the prayer stands even when your mind wanders. OCD will tell you to check anyway. This week, could you finish each prayer once and leave the doubt where it is?"
  • Watch for: Religious remedies (seeking refuge, dhikr) becoming new compulsions; Awad advises adjusting the plan if the client is distressed when unable to perform them. Imams who blame low devotion can worsen distress. Working: fewer repetitions, less time on wudu and prayer, less reassurance-seeking, tolerable uncertainty, worship continuing.

B5. Referral and collaboration with religious authorities

  • Purpose / when: For rulings, spiritual direction and teaching on khushu', and for scrupulosity. Awad (2017) describes imams giving rulings, teaching principles and offering spiritual cognitive restructuring, while clinicians handle assessment, therapy, family work and psychoeducation, coordinating through a release of information. TIIP names classical helping roles (murabbi, shaykh, tabib) the practitioner should understand. [source: Awad 2017; Khalil Center TIIP curriculum]
  • Steps: (1) Ask whom the client trusts (local imam, scholar of their school, Sufi shaykh, chaplain). (2) Obtain written consent specifying what will be shared. (3) Agree roles: rulings and spiritual guidance with them; clinical work with you. (4) If the client has no trusted authority, offer to help them find one through their community or a Muslim chaplaincy; do not choose for them [synthesis].
  • Example language (illustrative): "That question about whether the prayer counts is one for your imam, not me. Would it help if we spoke with them together, with your permission?"
  • Watch for: The client being caught between conflicting advice; the therapist ruling on fiqh. Working: consistent messages from both sides; the client feels supported rather than judged.

B6. Trauma-sensitive adaptation

  • Purpose / when: For clients whose trauma, or religious trauma, is triggered by aspects of prayer: closing or lowering the eyes, prostration, imagery of judgement, recalled abuse in religious settings, or bodily sensations. Trauma-sensitive mindfulness (Treleaven) is a published adaptation for secular practice [uncertain: not verified]; cross-refer Domain IV (trauma-sensitive yoga).
  • Steps [synthesis]: (1) Ask which parts of prayer feel unsafe. (2) Support choice and control within what the client's tradition permits; questions about modified postures or praying seated go to their scholar [uncertain: rulings not verified]. (3) Offer grounding before and after prayer (orienting to the room, feeling feet on the floor). (4) Pace: shorter focus on inner states, more on meaning of words; reduce intensity if hyperarousal or dissociation appears. (5) Address trauma itself in an evidence-based trauma therapy, with prayer kept as a resource where the client wants.
  • Example language (illustrative): "You don't have to go deeper inward than feels safe. What helps you stay here, in the room, while you pray?"
  • Watch for: Dissociation, flashbacks, panic in prostration, shame spirals. Working: the client can pray while staying grounded, and trauma symptoms reduce in treatment.

B7. Monitoring adverse experiences and telling spiritual crisis from illness

  • Purpose / when: Whenever a client intensifies contemplative practice (long night prayers, muraqabah, retreats or seclusion with a Sufi order) or reports unusual experiences in prayer. Lindahl et al. (2017, PLOS ONE), interviewing nearly 100 Western Buddhist meditators and teachers, mapped 59 challenging experiences in seven domains (cognitive, perceptual, affective, somatic, conative, sense of self, social), lasting days to over a decade, and influenced by practitioner, practice, relationship (including with the teacher) and health-behaviour factors; difficulties were not confined to people with psychiatric or trauma histories. The systematic review by Farias et al. 2020, Acta Psychiatrica Scandinavica, found adverse events in about 8% of participants across 83 studies, most often anxiety, depression and cognitive anomalies, including in people without prior mental health problems. [source: Brown University 2017; PubMed 32820538; Coventry University 2020] These studies concern meditation, not salah; how far they apply to khushu' practice is [uncertain]. Britton's support resources (Cheetah House) are a further reference [uncertain: not verified].
  • Steps [synthesis]: (1) Ask routinely about distressing or unusual experiences in prayer and devotions. (2) Before intensive retreats or seclusion, screen for current psychosis, mania, severe depression, suicidality, active trauma symptoms and sleep loss, and discuss with the client and, if they wish, their teacher. (3) If difficulties arise: reduce intensity of extra devotions (not the obligatory prayers unless the client's scholar advises), prioritise sleep, grounding, social contact and ordinary activity. (4) Differentiate: a spiritual struggle or sense of distance from God, held within the client's tradition and functioning, differs from psychosis (fixed false beliefs, hallucinations outside cultural norms, disorganisation), mania, major depression or dissociation. Awad (2017) gives the example that a client reporting seeing a devil needs assessment for psychotic disorder. Use the DSM-5-TR category religious or spiritual problem (Z65.8) where it fits. (5) Coordinate with the client's teacher when the client wishes, and with medical services when illness is suspected.
  • Example language (illustrative): "Sometimes deeper practice brings difficult experiences as well as good ones. Has anything in your prayers or devotions lately felt frightening or hard to make sense of?"
  • Watch for: Sleep loss, agitation, grandiosity, voices, losing touch with daily life, withdrawal, suicidal ideation. Working: experiences settle with reduced intensity and grounding, or illness is identified and treated without dismissing the client's faith.

B8. The teacher relationship and coercive control

  • Purpose / when: Some clients pursue khushu' within a Sufi order (tariqa) under a shaykh, where some teachings are given only within the order. Do not ask the client to disclose them. Lindahl et al. (2017, PLOS ONE) identify the teacher relationship as one influence on meditation difficulties. [source: Brown University 2017] Independent investigation of teacher misconduct specific to this practice: none found in the sources consulted.
  • Steps [synthesis]: (1) Ask respectfully about the teacher and community and what the client values there. (2) Listen for signs of coercive control: isolation from family or outside advisers, control of money, sexual contact or demands, threats about leaving, demands to stop medical or psychological treatment, harsh punishment for imperfect devotion. (3) Do not label the group; describe behaviours. (4) Support autonomy and safety planning; if the client leaves a group, attend to grief, religious trauma and community loss. (5) Follow safeguarding duties where children or vulnerable adults are at risk.
  • Example language (illustrative): "How do you feel about your teacher's guidance? Is there ever a sense you couldn't question it or say no?"
  • Watch for: Idealisation of the teacher alongside fear; secrecy that isolates. Working: the client can weigh guidance freely and keep outside relationships and care.

B9. Practical accommodation of prayer

  • Purpose / when: Practising clients may need sessions arranged around prayer times or a place to pray. [synthesis]
  • Steps [synthesis]: Ask about prayer times when scheduling; offer to pause if a prayer time falls in a long session; know where clients can pray on site. For inpatient or rehabilitation settings, Ahmed & Yousaf cite work on supporting salah in rehabilitation (Mohamed et al. 2015) [uncertain: not verified]; physical capacity questions go to the client's doctor and rulings on modified prayer to their scholar.
  • Example language (illustrative): "Does this time work with your prayers? We can move it or pause if that's easier."
  • Watch for: Prayer used to avoid hard material (raise gently) versus genuine obligation (respect it). Working: the client experiences the service as respectful of their practice.

B10. Role boundaries and the therapist's own beliefs

  • Purpose / when: Throughout. Vieten, Scammell, Pilato, Ammondson, Pargament and Lukoff (2013, Psychology of Religion and Spirituality 5(3):129–144) proposed 16 basic spiritual and religious competencies for psychologists, covering attitudes, knowledge and skills. [source: Institute of Noetic Sciences page] Professional ethics on competence, multiple relationships and respect for religion apply [synthesis].
  • Steps [synthesis]: (1) Do not act as imam, shaykh or confessor or issue rulings. (2) Avoid dual relationships, for example teaching or leading prayer with a client, or treating members of your own congregation without care over boundaries. (3) Reflect on your own religious or non-religious commitments and how they shape reactions; self-disclose only when it serves the client. (4) Seek consultation or training when the client's tradition is unfamiliar. (5) Refer or collaborate (B5).
  • Example language (illustrative): "I'm not a religious scholar, so I won't tell you what your prayer requires. I can help with the worry and the habits around it, and we can involve someone you trust for the religious side."
  • Watch for: Pressure from the client for rulings; the therapist's own agreement or discomfort steering the work. Working: clear roles, the client's tradition respected, clinical goals progressing.

5. Handling problems

Most guidance here is [synthesis] unless a source is named.

  • "My prayers don't count because I can't concentrate." Explore whether this is ordinary striving, low mood, anxiety or scrupulosity. Note that the tradition itself distinguishes validity from reward (Ma'arif al-Qur'an reports the majority juristic view that only the opening intention is required) and al-Ghazali's hope that the distracted worshipper is accepted; suggest the client confirm this with their scholar rather than relying on you. [source: quran.com Ma'arif al-Qur'an; synthesis]
  • Repeating prayers or wudu, reassurance-seeking. Treat as possible OCD (B4). Agree with the client and imam a single, consistent ruling and a scheduled question time; reduce reassurance from family and therapist too. [source: IOCDF; Awad 2017]
  • Client avoids prayer altogether because it triggers doubt or fear. Avoidance is part of the OCD or trauma cycle; plan graded return with the imam's endorsement rather than pushing full practice at once. [synthesis]
  • Low mood makes khushu' feel impossible; guilt worsens depression. Treat depression; frame lack of feeling as a symptom, not a verdict on faith; bring in the hope theme from the client's own tradition; screen for suicidal ideation. [synthesis]
  • Overwhelm or dissociation in prayer. Reduce intensity of extra devotions, ground before and after, refer trauma for treatment (B6); suspected psychosis or mania goes to urgent assessment (B7). [synthesis; Lindahl et al. 2017, PLOS ONE; Farias et al. 2020, Acta Psychiatrica Scandinavica]
  • Non-adherence to agreed practice goals. Check the goal was the client's own and realistic; check for hidden scrupulosity (goals "failed" because not perfect) and practical barriers (work, childcare, shared space). Do not frame missed devotional goals as therapy failure. [synthesis]
  • Client wants the therapist to rule or to pray with them. Decline warmly, explain roles, offer collaboration with their imam or chaplain (B5, B10). [synthesis; Awad 2017]
  • Conflict between therapist's plan and religious advice. Meet with consent; clarify where the advice is a ruling (defer) and where it is a clinical judgement (discuss). If an adviser blames the client's faith for OCD, help the client find a better-informed authority, as Awad notes this worsens distress. [source: Awad 2017; synthesis]
  • Rupture over perceived secularisation or judgement of faith. Name it, apologise for any misstep, ask what respect would look like, and return control of religious content to the client. [synthesis]
  • Therapist unfamiliar with Islam. Ask the client to teach you about their practice as they wish, consult a colleague or Muslim chaplaincy, and avoid generalising across schools and cultures. [synthesis; Vieten et al. 2013 competencies]
  • Different views within Islam. Schools and Sufi and non-Sufi currents differ; some early authorities held prayer without khushu' invalid while the majority did not. Do not choose for the client; route to their own authority. [source: quran.com Ma'arif al-Qur'an]
  • Physical limits on prayer (pain, disability, pregnancy, illness). Route physical questions to the client's doctor and questions about modified postures to their scholar [uncertain: specific rulings not verified]. Prayer is not presented as a treatment for physical illness.
  • Children and adolescents with prayer-related scrupulosity. Involve parents and, with agreement, a trusted religious authority; take assent from the young person; follow safeguarding procedures if religious practices are enforced harshly. [synthesis]
  • Pressure from a teacher or group to intensify practice or stop treatment. Explore safely (B8), support autonomy, follow safeguarding duties. [synthesis]

Sources

Books and chapters cited (details as listed in the Khalil Center outline) [uncertain: not verified]: Keshavarzi, H., Khan, F., Ali, B. & Awaad, R. (Eds.) (2020). Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. Routledge. Keshavarzi, H., Khan, F. & Syed, B. (2020). Islamically integrated treatment of Obsessive-Compulsive Disorder Scrupulosity (Waswasa) in Muslim patients. In Spiritual Counseling and Care in Health and Prison Services. Ensar Publishing. Other works mentioned: al-Ghazali, Ihya' 'Ulum al-Din, English translation of the worship chapters by Muhtar Holland, Inner Dimensions of Islamic Worship (Islamic Foundation), as cited in the Rasheed answer; Treleaven, D., Trauma-Sensitive Mindfulness [uncertain: not verified].

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