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Possession—the belief that an individual has been entered by an alien spirit—is encountered in many cultures. Lately it has come to the fore in African communities in the UK, where Christian fundamentalist pastors have labelled certain children as bewitched, with consequent abuse.1 In the Muslim community the issue is possession by jinn—a state that has attracted little comment in medical journals, perhaps because so difficult to manage effectively. The paper by Dr Khalifa and Dr Hardie on p.351 of this issue2 is thus very welcome. In this commentary I summarize key beliefs about jinn that healthcare professionals might bear in mind when treating their Muslim patients, and share some insights from my own experience in caring for those who believe, or about whom it is believed, that jinn are in some way responsible for symptoms.
Religion is essentially about the belief in unseen realms, and it is through developing an appreciation of these invisible forces that people who live within a sacred world-view seek answers to deep questions concerning existence. The Qur'an, for example, opens with the cautionary note that only those who believe in extrasensory realities have the capacity to benefit from its teachings: 'In it [the Qur'an] is guidance for those who are conscious of God; those who believe in the unseen, who establish prayer and spend (in charity) out of that which We have bestowed upon them...'.3 Of all that exists, only two of God's creation are considered 'weighty'—humans from the world of physical form and jinn from the metaphysical world. What distinguishes these two from all else in creation is their ability to choose between the paths of ascent and descent; and this autonomy means that they will be called to account for the choices they have made while on earth. The Qur'an's main subject matter is a discussion of how to discharge this weighty responsibility.
There is little detailed description of jinn in the Qur'anic and Prophetic literature. Their name is derived from the Arabic ijtinan, which means 'to be concealed from sight'. Though residing in what are in essence parallel worlds, humans and jinn are believed to have some ability to influence each other towards both positive and negative ends. Examples of jinn (anglicized to genie) who retained their innate wholesomeness or beauty include those who in Biblical times came to the service of King Solomon and those who in more recent days came across someone reciting the sacred text: 'A company of jinn gave ear, then they said, we have heard a wonderful recitation, guiding to right action. We believe in it and we will not associate anyone with our Lord'.4 Other jinn, however, have allowed their inherent goodness to be transformed into something hideous or gul (anglicized to ghoul). Satan (who is within the Islamic tradition a jinn and not an angel, and hence has the choice to disobey) is the most infamous of the ghouls and is primarily concerned with enticing humanity to forget its divine origin, this assault beginning from the very moment of birth as noted in the Prophetic tradition: 'When a human being is born, Satan touches it and thus it cries'.
What then does this all mean for medicine? The main point to appreciate is that possession states, which are acknowledged by virtually all of the world's major religions, may have a rational basis when viewed from within the Islamic narrative—these representing the handiwork of evil jinn. Whether this 'possession' is of the heart, mind or body has long been debated by Muslim jurists, but the important thing for healthcare professionals to recognize is that such beliefs may be held by a Muslim patient and his or her close circle. From my experiences both in Britain and abroad, jinn possession is a not uncommon lay 'differential diagnosis' in those with an altered mental state.
What then should clinicians actually do when a patient or the family or friends believe that jinn are the cause of symptoms or unusual behaviour? The first and most important step is to elicit, in an open and non-judgmental manner, the patient's (and if appropriate the family's) ideas, concerns and expectations. The second is to recognize that symptoms attributed to possession by jinn are commonly manifestations of a mental health disorder that may benefit from medical treatment. But the third is to appreciate that, although the patient and relatives may obviously have interpreted symptoms incorrectly, beliefs that are strongly held (and often socially convenient) will be hard to alter at a time when anxiety is running high. In such cases where patients are deemed to have a medical, psychiatric or psychological disorder but are not receptive to medical explanations, I have sometimes encouraged patients to 'hedge their bets' by taking the prescribed treatment while continuing with spiritual therapy. This double strategy may be the best hope of securing adherence to prescribed treatments. There may also be the additional very important benefit that patients and their families are willing to enter into discussion about the other therapies that are being tried. Whilst these usually consist of repeated readings of certain sacred texts, the concern is that in desperation some families may turn to exorcists who inflict physical harm in an attempt to free the individual from possession—sometimes with catastrophic consequences. It is very important, therefore, to establish channels of communications with the patient, the family and any spiritual practitioner whose help is being sought. Lastly, there is a need for humility since, despite all our scientific developments, the symptoms and experiences of patients commonly remain medically unexplained.
I thank Sangeeta Dhami for her helpful comments.