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Sikhism, spirituality and psychiatry
Asian Journal of Psychiatry 5 (2012) 339–343
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Sikhism, spirituality and psychiatry Gurvinder Kalra a, Kamaldeep S. Bhui b, Dinesh Bhugra c,* a
Department of Psychiatry, Lokmanya Tilak Medical College & Sion Hospital, Sion, Mumbai 400022, India Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK c Health Service & Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 April 2012 Received in revised form 10 August 2012 Accepted 13 August 2012
Sikhism has millions of followers in India and among the Indian diaspora. As a religion it is relatively young but carries with it unique perspectives which are often not well known. The holy book of Sikhism, Guru Granth Sahib, is not only the last Guru, but also remained a key text for this religion. Using descriptions of the religion and its followers we attempt to understand the context of spirituality within this religion and attempt to apply it to clinical settings. We explored various texts to understand the notions of spirituality and ethics and directions for living one’s life. We studied both the Gurumukhi version as well as the English translation of the Sikh holy text. In the context of history of the Sikhs, various descriptions related to mental well being were identified. In this paper we describe the history, development and the core values of the religion and we also review their role on psychiatric and mental health settings for managing Sikh patients. Guru Granth Sahib offers a very useful insight into what is understood by the term equivalent to depression and its phenomenology. The notions of dukh (loosely translated as pain, but can also mean sadness or suffering) and maya (illusion) and their role in daily living are also discussed. In this paper these descriptions are explored further and their importance explained. ß 2012 Elsevier B.V. All rights reserved.
Keywords: Depression Spirituality Sikhism Sikh Psychiatry
1. Introduction Sikhism originated in the Punjab province of India which remains the homeland of the religion, though the Sikh diaspora is very prominent in many countries, including the UK and Canada. The current geographical state of Punjab is smaller than it used to be centuries ago. Guru Nanak – first of the Sikh gurus – was born in 1469 in Talwandi (now Nankana Sahib), 55 miles west of Lahore. At that time, the indigenous population of the region was largely Hindu. His personal experiences inevitably led Guru Nanak to establish the Sikh religion. He had a mystical experience which led him to challenge the existing religious orthodoxies. After this experience, his first poetic experience is described as Mool Mantra, which encapsulates his concept of divinity. The term guru is applied to someone who dispels ignorance or darkness (gu) and who proclaims enlightenment (ru) (Cole and Sambhi, 1989). Following a series of journeys and events, he began to express his thinking, and individuals started to follow him and his teaching. Many of these teachings, writings and pronouncements from that time form the core of Sikhism. Guru Nanak then settled down with his family at the age of 50 and continued to develop the philosophy of Sikhism through creating a community.
* Corresponding author. Tel.: +44 20 7848 0500; fax: +44 20 7848 0333. E-mail address: [email protected] (D. Bhugra). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2012.08.011
A few days before his death, Guru Nanak chose a successor to carry on with his work by presenting him with a book of his own hymns (a pothi) and a woollen string (a seli) indicating renunciation of the world and devotion to God. The growth of the religion continued apace over the next three centuries with Guru Gobind Singh being the last guru. Born in 1666, he was a significant leader, a poet as well as a major warrior. He introduced rites how people were to be initiated into the religion. He also developed a code of discipline which prohibited certain diets and activities. Initiated men took the name of Singh (the lion) and members of the new community were called Khalsa (the Pure Ones). Guru Gobind Singh emphasized equality by inviting men and women from all castes to join the community. On his deathbed, he pronounced that Guru Granth Sahib becomes the last guru of Sikhs. We studied both the Gurumukhi and the English translation of this Sikh holy text and identified various descriptions related to mental well being. In this paper we describe the history, development and the core values of the religion briefly and we also review their role on psychiatric and mental health settings for managing Sikh patients. 2. Core concepts Guru Granth Sahib has contributions from all the gurus along with many others from Sufi tradition as well as other significant poets and scholars of the time. The scripture is subdivided
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according to musical settings; the names of the sections being those of Indian musical arrangements. Each section has a uniform organization with hymns of Guru Nanak appearing first, followed by the third, fourth, fifth and ninth gurus and then those of other Sufi ascetics. The scripture is unique, as it has contributions from Sufis, Hindus and Muslims as well. It also makes references to the great Indian epics Ramayana and Mahabharata. The language used is called Gurmukhi; the form is poetry and the aim is to provide a sense of essential unity with God to the listener or the reader. God is seen as supreme, but also as a friend and a lover and living is the key to a proper relationship with God. As Guru Gobind Singh, the last Sikh Guru, declared that after him there will be no Guru and the diktat of Granth Sahib shall be final, the Shri Guru Granth Sahib (Granth – book; Sahib – Supreme) thus is the final Guru of Sikhism. It is a voluminous religious text of 1430 pages, compiled and composed by the Sikh Gurus from 1469 to 1708 (Rahi, 1999). It consists of a collection of hymns which describe the qualities of God and the various reasons on why one should meditate on God’s name. The text was first compiled by the fifth Sikh guru, Guru Arjan Dev, from the hymns of the first five Sikh gurus. The holy book has been a source of emotional and psychological support, through the means of prayers in Sikhism. It is revered and worshipped by the Sikhs as their spiritual guide. Cole and Sambhi (1989) emphasize that Guru Granth Sahib is the visible focal point for Sikh devotions. It dominates the Sikh ritual and theology as well as has a significant role in daily living, ceremonies, festivals etc. Thus a notion of spirituality is at the core of functioning of Sikh individuals. Gurudwaras, their religious temples are at the centre of practice of religion, though Guru Granth Sahib will be present in most Sikh households. The functions of the gurudwara, apart from reading the scriptures, include providing a common kitchen, sharing food and offering shelter and support to those who need it. Sikh theology relies on a monotheistic approach. Ultimate reality is a unity with God, and as God is without qualities, truth becomes an inadequate description (Cole and Sambhi, 1989). The God is one, only one in this context which, according to Cole and Sambhi (1989), raises the question of whether it really is a monotheistic religion or monistic. These authors argue that Sikhism has no difficulty in coming to terms with scientific theories of evolution and that of an expanding universe. Within the religious writings there is an opposition to materialism. Interestingly, another key factor is the belief that God is residing at home, so every individual must do the duty at home. Man is not only the latest or highest product of an evolutionary process but is the result of God’s intention. The exact reasons of why God made man are not clear; man’s condition is of interest and not the reasons for birth. Like many philosophers and thinkers, ignorance on man’s part is the problem. Man is intelligent, is aware of the notions of right and wrong, but may still miss the chance to meet the Lord. The reasons for this vary from birth, environment, karma (the notions of cause and effect), maya (a materialistic view of the world) and self-dependence rather than an acknowledgement that God also has a role. This dependence upon God and obedience to his will (hukam) is at the heart of being liberated (Cole and Sambhi, 1989). This interaction between birth, environment, etc. is not dissimilar to the biopsychosocial models of understanding an individual. Cole and Sambhi (1989) argue that according to Sikhism the world exists in reality and is not to be rejected. Liberation is different from rebirth and is a release from the round of death with man uniting with God resulting from the soul reaching the stage of sack khand (the realm of truth, the ultimate stage in the development of the soul). Liberation is obtained by meeting the guru through naam simran (remembering the name). The name in this context is that of God, but can apply to anything. It has certain rituals attached
to it and the practice is that of transforming personality through practice. As noted above, the guru in this context must be an enlightened messenger of God and this approach has been used in psychotherapy in the Indian context (Neki, 1973). As writings of other authors were included in the scriptures, it is clear that the gurus saw that there are many paths to God and they themselves did not have exclusive access to the truth or there was not a single way of finding the salvation which is an intriguing show of open-ness. Rituals related to Sikhism are clearly described with emphasis on clean physical appearances and saying prayers regularly. Work, worship and charity form the core of Sikh ethics. Self-conceit is not to be encouraged, as it will lead to lust, anger, greed and materialism. Sikh charitable work is critical in supporting those who are vulnerable. Thus there is a clear direction away from an individualistic and ego-centric development and view. Spiritual aspects rely on the core notion of good deeds and concepts of heaven (suarg) (182-11) and hell (narak) (91-1). The emphasis on home responsibilities and duties are highlighted by the advice that one should not wish for a home in the heavens, and should not be afraid to live in hell (337-10) even though some yearn for paradise (bhisat) and others long for heaven (surgindoo) (885-11) thereby reflecting human nature. However, heaven cannot be attained without the karma of good actions (p. 952); thus there is a system of reward for good deed and a clear encouragement to do so. In the developmental context like Hindu beliefs there are four stages of life but unlike Hinduism where these stages are of celibacy, householder, societal obligations and giving up of worldly things the four stages in Sikhism are different (p. 113; p. 687). The first is that of creation of life, second is the sense of duality (dubidha), third is the three-phased maya, and the fourth stage, the highest is that of mukti where one attains a state of bliss and ultimate happiness. The process of creation, i.e. being in the intrauterine life has been described as a terrible hell (narak ghor) (706-7), wherein the fetus has to rest head downwards. Thus the relationship with the world starts in an upside down manner. The three-phase maya is said to affect almost every human being in the world (129-6; 297-3) and keep them in spiritual darkness (agyaan) (509-14). Maya is illusion but can also mean mirage especially when used to describe material things. Attachment to maya has been compared to a treacherous wilderness (maha-sankat) (220-2) and mirage (mrig-trisna) which is chased by individuals even though they know it is false (219-9); it has been compared to a witch (daainn) (868-3) and sweet wine (madu-meetha) which the intoxicated mind (muhn-matwala) continues to drink (350-7). One can break the bonds of the three-phase maya only by the guru’s shabad (words or teachings), after which one moves to the state of liberation (mukti) (127-12). This approach thus starts to make sense in the context of psychotherapy where the guru is able to teach the pupil to detach from maya and achieve mukti. Maya is also understood as having (undue) emotional attachment to anything apart from the Lord and described as having a pale color (sooha) while Lord’s love at the fourth level, a beautiful deep crimson color (laal) (221-3). With maya, the spiritual consciousness (soorat) is lost (p. 989); one is emancipated only after freeing oneself from maya. Pages 76–77 in the text specifically describe the process of birth, and the way in which emotional attachments develop between the child and the parents, through hugging and embracing the child. However, all this has been described as emotional and worldly attachments which is only transitional and mortal, leading one into grief. Attachment to the Lord on the other hand is immortal. The Lord himself has created maya and moh 1 The first number in parenthesis indicates page numbers from the Guru Granth Sahib while the second number indicates the line number on that page.
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(emotional attachment) (125-16). The enticing desire for maya leads people to become emotionally attached to their children, relatives, households and spouses (61-9). Only emotional attachment and love to god is considered pure and peaceful and full of contentment (p. 61). Key concepts in understanding the components of psyche are related to worldly attachment and also to the notions of mukti as described above. These are not only emotions but also experiences which form the core of one’s being. These words cannot be translated suitably as they mean much more than literal translation. 3. Dukh and sukh in Guru Granth Sahib Not surprisingly human beings live with emotions and undergo experiences—some of which are painful and others pleasurable. Some emotions and experiences may well be rather neutral. Like religious texts from other religions, notions of jealousy, pride, greed etc. are described in the text. Emotions of hatred/vengeance (vaeir), anger, and greed (lobh) have been looked down upon as bad (p. 108) for the living and for human experiences. The text also explicitly discusses sadness (dukh) and happiness (sukh) using many metaphors (Table 1). These terms and their descriptions highlight the intrinsic unhappiness in the world especially if one is detached from the God. The world whether it is at large or an individual one is unhappy (dukhiya) (413-2) and, overflowing with pain and suffering (767-6); where in only a few are happy (sukhiya) (413-2). This does not mean nihilistic interpretation but a realistic one where individuals perhaps expect too much and feel let down. The only way this unhappiness can be overcome is by devoting one to God. As both the experiences and emotions of dukh and sukh are created by the Lord (125-13; 787-12), he is the one who relieves it and is thus both Dukh-bhanjan (destroyer of dukh) (99-6) and Sukhsaagar (ocean of peace and happiness) (927-12). Happiness has been referred to as a jewel (ratan) which lies within the self, but we receive it only if the Lord wants us to get it (117-2). Thus this concept becomes incredibly important in our understanding of models of illness, pain and emotions that individuals carry with them. Throughout the text, Lord has been equated to peace and happiness and looking for him outside oneself leads to terrible pain (maha-dukh) (p. 124). This may refer to people searching for happiness outside themselves, whereas the emotions are internal. Thus, the external search can lead to sorrow. The text makes it clear that happiness is a state of mind and a choice we make. This cognitive reframing enables individuals to carry their emotions in the context of their functioning. The mind (muhn) is considered prone to get diseased with doubt (bharam), superstition (bhed) and duality (dooja) (416-7), all of which ultimately keep the person in dukh. Bharam is also a term used for delusions and overvalued ideas in clinical assessments but does not mean psychopathology in the spiritual context and does so as a philosophical argument and development. Interestingly it is noted that melancholy can affect anyone whether they are the rich or the poor and can affect them equally (182-1) indicating that unhappiness or depression in a broader context can have no specific targets but any one can be prone to it. The state of a person afflicted with melancholy has been symbolically referred to a tree with dried leaves and branches, which become green in an instant with the ambrosial name of the Lord (amrit naam) (191-8). Thus a ritual and cognitive approach is indicated to come out of the melancholic experience. Sukh comes when one remembers God (813-9); this clearly indicates how important it is to remember God if one wants to be happy. This feeling of being content and happy is critical to good functioning as an individual. Those who do not take his name, suffer in agony even after death (36-8) indicating that there is
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Table 1 Metaphors for dukh and sukh in Guru Granth Sahib. Dukh (sadness)
Sukh (happiness)
Agani (fire) (21-15)
Anad (190-10) or Annand or Anado or Annant (joy) Binod (joy) (547-2) Dheera or dheeraj (patience) (206-2)
Andesa (anxiety) Andh-gubbara (pitch darkness) (116-10) or Andh-andhara (125-7) Antar-maeill (inner filth) (22-10) Baavra (madman) (235-10) Bairaag (renunciation) (247-7) Baurani (insanity; 424-6) Bhau-jal (terrifying world-ocean) (22-6) Birha (1379) or Birtha (separation) (p.860) Chint (anxiety; 191-10) or Chind (anxiety; 299-18) Chint-rog (disease of anxiety) (188-13) Duhel (conflict, disturbance) (379-1) Dukh (sadness) (21-12) Jhoor (grieve, sulk, lament) (263-12) Kal-saagar (ocean of pain; 324-11) Klesh (anguish) Maeill (pollution or filth) (p. 18) Peerh (pain) (861-19) Rog (disease) (195-15) Sansaa (anxiety) (p. 1218) Sar saagar (world ocean) (p. 17) Sog (grief) (63-1) Sootak (pollution) (229-12) Udaas (sad) (71-8) Unmaad (madness) (867-4) Vaaeinn (cries of distress) (136-18) Vad-taap (deadly fever) (199-12)
Kalyan (welfare, happiness, blessedness) Khem (well being) (295-6) Kusal (well, happy, healthy) (256-2) Mangal (well, happy) (191-1) Nidhana (treatment) (186-1) Nihaal (rapture; 200-5) Paramanand (supreme bliss; 194-15) Ras (joy) (680-11) Saanti (peace) (516-2) Seetal (content) (191-12) Suhaila or suhel (soothing) (379-1) Sukh (contentment) (191-1) Thand (peace) Ulaas (rapture) (677-13)
Table 2 Characteristics of two types of individuals as per the Guru Granth Sahib. Gurmukh Carefree (nichand) (29-13). Have shed their egos (29-11). Sleep and wake in peace (p. 646). Enlightened, blessed and undefeatable and a virtuous being, who practices truth, self-discipline (sanyyam) and good deeds (26-15), and has radiant faces (mukh ujley-590-13). Never suffer bodily pain (125-3) and are always happy (131-10) to the point of never suffering in dukh (424-15; p. 1032). Manmukh Self willed (29-11). Egoistic (haumai) (29-16). Filled with wickedness (vikar) and desire (trishna) (29-7) and anger. Ignorant (agyan), evil-minded (durmat) and egotistical (ahankaari) (314-14). Filled with anxiety and cannot sleep (p. 646). Usually gamble (juuaa). Suffer in dukh (sadness) (131-10) because of their love of duality (128-1). They are born in dukh and die in dukh (p. 947).
happiness in the ritual itself. Those who sing his praises stay in ecstasy forever (sadaa anand) (36-12). Love for Lord is thus considered the prime achievement and ambition, and any other type of love has been referred to as the love of duality which leads to conflict (p. 111) and thence to dukh, distraction, distress and death (113-9); this is a characteristic of individuals who are described as self-willed manmukhs (113-18) as opposed to those who are described as gurmukhs (Table 2). Karma has been etiologically related to dukh; bad karmic deeds making one sit and weep (15-11). Those with good karma on the other hand, never get affected by dukh (pain), rogue (disease), and bhau (fear) (184-3,4). By the good fortune of good deeds done in the past, one can perform actions to determine one’s future (75-13). Thus good deeds are critical as the rewards can move across births.
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The collective unconscious thus may play a role here in our understanding. Grief related to death of the loved one may make the survivor’s life a worthless one (83-15) and the loss of the husband may leave the widow in sadness and dissatisfaction (226-2) thereby confirming that loss itself can lead to grief and sadness which may be compared with modern notions of depression. Other causes which may contribute to grief and misery include harsh words (fika-bol) (15-14) indicating a sense of alienation and hurt, hypocrisy (pakhand) (28-17) related to falsehood and pretensions, loss of wealth (dhan) (p. 59-14). Interestingly drinking wine results in madness (baral) (554-14) as does slandering the saints (sant ki ninda). These actions can cause sadness, hopelessness (niraasa), pollution of the intellect, restlessness, misery and thereby lead to all sorts of diseases (rogue) (p. 279 and 280). The notion that environment also plays a role in human functioning and dysfunction is illustrated by the observation that sadness can be caused by kaam—excessive and unfulfilled sexual desire, krodha— anger and ahankaar—egotism (p. 51). These demons (pareit) (51313) and wounds of the soul (jeeah mei chot) (152-11) are prevalent in the environment thus indicating that individual responses to specific provocateurs can cause problems. 4. Therapeutic context The text describes five ways to achieve salvation: listening (suniyai) to the spiritual hymns (Bani), obeying (mannai) these hymns, reciting the name of the Lord (Naam), meditating and subjective experience of the name, and with the company of saints (Rahi, 1999). A lot of this is therefore cognitive reframing. Intuitive balance is described as the perfect state of mind where understanding, peace and tranquility are produced, and a true devotion to God is seen leading to the final state of happiness: Samadhi (p. 68) and a connection to the Lord. This state of intuitive balance cannot be produced in a manmukh since he is always engrossed in maya. In various verses, the spiritually inclined person (Giyani) is considered a balanced individual (351-9). Nonspiritual people have been symbolically compared to an empty husk (p. 192). Spiritually, people live either in total spiritual darkness (andhiyaara) (128-4) or in light (chaanun) (129-3) of spiritual energy where the light of the lord may illuminate the heart, dispelling all ignorance (368-13). God is ubiquitous (p. 1226), pervading through water, land and the sky (89–15) and being the mind (muhn), body (tunn) and the breath (prana) (94-9), existing in each human’s heart (130-1). He is not limited to either the temple (dehura) or the mosque (maseete) (875-3). In many pages of the text, Lord has been mostly referred to as a male, a husband (p. 112; p. 127), lover (saajan), companion (sangi-261-17; saathi-375-4), friend (meet-108-5; sakha-375-6), darling (pyara), beloved (preetam), mother and father (maat, peeta-268-2), child (soot-780-4), brother (bhraata) (407-6), and relative (bandhap780-4). The Lord is described as formless, shapeless and colorless (130-1; 578-7) supporting (tek) and anchoring (aadhaar) mankind (212-10). This nirakaat (formless) description is in contrast with saakar (formed) God. The lord acts as a puppeteer (khilavanhaar), who dresses the puppets (kath ki puothi) and plays them around (p. 206). The world has been called the garden being looked after the Lord, the gardener (maali) (118-7), who himself plants all the saplings (humans), irrigates them and in the end, devours them leading to their death (554-11). The mind (muhn) has been variously described as an inscription or message (parwaana) written on the body (kaya) which is a paper (kaagad) (662-10) or as the priest (maulana) in the body which is a mosque (mahjeed) (p. 1167). The mind has been compared to an intoxicated elephant, which can be bridled by the guru who has a controlling rod or can be a rod himself (159-7). A mind-body connection has been clearly
stated to exist in some verses in the text, as on p.55 – man juthaey tan juth hai jihva jooth hoe – if the mind is polluted, then the body is polluted as well, and the tongue is polluted too (55-19). This is clearly in agreement with other great traditions of medicine (such as Chinese or Ayurvedic medicine) which talk of a similar connection and do not distinguish between ‘mental’ and the ‘physical’ (Kirmayer and Young, 1998); while it contrasts with the Western biomedical (especially Cartesian) concept of mind-body dualism (Chaturvedi and Desai, 2007). 5. Therapy: the role of Lord and the Granth The text thus not only describes the causes of dukh but also plays an important role in helping people deal with dukh at an individual level. After cure from depression, i.e. when peace and tranquility come to the mind, the state has been referred to as Samadhi (p. 327), wherein the mind is restored to its original balanced state (sanaatan), and does not suffer from any illness. The Lord is described as the true healer and physician (vaeid) (p. 962) providing counseling (maslat) after conversation (gallaan) with the dukhi (592-5). Diagnosing dukh in the mind by the physician (vaeid) is crucial (p. 1279). The name of the Lord is similar to medicine (aukhad) (259-14; 675-6), which can cure dukh (sorrow) and darad (pain) in an instant (288-8) providing happiness that cannot be described in words (431-19) and making the mind, immaculate and impeccable (nirmal) (p. 1299) without malice and abnormal emotions. The taking of the name of the Lord in itself is cooling and soothing for the mind (seetal) (p. 1142). Suffering (santaap), sorrow (dukh) and anxiety (chinta) do not touch those who are regular with the name of the Lord (p. 44; p. 45; 189-17; p. 201), thus making the gurmukhs resistant to depression. The darshan (glimpse) of Lord also brings happiness (p. 460) which can last for a long time (26-11). It has been recommended that one should renounce all maya and meditate only on the name of God. When the Lord dwells in mind, there is peace (18-7). If you sing of the Lord, your pain shall be sent far away and peace shall come to your home (2-8; 11-4; 11-19; 20-19), and the diseases of the ego (haumaey) and doubt (bhrama) are cast out (47-18). This peace has been symbolized with gems, jewels and rubies in the mind (2-12) (muhn wich rattan, jawahar, manak, je ik gur ki sikh suni). In planning any therapeutic interventions it is critical that the clinicians are aware of how these religious beliefs affect attitudes and help-seeking. These are formed not only as a result of being born into the religion but also due to developmental factors and cultural values. McMullen (1989) studied 500 Sikhs from six villages in the Punjab focusing on beliefs, practices and attitudes of the religious communities. The normative beliefs and practice of religion are distinct from its operative aspects. While studying these individuals, McMullen (1989) noted that over one-third had no education and 40% of the sample consisted of students and housewives, though it is not clear whether these students were female. One-third of the respondents regarded Guru Granth Sahib as the source of religious authority and one-fifth saw tradition as the source. Attending the gurudwara (38%), prayers (36%) and meditation (87%) were three key components of religious activity. Over three-quarters of respondents attended the gurudwara for theological and religious reasons. The five symbols of Sikh identity were considered extremely important by a majority of respondents. Over one-third (37%) felt the presence of God all the time and 16% did not. McMullen (1989) concludes that there did not appear to be a great deal of variation in the normative and operative beliefs of Sikhs. The notion of religious values and spirituality is thus inherent in the community, and feelings of unhappiness, sadness and difficulties are dispelled using prescribed rituals and religious
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practices. It is critical that clinicians take into account spiritual values and religious practices of Sikh patients. Five Ks – kirpan (sword), kesh (long hair), kara (steel bangle), kach (breeches) and kangha (comb) are symbols of Sikh identity. Managing their values in the context of treatment and therapeutic engagement may be challenging in some clinical settings, but need to be taken on board. The strength of the family and religious values can be a positive advantage in forming therapeutic alliances. It should be possible to use the scriptures as part of the treatment. 6. Conclusion The Sikh religion constitutes social, cultural, political and territorial identities and the role of spiritual values in daily functioning is widely accepted and crucial. It is significant that an individual’s cultural values and their slant on religious and spiritual values is taken into account and formulated in any therapeutic management. Sikhism is a product of its culture and time, but the values are applicable even today and are important to
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individual patients and their families. Notions of sadness and unhappiness need to be understood and managed in such a context. Conflict of interest The authors have no conflict of interests to report. References Chaturvedi, S.K., Desai, G., 2007. Neurosis. In: Bhugra, D., Bhui, K. (Eds.), Textbook of Cultural Psychiatry. Cambridge University Press, New York, pp. 193–206. Cole, W.D., Sambhi, P.S., 1989. The Sikhs. Rupa, Bombay. Kirmayer, L.J., Young, A., 1998. Culture and somatization: clinical, epidemiological and ethnographic perspectives. Psychosomatic Medicine 60 (4), 420–430. McMullen, C.O., 1989. Religious Beliefs and Practices of the Sikhs in Rural Punjab. Manohar, New Delhi. Neki, J.S., 1973. Guru-chela relationship: the possibility of a therapeutic paradigm. American Journal of Orthopsychiatry 43 (5), 755–766. Rahi, H.S., 1999. Sri Guru Granth Sahib discovered: a reference book of quotations from the Adi Granth, First ed. Motilal Banarsidass Publishers, New Delhi.
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Sikhism, spirituality and psychiatry Gurvinder Kalra a, Kamaldeep S. Bhui b, Dinesh Bhugra c,* a
Department of Psychiatry, Lokmanya Tilak Medical College & Sion Hospital, Sion, Mumbai 400022, India Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK c Health Service & Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 April 2012 Received in revised form 10 August 2012 Accepted 13 August 2012
Sikhism has millions of followers in India and among the Indian diaspora. As a religion it is relatively young but carries with it unique perspectives which are often not well known. The holy book of Sikhism, Guru Granth Sahib, is not only the last Guru, but also remained a key text for this religion. Using descriptions of the religion and its followers we attempt to understand the context of spirituality within this religion and attempt to apply it to clinical settings. We explored various texts to understand the notions of spirituality and ethics and directions for living one’s life. We studied both the Gurumukhi version as well as the English translation of the Sikh holy text. In the context of history of the Sikhs, various descriptions related to mental well being were identified. In this paper we describe the history, development and the core values of the religion and we also review their role on psychiatric and mental health settings for managing Sikh patients. Guru Granth Sahib offers a very useful insight into what is understood by the term equivalent to depression and its phenomenology. The notions of dukh (loosely translated as pain, but can also mean sadness or suffering) and maya (illusion) and their role in daily living are also discussed. In this paper these descriptions are explored further and their importance explained. ß 2012 Elsevier B.V. All rights reserved.
Keywords: Depression Spirituality Sikhism Sikh Psychiatry
1. Introduction Sikhism originated in the Punjab province of India which remains the homeland of the religion, though the Sikh diaspora is very prominent in many countries, including the UK and Canada. The current geographical state of Punjab is smaller than it used to be centuries ago. Guru Nanak – first of the Sikh gurus – was born in 1469 in Talwandi (now Nankana Sahib), 55 miles west of Lahore. At that time, the indigenous population of the region was largely Hindu. His personal experiences inevitably led Guru Nanak to establish the Sikh religion. He had a mystical experience which led him to challenge the existing religious orthodoxies. After this experience, his first poetic experience is described as Mool Mantra, which encapsulates his concept of divinity. The term guru is applied to someone who dispels ignorance or darkness (gu) and who proclaims enlightenment (ru) (Cole and Sambhi, 1989). Following a series of journeys and events, he began to express his thinking, and individuals started to follow him and his teaching. Many of these teachings, writings and pronouncements from that time form the core of Sikhism. Guru Nanak then settled down with his family at the age of 50 and continued to develop the philosophy of Sikhism through creating a community.
* Corresponding author. Tel.: +44 20 7848 0500; fax: +44 20 7848 0333. E-mail address: [email protected] (D. Bhugra). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2012.08.011
A few days before his death, Guru Nanak chose a successor to carry on with his work by presenting him with a book of his own hymns (a pothi) and a woollen string (a seli) indicating renunciation of the world and devotion to God. The growth of the religion continued apace over the next three centuries with Guru Gobind Singh being the last guru. Born in 1666, he was a significant leader, a poet as well as a major warrior. He introduced rites how people were to be initiated into the religion. He also developed a code of discipline which prohibited certain diets and activities. Initiated men took the name of Singh (the lion) and members of the new community were called Khalsa (the Pure Ones). Guru Gobind Singh emphasized equality by inviting men and women from all castes to join the community. On his deathbed, he pronounced that Guru Granth Sahib becomes the last guru of Sikhs. We studied both the Gurumukhi and the English translation of this Sikh holy text and identified various descriptions related to mental well being. In this paper we describe the history, development and the core values of the religion briefly and we also review their role on psychiatric and mental health settings for managing Sikh patients. 2. Core concepts Guru Granth Sahib has contributions from all the gurus along with many others from Sufi tradition as well as other significant poets and scholars of the time. The scripture is subdivided
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according to musical settings; the names of the sections being those of Indian musical arrangements. Each section has a uniform organization with hymns of Guru Nanak appearing first, followed by the third, fourth, fifth and ninth gurus and then those of other Sufi ascetics. The scripture is unique, as it has contributions from Sufis, Hindus and Muslims as well. It also makes references to the great Indian epics Ramayana and Mahabharata. The language used is called Gurmukhi; the form is poetry and the aim is to provide a sense of essential unity with God to the listener or the reader. God is seen as supreme, but also as a friend and a lover and living is the key to a proper relationship with God. As Guru Gobind Singh, the last Sikh Guru, declared that after him there will be no Guru and the diktat of Granth Sahib shall be final, the Shri Guru Granth Sahib (Granth – book; Sahib – Supreme) thus is the final Guru of Sikhism. It is a voluminous religious text of 1430 pages, compiled and composed by the Sikh Gurus from 1469 to 1708 (Rahi, 1999). It consists of a collection of hymns which describe the qualities of God and the various reasons on why one should meditate on God’s name. The text was first compiled by the fifth Sikh guru, Guru Arjan Dev, from the hymns of the first five Sikh gurus. The holy book has been a source of emotional and psychological support, through the means of prayers in Sikhism. It is revered and worshipped by the Sikhs as their spiritual guide. Cole and Sambhi (1989) emphasize that Guru Granth Sahib is the visible focal point for Sikh devotions. It dominates the Sikh ritual and theology as well as has a significant role in daily living, ceremonies, festivals etc. Thus a notion of spirituality is at the core of functioning of Sikh individuals. Gurudwaras, their religious temples are at the centre of practice of religion, though Guru Granth Sahib will be present in most Sikh households. The functions of the gurudwara, apart from reading the scriptures, include providing a common kitchen, sharing food and offering shelter and support to those who need it. Sikh theology relies on a monotheistic approach. Ultimate reality is a unity with God, and as God is without qualities, truth becomes an inadequate description (Cole and Sambhi, 1989). The God is one, only one in this context which, according to Cole and Sambhi (1989), raises the question of whether it really is a monotheistic religion or monistic. These authors argue that Sikhism has no difficulty in coming to terms with scientific theories of evolution and that of an expanding universe. Within the religious writings there is an opposition to materialism. Interestingly, another key factor is the belief that God is residing at home, so every individual must do the duty at home. Man is not only the latest or highest product of an evolutionary process but is the result of God’s intention. The exact reasons of why God made man are not clear; man’s condition is of interest and not the reasons for birth. Like many philosophers and thinkers, ignorance on man’s part is the problem. Man is intelligent, is aware of the notions of right and wrong, but may still miss the chance to meet the Lord. The reasons for this vary from birth, environment, karma (the notions of cause and effect), maya (a materialistic view of the world) and self-dependence rather than an acknowledgement that God also has a role. This dependence upon God and obedience to his will (hukam) is at the heart of being liberated (Cole and Sambhi, 1989). This interaction between birth, environment, etc. is not dissimilar to the biopsychosocial models of understanding an individual. Cole and Sambhi (1989) argue that according to Sikhism the world exists in reality and is not to be rejected. Liberation is different from rebirth and is a release from the round of death with man uniting with God resulting from the soul reaching the stage of sack khand (the realm of truth, the ultimate stage in the development of the soul). Liberation is obtained by meeting the guru through naam simran (remembering the name). The name in this context is that of God, but can apply to anything. It has certain rituals attached
to it and the practice is that of transforming personality through practice. As noted above, the guru in this context must be an enlightened messenger of God and this approach has been used in psychotherapy in the Indian context (Neki, 1973). As writings of other authors were included in the scriptures, it is clear that the gurus saw that there are many paths to God and they themselves did not have exclusive access to the truth or there was not a single way of finding the salvation which is an intriguing show of open-ness. Rituals related to Sikhism are clearly described with emphasis on clean physical appearances and saying prayers regularly. Work, worship and charity form the core of Sikh ethics. Self-conceit is not to be encouraged, as it will lead to lust, anger, greed and materialism. Sikh charitable work is critical in supporting those who are vulnerable. Thus there is a clear direction away from an individualistic and ego-centric development and view. Spiritual aspects rely on the core notion of good deeds and concepts of heaven (suarg) (182-11) and hell (narak) (91-1). The emphasis on home responsibilities and duties are highlighted by the advice that one should not wish for a home in the heavens, and should not be afraid to live in hell (337-10) even though some yearn for paradise (bhisat) and others long for heaven (surgindoo) (885-11) thereby reflecting human nature. However, heaven cannot be attained without the karma of good actions (p. 952); thus there is a system of reward for good deed and a clear encouragement to do so. In the developmental context like Hindu beliefs there are four stages of life but unlike Hinduism where these stages are of celibacy, householder, societal obligations and giving up of worldly things the four stages in Sikhism are different (p. 113; p. 687). The first is that of creation of life, second is the sense of duality (dubidha), third is the three-phased maya, and the fourth stage, the highest is that of mukti where one attains a state of bliss and ultimate happiness. The process of creation, i.e. being in the intrauterine life has been described as a terrible hell (narak ghor) (706-7), wherein the fetus has to rest head downwards. Thus the relationship with the world starts in an upside down manner. The three-phase maya is said to affect almost every human being in the world (129-6; 297-3) and keep them in spiritual darkness (agyaan) (509-14). Maya is illusion but can also mean mirage especially when used to describe material things. Attachment to maya has been compared to a treacherous wilderness (maha-sankat) (220-2) and mirage (mrig-trisna) which is chased by individuals even though they know it is false (219-9); it has been compared to a witch (daainn) (868-3) and sweet wine (madu-meetha) which the intoxicated mind (muhn-matwala) continues to drink (350-7). One can break the bonds of the three-phase maya only by the guru’s shabad (words or teachings), after which one moves to the state of liberation (mukti) (127-12). This approach thus starts to make sense in the context of psychotherapy where the guru is able to teach the pupil to detach from maya and achieve mukti. Maya is also understood as having (undue) emotional attachment to anything apart from the Lord and described as having a pale color (sooha) while Lord’s love at the fourth level, a beautiful deep crimson color (laal) (221-3). With maya, the spiritual consciousness (soorat) is lost (p. 989); one is emancipated only after freeing oneself from maya. Pages 76–77 in the text specifically describe the process of birth, and the way in which emotional attachments develop between the child and the parents, through hugging and embracing the child. However, all this has been described as emotional and worldly attachments which is only transitional and mortal, leading one into grief. Attachment to the Lord on the other hand is immortal. The Lord himself has created maya and moh 1 The first number in parenthesis indicates page numbers from the Guru Granth Sahib while the second number indicates the line number on that page.
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(emotional attachment) (125-16). The enticing desire for maya leads people to become emotionally attached to their children, relatives, households and spouses (61-9). Only emotional attachment and love to god is considered pure and peaceful and full of contentment (p. 61). Key concepts in understanding the components of psyche are related to worldly attachment and also to the notions of mukti as described above. These are not only emotions but also experiences which form the core of one’s being. These words cannot be translated suitably as they mean much more than literal translation. 3. Dukh and sukh in Guru Granth Sahib Not surprisingly human beings live with emotions and undergo experiences—some of which are painful and others pleasurable. Some emotions and experiences may well be rather neutral. Like religious texts from other religions, notions of jealousy, pride, greed etc. are described in the text. Emotions of hatred/vengeance (vaeir), anger, and greed (lobh) have been looked down upon as bad (p. 108) for the living and for human experiences. The text also explicitly discusses sadness (dukh) and happiness (sukh) using many metaphors (Table 1). These terms and their descriptions highlight the intrinsic unhappiness in the world especially if one is detached from the God. The world whether it is at large or an individual one is unhappy (dukhiya) (413-2) and, overflowing with pain and suffering (767-6); where in only a few are happy (sukhiya) (413-2). This does not mean nihilistic interpretation but a realistic one where individuals perhaps expect too much and feel let down. The only way this unhappiness can be overcome is by devoting one to God. As both the experiences and emotions of dukh and sukh are created by the Lord (125-13; 787-12), he is the one who relieves it and is thus both Dukh-bhanjan (destroyer of dukh) (99-6) and Sukhsaagar (ocean of peace and happiness) (927-12). Happiness has been referred to as a jewel (ratan) which lies within the self, but we receive it only if the Lord wants us to get it (117-2). Thus this concept becomes incredibly important in our understanding of models of illness, pain and emotions that individuals carry with them. Throughout the text, Lord has been equated to peace and happiness and looking for him outside oneself leads to terrible pain (maha-dukh) (p. 124). This may refer to people searching for happiness outside themselves, whereas the emotions are internal. Thus, the external search can lead to sorrow. The text makes it clear that happiness is a state of mind and a choice we make. This cognitive reframing enables individuals to carry their emotions in the context of their functioning. The mind (muhn) is considered prone to get diseased with doubt (bharam), superstition (bhed) and duality (dooja) (416-7), all of which ultimately keep the person in dukh. Bharam is also a term used for delusions and overvalued ideas in clinical assessments but does not mean psychopathology in the spiritual context and does so as a philosophical argument and development. Interestingly it is noted that melancholy can affect anyone whether they are the rich or the poor and can affect them equally (182-1) indicating that unhappiness or depression in a broader context can have no specific targets but any one can be prone to it. The state of a person afflicted with melancholy has been symbolically referred to a tree with dried leaves and branches, which become green in an instant with the ambrosial name of the Lord (amrit naam) (191-8). Thus a ritual and cognitive approach is indicated to come out of the melancholic experience. Sukh comes when one remembers God (813-9); this clearly indicates how important it is to remember God if one wants to be happy. This feeling of being content and happy is critical to good functioning as an individual. Those who do not take his name, suffer in agony even after death (36-8) indicating that there is
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Table 1 Metaphors for dukh and sukh in Guru Granth Sahib. Dukh (sadness)
Sukh (happiness)
Agani (fire) (21-15)
Anad (190-10) or Annand or Anado or Annant (joy) Binod (joy) (547-2) Dheera or dheeraj (patience) (206-2)
Andesa (anxiety) Andh-gubbara (pitch darkness) (116-10) or Andh-andhara (125-7) Antar-maeill (inner filth) (22-10) Baavra (madman) (235-10) Bairaag (renunciation) (247-7) Baurani (insanity; 424-6) Bhau-jal (terrifying world-ocean) (22-6) Birha (1379) or Birtha (separation) (p.860) Chint (anxiety; 191-10) or Chind (anxiety; 299-18) Chint-rog (disease of anxiety) (188-13) Duhel (conflict, disturbance) (379-1) Dukh (sadness) (21-12) Jhoor (grieve, sulk, lament) (263-12) Kal-saagar (ocean of pain; 324-11) Klesh (anguish) Maeill (pollution or filth) (p. 18) Peerh (pain) (861-19) Rog (disease) (195-15) Sansaa (anxiety) (p. 1218) Sar saagar (world ocean) (p. 17) Sog (grief) (63-1) Sootak (pollution) (229-12) Udaas (sad) (71-8) Unmaad (madness) (867-4) Vaaeinn (cries of distress) (136-18) Vad-taap (deadly fever) (199-12)
Kalyan (welfare, happiness, blessedness) Khem (well being) (295-6) Kusal (well, happy, healthy) (256-2) Mangal (well, happy) (191-1) Nidhana (treatment) (186-1) Nihaal (rapture; 200-5) Paramanand (supreme bliss; 194-15) Ras (joy) (680-11) Saanti (peace) (516-2) Seetal (content) (191-12) Suhaila or suhel (soothing) (379-1) Sukh (contentment) (191-1) Thand (peace) Ulaas (rapture) (677-13)
Table 2 Characteristics of two types of individuals as per the Guru Granth Sahib. Gurmukh Carefree (nichand) (29-13). Have shed their egos (29-11). Sleep and wake in peace (p. 646). Enlightened, blessed and undefeatable and a virtuous being, who practices truth, self-discipline (sanyyam) and good deeds (26-15), and has radiant faces (mukh ujley-590-13). Never suffer bodily pain (125-3) and are always happy (131-10) to the point of never suffering in dukh (424-15; p. 1032). Manmukh Self willed (29-11). Egoistic (haumai) (29-16). Filled with wickedness (vikar) and desire (trishna) (29-7) and anger. Ignorant (agyan), evil-minded (durmat) and egotistical (ahankaari) (314-14). Filled with anxiety and cannot sleep (p. 646). Usually gamble (juuaa). Suffer in dukh (sadness) (131-10) because of their love of duality (128-1). They are born in dukh and die in dukh (p. 947).
happiness in the ritual itself. Those who sing his praises stay in ecstasy forever (sadaa anand) (36-12). Love for Lord is thus considered the prime achievement and ambition, and any other type of love has been referred to as the love of duality which leads to conflict (p. 111) and thence to dukh, distraction, distress and death (113-9); this is a characteristic of individuals who are described as self-willed manmukhs (113-18) as opposed to those who are described as gurmukhs (Table 2). Karma has been etiologically related to dukh; bad karmic deeds making one sit and weep (15-11). Those with good karma on the other hand, never get affected by dukh (pain), rogue (disease), and bhau (fear) (184-3,4). By the good fortune of good deeds done in the past, one can perform actions to determine one’s future (75-13). Thus good deeds are critical as the rewards can move across births.
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The collective unconscious thus may play a role here in our understanding. Grief related to death of the loved one may make the survivor’s life a worthless one (83-15) and the loss of the husband may leave the widow in sadness and dissatisfaction (226-2) thereby confirming that loss itself can lead to grief and sadness which may be compared with modern notions of depression. Other causes which may contribute to grief and misery include harsh words (fika-bol) (15-14) indicating a sense of alienation and hurt, hypocrisy (pakhand) (28-17) related to falsehood and pretensions, loss of wealth (dhan) (p. 59-14). Interestingly drinking wine results in madness (baral) (554-14) as does slandering the saints (sant ki ninda). These actions can cause sadness, hopelessness (niraasa), pollution of the intellect, restlessness, misery and thereby lead to all sorts of diseases (rogue) (p. 279 and 280). The notion that environment also plays a role in human functioning and dysfunction is illustrated by the observation that sadness can be caused by kaam—excessive and unfulfilled sexual desire, krodha— anger and ahankaar—egotism (p. 51). These demons (pareit) (51313) and wounds of the soul (jeeah mei chot) (152-11) are prevalent in the environment thus indicating that individual responses to specific provocateurs can cause problems. 4. Therapeutic context The text describes five ways to achieve salvation: listening (suniyai) to the spiritual hymns (Bani), obeying (mannai) these hymns, reciting the name of the Lord (Naam), meditating and subjective experience of the name, and with the company of saints (Rahi, 1999). A lot of this is therefore cognitive reframing. Intuitive balance is described as the perfect state of mind where understanding, peace and tranquility are produced, and a true devotion to God is seen leading to the final state of happiness: Samadhi (p. 68) and a connection to the Lord. This state of intuitive balance cannot be produced in a manmukh since he is always engrossed in maya. In various verses, the spiritually inclined person (Giyani) is considered a balanced individual (351-9). Nonspiritual people have been symbolically compared to an empty husk (p. 192). Spiritually, people live either in total spiritual darkness (andhiyaara) (128-4) or in light (chaanun) (129-3) of spiritual energy where the light of the lord may illuminate the heart, dispelling all ignorance (368-13). God is ubiquitous (p. 1226), pervading through water, land and the sky (89–15) and being the mind (muhn), body (tunn) and the breath (prana) (94-9), existing in each human’s heart (130-1). He is not limited to either the temple (dehura) or the mosque (maseete) (875-3). In many pages of the text, Lord has been mostly referred to as a male, a husband (p. 112; p. 127), lover (saajan), companion (sangi-261-17; saathi-375-4), friend (meet-108-5; sakha-375-6), darling (pyara), beloved (preetam), mother and father (maat, peeta-268-2), child (soot-780-4), brother (bhraata) (407-6), and relative (bandhap780-4). The Lord is described as formless, shapeless and colorless (130-1; 578-7) supporting (tek) and anchoring (aadhaar) mankind (212-10). This nirakaat (formless) description is in contrast with saakar (formed) God. The lord acts as a puppeteer (khilavanhaar), who dresses the puppets (kath ki puothi) and plays them around (p. 206). The world has been called the garden being looked after the Lord, the gardener (maali) (118-7), who himself plants all the saplings (humans), irrigates them and in the end, devours them leading to their death (554-11). The mind (muhn) has been variously described as an inscription or message (parwaana) written on the body (kaya) which is a paper (kaagad) (662-10) or as the priest (maulana) in the body which is a mosque (mahjeed) (p. 1167). The mind has been compared to an intoxicated elephant, which can be bridled by the guru who has a controlling rod or can be a rod himself (159-7). A mind-body connection has been clearly
stated to exist in some verses in the text, as on p.55 – man juthaey tan juth hai jihva jooth hoe – if the mind is polluted, then the body is polluted as well, and the tongue is polluted too (55-19). This is clearly in agreement with other great traditions of medicine (such as Chinese or Ayurvedic medicine) which talk of a similar connection and do not distinguish between ‘mental’ and the ‘physical’ (Kirmayer and Young, 1998); while it contrasts with the Western biomedical (especially Cartesian) concept of mind-body dualism (Chaturvedi and Desai, 2007). 5. Therapy: the role of Lord and the Granth The text thus not only describes the causes of dukh but also plays an important role in helping people deal with dukh at an individual level. After cure from depression, i.e. when peace and tranquility come to the mind, the state has been referred to as Samadhi (p. 327), wherein the mind is restored to its original balanced state (sanaatan), and does not suffer from any illness. The Lord is described as the true healer and physician (vaeid) (p. 962) providing counseling (maslat) after conversation (gallaan) with the dukhi (592-5). Diagnosing dukh in the mind by the physician (vaeid) is crucial (p. 1279). The name of the Lord is similar to medicine (aukhad) (259-14; 675-6), which can cure dukh (sorrow) and darad (pain) in an instant (288-8) providing happiness that cannot be described in words (431-19) and making the mind, immaculate and impeccable (nirmal) (p. 1299) without malice and abnormal emotions. The taking of the name of the Lord in itself is cooling and soothing for the mind (seetal) (p. 1142). Suffering (santaap), sorrow (dukh) and anxiety (chinta) do not touch those who are regular with the name of the Lord (p. 44; p. 45; 189-17; p. 201), thus making the gurmukhs resistant to depression. The darshan (glimpse) of Lord also brings happiness (p. 460) which can last for a long time (26-11). It has been recommended that one should renounce all maya and meditate only on the name of God. When the Lord dwells in mind, there is peace (18-7). If you sing of the Lord, your pain shall be sent far away and peace shall come to your home (2-8; 11-4; 11-19; 20-19), and the diseases of the ego (haumaey) and doubt (bhrama) are cast out (47-18). This peace has been symbolized with gems, jewels and rubies in the mind (2-12) (muhn wich rattan, jawahar, manak, je ik gur ki sikh suni). In planning any therapeutic interventions it is critical that the clinicians are aware of how these religious beliefs affect attitudes and help-seeking. These are formed not only as a result of being born into the religion but also due to developmental factors and cultural values. McMullen (1989) studied 500 Sikhs from six villages in the Punjab focusing on beliefs, practices and attitudes of the religious communities. The normative beliefs and practice of religion are distinct from its operative aspects. While studying these individuals, McMullen (1989) noted that over one-third had no education and 40% of the sample consisted of students and housewives, though it is not clear whether these students were female. One-third of the respondents regarded Guru Granth Sahib as the source of religious authority and one-fifth saw tradition as the source. Attending the gurudwara (38%), prayers (36%) and meditation (87%) were three key components of religious activity. Over three-quarters of respondents attended the gurudwara for theological and religious reasons. The five symbols of Sikh identity were considered extremely important by a majority of respondents. Over one-third (37%) felt the presence of God all the time and 16% did not. McMullen (1989) concludes that there did not appear to be a great deal of variation in the normative and operative beliefs of Sikhs. The notion of religious values and spirituality is thus inherent in the community, and feelings of unhappiness, sadness and difficulties are dispelled using prescribed rituals and religious
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practices. It is critical that clinicians take into account spiritual values and religious practices of Sikh patients. Five Ks – kirpan (sword), kesh (long hair), kara (steel bangle), kach (breeches) and kangha (comb) are symbols of Sikh identity. Managing their values in the context of treatment and therapeutic engagement may be challenging in some clinical settings, but need to be taken on board. The strength of the family and religious values can be a positive advantage in forming therapeutic alliances. It should be possible to use the scriptures as part of the treatment. 6. Conclusion The Sikh religion constitutes social, cultural, political and territorial identities and the role of spiritual values in daily functioning is widely accepted and crucial. It is significant that an individual’s cultural values and their slant on religious and spiritual values is taken into account and formulated in any therapeutic management. Sikhism is a product of its culture and time, but the values are applicable even today and are important to
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individual patients and their families. Notions of sadness and unhappiness need to be understood and managed in such a context. Conflict of interest The authors have no conflict of interests to report. References Chaturvedi, S.K., Desai, G., 2007. Neurosis. In: Bhugra, D., Bhui, K. (Eds.), Textbook of Cultural Psychiatry. Cambridge University Press, New York, pp. 193–206. Cole, W.D., Sambhi, P.S., 1989. The Sikhs. Rupa, Bombay. Kirmayer, L.J., Young, A., 1998. Culture and somatization: clinical, epidemiological and ethnographic perspectives. Psychosomatic Medicine 60 (4), 420–430. McMullen, C.O., 1989. Religious Beliefs and Practices of the Sikhs in Rural Punjab. Manohar, New Delhi. Neki, J.S., 1973. Guru-chela relationship: the possibility of a therapeutic paradigm. American Journal of Orthopsychiatry 43 (5), 755–766. Rahi, H.S., 1999. Sri Guru Granth Sahib discovered: a reference book of quotations from the Adi Granth, First ed. Motilal Banarsidass Publishers, New Delhi.