Sama · Atlas

1. Introduction

Version followed: samāʿ as set out by al-Ghazālī in Book 18 of the Iḥyāʾ ʿulūm al-dīn (Kitāb ādāb al-samāʿ wa-l-wajd, the Book on the Etiquette of Listening and Ecstasy; English translation by Anthony Johns, Fons Vitae / Islamic Texts Society) as described by Lewisohn (1997) and Weinrich (2019), with present-day South Asian mahfil-e-samāʿ (qawwali gatherings) noted where sources describe them. The Mevlevi whirling ceremony (sema) and Chishti qawwali have their own guides (247 and 248) and are only cross-referred here.

What it is. Samāʿ (Arabic, "listening" or "audition") is a Sufi rite of listening to sung mystical poetry, with or without instruments, and in some orders with movement or dance. Its aim, as Sufi authors describe it, is to hear with the "ear of the heart" and so deepen awareness of God. [source: Lewisohn 1997] It is a ritual of a living tradition. It is not a therapy, and this guide does not teach it. A shaykh or order leads it, and Sufi manuals governed its conduct. [source: Lewisohn 1997]

How the tradition understands its effect. Al-Ghazālī holds that listening reveals the heart rather than putting something new into it. He quotes Abū Sulaymān al-Dārānī that it "stirs up what is in it". [source: Weinrich 2019, translating al-Ghazālī] The listener moves from fahm (understanding what is heard as it applies to the soul's relation with God), to wajd (ecstasy, literally "finding", linked to wujūd, "being"), to ādāb (right inward and outward conduct in response). [source: Weinrich 2019; Lewisohn 1997] Al-Ghazālī puts understanding before ecstasy and rejects "irrational" ecstasy. He praises stillness and self-control, and he permits movement only when ecstasy overtakes the listener involuntarily. [source: Lewisohn 1997]

Where the psychotherapist comes in. Samāʿ is an observance. The clinician's work runs alongside it: understanding what it means in the client's life; cultural assessment with the DSM-5-TR Cultural Formulation Interview (CFI) and its spirituality module; accommodation; health issues routed to the doctor; scrupulosity about whether music is permitted; grief and community; and collaboration with the client's shaykh, imam or chaplain if the client wishes. Because samāʿ can produce intense ecstatic and trance-like states, this guide puts weight on telling normative religious ecstasy apart from dissociative disorder, psychosis and mania. The aim is to avoid pathologising the first while not missing the others. [synthesis]

Contested status. Muslim scholars have long disagreed about samāʿ. Sufi advocates held it permissible or even obligatory. Opponents such as Ibn al-Jawzī and Ibn Taymiyya condemned it. Moderates accepted religious song and rejected profane song. Some orders, notably Indian branches of the Naqshbandiyya, rejected samāʿ. [source: Lewisohn 1997] The clinician does not take a side in this debate. Clients and families may.

2. Framework

2a. The rite as its sources describe it (context for the clinician, not instructions)

Conditions. Junayd's rule required proper time, place and companions (zamān, makān, ikhwān). For al-Ghazālī, time is a spiritual state, not a clock hour: avoid samāʿ when the heart is preoccupied, during prayer or meals, or when distracted. Place is a lodge (zāwiya, khānqāh) or mosque, made sacred mainly by the hearts present. Companions exclude the proud, the showy and those seeking entertainment. [source: Lewisohn 1997]
Who may attend. Al-Ghazālī held that beginners should not attend and should do dhikr and service instead. Abū Saʿīd ibn Abī l-Khayr disagreed, and the more liberal view later prevailed in practice. Attendance was often restricted to initiates, and masters decided who could take part. [source: Lewisohn 1997]
Stages in the listener (al-Ghazālī, Book 18 part II): understanding, then ecstasy, then conduct. He describes four levels of listening, from enjoying melody alone up to the listener "annihilated" beyond states. He distinguishes ecstasy that arrives unbidden from tawājud, ecstasy approached deliberately. Tawājud is praiseworthy with a sincere intention and blameworthy when feigned for show. [source: Weinrich 2019]
Etiquette. Full presence of heart, no looking around, no hand-clapping or feigned ecstasy, stillness restored after involuntary movement. Suhrawardī compared restraint in ecstasy to suppressing a sneeze. [source: Lewisohn 1997]
South Asia today. In the Chishtī order, samāʿ is closely tied to qawwali. The Firdausī order of Bihar Sharif is described as more "contemplative and subdued". [source: Tasnim 2025] Gatherings at shrines and on death anniversaries (ʿurs) are widely reported. [uncertain: not verified]
Restricted content. Order-specific practices, permissions and the inner instruction a shaykh gives a disciple are not public, and this guide does not describe them. [synthesis]

2b. The therapist's work alongside it

No source sets session counts or durations for this work. The phases below are the clinician's own structure. [synthesis]

Engagement and cultural assessment (the early meetings in which samāʿ comes up). Goal: understand samāʿ in the client's own words and community. Tools: an opening enquiry, the core CFI, and CFI Module 5 (Spirituality, Religion and Moral Traditions). Move on when you can state, in the client's terms, what samāʿ is for them, who leads it, and whether it is a resource, a source of stress, or both.
Clarifying the presenting concern. Goal: decide whether the concern involves samāʿ at all (often it does not). Where ecstatic or trance states are part of the picture, map them and run the differential (4.4 to 4.7). Move on when you have a working view: a normative experience, a religious or spiritual problem, a disorder needing treatment, or more than one of these.
Working alongside the observance. Goal: treat the presenting problem while respecting the practice. This covers accommodation, health coordination, scrupulosity work, values and family conflict, grief and community, and collaboration with religious leaders. Move on when the plan is agreed and any collaborators the client chose are in place.
Review. Revisit meaning, the differential (states can change), and the client's satisfaction with how faith is held in therapy. Use CFI question 16 on the clinician-patient relationship.

3. Guiding principles

Attribute, do not adjudicate. Describe wajd, ḥāl (spiritual state), nafs (the lower self) and the presence of God as the client and tradition hold them. In practice: say "in your tradition" or "as your shaykh teaches", and never affirm or deny the metaphysics. [synthesis; source: CFI instructions to use the person's own terms]
Normative first. Ecstasy, weeping and involuntary movement inside a sanctioned samāʿ are expected forms of the rite, not symptoms. ICD-11 and DSM-5 exclude trance or possession that is part of an accepted collective cultural or religious practice. In practice: only consider a disorder when an experience is unwanted, distressing or impairing, or spills outside the ritual context. [source: Pietkiewicz et al. 2022]
But do not miss illness. Psychosis, mania and dissociative disorders can take religious form, and communities may read illness as spiritual. In practice: assess carefully even when the content is religious. [source: Pietkiewicz et al. 2022; SCRC lesson 5.1]
The tradition has its own norms of healthy and unhealthy ecstasy. Al-Ghazālī distinguishes sincere from feigned ecstasy and praises self-control and the return to stillness. In practice: ask how the client's own community judges a given state. That judgment is data for the differential. [source: Lewisohn 1997; Weinrich 2019]
Use the client's words. The CFI asks the clinician to use the person's own terms for the problem and the tradition. In practice: say "samāʿ", "ḥāl" and "wajd" if the client does, and ask what they mean. [source: CFI; CFI Module 5]
Muslim opinion is plural. Muslims hold views on music ranging from obligatory to forbidden. In practice: do not assume a Muslim client values samāʿ, or that a Sufi client attends it. [source: Lewisohn 1997]
Stay in role. The therapist is not a shaykh, spiritual director or muftī. In practice: questions of permissibility, spiritual progress or practice go to the client's religious authority. [synthesis; Vieten et al. 2016 report broad clinician support for religious and spiritual competencies]
Respect restriction. Do not ask for, record or reproduce order secrets or the inner instruction given by a shaykh. Do not encourage the client to bypass their teacher. In practice: ask what the client wants to share, not what the order teaches privately. [synthesis]
Consent governs collaboration. Contact clergy or a shaykh only with explicit, specific consent. [synthesis]
Know your own position. Your own religious or secular commitments, including views on music in Islam, can shape interpretation. In practice: reflect on this before assessing, and use consultation. [synthesis; source: Pietkiewicz et al. 2022 on how clinicians' beliefs shape diagnosis]
Safety outranks interpretation. Whatever the frame, imminent risk to self or others is assessed and acted on under current standards. [source: SCRC lesson 5.1]

4. Intervention inventory

All interventions are the psychotherapist's work alongside the observance. None of them teaches or leads samāʿ. Example language is illustrative throughout.

4.1 Opening enquiry into what samāʿ means to the client

Purpose / when: When a client mentions samāʿ, qawwali, a Sufi gathering, a shaykh, or an experience during listening. It sets a respectful frame before any assessment. [synthesis]
Steps: (1) Ask permission to talk about it. (2) Ask what samāʿ is in their own words, how often and where they attend, and with whom. (3) Ask what it gives them (closeness to God, community, joy, grief, release) and what, if anything, troubles them about it. (4) Ask whether they belong to an order and have a shaykh, without asking for anything private. (5) Reflect back in their vocabulary and check accuracy.
Example language (illustrative): "You mentioned the gathering on Thursday nights. Would it be all right if I asked about it? I'd like to understand what samāʿ means for you, in your words, rather than assume." / "You don't need to tell me anything your order keeps private. I'm interested in what it's like for you."
Watch for: Guardedness, which may reflect experiences of being judged by clinicians or by Muslims who oppose music; go slowly. Signs it is working: the client corrects your wording, offers terms such as ḥāl or wajd unprompted, and links the practice to the presenting concern (or makes clear it is unrelated).

4.2 Core Cultural Formulation Interview with samāʿ in view

Purpose / when: At intake or whenever culture or religion bears on the problem. The core CFI is 16 questions in four domains (cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help-seeking; cultural factors affecting current help-seeking) plus a question on the clinician-patient relationship. [source: APA DSM-5-TR CFI]
Steps: (1) Introduce it as a way to understand the client's own view, with no wrong answers. (2) Get the client's definition of the problem and keep using their wording. (3) Explore causes, including spiritual ones (for example the state of the heart or the nafs), and how family and community see it. (4) Ask about supports and stressors; the order and the gathering may be either. (5) Ask what they have already tried, including religious help such as a shaykh's guidance, prayer, dhikr or attending samāʿ, and what helped. (6) Ask what help they want now and what their family or community suggests. (7) Ask about concerns with you or the service. The APA permits clinicians to reproduce the CFI for use with their own patients but not to modify it. Use the published form rather than retyping it. [source: APA DSM-5-TR CFI]
Example language (illustrative): "Some people see what's happening to them partly as a matter of the heart or of faith. Is that true for you, and does anyone in your community see it differently?"
Watch for: Multiple explanations held at once (for example spiritual and medical); the CFI explicitly accepts this. It is working when the client's explanatory model is clear enough to plan treatment that fits it.

4.3 CFI Module 5: Spirituality, Religion and Moral Traditions

Purpose / when: When religion shapes the problem, the stresses or the coping. The module has 16 questions covering identity and affiliation, the tradition's role in daily and family life, home and community practices and their importance, whether the tradition and its leaders have helped, and tradition-related stress, conflict or discrimination. [source: CFI Supplementary Modules]
Steps: (1) Substitute the client's own names ("the Chishtī order", "our silsila", "Sufism", "Islam") wherever the module has a placeholder, and explore each tradition named. (2) Ask about involvement in samāʿ specifically as a community practice: frequency, importance, and who else in the family takes part or objects. (3) Ask whether the shaykh, community or teachings have helped with the problem. (4) Ask directly about conflict, such as family members who regard music as forbidden, or discrimination as a Sufi or as a Muslim. (5) Link to core CFI questions as the module directs. [source: CFI Supplementary Modules]
Example language (illustrative): "Does anyone in your family feel differently about samāʿ than you do? How has that been for you?"
Watch for: Intra-Muslim conflict over music (Section 1) can be a major stressor that a non-Muslim clinician may not expect. It is working when the formulation names both the resource and the strain.

4.4 Mapping an ecstatic or trance experience in the client's terms

Purpose / when: When the client reports wajd, ḥāl, weeping, involuntary movement, loss of self-awareness, visions or a sense of presence during samāʿ, or others have raised concern. This mapping is the basis for 4.5 to 4.7. [synthesis]
Steps: (1) Invite a full description: what was heard (which verse or poem), what was understood, what was felt, what the body did, and how it ended. Al-Ghazālī's sequence of understanding, ecstasy and conduct is a respectful frame here. [source: Weinrich 2019] (2) Establish context: did it happen only within samāʿ, dhikr or other worship, or also elsewhere (at work, alone, during sleep)? (3) Establish voluntariness and control: did they choose to enter it, could they return when the music stopped, and did they regain stillness afterwards? (4) Ask how the shaykh and companions understood it: as a sound ḥāl, as excess, or as feigned. (5) Ask about after-effects: hours versus days, sleep, mood, functioning, relationships. (6) Ask how the client feels about it: welcomed, frightened, ashamed, confused.
Example language (illustrative): "Take me through it from the moment the qawwal started that verse. What did you understand, what happened in your body, and how did you come back?" / "How did your shaykh and the others there make sense of what happened?"
Watch for: Framing that implies abnormality ("symptoms", "episodes") before the description is complete. It is working when you can say whether the experience was bounded by the ritual, voluntary or welcomed, recognised by the community, and followed by a return to ordinary functioning.

4.5 Differential: normative religious trance or ecstasy versus a dissociative disorder

Purpose / when: When a trance-like or possession-like state is reported and there is distress or impairment, or others call it illness or spirit affliction. [source: Pietkiewicz et al. 2022]
Steps: (1) Apply the cultural exclusion first. ICD-11 possession trance disorder and DSM-5 dissociative categories exclude states that are part of a broadly accepted collective cultural or religious practice. Ecstasy within a sanctioned samāʿ is normally excluded on this ground. (2) Look for the features that point to a disorder: the state is involuntary and unwanted; it occurs outside the ritual context or exceeds what the community regards as normal there; it causes significant distress or impairment; it recurs, or a single episode lasts days (ICD-11); and it is not better explained by substances, medication, a medical or neurological condition, sleep disturbance or another mental disorder. (3) Ask about amnesia, identity alteration and other dissociative symptoms outside samāʿ (DSM-5 places possession-form identity disruption within dissociative identity disorder, and "dissociative trance" within other specified dissociative disorder). (4) Screen for trauma history gently; al-Ghazālī's teaching that listening stirs up what is already in the heart gives a culturally congruent way to talk about old pain surfacing. [source: Pietkiewicz et al. 2022; Weinrich 2019] (5) Rule out medical causes with the client's doctor. (6) Formulate and share your view in the client's terms.
Example language (illustrative): "What happens in the gathering sounds like something your tradition knows and expects. What worries me a little is the times you described at home, when you lost track of hours and felt frightened. Can we look at those separately?"
Watch for: Pietkiewicz et al. note that ICD-11 draws only superficial boundaries between possession trance disorder and dissociative identity disorder, that a possession label can reinforce supernatural beliefs and discourage treatment, and that treating such states as dissociative parts may be iatrogenic. Use specialist dissociation consultation when unsure. It is working when the client feels the sacred experience was respected and the distressing one was taken seriously.

4.6 Differential: spiritual experience versus psychosis

Purpose / when: When ecstatic experiences include perceptual changes, a sense of revelation or mission, or beliefs others find strange, and the client or family is worried. [source: SCRC lesson 5.1]
Steps: (1) Learn the basic tenets of the tradition before judging beliefs or rituals; consult if needed. (2) Check Lukoff's (1985) indicators of a mystical experience with psychotic features rather than a psychotic disorder, as summarised by the Spiritual Competency Resource Center: the content resembles a recognised type of mystical experience (ecstatic mood, a sense of new knowledge, perceptual alterations, mythic themes such as union or rebirth); no conceptual disorganisation (thought blocking, incoherence); good functioning beforehand; acute onset within about three months; a stressful precipitant; a positive, exploratory attitude; and no significant risk of harm to self or others. (3) Add Greenberg and Witztum's guidance, as the same source summarises it: psychotic experiences tend to be very personal, exceed the community's normative religious experience, terrify rather than uplift, preoccupy the person, and come with a decline in self-care and social functioning. Genuine religious experiences can also frighten and preoccupy, so apply this with cultural judgment. (4) Ask the client's permission to hear how their shaykh or community reads the experience; that is direct evidence on whether it exceeds community norms. (5) If psychosis is likely, arrange prompt psychiatric assessment and explain it in terms that do not dismiss faith.
Example language (illustrative): "Your tradition has a long history of people being deeply moved in samāʿ, and I don't want to treat that as illness. I'm also hearing that you haven't slept or eaten properly for a week and the voice is telling you things that scare you. I'd like a doctor to see you as well. Getting care for that doesn't mean your faith is wrong."
Watch for: These indicators are hypotheses for clinical judgment, not validated tools. The source itself calls for research on their reliability. [source: SCRC lesson 5.1] Communities may attribute schizophrenia-spectrum symptoms to spiritual causes, which can delay care. [source: Pietkiewicz et al. 2022]

4.7 Differential: religious ecstasy versus mania or hypomania

Purpose / when: When joy, energy or a sense of divine closeness after samāʿ persists, grows, or comes with reduced need for sleep. No source addresses this for samāʿ specifically; this section is [synthesis] from general clinical practice.
Steps: (1) Compare the state with its usual course: ecstasy that settles after the gathering, as the tradition's own ideal of returning to stillness expects, versus elevation that keeps building for days. [source on the ideal: Lewisohn 1997] (2) Ask about decreased need for sleep (not merely staying up for an all-night gathering), pressured speech, racing thoughts, spending, risk-taking, irritability and grandiosity beyond the tradition's frame (for example believing oneself above the shaykh or the law). (3) Take a personal and family history of mood disorder. (4) Ask whether others in the order see this as unusual. (5) If mania is possible, arrange prompt medical review; questions about medicines go to the prescriber. (6) If the client has bipolar disorder, plan with them and their doctor about late-night gatherings and sleep.
Example language (illustrative): "After a gathering, how long does that sense of joy usually last? This time it sounds like it has kept going, and you've been sleeping two or three hours. Has that happened before?"
Watch for: Mislabelling the ordinary afterglow of a meaningful gathering, or missing mania because its content is religious. It is working when the client can recognise their own early signs and still values the practice.

4.8 Naming a religious or spiritual problem without labelling a disorder

Purpose / when: When the focus is a spiritual struggle or experience that is distressing but does not meet criteria for a disorder, such as confusion after an overwhelming ḥāl, loss of faith, doubt about the permissibility of samāʿ, or conflict with an order. DSM-5-TR lists "religious or spiritual problem" among other conditions that may be a focus of clinical attention, code Z65.8.
Steps: (1) After 4.4 to 4.7, tell the client that no disorder is present, if that is your view. (2) Name what is present in their language ("a hard ḥāl", "a crisis of faith"). (3) Agree goals: understanding the experience, integrating it into ordinary life, deciding what to take to the shaykh. (4) Use the code if documentation requires it.
Example language (illustrative): "From everything you've told me, I don't see an illness here. I see someone who went through something very powerful and is still working out what it means. We can work on that together, and some of it may belong with your shaykh."
Watch for: Relief, which is a good sign. Watch also for pressure from family or a referrer to call it either madness or a purely spiritual matter; keep reviewing as things change.

4.9 Integrating challenging experiences

Purpose / when: When an experience in samāʿ, welcome or not, leaves the client unsettled: lingering fear, unusual perceptions, a changed sense of self, or old grief stirred up. Research on Western Buddhist meditators (Lindahl et al. 2017, PLOS ONE) found 59 kinds of challenging experience across seven domains: cognitive, perceptual, affective, somatic, conative, sense of self and social. Effects lasted from days to more than a decade. Influencing factors involved the practitioner, the practice, relationships (including the teacher) and health behaviours. [source: Brown University 2017, reporting Lindahl et al. 2017] That study was not about samāʿ. Applying it here is [synthesis].
Steps: (1) Normalise: such experiences are reported across contemplative traditions and are not the client's fault; the Lindahl team found this recognition reduced isolation. [source: Brown University 2017] (2) Explore meaning in the client's frame, including what al-Ghazālī's idea that listening "stirs up what is in it" means to them. [source: Weinrich 2019] (3) Separate the experience from its after-effects and work on the after-effects (sleep, fear, intrusive memories) with standard methods. (4) If old trauma has surfaced, treat it with an evidence-based trauma approach, paced to the client. (5) Help the client decide what to take to their shaykh, who may have a traditional understanding of such states. (6) Wider evidence on meditation adverse effects (Farias et al. 2020, Acta Psychiatrica Scandinavica) and support resources such as Britton's Cheetah House are relevant. [uncertain: not verified]
Example language (illustrative): "Many people in many traditions have had something powerful happen in prayer or listening that took a while to settle. That doesn't mean something is wrong with you or your faith."
Watch for: Persistent impairment, new psychotic or manic features (return to 4.6, 4.7), and shame ("my heart must be impure"). Working: the experience becomes something the client can think about rather than be swept by.

4.10 Grounding and pacing around gatherings

Purpose / when: When a client finds that gatherings leave them flooded or disoriented, especially a client with trauma history or a recent episode of illness. All steps are [synthesis]; trauma-sensitive mindfulness (Treleaven 2018) is a related published adaptation. [uncertain: not verified]
Steps: (1) Agree that the client stays in charge of how much they take part. (2) Plan ordinary grounding before and after: orienting to the room, feeling the feet and seat, naming surroundings, a trusted companion, and the tradition's own resources the client chooses, such as the return to stillness that al-Ghazālī's etiquette prizes. [source on etiquette: Lewisohn 1997] (3) Discuss reducing "dose": attending part of a gathering, sitting near the edge, or taking a break. These choices sit within what the order permits, so the client checks them with the shaykh. (4) Plan the journey home and sleep afterwards. (5) Review after the next gathering. Do not give breathing, dhikr or fasting instructions; those belong to the client's teacher.
Example language (illustrative): "What helps you come back to the room after a strong ḥāl? Is there a way to do more of that, in a way your shaykh would be comfortable with?"
Watch for: The client feeling that you are trying to stop their practice. Present this as protecting their ability to take part. Working: fewer days of disruption after gatherings.

4.11 Health issues routed to the doctor

Purpose / when: Gatherings can run late or all night and may involve long sitting or vigorous movement in some orders. No clinical source specific to samāʿ appears in the sources consulted; this section is [synthesis].
Steps: (1) Ask about sleep loss after gatherings, physical exertion, and any fasting or vigils the client links to them; do not set targets or limits yourself. (2) For clients with bipolar disorder, epilepsy, heart conditions, pregnancy or other conditions the client or doctor has flagged, suggest the client discuss participation with their doctor. (3) With consent, share relevant observations with the doctor. (4) Questions about medicines go to the prescriber. (5) Samāʿ is not presented as a treatment for physical disease. Sufi authors call it "food of the spirit" and Ṭūsī describes it as restoring harmony of body and soul; these are religious claims, untested as medical treatment. [source: Lewisohn 1997]
Example language (illustrative): "Since the gatherings sometimes go until dawn, would it be worth talking with your doctor about how that fits with your sleep and your condition?"
Watch for: Unexplained fainting, falls, seizures or injury during movement need medical assessment, not a spiritual or psychological reading alone.

4.12 Accommodation in scheduling and treatment

Purpose / when: At the start of therapy and around major gatherings. [synthesis]
Steps: (1) Ask which nights or anniversaries matter (weekly gatherings, a saint's ʿurs) and avoid scheduling against them where possible. (2) Avoid scheduling demanding sessions such as trauma exposure the morning after an all-night gathering. (3) Allow the client to refer to God and to recite or quote poetry in session if they wish. (4) Build homework around their practice calendar.
Example language (illustrative): "Are there times in the month or year when your gatherings are especially important, so we can plan around them?"
Watch for: Accommodation that drifts into the therapist directing practice. Working: no missed sessions or practice because of clashes.

4.13 Scrupulosity about music and about "sincere" ecstasy

Purpose / when: When doubt about whether samāʿ is forbidden, whether one's ecstasy is sincere or feigned (tawājud), or whether one's heart is pure becomes repetitive, fear-driven and impairing. The IOCDF describes scrupulosity as OCD attaching to what matters most; it is ego-dystonic and fear-driven, while healthy practice is ego-syntonic and values-based. Compulsions may mimic religious acts and include repeated reassurance-seeking from scholars, repeated prayer or ablution, and harsh self-criticism. [source: IOCDF]
Steps: (1) Distinguish sincere religious deliberation about music (a long-standing scholarly debate) from OCD doubt (repetitive, distressing, unresolved by answers). (2) Assess with standard OCD assessment. (3) Use ERP, which the IOCDF calls the first-line, gold-standard treatment, with exposures that stay within Islamic law while still provoking doubt. In samāʿ, that might mean attending without checking afterwards whether one's response was sincere. (4) Response prevention: limiting reassurance-seeking from scholars, family and the shaykh, and reducing mental checking. (5) With consent, consult an Islamic scholar or the client's shaykh so that exposures are religiously acceptable; clinicians are encouraged to learn the relevant Islamic law. [source: IOCDF Islam and OCD] (6) Obtain informed consent for exposure, explain that anxiety will rise before it falls, and do not proceed with exposure during acute psychosis, mania or suicidal crisis. [synthesis]
Example language (illustrative): "Your scholars have discussed music for centuries, and that's a real question. What you're describing is different: asking the same question over and over and never feeling settled. That pattern is what we can work on, without asking you to give up anything your faith asks of you."
Watch for: The IOCDF notes that self-shaming can increase during ERP. Do not decide the permissibility question yourself. Working: less time spent checking and more freedom to choose whether to attend.

4.14 Values, family conflict and moral distress over samāʿ

Purpose / when: When a client is torn between an order that practises samāʿ and family, a spouse or a mosque community that rejects music, or feels guilt after attending or after leaving. [synthesis, drawing on the legitimacy debate in Lewisohn 1997]
Steps: (1) Map the positions without arguing them. (2) Clarify the client's own values and what each choice costs. (3) Rehearse conversations with family. (4) If guilt rests on a religious question, encourage the client to take it to a scholar they trust. (5) Where the distress amounts to moral injury (acting against one's deepest values), use approaches for moral injury alongside religious counsel the client chooses.
Example language (illustrative): "It sounds like both your father's view and your shaykh's matter to you. What would it look like to honour what you most care about here?"
Watch for: The client hoping you will rule on it. Working: choices the client owns.

4.15 Grief, ritual and community support

Purpose / when: When the client is bereaved, isolated, or has lost access to their gathering (moving away, illness, conflict). Gatherings on a saint's death anniversary and remembrance of the dead are part of many communities' practice. [uncertain: not verified]
Steps: (1) Ask whether samāʿ or the community helps with grief, and how. (2) Support returning to, or finding, a gathering if the client wishes. (3) Invite the client to bring poetry or recordings meaningful to them into grief work if they want to. (4) Watch for complicated grief and depression and treat them in the usual way.
Example language (illustrative): "Is there a poem or a qawwali that has been with you since your mother died? Would you like to tell me about it?"
Watch for: Loss of the community itself as a grief. Working: the client is reconnected with support.

4.16 Collaboration with the shaykh, imam or chaplain

Purpose / when: When the client wants their religious guide involved, or when a religious question (permissibility, the meaning of a state, whether to attend) is central. The IOCDF calls for collaboration between faith leaders and clinicians. [source: IOCDF] Further steps are [synthesis].
Steps: (1) Get specific written consent: who, what may be shared, and for what purpose. (2) Agree with the client what you will ask. (3) Contact the guide as a colleague in a different role: ask how the tradition reads the state or question, and share only what is agreed. (4) Report back to the client. (5) Keep roles clear: the shaykh guides the spiritual path, and you treat the clinical problem. (6) If the guide's advice conflicts with medical safety (for example advising against psychiatric care), discuss it with the client openly and without disparaging the guide.
Example language (illustrative), to a shaykh: "With [client]'s permission, I'm hoping to understand how your tradition views the kind of experience they had at the last gathering, so that my work with them fits with yours."
Watch for: Breaches of confidentiality, and a client who feels caught between authorities. Working: a consistent message to the client.

4.17 The teacher relationship and group dynamics

Purpose / when: When the client's relationship with a shaykh or order is central to the problem, or there are signs of control or exploitation. Sufi discipleship gives the master authority over who attends and how, and Lindahl et al. 2017, PLOS ONE, found that the relationship with a teacher could be a source of either support or distress. [source: Lewisohn 1997; Brown University 2017] Independent investigations of teacher misconduct in this setting: none found in the sources consulted. Steps are [synthesis].
Steps: (1) Ask neutrally how the relationship helps and whether anything about it troubles them. (2) Listen for signs of coercive control: isolation from family, control of money or relationships, punishment for questions, sexual approaches, threats about leaving. (3) If present, support the client's own decision-making, safety planning and, where relevant, reporting; follow safeguarding duties for any child or adult at risk. (4) If a client leaves an order, attend to grief, identity and religious trauma without assuming they have lost faith.
Example language (illustrative): "What's it like to have a shaykh? Is there anything about that relationship you'd want to talk about here?"
Watch for: Treating ordinary deference to a teacher as pathological. Discipleship involves trust and obedience by design; the question is whether it harms the client.

4.18 Therapist self-reflection and role boundaries

Purpose / when: Before and throughout the work. A survey of clinicians found that 73.0% to 94.1% supported training in each of 16 religious and spiritual competencies, but most reported little or no such training. [source: Vieten et al. 2016]
Steps: (1) Note your own views on religion, Islam, Sufism and music in Islam. (2) Do not lead, attend as a practitioner or advise on samāʿ in therapy. Attending as a guest at the client's invitation raises dual-relationship questions; discuss it in supervision first. (3) Limit self-disclosure about your own beliefs to what serves the client. (4) Seek consultation from colleagues with knowledge of Sufism or Muslim mental health. (5) Follow your profession's ethics code on competence, multiple relationships and respect for religion. [synthesis]
Example language (illustrative): "I'm not a scholar of your tradition, so I'll ask when I don't understand, and I'll leave the religious questions to you and the people you trust."
Watch for: Over-identification (romanticising Sufism) as much as dismissal.

5. Handling problems

The sources above give little direct guidance on problems in therapy with practitioners of samāʿ. Unless a source is tagged, the responses below are [synthesis].

The client fears being called mad. Many clients withhold ecstatic experiences from clinicians. Say early that intense experiences in worship are part of many traditions and that you will not treat them as illness by default. Show it by doing the mapping in 4.4 before any differential. Explain the cultural exclusion in diagnostic manuals (4.5) if that reassures them.
The family calls it madness, sin or spirit affliction. Use the CFI to set the family's model beside the client's. [source: CFI] Offer a family meeting if the client wants one. If psychosis or mania is present, explain that treatment and faith are compatible. If spirit affliction is the family's frame, refer to the ruqya guide (cross-reference XI 049) and do not take part in or endorse any procedure.
Persistent states outside the gathering. If trance-like or ecstatic states start occurring at work, while driving or alone, against the client's wishes, return to 4.5 to 4.7, arrange medical review, and plan safety (for example not driving after a gathering if states linger).
An acute crisis during or after a gathering. If someone does not return from a state, is at risk, or shows signs of psychosis, mania or a medical emergency, follow standard emergency procedures, including risk assessment under current standards. Afterwards, help the client and, with consent, the order understand what happened without shame. [source on risk assessment as a responsibility: SCRC lesson 5.1]
Overwhelm when old pain surfaces. When listening "stirs up what is in" the heart [source: Weinrich 2019], trauma memories may surface. Slow down, ground (4.10), and move to paced trauma treatment. Discuss with the client whether to attend less for a time, as their own choice and with their shaykh's advice.
Shame at not feeling anything. Al-Ghazālī contrasts the receptive heart with one "frozen and hard of heart". [source: Weinrich 2019] A depressed client may read emotional numbness in samāʿ as spiritual failure. Assess and treat depression. Note, without giving rulings, that the tradition itself values stillness and does not require outward ecstasy. [source: Lewisohn 1997] Leave the spiritual meaning to the client and their guide.
Fear that one's ecstasy is feigned. The tradition condemns tawājud done for show. [source: Weinrich 2019] Sincere self-examination is religious; repetitive, unresolvable checking may be scrupulosity (4.13).
The client asks you to rule on whether samāʿ is permitted. Decline kindly, explain your role, and help the client identify a scholar they trust. Do not share your own view on the debate. [principle: stay in role]
The client invites you to a gathering. Thank them, explore what the invitation means, and take it to supervision before deciding; attending as a guest can be a dual relationship. [synthesis]
Rupture: the client feels judged. Possible triggers include clinical words for sacred experiences, a referral to psychiatry, or questions about the shaykh. Name the rupture, apologise for any wording that felt dismissive, return to the client's terms, and use CFI question 16 to invite concerns. [source: CFI]
Stuck: competing explanations. When the client, family, shaykh and psychiatrist each read the situation differently, agree on shared practical goals (sleep, safety, functioning, being able to attend) rather than on one explanation.
Non-adherence to medical care. If the client stops treatment because a guide advised it or because they see it as weak faith, explore this openly, offer (with consent) to speak with the guide, and involve the prescriber; do not advise on medicines yourself.
Concern about a teacher or group. If you suspect exploitation or abuse, prioritise the client's safety and autonomy, follow safeguarding and reporting duties, and avoid labelling the order as a whole. Children attending gatherings fall under ordinary safeguarding duties if harm is suspected. (4.17)
The client leaves the order. Treat it as a possibly mixed loss: of community, music and a teacher. Do not assume relief or regret. Support religious identity in whatever form the client chooses.
The therapist feels out of depth. Seek consultation on Sufism and Muslim mental health, and specialist dissociation or early-psychosis consultation where relevant. [source on the training gap: Vieten et al. 2016]

Sources

Web sources:

Books and papers cited:

al-Ghazālī. On Proper Conduct when Listening to Music and the Experience of Ecstasy (Iḥyāʾ Book 18), trans. Anthony Johns. Fons Vitae / Islamic Texts Society.
Lindahl, J. R., Fisher, N., Cooper, D. J., Rosen, R. K., & Britton, W. B. (2017). The Varieties of Contemplative Experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLOS ONE. doi:10.1371/journal.pone.0176239
Lukoff, D. (1985). The diagnosis of mystical experiences with psychotic features. Journal of Transpersonal Psychology (as cited by the Spiritual Competency Resource Center).
Farias et al. 2020, Acta Psychiatrica Scandinavica, systematic review of meditation adverse effects [uncertain: not verified].
Treleaven, D. (2018). Trauma-sensitive mindfulness. [uncertain: not verified]
ICD-10-CM Z65.8, Other specified problems related to psychosocial circumstances (includes 'Religious or spiritual problem'), https://www.unboundmedicine.com/icd/view/ICD-10-CM/945432/all/Z65_8___Other_specified_problems_related_to_psychosocial_circumstances

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