‘Being a Good ’: Suffering and Distress through the voices of women in the

Photo by Shahina Ali

Husna Razee Thesis submitted in fulfillment of the requirements for the Degree of Doctor of Philosophy

School of Public Health and Community University of New South Wales Sydney

August 2006 i

Dedicated to my , my inspiration in life and to the women of , Guraidhoo, Vilifushi, Thinadhoo and Seenu for their resilience. Table of Contents

TABLE OF CONTENTS...... I

ACKNOWLEDGMENT...... VI

ABSTRACT...... IX

CHAPTER 1 ...... 1

INTRODUCTION...... 1

1.1 BACKGROUND...... 2

1.2 SIGNIFICANCE OF THE STUDY...... 3

1.3 AIM OF THE STUDY AND THE RESEARCH QUESTION...... 5

1.4 ORGANIZATION OF THE THESIS ...... 6

1.5 STANCE OF THE RESEARCHER ...... 8 1.5.1 My personal life...... 9 1.5.2 My own health ...... 10 1.5.3 Professional experiences...... 11

CHAPTER 2 ...... 13

IMPLICATIONS FOR MALDIVIAN WOMEN’S HEALTH...... 13

2.1 CONCEPTUAL ISSUES...... 13

2.2 MENTAL HEALTH AS A PUBLIC HEALTH PROBLEM...... 15

2.3 UNDERSTANDING MENTAL HEALTH ...... 16 2.3.1 Risk factors and protective factors ...... 17

2.4 DETERMINANTS OF MENTAL HEALTH...... 17 2.4.1 Biological determinants ...... 18 2.4.2 Psychological determinants...... 18 2.4.3 Social determinants ...... 18

2.5 MENTAL HEALTH PROMOTION AND THE NEW PUBLIC HEALTH ...... 20

2.6 AND MENTAL HEALTH ...... 22 2.6.1 Islamic principles ...... 23 2.6.2 The role of the individual within society ...... 25 2.6.3 Islam and the human psyche...... 25

2.7 WOMEN, GENDER AND MENTAL HEALTH...... 27 2.7.1 Social construction of gender...... 27 2.7.2 Gender differences in mental health: what is known from the literature ...... 29 2.7.3 Explanations for gender differences in mental health...... 32 2.7.4 Interpersonal violence and mental health of women...... 35

i 2.8 CULTURE AND MENTAL HEALTH ...... 36 2.8.1 Anthropology and mental distress ...... 36 2.8.2 Why is culture important in addressing mental health?...... 37 2.8.3 Cultural variations in the definitions of abnormality ...... 39 2.8.4 Cultural influences on recognition of mental health problems ...... 40 2.8.5 Cultural explanations for suffering and distress ...... 40

2.9 SUMMARY...... 43

2.9 CONCLUSIONS...... 44

CHAPTER 3 ...... 45

STUDY SETTING ...... 45

3.1 GEOGRAPHY AND POPULATION ...... 45 3.1.1 Population and demography ...... 46

3.2 HISTORICAL, SOCIAL & CULTURAL SETTING ...... 46 3.2.1 Anthropological origins ...... 47 3.2.2 Language...... 47 3.2.3 Religion ...... 48 3.2.4 Government ...... 49

3.3 FAMILY LIFE AND CHILD BEARING ...... 49 3.3.1 and divorce...... 50

3.4 CULTURAL NORMS, PERCEPTIONS AND BELIEFS ...... 53 3.4.1 Emotions and self control...... 53 3.4.2 Beliefs in the supernatural ...... 54

3.5 ECONOMY, EMPLOYMENT AND TRANSPORT ...... 55 3.5.1 Transport and communication ...... 56

3.6 SOCIAL SERVICES ...... 57 3.6.1 Education ...... 57 3.6.2 Health services ...... 58 3.6.3 Mental health...... 58

3.7 WOMEN AND GENDER PERSPECTIVE...... 60 3.7.1 Gender roles and responsibilities...... 60 3.7.2 Women’s Health ...... 62

3.8 SUMMARY...... 63

CHAPTER 4 ...... 64

DOING THE RESEARCH...... 64

4.1 PLANNING AND DESIGNING THE STUDY...... 64 4.1.1 Research approaches ...... 64 4.1.2 Feminist approach to scholarship ...... 65

ii 4.2 ETHNOGRAPHY AS A METHOD FOR DATA COLLECTION, ANALYSIS AND INTERPRETATION...... 67 4.2.1 Choosing a study site...... 68 4.2.2 Selecting participants...... 70

4.3 ENGAGING IN FIELD-WORK ...... 73 4.3.1 Getting in and gaining entrance...... 73 4.3.2 Participant observation...... 75 4.3.3 Gathering data through planned encounters...... 78 4.3.4 Group interviews ...... 81

4.4 IRONING OUT THE CREASES...... 82 4.4.1 Ethics and politics of research ...... 82 4.4.2 Ensuring the rigor of the research ...... 85

4.5 MAKING SENSE OF THE DATA ...... 87

4.6 SUMMARY AND CONCLUSION...... 88

CHAPTER 5 ...... 89

EXPLAINING DISTRESS...... 89

5.1 OVERVIEW OF PARTICIPANTS ...... 89

5.2 SOCIETY MAKES WOMEN VULNERABLE TO SUFFERING AND DISTRESS ...... 90 5.2.1 Relationships with Significant Others ...... 90 5.2.2 Marital problems...... 91 5.2.3 Being Abused...... 92

5.3 GENDER DIVISION OF LABOUR ...... 96

5.4 BURDENS OF LIFE...... 98 5.4.1 Financial hardships...... 98 5.4.2 Struggles of a rural life ...... 99 5.4.3 Problems of space and congestion ...... 100

5.5 TENSIONS OF BEING A GOOD WOMAN...... 101

5.6 BIOMEDICAL EXPLANATIONS OF DISTRESS...... 102 5.6.1 Genetics...... 103 5.6.2 Sexual problems ...... 103

5.7 PSYCHOLOGICAL PROBLEMS ...... 103 5.7.1 Bottling up feelings...... 104 5.7.2 Aspirations and expectations...... 104 5.7.3 Acculturation and conflicting ideologies...... 104

5.8 SUPERNATURAL EXPLANATIONS FOR SUFFERING AND DISTRESS...... 106 5.8.1 Fanditha ...... 106 5.8.2 Esfeena or evil eye...... 112 5.8.3 Sorcery and evil eye as a cultural explanation of suffering and distress ...... 113 5.8.4 Jinni moyavun or spirit possession...... 114

iii 5.8.5 Spirit possession as social control and regulating human behaviour ...... 117 5.8.6 Fated by Allah to suffer...... 121

5.9 REFLECTION AND SUMMARY...... 124

CHAPTER 6 ...... 126

EXPRESSING AND EXPERIENCING DISTRESS...... 126

6.1 PRESENTATION OF DISTRESS AND SYMPTOMATOLOGY...... 126 6.1.1 Vague aches and pains...... 126 6.1.2 Loss of control of emotions ...... 128 6.1.3 Psychologizing of distress ...... 129

6.2 EMBODIMENT AND CULTURE ...... 132 6.2.1 Embodiment as a way of conforming to social and moral values ...... 133 6.2.2 The body as a metaphor for distress...... 137

6.3 ETIOLOGICAL IDIOMS OF DISTRESS ...... 140 6.3.1 Fikuru boduvun or thinking too much – Mind Distress...... 140 6.3.2 Hiy dathivun or heart difficulty - Heart Distress...... 141 6.3.3 Gaiga rissun or aches and pains - Bodily Distress ...... 142 6.3.4 Moyavun or Going Crazy ...... 143 6.3.5 Birugathun or Fear ...... 144

6.4 SOMATIC METAPHORS...... 144

6.5 CULTURAL SOMATIZATION ...... 145

6.6 JINNI MOYAVUN OR SPIRIT POSSESSION...... 146 6.6.1 Cultural models of jinni moyavun ...... 147 6.6.2 The meaning of jinni moyavun ...... 149

6.7 STIGMA AND LABELLING...... 150 6.7.1 Harm to others ...... 153

6.8 REFLECTIONS AND SUMMARY...... 155

CHAPTER 7 ...... 157

DEALING WITH SUFFERING AND DISTRESS ...... 157

7.1 DEALING WITH SUFFERING AND DISTRESS...... 157 7.1.1 Self-Healing...... 158 7.1.2 Seeking professional help...... 166 7.1.3 Traditional healing as a way of dealing with distress...... 168

7.2 PATHWAYS TO HELP-SEEKING...... 170 7.2.1 Control ...... 172

7.3 REFLECTIONS AND SUMMARY...... 172

CHAPTER 8 ...... 174

WOMEN’S SUFFERING AND DISTRESS THROUGH A GENDER LENS ...... 174 iv 8.1 SILENCING THE SELF THEORY ...... 175

8.2 DESCRIPTION OF CASES ...... 176

8.3 DISCUSSION ...... 178 8.3.1 Being betrayed by significant others ...... 179 8.3.2 Gender ideologies and moral goodness ...... 181 8.3.3 Silencing the self...... 185 8.3.4 Gender and power dynamics...... 190

8.4 REFLECTIONS AND SUMMARY ...... 199

CHAPTER 9 ...... 200

REFLECTIONS AND IMPLICATIONS FOR THEORY, PEDAGOGY AND SERVICE PROVISION ...... 200

9.1 CULTURE AND ETIOLOGY ...... 201 9.1.1 Social organisations and mental well-being...... 202 9.1.2 Meaning systems for illness causation ...... 204 9.1.3 Culture and diagnosis of mental illness ...... 207

9.2 PATHWAY TO HELP-SEEKING AND DEALING WITH DISTRESS ...... 210

9.3 THE FOR SUFFERING AND DISTRESS – A MULTIDIMENSIONAL MODEL...... 212

9.4 APPLICATION OF FINDINGS FOR THE MALDIVES...... 214 9.4.1 Public policy that promotes mental health...... 214 9.4.2 Creating supportive environments ...... 215 9.4.3 Community development ...... 216 9.4.4 Developing personal skills ...... 216 9.4.5 Reorienting health services ...... 217 9.4.5 Empowerment of women ...... 219

9.5 REFLECTIONS ON METHOD AND RECOMMENDATIONS FOR FUTURE RESEARCH...... 219

9.6 CLOSING COMMENTS ...... 220

APPENDIX 1: MAP OF THE MALDIVES & STUDY SITES ...... 222

APPENDIX 2: CONSENT FORM ...... 223

APPENDIX 3: PARTICIPANTS BACKGROUND...... 226

APPENDIX 4: VOCABULARY OF AFFECTS & METAPHORS...... 229

APPENDIX 5: PHENOMENOLOGY OF MENTAL HEALTH...... 231

APPENDIX 6: PHENOMENOLOGY OF JINNI MOYAVUN ...... 232

APPENDIX 7: PARTICIPANTS’ DETAILS—JINNI MOYAVUN ...... 233

REFERENCES...... 234

v Acknowledgment This very exciting and challenging academic journey could not have been completed alone. Many people have contributed to this journey in a myriad of ways. To them I owe so much and I can never be eloquent enough to adequately express my gratitude. First and foremost I acknowledge my mother though she is no longer with me to share this wonderful achievement. To her I owe everything for the sacrifices she made to ensure we had a stable family and all attained a good education. She was utterly selfless, especially after my father passed away when I was only nine years old. May both of them rest in peace and may Allah bless them.

My participants are the very reason for the evolution of this thesis. They shared their time and their personal stories without inhibition. I only hope that I have adequately reflected their rich life experiences. I will never forget their invaluable contributions. My field-work was the most delightful part with numerous people contributing to my positive experiences. The former Minister of Health Mr Ahmed Abdullah and his staff, especially Zareer from MOH, encouraged me, guided me and provided me with accommodation and transport. In Alifushi, Kabulo and Ali, Hawwa, Fathun and Sampafulhu fed me, accommodated me, treated me as a part of their family and acted as my guides. They shared their time and enabled me to gain insight into island life. Shameem and his staff from Vilifushi Health Centre, Abdullah Saeed from Seenu Regional Hospital and Najeeb from Raa Regional hospital provided accommodation and facilitated my stay in these islands. Shaheen from FHS was there whenever I needed any follow-up information after my return to Australia and I could totally rely on her. I thank all of them from the bottom of my heart.

I am heavily indebted to my supervisor Associate Professor Jan Ritchie for her willingness to go beyond her supervisorial responsibilities. She was always prompt, consistent and constant in her support throughout my candidature. Her constructive critiques and stimulating discussions during our qualitative research seminars have given me a broader insight and appreciation for qualitative inquiry. I especially acknowledge her empathy and understanding when I was experiencing various health problems, and her staunch support during the last stage of my candidature when she was willing to spend even her weekends reading my drafts and providing me endless feedback.

Professor Maurice Eisenbruch who was my primary supervisor for the first three years of my candidature and subsequently continued to be part of my supervision team influenced my thinking and sharpened my sensitivity to the questions of culture and mental health. He believed in my research and taught me that even a single word can make a huge difference to the meaning it conveyed. I thank him for his invaluable contribution. Debbi Long who later joined my supervision team was instrumental in crystallising my thoughts and making sense of my data. I was hopelessly lost and nearly drowning in the enormous amounts of data I had. Her forthright insights into ethnography and her creative way of turning words into a diagram that tells a story saved me from being totally engulfed by my data. I thank her for her contribution.

vi My profound appreciation and gratitude also go to Ilse Blignault, Alison Rutherford, Peter Whetton and Abdullah Demirkol (Apo) who carefully read my draft thesis and suggested critical direction for improvement. Their voluntary and very constructive feedback helped me improve the quality of my work. I also acknowledge with sincere gratitude Chintaka’s help with the final proof reading and Abbas who patiently helped me to format the final document.

Doing a PhD is certainly a daunting venture especially in the absence of family and friends and in unfamiliar surroundings. But it is also a process in which one finds and forges new friendships. I certainly have been blessed with many newfound friends who have become part of my extended family and who have helped me deal with the various ups and downs of this academic journey. To them I owe a debt of gratitude. Leah Bloomfield, Sophie Dicorpo and Emeritus Professor Arie Rotem with their kindness and friendship smoothed my transition to a new place. Lilanthi and Jaqui were always game to join me for a break from studies and indulge in some cultural experiences. Chubby and his family, and Anthu and her family were always there when I felt homesick or when I wanted to eat some Maldivian food or speak in Dhivehi. I also found a ready made family in Keith, Doris, Abbas, Cihat, Sophie, Augustine and others who were concurrently pursing their PhD candidature. They became my sounding board, my intellectual stimulation and also my social network. To them I owe my mental and social well-being especially Keith and Doris who organized social programs. Bibi was a constant source of intellectual stimulation and a good friend. I am especially indebted to Apo, Effat, Van and Chintaka for always being there for me. My utmost appreciation to Apo for having shown me the ropes around student enrolment and the like as well as being a friend, confidante and being there for me whenever I needed to unburden myself, seek intellectual stimulation or be in need of cheering up. The many lunches I shared with Apo, Chintaka and Van were the best part of the day. Van’s delicious noodles kept me from starving on those days when I had no time to cook or was so tired of eating take away food. Effat with her enthusiasm and her courage against all odds was a special inspiration for me and I will always remember her kindness and her unfailing support, especially for helping me with formatting at the nth hour. She and her husband filled in for the family I did not have here.

A number of others in the School of Public Health and Community Medicine have contributed to making my life as a student here so much easier. Associate Professor Deborah Black and her assistant Deborah Debono needs a special mention for the support and encouragement they provided.

My family and friends from home deserve special thanks, especially Bill who has been a good part of my life for a number of years and has been always willing to proof-read my draft chapters and provide me with constructive feedback. He also very succinctly guided me from not becoming too immersed in jargon and helped me not to get too carried away with a cultural gaze at my work. I thank him profoundly for his help. My siblings, especially Dondatta and Kokko have loved me, cared for me and have supported me throughout my life and my candidature. I cannot thank them enough for always being there for me. My vii niece Lamya deserves special thanks for having come all the way to spend a few weeks with me in Australia while I recuperated from major surgery during the latter part of my candidature. Last but not least I acknowledge my friends Hamdun and Shahina who would call me and talk to me at those times when I was especially homesick and who were so supportive when I was going through a really bad emotional period in my life.

Just to ensure that I have not left anyone out and lest hermit crabs crawl on my grave1, I thank all others who have contributed to this intellectual journey in any way.

1 A Maldivian expression that is used to convey the importance of acknowledging all those who contribute to ones life, or who deserve to be thanked.

viii Abstract

This ethnographic study explored the social and cultural context of Maldivian women’s emotional, social and psychological well-being and the subjective meanings they assign to their distress. The central question for the study was: How is suffering and distress in Maldivian women explained, experienced, expressed and dealt with? In this study participant observation was enhanced by lengthy encounters with women and with both biomedical and traditional healers. The findings showed that the suffering and distress of women is embedded in the social and economic circumstances in which they live, the nature of gender relations and how culture shapes these relations, the cultural notions related to being a good woman; and how culture defines and structures women’s place within the family and society. Explanations for distress included mystical, magical and animistic causes as well as social, psychological and biological causes. Women’s experiences of distress were mainly expressed through body metaphors and somatization. The pathway to dealing with their distress was explained by women’s tendency to normalize their distress and what they perceived to be the causes of their distress.

This study provides an empirical understanding of Maldivian women’s mental well-being. Based on the findings of this study, a multi dimensional model entitled the Mandala for Suffering and Distress is proposed. The data contributes a proposed foundation upon which mental health policy and mental health interventions, and curricula for training of health care providers in the Maldives may be built. The data also adds to the existing global body of evidence on social determinants of mental health and enhances current knowledge and developments in the area of cultural competency for health care. The model and the lessons learnt from this study have major implications for informing clinicians on culturally congruent ways of diagnosing and managing mental health problems and developing patient-centred mental health services.

ix Glossary of Terms

Term Meaning Amal-Salih Good deed Aql Intellect Baburu Black child Buruqa Scarf worn by to cover the hair and neck region Dahi Greedy Dhevi A type of supernatural spirit Dhivehi Language spoken in the Maldives Dhivehi Beys practiced in the Maldives but using herbs Dhivehibeys verin One who practices the traditional herbal healing a mechanised vessel built to a specific design used for sea travel in the Maldives Fanditha Knowledge related to magico and healing system Fanditha verin Faith healer Foni Proud Hadith Sayings of Prophet Muhammed Handi A type of supernatural being Ibadah Worship Insha Allah God willing Isthiri Love magic Jinni Supernatural being Jinni fanditha Healing practice for exorcising Jinni Jism Body Kiyeveli kiyevun Incantation: Reciting of Qu’ran to exorcise Jinni Maaiy kalaange aai vakeel Leave it up to Allah’s mercy Moya Mad or crazy Moyavun The phenomenon of going crazy Qalb Heart Rannamari A type of supernatural being Ruh Spirit or breath of life Rulhi Anger

x Sihr word for a spell caste on someone – or malevolent magic Sihuru Malevolent magic cast to harm someone Sunnah The life of Prophet Muhammed Tawhid Unity Thaan Written script of the Maldives Thavakkalthu Allah Trust in Allah Thaveedhu Talisman: Verses of Qu’ran is written on a piece of paper and this is worn on the body or is dissolved in water and the water used for bathing. Form of healing Valuthere Bush Vigani The spirit of the dead

xi Chapter 1

INTRODUCTION

Sabiha, a woman in the Maldives, is possessed by a jinni (supernatural being). She seeks help from a fanditha veriyaa (faith healer) who carries out a kiyevelikiyevun (incantation) to exorcise the jinni who is possessing her. The jinni is causing her to run around wildly; walk out into the deep sea or wander around the cemetery; have such extraordinary strength that even five strong men cannot hold her down; see gigantic, disfigured, black people with eyes burning like coal and feel black birds and hens attacking her. After the jinni is exorcised and a thaveedhu (talisman) is placed round her neck she leads a ‘normal’ life for two years, then she loses the thaveedhu and becomes possessed again.

If the above woman goes to a biomedical healer (psychiatrist, for example), (s)he might use existing biomedical theories to diagnose her with a mind disorder and treat her with drugs. His/her diagnosis and treatment is based on existing biomedical theories that evolve from professionals working primarily with clients in Western post-industrial urban settings. Applying such a Western perspective to this case fails to give due recognition to the relativity of Western constructions of suffering and distress. In this study I acknowledge the usefulness of the biomedical model but I go beyond it to find new ways of addressing the suffering related to mental illness.

Sabiha’s case brings up several questions for me. Is it right to diagnose her – or any woman from the majority making up the non-Western world - as suffering from a psychiatric illness like her Western counterpart? Will the medical solution offered to manage the disorder work for this Maldivian, who if she were to be diagnosed with a psychiatric illness, will be labelled as a moya (mad or crazy) woman? More importantly, is she truly suffering from a mind disorder or are her symptoms a way of coping with the suffering and distress associated with the social and cultural context she lives in? Is there a different meaning system for illness causation? If so, what implications do these different meaning systems and explanations have for the prevention of mental illness and the promotion of mental well-being in women?

In this thesis I explore the various features of Maldivian women’s everyday lives that contribute to their suffering and distress. I explore the subjective meanings they assign to their distress by listening to their individual voices and life experiences.

1 1.1 Background

World Health Organization (WHO) has identified mental illness as occurring worldwide and one of the most distressing and incapacitating health conditions and it can affect people of all ages, particularly women (WHO, 2001). It is also identified as one of the most important public health problems contributing to the increasing disease burden in the world. Mental ill health impairs not just the emotional functioning of the individual experiencing it, but also poses a heavy burden of human suffering on their families and incurs enormous direct and indirect economic costs (WHO, 2004). Although such costs are frequently indirect there is evidence that the strain they place on health services and society is considerable. Mental health problems also affect women disproportionately compared to men and mental illnesses such as depression rank as the most important women’s health problem (WHO, 2001).

Mental ill health accounts for nearly one quarter of all visits to a health care provider, worldwide (WHO, 1995). Studies in developed countries have reported that women were two thirds more likely than men to suffer from depression (Kessler et al., 1994). A WHO study in some developing countries (Colombia, , Philippines and Sudan) reported that 10-20% of a sample of primary care attendees suffered from anxiety and/or depression (Harding et al., 1983). Other studies have also pointed to similar findings (Dennerstein, Astbury, & Morse, 1993; Patel, Araya, de Lima, Ludermir, & Todd, 1999). These patterns apply to clinical and community samples across different racial and socio-economic groups, and do not differ with educational level or occupation (Kessler et al., 1994).

Researchers in the last decade have conducted numerous studies, building an extensive body of knowledge on mental health related issues particularly with respect to depression. But mental health in general is an under-researched area with mental health publications accounting for only 3-4% of the health literature (Saxena, Paraje, Sharan, Karam, & Sadana, 2006). Geographical disproportions exist in the mental health research with less than six percent of the documented literature being from low and middle-income countries (Patel & Sumathipala, 2001; Saxena, Maulik, Sharan, Levav, & Saraceno, 2004) and very few studies have looked at the suffering and distress of women particularly in developing countries (Patel et al., 2006). Moreover, most of these studies have explored mental distress from the etic or outsider’s (researcher’s) point of view rather than the emic or insider’s (participant’s) perspective. An emic perspective illuminates those factors within individual women’s specific social context that predisposes them to or protects them against mental illness. Such evidence is inadequate in developing countries, but is 2 essential for effective and appropriate mental health interventions and mental health promotion (Rowling, 2002). This study addresses this knowledge gap for the Maldives, exploring the experiences of women who have suffered from mental distress or mental ill health.

As I shall show in this thesis, suffering related to mental distress is multifactorial, involving a complex interaction of individual, cultural, social, biochemical and biophysical influences. Some of these factors are related to culturally defined gender roles; family dynamics; the culturally accepted attributes for men and women; help-seeking behaviours and mobility and marriage patterns.

Mental health is described by WHO (2001a) as:

A state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community (p 1).

Within this study suffering and distress is taken to include both the emotional distress related to mental health problems such as anxiety, depression and schizophrenia, and the impaired functioning associated with the distress and the symptoms of diagnosable mental disorders.

1.2 Significance of the study

The cultural and social context in which women experience distress influences how, when and if women seek help for their mental health problems and the kind of help they seek. Thus understanding the cultural construction of mental distress is necessary if we are to make a significant reduction in the prevalence of mental health problems. Miscommunication occurs in the absence of such an understanding when doctors from other cultures or with Western training have to diagnose and treat women who share a different set of cultural beliefs about illness and treatment (Guindon & Sobhany, 2001; Kleinman, 1978). The implications of miscommunications when health care providers are not familiar with the patient’s culture have been reported by various researchers (Al-Krenawi, 1999; Al-Krenawi, Maoz, & Riecher 1994; Budman, Lipson, & Meleis, 1992; Chiu, 1994; Eisenbruch, 1991; Wagner, Manicavasagar, Silove, Marnane, & Tran, 2006).

Kleinman contends that the description of a certain experience as ‘illness’ or distress and the presumed course of treatment developed in one cultural group, may not be applicable to people who share a different set of cultural beliefs about illness and treatment (Kleinman, 1980). As indicated at the beginning of this chapter, in some islands of the Maldives, people consider certain forms of suffering and distress to be the result of being possessed by spirits (jinni) and 3 seek treatment from traditional faith healers known as fanditha verin Belief in supernatural causes may mean that mental health problems can go unrecognized. Furthermore, those who have their mental health problems treated and managed by biomedical interventions may not receive the most appropriate care they need and this can increase the disease burden.

Mental health in the Maldives has not yet been identified as an important issue. The reason may be that attention has been focused on the urgency of infectious diseases. According to the Ministry of Health (MOH, 2004) although infectious diseases are on the decline they are being replaced by a host of modern, non-infectious diseases. It may also be related to cultural perceptions mentioned in the previous paragraph. Consequently, and as with many developing countries, the emphasis on women’s health in the Maldives has been on providing services that address the reproductive functions of women. Furthermore, the health information system has focused on collecting data related to maternal and child health. There is no reliable data that shows the morbidity situation in the Maldives, especially in relation to mental health problems. Furthermore, there is no hospital data and no mental health reporting system or data collection system and no epidemiological studies have been carried out to assess the mental health situation (WHO, 2001). While there is no ‘hard’ data, discussions with doctors from the main hospital in the capital Male’ indicate that almost 40% of outpatient visits are in relation to one form or another of mental distress. Doctors also note that women present the majority of such complaints (M. Ahmed, personal communication, 20 November, 2002).

Research conducted in other countries of the region (Desai & Isaac, 1998) together with the limited data available from the Maldives (Chandra, Pandav, & Bhugra, 2005; MOH, 2004) indicate mental distress to be a likely problem for Maldivian women. A qualitative assessment conducted for rapid assessment of the affect of the disaster of 2004 reported “tremendous psychosocial morbidity in children, adolescents and adults” (Chandra et al., 2005, p 11). It is hoped that my study will provide useful information that can help in designing both treatment interventions and programs for the promotion of mental well-being in the Maldives. As Gro Harlem Brundtland (1997) pointed out while Director-General of WHO, scientific evidence should be the basis for sound political decisions.

In this study I highlight the voices of Maldivian women so that we can come to understand how culture contributes to their mental health. My focus is women but this is not to say that men do not suffer the distress of mental illness or that culture does not play a similar role in making them vulnerable to such distress. Nor am I unaware of the existing evidence of how biochemical 4 processes in the brain interact with social determinants such as poverty, education, urbanisation and other social factors to contribute to mental health.

As I will demonstrate later in this thesis, the knowledge gained from this study stands to contribute not only to the health of Maldivian women but also to enhancing the global body of public health knowledge concerning:

1. Cultural patterning of mental distress. 2. Factors that expose women to and protect against mental illness. 3. Help-seeking behaviours for mental illness, and 4. Cultural competence in the delivery of mental health services.

1.3 Aim of the study and the research question

The aim of this study is to explore women’s perceptions of suffering and distress related to their emotional, social, and psychological well-being. I also want to look at the situations that contribute to their distress. It is not my intention to explore women’s mental health from a strictly biomedical or a psychiatric perspective. Rather I explore the mental health and well-being of Maldivian women from a cultural and gender perspective, the intention being that this study will give health care providers, other researchers, academics and policy makers an insight into the cultural construction of suffering and distress of Maldivian women.

I draw upon the suffering of women through their eyes, not to ignore the mental illness perspective, but to contextualize women’s social and cultural circumstances. In the following chapters I will argue that to be a woman within Maldivian society brings with it notions and feelings related to powerlessness which inevitably impact on women’s health and well-being. To do so I use an ethnographic approach that allows me to actively engage in women’s daily lives in their natural setting.

The central question for this study is as follows:

How is suffering and distress in Maldivian women:

• Explained? • Experienced and expressed? • Dealt with?

5

1.4 Organization of the thesis

I have chosen to organise the content of this thesis in the following chapter structure: In this first chapter I have given a brief overview of and background to the study together with the assumptions which underlie it and its aims and significance. The research objectives are specified and I articulate the knowledge gap, the research question and the rationale. I conclude the chapter having presented my childhood and personal and professional experiences that have shaped and guided this study. My personal and professional background reflects my stance as a researcher and acknowledges how the data is reported through the eyes of the researcher. Such acknowledgement is necessary since I am the main instrument for data collection.

I begin Chapter 2, Discourses on Suffering and Distress, by establishing the global significance of mental distress. I use statistical data from epidemiological studies to provide an overview of the global as well as the regional burden of mental distress. I then go on to clarify some of the conceptual issues and definitions that I use within this thesis. I present the various approaches to addressing mental distress. I also review and critique the existing discourses for conceptualising, diagnosing and managing suffering and distress, focusing on social determinants and, cultural, feminist and Islamic discourses. I conclude the chapter by identifying some of the gaps in the current literature and indicating how this study will address these gaps.

In Chapter 3, Study Setting, I provide a country background that helps to contextualise my findings and conclusions. The Maldives is a small, resource-poor country that is quite isolated and not very well known except as a tourist attraction. The geographic, cultural and social characteristics described in this chapter have potential to affect the well-being of women. These include family and household composition, marriage and divorce patterns, social, cultural and religious aspects of Maldivian life, economy and employment, access to transport and, communication services, social services, and health services, gender roles and responsibilities and the impact of all these on the health of women.

In Chapter 4, Doing the Research, I describe my inquiry approach and the methods used for collecting and analysing my data. Next I describe ethnography, my main method for data collection. I then proceed to discuss how I selected my participants and provide a description of my field-work and the data analysis methods used.

6 In chapters 5 to 8, I present my findings and discuss their implications. Chapter 5, Society puts Pressure on Women, addresses the first of my research questions: How do Maldivian women explain distress? In this chapter, I present the findings related to the various explanations and subjective meanings that emerged from the data. I discuss the main themes in relation to some existing theoretical constructs and the subjective meanings that women assign to their distress that relate to their particular social context. I conclude this section by reflecting on what the findings mean in terms of the social circumstances of women’s lives.

In Chapter 6, A Jellyfish Stuck to my Stomach, I present the findings that relate to my research question: How do women experience and express distress? I search for the important themes and categories that emerge from this data. I look at the subjective meanings embedded in the experiences of women and discuss some of the implications for recognition of mental illness.

Chapter 7, Being of Strong Heart, is on the findings relating to my third research question: How do women deal with their suffering and distress. Emerging themes and categories are presented. I discuss these in terms of broader existing theoretical constructs and the implications for service delivery.

In Chapter 8, Women’s Suffering and Distress through a Gender Lens, I use specific cases of women who have experienced suffering and distress to illustrate how their embodied experience of emotional distress can be explained through existing theories. I discuss these cases through a ‘gender lens’ and explore how gendered power relations come into play in women’s suffering and distress.

Finally in Chapter 9, Reflections and Implications for Theory, Pedagogy and Service Provision, I reflect on the previous chapters and discuss the practical implications of my research findings. These implications relate to: cultural etiology of suffering and distress, approaches to uncovering subjective meanings of distress, conceptual differences in meaning systems for illness causation, and pathways to help-seeking and care. In this chapter I also present an alternative model for conceptualising and managing suffering and distress in women. This model, which I call the Mandala for Suffering and Distress is a multi dimensional model which can be used at a local and global level for: training and educating the helping professions, assessing distress and choosing treatment/management modalities, promoting mental well-being and providing appropriate services. I provide practical recommendations for the promotion of mental well-being of women, education and training of health care providers and future research in the Maldives. I conclude by reflecting on the research process and my experiences of the field-work. 7 1.5 Stance of the researcher

In naturalistic inquiry, the approach used for this study, the researcher is the key instrument for data collection. The data is reported through the eyes and ears of the researcher (Bogdan & Biklen, 1982), in this case myself. As the research instrument, it is imperative for me to be constantly aware of what I bring to the research and constantly scrutinise how my own background shapes the research (Ely, Anzul, Friedman, Garner, & Steinmetz, 1991). In this section I therefore describe how I came to do this study and how my personal and professional experiences motivated me to undertake this research.

I bring perspectives to this research that come from more than fifteen years of work experience in a variety of capacities:

• as a health educator in the community working with young people and women to impart information related to healthy lifestyles; • as the head of a non governmental organisation working towards gender equity including the gender sensitisation of policy makers and media personnel, prevention of HIV/AIDS and prevention of drug abuse; • as the president of a local women’s committee set up to advocate for gender equity; • as a counsellor and confidante with women and young people, providing opportunities for them to discuss relationship or health issues that may be troubling them. • as a member of the Maldivian Government at various levels where I have been responsible for planning health strategies, contributing to health policy, assisting with health professional education and the development of curricula for nurses and other primary health care workers. Both my work and my personal life experiences from childhood to the present have developed in me a passion to contribute to changing women’s lives for the better, especially with respect to those aspects of their distress that are embedded in social and cultural norms. My personal, educational and professional experiences have shaped the concepts I investigate and the approach adopted for this study. As is required in rigorous qualitative research I now outline the pertinent aspects of my background that have formed my researcher stance.

8

1.5.1 My personal life

I come from a family for whom education was the most important thing in the world. I guess that is the true beginning of my journey of discovering new knowledge. From the time I was old enough to read, my mother had instilled in me the need to pursue knowledge. She was constantly encouraging us to do well in school. She believed that education was something that would ensure us a place in society; that knowledge was the one thing no one could take away from us. She also instilled in me a strong sense of right and wrong and the need for a woman to stand on her own feet economically and to be independent.

While my mother, through example, showed the importance of being educated and economically independent, she had grown up during a time when one’s position and role in society were defined by whether you were a boy or . As a result, within the household we were expected to follow the gender norms. Though my mother believed education was equally important for both and boys, education for girls also included learning to be a good mother and wife. It was the females who had to do domestic chores, caring for the old and the young. This has not changed much to the present day. Women’s and men’s roles and attributes continue to follow gendered norms.

Thus my childhood was filled with lessons of how a girl or boy was supposed to speak and behave. Every step of the way these norms set up by the society were instilled in us. While I observed these norms for most of the time, inside I was rebelling against them. Even as a child I felt it was very unfair for society to decide what a boy or girl should do. Thus I rebelled and did things that a ‘good girl’ in our society is not supposed to do. I climbed trees and would be on the roof most of the time and when I sat on a chair I never crossed my legs. My mother kept reminding me these were very unladylike behaviours. Interestingly enough my younger brother also turned out to be the opposite of what our society expected of a man, but only within the confines of the private domain of the household.

Although I did not agree with or enjoy what was expected of me as a girl, I did help with the cleaning and cooking and other domestic chores – not willingly though as I always detested these tasks. I empathised with my mother and knew if I did not do these tasks she would, and I could not allow her to do all of the work. Nevertheless I was always protesting against having to do all of this when my brothers were not required to even pour a cup of tea for themselves though it

9 was already made and in a thermos flask. As a child I dared not say anything against all of this as we were brought up not to question what our parents said; that is how a good and respectful child was supposed to behave.

When I started dating in my late teens, again I experienced the different ways we as girls and boys were treated. My brothers could go out or entertain girls in the house. I was not allowed to go out with boys and if I did go to visit girlfriends I had to be back before sunset. These were just some of the restrictions placed on me because of being born a female.

1.5.2 My own health

Just prior to embarking on my doctoral studies, I had problems with my right shoulder and was later diagnosed with psoriatic arthritis. The period of my field-work was the most severe phase of my illness. I had intense pain and stiffness in most of my joints including back, neck, shoulders, hips, wrists and ankles. My mobility was restricted and I could not sit in one position for long. My physical health was also affecting my emotional well-being. There were many times when I was depressed and did not feel like doing anything at all.

Just four days prior to my return to the Maldives to undertake my field-work, my back had completely given out and I was unable to move at all. I was in Australia, far away from family and my illness was taking its toll. I began to experience what it is like to suffer both physically and emotionally. After returning home the stress of my field-work added to the pressure I was already under and I found it difficult to continue. Having consulted my supervisors I took a break of six months. However I continued to wear my researcher’s hat in any interaction I had with people and found I was also looking at my own illness experiences from a researcher’s stance. For example I spent a month undergoing traditional treatment for my arthritis. This provided me with first hand experience of what it is like to be the patient of a traditional healer practicing Dhivehi beys (). It was an opportunity to gain insights into traditional healing practice I would not otherwise have encountered.

My illness had affected me in a number of ways. I walked more slowly and my face reflected my pain to the point that a former colleague saw me on the street and had difficulty recognizing the tired, apathetic person dragging along at snail’s pace. I had somewhat similar reactions from family and friends who were used to me being bubbly, active and taking charge. Despite their support I somehow felt a lesser person.

10 These experiences changed my perspective and made me appreciate the resilience and strength of Maldivian women. In particular I was able to empathise with, and better understand the situation of my participants.

1.5.3 Professional experiences

My professional life in the Maldives included being head of the Department of Public Health; later the Dean of the Faculty of Health Sciences, Maldives College of Higher Education; member of the National Council of Women; member of a special advisory council to the President of the Maldives; voluntary counsellor for child rights; president of the local women’s group and member of a special task force set up to formulate ‘Vision 2020’ for the Maldives. In these roles I was constantly fighting for the rights of women and the disadvantaged and this placed me under government scrutiny. On one occasion I was suspended from work for having stood up for the rights of my staff to equal remuneration to others in similar positions.

When it came to gender equality those fighting for women’s rights were faced with obstacles from key politicians. They did not believe there were disparities between men and women as a consequence of the cultural beliefs and attitudes of both women and men towards women’s roles and needs. I was often exasperated with expressions such as, “What do you women not get?” “Women have the same rights as men. It is up to the women to use the opportunities there are for them”. “There is no inequality between men and women because of their sex”, and so on. The absence of empirical data to convince such politicians proved a further constraint. The only information available was anecdotal evidence.

My work with women convinced me that women suffered unduly in their marital relationships. They endured various forms of abuse: physical, mental and psychological. But none of the women would speak out about their situation. Instead there was a culture of silence around the suffering of women, as they did not want others to know of what was happening within the confines of their homes. Instead they sacrificed their own health and well-being, suffering silently in their effort to ensure their children did not suffer. Such suffering has not received adequate attention from the government and the services that are being introduced are mainly focused on changing the situation of women in terms of reproductive health and bringing about changes in individual behaviour. Policy changes and services aimed at changing the health situation of women, for example reducing mortality, do not effectively address their suffering and distress.

11 Much of women’s suffering is embedded in the social and cultural context that gives them a subordinate position within society. Purely medical interventions do not address the social and cultural norms that influence women’s social and emotional well-being. This is made only too clear when I look at my own life experiences.

Unlike the participants in this study and others in my own culture I have had the opportunity to live in other cultures when undertaking post secondary education in places such as Beirut, Lebanon where I did my first degree in Environmental Health; Berkeley, California where I did my masters degree in Public Health (Behavioural Sciences) and now in Australia. I have had opportunities to travel widely and been economically independent since I left high school. Despite these empowering factors I am aware that I still take decisions based on what is culturally expected of a good and virtuous woman in my society, even though such decisions negatively influence my emotional well-being. Hence my passion to give a voice to women in terms of the social and cultural context that affects their health, particularly their mental health.

In the past and even now government efforts to consider women’s voices have mainly been token – women have often been used simply to rubber-stamp decisions already made. In recent years women have indeed been included in major policy decisions that affect their lives but only in decision-making groups heavily dominated by men. In a paternalistic society where tradition strongly encourages women to go along with what the men say it is not reasonable to claim as policy makers do that this is giving women a voice.

I believe that to truly give a voice to women they need to be provided with a non-threatening environment that allows them to freely express their feelings and they need to be given the time to become comfortable with those who are engaging with them to discover their opinions and needs. Women also need to be able to freely choose whether they speak or not. Last, but not least, their needs must be documented through empirical studies that can be used as evidence for policy changes. I believe that “the natural setting as the direct source of data and the researcher as the key instrument for data collection” (Bogdan & Biklen, 1982, p. 27) will provide an opportunity to give a voice to women.

12 Chapter 2

Discourses on Suffering and Distress

IMPLICATIONS FOR MALDIVIAN WOMEN’S HEALTH

In this chapter I review the literature on mental health and the various discourses related to women’s mental health that are pertinent to this study. I begin the chapter by clarifying the various concepts I use in this study, followed by a discussion on the significance of mental health to global public health. I then discuss the various factors that affect the onset, course and outcomes of mental illness. Next I identify the basic principles of the Islamic faith that guide the day-to-day lives of and that are pertinent to this study. I then move into a discussion of the various discourses on the socially constructed notions of women’s well-being and the importance and role of culture in mental health. I conclude the chapter by identifying some of the main ideas and gaps in the literature and their significance for this study.

2.1 Conceptual issues

According to Shweder and colleagues (1997) “to suffer is to experience a disvalued and unwanted state of mind, body or spirit” (p. 120). It is in this way I use the term ‘suffering and distress’ in this thesis. Specifically I allude to the various states of mind, body and spirit associated with mental health problems or mental distress and mental illnesses. Throughout this thesis I use the terms suffering and distress, mental health problems and mental distress interchangeably.

Mental health Mental health has been conceptualised in various ways. It has been considered as a positive emotion (affect), such as happiness, and as resilience. Resilience is the capacity to cope with adversity. Concepts of mental health include subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence and recognition of the ability to realise one’s intellectual and emotional potential (WHO, 2003, p. 7). Defining mental health is not easy because of the complexities around values, cultures, classes and gender. For example in Western countries such as the United States and Western Europe, mental health is mainly understood as an individual attribute (Sampson, 1988); whereas other cultures such as the

13 Japanese and the Indian perceive mental health in relation to how individuals interact within their family (Markus & Kitayama, 1991; Shweder & Bourne, 1992).

In its report on Investing in Mental Health, WHO (2003) states: “Mental health is more than the mere lack of mental disorders” (p. 7). WHO (2000) also provides the following definition in its report on the social dimensions of health

Mental health is the capacity of individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservations of conditions fundamental to equality (p. 11).

For the purposes of this study, I use the above definition as this definition encompasses the complex web of factors that extend beyond the individual and it acknowledges the role of the social and cultural context of mental health.

Distress There have been numerous references to distress in the international health literature in relation to patient signs and symptoms of acute and chronic illness. These references portray both physical discomfort and mental anguish (Cox, Enns, & Clara, 2002; Holley, 2000; McClement, Woodgate, & L., 1997; Nordin, Lidne, Hasson, Rosenquist, & Bergland, 2002). According to Lazarus (1998) distress caused by illness is one of the most poignant problems frequently experienced by individuals. However it is not just the individual that is affected by his/her illness. Studies have consistently reported that caregivers endure high levels of stress, fatigue and exhaustion, as well as financial hardship, isolation and loneliness (Brewer, 2001). This is particularly true of traditional cultures where it is the responsibility of the family members to provide both the physical care and the financial support required for older members (Horowitz, 1985).

My interest in the suffering and distress of Maldivian women relates to the emotional or psychological anguish associated with suffering and mental distress. Thus, for the purposes of this study, I will use the term distress within the context of mental health. Borrowing from the concepts used by Ridner (2004) I define distress as a state or discomfort or suffering of mental or emotional anguish experienced by an individual that results in harm, either temporary or permanent, to that individual. Distress within this context can be a response to, or a result of, a physical or mental illness. It can also be a response to the stressors and demands of everyday life. It is the state in which women feel they are unable to deal with their day-to-day life effectively; a state in which they may or may not experience a change in their affect and emotions. 14 2.2 Mental health as a public health problem

Mental health problems are associated with enormous suffering and burden for individuals, families and societies. Yet in most parts of the world, mental health and mental illnesses are not accorded adequate priority (WHO, 2003). Mental health problems include various mental illnesses such as addictive and behavioural disorders.

Numerous studies indicate that a substantial proportion of the world’s population suffer from mental illness (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Harding et al., 1983; Harding et al., 1980; Kessler et al., 1994; Ustun & Sartorius, 1995). WHO (2004a) states ten percent of the world’s adult population suffer from a mental health problem at any point in time. Half of the leading causes of disability worldwide are psychiatric conditions (Murray & Lopez, 1996). Currently 450 million people worldwide suffer from a mental health problem; more than 150 million persons suffer from depression at any point in time and one in four families has at least one member with a mental disorder (WHO, 2003). Mental illnesses account for approximately one quarter of all visits to health care centres worldwide (WHO, 1995). More than half the time general health care physicians fail to diagnose mental health problems properly and, even when they do diagnose the condition, the treatment provided is not appropriate to the condition (Cohen, 2002).

The impact of mental illnesses is “wide ranging, long lasting and enormous” (WHO, 2004a, p. 15). As mentioned, mental health problems are among the most distressing and incapacitating conditions in the world. The burden of mental illness has increased over the last decade (Blue & Harpham, 1994; Ustun, 1999; WHO, 2001) imposing substantial financial burdens on individuals, their families, and communities (Neugebauer, 1999; WHO, 2004a). Besides direct costs involved with service provision and treatment, there are indirect costs arising from the following: lost employment, reduced productivity, the impact on families and caregivers, the crime levels, public safety, the negative impact of premature mortality, the negative effect of stigma and discrimination and lost opportunity costs to individuals and families. Such indirect costs are hard to measure and so the total financial burden is not known (WHO, 2004a).

Epidemiological and anthropological data show different patterns of mental illness among women and men. A large body of data consistently reports higher prevalence rates of depression and anxiety disorders as well as psychological distress among women compared to men (Cyranowski, Frank, Young, & Shear, 2000; Hussain & Cochrane, 2004; Mumford, Nazir, Jilani, & Baig, 1996;

15 Piccinelli, Homen, & Tansella, 1997). This trend is consistent across a range of studies undertaken in different countries and settings (Desjarlais, Eisenberg., Good., Kleinman, 1995).

Women are also more likely to be diagnosed with obsessive compulsive disorder, somatisation disorder and panic disorder (Russo, 1990). Men, on the other hand, are diagnosed with antisocial personality disorder and alcohol abuse/dependency (Cleary, 1987; Pearlin, 1989). The origins of much of the pain and suffering associated with mental illnesses, particularly for women, can be traced to the social circumstances of their lives (Astbury, 1999; Doyal, 1995). Depression, hopelessness, exhaustion, anger and fear are a result of hunger, overwork, domestic and civil violence, entrapment and economic dependence (Broadhead & Abas, 1998). I will discuss the specific aspects of mental health for women in detail later in the chapter.

I find the above findings that reflect inappropriate treatment or management of mental distress problematic in many ways. First, inappropriate treatment may mean that patients do not get relief for their distress and so they keep coming back. Second, physicians may keep on doing unnecessary tests to find out why the patient does not get better. For countries with limited resources, increases in patient visits and diagnostic tests put extra pressure on an already overloaded system. From the patient’s perspective not getting better reduces her quality of life and further adds to her distress.

The existing literature establishes without a doubt that mental health is globally a major public health problem. Yet, as the evidence discussed above shows, a significant proportion of those suffering from mental illness do not receive the required support and help they need to address their health problem. I would argue cultural beliefs and attitudes towards mental illness and the mental health system contribute- to the help-seeking patterns. The stigma attached to mental illness is a barrier that prevents many people from seeking help (Al-Krenawi, Graham, & Kandah, 2000; Coker, 2005; Corrigan, 2004; Corrigan & Watson, 2002; Mann & Himelein, 2004; Raguram, Weiss, Channabasavanna, & Devins, 1996).

2.3 Understanding mental health

Research suggests mental health is determined by the interaction of multiple social, psychological and biological factors which shape the onset, course and outcome of mental illnesses (Piccinelli et al., 1997). Mental illnesses develop through complex causal interaction of these factors and so it is difficult to pinpoint the specific cause (WHO, 2001). Available evidence suggests the brain to be the final common pathway for the control of behaviour, cognition, mood

16 and anxiety. However, the links between the specific brain dysfunction and particular mental illnesses is not yet fully understood (Schwartz, 1999; WHO, 2001).

Research has established a clear link between physical and mental health (Phelan, 2001; WHO, 2004b). Mental illness can either contribute to, result from or share a common pathway with physical illnesses. For example, evidence shows depression and anxiety to be associated with cardiovascular and cerebrovascular diseases. Mental illnesses increase vulnerability to physical morbidity and poorer outcomes. Optimism, personal control and a sense of meaning have been known to be protective of mental as well as physical health. Furthermore, physical health is an attribute that influences mental and physical illnesses positively (WHO, 2004b)

2.3.1 Risk factors and protective factors

In considering factors that influence mental health it is important to differentiate between risk and protective factors. Risk factors are those that increase the likelihood that a mental illness will develop or factors that increase the severity or prolong the duration of the illness (WHO, 2004a). Protective factors reduce the likelihood of developing a mental illness. They can be truly protective by reducing exposure to risk or they may reduce the effect of risk factors (Rutter, 1985). Research has shown that, even when a person is exposed to risk factors, the presence of protective factors lowers their level of risk (Resnick et al., 1997). Examples of risk factors include poor social skills, low self-esteem, physical or emotional abuse, absence of a father, marital discord in parents and socio-economic disadvantage.

Examples of protective factors include resilience, good problem-solving skills, optimism, supportive caring parents, family harmony, involvement with a significant other person, sense of connectedness and access to support services. Social capital has been reported as a protective factor by providing effective support and serving as a source of self-esteem and mutual respect (Wilkinson, 1996). Social capital is described as “the features of social organization, such as civic participation, norms of reciprocity, and trust in others that facilitate cooperation for mutual benefit” (Kawachi, Kennedy, Lochner, & Prothrow-Smith, 1997, p. 1491).

2.4 Determinants of mental health

Determinants of health are those factors that enhance or threaten an individual’s or a community’s health status (Pilgrim, 2005). These can be biological, psychological, and sociocultural factors.

17 2.4.1 Biological determinants

Biological determinants include the biological and physical influences on mental health such as genes, infections, physical trauma, nutrition, hormones and toxins. The influence of genes on both normal and abnormal behaviour has long been established (Plomin, Owen, & McGuffin, 1994). Studies have shown that some mental illnesses, such as schizophrenia and bipolar disorder, run in families (Pulver et al., 1992). Genetic factors that affect brain chemistry may contribute to the onset and progression of mental illness. But the illness may manifest only in people who also experience certain environmental stressors. For example, a person who has genetic predisposition to mental illness is likely to develop a mental illness when exposed to trauma or a disrupted family environment (WHO, 2001).

2.4.2 Psychological determinants

Psychological factors include stressful life events, affect, and personality. A key finding throughout the twentieth century has been the importance of relationships with parents or other caregivers during childhood (WHO, 2001). Affect, attention and stable caring has been shown to be crucial for an infant and young child to develop normally and in the absence of such an environment the child could be at risk of developing a mental health problem. Psychological science has also shown mental illnesses such as anxiety and depression can occur as a result of the inability to cope adaptively to the environment (WHO, 2001). Furthermore, severe trauma such as physical or sexual abuse has been associated with mental health problems such as dissociative disorders, personality disorders, addictions and post traumatic stress disorder (Leverish et al., 2002; Rosenberg, Drake, & Mueser, 1996; Weiss, Longhurst, & Mazure, 1999).

In reviewing the literature on psychological and social determinants, I find that it is difficult to draw a firm line between them. Often psychological and social determinants are very closely linked.

2.4.3 Social determinants

A range of social and environmental factors has been documented as playing a major role in determining mental health status. Marmot, Shipley and Rose (1984) demonstrated that low socio- economic status, high stress levels in the workplace, job insecurity, low social support, and addictive behaviours were among some of the factors correlated with mental health. Poverty and socio-economic problems were reported as the most important cause of emotional distress in explanatory models of mental distress from India and Africa (Aidoo & Harmpham, 2001; Patel, Gwanzura, Simunyu, Mann, & Lloyd, 1995; Patel, Pereira, & Mann, 1998). 18 Urbanisation, poverty and technological changes have also been associated with poor mental health (Karasz, 2005), but the mental health consequences of these are not the same for all segments of society. Consequences differ depending on economic status, sex, race and ethnicity (Ross & Mirowsky, 2002; WHO, 2001). Modern urbanisation is associated with adverse effects on mental health through the influence of increased stressors and adverse life events such as overcrowded and polluted environments, poverty and dependence on a cash economy, high levels of violence and reduced social support (Desjarlais. et al., 1995). It is not just urban life that affects mental health negatively. Rural life for many people spells isolation, lack of transport and communication, limited educational and economic opportunities; all are factors that negatively influence mental heath (WHO, 2001). Moreover, rural dwellers have more limited access to mental health services than urban dwellers giving them very few options for treatment.

The relationship between poverty and mental health has been well established. According to Murlai and Oyebode (2004) “poverty and social inequality have direct and indirect effects on the social, mental and physical well-being of an individual” (p. 216). Poverty is both a determinant and a consequence of poor mental health and poverty is closely linked to inequality. Income inequality produces psychosocial stress (Wilkinson, 1997a). Income inequality affects not just the health of the individual, the effects spill over into the whole society, causing stress, frustration and family disruption (Wilkinson, 1996). The result is an increase in rates of crime, homicide and violence.

Epidemiological studies throughout the world have established that there is an inverse relationship between mental illness and social class (Murali & Oyebode, 2004). These differences have been found in a number of developed countries such as the Nordic countries, United Kingdom, United States and Australia (Arber, 1991; Belle, 1990; Lahelma, Manderbacka, Rahkonen, & Karisto, 1994; Najman, 1993; Rahkonene, Lahelma, Karisto, & Manderbacka, 1993). The same is true for low income and middle income countries of Africa, Asia and Latin American as demonstrated by a recent study (Patel & Kleinman, 2003). According to this study the direct and indirect costs associated with poor mental health worsened economic conditions, leading to a “vicious cycle of poverty and mental disorders” (p. 609).

Ethnicity and gender are important demographic determinants that differentiate health status in the population. Both ethnicity and gender are closely associated with other factors related to disadvantage that make people more vulnerable to mental distress. Low economic status is compounded by social marginalization.

19 It is evident from the literature reviewed above that psychosocial factors play a major role in either protecting against or increasing the risk of mental health problems. In the light of this evidence there has been an increasing effort made to address these psychosocial determinants. Nevertheless the predominant approach, especially in developing countries, is to emphasise the early detection and treatment of mental illnesses, that is, a medical approach to addressing mental health at an individual level. Although it is granted that treatment is an essential part of addressing mental health, especially in the case of more severe forms of mental illnesses, it is time to strengthen efforts to use the new public health approach (Baum, 1999) to accelerate population strategies for addressing mental health.

The new public health approach is concerned with the interplay between the various factors that affect health. It focuses on a positive definition of health and places strong emphasis on community participation and intersectoral collaboration rather than having the medical profession at the centre of intervention.

2.5 Mental health promotion and the new public health

Mental health promotion is an active form of public health in which communities and individuals are involved in partnership to push towards higher levels of health – a positive state of health rather than an absence of disease. Support for a population approach to mental health emerged with WHO’s declaration of the Global Strategy for Health for All by the Year 2000 (WHO, 1981) which linked health to overall social and economic development. The attainment of equity in health status was an important goal in the approaches used for achieving health for all. This emphasis was later expanded with the Ottawa Charter for Health Promotion (World Health Organization, 1986).

The Ottawa Charter shifted the focus from the individual disease prevention approach to address the underlying influences on health with the emphasis on the population as a whole. The key elements of the Ottawa Charter are to build healthy public policy, create supportive environments, strengthen community action, develop personal skills and reorient health services.

A number of different models have been developed by various scholars to address the determinants of health. The major feature of these models is their ecological perspective where they focus on the interconnectedness between individuals and communities with their social and physical environments. These models clearly indicate the complexity of the pathways leading to health problems.

20 VanLeeuwen and colleagues (1999) in their article Evolving models of human health toward an ecosystem context provide a good overview of models used for addressing health determinants that fit within the ecosystem health paradigm. The Mandala of Health is one such model which I explain below as I use it as a framework for this study.

The Mandala of Health Model

Figure 1: Mandala of Health (Hancock and Perkins, 1985)

Culture

Community Lifestyle Personal Psycho-Socio- Behaviour Economic Environment Spirit Sick Care Body Mind Work System 

Human Physical Biology Environment

Human-Made Environment Biosphere

The Mandala of Health model was developed by Hancock and Perkins (1985) contributing actively to newly evolving health promotion perspectives. At the time of its development it broke new ground and was very influential in establishing the new health promotion paradigm epitomised in the Ottawa Charter (World Health Organization, 1986). A mandala is a circular design of concentric geometric forms symbolising the universe. The model is provided in Figure 1. The centre of the model comprises three constituent parts: mind, body and spirit. Three circles of nested systems denote the influences on health and represent the systems around the individual: the family, the community and human-made environment, and finally the culture or biosphere. The rings are intended to be three-dimensional implying multilevel and multifaceted, and are dynamic in size and shape. Hancock and Perkins identify four groups of determinants of health within the family and community circles: personal behaviour (lifestyle), human biology, and 21 two types of environments, physical and psychosocioeconomic (PSE). Individuals’ health is also influenced by their lifestyle choices (their behaviour within the PSE environment), their work (their interaction between their physical and PSE environment) and how their consumption patterns of health care affect their body.

As emphasised in the Mandala of Health model and by WHO, health encompasses spiritual well- being as well as physical and mental well-being. In the Maldives, religion plays a dominant role in shaping the everyday life of the people. I will therefore now turn to some of the aspects of Islam that are pertinent to mental health.

2.6 Islam and mental health

The basic sources for understanding abnormality and attitudes towards the mentally ill in Islamic societies are the Qur’an, the holy book, and the prophet’s tradition (hadith). Islamic beliefs have also been influenced by ideas, myths, folklore and values brought in from the Muslim territories outside the (Al-Issa, 2000).

Islamic understanding of health and illness needs to be considered within the context of religious conceptualisation since religion plays a significant role in the everyday life of Muslims: social interaction, daily activity, marital interchange, raising children, and legal legislation. The dominant principle in Islam is tawhid or unity.

The principle of unity begins with the belief in the unity of Allah: there is only one God, followed by unity of purpose of the cosmos, that is Ibadah or worship, and unity of the human community in this purpose. Worship includes any Amal-Salih or constructive work or good deed (Khan, 1986). Ashy (1999) states the major goal of Islam is unity of all aspects of personality and of society. For example, when one’s neighbour does not have food or is sick it is within this goal of unity that one is expected to help the neighbour.

Islamic custom, as already stated, is largely derived from the five pillars based on the Qur’an and the life of the Prophet or the Sunnah. The path that all Muslims are to follow is provided in the Shariah. “Shariah is a set of regulations, principles and values from which Islamic legislation and law are drawn. It is a guide to every action, and divides them into five divisions: obligatory, meritorious, permissible, reprehensible and forbidden.” (Pridmore & Pasha, 2004 p, 381). The Islamic path emphasizes an integrated, comprehensive, harmonious and balanced development of the individual and the society (Riaz, 1992). For a balanced development a person, besides observing religious such as prayer, must also find time for family, eat in moderation, take 22 regular exercise, observe personal hygiene and cleanliness and, while regarding sex as natural, restrict it to the legal bounds of marriage (Ahmed, 2001).

2.6.1 Islamic principles

To understand and interpret the role Islam plays in the everyday lives of its followers, it is important to understand the following basic principles (Ruschoff, 1992). I would contend that these principles are particularly relevant to mental health.

Faith Faith in and of itself contributes to the peace of mind of any individual regardless of which faith it is (Al-Issa, 2000). For Muslims, faith in God is the basis of Islamic belief in fate (Ahmed, 2001). The faithful believe that everything is in the hands of Allah and destiny is ‘written’ and so the will of God has to be carried out. Events in life whether positive or negative are events predestined by Allah as part of life’s tests. Tests of faith for believers can come in the form of terrible life events such as the death of loved one or the loss of a home (Bilal Phillips, 1994). The belief in fate may at times give patients a sense of acceptance, especially when faced with circumstances beyond their control. The Qur’an provides an optimistic view of adverse events and promotes that all things happen for the good.

Say: Nothing shall ever happen to us except what Allah has ordained for us [Al-Taubah r1]. It may be that you dislike a thing which is good for you and that you like a thing which is bad for you. Allah knows but you do not know (Surah Al-Baquarah, 216).

Another element of faith is the belief in the Day of Judgment, when all Muslims who have walked the path of the righteous will be rewarded in their afterlife. Bilu and his colleagues (1990) suggest that the idea of reward, thawab, for the good done on earth and for being a good Muslim may be reassuring and help the Muslim patient to cope with a difficult life event.

Prayer and hope Islam advocates prayer and putting faith in God for relief from misfortune and asking God for helping to cope with adverse situations. Through prayer the believer may obtain the peace needed to deal with adversity.

O you who believe! Seek help in patience and As-Salat (the prayers). Truly Allah is with As-Sabirin (the patient ones) [Al-Baqurah, 153] Who when afflicted with calamity, say: Truly! To Allah we belong and truly to Him we shall return [Al-Baqurah, 156]

23 Patience Islam endorses patience, acceptance and being thankful for what God has destined. Patience does not mean bearing the pain of adversity and injustice without complaint or protest or in total silence. Patience means the acceptance in God’s decision and trust in God (Al-Issa, 2000). Having faith also means that individuals must take the initiative to help themselves or change the situation. The importance of individual action is emphasised in the following verse in the Qur’an, which Wadud (1999) clarifies as, “unless humans, individually and collectively, take the initiative, there can be no change for better or worse” (p.25). She says that this implies individual responsibility which is addressed later in this section.

God does not change the situation of a people until they change it themselves (13:11, 8:53)

The Qur’an points out adversity can befall someone as a test of their patience and faith.

Surely we will test you with fear, hunger, loss of wealth, and life and the fruits of your work, so give glad tidings to those who are patient (Soorah al-Baqaraha 2:155)

The concept of patience is demonstrated best in how Islamic philosophy suggests dealing with the death of a loved one. In the case of bereavement, Islam encourages the person to accept the loss and this trust and belief is thought to accelerate the process of grieving and enhance emotional adjustment (Al-Adawi, Burjorjee, & Al-Issa, 1997; Al-Krenawi & Graham, 1996, 1999).

Role of responsibility The Qur’an states that human beings are responsible for their actions and will be rewarded for their good deeds and answerable for their evil deeds (Ahmed, 2001; Wadud, 1999).

Say, shall I seek a lord other than Allah, while He is the lord of all things? No person earns any (sin) except against himself (only) and no bearer of burdens shall bear the burden of another. (Al-Anam, 164)

While Islam holds the individual responsible for his/her actions, it also acknowledges human limitations. For instance, human beings may be limited in terms of physical or mental ability or even in the resources available to them. Therefore, under certain circumstances, human beings are relieved of responsibility and their limitations are acknowledged. Islam also differentiates between intention and action.

There is no accountability for intention unless it is translated into action. Thus the concept of sin in the ‘heart’ does not apply in Islam. The Prophet Mohamed is reported to have stated that if a person has evil intentions but does not act on them, he or she will be rewarded for restraining from action. While one is responsible for one’s actions Islam does not consider illness to be a

24 punishment for wrongdoing. Al-Issa (2000) notes that the concept of original sin, and illness being a result of the inherent sinfulness of human beings, does not exist in Islam.

2.6.2 The role of the individual within society

Islamic society is based on a collectivistic social structure. This is in contrast to the individualistic style of European-American society (Al-Issa, 2000). The basic principle that is dominant in Islam is unity. Based on this concept of unity, Islamic culture is group-oriented and so the interests of family and society are considered to be far more important than those of the individual. Al-Issa (2000) observes this social context has implications for the development of the concept of the self. In view of this, he cautions the use of Western concept of autonomy as a state of individuation when using interventions for managing mental health problems in Muslim patients.

At the centre of Muslim society is the family. Within the family each member of the household plays an equally significant role in his or her own capacity in relation to the other members of the family (Ahmed, 2001). The father is the dominant figure in the family. The proper behaviour of all members of the family is constantly emphasized in the Qur’an and hadith with the ideal behaviour being one of dignity and modesty. Within the family, with age, people gain status and influence. It is the duty of every child to care for parents. Kindness to parents and gratitude to them come next to the worship of God and gratitude to Him respectively (Al-Issa, 2000).

Islam calls upon human beings to walk in the right path (al-sirat al-mustaqim) by following the principles and guidelines provided in the Qur’an and Sunnah to establish an altruistic, disciplined and fraternal society, based on piety, love, justice, wisdom, selflessness and good etiquette (Riaz, 1992). Piety includes the love of God, love for God and fear of God. Selflessness relates to humility, sweetness, gentleness, patience and sympathy for fellow human beings among other virtues.

2.6.3 Islam and the human psyche

Muslim scientists such as Avicenna did not separate the self from the body (Rabi, 1993). Avicenna argued that the body and the self are interdependent and directly affect each other. The self needs the body for its existence and for its expression and the body needs the self for its guidance and therefore functions of the body and of the self cannot be separated.

According to Amjad (1992) there are various dimensions of the human’s inner self specified in the Qur’an as ruh, nafs, qalb and aql which are important to understand the human psyche.

25 Ruh Ruh or spirit is the breath which was infused into the human being (Amjad, 1992). Ruh has been considered in different ways (Amjad, 1992; Ansari, 1992; Ashy, 1999) such as: synonymous to self, the inner nature of humans (Ansari, 1992), the “special spiritual and divine elements” (Amjad, 1992, p. 6), as a “life force that imparts power to the body” and as a “spiritual principle which vitalizes the body and controls it (Amjad, 1992, p. 43 citing Al-Ghazali). Other Islamic thinkers have spoken of ruh as ‘a ray of the Divine intellect’. Referring to the various notions of ruh used by different Moslem scholars, Amjad concludes that within Islamic psyche ruh (spirit) and nafs (soul) are two names for one and the same thing and can be used interchangeably.

Qalb Qalb or heart plays an important role in the Islamic psyche; it is the essence of a person and the seat of emotion (Amjad, 1992). In the Islamic psyche it is the heart that is associated with intellect and not the mind or brain as in Western biomedicine. Heart is the core of the Nafs or Self and the locus of the human psyche (Amjad, 1992; Ashy, 1999; Haq, 1992). Heart is the spiritual entity which dwells in the physical body and controls its organs and physical functions. According to Islamic psychology the heart is a non-material principle and the essence of the self. Ashy (1999), citing Al-Ghazali, points out that the heart is the point of union between Jism or body, and Ruh or spirit.

The unity of the heart is one of the main purposes of Islam. This means that according to Islamic psychology personality consists of both aspects of body and mind (Ashy, 1999). The heart is considered the place of faith and it can be blind or seeing and can guide humans in the right direction. The heart is allocated in the Qur’an as the seat of wisdom and intellect and described as the place of understanding which can be: closed or blocked, separated from the truth or from others by a barrier, hard as a rock or empty, the place of the memory, the place of extreme terror (Haq, 1992). It can be clean, sinful or unified and the site of love. Peace is a quality of the heart and hypocrisy and disbelief are considered to be diseases of the heart.

Aql Aql (intellect) or reason is essential to the concept of nafs or self (Amjad, 1992). According to Amjad, aql comprises two parts: aql-I-juz-I or reason, which is the faculty of discursive and analytical thought, and aql-I-kulli, the faculty of intuition. In attaining the self, intuition is the main source, although reason with the help of intellect, can differentiate between truth and fallacy.

26 In summary, Islam provides a set of guidelines that emphasize a life of balance and moderation which helps the individual to maintain both physical and mental well-being and, when faced with suffering, to cope with it. The family’s and society’s interests are held above those of the individual.

As a final point, while the guiding principles for everyday life prescribed in Islam are based on the Qur’an and Sunnah, the extent to which these are followed or applied varies from country to country and from individual to individual. So while the above overview is useful as a guide to understanding how Islam influences mental health it cannot be assumed that all Muslims follow the principles described above in the same manner. There is great diversity in how the Qur’an and Sunnah are interpreted depending on the Islamic scholar and the school of thought followed. There are various sects within Islam such as Sunni and Shia, and the philosophy practised may be different within different sects. Moreover, I would argue there are differences between practising Muslims even within the same sect. Individuals differ in the extent to which they observe the various teachings of Islam.

2.7 Women, gender and mental health

Understanding the concept of gender is essential to understand sexual dichotomies, the way in which men and women behave differently, sexual identity, the roles assigned or expected of women and men in a particular society (Oldersma & Davis, 1991). According to Connell (2002) gender is “above all a matter of the social relations within which individuals and groups act” (p. 9). Connell identifies gender as a social structure, but of a particular kind that involves a specific relationship with bodies. Gender is the outcome of recurrent interpretations of and definitions placed upon the reproductive and sexual capacities of the human body (Pilcher & Whelehan, 2004). This definition is echoed by other scholars (Doyal, 1995; Moore, 1988) and the conceptualisation of gender in this manner portrays gender as dynamic. Gender can change between cultures and over time. Femininities and masculinities are the multiple effects of the dynamic interpretations of gender “impacting upon bodies, influencing personalities and shaping culture and institutions” (Pilcher & Whelehan, 2004, pp. 62). However sex is biologically determined, is manifested as male and female, and does not usually change.

2.7.1 Social construction of gender

A social constructionist perspective of gender considers gender to be shaped by culture or institutions and social practices. Children are socialised into gender roles – the stereotypical roles 27 attributed to being male or female. This is seen as constituting gender (Leaper, 2000), a process whereby parents through their influence transfer their own beliefs related to gender stereotypes. Such transfer may be conscious or unconscious (Eccles, 1993; Leaper, 2000) and is a top-down process (Connell, 2002); a process which, according to Connell, ignores agency and assumes children are passively socialised into sex roles. But according to the American ethnographer Barrie Thorne (1993) who observed American school children, gender is situational. In this study Thorne recognized gender was important to these children as a human issue and not as a fixed framework that they adhered to like puppets.

The typical approach to thinking about gender focuses on the notion that women and men are different (Connell, 2002). This line of thinking as Lorber (1996) points out is based upon assumptions along dualist positions or binary models: nature vs nurture, male vs female, normal vs deviant, sameness vs difference, private vs public. Classical personality theories, especially psychoanalytic theories, are examples of such dualistic thinking. These theories consider men and women to have different personality traits, capacities and interests and lay out different criteria for maturity and mental health (Marecek, 2001).

Classical personality theories were criticised by feminists who developed alternative theories to explain the differences in personality traits between women and men. Cultural feminist theories of senses of self-in-relation (Miller, 1976), mothering experiences (Chodorow, 1978) and women’s different moral voices (Gilligan, 1982) are examples of such alternate theories. Self-in-relation theories are based on the notion that women possess a set of special feminine qualities such as intuition, capacities for empathy and relatedness and a propensity for nurturing and caring for others. These qualities are not an inherent part of being born a female, but a result of distinct experiences of their often hidden emotional life (Marecek, 2001).

Feminist sociologists have criticised the dualistic notions of socially constructed categories of gender (Connell, 2002) and argue that culture is grounded in material social relations along differing dimensions of power (Lykes, 1989). They call for transcending dichotomous sex and gender categories. This shift in focus is influenced by the assertion of post-modern philosophers that the body is not sexed in any way prior to its determination within a socio-political discourse (Connell, 2002; Foucault, 1983). Foucault suggested that the body gains meaning only through the discourse of power – primarily through husband-wife and parent-child interactions.

The various perspectives and approaches to theorising gender have been developed in and are based on research from developed countries. My literature review revealed that very little if any of 28 the theoretical notions have been developed through research based in developing countries. I question then whether gender constructs based on Western feminist theories apply to resource poor countries? Do women in resource-poor countries such as the Maldives view their gender as oppressed? If so how does this influence their mental health? These are questions that I cannot answer fully from the available literature.

My own experiences in the Maldives, however, led me to agree with Doyal’s (1995; 2000) observation: “those things defined as male are usually valued more highly than those things defined as female and men and women are rewarded accordingly” (Doyal, 2000, p. 934). Inequalities that arise from gendered societies (Kimmel, 2000) have a significant effect on men’s and women’s health. However, to do justice to women in resource poor countries, I would argue that it is essential to explore their own meanings of how gender influences their mental well-being and not impose a construct based on experiences that are very different from their own.

To me gender is dynamic and fluid; a person’s identity is therefore influenced by the ongoing social discourse. According to Butler (1993) an ‘agentic subject’ is an active participant. Hence to fully understand how gender influences the mental health of women it is absolutely essential to explore the interactions of body, identity and self and their interactions with class, race, nationality, ethnicity, religion and so on (Blume & Blume, 2003). In other words it is necessary to explore women’s individual life circumstances and how those affect her mental well-being.

2.7.2 Gender differences in mental health: what is known from the literature

Epidemiological and anthropological data point to differences in patterns of mental distress among men and women (Kessler et al., 1994; Kessler & McLeod, 1984; Kessler & McRae, 1981; Ustun & Sartorius, 1995). Women predominate in affective and anxiety disorders such as major depression, (McGrath, Keita, Strickland, & Russo, 1990; Piccinelli et al., 1997; Piccinelli & Wilkinson, 2000), eating disorders, somatisation disorder, as well as unspecified psychiatric disorder and psychological distress (Dennerstein, 1993; Murphy, 1986; Paykel, 1991; Russo, 1990). For more severe mental illnesses such as schizophrenia and bipolar disorders there seems to be no significant sex differences in rates (Piccinelli et al., 1997).

Sex differences in patterns of mental illness vary depending on the phase of life, from childhood to adolescence to adulthood. Most studies indicate a higher prevalence of mental health problems in younger boys than younger girls (Cynranowski, Frank, Young, & Shear, 2000). Boys experience more conduct disorders with aggressive and antisocial behaviours. The difference is

29 smaller during adolescence as girls experience more emotional problems, with fearful, anxious or over-controlled behaviours.

Desjarlais and colleagues (1995) reviewed 15 studies on psychiatric disorders and psychological distress conducted over the last decade in Africa, Asia, the Middle East and Latin America. This review showed consistent patterns across diverse societies and social contexts. Symptoms of depression and anxiety as well as unspecified psychiatric disorder and psychological distress were more prevalent among women, whereas substance use disorders were more prevalent among men. The researchers concluded that this trend reflected the tendency for men to externalise their suffering resulting in under reporting of psychological distress and for women to suffer distress in the form of depression, anxiety, ‘nerves’, and the like. Female preponderance for depression has also been demonstrated in other studies involving community based studies in developing countries (Almeida-Filho et al., 1997; Mumford et al., 1996; Patel, Araya, de Lima, Ludermir, & Todd, 1999).

A WHO commissioned study (Gater et al., 1998) in general health care settings adopting a cross- cultural approach evaluated the relative influence of sex differences of biological and social factors. This study assessed 26,969 primary care attenders in 15 centres in four continents using standardised methods across the centres and cultures. The results showed no sex differences for current depression, agoraphobia or panic disorder, however these results have been queried. To use a standardised assessment tool to measure distress is to assume that different cultural groups conceptualise distress in the same way. It is known from anthropological, cross-cultural and epidemiological studies that this is not the case (Guarnaccia, Good, & Kleinman, 1990; Jenkins, Kleinman, & Good, 1991; Kleinman, 1988; Rabelo, Alves, & Souza, 1995).

Evidence points to different patterns of help-seeking by men and women for mental health problems. More women than men seek services for mental health problems within the primary care setting (WHO, 1997). It appears to me that this 1997 WHO finding directly contradicts what Gater et al. found in the study mentioned earlier. The difference in help-seeking is not as significant when specialist mental health services and hospital-based services are considered. Men are more likely to be referred for specialist psychiatric care (Goldberg & Huxley, 1992). Such patterns have important implications for health policy and health service delivery. But they do not reflect the extent of treatment or the need for treatment (Goldman & Ravid, 1980).

A growing body of evidence demonstrates sex differences in the way men and women respond to and deal with distress. Evidence also indicates differences in how the health system responds to 30 women and men who seek health care. However the findings from recent research on mental distress are not consistent. Some studies have reported that doctors are more likely to diagnose depression in women than in men even when they present similar symptoms (Ono et al., 2000; Patel, 2002). The WHO study on mental illness in general health care, however, did not show such differences in the detection of depression and anxiety disorders by doctors (Gater et al., 1998). Studies in developed countries have shown female gender to be a significant predictor of being prescribed psychotropic drugs (Astbury, 2001).

In many developing countries a range of symptomatic are used such as analgesics for aches and pains, vitamin injections for fatigue and tiredness, and sleeping pills for insomnia (Patel, Abas, Broadhead, Todd, & Reeler, 2001). According to a multinational WHO study of psychotropic drug prescriptions in general health care, drugs of “doubtful efficacy” were used to treat psychological problems (Linden et al., 1999). The study reported that psychological treatments and antidepressants though efficacious and cost-effective in developing countries were rarely used (Patel et al., 2003; Sumathipala, Hewege, Hanwella, & Mann, 2000). A possible consequence of the ways in which mental distress is managed in developing countries, as mentioned above, is that patients are subjected to costly investigations and unnecessary consultations to gain relief from their illness.

In addition to gendered medical responses to mental illness, a number of studies have also uncovered gendered social responses (Ono et al., 2000; Patel, 2002). For example, women who suffer from mental illnesses face greater stigma and rejection than men. A mentally ill man may get married whereas mentally ill women are often left single. Furthermore, ill married women are more likely to be sent to their parental homes and to face desertion or divorce (Patel, 2001). Although society expected women to be the primary carers even if their husbands were mentally ill, when a woman was ill it was her own family that was responsible for her care (Patel & Oomman, 1999). As a result of such gendered social responses to mental illness in women, women may attract a greater amount of shame and dishonour. Such social responses also have a greater impact on family life because women are socially expected to be responsible for domestic activities of the household (Cooper et al., 1999).

The sheer volume of studies exploring patterns of distress among men and women is overwhelming but the great majority of these studies have been carried out in developed countries and only a small proportion have focussed on resource poor countries (Saxena, Paraje, Sharan, Karam, & Sadana, 2006). Thus there is a relative scarcity of research and consequently

31 evidence to guide health policy and health service delivery in developing countries, where the majority of the global population live. As for the Maldives I found hardly any empirical evidence that illuminates the mental health situation of women. This certainly is a gap that needs to be addressed.

2.7.3 Explanations for gender differences in mental health

Research has offered various explanations for the higher rates of mental distress in women compared to men. These include biological perspectives that focus on hormonal and physiological factors associated with reproduction (Bebbington, 1996) gender differences in the frequency of ‘life events’ (Weissman & Olfson, 1995; Wilhelm, Roy, Mitchell, Brownhill, & Parker, 2002), gender type responses to stress (Gold, 1998; Nolen-Hoeksema, Parker, & Larson, 1994) and help-seeking behaviours (Rhodes, Goering, To, & Williams, 2002). Other researchers have proposed social factors such as child-care responsibilities, experience of abuse, lack of employment, social isolation and social roles and values (Hussain & Cochrane, 2004; Patel et al., 2006).

In the medical sociological research prior to the early seventies, health and illness behaviour was explained with theoretical perspectives derived from the Parsonian sick-role theory (Williams, 2005). According to this framework, the traditional female sex role was seen as compatible with the adoption of the sick role (Nathanson, 1975, 1977). Recent research associates the male sex role as being dangerous to health (Kimmel, 2000; Waldron, 1995). As mentioned earlier, some studies have indicated men respond to distress by indulging in risk behaviours such as substance abuse. Current research on gender differences in mental distress, physical health and coping has extended the notion of ‘roles’ for both men and women, examining the effects of multiple roles on mental distress (Thoits, 1995; Waldron, Weiss, & Hughes, 1998). Current research also takes a functionalist view of health, illness and medicine. This view takes into account the gender system and the structures of institutions as well as the gender roles that contribute to ill health.

The first significant departure from an intrinsic biological, hormonal and reproductive model of theorising about women’s mental health was made by Brown and Harris (1978). Their study of depression in working class British women illustrated the significance of social factors and chronic life difficulties for the mental health of women. Following their pioneering work there now exists a substantial body of knowledge pointing to the social origins of mental distress (Horwitz & Scheid, 1999; Tausig, Michello, & S., 1999). This body of knowledge clearly demonstrates that social

32 factors such as income, employment, poverty, education and access to community resources are major contributors to mental distress (Kawachi & Berkman, 2001; Neugebauer, 2001; Patel et al., 1999).

Pugliesi (1992) proposed two perspectives to explain the gender differences in mental health. The first is a social causation perspective that associated women’s greater vulnerability to mental distress to their restricted social roles, the high demands placed on them as carers, learned helplessness and economic hardships. The second perspective is a social constructivist view which argues that women are more likely to be identified as distressed and to identify their own experiences in psychiatric terms.

Two key studies demonstrate the role of gender based stressors on mental distress in women from resource poor countries. Broadhead and Abas (1998) researched the social origins of depression in women living in the townships of Harare in . This study confirmed that adverse life experiences were associated with increased risk of depression. Adverse life experiences identified in this study included humiliation and entrapment related to marital crises such as being deserted with several children; premature death, illness in family members and severe financial difficulties occurring in the absence of an adequate welfare safety net.

A cohort study of attending a district general hospital in in India aimed at investigating the predictors, prevalence and impact of post- depression (Patel, Rodrigues, & DeSouza, 2002) is another key study that illuminates the social context of women’s lives in developing countries. This study explored the relationship between marital violence and sex of the newborn child and the risk for post-natal depression. The results showed marital violence both during and before pregnancy were strongly associated with post-natal depression. The study also showed the birth of a boy child acted as a protective factor for mothers exposed to other risk factors for depression.

In interpreting the evidence presented in this chapter it is important to consider the potential methodological issues that may influence the quality of the results. I see several such issues. First most of the research is based on treated cases. Many of the samples, especially in studies undertaken in developing countries, come from primary care facilities. Given the variations in access to health care, especially across countries and even within the same country across urban and rural areas it cannot be assumed that all individuals have equal access to treatment. Thus it is questionable whether the ‘treated prevalence’ represents ‘true’ prevalence. Also Piccinelli (1997) rightly notes that there is a lack of specificity in the definitions for mental health problems 33 such as depression. For example recognition of psychological morbidity being related to the training of doctors has been reported across primary care centres in developing countries (Patel, 2001). Patel suggests too that low recognition is also attributed to factors such as patient discomfort in reporting distress because of the stigma related to mental illness as well as patient’s perceived lack of personal skills in dealing with ‘mental’ problems.

Standardization of studies has also been reported as problematic for most research. In most studies only age and gender has been standardised and demographic factors such as class, education and occupation have been ignored (Brown & Harris, 1989). Also gender in these studies is not used to reflect the social construction. Rather it reflects the differences in the biological construct of males and females. Future studies need to formally assess femininity and masculinity as well as social role and economic, political and social status. Such a dissection I contend would provide a better account of the true social context of the lived experiences of women.

In recent years an extensive body of work has looked at the relationship between gender inequalities and the health of women (Doyal, 1995; Doyal, 2000). This body of knowledge points to the following gender risk factors for poor mental health in women: gender socialisation, role- related activities, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank, gender based violence and unremitting responsibility for the care of others. Gender creates inequality between men and women in terms of power, autonomy and well-being to the disadvantage of women (Belle, 1990; Doyal, 1995; Doyal, 2000; Murphy, 2003; Romans, 1999; WHO, 2005). Such inequalities lead to lower socio-economic status and poverty. While poverty is not associated just with women, women and girls often suffer additional disadvantages due to discrimination (Doyal, 2000).

Scholars such as Blue et al (1995) strongly argue social causes to be the most important factor contributing to the higher rates of mental distress in women. They point out that globally more women live in poor social and environmental circumstances associated with low education and low income. Furthermore women are often faced with difficult family and marital relationships. Faced with social disadvantage, women are two to two and a half times more at risk of adverse health outcomes, both mental and physical than those who experience less disadvantage (Bartley & Owen, 1996; Feinstein, 1993; Kessler et al., 1994; Kunst, Geurts, & Berg, 1995; Lahelma, Pekka, Rahkonen, & Silventoinen, 1999; Lahelma, Rahkonen, & Huuhka, 1997; Macran, Clarke,

34 & Joshi, 1996; Power, 1994; Stanfeld, Head, & Marmot, 1998; Wadsworth, 1997; Wilkinson, 1997a, 1997b).

2.7.4 Interpersonal violence and mental health of women

One of the most significant gender differences that contribute to poor mental health in women is interpersonal abuse both physical and emotional (Astbury, 1999; Heise, Raikes, Watts, & Zwi, 1994; Romito, Molzan Turan, & De Marchi, 2005). Globally millions of women suffer from violence or live with its consequence, but because of the sensitivity of the subject, the actual extent of the problem is not reflected in the data available (Naved, Azim, Bhuiya, & Persson, 2006; Watts & Zimmerman, 2002; WHO, 2002). Watts and Zimmerman report the most common and most severe forms of as including: intimate partner violence; sexual abuse by non-intimate partners; trafficking; forced prostitution; exploitation of labour and debt bondage of women and girls; physical and sexual violence against prostitutes; sex selective abortion; female infanticide; the deliberate neglect of girls and rape in war. Such violence has profound physical and mental health consequences for women (Patel et al., 2006; Russo, Koss, & Ramos, 2000).

The incidence of violence experienced by women is reported to range from 10% to more than 50% in different countries (Murphy, 2003). There is indisputable evidence from both community samples and psychiatric samples showing violence is associated with multiple negative mental health outcomes (Anderson, Yasenik, & Ross, 1993; Bifulco, G.W., & Adler, 1991; Brown & Anderson, 1991; Finkelhor, Hoatling, Lewis, & Smith, 1990; Mullen, Romans-Clarkson, Walton, & Herbison, 1988; Pribor & Dinwiddie, 1992; Waller, 1994). Women who have experienced violence have increased rates of depression, anxiety (Jaffe, Wolfe, Wilson, & Zak, 1986), dysthymia, stress related syndromes, phobias, substance abuse (Winfield, George, Swartz, & Blazer, 1990), and suicidality.

To summarise, there is a large body of evidence that conclusively points to a comparatively lower state of mental health for women worldwide, particularly in developing countries. Biological and social explanations have been provided to explain the higher rates of mental distress in women. There is also a large body of literature demonstrating that countless women, especially in developing countries, are systematically denied experiences of self worth, competence, autonomy, economic independence, and physical and emotional security because of gender based discrimination. Such socially constructed gender discrimination affects the onset and course of mental health problems and even access to health services. Cultural perceptions,

35 beliefs, values and expectations perpetuate gender roles so it is crucial to explore the role of culture in mental health.

2.8 Culture and mental health

Anthropological research has illuminated the cultural aspects of gender and health (Bendelow, 1993). Such research has also provided insight into women’s views of their body and bodily experiences (Warin, 2000; Watson, Cunningham-Burley, Watson, & Milburn, 1996), their selves and their ways of coping (Boddy, 1988).

Defining culture Culture has been defined in different ways by various anthropologists. Helman (2001) defines culture as follows:

A set of explicit and implicit guidelines (transmitted through language, symbols and rituals) that individuals inherit as members of a particular society, and that tell them how to view the world, how to experience it emotionally, and how to behave in it in relation to other people, to supernatural forces or gods and to the natural environment” (p. 2).

Helman describes culture as an “inherited lens” through which the individual perceives and understands the world that (s)he inhabits and within which (s)he learns to live.

2.8.1 Anthropology and mental distress

Anthropology offers an alternative approach to understand experiences associated with mental distress (Eisenbruch, 1990; Garro, 2000; Good, 1997). For example anthropology has complemented epidemiological and clinical studies providing ethnographic accounts that illustrate psychological pain may not necessarily be realised as ‘depression’ or ‘anxiety’ in all cultures. Instead local idioms of ‘nerves’ or ‘attacks’ (Camino, 1989; Foss, 2002), ‘sinking heart’ (Krause, 1989) and intrusions by unwanted ‘spirits’ (Boddy, 1988; Bourguignon, 1976; Littlewood & Lipsedge, 1989) are used. A voluminous body of anthropological data from countries spanning North and South America, the Mediterranean region, Africa, the , and the Middle East and beyond illustrate cultural ways of explaining and expressing distress (Good, 1977; Guarnaccia, Rivera, Franco, Neighbors, & Allende-Romas, 1996; Kirmayer, 1989; Lee, 1998; Obeyesekere, 1977; Weiss, Raguram, & Channabasavanna, 1995).

36 2.8.2 Why is culture important in addressing mental health?

The cultural background of a person influences how they perceive illness, how it is to be treated, and who should provide the healing (Al-Issa, 1995; Al-Krenawi, 1999; Kleinman, 1980; Weiss et al., 1986). Culture also affects how individuals define and describe and explain their distress (Good, 1977; Kirmayer, 2001; Marsella, DeVos, & Hsu, 1985; Patel, 1995). According to Kleinman (1980), people use various frameworks that are shaped culturally to explain their illness. Findings from international research, for instance, indicate that the symptomatology, help- seeking and course of many psychiatric illnesses are influenced by the way various cultures interpret these illnesses (Saravanan, Jacob, Prince, Bhugra, & David, 2004).

In some cultures, depression or anxiety is seen as a bodily and spiritual phenomenon (Bhatt, Tomenson, & Benjamin, 1989; Jenkins & Cofresi, 1998; Nations, Camino, & Walker, 1988). In various societies syndromes are described in relation to culture and religion (Obeyesekere, 1977). Thus it is important for health care providers to be familiar with and to understand the specific aspects of a particular society or culture that may influence the way in which a patient may present and explain his/her distress. The absence of such an understanding of the cultural norms, values and beliefs of the patient is likely to lead to misperceptions and quite possibly to misdiagnosis (Good, 1997; Patel, 2001; Raguram, Weiss, Keval, & Channabasavanna, 2001; Wagner, Manicavasagar, Silove, Marnane, & Tran, 2006).

Further support for the cultural differences in the understanding of mental distress comes from anthropological and sociological research. Research from Africa shows that while similar states of distress evoked recognition from local health workers, the causes were closely linked to the interaction of social, economic and spiritual problems afflicting the person (Patel, Musara, Maramba, & Butau, 1995). Concepts such as depression can be elicited (Kleinman, 1980), but may have a different meaning within the culture and for the person suffering. Hence, in many resource-poor countries, mental distress is not viewed as an illness that requires medical treatment (Patel, 1996). These studies further support the need to recognize the role of culture in dictating the presentation of illness as was pointed out by the seminal work carried out by Kleinman (1980). If the role of culture is ignored, the disjunction between aetiology, diagnosis and treatment will continue.

For many people psychiatry is associated with lunacy and insanity and both distressed persons and their carers are unwilling to associate themselves with the related stigma. Also stigma attached to mental illness becomes a barrier to accessing resources (Reidpath, Chan, Gifford, & 37 Allotey, 2005). These authors indicate that stigma is likely to prevent depressed people from seeking help from mental health professionals. For similar reasons distressed people tend to use somatic idioms of distress such as vague aches and pains (Conrad & Pacquiao, 2005).

Mental illnesses are diagnosed using different approaches depending on the type of healing system. The healing system describes varieties of severe mental disorder (unmada) arising from a particular humoral imbalance (dosa) or arising in association with specific demons and deities (Weiss et al., 1988; Weiss et al., 1986). In Western psychiatry the medical model for mental illness uses two distinct systems. These include the World Health Organization’s International Classification of Diseases, Tenth edition: ICD-10 (WHO 1992) and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth edition: DSM –IV (APA 1995). The diagnostic classification systems of Western psychiatry assume a mind/body dichotomy, whereas other systems such as the Ayurveda healing do not distinguish between mind and body but takes a holistic view of health (Alter, Bray, Guha, Joshi, & Leslie, 1999).

Diagnosis of mental illnesses using the medical model has been criticised for the vagueness and ‘intrinsically subjective’ nature of symptoms (Burr & Chapman, 1998) which might make it more likely for mental illnesses such as depression to go unrecognised. This may arise because some of the symptoms of depression such as depressed mood, diminished interest or pleasure in activities, fatigue and feelings of worthlessness, can easily be mistaken for a normal part of everyday experiences for many people (Burr & Chapman, 1998).

The above criticism of the medical model is particularly pertinent to cross cultural psychiatry where the debate between universalist versus relativist positions has been raised (Patel, 2001). Universalists argue that mental illnesses can be defined in ways applicable to a wide variety of contexts meaning incidence and causes of depression can be studied in many settings using standardised measurements (Marsella, 1978, 1979; Singer, 1975). Relativists argue that categories of mental illnesses have to be understood within the social and cultural context in which they are found (Patel et al., 1999; Patel et al., 1998; Patel et al., 1997). But some scholars argue that even fundamental emotions such as anger and sadness cannot be the same thing in different cultures (Kleinman & Good, 1985).

Evidence from the literature, as indicated earlier, demonstrates how concepts of mental illness differ from culture to culture. It is not the intention of this thesis to argue for or against the Western model and the diagnostic tools that go with it. The point emphasised here concerns the 38 need to be aware of the role of culture in shaping how people express their mental and emotional distress. Cultural differences need to be considered in conducting research into mental health as well as in provision of mental health services.

Culture also influences how practitioners communicate with their patients when exploring patients’ explanations of their suffering and interpreting these explanations to diagnose and treat them. Studies have shown that when practitioners were not familiar with the patients’ explanatory models of their illness, under-diagnosis and inappropriate treatment resulted (Al-Krenawi, 1995; Bravo & Grob, 1989; Budman, Lipson, & Meleis, 1992; Chiu, 1994; Eisenbruch, 1991; Kortmann, 1987b).

2.8.3 Cultural variations in the definitions of abnormality

Abnormality and normality are viewed in different ways depending on the specific culture (Marsella, 1979). By defining normality and abnormality every culture conditions the patterns of acceptable behaviour. Normality is socially defined, varies from country to country and is related to what is deemed the ‘proper’ way for individuals to conduct their lives in relation to others (Helman, 2001). Based on what a society perceives as ‘normal’ versus ‘abnormal’ and whether the behaviour is seen as ‘controlled’ or ‘uncontrolled’, behaviours can be labelled by societies as ‘mad’ or ‘bad’. These labels are fluid and likely to change with time and circumstance and the perspective of the onlooker. When the behaviour is not controlled by the rules of the society, then it is labelled as ‘mad’ or ‘bad’. For example when a person cheers loudly, shouts and runs around during a football match, this behaviour is seen as normal. However, the same behaviour within a classroom may either be labelled as ’mad’ or ‘bad’.

In many developing countries mental illness is perceived as ‘abnormal action’ rather than ‘mistaken belief’ (Littlewood & Lipsedge, 1989). Hence what is normal in one culture may be considered abnormal in another. For instance, the behaviour of an American or North European adolescent who is being rebellious against his parents may be seen as a part of normal growing up whereas the same behaviour in a young Arab man may be seen as abnormal or bad (Budman et al., 1992). Similarly a person who says she has been seeing a jinni or supernatural spirit who appears to her as this huge grotesque looking man may not been seen as abnormal in some cultures, whereas in a Western setting she may be considered as hallucinating and labelled as afflicted with a psychiatric illness. Thus how cultures define or describe what is normal or abnormal is an important consideration for mental health.

39 2.8.4 Cultural influences on recognition of mental health problems

There is documented evidence pointing to worldwide under-recognition and under-treatment of mental health problems such as depression, especially in primary care (Ballenger, Davidson, & Lecrubier, 2001; Lecrubier, 1998, 2001; Sartorius, Ustun, Lecrubier, & Wittchen, 1996). Under- recognition of mental distress is related to: different levels of awareness and recognition for cultural reasons (Lecrubier, 2001), popular perceptions of the role of the doctor in each country, and different pathways to care and health systems (Goldberg, 1999). Other factors contributing to under-recognition of mental distress include the following:

Some cultural groups present mainly somatic complaints and are less willing to express depressive ideas as was demonstrated in studies of people of South Asian origin in UK (Bhugra & Mastrogianni, 2004; Commander, Sashidharan, Odell, & Surtees, 1997; Gillam, Jarman, White, & al, 1980).

Some groups do not disclose their symptoms and so are unlikely to be recognized as having a mental health problem as was the case with Indian women consulting general practice in London (Jacob, Bhugra, LLoyd, & al, 1998).

Physicians are less likely to detect depression among some ethnic groups especially when the patient’s background is different from theirs (Borowsky et al., 2000; Comino, Silove, Manicavasagar, Harris, & Harris, 2001; Leo, Sherry, & Jones, 1998).

The recognition of mental health problems is complicated because cultural idioms of distress shape the way in which symptoms are presented, and there are variations in these depending on the setting (Chowdhury, Chakraborty, & Weiss, 2001; Manson, 1995; Manson, 1997; Weiss, 1985; Weiss et al., 1986)

2.8.5 Cultural explanations for suffering and distress

Explanations for suffering and distress are based on perceptions of the cause which, according to some researchers, revolve around concepts of the mind (Patel, 1995). Patel suggests illness causation can be looked at from the point of view of the concept of the mind and that disease causation is also intimately related to traditional and religious beliefs.

Shweder and colleagues (1997) states that human suffering of the soma, psyche, and spirit range widely and cover a “large territory of afflictions, symptoms, and complaints” (p. 121). However,

40 the ‘causal ontologies’ related to these sufferings are limited. They identify seven kinds of ‘causal ontologies’ which apply across the world, and they are described below (p. 121-123).

The biomedical ontology is common within Western biomedical explanations for suffering and includes genetic defects, hormone imbalances, organ pathologies, and physiological impairments. Within the non-Western healing systems such as Ayurvedic medicine, biological ontology includes humours, precious bodily fluids and juices (semen, blood, ascorbic acid), and interacting with nature in ways that enhance feelings of strength and well-being. Treatment usually includes ingestion of special substances, herbs and roots, vitamins, vegetable compounds, and chemical compounds, or it may include direct or indirect mechanical repair of damaged fibres and organs through surgery, massage or emetics.

Interpersonal ontology in traditional societies refers to sorcery, evil eye, black magic, spirit attack, poisoning, and bewitchment. In contemporary society this ontology relates to harassment, abuse, exploitation, ‘codependencies’ and ‘toxic relationships’. Interpersonal ontology is associated with the idea that one can fall sick due to the envy or ill-will of others in one’s physical world such as colleagues, neighbours, and associates. Suffering and ill health are alleviated through the use of talismans and other protective devices and strategies for avoidance of aggressive counterattack and the repair of interpersonal relationships.

Socio-political ontology associates suffering with oppression, colonial (including ideological) domination, or adverse economic or family conditions. Suffering is addressed through social reform aimed at changing one’s life circumstances.

Psychological ontology refers to suffering that results from unfulfilled desires and frustrated intentions (for example, repressed wishes) or various forms of fear. Intrapsychic and psychosocial interventions are used to address suffering arising from psychological ontology. Therapy also includes meditation, dialogue, therapeutic relationships, consciousness-raising and realistic goal setting.

Astrophysical causal ontology refers to malevolent arrangement of planets, moons, and stars and to auspicious and inauspicious periods of time. Treatment relates to waiting for the auspicious time when the recovery is believed to occur spontaneously or the treatment interventions can be effective.

External stress is an emerging causal ontology where stress or pressure or environmental risk factors are believed to cause suffering. The stressors may be of a social or biochemical nature

41 and therapy focuses on minimizing the level of stress achieved through relaxation, better use of leisure time, and the reduction of the ambient hazards in one’s environment. The minimization of environmental hazards is achieved through education and foresight.

The final ontology is the moral causal ontology which refers to transgressions of obligation. Suffering from this ontology is perceived to result from one’s own actions or intentions. A loss in moral fibre is seen to lead to misfortune and it is believed that outcomes are proportionate to actions. Treatment focuses on unloading one’s sins, confession, purification, reparation, moral education, and the adoption of the “right practices” sanctioned by a sacred authority

Explanations for mental health problems vary from culture to culture. In Africa, mental health problems have been attributed to a range of causal factors such as fear of certain objects and intoxication (Kortmann, 1987a); natural causes such as worms, rapid changes in climate, improper diet, infections, heredity, abnormal functioning of the brain (Cheetham & Cheetham., 1976; Fosu, 1981); thinking too much or excessive worrying (Avotri & Walters, 1999; Fosu, 1981); and supernatural causes such as God-given, angry or upset ancestors, deities or gods, evil forces or witches and sorcerers and the evil eye (Al-Issa, 1995; Aradom, 1996; Azhar & Varma, 2000; Boddy, 1988; Boddy, 1989; Cheetham & R.J., 1976; Odejide, Olatawura, Sanda, & Oyenye, 1977; Patel, 1995; Samuelsen, 2004; Somer & Saadon, 2000).

A number of anthropological studies carried out in other parts of the world such as the Middle East, , East Asia and Latin America have provided data which indicate a widespread belief in possession by supernatural agents such as jinni or an ancestral god or deity, or the evil forces of witches and sorcery as causes of mental health problems (Begelman, 1993; Castillo, 1994; Constantinides, 1985; Crapanzano & Garrison, 1977; Eisenbruch, 2000; Kapferer, 1991; Kemp & William, 1987; Littlewood & Lipsedge, 1989; Martinez-Taboas, 1999; Murdock, Wilson, & Frederick, 1978; Schwartz, 1985).

Given the research findings pointing to the existence of cultural ways of expressing and experiencing distress, it is crucial for clinicians to understand these local idioms, not just for accurate diagnosis, but also for building a rapport between the clinician and the patient so as to enhance success in treating mental health problems (Kirmayer & Groleau, 2001). Such understanding can only be gained if the information related to the ways in which culture shapes explanations of illness and how people express and experience and deal with illness is available. For the Maldives such information has not been adequately documented.

42

2.9 Summary

In summary the following are the key findings from the literature review:

• Mental illness is an important public health problem of global proportion. • Mental health problems such as depression and anxiety affect a disproportionate number of women compared to men. • Socially constructed gender differences between women and men in terms of their roles and responsibilities, status and power influence the onset and course of mental health problems in women as well as access to health services. • Mental health research is important for developing appropriate interventions and policies. But there is geographic disproportion for mental health research with less than six percent of documented mental health literature being from low- and middle-income countries. • A number of social and environmental factors make women more vulnerable to mental distress. At the same time social and environmental factors can also protect women from mental illness and promote their mental well-being. • Health care providers especially in developing countries fail to recognize mental health problems. Even when they do recognize mental health problems they often either misdiagnose or provide inappropriate treatment. • Inappropriate management of mental health problems occurs because health care providers may not be familiar with the culture- specific ways of explaining and expressing distress. • Culture influences how individuals and society conceptualize, experience, understand, express and deal with mental distress. • Culture influences how practitioners communicate with their patients in exploring the patients’ explanations of their suffering and interpreting these explanations to diagnose and treat them. • Suffering and distress associated with depression and anxiety in most cultural groups is presented in local ‘idioms of distress’ or ‘metaphors of distress’ and not in biomedically recognised symptom patterns.

43 2.9 Conclusions

The literature reviewed for this study provides sufficient evidence to demonstrate the need to pay careful attention to local cultural patterning and explanations of distress, especially the definitions of what is normal or abnormal and the idioms of distress, since these have implications for the recognition and successful management of mental health problems. However, information related to cultural patterning and explanations of distress in the Maldives is lacking. This study aims to address this gap.

There are other gaps in the existing literature. First, mainstream literature for the most part places the origins of suffering and distress within the biological body of the woman but does not adequately address the material conditions within which women experience their suffering and distress. Second, the cultural differences in suffering and distress have frequently been measured using implicit standards from the researcher’s own perspective, which are usually based upon the medical models used in Western psychological and psychiatric nosology. Women’s subjective experiences and their individual circumstances within which such experiences occur have not been adequately addressed, particularly in South Asia. Certainly sociological and anthropological studies have gone beyond the universal categories of mental illnesses and investigated subjective meanings and the material conditions surrounding individual’s experiences of distress. But these studies have been undertaken several years ago. I would contend that with globalisation and the social, political, environmental and technological changes that have occurred in the last decade, there is a need to update the evidence so that health services and health policy can be formulated to reflect the current situation.

Finally, to promote women’s mental well-being, mental health policies and programs must address women’s personal, social, cultural and environmental contexts that affect their illness experiences. Failure to address these contexts is “a loss of valuable opportunities to reduce the burden of mental illness” (Allotey, Reidpath, Kouame, & Cummins, 2003, p. 957). Policies and programs that target women’s concerns and needs will enable women to increase control over the determinants of their mental health and thereby improve their health status and health outcomes. This means listening to the women and giving voice to their concerns to ensure that the services provided are acceptable to them and suited to local settings. That is what this study seeks to do for women in the Maldives.

44 Chapter 3

STUDY SETTING

In this chapter I provide background to the study setting in terms of the geography, demography, cultural and social norms, gender perspectives and the health situation. This information is provided for two main reasons. First, the Maldives is an isolated and lesser known country and it will serve to acquaint the reader with the background details needed to contextualize my findings. Second, these factors have a bearing on women’s health.

The information I provide is, for the most part, based on documented literature and my own experiences of growing up and spending most of my life in the country. I also draw on my experiences of more than fifteen years working in the government health sector, the nongovernmental sector on issues related to gender equity and the community in the area of women’s and children’s rights.

3.1 Geography and population

The Maldives is an island nation situated in the just above the equator. According to the Ministry of Planning and National Development (MPND, 2004), the Maldives archipelago is made up of 1190 coral islands of which only 199 are inhabited. The islands are scattered over a territorial area of 859,000 square kilometres of which 95% is ocean. Geographically these islands are naturally formed as 26 . For administrative purposes they are divided into 20 atolls. An is not an economic, social or anthropological abstraction. It is a circular coral reef surrounding a lagoon, a unit based on geology and geomorphology.

Male’ is the capital of the Maldives and the only urban centre. Roughly two square-kilometres in area, Male’ is the seat of government and the economic centre of the Maldives. The only international airport is located just across from Male’ on the nearby island of Hulhule’. With twenty percent of the total population (74,069) living in Male’ it is among the most densely (in excess of 37,000 persons/square km) populated places in the world (MPND, 2004). The rest of the islands are considered rural.

The 199 inhabited islands make up only 57% of the landmass and less than one fifth of the islands of the Maldives. The islands are small, varying from small sandbanks with a few bushes to the largest islands with about a five square kilometre area. Only 33 of the inhabited islands

45 have a land area of more than one square kilometre, while just three islands are larger than three square kilometres. Eighty percent of the islands have an elevation of less than one metre above sea level, with maximum height above sea level being around three metres (MPND, 2004). The physical size of the islands has implications for the well-being of their inhabitants and I will elaborate on this later.

3.1.1 Population and demography

According to the last population census (2000), the total population was 270,101 of which 27.4 percent resided in the capital island Male’. The population of the other islands varies from about three hundred to over 3,000 with only six islands having a total population of over 3,000. Nearly 71 percent of all inhabited islands have a population of less than 1,000 (MPND, 2004).

The majority of the population of the Maldives is under 35 years of age. About 41 percent is less than fifteen years of age and more than a third between 16-35 years of age. The elderly population (above 65 years of age) makes up less than five percent of the total population. The dependency ratio (ratio of the population under fifteen years and over sixty five years to the working age population ages 15-64) is 0.8 dependents per working age person. Compared to the rest of the world this is one of the highest dependency ratios (MPND, 2004).

The geographical and demographic characteristics of these islands contribute to a stressful life. First, the sea-locked nature of the islands and the lack of regular transport mean the islands are isolated and cut off from the rest of the country. This means access to services and the delivery of basic supplies is time-consuming at the very least. Second, the geography and the small populations make provision of services very expensive and economically not viable. Third, the limited physical space means people have to live in close proximity, a factor that has implications for health and which is discussed later. Lastly, the high dependency ratios are particularly significant for women’s lives since it is women who are accorded the main responsibility of caring for the young, the elderly and the sick.

3.2 Historical, social & cultural setting

The country has been continuously independent politically except for a period of 17 years in the 16th century when Portugal is said to have gained control. In 1887 the Maldives became a British protectorate with the British responsible for the country’s defence and foreign relations while the

46 country itself took care of internal affairs and decision-making. The country gained full independence in 1965.

3.2.1 Anthropological origins

It is not clear when the Maldives was first populated and by whom. The Norwegian archaeologist Heyerdahl (1986) suggests it was earlier than the sixth century B.C. The biological expedition carried out in 1889 by Professor John Stanley Gardiner to determine the ancestral roots of indicate the population to be a mix of Indian, Arab, Sri Lankan, African, Indonesian and Malaysian blood (MPND, 2004). Maloney (1980) used linguistic and anthropological material from nearby (Laccadives) and from the coast of Kerala in India to trace historical ties to Tamil ethnicity. He suggested there was strong evidence that originally a matrilineal kinship system prevailed in the Maldives.

The influence of the various ancestral roots can be seen in some current cultural practices related to and healing. For instance Buddhist tantric components of superstition are still to be found in the Maldives (Romero-Frias, 1999). However, much of the old ritual and superstition originally derived from southern and northern India such as those related to female spirits and the ancient goddesses of the sea and the islands has slowly died out. Government policies do not encourage practices that reflect non-Islamic values and cultures.

Romero-Frias writes in his book The Maldive Islanders – A Study of the Popular Culture of an Ancient Ocean Kingdom - that some of the old healing practices in the form of occult magical practices, known locally as fandithaverikan still survive. These practices continue to influence some of the beliefs and perceptions related to suffering and distress in the Maldives.

3.2.2 Language

The is known as Dhivehi; it is spoken throughout the atolls but dialectical differences exist in the four southernmost atolls. Dhivehi spoken only in the Maldives and in in India is an Indo-Aryan language closely related to and derived from (The Dhivehi Language, 2003). Cain (2000) states Dhivehi is the only Indo-European language whose indigenous area extends into the Southern Hemisphere. Present day Dhivehi has been influenced by Persian, , Arabic and Tamil, and more recently English. The language has its own written script, , written from right to left and influenced by Arabic.

47

3.2.3 Religion

The Maldives is a Muslim country, and to be a citizen of the Maldives one has to be a Muslim. Most Maldivians observe and respect the five pillars of Islam2. Apart from this people are quite liberal in terms of the way they dress and men and women interact. Women are not required to cover their hair or their faces, although there is an increase in the number of women who wear the buruqa, a scarf that covers the hair, neck and chest area. Since Maldives is an Islamic state alcohol is forbidden and sex outside of marriage is illegal.

In the last few years some Maldivian men have studied in very strict and fundamentalist Islamic schools in and Saudi Arabia. Upon their return they have started spreading Islamic teachings some of which are more related to pre-Islamic tribal traditions. As a result, in some islands we now see almost all women wearing the buruqa and some girls and women facing restrictions in their mobility. During my work in the area of child rights I came across isolated cases of girls not being sent to school but being taught at home instead.

When I reflect back on the influence of Islam on the everyday lives of Maldivian women as I was growing up and compare that to what is happening today, I can see the possibility of fundamentalist Islam becoming a real problem in the not too distant future. If and when that happens it will have negative implications for Maldivian women. For instance, women will have less opportunity to work outside the home and there will be restrictions on their mobility. So far the government has played a strict role in ensuring that fundamentalist Islam does not gain a strong foothold.

Prior to the adoption of Islam around 1153 the Maldives was a Buddhist state. (1986) in his book, The Maldives Mystery, points to earlier different forms of worship; sun- worshipping seafarers called the Redin first settled on these islands. Even today many mosques in the Maldives face the sun and not Mecca as these were built on the ancient foundations of Redin culture temples. There is also some evidence that was practiced in the Maldives (Romero-Frias, 1999).

2 The five pillars include i) belief in one God (Allah) and Mohamed as his prophet ii) praying five times a day iii) fasting during the month of Ramadan iv) giving alms to the poor and v) pilgrimage to Mecca for those who are able in body, mind and financially.

48 3.2.4 Government

From the time of conversion to Islam up to 1968 a or and his or her various advisers and ministers governed the country. Currently political control is exercised at the central level by the President and his cabinet Ministers. Each of the atolls has an Atoll Chief (AC) who sees to the day-to-day administration of government policies. The Atoll Chiefs are assisted by Island Chiefs (IC) who serve as administrative leaders of island communities. The first Constitution was proclaimed in 1932 and the first republic declared in 1953. This was dissolved and a Sultanate re-established until 1968 when the second Republic was declared at the end of British rule. The Maldives then became a member of the UN as an independent state.

Maldivian government is based on a parliamentary system of democracy. However, whether the country is a true democracy or not is a matter of intense debate. The current political system is very much government controlled and leaves very little room for freedom of expression and speech. The media is mainly controlled by the government and there have been several incidents where people have spoken out against the government and consequently been arrested and detained.

At the time of writing this thesis, the country is going through a process of constitutional change with plans for establishing a better democracy, giving people more freedom of expression, and ensuring human rights and good governance. However, it is a slow and chaotic process with much conflict between those currently in power and those pushing for reform, resulting in increased tension and problems within the general population. An example of increasing tensions is the riots in September 2002 in the capital island which lead to a number of arrests. This kind of rioting and public expression of dissatisfaction is only the second such incident in the entire .

3.3 Family life and child bearing

The family continues to be the basic unit of Maldivian society, a society closely knit and unified by language and religion. Family, both nuclear and extended, provides the social support system be it in old age or during hard times. It is an accepted norm for two young people to live with either of their parents even after marriage. There is no compulsion to move in with the spouse’s family and the choice is more dependent on space availability and the financial status of the family.

The household is based on the extended family system. It is quite common for the extended family including grand parents, aunts and uncles and their families to be living under one roof. 49 Family authority rests with the patriarch of the family, usually the father. If the father is deceased the eldest son takes over the role, provided he is over fifteen years old.

Female members of the family are culturally and legally always under the protection of a male older than 15 years of age. Until she gets married this responsibility falls on the woman’s father or if he is deceased then her eldest brother or uncle. Once she gets married her husband takes on that role. If she is divorced, her father, her eldest son or her eldest brother becomes responsible for her. Protection and responsibility for a female member of the family include providing financial security, food, shelter, clothing, education, and health care. It also includes protecting her honour and dignity and ensuring her general well-being. While the law states her protector and guardian should provide her with all of the above, in practice numerous women are left to fend for themselves.

Protection and responsibility also means that major decisions in a woman’s life are made for her by her legal guardian. For instance a woman cannot get married unless her legal guardian gives his formal consent for her to marry. In the event he refuses to provide such permission, the current legal system does have provision for the woman to get a court order. Another example is decisions related to , which I illustrate below with an anecdote I encountered in my professional life.

The mother of a woman who worked for me was divorced when she was pregnant. This being her fifth child she wanted her gynaecologist to sterilise her when the baby was being delivered by caesarean section. However, hospital regulation required that she obtain her husband’s written consent for this permanent method of contraception. When she explained to the hospital that she was no longer married and her father was deceased she was asked to obtain her sixteen year old son’s consent.

In the above example, even though the woman was an adult she did not have the legal right to make a decision that involved her own body. This is not an isolated incident as health facilities which provide contraceptives to women officially require that a woman obtain her husband’s/guardian’s consent.

The average household size was 7 for the intercensual period 1995-2000 (MPND, 2004). Households in Male’ are extremely congested with the average number per dwelling being 8. Living in extended families, especially in congested households, brings with it numerous issues that influence the well-being of all members of the family.

3.3.1 Marriage and divorce

Marriage and divorce in the Maldives is based upon the Islamic Shariah. Thus both men and women have the freedom of choice of marriage and women are given the right to determine their 50 bride price or dowry. In most Islamic countries dowry is seen as a financial security for the woman and thus the woman receives a substantial amount either in terms of assets, property or money. However, in the Maldives, the tradition is to ask for a small sum of money as dowry, a small dowry being seen as a sign of her love for her husband to be.

The ease of marriage and divorce is noted by Ibn Batuta a native of Tangiers who lived in the Maldives from 1343 – 1344:

It is easy to get married in these islands, owing to the smallness of the dowry, as well as by reason of the agreeable society of the women. Most of the men say nothing about a nuptial gift, contenting themselves with declaring their profession of the Musalman (Muslim) faith, and a nuptial gift in conformity to the law is given. When ships arrive, those on board take wives and repudiate them on their departure: it is kind of temporary marriage. The Maldivian women never leave their country. (Gray, 1999, p. 13).

Before most the couple usually court each other for a while, which is again different from what usually happens in more conservative Muslim countries. Boys and girls and men and women have the freedom to visit each other in their homes and go out together but must not be sexually active prior to marriage. Yet in reality couples do become sexually involved before marriage and they may even end up not getting married to each other. Being a virgin is not perceived as a virtue any more by the husband, and a woman is not stigmatized for not being a virgin. However, if she happens to become pregnant out of wedlock, then she is ostracised by the community. Moreover, pregnancy out of wedlock is considered a crime punishable by law.

Maldivians have taken full advantage of the ease of marriage and divorce permitted by Islamic law resulting in a complex maze of relationships among parents, children, in-laws and cousins. Polygamy although uncommon does occur. Legally marriage is a simple process. Divorcing until 2001 was also a very easy process. A man could divorce his wife simply by saying so three times and formally registering the divorce within 3 days. He could send her a letter from thousands of miles away and tell her she is not his wife. This easy process of divorce and marriage is perhaps one of the reasons for the high divorce rate in the Maldives. This system changed in 2001 with the introduction of the family law requiring both husband and wife to appear in the court where the divorce is taking place. Violation of this process results in the man being fined or being placed under house arrest.

A study that I undertook in 2001 revealed that marriage patterns in the Maldives are influenced by parents (Razee, 2001). Parents welcome and facilitate early marriages in order to ease economic burdens and material responsibilities for their daughters. Furthermore, the absence or very limited

51 availability of employment or economic development or educational opportunities on the outlying islands leaves few alternatives for girls but to marry early and have children.

Marriage is an important aspiration for both men and women, especially for women. Even today, soon after one has completed high school, the next goal in life for a woman is to get married and start a family. To remain single past one’s twenties is seen as not fulfilling the social obligations of a woman. I faced this very situation as I did not marry until I was thirty five. Every time I met a family member or a family friend or even a colleague I was faced with the question “When are you getting married”? When I eventually got married the next question was “When are you going to start a family”?

Postponing having a child is often read as a sign that the woman is not fertile. Again this is something I have experienced. When I turned forty I consulted a gynaecologist in the Maldives for a routine medical check up. The specialist, having taken my history and seeing I had been married for five years but was childless, informed me of a visiting infertility specialist; she could refer me to the specialist if I wanted. Rather than finding out from me if I wanted a child and/or if I had a problem conceiving, she just assumed I had fertility issues. My only purpose in seeking her services was to be screened for cancers as a preventative measure. Moreover, I was not having fertility problems, but had chosen not to have children at that point in my life, for various personal reasons. This incident illustrates attitudes towards women who are childless. Such attitudes affect women’s emotional well-being.

The estimated mean age at first marriage for women in 2000 was 21.8 years (MPND, 2004). Previously young girls were sometimes forced into marriage even at the age of 13 or 14 years. Once the girl menstruated she was considered old enough to get married. Under the current family law women are encouraged to wait at least until they are eighteen years of age before getting married. The pattern of early marriages is more common for women than for men, and women often marry older men indicating the need for security and stability which men are culturally expected to provide (Razee, 2001).

About 58 percent of the population of the Maldives over fifteen years of age were married according to figures for the year 2000. Six percent of the population were divorced. Soon after marriage women start having children. In 1998, twelve percent of those who gave birth to a child were below the age of 19 years. Estimates from the 1995 census report a total fertility rate (TFR) of five per woman (MPND, 2004)

52 A combination of factors including relatively early marriages and easy divorce procedures have led to a high rate of marriage, remarriage and divorce. My recent study (Razee, 2001) showed it is quite common for women in the Maldives to have had three husbands by the time they are thirty years of age; she would have been married twice to at least one of them. As a result of this high rate of marriage and remarriage and serial monogamy, women usually spend quite a part of their life without a partner.

This study found that marriage/remarriage patterns and cultural attitudes toward marriage and child bearing have implications for women’s well-being. Given the relative lack of income-earning opportunities for women they are dependant on men for financial security. As a result when a woman is divorced there is a tendency for her to get married again, mainly in the hopes of the financial security that the husband might provide. As mentioned, a woman in the Maldives is brought up to believe there will always be a man in her life who will take care of her. Being single and taking care of the children without a partner’s support is a significant hardship for women.

3.4 Cultural norms, perceptions and beliefs

Island life, especially for women, revolves around the everyday routine of taking care of their children, their husbands and the house. Maldivian society respects family and communal values highly and a significant amount of caring is shown among family members. Family and community are important; cultural and social values as well as the political system emphasize the role of each individual in maintaining harmony and unity. Harmony and unity have to be maintained at the family, community and national levels. Culturally, anyone older than oneself must be treated with respect and politeness. At a family level, when parents are older, it is the responsibility of the eldest son and his wife to take care of them.

3.4.1 Emotions and self control

Within the houses there is usually very little room and island life places many constraints and stresses on people. In everyday life people present an outward appearance of being calm, quiet and contented. They usually speak in a mild voice and avoid gesticulating and showing emotion. Gentleness, self-control and discretion are generally observed and considered virtues, especially in women. The outward appearance of being in control is a sign of being brought up well and being a good Muslim. Direct violence is very rare and when it happens is considered a serious crime. Verbal fights and public expression of emotions such as anger are usually perceived as signs of being uncultured and uneducated. As children we were taught not to express anger by 53 raising our voice or throwing a tantrum. Whenever we heard verbal fights my parents would remind us that educated or well-brought up people would not behave in that way.

While there is a relative absence of physical violence, and to the outsider Maldivians appear to be a calm and smiling people, this is deceptive. Given the social and the physical environment of the islands there are always strong undercurrents of repressed anger, jealousy and other emotions that can be stirred up. The common way of dealing with such repressed emotions has been indulgence in the secret world of magic spells known as fanditha (Romero-Frias, 1999).

Envious feelings would traditionally have been allowed and served as a regulatory force in society. At the same time people are aware of the dangers that desire and jealousy can bring. Detachment from material things is seen as an important value and people who are generous are held in high esteem. Thus Maldivian popular wisdom nominates the worst sins as greed, arrogance and anger and the gravest insults are to call someone dahi (greedy), foni (arrogant), or rulhi gadha (short tempered/ anger prone) (Romero-Frias, 1999).

3.4.2 Beliefs in the supernatural

Despite their Islamic faith, Maldivians believe in supernatural beings. They believe there are numerous spirits inhabiting the islands. The words and names used to describe these supernatural beings are from Sanskrit and , ancient languages that have contributed to the Maldivian language. This connection suggests that belief in supernatural beings antedates Islam (MPND, 2004). Dhevi is one of the supernatural beings. However, with the increasing influence of Islam, today people call the supernatural beings jinni (jinn). In Islam, jinni is the third group of beings created by Allah after humans and angels. As children we were told stories of jinni and little baburu (black) spirit children and cautioned not to go into dark places where there were lots of trees.

Jinni are believed to possess people, causing them to exhibit behaviours that are considered to be akin to lunacy such as, attacks of fury, keeping hair unkempt, being careless about dress and general appearance and abandoning duties (Romero-Frias, 1999, p. 65). It is mainly women who are prone to jinni possession, fits of anger and madness. This condition is generally considered to afflict women only after puberty, when they are sexually mature, and never during childhood. This implies that there is a connection between active female sexuality and madness.

Vigani is another supernatural conviction being believed to be sent by Lord Death as an evil force that causes illness and death (Romero-Frias, 1999). Local wise men or faith healers known as 54 fanditha verin are called upon to deal with such evil forces. Fanditha verin (meaning masters of fanditha) are usually men well versed in the healing processes that use the power of the Qur’an. These men use fanditha, a special knowledge that is part scientific, part mystical (MPND, 2004). They use portions and charms and recite verses of the Qur’an to call upon spirits to resolve problems.

Fanditha is for the most part a benevolent form of magic, a kind of ‘love magic’, which provides a personal way of dealing with actual or perceived problems. Belief in it is seen to have had some connection with fishing (MPND, 2004). Fishing was and still is the traditional occupation upon which the average person’s livelihood is based. It has inherent uncertainties due to such factors as the unpredictability of weather leading people to feel they have no control over the day’s catch. So fanditha became popular as a means of calling upon supernatural forces to bring in a good catch. Fanditha verin would identify the auspicious time for a fishing dhoni (vessel) to set off on its maiden voyage; they would also bless the dhoni. There are also malevolent forms of magic called sihuru and they are performed to cause harm and misfortune to people. Sihuru is also believed to cause problems in relationships. Such beliefs in the supernatural and in magical charms and spells (sorcery) continue.

3.5 Economy, employment and transport

The country’s economy is based on and fishing (MPND, 2004). The gross domestic product (GDP) per capita for 2002 was US$2,107. Economic activities in the islands outside the capital are mainly limited to fishing and agriculture. Because of the soil condition, very little in the way of agriculture takes place. Thus most of the food is imported, including staples such as rice and wheat flour.

According to the Vulnerability Poverty Assessment (VPA) conducted in 1998 by United Nations Development Fund (UNDP, 1999), the average per capita incomes in the Maldives are low and there is considerable evidence of income poverty. The average per capita household income per person per day varied from Rufiyaa (Rf) 20 (approximately two Australian dollars or 1.56 United States dollars) for the islands outside Male’ and Rf 35 in Male’. It is estimated that about fifteen percent of the population (30,000 persons) live on incomes of Rf 7.5 per day or less which is well below the ’s definition of poverty

Prior to starting my PhD, I travelled quite extensively around the country in my capacity as Director of the Department of Public Health of the Maldives and later as Dean of the Faculty of

55 Health Sciences. During these trips I observed that the income levels of the majority of inhabitants of the outlying islands were low. This makes life very hard for these populations. Often they were just barely able to subsist. Very few opportunities for income generation are available on a typical island.

With their income based mainly on fishing and tourism many men have to be away from their home island for months at a time. This leaves the women, children and elderly alone on the islands which certainly has implications for the mental health of women in these small island communities. Their lives are harsh. These are women who have been brought up to be dependent on someone else, whose culture has schooled them to rely on males for travel and many household matters and who find themselves left to fend alone. For instance even to clean the roof or the well, women have been brought up to rely on men and so feel helpless when left on their own. Such a situation is highly likely to add to the suffering and distress of women.

3.5.1 Transport and communication

Travel between islands is mostly by sea transport in mechanized local boats called dhoni. There are four regional airports. Major transportation is between the islands and the capital Male’. With the exception of the ferry services among the islands of the greater Male’ region, there are no regular inter-atoll or inter-island boat services. On the islands people are typically required to arrange a special dhoni to travel to another island and the boats are too few and too costly. According to the VPA a quarter of the atoll population is found on islands where there is only one dhoni per 100 persons (UNDP, 1999).

Transport to the atoll capital is often more problematic than travel to the nation’s capital. One in five of the atoll population is to be found on islands where dhoni services to the atoll capital are limited to three or fewer per month. (UNDP, 1999) More than one half of the atoll population is to be found on islands that experience problems of accessibility. This has implications for people who need emergency medical service, particularly women. To reach an atoll health centre with a doctor could take two to four hours travel by sea; a regional hospital is even further away. In bad weather, people are totally cut off from other islands.

The transport situation makes life on the islands very isolated. Women especially may spend their entire lives on a small island bound up in a very limited routine. Again it is a situation with potential to negatively affect their social and psychological well-being.

56 All islands have at least one public telephone service available and mobile telephone services are on the increase. Internet access is available throughout the country, mainly in the form of dial-up. However, affordability, accessibility and slowness remain matters of concern with internet facilities.

3.6 Social Services

The provision of education and health services is particularly challenging given a country of 199 inhabited islands which are widely scattered and many of which have very small populations. The dispersion gives rise to severe diseconomies of scale; provision of services costs 4-5 times more than it would in continental resource poor countries (UNDP, 1999).

3.6.1 Education

All children in the Maldives have access to the first seven years of formal schooling, with at least one primary school existing on every inhabited island. Even the smallest and most remote islands have a primary school. The commitment to basic education is revealed by the high levels of literacy in the country, basic literacy being 98 percent for the adult population (UNDP, 1999, 2000). There is virtually no difference between literacy rates for Male’ and the atolls and between men and women. The official statistics indicating literacy rates must be considered with caution as the literacy rate only reflects ability to read and write simple texts; the official statistics do not mean that 98 percent of the population are functionally literate or have basic numeracy skills.

Lower secondary education (Grades 8-10) and upper secondary education (grades 11-12) is available, although not uniformly throughout the country. Not every island has facilities for secondary education. This has implications for women’s education as parents are reluctant to send their daughters to another island where they cannot keep a close watch on them. Culturally girls are more protected than boys and so receive closer supervision and more restriction in terms of where they go and with whom. This is mainly because parents are afraid that if they let their daughter out of their sight they may end up getting pregnant. Parents only allow their daughters to go to another island, even for study purposes, if they are assured that their behaviour and movements are closely monitored.

Tertiary education is provided in the capital island through the Maldives College of Higher Education which offers diploma level education in the areas of teacher education for primary, middle and secondary school teaching; health sciences that include training of nurses, community

57 health care workers and laboratory technicians; hospitality; management and computing studies; and technical education in areas related to engineering, building and construction.

3.6.2 Health services

Health services are provided through a four-tiered system. At the island level are the health posts where family health workers and trained traditional birth attendants provide very basic care in the form of antenatal services, conducting normal deliveries, addressing simple health problems such as treating fevers, coughs and colds and providing health education. At the atoll level, every atoll has at least one health centre which has a doctor and one or two trained community health workers and trained nurses. Health centres can take care of most of the common health problems and attend to minor surgical procedures that do not involve anaesthesia and operating theatres. Health centres also have facilities for inpatient care. Atoll hospitals have been established to serve high population atolls with difficult access to regional hospitals.

At the third level of the health tier are the regional hospitals which cater to a geographical region of 2 to 5 atolls, providing outreach services. These hospitals provide secondary level curative services and preventive services through public health units. The regional hospitals are fully equipped with diagnostic services and staffed by allied health professionals as well as general physicians, gynaecologists and surgeons.

At the fourth level, specialised curative care is provided by the 200 bed Indhira Gandhi Memorial Hospital in Male’ which is a government hospital, the privately owned ADK hospital and various private outpatient clinics.

As a result of the expansion of health services, there have been significant improvements in many of the health indicators. The Ministry of Health (MOH, 2004) reports that crude death rate has remained stable within the last decade with the current rate at 4 per thousand. Infant mortality rates have steadily reduced but still remain high at 14 per thousand live births in 2003. Further information on the health situation is provided in the appendix.

3.6.3 Mental health

There is a dearth of data on the mental health situation perhaps because mental health in the Maldives has not yet been identified as a priority health problem. As previously mentioned, the urgency of infectious diseases possibly diverted attention away from mental health issues in the past. Although these are on the decline they are being replaced by a host of modern, non-

58 infectious diseases. However, there are as yet no reliable data to show the real morbidity situation in the Maldives. Despite this, informal discussions with doctors from the main hospital in the capital island of Male’ indicate that almost 40% of the outpatient visits are in relation to one form or another of mental distress. During my professional life, I spoke to many doctors who stated that women present the majority of such complaints. This may be an underestimate because women frequently refer to mental health disorders as physical disorders such as an ache or a pain.

There have been two surveys conducted, by the Ministry of Health (MOH), one in 1989 and one in 2004 to estimate the prevalence of mental health problems in the Maldives (Chandra, Pandav, & Bhugra, 2005). But according to the consulting team from WHO sent to address the post tsunami mental health situation, the details of these surveys and definitions used were not available (Chandra et al., 2005). The 2004 survey did however make a recommendation that mental health problems are serious and the health sector needed to address these and indicated that further in-depth research was required to understand the factors associated with mental health problems in the country.

Available mental health services include psychiatric consultations. This is provided through the Indhira Gandhi Memorial Hospital in Male’ and through the Centre for people with Special Needs (CPSN) located in the island of Guraidhoo which is close to Male’. The current trained mental health work force consists of just two psychiatrists and one psychologist for the whole country. There are no trained psychiatric nurses or psychiatric social workers, but several trained counsellors work in the area of drug de-addiction (Chandra et al., 2005). The main focus of mental health services is the diagnosis of common and severe mental illnesses and treatment mainly by use of pharmacotherapy. The psychologist provides some forms of talk therapy. Marriage counselling is provided by the non-government organization Society for Health Education (SHE). Also the Unit for the Rights of Children provide counselling services for children who have mental health related problems, but more related to children from broken families.

Substance abuse in the form of narcotic drugs is a growing problem with a total of 419 cases of drug abuse reported for 2003 (MOH, 2004). Addressing drug abuse has been made a national priority. A drug rehabilitation centre has been established and a counselling service is provided for those who need support in stopping drug use. The drug rehabilitation centre provides rehabilitation services for those who are convicted or who voluntarily commit themselves to the centre.

59 3.7 Women and Gender Perspective

Historically women in the Maldives have held the highest office in the country. Bell (1940), in his monograph on the Maldives, wrote about a Queen who administered justice and reigned supreme over the country. Today this is not the case and in fact, according to the current constitution, a woman cannot be the President or the Prime Minister of the country.

Given their past political role one might expect that women could enjoy a relatively equal social position with men. On the contrary, women occupy a substantially lower social position. It is not clear why or when this change in women’s social position occurred as my literature review did not uncover any documented information related to this aspect. I would surmise the change is linked to the influence of male scholars who having studied in more conservative Islamic countries brought back values that place restrictions on women. Nevertheless, I think that some remnants of the historical role of women persist today. Compared to women in the neighbouring countries and in other Islamic countries, women in the Maldives do enjoy more freedom and a higher social status.

3.7.1 Gender roles and responsibilities

The general, social perceptions and mindsets with respect to women’s position in society and their roles and responsibilities have not kept pace with economic development. Traditional and cultural beliefs see women as the homemakers and men as the breadwinners working outside the home. Women are, in principle, free to pursue outside occupations, and are increasingly doing so. However, socially determined restrictions on the movement of some young women, which I mentioned earlier, combined with limited employment possibilities in most of the islands, inhibit women from achieving financial independence.

In the Maldives the combined influence of the country’s South Asian heritage and Islamic traditions have played an important part in conditioning social behaviour, especially in relation to the expected roles and responsibilities women and men undertake within the family and in society. Traditionally males dominated in economic and decision-making terms and this is still largely true, leaving women marginalized in those areas and in public life.

There is no overt discrimination of women on the basis of their biological sex. Nevertheless the social and cultural mindset regarding appropriate female social roles and cultural attributes inhibits women’s full enjoyment of the social and economic opportunities available to them. For

60 instance, while there are officially no laws and regulations to restrict women to certain types of jobs, families are still reluctant to send their daughters to work on tourist resorts.

The social and cultural values that contribute to gendered norms and roles are reflected in the results of a 1995 survey of girls in the Maldives (Ministry of Youth Women's Affairs and Sports, 1995). The survey revealed that they were expected to perform a range of household tasks whereas sons were not; parents wanted their daughters to be teachers, health workers or hold government jobs or take up home-island based jobs; and Island leaders believed teenage girls could contribute to island development by engaging in activities such as cleaning the island, teaching, sewing and mat weaving.

Women continue to have large families and spend most of their time in the home caring for and maintaining their family, more often by themselves, while men leave their homes to fish or migrate to other islands for employment. According to the VPA survey, about one third of the households were headed by a woman (UNDP, 1999). This survey also revealed that the most commonly cited hardships of life for women were related to financial difficulties, meeting child-rearing obligations and fulfilling roles traditionally played by husbands and fathers.

According to a survey conducted in 1991 (Ibrahim & Miralao, 1993), less than four percent of men contributed to cooking, childcare, cleaning or washing and ironing. As reported in this survey, the time spent by women in the capital on household chores exceeds the standard 36-hour work- week. Childcare consumes most of the women’s time at home and as many as 42 percent in this study spent over 48 hours a week on childcare while 51 percent spent at least 33 hours on this task each week. Looking at these statistics it is clear that women do not have much time to address their own developmental and personal needs.

As already explained, in terms of freedom of movement and association, women experience a more lax social ethos than women in traditional Muslim societies and countries of the South Asia region. Women in the Maldives have been described as the “most emancipated in the Islamic world” (UNDP, 2002, p. 23). However, there is still a protectiveness displayed by society towards women which impacts on their mobility. The same culture of protectiveness is seen in early socialisation when girls are encouraged to remain at home, helping them to develop characteristics such as shyness and subservience while boys are encouraged to be outgoing, forward and self-confident.

61 The protective attitude towards girls and women has various implications for women’s health. It makes women dependent on men, certainly for financial security. It creates a passivity in women such that they may be less likely to stand up for their rights. It also makes men dependant on women in terms of needing to be ‘looked after’. Being ‘looked after’ means providing the men with their meals and clean, ironed clothes and ensuring that the home is organised and clean.

3.7.2 Women’s Health

Female life expectancy at birth has increased with current trends (2003) showing a life expectancy slightly higher for women: 70.4 for men and 71.29 for women (MOH, 2004). The main health problem for women is seen to be related to reproductive health problems. However, in the absence of sex disaggregated data for different diseases, it is difficult to make a conclusive statement regarding patterns of women’s health problems.

As mentioned, reproductive health problems arise from early marriage and early child bearing. Unsafe sexual practices among adolescents are increasingly exposing them to unwanted pregnancies, induced abortions in hazardous conditions, and sexually transmitted diseases including HIV infection (Jenkins, 2000; Pearson & Cockcroft, 1999). While there are no official statistics on deaths related to unsafe abortions, unofficial reports and anecdotal information indicate there have been such cases (UNDP, 2000).

Women spend a significant part of their adult lives bearing and caring for children which impacts on their health. According to the Reproductive Health Baseline Survey (Pearson & Cockcroft, 1999), the mean number of children was 4.2 and the mean ‘ideal number’ of children mentioned by the women surveyed was 3.0. Given the high fertility rates women continue to suffer from morbidity and mortality related to their reproductive functions. About 50 percent of all emergency medical evacuations are obstetric and an estimated 25 percent of maternal deaths are due to haemorrhage, sepsis, pregnancy-related hypertensive disorders, obstructed labour, and unsafe abortions (UNDP, 2002).

While there is documented data indicating the extent of reproductive-related morbidity and mortality in women, there is no systematic data collected or hospital data available that reflect women’s mental health. Moreover, the health care providers at the island and atoll levels are not trained to recognize mental health problems and therefore there is a dearth of documented data to provide even an approximate estimate of the mental health situation of women.

62 My own experiences of working in the health sector and in the area of women’s rights and gender equity lead me to believe that, given the difficulties faced by women described above, mental health is likely to be a problem for women. Anecdotal reports by doctors show that a significant proportion of women who come to their private outpatient clinics come with psychosomatic symptoms and there is an increase in such women.

3.8 Summary

The country background provided above is important for contextualizing the findings of this study and reveals a number of aspects of daily life that influence both men’s and women’s health and well-being.

The sea-locked geography of the country and the absence of regular inter-island and inter-atoll transport make life on the islands quite isolated and routine as well as harsh. The lack of economic opportunities as well as the social norms that prevent women from taking up existing work options means women are dependent on men for financial security. The very limited or total absence of economic opportunities on individual islands also means that men are away from their wives and children for several months at a time. The small size of the islands and their populations, the close-knit nature of the community, the prevailing cultural norms and the gendered roles of women and men are all factors that may negatively influence the health and well-being of both men and women.

63 Chapter 4

DOING THE RESEARCH

“The real voyage of discovery consists not in seeing new landscapes but in having new eyes.” Proust

In this chapter I will first discuss the approaches used for collecting, analysing and interpreting my data. Following this I will examine the instruments, techniques, and processes used for collecting the data and finally I will demonstrate how I made sense of my data.

The discussion will cover the research approach and research methods. It will describe the research as it unfolded in the field, examine issues related to ethics and rigour and conclude with comments on data analysis.

4.1 Planning and designing the study

This study is aimed at uncovering the meanings of suffering and distress through the eyes of the participants, making subjectivity an important part of this research. The nature of the topic explored involves highly emotional and sensitive experiences and therefore subjectivity applies to both the participants and the researcher (Rowling, 1999). As I am the research instrument it is imperative for me to pay attention to how my knowledge, cultural background and personal experiences shape the research process. It is being upfront at the onset of my experience as a women’s rights and public health advocate, health educator, counsellor, teacher, academic and researcher. For this reason in Chapter 1, I described my stance as a researcher.

4.1.1 Research approaches

As indicated this is a study that goes beyond the current biomedical emphasis in addressing suffering and distress in women. I aim to achieve a deeper and richer understanding of the cultural and social world of my participants. I seek a deeper truth that will illuminate the suffering of Maldivian women by learning from them and exploring the subjective meanings they assign to their individual life circumstances (Carr, 1994; Chapple & Rogers, 1998; Creswell, 1998; Duffy, 1985; Greenhalgh & Taylor, 1997; Lincoln & Guba, 1985; Morse & Field, 1995; Silverman, 1998, 2000). The optimal way to do so is to use a qualitative method of inquiry (Denzin & Lincoln, 2000; Rice & Ezzy, 2001; Ritchie, 2001). The relevance of a qualitative approach or a naturalistic inquiry is also indicated by the following characteristics of this study.

64 1. This study focuses on the question of: How is mental distress in Maldivian women expressed or identified; explained; experienced and dealt with? Addressing this question requires exploration of what goes on in women’s lives that may contribute to their suffering and distress. The study has the following aims: First learning what is going on in the everyday lives of Maldivian women that influences their suffering and distress. Second, learning the subjective meanings and interpretations of women’s suffering within their social and cultural context. Third describing and understanding women’s experiences of suffering by generating ‘thick and integrative’ analysis of their stories and last presenting my findings from different perspectives. 2. In the absence of previous studies in this area I am entering this field with limited knowledge so this study is very much exploratory. A qualitative approach is better suited to such a study (Strauss & Corbin, 1990). A qualitative approach allows the flexibility of changing methods and directions depending on how the story unfolds as the study progresses. Various scholars have identified the characteristics of inquiry that are best approached through qualitative methods of collecting, analysing and interpreting data (Baum, 1995; Hammersley & Atkinson, 1995; Rice & Ezzy, 2001). The above listed features of this study fit these characteristics. In choosing a method of naturalistic inquiry, I was also guided by the medical work of Kleinman’s (1980) Patient’s and Healers in the Context of Culture. In this work Kleinman, a medical anthropologist and psychiatrist, suggests using an explanatory model framework for exploring notions of illness and treatment based on how healers and patients explain a particular illness episode. He uses this framework focusing on the areas of: etiology, time and mode of onset of symptoms, pathophysiology, course and treatment to elicit the general beliefs about illness and health care. Using this framework as a general guideline and ethnography as the method of uncovering the information seems an appropriate way to discover how Maldivian women, explain, express, experience and deal with their suffering and distress.

4.1.2 Feminist approach to scholarship

Since this is a study that stems from my desire for gender equity I am also informed by a feminist epistemological position (Harding, 1987; Smith, 1987). Research involving a feminist epistemological stance is based on the position that knowledge is built on and from women’s experiences. At the same time it includes the researcher’s subjectivity. It takes into account the

65 relationship between women’s experiences and the generation of scientific knowledge through the examination of the research process and the relationships in which it is produced.

In the research approach I used in this study, women’s voices are an inherent part of the research paradigm. Hence, instead of defining and assessing suffering and distress from the ‘experts’ preconceived notions (Stoppard, 1999), in this study I chose to engage participants actively. In the research process they were given the opportunity to explain and express their own understanding of suffering and distress and their ways of dealing with it. By using this approach, I treated the personal meanings of distress they articulated in their accounts as the valid source of knowledge (Harding, 1987).

There are four main characteristics of feminist approaches to scholarship (Fox & Murry, 2000). First, reflexivity, which has been referred to as the self-conscious sensitivity to the role of the researcher and the research process generating knowledge (Mays & Pope, 1995). It is the recognition that the researcher is an actor who is “intimately involved in the generation of knowledge” rather than being a mere “recorder and reporter of what is seen outside oneself” (Fox & Murry, 2000 p. 1161). The researcher needs to be aware of where (s)he is coming from and how her/his own background can influence the research process. Reflexivity also involves the willingness to engage in continuous self-criticism. It is acknowledging that the researcher’s actions, interpretations, and interests are an integral part of the research process.

Second, knowledge gained from the research must be applied not only for the purposes of contributing to theory, but also to the arenas of social change. My main purpose in conducting this study is my passion to contribute to social change, to provide knowledge that will contribute to reshaping the existing social conditions of Maldivian women and facilitate greater equality for Maldivian women and men. Third is the concern with process both in the focus and conduct of the research. The focus of the research process includes: describing and analysing current empirical realities in the lives of women and men; and the associated inequalities, constraints and privileges that are related to their different statuses. The fourth characteristic is the questioning of received disciplinary wisdom and this includes prevailing epistemologies. What is seen or experienced as authentic and real depends on the standpoint and perspective of the scholarship. Within a feminist standpoint epistemology gender is central to perspective and must be incorporated into the research design.

66 4.2 Ethnography as a method for data collection, analysis and interpretation

As revealed in Chapter 2, perceptions of suffering and distress related to mental health problems such as depression can differ from Western constructions. The difference is related to the local construction of what is normal and abnormal. In this study I am aiming to uncover the cultural principles or nuances that guide the assumptions Maldivian women make in explaining, expressing, experiencing and dealing with their suffering and distress. My initial reading related to this topic indicated that cultural principles are also related to assumptions about mind and body in non-Western countries. This means I need to use an approach that allows me to make observations of healing practices and rituals, engage in continuous dialogues to find out meanings, compare what I observe with what people tell me and to see how they relate. In an ethnographic approach, “data and mode of analysis are both predicated on engaging people in their own worlds” (Warin, 2000, p. 116) Therefore an ethnographic approach allows me to discover hidden meanings that may not be evident in interviews only.

Ethnography is a “scientific approach to discovering and investigating social and cultural patterns and meaning in communities, institutions and other social settings (Schensul, Schensul, & LeCompte, 1999, p. 1). Informed by the concept of culture, it is “a generalized approach to developing concepts and understanding human behaviour from the insider’s point of view” (Morse & Field, 1995, p. 26). What distinguishes ethnography from other approaches is the use of participant observation entailing prolonged field-work.

An ethnographic approach, as opposed to positivistic approaches, enables me to explore the suffering and distress as embedded within the social and cultural world of women rather than as an individual pathology requiring individual changes (Falicov, 2003; Stoppard & McMullen, 2003). Moreover, this approach allows me to explore Maldivian women’s subjective meanings of suffering and distress and how they make sense of their experiences (Morse & Richards, 2002).

The essential core of ethnography as Spradley (1979) argues is “to understand another way of life from the native point of view” (p.3). An ethnographer learns from people instead of studying people. In exploring healthcare issues, ethnography has been applied to study beliefs and practices within the context in which they occur; this has facilitated the understanding of behaviour surrounding illness and health (Savage, 2000). In the contemporary world ethnography

67 has been used as a popular method of gaining insight into how people conceptualize and make sense of their illness experiences (Bryman, 2001; Helman, 2001; Rice, 1998; Rice & Ezzy, 2001).

Atkinson and Hammersley (1994) point out the following features of ethnography as a form of social research (p. 248):

• A strong focus on exploring the nature of a particular phenomena • A tendency to work primarily with unstructured data • Examination of a small number of people, perhaps just one in detail • Analysis of data, which involves explicit interpretation of the meanings and functions of human actions - descriptions and explanations of the events take priority.

Spradley (1979) points out that ethnography is invaluable in that it helps to discover human needs and therefore, it helps to find ways to meeting these needs. According to Abu-Lughod (1988) living in the social world of the participants allows the researcher to grasp more immediately how the social world works and how members understand it. In this study participating in the social world of my participants brought richness to my understanding of their lives and enabled me to understand the cultural construction of women’s suffering and distress. My hope is that the data I have uncovered can be used to develop more appropriate mental health services for women.

4.2.1 Choosing a study site

As described in Chapter 3, the Maldives comprises a number of islands and in general the islands are homogeneous in terms of language, culture and religion. However, there are some differences in the islands of the south, such as islands in , , Gaaf Dhaal and Gaaf Alif atoll, and Thaa atoll. These atolls enjoy a reputation for having well respected and well known traditional healers practising the faith healing, known as fanditha verin, and practising herbal medicine by itself or together with fanditha, known as Dhivehi Beysverin. This is not to say that other atolls or islands do not have such healers, but the traditional healers in these atolls are especially reputed for their healing skills. This was confirmed during my initial discussions with key informants such as people who have worked as Community Health Workers for a number of years in the islands outside of Male’. When I mentioned I was interested in looking at fanditha as a form of healing they all recommended I go to the atolls in the South.

Why these atolls have such a reputation is not documented. I would speculate this might be related to two factors. First, these atolls are further away from the capital island and have geographical features that make travelling to Male’ difficult. Modern health care facilities were not 68 available in these atolls until three decades ago. In those times when there were no Western- trained health personnel who practised biomedical forms of healing, the community relied on traditional herbal healing and fanditha. Qualified doctors were not available in these islands until two decades ago, except in Addu atoll, which was a British naval base and therefore, had a small naval hospital.

Second, in the past Maldivian businessmen from the Southern atolls have carried Maldive fish and other local goods to and southern areas of India to exchange for other necessities. These connections have influenced some of the existing beliefs related to traditional healing practices such as belief in the supernatural. Obeyesekere (1970; 1977a; 1977b; 1978) in his studies in Sri Lanka mentions the practice of demonic possession and exorcism rituals based on the Ayurvedic healing practices. While these are not exactly the same practices that Maldivian traditional healers use, there are some similarities.

Morse and Field (1995) suggest selecting sites that “maximize both the intensity and the frequency of the phenomenon” studied and allow for comparing and contrasting the populations where the phenomenon occurs (p. 46). In the case of my study this means purposefully choosing islands where traditional healers still practised, where people explained mental illnesses in terms of cultural beliefs, there was a mix of rural and urban areas and the north, south and central areas of the country were represented to ensure findings cover a wider part of the Maldives and provide divergent view points. I also chose Alifushi as one of my study sites as this particular island had been reported in the local newspaper Haveeru to have incidents of an unexplained force in the classrooms that had caused young girls to “lose their senses and go raving mad”. Some of the islanders believed this to be the work of a ‘dark spell’ placed on the school and so a fanditha man had been called in (Unknown, 1999).

Guided by Morse and Field (1995), I made a decision to choose islands from the southern atolls and some from the northern and central parts of the country as well as the capital island that had specialized medical services, including psychiatric services available. This was my intention. When it came to the actual implementation of the study practical constraints emerged which I elaborate below.

Time and resources constraints Given the scattered nature of the population, the geography of the country and the lack of regular transport I had two options for accessing remote islands, either to hire a special boat or use the

69 local supply boats which usually operated monthly. The first option was too expensive as my research was self-funded. For example, visiting Thaa atoll cost Rf.1500, approximately AUD 150, and this was half rate because I used the health centre dhoni for which I had to pay only the fuel cost. The second option whilst economical was complicated from the timetable point of view. Boat times meant visits could be longer than needed. This threatened to extend my field-work beyond the time allowed for my candidature and also posed health problems as I needed regular treatment in the capital. So I adjusted my original visit schedule, confidant that my research goals would still be met. I purposefully selected islands where people sought the help of traditional healers and where traditional healers still practised on the island itself. The following study sites were chosen: Hithadhoo in Seenu atoll, Thinadhoo in Gaaf Dhaal, the capital island Male’, and Alifushi in the North.

Since I was following a qualitative approach I took advantage of the flexibility that it provides (Evans, 1998) and followed clues that emerged to potentially valuable sites. For example a woman in the capital island mentioned that in the island from which she came both men and women sought help from fanditha verin who prepared ‘love portions’ that were used to attract the love and affection of people they admired or had a crush on. She also said that a lot of marriages happened as a result of such ‘love magic’ or isthiri. I therefore, decided to visit this island and talk to the traditional healers there. Thus the island of Vilifushi became one of the field sites for my study. In a similar manner my findings took me to the island of Madaveli in Gaaf Dhaal atoll and Guraidhoo in Male’ atoll.

A map of the Maldives showing the study sites is provided in appendix 1.

4.2.2 Selecting participants

In qualitative inquiry the strategies used for selecting participants affect the quality of the research (Gifford, 1996). The aim of selection is to identify cases that will provide a full and detailed account of the phenomenon under study, and therefore it is important to choose information-rich cases to study in depth (Patton, 1990). Thus I used a selection strategy that provided the greatest chance of revealing the most about women’s suffering, focusing on the richness of the cases rather than their number (Coyne, 1997; Morse & Field, 1995; Patton, 1990; Rice & Ezzy, 2001; Ritchie, 2001; Sandelowski, 1993). I chose those participants who were likely to be information- rich and I studied them in depth. Traditional healers who specialized in jinni fanditha (spirit exorcism) were such a choice. I wanted to enrich my understanding of the plight of women by

70 exploring through the eyes of those practising Western models of healing and traditional healers known as fanditha verin.

Selecting healers I used a snowball or network technique to locate and recruit appropriate participants for my study, taking into account the various aspects I have detailed above (Ritchie, 2001). In the case of health care professionals practising biomedical healing, I used my own initiative to identify and contact them. This was quite simple as there are very few trained people. For instance there are only two psychiatrists (one local and one Indian) in the country and one practising psychologist and given my professional background I knew them quite well.

In the case of general practitioners I chose people who were Maldivians with at least ten years experience in the area of general medicine and extensive experience in the outer islands. One is a doctor with over 25 years experience and one of the first doctors to work in the mental health field. The second is the only Maldivian doctor who has worked in a regional hospital for a long time and therefore offered extensive knowledge about women’s health in the outer islands. In selecting them I was following the principles of ‘information rich cases’ (Patton, 1990). I knew both of them well and they were keen to participate. Through them I was also able to contact women to participate in my study.

Allied health professionals such as Community Health Workers (CHW) and Family Health Workers (FHW) were also included. Both CHWs and FHWs are natives of the island they work in. They are well respected and have an intimate knowledge of what goes on in their communities and their patient’s lives. I knew the CHWs and FHWs very well because of my work in the Department of Public Health (DPH). I had once stood up for their rights in my capacity as their boss, as mentioned earlier. My previous work in the Ministry of Health (MOH) and DPH also facilitated my obtaining approval for my research and I also received their help in informing health centres and regional hospitals about my goals.

Selecting women Upon arrival in any of my study sites I enlisted the help of the local health workers and also the presidents of the local Women’s Committees. They were key informants and guided me in ways that would maximize the possibilities of obtaining the data I needed and provide leads to uncovering more data (Glaser, 1978).

71 I also put up a notice in the local language in the health centres and family health posts. The notice contained very brief information that I was undertaking research on mental health of Maldivian women and invited women to participate in the study. In the capital island, I put up similar notices in health facilities and also met with some doctors and the psychiatrists to enlist their support in recruiting participants. I provided them with a letter of invitation they could hand to their patients.

In the outer islands as I sauntered along the streets I ran into women who would come and speak to me. I shared with them my interest in learning about their hardships and how they coped. This would inevitably lead to the mention of a particular woman who in their opinion was suffering. In this process I found some women would come to my residence either by themselves or having learnt of my presence through their FHW. Their main reason was to discuss with me a health problem they had and to seek advice from me. Often such health problems were of a very personal nature and I could see that they felt more comfortable talking to me about their problems than the male health worker on the island. Through these encounters I was able to select participants to my study on a strictly voluntary basis. If they agreed to participating in my study, which they all did, I then arranged a time and place that was convenient for them so that I could explore their experiences and perceptions using interview techniques.

In Alifushi where most of my field-work was done one of the women, whom I met during the women’s day celebrations, took it upon herself to help me with the research process. Fathun is what Hammersley and Atkinson (1995) call a gatekeeper. They caution against use of gatekeepers and self-selection stating the following:

While welcoming self-selection, and perhaps even selection by others [meaning gate keepers], the ethnographer must retain the leeway to choose candidates to interview. Otherwise, there is a grave danger that the data collected will be misleading in important respects and the researcher will be unable to engage in the strategic search for data that is essential to a flexible approach (p. 134).

However, Hammersley and Atkinson also acknowledge that in ethnography it may be essential to make use of gatekeepers. I did not include every woman Fathun brought to me or every woman referred to me by her for an in-depth interview.

To summarize the participant selection process, I chose a mix of sampling strategies that included, purposeful sampling, snowball sampling and opportunistic sampling and went to those areas where the richest data would be yielded (Rice & Ezzy, 2001). I also followed Patton’s (1990) suggestions that the logic and power behind purposeful selection of participants is that the sample should be information-rich. Following his guidelines, I used extreme or deviant case 72 sampling to ensure that informants who fit characteristics of interest to my study were included. In selecting women I chose a mix of education levels, employed and unemployed, some with young children and some with grown up children, and women who had gone through several marriages or only one or two and women in polygamous marriages.

4.3 Engaging in field-work

The ethnographer’s role is to understand and describe a social and cultural scene from the emic (an insider’s) perspective so he or she can be both a storyteller and a scientist. This was my role in the field; “overtly and covertly participating in people’s daily lives for an extended period of time, watching what happens, listening to what is said, asking questions” (Hammersley & Atkinson, 1995, p. 1). I collected whatever data was available that would provide me insight into the issues that were central to my research. I explored the meanings and emotions expressed by my participants from their own perspective primarily by engaging in the natural setting through participant observation.

4.3.1 Getting in and gaining entrance

Getting in and gaining entrance is the first phase in ethnographic research and involves gaining, building, and maintaining trust with the participants (Hammersley & Atkinson, 1995). At this stage of the study, the researcher is a stranger to the setting and so spends time negotiating entry, getting to know the setting, finding a role for him/herself, blending into the setting and identifying strategies to get the richest data to answer the question being studied. At this stage it is critical for the researcher to get to know the politics and conflicts within the organization or setting being studied (Morse & Richards, 2002; Morse & Field, 1995).

As a Maldivian I was already familiar with my research setting and I had been to the selected islands several times as part of my previous work, except for one site, Alifushi. I had presented several health promotion programs on national radio and television so my name, voice and face were familiar to my participating communities. In addition I had established a reputation through work as someone who cared for the health and well-being of the people, especially of the disadvantaged.

On arriving at my field sites my first point of contact was the health worker on that island. I called on them this time in a different capacity to that of my previous visits. I had informal chats with them to introduce them to the research I was undertaking and to also find out their own thoughts

73 on how best to go about establishing contact with potential participants. If the opportunity presented itself, I participated in some of the health centre activities and during these activities spoke about the research I was doing and invited women to participate.

While the health care providers were my main point of contact on every island, I also met with the women’s groups in the islands. Each island has a women’s committee whose role is to work towards the improvement of women’s situations and their position within the society. I met with the presidents of these women’s groups and through them recruited further participants to my study. Thus the presidents of the women’s committees and the health workers were the insiders who introduced me to the participants for my research: women and traditional healers.

In addition to these insiders, I also met with the Atoll Chiefs (AC) and the Island Chiefs (IC) as official protocol required that they were aware of any projects being undertaken in their area. However, I was very careful not to maintain any closer links than was officially required. This was to ensure there would not be any suspicion on the part of my participants that I may divulge any of the very personal information they shared with me. I also did not want to appear to have too much close connection with the island leaders as I felt that would hinder the women and the traditional healers from being open and honest with me and making their true feelings known. Furthermore, in my previous visits as a government official, I had closely associated with the Island and Atoll Chiefs and spent most of my time with them. This time I wanted to firmly indicate to my participants that I was here not as a government official and that my interest was to give voice to my participants.

Capitalizing on naturally occurring events to gain access As indicated above I was new to one of my study sites, Alifushi. I therefore needed to orient myself to the layout of the island and introduce myself to its health workers. By chance a wonderful opportunity presented itself for me to gain entry to the island when I was invited to participate in the World Women’s Day celebrations taking place there. As part of the official delegation to the island I was able to be a ‘fly on the wall’ and observe from a distance the way in which people interacted with each other and the activities that went on when there were many outsiders on the island. Staying behind after the official celebration was over gave me an opportunity to compare how women and men interacted in the presence of official delegations and visitors and when they were left to themselves. There were indeed differences.

74 Serendipity also provided me with a valuable female family connection named Awha3 whom I knew quite well and who had volunteered to participate. She turned out to be from Alifushi and made a visit there at the same time as me. So two chance factors provided me with good access to this population and helped me integrate into the island community.

4.3.2 Participant observation

As already stated this is an ethnographic study and the primary method of data collection is by immersing oneself in the culture being studied (Atkinson & Hammersley, 1994). I therefore became a participant observer to immerse myself into the culture and lives of my participants. Goffman (1989) talks about participant observation as follows:

Subjecting yourself, your own body and your own personality and your own situation to the set of contingencies that play upon a set of individuals, so that you can physically and ecologically penetrate their circle of response to their social situation, or their work situation, or their ethnic situation (p. 125).

I made observations over a period of one year, though continuous and systematic observations were undertaken over a 6-month period. I immersed myself in the daily life of women by spending time with them as they went about their day-to-day activities. I visited them in their homes, walked with them when they took their children to school, ate with them, sat in the waiting rooms of health centres with them and took part in their leisure activities such as sports and watching movies on television. In other words I spent as much of my waking time with them as possible.

On my own walks at different times of the day I observed the women in the various activities of their daily life, such as cleaning the public spaces, fetching water and playing . I stopped by and spoke to people informally chatting to them and observing what was going on. People were quite inquisitive and interested to know what I was doing on the island and I always told them my purpose. Finding I was genuinely interested in their lives, the women were open to interacting with me in informal chats and sometimes in formal encounters. Such encounters and observations gave me a wealth of information relevant to my research question. In the case of my host family, I was able to observe how the male and female members of the family interacted in their daily lives, who did what and how the boys and girls were treated.

3 Awha is not her real name. When I refer to her as a participant I have again changed her name as some of the issues she brought up were hypersensitive and I wanted to be doubly sure that her identity is not disclosed.

75 Immersing myself like this gave me a wonderful opportunity to observe the gender dynamics within family and community settings and compare these patterns with the views expressed verbally. This was certainly highly revealing. For instance, while at times people expressed verbally that both men and women are equal, their day-to-day interactions revealed power differences and gender dynamics that did not reflect equality. Such patterns gave me more insight into the women’s lives and how the social and cultural context of their lives affected their social and emotional well-being. Had I chosen just in-depth interviews I would not have been able to access this kind of rich and thick data. My mealtime conversations with my host family in Alifushi were particularly illuminating about the prevailing gender norms in the Maldives.

Observing interactions between family members within the home setting When I planned my research I had decided I would observe my participants within their home settings. The purpose of such observations was for me to be a ‘fly on the wall’ and take note of how they interacted with the various members of their family in the routine aspects of their day-to- day lives as well as observe how they dealt with family conflicts and disputes. However, as I continued my field-work I realized such observation was not feasible as I discovered that my participants did not feel comfortable to continue with their chores when I was present. When I visited them, the women would drop everything they were doing and come out and sit with me and entertain me as a guest. I soon realized that for them to allow me to participate in their chores and continue their work as if I was not there meant they were not showing me the proper respect that society expected of them. Also allowing me to observe their family disputes and problems was embarrassing for them and they therefore presented a friendly, polite and amicable front in my presence. I was not able to obtain the data I needed this way and most importantly I was disrupting their work and adding to their burdens. Hence I decided not to include observations within the home setting as a main tool for collecting data on how family members interacted with each other.

Observing healers and healing rituals Participant observation of biomedical healing interventions was undertaken on the capital island and in the island of Guraidhoo, the only two islands where psychiatric treatment is available.

Observation of traditional healers was not straightforward. I was working in a natural setting and therefore had to rely on incidents that occurred while I was present on an island. I wanted to

76 observe several sessions where traditional healers carried out incantations or kiyeveli kiyevun4 to exorcise supernatural spirits or jinni. At the same time I also wanted to observe women who were experiencing a spirit possession episode or jinni moyavun. These were not episodes I could observe as and when I liked. I had encounters with five women identified in the island of Guraidhoo as having experienced jinni moyavun. I was able to talk to them and some of their family members who narrated their experiences. According to them and their healers, during the time I was conducting my study they were protected from the jinni by the talisman or thaveedhu they wore on their body. Ethically I could not ask them or their healers to take this off since they believed they might experience an episode of jinni moyavun. Thus I had to rely on verbal descriptions provided by healers and the women who experienced these episodes and their family members who took care of them.

Although I was unable to observe any woman experiencing jinni moyavun, on the island of Thinadhoo I was called to a home where a man was experiencing such an episode. While my study focused on women and their perceptions, I felt it was important for me to observe the behaviours and actions of a person who was experiencing a jinni moyavun episode even if it was in a man. Thus I spent ten days observing the man at different times of the day and interacted with various members of his family and the healers who treated him. I was also able to observe traditional healers as they carried out their healing rituals on him.

My observation of healing rituals and cases of jinni moyavun depended not only on whether they happened to occur, there were also missed opportunities. Time, money, geography and my own health sometimes prevented me from observing an event. For example, I was undertaking field- work on an island 6 – 8 hours speed boat ride away from Male’, when one of the traditional healers whom I had contacted earlier was called upon to carry out a kiyeveli kiyevun on a possessed woman. He tried to contact me on my mobile to let me know but I happened to be on an island where there were no mobile telephone facilities. Anyway I would not have been able to reach Male’ in time to observe the session and ethically he could not wait for me.

4 Kiyeveli kiyevun involves a group of men (two or more) sitting around the possessed woman and they recite verses from Qur’an which has been selected by the healer. Sometimes the healer may decide to do the kiyeveli kiyevun himself.

77 On another occasion I had met with a traditional healer and had a long encounter with him where we talked about his experiences and his explanations about women’s suffering. The following evening he was carrying out a kiyeveli kiyevun on a young woman who was experiencing jinni moyavun. I was able to observe the healing ritual but could not explore this young woman’s suffering in the way I felt I needed to. To fully understand her suffering I needed to not only observe the kiyeveli kiyevun but also learn from her what it meant for her and also talk to her parents about the experience. But I had to leave for Alifushi the following day as the women’s committee there had organized a workshop that I was to conduct for the women of that island. The young woman being treated was not a local and by the time I returned from Alifushi she had departed for her island. Thus I missed out on this opportunity to fully understand the phenomenon of jinni moyavun from the perspectives of the sufferer herself and the significant others in her world. Instead I had to rely only on the data I gathered from the observation of one session of kiyeveli kiyevun and my discussion with her healer.

Observations at the mental health facility When I first planned the research I had no intention of deliberately selecting people who had been diagnosed with a mental illness and/or who were going through psychiatric treatment. But as my study proceeded my preliminary analysis showed that I was not obtaining data related to some of the specific issues related to manifestations of mental illness. To get a better picture I felt my findings would be enriched if I deliberately sought out, observed and spoke to people who were already diagnosed. Thus I observed patients in the mental health facility while the psychiatrist was examining them. I observed them at meal times and as they hung around in the facility. I informally chatted with them and those who worked in the facility.

4.3.3 Gathering data through planned encounters

Planned encounters with women more akin to in-depth interviews served as a secondary method of data collection. I wanted to learn in more in-depth women’s views on what I observed and what went on in the context of their world and their individual experiences. I wanted to explore how they made sense of their experiences; to understand the subjective meanings they assign to their suffering, the emotions, feelings, thoughts and beliefs related to their suffering. Hence I conducted in-depth interviews with women and healers. I considered these formal interactions, which I call encounters, as conversations “growing out of reported experiences, observed events and activities” (Evans, 1998, p. 3). These encounters were for the purpose of illuminating and

78 strengthening the data collected through the participant observation rather than stand-alone interviews.

The formal encounters were conducted in the local language Dhivehi with the exception of two, which involved biomedical healers who were foreigners working in the Maldives and did not understand the local language.

Initially I planned to use an interview guide or theme list that would serve as a prompt of what was to be covered. My theme list focused on the women’s experiences, explanations of emotional distress and how they dealt with it as well as their perceptions of emotional well-being. However, for the most part the participants themselves determined the structure of the encounters. With the first few encounters I had tried to be more structured and follow the theme list. But I found that the moment I explained the purpose of the research the participants launched into their own stories. They were very enthusiastic to share their experiences. When this happened, I let the participants steer the encounters. At times I intervened with gentle prompts to keep them on track, to clarify and to make sure that the objective of the encounter was met.

I had never conducted in-depth interviews in the manner needed for this study and this inexperience was reflected in my earlier transcripts. Realizing that I was inexperienced I made a point of completely transcribing each interview before I went to the next. Perusing the early transcripts showed me that I had over-adhered to my theme list, turning prompts into questions and asking one question after another. Those interviews did not flow very well, there were a lot of breaks, most of the talk was being generated by me, and the style was rather interrogatory because I was uncomfortable with silences and tended to jump in with another question to cover my discomfort. I was not coming up with enough useful information.

Learning from this, I changed my tactic. During my first few interviews I had started with the question, if you were to describe a happy and fulfilling life for you as a woman how would you describe it? In subsequent interviews I started with a general statement that expressed the following:

For each one of us what we have experienced in our lives is different. For some of us it is a happy life and for others it is not. I am interested in learning about your life experiences. Tell me about your life

I then let the women lead the encounter, only intervening to either clarify, encourage or signal them that I was listening and found the interaction interesting. This change led to much more useful and relevant data and my transcripts started showing chunks of data indicating I was not intervening as I did initially. Even if sometimes the women spoke of things that were not so 79 relevant to my study, I let them go on until there was a natural break where I could bring them back to focussing on the issues that were of interest to this research. In the end the theme list proved unnecessary.

One of the problems I constantly grappled with was how I should best interact with my participants during the in-depth encounters. To what extent should I engage or remain detached? At times I wanted to challenge their way of thinking. Other times I wanted to take the role of a counsellor or be a women’s rights advocate. But I also felt that to ensure rigor of research I needed to keep a distance. This is the clash of the various “I”s we bring in to research (Rowling, 1999) I found it very hard to keep strictly to my “Research I”. For example in my encounter with Ahmeema, a single mother with a child conceived out of wedlock she kept saying she had committed a sin and had to take responsibility for that. She spoke with detachment as if she was not at all angry at how unfairly she had been treated with her being punished and her lover not having to face the consequences. Ahmeema’s attitude evoked quite an emotional response from me because of some of my experiences related to women’s rights. I wanted to ask her if this did not make her angry but then thought this may be leading her to give an answer that I wanted to hear. Nevertheless I let my ‘Women’s Rights Advocate I’ intervene by saying that if I were in her shoes I would feel quite angry at the system for treating women so unfairly. My intervention brought quite a change to our interaction. Instead of the detached woman who was automatically narrating her life experiences, she revealed her true feelings and emotions. I realized all this time she had been wary of making her true feelings known because her conceiving a child out of wedlock was such a stigmatized act that she felt I would also be judgmental. From this interaction I realized what Patton (2002) meant when he spoke of non-judgmental mindfulness and that remaining too distant can reduce understanding. Had I not let her know how I would have felt in her shoes, she would never have let me know that she was angry at the system for treating men and women differently. I would have left this encounter with a different understanding of her feelings.

In another encounter, this time with Nazima, I realized none of the women had so far mentioned experiencing sexual abuse. I had never specifically probed for or asked directly about their experiences with sexual abuse. But with Nazima’s, at an appropriate moment in our interaction, I asked her directly if she had experienced sexual harassment. This direct intervention led to the revelation that she had been sexually harassed during her training but had never mentioned it.

80 This made me realize unless I specifically probed for sexual abuse, I may never obtain such data. Therefore, from this encounter onwards, I directly asked about sexual abuse.

4.3.4 Group interviews

Group interviews were conducted in both Alifushi and Hithadhoo with women falling into three age groups: 15–20 years, 25–25 years and over 50 years. Initially I wanted to conduct focus groups. But when I tried to do this, I realized that what was intended as a focus group was turning out to be a group interview as can be seen from the following excerpts from my journal.

The discussion did not go as smoothly as I wanted it to. There were many long silences. I then asked a question. One person would respond to a question and there was no discussion generated as a natural flow from one participant’s response to another. Most of the time there were only two participants talking. I found myself having to go round robin fashion to find out how others felt about a particular question. When I did this the response was “I feel the same way”.

The communication flow was mainly between the moderator and the participants. In most cases between two of the participants. Two of the members hardly said anything. When I asked each of them specifically how they felt, sometimes they would just smile and give a shy laugh or other times say, “I feel the same way”. There was one member who was always responding. (Field Notes: 28 Nov 2002)

After reflecting on how this focus group went, I read up some more literature on focus groups. In the next island, I had an observer to write down notes and I had the tape recorder on to free me totally to moderate and facilitate the session. I also made sure that the meeting place was private and non-threatening. Still the same thing happened. Upon further reflection, more reading and talking it over with a couple of my colleagues at home I came to the following conclusion. In our culture people, especially the less educated, were not used to the focus group type of interaction. We just answer questions we are asked. Also the topic was perhaps too sensitive for a focus group. So I treated the completed focus group sessions as group interviews and discontinued this form of data collection as it did not really add anything to my discoveries.

Most of my formal encounters were audiotaped after obtaining the participant’s consent. I transcribed all encounters at the initial phase of my study before I left the field site. My plan was to follow up on my first encounter either on the same visit or on subsequent visits, being guided by my data and continuing to follow up on emerging themes and exploring issues until saturation was reached. However, sometimes shortage of time or money determined that I leave a particular field site before saturation was reached. Furthermore, I was very conscious of disrupting the day- to-day lives of my participants in asking for a considerable amount of time. Thus in most cases I had to be satisfied with just one formal encounter with each of my participants, even though from

81 a methodological perspective I realize this was not the optimal situation. Nevertheless, this is the nature of naturalistic inquiry and every study will have its limitations.

On a final note, in the process of my field-work I always bore in mind the need to be flexible and to go where my data took me. For example, during one of my field visits to the island of Guraidhoo, I discovered that there were a number of women on this island afflicted with jinni moyavun that caused them suffering and distress. Jinni moyavun in women was something that kept cropping up in my informal encounters. When I realized this from my field notes I decided explore it more fully. Thus, as the study proceeded, I deliberately sought out women afflicted with jinni moyavun and healers who treated jinni moyavun or other forms of rituals that involved supernatural explanations of suffering.

4.4 Ironing out the creases

In this section I will first outline the various ethical issues related to this study and then discuss the measures taken to ensure the rigour of the research. I will conclude this section with the details of how I analysed my data.

4.4.1 Ethics and politics of research

There are two main dimensions to the ethical and political aspects of qualitative research (Liamputtong & Ezzy, 2005): those of a procedural nature such as obtaining the necessary ethics approval, in this case from the Ethics Committee of University of New South Wales and obtaining official clearance from the Ministry of Health and Ministry of Planning and National Development of the Maldives, and those related to the participants. The latter include issues related to access; informed consent; participation; confidentiality and anonymity; and protecting the participants from risk and harm and being sensitive to their needs.

I have described elsewhere how I gained access to my participants and will simply reiterate here that at no point were any of my participants under any pressure whatsoever to participate in my study.

Obtaining informed consent Informed consent is the protocol followed by the researcher to ensure that the informants and participants who agree to become part of the research process do so being fully aware of the nature and purpose of the research, who is undertaking it, and how the information is to be disseminated (Liamputtong & Ezzy, 2005). I used a consent form (see appendix 2), which had 82 been translated into the local language so that participants could read it, seek any clarification from me and sign once they had understood it.

The concept of consent forms is something totally new in the Maldivian context. Research following such strict ethical guidelines has never been undertaken there. Signing a consent form did not mean the same thing as it would to the Western world. In the political and cultural context of the Maldives, signing a consent form was more likely to be perceived as coercion than “informed consent”. I explained to the University Ethics Committee that I would therefore leave it up to the participants to sign the consent form or to provide verbal consent. In some cases participants did sign it without even reading it. When I suggested they read it they informed me they trusted me and therefore did not want to read it. Most of the participants took the option of verbal consent. Signature on a consent form is also a way of identifying the participant and this has implications for confidentiality and anonymity, which I discuss below.

Maintaining confidentiality and anonymity In this study I was dealing with very sensitive and personal issues some of which, if known to the appropriate authorities, could have had legal implications for the participants. Confidentiality was critical. For example I was aware that information related to sex outside of marriage might be revealed and the Maldives being a Muslim country sex outside of marriage is a punishable offence. Also certain types of faith healing such as fanditha are currently not encouraged by the government and participants in it might get into trouble. So I made every effort to ensure the privacy of the participants by concealing their identities using pseudonyms even in my field notes and interview transcripts. All material accessible to the general public such as future publications based on this study and this thesis once electronically available will be clear of information that can in any way lead to identification of my participants. For fear of revealing the identity of the participants and breaching my promise of confidentiality I did not even enlist the help of any Maldivian to transcribe my interview tapes. All my data including tapes and transcripts are being kept confidential and in a secure place not accessible to others.

Protecting the participants from risk and harm and being sensitive to participants’ needs This is an ethical consideration of utmost importance in my research since it deals with sensitive, distressing and highly emotional information from women. Some of them were going through emotional distress at the time of our encounters.

83 I was aware it is not always possible to protect the participants from harm, especially when it relates to issues that arise from their relations with their family members, particularly their husbands. For instance a woman may be subjected to physical and emotional abuse from her husband and under current legal processes there is little that can be done to guarantee her against further harm. The woman herself may not really be in a position to remove herself from harm’s way as that would mean either getting a divorce or finding a place to go and she has none.

Protection was a delicate question and posed an ethical dilemma. In the case of someone who has suffered from or is suffering from sexual abuse by a relative, what are the choices available? If I reported the matter I am violating the participant’s trust and confidentiality. If I did not, am I not causing her harm? Or in the case of someone who has suicidal ideations, what do I do? Such a situation did occur with Shaheen, a young woman of nineteen years. Shaheen’s aunt had organized this encounter, believing Shaheen was suffering from mental distress. Shaheen revealed to me that she had stopped taking the medication prescribed by her psychiatrist. Later on Shaheen’s aunt mentioned to me that at one point Shaheen had been suicidal which was why the family had taken her to see a psychiatrist. I did not want to violate my promise to Shaheen not to reveal anything she told me even to her aunt. I finally dealt with this situation by letting the aunt know that it was imperative that Shaheen get urgent professional help. I also gave Shaheen my contact information and told her that she could get in touch me any time she needed to talk with me, even after I left the island. Until I departed from the island I also checked with her aunt to see how she was. This was the best I could do under the circumstances, although even as I write this I cannot help but wonder how she is and if she is dealing with her illness.

When conducting research with people who are dealing with painful and distressing situations as in this study, “the interview could trigger memories” (Morse & Richards, 2002, p. 318). The participants may be very emotional and cry and the researcher needs to be prepared to offer comfort and empathize with them. This was the case with my encounter with Khadeeja. She had been forced into marriage at thirteen to a man several years older. He had a family history of mental illness and during their marriage he started showing signs of mental illness. Khadeeja with teary eyes recounted the story of how her husband enraged that his two-year-old would not stop crying took the baby out of the cot and slammed it onto the floor. The five-year-old sister was watching and the baby died from this incident. As she narrated her experiences her voice cracked and she could not go on and started crying. I myself was quite affected and felt like crying. I let

84 her cry while I sat beside her and held her hands. When she composed herself I told her gently that we could stop and talk later. But she assured me that though she still got emotional because it brought back memories it was also therapeutic to talk about it to someone.

My encounter with Khadeeja was the most distressing of my entire study. I had a hard time transcribing her interview as it induced tears. In the end I decided against doing a detailed transcription and made a summary of the main points. I was very tempted to exclude this interview as I was not sure how objective I could be in dealing with this encounter. I recalled Bergen’s (1993) experiences during her study of marital rape and her words: “If I had been a detached and objective researcher merely collecting data, I might have either terminated the interview and discarded the data, or possibly suggested that the woman receive outside counselling. As a feminist researcher, however, I was interacting with this woman on a personal level and her distress was deeply affecting” (p. 208 - 209). Bergen’s words reminded me that being emotionally involved and interacting with my participant and being sensitive to the needs of my participants was part of being a qualitative researcher exploring sensitive issues. Bergen writes, “During the most emotionally difficult interview, I spent a long time offering support to a woman who became extremely upset when she described her husband anally raping her in front of her child”. She highlights the need for researchers to explore sensitive topics with ‘conscious partiality’ and I realized by empathizing with my participant and taking the emotional aspects into consideration I was being ‘consciously partial’.

Throughout the study I took great care to remain empathetic, sensitive and patient. I acknowledged and validated my participant’s discomfort. For instance during one interview, although the participant had agreed to have the interview audio-taped, I spontaneously switched the machine off when I noticed her glancing at the tape when we started talking about some very personal issues. The relief on her face confirmed I had done the right thing.

In my formal encounters with all my participants I tried to ensure the participants were interviewed in a location where they were assured of privacy. I left it to them to choose a location that would give us privacy and make them comfortable.

4.4.2 Ensuring the rigor of the research

The main strategy to ensure rigor in qualitative research is systematic and self-conscious research design, data collection, interpretation and communication (Mays & Pope, 1995). Different qualitative researchers have suggested different criteria and ways of ensuring rigor.

85 Morse and Field (1995) use the terms “appropriateness and adequacy of data” (p. 80). The methods of data collection I used in this study, the in-depth encounters and the prolonged engagement in the field, enabled me to develop ‘full and rich descriptions’ that Morse and Field suggest to ensure rigor.

The concept of trustworthiness to ensure rigor in qualitative research was introduced by Lincoln and Guba (1985). Trustworthiness is “a fit between what they [researchers – my words] record as data and what actually occurs in the setting under study” (Bogdan & Biklen, 1982, p. 44). To meet the dimensions of credibility, transferability, dependability and confirmability suggested by Lincoln and Guba, I used prolonged engagement in the field, persistent observation, and data cross- checking.

Prolonged engagement in this study meant more than six months in the field collecting data. This period of time along with my previous professional background enabled me to build trust between the participants and myself. The multiple data collection methods – observation, formal encounters, informal encounters, encounters with others in the women’s social world enabled me to cross-check information, insights, results and conclusions that emerged from the data (Ely, Anzul, Friedman, Garner, & Steinmetz, 1991).

To ensure confirmability I asked colleagues and other professionals to review some of my transcripts and give their impressions. This is a process referred to as structural corroboration (Hoepfl, 1997). Lincoln and Guba (1985) refer to this as referential adequacy. As this study was a part of my doctoral research, there were a number of other doctoral candidates concurrently engaged in qualitative research. We met as a group on a monthly basis for a qualitative research seminar. I was able to use this forum and other peers in our group to exchange ideas and concerns and enlist their help to comment upon emerging themes, a process described by Lincoln and Guba (1985) as peer debriefing. One of my fellow doctoral candidates was undertaking a study looking at depression in the Chinese community. I was able to enlist her help in reviewing my transcripts and my coding.

I kept an audit trail, a detailed record of the research process to ensure that other researchers are able to accurately follow the process (Lincoln & Guba, 1985). These consisted of my journal where I noted all the steps I have taken in this study, along with all the methodological decisions, and emails I wrote to my supervisors on various issues related to my research. As I undertook the analysis I kept methodological notes and memos in a separate file, using both the computer- assisted program of Nvivo and also manually on my computer in Word documents. These steps 86 were taken to lay down a solid groundwork for future researchers to follow and to assure the soundness of my research process.

In addition to the above mentioned methods, Lincoln and Guba (1985) suggest reviewing transcripts with participants for accuracy and getting their reaction and comments. The functional literacy levels of most of the women in this study precluded giving them transcripts to read and getting feedback. However, during my encounters, I had used a technique of summarizing and repeating the responses back to my participants to ensure I understood and reflected their responses accurately. Furthermore, during write up of my thesis I sent relevant sections to two of the biomedical healers and to one of the more educated women participants to ensure that I had reflected their views accurately.

4.5 Making Sense of the data

The formal encounters were conducted in the local language and then transcribed and translated simultaneously into English. The main purpose of the transcripts was to provide a written version of what the participants said in their encounters rather than to record the interview process itself. Thus in transcribing my main focus was on the verbal content of the participants’ accounts, although I did attempt to identify some of the body language and changes in intonation.

The analytical strategies I used in this study were based on the grounded theory approach, particularly using thematic analysis. Grounded theory is an approach that guides the process of analysing verbal accounts generated through in-depth interviewing (Glaser & Strauss, 1967; Strauss & Corbin, 1997). In grounded theory, ideas are organized from the data gathered and these ideas contribute to theory generation. Grounded theory analysis is an ongoing process where data are simultaneously collected, coded and analysed for common themes and patterns of meaning. In this study I did not use grounded theory in its entirety. Instead I drew upon the principles of grounded theory to identify and organize themes in the participant’s accounts but not as a way of developing theory.

Analysis began with the first field notes and was continued recursively in cycles of data collection and analysis. As an initial step I examined the field notes and interview transcripts to gain a sense of what was happening.

I categorized the findings according to my three research questions and then I examined each category for themes and concepts. I used constant comparison of data within a particular source and between the different data sources to look for emerging patterns (Glaser & Strauss, 1967). At 87 later levels of analysis I looked for relationships between the contextual information and what I was seeing and what was documented in literature.

4.6 Summary and conclusion

I began this chapter by indicating the approaches to inquiry adopted in this study. I have also detailed the methods of data collection, the processes used for selecting participants, practical matters related to the actual field-work and ethical and rigor issues related to the study. I concluded by outlining how the data was analysed.

Throughout I have underlined the advantages of flexibility in the research processes. It was this that enabled me to illuminate the suffering and distress of Maldivian women from their own point of view, and in doing so to give them a voice.

88 Chapter 5

Society Puts Pressure On Women

EXPLAINING DISTRESS

It [mental health] is a big problem. Especially for women. It is because of what women encounter in their life. There are things in our society that make women vulnerable to mental health problems. (Primary health care worker speaking about the determinants of women’s mental health)

In this chapter I present and discuss the findings related to my research question, How do Maldivian women explain their suffering and distress. These findings reflect women’s understandings of their suffering and emotional distress and how it is embedded in the circumstances of their lives and the cultural norms and values that they have internalized. The accounts of women and healers emphasize the social and cultural bases of women’s ill health – the social and economic circumstances in which women live; the nature of gender relations and how culture shapes women’s own attitudes; what is important to women and how it defines and structures women’s place within the family and in society.

I begin with a brief overview of my participants.

5.1 Overview of participants

I interacted with a total of 44 participants. These included 29 women, 8 biomedical healers and 7 traditional healers. The biomedical healers included three medical practitioners, two psychiatrists, one psychologist and two multi-purpose community health workers. The traditional healers are those who practice faith healing and are locally known as fanditha verin. Of the 44 encounters all except 4 were quite lengthy in-depth encounters. To protect confidentiality and hide identity names have been changed. In some cases, given that the Maldives is so small, demographic data such as age, number of children, type of job and their home island have also been changed. A brief background on participants who were interviewed in-depth can be found in appendix 3.

The participants were aged from 19 to 60 years. In terms of education they ranged from those with just basic literacy skills to women with university qualifications. Marital status ranged from single women to those who are in polygamous marriages. Some of the women were not involved in income generation activities outside the home whereas others had full time jobs outside the home. Except for two of the women, none had been previously diagnosed with a mental health problem. 89 5.2 Society makes women vulnerable to suffering and distress

In this first section I present the various explanations that relate to the social circumstances of women’s lives that negatively influence their women’s emotional and social well-being. Women’s and traditional healers’ explanations of their distress were dominated by themes such as relationship issues, and the various burdens of women’s lives. However, biomedical and psychological factors were the dominant themes in the biomedical healer’s explanations.

5.2.1 Relationships with Significant Others

Women spoke at length about the relationships with significant others in their social world. During their childhood and teenage years, parents and extended family was crucial to their well-being. Having a stable family of both parents, who respected each other, did not fight or ill-treat each other and who showed their children that they loved and cared for them was what made a happy childhood. In the absence of parents the extended family such as grandparents or aunts and uncles filled the role of parents.

As women left their childhood and entered adolescence and early adulthood their happiness and mental well-being centred on their boyfriends. Having a boyfriend with whom they could be “close”, “share” things with and who loved them completely was mentioned as essential for their mental well-being.

As women entered into marriage and married life happiness and emotional well-being revolved around husband and children. A husband who was loving and caring and above all faithful to his wife was the most important aspect of an emotionally well-balanced married life. Having a “good husband” was what made their married life happy. A “good husband” was defined by the women as someone who loved his wife, showed he loved and cared for his wife above all other women, and was kind and considerate to his wife when she was sick. Kindness and care when women were ill were seen to be a very essential part of being a good husband.

For some women a good husband was also someone who shared the domestic chores and childcare responsibilities and communicated well with his wife, especially discussing important matters with her and basing decisions on such discussions. For the more educated women in this study a happy married life meant having a husband who supported and encouraged them to achieve their personal aspirations in life, allowed them to wear what they wanted to wear, and placed no restrictions on their freedom in choosing a career or to venture outside the home.

90 5.2.2 Marital problems

Biomedical healers perceived marital problems to be the most salient factor that negatively affected women’s well-being. They identified marital problems to include lack of communication, infidelity on the part of the husband, different forms of abuse, lack of intimacy within the marriage, sexual problems, and not being loved.

Women suffer at the hands of men The traditional healer Azee pointed out that “women suffer at the hands of men”. He spoke of how women suffered when they had to share their husband’s love with other women. According to Azee, men’s uncontrolled sexual desires made them look for other women. He saw some men as being unable to stop looking at other women or content themselves with just one woman so they would get into a polygamous relationship with a younger wife. When this happened the man often stopped caring for the older wife causing her pain and suffering.

In some cases the man concerned do not fulfil the needs of the first wife. I know of someone who has not given anything to his [first] wife for about 4-5 years. Does not give her right of sexual fulfilment. What a torment for her. Could this get any worse? As I see, sexual desire and the need for food are two basic things that anybody must be entitled. If these desires are not fulfilled there is no point in living. If you cannot satisfy your hunger, if you cannot fulfil your sexual needs… how can you live? Your life becomes empty. So it is because of men that the woman goes to hell or suffers. (Traditional healer)

Women’s accounts of their relationships with their husbands reflected ambivalence. They recognized paradoxes in what relationships meant for them. Divorced women brooded over their plight because they felt lonely. In the first place they got divorced because their marriage was not happy. At the same time the financial security that husbands were supposed to bring encouraged them to get married. Marriage as a necessary evil was a common pattern reflected in women’s accounts. Marriage was a means of financial security, social respect and for some companionship, love and support.

For some women marriage did not bring the financial security they hoped for. Instead it brought challenges and conflicts leading to suffering and distress. Sabeeha, a thirty-year-old woman, is a classic example. Sabeeha who has seven children below the age of thirteen years, married three different men and went through five marriages hoping for financial security. But as portrayed in these words, her marriages had only added to her financial and mental distress.

91 My mother married my father and got 3 kids. When she was pregnant with the youngest kid my father divorced her. Even before he had divorced her twice and then remarried her… he left her and went off without giving her any support at all. She worked and [sometimes she got some money] She could not educate me beyond grade 5. Because of poverty I had to stop my education at that point. So I thought the best thing to do was to get married. That would be how I could lead a better life. So I got married. I was so young … around 15 years and at 16 I had my first child. The same year I was pregnant with the second child. Then I got a third child and I got divorced… After the divorce he [ex husband] would come to the house and eventually I found myself pregnant again. My life went on and on like that and after a long long time I got married again. I did not have a choice (Sabeeha).

In Sabeeha’s account we see a very common plight among Maldivian women. Getting married at a very young age, going through serial monogamy and the whole cycle of marriage and divorce. Marriage for many women like Sabeeha was more to do with financial security than love. But as illustrated in Sabeeha’s case ‘marriage as financial security’ is just an illusion for most women. Despite this women go through the cycle of marriage and remarriage in the hope that they will find a husband who will bring the financial security they so desperately seek. Sabeeha, after five marriages, three husbands and seven children realised finally that marriage was not bringing financial security. Instead every marriage resulted in a child, adding to her burden. She has now decided that marriage is over for her.

The scenario of marriage and divorce and the ensuing suffering arises because of the gendered norms within the society and the lack of control women have over their lives. These will be discussed in further detail in Chapter 8. Besides Sabeeha, other women such as Maheena, Neeza, and Shareefa had all suffered from failed relationships. Their husbands left them on their own to care for their children. Without any child support these women struggled and were constantly distressed as a result of their life circumstances.

5.2.3 Being Abused

Some form of abuse by the men in their lives was mentioned by many of the women. Abuse included physical, sexual and psychological abuse. For some women abuse also included various forms of restriction placed on them by their fathers or husbands or boyfriends.

Physical Abuse Yasmin a woman of nineteen years who is still in high school spoke of how her mother had been abused by her father. It was difficult for Yasmin to talk about her father’s treatment of her mother. In Maldivian society there is a ‘culture of silence’ around the issue of violence against women. I had to probe Yasmin gently to find out more about the violence her mother experienced. Even then she was very reluctant to talk about it and she looked down, playing nervously with her hands as she very softly spoke about it. 92 He [father] would be upset at little things. Like there may be dust on the table and he would ask mom to clean the table. She is busy with something else and she would say she would do it a little later. This will make him fly into a rage, as he wanted her to do everything as he said and at the time he wanted. If she did not then there would be a major fight. Sometimes gets real nasty and father would beat my mother. Pull her by her hair and push her onto the ground and this sort of thing. (Yasmin)

I visited Yasmin’s mother who lives on a nearby island. Her mother confirmed what Yasmin said. Yasmin’s mother continued to live with her abusive husband as he provided financially for her and she had several children with him. She said that if she were to leave him she might lose her children. Even if the children remained with her she would not be able to support them without the husband’s financial input.

Azza a married woman in her fifties spoke emotionally of a life of abuse beginning from the time she was a child of seven. When I first met Azza I was shocked to see how frail, thin and apathetic she looked. Even in physical appearance one could easily see that this was a woman who was suffering. Azza’s mother died when she was 7 and her father brought in a stepmother who was cruel and abused Azza. Her stepmother would throw her into a corner and force her to keep herself against the wall and deprived her of food although Azza helped prepare the food.

My stepmother would beat me with an iloshifathi [a broom made with the hard stem of palm leaves and used for sweeping the floor] till I bleed. My stepmother abused me so much that I have scars on my body and skull [showing her skull where the scars were]. But father never said anything. (Azza)

Azza was so badly abused that she thought of getting married to a man from another island just to escape the abuse. Her father got wind of this and shut her up in the house to stop her running away and getting married.

Azza’s life it seems was one filled with suffering and distress from the most significant people in her life, her father and her husband. She was forced to marry at the age of 14 by her father encouraged by her stepmother who wanted her out of the house. At some point Azza fell in love, but her father prevented her from marrying that man.

I was in love with someone and I had written songs to him and I had kept these in a treasure box. My father broke this box, took all the songs and letters and tore them up. Then he held me down and tied my arms and legs and made fanditha and he forced me to marry. I was terrified and cried and cried. (Azza)

In her present life, Azza is continuing to be abused. Her husband of twelve years does not show her any love. He does not touch her at all even though they sleep in the same bed.

Sexual abuse The culture of silence earlier mentioned made it very difficult for women to talk about the violence in their lives, particularly in the case of sexual abuse. Also within Maldivian culture giving in to the

93 husband’s sexual desires is considered a wifely duty whether the woman feels like it or not. Azza’s words, “Going against my husbands’ wishes and not fulfilling it [sexual desires] is a sin”, reflect this.

Azza’s view of a woman’s role in sexually fulfilling her husband’s desires as part of being a ‘good wife’ is not uncommon. While being a ‘good wife’ gives a woman social recognition and acceptance, for some women it means psychological and emotional suffering.

Although the culture of silence prevented women from speaking of the violence in their lives, my past experiences and my familiarity with my own culture alerted me to the nonverbal cues that might indicate sexual abuse. Being conscious of these nonverbal clues I was able to probe further which in some cases led to the discovery of violence in women’s lives. I sometimes suspected that women had been raped by their husbands but in the short time I had with my participants I had no way of confirming my suspicions.

Hannah a woman in her fifties used words such as “Like animals do it and go. No gentleness”. “He would hurt me”. These words to me sound like her husband may have sexually abused her. She also stated she was distressed that her husband wanted to have sex with her when she was not ready for it. These words and her non-verbal cues point to the possibility of marital rape. But I cannot verify this as she was reluctant to discuss it further and I respected her wishes. Hannah, like other women, felt she had to do what her husband wanted. Here again, in Hannah we see an example of how the notions of being a “good wife” bring with it emotional suffering and distress. Also in Hannah’s case we see gendered power dynamics at play.

For some of the participants refusing to have sex was not an option. As already stated, refusing would be committing a sin and some of the women stated that even if they suffered in this world they wanted to be rewarded in the life hereafter.

Sexual abuse of girl children While women seemed to accept sexual abuse by their husbands as an unavoidable part of their life and had difficulty talking about it, they were quite vocal in talking about sexual abuse of girl children. This was particularly the case on the island of Guraidhoo where every woman I encountered who had a daughter expressed concern for their daughters and a desire to protect them from sexual abuse. Sabeeha, who was already extremely distressed over her failed marriages and the financial stresses in her life, was also worrying over protecting her daughters against sexual abuse.

94 Guraidhoo women’s concern over sexual abuse of children is related to a child abuse incident that had occurred on the island fairly recently. A twelve-year-old girl had been sexually assaulted by a close family friend resulting in her becoming pregnant. This child had to forgo her education as a consequence. The perpetrator after serving a brief period in jail was now back in the community.

Shaheen a young woman of nineteen years whose family had a history of mental illness had also been sexually abused by one of her cousins when she was six years old. As a result she was experiencing psychological problems. I will discuss this case in more detail elsewhere.

Yasmin too had experienced sexual assault which made her fearful of sleeping alone. She told me the story of how somebody had tried to “steal her virginity”. She was sleeping with the lights off and she woken up suddenly by someone trying to pull her pants off. He had tried to pull her out of the room with a towel over her face. Yasmin struggled and managed to scream waking up the person who was sleeping in another bed in the same room. The man got away and since then Yasmin was unable to sleep by herself.

Psychological and other forms of abuse From their stories it was apparent that women also suffered more subtle forms of abuse such as being ignored, having their concerns discounted, being insulted by being treated badly in front of others, verbal abuse and having their mobility restricted.

Aina, a woman in her thirties who is the sole breadwinner in her family spoke of how her husband’s indifference to the way her father-in-law and brother-in-law were treating her caused her distress. Aina’s in-laws badmouthed, nagged and verbally abused her. Yet her husband totally ignored this. Her words indicated her despair

He won’t even find out what is going on. Try to talk to his family and find out why they are badmouthing me. For him the problems I am having with his family are their problems and mine. Nothing concerning him. I have to sort it out with his family and deal with it. (Aina)

Health workers spoke of husbands placing restrictions on their wives. These included restricting their wives from going to their friends’ houses, talking to others especially their male friends, joining in community work and participating in sports activities or entertainment shows. According to the health workers husbands would sometimes use the threat of divorce to force their wives to comply. The health worker’s observation reflects the unequal gendered power dynamics that lead to abuse and suffering for women.

95 The husband orders her around. Limits her movement and freedom. She cannot even take a step without his permission. The husband may divorce her if she talks to a friend. So she is tied from all four sides [metaphorical expression]. There is no happiness for her at all (Health Worker)

One of the Psychiatrists spoke of how young girls who came to Male’ to study suffered because of being abused by their host family.

The other issue is those who are coming from other islands to Male’. This is a big problem now. These kids are faced with a lot of household chores and still continue to study and also put up with other kinds of abuse. I mean verbal abuse and sexual too. I think this is also an issue now. (Psychiatrist).

Rauna, a woman in her forties whose children are all grown up and living away from home, spoke of how her husband used to abuse her verbally and in other ways when the children were young.

He will not do anything or care for the kids. He will not come to the house. Stay away… day and night. Having to live alone… it made me so hiydhathi [heart distress]. We had four children. He does not care. If he comes in he will shout at me. Even the kids. He will start yelling. When he yells … I have told him to say what he wants softly, instead of shouting. When he shouts it affects me so much. But this is in him… I went to the doctor too because of my suffering. When you had kids and with a husband there, but he did not give you any attention or care, that is what would happen. (Rauna)

Again we see gendered power relations underlying women’s suffering and distress. It was a common theme in many accounts. Gendered power dynamics and the social circumstances of their lives mean women have little control over their lives. This lack of control has been associated in the literature with increased female vulnerability to mental distress (Thoits, 1987)

5.3 Gender division of labour

Women received little help with domestic chores, as revealed in the accounts of women and healers. This is reflected in the following words of one of the health workers.

He [husband] does not help caring for the children. The woman has to do it alone. In that case women will suffer from anxiety and worries. Women do everything alone. The husband even when he is on the island does not give a helping hand at all. It is the attitude of some men. They consider caring for the child and household chores to be responsibility of women and they will not involve themselves. But these days that is not acceptable and women protest and even fight with their husbands now. Women are sometimes not even able to attend meetings where their involvement is needed because husbands will not help with child care and so on. (Health worker)

As the health worker also stated, not sharing domestic chores is quite common among Maldivian men as cultural norms define the division of labour between men and women. Men are the breadwinners and women the ones who take care of the children and the home. Years ago a woman may have been content in this role but doing it alone is often hard work and the suffering it causes women is reflected in the following words of a health worker who describes the plight of some of his patients.

96 The school may call the parents for a meeting in the afternoon and another meeting in the evening. When they [wife] ask the husband to attend the evening meeting he will give all sorts of excuses. She has taken the children to school in the morning, brought them back for interval, taken them again, brought them back, gone to the meeting in the afternoon and again she has to go. She may start crying or fighting [with the husband] saying: “I have done all this work today and yet when I ask you to go to this meeting at 8.00 tonight you cannot do that. I have to do all the work in the house as well. I am all alone and yet I ask you to do one thing and you cannot do it” (health worker).

The health worker portrays the negative effect on women’s well-being when husbands do not share the burden of household chores and childcare. These words also reflect the vast range of responsibilities that fall on women. As portrayed here and as I have experienced in my work with women, the only role culturally expected of men seems to be that of breadwinner and provider of sperm. Everything else falls onto the woman.

In the present day world with increase in consumerism and the cost of living, more and more women are being forced into participating in the economy. Furthermore, more and more women are themselves choosing to be economically active. Yet social norms related to gendered division of labour within the private space of the home do not seem to change. For women who have jobs this means their multiple roles make them even more vulnerable to distress. Such was the case for women such as Aina, Alisha, Zuhaira and others in this study who had full time jobs. In literature two hypotheses have been explored to study the effects of multiple roles on health of women. The 'multiple role' hypothesis suggests that the effects are harmful, but the 'role accumulation' hypothesis argues that the benefits will outweigh the possible harmful effects (Martikainen, 1995). Evidence has been established for the cushioning effect of multiple roles against stress leading to positive mental and physical health (Sorensen & Verbrugge, 1987). In this study women who had multiple jobs such as Aina and Zuhaira considered the juggling of both roles in the absence of support from their husbands contributed to their mental distress.

As discussed in Chapter 3 the culturally determined gender norms confine women to the home front, whereas men are able to spend more time outside the home. These cultural and societal norms affect men’s and women’s mental health differently as portrayed in the following words of Faheem, a health worker.

In a lot of family matters, it is the woman who is responsible, who is concerned. It is the woman who is at home most of the time. The man spends a lot of time outside the home. When he is out he has a lot of friends. When he is among his friends and having fun, his worries are less. That sort of opportunity the woman does not get most of the time. The work that the woman does at home may not be hard labour. It may be light work. But she is kind of captive in her home. She has to be there. So constantly she is in that worried situation. So the problems will be more with women. But men. When you look at reality they are more free. I am also a man. But that is the real situation. For the woman it is compulsory for her to do the chores at home. (Health Worker)

97 Zuhaira, who is the president of her local women’s committee, echoes Faheem’s perspectives of societal norms and how they influence women’s well-being.

You may be under a lot of tension because of these issues. I suppose in this respect both men and women will be stressed equally. But then it is the women who spend most of their time at home. Men they go out. When tension becomes too much at home they go out. Tension is then gone (Zuhaira).

The accounts of both healers and women in this study reveal that the gender division of labour influences women’s mental well-being negatively. The multiple roles that women are socially and culturally expected to perform make them both more vulnerable to distress and less able to deal with their distress.

5.4 Burdens of life

While relationships were the predominant explanation provided for women’s suffering and distress another common explanation was what one of the traditional healers called “the burdens of life”. These relate to financial hardships, and the hardships of living in a small close-knit sea- locked community. The ‘burdens of life’ are clearly reflected in the following words of Sabeeha.

With seven children… sending them to school. I go to people and get from this one and that one and struggle to send them to school. There is not one child who is not sent to school… well, only the older three I have been able to send to school. The others are too young. Those three I made sure that they completed grade five. This year they are supposed to be in grade seven. Even this year I sent them. With great difficulty. Going to many people and begging them. To get the books. I would take the kids to and from school myself. Making sure I don’t leave them alone. These days there is so much sexual abuse of children and different forms of violence. I have more girls. I constantly worry about them. Where would I leave them? I have seven children now and I don’t get any child support from their fathers. I am all alone. I have faced so much suffering. Suffering I don’t know to describe. (Sabeeha)

The effect of the hardships of life on Sabeeha’s life was evident by the drawn, tired look on her face, her extremely thin frame and the way she spoke.

5.4.1 Financial hardships

Financial hardship adds to the already stressed life of women, who in many cases are struggling to take care of their family with no help from their husbands. On the islands there are very few jobs available and so often men go off to tourist islands to earn a living. This leaves the woman by herself on the island for months at a time to take care of the family alone, struggling to make ends meet with the money sent by her husband. Sometimes the money is not adequate for family needs. When a child falls sick the burden is financial and the woman faces the implications alone. Within Maldivian society she is responsible for the child’s care, for constantly attending to the child’s needs. Furthermore, cultural norms related to being a ‘good mother’ that she has

98 internalized from childhood means that it is the woman who constantly frets about how to provide for the child.

The biomedical healers spoke of some women seek professional help because their constant financial worries make it difficult for them to cope with their daily lives. As one of the medical practitioners stated, “This sort of demand is too much and what [the family] have to spend is not adequate to meet those demands. So there is a need to find lots of money. Which means you have to work for this. So the demands on your brain are too much”. The doctor clarified what he meant by “this sort of demand” - the increases in consumerism, general living expenses and education costs.

5.4.2 Struggles of a rural life

The accounts of women and my observations brought up several patterns reflecting the ‘struggle of a rural life’. These included: lack of job opportunities, educational facilities and health services on the islands, the monotonous routine of island life, and the struggles of coping with life on one’s own with husbands away in tourist resorts or elsewhere earning a living.

For Sabeeha life was harsh and a constant struggle. With seven children under the age of thirteen and the youngest just over a year she is unable to work outside her island. She used to have a job in the nearby tourist resort as a sweeper. But concerns about protecting her daughters from sexual abuse prevented her from going to this job. She had no help from her family to take care of her children. She could not ask her friends to keep an eye on the children when she had so many of them. There are no jobs available for her on her home island.

Zuhaira who comes from an island in the south has been active in her local women’s group. Her island has better health and education facilities and even more opportunities for employment than most of the other islands outside the capital. Yet even here life is a struggle, more for women than men. Zuhaira captures the various issues of living in a rural island in the Maldives very clearly in her following words.

There are lots of people who do not have anything to do socially. By the time they reach a certain age, they are still unemployed. Because of this… when you compare a woman who is employed and another who is not, the health problems the unemployed woman faces is much more. The complaints of that woman will be much more than the woman who goes to work. I think this is also due to physical problems and those that arise from psychological issues. When the woman stays home even the slightest problem becomes a bigger problem. If she does not have anything else to occupy her mind, that would be the case. In some places, women, even young women do not have anything to do to occupy themselves. There are no facilities here to go for further studies. So with nothing to do the next step is to get married. In marrying they want a good person who has some money. So there is no problem if a 20-year-old girl married a 40-year-old man. Someone who works in a resort. This brings with it other problems. (Zuhaira)

99 My participant observations on the islands provided further evidence of what Zuhaira was talking about. There is very little to do on the islands beyond housework and childcare. Not much exists in terms of entertainment and leisure activities, especially for young females. In one of the islands I had a group interview with young women between the ages of 17 and 20. They had completed their high school education and no jobs were available for them. According to them there was nothing for them to do on the island and they were bored.

The struggles of a rural life were also captured well by the psychologist who summed up why some of the women in the outer islands suffered, especially young women: “Because they are so bored of the monotony of this life. The routine… Lot of people comes with this [problem]”.

5.4.3 Problems of space and congestion

According to the biomedical healers congested living conditions, especially for those living in the capital, meant constant strain. A medical practitioner describes the situation as follows:

The space is so small. Family is big. So when the land is divided what each person gets is like an 8 feet by 8 feet room. There you have to have your children, the kitchen and everything. Then think of any aspect… the relationship between husband and wife… They are afraid their children may see them… The children grow up in that environment. So I would say the reason why mental distress is becoming so common is because of having to live in this kind of congested life. The reason why women are more affected in this… Sometimes and this is not talking bad about men… But for example where the man can have a close relationship with his wife is in that tiny little room [which is often shared with their children]. So if he can seek pleasure elsewhere, then he is able to fulfil his urge in a more independent way. So he would think of a way out… Probably. Otherwise, within the house the child may wake up or something else. So the woman will now have to think of all of these… Because her husband is going somewhere else. So this is also a factor. I think. Small things then become bigger and bigger and becomes major problems (medical practitioner)

The medical practitioner’s account of congested living conditions is a common problem in Male’. Land is so scarce that there simply is no room for expansion. Lack of employment opportunities and good quality education facilities in outer islands leads to families moving to Male’ and living in extremely congested conditions. Rents are so high that they cannot afford to rent an apartment. So many people are forced to rent just one room which becomes their bedroom, kitchen etc. In some of my previous work related to child rights I have been into homes where a three metre by three metre room is all the space a family of six or seven have to do anything and everything.

Even for people who are originally from Male’, land limitations, high rent and limited finances force people to live in extended families. It is not uncommon to find two or even three generations living under one roof. Each bedroom then becomes a household unit, with the mother, father and perhaps three children sleeping there. Living in extended families has some positive aspects – for instance women who have a full time job have their extended family taking care of their children.

100 However, as was mentioned by many of the women in this study, living in extended families, especially sharing congested living space brings with it numerous issues that negatively affect the social and mental well-being of all the family members.

The associations between overcrowding, poverty, economic hardship, urbanization and mental distress have been well documented (Murali & Oyebode, 2004; Patel, Araya, de Lima, Ludermir, & Todd, 1999; Patel et al., 2006). While both men and women experience these phenomena my findings reveal the impact is greater on women because of gendered cultural and social norms. This is reflected in the following words of one of the biomedical healers.

Like I said even within the home… Because of the conditions, the man goes elsewhere. The load on the woman’s mind increases. She has to think of: is there another person who is going to come to this small space? [meaning is her husband going to bring another wife to share the home] Is he going to throw me out and so on. She would have to think of these things. So she will be suffering from emotional problems. Then her physical health becomes affected. Then the husband takes her to the doctor and spends money on it. But she is not able to tell him that her problems are due to the fact that he is seeing someone else. (Medical practitioner.) 5.5 Tensions of being a good woman

In exploring the relationships between the various themes presented in the above sections, and comparing these to what I observed in my field-work, what emerges is a common pattern that I call ‘the tensions of being a good woman’. Traditional definitions of being a woman are related to being a good wife and a good mother. As indicated in Chapter 3, a girl child is socialised into growing up to be a good wife and a good mother. Prevailing gender ideology influences her well- being as she faces contradictions, resulting in suffering and distress. On the one hand women, especially educated women, want to achieve their aspirations. At the same time they are faced with the various difficulties associated with being first a good daughter and later a good wife and a good mother.

For Azza being a good wife meant she had to fulfil her husband’s sexual desires and living with a man she did not choose as her husband. For Mariya, being a good daughter meant accepting to get married at the age of 16 years to a man of 45 because that was what her grandfather wanted and that was what was expected of a good daughter. Once she had children, she had to think of her children. That meant continuing to be with the father of her children even though she did not love him and he was not the husband of her choice. She could not contemplate getting a divorce as that would affect her children. Being a good mother meant, putting the needs of her children above hers own feelings and needs.

101 Rauna had unsuccessful marriages. She lost her parents when she was a child and her brother forced her into marriage when she was 14. When her previous husband had divorced her for another woman she did not want to marry again. But being a beautiful woman many men came to her place to see her. She was not originally from this island. Other women started talking about her insinuating she was a bad woman to have so many men come to her home. So to avoid being labelled as a bad woman she married her current husband. This is reflected in her words as follows:

Women say things about me. I am from another island and all these men are after me. So the women of this island they always talk bad about me. I thought maybe I should get married again. If I stay single everyone will be talking badly of me. I am not someone who goes out. I will be within the premises of where I live. I don’t go out. I don’t talk to people. I am a very quiet person. I have never fought or argued with anyone ever in my life. I like to maintain peace. But because so many men come to my house, women bad mouth me and talk about me behind my back. That is natural. So I thought I must get married. (Rauna)

To get away from being considered a bad woman Rauna got into an unhappy marriage and stays there even though he demoralises her. Reflected in Rauna’s words are also some of the cultural attributes of a ‘good woman’ – quiet, keeps to the private domain of the house, does not argue, and maintains peace within the family.

Khadeeja forced into marriage to a man who turned out to be mentally ill, continued to stay with him despite the fact he was abusing her. If she asked for a divorce because he was mentally insane she would be considered a heartless woman. So she stayed with him and suffered silently until he died.

Ifhath, a woman with a university education, gave up the nursing job she loved because her husband did not want her to work. She was forced into staying home and being a good wife. She suffered silently because she did not want her children to lose their father. Eventually she could not take it any more and separated from her husband.

In all the above cases we see how the tensions of being a good daughter, wife, and mother lead to considerable suffering and emotional distress. Women lose their self (Jack, 1987, 1991; Jack, 1999) in trying to make life good for their children. I will discuss this further in Chapter 8.

5.6 Biomedical explanations of distress

Biological explanations for distress were sometimes offered by biomedical healers but were not a common theme in women’s and traditional healer’s accounts. What is very interesting is that it was only the more educated women such as Zuhaira who attributed suffering and distress to biomedical problems. 102 5.6.1 Genetics

Zuhaira brought up the issue of family history of mental illness when she spoke of Shaheen and her brother. Khadeeja also pointed to similar explanations when she spoke of her husband’s mental illness. One of her daughters now suffers from a mental illness. She implied that her daughter’s illness was related to her husband being mentally ill. But she also attributed her daughter’s health problems to the trauma of having watched her baby sister being violently bashed against the floor by her father.

5.6.2 Sexual problems

Biomedical healers mentioned sexual problems as a cause of women’s distress. The psychologist mentioned some of her clients, both men and women, had sexual problems that caused them distress. Some of them were related to women not being sexually satisfied because of orgasmic dysfunction or vaginismus. According to the psychologist sexual dissatisfaction was related to female circumcision in some cases.

Circumcision of females was practised in the Maldives in the past. Some women misconstrued circumcision to be related to religion and so they had little girls circumcised at birth. In my own family this was practised in the past and I was told by my mother that I too had undergone this procedure. In most cases this involved the midwife using a needle or a sharp blade to scrape the tip of the clitoris and cause bleeding at the time the baby girl is born. This was how my mother described the process to me several years ago. Traditional birth attendants have provided similar descriptions. According to the psychologist in some cases this procedure caused infection, which led to women experiencing sexual dissatisfaction later on in life. As far as I know female circumcision in no longer practised in the Maldives, but according to one of the biomedical healers the practise of female circumcision did occur though very rarely.

5.7 Psychological problems

Psychological explanations for suffering were provided mainly by the biomedical healers. Among the women, only the more educated raised this type of explanation. None of the other women directly linked psychological problems to their suffering though in some cases it was implied. Psychological explanations included such themes as: women not being able to talk of their worries and problems; issues related to expectations and aspirations; conflicting ideology; development and fast pace of life; and issues related to acculturation.

103 5.7.1 Bottling up feelings

Psychological problems associated with bottling up feelings was either directly identified or implied in some women’s and biomedical healers’ accounts.

I think maybe communication is also a problem. Between the husband and wife. Because you are afraid that your husband may get angry or your wife may get angry, you just cannot talk to each other. You are unable to discuss the problems. So each keeps the problems bottled up. Something like that. Maybe communication is a big issue. I guess in the Maldives we can still say that it is a male dominant society. (Psychiatrist).

Hannah and Zuhaira too spoke of bottling up feelings. According to these women and the views expressed above by the psychiatrist, it seems to me that bottling up feelings is linked to gendered power dynamics as well as the cultural norms associated with being a good wife. This aspect will be discussed in more detail in Chapter 8.

5.7.2 Aspirations and expectations

According to some biomedical healers children often suffered because their parents pushed them too hard to study. Exposure to television that linked people to the outside world and thereby increased consumerism was also mentioned as a reason for changes in people’s expectations. When these expectations are not met, the consequence is mental distress. A health worker reflects this in the following words:

The way I see it in the old days people did not have very high aspirations. Life was very simple. So there were not much people wanted to achieve in life. You just wanted enough to eat and drink and live happily. But now we are people who need to make use of a lot of resources. We have a lot more needs than before. These needs will keep increasing. As we develop people’s needs, aspirations will increase. So maybe when we are [unable to fulfil these] we then reach extreme levels of mental distress. When you do not realize there are ways you can minimize such distress, and you try to do it alone… maybe you reach that stage. In our country, development is taking place at a very fast speed. As we become more developed and living conditions change, we become more isolated. (Health worker)

5.7.3 Acculturation and conflicting ideologies

Conflicts in ideologies, especially religious ideologies, was mentioned by one of the health workers as a cause of distress especially for women, as reflected in the following words:

We are Muslims. There are lots of differences in thinking in relation to how we should dress. Some people have an extreme view of things. Others are a bit moderate. The conflict results in these differences in thinking (Health worker)

Conflicts in religious ideology portrayed in the above words may not be a significant contributor to suffering and distress at present. However I see this as a major problem for women in the foreseeable future, as was alluded to in Chapter 2. I have experienced such conflicts in my own life where my way of dressing has been under scrutiny. I am able to withstand and deal with such scrutiny. However, for some young women this may not be the case, especially if they are 104 dependent on family or their husbands for their livelihood. While my observations indicate some families pressure young women into wearing the buruqa, the opposite is also true. Young women voluntarily decide to wear the buruqa and face objections from their parents who do not want them to. Either way conflict arises as a result of differences in religious ideology.

Conflict arising from differences in ideologies relates not just to religious issues. As was mentioned by one of the medical practitioners and by Zuhaira, and as was revealed in my observations, women who have studied abroad and returned home with a different way of thinking suffer this form of conflict.

If we look at differences in thinking I would say… for example those who study abroad and return, they experience mental distress. What happens is they study abroad and they have seen the free life… ours is also free… but then what I am saying is there is a little fear of saying what you want to say. So maybe because of that they become mentally distressed. Even if you studied so much, you need to be able to adjust to the environment you are living in. No matter how free your thinking is…how open you are… You need to think of the culture and think within that environment and communicate and exchange your views based on that. But if these things are in your heart and you are unable to say what you want to say… may be those are the kind of things that make young intellectuals suffer from mental distress. Or you may say something and then you are arrested once… twice and then what would happen. We both know that. (Medical practitioner)

What is reflected in the medical practitioner’s words is the concept of acculturation (Berry, 1997; Bhugra, 2004). Acculturation is defined as a process that occurs “when groups of individuals from different cultures come into continuous first hand contact with subsequent changes in the original culture patterns of either one or both groups” (Bhugra, 2004, p. 246). As explained by the aforementioned medical practitioner in my study, Maldivians who go abroad to study come in contact with another culture and come to change their way of thinking with respect to women’s place in society. It is likely that upon returning home women especially find it stressful to be expected to fit into the more passive and compliant roles expected of women in the Maldivian society. The words of the medical practitioner also portray a form of political oppression; power dynamics between those in power and the powerless. I have personally experienced what he is saying, which is why he uses the words, “We both know that”. These power issues do not affect women only, they also affect men. I have alluded to some of these notions of political power play in Chapter 3 and I will be further discussing these in Chapter 8.

To summarise this section, the above findings and discussions illustrate that women’s suffering and distress is embedded in the social, cultural and political circumstances of women’s lives. It can be related to the contradictory and demanding reality of most women’s daily lives (Doyal, 1995). Women’s suffering and distress is influenced by societal and cultural values of being a

105 good daughter, a good wife and a good mother. In living up to these societal norms, women lose their sense of self.

The explanations provided by women for their suffering and emotional distress such as relationship problems and the various burdens of life are all interrelated and directly associated with being female. Certainly the sense of being ignored, disrespected and devalued arises from gender-related social conditions. Cultural values and norms that socialize a woman to obey and respect parent’s wishes, fulfil the sexual desires of their husbands, be a good mother, adopt traditional gender roles, take care of others, restrict the choices and options available to women.

Women who choose to stay home and adhere to the gender roles as socially sanctioned are left with less control and vulnerable to impoverishment. In the case of abusive relationships, making a decision to leave the husband may mean losing the children. So again women have very little choice in these matters and hardly any power to take control of their lives. These themes of power and choices and control are all strongly related to gendered power dynamics. What gendered notions of power mean to women’s social and emotional well-being will be further discussed in Chapter 8.

5.8 Supernatural explanations for suffering and distress

In this section I present the findings that reflect a supernatural aetiology of suffering and distress. Both women and healers associated suffering and distress with spirits, magic or sorcery and other supernatural causes. Some women explained their distress as fate willed by Allah. However, supernatural explanations were completely absent in the accounts of medical practitioners and psychiatrists. The psychologist’s account did mention supernatural explanations, but it was mainly reflecting her patients’ words.

5.8.1 Fanditha

Beyya, a traditional healer, explained that many women suffered as a result of fanditha. Fanditha as mentioned in Chapter 2 is a traditional form of healing akin to occult magical practice. It involves the use of prayer and verses from the Holy Qur’an as portions or charms. Beyya explained the power of fanditha to cause harm as well as bring joy and it’s use as a form of healing He spoke of two types of fanditha, isthiri and varutholhi:

106 Isthiri is not part of sihuru. For reconciling a married couple you may use isthiri. Or to get a person you are in love with, you may use isthiri. Varutholhi is something you use to break up a marriage. This is haraam [prohibited by religion]. When isthiri is done by someone who does not really know it, things go very wrong. It is a very powerful thing. Isthiri is so strong that if you do it without wearing glasses, it will affect the eyes and the eyes can be destroyed (traditional healer).

Beyya practises both fanditha and herbal medicine known locally as Dhivehi Beys. Beyya is in his seventies and has a good reputation for his healing powers. He included among the supernatural causes for women’s suffering esfeena or evil eye, sihuru (sorcery or magic) and jinni moyavun (spirit possession).

Like traditional healers, many women perceived the malevolent form of fanditha to be a cause of suffering and distress. Ahmeema believed her distress was caused by sihuru. Sihuru is a malevolent form of fanditha. Ahmeema is 33 years old and a single mother. When I first met her I was struck by how drawn and sad she looked and how thin she was. She looked as if like she had no pleasure in life. As her story unfolded I learnt that the man she loved jilted her just two days before they were to be married. Since then she had not been able to have a meaningful relationship, fearing every man would betray her in the same way.

Ahmeema attributed her suffering to a sihuru cast on her by her mother’s friend. He was in love with Ahmeema and wanted to stop her from marrying the boy she loved. Ahmeema said she did not believe in the supernatural. However, when she continued to experience all kinds of ill health that affected her body physically and doctors could not give her any explanation for this, she decided to consult a learned man who informed her that sihuru was the cause of her suffering.

He [the man she consulted] said I would never be able to get married. That [malevolent magic] had been done in this way. Unless [sihuru] is reversed I would never be able to get married. He said there were things buried. I had to dig it out. It was at a place where we would be stepping on. But he said he did not know exactly where. Also something had been buried in the sea. He said this was done so that my boyfriend and I will break up (Ahmeema).

What had happened to her was sudden and unexpected as reflected in her words below. Sihuru was the only plausible explanation to her for such an unexpected change in her husband to be.

The second day [her fiancé] married someone else. I don’t know what happened and why. He did this suddenly. I was very very sad. It is difficult to believe that this happened. I was in Male’. He brought me here. His family was not approving of our relationship. Before they were quite happy about it. But then something must have happened and they no longer approved our marriage. He brought me here and then [married someone else]. The second time I came to this island and met him, it was like he was someone I never knew. He was such a different person (Ahmeema).

To me, Ahmeema’s words tell that the only acceptable way for her to deal with the sudden change in her fiancé’s love and behaviour was to consider he was being controlled by some external power – that of powerful magic.

107 Azra a 33 year old woman with seven years of schooling explained that her grandfather had made fanditha to destroy her insides. It was because of the fanditha that she was suffering from mental distress. In Chapter 6 I will explain her experiences in more detail. At the time I met Azra she had been hospitalized and was under the care of a psychiatrist who had diagnosed her with schizophrenia. She was brought into the hospital by her husband when she slashed the blood vessel near her ankle with a knife

Isthiri and varutholhi that break up relationships and cause disharmony In Ahmeema’s case a form of fanditha - sihuru or malevolent magic caused her fiancé to leave her. For Mariya, Hannah and Rauna, fanditha was what led them to marry people they did not really love. This kind of fanditha is what is identified in the literature as ‘love magic’ (Golomb, 1993; Kang, 2003). In Maldivian culture it is known as isthiri. Kang reveals that the Petalangan people of Sumatra believe that love spells compel a targeted person to fall in love with the one who is having the spell cast. They believe magic spells penetrate the bodies and minds of the recipients and control their emotions.

Hannah’s first husband was an Island Chief who, according to her, used the power of isthiri (love magic) to get her to marry him. They did not have any children. Despite all her efforts to be a good wife he divorced her after thirty years. Hannah attributed her divorce to malevolent magic or varutholhi cast on her by his current wife who was then in love with him and wanted him for herself.

Like Ahmeema, perhaps Hannah too did not want to face the prospect that her husband no longer loved or had any use for her any more. Believing that fanditha was responsible for the break up of her marriage is less painful than facing being rejected for another woman.

The absence of children makes me also wonder if the reason for divorce could have been this. Her former husband has children, her current husband has children from his previous wife, Hannah wants children and she and her current husband have been sexually active and not used contraception. She had still not conceived. Children are crucial to a marriage as indicated in Chapter 3. Since I did not explore this angle, I can only speculate that for Hannah sihuru is perhaps a less distressing explanation for her divorce than to acknowledge even to herself her inability to conceive. . Similar explanations for the breakdown in relationships have been reported in some Islamic countries such as Saudi Arabia (Al-Subaie & Alhamad, 2000). Al-Subaie and Alhamad report that belief in Sihr or Sabab is provided as an explanation for the suffering related

108 to some types of mental illness. They suggest that Sihr or Sabab is linked to belief in witchcraft, an etiological factor that is based on Islamic principles. Although performing witchcraft is forbidden in Islam, its existence is referred to in the Qur’an which mentions that witchcraft can cause hatred between spouses which may lead to divorce.

The Sihr or Sabab mentioned by Al-Subaie and Alhamad in Saudi Arabia (2000) is similar to the sihuru of the Maldives that has been mentioned in the accounts of healers and women in the Maldives. In fact sihuru probably is derived from the Arabic word Sihr. Al-Subaie and Alhamad surmise that “witchcraft provides an explanation that relieves the spouse from being made accountable for his or her negative emotions towards the other partner” (p. 211).

Sihuru was also used as a way of taking revenge on those one disliked. According to Beyya this was how Alisha, a woman in her early forties, became ill. She has a background in health sciences and obtained her masters degree in psychology in the West. She works as a nurse and has three children. A year or so after Alisha got married she was very sick. Her husband took her to a general practitioner who diagnosed her condition as a nervous breakdown.

Alisha’s current husband had been previously married to Nadia. He had divorced Nadia and a few years later married Alisha. According to Beyya, Nadia was angry with and jealous of Alisha for marrying her ex-husband; Nadia believed Alisha to be the reason for her husband leaving her despite their two children. Nadia made a powerful sihuru to cause harm to Alisha and to break up their marriage. In her ill state, Alisha was a totally different person to the gentle, caring and happy person she had been and was totally confined to her bed.

In my encounter with Alisha she revealed that just before she had her breakdown, her husband had spoken to her about marrying his previous wife. After Alisha got better and she went back to her normal life, her husband divorced her and married his previous wife.

According to both Alisha and Beyya, Alisha’s nervous breakdown was indeed related to the break- down in her marriage. However, they both use a different way of explaining the cause of her distress. For Beyya her suffering was caused by the sihuru the jealous ex-wife had performed on her. Alisha explained her suffering as a psychological problem – a response to the threat of her husband leaving her. Alisha’s doctor provided a biomedical explanation - something was wrong with her brain chemistry. I believe that the change in the brain chemistry was precipitated by a stressful event – Alisha’s husband expressing his desire to get back to his ex-wife.

109 In Alisha’s example we see three different explanatory models at work (Kleinman, 1980). Williams and Healy (2001) prefer to call these ‘exploratory maps’ rather than ‘models’. Exploratory maps outline the avenues of thought explored by individuals in their attempt to understand the reasons for their suffering and distress. The women’s and healers’ accounts presented in this chapter, clearly indicate that various exploratory maps are used by these participants to understand their suffering and distress.

Ahmedbey, a traditional healer, spoke of how sihuru can cause a person to suddenly dislike or be bored with or even detest his/her partner. Another traditional healer, Azee, spoke of how sihuru is used to disrupt harmony and destabilize relationships by evoking ill feelings in people.

In cases where sihuru is performed to destroy someone’s life… this would lead to things such as the afflicted person developing dislike for certain things, refraining from work and the like. The jinni [called upon by the sihuru] tell the person to act like that, so much so that the person becomes alienated from the society. As for sihuru performed to destabilize families, this would result in various problems among various family members including causing hatred among them resulting in disastrous consequences if proper treatment is not received (Azee).

Azee received his education abroad in an Arabic speaking country where he studied Islam and became familiar with the Prophet’s Sunnah (way of life) and the Qur’an. He can read, write, speak and understand Arabic. Azee’s family also used to practice fanditha and he uses the knowledge he has acquired in Arabic to find ways of helping people heal and deal with their suffering. For this he uses the power of Qur’an and prayer.

Sihuru causes misfortune and suffering Beyya related the story of Mahmood a very prominent civil servant in Male’ who used to be quite well-off, had a good life and came from a family of high social standing. Mahmood’s life changed drastically because of sihuru as reflected in Beyya’s words below.

I told Mahmood he was experiencing the effects of sihuru. He should search in his house and inform me what he finds. They discovered a small coffin, a figure made with dough to represent Mahmood and on which there were writing, human bones and other things. These were buried there, which means a sihuru had been made to harm Mahmood. (Beyya)

I asked Beyya why he suspected sihuru to be the cause of Mahmood’s suffering and he responded as follows:

It is because of the kinds of behaviour Mahmood was showing and the way it happened. He had such a high position and I realized such a major change could not suddenly happen unless he was being affected by something like a sihuru (Beyya).

Beyya’s explanation of associating a sudden and unexpected change in status with sihuru is echoed in Ahmeema’s case discussed earlier.

110 Ahmedbey spoke of how sihuru can cause people to experience physical illnesses such as stroke. Ahmedbey is a fanditha veriyaa who used to be an Island Chief. Ahmedbey has practised his healing since he was twenty-five. He is now in his 70s and is very frail and sick. He has suffered from a stroke which has partially paralysed him on one side. He attributed his own experiences of having suffered a stroke to sihuru cast on him by someone who envied him.

There are lots of things that can happen [because of sihuru]. Some people come and say they are just so tired… feeling so lethargic all the time. Some sort of laziness. Cannot cope with life. Aches and pains here and there. Cannot be up and about. One day someone came and said she does not know what is happening to her at all. All that she knows is she cannot use any of her limbs to do anything. She is so lazy. She does not know what has happened. There is no illness that can be identified. Another day someone else came and said she was having this ache/pain on the right side from the waist up. She went to the health centre and they gave medicine. But this made her condition even worse. Another one came and said she used to be able to fall asleep the minute she went to bed. But now she cannot sleep anymore. This sort of thing… that is how sihuru affects people. Many women suffer from swollen breasts (Ahmedbey).

The above account of Ahmedbey reflects symptoms of mental distress that would probably be diagnosed as depression should a biomedical model be used. However, such signs or symptoms are not associated with an illness in Maldivian culture. Rather they are perceived as signs of a lazy person, a bad person. Not being able to cope, not being able to do things around the house because of perceived laziness or badness are not desirable qualities in a good wife or good mother. Mood and behaviours associated with depression in a married woman may mean she is unable to take care of her husband and child (ren) in which case it is likely that she may be divorced. The traditional healer understands the possible consequences to the woman and her family associated with her experiences of tiredness, lethargy, not feeling like doing anything and so on. So it is not surprising to me that Ahmedbey considers women with such behaviours to be under the control of a supernatural power – sihuru. Such an explanation removes the social stigma of being labelled a ‘bad’ person.

Beyya too indicated that sihuru could cause problems within the physical body, as reflected in the following excerpt.

Sihuru does a lot of things to you. You may become paralysed even. Most adolescents face problems related to isthiri (love magic). It turns into a sihuru and they may remain without getting married for a long time. What happens is when someone asks her to marry him and she refuses and he then does something. So the marriage door closes for them. (Traditional healer)

Dreams as an omen of sihuru Affliction caused by a sihuru was thought to be recognized by the kind of dreams one has. As Beyya recounts:

111 I ask them about their dreams. I ask them if they are afraid. She may say she had a dream and when she woke up she is very frightened and felt she could not breathe. If you are frightened and panic from what you dream, that means she is having a problem, may be related to the heart. Someone may dream of dying. They may tell me they dream of taking eggs from the nest. They dream of snakes. Also he/she will have dreams in which you see a snake on land or a black eel in the sea or taking eggs from a fowl’s nest. (Beyya)

Like Beyya, Azee also indicated dreams were a way of recognizing when a person’s distress and suffering is caused by a sihuru.

A person who has been afflicted by a sihuru … he/she will have nightmares (scary dreams). For example being in a cemetery and seeing dead bodies coming out of the graves… snakes attacking her… or a centipede or snake attacking her… some such frightful dream. Also when the person is falling a sleep… if she has been afflicted with a sihuru… such people will get startled… may feel as if falling from a great height or a sensation of being swallowed by the earth… these sensations while she is in bed make her be startled into wakefulness… These are the result of a person being afflicted by a sihuru. A person may not experience all of these signs. But will have many of these signs… Only by talking to the person can we know (Azee)

Although I had formal encounters with a total of 7 traditional healers or fanditha verin who practised fanditha, only two of them, Azee and Beyya, spoke of dreams as an omen of a sihuru.

Before her problems started Ahmeema had been dreaming.

I started dreaming of pits… and waves breaking over my head. I thought this was not good. This is getting from bad to worse. I must talk to someone else about this. So I told someone else secretly and he said somebody was doing something now. That is why things are getting worse. (Ahmeema)

Naeema a 30 year old woman spoke of dreaming of snakes and eels winding around her neck and attacking her. She believed these dreams were a sign of her suffering being the result of a sihuru.

All the traditional healers I spoke to vehemently stated that performing a sihuru to deliberately hurt or destroy the life of another person is forbidden in Islam. While certain verses from the Holy Qur’an had the power of destroying a person’s life and causing suffering, Allah prohibited using the Qur’an for such purposes. People nevertheless performed such sihuru because they were so greedy for money they were prepared to destroy the life of another.

5.8.2 Esfeena or evil eye

Esfeena or the evil eye was mentioned by all the healers I met as a cause of suffering.

Beyya, explained esfeena.

Someone lays his eyes on a child. If the child is a high achiever he [the one who has the evil eye] may, because of the thoughts he harbours about the student or what he says to the student, cause harm to fall on the student. The student may then suffer from the effects of esfeena. Most students suffer from esfeena. (Beyya)

112 Beyya then told me a story of a young boy of 13 who was very clever. A person who had the ‘evil eye’ once came to Beyya’s home when this boy was there. Seeing the boy, he pointed his finger at the boy and said, “Beyya this young man will be a Katheeb (Island Chief) one day”. The boy returned to his home and a few days later lost the ability to speak. He also gave the example of how a clever young girl after doing her final high school examination found it difficult to breathe and fell unconscious. Beyya attributed this to esfeena.

Esfeena is said to be related to a person’s eyes. Some people were known to have the ability to look at a person and bring about some form of suffering. Often such people may not be aware of the power of their eyes or even mean to cause any harm. Even without looking at a person, just uttering something or harbouring envious thoughts could cause evil to befall another. Esfeena affected not just humans, but plants and animals too.

I recall from my own childhood people talking of esfeena. Women who had healthy, robust babies would be afraid to take them out in case someone with an evil eye would look at the child and comment on how well the baby looked. To protect children against the evil eye, there used to be a ritual that was performed before the baby was taken out of the house. Although esfeena is rarely mentioned today, occasionally one hears esfeena being blamed for loss of weight in a baby. In this study none of the women mentioned esfeena. As for traditional healers only Ahmedbey and Beyya mentioned it.

5.8.3 Sorcery and evil eye as a cultural explanation of suffering and distress

Sorcery and evil eye have been associated with suffering and distress in many cultures and ethnic groups. For instance Al-Krenawi (1999), an international authority on mental health and social work, found that some of the Bedouin-Arab patients referred to a psychiatric clinic in the Negev, Israel explained their suffering and distress as a result of sorcery. It is also reported that fear of magic causing suffering and distress made bystanders in Africa and New Guinea reluctant to help individuals having a seizure (DeToledo, Gilula, & Lowe, 2001).

Golomb (1993), who investigated accusations of malevolent magic, reported that in countries in the process of modernisation such as Thailand the dependence on magic for treating physical and psychological disorders is on the decline, but magic is still used to influence others in one’s social environment. He points out that modernization brings increased competition in courtship, business and education and people use magic to succeed against those they compete with. He describes two types of magic. Malign magic is used by those competing for business, social

113 recognition, jobs or desirable partners. Manipulative magic is used by those in search of love or popularity, by parents and children to bridge the generation gap, by parents to influence their offspring’s choice of a mate and by those wishing to cement social commitment.

Some features of fanditha resonate with Golomb’s findings. Beyya’s description of varutholhi and sihuru can be seen as Golomb’s ‘malign magic’ and isthiri and other forms of fanditha are more what he describes as ‘manipulative magic’. Also in the Maldives, as Golomb found in urban Thailand, modernisation including modern medicine, has reduced the use of fanditha for physical and psychological problems over the last two decades. However there is evidence of a recent revival of interest in fanditha and sihuru for achieving political gain. The current President’s brother-in-law was convicted of having used fanditha to claim the presidency for himself. Some still also continue to use isthiri or “manipulative magic” in search of love as this study reveals.

Sorcery and evil eye have been reported in many Islamic countries as explanations for suffering and distress. Al-Issa (1990) in Al-Junun: Mental Illness in the Islamic World, indicates that in Algeria the condition of tankir (denial) described as loss of interest in the social environment, is perceived to be induced by a witch. A parallel to this is seen in this study. Ahmeema and Hannah used sihuru as an explanation for their suffering and distress. In such small communities as the Maldives, I think that explanations such as sihuru offers women a way of coping with their emotions, when they have to live in such close proximity to those people who have either divorced them or jilted them, such as the case with Ahmeema.

5.8.4 Jinni moyavun or spirit possession

Some of the women and all the traditional healers provided jinni moyavun or spirit possession as an explanation for suffering and distress. As mentioned in Chapter 4, jinni moyavun was frequently associated with women’s suffering as happened with Ahmiyya, Habeeba, Naeema, Raheema and Sabeeha in this study. I was able to engage in formal encounters with four of these women. Though Raheema decided to drop out because her husband did not want her to reveal her experiences to me, her mother spoke to me about her daughter’s possession. I also observed one of the traditional healers performing a spirit exorcism.

The traditional healer Azee spoke of three main ways in which a person comes to be possessed by jinni: a sihuru forces a jinni to harm a human, inadvertent harm caused to a jinni provokes a jinni to harm a human or a jinni falls in love with a human. He indicated that the first was the most severe form of possession and he likened it to getting a mercenary to kill someone.

114 Naeema, a nurse aged 30, had experienced four episodes of jinni moyavun. A sihuru cast by a young man who was in love with her had caused the jinni to possess her. In the other cases I encountered it was inadvertent harm that had provoked the jinni to possess the woman. I will go into further details of spirit possession in Chapter 6.

Inadvertent harm to jinni Healers spoke of how jinni come to possess those who have done them harm. The following excerpt from AW, a traditional healer, portrays how inadvertent harm can be caused to a jinni.

They [jinni] will show some excuse to be hurting the person. My house was destroyed, or he spit on me, or he threw stones at me and so on. The last case I treated. She was cleaning the house with an illoshifathi [a broom made of the middle hard long stem of the coconut leaf]. When you sweep there will be dust scattering and so on. A grain of sand landed on the jinni and this was why the jinni possessed her body (AW).

Other healers also provided examples of women possessed by jinni. Ahmedbey recounted how a woman who had participated in a festival following pilgrimage to Mecca came to be possessed. She and some other men were playing a traditional water game called Koadi where women go out and splash water on men. The man who gets splashed then picks the woman up and throws her into the sea. The woman had thrown water onto some single men. They threw her into the sea and after that she started having problems. She would become out of control and even run around the island naked. Ahmedbey said that when the men threw her into the lagoon she had hit a jinni which was now possessing her and causing her to behave strangely.

The explanation offered by Ahmedbey for the woman’s illness is interesting in terms of when behaviour is considered normal or abnormal. A woman running around naked would be labelled in Maldivian culture, and probably most others, as exhibiting ‘mad’ or ‘bad’ behaviour (Helman, 2001). In the Maldives such behaviour is normally even criminal. But under the circumstances described by Ahmedbey, that is when the behaviour is associated with jinni possession, then ‘running around naked’ is not stigmatised. It is understood that it is the jinni that is making a woman misbehave.

Existence of supernatural forces such as jinni, magic, sorcery and evil eye is a common belief among Muslims (Al-Issa, 1995). As stated in Chapter 3, the Maldives as a Muslim country is certainly influenced by Islamic teachings. At the same time, the Maldives has been influenced by folk beliefs and Hinduism and . In both Buddhist and Hindu culture, belief in supernatural causes is found (Kinzie, 2000). The literature associates the belief in supernatural forces with religion and popular culture and the views of my participants discussed here echoes

115 what is in the literature (Bourguignon, 1992; Brockman, 2000; Gaw, Ding, Levine, & Gaw, 1998; Onchev, 2001).

The belief in and fear of the supernatural forces of sihuru and jinni are transmitted from one generation to another by parents and traditional healers. The folk story of Rannamari is one vehicle used for their transmission. It is a story told and retold relating how the Maldives became a Muslim nation. Rannamari, a supernatural being, shows up in the capital island once a month. A virgin girl has to be sacrificed to prevent Rannamari from eating the rest of the population. An Arab traveller was visiting the Maldives and finds his hosts crying because their only child is to be sacrificed. Telling them not to worry he goes with the child to the appointed hut by the seaside. In the morning people find that they are both alive, whereas previously the girl had always been killed. The Arab tells them he recited the Qur’an and its power had driven Rannamari away. So he convinced the king to convert to Islam and the population followed.

Various other stories related to mysticism that we are told as children help to transmit belief in the supernatural to the next generation. I remember my mother used to tell me to behave myself otherwise the jinni may possess me. I was afraid of the dark because we were told jinni lived in trees and dark places. I also recall being afraid when a relative or neighbour died as we had been told that the spirit of the dead known as vigani walks around.

Beliefs in such supernatural forces are also perpetuated through the Holy Qur’an and Hadith (sayings of the prophet) (Al-Issa, 2000). According to Islamic cosmology, Allah created both humans and spirits (Bose, 1997). The spirits include Shaitan (satanic beings or the devil known as Iblis), angels and jinni. Both male and female jinni were created from smokeless fire while humans were created from clay. Jinni live with human beings and share their activities but are invisible to man. They possess powers that humans do not possess such as the ability to be invisible and when they do decide to be visible can take any form such as birds, animals or even humans. They may seek revenge when offended even if the offence is accidental and may be harnessed through sorcery (Bose, 1997). Jinni frequent places such as ruins, unclean places, graveyards and are mostly around at dusk. Jinni may be drawn to attractive persons or unusual persons or to a person of the opposite sex whom they may marry. Young women are particularly considered vulnerable to jinni especially during pregnancy, soon after giving birth, and during menstruation. The ways in which jinni come to possess human bodies have been reported in many of the healers’ accounts, which I have already discussed.

116 According to participants in this research jinni may live on the beach. When humans go there to defecate and they do not take the necessary precautions such as calling out a warning gaikolhu gaigai dhuru (meaning keep away – something may hit you), or recite prescribed religious prayers, then the jinni can be hurt. Such inadvertent harm to jinni makes them angry and they take revenge by possessing the person’s body and causing all kinds of suffering. Jinni can also be found in the sea or in the bush; in filthy places such as garbage dumps, marshy areas and rubbish heaps; in certain trees, especially flowering trees that bear red flowers. Healers specifically mentioned trees such as unimaa (a tree which bears a sweet smelling white flower), hibiscus and berebedhi (a tree which bears red flowers). When human beings pluck flowers from these trees, the jinni maybe sitting on the flower. Plucking that flower makes the jinni angry and so it then possesses the person by entering into his or her body.

5.8.5 Spirit possession as social control and regulating human behaviour

Traditional healers’ accounts of why jinni moyavun occurs reflect a pattern of what I interpret as the breaking of a social taboo and portray a form of social control. For instance Ilyas spoke of what happens to a woman who bathes naked in a gifili from late afternoon onwards. Gifili is an open compound used as a bathroom and toilet facility. It is an open uncovered area with a well in the centre or in one corner. This is also used as an area to grow vegetables such as chilli and eggplant.

She was bathing in the gifili and suddenly she said she had a headache. She said she did not know what happened. But she fell unconscious. Those fellows [jinni] will disturb women. Now after 4.00 or 5.00 in the afternoon, our teachers tell us… women should not go into the gifili and take her clothes off. She should go in by 3.00. After that she should not go into a gifili and bathe. That fellow [jinni] will be there with his body stretched to full height. The fellow [jinni] will be watching and seeing what is going in the gifili. (Traditional healer)

The above excerpt of Ilyas’s can be interpreted as culture acting as a form of social control. Social control is the interactions between social network members that entail social norms that regulate and constrains one’s actions and behaviours (Lewis & Rook, 1999). Women fall sick when they break certain social taboos, for example bathing in a gifili naked. In the island situation, the gifili is surrounded by lots of trees, especially coconut trees. Most houses would have at least one coconut tree used to tap toddy, the sweet juice of the coconut palm’s flowers. Toddy tappers usually climb the tree in the afternoon. The gifilis being uncovered, the toddy tappers who are all men can see the women’s bodies if they bathe naked. Women who violate the socially sanctioned behaviour of bathing naked in a gifili in the late afternoon as portrayed in Ilyas’s account above, face consequences – that of being possessed by a jinni. To me this reflects jinni moyavun (spirit 117 possession) being used as a way of regulating women’s behaviour, that is a form of social control.

Healers also spoke of women being possessed because they went onto uninhabited islands or into the bush, usually with a man. The bush in the Maldives is called valuthere. It is quite common for young men and women to go into the bush for some sexual fun. There are also folk stories of young men and women who go into valuthere and upon their return the woman suffers from jinni moyavun. Again, these are examples that illustrate social and cultural ways of governing the sexual behaviour of women.

The threat of spirit possession as a way of regulating women’s sexual conduct is further illustrated in the explanations offered for the behaviour of a woman, Mariyam Koe, regarded by the community as insane. The following excerpt from my field notes provides a description of her.

….Moya Mariyam passed by. She walked with a stick and carried a pot with her. She kept banging the pot with the stick now and then. I had seen her walking around the island aimlessly several times. She wore torn and very dirty clothes. It looked like she had not taken a bath or changed her clothes in months. I could smell urine and faeces on her from several yards away. She muttered to herself and when someone stopped her and made a remark to her she would holler out a volley of filth. (Field notes: 20 March 2003)

The traditional healer Ilyas explained to me that Mariyam Koe came to be the way she is, moya or insane, as a result of her frequent travels to uninhabited islands. She went there with men and eventually became possessed by a jinni. It was the jinni that was forcing her to be filthy and foul- mouthed. Lameer, a health worker, provided a different perspective on Mariyam Koe’s predicament. Lameer’s explanation also included that she went to uninhabited islands with men but her husband was among them. In Lameer’s explanation there was an implication that Mariyam Koe was being forced by her husband to be with other men and it was this experience that had lead her to go crazy.

Yasmeen a young woman of 19 years provided another instance of how jinni moyavun is used as a form of social control. She was asked not to pick flowers from trees, especially red flowers. She did not heed this and picked flowers from a tree in the school premises. She took these flowers into the classroom and she started getting very severe headaches. Another time Yasmin was told by her grandfather not to cut open some screw pine seeds as screw pine trees have a reputation for a kind of jinni known as handi. She ignored her grandfather’s advice and cracked them open and next thing she heard a terrifying laughter which gave her goose bumps.

118 So it would seem that supernatural explanations such as jinni function as a way of getting people to observe socially prescribed rules. Violation of the rules is punished through possession which causes suffering.

As mentioned earlier, jinni inflict suffering on humans even for actions that are done unknowingly. Azee provided the following explanation for this.

First of all, here there is something for which we have to take the blame. We are prescribed prayers to be recited in all situations in life while engaging in various actions… when we set foot on an uninhabited island… when we use the toilet… when we set off on a journey and so on. At every moment in our lives, we must stick to our spirituality…think of Allah. Failure to do these may result in getting into trouble with jinni. If we recite appropriate prayers we would not get into trouble. But if we are to get involved in various actions without appropriate invocations being recited, we have a very high chance of getting spells of bad omen. In most cases, in remote islands, the beach is used as a toilet. A lot of people fail to recite the appropriate invocations when using the beach for defecation. The reality is we fail in our duty to recite appropriate invocations. If we are going into the bush… if we recite the prayer. For example, in cutting a tree, if we started it in the name of God and proceed…there is going to be no harm (Azee).

Ilyas too went to great lengths to explain prescribed norms of behaviour necessary for our protection, especially when attending to our bodily needs such as passing urine or faeces. These again can be interpreted as ways of regulating people’s behaviours - in this case to observe behaviours prescribed by religion. Saying certain prayers before using the toilet, washing the genital area after passing urine or faeces and washing the hands afterwards are some of the behaviours prescribed by religion. Other protective measures recommended by religion include saying certain prayers before going to bed.

It seems that all the examples provided by the traditional healers of instances where one is vulnerable to being possessed by a jinni relate to the following:

• When a person frequents places, especially with people of the opposite sex, such as abandoned houses, deserted areas like the bush and uninhabited islands. • When people attend to bodily needs such as defecating or passing urine without saying the prescribed prayers. • When women bathe in the gifili after a certain time or naked. • When children do what they are asked not to such as picking flowers. Reflecting on the above, I would suggest that by linking behaviours that are culturally and socially inappropriate (not saying prescribed prayers before attending to bodily needs, bathing naked, picking flowers and so on) to negative consequences (being possessed by a jinni), is a means for society to impose control over what it deems as unacceptable behaviour. This is consistent with Rice’s (1998) view that the supernatural world acts as a social control agent to regulate human

119 behaviour. The fear of being possessed is a form of social control to prevent men and women engaging in sexual activity that is culturally unacceptable. This form of social control has been cited in the literature as rules that govern sexuality (Samuelsen, 2004).

The supernatural world also acts as a social control agent to regulate emotions such as jealousy and envy. This was reflected in Beyya’s explanation of how Mahmood lost his social standing and his wealth. Such explanations also serve to caution people against boasting or strutting their wealth and social standing. Fear of sihuru encourages humility, a trait seen as a sign of being a good Muslim. Similarly, associating jinni with ‘filthy’ and ‘unclean’ spaces can be interpreted as a social control mechanism that encourages cleanliness of homes and surroundings.

The phenomenon of jinni moyavun can also be interpreted as something Green (1999) identifies as naturalistic pollution. Jinni enters a person’s body when that person enters spaces considered to be the dwellings of evil spirits like the bush, the beach and rubbish dumps. These are places where people can be contaminated by substances that are considered dangerous or impure. In the Maldives up till a decade ago people went to designated parts of the beach to defecate. From a biomedical perspective such places do expose one to pathogenic material that can cause disease. In bushy areas one can come in touch with plants that cause allergies such as severe itch, rash and body welts. The traditional healer, Ahmedbey, explains such reactions as being possessed by jinni. The medical practitioner, Dr. R, associated such itching with exposure to scrub typhus. He explained that when a person goes into the bush for whatever reason, they might come into contact with pathogenic material such as the faeces of cats and rats as well as allergy-producing materials. Here we see a difference in the meanings systems of illness causation between those of the traditional healer and the biomedical healer.

Improper interaction with spirits of the bush, is about power relations according to Samuelsen (2004). Humans are supposed to respect the “domains of the spirits: they are not supposed to challenge, either deliberately or accidentally, the spirits by bumping into one or violating its space” (p. 104). When humans go into the bush or pick flowers from certain trees, or go into the cemetery and so on, they are violating socially sanctioned taboos. An improper contact takes place disturbing the relations between human beings and the spirit world. Thus the person suffers either through what traditionally is believed to be jinni possession or stepping on a place where an omen has been buried.

Anthropologists have focused on the association between spatial organization and social relationships. For example Samuelson (2004), citing Durkheim, states that spatial organization is 120 modelled on social organization. Samuelson argued that “spatial dispositions reflect not just social relationships but phenomena that are actively worked upon and reinterpreted as part of everyday practice” (p. 105).

In the accounts provided by the traditional healers in this research, there are different kinds of spatial domains involved. The first is the individual physical body. As was described in this chapter, a person falls ill when inappropriate substances enter the person’s body, for example food or water on which an isthiri (love magic) has been performed. The second is the island where both the violation of social taboos and sihuru occur in inhabited space. Inappropriate movements or actions in this domain include when a woman goes into the bush or deserted part of the island with a man; a jealous lover or an envious person interacts with the person and bewitches him/her; a person steps on things that have been buried as a way of causing her harm; a woman bathes in the gifili after a certain time in the afternoon, especially when she bathes in the nude. The third spatial domain is the bush, beach or a deserted area. Moving from the inhabited part of the island or the domestic domain to the bush or beach or deserted areas invites danger as I have earlier discussed. In these areas people come into contact with the spirits or risky acts such as defecating or socially taboo acts such as engaging in sexual relations.

The above discussed spatial domains: the island and their surroundings such as the bush, the beach, the houses, the rubbish dumps, the uninhabited islands and deserted parts of the island that people may go to either for gathering firewood, to play, to have fun, to defecate etc become spaces through ways defined by the local population’s practical operations and movements. While these movements are part of daily activities on the one hand (going for defecation, or gathering firewood, or throwing rubbish or for fun) they also entail danger in another respect.

5.8.6 Fated by Allah to suffer

Belief in a higher being, Allah who decides one’s fate, was mentioned by some women and healers as an explanation of suffering. In most cases this belief was not implicitly stated. However, my field observations provided various examples that point to this belief. Such instances include the use of prayer when doing something such as praying to Allah when a person embarks on a new venture, discussed in Chapter 6 in more detail. Some of the participants displayed verses from the Qur’an on the walls of their homes as a way of protecting their homes and their family from suffering and as a way of asking Allah’s blessings. Implied in all these actions is the belief that whatever explanations may be provided for suffering and distress,

121 ultimately Allah is the provider of all. Life and death rests with Allah as is reflected in the following excerpt from my encounter with the traditional healer Azee.

Even today, I got a call from someone. She said she did not want to live even one more minute in this world. She said that she had had enough of this world…suffered enough. I told her that, death is not something under our control. If it was, it could have long taken place. But the power of death rests with God and God alone (Azee).

Azza spoke of how it is Allah’s will that she has not received any love from her parents, her children or her husband. As a result of this she says she is always crying and suffering. She used words such as “Allah showed me this [her distressed life]”, “Allah’s mercy has brought this also to my lap – marrying someone I do not love”. Implied in these words is her belief that ultimately it is God, Allah that has fated her to a life of suffering.

Rauna described her life as one full of distress and suffering. She used words such as, “This is my life today”, and "this is Allah’s mercy”. These words again suggest her belief in a ‘super power’, Allah, as determining one’s destiny.

Belief that suffering is ‘a test of life’ or one’s fate or destiny, refers to the concept of fatalism which stems from religious beliefs and attributes all life events to the will of God (Ahmed, 2003). Many populations throughout the world associate illness to fatalism and is quite common in Muslim countries (Al-Issa, 1995). For example in a study of beliefs related to epilepsy among South Asians, Ismail and colleagues (2005) found that , Sikhs and Muslims attributed their suffering from epilepsy to their ordained fate.

Belief in possession by supernatural spirits and witchcraft was prevalent in Europe and in other parts of the world between the 15th century and 18th century; this belief even at present constitutes a major theory of illness, especially mental illness (Bourguignon, 1976; Crapanzano & Garrison, 1977). In the literature diverse views are provided on the form and function of spirit possession across cultures and even within one culture. In mental health, psychiatrists have differed in how they interpret possession (Chakraborty, 1990). Psychiatrists vary in how they consider possession as a diagnostic criterion; some psychiatrists consider possession as a socially accepted outlet for relieving psychosocial tensions.

There is a plethora of documented literature related to spirit possession. Possession has been considered as: a form of hysteria, a pseudo psychotic hysterical reaction (Castillo, 1994; Chakraborty, 1990); a multiple personality disorder (Allison, 2000; Spanos, 1996; Whiteman, 1996); a protest against forms of oppression (Somer & Saadon, 2000); as a culture bound phenomenon (Chiu, 2000); a social mechanism to integrate the sick into the community of the 122 well (Brockman, 2000) and a way of coping with intolerable life stress (Boddy, 1989; Schieffelin, 1996). Spirit possession has also been provided as an explanation for epilepsy (Carrazana et al., 1999; DeToledo & Lowe, 2003; Ismail et al., 2005; Stone, Binzer, & Sharpe, 2004) and schizophrenia (McCabe & Priebe, 2004; Wessels, 1985).

Researchers have classified supernatural explanations for suffering and distress in different ways (Eisenbruch, 1990; Murdock, Wilson, & Frederick, 1978). Eisenbruch suggests three sub categories, the first being mystical causes. Mystical cause “accounts for the impairment of health as the automatic consequence of some act or experience of the victim mediated by some putative impersonal causal relationship rather than by the intervention of a human or supernatural being (p. 713).

Second is the animistic theory which “ascribes the impairment of health to the behaviour of some personalized supernatural agent” (p. 713). Naeema, Habeeba, Ahmiyya and Sabeeha suffered as a result of being possessed by a jinni, the supernatural agent. The third subcategory is the magical theory which explains illness as caused by an envious or angry person “who employs magical means to injure his victim” (p. 713). In the case of Ahmeema, her mothers’ friend who was in love with her became jealous because she was going to marry someone else and bewitched her fiancé with a sihuru. The sihuru made her fiancé leave her for someone else and Ahmeema has not been able to succeed in love since then. Other examples falling into this category include the man who envious of the clever young boy cast his evil eye on him and made him lose his ability to speak.

Belief in supernatural causes of illness such as witchcraft, sorcery and spirit possession has been documented in the literature as prevailing in the countries of South East Asia (Azhar & Varma, 2000; Chiu, 2000; Eisenbruch M, 2000; Gaw et al., 1998; Watson & Ellen, 1993; Wikan, 1999; Yi, 2000), South Asia (Bose, 1997; Chandra shekar, 1989; Crook, 1997; Majumdar, 1997; Wagner, Duveen, Themel, & Verma, 1999) Sub Saharan Africa (Boddy, 1988; Boddy, 1994; Masquelier, 2002; Onchev, 2001; Patel, 1995), Arab countries (Al-Issa, 2000; Al-Krenawi, Graham, Dean, & Eltaiba, 2004), Caribbean (Wedenoja, 1995), Latin America (Cramer, 1980; Guarnaccia, Lewis- Fernández, & Marano, 2003) and North America (Sargant, 1974; Seltzer, 1983).

Beliefs in witchcraft, magic and sorcery, have been extensively discussed in anthropology (Boddy, 1988; Bowne, 1993; Ellen, 1993; Evans-Pritchard, 1937; Golomb, 1993; Lewis, 1974; Peletz, 1993; Samuelsen, 2004) . The earliest focus of the anthropological literature was on sorcery, witchcraft and (Eliade, 1964; Kiev, 1961; Lewis, 1966) suggesting a very 123 long anthropological tradition of studying beliefs about the supernatural. Some scholars later expanded into a broader engagement in medical anthropology with transcultural psychiatry (Foster and Anderson, 1978; Kleinman, 1980). Most of the anthropological material consider magic as a phenomenon very close to, or interrelated with, religious and cosmological ideas, beliefs and behaviour. The explanations that emerged from my research resonate with the findings from the above mentioned studies. Women’s and traditional healers’ beliefs in supernatural causes were related to Islam and are perpetuated through folklore.

5.9 Reflection and summary

The findings presented in this chapter addressed the research question: How do Maldivian women explain suffering and distress. Their explanations relate to both the natural and supernatural worlds. Explanations that encompass the natural world fall into three broad etiological categories: social factors, biomedical factors, and psychological factors. Social factors were the most common explanation provided by women and both traditional and biomedical healers. Breakdown in women’s most significant relationships and financial insecurity appear to be the most salient of social factors affecting women’s distress. Interpersonal violence emerged as an important risk factor for mental distress and was a theme common to biomedical and traditional healers’ accounts and women’s accounts. The social factors influencing women’s distress can be explained by gendered power dynamics and cultural nuances related to the notions of a good woman. Biomedical factors which included genetics and sexual problems were a common theme in the biomedical healers’ accounts. Only two of the women provided a biomedical explanation for their suffering and distress and such explanations were rarely mentioned by any of the traditional healers. Psychological factors associated with mental distress included bottling up of feelings which was linked to gendered power dynamics as well as cultural norms associated with being a good woman/wife and also linked to the concept of anonymity that is characteristic of small close-knit communities. Inability to meet desired aspirations and conflicts arising from differences in religious and political ideologies was mentioned by a few of the biomedical healers as contributing to psychological distress.

Supernatural explanations were common themes in both traditional healers’ and women’s accounts, but was notably absent in biomedical healers’ accounts. Supernatural explanations included sorcery, or magic commonly known as fanditha; evil eye; and being possessed by a

124 jinni. Suffering and distress experienced by women was also perceived as fate destined by Allah, and this was a common theme in both women’s and traditional healer’s accounts. Supernatural explanations have been categorized as mystical, magical and animistic in literature and can be also be interpreted as forms of social control and social taboos used as agents to regulate human behaviour. The supernatural explanations can also be articulated as dynamic associations between spatial domains and social relationships. Such explanations are embedded in the religious beliefs of Islamic cosmology and are perpetuated and passed on from generation to generation through folklore and stories told during childhood and by observing people who were perceived to be afflicted with spirit possession.

125 Chapter 6

A Jellyfish Stuck to my Stomach

EXPRESSING AND EXPERIENCING DISTRESS

See this here [pointing to the abdomen]. It feels like a jellyfish stuck to my stomach. (Azra expressing the discomfort she was experiencing)

In this chapter I present and discuss the general findings related to my research question: How do women experience and express mental distress? Women in this study were found to present to doctors with biological concomitants of what Western-trained practitioners might consider as depression or anxiety or some other form of mental illness. They complained of such symptoms as not being able to sleep, losing weight, nausea or lack of appetite, feeling weak and constantly tired, thinking too much, burning sensations and tightness or pain in the chest area. To convey their distress they used idioms and somatic metaphors.

6.1 Presentation of distress and symptomatology

While somatization was the dominant form of presenting distress in this study, three of the women expressed their distress in ways more similar to those found in contemporary Western societies.

6.1.1 Vague aches and pains

According to biomedical healers, the majority of the women presented mental distress as physical problems. Dr. MA’s words as he describes a patient’s complaints illustrate this.

For example pain under the chest. The pain does not go away whether you eat or not. Sometimes it feels like heat…sometimes like cold. Some will say it comes as heat and then leaves as cold. Vague complaints. These are not things you can see from any diagnostic tests no matter what tests you do. (Dr. MA)

One of the most vivid examples of distress manifested in the body came from Ahmeema’s description of her suffering after she was betrayed by her fiancé.

I started getting body aches. Like my back would ache. So much I cannot even sit like this. Chest pains… that day it will be chest pains. I got x-rays done. Tests done. A lot of tests. At that time all the money I earned was spent on doctors. But they could not find a cause for my problem. No disease. All those consultation and nothing wrong with me. But then I cough uncontrollably. But no health problem. Because I was coughing so much I would go [to the doctor] because I was afraid that I may have some disease. Actually no problem. Had sinus problems too. There was pus in the eyes. I went to the doctor. She said it is something to do with the head. When I get my head better there will not be any more problems. (Ahmeema)

126 Ahmeema’s and Dr. MA’s accounts illustrate how social, personal, and emotional problems can be expressed in physical symptomatology, commonly referred to as somatization in literature (Kirmayer & Young, 1998; Kleinman & Becker, 1998). Ahmeema’s words signify how the body becomes a metaphor for personal distress (Al-Krenawi, 1995). She has embodied the moral and societal values (Csordas, 1994b) of Maldivian culture so she codes her distress in physical symptomatology (Al-Krenawi, 1995). This form of illness presentation can result in misdiagnosis and ineffective management of the illness condition (Raguram, Weiss, Keval, & Channabasavanna, 2001), particularly in circumstances where the doctor is unfamiliar with the ways in which culture modulates the form and presentation of distress experiences.

Ahmeema’s case also illustrates the need for what Raguram and colleagues (2001) call a ‘culturally informed inquiry’ into illness experiences. Ahmeema’s doctor was neither a Maldivian nor was he familiar with Maldivian culture. He focused on medical concepts of disease and tried to evaluate her illness “against the bedrock of biomedical theory” (Raguram et al., 2001, p. 42). He therefore did various tests to establish a biological cause for her bodily distress and treated her symptomatically. Ahmeema was not satisfied with how her illness was managed by the doctor so went to another doctor who did more tests. Her case is a classic example of the shortcomings of some of the medical professionals in the Maldives to consider the cultural nuances of the illness experience and the meanings assigned to distress. Had her doctor been more familiar with the cultural meanings associated with mental distress in the Maldives, he most likely would have probed further and eventually been able to elicit the psychological nature of her symptoms and intervened more effectively. The doctor’s lack of cultural knowledge had several consequences: it prolonged Ahmeema’s suffering and even added to it with the financial costs incurred for diagnostic tests; the doctor’s time was wasted; and the health system was burdened with unnecessary diagnostic tests. As one Maldivian psychiatrist stated, “We try to always find the cause and this leads to unnecessary investigations, time and money”.

Ahmeema was aware of the psychological basis of her distress. This is clear from her words, “They were actually not physical problems. They were psychological problems”. Later she also said, “It’s become a psychological problem more than anything else. I have always been having psychological problems. But before everyone would know that I had headaches. My eyes would be red. But when I consult the doctor, he cannot see any problems”. Perhaps she was looking for authentication from her doctor that her distress was an illness needing medical attention, however, she did not volunteer to the doctor that her distress was psychological, she did not

127 psychologise her problems. The reasons for this are probably embedded in the following cultural norms: it is not culturally appropriate to voluntarily disclose information related to personal affairs to a doctor and distressed moods and feelings are not generally recognized as illness or as warranting professional help. One is expected to deal with such distress by being strong or seeking the help of family and friends.

Bodily sensations Women also expressed their mental distress as various bodily sensations. When her husband verbally abused her, Hannah experienced her distress as naaru (nerves) which she felt on the side of her neck or as a burning sensation just beneath her chest. Dhilanegun or burning sensation was associated with sihuru or supernatural causes. Dhilanegun could occur in any part of the body. Most commonly women spoke of mein dhilanegun which means liver is burning up, but they would point to the chest area as they spoke. Other forms of bodily sensations were described as hoonugadeh aranee (heat rising) or vaigadeh aranee (wind rising). Others experienced numbness in their limbs.

In this study bodily sensations of heat, wind or cold were only expressed by the less educated women but these women also had prior experience with traditional healing systems. So is it possible then that sensations of heat, cold or wind are linked to exposure to traditional healing systems and not associated with education level as such? Heat and cold are ways of describing illness that are common to traditional healing systems as opposed to biomedical healing systems (Foster, 1976; Quinlan & Quinlan, 2005).

6.1.2 Loss of control of emotions

For many of the women distress took the form of intense grief where they were unable to control their emotions. Distress made them cry continuously and even in front of others. Some spoke of feeling extremely sad. They did not feel like doing anything. Azza’s words “Crying always. Don’t stop crying. Even when I am praying I am shedding tears”, reflect this sense of losing control of one’s emotions. Her words, “even when I am praying”, reflects the severity of her inability to control her emotions. During prayer one is supposed to completely forget about worldly things, empty one’s heart and mind and devote one’s entire concentration to worship of Allah. But Azza’s uncontrollable weeping was getting in the way of her worship.

Azza also spoke of how her grief and lack of emotional control made her “faint, vomit and lose consciousness”. For Mariyam and Shareefa the effect of their sadness was to make them feel like 128 being in bed all the time, unable to do their daily chores or even, in the case of Shareefa, unable to care for the children.

For Aina, her husband’s constant ignoring of how his father and brother treated her was making her highly frustrated and unable to control her anger. This is reflected in her words, “It makes me so angry. Recently I find that I am always angry. I want to throw things and destroy them. I have tried to talk to my husband. He will not even listen. He will not discuss it. I do not know what to do.” Aina’s inability to take control of her anger was causing her to think and think and to be fearful of taking her feelings out on her children.

6.1.3 Psychologizing of distress

While most of the women in this study experienced their distress as body aches or other physical sensations, psychologizing of distress emerged in the accounts of Zuhaira, Shaheen and Ahmeema. Unique to Zuhaira’s and Shaheen’s accounts was a total absence of expressing distress as physical problems; they used only expressions that show a psychologizing of distress.

Being trapped and feeling hopeless When Zuhaira found out that her husband was having an affair with one of her students she was devastated. She described her suffering as follows:

When this happened, I completely lost interest in teaching [said with emotion and with a slightly raised voice] actually it is a profession I love. But at that point I changed my teaching job. I joined the in-service program. I was travelling to different islands and was doing in service training. But now again the program has changed. [laughs] There is no way of getting out. I am trapped. Sometimes I feel like I am being squeezed from four sides. I just want to get away. But then there is no choice. [tone of voice changes and this last sentence was said in a tone of hopelessness]. (Zuhaira)

Her feelings of being trapped are related to her perceptions of not having control over her life. Her words “But then there is no choice” to me reflects a sense of hopelessness and powerlessness in her situation. This will be discussed in more detail in Chapter 8.

Ahmeema too portrayed feelings of hopelessness. Speaking of the suffering associated with her conceiving a child out of wedlock she said: “I lost the opportunity to study. There is no chance of a future for me. Job-wise, education-wise, career-wise. Everything is at a stand still”. These words clearly reflect feelings of hopelessness and disempowerment which can be linked to living in a gendered society. This will be further discussed in Chapter 8.

129 Feeling worthless Biomedical healers indicated that women rarely expressed their distress in terms of feelings of worthlessness. Women’s own accounts in this study reveal the same. Only Ahmeema and Shaheen used expressions that reflected feelings of worthlessness. In describing her suffering and distress, Ahmeema used words such as “I wish I had not been born”. Shaheen spoke of feeling that no one would want to be with her and that she would always be alone.

Addicted to worrying Shaheen expressed her experiences as being “addicted to worrying”. She worried about her mother being poor and her mother’s constant feelings of distress at not being able to give her children the things they wanted. She worried about not having the confidence to go out and be with people. She felt that she might be a bother to others.

Like Shaheen, many of the other women spoke of worrying. However, unlike Shaheen they used the term “thinking too much” or fikuru boduvun to express the anxiety they felt over their financial difficulties and various life circumstances. What is interesting is that although my interaction with Shaheen was in the local language Dhivehi, she often used English terms. In fact she used the English word “worrying”. Psychologising words were used by Zuhaira, Shaheen and Ahmeema who have attained a higher formal education compared to other participants and these three used English words to psychologise. Maybe psychologizing then has to do with the absence of words in the local language to adequately express their feelings? My own experience is the same. I can only express my emotions and feelings adequately using English terminology.

Deficient self Shaheen was the only one in this study who expressed her distress in terms of a deficiency in the self. According to Shaheen the students in her school constantly teased her about how she looked. They told her she had a jutting nose. Shaheen’s concerns over her self image are reflected in her words:

I look at my self in the mirror and I don’t like what I see. I am not pretty. This boy in my class said I am ugly. He is so good looking. So handsome. If I was good looking why would that boy say I am ugly? I will not get anyone to share my life with. I will always be alone. I am old. Look at how my eyes are sunken (pointing to her eyes). That is a sign of getting old. (Shaheen)

Shaheen here portrays low self-esteem. During my one and half hour encounter with her she repeatedly spoke of how she looked ugly and old. She was 19 but looked more like someone of 15. She was also good looking but when I told her this she said that I was just trying to make her

130 feel happy. She said that even the counsellor at the Unit for Rights of Children had said the same thing. But she believed that we were both just saying so to make her feel better about herself. She also spoke of not having confidence, feeling nervous around people and anxious that her presence was causing them problems. So she isolated herself and preferred to stay home alone.

The findings of this study show that Maldivian women present their distress mainly as somatic complaints or physical problems. Within the medical sociology and anthropology literature, somatization refers to a pattern of illness behaviour, particularly a way of clinical presentation, in which somatic symptoms are a way of hiding emotional distress and social problems (Kirmayer & Young, 1998). Culture and society play a ‘formative role’ in shaping how illness experiences are expressed and experienced (Kleinman & Becker, 1998).

Somatization has often been associated with traditional societies. It has been reported in developing countries such as Sudan, India, Colombia and the Philippines (Harding et al., 1980); and in the African countries of Kenya and Ethiopia (Giel, Gezahegn, & van Luijk, 1968; Ndetei & Muhangi, 1979). Recent evidence indicates that somatization is common in all cultural groups and societies. A WHO study on psychological problems in general health care conducted in 14 countries in five continents revealed that 69 percent of the whole study population reported only somatic symptoms (Simon, VonKorff, Piccinelli, Fullerton, & Ormel, 1999)

The frequent presentation of mental distress as bodily symptoms as found in this study has implications for the diagnosis of mental illness. As was clearly portrayed in Ahmeema’s case, somatization of distress can mean that mental health problems go unrecognized and untreated. This resonates with findings from other studies. For example, primary care research in the United Kingdom (UK) showed that people of South Asian origin living in the UK who visited a general practitioner were less likely to be diagnosed with a mental health problem (Bhui, Bhugra, Goldberg, Dunn, & Desai, 2001; Commander, Sashidharan, Odell, & Surtees, 1997; Gillam, Jarman, White, & al, 1980). Studies from the USA showed similar trends. Primary care physicians were less likely to diagnose depression among African American and Hispanic patients as these cultural groups do not psychologise their distress (Borowsky et al., 2000; Leo, Sherry, & Jones, 1998).

Psychiatric research and clinical practice are for the most part embedded in assumptions that mind and body are separate (Eisenbruch, 1999; Kirmayer, Dao, & Smith, 1998). In this current study Ahmeema recognized the links between her emotional state and her embodied experience.

131 Likewise other women embodied their social and emotional distress as physical pain. This to me indicates a mind/body connection exists for Maldivians.

Anthropological research shows that patients from non-Western backgrounds and non-Western healing systems hold different views. Eisenbruch’s (1999) study of Cambodian traditional healers, for example, illustrates the “non-Cartesian view of mind-soul-body in which somatic symptoms are a product of moral and supernatural events” (p. 153). Similarly in the Chinese and Ayurvedic systems of healing there is no distinction between mental and physical health and the health of the body is treated in a holistic manner (Alter, Bray, Guha, Joshi, & Leslie, 1999). Leff (1977) contends that people from traditional cultures express distress in somatic terms and therefore do not distinguish between emotions of anxiety, irritability and depression and other physical illnesses For example Rauna who had been diagnosed with hypertension used the words hithuge bali (disease of the heart) to refer to her hypertension and also the breakdown in her relationships with her significant others. One of the psychiatrists too observed that women who experienced psychological problems would speak of it as hithuge bali. It appears for the women it is their heart that is affected whether it is related to a mental or physical illness indicating that they do not distinguish between physical and mental illness. These findings of my study are similar to the aforementioned observations of Eisenbruch and Leff in that women in the Maldives do not distinguish between mental and physical health. We see this also in the way for Ahmeema and the other women in this study, the self is not contained within the boundaries of the physical body but extends into the social world of significant relationships as further clarified in Chapter 8.

6.2 Embodiment and culture

Various studies have illustrated how cultural and social processes interact to locate and manifest suffering and distress within the physical body (Becker, 1998; Jenkins & Cofresi, 1998; Lee, 1998; Lock, 1998). Embodiment is how moral and social values are expressed through the body (Csordas, 1994a). In my study embodiment reflects the following: 1) the culturally prescribed ways in which emotions and distress are to be dealt with. 2) Cultural values related to disclosure of information. 3) The way in which women embody the social values of being a good woman/wife/mother. In this sense, the body is used as a metaphor of distress and embodiment signifies how emotions and distress should be handled and communicated (Coker, 2004; Ono et al., 2000).

132 6.2.1 Embodiment as a way of conforming to social and moral values

The way in which culture regulated or shaped the way distress is expressed and recognized was one of the most consistent patterns in women’s and healers’ accounts. Social and cultural norms made it difficult for women to voice their distress directly. Consequently some forms of distress such as depression go unrecognized and untreated.

The real sick person does not complain Without exception all biomedical healers observed that women who were likely to be clinically diagnosed with depression or anxiety were unlikely to seek professional help. This is reflected in the following words of Dr. MA.

You can rarely see an actual depression case. A depressed person does not usually come out of the house. She stays home. She does not stress much on personal hygiene or want to dress up and come out. They would just eat enough to satisfy hunger and then stay home. Others may watch TV. But she doesn’t want to even if she has a TV. She is an isolated person. That is an actual depressed person. Actually unlike in other places we do not really come across cases you can truly diagnose as depression. You have to go in search of those. The real sick person dies without getting the needed attention. No nurse will go to her. Because she does not complain. So she is isolated by herself and dies like that. (Dr. MA)

Dr. MA’s words reveal several significant features of mental distress in the Maldives. He mentions several typical depression symptoms - isolating oneself, loss of appetite, withdrawal, and not taking care of oneself - and these are symptoms that are also part of the Western medical model of depression. Yet the symptoms trigger quite different responses in the Maldives and the West. In the Maldives they are not considered to be symptoms of an illness requiring professional help. From Chapter 5 we know that mental distress is associated with relationship problems or day-to- day life struggles. Distress of this kind is not something one complains about. Rather it is perceived as a normal part of life. Such normalizing of distress is a reflection of the cultural norms and values within the Maldivian society, what I interpret as notions of good woman bad woman tension.

Within Maldivian culture a good woman is expected to patiently endure the distress related to her life circumstances. We are taught from a young age to have faith in Allah, to be patient and to be of strong heart to deal with the ups and downs of life. A good woman is expected to speak seldom and softly, and to be restrained and stoical. A soft-spoken woman who confines herself to the home unless it is absolutely necessary to go out is regarded as a virtuous woman. This is reflected in how people describe the qualities of a good woman. “Basmadhu” (woman of few words), “madumaithiri” (quiet), “gevehi” (housebound, taking care of family members and so on)

133 are words used for the woman who is regarded as a good wife. These very same attributes of a good woman was also reflected in Rauna’s words as she described herself (See 5.5).

Given the culturally prescribed features of a good woman it is not surprising that depressed women may go unnoticed and untreated. They may even die without anyone recognizing they are sick. This is what Dr. MA meant by: “The real sick person dies without getting the needed attention. Because she does not complain”.

Dr. MA’s remark is supported by my field observations. In one of the Northern atolls I heard about Ameena a woman who had “starved herself to death”. She had been abandoned by her husband of several years and was devastated by this event. But like the ‘good woman’ she is supposed to be she patiently endured and did not complain or voice her distress. She was not eating properly. Eventually she collapsed and that was when she was brought to the hospital, by which time she was in a critical condition having gone without food for so long. By then it was too late to save her. The nurse who recounted the story spoke of Ameena as someone who had starved herself to death. The nurse’s words “starved to death” imply that Ameena had not been strong enough to deal with her sorrow and reflect the moral values of the culture. Perhaps it implies that Ameena might have deliberately refrained from eating. Although this nurse has very basic training and probably does not have adequate knowledge to associate serious loss of appetite with any other cause she did recognize that the abandonment had something to do with not eating. Ameena’s case is an example of cultural norms of what is considered normal and moral and acceptable leading to non-recognition of mental illness with fatal consequences. Most likely neither Ameena nor her social entourage recognized that she was experiencing an illness that needed medical attention. For Ameena did not show any outward signs that are recognized culturally as an illness. Given the context and the end result I would argue that Ameena was experiencing severe depression as a result of being abandoned by her husband. But as already stated, emotional distress arising from divorce is not something one complains about. It is also not a reason for seeking medical attention.

In silently dealing with her distress and not complaining, Ameena was certainly conforming to the “rules of the culture, which govern how people should actually behave” (Helman, 2001, p. 3). Unfortunately for her, conforming to what is socially expected of a good woman resulted in fatal consequences. Ameena’s death is also tied to her inability to deal with her suffering without professional help. Had she received medical attention, it is quite likely she would have been

134 diagnosed as suffering from severe depression, and if she had received the proper medical care, it is likely that her death could have been prevented.

Being quiet and keeping to oneself, isolating oneself and constant crying, are signs that would be recognized in the Western world as signs of depression. However, as the findings of this study show, such manifestations are not perceived by most Maldivians as symptoms indicative of an illness. A quiet person is regarded in Maldivian culture as a thoughtful and well-behaved person - in the case of a woman, a virtuous woman. Not as a sign of being withdrawn as is likely within a Western context.

As Maldivian women grow up, they are socialized to acquire the attributes of a good woman – that is one who is uncomplaining, patiently bears the ups and downs of life and ensures that family members, especially the children are cared for. Through their social interactions with the significant others in their life such as parents, relatives and teachers, they learn to be in control of their emotions (Geertz, 1959 cited in Jenkins, Kleinman, & Good, 1991, p. 225). Ameena displayed the attributes of a good woman she was taught. She therefore, controlled her emotions and tried to bear the pain of being abandoned without complaining.

Ameena’s case and other women in this study illustrate that certain symptoms of distress listed in DSM IV for mental illnesses such as depression and anxiety are not recognized in the Maldives as symptoms of an illness that needs medical attention. This was also reflected by one of the psychiatrists who said: “For some people it is difficult to relate to the fact that it is because of depression that they are unable to do things around the house, take care of their children, or give their children the attention they need, or get angry with the children”. I would argue that the kinds of behaviours that the psychiatrist mentioned – unable to take care of the children, getting angry with children and so on will more likely be considered as being a bad mother, rather than be related to an illness. Just as Ameena’s inability to deal with her distress was associated with being weak.

Being a good woman As earlier indicated cultural notions of being a good woman govern how people express their emotions and distress. This was illustrated by Shareefa’s response to her husband’s infidelity. Shareefa had previously been hearing stories of her husband being unfaithful but had ignored these stories as gossip. However, during a party to name her second child she came upon her husband in the arms of another woman as reflected in her words:

135 I opened the door to this room and there he was hugging and kissing this other woman who was pregnant. She was so pregnant her arms could not reach her belly. When I saw this I was so sad. I cried. But I did not fight with him then (Shareefa).

Shareefa’s words, “I did not fight with him then” is a reflection of the culture which requires people to show a happy face despite what they feel inside, as outlined in Chapter 3. Wikan (1990) calls this ‘saving face’ which is something she observed in her work in Bali. Shareefa did not want to fight with her husband in front of her guests. Fighting then would be a loss of face for her and would cause her embarrassment and bring shame. So she kept a calm exterior until all the guests left. By doing so she was showing that she is of strong of heart and a patient woman, therefore a worthy and good woman. But after the guests left she confronted her husband as reflected in her words:

Later when he came into our bedroom I begged him not to do this. Not to see this other woman. He told me this was a woman he had been in love with before and he could not leave her. He cannot stop seeing her. I cried and cried. It was so hiy dhathi [heart was so distressed]. But what can I do? I had married him against my parent’s wishes (Shareefa).

Here Shareefa’s words of “But what can I do? I married him against my parents’ wishes” reflects her sense of having done wrong, that maybe the infidelity occurred because she went against her parents’ wishes and was not a good daughter. Shareefa was judging herself through the ‘culture’s eye’ (Whittaker & Connor, 1998). This comes through in her words, “But I must say now, don’t get married to someone your parents don’t approve. I now have experienced the results”.

Shareefa also appears to experience a sense of powerlessness and hopelessness when she says “but what can I do”. She had two children and was living in her husband’s place. If she did not accept his infidelity she would have no place to go. But then her husband continued to see his lover perpetuating her state of distress. Eventually she felt she could not continue to be passive about it as reflected in her words:

He started coming home late. Very late and then he will call me. One night I purposely locked the door. I had to do that. I had to take control of the situation, to try and find a solution to this. But he then divorced me (Shareefa).

In the above words, Shareefa is showing agency by challenging her husband. However, her action to take control of the situation and express her agency leads to negative consequences. Her husband divorced her, and the divorce precipitated her depression.

In Shareefa’s case the notions of a good woman and cultural norms such as ‘saving face’ could also be protective. To save face she did not embarrass her husband in front of family and friends. Arguably this way of handling her crisis is likely to have facilitated the couple working things out in

136 an amicable manner later on and to suit the well-being and needs of their family, especially the children. However, in this particular case the results were not favourable for Shareefa.

Being a good mother Though Shareefa had been experiencing symptoms similar to depression her account to me was dominated by how her divorce affected her children. This is evident from the following excerpt of my encounter with her:

We were living in such poor conditions. Why could not he [ex husband] provide at least a pillow for the children to sleep on? He could provide that at least… After the divorce, I had nothing. Not even milk for the children. Just the neighbour’s kindness helped me with that…

…But I tell my children to always think good of the father. I don’t talk bad of him in front of them. I hope that the day he is old and is in trouble, the children would take care of him. It does not matter about me. But why cannot he talk to the children and give them the love they need? But he won’t. One day the children saw the father at the telephone booth. The father did not even say hello to them. They came back and told me about it and they were so sad…

… I cannot marry someone else. He was the first one I married and I cared for him. Plus my children – sometimes they are teased by relatives who tell them mommy is going to bring a step daddy. The kids cry and say they don’t want a step-daddy. They want daddy. So when they keep saying that, how can I marry someone else? (Shareefa)

Shareefa’s words “It does not matter about me. The kids cry and say they don’t want a step daddy. When they keep saying that how can I marry someone else” portrays the concept of selflessness. She puts her children’s well-being above her own. Selflessness of women was a dominant theme in all of the women’s accounts. By giving importance to their children’s well- being these women are being good mothers but in the process they lose their self. This is further discussed in chapter 8.

6.2.2 The body as a metaphor for distress

There seems to be similarities between the findings of my study with the anthropological literature that report illness and the body as a vital and inseparable part of the wider environment (Coker, 2004). As Scheper-Hughes and Lock (1987) argued, sickness is not just an isolated event or unfortunate brush with nature but a way of communicating as an individual, a culture and a society. The body becomes the existential ground of culture (Csordas, 1994b) and the body is the terrain on which “social and cultural attitudes and struggles are played out” (Coker, 2004, p. 17). The findings of this study resonate with the views of the above mentioned researchers and demonstrate how the body becomes the playground for personal, social and cultural attitudes and struggles. When suffering and distress grow too great, the body becomes the ultimate metaphor for communicating distress. 137 The body as vehicle for communicating marital problems According to some of the biomedical healers women were embarrassed to talk about their distress when it was related to their marriage or problems within their immediate family. This was particularly the case when the distress was associated with any sexually related aspects, be it sexual abuse, pain related to sex, sexual dissatisfaction and so on. This is reflected in Dr. R’s words:

They find it difficult to talk. Shy to talk. There will be sexual incompatibility. But again they do not seek help. They come with sleeplessness, or getting angry too much. Funny symptoms. Aches and pains, numbness. All kinds of problems with the breast. They come telling us of all sorts of things are wrong with their breast. Like a phobia. High strung. Not that they are hypochondriacs. But they are emotionally starved. (Dr R)

As portrayed in Dr. R’s words, talking about sexual problems or problems related to their partners or spouses is difficult because of the way women are socialized. Women are socialized not to discuss issues related to sex. Parents avoid talking about sex. Thus sex becomes a taboo topic for discussion, except with your intimate friends and, these days perhaps, within some of the more educated families. Hence sexual problems are expressed as a pain or an ache or a sensation in the breast or a tightness or discomfort in the lower part of the abdomen. In this way women are able to deal with the notion of shame that is associated with discussing sexual problems, particularly when it relates to relationships with the husband.

Communicating about sexual matters becomes particularly difficult for women when the health professional is a male. A good woman does not talk about certain things, especially with a male or in the presence of a male. This can form a barrier for health workers trying to provide appropriate health care. I came across two instances during my field-work that illustrates such barriers. The first was an education session on family planning that I observed. This was a face- to-face session where a female health worker was imparting information on contraception. A male health worker was also present. I observed the female health worker was shy to talk about the specifics of contraceptive methods, avoided eye contact with the participants and resorted to medical terminology in giving information. When I later spoke to her about the session she revealed that she found it uncomfortable to speak explicitly about such personal issues as contraception. In the second incident, the president of the women’s committee on one island I visited spoke of how women who have reached menopause are reluctant to be sexually active. She explained that women believed being sexually active after one reaches menopause is wrong. Some women also experienced discomfort during sexual intercourse but were reluctant to seek help. The health worker on this island, though aware of the problem, felt too shy to talk about

138 such [sex related] personal issues. Here is a case of a female health worker embarrassed to discuss sexual issues with women.

Sexual problems were not the only problems that were embarrassing to talk about. As reflected in the following words of a psychiatrist, there was a reluctance to talk about anxiety.

The other category – anxiety disorders is quite common. Most people do not realize this as an illness. They think that this is an embarrassing problem. It is difficult for them to even talk about it. Maybe because of the attitude of others. Some people would say that they are pretending. That they can get over it by themselves. That they need to be strong and that will be all. (Psychiatrist)

The psychiatrist is recognizing here that mental health problems such as anxiety are not locally considered an illness. This is particularly the case if the anxiety is related to phobias. Phobias are known as birugathun or fear linked to weakness. All one had to do to over come such a fear is to be strong. Thus anxiety may be linked to shame as not being able to deal with fear is a weakness.

The body as vehicle for seeking attention According to some biomedical healers, women were brought to their attention for problems related to fainting, loss of consciousness and being hysterical. These incidents occurred most commonly among young girls and were related to problems with their boyfriends.

They then faint. Same symptoms as fainting… fall down. That is taken as a very serious thing in the community. Losing consciousness means you are really sick. That is the perception. The family is very concerned and that way they get the attention. The secondary gain is family attention. (Psychologist)

Fainting was also identified as a common symptom by a counsellor:

Fainting spells are very common in young females. Late adolescence or early 20s. Often it happens because of problems with their boyfriends. Or problems with parents. Something happened in school (Counsellor).

The psychologist too mentioned that fainting was quite common, especially with young people. Although fainting was often related to psychological problems, it was not recognized as such. A psychiatrist spoke of how a young woman from another island living in Male’ for study purposes was fainting.

While in Male’ she was having problems – fainting. She was working in a house in exchange for board and lodging and she was being scolded for not doing enough work around the house. Even when she was studying she was expected to be doing household chores or she would be reprimanded. First time she fainted while she was doing her exam. After that she would repeatedly faint. So this sort of thing happens. Psychological problems. But they are unable to identify it as psychological problem. It presents as a fainting spell. (Psychiatrist)

Living in Male’ as a student often entails working in another person’s home in exchange for board and lodging. This is highly stressful for students as reflected in the above words of the

139 psychiatrist. In my former job as Dean of Faculty of Health Sciences in the Maldives I came across such students struggling to meet the dual set of demands of passing exams and completing household chores for their hosts. Given the extreme pressure they are under I would interpret fainting as a way of coping. Fainting as one of the psychologists revealed is perceived as a serious problem that warrants the concern of the family. It also excuses one from the household tasks as fainting is perceived as an illness and an ill person is not expected to do household chores

The findings of this study indicate that women’s embodiment of their distress is related to their social, cultural and moral concerns as well as their personal values and concerns. Women described their distress within the context of social and interpersonal situations reflecting a situational model (Patel, Gwanzura, Simunyu, Lloyd, & Mann, 1995) rather than the bio- psychiatric model (Keyes, 1985) that is predominant in Western societies. Women’s expressions of their distress also reflect what Marsella (1980) terms “culture’s conditioning of the self- structure” (p. 255).

6.3 Etiological idioms of distress

In expressing their distress, Maldivian women rarely used equivalents of expressions such as I feel depressed, I feel sad and I feel down. Such expressions are quite common in Western patients experiencing mental health problems (Dwairy, 1997). Instead Maldivian women frequently used etiological idioms of distress (Nichter, 1981) and somatic metaphors to describe and talk about their distress.

6.3.1 Fikuru boduvun or thinking too much – Mind Distress

Women spoke of their distress as thinking and thinking, or they used the term fikuru boduvun which also reflects too much worrying. The word fikuru comes from the Arabic word fikr and implies a morbid state of brooding or preoccupation with things that are causing distress. Fikuru boduvun or “thinking and thinking” kept women awake at night, made them feel nauseous and sometimes unable to concentrate. They became forgetful and found themselves getting angry quickly. When there was too much thinking or fikuru it made their head or neck ache, made them feel heaviness in their head or sometimes tightness in their chest.

According to some women at a certain point fikuru boduvun would overload the brain and cause it to malfunction. When that happened the victim would reach the stage of being crazy or moya.

140 When women spoke about fikuru boduvun they pointed to their head or touched their head. Thinking too much or fikuru boduvun was associated with such worries as financial or social insecurity, problems related to children like children not studying or getting involved with drugs or being chronically ill, discrepancies in ideology and inability to fulfil one’s aspirations, discussed in detail in Chapter 5. Sometimes fikuru boduvun was related to conflict within the family or related to what significant others in their life or community thought of them. The context in which women mentioned fikuru boduvun and the way they described it have some similarity with Western notions of depressed mood or anxiety.

6.3.2 Hiy dathivun or heart difficulty - Heart Distress

Women often used the expression of hiy dhathivun or tightness in the heart or heart distress to describe how the various circumstances of their lives affected them. Hiy means heart and dhathivun means difficulty. Women spoke of hiy dhathivun in relation to the loss of a loved one through death or divorce or abandonment. Hiy dhathivun also was mentioned within the context of marital problems such as infidelity, or problems in relationships with significant others as discussed in Chapter 5.

When women spoke of the circumstance of their hiy dhathivun they pointed to their heart or lay their hands upon their heart. Women spoke of the following ways in which their heart was affected: Hiy falhaigen dhiun or splitting of the heart, hiy halaakuvun or heart break. Some women spoke of their heart being dead or hiy maruvun when their suffering became too much. Once they reached the point of hiy maruvun they became devoid of emotion. At that point, nothing could hurt them anymore. There was no life in anything and nothing anybody said or did had any impact on their feelings. Their tears dried up and they could not cry any more.

Mariyam spoke of how her suffering had reached the point of hiy maruvun. When she heard her son had been put in jail for drug abuse, she could not cry. In her words, “I have shed so many tears in my life, that I have no more tears left”. During my encounter with her, as she spoke of her inability to cry, she asked me if she was being an unfeeling person by not being able to cry. She wanted me to reassure her she was not being a bad mother.

Shareefa recalling the discovery of her husband’s infidelity and later when he divorced her spoke of her hiy dhathivun as follows:

141 Even now, when I think about it, it makes me want to cry. When he divorced me I was so heart broken. I cry and cry. I cannot sleep. I cannot think. Cannot do anything. Cannot eat. Did not want to get out of my room. I did not even take care of the children. It was my sister who cared for them. I just could not do anything (Shareefa).

Azza spoke of her suffering as follows:

I did not get a mother’s love or a husband’s love. From a child up to now I have suffered so. No happiness. Ever. Crying always. I cannot stop crying. Even when I am praying, I am shedding tears. I cannot sleep. How can I? When my heart is complaining? I try to read, but I don’t take anything in. My brain doesn’t take anything in. I have fainted, lost consciousness, vomited because of my grief. My heart is so distressed. It affects me so much. (Azza).

Mariyam, a woman in her fifties, experienced hiy dhathivun when her husband decided to take a second wife (polygamous relationship). She used words such as, “I was crying and crying all the time”, “My heart was so distressed”, “I did not feel like doing anything”, “Some days I did not feel like getting out of bed”. She also said that once she had thought it would be better to kill herself.

Both Azza’s and Shareefa’s physical appearance were indicative of the suffering they were experiencing. Looking at them I could make out that they had lost a lot of weight, they had a drawn look on their face and their gestures and demeanour were those of someone who did not have any life left in them From the descriptions, causal explanations, and emotions women associated with hiy dhathivun, and the context in which women experienced it, it seems to me that hiy dhathivun is what would be clinically diagnosed as depression in a medical framework.

6.3.3 Gaiga rissun or aches and pains - Bodily Distress

For the most part women experienced distress as an ache or pain or other physical sensation such as coldness in limbs, pins and needles or piercing or tingling sensations. They used the word gaiga rissun as a general term for bodily aches and pains. I call this bodily distress.

When women expressed their mental distress in these ways they would point to the part of the body where the pain or ache was located. Most often women spoke of headaches and pain in the chest area, the latter being referred to as meyga rissun (liver pain). Mey is the term used for liver and it is interesting to note that when they spoke of meyga rissun they would point to their heart and chest area. The pointing to the heart and chest area while referring to the liver brings up cultural ways of locating internal organs in the body. Other specific forms of bodily distress mentioned by women included baduga rissun (stomach or abdominal pain), karuga rissun (neck pain), bobifalheega rissun (pain between the shoulder blades) and unagaduga rissun (lower back pain). The body site they nominated seemed to be linked to the perception of the cause of distress and to moral values. For example distress associated with relationship issues was

142 located in the heart/chest area, and sexual problems with husbands located in the lower abdomen area or breasts.

6.3.4 Moyavun or Going Crazy

As already mentioned women spoke of how thinking and thinking or fikuru boduvun could drive them to the point of becoming moya or crazy. Some women indicated the same thing could happen when hiy dhathivun reached the stage where they were unable to cope with such intense distress. The etiological idiom of moya is known as budhdhi goasvun. Budhdhi means reasoning or ability to think or wisdom; goasvun means gone bad or not functioning or impairment. The origin of the word Buddhi is Sanskrit where it denotes wisdom, understanding or intellect (Kim- Hui, 2003). In a Sanskrit-English dictionary buddhi is defined as “the power of forming and retaining conceptions and general notions, intelligence, reason, intellect, mind, discernment, judgment” (Monier-Williams 1956:733 cited in Kim-Hui, 2003).

Moya persons behave in ways considered abnormal such as talking to themselves, uttering nonsense, wandering around aimlessly or pretending to be God or someone important. In its most extreme or irreversible form, the state of moya was sometimes referred to as Dhuniyein moyavun. Dhuniye means world. Thus dhuniyein moya implies the victim no longer belongs to this world, which would translate into English as insanity. Adding the word dhuniyein perhaps has connotations of marginalization and stigmatization? It was perceived to be an extreme form of craziness for which there was no cure. A dhuniyein moya person would do and say things that were not acceptable to society as portrayed in Dr. MA’s words:

When you describe a mad person, they would say there is nothing he would not do. There is nothing he would not say. He may even become naked in front of others. Shout and yell for no reason. Use words that are difficult for people to accept. What else. Will defecate and urinate anywhere. Any place is good enough for a toilet. Those are the things a mad person does. Does not sleep at all. Even at night be running around all over the island. Shouting and yelling. Most of the time he becomes like that when children ridicule him. That means you are a mad person. Budhdhi goasvefa or moyavefa. They may wear anything. Even if it is torn. No hygiene. Will stay without cleaning oneself. (Dr. MA)

Dr. MA’s words portray how normality is defined in Maldivian culture and his account brings up some important issues. First it illustrates how culture prescribes the way a person should talk and behave in public. Being naked and using foul language is unacceptable and is considered abnormal and taken as the signs of a mad person. Second, those who are defined as ‘abnormal’ or moya are perceived as not in control of their behaviours. Third, those who display culturally and socially unacceptable behaviours such as a moya person does are ridiculed and marginalized. Fourth, cleanliness is given a high value within the culture.

143 Those who flaunt what is prescribed as normal were marginalized and stigmatized. Depending on the extent to which their behaviour is disruptive as judged by the community and community leaders, they may be tolerated and allowed to roam freely or they are institutionalized. I will discuss some of the aspects related to marginalization and stigmatization, especially of moya people, later.

6.3.5 Birugathun or Fear

Birugathun or fear was associated with beliefs in supernatural causes, darkness and being abused by partners or family members.

Yasmin was frightened to sleep alone. When she was at home she would get her mother to sleep with her in the same bed. Even when she shared a room she was still inclined to feel frightened so she needed to have someone right in the same bed. Yasmin started experiencing birugathun soon after someone had tried to sexually assault her as discussed in Chapter 5.

While birugathun did affect normal functioning, as in Yasmin’s case, it was not considered an illness in the Maldives. It was seen more as a weakness and something to be conquered on one’s own.

6.4 Somatic metaphors

Some of the participants used somatic metaphors to express their emotional distress. Somatic metaphors are used by patients to express their subject meanings in verbal language that is metaphorically expressed (Dwairy, 1997). Maria, a woman with basic education who works in a health centre, was one such person. She was coerced into marriage at 16 years to a man several years older than her and did not love her husband so kept on asking him for a divorce. Maria described what happened to her when he eventually divorced her:

The moment he uttered the words, “you are divorced” it was like something took hold of me. I went cold, my limbs became paralysed and I had this awful sensation. I guess by then even though I was not really in love with him, I had begun to care for him. After all I had four children with him and I cared for him and the children. So even though I’d asked him for a divorce when he finally granted me the divorce, I was stunned. I could not accept it. For the next few days I was drained…tired. My face reflected my feelings. (Maria)

Maria’s description of how she felt – “I was stunned”, “I was drained” are examples of somatic metaphors (Kirmayer, 1989). The use of somatic metaphors has been documented in other countries as a way of expressing mental health problems such as depression. Somatic metaphors are quite common in Arab and Middle Eastern societies (Dwairy, 1997; Hamdi, Amin, & Abou-Saleh, 1997). Al-Issa (2000) observes somatization is a way to shift the cause of the 144 problem from the interpersonal or psychological to the natural realm. For some cultures open display of emotions in social interactions is unacceptable and symptoms of mental illness tend to become stigmatized. Somatic complaints serve to reduce the stigma of mental illness and legitimize entry into health care. In cultures where mental illness is stigmatized physical pain is an “opportunity to reintegrate the sick person into the social support group and to reaffirm the norms of solidarity and social control in [the Muslim community]” (Al-Issa, 1995, p. 22).

Hannah, who was distressed at her husband constantly shouting and yelling at her, could not voice her distress. She used the metaphor of “storing feelings inside the heart”, similar to the English expression bottling up feelings, to indicate her inability to talk to someone about her distress. Bottling up feelings manifested as headaches and chest pains and affected her nerves.

Other somatic metaphors used by women in this study include the following:

Feels like a jellyfish stuck to my stomach (Aruza). My heart complains (Azza) I don’t know what people say when they talk to me. I was turned to stone (Ahmeema). Someone is digging my stomach (Naeema). The pain was like nails being driven into me (Naeema). I felt like the four corners of the world (horizon??) are closing in on me (Zuhaira). The trees looked dead. Everything I looked at appeared dead to me (Ahmeema). My throat is sunk (Azra). There is tightness around my stomach (Azra).

6.5 Cultural somatization

Cultural somatization is when one particular organ is chosen as the main focus for all symptoms (Helman, 2001). Women’s accounts in this research and an exploration of the vocabulary of affects in the Maldives show that the chest, head, and liver are the core areas of the body where patients feel their distress. The abdomen is also included as a less important area. Such use of a core area of the body is illustrated by expressions such as hiy falhaigen higaadhaane (my heart will split open), meyah fen echcheh ossaali hen heevee (it feels like water is poured into my liver), boa falhaigen higaadhaane (my head will split open) and so on. In general the heart and surrounds is where feelings related to emotions such as sadness reside. The head and neck are where complex problems or worries that may affect the ability to think clearly or reason or make judgments are felt. The liver is the organ associated with emotions such as anger, jealousy, fright or shock.

145 As discussed in the preceding section, emotions such as grief and sadness associated with the loss of a loved one are seen to affect the heart. At the same time the heart is also linked to some aspects of cognition and mind. For instance, a person who is intellectual or good at learning is called a hiy ali person. Hiy ali is the ability to be enlightened. It also relates to the ability to choose what is right and wrong. A person who has difficulty learning is called a hiy gaa meaning heart of stone. A hiy gaa person is also one who is devoid of feeling, incapable of emotion. When someone is unsympathetic to another’s suffering or treats another in a harsh and hurtful way he or she is commonly called a hiy gaa person. The table provided in the appendix 4 gives more examples of words and metaphors that show the relationship between language and mental processes and how emotional distress becomes manifested in bodily terms.

The organ(s) chosen for somatization has a symbolic or metaphoric meaning for the cultural group. Examples documented in the literature include the following: liver, spleen, kidney or heart in China (Ots, 1990); ‘heart distress’ in Iran (Good, 1977); ‘sinking heart’ in the Punjab (Krause, 1989); liver in France - crise de foie; bowels in the UK; the penis in some Chinese groups (koro); liver and kidney among Koreans (Pang, 1998). The individual suffers from a particular symptom and at the same time embodies the core cultural themes of the society they live in (Helman, 2001) as a result of which their emotions and distress came to be embodied in a particular organ.

The pattern of cultural somatization has implications for the diagnosis of mental health problems. Health care professionals who are either unaware of the particular somatization patterns of the culture they are working in or generally inattentive to such cultural dimensions limit their capacity to offer appropriate interventions for managing mental distress and run the risk of misdiagnosing. Such failures in diagnosis and treatment have been reported in the literature (Chiu, 1994; Meleis & La Faver, 1984).

6.6 Jinni Moyavun or spirit possession

Jinni moyavun or spirit possession is believed to mainly afflict young women, men, however, are not immune. During my field-work I had the opportunity to observe Ibra, a man who was perceived to be suffering from jinni moyavun. A jinni moyavun episode could occur several times in a person’s life. Each episode might last from one to several days and each episode might consist of one or more jinni moya trances or possession trances.

Naeema described her jinni moyavun experiences as follows:

146 I came to this island with my father for a holiday. I met my husband and got married. The third day after marriage the pain started on that one spot of my abdomen. It would ache and ache. When the pain comes even three people cannot hold me down. I am not aware of anyone around me. It feels like nails being driven into that spot. When that stops I have no strength to even get up. The pain happens at noon. Most of the time it would happen on Friday and Monday evening.

The jinni they come. Give me bananas and that sort of thing. They want to do sexual things to me. That is when I struggle not to let them do this to me. First they will be at a distance and make gestures. So in terror I start to tremble and shake.

The jinni they are digging. Putting nails into my stomach. Other sorts of physical violence. Also harass me sexually. That is why I start to struggle. Lots of people [family] were trying to hold me down. I was struggling to get away from them [family] saying I wanted to go into the sea. They [jinni] are calling me to come to the sea. So I struggle to get away and because they [family] are stopping me I hit the bed with my foot and broke it. People cannot hold me down. I have such strength. Even seven men cannot hold me down… really strong men. When I am in that unconscious state I do not know what I am doing. When I get back to my normal state, those who were around me and saw what happened tell me what I said and did. (Naeema)

The characteristics of a jinni moya trance as described by Naeema and other women and traditional healers include sudden onset, alteration in the level of consciousness, amnesia for the period of the possessed state, duration of an hour to less than an hour, intense fatigue at the end of the episode, extra-ordinary strength and normal behaviour during the period between possession trances.

My encounters with Ibra and women who had experienced jinni moyavun indicate some similarity in behaviour to those suffering from buddhi goasvun or sikudi hamanujehun. (impairment of the mind or brain) These include behaving strangely such as roaming around aimlessly, taking clothes off, talking to oneself and seeing things. But jinni moyavun is not stigmatized, whereas dhuniyein moyavun or insanity is. A jinni moya person’s behaviour is perceived to be the result of a supernatural force – it is the jinni that makes the afflicted person behave strangely and not an impairment of the mind. Jinni moya victims are not labelled deviant or dangerous. Their condition is considered temporary and their mind is not affected.

6.6.1 Cultural models of jinni moyavun

The findings from this study reveal a prototype of jinni moyavun, that is a core image or description of a person who is afflicted with jinni moyavun (Guarnaccia, Rivera, Franco, Neighbors, & Allende-Romas, 1996). There are some similarities in the prototype of jinni moyavun and the prototypes Guarnaccia and colleagues developed for experiences of Ataques de nervios, an idiom of distress used by Puerto Ricans and other Latinos to express dislocations in the social world of the family. The overarching characteristic in each case seems to be an “over-riding sense of loss of control” (Guarnaccia et al., 1996, p. 350). Other characteristics of the prototype include emotions of anger and in some cases sadness; distress experienced as bodily 147 sensations; aggressive outbursts of behaviour; alterations in consciousness and seeing things. Loss of control was prominent in the women’s descriptions and also in my observations of Ibra as he was experiencing a jinni moyavun episode.

In describing the experience of jinni moyavun I use the framework developed for Ataque by Guarnaccia and colleagues (1996).

Emotional expression Habeeba, Naeema, Ahmiyya and Sabeeha all spoke of not having control over their emotions when they were experiencing a jinni moyavun episode. The main emotion experienced seemed to be uncontrolled anger. For Sabeeha it included uncontrollable weeping. Some of the examples mentioned during informal encounters included hysterical outbursts. Some would scream and yell at their loved ones.

Bodily sensations The most frequent and salient bodily sensation was intense and intolerable pain around the forehead, or between the eyebrows or in the abdomen. Such pain occurred at a specific time every day as was reflected in Naeema’s description of her experiences. Other bodily sensations included weakness, lethargy, and dizziness. Some healers spoke of coldness in the limbs. Frequently bodily sensations involved seizure-like episodes where the body became rigid, teeth were clenched and eyes tightly shut. Frothing and foaming at the mouth and muteness were reported in some people.

Aggressive behaviour Aggressive behaviour characteristic of jinni moyavun included tearing clothes, beating or biting self and others, pulling the hair, breaking furniture, throwing things, and shouting and screaming at people. Extraordinary strength was mentioned as typically aggressive behaviour of jinni moyavun verbalized with expressions such as “Even seven strong men could not hold me down”.

Alterations in consciousness During a jinni moyavun episode, as was also described by Naeema, women experienced a marked change in consciousness. For the duration of the episode they were in a semi-conscious state and after it was all over they could not remember anything. They seemed to be totally dissociated from their bodies and their selves. While change in consciousness was a part of the possession trance, traditional healers in fact would also deliberately put the women into a semi

148 conscious state to treat for jinni moyavun. Whether induced by the traditional healer or not women had amnesia for the duration of the trance. I observed one of these sessions with a young woman and could see that the young girl was completely oblivious of what was happening around her. Her body was tensed and rigid, her eyes were closed and teeth clenched. However she could hear what was said by the healer. When she woke up she did not seem to remember anything of what had happened.

Seeing things Seeing things that others did not see was typical of jinni moyavun. Naeema spoke of seeing huge, black, grotesque human forms with eyes like live coals. She also said that black hens or birds would attack her. She would dream of snakes or eels winding around her neck and trying to attack her. Habeeba too spoke of seeing big, black human forms with eyes like live coals. Ahmiyya would see things like a huge, black woman dressed in red national dress with long flowing hair and eyes like live coals. Sabeeha spoke of huge black human forms watching her bathe.

Traditional healers identified such experiences as typical signs of jinni moyavun. According to these healers the grotesque human figures were actually the jinni appearing before the possessed persons.

6.6.2 The meaning of jinni moyavun

In this study, when the whole experience of jinni moyavun is considered and the accounts of the women explored for the events leading up to it, it seems to me that jinni moyavun is related to what is going wrong for them in their social world. Each time Naeema, Sabeeha, Ahmiyya and Habeeba were possessed there was some stressful event occurring in their lives. Full details for this can be found in the appendix 7. For instance Naeema experienced four episodes of jinni moyavun over a period of about ten years. The first episode occurred when she was about 18 or 19 years of age. At that time she was living away from her family, in the capital Male’. She had a boyfriend her parents did not approve of. Despite that she continued to see him and then he dumped her. The second episode occurred soon after her marriage to a man from another island. She met this man soon after the boy she loved left her and from her account it sounds like this marriage occurred on the rebound. She married him just two months after she met him. Her mother was quite upset with her settling on an island that was not her own. The third episode followed several closely spaced events. She had a baby and went with it to visit her mother who

149 lived a long way from the island of her marital home. The mother persuaded her to stay there and her husband divorced her.

Patterns related to the sequence of events and the timing of the possession episodes strongly suggest that jinni moyavun for the women in this study is likely to be a way of coping with stressful life events. The healing process for jinni moyavun involves the whole family and during the healing process the healer asks the jinni possessing the woman to reveal the reason for the possession, to name who is responsible for it. The sequence of events leading to the jinni possession, the behaviours and emotions related to the possession trance and the healing process taken together suggest that jinni moyavun is a medium for the woman to express her anger and hurt and the depth of her feelings and the threat of what has gone wrong in her social world. This is implied in Naeema’s words as follows:

When I am in that state I will get angry with my husband too. I do not want him near me. Even if he tries to hold my hand I try to shake him off. Even try to inflict physical pain on him. The jinni tell me to do that to him. So I do it. I pull my hair. Try to tear my clothes. When the episode is over I realize how much my entire body aches. The places on my body which I would hit or hold tightly will be red and bruised. I would even try to strangle myself. (Naeema)

She is expressing herself. As a possessed woman she is able to let out her anger and frustration without being labelled a bad woman. Therefore to me jinni moyavun appears to be a culturally acceptable way for a woman to express herself and restore the balance of power in her social world.

Possession trances similar to jinni moyavun have been reported in (Azhar & Varma, 2000). Azhar and Varma observe possession trances in Malaysia to be a socially sanctioned behaviour that is recognized by the community as a sign of distress. They liken the condition to a defence mechanism that helps the individual to preserve their self-dignity and self-worth. I see a similar phenomenon with jinni moyavun in the Maldives.

6.7 Stigma and labelling

Stigma has been defined in various ways in the literature, ranging from the idea of a ‘mark of disgrace’ to notions of stereotyping, rejection and social distance (Reidpath, Chan, Gifford, & Allotey, 2005). Reidpath and colleagues note that many researchers revert to Goffman’s (1963) definition of stigma as a deeply discrediting attribute that globally devalues an individual (p. 12). The need to reduce stigma has been emphasized in public health (Weiss, 2001).

150 Stigma affects health in different ways (Reidpath et al., 2005). First, it has direct negative health consequences. For instance individuals and groups who are stigmatized experience psychological stress as a result of the stigma to which they are subjected. This is particularly the case for people with mental illness (Corrigan, 2004; Corrigan & Watson, 2002; Corrigan, Watson, & Ottati, 2003; Wright, Grofein, & Owens, 2000). Second, people may deliberately exclude themselves from seeking health care for fear of being stigmatized and subsequently discriminated against. Third, stigmatization can result in either the failure to provide treatment or the failure to provide quality health care. Finally, in some situations stigmatizing one group can negatively affect the health of the broader population. Some of these health implications of stigmatization that the aforementioned researchers observed are also reflected in how moya people are marginalized and stigmatized in the Maldives.

In the Maldives moyavun (as distinct from jinni moyavun) is stigmatized as will be further clarified in this section. In a similar manner to seek help from a psychiatrist is also stigmatized as a psychiatrist is seen to be the doctor who treats a mad person. This is reflected in the local term used for a psychiatrist – moyainge doctor, meaning the doctor for mad people. To seek help from a psychiatrist is to run the risk of being discovered as suffering from a mental illness which would embarrass most people. They would first be inclined to see their problem as physical and consult a number of doctors as Dr. MA indicates:

They do not consider it as moya (madness). They will first consider there is something wrong inside their body. They will then go to a physician. If they have a headache, they will go to the ENT specialist. If there is something happening with the lower part of their stomach, then they may go to a Gynaecologist. If any of these professionals have a brain, the client may be referred to a Psychiatrist. Otherwise the person will go from one doctor to another doctor, until they get any relief. Finally one doctor may realize that the problem is more to do with mental distress and send the person to a psychiatrist. They [client] are reluctant to go to a psychiatrist first. Because they do not want to be labelled as mentally ill. For instance even now Dr. E, the Psychiatrist is called the ‘mad person’s doctor’ (Dr. MA).

We can glimpse here too some aspects of the lay perception of the body. People with persistent headaches see an ear nose and throat specialist (ENT) known in the local language as a karunmathee doctor, a doctor for ‘above the neck’. If they experience pain in the chest/heart area they see a heart specialist. For abdominal sensations women see a gynaecologist. The whole abdominal area is referred to in the local language as stomach/tummy. Women associate their tummies with babies and consult a gynaecologist for any problems related to that part of the body.

The way people determine which doctor to see reflects their body image (Helman, 1995). Helman defines body image as an individual’s “collective attitudes, feelings and fantasies about his body”

151 as well as “the manner in which a person has learnt to organize and integrate his experiences” (p.169). Helman suggests that individuals use maps of internal space to interpret their own physical and psychological experiences. Maps of internal space are the individual’s concept of what lies ‘within the body’, that is the patient’s belief about the location and function of bodily organs and systems. The aspect of internal space has been explored by many researchers (Boyle, 1970; Tait & Ascher, 1955). Kleinman (1978) found the maps of internal space influenced patient’s attitudes towards medical interventions such as surgery, diagnostic tests and medical treatments. When Maldivians choose which doctor to seek treatment from depending on the location of their pain, they are using their maps of internal space. And in doing so they avoid the psychiatrist and thereby avoid being labelled as a mentally ill person.

The role of culture in stigma has been pointed out by various researchers who have called for a better understanding of the cultural nuances of stigma related to mental illness (Fabrega, 1991; Kirmayer, 1989; Littlewood, 1998; Raguram, Weiss, Channabasavanna, & Devins, 1996; Weiss, Jadhav, & Raguram, 2001). However, the level of stigma experienced varies across cultures. The findings of this study reveal that moya people are labelled and stigmatized. However, following Islamic principles there is a moral imperative to care for ill people and, therefore, moya people are tolerated. But depending on the degree of deviance or abnormality of the moya person, as identified by the society, moya people can be marginalized and excluded from society. I will illustrate this by using some of the findings from my field observations.

Nasira, a woman in her thirties or early forties, is known throughout the country as Moya Nasira and is marginalized and stigmatized as she is judged by society as abnormal and crazy. She walks around barefoot, sometimes muttering to herself, wearing clothes that are dirty and covered with dust. She looks like what would be considered a bag lady in the Western world. She appears to be unwashed but does not smell of urine or faeces.

Nasira’s case demonstrates what is culturally considered as moya, as normal and abnormal, in the Maldives. In section 6.3.4 I indicated a person is considered moya when the capacity of the brain to think and reason and make judgments is impaired. But it seems to me Nasira is in fact wiser than many of us and this is portrayed in the words of a psychologist who had spoken to Nasira about why she behaves the way she does.

152 She [Nasira] said people run when they see her. But she is a victim of sexual abuse. She has deep insight. She said when she goes onto the road she has to frighten that person and she has to run after people. She has a plan every day. She suffers from fear of water. She has suffered an episode of depression and this has sort of helped her to cope. She is not depressed now. She is fully functioning. She told me how when she was on her own men harassed her and sexually molested her. So she became like this [dirty and smelly]. So that people would not want to come near her. But now she sells the chillies. People buy them from her because they just want to see her. She is using the image people have of her. She said she runs after others. Chases them. This is people’s concept of madness. She told me how she was unable to cope with her problems and how she took this role of a mad woman (Psychologist)

Nasira has fashioned a role for herself as a result of the experiences she has had. She purposely acts as a mad person in order to protect herself from men. She wears dirty clothes so that no man will invade her social space (Helman, 1995) and come close enough to abuse her sexually again. This seems to show sound judgment. She talks to herself and she runs after others so that she is the one who is doing the running after instead of being the one who is pursued. By appearing to be mad, she is protecting herself. Unlike many others she also fends for herself and according to a former colleague of mine has a healthy bank balance. She buys chillies and mangoes and other fruits and sells them in the market. In doing so she is overstepping the culturally sanctioned boundaries for a woman as the local fruit market is not a space that is socially acceptable for women to go. Nor is the kind of economic activity she is engaged in perceived as suitable for a woman.

6.7.1 Harm to others

Having an attribute that can cause harm to the self or to others leads to marginalization as revealed in this study. Causing harm to others includes actual physical harm and disruption to the house or workplace. It also includes ‘contaminating’ others by transferring one’s behaviour to others.

In Chapter 5 I described Moya Mariyam (see section 5.8.5). When she passed by, one of the people I was with made the following comments: “That woman should not be allowed to roam around the community. She is a menace to the community and we should never let her close to the children. She should be locked up and I don’t know why the island office does not do anything to take her to Guraidhoo, [the island where there is a facility for the mentally insane people].” This clearly indicates that Mariyam is marginalized and given a ‘spoiled identity’ to borrow from Goffman (1963). She is perceived as likely to contaminate children by teaching them filthy words. That is she can cause harm. She fails to observe the rules of personal hygiene and wanders around the island banging a pot.

153 My observation at the Guraidhoo Centre for People with Special Needs (CPSN) gave me additional information on how normality is defined, and how people are stigmatized. The CPSN is a facility for the aged who have no one to take care of them, and for the mentally ill who have been rejected by their families or whose families are unable to take care of them. In this centre there are several barred concrete cells where people are isolated and locked up. The cells are cold and bare. A concrete bench with no mattress or bedding serves as a bed/chair etc. A pail serves as a toilet.

At the time of my observation the people who were locked up in these cells included the following: a man who was totally naked; a man who was talking nonsense to himself who at times would yell and shout filth; a woman who wore tattered, dirty clothes and who urinated and defecated where she was and played with her excrement. There was also a foreigner who was bare- chested and wore just a pair of shorts. He had been picked up by a Maldivian fishing vessel and had no papers on him. The Maldivian Government had not succeeded in finding any country who would accept him. He was previously under the care of the National Security Service but was now transferred to this centre because he had been aggressive and violent. According to the medical staff he was not a psychiatric case but had been isolated in his cell because he refused to wear a shirt and he would at times hit the inmates or staff and constantly argue with the staff.

One of the cells was occupied by a woman I will call Waheeda. She had been isolated because she constantly fought with other inmates and did not get along with any of her ward mates. She was placed in the cell as a punishment. But later on she had asked to be allowed to stay there.

My field observations at the CPSN facility reveal that the behaviour considered deviant included: being naked, aggressive behaviour, not observing cleanliness and hygiene, disrespecting and disobeying authority. These observations illustrate that stigmatization is not just related to suffering from a mental illness or the extent to which one’s mental capacity is impaired. The presence of the foreigner and Waheeda in the locked up cells resonates with Coker’s (2005) view of stigmatization as related to “how the illness and its ability to disrupt social relations and ‘contaminate’ those who come in contact with the disordered individual” (p. 927). This is what Coker calls ‘social contamination’. Coker in her study on psychiatric stigma in Egypt suggests, “The contamination is not due to direct contagion but through the powerful influence that people have on their direct associates” (p. 927) .To me in this notion of contamination there is also an element of power and control.

154 Waheeda’s presence in the isolation cell illustrates that power and control is central to marginalization. Waheeda was brought to the CPSN because she was epileptic and she did not have anyone to care for her. According to the psychiatrist her condition was totally under control and she was not a threat or danger to anyone. My own observation of Waheeda and my interaction with her did not give me any reason to think she was aggressive. She appeared normal and well-behaved. However, the head of the centre perceived her as a threat. Waheeda would talk to other people on the premises and she asked to be allowed to go outside the premises and into the community for part of the day. Those who were registered in the centre were barred from doing this.

When I asked the Director why Waheeda’s request was not approved he told me that allowing Waheeda to go out would mean others would want to be allowed out as well. While the Director’s explanation may have been justifiable in some cases, I think her request was rejected more because of what she might disclose to the community of what was going on in the centre. There are many reasons why such disclosure would pose a threat to the Director which cannot be explained here for reasons of confidentiality. What is important is that Waheeda was perceived as a threat. She would argue with the Director and disagree with him – a behaviour that is considered disrespectful. Thus she represents what Coker (2005) describes as ‘social contamination’; she could contaminate other’s view of the Director. The pattern that emerges from my observations is the role of power in marginalizing and stigmatizing people. Those who are in positions of authority exert their power by labelling and determining who is normal and who is not. They also decide the scope and nature of social exclusion.

6.8 Reflections and summary

The findings presented in this chapter reveal that many of the symptoms characteristic of depression and anxiety, namely tearfulness, inability to cope with daily tasks, loss of appetite, body aches and pains, sleep disturbance and tiredness, were present in the participants’ expressions of distress. In some cases suicidal ideation was also present. These symptoms were reflected in many of the women’s accounts when they spoke of hiy dhathivun. However, symptoms such as loss of purpose and loss of sense of worth as a person were rarely mentioned. This is because the perception of self and meaning of life within a Muslim culture is different from what is generally taken to be the norm is Western cultures. While a sense of self and self-worth may be important in Western cultures, the concept of self is not the same in other cultures (Shweder & Bourne, 1982) For instance, in Mediterranean countries, the self is ‘indexical’ 155 (Gaines, 1992), meaning that the self is constructed and experienced in relation to others in its social world. It is like this too in the case of the Middle East where the individual is evaluated by others in relation to the social context (Abu-Lughod, 1986). As was highlighted in Chapter 3, in the Maldives, being an Islamic context, the perception of self and meaning in life emphasize cosmic smallness and the insignificance of the individual and privilege family and community.

The women in this study expressed their distress in mainly physical terms such as aches and pains, feelings of cold and heat in their limbs and wind. The physical body became a metaphor for personal and social distress. This embodiment of distress was related to the socio-cultural and moral values of the society which they learned during childhood from significant others such as parents, relatives and teachers.

The clinical presentation of mental distress as somatic complaints is a function of the cultural and moral values related to being a good woman, wife and mother. Feelings, thoughts and behaviours associated with clinical depression or anxiety are considered part of normal life and not an illness. Women normalized their distress and thus tended not to seek professional help. When profession help was sought they did not psychologize but presented somatic symptoms instead which were often not recognized as mental health problems. The consequence was unnecessary tests, wastage of resources, misdiagnosis and delays in providing appropriate interventions for managing the mental health problem.

Women in this study used etiological idioms of distress such as hiy dhathivun or heart distress, which has symptoms that are characteristic of depression; fikuru boduvun or thinking too much which has characteristics of anxiety; gaiga rissun or bodily distress; moya vun or going crazy; birugathun or fear or phobias and jinni moyavun. Cultural idioms of distress were anchored in a part of the body such as the heart or chest area, the area above the head, the liver, the abdomen and the extremities. The heart seemed to be the main seat of emotion. The way in which a particular body part is associated with a particular emotion produced what I call a Maldivian anatomy of the emotional body and it has implications for help-seeking and service utilization.

156 Chapter 7

Being Strong of Heart

DEALING WITH SUFFERING AND DISTRESS

I force myself to feel okay. I don’t let myself have any time to worry or think… Keep myself busy. When I am busy, the day passes… If everyone thinks like this then you will not go crazy (Mariyam speaking of how she coped with a polygamous marriage.)

In the last chapter I presented the findings of this research as they relate to how women expressed, experienced and explained distress. In this chapter, I highlight the findings in relation to how women in the Maldives cope and deal with distress.

Women’s accounts of how they deal with their distress indicate that not all of them seek professional help. Most of them resort to various methods of self-healing, either by themselves or with the help of family and friends. However, in cases where women thought that a supernatural cause such as jinni or sihuru was the source of their distress they sought help from traditional healers. In cases where the distress was embodied as physical aches or pain they went to the local health care providers. Very few women sought psychiatric help for their distress.

In the following sections I first present my findings on how women in the Maldives deal with their distress and then discuss the patterns that emerge from these findings that are related to the pathways for coping and dealing with distress. The patterns that emerge have various implications for public health and I will conclude by discussing these implications.

7.1 Dealing with Suffering and Distress

Most of the women I encountered lived outside the capital island. They were geographically isolated and had access to only very basic health services. As explained in Chapter 3, the majority of the islands have an Island Health Post staffed by a family health worker/s and a traditional birth attendant. The atoll capital has a Health Centre with a team of health care providers comprising a doctor, community health workers (CHWs), nurse’s aids and family health workers (FHWs). Islands with a regional hospital have some specialists, mainly gynaecologists and surgeons.

Out of the twenty-nine women I was able to formally encounter only four lived on the capital island where the services of psychiatrists, psychologists and counsellors are available. Five of the women lived on an island close to the capital which had regular transport to the capital and where 157 the centre for the mentally ill was located. A psychiatrist visits the island, though infrequently. Five of the women lived on islands where there is a regional hospital. It must be pointed out that the health service situation I have described here applied to the time when the research was undertaken. Some of the women had their episodes of distress a few years ago when health facilities were even less accessible. Even now, except for the capital island, no island has regular access to mental health services.

7.1.1 Self-Healing

In many cases women were living apart from their husbands as their husbands were on tourist resorts or in Male’ to earn their living. The husbands came over to their family maybe once a year or at most twice a year. The women had to look after their children and make do with the little money that was sent by their husbands to meet the basic needs of the family. They had to go on with their lives no matter what challenges confronted them.

Seeking solace in faith and prayer Most women coped with their suffering and distress by having faith in Allah and seeking solace in His mercy. This was what kept them sane and prevented them from giving up. Accepting suffering and distress as a normal part of their lives as women, wives and mothers helped them to deal with their distress. Azza, who had lost her mother when she was a child, been physically abused by her father and stepmother during her childhood, been forced to marry a man she did not love, and was now having to share a bed with a husband who would not touch her, said that it was her faith that kept her going. These are her words:

It is said those who suffer like this in this world, on judgment day will be rewarded. I tell myself this and am thankful and accept this is what is destined for me. I tell myself this is Allah’s way of testing me. When I cannot cope any more I go and pray. I thank Allah and ask His support to cope with all this grief and suffering. If I did not pray so much I would not have been able to cope. (Azza)

Azza prayed to Allah to give her strength to deal with her life circumstances. Like many of the other women she appealed to Allah to make her strong of heart so she could go on with her life. At the times when she was feeling her worst, she would get onto her prayer mat and “pray and pray”. She would be crying as she prayed but she found after a while her crying stopped and “her heart was at peace”. She said that praying to Allah was her way of stopping herself from “going over the edge”.

Hannah also drew comfort from her faith. Whenever she felt she was getting depressed and could not sleep, she would pray, read the Qur’an or listen to an audiotape of the Qur’an or of the

158 life of Prophet Mohamed. She was then able to cope with the “feelings that threatened to overwhelm her”. She felt that prayer was the only way she could cope.

Rauna too prayed when she was finding it hard to deal with her distress. She would listen to the Qur’an on the radio or on an audiotape. This “calmed her down” and she was then able to deal with her suffering. Some nights she found she could not sleep. She would then get up and pray and this helped her to fall asleep.

Although not all women mentioned directly that they sought solace in Islam, my observations in the field showed that Islam played a significant role in helping the women deal with their distress. Their faith and prayer certainly seemed to have a protective effect and to prevent their distress from exacerbating, at least for most of them, at least for now. Islam also continues to play a major role in the lives of men. Both men and women freely and frequently used expressions such as Insha Allah (God willing), thavakkalthu Allah (trust in Allah), maaiy kalaange aai vakeel (I leave it to Allah’s mercy) when speaking of everyday activities, or of achieving something however routine. Many of the homes I visited had signs of belief in Islam on display. There may be certain verses of the Qur’an or prayers decorating the walls or hung at the entrance to the home.

The importance of religion was also evident in the different types of treatments that fanditha verin or faith healers used. They used the power of Qur’an and prayer in their healing practices. I will discuss this later in this chapter.

Keeping busy Mariyam spoke of how keeping busy was what enabled her to cope with her husband taking on a second wife and living in the same house with the ‘other woman’. Keeping busy was a way of forgetting those things that caused women to think and think as she indicates:

To try and forget [the misery and distress], the best thing is not to leave any free time for oneself. I think I did not go [crazy] because I had the children to take care of. At that time, you wash everything by hand. You had to light the fire and cook and so on. There would be so much work to be done. All the kid’s clothes. Washing them and ironing them. Life was not easy then as it is now. May be that is why my problems did not become so severe for me. I would always be thinking… there is this to do there is that do… When I am busy, the day passes. Sew, do household chores, prepare hedhikaa [finger food] for sale, and so on. So the days go by like that. If everyone thinks like this then you will not become moya [go crazy or insane]. (Mariyam)

This account provides an interesting glimpse into women’s daily routine. I observe that what women consider to be a source of hardship, namely being solely responsible for the day-to-day care of children and home, is also a source of coping. Mariyam recognised this. Ensuring the needs of her children are met left her no free time to dwell on the negative aspects of her life.

159 When Rauna was invited to tell me how she coped, she too indicated she kept herself busy as revealed in her words:

I have never had domestic help. I used to buy fish from everyone on this island and process those. I never had any helpers. I did my business activities alone. Even 24 hours a day I may spend in the kitchen processing fish. (Rauna)

Rauna felt she had to do something to “occupy her mind” so that she would not be thinking of how her husband’s way of treating caused her hiy dhathivun (heart distress). Now that she no longer processes fish, Rauna keeps herself busy in the shop she manages.

When Aina felt distressed she liked to listen to music. Or sometimes she would take out her photo albums or go through mementos she had saved over the years. She would take out cards and letters and things that were reminders of good times. She might also look at the embroidery work she had done or rearrange everything in her closet. By the end of the task she would feel less distressed and able to go on with the rest of the day. Naeema too would lose herself listening to music or sometimes watching television.

Except for Shaheen all of the women spoke of using some technique to keep their thoughts off the things in their lives that were causing them to think and think or to cry. Shaheen, however, isolated herself in her room most of the time to deal with her feelings of inadequacy and lack of confidence. While the techniques used by other women seemed to help them deal with their distress and help them to cope, Shaheen’s way of coping appears to add to her distress. She mentioned that keeping herself isolated was making her feel lonely.

Seeking support from family and friends At the times when Rauna’s shop was closed she would go out and see friends. She felt she needed to be with others and not to be alone in order not to give way to her feelings. This is how she describes one of her ways of helping herself:

During the day I go where there are people. Or watch TV. Go and see my friends. I go where people are enjoying themselves. Then only can I not let my thoughts overwhelm me. If I remain by myself I will go crazy. I realize I have to do this to cope with my suffering. Otherwise I know I will be insane. (Rauna)

Rauna’s words implies that she recognizes the continuum of distress and so she does something about it through attempting self-healing This makes me wonder that if there was better awareness related to mental health and if there were mental health services she trusted would she then seek professional help? Several women mentioned unburdening themselves to either friends or family as a way of preventing their distress from overwhelming them. However, some women felt they had no one to talk to, no one they could completely trust. This was the case for Zuhaira, a teacher 160 with a university education. While talking about her distress made her feel better, Zuhaira felt she had no one on the island she was working on that she could trust. She was afraid if she spoke of her marital problems that this information would be made the “talk of the island”. The only time she could talk to someone was when she had people from outside the community visit her island or when a trusted friend came for a visit. Talking to them and letting it all out gave her peace. Even the chance to talk to me as a researcher gave her a sense of relief.

The issue of confidentiality Zuhaira mentioned is one of the complexities of living in small island communities where everyone knows everyone else. Although Zuhaira’s island is quite large in size and population by Maldivian standards the land area is less than four square kilometres and the population is less than 9,000 (MPND, 2005). Most islands consist of a maximum of 1000 – 3000 people living on less than one square kilometre. So everyone knows everyone and everybody is related in one way or another. This brings in issues of anonymity which has implications for mental health services such as group discussion therapies

There is very little in the way of entertainment or leisure activities on these small islands. Thus chatting and gossiping become favourite pastimes. For women such as Zuhaira who have a certain reputation to maintain as President of her local women’s group, talking about personal issues becomes problematic. Moreover Zuhaira was educated overseas and her way of thinking is different to most. As she herself mentioned the community looks upon women educated abroad with special suspicion. With her overseas training her problems with her husband is likely to be blamed on her foreign ideas and her non-acceptance of the gender roles that she is expected to conform to. Thus she is denied one of the usual outlets for pent up feelings and dealing with her distress becomes especially challenging.

The issue of confidentiality is a significant one. It has implications for services such as counselling. The fear of not being able to trust another with innermost thoughts causes people to refrain from using counselling services. On small islands there is some kind of connection between most people, either familial, work or friendship. This may be one reason why some people keep things bottled up inside. When the distress relates to sexual problems, talking about it becomes even more complex and so the tendency is to keep it to oneself.

For most of the women family played an important role in coping. The importance of family and even neighbours is made very clear in the words of Shareefa who, after her husband divorced her, was so distressed that she could not carry out her daily duties. Unable to care for her

161 children she was so intensely distressed she was confined to her bed and recalled the support of her sister:

During that time [just after her divorce] my sister looked after my children even. I just could not do anything at all. My sister gave me so much support. Always pointing out to me what would happen if I went on like this. What about the children [she would say]. The children would suffer if I go on like this. She took me to the health centre. I did not want to go. She would make me get out of the room and take me for a walk and so on. That is how I got out of that phase. It took a lot of support from many people for me to get over and cope. (Shareefa)

Shareefa’s words illustrate the role of social support and the importance of social capital in promoting mental health. In the Maldives there is still quite a strong family and community spirit and neighbours are usually supportive and on the look out for each other. However, with modernisation and consumerism in the capital island things are starting to change. I can recall when I was a child how close we were to our neighbours and how much we shared as a family. However in the present day in our busy lives we seem not to have the time for each other as we used to have. Nevertheless my findings confirm that in times of need family friends and neighbours can still be counted on.

Getting it off one’s chest While many of the women spoke of “being strong of heart” (hiy varugadha kurun) as a way of dealing with their distress others also recounted the relief they felt when they were able to express their emotions. Mariyam described this as follows:

I want to let everything out when I am feeling sad. But I want to do so with someone I know and can trust. Someone I know will not give me bad advice. When I go over and enter her [best friend’s] room and close the door, she will know that I am sad about something. Then when I have cried as much as I want to, all she will say to me is May your heart be at peace. She will not say anything else. What I want to do is to cry. So when I have cried and stopped and have calmed down, she would then suggest that I stay for a while and then go home. I feel better when I am able to tell someone. When I keep everything inside I feel worse. I need to tell someone and then cry. Then I feel relaxed. (Mariyam)

Mariyam’s words show how important it is to be able to share with someone who will not judge or betray trust. Giving way to emotion is revealed as therapeutic. Being able to cry without being judged as weak-hearted brought her relief. Ahmeema would go and talk to friends she could trust. She would also sometimes go to her mother and cry her heart out.

Other strategies used by the participants to vent their feelings included writing and composing. Aina would write down on a piece of paper how she was feeling. Azza would write songs expressing how distressed she was. Even during one of my encounters with her she burst into a song about her own sorrows. The therapeutic effect of expressing distress in poetry and song has been noted in other cultures (Abu-Lughod, 1986).

162 The relief provided by talking about one’s distress to a trusted friend or family member, mentioned by participants in this study has implications for service provision. It highlights the need for providing a counselling service or other helping service that provides women with the opportunity to unburden their distress. However, as has been highlighted by women such as Zuhaira, it is of utmost importance that such a service ensures confidentiality of women.

Getting on with life Sabeena who had gone through several marriages and divorces and who had seven children under thirteen years and no outside job spoke of having to go on with life despite the suffering and distress she was experiencing. Indeed for the majority of the women life had to go on despite their suffering and distress. As Mariyam indicates:

There were days when my heart was so distressed. But then the next day I force myself to feel okay. There were days when I do not feel like doing anything all. I don’t want to get out of bed. But then I cannot stay can I? I had to work. I have to get up. Even if I lay there who would come? We have to live together [with her husband’s other wife]. If I went to my parents they would get furious. (Mariyam)

These women had children to look after and jobs to do, a house to take care of, people to feed. Giving way to distress and lying in bed was not an option. Society was depending on them to raise the children and they had to be of ‘strong heart’. Most of them dealt with their distress by giving priority to their expected roles as mother and wife. They talked about having to go on with their lives for the ‘sake of their children’. Their children needed them and the children were more important than their selves. Again Mariyam was eloquent on this theme:

I decided this is what happened to me. I will leave it at that. I did not have a happy life. There is one thing. I wanted my children to love me and my grandchildren love me. This makes me very happy. But I did not have a happy life. The world is such a place. I do not know if anyone lives happily…

The children are so young. I have to try and cope for their sake. Nothing else comes to mind. Maybe it is because we had kids. In everything we think of our kids. We see what happens to kids when the parents get separated. I think that every moment… when there is no father, children will be so sad… (Mariyam)

Mariyam reveals that her life is what is expected of a woman. Like many others she considers a woman’s life cannot be separated from her children’s well-being. There is a tendency for women to normalize their distress, which will be discussed later in this chapter.

Like Mariyam, Aina too felt there was nothing much that could be done about her situation. She could not move out of the husband’s family home as they had no place else to go. She could not think of a divorce at present, as that would hurt her children. Under the circumstances, the only choice she had, for the time being at least, was to try and live with her situation and get on with life.

163 Whether the woman is highly educated or not, whether they came from the capital island or a remote area, whether they had a job or not, whether they had their own means of income or not women privileged their children’s well-being. Their own happiness and well-being was secondary even to the point of willingness to suffer physically and psychologically abusive relationships with the men in their lives. They would put up with all of this to ensure that their children had a mother and father.

Accepting life’s ups and downs and being thankful for what you have. A common pattern in dealing with their suffering and distress was for women to accept the situation and try to be thankful for what they had. Women seemed to value this form of acceptance of what life had dealt them. It spared them the risk of harming themselves or succumbing to madness, becoming a moya person. Azza spoke of how important it is to accept your destiny in life. Acceptance was linked to having faith in Allah. Faith in Allah also gave hope for a better life. But a better life did not need to be tied to life in this world as indicated in Azza’s words:

It is said those who suffer like this on earth on judgment day will be rewarded. I tell myself this and am thankful and accept this life. I accept this is what is destined for me for now. I thank Allah and ask his support to cope with all this grief. (Azza)

Rauna enlarged on the theme of accepting and being thankful, indicating that it showed some sort of weakness to fail in this. When I asked her why some women were unable to cope with the suffering and distress they experienced, she responded as follows:

People go out of their mind and do things to harm themselves because they don’t know how to be thankful for their life. Not being thankful for what happens to them… You can go over the edge, [committing suicide, harming oneself, going crazy] only when you let it happen. Of course human beings will be sad. (Rauna)

Rauna’s words suggest an internal locus of control. Her words “only when you let it happen” implies that the individual has control over how (s)/he responds to stressful situations. Exerting that self control (Shapiro, 1990) can prevent the progression to more severe forms of mental illness. These themes of ‘being in control’ by being strong of heart were echoed in many of the women’s accounts and in my observations during my field-work. As cultured people, as good people, Maldivians are expected to be in control of their emotions. Even as children Maldivians, especially girls, are taught to be hiy varugadha (strong of heart) and keiy theri (patient). The virtuous woman is in control of herself and has endurance.

I recall several incidents in my childhood where my mother would say or do things to demonstrate the importance of being patient and to be prepared for the unexpected circumstances of life. If I 164 fell down and I started crying she would say to me: “You are a girl. You need to be strong of heart to cope with pregnancy and childbirth and the life of a woman”. Or if I got angry and threw a tantrum my mother would say: “You are behaving like a baazaaru mathee child”. Baazaaru mathee is a derogatory expression synonymous to ‘street people’ and has the connotation that one is uncultured and unruly. Anyone who cannot control their emotions, especially anger, is considered uncultivated and uneducated. This applies not only to women but also to men.

I recall another incident, this time related to my life as an advocate for women’s rights. I was then the President of our local women’s committee. To celebrate International Women’s Day we were putting on a show of short plays to highlight some of the issues related to gendered power relations and what women could do to empower themselves. One of the women in my group came up with a script for a play about a young woman experiencing distress because of how her husband was treating her. He was being verbally abusive and restricting her from being with friends and spending time on self-development. The young woman confides in her mother about her problems. The mother encourages her daughter to be patient, strong of heart and ensure she has met all her husband’s needs. In time he will come to realize what a good wife he has and everything will be all right. These incidents from my own life meant that it came as no surprise to find that being patient and strong of heart were key ways women were dealing with their distress.

Falicov (2003) talks about women’s ways of dealing with distress “through a cultural constellation of cognitions, affects and behaviours that has been labelled as ‘fatalistic’ [sic]” (p. 382). The fatalism that Falicov refers to can be seen in the Maldives in connection with how the women place their faith in Allah. It seems to me that for Falicov fatalistic tendencies are ways of coping with negative affects. In the Western framework fatalistic behaviours may be indicators of the learned helplessness, denial and passivity that often underlie mental distress. However, in the accounts of the women discussed in this chapter I believe that what we are seeing is fatalism as a way of dealing with the distress that arises out of the actual circumstances of island existence where the locus of one’s life is genuinely not within one’s control. So the women’s response for me is a healthy and realistic way of dealing with distress. While I see a certain amount of fatalism as necessary within the Maldivian context, with women such as Azza I also feel there is a need to go beyond prayers to prevent her distress from reaching more serious stages. Among all of the women I encountered Azza would seem to be one of the most at risk for a serious mental illness. She lost her mother when she was a child and the very people she trusted, her father and stepmother, abused her throughout her childhood. She was forced by her father when fourteen

165 years old to marry a man she did not want to marry. She has endured three marriages and believes her older children have deserted her. She has to care for her younger children all by herself with no help around the house. She finds there is no intimacy in her marriage and feels rejected by a husband who despite her begging him will not touch her.

Azza is crying all the time, and cannot sleep. She finds her mind cannot concentrate on things, and she is unable to take anything in when she tries to read. She appears listless, frail, weak and very thin. Her face indicates that she is a woman who is experiencing tremendous emotional distress. Her eldest daughter, at the time of my encounter with Azza, was hospitalized because she had attempted suicide and was under the care of a psychiatrist. Azza’s daughter was, according to the psychiatrist, suffering from schizophrenia.

Azza certainly represents someone who is undergoing intense distress. Yet she normalizes her distress, seeks solace in prayer, accepts this is what is destined for her and is thankful for what she has. It is questionable to me to what extent she can continue to cope. From her account, it is clear that she does not recognize she needs professional help. Even if she did, where would she seek help? She is on a remote island with no access to mental health services. So perhaps her resorting to spirituality and self-help only is also associated with the limitations in her choices for health care on her resident island? If she were to come to the capital island who would take care of her children? Besides if she were to seek professional help, she is likely to be perceived as not strong enough to deal with her life circumstances and therefore unable to meet the cultural standards of a good woman. So all she can do on the remote island she lives in is to pray and hope for better times.

7.1.2 Seeking professional help

Very few of the women indicated they consulted a professional for dealing with their distress. Ahmeema, Hannah, Hareera, and Rauna did consult biomedical healers to get relief for the aches and pains they experienced in their body. However, for the most part these women did not seem to get any relief for their embodied distress. Ahmeema spent all she earned on diagnostic tests and doctors’ consultation fees only to be told that there was nothing wrong with her body. Hareera went to the health centre and was given an injection and painkillers for her aches and pains. But she did not feel better. The bodily symptoms of her distress were treated symptomatically as the doctor seems to have fallen short of making a connection between her

166 physical problems and her mental distress. Dissatisfied with the care she received she ended up seeking help from a fanditha man.

The accounts of biomedical healers refer to a reluctance for women and men too to seek professional help for their distress from psychiatrists. This is related to stigma and normalization of distress, as reflected in the following accounts.

Mostly patients come in a crisis. Most don’t want to be seen by a psychiatrist. They are hesitant. Because of the stigma they do not come to us. (Psychiatrist).

The psychiatrist also seemed to think that Maldivians attitude towards life in general might have a protective effect on mental well-being as portrayed in the following words:

Maldivians can survive. They don’t plan much. They live day to day. Don’t talk much about competition in society etc. They are different in that from others in the rest of the world. When you don’t have such a long perspective and live from day to day you don’t have many problems [mental health problems]. (Psychiatrist)

“Living from day to day” and “not planning” and “not having a long perspective” are perhaps related to the reality of island life in the Maldives. I would argue such attitudes are a form of resilience. To be able to survive within the social and economic context of especially remoter islands with limited resources one has to be hardy and live from day to day. If one were to think too much into the future I would argue that would make one more vulnerable to mental distress. The psychiatrist in fact did refer to the role of resilience in the following words.

They [Maldivians] have remarkable resilience. Have a high threshold. One of the reasons could be right from the start they lack emotional closeness. The father or mother is the only figure they have. One is almost always going to be absent. From childhood they are used to it. They adapt to the absence of someone [they love]. They manage. They find their boy friends from a young age. They find their closeness. (Psychiatrist)

Women are often left on their own especially in the outer islands as mentioned at the beginning of this chapter and children are used to not have a father figure around. So the women and children adapt to the circumstances. This kind of response and development of resilience has been acknowledged by other researchers. A study of women living in a remote community of British Columbia, Canada reported that living with geographical challenges, limited options of goods and services and resources required the women to be hardy (Leipert & Reutter, 2005). Hardiness was described by these researchers as an increased feeling of confidence and the ability to carry on in spite of adversity. It involved taking positive attitudes, following spiritual beliefs and establishing self-reliance. Taking a positive attitude helped women to put into perspective and deal with the challenges of their life and advanced their ability to control their situations. I see a similar process happening in the Maldives

167 One of the reasons for women not seeking professional help for their distress is related to the fact that some forms of mental distress are not recognized as problems that need professional help as a psychiatrist indicates in the following words:

The other category – anxiety disorders is quite common. Most people do not realize that this is an illness. They think that this is an embarrassing problem; it is difficult for them to even talk about it. Maybe because of the attitude of others. Some people would say they are pretending. That they can get over it by themselves. That they need to be strong and that will be all. (Psychiatrist).

As reflected in the above biomedical healer’s account, there are issues related to stigma, normalization of distress and non-recognition of distress as a condition requiring professional attention that explain why so few women seek professional help. The women’s own accounts of their distress and coping strategies lend credence to the biomedical healers’ explanation of the reluctance to seek professional psychiatric help.

So some women took the path of self-healing, a few consulted biomedical healers and others relied on traditional healing through fanditha verin, which is now discussed.

7.1.3 Traditional healing as a way of dealing with distress

Several of the women relied on traditional healers as a way of dealing with their distress. These were women who believed the source of their distress to be a supernatural force such as a jinni possession or a sihuru. According to the biomedical healers I encountered most women and men too would first go to a fanditha man or other traditional healer before they came to them, as is reflected in the following accounts:

First they go to a fanditha veriyaa. They even go to them in Male’. First contact will be with a fanditha man. Then they come to me. (Psychologist)

Often they would say they have been treated with fanditha for a while and yet there is no improvement. Most of the time we also do not discourage them from continuing with fanditha… because people’s beliefs – faith is a very strong power isn’t it? So they can continue with that form of treatment too and also take medication as well. Sometimes they would say fanditha brings them immediate relief… that sort of thing when the stress factor is removed they will get better. We do come across this sort of thing. (Psychiatrist)

As the psychiatrist pointed out some of their patients used both systems, the traditional and modern healing systems. Studies have shown that in settings where both traditional and modern healing systems are available, traditionally-oriented communities tend to use both traditional and modern medicine (Al-Krenawi, 1995; Walman, 1990).

With the increase in the health services available and the introduction of psychiatric services, especially in Male’, I would have expected there to be a reduction in the reliance on traditional healing practices. To my surprise this was not the case. Of course I have no numbers to

168 compare. But I would not have thought that university-educated people would resort to fanditha verin. But Alisha who has a university education did seek help from fanditha verin and she still uses a talisman which is kept in a gold locket worn round her neck It was clear from the psychiatrists and the psychologist that many of their patients either first went to a fanditha veriyaa, or even after coming to them, combined traditional healing and Western healing methods.

One of the reasons for relying on traditional healing may be related to language and the rapport between the healer and the patient and her family. In the outer islands and even in Male’ most of the doctors are expatriates. This means an interpreter is needed for translating. When it comes to talking about personal problems there is a reluctance to reveal intimate details to yet another person, namely the interpreter, a reason directly cited by the CHW and also Zuhaira. This is particularly so in cases where the distress is related to sexual problems.

In treating distressed patients traditional healers use the power of the Qur’an and prayer. I saw this many times in the various healing rituals I observed. If a woman is considered to be possessed by a jinni, the power of Qur’an is used to exorcise the jinni as the following detailed excerpt from my field observations makes clear. Other forms of traditional healing involve what is called a thaveedh or a talisman. Certain prayers are written on a piece of paper and this is given to the ill person to wear on his/her body. In some cases the thaveedh may be dissolved in water and the person asked to bathe in that water.

Use of holy water is also part of the healing kit of fanditha verin. There are two ways in which holy water is prepared. One is called thashi liyun in Maldivian language. This involves writing verses from the Holy Qur’an with a wooden pen dipped in black ink. The writing is done on a flat dinner plate. Then the ink is dissolved in water and the sick person is given the water to drink or rub on the body. The second way of preparing holy water is by reciting verses from the Qur’an and then blowing into a glass of water. When the prayer is complete the water in the glass is given to the patient to drink or bathe with.

In each of the above methods of traditional healing religion dominates. Given that the family is involved in all the rituals and Islamic prayer and the Qur’an are used, this form of healing is quite appealing to those who have placed their faith in Islam.

I observed various situations where fanditha or forms of religious healing were used. When I was a child we used to have a family friend who was a faith healer and often we would use his healing

169 powers for various health problems. I remember having intense headaches as a child. Every time a headache came on this family friend would tie a coconut palm leaf strip around my forehead and then he would write a verse from Qur’an on the leaf with a pointed knife before cutting the leaf. The minute he cut the leaf around my forehead my headache disappeared. I was always surprised at how quickly I felt relief. During the fieldwork for this study I resorted to traditional herbal treatment for my arthritis condition.

These various personal experiences and my field observations led me to believe there are some factors other than those related to religion that contribute to the study participants’ reliance on traditional healing. First traditional healing is the only form of healing that is easily accessible. Usually the healers do not charge a fee, though it is generally accepted that something will be given for their services. This is entirely up to the family and will depend on how much they can afford. Second, the healers come from the community and know the families well. Thus there is an instant rapport with them, unlike situations where patients have to communicate through the use of interpreters as mentioned earlier. I think also the healers are in a good position to be able to deduce what exactly is going on and what is contributing to the breakdowns in women’s social world. They therefore use creative ways of conveying a message to the person who is causing the woman distress, without the woman herself having to get angry or express views that may lead to ill will among family members. Third healers usually come to the family and the entire family and even neighbours and community are involved in the healing process. Thus it becomes a ritual that functions as a kind of stress release, letting out the tension that has built up in the distressed women. Finally since the traditional healer comes to the client’s home and works in the home it creates minimal disruption in the daily lives of the family members.

7.2 Pathways to help-seeking

Factors such as age, socio-economic level, education, language, types of services available, distance from the capital, culture, belief about mental illness and religion all influence the pathway to help-seeking. By help-seeking I refer to those strategies and practices that Maldivian women engage in to ease and deal with their distress. These include both formal and informal approaches. Formal approaches include interventions that are obtained from professional sources of support such as hospitals, health centres, non-governmental organizations and private medical facilities. Informal approaches include those strategies that rely on non-professional and traditional approaches as well as self-healing strategies. The latter include those strategies that rely on support networks such as family and friends, religion and spirituality, solitude and 170 measures to take one’s mind off problems such as listening to music. These have been already been discussed.

The decision to use a particular form of treatment relates to perceptions about the source of the distress, seriousness of the distress, control, whether it is considered a normal part of life and the stigma related to the particular kind of distress or suffering. I have already discussed perceptions related to the source of distress. I will now examine some of these other influences on selecting a pathway to help-seeking.

Women’s accounts of how they dealt with their distress give us an understanding of the social and cultural context of their lives and how this shapes their experiences with distress. Their accounts of how they deal with distress in their everyday lives suggest how notions of femininity and the social/cultural/religious/moral values associated with definitions of good woman/wife/mother regulate their everyday lives. The role of a good woman/wife/mother is to take care of their husband’s and family’s needs.

The findings also suggest how women’s sense of self is constructed in relation to the social and moral values that surround the expectations of how a good woman should and ought to behave. It also provides a picture of how gendered power relations operate within the community.

The women in this study seem to deal well with their distress through self-healing and without the aid of pharmaceuticals or formal therapy. While in some senses their ways of dealing with stress may seem passive, to me the women are being resourceful and active in their coping efforts. They draw upon strategies that make sense to them under the circumstances and given the isolated and harsh economic and social environment they are faced with.

Women view their suffering and distress as a normal part of their everyday lives as mothers and as wives. Hence they do not seem to desire or believe they need services from mental health professionals. The process of normalizing their distress is associated with their understanding of the relevance and need for mental health services.

The major pattern that emerges in their ways of dealing with their suffering and distress is the determination to be strong of heart and have faith to accept their situation. This is fuelled by women’s desire to live up to the socially constructed expectations of being a good woman. To them it is important to be considered both by others and themselves to be a good woman and good mother. Also the religious beliefs that they grow up with provide a basis for them to accept their situation and continue their lives with a strong heart and determination.

171 7.2.1 Control

A sense of control has been documented in the literature to emerge from efforts made to achieve ‘self control’ (Shapiro, 1990). Shapiro concludes that it is this link to self-control that enables the healing professions to help their clients. What they are doing is helping their clients to regain a ‘sense of control’ in their lives. According to Shapiro, “this model of individual self-control and personal responsibility is an important one, and has been a hallmark of the holistic health and broad-spectrum psychosomatic medicine movements” (p. 40)

In the accounts of Maldivian women I have presented here a ‘sense of self-control’ plays a prominent role. They speak of it not in terms of ‘self-control’ per se but in terms of being strong of heart. Women used words like” You go over the edge when you let it happen”, implying that one can control one’s emotions.

Shapiro (1990) points out that individuals who do not use self-control strategies such as some cancer patients maintain a positive sense of control by believing that someone else is in control, namely The Doctor or a Higher Power. He calls this “control” by a benevolent other/Other” (p 40). This belief in benevolent control by the Other is seen in the women’s accounts. Azza, for example, indicates that her life circumstances have been destined for her, that they are Allah’s (benevolent Other) way of testing her faith. She believes Allah is controlling her life and so she prays to Allah to give her the courage to go on with her life. Through her faith in Allah she believes she has gained some control over her feelings and emotions.

What we see from the accounts of these women is the importance of maintaining control over their own emotions by being strong of heart and relying on Allah’s benevolence, we see a close connection between mind-body-spirit. This is contrary to commonly prevailing Western notions of health where there is a distinct separation of the mind/body and spirit.

7.3 Reflections and summary

The women’s and healers’ accounts provided a wealth of information related to how women dealt with their suffering and distress. Their accounts provide a picture of how social and cultural influences, especially those related to the notions of good woman/wife/mother, shape how they deal with their distress. Cultural notions of being a good woman/mother/wife permeated all aspects of their lives. While the demands of being a good mother and good wife contributed to their distress, they drew on these same ideals to deal with their distress, in other words the same cultural ideals could be at once a source of distress and a resource for coping with distress. As 172 some of the women indicated, recovery was to a great extent related to how readily they accepted the burdens of their life and how thankful they were for what they had. I believe recovery also related to how well they were able to live up to society’s expectations of them as mothers and as wives.

Women tended to consider their distress to be a normal part of their life. To them their suffering and distress was related to the demands of their lives as good women, good wives and good mothers. Thus for them ‘normalizing’ their distress was the way in which they could manage their distress given their circumstances. This is in contrast to what has been observed in some cultures where distress is pathologized and considered ‘abnormal’.

Two major mechanisms underlie the coping strategies adopted by the women in this study: acceptance of their ‘life’s burdens’ and being thankful for what they had and determination to get on with their lives. Acceptance is related to their belief in Islam. Getting on with life is linked to women’s desire to meet societal expectations of being a good woman.

While the majority of the women in this study did not utilize professional health services to deal with their distress, this study offers useful information to guide health services policy and health promotion. For instance there is certainly a need for traditional healers to collaborate with professional health services to better address women’s mental health needs. Furthermore, the findings of this study also highlight a need for health promotion strategies to encourage women to recognize early symptoms of serious mental health problems.

The findings of this study make a valuable contribution to understanding how women who live in small isolated island communities with minimal or no contact with mental health services deal with their distress. To my knowledge few studies have explored the pathways to help-seeking among such communities.

173 Chapter 8

WOMEN’S SUFFERING AND DISTRESS THROUGH A GENDER LENS

As noted in Chapter 2 the prevalence of mental health problems, especially depression and anxiety, is much higher in women compared to men. A large body of literature substantiates higher rates of mental distress in women in both industrialized and less resourced countries, and a variety of explanations have been presented to explain this gender difference (McGrath, Keita, Strickland, & Russo, 1990; Nolen-Hoeksema, 1990). Some researchers have pointed to poverty and caring for young children as well as women’s subordinate status as negative influences on their mental health (Coyne & Geraldine, 1991; Karasz, 2005; Patel et al., 2006). Others suggest women’s exposure to stress is socially organised in gender-specific ways as a result of which they become victims of partner violence, victims of poverty and consequently experience more suffering and distress than men. (Fischbach & Herbert, 1997; Maher & Kroska, 2002; Stoppard, 1989)

In this chapter I present specific cases of women who have experienced suffering and distress to illustrate how their embodied experience of emotional distress can be explained through a process of ‘loss of a sense of self’ or ‘the silencing of the self’ (Jack, 1991; Jack, 1999). I will also demonstrate how a ‘model of goodness’ proposed in Jack’s theory of self-silencing drives women to become ‘voice-LESS’ and ‘self-LESS’. Using case examples, I argue that the process whereby the women become ‘voice-LESS’ and ‘self-LESS’ is related to gender roles and perpetuated by the gendered society in which they live (Connell, 2002; Kimmel, 2000). Living in a gendered society, according to Kimmel, implies that the organizations within our society “evolved in ways that reproduce both the differences between women and men and the domination of men over women” (Kimmel, 2000, p. 16). ‘Gendered’ here describes something that is in the process of being continually created and maintained, as opposed to being given a quality in the individual. . For example societal norms of what a woman should do and how she should behave is not an inherent part of a woman but is based on cultural values and differs from culture to culture and may change over time.

I have chosen the cases to reflect two different generations (a woman in her early sixties, one in her early forties and one in her early thirties), different educational standards (one with very basic education, one who has completed primary school and the other with university education, different marital situations (one who is in a polygamous marriage, a single mother who has never 174 been married and a woman who is divorced). I have also chosen one extra case, the only woman in the study to be the sole income earner in the family. In choosing these cases I have deliberately sought out those which highlight the cultural, moral, and political aspects of Maldivian society that I consider to negatively influence women’s mental health.

Before introducing the cases I present some of the theoretical aspects of self-silencing that are pertinent to the discussion.

8.1 Silencing the self theory

Silencing the self theory was developed by Dana Jack (1987, 1991) to understand the higher rates of depression in women. Jack developed this theory as she strongly believed there is a need to understand how social factors work “interpersonally and psycho-dynamically to affect women’s vulnerability to depression” (Jack, 1999, p. 222). Based on her interviews with depressed women, she posited that the centrality of relationships to women’s sense of self, together with gender norms for interpersonal behaviour, placed women at a higher risk for developing interpersonal behaviours and beliefs that make them more vulnerable to depression. She strongly argued that, to understand how social factors become internalized and affect depression, it is necessary to “listen carefully to women’s inner dialogues and negative self- assessments” (Jack, 1999, p. 222).

Silencing the self theory postulates that women whose backgrounds or current contexts encourage them to meet their relational needs in self-sacrificing, in authentic ways are more likely to adopt gender-specific schemas about how to make and maintain intimate relationships. These schemas, or images of relatedness, reflect cultural prescriptions for feminine relationship behaviour that are based on inequality. Self-silencing contributes to decreased possibilities of intimacy, to a loss of self-esteem, to the experience of a divided self, and to a heightened vulnerability to depression (Jack, 1999, p. 229)

Silencing the self is measured using four different but related facets. These are the following:

1. externalized self-perception that taps women’s tendency to judge themselves harshly by external standards. 2. care as self-sacrifice which assesses the belief that putting the needs of others ahead of one’s own needs is imperative and that not to do so is selfish. 3. silencing the self which addresses the tendency to inhibit self-expression and actions in the belief this would avoid conflict and possible loss of relationship

175 4. divided self which is the tendency to present an outer self that complies with feminine role demands while an inner self grows hostile and angry - it is based on the belief that it is necessary to hide aspects of the self from relationship partners in order to avoid rejection. In developing the theory, Jack drew upon frameworks provided by relational theorists (Bowlby, 1988; Chodorow, 1978; Gilligan, 1982; Mitchell, 1988) who postulate that women’s sense of self is organized around connection, mutuality, and relationships, based on their socialization and processes involved in the development of their gender identity.

8.2 Description of Cases

Aina Aina is a married woman in her late 30s, with three children between the ages of 1 and 5. Aina lost both parents when she was a child and was raised by her aunt who depended on her husband for everything. Aina’s childhood experiences made her determined to be financially independent and so she trained to become a teacher and also learned embroidery and tailoring so that she could earn a living and be financially independent.

Aina lives on her home island. After she got married she moved into her husband’s home where she lives with her in-laws. Aina thinks her husband’s family is not educated and has old-fashioned ideas. She points to their belief that a woman should not be working like she is; that a woman’s place is in the home taking care of the children and husband.

Aina’s husband does not have a regular job. What he earns through odd jobs he spends on cigarettes. Aina is the one taking care of her family financially, including even her in-laws.

Zuhaira Zuhaira is in her late 30s. She comes from an island in the north. She has a university education and is a teacher. She was first married at the age of 20 and then divorced. She remarried the same man and is now once again divorced. She has three children. Since her divorce especially, but also during her marriage, she has experienced emotional distress.

Zuhaira and her husband had agreed after they got married that if their feelings for each other changed and either of them found they did not love each other, then they would let each other know. But her husband had an affair and she was the last person to find out. Her husband

176 remarried and his wife is in one of her classes and she finds this very difficult to deal with. Her children want to see their father and sometimes he will not even talk to them.

Ahmeema Ahmeema is a single mother in her early 30’s born in a rural area on one of the southern islands in the Maldives. She has never been married but has a daughter who is now three years old. Her face looks drawn and tired and she gives the impression of having very little strength. She told me that she had lost quite a bit of weight due to her distress and that she never used to be as thin as she is now. Ahmeema was born on the island where she now lives with her family. She is the eldest in a family of four. When she finished her schooling she wanted to get a job. For this she had to move to the capital island as there were no jobs on her home island. In Male’ she went to night school where she was studying to obtain her secondary school qualification. During the day she worked as a legal clerk in a government office. Ahmeema was ambitious and wanted a career. Her goal in life was to study further and get a better job – to be somebody.

Ahmeema started dating when she was about nineteen years of age. This was her first love. They dated for about two to three years. She was in Male’ all this time and her boyfriend proposed to her and asked her to come over to his home island, which was the same as hers, to get married. So she moved back to her island but on her second day back there found out he had married someone else. After the shock with her first boyfriend Ahmeema did not date anyone for a long time. She went back to Male’ and started to work again. She met her second boyfriend. They had a pattern of breaking up and getting back together again. Then Ahmeema found herself pregnant with his child. Soon after this he disappeared from her life and the child was born out of wedlock.

Mariyam Mariyam is a woman in her fifties with a basic education (less than primary level – that is five years of formal schooling). She is from the capital island and has several brothers and sisters. Mariyam grew up at a time when only very basic education was available to girls and women. Her family at that stage did not have much money and they struggled to raise all their children. Now they are all doing well. Mariyam has five grown up children and they all have children of their own.

She began her account by saying that even as a child her aspiration was to become a good wife. She had read a book by Sodiq who is a well-known author in the Maldives. The book is called

177 Alathu Abi which means first time wife. It inspired her to want to be a good wife as the author describes.

Mariyam married Ahmed when she was eighteen. She moved in with her husband’s family and began a life with her husband in their house. At nineteen she became pregnant with her first child. She and her husband and her in-laws were very close as a family and she was very happy. They had a second child and soon after her husband started seeing another woman, Ayesha. For five years he continued the affair and finally asked Mariyam to agree to him making Ayesha his second wife.

For the next fifteen years Mariyam shared the house with her husband’s second wife. Mariyam did not reveal to anyone how much she was suffering inside. She put on a happy face although inside she was being torn apart. She was resentful of and angry with the second wife. Some days she even felt she never wanted to speak to her again. She blamed the second wife for all that was wrong in her life. Despite how she felt inside she maintained peace in the house. Both she and Ayesha worked together starting a small business. Outwardly they appeared to get along and they did not say anything hurtful or express anger towards each other. When their children were sick they helped each other out.

Now Mariyam and Ayesha each have their own place. They maintain a friendship and visit each other. In time Mariyam came to respect Ayesha. However, she went through a lot of suffering and heartbreak when they were together.

8.3 Discussion

Some commonalities in the experiences of Ahmeema, Mariyam, Zuhaira and Aina emerge. First, they seem to have experienced a process of betrayal in their most significant relationships (Hurst, 1999). Second, they exhibit behaviours that are consistent with a loss of a sense of self (Jack, 1991) related to tensions of living up to the gender norms prescribed by society. Feminist literature has demonstrated that in most cultures, when women are faced with situations similar to the women in this study, they tend to maintain behaviours that support self-silencing (Demarco, Miller, Patsdaughter, Chisholm, & Grindel, 1998) and that such behaviours are related to the gender roles (Eagly & Steffen, 1984), and gender identities that reflect women’s subordinate position within the society. As will be discussed in the following sections, self-silencing behaviours are also linked to the ways in which gender ideologies within the culture dictate how one should behave within relationships (Gilligan, 1982) and how society judges and defines a good mother, a

178 good wife and a good woman. Such gender ideologies become evident in the way the women in this study use ‘moral language’ (Jack, 1999). Examples of this are provided later in the discussion.

All four women speak of their suffering and distress in terms of their interpersonal relationships and how they affected them. When invited to tell me about their life experiences they all began their accounts by placing their experiences in context. They spoke of the social conditions in which they lived and how their relationships with significant others brought them suffering and distress.

The critical role of relationships, especially the quality of the relationships and the role of gender, has been identified by feminist contributions to psychology (Chodorow, 1978; Gilligan, 1982; Miller, 1986) as of crucial importance to women’s self-esteem. According to these researchers, men and women differ in the way they respond throughout their life-cycle. Miller’s ‘self in relation theory’ proposes that men and women, through their socialization process, develop different self- perceptions and ways of relating that are fundamental to their identity and relationships. Thus women develop stronger expressive characteristics that emphasize connectedness and attachment. Chodorow asserts that men develop their ‘core identity’ mainly around the principles of separateness and autonomy while women develop theirs through attachment and relatedness. Gilligan suggests that women’s morality evolves around the importance of relationships.

The above-mentioned feminist perspectives emphasize a self-concept for women that is focused around relationships, attachment and connectedness all three of which are reflected not only in the accounts of the four women presented in this chapter but in all the encounters in this study. Rather than talking about the symptoms they were experiencing, all the women provided a history of their interpersonal relationships and talked about how these relationships affected their emotional well-being. Relationships with their husbands/partners, children, parents, extended family, friends, and even the community at large were the central focus in their accounts.

8.3.1 Being betrayed by significant others

Aina began her story by talking about how her in-laws were constantly criticizing and nagging at her for leaving her children behind and going to work. She spoke about how her husband ignored the way she was being treated by her in-laws. For Mariyam her happiness was marred by her husband taking on a second wife and her having to compete with the younger wife for her husband’s love and attention. In the case of Zuhaira, her suffering and distress were related to

179 her husband’s affair with one of her students, which eventually resulted in Zuhaira being divorced. Ahmeema was devastated when she was jilted by her husband to be two days prior to their wedding.

Betrayed by the men in their lives, the women whose experiences are presented in this chapter have gone through a process of demoralization. Betrayal may in such cases be defined as the failure to meet the expectation inherent in significant relationships that one will be treated with love and respect and that the relationship can be relied on for support (Hurst, 1999). Demoralization is described by Frank in his book Persuasion and Healing (1974) as “to deprive a person of spirit, courage, to dishearten, bewilder, to throw [her] into disorder or confusion. To various degrees the demoralized person feels isolated, hopeless, and helpless, and is preoccupied with merely trying to survive” (cited in Hurst, 2003, p. 159) The suffering and distress associated with the demoralization was embodied in physical symptoms.

Abandoned by the man she loved just two days before their marriage, Ahmeema developed somatic symptoms that included inexplicable body aches and pains, bleeding, coughing and fever. Her menstruation was affected and her periods would last for 20 – 25 days. She had dreams both prior to and after the two events in her life that had brought her suffering and distress. After she was jilted by her boyfriend he constantly appeared in her dreams. In these dreams he had tears in his eyes, was unable to speak and was then taken away from her by the woman he married. Prior to her becoming pregnant both she and her mother had ominous dreams. Her mother dreamt that their house started shaking from the foundation up. Her mother knew that something bad was going to happen. She also dreamt of being saved from a fire.

When Aina came home from a hard day’s work and her father-in-law started nagging and criticizing her she experienced chest pains. She used the metaphor of “sharp needles piercing my chest” to explain her distress. She did not feel like eating and found it hard to swallow. After she forced herself to eat she would vomit. She found it difficult to sleep.

When Mariyam’s husband took on a second wife she found she could not sleep. Through many nights she would lie awake right until morning. Some days she did not feel like getting up at all. There were days when she was unable to eat and her tears would not stop. She did not want to face the day. But she had children to take care of so she forced herself to get up and get on with life.

180 Ahmeema, Mariyam, Aina and Zuhaira had been betrayed by the most significant person in their lives, their husbands. Their experience of betrayal was what precipitated their suffering and distress. It is interesting to note that while all these women experienced emotional distress, there was a difference in how they embodied their distress. With Aina, Mariyam and Ahmeema distress was physically manifested in such things as aches and pains and not being able to sleep. Zuhaira, who is more educated than all the others in my study psychologized her distress, a phenomenon that is more commonly reported in Western societies (Jadhav, Weiss, & Littlewood, 2001; Kleinman & Kleinman, 1985). Zuhaira, instead of talking about bodily sensations, spoke of her experiences as “feeling trapped”, “unable to make a decision”, “constantly thinking” and “feeling angry”. She used expressions such as “When I lie down on my bed, the feelings overtake me… there is no way of getting out. Sometimes I feel like I am being squeezed from four sides… I just want to get away… but there is no choice”.

Zuhaira’s expressions illustrate the turmoil she is undergoing inside trying to live up to society’s expectations of her as a woman and mother while she struggles to also give in to what she as an autonomous individual wants in life. Her feelings of not having a choice stems from gender- related social conditions. As a woman she has less choice in job opportunities available to her which can meet her own individual needs and that of her role as a mother.

8.3.2 Gender ideologies and moral goodness

The impact of the gender ideology of morality, especially in terms of how women should and ought to behave, is strongly apparent in this study. Ideology, defined by feminists (Mitchell, 1971) as a set of ideas and beliefs or a world view which serves the interests of powerful groups in society, is perpetuated in various ways and disseminated through different organs of public opinion. One example is the ideology of motherhood, which Wearing (1996) considers is closely enmeshed with the ideology of femininity. Wearing elaborates on this stating: “to be considered a mature, balanced, full adult, a woman should be a mother; a good mother is always available for her children, spending time with them, guides them, supports, encourages and corrects them as well as loving and caring for them physically” (p. 85). Wearing, in her discussion of gender ideologies, is talking about contemporary Western society. Yet these same gender ideology notions apply to resource poor and traditional societies such as the Maldives, as illustrated in this study. Thus it seems to me that despite the cultural differences between the western and traditional societies there may be some similarity in the ideology of femininity as linked to motherhood. 181 The ideology of moral goodness as it relates to women, comes across clearly in this study in the way women used moral language such as, “I have done something wrong”, “that is my fault”, “someone who has been convicted of a crime”, “how can they ever think any good of me” and “I am guilty” to judge themselves. Looking at the moral language they use we are able to see how cultural norms of what is considered a good woman compete within the self and how this can lead to distress. The following dialogue of Ahmeema reflects how she is judged using the definition of ‘moral goodness’ the society accords women.

I approached a lot of people to see if I could get a job. I tried to join different things. Some people do not even want to talk to me. I am a sinner. Those times I feel very sad. I don’t necessarily complain about that. That will happen to anyone. They will be reluctant to talk to someone who has been convicted of a crime. [Or] to be friends… Even me… [I will do the same]. [Interviewer: You said according to some people you have committed a crime. Can you explain this more?] The way people see it I am someone who has given birth, in a bad way [out of wedlock]. [Interviewer: What is your crime?] It is a crime… a big sin… for a woman. From a religious angle. (Ahmeema)

Zuhaira too appears to blame herself for her failed marriage, when she says:

I keep thinking of failure. Since this [failed marriage] has happened once, I am even afraid of giving my trust to someone a second time. In my mind I realize I have also done something wrong. That is why it [marriage] failed (Zuhaira).

Ahmeema and Zuhaira like all human beings have ‘grown up gendered’. Connell (2002) describes this as occurring during the growing up process when agencies of socialization (family, school, the peer group, and mass media) convey to a boy or a girl, the social norms or expectations for her or his behaviour. Through this ‘growing up gendered’ process, women internalize the norms and values of what the society deems (Wearing, 1996) to be the virtues of a good woman. Ahmeema and Zuhaira have accepted and internalized the ‘moral code of behaviour’ for a woman to such an extent that it becomes part of their sense of self and identity. What it means to be male or female is formed within the relationships they experience growing up. Such experiences “become internalized into working models of self and other, which are continually reinforced by the environment in which they are formed and in which the person develops” (Hart, 1996, p. 49).

The internalized norms and values of being a good woman result in the women in this study struggling within themselves as they try to balance what society expects of them with what they want for themselves as individuals. I call this the good woman/bad woman tension and as seen in this study, this tension leads to suffering and distress. Thus, though part of Ahmeema does not consider herself a ‘bad’ woman, another part seems to condemn herself for the ‘sin’ she has committed. This is reflected in her words: “It is my fault. I have to take that responsibility myself

182 [emphasis], It is a sin I have committed, is me who went with him [boyfriend]. There is no point in blaming the other person”.

The women in this study have grown up “under the shadow of the gender ideologies” (Connell, 2002, p. 84) related to moral goodness which is defined on the following lines: a good woman does not engage in sexual encounters outside of marriage; a good mother only considers what is best for her children even if that means discomfort and pain to herself; a good wife does not argue with her husband but patiently cares for and obeys him. Even if Maldivian women do not fully embrace these ideologies, they cannot make a complete break from the gender patterns they have grown up with. To do so would mean they are found wanting by society and labelled as bad women, and, as is the case with Ahmeema, ostracized and alienated within her own community. The geographic isolation and close-knit nature of the small island communities in the Maldives make it even more critical for Maldivian women to conform to what is expected of them in society. Failure to conform leads to stigmatization and loss of face, a situation that appears to negatively affect the mental health of women. The impact of being judged comes through in Ahmeema’s words:

...Is it because I have not been educated to that extent [that this happened?] Or is it that I am such a bad person? Actually I am not a person who is a wanderer [promiscuous]. I am better than that. Up till I was 30 [years old] I have never done such a thing [had sex]. But then it suddenly happened. I lost my job. Everything happened at the same time… It is a most heartbreaking thing that could happen to a woman. The way people see her. That could be because her behaviour is bad. Or else the road she takes [morally wrong path]. Different types of reasons. But the way I see it, something could happen suddenly to a woman who has been on her best behaviour.

… The way I see it, when I have been punished for it, then I am no longer a sinner. But people do not see it that way. They see me always as someone who has sinned. I will not say that stain will go away where people are concerned. [ Interviewer: How do you feel about that?] I don’t consider when someone has already been punished for what she did, then she is any longer a criminal. She is like any other person, free. The government has given me the punishment for what I did… I am not a criminal.. a sinner anymore. But what some people say to me… they come in front of me and say these things [I am a sinner]. [ Interviewer: How does it make you feel, when people consider you a sinner?] Sometimes I feel very very sad. I wish I’d never been born. [Interviewer: How does your family treat you?] As the days go by, they start to forget. They have forgotten quite a bit of what has happened. [Interviewer: At the beginning how did they treat you?] I don’t even know how to tell you [laughs]. When I was in the hospital… there were three of my siblings in Male’ then. But only once did each of them visit me [sad tone of voice]. I have a younger brother. He would give even his life for me. He was very very sad. He cried a lot and grieved for me. I wished that I had thought about him even once [what my action would do to him]. Others did not cry. Mom was sad. (Ahmeema)

Ahmeema’s responses also reflect what Jack (1999) refers to as ‘divided self’. On the one hand through the ‘culture’s eye’, she considers herself a sinner. From the time she was a little girl, all through her growing up years in the Maldivian community, she has been taught that to have sex outside of marriage is a sin. She therefore cannot voice her act as anything other than ‘having committed a sin’, even to me since I am from her own culture. She also struggles within herself

183 over how her action has affected her siblings. This was clear in the way she expressed her regrets: “I was so sad… because of how their [siblings] life would be affected. How would my mother also trust the rest of the kids? How will my mother and them [siblings] ever think any good of me?” and “I wished I had thought of him [her younger brother] even once”.

Her responses also portray a dialectical tension between what can be perceived as opposing views. In others’ eyes she is a person who has sinned, an immoral person. As Ahmeema stated, “In others’ eyes… stained for life, a stain that will never go away”. Her concern here centres on how women who have sex outside of marriage are perceived as different by mainstream society (Gatens, 1988). Yet she knows there are others who like her have had sex outside of marriage, who are the same as she is, but have not been labelled as deviant or as sinners. This comes across when she says:

When someone commits a sin in secret and then considers himself not a sinner, why should I consider myself as a sinner? (Ahmeema)

Ahmeema’s words point to her internal struggles. While conscious of others’ negative perceptions of herself and that she has been appropriately labelled different because she transgressed, she is also wanting to regain her sameness, to claim her right to redefine herself as a good person, especially perhaps when others appear to have gone unpunished for the same transgression. This is what she is trying to do when she says, “I don’t consider when someone has already been punished for what she did, then she is any longer a criminal. She is like any other person, free. The government has given me the punishment for what I did…I am not a criminal… a sinner anymore”.

Like Ahmeema, Zuhaira’s attempts to live up to the socially expected standards of being a good woman also show a divided self. This divided self emerges in her words:

Recently I thought of changing my job also. But because I have made a commitment to this job… I think there will be so many people who endure such suffering… If you just let it go whatever happens… But if you want to stick to your social commitment you have to go on… I am not a selfish person. But now I keep thinking… Why should I do this [keep the current job of teaching] just because it is beneficial to some people?... I should think of what is good for me… I keep having this kind of thoughts. My personality is changing. Related to my work it is changing. Earlier I would have never thought of getting out of this field. But now it is always at the back of my mind. How can I get out of this. But this is also a dream. It is the dream of a number of people [students on her island who go for in-service teacher training]. When the program started here it is the dream of so many teachers. So I think about this. But now I tend to think of my own self. This is very sad. I have never at any time had this kind of thinking [of herself only] (Zuhaira)

Zuhaira’s words reflect her inner struggle. She increasingly finds herself “thinking of her own self” yet her professional self wants to live up to the “social commitment” she made and not strike at the “dreams of so many people” who are depending on her to keep the teacher training institute 184 going. In Zuhaira we see a persona who is living up to what is expected of her as a good woman. Zuhaira is highly educated, has a good job, has supportive parents, and plays a prominent role within her community as the president of her local women’s committee. She seems to believe she has failed in one relationship – the one with her husband. It appears that for her what is left is the relationship she enjoys within the community, a relationship that brings her respect and joy. Also a job that brings her professional satisfaction and financial security. So for her it is important to maintain this relationship, the relationship with the community.

Relational feminists such as Gilligan and Attanucci (1988) claim that experiences of inequality and subordination, the reality of women’s lives, give rise to a moral self grounded in human connections and therefore women give more importance to relationships. For the women in this study, these relationships extend beyond their immediate family to the community and the entire social and political fabric of the society they live in. This becomes especially important within a collective society (Dion & Dion, 2001) such as that of the Maldives.

Dion and Dion state that in collective societies (e.g. Taiwan, Singapore, the Maldives) loyalty to the in-group is highly valued and helps protect and look after the need of the individual members of the society. Personal identity based on one’s place in the group is an important characteristic of collectivist societies. In Zuhaira’s struggle to stay on in her current position while suppressing her individual need for seeking a job change I see a similarity to what Dion and Dion’s concept of “personal identity based on one’s place in the group”. Zuhaira is a teacher educator, and the president of the women’s committee on her island. She is therefore expected by the community to be self-LESS and do what is good for the greater good of the community. Thus Zuhaira’s decision to suppress the part of herself that wants to create distance from her ex-husband and his current wife may also at least to some extent stem from conforming to what is expected of her as a good woman in the society she lives in.

8.3.3 Silencing the self

Jack (1987; 1999), in her study of depressed white female physicians, noted that women constantly used moral language such as selfish, bad and worthless in assessing themselves when problems arose in their relationships. She called this ‘the model of goodness’, which differed from woman to woman, but nevertheless contained norms of ‘good wife’, and ‘good mother’. I would add good woman to this within the Maldivian context. She notes this is related to

185 the belief that selflessness is good, and observes that it is a standard that is unattainable and self-defeating in relationships.

According to Jack, women who adopt the ‘model of goodness’ believe that to be loved they have to put the needs of others over their own, which leads to the unspoken notion that “my needs are less important than those of others and they will never be met, or they will be met reciprocally only if I care for others first” (Jack, 1999, p. 224). Such notions arise from the mother-daughter relational position and are internalized through experiences and identification with a mother who is ‘selfless’ and subordinate in her relationship. Thus ‘selfless’ becomes associated in a woman’s mind with ‘goodness’ (morality), with femininity and with intimacy (providing safety from abandonment). It is this notion of being ‘selfless’ that is also expressed in the accounts of Zuhaira and Mariyam.

Culture, gender and silencing the self theory Jack (1999), points out women’s tendency to self-silence is related to culture and gender inequality. Cultures prescribe different behaviours for men and women in terms of expressing emotions. For instance in some cultures it is acceptable for women to cry but not for men. In some cultures such as Balinese culture, both men and women, but particularly women, are expected to control their emotions in public (Wikan, 1990). The same seems to apply to the Maldives as this study shows.

The standards used for self assessment are derived from the individual’s own family context, the current social context and the wider culture. All cultures and societies endorse gender inequality in some form or other. Children are subjected to this during their socialization. As a consequence of such socialisation women tend to view themselves as inferior to men (Fredrickson & Roberts, 1997). But according to Jack (1999) the extent to which women internalize an inferior image of themselves is dependant on social class, ethnicity, and individual history. Furthermore, the gender relations that a woman sees as she grows up powerfully influence women’s image of themselves (Connell, 2002; Jack, 1999). Women who grow up in a family context where they have observed their mothers being submissive in relation to dominating men may incorporate gender inequality into their images of relatedness.

According to the theory of self silencing presented in the earlier part of this chapter, women adopt a self-silencing schema based on social expectations that dictate that they must silence their

186 thoughts, feelings and beliefs if they are to maintain safe relationships. This is reflected in Zuhaira’s words:

There is a social value attached to this [expressing anger]. Society does not look upon women who get into this kind of verbal battle [fighting] as good women. So in this society we keep our feelings bottled up. So in societies with this kind of value, it is more stressful. For example if I am upset with someone for some reason, I would like to say it out… to express what I feel about it. To even yell at the person. To let it out. I will have a peaceful mind if I say it. But then I am unable to do it. This is because the social value I have learnt is that this yelling and shouting is not acceptable. My personal experience is also like this. My divorce. With my ex- husband. There are plenty of things I want to say to him. But I cannot. So it is deep inside me. I want to [stressing the word] pass on the message [with strong emphasis]. But I cannot [sighs] Because of the community I live in. So you keep things inside. You cannot let it out. This will have an impact on your mental health. [Interviewer: So what happens when you keep things bottled up inside for a long time?] Most people suffer silently. Even me. There are so many things, which are personally upsetting to me. But what can I do? I have to keep it bottled up. Sometimes if I can talk to someone it is good. I feel better. But then… Outwardly I look fine. But deep inside… When I lie down on my bed, the feelings overtake me… There will be so many women experiencing this.(Zuhaira)

When Zuhaira silences herself, especially her anger to her husband, by keeping it “bottled up” she is conforming to gender stereotypes, that is beliefs about what men and women do and how they should and ought to behave (Goodwin & Fiske, 2001).

Gender stereotypes exist in all societies and researchers have identified numerous consistencies across cultures. For instance men are stereotyped as having more agency, and being independent, aggressive, and physically strong, but less nice than women; women are more communal, nurturing, caring, emotionally expressive, empathetic and at the same time passive, submissive and weak. These ambivalent expectations about agency and communion are related to traditional gender roles (Eagly & Steffen, 1984).

Images of relatedness such as ‘oneness’, ‘goodness’, ‘self-sacrificing’, ‘pleasing’ (Jack, 1999), that are formed through early experiences of growing up female, guide women to silence vital aspects of themselves and become voiceless, for fear of consequences. Voicing anger, oppositional feelings and demands may have negative economic, physical and interpersonal consequences for women in some cases related to their subordinate social position and relative powerlessness (Christensen & Heavey, 1990; Dobash & Dobash, 1979; Uebelacker, Courtnage, & Whisman, 2003).

The fear and consequences of voicing oneself, as Jack (1999) points out, are related to personal history as well as social context. When Zuhaira expressed her feelings, especially anger, she was given the ‘silent treatment’ by her husband. Aina experienced the same thing. When she tried to talk to her husband about how his parents and his siblings were treating her, he would totally ignore her. Mariyam, finding that she could not cope when her husband brought his second wife

187 to live with them, decided to move to her parents’ place. She took her youngest child, leaving behind the other children and everything else including her clothes. The response she got from her husband was to send over some of her and her child’s clothes and then a total silence. In the end she could not deal with living separately from her older children and her youngest was missing his father. So suppressing part of her own feelings and giving priority to the needs of her children (being self-less), she moved back to her husband’s place to live with him and his second wife. But in Mariyam’s case she is also making a deliberate choice. She missed her children and wanted to be with them. So she gives precedence to this need to be with her children.

The response that Mariyam, Zuhaira and Aina received from their husbands when they voiced their needs and ‘demand behaviours’ for change (Jack, 1999) is similar to what researchers call ‘stone-walling’ (withdrawal through silence or passive resistance) (Babcock, Waltz, Jackobson, & Gottman, 1993; Gottman, 1994). These researchers hypothesize that men’s withdrawal behaviour is an attempt to control women and maintain the status quo of power relations.

One of the consequences of voicing one’s anger and oppositional feeling is that of being labelled a bad woman as Zuhaira points out in her account. Given a social context where women are under pressure to conform to the models of moral goodness prescribed by society, they choose to adhere to the societal norms expected of them. This is not because they are passive but because it is the only way they can deal with what is expected of them and maintain their relationships. So in a sense in silencing themselves these women may be demonstrating agency. They are making a conscious choice to avoid negative consequences (being divorced and losing their relationships, losing the financial security provided by their husbands) and providing a happy and secure environment for their children. Mariyam’s decision to go back to live with her husband and his second wife is an example of this. Silencing the self can thus be seen as a protective strategy to preserve the personal and professional relationships the women value (Demarco et al., 1998). For Mariyam she wanted to be with all her children. So she consciously chose to go back to her husband though she did not relish the thought of sharing the house with his other wife.

While self silencing may be considered an expression of agency, Jack (1999) contends that it is not an either or choice for women. If women choose to be ‘self full’ and express their own needs and feelings the result is either isolation or loss of relationships. If they adopt the culturally defined images of relatedness the result is subordination or loss of self. Either way, they lose and Jack asserts that “this kind of dichotomous thinking creates feelings of hopelessness about the

188 prospects for authenticity and connection”. She argues that if a woman adopts the prescribed attachment behaviours it leads to ‘compliant relatedness’. ‘Compliant relatedness’ although it offers intimacy and safety is characterized by “restriction of initiative and freedom of expression within a relationship” (Jack, 1999, p. 227) and in Jack’s view denotes dependence or anxious attachment behaviour which have a destructive effect on mental well-being.

Consequences of silencing the self In silencing the self, women experience two opposing selves: “an outwardly conforming, “nice,” compliant self trying to keep relationships and to please and an inner, hidden self that is angry, resentful, and increasingly hopeless about the possibility of genuine relationship or self expression” (Jack, 1999, p. 226). The consequence of such silencing is precipitation of self- negation through progressive devaluation of one’s own beliefs and ideas. Studies using the silencing the self scale have reported that such self-silencing is significantly correlated with depressive symptomatology (Carr, Gilroy, & Sherman, 1996; Duarte & Thompson, 1999; Hart & Thompson, 1996; Jack & Dill, 1992; Thompson, 1995).

The consequences of silencing the self, on the health of women, are reflected in the experiences of Aina, Mariyam and Ahmeema. Aina’s self-silencing has resulted in subordination or loss of herself as a consequence of which she finds herself constantly angry and unable to control her emotions, to the extent that she is afraid of totally losing control: As was mentioned in Chapter 6 Aina found her self unable to control her anger. She wanted to throw things and destroy them. Her inability to control her anger was making her anxious because she was afraid of what her anger may do to her children. In addition to the anger Aina experienced at having to ‘silence herself’, she also felt nauseous most of the time, had no appetite and was having difficulty sleeping.

For Mariyam, silencing herself led to bouts of crying, being unable to sleep, not having an appetite and even at one point to suicidal thoughts. For Zuhaira, keeping her feelings bottled up provoked feelings of “being trapped”. At times she felt she had no control, that she was powerless to do anything to make her life better. She found herself thinking that her life had been a failure as these words of hers reveal:

189 In some ways my life is destroyed. I have nothing to show for it. I don’t own anything. I have not achieved anything. When we have shared thirteen years of our life together, today there is nothing… What have I got? So that is on my mind… Because my mind is unsettled I cannot make a decision. Also I think I have failed once [in marriage]… I do not want to be a failure again. So it is very unsettling. I keep thinking of failure. Since this happened once I am even afraid of giving my trust to someone a second time. In my mind I realize I have done something wrong. That is why it failed. But then again I cannot accept this to be the case. I also wish I could forgive [him]. Fifty-five times a day I think then this will be over. But the moment I see him I get so very angry. I am so very angry. I keep thinking his life is so good… so comfortable… he’s got his house built… he has got this… he has got that… what have I got? Perhaps it is only human to feel this way? I cannot do anything to stop these feelings… If I had a knife I would kill him (laughs) But this is something I am only saying [killing him]. I wish I could turn back the clock. Not to have chosen him. But what to do? (Zuhaira)

8.3.4 Gender and power dynamics

Up to this point I have focussed mainly on how gender roles and gender identity have shaped the way women experience and embody distress and how gender explains the context in which the women in this study experience suffering and distress. While gender plays a crucial role in contextualizing women’s suffering and distress, as Kimmel (2000) asserts and I would strongly agree, gender cannot be explained without an adequate understanding of power. Power imbalance is the basis for gender inequity. In general terms “to possess power is to have the ability to achieve whatever is desired regardless of any opposition” (Pilcher & Whelehan, 2004, p. 115) Power was defined initially as an exchange between oppressors and oppressed. But later influenced by Foucault’s (1979) theoretical reflections, power was perceived as a concept that filters through all social relations. His views provided a way of moving beyond the notions of power as being merely repressive to a more positive way of challenging power that is the harnessing of power as a form of resistance. Power in the form of oppression of one group by another is an important part of the structure of gender (Connell, 2002). According to Blanc (2001), gender-based power is founded on the social meanings assigned to the biological differences between men and women.

Power ideologies and discourses Feminists from the eighteenth century onwards have strongly argued that gender inequality has oppressed and continues to oppress women, preventing them from having access to the same opportunities, challenges and rewards available to men (Rampage, 1994). Gender inequality is prevalent in both private and public life. It shapes the fabric of male-female relationships and gives rise to power differences within such relationships.

Wearing, in her book Gender: Pain and Pleasure of Difference (1996), provides a comprehensive account of the various feminist views of power that account for gender differences. First Marxist and socialist feminist views where gendered power is related to the means of production within

190 capitalist societies. Second radical views maleness as a material basis of power in patriarchal societies. Third liberal feminism that emphasizes individual struggle and negotiation together with institutional changes as the means for women to gain an equal footing with men and finally post-structural feminism which, like liberal feminism, emphasizes micro-level struggles and negotiations in gender power relationships.

From the above feminist views of gender-related power, and the experiences of the women in this study, it seems to me that radical feminism best describes the gender-related power system of the Maldives.

Power within patriarchal societies Rampage (1994) asserts that patriarchy (male domination in situations where predominant power is unequivocally held by adult men) has contributed to the creation and enforcement of a number of power differences between men and women, especially within the relationship of husband and wife. These include the unequal responsibility that women have for the care of their home and children, a male’s capacity to generate more earnings, the assumption that a man’s needs are what determine the tone and course of their sexual relationships and in some societies, the wife having to give up her name.

The unequal responsibility between husband and wife mentioned by Rampage is reflected in the following field notes from my encounters with Aina.

Aina’s husband will not even lift a finger to help her. Aina has to provide for her family: food, clothing, medicine and everything else. She has to do all the housework alone: all the cooking, cleaning and taking care of the children when she is not at work. Her husband even if he is at home will not lift a finger to help her even with the household chores. As far as he is concerned caring for the husband and children in terms of feeding and taking care of them is a woman’s responsibility. (Fieldnotes, 30th April 2003)

In Aina’s case she also bears the responsibility of being breadwinner for the family, since she is a teacher and her husband does not have a job. The only relief Aina receives from the culturally expected role of a wife is the help she gets from her in-laws in terms of babysitting when she is at work. But, as discussed in the preceding sections, this help is grudgingly provided and Aina is criticized and labelled a ‘bad wife and mother’ for leaving her children with the in-laws and having a job outside the private domain of her family.

Like Aina, Ahmeema, Mariyam and Zuhaira also have the major responsibility for taking care of the home and children with very little help if any from their spouses. While their husbands consider taking care of the home and children to be the woman’s responsibility, they seem on the surface to be quite happy about having their wife share the role of breadwinner, which is culturally 191 and traditionally seen as the role of the male. However whether they are really at ease with their wives role in contributing to the family finances is questionable. Given the economic situation these husbands have no choice except to allow their wives to take on a paid work. In Aina’s case her father-in-law does not like her to work, although the money she brings in is essential. And the husbands seem to control how the women spend the money they earn or at the very least, question and begrudge the way they spend it as Zuhaira’s words reflect:

Even where money is concerned…I would never know how much he earned, what his account balance was. But he would regularly keep track of my account. He would look at the balance on the butt [stub of the cheque]. He would question me what had I spent this cheque on. Sometimes I get so annoyed I think of saying something. But I don’t. My daughter would want a pair of shoes… you know children… they see things in the shops and they may want to buy it… He would say [sarcastically] are we going to open a shoe shop in this house?… Even where toiletries are concerned. The way I see it with the money you earn, you would buy what you use. From the time I was a child and I was in Male’ I did not buy just any old toiletry. So I would buy what I wanted. He would get very angry and upset. (Zuhaira)

Zuhaira’s husband’s commentary on how her money is spent is a sign of how men exert their power, dominance and control over the women in their lives. Despite the fact Zuhaira is bringing home almost an equal share of money, she still has to account for how she spends it. Since she is relying on him for part of the household finances, especially expenses related to the children, and also depends on him for intimacy she does not ultimately challenge his dominance. When questioned about the way she spends her money she chooses to remain silent. Remaining silent in such a situation is what the literature calls ‘adopting benevolent ideologies’ (Goodwin & Fiske, 2001). Not challenging male dominance, according to Goodwin and Fiske, contributes to smooth relationships with men. Smooth relationships with men are beneficial for women at an individual and interpersonal level considering women depend on men for intimacy.

Zuhaira is contributing financially and, not being totally dependent on her husband, she can be considered empowered to some extent. Thus she is able to continue to use agency in the spending of the money she has earned despite her husband’s efforts to exert his dominance and power. This is contrary to the position of some of the other women in this study, who are totally dependent on their husbands for economic security. In such situations the women were totally powerless. The literature indicates that powerlessness has been associated with lack of entitlement or access to resources (Falicov, 1995). This study suggests a similar association, however it appears that cultural norms related to the notions of the good woman also factor into the association. Women at times feel powerless of the perceived threat of losing their children.

192 Dominance and power dynamics within marriage and family Studies which have looked at gender-based power within marriages and within the family have looked at the various strategies and tactics used to pursue the needs and goals of the members within the relationship (Aida & Falbo, 1991; Blanc, 2001; Howard, Blumstein, & Schwartz, 1986). These studies indicate that the resources available to partners were an important component in determining the power strategies used by husbands and wives. Aida and Falbo’s (1991) study of the relationship between marital satisfaction, resources and power strategies revealed that power strategies were used more in imbalanced resource relationships, such as traditional marriage. Females in lower status positions report using more strategies to influence others. In other words women, because of their relatively lower power within the family, assume they will not succeed in influencing their male partner without the use of power tactics to get their voices heard. Negative affect such as withdrawing affection and becoming cold and distant has been cited in literature as strategies used to exert one’s power over the other (Wallston, Hoover-Dempsey, Brissie, & Rozee-Koker, 1989).

The women in this study and also their partners have used various strategies to achieve their needs and goals or to dominate. The following excerpt from my field notes of my encounters with Aina reveals some of tactics Aina used to address her needs. To me Aina’s interventions are ways of expressing agency and taking control of her life. in areas that mattered to her and of avoiding negative impacts on her physical and mental health.

At some point in their marriage her [Aina’s] husband had hit her when he got upset. Once he beat her. When he finished beating her, she said to him, “I don’t want to wear what you have given me and show off to people [that you are a good husband], if this is the way you are going to treat me”. Saying that she had taken a pair of scissors and cut her dress into pieces. This was one of the only four dresses he had ever given her. Also she started telling her friends about his abuse. (Field notes, 30th April 2003)

By beating her, Aina’s husband is certainly showing his power-over (Blanc, 2001; Rampage, 1994) her. Power-over is the ability of one person to exert control over another. Aina on the other hand is perhaps using coercive tactics or as I see it, is expressing agency. Aina knew that she would not be able to talk and reason with her husband. She also did not want to let him continue to abuse her. So she used this tactic, which she knew would have more of an impact than reasoning with him. Telling her friends about the abuse was a way of using cultural norms of morality to her advantage. Being physically abusive is regarded as immoral and against religion and hence an abusive husband will be looked down upon. Despite this such abuse does happen and usually it is shrouded in a ‘culture of silence’. Usually the woman does not want to be embarrassed and shamed by admitting to being beaten by the husband and nor does she want to 193 ‘launder her dirty linen in public’. However, Aina has some power as she is the only income earner within the marriage and this frees her to step out in this way. Aina’s telling her friends about the abuse may also be interpreted as a coercive control technique or indirect-unilateral power strategy. Either way by acting the way she did she has achieved her goal of stopping her husband from physically abusing her. She has taken control of her life and she is able to do so because she is not dependant on him for financial security.

On another occasion Aina’s husband went to another island without informing her. Aina reported him to the island court and informed them that he had not provided child support. So when he returned the court summoned him. This was embarrassing to the family and to him and stopped him from taking off again without telling her. However, Aina’s act was not without some consequences for her. As she explained she had to face the wrath and verbal bashing of her father-in-law.

While Aina was able to use influence tactics to achieve some of her needs and goals, in other areas she remained powerless. She was unable to change her husband ignoring the problems she was having with her in-laws. One way of coping with this situation was to remove herself from the stressful situation by getting a divorce. In fact she had considered this at one point and mentioned it to her husband. He threatened to take her children away from her if she filed for divorce. Here her husband was using his power, since he knew that Aina would be devastated if she had to live separately from her children.

A second alternative for Aina was for them to move to a place of their own where they could live as a nuclear family rather than within an extended family. She had offered her husband money to build their own place and he had agreed to start working on the building. But many months went by and he had never got round to doing it. He was avoiding moving out of his family’s place as perhaps he did not want to leave his father.

What we see in Aina’s situation is not just a man dominating a woman. What we see here is also the power play within a family situation where cultural and moral values dictate the dynamics within an extended family. Aina’s situation shows also how men themselves can be in a powerless situation because of the social expectations placed on them. In Aina’s extended family situation her husband is his father’s eldest son. Taking care of his father falls on his shoulders according to the law which is based on Islamic Shariah. Cultural values also dictate that one does not fight with one’s father and that he is treated with respect. Respect for parents is shown by not speaking harshly to them and in many instances never disagreeing with them or confronting them 194 in any manner. So to look at the situation from Aina’s husband’s point of view he himself is in a sense in a relatively powerless position where his father is concerned. This deconstruction of the power relationships becomes clear in the following entry from my field notes.

Aina told us that one time her father-in-law and her husband’s brother were both nagging her and criticizing her, verbally abusing her. Her husband walked in during this particular incident. He immediately went into his room and lay down on the bed. He looked quite unhappy and Aina gathered that he had overheard how his father and brother were verbally bashing his wife. (field notes, 30 April 2003)

Culturally, if Aina’s husband were to confront his father about this, he would be considered to be disrespectful to his father and taking his wife’s side. He may then appear to be ‘under his wife’s thumb’ and regarded as weak. Therefore he does not say anything. He is in a difficult situation. He cannot let his wife know that he is upset with the way his family is treating his wife without seeming weak and not to defend his wife at all is unacceptable to her. So from Aina’s husband’s perspective he too is powerless and voice-LESS.

These power dynamics within Aina’s family are what Connell (2002) and Kimmel (2000) term as gender relations. Gender relations are arrangements about gender within an institution such as work, family, political institutions, and other social institutions. According to Connell, not all gender relations are direct interactions between women on one side and men on the other. As we see in Aina’s situation discussed above, gender relations can be between men, in this case between Aina’s husband and his father. Whether they are between men, men and women, or women, these relations are nevertheless gender relations and they are being constantly constituted in everyday life. Gender relations dictate who is to do what, the relations within a family and how emotional relations are conducted and these form a pattern that is called a gender regime (Connell, 2002).

Connell asserts that gender practice is powerfully ‘constrained’ in real life. The issue of constraint and the patterns of relationships are captured in social theory with the concept of structure. The structure of relations defines possibilities and consequences and in doing so perpetuates the gender differences as well as the gendered power relations I have alluded to throughout this chapter.

The gender arrangements of a society that involve social structures such as religious, political, and conversational practices play a major role in perpetuating gender differences, gender identity and gender-based power. Power that operates through institutions in patriarchal societies, that is power in the form of oppression of one group by another, is, according to Connell (2002), an important part of the structure of gender. Such power also contributes to women becoming voice- 195 less and power-less, a process that has been documented in the literature as negatively impacting on women’s physical and mental well-being. A similar pattern is seen in the findings of my study as discussed in this chapter.

Institutional power, and subordination of women The role of institutional power on suffering and distress experienced by women is clearly illustrated in the case of Ahmeema. Ahmeema, as was earlier discussed, bore a child out of wedlock and as a result has been subjected to punishment under Maldivian law which is based on Islamic Shariah as explained in Chapter 3. According to Shariah law both men and women are prohibited from having sex with anyone other than their marital partner. The punishment is in theory the same for both sexes for the same act. Yet, when it comes to enforcing the law the ‘gendered structure’ within the legal system provides loopholes for the man but the woman having the womb finds herself biologically hindered from escaping the law.

Within the Maldivian legal system, in a case such as Ahmeema’s where a child has been born out of wedlock, the only way the man is convicted of the ‘crime/sin’ is if he confesses. For the woman the fact that she is pregnant, she cannot deny she is with child. The legal system as practised does not allow for bringing in witnesses and use of lawyers to defend oneself and one’s character. Nor is it set up to use biological evidence such as DNA evidence to prove paternity of the child.

Both Ahmeema and her partner were instrumental in the conception of the child. Yet the gendered legal structure has meant the woman and not the man end up distressed and suffering. Ahmeema and her daughter are both suffering as a consequence of being ostracized and alienated within the community they live. Ahmeema’s words are “stained for life”. Her case shows how both the legal system and the moral values of the society discriminate between men and women. This is a result of the structure of power, a set of social relations with some scope and permanence (Wearing, 1996) within patriarchal societies; a structure which advantages men. According to Connell “there is a core in the power structure of gender in advanced capitalist countries which enables males to control cultural practices, even as they control the productive processes in their own interests” (Connell, 1987, p. 109). Although Connell makes this statement in relation to capitalist countries, my study demonstrates that the statement is just as relevant to non-industrial and non-capitalist countries such as the Maldives.

196 In Ahmeema’s case we also see how man’s ‘position of power’ (Kimmel, 2000, p. 7) ensures that his standards are the standards against which both men’s and women’s behaviour are governed. This is what is portrayed in these words of Ahmeema:

The man [Ahmeema’s lover] was also taken. But he told me before… How could he take the responsibility. Then his life is gone. His job is lost. His career is lost. So he cannot plead guilty. I accept that. The person who can get away, he would try to get away. But how can he say this is not his child. When you see the child, he cannot say the child is not his. His family also cannot. Anyone who knows me or has seen him cannot say otherwise. Even if she is a girl, she does not have any resemblance to me. Even though they say you get four things from your father [local expression], she has got everything from him (laughs). ….. According to what the people there [in the court] said, he had not tried to disprove he was not guilty. He just said no. They [judges and others] knew. Why he had to be like that. He also would not want to have his entire future… his life gone. (Ahmeema).

The legal system, and all other institutions such as the religious sector, schools, the media and the political system in the Maldives, as with so many countries, is male dominated. Most of the people, especially those who occupy the upper echelons of these institutions are men and they define the situation in their own interests. To borrow from Wearing’s (1996, p. 78) description of Australian society, which also applies to Maldivian society:

Male institutional power defines the situation in their own interests. The privileged, the ‘masters’ have defined the roles and structured organizations. People are manipulated into believing their roles (p. 78).

As Wearing points out, if we examine the institutions of the society and the ideologies which bolster them we come to realize how men have influenced the society in ways that advantage them and in the process women’s rights have been inadequately protected. Thus within Maldivian society, the legal system, and even the cultural values of the community, judge Ahmeema and her lover differently. Granted in Ahmeema’s case if she did not become pregnant she would not have been ostracized. But to borrow Kimmel’s (2000, p. 87) words, this is a case of “biology provides the raw materials, while society and history” [and religion – my words] “provide the instruction manual” (p. 87) that is used to construct how men and women are to be judged and valued.

In present-day Maldivian society sex outside marriage happens as in every other society, and the majority of political, religious and community leaders turn a blind eye to it. At the same time within the confines of the private conversations the woman is at times labelled a ‘slut’ if she has had many partners, whereas a man will not be judged the same way. This is a reflection of how masculinity and femininity are socially constructed and sexual double standards are arrived at.

The sexual double standards that legitimize greater sexual freedom and rights of sexual determination (Blanc, 2001) to men are derived from gender-based power imbalances. In the

197 case of Ahmeema, the small-knit community in which she and her lover live knows very well who the ‘guilty parties’ in the conception of Ahmeema’s child are. Yet it is only Ahmeema who is ostracized. Leaving aside the legal system biased in favour of males that makes it easy for the man to escape being punished, the community itself judges only Ahmeema’s behaviour as discussed above.

Sexual double standards have been observed and documented in other cultures and considered ‘nearly universal’ (Blanc, 2001). Such double standards impact on women’s mental health as seen in the case of Ahmeema and in the literature (Blanc, 2001). Numerous studies also highlight the physical impact of such double standards. As Blanc (2001) states, the social construction of masculinity and femininity impacts on both men’s and women’s health. However, since this thesis focuses on women’s health, I will not elaborate further on the consequences for men, other than to acknowledge that both men and women become victims of the gender struggle, with risks to their physical and mental health.

The above discussion clearly illustrates how gendered institutions perpetuate the subordinate position of women within the society. Ahmeema’s subordinate position and her powerlessness in the face of the existing gendered Maldivian society are captured very well in the following dialogue from our encounter:

A: In Male’ I have not seen anyone, whether male or female who has not done it [had sex outside of marriage]. I: But then it is the woman who has to bear the burden? A: I sometimes think that even the law is one sided. Sometimes I think so. But then I cannot say it. I have not told a lie about the father of my child. I told his name because it is his child. If I can help it I want to look into this. To go to the highest authority even. Do everything possible to show legally that this is his child. But then there is no one who can help me in this. I: It is unfair. Just because he does not show pregnancy he is able to escape? His future is not affected. He also was part of this. You did not do it alone. A: I think so. When I am the only one who is punished… Am I the only one who is guilty? When some people advise me they say he has to take the responsibility. It is he who has destroyed my life. There are some who say that. But most people do not see it this way. Most people see me as the one who committed the crime. To me I am guilty. I: The way you see it you are guilty? A: I am guilty. But I am guilty this way. I went with him somewhere and that is why he was able to do what he wanted. I: So he is not to blame? A: He is also guilty, isn’t he? But people do not see it that way… If I had the power I would get all such couples to get married (laughs). I wonder who can then just get out of it. Sometimes I wish that the law was so. I really wish so. I have lost my job, my future… Not everyone can take on such a big burden. Really. More than a burden…. Without a lot of strength you just cannot face it.

198 Ahmeema lost her job when her employer discovered she was pregnant out of wedlock. She worked in a law enforcement agency and even after the birth of the child she could not get her job back as the civil service code banned employing anyone who had been convicted of a crime within the previous five years. There were many men, even within the senior management, who behaved exactly as she had, yet they were not convicted of a crime as they did not and cannot become pregnant. The gendered institute of law and even the culture appears to have shifted the focus of the sin associated with sex outside of marriage to pregnancy and therefore provided a way for men to escape the consequences. But for Ahmeema her future looks bleak. She has to live in a small community where she has to daily face those who judge and label her as a bad woman. She is unable to get a job on the island as there are very few jobs there. With a young child and no support, especially when the biological father has no legal obligation to provide child support, she cannot go to Male’ and live there. Changing her place of residence to Male’ would provide her with an environment where she has some assurance of anonymity and her actions are not common knowledge. However, not having access to resources, means she has to continue to live on her island depending on her parents to support her and giving up her life’s ambitions of studying and achieving her life’s dreams. For Ahmeema her current context is one where she sees no future for her or for her child. A hopeless situation, a situation where she is distressed and suffering.

8.4 Reflections and Summary

This chapter illustrates that social structures such as religion and politics play a major role in perpetuating gender differences. Gender ideology that is promoted by the various structures within the society affects the social status of women and the social status of women affects their mental health as was indicated in Chapter 2. The cultural and social sources of women’s suffering illuminated in this study, clearly points to the need to go beyond medical interventions to effectively address women’s mental well-being.

199 Chapter 9 REFLECTIONS AND IMPLICATIONS FOR THEORY, PEDAGOGY AND SERVICE PROVISION

In this chapter I bring together the major findings from my study and reflect upon the implications of these findings for: theory, pedagogy, service provision and future research.

I began this thesis by questioning the notion that the biomedical model of mental distress is universally appropriate. I called attention to problematic elements of this model, in particular those based on the assumption that meaning systems related to illness are similar across cultures. In my discussion of the literature I highlighted discourses about cultural differences in explaining and experiencing suffering and distress. A pattern of cultural differentiation emerges in my study and to handle this diversity I propose a multidimensional framework for conceptualising and managing suffering and distress, particularly in women.

My study contributes to the development of culturally congruent and competent approaches to mental health promotion and interventions for dealing with mental illness. It makes the following specific contributions:

For the Maldives, it provides a foundation for the empirical understanding of Maldivian women’s mental well-being and documents some significant determinants of women’s mental health. The data should offer a useful basis for developing mental health policy and mental health interventions and curricula for the training of health care providers in the Maldives. This is a significant contribution as up to this point there had been no empirical study of the determinants of women’s mental well-being for the Maldives.

At the global level, the data adds to the existing knowledge of social determinants of mental health including protective and risk factors for mental illness. The findings also enhance existing knowledge and developments in the area of cultural competency for mental health and health care in general.

The study further illuminates the subjective meanings assigned to mental distress and the cultural processes that foster and perpetuate such meanings. The proposed Mandala for Suffering and Distress may be useful in informing clinicians of the approaches that can be used for exploring subjective meanings and thereby enhancing cultural competency in the diagnosis and management of mental health problems from an emic or client-centred focus. The model may

200 also be a useful tool in developing culturally congruent patient-centred mental health services for clients from diverse cultural backgrounds.

The data provides insights into the complexities of making sense of mental health problems. It contributes to the existing body of knowledge related to cultural concepts and meaning systems for illness causation, explanatory models, the etiology and phenomenology of mental illness and the cultural patterning of mental illness.

I now reflect upon the findings in terms of the above contributions.

9.1 Culture and Etiology

It is now well understood that women try to make sense of their distress and actively seek meaning for the problems they face. The women in my study simultaneously moved between various explanations in trying to make sense of their suffering, pointing to the fluidity of the meaning-making process. Williams (2001) proposes the use of ‘exploratory maps’ rather than explanatory models when a complex set of causal beliefs is involved and this proposal works well for the Maldivian context with its layered explanations for suffering illustrated in Chapter 5. Figure 2 shows the complex nature of the women’s explanations. Many women attributed their distress to the breakdown in their interpersonal relationships but they also held onto the belief that betrayal by significant others in their life stemmed from sihuru (malevolent magic). At the same time they also perceived the breakdown in their personal and social world as their fate and associated the burdens of their life as a test of their faith in Allah. Leventhal (1980) has argued that people seek to identify their illness but if the identification is unwelcome or has socially unacceptable connotations then they may be more vague about cause as a way of maintaining hope and avoiding awkward implications. My study suggests a similar phenomenon is present in the Maldives and adds a further dimension, namely that uncertainty may be a way of coping with unpleasant problems such as being abandoned.

201 Figure 2: Conceptions and explanations of suffering and distress

Bad woman/ Good woman gender tension Naturalworld

BD Gaiga rissun Life’s burdens Hiy Dhathivun 2M Gender T uvun HD bod uru Oppression genetic Fik Of women

Buddhi goasvun Relationship Crazy problems Inherited DM

Insane Supernatural

JM world SP Allah’s Violations of Culture/ gender/ religion will Sihuru Social norms Sorcery

Legend BD: Bodily Distress T2M: thinking too much Idiom of distress RA / etic causes HD: Heart Distress SP: Spirit Possession Causes (emic) DM: Dhuniyein Moya JM: Jinni Moyavun

Figure 2 represents a schematic map for explaining and conceptualising distress. This diagram carries forward and distils the various explanations women provided for their distress which I discussed in Chapter 5. The smaller elliptical shapes represent the aetiological idioms used by the women in this study. These are the salient local terms used to describe the phenomenology of their illness experiences. The rectangles represent the emic explanations provided by the participants and the rectangular shapes with uneven corners represent the etic or the researchers (my) perspective. The arrows indicate the relationships and the directions of the associations. This explanatory framework generated from the findings of this study illustrates the multifaceted and complex nature of how women make sense of their distress. In contrast to psychobiological frameworks employed in biomedical models, this framework articulates women’s experience of suffering as a complex interaction of their material contexts and their physical embodiment. It also articulates women’s beliefs relate to both the natural and supernatural worlds.

9.1.1 Social organisations and mental well-being

The results of this study highlight the role of both formal and informal religion in the mental well- being of Maldivian women. Other studies have explained mental illness within a framework of religious and popular culture in the form of spirit possessions or violations of religious precepts or

202 moral principles (Al-Issa, 2000; Ramisetty-Mikier, 1993; Shweder, Much, Mahapatra, & Park, 1997). They have uncovered illness both physical and mental perceived as God’s will, related to past karma and associated with a fatalistic attitude. Past karma did not feature at all in my study.

In the Maldives Islam plays a prominent role especially when women are faced with distress, sadness, loss, grief, anxiety and loneliness. Islam provided a framework for dealing with the breakdown in their social world. Researchers have suggested that religious faith and spirituality have a beneficial effect on the mental health of individuals and populations, especially with respect to their subjective assessment of well-being (Koenig, 1998; Pardini, Plante, Sherman, & Stump, 2000). Some religious practices have been associated with encouraging altruistic behaviour, and devotional activities that allow people to relinquish psychological control and responsibility for circumstances with minimal self-blame or guilt (Ellison, 1991, 1995). In my study Islam appears to provide Maldivian women with a pathway to relinquish responsibility for circumstances beyond their control. It thus appears to have a protective effect preventing women from progressing along the continuum of distress. This was particularly evident in Azza’s case. According to the women’s own views Islam gave them hope and helped them cope and not let their distress get the better of them. However in some instances I would argue that there may be negative implications stemming from religious ideology. The distress Ahmeema experienced because of being marginalized by some members of her community for having born a child out of wedlock seems to reflect the religious ideology surrounding the act of sex outside of marriage. The cultural values that the community judges her against appear to stem from this ideology. But the application of this ideology is gendered as discussed in Chapter 8. Ahmeema is the one who is ostracized because of the local interpretation and application of the law which accords double standards that advantage men and therefore her lover did not face any punitive action.

Studies from Mediterranean countries, South Asia and the Middle East have shown family and/or religion to be central to mental well-being providing people with the strength to deal with the numerous difficulties in their life (Abela, Frosh, & Dowling, 2005; Al-Issa, 2000; Conrad & Pacquiao, 2005). While my study echoes the findings, of these researchers my data also suggest that institutions of the family and religion can precipitate, perpetuate and prolong suffering and distress through gendered norms and ideology, as discussed in Chapter 8. Rigid, formal and stereotyped roles that dictate the social position of women and discriminate against women, the social control that regulates women’s actions through the ideology of what one might call the good woman, and the cultural perceptions of shame and/or guilt adversely affect women’s well-

203 being. Gender and age play a major role in the social structure and interaction patterns as evident in Aina’s account.

While in contemporary Euro-Western societies mental distress tends to be explained and nuanced within an underlying organic or biomedical framework, my findings support the view that mental distress is context-dependent and defined according to the rules and norms of a given society. Western-derived biological concepts cannot be applied universally to diagnose and manage mental health problems. As evident in Chapters 3 and 8, the social world of the women, especially their significant others (husband/partner, children and extended family), contributed to women’s suffering and distress. However the response to these triggers (being abused, being ignored, and being abandoned) varied and the way in which distress was manifested differed depending on the individual’s level of empowerment, educational background, social status, economic status and the social support available to them (see Chapter 5 section 3 and Chapter 8). These differences in the individual context of the women, the subjective meanings they gave to their distress and their response to stress-provoking events have implications at a clinical level. The medical practitioner needs to consider the woman’s total life situation, their subjective meanings and their individual contexts when diagnosing and in interacting within the therapeutic relationship. The helping profession needs to adopt a ‘cultural gaze’ when history-taking, in making a diagnosis and in managing the healing process, if treatment is to be effective.

9.1.2 Meaning systems for illness causation

Findings from this study are consistent with Kleinman’s arguments that illness and disease occur within a cultural and social context and that human groups explain illness within contextually embedded meanings (Kleinman, 1988). Illness is defined by Kleinman (1977) as the personal, interpersonal, and cultural reaction to disease and disease is a malfunctioning or maladaptation of biological or psychological processes. As Warin (2000) too found in her anthropological research of Australians diagnosed with schizophrenia, illness experiences should not be interpreted within a ‘singular framework’. The meaning system for illness causation derived from my study differs from and stands out from what is commonly understood within a medical framework, in three main respects.

Material versus non material illness causation Material causes relate to tangible explanations that can be seen concretely, such as a change in brain serotonin levels or something happening to the physical body. Non-material causes relate to

204 the spiritual, supernatural and mystical explanations that are not visible in a concrete way and the material context of the body. Women and traditional healers in my study did not emphasize the material aspects of embodiment, but rather tended to relate their distress to the association between the supernatural world and their relationships and the social circumstances of their lives. For instance traditional healers attributed supernatural causes such as sihuru to loss of job or wealth that resulted in suffering. Non-material explanations featured in every one of the women’s accounts as was discussed in Chapter 5. Many of them used traditional healing methods to address the non-material causes of their distress, such as sihuru or jinni possession (see Chapter 7). Or the distress arising from a breakdown in their social world was dealt with through jinni moyavun in the case of some of the women. (See Chapter 6). Women relied on the power of the Qur’an and prayer to deal with what they believed to be a ‘test of their faith’.

The conceptual distinction between material and non-material causes of illness has implications for the pathway of help-seeking.

Mind/Body dichotomy Contemporary Western medicine differentiates mental and physical illness informed by Cartesian dualism according to which mental illnesses were considered diseases of the mind and different from diseases of the body. My study suggests Maldivian women and traditional healers do not separate the mind and body, but have a more holistic view of illness as involving mind, body and psyche. Illness experiences were seen as anchored in the physical body but able to travel to the mind (see Chapters 6 & 7). However, with moya-type behaviours women did sometimes consider this to be a problem of the mind only and did make a mind/body distinction.

Concept of the self In the Western psychology literature, self is interpreted in a number of different ways such as ‘ego-pole’, ‘bounded container’, and uniqueness (Kemp, 2003; Markus & Kitayama, 1991). The contemporary Western view of self emphasizes separation and individuality and mental illnesses such as depression are commonly attributed to internal disturbances affecting the physical, psychological and social functioning of the individual. The individual becomes the main focus and depression is often associated with the individual’s failure to deal with the inevitable losses of life. Contrary to the commonly prevailing Western notions of the self, Maldivian women’s sense of self as revealed in this study is embedded in a ‘web of relationships’ (Qin, 2004). The web of relationships include their husbands/partners, children, other family members, friends and even

205 neighbours and members of their community. Neighbours and other community members are particularly important for women who live in small isolated communities such as the Maldives. This was very clearly demonstrated in the case of Ahmeema and Rauna (see 5.5 and Chapter 8).

In the conceptualisation of the self within Maldivian culture, Islam plays a prominent role as mentioned in Chapter 3. For the majority of the women in my study, maintaining their image of themselves as good women/wives/mothers was crucial. It was seen as a way to preserve harmony within the family and community and to maintain their relationships. The literature suggests that the relations of the individual to society are based on a perceived ‘natural’ opposition between the demands of the social and moral order and egocentric drives, impulses, wishes and needs (Scheper-Hughes & Lock, 1987). Women in my study acted within the context of their social relationships and very rarely autonomously, and most of the women considered the socially and morally expected roles of themselves as mothers and wives not as individuals.

Conceptualisation of the self in the Maldives is related to values and beliefs that influence behaviour within a family and community, specifically the values attached to the notions of a good woman. The values uncovered in my study include sacrificing oneself for other, willingness to suffer, selflessness, ideas of tolerance, muting hostility, containing disagreement and avoiding disputes and saving face as virtues of a good woman. While these values made women vulnerable to distress, they also served as protective factors for some women and under some circumstances. For instance considering the needs of children or one’s parents or a significant other could be construed as a sense of purpose in life, something to occupy one’s mind and keep away unwanted thoughts and perhaps even as an aid to resilience. Mariyam’s case, for example, illustrates the positive role of the notions of a good woman. She at one point did have thoughts of killing herself but the thought of her children and what it would do to them gave her strength to deal with a polygamous marriage. In some respects this suggests that the importance given to children’s well-being enables women to develop resilience to protect their children from undue harm. Thus the self-sacrificing and selfless characteristics of women provide children with a loving and caring environment which promotes the well-being of children.

Avoiding disputes and containing disagreement or muting hostility were strategies women used to maintain their social world. Perhaps such tactics are a sophisticated way of accommodation that ultimately has a protective effect on the health of the women. However, for some women such as Zuhaira, being voiceless to express their own concerns and becoming ‘self-full’ provoked distress, as discussed in Chapter 8. The concept of ‘self as a web of relations’ can be both protective and

206 a risk factor. Cultural values of the family, being neighbourly and having community spirit serve as social capital that provide women with a sense of identity and belongingness as well as a social support network. At the same time these very values within the geographically-confined, close- knit island populations invite elements of anonymity that may act as a risk factor for mental health.

How self is conceptualized within Maldivian society has implications for mental health interventions such as talk therapies. Western psychotherapy emphasises the autonomy of the self. Within a patriarchal society like the Maldives, autonomy of the self for a woman may be difficult to achieve. Also it is generally expected that doctors and counsellors play a more directive than facilitating role. Therefore it is important in a therapy/helping situation to explore how the individual defines the problem and the consequences of the definition for that individual. Not privileging the therapist’s cultural views over those of the client’s or the family’s contributes to the success of the intervention. By being open and considering the views of the client, a safe environment is created allowing for manoeuvre in the therapist –client relationship.

9.1.3 Culture and diagnosis of mental illness

The findings presented in Chapter 6 reveal that Maldivian women present symptoms of mental distress in culturally specific ways. In this section, it may be appropriate to temporarily consider a psychiatric framework in addressing the manifestations of distress. The following aspects stand out in the patterning of distress in Maldivian women:

• Infrequent or very rare expressions of guilt and suicidal ideation. • Helplessness and hopelessness is not a prominent feature in illness presentation. • Feelings of inadequacy are rarely mentioned. • Presentation of distress as a physical discomfort experienced in the body. • Human organs are used as metaphors. The illness experiences that emerged in my study of what would most likely be diagnosed as depression from the perspectives of Maldivian medical professionals differ from the illness concepts specified in DSM-IV (the diagnostic framework used in the medical model). Previous studies have reported similar patterns suggesting that while some of the symptoms for major depression occur universally others vary across cultures (Conrad & Pacquiao, 2005). For example sad affect and loss of enjoyment were common to populations of Canada, Iran, Japan and Switzerland, but symptoms such as hypochondriasis, previous depressive episodes and

207 sleep disturbance varied. Depression has been categorized as a ‘pathoplastic culture-bound disorder’ (Westermeyer, 1989) and studies have shown cross-cultural variations in prevalence and manifestation (Raguram, Weiss, Channabasavanna, & Devins, 1996).

Diagnosis of patients with mental illness is based on behavioural signs and reporting of symptoms by patients so the clinical judgement and cultural sensitivity of the diagnostician play a major role in the accuracy of diagnosis (Conrad & Pacquiao, 2005). The clinician’s own assumptions and perspectives can influence the diagnosis when (s)he interacts with the patient, as was the case with Ahmeema. Within the clinical interaction, the differences in conceptualization of health and illness, language, cultural values, and ways of communication can influence the accuracy of diagnosis, the appropriateness of the treatment intervention and the client’s satisfaction with the care received and, ultimately, the success of the treatment. Researchers have recognised that successful treatment of disease is dependent on cultural perceptions of health and disease (Majumdar, Keystone, & Cuttress, 1999; Raguram, Weiss, Keval, & Channabasavanna, 2001). Different forms of physical dis-ease and discomfort are the most common presenting symptom of psychological distress and such forms of symptom presentation have been documented in the literature as reflecting suffering and dependency needs, while disguising the affective aspects of common mental disorders (Bhui, Bhugra, Goldberg, Dunn, & Desai, 2001). Somatic symptoms are also a more acceptable way of expressing distress because of the stigma associated with mental illness. This form of symptom expression also reflects the more holistic understanding of mind and body in some cultures. In Indian culture, for example, illness is perceived as a total experience (Varma, 1986) and attacks an individual through the mind, body and soul.

In my study somatization was reflected as a way of communicating and calling attention to the breakdown in women’s personal and social worlds, a way of dealing with the shame and embarrassment of addressing culturally taboo topics such as sex and sexual problems with their husbands. Somatization was also a way of coping with situations that were stressful. The embodiment of distress as dizziness or fainting spells and the phenomenology of jinni moyavun that emerged in my study may be construed as a way of coping with or expressing agency in the case of students facing undue demands from their host families or women experiencing breakdowns in their social world. Such insights are significant both for theory and clinical practice and lend support to those such as Young (1997) and Das (1997) who have argued for a different approach to analysing pain and suffering. In clinical practice this signifies the need for

208 practitioners to listen beyond the physical state of the body communicated through pain and to pay attention to the social and moral realms as well.

As was seen in Chapter 6 and 7, most of the women did not express their distress in terms of ideas of inadequacy or worthlessness. This appears to relate to the concept of self and religious ideologies prevalent in the Maldives. Only Shaheen out of the total of 28 women encountered, expressed distress in terms of inadequacy and worthlessness. Unlike the other participants Shaheen had been diagnosed by a psychiatrist – might this have influenced her way of expressing distress? The absence of thoughts of worthlessness may also be related to the fact that most of the participants in this study had not been diagnosed with mental illness. Is it then possible that most of the participants’ distress was a normal response to the everyday strains of life and not a mental illness? The present study cannot conclusively answer these questions. But what is important is the possible implication of women’s experiences and their subjective meanings for their well-being. From a positive mental health perspective (Rowling, 2002) it appears that their distress and their social and cultural context is significant irrespective of whether there is a medical basis or whether their distress can be classified as a mental illness.

Neither did most of the women express their distress in terms of hopelessness and this may have been for similar reasons to their not using notions of worthlessness. Or, as discussed in Chapter 7, it may be related to the Islamic belief that hope only rests with Allah. If one gives up hope that may be interpreted as not having faith, or not trusting and believing in Allah. Suicidal ideation was not expressed by most women and this too may be related to the influence of Islam. Faith perhaps protects against suicidal thoughts. Or it is possible that because I am a Muslim myself and from the same culture, women did not want to mention such thoughts to me because suicide is considered a sin? This is possible, though four of the women did reveal their suicidal thoughts to me. It could also be that the participants in this study were not so far down the continuum of distress. These are all questions that remain to be answered. There may also be other aspects that may have been silenced because of my position within the community and my previous affiliation with the Department of Public Health. What this study can safely conclude is that somatization is a common way of presenting distress, it is associated with cultural and social norms and it is a culturally accepted way of expressing the breakdown in the women’s social world.

209 9.2 Pathway to help-seeking and dealing with distress

Help-seeking here refers to the various strategies, activities, and practices that Maldivian women engage in to cope with, treat, and resolve their mental health problems. My study shows that factors such as age, socio-economic level, educational level, availability of health services, beliefs related to the cause of the distress influenced the type of help-seeking that women engaged in. The pathway to help- seeking may be explained by the following theoretical constructs:

• Normalization • Control • Stigmatization In Figure 3, I present a framework that illustrates the pathways to help-seeking. I have discussed the pathways in detail in Chapter 7.

Fig 3: Pathways to help-seeking

• self: prayer etc Gaiga rissun •Family Hiydhathivun • friends Fikuruboduvun • T Healers • Biomed healer Normal part of life part of Normal

Jinni •T Healers Moyavun • Biomed healers s Temp LOC - LOC Temp reversible t Buddhi vun i •T Healers - maybe g Dhuniyein • Biomed healer m Moyavun a Legend:

Condition/illness abnormal Help seeking

loss of control control of loss irreversible LOC: loss of control

Normalization Symptoms of distress such as sadness, feeling tired, not having energy, and other characteristics of depression or anxiety were not recognized by most women as an illness and this is the case 210 with many other societies (Jacob, 2001). Rather these were considered as unavoidable and a normal part of being a woman in the Maldivian society. Women perceived that all they needed was to be patient and strong of heart to deal with what was an inevitable part of the harsh life they had. As a result they did not perceive the need for seeking professional help and they only went for professional help when their behaviours and feelings were either considered abnormal as defined by culture and/or not controllable. Hence, in general, women resorted to self-healing to meet their emotional and spiritual needs. Seeking professional help for what is considered a normal part of life would be seen as being weak and therefore not a good woman.

The pathway to care was also centred on the perceived cause of their distress. If women considered that a supernatural cause such as a sihuru or a jinni was involved then they resorted to a traditional healer. It is also possible that choice of pathway to help-seeking reflects the availability and accessibility to mental health services. Mental health services were only present on the capital island. This study did not include enough participants from the capital island to provide conclusive insights into the association between accessibility to mental health services and the pathway to care.

The accounts of a traditional healer living in the capital Male’ and my informal encounters in Male’ do indicate that even in Male’ women did seek help from traditional healers for their illness, both physical and mental. Observations of the diagnostic and healing processes used by traditional healers and biomedical healers show that the former have better rapport and communication with the client. Traditional healers seem to be more attuned to the cultural and social nuances surrounding the breakdown of social relationships and they are well informed of what is going on in their community. They involve the whole family in the healing process in ways that discretely deal with the factors contributing to the breakdown in the women’s social world. Traditional healers do not demand a set fee for their services and the family decides what to pay. The evidence would suggest and show how cultural congruence plays a major role in determining the pathway to help-seeking.

Control and stigmatization My study revealed that for the Maldivian population being in control of their emotions and being able to deal with their various stresses in a calm, controlled and collected way is important. Controlling one’s desires and feelings, especially feelings of anger and jealousy, is embedded in religious ideology and the cultural notions of good woman. Chapter 7 makes it clear that control and stigmatization are linked. When people are not in control of their behaviour, thoughts and 211 feelings, as was the case with moya Mariyam, they face the likelihood of being stigmatized and marginalised. The stigma associated with not being in control and therefore being labelled a moya or crazy person prevented women from seeking help from the psychiatrist locally known as the moyainge doctaru or the mad person’s doctor. Thus the pathway for help-seeking as shown in Figure 2 is dependent on the perspectives of communities and individuals in relation to normalisation, control and stigma.

9.3 The Mandala for Suffering and Distress – a Multidimensional Model

As the findings of my study indicate, suffering and distress for Maldivian women is a multilevel phenomenon that is embedded in the experiences of their everyday lives. For the most part it arises from the gendered power relations within the family and even the community at large. Gender, culture and religion permeate the whole experience of distress. These findings echo Falicov’s (2003) views of distress as a “multi-level and ubiquitous phenomenon” (p. 284).

While the findings of my study are consistent with some of the previous documented studies referred to in the above discussions and in Chapter 2, the meanings tied to the specific cultural context are different in terms of social constructions of illness and approaches to treatment. Based on my findings I propose the Mandala for Suffering and Distress – a multidimensional framework. It is a framework based on Hancock and Perkin’s model of Mandala of Health (1985) described in Chapter 2.

The centre of my model, like the original Hancock and Perkin’s model, consists of three constituent parts: mind, body and spirit. But in contrast to the original model here these three overlap showing that women’s mental health experiences affect the mind, body and spirit in a holistic way. However, in the case of women who are moya (crazy) my participants consider only the mind to be affected. Three circles of nested systems denote the broader influences on mental well-being: the extended family, the community and culture/gendered power relations/religion. These rings are intended to be three-dimensional representing the multifaceted nature of illness experiences.

In the outer ring are the overarching and major influences on women’s mental health that dominate her social world and influence the concept of the self, that is gendered power relations, culture and religion. Within the family and community circles there are four groups of determinants that influence the woman’s health: help-seeking behaviour, the geographical position of the island and the size of the island, the political and economic environment, and

212 human biology. The spirit world too plays a role in determining women’s perceptions of their illness experiences as well as the pathway to help-seeking they choose. The availability of health services and traditional healers influence help-seeking behaviours.

Figure 4: Mandala for Suffering and Distress

community Self Concept

Help Extended Political Seeking family Behaviour & economic environment Sick spirit Care system

Trad’l body Healers mind Human Biology Geography & land

Spirit world

I propose the Mandala for Suffering and Distress as a tool to facilitate the greater understanding of how the social, political, cultural and moral realms surrounding women’s lived experiences come into play and affect their mental well-being. This model has applications for health promotion and health service delivery and may be used by clinicians and other helping professionals as well as educators as a tool to conceptualise mental health from an emic perspective, ensuring that the individual woman’s needs and concerns are given adequate priority. It may also be a useful tool to educate and inform mental health practitioners about the culturally congruent and culturally competent approaches to mental health promotion for Maldivian patients and patients who share their cultural concepts such as South Asians.

213 9.4 Application of findings for the Maldives

This section provides recommendations on how my research findings can be used to acknowledge, respond to and resolve the mental health concerns of Maldivian women. As already highlighted in this chapter and illustrated in the proposed Mandala for Suffering and Distress framework, my findings indicate Maldivian women’s mental health is embedded in their personal, social and cultural context. Hence to address women’s mental health effectively, it is necessary to focus on the ‘total story’ of the women (Antonovsky, 1987). My findings support the approach recommended by Ritchie and Rowling (1997), an approach that emphasises the context women live in, that is participatory and that involves multiple interventions to address women’s mental health. A mental health promotion approach as laid out in the Ottawa Charter (WHO, 1986) is best suited to address mental health of women. Empirical evidence shows mental health promotion to be effective and that it leads to not only improved mental health but to improved health in general and to social and economic development (Albee & Gullotta, 1997; Durlak, 1995; Hosman, 2000).

WHO has produced a number of policy documents and guidelines to address the global mental health problem (WHO, 1981, 2003, 2004a, 2004b), and the Jakarta Declaration on Health Promotion (WHO, 1997). The UK Department of Health (2001) and Commonwealth of Australia (2000) have also developed guidelines for mental health promotion. Recent works by Goldberg and colleagues (2000), Jacob (2001), Herman (2001), and Lester and Gask (2006) provide valuable insights into the concept of mental health promotion and models of care. I draw upon all these documents, my research findings and my professional experience in the Maldives in making the recommendations that follow.

9.4.1 Public policy that promotes mental health

At the present time no mental health policy exists in the Maldives and there is no national mental health program, mental health legislation or budget for mental health. The primary sources of mental health financing are the patient, the family and grants (WHO, 2001). Mental health is currently not a part of the primary health care system. A crucial first step then is to develop a mental health policy that emphasizes gender mainstreaming particularly in research. My research suggests such a policy needs to take a holistic, ecological approach as strongly recommended by Rowling (2002) rather than an illness perspective. The Mandala for Suffering and Distress I have

214 proposed offers a guiding framework for policy development. The policy on mental health promotion needs to focus on positive mental health and aim for the following:

• Reduce structural barriers to mental health and empower women to enable them to take control of their own well-being. This can be achieved by addressing social determinants of health such as promoting access to secondary and tertiary education for women, economic opportunities for women in the outer islands and equitable gender ideologies that ensure the cultural, social, political and legal status of women, reducing stigma, increasing community awareness of mental health and enacting laws that protect women against interpersonal abuse. • Strengthen the island communities by integrating mental health services into the primary health care system, introducing self-help networks, and forging partnerships with the private and public sectors and the community. • Strengthen the individual’s capacity to engage in promoting mental well-being through interventions designed to increase the emotional resilience and communication and negotiation skills of women. Finally the policy formulation process needs to actively involve women as they are the beneficiaries of the policy and such involvement ensures that the policy is appropriate to their needs. A participatory action approach that involves women and other stakeholders including men and at the same time builds an evidence base is essential to ensure appropriateness and successful implementation of the policy.

9.4.2 Creating supportive environments

My findings show that the absence of economic opportunities for women on their home islands, ideologies related to gender roles, a gendered legal system, and the absence of health services that address women’s needs all contribute to poor mental health in women. Stigma and normalisation of distress prevent women from seeking professional help. The media can play a major role in creating a supportive environment by increasing mental health literacy, reducing stigma, and promoting equitable gender ideologies, understanding of mental illnesses and appropriate help-seeking behaviours for mental health. Other suggested interventions include the empowerment of women which I elaborate on later.

215 9.4.3 Community development

A growing body of evidence shows the strength of community life or social capital within a community is extremely important for the emotional and social well-being of the individual and the community (Wilkinson, Kawachi, & Kennedy, 1998). Community interventions that focus on empowerment and building a sense of ownership and social responsibility among community members are proven ways to improve mental health. Community development is a people- centred approach that aims to develop the social, economic, environmental and cultural well- being of communities with a special focus on marginalised members. It is a participatory process that emphasises the identification of solutions to community problems based on local knowledge and priorities (WHO, 2004b). Community development initiatives need to build the capacity of and involve the women’s committees, traditional healers, Island Chiefs, youth groups, men and the health workers to identify the mental health issues and develop strategies to address these issues.

Community development strategies that directly targeted poverty, inequality, and gender discrimination have been implemented in India which led to significant gains in mental well-being (WHO, 2004b).

9.4.4 Developing personal skills

Personal skills relate to the ability to manage change and to recognize, acknowledge and communicate thoughts and feelings, both positive and negative, and the ability to make and maintain relationships (Commonwealth Department of Health and Aged Care, 2000). The findings of my study showed relationship problems to be a major factor in the mental health of women and the process of ‘silencing the self’ that women adopted to maintain their relationships led to emotional distress. Women in my study expressed powerlessness, hopelessness and feelings of not having control over their life. A sense of worthlessness and lack of confidence also emerged though to a lesser extent. Therefore it is important to build women’s skills in communicating and expressing feelings and concerns and negotiating with significant others so that they are able to resolve their interpersonal problems. Interventions need to focus on increasing individual feelings of self-worth and empowerment, on fostering the belief that women can control and influence their life experiences while accepting those aspects that are beyond their control. It is strongly suggested that the self-help measures uncovered in this study that serve as protective factors be emphasised and encouraged in any interventions to develop personal skills.

216 Health promoting schools have been established as a successful settings approach to health (Rowling & Jeffreys, 2000) that has improved competence and self-worth and decreased emotional and behavioural problems (Durlak, 1995; Greenberg, Domitrovich, & Bumbarger, 2001; Kellam, Ling, Merisca, Brown, & Ialongo, 1998; Tobler, Lessard, Marshall, Ochshorn, & Roona, 1999). The Positive Youth Development Programme (PYD) is another example of a successful school-based programme that was aimed at middle and high school students and focussed on building problem-solving skills (Caplan et al., 1992).

9.4.5 Reorienting health services

The findings of my study show that the meanings women attached to mental illness, the explanations they provided for the causes of their distress and the ways in which they presented their distress cannot be confined to clinical nosology and the diagnostic frameworks provided in the medical model. When clinicians in the Maldives used the medical model it sometimes resulted in misdiagnosis and inappropriate treatment. This study also highlighted that health care providers were not adequately aware of the cultural context of the mental health of women and lacked the confidence to talk about culturally taboo topics such as sex. Many of the women sought help from traditional healers for their suffering and distress. Traditional healers were aware of the personal and social contexts of the women’s suffering but particularly concerned with the medical aspects of mental illness. These findings show that a reorienting of health services along the following lines may be useful.

Concerning the training of health care providers: Provide training in culturally competent and congruent mental health care for all health care professionals and integrate mental health into the primary care system. With appropriate training and supervision, non-physician primary health care workers can learn to diagnose, treat and manage mental illnesses. This has been demonstrated in countries such as Pakistan, Iran and China (Goldberg et al., 2000). In Thailand too village-level health workers were trained to detect individuals with depression and those at risk of suicides using basic helping skills. This intervention achieved a significant decline in suicide rates and this model is being replicated in other countries (Desai & Isaac, 1998). It is suggested training be aimed at cultural competence and focus on the following:

217 • Building skills related to the recognition of mental illness through a ‘culturally informed inquiry’ (Raguram et al., 2001), client-centred management of mental distress, communication to build confidence in talking about culturally taboo and sensitive topics, recognition of when to refer to a specialist and possible signs of interpersonal violence, and culturally congruent counselling. • Imparting knowledge related to the cultural context of mental health, cultural metaphors used for expressing distress, meaning systems for illness, and the gender perspectives of mental illness. WHO has developed a number of training guides and these together with my Mandala for Suffering and Distress may be used as training tools. • Promoting attitudes that are non-judgemental and sensitive to the specific needs and concerns of women. • The Maldives’ health system relies on a number of expatriate doctors from countries such as India, and Russia where the meaning system for mental illness is different. My study indicates expatriate doctors are not fully aware of the cultural context of mental illness in the Maldives and therefore I suggest all expatriate doctors be given initial training in cultural competency for mental health care in the Maldives and be provided with a package to guide them on the key issues highlighted in this study. A number of guidelines have been produced by countries such as Australia and Canada for culturally competent health care and these may be useful frameworks for developing training packages for the Maldives.

Involvement of traditional healers in mental health My study indicates the manner in which many of the women encountered had sought help from traditional healers. It also reveals that traditional healers while not particularly concerned with the medical aspects of mental illness are vitally aware of the personal and social context of distress and in addition trusted by the women and their families. My findings suggest it would be useful to integrate these traditional healers into the health care system, particularly at the community level, and especially in the islands outside the capital. They need to be provided with training to recognize when they need to refer clients to a medical professional. Integration of traditional healers into the mental health services has been implemented in Nepal (Desai & Isaac, 1998), Pakistan and Kenya (Goldberg et al., 2000) and documented as being effective.

218 9.4.5 Empowerment of women

My findings regarding interpersonal abuse are chilling. Women in the Maldives are abused emotionally, physically and psychologically and part of this abuse is related to gendered structural processes that make women powerless and voiceless. Empirical evidence shows that interpersonal abuse is related to women’s unequal position in society (Watts & Zimmerman, 2002) which is linked to their education and economic status (WHO, 2002). It is strongly suggested that interventions to empower women in the Maldives focus on providing opportunities for education and income generation at the island level, reorienting health services to recognize and document interpersonal violence, promoting community efforts to break the culture of silence on interpersonal violence, and enacting legal measures to protect women’s rights and ensure gender equity. WHO’s document World Report on Violence and Health (2002) is an excellent resource to address the issue of violence to and empowerment of women.

9.5 Reflections on method and recommendations for future research

In this study I privileged women’s accounts of their suffering and distress and this enabled me to elicit the subjective meanings of women’s distress, the contextual significance of their suffering, the explanatory maps of what causes their distress, and the cultural, social and personal context of their distress. Choosing ethnography as my method of research enabled me to compare what people said and did and facilitated my obtaining a more in-depth knowledge of the cultural and social context of women’s suffering and distress. It is the qualitative inquiring approach that has allowed me gain insight into the dynamic, fluid and complex nature of women’s experiences and life circumstances and the cultural network of meanings that underpins their experiences. I was also able to generate a terminology and phenomenology of mental distress which is provided in appendix 5. Most of all the approach I used has enabled me to give a voice to Maldivian women.

The data generated from this study provides a foundation for future studies along the following lines. In this current study I explored only women’s mental health and my main focus was islands outside the capital. To gain a fuller understanding of the mental health of the overall population it may be useful for future studies to include both men and women and to cover a wider range of geographical areas. A comparison between the capital island and others may be interesting to see if the place of residence makes a difference in the mental health of the individual.

In this study only two of the 28 the participants had been diagnosed with a mental illness. It would be interesting in future studies to include those with a diagnosed mental illness and compare

219 them with others to find out if there are similarities and/or differences in their subjective experiences and the determinants of their mental well-being.

It may be useful to develop a full range of critical terms used by Maldivians for mental distress. This study provides a foundation and has indicated some of the terms. However, it was confined to women only and did not cover the geographical areas where different dialects are spoken.

Finally it may be useful to develop culturally validated tools and ways of qualitatively and quantitatively documenting the mental health situation in the Maldives and allow for cross cultural comparisons.

9.6 Closing comments

This research has been a challenging experience and a very emotional and personal journey for me. During the past five years of engagement with this study I have been battling physical health problems stemming from arthritis and also other issues in my personal life that have had implications for my emotional and mental well-being. Undertaking this study turned out to be a journey of personal discovery as well. It was a constant struggle not to reveal some of my own experiences that were similar to my participants and share those with them. After all, my participants were divulging to me very personal stories and sometimes I felt I was not reciprocating adequately. Shaheen’s experiences in particular surfaced memories I have been trying to forget. The experiences of other participants reminded me of some of the intimate interpersonal issues I was trying to escape in coming to Australia and embarking on this journey. My field observations at times provoked anger at the gendered institutions that perpetuate ideologies that make life for women more difficult than for men. These emotional reactions were at times hard to keep under control. At the same time I was constantly wary of how they might cloud the analysis and interpretation of my data.

While frustrating at times the journey has nevertheless been one of joy and intellectual satisfaction. I formed very close and cherished relations with my participants and felt a sense of loss when I had to leave my field sites. I have learnt a lot from the women who shared their lives with me. They have enriched my life and helped me to appreciate many things that I have taken for granted in my life. The resilience they show in the face of such hardship gives me comfort and helps me deal with my own emotional battles. The stories of their suffering have made me realize that my own problems are minuscule.

220 The impact my participants had on my life was heightened when I heard the devastating news of the havoc created by the tsunami that occurred on Boxing Day in 2004. The moment I heard the news that it had affected the Maldives, the first thought that crossed my mind was their well-being and I could not rest until I had managed to establish that they were safe and well. The impact of the tsunami brings a new dimension to the suffering and distress of women not covered in this study. The Maldives has not been exposed to this kind of devastation previously and the tsunami has doubtless brought with it issues of post traumatic stress disorder that I suspect will feature in any future inquiry into the population’s mental health. In the past, life on the islands was considered peaceful but following the tsunami, especially for those who lost loved ones, the power of the sea and the islands’ vulnerability to increased sea levels have triggered fear and uncertainty. This adds to the social and cultural challenges women already face in these tiny island communities.

As I come to the end of my thesis I appreciate the wealth of information I was able to gather but realize the gaps that still exist and cannot help thinking I could do so much more. I have learnt that being a Maldivian woman does not automatically mean I know everything about Maldivian women. My participants have taught me there is so much more I do not know about the suffering of women in the Maldives and they have inspired me to want to continue my journey of discovery. Together we can build on their remarkable resilience to break the cycle of suffering and help to ensure that young Maldivian women can in the future reach their full potential.

221 Appendix 1: Map of the Maldives & Study sites

Accessed through www.diving-world.com/maldives.htm; date 28 Aug 2006

222 Appendix 2: Consent Form

223

224 225 Appendix 3: Participants Background Women Participants

Name Particulars Ahmeema 33 years old. Completed grade 7. Single with one child of 2 years old. Never married. Resides in island in North. Aina 30 years old. Completed grade 7. Trained as teacher. Married. One marriage and one husband5. 3 children. Primary school teacher. Resides in island in North. Alisha 40+ years old. Post grad education from Western university. Practicing Nurse. Married with three children. Two marriages and one husband. Resides in Male’. Amani 20 years old. Completed grade 7. Married. Two marriages and one husband. Two children. Resides in island in Male’ atoll. Azeema 40 years old. Completed grade 7. Employed as a Nurses Aide. Married. 2 children. 2 marriages and one husband. Resides in Male’. Azra 33 years old. Completed grade 7. Not employed. Third marriage to third husband. Three children. Resides in island in North, but originally from the South. Diagnosed with schizophrenia. Attempted suicide. Azza 54 years old. Basic literacy. Not employed. Married with 6 children. Third marriage to third husband. Forced into marriage at 14 years. First child at 15. Abused as a child. (Mother of Azra). Resides in island in South. Hannah 50+ years old. Basic literacy. Not employed. Married and no children. Second marriage to second husband. Originally from an island in North but resides in Male’. Hareera 28 years old. Basic literacy. Not employed. Married twice to same husband. 2 children. First marriage at 15. Ifhath 40+ years old. Masters degree. Post secondary teacher. Divorced. Two marriages to two different people. First marriage in early 20s. From Male’. Khadeeja 50+ years old. Basic literacy. Not employed. Widowed. One marriage. Five children. Coerced into marriage at 13. First child at 14. Husband had a mental illness. Resides in island in the South. Maheena 28 years old. Completed grade 7. Not employed. Married. Second marriage and second husband. Two children. First marriage at 20. First child at 20. Resides in island in the South.

5 In the Maldives it is quite common for a woman or man to be divorced and remarry the same partner several times. One can marry same person up to three times and after third time (s)he has to marry someone else before (s)he can marry the same person again.

226

Name Particulars Mariya 40+ years old. Basic education. Trained as a traditional birth attendant. Employed as a cleaner. Widowed. Two marriages to same person. Resides in island in South. Mariyam 50+ years old. Basic literacy. Not employed. Married – older wife in polygamous marriage. 6 children. First married at 19. First child at 20. Resides in Male’. Neena 20+ years old. Completed grade 9. Used to be a teacher, not employed now. Married and one child. First marriage. From Male’ but currently residing in an island in North. Neeza 29 years old. Completed high school. Employed as secretary. Divorced. One child. First marriage at 26. Resides in island in South. Niuma 30 years old. Completed grade 9. Not employed now. Used to be a nurses aide. Married and 2 children. Two marriages and two husbands. Resides in island in Male’ atoll. Rauna 40+ years old. Basic literacy. Has own business – small shop. Married. Three marriages to three different husbands. First married at 15. First child at 16. 4 children all grown up. Resides in island in North. Reema 24 years old. Completed grade 5.Not employed. Married. Four marriages. Two husbands. Two children. First marriage at 15. Afflicted with jinni moyavun. Resides in island in Male’ atoll. Sabeeha 30 years old. Completed grade 5. Not employed currently. Divorced. 5 marriages. 3 different husbands. 7 children under 13 years of age. First marriage at 13 years. First pregnancy at 16. Resides in island in Male’ atoll. Afflicted with jinni moyavun. Shaheen 19 years old. Completed grade 9. Not employed. Single. Sexually abused as a child. Diagnosed with a mental illness. Resides in island in South. Shareefa 30+ years old. Completed grade 9. Self employed. Divorced. Two children. Resides in island in South. Yasmin 18 years old. Not employed. Still in school (grade 9). Single. Resides in island in South. Lives away from parents for – studying. Zuhaira 30+ years old. University education (post grad). Teacher. Divorced. Married twice before to same person. First married early 20s. Three children. From island in South.

227 Biomedical healers

Name Particulars

Dr. E Psychiatrist – Expatriate trained in the region. Over 10 years working in Maldives. Works in Male’. Dr. MA General practitioner trained in Russia. Over 25 years work experience. First doctor to work in the area of mental health. Works in public sector and has a private practice. Works in Male’. Dr. R Physician trained in India. Specialized in general medicine. Over 20 years work experience. Extensive experience working in rural areas. Works in public sector and has a private practice. Works in Male’. Dr. Maldivian Psychiatrist. Trained in Australia. Two years work experience in the Rasheeda field. Works in public sector. Works in Male’. Faheem Primary Health Care worker/ Regional hospital in the South. Two years training in the Maldives as community health worker and one year training abroad in health education. Over 20 years work experience in the rural area. HC doctor General practitioner. Expatriate. Two years work experience in Maldives. Currently working in a Health Centre in the South. Lameer Family Health Worker. Island in South. Over 25 years of work experience in his home island. Naaz Psychologist trained in India. Maldivian. Has private practice. Works in Male’.

Traditional Healers

Name Particulars

Ahmedbey Faith healer (fanditha veriyaa). Also practices herbal medicine (Dhivehi beys). Over 20 years experience. From island in the North. Learnt healing art as apprentice to well known masters in the field. Didi Faith healer (fanditha veriyaa). Specialises in jinni fanditha (exorcism). From island in South. Learnt healing art from books and being an apprentice to other fanditha men. Ilyas Faith healer (fanditha veriyaa). From island in North. Beyya Fanditha plus herbal medicine. Over 20 years experience. From island in South. Learnt healing from being an apprentice of his father who was a well known fanditha man. Nazeer Faith healer (fanditha veriyaa). From island in South. AW Faith healer (fanditha veriyaa). Specialises in jinni fanditha (exorcism). From island in South. Learnt healing art from books and being an apprentice to other faith healers. Over 15 years of practice. Azee Faith healer (fanditha veriyaa). Resides and practices mainly in Male’. Learnt healing from working with father who was a well known faith healer. Later studied on his own from books. Over 10 years of practice.

228 Appendix 4: Vocabulary of Affects & Metaphors Maldivian term English translation Emotion/ feeling/ attribute Explanation of meaning Hiy ali Intelligent heart Intellect Enlightened heart or one who can learn easily and quickly Hiy gaa Heart of stone Unfeeling Describes someone who is unfeeling and has no sympathy for others. Hiy gabu Stupid heart Lacking in intelligence Someone who is genetically unable to learn. Hithu dhaskurun Learning by heart Memorizing. Hiy seedhaa Straight heart Ethical, straightforward Someone who stays true to what he believes in. Ethical person. Hiy gaimu Pleasant heart Pleasing, attractive, soothing Someone or something that is pleasing to look at Hiy maru Dead heart Emotionless, unfeeling No longer able to feel any emotion. Hiy thiri Humble heart humble A humble person. Hiy gadha Strong heart controlled Someone who is in control of one’s emotions or can withstand pain. Hiy varugadha Strong of heart Patient But also denotes strength of Ability to cope with distress character. Ability to bear pain and cope with grief, sorrow and stress. Hiy heyo Kind heart kindness Kind hearted person Hiy bali Weak heart Weak or emotional Unable to control emotions. Easily hurt /upset/ frightened. Hithuga jehun Strikes the heart sadness Reflects emotion of sadness. Strikes the heart and makes a person cry. Hithuga rihun Aching heart Sadness or distress Aching of the heart due to being hurt or something bad done to the person Hiy nuthanavas Uneasy heart panic Indicates a state of nervousness or vun panic or anxiety Hiy khalaas Emptying the heart forgiving Wishing a person well or emptying kurun the heart of bad feelings for another. Hiy faaruvun Wounding the heart Pain, sadness Same as wounding the heart. Hiy halaaku Heart break Extreme distress Displays high negative emotions. Hiy falhaigen Heart splits open Heart broken Emotional outpouring – emotional dhiun response. Hiy ufaa Happy heart happiness Indicates positively displayed emotions. Hiy hamajehun Peaceful heart Calm relaxing, peaceful, A state of satisfaction and fulfillment. satisfied Everything under control Boa falhaigen Head splitting open Too much thinking. Or being Continuous worrying or state of dhiun irritated irritation. Boa haasvun Suffocating head worries Too much on the mind, that one cannot think clearly Boa sakaraaiy Head bad Erratic thoughts Something affecting the functioning vun of the brain. Boluga rissun Aching head worries Aching of head because of too much thinking or too much on the mind. Boa eburun Dizzy head Panic, worries Feeling dizzy. Bolah baruvun Heavy head Worries and anxiety A feeling of heaviness in the head. Mey ga rissun Aching liver Sorrow, grief pain or ache in the chest area. Mey boduvun Enlarging liver Panic, nervousness, shock, nausea fright Mey thelhun Trembling liver Nervousness, fright Happens when someone is shocked or extremely frightened or in a panic. Mey endhun Burning liver jealousy Ley kekun Blood boiling anger Anger.

229 Metaphorical expressions

Maldivian expression English translation and emotion explanation Birun fikkadaigen dhiun The spleen separates from the body fright with fright. Lagodiakah ketheh nuvaane Lagodi means “Adams apple”. The distress expression is used to indicate an extreme form of sadness or distress. Birun meygadu athah So afraid that the liver will come into Extreme fright athuvedhaane my hands Birun thuru thuru alhaa Trembling with fright fright Ladhun maruvedhaane Will die of shame shame Dheloa heevanee The eye is like live coals anger agurugadeh hen Dhebuma goh jahaafa Eye brows are tied anger Hathares fai finivejje Arms and legs are cold State of fright or panic Fai dhashun bingadu The ground slips from under my feet. Fright or extreme dhemigenfi distress Ley machah gossa Blood rising anger

230 Appendix 5: Phenomenology of Mental Health (Emic) Etiological idioms of distress Cognitive & perceptual Birugathun – fright feeling lonely Dhilanegun – burning sensation lack of concentration Dhuniyein moyavun – insanity loss of interest Fikuruboduvun – thinking too much, worrying ominous dreams Gaiga rissun – body aches and pains sadness Haasvun – panic, nervousness seeing things Jinni moyavun – spirit possession suicidal thoughts Moyavun – crazy thinking too much Naaru – nerves worrying Sihuru – malevolent magic worthlessness Somatic Symptoms Behavioural Symptoms Boluga rissun - Headache Aggression Burning Getting angry Dizziness Hitting others Fainting Loss of appetite Hoonugadeh erun – heat Not being able to see Lack of energy Taking clothes off Meyga rissun – chest pain Talking to oneself Nausea Tearfulness Tiredness Throwing things Trembling/ shaking Wandering around Unagaduga rissun – lower back ache Vai – wind Weight loss

231 Appendix 6: Phenomenology of Jinni Moyavun Participant Bodily senstations / Emotions Behavior Alterations in Seeing Things consciousness Habeeba • Aches n pains: forehead, headache, eye. • Pulling hair, beating chest, running around, • Fainting and loses • Big black, huge, human form – • Crawling (crabs) sensation – biting wrist. tearing dress, not eating. consciousness, clenched naked. Red (coal like) eyes, • Someone trying to sexually harass – rape? • Wanting to wonder around – get out of teeth house. • Cannot talk. • Extra ordinary strength – 5 men cannot hold • Not aware of actions/ her down. behavior Naeema • Aches n pains: abdomen, headache, • Pulling hair, tearing clothes, hitting self, • Fainting and lose • Black, huge, grotesque human between eye brows. bruising self, strangling self. consciousness forms. Red (coal like ) eyes. • Intense pain in abdomen – like nails being • Breaking furniture • Not aware of actions/ • Black hens/birds driven. • Attacking people holding her down. behavior • Dreams: snakes, eels • Attacked by black hen. • Wondering around – wanting to get away. attacking/ winding around • Someone trying to sexually harass. • Extra ordinary strength – 10 men cannot neck. • Fear, don’t want to do anything, thinking too hold her down. • Psychic abilities. much, anger, worry, crying. Ahmiyya • Aches n pains: chest, headache • Pulling hair out, chopping hair off, hitting • Fainting and lose • Black, huge woman dressed in • Fever body. consciousness red nat’l dress, long hair, red • Dizziness • Taking off clothes. • Not aware of actions/ eyes. • Someone pulling hair. • Wondering around – going to graveyard or behavior • woman, child and 3 men. 1 • Rash/ pimples on face sea. Man dressed in white flowing • Itching of body (large red ants on body) • Shouting and screaming at husband and robe. • Weak – no energy. child, hitting child. • Jinn appears looking like • Bleeding from mouth. husband, or other family members. Dressed in red or black. Sabeeha • Pain between eyebrows – like something • Pulling hair, beating self, clawing self • Fainting and lose • Dreams: huge black human piercing there. • Tearing clothes, running around. consciousness form watching me bath – • Excessive worry about children’s welfare. • Wondering off to cemetery. • Not aware of actions/ silhoutte. Says he’s been • Uncontrollable crying. • Excessive strength. behavior following me and with me • Beating/ strangling/ biting /tearing clothes always though I don’t see him. off husband Once day I hit jinn with dhani. • Talking to self. So now he will never let me go. 232 Appendix 7: Participants’ Details—Jinni Moyavun

Naeema (female) 30 yrs old, married 2 children. Divorced once and remarried same person Completed grade 8 Spent early years in Male’ to study Used to be a nurse. Currently not employed.

Episode 1 Episode 2 Episode 3 Episode 4

•18 or19 yrs. • 3rd day after marriage • soon after delivery •single • husband from another of first baby. nd • steady boy friend • soon after 2 island • own mother sick. • parents disapprove child. • living in husband’s Took baby and visited of boy friend • older child island away from her. •Boy friend dumps with mom in own family . • mom puts pressure on her and marries other island • Mom upset she her to stay with her. another married man from • living away from •In Male’away from another island husband  divorce parents to study.

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