““A jelly fish stuck to my stomach”: Maldivian A jelly fish stuck to my stomach”: Maldivian women’s experiences of suffering and distresswomen’s experiences of suffering and distress

Husna Razee, Maurice Eisenbruch, Debbie Long, Jan Ritchie

Presentation focusPresentation focus

Research questionMethod and field work Findings Pathways to distress and copingImplications of findings

AIMUnderstand the social and cultural context of suffering and distress for Maldivian women.

Research QuestionResearch Question

RESEARCH QUESTIONHow is suffering and distress in women:

Explained?Experienced and expressed?Dealt with?

OUTPUT• Taxonomy of suffering and distress• Explanatory model

Setting and contextSetting and context Pop: 270,000. 47% < 15 yrs

1190 islands 200 inhabited

Method and Field workMethod and Field work Method of inquiry: Ethnographic study / feminist epistemiological position.

Study Sites: Capital island Male’North: Alifushi, GuraidhooSouth: Hithadhoo, Thinadhoo, Vilifushi

Participants: Women (28)Traditional healers (8)Biomedical healers (8): 3 medical practitioners, 2 psychiatrists, 1 psychologist and 2 community health workersMan (1)

Data collection: Participant observationFormal and informal encounters

FINDINGSFINDINGSEtiology of Distress fikuru boduvun (thinking too much) hiy dhathivun (heart distress) gaiga rissun (bodily distress) moyavun (crazy) dhuniye in moyavun (insanity) jinni moyavun (spirit possession)

Culture as a mirror of distress Embodied metaphors vocabulary for affects

Fikuru boduvunFikuru boduvun – thinking too much – thinking too much

My children. Why won’t they come over here and live here? Aruza [daughter] says these things [insulting and bad things] even when she is okay. She also abuses her kids, physically. So I cannot say it is because her mind is not working (budhdhi goas). She gets angry and does these things. I think about it a lot. [My son] has a temper. But never does things like that. Ali will read and read and study and study so much and he is just barely able to pass. Other kids are not like that. I have to think so much. I am so sad I have to think so much (Azza)

Hiy dhathivunHiy dhathivun – Heart Distress – Heart Distress For twelve years we have been sharing the same room.

Same bed and he does not even touch me. I told him one night that I wanted to make love. He pretended to sleep. Ignored me totally. Even when I am sick and in pain. He ignores me. 12 years like this. No sex. Totally ignoring me. No love given. He says when he goes to the toilet his sexual desire goes away. How can that be? He is 57 and I am 54. So cannot be. 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. One night I even got out of the house – to go and drown myself in the sea. My husband saw me and went after me and got me out. (Azza)

Gaiga rissun – Gaiga rissun – Bodily DistressBodily Distress

The moment he uttered the words, “you are divorced”, it was like something took hold of me. I went cold, my limbs became paralyzed 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)

I have no one with whom I can talk to about my feelings. I cannot share my problems with anyone. So I keep my feelings bottled up inside me. The constant bottling up of my feelings gives me headaches and chest pains. My nerves are also affected because of this emotional suffering (Hannah)

Gaiga rissun – Gaiga rissun – Bodily DistressBodily Distress

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 was so bad for my heart. If he comes in he will shout at me. He will start yelling. When he yells, I lose my appetite. Get pain here (pointing to chest).. get fever and so on. I have told him to say what he wants softly instead of shouting. When he shouts it affects me so much. My neck hurts and all these things happen. (Rauna)

Gaiga rissun – Gaiga rissun – Bodily DistressBodily Distress

Yes after that. 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 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. I went to an ENT specialist regularly… for about three years. He said it is not a serious problem. But then I cannot sleep, cannot sit anywhere peacefully. (Ahmeema)

Culture as a mirror of distress: Culture as a mirror of distress: Embodied MetaphorsEmbodied Metaphors

“Something took hold of me. My limbs went cold. I could not move” (Maria).

“Feels like a jelly fish 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”. “The pain was like nails being driven into me”. “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” (Aruza)

Metaphorical expressionsMetaphorical expressions

Expression Meaning Emotion

Birun meygadu athah athuvedhaan

Liver will jump into my hands.

Extreme fright

Fai dhashun bingadu dhemidhaane

The ground is slipping under my feet

fright

Lagodi akah ketheh nuvaane

My adams apple cannot take it any more

Extreme grief

Birun fikkadaigen dhiun

Spleen will be torn off Extreme fright

Ley machah dhiun Blood is rising anger

Heart as the seat of emotionsHeart as the seat of emotions

Expression Meaning Emotion/ feeling attribute

Hiy gaa Heart is like a stone Unfeeling. No emotion

Hiy ali Heart is enlightened Intellect/ one who is learned/ intelligent

Hiy gabu Stupid One who cannot learn easily

Hiy seedhaa Heart is straight Ethical/ truthful

Hiy thiri humble

Jinni Moyavun – Jinni Moyavun – spirit possessionspirit possession

Bodily sensations/ emotions• aches and pains: headache, pain between the eye brows, intense pain like nails being driven into abdomen. • Crawling sensation (like crabs) biting wrist.• Someone trying to sexually violate the person. • Black hens or birds attacking

Out of control behavior• pulling hair/ beating chest/ running around wildly/ taking clothes off.• wanting to wonder into the sea/ wonder around the cemetery/ walk around aimlessly/ getting out of the house• extra ordinary strength. • excessive crying/ intense anger

Jinni Moyavun – Jinni Moyavun – spirit possessionspirit possession

Alterations in consciousness• Fainting and loses consciousness/ clenched teeth/ rigid body.• Cannot talk• Not aware of actions/ behavior• Does not remember what happened when in the possessed state.

Seeing/ hearing things/ other• Huge, black grotesque human forms with huge eyes burning like coal.• Black hens/ birds• psychic abilities• dreams: snakes, eels attacking/ winding round neck.

Episode 1 •18 or19 yrs. • single• steady boy friend• parents disapprove of boy friend• Boy friend dumps her and marries another• In Male’ away from parents to study.

• 3rd day after marriage• husband from another island • living in husband’s island away from own family .• Mom upset she married man from another island

• soon after delivery of first baby. • own mother sick. Took baby and visited her. • mom puts pressure on her to stay with her. • living away from husband divorce

• soon after 2nd

child. • older child with mom in other island

Episode 4Episode 3Episode 2

Naeema (female)30 yrs old, married2 children. Divorced once and remarried same personCompleted grade 8Spent early years in Male’ to studyUsed to be a nurse. Currently not employed.

Buddhi goas vunCrazy

Pathways to mental distress in women

Dhuniyen moyavunInsane

Gaiga RissunBodily Distress

stigma

•T Healers

•T Healers - maybe• Biomed healer

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Fikuru boduvunThinking too much

Hiy dhathivun Heart Distress

Jinni MoyavunSpirit possession

•Self healing•T Healers• Biomed healers

•Self healing•T Healers• Biomed healers

They [patients] will come and say they have a headache. Or chest pain. When they tell us this, we try to find out why. Did she fall down or.. We will ask some questions like that and try to find out the cause. But we may not find the real cause the first day. She will not come and say the husband is doing this and that. But will say she is having some sort of ache or pain. Then we ask her to come back again. Sometimes we may visit her in her home. During these visits we are able to directly find out what is going on in her life. Then she will say, “last night my husband pushed me, hit me… (Family Health Worker).

Implications of how distress is experienced

Ache or pain. They are not able to talk. 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. That they cannot cope. It is a culture specific syndrome. (Psychologist)

Implications of how distress is experienced

Maybe in our society rather than saying they are suffering from anxiety or depression, expressing their suffering as some sort of ache or pain is more acceptable. And then you get attention. If you have a physical problem this gets attended to. But saying you are anxious and that is making you suffer, people may not consider that as something to be treated. Someone who is admitted for anxiety or depression or anything like this, others may say there is nothing wrong with the person. (Psychiatrist)

Implications of how distress is experienced

For example the elderly – over 50s come mostly with complaints of multiple symptoms like headache, body aches, wind, burning sensation in the chest. When we carry out investigations we cannot find a cause for these symptoms. They find it difficult to relate these to mental health issues. We try to always find the cause and this leads to unnecessary investigations, time and money. For some people it is difficult to relate to the fact that it is because of their feelings of being depressed 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. Some of the more educated group would relate their feelings (Psychiatrist)

Implications of how distress is experienced

ConclusionsConclusions The findings understanding of the

social and cultural context of suffering and distress for Maldivian women health policy and health promotion strategies.

Lessons learnt from this study can be used for developing cultural competency, in the provision of mental health services. These lessons can be particularly helpful for countries such as Australia where there are diverse population groups; for societies where taxonomies are developed within a narrow Western cultural perspective.