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Transcultural Psychiatry
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“A woman’s life is tension”: ! The Author(s) 2020

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distress in poor urban India DOI: 10.1177/1363461520947836
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Saloni Atal1 and Juliet Foster2

Abstract
The mental health of women living in poverty is a growing public health concern, particularly in India where the burden
of illness is compounded by critical shortages in mental health providers and fragmented services. This was an explor-
atory study which sought to examine low-income women’s perceptions of mental illness and its management in the
context of urban poverty in India. This research was prompted by the lack of empirical studies documenting how women
in marginalized sections of society understand mental illness. Data were collected through a combination of 10 focus
group discussions and two individual interviews with a total of 63 women residing in low-income areas of Mumbai. Social
representations theory was used to explore shared meanings of mental illness among women in this setting. Thematic
analysis of the data showed that women use the expression “tension” to talk about mental illness. Tension was described
both as an ordinary part of life and a condition having its origins in more profound gender-related stressors, particularly
pressures surrounding motherhood, chronic poverty and domestic conflict. Approaches to managing tension were
pluralistic and focused on the resumption of social roles. Findings are consistent with other studies in similar cultural
contexts, suggesting a shared, transnational character to women’s distress and the need for scholarship on women’s
mental health in low-income settings to be more attuned to gendered forms of marginalization.

Keywords
gender, idioms of distress, India, resilience, South Asia, women’s mental health

Introduction
subscribed to a medical model, how their understand-
The mental health of women in the poorest parts of the ings relate to their particular sociocultural context, and
world has gained attention as a major global public how they approached the issue of managing their
health challenge with the rise of the Movement for mental health.
Global Mental Health (MGMH henceforth). This
movement is interested in scaling up mental health Women’s mental health in slums
care for low-income populations through the expansion
of mental health services in primary care settings and In the city of Mumbai in India, over 40% of house-
by popularizing strategies such as task-shifting, in holds live in slums or other resource-poor settings char-
which clinical tasks are performed by non-specialized acterized by overcrowding, insecure residential status,
mental health workers due to the shortage of specialists inadequate water access, and inadequate sanitation
(Patel et al., 2011). The present study is part of our access (Chandramouli, 2011). While urbanization
response to the growing interest in the mental health
of women in the poorest parts of the world. Our study 1
Primary Care Unit, Institute of Public Health, University of Cambridge
was conducted in India and aims to document how 2
Institute of Psychiatry, Psychology and Neuroscience, King’s College
slum-dwelling women experience and explain their London
mental health problems. Given the value placed on bio-
Corresponding author:
medical frameworks in programs of research and inter- Saloni Atal, Primary Care Unit, Institute of Public Health, Cambridge CB2
vention promoted by the MGMH (Jain & Orr, 2016), 3BC, UK.
we were interested in the extent to which women Email: [email protected]
2 Transcultural Psychiatry 0(0)

provides many social and economic opportunities, expressions of distress are not only cultural, but are
research suggests that the urban poor face a number also gendered and must be analyzed through intersec-
of stressors that can take a toll on their mental health tional frameworks. Although there are a few qualita-
(Subbaraman et al., 2014). To meet their financial tive studies in the Indian context examining how poor
needs, the majority of slum-dwelling women work, women make meaning around mental illness, these are
but they typically have limited job choices and heavy limited to women seeking treatment in the formal
workloads (Kotwal et al., 2008). mental health care system (e.g., Kermode et al., 2007;
Global mental health studies suggest that poor Pereira et al., 2007). These studies also look at women’s
women may face multiple pathways to disadvantage representations only instrumentally in terms of their
that cumulatively and differentially affect their mental resonance with existing diagnostic categories. A few
health. Women are more likely to be victims of violence notable exceptions are Parkar et al.’s (2003, 2012)
in their homes; emotional, physical, and/or sexual research on the gendered effects of slum life and
abuse is estimated to be nearly 40% among married Snell- Rood’s (2015) anthropological work on relation-
women in India (Malhotra & Shah, 2015). Women al and psychological coping strategies used by Indian
who experience such violence are far more likely to women living in slums.
suffer from depression and alcohol use and to attempt
suicide (Nayak et al., 2010). Cultural norms surround- Theoretical framework
ing marriage and male child preference also precipitate
Social Representations Theory (SRT henceforth) is
distress among women. Studies on low-income mothers
grounded in a consideration of the ways in which
show that they are at greater risk for developing post-
social groups communally make meaning out of the
natal depression if they fail to give birth to sons
concepts with which they come into contact, and how
(Pereira et al., 2007). Deliberate self-harm among
these representations constitute their social realities.
women has also been linked to harassment due to
Social representations have specific functions: they pro-
Dowry-related practices where the bride’s family is
vide groups with ways of understanding and making
expected to provide gifts or money to the groom’s
sense of issues and phenomena that surround them, as
family before marriage (Parkar et al., 2012). Such
well as ways of communicating about them (Moscovici,
data demonstrate that the pathways linking gender,
1984).
poverty, and mental health are complex and that this
SRT was employed in this study for several reasons:
nexus needs to be further investigated (Kruger &
Firstly, SRT stresses different forms rather than hier-
Lourens, 2016).
archies of knowledge and has traditionally been used
by researchers to “give voice” to socially disenfran-
Perspectives of lay women chised groups (Zadeh, 2017). There is a strong tradition
Women’s health problems have traditionally been of work using SRT in the area of mental illness where
defined by expert discourses, and feminist scholars lay knowledges have occupied a subjugated position
have objected to the absence of perspectives from the (e.g., Foster, 2003, 2006; Morant, 2006). Secondly,
women themselves (Ussher, 2010). We see a similar where other theories of public knowledge and attitudes
absence of women’s voices in the emerging literature have been accused of failing to adequately address the
on global mental health. Critical global mental health “social” in meaning-making systems held by individu-
scholars have raised questions surrounding the cultural als, an SRT perspective, dialogically oriented as it is,
relevance of biomedical discourses that are informing provides greater sociological awareness and access to
the work of this movement. Some have argued that a social meaning (Moscovici, 1963). This theoretical
privileging of biomedical frameworks is problematic in openness is particularly important in the present
non-Western cultures, where local explanatory models research given that one of our fundamental concerns
may not reflect dominant Western paradigms is the relationship between representations and gen-
(Summerfield, 2012). Others suggest that an exclusively dered forms of power.
biomedical discourse depoliticizes the issue of mental This article extends knowledge on women’s mental
health and detracts attention away from the need to health in low-income contexts in three key ways:
create supportive social contexts (Burgess & Firstly, in foregrounding women’s own perspectives
Campbell, 2014). Against the backdrop of such cri- on mental illness, our analytical approach marks a
tiques, there has been increasing interest in cultural departure from the bulk of contemporary work on
meaning-making systems and articulations of distress gender and mental health in India, which has tradition-
(e.g., Jain & Orr, 2016). ally been concerned with prevalence rates of mental
In the present study, we add a gendered dimension illness and evaluations of prevention and treatment
to these culturally focused critiques. We argue that programs. Secondly, we take an interest in
Atal and Foster 3

understanding how women’s representations of mental reveal details of their lives (Hey, 2003). FGDs were
health relate to the broader social contexts that they selected as the primary method for data collection to
inhabit. Thirdly, in focusing our study on a non-clinical replicate conditions under which respondents would
sample of women, we aim to highlight endogenous normally communicate and therefore produce insight
resources used by women with a view to supporting into their socially shared frameworks for understand-
efforts aimed at prevention and community capacity- ing and talking about mental illness (Farr, 1993).
building. The two individual interviews were conducted with
women who volunteered to describe their personal
experiences of mental ill health in greater detail. The
Methods
first author decided to interview them individually to
Study sites and sample protect them from stigma and also because it was not
practical for them to provide detailed personal
India scores poorly on measures of gender equality accounts in a group format. The discussions with
(Kishor & Gupta, 2009) and makes for an important them proceeded in the style of an episodic interview
case study for gendered dimensions of distress (Patel, to facilitate depth of inquiry (Flick, 2000). The FGDs
2005). We focus specifically on the city of Mumbai focused on participants’ responses to a vignette
because it houses a large agglomeration of low- describing the fictionalized case of a woman experienc-
income urban areas (Parkar et al., 2003). A total of ing psychological and behavioral symptoms of distress
63 respondents between the ages of 18 and 55 years (e.g., insomnia, social withdrawal, and appetite loss).
currently residing in low-income areas of Mumbai The vignette was designed with reference to previous
were interviewed. Fifty of our respondents were studies on mental health perceptions in the region
recruited in partnership with three non-governmental (Wagner et al., 1999) and piloted for clarity and cultur-
organizations (NGOs) involved with empowering al relevance (see Appendix A). The vignettes did not
women through skill building. An additional 13 mention the names of any mental illnesses, and during
women working as housemaids were recruited through the discussion participants were asked to consider ques-
the first author’s own community networks. The main tions such as “Is this a mental health problem?”, “What
characteristics of the sample are presented in Table 1. do you call it?”, “What kind of care or support does
The number of women to be interviewed was deter- this person need?”, “What care is available in your
mined iteratively using the criterion of saturation that community?”, and “What should be done for this per-
originates from grounded theory methodology (Guest son?” A vignette-based interview methodology was
et al., 2006). The participants who were included in the considered appropriate keeping in mind the stigma
study came from different professions and also repre- attached to mental illness in India and also that partic-
sent different ethnic and religious groups. While the ipants were mostly illiterate. FGDs lasted between 40
sample is not random, the range of women included and 60 minutes on average. They took place in quiet
adds some degree of analytical generalisability (Miles and relatively private locations in the community (such
& Huberman, 1994). as inside participants’ homes, in the local temple, or at
the NGO center), and these locations were chosen by
Data collection respondents themselves. All discussions were recorded
in Hindi using a digital voice recorder.
The data were collected by the first author in 2015 and
2016 through 10 focus group discussions (FGDs) and
two individual interviews. The first author is female, Data analysis
and we believe this facilitated a gendered connection The recorded discussions were transcribed verbatim
or what sociologists call a “short term contract”—pro- into Hindi and then translated into English by the
viding participants the necessary freedom to share and first author and another bi-lingual speaker to facilitate

Table 1. Background characteristics of respondents.

Group Profession Age range Religion Marital status Sample size

NGO A Unemployed (slum- 18–55 years Hindu, Christian, and All married with children 28
dwelling) Muslim
NGO B Beauticians and tailors 18–28 years Hindu and Muslim Unmarried 13
NGO C Sanitary napkin 20–50 years Muslim Some married with 9
manufacturing children
Non-NGO D Housemaids 30–50 years Hindu and Christian All married with children 13
4 Transcultural Psychiatry 0(0)

cross validation. In the process of translation, special Tension

attention was paid to conceptual equivalence, rather
Causes of tension. All women interviewed in the study
than mere line-by-line translation (Temple & Young,
used the English word “tension” in their responses to
2004). The data were coded through a partially induc-
the fictionalized character in the vignette. Tension was
tive and partially deductive framework. In the deduc-
used by respondents to describe a wide range of worries
tive stage, the first author read through all of the
and concerns in their own lives, from everyday hassles
transcripts and coded the data for segments of text
to more profound and chronic sources of distress.
using NVivo software 10. Codes were organized into
Thematic analysis of women’s descriptions identified
thematic categories following Braun and Clarke’s
(2006) method. Themes were defined as: “something three interrelated causal categories: family relation-
about the data that is important in relation to the ships, social roles, and poverty.
research question and represents some level of pat-
terned response or meaning within the data set” Family relationships. Respondents highlighted a
(Braun and Clarke, 2006, p. 82). While the identified number of challenging dimensions of family life that
themes are supported by a number of instances, no contribute to their tension. Those in our sample who
quantifiable criterion, such as repetition, was used. A were married spoke about the tension caused by alco-
data audit was performed to establish consensus holic, unsupportive, and absent husbands and the asso-
between the first and second authors on the allocation ciated lack of companionship and financial support.
of coded transcript material to thematic categories. This is illustrated in the following quotation where a
Communicative validation was employed, and efforts respondent describes the distress of a friend:
were maintained at all stages of the study to ensure
coherence and consistency, and also to ensure the Her husband for 15 years has not gone to work. Her
researcher’s own representations were taken into con- name is Megha. She has three children. She has to take
sideration (Duveen & Lloyd, 1993). care of her mother-in-law. Eating is difficult for her.
She works from morning till evening . . . there is a lot of
Ethical approval tension. So on her own alone what will she do, take
care of school, of her house, her rent, everything.
The study was approved by the Psychology Research Sometimes her children are also sick. Then what will
Ethics Committee at the University of Cambridge.
she do. (Group A)
Informed consent was sought from each individual par-
ticipant who provided verbal or written consent prior For younger and unmarried respondents, tension was
to participation in the group discussions or individual
associated with the death of family members and loved
interviews. Participants were assured of their right to
ones. Although insecurities around economic depen-
withdraw from the interview process at any time and
dency were implicit in their accounts, the primary con-
that their decision about whether to participate would
cern for them was the sudden shock and inability to
not have any bearing on their relationship with the
manage their grief. This can be gauged in the following
NGO. All information provided by respondents was
anecdote, where one of our respondents narrates the
kept confidential from the NGO in concern, aside
case of a young girl she knew who experienced unman-
from cases where NGO representatives were present
during the group discussions (relevant for respondents ageable tension following her mother’s death:
from groups A and B). An NGO representative was
She was a very nice and pretty girl, not more than 16 or
present in these cases to guide the researcher into the
17 years old. Suddenly, her mother died. The trauma of
relevant community location, but only participated
minimally in discussions and did not observe or evalu- the incident had really gone to her head and she went
ate the participants in any way. mad. She started behaving like a child, asking people
for laddoos [an Indian sweet]. Such was the effect of
the trauma . . . She could not even recognize people
Results anymore. (Group B)
In their responses to the fictionalized character, study
participants differentiated between two forms of All our respondents also reported being distressed by
mental affliction: tension and pagalpan (madness). intergenerational conflicts with siblings, parents, and
These were described as varying in their severity and in-laws. These disagreements were described as occur-
causes. Salient aspects of the representation are dis- ring primarily due to financial matters such as disputes
cussed in the following sections, with illustrative over land ownership and pressures arising from having
quotations. to send remittances to their villages:
Atal and Foster 5

I have been feeling very very bad. My head was hurting potentially serious illness. A number of respondents
so much last week that I fainted for a few hours. It was highlighted the somatic and psychological symptoms
because I have been having a lot of tension lately. My associated with tension, which included insomnia,
husband’s family in our village keeps asking us for lack of appetite, palpitations, and a racing heart:
money, you see. There is so much family and money
tension. (Group D) Tension causes you to feel weak and sick. When you
have tension, you can become very tired. Your head
hurts. You keep thinking about the things in your life
Social roles. Respondents across the sample alluded that are going wrong. In the process, you may stop
to tension associated with fulfilling social roles in eating properly as well. (Group A)
highly precarious circumstances. Married respondents
lamented the loss of autonomy after marriage and a In their efforts to manage tension, women relied on
number of them spoke of conflicts with their their own psychological and social resources and did
mothers-in law due to expectations surrounding how not see it as necessary to seek professional help. Advice
they should behave as “good wives” within their new seeking and unburdening through sharing with friends
family unit: “Once you are married, you are under the and kin were most frequently discussed as strategies to
care of your husband and his family. If for some reason alleviate tension:
they are not good to you, then life is hard and there is
tension” (Group A). My friend Manju is like my doctor and I share every-
Unequal gender norms were so central to their rep- thing with her to feel lighter. That is all you need when
resentations that tension was ultimately seen as being you have tension. You just have to feel loved and find
inseparable from the texture of a woman’s life in this
someone to talk to and then all of it comes out of your
setting. This sentiment is evocatively expressed by one
system like dirty water. (Group D)
of our respondents in the following statement: “Didi
[sister], a woman’s life is tension” (Group D).
Several respondents emphasized the importance of
Younger respondents in the study discussed coercive
thinking positively and actively reframing their life sit-
marital norms as contributing intensely to their ten-
uations: “Thinking positively is vital. If today is bad,
sion. In the following quote, a respondent speaks of
tomorrow will be better. That is how I see life. Start
the costs to young girls like her of indulging in roman-
every day anew” (Group D);
tic relationships or even simply engaging with non-kin
males: “Our society is very judgmental about how we
Every person has to create his or her own wajood
speak to men, whether we go to their houses or get too
[character]. As a woman, I feel that I have to fight
close to them. I personally do not look beyond my
for myself, through a thousand happinesses and sad-
work and my home” (Group B).
nesses . . . I have to work to educate my children. It is
Poverty. The experience of poverty was salient in only with this kind of “can do” attitude that we can
women’s accounts of tension. This was particularly make progress. (Group D)
the case for mothers in our study, who frequently dis-
cussed the tension associated with being a “good moth- The workplace was also discussed as a source of dis-
er” within a context of extreme poverty. In her traction from domestic tensions by respondents who
narrative below, one of our respondents demonstrates were in some form of employment:
that her distress is not due to her own hunger, but due
to the agony of being unable to feed her children: Whenever I come here in the morning, before we start
our work, we always talk to each other and share
When our kids are small, we have a lot of tension. We everything that has happened to us. This takes away
have to support them entirely because they are too all our tension. When we go back home, we have a
young to work and earn for the family . . . Sometimes fresh mind. (Group C)
when things are bad and I can’t feed my children, I
start feeling helpless; there is just too much tension. Although these might appear to be positive coping
(Group D) strategies, for many respondents they were shaped by
expectations that women “manage” their problems.
This was especially the case for mothers in the study,
Managing tension. Although respondents in our study who viewed any form of self-care as self-indulgence. In
used tension generically to refer to varied sources of this sense, while women did indeed “manage” on their
stress in their everyday lives, they also saw it as a own, it was at a cost to themselves: “As a mother, we
6 Transcultural Psychiatry 0(0)

have to put our kids before our own feelings and make Eventually, it becomes poisonous and causes you to
a serious effort to move forward in life” (Group A). go mad” (Group C).
A number of respondents also emphasized the ben- Themes of loss and abandonment in the context of
efits of drawing on group-based support networks, romantic relationships also featured centrally in
such as mahila mandals (women’s groups) and church women’s explanations. In the following narrative, one
groups. In the following account, a respondent speaks of our respondents attributes the odd behavior of her
of her reliance on religious faith as a means of coping sister-in-law to heartbreak in her youth: “I think she
with economic insecurity and family conflict: behaves in this way because she is not married. In her
younger days she may have been in love with some
Sometimes I do question the purpose of my life. It can fellow and it did not end well. That’s why she is men-
be very stressful when we are facing financial problems tally off” (Group A).
and I have to deal with all of her [sister-in-law] oddities. Although most spoke of “madness” in stigmatizing
But we are Christians and I believe very strongly in the ways, respondents who were younger and more educat-
power of prayer. Meeting others at Church helps me to ed took a critical stance and questioned the validity of
get relief and manage all of these problems. (Group D)
the label “mad.” They were also sympathetic to the
plight of the “mentally ill” and expressed concerns
Less commonly, women sought advice from medical around their subjective distress, loneliness, and isolation:
doctors. The decision to see a doctor was determined
Personally, I think no one is really mad. If you tell
both by the nature of the women’s financial situation
people they are mad, they will start believing it, even
and the severity of their physical symptoms: “The
if it is not true, and eventually they become like passive
amount of discomfort you are experiencing will deter-
recipients . . . We can really torture people with these
mine whether or not you make the decision to go and labels and unnecessarily harm them. (Group C)
see the doctor. If you can bear it, then you just bear it
by yourself” (Group A); “We always have to think Everyone calls her mad and other insulting names. But,
about whether or not we have the money to go and when she comes to work here, we treat her like one of
see a doctor. Going to the doctor is only worth it us and do not see her as a “mad person.” We don’t
when you are in pain” (Group A). want to be like everyone else in society. We want to
show more love and compassion because that is the
Pagalpan (madness) only way to get the best out of people. (Group C)
Madness was represented as an extreme or abnormal
form of tension. Madness was differentiated from ten- Respondents were generally skeptical of whether med-
sion through its associations with threatening, bizarre, ical doctors alone could help with tackling the problem
and socially inappropriate behaviors, such as talking to of madness, and emphasized the need for both medi-
cine and prayer (dava our dua). Babas (a Hindi term
oneself, showing aggression, and dressing inappropri-
used loosely by respondents to refer to religious and
ately. In this sense, “mad” persons were perceived as
faith healers) were described by respondents as being
having an experience that is qualitatively different from
capable of restoring inner harmony in ways that med-
those experiencing tension:
ical doctors cannot: “I think that when a person goes
mad, they need to find a way to calm their mind.
I feel scared just by looking at these mad people
Medicines cannot do this but the baba, a good baba,
because they behave in abnormal ways. I cannot under-
can” (Group A); “Just as a doctor has medical knowl-
stand them at all. I would not take the initiative to talk edge, the baba has spiritual knowledge and also expe-
to someone who is mad. But with a person in tension, I riential knowledge. Based on this knowledge, they give
will be more naturally inclined to help them. (Group B) us advice which can help us change the way we see
things” (Group A).
Madness was described by respondents as having its However, across sociodemographic categories,
origins both in psychological and social factors. The respondents also questioned the credibility of babas
internalization of tension due to rumination and lack and viewed any kind of engagement with them as
of social support was the most common cause of mad- taboo. Several respondents provided anecdotes of neg-
ness in their accounts: “It is largely because of the ways ative experiences that they (or others known to them)
in which people think that they go mad. When you take had had with babas:
too much tension, you start behaving in strange ways”
(Group C); “If you don’t share your feelings with In my village, there was a girl who was not well. They
others, the tension keeps on brimming within you. went to take her to the baba. The baba took her to a
Atal and Foster 7

closed room. Then he started touching her, holding her On the other, a coexisting sense of fear allows them
hair, and putting his hands all over her body . . . I don’t to maintain distance from the mentally ill in their
believe in these babas. Unmarried and sleazy men who own personal space (Renedo & Jovchelovitch, 2007).
take advantage of young and impressionable girls— The use of the English word “tension” to describe
that is what they are. (Group A) non-clinical mental distress by the respondents in our
study when a Hindi equivalent (i.e., tanav) exists sug-
gests that it carries social and cultural meaning. We
Discussion and conclusion take a feminist reading of our data and argue that
“tension” is used by respondents as a metaphor for
In this study, we were interested in examining how their sense of powerlessness in the face of gendered
women residing in poor urban communities in India oppressions. The quotations presented above provide
talk about their psychological distress. The findings a number of examples where respondents directly
presented above suggest that women’s representations attribute their tension to inescapable conditions of pov-
of mental illness are mediated by broader representa- erty. For many respondents, tension also has its origins
tions surrounding the performance of womanhood in pressures to conform to normative expectations sur-
under conditions of severe poverty. Across group dis- rounding femininity, womanhood, and marriage. To
cussions, respondents said that the character presented conflate tension with psychiatric illness would in our
in the vignette was experiencing “tension” and that this view be akin to medicalizing social problems, such as
was a relatively normal response to stressors in her life. poverty, food insecurity, and gender inequality.
Respondents did not generally think that the character The term tension has been reported in a number of
in the vignette was afflicted by a mental illness. They other studies examining how specific expressions of dis-
equated mental illness with “madness,” and described it tress are used by Indian women (e.g., Halliburton,
as a serious psychological state that results from 2005; Pereira et al., 2007; Rashid, 2007; Rodrigues
experiencing too much tension or from internalizing et al., 2003; Snell-Rood, 2015). Weaver (2017), for
tension. Madness was associated with danger, differ- instance, almost identically finds that middle-aged
ence, and more negative social consequences. women in urban North India attach the label of tension
The distinctions that respondents in our study made to various stresses of modern urban life, including low
between tension and madness resemble lay understand- levels of empowerment, poverty, spousal violence,
ings of mental illness in Western cultural contexts, family conflicts, sexual violence, and feelings of uncon-
where scholars have found that neuroses are repre- trollability. Some scholars argue that tension represents
sented as less Other than psychoses (e.g., Foster, a distinct cultural syndrome and that it is an illness in
2006). It is important to recognize here that there and of itself (Karasz et al., 2013). Although few studies
were ambivalent forms of Otherness in women’s repre- have taken tension as their object of inquiry, Weaver’s
sentations of tension, or what Moscovici called cogni- research (Weaver, 2015; Weaver et al., 2017) on Indian
tive polyphasia (Moscovici, 1984). While the term women with diabetes finds that tension does not map
tension was used in relatively non-stigmatizing ways neatly onto depression or anxiety (as measured by the
and was discussed by respondents as an ordinary part Hopkins Symptoms Checklist-25) and instead includes
of their lives, there was also recognition of its patho- elements of both.
logical character and potential to lead to more serious Similar associations between motherhood, poverty,
forms of illness. and mental health have also been reported in studies
From a social representations perspective, such looking at precipitators of distress among women in
polyphony makes good sense and is a reminder that other cultural contexts. Kruger and Lourens (2016),
representations serve social functions (Wagner et al., for instance, have found that women implicate the
1999). It may be the case that being part of a challenges of good mothering under destitution and
women’s organization sets up a social representational especially the hunger of their children in their accounts
challenge for respondents: how do they accept the of depression. Burgess and Campbell (2014), similarly,
notion of “mental illness” when folk theories and per- find that HIV/AIDS affected women stress poverty,
sonal experiences leave them with a sense of fear? cultural norms surrounding marriage, unemployment,
Perhaps, as Wagner and Kronberger (2001) suggest, and intergenerational conflicts when talking about their
polyphasic representations provide knowledge resour- mental well-being. In the medical anthropology litera-
ces that women can draw on in different social con- ture, a number of scholars have written of the “idioms
texts. On the one hand, rejecting traditional anchors of distress” (Nichter, 2010) that poor women use to
of “otherness” and displaying greater tolerance speak of their psychosocial health problems in the
toward the notion of mental illness enables them to face of economic hardship and inability to effect struc-
claim solidarity with the groups they are part of. tural change in their lives. Rashid’s (2007) study of
8 Transcultural Psychiatry 0(0)

Bangladeshi women, for instance, explores how the measure tension in India (e.g., Karasz et al., 2013;
nonspecific complaint of white vaginal discharge (i.e., Weaver et al., 2015), but additional research is
safed pani in Hindi) connects with profound sources of needed to validate their broader use. Following
distress in their lives. Kaiser et al. (2015), we suggest that taking idioms
In his seminal work, Nichter (2010) argued that such as tension into account also has the potential to
idioms of distress are important as culturally appropri- enhance social and communicative aspects of health
ate forms of expressing stigmatized experiential states. exchange despite the construct’s lack of diagnostic spe-
We extend Nichter’s argument in this article to say that cificity. Although our study has focused on women’s
idioms of distress are not only cultural, but are also understandings of tension, we would advocate that
gendered, and should be examined in relation to gen- future studies examine the ways that men experience
dered forms of disadvantage and vulnerability. and talk about tension as well. It is not clear from
Feminist scholars have long taken the stand that “the the literature whether the use of this idiom is restricted
personal is political.” That women transnationally use to women in South Asia. Comparative studies could
idioms of distress to implicate structural disadvantage provide a more rounded understanding of the signifi-
in their daily lives is revealing of the affective dimen- cance of this idiom of distress.
sions of uneven development and globalization in the In this study, we have demonstrated the importance
lives of women in the Global South (Chua, 2012). of documenting women’s own accounts of mental
We conclude this article with two practical implica- health. By drawing upon SRT, our study has extended
tions of our findings for enriching scholarship on insight into the social roots of women’s psychological
women’s mental health in poor countries. Firstly,
problems and implications for global mental health
respondents in our study understand mental illness in
policy and practice. Our data suggest the need for
essentially social terms through the idiom of tension.
greater sociological reflexivity in programs of research
Tension is directly tied to the material conditions of
and intervention. Importantly, we also argue that the-
their lives and misogynistic norms that govern their
oretical frameworks need to move beyond cultural nar-
behavior in the private and public sphere. They take
ratives to examine how expressions of distress in these
a pragmatic and pluralistic approach to managing their
mental health, placing emphasis on fulfilling gender settings relate to gendered forms of disadvantage.
roles rather than on accessing medical experts. Attempts at supporting women must recognize and
Representations held by this social group are at odds work with the concepts they hold and the social factors
with approaches currently being taken toward treat- that frame their distress.
ment and prevention. India’s National Mental Health
Programme (NMHP) as it currently stands places Acknowledgements
emphasis on enhancing accessibility to mental health The authors wish to express appreciation to the women and
care through transformations within the health community organizations that participated in this study.
system. While in theory the NMHP is meant to be inte-
grative and holistic, studies show that in practice the Declaration of conflicting interests
dolling out of pharmaceuticals is prioritized over psy- The author(s) declared no potential conflicts of interest with
chosocial aspects of treatment, and communities are respect to the research, authorship, and/or publication of this
seen as little more than the geographical setting in article.
which interventions take place (Jain & Jadhav, 2009).
Health system-based reform is of obvious importance Funding
in a large and diverse country such as India, but our
The author(s) disclosed receipt of the following financial sup-
data clearly suggest that there is a parallel need to
port for the research, authorship, and/or publication of this
address the social and ecological factors that are per-
article: The publication of this research project was supported
petuating women’s suffering. This may require activi-
by a PhD grant awarded to the first author by the Gates
ties outside the formal health sector that are aimed at
Foundation.
community empowerment and social development
(Raja et al., 2012).
ORCID iD
Secondly, “tension” appears to be a socially accept-
able expression by which women in this setting com- Saloni Atal https://orcid.org/0000-0001-8814-9907
municate their suffering. Taking gendered dimensions
of tension into account could have implications for References
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• What do you think Savita is experiencing?
stress among type 2 diabetic women in New Delhi, India. • Why do you think she is experiencing these
Social Science & Medicine, 131, 122–130. symptoms?
Zadeh, S. (2017). The implications of dialogicality for ‘giving • Do you know anyone that has had a similar experi-
voice’ in social representations research. Journal for the ence, and can you think of a specific case or
Theory of Social Behaviour, 47(3), 263–278. instance?
• Do you think that some people in your community
are more or less likely to experience these kinds of
symptoms?
Saloni Atal, MPhil, is a PhD student and a Gates schol- • What would you do if a member of your family or
ar at the Institute of Public Health at the University of someone else you know experienced these symptoms?
Cambridge. Saloni is a social psychologist researching • How would you help them?
social, cultural, and political factors that influence • Are there any resources in your community that you
women’s psychosocial well-being, voice, agency, and would use?
development in marginalized settings in South Asia. • Would you take them to a traditional healer, a
Her research takes an interdisciplinary approach, doctor, or to anyone else? If so, what do you think
drawing on sociocultural theories of knowledge, critical this person would do?