Abstract

The biomedical model categorizes certain features of suffering and distress as depression. These same features may receive different conceptualizations within different cultural or religious systems. Islamic approaches to conceptualizing the features of distress, and providing care for persons who display these features may be overlayed on, merged with, or even distinguished from the dominant biomedical model. Clergy play roles as informal mental health helpers, particularly for religious persons. They may also serve as gatekeepers or conduits for facilitating referrals to formal healthcare practitioners. Five clerics at a faith-based organization that serves two small Muslim communities in South Africa were interviewed about their conceptions of suffering that the biomedical model labels as depression. Rooted in their local cultural perspectives, community involvement, religious practice, and help-giving to Muslim persons, social constructionist thematic analysis of interviews with them revealed a nomenclature that contained three main frameworks: (1) depression as a ‘real’ illness, (2) depression as spiritual destiny, and (3) depression as unallowable sadness. The biomedical view informed their conception of depression as a ‘real’ illness, and this idea served as the central framework onto which the other two conceptions were hinged. Clergy legitimized certain features of depression as a ‘real’ illness but indicated that religious illness beliefs cannot be bracketed when serving Muslim individuals. The implication of the study is that mental health practitioners, trained in biomedical ideas, cannot assume that the term ‘depression’ is understood in the same way within different contexts. Clergy can educate health practitioners about these conceptions to improve caregiving and adherence to biomedical interventions.

Keywords: Clergy, depression, Islam, qualitative, religious beliefs, South Africa, thematic analysis

Suffering and emotional distress can have various explanations. The particular explanation for a type of suffering may determine its progression and help-seeking options. Since the arrival of biomedicine, the dominant conceptualization directed at suffering has been categorization as various forms of disease. Biomedicine holds master status as a taken-for-granted presence in contemporary society, and it has assumed hegemonic status as a truth. However, social constructionist critiques consider it to be just one master narrative and one version of describing suffering, among many (Lafrance & McKenzie-Mohr, 2013). Thus, any explanatory model not only serves a diagnostic purpose but also represents a cognitive system that guides both helper and help-seeker toward particular legitimated options for addressing that suffering (Leavey, Loewenthal, & King, 2016).

As part of this enterprise of assisting individuals who are suffering mentally or emotionally, biomedical logic has been incorporated into the knowledge domains of clinical psychology and psychiatry, with the purpose being the classification of distress so that cure or control can be strategized. This has been part of the modernist and positivist enterprise of science as a system to make society progress. Consequently, traditional systems of conceptualizing suffering and emotional pain have eroded, been displaced, or merged with biomedical aspirations. Objectivist science, however, when overlayed onto subjective or culturally specific experiences, results in stigmatization and, despite the stigma that a mental illness diagnosis can provide, patients and medical professionals have resisted the challenges to the DSM’s dominance in categorizing the world (Lafrance & McKenzie-Mohr, 2013).

Using the catch-all phrase ‘mental health’, modern societies have created scientific and medical institutions that cater for various forms of human distress. Mental health care is integrated into government to manage populations, but individuals who view the world with traditional, cultural, or religious beliefs may not always seek help from mainstream healthcare systems. With globalization and population mobility diffusing people across geopolitical borders (Leavey et al., 2016), certain groups are considered minorities amid the western, rationalistic, secular, and Cartesian systems, and some of these religious and ethnic minorities may still consult traditional healers, community leaders, or community helpers. In communities with a strong religious following, the systems of care for human suffering include community leaders such as clerics (Ahmed & Reddy, 2007).

The incorporation of faith-based organizations (FBOs) into mainstream mental healthcare services is thus a complex challenge facing western helpers (Leavey et al., 2016). One complexity is that clergy may hold stigmatizing attitudes as was found in a study of Nigerian Muslim and Christian clerics (Igbinomwanhia, James, & Omoaregba, 2013). If biomedicine is assumed to be the favored model and is integrated into (western) systems that render help, drawing on understandings of clergy’s beliefs about suffering and distress could assist mental health practitioners to gain insight into lay, cultural, and religious conceptions of illness; this may contribute to the provision of more culturally sensitive and inclusive services (Padayachee & Laher, 2014). Access to such appropriate services needs to be facilitated through communication between practitioners and religious leaders (Ali, Milstein, & Marzuk, 2005). This is particularly the case for Muslims who consult clergy before deciding to consult mainstream helpers (Sabry & Vohra, 2013); in these circumstances, clergy’s beliefs determine referral to mental healthcare facilities (Igbinomwanhia et al., 2013). In a preliminary study based on the rationale of collaboration and consultation in culturally sensitive mental health care and the first known to study imams’ recognition of mental illness and consequent referral patterns, Ali and Milstein’s (2012) national American survey of 62 imams found that referral patterns included a willingness to refer to mental health clinicians while intending to continue to provide support to a depressed client versus sending the client away for counseling alone. On average, imams considered that a depressed client, who was presented to them in a vignette, needed help if his condition was to improve. Ali and Milstein (2012) recommended increased collaborative practice with health professionals to bring enhanced care, as opposed to training imams in clinical skills only. The implication of this and other studies advocating culturally and religiously appropriate services is that interprofessional collaboration should be favored over training workshops.

Clergy thus play a role as conduits or gatekeepers for how the allopathic model is taken up by religious minority groups. Leavey and colleagues (2016) present a case for studying clergy and community organizations because they are active in patients’ help-seeking activities and contribute to the intersubjective and power dynamics that shape explanations of suffering. Because previous research focused on patients’ explanations for what has been known as the ‘psychiatric’, this study instead examined clergy’s explanations. When biomedical explanations were used, the clergy’s explanations were unicausal; that is, they attributed mental illness to an imbalance of chemicals, rather than using more sophisticated views. Clergy’s views were found to reflect the views of the layperson too and did not match a dualistic mind-body explanation because the biomedical and spiritual views of mental illness merged (Leavey et al., 2016).

Explanatory mental health models can shape negativistic attitudes. Igbinomwanhia and colleagues (2013) found that 80% of Muslim and Christian clerics in Benin City, Edo state, Nigeria, were fearful of having people who were mentally ill live in residential neighborhoods, and 69% of them endorsed the proposal that mental health centers should be situated outside of residential areas. Except for Leavey and colleagues’ (2016) study that included seven imams alongside Jewish and Christian clergy in London, and Igbinomwanhia and colleagues (2013) whose survey sample included 15 Islamic clergy alongside 92 Christian clergy, research on the topic of clergy’s explanations of mental illness has underrepresented Muslim leadership. A study of clerics at mosques in the United States that used a bigger sample (N=62) reported that imams were consulted for religious, relationship, marital, and social discrimination problems even though they may not have had counseling training (Ali et al., 2005) but, as this was a quantitative survey, the imam’s explanations for mental illness were not accessible. Research on how mental illness has been conceptualized has included both white and African American Christian clergy (Hankerson, Watson, Lukachko, Fullilove, & Weissman, 2013; Haugk, 1976; Neighbors, Musick, & Williams, 1998). Ministers of African American megachurches conceptualized depression as a disease, and causative factors were linked to biology, stress, life circumstances, racism, trauma, and identity crises (Hankerson et al., 2013).

Mental illness is conceptualized as biomedical (as opposed to, for example, religious framing of sin). For practicing Muslims, Islam is a prime determinant of cultural norms, beliefs, meaning-making, and social practices (Ahmad & Harrison, 2007). Questions may be raised about whether such a traditional and perceivably insular system can resist and challenge biomedicine’s infiltration, and whether Muslim helpers, who may be consulted for emotional distress, either engage with, encourage, or collaborate with the biomedical system. Dein (2004) recommended a two-way process for all religious personnel in the United Kingdom to be trained to be able to recognize psychiatric disorders and for mental health practitioners to be educated about spiritual meanings of illness and their impact on clinical decisions. Muslim clients may be hesitant to use healthcare practitioners who are perceived to lack integration of Islamic values into psychotherapy (Sabry & Vohra, 2013), a feature that has been known to characterize many religious groups’ unwillingness to engage with psychologists and psychiatrists (Dein, 2004).

Substantiating this complexity for the mental healthcare system, Muslim general practitioners working in a South African Muslim community disclosed that their patients (known to also consult Muslim clergy) were reluctant to seek help from psychiatrists and psychologists because of stigma attached to mental illness (Mohamed-Kaloo & Laher, 2014). Muslim clergy are thus situated between biomedical and Islamic paradigms that explain and ease suffering and emotional pain. They provide counseling and assist with resolving religious problems associated with health care (Padela, Killawi, Heisler, Demonner, & Fetters, 2011).

Islam offers a religious explanation for illness. Via the concept of divine predestination, suffering can be considered a means of reparation for sins (Al-Shahri & Al-Khenaizan, 2005). The Qur’an describes adversities like illness as a test from God, and an individual is not considered responsible for acquiring a mental illness (Ally & Laher, 2008). Furthermore, Islamic rulings on illness encourage the use of medical treatment for any ailment. Hadith (Sahīh al-Bukhārī Book 76, Hadith 2) reports the Prophet Muhammad to have said, "There is no disease that Allah has created, except that He also has created its treatment”.

The value of Islamic beliefs about illness regarding help-seeking behaviors was shown in a qualitative study with women diagnosed with cancer; qualitative data reflects the participants’ beliefs that Islamic healers function as moderators or mediums through whom Allah heals diseases (Suhami, Muhamad, & Krauss, 2016). Other than encouraging Muslims to seek out medical treatment, a Muslim is encouraged to turn to Allah through prayer during distress or extreme sadness (Pridmore & Pasha, 2004): The significance of prayer during periods of distress is mentioned in the Qur’an (Yucel, 2010) and the stories of prophets encourage Muslims to use prayer as a path to success over hardship (Sadeghi, 2011; Yucel, 2010).

Islamic conceptions of illness present an alternative to those of mainstream biomedical science. Incorporated into biomedicine, the Diagnostic and Statistical Manual of Mental Disorders-5^th edition (American Psychiatric Association, 2013) enables a common language so that people who are suffering may be assisted within consensually agreed upon and socially legitimated ways. This creates the assumption that mental disorders such as depression exist homogenously across varying cultural systems (Patel, 2001), even though the DSM is critiqued to be modeled on the experiences of middle-class white Americans (Kress, Eriksen, Rayle, & Ford, 2005). The medicalization of distress began with the third edition of the DSM (Lafrance & McKenzie-Mohr, 2013), with the effect that it has come to be the “default option for understanding and self-understanding while obscuring other possibilities for meaning and action” (Sutherland et al., 2016, p. 89). The epistemology and ideology of the DSM do not highlight cultural and sociopolitical dimensions of suffering, and isolate the sufferer via the western framework of pathology (Lafrance & McKenzie-Mohr, 2013).

Even the biopsychosocial model, called the “offspring” of biomedicine, reinforces biological and reductionistic explanations (Armstrong, 1987, p. 1216). By espousing the biopsychosocial conception of mental illness, clinical psychology, health psychology, and psychiatry do not offer an alternative to biomedicine, compared to critical (political), existential, or experiential approaches (Crossley, 2000). When terms like syndrome, diagnosis, treatment, and symptoms are used, mental problems become constructed as medical diseases (Gray as cited in Crossley, 2000). Rhetoric such as etiology (even if used by a model that claims to incorporate psychosocial factors) maintains biomedical ideology (Ogden, 1997). The DSM is based on classifications that are amenable to scientific study, which are constructed from experimental data; it maintains a biomedical ideology through its construction of emotional difficulties and through recommending clinical interventions for that suffering (Lafrance & McKenzie-Mohr, 2013). Even if the ‘social’ is claimed to be considered in the biopsychosocial model, such a framework takes a functionalist view of health and illness wherein the cultural and embodied elements are underemphasized (Lyons & Chamberlain, 2006; Stam, 2004). The ‘bio’, ‘psycho’, and ‘social’ are therefore not balanced and the positivist, biomedical assumptions deny subjectivity that allows for care that is sensitive to cross-cultural variations (Benning, 2015).

Nevertheless, the diagnostic and naming function of the DSM, via the medical assumptions, has allowed relief for many patients diagnosed with depression. Through giving a collection of symptoms a label, the diagnosis validates suffering, particularly because it ascribes a medical reality to something a patient has, rather than blaming the person for something that the person him/herself has created (Lafrance & McKenzie-Mohr, 2013). Sufferers are protected in this way: “they are repositioned from ‘being a problem’ to ‘having a problem’. . . . a DSM diagnosis is a powerful resource for individuals in distress as it affords the dual effect of defending their experiences and identities” (Lafrance & McKenzie-Mohr, 2013, p. 126).

Depression symptoms may, however, present a problem for some Muslims. The key controversial biomedical element is that suicidal ideation is considered a symptom, but according to the Islamic belief system, the act of suicide is a transgression (Rezaeian, 2009). Given this viewpoint, suicidal ideation in itself may often lead to feelings of guilt and shame for a Muslim individual (Sarfraz & Castle, 2002). The Qur’an explicitly states, “And make not your own hands contribute to your destruction; but do good; for Allah loves those who do good” (Qur’an, 2:195, 8^th Abdullah Yusuf Ali revised Amana edition). The Qur’an also states, “Nor kill or destroy yourselves: for verily Allah has been to you Most Merciful!” (Qur’an, 4:29). Relatedly, if a person who is not capable of making decisions objectively commits suicide, that person is considered not accountable, for it is God who judges the individual’s actions, and this can assuage the guilt for families of patients who have been severely mentally ill (Sabry & Vohra, 2013).

A further problem with the biomedical conception of depression is the underlying ideology that implies that the features represent a universal condition. The everyday, colloquial use of the word ‘depression’ is often associated with feelings of unhappiness and grief. This ordinary usage does not imply that clinical criteria are being used to describe an individual’s complaint or suffering; instead, an individual may conceptualize and experience symptoms using culturally relevant explanations. Depression, unhappiness, and grief may be understood in some cultural contexts as normal responses to adversity, loss, and severe social or personal threats (Abdul Kadir & Bifulco, 2010).

Even though mental illness conceptualizations across cultures have been acknowledged as having the potential to be controversial, depression in particular may have meanings and conceptualizations that need interrogation to inform better care. Because clergy are the gatekeepers for the constructions of illness in traditional Islamic communities, this study focused on clergy. Clergy may set the tone, as well as choose and facilitate the routes of access to care, and they shape the construction of what they or their congregants may call ‘depression’. This study aimed to explore how Muslim clergy conceptualize, intervene in, and advise individuals living with what they may consider mental illness and, particularly, depression. In other words, we sought to discover their conceptions of mental illness, with a focus on depression.

The DSM represents the dominant model for particular behavioral, emotional, and psychological features that coalesce to become known as depression. The ‘master status’ of the DSM has persisted despite decades of critiques against it, particularly in terms of its individualistic and westernized ideology. Lafrance and McKenzie-Mohr (2013) argue that such top-down processes do not account for the staying power of universalist discourse, because bottom-up uptake of the discourse is an active process whereby people who are suffering find those explanations useful. Focusing on clergy, this study explores how one particular bottom-up process can occur when they facilitate help for people with depression.

Differences in lay explanations for depression have been studied in western and nonwestern contexts. Hansson, Chotai, and Bodlund (2010) noted in a Swedish study that explanations for the cause of depression focused on life stressors. In Iran, Turks, Kurds, and Iranians perceived the cause of depression to be either internal factors (e.g., emotions) or difficult external events (e.g., family conflict; Dejman et al., 2010). A study of Indian women in a low socioeconomic area indicated that almost half of the participants reported suicidal ideation, with some attempting suicide, a marker of depression (Pereira et al., 2007). The women attributed their feelings to difficulties in finances, children’s wellbeing, health, excessive domestic responsibilities, and family members’ problems (Pereira et al., 2007). Despite the lack of biomedical insight, most of the participants had consulted medical professionals for their reproductive and somatic complaints (Pereira et al., 2007). Thus, depression may be understood by lay individuals as an expected reaction to social and personal problems (Kangas, 2009). The lay concepts of depression are thus understood best from within the social worlds that provide meaning to their symptoms.

The biomedical concept of depression may also not be recognized in a community’s understanding of illness, because the word ‘depression’ may hold little cultural meaning or value (Selim, 2010). The differences in help-seeking behaviors and adherence to treatment illustrate the importance of lay, cultural, and religious conceptualizations. For example, cultural beliefs in Norway were found to influence help-seeking behavior—individuals preferred self-help interventions such as rest, exercise, and spiritual activities over treatment offered by mental healthcare professionals (Erdal et al., 2011). Asian women suffering from depression used coping strategies that included prayer, talking, crying, and self-harm (Hussain & Cochrane, 2002). Similar findings indicated that Iranian women found solace in avenues such as prayer, help from family and friends, and positive thinking (Dejman et al., 2009). Iranian women viewed medication and consulting with psychologists as last resorts, primarily due to the stigma associated with accessing psychiatric intervention (Dejman et al., 2009).

The choice to use private coping strategies along with a reluctance to access mental health practitioners can be understood to be influenced by stigma (Cinnirella & Loewenthal, 1999). Dejman and colleagues (2009) call for depression to be publicized as a treatable medical illness to legitimize help-seeking. Family and friends could help patients seek out care; yet, patients’ families and friends could still undermine and discourage treatment and recovery because of negative messages about depression (Garcia et al., 2012). Many participants in Garcia and colleagues’ (2012) study said they were labeled, judged, lectured to, and rejected by family and friends when discussing depression. In this sense, social networks may hinder an individual from disclosing symptoms to mental healthcare providers and from adhering to treatment. It could be that depression, when categorized as a mental illness, gets associated with psychotic disorders, which explained the majority of Nigerian Christian and Muslim clergy believing that a person who is mentally ill can be differentiated from ‘normal’ people (Igbinomwanhia et al., 2013). Despite the stigma, clergy will be faced with congregants who present with depression as a reason for the visit; Ali and colleagues (2005) found 87% of imam participants in their survey reporting that sadness or depression was the reason for congregant visits sometimes, often, or very often.

Scrutton (2015) offers an overall framework that summarizes the models. Scrutton’s textual analysis of conceptualizations of depression addressed three models of depression: medical, moral, and social; of the three, medical and moral models locate the problem within the person and remove hope (Scrutton, 2015). Medical models, because of their essentialism, restrict expansion of purpose or utility, such as depression representing spiritual transformation (Scrutton, 2015). The moralizing model, as illustrated in Christian self-help books and websites, specifies that mental illness is a sign of living a life against God’s prescriptions. Moralizing models do not acknowledge social causes of depression, thus relinquishing the church’s responsibility from combatting factors of depression such as oppression and social injustice. Conceptualizations, therefore, should move away from depression as an individual sin because it can be caused by social sins such as discrimination, poverty, violence, and minority status (Scrutton, 2015).

Methods

Results

The analysis revealed three different conceptualizations of depression, or more specifically mental illness, because depression, as a term for a disorder, is a biomedical rather than cultural or religious construction. The clergy did not structure their narratives and thinking into the different types of depression, but this nomenclature arose from the researchers’ engagements with the data. The three themes were: (1) depression as a ‘real’ illness, (2) depression as spiritual destiny, and (3) depression as unallowable sadness.

Discussion

The findings revealed an underlying nomenclature that shapes Muslim clerics’ conceptualization of suffering that can be labelled as ‘depression’. These conceptions are characteristic of a particular Muslim community in which these clerics offer pastoral care and social services. Even though the types overlap in their everyday engagements with the condition, the ways in which clerics understand cause and consequence could impact on their interventions or the help they are tasked to render.

First, depression was framed as a ‘real’ illness, warranting medical intervention. This variant closely resembled biomedical models with structural (brain) or biochemical factors linked to depression. Second, conceived as spiritual destiny, depression required religiously based interventions because such a condition symbolizes a test of faith and spirituality. The third type of depression was constructed as being a consequence of everyday difficulties in living. This type, even while being distinguished from transient sadness, resembles an unacceptable response to life stressors. Clergy noted this unallowable type of depression resolved once the difficulty was removed. Muslims experiencing this depression were subsequently advised to remain steadfast and optimistic because, for example, being depressed as a result of worldly challenges is unacceptable. This conception of unallowable depression has implications for the clerics’ work: Working for a FBO with community goals, the clergy could revisit their conceptualizations, rather than being influenced by conceptualizations that arise from medicalization discourses of Muslim suffering.

Clergy’s conceptions of depression demonstrated that the biomedical model in Islamic settings is interspersed with competing models. Even though the biomedical conception asked of the clergy in our study to refer help-seekers to a mental health practitioner if they thought themselves unable to assist, the spiritual destiny conception directed the clergy to offer support from a pastorally congruent base. The implication of this contradiction is for training sessions to interrogate such conflicts rather than only provide medical knowledge as a direct top-down transfer of information.

Mental health practitioners, trained in biomedical ideas, cannot assume that the term ‘depression’ is understood in the same way across different contexts. Clergy can inform mental health practitioners about the impact of religion and culture on illness beliefs; this may improve adherence to biomedical interventions. Clergy in this study recognized certain aspects of depression as a ‘real’ illness but indicated that religious illness beliefs cannot be bracketed. They also expressed a need for medical practitioners to acknowledge the religious contexts of their patients; this collaborative venture applies to psychologists too. Clergy within this study perceived that their opinions would be disregarded as legitimate by mental health practitioners; they believed that mental health professionals were insensitive to the religious contexts of patients. Nevertheless, the conception of depression as a ‘real’ illness and the accompanying rigid adherence to the medical model, particularly via notions of chemical etiology and treatment together with their own layperson’s interpretation of the medical model, may be considered a barrier to referrals to mainstream healthcare workers; this can potentially inhibit opportunities for collaboration with formal healthcare systems.

The commonality in the three conceptions of depression is the individualistic focus, whether in cause (as biomedical, as an individual’s spiritual destiny, or as an individual response to stressors), or in intervention (e.g., medication, prayer, or financial assistance, respectively). The help for depression was considered to be helping the individual; a social stance, as found in Hankerson and colleagues’ (2013) focus groups with African American Christian clergy, would have conceptualized collaboration as participatory and community-based. Thus, the notion of participant clergy in our study working with mainstream health practitioners seemed to imply collaboration to be a linear one-on-one interaction with health practitioners, rather than specifically creating community programs for depression like that cited in the aforementioned study (Hankerson et al., 2013). In our study, this challenge is implied by the conception of depression as unallowable sadness for, in this variety, when this conception is used, sociopolitical stressors such as gender-based violence, poverty, or crime may become undermined. This social model of illness, Scrutton (2015) argues, is disregarded by clergy, but it is this model that shows sensitivity to context and social justice.

Additionally, opportunities already exist for collaboration within the FBO structures. For example, because mental health providers are available for consultation on cases, these sessions hold potential for vibrant discussion and negotiation between divergent conceptions of depression and mental illness. In this instance, the mental health professionals need to be the point of contact for being trained about how to sensitively work with traditional community resources, rather than them being allowed to uncritically disseminate mainstream views of health and illness. In other words, psychologists and psychiatrists need to have diversity training, so they can collaborate in inclusive ways with community and religious helpers when they do enter those FBOs and communities.

Overall and remarkably, the biomedical model seemed to be the overarching conception of mental illness. Even though it appeared to be dominant in these clerics’ understandings of depression, Islamic notions interspersed and even intruded into that conception. Even though this is a remarkable finding, we acknowledge that the interviewer’s probing and framing of the questions in terms of depression, rather than of distress or suffering, accounted for the biomedical ideas creating an intrusive, overlayering dynamic. Thus, the limitation of this study could be related to biomedical preconceptions in the interviewing questions. In the interviews, the preference for using the medical term ‘depression’ may have preempted the generation of biomedical conceptions as a dominant theme. Likewise, just the cleric’s knowledge of being interviewed by a mental health practitioner, as was the case in this research, may have created the condition for them to provide medically based responses, particularly if they had assumed that they were required to give ‘correct’ responses to the interview questions. Thus, we recommend that further research into conceptions of illness (including depression) with clergy, traditional healers, or even patients use neutral terminology so as not to preempt biomedical conceptions that are inherent in a (popularized) depression discourse. Future research that investigates culturally based or religiously based conceptions of mental illness should avoid such discourse in survey or interview questions. Other limitations may be related to the emphasis on sex segregation in Islamic social relations, yet our study had a female interviewer and male participants. The sex differential could have limited interviewee disclosure, or allowed dominance dynamics to come into play. Furthermore, the clergy might have found it difficult to decline the interview participation because their line manager had given their names to the interviewer in the recruitment stage. Future research should thus advertise for participation so that clergy can volunteer.

Depression discourse is rooted in medicalization. Thus, the uncritical buy-in into the depression as ‘real’ via adopting biomedical explanations may unintentionally go against the organization’s goals and mission. In other words, the individualist ideology inherent in the biomedical paradigm might overshadow religio-community values. A key recommendation for clergy, when they receive training via westernized disciplines like psychology and psychiatry, is to question and be aware of their buy-in into medical discourses. One finding that stands out is that training, which the clergy repeatedly mentioned they had received—seemingly for the discursive effect to position themselves as knowledgeable and as experts—inculcated biomedical conceptions of depression. This confirms Lafrance and McKenzie-Mohr’s (2013) analytic that biomedicine’s dominance is not due to top-down processes. Although bottom-up uptake is usually discursively attributed to those experiencing the emotional distress (Lafrance & McKenzie-Mohr, 2013), our study adds to this analytic by finding that clergy themselves—actively and forthright in the interviews in our study—engaged with placing biomedicine as powerful when they conceived of depression as a ‘real’ illness. In other words, clergy who have received uncritical ‘training’ in medical models contribute to bottom-up processes by legitimizing the dominance of psychiatric nosology.

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Notes

1. mufti: A male Muslim legal expert who has studied further than a moulana. Unlike a moulana, a mufti is able to interpret verses in the Qur’an and determine Islamic laws (Moj, 2015).

2. moulana: A title given to a Muslim male who has “completed a course of studies on Islamic education at the tertiary level” (Khan, n.d.).

3. taweez: In South Asian culture, an amulet worn for superstitious protection from the evil eye or black magic given by a traditional healer (Dwairy, 2006).

4. taqdeer: predestination; the idea that God has predetermined life events and circumstances. (Salem, 2014)

5. salah: “an Arabic word to mean a spiritual relationship and communication between the creature and his Creator. Salah is one of the five pillars of Islam. A special communication (Salah) is to take place five times a day for a Muslim” (“Key to Islamic concepts”, n.d.). Salah is the physical form of prayer, resembling yoga postures; dua are verbal supplications, silent or spoken aloud, either during salah or outside of it.

6. zakah: “A Muslim who has money beyond a certain quantity is to pay the Zakah. It is also called the alms due or poor due” (“Key to Islamic concepts”, n.d.). Zakah has rules governing its distribution.