The predawn call to prayer from the nearby mosque reverberates through the house as Bushra, 29, hurries to prepare for her day.
She quickly performs her ablutions while seated on a plastic stool in the bathroom of her family’s home in Srinagar, the summer capital of the Indian-administered state of Jammu and Kashmir.
After washing herself with water from a basin on the floor, she walks to her bedroom to perform the first of five daily prayers.
Bushra finds that these daily prayers help her to keep calm and restrain angry outbursts, she says. She has experienced bouts of agitation and uncontrolled anger since 2010 and has been receiving treatment from a faith healer.
She has never seen a psychiatrist and has not received a medical diagnosis of her condition.
Kounsar, 28, also lives in Srinagar. The sun is shining brightly through her bedroom windows when Kounsar wakes up.
It is 10 a.m., but Kounsar is lethargic. She moves sluggishly around her well-furnished room, going through her morning routine.
Kounsar has been diagnosed with obsessive-compulsive disorder, or OCD, and was once hospitalized when she became aggressive, she says.
Bushra and Kounsar, single women who live with their families, both struggle with mental illness. Their families protect and care for them.
Because mental illness carries a heavy stigma in Kashmir, both women – and all members of their families interviewed for this article – asked that they be identified solely by their first names.
In their search for treatment of their disorders, these women have pursued strikingly different paths: While one has turned to a psychiatrist, the other relies on the traditional practice of faith healing, administered by an Islamic teacher.
In Jammu and Kashmir state, mental illness is stigmatized, especially among girls and women, says Dr. Arshad Hussain, an associate professor of psychiatry at the Government Medical College in Srinagar. Women who are known to have struggled with mental illness often are not accepted as mentally healthy even if they’ve been successfully treated.
Unmarried women who have had mental health problems often have difficulty finding suitable partners. Married women who exhibit symptoms of mental illness are sometimes rejected by their in-laws, and their husbands often leave them and remarry.
Married and single women alike are inclined to hide their mental illnesses to avoid shame and rejection.
Muhammad Hyderi, 75, a faith healer who has been practicing for some 50 years, is no stranger to the stigma of mental illness. Hyderi practices healing rituals within the Sufi strain of Islam, which is widely espoused in the Kashmir Valley. He sees patients at his home in Srinagar.
“Whenever I treat any female patients with mental illness, I find that both she and her family are more concerned about others finding out about the illness than about the treatment for the illness,” Hyderi says. “The stigma begins with the family, as they don’t consider mental illness like any other physical illness, and consciously or unconsciously consider it a shame.”
Fearing that stigma, women often hide their mental health problems until their symptoms are severe, Hussain says.
That reluctance is borne out by the number of women who seek treatment at the Institute of Mental Health and Neurosciences, where Hussain works as a senior psychiatrist. The institute is the only government hospital specializing in psychiatric care in the Kashmir Valley.
The institute treats about 120,000 to 130,000 patients a year, and 70 percent are women who suffer from depression and anxiety disorders, Hussain says. In his judgment, women are more prone to mental illnesses than men.
“Females have to play multitasking roles, and there are more biological changes and hormonal changes that affect women,” he says.
Hyderi likewise says most of his patients with mental illnesses are women. He sees 40 to 50 patients a day, six days a week. About 20 to 30 of these patients suffer from mental illness, and about 15 to 20 of those are women.
The ongoing conflict over control of Kashmir has badly affected the mental health of people in the region, Hussain and Hyderi agree.
“My mother never felt confident to tell anyone about my illness as she knew that not only I, but my entire family, would be stigmatized and face the taboo of being labeled as 'crazy.'”
The conflict between Indian security forces and Kashmiri separatists began in 1989.
“Most of the people in Kashmir have directly or indirectly been affected by it, which has resulted in chronic post-traumatic stress disorder, depression, suicidal tendencies and drug abuse,” Hussain says.
In 1989, about 1,700 patients visited the institute, and more than 80 percent were male, Hussain says. By the late 1990s, the number of patients had increased to about 50,000 a year, and more than 63 percent were female.
Most of the women were suffering from post-traumatic stress disorder as the men in their lives – fathers, husbands, sons and brothers – were killed, injured or arrested, Hussain says. Oftentimes, the men have simply disappeared.
“Women formed the largest group of survivors in the conflict,” he says.
Although stigma prevents many women from seeking treatment for mental health problems, Hussain believes there is growing acceptance of psychiatric care in Kashmir. He has seen many women recover from mental illness through a combination of medical treatment and counseling at the hospital.
Hussain treats several patients who simultaneously seek treatment from faith healers. He believes that medical treatment and faith healing can be complementary.
Hyderi agrees. Given the influence of religious beliefs on the predominantly Muslim population, traditional treatment is still considered a viable option despite advances in medical care.
“Some mental health patients seek medical care as well as faith healing,” he says, “and we can’t force them to choose an option.”
Bushra rises from her prayer mat, having completed her first “namaz” – prayer – for the day. The house, located in a crowded area of Srinagar, begins to fill with the sounds of family members starting their day.
Bushra lives with her parents and a 16-year-old sister.
The day that changed Bushra’s life was Aug. 12, 2010. That evening, Bushra returned home from her job as an Urdu language teacher at a private school in Srinagar to find her parents fighting.
“My father beat my mother as she confronted him about not earning enough,” Bushra says. “I felt so helpless.”
Bushra’s father drives an auto rickshaw. He earns about 200 rupees ($3) a day.
Her sister was crying quietly in a corner of the bedroom they shared, Bushra says. But Bushra found that she could not cry or make any sound; she felt frozen and detached from what was happening.
“I had no feeling that day,” Bushra says. “For a while, I felt like I didn’t exist.”
When she awoke the next day, Bushra found that her mother was not in the house, she says. Her father did not know where her mother had gone.
“I became so angry that I hit my father with both hands, and he fell down, and I left the house screaming,” she says.
Bushra searched for her mother and found her praying at a Sufi shrine in the city, she says. They both returned home later that day.
That was the first of her episodes of uncontrollable anger and rage, Bushra says. Since then she has had several similar incidents.
She lost interest in her job and resigned in November of that year, Bushra says. She wanted to stay close to her mother to make sure she was safe from her father. She felt anxious whenever she was away from her mother.
Bushra began to experience insomnia. In February 2011, a neighbor advised her mother to take her to visit Sheikh Ghulam Rasool Hami, a local faith healer.
Hami started his organization, Karwan-I-Islami J&K, in 2004 to spread Islamic principles and spirituality, he says.
“Spiritual healing is based entirely on faith,” Hami says. “We don’t give any medications. We just encourage people to have faith in Allah and practice religion properly, and to give to charity.”
The Quran prescribes natural healing methods such as plants with curative properties, prayer, visits to mosques and shrines, and “zikr,” or remembrances of Allah, he says.
Bushra visits Hami once a week, traveling about 20 kilometers (12 miles) by bus, she says. She has rarely missed a visit in three years.
In each visit, Hami encourages her to share her week’s experiences. He then gives her advice and guidance, Bushra says. He also gives her some “tabruk,” sweets made while verses of the Quran are recited over them. She takes the tabruk five times a day as part of her treatment.
“In Islam, we believe aggression is another form of “Shaitan,” or devil,” Hami says. “So in Bushra’s case, as the Quran says, I tell her to have control over the anger, and when it is uncontrollable, go and pray and recite special verses from the Quran, and she feels better.”
Hami has advised Bushra to pray five times a day and to recite the Quran daily. She follows those instructions faithfully.
Bushra’s mother, Saleema, says her daughter’s illness has changed her dramatically.
"Bushra was very outgoing and full of life before her illness,” Saleema says. “She would always visit her relatives and markets, and was quite fond of the hustle and bustle. But her illness changed her altogether, and she started losing interest in normal activities, preferred to be alone, always lost in her thoughts, and got angry easily.”
Saleema has taken great care to ensure that no one outside the extended family or her neighbors learns about Bushra’s mental illness, she says. Bushra has distanced herself from their relatives, and no one visits their home.
“I don’t want them to pity us or publicize the problem that my daughter has,” Saleema says. “People would make fun of her. I am afraid to share my problems with anyone. Even if tomorrow she is healed from this illness, people would still consider her unwell.”
Bushra says she has never talked to anyone outside her immediate family about her mental illness.
“No one knows about my illness,” she says. “My mother never felt confident to tell anyone about my illness as she knew that not only I, but my entire family, would be stigmatized and face the taboo of being labeled as crazy."
Saleema feels comfortable taking Bushra to visit Hami each week because people with physical ailments and other medical problems also consult him, she says.
"With faith healing, I never faced any problem of stigma, as my relatives didn’t find out about my illness,” Bushra says. “People visit faith healers for different problems, and it is a normal thing in Kashmir, unlike visiting psychiatric doctors."
Saleema is also relieved that the family doesn’t have to pay anything for Bushra’s treatment. Hami provides treatment for free; all expenses are covered by Karwan-I-Islami J&K, which solicits donations for its work from individuals and Islamic groups.
The family only spends about 100 rupees ($1.60) for travel.
“We are lucky not to be dependent on medicines,” Saleema says.
“We never felt the need to visit any psychiatrist and get addicted to medicines,” she says.
Hami’s treatments are starting to show results, Bushra says.
“Earlier, I used to be restless all the time, and always impatient and aggressive,” she says. “I had become obsessive about my mother.
“But after Hami sahib’s treatment,” she says, using a traditional term of respect, “I have started to become calm and only do simple caring of my mother. I feel the change in the overall peace I have in my mind.”
Saleema says her daughter’s health has improved dramatically since she began visiting Hami. She notices that Bushra is less reactive and tries to control her anger.
“She had become so possessive of me and developed hate for her father, but now there is also a change in that behavior and she has become calm,” Saleema says. “She even advises me to offer prayers on time and to do good without expecting anything in return. I am so happy that she is healing through faith."
It is almost noon when Kounsar finishes washing and dressing for the day. Each morning, she takes a tablet of Fluvoxamine, an antidepressant, one of five medications she takes each day.
“The medicines are so bitter that I have vomited many times,” she says. “They taste like mud!”
Kounsar first experienced serious depression in 2001, when she failed the biology portion of her 12th-grade exam, she says. She had studied hard and was confident of passing, so she was shocked by the grade.
"I was shattered,” she says. “I couldn't accept my failure. Even today, I am still not able to."
Her family tried to convince her that failure, like success, is a normal part of life, Kounsar says. But as the eldest child, she felt she had failed to set a good example for her siblings.
She stayed home, not going out or socializing for nearly four years, Kounsar says.
“I would spend the entire day at home doing nothing and only fight with my mother over small issues and beat her whenever I turned aggressive,” she says. “I don’t know what happened to me. I started hating my mother without any reason.”
In 2005 Kounsar retook the exam as a private student. She passed, and the next year she enrolled at the Government College for Women in Srinagar. She earned a bachelor of arts in 2009.
“I was feeling good and had a lot of control over my anger,” she says. “I even worked for a year as an accountant in a private company.”
But in 2010 she started to experience attacks of depression again, Kounsar says. No specific incident triggered the depression, which deepened in a matter of months.
She started withdrawing from her family, feeling sad without any reason, suffering insomnia and bouts of aggressive behavior. She also became obsessed with cleanliness, washing herself four or five times a day.
She left her job and now stays in her room for much of the day. Occasionally she watches TV or listens to the radio, but mostly she just lies in bed.
“I feel my life is meaningless,” she says. “Many times I thought to kill myself, but then, I was scared to die.”
Her father, Bhat, says that at first the family did not recognize the severity of Kounsar’s illness.
“Initially, we didn’t take her illness seriously as we thought she is still not able to come out of her exam failure,” he says. “But after 2010, her illness got worse and she started to beat her mother and break things at home frequently.”
Since 2001, the family has taken Kounsar to various general physicians for treatment of her symptoms, Bhat says. She underwent a variety of tests and took medication for her loss of appetite, insomnia and lethargy.
She first went to a psychiatrist in March 2011, Bhat says. The psychiatrist diagnosed her condition as obsessive-compulsive disorder and began treating her with medication and counseling.
Bhat takes his daughter to a psychiatrist at a private clinic in Srinagar at least once a month, he says.
In addition to travel expenses, he spends 400 rupees ($7) for the consultation and more than 3,000 rupees ($50) a month for her medication. Kounsar takes four antidepressants and one medication for obsessive-compulsive disorder.
Bhat, who owns a Srinagar shop that sells shawls and bags, is able to afford the cost of treatment.
Fearful that someone will identify her, Kounsar wears a face veil whenever she visits the clinic, she says. She fears that if people see her visiting a psychiatrist, they will gossip about her and avoid her because they will think of her as mad.
"I never felt any sympathy about my illness from anyone other than my father,” Kounsar says. “Mental health illness is always looked down on and considered a lifelong disease, and people think that all the patients are crazy. When I started getting ill, I distanced myself from all my relatives and friends. I didn't want them to pity me and have any preconceived notions about me."
In June, Kounsar was admitted to the Institute of Mental Health and Neurosciences after becoming aggressive, Bhat says. In the midst of a fight, she beat her mother and broke a number of household objects.
Kounsar was medicated and kept in the hospital for five days, Bhat says.
Dr. Insha Rouf, a psychiatrist in the family ward of the Institute of Mental Health and Neurosciences, is one of the doctors who treated Kounsar.
“The patient was having severe OCD,” Rouf says. “We admitted her after her father complained of a violent episode at home. She was already on medications, and we were able to control her and make her better.”
Kounsar has been better since returning home, but she still experiences mood swings, Bhat says.
The family has learned that Kounsar has been inconsistent in taking her medication. Bhat believes that taking her medication regularly during her hospital stay helped her recovery.
“Now she has become less aggressive and doesn’t fight with her mother frequently,” he says. “She has become calm now and prefers to stay inside her room and watch TV rather than fight with her mother.”
He hopes Kounsar will get better by taking her medicines as instructed and avoiding confrontations with her mother, Bhat says.
Although many relatives have advised Bhat to arrange a marriage for Kounsar, he is reluctant to do so.
“I don’t want to do that unless she is healthy,” he says. “I don’t want her married life to suffer.”
Kounsar’s illness is a well-guarded secret in their family, she says.
“I don’t even tell my cousins or friends who call me sometimes or occasionally visit that I take medicines,” she says. “They would consider me mad.”
The family relies on medical treatment and has not yet taken Kounsar to a faith healer. However, determined to find effective treatment, the family is open to that option, Bhat says.
“All these years, she has taken a lot of medication, and whenever she stops the medicine, her condition gets worse,” he says. “We would take her to a faith healer to see whether there would be any improvement, rather than always have her dependent on medicines."
On a recent visit, Kounsar’s doctor said she probably will have to be on medication for the rest of her life, Bhat says. He has chosen not to share that news with Kounsar.
“The doctor told me not to tell her, because she may feel she will never again be fine,” he says.
GPJ translated some interviews from Urdu and Kashmiri.