Abstract Substance misuse is a global phenomenon. However, little is known about substance misuse issues in Islamic nations or about the provision of preventative and rehabilitative services in such nations. This thesis explores the legal context of such services in the Maldives and pays particular attention to tensions between the formal policies of the National Narcotics Control Bureau and clinical practice. Findings are drawn from a review of government and service policy documents, five semi-structured individual interviews with clinical practitioners and senior administrative staff from rehabilitative services, and a three day focus group workshop with clinical staff. Findings show the lack of awareness of the legal and policy contexts for service provision and the ways in which existing policy frameworks often detract from the forging of therapeutic alliances. The primary concern raised by the analysis is the lack of involvement of clinical staff in policy formation and revision. This contributes to series of tensions and contradictions between official aims for services and the actual provision of these services. Further a range of ethical issues arose as a result of inadequate professional monitoring, training, and peer review. Recommendations are made regarding how these issues should be addressed in order to enhance the Maldivian response to increasing substance misuse.