Feminine sexuality,religiousness and psychotic distress: Tracing a pattern

Method

The intervention was based on the “hearing voices” model developed by Romme and Escher (2000), combined with cognitive-behavioural therapy techniques (Thomas et al., 2014). Hearing voices in this model is not regarded as a symptom of mental illness but a distressing mental experience that has meaning and function for the hearer. The intervention aimed to support voice-hearers in making sense of their voices, through linking them with circumstances and events in their lives, and managing the voices, through developing more effective strategies for coping with them. It was conducted by the doctoral researcher, who is a trained clinical psychologist, with appropriate clinical supervision, at a psychiatric clinic of a university hospital, where the participants were customarily treated. It started when participants were in an acute psychotic state and lasted for one year, totalling 25–30 sessions per intervention. The participants were three men and two women, aged 21–48.

Permission to conduct the study was granted by the scientific council of the university hospital. Candidate participants for the study were suggested by the clinic director, were informed about the therapeutic intervention and the study by the doctoral researcher, and those who agreed to participate signed a consent form.

The study consisted in systematically tracing the process of therapeutic change regarding the characteristics of the voices, the voice-hearer’s understanding of the voices and the coping strategies used by the participants. The intervention sessions were analyzed using grounded theory principles (Tweed & Charmaz, 2012), extracting the main themes in each intervention, chronologically tracing the changes in the course of each intervention, and comparatively, between interventions. The final product was a model of change in experiencing, understanding, and managing voices through the course of the intervention.

Here, we focus on the two women participants, following a discernible gendered pattern that was found in this study, namely that the voices for all men participants were linked to parental demands regarding ability and professional success, while the voices for both women participants were linked to their sexuality, which was in turn understood in a religious frame. Details of participants have been removed or altered to safeguard anonymity. In what follows, we include only the aspects of the case studies that pertain to the topic of this paper.

The case of M

M was at the time of the intervention a woman in her mid-twenties, living with her family of origin. She was born in a predominantly Muslim country, where her family belonged to a Christian Greek minority, and moved to Greece with her family as a school-aged child. She described a deeply religious family, with conservative principles. M reported a series of difficult experiences in childhood and adolescence. It seemed from her account that both she and her family felt that they did not fit in their country of origin, due to their minority status there, while also experiencing racism and discrimination after migrating to Greece.

M was diagnosed with depression and was prescribed medication in her late teens. She attributed her depression to rejection by her school friends. In early adulthood she was hospitalized twice in psychiatric units, both times after break-ups of romantic relationships. Τhe intervention started during her third hospitalization, after a long period of social isolation and the onset of disturbing voices. M’s diagnosis at the time was schizophrenia. Previous diagnoses included schizoaffective disorder and psychotic depression. The client-defined aim of the intervention was to manage her experience of voices.

The voices appeared six months prior to the current hospitalization. The main problem before the emergence of voices was intense experiences of bodily harm. She described the time of the onset of voices as follows:

When I started hearing voices, I felt that an Afghan man stuck a microchip in my brain, then I felt my ear buzzing. At that time, I was screaming when I was at home, I felt that my nose, my tongue and my womb were being cut off with scissors, I had a smell of iron, I felt pain, that something is eating my insides.

M heard two main voices, attributed by her to God and to the Devil, that were negative and threatening. She was unable to describe the exact characteristics of the main voices, because as the treatment progressed the voices forbade her to talk about them. M also heard negative voices of unknown men, women, and children, that criticized her sexuality, personality, and gender identity and threatened her with bodily harm. There were also positive voices of saints, which called her a saint.

I hear voices, like a conversation between a man and a woman, while at the same time I hear young children, who sound very threatening, they tell me that they will cut off my nose. The children are about 7, 12 and 14 years old … Some voices call me a whore, although I have abstained from sexual relations for 4 years now, and that I am a lesbian. I hear them say that they detest me … I hear voices that call me a saint. I think that these are voices of saints and I feel that God is protecting me. They tell me that I am a saint, good, a decent person. I have not thought which saints they belong to, maybe to those who I pray to, Santa Barbara and Saint Saviour.

A repetitive pattern was discerned by the therapist, whereby feelings of anger and anxiety produced a sense of threat and sensations of bodily harm, which in turn activated the voices, which further intensified the bodily sensations. The following extract is an example:

The landlord came to collect the rent, I felt anger and I heard “I stole her”, I felt like he harassed me, he raped me. I felt like something came off me and I heard a voice say “the old man stole her”. This happened when I was in the bathroom and the owner was outside the house. I felt like my spirit left, I got anxious and I started calling him a dirty old man. The voices were commenting: “the old man stole her, he raped her”. I could hear them from across the street, they were male voices.

It was made clear during treatment that M experienced the world as abusive and controlling. She perceived the voices as omnipotent and seemed to feel completely powerless. She attempted to manage the voices and the distress they caused mainly through religious thoughts and rituals. She adopted mainly religious explanatory frameworks for the voices, treating them sometimes as an attack on her by demons because she was faithful and sometimes as punishment from God for her sins. She also at times talked about them as symptoms of mental illness.

M seemed to have had a persistent sense of being inferior to others, dismissed and criticized since childhood. Her perception of herself as a sinner, due to sexual practices, seemed to have also been present for many years and was further encouraged through the psychotic experiences. A sense of being superior and saintly seemed to have emerged since the beginning of psychosis, providing a counter-balance to her long-standing negative self-perceptions. Later in therapy, she also started thinking of herself as someone who can manage the voices.

In the course of treatment, further distressing events were recounted and linked to the emergence of voices. M said that she started masturbating as an early school-age child. Her parents, alarmed, took her to a paediatrician, who said that she had intense sexual urges. The masturbation, which was the only source of sexual pleasure for her, continued until early adulthood, when she decided to discontinue it as an act of purification. She had sexual relations with men since the age of 18. These were disapproved of by her family and were later perceived by her as sinful. She reported having had an abusive relationship with a man involved in trafficking of women.

The content of the voices and other information led the therapist to hypothesize earlier sexual abuse, memories of which were activated by adult sexual experiences. In the course of therapy, M described bodily sensations of rape before the age of 18 and named the Devil as the abuser.

In the course of therapy, M linked the experience of voices with her guilt regarding her sexuality and the last abusive relationship. The exploration of the meaning of the voices was, however, hindered by the intensification of the abuse by the voices and of sensations of bodily abuse every time she attempted to understand the voices. Through the course of therapy, M made progress in terms of developing an understanding of the voices as well as a degree of control over them.

The case of K

K was at the time of the intervention a middle-aged woman, living in the family home with her sister, also diagnosed with schizophrenia, after the death of their parents a few years earlier. Their family, like that of M, was deeply religious, with conservative principles. K’s first psychiatric hospitalization took place in late adolescence, when she was studying abroad, after having an abortion. She had experienced several psychiatric hospitalizations since. She was hospitalized in an acute psychiatric ward in the beginning of the intervention, with a diagnosis of schizophrenia.

K’s voices started in late adolescence, precipitated by an abortion she had at the time. She describes the onset of the voices as follows:

There were two then, the voice of the Virgin and Princess Diana, I felt that I had their form and I could hear them talk to me. When they put me on the gurney to take me for the abortion, I felt that my soul left my body and I could see underneath the English man and my sister. Before they took me to hospital for the abortion, I died, and I was in a dark room. There I saw Christ and I spoke with him.

The same voices continued up until the time of the current treatment. K reported two main voices, the voice of the Virgin Mary, which guided her in sexual abstinence and protected her from other people, and the voice of Princess Diana, which advised her on dressing and appearance. The voices seemed to encourage a sense of superiority and mediate her relation to other people. In her words:

I like all the men, but I am not allowed to have sex with them, the voice does not allow it. I am a virgin. I went and got myself sewn up after my abortion, and I became a girl again. The Virgin does not allow me to go with men. Diana lets me choose clothes, gives me advice on my hair. The voices help me define who I am, my image. Aesthetically, when I see someone ask for help, I am the Virgin, when I see a beautiful girl, I am Diana.

In the course of treatment, K recounted several distressing events and circumstances that she linked to the emergence of her voices. She talked about the religious and conservative family morals, especially regarding sexuality. She recounted instances indicating strict supervision and control by the father of all his three daughters, but particularly of K, in matters of femininity and sexuality. The father, according to K, did not allow her to look at herself in the mirror, controlled her dressing and appearance, and forbade her to have sexual relations.

My father did not interfere with my appearance only, my father was generally intervening. He wanted all three of us to be pure and clean in body and soul. When I was in the UK, he used to send me emotional letters, asking me to be a good person, poetic and romantic.

K also mentioned having experienced sexual abuse by unknown men in middle childhood. However, it was unclear to the therapist whether this referred to real or fantasized events. Finally, she mentioned homosexual desires and fantasies, linked to masturbation, in adolescence. She specifically described masturbating in adolescence while fantasizing about Princess Diana.

A sense of being a sinner seemed to have persisted for K since childhood. Similar to M, she started considering herself as superior and pure at the beginning of psychosis, and this seemed to counter-balance earlier negative evaluations of herself.

Initially, K held a metaphysical view of the voices as originating from higher beings. As therapy progressed, she started considering them part of her own thinking. In the course of therapy, K painfully realized the incestuous desires of her father towards her and the function of the voices as an extension of her father’s desires.

My father always wanted me to be elegant, to always speak well, dressed in clothes that he liked. He has done all of this, the voice of the Virgin represented my father’s desire for me to be pure and the voice of Diana represented my father’s desire for me to be elegant … My God! I feel so terrible, God forgive him. That was my father! This is why I saw my mother as a competitor.

Initially she was extremely distressed and expressed suicidal thoughts; later she came to terms with it and stopped feeling guilt for having failed her father. The voices had a positive and regulating function in K’s life. For this reason, her demand was not to control the experience but to understand the voices, something that was achieved through the intervention.

Method

This was a multiple case study of families with a member with experience and diagnosis of psychosis. According to the research design, biographical interviews would be conducted with the person with a diagnosis of psychosis and with as many members of their family as possible. The interviews would centre on family life before and after the emergence of psychosis as well as the impact of psychosis on family life to the present.

The two researchers, who were psychology students at the time, sought families in the provincial towns where they came from. Four families participated. In all of them, the family member with a diagnosis of psychosis was a woman. All women were at the time of the study in their 50s and were living with their family of origin or their marital family in provincial towns. Some participants had received diagnoses of schizophrenia and others of bipolar disorder. The families identified were approached by the researchers, informed about the aims and process of the study and called to participate. After the initial expression of interest, all the family members who agreed to give an interview were briefed in detail and signed a consent form. Biographical interviews were conducted separately for each family member by one of the researchers. Thirteen interviews were conducted in total, four with the women with psychotic experience and nine with their relatives.

The interviews were analyzed with a combination of biographical analysis (Merril & West, 2011), tracing the sequence and interconnection of events, and thematic analysis (Joffe, 2012), identifying and organizing the main themes on each topic. After separate analysis of each interview, the interviews of members of each family were comparatively analyzed, forming an account of each family narrative, followed by a comparison between the four families, arriving at an overall pattern.

Biographical pathways of women through psychosis and religion

All families interviewed lived in regional towns and were in relatively good financial situations. They were all members of the Orthodox Christian faith and actively participated in the activities of the local parish. According to their descriptions, participants observed religious rules and participated in religious rituals, for example Sunday school, in their childhoods. Despite references by participants to witnessing domestic violence, experiences of bullying and one account of childhood sexual abuse, the sense that came across from all interviews was of a “normal”, uneventful childhood. All the women came across in the family members’ narratives as sensitive, helpful, and of good will. As adolescents, the women participants seemed to have developed interests and activities and to have socialized outside the home. They all left the family home at the age of 18, three of them to study and one through marriage. The three participants who went away to study described an active social life and engagement in social activities and political activism. All participants described having had sexual encounters with men or with women. They commented on how this was in contrast to the principles of their conservative upbringing and the analysis of their narratives indicates that it was later treated by them with shame and guilt. Some characterized that period of their lives as “wild” and “sinful”. However, they commented that their behaviour, regarded as “deviant” by their religion, ended up strengthening their faith. One participant explicitly interpreted the difficulties she had faced subsequently as punishment for her “sins” of that period. Their time of being away from the family of origin seemed to have brought about emotional and psychological distance from their family. Most participants mentioned not sharing their life details with their parents and some parents admitted to not knowing much about their daughters’ lives back then.

The onset of psychosis was located by all participants between the ages of 20 and 23, after some stressful life event or situation. With the emergence of psychotic experiences, all four families focused upon their troubled daughter and took over her care. It is worth noting that in three out of four families interviewed relations between parents and children were not described as close, and in two there was open conflict. The onset of psychotic experiences in the daughter of the family seemed to have pulled the family together in pursuit of the common goal of looking after the member in need.

In all cases, the first contact with a mental health professional was described as crucial and negatively charged. The psychiatrist was seen by family members to be concerned only with the management of symptoms and not with helping the family understand and deal with the situation of their loved one. Some family members were also concerned about the effects of excessive medication. In the words of a mother: “She was taking such large doses of drugs that she was completely apathetic. Sometimes she would fall into a stupor, sleep so deeply that I was afraid that she would die, and I would go and open her eyes to see if she is alive.” One participant was initially hospitalized in a psychiatric ward before moving back to her family home. The other three returned to live with their family of origin.

According to their accounts, all participants went through a prolonged period of social isolation upon their return home, experiencing a reduction of their social contacts, with some completely withdrawing to their immediate family circle. This they attributed to their own mental state due to their mental health problems and the effects of medication, the difficulty of other people in understanding and handling their psychotic experiences as well as the stigma of being “crazy”, which was difficult to avoid in a small town. For the following decades, to the time of the interviews, three of the women lived a completely secluded life in their family home. Only one participant had completed her studies, had worked in her specialized field and had created her own family.

All participants reported having had recurrent psychotic crises, which they dealt with either at home or through hospitalizations. They were generally dissatisfied with their contact with mental health professionals, whom they tended to change often, because they did not share their views or prescribed too much medication. One participant described: “He was very good, like a father, we had a loving relationship, it is just that we did not understand one another, he had a different view of life.”

After a period of abstaining from religious activities, at the time when they had left home in their early adulthood, all women returned to an active and intensive re-engagement with religion. They all proclaimed their faith as central to their lives. Moreover, they actively engaged with religious practices in the parish to which they belonged, and, for some, these practices dominated their everyday life and their relationships with others. According to one participant: “It is like finding a home, everything we heard in our childhood about a society of love and solidarity is fulfilled.” The main role, however, that the return to religion played, for three of the participants, was the opportunity it gave them to re-signify and make sense of their experience. According to one of them: “It is like the child in the parable of the prodigal child, who returns home and the father is always there, waiting for him with love.” One participant did not recognize her mental health state as a problem, while the others adopted a combination of religious and psychosocial explanations of their mental distress. Regardless of the frame of explanation they utilized, all participants said that their faith offered them safety and relief, and they considered it central for their well-being.

Tracing a common pattern

All the participants, who as young women developed psychotic experiences, shared an upbringing in conservative families, with strict family morals and strong religious affiliations. A few of them reported family conflict, abuse, and victimization at home or school, and for some there were unconfirmed indications of sexual abuse. From adolescence onwards, they seemed to engage in an exploration of female identity and sexuality, through establishing sexual relations. This was accompanied by pursuing independence from their family of origin in early adulthood, through moving away and engaging in higher studies as well as social and political activities.

The emergence of psychotic experiences in early adulthood marked the women’s return to and enclosure within the family of origin. They also marked their return to a conservative religious frame of reference and the perception of previous sexual relations and experiences as sinful and shameful. All the female participants adopted religious understandings. Moreover, their coping strategies were drawn from their faith, consisting mainly of prayer and religious ceremonies as well as abstinence from sexual activities, relations, and pleasures. The enclosure within the family home and the religious frame of conducting their life was accompanied for most participants by an almost complete withdrawal and disengagement from the world and social relations.

Based on this pattern, psychotic experiences may be understood as a response of an embodied subject raised in a conservative religious environment to the tensions that emerge when that individual enters a world that is profoundly at odds with this upbringing. According to the cultural principles that the female participants in these studies were raised by, sexual abstinence is located on the side of purity and most forms of sexuality are rigidly on the side of sin, rendering any expression of sexuality as deserving of punishment and marking the subject as fallen and shameful. These tensions, in the shape of shame and punishment, were expressed in the psychotic experiences. These tensions were subsequently dealt with by denouncing the world and returning to discourses, practices, and spaces associated with the family of origin. Moreover, this return to and enclosure within the family environment led to re-shaping feminine identity and sexuality along conservative religious principles, inducing sexual chastity in practice.

Psychosis, religion, social conservatism, and female sexuality

Many of the childhood adversities linked to later development of psychotic experiences were mentioned in the accounts of the participants in these studies, including negative family relations, abuse and victimization, as well as experiences of undermining and rejection (Harper et al., 2021; Tseris, 2019). The common element binding all the participants’ accounts, however, was upbringing in a conservative religious family, pointing to the role of family culture, in conjunction with broader cultural environments, in the development and form of psychotic experiences.

We have information regarding the psychotic experiences of only two participants in the first study. These experiences had a clear sexual and gender related content, in line with the few reported studies (Haarmans, 2019; Jones et al., 2018). Specifically, they related to beauty and desirability but mainly expressed shame and guilt regarding sexuality. The experiences were denigrating, controlling, and punishing for issues related to gender and sexual mores and standards. Particularly striking were the reports of visceral experiences of rape and mutilation. The psychotic experiences reported also had a clear religious content, in line with findings of relevant research (Cook, 2015). They involved religious figures and were centred on punishment for sins, purification, and redemption. The intersection of gendered and religious themes in psychotic experiences has been hinted at in other studies (Haarmans et al., 2016; Jones et al., 2018). This study demonstrates a particular combination of gendered and religious themes in women’s psychotic experiences which was related to the specific sociocultural context of their development.

Jones et al. (2018) observed that the sexual and gendered themes found in their study of psychotic experiences were linked to religious and spiritual beliefs, cultural mores concerning sex and sexuality, personal struggles with gender and sexuality, and past sexual experiences. This rings true in the present studies, supporting the argument that the modes of understanding and coping with psychotic experiences are mediated by socially available discourses (Marriott et al., 2018). Social norms regarding gender and sexuality as well as religious and spiritual cultural beliefs seem to contribute to the form and content of psychotic experiences, as well as to their understanding and their management (Wittkowski et al., 2014).

Regarding women specifically, it is clear that their psychotic experiences are gendered and express socially sanctioned norms regarding femininity and female sexuality. It has been argued that sexism, sexist exploitation, and oppression influence and are expressed in women’s hearing-voices experiences (McCarthy-Jones et al., 2015). From a feminist perspective, women’s distress, expressed in psychotic symptoms, is a result of experienced gendered oppression. Women are constrained and regulated by culturally prescribed gender norms and punished when they deviate from them (Ussher, 2011). Psychotic distress seems to be an expression and enactment of engrained experiences of shaming, silencing, and restriction imposed by social practices and norms that control women’s bodies and minds (Fahs, 2020; Shefer & Munt, 2019)

Psychotic experiences, like all experiences, serve certain functions in the person’s life (Romme et al., 2009); these are closely related to the content and form of the experiences and to the modes of their understanding and management that the person employs. In the studies reported here, the psychotic experiences seemed to be understood by the women who experienced them in religious terms, leading to their voluntary sexual abstinence, use of religious coping strategies and more generally the adoption of a lifestyle that was consistent with their religious beliefs. It seems as if the psychotic symptoms led these women to resignify and manage their female identity and sexuality along the lines of the socially conservative religious frame of their families’ values.

The family also plays an important role in regulating its members’ conduct, bringing it in line with social and moral norms (Bhavsar & Bhugra, 2008; Smolak et al., 2013). This is more so in traditional societies, such as Greece, where families assume a central role of protecting and supporting the well-being of its members, especially those in need (Koutra et al., 2016). The studies reported here demonstrate the role of the family in enforcing gendered moral standards upon its female members with psychosis, bringing their “prodigal” members back in line with social and religious principles.

The central role of religion in the studies reported here is related to the conservative cultural and social norms in Greece, permeated by the strong presence of the Orthodox Christian faith. Despite the decline in religious content of psychotic experiences documented in Western countries (Duñó et al., 2020), the dominance of religion in conservative sociocultural environments in Mediterranean societies, where the honour of women is linked to sexual shame, seems to provide fertile ground for repressive regulation of female identity and sexuality through religion. It is not accidental, we think, that the topic of sexual chastity was found to be central in the psychotic experiences of women in Greece (Mitropoulos et al., 2015) and in Lithuania (Wittkowski et al., 2014). Moreover, voluntary abstinence from sexual activities and pleasures as a result of experiencing psychosis has been documented in the majority of cases in a study in Poland and was linked to religious beliefs (Budziszewska et al., 2020).

Thus, both psychotic experiences themselves and their repercussions of social withdrawal and enclosure within a conservative family frame function to control and regulate women’s desires, thoughts and conduct along socially prescribed moral codes. In this sense, it can be argued that psychotic experiences, in conjunction with their understanding and management, may operate as a form of policing feminine identity, conduct, and sexuality in conservative social and familial environments, such as contemporary Greece.

Limitations

The results of the studies reported here were based on very small samples, drawn from a particular sociocultural context, and are therefore not generalizable to other contexts and populations. However, the fact that these were independent studies, conducted by different researchers, with participants from different regions of Greece, and driven by different aims and utilizing different methods, adds to the ecological validity of the study, indicating that this may be a distinctive pattern beyond the particular studies. We suggest that this pattern may be characteristic of women raised in traditional religious families within conservative social environments. In this sense, it may be encountered in conservative societies other than Greece and religions other than Orthodox Christianity, but this remains to be established by future studies. Due to the small samples, we have no indication of how widespread this pattern may be, even amongst families with the characteristics outlined above, and therefore we cannot claim that this is an exclusive or even a dominant pattern.

Contribution

This paper examined the combined role of gendered social prescriptions and religious principles within a conservative family and social context in the generation and management of women’s psychotic distress. Moreover, it shows how psychotic experiences and their management may serve to regulate women’s identity and sexuality. As such, the paper contributes to the literature documenting the links between psychotic distress and sociocultural conditions, including culturally sanctioned understandings and experiences (Bhavsar & Bhugra, 2008). It contributes more generally to the flourishing literature linking systemic inequalities and injustices with psychotic experiences (Bentall et al., 2014), and particularly to feminist literature examining the role of patriarchy, including mental health discourses and practices, in generating and regulating women’s distress (Marecek & Gavey, 2013; Marecek & Lafrance, 2021). More specifically, it expands recent research on intersectionality (Haarmans et al., 2018), adding culture and religion to the examination of gendered and racialized aspects of women’s psychotic experiences. This has obvious clinical implications, highlighting the importance of adopting a psychosocial approach to understanding and managing psychosis, and more specifically of paying attention to the particularities of the sociocultural context of women’s distress in order to support them in their recovery.

Responding to the call for more culturally diverse and sensitive research on psychosis (Kovess-Masfety et al., 2018; McCarthy-Jones et al., 2015), the paper highlights a very particular combination of gender, religious, and cultural norms in women’s psychotic distress, in a particular cultural milieu. Whether this or similar combinations of societal factors operate to shape mental distress remains to be seen by research conducted in other cultural contexts.