MENTAL HEALTH, RELIGION & CULTURE

2020, VOL. 23, NO. 5, 347–362

https://doi.org/10.1080/13674676.2020.1737920

Exploring identity, culture, and psychosis in cannabis

dependence – an interpretative phenomenological case study
from India
Shaima Amatullaha*, Arun Kandasamyb, Vivek Benegalb and Gitanjali Narayananc
a
Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Bangalore, India;
b
Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neuro
Sciences, Bangalore, India; cDepartment of Clinical Psychology, Centre for Addiction Medicine, National
Institute of Mental Health and Neuro Sciences, Bangalore, India

ABSTRACT ARTICLE HISTORY

The aim of this paper is to recount the phenomenological experiences Received 29 April 2019
of an individual with cannabis dependence and psychosis. The Accepted 26 February 2020
transformations of the participant’s “self” interwoven in a nexus of
KEYWORDS
culture, religion, and ethnicity are captured scrupulously. Identity; culture; IPA;
Components like self-concept, body image, homosexual identity, cannabis; Sikhism
and religious identity are examined to understand substance use
and psychosis in a new light. Data were collected and analysed
using interpretative phenomenological analysis. The main themes
that emerged are “Self as a burden”, “Conflictual experience of
identity”, and “Emergence of a new unifying self”. The role of intra-
psychic and socio-cultural factors in substance use disorders is
emphasised to implicate better treatment outcomes.

Introduction
Indian culture is regarded as collectivistic wherein the “we” takes higher priority than “I”.
Indians have shown preference to conform to social norms, maintain in-group ties, and
interdependence than being independent and self-driven (Sinha et al., 2001). Religion
forms an important base as it guides cultural customs and traditions to a large extent
and law of the country also accommodates religious diversity (Larson, 2001). Indian
parents impose their cultural and religious norms with great rigour (Kakar & Kakar,
2007; Tuli, 2012). Deviating from the rules set by the family and larger social context is fre-
quently rebuked (Kakar & Kakar, 2007). Thus, the identity formation and development of
an individual is almost entirely embedded in the socio-cultural and religious structures.
In current times, the identity of Indian youth is in a considerable state of flux leaving
them torn between the demands of a globalised world and traditional values (D’Cruz &
Bharat, 2001; Sooryamoorthy, 2012). There is an increasing inclination towards the indivi-
dualist orientation; however, these “I” goals or needs can be realised only through cultu-
rally sanctioned ways (Sinha et al., 2002).

CONTACT Shaima Amatullah shaima.amatullah@gmail.com

*Present address: National Institute of Advanced Studies.
This article has been republished with minor changes. These changes do not impact the academic content of the article.
© 2020 Informa UK Limited, trading as Taylor & Francis Group
348 S. AMATULLAH ET AL.

In the following paragraphs, the lead author discusses topics that are pertinent to
the study so as to enable the readers to gain a broader contextual background of the
participant.1

Sikhism
Sikhism originated in Punjab, India. However, Sikhs form only 1.72% of the population and
over 70% of them live in Punjab (Census Organization of India, 2011). Sandhu (2009) aims to
distinguish Sikhism as a religion from the Punjabi culture to clarify the common misnomer of
Punjabi-Sikh. The “Punjabi” culture refers to the norms, values, beliefs, and traditions of
people belonging to people of Punjab the roots of which date back to the Indus Civilization
(Grewal, 1994). Sikhism, on the other hand, is a religion founded by Guru Nanak and other
gurus who mostly lived in Punjab. The important teachings include oneness of God, medita-
tion to attain enlightenment, giving up of worldly pleasures and influences of the ego that
may divert one from his path and service to others. While the Punjabi culture adorns alcohol
and drug use as a symbol of masculinity, Sikhism strictly prohibits use of psychoactive sub-
stances and considers it as a distraction to the spiritual path of “gurumukh” (uniting with
one’s inner experience to discover one’s true essence) as these substances alter conscious-
ness (Sandhu, 2009). Other prohibitions include cutting of one’s hair, adultery, and homo-
sexuality. Several authors have identified that the Sikh identity cannot be narrowed down
to a single dimension due to its diasporic form with diverging geographic locations or
socio-economic status (Morjaria-Keval & Keval, 2015).

Homosexuality
In India, heterosexuality is the norm whereas homosexuality is culturally unaccepted, and
most men would make significant efforts to hide their identity with a fear of becoming
known as gay (Bhugra, 1997). The stigma dates back to colonial influences of the eight-
eenth century, which made it punishable by law, which has been revoked only recently
(Rajagopal, 2018). Homophobia is prevalent due to the socio-religious and political
belief systems and people belonging to sexual minorities are discriminated, marginalised,
subjected to violent attacks, and evicted from their own homes (Subhrajit, 2014).
Interestingly, the mention of same-sex relationships has been found in several ancient
Hindu texts and much evidence suggests its prevalence in history and in recent times
(Patel et al., 2012). It is also found that sexual identities in same-sex relationships are
more fluid in India as compared to the distinctions in the West (Khan, 2001). The idea
of identifying oneself as “gay”, which is uncommon, is more likely to exist in the educated
class (Patel et al., 2012). Nevertheless, sexual behaviour varies despite the identity labels, as
many self-identified homosexual men may still be married to women owing to the social
circumstances (Hernandez et al., 2006).

Substance use
With respect to the use of substances, traditionally, India is seen as a dry or abstaining
culture (Benegal, 2005). Addiction is, however, an established phenomena with the last
few decades witnessing a steep rise in the use of substances among both men and
 MENTAL HEALTH, RELIGION & CULTURE 349

women (Basu et al., 2015). In the wake of recent socio-economic transitions, and globalisa-
tion, there is a ubiquitous shift towards greater acceptance of alcohol use leading to a
decreased age of initiation (Benegal, 2005). This descriptive social norm that more adoles-
cents use substances (sending a message it is accepted and expected) can in turn result
in the increase of its prevalence (Eisenberg et al., 2014), which is especially true of the
urban Indian youth. It is also worthwhile to note is that though religion was found to be
one of the protective factors against substance use, this did not hold true in the sexual min-
ority populations (Rostosky et al., 2007). Useful insights about how substance use and its
social context bolster each other have been gained through qualitative research about
heroin and alcohol, however cannabis is still understudied (Hammersley et al., 2001). Such
emic orientations in literature are limited internationally and absent in India.

Present study1
This case study is on an individual who was brought into a mental health treatment setting
on the pretext of having become dependant on cannabis and alongside had developed
several psychotic episodes. While the psychiatric history of the patient was elaborated
in detailed, I was intrigued by his unique presentation, the mix of socio-cultural beliefs,
his confusion about himself in terms of career, sexuality, religion, his cannabis use, and
psychotic experiences. They echoed like pieces of a puzzle wanting to come together.
The aim of this study is to explore the different facets of identity and experiences of
selfhood while transitioning in and out of the effect of cannabis and psychotic episodes,
embedded in a complex socio-cultural context.

Method
The present study uses a qualitative mode of enquiry based on social constructivist para-
digm, which seeks to understand the subjective meanings of the participants’ world con-
sisting of social interactions and norms (Creswell & Poth, 2018). It enables researchers to
explore multiple and complex views of the participants while “positioning themselves”
by accounting for their own experiences (Creswell & Poth, 2018). Instead of following a
deductive approach, which begins with a theory (as in post positivism), the process is
inductive and can result in developing a theory (Creswell & Poth, 2018).
Within this paradigm, Interpretative Phenomenological Analysis (IPA) seeks to offer an
“insider perspective” with the primary aim understanding “what the participant’s world is
like” and then providing a rigorous idiographic interpretation of “what it means” in a
broader social context (Larkin et al., 2006). The researcher aims to explore how a person
makes meaning and also captures his “relatedness” to the world by giving him an oppor-
tunity to share his story (Larkin & Thompson, 2012). Here, the participant’s symptomatol-
ogy is immersed in the nuances of his social context. The evolution of his self within the
intricacies of his culture could be best captured using a phenomenological stance.
IPA requires a small sample size or a single case and uses an interview or focus group to
obtain data. The analysis is iterative and inductive. At the end, it yields themes and a
gestalt, which comprehends the relationship between themes (Larkin & Thompson, 2012).
Thus, I chose to use a qualitative method like IPA for a single case to explore my research
questions. It allowed me to explore the participant’s subjective world and the meanings
350 S. AMATULLAH ET AL.

attached to identity, cannabis use, and psychosis and then interpret them in the multifarious
socio-cultural context.

The participant
Z is a 25-year-old unmarried male, belonging to Sikh religion from urban Bangalore. He
was seen by a multi-disciplinary team consisting of Psychiatrists, Clinical Psychologists,
and Psychiatric Social Workers. The psychiatrist’s case notes showed that he presented
with a psychotic episode characterised by increased suspiciousness, ideas of reference,
irritability, and anger outbursts lasting for two weeks along with increased cannabis use
during the last three months.
Historically, Z began using nicotine and cannabis during his adolescence with friends.
From then on, he continued using cannabis for recreation, to appear “cool”, to experience
a state of excitement while attending rock shows along with a strong need to fit into his
peer group. He delayed joining an undergraduate course on being confused about a
career choice. He had difficulty in adjusting to college as he felt he was older than his class-
mates, which in turn, increased his cannabis intake. During this time, he also became inter-
ested in the teachings of Bhagwad Gita (Holy Scripture of the Hindus). On one occasion
under intoxication, he developed his first psychotic episode; wherein he felt the person
next to him was “Shani” (a Hindu deity ascribed to bring bad luck). He became suspicious,
fearful, and believed all events had personal significance to him. Subsequently, he joined
work, where his cannabis intake increased. While at work, he had another abrupt psychotic
episode; he locked himself up in the bathroom and felt he was calling the Hindu Gods
“Varuna” and “Agni”, with a belief that he is a God messenger along with symptoms
similar to the first episode. He lost his job. Eventually, he took up several jobs, however
he would quit because of the monotony and dislike for routine. Over the years, there
was a gradual deterioration in his daily functioning. He then developed the third and
the fourth episode characterised by increased religious thoughts like “I am Kalki’s
(avatar of the Hindu God Vishnu) warrior”, irritability, fights at home and suspiciousness
which warranted this admission. For each episode, he was hospitalised and treated with
anti-psychotics.
He was born to a Sikh family but got interested in Hinduism at 19. He lived with his
parents in Bangalore. There had been long-standing marital discord between parents.
The family also witnessed financial stressors since Z’s father stopped working. Ever since
his mother had borne financial and emotional burden and was supported by the older
sister. Z shared a distant relationship with father but was close to his mother and siblings.
In his extended family, there was Schizophrenia in father’s brother, cousin, and multiple
second-degree relatives. Temperamentally, Z described himself as impulsive and had
phases of being very isolated and alone and other times where he is social and popular
in his group. His mother corroborated the same. He said he was attracted towards same
sex since the age of 10 but came out at 20. Interestingly, his sisters and family were sup-
portive after the disclosure. Z had three to four relationships at college not lasting for more
than six months. He also exhibited high-risk sexual behaviour under intoxication. In his
current admission, his diagnosis as per DSM-5 was Cannabis Induced Psychosis. He was
treated with anti-psychotics and anti-craving drugs with psychotherapy of 20 sessions
using person-centred therapy and motivational interviewing.
 MENTAL HEALTH, RELIGION & CULTURE 351

Data Collection
I (first author) planned an in-depth interview using the interpretative phenomenological
framework and The Cultural Formulation Interview from Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013).
The questions were prepared using the “funnelling” technique that aims to draw
responses that move from general views to specific experiences (Smith et al., 2009).
Z was seen at NIMHANS (National Institute of Mental Health and Neuro Sciences), Ban-
galore, which is tertiary care setting, three months after the admission. At the time, he was
asymptomatic and abstinent from cannabis. The Institutional Ethical Guidelines and Pol-
icies along with guidelines from the Indian Council of Medical Research (2017) were
adhered to while conducting the study.
A written informed consent was taken for participation in the study and for the audio
recording and the details of the study were explained clearly beforehand. Though the
patient has given permission to share his details, for reasons of anonymity-specific infor-
mation has been removed. The interview was conducted in an ambient therapy room. It
was conducted in English, in one session, which lasted for 1.5 h. He was open and comfor-
table in sharing his experiences. As he went through the process of revealing, he found
himself linking different aspects of his life, which he had never done so deeply before.
Apart from asking questions, I mostly listened (verbally and non-verbally) and reflected
some of his words. He said he gained new insights and became overcome with emotions.
His eyes brimmed with tears at the end and he thanked me for having this experience. I
summarised, debriefed, and thanked him as we finished.
The recording was then fully transcribed by a research associate with a Masters level
background in social sciences.

Analysis
I spent the initial phase of analysis by reading the transcript multiple times, and I also
recorded some of my own reactions to what Z was saying. As I felt more familiar with
the data, I began marking the key events, relationships, experiences, and concerns in
Z’s life. It struck me that he remembered every bit very clearly and his descriptions
were vivid and “emotionally charged” which he conveyed using interesting meta-
phors. I wrote down descriptive comments based on the content and sticking close
to the explicit meanings provided by him. Along with this, I added linguistic com-
ments, which marked the metaphors he used, how he switched between “they” and
“us” reflecting his group membership. Next, I moved towards writing exploratory
and conceptual comments, which helped me immerse more deeply into the data.
At this stage, I could draw on from my own experiences to understand Z’s inner
world while processing my reflections, I could ask logical questions to the transcript
and make conclusions and eventually I could build an overarching understanding
by connecting different parts of the transcript. After several reiterations, I then
looked for patterns and connections in my exploratory comments and allowed the
themes to emerge, and further looked for connections in these emerging themes.
Each theme was mapped to the original transcript. Finally, main themes were
formed by grouping emergent themes.
352 S. AMATULLAH ET AL.

Table 1. Main themes and sub-themes.

Main theme Sub-theme
Self as a burden Loss of self
Religious and homosexual identity
Liberated self-expression of identity
Conflictual experience of identity Religious identity v/s cannabis use
Religious identity v/s Homosexual identity
The conflict in values
Psychosis and cannabis use
Emergence of a new unifying self Psychosis as a bridge
An amalgamation of identity without cannabis

Results
The main themes obtained were “Self as a burden”, “Conflictual experience of identity”
and “Emergence of a new unifying self”. The first theme captured different aspects of self
(self-concept, religious identity, body image, sexual identity) and it’s lived experience,
the second theme highlights the conflicts in identity and the final theme examines
the transition to a new integrated self. The main themes and sub-themes are described
in Table 1.

Self as a burden
In this theme, the specific burdensome features of Z’s self and how he coped with it is
described.

Loss of self. Identity for Z was felt as something that he was unclear about. He often
spoke about how his difficulties in the way he experienced his “self”:
“A wish that I had from childhood to be anonymous and to not have an identity that makes me
separated from the crowd.”.

“I would say I felt odd … I never felt right I never felt like I can just be myself or I have to be
something else is what I thought”

“I was always thought like if I did not have this external marker of having long hair then i could
may be normal and no one would notice me”

“For the longest time I felt like I did not want to have a background and felt dissociated from
my background, rejected it … I am Sikh I have been brought up in Sikh family. But I never felt
close to my roots so as a sign of rebellion I even cut my hair”

“My experience with cannabis was fun seeking, it was also an escape from being feeling tied
down to living like you’re free”

He describes his “wish” as wanting to be anonymous. This was combined with a desire to
be like others and to go unnoticed. He says he was unusually tall for his age, lean, wore a
turban, and had misaligned teeth. He always found himself getting negative attention
from people around him, which further left him wanting to be someone else. Accepting
himself as he was posed a challenge for Z. A feeling of being caged in his own body and
the response from his environment worsened his sense of self from his early childhood.
He dealt with this burden by shunning his identity, rejecting his religion, and using cannabis.
 MENTAL HEALTH, RELIGION & CULTURE 353

Religious and homosexual identity

Wearing the turban was an obvious feature of his religious identity of a Sikh. Z describes
that it added inches to his height and also a reason for others to bully him. At 10 years of
age, he discovered that he was homosexual, simply adding to the struggle. He was unable
to gather himself and it took him another four years to accept it.
“They would sometimes make fun of it. They would say tomato on your head something like
that and I did not have strength to answer, I didn’t no know myself or my religion to give them
valid arguments so it was basically like being weak on the inside and then someone coming
and egging your face and then you feel more weak”

“so wearing a turban becomes a very clear indication of Sikh and it was not something I was
proud of … I never wanted to even attempt to know the religion what it stand for, the gurus.”

“first time in my head I knew I was gay and that was tough with all of these things like being
Sikh, being tall, being weak physically, another thing gets added there so it was perplexing.”

“I was embarassed that I was … that I am gay”

He “abhorred” the idea of religion and was shy of being an “outright” Sikh. He never
wanted to understand religion and chose to shrug it off. Religion came with the weight
of visible features, which was the most defining element of his identity. Z developed a
sense of powerlessness by not being able to question it. His self-image dampened due to
his religious identity, which eventually made him believe that religion is only a “show”.
Being homosexual and religious aspects of identity were a deep source of shame, helpless-
ness, and “embarrassment”. He experienced a stronger need to detach from himself on dis-
covering his sexual orientation. The fact that he will never have a conventional life like other
heterosexuals confirmed his perception of being odd and different from others.

Liberated self - expression of identity

Z began to use cannabis with peers and said that it helped him “escape from feeling tied
down to feeling free” and help become “comfortably numb”:
“I opened my hair up or and that give me a different identity because people think of me as a
very stereotypically as a rock person someone who listens to rock, heavy metal”

He decided to shed his religious identity by opening up his hair initially and later by
cutting them. He gained a great deal of acceptance from his peers and severe “admonition”
from parents due to this. He describes that others thought of him as “rock” music fan and
found him “cool”. His loss of self was helped by cannabis and provided a real route for
him to “disconnect” from himself. Just the absence of self under intoxication was a relief.
Cannabis was also a unifying factor. It allowed him feel “similar” to others than the usual
state of being different. Getting rid of his religious identity had intrapersonal consequence
of feeling “exhilarated” and interpersonal consequence of being popular among peers.
After knowing he was homosexual, he had a desire to make others known of this aspect
of his identity:
“I felt like it was very scary because I don’t know what people what they say or how they react. I
would consider, my friends would say, its disgusting that I don’t want to see you anymore
something like that. But fortunately till now I have not had any reaction like that so its
been great and its always exhilarating.”
354 S. AMATULLAH ET AL.

“Yah definitely it made a differences telling people (about being homosexual)..(it) made me
accept myself then even more, their acceptance of myself made me accept myself more”

It was “liberating” for him to come out after carrying the strain for eight years feeling as
if “a load has been lifted off his chest”. It relieved him when his friends very easily accepted
him while he expected to experience “disgust”. He lacked strength in being able to com-
municate who he really was to others. Z could only do so through outwardly actions,
leaving him partly feel cowardly inside. In religious and homosexual identity, there is
strong desire to display or convey his real self, which was not how he was being perceived.
The feedback from the environment played a major role in strengthening his identity.

Conflictual experience of identity

This theme captures the conflicts between different dimensions of Z’s identity.

Religious identity v/s cannabis use

Z recollects a “social” pressure to live up to his religion though he did not quite understand
it:
“I did not know what it meant to have respect for your hair. The way Sikhs view it, it’s a thing of
pride almost not like worldly pride but its an internal pride that you have.. you want to show
off to people who you are, I think that’s a very different experience, that’s the true liberation
that exists. I think being who you are.”

“But with the smoking coming to picture it became more strong to shed this Sikh identity
because I would be letting down people and I didn’t want that, not for my parents not for
myself.”

While his peers saw his new image without the turban as “cool”, he was “dishonoring
his hair” as per the family. An emergence of a dual self due to this inconsistent feedback
led him to seek refuge in cannabis. Again Sikhism did not allow Z to use intoxicants. He did
not feel “free” to smoke. A strong need for egosyntonicity in his religious identity even-
tually led him to become interested in Hinduism which depicts Lord Shiva as a propagator
of cannabis. He could now “justify” his use. Interestingly, there is a deep struggle within
himself to bring the conflict in his religious identity to an end though he completely
“shut himself off” from religion. The new meaning of cannabis was that it was a way to
enlightenment and thus became a “crucial part” of his identity.

Religious identity v/s Homosexual identity. Z wanted to reject his religious identity more
strongly after discovering his sexual identity. Since Sikhism prohibits homosexuality, he
opted for Hinduism instead
“it may be kind of blasphemous to say this but they were themes of home sexuality even in
mythologies..lord Ayappa was the off spring of Vishnu and Shiva. Vishnu was in mohini avatar
as a woman but shiva knew it was Vishnu in the form of woman and even though he was
married to Parvathy then, he engaged in the act. So there is subtle hinting about something
on lines of home sexuality in that story”.
 MENTAL HEALTH, RELIGION & CULTURE 355

“I believe there may have been cases of these of homosexuality when scriptures were written
and I believe that Greeks were so much open about it and quite mature about it”

“my partner had done some research on what Sikhism tells about marriage and in his finding
they have not use word man or woman but two souls or two beings of souls are bound by
values of love, trust or responsibilities and so may be but they have said like man and man
also but I think it was forward thinking of them to use those words exactly as they did,
they probably have an idea of that in times to come these things would come up”.

His choice of Hinduism was assuring when he found that there were “themes of homo-
sexuality” in Hindu mythology. Z would constantly look out evidences to gain support in
religion for homosexuality. He also describes that Sikhism mentions the “joining of two
souls” rather than saying man or woman. A desire to bring these two aspects together
even if with the help of remote pointers helped Z deal with the discomfort of this
discrepancy.

The conflict in values

Z experienced several conflicting values between his family and his peer group in how
they construed physical appearance, using cannabis, and being homosexual:
“When I came back home without the turban and first they were shocked, why is he doing
such things, why are you dishonoring your hair and I did not know what it meant to have
respect for your hair the way Sikhs view”

“Its very dual life one way either get admiration or other been mocked”.

“it was very tough with knowing that i was not going to get married conventionally, have chil-
dren conventionally … and it was like a hedonistic idea.. I never really thought i would be in an
relationship with anyone. i thought i would be hedonistic would go here and there, 3 months
with someone here and there someone else”

Z felt he wanted to look different from what his cultural value system expected him to
look like. This conflict resulted in a poor body image. When he cut off his hair, he gained
greater acceptance among his peers. Also, his peer group attached positive value to can-
nabis and was open to his sexuality, whereas his social and religious values were dead
against it. He associated a “hedonistic” value to homosexuality, which was against the con-
ventional values of getting married and having children. This again caused another divide
within him. There has always been an intense yearning within Z to bring about congru-
ence within him with respect to all these aspects. His response to these conflicts were
in extremes of either completely avoiding by “shutting off” or a marked display of
rebellion.

Psychosis and cannabis use

Z terms his first psychotic episode as a “spiritual experience” with “pure bliss”. He enjoyed
what he felt. All the episodes contained themes of him being “powerful”:
“yes.. I felt like I have the power, the pureness.”.

“at one point of it was my only ambition of life for an avatar or messiah or saint of this new
generation to come about and made those changes for us”
356 S. AMATULLAH ET AL.

He believed that he was one of the characters from Hindu mythology, sent for a
purpose to save the world and do good. Cannabis and psychosis allowed him to restore
his association with religion. He did not have complete memory of the episodes but
remembers feeling special and in control of things. He also recalled his display of his
power by becoming violent towards others. On knowing that his psychosis could be
induced by cannabis use, he rejected his diagnosis because it went against his desire to
use. It did not fit in with interpretation of cannabis use as a “spiritual experience”, which
was in sync with his belief in Hinduism and cannabis use. He saw cannabis as a permanent
cure to all his painful feelings of helplessness and shame and a balm to his conflicted split
self.

Emergence of a new unifying self

The transition to a new identity and its emergence is detailed in this theme.

Psychosis as a bridge
For Z, the end of each psychotic episode brought him closer to religion. He began to see
religion, as a source of strength, a unifying force and a way to enlightenment rather than a
burden:
“at one point of it was my only ambition of life was to be a saint of this new generation of but I
think now a change my stand a little and I believe that if I make those changes in my own life
may be by the end of my life two people will get affected by it, and they affect another two.”.

“I would say yes, some of those concepts were spurred on by psychosis and use of substances”

“… its (goal) more practical now, it empowers me rather than something that is external or
praying for something to happen”

“ you know it always easier to deal with the things at hand rather than dealing with outside
elements or an outside world.”.

Though he chose Hinduism as a religion as opposed to Sikhism, it gave him the reli-
gious identity he was longing for. A part of struggle was over when this fell into place
and there was a sense of relief with this state of congruence. His thoughts during psychosis
were to bring about change as a messiah. However, after the symptoms resolved, he con-
verted this into a practical goal of impacting at least few people unlike the grandiosity of
uniting the whole universe during the episode. He felt “empowered” and his vague ideas
got a direction.

An amalgamation of identity without cannabis

The emergence of Z’s new self culminated in him deciding to give up cannabis. He attri-
butes this change to the treatment process. Though it was an essential part of him he
describes letting go of cannabis as a “pleasant amputation”
“I can say for sure every time it (psychosis) happened I had taken cannabis.”.

“Like I used to think like if I don’t take cannabis I will be a loser something like that and its
changed, I don’t think anymore that it’s the most crucial part of my identity and I don’t
think like everything else rests upon that.. yah its been very long journey”.
 MENTAL HEALTH, RELIGION & CULTURE 357

He developed insight into his fragmented self and the role of cannabis in uniting them.
Once the positive and conditional beliefs about cannabis were reconstructed through
therapy, Z was able to let go off cannabis. Instead of creating a void, it instilled peace
in him. He then turned back to Sikhism as he felt the conflict between religious identity
and cannabis use had ended. He did not need psychosis to feel powerful anymore nor
he needed to justify using cannabis. This also brought him closer to his family and cultural
values. Through psychosis was the primary reason he came to treatment, and in the
process he became symptom-free, found real-life goals, and quit cannabis.

Discussion
Through this case, I was able to examine several facets of a young individual’s identity and
understand its course of development, and how it was intricately linked with cannabis use
and psychosis.
Since the very early days of his childhood, Z was distanced from his religion and its
meaning in his life. As a Sikh, he bundled up his hair into a small turban before he
went to school. A Sikh religious identity comprises of 5K’s: Kesh (unshorn hair usually
tied up in a turban), Kangha (wooden hairbrush), Kara (metal bangle), Kachera (undergar-
ment) and Kirpan (dagger). These 5K’s are not just symbolic but are considered the embo-
diment of faith and pride. With his cognitive resources not yet developed, he did not
understand what it meant to be a Sikh let alone what the 5K’s meant. The discomfort
experienced from these, his physical identity, his unusual height, and crooked teeth
created a sense of wanting to hide. The self-concept of young children (below six years)
is formed, based their bodies, i.e., physical self and eventually (between 6–12 years) it
begins to develop into a psychological self, which solidifies during adolescence (Baume-
ister, 1999). Z’s very initial understanding of himself, made him vulnerable, which
marked the beginnings of the damage to his self-concept.
His distinct appearance brought him a lot of attention and his peers constantly mocked
at him especially directed to his turban. While self-concept is internal to oneself (beliefs
and attributes about self), identity entails the social component of self (Baumeister,
1999). Identity formation, therefore, includes a social process by which a person defines
himself based on social dimensions like family roles, group memberships, and other cul-
turally important factors. Individuals incorporate what others think of them into their
“self” (Oyserman et al., 2012) and this interdependent self-construal is more prominent
in Asian cultures (Heine, 2010). The negative appraisal by Z’s peers only did more
damage. He mostly withdrew from them as could not fit in to the group. He used day-
dreaming as a method of coping. A greater finality in him being different was attained
with the discovery of being homosexual at 10 years. This increased his underlying need
to hide. It caused an internal struggle and confusion about his sexual identity. With this,
Z’s interpretation of his “self” left him with an overwhelming feeling of helplessness and
caused further disparity in his identity formation.
Carrying this fragile self, exposure to tobacco and cannabis during his adolescence
served as a quick fix. He not only coped better but also felt liberated and for the first
time experienced a sense of similarity with his peers. Individuals with diffused identity
tend to escape from their life stressors by the use or abuse of substances (Rose & Bond,
2008). His avoidance coping had turned in to cannabis use to break free from interpersonal
358 S. AMATULLAH ET AL.

and intrapersonal stress. It took him four years to accept his sexual identity however he
was fearful of coming out expecting strong socio-cultural rejection. One of the ways
that persons who belong to sexual minorities deal with homophobia (fear being known
as gay or fear of one’s own attraction to the same gender), low self-esteem, and stress
is by the use of substances like alcohol or tobacco (Rawat, 2015). It has been well estab-
lished throughout the literature that use of substances in the LGBT community is much
higher as compared to heterosexuals (Rotheram-Borus et al., 1994; Russell et al., 2002).
As his cognitive abilities strengthened, he experienced greater conflicts within aspects
of himself. His family, religion, and culture strictly prohibited the use of substances and
homosexuality and his awareness of letting them down by his unacceptable behaviour
caused dissonance. He felt so bound to his culture that he experienced immense guilt
each time he lit a cigarette despite the peer approval. Incongruence in self-concept
between how one actually is, and how he or others expect him to be, leads to emotional
states such as guilt, self-dissatisfaction, shame, lack of pride, loneliness, self-contempt, and
self-criticism (Higgins, 1987). In turn, this discrepancy and the states caused by it can
motivate the individual to remove disparity and have an improved self-concept.
However, Z could not modify his physical attributes or sexual orientation despite his dis-
comfort. He began to think of religion as a show or an unnecessary outer cover and finally
rationalised his decision of getting rid of his turban and cutting his hair. It set him free from
the view that people could not look down upon on him as a person who belonged to
Sikhism (which was not obvious without the turban) yet used nicotine or cannabis. In a
way, he seemed to prioritise his conflicts, he had to choose between using substances
with the display of religious identity versus shedding that identity leading to serious
family admonition. In some way, valued his religion, felt responsible for it and could not
bear tarnishing its image.
Going against the family values posed more challenges in Z’s life. The children had
observed obvious discord in the parental sub-system causing poor boundaries, role expec-
tations with significant financial stress. The level of family functioning also is closely linked
with a person’s identity. Positive family functioning during adolescence leads to lower con-
fusion in identity and thus fosters abstinence from substances and precocious sexual
behaviour (Schwartz et al., 2008). Particularly with respect to substance use, the risk
factors are family conflict, substance use in siblings and being part of an ethnic minority
whereas greater involvement, family obligation, religious affiliation, higher parental edu-
cation are seen as protective factors (Telzer et al., 2014; Vakalahi et al., 2000; Wagner
et al., 2010). Z had rejected his religious identity, was using cannabis despite being repri-
manded and was also becoming surer of his homosexual identity. In more than one way,
he had earned their anger. The nature of interaction of an adolescent with parents and
perceived disapproval from them again influence substance use (Scheer et al., 2000)
An important aspect of a non-heterosexual identity is “coming out”. Most men choose
to come out between the ages of 15–24, usually at a time when the peer group support is
strong and due to the fear of family’s poor response. In the light of society, gay men tend
to compartmentalise their sexual identity (Bhugra, 1997). The ego-dystonicity in a homo-
sexual identity is linked to external factors like religious prohibition, rejection from family,
and poor social support networks (Sebastian Maroky et al., 2015). They seek gaining accep-
tance from friends despite the difference (Schwartz et al., 2008). Z got good support from
his peers when he came out to them, which helped him to muster courage to tell his
 MENTAL HEALTH, RELIGION & CULTURE 359

family. He then managed to get support from his siblings, however to the parents,
grounded in their traditional values, it came as a huge shock. He also began looking for
support of homosexuality in religion. Indian scriptures of the Hindu religion such as
Puranas, Mahabharata, Susruta, and Caraka Samitas, provide evidence of same-sex
relationships (Patel et al., 2012), which made him interested in Hinduism. There was a con-
stant, active attempt to bring his long-standing intra-psychic incongruities to rest unlike
his earlier passive self, which simply shunned them.
Despite his cannabis being an essential positive element of his life, he began to have
psychotic episodes after intoxication. During episodes, he shut himself in a room while
his family were frantic and calling him to offer help. This paralleled his desire to “shut
off” from them in reality. A powerless self in reality found an answer in psychosis by believ-
ing he was an avatar sent for a special purpose. He wanted to call upon a higher power to
fulfill his need to feel one with the universe. Strikingly, this is similar to his real ambition of
uniting people for the greater good, bringing about change, giving up “the ego” with
strong influences from the Marxist theory. While in the episode, he felt guilty for becoming
violent towards his family members and in reality, he felt guilty for hurting their sentiments
by his rebellion.
However, interestingly, psychotic experiences became a tipping point wherein the turn
of his identity took place. The delusion of being an all-powerful destructive avatar during
the episode was converted into a realistic aim of bringing positive changes in society and
practically working towards it. Despite the initial episodes, he continued to use cannabis. It
was only after the 4th episode he had good insight into his illness. With the help of inten-
sive therapy, he finally decided to quit cannabis. He realised that his desire to attain peace
could be fulfilled without cannabis. This in turn allowed him to turn back to Sikhism. His
guilt about betraying his family and religion had resolved. The absence of a core self and
the discomfort felt by that void was filled with cannabis earlier on. Once he found his
purpose, he experienced a “powerful self”. Also, he could now integrate the diagnosis
and find treatment process more meaningful. Z also found evidences in Sikhism that he
interpreted could be in support of homosexuality. This brought his religious and homosex-
ual identity together. All the fragmented conflicting selves of religion, sexuality, cannabis
use, and psychotic disorder came together with the emergence of this new, empowered,
congruent, amalgamated self. Without them, he believes he could have never found
himself. While a clinician may understand “psychosis” differently, for Z it came to be a sol-
ution and led him to mend his broken “self” and be more open for subsequent
intervention.
Clearly from the case, the importance of socio-cultural and religious context cannot be
neglected. Substance abuse entails family and community factors and never occurs in iso-
lation (Scheer et al., 2000). The interview process further deepened Z’s insight (gained
through therapy) into his illness, understand the role of cannabis in his life, and connect
different facets of his identity together. On a one-year follow-up, he maintained absti-
nence without any episodes while on regular therapy and medications.

Limitations and future directions

The participant identifies with the LGBT, which, in India, is a not only marginalised group
due their numbers but also subjected to serious cultural and religious shaming and
360 S. AMATULLAH ET AL.

rejection. My minimal exposure to the members of this group may have limited my probes
during the interview process and my interpretations about homosexual identity. There
may have also been certain intragroup experiences that I did not delve into. The partici-
pant also shared some of his artwork in the form of paintings, which were not included
as a part of the study as it was beyond the scope of this paper to get involved in such
an analysis of each painting drawn at particular points in his life. Perhaps including
them may have brought more intricacies to my interpretations.
Basu et al. (2015) in their comprehensive review suggest that a combination of
pharmacological and psychosocial interventions for substance use disorders to be far
more effective than either of them standalone. However, it is important to note that,
among special populations in India, only prevalence of use has been studied while
the treatment approaches have not, especially true of cannabis (Basu et al., 2015).
Each person’s substance use has more nuances to it. Tailor-made approaches have
been often talked about, but little has been concluded about how far it should be
taken. Allowing the client to express his story in a rich and deep way itself can be
very validating and insightful to begin with, considering how substances help to cut
off from their “self”. This then broadens the scope to deepen therapy meaningfully,
thus preventing dropouts. Clinicians working in this area therefore need to accommo-
date the interpersonal and intrapersonal contexts of these disorders thereby moving
treatment a notch up.

Note
1. The data collection and analyses were carried out by the lead author. Throughout the paper
the personal pronoun I is used to describe the collective work of the authors.

Disclosure statement
No potential conflict of interest was reported by the author(s).

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