Clinical and Diagnostic Issues of Cultism Group Dependence Disorder
Clinical and Diagnostic Issues of Cultism: Group Dependence Disorder
This paper reviews some diagnostic proposals on the clinical complexity of cults. The diagnostic criteria of group dependence disorder employed in the therapeutic service of Attention and Research on Social Addictions (Attention e Investigación de Socioadicciones - AIS) are introduced. A psychoanalytically based psychopathological model derived from the research is also presented.
Keywords: sect, cult, diagnosis, follower, group dependency, psychological manipulation, social addiction
The history of diagnosis goes back to Hippocratic medicine of the fifth and fourth century B.C., when the need appeared to assign words to illnesses for treatment. At that time, diagnosis had two meanings: on the one hand, diagnosis as a path of knowledge of the difference (diagignôskein), and on the other, diagnosis as profound knowledge (diágnôsis). These two meanings have carried through to current times, and thus we can find diagnosis as a classification (medical-psychiatric diagnosis) and diagnosis as knowledge of what is happening to the patient (psychological-psychoanalytical diagnosis) (Echevarría & Font, 1991).
The psychiatric-medical diagnosis is based on detecting, classifying, and differentiating a disorder, with the establishment of specific syndromes. Alternatively, the psychological-psychoanalytical diagnosis is progressively established as we enter into a relationship with the patient (thus, for example, we can understand psychotherapy as a complete diagnostic process).
Although establishing a diagnosis helps put order to thinking and information, as well as to communicating and doing research, it can also fulfill certain counter-therapeutic functions: erase the patient’s anxiety toward the uncertainty that his or her suffering can generate and produce in the therapist a sense of omnipotence and of control over the problem. These functions may calm the patient and make the therapist feel much better, but they don't necessarily solve the patient's problem.
Regarding the present subject, we are not concerned in justifying one or another type of diagnosis as suitable—since both can be complementary—but rather in developing an approach to the problem of diagnosis in cult commitments, and reviewing diverse proposals along with the one employed by our group.
All of the proposals are oriented toward defining a specific disorder that a follower committed to a “cult group” might possibly present, which does not indicate that all followers will automatically suffer this disorder.
Thought Reform and Dissociative States
From his recent literature review, Cubero (2001) shows us that psychiatry as a discipline seems to be little interested in the psychopathological complexity of cults. Only a few professionals have become interested in this field and have offered us different clinical descriptions, though these have received little attention.
The model that underlies the diverse diagnostic proposals that have been offered is the model of thought reform. Closely related are the dissociative model (thought reform would be a form of a dissociative state) and the dependence model (thought reform gives way to dependency).
In the first theoretical line (thought reform), we find proposals such as that of West & Singer (1990), which concurs with the observations of Delgado (1977) and helped to delineate the diagnosis of Cult Indoctrinee Syndrome:
Sudden, drastic alteration of the victim’s value hierarchy, including abandonment of previous academic or career goals. The changes are sudden and catastrophic, rather than gradual changes that might result from maturation or education.
Reduction of cognitive flexibility and adaptability. The victim answers questions mechanically, substituting stereotyped, cult-specific responses for what his own responses might have been.
Narrowing and blunting of affect. Spontaneous feelings of interpersonal affection or love are suppressed. The victim may appear emotionally flat and lifeless or almost frantically cheerful and ebullient.
Regression. The victim becomes childishly dependent on the cult leaders, and desires that they make decisions for him.
Physical changes. These often include weight loss, considerable deterioration in the victim’s physical appearance, and a strange or mask-like facial expression, with a blank stare or darting, evasive eyes.
In some cases, clear-cut psychopathological changes may appear, including dissociation, obsessional ruminations, delusional thinking, hallucinations, and various other psychiatric signs and symptoms.
In the second theoretical line (dissociative model), there is a marked reference to atypical dissociative disorder (or dissociative disorder not otherwise specified) included in DSM III and IV (APA, 1983). The DSM diagnosis refers only to “dissociative states that can present themselves in individuals that have been subjected to periods of prolonged and intense coercive persuasion (ex. brainwashing, thought reform or indoctrination in subjects in captivity),” but at no point are the specific symptoms listed that would conform to this residual category. Galper’s research (1983) offers more content concerning the dissociative disorder related to the complications of cults:
Identity loss; group context mobilizes an identity crisis to achieve a profound and rapid identification with the group ideology: group process leads to rejecting a previous identity; the follower is impelled to adopt a new ideological system by identifying with the aggressor.
Psychological regression, decrease of secondary process of thinking, accompanied by an intensification of primary processes: capacity for rational analysis diminishes, cognitive flexibility is lost, primitive fusional aspects appear, a strong group feeling is experienced, with the predominance of omnipotent thought.
Extraordinary narrowing and intensification in the phenomenological field of conscious attention: strong group investing, relationships become potential spaces for recruitment, affective alterations.
The group dynamics devalue the development of personal individuality and uniqueness: internalizing norms stunts personal development.
A unique proposal of Sirkin and Wynne (1990) suggests that cult involvement be classified within the diagnostic category relational problems (as a type of extrafamilial relational problem), which, along with “foliè a deux,” would constitute two specific identities of such a category. Sirkin and Wynne's proposal also specifies severity, a very necessary element. Thus, the diagnosis may be further specified as mild (two symptoms), moderate (three symptoms), or severe (four or more symptoms). The following are this proposal's diagnostic criteria:
The patient’s involvement with a group or organization is characterized by impaired autonomous mental functioning (outside the group context) as evidenced by any two of the following: a) extreme anxiety when separated from the group or group members; b) difficulty processing and evaluating information that contradicts the doctrine; c) impaired reality testing, especially around issues pertaining directly to the cult or cult leader; d) commission of antisocial acts supposed justified by cult doctrine or directions from a leader; e) decisions made outside the group context repeatedly reversed upon pressure from the group or group members.
The patient’s involvement with the group has been facilitated by partial and incomplete disclosure of the group’s doctrines, beliefs, and goals. Full disclosure following intense involvement may not be sufficient to counteract group influence.
The patient’s involvement has not been preceded by psychotic disorder within the past six months.
Obviously, along with these two diagnostic proposals, other psychopathological complications that can arise among the followers are not excluded, such as (1) schizoid affective reactions in people without a previous history, (2) post-traumatic stress disorders, (3) anxiety induced by relaxation, and (4) miscellaneous reactions (phobias, memory deficits, etc.) (Singer and Ofshe, 1990).
Group Dependency States
Since its start in 1986, the therapeutic team of Attention and Research on Socioaddictions (formerly, Assessment and Information on Cults, AIS) works toward an improved diagnostic delineation of the problem at hand. The model that in this case includes the description of the psychopathological state of the follower is that of dependence.
Beyond the phonetic similarity of “addict” and “follower” in Spanish, there is interesting clinical evidence, as pointed out by a Canadian psychoanalyst (Roy, 1998): (1) the phenomenon of crossed dependence, which leads to different addictions being interchangeable; (2) the fact that drug addicts more frequently commit to highly manipulative groups and do not seem stimulated by groups with a low manipulative profile; (3) the observation that, when an addict commits to a group, he can temporarily or permanently quit his addiction; (4) the fact that some rehabilitation groups for addicts present manipulative characteristics; (5) the similarity between the discomfort that the person who abandons a group experiences with the withdrawal symptoms of an addict; (5) the evidence that the states of depersonalization an ex-follower can experience are close to the states ex-addicts experience; (6) the fact that the sensations of depersonalization, along with the anxiety peaks that are experienced during group practices, also hold a parallelism with the sensations that the addict obtains from his drug; (7) the existing bond between affective dependence and cult dependence, as referred by ex-followers; and (8) the sensation that both the follower and the addict have of being “beyond it all,” to the point of believing that drugs and/or dogma does not affect them.
But the clinical model of dependence goes far beyond dependencies to exogenous substances, in that along with such exogenous dependencies we would also find (1) dependence on endogenous substances (secreted by the organism), as, for example, dependence on physical exercise; and (2) psychosocial dependency, wherein we could include certain affective or financial dependencies (such as compulsion to work); we include in this group new forms of addiction, such as to the Internet and sexual dependencies (in which compulsive sexual behavior predominates, such as pornography, sexual tourism, etc.).
In the AIS therapeutic team, the field of work has increased to comprise these diverse forms of “socio-addictions,” in which we would include the dependency to cults. In relation to the latter, we have arrived at a compact systematization extracted from clinical work, and that has recently been defined as follows under the designation of group dependence disorder, which will be diagnosed when at least seven of the following criteria are met:
Excessive time dedicated to group (at least one of the following criteria): a) the time dedicated to the group tends to increase progressively; b) time dedicated to the family, work, or social relationships decreases excessively.
The subject reacts with great irritability and/or anxiety when unable to attend meetings or group activities.
Subject manifests intense affiliation feelings toward the group and its members.
Changes in attitude toward people in his previous environment (at least two of the following): a) cold and distanced attitude, b) lies, c) hostile attitudes.
Unmeasured self-criticism of his pre-cult past.
Conceding the group an excessive importance, which is in disagreement with reality.
Tolerates and justifies personal exploitation in different areas; for example, work, economic, or sexual.
Increase of daily activities as a consequence of the growing dedication to the group.
Experiences of great euphoria or enthusiasm.
Tendency to a monothematic discourse.
Behavioral changes that stand out that are in accordance with group norms or habits (at least two of the following criteria): a) in dressing or personal care, b) in language, c) in hobbies, d) in sexual behavior.
Relational Aspects in Cult Involvement
The problem of cults is not only scarcely addressed by psychiatrists, but also by those who work within psychoanalytical theory. Although there is some interesting research in this respect, neither the “cult-group” nor its complexity are the object of substantial psychoanalytical research. At the same time, the psychoanalytical model is not comparable to thought reform models, whether dissociative or based on dependency, in that psychoanalysis is in itself a metapsychology.
In its more than 100 years of evolution, psychoanalysis has gained comprehension and has left far behind mechanistic models that are more commonly known.
At an individual level, analytical practice has shown how, inside every one of us, many diverse nuclei exist that can combine with each other. Hence, we find neurotic structures with psychotic nuclei, such as psychotic patients with a neurotic area of personality that is sufficiently ample so as not be engulfed by the patients’ pathologies. Other research has shown that the existence of fanatical nuclei, as presented in Lifton´s psychohistoric work (1961), set always within a model of thinking reformation, is nonetheless full of psychoanalytical references. One of the most important observations within this research is that, within each individual, parts exist that can be totalized.
At a group level, the “cult-group” is the result of a process, largely unconscious, in which all members participate. Psychoanalytical work with groups shows how the entire group carries the bud of what would be a “cult-group.” The work by Anzieu (1998) on groups shows, for example, the description of the state of “group illusion,” understood as the group majority's shared fantasy of believing one is doing very well and lacking problems, along with the conviction of having a good leader. At another level, the group as a dream triggers a triple regression (topic, formal, and chronological), to a large extent due to the cultural isolation (in the same way that a dream takes place isolated from external reality).
From this perspective of group, we can understand “mental manipulation” as an indicator of group evolution in a process that we know to be continuous, though we do not yet have a scale available to establish degrees. This state is characterized by the emergence and imposition of the dogmatic voice of the group leader upon a group member, later extended upon other people. In this sense, it is interesting to observe that the majority of “cult-groups” reveal a founding couple at the start. (We will leave for a later publication, however, a clinical description of the configuration of such a process in a group we had the opportunity to study.)
“Mental manipulation” rests also upon a very intense transferential bond exploited for personal purposes. Contrary to the objective of an analysis, what happens in these situations is that the regression of the follower is favored and increased to maintain him in a greater state of dependency. The imaginary relationship, established at a fantasy level in transference, is taken as real by the leader, who presents himself as the sole object capable of satisfying the follower.
As seen from a relational point of view, cult involvement can be understood as a mutual dependence: on the one hand, a leader who esteems himself as chosen, and on the other, a follower who ends up yearning to be chosen by the leader. Inasmuch as the leader needs the grandiosity, he looks for followers to enlarge himself, and if he is without these followers, he tends to feel a lack of structure. On their part, the followers come to confide in the leader, expecting him to offer the certainty of absolute conviction. Underneath this mutual dependence, we find a perverse relationship that affects a great part of the narcissistic links of the follower. In a sense, we could consider the leader as the first follower; in this case, a follower of his own omnipotent fantasies.
From this relational framework, and from the fruit of the work carried out with “cult-groups” in Barcelona between 1990 and 1992, the psychopathologists Atotxegi & Font (1995) isolated certain characteristics, based on psychoanalytical nosology, that merit our attention:
Perverse psychopathology that would be expressed through relationships based on deceit, domination, and abuse of someone, and where personal benefits are obtained at the expense of suffering or destruction. Within these manifestations, narcissistic personality traits and sadomasochistic traits stand out.
Paranoid psychopathology, expressed through a doctrine, which places the subject in partial object functioning, where that inside the group is good and that external to the group is negative. Fanatical manifestations may appear in this line.
Obsessive psychopathology, which is expressed through individual and group control aspects, such as information restriction, imposition of certain rituals, rigidity when complying with group norms, harsh discipline, and so on.
Combining the observations, Atotxegi and Font isolated specific behavior that could appear, among followers with greater frequency: (1) dissociative type functioning in its manic aspect (perverse, paranoid, and obsessive pathology) and (2) dissociative type functioning in its depressive aspect (emphasizing masochistic dependence-type pathology). Between both types is a possibility of a collusion of a dominating (manic-dissociative) and subjugated (depressive-dissociative) type.
Although a diagnosis of dependence should enable us to increase our comprehension about a case and facilitate approaching the patient, in practice we find that people who surround the affected parties often behave counter-therapeutically. In these cases, and independently of the manipulation that the group can exert, we find another source of manipulation that comes from someone close to the affected person and that can interfere with the therapeutic process. Here is an example from our clinical records:
Maria is a 50-year-old woman with two children. Within a year, her parents died, she had to undergo a delicate surgical procedure, and her son died in a car accident. In the past six months, the patient has been connecting to an Internet chat group, and the connection frequency has kept increasing. In the chat sessions, she connects with a group of about 40 people, and occasionally she has met up with some of these. Although her husband claims she is dependent on the Internet, throughout our interviews with both of them, we observed that he shows serious difficulties listening to his wife and recognizing the lack of emotional commitment on his part. Although we prescribed a couples’ treatment so they could talk in depth about their current situation, the husband refused to attend any sessions, since he considered the problem to be his wife’s and in no way his own.
In situations such as these, the diagnosis is used as means of defense on the part of those close to the affected person, and as a way to deny any responsibility in the matter. Although in this case the patient’s dependence on the Internet was real, and within the chat sessions there was a person linked to a group who tried to captivate her, the problem that Maria presented was one more symptom of a larger and more profound conflict within the couple.
On other occasions, our task is not only to differentiate group dependence from a syndrome or a symptom of another situation, but to be able to understand diagnosis management within the couple or the family. We have found, with certain frequency, that the cult is employed to attack the person who either took part in a group or who initiated contact with a group without further commitment. The following demonstrates such a situation:
Beth is a woman in the process of a divorce that began a couple of years back. The marriage deteriorated due to lack of affect, and she decided to end the relationship. Faced with a negative response to a divorce from her husband, Beth decided to consult, along with him, a “therapist.” After a month went by, the “therapist” turned out to be a “group captivator” and suggested to the partners that they take group courses, which they did, but soon quit. This action left Beth needing to find another therapist to help solve couple problems. Once the judicial process was initiated, the husband accused her of being part of a cult and thus being incapable of taking care of the children; he provided all kinds of documents to prove that the group was a cult and that his wife was still in contact with it.
One of the most obvious demonstrations of harmful diagnostic management is found among those groups with a healing and/or therapeutic base. In these cases, the diagnosis is employed as a method of controlling the subject and as a means of justifying that he needs “therapy,” or “courses,” or those activities that the group proposes. Here’s a case in point:
Rebeca is a 40-year-old woman who has spent eight years in a group with a healing base. The captivator, a “psychologist,” combines alternative approaches with psychology and esoteric practices. The woman was captivated through the establishment of a nonexistent diagnosis and was maintained in the group with the aim to “change.” In time, besides therapy, she is advised to take courses on self-improvement, as well as courses to train as a “therapist.” After violently leaving the group, and with assistance, the patient was able to realize that she was not “schizophrenic,” as she had been led to believe.
As you can see, in these situations and other similar ones, we can end up with two focuses of manipulation, one corresponding to the actual group and another corresponding to the use that people surrounding the affected party can make of the diagnosis.
Finally, there is a diagnostic aspect that I would like to recall. As we assess the group, we are simultaneously diagnosing and setting the basis so that a posterior treatment might take place, were it necessary. The reactions of family members to the diagnosis may vary from acceptance to denial of the problem; on other occasions, certain families seem to see the conflict in an exaggerated dimension, maintaining that there is dependency in situations where that is not what we, as professionals, observe.
When intervening with the follower, and during initial moments of the assessment, the diagnosis is experienced as a violent intrusion on our part into their world, and the follower reacts with strong rejection toward us. On occasions, this makes the follower refuse any additional help from us, though he may go on to find it elsewhere.
Although several diagnostic proposals exist, it seems that research and its validation by different specialists is still a pending matter. Criteria unification by different professionals, as well as more extensive and international work with a specific diagnostic outline, could help in the research of this phenomenon.
We feel it is important not to forget that, although we identify a specific syndromic pattern valid to research and to clinical work, our work should not limit itself to detecting such a disorder, but should also be able to explore deeply other areas of the follower’s functioning to accomplish a diagnosis on multiple levels.
The psychopathological manifestations both in groups and in individual followers tend to be complex, and our function is not to attach a label but to advance in the knowledge of cult involvement, independently of the theoretical model that supports us. Gatherings such as this one, at the AFF conference, can help to provide the exchange of experiences, and thus progress, in securing a solid diagnostic model, although doubtlessly we need more time to work on the problem in depth.
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This material was originally prepared for a presentation at AFF’s annual conference, June 14-15, 2002, at the Crowne Plaza Hotel, Orlando (FL) Airport.
 In Spanish, we use the terms “adepto” and “adicto”.