Today, we're going to talk to you about a fascinating topic, drinking the Kool-Aid, parallels between cult membership and substance use disorder. I'm Dr. Nidal Mukaddam, I'm faculty at Baylor, and it is really an honor and a privilege for me to be able to present today, especially since it's the last stretch on Sunday. So I thank everybody who's still present and paying attention. Please feel free to ask questions in the chat if you have any. We welcome lively discussions. I'm going to present two wonderful young professionals, Dr. Konana and Dr. Shinoy, who are both trainees at the Baylor College of Medicine, and they are the ones who got me involved in this topic, which was not even on my horizon, but it turned out to be very interesting in terms of how substance use disorders, parallel cult memberships, and concepts in the way people join and what keeps them in, so perpetuating factors. So without further ado, we're going to get started. This presentation will involve live audience polling, so I will ask you to cast answers at some point. None of us has relevant financial disclosures, and we have a lot of objectives for this. We're going to start you by examining the history and definition of a cult because that has really changed through the centuries. We're going to identify patterns of attachment styles found in cult members versus those in individuals with substance use disorders. We're going to talk a little bit about how former cult members present with a complex psychopathology constellation, which defies diagnostic criteria sometimes, describe the concept of group psychological abuse, and then identify the four primary dimensions and strategies that cult leaders use to psychologically abuse their members. So the first part is really about introducing how a cult might work. Then we're going to talk about factors that predispose one to join cults versus factors that predispose one to developing a substance use disorder, and start drawing parallels between that area and the next one. We're going to then describe psychiatric comorbidities of cult members and those of SUD. Identify the neurocircuitry involved in those natural highs and substance-induced highs, and finally take another look at neurocircuitry involved in SUD and how this may be applicable to the psychology involved in cult membership. Now, by attending this workshop, I want you to remember that we don't know enough about cults, and our knowledge of substance use also is a bit fragmented between clinical practice and neurocircuitry. So what we're doing in this workshop is a lot of dot connecting. We're connecting the dots between multiple things. So bear with us while we connect all the dots, and we invite conversation about this, especially at the end. So let's start by polling the audience. Have you ever treated a patient who belonged to a cult? And so to join, you're going to either join by website at the top, pollev.com slash NMUKADAM, or you text 22333 NMUKADAM, and then you will get a confirmation that you've joined, and that allows you to enter an answer. Let us know if you have any trouble. Just checking that everybody got their poll prompt. So if you do it by text, you receive a confirmation. If you do it online, it also sends you a confirmation. Okay, so less than half of us have treated cult members, yet cults exist, and former cult members have a lot of issues. And so what that tells us is that either we're not identifying it, or they're not getting care enough, or they are seeking specialist care. And all of these options point to the need to know more about it, because we want to identify whether somebody has been in a cult-like structure, and we want to be able to help them once we have identified this. Okay, we're almost at 50-50. I'm going to move on to the next question. The next question is, how do you define a cult? This is a word cloud, so maybe two to three words only, please. So this is a free form entry. Mind control, coercive control, K, another mind control, a closed group, closed community, insidious. Okay, that's an interesting one. High control group, subversive induction, Wonderful. I'm going to point out that as somebody who has psychiatric training that one of the difficulties with cult memberships is sometimes it sounds like a delusional manifestation in a group. If your group believes certain things that are not mainstream, if enough people believe it, it is no longer a delusion. That's always baffled me. I think that as we talk more about cult definitions, we should touch on that a little bit. The last answer, isolation, is also highly pertinent. Initially appealing, yes, exactly like drugs. You have a high in the beginning and then you think you like it, then you probably sign on for more than you thought. Love-bombing, yes, we're definitely going to talk about that. Let me give it 20 more seconds here. Yes, definitely dopaminergic among others. Thank you. I think we're dealing with a very, very knowledgeable audience. You've touched on most of our big topics. Now, complete the following sentence, cults have existed since, that's also a free entry. Yes, the beginning of time. Okay. That's because as human beings, we really, really like to bend together and have a joint mentality. Forever. Okay. I think the group agrees. So the term cult right now in this day and age is somewhat pejorative, but can you think of organizations that resemble a cult structure without the negative connotation? Again this is free form entry. Wall Street, okay, yes, AA, politics, yes, there has been a lot of polarization and division recently and I think we're all seeing it, religion, Girl Scouts, okay, so, oh and academia, absolutely. So basically what this group is saying is that in order to form a cohesive entity or a cohesive group you have to define who the group is and the definition of who the group is can walk the line between healthy and unhealthy. Medicine, self-help, families, military, and for those of you who've used Poll Everywhere before you would know that the size of a word correlates with how many people have answered that word, so it seems like our top winners for this question today is religion as number one and academia as number two. Okay, now thinking back to this last question, what characteristic were you thinking of that was resembling a cult but not necessarily negative? Okay, community, cohesiveness, yep, affirmation, family, so, and it provides validation, yes, so obviously a cult will provide a certain structure that fulfills certain psychological needs but what the group is saying, if I'm getting you correctly, is that you start off with good things like belonging and validation and a family-minded direction and then it goes above and beyond, okay, awesome, so affirmation and belonging are the top winners for this particular poll, as you see their size is much bigger compared to the others. Okay, with that, I'm going to turn it over to Dr. Konana who is going to talk to us about a conceptual understanding of cult membership and its relationship to addiction. Thank you for the group for sharing your thoughts. Dr. Konana, are you ready? Yes. I'm going to mute myself. Awesome, thank you so much, Dr. Mokadam. Good afternoon. My name is Onisha Konana. I'm a fourth-year psychiatry resident at Baylor College of Medicine. So, for this initial part of the workshop, I'm going to be presenting on concepts of cult membership and addiction with emphasis on substance use disorders. I'm going to go over similarities and differences of psychological impacts on people who've been involved in cult membership and those who had various addiction disorders and in the next presenter's section, Dr. Shannoy's section, ideas from this part of the workshop will be used to open a discussion regarding how these similarities and differences could be utilized in theorizing treatment models for various psychiatric conditions experienced by former cult members. Next slide. So, to better understand the modern-day conceptualization of the term cult, it might be helpful to understand the origins of the word. So, in the 17th century, the term cult merely referred to worship. There was no negative or positive connotations attached. By the 18th century, the term expanded to include a non-religious admiration or devotion to a person, idea, or fad. This could include even devotion to financial success. And then by the 19th century, cult referred to a religion regarded as unorthodox or spurious. So, it began to adopt somewhat of a negative connotation. By the 1930s, certain cults became the object of sociological study. The sociologist Howard Becker differentiated the terms religious sect and cult by demonstrating that religious sects maintain continuity with traditional beliefs and practices while cults were novel and arise more spontaneously. But other sociology scholars at the time conceptualized the term cult in ways that focused more on the critical aspects and less on the origins of the group itself. So, this eventually led to the modern-day understanding of the word cult. Next slide. So, there's very little literature regarding clinical treatment of mental conditions that develop from cult participation. So, this workshop aspires to address concepts of modern-day cult and look at how its overlaps with addiction disorders can be used as treatment models, since addiction disorders have much more literature present. So, in order to start going down that road, let's dive into this question. What is the modern-day understanding of the word cult? So, this definition is from an article published in 1996 in Psychiatric Times. Cults are groups that often exploit members psychologically and or financially, typically by making members comply with leadership's demands through certain types of psychological manipulation, popularly called mind control, and through the inculcation of deep-seated anxious dependency on the group and its leaders. Next slide. So, because the modern-day idea of cult is very focused on the idea of mind control and psychological manipulation, brainwashing usually goes hand in hand. The definition of brainwashing is to make someone adopt radically different beliefs by using systemic and forcible pressure. Let's look at an example of this called exploration of meaning. This technique was created by one of the leaders of the cult called NXIVM, which will be addressed more in detail in Dr. Shannoy's part of the workshop. So, this is a method used in group settings where the leader intentionally extracts traumatic and vulnerable moments of a member in front of a whole crowd, with the intention of changing that member's perspective on the trauma they've endured. The cloud then claps for the member, creating powerful and emotionally heightened mind states, stimulating the reward pathway for the person undergoing the exploration of meaning. Other more obvious brainwashing techniques used in cults include physical abuse, fostering dependency, and inciting fear within the members. Also, having members chant mantras to adopt beliefs being imposed by the cult. So, for example, in NXIVM, members were told to chant, I am nothing and I have no emotions, for hours and hours. This can actually promote neuroplastic changes. Again, further details on some of these NXIVM strategies will be discussed again later. Next slide. So, now we've established some background on the definition of cult and brainwashing techniques. So, we can start to explore the psychology of cult membership. Again, the idea is we're going to tie in these theories with how it relates to psychological concepts and addiction disorders. So, with that said, let's go over attachment styles. Attachment is an emotional bond that is created with another person. Just as a refresher, Mary Ainsworth described three major styles of attachment, including secure, anxious-insecure, and avoidant-insecure. A fourth one known as disorganized attachment was added later, where poor coping skills and minimal boundaries develop. Next slide. So, literature has shown that insecure attachment styles tend to be present in people who are more susceptible to joining cults. The insecure attachment may worsen once within the cultic environment. This may be because the group encourages devaluation of non-cult members and idealization of the leaders. This leads to lack of healthy attachment to people who are not codependent and enmeshed in the group. In fact, it encourages stronger attachment to people who encourage erratic thought processes and behaviors. Leaders and other members within the cult may offer positive validation when members oblige with cult demands, creating a source of comfort, similar to what is offered by caregivers during adolescence when they follow rules or do well on assignments or do what their parents want them to do. However, these same people may also prove to be a source of threat when the member fails to comply with demands. So, the leader may threaten to abandon the member. They may inflict pain or be emotionally abusive. This constant state of fear that is created within cultic environments may lead to more anxious, insecure, and disorganized attachment styles. Next slide. So, the insecure attachment styles certainly pave the way for people to be more susceptible to group psychological abuse, which is one of the main things in cults. There are four primary dimensions within the taxonomy of group abuse strategies. The four dimensions are emotional, cognitive, behavioral, and contextual. From the emotional domain, group leaders will activate and intensify positive emotions of the members in order to strengthen ties and foster a false sense of emotional connection. An example of this is love bombing, which I think one of you mentioned in the poll everywhere. So, love bombing is also a strategy used in abusive relationships, unfortunately. So, love bombing is the concept of using excessive flattery, affection, and displaying intense levels of attention to a person with the intention of manipulating and influencing them in some way. So, this strategy may help cult leaders successfully recruit new members or have already existing members comply with the cult demands, no matter what the risk might be for the victim. Regarding the cognitive dimension, the cult rejects any reasoning by the member that's not consistent with the group beliefs, which impacts critical thinking ability. This also forces members to place group values above social and legal laws, which could be dangerous. In the behavioral dimension, the leader and other members of the group may coerce, show contempt, humiliate, and reject members for behaviors that are not in line with the group interests. Finally, there's a contextual domain. This consists of strategies used by leaders to control the member's environment and may consist of withholding information, controlling who the member can and cannot spend time with, or forcing the member to isolate themselves. Next slide. So, how would a clinician involved in the mental health care of a former cult member even gauge the extent and means of abuse inflicted on them by the cult? The group psychological abuse scale is a measurement tool for determining extent of psychological damage resulting from cult membership and allows the person to rank certain categories on a scale of one to five, one being not characteristic at all of the group and five being very characteristic. And I have a question that maybe some of you could reply in the chat, but some of you mentioned having had worked with former cult members. So, I was just curious about what tool you use to be able to measure the means of which abuse is inflicted on them. So, this group psychological abuse scale has a variety of items. So, I'm just going to go over the few examples that are on this tool. One item is the group does not tell members how to conduct sex life. So, if this were a true statement, the member would rank somewhere around five, but if it was completely false, they'd rank one. Another example is this group discourages members from displaying negative emotions. Another one is the group advocates or implies that breaking the law is okay if it serves the interests of the group. Another one that's quite characteristic of NXIVM is women are directed to use their bodies for the purpose of recruiting or of manipulation. Next slide. So, in this slide, we're going to totally switch gears and discuss attachment theory in regards to substance use disorders. When we treat addiction, we do our best to use psychotropic substances to address the underlying manifestations such as cravings and comorbid psychiatric conditions. However, as you might know, there's also psychological dimension to addiction outside of what medications can address. So, that's where we're headed right now. In the self-medication model, substance use may be linked to attempts at mitigating feelings of emptiness, struggles with self-esteem, struggles with emotional regulation, and struggles with relationships. This helps understand how self-medicating may alleviate pains associated with insecure attachment. Those who abuse stimulants are linked to seeking more closeness with others, thus requiring a hyper-activating substance. On the contrary, those who abuse sedatives may be linked to seeking more distance from others. Meanwhile, opioid abuse is linked to more insecure attachment styles in general. Once the patient has reached abstinence from any of these substances, they may still have insecure attachment styles that have not been addressed. Therefore, mentalization-based therapy is used for improving security in interpersonal relationships to build rapport and more secure attachment styles. The same concept could be applied to former cult members who have left the cult with a significant help, but still struggle with the insecure attachment styles. Next slide. So let's look at risk factors that predispose one to joining cults. There is increased familial conflict, loneliness, emotional abuse, having family members in a cult already, an acute stressor requiring psychological relief, seeking a sense of higher purpose, high suggestibility, psychiatric comorbidity, and peer pressure. Next slide. So this slide shows how many of those risk factors from the previous slide of joining cults actually overlap with risk factors that predispose to development of substance use disorders. So this also includes familial and social tensions, emotional abuse and neglect, psychiatric comorbidities, peer pressure, physical health, and history of physical and sexual abuse. Next slide. So, okay, let's now tie in how these overlapping risk factors and insecure attachment styles pave the way to increased risk of developing substance use disorders and joining cults. The light blue rectangles and solid green arrows in this diagram depicts the neurobiological research and reward deficiency hypothesis that's already well-established as a theory for addiction. The dark blue box and the hollow green arrow depicts how this established hypothesis could also theoretically be applicable to cult membership. So what exactly is this hypothesis? Well, negative attachment experiences earlier in life leads to insufficient satisfaction from normal social contact. So while pleasant social interactions would normally have caused endorphins to be released in the ventral tegmental area, the insecure attachment may actually lead to lack of endorphins to be released from those same normal social interactions. This causes a lack of sufficient reward and satisfaction. So this leads to feelings of emptiness as normal life experiences do not feel satisfying enough. This ultimately leads to increased risk for developing addictive behaviors. So these same feelings of emptiness could be what increases susceptibility for being recruited into a cult, especially since these groups may advertise themselves as being able to offer answers for personal existential problems and offer a higher sense of purpose. This would feel extra appealing to those with insecure attachment styles that are not finding sufficient reward from normal, healthy social contact. Next slide. So let's look at a study. There is one study regarding psychiatric comorbidities of cults, of members who join cults. And this study is from the Psychiatry Research Journal from 2017. In my literature review, this was one of the, I think this was the only one that actually addressed this. It's difficult to conduct studies with former cult members because many of them are ashamed and don't want to be open about it. So unfortunately, the study only had 31 members that were part of it. And they were studied using structured interviews such as the mini international neuropsychiatric interview. And the study found that 50% of the former cult members were found to have anxiety disorders preceding cult commitment. Mood disorders actually decreased during the membership period compared to the year preceding the cult commitment. Mood disorders then increased again in the year following departure of cult membership. So we'll discuss some reasons for why this may be in future slides. Substance use disorders and eating disorders decreased during cult membership. This may be due to a concept known as addiction switch where people replace their substance of choice with another addiction. In this case, participation in the cult. This article also goes a step further to address other similarities found between addiction and cult membership outside of just psychiatric comorbidities. For example, both those struggling with substances and those in cults feel great difficulty to change their situation despite the damage and negative impacts on familial and social lives. Also, both groups of people have an initial feeling of psychological relief at the beginning of their substance use or beginning of their cult membership and thus may have temporary relief of their mood symptoms. This is probably why mood disorders decrease during membership period compared to before the cult commitment. Next slide. So now let's look at neurological impacts of cult membership. Some research indicates that symptoms described by cult members may resemble personality changes regularly associated with disorders of the temporal lobe of the brain. These symptoms include irritability, loss of libido, compulsive attention to detail, mystical states, paranoia, and lack of humor. Furthermore, lower cognition may result from long-term sleep deprivation, sometimes calorie restriction, long monotonous hours of work with no break and deprivation of sensory input. Former cult members may also exhibit negative characteristics such as depression, guilt, memory impairment, fear, slow speech, rigidity of facial expression, and indifference to their physical appearance. Finally, psychophysiological changes may occur due to hours of chanting mantras leading to alterations in consciousness and even psychotic breaks. Next slide. So let's look at the actual neurocircuitry involved in addiction disorders. And in a few slides, we'll tie all of this in together. So just bear with me. The orange line on this diagram demonstrate the mesolimbic pathway from the VTA to the nucleus accumbens. This is a pathway that's crucial for reward, as many of you already know. Impulsive traits and a dysfunctional reward system combined leads to a higher chance of developing a substance use disorder. Next slide. This diagram is a very simplified version of how natural highs work. So things that make us feel good in day-to-day life, including good food, accomplishments, pleasant views, sex, and exercise, leads to a release of neurotransmitters such as anandamide, acetylcholine, and dopamine. This leads to feelings of satisfaction and reward without at all impacting the actual reward circuitry. And therefore, these things are considered healthy, these natural highs. Next slide. So on the other hand, substance-induced highs and certain behavioral addiction-induced highs all affect the mesolimbic dopaminergic system. And therefore, that's dangerous and unhealthy. This simplified diagram portrays how substances such as marijuana, benzos, stimulants, opioids, and alcohol and nicotine lead to excessive and fast dopamine releases within the mesolimbic system. Certain psychedelics and hallucinogens are also said to maybe have the same effect, though there is some debate about that. The volume and speed at which dopamine is released eventually affects the reward circuitry itself at the molecular level, leading to diminished pleasure of using substances over time. It also then leads to cravings and obsessions about the drug in the drug's absence. Next slide. So in this slide, we're gonna look at what types of neuroplastic changes occur with stimulant use. It may seem counterintuitive that stimulants are prescribed for improving cognition and impulsivity when we consider how fast dopamine-releasing substances affects neurocircuitry in a negative way. So to address this counterintuition, I'm going to also discuss differences between prescribed stimulants versus things like methamphetamines and cocaine. So while stimulants prescribed for ADHD and other disorders come in formulations that are control-released, substances like cocaine and methamphetamine are immediate and they have rapid acceptance into the blood-brain barrier causing powerful biological highs and very intense reinforcement. The control-released stimulants that have clinical use are directed towards the prefrontal cortex for impulse control, and theoretically have less of an impact on the actual reward pathway, though if used in high enough quantities, it can affect that too. So let's see. So with the illicit substances without control-release, they have really rapid highs. They affect the reward pathway over anything else. This leads to neuroplastic changes that cause a shift in activation of the ventral striatal loop to its neighbor, the dorsal striatal loop, and the dorsal striatal loop is involved in forming habits, and it's not as involved in deriving reward and satisfaction. Eventually, the dopamine neurons stop responding as much to the primary reinforcement. So the primary enforcer may initially be substance use, as discussed, or it might be addictive behavior like gambling, sex, or seeing the number of likes on social media posts. Eventually, the dopamine neurons stop responding to that and will eventually start responding to things that just stimulate that habit pathway. So these are things that would actually relieve the anticipation of that reinforcer. So instead of the substance itself, it'll now be the site of the substance. Instead of gambling and getting the money from gambling, it'll be the site of a casino. Instead of seeing the number of likes on your social media posts, it could be the site of a smartphone. Next slide. So now that we've looked at all this, there's clearly a lot already known about the neurocircuitry involved in addiction, and that has been very useful for developing psychotropic treatments that target the neurocircuitry. If we could understand neurocircuitry of group psychological abuse, perhaps that could help former cult victims in a similar way. So in this slide, I'm going to address how the neurocircuitry of addiction could potentially be applicable to neurocircuitry involved in group psychological abuse. So it's very theoretical. So people seeking a higher purpose may do so because they lack sufficient stimulation of their own reward circuitry. This was already discussed earlier when addressing how those with insecure attachment styles may have insufficient reward from normal social interactions. So these people may be more susceptible to being recruited into the group with the promise of self-improvement, transcendence, or financial and academic success. By performing behaviors that are mandated by the cult and receiving constant personal validation upon complying with the cult demands, the reward pathway is constantly activated by behaviors promoted by the cult. So this resembles the fast and rapid dopamine releases caused by certain behavioral addictions and substance use disorders. Over time, the cult member may start to perceive the behaviors they're engaging in as toxic. So for example, members of Jonestown and NXIVM expressed feelings of feeling uncomfortable and scared once cult demand started to increase after being in the group for quite some time. But the member may hear the demand made to them once by the group leader, and rather than complying for the sake of feeling that reward of high praise or validation, they might do so because now they're aware of the need for validation, they might do so because now it's wired into them as habits to comply blindly with such demands. The member may constantly feel trapped, like they cannot leave the cult, even if they have family members who are willing to help them. While part of their lack of leaving is certainly due to a trauma aspect and the fear of consequences, part of their fear or part of their feeling stuck may also be because of the habits that have formed. So for a brief example, members of NXIVM were told to respond to any text from their leader within one minute of being texted, no matter what they're doing, whether they were sleeping or they're driving. So it's pretty inconvenient and it's actually pretty dangerous to be complying with such a demand. However, the compulsion to engage in this demand has now become routine habit for the member. Next slide. So this leads me to the conclusion of my portion of the presentation. These are some questions that are going to be addressed towards the end of Dr. Shannoy's presentation. And at that point, when the slide opens again later on, there's going to be interactive discussion for 10 to 15 minutes. So I encourage you to keep some of these questions in mind. Thank you so much for listening. I'm going to now hand it over to Dr. Shannoy. Thank you, Dr. Kanana. I'm going to pull up the presentation one more time. Okay, so I'm Dr. Nancy Shannoy, I'm a PGY3 at Baylor College of Medicine and General Psychiatry. And the next portion of our presentation is going to be about cult case studies. So our objectives in this section are to utilize interactive case illustrations, including survivor accounts, to examine how the organizational structure of cults coercively keep participants adherent to doctrines. We also intend to identify the overlap between cult and addiction psychiatry, and examine which therapeutic interventions are appropriate for treating those who are exiting a cult. One last objective is for us to discuss optimal psychotherapy practices. So our first case study is Nexium, and as you can see in the picture, the words on the board say executive success programs. And so to talk a little bit about this cult, it was led by two people named Keith Raniere, known to his followers as Vanguard, and Nancy Salzman, known as Prefect, who started this self improvement program for professionals called executive success programs that drew upon influences within psychology, neuro linguistics, and hypnosis. The intention of the organization was to enhance people's leadership strategies and make them more effective at whatever their line of work was. And so part of this program's emphasis was on selecting people who were legitimate, lended legitimacy to the organization, including people of status, families of leadership of other countries, including the children of a former Mexican president, celebrities, including Hollywood celebrities, and even the Seagram Liquor heiresses. At one point, the cult leaders arranged for a visit from the Dalai Lama, which also helped lend the cult's legitimacy. Typically, the cult would have these annual high intensity retreats. Every birthday of Keith Raniere's to honor him. And this really enforced the cult leadership structure. There were various subgroups for men, women, and even childcare provided for people who participated, who happened to be parents. Eventually, the cult folded because of issues that were criminal in nature, and the cult leaders were found to be guilty of racketeering, labor and sex trafficking and other crimes by the Eastern District of New York. So what were some elements of manipulation that made this cult so successful in retaining membership? Well, for one, as mentioned by Dr. Konana, there was an emphasis on preying on existing insecurities. So during these explorations of meaning, which were the short public psychotherapy sessions, people's emotional experiences would really come across to the audience, including breakthroughs to quote, break their stimulus response chain. In doing so, the cult was able to identify individuals insecurities in order to leverage and gain control of that person in a public setting. Additionally, during these explorations of meaning, there were also the utilization of neuro linguistics to really enhance the experience and hypnosis techniques, which in this case was really a form of mind control that the leaders of the cult employed. Another key facet with regards to manipulation was self blame. So members would say things like, I will actively choose not to be a victim and other statements like I am nothing and I have no emotions. And these were considered normal mantras. At some point, members were asked to choose between their careers, which they had initially worked to enhance and group belonging to the cult. Additionally, during sessions, there were mentions of uncomfortable subject material, including rape of others, ideas that males should not have to be monogamous and women wouldn't have to question that. And if there was ideology that a member did not feel was reasonable, they were told to get an EM to explore why they weren't agreeable to the doctrines. Another strategy employed included high arousal techniques. So Vanguard Week, the retreat week to honor Keith Renier, the leader of the cult, was packed with activities that were simultaneously overwhelming and exhausting so that there was no time to think. It was described as an adult vacation slash retreat that was jam packed with activities, including, well, leading to really at some point, sleep deprivation. As participants became more involved in the cult, both in and outside of this retreat week, there was an emphasis on sleep deprivation with people reporting sleep as much as really five or six hours maximum at times. And for some individuals, there was even a prescribed diet of as little as 500 to 800 calories a day. And the deprivation of sleep and really food and nutrition made it difficult for people who were part of the cult to dissent with leaders of the cult. Another key event that really happened was readiness texting drills. So participants who were in the cult were required to reply within a minute to the person that they reported to. And this was a strategy used to control the individual. There was another set of strategies related to a division that would separate marriages and other relationships. For one, India Oxenberg and Catherine Oxenberg, the latter, a famous actress within Hollywood, were encouraged to separate and were isolated, in fact, at cult activities. It was framed that the daughter was encouraged to individuate from her mother. Another facet of the divisions included the promotion only of people who had a certain physique, in this case, women who were slender and considered conventionally beautiful. Cult leaders interfered in romantic relationships and marriages as well to ensure dependence only on the cult. In fact, the leader Keith Renier wrote marriage vows for various couples within the cult. Misrepresentation was another important form of control. One subgroup within the cult was DOS, and this really stands for Dominus Obsequius, and then the S is part of it as well. And this was a secret sorority of women dedicated towards female empowerment, but instead, this subgroup really involved elements of sexual abuse, where members were required to have relations with the leadership of the cult, and physical abuse escalating to the point where women received brands on their skin. Another group was Jeunesse, and this group received curricular education about female empowerment that was also led by Keith Renier, the leader of the cult, but did not truly espouse some of the more conventional elements of feminism. Ultimately, the end of the cult came about by an emphasis on criminal activities. So it was common for cult leaders to require notarized collateral, which would be damaging statements or blackmailable information that cult participants would hand over. Other constituents of the cult were sexually coerced by the leaders. And mid-level participants, or mid-level management, so to speak, were encouraged to gather this collateral or blackmail from those below them in the cult structure to really retain control of every layer within the cult. Cult participants were actively encouraged to help with the criminal acts within the cult, such that they would be accountable as well. And eventually, there was a branding of women and physical abuse of them, as spoken about earlier within DOS, which was a secret society within the cult itself. So one survivor account is spoken about here, and so this is Catherine Oxenberg, and she's an actress in Dynasty, a common TV serial, and she's also the daughter of the Princess of Yugoslavia, or the former Yugoslavia. And so Nancy Salzman, the cult leader, asked Catherine to think back during an exploration of meaning, and Catherine spoke about how she had flashbacks of a man sexually assaulting her when she was four years old, and then again when she was assaulted again at one of her workplaces. Publicly, she was asked to draw a link between these flashbacks. She said, it occurred to me that I have a fear of men in power. And Nancy asked her, does this change your perception of the situation? Catherine said she felt like she no longer had fear. In the session, she said, I felt like I had made a breakthrough, and the coaches, the mid-level management of the cult, told her that this was the equivalent of 10 years of therapy in 10 minutes. Catherine felt that she had made an incredible breakthrough, and at that time was asked to commit to more within the organization, as was common within the cult. So that concludes the summary of the case study pertaining to NXIVM, so now we're going to transition to the People's Temple in Jonestown to identify some of the common practices within that cult. And in the picture, we have the entry to the People's Temple at Jonestown. This was a commune in Guyana that the leader of the cult took his followers to eventually. So who was the leader of the cult? For the People's Temple, this was Jim Jones, who was a political activist, preacher, and self-proclaimed faith healer. He appealed to the disenfranchised and people of multiple ethnicity. He himself had a family with children of multiple ethnicities, and so he was considered ahead of the current race relations climate of the time. He understood that power was related to faith, and faith was determined or dependent on how many people belonged to his group, so the number of adherents. So he emphasized the importance of group acceptance and believing in a cause or in something greater than oneself. His group did a lot of charitable work, including feeding the poor, paying for rehab for substance using members, and building homes for the elderly. He was known to have an uncanny instinct for figuring out people's values and their fears. So what were some elements of manipulation within this cult? For one, as with the other group, there was the emphasis on creating a sense of unique belonging. One way he did this was an appeal to human fear of existing stressors in the world, and blaming of other groups, statements like, the world was not ready to let us live. He also uprooted members who were part of the cult. At one point, 150 adherents followed Jim Jones from Indiana to California. As he told them, this was one of the nine places to be in the event of a nuclear holocaust. Eventually, after facing media and political pressure in San Francisco, California, a large group of followers fled to Jonestown, Guyana from California, when the group faced pressure. He was thought to have remarkable abilities as well, including supposed faith healing abilities, theatrical revival churches. So this was in group settings. Jim Jones would purportedly heal people of their ailments. With that, he was also a gifted orator, and was known for his ability to keep the crowd pretty engrossed in his sermons. His group, large as it was, wielded a great degree of political prowess in California, and he knew that as a group, the cult could, quote, turn out the vote. One other strategy or set of strategies employed by the People's Temple included fear and intimidation. Much like NXIVM, there was a requirement that participants give false confessions, and would often be victims of blackmail, and sign letters giving Jim Jones' power of attorney giving away their signature or even their U.S. passport, or even the mortgage to their house. Others who were vocal about how they felt were publicly beaten, and once the group had transitioned to the Jonestown commune in Guyana, there were armed guards that prevented people from leaving the cult. The eventual goal of the leadership in the cult was to emphasize to people in Jonestown that there was no outside world to go to. And the compound in Guyana itself was a difficult one to be at because of deprivation conditions, including starvation, sleep deprivation with nightly suicide drills, where participants would have to be ready to commit mass suicide if asked to, and of course labor-related exhaustion. People would spend up to 16 hours daily in the field, toiling at the Jonestown commune. As with the previous cult, there were enforcers that helped Jim Jones retain leadership. And so part of this was during the mass suicide event that ultimately led to the downfall of the cult. During this mass suicide event, children were forcibly killed with cyanide and needles and people were shot in the back who tried to escape the compound. The ideology that the enforcers and that Jim Jones really wanted to propagate was that cult members needed to lay down their life with dignity and that the act of suicide was revolutionary in this inhumane world. And with that dedication to the cause, Jim Jones was manipulative towards the adherence to his in his group. He was sexually manipulative with women, telling them to have relationships with him because of the cause, much like the other cult, he would encourage alienation of members from their families and force them to remarry in certain situations. He also inspired his constituents to have a great degree of loyalty towards him, saying statements like, we all need to go down if they come for us, they will have to kill us all first. So these are some pictures from the cult itself. And what had happened was that politicians had come to view the compound. Jim Jones enforcers ultimately ended up shooting at journalists, defectors who wanted to leave the compound and politicians, including Congressman Leo Ryan and his delegation. And there were some casualties given that politicians lives were at risk. This was considered an act of terrorism and the Federal Bureau of Investigation became involved. Expecting an imminent FBI raid, Jim Jones encouraged everyone in the People's Temple to commit suicide. People drank flavor aid laced with cyanide or injected cyanide. If they didn't want to, it was done forcibly to them by the enforcers within the cult. There were over 900 casualties. And this was the single largest number of casualties until September 11th. So as you can see in the picture on the right, all of these are bodies of people who passed away. It took days for authorities to fully realize the scale of what had happened and the true death toll. So how does this have to do with substance use disorders? Well, for one, Jim Jones himself had at least five substance use disorders, autopsies from the site revealed that he had levels of pentobarbital at toxic doses, suggesting that he had developed a tolerance to benzodiazepine, I'm sorry, to barbiturates, though he did not die of an overdose itself. He also used a number of amphetamines, opioids, including Darvon and methaqualone, morphine, oxycodone, and then benzos like liquid Valium. The amphetamines would allow him to preach for hours. And he also consumed alcohol and abused antibiotics and even insulin. So that concludes the two case studies. Now we're going to talk about future directions for therapeutic interventions. So how does one leave a cult like the two spoken about earlier? Well, for one, cults deny basic freedoms of speech, thought, and association with others that can limit one's psychological growth, and it can be difficult for family members to extract loved ones from cults. When cult practices involve illegal activities, threats, or abuse, the law or the legal system can intervene, especially as it did in the case of NXIVM. Additionally, newsworthy scandals make it hard for cults to retain membership. But why don't people leave? Well, for one, as mentioned earlier in the presentation, it's easier to or there is a desire to belong and attain rewards. There's also an element of cognitive dissonance that keeps participants trapped. It's hard to admit you were deceived by the cult. There are also intrinsic vulnerabilities related to deprivation, whether through starvation or sleep deprivation. Also people are controlled by cults with damaging information or personal secrets in the form of collateral or even financial entanglements. Lastly, people join at vulnerable transitional points in their lives, such as when they move to a new city, at the time of graduation, or the death of a spouse, and may be isolated and particularly vulnerable because of that isolation. So as we mentioned before, cults do involve behavioral addiction. There are short-term rewards that engender persistent behavior despite knowledge of adverse consequences and knowledge of bad features of the cult itself. There also may be, as with substance use disorders, an element of tension arousal prior to participation in cult activities and a relief and gratification after participating. As with substance use disorders, all activities of members are devoted in service of the cult and a lot of time is spent, again, in service of the cult, as it is with addiction to substances for those who have substance use disorders. As mentioned before, people who are part of cults tend to have higher prevalence of psychiatric comorbidities, including anxiety disorders at 51.6% and mood disorders at 45.2% during the first year of joining a cult, much like those who have substance use disorders, who are also vulnerable to psychiatric comorbidities. Related to the initial psychological relief upon joining or using, we have two interesting points. You can either be part of an addiction switch, where your addiction might switch from a substance to cult participation, or you can experience improvement in your original addiction, meaning that joining a cult improves or lessens one's addiction to a substance. As with substances, there is a degree of social impairment upon leaving a cult, similar to how there might be a degree of social impairment associated with using, cutting down, or stopping use of a substance. Additionally, family conflicts can be common for cult members at 23% or so of people, and we suspect this number is underreported, as family conflicts are also common among those who use substances. What therapy options do we have? To learn more about this, our team interviewed sociologist and cult expert Dr. Janja Lalek, a former member of the Democratic Workers' Party. She's working with two psychologists to connect former cult victims via psychotherapy groups. In these groups that her office runs, participants do dialectical behavioral therapy and cognitive behavioral therapy exercises. There's also components of trauma-related work for participants. And key factors about psychotherapy pertaining to this population are that assessments should be sensitive to cult victims' trauma. Motivational interviewing strategies may also be useful if an individual is pre-contemplative or contemplative about leaving a cult, and this is if you meet someone who's in the process of leaving a cult as opposed to somebody who's seeking treatment after leaving a cult. Another important point to remember is to evaluate positive and negative aspects of the cult environment and the person's psychosocial history. It's important to distinguish a patient's innate susceptibilities to manipulation, determine which pre-cult psychological problems are significant, help cult victims reconnect with loved ones and repair their past, and help the individual integrate their cult experiences into their entire life experiences. Lastly, one other goal that you should have as a therapist is to mobilize their support network to keep the person safe. And so with that goal in mind, a great degree of family work is required in therapy. So family therapy entails educational interventions that help family members cope with their reactions to the loved one's cult involvement. In working with families, it will be essential to explore the family history, the strengths, the weaknesses, and knowledge of the loved one's involvement. And you would like to ask the family a key question. If your loved one was not in a cult, what would bother you about his or her behavior? Lastly, it's important to provide psychoeducation about manipulation within cults and help families develop negotiation and communication strategies and skills. So deprogramming and brainwashing are terms that have fallen out of favor. Dr. Lollick, as mentioned before, prefers the term bounded choice. And this refers to seeing a true believer, seeing that a true believer is constrained in terms of the choices available, but that makes sense in context of the cult. Cults can provide a substitution for family, which can make extraction much more difficult. And so it's important to remember that exit counseling will be a difficult process. So what is exit counseling? It consists of voluntary, non-coercive, time-intensive processes initiated by families to extract loved ones. And these processes are structured in ways that work within the cult framework in order to appeal to the individual in light of the cult framework. Lastly, in terms of medication management, it is important to screen for comorbid psychiatric disorders. These might include PTSD, including complex PTSD, given the duration of abuse, depending on how long the individual may have been part of the cult. Substance use disorders, of course, major depressive disorder, eating disorders, grief and persistent complex bereavement disorder, and brief psychotic disorder is not uncommon for participants in cults who leave the cult to have transient psychosis or psychotic breaks. And these may well resolve in inpatient settings, which is why taking a detailed history within an inpatient psychiatric unit can be really key. And when it comes to medication management, it's important to start medications as you would for these disorders typically. And of course, psychotherapy, as mentioned before, will really be key. So that concludes this part of the presentation. Next we have the discussion questions. Dr. Kanane, can you pull them up? One second. So while you do that, let me give a summary on this. So it is not often that you think you encounter cult members, but sometimes in psychiatry, you will encounter individuals who are or were in groups that are demanding certain ideologies or demanding that they behave in a certain way. And different individuals will take it differently, of course. So you want to screen for delusional material. You want to screen for persistent psychotic symptoms. But you also want to work with the patient, if possible, to establish a new social network. And unfortunately, with these patients, it is hard because you are starting with previous issues that have hindered them from doing this. Now, that being said, a very big clue for patients like this or for you to suspect that there is some sort of aberrant cult membership is to try to figure out if they have multiple diagnostic symptoms, multiple diagnostic labels that do not mesh well together. So if you are somebody who has this touch of PTSD, this touch of depression, they have those weird psychotic symptoms, and you can't quite figure it out, you may want to inquire further about how their social networks have evolved. An example we've had recently in our group therapy is a patient who has been into every group modality we have in our hospital. And apparently, he was an occult, but we did not know this for a while. So while in college, he had a fairly okay childhood, I would say, but a history of bullying. And while in college, met this woman who within two weeks separated him from his family because she told him, we're in love, you don't need your family anymore. And that's it. That was the end. And for 20 years, they lived within the context of that cult. And he had multiple suicide attempts while in the cult. And every time she had asked him to discontinue his medications. So this man now meets criteria for schizophrenia, because he still thinks that he can hear his her voice telling him that what he's doing is a sin. And he does that even though the depressive symptoms are well controlled. He doesn't look like he is schizophrenic, otherwise, he has absolutely no negative symptoms. And he barely meets the criteria cut off. But it is just an atypical picture in multiple ways. And so this is one of the issues with patients who belong to cults, they really defy our diagnostic boundaries. Okay, so back to the discussion. Let's see what questions we have in the chat, Dr. Konana and Dr. Shinoi. Okay, thanks, Dr. Mukodam. So one point brought up by one of the respondents was that high arousal techniques share some similarities with residency training, especially pre-ACGME work hour restrictions, high powered business consultancies and law practices. Agree, yes, that is an excellent point. In residency, people will try to tell you to tell you that the overwork and the cheap labor aspect of it essentially is you developing muscle memory so that you can handle things under stress. I agree with the cheap labor part. I also agree that it does allow you to function under stress, but it is highly unhealthy. So yes, whoever said medicine was a cult in the beginning probably was hitting on something very useful. Same thing for consultancies, same thing for membership in any society. There's a fine line between healthy and unhealthy. Another comment links us to the New York Times, and I'm afraid I'm unable to connect to that link. Maybe Dr. Mukram, you could. Oh, I probably can. So we also want to remind people that the word cult and culture come from the same etymology, and those two words have taken different meanings. So cult has become pejorative, but culture has stayed positive. So this is our very first comment in the chat, that they both come from the Latin word cholere, and it's really meant to inhabit, cultivate, and protect honor with worship. So basically band together because it's us versus them. And the two terms have diverged. I cannot link to the New York Times easily. I'm sorry. Yeah. I think those techniques that we talked about today, so the psychotherapy, the need for diagnostic clarification, the fact that we have to respect the idea that a cult does fulfill a certain psychological need, all these principles are really useful when you treat people who are not necessarily informal cults, but who are in any sorts of membership that is becoming polarized. So you have sites that encourage suicide, as Dr. Haney is mentioning. Those sites will refer to people as heroes if they've committed suicide. That is not very different from an ideology that says you're a martyr if you have killed yourself for cause X. And so because cults have existed since the dawn of history, so think the assassins, for example, more than a thousand years ago, the concepts are very common. And what we're seeing now in our polarized society is basically sub-threshold cultish practices. And those sub-threshold cultish practices are easily spread because of the internet. And so, of course, that is something that we need to really screen for when we do psychiatric assessments. Another question brought up by the audience included any information regarding prevalence rates for U.S. cult membership and trends in prevalence. So a lot of this data isn't very available to us. I mean, estimates really show that I think the number has been ranging from 300,000 cult participants in the United States to up to 3 million. But we really don't know this information because people aren't always forthright with saying I belong to a cult. There's a great degree of stigma and shame associated with belonging to one of these groups. And we have to be thoughtful as providers that this is the case when we interview our patients. Absolutely. There's also the super interesting comment about AA and sub-cultish practice. So, yes. So sub-threshold cult practices are not something that are published. This is, as I've said initially, by doing this workshop, we are trying to connect the dots. We're trying to see how can we take this information in useful directions. Because we see these patients, we just fail to identify what they've gone through well. Or we identify it, but we cannot link it to treatment. I would say that a group, any group that preys on its members' insecurities and shortcomings is unhealthy for them. So that is my first pointer. You want to explore whether the group they are in is unhealthy for them. If the group makes them stop their medications or not get treatment, medications are not the only treatment. And sometimes it is a very valid point to say, you know, maybe this person should not be on psychotropics. But in general, a group that discourages individuals from pursuing all available treatment options would fit that sub-threshold cult or harmful environment, I would say. So to take the example of AA, and I respect AA tremendously because I know many patients who have done well in it. But AA works once somebody establishes ties and friendships. And it basically gets the person to say, oh, I can't do GLAW, I can't relapse because somebody might be mad at me. I might disappoint this person. My sponsor will call, I will lose friendships. So AA is basically establishing a social network. And to gain acceptance by that social network and to keep validation going, the person might then abstain from relapsing on alcohol. And at that point, AA will gain power over, oh, you should or should not be on medications, depression is a matter of willpower, etc. So once you gain access to a network, and the network becomes important to you, then what the network thinks will become important. So in your assessment and your risk benefit assessment of any social network, this would be how I would look very carefully at sub-threshold cultish practices. And I would not necessarily call them that in my notes, of course, because we don't want to use pejorative terms in the notes. But I would certainly look at how people are changing perspectives on things. And if this is ultimately in the best benefit of the patient. Someone brought up the definition of sub-threshold cult practices. And so I think when we talk about these, we might want to frame this as we frame other mental health disorders too, in that at what point does participation in the cult become destructive to social and occupational functioning, and emotional dysregulation. So if we feel that these things are all affected in a meaningful way, then we can say that these are threshold practices. But if someone's not quite distressed by it, then that would be another scenario. With that said, of course, many people who present to therapy and doctor's appointments can be brought in by family members, and can often be pre-contemplative or even contemplative about leaving the cult. So we must keep all of these things in mind while employing exit counseling strategies. And often families who are trying to get somebody out of a cult might enlist experts who have experience doing these things, particularly because they know how to frame exit counseling in light of the cult's existing practices. So it can be a tricky line to walk as a mental health provider, but we must always keep in mind that sometimes we need to ask for help. We do, absolutely. And one really important issue, and it has come up repeatedly with psychiatric practice and the scope of psychiatry, is how do you define one as being a psychiatrist? We do a lot of medication management, but we also get a very nice theoretical education, you know, to connect the dots. And so these kinds of patients are really the kind of patients who need that dot connecting and that big, comprehensive, nuanced formulation as much as possible, because sub-threshold cultish thinking is very prevalent. And our job is constantly to assess whether there is a risk-benefit, positive, or beneficial relationship going on with the patient and their environment. And based on that, we can tailor treatment. It is very unfortunate that nuanced formulations are not glorified a little more. I love the quote that was just put in the chat. Mass movements demand a total surrender of the distinct self, and one would identify as a member of a certain tribe. So, thank you, Dr. Haney. One thing to also think about here is when do you define things as harmful? Is it just you? Is it when the family says so? Or is it when the patient says so? And again, this has to be part of your formulation in the way you comprehensively think about the patient case. And sometimes it is a bit hard to discuss, and of course, as with most of our patients, you might say it once and it falls on deaf ears, and you might have to introduce the topic again and again. This is very similar to people stuck in a cycle of intimate partner violence. This is similar to people stuck in substance use disorders. This is similar for any group membership that is basically bad. But when you are introducing it, a motivational interviewing framework works really well, because you are saying this is bad for you, and the patient is saying, why do you say that? These people are my friends, or this person loves me, or that drug made me feel good. And so, really transitioning the person to think or to see what this membership has done to them is a pretty tricky one. Do you have any other comments or questions? There is another on, I'm going to read it. There are also many similarities with con artists who individually scam service-connected veterans out of their monthly checks. The factors that perpetuate cults and individual relationships with a con artist, especially the ongoing rewards and the difficulty admitted being duped. Is there any literature on treating someone who has been conned that may also apply to cults and service-connected veterans? Do you want to answer that? It's the same principles that apply. Do you want to talk about that a bit? I mean, that was what I was going to say too, is that there are similar principles that apply within domestic abuse, interpersonal partner violence situations as well. So, specifically those that are con versus those that are in cults, not per se, but there are certain elements of the situations that affected these people that bear a lot of similarity. So, making sure that we screen for the proper DSM psychiatric diagnosis is really key. And of course, providing therapy. And I'm going to bring everyone back to your days of making biopsychosocial formulations. There is the other formulation model, which is the 3P, predisposing, precipitating, and perpetuating. And it's really helpful with cult members to lump all your risk factors in a predisposing bucket. So, the factors that predispose you to become a cult member are the same as those that predispose you to become a substance user, and to be a victim of violence, and to be a victim of being conned. The precipitating factors might be anything from an accident, a surgery, a life change, like a divorce or a move, etc. And the perpetuating factors are very similar bucket list to the one that is predisposing. I would recommend people use a motivational interviewing framework to explore this with patients and just steer them into a more balanced risk benefit approach to their social memberships. Now, that being said, we know from treating patients that they do not do very well usually with finding new friends and their patterns are very ingrained. So, psychotherapy will be essential. And I'm afraid it's hard to find good psychotherapy for a lot of our patients, especially if they're underserved. So, there has to be a little bit of effort put in in the beginning to get this patient connected to proper psychotherapy, proper group therapy, etc. And we have a question here about standardized screens. Yes, Dr. Konana had shared a questionnaire for cult membership. Do you want to comment on this, Dr. Konana? Yes. So, let's see. So, the question is by Dr. Hathaway saying, Oh, okay. So, have any standardized screens for cult membership been formally validated? Under some screens may work better for some cultures or particular cult backgrounds than others. It's a very good question. So, there's not, when I was looking for literature on this, I don't think there are standardized screens. The group psychological abuse scale was a tool I came across that was used to conduct, it was not used for clinicians necessarily, but it was used by people trying to study cult members. But when I was going through some of the material on the group psychological abuse scale, I think it would also be a valuable tool for clinicians as well. And you're absolutely right. I wonder if like in some cultures, some of the, some of the things that might be considered like toxic for one culture might not be in another culture. So, having that adapted based on the cultural background would be a good idea. But that has not been done. And so, what I would add to this is the, if you get familiar with that screening tool or that questionnaire, what the first thing it will do for you is you will be more familiar with what questions to ask. For example, we often do not ask about whether somebody has controlled the patient's sexual practices. And we don't often ask if somebody has put them in sleep deprivation mode. And this is like learning how to do an evaluation for asylum purposes or for torture screening, et cetera. You ask certain detailed questions. So, I would say that the first value of these questionnaires is for us as clinicians to get familiar with what information are we looking for? And then once you do that, you kind of learn about the normative curve and where do the symptoms fit and what do we see more often? Are there any more questions? This was a great audience. Thank you for all the interaction and everything, all the comments and questions. And the New York Times article, I think I can share it here. This was about a website that basically gave people suggestions, means, and support to commit suicide. And they discussed methods of suicide and they encouraged it. And it's apparently a lot of the individuals who joined that site were dead very shortly after. It is asking for a subscription though. So, I'm facing the same problem as with the first link. Okay. Maybe I'll give up on that. Okay. Thank you very much. With that, we will end our workshop. I appreciate everybody and have a great afternoon.

cult membership

substance use disorder

parallels

attachment patterns

complex psychopathology

cult characteristics

psychological abuse

risk factors

neurocircuitry

natural highs

addiction

manipulative tactics