Conduct Therapy Sessions Like Ellis Or Rogers In 7 Days Or Your Money Back!

Okay Rosenthal, tell me something about psychotherapy I don't know. Fine: I will! If you've read all the textbooks, analyzed the classics, and been to enough workshops to receive frequent flyer miles, I've got something new to teach you so put down the managed care forms, and pay attention.

My secret weapon for improving your psychotherapy sessions comes from the field of copywriting. That's correct, I said copywriting. Copywriting is the act of creating written documents that persuade customers to reach into their wallet or your purse, and hand over some greenbacks, a plastic card, or simply click that familiar Paypal button.

When you receive a letter trying to sell you Ginsu knives or the latest Ab blasting exerciser, that's copywriting. Ditto for those letters begging for a contribution for your Alma Mater. According to many experts, the greatest copywriter of our time was an upbeat fellow named Gary Halbert. Now according to Gary Halbert (aka "the Prince of Print"), one of the fastest ways to become a master copywriter is to take samples of the best ads ever written and simply copy them in your own handwriting. Rumor has it that Gary did this himself for hours, if not days on end, when he first entered the business. The result was that he transformed himself (and later many of his students) into consummate professionals in weeks, rather than years, using this paradigm.

Along those same lines, I would urge you to select a well-known therapist you believe in and copy their therapy dialogues in your own handwriting. Better yet, since psychotherapy is a verbal pursuit, read the helping sessions aloud. In fact read the session (or portions of the session) again and again. Notice, I said "believe in" inasmuch as Rogers would certainly conduct a therapy session with a given client in a different manner than Ellis. O'Hanlon would no doubt rely on an intervention that bears little or no resemblance to either of the aforementioned luminaries.

When you get to the point that you can guess with a high degree of certainty what the world class therapist will say next you are well on your way to becoming an accomplished practitioner in that particular psychotherapeutic modality.

Will I really give you your money back if this strategy doesn't transform you into a world-class therapist in 7 days? Hey, I'll let you know. I'm still copying a master's ad and I haven't reached the small print section yet.
 

Ethical Guidelines: Do We Really Want What Is Best For Our Clients?

Most therapists are familiar with the affliction of Seasonal Affective Disorder (SAD). SAD impacts approximately seven million people each year in America, mainly women.

At one point in my career I shared a private practice office with a psychiatrist. She would use the office on some days and I would use it on others. When I entered the office for the first time I was struck by the fact that she had a phototherapy apparatus in the room. It was physically huge and was much larger than any commercial unit I had ever seen. Many experts believe that SAD is caused (or at least intensified) by a lack of sunlight. Hence, when the sun is not shining very often or the days get shorter depression sets in. Phototherapy devices fight the depression and emit massive amounts of full spectrum light. The phototherapy simulates or mimics the sunlight you would receive if you more spent time outdoors.
My initial reaction to this situation was beyond positive. I was elated that this psychiatrist was utilizing cutting edge technology. I thus decided to praise her and let her know in no uncertain terms that I was impressed.

The good doctor's reaction, nevertheless, was hardly what I expected. "Oh my gosh, no, I don't use it for my clients. That's fringe psychiatry. Somebody might think it was unethical. I might even be sued or reported to the Board of Healing Arts. I might be branded as a quack."

"Well what in the world is a light therapy lamp doing in your office?" I asked inquisitively.

"In the dreary short days of winter I am stuck in this office all day and I generally become extremely depressed, so I had an engineer build me a phototherapy unit that is stronger than anything you can purchase. As soon as my current patient exits the treatment room I flip on my phototherapy device. I then turn it off before the next patient enters the office."

Oh, so now I get it: It's good enough for you, but not for your patients. Go figure.

In one of my recent books, Favorite Counseling and Therapy Techniques, I share a fascinating story about a young man I treated who had such low self-esteem that he walked bent over like an ape. The kids at school thought it was hilarious and made the situation worse by calling him the Ape Man.

One reason for the young man's Ape Man posture was that he believed he was extremely ugly and could never date a nice young woman. To counter his feelings I set up a contrived situation in which a female colleague walked in the room and said, "Gosh, is that your client, he's really cute." He seemed shocked (exactly the reaction I wanted). I told him we weren't going to discuss his looks because we both knew he was an exceptionally good looking guy and there were serious issues of his we needed to work on. He walked out with the finest posture he had displayed in years. Cured, no. Improved, yes.

Unfortunately, I also point out in my book that today's ethics which stress informed consent would not permit an intervention of this ilk. The female colleague who gave him the compliment would need to be identified as part of the treatment or therapy team up front and there is a 99% chance he would have totally discounted her remarks as being staged. (The young man's mother had repeatedly told him he was a good looking guy many times to no avail.)

Along these same lines a client I shall call John came to see me who severely depressed. John's brother was a very well-known psychiatrist. Now I was aware of the fact that ethical codes frown on (or downright prohibit) dual or multiple relationships, but certainly John's brother knew another top notch psychiatrist who could help. Why was John seeking my little old services?

When I asked John why his brother did not provide a psychiatric referral John quoted his brother verbatim. "Look I give those dangerous psychiatric medicines to my patients, but I'm not going to let my family take them. You need psychotherapy."

I so I get it. It's not good enough for your family, but it's okay for your patients. Oh sorry, I think I said something similar to that that before.

I remember hearing a presentation given by Jay Haley once. He told a powerful story regarding a difficult client he had successfully treated. I raised my hand and asked if his psychotherapeutic intervention was in violation of the ethical principle of informed consent. It certainly seemed like that was the case.

Haley was silent for a moment and then grinned. "I never let ethics get in the way of good treatment."

The problem for those of us who are mere mortals is that Haley's philosophy might leave us without a therapist's license and standing in a long unemployment line.
 

How One Desperate St. Louis Psychotherapist Cured A Schizophrenic

Maggie began the session by telling me that she had been diagnosed by three different psychiatrists. The good news was that all three agreed on the diagnosis. The bad news was that each psychiatrist told her she was schizophrenic.

"So, what brings you here today?" I asked.

"Well, I saw something in the newspaper and it said you wrote some books on mental health and teach in the field so I thought you might know something these psychiatrists don't."

(Wow. How refreshing. A client who actually thought that a nonmedical mental health professional such as myself would know more than a bona fide MD psychiatrist. Perhaps this was my lucky day. Maybe I should purchase a lottery ticket or search Google for the nearest horse race track.)

As Maggie began talking my elevated mood and optimism began dropping like a thermometer placed in an overactive refrigerator freezer. In short order I was convinced that the psychiatrists were wrong — dead wrong. This lady wasn't just schizophrenic. Maggie displayed more hallucinations, delusions, and thought disorders, than ten schizophrenics combined. As I listened I couldn't help thinking that the folks who penned the DSM needed a new category. What? Oh heck, I didn't know, perhaps mega-psychotic or super-schizophrenic or something. Now I realize that doesn't sound nice and isn't very high on the Carkhuff Scales, but at least I was facing reality: something Maggie clearly was not doing.

The session went on for what seemed like eternity. At the end of our meeting I was faced with a dilemma. If I diagnosed Maggie as schizophrenic for the fourth time she would be devastated. I scribbled something on her insurance super bill and scheduled her for another appointment.

I continued to see Maggie weekly for approximately one year. To say that she made monumental progress would be an understatement. I thus terminated her.

About a year later I saw an article about her in the neighborhood newspaper. Maggie was being honored by her college for being the only student in her program to snare a perfect 4.0 straight A average as a chemistry major. The article also boasted that she landed a pristine job in her chosen field.

Just days after I read the article Maggie dropped in not for a therapy session (because she was doing very well), but just to say "hello."

"You are doing fantastic," I said. "Listen, I just have to know. What I'm about to ask you will help me with all the clients I will be seeing in the future. Why do you think you made such good progress in therapy? Was it because we explored the abuse in your childhood? Was it the relaxation techniques? Perhaps it was the dream work. Maybe it was the focus on your self-talk."

"Oh no," she replied. "I'm sure those things were helpful, but none of them cured me. No, not a single one of them. I can tell you precisely what it was.

Do you remember when you saw me for the first time and I mentioned that three psychiatrists had diagnosed me as schizophrenic? Well we decided right then and there that because you had written some books and taught in a college you knew a lot more than those psychiatrists. And when I left your office after my first session I felt terrific because I glanced at the insurance bill you gave me and you said I was an undifferentiated type. And that was wonderful news because schizophrenia is caused by chemical imbalances and genetics and it can't be cured. You know that.

But, I wasn't schizophrenic. I was just a normal person who was an undifferentiated type. And that meant I could be cured."

Thus, if you happen to be an advisor in a graduate program and an upbeat perky chemistry major named Maggie comes strolling in, please, pretty please with sugar on top, promise me you won't even think about letting her enroll in an abnormal psychology class.

Violet Oaklander on Gestalt Therapy with Children

An Unorthodox Notion

Rafal Mietkiewicz: Violet, what makes me curious is that you are trained as a Gestalt therapist and people connect you with Gestalt therapy, but Gestalt therapy was mainly considered, at least here in Europe, to work primarily with adults. How did you find your way to do Gestalt therapy with the kids?
Violet Oaklander: I was already working with emotionally disturbed children in the schools when I got interested in Gestalt therapy. One of my children became very ill and died. I was very depressed. My friend was going to Esalen Institute to be in a group for a week with Jim Simkin, so I went with him, and I was so impressed with what happened to me. It made such a difference for me that when I came back, I started training in the Los Angeles Gestalt Therapy Institute, and while I was training, I thought, “How could I apply this to children?”It seemed very organic to me. Fritz Perls talked about the body and senses and all of that. I found that it fit my work with children and child development. And of course, over the years, I started using a lot of creative media, like drawing and clay and puppets and music, because that’s the only way it would interest children. But behind that, the basis of my work was Gestalt therapy theory and philosophy. And I developed it more and more as time went by. That’s how it got started.

RM: That’s what you wrote in your book—that children already know, but they are wearing special glasses, so you just take the glasses off?
VO: Yeah. I have many stories working with kids. I’m trying to think of when I first started. When I first began, I was working in the schools with maybe a group of 12 children. And they were older—maybe 12 and 13 years old, all boys. These were kids that didn’t make good contact; they didn’t connect very well with other children.I started doing things that were sort of different. I would have them finger paint. I’d line up the desks so it was like a table, and they’d stand around the table finger painting. At first, they didn’t want to do it. “It’s for babies.” But while they were finger painting, they would talk to each other, make really good contact. And of course it was important to establish boundaries—what they could not do and what they could do. So that was very clear.

Another thing I started doing was bringing in wood, and they would build things. These were children who weren’t allowed to hold a hammer or a saw because they were very disturbed children—it was dangerous. But I saw other classes had wood and got to build things, so I got that. And they had rules: they couldn’t swing the saw or the hammer, or else they had to sit down that day.

I wouldn’t let them build guns, but they could build boxes and birdhouses, and they would work together because they had to share the tools. You would not believe they were emotionally disturbed children. They were making such good contact and really enjoying this. I did many things like that.

RM: You look like you really enjoy your work.
VO: Oh, yeah. I even had the old empty chair. I had two chairs in the front of the room, and when a kid would get really upset and angry, I would have him sit in the chair and talk to the empty chair.And the child that he was angry at might be in the room there, but he would be talking to the empty chair. And then I’d have him switch and say, “Well, what do you think he would say back to you?” and it was so amazing because he would realize that he was projecting. They didn’t know that word—they didn’t have that insight. But they could see that they were projecting their own stuff on the other boy.

It would be so amazing. They would come into the room and say, “I need the chairs.” They would talk to a teacher who had yelled at them outside. They would talk to that teacher, and then they would begin to see that the reason the teacher yelled at them is because they did something they weren’t supposed to do. They knew this, but when they sat in the empty chair, they’d say, “Well, I yelled at you because you hit this other boy!” And then I’d say, “Now, what do you say to that?” They’d say, “Yeah, I guess I did. I did do that, yeah.” It was just little things like that that I began to do, to experiment with some of the techniques.

After I left teaching and I was in private practice, I thought a lot about what I was doing, and I started developing a therapeutic process that was based on Gestalt therapy, beginning with the “I-thou” relationship, and looking at how the child made contact, and then building his sense of self and helping him to express his emotion.

RM: It seems like you combine a bunch of techniques and approaches in your work—like expressive art therapy or child group therapy.
VO: Yeah. We do a lot of sensory work. I mentioned finger painting—anything they can touch. Clay is incredibly sensory and evocative. If it seems like they need to do some movement, we do that. Sometimes we play creative dramatics—charades—because to show something, you have to really be in touch with your body. We might start with fingers: “What am I doing? Now, you do something.” And they think of something and they have to use fingers to act it out.And then maybe we do a sport—they have to show with their body what sport they’re playing, and I have to guess. It might be obvious, but they enjoy doing that anyway—maybe catching a ball or hitting with a bat or tennis racquet. They have to get in touch with their body to do that.

The projective work with drawings and the clay is also very important, because this is how they can project what’s inside of them and then own it. One example is a boy who had a lot of anger but he kept it inside. He presented himself as just very nice and sweet, and nothing was wrong with his life. It was only after I asked him to make something, anything—I usually say, “Close your eyes and just make something, and then you can finish it with your eyes open”—he made a whale, and told a whole story about how the whale had a family—a mother and a father and sister.

What I always do after they tell the story is try to bring it back, so I said, “Well, does that fit for you? Do you have a family like that?” He said, “No, my father lives far away because he and my mother don’t live together. I never see him.” “Well, how do you feel about that?” And then we started talking about his father, which he would never have mentioned, and all this feeling came up. It’s very powerful.

The First Session

RM: How do you approach the first session with a child?
VO: I always meet, if possible, with the parents and the child the first session, because I want the child to hear whatever the parents tell me. I don’t want the parents to tell me things and have the child not know what they told me.Even if the parents are saying bad things about the child, the child needs to hear what I hear from the parents.

Usually in the first session, I have a checklist, and very often I would put it on a clipboard. First I would say, “Why are you here?” and all that. Then I would ask the child these questions. “Do you have a good appetite? Do you have bad dreams?” A whole list of questions.

Sometimes the parent would chime in, but mostly it’s to the child. It was a way of really making a connection with the child. Of course, if they were very, very young, four years old, maybe I’d still ask these questions, but not everything—and use language they could understand.

That’s always pretty much the first session. But if there are no parents involved—because I saw many kids who were in foster homes or group homes—the first session is an important one to establish some kind of connection or relationship. Sometimes I’d ask the child to draw a picture on that first session. I’d ask them to draw a house-tree-person. But I wouldn’t interpret it. It’s not for interpretation. It was to say to them when they were done, “Well, this picture tells me that you keep a lot of things to yourself. Does that fit for you?”—because maybe they wouldn’t draw many windows. And they usually would say “yes.” Or, “This picture tells me that you have a lot of anger inside of you. Does that fit for you?” If they’d say, “No, I’m not angry,” I’d say, “Oh, okay. I just need to check out what I think it tells me,” and we would have that kind of a session.

I did that once with a very resistant 16-year-old girl who at first said she wouldn’t speak to me. And when we finished, she wanted her sister and her mother to come in and do that drawing. So it’s a way of connecting.

But we don’t always do that. If it’s a child who is very frightened—I had a girl, for instance, who was very severely sexually abused for many years, and it finally came out when she was about 11, and she was removed from the home. So she was in a foster home, but the foster mother was very devoted to her and came in, too.

But she was very, very frightened and didn’t want to talk to me. So in the beginning we would take a coloring book, and we’d both color in the book. And we wouldn’t really talk about anything. I’d say to her, “Should I use red for this bird? What do you think?” and just begin to connect with her that way. Pretty soon I was asking her, “Well, what do you think the bird would say if it could talk?”—that kind of thing.

Pay Attention

RM: It’s my guess that you don’t really diagnose kids in clinical terms.
VO: No. I mean, sometimes I would have to for an insurance company. But it’s a matter of seeing where they’re at, where they’re blocked. I had one boy who walked very stiffly all the time. He was 11 years old. And I thought, “Maybe we need to do something to help him loosen up before we even talk about his feelings”—that kind of diagnosis.
RM: So, you don’t find clinical diagnosis useful in therapy?
VO: Not very much, no.
RM: You trust in what you see and what you feel about the kid.
VO: What I see, yeah.If, for example, the child has a lot of difficulty making a relationship with me, that’s what we have to focus on, because I can’t do anything unless we have that relationship. Sometimes children have been very hurt and damaged so early, they have trouble making a relationship. So we have to figure out how we could do that.

I used to see a lot of adolescents who were arrested by the police because they had committed a crime. I was involved in a program where they would send these children to counseling. It was a special program they were trying. So this one girl came in. She had to come—she had no choice. She was 14. She wouldn’t look at me, she wouldn’t talk to me. She just sat there. Naturally when a child does that, it makes you have to come forward more. Well, it didn’t work. So I thought, “Maybe I cannot see this girl. Maybe I have to refer her to another person.”

I went out into the waiting room the next time she came, and she was reading a magazine. I sat down next to her and I said, “What are you reading?” She flashed the cover at me. I said, “I didn’t see it,” so she held it up.

RM: And that was the beginning of contact.
VO: Yeah. Already we were making contact. And it was a music magazine about different groups. I said, “I don’t know anything about that. Could we look at it together?” So we went into my office and looked at the magazine, and she was telling me about the different groups. It was mostly heavy metal. And she was all excited, telling me about the groups and which ones she liked.We tried to find the music on the radio because I said, “I don’t know what it sounds like.” We couldn’t find it, so she said she would bring in a tape. The next week, she brought it in and we listened together. Some of the songs were so amazing—all these feelings and anger. So we just started working with that. And we had a relationship.

But we need to do that—start with where they are. Pay attention. I wasn’t paying attention in the beginning. It was only when I thought, “What am I going to do?”

RM: So apparently the child therapist must be very in touch with his own senses. I guess it’s more important than clinical knowledge.
VO: I think you’re right. You have to know things, but that’s most important—to be in touch with yourself. It’s not easy to be a child therapist. An adult comes in and says, “This is what I want to work on,” or, “This is what’s happening.” When a child comes in, she doesn’t have a sense of what she needs to do. And you have to talk to parents, and you have to talk to teachers, and that kind of thing, too. So it’s different.
RM: Do you do something particular to help bring each session to an end—to help bring the child back to “regular life?”
VO: I think the job of the therapist is to help the child express what’s going on inside. But I notice that most children will only express what they have the strength to, and then they get resistant or they close down. They take care of themselves better than adults that way.But if they do open up a lot, we have to pay attention to what I call “grounding” them. I have a policy that children have to help me clean up whatever we’ve used. So we start cleaning up and then I’ll say, “Well, that was hard. Maybe we’ll talk some more about it next time, but where are you going now?” or “What are you having for dinner?” or “What did you have for dinner?” We talk about regular things to help them come back to ground.

RM: I know that Gestalt therapists hate “shoulds,” but using a paradox, are there any “shoulds” that a good child therapist should obey?
VO: Nothing comes immediately to mind, other than things I’ve already said. But speaking of “shoulds,” it’s worth noting that children have a lot of “shoulds.” People don’t realize that, but children are very hard on themselves. They’re split—there’s a part of them that’s very critical of themselves and then a part of them that, of course, rebels against that. Sometimes we help them understand that, especially if they are adolescents.
RM: Do you touch or hug your clients?
VO: Sometimes, but I’ll always ask them. I might say, “Can I give you a hug?” I don’t just do it. I have to ask them. Or I might put my hand on their shoulder. I can tell if they pull away that that’s not a good thing to do. Or sometimes we shake hands. We do a little bit—not a lot.

Working with Parents

RM: Do you often talk to parents?
VO: Oh, yes. This girl that I just mentioned, she lived in a foster home, and they didn’t care about her, so they weren’t interested. They just did what they had to do. But yes, parents come in. Every three or four weeks they have to come in with the child. Sometimes we just have a family session and I don’t see the child individually. It depends. You have to just decide which is the best way to go.
RM: We have agreed that it’s important for therapists to be in touch with their own feelings. What other qualities should one have to be a good child therapist?

VO:

You have to understand child development so you have a sense of if the child is not at the level she needs to be at. You have to understand the process. You have to be in touch with yourself. You need to know when your own buttons are being pressed—in psychoanalytic vocabulary, they call it transference. You have to understand when you have some countertransference, and to deal with that and work with that.

RM: In your Child Therapy Case Consultation video, a therapist is presenting a case of a child who is acting aggressively. You state at one point that kids can’t change their behavior with awareness. Is this why you often use art or have kids smash clay or other activities, versus just talk therapy?
VO: Yeah. What I mean is children don’t say, “This is what I’m doing to keep me from being happy or satisfied.” Even adults have trouble being aware of what they do to keep themselves stuck. So, with children, these drawings and clay are powerful projections. And it’s the way they can articulate what’s going on with them, without bypassing the intellect, but coming out from a deeper place. And at some point, they will own it. They will say, “Oh, yes, that fits for me.”When children feel stronger about themselves and they express what’s blocking, their behaviors change without having to force it or say anything. I mean, what makes children do what they do? All the behaviors that bring them into therapy are really ways of not being able to express what they need to express—of not being heard or not feeling good inside themselves.

RM: How do you measure progress in your work with children?
VO: It’s important to help the parents see the small changes, and not to expect complete reversal. And, of course, we have to work with the parents, too. Often the parents have a lot of difficulty with their own anger, and we have to work to help them understand how to express these feelings without hurting people around them. We can often do that in family sessions—help them to express what they’re feeling and what they’re wanting and what their sadness is about.One of the things I’ll say to parents is that I don’t fix kids. But what I do is I help them feel better about themselves. I help them express some of their deeper feelings that they’re keeping inside, and help them feel a little happier in life. We do many things to make this happen. And that’s what you have to look for. So when a parent comes in a month later and I say, “How are things going at home?” and the father says, “I think he’s a little happier,” then I know that this father has got it, and he’s seeing some progress here.

I am thinking of this was a boy of maybe 14 who was stealing, and the father wanted to send him to a military school because he couldn’t control him. There was a lot of reason the boy was like that, but that doesn’t help to understand the reason. It’s good to understand the reason why he’s like that, to help him change and be different.

So that’s how I look at progress. When they’re doing better out in life, they’re going to school and have some friends, and doing some of the things they have to do at home, and doing their schoolwork, then you’re seeing progress. They may not be altogether different, but they’re functioning in life.

The other thing that’s important is that it has to be at their level. Children can’t work everything out. They have different development levels. So the girl who was very severely sexually abused, we did a lot of work about that. But when she was 13, she had to come back into therapy for more work—things came up. They reach plateaus. They have to go out and be in life, and then maybe more things come up.

Becoming a Child Therapist

RM: Does it happen often that, when therapists work with a kid, the therapists’ trauma from childhood appears?
VO: Absolutely. That’s something one has to really know about—be in therapy, have a therapist. I have several people who come to me for supervision who are very experienced therapists, and that’s the reason they come. I think it’s really good for a child therapist to have somebody to talk to and consult with because it’s very difficult sometimes. You can’t always see what’s going on.
RM: How long does it take to be fully trained as a child therapist?
VO: Oh, gosh. For many years, I did a two-week training. People would come from all over the world. And sometimes they would get it in those two weeks, and other times they didn’t, so I don’t know. Two weeks is not enough, but it was the most that people could give of their time. Sometimes they’d come back two or three times to the training, but those were people who actually got it the most, because they were so committed to learning more.I can’t define a time. They have to have the experience of working with children first, I suppose, and understand about children. You have to have patience when you work with children. If one thing happens in a session—if they say, “I’m like that lion. I get so angry, just like that lion,” or whatever—if they say one thing, sometimes that’s it for a session. You have to be patient.

RM: What are the most frequent mistakes that therapists make when they work with kids?
VO: Usually what happens is therapists get stuck. They don’t know where to go next or what to do next.
RM: But why do they get stuck?
VO: Maybe they’re just not able to stand back and look. Sometimes, in a supervision or consultation, I’ll give a suggestion, and they’ll say, “Oh, of course, why didn’t I think of that? Of course, I know that.” They get too close to it and worry about doing the right thing. They’re afraid to make mistakes, really. I always tell them, “No matter what you do, you can’t really go wrong.”
RM: If you were to give the best advice to the young therapists about working with children, what would be this advice be?
VO: I might say if you’re working with children, you have to like children!

If you’re working with children, you have to like children!

What Keeps Me Going

RM: My last question is personal. How do you manage to keep so vital?
VO: You know, I’m 84.
RM: You don’t look it.
VO: I don’t know. I am who I am, I guess. I’m still working some. I have this foundation (The Violet Solomon Oaklander Foundation), and we’re having a conference this weekend at a retreat center, and I’m going to do a keynote. So every now and then I still do something like that, or conduct a supervision. That’s what keeps me going. I do a little writing. I read a lot.I lived in Santa Barbara, California, for 21 years. And my son, who lives in Los Angeles, decided I was getting too old to live there by myself. So he tore down his garage and he had a little cottage built, and that’s where I live now, in this little cottage behind their house.

I miss Santa Barbara. I had a lot of friends. I’d be more vital if I was back in Santa Barbara. But I am getting older, and I had a little heart attack this year—little. I’m okay. But I was in the hospital a few days. So it’s good that I’m near my son and my daughter-in-law.

RM: It is obvious for me that you, at 84, have still have so much to give to the others.
VO: Thank you very much for those nice words. I will, as long as I can.That’s what keeps me vital: just doing as much as I can, as long as I can. I just have to learn to take it easy.

The God of Hellfire Will See You Now

The Crazy World of Arthur Brown

On a number of occasions in the late 1960s, an exceptionally gangly gentleman made up in skeleton face paint would affix what has been described as a metal plate to the top of his head with a leather strap and commence singing a song called “Fire” to assembled crowds in a dark, cramped Paris nightclub. The song begins with the spoken/shouted intro, “I am the God of Hellfire and I bring you…FIRE!” The key to making this routine particularly dangerous (rather than just slightly odd) was the fact that the plate, probably more of a shallow bowl, contained gasoline, which would be set aflame as the performer took the stage. The showman in question would cavort about the stage in an approximation of a cross between a witch doctor’s contortions and the popular ’60s novelty dance, the Frug. Not surprisingly, his ill-designed headgear would tip and spill varying amounts of flaming liquid on his body and brightly-colored stage costume, turning the already smoky club even more so. Fortunately for him, his bandmates quickly became adept at performing as an ad hoc fire brigade.

While the DSM may not have a particular diagnosis for such behavior (yet), a casual observer might be forgiven for assuming that the sort of person who would behave in such a manner might be more likely to be a recipient of psychotherapy rather than a provider. The fact that in this instance the reverse is true provides one of the more interesting chapters in the annals of mental health practice. Arthur Brown, the pop singer who gave new meaning to the term “smoldering stage presence,” followed a long and unusual path from performing rock and roll in the psychedelic sixties to performing psychotherapy in the early 1990s in Texas.

Brown was born in England on June 24, 1942. Like many artistically inclined young Englishmen of his generation, Brown went away to college and ended up in a band. But unlike ersatz “art” students Mick Jagger and John Lennon, despite his keen interest in music, Brown stayed the course and graduated with a bachelor’s degree in philosophy.

Soon after, music became his full-time vocation, and his band, The Crazy World of Arthur Brown, released their eponymous debut album in 1968. Their single, the aforementioned “Fire,” reached number 1 in the UK charts and number 2 in the States. Their failure to follow up this initial success marks Brown and company as one of the benighted breed popular culture terms “One-Hit Wonders.” Despite their lack of chart success, Brown, with his band and later as a solo artist, continued to work steadily well into the 1970s. His greatest contribution to music history, however, may be the influence he wielded through his choice of material and stage persona. Brown may today be viewed as a clear link on the continuum from Screamin’ Jay Hawkins in the 1950s to artists like Alice Cooper in the 1970s and Marilyn Manson today. You may or may not have heard of Brown or his most famous song, but his Goth-before-Goth-was-cool style has influenced just about every bombastic and excessively theatrical heavy metal/progressive rock act you’ve ever seen.

By 1980, his career as a musician was at such a low ebb that Brown and his then-wife decided to make a fresh start in America. They chose as their destination “the live music capital of the world,” Austin, Texas. Willie Nelson had famously retreated there for similar reasons a decade earlier with productive results, and Brown found amiable company in a number of other expatriates from the world of rock stardom. Brown kept at the music but soon found himself working as journeyman carpenter and the proprietor of a house painting business. While the work was rewarding enough financially, it did little to satisfy the creative muse. Brown found himself ready for another change but unsure what it was to be.

From Rockstar to Masters Student

Then in 1989, Vincent Crane, former keyboardist in The Crazy World of Arthur Brown and Brown’s longtime friend and bandmate, lost his long battle with bipolar illness, committing suicide. Whether this tragedy was the catalyst for Brown’s next move is open to speculation. But not long after returning to Texas from the funeral in Britain, Brown enrolled in the Masters in Counseling program at Southwest Texas State University (today known as Texas State University).

Such an endeavor may seem to be a truly unexpected left turn in the life of an avant-garde artiste. However, there were portents aplenty in Brown’s past which indicated an interest in helping others and exploring personal growth. In a period when it seemed almost de rigueur for pop stars to explore Eastern religion, Brown took a shine to Sufism. Other religions had been a fascination as well, as he studied formally and informally with everyone from practicing Druids to priests of the Greek Orthodox Church. Moreover, Brown seems to have delved deeply into the primordial soup of the ’70s self-actualization/encounter ethos, taking a self-guided tour of the “Me” decade. A trip to Israel during the Yom Kippur War to entertain wounded soldiers (presumably he spared them the flaming hat) inspired in him a keen interest in the healing properties of music.

But perhaps the biggest giveaway to his future career was the b-side of “Fire,” a song called “Rest Cure.” While the term is now archaic, it refers to a discreet stay in a sanitarium of the sort described by Simon and Garfunkel in “Mrs. Robinson”—a getaway to nice, quiet facility to collect one’s nerves. The lyrics reveal that Brown seems even then to have seen himself as able to provide a cure for the ills of modern society.

When the world is getting you down.
And nothing is in its right place;
Your friends are letting you down.
And you can’t seem to find the right face.
All you want is me,
All you need is me to give you,
Rest cure for all your ills,
Rest cure to make the world stand still.
Rest cure and the world won’t bring you down no more.

Brown was an able and ardent non-traditional student, making the 60-mile round trip from home to school each day, and he rapidly established positive relationships with classmates and professors alike. It was at a party on campus one day at which both groups mixed that Brown performed a light-hearted impromptu tune, name-checking all present. This so impressed one of his professors that she was moved to suggest he find a way to blend his musical gifts with his newly minted learning.

Brief Atypical Music Therapy

Shortly after picking up his diploma, he set up a counseling practice with a fellow alumnus to do just that. They named their venture “Healing Songs Therapy,” and in this context Brown and his cohort introduced a new therapeutic form.

As described in various media outlets, the session began much like a normal 50-minute hour. Brown’s partner would allow the client to describe his or her concerns and issues offering feedback in the normal therapist-client interaction as Brown sat to the side of the room with notepad and guitar at hand. Following the cessation of the first portion of the session, Brown would then perform an original song in which he brought forth insights and reflection about things he believed he had heard in the client’s narrative. The client would be given an audiotape of the song and be sent on his or her way, having completed a course of what might be called Brief Atypical Music Therapy.

In 1992, not long after Healing Songs had opened up shop, a feature reporter from the Austin daily paper came to Brown and his partner ostensibly seeking help with a mild phobia of driving in rush hour highway traffic, and more to the point, for a story. Following her hour with the duo, she reported coming away with her trepidations at least somewhat alleviated, along with a personalized song on cassette which she could pop into her stereo the next time she was caught in traffic. Evidently from the snippet of lyrics she published of her seven-minute personalized “healing song,” Brown saw in her presenting problem echoes of deeper existential issues.

I have a dream that I am keeping,
And I will not let it surface,
For the fear that rules my life
Has taken me and chained me to my own
Image of reflecting everything,
That I can’t hold onto.

A certain amount of notoriety followed as the fledgling practice grew. Other news outlets across Texas began to feature stories, as did People magazine with a story entitled “The Singing Shrink.” Of these stories, the early reporter/client from Austin offered one of the few independent reviews of Brown’s new therapy technique. Most of the accounts are long on Brown’s unmistakable enthusiasm for his latest venture and favorable words from experts about the broad efficacy of more traditional forms of music therapy, but very short on any sort of objective examination of the Healing Songs modality. The rejoinder from more knowledgeable quarters (such as representatives of the duos’ alma mater) was less than favorable, however. In response to the mostly positive article in the Austin paper, a professor from the Southwest Texas counseling faculty took exception in a letter to the editor decrying the inference that the university in any way endorsed or even recognized the potential validity of Brown’s approach.

The perturbed prof seemingly didn’t need to worry so, as what might one day have developed into a new therapeutic discipline seems to have fallen by the wayside when Brown’s music career began to heat up once again, probably due in part to the sudden spate of publicity regarding his side venture. Just when Brown put aside the formal role as a budding psychotherapist is hard to ascertain. The state credentialing board offers no record of Brown ever actually obtaining licensure as a Professional Counselor or Music Therapist. However, it’s safe to assume he gave up formal counseling at some point after departing Texas for a European tour with his new band in late 1992. Given Brown’s interest in his own inner world as well as that of other human beings, it seems likely that he still, shaman-like, exerts whatever healing powers he believes are in his possession from the stage. However, office hours are a thing of the past.

In the end, one has to wonder about the great unreleased Arthur Brown album. Ballads and Poems of Fin-de-Siècle Problems of Living, it might be called, or Arthur Brown Makes Your World Not So Crazy. According to the account in People, Brown and his partner had reached a height of 20 sessions a month at the time of writing. Thus, there could well be as many as hundreds of unknown Arthur Brown compositions out there in the world. While cassette tapes are today an almost forgotten technology, surely a personalized song dealing with a deeply personal issue and written by an erstwhile rock star is the sort of thing more than just a few people might have held onto. Secreted away in junk drawers and the back of closets, they await a 21st-century John Lomax to bring them to light once more.

Robin Rosenberg on Treating Eating Disorders

Rebecca Aponte: When you think about eating disorders, do you think of both anorexia and bulimia? Is there a lot of overlap in people who engage in these behaviors?
Robin Rosenberg: There are people who engage in both types of behaviors. In DSM-IV, individuals who exhibit all the criteria for anorexia but who also binge and purge would be diagnosed as anorexia nervosa binge/purge type. So diagnostically, anorexia trumps bulimia, if you will. But that is just the DSM-IV; who knows what will happen in DSM-V?
RA: Are they related?
RR: They appear to be, at least for a significant subset of people. So in terms of the research, when you look at people who have bulimia versus people who have anorexia, that is not necessarily a helpful distinction. Anorexia has, in DSM-IV, two subtypes. There is the traditional restricting type, which is the people who eat minimally, and then there is the form of anorexia where people are significantly underweight and may be amenorrheic [they have stopped menstruating], but they may also binge or eat without restricting, but then purge in some way, or use other compensatory behaviors. Those people are classified as anorexia binge/purge type, but in studies, those people have more in common with people who have bulimia than they do with anorexia restrictive type. Some of this is a bit of a diagnostic artifact, because it’s the way that it has been defined in DSM-IV.The most interesting thing about eating disorders in terms of classification issues is that it is not uncommon for people to move from one eating disorder to another over time.

Chicken or Egg: Looking at Causes of Eating Disorders

RA: What do you think are the causes of anorexia and bulimia? Is there a general consensus on what causes them?
RR: One of the things that is clear is the influence of culture, in that our culture is pretty screwed up about body ideal, especially for women. And it is hard to be a young woman or an older woman in our society and have a positive relationship with your body because of the cultural messages about how women should look, which is basically unattainable unless it is a full-time job or you have a lot of plastic surgery.There was a fascinating study by Anne Becker and her colleague. She went to Fiji and happened to be there right as they were getting Western television. Fiji is a Polynesian culture in which typically the ideal body type was the voluptuous large woman, and they were seeing Western TV with our ideal body types—very thin. So she had a chance to study girls and young women, and what was fascinating but sad is that over the time that television was there, the girls basically stopped liking their voluptuous bodies. They started dieting, talking about dieting; there was a lot of peer stuff about food and weight and appearance, consciousness which hadn’t been there before.

It is not a true experimental design, but it is pretty compelling. These young women were from a culture that had historically had an ideal of a heavyset look for women—yet some of them started spontaneously throwing up because they felt they had eaten too much, which could be a symptom of bulimia. Very sad. So culture is clearly part of the equation for both anorexia and bulimia.

RA: There are images surrounding us constantly of unrealistically thin or fit men and women, but it seems that not everyone is as susceptible to negative self-comparisons.
RR: That’s exactly right. Because this is a multi-determined category of disorders, there is no one factor that stands out, but people with eating disorders often report having been teased about their appearance or body size or shape. At least, these experiences are on their minds in such a way that they tend to report them. So that is another cultural piece, if you will.Personality factors or being perfectionistic—that is particularly true for people who have a restrictive type of anorexia. The thought is they will diet and then they keep dieting. It is a very slippery slope of weight loss.

People who binge and purge or have a binge/purge-type anorexia may have some issue around impulsivity or emotional regulation. Sometimes they will have more substance abuse issues, alcohol in particular. There is sometimes a cycle where they become disinhibited by drinking, and then they overeat, and then they feel bad, and then they throw up or purge and whatever they do with the eating. Frequently, they exercise the next day.

RA: Is it as if they are using these behaviors as external tools to try and help deal with their emotions?
RR: Exactly. In fact, people who binge talk about using it to zone out, to get away from themselves, but then they just feel really bad afterwards, so it doesn’t really work. It works in the moment, but not later.
RA: Are there common family dynamics in eating-disordered people? You mentioned some personality issues of being perfectionistic, but are there any relational patterns that stand out?
RR: The biggest one is a family preoccupation with weight, food and appearance, or being teased in other ways, their body shape being an issue—which makes sense, right?If your family is really attuned to how you look or how they look, that is what you learn and what you internalize. There appear to be some causal biology issues as well, but that is also very hard; it is sort of a chicken-and-egg thing, because people often don’t come to the attention of research studies until they have an eating disorder. And once your eating is disordered, you are changing your biology.

So there are lots of associations, but it is just not clear. Sometimes eating disorders run in families. Is that genetic coding? If a parent had eating issues, the odds are that there will be a family dynamic around food. So is that genetic or is that biological? They are trying to tease this part out. Is the eating disorder co-morbid with a mood issue, which could explain why antidepressants might work for people with bulimia? I think the biology part maybe a bit oversold. People have different temperaments that make them vulnerable to different sets of disorders if environmental circumstances trigger them. But I don’t think it is the case where someone has the gene and therefore he or she gets it.

RA: It certainly seems like you are leaning much more towards a social explanation.
RR: Right. It’s not as if eating disorders typically arise across like multiple generations in the same family.
RA: That is what I was going to ask, too. Are the rates of anorexia and views around eating disorders different in different parts of the world?
RR: There have been people with anorexia in recorded history going back quite a while, but they were mostly young women or older girls, and it was religiously motivated—a sort of asceticism. There weren’t issues about body image per se. And in current times in Asia, at least 10 years ago when they did some of these cross-cultural studies, some of the young women with anorexia didn’t say that they felt fat, but they complained that the reason they didn’t eat much was because they didn’t like the way that they felt. They did not express the same fear of weight issues that Western girls or adults with anorexia have.The other thing is that 30 years ago anorexia was a kind of white upper-middle-class disorder; now it is an equal opportunity disorder.

Dissatisfied or Delusional?: Body Dysmorphia and Pro-Ana Culture

RA: What is the role of body dysmorphia—a disturbed image of someone’s own body? Is that causative, or is that more like a symptom?
RR: It is hard to figure out what is normal eating for a woman in our society. It is hard to sort out where the line is between normal and abnormal size. When guys are hungry, they eat; it’s fuel. But it is really hard for women to view food as fuel that they need and not use it in other ways, and listen to their body about when they are hungry and full and not be externally regulated—”This is the amount I should eat, and this much is too much,” or that kind of thing.So many women feel fat, or feel fatter than they actually are. Is that body dysmorphia, or is that just part of what women think it means to be a woman? Is that what our culture tells us women are supposed to do? Women say, “How do I look? Do I look fat in this?” That is part of the culture.

Real dysmorphia is preoccupying—it is almost delusional. They have done some studies on women with anorexia: they have an Adobe Photoshop morphing program where there is a photo of them and they can turn a dial to make themselves thinner or heavier. So you ask them to adjust the image to what they think is their actual body size. Some of the studies show they are actually pretty accurate—it is not that they necessarily see themselves as heavier than they are—but some studies don’t show that. It is a little hard to say.

The dysmorphia isn’t about being unhappy with your body; it is really thinking that your body is different than it is. And I think it is not uncommon for people who were heavy when they were younger—no matter how thin they are, they may feel like they are heavy. It is not a dysmorphia—it is just how they encoded their body image, and it is really, really hard to update it accurately. It is like people who grew up poor: no matter how much money they have, they often feel poor. It’s not like they are delusional. They know that they have this money, but it’s hard to fully accept the new circumstances in a deep way.

RA: Do you find that restrictive eating is often a way to get attention, or is it really primarily an attempt to fix a perceived flaw in oneself?
RR: I think people come to it for really different reasons. It’s sort of like substance abuse. There are many different reasons why people start this slippery slope of using or abusing a substance. But once they are dependent on the substance, it takes on a life of its own, and ultimately they all look similar at that end of the process. Some people start out trying to lose some weight. It feels really good. They get a lot of positive feedback about it. They say, “Okay, I will just lose a little bit more, a little bit more.” And then, before you know it, they are underweight and their self-esteem has gotten tied up with it. They have gotten this reinforcement from, who knows, their boyfriend.And then it is really hard to come out of it, because depending on how underweight you are, you start having some cognitive impairment issues, and then it is hard to make good decisions. Bulimia or binging and purging is a similar thing: it may start out where someone ate so much that she felt either physically uncomfortable or emotionally uncomfortable with how much she had “pigged out,” so to speak. So she may have made herself throw up, and then in that moment she felt better—there was immediate positive reinforcement for the behavior. So the next time she feels uncomfortable she thinks, “Oh, well, this worked last time. I will do it this time.” And then she does it again and she start to think, “Well, it’s okay if I overeat, because if I do, I can just throw up, or I can take laxatives, or I will just do another half hour on the Stairmaster,” or something.

Then it becomes a slippery slope. It is not necessarily for attention, but once they do it, it becomes a coping strategy that it is hard to switch off. And it often becomes the primary coping strategy.

RA: Has there been a shift in anorexic culture with the rise of pro-ana websites? (These are websites that act to support groups for eating disordered women, to encourage each other in extreme weight loss.)
RR: Yeah, it’s really sad. It is one of the downsides of the Internet. It is ubiquitous—if you want that kind of support, it’s there for you. And I think it is really hard for families and caregivers, because you can’t forbid someone to use the Internet, so it is much harder to control the environment in a way that is positive.
RA: Is that the main difference since the rise of these kinds of websites—that it is more difficult to create a healing environment and to control that space?
RR: I think that is one of the differences. I think there is also a “me, too” copycat issue. In psychotherapy, there is a certain competitiveness that happens. It is not just advice. If you have a therapy group of women with anorexia, you have to have a skilled group therapist to make sure that the group doesn’t end up being de facto pro-ana. You don’t want people to get into this competitive “I’m thinner than she is, I eat less” dynamic.

The Importance of Teamwork: Treating Eating-Disordered Patients

RA: What kinds of events precipitate eating disordered individuals seeking treatment?
RR: Sometimes the individuals recognize they have a problem—either they saw something on television or a film or online. Or they vomited up some blood or they passed out. Sometimes people just feel like it is taking over their lives and they haven’t quite realized it until they were late for some event because they were engaging in these behaviors. Or a friend was using the toilet, the bathroom was left disgusting, and they had a fight.Sometimes it is family members being concerned. Sometimes if they are under 18 or even if they are college age, parents may say, “You have to do this,” or, “We won’t pay for college if you don’t do this.” So there may be a certain level of coercion.

RA: Do eating disordered clients usually minimize their problem?
RR: I think it depends on why they are there. If they are not there because they want to be, then they may be tempted to minimize it. I think it is like substance abuse in that way. If people are really there because they feel totally committed and want to be there, they are likely to be more honest than people who are ambivalently there.
RA: Are there pitfalls to getting in the role of monitoring their eating or bulimic episodes? How do you balance concern for their physical well being with the need to give nonjudgmental support?
RR: Great question. One of the things that is really important for psychotherapists treating eating disorder patients is to work with either an internist or a pediatrician who has experience and knowledge about medically treating eating disorders. This is super important, because as the psychotherapist you don’t want to get into that dilemma of having to be the bad cop, or any cop. You just don’t want to have to be monitoring their medical status. And frankly, most mental health clinicians don’t have the training. Even psychiatrists shouldn’t be in that role because that is really a medical role.And not all internists and pediatricians really know how to monitor patients with eating disorders. They don’t necessarily know what to look for, and they don’t know how patients might try to game the medical exam. For example, a good practice for any kind of eating disorder, and patients who have anorexia in particular, is that they should be weighed every time they come in. And they should be weighed with only a gown, because sometimes anorexic patients will put weights into their clothes to make themselves heavier on a scale so it looks like they have gained weight.

If you have them wear a gown, or even if you don’t, you really need to palpitate their bladder, because sometimes patients will water-load before they come in as a way of being heavier on the scale. Water-loading is very dangerous because it can make their electrolytes go all out of whack. So there are all these things that you wouldn’t necessarily think to do.

For eating disordered patients, the internist should explain that they have to be weighed every time. If they don’t want to know the numbers on the scale, the internist is happy to weigh them backwards, or have the nurse or the physician’s assistant weigh the patient backwards. Sometimes patients freak out by the numbers on the scale every time they come in, if it is up or down or that kind of thing. It can be devastating for patients to see the numbers on the scale show they are gaining weight, even if they know that they are and they should.

RA: Other than working with internists, are there other things that therapists should know about working with anorexic or severely bulimic clients?
RR: It’s really good to have a dietician who knows about treating people with eating disorders. Sometimes a dietician who doesn’t have specific training in eating disorders can do more harm than good. It is really about specializing. They are a valuable part of the program because they can look at a patient’s food chart and see, “Gee, maybe you are having cravings for ice cream because you are not getting enough fat earlier in the day. So what happens is by dinner time you are not being sustained by the food that you are eating because you need fats to give a sense of satiety.”So if they are basically having a low-fat diet, they will be much more likely to be at risk to binge later in the day. It is little things like that, where even a nutritional consult can be helpful.

RA: What do you think about residential eating disorder programs? Are they worth the cost? Is it possible to get that kind of care as an outpatient?
RR: I leave the medical decision to have someone do residential treatment to the person’s pediatrician, doctor, or internist. We consult with part of a team, but at some point it is a medical decision, which means it is really not safe for the person to be doing what they are doing on an outpatient basis.There are various steps of care for eating disorders. You can have a 24-hour inpatient experience. You can have residential, which means that is where they sleep. They have a dinner meal and they sleep there, but during the day they are doing other things. You can have a day treatment, which is their 9 to 5, but then they sleep somewhere else. You can have intensive outpatient treatment, where the person comes three to five times a week for a psychotherapy session, or more regular once- or twice-a-week outpatient psychotherapy.

There is a range of different options available depending on the severity, the patient’s motivation, insurance issues, or practical issues. Sometimes residential is really the best course of action because the eating is so out of control that they need an environment that is totally structured for them 24 hours a day.

The main problem with residential is that when people leave, they typically go back to the same environment that they came from, and they have all the situational cues. It’s like putting an alcoholic in detox—if afterwards you put them back with their friends who are going to bars, or they have all of the alcohol in the house, or they haven’t learned new coping strategies adequately, then they are kind of back to square one.

RA: Because they are surrounded by enablers?
RR: Right, depending on the situation. And honestly, unlike alcohol, someone can not drink, but you can’t not eat. And I think that is one of the hardest things about recovering from an eating disorder—it is really having to figure out how to do it in a different way. It is not an all-or-none thing. And it is really hard, I think, to figure out how much food is enough. When should I get up from the table? How hungry should I be before I start a meal? How hungry should I be to have a snack?
RA: With regards to psychotherapy, in your experience, what kind of treatment works best?
RR: The kind for which the patient is most motivated. The track record in research studies is for cognitive behavioral therapy; that is the gold standard and the treatment of choice for bulimia. For young people with anorexia, if a family is willing to do it, there is what is called the Maudsley Approach, named after Maudsley Hospital in England, which is where the treatment originated. The idea for this treatment is that the therapist’s role is to support the parents and the parents’ wisdom and authority in getting their child to eat. So the child lives at home, and one of the parents is home 24 hours a day, and they alternate. The idea is that the kid can’t do anything until she eats, and as parents it is their right to get their kid to eat. But you don’t want to literally force it down her throat, so the therapist is a consultant helping the parents use their knowledge of their child and their authority to help the person eat. There is a great book for the Maudsley Treatment called Treatment Manual for Anorexia Nervosa.
RA: That sounds pretty intense for a family.
RR: It is incredible intensive. It is a huge family investment in time and energy, and it has a very good track record. But obviously, you are not going to use this with a 30-year-old.For people with anorexia who are older or for whom Maudsley doesn’t make sense, if they are medically stable, so they don’t need to be in an inpatient unit, cognitive behavioral therapy can be very helpful. But the main problem with cognitive behavioral therapy for people with anorexia is if they are underweight enough, their cognitive functioning is compromised; it is subtle, so patients don’t always realize that their cognitive functioning is compromised.

So what happens is that you can’t really do the cognitive work, because they can’t do it. They can pretend to do it, but they believe that their thoughts about food are actually rational.

RA: What do you do at that point?
RR: If this is because they are underweight, you may actually want to do a brief inpatient or day treatment stay to get their weight into a healthier range so that the cognitive functioning is better.Sometimes depending on how old they are, their living circumstances, they are having family therapy or even couples therapy, if they are older. And they are trying all different kinds of things. Interpersonal therapy (IPT) is being used for bulimia. It has actually got a pretty good track record. Most people don’t have training in IPT, so it is not as widespread. Another thing that can be helpful is dialectic behavioral therapy for people with intense bulimia, because it is really an emotional regulation problem, so DBT aimed at helping with emotional regulation can be very helpful. Researchers are beginning to apply DBT as a way of treating bulimia, and results are encouraging.

Tips for the Novice

RA: If a client reveals to his psychotherapist that he has some form of disordered eating but he is not drastically underweight, at what point should he be referred out to someone who specializes in these kinds of issues?
RR: What might make sense before clients are referred out is if therapists are willing to have a consult with someone who has this expertise in eating disorders, because it can’t hurt.If the psychotherapist doesn’t have an expertise in eating disorders, even in a one-shot consultation they will learn something that will help them for other patients in their practice. They themselves will get to ask that question—”What is the cutoff? What are the questions I should be asking patients when they mention eating that seems a little odd to me?”

Therapists who are at all wondering if a consult is a good way to go should do what therapists naturally do when a flag goes up with something a patient mentions, which is to ask more about it. Try to get a little bit of a history of the problem. Does the patient see it as a problem? Do family members or friends mention it? What does the patient think the function is? What function does it serve? What are the drawbacks? What are ways in which it seems the patient thinks it is working for him or her to have that disordered system? So collect information.

When there is any doubt, a consultation is a really good idea. Or, if it is really clear that the person has a problem that is enough out of the therapist’s expertise, he makes a referral and explain to the patient, “You know, it’s not necessarily an ‘eating disorder,’ but it sounds like it is enough of a problem in your life that it is worth just getting some advice from someone who has an expertise about this.”

Again I wouldn’t frame it as the person should enter lifelong eating disorder treatment. If the therapist doesn’t think she needs a consult herself, let the patient have a consult.

RA: What is the biggest challenge of working with these kinds of clients?
RR: One of the things about the process of becoming a better therapist is figuring out the kinds of clients that aren’t a good fit for you. And patients with eating disorders are definitely not a good fit for some therapists. One of the things is just to realize that and there is no shame in that. It’s really not an issue. We all have kinds of patients who we work better with and kinds of patients that we work less well with.So if you as a therapist feel like, “Ugh, I don’t really want to get into this. This is just not my thing,” that’s really useful information and it may make sense to refer the person to someone else.

Again, I think the best thing to do when that happens is to have a consultation. I am a big believer in either peer consultation, groups with people who have an expertise in eating disorder or paying for a consult, but if you feel like you are not being as helpful as you can, if it feels like the treatment is standing still, it is always good to get another take on the case. That is where we have case conferences and things like that.

The easy cases, where the work gets done very quickly, usually happen when it is a newly diagnosed eating disorder or new onset, and the person is really motivated. But I think more and more there are the chronic cases where people have been doing it for a long time and it is one of the main coping strategies that they have. And if they got the eating disorder at a young age, they never really developed themselves as people outside of the eating disorder, so they don’t actually know who they are. There is no baseline they can return to.

And it can be very slow-going work. The patient may be ambivalent about getting better, so it may feel like it is two steps forward, one step back, or just sometimes like you are standing still.

RA: What is the hardest thing for you personally in working with it?
RR: I think it is my own impatience to want to help them get better sooner.
RA: Having more motivation than they have sometimes?
RR: Yeah, exactly.
RA: You mentioned it is important for therapists to figure out what kinds of clients are a good fit for them. Have you noticed personality characteristics that make really good therapists for working with eating disorders?
RR: Yes. One of them is people who aren’t squeamish about talking about vomit, about loose stool, about bodily functions in great detail. If someone is uncomfortable about that, then it is definitely not a good fit. Some people may feel like they are being too intrusive to ask the kinds of questions that should be asked: “How often are you throwing up? How do you throw up? What does it feel like when you throw up?”The other part is there is a lot of work about body image. The actual eating disorder symptoms sometimes, with appropriate treatment, can get better remarkably quickly. But what happens is residual body image issues remain; the person may be eating in a normal way but he or she doesn’t like their body, they may be cutting—not parasuicidal cutting, but they make little marks with a razor on their thighs, that kind of body hatred. That is a different level of work that then has to get done.

RA: When you are at that piece of the work, is cognitive behavioral therapy still the best modality for that?
RR: If people are having that kind of self-harming behavior, probably DBT, dialectical behavior therapy, or some of those techniques can be very useful because, again, it is about emotional regulation. If you hate your body so much that you hurt yourself like that, then I would say DBT is a good way to go.Often, there are psychodynamic issues as well. And there is a fantastic workbook by a man named Tom Cash called The Body Image Workbook, and it is just a fantastic book—well researched, very effective treatment for body image issues. The main problem is that people don’t necessarily want to do the work that is in the workbook. They have to be really motivated to do it. It is a lot of record keeping and exercise, not physical exercise but things like “stand naked, look in the mirror”—Mirror Exposure, it’s called. And that can be really hard for people. So therapy can actually be helpful in getting people over the hump to do that work.

RA: Have you learned anything in specializing in eating disorders that has informed your general practice?
RR: Absolutely. I have a deep respect for people’s ambivalence about getting better, and about how the longer symptoms persist, the harder it is to turn them around because people forget who they were before. The saddest part about eating disorders developed early is there was no “before.”But that’s generalizing. The other thing is just the awesome human spirit and the general capacity to try valiantly to cope. Human beings are amazing, and to a certain extent we are very resilient. Eating disorders, in some sense, are a type of resilience that just went awry, that became pathological.

RA: Say more about that.
RR: If you are having a hard time, if your boyfriend broke up with you and you are sad, it’s not uncommon in our culture to go have some ice cream to console yourself. People are just trying to do the best they can, and I think that is true for eating disorders. People who are depressed who struggle valiantly to get out of bed in the morning when they just want to curl up—the fact that they get out of bed is amazing. That is what I mean about the human spirit to keep going, despite all of the things that people are juggling and the mental and physical handicaps, being exhausted, feeling like they are going to faint, just not being able to function well, being preoccupied with lots of food.

Most people, most of the time, are able to put one foot in front of the other and keep going in trying to get better.

RA: What have you found most enjoyable in this work?

RR: I think it is about the essential human contact of really hearing someone in the fullness of who they are—the good, the bad, the ugly—and their profound relief at being accepted for who they are. And then the sense of being able to help them. The amazing thing is, when therapy works, the idea that you helped make someone’s life better.

Sleep and the Therapist: A Poem

Most times it is courteous
Sending notice of its pending arrival
Yawns that begin tiny, politely, and gradually stretch the jaw
Blinks that seem to beat in slow motion to some unknown tune and then even slower to some unheard command
This time, however, its approach was one a stealth bomber would envy
A stealth attack if there ever was one and in the most inconvenient place . . . a therapy session

It was not that I was bored or even distracted
Looking at the clock in disbelief that what I knew was half an hour
was in fact just five minutes
Just seconds before, I had been attentive, present when suddenly, sleep descended
Seductive, irresistible, folding me in soft arms
And I was in trouble
Struggling to contain jaw splitting yawns in the twin caves of my cheeks
Changing positions frequently as if the chair's cushion was suddenly holding the heat of a Texas summer day
or had morphed into its cousin, holding pins
Crossing first the right knee over the left
Then the left over the right
Crossing the ankles in similar fashion
Trying to do all this with style and nonchalance

Usually I value eye contact but now I am grateful for the seconds my client looks down or away
Shutting my eyes quickly for sweet relief
Hoping I can open them before she looks up again
But desperation sets in when I see three identical clients where there is only one
Prayers ascend rapidly and fervently
"God, please don't let me fall asleep." "Please help me stay awake." "Please, God, please!!"
"Just for a few more minutes, help me keep my eyes open"
And I almost believe that I hear sleep's soft laughing whisper, "Stop fighting and embrace me."
My prayers are now one word, "Help!" "Please!"
Then finally, it is time to end and if I was ever happier to see quarter or ten till the hour
I cannot recall it

Psychotherapy with Former Cult Members

Two years ago, I received a late-night telephone call from a man who would give me only his first name. Bill said that he’d recently moved to Oakland and had been referred to me by a cult awareness organization in Florida. I get calls like this a few times a year—sometimes a referral from the cult awareness network, occasionally from the internet, and once in a while from someone I’d already met with. Because I was working full time as a clinical psychologist and lecturer at the university, I told Bill that he’d likely be better served calling a county psychological association for a referral to a private practice psychologist. “I’ve done that already,” he replied irritably. In fact, he had already tried therapy with both a psychologist and an MFT, but neither seemed to understand what he’d gone through. ““They couldn’t tell me what happened.””

Relenting, I told Bill that I’d be happy to meet with him, and suggested a coffee shop in Berkeley. As with each of these referrals, I was curious to hear Bill’s story. Although I would not provide psychotherapy to him, I hoped to explain to him how cults operate. Once he understood the powerful techniques of persuasion that were used against him, perhaps at least some of the guilt and foolishness he might be feeling over his cultic involvement would decrease.

The next morning I arrived in the crowded coffee shop 15 minutes early. Bill was there already, sitting at a small corner table in the Phillies baseball cap he told me to look for. He was a tall, red-faced man in his mid-thirties, with the kind of physical build that suggested a retired athlete. I introduced myself and he nodded, his eyes tight.

As I sat down across from him, he launched right into his story. “It’s about a church I joined in college,” he began. “I think it’s a cult—I read up on cults, but I just don’t know. The group I belonged to doesn’t sound like any of those famous ones, like Heaven’s Gate or Jonestown, and it’s not big or anything. But it’s a bad place.” He shook his head, gaze focused on the Formica tabletop. “I’m kind of a loss as to what exactly happened,” he continued. “I’m not a stupid man. I’m not, really. And I just can’t seem to figure out what went wrong.”

Bill's Story

Though Bill’s story was unique to him, it followed a pattern I was familiar with. He had been raised in a devout Lutheran family. As a freshman in college and far from home, he had been approached one day in the quad by a woman named Sarah. “She was real pretty and so nice to be around. She told me she was a student and we talked about school and God—we were both Christians.” She ended up inviting him to a prayer meeting that night at her church. Grateful for the attention of an attractive woman when he was struggling to find new friends, he went along.

The prayer meeting was held in a storefront church a few blocks from the campus. “Bill began attending weekly services there, and was made to feel so welcome that within a month he was visiting the church daily.” There always seemed to people there, no manner when he dropped by, and they were always glad to visit with him. The pastor, Brother Jacob, was an inspiring teacher who seemed to know just about everything about Bill, “or it seemed to me then that he did! About my spiritual struggles and my loneliness, about my trying to figure out what I was supposed to do with my life and wondering if I was even a good man.”

By the end of his freshman year, Bill had dropped out of college to live with the group. “School just didn’t seem that important to me anymore,” he explained. “I was more concerned about the spiritual crisis in America.” As he became immersed in his new church family, he was persuaded that the Lutheran religion he’d been raised in was a false religion and that his only hope for salvation and peace of mind was with Brother Jacob’s church family.

Over the next several years, Brother Jacob’s small, insular spiritual group moved often, eventually settling in Sonoma County, California. By the time they arrived, they included over 40 members. The theology of the group, as espoused by Brother Jacob, gradually morphed into an amalgam of fundamentalist Christianity and nebulous New Age teachings. In his daily sermons, Brother Jacob reinforced the belief that he was a divinely appointed prophet chosen by God to usher in a universal spiritual awakening.

Despite Bill’s initial infatuation with her, he never became romantically involved with Sarah, the girl who introduced him to the church. Once he was firmly ensconced with the group, she distanced herself from him. Only belatedly did he learn that the other members considered her and Brother Jacob a married couple.

The church members were forbidden contact with family or past friends without Jacob’s explicit permission, and the church community did not have television or radio and did not subscribe to newspapers. Bill and the other congregants relied solely on Jacob for outside news. Five years after his recruitment into the church, Bill married a church member new to the group, and they had a daughter together, six years old at the time I met with Bill. Brother Jacob officiated at the wedding and no marriage license was filed.

“It got really bad after that,” Bill told me. “I didn’t have an education and mostly did construction work, odd and ends—grunt work like everybody else.” He turned his paychecks directly over to Brother Jacob.

“I started thinking that this was pretty bad—and my wife and I weren’t getting along so good. I just prayed harder. Jacob preached to us every night for hours, and God help any one of us who fell asleep while he was talking. Mostly I was just tired all the time.” Bill couldn’t sleep and started losing weight. It was about then, around six months before he phoned me, that Brother Jacob began the ordeal he called “confession and redemption.”

Brother Jacob would choose a member of the community to be criticized and belittled by the entire community for hours at a time, rationalizing this exercise as a way to rid the community of sin and temptation and put the sinner on a strong foothold to spiritual purity. It was at one of these group confessionals, when Bill was on “the hot seat,” that he finally “cracked up. My wife went after me, along with everybody else. Brother Jacobb egged her on until she ridiculed our sex life and made fun of my unspiritual, lustful attitudes and my shortcomings as a husband. Nobody there seemed to care how horrible that was for me. I was shamed in front of everybody.” At the end of that meeting, which seemed to go on for hours, Brother Jacob ordered Bill to maintain chastity until he’d worked through all his sins and worldly thoughts—until the spiritual welfare of the planet became his overwhelming desire. He was ordered to live in the garage until further notice.

“It was then that I realized it was all like a really bad nightmare and I’d just wasted thirteen years of my life,” Bill told me. “I hadn’t spoken to my parents or brother in years, had no friends, and never finished school.” Bill was now working at two low-paying jobs and had hired an attorney to try to get custody of his six-year-old daughter, whose mother had remained in Jacob’s church. His attorney warned him to prepare for a long legal battle—he and his wife had never been legally married, and his wife disavowed his paternity of the child.

Cult Recruitment Tactics

Bill’s story illustrates perfectly the classic cultic recruitment and retention process. Margaret Singer, a preeminent 20th-century authority on cults, wrote in her definitive Cults in Our Midst about the six stages of cultic recruitment and retention.

1. Keep the person unaware of what is going on and the changes taking place.
 Bill was recruited as a college student, when he was most vulnerable. He was away from home, far from his social support system, emotionally insecure, and lonely. It’s likely that Sarah had spent days recruiting on the campus and had approached dozens of solitary students before finding Bill. When he initially became involved with Brother Jacob, Bill thought he was joining a Christian church with spiritual and ethical beliefs much like his own. He had no inkling that Sarah had been trolling for new members and that the initial stages of his involvement with the group were carefully orchestrated to reinforce the commonalities Bill felt with the cult members.

2. Control the person’s time and, if possible, physical environment.
 Once Bill actually moved in with Jacob’s group, his time was rigorously controlled as he worked multiple physically exhausting jobs. Bill relinquished his income to Jacob, had no meaningful emotional contact with anyone outside the church community, and was dependent on Jacob and the other congregants for shelter, emotional support, and food.

A cult could be in your own neighborhood and you might well not know it because the members have such superficial social interaction with nonmembers. If a cult member were to have outside interests, meaningful contact with friends and family outside of the cult, or personal interests not specifically tied to the cult, it would be a whole lot easier for him or her to just walk out when things got bad. Recruits are not allowed exposure to any people, situations or ideas that might help them look at the situation objectively; the consequence is that the ideas of the cult gradually replace independent thought.

3. Create a sense of powerlessness, covert fear, and dependency.
One of the unbending tenets of cults is the “us versus them” mentality. Cult leaders justify this insularity in innumerable ways. In Bill’s case, Brother Jacob convinced his followers that his was a divinely directed spiritual path and that all other religions, Christian or otherwise, were either well meaning but false, or were diabolical. Citing the danger of “contamination,” Brother Jacob instructed his followers that to maintain their spiritual purity and avoid damnation, they needed to avoid as much as possible all contact with persons outside the community. To do otherwise would mean impeding God’s design for world spiritual harmony.

4. Suppress much of the person’s old behavior and attitudes.
In his groundbreaking book on “brainwashing” techniques used by Communist prison guards during the Korean War, Dr. Robert Jay Lifton points out that

“Whatever its setting, thought reform consists of two basic elements: confession, the exposure and renunciation of past and present ‘evil,’ and re-education, the remaking of a man in the Communist image. These elements are closely related and overlapping, since both bring into play a series of pressures and appeals—intellectual, emotional, and physical—aimed at social control and individual change.” (5, 1961)

This is certainly what happened to Bill. He had renounced his past beliefs and affiliations, but in this case the “confession and redemption” exercise that he participated in finally caused him to metaphorically snap. Years of hard physical labor, a failed marriage, and humiliation from his wife, Jacob, and the other cult members caused such emotional exhaustion that he fled the cult to try to recoup his sanity.

5. Instill new behavior and attitudes.
With cults, the goal is to take whatever sense of morality or personal identity the person originally had and replace it with the leader’s own vision. Cultic indoctrination is gradual and incremental, just like the mind control described by Dr. Lifton. Everything happens in small, sometimes seemingly inconsequential steps. Had Bill been told at the first service at Brother Jacob’s church that he would have to disavow his family, drop out of school, perform mind-numbing physical labor for years, accept Jacob as a prophet, and be subjected to continual emotional abuse, it is unlikely he would have attended a second service. Jacob and his followers, however, kept hidden the central precepts of Jacob’s message.

6. Put forth a closed sense of logic; allow no real input or criticism.
Brother Jacob continually reminded his congregation that to desert the group was tantamount to eternal damnation. Members of the community were taught that temptation was everywhere and could come from anyone and everyone not associated with Jacob. For hours each evening, Jacob lectured on theology, the evils of modern society, and the hypocrisy of organized religion. He warned his congregation that to lose sight of his message, even for a minute, would be tantamount to suicide.He urged them to report any doubts or negative thoughts to Jacob immediately, and to assist each other in remaining spiritually pure by informing Jacob of any concerns they felt about the purity and purpose of their fellow congregants. Bill tried his best to live up to these strict rules; in doing so, he came to unquestionably accept the belief that Jacob was a prophet appointed by God.

Exploiting Vulnerability

Despite decades of research on cults, there is no typical personality that is particularly susceptible to cult involvement. You can’t say, for instance, that cults recruit only timid, uneducated, or naïve people. But one thing that continually comes up is that most people who become involved with a cult are going through a vulnerable time in their lives. In the 1960s and ‘70s, the most typical recruits were young, which makes sense as there were thousands of young people adrift looking for a sense of direction and purpose.

Today, college campuses remain good recruiting spots with young students away from home for the first time, vulnerable and lonely. But life transitions make us vulnerable at any age, and a cult can present itself favorably as a support network during these times. You might think of a woman whose husband divorces her after a 30-year marriage—her identity and sense of purpose have been focused on her family and now the family is gone; or a single parent whose children go away to college; or someone who has had a catastrophic death in the family; or a 50-year-old man who just lost his job of 20 years. These people bring job skills and potential earning power to the group. The elderly have become particularly good recruits because they have assets. If they own their own homes, the homes are probably paid off, they have Social Security and pensions, and they have free time to devote to the cult. Cults need these recruits to ensure their financial and social sustainability.

During my predoctoral internship at a day treatment facility in the San Francisco Bay Area, I came to learn that one of my co-interns, doing her postdoctoral internship, had suffered a series of personal tragedies on the East Coast and had moved to California to start her life over. There had been a lapse of a few years before she felt organized enough to finish up her internship hours. One of the personal tragedies she was running away from was an abusive sexual relationship. She settled in Berkeley and, feeling the need for friendship and quiet reflection, she joined a free spiritual meditation group. At first they met twice a week, but gradually these meetings became more frequent and took up most of her free time. When I met her, the only people she really knew in California were the therapists at the day treatment center and her new friends in the meditation group.

The group was part of a national spiritual organization controlled by a self-described guru. I realized early on that she had joined a cult, but my attempts to talk to her about it failed. She had a stack of cards on her desk, each printed with a quote by her guru. When I tried to talk with her about my research on cults, she would pick up one of the cards and read its message to me. These messages were innocuous, cloying, vaguely spiritual sayings. She was doing something called a thought-stopping technique. Followers of charismatic leaders are often taught that when they are faced with adversity, doubt, or challenge, they’re to say a specific mantra or prayer or do some specific activity that will bring the cult and its leader to the front of their minds and drive doubt away.

Since she wasn’t open to my concerns about the group she’d joined, I stopped mentioning them. I figured that if she ever did decide to leave the group, she would know that she could talk to me. The other therapists avoided her. They found her smugness, her meditating during breaks, the photo of her guru on her desk, and the little aphorism cards irritating and troubling.

When her postdoctoral internship was completed and my predoctoral internship was finishing up, she and I had the opportunity to receive funding to start a small drop-in clinic for runaway teenagers. For the first time in the 15 months I’d known her, I met with her outside the clinic. She refused to meet either at my home or at hers, so we arranged to convene at a picnic spot in a Berkeley park. When we met, she was flustered and nervous; she revealed that the local leader of her spiritual group had told her she shouldn’t trust me. We were writing out the rough draft of our proposal when it started raining. She suggested that, after all, it was okay to meet at her apartment.

We hadn’t been at her apartment three minutes when her local spiritual leader phoned and informed her that he was holding an emergency mandatory meeting for the entire group. So much for that; I left. The next Monday, she left me a voicemail message stating that she had no interest in running a clinic with me. A month later, this woman who had a Ph.D. in clinical psychology was working at the cult’s San Francisco restaurant 12 hours a day, five days a week for $280 a month, while living in a group home owned by the cult. “There was no way the group she belonged to was going to let her act independently.” She was too valuable to them. At the restaurant, they could watch over her.

Treating Former Cult Members: Common Issues

Very few of those who briefly become involved with a cult will stay. As a PhD candidate I studied a small cult for my dissertation. Along with 18 other people, I attended a free introductory psychic healing offered by a local group. Six of us signed up and paid for a psychic healing class. When I finally stopped attending the group’s services eight months later, only one other person from the original 19 was still involved with the group.

But the damage done once someone decides to break away can vary tremendously, and the challenges of providing to psychotherapy to ex-cult members can be daunting. There is no one-size-fits-all strategy for former members, and there’s no reliable data I am aware of that indicates success rates using any specific psychotherapeutic tool. Each client brings his or her own personal issues to the therapy session, which will vary depending on variables such as duration of involvement, age, educational background, and whether sexual abuse was part of the cult’s practices. Along with collaboratively developing a treatment plan that is unique to that client and which most clearly addresses the client’s pain and sense of loss, the most reasonable and helpful psychotherapy for a former cult member will involve education, patience, and case management when it’s needed.

Although I wasn’t in a position to offer psychotherapy to Bill when he contacted me, I will use his case as an example to highlight many of the issues to consider when providing psychotherapy to a person who has left a cult. When Bill exited the cult, he was 33 years old. He had dropped out of college in his sophomore year and worked as a construction laborer. He had acquired no job skills that could pay him much above the minimum wage, and now faced the daunting tasks of supporting himself, paying child support, and somehow earning enough money to finance what looked to be an expensive child custody legal battle. He was estranged from his biological family and had no friends outside of the cult.

Social Services Referrals

It is important that the therapist learn the specifics of Bill’s current living situation. Bill has met with two psychotherapists already and psychotherapy is not cheap; he may have paid a third or more of his weekly income for each visit, and clearly he can’t do that indefinitely. It’s quite possible, too, that Jacob placed little priority on his followers’ physical health; it may have been years since Bill visited a medical doctor or dentist. As a first step in the psychotherapeutic process, it may be necessary to assist Bill with basic case management services. Bill said that he’s working at two low-paying jobs, but does his income disqualify him from food stamps or Medi-Cal eligibility? And where is Bill living? He may be staying in a homeless shelter or in his car. In order to be helpful to Bill, the psychotherapist needs to know the answers to these questions and be prepared to refer him to county agencies that can assist him.

Assessing Risk of PTSD, Depression, and Other Diagnoses

For years, Bill was subjected to ongoing emotional abuse from Jacob. The consequences of that abuse, coupled with his current poverty and the dissolution of his marriage and loss of meaningful contact with his daughter, is likely causing overwhelming psychological pain. He may be experiencing difficulty sleeping and have an accompanying high startle response. Christian symbolism might remind him of Jacob’s theology. Even driving by a church with the congregation mingling outside could trigger unpleasant memories. His self-esteem was still forming when he met Jacob, and will almost certainly be low; he’s without friends and lives in poverty. All of these factors put him at risk for depression. It was already noted that Bill is quite thin. Does he have an appetite? It’s understandable that he may be feeling guilt about having abandoned the only friends and family he has known in the past decade, but is the guilt overwhelming? Does he do anything at all that gives him pleasure, or does he spend all of his time working and worrying?

At intake, the therapist should do a Mental Status Exam and perhaps use other assessment measures such as the Beck Depression Inventory screening to determine Bill’s level of concentration, document his physical appearance and affect, and determine whether Bill is experiencing depressive symptoms. The results of these screenings will indicate whether formal psychological testing is advisable. In eliciting his life story from Bill and the diagnoses based on the initial screening and psychological testing, the therapist can then formulate a treatment plan that prioritizes Bill’s problems and the diagnoses determined by the psychological testing.

While it is common for ex-cultists to experience posttraumatic stress disorder, not all of them will, any more than will all soldiers who experience combat. Depression and anxiety are very frequently found in persons who have left a cult, but it is an error to automatically assume that all former cult members suffer from these dysfunctions. Shame, low self-esteem, and anger, however, are nearly always present.

In these cases especially, journal keeping can become an important adjunct to therapy. Bill should be encouraged to keep a daily journal as a way to document his feelings and reactions to stressors. If, for example, he feels a surge of anxiety when driving past a church or seeing a parent and child, Bill and the therapist can collaboratively develop coping strategies to lessen the chances of Bill reacting adversely to such stimuli. He should also be encouraged to write down his feelings about his future and the impediments he sees as preventing him from more fully taking advantage of his intellect and ambition. Journaling will allow the therapist to better understand Bill’s dilemma as Bill views it.

Life Decisions

As an adult, all of Bill’s meaningful life decisions had been made by Jacob; Bill had no say in his education and employment and had limited say in his own marriage. Now all decisions are his. After viewing what he sees as a waste of 13 years of his life, he may feel either like he needs to make up for lost time and immediately “jump back into” the life he put on hold when he was 19 years old, or, conversely, believe it’s too late for him to make the needed changes in his life.

Although Bill is in his thirties, emotionally in many ways he is still an adolescent. While with Jacob, he’d learned to suppress doubt; now he is likely overwhelmed by doubt. Does he fear that if his decision to leave Jacob was the wrong decision, he will be damned? Does he believe that he has offended God?

In addition to focusing on Bill’s immediate psychological dysfunction, the therapist should also assist him in realizing what his long-term goals are, something that was never addressed while he was with Jacob. At some point, he may want to look beyond remaining a laborer. The therapist can assist Bill in expressing his interests and hopes for the future. Because Bill’s self-esteem is almost certainly poor, he may be timorous in talking about what he would like to do; he may feel that he is not smart or worthy enough. The therapist can help Bill past his timidity and low self-regard. Bill is an intelligent man and there are a myriad of options available to him; finding the confidence to speak to his therapist about his goals will be of great emotional benefit.

Social Reintegration

Because of the cult practice of social isolation, Bill will now almost certainly feel alienated from just about everybody. He’s left the only people he’d known for over a decade, and he has no one to replace them. As a result of his isolation as well as the cult’s “us-versus-them” mentality, he may view people with distrust, fearing that they’ll take advantage of him. Because he was also taught to harshly judge “outsiders” who did not conform to the cult’s standards of conduct, he may need help developing a less judgmental and more open approach when interacting with other people as a way to more fully re-integrate himself into society.

Finding a way to fit into a mainstream that he has spent nearly his entire adult life viewing with suspicion and judgment will be difficult. What will he talk about with people he meets at work? “How can he explain his involvement with the group without provoking ridicule and disbelief? If he chooses not to talk about his cult membership, what will he say he’s been doing for the last 13 years?”

For these reasons, group psychotherapy is often useful when working with former cult members. For Bill, group therapy would allow him to hone his social skills, which have been dormant for over a decade; he may not even know how to speak to people in a friendly, unassuming manner. Additionally, receiving feedback from the other group members will assist Bill in thinking about his experiences in the cult from a different standpoint. Good group therapy creates a safe environment Bill for to learn socially appropriate ways to assert himself. By interacting with peers in the group, Bill will learn coping skills and reframing strategies, and improve his ability to speak about his experiences and hopes for the future. Group therapy will also assist him in realizing that he is not metaphorically alone, that the turmoil he is experiencing is not unique.

Challenges in Reconnecting with Family

Bill has had no contact with his biological family in over a decade. It is not uncommon for cult leaders to persuade followers to borrow money from their families, most often by promising to use the money to return home or return to school. If this happened with Bill, the therapist should know about it; it might make reconciliation more difficult, and the shame of having stolen from his family may be a contributing factor to Bill’s emotional problems. Reconciling with his family could both decrease Bill’s isolation and ease some his guilt. His parents might not know that Bill has left the cult; they might not even know he has a daughter, and learning of a grandchild could make reconnecting with his family easier.

The therapist will also want to explore Bill’s current disenfranchisement from his family and his reasons for avoiding contact with them. Bill can be encouraged to talk to the therapist about the worse-case scenarios he envisions might happen if he attempts reconciliation. Rejection? Anger? Legal action to recover unpaid debts? If Bill is prepared to reach out to his family, the therapist can offer to meet with them together, to act as a sort of referee and to explain to Bill and his family the forces that were put into play by Jacob that led to Bill’s recruitment into the cult. It could be healing for the family to learn about tools of undue influence used on Bill, and understand that Bill’s cultic involvement was not due to Bill’s upbringing, but were rather a result of Jacob using remarkably successful tools of persuasion on a particularly vulnerable young man.

Managing Self-Blame with Psychoeducation

Persons who leave cults, or any abusive relationships for that matter, very often feel foolish and angry for having been so badly manipulated. It’s important that Bill knows that the techniques used against him by Jacob were not Bill’s fault. It wasn’t weakness on Bill’s part that caused him to join Jacob’s cult; rather, it was his innocence and Jacob’s pathology that were ultimately responsible. There is a genuine sense of empowerment when a former cult member understands the tools of manipulation that were used against him or her. While bitterness and anger may linger, the former cultist no longer feels somehow defective. This goes a long way in eliminating feelings of low self-worth.

Follow-up: A Slow Recovery

Over the next several months, I heard from Bill occasionally. At his suggestion, about a year later, I met with him again at the same coffee shop. This time he was more relaxed but still maintained a reserved, moderately nervous affect. He told me that although he had met with three more psychotherapists, he’d been unable to find one he believed understood his experience well enough to be able to help him. He mentioned that he’d joined a psychotherapy group a month earlier and felt that he was receiving support from the other members of the group, who do not see him as weak or foolish. He was hopeful that the group therapy would work out.

He still worked in construction and paid monthly child support. The courts had determined that he was the biological father of his daughter, and he’d been granted visitation privileges with her, which his ex-wife was contesting through an attorney hired by Jacob. In response to my question, he said that he still considered himself a Christian but, despite attending several churches, had not found one where he felt he belonged. He added that he still had difficult mentally separating Christian theology from Jacob and what Jacob had done to him. Bill remained quite bitter over having lost so much of his life to the cult.

I hope Bill’s story makes clear that ex-cult members are a traumatized segment of the population that needs more therapists who are educated about and sensitive to their particular experiences. Patience is a necessity in doing this work, but it is often helpful to remember that while these individuals suffered extreme measures of manipulation, their susceptibility to such influence is not surprising, or even necessarily difficult to understand. As Dr. Margaret Singer was fond of saying, anybody is capable of cultic recruitment if approached at the right time—a time when they are most vulnerable. That was certainly the case with Bill; he was young and naïve with minimal life experience, and he was lonely and cut off from his family. Jacob used an attractive woman as the initial bait and then played into Bill’s isolation, Christian beliefs, doubts about his direction in life, and his yearnings to be part of a community of friends who shared his principles.

Sources:
Lifton, R. (1961). Thought Reform and the Psychology of Totalism. New York: W.W. Norton and Company, Inc.
Singer, M. and Lalich, J. (1995). Cults In Our Midst. San Francisco: Jossey-Bass Publishers.

 

Training for the Treatment of Eating Disorders

Eating disorders are widely recognized as some of the most challenging psychological diagnoses. I was surprised to learn that they are also the most dangerous: eating disorders have the highest mortality rate of any diagnosis. Many clinicians assume that eating disorders only occur in young women. However, research has shown that the frequency of eating disorders is rising across a wide range of client populations, including men, middle-aged, and the elderly. Regardless of the population you work with, sooner or later you will encounter clients with eating disorders.

How can a clinician get training to help clients with eating disorders? I recently discussed this with Deborah Brenner-Liss, PhD, the director of the Association of Professionals Treating Eating Disorders (APTED). APTED is an affiliation of eating disorder specialists based in the San Francisco Bay Area. APTED provides support and training for clinicians, and referrals and direct service for clients.

APTED emphasizes a multi-modal method of treating eating disorders, including trauma, attachment-focused, somatic, experiential and affect-focused treatments. Given the complexity of eating disorder ontology and treatment, Dr. Brenner-Liss encourages students to “enlarge the depth of their conceptualizations”. APTED treatment includes a wide range of providers in the treatment team, including therapists, social workers, physicians, psychiatrists, nutritionists, body workers and coaches. (I personally find this to be a welcome relief from the all-too-common clinical turf battles!)

For clients with sub-clinical eating disorders, Dr. Brenner-Liss recommends consulting with an eating disorder specialist. Like other addictions, eating disorders are behaviors that build over time, and can sometimes be arrested in the early stages if they are addressed early with serious treatment.

For clinicians who want to work with clinical-level eating disorders, Dr. Brenner-Liss recommends getting formal training. In the San Francisco Bay Area, both UC Berkeley extension and JFK University provide eating disorder certificates. For those in other areas, the International Association of Eating Disorders Professionals Foundation (IAEDP) provides an online training and certification course (http://www.iaedp.com/). The IAEDP course includes readings, audio records from IADEP conferences, and writing assignments. I am currently taking this course myself, and have found it very rich.

Dr. Brenner-Liss also recommends joining a eating disorder-focused consultation in order to get exposure to a wide range of case material. Likewise, attending a weekly 12-step eating disorder group for a few months can provide valuable insight into the nature and course of eating disorders. Most ED groups are “open” so clinicians can be a “fly on the wall.”

For those in the SF Bay Area, APTED is hosting a two-day conference, “Re-Finding Our Way to Wholeness: What heals? Eating Disorders and Trauma,” September 24-25th, 2011, in Berkeley.  Registration required by September 10th. For more info, call 415-608-6307, or e-mail AptedSF@aol.com.  Notably, the conference is open to both clinicians and individuals in recovery.  I am personally encouraged by the growing movement in the psychotherapy community to break down the barriers between providers and clients.  (Another notable recent example is the Marsha Linehan's courageous self-disclosure about her struggle with mental illness.)

Listening versus Hearing in Psychotherapy

In my memoir, The Gossamer Thread: My Life as a Psychotherapist, I describe my treatment of ‘Angie’, a young mother with horrific fantasies of killing her two young children by stabbing them through the heart with a kitchen knife. It was back in the 1980s and I was in the process of shedding my old behaviour therapy skin, realising I needed to listen to the client more carefully before embarking on any specific intervention. My therapy was a success, or so it seemed at the time. I even wrote her case up for a behaviour therapy journal under the grandiose title, Verbal methods of behaviour change. I had confidently formulated her fantasies as extreme anxiety since there was no evidence of her ever harming her children. I discovered that they had begun after she had read a newspaper account of a couple’s murder of their children in a Satanic ritual. She worried that, however much she loved her children, that she too could be taken over by the Devil and do things she would never normally do. I saw this as vicarious traumatisation and her anxiety stemmed from her ruminations about this. I was able to help her, getting her to monitor the fantasies, reframing them as anxious thoughts, and substituting more positive ones, until the fantasies declined significantly in both intensity and frequency. This was my pre-cognitive therapy days and Angie was to lead me into training as a cognitive therapist. But that is another story.

I revisited the case in my book and, looking back, I realised that, while I had listened to Angie, I had not really heard her. Or rather I had heard what I had wanted to hear. She was a young mother, looking after two very young children while her husband was away working on the North Sea oil rigs. She was living hundreds of miles from her home town and the family she had grown up with. She had relatively little money and had given up her job. She was trapped like many young mothers are. Was that perhaps what this was all about? After all, what trapped her most were her children as they needed her constant care and attention. Could her fantasies be an unconscious expression of her resentment of them? If I had trained in systemic therapies, I might have heard a different story to the one I had carefully elicited with my prototype cognitive therapy hat on. I might have heard how unhappy she was, perhaps heard her fear that her marriage was a mistake and that she no longer loved her husband. Or had I been more analytically inclined, I might have wondered about the aggression in the fantasies and perhaps linked that to infantile aggression or sibling rivalry or other possible unconscious conflicts from her past. I did none of these things because I had heard what I had wanted to hear. I prided myself on attentive listening, on my sensitivity and creativity as a therapist. I had done a really good job. But had I? Listening is not a passive matter. It always reflects what we expect to hear. Hearing, on the other hand, is something else altogether as I later went on to learn. To hear properly one has to suspend one’s preconceptions and be prepared to question one’s own thoughts and beliefs. It is important to give a space to the client and not fill it with one’s artful questions, ideas or interpretations. It is to take a step back for a moment and wonder. We all listen but how much do we actually hear?