Are enough people involved to constitute a significant problem? A conservative estimate is that between two million and five million Americans have experienced cult participation.¹ With this level of involvement, even a low incidence of abuse is likely to mean that thousands of people are affected.

A shifting definition

Cult is a controversial word that people use differently, depending on their perspective. In North America, most information about cults is provided by three broadly defined approaches:

1. Some religious conservatives, in accordance with their own doctrine, define cults as religions that deviate from orthodox scriptural truth as they define it. These diverse groups are sometimes referred to as the CCM or Counter-Cult Movement. One example of such an approach is the Apologetics Index.
2. Sociologists and academic theologians study cults —a word they find pejorative — as normal vehicles of social change found in all cultures. They feel that people are dangerously quick to brand and persecute innocent groups whose only crime is being different. An international perspective can be gained from The Center for Studies of New Religions. A list of academic groups that focus on this areas can be found through The Ontario Consultants on Religions Tolerance.
3. Those most critical of cults — often former cult members, their families, and mental health workers who treat them —focus not on the beliefs of any group, but on specific behaviors they feel violate human rights, causing harm. They are sometimes called the ACM or Anti-Cult Movement. An example of this perspective is the International Cultic Studies Association, formerly known as the American Family Foundation.

It is this third view that has implications for nurses, who are involved with identifying and treating influences that harm their patients. From this perspective, a cult is a group that has excessive devotion to a person or cause and that uses unethically manipulative persuasion and control to serve the goals of the leaders, regardless of possible harm to its members and others.²

Cult characteristics

To outsiders, cults may be inexplicable, but each trait that describes a cult is commonly found in human society. It is the combination of traits and the intensity of each that create the potential for exploitation and harm.

Cults usually exhibit most or all of the following characteristics, in extreme degree and without the presence of cultural checks and balances:

1. A rigid belief system that cannot be questioned
2. A charismatic, authoritarian leader who claims to have a new truth or vision and who exercises considerable control over the members
3. Isolation from nonmembers and families of origin, imposed by lifestyle, communal living, or the group's belief that contact with nonmembers is detrimental
4. A high-demand schedule with much time spent in group-centered activities, such as meditation and chanting, fund-raising, proselytizing, and religious study. Extreme peer pressure urges conformity, and nonconformists may be shunned or expelled.
5. Deceptive recruitment tactics; extreme emotional manipulation of members; privileges granted to the leader, but denied to members; and the expectation that members relinquish all financial assets to the group.³

Be careful applying these criteria. Each carries an element of control, but none is necessarily harmful by itself. Some, like charisma, are admired in other settings.

Cults are often religious, but notable examples are not, such as extremist political cults, with or without a religious bias; some large group-awareness training and psychotherapy groups; and some pyramid and multilevel marketing groups.⁴

Information about cults and specific groups is most accessible via the Internet, though sources must be carefully chosen. When consulting printed references, note the publishing date, since groups and ideologies change over time. For instance, Jim Jones started the People’s Temple in the 1950s as an offshoot of a standard Protestant congregation devoted to supporting integration and helping the sick, poor, and homeless in Indianapolis, IN. But in the following decades Jones began abusing illegal drugs. The resulting paranoia and delusions eventually led to the murder or suicide of more than 900 of his followers and their children.⁵ The complete story can be found at The Religious Movements Homepage Project at the University of Virginia http://religiousmovements.lib.virginia.edu/ nrms/Jonestwn.html.

Cults affect health through abuse of power over members, by preventing or delaying proper health care to members, and, in a few groups, by advocating violence.

Psychological abuse

A psychiatric nurse has a young patient with some ordinary but serious problems, along with a rather unique connection. Her problems are slipping grades, depression, and a recent suicide attempt. She belongs to a cult, which has become entrenched in her life.

Those who join cults do not necessarily show symptoms of preexisting pathology.¹ Psychologist Paul Martin, PhD, who treats recovering cult members, describes three types typically recruited — seekers looking for a worthy cause or a way to serve God, the lonely or depressed who find a caring community in the group, and those who are caught up by the excitement of the movement or the charisma of its leader.⁶ However, in recent years, many non-religious cults have evolved an appeal to the mainstream population, marketing happiness, financial and social success, and self-fulfillment.⁴

There are striking similarities between the psychological events of domestic abuse and cultic abuse.⁷ Just as people do not set out to marry an abusive partner, they do not knowingly join a repressive cult. Think about commitments you have made in your own life. Choosing a career, life partner, new house, or new job —all require some degree of faith at the outset and can result in unwelcome discoveries afterward. Even when you think you know what you’re getting into — say a job change at a place you already work — you may still encounter some unwelcome surprises. Most of us try to adapt and cope initially, but while some choose an early exit, others may stay to the point of burnout.

While abuse by individuals can be found throughout society, conditions within a cult are conducive to abuse. A combination of normal elements, taken to the extreme, initiates a series of choices that lead to deepening cult involvement and, some would say, psychological victimization. Those most critical of cults believe that cults “brainwash” their recruits, leading them to join and perform actions against their will. This belief has wide acceptance by the American public and the press. More recently, however, the academic viewpoint is gaining acceptance, namely that there is no proof that such mind control exists, and that the groups merely use an intense form of social influence common to daily living.⁸ To read further, check out the online article about allegations of brainwashing in new religious movements www.religioustolerance.org/brain_wa.htm.

The success of high-pressure sales techniques and the prevalence of con games in our culture show that anyone can be vulnerable to the same techniques of persuasion that cults use. Kelton Rhoads, PhD, an expert in the psychology of influence, identifies a continuum of influence starting with the least deceptive example, education, and progressing through advertising, propaganda, and indoctrination, to thought control.⁹

The effects of persuasion will be visible to others, and social psychologist Brad Sagarin, PhD, identifies nine symptoms family and friends might see in someone under the influence of a cult:

1. Personality changes
2. Dramatic shifts of values or beliefs
3. Changes in diet or sleep patterns
4. Refusal to attend important family events
5. Inability to make decisions without consulting a cult leader or guru
6. Sudden use of a new ideology to explain everything
7. Black-and-white, simplistic reasoning
8. A new vocabulary
9. Insistence that you do what he or she is doing¹⁰

One explanation of these symptoms is the development of a pseudoidentity, a new persona the individual adopts to fit into the cult environment.⁶

To date, there have been many studies addressing the question of psychological harm caused by cult membership, but like any research into the effects of trauma, ethics preclude much prospective study, which limits validity. In an extensive review of research, three researchers concluded that a substantial subset of ex-cult members has problems readjusting to life outside the cult.¹

Why some are harmed and others are not has yet to be determined. A Group Psychological Abuse Scale has been developed for measuring the degree to which influence exists in different groups. It’s hoped that this will help differentiate benign groups from coercive ones.¹¹,¹²

Psychological abuse is not the only form of abuse suffered, states Martin  who also directs the Wellspring Retreat and Resource Center, Albany, OH, a residential treatment center for recovering cult victims. He finds that a third of postcult counseling clients report physical or sexual abuse during cult involvement.¹²

Symptoms experienced by ex-cult members vary widely but include anxiety, depression, guilt, sleep disorders, loss of identity, trouble concentrating and handling emotions, trouble making decisions, floating (a dissociative return to the cult pseudoidentity), and psychosomatic problems.¹

Concerned families and friends of current cult members should educate themselves about specific groups and cult involvement in general. They need to keep the lines of communication open with the member, treading lightly when discussing his or her group and creating a safe, nonjudgmental place he or she can go to when ready.¹³ Nurses should similarly educate themselves and tread lightly. No one is likely to admit to belonging to a cult; however, the same person might confess to lifestyle habits that call for further questioning.

Social worker Livia Bardin, in Coping With Cult Involvement, lists concrete steps to evaluate the cult and its effect on the member as well as resources to use in managing the situation.¹⁴ The coercive “rescue” technique called deprogramming has been abandoned in favor of a less traumatic, voluntary educational approach called exit counseling. Steve Hassan, former cult member turned mental health counselor, describes his own noncoercive approach in his book, Releasing the Bonds.¹⁵

While research shows that 90% of former cult members leave their groups independently, they often experience complex problems during their recovery period.⁷ No matter how people leave a cult, they will probably need assistance in dealing with feelings, future plans, and reentry to society. In addition to the psychological care of individual and group therapy, as well as exit counseling, they might require medical and dental care, nutrition and rest, education, job counseling, legal and financial aid, and spiritual help. They often need housing, material help with anything from new clothes to furniture, and a new social network. Service needs depend on when their lives were interrupted and what they did before joining.¹⁶ As cults have moved into the mainstream, older affluent people are involved. An ex-member in middle or old age may find himself without family support, life savings, or a career, and with little prospect of financial recovery.⁷

People should choose a therapist familiar with cult experiences. Many therapists aren’t trained to recognize signs of postcult trauma and may misinterpret certain behaviors. If the cult is religious, spiritual counseling is indicated. As previously mentioned, Wellspring Retreat and Resource Center is a residential rehabilitation center that focuses on cult recovery. Its staff offers spiritual counseling if the client requests it. Wellspring’s website provides information about spiritual and other cult-related concerns.¹⁷ Problems related to cult involvement are not mentioned in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published and updated by the American Psychiatric Association. Miguel Perlado, a psychologist and psychotherapist who currently works with attention and research on social addictions and also as an exit counselor, presents three diagnostic models that may be useful to those treating clients in recovery from cult membership. They focus respectively on thought reform, dissociation, and group dependency.¹⁸

As with any abusive situation, victims need to be heard, not judged. Listen empathetically, and then try to connect them with professional helpers. Therapists at Wellspring stress the importance of a trusting and nonjudgmental relationship. Cultic involvement is intensely personal, and so is the therapy. Clients need to understand that the ideals that brought them into the group, like serving God or humanity, can be fulfilled in other contexts. They need to regain belief in self and see the world as meaningful and themselves as a positive part of the world.¹⁹

The faith group that refuses standard healthcare

A school nurse at a metropolitan primary school is aghast and frustrated. She is confronted by a father who has refused to have his two children vaccinated. He belongs to a Christian-based group that believes in faith healing and does not allow immunization.

Even without specific policies, cults can foster ill health through overwork, an uneducated approach to dietary restrictions, and neglect. Groups that have specific beliefs precluding health care may or may not meet criteria for a cult, but all need to be examined in a discussion of beliefs and health.

Most religions or philosophies take an ethical stand on one or another medical procedure. Familiar to nurses is the position of the Roman Catholic Church on reproductive and end-of-life issues, refusal of blood products by Jehovah’s Witnesses, and refusal of medical care by Christian Scientists.

Less well known are some newer belief systems. Scientology, for example, is strongly opposed to psychiatry and all psychiatric medications and procedures.²⁰ Popular culture, New Age beliefs, television infomercials, and magazines contribute countless philosophies, products, and approaches to health care that, regardless of research, are largely accepted on the basis of faith by the public. There are also the small, usually Christian, congregations that believe in faith healing and suffer deaths from what is called religion-motivated medical neglect. A 1998 study found that between 1975 and 1995, 172 child fatalities in the U.S. were clearly linked to religion-based neglect. Investigations revealed 140 could probably have recovered if treated. Another 18 would have had a 50% chance of survival, and all but three of the remaining 14 would have benefited from some clinical help.²¹ Eleven fatalities were preventable by vaccination.²² Of the 59 prenatal and perinatal deaths, all but one should have had a good outcome. None of the deliveries were attended by a licensed midwife, and six mothers died of obstetrical complications.²¹

The First Amendment to the U.S. Constitution guarantees American adults freedom to choose beliefs over medical care, even in the face of imminent death. When minor children are involved, however, state child-neglect laws come into play, and every state is different. Some states have “faith-healing” clauses that give criminal immunity, but in other venues, parents have been charged with child abuse, manslaughter, or homicide when their children died for lack of medical care.²³ In some states, courts can overrule parents only when a child’s life or long-term health is threatened and only if the ill child is discovered in time. Such laws don’t address the suffering and disability of those who survive.²⁴ As for refusing vaccination, most states exempt religious parents from prosecution under the child abuse and immunization laws, though a large percentage of unvaccinated individuals increases the risk of the disease to the community at large.²²

Be sure you know the laws of your state and the policies of your institution, including the definition of “minor.” Remember, treating a child in a nonemergent situation without parental permission makes you and your organization liable to a suit. Document well, quoting when possible. Describe mental status to ensure that the parent making the decision is mentally competent. If a physician is not present, try to detain the patient until the provider arrives.²⁵ Except for refusal of ambulance transportation,²⁶ the physician is ultimately responsible for providing the data for informed consent or refusal of care. However, you must speak up if you believe the patient doesn’t understand or is being coerced. Explore not only the risks of refusing medical care, but also the implications, from the patient’s viewpoint, of accepting it. Offer options as accurately as you can, but do not expect argument to triumph over matters of faith.²⁵

Evaluate patient and family actions within the context of their religious community. Are other members applying pressure? If so, what are the consequences to the patient and family? The patient may or may not choose to share information with fellow church members, but staff must maintain strict confidentiality at all times.²⁷

Try to build trust, and engage with the patient and community, rather than setting up an adversarial relationship. Keep lines of communication open, and avoid assumptions about any one person or faith. Doctrinal positions can change over time,²⁸ and people can, too. If the situation allows time, keep creatively searching for the middle ground. It may turn out that refusal of care varies with the circumstances. In one case, for example, the members of a religious group opposing vaccinations became willing to be immunized once they realized their refusal increased the risk to the community at large.²²

To deal with future problems, contingency planning can be helpful, especially when based on actual experience. Hypothetical situations that at first seem fairly straightforward become, in reality, complex dilemmas involving an ever-widening number of participants.  One documented case demonstrates this progression so well that it has been condensed to form our Clinical Vignette.²⁹

A potentially dangerous group

A nurse working at a rural regional health center is worried about a small group outside of town. They dress in long black robes, keep to themselves, and are rumored to be stockpiling weapons. When someone’s cat disappears, talk turns to satanic ritual abuse, and fear grips the town. Is this a dangerous cult, or is it an innocent group suffering from fear-induced prejudice?

To identify potentially dangerous groups, the Ontario Center for Religious Tolerance suggests the following additions to the earlier list of cult characteristics:

1. The belief system is intensely focused on the impending end of the world and the group’s elite role in the event.
2. The leader dominates the members, closely controlling them physically, sexually, and emotionally.
3. Contact with nonbelievers is severely restricted. Members demonstrate extreme paranoia, believing they are closely monitored and in danger of persecution by the government or outsiders.
4. Members may violate serious laws and justify antisocial acts that further their cause (probably the most dangerous sign).
5. Group leaders stockpile firearms, poisons, or weapons of mass destruction.³⁰

Again, these criteria must be applied with caution. For example, apocalyptic theology is part of many mainstream religions; however, the congregations do not stockpile weapons to launch Armageddon.

Some might be tempted to view a terrorist group like al Qaeda as a dangerous cult, but cults and terrorist groups have differences as well as similarities. Cults focus inward on proselytizing to the members, making money, and gaining more power for the leader. Terrorist groups focus outward on political and social change. Their recruitment is selective, and members arrive with a firm ideology already in place.³¹

There is no question that, though rare, dangerous groups exist, both known and unknown. Many groups making headlines over the past three decades are still in existence. The UFO cult, Heaven’s Gate, and David Koresh’s Branch Davidians reportedly have a handful of remaining loyal members, despite the death of their peers. Aum Shinri Kyo (known for releasing sarin gas in the Tokyo subway in 1995) and the Solar Temple (murders and suicides in Europe and Canada, 1994, 1995, and 1997) reportedly still have active believers. Membership in potentially violent racist groups and militias also adds to this number.³²

Our concern lies in the extent to which human rights abuses can and do occur by and within these potentially dangerous groups. But a response based on rumor rather than fact can risk the same abuses it purports to eliminate. Violence is committed against people in cults as well as by them, including bombings, shootings, and, murder.³³ Frequently these events are more heinous than the “crimes” the victims are said to have committed.

As professionals educated in human behavior, nurses have a responsibility to support rational decision-making and legal responses in the face of rumor and panic. Though our vignette presents some troubling issues, it clearly does not offer any hard data to make a judgment. Take, for instance, the fear of satanism. Satanic cults do exist, but no claims of satanic ritual abuse have ever been proven despite intensive investigation by the FBI and other authorities.³⁴ Talk-show hosts over the past 20 years have done much to heighten American belief in satanic activity, most notably Geraldo Rivera, who publicly recanted and apologized for this in 1995.³⁵

In addition to consulting the websites noted in the online version of this module, you can contact organizations that both track potentially dangerous groups and value religious and political tolerance. The Southern Poverty Law Center in Montgomery, Ala., is one. Law enforcement authorities can investigate weapon offenses and reports of illegal activity. The FBI provides additional clues to detecting signs of impending danger at www.fbi.gov/publications/leb/2000/sep00leb.pdf.³⁶ In the event of violence involving any group, we are ethically committed to provide care to all, regardless of their value system.

Respect for a patient’s beliefs can be controversial when a cult is involved. When healthcare conflicts with beliefs, you may find yourself unable to reconcile the demands of the situation. The American Nurses Association Code of Ethics37 directs us to consider a person’s lifestyle, value system, and religious beliefs as we promote and restore health, prevent illness, alleviate suffering, and give supportive care to the dying. We support self-determination, and we also realize that sometimes public health needs may outweigh individual rights. As we resolve conflicting interests, we must try to ensure patient safety, guard the patients’ best interests, and preserve our professional integrity as nurses.