[This book chapter appeared in Cooper, S. (Ed.), Casebook of brief psychotherapy with college students. Binghamton, NY: Haworth, 153-170.]

Introduction

I am a counseling psychologist in independent practice in Philadelphia. Over the years, a major focus of my work has been adolescents and young adults struggling with a broad range of issues, including involvement in High Demand Groups (HDGs). "HDG" is a term applied to a sometimes slippery category of religious, political, therapeutic and marketing groups and movements that are often labeled "cults" by the media.

My introduction to the psychology of HDGs took place in 1975, when as an undergraduate researcher I allowed myself to be recruited into the Unification Church (the "Moonies"), a controversial HDG that was recruiting heavily on my campus. The most fascinating and disturbing component of my research was a participant-observation of their one-week indoctrination program. This experience, documented in the first chapter of a special issue of Cultic Studies Journal (Dubrow-Eichel, 1989b), eventually led to a clinical specialty working with young adults and families who have become involved with High Demand Groups (HDGs).

Since 1983, I have worked cooperatively with a network of mental health professionals and paraprofessional "exit counselors" called RETIRN, the Re-Entry Therapy, Information & Referral Network. RETIRN's stated purpose is to provide "counseling, forensic, consultation, information and referral services to individuals and families adversely affected by manipulative/coercive individuals, and totalistic/high demand groups or movements" (RETIRN, 1983). While I enjoy the challenge, complexity and uniqueness of this work, I am pained by the intensity, frustration and pressure brought by families and individuals who are typically desparate for a quick and/or simple resolution to a loved one's involvement in an HDG.

However, I don't blame them. A typical RETIRN referral involves a young adult, away at college or perhaps just graduated, who has either secretly become involved or (worse yet) has gradually become involved without disrupting his/her family relationships until it is "too late." Either way, by the time the family contacts us, their loved one is usually deeply involved and thoroughly convinced in the absolute and preeminent righteousness of the group's purpose. The member will typically refuse any direct request to talk to anyone they consider critical (or, worse yet, an apostate). Most HDGs are vehemently opposed to psychologists and psychotherapists.

The case I present describes the use of "brief intermittent developmental" (BID) therapy, an integrative treatment modality that combines developmentally-based psychotherapy (Greenspan, 1997) with time-limited intermittent therapy (Kreilkamp, 1989) and motivational interviewing (Miller and Rollnick, 1991). The central principle of developmentally-based psychotherapy is to "build on the patient's natural inclinations and interests to try to harness a number of core developmental processes at the same time" (Greenspan, 1997, p. 8). The developmental processes we want to mobilize involve age-appropriate ego functions, such as autonomy, decision-making, and affect and impulse regulation. Time-limited intermittent therapy relies on relatively focused and structured sessions that emphasize taking action. Developing insight is viewed as a by-product of taking action. This approach also relies on developmental theory, with the various stages of therapy viewed as a developmental process itself. In my experience, Kreilkamp's (1989) description of his approach fits in markedly well with the "stages of change" model developed by Prochaska and his colleagues (Prochaska & DiClemente, 1982, 1984; Prochaska, 1999) and his colleagues as a transtheoretical approach to therapy.

Phase 1: Parental Intervention

Mr. and Mrs. Bader (not their real names) initially contacted me in early 1995. Their 16 year old son, David, had become involved in a local group that seemed cultic, and he had just informed them that he would be leaving for an ashram in India in a few months. The Baders, like many parents who contact me, knew of their son's involvement for almost ayear, but they initially viewed it as benign, and even as beneficial. David's grades had improved somewhat, he had cut his long hair, and he seemed "calmer." They knew little about David's group and rejected the opinions of some friends as an overreaction. As months passed, however, they began to notice what seemed like radical personality changes. Some of these changes seemed superficially positive; David stopped listening to heavy metal rock music, and he became more concerned with hygeine. Moreover, he seemed more energetic in spite of his new, rigid vegetarian diet. Other changes caused great concern. For example, David spent a great deal of time on his own chanting Hindu phrases. He became irritable and judgmental; he constantly preached to his family, and criticized them for being materialistic. Although his grades improved, David's thinking became more rigid. He seemed distant, "spaced out," and, oddly, "too content." And David began to manipulate and lie. When he claimed to be visiting friends, he was in fact spending time at the local temple or ashram affiliated with his group. In fact, David was completely neglecting his old friends, preferring to spend all his free time in the company of group members, whom he referred to as his "adopted family." David also lied about money. The Baders were an upper-middle class family and David received a liberal weekly allowance in addition to having all his other material needs met by his family. At this time, however, it gradually became clear that David was giving most or even all of his money to his group.

The Baders did what a great many families do in this situation: They took matters into their own hands, confronted David, made new rules, and demanded an honest accounting of his time and money. The Baders found a book about David's group and began confronting him about them. Family gatherings became highly argumentative and typically ended with David retreating to another room in the house where he would begin chanting, sometimes for hours on end. As David's parents put it to me: "There was just no getting through to him." At one point, David became so incensed that he picked up a chair and threw it through a window. The Baders called the police. David became enraged and destroyed some furniture before running from the home. The police on routine patrol enocuntered him a few blocks away, acting suspiciously. When they confronted him, David refused to talk to them and chanted continuously instead.

David's parents eventually found out their son was being held by the police. Upon the recommendation of a police sergeant, they agreed to arrange for a one-week stay at a local psychiatric hospital. David reluctantly agreed with the plan. At the hospital, David initially refused to participate in group or milieu therapy. In meeting with his individual therapist, David agreed to participate on the condition that the hospital allow him to obtain his group-sanctioned prayer beads and books. The hospital, naively believing that facillitating David's "spritual growth" would help him in his therapy, convinced the Baders to bring their son's books and beads to the hospital. David did not live up to his end of the bargain. Once David had his beads and books, he remained in his room for the remainder of the week, reading and chanting.

Following his release from the hospital, David was angrier than ever. He refused to even talk with his parents, and he openly defied them by spending every spare moment at his group's meeting house just outside Philadelphia. He began staying overnight (something he had never done before) and he began to refuse to attend his school.

It was at this point that the Baders contacted me. Over the course of 3 sessions in 2 weeks (Phase 1), I obtained a family history and began to educate the Baders about their son's group and HDGs in general. My goal was to first diminish their panic, since actions taken out of panic typically make matters worse. By discussing their son's behavior in the broader context of HDGs, the Baders were reassured that for now there was still a considerable amount of hope. In many HDG cases, for example, parents do not know where their children are or have no way to contact them. I also explained why "deprogramming" was not an option in this situation. My own research (Dubrow-Eichel, 1989a, 1989b) dispelled many popular misconceptions about deprogramming, and by the early 1990s this heavy-handed intervention had been replaced by a gentler, more appropriate yet equally effective intervention called "exit counseling." I strongly advised against attempting a forced deprogramming. Yet, it was clear that some sort of action needed to be taken. Therefore, I referred the Baders to a "cult aware" attorney who might assist them; David was, after all, still legally a minor and they were his guardians.

Mr. Bader: We've had it with David. This group is ruining his life and ruining ours, and we're deeply worried about him. Isn't there something we can do? What about deprogramming?

Therapist: You're deeply upset, and that's to be expected. Your primary reason for being here is to explore your options and develop a plan. I'm not sure what deprogramming means to you. If you're talking about the kind of process involving holding David against his will, I don't advise it. I also don't work with any so-called deprogrammers.

Mrs. Bader: Then what do we do? Just leave him in his group? If he goes to India, it will be too late to do anything.

Therapist: Folks, the best thing to do right now is to look at these events as objectively as possible, to evaluate options as objectively as possible. It will be helpful to distinguish between your understably intense feelings and any actions that might be taken.

Now first of all, let's not forget that David is still legally a minor. And that means as his parents, you do have certain rights.

Mr. Bader: OK, I know that. But what do we do?

Therapist: First, find out what your legal options are.

Mrs. Bader: You mean talk with a lawyer? But this is all so strange, and I don't think a lawyer would really understand.

Therapist: Well, if you need a referral to an attorney, there is one we work with fairly routinely. She's very tuned into these groups and these issues, and she's an expert on domestic law.

The attorney hired by the Baders wrote a letter to the leader (guru) of the HDG reminding him that David was a minor and urging a cessation of contact between David and his group. Upon receiving the letter, the local leader of the HDG made it clear that David would not be welcome until he turned 18. David was initially quite angry. The Baders had been coached in how to effectively listen to their son's anger while still firmly maintaining their stance regarding David's group and his planned trip to India.

Our next step was to get David involved in counseling. The Baders presented me to their son as a psychologist who also had expertise in group dynamics and social coercion. As per my recommendation, the word "cult" was not used. David was very interested in meeting with me, and so we began Phase 2 of treatment.

Diagnostic/Developmental Formulation

When I first met David, he presented as a thin, 16-year old, white male adolescent with blonde buzz-cut hair. He seemed oriented in all spheres and showed no gross signs of cognitive impairment. David is the youngest of four siblings; his three older sisters were all adults, living on their own. His father owned a construction business and was proud of his Ivy League undergraduate education. His mother worked at home, part-time, typing medical transcripts. The marriage was presented as conflictual: David's father struggled on and off with drinking; his mother was a devout born-again Christian who greatly disapproved of her husband's behavior but felt duty-bound to remain in the marriage while praying for her husband to change.

Prior to his adolescence, David enjoyed a very close relationship with his father. Eight years separated him from his next-oldest sister, and he had very few memories of growing up with his two other older sisters, both of whom left home at age 18 while David was still a youngster. David performed well in elementary school where he attended classes for the mentally gifted. He played tennis and learned guitar and drums.

Adolescence hit David hard. When he was 12, his parents separated for almost a year. David remained with his mother but longed for his father. At 13, David began showing signs of psychosocial disturbance. He developed a severe case of acne that contributed to him being very shy and reclusive. He began experimenting with alcohol and hallucinogens (LSD, mushrooms and marijuana). He was often truant from school and his grades dropped considerably. By age 14, David was in open rebellion. He began to dress in "punk" or "gothic" clothing, he wore his hair in a punk spike fashion, and withdrew considerably from his family. I later learned that he was introduced to sex in a somewhat coercive/traumatic manner (in which he was the victim), while high on alcohol and psychedelic mushrooms. It was an experience that would later be repeated under similar circumstances and that caused David considerable guilt and self-loathing.

By the time I became involved with the Baders, David had met the criteria for Oppositional-Defiant Disorder. But that diagnosis only scratched the surface of this young man. He was clearly using his group as a means of defending against considerable internal and external turmoil. His chanting, for example, served to suppress his feelings and thought. Chanting for hours can become a means of denying and dissociating from difficult feelings, thoughts and impulses (Dubrow-Eichel & Dubrow-Eichel 1985; Goldberg & Goldberg, 1982; Persinger, Carrey & Suess, 1980; Zeitlin, 1985). Devoting himself for hours on end to studying esoteric religious texts prevented him from more mundane school subjects. Involvement with the group also served to provide a potent sense of community with other devotees and quick answers to difficult existential questions, while the guru of the group provided David with an idealized father substitute.

Phase 2: Initial intervention with HDG member

Although the number of young clients who come to counseling with HDG-related issues is relatively small, the process involved in counseling them is in many ways similar to addictions counseling (Dubrow-Eichel, 1989a). Most of these clients come to counseling with ambivalence about the counseling process itself; they often perceive the problem as involving acceptance on the part of significant others in their lives. Although most HDG members harbor suppressed doubts (Galanter, 1999; Hassan, 1988) and may even have developed a "doubled self" or pseudoidentity (Lifton, 1986), when they do come for counseling they are typically (and understandably) suspicious. An early exchange between David and myself illustrates this early suspiciousness and also illustrates early rapport-building and an incitement to be curious.

Therapist: Do you inow why you're here?

David: You're going to try to talk me out of The Society.

Therapist: Do you know that for a fact?

David: Well, I think that's a pretty safe bet!

Therapist: So you have a belief about what I'm going to do.

David: Yes.

Therapist: That's interesting to me. How sure are you about your beliefs about me and why you're here.

David: What do you mean?

Therapist: Well, we only just met.

David: Yeah, OK.

Therapist: We don't really know each other.

David: OK, that's true.

Therapist: What we know about each other is based either on what we've heard about each other, or our immediate first impressions.

David: Yeah, OK.

Therapist: Those impressions may be accurate, the may be inaccurate, they may be some combination of accurate and inaccurate.

David: OK.

Therapist: How do you determine if your impressions are accurate?

David: Over time, I guess.

Therapist: Yes, me too. We usually have beliefs about things before we have complete facts. Are you willing to test your hypotheses with me over time?

David: I don't know. Maybe.

Therapist: I'll take that as a conditional "yes" and that's good enough for me.

David: OK, fine then. What do we talk about?

Therapist: Whatever you want to talk about.

David was now a little curious. We began talking about his life, his values both before and during his involvement with his group. As we talked, I listened carefully to what seemed to be connected to David's core beliefs and values, the ones he had prior to becoming involved with an HDG. From my point of view, David was in the "precontemplative" (Prochaska, 1999) stage of therapy, and my primary goal was to spark an interest and motivate David to engage in the counseling process (Miller & Rollnick, 1991). In subsequent sessions, as David expressed more uncertainties about his group and its leader, I became somewhat more directly challenging. The following exchange, which occurred in the fifth session, is a good example:

Therapist: David, at one point you said one of the things that attracted you to this group was a sense of great loyalty among the members. You said devotees would die for each other, if necessary.

David: Yeah, so?

Therapist: David, why hasn't your group leader contacted you?

David: Because there's a stupid court order telling him not to.

Therapist: So why not disregard the court order?

David: Then my leader might get arrested.

Therapist: Maybe. Let's assume he would. So what? A little bit of jail time doesn't seem that bad if you're committed to die for each other.

[Pause during which David seems to be thinking, hard.]

David: If my guru were in jail, then he wouldn't be able to spread the word to nonbelievers.

Therapist: David, I'm going to ask you to listen carefully to me for just a moment. David, my primary purpose is to get at the truth of your group and your involvement in your group. If, after you have time to think things through, you still want to be in this group, then that's your perogative. When you're 18, you can pretty much do what you want to do anyway.

David: So what's your point?

Therapist: David, you said your guru would not want to go to jail because it might keep him from recruiting new members. Did I hear you correctly?

David: Yes.

Therapist: So then recruiting other members is more important to your guru than sticking by you.

David: [Long pause.] Hmmm.

Therapist: I'm not trying to bash your guru. I'm just kind of repeating back to you what you apparently already know. Your guru has told you repeatedly that you are the more important to him than anything, yet that apparently isn't so. Recruiting new members is more important to him than you.

David: [Long pause.] Yeah, I guess I never thought of it that way. But why should I expect him to violate the law?

Therapist: Oh, but I'm not saying it's right to violate the court order. I'm just saying that what your guru told doesn't seem entirely true, when push came to shove. Your guru and your group claim to be true and honest at all time. How does your guru's actions reflect on this?

We continued to meet on a somewhat sporadic basis with appointments ranging from being a week apart to be a month apart. Allowing the HDG member to exercise considerable control over the frequency of sessions is important because it emphasizes the noncoercive nature of counseling and is conducive to the development of autonomy in the young adult (Dubrow-Eichel & Dubrow-Eichel, 1988). Over the following 13 sessions, David's critical reasoning abilities seemed to grow. He questioned many things including the research and theoretical basis of counseling. Over this period of time, David decided to remain apart from his group and its leader, but he continued to find worth in some of the group's scriptural writings and religious rituals. I encouraged David to continue to explore these on an intellectual as well as an experiential level and David agreed. At his 17th session, we decided a "sabbatical" was appropriate, and the following session was our last meeting for two years.

Phase 3: First post-HDG crisis

David contacted me in late 1996 to discuss a number of issues. In the year since I'd last seen him, he graduated from high school and then decided to work and pursue his music rather than attend college. He was still practicing some of the rituals he'd learned in his HDG. David was feeling extremely guilty about his sexuality. In our previous work, David would only discuss sexuality in abstract, theoretical terms. Now he admitted that he was "plagued" with sexual impulses, primarily toward women but occasionally toward men. In addition, he was worried that he masturbated excessively. His call to me followed an incident in which a middle-aged man made a sexual advance toward David while they were in a health club sauna. David reacted with panic, fearing that he was "sending out gay vibes." Concurrently, David had begun dating a young woman, and the relationship had become sexual.

David's sexual concerns were not highly remarkable; they are typical of young adults. However, David's involvement in an HDG colored his personal struggle. The tendency of HDG involvement to delay normal development has been described by several researchers (cf. Dubrow-Eichel & Dubrow-Eichel, 1988; K. Schwartz, 1986; L. Schwartz, 1983; and Schwartz & Kaslow, 1981). In David's case, his HDG had been highly condemning of sexual impulses and any desires that might be described as "materialistic." Thus, his continued religious practice and belief structure caused him ongoing guilt and shame. David seemed to need permission to discontinue his rituals and to reexamine his belief structure. Yet he was also highly ambivalent about becoming "dependent" upon a therapist. I therefore concentrated on suggesting how David might find other sources of information against which he could evaluate the beliefs and practices that were causing him guilt. I couched my suggestions as invitations to "experiment:"

David: I don't know...I mean, I've read that everybody does it [masturbates] but scripture says it's a form of self-pollution. And I always feel bad about myself after I do it.

Therapist: So one of the issues seems to be, is your negative feeling due to the masturbation itself, or is it a result of your belief system. Your negative feelings certainly seem to reinforce the belief system.

David: Not only that, but then when I don't do it, I seem to think about sex even more. It's so screwed up [laughs]...so to speak.

Therapist: Are you aware of any spiritual people or belief systems that do not condemn sexuality or do not view it as demonic and evil?

David: Are there any?

Therapist: I invite you to find out. How might you do that?

David: I know a this theology student who comes into the restaurant a lot, and I have a friend who knows some pretty cool ministers. I think they're ministers, but I'm not sure.

Therapist: Would you be willing to try an experiment?

David: Sure.

Therapist: And remember, experiments always have some kind of result. Do you remember doing experiments in bio or chem class in high school?

David: Yeah, sure.

Therapist: Did you label a result "good" or "bad?"

David: No, not really. A result was a result. It always led to knowing something, even if it didn't come out the way you wanted.

Therapist: Exactly. And I invite you to view the results of this experiment in the same way.

David: I can do that. What's the experiment?

Therapist: I invite you to talk to three different "spiritual" or "religious" people about their beliefs about sexuality. Or you can check it out in books instead, if you prefer.

David: Yeah, I can definitely do that.

Over the course of the next seven sessions, David discovered that there are a broad range of beliefs about the role of sexuality in a spiritually-involved person. He was surprised to find that some religions consider sexuality one means toward enlightenment (e.g., tantric Buddhism). David ultimately decided to put his spiritual practices and beliefs "on hold" pending further investigations.

With this concern reasonably resolved, David began to experience his sexual relationship with his new girlfriend in a positive way. He was able to see himself as perhaps tending toward bisexuality with the freedom to choose to act or not act on those impulses.

Phase 4: Second post-HDG crisis and maintenance of gains

I next heard from David two years later. David was very dissatisfied with his current employment. He was working as a waiter, a job he found both boring and financially unrewarding. Sessions during this phase of BID therapy were therefore concerned primarily with David's career interests and college. David was clearly struggling with his rebellious attitudes toward "traditional" learning environments (i.e., college). He disliked his current work and realized that a college degree might be the best means toward a more agreeable career, yet he also wondered if he were being too "materialistic." Again, this decision was colored by his HDG belief system, which labelled his career concerns as "an attachment" and "an ego-based illusion" that would impede his enlightenment. After examining his feelings in the contexts of both his HDG involvement and his "true self," David decided he would apply to college for the next semester. David no longer seemed to be struggling with concerns about being "dependent" on therapy. He clearly asked for, and received, concrete guidance on how to apply to college.

Conclusion

In the 5 year period between my initial contact with David's parents and my last session with David, I have seen an adolescent move progressively toward fulfilling his potential. When we first met, David was a rigid ascetic. His HDG involvement served the dual purpose of circumventing difficult developmental conflicts and rebelling against his parents and, more broadly, a "materialistic society." It remains unclear whether David "really" would have proceeded to live in an Indian ashram. However, because of the real possibility of David leaving the country, his parents were faced with an immediate crisis that demanded thoughtful action. With brief but intensive coaching on how to interact with their son, the Baders were able to convince David to attend counseling. Once in my office, it was my goal to appeal to David's underlying curiosity and desire to find the truth. By combining a dialectical counseling approach (that borrowed liberally from motivational interviewing) with specific knowledge of cultic groups and a very non-coercive approach, I was able to pique David's interest enough to get him to return for subsequent sessions. Had I employed a more open-ended and "traditional" long-term treatment paradigm, it is doubtful that David would have continued beyond that first session.

I am becoming more and more convinced that for many people, brief intermittent developmental therapy yields results that are at least as beneficial as ongoing long-term therapy. I have tried to present an example of Brief Intermittent Developmental therapy as it is applied to a somewhat unusual case: that of an adolescent deeply involved with a High Demand Group (HDG) or "cult." In my experience, the BID therapy approach is uniquely suited for working with former HDG members. It closely resembles a developmental process, as the changes made by the client typically begin as assimilations (a first-order change) but may ultimately involve accomodation (a second-order change). The client-therapist relationship shifts slowly toward an increasingly collaborative one. Gains made in the first two phases of therapy are maintained and strengthened as the client progresses through fairly predictable post-HDG developmental crises. The client moves toward increased personal efficacy and autonomy and a more coherent and robust identity.

I have found the BID approach to be at least as effective as long-term therapy for the same or similar problems in clients with the same or similar demographics, a finding that is consistent with research on brief intermittent approaches to therapy as a whole (Roth & Fonagy, 1996).

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