Mental Health Issues Thought Reform Programs and the Production of Psychiatric Casualties by Margaret Thaler Singer, Ph. D., and Richard Ofshe, Ph. D.

Psychiatric Annals 20:4 April, 1990 The term thought reform was introduced into the psychiatric literature by Lifton and the term coercive persuasion by Schein.

Both described the organized ideological remolding programs introduced by the Chinese Communists after their 1949 takeover.

Thought reform programs were used in the revolutionary universities, other educational settings, and prison environments. Lifton, Schein, and other authors wrote about psychological effects in military and civilian prisoners. as well as in individuals exposed to thought reform programs in non-prison settings. These authors called attention to the manipulation processes that had been organized into effective psychological and social influence programs aimed at changing the political beliefs of individuals.

As early as 1929, Mao Tse-tung was waging a thought struggle to achieve unity and discipline in the Chinese Communist Party.

Following the proclamation of the People's Republic of China in 1949, hundreds or thousands were exposed to thought reform programs to achieve ideological remolding. Group struggle sessions convinced individuals to denounce their past political views and to adopt the new state-approved political outlook.

Neither mysterious methods nor arcane new techniques were involved;

the effectiveness of thought reform programs did not depend on prison settings, physical abuse, or death threats. Programs used the organization and application of intense guilt/shame/anxiety manipulation, combined with the production of strong emotional arousal in settings where people did not leave because of social and psychological pressures or because of enforced confinement.

The pressures could be reduced only by participants' accepting the belief system or adopting behaviors promulgated by the purveyors of the thought reform programs.

History of Thought Reform Programs There have been two generations of interest in extreme influence and control programs. The first generation of interest was in Soviet and Chinese thought reform and behavior control practices that were studied 20 to 30 years ago. The second generation of interest is in thought reform programs either currently operating or that have been in existence during the last decade in the United States and the Western world.

Far more of these programs exist than most nonspecialists realize, and these newer programs are more efficient and effective. They also may be more psychologically risky for individuals exposed to them than research suggests first-generation programs to have been. Second-generation programs use influence techniques long recognized as essential elements of thought reform programs, as well as a variety of new influence techniques. Such programs can and regularly do produce psychiatric casualties.

Psychiatric casualties appear to result from errors in the application of these attitude-change programs. The subject person's motivation to adopt the manipulator's position and to become obedient is manufactured by inducing extreme anxiety and emotional distress.

Lifton reported that the managers of first-generation programs attempted to closely monitor subjects so that when they reached the brink of decompensation, pressures could be reduced. The goal was to hold the subject at the point of maximum stress without inducing psychosis. Second-generation programs have increased room for error because subjects tend to be less well monitored, the techniques used to induce anxiety and stress are more powerful and less predictable in the magnitude of their effects on an individual, and often these programs attempt to Second-generation thought reform programs also pose psychological risks to subjects because of the sophistication of the influence tactics employed. Attacking a person's evaluation of the self is a technique present in both older and newer programs. However, in first-generation programs, primary attack was made on the political aspects of an individual's self-concept -- a peripheral aspect of most people's sense of self .

In the newer thought reform programs, attacks appear to be designed to destabilize the subject's most central aspects of the experience of the self. The newer programs undermine a person's basic consciousness, reality awareness, beliefs and world view, emotional control, and defense mechanisms. We suggest that attacking the stability and quality of evaluations of self-concepts is the principal effective technique used in the conduct of a coercive thought reform and behavior control program.

Second-generation programs induce changes in expressed behavior and attitudes much as the earlier versions did by manipulating psychological and social influence variables within a format that generally follows a symbolic death and rebirth theme. Second-generation programs often include techniques similar to those found in first-generation programs, e.g., group pressure, modeling, accusations, and confessions. Additional sophisticated techniques to destabilize a person's sense of self and to induce anxiety and emotional distress are also employed. Second-generation programs often incorporate technical advances in influence production, such as hypnosis to intensify recalled or imagined experiences, emotional flooding, sleep deprivation, stripping away of various psychological defense mechanisms, and the induction of cognitive confusion.

Second-generation programs are illustrated by certain cults, in therapeutic communities gone astray, and in some large-group awareness programs.

What Is a Thought Reform Program?

In essence, a thought reform program is a behavioral change technology applied to cause the learning and adoption of an ideology or set of behaviors under conditions. It is distinguished from other forms of social learning by the conditions under which it is conducted and by the techniques of environmental and interpersonal manipulation employed to suppress particular behavior and to train others .

Six conditions are simultaneously present in a thought reform program:

obtaining substantial control over an individual's time and thought content, typically by gaining control over major elements of the person's social and physical environment,
manipulating a system of rewards, punishment. and experiences in such a way as to promote new learning of an ideology or belief system advocated by management, manipulating a system of rewards, punishments, and experiences in such a way as to inhibit observable behavior that reflects the values and routines of life organization the individual displayed prior to contact with the group, maintaining a closed system of logic and an authoritarian structure in the organization and maintaining a non-informed state existing in the subject.

The last two conditions work because there is no effective way for the subject to influence the system and because the program moves along in such a way that the subject is unaware of being changed for a hidden organizational purpose. In a closed system of logic, criticism or complaints are handled by showing the subject that he or she is defective, not the organization. Observations may be turned around and argued to mean the opposite of what the critic intended. When a subject questions or doubts a tenet or rule, attention is called to factual information that suggests some internal contradiction within the belief system or a contradiction with what the subject has been told: the criticism or observation is turned around and the subject made to feel he or she is wrong.

In effect the subject is told, You are always wrong; the system is always right.

The system refuses to be modified except by executive order.

In addition, by keeping a subject in a non-informed state, he or she functions in an environment to which he or she is forced to adapt in a series of steps, each sufficiently minor so that the subject does not notice change in him- or herself and does not become aware of the goals of the program until late in the process (if ever). The tactics of a thought reform program are organized lo destabilize individuals' sense of self by getting them to drastically reinterpret their life's history, radically alter their world view, accept a new version of reality and causality, and develop dependency on the organization, thereby being turned into a deployable agent of the organization operating the thought reform program.

Types of Psychological Responses Not everyone who is exposed to a thought reform system is successfully manipulated nor does everyone respond with major reactive symptoms.

Some authors described the psychological responses and casualties seen in the first-generation groups. No definitive figures about casualty rates for second-generation programs can be offered.

However, scattered anecdotal reports in the psychiatric literature, the number of people seeking treatment, counseling, and other forms of help after leaving thought reform programs, and the growing number of persons seeking compensation for damages through litigation suggests that many experience different degrees and durations of distress, disability, and dysfunction following such programs.

Actual rates of damage may be far higher than estimations made from the sources cited above. The sole experimental study of the destructive potential of encounter groups reports psychological casualty rates higher than 10% for those groups that use intrusive and high confrontation techniques with aggressive leaders. These damaging techniques have much in common with the destabilizing techniques of second-generation programs. The full range of personality and situational factors that predispose individuals Second-generation thought reform programs expose participants to exercises and experiences that disrupt psychological defense systems, causing some individuals to be flooded with emotions and others to dissociate and split off parts of their awareness.

Psychological decompensations and the onset of other symptoms appear related to the combined effects of features described earlier, especially to rapid, intense arousal of aversive emotional states and to dissociation-producing techniques.

The analysis presented here is based on observations made since 1972 with over 3,000 people who have been exposed to thought reform programs in three types of closed restrictive groups:

certain cults, some therapeutic communities, and certain large-group awareness trainings. At a surface level, these groups seem to be a varied lot. From the descriptions we have secured from people who participated in groups carrying out programs that met criteria for a thought reform program, we have begun to identify types of psychological responses. This work is in progress, and the following is an overview of our results to date. At this point in our research we class the various thought reform programs into two main groupings that reflect the most characteristic negative psychological effects observed. The first cluster consists of those groups whose main effects are the product of intense aversive emotional arousal states: the second cluster is comprised of groups relying more on the use of meditation, trance states, and dissociative techniques. The thought reform systems we have studied tend to use a variety of techniques and do not restrict A program relying heavily on meditation, trance, and dissociation techniques is likely to include elements of intense emotional arousal devices; the reverse also is true. Some of the most intense emotional arousal responses can be produced by guided imagery and other trance-inducing procedures. In our preliminary classification of thought reform techniques, we have used the division of primarily emotional arousal or primarily dissociative as our major division.

Our interviewees (all of whom were reporting some form of distress)were divided into six groups according to their responses after leaving the program. The first and largest group is the majority reaction The Majority Reaction Degrees of anomie. The majority reaction seen in people who leave thought reform programs, almost regardless of the time spent with the group, is a varying degree of anomie -- a sense of alienation and confusion resulting from the loss or weakening of previously valued norms, ideals, or goals. When the person leaves the group and returns to broader society, culture shock and anxiety usually result from the theories learned in the group and the need to reconcile situational demands, values, and memories in three eras -- the past prior to the group, the time in the group, and the present situation.

The person feels like an immigrant or refugee who enters a new culture. However, the person is reentering his or her former culture, bringing along a series of experiences and beliefs from the group with which he or she had affiliated that conflict with norms and expectations. Unlike the immigrant confronting merely novel situations, the returnee is confronting a rejected society. Thus, most people leaving a thought reform program have a period in which they need to put together the split or doubled self they maintained while they were in the group and come to terms with their pre-group sense of self.

Induced Psychopathologies Reactive schizo affective-like psychoses. These occur in individuals with no prior history of mental disorder and from families free of such history, as well as in individuals with no prior history of mental disorder, but whose families have members with affective disorders.

These psychotic episodes vary in length from days to nearly a year's duration, with most ranging from 1 to 5 months. The decompensation typically occurs in immediate response to a peak stress-inducing experience. Strong affective components, mostly of a hypomanic or manic quality, are noted near and after the decompensation. These components appear related to the behavior modeled in the group and to attitudes advocated by the group.

Certain programs appear to interact with personal histories and situational properties of the group to produce depressive reactions.

Postraumatic stress disorders. This type of disorder is described in section 309.89 of the DSM-III-R.

Atypical dissociative disorders. This type of disorder is described in section 300.15 of the DSM-III-R.

Relaxation-induced anxiety. This is a type of atypical anxiety if one uses DSM-III-R classification, but is best described Miscellaneous reactions. These include anxiety combined with cognitive inefficiencies, such as difficulty in concentration, inability to focus and maintain attention, and impaired memory (especially short-term); self-mutilation; phobias; suicide and homicide; and psychological factors affecting physical conditions (described in section 316.00 of the DSM-III-R) such as strokes, myocardial infarctions, unexpected deaths, recurrence of peptic ulcers, asthma, etc.

Case Examples Both of the following cases illustrate the production of psychiatric casualties in individuals exposed to thought reform programs.

Neither individual described below had a history of personal or family mental disorder.

Kirk:

Kirk illustrates the splitting or doubling of the self that occurs when one drops an ordinary world view and accepts the alternative world view trained through exposure m a thought reform program. Professionals who treated Kirk diagnosed his condition as relaxation-induced anxiety that evolved into panic attacks and atypical dissociative states.

He affiliated with a mantra meditation group, initially attempting to empty the mind of all reflective thoughts for a few minutes each morning and evening. The mantra, supposedly a meaningless word, is the Sanskrit name of a Hindu deity. Kirk has an advanced degree in a physical science from a prestigious university.

A friend took him to a free lecture on how to reduce stress in one's life. Kirk was not stressed, but responded favorably to the lecturer's charts and graphs alleging scientific proof that meditation was accomplishing feats unknown to mankind -- except through the group leader's methods. Because of its seemingly scientific basis, Kirk paid his fees and began meditation lessons.

These lessons began with short periods of meditation, which soon lengthened and were combined with prolonged periods of chanting and hyperventilation.

After a few months he began to have bouts of chest pains, fainting spells, palpitations, and lassitude. When he complained at the meditation center of his symptoms, he was assured these were normal signs of unstressing and evidence that he was reaching a higher state of consciousness. Hence, Kirk discounted his distress, accepting it as the price he had to pay to reach the leader's promised goal. Had Kirk not been following the meditation practice with simultaneous involvement with the group, he probably would have abandoned the practice as soon as he started having these adverse reactions.

During one panic attack, he was taken to an emergency room where a physician attributed his condition to stress and pressure.

He stopped meditating for a few days, and the symptoms disappeared.

However, the group instructed him to increase the time he chanted, hyperventilated, and meditated. Over the years his condition worsened. Panic attacks continued; he reported he felt spaced out and forgetful, and he began to let his career, social life, and intellectual development decline. Upon advice from the group leader, to help his deteriorating condition, he frequently spent 8 hours a day for an entire week, chanting, hyperventilating, and meditating. He spent several individual months on such a regime.

His distress increased. He was markedly dizzy and objects seemed swirl, float, and waver in the air. He felt nauseous, disoriented, distraught and confused. At work he began to lose confidence He soon found himself unable to focus on his surroundings: when he did, things appeared distorted, obscure, and foreign. He felt overwhelmed by anxiety, depression, nausea, and debilitation.

He took a week off from work and sat crying in his apartment in an apparent state of depersonalization and derealization, accompanied by a multitude of odd sensations and mental contents.

He visited several general practitioners who could not diagnose his symptoms. One day while driving he lost his memory. He was unable to recall who he was or w here he was going. He parked and went into a restaurant. When he left, it took him 2 hours to find his car because he had forgotten where he had parked.

Soon after this transient but alarming amnesic episode, he resigned from his job because he could no longer instruct workers as part of his technical job. When he had to speak he felt faint, Beverly:

Beverly, now 27, was in a cult from ages 15 to 24. For 2 years after leaving the cult, she was too frightened to seek help or tell anyone what had happened during the years she was in the group. Finally, she saw a psychologist over a prolonged period. Initial symptoms were severe depression., anxiety, multiple phobias and identity diffusion. As her story unfolded during therapy, a diagnosis of posttraumatic stress disorder was made.

The group Beverly joined was started by an immigrant who conferred upon himself the titles of guru, yogi and teacher after reaching the United States. He began to collect a small following by advertising himself as an exercise and diet specialist.

A relative of Beverly's had lived for some time in the commune he developed. The relative asked 15-year-old Beverly to spend the summer in the commune; she remained in the commune for 9 years. Beverly was an easy mark for the leader and his assistants to completely dominate. His indoctrination and influence program led her to believe all his claims -- that he was the most learned man alive, that he knew hidden health and living secrets which he would reveal to her. The group preached bizarre and ever-changing diets. Beverly came to think the leader was omniscient, omni-present and omnipotent. He treated her as his protege, subjecting her to endless sessions of indoctrination and withdrawing alternative sources of social support until she became totally dependent on him.

She believed that he knew all the secrets of the universe. She believed that he held the power of life and death over her and her family because he claimed that he was above the law and that he could order the execution of anyone who displeased him.

He repeatedly stated that I he would have her and her family put to death if she ever left him. Eventually when she did attempt to leave after almost 9 years. he put her under armed guard and prevented her from leaving. The most traumatic episodes with the leader began after Beverly had been in the group several years. He told her that he was going to cure her of what he termed her sexual neurosis. He proceeded to rape her while she was held down. After this event, she became stunned, depressed, withdrawn and suicidal for nearly 3 years, she was anally and genitally raped repeatedly and given gratuitous brutal beatings by the leader. She became pregnant twice: each time he leader ordered her to have an abortion. Hours after undergoing one of the abortions, he raped her.

Beverly eventually ceased to regard him as divine after she developed herpes and chronic kidney and bladder infections;

she saw him only as a violent, brutal rapist. At this point, the leader assigned armed guards to restrain her from escaping.

She remained virtual prisoner for over a year.

She finally escaped several years ago, still believing the leader or his helper would find and kill her and her parents. This fear continues.

Beverly has a driving phobia. This appears related to the leader telling her that if she ever left him she would die in an automobile crash. After a year of treatment, she is able lo drive short distances, but only at the expense of considerable anxiety.

Beverly becomes excruciatingly anxious over what she calls flashbacks.

She vividly reexperiences how she felt when she had to sit tor endless hours listening to the rambling, nonsensical lectures given by the leader. During those lectures she resented having to sit for so long yet she was unable to move or leave. She feared that the leader had magical powers and that it she incurred his disfavor, she would come to harm or even die as he claimed happened to those who defied him. Because of these negative associations with prolonged sitting, she has been unable to attend classes, church services, or similar events. Thus, her educational level remains as it was at age 15 when she entered the cult. She has panic attacks with agoraphobia in which she has to abandon whatever she is doing and return to her apartment to feel safe. These attacks have prevented her from maintaining employment and reliably enjoying recreational activities. She Beverly has trouble going to sleep as fearful images of the leader intrude, arousing fear. When she does sleep she has nightmares involving his attacks on her. She sleeps fully dressed because she fears she may have to flee the leader's guards. This is not without foundation as such happened before she escaped from the commune. Her numbed, stunned state seen at the start of therapy has declined, but the rest of the posttraumatic stress syndrome remains. She feels her life is ruined and suffers generalized anhedonia.

Summary The techniques used to induce belief, change, and dependency by various thought reform programs appear to be related to the type of psychiatric casualty the program tends to produce. Large group awareness training programs appear more likely to induce mood and affect disorders. Groups that use prolonged mantra and empty-mind meditation, hyperventilation, and chanting appear more likely to have participants who develop relaxation-induced anxiety, panic disorder, marked dissociative problems, and cognitive inefficiencies.

Therapeutic community thought reform programs appear more likely to induce enduring fears, self-mutilation, self-abasement, and Many people subjected to thought reform programs of sufficient duration report transient to longer lasting cognitive inefficiencies with impaired concentration, attention, and memory. Most are self-reported observations; others come from family and friends who note the inefficiencies either were not present prior to the thought reform program or are exacerbations of preexisting tendencies.

There is an interactional-transactional interplay between a program's philosophical contents, exercises, and practices, and each person exposed to it. The thought reform program impinges on cognition, defenses, affects, values, and conduct. Additionally, each person's genetic-biological make-up, life experiences, personality, and mental make-up interact with the stressors induced by the interface of the person's old value, belief, and behavior codes with the new beliefs and behavior promulgated by the program.

Prediction of any one person's responses to any one thought reform regime is difficult, if not impossible. However, as with all stressful, conflict-inducing, and intense negative emotionally arousing situations, certain forms of behavioral pathology are more likely than other types to occur among individuals exposed to certain combinations of stressors.

* * * * * * * * * * Dr. Singer is Adjunct Professor, Department of Psychology, University of California, Berkeley.

Dr. Ofshe is Professor, Department of Sociology, University of California, Berkeley.

This article was presented as the Virginia Tarlow Memorial Lecture, Northwestern University Medical School, Chicago, Illinois, June 1987.

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