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A Single-Case Design Implementing Eye-Movement Desensitization and Reprocessing (EMDR) with an Ex-Cult Member


Cultic Studies Review, 8 (2), 139-153.

A Single-Case Design Implementing Eye-Movement Desensitization and Reprocessing (EMDR) with an Ex-Cult Member

Robert R. DeYoung, Ed.D.

The Family Center for Behavioral Health


This single case study used a repeated-measures design with an ex-Jehovah’s Witness who was treated with EMDR over a two-month period. A follow-up session was conducted one year later, which indicated that all targeted gains remained. A brief background relevant to a 37-year-old female who was “disfellowshipped” by her entire support network and family after 28 years served as a backdrop for treatment. A limited review of criteria related to cult-like behaviors and attitudes commonly exhibited by Jehovah’s Witnesses (JWs) is included. Symptoms relevant to Post-Cult Trauma Syndrome (PCTS), as defined by Singer (1979), are addressed via the Validity of Cognitions Scale (VOC) and the Subjective Units of Distress Scale (SUDS) used by practitioners of EMDR. In addition, the Beck Depression Inventory (BDI) and the Impact of Event Scale (IES) were implemented to further assess intervention results. All measures revealed significant improvement in targeted symptoms following this brief, short-term treatment. Follow-up results indicated symptoms did not reoccur.

By 1997, Francine Shapiro’s[1] eye-movement desensitization and reprocessing (EMDR) had already become one of the most popular and well-researched approaches in the field to post-traumatic stress disorder (PTSD) treatment. A relatively simple technique to learn, EMDR utilizes eye movements and cognitive, emotive, and imagery changes in reference to past upsetting events. This approach quickly gained momentum as an innovative clinical treatment that could be applied effectively not only to various forms of trauma but also to depression, phobias, nightmares, grief, and addiction (Shapiro & Forrest, 2004). The actual dynamics of how EMDR works remain debatable (Bruhn, 2008), and there has been criticism about whether or not it is more efficacious than other treatments (Rauch & Cahill, 2003). EMDR, however, has been the subject of many empirically based studies that support it as an effective brief, short-term intervention (Shapiro, 2002) with long-term benefits that appear to last at least as long as any other form of psychotherapy (Tootell, 2004). Many state departments and trauma organizations now accept EMDR as a treatment of choice for trauma victims.[2] It is noteworthy, however, that there are virtually no studies that explore the application of EMDR with individuals exiting from cults.

We can define the term cult as “an ideological organization held together by charismatic relationships and demanding total commitment” (Zablocki, cited in ICSA, 2008, p. 4). According to the ICSA, the high-demand, leader-centered atmosphere generated in many cults produces social settings that can place such groups at substantial risk of injuring and exploiting its members. Landau, Tobias, and Lalich (1994), in their seminal book on cults, Captive Hearts—Captive Minds, claim many members of cults typically describe themselves as being “enthralled” (p. 11) with an ideal, a group, or a person—usually a leader. The dictionary defines thrall as “One held in bondage; slave; servitude” (American Heritage Dictionary, 2001, p. 851).

Cults in Our Midst: The Hidden Menace in Our Everyday Lives (Singer & Lalich, 1995) is considered essential reading for individuals who work with cult members. According to Singer, some researchers count religious groups as cults only when followers can, in fact, be more clearly identified via “cultic relationships” (p. 7). She claims, however, that the label of cult can more easily refer to three factors:

The origin of the group and role of the leader(s)

The power structure, or relationship, between the leader (or leaders) and the followers…, and
The use of a coordinated program of persuasion (which is called thought reform, or, more commonly, brainwashing) (p. 7).

Singer attempts to explain the “metamorphosis” of how ordinary citizens can be persuaded to leave their everyday lives to become part of groups that carry out acts ranging from bizarre, such as proselytizing door-to-door,[3] to unethical and destructive, such as putting their infants’ lives at risk by kidnapping them from hospitals that offer potentially life-saving blood transfusions.

It is difficult to accurately assess the prevalence of cults, but the ICSA does receive thousands of inquiries about various groups that have been the object of critical news reports.[4] In 1997 an estimated 2 million to 5 million young adults were involved in cult groups in the United States alone (Robinson, Frye, & Bradley, 1997). This report is consistent with other prevalence research (http://www.icsahome.com/infoserv_ topic/tp_prevalence.asp).

Jehovah’s Witnesses

According to Kim C. Callaghan (1996), JWs naturally deny that they constitute a cult, and they are fairly mainstreamed at this time. Despite their being seen by many as misguided, albeit benign, even well-intentioned nuisances, mainline theologians and mental-health professionals alike may disagree. The following limited criteria, supported by referenced JWs literature, identify only a few of the cult-like behaviors and attitudes sometimes exhibited by JWs:
JWs leaders (Governing Body) promulgate the belief that they are “…Jehovah’s organization alone, in all the earth … the only organization that understands the “deep things” of God!” (Watchtower, 1973, p. 402). They believe they are in sole possession of the “Truth,” quite common among cultic groups, and JWs members are not permitted to doubt or question the organization’s leadership in any way. Examining any information that is critical of the religion is also forbidden. This exclusive so-called knowledge conferred upon the group, to the exclusion of all others is, according to Callaghan, a “…factor that clearly identifies JWs as a religious cult” (p. 1).

The attitude that allows the JWs to operate as pseudo-superior, elevated above the rest of society, is another clear characteristic they hold in common with other cults. The Watchtower (WTBTS) states: “Jehovah’s Witnesses invite everyone to … experience the joy that comes not only from having found a religion that surpasses all others but from having found the truth!” (1995, Vol. 116, No. 7); this “special status,” according to Booth (1991), is a clear marker.

Once a potential convert has progressed past the rhetoric of tolerance and “open-mindedness,” tolerance quickly evaporates. Witnesses who come to doubt the veracity of their beliefs, or who dare to disagree with Watchtower teachings, are labeled “apostates.” The Watchtower states: “Apostate ones are judged with the greatest severity; they are disfellowshipped (excommunicated), no more to act as leaven (an undesirable influence) among God’s people” (WTBTS, 1988).

Booth (1991) quotes The Watchtower as warning against “independent thinking.” The convoluted reasoning, often seen in cults is that “the Devil” lures people to “pursue a course of pride,” which leads to insubordination to directives of The Watchtower (1995). Booth claims, “…if you cannot question or examine what you are taught, if you cannot challenge authority, you are in danger of being victimized and abused” (p. 62). He describes the shunning (disfellowship) of anyone who does not strictly adhere to rules within the cult. Even family members are pressured to engage in the shunning that disfellowshipped Witnesses must endure. JWs explain the abuse in terms of “keeping the fellowship clean,” and it is not uncommon for parents, family, and “best friends” to completely dissociate themselves from loved ones who are disfellowshipped, sometimes for the rest of their lives. Callaghan (1996) claims, “The organization insinuates itself into salvation, stating that anyone desiring to be saved must learn and practice truth as taught by the faithful and discreet slave, the men at the helm of the Watchtower Society” (p. 3); and leaving the group can be traumatic.


Post-Cult Trauma Syndrome

Margaret Singer (1979) described the post-cult trauma syndrome (PCTS) that is characterized by an emotional upheaval period after a member exits from a cult.[5] The intense and often-conflicting emotions exiting cult members commonly experience are frequently exacerbated by members’ grief over the loss of positive elements such as a sense of belonging or personal worth that the group’s mission or ideals generated. Singer goes on to describe a process in which ex-members pass through stages of accommodation to the change of having left the cult, similar to stages of grief with the loss of a loved one. In some cases, members will return to the cult or experience PCTS. PCTS symptoms include:
Spontaneous crying
Sense of loss
Depression and suicidal thoughts
Fear that not obeying the cult’s wishes will result in God’s wrath or loss of salvation
Alienation from family and friends
Sense of isolation and loneliness as the result of being surrounded by people who have no basis for understanding cult life
Fear of evil spirits taking over one’s life outside the cult
Scrupulosity; excessive rigidity about rules of minor importance
Panic disproportionate to one’s circumstances
Fear of going insane
Confusion about right and wrong
Sexual conflicts
Unwarranted guilt

Subject

Susan[6] first contacted the office complaining of depression and anxiety. She had been being born and raised, over her 28 years, in the JWs “organization” and had recently been “disfellowshipped” for the second time. Before her second disfellowship, which was instituted because of marital infidelity, she had participated in both individual and couples counseling. The counseling had involved three different counselors, for a total of approximately 2 years, with minimal benefit. Susan described the previous therapists as “understanding very little about cults,” and they apparently “didn’t address any of the real issues I was dealing with.” She had a brief voluntary inpatient hospital admission following a suicide gesture in which she ingested pills. She had also been prescribed antidepressants for a total of 3 years with little or no benefit. Susan had been homeschooled, which is common among JWs; and her marriage was, for all intents and purposes, an arranged one. JWs are discouraged from attending college, especially if doing so involves being away from the congregation; so she had no career other than that of homemaker. All her friends, associates, and family members were Witnesses, and she experienced an “us versus them” socialization most of her life.

Before her initial treatment session with me, Susan completed the Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996). Her total score was 28,[7] which indicates high moderate depression. She completed the Subjective Units of Distress Scale (SUDS),[8] as well as the Validity of Cognition (VOC)[9] scales typically used in EMDR (Montgomery & Ayllon, 1994). She also completed the Impact of Event Scale (IES)[10] prior to treatment (Horowitz, Wilmer, & Alvarez, 1979). According to DSM-IV-TR (2000), Susan could clearly be diagnosed with a Major Depressive Disorder, Recurrent, Moderate: 296.32; she could also qualify for a diagnosis of Post Traumatic Stress Disorder: 309.81.

In terms of Singer’s symptoms relevant to Post Cult Trauma Syndrome (PCTS), Susan checked off the following: sense of loss; depression and suicidal thoughts; fear that not obeying the cult’s wishes will result in God’s wrath or loss of salvation; alienation from family and friends; sense of isolation, loneliness due to being surrounded by people who have no basis for understanding cult life; scrupulosity, excessive rigidity about rules of minor importance; panic disproportionate to one’s circumstances; confusion about right and wrong; sexual conflicts; and unwarranted guilt (10 out of 13 items on the list). I used Singer’s criteria to determine the focus of treatment.

Because the behavioral targets of my intervention were occurring frequently enough to be measured regularly, I rated Susan’s symptoms at the beginning of each session via the aforementioned methods.
Method

This study utilized an AB design in which I recorded a single baseline (A) and then implemented a treatment (B). Following the baseline measurement, I recorded three intervention measurements and three follow-ups, over a period of 2 months. I conducted one additional follow-up session 1 year after the last treatment session. It is not unusual for EMDR to work so rapidly that the actual intervention phase covers only a few sessions.

EMDR protocol is as follows:
Specific Instructions: Explaining how EMDR works.
Presenting Issue or Memory: Identifying the most salient/upsetting thing the patient can recall relevant to the presenting problem.
Picture: Asking the patient, “What picture (mental image) represents the worst part of the incident?”
Negative Cognition (NC): Having the patient come up with an “I” statement in the present tense—a presently held, negative, self-referenced belief. (A list of examples can be supplied, from which the patient can choose, such as “I don’t deserve love; I am a bad person; I am not in control; or I cannot trust anyone.”)
Positive Cognition (PC): Having the patient offer a presently desired, self-referencing belief. (Examples of such PCs are “I am lovable; I deserve to live; it’s over; I am safe now.”)
VoC (Validity of Cognition): Occurring on the scale of 1 to 7 relevant to how true the PC feels to the patient. (This score increases as the patient improves; e.g., Q: “On a scale of 1 to 7, where 1 feels completely false and 7 feels completely true, how true does the statement, ‘I am safe now’ feel to you when you bring up the scene of waiting for the ambulance at the Kingdom Hall?”).
Emotions/Feelings: Identifying current feelings the incident and the NC bring up.
SUDS: Rating how disturbing the incident feels now (this score decreases as the patient improves).
Location of Body Sensation: Identifying where in his/her body the patient feels the disturbance.
Desensitization: Asking the patient to bring up the picture, the NC, and to notice where he/she feels it in his/her body. I asked Susan to complete the SUDS, VoC, BDI-II, and IES before the beginning of each session; so her first recorded level of symptoms was actually prior to EMDR.
Results

Despite the fact that Susan had previously participated in rather extensive therapy, including psychiatric medication, she verbalized little relief from her symptoms. As noted, she had been disfellowshipped for the second time and had “officially” been out of the JWs for approximately 6 months at the time we initiated the first EMDR session. As you can see from Table 1, her response to the EMDR was so dramatic that, within only three sessions, her presenting symptoms were well on their way to being resolved. It is important to note, however, that Susan chose to work on quite a few social and occupational issues, which we did not address in EMDR, following this study.

During Susan’s EMDR sessions, she decided to choose the past suicide attempt as something that depicted an “old issue or memory” of her cult experience. The word picture that represented the worst part of that memory was ”…having taken the pills, sitting on the bathroom floor of the Kingdom Hall.” Her Negative Cognition was “I’m helpless”; her Positive Cognition was “I’m in control.”

Susan’s treatment rapidly progressed, and, as Table 1 reflects, her Subjective Units of Distress—SUDS (how upsetting the old memory was) reduced to 0, while her Validity of Cognition—VoC (how true her positive cognition ‘felt’) increased to 7; both measurements were in the desired direction.

Table 2, following, reveals that Susan improved in virtually every target area. Her BDI-II score remained within the nonclinical area, as did the IES. Follow-up 1 year later confirmed that the specific targeted benefits remained.

We could compare the baseline to each intervention mean using a paired samples t-test, calculated separately per outcome variable; inferences, however, may not have been statistically meaningful because this study included only one baseline measurement. A repeated baseline might possibly have yielded more of a workable statistic. That option was not practical, however, for this design. As a result, this study is presented as largely anecdotal in nature.
Discussion

Susan’s progress by way of EMDR was very significant, considering her heretofore lack of progress via “traditional” treatment methods. There is no way to determine what, if any, latent learning may have occurred before her EMDR sessions; and this outcome must certainly not be seen as a “born again”-like experience. Understandably, the limits of having only one subject, with only one baseline measurement, severely restrict generalization of these results. In addition, Susan verbalized that she had “officially” been out of the cult for approximately 6 months prior to her EMDR treatment. During the interview, no other obvious extraneous variables appeared to account for the positive results.

Table 2

Results of Entire EMDR Treatment and Follow-up



It is important to note that this patient, born in a cult and having spent so many years raised in the cult setting, felt rather skeptical about EMDR. Cult members frequently remain afraid of any type of procedure that hints of “mind control” or hypnosis-like techniques, and it is important to emphasize that EMDR has very little in common with either of these approaches. EMDR addresses this type of concern by making available abundant empirically-based studies to any inquisitive person. In addition, EMDR offers literature and clarification that explains that “it is your (the patients’) brain doing the healing—you are the one in control” at all times (Shapiro & Forrest, 2004). And this protocol is usually read and explained to every patient before they are considered for EMDR.

I also encouraged Susan to research the topic on the Internet before we initiated her sessions. She did relate that she participated in some support groups, and in conferences for exiting cult members, following her first EMDR sessions. Aside from a history, which the patient herself provided, there is no clear way to ascertain what, if anything, may have further influenced the results. There are certainly many more important issues that one also should address when treating exiting cult members (Langone, 1993; Robinson, Frye, & Bradley, 1997). Certain family dynamics (Whitsett & Kent, 2003) and significant group-oriented interventions must be taken into account (Perlado, 2003; Burghoffer, 2004) with exiting members. A multi-modal approach may ultimately prove necessary to effectively intervene with this unique population.

I had no way to accurately determine any premorbid characteristics or symptomatology with Susan; and she may have sustained a unique impact by having been raised in a cult (Goldberg, 2006). Finally, despite the remission of the targeted symptoms, previously mentioned, I interviewed Susan several times throughout the years following EMDR, and she described ensuing difficulties. She is an exceptional woman who returned to college and is currently enrolled (at the time I am writing this article). Since the EMDR treatment, Susan has participated in more groups for exiting cult members. Unfortunately she lost primary custody of her child, and she remains in supportive counseling through the present.

The results of this case, however, should lead clinicians to seriously consider the use of EMDR as a protocol, or at least an adjunct, in successfully treating any exiting cult members. And there is certainly a need for additional, well-controlled studies that explore this seemingly effective intervention technique.

References


The American Heritage Dictionary (2001). (4th ed., Rev.). New York, NY: Houghton Mifflin Company.

American Psychiatric Association (Ed.). (2000). Diagnostic and Statistical Manual of the Mental Disorders (DSM-IV-TR). Washington, DC: American Psychiatric Association.

Beck, A. T., Steer, R. A., & Brown, G. K. (Eds.). (1996). BDI-II: Manual. San Antonio: The Psychological Corporation, Harcourt Brace & Company.

Booth, L. (1991). When God Becomes a Drug: Breaking the Chains of Religious Addition and Abuse. Los Angeles, Ca: Jeremy P. Tarcher.

Bruhn, A. R. (2008). What makes EMDR work? PsyCRITIQUES, 53(30).

Burghoffer, K. (2004). Cults: Membership, Effects and Treatment. (Doctoral dissertation, Widener U, Institute for Graduate Clinical Psychology, 2004).

Callaghan, K. C. (1996). An examination of cult-type behaviors exhibited by Jehovah's Witnesses. Retrieved from http://home.sol.no/~janish/wteng/cultic 1.htm

Goldberg, L. (2006). Raised in cultic groups: the impact on the development of certain aspects of character. Cultic Studies Review, 5(1), 1–28.

Horowitz, M., Wilmer, N., & Alvarez, W. (1979). Impact of event scale: A measure of subjective stress. Psychosomatic Medicine, 41(3), 209–218.

International Cultic Studies Association. (2008). International Cultic Studies Association: Goals, Programs, Achievements [Brochure]. Retrieved from http://www.icsahome.com

Landau Tobias, M., & Lalich, J. (1994). Captive Hearts, Captive Minds: Freedom and Recovery from Cults and Abusive Relationships. Alameda: Hunter House Inc.

Langone, M. D. (1993). Exiting Counseling: A Practical Overview. New York, NY: W. W. Norton & Co.

Montgomery, R. W., & Ayllon, T. (1994). Eye movement desensitization across images: A single case design. Journal of Behavior Therapy and Experimental Psychiatry, 25, 23–28.

Perlado, M. (2003). Clinical and diagnostic issues of cultism: Group dependence disorder. Cultic Studies Review, 2(2).

Rauch, S. M., & Cahill, S. P. (2003). Treatment and prevention of Posttraumatic Stress Disorder. Primary Psychiatry, 10(8), 60–65.

Robinson, B., Frye, E. M., & Bradley, L. J. (1997). Cult affiliation and disaffiliation: Implications for counseling. Counseling and Values, 41(2), 166–173.

Shapiro, F. (1997) EMDR: Setting the record straight. PsycCRITIQUES, 42(4), 363–364. doi:10.1037/005088.

Shapiro, F. (2002). EMDR 12 years after its introduction: Past and future research. Journal of Clinical Psychology, 58(1), 1–22. doi:10.1002/jclp.1126.

Shapiro, F., & Forrest, M. S. (2004). EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma (Rev. ed.). New York, NY: Basic Books.

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Singer, M. Thaler (1979). Coming out of cults. Psychology Today, (Jan), 75.

Tootell, E. (2004). Eye movement desensitization and reprocessing: A comprehensive literature review. Dissertation Abstracts International, 2004–99014–203, 455.

Watchtower (1973), Praise Jehovah with His people. (July), Brooklyn, NY: Watchtower Bible and Tract Society.

Watchtower (1988), Discipline can yield peaceable fruit. (April), Brooklyn, NY: Watchtower Bible and Tract Society.

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About the Author

Robert R DeYoung, Ed.D., is the Founder and Director of the Family Center for Behavioral Health in Matamoras, Pennsylvania. He also teaches psychology at the State University of New York, Orange, and he is an instructor at the Police Chief's Association, Police Academy in New Windsor, NY.

Cultic Studies Review, Vol. 8, No. 2, 2009, Page

[1] Francine Shapiro, originally a cognitive behavior therapist, developed EMDR as the result of her own scare with cancer.

[2] Go to http://www.emdr.com/efficacy.htm for a more extensive efficacy/validation overview of EMDR.

[3] Interviews with ex-JWs clarify that a detailed record of hours spent going door-to-door, as well as of pieces of literature distributed, must meet certain standards; otherwise, members are reprimanded by the elders, and privileges are removed.

[4] For a summary of prevalence, see http://www.icsahome.com/infoserv_topic/tp_prevalence.htm.

[5] You can access this information, and more, via the reFOCUS network Website at http://www.refocus.org/postcult.html.

[6] The patient’s identity, as well as any other distinguishing characteristics, have been changed to protect confidentiality.

[7] The BDI-II is a popular, reliable, and valid measure of depression; it has a test-retest stability of .93 when taken at 1-week intervals, and the Total Scores are interpreted as follows: 0–13 minimal; 14–19 mild; 20–28 moderate; and 29–63 severe.

[8] A 0–10 scale, on which 0 represents no disturbance, to 10, which represents the worst disturbance the patient can imagine. J. Wolpe, M. D., originally developed this concept (Wolpe, 1974).

[9] A self-report scale from 1 to 7, on which 1 represents totally unbelievable, to 7 which represents totally believable. F. Shapiro, Ph. D., developed this concept

[10] A self-report Likert-type scale, developed by M. Horowitz, N. Wilmer, and W. Alvarez, is a measure of subjective stress and ranges from 1—“not at all” to 4—“often”; the scores are interpreted as follows: 0–8 Sub Clinical; 9–25 Mild; 26–43 Moderate; more than 43 Severe.

[11] Note that the first measurement was taken just before the first EMDR session.