Folie-a-deux can be defined as a paranoid disorder in which the same delusion is shared by two (or more) persons. The delusion is thought to be transmitted from a dominant but paranoid person to his or her dependent intimate(s), and the latter may recover “normal” reality testing after separation from the former.
To my mind the interesting essential of this situation is that the sharing of a belief bonds and comforts its adherents; this feature may be obvious even where the belief is shared by many and would not ordinarily be regarded as delusional. For example, picture a church congregation reciting its creed in unison.
The Comfort of Shared Belief
What is the nature of the comfort so provided? In our prototypical, pathological case, where the belief is a persecutory delusion, the acceptance of the belief by a “significant other” signifies to “the beleaguered one” that he has found an ally or a protector; contrariwise, skepticism creates the kind of anxiety that would be felt by a small child who hears a robber entering his bedroom, but can’t convince a nearby parent to come to the rescue.
The delusional belief can thus function as a probe with which to test the love, loyalty and ready courage of the other. Where the belief is less persecutory (e.g., belief in God), the sharing of it is at least friendly, like sharing a meal; and the belief may seem to be validated by the numbers subscribing to it.
In either case, if a newcomer to the “church” demands evidence, he either misses the symbolic point, or is being deliberately obtuse and distinctly unfriendly. Those of us who are skeptics at heart will hesitate at the church door, having in the past experienced conflict between that social pressure and its opposite, a desire to be the maverick whose superior science will expose the error of the herd.
Or, if we were doctors, thought we had joined another sort of church, whose members sing in unison, credo in unum deum, Reality; and otherwise have to agree only on the means for finding it (the scientific method).
As doctors, we still take a great deal on trust in our human relationship with patients, and find warmth in that relationship that is cemented, without our consciously considering it, by mutual and traditional assumptions (for example about the nature of the roles each is to play). Generally, we assume the patient is trying to be honest, and certainly don’t demand proof for every detail of the history.
By being credulous in that way, we become the parent who will keep the robber, Death, at bay. Sometimes we come running even when we think the robber is imaginary. And after all, how can one be sure? In a case of suspected child abuse, better to call Social Services after a minimal reality check. “Time may be of the essence.” “Better to be safe than sorry.”
Yet there are many situations in which the credulous posture becomes problematic. The simplest of these is when the patient has been identified as “delusional”, which means that the doctor has decided in her heart that she does not believe, does not stand on common ground with her patient in regard to the delusional idea and does not wish to.
In the interests of the alliance, or out of empathy, she may still search for the grain of truth on which they can agree. Might she even disguise her belief for strategic purposes? Perhaps, after all, her patient is repeating in this doctor-patient relationship a childhood experience of being unable to summon a parent in the moment of terror.
Believing the Fantastic: The Problem
An especially muddled situation depending on credulity in the therapist-patient alliance has been the proliferation in recent years of therapies for victims of fantastic post-traumatic syndromes.
For example hypnotherapies for people who have been contacted, abducted or violated by extraterrestrials, or who have suffered trauma in a previous existence. I assume the reader shares my automatic scepticism regarding these trauma and their treatments. In any case, do we need to concern ourselves with this phenomenon beyond perhaps noting it as an interesting example of folie-a-deux?
But if such is their church, and it comforts them, why not leave them to it? Are not all the communicants consenting adults? The phenomenon is spreading. Abduction stories are becoming epidemic and are gaining more credibility in the media.
Another example, which has been closer to home for psychiatry, is the “growth industry” of treatments and conferences pertaining to multiple personality disorder and Satanic ritual abuse.
I say “closer to home” because, according to the sociologist Jeffrey S. Victor, fifty psychiatrists (and two hundred other professionals) attended the conference on ritual abuse he describes in his article, and two-thirds of the audience at one lecture raised their hands when asked if they had treated Satanic ritual abuse. Most seemed to assume that the survivor stories were literally true and that often such abuse had been the etiology of a multiple personality disorder in the surviving adult.
Admittedly such a conference will concentrate believers, but in my everyday work for a large health plan I too have had occasion to discuss Satanic ritual abuse with credulous therapists and to interview patients who presented typical survivor stories.
The contents of a typical ritual abuse story by now are familiar to many readers: perverse sexual activities occurred at length, repeatedly over the years, between Satanic perpetrators and the child protagonist, embellished with black robes and candles and laboured misuse of Christian symbols; the child was forced to take an active role in the murder of another child; blood was drunk or babies were dismembered and eaten; babies were being bred by the cult for the purpose of ritual sacrifice. Satan himself might appear on the scene.
In day-care cases, the lack of disinterested witnesses is explained by improbable transportation of children to a hidden site (by plane, by tunnels etc.), reminiscent of the “night flight” aspect of witchcraft hysteria. Enthusiasts for the theory hold that such abuse is widespread, for example that fifty thousand ritual sacrifices occur yearly, or that Satanic cults comprise a world-wide multi-generational conspiracy.
According to Kenneth Lanning, in charge of an FBI unit investigating Satanic cult crimes, “We now have hundreds of victims alleging that thousands of offenders are murdering tens of thousands of people, and there is little or no corroborative evidence, from a law-enforcement perspective”.
As therapists, should we care one way or the other about corroborative evidence? Is it not in the nature of an empathic therapeutic alliance to enter into the spirit of the patient’s experience? Is it not in the nature of the therapeutic process to deal evenhandedly with material drawn from fantasy and reality alike? And when it seems that numbers of professionals are unduly impressed by such stories, perhaps it is only their empathy at work; instinctively recognising that there is no better way of forging an alliance with the patient than to endorse the patient’s view of reality.
Yet, I am concerned that in pursuing this course, the therapist can lose track of how much sacrifice of her own intellectual autonomy is being made on behalf of the therapeutic relationship. Taken to an extreme, this kind of empathy ultimately places the therapist in the position of the dependent partner in a folie-a-deux.
There are other possible formulations of the problem I am addressing. Some ritual-abuse patients may be diagnostically closer to having a factitious disorder than to having paranoia, in which case the involved therapists might be regarded as the susceptible targets of a fraud. For example, I interviewed one patient who had obtained disability income on the basis of her post-Satanic multiple-personality disorder, while working with a therapist who had accepted this history without corroboration.
In the case of an adult who identifies cryptic signs of ritual abuse in a child and then applies for treatment or legal action, I see a parallel with the parent enacting a Munchhausen-by-proxy (in which the child is presented for treatment of an odd physical illness which has been fabricated or induced by the parent). In both cases, the parent usually appears especially devoted and concerned for the welfare of her child and compels the admiration of physicians and others involved, until the true situation is uncovered.
What factors beside empathy may have paralysed our capacity to doubt?
We all realise the harm that can result from not taking a sexual abuse story seriously, particularly when it comes from a child. We now practice in a state of heightened vigilance to prevent such abuse, interrupt it, or treat its post-traumatic stress disorder. We bend over backwards to correct Freud’s under-estimate of the true incidence of incest.
As a result, many of us have come to feel embarrassed to question any aspect of any story involving sexual abuse, no matter how truly fantastic. Even in the privacy of our own minds, it can seem that belief is obligatory. And when it comes to voicing doubts out loud, we anticipate a consensus to the contrary, or arguments ad hominem that charge our scepticism to our squeamishness, denial or insensitivity.
And here let me make a personal value explicit: that belief ideally rests on evidence that convinces, and that scepticism is a healthy, or at very least, a permissible first response to someone else’s novel hypothesis, especially when that hypothesis involves the supernatural or challenges common sense.
A third formulation to explain therapist credulity is favoured by Jeffrey Victor and other sceptical sociologists. They suggest that the Satanic ritual abuse phenomenon is an example of mass hysteria (a.k.a. moral panic), in which therapists, patients, clergymen, police and others become involved according to individual vulnerability and social context. They support this theory by an analysis of the manner in which the Satanic cult rumours are spread, and by amassing the cases in which no evidence could ever be found to demonstrate a reality behind the rumour.
The content of ritual-abuse stories also lends support to this explanation. For example, some women who seek “deprogramming” claim to have been practicing witches under the domination of Satan. Their scenario of an indulgence followed by repudiation is an exact duplication of that sequence in the behaviour of the children at the core of the seventeenth century witchcraft hysteria in Salem Village in Massachusetts. Beliefs about blood-drinking, baby-sacrifice, perverse intercourse with demons etc were also all represented in such earlier hysterias.
In the three hundred years of European witchcraft hysteria, ending not long after the Salem outbreak, 200,000 innocent men and women were murdered as witches. The hysteria was supported by the establishment, partly because the estates of wealthy “witches” could be confiscated by the court after they had been executed.
It is hard to imagine that three hundred years later, there is any danger of the whole social structure becoming caught up in teh hysteria in the way that it was in those times. It is alarming that part of the contemporary legend is a belief that individual modern cults are part of an ancient conspiracy, whose goal is to “create international chaos in order to allow Satan to take over the world.”
While believers in this theory may never succeed in creating the kind of panic that leads to sanctioned executions, “an unjustified crusade against those perceived as satanists could result in wasted resources, unwarranted damage to reputations, and disruption of civil liberties,” as Kenneth Lanning wrote in 1990. It has happened. Thousands of families in the United States have been needlessly disrupted, even if one can speculate that in some cases distancing the family might have been part of the patient’s agenda.
Causes of Mass Hysteria
The phrase “mass hysteria” describes a social phenomenon not necessarily restricted to people who individually suffer from histrionic or paranoid disorders. Other factors thought to contribute to vulnerability include gender (more often female) and pre-existing social ties. In the case of the Satanic cult hysteria, the “pre-existing social ties” exist within certain sub-groups of the mental-health professional communities. And the law-enforcement contingent at the seminars shares a fundamentalist Christian perspective:
“The most notable circular among cult-crime investigators, File 18 Newsletter, follows a Christian world-view in which police officers who claim to separate their religious views from their professional duties nevertheless maintain that salvation through Jesus Christ is the only sure antidote to Satanic involvement, whether criminal or noncriminal, and point out that no police officer can honourably and properly do his or her duty without reference to Christian standards.”
Many of the participating therapists also share this context.
Modern “local panics” about satanic cults “have almost all occurred in economically declining small towns and rural areas of the country”. Similarly, an analysis of the economic and political factors favouring hysteria can be made on the basis of the location on the Salem map, in 1692, of the homes of the accusers, the accused and their defenders.
It is interesting to speculate about other social causes of such hysteria. One possibility is that many people are interpreting the AIDS epidemic as God’s punishment for sexual wrongdoing, especially as it occurred concurrently with increasing public awareness of the reality of incest. A subgroup of these people may have been conditioned, by religious upbringing or personal history, to deal with anxiety about forbidden impulses through projection and splitting, and the real existence of Satanic cults provided the seed crystal for a conspiracy theory.
Similarly to a conversion symptom, the hysteria also provides the opportunity for disguised expression of sexual and aggressive interests, as the participants can discuss the details of abductions and orgies while claiming to be traumatised or outraged.
Relationship to Real Sexual Abuse
This brings me to the question of just what relationship the Satanic ritual-abuse hysteria bears to real instances of physical and sexual child abuse.
Obviously it can be viewed as a simple imitation of a true abuse situation, which appears cruder or gaudier than the original, as natural imitations generally do. Like the larger and more brightly spotted eggs of the cuckoo, the ritual-abuse story is a winner in the contest for nurturing behaviour.
In some cases, professionals involved in the hysteria have had personal knowledge of real cases of child pornography, incest, physical abuse, neglect, or those rare instances where the sexual molestation of a child was associated with Satanic embellishments (such perhaps was the case of Frank and Iliana Fuster, described by Roland Summit and others). Their subsequent participation in mass hysteria could be viewed as a manifestation of professional shell-shock.
In the New York Times of March 3, 1991, there was a description of a case in which a couple abandoned an infant to death by starvation because of their participation in an extended crack orgy. Three years ago I was involved in a similar case (the mother had been my patient). When her crime was discovered, incredulous friends attributed it to her having been kidnapped by a Satanic cult, which forced her to kill her baby.
This colourful explanation eased vicarious guilt (mine included, at the moments I was tempted to believe it) and extracted a drop of pleasurable drama from what was, in stark reality, an unmitigated horror.
The Satanic ritual-abuse hysteria could well be, in part, the product of that amazing ability of the human mind to transmute pain into pleasure. If so, I can understand why its adherents would be tenacious. Supposing them to have had childhoods studded by such painful episodes, one can hardly begrudge them the soothing balm and spangly entertainment of hysteria; of fictionising and dramatising their trauma at the moment of its emergence into publicity. At one remove, I am doing something similar as I now write.
Let me look a little more closely, though, at the nature of the relief provided to the ritual-abuse patient. It could go like this: if Satan and all his minions ravished her or her child, she was really not to blame. Never mind if mental health professionals had been trying to tell her that for years; when it comes to ground-in guilt, nothing gets it out like a home-made remedy.
How can it hurt to let the patient go on feeling that we validate this version of her story? In some cases that might seem the best course, or is the only alliance the patient will allow. But leaving aside the potential division of a family, within the patient herself, the split is left unhealed. Somewhere deep in her heart, she could still be wondering whether Satan, penis and all, is not a piece of herself, torn like Adam from her own chest.
And to get at that question, she will have to tell the real story — more homely, sad, or embarrassing. It might be a real incest story, but more likely it will be the story of a puritanical childhood, which — as in Marion Starkey’s Salem — allowed exitement only via tales of sin and punishment.
And what of the patients who, though now in no great distress, instinctively exploit a mass hysteria? What treatment will divert them from a life of disability under a factitious personality disorder or post-Satanic stress syndrome?
Thigpen and Cleckley, the authors of The Three Faces of Eve, believe that full-blown multiple-personality is extremely rare. Most patients seeking the diagnosis are histrionic personalities with a capacity for some dissociation, and a desire to promote that capacity “to … gain attention, or maintain an acceptable self-image, or accrue financial gain, or even escape responsibility for actions.” Multiple personality is almost unknown in England, where sensational biographical accounts of such patients are less available.
Fahy et al suggest treating multiple personality and lesser degrees of dissociation as symptoms of personality disorder. “It is our contention that sanctioning the dissociative behaviour, by concentrating on symptoms or encouraging symptomatic behaviour, may lead to reinforcement and entrenchment of the relevant symptom.” (The same argument applies to preoccupation with the ritual-abuse story.)
In a personal communication, Bessel VanDerKolk reframed the “attention-getting” motive I have here attributed to the multiple-personality or ritual-abuse patient. He takes a therapist’s sense that a patient is exhibiting or “getting off on trauma”, to be a marker for the presence of narcissistic issues in that patient, such as would derive from a childhood that was lacking the minimum essential mirroring from the parents. The resulting hunger to feel important to someone is appropriately gratified by an outraged therapist, even if the trauma is mislabelled by both therapist and patient.
There is a lively dialogue on the subject of therapist scepticism regarding multiple personality in The Journal of Nervous and Mental Disease. I wonder if professionals polarise over endorsing this diagnosis because of personal values regarding responsibility vs. dependency.
Physicians tend to be responsible, counterdependent stoics; as such we face a continual choice between envying the apparent ability of the dissociative patient to escape accountability, or merging with this patient in order to enjoy vicariously the gratifications he seems to achieve in that way. It is possible to shift between the two positions, but most will have a tendency toward one or the other.
Iatrogenic Contributions to Mass Hysteria
We must finally confront the fourth, and least palatable form in which therapist particiption has contributed to mass hysteria: case-finding therapists have been playing a role analogous to the witch-finders of earlier hysterias.
Of course then, the witches were not so much found as created, often by quite deliberate fraud with an obvious profit motive; I had presumed the therapist motivation to be more complicated, including for example the understandable pleasure of sharing the limelight falling on such a case.
An article on Satanic ritual abuse in the April, 1992 issue of The Psychiatric Times describes a case of a therapist who allegedly pressured her patient into telling the ritual abuse story. The patient explained, “It was never just enough to tell her that my grandmother had abused and tortured me. It always needed to be worse.”
This was a harbinger of the flood of false-memory retractions now appearing in the United States. Such zealous therapists would be the dominant partners of the folies-a-deux, the parents in a Munchausen-by-proxy, and the driving force behind hysteria. The past year’s work of the False Memory Syndrome Foundation would suggest that numbers of recanting accusers feel they had been pressured by their therapists in just this way.
The profit motive must now be taken more seriously. It is not necessarily unethical to pursue a specialty which meets the need of fashion, even if one does so with the covert through, “there’s money to be made from this”. Consider for example a hypnotist who decides that because of new anti-smoking laws, a smoking-cessation practice is likely to succeed. It is perfectly possible that he is sincere and zealous about this practice which also happens to be profitable. Yet, if somehow it turned out that hypnotism were more harmful than cigarettes, we would begin to wonder just how long the practitioner might have secretly stilled the doubts now shared by all.
Education or Tolerance?
It will not be possible to eradicate this type of mass hysteria, which has such a strong appeal and is so nearly adaptive for so many. Indeed, a fifth and final reframe for the phenomenon was suggested to me by the anthropologist Sherrill Mulhern (director of the Laboratoire des Rumeurs, des Mythes du Futur et des Sectes at the University of Paris). She believes that the satanic-abuse survivors and their convert therapists comprise an American possession cult.
Labeling mass hysteria in this way, reminds us of the adaptive and comforting aspects of religion, and blames no one (not parent, nor patient, nor therapist) for a phenomenon that springs from some widespread cultural source.
Yet (along with Ms. Mulhern) I remain concerned about the dangerous and counter-therapeutic aspects of cultic religions, in which vulnerable individuals may feel too much pressure to conform and to renounce family ties that might still have been a net positive resource.
And I feel bewildered to walk into my scientific church and find a significant portion of the congregation busily sacrificing a scapegoat on the altar.
Part of our role as doctors is to educate. We can make an effort to enlighten those of our colleagues who are treating factitious and conversion disorders without recognising them as such, and to come to the aid of those who sense the symptomatic nature of the story-telling but are confused as to what “empathy” requires in that situation.
Empathy need not disable the therapist’s observing ego, nor its faculty of critical thought. That is what generates the full list of diagnostic hypotheses and assesses the quality of the evidence available for choosing between them, so our empathy will be attuned to the real source of pain in a particular patient.
Institutionally, we can make more conscious choices about limiting clinical resources such as hospitalisations, especially where the relevant symptom is fully ego-syntonic or factitious. And finally, I think we need to examine the role played by ritual-abuse conferences, courses or therapies in feeding hysteria or proselytising for a new religion.