Tuesday, June 11, 2013

Religious Beliefs and Alternative Psychotherapies: Mutual Influences of Cult-like Groups?

There has been little discussion of associations between unconventional religious beliefs and alternative psychotherapies (APs), a class of mental health treatments that lack a systematic evidence basis and that are implausible with respect to conventional psychological systems. This paper examines the possibility of defining both religious groups and organizations advocating APs as cultic in nature. Apparent connections between two specific groups are discussed with respect to their beliefs about mental health diagnosis and treatment.   An AP, Attachment Therapy, is compared with the “deliverance” practices used by Pentecostals as a mental health intervention, and a number of parallels are noted between these examples of an AP and a religious belief system. The importance of understanding connections between religious beliefs and APs is underscored by the occurrence of injuries and deaths in association with both the described approaches.
Keywords: cult-like groups, religious beliefs, mental health interventions, alternative psychotherapies, deliverance, adverse events

                                Religious Beliefs and Alternative Psychotherapies
            During many years of discussion of the meaning of the term “cult”, the focus has generally been on groups that are unquestionably religious in nature, with an orientation toward some form of the supernatural. In their discussion of religious cults, Stark and Bainbridge (1979) offered several useful definitions. They defined religions as “solutions to questions of ultimate meaning which postulate the existence of a supernatural being, world, or force, and which further postulate that this force is active, that events and conditions here on earth are influenced by the supernatural” (p. 119). Stark and Bainbridge described religions as “system[s] of general compensators based on supernatural assumptions” (p. 121), while defining compensators as “postulations of reward according to explanations that are not readily susceptible to unambiguous evaluation” (p. 120). The same authors differentiated cults from conventional religions by noting that cults “do not have a prior tie with another established religious body in the society” (p. 125), but instead involve an independent belief system.
Although many cult-like groups obviously posit forms of supernatural force and of related compensators, such groups may also focus on issues that are not self-evidently supernatural. Richardson (1993) used the example of a communist “cell” as a possible form of a cult. Stark and Bainbridge (1979) mentioned that Scientology and another belief system had begun as forms of psychotherapy. Bainbridge (1978), Lewin (1988), Ayella (1998), and Gaydics (2007) all discussed forms of psychotherapy they considered cult-like in nature. Noll (1994) and Eros (2004) addressed cult-like groups concerned with C.G.Jung and Sandor Ferenczi, respectively.
Does it make sense to think of non-religious belief systems, and particularly of psychologies, as potentially cultic? How do they compare to cults that clearly involve the supernatural? Generally, religions contain the seeds of psychologies in the form of statements about the nature and right actions of human beings. Psychologies in turn contain elements that may be supernatural (e.g.,  some assumptions about the personality’s survival of bodily death) and which when not supernatural are likely to be only indirectly observable, or inferable from behavior or self-report. To borrow Stark and Bainbridge’s terminology, psychologies propose systems of general compensators (feeling happier, being more productive) based on those indirectly observable elements that are “not readily susceptible to unambiguous evaluation”. This unpacking of psychological thought suggests an overlap with religion; the existence of conventional psychological belief systems and of other independent systems suggests that the concept of cults, as discussed by Stark and Bainbridge, can thus also apply to psychological systems. 
            Can a specific belief system that is publicly presented as a psychotherapy be correctly described as “cultic”? And, if it can, can it be shown to overlap conceptually and practically, and cooperate rather than compete, with a religious system that meets many of the criteria used to define cults? This paper will explore those questions by examining the cult-like nature of an unconventional psychotherapy for children, called Holding Therapy or Attachment Therapy (Mercer, Sarner,& Rosa, 2003), and comparing its principles and practices to those of the “deliverance” beliefs associated with Pentecostalism.
                                  What Are Alternative Psychotherapies?
            Before addressing Holding Therapy/Attachment Therapy as a specific type of unconventional psychotherapy, it will be helpful to consider unconventional or alternative psychotherapies in general. Psychological and medical treatments, however unorthodox, are not usually referred to as cults, although their supporters’ behavior may closely resemble that of cultic groups, as will be discussed later in this paper. More generally, unconventional treatments are categorized as “complementary and alternative” (CAM) medical practice; although this term has been applied to psychotherapies as well as to medical techniques, unconventional psychotherapies can more accurately be referred to as “alternative psychotherapies” (APs) as they are rarely employed in a complementary manner as adjuvants to conventional treatment.
Over the last decade, investigations of the connections and overlaps between religious or spiritual belief and CAM medical practice have become more frequent. The use of CAM techniques for physical ills has been associated with race or ethnicity as well as with other client factors (Gillum & Griffith, 2010; Krause, 2011; Sutherland, Poloma, & Pendleton, 2003).  In spite of the developing interest of psychologists in evidence-based practice (Chambless & Hollon, 1998), following the slightly earlier medical discussion (Sackett et al, 1996) that underscored CAM as a category of medical treatment, and the description of categories of unconventional and non-evidence-based “alternative” psychotherapies analogous to CAM (Mercer & Pignotti, 2007), few psychologists have considered the possible connections between religious beliefs and the preference for APs. Instead, psychotherapists have tended to focus on ways in which clients’ religious or spiritual concerns could be integrated into conventional therapies (Aten, Mangis, & Campbell, 2010; Gonsiorek, Pargament, Richards, & McMinn, 2009; Post & Wade, 2009), or treatment of problems experienced after leaving a high-demand group (Coates, 2010)
A client’s choice of an unconventional AP, rather than conventional psychotherapy, is a different issue from the possibility of integrating religious and psychotherapeutic principles and is a more basic one, as it deals with an initial choice of treatment and practitioner. Such a choice may be based on a framework composed of the client’s experience of religious beliefs and practices, which may be confirmed by existing membership in a cult-like group. Religious dogmas, legends, and personal experiences form shared “traditions of belief” (Bennett, 1987) that can provide the metaphors people employ in attempting to describe or reason about invisible mental or emotional processes (Danziger, 1997; Lakoff & Johnson, 1980), and thus about the nature and treatment of mental illness. For example, the use of folklore or similar informal traditions of belief to provide metaphors about mental or physical illness is a point discussed by Ellis (2000), in a careful analysis of the “Satanism scare” of the 1980s. Folkloric metaphors can help confirm beliefs in mental health interventions when those beliefs are presented in a cult-like social context.
Metaphors Characteristic of Alternative Psychotherapies
 CAM treatments have been addressed in more detail than APs have, and it is difficult to consider metaphors associated with APs without discussion of the analogous unorthodox beliefs about physical illness. CAM treatments for physical disorders are those which are not only without a systematic evidence basis, but are implausible in terms of the causal frameworks that are the foundation of evidence-based medicine (EBM). (An experimental treatment that lacks an established evidence basis is thus not considered a CAM practice if it is plausible in terms of conventional medical assumptions about the natural world.) The frameworks of EBM involve a number of a priori assumptions about the nature of the universe. Included are the beliefs that all forces at work in health and illness are at least potentially describable by natural science and are physical in nature, and that causal factors work from past to present rather than the other way around.
CAM treatments for physical disorders are based on alternative a priori assumptions that allow for non-natural/supernatural factors’ influence on the body. Homeopathic treatment, for instance, assumes that substances can be changed in their spiritual nature and made effective by operations that would conventionally be expected to diminish any effect they could have. Chiropractic treatment is historically based on the belief in a vis naturae or natural healing principle that can be blocked by muscular distortions (Whorton, 2002).
APs, like their CAM cousins, are implausible in natural science terms as well as lacking in a systematic evidentiary foundation. Some are based on a belief in an energy system that is not measurable by natural-scientific methods; for example, Thought Field Therapy (Callahan, 2001) assumes that tapping or gesturing on or near body parts can change the flow of an untestable energy and thus affect mood and behavior. Other APs use different concepts that are contradicted by natural science. Primal Therapy (Janov, 1970) and the belief in the Primal Wound suffered by adopted children (Verrier, 1993) have as foundations the assumption of “cellular consciousness” that allows memory to be mediated by individual cells (even sperm and ova) rather than by the nervous system.
The definition of APs is rendered more difficult by the fact that some conventionally-accepted treatments, such as psychoanalysis, contain some implausible concepts (e.g., catharsis) and lack clear evidentiary foundations. In addition, APs may or may not deserve classification as Potentially Harmful Treatments (PHTs; Lilienfeld, 2007; Mercer & Pignotti,2007), a designation earned when clearly adverse events such as injury or death of the client are documented following the treatment. Generally, however, an AP is a treatment that lacks evidentiary support from either randomized or well-designed nonrandomized controlled trials AND that is also based on  implausible foundations.
APs as Practices of Cult-like Groups
Are APs as a general rule cultic in nature? Answering this question brings us up against the still-evolving definition of “cult”, with its various suggested criteria, and the fact that few groups actually meet all requirements for categorization as cults. Rosedale and Langone (n.d.) gave an extensive list of characteristics that have been suggested as requirements for the “cult” classification. These include excessive devotion to a person, idea, or thing; unethical manipulation for purposes of control, for example through social isolation; information management; promotion of dependency on the group and fear of leaving it--  all of these aimed at the promotion of the group leaders’ agendas.  Richardson (1993) cited his own earlier definition of a cult as a small, informal group with an indefinite authority structure but sometimes with a charismatic leader, transitory, mystical and evangelistic, and taking its inspiration from outside the predominant religious culture. In defining religious cults, as mentioned earlier, Stark and Bainbridge (1979) focused on groups with no prior tie to established religious bodies in their societies; a psychological cult may be considered similarly as independent of conventional psychological thought.
APs almost by definition involve excessive devotion to an idea and are associated with claims of success that are unsupported by the research evidence demanded in conventional circles. Where research evidence is presented, it may involve weak research designs or unacceptable anecdotes or testimonials. Each AP has one or more foundational ideas that are implausible in terms of conventional systems, but the implausibilities are not addressed or explained.  APs are also associated with charismatic group leaders such as Janov (1970), the originator of Primal Therapy, or Jacqueline Schiff (1970), the advocate of a “reparenting” procedure that proved fatal in one case. Some AP leaders consolidate their power by commercializing their methods and allowing access to information only for those who have paid and enrolled (for example,  Roger Callahan’s Thought Field Therapy); this ploy also prevents outsiders from conducting well-designed research by concealing the methods of the AP. Proponents of APs may be made dependent and prevented from leaving the group by fear of the disapproval of valued colleagues, but they may also find themselves unable to move to more conventional practices because they have concentrated their training in unorthodox areas and lack a network or recommendations from respected conventional practitioners. AP clients too may have cult-like commitments to the group, and they may be fearful of leaving because of dire warnings about worsening of their conditions without the AP, or even of deleterious effects of conventional mental health treatments. In addition, AP clients may have formed social networks with other committed believers (often by Internet) and may have developed social and practical habits that prevent social engagement with those outside the group; in addition, they may have maintained secrecy about the AP practices out of a wish to avoid criticism from outsiders, and this secrecy may have limited their social contacts to group members.
Groups of AP proponents thus function in a cult-like manner by Rosedale and Langone’s definitions.  They also meet Richardson’s criterion of being inspired by something outside the predominant religious culture as well as outside the predominant, conventional views of mental health professionals. The “something” outside both of these conventional frameworks involves explanations or practices founded on non-naturalistic, mystical views of human life; for example, one common tenet of APs is that human beings have memories stored in all their cells and therefore are able to remember events that occurred when they were ova or sperm. However, APs do not meet Richardson’s criterion of informal, non-hierarchical organization, as the promulgator of the treatment serves as teacher and mentor as well as therapist to other group members.
              Attachment Therapy as an Alternative Psychotherapy
Attachment Therapy (also known as Holding Therapy, Rage-reduction Therapy, Z-Therapy, Prolonged Parent-Child Embrace, and so on) is an alternative psychotherapy originally directed at correcting emotional disturbances such as schizophrenia and autism (Zaslow & Menta, 1975) but during the 1990s re-invented as a treatment for adopted children or others said to suffer from attachment disorders (Cline, 1992 ). It is presently also used for problems of gender orientation and for marital relationship problems. It has been described as “cult-like” in nature (Mercer, Sarner, & Rosa, 2003), but without any specific analysis of its cultic characteristics. Although the treatment has been rejected by professional organizations (e.g.Chaffin et al, 2006), its practice has continued and was recently approved by an article in a professional journal (Sudbery, Shardlow, & Huntington, 2010).
 Following the death of a ten-year-old patient, Candace Newmaker, in 2000, as well as other documented deaths (Mercer, Sarner, & Rosa, 2003), Attachment Therapy (AT) is said to have altered in its practices, although some practitioners appear to have continued to use the original style. AT is, or was, a physically-intrusive proceeding based on the implausible assumption that adult physical force and dominance are causes of young children’s emotional attachment to their parents. AT uses a number of terms derived from Bowlby’s (1982) conventionally-accepted work on emotional attachment, but ignores Bowlby’s description of the timing of developing attachment in favor of the implausible belief that infants form emotional attachments to their mothers before birth and are traumatized by separation from the birth mother no matter how early it occurs. AT also attributes child disobedience, mood, or behavior problems to the absence of attachment, and predicts that  adopted children will grow up to be serial killers even if presently asymptomatic. AT practitioners claim to create attachment by re-enacting with children the dominance relationship that they believe is the normal cause of continuing attachment following birth.  AT is thus implausible in the context of conventional understanding of early development; in addition, it lacks an evidentiary foundation (see Mercer, Sarner, & Rosa, 2003).
Proponents of AT sometimes state that the children they treat are diagnosed with Reactive Attachment Disorder (RAD), but in fact the stated symptoms (such as “crazy lying”) do not meet published criteria for the RAD diagnosis (American Psychiatric Association, 2000). An alternative diagnosis, Attachment Disorder tout court (AD), is often offered. AD is diagnosed on the basis of a lengthy list of symptoms, as given in the Randolph Attachment Disorder Questionnaire (RADQ; Randolph, 2000) or on many related websites (e.g., www.attachmentdisorder.net). This list includes intense control battles, unwillingness to show affection on the parent’s terms, lack of eye contact except when lying, lack of conscience, incessant chatter, and a fascination with blood and gore.
According to AT proponents, conventional treatments exacerbate the children’s conditions, but AT may cure them. The intervention is deliberately intimidating, frightening, and physically intrusive, as therapists or parents hold the child down or lie on top of him, poke and prod at his or her body, shout, threaten abandonment, and demand that the child “confess” by repeating the therapist’s statements about misdeeds or culpable thoughts like a wish to kill the mother (Mercer, Sarner, & Rosa, 2003). Dire predictions to the effect that the child will be “the next Jeffrey Dahmer” may be included. These methods are repeated for several hours at a time, sometimes day after day, as the child is put through a two-week “intensive” treatment. After a treatment session, the child goes to a respite/therapeutic foster family rather than rejoining his parents; at the respite home, he is given assignments of tedious work, and has limited diet and other comforts. If the child returns to the parental home, he or she may be required to ask for permission for anything needed, including use of the toilet, in an age-inappropriate way.
The cult-like characteristics of AT include the drawing of its ideology from outside either the predominant religious culture or predominant beliefs of mental health professionals (see Richardson, 1993). Although the list of characters has been changing since the death of Candace Newmaker led AT proponents to reposition themselves, a small number of prominent members form the group’s leadership, followed in the hierarchy by a larger number of those trained within the group. As Rosedale and Langone suggested, the financial affairs of the AT group are directed primarily to the benefit of these leaders.  A parent-professional group, the Association for the Treatment and Training of Attachment in Children (ATTACh) provides courses taught by major figures in the group and leading to certification as “Registered Attachment Therapist”, a title unrelated to any professional licensure; however, conventional organizations like the National Association of Social Workers provide approval for continuing education credits earned through such courses. Parents of children receiving AT form the lowest echelon of the group and support each other in the face of conventional critics by means of Internet sites like www.RadZebra.org and www.AttachChina.org.  Discussion at these sites emphasizes the ignorance of conventional sources and the need to turn to the group for support of unconventional beliefs and practices. Contributors who disagree with the group are intensely criticized by other members, and because contributions are anonymous, these exchanges take on the viciousness so often found on the Internet.  Information management techniques convince parents that their children will grow up to be serial killers if not treated by AT methods, and that conventional psychotherapies are not only useless but will exacerbate problems. These threats produce fear of leaving the group and add to the cultic nature of the organization. Payment for AT services is out-of-pocket rather than by health insurance, potentially creating cognitive dissonance for those who might consider recanting after making this expensive choice.
Who are the members of the AT group, and what advantages do they derive from their membership? AT’s primary focus on childhood mental illness means that the people most affected by the belief system are children and not in a position to make their own decisions about their involvement. Although personal communications suggest that some children buy into the beliefs presented to them and grow up assuming that AT is a conventionally-accepted therapy, and although most of the children cooperate with the treatment for various reasons, the children do not seek the treatment and therefore are not the cult members in the usual sense. The decision to belong to the group rests with adults, who are the actual members. Leadership of the group belongs primarily to AT practitioners, who show their authority through child diagnosis and treatment decisions as well as through published material, videos, Internet sites, and training workshops (which in some cases are given continuing professional education credits by approved providers certified by the American Psychological Association and the National Association of Social Workers; the approved provider system does not require the national organization to approve of individual presentations).
In a recent publication of ethnographic observations of AT around 2000, Stryker (2010) discussed the involvement of adoption caseworkers and agencies as well as parents in facilitating involvement with AT. Stryker pointed out that both parents and caseworkers were rewarded by the sense of participating in family formation. They emphasized the perceived criticism of adoptive parents by conventional psychotherapists and repeated to each other the belief that conventional methods exacerbate the childhood mental health problems they had identified, thus confirming their membership in the group and differentiating the group’s practices from those in the larger society. Both caseworkers and practitioners provided a comforting re-frame in the not infrequent case of disrupted adoptions, by describing the placement of a child in a residential treatment facility (usually to stay there until “aging out” at 18) as “loving at a distance”. The adoptive parents were encouraged to consider themselves and the separated child as a family although there might be no contact between them. These beliefs contradicted conventional thinking about family ties, and once again contrasted the supportive attitudes of the AT group with the criticism to be expected from the larger society. In similar contrast of conventional and group positions, AT chat groups on the Internet often mention  disapproval of AT methods by friends and family members and describe the intense need for support by other AT proponents; a repeated theme in these chats is that no one can understand or help with their problems unless that person has an adopted child, thus effectively limiting sources of help or information to group members. (Adoptive parents who report no particular problems are said to be “in denial” or lying.)
At a practical level, AT practices provide parents with freedom from child care responsibilities for days or weeks at a time, or even permanently, outcomes that would not be encouraged in most cases by conventional child mental health interventions. In one case in Georgia (in which I testified as an expert witness), AT-oriented caseworkers managed disruption of an adoption and adoptive placement of a child with another family, without a conventional family evaluation, and apparently simply through influence on a judge; when the child ran away from the new home where she was receiving AT treatment, she was placed in an AT-oriented facility in another state. Experience of these unconventionally parent-friendly practices helps to hold members in the group.
                 A Religious Framework: Deliverance Beliefs  
The purpose of this paper, as stated earlier, is to examine the connections between an AP and a religious group, each of which meet some of the criteria for classification as cultic. The possible religious parallel to AT is the commitment to “deliverance” beliefs and practices, as evinced by Pentecostals and other charismatic Christians.
As is well-known, traditions of exorcism of evil spirits date back to ancient times. Roman Catholic rituals for exorcism were formulated in the 17th century, as were those of the Church of England (Malia, 2001). However, Pentecostal deliverance practices are not obvious developments of the Renaissance tradition. The older rituals did not consider the capacity for deliverance (the expulsion of demons) as a gift of the Holy Spirit, and as one among several gifts said to have been received by the Apostles at the event celebrated as Pentecost or Whitsunday, and described in the New Testament Book of Acts. Neither were the spiritual gifts, which included “speaking in tongues”, part of the periodic religious revivals experienced in North America in the 18th and 19th centuries. The Pentecostal practice of glossolalia apparently emerged in about 1830 in a British millennial Presbyterian group known as the Catholic Apostolic Church (Ellis, 2000). The practice of “pleading the Blood” and preoccupation with Jesus’ blood as a way of exerting power over both physical and spiritual worlds began in the early 1900s, and was formalized as a method of casting out spirits in a book by the Pentecostal author H.A. Maxwell White in 1959. 
These developments paralleled the growth of the Pentecostal belief that the “indwelling” of demons in human beings is responsible for mental illness as well as for physical problems  (see Mercer, in press). More recently, manuals of deliverance (Banks, 1985/2008; Hammond & Hammond, 1973/2010, 1996/2010; Wagner, 2000 ) have described causes of mental illness and outlined methods of expelling the related demons; these authors agree that expulsion of demons/evil spirits involves coughing or vomiting out physical substances. 
Is Pentecostalism a cult, or a loose organization of cult-like groups? To understand  Pentecostalism, it is first necessary to recognize it as a religion, one of several “solutions to ultimate meaning which postulate the existence of a supernatural being , world, or force, and which further postulate that this force is active, that events and conditions here on earth are influenced by the supernatural” (Stark & Bainbridge, 1979, p. 119).  In describing religious cults, Stark and Bainbridge identified these groups as having no prior tie with established religious bodies in their societies, and in that way differing from schismatic sects. The beliefs of religious cults may have been imported from an alien group, or they may be innovations with a background in the same society.
Pentecostal churches are associated with each other, but there is no over-riding hierarchical organization or statement of dogmas to be accepted by all Pentecostals. Constant schismatic splitting means that any specific church may have somewhat different beliefs and practices from others. Nevertheless, there is sufficient agreement among the groups for them to share publications that discuss deliverance and associate it with healing of mental and physical disorders.  These publications and other Pentecostal materials suggest that the group is cultic in nature.
Pentecostals believe that each Christian experiences a direct connection to God and is a potential recipient of the gifts of the Holy Spirit discussed earlier. Religious training or ordination have little importance in the development of group leaders, so that any individual who is “charismatic” (in the common meaning of the term) can exercise authority. Members of the congregation are devoted to these leaders (as Rosedale and Langone suggest), and the informal and schismatic nature of the group means that any leader who does not inspire devotion can quickly be left behind. Pentecostals are also devoted to the idea that their lives are simultaneously involved with the natural and the supernatural worlds, in a real day-by-day connection as well as a concern with the afterlife. This belief, unshared with the great majority of non-Pentecostals in the developed world, sets the group apart and provides a strong motivation to remain engaged with similar believers; non-Pentecostals are thought to behave dangerously and attract evil spirits by their casual involvement with the occult (e.g., Halloween) and by their ignorance about association with owl figures or the telling of ghost stories (an innovative position, as suggested by Stark and Bainbridge). A positive reason for staying with the group stems from the Pentecostal adoption of “prosperity theology” and the assumption that right belief and behavior wins the gifts of this world as well as those of the Holy Spirit (Roberts & Montgomery, 1966). However, although Pentecostals may fear leaving the group, and desire the “compensators” they associate with membership, they may feel under less pressure than many cult members, as they believe that they are individually capable of receiving the gifts of the Holy Spirit (although paradoxically they consider successful deliverance to depend on confession of sins). In addition, Pentecostals as a group assume that every person will sometimes “backslide” and that noncompliant behavior should not necessarily cause expulsion from the group.   
            Deliverance Beliefs and Choices of Mental Health Intervention
The brief history of deliverance beliefs and practices in the last section shows a cult-like organization with a rich source of metaphors that can be applied to consideration of mental illness. These metaphors have the potential to shape preferences or acceptance of APs that are not in themselves directly deliverance-related. The stress deliverance believers place on the supernatural may provide metaphors encouraging acceptance of non-material factors in explanations of mental illness. These non-material factors may involve posited  spiritual components such as demonic presences or the Holy Ghost,  undetectable by physical measurement, that are said to underlie physical and mental functioning. They may also involve pre-existing and immortal personality components that enable the individual to remember events during embryonic life, or even prior to conception. AP treatments almost invariably posit factors of these types, and conventional treatments do not, so it can be hypothesized that a preference for AP mental health interventions can result from metaphors derived from deliverance beliefs. Such metaphors could result simply from exposure to these beliefs, and would not necessarily require a serious commitment or conversion.
Testing the hypothesis that AP preferences are encouraged by exposure to deliverance beliefs is not within the realm of practical politics. As an alternative, and with the goal of accumulating evidence relevant to this issue, this paper will now discuss resonances between deliverance beliefs and one AP mental health intervention, AT, described earlier. It is notable that Nancy Thomas, a long-time proponent of AT, is mentioned with admiration by at least one deliverance-related website, as are a number of books advocating AT (“Ministering to deeply troubled children”, n.d.). I am well aware of the dangers of cherry-picking information and of the inappropriateness of displaying only those points that support my hypothesis, but for obvious reasons I will not attempt to list all those hundreds of ways in which AT does not resonate with deliverance beliefs, and will presume that readers understand why I am taking this preliminary approach.
What are the resonances between AT and deliverance beliefs and practices?  The most obvious parallel is an element of the supernatural, shown by the  AT claim that unborn infants communicate with and know their mothers through means that are unstated but that cannot include natural sensory modes or the level of cognition usually attributed to the human fetus (Verny, 1983). The unborn child is considered to have abilities that are superior to those of a neonate, an implausible idea given that earlier development is invariably characterized by less mature capacities than is later development. The implication is that the unborn child retains the abilities of its spiritual origins, which are more advanced than allowed by the material nature following birth.
In addition to the supernatural theme, resonances between deliverance and AT can be seen in both diagnostic approaches and treatment methods. Some of the parallels, like that between being “born again” and the “rebirthing” techniques sometimes associated with AT, are obvious, but most are less apparent unless examined in detail. The information used for this examination in the next section will be drawn from Hammond & Hammond (1973/2010; 1996/2010) or Banks (1985/2008) if it is not otherwise attributed.
Diagnostic Approaches
            Several diagnostic themes are shared by deliverance and AT proponents, although the two use different language to describe them. Generally speaking, these shared items are not found in conventional diagnostic approaches to Reactive Attachment Disorder, the diagnosis often mentioned for children who receive AT treatment, or any other mental illness.
            Discernment. Deliverance believers consider that it is possible to receive a divine word of knowledge through a vision, dream, thought, or mental image, and that this knowledge helps to discern which demons are causing a problem and why they are present. AT proponents do not state this, but they present themselves as finding it fairly simple to decide whether a child has an attachment disorder. They may make this diagnosis over the telephone after asking the parent to respond to a checklist (this occurred for Candace Newmaker, a child who died during AT treatment; see Mercer, Sarner, & Rosa, 2003). Elizabeth Randolph, the developer of the Randolph Attachment Disorder Questionnaire (RADQ), an assessment often used in AT proceedings, apparently used her own diagnoses of children as the criterion for validation of the RADQ (Randolph, 2000). It is not clear whether this is simply a matter of careless or na├»ve test development, or whether Randolph believed that she could accurately discern the child’s condition. Randolph also stated that she could diagnose attachment disorders by noting the child’s inability to crawl backward on command (Randolph, 2001), an implausible criterion that would conventionally be considered to have nothing to do with an emotional disorder.
            Control battles. AT checklists are much concerned with the child’s desire or attempts to control and manipulate others. Disobedience, lack of gratitude, and failure to show affection on the parent’s terms are all seen as symptoms of attachment disorders. Deliverance practitioners similarly see an intense desire for control as a sign of demonic possession. In addition, parents are advised to quell disobedience at all costs (Pearl & Pearl,1994).
Fascination with blood and gore.  Although an obsessive interest in blood might well indicate emotional disturbance of some kind, the DSM-IV-TR criteria for RAD (American Psychiatric Association, 2000) include absolutely nothing related to blood in any way. As was noted earlier, however, criteria in checklists about AD, as promulgated by AT advocates, always include the idea that the child is “fascinated by blood and gore”. There may be a resonance here with the deliverance theology emphasis on “pleading the Blood” and “the power of the Blood”. H.A. Maxwell White’s 1959 book on this topic stressed the great spiritual significance of blood, its use in sacrifice, and the Biblical idea that “the blood is the life”. Because AT proponents are concerned with children seeking to control adults, they may read an interest in blood as a desire for control in a spiritual as well as the obvious material sense.
Lying.  Excessive fantasy or efforts at deception may also be symptomatic of emotional disturbance , but again play no part in the criteria for RAD. However, Attachment Disorder  checklists, used by AT practitioners, emphasize habitual lying, especially what they call “crazy lying”--  lying that will obviously not be believed. Demons are thought of as liars, and are of course under the management of Satan, the “father of lies”. In addition to their lying propensities, demons are considered to be highly legalistic and to be permitted to lie about or refuse to answer a question that is not asked in exactly the right way. Demons are thought to lie in order to escape from deliverance proceedings without giving up their “indwelling” of the victim’s body.
Eye contact. Although eye contact is unmentioned in descriptions of the criteria for RAD, and although mutual gaze is a behavior much influenced by cultural demands, failure to make eye contact except when lying is mentioned by AD checklists, and eye contact upon demand is part of AT practice.  Deliverance proponents in some cases regard the appearance of the eyes and of the gaze as revealing demon possession, as if the eye is not only literally “the window of the soul”, but a window into whatever spirit entity is inside a body. Hammond and Hammond (1973/2010) considered that a glazed or fixed appearance of the eyes could reveal whether a demon or the person himself was responsible for speech or movement. (It is also possible that the AT concern about this symptom was adopted from information about communicative behavior problems in autism.)
Chatter. AT proponents suggest that attachment disorders are characterized by the child’s constant chatter and “silly” questions, for example about when they will see their parents again (Thomas, 2000), and advise caregivers to refuse to answer or to answer with another question. Deliverance practitioners caution against yielding to the temptation to exchange banter or persiflage with demonic entities who are being addressed during a deliverance event; demons are thought to use words to confuse issues as well as to lie. “Speaking in tongues”, a gift of the Holy Spirit, involves chatter and incomprehensible speech or singing, but in its own context is seen as sacred rather than diagnostic of demonic possession.
History of adoption. The conventional criteria for  RAD are unusual in their inclusion of etiology as a factor to be considered along with behavior symptoms. A history of early neglect or abuse, or inconsistent care, is necessary but not sufficient for a diagnosis of RAD.  Adoption in itself would not be considered relevant to RAD, unless it occurred when the child was older, or was accompanied by experiences of neglect or abuse. AT proponents, however, emphasize the posited role of adoption in interfering with attachment and creating AD (see Keck & Kupecky, 2009; the publisher of this book is described as the publishing ministry of an international Christian organization). Infants adopted in the first days of life and cared for well and consistently are nevertheless thought to be susceptible to AD. This view parallels the serious concern of deliverance believers with respect to the attraction of demons by events preceding adoption, including the death of a parent, conception outside wedlock or through violence and lust, or under circumstances such that one or both parents consider the possibility of abortion. Adopted children are considered to be vulnerable to demonic possession through both the biological and the adoptive family lines, so generational curses based on ancestral behavior are exceptionally likely to be at work in adopted persons (Hammond & Hammond, 1973/2010; 1996/2010).
Incontinence. Accounts of cases by AT practitioners often note that children urinated or defecated inappropriately (Thomas, 2000). Incontinence is attributed to demonic influences by deliverance authors.
            AT and deliverance practices share a number of procedures; expected behaviors of persons in treatment also have some similarities. These shared items are not found in conventional scenarios of treatment for mental health problems.
            Restraint. Although physical restraint of persons in treatment is sometimes used for safety and security reasons, restraint is not conventionally considered to be of psychotherapeutic value. On the contrary, recommended goals are for reduction in the use of restraint and seclusion even outside the therapeutic situation . In AT thinking, however, restraint itself is thought to be of therapeutic benefit , whether as applied provocatively to an initially calm client (Cline, 1992; Zaslow & Menta, 1975), or to one who is already agitated (Federici, 2001; Ziegler, 2001).    Deliverance practices involve parallel uses of restraint, whether applied when the deliverance candidate begins to thrash and fight, or initially, when a child might be held on the lap of a deliverer or a parent. 
            Eye contact. Although conventional therapists use gaze signals as part of their communication with a client, they do not regard eye contact as a magical or transformative event. AT practitioners, however, consider the maintenance of eye contact to be a powerful tool. While restraining a child across the adult’s lap, or while lying on top of the child, the practitioner insists on a prolonged mutual gaze and scolds or threatens the child if he or she does not comply. The child is especially to look into the therapist’s eyes while making confessions or repeating therapist-supplied statements about feelings. Similarly, deliverers consider eye contact a useful tool for communication of commands to demons, although they appear to recognize that mutual gaze cannot be forced.
            Confession. Many conventional psychotherapies involve disclosure of actions, thoughts, and feelings that a client may have wished to keep secret in the past. In AT procedures, children are often told what feelings they must have (e.g., hatred for the biological mother, rage against the adoptive mother) and what actions they must have wished to carry out. They are instructed to shout related statements (“I want to kill my Mom!”) repeatedly, and are informed that if they do not change they will actually do these things and will go to prison (Mercer, Sarner, & Rosa, 2003). In deliverance proceedings, confession of thoughts or behavior that could attract demons is a prerequisite to the casting out of those demons. “Occult” activities, like celebration of Halloween or use of a Ouija board, must be described as well as more obviously prohibited activities involving sex or drugs. In a parallel with AT, what is confessed might never have been acted on, as in the case of a considered abortion (Hammond & Hammond, 1973/2010). Deliverance proceedings include the verbatim repetition of prayers by the deliverance candidate and the deliverance team. One point of interest is that in the course of deliverance, confessions that are spoken may not be clearly identified as information from the deliverance candidate; the demon might be speaking and lying.
            Vomiting. Vomiting, urination, and defecation are not expected events during most conventional psychotherapy, and if they occur are considered symptoms of physical illness or of a child’s immaturity. In AT practice, however, these physical actions are regarded as completely under the control of the child and as used to resist the therapist’s pressures for change. A much-quoted paper by Reber ( 1996) described children in AT as vomiting, begging to use the toilet, and crying that they were going to die, and positioned these behaviors as normal parts of the therapeutic proceeding (this paper, incidentally, was cited by Furnari [2005]) . The AT-associated death of Candace Newmaker in 2000 involved the child’s vomiting while restrained inside a rolled sheet; several adults present ignored this and its potential for serious harm, apparently considering it a normal part of treatment. Deliverance proceedings, in a striking parallel, are not only tolerant of vomiting, but consider vomiting and coughing phlegm as indices of the expulsion of demons and therefore as desirable (Bialecki, 2011; Cuneo, 2001). Preparation for the deliverance includes provision of containers and towels. Again, incontinence may be interpreted as a sign of demonic possession.
            Fasting. Conventional psychotherapies assume that good physical health is advantageous for successful mental health interventions. AT practices, on the contrary, hold that respite or therapeutic foster care practices encourage emotional change when they limit the amount and variety of children’s diets (Thomas, 2000), or force food or water as a way to obtain compliance (Mercer, Sarner, & Rosa, 2003). Deliverance believers use fasting as a method of purification that is helpful to the deliverer’s abilities, but they may also advise the deliverance candidate to prepare himself through fasting and prayer. I have found no evidence that fasting is imposed on children, however.
            Number and length of treatment sessions. Conventional psychotherapies often use the standard “fifty-minute hour” and employ sessions that occur weekly, or not much more often. AT sessions last for several hours, and although they sometimes occur weekly, are much more frequent in the case of the two-week “intensive”. Deliverance events also last several hours, and although they are not at daily intervals, they are generally repeated on a number of occasions, especially because it is thought that the same demons may return, or other demons may be attracted to the “empty” person.
            Practitioners. Licensure for conventional psychotherapists attempts to ensure an appropriate level of training. Some AT practitioners have found some ways to avoid such requirements. They may practice in a state like Colorado, where therapists may be registered but unlicensed, or may work under the cover of a sympathetic licensed practitioner. These options permit a AT therapist to limit training on some topics to weekend seminars (as was the case for Julie Ponder, one of the persons responsible in the death of Candace Newmaker), or to claim the credential of “registered attachment therapist” as provided by the Association for Treatment and Training of Attachment in Children (ATTACh). Some AT practitioners have doctoral degrees from intermittently-accredited organizations like the Union Institute. Some have sought licensure as massage therapists in order to avoid restrictions on physical contact with patients. Deliverance practitioners have similar training issues. Pentecostal groups are highly congregational in organization, so the hiring of pastors is based entirely on the wishes of an individual church, and there is no denominational set of standards for educational background. Deliverers learn informally from each other, unless they themselves wish to study conventional materials; there is no encouragement or requirement for any formal training in any mental-health-related area. Indeed, their training may depend on items like the Demon possession handbook for human service workers (1995).
            Further concerns. A still unexplored issue in the continuing development of both deliverance beliefs and acceptance of APs is the influence of African Pentecostalism. This set of beliefs, which to some extent combines African traditional religions with Pentecostal tenets (Asamoah-Gyadu, 2004), began with missionaries to Africa from the United States, but may be affecting U.S. Pentecostals in return as African evangelists return to preach and carry out deliverance in the United States.  An event of recent concern was the planned (but postponed) visit of the Nigerian evangelist Helen Ukpabio, who has been associated with many accusations of children as witches, followed by torture and death of the children (Ngong, 2010; “Marathon deliverance”, 2012).
            “Deliverance” believers and AT proponents both form groups that meet some criteria associated with cults. Although cult-like groups may be expected to compete rather than cooperate with each other, these two groups, which have different apparent goals, share practices and beliefs to such an extent that they seem to be mutually influential. However, the much longer history of Pentecostalism, as well as its far broader concerns, suggests that Pentecostal beliefs and metaphors are more likely to have influenced AT than the other way around.
            The parallels between deliverance practices and AT are clear, but there may well be an equal number of non-parallel characteristics. As I noted earlier, I can hardly conclude that the existence of many parallels between a religious framework and an AP necessarily means that religious beliefs increase the acceptability of the treatment to believers. However, it is noteworthy that there appear to be many more overlapping factors between deliverance practices and AT than there would be between, say, deliverance practices and conventional psychotherapies like Parent-Child Interaction Therapy (Eyberg & Bussing, 2010) or DIR/Floortime (Greenspan & Wieder, 2006). Neither of the latter  two treatments (one with and one without a clear evidence basis, but both highly plausible) employs restraint or the forcing of eye contact or confession; both emphasize following the child’s lead as an essential part of establishing a good relationship, rather than seeing a controlling parent as one who is fostering a child’s attachment. 
            Understanding the possible role of religious beliefs in encouraging clients to choose AP treatment is especially important because of the potential for harm in some unconventional methods. That potential goes beyond the expenditure of scarce resources on ineffective treatment, or even the possible avoidance of evidence-based treatment because of advice from AP practitioners. Both deliverance practices and AT have been associated with injuries and deaths (“Autistic boy’s death at church…”, 2003; “Police: ‘Cult’ starved toddler…”, 2008; Mercer, Sarner, & Rosa, 2003).  They deserve to be categorized as Potentially Harmful Treatments (Lilienfeld, 2007; Mercer & Pignotti, 2007) and to have their beliefs and practices publicly vetted for the benefit of those who may be attracted to these cult-like organizations. Some vetting is currently proceeding in a British case discussed at http://invisibleengland2.wordpress.com, as well as in a case in the U.S. in which a man in his 30s is seeking redress for being confined and treated with AT for eight years of his childhood.
Practical Effects of Differing Social Environments  
            Although this paper has called attention to resonances between a cult-like psychotherapy and a cult-like religious system, these two phenomena cannot be argued to be identical. Psychotherapeutic cults and religious cults (assuming that both exist) operate under very different social pressures and are thus forced to behave differently in related ways.
Religious leaders need not be licensed or conform with specific guidelines or messages unless they belong to established groups that ordain clergy who are to teach agreed-upon dogma. Religious leaders may volunteer their services or may be paid a salary by a congregation, but generally do not perform fee-for-service work in the usual sense.  There is no pressure for leaders of religious cults to state their conformity with the beliefs of established groups; on the contrary, their positions may be strengthened by clear antagonism to conventional beliefs and practices. There is thus little beyond the opinions of group members to encourage the group to resemble established religious systems.
Psychotherapists, on the other hand, cannot ordinarily practice, advertise, or identify themselves as such without some degree of approval of the larger society. That approval is generally based on the approval of established professional groups that work to the benefit of conventional belief systems and practices. Although there are some states in which unlicensed psychotherapists have practiced, alone or under the direction of another practitioner, licensure is a common requirement and is based on meeting conventional standards of education and training. Unless the unlicensed practitioner can find a licensed individual to handle billing and other arrangements, he or she will be unable to receive third-party payment. Without the salary that a religious leader often receives, the unlicensed AP practitioner may be unable to make a living unless he or she can convince potential fee-paying clients of the efficacy of the treatment. To accomplish this involves a high level of information management. In the present era of emphasis on evidence-based treatment, AP practitioners make claims about the way their treatment “works” and count on the inability of the client to understand the systematic evidence required to make such claims (Mercer, Pennington, Pignotti, & Rosa, 2009).
AP practitioners also provide rationales for their practices that allude to respected psychological authors whose theories are foundational to conventional approaches; for instance, AT proponents frequently reference John Bowlby, the originator of attachment theory, even though the AT concept of attachment is quite different from that proposed by Bowlby (see www.attach.org for examples). AP practitioners recognize current assumptions in conventional psychotherapy and attempt to position their treatments either in contradiction or in compliance with them. In AT circles, for example, authors in the 1990s argued against the conventional child psychotherapy dictum of “following the child’s lead” and declared that such practices would exacerbate childhood mental illness. Following the death of Candace Newmaker and the repositioning of AT thinking, AT authors have responded to guidelines requiring informed consent of clients to treatment by claiming that children are always asked if they agree to being held, a claim that ignores the conventional view that children are in fact not capable of informed consent, and that bypasses the more important requirement that parents and guardians must be fully informed of risks and benefits before giving their consent to treatment. Some AP proponents have addressed their practical need to appear in conformity with conventional practices by insisting that professional journals were unfairly excluding submitted papers; in 2001, the editor of the Journal of Clinical Psychology permitted non-reviewed publication of papers about the AP Thought Field Therapy (Callahan, 2001) in order to show openness on this point.
These practical issues may conceal the resemblances of the religious and the psychotherapeutic groups to each other, and their sharing of cult-like characteristics. Nevertheless, as this paper has shown, the two belief systems examined here have much in common. The same may be true of other cult-like religious and psychotherapeutic groups, but in order to determine this it is probably necessary to compare the details of  specific groups with each other rather than attempting a broad comparison of  all groups of each type.

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