309.82 Cult and Ritual Trauma Disorder[1]

Diagnostic Features

Ritual abuse consists of traumatizing procedures that are conducted in a circumscribed or ceremonial manner. Such abuse may include the actual or simulated killing or mutilation of an animal, the actual or simulated killing or mutilation of a person, forced ingestion of real or simulated human body fluids, excrement or flesh, forced sexual activity, as well as acts involving severe physical pain or humiliation. Frequently, these abusive experiences employ real or staged features of deviant occult or religious practices, but this is not always the case. Some reports of this phenomenon indicate that the abuse may occur outdoors, in a residence, day care, laboratory or hospital setting as well as other locations. Ritual abuse may occur in a group setting, but occasionally it is perpetrated by an individual.

Associated Features and Disorders

Dissociation of identity is a feature of Cult and Ritual Trauma Disorder, and Dissociative Identity Disorder or Dissociative Disorder Not Otherwise Specified, are frequently concurrently diagnosed.

Features of Borderline Personality Disorder are also often exhibited and occasionally individuals with Cult and Ritual Trauma Disorder will also experience brief psychotic episodes, sometimes with auditory or visual hallucinations. More commonly these individuals experience or act out strong self-destructive urges including attempted or actual suicide and self-mutilation. Frequently there is a strong desire to injure the self in a manner that produces blood (e.g., "I have to see blood"). Sometimes the individual will report a desire to taste, touch, or smell their own blood. Chronic and unmodulated anger and sometimes rage alternate with other mood states to create the impression that the individual is unpredictable in mood and unable to manage anger. Strong feelings of dependency alternate with social aloofness. Narcissism and self-hatred are frequently experienced separately and together.

In children (in addition to the above) motoric hyperactivity, impulsivity and problems in attention and concentration are seen at a rate which exceeds the baseline for children without psychiatric disorders.

Associated laboratory findings. Individuals with Cult and Ritual Trauma Disorder typically show evidence of psychological trauma and dissociation on psychological testing.

Associated physical examination findings and general medical conditions. There may be scars from self-inflicted injuries or physical abuse. Somatic symptoms with or without objective medical findings typically include headaches, gastrointestinal, and genito-urinary complaints, but other reports of physical pain may be present. In some cases, physical pain will not reflect a current injury but will be a psychological component of implicit memories (e.g., "body memories") associated with previous abuse. These individuals also frequently show evidence of mild neuropsychological impairment that in some cases may result from a history of head trauma. Others have argued that psychological trauma in childhood may cause mild neuropsychological deficits in some individuals (e.g., van der Kolk, 1987) but further research is needed to clarify this question.

Prevalence

Course

Familial Pattern

Differential Diagnosis

Diagnostic criteria for 309.82

Cult and Ritual Trauma Disorder

1. The presence of clinically significant distress or functional impairment with either (1) or (2):
   1. disturbing or intrusive recollections of abuse.
   2. involuntary dissociated mental states consisting of at least one of the following:
      1. dissociated alter identities
      2. involuntary trance states
      3. automatisms
      4. catalepsy
      5. stupor, coma or coma-like states
2. The disturbance described in A is the result of ritual (circumscribed or ceremonial) abuse.
3. The disturbance described in A cannot be better accounted for by Delusional Disorder or another psychotic disorder in which delusions are present, Malingering or Factitious Disorder or as a consequence of the patient's suggestibility.

A patient claimed that she had been sexually assaulted by someone gaining access to her second floor bedroom via a window. The patient's house-mates denied the possibility that the patient could have been assaulted in such a manner and within the time-frame as she reported it since the house-mates were at home during the times the patient reported the attacks, and the bedroom was inaccessible from the outside. The patient held firm in her beliefs that she was being continually revictimized until she came to recognize that she was actually experiencing vivid recall of what she believed to be past experiences.

One of the most disturbing observations regarding the language of ritual abuse that has been developed thus far is that the language applied to such experiences has come almost exclusively from the survivor and backlash communities. The survivor community has provided such terminology[2] as "ritual abuse," "programming," "triggering," and "accessing." The backlash community has contributed such terms as "recovered memory therapy," "false memory syndrome," and "parental alienation syndrome," although these terms do not apply exclusively to the area of ritual abuse. The treatment community has been dangerously reactive and passive with respect to both their patient's claims and the assault on their professions by backlash organizations. It has become commonplace for the media to report on unethical practices by "recovered memory therapists" who routinely destroy families by implanting false memories of horrific experiences. The media, television, radio and print journalism, serves as both arbiter and catalyst for the ongoing debate regarding the veracity of ritual abuse allegations and claims of recalled accounts of childhood abuse. Unfortunately, the media appears to uncritically accept and promulgate the version promoted by the most effective lobby, regardless of evidence in its support. Terms such as "recovered memory therapy," "false memory syndrome," and "parental alienation syndrome," permeate the scanty literature on modern day accounts of ritual abuse.

Kenneth Lanning, an agent of the Federal Bureau of Investigation, authored the monograph, Investigator's Guide to Allegations of "Ritual" Child Abuse, in which he wrote, "There is little or no evidence for . . . organized satanic conspiracies," (1992, p.40.) Individuals and organizations taking the position that ritual abuse allegations are false have subsequently adapted this claim. It is interesting to note that from the time of its creation in 1908, the FBI was invested with the investigation and prosecution of the elusive Mafia, to which a large portion of crimes ranging from extortion, to gambling, to bootlegging, to murder were attributed. Because of an extensive and effective lobby by a coalition of Italian-American advocacy groups and other individuals and organizations, the FBI was unable to substantiate the existence of the Mafia until 1989, when a Mafia initiation ceremony was audio-taped by undercover agents. Previously, in order to facilitate prosecutions despite its inability to specifically identify a criminal entity called the Mafia, the FBI broadened its focus by targeting "organized crime" as its primary agenda. This raises the question of why, when there are thousands of individuals alleging ritual abuse, some of which has resulted in arrests, confessions, criminal convictions[3] and civil litigation, the FBI, or specifically Agent Lanning, clings to the position that there is no evidence of widespread satanic ritual abuse. In truth, there may be no evidence of an "organized satanic conspiracy," but there is all manner of evidence in support of crimes against people and property that have occultic or ritualistic elements[4]. If the FBI could alter its language in order to justify its investigations into the Mafia, it seems a small thing to reconsider the terminology it applies to investigations of crimes that contain ritualistic elements.

Considering the history of crimes against children and the traditional denial with which society has responded to such allegations, it is not surprising that reports of ritual abuse against children and others are frequently discounted. There appears to be a greater societal interest in protecting the illusion that our children are safe, that families are inherently good and decent, and that danger comes infrequently and only then at the hands of demented strangers. In reality, most individuals reporting histories of ritual abuse allege that the abuse occurred within the family. And while there are periodic reminders that families do not always protect their own children and may, in fact, represent the greatest threat to their child's safety and life, it is evidently too painful for the public to accept the probability that some children are regularly and deliberately abused within their family unit. Nevertheless, this is a harsh reality we must all be willing to face if we are ever to be able to fully protect children or to comprehend and address the sequelae of such abuses.

Several years ago, I was contacted by a woman in another state requesting advice regarding her four foster children, siblings who had been removed from their family of origin by the state due to chronic abuse and neglect. These children, ranging in age from 18 months to five years, demonstrated extremely maladaptive behaviors. They had poor vocabulary and limited capacity to communicate. They had no apparent experience with modern plumbing. They could not identify or manipulate eating utensils. They were fearful of water, certain foods, and the night. The children were violent with each other and other people. They had uncontrollable rages without apparent cause. They were all sexually self-abusive. Upon physical examination, all four children were diagnosed with genital herpes. The boys suffered from impacted bowels and scarring of their rectums. All four children had scars all over their bodies, most of which appeared to have been the result of deliberate injury. The three older children talked about being tortured by people in black robes.

None of this information had been revealed by the Department of Social Services caseworkers responsible for transferring the children's care from the state to the foster family. The foster parents were frightened, anxious, concerned and confused. They wanted to help these extremely needy children, but were at a loss as to how to accomplish this. They contacted me in my capacity as executive director of the International Council on Cultism and Ritual Trauma to obtain information about ritual abuse and to gain some insight into its effects. This telephone conversation evolved into several more between the foster family and myself and eventually, I was able to assist the family in obtaining consultation from my co-author, psychologist James Randall Noblitt, who has had extensive experience in the area of evaluating and treating individuals with ritually abusive backgrounds. Dr. Noblitt and I visited the family, interviewed everyone involved including the foster family, DHS caseworkers and administrators, and ancillary helping professionals. Dr. Noblitt evaluated the children and reviewed the records of their previous therapists. I researched the children's histories, the manner in which they came to the attention of DHS caseworkers and the mechanisms by which their care was being funded by the state. What our investigations revealed was evidence of a conspiracy designed to shield various county and state agencies from liability for negligence and fraud.

A review of the family history revealed that the children's mother had been the subject of investigations by the DHS as a victim of child abuse and neglect perpetrated against her by her parents. This child was evaluated by a DHS staff psychologist who diagnosed her as marginally retarded and disoriented to person, place and time. His notes from his meeting with her reflect her report of hearing voices in her head that directed her behavior. She was under DHS supervision when she became pregnant with her first child at age 15. Between the ages of 15 and 20, this young woman had four children from four different fathers, at least one of whom is likely to have been a close family member. Despite this young girl's age and legal status at the time of her first pregnancy, no intervention was made on her behalf to educate her in either birth control or child care, or to assist her in improving her living situation. This young woman continued to reside in the home of her parents along with her children, exposing this new generation to the same neglectful and abusive environment in which she was raised. DHS caseworkers did continue to observe the family and did intervene on the children's behalf as they observed neglectful conditions, including lice infestation in all the children, malnourishment, unhygienic conditions, etc. The children were removed from the mother's custody on two occasions during which they were placed in foster care while an effort was made to educate the mother in order to repatriate the children. These attempts failed and the mother's parental rights were finally terminated, at which time the children were placed with their third foster family, who had an interest in adoption.

The children's bizarre behaviors led to psychiatric hospitalizations and placement with therapists in the community to pursue outpatient psychotherapy. During the course of their therapy, the children revealed more and more details of abuse, including sexual abuse in their second foster home and in their family of origin. However, the three therapists engaged in these children's care never made a report to law enforcement as mandated child abuse reporters. Furthermore, the therapists appeared unqualified to address the children's behaviors and emotional distress and the children subsequently deteriorated under their care. When the foster parents repeatedly complained about the failure of these mental health professionals to address the children's reports, the therapists were asked to resign from the case by a supervising psychologist contracted by DHS to supervise distribution of services. The therapists subsequently wrote a letter of termination in which they blamed the children's symptoms and deterioration on the foster mother's overprotective position.

The children required additional supervision by paraprofessionals called High Risk Interventionists (HRI). The HMO charged with the administration and dispersal of Medicaid funds funded the children's psychotherapy and high-risk interventionists. Our investigations revealed that this HMO also operated the HRI program and in effect, subcontracted the children's care to their own agency resulting in hundreds of thousands of dollars paid to itself. In the meantime, few of the dollars allocated to the foster family and the children were actually delivered. Furthermore, the case supervisor employed by the HMO was the same psychologist who years before had worked for DHS and had been the professional who evaluated the children's biological mother.

What we learned is that the professionals involved in the care of the children were motivated more by self-interest than in concern for the well being of the children. In the meantime, the foster parents engaged in a concerted effort at recognizing and understanding their charges' psychological, emotional, physical and educational concerns and succeeded in creating a highly effective integrated program to address these concerns. Now, several years have passed and the children have been adopted by their foster family. But the effort to provide for these children's therapy and safety needs continues to be a struggle between the adoptive parents and the county and state agencies controlling their funding. And for this, we would have to ask, "Why?"

Why is there so much resistance to assisting these and other child victims? Why is there such a contentious environment when victims, children and adults abused as children, make an outcry? What motivates individuals to organize into lobbying groups with the intended purpose of impeaching the testimony of abuse victims and vilifying their advocates? What are the politics behind such machinations? There are several possible answers to explain this disturbing trend. One possibility is that there is truly a conspiracy of individuals and groups who perpetrate against children and other vulnerable people using ritual abuse as a mechanism of control and containment. Some of these individuals are likely to have infiltrated various areas of society including child protection, the court system, law enforcement, government, military, the media, etc., resulting in a vast cover-up. A second possibility could be that the reality that children are being systematically tortured and betrayed by their families and trusted others is so frightening and painful to the majority of people that they are in denial of this possibility. And in order to accommodate the accounts that allege that such things can and do happen, society has "killed the messenger" by blaming the epidemic of reports of child abuse on the mental health professionals and child advocates who attempt to intervene.

The resulting attack on mental health professionals has been devastating to both the profession and to individuals desperately in need of psychological services. Therapists under constant threat of litigation have been forced to amend their treatment style and even the manner in which they document patient claims. For example, in the interest of protecting patients from potential harm by recording claims that could be self-incriminating if records were subpoenaed, therapists routinely made vague or sketchy notes, interpretable only by themselves. Now, to protect their own professional status, therapists are taking a more self-protective stance. Fewer hospitals are providing inpatient programs that address the special needs of this patient population, increasing the danger to patients and society. In response to growing allegations against mental health professionals, licensing boards are altering and adjusting rules of practice. As a consequence of civil suits brought against therapists for "implanting false memories" of abuse, malpractice insurance carriers are increasingly limiting coverage for the treatment of certain types of psychological disorders. Consequently, fewer mental health professionals are willing to see patients alleging ritually abusive experiences or demonstrating symptoms of dissociative disorders.

What is clear is that something is happening that results in sometimes disabling psychological illness that impacts on the individual, the family, and society. How we respond to the resultant crisis is a measure of our collective character. Will we ignore the outcries of people in pain in order to embrace the comfort of denial? Or will we confront our worst nightmare, acknowledging the worst threat to children may be our own reluctance to admit that the dark secrets of our ancestors survive today?

Bibliography / References

• Gardner, R.A. (1991). Sex abuse hysteria: Salem witch trials revisited.
• Cresskill, NJ: Creative Therapeutics.
• Goldstein, E. (1992). Confabulations: Creating false memories, destroying families. Boca Raton, FL: SIRS Books.
• Kahaner, L. (1988). Cults that kill: Probing the underworld of occult crime. New York: Warner Books.
• Lanning, K.V. (1992). Investigator's guide to allegations of "ritual" child abuse.
• Quantico, VA: National Center for the Analysis of Violent Crime.
• Newton, M. (1993). Raising hell: An encyclopedia of devil worship and Satanic crime. New York: Avon Books.
• Noblitt, J.R. (1998). Accessing dissociated mental states. [Self-published monograph available through the Center for Counseling and Psychological Services, P.C., PO Box 820729, Dallas, TX 75382].
• Noblitt, J.R., & Perskin, P.S. (1995). Cult and ritual abuse: Its history, anthropology and recent discovery in contemporary America. Westport, CT: Praeger Publishers.
• Noblitt, J.R., & Perskin, P.S. (2000). Cult and ritual abuse: Its history, anthropology and recent discovery in contemporary America, revised edition. Westport, CT: Praeger Publishers.
• Ofshe, R., & Watters, E. (1994). Making monsters: False memories, psychotherapy and sexual hysteria. New York: Charles Scribner's Sons. for the Study of Multiple Personality and Dissociation, Chicago.
• Raschke, C.A. (1990). Painted black. New York: HarperCollins.
• Terry, M. (1987). The ultimate evil. Garden City, NY: Doubleday.
• Wassil-Grimm, C. (1995). Diagnosis for disaster. Woodstock, New York: The Overlook Press.
• Waterman, J., Kelly, R.J., Olivieri, M.K., McCord, J. (1993). Beyond the playground walls: Sexual abuse in preschools. New York: Guilford
• Yapko, M.D. (1994). Suggestions of abuse: True and false memories of childhood sexual trauma. New York: Simon & Schuster.

• [1] From Noblitt and Perskin (1995, 2000)
• [2] I have no objection to the terminology introduced by the survivor community. My concern is that the professional community has not generated adequate language to meet the requirements of science and law.
• [3] Newton, M.
• [4] Terry (1987), Raschke (1990), Newton (1993), Kahaner (1988).