Monday, March 10, 2014

Satanic Ritualistic Abuse - Revisited?

Mickey Nardo, MD on his 1 BoringOldMan blog has been writing a lot about the issue of satanic ritualistic abuse or SRA as it has been abbreviated.  His key reference is an article in the Psychiatric Times by Richard Noll, PhD entitled When Psychiatry Battled the Devil.  Dr. Nardo details the fact that the original paper by Noll has been pulled apparently out of concerns about litigation.   I luckily printed it out and will add a different perspective to Dr. Noll's invitation to discuss the moral panic.

It was about 1989 and the era of satanic ritualistic abuse was born.  I was in the middle of running a public health clinic on the northern fringe of the United States at the time and did not see any cases until I moved south to the Twin Cities (Minneapolis-St. Paul, MN).  Showalter documents how the stories spread in the media until there was a fairly standard description of women "... forced to kill and eat babies at satanic ceremonies, about seeing children dismembered boiled an burned, about being drugged, tortured with cattle prods, branded with branding irons, raped with crucifixes and animal carcasses....." (p. 172).  As the stories intensified prosecutions occurred in some areas based on these stories.   After all, the alleged magnitude of these rituals would have left a significant amount of eye-witness and physical evidence.  But it turned out that was never found.  There were parallel phenomena of false prosecutions based on these accusations and ultimately malpractice cases against therapists making the diagnosis and proceeding with treatment on the basis of traumatic events that had never occurred and seemed to be introduced as a result of the therapy.

I started to see the initial traces of the multiple personality epidemic at my new job, and recall two distinct reactions from psychiatrists involved with these folks.  But before I get into that, a little background about psychiatric interviewing is in order.  In this era of rapid checklist diagnoses, it may be difficult to believe that psychiatrists are actually trained to interview people and question what they hear.  The questions naturally come up for a number of reasons.  The first has to do with how accurate the patient seems to be able to recall the history.  That leads to associated questions about any inability to recall the history. The second has to do with common distortions that patients have in their perception of reality.  Those distortions may occur at a neurotic or a psychotic level of consciousness.  In the initial interview the focus is on understanding the patient's mental state to the point that if it was repeated back to the person they would agree with the interpretation.  That interview process can be interrupted for any number of reasons along the way, ranging from cognitive disorganization to paranoid psychosis and aggressive behavior.  It is important to keep in mind that the interview is a dynamic process that has elements far beyond a checklist or list of symptoms in DSM-5.  Reading about confabulation is not the same thing as having assessed hundreds of patients with that problem.  That assessment flows from the initial question in the mind of the psychiatrist: "Is this confabulation?' and noting all of the features in the interview situation to support or refute that question.

Of the psychiatrists I was affiliated with at the time, a few believed that there was such a diagnostic entity as dissociative identity disorder but the majority (as in >90%) did not.  The psychiatric literature as early as 1988 doubted the existence of the disorder and suggested that it was iatrogenic. I can recall a journal club discussion we had about a British Journal of Psychiatry article that was not only skeptical of the diagnosis but suggested that it was iatrogenic.  It seemed like a geographically based movement and in order to make the diagnoses and treat people you had to be trained by very specific people.  Even though the diagnostic criteria were fairly straightforward it seemed like you needed the attend the appropriate seminars in order to make the diagnosis.  You definitely did if you expected to proceed with treatment and even then it was unclear about how much additional training was necessary.  I had the impression that most people affected had moderate to severe personality disorders and they could be approached using standard techniques.  That approach was highly successful in stabilizing people in acute care and transitioning them to outpatient settings.  The diagnosis could be reinforced by the time patients presented to a tertiary care center.  Any hint of skepticism on the part of the attending physician could precipitate intense reactions if the patients thought they were not believed.  That usually threatened any therapeutic relationship, created staff splitting, and great pressure on psychiatrists to accept the diagnosis and whatever the current treatment plan was at the time.  There was also the novelty of the diagnosis that held a certain fascination for anyone who could not see that there was more heat than light.

At the time I was dutifully reading volumes of the Annual Review of Psychiatry and completing the CME questions.  Volume 10 had an entire section on Dissociative Disorders with some optimistic introductory lines (p 143):

"Dissociation is here to stay.  The chapters that follow indicate there is a growing body of clinical observation and research documenting the prevalence, phenomenology, psychophysiology, and treatment of dissociation."  

What happened instead was a flattening of publications as indicated by this Microsoft academic search and the end of a specialty journal (click to enlarge)

Despite the solid review that SRA  probably did not exist, some bizarre reports began to surface.  According to Elaine Showalter's book  Hystories: hysterical epidemics and modern media:

"....almost half the patients.......were "reporting vividly detailed memories of cannibalistic revels and extensive experiences such as being used by cults during adolescence as serial baby breeders for ritual sacrifices."

My position on the subject has always been the position quoted by Elaine Showalter in her excellent book Hystories: hysterical epidemics and modern media.  That position is all of these events never happened.  But I took it one step further.  Near the end of the decade, I contacted the author to see if she had any updated information.  She did not and so I put in a Freedom of Information Act request for all of the information suggested in the book - specifically the results of of the investigations by Kenneth V. Lanning, then Special Agent of the FBI Behavioral Science Unit in Quantico, Virginia.  I have previously listed problems with FOIA requests to the FBI and this was no exception.  I was looking for the results of 300 case investigations that were all negative.  After sending in the request through proper channels I was told that the information did not exist.  In the 2000s, that  report surfaced on the Internet, but it is still difficult to find a reliable copy.

I invite any reader to place themselves in the position of interviewing a person making claims, like the statements made in paragraph two of this post.  Keep in mind that these patients are generally talking about local geography that everyone is aware of and the descriptions involve fairly massive abuse and homicide of large numbers of people.  Even an untrained interviewer should have a degree of skepticism based on the fact that there have not been large numbers of missing persons and when these reports invariably get to local law enforcement, no hard evidence of a crime can be found.  The reports did create considerable confusion among family members, prosecuting attorneys, inpatient staff and some psychiatrists but in the end even the psychiatrists who thought the SRA phenomenon was real realized that it was a distortion.

In answer to the idea that this era needs to be "reopened" I guess it depends on the intent.  If the intent to illustrate once again that some or all psychiatrists are fools - there is more than enough propaganda out there already for the detractors of psychiatry to use.  My perspective is that not only were the vast majority of psychiatrists not fooled by this phenomena there were articles at the time accurately describing the problem as a non-specific diagnosis and an iatrogenic problem and what to do about it.  I would also question the applicability of the term moral panic.  The phrase seems a bit too strong.  It could apply in very small areas, but the majority of people in any community were generally unaware of the stories that were being told to psychiatrists in that era.  If people were aware there would have been a larger buzz created by the media asking clinicians for examples and an analysis of the event.  I suppose it would have been interesting to see what the local investigative news team found out if they were directed to a site where ritualistic abuse was alleged to have occurred.  I would also not forget that in the majority of cases there were no attempted prosecutions.  I think the moral panic was forgotten because for most people it was under their radar rather than a cataclysmic event like the Influenza Pandemic of 1918 where people were dropping dead in the streets.  There were also psychiatrists at the time who investigated the issue of repression and false memory syndrome and became an asset to families affected by the hysteria.  I would Showalter's book for a good discussion of the cultural determinants of the problem (there were many).  If the suggestion is to reopen the issue with the appropriate perspective that it was a controversial and erroneous phenomenon that in some cases hurt individuals and families rather than a moral panic, that mistakes were made, and for the purpose of teaching appropriate evaluations and interviewing technique, then I am all for it.  In addition to diagnostic issues, the area of dissociation and trauma in general also have treatment implications.  Psychiatric residents need to know how to plan and conduct therapy on affected individuals, particularly since the main part of that treatment does not involve medications.  They also need to know how to interview people without introducing artifacts as part of the interview process.

If the Psychiatric Times has pulled the original article, it probably makes sense to write a book or a review article for a journal less concerned about litigation.  There are a number of public access online journals that I am sure would be willing to publish the article and probably consider a theme issue on the topic.

George Dawson, MD, DFAPA

Elaine Showalter.  Hystories: hysterical epidemics and modern media.  Columbia University Press.  New York, 1997.

Merskey H. Multiple personality disorder and false memory syndrome. Br J Psychiatry. 1995 Mar;166(3):281-3. PubMed PMID: 7788115.

Piper A Jr. Multiple personality disorder. Br J Psychiatry. 1994 May;164(5):600-12. Review. PubMed PMID: 7921709.

Supplementary 1:

From Merskey 20 years ago:

"It has been all right to treat patients on the basis of dynamic notions of repression so long as the concept was only one which was exchanged between therapist and patient and merely served to revise, in a positive fashion, the patient's view of himself or herself in the world. Using repression as an idea which works to the detriment of other people, disrupts families, wipes out the life savings of parents, abolishes their contact with children and grandchildren, and embroils some in painful legal battles, is another matter altogether and not compatible with the old principle "first do no harm"."

From  Piper 20 years ago:

"However, there is a profound difference between standard psychiatric interview procedures -where practitioners take great care not to bias patients' reports-and the techniques and treatment espoused by the leading contributors in the MPD field.  It is absurd to maintain that those techniques are not vehicles of grossly overt suggestion to patients.  It is equally absurd to believe that in any other branch of psychiatry, one would see a clinician prodding a schizophrenic patient to produce more voices, or taking part in a 4 hour interview with a patient who might possibly be bulimic to suggest more frequent binging."

Supplementary 2:   To this day I have not been able to locate a copy on any FBI report describing the investigation of 300 case reports of alleged SRA  activity.  My FOIA experience with the FBI is very negative and it is clear to me that if they don't want to give you information you will not get it.  If anyone has this report consider sending me a copy.

Supplementary 3:  The Psychiatric Times decided to publish an edited version of Nolls original article today.  That is certainly the preferable course.  Their rationale:

"Editorial Note: In light of the responses we have received regarding this article by Richard Noll, PhD, that was posted on our website on December 6, 2013, the article has been reposted with a modification. Additionally, we are posting responses from certain of the individuals mentioned in the article and from Dr. Noll in order to leave analysis of the article up to our readers"


  1. Your point about psychiatrists interviewing patients with an ear towards holes in the story or conflusion in the patient is sooooo important. Symptom checklists are completely devoid of follow up questions.

    Your statement "psychiatrists are actually trained to interview people and question what they hear" is unfortunately becoming less and less true in residency training programs, where dogma has at times been substituted. A few years back I personally heard the training director at Wash U, biopsych central, complain about the ACGME requirement that 5 types of psychotherapy be taught in programs, suggesting in so many words that the entire endeavor of actually listening to patients should be relegated to the dark ages like the use of leeches or something.

    Stories about patients making up stuff can cut both ways, however.

    On a panel about the prevalence of child sexual abuse at the APA annual meeting a few years back, an "expert" pointed to the obvious nonsense concerning SRA and even reports of alien abduction to make the case that adults coming forward with accusations of having been molested as children when no such abuse had ever been "reported" at the time it occurred were all basically liars. Of course, the entire Catholic Church sex abuse scandal started with a case of "recovered" memory. And there was also a good study in the Journal of Consulting and Clinical Psychology in which young kids who had been proven beyond all doubt to have been molested at the time of the molestation (like with sperm in them) were interviewed as adults. A sizable proportion of the sample claimed not to recall any abuse, or even having gone to the hospital!

    1. David - I would be very interested in getting the reference to the J Clin Consult Psychology if you have it handy.

      On the matter of interviewing, checklists are also devoid of the pattern matching and clustering of data that experts seem to use to diagnose problems. The MPD issue was further clouded by the direct introduction of material by the clinician as indicated in the quote from the article by Piper. Neutrality is also a tool that is often forgotten. At first appearance a checklist may appear neutral and objective - but not when the outcome is a psychiatric diagnosis based on insufficient evidence.

    2. Williams, Linda Meyer (1994). "Recall of childhood trauma: A prospective study of women's memory of childhood sexual abuse." JCCP 62 (6), 1167-1176.

  2. Dr. Allen,

    You make excellent points, and all are deeply concerning. However, isn't it blatantly obvious that the "expert" was outrageously misapplying anything learned from SRA? As I understand it, the claims of SRA had so much physical implausibility that I don't know why any rational law enforcement officer believed them or why any mental health worker in the future wouldn't investigate an individual case report of abuse based on anything from that phenomenon. Btw, I hope someone called the expert out on this when he spoke at the meeting.

    That it took a "recovered" memory to out the sexual abuse by priests is particularly disturbing, and it reminds me of the Penn State scandal. I am positive there were enough of those with perfectly functioning memories that were either not being listened to or shut down, to have brought the abuse to light earlier and prevented more victims.

    1. Hi not,

      Yes, that was actually my point - that the lack of validity of the comparison this SOB was making between the falsehood of SRA and alien abduction claims with claims of child abuse was obvious, and he was being disingenous at best.

      I tried to call him on it but of course he sidestepped the issue. I asked him if my patients who claimed not to remember ANYTHING from certain ages of their childhood (and I have had many patients make that claim) were all lying to me. His answer was, "Well of course you have to evaluate them." He then didn't let me ask a follow up question, quickly taking another question from the next person in line. (Obviously, I had ruled out dementia in these patients).

      Most people really do remember what happened to them, and are really saying "I don't want to think or talk about it" when they say "I have no memory." They lie to themselves as well as others about it. In reality, they are just afraid to come forward.

      Many of the Catholic children who were abused, for instance, had parents who idolized the very priests that molested them, so they kept their mouths shut. Speaking up would be like them mocking their parents' most cherished beliefs. So they tried to forget what happened.

      As soon as one guy went public, however, there was a huge outpouring of victims coming forward.

      Most trauma victims would LIKE to forget about it but can't. That's what PTSD is all about.

  3. Hi Dr. Allen,

    Thanks for your reply. I think I understood your point, especially when you stated that stories about patients making up stuff can cut both ways. I took it as a concern that reaction can swing back too far the other way, where patients won't be believed, and it is a valid concern.

    I apologize for not making my points very clear and I'll try again. The very fact that you have this concern, especially in relation to something so oddball as SRA, makes me angry, and not angry at you. I stated the obvious disconnect, meaning it is so obvious even to my untrained self, why wasn't everyone in the room with you at that meeting thinking the same thing you were thinking when the "expert" said what he did? And, if they were, why didn't at least one person say anything. Now that I know, I commend you on being that one person that called the "expert" out on his stupidity. I hope he is not still considered to be an expert on this subject, but I won't hang my hopes on that.

    For the second subject, I am well acquainted with why a victim doesn't speak up. When I was younger, I thought the line told to us girls about rape, that if you don't speak up then there will be other victims (with the implication that it would be your fault). was true. Now that I know what it involves, I don't condemn a victim in this way. What I was referring to in my first comment were others that were not victims that know about or suspect abuse and keep quiet.

    You are absolutely right to be concerned about patients being believed and I think it greatly impacts victims not saying anything. Which brings up a question about something you wrote. When the one guy went public and the others came out, wasn't the dynamic about not mocking their parents' beliefs still there? My gut tells me that if the victims thought that someone would have believed them and supported them in an accusation against someone as powerful and idolized as a priest, they would have said something, while still in their personal lives doing all they could to forget it. I think that many of us perceive that as a victim you are tainted twice.

    Please feel free to correct me if I got something wrong. I am trying to understand how the whole SRA thing happened, its impacts and how as a member of the public to not let it happen again. Those of you who are on the "front-lines" know more, and see more, then I do or could ever cope with, so I like to read your thoughts and learn from them; preferably before a time that I would be called on to deal with it in my own life. I sometimes think I drive Dr. Dawson a little crazy with this, yet he is a patient man and willing to be a sometimes mentor at least for now.

    1. Your question about why a lot of other people were able to come foreward once one person in the church abuse scandal did is a good one, but I can only speculate about the answer. Perhaps, as you suggest, having someone else come forward made them feel like they would be more credible. Or perhaps it was because, in the initial investigation after Frank Fitzgerald's accusation, Father Porter made some self-incriminating statements on a tape-recorded interview. Later on, he in fact pled guilty in court.

  4. Hey I've seen reports from psychiatrists that claim post concussive amnesia "I can't remember" and PTSD "I can't forget" from the same event.

  5. Psychiatric Times is pretty thin skinned in general. There's a retired psychiatrist who has a blog and basically writes like a 13-year old girl with a unicorn poster over her bed. His writing usually consists of whiney wish lists from the Federal Government without accountability, mandatory mental health screening, absurd articles about mass murders suggesting that more mental health funding or recognition of Asperger's as a disease would have stopped the Newton tragedy. There is a complete lack of editorial oversight and if you point out obvious factual errors, they accuse you of ad hominem attacks and in the next blog they whine about cyberbullying. I'm not sure I would read anything into a pulled Psych Times article except it being their oversensitivity issue. I don't think it's even fear of litigation, I think they just hate anything that's too provocative. A Socratic site for exchange of ideas it is not.

  6. Dr. O'Brien,

    You use wonderfully creative language. I can't speak to the conclusions drawn, but your description of Psychiatric Times, its content and their reactions, strikes me as very accurate as well as colorful.

  7. What is upsetting is that an excellent, scholarly, researched article like Dr. Noll's gets scrubbed while nonsensical aging hippie wish lists and rants based on falsehoods can't even get challenged on obvious factual errors.

    I don't like this idea that public debate on important subjects is somehow stifled by fear of lawsuits. If this is happening it needs to stop. If you are suing someone because you don't like how they've challenged your theory, I suggest that theory is probably weak and really deserves the onslaught. Otherwise it would stand on its own merit. Michael Mann is now suing critics because his hockey stick theory of global warming didn't pan out. If this is the future of science, we're going back to the Middle Ages.

    1. Well this is America. Any time I have read through statutes and laws that apply directly to me or my patients I am always impressed about how they are written to facilitate litigation. It is to the absurd point that I have heard attorneys advising physicians: "I would rather defend you for this rather than that." meaning that the civil risk is omnipresent and you are always potential cannon fodder.

      That said, some of the journal articles from 20 years ago and even recent articles are more strongly worded than the Noll article.