Mental Illness and Danger: The Data

Yet again, Neuroskeptic delivers well vetted empirical data on topic and, as if, on cue.  In this case a massive study in Australia exploring the statistical links between crime and mental illness.

Mental Illness and Crime, Yet Again

Mental Health or Gun Control?

[accidentally deleted this post, so I'm reposting]

Public discourse, political, media, whatever, likes to frame things in dichotomies, false or otherwise.  No wonder that in the wake of yet another tragedy we seem to hear we have a choice with two options.  Limit access to military style weaponry or provide more mental health services.

I don't like forced choice questions.  Usually makes me feel like I'm being railroaded.  Usually is the case too.

Just a few thoughts on the mental health side of the equation.  People on both, or all, sides of the political spectrum are generally supportive of increased mental health services when something like this happens, but few people are aware of what that means or the issues involved.

Here is just an outline of a few things people should be aware of.

• Not every mental health problem can be resolved by talk therapy (an understatement)
• Not every mental health problem can be resolved by medication (another understatement)
• Except under very legally circumscribed circumstances, we, as a society, cannot make people visit and talk to a therapist.
• Even where we can legally compel someone to see a therapist, we can't compel individuals to care or to want to change or to benefit from therapy they don't want.
• Likewise, we cannot compel most people to take medications even if we think they are very not sane.
• When we can compel someone to take medications, it may not actually help much, and may have severe repercussions for the individual (side effects up to and including death, psychological and physical trauma from restraints and forced injections).
• Civil commitment laws (or interpretation of them) have drifted toward the individual liberty side of the equation.  This is in no small degree a result of historical abuses in the mental health system.  It likely also reflects shifts in the overall sociopolitical zeitgeist.
• We generally cannot civilly commit, and thus compel treatment and seclusion, unless someone has already engaged violently or they have made credible threats.  There are times when individuals with mental health problems plan violent actions and choose not to broadcast their intentions to mental health professionals.  In these cases it is very hard to predict and even where we have concerns there is often very little we can do.

This continues to be the state of the field when it comes to extreme mental states and available interventions

It saddens me deeply every time I talk to some parent who has come to me believing I will be able to intervene with their adult son or daughter with a psychiatric disability and I see the relentless disappointment on their faces as I explain to them the limitations of what we can do to intervene with an adult who does not want help.

Just so everyone knows.  Increasing availability of mental health support may be a good thing and it may help, but it will never be a complete solution to protect us and our children from rampages and violence.

addendum -- Oregon is now looking at increasing civil commitment from six months to two years after a Eugene police officer was gunned down by a woman in a psychotic and paranoid mental state.  I happen to think this is the wrong approach.  Lengthening commitment would have made no difference to the death of the officer.  The real rub is what it takes to place a hold and then commit someone.  If the legislators want to make a difference, they will need to look at that issue instead.

A Buffet of Childhood Diagnoses

I just want to promote this very good post on Neuroskeptic on the North American epidemic of diagnosing young children with the adult disorder of Bipolar and the American Psychiatric Association's attempt to fight this problem by writing yet another childhood disorder into the DSM-V.

Psychiatrists: Does Fire Put Out Fire?

What is it about North America that we want to believe all our children are mentally sick?

Dissociation, DID, Culture, and Empirical Evidence

Dissociation is some kind of human phenomenon that crosses time and place in the human experience.  Most forms of dissociation occur in the context of religious ecstasy.  There are many many examples.  Umbanda in Brazil.  Indigenous Taiwanese healers.  Balinese ritual trance (people have been know to go into spontaneous trance states even working in factories in Indonesia).  Pentecostal direct experiences with the Holy Spirit.  Speaking in tongues.

The list goes on.  But, we find that dissociation manifests differently in different cultural contexts.

Dissociation itself is not what is in question, but Dissociative Identity Disorder (DID), previously known as multiple personalities, is.

In North American culture, dissociation generally manifests, if not in a tent revival, than in the context of hypnosis or with the patients of certain therapists with proclivities for the promotion of DID.

Does DID occur universally or is it a product of the North American culture of psychopathology?  We already know that mental health disorders can be a product of cultural place and time.  Hysteria in Victorian Europe and America is one well known example.  Neurasthenia in China is another example that has been written on extensively.

Is DID another disorder that is not universal but tied to the Zeitgeist of a particular place an time?  Right now the field of mental health is in an intellectual tug of war on the topic.  We have the historical record that gives us some insight.  The concept of multiple personalities appeared early on in the development of the field of psychology, but it was an extremely rare diagnosis up to a certain point.  That point was the publication of "Sybil" in 1973 and the subsequent film adaptation.  This was the story of Shirley Mason, AKA Sybil Dorsett, who claimed to have multiple personalities, (and later said she made the whole thing up to please her therapist, and then changed her mind again).  After the popularization of multiple personalities by "Sybil" it became a mainstream diagnosis and has benefited from several waves of popularity since.

Sally Field acting

Shirley in youth

"Sybil" acting?

Dr. Richard J. McNally, et al., has now provided us with an empirical window on the topic.  He crafted a controlled study to test a fundamental basis of the DID construct, the amnesic barrier.  The amnesic barrier being the concept that as a DID identified individual transitions from personality to personality, the one personality has no direct memory of the other personality or personalities.

These researchers used a concealed information task that consisted of flashed words on a screen in which subjects were instructed to push "yes" or "no" based on whether or not the word was on a list.  What DID identified subjects did not know is that some of the words flashed on the screen were taken from surveys conducted with at least two of each of their personalities.  The words were specific to the personalities, such as the name of a friend or a favorite food, for instance.

The crux of the study was on a microsecond lag in pressing the button related to words autobiographical to the personality.  This occurred as expected.  Unfortunately for the construct of DID, the same delay occurred for words related to alternate personalities (not currently present/aware personalities), showing that knowledge crosses alternate personalities, undermining if not disproving the amnesic barrier.  It also implies, if not deception, at least an attempt on the part of the subjects to conform to the cultural model of DID.

McNally concludes that "Cultures provide envelopes for people to express suffering or psychological pain and DID is one such cultural trope. . . . I don't think much would be lost if the diagnosis were eliminated from the Diagnostic and Statistical Manual."

Source:  "A story that doesn't hold up" in the Harvard Gazette

Original paper is on PloS ONE here

DID in defense of crime: the case of William Bergen Greene and his therapist

William Bergen Greene was a troubled man who started with a troubled childhood.  He apparently suffered severe abuse as an early child until he was made a ward of the state at age eight.  He suffered further abuse in foster homes and institutions.  At age 17 he escaped from his institution and started his adult life of chronic criminality.  He was so frequently convicted of sexual offences that he spent the vast majority of his adult life in prison.  He remains incarcerated today in Washington State.

He became a prison sex offender patient after a 1988 conviction.  His prison sex offender therapist, known to the public only by the initials M.S. (because she later became another victim of Mr. Greene's many sex offenses), was the first to diagnose him with Dissociative Identity Disorder (DID) otherwise known as multiple personalities.

Her course of therapy started with hypnosis.  With this extremely questionable (if not negligent) technique she proceeded to draw out (or co-develop) some 24 personalities in her patient, not the least of whom were "Auto," a non-human robot personality, and "Smokey" the dragon.  Yes, a dragon personality.

Another therapist at the prison disagreed with M.S.'s diagnosis.  Instead he diagnosed Greene with Malingering.  Incidentally, malingering is listed and described in the psychiatric diagnostic manual and is designated with code V65.2.  V-codes generally indicate a diagnostically important factor or condition that is not itself a disorder.  Malingering, of course, is not a disorder that is treatable under Medicaid but is described as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives."  Typically, external incentives have to do with financial gain, or avoidance of responsibilities or consequences.  In this case, Greene was already convicted and incarcerated.  The dissenting therapist warned that Greene's malingering was motivated by his life-long pursuit of sexual victims.  He warned that Greene was setting his therapist, M.S., up for a future assault.  The dissenting therapist's assessment proved to be prophetic, but sadly failed to influence M.S.  Not only did she continue her work treating Greene's purported DID, she seemed to become increasingly close to her patient.

Greene was released from prison in 1992.  Within days of his release, M.S. quit her job at the prison and took Greene on as a private patient.

Was it coincidence that she quit immediately after his release?  I can't say, but it is suggestive of a therapist who was severely enmeshed with her patient.

She met him for therapy on a routine of bi-weekly sessions, but if so, they must have been extremely long sessions, because by the end, when he finally assaulted her in 1994, she had racked up over 2000 hours of therapy with this single patient.  By comparison, standard out-patient therapy is generally in the range of 12 to 54 hours of therapy per year.  Yet more evidence of enmeshment if not outright obsession on the part of the therapist.

M.S. received a phone call from a distressed Greene on April 29, 1994.  She knew he was under stress from several things and she was worried he might be suicidal, so she went to meet him at his apartment.  He was talking very slowly with a childlike voice.  He kept referring to himself as "we."  I will add here, the "royal we" is a common trait or affectation among DID patients and it seems unlikely it was the first time he used it in M.S.'s presence but later, in court, she would use it as one of the evidences of his personality fragmentation at the time of the crime.

At some point, as M.S. tried to console the oddly behaving Greene, alone with him in his apartment, she figured out that he was on cocaine.  In a moment of good judgment, she chose to leave.  Unfortunately for her, he barred her way out.  They struggled and M.S. fell.  He ripped off her shirt and bra and touched her, ignoring her protestations and clear statements for him to stop.  He took her to the bathroom and held her there for two hours.  He continued to molest her there, taking breaks only to shoot up a drug, presumably cocaine.  Throughout this incident, Greene's behaviors were later described by M.S. as childlike with frequent but brief bouts of crying. Near the end he removed his own pants and touched himself but failed to achieve a result and soon after said she could go, but when she tried, he changed him mind, tackling her and left her bound and gagged as he removed himself from the scene in M.S.'s car.

Once Greene had fled, M.S. was able to remove her bonds and escaped to a hospital across the street where she called the police.  Greene was soon apprehended and charged with kidnapping and indecent liberties.

Greene plead not guilty by reason of insanity, but in his first trial, Judge Thorpe ruled that DID could not be used in an insanity defense due to lack scientific consensus on the existence of the disorder.  The defense attorney, David Koch, was not permitted to even mention DID.  Greene himself assisted his defense attorney, telling his attorney that one of his alter personalities was trained in law.  Without DID as a defense, the case rested solely on whether or not Greene had committed the deeds.  He was quickly found guilty on both counts.

In 1998, Greene and Koch appealed to the Washington Court of Appeals.  Appeals continued back and forth up to the U.S. Ninth Circuit Court and, in the end, he was granted a retrial.

A pre-trial hearing was held to determine if DID could be used as an insanity defense.  The defense team brought in expert Dr. Robert B. Olsen who testified that DID was generally accepted in the field but conceded after interviewing Greene, he could not say who Greene really was much less determine his sanity due to the number of alter personalities.  The prosecution brought in their own expert, Gregg J. Gabliardi who failed to challenge DID, stating that he agreed it was generally accepted.  His only contribution to the prosecution was to testify that it would be impossible to determine the sanity of each separate personality or determine which personality was responsible for which of the actions Greene had taken.

This was clearly a low point in the field of psychiatry when two psychiatrists under oath fail to mention any controversy related to this diagnosis.  One wonders if Olsen or Gabliardi had in fact believed they could determine guilt and responsibility of one specific personality out of 15, what the criminal justice system would be expected to do with that information?  How do you incarcerate one personality out of many?

With the given experts, it is not surprising in the retrial the defense was allowed to use DID as an insanity defense to claim that Greene was not legally responsible for his actions.  He had two new public defenders in the second trial, Teresa Conlan and Marybeth Dingledy.  The second trial took place over five days in September 2003 in Snohomish County courthouse.

In one of the strangest twists in the history of DID being used to avoid truth and consequences, Greene's victim, his former therapist, the now 53-year-old M.S. demanded to testify in his defense.  In the retrial she was permitted to do so.  She claimed that only she could explain the impact of his terrible disorder, DID, on Greene and its role in causing his behavior on the night of his attack on her.  M.S. testified before the court that it was not Greene himself who had attacked her but actually three of his alter personalities:  Sam; Tyrone, a three or four year old; and Auto, a robot.  She explained to the jury it was not Greene, but Auto the robot who grabbed her and held her down.  It was not Greene who molested her for two hours, but Tyrone the child.  The personality Sam appeared for only a moment and tried to save her, but was quickly taken over by the other two personalities.  M.S. testified her belief that the chronic sex offender Greene was not responsible for the attack because he was not present during the attack and had no awareness of it until he was informed of it later when he was in police custody.

In an odd about face, the expert witness, Dr. Olsen, who had originally testified for the defense, switched sides and testified for the prosecution in the actual trial itself.  He now said he believed Greene was malingering.  In the trial, the prosecution also brought in a new expert witness, psychologist Richard Packard who testified that Greene did not have DID at all.  Packard diagnosed the chronic sex offender with antisocial (AKA psychopathic) personality disorder and a sexual paraphilia disorder.  Packard further stated his doubt about the veracity of DID as a legitimate disorder.  Packard firmly believed that Greene had simply been faking DID from the beginning.  Greene's cellmate, a certain Eric Fleischmann, testified that he too attempted to fake DID with Greene's coaching but had failed.

Defense witness, Dr. Marlene Streinberg, then vice president of the International Society for the Study of Dissociation, testified that DID was real and that Greene fit the profile.  In spite of Dr. Streinberg's rather weak assertions and in spite of the frantic testimony of an enmeshed and obsessed therapist, Greene lost his second trial and was again found guilty on both counts.  The jury deliberated for five hours and were done in time to go home for dinner.  Greene was sentenced to life as a three-strike felon

Now in prison, Greene has since been charged with the 1979 rape and murder of a 25 year old woman by the name of Sylvia Durante in Seattle.  Greene's DNA from his sperm was found on Ms. Durante's body.  He was convicted of her murder in 2005.

Not everybody is a believer in DID.  No matter how self important and self righteous the tone of its promoters like Streinberg, jurors, and most people with any level of critical thought or common sense, remain unconvinced.  Juror, Jim Camp, from Greene's retrial, stated the jury "just didn't believe it."

Sources:

Sullivan, Jennifer; Insanity defense fails for attacker; The Seattle Times; Nov. 21 2003; as viewed on web 8/2012. 

Fersch, Ellsworth; Thinking About the Insanity Defense: Answers to Frequently Asked Questions; iUniverse, Lincoln, NE: 2005

Multiple Personalities and Responsibility

Multiple Personalities, now known as Dissociative Identity Disorder (DID), is the single most controversial diagnosis in the diagnostic manual.  Most would agree with that statement I think.

One of the most bizarre aspects of this diagnosis and its promoters is the wish to have their cake and eat it too.  Let me give you a few examples of what I am talking about.  These are composite examples that have been slightly altered, not pertaining to any individual patient, but the comments attributed to therapists essentially express comments I have heard at one point or another.

Patient A signed a legal contract and later wanted to back out.  Patient A's therapist states, without any sign of misgiving or embarrassment: "People just don't understand that [Patient A]'s part [alternate personality] signed the contract and [Patient A] can't be held responsible."  Why is this having and eating cake simultaneously?  Well, let me explain.  Both the patient and the therapist believe and strongly advocate for Patient A's right to live and act in the community as a fully fledged adult citizen, and yet, they both want the world hold Patient A free of all agreements and obligations that Patient A has selectively decided some other personality inhabiting her body is responsible for.  This sort of undermines the basic social contract doesn't it?  Either Patient A is mentally competent to make agreements and sign contracts and be held responsible for her obligations, or if she really cannot competently sign contracts and be held responsible due to her psychiatric condition she should not be allowed to and her her therapist needs to be working to develop a legal guardian who can actually make binding decisions on behalf of Patient A who is apparently not competent to do so on her own.

Patient B is granted Social Security Disability for a psychiatric condition.  His primary diagnosis is DID.  He then enters university and goes through to complete a graduate program.  Throughout, he continues to receive monthly disability payments intended for individuals who are too disabled to work.  Both he and his therapist maintain that Patient B is both entitled to disability and able to legitimately complete a graduate program in the field of economics because his parts switch only when he is at the school and he can temporarily maintain his "host personality."  When returning home or out in the community he "switches" to different personalities and is therefore disabled.  After receiving his degree in economics, he continues to receive monthly disability payments and his therapist continues to be paid by Medicaid.  Patient B is both disabled and yet he is not.  It seems to me an ethical and competent therapist would be working with Patient B to utilize his graduate degree in a productive manner to his own personal and financial benefit.  Instead, the therapist continues to promote the idea that in spite of earning a graduate degree Patient B is too disabled to work and must continue in therapy indefinitely.  It may be no coincidence that if Patient B earns wage income, he will ultimately lose both Social Security Disability and Medicaid and the therapist's cash cow with dry up.

Patient C commits a felony crime of posing as a property owner (which she is not), collecting deposits and rents from multiple prospective renters and then flees the scene.  She spends the money on a car, clothing and a purebred Pomeranian dog for herself.  When tracked down by detectives and arrested, Patient C, her therapist and her defense lawyer all maintain that Patient C cannot be held responsible for the crime.  None of them dispute that her physical body was present at the time of the crime and in fact committed the crime, but they claim her body was inhabited by a personality who believed it was the property owner, therefore person/body of Patient C (the only legal and biological entity in this case) cannot be held responsible.  The "host personality" of Patient C cannot be held responsible because she was dissociated and was not aware of what occurred and had no control over it.  Furthermore, the "property owner" personality cannot be held responsible either because he/she/it really believed it was a property owner and did not realize it was committing a crime.  What does the therapist and defense attorney request?  That Patient C be freed and allowed to continue the same therapy (that failed to prevent her criminal behavior in the first place) because this is what Patient C "needs."

DID patients, therapists and promoters seem to have a problem with responsibility.  Basically they can disavow responsibility for anything with negative consequences for the patient/client/consumer but otherwise expect the world to treat the DID patient as a completely competent and responsible citizen.  Does that sound just a little too convenient?  Most jurors find it pretty fishy, that's why it almost never succeeds as a legal defense, but that doesn't stop people from trying.

Here are some interesting facts about DID and crime.  A small study published in 1989 (Putnum, Diagnosis and treatment of multiple personality disorder) found that 35% of female DID patients reported committing crimes including 7% of which were homicides and 47% of men with DID reported committing crimes of which 19% had committed homicide.

In the end, you can't have your cake and eat it too.

Why Does Norway Want Breivik to Be Insane?

Anders Breivik bombed downtown Oslo and went about methodically murdering 77 people and injuring many more.  In his recent trial that came to a close last month he calmly described how he did it and discussed with detached curiosity the victims' various reactions or lack of reactions to his attacks.  Throughout, he taunted family members, survivors and the world with what can only be described as a psychopathic sneer.

A sneer, micro or macro, is the universal expression of contempt

Is he insane?  This was the central question the recent trial revolved around.  Prosecutors want him to be insane, even though they now admit their doubt on the subject.  Prosecutor, Svein Holden, is quoted by the BBC as stating, "We are not convinced or certain that Breivik is insane but we are in doubt."  And yet, they continue to argue he should not be imprisoned but should instead be committed to a psychiatric institution.

Here, insane is more or less defined as psychotic.  Is he psychotic (insane) or psychopathic (sane but very very bad)?  That is the question.  Technically the defense is on a fool's mission to explain his actions as justified, but that is beyond absurd.  One wonders if the defense attorneys have undergone cognitive deficiency testing themselves--if not, perhaps they should.  While there is little if any evidence of actual psychosis there is a strong desire to place Breivik in that category, or maybe more to the point, to place him outside the categories of normal or sane.

Other than the fact that Norway has one of the most lenient and forgiving criminal justice systems on the planet, I know too little of that place and culture to fully understand their reasoning.  I can only surmise it gives some comfort to hold a belief that a man capable of doing what Breivik did cannot be normal or sane.  In a lay sense, what Breivik did makes him, by definition, insane.  This creates a safe psychological boundary between him and us.

It is an understandable sentiment, I'm sure.  But what does it say about a criminal justice system where prosecutors are not motivated by truth but by the outcome that makes them the most comfortable?

Can a man like Breivik be helped by psychiatric care?  If he were in fact psychotic, there are drugs that may (or may not) help.  Add some cognitive-behavioral whatnot and sometimes we see improvement, even dramatic improvement at times.  Conversely, if he is a straight up psychopath (as is likely the case), there is very little help possible if we want to be honest about it.

The Norwegian prosecutors fail to recognize the collateral impact of their strategy is to add more fear and stigma to the actual insane, the 1% or so of the world's population with a form of psychosis at some point in their lives.  Granted there have been plenty of psychotic shooters and killers over the years, and we may very well have experienced another one in Colorado just this month, but the vast majority of people with psychotic experiences, 1% of the world's population, are as non-violent as anyone else.  Some psychotic individuals can be dangerous, but lets not pin everything too horrific to comprehend on them just to make us feel a little more removed from the human potential for evil.

They Want Us to Believe

There is a ubiquitous use of tense in mental health treatment, and curiously, it highlights an interesting contrast with the evangelists of multiple personalities.

In working with people on the more severe end of the spectrum of mental health disease (or "disease" in quotations if you prefer) we usually find that we cannot directly challenge beliefs we believe are delusive without threatening to lose the relationship, the precious rapport, that is often our only hope of helping, and yet we don't want to reinforce the delusion just in order to maintain rapport as that would also be counterproductive, so we try to ease our way through the dilemma with a little play of tense.  The client speaks in the indicative, "I have an implant in my neck that Richard Nixon speaks to me though." It is a solid fact.  Meanwhile, we clinicians reflect in the subjunctive, "You believe . . .", "You said . . .", or you might even risk a "I believe you believe . . ."  We leave it in an open and conjectural mood to show understanding, and thereby avoiding conflict, but without reinforcing.

Changes in tense are also important in the strictly professional side of mental health when we take our professionally sanctioned beliefs and apply them in the real world.  The ultimate document of professional belief, the Diagnostic and Statistical Manual, The DSM, is written entirely in the indicative tense.  Every mental health diagnosis is a fact and every criterion of every diagnosis is a fact.  These facts are immutable immobile objects with crisp edges.  The DSM is seemingly free from conjecture or uncertainty, much less fantasy and make believe.  Here we find ourselves in another dilemma because most clinicians (and researchers too I would guess) do not believe the diagnostic categories handed down from on high are factual at all.  Most of us handle these interesting but crude objects with healthy skepticism.  They are all works in progress that may or may not hold up long enough for the next edition.  The clients we work with are individual people who do not always so easily fit these models.  We are well aware they are just that, models.  Is Schizophrenia really a single disease entity or several that happen to look similar?  No one really knows for the time being.  So, we think and talk about these things in the subjunctive manner even though Medicaid forces us to write out our final diagnoses in the indicative.

It has recently struck me, however, when it comes to therapists who are wont to diagnose and promote Dissociative Identity Disorder (or Multiple Personality Disorder), the above outlined patterns do not hold.

Firstly, there is no distance between the belief of the clinician and the belief of the client.  They become fused in a shared belief.  A shared fantasy.  A shared dramatic enactment.  Between clinician and client, the belief system is spoken of in the indicative.  Changes of mood are distinct personages inhabiting a single body.  The clinician pronounces it.  The client reflects it and gradually comes to act it and be it.  The reality that DID becomes depends on the indicative mood.  The clinician and client must truly believe and always speak of it in the most confident and unwavering language.  Any doubt may cause the mirage to waver and blow away in the wind.  The clinician is on stage also, enacting the role of professional therapist, but it is an "as if" that only looks like therapy.  In fact, it is therapy in reverse, rather than curing or ameliorating, with this therapy the symptoms of the client strangely increase in strength and definition over time and eventually become cemented facts.

Secondly, there is no healthy skepticism on the part of the clinician in the professional realm.  Always these therapists use the same indicative tense used in the DSM whenever discussing their one cherished true diagnosis of DID.  They are believers who want us to believe in it too.  To convince themselves and us, they don't use the language of belief, they use the language of hard facts.  There are no maybes or uncertainties.  The facts of DID are proven and true.  Professionals who doubt run the risk of being called closed-minded or ignorant of the facts, or finally when we fail to align we are told we are invalidating toward their clients--spoken as if it is the worst possible insult.  It always strikes me that the selfsame therapists who want so hard to believe in the fact of DID are often the most doubtful of just about any other diagnosis in the DSM.  I have been told by a straight faced bearded therapist that many cases of Schizophrenia are actually DID.  There are many many people out there with mood fluctuations who have DID and don't even know it.  Or so I'm told.  I suppose the right therapist can skillfully draw out the symptoms and turn annoying mood fluctuations into a disabling condition and Medicaid will reward the therapist for many years to come.

It may be no coincidence the only other people I have experienced such a hard sell from, miraculously turning uncertainties into facts, are car salesmen and preachers.  I can't say that I've ever knowingly been part of a cult, but I imagine cult leaders also are inclined toward an indicative mood.