Igor Salganik, M.D.
Menashe Mental Health Center
Mobile Post Hefer
The authors thank Rena Kurs
editorial assistance in preparation of the manuscript.
the introduction of folie a deux in 1877 by Lasegue and Falret (1964)
contributions were made to the understanding and treatment of this
suggest that folie a deux is a
group-originated disorder. We use the theoretical elaboration of social
psychology such as social influence, group leader role, and group
describe the processes within the folie a deux group. We propose a
treatment approach that we call reconceptualization therapy, which is
the group-relevant issues in folie a deux patients.
social influence, group leader role, group identity
Folie a Deux
– a Social-Psychological Approach.
a statement is true is an entirely different question from whether you
anybody believes it. ... There can be truths that no one believes.
Symmetrically, there can be beliefs that are not true. ... “
Sober, (1991) in Parsimony, Evolution, and Inference. Cambridge, MA,
MIT Press, , pp. 15-16 ]
In 1877 Lasegue and Falret
introduced a totally new phenomenon in the realm of mental illness
&, Falret , 1877). Until then, mental illness was
associated with a single person who suffered from the disorder. For the
time the definition of an illness included the context of a specific
group. This was one of the few examples where a mental illness was
solely by communication. It is intriguing to understand the precise
that cause the previously “normal” person to loose his/her control of
The literature on the topic is scarce, and includes mostly case
classification attempts concentrated mainly on the individual features
persons who participate in the shared psychosis (SP).
Scharfetter ( Scharfetter, 1972) claimed that a
hereditary schizophrenic predisposition was absolutely necessary for
development of SP. Gralnick ( Gralnick, 1942)
reported in his patient’s cohort that 91% of shared disorders had
similar inheritance and he concluded that this formed the basis for the
Psychoanalytical theorists agreed on the assumption that the
transfer of delusions and hallucinations in SP occurs to fulfill needs
the source and recipient of the psychosis. Hart and McClure (Hart J,
1989) suggested that SP allows the
mentally ill person to maintain a link to reality. For the submissive
recipient, the underlying process is identification with the inducer
fulfill dependency needs (Hart J, McClure , 1989) and avert
threat of loss, which is greater
than the threat of becoming psychotic (Salih, 1981).
efforts have been made to understand the social framework of this
suggest a group approach to shared psychosis, and postulate that the
participating in folie a deux could be identified as belonging to a
group. We hypothesize that some mechanisms that take place in the
functioning of such a group are similar to that of any other social
this phenomenon can be investigated in terms of interactions within
and intercommunication with other groups.
Social psychology addresses a number of characteristics that are
inherent to a social group. Group is defined as two or more persons who
interact and influence each other for longer than just a few moments
conceptualize themselves as “we” (Shaw, 1981).
influence and reality testing
influence has been equated with conformity. Conformity is reliance on
judgment in the absence of or even in contradiction to one’s own
to Muzafer Sherif (Sherif, 1936) norms
emerge through social interaction and social interdependence is based
uncertainty reduction – people use the opinions of others as a guide to
reality in situation that is ambiguous and uncertain. Through
interaction, groups converge on unique group norms. Group
norms persist in later judgments of individuals. In the paradigm where
electrical shocks were believed to be applied to an innocent victim,
Milgram (Milgram, 1963) demonstrated that people are prone to act
against their own beliefs and even to harm another when instructed by
authority to do so. Solomon
Asch’s line length experiments (Asch, 1955) showed that in a
constellation of 1 proband against more than 3 others, who deliberately
wrong answers the overall error rate increased to 36.8% (compared to
controls). Asch clearly demonstrated the influence of social pressure.
explanations were provided to explain the phenomenon of social
Sherif et al (Sherif,
1936) regarded a rational process of information
thought to be responsible, on the other hand Asch et al. (Asch,
1955) saw irrational
acceptance of others’ judgments while within the group as a cause.
to be accepted and approved as a normative group member was considered
principle motivation. Deutsch and Gerard
& Gerard, 1955) coined the
terms informational and normative influence. In their understanding
informational influence was influence to achieve accurate perceptions
market rates, weather forecast, etc.) and normative influence was based
approval and rejection avoidance and associated with peer group
Latan (Latan, 1981) in his Social Impact Theory argued that social
influence depends on:
a) strength of the influence agent (powerful and important vs. weak and
b) immediacy of the influencing agent (proximal vs. distant); c) number
influencing agents (the larger the number the smaller the influence).
was coined by psychologist Irving Janis in 1972 (Janis & Mann,
1977) to describe a process by which a group can
make bad or irrational decisions.
In a groupthink situation, each member of the
group attempts to conform his or her opinions to what they believe to
consensus of the group. Thus, the group may ultimately agree on an
each member might normally consider to be unwise. Janis' original
the term was "a mode of thinking that people engage in when they are
deeply involved in a cohesive in-group, when the members' strivings for
unanimity override their motivation to realistically appraise
courses of action." The word groupthink was intended to be reminiscent
George Orwell's coinages (such as doublethink) from the fictional
Newspeak, which he portrayed in his ideological novel Nineteen
Janis described 8 symptoms that characterize groupthink:
invulnerability, rationale, morality,
stereotypes, pressure, self-censorship, unanimity, and mindguards,
striving for conformity is one of the main motivating forces.
is practiced in order to stick to the consensus, an illusion is formed
everything said and agreed within the group is true (unanimity),
thinking is avoided. The closer the group the tighter the boundaries of
conformity, and any disagreement within the group is perceived as a
symptom of invulnerability is the shared illusion that the group is
powerful. This feeling prevents the group from critically evaluating
“Morality” in Janis’s sense is a conviction that what the group
does is always right. This symptom puts the group into position to
actions even if they are highly polemic – “rationale” in Janis’s
Stereotype “black-white” thinking facilitates the construction of enemy
The “enemy” is always wrong and evil and any aggressive action against
justified. Pressure is exerted against any disagreeing
individual. Mindguards are used for that purpose. In
Janis’s opinion groupthink may lead to a serious bias in the
process of a cohesive group.
Moscovici and Zavallini
(Moscovici & Zavallini,
1969) described a phenomenon
of group polarization – enforcement of the average tendency of the
members. During group discussion a data bank of ideas is formed, most
conform to the dominating point of view.
a new approach, which attempted to determine that group influence is
terminated after discontinuation of the physical contact of the
the group. In his Self-Categorization Theory (Turner, 1987, Turner,
conceptualized that a group is not necessarily an external influence
the group values and standards (group norms) are internalized by an
and become part of his/her social identity as ones’ self is defined in
In (1954), Leon Festinger postulated in his
Social Comparison Theory (Festinger, 1954) that there
are two main sources of uniformity pressure within small groups: social
validation and group locomotion. Accordingly, social reality testing
occurs when physical reality testing is unavailable and increases with
growing dependence of the members of the group. He noted that group
tend to check their opinions by comparison with the dominant opinion of
group. Group locomotion underlines the other source of social pressure.
Presence of important group goals requires uniformity if they are to be
attained. Several studies show that the
more a deviant prevents attainment of a valued goal, the more rejected
becomes (Schachter , 1961, Earle, 1986). In
the experimental elaboration of Theory
of Social Influence, Deutsch and Gerard ( Deutsch & Gerard, 1955)
that Festinger’s theory was incomplete as people sometimes conformed to
truth even if physical reality suggested
otherwise only to avoid being stigmatized.
In 1950, Festinger
summarized the basic principles of his cognitive dissonance theory: "If
you change a person's behavior, his thoughts and feelings will change
minimize the dissonance." As Festinger described, "dissonance"
is the psychological tension that arises when a person's behavior
with his beliefs. People
prefer that their behavior, thoughts, and emotions be mutually
can tolerate only a certain amount of discrepancy between these three
components. Psychological research has shown that if any of the three
components changes, the other two will shift to reduce cognitive
dissonance. Festinger's theory is based on three components:
control of behavior, control of thoughts, and control of emotions,
complemented by a fourth component - control of information introduced
Steven Alan Hassan (Hassan, 2000). Some of the means of information
mentioned by Hassan were use of deception, discouraging access to
sources of information, etc. (Hassan, 2000).
Role of a Group Leader
is a person having authority over others in concert… (Webster’s
Among the various leadership theories the Charismatic Leadership Theory (House, 1976)
seems most appropriate for SP group dynamics.
to this theory the charismatic leader possesses following features:
1. Determination and persistence 2.
Exceptional self-confidence 3. Advocacy of change and challenge
status quo 4. Ability to mobilize a
critical mass of followers in the interest of the leader's vision. 5.
insensitivity to criticism 6. Low affiliative motivation or no
concern for establishing, maintaining and restoring close personal
relationships with others. 7. Advocacy of a vision of a better future
collective. 8. No interest in self-aggrandizement. 9. Sense of social
responsibility and collective interests." (House, 1976) .
Destructive Cult. Thought Reform or Cohesive
A cult (totalist type) is a group or movement that
excessive devotion or dedication to a person, idea, or thing and
unethical manipulative techniques of persuasion and control (e.g.,
from former friends and family, debilitation, use of special methods to
heighten suggestibility and subservience, powerful group pressures,
management, suspension of individuality or critical judgment, promotion
total dependency on the group and fear of leaving it, etc.) designed to
the goals of the group’s leaders to the actual or possible detriment of
members, their families, or the community (West & Langone , 1986).
The term “thought reform” was coined
by Robert Lifton, one of the early psychologists to study brainwashing
control, and to describe mind manipulation in destructive cults (Lifton, 1989, Lifton, 1961). Margaret Singer (Singer,
6 conditions necessary to perform such thought reform in cult members.
person is kept unaware of the processes occurring within the cult or
agenda; 2. Person is led to think about a group and its content most of
time; 3. The belief in one’s own perception and good judgment is
ordinary view of reality is destabilized, the member is led to a sense
confusion and powerlessness; 4. The person’s former social identity is
discredited through a system of rewards, punishments, and experiences
especially designed for that purpose. 5.
The creation of the new belief system is promoted though a system of
punishments, and experiences especially designed for that purpose. 6. A
system of logic is created within the authoritarian structure that
feedback and refuses to be modified except by leadership approval or
destructive cult is usually led by a charismatic leader (Robbins, 1988).
“Folie a Deux” Group
In our opinion the “folie a deux group” is characterized by the
Group formation is spontaneous; 2) The group life expectancy is not
3) The group includes 2 or more
individuals; 4) Recruitment to the group is usually based
on family bonds (ties); 5) Group members live in close proximity
usually within the same flat; 6) The group is based on pronounced
structure ; 7) One of the group members (inducer) possesses charismatic
leader-like qualities; 8) The group has sharply defined borders;
9) The group is a “closed” group, there is no
enrollment of new members; 10) Very high group cohesion; 11) The
central element of group cohesion is a
delusional idea; 12) The group initially
served completely different purposes – sexual bond, living together of
relatives, and purposes were later
modified due to the delusional idea; 13) The group norms are based on
the delusional idea and are communicated by the group leader; 14) The
input of external
information is highly selective
and is absorbed only after interpretation
through the internal (delusional) group values; 15) Expressed
intolerance to any “alternative” solution or interpretation or
The relation towards other groups is defensive and not cooperative ;
17) The defense mechanisms are psychotic – split, denial,
black-white thinking; 18) At the beginning the group tends to propagate
central idea to the society and tries to gain its acceptance, later on
up and demonstrates a hostile attitude towards society.
The conceptualization of folie a deux first published by
Laseque and Faret (Laseque & Faret, 1877) at the end of 19th
century has not essentially been challenged until the present. The
who confronts this disorder today uses mainly the same tools both in
and treatment of the disorder (apart from psychopharmacological
It seems to us that understanding of SP demands a
approach. The very fact that the disease is defined not through a
patient, but explicitly includes additional individuals invites other
than we are used to in our traditional assessment of psychopathology.
“pure” folie a deux case a psychiatrically morbid person “inflicts” a
on a previously mentally healthy individual. Though some authors claim
such an individual is a actually a myth, because in vast majority of
there is a common genetic load, it can be argued that if this load
be of principal significance, a much higher incidence of the disorder
expected. Interestingly, the definition of shared psychosis according
states explicitly that “The disturbance
is not better accounted for by another Psychotic Disorder (i.e.
or a Mood Disorder With Psychotic
Features and is not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication)
or a general medical condition”. DSM-IV (American Psychiatric
in other words refers to a “pure” case of SP where a recipient is not
ill. Additionally, Musalek and Kutzer (Musalek &
Kutzer, 1990) have indicated in their study
of 107 patients affected with shared delusions of infestations that the
of blood relations to non-blood relations was 1:2.3, so that genetic
seemed to be less important than the direct impact of deluded patients
environment. Thus, one may conclude,
factors may be of greater importance in the creation of the phenomenon.
attempt to explain the evolvement of a disorder merely through the
involved a person that has been undertaken by a number of
oriented authors may have contributed to the understanding of the
unconscious motives. It does not take into consideration, however, the
universal mechanisms that occur in every group of humans and that have
profound impact on their behavior.
The analysis of SP patients as a specific
group enables the observer
to apply the powerful arsenal of tools that is commonly used in social
psychology. The reality testing as it is understood in group context is very different from the reality testing of
an individual, as described by Freud, for example – “a concern of the definitive reality-ego, which develops
out of the initial pleasure-ego” (Freud, 1955).
Distinguishing between physical
and social reality testing (Festinger, 1954) provides us
new understanding that is relevant to
SP. Festinger et al. (Festinger, 1954) demonstrated that in situations
high levels of uncertainty social
reality testing overrules and physical reality testing is rendered
less important. He also proved that social reality testing becomes more
dominant in situations with increased dependence. This is precisely
happens within the SP group - where the
recipient usually possesses features of dependency. The mode of social
influence within a SP group is mostly of a normative character11.
Checking the opinion of the dependent group members with the “dominant”
(in the case of a SP group, the opinion of the inducer) is also a
phenomenon as is avoidance of stigmatization (by the inducer in SP)
& Gerard, 1955). In the case of a SP
group physical reality testing by group members is discouraged, thus
reality testing is the main evaluation of reality. However, social
testing is almost the same as physical
reality testing of the leader, and he is psychotic. Festinger’s
reflected in SP as grouping around the delusional idea that exerts
social pressure on the recipient to conform with the group. As a
closed group, the SP group undergoes extreme polarization (Moscovici
Zavallini, 1969). The way the recipient is “talked into” SP could be
interpreted by the manipulation of his behavior, cognition, emotion,
information he receives from the outer world though the inducer
The SP group is an extreme example of
“groupthink” (Janis & Mann,
1977). All 8 components mentioned
by Janis are highly functional and reach psychotic dimensions.
The inducer in the SP group may be
characterized in terms of the
Charismatic Leadership Theory. He is generally expected to possess all
cited qualities except the sense of social responsibility and
interests (at least in the general sense) (House, 1976).
The strength of the influencing agent (Latan,
1981) is maximal in the SP group – the inducer is powerful and
important, he is in close proximity to the inducer and he inflicts his
influence alone without sharing it with anyone else.
The tendency of many recipients to insist on their
content though separated from the inducer may be interpreted through
Self-Categorization Theory of Turner, the recipient internalizes the
norms” of folie a deux group that actually become a part of his
Some notes may be made about the analogous features
destructive cult group and the folie a deux group. In a destructive
cult the central
idea is an overvalued idea, whereas in folie a deux it is a delusion.
destructive group is built according to the plan of a leader, in folie
the group is formed out of a previous group formation such as family
in a spontaneous manner (group transformation). The motivation of the
destructive cult’s leader is a conscious one, in folie a deux
usually unconscious. Recruitment is possible in a destructive cult, in
deux no specific arrangements for recruitment are provided. The
thought reform in a destructive cult are applied in a purposeful
whereas in folie a deux such mind manipulations are built on
motives. Both groups are similar in their authoritarian structure,
consolidation around a charismatic-like leader figure, sharp group
high level of cohesiveness, extensive use of external enemy image,
from the society, intolerance to any critical thinking, extensive use
thought reform, demand of total spiritual commitment, and social
testing clearly overrules physical reality testing which is
Both destructive cults and folie a deux groups may
behavior in their members (Singer, 1990).
The analysis of both destructive cults and folie a
deux suggests the
existence of certain spectrum of affected groups – starting with
folie a deux, folie a trois, folie a
“folie a societe” in the case of an extended group.
Suggestion for therapy
Laseque’s recommendation to isolate the originally
recipient seems not to be sufficient. The persistence of delusions in a
recipient even after separation from the inducer is quite common – 60%
reported cases (Howard, 1994). Some authors advocate the “conjoined”
where both individual and family therapy are applied.
We sense a need for a specific psychotherapeutic
approach aside from
pure separation. We suggest here a therapeutic intervention, that aims
rebuild the misconceptions, that in our
view, play a crucial role in the establishment of psychosis in a
call it “reconceptualization therapy”. It is based on an assumption
recipient has internalized pathological group norms (in case of shared
psychosis formed by the inducer) that have a profound influence on his
emotions, thinking, and behavior. The goal of the reconceptualization
is to challenge these norms and to provide grounds for a more
attitude. This approach is based on a conjoined model - both individual
family therapy, each one having its specific objectives.
The description bellow addresses the treatment of
only. The treatment of the inducer depends on the context of his
psychopathology and is not the focus of this paper.
The treatment should be performed on an inpatient
basis. In many
cases, the recipient will be involuntarily committed. It is preferable
conduct a treatment within a closed ward. It should be mentioned that
therapy implies the total separation between the inducer and
(s). The inducer and the recipients are informed at the initiation of
therapy that no visits, no telephone calls, or any other contacts are
during the main course of the therapy. In the case that psychopathology
recipient demands pharmacological intervention it will be initiated at
beginning. In questionable cases the initiation of the psychotropic
will be postponed until the final diagnosis is established.
Three stages may be identified. 1. Trust Building
phase. At this stage, anamnesis and heteroanamnesis is collected, the
immediate needs are addressed in an empathic manner. Empathy with the
suffering, his sense of defenselessness and his fears is shown. No
evaluation of delusional content, no clarification, no interpretive
interventions or confrontations are expected. Therapeutic alliance
2. Concept Reconstruction
Phase. At the beginning of this phase, the general issues regarding the
influence are discussed with a patient in popular terms, illustrated by
known social-psychological experiments (Asch , 1951; Milgram, 1964;
1957). Three main issues are addressed: a) social reality vs. physical
reality; b) the only interpretation of an
fact vs. possibility of alternative interpretations; c) “unmistakable” leader concept vs. “we all make
mistakes” and critical
approach to leader figure.
conceptions are analyzed in terms of
socially formed conceptions. A patient is encouraged to suggest the ways of their verification. The process
of verification must be as transparent
to a patient as possible.
Delusional interpretations of
events and facts in the patient’s life are discussed. The patient is
to look for alternative interpretations. If it seems difficult for a
talk about himself, other more general subjects should be discussed
articles, TV programs, etc.).
Different leaders (e.g.
historical figures) are analyzed. A patient is encouraged to critically
evaluate their actions and to build an integrative approach. At a later
the inducer himself becomes the subject for such an analysis; it is
to switch from one-sided viewing to a more critical and comprehensive
understanding of inducer’s way of thinking and behavior.
Towards the end of this phase family therapy is
3. Concept Consolidation Phase. At this phase, for
the first time,
the patient is exposed to the inducer in an individual session (a
should be arranged) parallel, to family therapy. In the aftermath of
meeting a patient’s evaluation of the inducer is discussed. The issues
need further elaboration have to be worked through.
therapy is performed with the extended family, including all the
percipients and all members that have
ambivalent attitudes towards the delusional ideas. Some non-family
can be included if they may contribute significantly to the therapeutic
process. The group actually has the character of a “transitional
the group members represent both worlds – from one side they are the
the same family sharing family values,
myths, etc., on another side they represent a door to society, where social
and physical reality testing are combined.
The phases of the therapeutic process are similar to
those of the
individual therapy. The inducer will be excluded from the
first two phases and introduced during the
The present work is consistent with the main stream
research that adapts a psycho-social-biological approach (Engel, 1977).
Folie a deux may serve as a model which underlines
the importance of
social influence on establishment and course of a psychiatric disorder.
well established techniques of family and couple therapy that are in
in everyday work with psychiatric patients may be enriched by
social psychology both at the stage of assessment and treatment.