The International Journal of Psychosocial Rehabilitation
Folie a Deux – a Social-Psychological Approach.
 

Igor Salganik M.D. and Peter Soifer M.D
.

  Sha’ar Menashe Mental Health Center, Mobile Post Hefer 38814, Israel
 

 

 
  Citation:
Salganik, I., Soifer, P.  (2006). Folie a Deux – a Social-Psychological Approach
.   International Journal of Psychosocial Rehabilitation.  10 (1) 141-151
 
Correspondence:
Igor Salganik, M.D.
Sha’ar Menashe Mental Health Center
Mobile Post Hefer 38814

Israel

 
e-mail: Salganik@shaar-menashe.org.il

 
   
 
Acknowledgment
The authors thank Rena Kurs for editorial assistance in preparation of the manuscript.



Abstract
Since the introduction of folie a deux in 1877 by Lasegue and Falret (1964) few contributions were made to the understanding and treatment of this disorder. We 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 identity to describe the processes within the folie a deux group. We propose a specific treatment approach that we call reconceptualization therapy, which is based on the group-relevant issues in folie a deux patients.  
Keywords: social influence, group leader role, group identity
 


Folie a Deux – a Social-Psychological Approach.
Whether a statement is true is an entirely different question from whether you or anybody believes it. ... There can be truths that no one believes. Symmetrically, there can be beliefs that are not true. ... “
[Elliot Sober, (1991) in Parsimony, Evolution, and Inference. Cambridge, MA, MIT Press, , pp. 15-16 ]

Introduction

In 1877 Lasegue and Falret introduced a totally new phenomenon in the realm of mental illness (Lasegue &, Falret , 1877). Until then, mental illness was associated with a single person who suffered from the disorder. For the first time the definition of an illness included the context of a specific social group. This was one of the few examples where a mental illness was initiated solely by communication. It is intriguing to understand the precise mechanisms that cause the previously “normal” person to loose his/her control of reality. The literature on the topic is scarce, and includes mostly case reports. Some classification attempts concentrated mainly on the individual features of the persons who participate in the shared psychosis (SP).
 
Scharfetter ( Scharfetter, 1972) claimed that a hereditary schizophrenic predisposition was absolutely necessary for the 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 phenomenon.
 
Psychoanalytical theorists agreed on the assumption that the transfer of delusions and hallucinations in SP occurs to fulfill needs of both the source and recipient of the psychosis. Hart and McClure (Hart J, McClure , 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 that may fulfill dependency needs (Hart J, McClure , 1989)  and avert threat of loss, which is greater than the threat of becoming psychotic (Salih, 1981).
Few efforts have been made to understand the social framework of this phenomenon.
 
We suggest a group approach to shared psychosis, and postulate that the persons participating in folie a deux could be identified as belonging to a specific group. We hypothesize that some mechanisms that take place in the evolving and functioning of such a group are similar to that of any other social group. Thus this phenomenon can be investigated in terms of interactions within this group 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 and who conceptualize themselves as “we” (Shaw, 1981).
   
Social influence and reality testing
Social influence has been equated with conformity. Conformity is reliance on another’s judgment in the absence of or even in contradiction to one’s own judgment ( Smith, 1982).

According to Muzafer Sherif  (Sherif, 1936)  norms emerge through social interaction and social interdependence is based on uncertainty reduction – people use the opinions of others as a guide to the 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 an 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 provide wrong answers the overall error rate increased to 36.8% (compared to 0.7% in controls). Asch clearly demonstrated the influence of social pressure.

Two different explanations were provided to explain the phenomenon of social influence. 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. One’s desire to be accepted and approved as a normative group member was considered a principle motivation.  Deutsch and Gerard (Deutsch & Gerard, 1955) coined the terms informational and normative influence. In their understanding informational influence was influence to achieve accurate perceptions (stock market rates, weather forecast, etc.) and normative influence was based on approval and rejection avoidance and associated with peer group pressure.
 
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 unimportant);
b) immediacy of the influencing agent (proximal vs. distant); c) number of the influencing agents (the larger the number the smaller the influence).
 
"Groupthink" 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 be the consensus of the group. Thus, the group may ultimately agree on an action which each member might normally consider to be unwise. Janis' original definition of 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 alternative courses of action." The word groupthink was intended to be reminiscent of George Orwell's coinages (such as doublethink) from the fictional language Newspeak, which he portrayed in his ideological novel Nineteen Eighty-Four.
 
Janis described 8 symptoms that characterize groupthink:  invulnerability, rationale, morality, stereotypes, pressure, self-censorship, unanimity, and mindguards, where striving for conformity is one of the main motivating forces. Self-censorship is practiced in order to stick to the consensus, an illusion is formed that everything said and agreed within the group is true (unanimity), critical thinking is avoided. The closer the group the tighter the boundaries of conformity, and any disagreement within the group is perceived as a threat. The symptom of invulnerability is the shared illusion that the group is very powerful. This feeling prevents the group from critically evaluating reality. “Morality” in Janis’s sense is a conviction that what the group believes and does is always right. This symptom puts the group into position to justify its actions even if they are highly polemic – “rationale” in Janis’s definition. Stereotype “black-white” thinking facilitates the construction of enemy images. The “enemy” is always wrong and evil and any aggressive action against him is 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 decision-making process of a cohesive group.
 
 Moscovici and Zavallini (Moscovici  & Zavallini, 1969)  described a phenomenon of group polarization – enforcement of the average tendency of the group members. During group discussion a data bank of ideas is formed, most of which conform to the dominating point of view.
 
Turner introduced a new approach, which attempted to determine that group influence is not terminated after discontinuation of the physical contact of the individual with the group. In his Self-Categorization Theory (Turner, 1987, Turner, 1991)  he conceptualized that a group is not necessarily an external influence and that the group values and standards (group norms) are internalized by an individual and become part of his/her social identity as ones’ self is defined in terms of social norms.
 
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 only occurs when physical reality testing is unavailable and increases with the growing dependence of the members of the group. He noted that group members tend to check their opinions by comparison with the dominant opinion of the 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 he becomes (Schachter , 1961, Earle, 1986). In the experimental elaboration of  Theory of Social Influence, Deutsch and Gerard ( Deutsch & Gerard, 1955) demonstrated that Festinger’s theory was incomplete as people sometimes conformed to social 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 to minimize the dissonance." As Festinger described, "dissonance" is the psychological tension that arises when a person's behavior conflicts with his beliefs. People prefer that their behavior, thoughts, and emotions be mutually consistent, and 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, which were complemented by a fourth component - control of information introduced by Steven Alan Hassan (Hassan, 2000). Some of the means of information control mentioned by Hassan were use of deception, discouraging access to outside sources of information, etc. (Hassan, 2000).
 
The Role of a Group Leader
Leader is a person having authority over others in concert… (Webster’s Dictionary).
 
Among the various leadership theories the  Charismatic Leadership Theory (House, 1976) seems most appropriate for SP group dynamics.
According to this theory the charismatic leader possesses following features:
 
1. Determination and persistence 2.  Exceptional self-confidence 3. Advocacy of change and challenge for the status quo 4. Ability to  mobilize a critical mass of followers in the interest of the leader's vision. 5. Relative insensitivity to criticism 6. Low affiliative motivation or no conscious concern for establishing, maintaining and restoring close personal relationships with others. 7. Advocacy of a vision of a better future for the collective. 8. No interest in self-aggrandizement. 9. Sense of social responsibility and collective interests." (House, 1976) .

Destructive Cult. Thought Reform or Cohesive Influence.
A cult (totalist type) is a group or movement that exhibits excessive devotion or dedication to a person, idea, or thing and employs unethical manipulative techniques of persuasion and control (e.g., isolation from former friends and family, debilitation, use of special methods to heighten suggestibility and subservience, powerful group pressures, information management, suspension of individuality or critical judgment, promotion of total dependency on the group and fear of leaving it, etc.) designed to advance 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 and mind control, and to describe mind manipulation in destructive cults (Lifton, 1989,  Lifton, 1961). Margaret Singer (Singer, 1990). identified 6 conditions necessary to perform such thought reform in cult members. 1. The person is kept unaware of the processes occurring within the cult or its final agenda; 2. Person is led to think about a group and its content most of the time; 3. The belief in one’s own perception and good judgment is discouraged, ordinary view of reality is destabilized, the member is led to a sense of inner 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 rewards, punishments, and experiences especially designed for that purpose. 6. A closed system of logic is created within the authoritarian structure that permits no feedback and refuses to be modified except by leadership approval or executive order.
The 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 following:
1) Group formation is spontaneous; 2) The group life expectancy is not self-limited;
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 hierarchical 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 closed 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 behavior; 16) The relation towards other groups is defensive and not cooperative ; 17)  The defense mechanisms are  psychotic – split, denial, grandiosity; black-white thinking; 18) At the beginning the group tends to propagate its central idea to the society and tries to gain its acceptance, later on it gives up and demonstrates a hostile attitude towards society.
 
Discussion
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 therapist who confronts this disorder today uses mainly the same tools both in assessment and treatment of the disorder (apart from psychopharmacological therapy).

It seems to us that understanding of SP demands a multidisciplinary approach. The very fact that the disease is defined not through a single patient, but explicitly includes additional individuals invites other methods than we are used to in our traditional assessment of psychopathology. In a “pure” folie a deux case a psychiatrically morbid person “inflicts” a disorder on a previously mentally healthy individual. Though some authors claim that such an individual is a actually a myth, because in vast majority of cases there is a common genetic load, it can be argued that if this load alone would be of principal significance, a much higher incidence of the disorder might be expected. Interestingly, the definition of shared psychosis according to DSM-IV states explicitly that  “The disturbance is not better accounted for by another Psychotic Disorder (i.e. schizophrenia) 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 Association, 1994), in other words refers to a “pure” case of SP where a recipient is not mentally ill. Additionally, Musalek and Kutzer (Musalek &  Kutzer, 1990) have indicated in their study of 107 patients affected with shared delusions of infestations that the ratio of blood relations to non-blood relations was 1:2.3, so that genetic factors seemed to be less important than the direct impact of deluded patients on their environment. Thus, one may conclude, other factors may be of greater importance in the creation of the phenomenon. The attempt to explain the evolvement of a disorder merely through the analysis of involved a person that has been undertaken by a number of psychoanalytically oriented authors may have contributed to the understanding of the interpersonal unconscious motives. It does not take into consideration, however, the universal mechanisms that occur in every group of humans and that have a 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 with the new understanding that is  relevant to SP. Festinger et al. (Festinger, 1954) demonstrated that in situations with high levels of uncertainty  social reality testing overrules and physical reality testing is rendered considerably less important. He also proved that social reality testing becomes more dominant in situations with increased dependence. This is precisely what 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” opinion (in the case of a SP group, the opinion of the inducer) is also a common phenomenon as is avoidance of stigmatization (by the inducer in SP) (Deutsch & Gerard, 1955). In the case of  a SP group physical reality testing by group members is discouraged, thus social reality testing is the main evaluation of reality. However, social reality testing is almost  the same as physical reality testing of the leader, and he is psychotic. Festinger’s locomotion is reflected in SP as grouping around the delusional idea that exerts powerful social pressure on the recipient to conform with the group. As a cohesive and closed group, the SP group undergoes extreme polarization (Moscovici & Zavallini, 1969). The way the recipient is “talked into” SP could be partially interpreted by the manipulation of his behavior, cognition, emotion, and information he receives from the outer world though the inducer (Hassan, 2000, Festinger, 1959).

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 the cited qualities except the sense of social responsibility and collective 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 delusional content though separated from the inducer may be interpreted through the Self-Categorization Theory of Turner, the recipient internalizes the “social norms” of folie a deux group that actually become a part of his identity (Asch, 1955).
 
Some notes may be made about the analogous features in the 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. The destructive group is built according to the plan of a leader, in folie a deux the group is formed out of a previous group formation such as family bond etc. in a spontaneous manner (group transformation). The motivation of the destructive cult’s leader is a conscious one, in folie a deux motivation is usually unconscious. Recruitment is possible in a destructive cult, in folie a deux no specific arrangements for recruitment are provided. The techniques of thought reform in a destructive cult are applied in a purposeful manner, whereas in folie a deux such mind manipulations are built on unconscious motives. Both groups are similar in their authoritarian structure, consolidation around a charismatic-like leader figure, sharp group boundaries, high level of cohesiveness, extensive use of external enemy image, isolation from the society, intolerance to any critical thinking, extensive use of thought reform, demand of total spiritual commitment, and social reality testing clearly overrules physical reality testing which is discouraged.
Both destructive cults and folie a deux groups may produce psychotic 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 classical folie a deux, folie a trois, folie a famille, and “folie a societe” in the case of an extended group.
 
 
Suggestion for therapy
Laseque’s recommendation to isolate the originally mentally healthy recipient seems not to be sufficient. The persistence of delusions in a recipient even after separation from the inducer is quite common – 60% of reported cases (Howard, 1994). Some authors advocate the “conjoined” therapy 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 to rebuild the misconceptions,  that in our view, play a crucial role in the establishment of psychosis in a recipient. We call it “reconceptualization therapy”. It is based on an assumption that a 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 therapy is to challenge these norms and to provide grounds for a more reality-oriented attitude. This approach is based on a conjoined model - both individual and family therapy, each one having its specific objectives.
 
The description bellow addresses the treatment of the recipient(s) 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 to conduct a treatment within a closed ward. It should be mentioned that the therapy implies the total separation between the inducer and recipient (s). The inducer and the recipients are informed at the initiation of the therapy that no visits, no telephone calls, or any other contacts are allowed during the main course of the therapy. In the case that psychopathology of a recipient demands pharmacological intervention it will be initiated at the beginning. In questionable cases the initiation of the psychotropic therapy will be postponed until the final diagnosis is established.
 

Individual therapy
Three stages may be identified. 1. Trust Building phase. At this stage, anamnesis and heteroanamnesis is collected, the patient’s immediate needs are addressed in an empathic manner. Empathy with the patient’s suffering, his sense of defenselessness and his fears is shown. No critical evaluation of delusional content, no clarification, no interpretive interventions or confrontations are expected. Therapeutic alliance starts to form.

1.      2. Concept Reconstruction Phase. At the beginning of this phase, the general issues regarding the social influence are discussed with a patient in popular terms, illustrated by well known social-psychological experiments (Asch , 1951; Milgram, 1964; Festinger, 1957). Three main issues are addressed: a) social reality vs. physical reality;  b) the only interpretation of an event or fact vs. possibility of alternative interpretations; c) “unmistakable” leader concept vs. “we all make mistakes” and critical approach to leader figure.

        ·          Patient’s delusional 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 encouraged to look for alternative interpretations. If it seems difficult for a patient to talk about himself, other more general subjects should be discussed (newspaper 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 stage, the inducer himself becomes the subject for such an analysis; it is encouraged 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 initiated.
 
3. Concept Consolidation Phase. At this phase, for the first time, the patient is exposed to the inducer in an individual session (a meeting should be arranged) parallel, to family therapy. In the aftermath of the meeting a patient’s evaluation of the inducer is discussed. The issues that need further elaboration have to be worked through.
   
Family Therapy
The 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 participants can be included if they may contribute significantly to the therapeutic process. The group actually has the character of a “transitional group”, where the group members represent both worlds – from one side they are the members of 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 consolidation phase.
 
The present work is consistent with the main stream of psychiatric 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. The well established techniques of family and couple therapy that are in common use in everyday work with psychiatric patients may be enriched by instruments of social psychology both at the stage of assessment and treatment.
  


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