Clinicians should also assess patients' understanding of how cults manipulate and the patients' educational and job-skill levels (many cult members, especially those raised in cults, are educationally and vocationally deprived). Standard psychiatric medications can sometimes be helpful, but because these patients tend to appear to be more disturbed than they actually are, a conservative and watchful medication stance is called for. Psychotherapy with former cult members includes five overlapping goals:
- Help patients understand the psychological manipulation and abuse to which they were subjected;
- Help them manage the day-to-day crises (e.g., how to deal with skeptical Aunt Carol's visit) that often seem out of proportion to patients' level of intellectual functioning and psychological history (and that often cause therapists to overestimate the degree of psychopathology in ex-member patients);
- Help patients reconnect to and repair their pasts (personal relationships, goals, interests), grieve over lost time, friendships, and sense of purpose (however illusory it may have been), and compare and contrast their cult and mainstream lives;
- To the extent possible, mobilize patients' social support network and other resources (e.g., educational or vocational resources);
- Help patients integrate their cult experience into the rest of their life experience and deal with residual psychological problems.
Helping families. Clinical work with families is usually through consultation, though sometimes treatment (Singer 1986). Consultation involves educational interventions designed to help families respond effectively to a loved one's cult involvement. Treatment aims at helping family members cope with their emotional reactions to the cult involvement. However, even treatment requires some educational work because the troubled family member needs to better understand the cult phenomenon in order to reduce the confusion, fear and despair that results from the family's unsuccessful attempts to help their involved loved one. Other than this educational component, treatment of family members' emotional reactions can include standard clinical procedures.
Consultation with families addresses three areas: assessment, education and training (Langone; Ross and Langone).
Assessment should include an exploration of the family's history, strengths, weaknesses, current functioning and knowledge about the loved one's involvement (frequently families become alarmed, though not necessarily inappropriately, even though they have minimal information about the group in question). I use the following question to help focus the family: "If your child (spouse) were not in a cult, what if anything would bother you about his or her behavior?"
If there are no troublesome behaviors, it is likely that the family is overreacting. If troublesome behaviors are identified, then the consultant tries to help the family determine whether there is reason to believe that these behaviors are linked to the group's practices.
During the assessment process the consultant should begin to teach the family about cults and psychological manipulation (many useful resources can be obtained from the American Family Foundation, P.O. Box 2265, Bonita Springs, FL 33959,  249-7693). It is important, however, not to let the unavoidable generalizations of books, articles, and audiovisual materials obscure the uniqueness of the individual case.
The training component has three goals: (1) to improve communication; (2) to identify a strategy to help the involved person; and (3) to implement the strategy. Standard communication and negotiation skills training can contribute much to the first goal. In addressing the second, the consultant and family will usually choose from one of the following options: (a) postpone a decision about strategy and focus on collecting more information to complete the assessment properly; (b) acknowledge the family's limited influence, devise a strategy for making the best out of a bad situation and carefully look for reasons to hope that the situation may someday change for the better; and (c) develop a strategy for intervention, which may include family counseling with the involved person or exit counseling.
Exit counseling (Giambalvo) is a voluntary, intensive, time-limited contractual educational process that emphasizes the respectful sharing of information with members of exploitatively manipulative groups. Exit counselors ideally should have intimate knowledge about the group in question. Exit counseling is distinguished from deprogramming, which received much media coverage in the late 1970s and 1980s, in that the former is a voluntary process, whereas the latter is currently associated with a temporary restraint of the cult member. If the implementation strategy focuses on family counseling, the clinician may nonetheless consider bringing in an exit counselor consultant at some point in order to help the involved person better understand details about the group's manipulations.
Helping current cult members. Because cults tend to be elitist and distrustful of the outside world, members will rarely consult a mental health professional, so my suggestions are based more on reasoning than experience. If a cult member consults a clinician at the urging of family members concerned about a possible cult involvement, then the clinician can explore the cult issue in depth and, if indicated, bring in the family. If, however, the cult member comes in voluntarily (e.g., to deal with depression that may or may not be causally connected to the group's practices), clinicians should be even more sensitive to the ethical implications of their actions. Even if the destructiveness of the group involvement is obvious to the clinician, the cult member may not be willing even to consider this issue. Does the clinician force the issue? Keep a hidden agenda? Do what is possible within the boundaries established by the patient? Refer the person elsewhere? The answer to these questions will depend upon the patient's situation (e.g., is he or she suicidal?) and the clinician's ethical analysis of the situation.
If clinicians address the cult issue when working with a cult member, they may find it helpful to take a careful chronological history in order to try to help the patient see how his or her behavior and psychological state may have been influenced by the group's practices. Sometimes it may be appropriate to bring in an exit counselor, with the patient's permission, of course.
Working with cult victims and their families demands a special understanding and appreciation of the potential power of highly manipulative environments. It is a field full of uncertainty, ambiguity, frustration and complexity. But it is also a field in which success brings the special gratification of having helped to liberate both a body and a mind.