Howard L. Forman, MD

, Amanda Montell discusses some of her surprising discoveries on the ways in which language can manipulate. Howard Forman, MD, sat down to discuss this with her.

 What do you want psychiatrists to know about the phenomenon, “cultish”?

 The main takeaway is that this sort of cultish language shows up in places you might not think of as cults. Remote Jonestownian communes are not the only environments in which one would find cultish influence. We take language for granted—it can work invisibly and powerfully to discourage independent thinking and can often discourage questioning in order to encourage conformity. One of the most humbling discoveries that I made in my research for the book was how similar the techniques of manipulation are between cult leaders and abusive partners. A toxic relationship is, in a lot of ways, a cult of 1.

 Can you please expand on the “cult of 1” to describe an abusive partner?

 An abusive partner, like a cult leader, will coerce people into doing things that they might not otherwise. The abuser can obscure truths to gain and maintain power. A charismatic cult leader does the same. The language we use to describe the techniques is different, but the substance is the same. Love-bombing, gaslighting, “us versus them,” and thought-terminating cliches prolong these toxic bonds.

 What are some clues we can listen for in our patients’ descriptions to know if they are possibly under the influence of seemingly good, but ultimately destructive influences?

 Social media is an important entryway to influences you may hope your patients can avoid. In 2011, sociologists coined the term, 

. Conspirituality is a portmanteau of conspiracy and spirituality. You increasingly see conspiritualityin online movements that combine 2 core principles: conspiratorial thinking and new age spirituality. These movements combine ideas that there are dark underlying forces that are secretly controlling society, and simultaneously that we are on the brink of a spiritual awakening or paradigm. Conspiracy theorists are no longer these MAGA-type dudes living in their parents’ basements thinking about Flat Earth; they appear to be neighborhood moms who were introduced to this ideology in their yoga studios. Alternatively, there are people who appear to have discovered useful holistic health remedies and shared them on YouTube in their first video, but then descend a rabbit hole into conspiracy theories in later posts.

 What emerging online movements do you believe portend the most harm?

 The exploitation of people’s mental health on social media is a very pressing threat. “What do you think is one of the most pressing cultish-cult leader type of threats that you see coming up more and more in the near future?” is a question I receive a lot. My answer is always the same: mental health influencers. Obviously, mental health care is wildly inaccessible to a lot of people. There is still a stigma. There are still all these barriers to people accessing mental health care, which everybody should have access to. But just following someone on Instagram is really easy. It is private. You are going to be hearing messages that you make you feel understood. You may be a vulnerable person, and here is this maternal figure telling you, “you do not need psychiatry, you do not need a therapist, all you need is me.”

 is an attending psychiatrist at Montefiore Medical Center. He is the Book Review editor at 

Articles

What cultish language do cult leaders and abusive partners both commonly use? 

Cultish: Techniques of Manipulation 

by Devon Price, PhD; New York: Atria Books, 2021.

Editor's Note: As clinicians who treat mental illness, we have undoubtedly seen individuals who are labeled “lazy.” Some of our patients who are suffering the most may be those who have labeled themselves lazy. Fortunately, for those of us who chastise ourselves for taking even a moment away from work to focus on ourselves, and for our patients who cudgel themselves too, 

. Dr Price, a social psychologist and professor at Loyola University of Chicago’s School of Continuing and Professional Studies, recently sat for an interview, conducted via Zoom, on the topic of laziness. The interview will hopefully whet the appetite to read and recommend this truly helpful book.

Q: When I heard that you had written a book about the concept of laziness, the first question that came into my mind was: have you ever been called lazy?

A. I have only ever called myself lazy. I think I have absolutely been a workaholic in the way that I think a lot of academics are trained to be. You get this idea that you need to have a full course load, you need to be doing service to the university, you need to be doing research. And you need to be a self-starter if you want to have even a prayer of a career. They kind of drill that into you even as an undergrad. I think I have always had that bug in the back of my brain telling me that I was not doing enough. Many of us feel pressure to be a self-made individual and to be very individualistic and successful. So I am someone who has not been called lazy too often, because I have been able to check off a lot of society’s little boxes that make you look like a good little worker bee.

Q: I have always thought that when someone comes to me and tells me “my spouse is lazy” or “my employee is lazy,” they are using a lazy word, because it does not really give a useful description of what is going on. Why do you think the word lazy is used so frequently in our society?

A: The word has always had an air of moral condemnation to it. Its root words mean both feeble or weak willed and morally corrupt. A lot of times it is easier to write someone off as lacking essential qualities, lacking some drive or willpower that you need to succeed, than it is to ask what can be done to help. Does this individual have needs that are not getting met? What struggles is this individual facing that are not being taken seriously? What structural problems are getting in their way? When somebody looks lazy, maybe they just see no reason why they should be doing a task. So that is also an important question to ask. Have we failed to motivate them and empower them?

Q: Those are much more difficult questions to ask.

A: It is hard to ask those questions. It is even harder to solve those problems once the questions have been asked. It is much easier to say, “Oh, I give up on this individual. They lack that essential quality that they need for success.”

Q: Your answers make it impossible to ignore the uneven playing field that so many individuals face when trying to succeed in life, and particularly in science and academia. Do you have any thoughts on how inequities affect perceptions of laziness?

A: It is a thorny problem. When you are teaching and mentoring, it is important (as much as possible) to be flexible when you can. At the same time, I think giving honest feedback is essential. “Listen, I understand that you have things going against you. I know that this is not a reflection of some flaw or failure in you. But we do need to get you to a certain level, and I really am invested in seeing you reach that level. So, what can I do to help support you?” There is a lot of social psychology research suggesting that instructors, especially white instructors, are uncomfortable giving critical feedback to black students. Even black students who are doing really well! They are afraid of being perceived as racist, so they overcorrect, and this is true of sexism and other biases as well. If you can, try to level with them: tell them where they need to grow and give them the same critical feedback that you would give anyone else. Also be there to support them through hardships that are not their fault. I think that can really make a big difference. But it is a steep uphill battle.

A: There are so many areas of life where individuals are made to feel like they are not enough. We have already talked about racism, sexism, and things like that. But workaholism pervades almost everything in American culture and life. That affects individuals’ self-image, their depression levels, their anxiety levels, and how much they put on their plate. We know that those things are huge risk factors for all kinds of psychiatric and psychological issues. If you are doing too much, that looks a lot like an anxiety disorder, or anxiety profile, even if maybe you otherwise would not be in that situation.

is an attending psychiatrist at Montefiore Medical Center. He is the Book Review editor at 

Patients and care providers often call themselves lazy. But what are the clinical consequences and cultural meanings of this term? 

Laziness Does Not Exist

by Adam Bisaga with Karen Chernyaev; New York: Experiment Publishing, 2019

Reviewed by Howard L. Forman, MD and Alexander Lichtenberg

Dr Forman is Assistant Professor of Psychiatry, Albert Einstein College of Medicine, and Director of the Addiction Consultation Service at Montefiore Medical Center, Bronx, New York. He is the Book Review Editor for Psychiatric Times. Mr Lichtenberg is a fourth-year medical student at New York Medical College and is currently applying for residency in psychiatry.

In recent years, hardly a day has passed without some news outlet mentioning the latest opioid epidemic. Indeed, there is a lot to cover: the origins of the epidemic in the promotion of opioid analgesics, the way opioids have torn apart families and communities across the country, and how lawmakers have attempted to respond. Doctors, patients, politicians, and journalists have all weighed in with different perspectives. As psychiatrists we see the destruction in our hospitals and clinics and many have grown weary of reading more and more tales of woe and chicanery masquerading as treatment.

Since so much has already been written, it is reasonable to wonder whether we need another book about this phenomenon? Dr Adam Bisaga, an addiction psychiatrist at Columbia University, makes the case for why we need more information-and urgently-in 

Overcoming Opioid Addiction: The Authoritative Medical Guide for Patients, Families, Doctors, and Therapists

. Despite the multitude of articles and books on the subject, there is little in the way of guidance for addressing opioid use disorder (OUD) that specifically addresses patients, their families, and non-expert medical professionals. Worse, there is even less accessible literature that is grounded in sound scientific evidence. Dr Bisaga, along with his coauthor, health writer Karen Chernyaev, seeks to fill that gap with this practical, intelligently constructed book.

The book is divided into four parts. Each can be read independent of the others since they cover similar material but address separate audiences. The first part describes the nature of OUD and its role in fueling the latest iteration of an opioid epidemic. The next part delves into the details of treating OUD with medication-assisted treatment (MAT), the only evidence-based means of managing OUD. The project of explaining and promoting MAT lies at the heart of the book and distinguishes it from other approaches to OUD that ignore, or may be hostile to, using any medications to treat OUD. The third section addresses the needs and concerns of family members of OUD sufferers, and the fourth part addresses patients.

What struck us most was the plain and direct language used in each part. The authors successfully distill their expertise in OUD into a text that can be understood by readers who have little or no scientific background. Free of medical jargon and pretentiousness, this volume will be especially useful for patients and their families looking for sensible advice in navigating the perils of OUD.

Dr Bisaga does not present MAT as a cure-all. To the contrary, he emphasizes the challenges of treating OUD with MAT and notes that OUD has no definitive cure. A key part of his argument is that more people should think of OUD as they would diabetes or any chronic medical condition. MAT, he writes, is a necessary but insufficient component of recovering from OUD.

He is remarkably conciliatory towards engaging with nonmedical modes of treatment-as long as those other methods do not interfere with MAT. For example, he encourages patients to try attending support groups such as Narcotics Anonymous, a 12-step program modeled after the popular Alcoholics Anonymous. However, he warns that some people in Narcotics Anonymous may not be accepting of individuals recovering with the use of MAT. The goal is to have MAT serve as a bedrock for patients to lead meaningful lives in a way that makes sense for each patient.

Whether for a patient, family member, or a professional working with OUD patients, 

 will serve as an invaluable resource for those who want to treat OUD with an evidence-based and compassionate approach. While trying to stop an epidemic can seem like an insurmountable task, Dr Bisaga has shown how progress can be made using medicine, one patient at a time.

This article was originally posted on 10/5/18 and has since been updated.

Since so much has already been written about the opioid epidemic, it is reasonable to wonder whether we need another book about this phenomenon? Experts make the case for why we need more information-and urgently.

Overcoming Opioid Addiction: The Authoritative Medical Guide

, but it may be more accurate to say she is a co-author, an editor, a dogged investigator of her own family’s history, and a sharer of her uncle’s memoir-a man who received a diagnosis of paranoid schizophrenia in his late adolescence. The book alternates between chapters Allen wrote and chapters that her Uncle Bob sent-a 60-page, single-spaced, typed-in-all capital letters manuscript-for her to edit and share. The book is timely but will also stand the test of time as an excellent contextualized first-person narrative of schizophrenia.

The release of the book comes amid a rising understanding that although we are 60 years into the antipsychotic era, these medications only partly help people with schizophrenia. In reading about Bob’s travels throughout the US, one comes across instances where working conditions, friends, and neighbors propelled Bob to periods of productivity and meaningfulness, despite the psychosis.

Another element of the book that makes it particularly relevant is its description of the sexual abuse and coercion of patients witnessed by Bob during several psychiatric inpatient stays. The #MeToo movement has brought growing recognition of the scale of sexual harassment, abuse, and assault across all arenas where imbalances of power exist. We would all like to believe that the care of vulnerable psychiatrically ill patients who are often placed on locked units for their “own good” would be immune to this societal ill. But, at the same time we know that these Pollyannaish beliefs cannot be true. As the people charged with fiduciary responsibility for our patients, the book motivates us to do more to protect our patients.

 includes cringe-worthy psychiatrists and heroic ones. One psychiatrist consistently refuses to engage with Bob but instead makes medication decisions without examination. Later, Bob meets a psychiatrist who works in both inpatient and outpatient settings to develop a treatment that is consistent with Bob’s values and hopes. Similarly, there are hospitals that patients seek out for their peaceful and healing environments while others are like prison.

Psychiatrists may find Allen’s book useful when considering the sacrifices families make to help their severely and persistently mentally ill loved ones get treatment. The financial and emotional toll is huge for those who seek access to mental health care for their loved ones or for those who advocate for them in the criminal justice system. Although laws governing patient privacy often prevent us from being able to reduce this toll, awareness can lead us to be more sensitive caregivers.

As a psychiatrist, I have sought to understand the minds of my patients who exist in both the “real” world and in the delusional world. Bob’s writing offers the reader an eloquent way of seeing the way these worlds flow seamlessly from one to another and back. My hope is that it will become a classic and universally read by all psychiatrists.

Dr Forman is Assistant Professor of Psychiatry, Albert Einstein College of Medicine, and Director of the Addiction Consultation Service at Montefiore Medical Center, Bronx, New York.

The release of the book described here comes amid a rising understanding that although we are 60 years into the antipsychotic era, these medications only partly help people with schizophrenia.

A Kind of Mirraculas Paradise by Sandra Allen

Fantasy, suicidal ideation, ecstasy, pride, shame, opportunities gained, opportunities lost, fortunes made and fortunes squandered-these are some of the topics that a psychiatrist will encounter. Often, they are the factors that drive people into states of mental illness or ones that perpetuate suffering. Each of these topics is given thorough consideration in a new podcast series, 

by Jon Ronson and produced by Lina Misitzis (available at 

 tells the story behind the wide availability of free internet pornography, the psychiatrist listener will quickly appreciate that this is only the beginning of the story.

, a book that told the story of nearly instant and almost universal shaming made possible by social media. In this book, he encourages all to consider others not as either “intelligent” “stupid” “moral” or “immoral” but rather everyone is a mixture of these and infinite other elements.

studies free internet porn as a continuation of his study into shame and its harmful effects. The stories he tells will resonate with practicing psychiatrists who now toil in the tidal wave that this pornographic expansion has set in motion; the unprecedented numbers of young people who now have video of sexual behavior living for eternity, the exposure to performance sex that is perfectly matched to and the emergence of younger generation of men unable to achieve arousal with their real-life sexual partners.

Mr. Ronson was interviewed in New York about 

in general and about its relevance to the practicing psychiatrist.

 I consider myself, I guess a storyteller. I try and find stories, mainly nonfiction, but sometimes fiction these days, that sort of shed light on the way the world works. And I suppose I'm always ... I'm pretty much always looking for stories that are kind of humanist, for want of a better word. And sort of stories ... The older I get, I think it's more stories that kind of bring people together as opposed to push people apart. So I guess stories about empathy and curiosity as opposed to what a lot of other journalists do, which is judgment.

 You have said in other interviews that you like stories about outsiders. And I was wondering, do you have any insight or ideas as to why this is the case?

 Yeah, I'm pretty sure. This famous British writer called Caitlin Moran said that it definitely goes back to the fact that I was bullied at school. And so I'm trying to make sense of the horrors of the world by going to the places where you might find horror and de-horrorizing it.

But I think I would say I'm definitely drawn to outsiders because both as a Jew and also as somebody who grew up in wrong town, I was an outsider.

as a continuation of your appraisal of internet shaming in 

 Yes, It's all about re-humanizing . . . It's all about people not thinking about the consequences of their actions on the internet. So that's a very big parallel between the two stories. It's about me trying to re-humanize demonized people-and also about making people think about ripples and consequences.

 Can you comment on what you perceived as the presence of mental illness in the pornography industry that you studied so intensely for this project?

 Suggest a sentence rephrase: When I started writing 

 I asked psychologist Ray Hymen, "Why are so many people who believe crazy things inside the intelligence services?" He said, "Because people are nuts. People are nuts inside the intelligence services; they're nuts outside the intelligence . . . They're just nuts."

And I thought, the other day I was talking, I was being interviewed by this really great British podcast they've got out and the interviewer asked "Yeah, but surely the porn world is full of people who've had really terrible childhoods, and are very sort of emotionally damaged." And I was like, "Yeah, but where else do you find people who've had really bad childhoods and they're really emotionally damaged? Everywhere."

 What do you hope most practicing psychiatrists take away from 

 I think it's about empathy and curiosity and compassion and being more important than judgment and suspicion. In many ways it's about trying to get people to rethink what they consider reputable and what they consider disreputable. And then speaking out about that.

While ostensibly The Butterfly Effect tells the story behind the wide availability of free internet pornography, the psychiatrist listener will quickly appreciate that this is only the beginning of the story.

The Butterfly Effect: An Interview With Jon Ronson

Ranger Games: A Story of Soldiers, Family and an Inexplicable Crime

With the exception of his last name, Alex Blum was as all-American a kid as one could conjure up for any afterschool special. Growing up in Colorado his only dream was to be an Army soldier and to serve his country as a member of its most elite infantry formation, the Rangers. Before his enlistment he coached youth hockey teams; he didn’t drink alcohol or use drugs because he worried they would ultimately make him a weaker soldier.

After completing basic training and the Ranger Indoctrination Program, Alex was days away from being deployed to Iraq to fulfill his dream of fighting for the US. He never made it. On August 7, 2006, he robbed a bank.

 (Penguin Random House), written by his first cousin Ben Blum, is the 400-page account of the life leading up to August 7, 2006, and the psychiatric considerations of what led to this seemingly inexplicable crime and its aftermath. While non-fiction, the psychiatrist reader will recognize the many fictions accumulated when a single event is visited over and over again, by patients and by ourselves. The reader of 

 will become familiar with many psychiatric explanations for aberrant behavior and see each held up to light to determine if they are “authentic.” Moreover, at a time when there are more living veterans of the Armed Forces than at any other time, the book gives an inside account of what many of our service men and women endure in order to serve their country. The book is a roller-coaster ride that you won’t want to end, but is over much too quickly.

: What other titles did you consider for the book and how did you settle on Ranger Games?

: The original working title was Bad Apples, referring to the typical military characterization of errant soldiers as independent bad actors rather than manifestations of systemic problems. After that I considered, Of Their Own Accord, the English translation of the official Ranger motto, Sua Sponte, which addresses the extremely complicated question of how freely the various participants in the robbery acted. Eventually my editor and I settled on Ranger Games, which points to the way our behavior, beliefs, and moral norms can be incrementally redirected through seemingly unreal situations, “games,” that appear to have no real stakes.

Modern military training operates on this principle-as does, increasingly, modern military practice, in which drone killings can be effected on a video screen from thousands of miles away. Specialist Luke Elliott Sommer managed to ensnare half a dozen elite soldiers in a ludicrous bank robbery scheme which they all thought at first was just a game.

 In addition to being “about” Alex, the book also considers family mythology. Mythology often replaces ugly fact with beautiful fantasy. What types of mythology do you think are helpful or were helpful to the Blums? Which were or are hurtful? Do you miss your family’s mythology?

 Good mythology preserves the heroic essence of history, uniting us in a vision of our best selves. Much of Blum family mythology centered around our grandfather, Albert Likes Blum Senior, who landed in Normandy shortly after D-Day. Alex and I grew up thinking of him as a maverick war hero. The stories about Al Senior conveyed core Blum family values: toughness, self-sufficiency, questioning of arbitrary rules and authority. On digging further into his story, though, I discovered that the mythology obscured some pretty ugly misconduct. Learning about my grandfather’s faults shed enormous light on certain unhealthy strains in our family culture. I’m not at all sad to see those myths go.

I’ve come to view mythology as a necessary container for truths we either don’t yet know or are not yet ready to face. Some mythology is explicitly for children: complex human stories boiled down into simple tales that can fill out with nuance the more children learn about human nature. Other mythology, for instance nationalist mythology, is addressed to those unexamined parts in all of us that haven’t grown into full enough understanding to process the uncomfortable historical truths that myths ignore.

 How do you feel about the Ranger Indoctrination Program? Am I wrong to have thought at one point that this is the worst thing I have ever read about and then later to question whether Alex accurately reported it?

 You’re right to question whether Alex was an accurate reporter of the extent to which the training influenced his participation in the robbery. Some of the rhetoric about the way it turned him into a mindless automaton is way overblown. But as a record of what recruits are made to endure, and of the emotional experience of enduring it, I’ve found no reason to doubt Alex’s account-other Rangers have read it and confirmed the basic facts. Whether for a fraternity or an elite military organization, initiation rites are meant to be agonizing. That’s what gives them their power. If they don’t break you, they induce tremendous loyalty and deep fraternal bonds. As long as we have war, I believe we’re going to have training of that kind.

 Do you have any thoughts on what you believe a therapist needs to know or should know about veterans of our elite forces who may seek help from a mental health professional?

BB: It was very hard for Alex to accept any pushback on his own deeply entrenched narratives about the Rangers and the crime before I learned enough about the Rangers to express what he viewed as the proper level of respect. The culture of elitism makes for a radical distrust of outsiders. Mental health professional should be open to what these individuals have to tell you. Much of what elite forces do is incredibly impressive and embodies values that we all hold dear.

 is a book that will leave the reader with lots of questions answered but also a desire to ask many more. One may ask where Alex Blum is today, and I can assure you that the book answers that questions. But telling you would be a spoiler and would cheat you of finding out for yourself by reading about the highs and lows that led Alex to his current state of being. If you cannot take the suspense but don’t have the time to (or don’t want to) read the book, you can email me and I will let you know (

An inside account of what many of our service men and women endure in order to serve their country.