NOTE:

The following text is a transcription of Grinspoon & Bakalar's introduction to the history and use of psychedelics in the field of psychotherapy, originally published in Current Psychiatric Therapies in 1981 (20:275-283). Lester Grinspoon is an Associate Professor of Psychiatry at Harvard University, and James Bakalar is a Lecturer in Law in the Department of Psychiatry at Harvard Medical School. One error in reference numbering and one in spelling (a typo) were corrected.

Ron Koster
October, 1996


Lester Grinspoon, M.D.
James B. Bakalar


The Psychedelic Drug Therapies


Between 1950 and the mid-1960s there were more than a thousand clinical papers (discussing 40,000 patients), several dozen books, and six international conferences on psychedelic drug therapy. Almost all publication and most therapeutic practice in this field have now come to an end, however, as much because of legal and financial obstacles as because of loss of interest.
There were two main sources of therapeutic involvement. One of these was the belief of some experimental subjects that, after taking a psychedelic drug, they were less depressed, anxious, guilty, and angry and more self-accepting, tolerant, deeply religious, and sensually alert.1 The other main interest arose from the possibility that therapeutic use could be made of the powerful psychedelic experiences of regression, abreaction, intense transference, and symbolic drama in psychodynamic psychotherapy.
As a result, two polar forms of lysergic acid diethylamide (LSD) therapy emerged: one emphasized the mystical or conversion experience and its aftereffects; the other concentrated on exploring the labyrinth of the unconscious in the manner of psychoanalysis. Psychedelic therapy, as the first of these was called, involved the use of a large dose of LSD (200 µg or more) in a single session and was thought to be helpful in reforming alcoholics and criminals, as well as in improving the lives of normal people. The second type, psycholytic (literally, mind-loosening) therapy, required relatively small doses (usually not more than 150 µg) and several or even many sessions; it was used mainly for neurotic and psychosomatic disorders.2,3
In the psycholytic procedure, patients may be hospitalized or not; they may be asked to concentrate on interpretation of the drug-induced visions, on symbolic psychodrama, on regression with the psychotherapist as a parent surrogate, or on discharge of tension in physical activity. Props such as eyeshades, photographs, and objects with symbolic significance are often used. Music often plays an important part. The theoretical basis of this kind of psychotherapy is usually some form of psychoanalysis. If birth experiences are seen as true relivings of the traumatic event, Rank's ideas may be introduced; if archetypal visions are regarded as genuine manifestations of the collective unconscious, the interpretations will be Jungian.
An advantage of psychedelic drugs in exploring the unconscious is that a fragment of the adult ego usually keeps watch through all the fantasy adventures. Patients remain intellectually alert and remember their experiences vividly. They also become acutely aware of ego defenses such as projection, denial, and displacement as they catch themselves in the act of creating them. Transference can also be greatly intensified.
Psycholytic therapy has been recommended to speed up psychoanalysis and psychoanalytically oriented psychotherapy, especially for people with excessively strict superegos and a lack of self-esteem. It has also been used to overcome the resistance of severe chronic neurotics with defenses so rigid that they would otherwise be inaccessible to treatment.
In practice, many combinations, variations, a special applications with some of the features of both psycholytic and psychedelic therapy have evolved. Stanislav Grof regards the form of treatment he developed in Czechoslovakia as a bridge between psycholytic and psychedelic therapy. The unconscious material brought into consciousness by LSD is said to incorporate the most significant events in the patient's emotional life and permit a systematic exploration of personality along Freudian lines. This is followed by reliving the birth trauma and then passage into the realm of archetypes and mystical or transpersonal experience.4
The Chilean psychiatrist Claudio Naranjo has pioneered the use of psychedelic drugs that do not produce the same degree of perceptual and emotional disturbance as LSD. Harmaline and ibogaine, which he calls fantasy enhancers, permit the use of guided fantasy techniques borrowed from Gestalt therapy to explore unconscious conflicts. The "feeling enhancers," 3,4 methylenedioxyamphetamine (MDA) and the 3-methoxy-4,5 compound (MDMA), give a heightened capacity for introspection and intimacy along with a temporary freedom from anxiety and depression.5


NEUROTIC DISORDERS

One woman described her experience with psycholytic therapy this way:6

I found that in addition to being, consciously, a loving mother and a respectable citizen, I was also, unconsciously, a murderess, a pervert, a cannibal, a sadist, and a masochist. In the wake of these dreadful discoveries, I lost my fear of dentists, the clicking in my neck and throat, the arm tensions, and my dislike of clocks ticking in the bedroom. I also achieved transcendent sexual fulfillment. . . .
At the end of nine sessions, over a period of nine weeks, I was cured of my hitherto incurable frigidity. And at the end of 5 months, I felt that I had been completely reconstituted as a human being. I have continued to feel that way ever since.
These passages were written 3 years after a 5-month period during which she took LSD 23 times. Before that, she had had 4 years of psychoanalysis, but it was only after taking LSD that she became fully convinced of the value of Freud's theories.
Psycholytic therapy has also been reported to be successful in treating chronic migraine headaches:7
A 22-year-old woman who had suffered from migraine for 11 years went through nine LSD sessions. She relived trips to the dentist, her fear when she was given anesthesia for a tonsillectomy, and her desolation at being abandoned in a hospital when she was 11 years old. The migraine disappeared; 3 years later she and her husband wrote that she has felt less tense, more at peace with herself, and more mature; the migraine never returned.
Psychedelic drugs can also be used as a treatment for more ordinary forms of neurotic depression and anxiety and to resolve sexual problems.8, 9
Individual case histories, however impressive, can always be questioned; placebo effects, spontaneous recovery, and the therapist's and the patient's biases in judging improvement must be considered. Not many studies satisfy stringent methodological conditions; the most serious deficiencies are absence of controls and inadequate follow-up. In the case of LSD there is the special difficulty that a double blind study is impossible, since the effects of the drug are unmistakable. No form of psychotherapy for neurotics has ever been able to justify itself under stringent controls, and LSD therapy is no exception.10, 11 Most psychiatrists who have done LSD therapy with neurotics would, however, probably regard all the recorded controlled experiments as far too brief and superficial to provide a genuine test, especially where so much may depend on the quality of the therapeutic relationship.
For LSD therapy, as in psychoanalysis, psychiatrists tend to favor neurotics with hight intelligence, a genuine wish to recover, a strong ego, and stable, even if crippling, symptoms. Beyond that, little is clear. Should the emphasis be on expression of repressed feelings, or working through a transference attachment to the psychiatrist, or elsewhere? What should the psychiatrist do during the drug session? How much therapy is necessary in the intervals between LSD treatments? The fact that there are no general answers to these questions reflects the complexity of psychedelic drug effects; for the same reason a dose and diagnosis cannot be specified in the manner of chemotherapy.


ALCOHOLISM

Assuming that a single overwhelming experience can sometimes change the self-destructive drinking habits of a lifetime, can psychedelic drugs consistently produce such an experience?
There is no doubt that LSD often produces powerful immediate effects on alcoholics; the question is whether these can be reliably translated into enduring change. Early studies reported dazzling success: about 50% of sever chronic alcoholics treated with a single high dose of LSD recovered and were sober a year or two later.12, 13
Unfortunately, as the results of more careful research began to come in, the picture changed. All the early studies had insufficient controls, and most lacked objective measures of change, adequate follow-up, and other safeguards.14 When patients were randomly assigned to drug and control groups, it proved impossible to demonstrate any advantage for LSD. Even the most enthusiastic advocates of LSD have not been able to produce consistently promising results.15
Ludwig et al. at the Mendota State Hospital in Madison, Wisconsin undertook an elaborate and methodologically adequate study of psychedelic therapy for alcoholics. The 195 patients were randomly divided into four treatment groups. All had 30 days of milieu therapy; three groups had in addition, LSD alone, LSD with psychotherapy, or LSD with psychotherapy and hypnosis. The results in all four groups were the same after 3, 6, 9 and 12 months; about 75% improved on measures of employment, legal adjustment, and drinking habits.16
It would be wrong to conclude that a psychedelic experience can never be a turning point in the life of an alcoholic. Bill Wilson, the founder of Alcoholics Anonymous, said that his LSD trip resembled the sudden religious illumination that changed his life. Unfortunately, psychedelic experiences have the same weaknesses as religious conversions. Their authenticity and emotional power are not guarantees against backsliding when the same frustrations, limitations, and emotional distress have to be faced in everyday life. When the revelation does seem to have lasting effects, it might always have been merely a symptom of readiness to change rather than a cause.
Analogous are the religious ceremonies of the Native American Church, in which regular use of high doses of mescaline in the form of peyote is regarded as, among other things, part of a treatment for alcoholism. Obviously peyote is no panacea; otherwise, alcoholism would not be the major health problem of Native Americans. Nevertheless, Native Americans themselves and outside researchers believe that those who participate in the peyote ritual are more likely to be abstinent.17 Peyote sustains the ritual and religious principles of the community of believers, and these sometimes confirm and support an individual's commitment to give up alcohol.


DYING

In a letter to Humphry Osmond, Aldous Huxley recounted a mescaline trip during which he came to the conclusion that, "I didn't think I should mind dying; for dying must be like this passage from the known [constituted by lifelong habits of subjectobject existence] to the unknown cosmic fact [p.306]"18 When Huxley was dying, he asked his wife to give him 100 µg LSD, the drug he had portrayed in his last novel as the liberating moksha medicine. After that he looked at her with an expression of love and joy but spoke little except to say, when she gave him a second injection of LSD, and shortly before he died, "Light and free, forward and up." Laura Huxley, in the memoirs of her husband writes: "Now is his way of dying to remain for use, and only for us, a relief and a consolation, or should others also benefit from it? Aren't we all nobly born and entitled to nobly dying? [p. 308]."18
There is a new concern today about dying, in full consciousness of its significance as a part of life. As we look for ways to change the pattern, so common in chronic illness, of constantly increasing pain, anxiety, and depression, the emphasis shifts away from impersonal prolongation of physiological life toward a concept of dying as a psychiatric crisis, or even, in older language, a religious crisis. The purpose of giving psychedelic drugs to the dying might be stated as reconciliation: with one's past, family, and human limitations. Granted a new vision of the universe and their place in it, the dying learn that there is no need to cling desperately to the self.
Beginning in 1965, the experiment of providing a psychedelic experience for the dying was pursued at the Spring Grove State Hospital in Maryland, and later at the Maryland Psychiatric Research Institute. Walter N. Pahnke, the director of the cancer project from 1967 until his accidental death in 1971, was a doctor of divinity as well as a psychiatrist, and he first reported on his work in 1969. Seventeen dying patients received LSD after appropriate therapeutic preparation; on-third improved "dramatically," one-third improved "moderately," and one-third were unchanged by the criteria of reduced tension, depression, pain, and fear of death.19 The results of later experiments using LSD and dipropyltryptamine have been similar.20 These studies lacked control groups, and there is no sure way to separate the effects of the drug from those of the special therapeutic arrangements that were part of the treatment.


COMPLICATIONS AND DANGERS

The main danger in psychedelic drug therapy is the same in any deep-probing psychotherapy: if the unconscious material that comes up can be neither accepted and integrated nor totally repressed, symptoms may become worse, and even psychosis or suicide is possible. The potential for harm has, however, been exaggerated, for two reasons. First, much irrational fear and hostility is left over from the cultural wars of the 1960s. Second, and more generally, we tend to misconceive drugs as something utterly different from and almost by definition more dangerous than other ways of changing mental processes. Actually, the dangers in work with LSD do not seem obviously greater than in comparable forms of therapy aimed at emotional insight.
The most serious danger is suicide, and there are several reports of suicide attempts or actual suicide among patients in psychedelic drug therapy. But many people who have worked with psychedelic drugs consider them more likely to prevent suicide than to cause it. H Clark and R Funkhouser asked about this in a questionnaire distributed to 302 professionals who had done psychedelic drug research and to 2230 randomly chosen members of the American Psychiatric Association and American Medical Association. Of the 127 answering in the first group, none reported any suicides caused by psychedelic drugs, and 18 thought they had prevented suicide in one or more patients; of the 490 responding in other groups, one reported a suicide and seven believed suicidal tendencies had been checked.21
All available surveys agree that therapeutic use of psychedelic drugs is not particularly dangerous. In 1960, Sidney Cohen made 62 inquiries to psychiatrist and received 44 replies covering 5000 patients and experimental subjects, all of whom had taken LSD or mescalinea total of 25,000 drug sessions. The rate of prolonged psychosis (48 hours or more) was 1.8 per 1000 in patients and 0.8 per 1000 in experimental subjects; the suicide rate was 0.4 per 1000 in patients during and after therapy, and zero in experimental subjects.22 Other studies have confirmed Cohen's conclusion that psychedelic drugs are relatively safe when used experimentally or therapeutically.
All these studies have serious limitations. Many psychiatrists may have minimized the dangers out of therapeutic enthusiasm and reluctance to admit mistakes; a few may have exaggerated them under the influence of bad publicity; long-term risks may have been underestimated if follow-up was inadequate. The problem is the absence of a basis for comparison between these patients and others with similar symptoms who were not treated with psychedelic drugs or not treated at all. However, psychedelic drugs were used for more than 15 years by hundreds of competent psychiatrist, who considered them reasonably safe as therapeutic agents, and no one has effectively challenged this opinion.


CONCLUSION

When a new kind of therapy is introduced, especially a new psychoactive drug, events follow a common pattern. At the beginning, there is spectacular success, enormous enthusiasm, and a conviction that it is the answer to a wide variety of psychiatric problems. Then the shortcomings of the early work become clear: insufficient follow-up, absence of controls, inadequate methods of measuring change. More careful studies prove disappointing, and the early anecdotes and case histories begin to seem less impressive. Later, psychiatrists fail to obtain the same results as their pioneering predecessor. As Sir William Osler said, "We should use new remedies quickly, while they are still efficacious."
The rise and decline of LSD, however, took an unusual course. In 1960, 10 years after it was introduced into psychiatry, its therapeutic prospects were still considered fair and the dangers slight. Then the debate received an infusion of irrational passion from the psychedelic crusaders and their enemies. The revolutionary proclamations and religious fervor of the nonmedical advocates of LSD began to evoke hostile incredulity rather than mere natural skepticism about the extravagant therapeutic claims backed mainly by intense subjective experiences. Twenty years after its introduction it was a pariah drug, scorned by the medical establishment and banned by the law. In rejecting the notion that psychedelic drugs are a panacea, we have chosen to treat them as entirely worthless and extraordinarily dangerous. Perhaps the time has come to find an intermediate position.
If therapeutic research becomes possible again, it might be good to begin with the dying, since in this case only short-term effects have to be considered. Psychedelic drugs might also be used to get past blocks in ordinary psychotherapy: to help patients decide whether they want to go through the sometimes painful process of psychotherapy, or to help a psychiatrist to decide whether a patient can benefit from the kind of insight that psychotherapy provides. In addition, MDA, harmaline, ketamine, and other psychedelic drugs with unique effects still need to be evaluated.
Psychedelic drug therapy apparently still goes on unofficially. People would not continue to practice it under difficult conditions unless they believed they were accomplishing something. Many regard it as an experience worth having, some as a first step toward change, and a few as a turning point in their lives. It would simplify matters if we would be sure that they were deceiving themselves, but we do not know enough about what works in psychotherapy to say anything like that. No panacea will be discovered any more than in psychoanalysis or religious epiphanies. Nevertheless, the field obviously has potential that is not being allowed to reveal itself.


REFERENCES

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2. Sherwood JN, Stolaroff MJ, Harman WW: The psychedelic experiencea new concept in psychotherapy. J Neuropsychiatry 2:59-66, 1967

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4. Grof S: Realms of the Human Unconsious: Observations from LSD Research. New York, Viking Press, 1975

5. Naranjo C: The Healing Journey. New York, Ballantine Books, 1975

6. Newland CA: My Self and I. New York, New American Library, 1962

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13. Hoffer A: A program for the treatment of alcoholism: LSD, malvaria and nicotinic acid, in Abramson H (ed): The use of LSD in Psychotherapy and Alcoholism. New York, Bobbs-Merrill, 1967

14. Smart RG, Storm T, Baker EFW, et al: A controlled study of lysergide in the treatment of alcoholism. Q J Stud alc 27:469-482, 1966

15. Sarett M, Cheek F, Osmond H: Reports of wives of alcoholics on effects of LSD-25 treatment on their husbands. Arch Gen Psychiatry 14:171-178, 1966

16. Ludwig AM, Levine J, Stark LH: LSD and Alcoholism: A Clinical Study of Treatment Efficacy. Springfield, Ill, Charles C Thomas, 1970

17. Roy C: Indian peyotists and alcohol. Am J Psychiatry 130:329-330, 1973

18. Huxley LA: This Timeless Moment. New York, Farrar, Straus, & Giroux, 1968

19. Pahnke WN: The psychedelic mystical experience in the human encounter with death. Harvard Theol Rev 62:1-21, 1969

20. Grof S, Goodman LE, Richards WA, et al: LSD-assisted psychotherapy in patients with terminal cancer. Int Pharmacopsychiatry 8:129-141, 1973

21. Clark WH, Funkhouser GR: Physicians and researchers disagree on psychedelic drugs. Psychol Today 3:48-50, 70-73, 1970

22. Cohen S: Lysergic acid diethylamide: Side effects and complications. J Nerv Ment Dis130:30-40, 1960

23. Malleson N: Acute adverse reactions to LSD in clinical and experimental use in the United Kingdom. Br J Psychiatry 118:229-230, 1971