Comprehensive Crisis Intervention In Psychedelic Emergencies

Having discussed the factors that contribute to the development of emergencies in unsupervised LSD sessions and described the harmful practices that characterize most professional and lav interventions, I would like to outline what I consider the optimal approach to psychedelic crises, based on the understanding of their dynamics. What constitutes an emergency in an LSD session is highly relative, and depends on a variety of factors. It reflects an interplay between the subject's own feelings about the experience, the opinions and tolerance of the people present, and the judgment of the professional called upon to offer help. This last is a factor of critical importance; it depends upon the therapist's degree of understanding of the processes involved, his or her clinical experience with unusual states of consciousness, and his or her freedom from anxiety. In psychedelic crisis intervention, as in psychiatric practice in general, drastic measures frequently reflect the helpers' own feelings of threat and insecurity, not only vis á vis possible external danger, but also in relation to their own unconscious. The experience from LSD therapy and the new experiential psycho therapies clearly indicates that exposure to another person's deep emotional material tends to shatter psychological defenses and to activate corresponding areas in the unconscious of the persons assisting and witnessing the process, unless they have confronted and worked through these levels in themselves. Since traditional psychotherapies are limited to work on biographical material, even a professional with full training in analysis is inadequately prepared to deal with powerful experiences of a perinatal and transpersonal nature. The prevailing tendency to put all such experiences into the category of schizophrenia and suppress them in every way reflects not only a lack of understanding, but also a convenient self-defense against the helpers' own unconscious material.

As the sophistication and clinical experience of LSD therapists has increased, it has become more and more evident that negative episodes in psychedelic sessions should not be seen as unpredictable accidents, but intrinsic and lawful aspects of the therapeutic work with traumatic unconscious material. From this point of view the colloquial term "bummer" or "bad trip" does not make sense. To an experienced LSD therapist an unsuccessful psychedelic session is not one in which the subject experiences panic anxiety, self-destructive tendencies, abysmal guilt, loss of control, or difficult physical sensations. If properly handled, a painful and difficult LSD session can bring about an important therapeutic breakthrough. It can facilitate resolution of problems that have plagued the subject in subtle ways for many years and contaminated his or her everyday life. An unsuccessful session, however, is one in which difficult feelings begin to emerge, the subject does not fully surrender to the process and the gestalt remains unresolved. From this point of view, all psychedelic experiences in which the process is thwarted by the administration of tranquillizers and external distractions such as transfer to a psychiatric hospital are not failures because of the nature of the psychological process involved, but because the crisis management has interfered with a positive resolution.

Although LSD can induce difficult experiences even under the best cir-

curnstances, it would be a mistake to attribute all "bad trips" to the drug itself. The psychedelic state is determined by a variety of non-drug factors; the incidence of serious complications depends critically on the personality of the subject, and the elements of set and setting. This can be illustrated by comparing the incidence of complications during the early supervised experimentation with LSD, and the psychedelic scene of the sixties. In I960, Sidney Cohen published a paper entitled, LSD: Side Effects and Complications. ]. Nerv. Ment. Dis. 130:30, I960. It was based on reports from forty-four professionals who had administered LSD and mescaline to about five thousand persons over twenty-five thousand times; the number of sessions per person ranging between one and eighty. In the group of normal volunteers, the incidence of attempted suicides after the session was less than one in a thousand cases, and that of prolonged reactions lasting over forty-eight hours was 0.8 per thousand. The numbers were somewhat higher when psychiatric patients were used as subjects; in every thousand patients there were 1.2 suicide attempts, 0.4 completed suicides and 1.8 prolonged reactions lasting over forty-eight hours. In comparison with other methods of psychiatric therapy, therefore, LSD appeared to be unusually safe, particularly when contrasted with other procedures used routinely in psychiatric treatment at that time, such as elec-troshocks, insuline comas, and psychosurgery. These statistics contrast sharply with the incidence of adverse reactions and complications associated with unsupervised experimentation. During my visit to the Haight-Ashbury clinic in San Francisco in the late sixties, I was told by its director David Smith that tlicy were treating an average of fifteen "bad trips" a day. Although this docs not necessarily mean that all these clients had long-lasting adverse effects from their psychedelic experiences, it illustrates the issue in question.

The experience and sophistication of psychiatrists and psychologists in relation to psychedelics was certainly not great during the early years and the settings were far from ideal. However, the sessions reported in Dr. Cohen's paper were conducted in protected environments, under reasonable supervision and by responsible individuals. In addition, those who had difficult experiences were in a place that was equipped to provide help in case of need and they did not have to be subjected to the absurd ordeal of transfer to a psychiatric facility.

The psychedelic crisis is caused by a complicated interplay of internal and external factors. The therapist has to distinguish which of the two sets of influences is more important and proceed accordingly. The first and most important step in handling a psychedelic crisis is to create a simple, safe and supportive physical and interpersonal environment for the subject. In cases where external factors seem to have played a crucial role, it is important to remove the individual from the traumatic situation or change it by active intervention. If the crisis occurred in a public locale, he or she should to be taken to a quiet, secluded place. If the incident happens during a party in a private residence, it is important to simplify the situation by moving to a separate room or asking the guests to leave. A few close friends who appear sensitive and mature may be asked to assist in the process. They can provide group support or help the subject to actively work through the underlying problem during the termination period of the session. The techniques of group involvement in psychedelic sessions have been discussed earlier in this book (p. 157).

After creating a safe environment the next important task is to establish good contact with the subject. A relationship of trust is probably the most significant prerequisite for the positive outcome of a psychedelic session in general and for successful handling of a crisis in particular. A person asked to intervene in a crisis triggered by LSD is at a great disadvantage as compared to an LSD therapist facing a similar situation in the course of psychedelic treatment, because the therapeutic session is preceded by a drug-free preparation period during which there is enough time to establish good contact and a relationship of trust. If a difficult situation arises in the course of an LSD series, the client can also draw on his or her memories of previous sessions where painful experiences had been successfully worked through and integrated with the help of the therapist.

In contrast, the professional dealing with a crisis outside of the therapeutic context walks into the emergency situation as a stranger, usually without any previous contact with the subject and other persons involved. Trust and cooperation have to be established in a very short time and often under dramatic circumstances. Freedom from anxiety, an ability to remain centered, deep empathy, and intimate knowledge of the dynamics of psychedelic states are the only means of generating trust under these circumstances.

It is essential to convey a sense of safety and security by emphasizing the self-! limiting nature of the LSD experience. No matter how critical the condition appears to be, in most instances it will be resolved spontaneously five to eight hours after the ingestion of the drug. This time limit should be clearly communicated to the subject and other people present; until that time there is absolutely no reason to panic or worry, however dramatic the emotional and psychosomatic manifestations might be. It is also of great advantage to keep the subject in a reclining posi^ tion, but this should be attained without using physical force and open restraint. With a little experience, one can develop a technique with which it is possible to effectively restrain the individual using a context of support and cooperation rather than conflict.

When adequate contact has been established, a positive framework should be offered for the difficult LSD experience. It is essential to present it as an opportunity to face and work through certain traumatic aspects of one's unconscious ■ rather than as an unfortunate and tragic accident. A person assisting in a psychedclic crisis should make consistent attempts to internalize the experience of _ the LSD subject and encourage him or her to face the critical issues involved. The LSD subject should be encouraged to keep his or her eyes closed and confront the experience, whatever it is. The therapist should repeatedly communicate to the subject that the quickest way out of this difficult state is through surrendering to the emotional and physical pain, experiencing it fully and finding appropriate channels to express it. This process of surrendering can be greatly facilitated by music. If a good high-fidelity stereo set is available, and the subject is open to it, music should be introduced into the situation as soon as possible.

When good rapport has been established, it is possible to offer active assistance using comforting physical contact, elements of playful struggle, and pressure on or massage of the parts of the body where the energy appears to be_ blocked. This should not be done if the trust bond is precarious or absent; it is absolutely contraindicated if the subject is paranoid and includes the people present among his or her persecutors. In some instances simply being with the client and playing for time might be the only solution. Under such circumstances, it is essential to use any possible means and existing resources to keep the LSD subject from hurting himself or others and causing serious material damage. While following this basic rule, occasional attempts should be made to establish rapport and gain the individual's cooperation.

If the gestalt of the experience remains unfinished when the effect of the drug is subsiding, psychological and physical activity should be used to facilitate integration. Ideally, the subject should complete the session feeling comfortable and relaxed, without any residual emotional or psychosomatic symptoms. The two techniques that have proven useful in this context — the abreactive approach and the cleansing hyperventilation — have been discussed earlier in this book (pp. 156-7, 159-60). After the subject reaches a psychologically and physically comfortable state, it is important to create a safe and nourishing atmosphere for the rest of the day and night. Ideally, a person who has been through a psychedelic crisis should not be left alone for at least twenty-four hours after the ingestion of the drug. After this time the therapist should see the client again, reevaluate the situation and, depending on his or her condition, choose the future strategy. In most instances no further provisions are necessary if the crisis was properly handled. It is useful to discuss the LSD experience in detail and facilitate its integration into the client's everyday life. If significant emotional and psychosomatic complaints have appeared as a result of the LSD experience, arrangements should be made for follow-up uncovering therapy and body work. An individualized selection of meditation techniques, Gestalt practice, neo-Reichian approaches, guided imagery with music, controlled breathing, polarity massage or rolfing should be? offered to the client.

Where the clinical condition remains precarious despite all the uncovering work, this treatment may have to be continued on an in-patient basis. If all the above approaches prove ineffective, integration can be facilitated by chemical means. Ideally, a supervised psychedelic session should be scheduled after adequate preparation. .This approach might seem paradoxical to the average mental health professional, since it involves administration of the same drug or category of drugs that apparently brought the client trouble in the first place. Yet judicious use of psychedelics under these circumstances is the preferred treatment. Clinical experiences have shown that it is extremely difficult to restore defenses by the use of covering techniques such as tranquillizers, once the unconscious has been opened by a powerful psychedelic substance. It is much easier to continue the uncovering strategy and facilitate completion of the unfinished gestalt.

Psilocybin, methylene-dioxy-amphetamine (\JDA), tetrahydrocannabinol (THC), and dipropyltryptamine (DPT) are viable alternatives to LSD. They have the same general effects and are less contaminated by bad publicity. MDA and THC seem to be particularly useful in this context, because of their gentle effect and selective affinity to positive governing systems in the unconscious. Effective psychological work with these substances involves less emotional and psychosomatic pain than when LSD is used.

Since the above psychedelics are not readily available, and obtaining per-,, mission to use them involves tedious administrative procedures, a session with Ritaline (100-200 milligrams) or Ketalar (100-150 milligrams) might be a more feasible approach. Tranquillizers should not be used in any condition related to the use of psychedelic drugs until all the above uncovering approaches have been tried and have failed.

Powerful non-drug approaches could also be used in lieu of tranquillizers in all those cases where a poorly resolved LSD experience results in a long-term psychotic condition and psychiatric hospitalization lasting months or years. If these do not bring about sufficient clinical improvement, psychedelic therapy, Using the substances mentioned above, is the next logical choice. Ketalar, a drug that is legally available and has been used in a medical context for general anesthesia could prove promising in these otherwise desperate cases.

I would like to conclude this discussion of psychedelic crisis intervention with a description of the most dramatic situation of this kind I have encountered in my professional career.

In my third year in Big Sur, California, I was awakened at 4:30 one morning by a telephone call. It was the night guard from the nearby Esalen Institute asking for help. A young couple called Peter and Laura, who were traveling down the coast, had parked their VW camper on coastal route I in the vicinity of the Esalen Institute and had decided to take LSD together. They rolled out the bed in their car and shortly after midnight both of them ingested the drug. Laura's experience was relatively smooth, but Peter progressively developed an acute psychotic state. He became paranoid and violent, and after a period of verbal aggression he started throwing things around and demolishing the car. At this point Laura panicked, locked him in the car and sought help at Esalen. She appeared at the guard shack completely naked, holding the car keys in her hand. The night guard knew about my previous work with psychedelics and decided to give me a call; he also woke up Rick Tarnas, a resident psychologist who had done his dissertation on psychedelic drugs.

While the guard was taking care of Laura, who calmed down and had a pleasant, uncomplicated LSD experience, Rick and I walked to the camper. As we approached the car we heard loud noises and shouting; when we came closer we noticed that several of the windows were broken. We unlocked the car, opened the door and started talking to Peter. We introduced ourselves and told him that we had had considerable experience with psychedelic states and had come to help him. I tentatively stuck my head inside the door and looked into the camper; a half-gallon bottle missed me by about four inches and landed on the dashboard. I repeated this several times, and two more objects came flying in my direction. When we felt that Peter had nothing more to throw, we quickly moved into the camper and lay down on the roll-out bed on either side of him.

We continued talking to Peter, reassuring him that everything would be all right in an hour or two; knowing that he and his girlfriend had taken LSD after midnight, we could give him this definite time limit. It became obvious that he was in a paranoid state and saw us as hostile FBI agents who had come to fetch him. We held his arms in a comforting and reassuring way, changing this into a firm grip whenever he made an attempt to escape, but avoiding real physical antagonism and struggle. All the while, we kept talking about having had difficult experiences ourselves, and find ing them retrospectively useful. His condition oscillated for about an hour between mistrust with anxiety-laden aggressive impulses, and episodes of relief when it was possible to connect with him.

As time went by and the LSD state became less intense, Peter slowly •J developed trust. He was more and more willing to keep his eyes closed and i(| face the experience, and we were even able to start working carefully on the ) blocked parts of his body, encouraging full emotional expression. By seven o'clock all negative elements completely disappeared from Peter's LSD experience. He felt cleansed and reborn, and was thoroughly enjoying the new day. His previous hostility turned into deep gratitude and he kept repeating how much he appreciated our intervention.

At about half-past-seven Laura appeared at the camper and joined us; she was herself in very good condition, but was naturally concerned about Peter. Rick and I helped dispel the negative aftermath of the dramatic events of the night and facilitated their reunion. We advised them strongly against driving that day. They spent a leisurely day by the Pacific Ocean and the next day continued their journey south. They were both in good spirits, although somewhat worried about the bill for the repair of their damaged camper.

APPENDIX: The Effects of LSD on Chromosomes, Genetic Mutation, Fetal Development and Malignancy

In the last decade, a serious new dimension has been added to the LSD controversy. A number of scientific papers have been published indicating that LSD might cause structural changes in the chromosomes, genetic mutations, disturbances of embryonic development, and malignant degeneration of cells. However, a comparable number of publications question the accuracy of these allegations. Some are independent experimental studies which have yielded negative results, others criticize the original papers for serious conceptual and methodological inadequacies. Despite all the experimental work done in this area, and the vast expenditure of time and energy, the results are ambiguous and contradictory. It seems appropriate to include in this book a critical review of all the relevant research because the issue is extraordinarily important to the future of LSD psychotherapy.

The following discussion is based almost exclusively on careful study of the existing literature. 1 have limited firsthand research experience in this area, and genetics is not my primary field of interest and expertise. In the LSD study conducted in the Psychiatric Research Institute in Prague we did not examine the el feet of LSD on the chromosomes or its implications for heredity; there were at that time no experimental or clinical observations that would suggest the need for such studies. The first paper that attracted the attention of scientists to this area did not appear until the late 1960 s. (22)* After niv arrival in the United States, I participated in a major study concentrating on structural changes of the chromosomes in the white blood cells lollowing LSD administration. This was one of the few genetic studies using pure pharmaceutical LSD, a double-blind approach, and comparison of the samples before and after the administration of the drug. (106)

The material discussed in this review will be divided into several thematic groups. The first group includes papers describing structural changes of the chromosomes produced by LSD in vitrot; in these experiments various concentrations of LSD are added to cultures of cells from human, animal, or plant tissues in a test-tube. The second group involves in vivo] studies of LSD; in this type of

'Numbers apply to references that appear after this Appendix.

t/n vitro literally means in glass, and refers to experiments conducted in test-tubes; in vivo is a medical term for experiments in living organisms.

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