Prevention And Management Of Complications In Lsd Psychotherapy

*, Occasional activation of the unconscious material associated with various kinds ! ' and degrees of emotional and psychosomatic discomfort is part of every uncovering process. Instances of this have been observed occasionally even in the course of conservative and traditional psychoanalytic treatment, and it is a common occurrence in various experiential psychotherapies—neo-Reichian work, primal therapy, Gestalt practice, encounter groups—where no psychoactive drugs are v used. Dramatic intensification of emotional or psychosomatic symptoms and inter-I personal maladjustment indicates that a patient has approached areas of impor-' tant unconscious problems. Ill LSD therapy, which considerably deepens and intensifies all psychological processes, this mechanism is more apparent than in more conservative forms of therapy, but is in no way specific to it.

Understanding the basic dynamics of the complications that arise in LSD psychotherapy is absolutely essential for their prevention and treatment. An important part of this work has to be done during the preparation for the first LSD session. The therapist has to explain clearly to the patient that intensification of symptoms, deep emotional turmoil, and even psychosomatic manifestations in the course of LSD therapy do not mean failure of treatment but are logical and meaningful parts of the process. As a matter of fact, such phenomena frequently occur just before a major therapeutic breakthrough. Another important message that has to be communicated before the drug is administered is that the incidence of these complications can be considerably reduced by consistent internalization of the LSD sessions. Full, unselective experiencing of whatever surfaces during the drug sessions, and finding appropriate channels for discharging deep pent-up energies are of crucial importance for safe and effective psychedelic therapy. It is also essential that patients understand the function and importance of active work during the termination period on unresolved issues. Explaining the rationale, basic principles, and rules for cooperation increases the chances for good integration of the sessions and reduces the incidence of prolonged reactions or "flashbacks."

The basic principles of conducting the LSD sessions have already been described and will be only briefly summarized here. A patient who removes the eyeshades to avoid confrontation with difficult emotional material that is surfacing is not likely to have a smooth and clean reentry and should be prepared for difficulties in the post-session interval. Similarly, unwillingness to work hard on unfinished material in the termination period of the session might mean a prolonged process of integration with investment of the therapist's and patient's time and energy for days to come.

Even if the above criteria are met, it is not possible to eliminate with any certainty the belated occurrence of various emotional and psychosomatic aftereffects. Psychedelic experiences represent powerful interventions in the dynamics of the unconscious and it takes time to integrate them. Even a well-resolved session may be followed by later upsurges of additional unconscious material, because the experience might have removed an important block and made available new contents that were previously successfully repressed.

I remember in this context a very beautiful and fitting simile which one of my Czech patients used to describe the process. Lumberjacks floating trees down a river occasionally encounter a situation in which the trunks form a barrier that obstructs the stream. Their approach to this situation is not to remove every log systematically, but to look for what is called a key-log, one piece that holds a strategic position. Experienced lumberjacks will approach the obstruction paddling against the stream, find the key-log, and remove it with a hook. After this intervention, the logs start moving in a way that ultimately reestablishes the free flow of the river. This process can take days or weeks, but it is made possible by removing the crucial block. Similarly, LSD sessions can eliminate dynamic blocks in the unconscious; this opens the way to emotional liberation, although the actual mechanics of it may extend over a long period of time.

For patients who are properly instructed and guided, these reactions usually do not represent serious problems. They are trained in dealing with unusual states of consciousness and see thenfas windows into their unconscious and opportunities for self-exploration, rather than as threats to their sanity. Since the emotional material usually tends to surface in the hypnagogic and hypnopompic periods, it is not difficult to take some time and approach such episodes as "micro-sessions." A short period of hyperventilation can help to activate the underlying problem and facilitate its resolution through fuller experience and energy discharge. This approach is far preferable to the usual effort to suppress and control the emerging material, which prevents lasting solution and binds much of the patient's energy. Frequently, difficult emotions and physical symptoms can disappear after half an hour of introspective work.

This situation is more complicated if the material is so close to the surface and its affective charge so strong that it tends to emerge unpredictably under the circumstances of everyday life. In that case, the patient should be instructed to arrange for situations where it is possible to face and express whatever is emerging. If this is not available, regular therapeutic sessions should be scheduled and systematic uncovering work done on the unresolved issues with the assistance of the sitters. The techniques used in this work are essentially the saine as those that we described for the termination period of the LSD sessions. After a short episode of hyperventilation that tends to unspecifically activate the underlying emotional structure, the sitters assist the patient by accentuating the physical sensations and states that he or she is already experiencing. Depending on the nature of the problem, they can use a combination of bioenergetic exercises or other neo-Reichian approaches, Gestalt technique, psychodrama, guided affective imagery, and deep massage to mobilize and work through the unfinished matrices. Stereophonic music, especially the pieces that were played in the session, can be of great help during this work.

If LSD therapy is being conducted in the atmosphere of a therapeutic community, it can be very useful to engage a group of co-patients in this uncovering work. For example, the group can enact in a very convincing way the experience of the encroaching birth canal, the atmosphere of a life-and-death struggle, or the comforting and nourishing womb. On occasion, stimulating or comforting sounds produced by the group members during this work can be very effective. Individuals in this team may also volunteer or be chosen by the patient or therapist for specific psychodramatic roles—surrogate mother, father, sibling, spouse, child, or employer. This approach is not only very effective for dealing with unresolved gestalts, but can also have a very powerful catalyzing effect on the assisting persons. It is not infrequent that under these circumstances the intense experiences of the protagonist can trigger valuable emotional reactions in some of the helpers. The material and observations from such therapeutic events can become an important addition to later group sessions. The experience of the role of helper also has an important function for the self-esteem of the group members and contributes to their sense of mastery. Collective efforts of this kind tend to create a sense of closeness, intimacy and togetherness which contribute to the social cohesion of the therapeutic community and its healing potential.

In the rare instances where the adverse aftereffects are very intense and the patients are potentially dangerous to others or to themselves, it may be necessary to keep them in the therapeutic facility twenty-four hours a day until these reactions subside. Nurses and co-patients should be trained to assume collective responsibility in these situations, and provide continuous assistance and surveillance. If the non-drug work fails to bring desirable results it is advisable to shorten the free interval and run another LSD session as soon as possible, to complete the unfinished gestalt. An interval of less than five to seven days tends to decrease the intensity and the therapeutic efficacy of the next session, because of the biological tolerance incurred by the previous administration of LSD.

In particularly resistant cases the therapist may decide to resort to the use of other pharmacological substances. Major or minor tranquillizers should be avoided, since their effect is contrary to the basic strategy of any uncovering approach and psychedelic therapy in particular. By inhibiting the process, blurring the experience, and obscuring the nature of the underlying problem, they prevent its resolution. In those instances where the unconscious material is close to the surface but is blocked by a barrier of intense psychological resistance, inhalation of Meduna's mixture (thirty percent of carbon dioxide and seventy percent of oxygen) can be very useful. A few inhalations of this mixture can cause a brief but powerful activation of the underlying unconscious matrix and facilitate a breakthrough. A session with Ritaline (40-100 milligrams) can occasionally help in the integration of material from the previous LSD session. Psychedelic drugs with a certain affinity for positive dynamic systems, such as tetrahydrocannabinol (THC) or methylenedioxyamphetainine (MDA) can be used with advantage. A drug that holds great promise in this indication but has not been sufficiently explored, is ketamine (Ketalar). It is a drug approved for medical purposes, which has been used by surgeons for general anesthesia.3 This anesthesia is of a dissociative type, which is very different from the one induced by conventional anesthetics. Under the influence of ketamine consciousness is not obliterated but deeply changed and drastically refocused. An out-of-body state is induced in which the patient loses contact with and interest in objective reality and gets involved in various cosmic adventures, to a degree that makes surgical operations possible. Optimal dosages for psychedelic purposes are relatively small, 50-150 milligrams, which is about one-twentieth to one-sixth of the standard anesthetic dose. The psychoactive effect even in this low-dose range is so powerful that it catapults the patient beyond the point of impasse from the previous LSD session, and can make it possible for him or her to reach a better level of integration. This approach should be explored with individuals who have developed long-term psychotic states as a result of unsupervised self-experimentation with LSD.

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