note: The criticisms expressed in the following paper, relatively typical of those workers whose establishment opinions helped to bring on the current era of Prohibition, are answered by Humphrey Osmond and Abram Hoffer in their 1967 book, The Hallucinogens. An excerpt from that book dealing with the Cole And Katz criticisms can be found in this library.
For many years several pharmacologically similar
drugs lysergic acid diethylamide (LSD-25), psilocybin, and mescaline, among
others have been of special scientific interest. In volunteer subjects, they
have been known to produce a variety of intense and unusual psychic effects.
These include bizarre visual phenomena, ranging from heightening of the apparent
brightness or beauty of colored objects in the environment, through distortions
in the perceived nature or meaning of real objects (illusions) to true visual
hallucinations of colors, shapes, or even of complex scenes or events. These
visual phenomena are usually accompanied by intense and often rapidly shifting
emotional experiences (ranging from mild apprehension to panic, severe
depression or mystical elation) or by concurrent emotions (such as depression
and joy) which are not experienced simultaneously under ordinary conditions.
Subjects describe changes in body image, the body or its parts appearing larger
or smaller, intense feelings of depersonalization, including states in which the
subject believes he is outside his own body viewing it from afar, or even
sensations of death and rebirth.
Occasionally there may be
loss of insight into the drug-induced nature of these sensations, with paranoid
delusions about other people in the environment who are believed to be trying to
harm or kill the subject. Intense self-loathing with suicidal impulses or great
feelings of mystical revelation can also occur. Distortions in experiencing
passage of time and, more rarely, disorientation as to time and place can occur.
The exact quality, nature, and content of these experiences appear to depend in
a complex manner on the personality and expectations of the subject, the dose of
the drug, and the setting in which the drug is administered (1, 2).
Particularly since the synthesis of LSD-25 in 1943, there has been
intense scientific interest in the possibility that these agents reproduce
naturally occurring schizophrenic states. After twenty years of research, it
seems most reasonable to state that these drugs can produce a state which is
similar but not identical to naturally occurring schizophrenia, and which may
also resemble the toxic deliria caused by other agents such as atropine or
scopolamine. Since subjects acquire tolerance to LSD, psilocybin, and mescaline
after repeated administration (3-6), the possibility that such compounds are of
etiological significance in naturally occurring schizophrenia seems remote.
Because of the assumed similarities of the state produced by
these agents to schizophrenia, they have been termed "psychotomimetics" or
mimickers of psychosis. Even less accurately, because of the visual effects,
they have been termed, "hallucinogenics." These names reflect a careful
scientific concern with potentially dangerous, though unique drugs. More
recently Osmond (7) has coined a term, "psychedelic," meaning "mind
manifesting," which has begun to be used widely. Its implications are certainly
more vague than those of the other terms. In the contexts in which it is used,
it seems to imply that these drugs bring to the fore aspects of the subject's
mind previously hidden or at least less manifest, and suggests that these
effects may be "good." Assuredly, many investigators believe that the effects of
these drugs result in an intensity of personal experience and emotion more
meaningful than the terms "psychotomimetic" or "hallucinogenic" imply.
Therein lies the present problem in the use or abuse of these
agents. Rather than being the subject of careful scientific inquiry, these
agents have become invested with an aura of magic, offering creativity to the
uninspired, "kicks" to the jaded, emotional warmth to the cold and inhibited,
and total personality reconstruction to the alcoholic or the
psychotherapy-resistant chronic neurotic. On the West Coast, the effects are
judged by some to be related to the insights of Zen Buddhism; on the East Coast,
they are judged by others to lead the way to a new and free social order. Like
the broom in "The Sorcerer's Apprentice," the drugs seem to have walked out of
the laboratory into the outside world on their own feet and to have turned on
the unsuspecting apprentice.
To be sure, the therapeutic uses
of these agents have been pioneered by psychiatrists in many instances,
including Abramson (8), Frederking (9), Osmond (7), Savage (10, 11), and
Sandison (12, 13). With much of the published work, however, there is an
implicit or explicit attitude that the self-knowledge of the leverage for
self-change allegedly effected by these drugs may be of value or benefit to
individuals who do not ordinarily consider themselves psychiatrically ill. At
the extreme of this attitude-dimension is the International Foundation for Inner
Freedom, formed by two psychologists, Doctors Leary and Alpert, who claim that
these agents (14) should not be considered drugs at all but should be classed
with poetry, music, literature, and art, and should be available to all men
wishing to improve their minds and "expand their consciousness." There is,
apparently, an active black market in these drugs in major urban centers, where
these drugs may have more snob appeal than diacetyl morphine (heroin),
marihuana, or dextroamphetamine.
Major attention has been
focused on these drugs, their effects, and the personal eccentricities and
misadventures of the more notorious people advocating their use by a series of
articles in national popular magazines Look (14), The Reporter
(15), Cosmopolitan (16), Time (17), the Saturday Evening
Post (18), and the Ladies' Home Journal (19). As with other forms of
illicit drug abuse, it is hard to tell the real extent or seriousness of the
psychotomimetic problem, despite this rather florid publicity.
The present article has two purposes: first, to underline the real and important
dangers inherent in the self-administration of these agents or in their
administration by uncritical enthusiasts and inadequately trained individuals;
second, to stress that some of the therapeutic claims made for these drugs are
of sufficient potential importance to warrant serious, unprejudiced study.
We take the second issue first, since the first issue has
already been outlined above. There have been an increasing series of studies
reporting LSD-25 and/or mescaline to be effective in the treatment of chronic
alcoholism, with remission rates of approximately 50 percent being usually
described (20-25).
Similar results have been observed in the
treatment of chronic neuroses (9, 10-13, 26, 27). The claims for the utility of
these drugs in the treatment of chronic neuroses range from dramatic improvement
to modest descriptions of improved communication with the therapist, emotional
release, and ability to talk about difficult personal topics. There have also
been informal claims that these drugs are useful in producing valuable
personality changes in juvenile delinquents and other individuals with serious
personality disorders.
In brief, it is claimed that these
agents are of striking value in some groups of patients who are highly resistant
to more conventional forms of psychotherapy or pharmacotherapy. Many of these
claims stress, further, the occurrence of basic changes in attitudes or
personality, not mere symptom reduction. If these claims are confirmed, this new
therapeutic approach could add substantially to the psychiatrist's tools. We
must stress that none of these claims are based on detailed, carefully
controlled studies designed to be free from possible distortions due to bias or
enthusiasm. Further, the terms in which the effects are often explained are not
formulations common either to medicine in general or to psychiatry in
particular. "Our own conception is that people live an inauthentic existential
modality (i.e., alienation), and that illness arises from an inability to see
meaning in life. LSD provides an encounter which brings a sudden liberation from
ignorance and illusion, enlarges the spiritual horizon and gives a new meaning
to life" (11).Such explanations may have a mystical or philosophical sound which
appeals to the enthusiast, but they are likely to produce doubt or even violent
disbelief and concern in physicians used to a more pragmatic approach and in
scientists used to a more communicative language. The present authors occupy a
skeptical middle position, favoring the Scotch verdict of "not proven." We feel
strongly that this approach to therapy should neither be rejected out of hand as
"crazy," nor accepted and applied in an uncritical manner, but should be
subjected to careful study under closely controlled conditions.
It is important also to note that the "treatment" discussed above is not
a drug therapy in the conventional sense. It is, rather, a complex mixture of
drug therapy and brief psychotherapy, with one or more prolonged sessions,
lasting eight to ten hours, during which the patient experiences the drug effect
and discusses his experiences and the light they throw on his problems, needs,
and past experiences in a prolonged and intensive manner. The drug session is
usually preceded by several interviews in which the patient's problems and the
changes he desires from treatment are explored, a relationship with the
therapist is established, and strong positive expectations concerning the drug
session are developed. The treatment, as administered by many, seems to include
strong suggestion, aspects of dynamic insight-oriented psychotherapy,
mystico-religious exhortation, catharsis, and pressure on the patient to
confront his problems head on. It is possible that with all these components the
intense and bizarre drug experience may indeed permit an impact on the subject
not obtainable by any other means. It is difficult to break down the therapeutic
process into its component parts. The proportions of the components may vary
from therapist to therapist or from patient to patient, especially with regard
to the amount of therapist interpretation and the extent of his active
participation in the solution of the patient's problems.
When
this treatment is given in a hospital setting, there is also considerable
personal interaction between the individual patient and other patients who have
already undergone this experience or are about to undergo it. The whole milieu
has an aura of intense conviction that change will occur and that the experience
will be highly meaningful and highly therapeutic. Intensive group therapy
sessions may occur before and after the actual LSD experience. The entire
therapeutic process, including preparation for the psychotomimetic experience
and subsequent reinterpretation of it, may resemble the group interaction common
to successful experience with Alcoholics Anonymous. It may resemble also the
intense personalinteraction used at the National Training Laboratory, at Bethel,
Maine (16), where revelations and emotional experiences are created by intensive
interpersonal and group interaction alone, without the aid of any drug.
This form of treatment is, therefore, highly intense and highly
complex, necessitating strong convictions and great sensitivity on the part of
the therapist, and requiring the creation of a social milieu in which all
patients not only share in a strong conviction that change will occur but also
hold a personal commitment to make certain that change does occur. Dramatic
short-term effects under such conditions have been described. The durability on
prolonged follow-up study of acute changes in behavior, induced by therapy or
perhaps even changes in personality, is yet to be determined.
Several problems face investigators who wish to make careful studies of such a
complex treatment. It seems likely that people who administer the treatment
effectively must be convinced of its efficacy. Further, they must be highly
biased in favor of it for the treatment to have the described effect. The
physician may be so involved in the treatment that he can not evaluate its
effects objectively. Independent evaluation of outcome is, therefore, essential
to any good research design in this area. This independent procedure should make
it easier to evaluate the efficacy of treatment in a condition like chronic
alcoholism where an objective index of success or failure, namely, excessive
drinking, exists.
A much more complex problem must be faced in
evaluating the effects of these drugs on individuals with personality disorders,
severe or mild. Here a value judgment must be made concerning the goodness or
badness of the changes which occur, if any. For example, how should one evaluate
outcome if an individual were to divorce his wife and take a job which paid him
less but which he said he enjoyed more than his previous job? If a person
becomes more relaxed and happy go lucky, more sensitive to poetry or music, but
less concerned with success or competition, is this good? There are suggestions
that individuals who take drugs like LSD either illicitly or as therapy may
become more detached from reality or less concerned with the real world, more
"transcendental." A few of the reports concerning this treatment, both published
and unpublished, mix a variety of poetic metaphors and occasionally
bizarre-sounding elaborations with serious descriptions of the details of
treatment and the valuable changes to be expected. For example, certain kinds of
artistic experience, certain types of music, etc., are said to be particularly
valuable in inducing the desired effects. Specific components of the therapeutic
process described may often have a bizarre - almost schizophrenic - component, which
tends to make serious investigators discount this whole area as a delusional
belief shared by a group of unstable clinicians and lay enthusiasts. Whether or
not this criticism is justified can be judged only by future studies designed to
be immune to such criticism. Future studies must decide whether these treatments
do indeed have promise for specific clinical conditions which are now highly
resistant to conventional psychiatric approaches.
At present a small number of facts are strikingly clear. None
of these drugs has been proved to be effective or safe therapies for any
psychiatric condition. Because of the apparent potential of these agents for
producing bizarre behavior, suicidal impulses, or undesirable personality change
in some subjects or patients receiving them (28, 29), there is some question as
to whether they should be administered outside a hospital. They are not
available for general prescription use, and there is some question whether they
should ever be so available. Because neither their safety nor their efficacy has
been adequately demonstrated, two of these agents, LSD-25 and psilocybin, are
being controlled as investigational drugs in conformity with the existing Food
and Drug Administration regulations under the sponsorship of the drug company
which holds the patent rights for both substances. It is our understanding that
this company is at present providing these agents for scientific study only to
investigators functioning within federal or state agencies with formal approval
of the agency, or to investigators doing research under ,rants from these
agencies. This policy decision has been made presumably to insure that these
drugs will not be misused by unqualified or unscientific investigators without
adequate checks and balances necessary for safe and careful research. The other
agent, mescaline, is not to our knowledge being sponsored currently by any
pharmaceutical company, although it can be obtained for animal or biochemical
research from certain biochemical supply houses.
Legally none
of these agents can be used, even on an investigational basis, except by
investigators who have filed a formal research plan with the FDA through a
sponsoring pharmaceutical company, or by investigators who have themselves
assumed sponsorship and satisfied the FDA concerning the safety of the agents
and their proposed research use in man. Any reported use of these agents outside
of these approved channels should be reported to the FDA. Since there have been
a number of reports of suicide attempts or prolonged psychotic reactions
requiring psychiatric hospitalization in persons obtaining these drugs outside
of approved medical channels, their indiscriminate unsupervised use is clearly
dangerous. In addition, there have been reports of insidious personality changes
occurring in individuals who have indulged in repeated self-administration of
these agents. It is, of course, difficult to determine whether or not some of
the bizarre behaviors of such individuals are a product of the drug itself or
are a product of the underlying personality aberrations which lead the
individuals to seek out these agents. In any case, there is no evidence that
uncontrolled self-administration of these drugs is either safe or desirable.
There has also been concern over the possibility that investigators who have
embarked on serious scientific work in this area may have been subject to the
deleterious and seductive effects of these agents.
Thesee
statements are made in hope that warranted concern over illicit abuse of these
agents will not prevent systematic study of their possible potential in the
treatment of psychiatric conditions which are otherwise severely treatment
resistant.
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* Dr. Cole is chief and Dr. Katz is research psychologist of
the Psychopharmacology Service Center, National Institute of Mental Health,
National Institutes of Health.