by Bruce Sewick
| Psychedelic-Assisted Psychotherapy for the Terminally Ill A Thesis Submitted to the Faculty of the College of Arts and Sciences In Candidacy for the Degree of Master of Arts In Psychology By
Bruce Sewick ACKNOWLEDGEMENTS |
| ACKNOWLEDGEMENTS |
| The writer wishes to express his gratitude and appreciation to Dr. Judy
Lam, chairman of his thesis committee, for her advice, criticism, and
guidance.
The writer also wishes to thank Dr. Heidi Harlow, the other member of the committee for her unconditional support. The writer also wishes to thank Dr. Janice Kowalski for her timely consultation. The writer also wishes to thank Rick Doblin and Sylvia Thyssen of MAPS. They were able to respond to any questions and provide necessary information to complete this task. The writer also wishes to thank Karen Sewick for her unwavering assistance in completing this paper. Finally, this paper is dedicated to my Mother, Jean Sewick, whose resiliency and courage in the face of cancer has inspired me to write this. |
| INTRODUCTION |
Helping to Make Death Meaningful: Addressing the Psychological Needs of the Dying The subject of death and dying is usually avoided by medicine and psychology. In medicine, death is seen as a sign of failure, while psychological intervention is seldom offered to the dying. This paper explores the Western concept of death, the stages of dying and the attempt to make death meaningful. Current available treatments for the dying are noted including hospice and palliative care. In addition, this paper reviews the use of psychedelics in pre-industrial societies. The development of psychedelics as medicine is also traced, first as an analgesic, then as an adjunct to psychotherapy with the terminally ill. As part of this review, current studies are cited and a proposed model of psychedelic- assisted psychotherapy using D.P.T. is evaluated. Finally, the future of psychedelic psychotherapy is discussed in the context of Western society. |
| CHAPTER I |
The Process of Dying The traditional Western view of death is one of denial (Rando, 1984). This denial is evident in the way death is referred to or labelled in Western society. For example, expiring or passing on are typical of the type of terms used to describe this phenomenon (Richards, 1975). Once the person dies, the individual is often quickly removed to the funeral parlor, in efforts to minimize the family's exposure to death. Furthermore, the corpse is made to look as lifelike as possible, further perpetuating the illusion of life and the denial of death. Thus, an attitude that death is not a natural part of human existence is conveyed. Feifel (1977) suggested that the denial of death is influenced by death being seen by the American culture as the destroyer of the American vision of life, liberty, and the pursuit of happiness. The American culture's vision of life sees aging, terminal illness, and death as the defeat of our attempts to master nature. The dying patient is thus viewed as a loser in life's race (Grof & Halifax, 1977). Once the patients die, their deaths can be scrutinized by the families for mistakes along with any liability issues by the medical personnel (McCue, 1995). This "medicalization" of death leads to the avoidance of acknowledging the inevitability of death. The Western medicalization of death causes physicians to ignore the emotional and spiritual side of the patient and focus instead on the biological aspect (McCue, 1995). Therefore, the struggle to delay death at any cost becomes more important than the quality of the patient's remaining days (Grof & Halifax, 1977). Alternatively, if the patient is terminally ill, a social death may precede biological death in the form of psychological distancing from the patient by family and medical personnel (Rando, 1984). In contrast to Western society's denial of death, some primitive, pre-industrial societies such as that found on the Fiji islands, accept death as natural and inevitable (Rando, 1984). In these cultures, death is not seen as the end of existence, instead death is regarded as a transition or transfiguration. The dying individual is likely to have had experiential training in altered states of consciousness through the use of psychedelic or powerful non-drug methods. These altered states of consciousness may include symbolic confrontations with death, giving one a realization of life's impermanence and providing an insight into the transcendent nature of consciousness (Grof, 1980). Despite the Western history of death denial, the last two decades have brought about changes in care and treatment of the dying. These changes have been brought about by the Hospice movement, Kubler-Ross, and thanatological research. First, the Hospice movement began in England due to the efforts of Saunders. She founded St. Christopher's Hospice in 1948 with a donation from a dying patient (as cited in Fiefel, 1977). The movement encourages the dying and their families to accept death, and focuses on relieving pain and improving the quality of life and death (Saunders, 1981). This focus allows the dying a chance to make death more personal and spiritual. Second, Kubler-Ross brought a similar message to Americaand created an interest in the experiences associated with death. From her work with patients, Kubler-Ross noted that the dying appeared to be more anxious about the dying process than what happens after death (Kubler-Ross, 1975). However, these anxieties are typically treated as a physical pain is treated, and the patient is sedated rather than counseled. Based on interviews, Kubler-Ross was able to identify five consecutive stages of the dying process through interviews with the dying. The five stages are: denial and isolation, anger, bargaining, depression, and acceptance (Kubler-Ross, 1969). Kubler-Ross' guidelines on the stages of the dying process have provided professionals guidance in their work with these patients. Effective psychotherapeutic interventions have been developed to address patients' needs associated with each stage. Denial, the first response after receiving the report of impending death, gives the patient time to collect himself. Denial is then replaced with anger, the second response. In this stage, the anger may be projected onto other people. The third stage, bargaining, reflects an attempt to postpone death in exchange for some sacrifice by the patient. This stage may help the patient resolve feelings of guilt (Kubler-Ross, 1969). Depression, the fourth stage of this process, occurs when the feelings of numbness and anger are replaced with a sense of great loss. Kubler-Ross (1969) has distinguished between reactive depression and preparatory depression: reactive depression occurs as a result of a past loss, preparatory depression is taking into account impending losses. This preparatory depression is necessary if the patient is to die in a stage of acceptance. Kubler-Ross felt that only patients who have been able to work through their distress and anxieties are able to achieve this last stage. Finally, Noyes (1971), added to Saunders' and Kubler- Ross' work with thanatological research of near death experiences. He identified three, instead of five, successive stages of dying: resistance, life-review, and transcendence. The resistance phase was characterized by recognition of danger, fear of dying, struggle to live, and finally, acceptance of death. Next came life-review, a condensed replay of one's life. The final stage, transcendence, was characterized by a mystical state of consciousness, analogous to Maslow's peak experience (Noyes, 1972). A peak or mystical experience occurs when personal boundaries are dissolved and one feels a sense of becoming one with other people, nature, the entire universe, and God (Grof, 1990). Other published reports of near-death experiences and mystical, psychedelic states of consciousness resembling death, provided an additional impetus for change by making death experientially possible (Ring, 1988). Noyes (1972) noted that persons who have experienced these states naturally or artificially have expressed what happens to them in terms of death and rebirth. This death-rebirth experience provides Western culture with an analogy to the symbolic, transformational death of pre- industrial cultures, and thus a way to accept death by experiencing it symbolically. Western society's denial of death began to change with the publication of books and studies on dying by Saunders, Kubler-Ross, and Noyes. This information helped shift the Western view of death away from denial towards acceptance. The next chapter examines the treatments used with the terminally ill. |
| CHAPTER II |
Current Treatment for the Terminally Ill More than 80 percent of the people in the United States die in institutions, thus making the medicalization of death inevitable (McCue, 1995). This chapter describes the current treatment for the terminally ill as a result of this trend. Physicians tend to be disease-oriented in their approach with the terminally ill (Heinemann, as cited in Goldberg, Malitz, and Kutscher, 1973). Psychotherapists tend to focus on helping the patient cope with the disease (Weisman & Sobel, 1979). This separation of care leads to the patient being over or under medicated (Munley, 1983). Klerman suggested that the prescription of psychotropic drugs was determined by the physician's desire to avoid the patient (as cited in Goldberg, et al.). This disease-oriented approach leads to pharmacologic intervention for the pain (Foley, 1985), anxiety, and depression (Breitbart, 1989) associated with terminal illnesses, particularly cancer. Pharmacologic interventions for pain relief include non-narcotic and narcotic drugs (Foley, 1985). Foley listed non-narcotic analgesics (e.g. aspirin and acetaminophen) for mild to moderate pain, and narcotic analgesics (e.g. codeine and morphine) for acute pain. Shapiro (as cited in Goldberg, et al. 1973), suggested the use of minor tranquilizers (e.g. meprobromate) for anxiety, and antidepressants (e.g. tricyclics and monoamine oxidase inhibitors) for depression. Psychotherapeutic interventions for coping with a medical disease tend to deal with immediate problems. For example, cognitive-behavioral therapy, hypnotherapy, and relaxation/imaging techniques may be introduced to help ease the pain (Breitbart, 1989). In 1995, a study identifying patient preferences for end of life care was completed. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) examined the care and treatment of 9,105 terminally ill patients. This was a two phase study: Phase I was observational, Phase II was an intervention to correct deficiencies noted in Phase I. Based on the results from the first phase, a specially trained nurse was assigned to each terminally ill patient to facilitate communication between physician, patient, hospital personnel and family. Information regarding patient and family preferences, understanding of outcomes, and advance care planning was available on an as needed basis to all involved. No improvement in care was seen in Phase II of this study (Support Principal Investigators, 1995). Pain was also reported as moderate to severe for half of the patients who were able to communicate in their last few days. Apparently, increased attention to the physiological components of dying did not improve the quality of death. It can be inferred that the treatment of the physiological dimension of dying as a disease-related event and the psychological aspect as a pain reduction method leaves out the personal and spiritual dimension of dying (McCue, 1995). Kubler-Ross equates the peaceful, spiritual part of death to feeling a sense of history - that one is part of what has come before and part of what is yet to come (Kubler-Ross, 1975). Prior to the Western industrial revolution, religion provided this sense of history in the form of a spiritual reality. Affirmation of this spiritual reality stressed the subjective inner experience, rather than the manipulation of the external world. Religion went from being an endogenous experience to an exogenous experience along with the accumulation of wealth, admiration of science and control of nature (Noyes, 1971). The focus on prolonging life without nurturing personal growth does not make dying less painful, as the SUPPORT study clearly shows. Richards (1975) noted that physical pain is lessened when areas of psychological pain are confronted and resolved. Kubler-Ross (1975) advised that by transcending one's individual existence and becoming at one with yourself and others, death can be a growing experience. The pharmacologic and psychotherapeutic treatments just described primarily treat the physiological and psychological effects of disease. Hospice and palliative care treatments, however, can include these interventions but focus on the patient rather than the disease (National Hospice Organization [NHO], 1996). Hospice care refers to care provided to the terminally ill with a life expectancy of six months or less, and began in the U.S. in 1974 (Rhymes, 1996). The National Hospice Organization describes hospice as a concept of humane, compassionate, and palliative care which can be implemented in a variety of settings (NHO, 1996). Palliative care regards dying as a normal process and neither hastens nor postpones death. It focuses on symptom relief and integrates psychological and spiritual aspects into patient care. Palliative care also offers a support system for the patient and family (World Health Organization [WHO], 1990). Palliative and hospice care is necessary for the humane care of dying patients, but is poorly integrated into routine medical settings (Rhymes, 1996). There is a need for a brief therapeutic method that is consistent with the philosophy of palliative care and can integrate well in various settings. Chapter 3 traces the development of a brief, psychedelic- assisted method of treating the terminally ill consistent with palliative care philosophy. |
| CHAPTER III |
The Use of Psychedelics in Treating the Terminally Ill Ancient or pre-industrial cultures have used hallucinogenic plants for healing, religious rites, and for death-rebirth experiences (Schultes & Hoffman, 1979). This symbolic death was offered as a core experience of shamanic initiation and rites of passage, resulting in spiritual opening and insight into the transcendent nature of human consciousness (Grof, 1980). Hallucinogenic plants have been used in death-rebirth experiences for thousands of years by shamans who either ingest the plants themselves, or supervise its use by a client (Grinspoon & Bakalar, 1983). In contemporary times, these hallucinogenic plants have been synthesized, and psychoactive ingredients isolated and evaluated by Western scientists and psychiatrists. The hallucinogenic plants which have been synthesized include: rye fungus (from which lysergic acid diethylamide, LSD, is derived), the psilocybin mushroom (psilocybin), and the peyote cactus (mescaline) (Weil, 1983). Since their discovery, the synthetic versions of hallucinogens have been used for their psychotomimetic properties, including the production of states of temporary psychosis (Osmond, 1957). Mental health professionals have been able to familiarize themselves with temporary psychotic states through didactic LSD experiences. In addition, the pharmacology of these substances was also thought to provide the chemical explanation for endogenous psychosis, as the chemical structure of these substances has been found to be closely related to the chemical structure of neurotransmitters found in the human brain (Restak, 1994). This also explains why moods and emotions are impacted by psychedelics. The term "psychedelic" is interchangeable with "hallucinogen" throughout this paper. Grinspoon & Bakalar (1983) described hallucinogens as non-addicting psychopharmacological agents that produce changes in thought, mood, and perception. These changes are similar to those experienced in dreams, religious exaltation, flashes of vivid involuntary memory and acute psychosis. The emotional effects of psychedelics are more profound than the perceptual ones. Everything in the field of consciousness assumes importance and feelings become magnified. Forgotten incidents from the past are sometimes retrieved and relived. Loss of self by ego dissolution is not uncommon, sometimes in the form of a death-rebirth. In some cases, the experience culminates in a peak, mystical experience that is boundless, timeless, and ineffable. The nature of the psychedelic experience is dependent on individual set and social setting (Grinspoon & Bakalar, 1983). Strassman (as cited in Pletscher & Ladewig, 1994) has suggested that the most useful classification of hallucinogens is in the context of their time course, notably onset, peak effect, and duration of action. In general, short-acting hallucinogens have an onset between 15 to 30 minutes, peak effects between 30-90 minutes, and duration between one and three hours. Dipropyltryptamine(DPT) and Methylenedioxymethylamphetamine (MDMA) are examples of this category. In contrast, intermediate-acting hallucinogens have an onset of 30-60 minutes, peak effects at 2-3 hours, and duration of 4-6 hours. An example of such an hallucinogen is psilocybin. Finally, long-acting hallucinogens have an onset of 30-90 minutes, peak effects occur within 3-5 hours, with a duration of 8-12 hours. LSD and mescaline are examples of this category. Early research with psychedelics focused primarily on LSD, the most potent of the hallucinogens. Bush and Johnson (1950) administered LSD to eight cases of psychoneuroses to induce a chemical shock, similar to Electroconvulsive Therapy. They concluded that LSD offered an expedient way to gain access to the chronically withdrawn patient, and could be used as an adjunct to psychotherapy. In 1953, Sandison opened the first LSD clinic at a small mental hospital in England. He and his colleagues published their preliminary findings in 1954. Thirty six mentally ill patients with diagnoses ranging from obsessive reactions to schizoid personality were given small doses of LSD, starting at 25 mcg. and increasing dosages incrementally until there was a reaction. Fourteen patients recovered and three showed moderate improvement. Sandison and his group concluded LSD to be more effective when used as an adjunct to psychotherapy (Sandison, Spencer, & Whitelaw, 1954). They felt that LSD therapy works best with obsessional and anxiety groups. In a subsequent study from the clinic, Sandison and Whitelaw (1957) examined 94 psychiatric patients treated with LSD, including 30 of the orginal 36. They reported that 65% were considered to be recovered or improved. Sandison and Whitelaw concluded that LSD treatment shortened the time necessary for a full psychological analysis. After nearly a decade of research, LSD and other hallucinogens came to be used more as adjuncts to psychotherapy than as psychotomimetics. Osmond (1957) successfully treated chronic alcoholics with LSD and coined the term psychedelic, or mind-manifesting to describe this change in therapeutic use. The term "psychedelic therapy" was then used to describe Osmond's method of administration of high doses of LSD (300 mcg. or more) sometimes in conjunction with other hallucinogens at one, or if necessary, two or three sessions of therapy. The theory underlying this approach is that providing a single, overwhelming and profound experience can result in a personal change that will continue in the following months and years (Sherwood, Stolaroff & Harman, 1962). Sandison coined the term psycholytic therapy to designate the administration of moderate doses (75-300 mcg.) of LSD at one to two week intervals, for an average of 40 sessions. This treatment method represents an extension and modification of psychoanalytically oriented psychotherapy Traumatic experiences from childhood are relived, with emphasis on emotional abreaction and integration resulting in valuable insights (Grof, 1980). Sherwood, et al., (1962) detail their procedure and results of psychedelic psychotherapy on 25 patients at an outpatient clinic. An autobiographical review in the context of the patient's life philosophy and hierarchy of values preceded the psychedelic session by a period of a few weeks or months depending on the individual patient's needs. Experiential training in altered states of consciousness also preceded the psychedelic session by the inhalation of a 30% carbon dioxide -70% oxygen mixture. This rendered a didactic experience by providing ventilation and abreaction. An LSD dosage of 100-200 mcg., was administered, followed by 200-400 mcg. of mescaline, after a thirty minute interval. The psychedelics were administered orally in a non-clinical setting. An additional 100-200 mcg. of LSD was added a few hours later if needed. The results were measured by the degree to which the presenting problem was resolved; out of 25 patients, 4 reported no improvement, 9 reported improvement, and 12 reported much improvement. The experiential training preceding actual therapy along with the emphasis on a non- clinical setting, made this study significant. The researchers noted the transcendent mystical nature of the psychedelic session and its effect on the patient. Savage, Savage, Fadiman, and Harman (1964) corroborated the therapeutic methodology of Sherwood, et al., (1962). They also developed a questionnaire to quantify the negative and positive therapeutic effects of psychedelic therapy. Based upon the retrograde assessment of 113 patients in the first group, 83% of the respondents reported lasting benefits from psychedelic therapy. These reported benefits included: increased ability to love, handle hostility, communicate and to understand self and others. Improved relations, decreased anxiety, increased self-esteem and a new way of looking at the world were also reported. Savage et al., reported that for the second group of 74 patients, 46% showed moderate or marked improvement, 35% showed minimal improvement, 18% showed no change, and 1% was reported as worse. From these results they concluded that post-LSD changes included elevated mood, increase in extroversion, decrease in compulsive habits, somatic complaints, and anxiety symptoms. Both the Sherwood et al., and the Savage et al., studies noted that a number of patients reported that they had overcome their fear of death. Sherwood et al., reported that a 34 year old female stated that the psychedelic experience made her view death as another level of reality. The use of psychedelics to aid the dying resulted from the work of Kast and Collins (1964). They became interested in LSD when they learned it produced a marked distortion of the body image, altered body boundaries and interfered with the ability to concentrate. These observations led Kast and Collins to hypothesize that LSD could alter the perception of physical pain. In a comparison of LSD, Demeral, and Dilaudid, they found that the analgesic effect of LSD was superior to either of the two analgesics. In addition, Kast and Collins observed that some of the patients also showed a striking disregard for their impending death as a side effect. Kast (1966) then went on to explore the effects of intramuscular injections of 100 mcg. of LSD on 80 terminally ill patients. A reduction of physical pain, in addition to a positive effect on mood and sleep were noted. Kast felt that a certain change in philosophical and religious attitudes took place that is not reflected in numerical data and graphs. He noticed improved communication on the part of the patient and the occurrence of happy, oceanic feelings lasting up to twelve days. This was the first time an association was noted between a transcendent experience and the relief of physical and emotional pain. In a final study, Kast (1967) examined the effects of LSD on sleep patterns, emotions, and attitudes toward illness and death. In this study, the 128 patients used had severe metastic cancer and were given 100 mcg. of LSD orally. Pain decreased substantially for many in the group and lasted an average of twelve hours. In addition, pain intensity for the entire group decreased for a period of three weeks with concurrent improvement of sleep and less evidence of concern about the terminal illness. Other researchers reported LSD's effect on the dying. Fisher (1970), for example, published a paper emphasizing the significance of spiritual, spontaneous, or psychedelic transcendental experiences in preparation for death. These experiences helped the individual see death as a part of the life cycle. Fisher discussed LSD therapy within the framework of a research project comparing LSD to an experimental analgesic. He observed dramatic results in pain reduction, psychological aftereffects and adjustment to death. Kast's work showed up in a literature search initiated by a member of the Spring Grove State Hospital's psychiatric staff who had metastic cancer. The psychiatric unit was researching brief, but intensive LSD psychotherapy at the time. She was granted an LSD session and experienced a psychedelic, peak experience, which relieved her depression and anxiety. The dramatic success led to an expansion of the program to include the treatment of terminal cancer patients (Pahnke, Kurland, Unger, Savage, & Grof, 1970). The following studies represent a decade of research at Spring Grove, which later became the Maryland Psychiatric Research Center (MPRC), using a form of psychedelic psychotherapy with the terminally ill. These studies were the largest, most sustained and systematic study of psychedelic psychotherapy yet attempted (Yensin & Dryer, as cited in Schlichting & Leuner, 1995). Pahnke, Kurland, Goodman, and Richards (1969) used 200- 500 mcg. of LSD on 22 metastic cancer patients. The results showed improvement in 14 patients, with 8 unchanged. Decreases were shown in depression, anxiety, and fear. Pahnke, Kurland, Unger, Savage, Wolf, and Goodman (1970) studied the effects of 200-300 mcg. of LSD on six metastic cancer patients. Overall, they noted a decrease in the need for pain medication and improvement in global change for all of the patients. This global score was based on ratings for the patients on such areas as depression, psychological isolation, anxiety, difficulty in management for all physical complaints, tension, and pain. Pahnke, Kurland, Unger, Savage, and Grof (1970), described the psychedelic therapy administered at the Maryland Psychiatric Research Center (MPRC) as psychedelic peak therapy. The immediate goal of such therapy was to achieve a peak or transcendental experience using a high dose of psychedelics, usually 350-450 mcg. Intensive psychotherapy prior to, and for weeks following the psychedelic drug session distinguishes psychedelic-peak therapy from psychedelic therapy. The preparatory psychotherapy focused on psychodynamic resolution and self-understanding, and averaged about 20 hours per patient. The MPRC researchers found that the setting had a profound effect on the nature and outcome of the psychedelic peak psychotherapy session (Bonny & Pahnke, 1972). The following is a description of the Protocol used at the MPRC. The room used for the session was furnished like a living room, with a couch and music provided. A music therapist was often present during the session. Music complemented the therapeutic objective by helping channel effective expression, facilitate relaxation, and provide a sense of continuity during the various stages of consciousness alteration facilitated by psychedelics. Quiet, reassuring music was played until the effects of the drug were felt. During this time, the therapist spoke with the patient about his expectations from the session. Once the drug effects were felt, the patient was directed to lie down on the couch, and was given eyeshades and a stereophonic headset in order to better focus on the inner experience. The music therapist then chose selections corresponding to the patient's psychological state in order to facilitate a peak experience. At intervals during the session, the eyeshades and headphones were removed in order to give the patient an opportunity to verbalize any thoughts or feelings he cared to communicate. The patient's psychiatric nurse and therapist were also present throughout the entire period of drug action. During the immediate post drug period, and for weeks afterward, psychotherapeutic work was continued by the therapist. The researchers claimed 68% of the patients who received a total of 450 mcg. of LSD achieved a peak experience (Bonny & Pahnke, 1972). Richards, Grof, Goodman, and Kurland (1972) administered 200-500 mcg. of LSD to 31 cancer patients. The dosage was determined on the basis of the patients psychological defenses and body weight. The results showed 9 patients dramatically improved, 13 moderately improved, and 9 essentially unchanged based on an expanded version of the global index cited in Pahnke, Kurland, Unger, Savage, Wolf, and Goodman (1970). In addition to the original categories, three more were developed. These included denial of the imminence of physical death, fear of death, and preoccupation with pain and physical suffering. Twenty-five percent of the patients had peak experiences and less fear of death afterwards. Richards et al. (1972), studied the psychedelic DPT, a shorter acting drug with properties similar to LSD. They were interested in DPT because it was more convenient to use than LSD, which demanded a considerable commitment of time. In contrast to LSD, DPT's duration of action is 1 1/2 to 6 hours, depending on dosage. Its effects terminate quickly, unlike the wavelike termination period of LSD. Moreover, patients often reported more energy after the session because of DPT's properties. Two studies examined the effects of DPT in lieu of LSD. Richards, Rhead, DiLeo, Yensen, and Kurland (1977) administered 75-127.5 mg. of DPT intramuscularly to 34 cancer patients who had received an average of 20.5 hours of therapy during the preceding month. Following the protocol used by Bonny and Pahnke (1972), Richards et al., examined whether the patients experiencing a peak experience showed greater clinical improvement than the group of non-peakers. To assess improvement, two psychological tests, the Personal Orientation Inventory (POI) based upon Maslow's concept of the self-actualizing person and the Mini-Mult, an abbreviated form of the MMPI, were administered. In addition, interviewers using the Brief Psychiatric Rating Scale assessed psychological distress. Additional psychological inventories and the interviews were used to assess clinical improvement in the patients. The Psychedelic Experience Questionnaire (PEQ) and the Peak Experience Rating Form (PERF) determined whether the patient had a peak experience as defined by Pahnke and Richards (1966). The results indicated a greater magnitude of clinical improvement for those experiencing a peak experience than those who did not. Richards, Rhead, Grof, Goodman, DiLeo and Rush (1979) quantified the clinical improvement brought about by DPT- assisted psychotherapy with 30 cancer patients. Psychotherapeutic procedures utilized the same protocol as those used in Richards (1975). The patients showed a decrease in depression, anxiety, hysteria, paranoia, hypomania, and schizophrenic qualities in the Mini-Mult after DPT-assisted therapy. Post therapeutic results on POI variables showed the patients were living in the present rather than the past, were more assertive and confident, had increased feelings of self worth and acceptance, and had a greater capacity for intimate contact. >From these results, Richards, Rhead, Grof, et al., concluded that DPT was a better psychedelic alternative than LSD. Their only caveat, however, was that the rapid onset of DPT increased the role of the therapeutic relationship. Because the patient encountered potent psychological material within ten minutes of DPT administration, as opposed to two hours or more with LSD, the therapist had to be skilled in averting any panic or paranoid reactions. According to Yensen and Dryer, the studies at MRPC ended in 1976 due to political pressure (as cited in Schlichting & Leuner, 1992). This was due to enactment of the Comprehensive Drug Abuse Prevention and Control Act of 1970 which had made psychedelic research difficult, particularly in light of its shift in emphasis on drug abuse (Grinspoon & Bakalar, 1979). As a result, psychedelic research declined in the U.S. (Lukoff, Zanger & Lu, 1990). In spite of this emphasis on drug abuse research, several of the MRPC researchers continued their psychedelic research and continued to publish papers supporting it. For example, Yensen (1985) continued his study of this area, advancing the proposition that LSD was a non-specific catalyst of mental activity with a broad range of applications. Moreover, he recommended the use of psychedelic treatments with terminal cancer patients. Similarly, Kurland (1985) summarized the MPRC work in terms of peak experience. As a result of such efforts, he proposed a positive relationship between peak experience and successful reduction of death fears accompanied by a relief of their depression, isolation, and sense of alienation. From his work, Kurland estimated that one third experienced such reactions. Another third of the terminally ill patients felt an effect, but did not obtain significant relief. The remaining were non-peakers who were neither helped nor harmed by the experience. In contrast to its decline in the U.S., psychedelic psychotherapy continued to flourish in Europe through the 1980's. Most of the research, however, was done in private practice and if reported, was published in the form of anecdotal clinical case studies. Bastiaans used LSD assisted psychotherapy in Holland until he retired in 1988. Leuner utilized LSD, ketamine, and non-scheduled MDMA analogues in psycholytic therapy in West Germany until his death in 1996. In 1988, the Swiss government issued five year licenses permitting MDMA, psilocybin, and LSD assisted psychotherapy by certain members of the Swiss Physicians Association for Psycholytic Therapy (Lukoff et al., 1990). In the United States, MDMA, a short-acting hallucinogen, became the focus of limited psychedelic research until it was listed as a Schedule I drug in 1985 (Lukoff et al., 1990). MDMA is a relatively mild, short-acting drug which gives a heightened capacity for introspection, intimacy, and self disclosure. It does not produce the perceptual changes of LSD, and relieves anxiety and depression (Grinspoon & Bakalar, 1986). Greer, a psychiatrist, and his wife Tolbert, a psychiatric nurse, used MDMA in their private practice before MDMA became a Schedule I drug. Up until that time, California law permitted use of drugs not commercially available if the drug was manufactured by a physician or pharmacist (Greer & Tolbert, 1986). They administered oral doses of 75-150 mg. of MDMA to 29 subjects in their respective homes. These subjects were referred by their psychotherapists for an MDMA session. Eyeshades and headphones were used to facilitate an inner experience. When the effect of MDMA began to subside, the subjects were offered a second dose of 50 mg. to prolong the session and provide a gradual re-entry. Every subject was reported as having experienced some benefit from the MDMA session, with 55% reporting they had realized the purpose or goal they had established prior to the session. Five subjects (17%) also reported a change in their attitude towards death. The researchers concluded MDMA was physically safe for all participants and is best used to facilitate communication between people involved in a significant relationship. Greer & Tolbert (as cited in Peroutka, 1990) administered 75-150 mg. of MDMA to 80 people with dosages proportionate to the depth of the experience sought. If an individual wanted to focus his attention internally, a larger dose was used. If a couple wanted to spend time together, a smaller dose was used. Eyeshades and music were provided. Psychotherapeutic interaction was not initiated during the session unless requested, so as not to dilute the inner process. After one-and-a half hours, patients were offered an additional 50 mg. to extend the peak experience and make re-entry more gradual. After the MDMA state passed, the researchers spent one to three hours helping integrate the experience. Total time spent with the patient was six to eight hours. Approximately 90% of the patients had positive and useful experiences. Greer and Tolbert (as cited in Peroutka, 1990) concluded that under the right circumstances, MDMA decreased the fear response to a recognized threat to a patient's emotional balance, leading to a corrective feeling that diminishes earlier, traumatic experiences. The learning that took place during the session was easily consolidated into a patient's life because MDMA does not distort perception, thinking, or memory in the dosages administered. A case study was reported of a terminal cancer patient who was better able to cope with his pain and adjust to his current life changes due to four MDMA sessions. Greer and Tolbert (as cited in Peroutka, 1990) explained the effect of these sessions: "... his ability to hypnotically re-anchor his pain-free experience greatly assisted him in reducing the pain by himself" (p.30). The scheduling of MDMA in 1985 effectively stopped psychedelic research. In fact, Greer was even denied FDA approval to continue his treatment of a terminal cancer patient in 1986. Subsequent applications to the FDA to study MDMA in humans were denied on the basis of neurotoxicity. The Multidisiplinary Association for Psychedelic Studies (MAPS) and the National Institute on Drug Abuse (NIDA) then embarked on a series of toxicity studies, that resulted in FDA approval of a Phase I (safety) study of MDMA in a healthy, normal population in 1992. The results suggested that MDMA could safely be administered to humans in the context of research (MAPS, personal communication, April 9, 1997). In 1996, Grob and Poland received private funding to proceed on an FDA approved protocol design for a study investigating the use of MDMA in the treatment of pain and psychological distress in end-stage cancer patients. The FDA approved the safety studies which preceded the research because the studies used volunteers with prior drug experience (C. Grob, personal communication, April 8, 1997). The researchers speculate MDMA will prove useful as an adjunct to pain reduction, as a treatment of anxiety and depression, or as a tool to facilitate stimulation of the immune system (Doblin, 1996). Twelve subjects, all screened and referred by their oncologists, will participate. The subjects will be trained in a guided imagery technique designed to reduce physical pain and psychological distress. They will receive four sessions of MDMA, separated by two to four weeks within a structured setting that includes guided imagery exercises. The population will be selected for their desperate life circumstance (Grob, 1995). Grob's study also provides a protocol for future psychedelic research because of the methods he will use to evaluate safety and efficacy. First, this study will assess MDMA'S safety utilizing a battery of neuropsychological tests. Pharmacokinetics, along with organ and immune system function will be assessed by blood workups before, during, and after specified sessions. Acute psychological effects will be measured through the use of the Brief Profile of Mood States -SR (POMS-SR) and the State-Trait Anxiety Inventory (STAI). The Hallucinogenic Rating Scale (HRS) will also be administered (Grob, 1995). Second, efficacy will be evaluated through the use of the McGill Pain Questionnaire, Dallas Pain Questionnaire and the Memorial Sloan Kettering Pain Card. Pain medication will also be monitored. Psychological treatment efficacy will be measured through a battery of standardized tests. Finally, immune system function will be evaluated by measuring tumor size, location and the immunoglobulin antibody, Ig A. This protocol design and subsequent approval process is scheduled for completion before the summer of 1997. The design of this research and subsequent results should help move psychedelic-assisted psychotherapy into mainstream psychology. At present, this is the only ongoing research in the use of psychedelic assisted psychotherapy with the terminally ill in the United States due to continued emphasis on drug abuse research. However, Grob has indicated that although there has been a policy shift by the FDA, getting permission to use a psychedelic treatment model with a clinical population has not been approved in twenty-five years (C. Grob, personal communication, April 8, 1997). Any future psychedelic research should use Grob's pilot as a model for comparison to facilitate FDA approval. Achieving a balanced perspective about psychedelic drugs is difficult. The way psychedelics are currently used and viewed make them a medical, legal, and philosophical problem in Western society. Evaluating psychedelics as drugs forces them to be viewed in the same context as aspirin or antibiotics. The model for this evaluation is Western physical medicine which looks to drugs to relieve a simply defined problem, and be able to demonstrate this in drug studies. Drug studies usually involve double blind experimental procedures to be able to separate the effects of the drug from any preconceptions on the part of the subject or experimenter (Reber, 1985). The psychological effects of psychedelics, however, are so dramatic that it becomes apparent as to which subject received the psychedelic and which received the placebo (Lukoff, Zanger & Lu, 1990). Based on the Western medical paradigm, anything called a drug must be simple medicine or a drug of abuse. Since psychedelics are not simple medicine, they must therefore be drugs of abuse (Grinspoon & Bakalar, 1986). The categorization of psychedelics as drugs of abuse, places them in a Schedule I category by the Comprehensive Drug Abuse Prevention and Control Act of 1970. This category is for drugs having a high potential for abuse, no current medical use, and a lack of safety for use under medical supervision (Grinspoon & Bakalar, 1979). This legislation severely restricts experimental and therapeutic research. The irony of this legislation is that the uncontrolled use of psychedelics continues, while controlled legal use has become almost impossible. The FDA under the current Democratic administration has permitted a limited number of studies investigating the beneficial use of psychedelics, in addition to the ongoing MDMA study (Heffter Research Institute, 1996). Funding for such research is difficult due to other priorities and the assumption that this research will foster the illegal use of drugs. The current controversy over medical marijuana illustrates how difficult it is to separate politics and research. This has not stopped psychedelic research from continuing in private practice, however, and the results disseminated through various publications and conferences such as the International Congress of the European College for the Study of Consciousness (ECSC). In addition, the founding of (MAPS) allows people to contribute funds toward government approved psychedelic research. This organization provides the "seed money" to initiate research and generate outside interest and funding (Stafford, 1992). This is a slow process that discourages all but the most persistent of researchers. Western society and philosophy is also uneasy about experiences we can't quickly classify. Psychedelic experiences are not easily classifiable and can blur the distinction between religious, medicinal, and recreational activities (Grinspoon & Bakalar, 1986). Ring (1988) suggested that psychedelic drugs can induce a genuine mystical or religious experience. Pahnke proved this in 1964, by administering psilocybin to ten theology students and a placebo, nicotinic acid, to 10 control subjects. Both groups listened to the same Good Friday service and had their written reports of the experience evaluated afterwards. Pahnke concluded that the mystical experiences reported by both groups were indistinguishable from each other (as cited in Ring, 1988). The medicinal use of LSD for pain reduction was explored by Kast (1964, 1966, 1967). Weil (1972) explains the recreational use of psychedelics as due to an innate drive to alter one's consciousness and escape from ordinary waking consciousness. Achieving a balanced perspective about psychedelics is indeed difficult with the lack of information available. The problem is not so much how to get these drugs off the streets, but how to get them back in the laboratories, hospitals, and other supervised settings (Grinspoon & Bakalar, 1986). The future of psychedelic research will be determined by the results of the limited number of studies now under way and how the media presents these results. To accomplish an unbiased presentation of the results, the politics must be taken out of scientific research. |
| CHAPTER IV |
Proposed Model of Psychedelic-Assisted Psychotherapy with the Terminally Ill The proposed model of psychedelic assisted psychotherapy will use a modified form of the psychedelic peak format developed at the Maryland Psychiatric Research Center (Kurland, 1985). The terminally ill, e.g., cancer patients, who are aware of their prognosis, have approximately three months to live, and have an open mind to psychedelics would most benefit from this model. The attending staff would be the psychedelic therapist, psychiatric nurse, and a doctor (on call). DPT will be the psychedelic drug used, due to quick onset of action and re-entry. The psychedelic therapist should be familiar with DPT's effects experientially, physiologically, and psychologically. This protocol could be used in various settings, hospital, institutions, or the patient's home. There will be three phases of therapy: preparation, psychedelic intervention, and integration. The total treatment period is approximately four weeks. The preparation phase occurs the first week. It consists of two sessions: the first session is an exploratory session with the patient, the second session is with the family. The first meeting between the therapist and the patient lasts about three hours. At this initial session, the therapist guides the patient through the unresolved issues in his life. No major effort is made to explore deep conflict material. The session ends on a philosophical note, with the therapist summarizing the session in terms of the patient's life philosophy. The family attends the second session where any family issues outstanding from the first session are discussed. The second week of treatment consists of familiarizing the patient with altered states of consciousness. Total psychological surrender to the experience is emphasized with experiential training using the inhalation of a 30% carbon dioxide - 70% oxygen mixture. This will provide ventilation and abreaction. Eyeshades are used to eliminate visual distractions. Instrumental, relaxing music will be provided through the headphones. In addition to eyeshades and music, the choice of an aromatic oil will be offered to the patient, to be diffused in the room. This aromatherapy should stimulate the limbic system to release emotions and memory (Jacobs, 1996). The therapist will emphasize the importance of the patient allowing himself to feel and experience everything that emerges. The psychiatric nurse will attend this session. This same nurse will be present at the psychedelic session. The patient will be reclining on a bed or comfortable sofa depending on his physical limitations. If the setting is institutional, the room should be as comfortably furnished as possible with emphasis on a living room type setting. Significant art work or family photographs can be used based on the patients needs. If the patient is anxious, guided imagery will be introduced to help the patient relax and go with the experience. A second session is set up at the end of the second week to go over the altered state experience. The patient is assessed at this session for resistance to altered states and ease of surrender to the experience. There are three categories of resistance/ease with corresponding DPT dose: flexible (75 g.), resistant (100 g.), and rigid (125 g.). All tranquilizing medicine is stopped the second week. Medication pertaining to the maintenance of the physical state is continued. The psychedelic intervention session is held early in the third week. The therapist and psychiatric nurse will be present with a doctor on call should an emergency arise. A light breakfast will be served, with any last minute questions or concerns discussed immediately following breakfast. The patient then receives an intramuscular shot of DPT, according to the assessed dosage. Relaxing music provides the background, along with the diffusion of the patient's choice of aromatic oil. The patient is encouraged to adopt a meditative state without focusing on any one thought during the latency period. Once the effects of the drug are felt, the patient reclines and puts on the eyeshades and headphones. Cathartic music characterized by insistent rhythms and dynamic crescendos is used. Examples of this would be Bernardo Rubaja's New Land and Pat Metheny Group's Off Ramp. At the peak, uplifting lyrical music with slower rhythms such Enya's The Memory of Trees and Steve Halpern's Comfort Zone would be appropriate. The music serves to direct and structure the psychedelic session. At the halfway point (approximately 1 1/2 hours), the patient's eyeshades and headphones are temporarily removed, so the condition of the patient can be checked on. If the patient needs an additional shot of DPT to peak, another 50 g. is injected at this point. If there are no complications, the session continues as described until the drug wears off. The music is changed to relaxing music as the peak diminishes. The therapist spends the first two hours after re-entry going over the material that surfaced with the patient. The family then joins the patient for an early dinner with the therapist in attendance. If there are some immediate family issues that need to be addressed, the therapist assists; if there are no issues, the session ends and the patient is free to go to sleep. The next day the patient is contacted to set up a final counseling appointment. This can be done during the remainder of the week. At this session, the results of the psychedelic experience are compared with the issues addressed during the first week. If the patient requests another session, one is scheduled eliminating the two week preparation phase. Instead, a pre-psychedelic session is held a few hours before DPT administration. Unresolved issues are noted and the session begins once the patient feels ready. Re-entry and integration take place without family members, unless the patient requests their presence. The therapist will continue to check on the patient during the remaining weeks or months. A mutually comfortable interval is established for psychotherapeutic sessions where the patient can continue to integrate the material uncovered throughout the psychedelic session(s). This continues until it is no longer needed or no longer possible. The proposed model of psychedelic assisted psychotherapy elevates dying from the purely physiological to a more conscious and spiritual process, as Huxley suggested: "...the living can do a great deal to make the passage easier for the dying, to raise the most purely physiological act of human existence to the level of consciousness and perhaps even of spirituality" (cited in Grof & Halifax, 1977). Psychedelic psychotherapy attempts to facilitate a peak, mystical experience resulting in a more peaceful, conscious, and spiritual death. The accompanying psychotherapy confronts and resolves issues, which in turn lessens the physical pain (Richards, 1975). The effects of DPT also allow the patient to shift his focus away from pain, thus reducing the use of sensorium dulling narcotics. The proposed model also fits into the palliative care model: it helps in control of pain, other symptoms, and control of psychological, social, and spiritual problems (WHO, 1990). Psychedelic psychotherapy could be a palliative care option for those who chose it. The problem with the model as proposed, is that there is not enough current research available upon which to base a more complete model of psychedelic assisted psychotherapy. Each psychedelic has different properties that may lend themselves to different personalities, but at this time DPT is the only non scheduled psychedelic which has been used to treat the terminally ill (MAPS, personal communication, March 18, 1997). In addition to the scheduled drugs, there other short acting "designer" psychedelics that could provide all the positive aspects with minimal side effects. CZ-74 (a psilocybin derivative) and LE-25 (a phenethylamine) are examples of this (Passie, cited in MAPS, 1996-97). |
| CHAPTER V |
Conclusion The association of dying with the failure of Western medicine makes death into a purely physical event. Dying then becomes a difficult and painful experience both emotionally and physically. Western society has the means to make the passage easier for the dying using psychedelic assisted psychotherapy. Over forty years of research using psychedelics with the dying has shown positive changes in the emotional symptoms of dying and pain reduction. Patients who had peak experiences also showed a decrease in the fear of death. In this context, death is not the enemy of Western medicine, suffering is. Psychedelic-assisted psychotherapy can help dying be of more than medical significance. This relatively short and effective therapy can help alleviate the emotional and physical distress of dying. |
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