Winter 1995 Vol. 05, No. 3 Clinical Trials and Tribulations
After the discovery of LSD in Basel, Switzerland in 1943, important research into the use of psychedelic drugs in psychotherapy took place all over the world. Research in this field was very active until the late sixties, resulting in over a thousand scientific publications. In the early years, research was focused on the so-called "model psychosis" produced by psychedelics. Drug effects were investigated in healthy volunteers, mentally ill persons, or during self-administration by the researchers themselves. In Switzerland, important work was done by Stoll and Condrau. In a later phase, research interest was concentrated on enhancing the psychotherapeutic process with psychedelic drugs. Therapeutic models were established by Leuner in Germany and Grof in the USA. Leuner developed psycholytic therapy, which is the administration of relatively low doses and is practiced mostly in Europe. Grof developed psychedelic therapy, which is the administration of relatively high doses and is practiced mostly in the USA.
In 1966, as a reaction to widespread use of drugs within the hippie culture, LSD and psilocybin were declared Schedule 1 narcotics. Today, psychedelic substances are considered worldwide to be narcotics and their therapeutic use is no longer permitted. Psychotherapeutic research into psycholytic or psychedelic therapy has been almost completely forbidden since the early 1970’s, though a few basic psychedelic research projects were permitted to resume within the United States and Germany in the early 1990’s.
In 1986, within a different cultural background, MDMA was scheduled throughout the world. Psychotherapeutic use of MDMA and all research with the drug were forbidden worldwide until 1988, when the Swiss Federal Office for Public Health granted special permission to several specialists in psychiatry and psychotherapy working in private practice to conduct psychotherapy with MDMA. Permission was also granted for the use of LSD. The Swiss researchers were all members of the Swiss Medical Society for Psycholytic Therapy, a society founded in 1985 with the goals of promoting psycholytic psychotherapy as a psychotherapeutic method and training qualified therapists.
Permission to work with MDMA and LSD lasted until the end of 1993, when all psychedelic research in Switzerland was once again forbidden. Three of the initial five therapists, Dr. Marianne Bloch, Dr. Jurai Styk and Dr. Samuel Widmer, worked all five and a half years with drug-assisted therapy.
This follow-up study has been prepared for the Swiss Federal Office for Public Health. It reports on the results of the Swiss research conducted during the 1988-1993 period of special permission for psychotherapy with psychedelic substances. This follow-up study is meant to contribute to the discussion concerning whether psycholytic psychotherapy and research should continue in Switzerland in the future. Hopefully, this data will inform negotiations with the Swiss authorities and their scientific consultants.
Patients sampled were those who had been in psychotherapeutic treatment with one of the three therapists mentioned above. The patients had to have participated in at least one psycholytic session and finished their treatment by July, 1993. One hundred seventy one ex-patients fit this criteria. Each of these was mailed a standardized questionnaire created by the author. The questionnaire asked the patients to describe their social situation before and after psycholytic treatment, other psychiatric or psychotherapeutic treatments before and after psycholytic treatment, reasons for treatment, self-evaluation of improvement during and after treatment, summary of influence and content of the psycholytical session(s), and their life situation after treatment. Space was left in the questionnaire for individual remarks. Four weeks after mailing, those who had not initially responded were requested once more to answer the questionnaire.
In addition to the questionnaire, the patients’ medical records written by their therapists were reviewed for diagnosis, duration of therapy, number of non-drug and drug sessions, and duration of the follow-up period.
A total of 171 ex-patients received the questionnaire. One could not be reached because of travel. Of the remaining 170 patients, 135 (79%) responded. Fourteen (8%) were sent back blank. One hundred twenty one (71%) questionnaires were thus evaluated.
Of the 121 patients, 53% were female and 47% were male. The mean age was 41 years (s = 8.7 y).
Prior to psycholytic treatment, 45% of the patients had sought out psychotherapeutic or psychiatric treatment. These subjects participated in one to five periods of treatment with an average duration of 2.5 years. Seven percent of the 121 ex-patients had undergone inpatient treatment in a psychiatric hospital. The mean duration of this inpatient time was 8.2 months.
After psycholytic therapy, 13% continued with psychotherapeutic treatment (this in-cludes those who were in psychotherapeutic treatment for self-exploration in the course of professional training). While none of the patients were hospitalized in a psychiatric hospital during the course of their psycholytic treatment, 1.6% were hospitalized in a psychiatric hospital after their psycholytic treatment was concluded.
The procedure common to all three therapists was the creation of a group therapy setting. Group therapy enables the patients to interact with the therapists and with other patients. During drug experiences, therapists played specially chosen music to support the patients’ process and to give guidance and structure. Music was alternated with long periods of silence to bring about a meditative experience. Elements of psycholytic therapy developed by Leuner (low to medium dosage, group setting, continuous verbal therapy) were integrated with elements of psychedelic therapy as developed by Grof (high dosage, use of music and silence as a therapeutic method).
Dr. Bloch worked with administrations of 125 mg of MDMA alone. The other therapists, Styk and Widmer, used 125 mg of MDMA for the first three or four sessions; after that they gave LSD in dosages ranging from 100 mcg to 400 mcg. Duration of therapy ranged from participation in only one drug session (in one case) to nine years and three months. On average, therapy lasted three years and one month (s = 23 m). The follow-up period amounted to one year and eleven months on average (s = 19 m), ranging from one month to fifty-nine months. Simplifying slightly, the average duration of therapy was three years and the average follow-up period was two years.
The patients took part in an average of 70.3 non-drug sessions of verbal psychotherapy (s = 55.2 sessions). This means that patients generally saw their therapist once every two weeks during their three year period of therapy. The psycholytic sessions took place during this time. Patients varied from experiencing 1 to 16 drug sessions, with an average of 6.8 sessions (s = 4.3 sessions). On average, patients participated in a drug session with MDMA or LSD every 5 months after attending 10 non-drug psychotherapy sessions.
Reason for beginning psycholytic therapy
Patients were asked to list all the reasons that led them to begin psycholytic therapy, both major as well as minor. Social and interpersonal problems were reported by 66.9% of the patients. Psychological symptoms were also reported by 66.9% of the patients. Self-exploration was a reason for therapy given by 57%, somatic symptoms were reported by 28.9%.
Addiction was mentioned by 21.5% of the patients as one of the reasons they began therapy. However, this word was used in the every day meaning of the word rather than the scientific. Patients’ descriptions of their addictive behaviors included a need to be used (co-dependency) and excessive sexual or workaholic behavior.
Other reasons for initiating therapy were given by 18.2% of the patients. Under other reasons, patients mentioned partner is in therapy, family undergoing therapy, therapy ordered by law, problems in military service or HIV-infection.
In determining the diagnosis of the patient, only the main problem or symptom that brought the patient to seek therapy was considered. These diagnoses follow the guidelines of the World Health Organization’s International Classification of Diseases (10th revision). The most common diagnosis was Personality Disorder, given to 38% of the patients. Adjustment disorders was the diag-nosis given to 25.6% of the patients. Affective Disorders was experienced by 24.8%. Just 6.6% of the patients experienced Eating Disorders. Addiction, Psychosis and Sexual Deviation each affected only 1.7% of the patients.
Subjective changes resulting from psycholytic treatment
Patients were asked if they experienced any changes both during and after treatment and, if so, what the quality of those changes were. During their course of therapy, good improvement was reported by 46.3%, slight improvement was reported by 38.8%, no change was reported by 5.8%, and slight deterioration was reported by 4.2%. Five percent said they experienced fluctuating changes, with both improvement and deterioration. After their period of treatment, good improvement was reported by 65%, slight improvement was reported by 25.6%, no change was reported by 4.1%, and slight deterioration was reported by 2.5%. Two and a half percent said they experienced fluctuating changes, with both improvement and deterioration.
To summarize, the percentage of patients who considered themselves to have experienced good improvement or slight improvement during their psycholytic treatment was 85.1%. After treatment, that percentage climbed to 90.9%. As a point of comparison, in a follow-up study undertaken by Mascher (1967) in Germany, 62% of the 82 patients treated by Leuner et al. considered themselves to have experienced good improvement or slight improvement.
Influence on the levels of experience
Patients were asked to rate the impact of their psycholytic sessions on their emotions, their interpersonal relationships, their biographical insights, and on any important decisions they made during or after the course of treatment.
The impact of their psycholytic sessions was greatest on the patients’ emotional lives. The percentage of patients who said the sessions were very important emotionally was 64.5%. The percentage of patients who said the sessions were very important for their interpersonal relations was 56.2%. The percentage of patients who said the sessions produced very important biographical insights was 48.8%.
The percentage of patients who said the sessions were very important in helping them make life decisions was 36.4%; 12.4% decided to pursue professional training, 10.7% separated from a relationship, and 8.3% of the ex-patients decided to begin or to deepen a relationship with a partner. Other experiences that were very important were reported by 28.9% of the patients; 4.9% mentioned spiritual and religious experience, 6.6% mentioned better self-esteem and self-confidence, and 2.5% reported more creativity and awareness.
Content of the experience
The questionnaire also asked patients to say something about any of their therapeutic experiences that had long-lasting consequences or were of great importance.
The experience that was very important to most people was one of unity and complete love, reported by 71.1% of the respondents. Religious and spiritual experiences were very important to 44.6%, and visions were important to 39.7%.
Experiences of intense and unfamiliar sense perceptions were very important to more than half the subjects (54.5%). This category does not refer to hallucinations but instead to a previously unknown intensity in all modalities of sense perception.
Although experiences of anxiety, panic and horror, emptiness and absurdity were all of significant importance for about one third of respondents, only one of them wrote that he felt persisting disadvantages as a result of those experiences. For all the others it seems that so called bad-trips were not detrimental when experienced within a therapeutic setting.
One long section in the questionnaire asked about the respondents’ consumption of stimulants, quality of life, social behavior and spiritual life. Words like autonomy, quality of life, religion or spirituality were not explained in the questionnaire, so that each respondent understood them in his or her own way.
Virtually no patients reported an increased use of drugs after their therapy. Nicotine was used more frequently by 3.3% of patients, cannabis by 1.7%, alcohol by 1.7%. On the other hand, a substantial number of patients reported a decreased use of drugs. Nicotine was used less frequently by 20.7%, alcohol by 19.8% and cannabis by 7.4%. About half of the patients considered themselves to be nonsmokers of tobacco (57.8%). Marijuana was not used by 84.3% and 49.5% were non- consumers of alcohol. The number of non-consumers of alcohol may be a test artifact, in that some of the non-consumers of alcohol may have meant to say that they had no problem with alcohol.
Quality of Life
Fully 84.3% of the patients reported an improved quality of life; 3.3% reported a worsened quality of life. Better self-acceptance was reported by 81.8%; 2.5% reported decreased self-acceptance. More autonomy was reported by 67.8% of the respondents; 2.5% reported less autonomy. Since demographic data such as family status, livelihood and housing generally remained stable, the increased degree of autonomy probably refers to the patients’ estimates of their inner independence.
Improved relationships with family were reported by 81% of respondents, worsened relationships were reported by 3.3%. Involvement with work was improved in 57% of respondents, worsened in 2.5%.
About seven of ten patients (73.6%) said that they had a better approach to the Divine; .08% felt their approach was worse. About six of ten (57.9%) felt less fear of death; 1.7% felt more fear. The impact of the treatment on the spiritual lives of the subjects is based mainly on the content of the psycholytic experiences themselves. All of the three therapists consider themselves to be psychotherapists and not spiritual teachers. A dissertation by Benz (1989) discusses the personalities and techniques of the Swiss psycholytic therapists.
Discussion and Outlook
The aim of this follow-up study was to gather information from and about the patients treated with psycholytic therapy in Switzerland from 1988 to 1993. Psycholytic therapy is a controversial method of therapy in which patients are treated with psychedelic drugs in a specialized setting. Nine out of ten patients declared themselves to have experienced good improvement or slight improvement concerning the problems that brought them to therapy.
The feedback of the ex-patients permits us to say that psycholytic psychotherapy is a safe treatment. In the personal notes, only one patient complained of persistent depression that appeared three months after his last psycholytic session. During psycholytic therapy, none of the patients committed suicide, were hospitalized in a psychiatric hospital, or had a psychotic episode for more than 48 hours.
This result is consistent with other studies. In a 1960 paper by Cohen, the complication rate from 44 therapists with about 5,000 patients and 25,000 applications of LSD or Mescaline was 0.04% for suicide and 0.18% for the risk of a psychosis longer lasting than 48 hours. In a 1971 study by Malleson, the complication rate for 4,300 patients and 49,500 applications of LSD was 0.07% for suicide and 0.9% for a longer psychotic crisis.
The results of this questionnaire follow-up study do not offer objective proof for the efficacy of psycholytic therapy. A different study design would be needed to obtain more persuasive evidence of efficacy. Such a design would require testing subjects before and after treatment, and randomly assigning subjects to treatment and control groups. Personally, I am convinced that the efficacy of psycholytic therapy could be demonstrated if it were possible to obtain the necessary permission for research from responsible officials, along with the funding and expertise required to conduct the studies. Unfortunately, in Switzerland we have no university-based support for psychotherapeutic research into psycholytic therapy.
From 1988 to 1993, a significant number of patients with narcissistic personality disorders sought therapy with psychedelic drugs. The borderline personality disorder was also diagnosed rather often, as were depressed mood disorders and adjustment disorders. We can presume that the treatment is well suited for these disorders. To prove this would require a different study design.
In 1993, a valuable psychotherapeutic experiment in Switzerland was interrupted. The Swiss Medical Society for Psycholytic Therapy doesn’t know at the moment if its research will continue and, if so, under what circumstances. Negotiations are currently underway with the Swiss Federal Office for Public Health to start a new project to work under psychotherapeutic conditions with psychedelic drugs. The project is still in the planning stages because of very high demands concerning the scientific design.
Without work and research into psycholytic therapy, we cannot increase our knowledge of this method. I am convinced that it is a valid method that can be helpful for a certain selection of patients. If conducted by well-trained therapists who create a protective setting, it is a safe treatment.
Besides the claims about their benefits in psychotherapy, there is an additional reason to deepen our knowledge about psychedelic drugs. Today, these drugs are very popular, despite their illegality. MDMA especially is taken in large amounts under uncontrolled, sometimes dangerous conditions. I think that it would be very important to learn about the reaction of people to this substance under controlled, protected circumstances. The existence of these substances is a reality, so it seems to me more helpful to investigate their potential benefits and risks than to prevent research. Continued ignorance will not prevent prohibited substances from being used destructively in the underground.