In- Advances, ln neuropsychopharmacologv Proc. Symp. VII _ C_!Z. !mtermat. N_ur_ Psyc_=p_ ..... _,,1o ............

i _i for ANOVA !s. _ ,

!

d. by: O. V1nar,

Z.Votava,

P.B. Bredley. Avicanum, r._ _

Nortn-Holland Pub1., Amsterdam/London Praoue_ 1971 ; p_-.361- _ ,x"o_.

| |

LSD 2129 a LSD IN THE TREATMENT OF ALCOHOLICS

mt

differences
A.A. KURLAND, C. SAVAGE, W. N. PAHNKE, J.E. OLSSON S. GROF

Wird
and

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Maryland

State Psychiatric Researctz Center, Baitimore

INTRODUCTION ,x_ ea,,y r,,ocarc,, ,_ ' , c_m_,,_a,_and _.___ Hoffer on I,SD in the treatment of alcoholism was based on their .idea that its psychotomimetic propotties could produce a delirium tremens-like _tate. it was hc,pcd that such a state might have a favorable effect on the patient's drinking in a similar way as has been known for naturally occuring D.T.'s. Although their early hope was not substantiated, they found that some of their patients who had pos'_tive experiences wkh LSD did we!! thereafter. In a paper read to the New York Academy of Science in 1956, entitled, "A Review of the Clinical Effects of Psychotomimetic Agents", OSMOND (1957) proposed the hypothesis that a sh_ojle overwhelming transcendental experience with psychedelic drugs might be beneficial to alcoholics Within a relatively short time, Osmond's suggestion led to clinical studies seekivg to verify this hypothesis.*) Uncontrolled studies carried out by SMI3H (1958) a_d CHWELOS (1959) yielded favorable impressions which subsequent!y led to controlled trials on alcoholic p_tients. In these studies, different treatment techniques were employed. SMART et al. (1967), _OHNSON (1969), and HOLLISTER et al. (1969) utilized a treatment method that is perhaps best described as psychedelie chemotherapy, in which the major emphasis was on the administration of the drug itself. The amount of psychotherapy in the preparation for the session and in the post-treatment per'_ed was minimal.

ring the actual orion. nay have been _,_, different rough so that :eflected. aitable in that tp l.hetapy and pic which had ions, and only the emotional

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* The single overwheln'6ng experience has sometimes been referred to as "transcendental" by I-IoF_zR (1967) and SAVAG_(1960), "psychedelic" by KIIRLANDet al. (1967), and "psychedelic peak experience" by PAttNK_. et al. (1970). 361
I

362

A.A. KURLAND ET AL.

! i _,
i

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In a modification of this approach, LUDWIG et al. (1969) added hypnotic induction during the very limited preparation for the session and in the session itself. These studies have yielded essentially similar findings, namely, that the results of LSD therapy in this treatment context were not significantly different from those obtained in the control groups, In the present study, psychedelic-peak therapy has been used; a treatment technique distinctly different from those described above, One of its basic characteristics and immediate goals in the drug session itself is the achievement of a peak or transcendental experience, but just as important is the intensive psychotherapy which occurs in the weeks prior to the psychedelic drug session and the follow-up therapy in the weeks after to help with the work of integration. The method of facilitating this experience has been described in detail elsewhere (see SCHLIENet al., !968; KURLAND et al., 1967 and PAHNKEet al., 1970). The preparation for the drug session involves an average of about twenty hours of intensive psychotherapy. During this period, the therapist aims at establishing close rapport with the patient and gaining intimate knowledge of the patient's developmental history, dynamics, defenses, and difficulties. In specific preparation for the session itself, the patient is acquainted with the basic effects of the drug and encouraged to trust the therapist, himself; and the situation. This is a very important part of the preparation that enables the patient to utilize the session in the optimal way -- to let go voluntarily of his usual ego controls and so be completely open to whatever experiences he encounters, The experimental drug sessions themselves are carried out in a special treatment suite, furnished hke a comfortable living room, with sofa, easy chairs, rugs, drapes, pictures, flowers, and highfidelity music equipment. The patient's therapist and a psychiatric nurse are in constant attendance throughout the period of drug action (10_12 hours). For most of the session, the patient reclines on the sofa with eyeshades and stcrcoplionic earphones, alternately listening to carefully selected classical music or interacting with the therapist, The experiences that tile patients have under these circumstances cover a wide range from aesthetic visions and sensations, through reliving of traumatic life experiences with a powerful abreaction and catharsis to psychedelic peak reactions. The psychedelic peak experience has been found most useful from a therapeutic point of

'

view andthepret structured in ord of the therapist the experience o The basic cha: described by Pal 1. Sense of m usual sense 2. Transcendt 3. Deeply felt 4. Sense of a 5. Meaningfu 6. Ineffability by verbal

i _

METHODOLOGY In this doub!q mitted to the A Hospital, were group (450 mcgl one basis (90 hJ alike dining th which group tb Analysis shov therapy (exclusi averaged 20.0 Ii last therapy apF 7.3 weeks in tre

Despite ran& ficantly differer group, 47.7% separated or d married, 4% si: group also has missions _ !8 percent of the I; pared to 36 % achieved match antly, on the

LSD IN ALCOHOLICS

363

(1969) added xfor the session ;entially similar this treatment _btained in the xas been used; escribed above, :he drug session experience, but ,hich occurs in 1 the follow-up of integration. :n described in et al._ 1967 and _ession involves :herapy. During apport with the s developmental :ific preparation Lhe basic effects dmself, and the ,reparation that imal way -- to , be completely carried out in _le hying room, vers, and highad a psychiatric d ofdrugaction rechnes on the rnately listening th the therapist, ;e circumstances _ations,through 1 abreaction and _edelic peak extpeutic point of

view and the preparation, as well as the set and setting, is specifically structured in order to iacdRatc Its occurrence. One of the major goals of the therapist during the session is to help the patient to stabilize the experience on this level. The basic characteristics of the psychedelic experience have been described by Pahnke: 1. Sense of unity or oneness: (positive ego transcendence, loss of usual sense of self without loss of consciousness). 2. Transcendence of thne and space, 3. Deeply felt positive mood (joy, peace, and love). 4. Sense of awesomeness, reverence and wonder. 5. Meaningfulness of psychological and/or philosophical insight. 6. Ineffability (sense of difficulty in comrmmicating the experience by verbal description).
METHODOLOGY OF THE PRESENT STUDY

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In this double-blind controlled study, 135 alcoholic patients admitted to the Alcoholic Rehabilitation Unit of Spring Grove State Hospital, were randomly assigned either to a high-dose treatment group (450 meg) or a low-dose control group (50 meg), on a two-toone basis (90 high dose vs. 45 low dose). All patients were treated alike during the preparation since the therapist did not know to which group the patient belonged. Analysis showed that the high-dose group averaged 21.6 hours of therapy (exclusive of the LSD session itself), while the low-dose averaged 20.0 hours. The length of time in treatment from first to last therapy appointment was similar; the high-dose group averaged 7.3 weeks in treatment and the low-dose group averaged 6.7 weeks Despite randomization, the high- and low-dose groups were signifieantly different on several important variables. In the high-dose group, 47.7% were married, 20% single or widowed, and 33% separated or divorced, while in the low-dose group, 36% were married, 4% single, and 60% divorced or separated. The low-dose group also has a large percentage of patients with five or more admissions- 18% as opposed to 3% of the high-dose group. Fifty-two percent of the high-dosegroup had completed high school as compared to 36% of the low-dose group. Randomization, however, achieved matching on IQ, age, occupational status, and most importantly, on the pre-treatment rating of abstinence.

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364

A. A. KURLAND

ET AL.

RESULTS

A comprehensive psychological test battery including performance and inte_gence tests, projective techniques, and personality inventories was administered just prior to acceptance into the program and one week after the LSD session. A more limited battery of tests was given at the six, twelve, and eighteen month follow-up points, While the great majority of these psychological test results indicated significant improvement in both treatment groups from pre- to post'

treatment, the highprovement over the week of the LSD s. the pre- and post-/_ dose groups respec_ treatment profiles ot ment, particularly scales, but the highof improvement ow Other personaliq Eysenck Personalit_ sures of intelligenc,

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LSD IN ALCOHOLICS 365 !

ng pertbrmance rsonality invento the program battery of tests )w-up points, :esults indicated _m pre- to post-

treatment, the high-dose group showed no significantly greater iraprovementover the low-dosegroup on any test variableswithin one week of the LSD session. As an illustration, figures 1 and 2 show the pre- and post-MMPI compositeprofilesfor the low- and highdose groups respectively, while figure 3 compares the adjusted posttreatment profilesof both groups. Both groupsshow much improvement, particularly in the Depression (D) and Psychasthenia (Pt) scales, but the high-dose group shows no clear superiority in degree of improvement over the low-dose group. Other personality inventories, such as the Personal Orientation

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sures of intelligence and perceptual-motor performance (inciuding Inventory (POI) , theInve Psychiatric Evaluation rofile (PEP ), and the Eyse nck Pers onality ntory (EPI) showed P similar findings. Meathe Benton Visual Retention Test, Wechsler Adult Intelligence Scale, Raven Progressive Matrices and Imbedded Figures) showed significant improvement on some variables within both treatment groups, but again no significant differences were found between high- and low-dose treatment groups. It is important to note that no patients showed decrement in performance on IQ or evidence of organic damage pre- to post-treatment. The results for three other tests, Holtzman Inkblot Test (HIT), Rotter Sentence Completion Test and Human Figure Drawings, which can be considered primarily projective in nature also showed no significant differences between the high- and low-dose groups. However, both- high and low-dose groups showed a large, significant reduction in maladiustment as measured by the Rotter Sentence Completion Test. Final analyses of psychological test results at six and twelvemonths follow-up and preliminary statistics at eighteen months are consistent with the above findings from the immediate post-session period in that there were no significant differences between high and low treatment groups. Follow-up interviews and ratings of adjustment are now completed at the six-month, twelve-month, and eighteen-month checkpoints for a total of 121 of the 135 alcoholic patients who were treated with psychedelic psychotherapy. While the study design made it possible for the patients to have up to three sessions, the vast majority in both experimental and control groups (total of 117 patients) received only one treatment with LSD. The 18 patients who had more than one

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LSD session were not found to be different from the other 117 in psychological and social measures based on pre-treatment testing, but as a group they received more average hours of treatment. Therefore, in the interests of uniformity concerning amount of treatment, results were analyzed separately for the 117 patients who had only oneLSDsession (either a highor a lowdose). The percentage of patients found and interviewedat the six-month follow-up point was 89 % (104 out of 117 treated cases). Although the percentages dropped somewhat at the twelve and eighteen-month follow-up points to 80 % and 78 % respectively, this is considered a very good follow-up rate, realizing that many alcoholics are difficult to keeptrack of in thecommunity. The follow-up ratings of adjustment were made by an independent team of social workers. Ratings were made on each patient on a predetermined 0 to 10 behavior rating scale. The Global Adjustment rating included occupational, interpersonal, and residential factors as well as the patient's use of alcohol, with a score of zero indicating poorest adjustment and ten indicating superior adjustment. Zero on the scale measuring Drinkingtotal Behavior indicated daily almhol consumption, and ten indicated abstinence. Mean ratings of Global Adjustment and Drinking Behavior for the high and low-dose groups at the pre-treatment and six, twelve, and eighteen-month follow-up pointsare shown in Table1. As shown, the high-dose group shows consistently higher mean ratings than the low-dose group at all follow-up periods. However, mean change scores (post-minus pre-means) do not show as large differences between the two treatment groups. In fact, when the data were submitted analysis of LSD covariance which pre-level into consideration , 6 to months after was the only takes time that Drinking Behavior and Global Adjustment showed a significant differencebetweenthe high and low-dosegroups (p <.025 and .05 respectively _ one-tailed test). The magnitude of difference in Drinking Behavior mean scores between the groups at 6 months is 1.4 and the difference in Global Adjustment is .50. At 12 and 18-months, this statical advantage of the high-dose group has disappeared and there is virtually no differencebetween the two groups in mean change scores. Apparently the significant, but small advantage of the high-dose treatment holds for onlysixmonths. The percentage of patients functioning in an "essentially rehabili-

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:he other 117 in eatment testing, reatment. Thereunt of treatment, _ts who had only _ _ ._ _. _ _6 +_ _ _ +

367

_l c a atthesix-month ses). Although ad eighteen-month , this is considered :oholics are difficult : by an independent : each patient on a : Global Adjustment d residential factors _re of zero indicating or adjustment. Zero ,dicated daily alcohol ace. Mean ratings of the high and low-dose , and eighteen-month asistently higher mean '-up periods. However, ) do not show as large ._.In fact, when the data rich takes pre-level into only time that Drinking significant difference be_5and .05 respectively _ _ce in Drinking Behavior _sis 1.4 and the difference 18-months, this statistical _ppeared and there is virps in mean change scores. lvantage of the high-dose in an "essentially rehabilii ! ! i I i i _ _, i

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tated" fashion is shown for the various groups in Table 2. A score of 8 or more on the 0 to 10 scale was considered a rigorous criterion, indicating for Global Adjustment that a patient was making "good attainment or adjustment" with regard to drinking, occupation, interpersonal relations, etc. A score of 8 on the Drinking Behaviorscale indicated some, but only minimal, departure from total abstinence. Statistical analysis revealed that there were significant differences between the high- and low-dose groups in percentage of patients reaching this criterion, both in Global Adjustment and in Drinking Behavior, but again, only at the 6-month follow-up. In regard to the most important target symptom, Drinking Behavior, Table 2 reveals that at six months after LSD, 53% of the high-dose group are greatly improved as opposed to 33 % of the low-dose group. By chi square this is significant at the .05 level (one-tailed test). This significant advantage does not obtain at 12 and 18 months after LSD. At 12 months, 47% of the high-dose patients are greatly improved as opposed to 48% of the low-dose patients, and at 18months, 54% of the high-dose patients are so rated as opposed to 47% of the low-dose patients. The change in percentage of patients "greatly improved" in the high and low-dose groups from the six-month follow,up point to the 12 and 18-months points is in part to the decrease in the number ofcarried patients found at these latter due points. However , other calculations out taking the unfound casesinto consideration alsoindicated that the advantage of the high-dose group occurs only at the six-month follow-up point. In speaking to questions which might be raised concerning the harmful effects of LSD administration, only one adverse reaction has been observedin our entire seriesof well over 200alcoholics treated with either high or low dose to date (June 1970).Furthermore, even in this one case,the reaction was reversedby conventional therapy, These observations would tend to indicate that the risk of therapy is not substantially increased by the addition of a high dose.
DISCUSSION

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The main finding of a differenceat six months follow-upof 53% of the high-dose group essentiallyrehabilitated in regard to drinking behavior as opposed to 33% in the low-dosegroup is on the face

LSD

IN ALCOHOLICS

369

_ble 2. A score of igorous criterion, as making "good accupation, interag Behavior scale total abstinence. ificant differences ntagc of patients t and in Drinking om, Drinking BeI.SD, 53',';,,of the "d to 33 % of the _t at the .05 level otobtain at12 and high-dose patients low-dose patients, aresorated asoprage in percentage t low-dose groups t 18-months points f patients found at carried out taking _that the advantage x-month follow-up .sed concerning the he. adverse reaction over 200 alcoholics ane 1970). Furthereversed by convento indicate that the _y the addition of a i_ o _ _ _ _ _ o _ _: _ _ -_ _ _ _ ,_ _ " _ _ O_ _ __ _ _ ._ _ _ b_ _ -_ '* _ _ _ _ _ ._ _o0 _ ._ "_ '_ ._ ,_ _ _o -' ._ _ b_ _ _ _ _ _o _ _ _ _ _

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of it quite substantial. However, the significance of this difference is at the .05 level, and from a more rigorous point of view, we would have to say that a higher level of confidence would be more convincing, Also, we must face the fact that randomization failed to match the two groups on such variables as marital status and previous admissious, although they were matched on IQ, age, occupational status and pre-treatment abstinence. This failure of randomization may have conferred some advantage to the high-dose group. There is also the possibility that a therapist may have been more effective with the high-dose group though the high improvement rate of the low-dose group suggests that this is not true. It is also possible that the people in the high-dose group were able to take more advantage of vocational rehabilitation, etc. On the other hand, the fact that the low-dose group did as well as it did probably reflects the intensive preparation therapy and LSD session which they received. Many of our 50 mcg sessions involved considerable abreaction and catharsis of psychodynamically charged material. The dramatic changes observed in some of our high-dose sessions suggests that for some patients the high-dose procedure is probably most beneficial, but for a considerable number of other patients the low-dose treatment was also quite helpful. In retrospect, a control group receiving no LSD would have been helpful in differentiating the exact role of psychotherapy as opposed to LSD session. In actual practice, however, these two factors it must be pointed out are ciosely interwoven and work together as a unified treatment approach. In the context employed, the psychedelic psychotherapy was successful in helping over half of the alcoholics treated in this program as opposed to a 12 _,_i ,mprovement rate at 18 months follow-up for comparable alcoholics in this treatment facility at Spring Grove State Hospital. This 12,/ofactor is from a prior study and does not repre'

that may yield additic the duration of the th be tried, including t] many different dosag

_ i ! i 1 t _ _ ,

ACKNOWLEDGEME These investigatio Public Health Servk FR-05546, administe Baltimore, Maryland Grateful acknowle Unger, Ph. D., Lee Richards, S.T.M., ar study.

ABR_ISO Macy NH , ., A. Jr. , edP1 . _, ed., 1967. T] Bobbs-Merri] CnwrLosStN., BL_ udiesD. on A

COLBY,K. /vl., 1964. Hxcxs, R. E. and P. V New York. HOFFER, A., 1960. In _, 1967. InAb HOLLIST ER L,. E ., J.

125, 58. JOHNSON, G., 1969. B KURLAND A. , A., S. I. 1. Psychiat. LEUNERH , ., 1967. In
LUDWIG, A., J. LEVlN

sent a concommitant comparison control group. It would also appear that there may be a correlation between the psychotherapist's sldll and its contribution to the meaningfulness of the drug experience session. However, this is an issue requiring further investigation. Finally, it is our impression that the overall clinical achievements of only one psychedelic peak experience and its maintenance for a period of several months in these types of patients is an observation that cannot be discomlted. This will require further study of those factors

126, 59. OsMorm, H., 1957. A

i PAHNKE, W. N. and

_ '_

--,

5, 175. A. A. K u_, Amer. Med.

S_LZMaN,C., 1969. ( In Hicks, 1o SAVAGE, C., 1960. In

!
LSD IN ALCOHOLICS 371 !

fis differenceis ,Jew, we would ore convincing, d to match the ,revious admisLpational status :ation may have here is also the ective with the _f the low-dose ssible that the :e advantage of mp did as well _.rapy and LSD _sions involved
aically charged our high-dose e procedure is mber of other In retrospect, _ful in differenLSD session.

that mayyield additionalenhancementsthat can intensify and extend the duration of the therapeutic effect. A variety of approaches should be tried, including the use of LSD as an aid to psychotherapy at many different dosage levels.
ACKNOWLEDGEMENTS

t
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] 1

These investigations were supported in part by United States Public Health Service research grants MH-13747, MH-15555 and FR-05546, administered by Friends of Psychiatric Research, Inc., Baltimore, Maryland. Grateful acknowledgement is made te the effe_s of Sanford Unger, Ph.D., Lee McCabe, Ph.D., Sidney Wolf, Ph.D., William Richards, S.T.M., and Harry Shock, LL.B who collaborated in this study, REFERENCES
ABV,AMSON, H. A., ed. 1960. The Use of LSD in Psychotherapy. Josiah Macy, Jr. Publication, New York. --, ed., 1967. The Use of LSD in Psychotherapy and Alcoholism. Bobbs-Merrill Co., New York. CnWELOS N., D. BLEWETT, Studies on Alcohol. C. SMITH and A. 20, 577.
HOFFER,

!
I |

l [ [

i
l i

1959.

Quart.

J.

!
t

COLBY, K. M.,and 1964. Review Pe sychology 347. HICK S, R . E. P. V.Annual FINK, 1969 . Psyof ched lic Drugs.15,Grune

& Stratton,

ast be pointed
Jfied treatment

New York.
HOFFER, A., 1960. In Abramson, loc. cit. --, 1967. In Abramson, loc. cit. HOLLISTER, L. E., J. SHELTON and G. KRIEGER, 1969. Amer. J. Psychiat. 125, 58. JOHNSON, G., 1969. Amer. J. Psychiat. 126, 481. KURLAND, A. A., S. UNGER, J. W. SHAFFER and C. SAVAGE, 1967. Amer. J. Psychiat. 123, 1202. LEUNER, H., 1967. In Abramson, loc. cir. LUDWIG, A., J. LEVlNE, L. SPARK and R. LAZAR, 1969. Amer. J. Psychiat.

_"

erapy was sucn this program _:follow-up for ag Grove State ioes not repre-

uld also appear

:herapist's skill rug experience

126, 59.
1957. Annals N. Y. Acad. Sci. 66, 418. N. and W. A. RICHARDS, 1966. J. of Religion & Health, 5, 175. --, A. A. KURLAND, S. UNGER, C. SAVAGE and S. GROF, 1970. J. Amer. Med. Assoc. 212, 1856. S_ZMAN, C., 1969. Controlled therapy research with psychedelic drugs. OSiOl, m, H., PArtaKE, W.

,estigation.
chievements Ice of

for a period )servation that )f those factors

In Hicks, loc. cit.

SAVAGE, C., 1960. In Abramson, loc. cit.

t
i 1
l

t,

372

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KURLAND

ET AL.

SCHLIEN,J. M., H. F. HUNT, J. P. MATARAZZO and C. SAVAGE (eds.) 1968. Research in Psychotherapy. American Psychological Association, Washington, D. C. SMART,R. G., T. STROM,L. SOLURSH and E. F. W. BAKER,1967. Lysergic Acid Diethylamide (LSD) in the Treatment of Alcoholism. Toronto, University of Toronto Press. SMITH,C. B., 1958. Quarterly J. of Studies on Alcohol 19, 406. A. A. K., Maryland State Psychiatric Research Center,
Box 2235, Baltimore, Maryland U.S.A.

SPECIAL QUESq SUBJ