Chapter 48. Hazards of LSD psychotherapy

From the very beginning, psychiatrists were aware that LSD, like most other medicaments, poses hazards. The hazards visible during the early years were summed up in a classic 1960 paper, "Lysergic Acid Diethylamide: Side Effects and Complications," by Dr. Sidney Cohen.1

Dr. Cohen sent a questionnaire to 66 researchers who were known to have administered LSD or mescaline to humans, either therapeutically or experimentally. Forty-four of them replied; they had administered LSD on more than 25,000 occasions to nearly 5,000 men and women. Dr. Cohen also searched the medical literature for published reports of adverse effects.

From the physical point of view, LSD was found to have a remarkable record. "No instance of serious, prolonged physical side effects was found either in the literature or in the answers to the questionnaires. When major untoward reactions occurred they were almost always due to psychological factors." 2 No physical complications were observed even when LSD was given to skid-row alcoholics with impaired liver function and generally deteriorated health.

As for adverse psychological reactions, Dr. Cohen noted that the published LSD literature "directly records only one suicide and that in a schizophrenic patient, and a 'Small number of short, self-limited psychotic reactions and other lesser side effects ." 3

Dr. Cohen's survey of LSD therapists, however, turned up several kinds of adverse psychological reactions. These he divided into immediate and subsequent.

The most common, but still infrequent, immediate problem [Dr. Cohen reported] was one of unmanageability. This apparently occurs when insight into the situation is lost and the individual acts upon delusory, usually paranoid ideas. Instances of running away from the tester, disrobing, or accidental self injury were described. . . .

Panic episodes were likewise mentioned. When these develop early they seem to represent the terror involved with the loss of ego controls. At the height of the reaction panic may be precipitated.... Finally, after many hours of frightening dissociation the subject could develop an intense fear that he will not be able to get back to his ordinary state.* 4

* Others have similarly commented that the duration of the LSD trip-more than six hours in most cases-is a disadvantage. Few trials have as yet been made of psychotherapy with short-acting LSD-like drugs such as DMT.

Certain kinds of people, the Cohen survey revealed, are particularly likely to have bad trips of these kinds. "Those with excessive initial apprehension" are the prime example; fear of a bad trip increases the likelihood of a bad trip. Dr. Cohen also mentioned people with "rigid but brittle defensive structures, or considerable subsurface guilt and conflict." 5

People hostile to LSD were also noted as likely to have bad trips. "Invariably, those who take hallucinogenic agents to demonstrate that they have no value in psychiatric exploration have an unhappy time of it. In a small series of four psychoanalysts who took 100 [micrograms] of LSD, all had dysphoric [unpleasant] responses. Two Zen Buddhists were given LSD in order to compare the drug state with the transcendent state achieved through meditation. Both Zen teachers became so uncomfortable that termination [of the trip] became necessary." 6

The Cohen survey also noted two kinds of hazard during the day or two after LSD. "The first is a simple prolongation of the LSD state. Ordinarily, after a night's rest it is to be expected that complete cessation of the drug effect will have occurred. However, the persistence of anxiety or the visual aberrations for another day or two in wavelike undulations has been described." 7 More frequent were short-lived depressions following LSD. These, Dr. Cohen noted, might be due to simple "letdown" on returning to humdrum everyday life, or to other factors.

While bad trips were infrequent, Dr. Cohen offered a number of suggestions for reducing the frequency still further. One was adequate screening of patients through a preliminary psychiatric interview and history-taking-especially to exclude schizophrenics and schizoids. The briefing of the patient in advance is also "a matter of some importance, with the value of the drug interview sometimes depending on the preliminary instructions. Something of the nature of the experience and the expectations for the session are communicated at this time. Misconceptions are corrected and necessary reassurances are given ." 8

Precautions during the LSD trip are also essential. "That the person under the influence of LSD should not be left alone is universally agreed. Human contact is comforting and serves as a pivot between every day reality and the strange world of LSD. Without it the patient can readily lose all orientation. Personnel in contact with the subject should be experienced and sympathetic.... The [LSD] state is a highly suggestive one with the patient responding strongly to environmental cues. He can sense the therapist's unspoken feelings with phenomenal accuracy. Impersonality, coldness and disinterest is the equivalent of being left alone." 9

Finally, Dr. Cohen noted that although they are rarely needed, LSD antagonists should be on hand. Several drugs are capable of terminating an LSD trip quite promptly. Psychological measures such as reassurance rather than drugs, however, are commonly used today to abort an LSD bad trip.

A much feared aftermath of LSD during the 1950s was suicide-in part because of widespread rumors of a European suicide following LSD use, and in part because one actual LSD suicide had been reported in the medical literature. In this respect, the 1960 Cohen survey was reassuring.

The patients given LSD included many who were seriously depressed or suffering from other severe forms of mental illness. In such a population, the incidence of suicide is relatively high. Among the patients covered in the Cohen survey, the suicide rate was one per 2,500 patients. Among healthy experimental subjects given LSD, the suicide rate was zero. The rate of suicide attempts among psychiatric patients given LSD was 1 in 800; the rate among experimental subjects given LSD was zero.

Licit and Illicit Drugs