THE PSYCHEDELICS AND GROUP THERAPY

DUNCAN BLEWETT

The psychedelic drugs offer certain rather profound advantages in the group psychotherapy situation. Examination of these, as well as the disadvantages or hazards related to the group psychedelic process, requires a comparison of group psychedelic experience with that of the more conventional situation. Any group process depends upon the development of the individual subjects within the particular context of the group. Since in group psychedelic sessions this process is so compressed and accelerated, it is advisable first to consider the effect of the drug upon the individual and then to trace the reflections of this in the group process.

Psychedelic and Conventional Group Therapy

In psychedelic and non-psychedelic groups, there is a similar development of basic trust between members, which increases group cohesiveness and permits greater freedom of expression and self-exploration. This leads, in turn, to therapeutic advance through the broadening of self-understanding. In this process, each group member acts both as a mirror and as an alternative pattern of adjustment for each of the other members. Each person finds himself in a gradually growing environment, in which his perspectives may enlarge, his potential modes of response increase, and his defensive strictures relax.

The essential difference between psychedelic and conventional group therapy is the speed with which developments occur. In the psychedelic session, the sequence of events is remarkably compressed in time. This compression sacrifices neither quantity of experience nor the totality of emotions involved. It includes the whole process of therapy, from the establishment of trust and transference to the final development of self-confidence and self-acceptance in a realistic appraisal of personal defects and personal strengths. It results in a dramatic acceleration of events and a vastly magnified intensity of emotional response within the psychedelic session. The strong emotions that must be discharged to loosen crippling cathectic bonds may be released under psychedelics in a matter of a few hours, and the emotional turmoil may become so overwhelming that the individual "loses control." Where individual therapy permits the gradual development of freedom in the individual, in the psychedelic situation this becomes a surrender of confining, defensive self-interpretations.

Process of Group Psychedelic Treatment

The great advantage of group psychedelic treatment is the shortening of the therapeutic process. Its disadvantage is the intensity of the resultant reaction. The therapist must be able to give his attention to the group for an extended continuous period of time. It should be recognized that even though the most intense psychological effects will occur in about three hours, the latter stages of the experience are also likely to be of marked importance. After the initial crescendo of alterations, logical and conceptual reasoning begins to reassert itself. The submergence of the individual in his experience ends, and he becomes, as he usually is, both participant in and observer of his experiences. He must be able to symbolize his experience in order to use it. It is not sufficient for an individual to experience something in order for him to gain knowledge. Before he can conceptualize his experience, he must be able to tell himself in one set of symbols or another what has happened. For instance, to answer the question, How do you feel now? you must be able to step back and observe how you are feeling, and apply some word or conceptual symbol to that feeling, before you "know" what you are feeling.

This objectivity—the capacity to "step back and observe" the experience—begins to reappear about three and one-half or four hours after the ingestion of the drug. It gradually increases, and it permits the individual to explain to himself the nature of his experience and what he has found out about himself. He retains sufficient freedom from his defenses and sufficient acceleration of mental processes to be particularly insightful and efficient in this task of formalizing his insights and storing his findings in memory. Because of the vastness of the experience and the complexity of the self, sessions should be extended to permit this process to go on, and should not be terminated until there is general agreement among the participants to do so.

The intensity of the experience and its overwhelming effect upon the individual also render difficult the mechanics of psychedelic therapy. The question of when to terminate a session is different for patients in a hospital as opposed to outpatients. If possible, group members should be admitted overnight to a hospital where they can sit up and continue the session until they are ready to sleep. Where this is not possible, they should stay together in a large room or suite, accompanied by a "sitter" familiar with the drug experience. If this arrangement is also not possible, a "sitter" should accompany each of the subjects home, and arrangements should be made for a trusted person to spend the night with him. The "sitter" should spend sufficient time with the subject and his attendant to bridge any gaps and be sure that they are comfortable with one another.

Psychedelic States and Personality Dynamics

In order to be able to discuss the problems encountered in different methods of group psychedelic treatment, it is important to understand the psychological processes involved in the experience. Chwelos et al. (1959) has classified these psychological changes as involving (1) prolongation of subjective time, (z) enhancement of perceptual clarity, (3) acceleration of thinking, (4) emotional lability, with increased intensity of emotion, ( 5) added depth in all mental processes, (6) increased sensitivity and empathic awareness of the feelings of others, (7) a feeling of depersonalization, and (8) psychotic changes including thought disorder and delusional and referential thinking. These changes are not independent, and the relationships between them aid in understanding the underlying process in which they originate.

The ability to judge time is learned, and is one of the major elements in the socialization and maturation of the individual. It involves developing a relationship between a given quantum of objective time and a corresponding quantum of subjective experience. Psychedelic drugs alter this time-metering process by prolonging subjective time and enhancing stimulus input per unit of objective time. The enhanced input involves a corresponding acceleration of ideation and a widening of the scope and meaning of concepts through a flood of novel associations. This overextension of concepts results in their melting and blending in such a way that classification begins to break down. The connection and association of concepts is made nearly instantaneously. Not only is each concept distended in terms of the associations it evokes, but any combination or comparison of concepts produces a vast array of new possibilities, ideas, connotations, and similarities.

Customarily, consciousness acts as a reducing valve on the amount of information permitted into awareness, but the drug disturbs this function, and the subject's thought processes are swamped with an "information overload." Ideation becomes so rapid and extended as to be more aptly described as intuition. What would normally be regarded as overinclusiveness of concepts becomes in the psychedelic experience the basis for remarkably speeded, enriched, and extended modes of ideation. In psychotomimetic reactions, however, the overgeneralization disrupts thought processes and produces intense confusion and bewilderment.

Experience defines value and belief systems in all aspects of the learning process through which concepts are formed. These values and beliefs form the yardstick by which an individual measures the worth and meaning of himself and the events, people, and objects of his environment. They determine the choice of coping mechanisms. Out of them develop what Freud (1936) refers to as the "ethical, aesthetic, and personal pretensions" of personality. These pretensions render unacceptable certain aspects of self, and open a cleavage between the actual and the ideal self. Repression does not rid the self of these unacceptable aspects but merely covers them over, and they remain hidden.

In the psychedelic experience, as the concepts blend and classification brealcs down, those concepts that represent the pretensions of the individual also blend, melt, and break down, with other, often opposite, concepts. These particular beliefs and values, which represent classifications of right and wrong, acceptable and unacceptable, lose their pre-emptive power and value. Repressed material breaks through into consciousness as the barriers disappear.

The self-concept and its system of defense mechanisms are intricately interwoven. The breakdown of defenses induces depersonalization. Because defenses limit our ability to see ourselves with clarity and objectivity, the therapeutic potential of the psychedelics resides in the fact that, through depersonalization, they permit a temporary escape from the prison compound of one's own conditioning. The result is a confrontation with the self, with no means of defense against one's own scrutiny or enmity.

At this point the individual must either struggle to reassemble his shattered defenses—an agonizing process very likely to induce the extreme anxiety and confusion of the psychotomimetic response—or he must forgo his customary defenses and surrender them by accepting a revision of his self-concept. This point of surrender is the crux of the experience, for it forms the great divide in the individual's psychological response to the impact of the drug. On the one side lies the process of psychotomimetic response in the form of psychotic depersonalization and its accompanying loss of orientation for time, space, and identity. On the other side, psychedelic reactions appear to extend through a series of levels of ego loss into the experience of transcendence, or peak experience.

That which is yielded up in the process of surrender is a value or pretension about the self. As repression breaks down and a particular item begins to find its way into awareness, the individual tries to maintain his defenses. The interpretation that initially forced the repression colors the imagery that arises, and this may take on frightening or revolting characteristics. As long as the pretentious interpretation is clung to, the imagery will be frightening, unacceptable, and distressing. Surrender is the letting go of the interpretation. Because of the psychological proximity of the self-concept and its defenses, this act of surrender calls for undergoing and overcoming the ultimate fear that is locked in each man's heart: If I should come to know myself completely and still hate and revile myself—what then? What if the self is unacceptable, completely unwanted—an entity without purpose or meaning?

The deeper and more anguished my self-hatred, the more I am likely to fear the ultimate revelation of myself to my own scrutiny. Yet it is the person with the greatest self-rejection who feels the most severe distress and is most likely to be undergoing therapy. To the individual in the group, therefore, surrender is likely to be equated with the destruction of the self through its submergence in the terrible power of the images. In this struggle, it is the balance between faith and anxiety that becomes the overwhelming fact of consciousness. In this context, faith refers to the expectation of love and to the acceptance of trust that pain will bring understanding and be bearable. Anxiety is the anticipation of pain and is increased by unwillingness to accept pain and the fear that it may prove unbearable.

When the individual can look into and accept the manifest images of the repressed, he effaces the conditioned interpretation through which alone they are seen as disgusting, meaningless, artificial, or terrifying. The acceptance of the repressed portion of the self is accomplished by the acceptance of the images. Repression has distorted reality by not recognizing those aspects of the self that have been interpreted as unacceptable in the Tight of the conditioned pretensions. Acceptance of the imagery by being able to project love toward it means that beauty has been found in the repressed area of the self and that compassion is extended toward it. The breach is healed, the severed aspects of the self rejoined, and the individual feels a great release of tension and anxiety and an unaccustomed sense of peace. With defense needs gone, repressed energies are released, heightening the feelings of reality and depth. The individual is psychologically open, where he was defensively closed.

The release of a particular area of repression alters only that area of the conditioned attitudes toward the self. Other, perhaps deeper, areas of repression remain unchanged. Self-surrender is not an event that occurs only once, but must be repeated as additional repressed material is released. Each repetition becomes easier because of the positive reinforcement given by each previous self-surrender. Sometimes, however, the strong emotional impact of the particular repressed material emerging may intensify the difficulties encountered. This is why psychotomimetic reactions may occur even after an individual has experienced a number of psychedelic sessions.

Effects of Enhanced Interpersonal Communication

The openness of the undefended self produces the increased sensistivity and empathic awareness of the feelings of others cited by Chwelos et al., and reported almost universally by subjects who have taken one of the psychedelics in a group session. Indeed, subjects generally cite it as the most outstanding aspect of the experience. Communication, cleared of the distortions of defensive screening, becomes so unusually direct, clear, and proximate that it is a process of empathic bonding. The release of psychic energies formerly trapped in repression and resistance lends to all psychological functions a novel clarity and profundity. This is what is referred to in the vernacular as being "turned on."

It should be noted that the compressed intensity of the psychedelic session will affect the therapist through his own sensitivity and empathy, even more than may be the case with conventional therapy. The therapist may well find himself drawn into a profound self-examination. To overcome fear and to help the patient gain insight is the aim of the therapist. But what guarantee can he provide to the individual who fears and reviles himself, that self-knowledge will lead to self-acceptance and self-compassion? The quality of transference grows from his conviction that to know all is to forgive all, and to find what is, is to locate the grounds for compassion. But does he really believe it? Does he impart it properly? Myriad questions of this sort are likely to come up in his own mind with such insistence that they cannot be brushed aside. The therapist should be prepared to deal with them.

This effect on the therapist is the result of the reduction of the defenses of the group members. Customarily, persons communicating are relating to each other through their defensive screening. Breaking down barriers on the patient end of the communication channel puts pressure on the defenses of the therapist, and they tend to become permeable, often before he realizes what is happening. The empathic bonding between participants in the session is the inevitable consequence of the breaking down of defensive walls. It can develop only to the extent that the participants accept themselves and each other, because in depersonalization the individual feels emotionally naked and vulnerable. It takes place when each individual becomes open with the others and can engage in emotional give-and-take with little or no reservation. The participants are able to feel a union so complete as to verge upon the telepathic. Generally the communication of feeling in this bonded state occurs in the form of rather gross, holistic, undifferentiated feelings of pleasantness or unpleasantness.

When one member of the group becomes anxious, hostile, depressed, or confused, the other members of the group become aware of his discomfort. This is not encountered as an external fantasy impinging upon them, but as an endogenous process. They find themselves casting about seeking an explanation for their discomfort within their own functioning and experience. One of the skills each group member must acquire is the ability to detect the source of disturbing feelings. The therapist will be able to mark this development by a shift in the group from statements like, "I feel anxious, but I don't know why," to statements like, "Somebody is feeling very anxious." There will then be a further shift to forms indicating that the members of the group have come to recognize where the feelings are coming from. The participants will direct questions about what is wrong at particular group members. This is not simply a matter of projection, for, at this stage, the group will agree as to who is disturbed, the therapist will note signs of disturbance in that person, and if the individual himself is not too withdrawn, he will readily admit his discomfort.

The empathic bond is the vehicle upon which the group process proceeds so rapidly. As defenses fall, the intensification of each individual's functions lends a critical and acute poignancy to any element of rejection, for the rejected aspect of the self is mirrored with tremendous insistence and clarity. Where it is projected, the individual finds the other group members frightening or revolting. In either case, he will become anxious, withdrawn, and probably paranoid, until the rejection is overcome.

Occasionally a subject will react with anger, hostility, or grandiosity, rather than withdrawal. Agitation and excitement may build to a point where restraint is necessary. To prevent negative consequences for the group, it is well to assure the participants in advance that should they lose control, there is nothing to worry about because the therapist and other group members will simply hold them until, after a few minutes, they will have worked through the disturbing material. This assurance protects all the group members from anxiety, and if, as rarely happens, restraint is needed, it makes it easy for them to co-operate with the therapist.

In such a situation, it is unwise to terminate the session with chlorpromazine, because the disturbance and anxiety are then the most vivid memories of the session, and the individual is denied the possibility of working through the problem. The physical contact required in restraint is often helpful in the same way the holding technique is useful with disturbed children. A patient mired in a problem may be released by administering an additional dose of the drug. Because he will often be unwilling to take more for fear of adding to his distress, and because most psychedelics are rather slow-acting, carbogen or DMT might be considered.

These problems are important, because with any technique the hazards become greater as the speed of progress is increased. Such troublesome reactions are rare, however, and occur in less than z per cent of the cases treated.

Patterns of Psychedelic Group Therapy

Psychedelic group therapy may be used in three fundamental ways: (1) with participants selected on the basis of clinical considerations alone (Type A), (z) as an adjunct to conventional therapy in groups that have been working together for some time (Type B), and (3) in a program of regular drug sessions in which group membership is not constant (Type C). Other approaches may be possible, but they are probably only variations of these basic approaches.

In a Type A group, the therapist selects from among his patients those whom he deems most apt to benefit from a psychedelic drug experience. The advantage of this approach is that it is designed to minimize treatment time. When successful, it accomplishes in one session what would otherwise require a prolonged course of conventional therapy or several individual psychedelic sessions. Its disadvantages are that participants must adapt not only to the drug, but to the strangeness of the individual group members to one another. This enhances the probability of a psychotomimetic reaction. Additional group sessions may be scheduled, which, however, diminishes the advantage of any time gained.

Intensive preparation of the subject should precede the session, and aftercare should follow. If possible, patients should be kept in a hospital during the night following the session. Participants should be interviewed by the therapist on the following day or soon afterward.

Type A treatment relies on the effect of the overwhelming psychedelic experience. Dosage levels too low to induce the critical experience of surrender leave the individual trapped in his pretensions. Massive doses may release material too fast and too heavily charged with emotion for the subject to find symbols to encode the experience until so late in the session that much is forgotten and repressed again. Very heavy demands are placed on the therapist during the session, and ideally he should have an assistant familiar with psychedelic experience sitting in on the session. Group size should never involve more than three patients unless the therapist has help, and no more than five in any case.

In Type B group psychedelic sessions, drug administrations may be scheduled at various times during a conventional group treatment program. While this method does not produce the same marked economy in treatment time as Type A, it speeds the group process greatly and may produce profound insight. The spacing of the sessions can be regulated to shorten plateaus in the group learning experience. It offers the advantages of both group therapy and psychedelic treatment. Some possibility of a psychotomimetic response remains, but the danger is much reduced.

In Type B treatment, dosage levels can be varied to suit the occasion. Group process can be accelerated by the use of doses of LSD as low as 25-50 jig. The group size should be relatively small, with five members optimum. The therapist will probably not need any help during a session, and the introduction of a stranger will inhibit the group.

Type C treatment, like Type A, focuses attention on the psychedelic experience itself. Before the treatment, the individual patient meets for several sessions with a group comprising therapists, "sitters," patients experienced in the use of the drug, patients currently under treatment, and a group preparing to undergo psychedelic treatment. This extended group functions as a self-help fellowship, in which understanding of one's own difficulties can be gained, and problems and anxieties aired. Group participation gives the patient assurance that others, whom he knows and with whom he has discussed the experience, have taken the drug and found it useful for problems not unlike his own. Subjects and therapists can select from the extended group a congenial set of participants for maximizing therapeutic possibilities in any particular psychedelic session. Advanced patients can use what they have learned in previous sessions to function as sitters or participants with less-advanced patients, thus enhancing their own personal sense of worth, service, and accomplishment.

Many critics of psychedelics have pointed out that they seem to produce cults. There is a degree of truth in this observation, since people who have shared in any major experience find it interesting to talk to one another and compare notes. The unusual, complex, and exciting qualities of psychedelic experience create an attraction among users, and the therapist can utilize this treatment potential. As with Alcoholics Anonymous, this group can provide valuable support between sessions. It provides an other-directed outlet for the patient. At the group's inception, it can be given a strong community-service orientation. Although the therapist is a member of the group, its structure is egalitarian.

The larger interest group will increase in size as time passes, but should probably not exceed twenty-five members. As individuals recover, an appreciable number will drop out. More than two large groups with a maximum membership of twenty-five will not be necessary. The larger groups fill some of the functions of a halfway program, permit the training of patients as "sitters," and provide a place to which ex-members can return if they have difficulties. It also makes follow-up studies easier, and provides a pool of stabilized subjects for projects dealing with psychedelics.

In the Type C treatment program, dosage will be variable among members of any group, with experienced subjects requiring lower doses. The number of participants in any session depends upon the goals of the sessions. Group size is an important determinant of experience. When one takes the drug alone, the emphasis is on self-analysis, and it seems almost impossible to communicate with others. Moved into a group, the subject, first by self-surrender, becomes able to give without reservations stemming from areas of self-rejection. Subsequently, he learns to accept when he learns to regard what another person has to offer as being as valid, worth while, and beautiful as his own way of doing things.

Use of Psychedelics by the Therapist in Therapy

Because it is difficult to learn about interpersonal relationships in an individual session, some therapists begin to take the drugs with their patients to maximize the empathic process. This kind of activity limits the number of people with whom the therapist can be effective to only one or at a session. Repeated use by the therapist of up to thr: or four sessions a week at which he takes drugs is very fa guing and may leave him exhausted after a few months. I addition, there is always the possibility of psychological I physical injury from excessive use, even though the data a negative with respect to the likelihood of such injury. In an case, very small doses (on the order of 30 pg of LSD) a sufficient to establish the empathic bond.

The more sophisticated objection that the therapist wh takes the drug with his patients has rendered his prof - sional judgment at least partially inoperative can be met b a system that calls for the screening of all treatment de** sions made during the session by a colleague before they are put into effect. Of more profound concern is the fact tha in the shared experience of altered reality, particularly with delusional patients, the therapist may lose his own capaci to distinguish the delusional from the real and may even rein force the patient's delusion by accepting the premises upon which it is based. Therapists should be certain of their hold upon reality under psychedelics before venturing into treatment sessions, particularly with schizophrenic patients.

It should be noted that when a therapist takes LSD, he enters a state in which he can communicate with schizo-. phrenic patients in a direct, close, empathic fashion. This communication opens the door to effective psychological treatment for schizophrenia. The schizophrenic is lost in time, and a therapist who will enter the paths of his disordered thinking, once he can establish trust, can lead the patient out of the disorder. It is not always sufficient to call out from the forest's edge to rescue someone lost. One must sometimes go in himself.

There is one other problem involved in this method of treatment. The therapist may feel that the subject is wasting time in largely unproductive hypochondriacal or psychotic periods. Often, however, these difficulties are steppingstones to self-acceptance. Because of the therapist's close contact with the patient, he is better able to help him reach and maintain a stabilized experience. In so doing, he may inadvertently "help" too much and permit the subject to stabilize the experience without working through his difficulties and areas of lack of self-acceptance.

Despite these difficulties, the occasional co-use of the drug by the therapist in appropriate situations can add remarkable power to the therapeutic program in the most difficult cases. When used as a training technique, it sensitizes the therapist and teaches him the characteristics of the psychedelic process as nothing else can.

The Effect of Group Size on Group Process

When drugs are used in a group of two individuals, the results are a high level of intensity and a continuous pressure to relate to the same person. The concentration of the bonding makes it difficult to withdraw even briefly. Any suspicion or hostility is excessively disruptive, and its effect tends to be prolonged. In a group of three, the withdrawal of one individual to engage in self-analysis can occur from time to time, leaving the others to relate to each other. Relationships can be shifted as needed, and temporary negative feelings are much less destructive and more quickly overcome. The group of four leads to a high level of intellectual stimulation and to very excellent discussion, but the level of group empathy is lower than in the group of three. The group of four may break up into two dyads, or three may form a group leaving the fourth member out. The effects of psychedelics on larger groups are unknown and not likely to be known in the near future because of existing government restrictions on needed research.

Some Specific Techniques for Furthering Psychedelic Group Processes

Although there are individual variations in drug reaction and in the nature of the therapy sessions, the first two or three hours after the onset of the physical or perceptual changes that mark the beginning of the experience are apt to be full of stress. Before the sessions begin, it is well to have the' participants agree that while the early hours of the session will be free time, devoted to enjoyment and experience, and especially the enjoyment of music, they will make the effort to communicate and work with each other when th therapist deems it advisable.

Procedures that foster the examination of one's own d naznics and those of others are extremely useful. Role-playin of all kinds is helpful. Assuming the role of an actor wh plays a number of characters, male and female, young an old, bitter and harsh, loving and gentle, is difficult but useful. Finally, the actor is called upon to role-play himself o the other members of the group.

Another useful procedure is to have the therapist presen a subject with a card bearing the name of an emotion (e.g fear, anger, joy, sorrovv, etc.). The subject is then supposa, to feel that emotion so strongly that the others can identi it. While this appears to be an investigation of commun' cation, it is actually a training in how emotion functions. This method also teaches the participants how to recognize their own emotions, how to change them and, to some extent, how to control them.

Another technique that has been found to be particularly useful is for the group to become a junta governing a count try. Each of the members in turn takes the role of dictato or director, the others serving as his cabinet. Each cabine minister must try to work out a method by which he can overthrow and succeed the dictator, but must make certain . that none of his fellow cabinet ministers can achieve the position. The dictator's role is to assign to each minister the role or task that best suits him. It must be a position in which the person will work hard. The dictator tries to keep power by skillfully motivating and manipulating the others. This very simple game brings the person to an understanding of how others attempt to manipulate him and why they choose the methods they do for him. Other games are possible to highlight other aspects of functioning. The therapist may choose some, but it is very likely that the patients will invent their own games to explore problems useful to them.

Conclusion

In conclusion, there is little doubt that individual and group psychedelic therapeutic experiences have much to offer and that the therapist should aim at giving both kinds of experience to each patient. As there has been much discussion but no research on the order in which these should be undergone, this still remains a matter of clinical judgment.