LSD-Assisted Psychotherapy with Terminal Cancer Patients

by WALTER N. PAHNKE, M.D., PH.D., ALBERT A. KURLAND, M.D., LOUIS E. GOODMAN,M.D., AND WILLIAM A. RICHARDS, S.T.M.

HE FINAL MONTHS of life for the person dying of cancer are usually marked by increasing depression, psychological isolation, anxiety and pain. In spite of heroic treatment efforts that seek to keep the patient comfortable and prolong his life, the impending and inevitable failure of these attempts often leads to feelings of defeat and despair within the patient, his family and even the attending medical personnel. In recent years considerable attention has been focused upon attempts to alleviate the psychological stress and physical pain experienced by the dying cancer patient. Since 1959 when Feifel's book, The Meaning of Death,! appeared, there has been continuing discussion of these problems, highlighted by the conference on Care of Patients with Fatal Illness, sponsored by the New York Academy of Sciences in February 1967; but there has been little improvemerit in methods for relieving the mental and physical anguish of the dying cancer patient. Clearly the suffering caused by terminal cancer is an area urgently in need of more effective treatment. Research in this area was pioneered by Kast of the Chicago Medical School. In a series of articles.v" he reported that LSD not only had a significant analgesic effect, but also in some patients lessened depression and apprehension concerning death. This new psychological outlook was usually noted for longer periods of time (sometimes for several weeks) than the analgesic action lasted. None of the patients appeared to have an adverse medical reaction to the drug's effect, even though they were critically ill. The emotions released by LSD seemed well tolerated. Elsewhere, in a report of a single terminal cancer case, Cohen" was able to confirm Kast's findings and concluded: "LSD may one day provide a technique for altering the experience of dying." On the basis of our own extensive clinical research experience with LSDassisted psychotherapy in the treatment of alcoholic and neurotic patients, we attempted to check these results and investigate ways of improving upon
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them. Kast, for example, used primarily a chemotherapeutic procedure that did not utilize the full technique of psychedelic peak therapy which has been developed in our work. Since 1963 over 270 patients have been treated with LSD at the Spring Grove State Hospital in the double-blind controlled, NIMH sponsored projects with alcoholic and neurotic patients.I-" The results of these studies appear to indicate that trained personnel can carry out the psychedelic procedure with relatively high safety. Proper preparation for the drug experience, including programming of the period of drug action, has so far almost wholly eliminated any disturbing or undesirable complications of this treatment. In this regard, despite severe psychiatric disorders in many of the cases treated, there has been no evidence of psychological or physical harm directly attributable to the treatment, although there have been two transient post-LSD disturbances which have subsequently responded well to standard chemotherapy and psychotherapy. A significant finding from both the alcoholic and neurotic study has been that emotional experiences of a profound and meaningful nature have been reliably reproduced.
DESCRIPTION OF PSYCHEDELIC PEAK THERAPY

It is important to note that our use of LSD is not predicated on any conventional drug or chemotherapeutic model. In the context of psychedelic peak therapy, LSD is actually administered only after weeks of preparatory psychotherapy and followed by intensive help toward integrating the experience. Thus the LSD session is undertaken only after the therapist has: (1) gained intimate knowledge of the patient's developmental history, dynamics, defenses and difficulties; (2) established with the patient close rapport and (3) specifically and comprehensively prepared the patient for the procedure. The therapist, in a demanding and arduous role, attends the patient throughout the entire period of drug action. Keeping in mind that the LSD session itself is only one part of psychedelic peak therapy, Unger" has summarized its unique role as follows. In a dosage of 200 mcg. or more, LSD produces a 10 to 12 hour period of striking, varied and anomalous mental functioning; the range of possible effects and/or episodes of reaction is multiform. Certain dimensions of possible reactivity are therapeutically irrelevant (e.g., sensory changes) ; others have distinctly antitherapeutic consequences (e.g., panic, terror or psychotic reactions). The major dimension of therapeutic relevance of drug-altered reactivity is in the emotional sphere; intense, labile, personally-meaningful emotionality is uniformly produced, with periodic episodes of an overwhelming affect. In terms of sequence of events, the first several hours of a psychedelic session are non-specific and pervasive:

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perseverative preoccupations and emotional distress patterns are "broken" or fragmented, and subsequent recall for this period is nearly always poor. During the third to fifth hours, psychedelic reactivity usually appears at peak intensity. With skillful handling, the remainder of the session may be stabilized in an elevated mood state in which psychotic and other turbulent phenomena are no longer problems. The most therapeutically useful kind of LSD experience, and therefore the immediate aim of the LSD session itself, is the psychedelic peak experience with the following six major psychological characteristics: 9 (1) sense of unity or oneness (positive ego transcendence and loss of usual sense of self without loss of consciousness), (2) transcendence of time and space, (3) deeply felt positive mood (joy, peace and love). (4) sense of awesomeness and reverence, (5) meaningfulness of psychological and/or philosophical insight and (6) ineffability (sense of difficulty in communicating the experience by verbal description). It should be emphasized that even with optimal programming, such peak experiences are neither universally achieved nor by any means automatic. If the psychedelic peak experience is achieved and stabilized, mood is elevated and energetic; there is a relative freedom from past guilt and anxiety, and the disposition and capacity to enter into close interpersonal relationships is enhanced. These psychedelic feelings generally persist for from two weeks to a month and then gradually fade into vivid memories that can still influence attitude and behavior. During this immediate post-drug period, renewed appreciation for meaningful present experience can provide a fulcrum for effective psychotherapeutic work on strained family or other interpersonal relationships.
THE TREATMENT PROCEDURE USED WITH CANCER PATIENTS

Utilizing psychedelic peak therapy in a pilot study, we have thus far treated 22 terminal cancer patients.lOn All but one of our patients was referred for psychedelic therapy by the Chief of the Oncology Service (L.E.G.) of the Sinai Hospital. The initial selection criterion was the presence of a depressive reaction associated with the patient's physical condition. Anxiety, psychological withdrawal and physical pain were also indications for treatment. Another factor considered was the feeling of frustration and futility on the part of the hospital staff in the face of demands for help from patients whose condition was chronically deteriorating. The emotional distress of the relatives also played a role in the selection. After screening by psychiatric interview and psychological testing, an informed consent was obtained in writing from the patient and his family. Possible benefits and dangers were discussed openly. The sensationalistic coverage in the mass

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media of the current dangerous abuse of LSD in the U.S.A. had frightened some of the potential candidates to such a degree that they refused to participate in the treatment. This influence made the task of preparation for a positive experience more difficult for those who accepted the treatment. In preparation for the LSD session, it should be emphasized that the initial goal was focused on getting to know the patient and instilling within him a feeling of confidence and trust. Once rapport had been established, interviews focused more closely on possible results, the nature of the LSD experience, and on the way of responding most constructively to this altered state of consciousness. No sustained attempts were made to probe into deep conflict material or traumata in contrast to our usual procedure with alcoholic and neurotic patients. Discussions with the patients tended to revolve about philosophical issues and current interpersonal relationships with significant figures in their lives. This necessitated the involvement of the family members as much as possible in order to open up a greater degree of communication. Families were seen both with and without the patient. They were given a chance to discuss their own feelings about the approaching death and were encouraged to increase their interaction on as many levels as was appropriate to decrease the psychological isolation usually felt by such patients. Their fear of upsetting the patient and the fear of death itself were usually significant issues. Our usual practice was not to confront the patient himself with the fatal outcome of his illness, but to encourage an attitude of "taking one day at a time," and living it as fully as possible. It was important, however, for the therapist to be willing to discuss issues of diagnosis and prognosis and to be on guard lest his own anxiety over such an encounter unconsciously lead him to give non-verbal cues to the patient that such a subject was not to be discussed. In this tenuous situation, reliance was placed on the intuitive sensitivity of the therapist in charting the course. The conduct of the actual LSD session was patterned along lines which had been employed with psychiatric patients, namely, the therapist and a nurse were present during the entire psychedelic session. The session lasted 10 to 14 hours, with the therapist providing constant guidance and support for the patient. On the day prior to the session, flowers were brought into the patient's room and portable high fidelity music equipment was set up. On the day of treatment, carefully chosen musical selections were used to channel affective expression; likewise, family photographs were used to help resolve interpersonal difficulties and to mobilize positive feelings. In the evening of the treatment day, therapy was continued with the family and the patient together, and usually this resulted in a period of very gratifying

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emotional exchange. Arrangements were made for follow-up contact, and it was indicated that additional LSD treatment was a possibility. After the LSD day, time was spent with the patient and family for integration of the experience and data collection. The patient was asked to write a subjective account of the session in as much detail as possible. Data were collected on the physical and emotional status of each patient and on the amount of drugs used for control of pain both pre- and postLSD. Any phenothiazines were discontinued at least one week prior to the administration of LSD. Psychotherapeutic preparation averaged around 10 hours per patient, including time spent with family members, both individually and in groups.
RESULTS OF THE PILOT STUDY WITH

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PATIENTS

Most of our 22 patients had metastatic disease, and all were depressed. Measurements were made pre- and post-LSD on depression, anxiety, emotional tension, psychological isolation, fear of death and the amount of pain medication required. The average global change in each patient was calculated from pre- and post-LSD ratings made by the attending physicians, nurses, family, and LSD therapist. Tentative results from this investigation have indicated that after LSD treatment of 14 of the 22 patients showed improvement in varying degrees while 8 remained essentially unchanged. Sometimes there was greater tolerance of pain and diminished need for analgesics and narcotics, but this effect of LSD does not seem to be either long-lasting or predictable enough to justify the large expenditure of time and energy involved if analgesia is the primary goal. The positive psychological effects, however, have been much more promising. We have noted decreased depression, anxiety and fear of death, while observing increased relaxation, greater ease in medical management and closer interpersonal family relationships with more openness and honesty. In approximately two-thirds of the patients, there was a meaningful positive change and in 6 of these 14 patients a dramatic improvement. The data also suggest a correlation between the occurrence of a psychedelic peak experience and the amount of clinical improvement. Six of the 22 patients had what was judged to be an intense peak experience under LSD and of these, 5 were the patients who later improved most dramatically. Another interesting correlation was with the stage of the illness; our consistent impression has been that sicker patients tended to show less positive changes and could not use the experience as rewardingly as those who were relatively less sick. Our tentative conclusion is that the earlier a case is treated in the course of the disease the better.

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While not all patients were helped dramatically, none, even the most ill, appeared to have been harmed. This finding in regard to the safety of the procedure has been consistent with our results in alcoholic and neurotic patients. The following case summaries on two patients are presented to illustrate more specifically our method and some of the results we have obtained. Case D-8: This 43 year old, white, protestant married female was referred for LSDassisted psychotherapy because of depression and severe intractable pain, secondary to an inoperable metatastic adeno-carcinoma of the pancreas. She had been treated at home after her exploratory laporatomy four months before. She had been brought back to the hospital by her husband and daughter when they could no longer tolerate her increasing agony which was not satisfactorily controlled by narcotic drugs. The family found it impossible to cope with the psychological stress generated by her suffering. Preparation for LSD therapy was of eight hours duration, consisting of interviews with the patient and her family. The chief points of her life history were reviewed, and her attitude toward her disease and situation was discussed, although at this point the patient was not aware of the seriousness of her condition or diagnosis. On the day of her LSD session, the patient received 200 micrograms of LSD. After a brief initial psychological struggle, the patient was able to relax and let herself be carried by music into a positive emotional experience. Although she had some moments of joy and ecstacy, the psychedelic peak experience was not stabilized. About three hours after initial injection, the patient's physical pain became disruptive and after one more hour the patient was given an extra 50 micrograms of LSD intravenously with some temporary relief of the pain. During the afternoon, however, the patient needed to be given narcotics to control her intense gas pains. After a light supper and enema, the patient was fairly comfortable and was visited by her family and minister during the evening. The day after the LSD treatment, the patient still complained of pain, but felt more cheerful. Because of these gains and because the patient had not experienced the maximal effects, she requested another treatment. During the intervening week the patient and family were seen for eight hours of psychotherapy, and at the patient's instigation the issues of diagnosis and prognosis were thoroughly explored. Both the patient and family expressed emotional relief at being able to discuss these difficult problems for the first time in an open way. One week after her first session with LSD the patient was given a second, 400 microgram session. During the first three hours, the patient experienced several psychedelic peak reactions and felt resolutions of several problems relating to interpersonal relationships with her family. One of her major concerns had been the way she would explain to her young grandchildren what was happening to her and what the ultimate outcome would be. Her daughter had wondered whether she should even

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let the children see their grandmother who was becoming progressively emaciated. During the LSD session the patient had a vision of all her grandchildren standing by her bedside. She had a very intense experience of positive emotional feeling of the love which she had for these children, and was able to come to a resolution of what she could share with them in the days ahead. In general there was more positive content during this second experience than during the previous one, and less abreaction and catharsis of unpleasant memories from her childhood. When her family visited during the evening, the patient was not yet completely free from the- drug's affect, but was able to talk meaningfully with them. The day immediately following the LSD treatment, the patient was extremely tired, but in the subsequent days seemed more calm and peaceful than she had before the experience. Eight days after her last session the patient was discharged to the home of her family. Her husband and daughter were able to care for her satisfactorily during the month before she died. Her pain was now adequately controlled with the aid of narcotics, and the daughter especially remarked on how much better her mother seemed to be able to bear the pain than previously. The patient was able to see her grandchildren for some time each day, and they understood what was happening as she got progressively weaker. They took this opportunity to discuss with her some of their own questions about death and particularly her own death. Case D-18: This 56 year old Negro male had an abdominal-perineal resection for carcinoma of the rectum one and a half years prior to being evaluated for LSD treatment. Five months before this treatment, an exploratory laporatomy for intestinal obstruction revealed carcinomatosis involving the pelvis and omentum, with regional node infiltration. In spite of cancer chemotherapy, the patient continued to complain of persistent perineal pain which did not respond satisfactorily to medication. He became increasingly depressed and complained of inability to sleep and loss of appetite. At the time he was admitted for LSD, the family was finding it increasingly difficult to cope with him. In preparation for LSD, the patient and his family were seen for a total of nine interviews of one hour each. Most of his preparation was on an out-patient basis, and the patient was admitted to the hospital primarily for LSD treatment. Two days after admission the patient was given 300 micrograms of LSD intramuscularly. Most of the day was spent very quietly listening to music, and the patient was in no obvious distress or turmoil. The patient did not communicate much of his experience at the time except by brief words and phrases, or by his contented facial expression and posture. He was deeply relaxed most of the time. After the fifth to sixth hour of the session when the patient began to verbalize more, he indicated that he was overwhelmed by the profundity and intensity of his experience. As he returned more and more to his usual state of consciousness, he was able to be more explicit about what had happened. As he approached the

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point of ego loss he felt, in his own words, "that I was taking my last breath and thought I was about to die." At this moment the patient had enough trust to let himself be completely swept into the experience, just as he had been instructed to during his preparatory psychotherapy. He then experienced positive ego transcendence and felt that he entered another world which subjectively had a great meaning for him in terms of his own religious tradition. He felt great joy and a sense of profound peace. His facial expressions depicted serene relaxation and quiet ecstasy. At supper time the patient ate a good meal and was eager to see his family. When they arrived, the patient seemed very pleased to see them and to share part of his experience. There was an exchange of deep feeling among all present and the family was quite impressed by the positive change in the patient, who radiated joy and a sense of deep peacefulness. Although there was no significant improvement in the amount of medication required, he was better able to tolerate the pain without becoming unduly upset. His appetite improved dramatically and this was sustained. He was discharged home three days after his LSD treatment and was followed at weekly intervals for three months until he had to be re-admitted to the hospital because of intestinal obstruction. Throughout this period after his LSD treatment and in spite of a slowly worsening physical condition, he maintained a cheerful outlook and remembered his LSD experience with great joy and enthusiasm. He repeatedly stated that he had not given up hope of fighting his disease, but that on the other hand, when his time to die came he was ready to go. After a two-week hospitalization he died quietly from an internal hemorrhage secondary to the spread of his cancer. Times of death are times of crisis in any family. Psychiatrists are well acquainted with the crucial importance of how any person reacts to and integrates the death of an important figure. We have a striking opportunity to practice preventive psychiatry. Help can be given in handling the psychological trauma in those who will survive the patient, but are vulnerable to long-lasting emotional scars. The psychedelic experience seems able to mobilize much positive affect, not only from the patient who receives the LSD, but also in other family members who react to the whole treatment procedure at many psychological levels of their own. Therapist enthusiasm, both verbal and non-verbal, is a powerful factor, as in many forms of psychotherapy. Because of the psychological power of the LSD reaction, few patients are disappointed when they are promised an unusual and compelling psychological experience. The dramatic positive changes in attitude and behavior when the treatment is successful are more than enough to keep the enthusiasm of the therapist at an effective level, even in the face of what is at best a grim reality situation. As a final caution to those who may attempt psychedelic psychotherapy with cancer patients, we definitely would not advise its use without specialized training under supervision from those already familiar with the reactions

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facilitated by this powerful psychoactive drug. Given adequate training, however, our clinical experience so far suggests that skilled use of the psychedelic procedure can be a relatively safe and promising approach in an area which has been most discouraging up to the present.
REFERENCES

1. FEIFEL, H. (Ed.): The Meaning of Death. New York, McGraw-HilI, 1959. 2. KAST, E. C.: The Analgesic Action of Lysergic Acid Compared with Dihydromorphinome and Meperidine. Bull. Drug Addiction and Narcotics, Appendix 27:3517,1963. 3. KAST, E. C.: A Study of Lysergic Acid Diethylamide as an Analgesic Agent. Anaesthesia and Analgesia. 43: 285, 1964. 4. KAST, E. C.: Pain and LSD-25: A Theory of Attenuation of Anticipation. In: D. Solomon (Ed.): LSD: The Consciousness-Expanding Drug. New York, Putnam's, 1964, p. 241. 5. KAST, E. C.: LSD and the Dying Patient. Chic. Med. Sch. Qu., Vol. 26: 80, 1966. 6. COHEN, S.: LSD and the Anguish of Dying. Harpers, Vol. 231: 69, 1965. 7. KURLAND, A. A., UNGER, S., SHAFFER, l W., AND SAVAGE,C.: Psychedelic Therapy Utilizing LSD in the Treatment of the Alcoholic Patient: A Preliminary Report. Amer. l of Psychiat. 123, 1202, 1967. 8. UNGER, S., KURLAND,A. A., SHAFFER, j. W., SAVAGE,C., WOLF, S., LEIHY, R., AND MCCABE, O. L.: LSD-Type Drugs and Psychedelic Therapy. In: Shlien, l, Hunt, H., Matarazzo, J., and Savage, C. (Eds.) Research in Psychotherapy, Volume III. American Psychological Association, Inc. 1968, p. 521. 9. PAHNKE, W. N., AND RICHARDS,W. A.: Implications of LSD and Experimental Mysticism. Journal of Religion and Health. 5: 175, 1966. 10. KURLAND,A. A., PAHNKE, W. N., UNGER, S., SAVAGE, C., ANDGOODMAN,L. E.: Psychedelic Therapy (Utilizing LSD) with Terminal Cancer Patients. In Press, l of Psychopharmacology, 1968. 11. KURLAND,A. A., PAHNKE, W. N., UNGER, S., SAVAGE, C., ANDGOODMAN,L. E.: Psychedelic Psychotherapy (LSD) in the Treatment of a Patient with a Malignancy. Presented at the Collegium Internationale Neuropsychopharmacologicum, Terragona, Spain, April, 1968. To be published in conference proceedings.