LSD-Assisted Psychotherapy withTerminal Cancer Patients

by WALTERN. PAHNKE, M.D., PH.D., ALBERTA. KURLAND,M.D.,LOUIS E. GOODMAN,M.D., ANDWILLIAMA. RICHARDS,S.T.M.

THE FINAL MONTHS of life for the person dying of cancer are usuallymarked by increasing depression, psychological isolation, anxiety and

pain. In spite of heroic treatment efforts that seek to keep the patient com-fortable and prolong his life, the impending and inevitable failure of theseattempts 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 toalleviate the psychological stress and physical pain experienced by the dyingcancer patient. Since 1959 when Feifel's book, The Meaning of Death,! ap-peared, there has been continuing discussion of these problems, highlightedby the conference on Care of Patients with Fatal Illness, sponsored by theNew York Academy of Sciences in February 1967; but there has been littleimprovemerit in methods for relieving the mental and physical anguish ofthe dying cancer patient. Clearly the suffering caused by terminal cancer isan area urgently in need of more effective treatment.

Research in this area was pioneered by Kast of the Chicago MedicalSchool. In a series of articles.v" he reported that LSD not only had a signifi-cant analgesic effect, but also in some patients lessened depression and ap-prehension concerning death. This new psychological outlook was usuallynoted for longer periods of time (sometimes for several weeks) than theanalgesic action lasted. None of the patients appeared to have an adversemedical reaction to the drug's effect, even though they were critically ill.The emotions released by LSD seemed well tolerated. Elsewhere, in a reportof a single terminal cancer case, Cohen" was able to confirm Kast's findingsand concluded: "LSD may one day provide a technique for altering the ex-perience of dying."

On the basis of our own extensive clinical research experience with LSD-assisted 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 thatdid not utilize the full technique of psychedelic peak therapy which has beendeveloped in our work.

Since 1963 over 270 patients have been treated with LSD at the SpringGrove State Hospital in the double-blind controlled, NIMH sponsored pro-jects with alcoholic and neurotic patients.I-" The results of these studies ap-pear to indicate that trained personnel can carry out the psychedelic pro-cedure with relatively high safety. Proper preparation for the drug ex-perience, including programming of the period of drug action, has so faralmost wholly eliminated any disturbing or undesirable complications of thistreatment.

In this regard, despite severe psychiatric disorders in many of the casestreated, there has been no evidence of psychological or physical harmdirectly attributable to the treatment, although there have been twotransient post-LSD disturbances which have subsequently responded well tostandard chemotherapy and psychotherapy. A significant finding from boththe alcoholic and neurotic study has been that emotional experiences of aprofound 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 con-ventional drug or chemotherapeutic model. In the context of psychedelicpeak therapy, LSD is actually administered only after weeks of preparatorypsychotherapy and followed by intensive help toward integrating the ex-perience. 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 closerapport and (3) specifically and comprehensively prepared the patient forthe procedure. The therapist, in a demanding and arduous role, attends thepatient throughout the entire period of drug action.

Keeping in mind that the LSD session itself is only one part of psychedelicpeak therapy, Unger" has summarized its unique role as follows.

In a dosage of 200 mcg. or more, LSD produces a 10 to 12 hour periodof striking, varied and anomalous mental functioning; the range of pos-sible effects and/or episodes of reaction is multiform. Certain dimensionsof possible reactivity are therapeutically irrelevant (e.g., sensory changes) ;others have distinctly antitherapeutic consequences (e.g., panic, terroror psychotic reactions). The major dimension of therapeutic relevance ofdrug-altered reactivity is in the emotional sphere; intense, labile, per-sonally-meaningful emotionality is uniformly produced, with periodicepisodes of an overwhelming affect. In terms of sequence of events, thefirst 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 atpeak intensity. With skillful handling, the remainder of the session maybe stabilized in an elevated mood state in which psychotic and otherturbulent phenomena are no longer problems.

The most therapeutically useful kind of LSD experience, and thereforethe immediate aim of the LSD session itself, is the psychedelic peak ex-perience with the following six major psychological characteristics: 9 (1)sense of unity or oneness (positive ego transcendence and loss of usual senseof self without loss of consciousness), (2) transcendence of time and space,(3) deeply felt positive mood (joy, peace and love). (4) sense ofawesomeness and reverence, (5) meaningfulness of psychological and/orphilosophical insight and (6) ineffability (sense of difficulty in com-municating the experience by verbal description). It should be emphasizedthat even with optimal programming, such peak experiences are neitheruniversally achieved nor by any means automatic.

If the psychedelic peak experience is achieved and stabilized, mood iselevated and energetic; there is a relative freedom from past guilt and anx-iety, and the disposition and capacity to enter into close interpersonal rela-tionships is enhanced. These psychedelic feelings generally persist for fromtwo weeks to a month and then gradually fade into vivid memories that canstill influence attitude and behavior. During this immediate post-drugperiod, renewed appreciation for meaningful present experience can providea fulcrum for effective psychotherapeutic work on strained family or otherinterpersonal relationships.

THE TREATMENT PROCEDURE USED WITH CANCER PATIENTS

Utilizing psychedelic peak therapy in a pilot study, we have thus fartreated 22 terminal cancer patients.lO•n All but one of our patients wasreferred for psychedelic therapy by the Chief of the Oncology Service(L.E.G.) of the Sinai Hospital. The initial selection criterion was thepresence of a depressive reaction associated with the patient's physical con-dition. Anxiety, psychological withdrawal and physical pain were also in-dications for treatment. Another factor considered was the feeling of frustra-tion and futility on the part of the hospital staff in the face of demands forhelp from patients whose condition was chronically deteriorating. The emo-tional distress of the relatives also played a role in the selection. After screen-ing by psychiatric interview and psychological testing, an informed consentwas obtained in writing from the patient and his family. Possible benefitsand 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 frightenedsome of the potential candidates to such a degree that they refused toparticipate in the treatment. This influence made the task of preparation fora positive experience more difficult for those who accepted the treatment.

In preparation for the LSD session, it should be emphasized that the in-itial goal was focused on getting to know the patient and instilling withinhim a feeling of confidence and trust. Once rapport had been established,interviews focused more closely on possible results, the nature of the LSD ex-perience, and on the way of responding most constructively to this alteredstate of consciousness. No sustained attempts were made to probe into deepconflict material or traumata in contrast to our usual procedure withalcoholic and neurotic patients. Discussions with the patients tended torevolve about philosophical issues and current interpersonal relationshipswith significant figures in their lives. This necessitated the involvement ofthe family members as much as possible in order to open up a greater degreeof communication.

Families were seen both with and without the patient. They were given achance to discuss their own feelings about the approaching death and wereencouraged to increase their interaction on as many levels as was ap-propriate to decrease the psychological isolation usually felt by such patients.Their fear of upsetting the patient and the fear of death itself were usuallysignificant issues.

Our usual practice was not to confront the patient himself with the fataloutcome of his illness, but to encourage an attitude of "taking one day at atime," and living it as fully as possible. It was important, however, for thetherapist to be willing to discuss issues of diagnosis and prognosis and to beon guard lest his own anxiety over such an encounter unconsciously lead himto give non-verbal cues to the patient that such a subject was not to bediscussed. In this tenuous situation, reliance was placed on the intuitivesensitivity of the therapist in charting the course.

The conduct of the actual LSD session was patterned along lines whichhad been employed with psychiatric patients, namely, the therapist and anurse were present during the entire psychedelic session. The session lasted10 to 14 hours, with the therapist providing constant guidance and supportfor the patient. On the day prior to the session, flowers were brought intothe patient's room and portable high fidelity music equipment was set up.On the day of treatment, carefully chosen musical selections were used tochannel affective expression; likewise, family photographs were used to helpresolve interpersonal difficulties and to mobilize positive feelings. In theevening of the treatment day, therapy was continued with the family andthe 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, andit was indicated that additional LSD treatment was a possibility. After theLSD day, time was spent with the patient and family for integration of theexperience and data collection. The patient was asked to write a subjectiveaccount of the session in as much detail as possible.

Data were collected on the physical and emotional status of each patientand on the amount of drugs used for control of pain both pre- and post-LSD. Any phenothiazines were discontinued at least one week prior to theadministration of LSD. Psychotherapeutic preparation averaged around 10hours per patient, including time spent with family members, both in-dividually and in groups.

RESULTS OF THE PILOT STUDY WITH 22 PATIENTS

Most of our 22 patients had metastatic disease, and all were depressed.Measurements were made pre- and post-LSD on depression, anxiety, emo-tional tension, psychological isolation, fear of death and the amount of painmedication required. The average global change in each patient wascalculated from pre- and post-LSD ratings made by the attendingphysicians, nurses, family, and LSD therapist.

Tentative results from this investigation have indicated that after LSDtreatment of 14 of the 22 patients showed improvement in varying degreeswhile 8 remained essentially unchanged. Sometimes there was greatertolerance of pain and diminished need for analgesics and narcotics, but thiseffect of LSD does not seem to be either long-lasting or predictable enoughto justify the large expenditure of time and energy involved if analgesia isthe primary goal. The positive psychological effects, however, have beenmuch more promising. We have noted decreased depression, anxiety andfear of death, while observing increased relaxation, greater ease in medicalmanagement and closer interpersonal family relationships with more open-ness and honesty. In approximately two-thirds of the patients, there was ameaningful positive change and in 6 of these 14 patients a dramatic im-provement.

The data also suggest a correlation between the occurrence of apsychedelic peak experience and the amount of clinical improvement. Six ofthe 22 patients had what was judged to be an intense peak experience underLSD and of these, 5 were the patients who later improved mostdramatically. Another interesting correlation was with the stage of the il-lness; our consistent impression has been that sicker patients tended to showless positive changes and could not use the experience as rewardingly asthose who were relatively less sick. Our tentative conclusion is that theearlier 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 theprocedure has been consistent with our results in alcoholic and neurotic pa-tients.

The following case summaries on two patients are presented to illustratemore 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 LSD-assisted 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 fourmonths before. She had been brought back to the hospital by her husbandand daughter when they could no longer tolerate her increasing agonywhich was not satisfactorily controlled by narcotic drugs. The family foundit impossible to cope with the psychological stress generated by hersuffering.

Preparation for LSD therapy was of eight hours duration, consistingof interviews with the patient and her family. The chief points of herlife history were reviewed, and her attitude toward her disease and situa-tion was discussed, although at this point the patient was not aware ofthe seriousness of her condition or diagnosis. On the day of her LSDsession, the patient received 200 micrograms of LSD. After a brief initialpsychological struggle, the patient was able to relax and let herself becarried by music into a positive emotional experience. Although she hadsome moments of joy and ecstacy, the psychedelic peak experience wasnot stabilized. About three hours after initial injection, the patient'sphysical pain became disruptive and after one more hour the patient wasgiven an extra 50 micrograms of LSD intravenously with some tem-porary relief of the pain. During the afternoon, however, the patientneeded to be given narcotics to control her intense gas pains. After alight supper and enema, the patient was fairly comfortable and wasvisited by her family and minister during the evening. The day after theLSD treatment, the patient still complained of pain, but felt more cheerful.Because of these gains and because the patient had not experienced themaximal effects, she requested another treatment. During the interveningweek the patient and family were seen for eight hours of psychotherapy,and at the patient's instigation the issues of diagnosis and prognosis werethoroughly explored. Both the patient and family expressed emotionalrelief at being able to discuss these difficult problems for the first time inan open way.

One week after her first session with LSD the patient was given asecond, 400 microgram session. During the first three hours, the patientexperienced several psychedelic peak reactions and felt resolutions ofseveral problems relating to interpersonal relationships with her family.One of her major concerns had been the way she would explain to heryoung grandchildren what was happening to her and what the ultimateoutcome would be. Her daughter had wondered whether she should even

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let the children see their grandmother who was becoming progressivelyemaciated. During the LSD session the patient had a vision of all hergrandchildren standing by her bedside. She had a very intense experienceof 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 themin the days ahead. In general there was more positive content during thissecond experience than during the previous one, and less abreaction andcatharsis of unpleasant memories from her childhood. When her familyvisited during the evening, the patient was not yet completely free fromthe- drug's affect, but was able to talk meaningfully with them. The dayimmediately following the LSD treatment, the patient was extremelytired, but in the subsequent days seemed more calm and peaceful thanshe had before the experience.

Eight days after her last session the patient was discharged to the homeof her family. Her husband and daughter were able to care for hersatisfactorily during the month before she died. Her pain was nowadequately controlled with the aid of narcotics, and the daughter espe-cially remarked on how much better her mother seemed to be able tobear the pain than previously. The patient was able to see her grand-children for some time each day, and they understood what was happeningas she got progressively weaker. They took this opportunity to discusswith her some of their own questions about death and particularly herown death.

Case D-18:

This 56 year old Negro male had an abdominal-perineal resection forcarcinoma of the rectum one and a half years prior to being evaluatedfor LSD treatment. Five months before this treatment, an exploratorylaporatomy for intestinal obstruction revealed carcinomatosis involving thepelvis and omentum, with regional node infiltration. In spite of cancerchemotherapy, the patient continued to complain of persistent perinealpain which did not respond satisfactorily to medication. He becameincreasingly depressed and complained of inability to sleep and loss ofappetite. At the time he was admitted for LSD, the family was findingit increasingly difficult to cope with him.

In preparation for LSD, the patient and his family were seen for atotal of nine interviews of one hour each. Most of his preparation was onan out-patient basis, and the patient was admitted to the hospital primarilyfor LSD treatment.

Two days after admission the patient was given 300 micrograms ofLSD intramuscularly. Most of the day was spent very quietly listening tomusic, and the patient was in no obvious distress or turmoil. The patientdid not communicate much of his experience at the time except by briefwords and phrases, or by his contented facial expression and posture. Hewas deeply relaxed most of the time. After the fifth to sixth hour of thesession when the patient began to verbalize more, he indicated that hewas overwhelmed by the profundity and intensity of his experience. Ashe returned more and more to his usual state of consciousness, he wasable 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 lastbreath and thought I was about to die." At this moment the patient hadenough trust to let himself be completely swept into the experience, justas he had been instructed to during his preparatory psychotherapy. Hethen experienced positive ego transcendence and felt that he enteredanother world which subjectively had a great meaning for him in terms ofhis own religious tradition. He felt great joy and a sense of profoundpeace. His facial expressions depicted serene relaxation and quiet ecstasy.

At supper time the patient ate a good meal and was eager to see hisfamily. When they arrived, the patient seemed very pleased to see themand to share part of his experience. There was an exchange of deep feelingamong all present and the family was quite impressed by the positivechange in the patient, who radiated joy and a sense of deep peacefulness.

Although there was no significant improvement in the amount ofmedication required, he was better able to tolerate the pain withoutbecoming unduly upset. His appetite improved dramatically and thiswas sustained. He was discharged home three days after his LSD treat-ment and was followed at weekly intervals for three months until hehad to be re-admitted to the hospital because of intestinal obstruction.

Throughout this period after his LSD treatment and in spite of aslowly worsening physical condition, he maintained a cheerful outlookand remembered his LSD experience with great joy and enthusiasm. Herepeatedly 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 togo. After a two-week hospitalization he died quietly from an internalhemorrhage secondary to the spread of his cancer.

Times of death are times of crisis in any family. Psychiatrists are well ac-quainted with the crucial importance of how any person reacts to and in-tegrates the death of an important figure. We have a striking opportunity topractice preventive psychiatry. Help can be given in handling thepsychological trauma in those who will survive the patient, but arevulnerable to long-lasting emotional scars. The psychedelic experience seemsable to mobilize much positive affect, not only from the patient who receivesthe LSD, but also in other family members who react to the whole treat-ment procedure at many psychological levels of their own.

Therapist enthusiasm, both verbal and non-verbal, is a powerful factor, asin many forms of psychotherapy. Because of the psychological power of theLSD reaction, few patients are disappointed when they are promised anunusual and compelling psychological experience. The dramatic positivechanges in attitude and behavior when the treatment is successful are morethan 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 psychotherapywith cancer patients, we definitely would not advise its use without specializ-ed 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 thepsychedelic procedure can be a relatively safe and promising approach in anarea 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 Dihydro-

morphinome and Meperidine. Bull. Drug Addiction and Narcotics, Appendix27:3517,1963.

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 Pre-liminary Report. Amer. l of Psychiat. 123, 1202, 1967.

8. UNGER, S., KURLAND,A. A., SHAFFER, j. W., SAVAGE,C., WOLF, S., LEIHY, R.,ANDMCCABE, 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., ANDRICHARDS,W. A.: Implications of LSD and ExperimentalMysticism. 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 Ma-lignancy. Presented at the Collegium Internationale Neuropsychopharmacologi-cum, Terragona, Spain, April, 1968. To be published in conference proceedings.