The Long, Hard Road to a Science of Bad Drug Trips
If we’re going to use psychedelics for therapy, we’re going to have to figure out the proverbial bad trip.
Illustrazione di Chris Kindred
This story is part of When the Drugs Hit, a Motherboard journey into the science, politics, and culture of today's psychedelic renaissance. Follow along here.
In 1968, Thomas Ungerleider and Duke Fisher, two psychiatrists from UCLA, traveled to the suburbs of Los Angeles to witness the rituals of an LSD cult.
Two years earlier, Ungerleider and Fisher had authored "The Dangers of LSD," a paper that documented the rising incidence of admissions to the UCLA psychiatric ward by people reporting adverse effects while tripping on lysergic acid diethylamide. The doctors had recently given a lecture on the subject of what's come to be known as the "bad trip," a catchall term for the difficult experiences some psychedelic users report, from mild anxiety to full blown psychosis and persistent delusions.
At that lecture, a particularly riled-up audience member had attempted to read a manifesto advocating for unlimited LSD use during the post-lecture Q&A. After the lecture, the same audience member approached the psychiatrists and insisted that plenty of people took LSD and were just fine. In fact, he was part of a religious group that called themselves the "Disciples" and claimed they ate acid every weekend without issue.
The researchers were intrigued. After some of the Disciples screened them to make sure they weren't cops, Ungerleider and Fisher were cleared to visit the group's compound to observe their ritualistic use of LSD. As the researchers detailed in their paper, at the compound they found:
...about a dozen of the group living in a large house on spacious grounds. They were literally tilling the soil and had decorated the house in psychedelic fashion. There were pictures of Buddha and Jesus on the walls. Every Wednesday night the group gathered to have a non-LSD religious experience consisting of prayer and meditation. The drug-taking sessions were scheduled for the weekends.
By observing and interviewing participants in these "love sessions," the researchers learned that many of the Disciples were ex-cons and drug addicts who were using LSD to facilitate their recovery. Many of these individuals reported to have found God through the ritual use of LSD. Importantly, not one of the Disciples reported having a bad trip while on acid in the group.
For the psychiatrists, this was a perplexing observation. What separated this cohort from those who were being admitted to psychiatric wards after taking the same drug? In other words, what were the contributing factors to a bad trip?
"Such a complex interaction—which is difficult to anticipate even with the best of clinical and test data—would predict that adverse LSD reactions will be with us for some time to come."
To answer this question, the researchers ran a study that compared 25 Disciples with 25 patients who had been hospitalized following adverse reactions to LSD, including "hallucinations…anxiety to the point of panic…depression, often with suicidal thoughts or attempts, and…confusion." In 1968, the researchers published their results in the Journal of American Psychiatry in the first scientific attempt to identify the causes of negative psychedelic experiences.
As the researchers found, there were no significant differences between the two groups in terms of race, sex, age, education, or "early parental deprivation." Forty-four percent of the inpatients (compared with only 24 percent of the Disciples) had previous psychiatric history, but this also wasn't a guarantor of a difficult psychedelic experience. None of those in the religious group with previous psychiatric history had ever encountered difficulty from taking LSD.
"In all of our comparisons there were no historical elements or current clinical aspects that were unique to either group," the authors concluded. Interestingly, Ungerleider and Fisher were some of the first to predict that LSD could interact with "schizoid trends," a hypothesis that would be bolstered by later research. Even so, the authors realized that "such a complex interaction—which is difficult to anticipate even with the best of clinical and test data—would predict that adverse LSD reactions will be with us for some time to come."
If psychedelics are ever going to properly graduate from the lab to the clinic, then we're going to have to have some science that can explain the underlying mechanisms of the proverbial bad trip.
If you haven't heard, psychedelic research is experiencing something of a renaissance these days. The latest studies on mind-altering substances like LSD, MDMA, and psilocybin ("magic mushrooms"), which are all currently illegal in the US under federal law, show a potential for therapeutic use. New evidence suggests psychedelics can help in lowering one's risk of suicidality, dealing with grief, kicking substance addictions, and alleviating painful cluster headaches, also known as "suicide headaches."
Still, psychedelics aren't perfect. And a half-century after Ungerleider and Fisher's groundbreaking study on bad LSD trips, we're not much closer to understanding difficult psychedelic experiences in any empirical sense. Due to the highly subjective effects of these substances and their unknown neural mechanisms, predicting when someone is going to have a rough time on psychedelics is nearly impossible. That's why, instead of trying to forecast these difficult psychedelic experiences, attention in the research community has shifted to preventing their onset and alleviating negative effects when they do happen.
Among psychonauts and mental health professionals alike, the common wisdom for avoiding difficult experiences on psychedelics can be boiled down to two words: "set" and "setting." Popularized by the late Harvard psychologist-cum-psychedelic evangelist Timothy Leary, the idea behind the "set and setting" mantra is that if you're mentally prepared for a psychedelic experience and are having this experience in a safe and comfortable setting, the likelihood of having a challenging or traumatic experience is significantly lower.
You'll likely avoid a bad trip if you get into the proper headspace before you dose up, and if you have also situated yourself in optimal physical surroundings with familiar faces so that when the drugs kick in you don't, say, find yourself wandering the streets of New York City by yourself.
At least, that's the idea.
More pro trip tips: In the above lecture clip, the late ethnobotanist, psychonaut, and advocate for responsible psychedelic drug use, Terence McKenna, advises singing as a way of fending off the onset of a potentially bad psychedelic experience. That, and cooling the nerves by taking a hit or two off a pre-rolled cannabis joint.
Although this set-and-setting wisdom has deep roots in the psychonaut community, a formalized set of standards for psychedelic harm reduction didn't really begin emerging until the 1970s. One of the first papers published on the subject appeared in the July 1970 issue of the Journal of the American Medical Association, which described the "management of 'bad trips' in an evolving drug scene."
Here the authors argue for "rational therapy" to protect patients from dangerous behavior while under the influence of psychedelics. The case is made for talking down a patient who is having a hard time rather than trying to directly administer tranquilizers to restore the individual's ego, a progressive stance at a time when many psychiatrists were quick to prescribe downers to bring a bad trip to an end.
That same year, the federal government would pass the Comprehensive Drug Abuse Prevention and Control Act. The Act applied a Schedule I label to most psychedelic substances, meaning the substances had a high potential for abuse and no recognized medical benefit in the eyes of the law. But despite the law enforcement crackdown, psychedelic use didn't stop. And neither did the bad trips.
In 1977, William Abruzzi, a medical doctor in New York, published "5000 Bad Trips," an article in the International Journal of Addictions, in which he described his experience helping thousands of strangers work through difficult psychedelic experiences. By that point, Abruzzi had seen a thing or two. In 1969, he had hired 81 medical assistants, physicians, and nurses to work the Woodstock Festival, taking care of some "25 freakouts each hour from LSD-type drugs."
Abruzzi would continue attending rock concerts to tend to people having bad trips, and summarized his wisdom in "5000 Bad Trips." In the article, he cited the efficacy of having these treatment options on site during music festivals and in many ways prefigured the harm reduction efforts that have become a mainstay at contemporary gatherings like Burning Man, Lightning in a Bottle, or Coachella.
The revival in psychedelic harm reduction efforts was largely spearheaded by the Multidisciplinary Association for Psychedelic Studies through the Zendo Project, which gives festival-goers who are having a difficult time on psychedelics a supportive space—tents—where they can receive medical attention or just chill out.
This renewed interest in psychedelic harm reduction has increasingly attracted individual researchers running psychedelic studies at various research institutions around the world. At the forefront of these psychedelic studies is Johns Hopkins University, which has been pioneering research into the therapeutic potential of psilocybin, the psychoactive component of magic mushrooms, for the last few years.
At the recent MAPS Psychedelic Science conference in San Francisco, Darrick May, a Hopkins psychiatrist specializing in addiction medicine, presented the results from the largest-ever study on bad trips, in which nearly 2000 respondents took an intensive online survey describing their difficult experiences on psilocybin. Like Abruzzi, May had cut his teeth working in psychedelic harm reduction at festivals like Burning Man and has guided some 40 psilocybin experiences in the Hopkins clinic.
"I think challenging experiences occur somewhat randomly."
According to May, the Hopkins bad trip study found that previous psychedelic experience wasn't correlated to the likelihood that someone would have a bad trip. However, younger ages correlated to more difficult experiences with psilocybin. Still, May noted that this observation "needs to be tempered with the idea that the more difficult the experience, the more positive the attribution." In other words, even if someone had a rough time, this was retroactively interpreted as an opportunity to grow as a person.
Moreover, the Hopkins team found that people who had reported seeking mental health professionals after their mushroom experience were twice as likely to have sought out mental health professionals before their experience. But this doesn't necessarily mean that bad trips were tied to pre-existing mental illnesses. Rather, these people might simply be more inclined to seek help for their mental problems or have the means to do so.
"I think challenging experiences occur somewhat randomly," May told me at the MAPS conference. Although the psilocybin study didn't peg any determining factors of a bad trip, it did provide a good baseline for other "bad trip" questionnaires that can be used to standardize research into the phenomenon. "We now have a psychometrically validated tool that can better characterize different aspects of these experiences so we can better characterize that experience itself," May added. "We need that tool to be used in all areas of psychedelic research so it's consistent across studies."
Yet determining factors in bad trips on psychedelics remain elusive. Other groups are focusing less on the cause and more on mediating negative effects after the experience, a process known as integration.
In late 2015, the New York-based Center for Optimal Living launched its Psychedelic Education and Continuing Care Program after a number of psychologists and harm reduction therapists recognized the need for a place to work through bad trips. According to Ingmar Gorman, one its founders, the program has been a resounding success so far.
Twice a month, the center will host psychedelic integration groups that usually receive 10 to 15 visitors, although Gorman says there have been up to 45 participants in a single session. During these sessions, the visitors will work with counselors and other participants to work through their difficult experiences in a confidential and safe setting. According to Gorman, many of those attending the sessions have had difficulties related to improperly led ayahuasca ceremonies in particular. But he also acknowledges that many participants come simply to provide support to others or learn more about psychedelic harm reduction.
One participant, John*, began attending group sessions at the Center for Optimal Living late last summer. After witnessing the September 11 terrorist attacks in New York City, John told me he started experiencing cluster headaches on a regular basis. These debilitating attacks occur frequently but randomly, last for around an hour, and may occur several times in a single day. They usually landed John in the emergency room, where doctors would pump him full of pain medications, which did little to relieve the headaches.
He described the pain as "like Freddy Krueger taking the blade on his middle finger, heating it up and sticking it in my left eye."
While surfing the web one day a few years ago, John read about the Harvard study on people who suffered from cluster headaches and were finding relief by dosing psilocybin. Although he had never had a psychedelic experience before, John said he was willing to try anything to relieve his bouts of excruciating pain. After some initial difficulty procuring psilocybin, John finally got his hands on the stuff and made a mushroom tea. To his amazement, the cluster headaches stopped.
At this point, John has been taking moderate doses of psilocybin every other month for about two years. Only once during this time have the cluster headaches returned, he claimed, and this was because he had been unable to find mushrooms for about three months. While John initially began attending sessions at the center to learn more about psychedelic research, after recently having his first run in with a bad trip on mushrooms, he told me he's also found therapeutic relief by attending the sessions as well.
"It allowed me to look at myself and really get some introspection about how things like 9/11 changed my life," John told me. "I'm still working on the integration part right now, but what I like about these sessions is they're grounded in the science of these difficult experiences. They're not going to point you to a shaman and say he'll solve all your problems. It's grounded in fact and research."
Read more: How to Legally Buy a Kilo of Pure MDMA
According to Gorman, the Center for Optimal Living hasn't done any studies with its visitors yet, but he said the program is interested in pursuing empirical research to better understand its clients and the issues they're facing with psychedelics.
"Evidence-based approaches are a priority for us and we value research," Gorman told me via email. "We are beginning to look into studies, but we are approaching data gathering carefully as we don't want to jump into a project that could feel intrusive or interfere with the confidentiality of our clients."
Bad trips are a touchy subject, not only because of the lingering social taboo surrounding psychedelic drug use, but also due to the pervasive idea that a bad trip is the manifestation of deep-seated psychological trauma working its way to the surface. While such thinking is largely rooted in the mid-century psychoanalysis boom, the intuition is also beginning to be borne out in clinical research trials that use psychedelics to facilitate therapy. One of the most promising uses of psychedelics in this sense has been the MAPS trials, which are administering MDMA to veterans with post-traumatic stress. Researchers at Hopkins have also found psilocybin to be particularly effective in assuaging fears of death in terminally-ill patients.
In any case, these trials are lending empirical evidence to the shamanic notion that what many think of as a "bad trip" on psychedelics isn't actually bad at all.
Psychedelic experiences like ego dissolution, which can undoubtedly be terrifying for those not prepared for it, have proven to be some of the most potent avenues for addressing traumatic life events. This is why psychonauts and psychedelic researchers like Darrick May have largely abandoned the "bad trip" terminology, preferring instead to call these "difficult" or "challenging" experiences. For as multiple Hopkins psilocybin studies and countless online testimonies go to show, it is often the most harrowing psychedelic experiences that result in the largest benefit to the user.
Of course, psychedelic use isn't for everyone. No serious contemporary researchers are taking the line of the Disciple who argued in 1968 that everyone should have access to unlimited LSD. More work needs to be done on the neurological mechanisms of psychedelic substances in order to understand their interactions with pre-existing mental conditions like schizophrenia, in order to reduce the likelihood of lasting mental damage from what is otherwise a promising suite of therapeutic substances. Others are attempting to get to the neurological root of hallucinogen persisting perception disorder, otherwise known as flashbacks, which are far from accepted as a separate mental condition, but nevertheless have been widely reported for decades.
In the meantime, intrepid psychedelic researchers are painstakingly putting together psychedelic support manuals, clinical best practices for other researchers, and volunteering their time in festival harm reduction tents in an effort to alleviate the worst effects of a difficult experience. Will these adverse psychedelic reactions be with us for some time to come? Most likely. But that doesn't mean a trip has to be bad.
*Not his real name.