Bad Drug Trips and Flashbacks

PRACTICE FORUM

JERRY L. JUVE

CHILD WELFAREhas asked for manuscripts helpful to social workers dealing with drug-connected problems. The author of this report provides direct help to adolescents who are on drugs, and discusses here the special handling of those who are experiencing bad reactions.

The following material is the result of observations and techniques de- veloped and practiced by the author for 3 years as a social worker in a hip- and drug-oriented free clinic in Portland, Oregon. The clinic sees 30 to 40 people, mostly in a 3-hour period, 7 to 10 p.m., and I handle as many as six drug crises (i.e., "bummers" and "flashbacks") a night. The clinic opened June 21, 1968, developing out of concern for the growing alienation of youth from parents and from society, an alienation exemplified by illicit drug use, runaways and antiestablishment behavior. The clinic has four goals: (I) to bridge the gap between the established community and the alienated community by providing free professional medical and counseling services; (2) to provide a neutral drop-in center where youth experiencing conflict or uncomfortable feelings can discuss them with a professional counselor; (3) to provide a neutral setting where parents and interested adults may corne to learn about drugs or gain additional knowledge relative to adolescent experiences; and (4) to maintain an ongoing research program that will provide both the health care community and the community at large with a better understanding of alienation, drugs and youth. The clinic is confidential, neutral and professional. It is privately op- erated by a board of directors, and financing is provided by donations and matching state-federal mental health funds. Social workers at the clinic encounter individuals with a wide range of psychological problems and from a variety of environmental situ-

Jerry L. Juve, MSW, is Social Worker,Multnomah County Child Welfare, Portland, Oregon.

Juve / Bad Drug Trips and Flashbacks 41 ations. In this article, however, I address the area of drugs, and specifically the short-term counseling of individuals who are experiencing "bummers" and "flashbacks."

Bummers "Bummer" is a street term for an adverse, unpleasant and frightening reaction to drugs. Bummers result primarily from the use of hallucinogens such as peyote, psilocybin, mescaline, DET, DMT, STP and LSD. A bummer is usually psychological-a mind trip-in that the individual experiences disorientation, anxiety and frequently hallucinations or delusions. Physiological effects, such as unusual and unpleasant tingling sensations, can also be experienced-a body trip. Frequently, a bummer will be a combination of the two. Some hallucinogens are known to cause certain types of bummers. For example, the drug STP generally provides as much of a body trip as a mind trip. It should be noted that the current psychological equilibrium of the individual ingesting the hallucinogen and the psychological integration of his past strongly determine the type of trip and therefore the type of bummer he will experience. An individual's behavior while experiencing a bummer will often fluctuate drastically from one moment to the next. The following patterns of behavior are often manifested on bad trips: Depersonalization. Often persons on bad trips speak without inflection in their voices and fail to display any affect or emotion when referring to themselves or to their experiences. Some will subjectively separate their minds from their bodies, and some refer to themselves as 0 bjects rather than as persons. For instance, one evening a 15-year-old boy came into the clinic asking to talk to someone. He had dropped mescaline and said he was curious about how it would feel to cut his throat. He discussed his curiosity with me in detail for more than 2 hours, but on a verbal and intellectual level, without displaying any emotion and with no inflection in his voice and minimal eye blinking. Another time, a 23-year-old youth on LSD informed me clamly that he "saw" his body sitting in the chair talking to me, that his mind was moving around in another section of the room observing his body. Segmentation. A segmented individual is noticeably unable to think through or concentrate on anyone subject for any length of time. Ob- vious segmentation in thinking or speech is common during a bummer, and also often occurs with people involved with drugs over a long period, who are unable, or feel they are unable, to use their optimum cognitive powers. Frequently a person strung out on speed will be speech-segmented and will be unable to maintain any continuity in conversation, as he finds his mind racing much faster than he is able to speak. One type of segmentation resulting from hallucinogens is not unlike this. It appears that segmentation is the result of a number of

42 Child Welfare / Volume LI Number 1 1972 thoughts and sensations coming to consciousness simultaneously. When the intellectual processes are already impaired, the sudden bombard- ment of many divergent thoughts causes marked confusion and segmentation. Disorientation. This pattern of behavior is similar to the clinical psy- chotic state, and a person manifesting it is the most difficult to work with, often warranting inpatient treatment if some degree of orientation is not quickly attained. A disoriented individual will appear detached, schizoid and completely bewildered about his identity, his surround- ings and their functioning, and the identity of others. Anxiety. The victim of a bummer finds his thought difficult or impos- sible to control. Familiar thought patterns, conceptual frameworks and perceptual boundaries are suddenly vague and may disappear, while new thoughts and distortions indiscriminately appear and reappear. One client described this as having someone use his TV screen (eyes, ears, etc.) as a means of recall of experience without being able to control what is being shown. Experiencing this sudden and often complete lack of control significantly deteriorates self-confidence, and if self- confidence is not somehow regained and reinforced, the rising anxiety and fear are manifested in agitation and even paranoia. The most common fears expressed by people on bad trips have con- cerned insanity, suicide, homicide, homosexuality and complete loss of control of mind or body. The first responsibilities of the social worker in encountering a bummer is to help bridge the gap between reality and unreality and to provide treatment or referral upon termination of the bad trip.

Need for Street Knowledge An awareness of the drug scene, including philosophy, is mandatory for a social worker to be effective in providing either of these services. The degree to which he is effective is often the degree to which he is con- fident in his street knowledge. This does not mean, of course, that the social worker must have used drugs himself (although at the beginning of the drug culture the only persons experienced in coping with bummers and the only persons who were trusted were those well into drugs personally). The social worker should be diligent, however, in ac- quainting himself with street drugs, slang names and popular and current drug combinations. He should also keep informed of the quality, potency and ingredients of the illicit drugs in his area. Such an awareness helps establish the immediate relationship essential in helping the client cope with the trauma of a bad trip. For example, in August 1970 two 17-year-olds came into the clinic on bummers. They were very anxious and expressed fears of not coming down from the trips and of "going insane." They had purchased and dropped several tablets of what was purportedly mescaline, a hallucino-

Juve / Bad Drug Trips and Flashbacks 43 gen with an average trip of 6 hours. After 8 hours, they were in the clinic and were continuing to experience bad hallucinations. One of the youths realized he was in the clinic, that he was with a friend, that we were counselors, and that he was on a bad trip; however, he also knew that if he closed his eyes he would die. We were aware, through our street workers as well as other contacts, that the majority of the "mescaline" being sold in the Portland area at that time was actually LSD mixed with speed. The usual trip on LSD will last from 8 to 12 hours, and will ordinarily be a mind trip. Speed (amphetamines) produce body trips in which the user becomes hyperactive and energetic to various degrees. The LSD-speed combination is unpopular, and at the time was rather uncommon. Sharing our knowledge of what kind of trip they were on allayed some of the youths' anxiety. We are constantly reminded of the necessity of keeping up to date on the drug scene. The most dramatic instances occurred when drugs laced with strichnine appeared in the Portland area. The combination often produced severe stomach cramps prior to the hallucinative effects of the LSD. The result was acute physical distress and consequent psychological distress, ideal conditions for a bad trip. Awareness of the introduction of strichnine helped us prepare for an increased influx of bummers and allowed us to accept readily as valid complaints of physical discomfort (rather than assuming that the patient was suffering from hysteria conversion). Thus, anyone expressing stomach discomfort was immediately examined by a physician. Another way a social worker should prepare himself to be effective in providing treatment is to observe a competent and experienced counselor, either lay or professional, working with a person on a bad trip. The observation will help provide an awareness of the precariousness of the person's sense of well-being and the volatile nature of the situation, and a sensitivity to behavior and reactions experienced by individuals on bummers. To help a person on a bummer, it is necessary to make him feel comfortable and secure. The ability to do this will, of course, depend on the competence of the counselor, and the degree to which he is knowledge- able about the drug scene.

Use of the Setting There is one important, basic way in which the counselor can help provide this comfort and security-by manipulating the tangible variables in the physical setting cond ucive to reducing anxiety. Sound, for instance, is frightening and distracting for most persons on bummers. Some types of music (depending largely on the taste of the individual) are soothing, but car noises and laughing, and sometimes any loud or easily discernable noise, will be terrifying. Usually, a room without any sounds is most helpful. It reduces distractions, al-

44 Child Welfare / Volume LI Number 1 1972 lows communication between worker and client at whatever sound level is comfortable, and allows the client to hear his own voice. This is particularly necessary in cases of depersonalization and disorientation. The degree to which sound should be controlled must be assessed in each case, however, as some people on bummers become extremely anxious in a sound vacuum. Dim lighting is usually preferred, but this should be determined by asking. (One youth was "seeing spiders everywhere," and wanted the lights as bright as possible so he could see the spiders better and be able to fight them.) The worker should usually be alone with the patient; the fewer persons present, the easier it is to neutralize the immediate environment. Sometimes, however, the client will refuse to be out of contact with a friend, and in such cases the friend can be helpful in reducing or main- taining the anxiety level. (Usually the anxiety threshold appears very low, and when working with someone on a bad trip there is the con- stant possibility of its rising and leading to further incapacitation.) A closed room wards off most distractions, including people; however, many people on bummers cannot tolerate being closed in. Close observation can determine which alternative is best. The counselor should attempt to keep motion smooth, unassuming and minimal. This includes gesticulating. If the room is closed, one should attempt to keep moving objects (pendulum clocks, etc.) to a minimum. If cars and people are moving past the window, the blinds should be drawn. While attempting to provide a neutral setting, the social worker must concentrate on relating to the client. It must be determined from the client or his friends what drugs he is on, how much he is on, when he dropped, his past drug experience (including frequency, amounts and previous bummers), and any other pertinent information. The patient should always be asked these questions, even if his friends in the lobby have already supplied the answers. This maneuver forces him to communicate with the counselor and to relate to him. The questions should be asked in a direct, unthreatening manner, and not all at once. Although they may confuse him, they ordinarily help the client organize and orient his thoughts about himself, drugs and his current situation. The answers are essential in knowing, or at least in speculating, about the duration of the trip, the probability of its worsening, and what kind of help might be necessary; primarily, however, the questions maneuver the client into focusing on the idea that he is on a trip, a temporary, transitory experience that will end. It is of paramount importance at this time to help the client avoid thinking about personal problems until he comes down from the bummer. (This is not difficult, if a degree of trust has been established.) The person on a bummer, whose cognitive processes are affected, cannot accurately perceive or reason and cannot deal with his problems in

Juve / Bad Drug Trips and Flashbacks 45 any rational manner. It is supportive to offer to talk with him about a problem at some specific date after he is down from the trip, but the worker must return the focus to the trip. The patient should be encouraged to relax and let the trip "flow," and to share the experience with the worker. The counselor must accept the trip in an understanding way and be totally honest in talking. He should be supportive but not oversupportive, and refrain from inter- fering with what he is told. The worker should allow the subjective experience but represent objective reality. I have been told by some patients that they felt their minds "disintegrating" physically and psychologically. In these cases, I have acknowledged that they felt that way, but that they appeared normal, and I identified strengths in their current communication with me. This soothed the patients and at the same time offered the support of my acceptance of the integrity of their feelings. The worker should be aware that disintegration is usually a subjective feeling connected with the trip. Some people on bummers are almost completely nonverbal. With them it is important not to push. I have had several cases in which it proved helpful for me simply to sit in the same room and mutely share the trip. If this type of case is encountered, it is important for the counselor to state his reason for remaining quiet. Even with my most nonverhal cases, the patients have suddenly changed expression or looked up to indicate they wanted me to say something. It is necessary to say a few words every 15 or 20 minutes, such as "You look more re- laxed," or "You appear nervous." This helps the client to realize he is to some degree in contact with reality and that the worker cares about him and is sufficiently interested in him to observe him carefully and empathize with his feelings. This worker has observed lay counselors and some communal people employ physical support and acceptance. I have seen men embrace men on bummers, women embrace men, and this has been effective in certain situations. In several situations I found it helpful to touch the client's wrists or forearms. In these situations, touching augmented the minimal verbal communication, and directly communicated understanding, empathy and caring. I believe that physical contact between worker and client requires the same sensitivity, caution and awareness from the worker as do his demeanor and other nonverbal communication agents. Lack of self-awareness and failure to perceive accurately how he is relating to the client are dangerous at both the verbal and nonverbal level. Only if a person is comfortable and adept at assessing when physical support is appropriate can it be a helpful adjunct. On all levels, the worker must be aware of his own responses and behavior while communicating with a person on a bummer. The counselor's facial expression, mannerisms, stare or general countenance can freak a stoned person. Once, two girls on mescaline were in the clinic, and in giving them directions to a local coffee house, I gestured with my

46 Child Welfare / Volume LI Number 1 1972 arm. The girls cried that my gesture reminded them of a policeman, and they ran from the clinic before I could finish the instructions. One cannot avoid a few such incidents.By closely observing the clients, however, one can usually determine whether such things as avoidance of eye contact are conducive to reducing anxiety or not.

Flashbacks

A person suffering a flashback is reliving a trip. The trip could have been considered a good trip or a bummer, but the flashback is a bad trip, because of its unpredictability and the disruption it causes. Some patients have flashbacks days, weeks, even a year after experiencing the identified trip. (The longest I have worked with was 18 months.) Flashbacks vary in frequency with each person. Some experience them daily, others weekly or monthly, and others erratically. The client does not always know when he will experience a flashback, if he will experience it, or how long he will continue to experience it. It is probably because ofthis un predictability that some patients become suicidal. Flashbacks are confined to the user of hallucinogens, particularly LSD, STP, and mescaline. In all the cases I have seen, the flashback occurred after the chemicals should have been eliminated from the body. (According to doctors working with drugs, most hallucinogens ingested into the body are assimilated and eliminated within 3 days.) Perhaps the most poignant flashback case I have worked with involved a 23-year-old man who was plagued daily with flashbacks cen- tered around an immobilizing fear of cars, bridges and himself. He was terrified that his mind would throw his body in front of a moving auto or from a bridge. The magnitude of these flashbacks was indescribable. Several times a week the incapacitating fears would be re-experienced. He would attempt to find his way home, where he felt secure, but he would be so frightened of cars that he could not cross the street. He would consequently circle a block for hours in an attempt to reach home without crossing the street. The flashback usually culminated in his be- coming too terrified to remain on the street, so he would enter a build- ing and curl up in the prenatal position and cry until someone found him and accompanied him home. The flashback phenomenon continues to avoid exact clinical analysis and classification. However, for the purpose of simplicity, I have sep- arated flashbacks into three categories: (1) recall, (2) hysteria, and (3) functional. Recall flashbacks appear to be the product of an involuntary stimu- lus-response pattern. The original trip is re-experienced through memory. In many of the cases with which I have worked, the flashback was triggered by an incident that occurred during the trip or by an incident similar to one experienced during the trip. For example, a client of another worker had entered a hamburger drive-in while on an LSD trip

Juve / Bad Drug Trips and Flashbacks 47 and observed the employees preparing milk shakes. From that time on, the sound of any kind of mixer set off a rainbow 6f swirling colors for the client. Some individuals are unable to interpret and integrate the drug trip at a conscious level, and in some cases patients have not resolved their experience, but are carrying it, mostly at the conscious level. This inter- feres with their mental functioning and contributes to the flash backs. Hysteria flashbacks are less rational than recall flashbacks and are characterized by a lack of actual recall of the identified trip. Patients come into the clinic stating that they are experiencing a flashback, when actually it is the anxiety and discomfort experienced during and as a result of the trip that is paramount in their consciousness, not the trip per se. It is the fear of re-experiencing the trip that motivates them to come to the clinic, rather than an actual flashback. Hysteria flashbacks appear to be involuntary. Functional flashbacks are an unconscious attempt to re-experience the trip. With the functional flashback, as with the hysteria flashback, there is no actual recall of the trip. The idea of a flashback is quite functional in the patient's psychopathology. In some cases the flashback may be a maneuver to solicit attention, concern or interpersonal relations, or to meet masochistic needs. I have found that in a number of cases the patients are experiencing guilt feelings and feelings of hos- tility toward themselves for having placed themselves in the discomfort of the original trip. This includes a reflective fear of what could have happened during and as a result of the trip.

Techniques in Flashbacks My approach to a purported or actual flashback is on both a con- crete behavioral level and a more abstract, mental level. It is essential to learn first of all where the patient is mentally and emotionally by asking him what he is experiencing, the frequency of flashbacks, in what situations (physically and socially), and his past drug usage. One must accept the subjective experience, but keep it in perspective with reality. After obtaining the essential information, the client should be helped to understand the flashback by remembering the identified trip as well as the confused feeling. He may understand the flashback, but may not be able to feel completely secure because of the profound impact and vividness of the experience. One should attempt to dispel some of the immobilizing anxiety about future flashbacks, as well as of the present one, by explaining that if a flashback does occur, he will know what is happening, even though he may feel that he cannot control it, and that this understanding will render the flashback less frightening. The client may be reassured by the knowledge that any future flashback will not happen any faster; this will be a familiar pattern. The worker can also help tangibly by assisting the patient in developing a plan to find immediate help if a flashback begins to happen. Friends or a counselor

48 Child Welfare / Volume LI Number 1 1972 should be chosen to call for help. (On many bummers, persons have found themselves isolated or alone and this is sharply fixed in their memory.) The foregoing is ordinarily all that can be accomplished in one inter- view, and this takes a minimum of I or 2 hours. If there is a later oppor- tunity for treatment of a continuing flashback, 1 concentrate on the content of the flashbacks, the meaning of the content to the client, the possible function of the content, and the possible function of the flashback in general.

Conclusion When a person on a bummer or a flashback cannot be quieted down or his anxiety reduced appreciably within about 2 hours, the best alternative is voluntary placement in a psychiatric inpatient facility.If a facility does not exist, or if he does not voluntarily choose to stay overnight, then the second choice is for him to remain with friends that evening. The third and least desirable alternative is to coerce the person into admitting himself to a psychiatric inpatient facility. This is necessary when the client is suicidal or homicidal. Bummers are more critical and more volatile than flashbacks because of the greater degree of impulsiveness and unpredictability. With a bummer, many of the sensations, thoughts, hallucinations or delusions that occur are alien to the patient, and he cannot predict either their intensity or his reactions to them. Flashbacks are somewhat predictable as to the types of experiences being encountered, although the magnitude may differ. Past behavior (during the identified trip) mayor may not be repeated; however, past stimuli will be similar. Behavior on a bummer or a flashback sometimes remains within a certain identifiable pattern, such as depression; however, the client's behavior does not always remain within one category, but often assumes several seemingly incongruous and segmented patterns from one moment to the next. Bummers and flashbacks are characterized by a feeling of loss of control, lack of confidence, disorientation, confusion and anxiety. The factors behind these feelings (the degree of personality homestasis, the chemical components and the totality of the physical setting) are constantly changing, although the general types of feelings are character- istic of both bummers and flashbacks. A person unable to cope with his feelings and unable to find help in coping with them usually experiences a magnification of the exist- ing feelings. The result can lead to psychosis, suicide or homicide. The most generally observable difference in working with bummers and flashbacks in a clinic situation, compared with many other types of presenting problems, lies in the volatile nature of the situation, the lack of knowledge about an individual's background, and the lack of

Juve / Bad Drug Trips and Flashbacks 49 control over his leaving. Because of this, as well as the client's high level of anxiety, the worker will usually feel constricted in communicating with the client and providing support. The constriction is reinforced by the need to facilitate the client's relating to him before the situational and personal variables change. This necessary relationship and communication between the worker and the client are dependent upon where the client is, which is in the middle of a drug experience. The significance of the current drug experience, as well as of past drug experience and present and past attitudes about drugs, is extremely pertinent. Because of this, the worker must have an understanding and an awareness of what his client has experienced and is being ex- posed to socially, culturally and interpersonally. In essence, I believe that a combination of professional knowledge, technical knowledge, and street knowledge and awareness is essential in giving maximum help to people on bummers and flashbacks. •

A Glossary of Terms Dealing With Drugs

Hallucinogen-A drug that produces hallucinogenic (nonreality- based perception) and illusionogenic (distortion of reality-based perception) effects. DMT-Dimethyltryptamine, a hallucinogen made from the seeds of plants indigenous to the West Indies and South America. An average trip lasts from 40 to 60 minutes. DET - N-dimethyltryptarnine, a synthetic hallucinogen, with an average trip lasting 2 hours. Similar to DMT. STP-2,5-dimethoxy 4-methylamphetamine, a synthethic hallucinogen. An average trip lasts 8 hours. LSD-Lysergic acid diethylamide, a synthetic hallucinogen. An average trip lasts 8 to 12 hours. Extremely potent. To drop-To ingest or swallow a tablet or capsule containing a drug. Come down- When a drug-taker begins to regain his physiological and psychological equilibrium. Speed-Street term for amphetamines, specifically for methe- drine. To freak- To become disoriented and anxious, due to drugs. Stoned- Under the influence of a drug. Strung out-Psychologically or physiologically dependent on a drug.

50 Child Welfare / Volume LI Number 1 1972