Bull. Org. mond. Sante 1959, 21, 505-515 Bull. Wld Hlth Org.

The Role of Psychotropic Drugs in Group Therapy* R. A. SANDISON1

The purpose of this paper is to examine those aspects of the drug treatment of mental disorder which relate to the human environment or group in which the patient finds himself. Although great claims are made for modern drug therapy, a distinction must be drawn between the specific effects ofdrugs and the effects of the environment itself. Psychotropic drugs are not specific in a particular disease, although they may modify specific symptoms. Two special cases are selected for an examination of the effects of the environment on drug action-deep insulin treatment and lysergic acid diethylamide. The psychological phenomena induced by deep insulin differ according to whether treatment is given individually or to a group ofpatients; and the psychological significance of insulin treatment lies in the ability of the treatment situation to help the patient to become a full member of the group. .Similarly the group influences relating to LSD treatment are examined. It is concluded that the attitude of social groups to psychotropic drugs is determined by the real or apparent effects these drugs have on super-ego function. This appears to have some relationship to the so-called placebo phenomenon. The fact that clinical trials tend to lead to results unduly favourable to the drugs tested is noted and some suggestions are made as to how these trials can be improved.

" Physiological treatment is booming; the past year sympathetic magic and the empirical use of (1956) has seen a glut of conferences and papers on galenicals homeopathic medicine arose. Findlay chlorpromazine, the rauwolfia alkaloids, and the (1950) dates the commencement of modem chemo- newer drugs intended to relieve neurotic and psychotic therapeutics from the discovery of arsphenamine by symptoms. World-wide publicity has stimulated public interest and demand, while the indiscriminate use of the Ehrlich and Hata in 1910. The great advances in drugs for the common neuroses, conduct disorders, this field did not occur until the introduction of reactive states and depressive states, where they are prontosil rubrum by Domagk in 1935, rapidly to be least effective, has led to official protests and counter- followed by sulfonamides, antibiotics and other measures.' specifics. Drug therapies can now therefore be Thus Wortis (1957) summarizes the situation classified as follows: created by the inventiveness of chemists in the field 1. Specific remedies, e.g., penicillin. of psychiatric treatment, concluding: 2. Remedies which modify disease or control " The new drug treatments have practically abolished symptoms, e.g., anti-convulsants in epilepsy, insulin lobotomies and greatly diminished the need for both in diabetes mellitus. electro-shock and insulin, although E.S.T. remains an 3. Remedies which modify symptoms, e.g., insulin almost specific therapy for depressions." in schizophrenia, tranquillizers. MODE OF ACTION OF DRUGS AND 4. Remedies which may modify symptoms but THE PLACEBO RESPONSE are not of proven value. Ancient chemical methods of treatment were One notices as one descends the list (a) that the directed towards the expelling of real or suspected remedies become more numerous, (b) that their causal agents of disease from the body. Out of action is less susceptible to proof by clinical trial, and (c) that their action is more susceptible to group, * Revised revision of a paper submitted to the WHO cultural and other environmental influences. Presum- Study Group on Ataractic and Hallucinogenic Drugs in ably penicillin will cure pneumonia, provided the Psychiatry, November 1957 causal is weli in 1 Consultant Psychiatrist, Powick Hospital, near Wor- organism sensitive, equally any cester, England country or culture in the world, whereas not only

831 -505 506 R. A. SANDISON is proof lacking concerning the efficacy of most of more than 200 names. The ancient Greeks, Celts and drugs used in psychiatric practice but their beneficial Scandinavians were mycophobes, as are the Anglo- effect varies from one country to another and even Saxons. There was another phenomenon that arrested between different wards in the same hospital. The our attention: wild mushrooms from very earliest times were steeped in what the anthropologists call position is further complicated by the fact that we 'mana ', a supernatural aura." do not know how ataractics work. Are they specifics like penicillin, are they modifiers, or do they partially From Wasson we learn that " Among the [Ameri- replace metabolic deficits? Nor are psychiatrists can] Indians, their use is hedged about with restric- clear as to what they are looking for in the search tions of many kinds. Unlike ordinary edible mush- for new drugs. North American opinion appears to rooms, these are never sold in the market place and favour the old medieval idea of a drug to counteract no Indian dares to eat them frivolously, for excite- an alleged toxin (i.e., the search for a hallucinogenic ment. The Indians themselves speak of their use as substance circulating in schizophrenics and research ' muy delicado ', that is ' perilous ' ". These empiri- into anti-hallucinogens). Others are content with cal observations of Wasson have now been confirmed drugs which modify behaviour. While so little is by the extraction and synthesis of psilocybin by known even as to which of the psychoses are func- recent experimental work, which makes it almost tional and which are organic, physiological treatment certain that psilocybin is hallucinogenic (see Hoffman must remain empirical and therefore subject to wide et al., 1958, and papers by A. Cerletti and by fluctuations in its results in different syndromes in A. Hoffman presented at the meeting of the Col- different places. legium Internationale Neuro-Psycho Pharmacologi- HISTORICAL cum held in Rome in September 1958). These observations fit in with our knowledge of The remarkable development of drug therapy the use of powerful drugs, amulets or charms in during recent years appears to mark the climax of many societies until recently. Such was the power many years' development of physical treatments in attributed to the remedy that responsibility for its psychiatry, which have arisen not perhaps so much use was divided amongst the group who gathered out of conviction or proof that mental disorder is round the afflicted person. In some countries the organic in nature but as a reaction after a century group is also employed to ward off the evil god, held of moral, philosophical and psychological treatment. responsible for the disease (cf. Pettigrew, 1844). It is also an inevitable by-product of a materialistic The secrets of the apothecaries and others were and scientific age. Drug treatment in psychiatry closely guarded and there was frequent rivalry revives the whole question of the nature of mental between the medical man and the priest as to who disorders and of group and community attitudes had the more effective remedy. In the years before towards all those substances which interfere with homeopathy was practised the principle of treatment central nervous activity. Right down the ages man was, according to Culpeper (1653), "All diseases has looked with mixed fear and fascination upon are cured by their contraries, but all parts of the natural products which can change his mental body maintained by their likes ". Thus the more outlook. Alcohol, one of the oldest, has become serious diseases were held to be curable only by partially accepted and has gained an uneasy and, in remedies of an obscure nature which were expensive some countries, a highly taxed place in society. and difficult to prepare and which had to be admin- Of all the natural products which soothe, excite istered by a person of undoubted authority supported or change the psyche, the hallucinogens form one of by the utterances of the group with which he himself the most interesting and exciting groups. Rejected was identified, e.g., by the prayers or incantations by Anglo-Saxons, our knowledge of them has come of the people. The Anglo-Saxons do not appear to only recently with the medical uses of mescaline have recognized group influences so greatly as more and lysergic acid. Wasson (1957) has extensively primitive peoples in relation to drug-taking. Accord- investigated the social use of hallucinogenic toad- ing to Wasson the American Indians eating the stools in many cultures and has decided that hallucinogenic mushrooms do so in a group and do " Each Indo-European people is by cultural inheritance not themselves expect a curative effect; they only either ' mycophobe ' or ' mycophile' ". He says, " The ask a question and expect a prophetic answer. Thus great Russians, we find, are mighty mycophiles, as are they frequently take the mushrooms for advice when also the Catalans, who possess a mushroom vocabulary someone is ill. This ritual has something in common PSYCHOTROPIC DRUGS IN GROUP THERAPY 507 with the Chinese casting of hexagrams mentioned PSYCHOTROPIC DRUGS AND THE ENVIRONMENT in the I Ching, in that the particular time at which It is well known that the action of certain drugs the experiment is carried out is important, a group which modify central nervous activity varies accord- of people must be present, and a definite question ing to the mood of the individual at the time and must be asked. As to how the answer is given, it is according to the environment. For example, the clear that the primitives believe that the gods speak state of mind induced by alcohol in the solitary and to them through the mushroom. We might say in secret drinker is usually different from that observed the language of contemporary psychology that the when alcohol is taken socially. It is not certain archetypes are raised into consciousness as hallucina- whether this difference is related only to the tempera- tions or ideas which can be communicated to others. ment of the individual, but one suspects that the Wasson reproduces a Mexican drawing of the environment also plays its part. Environmental sixteenth century in which there are three mushrooms conditions under which psychotropic drugs are given on one side, a man eating them in the centre and a have hitherto largely been a question of expediency. god behind him, who is speaking through the For example, insulin coma treatment is usually mushroom. This, in passing, is exactly what one administered to patients in a group, whereas LSD feels about the action of LSD (lysergic acid diethyl- is almost invariably given to a patient who is amide)-that it compels the unconscious to speak confined to a single room. Little attention, until and that the archetypes appear in consciousness in recently, has been paid to the different conditions the form of images, thoughts, feelings and sensations under which tranquillizers are administered. which are strange and unusual but which are In the field of neuropharmacology evidence is nevertheless part of the subject concerned. being collected concerning the existence of neuro- It is likely that in ancient times the use of drugs humoral transmitters within the central nervous was attended by a group, and that the individuals system and it is being suggested that the brain stem taking part had to expend some effort, mental or and mid-brain reticular arousal systems are peculiarly physical or both, if the value of the substance was susceptible to external stimuli conveyed through to be realized. Dale (1957) points out that the receptor mechanisms. Experimental evidence is curative value of drugs in the sixteenth to eighteenth accumulating which suggests that those drugs which centuries was proportionate to their rarity, value or act on the brain stem and mid-brain structures with difficulty of preparation, and this must be an indica- their associated nuclei may be modified by sensory tion of the psychological power inherent in the impressions.' There is already much clinical evidence preparations. One can therefore see the necessity to support this. We know that LSD phenomena for the group being present, dissolving the magical can be modified by the extent to which the patient power of the drug lest it should prove too dangerous concentrates on his environment. For example, if for the patient. In ancient legends the more effective a patient is asked to read an interesting book fol- drugs were also dangerous to life. Now these same lowing a dose of LSD the psychic manifestations of drugs or their modern equivalents have become the drug can be entirely inhibited. Concentration debased, sold in vast quantities over the counters on manual tasks or irrelevant conversation with of chemists' shops, or worse, dispensed for next to another person can also inhibit them. On the other nothing on the doctor's prescription, demanding hand, the presence of another person who reminds from the patient no effort for their collection or the patient of a psychological situation can intensify preparation and no contribution from him on the reaction. This intensification is best seen in the either a psychic or social level while under their case of paranoid patients. The author has found influence. that the production of repetitive and irritating noises It might therefore be helpful at the present time close to the room in which such a patient is having to write down a little of what we know about the LSD can arouse him to a great intensity of fury and effects of drugs in relation to the group influences hostility. In one case a faint whistling noise from which surround the patient. The drugs which we some nearby machinery brought back war-time are about to consider are called psychotropic, those experiences. Excitation of the sense of smell has which alter the state of mind of the patient. They been found to be a powerful stimulator of emotion- might therefore be supposed to carry great " mana" ally charged memories. value and we should expect their action to be 1 Elkes, J. Address to the Section of Psychiatry, Birming- unusually susceptible to group influences. ham Medical Institute, 1957 508 R. A. SANDISON

Bannerjee (1957), most of whose work has been throwing the ball round to each one in turn. This done in Calcutta, believes that the efficacy of the coincided with clinical improvement. The critical Rauwolfia alkaloids is much enhanced by group psychological phase for a patient undergoing deep therapy of an active kind carried out when a patient insulin treatment is during the period of recovery is taking the drug. He believes that Rauwolfia has from the coma, and one not infrequently finds a specific effect on paranoid and confused mental patients who are afraid of dying during this period states. One method of demonstrating this is to and who experience a great struggle to come to devise group games in which patients are compelled consciousness again. There are other patients who to make some positive contact with each other; to object to being brought out of the coma, preferring work as teams and to trust each other. He reports to remain out of touch with the realities of life, and not only that the patients undergoing Rauwolfia this is usually associated with a bad prognosis. treatment lose their suspicions when these methods Many patients describe the insulin experience as are applied but that the degree of co-operation is unpleasant, like dying. One of my patients cried out much greater in those groups receiving the Rauwolfia loudly and screamed against death, but at the end alkaloids. of the struggle she saw an urgent need to live and a great impulse came over her to eat and she stuffed DEEP INSULIN TREATMENT: quantities of food into her mouth almost to the INFLUENCE OF THE GROUP point of choking. Another patient on waking from coma every day would think she was dead; this For several reasons deep insulin treatment may went on for weeks without any change, and the be taken as a model for examining the role of patient said " Now I take it for granted that I am psychotropic drugs in group therapy. The treatment dead ". Another patient thought she had had a has been widely practised for over twenty years. serious operation during treatment; that she was The patients are almost invariably treated in a group dead and the process of restoration to life was too under conditions which are favourable to a study hard to go through. The interest of these death of the psychological factors at work both in the experiences lies in the fact that they are not entirely patients individually and in the group as a whole. individual, for sooner or later the patient becomes Although it is generally held that insulin is a purely concerned about the other members of the group. physical method of treatment, there are some who I had one patient who insisted on being brought say that the good results achieved by insulin are round from coma before any of the other patients attributable only to the individual attention and because she felt that she could then watch over resocializing effects resulting from the patients living them and assist in their recovery. Another patient in a small group and being looked after by a rela- was convinced that I was giving insulin to the other tively large number of staff. The truth, however, patients to make them die and on one occasion would appear to lie midway between these, since actually tried to prevent me from giving the injection. close study of an insulin group reveals that the Another patient in the course of a group meeting patients are capable of producing a great deal of expressed much the same idea, saying " Why do you significant psychological material. Few observers put them in a coma? You must be hurting them ". appear to have noticed this. Close questioning of There are psychological reasons for believing that the patients reveals, however, that they do have the the overcoming of the death experience and of the most interesting fantasies, which at first concern state of regression induced by insulin are factors only themselves but which subsequently concern of great importance in the patient's recovery. It is the rest of the insulin group, and if this latter occurs well known that both animals and human beings it is invariably associated with clinical improvement. under the influence of danger tend to congregate One of the best examples of this, in my experience, into groups and that this has the effect of diminishing concerns a young girl who at the beginning of the the individual fear of death. There is therefore insulin treatment had a childish fantasy during every reason to believe that the gathering of patients recovery that she was playing with a ball. Within undergoing insulin treatment into a group is a most a few days the fantasy extended to the doctor and desirable thing. she had an idea on waking that she was playing Another type of experience frequently observed tennis with him. Finally all the patients were drawn amongst those undergoing insulin treatment may be into this game, the patient thinking that she was described as the experience of initiation or re-birth. PSYCHOTROPIC DRUGS IN GROUP THERAPY 509

This phenomenon has been well described by Scott from treatment the bed-clothes became like a tunnel (1950). Initiation ceremonies amongst primitive and that she was born over the end of the bed. We peoples are carried out with the support of the whole could not help being impressed by this change after group and they are presided over by the senior the patient was removed from the isolation of the members of the community. A study of primitive single room. initiation ceremonies shows that their chief object Jung, analysing the different forms of re-birth, is to mark the physical and psychological passage considers that the re-birth or transmutation exper- from one way of life to another. In the Arapesh iences of groups sharing a common experience are society, where the girls as well as boys go through a form of identification with a group and that this an initiation ceremony, there is no change in the is something entirely different from experiencing the way of life of the girls before and after the ceremony. re-birth in oneself. These insulin experiences seem They have already been betrothed to their husbands to be both; there is evidence that the transmutation at the age of 7 or 8 and usually for four years or experience is personal and that the group is required so have lived in their husbands' households, assisting both for its completion and its performance. the women with their tasks. The true psychological Another female patient, after 34 comas, had an significance of the initiation is, therefore, seen best idea that those undergoing insulin treatment could in the case of the girl in that she is initiated into the not endure legal marriage and that they either had being of another woman. In Greek mythology the to experience natural unions or else remain virgins. figures of Pallas Athene, Artemis and Persephone This patient, herself married, felt after the next coma give us some idea of the threefold nature of woman that she was no longer married; that the group and as an ideal image (Karenyi & Jung, 1951). Jung her husband were mutually exclusive. She said it remarks that this image in the man is the anima in was like being married to the group instead of to its various forms, but in the woman it is the super- him. In the 36th coma this notion was developed ordinate personality, the one which she has to exper- and she feared that the treatment had turned her ience and come to terms with before she can con- into a harlot. We have, therefore, in this experience sider herself initiated into the completeness of the chief feature of the initiation rites-namely, the womanhood. Among the women of western Europe subjection to those in authority, the pain and dis- this process of psychological immaturity is common comfort of the treatment, the segregation in hospital, and is seen in neurotics, particularly hysterics, and the emergence into the group and the acceptance also in schizophrenics. Among the schizophrenics of the patient when he is better as a more adult and those who are married with children of their own balanced individual. One may conclude that these are psychologically undeveloped and are still child- results can be obtained only through giving the drug, ren at heart. This is demonstrated by the fact that in this case insulin, to the patients as a group. The schizophrenia, particularly in the female, is likely phenomena can quite easily be demonstrated and to follow a love affair or to occur shortly after worked out by anybody who cares to look for them, marriage or childbirth. and it seems unfortunate that studies on the effects One example can be given of the need for the of insulin treatment have not included any com- group. A female patient, 28 years of age, married mentary on these important psychological factors. and with a child, had a schizophrenic breakdown Whether insulin is the only method of bringing out in which she thought she was being hypnotized. these phenomena remains to be seen. Leyton (1958) She was confused, aggressive and restless. As she has recently reported on the treatment results in was so disturbed insulin treatment was carried out two identical groups, one of which received distilled in a single room. She became progressively more water injections and the other insulin. The results regressed, incontinent and degraded. She later in the two groups were similar. Furthermore, she explained that she believed there were three dragons adds in a personal communication, some of the on one arm and three on the other which were patients in the placebo group thought they had been trying to make her completely insane. Her remedy in coma after the injections. was to retreat into infancy so that she became childish and incontinent and she actually believed LYSERGIC ACID DIETHYLAMIDE herself to be taking refuge in the womb. As soon AND GROUP THERAPY as she was transferred to the insulin room she This raises the whole question of the circum- started to recover. She had a fantasy that on recovery stances under which lysergic acid diethylamide (LSD) 510 R. A. SANDISON should be given. For a considerable period the and because of the intensive nature of the treatment author met a number of patients undergoing LSD there is a greater sense of urgency and a greater treatment as a group, when they were not under the drive towards endeavouring to solve psychological the influence of the drug. In the case of these LSD problems. patients the basic material was much the same as In the early stages of the experiment it was neces- that obtained from neurotic groups not having LSD. sary for the therapist to take a more active role than Men and women were mixed and they were roughly usual as the one who could explain the treatment. within the 20-40-year age-group. Patients from The author came to the conclusion that the techniques several different therapists formed the group, which were used were only partially successful in including the group leader's own patient's. It must be solving the problems presented by this kind of group. noted that in a community where some of its mem- For example, if one included one's own patients in bers are taking LSD there is an immediate tendency the group the others regarded them as specially for the subjects to get together and to discuss its privileged and on occasion openly accused them of effects. This has been noticed many times among inventing material. Discussions on transference were volunteer groups, who immediately form themselves exceedingly difficult; those patients belonging to into a kind of club among whom the sole topic of other therapists started maintaining that transference conversation is LSD. This was immediately noticed problems did not exist and expressed great surprise among the patients in the hospital. All the male that any of the therapist's patients could have other in-patients were in a ward of about 30, most of whom than purely professional feelings for him. When were recent cases, neurotic and early psychotic these patients were removed from the group trans- cases being mingled. The women in-patients were ference difficulties continued to arise, the patients in a ward of about the same size, but in their case being inclined to compare one therapist unfavourably the majority of the patients were psychoneurotic with another; this was good in its way, but it must with only occasional cases of early or convalescent be remembered that the techniques of giving LSD psychoses. Some patients were being treated as were still in their early stages and the therapist was out-patients and these either came in for the day or always in a difficult position where he felt that the stayed in hospital for one or two days of each week. methods of a colleague ran contrary to his own ideas. These patients also joined the group. It was noticed It was concluded that the best solution was for the quite soon after we started giving LSD to patients therapist to see only his own patients, but this was that this tendency for them to get together and not entirely satisfactory as it was felt that much of discuss their experience was strongly present. the point of group therapy was thereby lost. The Furthermore, we found that patients having treat- patients tended to take a less serious view of the ment on a particular day often liked to have another group sessions and to withhold more intimate patient with them who had received treatment on a information on the grounds that this could better different day. Nevertheless there grew up a great be discussed in private. The biggest problem, how- deal of rumour and mythology concerning the ever, was the development of a group neurosis which treatment, particularly among those about to receive revealed a marked psychological inflation in the it or in the early stages of treatment. Several of the patients. They tended to become highly introspective patients thought that it was a necessary part of the and spent more and more time trying to work out treatment that they should show uninhibited be- problems which were insoluble. It is true that all haviour such as screaming, breaking windows, these difficulties provided important material for the tearing up clothes, etc. This atmosphere of rumour therapist and naturally they were discussed with the was the chief reason for forming the group, on the group. It does seem that this combined individual grounds that knowledge is the best dispeller of fear and group therapy can go on only for a few weeks and anxiety. Important differences were observed at a time, and it is best to break up the group every between this group and the group to whom no drugs eight or ten weeks and start again three or four weeks were being given. The patients in the LSD group later. This fact has led the author to the idea that were not only bound by the common experience of LSD treatment should be carried out after the neurosis, which to many patients is something they fashion of school terms and holidays as they are would prefer to be without, but they were bound normally thought of in England, with three holidays by the much more whole and telling experience of a year of from four to eight weeks' duration. Some LSD. Such patients are subject to fear and rumour, of the patients never became absorbed into the group PSYCHOTROPIC DRUGS IN GROUP THERAPY 511 and these were usually those with rigid, obsessional group and individual therapy. It is of the utmost personalities who produced little material during importance that further studies on insulin should the LSD sessions. These patients usually felt on the pay attention to the group aspects of the treatment. fringe of the group, but they derived a certain Quite apart from the urgent need to study com- amount of help from other members. parable groups of patients receiving insulin and One should now consider the benefits to be derived other forms of treatment, there is a great need to from this method of group therapy. Although it has divide the insulin patients themselves into two been held that a group of patients taking tranquil- groups. In one group the insulin should be given lizers would have their aggressive feelings damped purely as a physical method, and in the other the down to such an extent that the object of group psychological material should be studied and dis- therapy and the bringing out of latent aggression cussed with the patients at group therapy sessions. would be frustrated, in this group the reverse holds Similarly with LSD there is a great need to study good. In fact, the problem is to know how to deal the precise effects of group influence on the treat- with the breaking down of the resistance against ment, and here a rather similar programme should aggression which occurs during LSD treatment. be carried out. Research into LSD groups should be In some patients it is noticeable that their aggressive directed towards making studies on the behaviour drive is put to use. For example, one patient in the of patients. Too little is known about the type of course of treatment gave up a routine job and reaction to LSD in relation to the personality of the started his own business, although it was interesting patient. The influence of others on the inhibition to observe that his chief problem-namely, the lack or reinforcement of the LSD experience also needs of sexual ability-was unchanged. This conversion investigation. All the material requires classification of aggression into other channels yet missing its and analysis before we can come to understand the main object is one of the great problems of LSD best way to use this and allied drugs. Only then treatment, and when carried a stage further aggres- should we be in a position to carry out controlled sion becomes converted into anxiety, bodily symp- clinical trials which will accord or deny LSD a toms, often of a severe nature, depression and place in the psychiatric armoury. suicidal impulses. In my view this material can be satisfactorily dealt with in the group, and some patients who might have been forced to give up ATARACTICS AND GROUP THERAPY LSD treatment were undoubtedly helped to continue. The next question concerns the role of the tranquil- lizing drugs in group therapy, and here we must FUTURE RESEARCH ON INSULIN AND LSD GROUPS confess that much less is known and that there is great scope for further experiment. The attitude of One might appropriately here put forward a few the general public, patients and staff towards the suggestions about the future study of insulin and taking of what they usually refer to as drugs must LSD groups, for both treatments require much basic first be considered. Certainly in England there are research. Insulin treatment has been practised for deep-rooted prejudices against long-continued drug- 21 years in many countries; a great many reports taking unless it can be clearly shown, as, for example, have been published concerning the results, and in the insulin treatment of diabetes, that the drug- long-term follow-up studies have also been carried taking is essential to life. Even among epileptics, out. The most these studies tell us is that a definite who know quite well that the anti-convulsion drugs percentage of schizophrenic patients are improved will stop the fits, there is a tendency to discontinue as a result of the treatment and that in all probability the tablets. This is not just laziness on the part of the remissions obtained are superior, both in their the patient. We can see evidence of the emotional quality and in the length of time they can be sus- content of people's attitude towards drugs when we tained, to other known methods of treatment. consider tobacco and alcohol, the evil effects of both Although evidence has been collected that the long- of which are frequently exaggerated. Some drugs term use of the phenothiazine drugs may be a close of addiction have particularly severe sanctions rival to insulin treatment, nevertheless there is no applied to their use. The same kind of prejudices definite evidence that the immediate recovery rate are involved when patients are advised to take drugs with insulin treatment is superior to other accepted for the treatment of mental and neurotic disorders. methods, including such methods as occupational The very term " tranquillizer ", conveying freedom 512 R. A. SANDISON

PSYCHOLOGICAL EFFECTS OF, AND SOCIAL ATTITUDES TOWARDS, CERTAIN DRUGS

Drug Psychic action Social attitude

Alcohol Diminishes super-ego control; ego becomes expan- Varies from condemnation to sive and disinhibited. acceptance. Barbiturates Diminishes super-ego control; tranquillizes ego in small Widespread addiction; limited doses; may increase unconscious contents. condemnation. Minor Tranquillizes ego; may diminish super-ego control. Widespread addiction; limited tranquillizers condemnation. (e.g., meprobamate) Major Reduces flow of unconscious contents; may improve Widespread acceptance. tranquillizers super-ego control. Hallucinogens Increases flow of unconscious material; ultimate Limited acceptance; general strengthening of super-ego control. anxiety and religious criticism more usual. Morphine group Increases flow of unconscious material; permanent Almost universal condemnation damage to super-ego if long continued. from anxiety, leads, in people's imagination, to the Among hospital groups one begins to get an idea idea that those taking tranquillizers will have a of the factors involved. I have tried the experiment diminished sense of moral responsibility. It has of taking ten patients in a ward of thirty patients even been stated that sexual perverts taking these and putting them all on one of the phenothiazine drugs will be able to continue their perversions drugs and observing them closely both as individuals without feeling guilty about them. It is probable and as a group. The first thing to notice when these that the word " tranquillizer " is a misnomer, but groups are started in various parts of the hospital is so far a more satisfactory term has not been intro- that the response to treatment appears to depend duced. Lastly, it is not surprising that many patients to some extent on the attitudes of the nursing staff. object to taking drugs over a long period and Some nursing staff are very enthusiastic about drug frequently tell their doctor that they have tried to treatment. Others, more prejudiced against the use leave off the tablets. One occasionally meets patients of drugs, will regard such groups as just another who say that the tablets made them feel worse. whim on the part of the doctor and there is no doubt Others fear that tolerance and addiction may that these patients do not do so well. Therefore one develop. Chlorpromazine, in particular, is inclined immediately has a situation in which both directly to cause feelings of anxiety in patients with active and unconsciously the patients are influenced by the sympathetic systems, yet the fact remains that environment. The psychological forces which bind sedative drugs of various kinds are consumed by the LSD group together are largely absent, but one Western communities in enormous quantities, and finds that in those cases where the nursing staff are the impact of this drug-taking on groups of various enthusiastic the patients on the treatment gain a kinds is by no means clear. sense of importance, and in such wards requests are It may be interesting to try to tabulate the psycho- received from other patients to be allowed to take logical effects of some drugs and to correlate social the drug. These matters are of the greatest import- attitudes towards them; this is done in the table ance and should be discussed with the patients as a above. group, and these group discussions require to be Thus the attitude of social groups to psychotropic continued after the patient has left the hospital. If drugs is determined by the real or apparent effects drugs are to be given with any benefit to schizo- these drugs have on the super-ego function. People phrenics they should be continued for a long time, are less concerned by the effect of the drug on perhaps for years. Long-term drug therapy occa- unconscious activity unless this leads to psychosis sionally meets with resistance from relatives and from or suicide, both of which possibilities lead to the general practitioner, and it may be not only that therapists fearing to use LSD and which are the treatment should be discussed with the patients occurrences the frequency of which has been as a group but that groups of general practitioners exaggerated. and other interested people should get together to PSYCHOTROPIC DRUGS IN GROUP THERAPY 513 consider the relationship of drug therapy to mental treatment gave a recovery rate in schizophrenia of disorder. About two years ago we had a large group 80%, a figure never since approached, while recent of patients taking a phenothiazine compound known studies (Ackner et al., 1957) have suggested that as NP 207. This substance was superior to any the results may be no better than those obtained known drug in the phenothiazine group, but un- with amylobarbitone. Not only are we in the dark fortunately its use had to be discontinued owing to concerning the usefulness of many psychiatric the development of eye changes in some patients treatments which are introduced as " specific" receiving large doses. We were therefore forced to for certain syndromes, but even the most elaborately change over to chlorpromazine for some of the designed clinical trials have frequently failed to patients who were unable to discontinue taking distinguish between remedies which offer an advance drugs altogether. Many of these patients showed on their predecessors and those which do not. Baker marked symptoms of anxiety and some for a time & Thorpe (1957) review the literature in which inert even had pseudo-manifestations of their original tablets and active substances, when compared, had psychosis. Although these cases were dealt with the same action. They report an experiment in which individually, they could probably have been dealt the inert tablets led to a favourable response not with better and more expeditiously by getting them observed with the so-called active drug. The authors together as a group and discussing the meaning of attribute this, in part, to the fact that the placebo was the symptoms and of their anxieties. Thus one sugar-coated. " Thus in terms of total experience, would appear to be coming to the stage where our control group received several small sweets daily patients undergoing long-term drug therapy should from the nurses while the other group received a be seen in groups, but again the kind of material bitter pill." A number of suggestions follow as to one must expect to obtain must differ from that in how these environmental influences can best be groups not receiving any other form of treatment. estimated or limited. It is possible that the phenothiazine drugs diminish dream and fantasy material. The first changes to Suggestions be observed when phenothiazines are given to 1. Most clinical trials lead to results unduly schizophrenics are reduction' of thought disorder and favourable to the drugs being tested for three main hallucinations, and it is only later that the affective reasons. state of the patient undergoes improvement. The (a) The spontaneous improvement rate of a similar function of group therapy should therefore be group of patients is not estimated accurately. directed towards improving the affective life of the Remedy: controlled trials, "double blind" pro- patient-a role for which it is particularly suited. cedure etc., but even these trials may favour drug This no doubt accounts for the more rapid rate of action. improvement among those patients undergoing (b) The methods of measuring improvement are group and occupational therapy. inadequate and are susceptible to conscious or Foulds (1958) has reviewed recent drug trials on unconscious bias on the part of the observer. both sides of the Atlantic and has drawn attention Remedy: better rating scales and improved design to the misleading results to be obtained from clinical of trial (Rashkis, 1957). impressions. Uncontrolled studies are of little, if (c) The trial is influenced by the " placebo" any, value and may lead to clinically ineffective response. Remedy: Research is still required but substances being given to psychotic patients for the following suggestions are put forward. First, whom there are more efficient remedies. the pressure from drug manufacturers on clinicians The clinical results obtained with new drugs to carry out rapid clinical trials should be resisted diminish as time goes on, and there is no really at all costs. The patients should be on placebos for satisfactory explanation of this unless we accept the weeks or months before the drug is introduced. psychological power which new remedies subtly Before a controlled clinical trial is carried out the exert over the judgement of the investigators. How staff should learn how to use the drug and get some else can we account for the world-wide enthusiasm idea what can be expected of it. The editors of which was accorded to cortisone in the treatment of medical journals should insist that authors have rheumatic disease when it was introduced ten years used the drug for at least a year before their paper ago, while later clinical trials show it to be no better is accepted for publication. Secondly, the first few than aspirin? Sakel's early work with deep insulin clinical trials at any one hospital must be regarded 514 R. A. SANDISON

with suspicion because of the placebo response. necessary (Rees, 1956). The more severe critics of Thirdly, group meetings must be held in wards intramural socializing programmes state that the where clinical trials are going on, and the attitude patients have become in a way more institutionalized of the staff and patients towards the trial must be because the hospital has come to depend on them ascertained. All the uncertainties and errors in for its social structure and for much of its labour for clinical trials at mental hospitals or out-patient carrying out routine tasks in the hospital. Many clinics lie within the emotional lives of the staff, and feel that paid employees should carry out the work the operating factors should be clearly stated. The of the hospital and that the doctor-patient relation- size, training and personality of the staff must be ship should be directed towards healing the mind. assessed, the daily lives of the patients studied, the When as much as possible has been done in hospital frequency of parole and leave, etc., compared. How the patient should be returned to the community these factors can be assessed is difficult to say, and where, if necessary, treatment can be continued. whether anyone would accept the loading of the In other words, what is done inside some hospitals results according to the group situation in the ward by rehabilitation and occupational therapy should is doubtful. Nevertheless, until more objective be done outside the hospital by the community studies of the social factors surrounding a clinical assisted by social workers and psychiatrists. trial are published alongside the clinical results, data One must conclude from these observations that will be lacking on the real efficacy of the drugs, and the occupational programme for the ward must be psychiatry will continue to be bewildered by an static for a drug trial to be of any value. So often alarming confusion of new drugs. the patients who improve are given more stimulating 2. The most favourable results of clinical trials forms of occupation. This tendency must either be are obtained in backward hospitals or in wards resisted or reliably assessed. where little effort has been made to resocialize the Only by attention to all these factors and possibly patients. In some mental hospitals (e.g., Warlingham many others, can Wortis's claim made at the Park, England) nearly all the social benefits achieved beginning of this paper that " new drug treatments elsewhere by ataractics have been produced by have practically abolished lobotomies and greatly group therapy, and the advocates of the open-door diminished the need for both electro-shock and system and rehabilitation claim that drugs are un- insulin . . . " be reliably measured.

RItSUMIt

L'auteur de l'article se propose d'examiner ceux des bien qu'incontestablement substance chimique, produit aspects du traitement pharmacologique des troubles des troubles presque exclusivement psychologiques. mentaux qui sont en rapport avec le milieu humain ou 11 existe heureusement un exemple historique: celui le groupe social dans lequel le malade se trouve place. I1 des Indiens du Mexique, qui utilisaient un champignon rappelle que les medicaments psychotropes sont desor- hallucinogene. On notera A ce propos que, primitivement, mais d'un emploi generalise et passe en revue les effets l'habitude de consommer ce champignon, le milieu qu'ils sont censes produire. A l'origine, on utilisait des humain et la structure sociale etaient etroitement lies. drogues et autres substances medicamenteuses pour Les faits exposes montrent qu'en cas d'administration de eliminer de l'organisme des agents pathogenes reels ou LSD, le milieu exerce une influence d6terminante sur supposes; leur usage se situait dans une atmosphere le type d'experience psychologique vecu par le malade sociale de caractere rituel et empirique. La chimio- et que les rapports de ce demier avec autrui peuvent th6rapie des maladies physiques ne date que du d6but modifier profondement le contenu de cette experience. du present siecle; appliquee aux troubles mentaux, elle On a egalement constate que Rauwolfia serpentina est plus recente encore et les produits employes manquent produit un etat de detente qui rend le malade plus acces- de specificite. I1 convient d'examiner les raisons de sible aux influences du groupe humain. l'interet considerable porte A la pharmacotherapie, A Des indications ici presentees, il ressort que l'insulino- la fois manifestation inevitable d'un Age scientifique et therapie A forte dose provoque chez le malade un nombre reaction contre un siecle de traitements moraux et psy- remarquable de phantasmes, dont la production atteint chologiques. La psychoth6rapie a d'ailleurs conserve sa en general son maximum d'intensite au moment ou le place et elle a ouvert la voie A l'emploi de medicaments malade sort du coma. L'effet est diff6rent suivant que le tels que le diethylamide de l'acide lysergique (LSD), qui, malade est traite isolement ou avec d'autres sujets. En PSYCHOTROPIC DRUGS IN GROUP THERAPY 515 outre, il y a lieu de penser que cette production de phan- Les attitudes sociales A 1'egard de la pharmacotherapie tasmes reste d'une portee assez limitee si d'autres malades ont une grande importance et l'article etudie celles qui ne sont pas egalement presents. L'auteur souligne l'ana- se manifestent a 1'egard de substances aussi differentes logie de la guerison des psychoses par insulinotherapie que I'alcool, les barbituriques, les tranquillisants, les avec les rites d'initiation primitifs et les phenomenes de hallucinogenes et les composes du groupe de la morphine. re-naissance. I1 donne quelques exemples des phantasmes I1 estime que I'attitude des groupes sociaux envers les de femmes appartenant a un groupe de malades traites medicaments psychotropes est determinee par les effets par l'insuline. D'une fagon generale, pendant la phase reels ou apparents de ces medicaments sur le fonctionne- initiale de ce traitement, le phantasme consiste en une ment du surmoi. L'attitude du personnel infirmier a regression du malade a un stade infantile d'extreme de- 1'egard des tranquillisants est passee en revue, et l'auteur pendance, d'oii il sort transforme et renait au sein du conclut que l'emploi de ces medicaments ne peut donner de groupe, individu maintenant rattache aux autres malades. bons resultats a 1'h6pital que si la therapie de groupe impli- Au stade final de la cure, le malade quitte le groupe; le que la double participation des malades et du personnel. traitement acheve, il a recupere son independance. Des Ces remarques conduisent a l'examen des methodes considerations analogues s'appliquent au traitement par qui servent A apprecier l'efficacite des tranquillisants. le LSD. En raison des prejuges collectifs et individuels, les L'article presente des observations sur une th6rapie etudes faites sans groupe-temoin sont A peu pres depour- de groupe appliquee a un certain nombre de malades vues d'utilite et peuvent meme etre nuisibles aux malades. traites chacun par le LSD. Cette therapie de groupe L'auteur conclut donc que tous les essais cliniques doi- avait pour objet d'eliminer les rumeurs, de resoudre les vent etre controles et que le point faible de ces essais problemes de transfert et d'integrer les nouveaux sujets reside dans la methode utilisee pour apprecier l'evolution au groupe. Le groupe confere egalement une certaine de l'etat du malade. I1 faudrait etablir des echelles de protection aux malades contre les effets de l'effondrement classement plus satisfaisantes; en outre, le milieu dans de la resistance, qui est un el6ment important et inevitable lequel le malade est traite devrait etre attentivement du traitement par le LSD. L'auteur examine le role des surveille et demeurer stable pendant toute la duree des tranquillisants dans les therapies de groupe; il cons- essais. C'est seulement en veillant a ces details qu'il tate que les lacunes de nos connaissances sont particulie- sera possible de confirmer ou d'infirmer les vertus consi- rement nombreuses dans ce domaine. derables attribuees aux nouveaux medicaments.

REFERENCES

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