ARTICLE

Emotional processing - Psychotherapy and altered states of consciousness: Principles, therapeutic possibilities and challenges

Marianne Kaspersen and Halvard Hrklau

Emotional processes are by means of almost any psychotherapeutic intervention regarded as difficult for patients to enter. Such work may involve the delving into memories so anxiety provoking that patients often seek to avoid them, in therapy as well as in life in general. Therapy that provokes emotional material and subconscious processes therefore often requires a special therapeutic setting, and patient- and therapist characteristics especially suited for this kind of work. What seldom is discussed is whether the consciousness state that most therapies work through is suited for working with subconscious processes, especially if trauma material is involved. This article seeks to discuss this. This article presents principles, possibilities and challenges involved in therapeutic interventions using non-ordinary states of consciousness (NOSCs). It is argued that certain NOSCs may be more suited for certain therapeutic workings than the ordinary state is. NOSCs can be arrived at through a variety of ways, among them meditations, expressive therapies, breathing techniques, hypnosis, and through the use of certain psychoactive substances, mainly the so-called psychedelics1. In all these techniques, if there is a wish to induce a NOSC, this state is best described as a type of mindfulness meditation with increased awareness of emotions as a central feature. Although NOSCs can be induced in a variety of ways, in a therapeutic context, there are reasons why such states preferably may be induced by the use of psychedelics. First, most psychedelics are non-toxic, they are non-addictive, they never cause drugseeking behavior (Vetulani, 2001; Gable, 2006; Halpern, 1999; 2003), and they quickly lead to a very distinct NOSC that demands an effort to master. Due to the fact that they are distinct NOSCs and because they are demanding to master, this makes psychedelic-induced NOSCs suitable for therapeutic work. They provide possibilities for making use of therapies from several schools of thought, such as behavioral therapy, insight-oriented therapy, psychodynamic disciplines, and Gestalt oriented therapies. In order to illustrate the main points in therapeutic work with NOSCs we therefore restrict this presentation to therapeutic work with psychedelics in western and shamanic therapy practices. Three traditions that have used psychedelics in therapeutic
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work will be presented and compared to the western drug-paradigm. Thereafter we outline principles in which NOSCs can be used in therapeutic contexts, as well as therapeutic possibilities and challenges. To define a NOSC is demanding, and it is beyond the scope of this paper to provide such. Tart (1969) defined the analogue term altered state of consciousness (ASC) as a state in which a given individual clearly feels a qualitative shift in his pattern of mental functioning, that is, he feels not just a quantitative shift (more or less alert, more or less visual imagery, sharper or duller, etc.), but also that some quality or qualities of his mental processes are different. Other researchers have used the term mind-body state (Roberts, 2008) to denote that mind and body can exist in different states, each of which is more or less suited

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for the performance of specific tasks. Grof (1990) has proposed the term holotropic state to denote a condition in which the conscious mind moves toward a more integrated state that also involves a more complete understanding of the self. In Tarts definition an ASC is separated from altered states of alertness, although ASCs in some cases may involve enhanced clarity. Some authors have proposed that certain human activities, such as for instance creative work and problem solving may be better performed in certain NOSCs (Roberts, 2008). The claim that our ordinary waking consciousness is the only state through which to approach human endeavours is a contention that Roberts (2008) has termed the singlestate fallacy. In most cultures other than the Western civilization such nonordinary states have through millennia (Rtsch, 1998) been part of integrated cultural life, as in ritual- and ceremonial settings, or as part of healing- and divination practices. The only known society that does not include NOSCs as a part of the culture is the Western civilization (Winkelman, 1995). NOSCs have in European culture further been termed as pathological (Noll, 1983; Grof & Bennett, 1990). NOSCs have even been confused with drugged states, and to a certain extent therefore been subjected to criminalization. Such differences in interpretation of the same phenomena have furthered and contributed to the gap between western and indigenous perspectives. The psycholytic and the psychedelic paradigms The use of NOSCs as an aid in therapeutic interventions is not new. South-American traditions have been skilled in the use of psychoactive plants for millennia (Naranjo, 1979). In Western countries the first uses that eventually became therapy traditions were established during the 50s in North America and in Europe. These became the psycholytic tradition in Europe and the psychedelic tradition in Canada and the US, both of which used psychedelics, mainly LSD, in order to facilitate psychotherapeutic processes

and further therapeutic effectiveness through the reprocessing and integration of previously non-processed emotional material. The psycholytic tradition was a theoretical and practical extension of psychoanalytically oriented therapy, in which a low dose of LSD was given biweekly (Grof, 2001). LSD served as an adjunct to therapy, making subconscious material more available for analysis. All therapeutic mechanisms were intensified during this therapy, such as emotional abreaction, the reliving of traumatic experiences, insight, and transference phenomena (Grof, 2001). The induced NOSC was easily remembered by the patient, thus making it available for later analysis without the substance. About 700 publications attesting to the effectiveness of these methods were written (Passie, 2007) and psychologists and psychiatrists within these traditions used these methods for about 20 years. In the 60s, however, unsupervised selfexperimentations with psychedelics by the youth movement turned into serious problems, resulting in necessary legislative measures in an attempt to control this, which unfortunately also hampered most therapeutic and research-based uses of these substances. The psychedelic tradition was developed by Osmond and Hoffer during the early 50s. One of the most famous research programs within this approach was an alcohol treatment program, developed in Saskachewan, Canada (Dyck, 2006). As part of the program the intention was to induce a fake delirium tremens by administering a single, high-dose LSD, after which the patient was thought to reduce or stop drinking. The results were surprising: Patients to a large extent quit or seriously reduced alcohol consumption, but the reasons they did so were different than assumed. Many patients quit or reduced alcohol intake, due to a transforming experience often perceived to be of a religious nature. Therapy was thereafter furthered and developed based on this first high-dose session. When legal issues made psychedelic and psycholytic therapies illegal, both these traditions merged with

other therapeutic movements, mostly expressive therapies, art therapy, and guided affective imagery techniques. To a large extent they also merged into transpersonal psychology and psychiatry, in which Stanislav Grof has been a central figure. The shamanic paradigm In the South-Americas, among North-American Indians, and among indigenous peoples of Africa and Asia, healing work, divination and ritualreligious work has been and many places still is part of normal cultural settings (Eliade, 1964). This draws attention to the fact that NOSCs were and still are present in natural therapeutic work in most continents. We will focus on work done by indigenous peoples practicing in the Amazonian parts of Peru and Brazil. Shamanism is based on an essentially animistic orientation that influences the way disease, therapeutic work and what constitutes medicinal work in general is viewed. It is beyond the scope of this article to present a complete conceptual framework in this regard, but a few points will be mentioned. From the animistic orientation emerges the conception of plant spirit or plant teacher (Luna, 1984). In Amazonian culture certain plants with psychoactive properties are regarded as plant teachers. The most known of these is Ayahuasca , a plant concoct that have been in use among indigenous Amazonian cultures for millennia (Naranjo, 1979). Plant spirits are said to present themselves to the individual ingesting Ayahuasca through visions (mostly closed-eye visions) and certain songs (icaros). By the recitation of these songs the shaman enters the spirit realm (Luna, 1984). In the Amazonian culture a distinction is made between plant body and plant spirit. If a plant is regarded as having healing properties, then this is assumed to be connected to the plant spirit, not to the physical plant itself (plant body) (Yensen, 1995). This marks a fundamental difference between western and shamanic paradigms as regards what constitutes the medicinal value of plants.

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In Peru, the shamanic paradigm has recently found uses in conjunction with more western treatment methodologies. This has mostly been applied to drug addiction therapies. At the Takiwasi rehabilitation center in Peru, founded by Dr. J. Mabit in 1992, a program for the treatment of cocaine- and alcohol addiction has been established (Mabit, 1996). The center is authorized by the Peruvian Ministry of Health and is affiliated with The National Institute of Traditional Medicine (INMETRA). Treatment at Takiwasi is based on a non-profit, cost-effective, apolitical, and a non-coercive policy. There is no religious affiliation attached to the treatment, and an objective exists to explore botanical resources in the Amazonian forest as well as to protect Amazonian ecology. Initial treatment begins with a thorough detoxification program and is followed with psychotherapy with Ayahuasca2, a potent psychoactive that provides access to deep emotional conflicts. To enhance awareness of personal problem areas is made a main focus of the treatment through a series of Ayahuasca sessions.

In addition, group therapy sessions aiming at the reprocessing of personal conflict material are available. In this phase other treatments are also offered, such as narrative therapy, expressiontherapy, and holotropic breathworkTM, techniques that all induce a heightened sense of sensibility and awareness and in the case of holotropic breathwork also may induce a NOSC. In the end of the therapeutic program there is a focus on social reintegration into workand family life functions. The treatment lasts from a couple of months to eight months depending on the severity of the problem. The Western drug paradigm We choose to term the Western medical view on psychedelics as the drug paradigm. This is based on the fact that the Western view emphasizes chemical effects of any substances, including foods, while the effects of set and setting parameters are de-emphasized or even overlooked. The Western paradigm view chemical processes as determinative of biological and psychological processes. Along this line

of thinking, the drug paradigm does not accept conceptions such as plant spirit. This results in a view that places plant materials in a category along other chemicals. The reduction of living materials to chemical substances represents attitudes that comes out so strongly in Western culture that it is difficult to think otherwise if not specifically trained to do so. Applied to psychedelics, the drug paradigm emerged as the psychotomimetic hypothesis. According to this, LSD was viewed as a psychosis mimicker. When the effects of LSD were discovered in 1943 by chemist Albert Hofmann, there was ambient hope that this would provide an ultimate explanation for the mechanism behind psychotic breakthroughs (Hofmann, 1979). However, LSD did not turn out to be a psychosis mimicker, but rather an opener to repressed emotions and subconscious material via a temporary loosening of defense mechanisms. This led to the development of several therapeutic traditions using the substance in therapy (Grof, 2001).

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Comparison between views According to the above, the western drug paradigm de-emphasizes psychological variables (set parameters) in general, and also considers social and anthropological aspects (setting parameters) to be less important than pharmacological effects. This is probably where the drug paradigm becomes totally detached from the shamanic view and also departs from both the psycholytic and the psychedelic traditions. A question should be asked: Could this lack of credit given to psychological and social factors explain why the use of mindexpanding substances was considered as having no medical potential? In any case: The western drug-paradigm contrasts a shamanic paradigm in several ways: First, the administration of a psychedelic substance in a nondrug setting, aiming at a mindful exploration of the subconscious, will, within the drug paradigm be difficult to conceptualize. Similarly, a therapeutic or a religious setting with psychedelics will be equally difficult to grasp within such a view. Within a drug-oriented understanding of substances, the very fact that something is ingested brings about the association of drugtaking. To alleviate this, the concept of non-drug setting (Halpern, 2003) becomes meaningful. The weight put on chemistry relative to psychological and social factors versus the emphasis on rituals and setting conditions indicate a fracture between western and indigenous views. However, the western traditions that used psychedelics in the 50and 60s, stressed the importance of set and setting parameters and that these conditions modulated the pharmacological effects extensively (Grof, 2001). This indicates that these two western traditions in effect are closer to the shamanic paradigm than to the drug paradigm. During the 60s and 70s there were also warnings from the scientific communities that psychedelics should never be used outside of structured therapeutic or religious settings (Grof, 2001), warnings that continue to come from shamanistic communities today

(Tsamani, 2008). This may suggest that reconciliation is possible between these traditions. These substances are usually regulated in indigenous cultures, a fact that adds to such reconciliation. Regulations have mostly been exerted through highly ritualistic settings and religious taboos, and uses outside of such settings have been and still are rare and seldom culturally accepted (Luna, 1984; Naranjo, 1979). This may give hope for a way to regulate psychedelics in a healthy and wise manner that will accept and utilize their therapeutic potential, while unauthorized uses and unsupervised self-experimentations are being warned against. Psychedelics in therapy aiming at emotional integration: Findings from clinical research Clinical research on Ayahuasca is scarce. However, Ayahuasca is, due to its botanical and chemical complexity and its cultural heritage, probably the most interesting psychoactive in the

entire Amazonian forest (McKenna, 2004). Findings from the so-called Hoasca project (Grob et al., 1996), suggest that ritual use of Ayahuasca may alleviate a variety of psychiatric conditions, such as depression, anxiety, drug-and alcohol-abuse, and antisocial behavior. It was also found to have a redeeming social value. Ayahuasca has further been established to be relatively non-toxic (Gable, 2007), and safe to use by humans (McKenna, 2004; Callaway, 1999; Grob et al., 1996). In a study by Halpern, Sherwood, Passie et al. (2008) results indicated long-term use of Ayahuasca to have beneficial health effects, especially as regards drug addiction and also as regards general psychiatric health measured as SCL-90-R. The results were statistically significant. No harmful effects could be established in this study that was performed among participants in an American Ayahuasca church. Clinical data in Ibogaine3 research exist as empirical group studies

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and a vast body of anecdotal data stemming from underground therapy networks (Alper, 2008). In 1963, it was unintentionally discovered that a single ingestion of ibogaine effectively terminated opiate craving. Later it also became obvious that this termination of craving in some cases had longlasting effects. Mash et al. (1998) attests to the view that the alkaloid noribogaine from Tabernanthe iboga is responsible for the anti-addictive effects, and that this can be synthesized and given in pill form. Others assert that the visions induced and the personal insights they provide relevant for underlying addictive behavior are necessary prerequisites for successful therapy. Empirical results have revealed that of 33 patients diagnosed with opiatedependence, 76% reported no signs of withdrawal symptoms 72 hours later (Alper et al., 1999). Similar results have been found by Mash et al. (2001). The MAPS-funded therapy research program that is running at the Iboga

Therapy House has currently treated 5 persons, and results are too few to predict any outcome results. In a possible future therapeutic context, it should be emphasized that the mentioned substances are meant as an adjunct to therapy, aiming at providing the therapist with a better clinical platform for further work with the patient. Most therapies will then be substance free sessions, dedicated to integrative work, and focus on resource implementation of more dynamic defense styles, in addition to inducing a greater ability to tolerate ego-dystonic emotional material. It should also be mentioned that some projects are currently running in several countries using other substances than those mentioned above (f ex MDMA and LSD) aiming at the facilitation of such therapeutic work. Mechanism: Reprocessing and integration of emotional material The above results indicate that recent

research on drug-addiction therapy using certain psychedelics point in the same direction that similar therapies did in the 50s and 60s. The question remains: Why do certain psychedelics often have beneficial effects on psychiatric conditions? Winkelman (1995) has argued that these substances and plants effectuate cognitive, emotional and, in turn, behavioral re-processing resulting in integration; therefore he termed them psychointegrators. Anderson (1998) assert that ibogaine effectuate synchronization between the hemispheres. An EEG experiment with Ayahuasca may support these suggestions in the case of Ayahuasca: An EEG pattern was found suggesting hemispheric synchronization as well as a meditative state indicative of mindful awareness of subconscious processes (Hofmann et al., 2001). According to Mandell (1985), generally NOSCs that has been thoroughly worked through, including those induced by psychedelics, will cause better hemispheric co-ordination, thus causing a more integrated relationship between emotional and cognitive facets, which, in turn, will have advantageous behavioral effects. All this is at present speculative, and research will have to further these contentions. Challenges: Clinical work with psychedelics require specialized therapeutic skills Therapeutic work with psychedelics and NOSCs in general brings about the need for specialized therapeutic skills and also presents some challenges. Difficult situations, or psychedelic crises as they are called, are part of the therapeutic potential of the sessions and are generally not regarded as dangerous or negative (Grof, 2001). They may, however, be unpleasant to the person having them, and may therefore call for active therapeutic assistance. Generally, according to Grof, medications are unnecessary and should be avoided. During the therapy, a problem area, a Gestalt, may surface, and this Gestalt should be allowed to finish itself, without resorting to any medications. If so handled, psychological defense

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will in most cases be restored naturally, and the experience will be easily remembered by the patient for later therapeutic work. Depending on the substance being used, this will happen within a few to 24 hours. According to Grof, tranquilizers almost always worsen the condition, especially antipsychotic medications, which tend to close the Gestalt prematurely without restoring defenses properly. This may result in a resurgence of the emerged material when medications are removed, a phenomenon that erroneously often is interpreted as a sign that the patient has gone into a permanent psychotic condition, something that almost never happens (Grof, 2001). The clinical features that emerge in these situations should seldom be regarded as psychotic, but may to the lay clinician, easily present themselves as such. This has led to a need for special training programs

in the handling of psychedelic sessions, and such programs have previously been arranged in Switzerland (1988 to 1993) and is now also under application in the US and in Switzerland (Doblin, 2008, personal communication, 21st of March 2008, Basel, Switzerland). Shamanic traditions have developed their own ways of handling psychedelic crises, and often rely on many years of extensive personal experience with the use of psychedelics as well as many years of training in the handling of such crises. In these traditions the psychedelic crisis is regarded as a process of awakening and also as a healing process. To serve as a helper in such a crisis is an ancient way of relating and is not very different from the relation-based therapies in the west. Emphasis is put on serving as a quiet center and to be mindfully present. Without previous experience with psychedelics it is regarded as
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impossible to meet a psychedelic crisis, an attitude that is shared with the psycholytic western paradigm. It is furthermore important to pay attention to the role of the sitter during the crisis, and priorities should be made to be supportive, to make a supportive and calm space for the emergence and to try to follow the experience. Above all, one should never try to take over the experience by talking or leading in a specific direction. As mentioned, psychedelic crises are usually not dangerous, and will in most cases solve within reasonable time, depending on the substance taken and the type of problem encountered (Grof, 2001). In shamanistic traditions these crises have been known for millennia and they are traditionally regarded as very safe, an observation that goes along well with experiences from western traditions, in which specialists have made similar experiences through clinical work with patients. In a study using clinical data from forty-four professionals that had utilized psychedelics in therapy with psychiatric patients, in only 1.8 cases out of a thousand was a prolonged reaction reported (defined as more than 48 hours) (Cohen, 1960). In groups without psychiatric problems, the prevalence was much lower 0.8 out of thousand treated In these rare cases, professional and responsible therapeutic after-work will, almost always resolve the problem (Grof, 2001). Conclusion There is reason to suggest that NOSCs may be suited for working with emotional material that is difficult to access in the ordinary waking state. This is especially the case when the emotional conflict has been therapy resistant for some time and over several trials with other therapies. There is further reason to believe that the use of certain psychedelics is safe if properly used in clinical settings, supervised by specially trained therapists Clinical psychology and psychiatry are furthermore in need for more effective methods for reaching and working with subconscious

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material. They are also in need for more cost-effective methods. This should argue for the need to investigate the clinical potential of psychedelics.
Footnotes Psychedelic (Greek) = mind-manifesting Ayahuasca means Vine of the Dead. Ayahuasca is usually made from two plant constituents: Psychotria viridis and Banisteriopsis caapi, which contain dimethyltryptamine (DMT) and a series of beta-carbolines respectively. 3 Ibogaine, an indole alkaloid from the plant Tabernanthe iboga. The alkaloid is used ritually in Western Africa, especially in the Bwiti-cult.
1 2

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Yatra-W. M. da Silveira Barbosa (2001). Effects of a Psychedelic, Tropical Tea, Ayahuasca, on the Electroencephalographic (EEG) Activity of the Human Brain During a Shamanistic Ritual. MAPS XI,: 25-30. Hofmann, A. (1979). LSD. My problem child. MAPS-bulletin. Luna, L. E. (1984). The Concept of Plants as Teachers among Four Mestizo Shamans of Iquitos, Northeastern Peru. Journal of Ethnopharmacology, 11, 135-156. Mabit, M. (1996). Takiwasi: Ayahuasca and Shamanism in Addiction Therapy. MAPS 6(3). Mandell, A. J. (1986) Toward a neuropsychopharmacology of habituation: A vertical integration. Mathematical Modelling, 7, 809-888. Mash, D. C., Kovera, C. A., Buck, B. E., Norenberg, M. D., Shapshak, P., Hearn, W. L., & Sanchez-Ramos J. (1998). Medication development of ibogaine as a pharmacotherapy for drug dependence. Ann N Y Acad Sci. 844, 274-92. Mash, D. C., Kovera, C. A. , Pablo, J., Tyndale, R., Ervin, F. R., Kamlet, J. D. & Hearn L (2001). Ibogaine in the Treatment of Heroin Withdrawal. Alkaloids Chem Biol., 56,155-171. McKenna, D. J. (2004). Clinical investigations of the therapeutic potential of ayahuasca: rationale and regulatory challenges. Pharmacology & Therapeutics, 102,111-129. Naranjo, P. (1979). Hallucinogenic Plant Use and Related Indigenous Belief Systems In The Ecuadorian Amazon. Journal of Ethnopharmacology, 1,121 145. Noll, R. (1983). Shamanism and schizophrenia: A state-specific approach to the schizophrenia metaphor of shamanic states. American Ethnologist 10(3), 443-459. Passie, T. (1995). Die Psycholyse in den Skandinavischen Lndern. Ein Historisher berblick. Jahrbuch fr Transkulturelle Medizin und Psychotherapi (pp183-204). VWB - Verlag fr Wissenschaft und Bildung 1996. Passie, T. (2007). Contemporary Psychedelic Therapy: An Overview. In MJ Winkelman & TB Roberts (eds.). Psychedelic Medicine. New evidence for hallucinogenic substances as treatments. London, Praeger Perspectives. Rtsch, C. (1998). Encyclopedia of Psychoactive Plants. Vermont, Park Street Press. Roberts, T. B. (2008). New Horizons: Potential Benefits of Psychedelics for Humanity. Lecture at World Psychedelic Forum, 23rd of March 2008, Basel, Switzerland. Tart, C. T. (1969). Introduction. In C. T. Tart (ed.), Altered States of Consciousness (p. 1). NY, Anchor Books. Tsamani, K. (2008). Ayahuasca: Vine of the Soul, Cord of the Universe. Lecture at World Psychedelic Forum, 22nd of March 2008, Basel, Switzerland. Vetulani, J. (2001). Drug addiction. Part I. Psychoactive substances in the past and presence. Pol J Pharmacology, 53, 201-14. Winkelman, M. (1995). Psychointegrator plants: Their role in human culture, consciousness and Health. In M. Winkelman & W. Andritzky (eds.). Jahrbuch fr Transkulturelle Medizin und Psychotherapie (pp. 953). Berlin, Verlag fr Wissenschaft und Bildung.

Yensen, R. (1995). From Shamans and Mystics to Scientists and Psychotherapists: Interdisciplinary Perspectives on the Interaction of Psychedelic Drugs and Human Consciousness. In M. Winkelman & W. Andritzky (eds.). Jahrbuch fr Transkulturelle Medizin und Psychotherapie (pp. 109-128).. Berlin, Verlag fr Wissenschaft und Bildung. Foto: sxc.hu

Marianne Kaspersen ble uteksaminert psykolog i Bergen hsten 1995. Hun har ogs i overkant at tre r fra medisinstudiet ved samme universitet. I Trondheim har hun arbeidet med forskning, undervisning og ulike former for klinisk virksomhet. I en periode p 3 r arbeidet hun ved NTNU, seksjon for Biologisk psykologi. Hun har ogs hatt undervisningsoppdrag ved andre universitet og er n i ferd med fullfre spesialisering innen klinisk voksenpsykologi. Hun har videreutdanning innen barnefaglig sakkyndighetsarbeid og tar oppdrag som rettsoppnevnt sakkyndig. Hun har tre vitenskapelig publikasjoner i internasjonale tidskrift og flere str for tur. I disse dager leverer hun sitt doktorgradsarbeid: Diagnostikk og prediksjon av PTSD: Muligheter og utfordringer.

Halvard Hrklau er utdannet ved NTNU med hovedfag i biokjemi. Han har undervist bde for NTNU og andre oppdragsgivere i en rrekke. I en periode var han ogs involvert i et forskningsprosjekt innen protein-kjemi, og har i den forbindelse hatt to utenlandsopphold ved University of California - Davis i USA. Han har tre publikasjoner innen proteinkjemi.

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