Bull. Org. mond. Sante 1959, 21, 505-515Bull. 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 mentaldisorder 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 drawnbetween the specific effects of drugs and the effects of the environment itself. Psychotropicdrugs 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 ondrug action-deep insulin treatment and lysergic acid diethylamide. The psychologicalphenomena induced by deep insulin differ according to whether treatment is given individuallyor to a group ofpatients; and the psychological significance of insulin treatment lies inthe ability of the treatment situation to help the patient to become a full member of thegroup. .Similarly the group influences relating to LSD treatment are examined.

It is concluded that the attitude of social groups to psychotropic drugs is determinedby the real or apparent effects these drugs have on super-ego function. This appears tohave some relationship to the so-called placebo phenomenon.

The fact that clinical trials tend to lead to results unduly favourable to the drugs testedis noted and some suggestions are made as to how these trials can be improved.

" Physiological treatment is booming; the past year(1956) has seen a glut of conferences and papers onchlorpromazine, the rauwolfia alkaloids, and thenewer drugs intended to relieve neurotic and psychoticsymptoms. World-wide publicity has stimulated publicinterest and demand, while the indiscriminate use of thedrugs for the common neuroses, conduct disorders,reactive states and depressive states, where they areleast effective, has led to official protests and counter-measures.'

Thus Wortis (1957) summarizes the situationcreated by the inventiveness of chemists in the fieldof psychiatric treatment, concluding:

" The new drug treatments have practically abolishedlobotomies and greatly diminished the need for bothelectro-shock and insulin, although E.S.T. remains analmost specific therapy for depressions."

MODE OF ACTION OF DRUGS ANDTHE PLACEBO RESPONSE

Ancient chemical methods of treatment weredirected towards the expelling of real or suspectedcausal agents of disease from the body. Out of

* Revised revision of a paper submitted to the WHOStudy Group on Ataractic and Hallucinogenic Drugs inPsychiatry, November 1957

1 Consultant Psychiatrist, Powick Hospital, near Wor-cester, England

sympathetic magic and the empirical use ofgalenicals homeopathic medicine arose. Findlay(1950) dates the commencement of modem chemo-therapeutics from the discovery of arsphenamine byEhrlich and Hata in 1910. The great advances inthis field did not occur until the introduction ofprontosil rubrum by Domagk in 1935, rapidly to befollowed by sulfonamides, antibiotics and otherspecifics. Drug therapies can now therefore beclassified as follows:

1. Specific remedies, e.g., penicillin.2. Remedies which modify disease or control

symptoms, e.g., anti-convulsants in epilepsy, insulinin diabetes mellitus.

3. Remedies which modify symptoms, e.g., insulinin schizophrenia, tranquillizers.

4. Remedies which may modify symptoms butare not of proven value.One notices as one descends the list (a) that the

remedies become more numerous, (b) that theiraction is less susceptible to proof by clinical trial,and (c) that their action is more susceptible to group,cultural and other environmental influences. Presum-ably penicillin will cure pneumonia, provided thecausal organism is sensitive, equally weli in anycountry or culture in the world, whereas not only

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is proof lacking concerning the efficacy of mostdrugs used in psychiatric practice but their beneficialeffect varies from one country to another and evenbetween different wards in the same hospital. Theposition is further complicated by the fact that wedo not know how ataractics work. Are they specificslike penicillin, are they modifiers, or do they partiallyreplace metabolic deficits? Nor are psychiatristsclear as to what they are looking for in the searchfor new drugs. North American opinion appears tofavour the old medieval idea of a drug to counteractan alleged toxin (i.e., the search for a hallucinogenicsubstance circulating in schizophrenics and researchinto anti-hallucinogens). Others are content withdrugs which modify behaviour. While so little isknown even as to which of the psychoses are func-tional and which are organic, physiological treatmentmust remain empirical and therefore subject to widefluctuations in its results in different syndromes indifferent places.

HISTORICAL

The remarkable development of drug therapyduring recent years appears to mark the climax ofmany years' development of physical treatments inpsychiatry, which have arisen not perhaps so muchout of conviction or proof that mental disorder isorganic in nature but as a reaction after a centuryof moral, philosophical and psychological treatment.It is also an inevitable by-product of a materialisticand scientific age. Drug treatment in psychiatryrevives the whole question of the nature of mentaldisorders and of group and community attitudestowards all those substances which interfere withcentral nervous activity. Right down the ages manhas looked with mixed fear and fascination uponnatural products which can change his mentaloutlook. Alcohol, one of the oldest, has becomepartially accepted and has gained an uneasy and, insome countries, a highly taxed place in society.Of all the natural products which soothe, excite

or change the psyche, the hallucinogens form one ofthe most interesting and exciting groups. Rejectedby Anglo-Saxons, our knowledge of them has comeonly recently with the medical uses of mescalineand lysergic acid. Wasson (1957) has extensivelyinvestigated the social use of hallucinogenic toad-stools in many cultures and has decided that

" Each Indo-European people is by cultural inheritanceeither ' mycophobe ' or ' mycophile' ". He says, " Thegreat Russians, we find, are mighty mycophiles, as arealso the Catalans, who possess a mushroom vocabulary

of more than 200 names. The ancient Greeks, Celts andScandinavians were mycophobes, as are the Anglo-Saxons. There was another phenomenon that arrestedour attention: wild mushrooms from very earliesttimes were steeped in what the anthropologists call'mana ', a supernatural aura."

From Wasson we learn that " Among the [Ameri-can] Indians, their use is hedged about with restric-tions of many kinds. Unlike ordinary edible mush-rooms, these are never sold in the market place andno Indian dares to eat them frivolously, for excite-ment. The Indians themselves speak of their use as' muy delicado ', that is ' perilous ' ". These empiri-cal observations of Wasson have now been confirmedby the extraction and synthesis of psilocybin byrecent experimental work, which makes it almostcertain that psilocybin is hallucinogenic (see Hoffmanet al., 1958, and papers by A. Cerletti and byA. Hoffman presented at the meeting of the Col-legium Internationale Neuro-Psycho Pharmacologi-cum held in Rome in September 1958).

These observations fit in with our knowledge ofthe use of powerful drugs, amulets or charms inmany societies until recently. Such was the powerattributed to the remedy that responsibility for itsuse was divided amongst the group who gatheredround the afflicted person. In some countries thegroup is also employed to ward off the evil god, heldresponsible for the disease (cf. Pettigrew, 1844).The secrets of the apothecaries and others wereclosely guarded and there was frequent rivalrybetween the medical man and the priest as to whohad the more effective remedy. In the years beforehomeopathy was practised the principle of treatmentwas, according to Culpeper (1653), "All diseasesare cured by their contraries, but all parts of thebody maintained by their likes ". Thus the moreserious diseases were held to be curable only byremedies of an obscure nature which were expensiveand difficult to prepare and which had to be admin-istered by a person of undoubted authority supportedby the utterances of the group with which he himselfwas identified, e.g., by the prayers or incantationsof the people. The Anglo-Saxons do not appear tohave recognized group influences so greatly as moreprimitive peoples in relation to drug-taking. Accord-ing to Wasson the American Indians eating thehallucinogenic mushrooms do so in a group and donot themselves expect a curative effect; they onlyask a question and expect a prophetic answer. Thusthey frequently take the mushrooms for advice whensomeone is ill. This ritual has something in common

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with the Chinese casting of hexagrams mentionedin the I Ching, in that the particular time at whichthe experiment is carried out is important, a groupof people must be present, and a definite questionmust be asked. As to how the answer is given, it isclear that the primitives believe that the gods speakto them through the mushroom. We might say inthe language of contemporary psychology that thearchetypes are raised into consciousness as hallucina-tions or ideas which can be communicated to others.Wasson reproduces a Mexican drawing of thesixteenth century in which there are three mushroomson one side, a man eating them in the centre and agod behind him, who is speaking through themushroom. This, in passing, is exactly what onefeels about the action of LSD (lysergic acid diethyl-amide)-that it compels the unconscious to speakand that the archetypes appear in consciousness inthe form of images, thoughts, feelings and sensationswhich are strange and unusual but which arenevertheless part of the subject concerned.

It is likely that in ancient times the use of drugswas attended by a group, and that the individualstaking part had to expend some effort, mental orphysical or both, if the value of the substance wasto be realized. Dale (1957) points out that thecurative value of drugs in the sixteenth to eighteenthcenturies was proportionate to their rarity, value ordifficulty of preparation, and this must be an indica-tion of the psychological power inherent in thepreparations. One can therefore see the necessityfor the group being present, dissolving the magicalpower of the drug lest it should prove too dangerousfor the patient. In ancient legends the more effectivedrugs were also dangerous to life. Now these samedrugs or their modern equivalents have becomedebased, sold in vast quantities over the countersof chemists' shops, or worse, dispensed for next tonothing on the doctor's prescription, demandingfrom the patient no effort for their collection orpreparation and no contribution from him oneither a psychic or social level while under theirinfluence.

It might therefore be helpful at the present timeto write down a little of what we know about theeffects of drugs in relation to the group influenceswhich surround the patient. The drugs which weare about to consider are called psychotropic, thosewhich alter the state of mind of the patient. Theymight therefore be supposed to carry great " mana"value and we should expect their action to beunusually susceptible to group influences.

PSYCHOTROPIC DRUGS AND THE ENVIRONMENT

It is well known that the action of certain drugswhich modify central nervous activity varies accord-ing to the mood of the individual at the time andaccording to the environment. For example, thestate of mind induced by alcohol in the solitary andsecret drinker is usually different from that observedwhen alcohol is taken socially. It is not certainwhether this difference is related only to the tempera-ment of the individual, but one suspects that theenvironment also plays its part. Environmentalconditions under which psychotropic drugs are givenhave hitherto largely been a question of expediency.For example, insulin coma treatment is usuallyadministered to patients in a group, whereas LSDis almost invariably given to a patient who isconfined to a single room. Little attention, untilrecently, has been paid to the different conditionsunder which tranquillizers are administered.

In the field of neuropharmacology evidence isbeing collected concerning the existence of neuro-humoral transmitters within the central nervoussystem and it is being suggested that the brain stemand mid-brain reticular arousal systems are peculiarlysusceptible to external stimuli conveyed throughreceptor mechanisms. Experimental evidence isaccumulating which suggests that those drugs whichact on the brain stem and mid-brain structures withtheir associated nuclei may be modified by sensoryimpressions.' There is already much clinical evidenceto support this. We know that LSD phenomenacan be modified by the extent to which the patientconcentrates on his environment. For example, ifa patient is asked to read an interesting book fol-lowing a dose of LSD the psychic manifestations ofthe drug can be entirely inhibited. Concentrationon manual tasks or irrelevant conversation withanother person can also inhibit them. On the otherhand, the presence of another person who remindsthe patient of a psychological situation can intensifythe reaction. This intensification is best seen in thecase of paranoid patients. The author has foundthat the production of repetitive and irritating noisesclose to the room in which such a patient is havingLSD can arouse him to a great intensity of fury andhostility. In one case a faint whistling noise fromsome nearby machinery brought back war-timeexperiences. Excitation of the sense of smell hasbeen found to be a powerful stimulator of emotion-ally charged memories.

1 Elkes, J. Address to the Section of Psychiatry, Birming-ham Medical Institute, 1957

R. A. SANDISON

Bannerjee (1957), most of whose work has beendone in Calcutta, believes that the efficacy of theRauwolfia alkaloids is much enhanced by grouptherapy of an active kind carried out when a patientis taking the drug. He believes that Rauwolfia hasa specific effect on paranoid and confused mentalstates. One method of demonstrating this is todevise group games in which patients are compelledto make some positive contact with each other; towork as teams and to trust each other. He reportsnot only that the patients undergoing Rauwolfiatreatment lose their suspicions when these methodsare applied but that the degree of co-operation ismuch greater in those groups receiving the Rauwolfiaalkaloids.

DEEP INSULIN TREATMENT:INFLUENCE OF THE GROUP

For several reasons deep insulin treatment maybe taken as a model for examining the role ofpsychotropic drugs in group therapy. The treatmenthas been widely practised for over twenty years.The patients are almost invariably treated in a groupunder conditions which are favourable to a studyof the psychological factors at work both in thepatients individually and in the group as a whole.Although it is generally held that insulin is a purelyphysical method of treatment, there are some whosay that the good results achieved by insulin areattributable only to the individual attention andresocializing effects resulting from the patients livingin a small group and being looked after by a rela-tively large number of staff. The truth, however,would appear to lie midway between these, sinceclose study of an insulin group reveals that thepatients are capable of producing a great deal ofsignificant psychological material. Few observersappear to have noticed this. Close questioning ofthe patients reveals, however, that they do have themost interesting fantasies, which at first concernonly themselves but which subsequently concernthe rest of the insulin group, and if this latter occursit is invariably associated with clinical improvement.One of the best examples of this, in my experience,concerns a young girl who at the beginning of theinsulin treatment had a childish fantasy duringrecovery that she was playing with a ball. Withina few days the fantasy extended to the doctor andshe had an idea on waking that she was playingtennis with him. Finally all the patients were drawninto this game, the patient thinking that she was

throwing the ball round to each one in turn. Thiscoincided with clinical improvement. The criticalpsychological phase for a patient undergoing deepinsulin treatment is during the period of recoveryfrom the coma, and one not infrequently findspatients who are afraid of dying during this periodand who experience a great struggle to come toconsciousness again. There are other patients whoobject to being brought out of the coma, preferringto remain out of touch with the realities of life, andthis is usually associated with a bad prognosis.Many patients describe the insulin experience asunpleasant, like dying. One of my patients cried outloudly and screamed against death, but at the endof the struggle she saw an urgent need to live anda great impulse came over her to eat and she stuffedquantities of food into her mouth almost to thepoint of choking. Another patient on waking fromcoma every day would think she was dead; thiswent on for weeks without any change, and thepatient said " Now I take it for granted that I amdead ". Another patient thought she had had aserious operation during treatment; that she wasdead and the process of restoration to life was toohard to go through. The interest of these deathexperiences lies in the fact that they are not entirelyindividual, for sooner or later the patient becomesconcerned about the other members of the group.I had one patient who insisted on being broughtround from coma before any of the other patientsbecause she felt that she could then watch overthem and assist in their recovery. Another patientwas convinced that I was giving insulin to the otherpatients to make them die and on one occasionactually tried to prevent me from giving the injection.Another patient in the course of a group meetingexpressed much the same idea, saying " Why do youput them in a coma? You must be hurting them ".There are psychological reasons for believing thatthe overcoming of the death experience and of thestate of regression induced by insulin are factorsof great importance in the patient's recovery. It iswell known that both animals and human beingsunder the influence of danger tend to congregateinto groups and that this has the effect of diminishingthe individual fear of death. There is thereforeevery reason to believe that the gathering of patientsundergoing insulin treatment into a group is a mostdesirable thing.Another type of experience frequently observed

amongst those undergoing insulin treatment may bedescribed as the experience of initiation or re-birth.

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This phenomenon has been well described by Scott(1950). Initiation ceremonies amongst primitivepeoples are carried out with the support of the wholegroup and they are presided over by the seniormembers of the community. A study of primitiveinitiation ceremonies shows that their chief objectis to mark the physical and psychological passagefrom one way of life to another. In the Arapeshsociety, where the girls as well as boys go throughan initiation ceremony, there is no change in theway of life of the girls before and after the ceremony.They have already been betrothed to their husbandsat the age of 7 or 8 and usually for four years orso have lived in their husbands' households, assistingthe women with their tasks. The true psychologicalsignificance of the initiation is, therefore, seen bestin the case of the girl in that she is initiated into thebeing of another woman. In Greek mythology thefigures of Pallas Athene, Artemis and Persephonegive us some idea of the threefold nature of womanas an ideal image (Karenyi & Jung, 1951). Jungremarks that this image in the man is the anima inits various forms, but in the woman it is the super-ordinate personality, the one which she has to exper-ience and come to terms with before she can con-sider herself initiated into the completeness ofwomanhood. Among the women of western Europethis process of psychological immaturity is commonand is seen in neurotics, particularly hysterics, andalso in schizophrenics. Among the schizophrenicsthose who are married with children of their ownare psychologically undeveloped and are still child-ren at heart. This is demonstrated by the fact thatschizophrenia, particularly in the female, is likelyto follow a love affair or to occur shortly aftermarriage or childbirth.One example can be given of the need for the

group. A female patient, 28 years of age, marriedand with a child, had a schizophrenic breakdownin which she thought she was being hypnotized.She was confused, aggressive and restless. As shewas so disturbed insulin treatment was carried outin a single room. She became progressively moreregressed, incontinent and degraded. She laterexplained that she believed there were three dragonson one arm and three on the other which weretrying to make her completely insane. Her remedywas to retreat into infancy so that she becamechildish and incontinent and she actually believedherself to be taking refuge in the womb. As soonas she was transferred to the insulin room shestarted to recover. She had a fantasy that on recovery

from treatment the bed-clothes became like a tunneland that she was born over the end of the bed. Wecould not help being impressed by this change afterthe patient was removed from the isolation of thesingle room.

Jung, analysing the different forms of re-birth,considers that the re-birth or transmutation exper-iences of groups sharing a common experience area form of identification with a group and that thisis something entirely different from experiencing there-birth in oneself. These insulin experiences seemto be both; there is evidence that the transmutationexperience is personal and that the group is requiredboth for its completion and its performance.Another female patient, after 34 comas, had an

idea that those undergoing insulin treatment couldnot endure legal marriage and that they either hadto experience natural unions or else remain virgins.This patient, herself married, felt after the next comathat she was no longer married; that the group andher husband were mutually exclusive. She said itwas like being married to the group instead of tohim. In the 36th coma this notion was developedand she feared that the treatment had turned herinto a harlot. We have, therefore, in this experiencethe chief feature of the initiation rites-namely, thesubjection to those in authority, the pain and dis-comfort of the treatment, the segregation in hospital,the emergence into the group and the acceptanceof the patient when he is better as a more adult andbalanced individual. One may conclude that theseresults can be obtained only through giving the drug,in this case insulin, to the patients as a group. Thephenomena can quite easily be demonstrated andworked out by anybody who cares to look for them,and it seems unfortunate that studies on the effectsof insulin treatment have not included any com-mentary on these important psychological factors.Whether insulin is the only method of bringing outthese phenomena remains to be seen. Leyton (1958)has recently reported on the treatment results intwo identical groups, one of which received distilledwater injections and the other insulin. The resultsin the two groups were similar. Furthermore, sheadds in a personal communication, some of thepatients in the placebo group thought they had beenin coma after the injections.

LYSERGIC ACID DIETHYLAMIDEAND GROUP THERAPY

This raises the whole question of the circum-stances under which lysergic acid diethylamide (LSD)

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should be given. For a considerable period theauthor met a number of patients undergoing LSDtreatment as a group, when they were not under thethe influence of the drug. In the case of these LSDpatients the basic material was much the same asthat obtained from neurotic groups not having LSD.Men and women were mixed and they were roughlywithin the 20-40-year age-group. Patients fromseveral different therapists formed the group,including the group leader's own patient's. It must benoted that in a community where some of its mem-bers are taking LSD there is an immediate tendencyfor the subjects to get together and to discuss itseffects. This has been noticed many times amongvolunteer groups, who immediately form themselvesinto a kind of club among whom the sole topic ofconversation is LSD. This was immediately noticedamong the patients in the hospital. All the malein-patients were in a ward of about 30, most ofwhomwere recent cases, neurotic and early psychoticcases being mingled. The women in-patients werein a ward of about the same size, but in their casethe majority of the patients were psychoneuroticwith only occasional cases of early or convalescentpsychoses. Some patients were being treated asout-patients and these either came in for the day orstayed in hospital for one or two days of each week.These patients also joined the group. It was noticedquite soon after we started giving LSD to patientsthat this tendency for them to get together anddiscuss their experience was strongly present.Furthermore, we found that patients having treat-ment on a particular day often liked to have anotherpatient with them who had received treatment on adifferent day. Nevertheless there grew up a greatdeal of rumour and mythology concerning thetreatment, particularly among those about to receiveit or in the early stages of treatment. Several of thepatients thought that it was a necessary part of thetreatment that they should show uninhibited be-haviour such as screaming, breaking windows,tearing up clothes, etc. This atmosphere of rumourwas the chief reason for forming the group, on thegrounds that knowledge is the best dispeller of fearand anxiety. Important differences were observedbetween this group and the group to whom no drugswere being given. The patients in the LSD groupwere not only bound by the common experience ofneurosis, which to many patients is something theywould prefer to be without, but they were boundby the much more whole and telling experience ofLSD. Such patients are subject to fear and rumour,

and because of the intensive nature of the treatmentthere is a greater sense of urgency and a greaterdrive towards endeavouring to solve psychologicalproblems.

In the early stages of the experiment it was neces-sary for the therapist to take a more active role thanusual as the one who could explain the treatment.The author came to the conclusion that the techniqueswhich were used were only partially successful insolving the problems presented by this kind of group.For example, if one included one's own patients inthe group the others regarded them as speciallyprivileged and on occasion openly accused them ofinventing material. Discussions on transference wereexceedingly difficult; those patients belonging toother therapists started maintaining that transferenceproblems did not exist and expressed great surprisethat any of the therapist's patients could have otherthan purely professional feelings for him. Whenthese patients were removed from the group trans-ference difficulties continued to arise, the patientsbeing inclined to compare one therapist unfavourablywith another; this was good in its way, but it mustbe remembered that the techniques of giving LSDwere still in their early stages and the therapist wasalways in a difficult position where he felt that themethods of a colleague ran contrary to his own ideas.It was concluded that the best solution was for thetherapist to see only his own patients, but this wasnot entirely satisfactory as it was felt that much ofthe point of group therapy was thereby lost. Thepatients tended to take a less serious view of thegroup sessions and to withhold more intimateinformation on the grounds that this could betterbe discussed in private. The biggest problem, how-ever, was the development of a group neurosis whichrevealed a marked psychological inflation in thepatients. They tended to become highly introspectiveand spent more and more time trying to work outproblems which were insoluble. It is true that allthese difficulties provided important material for thetherapist and naturally they were discussed with thegroup. It does seem that this combined individualand group therapy can go on only for a few weeksat a time, and it is best to break up the group everyeight or ten weeks and start again three or four weekslater. This fact has led the author to the idea thatLSD treatment should be carried out after thefashion of school terms and holidays as they arenormally thought of in England, with three holidaysa year of from four to eight weeks' duration. Someof the patients never became absorbed into the group

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and these were usually those with rigid, obsessionalpersonalities who produced little material duringthe LSD sessions. These patients usually felt on thefringe of the group, but they derived a certainamount of help from other members.One should now consider the benefits to be derived

from this method of group therapy. Although it hasbeen held that a group of patients taking tranquil-lizers would have their aggressive feelings dampeddown to such an extent that the object of grouptherapy and the bringing out of latent aggressionwould be frustrated, in this group the reverse holdsgood. In fact, the problem is to know how to dealwith the breaking down of the resistance againstaggression which occurs during LSD treatment.In some patients it is noticeable that their aggressivedrive is put to use. For example, one patient in thecourse of treatment gave up a routine job andstarted his own business, although it was interestingto observe that his chief problem-namely, the lackof sexual ability-was unchanged. This conversionof aggression into other channels yet missing itsmain object is one of the great problems of LSDtreatment, and when carried a stage further aggres-sion becomes converted into anxiety, bodily symp-toms, often of a severe nature, depression andsuicidal impulses. In my view this material can besatisfactorily dealt with in the group, and somepatients who might have been forced to give upLSD treatment were undoubtedly helped to continue.

FUTURE RESEARCH ON INSULIN AND LSD GROUPS

One might appropriately here put forward a fewsuggestions about the future study of insulin andLSD groups, for both treatments require much basicresearch. Insulin treatment has been practised for21 years in many countries; a great many reportshave been published concerning the results, andlong-term follow-up studies have also been carriedout. The most these studies tell us is that a definitepercentage of schizophrenic patients are improvedas a result of the treatment and that in all probabilitythe remissions obtained are superior, both in theirquality and in the length of time they can be sus-tained, to other known methods of treatment.Although evidence has been collected that the long-term use of the phenothiazine drugs may be a closerival to insulin treatment, nevertheless there is nodefinite evidence that the immediate recovery ratewith insulin treatment is superior to other acceptedmethods, including such methods as occupational

group and individual therapy. It is of the utmostimportance that further studies on insulin shouldpay attention to the group aspects of the treatment.Quite apart from the urgent need to study com-parable groups of patients receiving insulin andother forms of treatment, there is a great need todivide the insulin patients themselves into twogroups. In one group the insulin should be givenpurely as a physical method, and in the other thepsychological material should be studied and dis-cussed with the patients at group therapy sessions.Similarly with LSD there is a great need to studythe precise effects of group influence on the treat-ment, and here a rather similar programme shouldbe carried out. Research into LSD groups should bedirected towards making studies on the behaviourof patients. Too little is known about the type ofreaction to LSD in relation to the personality of thepatient. The influence of others on the inhibitionor reinforcement of the LSD experience also needsinvestigation. All the material requires classificationand analysis before we can come to understand thebest way to use this and allied drugs. Only thenshould we be in a position to carry out controlledclinical trials which will accord or deny LSD aplace in the psychiatric armoury.

ATARACTICS AND GROUP THERAPY

The next question concerns the role of the tranquil-lizing drugs in group therapy, and here we mustconfess that much less is known and that there isgreat scope for further experiment. The attitude ofthe general public, patients and staff towards thetaking of what they usually refer to as drugs mustfirst be considered. Certainly in England there aredeep-rooted prejudices against long-continued drug-taking unless it can be clearly shown, as, for example,in the insulin treatment of diabetes, that the drug-taking is essential to life. Even among epileptics,who know quite well that the anti-convulsion drugswill stop the fits, there is a tendency to discontinuethe tablets. This is not just laziness on the part ofthe patient. We can see evidence of the emotionalcontent of people's attitude towards drugs when weconsider tobacco and alcohol, the evil effects of bothof which are frequently exaggerated. Some drugsof addiction have particularly severe sanctionsapplied to their use. The same kind of prejudicesare involved when patients are advised to take drugsfor the treatment of mental and neurotic disorders.The very term " tranquillizer ", conveying freedom

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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 tosive and disinhibited. acceptance.

Barbiturates Diminishes super-ego control; tranquillizes ego in small Widespread addiction; limiteddoses; may increase unconscious contents. condemnation.

Minor Tranquillizes ego; may diminish super-ego control. Widespread addiction; limitedtranquillizers 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; generalstrengthening of super-ego control. anxiety and religious criticism

more usual.

Morphine group Increases flow of unconscious material; permanent Almost universal condemnationdamage to super-ego if long continued.

from anxiety, leads, in people's imagination, to theidea that those taking tranquillizers will have adiminished sense of moral responsibility. It haseven been stated that sexual perverts taking thesedrugs will be able to continue their perversionswithout feeling guilty about them. It is probablethat the word " tranquillizer " is a misnomer, butso far a more satisfactory term has not been intro-duced. Lastly, it is not surprising that many patientsobject to taking drugs over a long period andfrequently tell their doctor that they have tried toleave off the tablets. One occasionally meets patientswho say that the tablets made them feel worse.Others fear that tolerance and addiction maydevelop. Chlorpromazine, in particular, is inclinedto cause feelings of anxiety in patients with activesympathetic systems, yet the fact remains thatsedative drugs of various kinds are consumed byWestern communities in enormous quantities, andthe impact of this drug-taking on groups of variouskinds is by no means clear.

It may be interesting to try to tabulate the psycho-logical effects of some drugs and to correlate socialattitudes towards them; this is done in the tableabove.Thus the attitude of social groups to psychotropic

drugs is determined by the real or apparent effectsthese drugs have on the super-ego function. Peopleare less concerned by the effect of the drug onunconscious activity unless this leads to psychosisor suicide, both of which possibilities lead totherapists fearing to use LSD and which areoccurrences the frequency of which has beenexaggerated.

Among hospital groups one begins to get an ideaof the factors involved. I have tried the experimentof taking ten patients in a ward of thirty patientsand putting them all on one of the phenothiazinedrugs and observing them closely both as individualsand as a group. The first thing to notice when thesegroups are started in various parts of the hospital isthat the response to treatment appears to dependto some extent on the attitudes of the nursing staff.Some nursing staff are very enthusiastic about drugtreatment. Others, more prejudiced against the useof drugs, will regard such groups as just anotherwhim on the part of the doctor and there is no doubtthat these patients do not do so well. Therefore oneimmediately has a situation in which both directlyand unconsciously the patients are influenced by theenvironment. The psychological forces which bindthe LSD group together are largely absent, but onefinds that in those cases where the nursing staff areenthusiastic the patients on the treatment gain asense of importance, and in such wards requests arereceived from other patients to be allowed to takethe drug. These matters are of the greatest import-ance and should be discussed with the patients as agroup, and these group discussions require to becontinued after the patient has left the hospital. Ifdrugs are to be given with any benefit to schizo-phrenics they should be continued for a long time,perhaps for years. Long-term drug therapy occa-sionally meets with resistance from relatives and fromthe general practitioner, and it may be not only thatthe treatment should be discussed with the patientsas a group but that groups of general practitionersand other interested people should get together to

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PSYCHOTROPIC DRUGS IN GROUP THERAPY

consider the relationship of drug therapy to mentaldisorder. About two years ago we had a large groupof patients taking a phenothiazine compound knownas NP 207. This substance was superior to any

known drug in the phenothiazine group, but un-

fortunately its use had to be discontinued owing tothe development of eye changes in some patientsreceiving large doses. We were therefore forced tochange over to chlorpromazine for some of thepatients who were unable to discontinue takingdrugs altogether. Many of these patients showedmarked symptoms of anxiety and some for a timeeven had pseudo-manifestations of their originalpsychosis. Although these cases were dealt withindividually, they could probably have been dealtwith better and more expeditiously by getting themtogether as a group and discussing the meaning ofthe symptoms and of their anxieties. Thus one

would appear to be coming to the stage wherepatients undergoing long-term drug therapy shouldbe seen in groups, but again the kind of materialone must expect to obtain must differ from that ingroups not receiving any other form of treatment.It is possible that the phenothiazine drugs diminishdream and fantasy material. The first changes tobe observed when phenothiazines are given toschizophrenics are reduction' of thought disorder andhallucinations, and it is only later that the affectivestate of the patient undergoes improvement. Thefunction of group therapy should therefore bedirected towards improving the affective life of thepatient-a role for which it is particularly suited.This no doubt accounts for the more rapid rate ofimprovement among those patients undergoinggroup and occupational therapy.

Foulds (1958) has reviewed recent drug trials on

both sides of the Atlantic and has drawn attentionto the misleading results to be obtained from clinicalimpressions. Uncontrolled studies are of little, ifany, value and may lead to clinically ineffectivesubstances being given to psychotic patients forwhom there are more efficient remedies.The clinical results obtained with new drugs

diminish as time goes on, and there is no reallysatisfactory explanation of this unless we accept thepsychological power which new remedies subtlyexert over the judgement of the investigators. Howelse can we account for the world-wide enthusiasmwhich was accorded to cortisone in the treatment ofrheumatic disease when it was introduced ten years

ago, while later clinical trials show it to be no betterthan aspirin? Sakel's early work with deep insulin

treatment gave a recovery rate in schizophrenia of80%, a figure never since approached, while recentstudies (Ackner et al., 1957) have suggested thatthe results may be no better than those obtainedwith amylobarbitone. Not only are we in the darkconcerning the usefulness of many psychiatrictreatments which are introduced as " specific"for certain syndromes, but even the most elaboratelydesigned clinical trials have frequently failed todistinguish between remedies which offer an advanceon their predecessors and those which do not. Baker& Thorpe (1957) review the literature in which inerttablets and active substances, when compared, hadthe same action. They report an experiment in whichthe inert tablets led to a favourable response notobserved with the so-called active drug. The authorsattribute this, in part, to the fact that the placebo wassugar-coated. " Thus in terms of total experience,our control group received several small sweets dailyfrom the nurses while the other group received abitter pill." A number of suggestions follow as tohow these environmental influences can best beestimated or limited.

Suggestions1. Most clinical trials lead to results unduly

favourable to the drugs being tested for three mainreasons.

(a) The spontaneous improvement rate of a similargroup of patients is not estimated accurately.Remedy: controlled trials, "double blind" pro-cedure etc., but even these trials may favour drugaction.

(b) The methods of measuring improvement areinadequate and are susceptible to conscious orunconscious bias on the part of the observer.Remedy: better rating scales and improved designof trial (Rashkis, 1957).

(c) The trial is influenced by the " placebo"response. Remedy: Research is still required butthe following suggestions are put forward. First,the pressure from drug manufacturers on cliniciansto carry out rapid clinical trials should be resistedat all costs. The patients should be on placebos forweeks or months before the drug is introduced.Before a controlled clinical trial is carried out thestaff should learn how to use the drug and get someidea what can be expected of it. The editors ofmedical journals should insist that authors haveused the drug for at least a year before their paperis accepted for publication. Secondly, the first fewclinical trials at any one hospital must be regarded

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with suspicion because of the placebo response.Thirdly, group meetings must be held in wardswhere clinical trials are going on, and the attitudeof the staff and patients towards the trial must beascertained. All the uncertainties and errors inclinical trials at mental hospitals or out-patientclinics lie within the emotional lives of the staff, andthe operating factors should be clearly stated. Thesize, training and personality of the staff must beassessed, the daily lives of the patients studied, thefrequency of parole and leave, etc., compared. Howthese factors can be assessed is difficult to say, andwhether anyone would accept the loading of theresults according to the group situation in the wardis doubtful. Nevertheless, until more objectivestudies of the social factors surrounding a clinicaltrial are published alongside the clinical results, datawill be lacking on the real efficacy of the drugs, andpsychiatry will continue to be bewildered by analarming confusion of new drugs.

2. The most favourable results of clinical trialsare obtained in backward hospitals or in wardswhere little effort has been made to resocialize thepatients. In some mental hospitals (e.g., WarlinghamPark, England) nearly all the social benefits achievedelsewhere by ataractics have been produced bygroup therapy, and the advocates of the open-doorsystem and rehabilitation claim that drugs are un-

necessary (Rees, 1956). The more severe critics ofintramural socializing programmes state that thepatients have become in a way more institutionalizedbecause the hospital has come to depend on themfor its social structure and for much of its labour forcarrying out routine tasks in the hospital. Manyfeel that paid employees should carry out the workof the hospital and that the doctor-patient relation-ship should be directed towards healing the mind.When as much as possible has been done in hospitalthe patient should be returned to the communitywhere, if necessary, treatment can be continued.In other words, what is done inside some hospitalsby rehabilitation and occupational therapy shouldbe done outside the hospital by the communityassisted by social workers and psychiatrists.One must conclude from these observations that

the occupational programme for the ward must bestatic for a drug trial to be of any value. So oftenthe patients who improve are given more stimulatingforms of occupation. This tendency must either beresisted or reliably assessed.Only by attention to all these factors and possibly

many others, can Wortis's claim made at thebeginning of this paper that " new drug treatmentshave practically abolished lobotomies and greatlydiminished the need for both electro-shock andinsulin . . . " be reliably measured.

RItSUMIt

L'auteur de l'article se propose d'examiner ceux desaspects du traitement pharmacologique des troublesmentaux qui sont en rapport avec le milieu humain oule groupe social dans lequel le malade se trouve place. I1rappelle que les medicaments psychotropes sont desor-mais d'un emploi generalise et passe en revue les effetsqu'ils sont censes produire. A l'origine, on utilisait desdrogues et autres substances medicamenteuses poureliminer de l'organisme des agents pathogenes reels ousupposes; leur usage se situait dans une atmospheresociale de caractere rituel et empirique. La chimio-th6rapie des maladies physiques ne date que du d6butdu present siecle; appliquee aux troubles mentaux, elleest plus recente encore et les produits employes manquentde specificite. I1 convient d'examiner les raisons del'interet considerable porte A la pharmacotherapie, Ala fois manifestation inevitable d'un Age scientifique etreaction contre un siecle de traitements moraux et psy-chologiques. La psychoth6rapie a d'ailleurs conserve saplace et elle a ouvert la voie A l'emploi de medicamentstels que le diethylamide de l'acide lysergique (LSD), qui,

bien qu'incontestablement substance chimique, produitdes troubles presque exclusivement psychologiques.

11 existe heureusement un exemple historique: celuides Indiens du Mexique, qui utilisaient un champignonhallucinogene. On notera A ce propos que, primitivement,l'habitude de consommer ce champignon, le milieuhumain et la structure sociale etaient etroitement lies.Les faits exposes montrent qu'en cas d'administration deLSD, le milieu exerce une influence d6terminante surle type d'experience psychologique vecu par le maladeet que les rapports de ce demier avec autrui peuventmodifier profondement le contenu de cette experience.On a egalement constate que Rauwolfia serpentina

produit un etat de detente qui rend le malade plus acces-sible aux influences du groupe humain.Des indications ici presentees, il ressort que l'insulino-

therapie A forte dose provoque chez le malade un nombreremarquable de phantasmes, dont la production atteinten general son maximum d'intensite au moment ou lemalade sort du coma. L'effet est diff6rent suivant que lemalade est traite isolement ou avec d'autres sujets. En

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PSYCHOTROPIC DRUGS IN GROUP THERAPY 515

outre, il y a lieu de penser que cette production de phan-tasmes reste d'une portee assez limitee si d'autres maladesne sont pas egalement presents. L'auteur souligne l'ana-logie de la guerison des psychoses par insulinotherapieavec les rites d'initiation primitifs et les phenomenes dere-naissance. I1 donne quelques exemples des phantasmesde femmes appartenant a un groupe de malades traitespar l'insuline. D'une fagon generale, pendant la phaseinitiale de ce traitement, le phantasme consiste en uneregression du malade a un stade infantile d'extreme de-pendance, d'oii il sort transforme et renait au sein dugroupe, individu maintenant rattache aux autres malades.Au stade final de la cure, le malade quitte le groupe; letraitement acheve, il a recupere son independance. Desconsiderations analogues s'appliquent au traitement parle LSD.

L'article presente des observations sur une th6rapiede groupe appliquee a un certain nombre de maladestraites chacun par le LSD. Cette therapie de groupeavait pour objet d'eliminer les rumeurs, de resoudre lesproblemes de transfert et d'integrer les nouveaux sujetsau groupe. Le groupe confere egalement une certaineprotection aux malades contre les effets de l'effondrementde la resistance, qui est un el6ment important et inevitabledu traitement par le LSD. L'auteur examine le role destranquillisants dans les therapies de groupe; il cons-tate que les lacunes de nos connaissances sont particulie-rement nombreuses dans ce domaine.

Les attitudes sociales A 1'egard de la pharmacotherapieont une grande importance et l'article etudie celles quise manifestent a 1'egard de substances aussi differentesque I'alcool, les barbituriques, les tranquillisants, leshallucinogenes et les composes du groupe de la morphine.I1 estime que I'attitude des groupes sociaux envers lesmedicaments psychotropes est determinee par les effetsreels ou apparents de ces medicaments sur le fonctionne-ment du surmoi. L'attitude du personnel infirmier a1'egard des tranquillisants est passee en revue, et l'auteurconclut que l'emploi de ces medicaments ne peut donner debons resultats a 1'h6pital que si la therapie de groupe impli-que la double participation des malades et du personnel.

Ces remarques conduisent a l'examen des methodesqui servent A apprecier l'efficacite des tranquillisants.En raison des prejuges collectifs et individuels, lesetudes faites sans groupe-temoin sont A peu pres depour-vues d'utilite et peuvent meme etre nuisibles aux malades.L'auteur conclut donc que tous les essais cliniques doi-vent etre controles et que le point faible de ces essaisreside dans la methode utilisee pour apprecier l'evolutionde l'etat du malade. I1 faudrait etablir des echelles declassement plus satisfaisantes; en outre, le milieu danslequel le malade est traite devrait etre attentivementsurveille et demeurer stable pendant toute la duree desessais. C'est seulement en veillant a ces details qu'ilsera possible de confirmer ou d'infirmer les vertus consi-derables attribuees aux nouveaux medicaments.

REFERENCES

Ackner, B., H:v(s, A. & Oldham, A. J. (1957) Lancet,1, 607

Baker, A. A. & Thorpe, J. G. (1957) Arch. Neurol.Psychiat. (Chicago), 78, 57

Banerjee, S. (1957) Psycho-Therapy, 1, No. 3, 2Culpeper, N. (1653) The physician's library, LondonDale, H. (1957) Brit. med. J., 2, 423Findlay, G. M. (1950) Recent advances in chemotherapy,

London, Churchill, vol. 1.Foulds, G. A. (1958) J. ment. Sci., 104, 259Hoffman, A., Heim, R., et al. (1958) Experientia (Basel),

14, 107

Jung, C. G. (1940) Verschiedenen Aspekte der Wieder-geburt. In: Eranos Year Book, Zurich, Rhein Verlag

Karenyi, C., & Jung, C. G. (1951) Introduction to ascience of mythology, London

Leyton, S. (1958) Lancet, 1, 1253Pettigrew, T. J. (1844) Superstitions connected with

medicine and surgery, LondonRashkis, H. A. & Smarr, I. R. (1957) Arch. Neurol.

Psychiat. (Chicago), 77, 202Rees, T. P. (1956) J. ment. Sci., 103, 303Scott, R. D. (1950) Brit. J. med. Psychol., 23, 15Wasson, G. (1957) Life, issue of 10 June, p. 45Wortis, J. (1957) Amer. J. Psychiat., 113, 611

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