The Combination of Psychedelic and Aversive Approaches in Alcoholism Treatment:
The Affective Contra-Attribution Method

ABSTRACT. The “Affective Contra-Attribution” method of alcoholism treatment consists of three stages: (1) an introductory psychotherapeutic stage; (2) psychedelic treatment with ketamine utilization; and (3) therapist led group discussion of the patients' psychedelic experiences. The stages of psychedelic treatment include psychotherapeutic dialogue with the patient within the context of the negative hallucinatory emotional experiences induced pharmacologically by subanasthetic ketamine doses in combination with bemegride and aethimizol. This method of treatment is compared to a more traditional form of therapy and the outcome indicates that the ACA method is more effective.

Authors Krupitsky, Grineko, Berkaliev, Paley, Tetrov at the time were affiliated with The Leningrad Regional Dispensary of Narcology, Novo-Deviatkino, 19/1, 18861, USSR; Authors Mushkov and Borodkin were affiliated with the Department of Pharmacology, The Institute for Experimental Medicine, Academy of Medical Sciences of the USSR, Leningrad, 197022, USSR.

Correspondence should be addressed to E. M. Krupitsky.

Alcoholism Treatment Quarterly, Vol. 9(1) 1992
© 1992 by The Haworth Press, Inc. All rights reserved.

INTRODUCTION

Traditional methods of aversive therapy are oriented towards creating negative associations between the use of alcohol and undesirable physical effects. Such approaches leave the attitudes of the alcoholic untouched. Psychedelic therapy for alcoholism seeks to change an individual's attitude towards the use of alcohol but fails to imprint negative associations around the use of alcohol (Smith, 1964; Smith and Seymour, 1983). The Affective Contra-Attribution (ACA) combines both of these approaches and attempts to limit the side effects and shortcomings of both. A ketamine induced anesthetic, in combination with bemegride and aethimizol, produces strong negative emotions towards alcohol in the context of a bright hallucinatory experience; this forms the basis of ACA method. These negative experiences are connected with the use of alcohol and with the alcoholic's life style.

METHODS

In the first stage of the procedure, the process is explained to the patient as one which will remove their dependence on alcohol through the induction of an altered mental state in which the realization of the negative effects of the alcohol on their lives will be developed. The therapist explains that unconscious attitudes towards alcohol must be introduced and removed from the patient's consciousness through an awareness of the negative aspects of one's alcoholism. Negative aspects which result from alcoholism will be introduced into the patient’s consciousness in association with emotively constructed hallucinations. The conscious experience of the negative aspects of alcoholism will ultimately provide a basis for continuing sobriety. The orientation of patients to the program lasts from two to three hours.

The second stage is the actual ACA procedure itself. During this procedure, aethimizol (1.5% 3 ml, i.m.) is injected, followed by bemegride (0.5% 10 ml, i.v.) and, finally, ketamine (3 mg/kg, i.m.) for the achievement of a light ketamine anesthesia. The anxiogenic property of the bemegride potentiates the negative emotional experiences and visions while the aethimizol promotes the fixing of experiences in the long-term memory. (Smirnov and Borodkin, 1979). The therapist communicates with the patient against a background of emotionally laden music which is dramatic in nature. At the most intense point of the hallucinatory experience, the patient smells and tastes alcohol, and with the therapist's intervention, the patient associates his negative experience with the smell and taste of alcohol. This procedure is conducted by two physicians, a psychotherapist and an anesthesiologist. The procedure lasts from one and a half to two hours.

The third stage of treatment, group psychotherapy, occurs on the day following the ACA procedure. Group size is limited to four or five persons. During this session, the patients discuss the negative experiences and hallucinations induced during the ACA procedure. The patients interpret, with the help of the therapist, the personal significance of the symbolic content of that experience. The discussion centers on the correlation of the negative hallucinatory experiences with the problems they have experienced in living because of their alcohol abuse. This session is aimed at inpatient awareness of the negative experience of the alcohol; this session lasts from two to four hours.

SUBJECTS

The patients were recruited from a population who had been treated for three months in a clinic which used traditional methods of treatment. The traditional methods used were aversive emetic therapy, the pharmacological treatment of craving, and individual and group therapy aimed at promoting sobriety. The patients selected were unable to maintain sobriety over a three month period and all had experienced definite alcohol withdrawal symptoms. In addition, all the subjects reported their inability to control their alcohol consumption. All the patients who volunteered for participation in this program gave written consent.

The patients were assigned, by random selection, to a treatment group and a control group. The ACA group consisted of 86 alcoholic male patients whose mean age was 33.4 ± 1.07 yrs. These patients had experienced alcohol withdrawal symptoms for a mean period of 5.6 ± .47 yrs. The control group consisted of 100 alcoholic males whose mean age was 38.4 ± .81 yrs. Their experience of alcohol withdrawal symptoms was the same as the experimental group. The important feature in matching both groups was the relative similarity in the degree of impairment between the two groups. The experimental group of patients received the ACA method of treatment, while the control group continued with the traditional method of treatment (which have been explained above). Treatment efficacy was based on the degree of sobriety achieved by comparing the two groups one year following treatment.

RESULTS

At the end of one year, 60 subjects (69.8%) from the ACA group were fully abstinent from alcohol. Twenty-four patients (27.9%) had relapsed; data was not received from 2 patients (2.3%) of the experimental group. In the control group, abstinence with full remission from the use of alcohol was observed in 24 individuals (24%). The remainder of the control group were abusing alcohol. This data would suggest the possible effectiveness of ACA as an effective treatment modality. It is interesting to note that the effectiveness rate of ACA outstrips all other forms of therapy. Chernovsky (1986) reports abstinence rates of thirty-three percent (33%) as the optimal Treatment outcome.

DISCUSSION

The effectiveness of the ACA therapeutic method may be explained in the following terms. The association of the taste and smell of alcohol with the negative emotional experiences of the hallucinatory stage sets up an obvious aversive response in the patients. The formation of a negative reaction to the alcohol is seen in the attempts of the patients to escape from the presence of alcohol during the ACA experience. The action of the aethimizol may help in the rapid formation of stable associative bonds within the ACA experience (Smirnov and Borodkin, 1979). A negative conditioned reflex to the alcohol appears to develop quickly during the procedure, and patients reported that a physical aversion to alcohol continued during the year following the treatment experience.

A certain similarity exists between the ACA treatment approach and individual hypnotherapy which is directed towards changing a patient's attitude towards alcohol abuse. The increased suggestibility of the ACA approach may depend on the interaction between the ketamine and the aethimizol. The light ketamine anesthesia assures the possibility of contact and dialogue between the patient and the therapist during the procedure. The aethimizol seems to have the ability to imprint the imaginative and emotional qualities of the hallucination on patient memory. Moreover, the specific reduction of psychological defenses in response to the ketamine allows an interaction between the patient and the therapist around the more basic sources of the patient's problems. One can speculate that the psychotherapeutic influences during the actual ACA procedure can be attributed to the establishment of stable bonds between the negative emotional experiences and the hallucinatory images within the context of alcohol use and its effect (negative) on the patient's life.

The inclusion of the patient in all aspects of the ACA treatment is of primary importance. The patients were encouraged to describe and relive their experience. The descriptions had much in common: the experience of personal death and rebirthing, the horror of approaching catastrophe, the feeling of the loss of identity, the profound suffering resulting from one's own isolation and from the loss of significant relationships, the loss of self control, the feeling of being caught up in rapid, chaotic movement, the experience of falling, etc. Two examples from patient interviews will illustrate this.

One patient describes his experience as follows: “I found myself inside a gigantic funnel, the opening of which disappeared into unbelievable darkness. A red capsule spiraled up and down the surface of this funnel. I was inside this capsule and felt myself rushing towards the blackness. Suddenly, I was at the entrance to the funnel, and what I saw made me freeze with horror. The terrible, dark, cold abyss gaped before me. I felt horror of this abyss in every cell of my body. One more move and I will be in this darkness and shall fall and fall. On remembering this procedure afterwards, I felt terrible. I understood the gaping abyss where I stood alone, and that which threatens me most as my alcoholism.”

Another patient describes his experience as follows: “I experienced a presentment of death. It seemed to me that I would never get out of this nightmare and that I am caught up in a slow, tormenting form of dying. I feel that my body was being melted into some great black morass while my brain continues to function. I am able to think and feel but not live. I related this experience to my drinking life as an alcoholic. It seemed as if all the misery which had amassed in my soul over many years splashed out during that hour. I don't want to feel it again. I don't want to go back there. I am afraid to experience this nightmare again. I can never forget it.”

The patients did not attribute their hallucinogenic experiences to the action of the medication used during the procedure. They attributed the negative aversive character of the hallucinogenic experiences to the destructive affects of their alcoholism. It seemed that their denial was breached during the procedure and that they were able to identify the destructive nature of their alcohol abuse. The participants had a sense of their ability to deal with their own individual psychological issues.

It is worth noting that this method is perhaps most effective with patients who suffer from alcohol dependence alone. Patients experiencing concomitant psychiatric disorders or conditions involving memory loss would not benefit from it. Epilepsy, hypertension, various forms of arrhythmia and also expressed stenocardia are contraindications for ACA administration. In the patient population which we treated, we did not observe any adverse reactions during the administration of the ACA procedure.

CONCLUSION

The Contra-Attribution Procedure produced stable remission from alcohol use in a significant number of the alcoholic population which was studied. Two factors appeared to be operative. First, lasting memories of the destructive effects of alcohol, associated with perduring recall of negative emotional states effectively changed the alcoholic's lifestyle. Secondly, the interaction between the patient and the therapist during the ACA procedure itself and in the subsequent group activity seemed to imprint on the patient's consciousness a deep awareness of the destructiveness of the alcoholism and of the need to maintain abstinence as a necessary condition for meaningful living. The interpretative feature was a decisive element in the effectiveness of this approach.

REFERENCES

Chernovsky, L. L. (1986). Control groups in routine evaluation of outcomes of alcoholism treatment. Advances in Alcoholism and Substance Abuse, 6(1), 77-87.

Smirnov, V. M., Borodkin, Yu. S. (1979). Artificial stable functional connections.

Leningrad: Institute for Experimental Medicine, Academy of Medical Sciences.

Smith, C. M. (1964). Notes and comments, exploratory and control studies of lisergide in the treatment of alcoholism. Quarterly Journal of Studies in Alcohol, 25(4), 742-746.

Smith, D. E., Seymour, R. E. (1985). Dream becomes nightmare: adverse reactions to LSD. Journal of Psychoactive Drugs, 17(4), 297-303.