The Combination of Psychedelic and Aversive Approaches in Alcoholism Treatment:
The Affective Contra-Attribution Method
E. M. Krupitsky, MD; A. Ya Grineko, MD;
T. N. Berkaliev, MD; A. I. Paley, MD; U. N. Tetrov, MD; K. A. Mushkov, MD; Yu. S. Borodikin, MD
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,
Correspondence should be addressed to E. M. Krupitsky.
Alcoholism Treatment Quarterly, Vol. 9(1) 1992
© 1992 by The Haworth Press, Inc. All rights reserved.
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.
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
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.
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.
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.
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
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
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.
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.
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
Leningrad: Institute for Experimental Medicine, Academy of Medical
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.