This review (2022) makes the case for lower dose (75-125μg) LSD with multiple sessions (5-8x) in combination with talk therapy. 15 years of use in Europe in the 1960s is explored to define the features of psycholytic therapy.
Lysergic acid diethylamide (LSD) and similar psychoactive drugs have been used in psychotherapy since 1949, when the first clinical study with lower-dose LSD showed therapeutically relevant effects. This caused an intense interest among psychotherapists and researchers, alike, on an international scale. In 1960, the use of serial lower-dose LSD/psilocybin sessions in a psychoanalytical framework, which was dominant at the time, was named “psycholytic therapy”. Psycholytic therapy was usually conducted in clinical environments, on both an inpatient and outpatient basis. Psycholytic therapy was developed and established over a 15-year period on the European continent, where it was used at 30 clinical treatment centers and by more than 100 outpatient psychotherapists. Psycholytic approaches were employed minimally in North America, where the psychedelic approach (use of one or two high-dose sessions for “personality-transforming mystical experiences”) became the dominant method in use. The leading figure in psycholytic therapy was Professor Hanscarl Leuner in Germany, who laid the ground with his uniquely fine grained analysis of the LSD reaction in a 1962 monograph. He was central in establishing and distributing psycholytic therapy in Europe and abroad. The article provides comprehensive background information and outlines the essential features of psycholytic therapy. Evidence for the efficacy of psycholytic therapy is reviewed and a case for the inclusion of the psycholytic approach in the field of substance-assisted psychotherapy is made.
Recent decades have seen a revival of research into psychedelic drugs, but contemporary randomised controlled trials and public attention have largely focused on high-dose, mystical-experience–oriented models of treatment (the ‘‘psychedelic’’ or peak-therapy approach). By contrast, psycholytic therapy—an approach developed mainly in Europe from the 1950s to 1970s that uses repeated lower doses of substances such as LSD or psilocybin to soften defenses, evoke psychodynamic material and support psychotherapeutic work—has been relatively neglected in the modern ‘‘psychedelic renaissance’’. Earlier work, notably by Hanscarl Leuner in Germany, produced detailed phenomenology and clinical protocols for psycholysis, but much of it remained in German and was not incorporated into the recent wave of clinical research. Borgwardt and colleagues set out to reintroduce and summarise the history, methods, indications, phenomenology, safety data and efficacy evidence for psycholytic therapy. The paper aims to provide clinicians and researchers with a comprehensive overview of psycholytic practice as it developed in the mid-20th century, to compare it with the dominant psychedelic peak model, and to argue for renewed empirical investigation and possible clinical inclusion of psycholytic methods in substance-assisted psychotherapy. The authors also disclose relevant clinical experience: one author trained with Leuner and another supervises lower-dose psycholytic work in Switzerland, where a modified psycholytic model has been used in a compassionate-use context.
Papers cited by this study that are also in Blossom
Osmond, H. · Annals of the New York Academy of Sciences (2010)
Bogenschutz, M. P., Ross, S., Bhatt, S. R. et al. · JAMA Psychiatry (2022)
Carhart-Harris, R. L., Giribaldi, B., Watts, R. et al. · New England Journal of Medicine (2021)
Grof, S., Goodman, L. E., Richards, W. A. · Pharmacopsychiatry (1973)
The extracted text presents a narrative, historical and clinical review rather than a formal systematic review or meta-analysis; no explicit search strategy, databases searched, inclusion/exclusion criteria or PRISMA-style methods are reported in the available extraction. Instead, the paper synthesises primary historical sources, clinical monographs (notably Leuner's work), contemporary surveys and follow-up datasets from psycholytic practitioners and professional societies active in the 1960s and later. Material reviewed includes descriptive clinical reports, two large mid-20th-century surveys covering psycholytic and psychedelic applications, naturalistic follow-up studies conducted by Leuner's group (patients treated at the University of Göttingen from 1959 to 1985), and later retrospective data from Switzerland. The authors describe treatment protocols, dosing practices, setting and staffing norms, theoretical frameworks (e.g., Leuner's cartography, transphenomenal dynamic control systems, Grof's COEX systems), and summaries of outcome rates assembled from historical publications. Where the prose referenced tables or figures (for example, compilations of treatment success rates by diagnosis), these aggregated numbers are incorporated into the narrative. The extraction does not clearly report formal quality or risk-of-bias assessments of the historical studies.
Historical reach and practice: Psycholytic therapy was developed primarily in continental Europe from the late 1950s through the mid-1970s. By the mid-1960s it was reported as being used in more than 30 clinics and by over 100 outpatient therapists. The European Medical Society for Psycholytic Therapy (EPT) coordinated education and standards from 1965 until its dissolution in 1974. The approach declined after the late 1960s due to legal restrictions and regulatory prohibition, though a few practitioners continued into the 1980s and limited exemptions occurred in Switzerland between 1988 and 1993. Substances and dosing: The principal agents used were LSD and psilocybin and related congeners, including short-acting psilocybin derivatives developed by Sandoz and, later, the mescaline derivative 2C-D. Doses were individually titrated to preserve contact with consensual reality and a ‘‘reflective ego remnant’’. Typical psycholytic ranges reported for Leuner-era practice were about 75–125 µg LSD (with an overall range cited of 50–200 µg) and 8–15 mg psilocybin orally. Dosing was often escalated in small increments (10–25 µg LSD per session) until a desired level of psychic activation without loss of reflective capacity was reached. Treatment structure and setting: Psycholytic therapy was usually embedded in longer-term psychodynamic treatment. Typical inpatient admissions lasted 6–10 weeks, during which 5–8 psycholytic sessions were administered. A session day commonly involved preparatory meetings in the morning, administration of the drug around 9 a.m., 4–8 hours of in-room experience supported by a lead therapist and a sitter, followed by immediate group processing and creative therapies such as art. After the inpatient phase, patients often returned periodically (for example, at two-week intervals) for additional psycholytic sessions. Frequency between sessions was commonly every two to three weeks, with psychotherapy hours in between. Reported session counts varied with severity: 5–10 sessions for mild cases and about 20 sessions on average for more severe presentations; Leuner's follow-ups noted an average of 12 sessions (range 5–25). Staffing and therapeutic stance: A lead therapist (psychiatrist or doctoral-level psychologist trained in psychotherapy) oversaw treatment, supported by sitters whose role emphasised calm presence, containment and flexible empathic responses; marginal, consented physical touch was acceptable in some cases. Preparatory work, attention to transference and countertransference, supervised self-experience for therapists and post-session integration (group therapy and creative work) were central components. Phenomenology and theoretical constructs: Leuner described three temporal phases within a psycholytic session (early twilight with pictorial-symbolic imagery; mid-phase with intensified transference and increased verbalisation; late phase with detailed verbal reporting and insight). He and others distinguished two broader course-types: a continuous-scenic course (coherent, film-like imaginal sequences, preserved reflective capacity) and a stagnating-fragmentary course (disjointed, repetitive, potentially tormenting material with impaired reflective capacity). Theoretical mechanisms invoked included activation of affect, loosening of defenses, vivid symbolic imagery, age regression and affective abreaction, broadening of associations, intensified transference phenomena, and the activation and successive integration of complex memory constellations (Leuner's transphenomenal dynamic control systems and Grof's COEX systems). Safety data: Two major mid-20th-century surveys (1960 and 1971) covering psycholytic and psychedelic applications, together with a more recent retrospective Swiss survey, found that rates of major complications—such as suicide attempts, completed suicides or prolonged psychotic reactions—were not higher among patients in psycholytic therapy than among patients receiving conventional psychotherapy. The extracted text reports these comparative safety conclusions but does not detail the methodologies of those surveys. Efficacy data: Empirical evidence is limited and predominantly naturalistic. A table summarising historical outcome reports lists numbers of studies and treatment-success rates by diagnostic group: anxiety disorders (9 studies, 70% success), depressive neuroses (4 studies, 62%), personality disorder (10 studies, 61%), sexual disorders (7 studies, 50%), obsessive–compulsive disorder (7 studies, 42%), and hysteria/conversion (2 studies, 31%). Leuner's naturalistic follow-up studies of patients treated at Göttingen (1959–1985) reported a success rate exceeding 66% in a severely refractory cohort and suggested a favourable economic profile; however, these studies were uncontrolled and used outcome assessments typical of their historical era. The authors emphasise that controlled modern trials are lacking and that historical methodologies were often unsophisticated compared with contemporary standards.
The authors interpret the historical record as showing that psycholytic therapy was once a prominent and widely practised model in Europe but has been neglected in recent decades while psychedelic peak therapy has dominated contemporary research. They caution that this current dominance may reflect historical, cultural and funding factors—shorter-duration psychedelic protocols are easier and less costly to study, and philanthropic funding patterns in the United States favoured the psychedelic peak model—rather than a clear superiority of one therapeutic paradigm over the other. Borgwardt and colleagues suggest psycholytic therapy may be especially relevant for patients with chronic, complex or personality-related problems for whom longer-term, repeated lower-dose sessions integrated into psychodynamic work might produce durable change. They note conceptual and practical overlaps between psycholytic therapy and MDMA-assisted psychotherapy, since MDMA preserves ego functions and supports trauma reprocessing without inducing ego-dissolution. The authors also highlight prior proposals and some early empirical attempts to combine approaches (so-called ‘‘psychodelytic’’ models) and cite past suggestions that single or double high-dose sessions may be inadequate for certain clinical populations. Limitations acknowledged in the paper include the long interruption of research after legal prohibition in the late 1960s and 1970s, the predominance of uncontrolled and methodologically limited historical studies, language barriers (Leuner's influential monographs were published in German), and the scarcity of modern controlled trials testing psycholytic protocols. The authors call for contemporary empirical work to revisit psycholytic paradigms, ideally using rigorous study designs to test indications, dosing strategies, safety and durability of effect. They argue for consideration of psycholytic therapy as a complementary or alternative model within substance-assisted psychotherapy and propose renewed investigation of psycholytic, MDMA-assisted and combined approaches to expand therapeutic options for populations less likely to benefit from single or a small number of high-dose psychedelic sessions.
Recently, after an interruption in research of more than 30 years, a "psychedelic renaissance" (1) has emerged, that is a revival of research and therapeutic studies with psychedelic drugs. During the late 1950s, Abram Hoffer and Humphrey Osmond, two Canadian psychiatrists, developed the psychedelic treatment technique. This procedure made induction of mystic-religious experiences the basis of its therapeutic action. It uses a specific preparation of the patient, high to very high dosages, specific surroundings, and music to favor evocation of transformational insights and mystical experiences. Psychedelic treatment was developed and used during the 1960's in a few clinics in North America. Notably, none of the controlled efficacy studies showed significant results in favor of psychedelic peak therapy for alcoholism, or chronic neuroses. More recent studies, however, suggest that better results can be reached, especially with patients treated for their anxiety and depression induced by a lifethreatening somatic disease. However, most of these patients had a healthier personality make-up at baseline, a better base to activate salutogenetic forces by psychedelic peak therapy. From an overview of the last ten years, we observe that recent RCT studies are solely focused on the psychedelic approach. The appeal of this seemingly rapid, novel and impressive treatment and the much greater time required for psycholytic therapy may help explain why psycholytic therapy is underutilized and undertheorized in the contemporary psychedelic research scene. With this as background, we offer education about psycholytic therapy. We invite consideration of the vital and extensive history of psycholytic work, in particular the work done by its most central figure, Professor Hanscarl. Leuner worked at the University of Göttingen in Germany, on the foundations of psycholytic therapy and headed the European Medical Society for Psycholytic Therapy (EPT) as its president. We include basic research, methods, findings and concepts developed by researchers and analytically oriented clinicians using psychedelics to facilitate psychotherapy. Relevant disclosures: the first author (TP) worked clinically with Hanscarl Leuner for three years. The last author (RK) is Medical Director of a 280 bed psychiatric hospital in Switzerland, the Münsterlingen Psychiatric Hospital, where he has supervised the use of lower-dose psycholytic therapy for treatment-resistant patients with anxiety and depression syndromes. A modified model of psycholytic therapy is currently an approved treatment approach in Switzerland in a compassionate use program.
In the 1920s, researchers provided extensive clinical description of the mescaline intoxication, but most researchers at the time did not find that the experiences reflected the psychodynamics of their experimental participants [cf.]. In contrast, the first systematic clinical experiments utilizing lower doses of LSD (10-50 mcg) in "psychologicallyminded" participants revealed the usefulness of LSD in evoking psychodynamic material. Many psychoanalysts followed these observations and began to utilize LSD assisted psychoanalytic sessions in order to evoke psychodynamic processes, e.g., softening of defenses, regression, deepening of transference, spontaneous childhood memories. Observations of two authors were key for the development of the psycholytic approach. In 1953, the British psychiatrist Ronald A. Sandison worked with LSD in non-therapeutic experiments. He described intensification of affect and abreactive memory actualizations which led to a marked improvement in symptoms for some experimental subjects. In 1953, the German psychiatrist Hancarl Leuner developed a day-dream technique for use in psychotherapy, which he termed "Guided Affective Imagery". He found that the use of small doses of LSD lead to enhanced generation of images and emotions, and that the therapeutic process was deepened, including experiences of regression and catharsis. In his extensive basic research on the LSD reaction, overseeing and carefully evaluating more than 1,000 experimental LSD sessions, he found proof of psychodynamically relevant experiences and their basis in biographical history of the patient. He also was able to outline the principal mechanisms for LSD's therapeutic action in the framework of psycholytic therapy. His fine-grained analysis of the LSD reaction in his 300-page monograph is one of the most comprehensive psychological analysis of the LSD reaction up to today. Unfortunately, Leuner's monograph as well as all his later research until the 1990s has been published just in German. This contributed to the neglect of psycholytic therapy on an international scale. Fortunately, a comprehensive English monograph on the work of Leuner will be issued in 2023. The psycholytic method was developed in the conventional context of the psychoanalytic therapies which supported the activation of memories, emotional states, and focused on the psychological conflict which was usually centered in the drive/defense/conflict model of treatment that was prevalent at the time. The use of repeated, small LSD sessions in the context of psychodynamic therapy was termed psycholytic therapy (psycholysis in short) by Ronald Sandison at the First European Symposium for Psychotherapy under LSD-25 in 1960. It should be mentioned here that in psycholytic therapy, as with all psychotherapeutic work, it is not assumed that the memories of the patients represent historical truth, but they contain emotionally meaningful content. Memories recovered during altered states of consciousness are often distorted and bizarreand must not be taken as historical anamnesis. The best known writers and practitioners of psycholytic therapy were: Ronald Sandison (UK), Hanscarl Leuner (Germany), Walter Frederking (Germany), Einar Geert Jörgensen (Netherlands), Stanislav Grof (Czechoslovakia, USA), Milan Hausner (Czechoslovakia), John Buckman (UK, USA), Joyce Martin (UK), Cornelius van Rhijn (Netherlands), Harold Abramson (USA), Charles C. Dahlberg (USA), and Claudio Naranjo (Chile/USA) [cf.]. A review of the academic literature on psycholytic and psychedelic therapy reveals that psycholytic therapy was applied almost exclusively in Europe, whereas psychedelic therapy was more prominent in North America (Canada and USA) [cf.]. Reasons for this are likely to lie in historical and cultural factors, which are outside the scope of this paper. Tableprovides an overview of essential characteristics of the two methods. From 1960 to 1975, numerous congresses and conferences were held at which psycholytic therapists presented their procedures, cases and results [cf.]. By the mid-1960s, psycholytic therapy was a promising and widely applied approach, being conducted at more than 30 European clinics and by more than 100 outpatient therapists. Out of the need for community as well as codifying and teaching psycholytic therapy, the European Medical Society for Psycholytic Therapy (EPT) was founded in 1965. The EPT conducted 5 symposia until its dissolution in 1974. During these years, psycholytic therapy was refined and established as a respected clinical method [cf.]. Psycholytic therapy did not come to an end due to dangers or lack of efficacy. The end of the 1960s saw increasing prohibition of psychedelic research, especially in the USA, and the subsequent laws enacted by the US Drug Enforcement Administration and in the sequel by the United Nations led to the cessation of research with LSD and similar psychoactives. Therefore, the expansion of psycholytic therapy was no longer possible. In spite of these realities, two professors central to the psycholytic therapy (Hanscarl Leuner in Germany and Jan Bastiaans in Netherlands) retained their licenses until their retirement in the mid-1980s, and continued their work. And between 1988 and 1993, five Swiss psychiatrists were granted exemption licenses for the use of 3,4-Methylenedioxymethamphetamine (MDMA) and LSD in psycholytic therapies [cf.].
The primary substances used in psycholytic therapy in the 1960s were LSD and psilocybin and their congeners. The general term for these substances was "psycholytic drugs" or "psycholytics." Around 1960, Sandoz developed two short-acting derivatives of psilocybin, codenamed CZ-74 (4-HO-DET, 4-hydroxy-N,N-diethyltryptamine) and CEY-19 (ethocybin, 4-phosphoryloxy-N,N-diethyltryptamine), which were used in psycholytic therapy [e.g.]. In the 1990s, Leuner also worked with the short-acting mescaline derivative 2C-D (2,5-dimethoxy-4-methylphenethylamine) (Figure). In psycholytic therapy, dosages were individually adjusted so that the patient remained oriented to the present situation and in communication with the therapist. This preservation of a "reflecting ego remnant" (Leuner) marks a significant distinction between psycholytic and psychedelic therapy, where the patient may lose track of consensual reality for a period of time [e.g.].
In an international discussion at the 1969 symposium of the EPT in Würzburg, Germany, a "list of indications" was assembled (cf. Table). The list includes a broad spectrum of diagnoses, using the language of the time, that were treated with psycholytic therapy. While many of these diagnoses are antiquated in their terminology, the human conditions they describe are certainly still present among patients seeking help from psychotherapy and substance-assisted therapy in general. Leuner repeatedly asserted that the indication for psycholytic therapy -as always in psychotherapy -"does not [depend] solely on the diagnosis of a case. Much more decisive are prognostic considerations that arise from the peculiarity of the patient . . . his sociological situation, the duration of the symptoms, and other factors". Prognostically favorable, in his opinion, were: sufficient ego strength, success in professional life, suffering under genuine pressure of daily life, and intrinsic motivation for therapy. Absolute contraindications were brain-organic conditions, serious liver and kidney diseases, endogenous psychoses, pregnancy. Relative contraindications were: lack of motivation for psychotherapy, histrionic personalities with tendency to act out, and personality disorders with lack of suffering. Most authors in the 1960s excluded patients with first-degree relatives suffering from psychosis for reasons of safety [e.g.].
Leuner and colleagues followed a somewhat flexible, but standardized treatment protocol (see Figureand Tablefor illustration): at the beginning of the treatment, questions regarding psychotherapy, substances, dosages and the setting to be used were discussed in detail with the patient in advance of the psycholytic sessions. This was followed by several interviews to learn about the patient's life story and his medical history, to establish a working alliance and to prepare the patient for a psychodynamic framework for the substance session. Transference reactions were also a focus of the discussion. The preparatory sessions lasted 60 to 90 min and were conducted by one or two lead therapists. Psycholytic therapy was typically initiated during an inpatient admission; such admissions usually lasted 6 to 10 weeks. 5 to 8 psycholytic LSD or psilocybin sessions were applied during this stay. A typical schedule on the day of the psycholytic session is outlined in Figure. For the substance assisted therapy sessions, there typically was one support person (sitter) permanently in the room with the individual patient and one lead therapist who was in charge.
The terms used in the table -admittedly outdated in terms of diagnostic designations -are intended to present a historical reference and starting point for psycholytic psychotherapy. This is also in view of the fact that not much has happened since then in terms of research in psycholytic therapy and that future clinical trials may test the historical indications using rigorous study designs. of the psychotherapeutic interventions and who was in and out of the room. The 4 to 6 patients scheduled for treatment on a specific day met in the morning for individual preparatory sessions with their lead therapists and the sitter. The selected therapeutic substance was usually given around 9 a.m. The duration of the drug-session was between 4 to 8 h, depending on the substance used. Immediately after the session, the patients and the sitters as well as the lead therapists met in a group therapy session to discuss the experiences. Thereafter, an art therapy group session was held where the patients were invited to give their subjective experiences and artistic expression by painting and working with clay. Following the inpatient phase of treatment, the patient was usually transferred to a so-called Inpatient Interval Treatment. In this, the patient visited the clinic for a day and a night at 14-days (or longer) intervals for a psycholytic session.
In a typical psycholytic clinic in the 1960s, there were several single rooms for the individual sessions and group rooms where group therapy and creative therapy took place after and between the psycholytic sessions. During the session, the patient was instructed to lie or sit on a bed. The room was simply but tastefully decorated. It was either soundproofed to minimize distracting outside noise or somewhat secluded from clinic noise (see Figures).
Psycholytic therapy was conducted under the direction of a psychiatrist who has been thoroughly trained in psychotherapy or of a doctoral level psychologist, similarly trained in psychotherapy. Supervision and case conferences were of considerable value. Sitters were instructed and called in for case conferences at regular intervals; some had supervised self-experiences to be more able to empathize with the patients. The sitter's role was to establish an informal and relaxed atmosphere in which the patient felt comfortable and safe. Otherwise, sitters were expected to be flexible in adapting his or her responses to the situation. However, the requirements varied greatly. Some patients required only brief contact from time to time, while others desired assistance throughout the session. In general, more flexible empathic behaviors were required than in ordinary psychotherapy sessions. Active support was sometimes necessary by a question or an offer to talk, but the basic attitude of the sitters was one of quiet presence and containment. Non-invasive physical touch (e.g., holding a hand) was offered, provided careful informed consent was obtained during the preparatory session. Interestingly, every psycholytic therapist in the past was in favor of marginal physical touch (e.g., holding a hand) as an occasionally necessary component of psycholytic therapy [e.g.]. Leuner's rule of thumb was to limit therapeutic touch to the region upwards of the shoulder, including arm and hand. In individual cases, elements of Psychodrama were useful to bring into the session. In this process, the patient, as the main actor in the here and now, created his therapeutic theme as if on a dramatic stage, in accordance with Psychodrama procedures (Moreno, etc.). The therapist allowed himself to be touched by the patient's play as a co-player or spectator, intervened if necessary, and then gave feedback. This approach could lead to a healing experience of abreaction or catharsis. The goal was for the patient to find a new and appropriate reaction to a new situation or one that was already well known. The attitude of the lead therapist was one of calmness and empathy, striving to create a positively valenced, secure and safe setting. Therapists had well honed skills in perceiving the patient's emotional transference and their own countertransference reactions. According to EPT guidelines, it is highly valuable for the therapist to have had at least 5 supervised self-experiences to deepen the understanding of the spectrum of inner experiences and to guide the patient with a maximum of empathic attunement. Overview of the psycholytic therapy treatment process.
Patients were invited to assume a relaxed position and asked to pay introspective attention. They were asked to surrender themselves openly to the impressions, emotions and visions which may appear. Verbal expressions by the patients were recorded. These recordings were used in integration sessions following the psycholytic sessions. The psycholytic sessions evoked an intense emergence of psychodynamic contents of the patients; there may or may not has been overt connection to explicit symptoms. It this way, psycholytic therapy is a particularly powerful tool to awaken imagination and awareness of conflicts, and honesty about the self. Therapist and support person must ultimately follow a middle course in order to provide the patients with a sense of security on the one hand and avoiding intrusiveness or an excess of guidance that is based on the therapists sense of what should be happening, rather than the patient's. A flexible, intuitive balance between the two emerges with practice. Some patients need this human contact more than others. In both the time of Hanscarl Leuner's work and present psycholytic therapy it is the standard approach to not try to stop or decrease abreactive patterns, but instead, to support the expression of intense emotions, communicating the value of the intense experience. The patients may desire to talk, but cognitive discussions, practical questions or small talk should be avoided. The patients are in a heightened state of sensation, sensitive to small things, and may become irritated or distraught easily. The therapy environment may be full of projections, fantasies, longing for love or frantic despair. All these are held as welcome phenomena by the therapists and caregivers in the room. Training in being the recipient of erotic or paranoid transferences is vital for therapists in this work.
The psycholytic sessions were generally embedded in a long-term psychotherapy. Psycholytic therapy done by Leuner and colleagues during the 1960s had 50 to 200 hours of psychodynamic or psychoanalytic therapy, with 5 to 25 psycholytic sessions interspersed in the treatment. Leuner's approach was congruent to the approach used today: both tend to have a more phenomenological intention: facilitating a narrative by the patients of their experience, saving any interpretation or meaning making for later. As the peak intoxication period ends, and usually following a period of high affective arousal, an opportunity for verbal exploratory work comes, and this period is noted for its significance by historical and contemporary practitioners alike. During the fading intoxication the patients still experience a decrease in defensiveness, the expansion of associations and an altered feeling of connection with the therapist, the sitter and other patients. The psychodynamic group therapy session immediately after the psycholytic sessions is a particularly rich setting for quiet sharing, story telling, relational processing, new perspectives and self awareness. The patients may be newly aware of resistances, defenses and fixed, rigid beliefs that need to be released. Following the group session, an art room setting is provided for the group for possible growth experiences The illustration shows a treatment facility specific to psycholytic therapy as it was held in various clinics in the 1960s. The illustration shows a treatment room with furnishings typically used in psycholytic therapy. One method would be to apply a therapist's usual way of working with dreams to the psycholytic journey. The degree of active interpreting versus evocation of narrative telling will vary among different therapists and their way of working.
With psycholytic therapy, in Leuner's days, primarily the individual model was used for conducting psycholytic sessions. Experiments with conventional group therapy settings during the medicine session were abandoned because of the inability to follow-up group interactions, e.g., by distractions from individual absorption ("tripping"). Sandison and Leuner put group therapy in the period immediately after the psycholytic sessions to use the loosening of defenses in the post intoxication phase for psychotherapeutic work. Some psycholytic therapists experimented with modified group treatments with some success [e.g.], but psycholytic group therapy never became broadly used [cf.]. However, it experienced a revival with the Swiss Physicians Society for Psycholytic Therapy (SÄPT) since the late 1980s [cf.].
The substance and the dose should be chosen very carefully. One goal is for the person to remain fully oriented and capable of communication with the therapist; this includes, of course, the full awareness of the specific therapeutic situation that is happening. Leuner has referred to this as "double consciousness" and named it technically as the "reflective ego remnant". Dosages used in Leuner's days for psycholytic therapy were in the lower range of usually 75-125 µg LSD (range 50-200 µg) or 8-15mg psilocybin by mouth. According to a psycholytic discourse, the dose cannot be determined linearly in relation to body weight, but preferably should be based on the patient's characteristics (e.g., constitutional factors, obsessive vs. hysterical personality structure, specific defense mechanisms). Obviously, these attributions are embedded in the doctors training and culture, as well as countertransference reactions evoked by the patient. In the 1950's, Sandoz, as well as the EPT guidelines recommended gradually ascending dosing of, e.g., LSD in increments of 10-25 µg per session until the desired level of consciousness alteration was achieved. The criteria for the correct dosage were a noticeable psychic activation, emergence of some psychedelic phenomena but not all, and the preservation of the reflective ego capacity. If the latter was lost, the dose was considered too high. Usually, one session was given every two to three weeks, with 1-3 psychotherapeutic hours per week in between. This procedure was modified according to the individual patient and his progress. About 5-10 psycholytic sessions were used for mild cases, and about 20 sessions on average for severe cases [e.g.].
Since psycholytic therapy does not aim at the "dissolution of the ego" as is the goal in psychedelic therapy, some specific psychic phenomena emerge in psycholytic sessions. Leuner offered a cartography of each LSD session having three phases that can be distinguished.
A daydream-like twilight develops with elements of altered feeling and mood, but little verbal communication. Unusual perception of the environment is common, including hyperawareness of somatic sensations. Biographically determined pictorial-symbolic representations of personal problems strongly preoccupy the patient. Regressions into non-verbal states can occur, but less than is seen in psychedelic therapy. The therapist's overt attitude is of promoting a contemplative attitude for "introspection."
This phase usually contains a stronger attention to the therapist; intensified transference phenomena are seen (this may evoke countertransference phenomena in the therapists). Commonly seen is an increased willingness to communicate (talkativeness, garrulousness) and selfreflection. It is generally recommended to leave the self-oriented narratives to the patient and refrain from creative interpretations at this time.
In this phase, there is often a pronounced wish to communicate verbally. Experiences are described in detail. Curiosity and discovery are the therapist's goals, not formulation or problem solving, even though the therapists may feel moved to make such formulations. Deeply meaningful insights into one's own fixed beliefs and relationship patterns may become extraordinarily apparent to the patient. In addition, LSD has been described by Fernandez-Cerdeno and Leunerand others [e.g. ()] as leading to the reexperiencing of repressed childhood memories at a somatically real level, so that the patient feels as if he were at the age in which the traumatic experience took place (so-called age regression). This may be accompanied by high levels of somatic arousal. Unlike psychedelic therapy, psycholytic therapy aims at a less deeply altered state, with less loss of core self identity. It does not aim at a dissolution of the ego, but only at a temporary change or softening of ego experience. This serves to facilitate access to repressed conflicts, affects, fantasies, and memories in a psychological state, which allows a familiar process of psychotherapeutic work, including emotional abreaction, insightfulness, and compassion that the therapist can support. Another core concept derived from Leuners basic research: Leuner, in 1962, based on observations from more than 1,000 LSD sessions, described two typical courses the experience can take. These are:. the continuous-scenic course and (2). the stagnating-fragmentary course. We offer these as one possible cartography of the psycholytic process. Which of the two courses occurs is partially determined by the dose level i.e., an individually adjusted dosage can influence which kind of course will occur.
This is characterized by scenic imaginations with closed eyes, which develop in coherent processes -occasionally like the scenes of a film -and are closely integrated with affective resonance. Sense-filled emotional experience flows in a continuous stream of consciousness. The contents and scenes are mental projection processes, sometimes described as complex imagination, and show individual biographical meaning-relatedness. Age regressions may occur, as can vivid childhood memories. The experience has a continuous sequence and often stimulates the person to meaningful reactions and reflections. The reflective ego capacity is preserved and the patient can face, describe and reflect on the experiences with some distance.
In this course form, the experience may show some features of the scenic course, but instead of the fluctuating emergence of the contents, a stagnation of the contents occurs. Over longer periods, the person may be repeatedly occupied by the repetitive emotional memory and complex visions with painful emotional content. The flow of experience seems "stuck" and the condition is experienced as one of torment. There may be an erratic quality and choppiness of inner sequences of experiences, similar to psychotic disjointedness and disconnection. The complex perceptions are formed as single elements, or fragments of whole objects; there may be fragments of objects or humananimal figures. As single, disconnected parts they stand next to each other but in a non-integrated way, and follow one another as isolated, unconnected single images. The individual perceptual contents become sluggish and viscous, separated by pauses, and a sense of fragmentation. An integrative context is no longer recognizable. Frequently, emotions without subject matter or content become interspersed in the experience. The patient's reflective ego capacity may be missing. Arousal-consuming regressive symptoms such as psychomotor phenomena, restlessness, motility disorders, or instinctual actions may be seen. Leuner and others at that time considered only the continuous-scenic course as therapeutically beneficial. Therefore, by carefully considering the dosage and the therapeutic container, the conditions for the continuous-scenic journey are offered. The main sign that the dosing was correct is that the reflective capacity of the ego is preserved.
Leuner hypothesized that many LSD phenomena observable in the context of psycholytic therapy can be understood through a concept of specific memory constellations. These constellations selectively determine the field of experience. Such systems controlling the sequence of experiential contents were described by, who named them "Transphenomenal Dynamic Control Systems" (tdySt). They are "transphenomenal" in the sense that they are not restricted to specific mental functions or any particular life event. Rather, they propagate through the personality in various functions of thought and behavior. Leuner [(25), p. 119] defines these constellations as "driving emotional forces of a tense dynamic system, an unfinished need pressing for completion or settlement." Not every unfulfilled need becomes an experiential phenomenon "rather, the symbolic image enters consciousness as a substitute, as it were as a preceding part, as an image projection of this emotional state. The symbolically representing emotion, more generally speaking dynamics, remains transphenomenal." [(25), p. 119]. In the context of psycholytic therapy, LSD "thereby assumes the role of an activator of the affective complexes which had hitherto been dormant or, in any case, had expressed themselves only in a relatively lavish and symptomatic manner" [(24), p. 97]. Some activated tdySt can be integrated on a verbal level, others on a symbolic level, others at a somatic level, and others through the disclosure of a traumatic event and its psychotherapeutic processing. Leuner's tdySt shows extensive congruence with the Systems of Condensed Experience (COEX-Systems) postulated later by LSD therapist Stanislav Grof (54) from his early work with psycholytic therapy. Grof defines a COEX-System as a specific constellation of memories (and/or fantasies) from different stages of a person's life. The memories belonging to a particular COEX-System have a similar underlying theme or common basic elements and are occupied by strong emotions of the same quality. The deepest layers of these systems usually contain very vivid, colorful memories of early childhood experiences. The more superficial layers store memories of similar experiences from later in life to the present life situation. The emotional intensity of the COEX-Systems (recognizable by violent abreactions accompanying the uncovering of these systems in LSD sessions) seems to be a summation of all emotions belonging to the memories of a particular system. As a rule, after activation of a COEX-System under the influence of LSD, there is reliving of related memories as well as cathartic abreactions, which then leads to their integration, also via the accompanying psychotherapy. Afterward, the COEX-System in question loses its energetic charge and thus its influence on the field of experience and the psychological state. Repeated LSD sessions can thus be viewed as successive uncovering, abreaction, and integration of individual COEX-Systems. However, like Leunerand Grof, psycholytic therapists Ling and Buckman (41) point out that abreaction alone is not of lasting value unless the associated feelings are processed and integrated by the patient in a psychotherapeutic framework.
The psychological mechanisms of action of psycholytic therapy were concisely described by, Grof, and Leuner. • Activation of affect and sensory perception • Loosening of psychological defenses • Personally meaningful symbolic visualization of affects • Therapeutic splitting of ego functions with a preserved "reflective ego capacity" • Broadening of associations • Exceptionally vivid reliving of disavowed conflicts and memories • Age regression with great depth of experience • Pronounced affective abreactions • Intensification of transference experienced and observable in the here and now on the therapist
As these authors consistently described some psychological mechanisms based on systematic clinical observations of more than a thousand cases, it is likely that their observations remain resonant and valid. In addition, there is the increased possibility of corrective new experiences in both the intrapsychic and especially the interpersonal areas. This has important implications in relation to Grawe's postulated "neurobiological reshaping through re-experience". "The clarification perspective, which in the form of improved introspection and insight into the psychogenesis of the disorders and problems, into the roots of one's own life history, but also into one's creative potentials as well as into one's own possibilities of experience and behavior, has a great significance in psycholytic treatment" [(58), p. 74].
Two major surveys in 1960 and 1971 covering psycholytic (and psychedelic) applications with more than 9,000 patients and a more recent retrospective survey from Switzerlandshow that the risk of major complications (suicide attempts, suicide, prolonged psychotic reactions) is not higher for patients in psycholytic therapy than those in conventional psychotherapy (Table).
Because of the long interruption of research and a certain neglect during the last thirty years of the "psychedelic renaissance, " studies of psycholytic therapy are scarce. This was, among other things, due to the unsophisticated and lax methodology used for psychotherapy research at the time. It was in its infancy and without the mature methodology that would emerge in contemporary academic settings. Mascher published a review in 1967 [(62), pp. 441-444] about results as well as favorable indications for psycholytic therapy. Regarding treatments rated as "successful, " psycholytic therapists reported long-term improvement in approximately two-thirds of their difficult to treat and chronic psychoneurotic patients (see Table). Due to the marginalization of psycholytic therapy and psychedelic therapies in general in the late 1960s, larger controlled studies could not be conducted. Two research projects were conducted by Leuner, with the goal of studying the efficacy of psycholytic therapy. These were naturalistic studies. As mentioned above, practitioners of psycholytic therapy were focusing on conditions that were not helped by conventional
Anxiety disorders 9 70% Depressive neuroses 4 62% Personality disorder 10 61% Sexual disorders 7 50% Obsessive-compulsive disorder 7 42%
Frontiers in Psychiatry 10 frontiersin.org therapy. In these refractory patients, it was reasoned, virtually all improvements achieved would be considered a success, and an analysis of pre/post outcomes could accordingly be taken as evidence of efficacy. With this in mind, Leuner's research group followed up patients treated at the Göttingen clinic (Germany) from 1959 to 1985. Diagnoses of patients were: anxiety neuroses and phobias, cardiac neuroses, personality disorders, conversion neurosis, neurotic and reactive depression, and sexual deviations. Both studies focused on performance in everyday life and at work, using an established grading to characterize the patients general status. Number of psycholytic sessions varied between 5 and 25, with an average of 12. The two follow-up studies -with obvious limitations -demonstrated a good success rate of more than 66% and a favorable economic profile. If these results could be confirmed in controlled studies, psycholytic therapy, especially when applied with treatmentrefractory patients, could make a significant contribution to psychotherapeutic care.
After a hiatus of about forty years since the United Nations' prohibition of psychedelic substances in 1971, therapeutic research resumed some 30 years ago. However, there seems to be a recent dominance of psychedelic therapy and a neglect of psycholytic therapy. This is somewhat surprising, given that less than one third of the publications about hallucinogen-assisted psychotherapy in the 1955 to 2000 timeframe had been about psychedelic therapy, the other two-thirds about psycholytic therapy [cf.]. For various reasons, the psycholytic approach hasn't been developed or cultivated in North America and is virtually unknown to most researchers and therapists today. The distribution of psycholytic therapy with more than 30 treatment centers and around 100 outpatient psychotherapists was much broader than that of psychedelic therapy. One might ask whether the recent dominance of psychedelic peak therapy is an historical artifact. For instance, research on hallucinogens -which is very costly because of immense regulatory hurdles -has been mainly financed by noncommercial philanthropy; wealthy U.S. individuals, during the 1990 to 2010 timeframe, showed a pattern of financial support unknown in Continental Europe. In this context, because of its short-term application, the psychedelic approach has a clear advantage over the psycholytic approach. Studies are easier to design and conduct, which makes efficacy studies less expensive than long-term psycholytic therapy research. This is true not only for the comparison between the psycholytic and psychedelic approach, but also for longer-term versus short-term psychotherapies, where evidence has been in favor of longer-term psychotherapies, especially in complex and chronic cases. A relevant background of the recent enthusiasm regarding the therapeutic use of hallucinogens and entactogens is the fact that after 30 years of neurobiological research in psychiatry, no breakthroughs in respect to new pharmacological agents has been reached. This created significant "therapeutic underpressure" in psychiatry for new approaches. Against the backdrop of this underpressure, anything that appears to be effective is readily embraced, though often with heightened expectations. The mystical experience of unity and connectedness is central in psychedelic therapy and has been described as its most important active factor. Although it seems that mystical experiences are correlated with symptom reduction in certain groups of patients, some controlled studies in the past as well as today have failed to prove a causal relationship [e.g. ()] or rely on largely uncontrolled trials. Mystical-type experiences have been observed by psycholytic therapists as well. However, in psycholytic therapy, mystical-type experiences are not a specific goal, given that retaining a state of self-reference is a central characteristic. Nevertheless, the psycholytic approach might also be suited for treatment of life-threatening diseases given that this specific group of patients usually does not suffer as much from entrenched long-term neurotic dysfunctional behavioral, relationship and psychosocial performance. This could imply that their psychological coping resources are more intact and salutogenetic forces easier to access and activate. In this vein, the activation of self-healing forces has been discussed as an essential part of psycholytic, psychedelic and MDMA-assisted therapies likewise [e.g.]. The activation of self-healing forces could even represent a non-specific component for psychedelic-assisted psychotherapy, independent of the respective specific psychotherapy model. MDMA-assisted psychotherapy differs from psychedelic therapy, since MDMA does not induce an ego-dissolution with mystical overtones. In MDMA-assisted psychotherapy, ego functions and cognitive functions are preserved to a large degree. Therefore, MDMA-assisted psychotherapy shares many similarities to the psycholytic approach. MDMA-assisted psychotherapy has been used in psycholytic contexts in Switzerland in the 1988 to 1993 timeframe as well as today in a compassionate use program [cf.]. In contrast to the psychedelic model, the psycholytic model interprets mystical-type experience not primarily as a transpersonal experience. Some psycholytic therapists argued that their patients tend to use these experiences to avoid working on their real everyday problems [e.g.]. However, they recognized the healing power of such aspects of "syntheticmagical integrative experiences, " as they sometimes called them. They've found them often occurring at the end of psycholytic therapies and described them as a reinforcing therapeutic progress. It is interesting to know that the group of researchers at the Maryland Psychiatric Research Center -the most prominent center for psychedelic therapy worldwide (79) -concluded, in view of their inconclusive study results [e.g.] that a combination of psychedelic and psycholytic therapy would be an interesting option, especially to enhance durability of treatment results. In this vein, Grofand Yensenproposed to name that combined approach "psychodelytic therapy". Eventually, this group conducted several studies using the psychodelytic approach with neurotic outpatients and inpatient alcohol dependent patients by administering compounds with a shorter duration of action such as dipropyltryptamine and psilocybin. In respect to the treatment of neurotic patients or those with personality disorders, "there was a suggestion that the single or double dose approach was inadequate for this level of pathology" [(82), p.13]. In sum, it seems that the psycholytic approach, while being dominant in Europe in the 1960s, has been neglected in the recent revival of substance-assisted psychotherapy. However, MDMA-assisted psychotherapy does not follow the recent popular psychedelic approach of using the ego-dissolving mystical experience as a focus of therapeutic change. Similar to classic psycholytic therapy, MDMA-assisted psychotherapy aims to just gradually alter ego functions and defenses, and focuses on reprocessing of trauma, catharsis and corrective emotional experiences. If, as in the best studies of the 1960s, it should again be seen that the successes of psychedelic peak therapy are not broadly effective for all patients [e.g.], or are not lasting for those patients, the currently postulated "psychedelic renaissance" (1) may well be followed by a "psycholytic renaissance." This renaissance would presumably be more modest in its basic attitude and characterized by acknowledgement of the protracted and small-scale nature of psychotherapeutic change processes. In addition, psycholytic therapy described above as well as a combination of psychedelic and psycholytic paradigms warrants further investigation in the future.
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