Lindesmith 1947; Metzner et al. 1965; Aberle 1966; Schachter and Singer 1962; Nowlis and Nowlis 1956). (1) Many drugs, including those used to produce changes in subjective experience, have a great variety of effects, and the user may be unaware of some of them, or may not recognize them as attributable to use of the drug. (2) The effects of the same drug may be experienced differently by different people or by the same people at different times. (3) Since recreational users take drugs in order to achieve some subjective state not ordinarily available to them, they expect and are most likely to experience those effects which are different from ordinary patterns. Thus, distortions in perception of time and space and shifts in judgment of the importance and meaning of ordinary events are the most commonly reported effects. (4) Any of a great variety of effects may be singled out by the user as desirable or pleasurable. Even effects which seem to the uninitiated to be uncomfortable, unpleasant, or frightening--perceptual distortions or visual and auditory hallucinations--can be defined by users as a goal to be sought (Becker 1963). (5) How people experience the effects of a drug depends greatly on the way others define those effects for them (Becker 1963; Blum and Associates 1964; Lindesmith 1947; Metzner et al. 1965; Aberle 1966; Schachter and Singer 1962; Nowlis and Nowlis 1956). If others whom users believe to be knowledgeable single out certain effects as characteristic and dismiss others, they are likely to notice those same effects as characteristic of their own experience. If certain effects are defined as transitory, users are apt to believe that those effects will go away.

The scientific literature and, even more, the popular press frequently state that recreational drug use produces a psychosis. What writers seem to mean by "psychosis" is a mental disturbance of some unspecified kind, involving hallucinations, an inability to control one's stream of thought, and a tendency to engage in socially inappropriate behavior In addition, and perhaps most important, psychosis is thought to be a state that will last long beyond the specific event that provoked it.

Verified reports of drug-induced psychoses are scarcer than one might think (Cohen 1960; Cohen and Ditman 1962, 1963; Frosch et al. 1965; Hoffer 1965; Rosenthal 1964; Ungerleider et al. 1966; Bromberg 1939; Curtis 1939; Nesbitt 1940). Nevertheless, let us assume that these reports represent an interpretation of something that really happened. What kind of event can we imagine to have occurred that might have been interpreted as a "psychotic episode"?

The most likely sequence of events is this. An inexperienced user has certain unusual subjective experiences, which he or she may or may not attribute to having taken the drug, such as a distorted perception of space, so that it is difficult to climb stairs. The user's train of thought may be so confused that it is impossible to carry on a normal conversation. The user may suspect that the way he or she sees or hears things is quite different from the way others see and hear them. Whether or not the user attributes what is happening to the drug, the experiences are apt to be upsetting. One of the ways we know that we are normal human beings is that our perceptual world seems to be

Material on this page was taken from "History, Culture and Subjective Experience: An Exploration of the Social Bases of Drug-Induced Experiences." See footnote 1.

pretty much the same as other people's. If this is no longer true--if we find our subjective state so altered that our perceptions are no longer like other people's, we may think we have become insane. This is precisely what may happen to the inexperienced drug user. Moreover, this interpretation implies that the change is irreversible or, at least, that normality is not going to be restored easily. The drug experience, perhaps originally intended as a momentary entertainment, now looms as a momentous event which will disrupt one's life, possibly permanently. Faced with this conclusion, the user develops a fullblown anxiety attack, but it is an attack caused by the reaction to the drug experience rather than a direct consequence of the drug itself. (It is interesting that, in published reports of LSD psychoses, acute anxiety attacks appear as the largest category of untoward reactions [Frosch et al. 1965; Cohen and Ditman 1963; Ungerleider et al. 1966; Bromberg 1939].) Of course, long-time users may have similar experiences if they take a higher dosage than they are used to or because illicitly purchased drugs may vary greatly in strength.

The scientific literature does not report any verified cases of people acting on their distorted perceptions so as to harm themselves or others, but such cases have been reported in the press. If users have, for instance, stepped out of a second story window, deluded into thinking it only a few feet to the ground (Cohen 1960; Hoffer 1965), it would be because they had failed to make the necessary correction for the drug-induced distortion rather than because of an anxiety attack. Experienced users assert, however, that such corrections can be made and that they can control their thinking and actions so as to behave appropriately (Becker 1963).

Thus the most likely interpretation we can make of the drug-induced psychoses reported is that they are either severe anxiety reactions to an event interpreted and experienced as insanity, or failures of the user to correct for the perceptual distortions caused by the drug. While there are no reliable figures, it is obvious that a very large number of people use recreational drugs, primarily marijuana and LSD. One might suppose, then, that a great many people would have disquieting symptoms and that many would decide they had gone crazy and thus have a drug-induced anxiety attack. But while there must be more such occurrences than are reported in the professional literature, it is unlikely that there are any large number. Since the psychotic reaction stems from a definition of the drug-induced experience, the explanation of this paradox must lie in the availability of competing definitions of the subjective states produced by drugs.

Competing definitions come to users from other users who are known to have had sufficient experience with the drug to speak with authority. New users know that the drug does not produce permanent disabling damage in all cases, for they can see that other users do not suffer from it. The question remains, of course, whether the drug may not produce damage in some cases, however rare, and whether a particular person may be one of those cases.*

*Material on this page was taken from "History, Culture and Subjective Experience: An Exploration of the Social Bases of Drug-Induced Experiences." See footnote 1.

When users experience disturbing effects, other users typically assure them that the change in their subjective experience is neither rare nor dangerous. They may, for instance, know of an antidote for the frightening effects. They talk reassuringly about their own experiences, "normalizing" the frightening symptom by treating it as temporary. They maintain surveillance over affected users, preventing any physically or socially dangerous activity. They show them how to allow for the perceptual distortion the drug causes and how to manage interaction with nonusers. They redefine the experience the novice is having as desirable rather than frightening, as the end for which the drug is taken (New York City Mayor's Committee on Marihuana 1944; Becker 1963). What they say carries conviction, because the novice can see that it is not some idiosyncratic belief but is instead culturally shared. He or she thus has an alternative to defining the experience as "going crazy," and may decide that it was not so bad after all. We do not know how often this mechanism comes into play or how effective it is in preventing untoward psychological reactions. However, in the case of marijuana, at least, the paucity of reported cases of permanent damage coupled with the undoubted increase in use suggests that it may be effective.

For such a mechanism to operate, a number of conditions must be met. First, the drug must not produce permanent damage to the mind. Second, users of the drug must share a set of understandings--a culture--which includes, in addition to material on how to obtain and ingest the drug, definitions of the typical effects, the typical course of the experience, the impermanence of the effects, and a description of methods for dealing with someone who suffers an anxiety attack because of drug use or attempts to act on the basis of distorted perceptions.

Third, the drug should ordinarily be used in group settings, where other users can present the definitions of the drug-using culture to the person whose inner experience is so unusual as to provoke use of the commonsense category of insanity. Drugs for which technology and custom produce group use should produce a lower incidence of "psychotic episodes."

The last two conditions suggest, as is the case, that marijuana, surrounded by an elaborate culture and ordinarily used in group settings, should produce few psychotic episodes. I will discuss evidence on this point later.

Users suffering from drug-induced anxiety may also come into contact with nonusers who will offer definitions, depending on their own perspective and experience, that may validate the diagnosis of "going crazy" and thus prolong the episode, possibly producing relatively permanent disability. These nonusers include family members and police, but most important among them are psychiatrists and psychiatrically oriented physicians.

Material on this page was taken from "History, Culture and Subjective Experience: An Exploration of the Social Bases of Drug-Induced Experiences." See footnote 1.

Medical knowledge about the recreational use of drugs is spotty. Little research has been done or--as in the case of LSD--its conclusions are not clear, and what is known is not at the fingertips of physicians who do not specialize in the area. Psychiatrists are not anxious to treat drug users, so few of them have accumulated any clinical experience with the phenomenon. Nevertheless, a user who develops severe and uncontrollable anxiety will probably be brought to a psychiatric hospital, to an emergency room where a psychiatric resident will be called, or to a private psychiatrist (Ungerleider et al. 1966).

Physicians, confronted with a case of drug-induced anxiety and lacking specific knowledge of its character or proper treatment, rely on a kind of generalized diagnosis. They reason that people probably do not use drugs unless they are suffering from a severe underlying personality disturbance; that use of the drug may allow repressed conflicts to come into the open where they will prove unmanageable; that the drug in this way provokes a true psychosis; and, therefore, that the patient confronting them is psychotic. Furthermore, even though the effects of the drug wear off, the psychosis may not, for the repressed psychological problems it has brought to the surface may not recede.

On the basis of such a diagnosis, the physician hospitalizes the patient for observation and prepares, where possible, for long-term therapy designed to repair the damage done to the psychic defenses or to deal with the conflict. Both hospitalization and therapy are likely to reinforce the definition of the drug experience as insanity, for in both the patient will be required to "understand" that he or she is mentally ill as a precondition for return to the world (Szasz 1961).

Physicians, then, do not treat the anxiety attack as a localized phenomenon, to be treated in a symptomatic way, but as an outbreak of a serious disease heretofore hidden. They may thus prolong the serious effects beyond the time they might have lasted had the user instead come into contact with other users. This analysis, of course, is frankly speculative; what is required is more study of the way physicians treat cases of the kind described and, especially, comparative studies of the effects of treatment of drug-induced anxiety attacks by physicians and by drug users.

A number of variables, then, affect the character of drug-induced experiences. It remains to show that the experiences themselves are apt to vary according to when they occur in the history of use of a given drug in a society. In particular, it seems likely that the experience of acute anxiety caused by drug use will so vary.

Let us suppose that someone in a society discovers, rediscovers, or invents a drug which has the ability to alter subjective experience in desirable ways. This becomes known to increasing numbers of people, and the drug itself simultaneously becomes available, along with the information needed to make its use effective. Use increases, but users do not have a sufficient amount of experience with the drug to form a stable conception of it. No drug-using culture exists, and there is thus no authoritative alternative with which to counter the possible

*Material on this page was taken from "History, Culture and Subjective Experience: An Exploration of the Social Bases of Drug-Induced Experiences." See footnote 1.

definition, when and if it comes to mind, of the drug experience as madness. "Psychotic episodes" occur frequently.

But individuals accumulate experience with the drug and communicate their experiences to one another. Consensus develops about the drug's subjective effects, their duration, proper dosages, predictable dangers and how they may be avoided. All these points become matters of common knowledge, available to the novice user as well as the experienced one. A culture exists. "Psychotic episodes" occur less frequently in proportion to the growth of the culture.

Is this model a useful guide to reality? The only drug for which there is sufficient evidence to attempt an evaluation is marijuana. Even there the evidence is equivocal, but it is consistent with the model. Marijuana first came into use in the United States in the 1920s and early 30s, and all reports of psychosis associated with its use date from approximately that period (Bromberg 1939; Curtis 1939; Nesbitt 1940)--before there was a fully formed drug-using culture. The subsequent disappearance of reports of psychosis thus fits the model. .It is, of course, a shaky index, for it depends as much on the reporting habits of physicians as on the true incidence of cases, but it is the only thing available.

The psychoses described also fit the model, insofar as there is any clear indication of a drug-induced effect. The best evidence comes from the 31 cases reported by Bromberg. Where the detail given allows judgment, it appears that all but one stemmed from the person's inability to deal with either the perceptual distortion caused by the drug or with the panic created by the thought of losing one's mind (Bromberg 1939, pp. 6-7).

The evidence cited is extremely scanty, which leaves the final question, then, whether the model can be used to interpret current reports of LSD-induced psychosis. Are these episodes the consequence of an early stage in the development of an LSD-using culture? Will the number of episodes decrease while the number of users rises, as the model leads us to predict?

We cannot predict the history of LSD by direct analogy to the history of marijuana, for a number of important conditions may vary, and evidence on a number of important factors is still highly inconclusive. For example, there is a great deal of controversy as to whether or not LSD has any demonstrated causal relation to psychosis, apart from the definitions users impose on their experience. My own opinion is that while LSD may be more powerful in its effects than other drugs that have been studied, the cases in the literature support the belief that most of the psychotic episodes are panic reactions to the drug experience occasioned by the users' belief that they have lost their minds, or further disturbances among people already quite disturbed.

Is there an LSD-using culture? Here again, discussion must be tentative. It appears likely, however, that such a culture is in an early

*Material on this page was taken from "History, Culture and Subjective Experience: An Exploration of the Social Bases of Drug-Induced Experiences." See footnote 1.