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Psychedelic Crisis FAQ
Helping someone through a bad trip, psychic crisis, or spiritual crisis
by Erowid
v 2.1 - Aug 1, 2005
This FAQ is not regularly updated or maintained. It may include out-of-date information. Please check the version date to see when it was most recently revised. For current information, see Erowid's summary pages in the substance's main vault.
INDEX



Disclaimer

This FAQ is presented for informational purposes only. We do not advocate illegal activities. We do believe in the right of the individual to have free access to information and ideas. We strongly recommend that the reader learn about applicable local and federal laws regarding possession, sale, and purchase of any psychoactives they intend to use. This FAQ may be redistributed as long as the text remains unchanged and all credits remain attached. If you create copies of this FAQ on the web, please try to keep them updated to the current version.



Credits

The information contained in this FAQ has been culled from a variety of sources. The collection, organization, layout, and writing of information for the FAQ were done by Erowid.

Revision History
0.5 - 09/10/97 - Assembled emails and passed around for comment
1.0 - 05/03/98 - Created the basic HTML, FAQ.
1.1 - 11/07/98 - Added index, disclaimer, credits, and significantly improved organization.
1.2 - 12/18/99 - Updated Antidotes section.
2.0 - 08/22/01 - Reorganized from a realtime usage perspective, added Assessment section
2.1 - 08/01/05 - Changed reference to CPR/Rescue Breathing in "Critical or Life Threatening Situation" section
2.2 - 02/17/14 - Added Tripsit link


Introduction

There are a lot of different situations in which someone might need help while using psychoactives. Deciding what to do in any particular instance requires calmness, clear thinking and the ability to make decisions. This FAQ is intended to provide ideas of what one can do. Which particular method(s) should be used is unique to each situation. Remember, while not easily done in the most severe situations, the single most important thing an aide can do is to STAY CALM and as clear-headed as possible.



Assessment

Helping someone through a crisis situation should be broken down into two stages: assessing and acting. The first step is to assess the situation and try to determine what type of action needs to be taken.

Type of Situation
  1. Is there immediate or potential physical danger? [Critical] Is the person conscious? Is breath rate depressed or accelerated? Heart rate? Is there any skin discoloration? If unconscious, is there an appropriate pain response?
  2. Is the person a danger to themselves or others? [Critical] Are they violent and acting threateningly towards others? What are the chances that they will attack someone? Hurt themselves unintentionaly? Get in a car and drive? Attempt suicide?
  3. Are they having a spiritual, mental, or emotional crisis? [Crisis] Do they seem overly scared, depressed, or angry? Mood swings? Acting crazily? Awake but non-responsive?
Helpful Information
The following information can be helpful in determining what action should be taken. Try not to leave the person alone while collecting the information. In cases of spiritual / emotional crisis, it is often better to ask friends or nearby people rather than trying to get the information out of the individual experiencing the crisis.

  1. What substance did they take? If possible, learn what substance(s) they took and in what form (oral, smoked, injected). How much did they take? When did they take it? Are they on any other medications or supplements?
  2. Who are they? Do they have friends nearby? Where do they live? Do they have a history of this type or similar problems?


Find out all you can. Without a good assessment of what's happening, critical errors in handling it (pumping someone full of benzos unnecessarily, failing to call 911 in time, etc.) are more likely to occur. With as much of that information as possible in hand, decide the severity of the crisis and act accordingly:
  • Critical - Potential or immediate physical danger to self or others, possibly requiring medical attention.
  • Crisis - Benign to extreme psychotic behavior, negative thought loops, panic attacks.


Situations that Require Professional Help

  1. If you feel that lives are in danger.
  2. If you feel that the situation is out of control and there is nobody else willing to take responsibility for the individual.


Critical or Life Threatening Situation

  1. Who is available to help you? Find someone with medical emergency experience. The more, the better, but someone with Red Cross training is much better than someone who knows no basic first aid.
  2. If the person is seizing. Loosen clothing, cushion and position the person's body to prevent injury and choking. Seizures can be very, very serious, are more risky the longer they last or the more frequently they occur, and can cause permanent brain damage in the worst of cases.
  3. If the person is conscious. Look for telltale signs of what they took: severe jaw tension is usually associated with MDMA or other stimulants. Watch for nystagmus (eye-wiggles), also a sign of stimulant use. Look for sweating -- sweating is a good sign at this point. Watch for chills, cover them with a blanket if they appear to be shivering.
  4. If the person is unconscious. Gently try to wake them. Shake them gently, speak to them in a firm voice ("Are you ok? Should I get a doctor?") If they are vomiting, turn them on their side so the vomit can flow out of their mouth (so they don't choke). Try to determine if the person is in a coma, or a dissociated state [see below].
  5. If the person is not breathing, attempt to get their breathing going again. Loosen clothing. Shake gently. Clear airways, especially if they have vomited. Rescue Breathing can be performed by someone certified to do so.

  6. If the person's heart is not beating, CPR can be performed by someone certified to do so.

  7. Call 911. Remember that it will take time for assistance to respond and be prepared for the arrival of emergency vehicles and possibly police officers. Clear a way for emergency personnel to get to the person. If you are at a party, get the music turned off and get an announcement made to locate friends...if any are available.

    This can be a difficult decision in many situations, but at this point we're talking about a life-threatening event. The consequences of calling in outside help will be far less severe than the consequences of losing a life.


Crisis Situation (Emotional, Mental, Spiritual)

Crisis situations can manifest themselves in countless ways, anything from belligerent, potentially violent outbursts to complete withdrawal from external stimuli to debilitating paranoia or fear to relatively harmless compulsive or psychotic behavior. How one deals with the situation depends greatly on the symptoms the person is experiencing.

In most situations you're not trying to force any particular action or reaction on the part of the person experiencing the crisis. The point isn't to "talk them down" since this doesn't work and usually makes things worse. Make sure they know that everything in the outside world is ok...you're with them, watching out for them. Make sure they don't hurt themselves or others, and if things get out of control, call for help. Whatever you choose to do, watch for their reaction. If what you're doing seems to make things worse, move on to something else.

Many guides and counselors who have experience with this type of acute emotional/spiritual crisis say that the best thing to do is to tell someone to let go and relax into the feelings. The mantra "breathe, relax, let go" was developed in the 1960's and 1970's for psychedelic therapy and it is argued that much of the emotional dissonance and mental stress comes from fighting and resisting potentially uncomfortable internal processes. Guides suggest that it is the fear which is often the dominant force precipitating a crisis and the main role of a crisis-manager is to help create a space where the person can feel safer.

Quick List
  • Try to get a sense of 'how far out' they are. Do they think they are in the same place you think you are? Do they know what time of day it is, what their name is? Do they know they ingested a psychoactive?
  • Reassure them in a calm, matter-of-fact tone that you are with them and watching out for them.
  • Remind them that this is a substance-induced state of mind, which will end.
  • Remind them to breathe and relax.
  • Let them know that spiritual crises are normal.
  • Be as calm as possible while talking to them, and use a normal tone of voice even if you are feeling anxious yourself.
  • If possible, bring them some water or a piece of bread. Ask them if they would like a sip or a bite.
  • Sit and talk. Pass the time with them.
  • If you know their name, use it a couple of times. "Hey John, how are you?
  • Introduce yourself, say your name and how you come to be there.
  • Look at beautiful things.
  • Sing (anything, but especially children's songs such as Row, Row, Row Your Boat).
  • Pet or play with an animal.
  • Go for a walk.
  • Recall good memories (beach, children, etc.).
  • Dance.
  • Hold hands.
Pitfalls to Avoid

  • Don't try too hard to 'get them to come down'. This often makes things worse.
  • Don't confuse them by repeatedly asking them questions they can't answer.
  • Don't make them feel even more isolated by acting worried and nervous around them.
  • Probably avoid any complex physical activities, like trying to zipper a jacket or fixing the stereo or lighting the pilot light on the stove.
  • Respect their needs and boundaries.
    • Don't touch them if they don't want to be touched.
    • Give them space if they seem to want it.
What To Do

  1. If someone seems to be having a hard time, gently ask them if they would like someone to sit with them. If it seems disturbing to them to have someone sitting with them, have someone nearby keep an eye on them unobtrusively.

  2. Relate to them in the space they are in. Oftentimes, the thing which isolates people and creates a sense of paranoia or loss is that they are *so far out* of normal awareness that people are trying hard to ground them. Start off instead by trying to just be there for them. Try to see the world through their eyes.

  3. What different ways can you change setting (noise level, temperature, outside vs. inside, etc.)? A party/rave/concert setting can aggravate a person's state of mind. Consider finding the quietest place if it seems like it will help (taking cues from the experiencer), and ask people to not crowd around. Reassure them the situation is under control, noting those who offer help in case help is needed later.

  4. How can you minimize risk of emotional or physical harm? Remember your concern for how the person is feeling, not concern for the situation (as in "oh my gawd, we've got to do something.")

  5. Paranoia: If the person doesn't want anyone near them, hang back, turn so you aren't staring at them, but keep an eye on them as discretely as possible. Think about what it would feel like to be in a paranoid state, having some stranger (whether you are or not) follow you around and watch you.

  6. What objects/activities/distractions might help the person get through a difficult space (toys, animals, music, etc.)?

  7. No Pressure: Just be with them. Unless there is risk of bodily injury, just make it clear you are there for them if they need anything.

  8. Touch. Touch can be very powerful, but it can also be quite violating. In general, don't touch them unless they say its OK or they touch you first. If it seems like they might need a hug, ask them. If they are beyond verbal communication, try to be very sensitive to any negative reaction to touch. Try to avoid getting pulled into any sexual contact. Often, holding hands is a very effective and non-threatening way to let someone know you are there if they need you.

  9. Intensity can come in cycles or waves. It also can work as a system -- a movement through transpersonal spaces which can have a beginning, a middle, and an end. Don't try to push too hard to move it.

  10. Not Forever: If they are connected enough to worry about their sanity, assure them that the state is due to a psychoactive and they will return to their 'home' state of mind in time.

  11. Normal Drug-Induced: Tell them they are experiencing the acute effects of a psychoactive (if you know what, tell them) and tell them that it is normal (although uncommon) to go through spiritual crises and they (like thousands before them) will be fine if they relax and let the substance run its course.

  12. Breathing: breathe with them. If they are connected enough to be present for assistance, get them to join you in deep, long, full breaths. If they're amenable to it, or really far out and freaking, putting a hand on their belly and saying, "breath from down here", "just keep breathing, you 'got it", can help.

  13. Relaxing: It can be very very hard to relax in the middle of dying or being pulled apart by demons, but tell them that you are there to make sure nothing happens to their physical body. One of the most important things during really difficult internal processes is to learn to be OK with them happening, to 'relax' one's attempt to stop the experience and just let it happen.

  14. Getting Meditative: Gently suggesting they try to close their eyes and focus inward can sometimes change the course of their experience.


  15. Barefeet on the ground: One of the most centering and grounding thing to do is to take off shoes and socks and get your feet directly on the hard ground. Be careful of doing this in toe-dangerous surroundings.


  16. Eye contact: If the person is not acting paranoid and fearful of you, make sure to include a lot of eye contact.


  17. Everything is Fine with Me: Make it clear that the whole world may be falling apart for them, but everything is OK with you.


  18. Healthy process: Crises are a normal part of the human psychological process and one way to engage them is as a process of healing, not a 'problem' to be fixed. See Grof, Bill Richards, et al.




It can be very very difficult to talk, relate, or even really be fully aware of other people's presence at the peak of intense experiences. If you're sitting with a person who is in this state, listen to what they say and (if it seems appropriate and useful) you can prompt them with very simple questions about their experience...

"What color is it?" -- "Are you sad?" -- "How old are you?"

It seems likely that the answers you will receive will be metaphoric and not concrete. "All the colors" - "I'm as old as the river". Don't expect to carry on a normal conversation.

The most comforting thing some people have reported helped them during acute experiences is a blanket wrapped around them. We cannot recommend enough having a thick, weighty blanket for emergencies.



Summary

While dealing with a psychedelic crisis can be unnerving for participants, sitters and observers alike, most events are manageable with a careful assessment and calm, decisive response. For the person who had the episode, integrating the experience once the acute phase has passed is just as important as facing the crisis itself.




APPENDICES


Antidotes

This section is for discussing substances which are used to treat psychedelic crises. The most well known drug used by emergency professionals is Thorazine, although its use has dropped somewhat because it seems to be extremely psychologically hard on the recipient.

Most acute crisis which land someone in the care of an emergency professional are the result of intense anxiety. Psychedelics can and do precipitate uncontrollable feelings of anxiety, fear, paranoia, and other agitated states. According to medical professionals who have experience dealing with psychedelics, the primary pharmaceuticals used to treat these acute agitated states are the benzodiazapenes such as Valium or Xanax.

"If all psychological approaches fail and tranquillizers have to be used, it is much better to start with Librium (30-60 milligrams) or Valium (10-30 milligrams), which seem to alleviate painful emotions without interfering with the course of the session. As soon as possible, the patient should resume a reclining position with eyeshades and headphones, to continue the introspective approach to the experience."
-- Stan Grof, LSD Psychotherapy
Haloperidol - An antipsychotic drug used to treat acute and chronic psychosis and is "considered particularly effective in the management of hyperactivity, agitation, and mania."
[mentalhealth.com]

Risperdal (risperidine / risperidone) - A somewhat newer antipsychotic often considered the first choice among the anti-psychotics for treating extreme acute hallucinogen-induced psychotic episodes because of its high affinity for 5HT2a receptors. Anti-psychotics are not generally used to treat panic reactions or other psychedelic crisis which do not involve acting out.
[TrauamSurvival.org]

Thorazine (chlorpromazine) - An antipsychotic with a large number of unpleasant side effects, a distant third or fourth choice when treating most psychosis or anxiety. "Thorazine and Mellaril are antipsychotic agents in a class called phenothiazines. They are excluded for use in the elderly because they do not have a very favorable side effect profile. If an agent is needed to control acute episodes of threatening behaviors or aggression, newer antipsychotic drugs like Risperdal or Haldol are preferred. "
[Geriatric Drug Review]

"Thorazine and other major tranquillizers are not specific neutralizers of the LSD effect. Used in high dosages, they have a general inhibiting effect that overrides and masks the psychedelic action of LSD. Detailed retrospective analysis of this situation usually shows that the patient experiences the action of both drugs simultaneously, and that the combined effect is rather unpleasant."
-- Stan Grof, LSD Psychotherapy

Treating a psychedelic crisis with Thorazine is to be avoided and is considered a form of extreme mental torture and has been known to result in weeks or months of psychological trauma for the person treated with this "mental straightjacket" while in the middle of a psychedelic crisis.
[Thorazine Vault]

Valium (diazepam) - is used to treat anxiety and muscle spasms, as well as generally calming people down. Dosage used is between 2 and 10 mg for low level anxiety and 10-30 mg for acute, extreme attacks. Valium is schedule IV in the US partially because some people find the effects pleasant enough to use them recreationally. Valium, Xanax, and other equivalent benzodiazepines are considered by some members of the psychedelic community to be the best chemical treatment for extreme psychedelic crises.
[Valium Vault]

Xanax (alprazolam) - Another benzodiazepine (like Valium) used to treat anxiety, muscle spasms, and to calm people down. Xanax comes on more quickly than valium and is considered more useful for treating acute episodes. Xanax pills are sometimes chewed to speed onset, although the taste can be unpleasant and soda, water, or fruit may be necessary to reduce the bitterness. Dosage for Xanax is .25-1 mg for low anxiety, and 1-3 mg for extreme acute attacks. See Valium. Xanax may be somewhat more sedating than Valium.
[Xanax Vault]



Definitions

Coma - Unconsciousness and unrousability together are considered a 'coma' and should be taken very seriously. Comas are a common overdose reaction with GHB, opiates, ketamine, and DXM; and not unheard of with other substances (2C-T-7, DMT, 5-MeO-DMT, and possibly others) and some combinations; but quite uncommon with the vast majority of entheogens/psychedelics. If the person is unconscious, say their name, gently try to rouse them and ask them if they are sleeping. Take their pulse and feel their forehead for temperature. Check their response to pain by pinching the muscle along the collar bone and twisting or by pinching hard at the base of a fingernail; look for physical response to this (at the very least, their pupils will dilate temporarily). If you get no response to any of this, it sounds like a coma. Strong dissociated states can look similar to a coma but as with someone passed out from alcohol, most dissociated states will include some movement, some response to stimulus (you pinch them and they say ouch, or try to push away your hand, or roll over).



Acute Physical Dangers by Substance

GHB - OD can suppress respiration or cause coma. The data is somewhat confusing about how likely death is without hospitalization, but it has been reported by many people who they were 'saved in the nick of time by medics' when they quit breathing. Some of the data are less than reliable, but GHB definitely is more problematic than most others. GHB can be very bad in combination with other depressants. Vomiting, nausea, and unconsciousness are common.

Ketamine - Can cause nausea, unconsciousness.

LSD - Can cause long (6-18 hour -- or more) acute psycho-spiritual crises, ego loss, detachment from consensual reality, paraonoia, fear, sadness, despair, and extreme moodswings. Any type of experience, really, is possible. No deaths have been reported that did not involve physical injury.

Mushrooms - Can cause medium long (4-10 hour -- or more) acute psycho-spiritual crises, including ego loss, detachment from consensual reality, paranoia, fear, sadness, moodswings. Mushrooms tend to be more 'dreamy' than LSD, less energetic. No deaths have been reported that did not involve physical injury.

Cannabis - Most acute crises with cannabis are related to oral ingestion. Cannabis crises last 2-6 hours (or more) and can include paranoia, panic attacks, sluggishness, going in and out of consciousness, extremely bloodshot eyes, and mood swings. No deaths have been reported that did not involve physical injury. A few people reportedly have severe asthmatic attacks precipitated by smoking cannabis.

Cough Syrup / DXM - DXM alone can cause dissociation, confusion, nausea/vomiting, and unconsciousness at high doses. One of the primary dangers, however, is in the ingestion of other active ingredients contained in various brands of cough syrup. If problems occur in someone who has reportedly consumed cough syrup, try to determine what source material was used and whether it contained any other ingredients. [More Info]

MDMA - MDMA is tricky because many other substances are sold as MDMA, so if someone took "E" they may have something else entirely. MDMA itself can cause crises in a couple different ways:
  • Overheating/Dehydration - Have the person sip on a big glass of water [more info about water intake] if they are not likely to choke on it -- MDMA seldom causes catatonia (unconsciousness), though it does happen.
  • MDMA can cause uncomfortable feelings because it is a very strong stimulant. Breathing, relaxing, lying down, sitting and talking are all good.
  • MDMA can also cause a crisis because it opens up internal feelings that may be difficult or uncomfortable, unblock memories, etc. MDMA (unlike other psychedelics) does not often cause extreme paranoia or fits of anger.
  • Death with MDMA is associated with dehydration and overheating from overexertion. If someone stays on the dancefloor for a few hours straight, get them some water and ask them to step off for a drink and short rest.

2C-T-7 - Can cause severe nausea, seizures, and respiratory distress. The experience of vomiting is different on 2C-T-7 and a person vomiting on it can be more prone to asphyxiation. Perhaps more than many other psychedelics, 2C-T-7 has been reported to cause belligerent and/or violent outbursts at high doses. It has also been the cause of several fatalities.

5-MeO-DMT - Can cause nausea, seizures, and catatonia. No known deaths.



Other Languages
Francais: Crises Psychedeliques
Hungarian Translation of the Psychedelic Crisis FAQ


Other Resources
How to Talk Someone Down
How to Avoid a Bad Trip
Guiding & Sitting Vault
TripSit - Includes chat space
The Good Drugs Guide: Essential Info - Bad Trips

Post-Crisis Therapy Resources
Spiritual Emergence Network (SEN)
The SEN is a referral service to therapists around the United States who are trained in dealing with personal crises from the perspective of healing and wellness. Generally considered to be psychedelic-aware, meaning that SEN therapists will react compassionately and non-judgementally when an individual seeks help after a difficult or traumatic experience precipitated by a psychedelic or strong psychoactive.