Constructing drug effects: a history of set and setting

This review paper (2017) provides an overview of the concept of set and setting, from early (and non-drug) perspectives to current day set and setting.

Abstract

“Set and setting is a term which refers to the psychological, social, and cultural parameters which shape the response to psychedelic drugs. The concept is considered fundamental to psychedelic research and has also been used to describe nonpharmacological factors which shape the effects of other agents such as alcohol, heroin, amphetamines, or cocaine. This paper reviews the history and evolution of the concept of set and setting from the 19th-century Parisian Club des Hashischins, through to 1950s psychotomimetic research on nondrug determinants of psychopharmacology, the use of extra-drug techniques by psychedelic therapists of the 1950s, and the invention of the concept of set and setting by Leary. Later developments and expansions on the concept of set and setting are discussed, and the term of collective set and setting is suggested as a theoretical tool to describe the social forces which shape individual set and setting situations. The concept of set and setting, it is argued, is crucial not only for psychedelic research but also for advancing drug research and developing more effective drug policy.”

Author: Ido Hartogsohn

Summary

Set and setting is a term that refers to the psychological, social, and cultural parameters which shape the response to psychedelic drugs. It has also been used to describe nonpharmacological factors which shape the effects of other agents such as alcohol, heroin, amphetamines, or cocaine.

Introduction

The effects of psychoactive drugs can vary significantly between users across societies, cultures, and subcultures, yet we still do not have a solid working theory as to why this happens.

In a world that is growing increasingly skeptical of the war on drugs, it is becoming increasingly important to study extra-pharmacological variables to develop effective strategies for harm reduction.

A key concept in the field of drug research is set and setting, which holds that the effects of psychedelic drugs are dependent first and foremost upon set (personality, preparation, expectation, and intention of the person having the experience) and setting (physical, social, and cultural environment in which the experience takes place).

Issues of set and setting are important in accounts of mid-20th-century psychedelic research, and they continue to do so even today.

Set and setting are critical not only to experimental results obtained in labs, but also to the ways drug experiences play out in the field. Thus, studying set and setting is essential to the success of any drug education program.

Despite its popularity and applicability, the concept of set and setting has never been integrated into the study of psychopharmacology. This is lamentable, because a better understanding of set and setting can often reduce drug harm and increase potential drug benefit.

The discourse on set and setting has remained largely underdeveloped over the years, and a history of the concept would be valuable for understanding how it evolved and how it can be relevant for different clinical and extra-clinical situations.

This paper presents a history of the concept of set and setting, and suggests ways to improve its understanding.

The origins of set and setting

Timothy Leary coined the concept of set and setting, which is understood as the internal state of a person, the emotional/social environment, and finally the cultural environment. These factors are the most important determinants of the contents of psychedelic experiences.

Although the term set and setting emerged in the 1960s, its roots go further back. Shamans use elaborate schemes to amplify and control drug effects through the use of icaros (ritual songs), whistles, smoke blowing, and sucking, as well as host of other indigenous techniques.

When Hashish was discovered by Parisian society, the principles of set and setting were quick to remerge. Psychiatrist Jean Joseph Moreau noted some of the principles that govern the effects of hashish, including the fact that identical doses can produce fundamentally different results and that the user must ward off anything that might turn their madness into depression.

Moreau and Baudelaire noted that the effect of hashish varies widely, and in a single individual, it can induce sleep or great immoderate elation. To ensure a positive reaction, the user should clear his schedules and find himself in the right environment.

The writings of 19th-century French bohemians on set and setting were largely lost to drug researchers, but the late 1800s occult revival gave rise to some renewed literary-mystical experimentation with hashish, which led to the publication of The Psychology of Hashish by Aleister Crowley.

A study of the mescal ceremony found that the psychological effect of hashish was influenced by ceremonial elements such as prayer, song, rattle, and the use of fire.

In the first half of the 20th century, studies focused on the role of constitution and personality in drug reactions. However, these studies left out the role of preparation, expectation, intention, and social environment. German researchers took interest in the dependency of mescaline effects on personality, yet were unable to draw any conclusive inferences on the relationship between personality and drug effects.

During those years, the medical profession escaped the idea of set and setting, which runs contrary to a basic principle of pharmacology.

The insights of the members of the club des hashischins regarding the importance of extra-drug parameters would resurge in a crucial historical moment, when Timothy Leary was just starting his research on psilocybin.

The 19th-century Parisian club’s ideas would prove influential for mid-20th-century hallucinogenic drug research in another crucial way, by popularizing the psychotomimetic hypothesis of hallucinogenic drug effects.

Psychotomimetic investigations of extra-drug parameters

LSD research in the 1950s was dominated by the idea that the drug could be used to induce and study mental illness. This expectation created negative experiences and aggravated adverse effects. Many subjects who participated in research were hospitalized psychiatric patients who had little choice about partaking in experiments. Preparation for sessions was poor, and there was no therapeutic intention involved, and the social setting was composed of hospital psychiatrists who studied patients impersonally.

Psychotherapeutically oriented LSD researchers described the drug’s effects as cognitive enhancement and consciousness expansion, rather than distorted perceptions and thought retardation. They asked their subjects to repeat the experience time and again, expecting positive and even life-transforming experiences.

The setting for hallucinogenic drug research was considerably more benign, with subjects allowed to recline and listen to music with headphones. The results were dramatically different from those instigated by psychotomimetic researchers.

Mid-20th-century literature on extra-pharmacological determinants of drug action includes papers by some of the era’s leading psychotomimetic researchers. These papers include analyses of the relationship between subject and researcher, personality type, physical environment, social setting, and relationship between subject and researcher.

Robert Hyde conducted a three-year experiment in the Boston Psychopathic Hospital to study how the social milieu and study design might shape the LSD experience. He concluded that impersonal treatment and the necessity of performing structured tasks intensified symptom severity, whereas support and freedom lessened it.

Further experimentation showed that results varied widely depending on whether subjects spent the time of their experience in a familiar environment or in strange and hostile situations in the ward. In addition, subjects who were allowed to experiment in an environment to their choosing displayed the least incidence of schizophrenic-like reactions.

Hyde concluded that rigid research design, impersonal attitudes, negative attitudes, and nonacceptance led to intensified negative response, whereas peer support, familiarity with surroundings, flexible research design, acceptance, and opportunity for expression led to significantly more favorable reactions.

Psychotomimetic literature stressed the importance of new elements, such as social setting, social interaction and degree of freedom from tasks and examinations, while disregarding some elements, such as physical surrounding and preparation.

While the 1950s literature on extra-pharmacological determinants of drug action was primarily from psychotomimetic authors, it avoided reconsidering the universal validity of earlier research results with LSD.

Psychotherapeutic and socioanthropological investigations of nondrug variables

Psychotomimetic researchers considered nondrug parameters in shaping drug effects, and pioneers in psychedelic therapy explored how these variables could be used constructively. Alfred Matthew Hubbard, a colorful figure widely known as the ”Johnny Appleseed of LSD”, was one of the first to attempt to create a therapeutic environment for the optimization of LSD effects. He introduced many people to LSD and was influential in spreading the idea that one could improve LSD effects by manipulating the environment.

In 1959, an early textbook of psychedelic psychotherapy was published, which credited A.M. Hubbard for being the one from whose work the methods presented in the book grew out.

Researchers were increasingly accepting that setting and conditions are crucial to determining the effects of hallucinogenic drugs, and psychologist Betty Eisner was charged with studying the techniques for creating optimal conditions for integrative psychedelic experiences. Eisner’s work on LSD therapy was inspired by Hubbard and Osmond, and she used musical selections, photographs, mirrors, and postsession activities in the hospital’s art clinic to make subjects’ experiences as comfortable, evocative, and integrative as possible.

The clinical picture was almost complete, but one crucial element was still missing: the link with the greater culture.

Anthony F.C. Wallace drew attention to the role of cultural beliefs and values in shaping the effects of hallucinogens, and suggested that this was responsible for the differences between how hallucinogenic drug experiences manifest themselves in various societies.

White mescaline users exhibited extreme mood swings, exhibiting sexual and/or aggressive behavior, while Native American peyotists kept up their proper behavior, and reported feelings of deep connection with a more meaningful, higher order of existence.

Wallace suggested that cultural response to hallucinogens could be defined by a number of parameters such as communication, mechanism of control, induction, concealment, punishment, therapy, role assignment, and behavior guidance.

Wallace noted that hallucinogenic drug users incorporate the views and perceptions of their surrounding society into their hallucinations, and that this situation holds grave implications for western users of hallucinogens.

In the 1950s, Howard Becker wrote a classic paper on the social aspect of extra-drug variables. Becker predicted that the number of LSD psychoses would diminish in conjunction with the development of an LSD culture.

The term set and setting emerges

The idea that extra-pharmacological factors play a detrimental role in shaping the effects of hallucinogens was becoming well established in the field of hallucinogenic drug research.

Timothy Leary’s concept of set and setting was not original, but rather turned a growing sentiment into a simple slogan and made explicit the crucial importance of the set and the setting in which a drug experience takes place.

Leary’s most comprehensive account of set and setting can be found in The Psychedelic Experience: A Manual Based on the Tibetan Book of the Dead (1964). The book advised readers to allocate at least three days for the experience and its integration.

Leary’s work with psychedelics during the 1960s could be viewed as an ambitious exploration of the many ways in which psychedelics might interact with different set and setting conditions.

Leary continued to consider the issue of set and setting well into the second part of the 1960s, and suggested that psychedelic experiences could be programmed beforehand using Tibetan yantras, mantras, incense, and specific yogic postures.

Leary’s concept of set and setting was a valuable contribution to the psychedelic movement, and helped raise the probability of a positive experience for generations of researchers and drug users since.

Post-1960s developments in the theory of set and setting

Mid-20th-century hallucinogenic drug research provides ample examples for the centrality of set and setting in shaping drug effects. There were nine distinct types of uses for LSD at the time, leading to highly divergent descriptions of the effects of LSD.

By the 1970s, the concept of set and setting had all but disappeared from the literature, but in the 1980s it would reemerge in Norman Zinberg’s Drug, Set and Setting.

Betty Eisner added the concept of matrix to the scheme of things, which refers to the environment in which a patient returns after his psychedelic experience. The matrix should be a safe, nonjudgmental, supportive surroundings in which the patient can transform himself.

In sociological and anthropological accounts of drug action, elements of set and setting are prominently discussed, but therapists and medical practitioners have focused on immediate factors shaping drug effects in concrete circumstances.

A person’s personality, preparation, expectations and intentions are all shaped by the society and culture in which they grow up and live. Likewise, the physical setting and social setting are also shaped by the society and culture in which they live.

The concept of collective set and setting is similar to the concept of hinterland, and refers to the way in which certain kinds of realities are privileged over others through the use of epidemiological research methods, drug policy, media reporting, and Western Metaphysical assumptions about reality.

The concept of collective set and setting helps make sense of the markedly divergent types of responses LSD elicited in 1950s and 1960s American society. The Harvard psilocybin project of the early 1960s was possible because the cultural set and setting of the early 1950s would never have permitted it, and because the young generation that would take LSD and turn it into a countercultural symbol was not yet in sight. LSD and other psychedelics reflect the mind states of entire societies and cultures by acting in a variety of different ways depending on the time and the place.

Set and setting and other drugs

Psychedelics are the substance family whose effects are most susceptible to changes in set and setting conditions. But what about other drugs?

The ideas of set and setting surfaced twice in relation to the emergence of the use of hallucinogenic agents, with psychedelics being the most plastic and responsive to conditions of set and setting.

Despite the fact that the concept of set and setting has not been absent from accounts on the extra-pharmacological construction of other, nonpsychedelic, drugs, several scholars have used the concept to examine how extra-drug parameters shape the effects of nonpsychedelic drugs.

Zinberg observed that the setting created by the military service in the Vietnam war contributed to the soaring use of heroin within the American army. When these ex-soldiers returned to the US, 88% of them stopped using the drug spontaneously.

Alcohol effects vary across societies, as well as within societies over time, and depending on the context in which it is consumed.

Cohen (1990) used set and setting to examine the habits of Dutch cocaine users, while Dwyer and Moore (2013) used it to argue that social factors shape methamphetamine effects in recreational users. Carl Hart (2013) used set and setting to discuss the effects of cocaine and crack-cocaine on high earning executives and homeless people.

In studies on rats, environments can influence drug use. Solitary cages symbolize the slums and ghettos in which much of modern drug abuse takes place, and environments lacking alternative reinforcers can contribute to patterns of drug abuse.

The concept of set and setting may help explain human experience in general, and may also apply to hypnosis, meditation, dreams, or the ordinary waking state of consensus reality.

The concept of set and setting can be useful in explaining and controlling drug-altered states of consciousness.

medicine and culture

With the recent resurgence of psychedelic research, the concept of set and setting has once again become relevant. However, the current dominant model of controlled trials demands neutral experimental conditions to isolate drug effects.

The dilemma of performing double blind experiments with psychedelics is not a new issue for psychedelic therapy, and achieving an objective or even neutral set and setting is problematic by definition. In the 1950s, the Canadian Addiction Research Foundation (ARF) challenged the results of LSD treatment for alcoholism by Saskatchewan psychiatrists Osmond and Hoffer, claiming that the researchers failed to effectively remove the effects of environmental parameters from their design.

Wallace lamented the lack of cultural controls in 1950s hallucinogen research, and Hyde went in that direction when he studied how various social variables influenced the effects of LSD on subjects. Nevertheless, such efforts were largely abandoned.

Psychedelic drug research needs to take into consideration extra-drug factors, and avoid excessive reliance on a biomedical model. There is no one ”correct” type of setting, and various ”incorrect” types of setting.

Over the last decades, many different initiatives have been launched to reduce drug harms, including Dutch coffee shops, chill out rooms and free availability of water in clubs where MDMA is commonly used.

The ways nondrug factors shape the effects of drugs can be studied to improve the use of psychopharmacological agents and prevent or minimize the social harms of drug use. In the late 1960s, the percentage of bad LSD trips rose sharply. By the mid-1970s, the percentage of bad LSD trips sank by a dramatic 45%, a fact which Bunce credits to changes in the cultural climate.

Social policy can have a profound impact on the levels of harms drug users suffer.

To reduce drug harms, we need to create an open environment of information, trust, and support for drug users.

In a drug suffused world, educating the public on set and setting is an urgently needed skill. Medical marihuana patients receive training, and such initiatives show that educating the public on set and setting is not impractical or inconceivable in any way.