Crisis Intervention Related to the Use of Psychoactive Substances in Recreational Settings – Evaluating the Kosmicare Project at Boom Festival

This observational field study (n=176) evaluated the efficacy of a natural setting-based crisis intervention program aimed at festival attendees who encountered challenging experiences while using psychoactive substances. While many of the care-seekers resolved their crises in response to onsite interventions, unresolved crises were more often related to outbursts of mental health episodes that were either brought on by psychoactive substance use or not.

Abstract

Introduction: Kosmicare project implements crisis intervention in situations related to the use of psychoactive substances at Boom Festival (Portugal). We present evaluation research that aims to contribute to the transformation of the project into an evidence-based intervention model. It relies on harm reduction and risk minimization principles, crisis intervention models, and Grof’s psychedelic psychotherapy approach for crisis intervention in situations related to unsupervised use of psychedelics. Intervention was expected to produce knowledge about the relation between substance use and mental health impact in reducing potential risk related to the use of psychoactive substances and mental illness, as well as an impact upon target population’s views of themselves, their relationship to substance use, and to life events in general.

Methods: Research includes data on process and outcome indicators through a mixed methods approach, collected next to a sample of n=176 participants. Sample size varied considerably, however, among different research measures.

Results: 52% of Kosmicare visitors reported LSD use. Over 40% also presented multiple drug use. Pre-post mental state evaluation showed statistically significant difference (p<.05) confirming crisis resolution. Crisis episodes that presented no resolution were more often related with mental health outburst episodes, with psychoactive substance use or not. Visitors showed high satisfaction with intervention (n=58) and according to follow-up (n=18) this perception was stable over time. Crisis intervention was experienced as very significant.

Discussion: We discuss limitations and implications of evaluating natural setting based interventions, and the relation between psychoactive substance use and psychopathology. Other data on visitor’s profile and vulnerability to crisis showed inconclusive.”

Authors: Maria C. Carvalho, Mariana P. de Sousa, Paula Frango, Pedro Dias, Joana Carvalho, Marta Rodrigues & Tânia Rodrigues

Summary

INTRODUCTION AND FRAMEWORK

Over the last decades, we have witnessed considerable transformation in psychoactive substance use patterns in Portugal, with a slight reduction and stabilization in recent years. This is also reflected in Portuguese nightlife and outdoor recreational environments, where PAS use is seen to not significantly harm global adjustment.

Partygoers report their experiences of PAS use at raves and trance parties with specific meanings and motivations. Intervention modalities based in proximity and informality are particularly important in these environments if we further consider that the user populations participating are not covered by any other program or service.

Kosmicare, a project that develops crisis intervention in situations related to the use of PAS at Boom Festival (Portugal), is being evaluated to develop into an evidence-based intervention model.

1.1.1. Crisis Intervention – General Aspects

Crisis intervention is a support therapy modality that offers quick resolution and relief of symptoms. It has gained popularity in the field of Community Intervention, but no specific references were found that described using crisis intervention with recreational users.

1.1.2. PAS Use Induced Crisis

Intervention in crisis related to PAS use can result in a profound transformation in the sense anticipated by Abraham Maslow, but if the approach is conducted by inexperienced staff, there is probability of serious psychological damage.

There are several explanations for why such benefits are apparently possible, including psychoactives’ chemical capacity to “open the mind”, the environment surrounding the experience being the most determining factor, and the experience lasting long after.

There is a thin line separating an extremely positive experience from an overt crisis episode, and factors related to the drug, the set and the setting can all contribute to this.

Set refers to the psychological characteristics of the individual influencing his motivations, expectations and attitudes towards use. Specifically, the users’ personality, pre-existing mental health problems, past history of trauma, abuse and other life-events are considered of extreme relevance.

Setting refers to the physical and social environment where the experience actually occurs, and includes factors such as place, company, and opportunity to share the unfolding experience. Several physical and social dimensions are recognized as relevant factors as well, including loud sound, dust, visual stimulation, asymmetric temperatures, and bad resting conditions.

A crisis episode can occur when a person ingests a PAS, when the person perceives the event in a hurtful way, or when the person lacks coping strategies to deal with the situation. Empathy allows a decrease in anxiety and facilitates the emergence of a less threatening perception of events.

Unsupervised PAS use can cause complex symptoms, including physical symptoms, consciousness, alertness, attention and orientation alterations, odor, texture, pain and sense of balance alterations, temporal and spatial orientation alterations, and language alterations.

There is considerable discussion around the relation between PAS use and the emergence of psychiatric symptoms during crisis episodes. Some argue that it is more likely to reflect pre-existing disorders than PAS effects.

Psychiatric comorbidity research is divided on whether PAS-users present increased incidence of psychiatric comorbidity or whether disorders pre-exist or are consequent to PAS use.

Crisis might occur over the life of any individual and should be understood as a normative developmental process. Intervention can help the individual reestablish coping and control.

1.1.3. Crisis Intervention Principles

Crisis intervention should follow a number of principles oriented towards transforming an unpleasant experience into a positive one.

Space should include a place to rest, warmth, privacy and basic needs such as comfort, hydration, nutrition and refrigeration.

Facilitation is the presence of a supportive professional, with whom a trusting relationship can be established. Empathy, ability to keep focus, and intimate knowledge of altered states are strategies that guarantee the generation of trust. During crisis intervention, the facilitator should use an approach that invites the individual to talk through the experience, instead of talking down. This approach is based on the assumption that “a bad experience isn’t necessarily a negative experience”.

Intervention must ensure the individual is safe from hurting himself or others, and must not focus on messages such as “keep calm” or the attempt to convince the person that “everything is okay”. Questioning is also counter indicated, since it might reflect the facilitator’s anxiety or apprehension about the situation.

HRRM is a model for intervention that aims to promote health and globally reduce risk by replacing high risk behaviors with others that have the potential to drastically reduce negative aspects of PAS use.

1.2. The Kosmicare (KC) Intervention Model

Boom Festival, a biennial independent artistic expression multidisciplinary cultural event, implemented KC1 in 2002 as a strategy to deal with multiple levels of risk associated with PAS use. KC1 includes HRRM (information and outreach, chill-out, drug use paraphernalia, testing) and a care space especially designed for people undergoing difficult psychedelic and emotional experiences.

The project offers care and support to people undergoing a crisis episode related to PAS use, particularly psychedelics, and aims to reduce the risk for mental disorders and enhance possible benefits that emerge from this experience.

A care space was created on the Festival premises, including a main area for most situations and an additional area for situations that required isolation due to their serious clinical presentation.

The project was implemented by a team composed mostly of volunteer staff, including coordinators, team leaders, sitters, a medical team, secretaries, and over twenty people of several nationalities.

In 2010, we began to develop evaluation research to examine the efficacy of the KC intervention in reducing the number of crisis symptoms among the various groups of visitors. We also wanted to know what long-term consequences of crisis intervention might emerge.

Visitors were either transported by Festival staff cooperating with KC, or arrived on their own. Situations were evaluated by the team leader, who assigned a sitter, and coordinated shift turnovers and passed information to the next scheduled team.

The sitters were a group of experienced and trained peers responsible for individual intervention. They were selected for their skills in active listening, intuition, knowledge of PAS and associated effects, and empathy with intervention targets.

During intervention, collaboration between production staff, medical staff and security was important. Partnerships with entities outside the Festival were also important, but transfer to another facility was considered a last resort.

KC’s evaluation research has included several studies that have contributed to the development of an evidence-based intervention model. These studies have aimed to describe the intervention process and have identified qualitative and quantitative indicators.

METHOD

According to the Society for Prevention Research, an efficacious intervention will have been tested in at least two rigorous trials and show consistent positive effects without serious iatrogenic effects.

The study design was inspired by program evaluation methodology, which includes a number of process and outcome indicators. It examines how the intervention unfolded and participants’ reactions to the program, as well as the issue of quality, gathering information relevant to the appraisal of effectiveness and the introduction of future improvements.

We used a mixed methods approach to gather data on process and outcome evaluation, which involved the integration of the data at one or more stages in the process of research.

The global research project design is presented in Table 1. A number of factors account for differences in sample sizes for the different measurements, including the fact that many visitors are unavailable for feedback immediately after intervention.

2.1. Participants

Kosmicare attended 122 festival participants, including male and female visitors from a wide age range and from very diverse nationalities, for intervention and evaluation research. The project offered support for personal crisis unrelated to PAS use, and for situations unrelated to crisis at all.

We estimate that a small proportion of situations attended at KC might be missing from our global 2010 research sample.

Sample 3 consists of 18 visitors gathered among KC 2010 and 2012 editions of the festival editions. Of the 121 e-mail contacts from both editions available, 18 participants were recruited.

There are a number of reasons that can be pointed out to justify difficulties accessing participants for follow-up purposes, including the fact that most were unavailable and uncooperative, still presenting difficulty to write, being in a hurry to leave the intervention area, among other reasons.

2.2. Research Procedures

Data collection took place over three different moments: during the KC 2010, and at the moment visitors left KC. Visitors’ final feedback concerns a much smaller sample of n=58 participants.

A total of 18 visitors were approached for follow-up purposes via e-mail, requesting collaboration to answer an online questionnaire. They were approached after eighteen months had passed since intervention.

2.3. Measurements

Flay et al. refer to the importance of using psychometrically sound measures and data collection procedures in prevention research.

Several measurements were collected over several intervention stages, but due to the short time between intervention implementation and research project presentation, pilot-tests were not possible.

During implementation, secretaries approached sitters requesting information. Sitters filled out Forms 0, 1, 2 and 4 (mental state on arrival, intervention, and departure), and Form 3 (condition when leaving KC) was specially designed to obtain a quantitative indicator of crisis resolution.

We developed the Mini-Mental State Exam (MSEC) to evaluate mental state alterations during crisis resulting from the use of PAS. Its psychometric properties suggest high levels of internal consistency in all dimensions of mental state exam, suggesting its high reliability.

We collected data using an online questionnaire during a follow-up period of 18 to 6 months after intervention. The burden put on visitors was minimized by using Google Drive – Forms.

3.1.1. Participants and Crisis Characterization

Table 3 summarizes information about participants from three research samples (n=176). Most participants were males, aged 19-39, European, and highly qualified.

Visitors attended KC due to difficult experiences involving PAS use, personal crises not involving PAS use, and noncrisis situations not related to a crisis episode. These situations included requests for a rest area, information or minor healthcare requests, in the absence of distress.

The situations in which visitors presented mental crisis involving PAS use were probably the ones less accurately accounted for in Sample 1 (n=122), since they presented less severely and required less time and effort to be solved.

The project covered a wide range of needs, surpassing its main focus on difficult experiences involving PAS use. It also suggested the need for a broader, multi-leveled definition of crisis.

Results suggest that frequent poly drug use is common among KC visitors, but also point out to cases when no PAS were used.

Table 4 presents descriptive frequency data concerning use of different PAS in KC visitors. Because cannabis is less frequently associated with unpleasant effects and crisis symptoms in users’ perceptions, it is possible our data under-reports its prevalence and its influence over crisis symptoms.

When poly drug use occurred, LSD, alcohol and cannabis were the most frequent combinations, followed by amphetamines and alcohol and LSD and MDMA.

Analysis of symptoms according to gender shows a predominance of crisis symptoms in male visitors. However, data concerning symptoms collected through the MSEC are missing for n=39 participants.

Analysis of symptoms per PAS according to sitter’s perception showed that affect and emotion-related symptoms were the most frequent category induced by all PAS. Visitors using LSD and MDMA presented a larger number of symptoms.

Visitors presenting alcohol use, amphetamine use, cannabis use, ketamine use, and cocaine use showed affect and emotion alterations such as aggression, suicidal ideation, expressions of low self-esteem, anxiety, and fear.

A number of aspects limit interpretation of PAS use related symptoms in crisis, including the fact that many visitors presented poly drug use and that only testing of all ingested PAS could guarantee rigorous conclusions.

3.1.2. Intervention Implementation Characterization

We concluded that 50% of crisis episodes were solved within a 1- to 5-hour period, and 31% took over 24 hours of intervention.

We described intervention strategies used by sitters, including talk therapy, homeopathy, transpersonal psychology, reiki, and others. We emphasize the importance of logistical strategies such as offering a rest area, or providing warm clothes, since offering a safe, supportive and comfortable space is considered fundamental.

3.1.1. Team Satisfaction

The degree to which team members considered the project to have achieved its goals was high, and over 90% considered the intervention to be very positively accepted by targets.

SWOT analysis expressed team members’ concerns with project location and safety. This feedback led to the decision to move KC to more central Festival grounds, to supply the area with permanent security staff, and to improve communication with organizers.

3.2. Intervention Outcomes

The outcomes of intervention were measured by the MSEC, observation of crisis symptoms, and follow-up inquiry.

3.2.1. Symptoms and Mental State

The IF describes the development of crisis symptoms based on sitters’ perception. The increase in symptoms during the middle stage of intervention could be explained by the fact that some Visitors are brought shortly after the emergence of the crisis episode.

We used paired t-tests to compare pre- and post-values of mental state exam symptoms. The results showed significant differences in symptoms presented on these two occasions, which can be understood as indicating crisis resolution.

We explored the relation between resolution and visitor behaviors in association with intervention strategies in a valid sample of n=54 visitors. We found that complementary, medical, logistical and psychotherapeutic strategies all contributed for crisis resolution, and that large percentages of participants also expressed behaviors indicative of well-being.

We wanted to understand the relation between type of crisis and resolution in a sample of 54 visitors. Mental health outburst episodes and PAS use were the most common types of unresolved episodes.

3.2.2.1. Visitors’ Satisfaction on Departure

Visitors’ satisfaction with KC implementation reached levels of excellence, with 81% expressing total agreement towards the item “I have been helped by KC”, and 75% expressing total agreement towards the item “KC staff was helpful, caring and available”.

Crisis intervention data were collected for follow-up purposes from a universe of N=322 KC visitors from 2010 and 2012 editions. Answer return rates were considerably lower, referring to n=7 visitors from 2010 and 11 visitors from 2012 editions.

Visitors considered KC effective in solving their crisis episode, and considered intervention a very significant experience in their lives. They also highlighted the importance of psychotherapeutic intervention strategies used by sitters.

We understood visitors’ most positive aspects to be sitters’ empathy, availability, ability to calm them down and talk therapy. Empathy is a basic relational skill that encourages the person to verbalize difficulties.

The lack of medication to interrupt the crisis, shift changes, and the spatial setup of the intervention were signaled as the most negative aspects.

Long-term impact of crisis intervention included increased knowledge of how to deal with crisis situations, acquisition of a more responsible attitude towards drug use, and gaining a more positive appreciation of oneself and relationships with others. Increased positive appreciation for oneself and for relationships with significant others may be triggered by a psychedelic crisis episode.

We wanted to understand Visitors’ perceptions of how long the benefits of intervention lasted, and how crisis had been integrated over time. We found that positive integration was the most common outcome, while negative integration was more common.

Several dimensions were indicative of positive integration, including the willingness to repeat the experience, increased insight about oneself, personal problems and daily situations, the desire to search for a more positive experience, and the expression of happiness.

Our follow-up sample is insufficient for effective feedback, and our data concerning visitors’ feedback should be considered merely exploratory.

  1. DISCUSSION

According to Flay [65], outcome research results are specific to the program, populations and settings tested, and the settings for which their efficacy is claimed. The study confirms that process and result indicators can be collected and analyzed systematically.

Although heavily reliant on the perceptions of the intervention team, results confirm that the program is having impact in the field it is designed for – crisis intervention and HRRM in PAS use in recreational environments.

The literature confirms that offering a safe, supportive and comfortable care space is an effective crisis intervention strategy.

Multiple drug use among adolescent Europeans has been increasing since the 90’s. This makes it impossible to accurately associate crisis with specific PAS and mental state alterations, which appeals for a broad and multi determined understanding of crisis in recreational environments.

The study contributes to characterizing crisis in recreational environments, including episodes that don’t include PAS use. LSD and MDMA are largely predominant in crisis episodes and mental state alterations, with cannabis appearing possibly underrepresented.

The measurements for PAS use in our study are based on self-reported use, which has a bias towards substances visitors believe are more responsible for unpleasant effects and crisis triggering. Consequently, we cannot accurately say if LSD and MDMA are in fact responsible for such high prevalence and crisis symptoms among KC visitors.

Studies in the past have determined that PAS use is related to anxiety, depression and dissociation, that PAS use could trigger or intensify psychopathology, and that people with expressive emotional or psychiatric distress pre-existent to crisis will potentially experience escalation in symptoms following PAS use.

The program used diverse intervention strategies, but psychotherapeutic strategies were the most frequently used. These strategies were notable for helping visitors to traverse crisis, as reported by our follow-up sample.

According to literature, crisis resolution occurs when the person is feeling comfortable and no emotional or psychosomatic symptoms are presented. The results indicate that the intervention was effective in addressing crisis episodes and contributing to crisis resolution.

Respondents reported a more positive attitude towards themselves and significant others following crisis intervention. This seems to confirm the potential for crisis to promote healing.

In a long term impact follow-up study, a small group of respondents reported that the crisis resulted in an increase of symptoms. This result may be explained by previous psychopathology or vulnerability to psychopathology without previous manifestations.

KC attended a number of situations referred above as mental crisis related and not related to PAS use. These individuals were at higher risk for mental disorders and were more likely to see their condition aggravated after a crisis episode.

The project’s characteristics and crisis intervention features are impediments to an accurate knowledge about the relation between PAS use, crisis, and mental disorders.

The intervention increased knowledge of the risks and benefits of altered states of consciousness, and promoted learning on how to deal with future problems. Some respondents also reported having learned how to deal with crisis episodes, and having developed a more responsible attitude towards PAS use in general.

KC evaluation research suggests that partnerships with mental health structures outside the festival and providing written information about their crisis episode could improve intervention with these visitors.

CONFLICT OF INTEREST

Kosmicare Research hasn’t received any formal financial contributions until the present time. It is developed thanks to the same institutional collaborations that allow the project’s implementation.

ACKNOWLEDGEMENTS

The authors thank Boom Production, the Faculty of Education and Psychology – Catholic University of Portugal, and the Government of Portugal for their support.

PDF of Crisis Intervention Related to the Use of Psychoactive Substances in Recreational Settings – Evaluating the Kosmicare Project at Boom Festival