Send Orders for Reprints to reprints@benthamscience.ae Current Drug Abuse Reviews, 2014, 7, 81-100 81 Crisis Intervention Related to the Use of Psychoactive Substances in Recreational Settings - Evaluating the Kosmicare Project at Boom Festival Maria Carmo Carvalho*,1, Mariana Pinto de Sousa2, Paula Frango3, Pedro Dias4, Joana Carvalho5, Marta Rodrigues2 and Tânia Rodrigues2 1 Centre for Studies in Human Development, Faculty of Education and Psychology – Catholic University of Portugal, Portugal 2 Faculty of Education and Psychology – Catholic University of Portugal, Portugal 3 General-Directorate for Intervention on Addictive Behaviors and Dependencies, Portugal 4 Centre for Studies in Human Development, Faculty of Education and Psychology – Catholic University of Portugal, Portugal 5 Faculty of Psychology – University of Lisbon, Portugal Abstract: 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. 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. 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. 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. Keywords: Crisis intervention, evaluation research, harm reduction and risk minimization, mental health disorders, psychoactive substance use, recreational environments. INTRODUCTION AND FRAMEWORK 47%), techno-raves (25%) or trance parties (19%) [3]. According to Fletcher, Calafat, Pirona and Olzewski [4] Over the last decades we have witnessed considerable (recreational substance use “concerns the use of PAS that transformation in psychoactive substance (PAS) use patterns takes place for pleasure, typically with friends, in either that have also been observable in Portuguese nightlife and formal recreational settings, such as nightclubs, and/or outdoor recreational environments. After an initial period informal settings, such as on the streets and in the home” (2001-2007) during which illicit drug use indicators in (p.357). This definition presents considerable evolution since general population showed an increase, the period between EMCDDA’s former exclusive focus on young people’s drug 2007-2012 was marked in Portugal by a slight reduction and use in a ‘nightlife’ context. This also translates to a tendency stabilization, observable in lifetime use but also in last month towards non-problematic drug use, a scenario in which and last year indicators [1, 2]. In Portugal, when the general partygoers’ PAS use is seen to not significantly harm their population is asked about preferred PAS use environments, global adjustment, as shown by recent studies of Portuguese recreational settings come up largely dominant, whether in partygoers [5]. the form of calendar events such as new-years’ eve parties Despite variability, qualitative research shows that specific meanings and motivations are evoked when *Address correspondence to this author at the Centre for Studies in Human partygoers report their experiences of PAS use at raves and Development, Faculty of Education and Psychology – Catholic University trance parties. A number of recent studies [5-9] as well as of Portugal. Rua Diogo de Botelho, 1327, Mail Code 4169-005 Porto, more classic references [10] associate themes such as Portugal; Tel: (+351)226196100; E-mail: mccarvalho@porto.ucp.pt spiritual growth, transcendence, potentiating insight, getting 1874-4737/14 $58.00+.00 © 2014 Bentham Science Publishers 82 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. in touch with one’s inner world, potentiating creativity as 1.1.2. PAS Use Induced Crisis reported intentions behind PAS use in recreational settings, especially in outdoor environments such as rave and trance Intervention in crisis related to PAS use has been scenes. However, the fact that these events potentially described as having the purpose of turning an unpleasant accommodate many visitors interested in experimenting with psychedelic experience into one that is as constructive and PAS, combined with the fact that some of them are likely to transformative as possible [26]. Abraham Maslow [27], encounter some sort of difficulty during these experiences, referring to his definition of peak experiences, says that on cannot be neglected. some occasions in life an individual will transcend his/her own self, enter a state of complete harmony with his Taking these factors into consideration there is a strong surroundings, and will achieve full self-actualization. In case for the election of such scenarios as intervention other words, peak experiences would allow the kind of priorities from the perspectives of selective and indicated satisfaction that could spiritually fulfill an individual, prevention, as well as harm reduction and risk minimization helping him/her become affectionate, creative, realistic, (HRRM) [11, 12]. Intervention modalities based in proxi- productive, and in tune with himself and others. According mity and informality are particularly important in these to Grof [14], appropriately conducted intervention in crisis environments if we further consider that the user populations related to the unsupervised use of psychedelics has the participating are not covered by any other program or service potential of resulting in an individuals’ profound and are unreachable by conventional intervention protocols transformation in the sense anticipated by Maslow; on the [11, 12]. other hand, if the approach is conducted by inexperienced The paper presents evaluation research that intends to staff, there is probability of serious psychological damage, transform Kosmicare (KC) - a project that develops crisis such as severe psychotic conditions and years of psychiatric intervention in situations related to the use of PAS at Boom hospitalization. Festival (Portugal) - into an evidence-based intervention There are several explanations for why such benefits are model. The project relies on intervention principles drawn apparently possible. Psychoactives’ chemical capacity to from HRRM practice, crisis intervention models [13], and “open the mind” by releasing the central nervous system Stanislav Grof’s psychedelic psychotherapy approach, from operating under normal patterns of functioning has particularly his conceptualization of crisis intervention in been referred for long [28]. Some factors and triggers related situations related to unsupervised use of psychedelics [14]. with benefits of the psychedelic experience have been The approach intends to help reduce risks related to the use highlighted by literature. Transpersonal psychologists of PAS and development of mental illness, but also to impact present the environment surrounding the experience as the target populations’ views of themselves, their relationship to most determining factor, since it allows conscious resistance PAS use, and their relation to significant life events. to be surpassed, and reality perception to be modified [29]. Other studies have reported emergency intervention Vaughn describes her ability, under the influence of PAS, to results in recreational environments [15-19]. These reports focus her attention on what she chose; this resulted in a focus, however, in medical crisis intervention aspects in personal change that she claims made her more appreciative raves and dance parties or in emergency departments of music, art, nature and human relations – something that attending recreational PAS use related episodes, with little or was achieved during her psychedelic experience that stayed no feedback regarding protocol aimed at assisting with her long after [29]. psychological emergencies. There is a thin line, however, separating what could be an extremely positive experience from an overt crisis episode 1.1. Crisis and Crisis Intervention Rationale that unfolds with difficulty and unpredictable symptoms. Zinberg [34] argues that concepts such as drug, set and 1.1.1. Crisis Intervention – General Aspects setting are fundamental for the understanding of PAS-related experiences. Drawing from Zinberg’s contribution we have Crisis intervention is a support therapy modality organized literature on crisis factors in three categories – characterized by its short term action. Its main purpose is to factors related to drugs, to set, and to setting. offer quick resolution and relief of symptoms that will allow the subject to recover regular functioning in a short time- A number of factors that might trigger crisis are closely frame. This approach is particularly indicated for acute related to characteristics of the ingested substance and the emergency situations [20-22]. It has gained popularity in the immediate circumstances of ingestion (drug). Street field of Community Intervention, where alternatives to substances have a high potential for adulteration and traditional clinical services are often required [23, 24]. impurity, which can generate effects contrary to users’ Although extensively used and researched for a number of expectations. An inexperienced user might also be uncertain intervention contexts and populations, no specific references regarding quantities and dosage, which might result in fear were found that described using crisis intervention in relation or lowered ability to tolerate unpleasant effects [14]. to PAS use in nightlife and recreational environments. In the Multiple drug use is an increasingly common and risky global field of addiction intervention, crisis intervention has situation among adolescents and young adults, visible in been used in treatment contexts where the subject recreational environments, in which varying quantities of experiences a loss of control over PAS use behavior [25], but psychoactives from very different pharmacological groups no references are made concerning implementation with are ingested simultaneously. This leads to effects that are recreational users. unpredictable both in form and duration [30]. Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 83 Set has to do with the individual’s psychological alertness, attention and orientation alterations [38-40]; odor, characteristics influencing his motivations, expectations and texture, pain and sense of balance alterations [38]; temporal attitudes towards use. Specifically the users’ personality, and spatial orientation might be compromised [39-42], as pre-existing mental health problems, past history of trauma, well as perception of time [14]; symptoms related to thought abuse and other life-events can be triggered and re-lived processes such as reasoning and judgment alterations, while under influence [31, 32] and are considered of extreme interference with decision-making and problem-solving [43], relevance. According to Stolaroff, while under influence, the difficulty differentiating cause and effect [42], de-realization degree to which the individual is able to accept the altered and depersonalization [43]; language alterations [14, 38, 43]; state will determine his/her ability to learn from emerging or symptoms related with the individual’s emotional sphere unconscious contents; on the other hand, resisting the effects (euphoria, a sense of peace, serenity, or pleasure, but also might generate the kind of discomfort responsible, in more states of anxiety leading to a feeling of panic, sadness, extreme situations, for psychotic outbursts [33]. crying, melancholy, apathy, and sometimes aggression [14]). Setting refers to the physical and social environment There is considerable discussion around the relation where the experience actually occurs, including factors such between PAS use and the emergence of psychiatric as place, company, and opportunity to share the unfolding symptoms during crisis episodes. On the one hand there is experience [34]. If the individual is surrounded by a pleasant the argument that the adverse effects of PAS are primarily environment, in contact with nature, and in the company of related to subject’s intrinsic characteristics (set), more than an experienced user with whom the experience can be the products’ pharmacological properties (drug). According shared, these factors could provide the basis for an enriching to this perspective, the scenario in which symptoms related and enlightening transpersonal state to unfold [33]. In fact, a to a broad range of mental disorders appear during the large number of physical and social dimensions that sequence of PAS use is more likely to reflect pre-existing compose the environment surrounding the experience are disorders rather than PAS effects, the co-occurrence recognized as relevant factors as well. Frequently someone probably being a coincidence [43]. On the other hand, a undergoing a crisis related to the use of PAS is also predominantly medically-focused approach emphasizes how surrounded by extremely loud sound, dust, visual stimulation PAS-induced altered states of consciousness appear to be (e.g., radical self-expression), asymmetric temperatures, and responsible for the onset of mental disorders like DSM-V’s bad resting conditions [35]; other social context dimensions [44] diagnosis of substance use disorders and the particular that we have found to greatly interfere and negatively case of Hallucinogen Persisting Perception Disorder [44]. potentiate a using episode have to do with inappropriate, This debate is also developed by psychiatric comorbidity unfriendly or unsupportive companionship while under research. If on the one hand it is assumed that PAS-users influence; the user being left alone; or simply having taken might present increased incidence of psychiatric comorbidity PAS inadvertently [31, 32, 35]. Several of these factors [45, 46], on the other hand, comorbidity research still fails to might appear associated with each other in a given situation; provide an understanding of the underlying causality in the and more importantly, some of them might be responsible relation between PAS use and mental disorder onset, with no for crisis situations in the absence of PAS use [32]. This definitive answer presented as to whether disorders pre-exist leads us to the conclusion that crisis intervention in or are consequent to PAS use [47]. recreational settings shouldn’t be restricted to PAS use situations [35]. Crisis might occur over the life of any individual and should therefore be understood as a normative The definition of a crisis episode of any kind typically developmental process [36]. The same understanding can be encompasses the consideration of three general dimensions brought to what concerns crisis connected with the [36]. The process starts with a precipitating event, unsupervised use of PAS – so, similarly, intervention will corresponding to the moment a PAS is ingested. Secondly, develop efforts to help the individual reestablish coping and the perception of the event arises, potentially in a hurtful control and, if possible, end the process with an expanded way. This corresponds to the moment the first effects of the view of the problem, himself and his/her relationships [14, PAS arise and are perceived with fear, discomfort, or other 37]. negative emotions. When the therapist expresses empathy and encourages the person to verbalize his/her difficulties, 1.1.3. Crisis Intervention Principles showing an understanding of the situation and connecting to the person, this enables self-understanding and encourages Regardless of the severity of symptoms presented, crisis acceptance of the process [37]. Finally, crisis can occur due intervention should follow a number of principles [14, 48] to the lack of coping strategies to deal with the situation. The oriented towards transforming what is being experienced as lack of coping strategies leads the individual into a state of an unpleasant, uncomfortable or even a terrifying experience fear, tension, confusion, discomfort and unbalance defined as into a positive and possibly transformative one. Following crisis [13]. Because the person might not understand what is good practice recommendations in this field [14, 49, 50, 51] happening, significant subjective distress arises that we have considered these intervention principles: potentiates the lack of coping. Empathy allows a decrease in Assessment of physical safety and information collection, anxiety, and facilitates the emergence of a less threatening such has PAS used, quantities, ingestion time, description of perception of events [36]. the person’s condition and symptoms observed before Symptoms in crisis related to unsupervised PAS use are assistance was provided. complex, diverse, and require careful evaluation. Crisis Offer a safe, supportive and comfortable care space, might include physical symptoms [38, 39]; consciousness, considering physical variables, as well as social ones. A care 84 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. space should include an area where sound is more controlled, crisis intervention, HRRM has been extensively implemen- where there is warmth if needed, and privacy is kept from ted in nightlife and recreational settings [54-57]. The inter- outside observation. Basic needs are addressed, such as vention model and its strategies pursue principles of prag- comfort, hydration, nutrition and refrigeration. Individuals matism, humanism and proximity [58, 59]. These intervent- are expected to improve just on the provision of a place to ions aim to replace high risk behaviors with others that have rest and obtain some of the resources at the most basic level the potential to drastically reduce negative aspects of PAS of Maslow’s Hierarchy of Needs [27]. use [12, 60]. This approach is relevant regardless of the specific PAS being considered, since knowledge of PAS use Facilitation means offering the presence of a supportive consequences is considered useful starting from the very first professional (or even someone close to the person, supported experience [60, 61]. Proximity and pragmatism are also by a professional), with whom a trusting relationship can be established. This is perhaps one of the most decisive fundamental to ensure that intervention takes place in the environments in which the phenomena are occurring, since intervention aspects. Given the circumstances surrounding target-populations involved are frequently absent from other crisis intervention in the field, trust and cooperation between more conventional intervention settings [8, 62]. the person and the facilitator has to be established in a short period of time, and sometimes under demanding circumstances. Empathy, ability to keep focus, and intimate 1.2. The Kosmicare (KC) Intervention Model knowledge of altered states are strategies that guarantee the KC1 was first implemented in 2002 at Boom Festival. generation of trust. During this contact, the facilitator should Boom is a biennial independent artistic expression use an approach that invites the individual to talk through the multidisciplinary cultural event that involved around 25 000 experience, instead of talking down [51]. It is important to participants from over 102 countries in 2012. The program emphasize that the experience will eventually end, and offer includes a strong artistic component, technology, and assistance to integrate possible traumatic content emerging from the crisis episode once it is over. This happens through promotion of contact with nature. It has been awarded a number of times for its ambitious environmental program, a process in which the person is invited to turn once more to and operates outside mainstream marketing circuits and the experience, and is encouraged to deal with the critical branding (it is a no-logo area). The Festival’s public reflects events brought to surface. For this process to occur it is this diversity and dimension, largely surpassing the scope of fundamental to let the experience unfold, for e.g. using electronic music, psychedelic community and psychedelic music [14]. For this reason, the use of prescribed pharmaceuticals such as benzodiazepines or other neural- subculture, even though the presence of these expressions is relevant. The festival is characterized for pursuing values depressants is discouraged in crisis intervention, since it is like humanism, sustainability and equality, and is famous for understood that they prevent the individual from dealing the investment put into care of partygoers. KC was assumed with emerging conflict, contributing to an increase of as festival production’s responsibility, following needs psychosomatic and chronic emotional problems after the identified in the field. KC is understood as a strategy to deal episode [14]. This approach is based on the assumption that “a bad experience isn’t necessarily a negative one” [14]. with multiple levels of risk associated with PAS use. At KC, partygoers can find a range of services that include HRRM Ensure safety. Intervention must ensure the individual is (information and outreach, chill-out, drug use paraphernalia, safe from hurting himself or others [14]. A speech focused testing) and also a care space especially designed for people on messages such as “keep calm” or the attempt to convince undergoing difficult psychedelic and emotional experiences the person that “everything is okay” is highly discouraged, [26, 31, 35, 41]2. since these might increase the subject's distress. Questioning, It has the main purpose of offering care and support to especially if repeated and confusing, is also counter people undergoing a crisis episode related to PAS use indicated, since it might reflect the facilitator’s anxiety or particularly psychedelics, allowing their experience to unfold apprehension about the situation. in a safe environment and be adequately integrated. Dass-Brailsford has highlighted that besides professional Intervention intends to reduce the risk for mental disorders help, a person’s reactions after a crisis episode are highly related to PAS use and to enhance possible benefits that dependent not only on personal characteristics, but also on emerge from this experience. The project therefore attempts the event itself and the surrounding context [52]. Integration, to reduce harm related to PAS use, while respecting the or the moment when the person will search for a meaning for individual’s choice and personal responsibility towards this the experience [53], is more likely to occur in contact with behavior. Prevention of abuse and drug dependency is also those who are able to recognize and identify change that was generally intended. put in motion after trauma [53]. In other words, insight These goals go hand-in-hand with current definitions of regarding the crisis episode and change occurring after health promotion, according to which preventive and trauma are processes that lead to integration of the promotion interventions should aim at reducing impact and experience. In this sense the adherence to intervention principles above has a strong potential to influence crisis context, facilitate recognition and identification of change 1Initially Ground Central Station, and later on Cosmikiva, implemented (trigger insight), and promote integration, thus determining with the support of MAPS – the Multidisciplinary Association for Psychedelic Studies – an organization contracted by Boom organizers to crisis resolution. provide care for visitors during early incarnations of the festival. 2 Promote health and globally reduce risk. As defined by This is achieved every edition through a number of partnerships and services offered by some of the worlds most renowned and qualified HRRM model, this principle requires a naturalistic approach agencies, such as MAPS/USA, Erowid.org, Energy Control/Spain, to intervention and proximity to intervention targets. Unlike TEDI/EU, APDES/Portugal, among other agencies. Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 85 exposure to risk factors for the development of mental, use-related crises. Visitors arrived at the care space either emotional and behavioral disorders; and also to strengthen following directions or transported by Festival staff cooperating protective factors in individuals, families and communities with KC, including paramedics and fire-fighters. The that might increase health and well-being, and thus diminish coordination team was available to cover the festival area with a the likelihood that problems arise [63]. vehicle to pick up people who required transport. KC Visitors were also being brought by friends or arrived on their own. On For this purpose a care space was created on the Festival arrival, situations were evaluated by the team leader, who premises following the principles described above. It collected basic information and assigned a sitter. Intervention included a main area where most situations were assisted, covered all Festival days, twenty-four hours a day. Teams were and an additional area for situations that required isolation organized in pre-scheduled shifts that ensured this coverage. It due to their serious clinical presentation [35, 41]. Another area, located next to the Festival’s main dance floor, offered was the team leaders’ responsibility to coordinate the functioning of shifts and the team of sitters. They supervised all basic HRRM strategies such as outreach and information, interventions taking place, provided guidance, coordinated shift distribution of PAS use paraphernalia and other HRRM turnovers and ensured information was passed to the next materials, and testing of PAS including identification of scheduled team. adulterants (thin-layer chromatography)3. The project was implemented by a team composed The sitters were a group of experienced and trained peers responsible for individual intervention, selected for their mostly of volunteer staff. Recruitment emphasized expertise skills in active listening, intuition, their knowledge of PAS and knowledge of crisis situations. Team members were also and associated effects, and their ability to establish empathy experienced with participation in nightlife and recreational with intervention targets. Sitters were also recruited environments, and in establishing contact with its publics. according to their language skills, in order to guarantee that a The team received on-site training prior to intervention, and online training and guidance in the months before wide range of languages be available in the team. Each team was assigned a secretary who offered logistical support, intervention. The team was composed of coordinators (pilot, facilitated the passage of information on clinical status of co-pilot), team leaders (more experienced therapists intervention targets, collected information for research, and coordinating a number of sitters), sitters (psychologists and monitored arrivals and releases. other therapists), a medical team (nurse, psychiatrist and homoeopath), secretaries (who assist the running of space During intervention it was important to maintain and keep track of Visitors for clinical and research cooperation between production staff, medical staff and purposes), and a number of consultants. In addition, the security, in order to provide each situation with the best HRRM team included over twenty people of several possible diagnosis and resolution. Partnerships with entities nationalities. All together these staff members count for a outside the Festival were also important. Entities such as the total of around seventy people. local addiction treatment center and general hospital were In 2010 we began to develop evaluation research that also contacted promptly when their resources were considered necessary for a small number of cases, involving allowed us to describe and receive feedback on the intervention heroin addiction or mental illness that required transfer to process, to examine the efficacy of the intervention, and to another facility. However, such transfer was considered a further describe the target population and contribute to the last resort. When a person is transported in an ambulance understanding of crisis symptoms triggered by modified states this generates an atmosphere of danger and emergency that of consciousness. We wanted to know, specifically, if KC intervention was efficacious in reducing the number of crisis can contribute to aggravating the crisis episode [14]. symptoms among the various groups of visitors. After the first The general purpose of evaluation research is to results of visitors’ feedback (short-term) were analyzed, we transform KC into an evidence-based intervention model that raised the possibility that intervention could be benefiting them can be disseminated to similar settings and populations. Over further than simply providing a satisfying resolution to their the past two editions (2010 and 2012) several studies were crisis episode. For this reason another research objective developed that contributed to this objective. Specifically, we emerged: to understand what long-term consequences of crisis have developed a number of instruments and identified intervention might emerge, according to visitors’ views of the qualitative and quantitative indicators that set the basis of positive and negative aspects of the project. For the purpose of KC’s evaluation research. One of our main goals was to research we initiated an innovative partnership in 2010, describe the intervention process. This goal considered the including a University and a Governmental Agency 4 that, fact that the project had been taking place during earlier alongside with Festival Production, offered basic minimum incarnations of the festival with little formal knowledge resources for research about HRRM, crisis intervention and around methods or results being produced. For this purpose a mental health promotion associated with risk in PAS use in number of reports were extracted, aimed at consolidating recreational environments. For evaluation research, all festival knowledge of our target-population and intervention process, attendants were considered potential intervention targets. with instruments thoroughly describing all intervention Situations related to PAS use were given priority, without stages from admission, intervention, departure and follow-up disregarding the importance of care in the event of non-PAS [35, 64]. 3 These interventions were offered by Portuguese HRRM Team Check!N METHOD and Spanish HRRM Team Energy Control Barcelona. 4 The Faculty of Education and Psychology – Catholic University of Portugal According to the Society for Prevention Research and the Portuguese General−Directorate for Intervention on Addictive efficacious interventions will have been tested in at least two Behaviors and Dependencies. 86 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. rigorous trials that (1) involve defined samples from defined indicators [66, 67]. We used a mixed methods approach that populations, (2) use psychometrically sound measures and enabled “the collection or analysis of both quantitative and data collection procedures, (3) analyze their data with qualitative data in a single study in which the data are rigorous statistical approaches, (4) show consistent positive collected concurrently or sequentially, are given a priority effects (without serious iatrogenic effects) and (5) report at and involve the integration of the data at one or more stages least one significant long-term follow-up [65]. A pretest- in the process of research” [69]. According to literature, posttest design, with a twelve-month to two-year follow-up, approaches to typologies of mixed methods research designs without a control group, was used in this study. We will have mostly drawn from evaluation, as well as from a review methodological aspects of research contributing to number of other disciplines [70]. the purpose of transforming the program into an evidence- Table 1 presents the global research project design. To based intervention meodel. address the research objectives, quantitative data where The study design was inspired by program evaluation analyzed with PASW 18 software. QSR NVIVO 9 software methodology [66, 67]. According to this approach, proced-ures was used for qualitative data analysis. A number of factors for evaluating intervention programs should answer to a number account for differences in sample sizes for the different of process and outcome indicators. The primary purpose of measurements. These globally refer to the challenges process evaluation is “(to) determine the extent to which the inherent to a naturalistic unconventional intervention and program is operating as planned (…) facilitating improvement research setting that rose difficulties to the implementation by identifying problem areas that may require adaptation of of experimental design criteria and to the exhaustive program standards or operations, and by highlighting program monitoring of all cases attended. A number of cases elements that are being effectively implemented.” [68]. Process unrelated to crisis are probably unaccounted for from our evaluation analyzes project implementation and participants' global research sample from 2010 (n=122). Difficulties reactions to the program, describing how intervention unfolded, accessing participants for follow-up purposes were also if the intervention design was appropriate, and whether the found. These arise from the fact that many visitors are target group was effectively integrated. Additionally, it takes unavailable for feedback immediately after intervention and into account the issue of quality, gathering information relevant also from the fact that intervention made efforts to minimize to the appraisal of effectiveness and the introduction of future the burden put into visitors for research purposes. Sample improvements [68]. Outcome evaluation includes a number of size differences for different measurements pose limitations indicators aimed at understanding to what degree the to data interpretation that must be acknowledged. intervention produced the expected results. It examines the effects of intervention by determining to what extent goals have 2.1. Participants been attained, and is considered an essential instrument to determine whether intervention should be kept, adapted or All festival participants were considered eligible for abandoned [68]. intervention and evaluation research. Considering Boom Data on process and outcome evaluation can be gathered Festival has an estimate of twenty thousand participants per edition, this means that for the KC 2010 edition the project through the collection of quantitative or qualitative Table 1. Evaluation research design. General Objectives Specific Objectives Indicators Year Sample PAS use patterns characterization n = 122 PAS associated symptoms n = 107 Characterization of participants Symptomatology per gender 2010 Symptomatology per age n = 83 Level 1. To characterize Symptomatology per number of previous occasions ate festival intervention model and implementation Nº interventions/day 2010 n = 123 process Characterization of Intervencion Duration of intervention/hours (permanence) n = 122 Implementation Intervention strategies n = 107 Description of team perception Team´s perception about the results and impact of the on intervention outcomes and 2010 n = 36 intervention impact Mental state before and after the intervention 2010 n = 83 Evaluation of intervention Level 2. To Symptom evolution during different intervention stages n = 107 outcomes characterize Intervention Resolution 2010 n = 107 intervention outcomes Participants' perception on Visitors perception in the end of the intervention 2010 n = 54 intervention outcomes and impact Visitors perception in the follow-up 2010 & 2012 n = 18 Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 87 attended approximately 0,6% of all festival goers (n=122). 2.2. Research Procedures Kosmicare intervention group (Sample 1) included male and female visitors from a wide age range and from very diverse Data collection took place over three different moments. nationalities, consistent with the Festival’s participant The first moment was during the KC 2010. Data were profile. The sample included the total of situations attended, gathered through sitters and secretaries’ feedback regarding that corresponded to a range of distinguishable requests and the situations attended (n=122), and through feedback needs, organized in a typology of situations for research and offered directly by visitors at the moment they left KC. At intervention purposes. Priority was given to crisis situations this stage we intended to gather information concerning involving PAS use, and to mental health outburst episodes satisfaction with intervention. For this purpose, a secretary whether these involved PAS use or not. Whenever possible, approached the visitor on departure from KC requesting for KC also offered support to situations of personal crisis feedback. Difficulties concerning intervention setting and unrelated to PAS use and to situations unrelated to crisis at visitors’ frequent unavailability to offer feedback all, such as requests for a resting period, hydration, nutrition, immediately after intervention account for the fact that medication and minor health care, etc. Children could also be visitor final feedback concerns a much smaller sample of attended for this purpose, if accompanied by their parents. n=58 participants. But the team wasn’t prepared for other therapeutic A second moment, regarding intervention team feedback, interventions involving these targets. occurred a month after implementation (form 5). We estimate that a small proportion of situations attended Intervention team feedback was collected using a number of at KC might be missing from our global 2010 research quantitative indicators about teams’ perceptions of KC sample (n=122), since guaranteeing exhaustive monitoring efficacy and satisfaction with the project, as well as SWOT of all cases is a challenging process at a non-clinical, analysis followed by content analysis. naturalistic and unconventional intervention setting such as A third moment concerns visitor follow-up feedback. A ours. However, we anticipate unaccounted interventions are total of n=18 visitors from 2010 and 2012 were approached more likely to correspond to situations unrelated to crisis. for follow-up purposes via e-mail, requesting collaboration Sample 2 includes a group of n=36 team members from to answer an online questionnaire. Given the difficulties in the 2010 edition. These were the team members that obtaining access to a follow-up sample we decided to participated in crisis intervention, composed in total by n=50 include visitors from both editions, since intervention model, elements. This means our evaluation sample considers the team structure, intervention stages and procedures were feedback of approximately 70% of all KC 2010 Edition staff. implemented in both editions according to the same principles, project structure, context and intervention Sample 3 refers to a group of n=18 visitors gathered strategies. Visitors from the 2010 edition were approached among KC 2010 (n=7) and 2012 (n=11) editions of the after eighteen months had passed since intervention. For festival editions. These participants were recruited among visitors from the 2012 edition this period was of six months. those that offered their e-mails for posterior contact at the end of intervention, before leaving KC. At the 2010 edition n=58 participants offered final feedback when leaving KC, 2.3. Measurements and n=44 visitors also offered their e-mails; at the 2012 Flay et al. [65] refer to the importance of using edition n=77 visitors were available for posterior contact. psychometrically sound measures and data collection From a total of n=121 e-mail contacts from both editions procedures in prevention research. These measures and available, the final sample composed of n=18 participants procedures should refer to the intervention description corresponds to a very low return rate. (process evaluation) in a way that allows others to replicate There are a number of reasons that can be pointed out to it; and also include statements of measurable behavioral justify difficulties accessing participants for follow-up outcomes of intervention. purposes. Offering feedback and availability for a future A number of measurements were collected over several contact is a difficult request to attend for after having just intervention stages. finished integrating a crisis experience. Although some participants were receptive to our request, most of them were Instruments were predominantly designed to collect evidently unavailable and uncooperative, still presenting information based on sitters' and secretaries' reports about difficulty to write, being in a hurry to leave the intervention visitors’ condition. In addition to the time contingency of the area, among other reasons. This uncooperativeness with KC project (taking place solely during the biannually research, specifically follow-up, was always respected, since occurring Boom Festival), the short time between we placed visitors’ needs above research interests. The fact intervention implementation and research project that we approached those initially available through email presentation and approval made it impossible to do pilot- contact after a considerable period of time had elapsed also tests on our research instruments. raises additional challenges to sampling for follow-up Table 2 presents research forms according to types of purposes. Given this scenario, it is evident that data data collected and data collection moment. concerning follow-up must be considered exploratory and require further research. Nevertheless, we consider our First moment. During implementation, secretaries would samples to represent a significant effort and contribution for approach sitters requesting information. Data collection of research at a naturalistic setting that offers such a forms 0, 1, 2 and 4 relied on sitter feedback, supported by challenging intervention context. that of secretaries. Data was collected during intervention 88 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. Table 2. Assessment protocol. Forms Type of Data Collected/Dimensions Data Collection Moment Numeric Registration of Visitors Form 0 Visitor Arrival/ Arrival; day; time; shift; sitter VL Departure Departure: day; time; shift; sitter Visitor Demographics Form 1 Arrival at KC (brought by); Visitor Arrival VRA Psychoactive Substance Use (PAS) 1. Appearance, attitude and awareness of personal condition; 2. Psychomotor Behavior; 3. Conscience, Alertness, Attention and Orientation; 1st - Visitor Arrival Form 2 4. Language and Speech; 2nd – Visitor departure MSEC 5. Thought Processes; (Pre and post intervention) 6. Self Consciousness; 7. Affect and Emotions; 8. Physiological Functions Condition on arrival Description of interventions that occurred Form 3 (Therapeutic strategies used with t visitor: psychological -sitter; medical - medical team; social – social During all intervention stages IF worker) Effects observed /conditions of departure (description of visitor’s current psychological and physical condition) Form 4 Satisfaction about KC intervention Visitor Departure VFFIC Informed Consent to use personal data in research Staff’s Experience in KC Perception on KC’s functioning Opinion of: Self-participation on KC Form 5 KC Training One month after Intervention SFF KC Team Work Conditions Boom Organization Harm Reduction Team KC Implementation Visitor Demographics Form 6 Six to eighteen months after Outcomes from the intervention evaluation VFFFU intervention Characterization of crisis episodes Note. VL = Visitor List. VRA = Visitor Report Arrival. MSEC = Mental State Exam Checklist. IF = Intervention Form. VFFIC = Visitor Feedback Form & Informed Consent. SFF = Staff Feedback Form. VFFFU = Visitor Feedback Form Follow-up. KC = Kosmicare. Consciousness Rating Scale [73]; or the 5D-ASC – Five Dimensions of Altered States Questionnaire [74]. These and covered the period from arrival to departure. On arrival, instruments represent valuable and reliable alternatives for Visitors were welcomed by a sitter and assigned an the study of altered states of consciousness. However, both individual or open area in KC. At this stage Forms 0, 1, and the OAV as the 5D-ASC are lengthy instruments that rely on 2 (MSEC on arrival) were collected. During intervention the sitter would fill out Form 3, with a review of the overall self-reported administration, making them unsuitable for our research setting and participant profile. The Mini-Mental interventions that took place, and observed effects. On State Exam [75] was also considered unsuitable, since we visitor departure, the sitter would fill in Form 2 (mental state intended to assess a wider range of mental state dimensions. on departure), and Form 3 (condition when leaving KC). Although conceived for the evaluation of mental state Form 2 (MSEC) was specially designed with the purpose alterations during crisis resulting from the use of PAS, the of obtaining a quantitative indicator of crisis resolution. A MSEC also prove its ability to identify symptoms potentially number of instruments for mental state evaluation are connected to other diagnoses. It does not require self- available for altered states of consciousness related to the use administration, relying on an observer’s evaluation of the of PAS, such as the APZ - Abnormal Mental States [71, 72]; presence of the symptoms on a dichotomous scale checklist. its’ improved version, the OAV - Altered States of In 2012 we developed the first studies of the instruments’ Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 89 psychometric properties with results pointing to high levels were probably the ones less accurately accounted for in of internal consistency in all dimensions of mental state Sample 1 (n=122), since they presented less severely and exam, suggesting the MSEC’s high reliability [69]. The required less time and effort to be solved. There were also instrument’s psychometric studies are, however, still in situations in which visitors presented mental crisis involving progress, and these results require further research. PAS use (T4) and situations in which the mental crisis was not involving PAS use (T5). Both these scenarios required Second moment. One month after KC implementation, the presence of psychopathological symptoms like psychotic the team was approached via e-mail and asked to contribute outbursts, paranoia, depression, that raised the possibility of to a questionnaire sent via e-mail. (Form 5). a diagnosis prior to festival participation or PAS use. An Third moment. Form 6 was collected during a follow-up important criterion for assigning this category was the fact period of 18 to 6 months after intervention. Data was that after a considerable amount of time had elapsed, collected using an online questionnaire developed through symptoms showed no alteration. These were also the Google Drive – Forms. situations where intervention was more likely to include Efforts were made to minimize the burden put on visitors prescribed pharmaceuticals. for data collection purposes, considering the serious The different types of situations attended demonstrate the condition in which they could arrive at the space, anticipated project covered a wide range of needs, surpassing its main paranoia symptoms, difficulties with language and verbal focus on difficult experiences involving PAS use. This is processing of information and experience, and hurry in suggestive of a more diverse intervention field than initially leaving the space following crisis resolution. These are the expected, since implementation signaled new needs reasons underlying difficulties in our research design, requiring the formulation of additional goals in future namely concerning the differences in sample sizes for the editions and intervention designs. It is also supportive of the various research groups. need for a broader, multi-leveled definition of crisis and crisis intervention, in what concerns recreational 3. RESULTS environments. Results concerning the number of PAS used by KC 3.1. Intervention Model and Implementation Process visitors from Sample 1 and Sample 3 are suggestive of 3.1.1. Participants and Crisis Characterization frequent poly drug use, since large percentages of both samples report having used 2 or more substances. However, Table 3 summarizes information about participants from results also point out to cases when no PAS were used, once three research samples (n=176). more supportive of the need for broader crisis definitions in Research participants were predominantly males, aged recreational environments. 19-39, European, and highly qualified. However, Table 4 presents descriptive frequency data concerning demographics on Sample 1 are limited. During intervention use of different PAS. For this purpose we used a measure it is important interviewing concerning visitors’ background based in self-reported use – that is, visitors reported the is kept to a minimum. This fact raises difficulties to our substances they believed they had ingested. Consequently, intention of presenting rigorous demographics of KC this influences feedback concerning the PAS visitors visitors. perceive as responsible for unpleasant, crisis triggering The reasons why visitors attended KC were categorized effects. Differences between self-reported use and products according to different possibilities. Some visitors attended actually ingested represent a common bias also present, for due to a difficult experience involving PAS use (T1). This example, in epidemiological research. However, implications type of situation could happen due to intentional or non- for our intervention context are particularly relevant since intentional use. We considered non intentional use occurred PAS circulating in recreational environments frequently when a visitor reported being offered a designated PAS that include adulterants and/or other products not announced by turned out to be a different product, when use occurred sellers, unknown to users, not accounted for in self-reported without previous consent, or when use occurred accidentally use, and potentially responsible for unpleasant effects and (drinking from an abandoned bottle of water that contained a crisis. This scenario is undoubtedly present at our data, since PAS). This type of situation was responsible for the majority we cannot accurately say if LSD and MDMA are in fact of interventions performed at KC. Another type of situations responsible for such high use prevalence and crisis was a personal crisis not involving PAS use (T2). Relational symptoms among KC visitors. problems with significant others, being lost, disoriented, Because cannabis is less frequently associated with overheated, tired, overwhelmed by the highly stimulating unpleasant effects and crisis symptoms in users’ perceptions, environment of the festival, among other factors, might it is possible our data under-reports its prevalence and its trigger emotional responses and distress that could also be influence over crisis symptoms. integrated through intervention offered at KC. We considered T2 situations involved these triggers in the When poly drug use occurred, the most frequent combinations were of LSD and alcohol (12%), as well as absence of references to PAS use, although complete MDMA and Cannabis (10%). Other less frequent absence of PAS use couldn’t in fact be demonstrated. Non- combinations were amphetamines and alcohol (7%), and crisis (T3) were situations not related to a crisis episode that LSD and MDMA (8%). These data indicate that LSD, had to do with requests for a rest area, information or minor Alcohol and Cannabis are the most frequent SPA present in healthcare requests (a bandage, a pregnancy test, HRRM materials, etc.), in the absence of distress. These situations poly drug use patterns among KC visitors. 90 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. Table 3. Research samples. Demographics Totals Sample 1 Sample 2 Sample 3 Total (N=176) n % 122 % 36 % 18 % FESTIVAL EDITION 2010 165 93,8% 122 100% 36 76% 7 38% 2012 11 6,3% 11 61% Missing Valid N 176 122 36 18 AGE ≤18 4 2,5% 4 3,28% 19-29 108 68,8% 77 63,1% 20 56,25% 12 66,6% 30-39 31 19,7% 19 16% 5 12,5% 6 33,3% ≥40 14 8,9% 3 2,5% 11 30,5% Missing 19 19 Valid N 157 103 36 18 SEX 69,9% Males 123 82 67,7% 30 83,5% 11 61,1% Females 53 30,11% 40 32,2% 6 16,5% 7 39% Missing Valid N 176 122 36 18 ORIGIN European 124 85% 83 90,2% 28 77,7% 13 72,2% Other 22 15% 9 9,8% 8 22,2% 5 27,7% Missing 30 30 Valid N 146 92 36 18 QUALIFICATION Secondary 7 13,2% 3 8,3% 4 23,5% Graduate 39 73,6% 27 75% 12 70,6% Post-Graduate 7 13,3% 6 16,6% 1 5,9% Missing 123 122 1 Valid N 53 0 36 17 OCCUPATION Psychol/therap/psychotherap 47 65,3% 25 68,8% 4 22,2% Medical profession 9 12,5% 9 25% Academic 2 2,8% 2 6,3% Other Payed Occupations 5 6,9% 5 27,7% Students 6 8,3% 6 33,3% Unemployed 3 4,1% 3 16,6% Missing 104 122 Valid N 72 0 36 18 TYPE OF CRISIS T1 87 69% 80 74% 7 38,9% T2 3 2,4% 2 1,9% 1 5,6% T3 17 13,4% 12 11,1% 5 27,8% T4 12 9,5% 8 7,4% 4 22,2% T5 6 4,8% 6 5,6% T6 1 0,8% 1 5,6% Missing 50 14 Valid N 126 108 (NA) 18 NUMBER OF PAS 0 PAS 12 9% 12 10,3% 1 PAS 67 51% 57 49,1% 10 71% 2 or more 51 39% 47 40,5% 4 29% Missing 10 6 4 Valid N 130 116 (NA) 14 Note. T1 = A difficult experience involving PAS use. T2 = A personal crisis not involving PAS use. T3 = Non-crisis. T4 = Mental crisis involving PAS use. T5 = Mental crisis not involving PAS use. T6 = Doesn’t know. NA = Not applicable. Sample 3 (n=18) that integrates data from our resulting from mean comparison at the pre-test samples, and exploratory follow-up study, follows a similar tendency in mean difference being marginally significant. Data terms of PAS use. An exception to this is an important concerning symptoms collected through the MSEC were frequency of 2CB in Sample 3, when 2CB use in Sample 1 collected next to n=83 participants. This means outcome data assumes lower comparative frequency. are missing for a total of n=39 participants. A number of factors related to unexpected circumstances that arise in Analysis of symptoms according to gender (Table 5) shows a predominance of crisis symptoms in male visitors, naturalistic field intervention cause problems to experimental Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 91 Table 4. Frequency of self reported psychoactive substance use. PAS Totals Sample 1 Sample 2 Sample 3 Total (N=176) N % 122 % 36 % 18 % LSD 72 53% 68 4 29% MDMA 27 19% 58% 20% 3 21% Amph 19 14% 24 14% 2 14% Ket 7 5% 17 6% Coc 7 5% 7 6% Cann 17 12,5% 7 13% 1 7% 2CB 7 5% 5 4% 2 14% Mushr 2 1% 2 2% Alc 26 19% 24 20% 2 14% Other 1 0,7% 1 0,8% Missing 4 4 Valid N 136 122 (NA) 14 Note. Amph = Amphetamines. Ket = Ketamine. Coc = Cocaine. Cann = Cannabis. Mushr = Mushrooms. Alc = Alcohol. NA = not applicable. Other = DMT, DOC, opium, methadone, proscaline, GHB and zopidone. clinical design requirements, and are responsible for this loss alterations other common symptoms included alterations in of study participants. consciousness, alertness, attention and orientation, such as Table 5. Mean comparison of pre-test symptoms according to confusion and disorientation; thought process alterations gender (p<0.10) at Sample 1. included paranoia; and physiological function alterations included sweating, sleep deprivation, vomiting and/or nausea, fatigue, pain, dehydration, malnutrition, insomnia Symptoms (Pre-Test) and fatigue. Total (N=122) N Mean SD Alcohol use showed relation to affect and emotion Male 58 9,17 (9,47) alterations such as aggression, suicidal ideation, expressions Female 25 6,20 (4,86) of low self-esteem, fear, emotional lability, affective Missing 39 incontinence, anxiety, and euphoria. Visitors presenting Valid N 83 amphetamine use also presented affect and emotion t (78,72) -1,89† alterations such as anxiety, and thought-content alterations such as paranoia. Note. SD = standard deviation. Besides affect and emotion alterations such as anxiety Analysis of symptoms per PAS according to sitter’s and fear, cannabis triggered consciousness, alertness, perception (Table 6) showed that affect and emotion-related attention and orientation alterations such as confusion, symptoms were the most frequent category induced by all unconsciousness, lethargy, and spatial, temporal and PAS. These included symptoms such as anxiety, fear, personal disorientation. Visitors that presented ketamine use suicidal ideation, and crying. Visitors using LSD and mostly showed, besides affect and emotion alterations such MDMA presented a larger number of symptoms, allowing us as anxiety, fear and sadness, also physiological function to assume these were the PAS visitors reported were related alterations such as sleep deprivation and dehydration, and to more crisis symptoms. Besides affect and emotion-related thought content alterations such as paranoia. Visitors presenting cocaine use presented affect and emotion Table 6. Crisis Symptoms and PAS use. Symptoms PAS Physiological Thought Affect and Conscience, Alertness, Motor Thought Functions Content Emotions Attention, Orientation Activity Process LSD (n=58) 31% 21% 71% 57% - - Alcohol (n=23) 29% 17% 61% 29% - - MDMA (n=22) 32% 36% 77% 14% 14% 14% Amphetamine (n=17) 24% 47% 82% - 18% - Cannabis (n=15) 27% - 85% 33% - - Ketamine (n=7) 29% 29% 86% - - - Cocaine (n=4) - - 100% - - - 92 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. alterations exclusively, such as suicidal ideation, expressions 3.1.1. Team Satisfaction of low self-esteem, anxiety, and fear. To assess the degree to which team members considered A number of aspects limit interpretation of PAS use the project to have achieved its goals, and their evaluation of related symptoms in crisis. First, a large percentage of our project functioning (team satisfaction with KC Visitors presented poly drug use. Thus it is not possible to implementation), each member responded to a number of ensure these symptoms were determined by a single PAS. items to express agreement or disagreement with a set of Second, visitors report the PAS they believe to have affirmations (e.g. “KC’s implementation was high”). Team ingested. However, only testing of all ingested PAS could in members were also asked to report on their perception of fact guarantee rigorous conclusions in relation to PAS use how Visitors received intervention, as well as their and crisis symptoms, offering reliable feedback regarding the perceptions of the project’s relevance and overall efficacy. PAS visitors were in fact reacting to. Finally, and following our understanding of psychological crisis related to PAS use Team satisfaction with project implementation (Table 8) in recreational environments as a biopsychosocial response, was positive, with close to 80% of responses expressing we must acknowledge it is not only triggered by drug related agreement or total agreement with the item Project’s degree factors, but also by set and setting factors. of implementation was high. Over 90% of respondents considered intervention to be very positively accepted by 3.1.2. Intervention Implementation Characterization targets. Similar results were found regarding Team’s perception of the relevance of intervention, and its ability to Analysis of crisis episode interventions in terms of their satisfy the needs of the target group. length allowed us to conclude that approximately 50% of all episodes attended to were solved within a 1- to 5-hour Additional data gathered through SWOT Analysis and period. This means most situations were likely to be solved content analysis of Team feedback allowed us to understand within a shift interval. 31% of episodes attended to could last that some of the strengths expressed about project efficacy the equivalent to a 2-shift period of time prior to discharge. included the perception that intervention provided high A smaller proportion of situations took over 24 hours of quality services and was extremely well received by targets. intervention and up to several days (13%). According to team members, “Regardless of adversity, the work was done with impressive acceptance by the Visitors” We also described intervention strategies used by sitters (TM25); “For me, everyone who got to us was helped in a (Table 7). very secure way.” (TM3); “Kosmicare has developed a Most strategies assumed the form of some kind of basic working model and ethos that is highly functional and gives psychotherapeutic skill such as talk therapy. Talk therapy great service to the festival and its participants” (TM13). occurred when the Visitor was able to discuss issues or life SWOT analysis also expressed team members’ concerns events that the crisis episode brought up, and implies the use with project location and safety. In 2010 KC area was of active listening to enable insight and relief. distanced from other festival areas, which made the project All therapeutic strategies being implemented followed a more vulnerable to punctual episodes involving theft and non-directive, holistic, accepting, and active-listening aggression - “Being so isolated meant that Kosmicare orientation. Intervention intended to establish a relationship received poor security support at times.” (TM10); “I felt a based on support, care and the individual's needs. Specific vibe of unrest due to lack of security staff in our area, as it strategies could vary according to each sitter/therapist’s alerted us about the possibility of risk situations while not skills, while still guaranteeing adhesion to these general having the conditions to deal with it.” (TM34). This principles. Strategies and approaches included homeopathy, feedback gave way to the decision to move KC to more transpersonal psychology, reiki, and others. Physical contact central Festival grounds, to supply the area with permanent through massage was considered useful once trust was security staff, and to improve communication with established, except in situations presenting paranoia and organizers, all of these being implemented in following related symptoms [41]. editions. We emphasize logistical strategies’ centrality such as offering a rest area, or providing warm clothes, since according 3.2. Intervention Outcomes to crisis intervention principles, offering a safe, supportive and Intervention outcomes were assessed through comfortable space is considered fundamental [26, 31]. measurement of the Visitor's mental state upon admission and discharge (pre and post test). For this measurement we Table 7. Crisis intervention strategies. Psychotherapeutic Strategies Complementary Strategies Medical Strategies Logistic Strategies Talk therapy 72% Music therapy 13% Nutrition 8% Offering a resting space 27% Sitting with quietly 28% Massaging 11% Hydration 8% - - Walking with 13% Homeopathy 10% - - - - Physical contact 13% - - - - - - Working with significant others 9% - - - - - - Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 93 Table 8. Team’s satisfaction with project implementation. KC Implementation (N=36) Totally Disagree Disagree Agree Totally Agree Project’s degree of implementation was high. (n=24) 8,3% 12,5% 66,7% 12,5% Visitor’s acceptance of intervention was positive. (n=33) 3% 3% 30,3% 63,6% KC was effective achieving its goals. (n=31) - - 61,3% 38,7% KC is relevant. (n=32) - - 18,2% 81,8% KC is able to satisfy intervention’s needs (n=31) - 12,9% 71,0% 16,1% used the MSEC [69, 70]. We also observed how crisis resolution. No differences among groups with and without symptoms developed during intervention, and gathered data post-test were explored, since our focus was on mean on visitors' satisfaction upon departure of KC and in a differences regarding symptoms. follow-up inquiry (twelve to eighteen months). Another indicator of crisis resolution resulted from our qualitative data. Using indicators included in IF (Form 3) we 3.2.1. Symptoms and Mental State explored resolution regarding a valid sample of n=54 visitors, consisting of 44% of our intervention sample The IF (Form 3) describes the development of crisis (N=122). 76% (n=41) of crisis episodes obtained resolution, symptoms based on sitters’ perception. This description 17% (n=9) crisis episodes were left unsolved, and 7% (n=4) occurred throughout intervention – initial stage refers to symptoms presented on arrival; development stage refers to crisis episodes intervention was interrupted before intervention was considered complete. symptoms presented during intervention; final stage refers to symptoms presented at the moment the Visitor left the space. In order to understand characteristics of resolved and Each crisis episode, however, could present differences in unresolved episodes we explored the relation between terms of length. This makes it impossible to quantify each resolution and visitor behaviors in association with stage’s duration. intervention strategies (Table 11). Table 9 shows that despite the increase in symptoms Complementary, medical, logistical and during the middle stage of intervention (for example in psychotherapeutic strategies all contributed for crisis physiological functions, thought processes and thought resolution. Additionally, large percentages of these content, affect and emotions) considerable resolution is participants also expressed behaviors indicative of well- achieved at final stages for all symptom categories. The being such as smiling, being calm and relaxed, being stable, increase during middle stages of intervention could be regaining consciousness, expressing feeling safe, falling explained due to the fact some Visitors are brought shortly asleep among others. A number of collaborative behaviors after the emergence of the crisis episode, which peaked such as accepting medications or showing interest in while intervention was already taking place. intervention were also presented. In smaller percentages of cases these strategies were unable to produce crisis For pre- and post- values of mental state exam symptoms comparison we paired t-test of n=44 participants (Table 10) resolution. This fact encourages, in our opinion, the need for diverse intervention strategies to achieve crisis resolution in order to ensure an equivalent number of participants at and the importance of the project’s integrative approach. both samples, since no post-test data were available for approximately 50% of visitors. In the context of resolution data we wanted to further understand the relation between type of crisis/episode and Pre- and post-test comparisons showed significant differences in symptoms presented on these two occasions, crisis resolution (Table 12). We explored the relation between type of crisis and resolution regarding a valid with a mean difference of 6,84. This is a statistically sample of n=54 visitors, consisting of 44% of our significant difference (p<.000) confirming pre/post symptom intervention sample (N=122). differences that can be understood as indicating crisis Table 9. Symptom evolution during intervention. Evolution During Intervention Symptomatology Initial Stage Development Stage Final Stage Motor activity (n=11) 82% 73% 0% Attention, awareness, alertness and orientation (n=26) 81% 73% 25% Physiological functions (n=33) 61% 85% 6% Though Process, speech and language (n=10) 90% 100% 40% Though content (n=29) 76% 90% 10% Affections and emotions (n=75) 85% 93% 9% 94 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. Table 10. Pre-post mental state evaluation results. purposes. These data present considerable limitations since they refer to a very small sample of participants (n=18) from Pre-Test Post-Test two different project editions (2010 and 2012), approached (n=44) (n=44) after different periods of time had elapsed from intervention Mean (DP) Mean (DP) t (43) (twelve and eighteen months respectively), and no statistical data being offered considering 2012 intervention. These Symptoms 8.89 (8.91) 2.05 (4.63) 5.48*** obstacles reflect, once more, difficulties with data collection ***p<.000. that arise from our naturalistic intervention and research setting, as already stated above. Follow-up participant Unresolved episodes were mostly associated with cases sample was gathered from a universe of N=322 KC visitors where Visitors presented a mental health outburst episode (men- from 2010 (n=122) and 2012 (n=200) editions. A total of tal crisis), whether related with PAS use or not. These two types n=44 visitors from 2010 and n=77 visitors from 2012 left of unresolved crisis account for 78% of all unresolved episodes. their e-mails for posterior contact at our request. But answer return rates were considerably lower, referring to n=7 3.2.2. Targets Satisfaction and Intervention Impact visitors from 2010 and n=11 visitors from 2012. 3.2.2.1. Visitors’ Satisfaction on Departure Data shows that the vast majority (n=15) of Visitors who participated in the follow-up study (n=18) reported a positive Outcome assessment also included measurements and perception of the intervention. This suggests our follow-up qualitative data analysis regarding the satisfaction of the sample considered KC effective in solving the crisis episode. target group. Descriptive statistics showed that 81% (n=41) The fact that we were approaching these subjects after a of 2010 Visitors that offered feedback at the moment they considerably long period after intervention shows us that this left KC (valid n=58) expressed total agreement towards the perception was stable over time. We also wanted to know item “I have been helped by KC”. Satisfaction was also high about intervention’s impact and relevance to Visitors' lives. in relation to project’s physical conditions (58% expressing Data shows the majority (n=10) considered intervention a total agreement); and in relation to technical human very significant experience in their lives. This shows resources (75% expressing total agreement with the item respondents have been able to reflect upon the meaning of “KC staff was helpful, caring and available”). Additionally, their crisis experience, a relevant last step in crisis satisfaction was also expressed at the item “KC had well- resolution. prepared efficient staff”, with 80% visitors declaring total agreement with this item. This allowed us to conclude that Finally, we wanted to understand which aspects of Visitors’ satisfaction with KC implementation reached levels intervention were perceived positively and which negatively. of excellence, which suggests that intervention was effective. We considered this evaluation to be central for the improvement of the intervention’s future implementations 3.2.2.2. Long-Term Satisfaction [71]. Visitors globally emphasize the centrality of Long term satisfaction data and long-term impact of psychotherapeutic intervention strategies used by sitters crisis intervention data bellow were collected for follow-up (“People working at KC are so calm they give a sense of Table 11. Association between intervention strategies, intervention episodes resolution and visitor’s behaviors. Intervention Episodes Resolution Visitors’ Behaviors Intervention Strategies Solved Unsolved No Information Well-being Collaborative n% n% n% n% n% Psychotherapeutic (n=90) 27 30% 8 9% 55 61% 30 33% 3 3% Medical (n=18) 7 39% 2 11% 9 50% 7 39% 2 11% Logistic (n=34) 12 35% 3 8% 19 57% 20 59% 1 3% Complementary (n=32) 15 47% 4 13% 13 40% 18 56 4 13% Table 12. Resolution according to type of crisis/episode. Intervention Episodes Resolution Type of Crisis (n = 54) Solved Unsolved Interrupted n=41 (n=9) (n=4) Difficult, intentional experience with a PAS (n=33) 82% (n=27) 6% (n=2) 12% (n=4) Difficult, accidental experience with a PAS (n=1) 100% (n=1) 0 0 Mental crisis not related to PAS (n=4) 50% (n=2) 50% (n=2) 0 Mental crisis related to PAS (n=6) 17% (n=1) 83% (n=5) 0 Non crisis (n=10) 100% (n=10) 0 0 Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 95 peace, harmony, a good energy that penetrates us and helps We also wanted to understand Visitors’ perceptions of coming out of madness” V6). Specifically, we understood how long the benefits of intervention lasted. An expressive visitors referred to sitters’ empathy (n=6), availability (n=6), majority (n=12) reported their current perception as being ability to calm them down (n=7) and talk therapy (n=4), as that such benefits would have a definitive impact on their the most positive aspects. Empathy as a basic relational skill, lives, further supporting the notion of crisis episode defined as the ability to understand the experience of others resolution as a meaningful experience with positive and while accepting them, was fundamental for encouraging the lasting effects. person to verbalize difficulties (“I have met someone at KC Finally we wanted to understand how crisis had been who I felt understood what was wrong with me” V4). integrated over time. This data presented us with situations Availability was defined as the ability to establish rapport for where integration was clearly positive, as well as cases a considerable amount of time while crisis was developing where integration was negative. Negative integration (“People that love to help and can stay for maybe hours by situations had to do with an increase in symptomatology that someone's side” V12). The ability to calm the visitor down had appeared prior to crisis (n=1) (“I have had problems was defined as the capacity to change crisis perception in with social integration also before this experience, but after ways resulting in the reestablishment of emotional balance it's worse to control the anxiety and panic” V1); (“It was nice that someone talked to me and calmed me symptomatology that was triggered by the crisis episode down” V8). (n=1) (“My perception is also changed. I see things moving On the other hand, the lack of medication to interrupt the in the corner of my eyes that aren’t really moving…” V14); crisis (n=1), shift changes that might present the need for the and the wish not to have had the experience at all (n=2) visitor to repeat information concerning their symptoms to a (“My life would have been better if I wouldn’t have had the new sitter (n=1), and the spatial setup of the intervention not trip and been forced to go there” V7). providing enough privacy (n=1), were signaled as the most Several dimensions were indicative of positive negative aspects. However, frequency analysis shows integration. The willingness to repeat the experience (n=2) is considerably inferior results as far as negative aspects are shown by the emergence of increased insight about oneself, concerned. personal problems and daily situations, indicating that not 3.2.2.3. Long-Term Impact of Crisis Intervention only was the crisis episode positively solved, but it also Follow-up assessment was developed with the aim of triggered new skills about understanding oneself and others (“I had this urge and need to find out what happened that collecting data on Visitors’ perception of the long-term day and why I went through what I went through” V13). benefits of intervention, how long those benefits lasted, and Other reported dimensions were an increase in self- current perceptions of the crisis experience. knowledge (n=3) (“It helps me to see more clearly Long-term impact of crisis intervention included a circumstances and parts of this problem” V5); the desire to number of benefits perceived as enduring long after search for a more positive experience (n=3) (“What really intervention occurred. Respondents reported a number of bothers me, and the only negative aspect I still carry with changes that occurred at a personal level, including changes me, is that I couldn’t experience a good, intense, fun, in how they related to drug use. Specifically, they reported changing, interesting and positive LSD experience” V10); increased knowledge of how to deal with crisis situations and the expression of happiness (n=4) (“I am actually quite (n=2), acquisition of a more responsible attitude towards happy that the incident happened because I now know about drug use (n=5), and gaining a more positive appreciation of Kosmicare and can avail of it in the future” V18). oneself and relationships with others (n=5). Acquiring a Globally our follow-up sample can be clearly considered more responsible attitude towards drug use as a result of KC insufficient for effective feedback, is probably highly intervention was possible due to increased awareness of PAS selective (respondents potentially being participants with effects and safer use practices (“The benefits have been my more positive experiences to share) and doesn’t satisfy the mindset towards drugs and the effects of drugs on you. Where to use drugs and how to use them more responsibly.” purpose of obtaining a reliable follow-up feedback. Given these limitations, our data concerning visitors’ feedback for V15). Increased knowledge of how to deal with crisis follow-up purposes should be considered merely situations implied a more informed and conscious attitude exploratory. about PAS use-related risks, and the intention of managing these in the future to prevent crisis (“I know better how to handle bad trips.” V17). Increased positive appreciation for 4. DISCUSSION oneself and for relationships with significant others has been According to Flay [65], “because outcome research described as an opportunity presented by crisis, since healing results are specific to the program or policy actually tested, and resolution of daily difficulties might be triggered by a the samples, and the outcomes measured, it is essential that psychedelic crisis episode [72] (“This day I had a conclusions from the research be clear regarding the breakthrough in my relationship with my father. Not program, populations and their settings, and the settings for everything had been solved this night. It was more like the beginning of a wonderful process, which led me to the which their efficacy is claimed.” (p.154). The study confirms that process and result indicators can be collected and realization, that my parents always wanted the best for me analyzed systematically, supporting the advantages of and gave me all the love that they could give. With time I evaluating an innovative natural setting-based intervention in managed to look at my childhood from different perspectives close proximity to emerging problems. A number of other and found peace with myself and my relationships” V9). good-practice evaluation principles - such as the search for 96 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. statistically unbiased estimates of relative effects, or The study contributes to characterizing crisis in inclusion of a long-term follow-up with an appropriate recreational environments, including the episodes that don’t interval - were attempted at this evaluation research of KC include PAS use. This scenario, although less frequent, project, even if with limitations imposed by an exceptional confirms once more the need for a broad definition of crisis and unconventional intervention setting. in these contexts [32]. LSD and MDMA are largely predominant in crisis episodes and mental state alterations, Although heavily reliant on the perceptions of the cannabis appearing possibly underrepresented. The intervention team results confirm that the program is having substance’s widely disseminated and normalized use [76] impact in the field it is designed for - crisis intervention and could be responsible for this aspect of our data, since HRRM in PAS use in recreational environments. Visitors might tend not to relate cannabis to negative Additionally, KC is addressing a PAS-using population and context that is identified by epidemiology as being at the outcomes, particularly crisis episodes. center of emerging patterns of use and related problems [4, The measurements for PAS use in our study are based on 11], and in need of attention from a public health self-reported use – that is, visitors reported the substances perspective. This is especially relevant since this PAS-using they believed they had ingested, or the PAS they were told population is considered distant from formal intervention they were ingesting. Consequently, this influences feedback structures [8, 62], and thus particularly able to benefit from concerning the PAS visitors believe are more responsible for an informal and proximal intervention such as the one being unpleasant effects and crisis triggering. Although this is a offered by KC. common bias of self-reported use measurement (even in epidemiological research), we assume it presents particularly The nature of crisis intervention, the project’s approach severe implications in our intervention context, since PAS to settings where behaviors are occurring spontaneously, and circulating in recreational environments frequently include the commitment to visitors’ well-being dictated that despite the interest in developing evaluation research, minimum adulterants and/or other products not announced by sellers, unknown to users, not accounted for in self-reported use, and interference occurred with intervention process. There was, potentially responsible for unpleasant effects and crisis. however, an effort to involve defined samples from defined According to the 2nd TEDI Trend Report that has published populations, a criterion identified in prevention research as data relying on drug checking services implemented by the first objective of efficacious intervention trials, since several HRRM teams all across Europe, MDMA, statements of efficacy should be able to determine that a program is specified to produce a given outcome for a given amphetamines and cocaine remain the most frequent substances used in recreational settings, with great variation population [65]. considering their levels of purity and the number and According to the literature, offering a safe, supportive percentage of adulterants. KC evaluation data also reflects and comfortable care space is one of the principles of crisis this phenomenon. Because of this we cannot accurately say intervention in recreational environments [14, 32, 33, 51]. if LSD and MDMA are in fact responsible for such high Our data confirm the effectiveness of project logistics from prevalence and crisis symptoms among KC visitors. the visitors’ perspective, which is indicative of the program’s Studies in the past have determined that anxiety, ability to deliver this level of support. depression and dissociation were influenced by the According to the EMCDDA multiple drug use among frequency and length of the lifetime prevalence rate of PAS adolescent Europeans has been increasing since the 90’s in a use [77], that PAS use could trigger or intensify the variety of drug-using repertoires, potentially indicating early development of psychopathology [78], and that people initiation and risk behaviors; among young adults it can be presenting expressive emotional or psychiatric distress pre- symptomatic of more established patterns of multiple existent to crisis will potentially experience escalation in substance use, potentially carrying long-term health symptoms following PAS use [14, 79]. Our data also support problems and acute risk during leisure time [30]. For these the existence of relation between PAS use and reasons, signaling poly drug use has been considered highly psychopathology. Unsolved crisis episodes tend to reflect relevant for HRRM intervention. Our data indicate which cases where it was suspected visitors had a pre-existing PAS were involved in crisis episodes, with LSD and MDMA psychopathological diagnosis. However, the relation predominating. Multiple drug use situations involved use of between PAS use and psychopathology cannot be presented LSD and alcohol, MDMA and cannabis, amphetamines and linearly since it is yet to be determined if use actually alcohol, and LSD and MDMA. Epidemiological data triggers mental disorders or if, on the other hand, contributes available for the EU ignore most of these PAS use patterns, to an escalation of preexisting symptoms. Future follow-up focusing on combined use of cannabis with ecstasy, studies should analyze visitors’ PAS use patterns and amphetamines or cocaine [30]. This allows us to conclude trajectories, which should increase knowledge on the relation that our participants present a multiple drug use pattern that between these variables. probably remains unaccounted for in available The program used very diverse intervention strategies. epidemiological literature. This also means multiple drug use Among them, psychotherapeutic strategies were the most patterns encompass significant implications for intervention because they make it impossible to accurately associate crisis frequently used. Psychotherapeutic strategies were notable for their contribution in helping visitors to traverse crisis, as with specific PAS and mental state alterations, which in turn reported by our follow-up sample. The program’s approach appeals for a broad and multi determined understanding of is consistent with literature according to which help and crisis in recreational environments. We globally conclude support professionals should share common skills in terms of that PAS use and its relation to crisis type and vulnerability their ability to relate to others, use active listening, and require further research. Crisis Intervention – Evaluating Kosmicare Project Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 97 demonstrate deep understanding of problems being presented KC attended a number of situations referred above as mental by people in need [80]. Our data support literature indicating crisis related and not related to PAS use. Although both these skills as especially important in crisis intervention, included visitors that presented symptoms related to since they are essential to reduce crisis impact and increase paranoia, dissociation or depression, they could be coping [53]. distinguished whenever the persistence of these symptoms remained far beyond the expected length of PAS use-related Medical strategies, which included the use of prescribed effects. We consider this type of less frequent crisis episode allotropic as well as homeopathic substances, were used to to be possibly related to a previous diagnosis, and these facilitate resolution of a limited number of crisis episodes. individuals to be at higher risk for mental disorders. If, on However, our data presents limitations in reporting the the one hand, it is possible that intervention is having number and types of episodes where such strategies were deployed. demonstrable impact on preventing further progression of these at-risk mental states [83] among those that present According to literature, crisis resolution occurs when the increased vulnerability to mental disorders, on the other hand person is feeling comfortable and no emotional or it is expected that individuals with a previous diagnosis are psychosomatic symptoms are presented [14]. Significant most likely to see their condition aggravated after a crisis differences between pre- and post-tests of average crisis episode. symptoms indicate that expected results were confirmed and The project’s characteristics and crisis intervention crisis episodes were resolved by intervention. Some aspects features themselves are impediments to an accurate may pose limitations to this conclusion. Firstly the sample knowledge about such levels of impact. However, it is we considered for our pre- and post tests is considerably expected further research will keep contributing to the smaller than the total of interventions performed. Secondly understanding of the relation between PAS use, crisis, and these results were only considered globally since our instrument’s subscales lacked the required internal mental disorders. And it is also possible to conclude that the intervention’s proximity to these episodes of increased risk consistency, preventing the analysis of symptoms for mental disorders might prove to be a relevant tool in the distribution in the various subscales. A number of reasons prevention of the onset of chronic and more severe mental may explain these limitations. The considerable loss of illnesses. respondents is possibly explained by the large number of measurements that relied on sitters’ feedback. We have Other results concern the intervention’s long term impact altered the instrument’s structure to facilitate this feedback in relation to HRRM. One of KC’s goals is to increase by sitters and prevent loss of data in the future. Further knowledge of the risks and benefits of altered states of studies aimed at the instrument’s psychometric properties are consciousness and promote learning on how to deal with currently being developed, which in the future will allow an future problems. A small group of respondents to our increased understanding of the evolution of crisis symptoms. qualitative follow-up study reports having acquired However, we believe the project’s effectiveness in knowledge and increased awareness on strategies for safer addressing crisis episodes and contributing to crisis PAS use. Other groups of respondents also reported having resolution is overall demonstrated. learned how to deal with crisis episodes, and having developed a more responsible attitude towards PAS use in Long term impact was expressed with respondents stating general. Even though these results refer to a small, that they acquired a more positive attitude towards qualitative follow-up sample and need to be confirmed by themselves and relations with significant others following crisis intervention. These results seem to confirm what Grof further studies, we believe these to be encouraging data in terms of the project’s ability to reduce risk and promote & Grof [81] have signaled as the potential for crisis to bring safety. resolution to relevant life problems, to promote healing and, according to Stolaroff [33], to allow the progression from a We emphasize that follow-up data refer to a very limited state of distress to a more integrated resolution of personal and selective sample preventing us from reliable evidence- and relational troubles. based conclusions regarding long term intervention impact. Nonetheless, and even if only exploratory, we have chosen However, a need remains for knowledge about the to include these data since we believe them to offer valuable circumstances of less positive crisis resolution. According to input about relevant aspects to consider in future research, our long term impact follow-up study a very small group of and since updated literature about benefits of psychedelic use respondents says crisis resulted in an increase of symptoms and psychedelic crisis intervention are so scarce. or in more severe presentation of previous symptoms. It is possible that this result can be explained in relation to Finally, some clinical and practical implications emerge previous psychopathology or vulnerability to from KC evaluation research. Since difficulties in crisis psychopathology without previous manifestations, but the resolution are expected among episodes that involve higher relation between these two variables must be further risk of mental health disorders, the program should take into researched. Yung et al [82] have studied several groups in consideration how intervention with these visitors could be the process of determining ultra-high risk of psychosis and improved. Partnerships with mental health structures outside relation to psychosis onset, including a group with history of the festival and providing the visitor with written brief, self-limited psychotic symptoms assessed with an information about their crisis episode for future reference instrument that detected sub-threshold and threshold levels might be useful resources to promote in the future. of delusions, hallucinations and formal thought disorder. 98 Current Drug Abuse Reviews, 2014, Vol. 7, No. 2 Carvalho et al. LIST OF ABBREVIATIONS [5] Machado C, Cruz O. Consumo "não problemático" de drogas ilegais. [“Non-problematic” use of ilegal drugs] Revista DSM-V = Diagnostic and Statistical Manual of Mental Toxicodependências. 2010; 13: 39-47. [6] Bernardo M, Carvalho M, Ed. El significado del uso de las drogas Disorders en el discurso de los jóvenes consumidores portugueses [The HRRM = Harm Reduction and Risk Minimization meaning of drug use in Portugueseyoung users’ speech] [monograph on the internet]. Salud y Drogas 2012 [cited 2013 Aug KC = Kosmicare 18]. Available from htttp://www.redalyc.org/pdf/839/839249650 04.pdf. MSEC = Mental State Exam Checklist [7] Carvalho M. Culturas juvenis e novos usos de drogas - o trance psicadélico como analisador. [Youth cultures and new Drug use PAS = Psychoactive Substances patterns – an analysis through psychedelic trance] Porto: Campo de letras 2007. CONFLICT OF INTEREST [8] Calado V. Trance psicadélico, drogas sintéticas e paraísos artifici- ais. Representações: uma análise a partir do ciberespaço. [Psych- edelic trance, synthetic drugs and artifical paradises. Representat- Kosmicare Research hasn’t received until the present ions: an analysis of cyberspace.] Revista Toxicodependências time any formal financial contributions. Research is 2007; 13(1): 21-8. developed thanks to the same institutional collaborations that [9] Chaves M. Rave Parties: images and ethics of contemporay part- allow the project’s implementation – a partnership between ying. In: Cordeiro F, Baptista L, Costa A, editors. Urban Ethno- Boom Festival Production, the Centre for Studies in Human graphies. Oeiras: Celta: 2003. [10] Beck J. Rosenbaum M. Pursuit of ecstasy. The MDMD experience. Development - Faculty of Education and Psychology – Albany: State University 1994. Catholic University of Portugal (Porto), and the General [11] Merchant J, Macdonald R. Youth and rave culture: Ecstasy and Directorate for Intervention on Addictive Behaviors and health. Youth Policy 1994; 45: 941-64. Dependencies (Government of Portugal). The team involved [12] Service for Intervention in Addictive Behaviors and Dependencies - SICAD. Enquadramento à redução de riscos e minimização de in research is also involved in the project’s implementation. danos - RRMD. [Framework for harm reduction and risk minimi- This is the case for Maria Carmo Carvalho, Mariana Pinto de zation]. [Internet]. [cited 2011 Apr 20]. Available from: http://ww Sousa, Paula Frango, Joana Carvalho, Tânia Rodrigues and w.idt.pt/PT/ReducaoDanos/Paginas/Enquadramento.aspx. Marta Rodrigues. Research team members develop research [13] Roberts A. Crisis intervention handbook: assessment, treatment and activity as part of their academic and/or technical activities, research. California: Wadsworth 1990. [14] Grof S. Lsd psychotherapy. The healing potencial of psychedelic performed as professionals of the referred institutions. An medicine. Florida: MAPS 2008. exception to this scenario is researcher Joana Carvalho [15] Krul J, Sanou B, Swart E, Girbes A. Medical care at mass currently contributing voluntarily to Kosmicare research. gatherings: emergency medical services at large-scale rave events. Prehospital Disaster Med 2012; 27: 71-4. [16] Halpern P, Moskovich J, Avrahami B, Bentur Y, Soffer D, Peleg ACKNOWLEDGEMENTS K. Morbidity associated with MDMA (ecstasy) abuse: a survey of emergency department admissions. Hum Exp Toxicol 2011; 30: Authors wish to thank Boom Production, the Faculty of 259-66. Education and Psychology – Catholic University of Portugal, [17] Krul J, Blankers M, Girbes A. Substance-Related Health Problems and the General-Directorate for Intervention on Addictive during Rave Parties in the Netherlands (1997–2008). Plos ONE 2011; 6: e29620. Behaviors and Dependencies of the Government of Portugal [18] Meehan T, Bryant S, Aks S. Drugs of abuse: the highs and lows of for supporting Kosmicare intervention and research. Authors altered mental states in the emergency department. 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