Therapy Shows Promise for Some Patients
The use of psychedelics for healing is not new. There is evidence that ancient civilizations throughout the world used psychedelics for a variety of reasons for a very long time, extending well into the modern era. In fact, in the 1950s and first half of the 1960s, psychiatrists, researchers and other professionals were both studying and prescribing psychedelics to help patients struggling with their mental health.
By the end of the 1960s, however, a number of factors contributed to the decline of psychedelic use and research, including the War on Drugs and increased pharmaceutical restrictions. As a result, psychedelics largely fell by the wayside, deemed to be party drugs, among other things.
Recently, the bias around psychedelics has started to shift, however. Helped by mainstream conversations and publications, such as American journalist and author Michael Pollan’s book “How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression and Transcendence,” the public’s understanding of what psychedelics are and can do is expanding and shedding light on work that has been growing since regulatory approval to research psychedelics in the U.S. resumed in 2000.
That work includes psychedelic-assisted therapy.
Psychedelic-assisted therapy can be used to assist individuals struggling with their mental health. And while it is neither a cure-all nor for everyone, the results are promising for those to whom it does fit. “It is not a panacea,” cautions Mary Cosimano, LMSW, psychedelic session facilitator at Johns Hopkins Center for Psychedelic & Consciousness Research.
Types of Therapy
As with anything, the use of psychedelics for mental health treatment can be offered in various ways. At present, ketamine is the only psychedelic the U.S. Food and Drug Administration has approved for treatment, though states have and may additionally take action to decriminalize other psychedelics. For example, on Jan. 1, Oregon became the first state to legalize adult use of psilocybin. In June, the FDA released a first draft of guidance to researchers studying psychedelic drug development.
Individuals receiving ketamine treatment are not necessarily receiving ketamine-assisted psychotherapy, says Stephen Thomas, LCSW, psychotherapist and Ketamine Assisted Psychotherapy (KAP) practitioner in Fort Collins, Colo. It is more likely, he says, that ketamine treatment refers to ketamine infusion—the current dominant model of ketamine treatment. This model “involves the administration of a single infusion or a series of infusions for the management of psychiatric disorders like major depressive disorder, post-traumatic stress disorder, acute suicidality,” according to the Psychiatric Research Institute at the University of Arkansas for Medical Sciences.
The infusion model does not necessarily involve psychotherapy or other support. The individuals overseeing and administering the infusion are not mental health practitioners but rather physical health practitioners, and there is no guarantee of a built-in process in which the patient has the opportunity to discuss their experience.
“It’s not to say that some people don’t get benefits from that, because they can,” Thomas says. “[But] there’s a missed opportunity in the synergy and the depth that psychotherapy interwoven into that modality can bring. It’s not just that experience people have for two hours,” he adds, referring to the experience a patient has while taking the ketamine. “It’s about what you do with it afterward.”
KAP varies from infusion therapy in many ways—from the preparation to the session itself to the unpacking afterward. Medical professionals are still involved, but mental health practitioners play a significantly more pivotal role. At present nationally, other psychedelics may be used in psychedelic-assisted therapy when research is being conducted. For example, at Johns Hopkins, the research focuses on psilocybin, a naturally occurring fungi-produced psychedelic. Additionally, MDMA, a synthetic hallucinogen — also called Ecstasy — is being studied for its use in treating PTSD.
What the patient experiences and what happens inside their brain when taking a psychedelic will depend on the type of psychedelic administered and is ultimately not yet fully understood, despite ongoing research. For example, a study at Weill Cornell Medicine found that psilocybin activates the “serotonin receptors on brain cells in a way that reduces the energy needed for the brain to switch between different activity states.” Ketamine studies have shown that the psychedelic reorganizes the activity in the brain, quieting typically active neurons and awakening typically quiet ones, according to Penn Medicine. The differences in the psychedelics taken will impact the medicine session, in which the patient is administered the psychedelic. However, commonalities exist in the preparation and integration of the session when discussing generally psychedelic-assisted psychotherapy.
As mentioned, while psychedelic-assisted therapy is proving to be helpful for many patients, it is not for everyone.
“This type of treatment has been beneficial for individuals who suffer from anxiety, depression, OCD, PTSD, and other trauma symptoms,” explains Molly Zive, LCSW, psychedelic assisted therapist, advocate and senior social worker at the U.S. Department of Veterans Affairs. She is based in the San Diego area. “I would recommend psychedelic-assisted therapy to those who have been investing in their own inner development and want to go deeper. I would recommend (it for) someone who is already in therapy who has both internal and external coping strategies,” she adds.
Zive says she would not recommend this type of therapy to those with borderline personality disorder, schizophrenia or schizoaffective disorder, as well as to those who are pregnant.
Thomas is less specific in discussing who the treatment (in his case, ketamine) may be best for. “In some ways, it is still kind of an open question,” he says. “The community of practice is split on some of these things.” However, he says he would not work with someone who has had an active psychosis, for example. The ketamine experience can be disorganizing and destabilizing for certain individuals, and not worth the risk.
Practitioners say they can get a sense for whom psychedelic-assisted therapy may be appropriate through diagnosis, and also their preparatory work and information-gathering.
Shannon Hughes, PhD, MSW, associate professor at the Colorado State University School of Social Work, says many of the individuals who reach out for psychedelic-assisted psychotherapy are simply looking for relief. “We get calls constantly,” she says. “It’s all ages—from teenagers to folks who are 75 or 80 years old. We see the full range. They are people who are really suffering, people who have tried a lot of things and gotten no or only momentary relief. They’re looking for a breakthrough of healing, whether it’s from trauma or depression.”
Screening those looking for help through this treatment depends on the setting. For Cosimano, the preparation begins before the patient even meets the practitioners. “We have extensive screening,” she says. “An online screening, then a phone screening. Then if they qualify, we bring them in for an in-person screening. That involves medical and psychological screening.”
Medical evaluation is an important part of the process, as the medical provider will determine not only the individual’s physical ability to undergo the treatment but also the dosage. Again, depending on the setting, the medical provider may continue to be updated throughout the treatment or if a medical concern arises.
In addition to the medical assessment, patients undergoing psychedelic-assisted psychotherapy spend a significant amount of time preparing for their medicine sessions. A patient does not simply receive the psychedelic once a doctor clears them. Instead, they spend time preparing with their mental health practitioner(s). Some of that preparation involves talking about logistics, says Cosimano.
“There’s a lot. How to show up for the day, what to wear, what to bring.” But most importantly, she says, the lead-up sessions are about building trust.
“So much can come up that’s difficult: the things that you feel the most ashamed or embarrassed about or have grief around. Oftentimes, you’re only going to want it to come up if you feel safe,” she says.
Zive agrees, adding that she also focuses on intention.
“I am an IFS (Internal Family Systems)-informed provider and review parts work with my clients. I ask if there is a part of them that we need to get permission from. It is especially important for those who have suffered childhood trauma, because they were often mentally or physically violated. It is important to build trust with one another. I encourage my clients to create intentions with journal exercises about where they want to be in one month, one year, 5 years from now,” she says. “I want my clients to know that they can be held in this space in the safest way possible.”
The trust goes both ways. The practitioner must also trust the individual they are supporting. One of the ways that bidirectional trust can be built is by discussing the boundaries for the patient and the practitioner(s). For example, touch can be a part of the medicine session whether through a hand hold or a hug.
”Typical clinical practice is you just don’t touch,” says Hughes. “With psychedelics, it’s a vulnerable state. It’s not ordinary consciousness. Clients are much more vulnerable. Touch—skillful, careful consensual use of touch—can be very much part of the healing process.” She adds that what is offered must be comfortable for everyone involved. If a practitioner is only comfortable with hand-holding, they can redirect an individual who may want a hug and encourage a pre-discussed self-soothing exercise.
Building rapport with the client and going over logistics, possible scenarios, and needed boundaries allows all involved to enter a medicine session with confidence.
The sessions themselves vary depending on the psychedelic, dosage, administration and setting. While Thomas describes the medicine portion of a ketamine session as lasting from 45 minutes to two hours, Cosimano says that a session day with psilocybin involves six hours of monitoring. The pscyhedelics are simply different in how they interact and move through a person’s system.
Regardless of time, both the practitioner and the patient must enter the session ready for the experience. For a practitioner, that may mean preparing to be in a room observing and guiding for six hours by getting in some exercise and eating a large meal beforehand. (Cosimano does note there are two practitioners in every session day at Johns Hopkins, allowing for short breaks as needed.) But it also often requires grounding.
“This work can be very intense,” says Zive. “I like to smudge the room by lighting the incense, palo santo or sage. I create my own intention around the medicine work and create mantras that feel true to me.”
“I meditate,” says Thomas. “I’ll do some grounding beforehand. I’ll set the space up and set my own intention, which is to honor their process and be a safe person and a safe container.” For Thomas, the idea of a container in this practice “is kind of just the energetic and relational structure that holds the experience. Set and setting comes into play there. It’s the conversations, the trust and safety, and the feel of the space. People can feel like they’re held and that they feel comfortable and safe in that way.”
Hughes further describes the container as “most of the physical and energetic space that surrounds the psychedelic encounter. We think about strong containers and tight containers. Containers include partly the preparation, the mindset that you’re going in with. You have that sense of preparation, plus I think of rules, ritual—something that marks the beginning and the end,” she says.
“Then your presence as a facilitator, as a therapist. You’re not feeling chaotic inside. You’re not trying to check your emails. You’re calm. You’re unhurried. You’re holding good boundaries. You have compassionate witnessing. You’re fully present. It’s the physical and the energetic.”
Once the patient has arrived and also set their intentions for the day, the patient’s experience—not the goals of either the therapist or the patient — guides the session.
“The therapist is not guiding. They’re following alongside,” says Thomas. “One thing that can get in the way of a process is if someone comes in very outcome-oriented. Psychedelics enable a person to open up to an inner healing intelligence. That’s not something that the ordinary mind is always in contact with. We spin the wheel, and the medicine is going to take us where it is going to take us. The intention is not an outcome.”
Integration and Benefits
After the medicine session, patients receiving psychedelic-assisted psychotherapy discuss the experience in separate sessions with their therapist. In some instances, the patient has been asked to write down in their own time a reflection on the medicine session prior to the integration. The therapist also will have notes from the session, so they can explore what came up and the patient’s reaction to those topics.
The medicine sessions coupled with the integration sessions can have positive impact but they will not necessarily stimulate immediate and permanent change. “For both patients and practitioners, a common misconception is that psychedelic work will fix everything,” says Zive. “This intervention is not a silver bullet. In most cases, when working with clients, the psychedelic illuminates the area of their life they have been suppressing or neglecting (consciously or unconsciously).”
“I can’t help but bring to mind this meme circulating on social media that reads ‘Everyone wants to take Ayahuasca, but no one wants to do the dishes.’ This metaphor demonstrates to me that some folks find relief in taking a psychedelic but are unaware of the actual inner work or integration practices it requires to truly work with the medicine outside of actually ingesting it,” she explains.
Hughes adds that psychedelic-assisted psychotherapy cannot change the often systemic challenges clients face. “Psychedelics aren’t going to give you a house and produce income equality,” she says. They offer an option for mental health concerns, but, as with any treatment, must be coupled with solutions to the additional needs of the individual and their environment.
When a patient is the right fit, is willing to do the work, and is open to the possibilities of what psychedelic-assisted psychotherapy may achieve, the effect can be great.
“I have experienced firsthand the ability of psychedelic medicines to shift my perspective, alleviate grief [and] depression, and give me other perspectives,” Thomas says.
Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.