Global Courant
Psychedelic therapy is on its way to becoming a widely used medical treatment in mental health care.
In 2020 and 2022, residents of Oregon and Colorado voted to legalize the use of psilocybin, the psychoactive ingredient in hallucinogenic mushrooms, and the Food and Drug Administration (FDA) is expected to approve it along with MDMA, or ecstasy, to treat depression and post-traumatic stress disorder in 2024.
While there is growing evidence that psychedelics could offer much-needed new treatments for intractable mental illnesses, stories of abuse or trauma have also emerged, which have more to do with therapists than drugs.
In some cases it is clearly sexual assault.
In others, the therapist may have meant well, but still caused more harm than healing.
In a recent clinical trial, in which psilocybin was shown to offer relief for treatment-resistant depression, three participants reported suicidal thoughts and self-harm in the weeks following therapy.
Twenty years of research have standardized the doses of drugs used in clinical trials, but the therapeutic part has not received similar scrutiny.
Instead, the work of therapists is often based on tradition rather than empirical evidence, says Dr. Charles Raison, director of clinical and translational research at the Usona Institute in Wisconsin and professor of psychiatry at the University of Wisconsin.
The lack of scientifically supported best practices has led researchers, clinicians, and former patients to call for a more critical view of the therapeutic component of psychedelic therapy.
“I am very concerned about the ways that well-meaning therapists can do harm,” said Sarah McNamee, a licensed psychotherapist and research coordinator at McGill University’s School of Social Work.
Because people are so emotionally vulnerable when using psychedelics, there is an increased risk of psychological harm, especially from inept or inexperienced therapists.
“It’s easy for someone to get worse,” says Janis Phelps, director of the Center for Psychedelic Therapies and Research at the California Institute for Integrative Studies, which offers bachelor’s degrees in psychology and counseling.
This is what is currently happening in many psychedelic therapy sessions, and where red flags might appear.
choose a therapist
In most of the country, the only way to legally try psychedelic therapy with psilocybin or MDMA is to enroll in a clinical trial.
(Ketamine can be administered in clinics or even sent to your home, but experts strongly recommend that it only be used in conjunction with therapy.)
The professional you work with should be a mental health professional, ideally specialized in your illness, and certified in psychedelic therapy, for which there are now several training programs.
Amy Lehrner, clinical director of the Center for Psychedelic Psychotherapy and Trauma Research at the Icahn School of Medicine at Mount Sinai, recommends that a prospective psychedelic therapist be evaluated as one would any other mental health professional:
Ask about their training, professional certifications, and experience.
There have also been clandestine options for decades, some run by professional therapists and others by hobbyists.
Experts advise against using this type of provider because supervision is even less. Researching the practitioner is doubly important if you are seeking a psychedelic therapy outside of a clinical trial.
In any case, it is crucial that you feel safe and comfortable with the therapist, which is why the preparatory sessions are so important for building trust and rapport.
preparatory sessions
Before you take the drug, the clinician should meet with you for several hours over a few days to explain what the treatment will consist of, especially regarding the physical and psychological effects of the drug.
The therapist should ask about your history and symptoms, as well as your goals and intentions for treatment.
The therapist may advise you to adopt a certain state of mind during the session or teach you breathing or meditation techniques to use if you are faced with an uncomfortable emotion or physical sensation while taking the drug.
“We teach them to be excited and curious about what they don’t know yet, what’s coming out of them, and to welcome it, even if it’s unsettling for a few moments—or an hour, if that’s the case,” Phelps says.
A fundamental objective of these sessions is to obtain informed consent for what may occur during the drug session, especially with regard to touch.
Since it is not normally part of talk therapy, the role of touch in psychedelic therapy is controversial.
Some experts say that it can be helpful for someone on a psychedelic trip to receive a calming touch.
Others claim that it could create an opportunity to cross the boundaries.
Most agree that contact should be limited to holding hands or a hand on the shoulder; anything that involves full body contact, including a hug, could be construed as sexual.
session on drugs
During most of an MDMA or psilocybin drug session, the patient is usually lying down, eyes closed, listening to music.
The experience does not usually involve much conversation and is more internal to the patient.
If the patient begins to feel anxious or encounters a traumatic memory or vision, the therapist can reassure or guide them through a breathing exercise.
In such cases, the goal is not for the patient to avoid or be distracted from the experience.
“The therapist’s role here is to try to help people move on,” Raison says.
“If you fight against experience, you tend to have bad results.”
Therapists should never force a particular experience on a patient;
they are there to follow the lead of the patient, not to direct, Lehrner said.
“It’s never about meddling or leading by pushing someone” beyond their limits.
However, McNamee, who has participated in psychedelic clinical trials, said uncritically encouraging patients to go through pain could do more harm than good.
In psychedelic therapy, therapists often push people “to face the anxiety,” he said, when sometimes “it might be a good idea to get away from the anxiety, calm down, regulate, distract.”
It is not about whether a practice is good or bad, he added, but rather to determine in which contexts it can be useful or harmful.
integration sessions
Integration sessions, in which the patient processes the experience in the days and weeks after the trip, are the most similar to traditional therapy.
The exact number of sessions varies, but four hours spread over two to three weeks is typical, although some experts say it’s not enough.
The therapist helps the patient make sense of the feelings, perceptions, and memories that arose during the use of the psychedelic.
The most common tactic, according to Raison, is to ask open-ended questions and let the patient lead the conversation.
For example, a therapist may ask:
How did the experience change your relationship with yourself?
The goal is to extract those lessons and incorporate them into the patient’s life, with the philosophy that “the patient has his own wisdom, the psychedelic experience has its own wisdom,” he said.
Some researchers are beginning to experiment with alternative therapeutic approaches, such as cognitive behavioral therapy or acceptance and commitment therapy, which encourage patients to reexamine beliefs about themselves, potentially aided by insights gained during the psychedelic session.
For Lehrner, what researchers should try to standardize now are general therapeutic principles while continuing to test whether the treatment as a whole is safe and effective.
“Afterwards,” he said, “people can investigate: ‘Well, what if we tweaked it like this? What if we changed it like this?’
McNamee disagrees.
“I am concerned that this field is moving too fast” without enough research into what constitutes a safe and ethical practice.
“That we can standardize things that are problematic, I think, is something worth thinking about.”
c.2023 The New York Times Company
