What is Psychedelic Assisted Psychotherapy?
Since the mid-1990s, renewed interest in psychedelics has spurred more and more research into their therapeutic potential. The results so far have been promising. They suggest with reasonable confidence that certain drugs broadly defined as “psychedelic”—psilocybin, MDMA, and ketamine among the most studied—are generally safe, well-tolerated, and may be uniquely effective treatments for disease states such as depression, OCD, PTSD, alcohol and nicotine addiction, and end-of-life anxiety among terminally-ill patients. Amid all the buzz, many are wary of getting swept away by the excitement, turned off by the efforts of some health-tech companies to market psychedelics as a panacea for all personal and collective woes. Can a few milligrams of psilocybin really cram the benefit of decades of psychotherapy into just four hours, as some testimonials advertise? Are we inadvertently packaging drug-induced euphoria and pushing, as Michael Pollan put it in his book, How to Change Your Mind, a “comforting delusion on the sick and dying”?
As psychedelic science progresses, serious philosophical and ethical work will be required to guide its increasingly ubiquitous clinical use; what makes these compounds so powerful is what makes them risky without the proper precautions or preparation, as I’ll discuss. If, as a society, we wish to fulfill the promise of these compounds, we will take pains to limit their careless and indiscriminate use.
Classic Psychedelics and Plant Medicine
I will be referring here mostly to the use of “classic psychedelics,” the group of psychoactive substances with a strong affinity for the brain’s serotonin 2A receptor. This group (also known as the “classic hallucinogens”) includes psilocybin, LSD, mescaline, and DMT, the active component in ayahuasca. A detailed exploration of their neurobiology is outside the scope of this article, but conceptually speaking, these chemical agents are best understood as “non-specific amplifiers,” a term the psychiatrist Stanislav Grof used to stress their extreme sensitivity to context.
Psychedelics can unveil and illuminate parts of the mind that normally lie outside the spotlight of waking consciousness. Which parts take center stage depends heavily on one’s mood, intention, personality, and immediate physical and psychological circumstances. A full-dose psychedelic trip, undertaken amid a painful break-up, will likely intensify, rather than soothe, the guilt, anger, or sadness one may be feeling. On the other hand, the same amount, taken in good company, on a beautiful day, surrounded by nature, might constitute one of life’s most memorable and meaningful experiences, as most patients in psychedelic studies have attested. It’s worth noting that to be “meaningful” does not require every stretch of the experience to be entirely blissful and sublime, untouched by moments of real fear and torment. Everything under the floodlight of a psychedelic is subject to amplification—a heightening of significance. What becomes significant varies widely, and can change suddenly, even within a single trip itself.
The Benefits of Assisted Trips and Well-Informed Guides
This is where the therapeutic value—and the necessity for proper guidance and support—becomes more apparent. Consider another analogy. Imagine being strapped to a jetpack and launched into outer space. (Having to stretch one’s imagination is part of the point.) If you are stuck in the morass of neurotic depression, a sufficiently fueled tryptamine-powered jetpack is guaranteed to shake you up and get you somehow out of the muck, at least temporarily. Where exactly you will land—and how rough the landing—will depend: What gear did you pack? Where did you set the coordinates? Can you read a map?
Just like most of us are not astronauts, however much we wish to travel to space, most of us are not experienced psychonauts, however much we cherish exploring and expanding the horizon of our minds. Neither field of exploration is easily nor meaningfully pursued on a whim. That’s why, as psychedelics become more entrenched in the Western medical tradition and the culture at large (they have only been around in modern societies for the historical equivalent of an eyeblink, after all), it would be wise to incorporate their use within the broader mind-revealing rituals, traditions, and institutions that already exist today and which have been fine-tuned for well over a century now—namely, psychotherapy.
Enthusiasm for psychedelics as a complement to classical psychotherapy is not new. In the 1950s and 60s, Betty Eisner, Sidney Cohen, and Hans-Carl Leuner were among the first clinicians to systematically document how small doses of LSD, combined with standard talk therapy, could potentiate psychological growth and ameliorate neuroses. They observed that this combination, termed “psycholytic therapy,” helped patients reduce their defensiveness, accept conflictual material, and better connect with their therapist. Nowadays, most clinical trials implement a different protocol, simply called ” psychedelic-assisted therapy.” This approach involves 1-2 preparatory sessions that set the stage for the upcoming psychedelic journey through comprehensive psychoeducation, intention-setting, and rapport-building, followed by one full-dose psychedelic experience. The patient typically wears eyeshades, reclines comfortably on a couch, and listens to therapeutic music while the medicine takes effect, in the supportive presence of one or two therapists trained to respond appropriately to any adverse events. Finally, the patient engages in 2-3 integration sessions with their therapist to process the experience, making sense of it so that insights and cathartic moments may translate into durable, actionable change.
The Importance of Set and Setting
Much of what we have learned about psychedelics from these trials reinforces a tenet espoused by the early psychedelic researchers of the 1950s; “set and setting” matter. Simple enough! The set encompasses all that one brings to the experience from their inner world: attitudes, expectations, hopes, and fears, as well as the parts of themselves of which they may not be immediately aware or cannot readily control, i.e., temperament, personality, traumatic history, genetic predispositions, etc. The setting refers instead to everything in the patient’s outer world that comprises the experience, including the dose of the medicine, the physical space, and the surrounding environment (e.g., the location, the music, the artwork, the others present, etc.) The psychologist Betty Eisner included a third element—the matrix—which forms the backdrop to the set and setting, incorporating the larger cultural and societal context and the patient’s everyday living space between sessions.
We know, both anecdotally and experimentally, that the interplay of these variables can influence the subjective character of the psychedelic experience. We also know that the subjective qualities of the experience determine the durability and magnitude of therapeutic change. Studies from the John Hopkins Center for Psychedelic and Consciousness Research have demonstrated that patients who report “mystical” states during their trip—characterized by feelings of unity and connectedness with the universe, a sense of sacredness, ineffability, and an intuitive belief that the experience conveys objective truths about reality—are more likely to endorse persisting positive effects.
Some will balk at the supernatural and otherworldly descriptions of these states, but their transformative value can be grasped without recourse to exotic metaphysics. To someone on 25mg of psilocybin, the belief that “all things are interconnected” may appear, accompanied by astonishing visuals, as if divulged by an alien intelligence. Still, we can remain agnostic about extra-terrestrials while accepting the underlying idea of interconnectedness, which requires no ontological leaps and fits comfortably within our naturalistic conception of the universe.
It also aligns with developments in post-Freudian psychoanalytic theory, which highlight the interpersonal influence between patient and therapist. Modern psychoanalysis treats the therapist no longer as a neutral “blank screen,” as Freud may have wished, but rather as a subjective participant and mutual enactor, emphasizing the “felt experience of the other as a separate yet connected being with whom we are acting reciprocally,” (Benjamin 2004). It is precisely this “felt” quality of reciprocal connectivity that psychedelics appear to intensify and make vibrantly self-evident, evoking the Buddhist concept of interpenetration. (In an attempt to express this transcendent feeling, psychedelic users have turned to the Buddhist metaphor of Indra’s net, which, in its infinite dimension, possesses a multifaceted jewel at every node, each of which infinitely reflects all the other jewels in the net).
To the extent that heightened emotional intensity accelerates the formation of affective bonds, psychedelics are exquisitely poised to strengthen the connection a patient feels to their therapist. This emotional connection, in addition to the agreement on the goals and tasks of the therapy, is a critical component of the therapeutic alliance, which is the only psychotherapeutic factor reliably predictive of positive outcomes across all theoretical approaches. It can be argued that mystical states represent potent and condensed examples of a generalized therapeutic process toward an expanded sense of self, one imbued with greater meaning, purpose, and feelings of emotional connectedness.
Again, while spiritual images and concepts may be accentuated under psychedelics, one need not believe in numinous forces to appreciate the origin of the name “psychedelic”—literally, mind-revealing in Greek. If so, what do psychedelics reveal about the mind, really? And how is it pertinent to psychotherapy?
In my estimation, scientists, philosophers, and psychoanalysts are free to argue about the legitimacy of almost all psychedelic revelations, except this one: the mind can change. Provided a large enough dose, one is virtually guaranteed to have a radical shift in consciousness, whatever its altered contents may be. For those feeling hopelessly stuck, the knowledge that they can move, that things can change, might make all the difference. For those whose depression has cast an ever-present fog over their world—to glimpse just once the vast space beyond it, to catch, perhaps, even the glimmer of a star, may be reason enough to start looking skyward.
Loss of “Sense of Self”
This depiction of depression and its antidote is not pure fancy. Matthew Ratcliffe, a phenomenologist and philosopher of psychiatry, has laid forth an account of Major Depressive Disorder that unifies its many faces under one common feature: loss of possibility. This loss can occur in relation to the body, the self, or others. In the deeply depressed, all three relational spheres become impoverished and deprived of freedom, spontaneity, and authenticity.
The reasons for this are complex and multifaceted. They involve biological, psychological, and social factors that are different for everyone. A helpful way to conceptualize it is this: As a result of genetics, past traumas, unstable attachments, or other unfortunate environmental circumstances, the brains of some people become ultrasensitive to threats. To protect against the repetition of pain or the proliferation of present suffering, they learn to interpret every new and unfamiliar situation with a mixture of anxiety, fear, and suspicion. The brain’s intention is a noble one. Keep the world at a distance, it thinks, and the world cannot hurt you anymore.
It is hard to argue that this is a reasonable strategy if the aim is to play it safe. When survival is truly at stake, it is indeed best to “shut it all down.” But if avoidance and escapism become confused as a way of life—if it seems like this is the only way to live—one fails to live at all.
Construed as such, Ratcliffe says, we can appreciate the poignant terms sufferers use to describe their experience—”trapped, imprisoned, cut off from the rest of the world by some impenetrable substance.” What remains after the world has receded from view is what the philosopher Fredrick Svenaeus calls an “unhomelike being-in-the-world,” or what Rahel Jaheggi has defined as “the relation of relationlessness”—the alienation of illness, itself.
In his memoir, The Noonday Demon, Andrew Solomon suggests that the opposite of depression is not happiness but vitality. We might define vitality as that resonance of significance, borne of possibility, through which we intuit beyond doubt that our relationship to the world is interdependent, that we are capable of both affecting the world and being affected by it.
An Intense Feeling of Vitality
If there is one word to describe what gets infused into the contents of consciousness when one takes a psychedelic, vitality would be a good one. Under the psychedelic sheen, surroundings take on a quality of being alive and intentional; the sight of “walls breathing” is an almost universal psychedelic trope. The Psychologist Benny Shanon describes the animistic qualities of ayahuasca, administered in a ceremonial context, as such: “A tremendous force permeates and animates everything around…Coupled with this is the recognition of the abundant bounty that impregnates all Existence. The feeling is that the world is rich with plenty and that, in essence, it is so good and wonderful.”
In other words, together with a sense of things coming to life, there is a sudden and dramatic increase in possibility, phenomenologically speaking. At the level of the brain, we could speak of an increase in “entropy” or “free energy,” terms the prominent psychedelic researcher and neuroscientist Robin Carhart-Harris has borrowed from physics to explain how psychedelics exert their transformative effects. They provide, as it were, the neurochemical equivalent of heat to render rigid self-narratives malleable enough for rewiring. The rescripting of pathogenic meaning—one of the fundamental goals of any psychotherapy—is thus greatly facilitated using psychedelics as therapeutic instruments.
Much more can be said on this last point, especially as it pertains to the other metaphor now introduced—that of heat. Psychedelic users will often comment that their reality appears to be melting in front of them—material objects lose their solidity and merge with their surroundings; “everything flows,” to echo Heraclitus’ famous pronouncement. Themes of dissolution, disintegration, disappearance, and deconstruction pervade the psychedelic literature, with profound implications for another seemingly stable, solid percept, one of particular interest to psychology and psychotherapy—the ego.
Creating New Meaning
As the heat is turned up, one’s self-narrative can become increasingly fluid and chaotic. At the point of phase transition, it may even evaporate, in what is commonly described as ego death. But a complete ego dissolution is not a prerequisite for meaningful therapeutic change. Writing about the psychoanalytic inquiry, with no reference at all to psychedelics, the late psychoanalyst Philip Bromberg put it most eloquently: “The very breakdown of narrative order, the temporary chaos which is provoked, may, in itself, be vital to a creative process, a reorganization of experience into far more complex and flexible patterns…To tolerate the fragmentation of meaning is to create new meaning.”