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Very short history
Types of Psychedelics
What is psychedelic-assisted psychotherapy?
How to Access it?
what to be cautions about?
summary
This is addressed to the general public with an interest in psychedelics and to mental health professionals. It’s an overview of the different substances and what therapy would involve.
A short disclaimer before I start: I am a psychiatrist and psychotherapist. My psychotherapy training and experience are mainly in psychodynamic modality, but I have experience in several other modalities, including DBT, CBT, BFT, systemic therapy, and PIT; however, I do not have direct experience in psychedelics-assisted psychotherapy (yet), so this summary is based on my reading, networking and courses I attended. Please read the below as general information; for tailored advice, please seek direct medical care from your health care provider.
Very short history
The name psychedelics was coined by Humphrey Osmond in 1957, as they have a mind-manifesting capability, revealing useful or beneficial properties of the mind. reference here (this is a good paper summarising history, mechanism of action and side effects)
There is evidence that naturally occurring psychedelics were likely used for millennia. Ayahuasca, mescaline (from San Pedro cacti), psilocybin were used by native cultures part of spiritual ceremonies and healing.
Their use is not restricted to one geographical area only; there is evidence that they were used in ancient India, near Athens, in South and North America, Australia, Tanzania. reference here.
In modern times, their use exploded in the late ’50s-60s.
“Between 1950 and the mid-1960s there were more than a thousand clinical papers discussing 40,000 patients, several dozen books, and six international conferences on psychedelic drug therapy. It aroused the interest of many psychiatrists who were in no sense cultural rebels or especially radical in their attitudes.” (source: Grinspoon L, Bakalar JB. (1979) Psychedelic Drugs Reconsidered)
The research halted with the “war on drugs” in 1970 when they were classified as Schedule one substances in the US. Mainstream research and work with psychedelics became impossible. Their use stopped or it moved “underground”. Some researchers or professionals who were experienced in their use looked for other ways to reach “altered states of consciousness”, such as Stanislav Grof who developed and popularised “holotropic breathwork” –more about him here. Others dedicated their life to make their use in psychotherapy legally possible. Rick Doblin is the founder of MAPS (multidisciplinary association for the study of psychedelic study) who has been pivotal in the psychedelics resurgence. more about MAPS here
The research has re-emerged in the last two decades; have a look at The Johns Hopkins Center for Psychedelic and Consciousness Research here or the Centre for Psychedelic Research at Imperial College London here.
In short, the evidence shows benefits for psilocybin for depression, end-of-life anxiety, addictions, MDMA for PTSD, ketamine for treatment resistant depression. The effect sizes are remarkable, almost in the category “too good to be true”. Here is a very detailed summary of the research to date. Also there are several papers in Nature.
For example (source here)
“The world’s first FDA Phase 3 trial using MDMA to treat PTSD found that after three MDMA-assisted therapy sessions, 67 percent of participants no longer qualified for a PTSD diagnosis, and 88 percent experienced a clinically significant reduction in symptoms (Mitchell et al., 2021)
A Phase 2 trial found psilocybin was efficacious in treating major depressive disorder, with a clinically significant response in 71 percent of participants and remission from depression in 54 percent at four weeks post treatment (Davis et al., 2021).”
Types of psychedelics
based on origin, there are
- Natural psychedelics, that we can find in nature, such as psilocybin (“magic mushrooms”), mescaline (found in certain species of cacti), ayahuasca (a brew made from certain plants, usually used in ceremonial contexts in South America), DMT (found in certain trees from Central and South America).
- Chemically synthesised psychedelics, such as LSD, ketamine, MDMA (ecstasy). (some don’t consider ketamine and MDMA as “psychedelics” but include them in hallucinogens)
- to complicate things further, some synthetic substances are based on naturally occurring substances: eg LSD was initially derived from ergot, mescaline can be synthesised and even psilocybin can be made in a lab.
Why is this relevant?
- Some substances have been used in ceremonies for (possibly) millennia or at least for a long time. They are better understood in the context of the culture and as belonging to the culture. For people who see these substances are a way of connecting to the natural world, it makes more sense to be drawn towards the naturally occurring ones.
- However, there seems to be good evidence for the benefit of both natural and synthesised versions.
based on Duration of action
This is particularly relevant if the use of psychedelics is within a psychotherapy context, as the “medication session” needs to be supervised by at least one qualified professional. If the experience lasts a few hours, this significantly increases the cost of therapy.
- Some are very short lasting, such as DMT, which lasts up to 30-45 minutes if smoked and 4 hours in the context of ayahuasca (they add a second herb to prolong its effects). reference here
- Ketamine is relatively short lasting, but the psychedelic duration depends on how it is administered. As expected, the effects if quicker and shorter if injected. If taken sublingually, it lasts 30-60 minutes, with up to 2-3 hours for a full return to baseline. Taken intranasally, it lasts between 1-3 hours. reference here
- Medium duration, such as ayahuasca, MDMA and psilocybin. Ayahuasca peaks at 1-2 hours but lasts up to 4-6 hours. reference here. Psilocybin’s effects can last up to 3-6 hours; similar for MDMA reference here.
- LSD is longer lasting, up to 6-15 hours, but typically not longer than 12; the changes in perception can persist up to 24 hours reference here
Based on the type of experience
Although they are all psychedelics, the quality of the experience tends to be a bit different.
Some tend to induce experiences of connection with nature, belonging to something bigger than us (psilocybin); others reduce the emotional pain associated with memories, making the process of trauma processing easier and are less about a vivid hallucinogenic experience (EMDA). Ayahuasca seems to be about learning from the plants, connection with the world and the power of the ceremony. In LSD is described the “ego dissolution”, when the understandings we have about ourselves, the world and time seem to dissolve; a similar experience can be obtained with high doses of ketamine.
The same substance can have different effects depending on the dose; for example, ketamine at a lower dose can increase relaxation and ability to open up but at a high dose, it can induce a full psychedelic experience.
The above is a very succinct summary and the effects can be similar between them; usually, people who have had a good experience describe it in more ecstatic words than I did, usually with an underlying message that “the words can’t describe it”.
Based on mechanism of action
If you read a paper or another, you can think that the mechanism of action is fully understood. Based on what I read so far, it’s still being debated. Is it the effect on receptors that helps with depression, PTSD and other conditions? or is it the experience of seeing the world differently, or feeling that we are an integral part of something larger? Or the re discovery of beauty in all things? Do we need the “psychotic like” experience for the therapeutic benefits or can people have similar benefits if they have the substance during sleep or together with another substance that cancels the psychedelic effect? Some of these questions are being looked at in research studies.
Most of them act on serotonin 5HT2A receptors, with the exception of ketamine, which acts on glutamate sites. This is important as patients may need to discontinue antidepressants if taking psychedelics that act on serotonin but not if taking Ketamine, so it’s easier to add to treatment.
Why is this important?
Particular caution is needed regarding Ayahuasca, as one of the plants used acts like an older class of antidepressant (MAOI) which can have many drug interactions.
The risk of associating psychedelics with antidepressants (SSRI in particular) is two fold:
- one aspect is the increased risk of serotoninergic syndrome (in short, toxicity due to too much serotonin); this risk appears to be less likely with LSD, psilocybin, DMT), small risk with MDMA plus antidepressants. The highest risk is with ayahuasca, as one of the plants is a MAOI (monoamine oxidase inhibitor), which can lead to toxicity in combination with some antidepressants. reference here
- second, is the decrease in the psychedelic experience, with possible reduced therapeutic effect
What is psychedelics assisted psychotherapy?
Psychotherapy usually refers to “talking therapies” and there are hundred if not thousand different kinds of psychotherapies. Psychedelics can be incorporated in various forms of psychotherapy. The ones I heard shared experiences about are: psychodynamic, mindfulness, internal family systems, acceptance and commitment therapy, to name a few. The preliminary conclusion is that psychedelics can be incorporated in any of them.
In psychedelics assisted psychotherapy, the key words to remember are: preparation sessions, medicine sessions and integration sessions.
The role of the preparation sessions is to get to know your therapist(s), to explore the main difficulties you need help with and to learn about the protocol. A medication and health history is important, to rule out any contraindications. As things stand now, a history of psychosis is a contraindication for all of the psychedelics.
The protocols in different studies differ and it’s different depending on the substance.
For example, with psilocybin you’d get a very powerful and long lasting experience so one therapy course can include one medicine session only. With ketamine and MDMA you’d normally need several medicine session in a treatment course.
The role of the integration sessions is to make sense of the experience and ideally to develop new ways of thinking and new meanings. The therapy doesn’t happen during the medication session, as it’s usually an inward experience, where the person is overtaken by the effects of the substance; it is possible to have a two way communication and some sense making during the sessions with MDMA and lower dose of ketamine. Otherwise, the integration sessions usually start the day after and last a few more sessions, depending on the protocol.
The above is a very short summary, for each substance and provider you would need to find out the specific protocol.
How can you access psychedelics Assisted psychotherapy?
I will need to regularly update this page, but so far they are not in mainstream use. There are a few options though:
- Through research trials. You can look up if any research trial needs volunteers and if you meet the criteria.
- At the moment, Ketamine is the only one that can be legally used for psychedelic assisted psychotherapy. There are a few options available (private in the UK, such as Awakn clinic in London and Bristol). Of course, you will need to search the availability in your area. Be aware that Ketamine is mostly used in mental health in “ketamine infusion clinics” which is different than “ketamine assisted psychotherapy”. In ketamine clinics, the psychedelic experience is dismissed or not relevant and is not explored psychotherapeutically. The substance itself has benefits, but in psychotherapy you can make sense of the experience and its meaning.
- Touristic use, by traveling to places where it’s legal. I would be more tempted by retreats in Netherlands than landing in Peru and finding an ayahuasca experience. There have been reports of sexual abuse so you need to do a good background check if you were to embark on anything like this.
- If you happen to live in Oregon, it’s the first state where psilocybin is legal for psychotherapy use. More states to follow, I expect.
what to be Cautious of and other warnings
Unrealistic expectations
There has been quite a hype in recent years. Remember that the people who responded so well in the trials were people drawn towards these substances and our belief that something can help can play a huge role in its effect. There were trial participants who had a full psychedelic experience but they didn’t receive the substance (they received placebo). Based on all the data, it’s reasonable to be optimistic. But don’t place all the hope in the substance, the capacity to heal is inside you, regardless of the substance (but the substance can potentiate it).
Provider’s training and credentials
Make sure that the provider is trustworthy. I recommend finding legal providers and not underground sources. If you decide to go underground, find several recommendations.
Boundaries and setting
The experience is altering your state of mind so consent needs to be reached prior to the experience. Agree if you prefer to be touched or not, for example, and the specifics. The details of the room, music, basic needs have to be discussed in the preparatory sessions.
EMDA is a drug that enhances senses and can be highly sexual. That’s why in research trials there is a couple of therapists, usually a man and a woman.
If you decide to try any of these outside of a therapeutic context, make sure that there is someone you trust who can supervise you.
Legal implications
Medical and psychiatric risks
Particular cautions or contra indications apply in psychosis, bipolar, heart problems and certain medications. That’s why is best to have a full assessment in a clinical setting
Conclusion
Are these substances the response to the mental health crisis? Yes and no
Yes
- Studies show remarkable effects, and some of the personal accounts are memorable.
- There are conditions where current mental health practice is still unsatisfactory (treatment resisted depression, addictions, chronic PTSD), and it helps to have extra options.
- The side effects or risks are relatively small, making them acceptable substances (but the psychedelic experience itself can be scary for many)
No
- It is very hard to scale the provision, as we’d need thousands of new therapists and the medicine sessions last several hours, increasing the costs (unless DMT, which is very short lasting, proves effective)
- The clinical results may be less impressive than the studies as the training and protocol concordance will likely be less than the ideal conditions of the studies or will vary greatly.
- It may lead to further inequalities in mental health, becoming an option for the ones who can afford it privately.
What do you think? Share in comments
References
cited many references in the text, please follow the links for sources
I also attended 2 courses – one online which is still available to purchase, I highly recommend it, “Psychedelics assisted psychotherapy global summit” click here
the other one was at the Royal College of Psychiatrists, “Psychodynamic Perspectives on Psychedelics Assisted Therapy for Depression, Complex Trauma and Eating Disorders” (which shows that the topic is becoming really mainstream)
published 23rd of November 2022