Psychedelic Assisted Psychotherapy: Past, Present and Future

integrative
Written By Cyndi Collen

Written by Hannah Dresdner, LCSW

In a quickly evolving world of therapeutic modalities and therapy speak, psychedelic psychotherapy has a tendency to stick out. Psychedelics are making the comeback of the century in the western world; from their villainization and criminalization beginning in the 1970’s to their uprising as healing agents 50 years later.  We are amongst one of the greatest paradigm shifts of our times!  This shift comes at a time when individuals are struggling to make use of the tools at hand. Fresh out of a three year pandemic, re-integrating into a world that may or may not make any sense anymore, individuals are seeking connection, meaning making and solutions to issues and challenges outside of the conventional medicine and pharmaceutical industries.  And so enters something new; or something really, really, ancient.


Brief History of Psychedelics

Psychedelics have been used for millennia, dating back 7,000 to 9,000 years ago. There is evidence of different psychedelic substances including mushrooms and cacti that have been found in historical relics throughout time. These substances have been, and continue to be, used by indigenous groups in healing rites and rituals. They were first “discovered” in the western world in 1496 on Christopher Colmbus’ journey when native Tiano peoples of the Dominican Republic/Haiti were observed ceremonially consuming Cahoa/Yopo, a shrub that contains DMT (dimethyltryptamine), a strong psychedelic found in plants. Later, western explorers and conquistadors encountered the Aztec people engaging with their native medicines, peyote and psilocybin mushrooms, Brazilians with ayahuasca and the people of present day Gabon and Congo using iboga root. The native ancestors of these groups continue to utilize these substances to this day. 

Nearly 450 years after the western world first stumbled upon psychedelic substances, scientist Albert Hoffman self administered 250 mg of LSD after synthesizing it, kicking off the first round of modern psychedelic research in 1943. By the late 1940’s psychiatrists began exploring the potential of psychedelics within the field primarily using LSD for depression and alcoholism. By 1952 many psychiatrists were integrating psychedelic medicine into their practices; between 1960 and 1964 Stanslof Groff provided more than 4,000 LSD-assisted psychotherapy sessions. 

At that time there were no regulations on these substances and practitioners and scientists had free reign to use them as they saw fit. Eventually LSD made its way into popular culture and shortly thereafter bans on psychedelic use became more prevalent. In 1971 Nixon launched his “War on Drugs'' campaign, increasing the size and presence of federal drug control agencies and mandatory sentences. This push led to complete prohibition of entheogens as well as any research that was being conducted with these substances. Along with these policy shifts came a mountain of anti-drug rhetoric leaning on intensely hyperbolized caricatures of psychedelic drug use, touting potentially deadly results. This propaganda has had a lasting impact, stimulating fear and uncertainty around these substances that is still present today. 

The Multidisciplinary Association for Psychedelic Sciences (MAPS) has been patiently waiting in the background since 1986. Spearheaded by Rick Doblin, PH.D., MAPS has worked relentlessly to end the prohibition on psychedelics by focusing efforts on policy reform and research. In 1990 the FDA created a group to oversee psychedelic research protocols, thus reinstated the possibility of psychedelic research. In 2004 MAPS began its first trials of MDMA assisted psychotherapy for PTSD. In 2006 Johns Hopkins published the results from this study reporting on the mystical experiences associated with psilocybin; at the 14 month follow-up, volunteers reported this experience was among the most “personally meaningful, and spiritually significant” of their lives. A 2008 study found that 80% of individuals no longer met criteria for PTSD following MDMA assisted therapy. In 2015, the first LSD study since the 1960’s produced evidence that refuted the claim that psychedelics produce mental illness and that in fact patients reported benefiting from the treatment. Hence, the renaissance has begun, yielding many more scientific studies as well as advocates speaking up for the place of psychedelics in the field of mental health care.


The Current State of Psychedelic Medicine 

Currently substances such as psilocybin (magic mushrooms), LSD, ectasy (Molly, MDMA) and marijuana are on the U.S. Drug Enforcement Agency’s (DEA) Schedule 1. This categorization, on the DEA’s website, states these “drugs <have> no currently accepted medical use and a high potential for abuse.” To remove a substance from Schedule 1 there needs to be a body of research supporting safe medical uses but it can be hard to get funding and approval to research a substance that is on Schedule 1 . Plus there are powerful pharmaceutical interests that benefit from keeping these substances on Schedule 1. Hence a stalemate exists: some psychedelic substances hold great therapeutic benefit but its’ placement on Schedule 1 presents legal challenges in research, therapeutic use, and distribution.

Ketamine, which has been historically used as an anesthetic, is an exception as it is on Schedule III which allows it to be prescribed by a licensed medical professional. Ketamine can be quite psychedelic in nature, even though people may react differently, it does carry the potential of offering mystical experiences which have been found to have healing potential in and of itself. Ketamine has been found to offer rapid remission for individuals suffering with treatment resistant depression but there is inadequate research showing efficacy that remission is sustainable. Yet there are ketamine clinics offering IV infusions of the medication sprouting up all over the U.S. Some of these clinics have a therapeutic component built into their model, while the majority fall under the domain of a prescribing doctor and nurses who simply administer the medicine without further guidance or support. While this approach can still produce beneficial results, it can be quite difficult to manage the rapid transformation and life shifts that may ensue without the assistance of an informed and trained therapist, counselor, or guide. As the field continues to evolve, it is our hope that more ketamine clinics will integrate therapists and coaches into their model to provide the necessary support to individuals receiving the medicine. 

Less widespread is the legalization of psilocybin (‘magic mushrooms’)  for therapeutic use which has recently gone into effect in Oregon and soon in Colorado. Both states have passed legislation creating the possibility of therapeutically assisted use of magic mushrooms carving pathways for other states who are in their initial phases of forging legislative change. Despite the potentially long road to legality for most states, training institutes and universities are beginning to offer Psychedelic Assisted Psychotherapy training to certify clinicians as ketamine assisted therapists, as well as teaching them on best practices for MDMA and Psilocybin in anticipation of their eventual legalization. There are also clinician- and psychedelically-oriented coaches finding legal loopholes by offering medicine sessions outside of the continental US in countries that don’t have bans on psychedelic substances. Individuals are also seeking more traditional medicine experiences by engaging with plant medicines in ceremony with shamans from all over the world. As the public’s interest in natural healing grows so does the psychedelic tourism industry, creating an opening for indigenous practices and wisdom to be shared with the western world in a new way. 

Importance of Set and Setting

Despite the amplification of positive research relating to psychedelic medicine it is important to note that these medicines are no panacea. They are incredibly helpful tools to be used on one's healing journey, fostering a sense of internal awareness and creating the possibility of tending to the root causes of issues in a new way. But, there is still work to be done, both prior to engaging in medicine work as well as after the journey outside of the psychedelic space,   Set and setting are two critical aspects of preparing for a safe and profound experience.

‘Set’ refers to the mental state of the participant upon entering the medicine space. Psychedelic medicines are nonspecific amplifiers; this means they magnify whatever emotions or feelings the participant comes in with. For example, if a participant comes in with an anxious mental set, i.e. holding fears relating to the medicine, their experience within the medicine space will likely enhance these sensations, leading to a potentially darker, more challenging experience.  In order to ensure a positive and productive experience it is important to work with a qualified professional in preparation sessions prior to embarking on such a journey. The objective of preparation sessions are similar to that of a regular therapeutic intake; gathering the patient's history (personal and psychedelic), building therapeutic rapport, working  through biases and fears and creating clear intentions for the psychedelic session. 

Creating safety with, and for, the person who will be experiencing a psychedelic journey is critical. The psychedelic space is even more vulnerable for participants than traditional talk therapy. In this space, the patient is entrusting their safety to the sitter while they release into an altered state of consciousness. It is possible during these sessions, depending on the medicine, that feelings may be felt and expressed more dramatically; sensations may be enhanced and/or intense; associations may possibly be made between the therapist and the client’s personal life (transference); and potentially nonsensical comments, statements, and feedback could be spewed about.  

It is with all of this in mind to understand the importance of the presence of someone trained to have a grounded, non judgemental, trauma informed figure in the room; one who is able to stay calm and grounded in the wake of intense emotional episodes and one who could navigate the possibility of transference as it arises. Beyond the clinical skills, it is important the recipient feels trust in their therapist/sitter in order to be able to fully release into the experience without concern for the external world. A trained professional will emphasize the significance of building therapeutic rapport on the front end, making sure the client is fully aware that all their needs will be taken care of during the session itself. The role of the sitter or therapeutic presence is critically important as it provides the individual with a calm, grounding presence that is able to provide reassurance and comfort should the experience become intense or challenging. 

Setting refers to the physical setting of the experience. Many individuals have reported difficult experiences with hallucinogens when engaging with them at concerts, events or just generally the wrong circumstances. The intention of psychedelic assisted therapy is to remove any unnecessary environmental variables to create a warm and comforting space, minimizing any sense of uncertainty, unpredictability or external interruptions. 

During a medicine session clients will typically undergo their experience with eye shades and headphones. The eye shades provide the participant with the opportunity to tune out external distractions and journey inside of themselves. Typically specific playlists are selected that incorporate a variety of music from classical to soundscapes and include natural sounds and indigenous instruments. Music plays a key role in these journeys, lubricating the experience and engaging a familiar sense to help the participant dive deeper into themselves and the journey. 

These considerations are important to keep in mind whether you are planning to engage with psychedelics recreationally, in a therapeutic setting or on retreat.  Set & setting is a helpful framework to take with you to be able to gauge whether or not a psychedelic experience is in alignment with your intentions and desired outcome. These experiences are not to be taken lightly; while they have immense healing potential, they equally hold the risk of traumatizing or re-traumatizing the journeyer if the space is not held adequately by a safe, competent sitter.  


The Importance of Ceremony & Indigenous Reciprocity

Psychedelic medicines are ancient and highly energetic and they open up the user to mystical experiences as well as a new understanding of reality. In a world so incredibly focused on clinical trials and evidence based modalities, there is something far beyond our intellectual understanding taking place when we engage with these sacred substances. It is critical to hold these medicines, whether natural plant medicines or synthetically derived, with an immense amount of reverence and respect. Including an element of ceremony in the medicine space can be an important part of the session. Creating space to honor the substance and its’ wisdom before the medicine enters the participant's physical body can create a palpable shift in the room, positively affecting mental ‘set’ and the journey itself. 

It is important to acknowledge the native roots of these substances as well as the lineage of native peoples who have worked with these substances for millenia. Indigenous reciprocity is a crucial theme amongst what promises to be a multibillion dollar industry. Indigenous reciprocity is the term used to describe the need to acknowledge how these healing practices have been appropriated and give back to the communities from which these medicines and their wisdom have been taken. It incorporates a need to tend to ecological wellbeing and seeks to find balance between these communities and the western world which is now profiting off of their rituals.. The Indigenous Initiative of the Americas (IRI)  is working alongside some of the key players in the developing psychedelic field in attempts to uplift and support the communities from which these medicines came. It is paramount that the indigenous wisdom, and contributions to this field are continually given a voice as the field evolves.


Are psychedelics and/or psychedelic-assisted therapy right for you?

  1. Are you willing to take the time to get educated, talk to professionals and prepare for the experience? Education and preparation are key to receive therapeutic benefit from psychedelics. MAPS is a great place to start for learning about the fundamentals, clinical research and harm reduction.

  2. Has a licensed health professional suggested exploring Ketamine for 'treatment resistant' PTSD or depression?   Psychedelics, whether experienced in a clinic with or without therapy assistance is not a substitution for longer term talk therapy but can bring awareness and new perspective to the client which can then be turned into a transformative experience with a therapist. Ketamine treatment, either at home or in a clinic, with or without therapy assistance, is currently very popular; however, it’s not for everyone as research has not be done to show the benefits can last over middle- to long-term. We recommend putting expectations aside and receiving therapy-assistance while ingesting ketamine to achieve the best possible outcome.

  3. A friend has a source for mushrooms and you are curious to try them. As we mentioned above, ‘set’ and ‘setting’ are paramount to your safety. Again, these experiences are not to be taken lightly; while they have immense healing potential, they equally hold the risk of traumatizing or re-traumatizing the journeyer. If you still want to do them please make sure you are accompanied by a grounded, competent, sober ‘sitter’ and have ‘set’ the appropriate intentions, expectations and reverence for the medicine.

  4. You are planning to engage with psychedelic medicines in a ceremonial retreat space. It is important to do your due diligence when vetting ceremonies that fall within the psychedelic tourism space. Consider:

  • How many people will be sitting with the group and how many attendants will be present?

  • What are the backgrounds, credentials and experiences of the attendants / facilitator(s)?

  • How do they manage when trauma or different experiences arise in a group setting?

  • Some medicines require a level of medical clearance and most should at least take into account an individual's current state of mental and physical health. It is vital to note whether this is considered as part of the intake process and if there is an intake/interview process at all. If there is no intake process, space holders may not be properly aware of the needs of the individuals sitting in the group. This can create an unsafe space which may affect you directly, or indirectly, by way of the experiences or actions of those around you.

  • If you are planning to travel for the ceremony it is critical to consider the buffer time between the medicine portion of the retreat, and when you plan to head back home. It can take days to weeks to integrate big experiences. Sometimes individuals report feeling more sensitive to their surroundings and/or a desire to spend more time with themselves. It is best to build time into your itinerary to lay low after the ceremony and before returning to life and work. Going straight from a medicine retreat back to work or family life may be jarring, and it is important to set up appropriate integration practices after the experience. This may be attending integration groups or seeking out a therapist who is open to aiding in the integration process.

Check out Last Week Tonight’s piece on Psychedelic Assisted Therapy

Cyndi Collen
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