A Worrisome Narrative
I’m writing this article as I’ve noticed a trend in the dialogue within psychedelic communities towards a narrative requiring a psychotherapist (therapist) to effect psychedelic healing of mental illness. Some have even suggested it unethical for those that are not licensed therapists to be involved in facilitating psychedelic use, especially when there is a user intention of healing. This narrative seems to largely be driven by therapists and others with licenses to perform psychotherapy involved in medical legalization efforts of psychedelics, namely those involved in the emerging modality of psychedelic-assisted psychotherapy (PAP). It’s worrisome because it threatens cognitive liberty at a time when decriminalization movements are gaining traction and could end up limiting the widespread adoption of psychedelics back into society.
I have to make it explicit that I’m not opposed to therapists being involved in psychedelic healing
Before I get to what I want to say about this narrative, I have to make it explicit that I’m not opposed to therapists being involved in psychedelic healing. As a clinical pharmacist with advanced training and board certification in psychiatric pharmacy, I wish to make the use of psychotropic drugs safe and effective, especially when they’re being used to achieve a therapeutic end. I do think that preparing a person for a psychedelic experience, having supervision and a safe environment for the experience, and post-experience support and help integrating the experience is an important aspect of using psychedelic drugs therapeutically. I also think that some persons with severe mental illness may be best served by persons with advanced training and experience in mental health.
I first and foremost support cognitive liberty
On the other hand, I first and foremost support cognitive liberty, meaning that the user should be empowered to go about healing with psychedelics in the way they choose (or even to use psychedelics for non-therapeutic purposes, but that’s a different conversation). I also believe psychedelics have the ability to catalyze intrinsic healing capabilities within the user that are not dependent on the presence of, or engagement with, a psychotherapist.
Let me walk you through why I believe these things are true.
The crux of my argument is that there is little evidence that a psychotherapist and psychotherapy are necessary for a therapeutic effect to occur and myriad evidence across a range of settings and psychedelics supporting their ability to heal. It is this evidence that I want to present and discuss in this article.
Recreational Psychedelic Use
Before we examine psychedelic use with healing intention, I want to take a bird’s eye, big picture look at recreational psychedelic use, which is likely the highest risk setting for ingestion with the least structure and oversight for the experience itself.
Data from the general US population suggests psychedelic use is associated with lower likelihoods of mental illness [1]. Use in populations of persons that have been incarcerated shows psychedelics are associated with less property crime, less violent crime and a lower likelihood to return to jail or prison [2, 3]. While criminality and mental illness are distinctly different, prisons are the largest providers of mental health care in the United States, increasing the chances that prison populations using psychedelics also have mental illness.
This type of data is not strong enough to conclude that psychedelics treat mental illness without a psychotherapist being present, but it does support an association between using psychedelics and lower rates of mental illness. This could occur for a number of reasons, such as recreational psychedelic users having lower chances of having a mental illness at baseline, psychedelics playing a protective or prophylactic role in the development of mental illness, or because they are able to effectively treat mental illness.
Some researchers have concluded that psychedelic use is no more dangerous than riding a bike or playing soccer [4]
Not a smoking gun, but it is comforting to think that when psychedelics are taken (likely) without much oversight, preparation, or integration, they are not associated with increased rates of mental illness. It does seem to refute that psychedelics are so dangerous they require supervision from licensed therapists, as we’d surely see the harms evidenced on a societal level if that were true. Psilocybin mushrooms consistently rank lowest as far as harms to users among recreational drugs and countries that have legal psychedelics do not have rampant safety problems as a result despite psychedelic use not involving psychotherapists in most contexts [5].
Ritual Use of Ayahuasca
Psychedelic drugs have known to be used for millennia in ritual settings for communion with the divine and some ritual sacraments have been studied in both ritual and medical settings [6]. For example, ayahuasca is used traditionally by several cultures in the greater amazon basin and its use as a ritual sacrament has grown into a worldwide booming medical tourism industry, with many users seeking healing or spiritual experience [7]. Both traditional and non-traditional uses of ayahuasca in ritual settings is associated with lower scores of psychometric assessment of psychopathology. While I may be criticized for conflating spiritual and healing intentions when discussing ritual psychedelic use, data supports that mystical spiritual experiences mediate healing effects, thus it appears the line between spiritual experiences and healing effects is not well defined and perhaps non-existent [8-12].
Many westerners seek ayahuasca in order to treat or heal mental illness [7]. In these settings, there is a formal container and a shaman facilitates the ceremony. While there is certainly a great diversity in the skill sets of shamans which could lead to variable outcomes, there is no reason to think that therapists are any different in this regard. In shamanistic ayahuasca settings, there is often some discussion prior to ayahuasca use and a group council the morning after use, however these discussions are not considered to be psychotherapy and not performed by therapists.
Ayahuasca has also been studied in medical contexts with positive results and seems to act as a potent and rapid-onset antidepressant in persons with treatment resistant depression. Studies to date are small, although do not mention the presence of therapist or formalized psychotherapy sessions before or after as part of the process, yet results persist for weeks after use [13-15]. In fact, one study mentions that ayahuasca was deliberately used without therapist oversight, a musical playlist, or post-use psychological intervention because they wanted to understand what the intrinsic antidepressant effects of ayahuasca were [15]. Rapid antidepressant effects were observed with remote supervision of users and absence of psychotherapy that persisted at least two weeks later.
There are other examples: Peyote, a mescaline-containing cacti, has anecdotally helped many Native Americans with problematic use of alcohol. Emerging ritual sacraments and synthetic psychedelics such as venom from Bufo alvarius or 5-MeO-DMT are characterized by short experiences that are so intense that most users couldn’t talk with a therapist if they wanted to. Despite methodologic shortcomings of online surveys, it’s been reported this short lived and intense experience can relieve anxiety and/or depression for at least a month [16].
All of this clearly demonstrates that profound healing can occur by using psychedelics without a psychotherapist’s involvement and has been occurring without a psychotherapist’s involvement for time immemorial
Ibogaine for Addiction
Iboga and its primary psychoactive alkaloid ibogaine, is touted to be potent for the treatment of substance use disorders, particularly opioid use disorders due to its ability to simultaneously block physical withdrawal symptoms of opioids while providing the user psychological insight into the roots of their addiction. Iboga and ibogaine is known to be an exceptionally long experience, often lasting 24 hours or more, which could be difficult to endure for a psychotherapy intervention. There are no clinical trials of ibogaine-assisted psychotherapy, yet several articles have reported successful detoxification and abstinence after iboga or ibogaine use [17-29]. This is not to say that continued support and treatment after use is not beneficial or even a critical part of successful long-term recovery, but it does support that a therapist need not be involved in the acute experience for it to work.
Ketamine for Mood Disorders
Ketamine is categorized as a dissociative anesthetic, but shares many dimensions of subjective experience with psychedelics. A nasal formulation of S-ketamine was recently approved for treatment resistant depression, although racemic ketamine has been heavily studied for mood disorders in the past 15 years. At this point there have been dozens of studies examining the effects of ketamine on mood disorders, all with positive results, the vast majority of which never involved a psychotherapist [30-32]. Could the efficacy or safety of ketamine be improved with adjunctive psychotherapy? Probably, and there has been some data published by persons preforming Ketamine Assisted Psychotherapy (KAP) that supports this [33]. However, until there is a head to head study of KAP vs. ketamine use, we will not know how much the efficacy or safety of ketamine is improved or if the involvement of a psychotherapist is worth the additional resources expended. Regardless of whether KAP improves efficacy or safety, it’s apparent that ketamine can be used safely and effectively without a psychotherapist [34].
Neurobiology of Healing
Albeit observational and outside of neuroscientific modeling, several psychiatrists with intimate familiarity and extensive experience with psychedelic healing have purported psychedelics to activate the ‘inner healer’ or innate healing intelligence of the organism, Stan Grof, MD, PhD to name one. Now, the neuroscience that explains and models how psychedelics act in the brain is rapidly advancing and corroborating the ability of psychedelics to heal innately. It appears that tryptamine psychedelics are able to modulate a group of functionally interconnected neural networks termed the default mode network (DMN) [35-38]. Hyper- and hypo-connectivity or maladaptive relationships between structures of the DMN have been implicated in the pathophysiology of many psychiatric disorders [39]. It also appears the DMN serves a self-referential function and constructs a sense of identity (‘ego’ in the terms of psychotherapy). Acute diminishment of DMN activity by psychedelics are associated with mystical experiences, increased mindfulness, a ‘reset’ effect of maladaptively connected circuits, and long term improvements in psychosocial functioning [35-38]. Psychedelics such as N,N-dimethyltryptamine (DMT) and ketamine have been coined ‘psychoplastogens’ as they are able to stimulate neurogenesis, upregulate neurotrophic factors, and increase synaptogenesis between neurons [40]. This data has been collected in neuroscientific studies and support psychedelics can disrupt psychopathology all by themselves.
Psychedelic-Assisted Psychotherapy
So far, the only niche of psychedelic drug-taking that regularly involves therapists is psychedelic-assisted psychotherapy (PAP), which has primarily been centered on MDMA and psilocybin during the psychedelic renaissance. In the last 15 years there have been a number of randomized-controlled trials utilizing a design in which participants undergo a number of hour-long preparation sessions, an experience session in which a dyad of two therapists are present, and a number of follow-up hour-long integration sessions. This process is then repeated until 1-3 drug exposures have occurred with weeks to months between drug sessions. This makes the total intervention 2-4 months long with 6-12 hour-long therapy sessions. In these studies, all participants receive psychotherapy including those in controls groups [41-50].
It appears that the use of a psychedelic increases the effectiveness of the intervention by approximately 3-5x compared to psychotherapy alone [39, 45, 51, 52]
Due to the absence of a control group that lacked psychotherapy, there is no way to accurately deconstruct the PAP intervention to understand the contribution of therapy to improvements observed. Yet it is reasonable to think that the psychedelic plays a prominent role in achieving the outcomes, given it enhances the benefits by such a massive magnitude compared to control groups that received psychotherapy alone.
Rightfully so, PAP is being studied cautiously by using a resource-intensive model that creates an environment of exceptional safety. Psychedelic drugs are largely illegal and non-ordinary states of consciousness are taboo and stigmatized within the medical community as well as society at large. Psychedelic research has been largely stagnant for the past half-century and even a few bad outcomes in clinical trials could be enough to shut the research down.
Psychedelic-Assisted Psychotherapy – A Semantic Entitlement?
Therapy in PAP settings encourages a ‘non-directive’ approach, meaning that unless the participant really wants to engage in dialogue, the therapist is serving a supportive role [54, 55]. It is an experience-centric model during drug sessions that features blindfolds and a music playlist.
It is curious that the modality is branded as psychedelic-assisted psychotherapy opposed to, say, psychotherapy-assisted psychedelics.
At this point, you’re perhaps rolling your eyes and wondering why I’d even want to discuss what may seem like petty semantics. However, these semantics may be playing a role in the narrative and territorial attitude that some therapists are displaying when it comes to psychedelic drugs. It seems that psychedelic-assisted psychotherapy suggests that the psychedelic simply augments the psychotherapy, while in my (evidence-based) opinion it is precisely the opposite – the psychotherapy simply augments what the psychedelic drug accomplishes.
Don’t confuse the finger that points to the moon with the moon itself
Final Thoughts
Really, there is very little evidence supporting psychotherapists are necessary for psychedelic healing to occur and an abundance supporting that psychedelics can offer healing without them.
The totality of the evidence suggests that psychedelics are driving the healing bus rather than the psychotherapist
To recap, psychedelic use in the general population as well as in prisoners is associated with lowered risks of mental illness and crime. Psychedelics in ritual settings do not involve therapists, yet regularly produce therapeutic results for participants with mental illnesses. There are medical studies that exist with psychedelics such as ayahuasca, ketamine, or ibogaine that do not feature psychotherapy, yet demonstrate therapeutic effects. Psychedelics have the ability to disrupt engrained neurocircuitry and offer users a fresh perspective on their life and their illness that is mechanistically independent of psychotherapy. Psychedelics can occasion profound states of euphoric ecstasy and spiritual experience that are linked to healing effects. Even trials of PAP have utilized mental health professionals that are not psychotherapists themselves. Many describe the healing effects of a psychedelic experience as equivalent “10 years of psychotherapy”. Why do people say this? Because it’s true!They get more out of their single drug experience than a hundred hours with a psychotherapist. They’re not speaking to the effect of having a psychotherapist present during their drug experience, they’re speaking to the drug experience itself.
Again, all of this is not to discount the benefits of proper support before, after, and during use or to neglect the role of set and setting in beneficial, safe, and healing psychedelic experiences. It is simply to point out that psychotherapists and psychotherapy are not necessary components for psychedelics to heal. Therapists may be a necessary component of psychedelic treatments if and when psychedelics become legalized for medical use, but this will mostly be because of the way research was dictated to be carried out by the companies advancing them and the regulatory authorities they have to appease to gain approval for use. The PAP model is surely therapeutic and healing, but it is not the only way psychedelics can be healing. Let’s not let PAP become a dogmatic model.
Therapists are a welcome and complementary addition to the psychedelic community. For many, they may deepen insights and support difficult emotions that arise in psychedelic healing processes. However, they should not attempt to assert themselves as the only conduit for psychedelic healing and/or gatekeepers of psychedelics in our society
It’s a disempowering narrative and unnecessary turf war to purport psychedelics as being too risky or inefficacious to use without therapists, as well as simply untrue. Psychedelics, whether they’ve been ritually used for millennia or synthesized in a lab during the last 10 years, should belong to us all and we should be empowered to find healing with them in the way that best fits us, even if that doesn’t involve a therapist.