Chapter 28 – Psychedelic-Assisted Psychotherapy


In recent years there has been a resumption of research into the potential therapeutic benefits of psychedelic1 drugs such as MDMA2, psilocybin and LSD3. Clinical research suggests significant efficacy for psychiatric disorders that have traditionally been hard to treat. The evidence base has accumulated to the point that psychedelic-assisted psychotherapy appears to be moving from a fringe subject to a significant new treatment method that all psychotherapists should at least be aware of and that some may develop into a special interest.

Chapter 28 Psychedelic-Assisted Psychotherapy

Tim Read

The future may teach us to exercise a direct influence on the mind by means of particular chemical substances …. … and there may be still other undreamt of possibilities for therapy as a result.

Sigmund Freud [1]

Why is This of Interest to Psychiatry and Psychotherapy?

In recent years there has been a resumption of research into the potential therapeutic benefits of psychedelic1 drugs such as MDMA2, psilocybin and LSD3. Clinical research suggests significant efficacy for psychiatric disorders that have traditionally been hard to treat. The evidence base has accumulated to the point that psychedelic-assisted psychotherapy appears to be moving from a fringe subject to a significant new treatment method that all psychotherapists should at least be aware of and that some may develop into a special interest.

Psychedelic substances and the psychological experiences associated with them do tend to challenge paradigms and elicit powerful reactions ranging from prohibition to evangelical enthusiasm. Neither of these positions predispose to the sober and thoughtful consideration of their clinical potential for psychiatric disorders, based on a developing evidence base. This would appear to be an important area of interest to psychiatry and psychotherapy inviting us to appraise potential benefits and risks, expand our models of therapeutic change, learn new skills and potentially take a leading role in the development of research and new treatments.

I will discuss the general principles of drug-assisted psychotherapy, the ways in which it differs from conventional psychotherapy, areas of therapeutic promise and implications for our understanding of the psyche.

Drug-assisted psychotherapy, as will be described here, involves the patient undergoing a short, time-limited course of psychotherapy, during which some of the sessions are enhanced by the acute action of a drug that has specific properties conducive to improving the efficacy of the psychotherapy. There is a class of powerful psychoactive substances, termed psychedelic drugs, that amplifies psychological material in a manner that can be used therapeutically. This is different to the use of psychoactive and mind-altering drugs as pharmacotherapy, such as ketamine for treatment-resistant depression.

The current psychedelic renaissance is necessarily driven by neuroscience and clinical research and is as yet less concerned in the complexity, topography and detail of the psyche that is uncovered. The clinical work of the first generation of psychedelic research in the 1950s and 1960s allowed a range of usage with different settings, variable dosages and greater numbers of sessions. Although much of the research from this era does not meet modern standards, it did allow a creative development of ideas leading to expanded models of the psyche to account for some of the phenomena that emerge in the psychedelic experience that could not be accounted for by existing models. I will discuss this briefly later.

The Crucial Elements of Psychedelic-Assisted Psychotherapy

Clinical outcome with therapeutic use of psychedelic substances depends on setting and integration as well as choice of substance and dosage. I will begin with a brief discussion of these critical factors.

The Set – is the mental state a person brings to the experience – thoughts, mood and expectations. The set needs to have the same qualities of curiosity, openness, therapist engagement and willingness to tolerate discomfort as in conventional therapy. There needs to be an additional psychoeducation process about the drug effects and how to tolerate and make therapeutic use of the intensity of the experience.

The Setting – is the physical and social environment, which is very different to the setting for conventional psychotherapy. The sober use of psychedelics as a method of treatment is a journey through the landscape of the interior. In properly supported psychedelic sessions, any contact with the everyday world or interpersonal communication is kept to a useful minimum. A relaxing non-clinical environment encourages a primary focus on the inner experience enhanced by optional use of eyeshades and music and accompanied by at least one sitter. The sitter is in a position of care and responsibility, and should have familiarity with the psychedelic territory and some of the mental states that may arise. The key role of the sitter is to support a naturally unfolding process that is assumed to have an intrinsic healing trajectory. The sitter takes a passive role and will not interfere with a person’s process except on matters of care and safety, but is available to offer support if required. The support may be verbal, emotional or physical.

Integration – the drug session itself often has little verbal interaction. There follow structured meetings to process the content of the session, with additional support if required. This integrative process addresses emotional, intellectual and physical response to sessions, monitors risk and encourages self-caring activities and rest. The depth of the integration is enhanced by the therapist’s preparatory work with the patient, the shared experience of the drug session and the therapist’s experience and range of clinical skills.

Choice of drug – classical psychedelics such as LSD and psilocybin provide a range of emotional experiences ranging from sessions with a deeply positive spiritual (numinous) tone to more challenging encounters with previously hard to access psychological material. Empathogens/entactogens such as MDMA reliably provide positive affect and increased empathy that is a fundamental component of the current clinical research into treatment of post-traumatic stress disorder (PTSD) and was sometimes used in couple therapy before such treatment was made illegal in 1985.

Dosage – high-dose LSD was historically used to induce transpersonal/spiritual experiences thought to be the mutative factors in the treatment of alcoholism, addiction and terminal illness. Low to moderate dose LSD was used in psycholytic psychotherapy as a catalyst to access and amplify psychological material and places more emphasis on verbal interaction with the psychotherapist. There is developing research interest in microdosing, doses that are too low to have discernable clinical effects but may act as cognitive or emotional enhancers. In MDMA-assisted psychotherapy for PTSD there is accumulating evidence that a moderate dose of 75 mg has superior efficacy to a lower (30 mg) or higher dose (125 mg) [2].

MDMA-Assisted Psychotherapy for Treatment-Resistant Post-traumatic Stress Disorder

Researchers in the United States have led the field in developing MDMA as an adjunct to the psychological treatment of severe, treatment-resistant PTSD. The results have shown improvement that was sustained at follow-up. In August 2017 the USA Food and Drug Administration (FDA) granted Breakthrough Therapy Designation to MDMA for the treatment of PTSD. At time of writing phase 3 trials are underway with a view to making this treatment available for clinical use. So in the USA, MDMA-assisted psychotherapy appears likely to become a mainstream treatment.

The research is funded and coordinated by the Multidisciplinary Association for Psychedelic Studies (MAPS) and led by Dr Michael Mithoefer who is co-therapist with his wife Annie; a detailed treatment protocol can be found on the MAPS website [3]. The model of treatment in MDMA-assisted psychotherapy combines biological and psychotherapeutic approaches, which are applied synergistically to facilitate trauma processing, thereby decreasing or eliminating chronic hyperarousal and stress reactions to triggers. A key point in psychedelic-assisted psychotherapy is that the substance is seen as a catalyst for the process of therapeutic change – not as a pharmacological treatment in itself. The therapeutic effect is thought to flow from the interaction between those pharmacological effects, the therapeutic setting and the mindsets of the participant and the therapists. MDMA produces an experience that appears to temporarily reduce fear while increasing positive emotions and interpersonal trust, without clouding consciousness or reducing access to emotions.

MDMA may catalyse therapeutic processing by allowing participants to revisit traumatic experiences without being overwhelmed by anxiety or dissociating. This in turn enables a processing of the index trauma, as well as underlying vulnerability related to previous traumas. This trauma processing occurs both in the drug sessions and the non-drug sessions and the therapeutic process may be amplified by the enhanced therapeutic alliance with the therapists, which not only facilitates the processing of trauma but may also allow for an experience of secure attachment [3]

The British psychiatrist Ben Sessa describes MDMA as possessing all the required qualities to enhance psychotherapy. The drug is short-acting, has no dependence potential and is not toxic at therapeutic doses. It enhances the therapeutic alliance by amplifying a feeling of trust and closeness with the therapist, which in turn enables the addressing of trauma that may otherwise be too difficult. MDMA reduces depression and induces relaxation while simultaneously raising arousal levels for the therapy session with heightened sense of clarity, compassion and connectedness. It is consistent in its effects, almost always inducing positive affect and does not usually cause perceptual disturbances [4]. The effects last for between 6 and 8 hours.

The mechanism of action is incompletely understood, but MDMA is known to significantly decrease activity in the left amygdala [5]. This is compatible with some of the effects of MDMA such as reduction in fear or defensiveness and enhanced interaction with the therapist. Psychological models concerning the process of change and the interaction between substance, patient and therapist are developing. A psychoanalytic model of trauma and PTSD includes an overwhelming of the defences and loss of the ability to symbolise, so that the experience can only be repeated through flashbacks and nightmares rather than being processed. This can cause major challenges in establishing a therapeutic alliance when there is no longer any good object to call upon to help with the psychological tasks of facing a terrible reality and mourning one’s former, untraumatised self. It appears that the euphoriant effect of the psychedelic substance enhances the potential to create a positive transference, which can allow some of the psychological work towards recovery that had previously not been possible.

The Treatment Programme for MDMA-Assisted Psychotherapy

The treatment programme in the research programme is carefully structured. Each participant has three preparatory sessions before the first drug session. There are usually three drug sessions in total over a three-month period and each drug session is followed by three integrative sessions. The therapeutic team comprises a male/female pair who are both present in all the drug and non-drug sessions, including the preparatory sessions.

The purpose of the preparatory sessions can be summarised as follows:

  • Full history is taken together with exploration of client expectations and concerns

  • Detailed explanation of the setting, the practical aspects of the treatment, the effects of MDMA, the structure of the sessions and the aftercare

  • Explanation of the therapeutic approach, to try to stay with and tolerate emerging experiences, trust in the approach, focus on the body and inner processes

  • Discussion of music, use of eyeshades, optional use of supportive touch from therapists if appropriate

  • Agreement to stay in the treatment area, discussion of physical safety issues, anxiety management and support

  • Establishment of therapeutic alliance, openness about any transference issues

The drug sessions have some important differences to conventional psychotherapy. There are two therapists throughout who are there in a supportive capacity. The effect of the male/female pair combined with the mood-enhancing effects of the drug has powerful transference implications. The patient is encouraged to lie on the couch, use eyeshades and maintain an inner focus. Music is carefully chosen to enhance the setting. There is regular monitoring of vital signs and this is an opportunity for the therapists to check in with the participant. Inevitably in this group of patients with PTSD the trauma will emerge and be available for discussion – at least to some extent. Anxiety management techniques allied with verbal, emotional and physical support may be helpful.

The integration process is integral to the therapeutic process. Thus the participant is encouraged to use their own curiosity and tools in addition to the structures provided by the programme. Integration after the drug session begins with an informal recap of the session with the therapists. The participant spends the evening and night in a safe setting with recourse to additional support if required – this is a time for quiet and reflection. There follow three scheduled 90-minute integration sessions after each drug treatment using an active dialogue approach to uncover emotional, intellectual and physical response with consideration of emerging thoughts, feelings and concerns, risk assessment while encouraging self-caring activities and rest. Partners and important others are encouraged to participate – at least to some extent.

Mithoefer describes how the effects of MDMA can lead to profound insights about cognitive distortions with little or no intervention from the therapists; the largely non-directive approach often results in spontaneous cognitive restructuring resulting from qualities engendered by MDMA with increased mental clarity, confidence, and the courage to look honestly at oneself [6]. This cognitive restructuring is amplified and perpetuated in the integration sessions.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 28 – Psychedelic-Assisted Psychotherapy
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