Brian Pilecki, PhD - Oregon Health and Science University & Portland Psychotherapy
Over the last decade there has been a significant increase in research on the potential of psychedelic-assisted therapy (PAT) to treat various mental health conditions. PAT was originally developed in the 1960’s and used to address such disorders as alcohol abuse and schizophrenia. Research into this novel form of treatment stopped in the early 1970’s when LSD and other psychedelics became scheduled substances that were deemed to have no medical value. Due to various factors such as loosening restrictions, the need for improvements in mental health treatment, and the persistence of advocates of psychedelics, there has been a surge of clinical research that has reconsidered PAT as a tool for addressing mental health problems. Early-stage trials indicate that psilocybin, the psychoactive component in “magic mushrooms,” may be effective in treating end-of-life anxiety, treatment-resistant depression, major depressive disorder, and substance use disorders (Agin-Liebes et al., 2020; Bogenschutz et al., 2015; Carhart-Harris et al., 2021; Davis et al., 2021; Garcia-Romeu et al., 2019; Griffiths et al., 2016; Luoma, Chwyl, Bathje, Davis, & Lancelotta, 2020; Swift et al., 2017). MDMA, a drug more commonly known as “molly” or “ecstasy,” has also been tested in the treatment of post-traumatic stress disorder (PTSD) and shown to result in large effect size differences compared to placebo controls in Phase II and Phase 3 trials (Mitchell et al., 2019; Mithoefer et al., 2019). The FDA granted breakthrough therapy status to both MDMA-assisted therapy for PTSD (Feduccia, 2019) and psilocybin-assisted therapy for treatment-resistant depression (Lowe et al., 2021). It estimated that each will become approved and available treatments sometime over the next several years.
PAT is a unique combination of both psychotherapy and a drug-induced altered state of consciousness. While PAT differs based upon the particular psychedelic that is used, there is a basic model emerging from the clinical trials that involves three components (Schenberg, 2018). First, in preparation sessions, participants are provided with basic information about the drug that they will be taking, what to expect on the day of ingestion, and how this treatment relates to their mental health problems. A safe, supportive environment is created with typically two therapists present throughout all the sessions. Second, the dosing session involves taking the drug and can last anywhere from 3-8 hours depending on the length of effects. With the aid of eyeshades and music, participants are mostly encouraged to focus on their inner experience while therapists employ a non-directive, open, and supportive approach. Finally, integration sessions involve processing the experience with a focus on how new thoughts, feelings, or memories may relate to the participant’s treatment goals. Because psychedelic experiences do not automatically translate to behavior change, integration sessions are important in helping enhance therapeutic benefits associated with psychedelics.
The legal status of psychedelics can be confusing. Many clients encounter news about PAT or decriminalization of psychedelics, but often do not realize that psychedelics remain largely illegal. Some clients are looking to use psychedelics now and are bringing this interest up for discussion with their current therapist. Therefore, it is helpful for therapists to have some basic knowledge of psychedelics and how they might be relevant for certain conditions. Some therapists with a specialty in this area offer harm reduction and integration therapy for clients who are using psychedelics on their own (Gorman, Nielson, Molinar, Cassidy, & Sabbagh 2021). While incorporating clients’ use of illegal drugs may sound risky to professionals, there are several guidelines that can help providers understand the associated risks and ways to mitigate them (Pilecki, Luoma, Bathje, Rhea, & Narloch, 2021). For example, make it clear on your website that you don’t provide illegal drugs and obtain CE’s related to psychedelic integration to demonstrate competence in this burgeoning clinical area.
While most early research on PAT has focused on outcomes using symptom severity measures, there has been less focus on underlying processes of change relevant to PAT. Understanding why psychedelic experiences produce therapeutic change is important in informing the psychotherapy components (e.g. preparation, integration) of PAT. For example, some evidence suggests that the degree to which a participant has a mystical experience predicts outcomes related to reductions in anxiety and depression in a trial of psilocybin-assisted therapy for end-of-life distress (Griffiths et al., 2016). Investigation into what therapy models are the best fit for PAT is still in its infancy, as there are not yet any trials comparing different psychotherapy interventions for psilocybin or MDMA. CBT (Yaden et al., 2022) and ACT (Luoma, Sabucedo, Eriksson, Gates, & Pilecki, 2019) have been identified as good candidates for informing PAT, and many of the recent psilocybin trials have already used ACT as a foundation for their therapeutic models. I am one of the study therapists on a clinical trial of MDMA-assisted therapy for social anxiety disorder that is taking place at Portland Psychotherapy (Lear, Smith, Pilecki, Stauffer, & Luoma, under review). One of our aims is to better understand how MDMA might enhance underlying processes of psychological flexibility that lead to therapeutic growth in individuals with social anxiety.
While recent research has demonstrated that both psilocybin and MDMA can be administered safely in the context of psychedelic-assisted therapy, using psychedelics is not without risk. In uncontrolled environments, such as taking psychedelics in a public setting (e.g. club, music festival), there is greater potential for psychological difficulties to occur, such as paranoia and fear. Taking a psychedelic, especially at substantive doses such as those used in the trials, is often an ordeal and should be approached with thoughtfulness and preparation. When in the safe container of a therapeutic environment, challenging experiences with psychedelics can be navigated well and often result in therapeutic growth. In many ways, this is no different that standard therapy that often involves confronting painful emotions or memories. Another risk of taking psychedelics in any context is that one is place into a vulnerable state in which even physical mobility may be dependent on others. As a result, the potential for abuse and boundary violations may be greater than in traditional psychotherapy. Finally, PAT will likely be initially expensive and may not be covered by insurance. This creates problems such as lack of access for marginalized populations.
In summary, we are just beginning to scratch the surface of understanding about under what conditions and for whom PAT may be helpful or not and , how to best use psychotherapy to support growth from psychedelic experiences, and how this new treatment works. However, initial data from rigorous placebo-controlled randomized trials suggests that PAT may be another tool that we can use, especially in cases where clients have not responded to existing treatment options.
Agin-Liebes, G. I., Malone, T., Yalch, M. M., Mennenga, S. E., Ponté, K. L., Guss, J., Bossis, A. P., Grigsby, J., Fischer, S., & Ross, S. (2020). Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer. Journal of Psychopharmacology, 34, 155-166.
Bogenschutz, M. P., Forcehimes, A. A., Pommy, J. A., Wilcox, C. E., Barbosa, P. C. R., & Strassman, R. J. (2015). Psilocybin-assisted treatment for alcohol dependence: A proof-of-concept study. Journal of Psychopharmacology, 29, 289–299.
Carhart-Harris, R., Giribaldi, B., Watts, R., Baker-Jones, M., Murphy-Beiner, A., Murphy, R., Martell, J., Blemings, A., Erritzoe, D., & Nutt, D. J. (2021). Trial of psilocybin versus escitalopram for depression. New England Journal of Medicine, 384(15), 1402-1411.
Davis, A. K., Barrett, F. S., May, D. G., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., Finan, P. H., & Griffiths, R. R. (2021). Effects of psilocybin-assisted therapy on major depressive disorder: a randomized clinical trial. JAMA Psychiatry, 78, 481-489.
Feduccia, A. A., Jerome, L., Yazar-Klosinski, B., Emerson, A., Mithoefer, M. C., & Doblin, R. (2019). Breakthrough for Trauma Treatment: Safety and Efficacy of MDMA-Assisted Psychotherapy Compared to Paroxetine and Sertraline. Frontiers in psychiatry, 10, 650.
Garcia-Romeu, A., Davis, A. K., Erowid, F., Erowid, E., Griffiths, R. R., & Johnson, M. W. (2019). Cessation and reduction in alcohol consumption and misuse after psychedelic use. Journal of psychopharmacology (Oxford, England), 33, 1088–1101.
Gorman, I., Nielson, E.M., Molinar, A., Cassidy, K., & Sabbagh, J. (2021). Psychedelic harm reduction and integration: A transtheoretical model for clinical practice. Frontiers in Psychology, 12:645246.
Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D.Cosimano, M. P., & Klinedust, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology, 30,1181–1197.
Lear, K.M., Smith, S.M., Pilecki, B., Stauffer, C., & Luoma, J. (under review). Social anxiety and MDMA-assisted therapy investigation (SAMATI): A novel clinical trial protocol.
Lowe, H., Toyang, N., Steele, B., Valentine, H., Grant, J., Ali, A., Ngwa, W., & Gordon, L. (2021). The Therapeutic Potential of Psilocybin. Molecules, 26, 2948.
Luoma, J.B., Sabucedo, P., Eriksson, J., Gates, N.A., & Pilecki, B. (2019). Toward a contextual psychedelic-assisted therapy: Perspectives from Acceptance and Commitment Therapy and contextual behavioral science. Journal of Contextual Behavioral Science, 14, 136-145.
Luoma, J. B., Chwyl, C., Bathje, G. J., Davis, A. K., & Lancelotta, R. (2020). A meta-analysis of placebo-controlled trials of psychedelic-assisted therapy. Journal of Psychoactive Drugs, 52, 288-299.
Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., Ot'alora G, M., Garas, W., Paleos, C., Gorman, I., Nicholas, C., Mithoefer, M., Carlin, S., Poulter, B., Mithoefer, A., Quevedo, S., Wells, G., Klaire, S. S., van der Kolk, B., Tzarfaty, K., … Doblin, R. (2021). MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nature medicine, 27, 1025–1033.
Mithoefer, M. C., Feduccia, A. A., Jerome, L., Mithoefer, A., Wagner, M., Walsh, Z., Hamilton, S., Yazar-Klosinski, B., Emerson, A., & Doblin, R. (2019). MDMA-assisted psychotherapy for treatment of PTSD: study design and rationale for phase 3 trials based on pooled analysis of six phase 2 randomized controlled trials. Psychopharmacology, 236, 2735–2745.
Pilecki, B., Luoma, J., Bathje, G.J., Rhea, J., & Narloch, V.F. (2021). Ethical and legal issues in psychedelic harm reduction and integration therapy. Harm Reduction Journal, 18, 40.
Schenberg E. E. (2018). Psychedelic-Assisted Psychotherapy: A Paradigm Shift in Psychiatric Research and Development. Frontiers in pharmacology, 9, 733.
Swift, T. C., Belser, A. B., Agin-Liebes, G., Devenot, N., Terrana,S., Friedman, H. L., Guss, J., Bossis, A. P., & Ross, S. (2017). Cancer at the dinner table: Experiences of psilocybin-assisted psychotherapy for the treatment of cancer-related distress. Journal of Humanistic Psychology, 57, 488–519.
Yaden, D. B., Earp, D., Graziosi, M., Friedman-Wheeler, D., Luoma, J. B., & Johnson, M. W. (2022). Psychedelics and Psychotherapy: Cognitive-Behavioral Approaches as Default. Frontiers in Psychology, 13, 873279.
Published August 31, 2022
