While still not entirely devoid of stigma, psychotherapy has transcended cultural boundaries, with millennials seeking both in-person and virtual sessions at a 10% larger rate than Boomers. Rising student loan debt, financial instability, workplace stress, and a volcanic political climate are just some of the catalysts contributing to an increased demand, one that’s been met with an adaptive supply via fingertip therapy like TalkSpace and text lines for immediate help. Therapy certainly isn’t relegated to an armchair chat—there’s art therapy, music therapy, and alt methods like reiki and EFT. And bubbling below the surface is a treatment modality that could change the course of therapy as we know it, but it’s met with its own set of stigma that could be challenging to dispel before it hits the mainstream: psychedelic therapy. It certainly isn’t new, but even despite the science and successes, there’s still a long road ahead of us until it’s easily accessible to the masses.
A Brief History
Psychedelic, which translates to “mind manifesting,” is a term coined by psychiatrist Humphrey Osmond in the early 1950s. He believed that LSD could help treat mental illness, specifically alcoholism, and hypothesized that placing patients into a temporary delirium would “scare” them into quitting. He, along with his research partner, Abram Hoffer, administered a single large dose of LSD under controlled settings to 2000 patients with alcoholism and found that 40-50% of them did not return to drinking a year following treatment. However, rather than scaring the subject, the psychedelic experience helped provide spiritual, transformative insight that would help encourage them to cease drinking. (It’s important to note that the studies lacked controls and patient follow-up; still, the findings were impressive.)
in 1952, psychiatrist Ronald Sandison met with Albert Hofmann (a chemist for the pharmaceutical company Sandoz who first synthesized LSD) in Switzerland where he obtained vials of the drug under the trade name Delysid and brought them back to the U.K where he treated thousands of patients with a combination of micro-dosing and traditional psychotherapy, a modality he called “psycholytic therapy.” Under the influence, his patients were supposedly able to tap into their subconscious and relive lost memories.
More success with LSD-assisted psychotherapy cropped up elsewhere, with the National Institute of Mental Health sponsoring the use of LSD and psilocybin to treat anxiety and depression in terminally ill patients. Promising (yet limited) data was also observed in trials with children with autism who saw increased verbal communication skills following treatment. Soon, psychedelic assisted therapy trials were growing at a rapid pace, but quickly came to a halt when, in 1962, congress passed new drug safety regulations and the The Food and Drug Administration declared LSD an experimental drug, meaning it could only be used for research purposes and never for general psychiatric practice. (Ironically, in the ‘50s and ‘60s, the CIA had funded trials to examine LSD as a sort of truth serum in the quest for mind control.) Fueled by stigma associated with the counterculture movement, LSD, psilocybin, and other hallucinogenics were eventually deemed illegal in the U.S., and the negative media depiction—along with President Nixon’s war on drugs—caused research and the funding behind it to come to a standstill. European studies of psychedelic therapy continued, but dwindled as most research was done in private practice and went unreported in general scientific and medical journals.
Fast-forward to about a decade ago when researchers and legislation began to "move away from their traditional standpoints and ... concentrate on sound scientific research” according to the Multidisciplinary Association for Psychedelic Studies. In the U.S., researchers have received grants for psychedelic research with human subjects, specifically using DMT and psilocybin. There have also been trials with MDMA and, of course, further research with LSD. And just last year, John’s Hopkins University launched a dedicated center for psychedelic studies.
What Will You "Feel" in Psychedelic Therapy?
The mechanics of psychedelics as a form of therapy go a little something like this: they reduce the level of activity in the default mode network, which is essentially a network of brain regions that are active in the resting state and are not focused on the here-and-now of the outside world, but rather on the self, specifically as it relates to memory and ruminating in a self-critical way. Psychedelics help reduce activity in the amygdala (where fear is processed) and increase activity in the prefrontal cortex (where we think logically). This helps patients process triggers, fears, and anxieties rather than suppressing them, which can uncover important breakthroughs and realizations.
To understand what it’s like to be "under the influence" in therapy, I spoke with Dr. Diva Nagula, a physician who was diagnosed with stage 4 non-Hodgkin’s lymphoma in 2014 and sought psychedelic therapy to manage depression and anger related to his diagnosis.
“For me, it’s been a game-changer,” he tells me over email. “At first, it was tough because I had a hard time surrendering to the experience. After subsequent sessions, I learned to surrender and trust the therapy and the therapist. Once I surrendered, the healing began. One psychedelic therapy session can equal years or even decades of regular therapy. It helped and continues to help me resolve traumatic issues experienced throughout my life. It also opened up a window to the spiritual world and gave me meaning and purpose that I was desperately seeking. I have so much clarity now.”
Roland Griffiths, PhD, a clinical researcher who has studied the role of psilocybin in treating depression and anxiety in patients with life-threatening cancer found that high doses of the hallucinogen yielded impressive long-term results, especially when compared with other psychedelics. “Under conditions in which people are very carefully selected, they’re supported, they’re prepared... [the treatment] has effects that are deeply and profoundly personally and spiritually meaningful to people,” he tells Rhonda Patrick, PhD on the FoundMyFitness podcast. “And what’s interesting, with respect to other mood-altering drugs, is these experiences are deeply valued well after the experience has finished, so months later, people continue to reflect back on that experience and opine that it’s among the most personally meaningful and spiritually significant of their lives... in the top five, if not, the single most, comparing these experiences to that of the birth of a firstborn child or the death of a parent.”
It’s important to note that no two sessions will be the same: what happens in one patient’s trip will vary substantially from the next. Says Griffiths, “It could be autobiographical features where people remember issues from childhood or they reflect on relationships in their own lives… there could be aesthetic experiences where people get involved with imagery or color or geometric shapes… ” Despite the variables, the underscore of the experience is a sense of unity and a truthfulness, of feeling as though the trip is “more real and more true than everyday waking consciousness,” says Griffiths.
Making Headway With Ketamine
While LSD, psilocybin, and MDMA are all schedule 1 drugs—meaning the DEA has concluded that they have a high potential for abuse; they're not currently accepted medical treatments in the U.S.; and they have a lack of accepted safety for use under medical supervision—ketamine, a dissociative anesthetic, is a schedule 3 drug that could provide similar profound therapeutic breakthroughs with greater accessibility. According to Dr. Michael Verbora, a practitioner at Field Trip, a psychedelic-enhanced therapy center in Toronto, NYC, L.A., and Chicago, “[Ketamine-assisted therapy] is like supercharging therapy because the ketamine not only provides a near immediate improvement in mood, but also creates a period of neural plasticity that enables people to change their patterns, behaviors, and outlook faster. By comparison, it takes months or years in CBT [cognitive behavioral therapy] to achieve what we can do in 1-2 sessions with ketamine-assisted psychotherapy (or KAP). KAP helps remove barriers to socializing, being comfortable, and exploring our own psyche more rapidly.”
Fundamentally, ketamine is most commonly used in medicine for starting and maintaining anesthesia, during which it induces a trance-like state while providing pain relief and sedation. For psychotherapy purposes, studies suggest it’s a helpful treatment for individuals with depression, and there is some evidence for using KAP to treat PTSD and anxiety, as well as eating disorders and addiction, according to Verbora.
What Are the Logistics of a Psychedelic Therapy Session?
In KAP, the session will typically last 45-60 minutes, but patients will be asked to stay on site for 1.5-2 hours before leaving the clinic. The ketamine is administered either orally via sublingual lozenges or through intramuscular (IM) injection, though availability will depend on location. Patients are told to bring a friend or family member for support (as well as for a safe ride home), but they won't be allowed in the treatment room during the session.
With psilocybin, typically the patient will be given a capsule and is instructed to lay down and put on headphones while a caregiver is present to provide safety and reassurance that "despite what they may be feeling, they'll be back to consensual reality by the end of the day," says Griffiths. The session is much longer than KAP and could last up to eight hours.
While there are over 300 clinics in the United States that offer KAP, reserving a session unfortunately isn't as easy as calling and making an appointment. Says Verbora, "At Field Trip, our process begins with a psychiatric assessment to determine if KAP is medically appropriate, which is then followed by psychotherapy intake (to determine a patient's readiness for this type of treatment) and lastly, medical assessment (to ensure that ketamine is safe to give)."
For therapy done in conjunction with psychedelics like MDMA, psilocybin, DMT, mescaline, and LSD, these sessions can only be conducted in clinical research settings for diagnoses such as depression, anxiety, addiction, and PTSD. (If you're interested in participating in a trial, you can search for current recruitment at clinicaltrials.gov.)
What If You Have a "Bad" Trip?
Because you can't control how the drug will affect your body, the possibility of a negative hallucinogenic experience may deter a patient from considering treatment. However, the beauty lies in the unknown. "Current belief is that there is no such thing as a 'bad trip' per se," explains Verbora. "Rather, there are 'easy' trips and 'hard' trips. Hard trips can still be therapeutic if experienced in the proper context and setting, and with the right therapeutic support. At Field Trip, we control the entire experience and dose, helping people establish a good set (mindset) and by providing a safe and welcoming setting, as well as making sure patients have the incredible support of our therapists, the risk of patients having a 'bad trip' is lower."
To prepare yourself for the experience and help set your mind at ease, Nagula advises experimenting with sober simulators. "The best way to do so is to engage in meditation or breath work practice," he says. "This prepares the mind to surrender. Additionally, floating in a sensory deprivation tank also helps you prepare for the ‘trip.’ It simulates a psychedelic experience. If you can master a float tank, then you are ready for the real thing."
Are There Any Side Effects?
For Nagula, micro-dosing with psychedelics like LSD didn't pose any negative reactions because, as he explains, no trip was involved. "Micro-dosing is ‘sub-perceptual,’ so there isn’t a ‘trip’ that occurs." However, the issues present themselves when the psychedelic is not used in a controlled medical setting. He continues, "There are interactions with conventional medicines, whether micro-dosing or taking a ‘trip’ dose, [so] it is best to be monitored and evaluated by a professional. Additionally, if not taken appropriately or monitored by an experienced person, the experience can be traumatizing." In terms of dependency, despite individuals developing some level of tolerance to LSD, there is no significant research indicating withdrawal symptoms; in other words, addiction and dependency are unlikely, though isolated incidents of chronic abuse are possible.
With ketamine, Verbora notes that the drug has some "mildly addictive properties," but that these are rarely experienced. They also note that there is a rare condition called "ketamine bladder," where abuse can lead to inflammation in the bladder, but that this has yet to be seen in patients using ketamine for medical treatment. Work closely with your physician and provider to ensure you're properly utilizing the treatment.
What Does the Future of Psychedelic Therapy Look Like?
After over 34 years of research, MAPS founder and executive director Rick Doblin, PhD says that he has initiated Phase 3 studies of MDMA-assisted psychotherapy for PTSD and is hopeful that the FDA will approve its use by 2021. At this point, trained therapists will be able to administer MDMA under direct supervision in clinical settings. The FDA considers this type of treatment a "breakthrough therapy," which means that clinical evidence indicates that the drug may help treat serious or life-threatening conditions over available therapies; it has also declared psilocybin a breakthrough therapy for treatment-resistant depression.
Although ketamine is already FDA-approved for anesthesia and analgesia and widely available as a medical supply, it is not approved for a psychiatric indication. However, when Johnson & Johnson filtered regular ketamine to create esketamine, it was approved by the FDA for treatment-resistant depression and can be prescribed by your provider under the pharmaceutical name Spravato. (Ketanest is another available esketamine treatment, but it's off-label as it has not yet been approved by the FDA.) It is administered intranasally under the supervision of your provider in a clinical setting, and you will need to be driven home following treatment. While esketamine is very expensive (generally to the tune of $850 per dose), it's a stepping stone to hopefully getting generic ketamine approved for psychiatric indication so that health insurance companies will cover the cost of treatment.
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