Psychedelic-assisted psychotherapy (PAP) is a unique marriage of psychedelic drugs and psychotherapy administered in a professionally monitored environment to create rapid and long-lasting psychological and behavioral change in people suffering from persistent disorders, such as PTSD. Designated by the U.S. government as a potential “breakthrough therapy” for PTSD and treatment-resistant depression, PAP involves psychotherapy individually tailored to a patient’s experience upon receiving a pharmaceutical-grade psychedelic drug in a medically safe way.
Although PAP is still investigational and therapy guidelines are still under development, clinical trials usually consist of one or two drug-free sessions of preparation, two to three treatment sessions with the drug, and two drug-free sessions of psychotherapy to fully explore and integrate the profound changes in perspective that are typical. Likely to be considered for approval by the FDA in 2024, psychedelic-assisted psychotherapy with MDMA for the treatment of PTSD is expected to be the first means by which psychedelic agents can be legally administered in the U.S. since the mid-1900s.
Studies show that the psychedelic agent presents vivid new information to patients and enables them to approach memories and feelings they were unable to process before. Specially trained psychotherapists serve as guides for interpreting their experience and helping them integrate the insights into their lives. Researchers contend that it is the psychotherapy that transforms hallucinogens from a novelty into a medicine. All clinicians delivering PAP are required to undergo special training in psychedelic psychotherapy and achieve certification in its use.
Psychedelic-assisted psychotherapy is an important innovation for a number of reasons. It creates long-lasting effects after only a very short course of treatment, and improvement typically continues long after active treatment ends. PAP is an entirely new model of treatment in which drug and psychotherapy work synergistically. Further, it shifts the approach to mental illness away from daily neurochemical correction of a brain dysfunction toward modification of conscious experience and meaningful interpretation of it.
The guidelines for the prescription of psychedelic-assisted psychotherapy have not yet been established because the treatment has not yet undergone scrutiny by the FDA’s new-drug approval process. However, in 2018, PAP using the psychedelic agent MDMA was designated a “breakthrough therapy” for PTSD by the FDA to expedite research and evaluation in the approval process. The designation means that the MDMA-psychotherapy combination demonstrates substantial improvement over any currently available treatments for PTSD.
PAP with psilocybin has also been designated a “breakthrough therapy” for treatment-resistant depression. Interventions of other psychedelic agents are in various stages of clinical investigation as treatment for substance use disorders, various forms of anxiety, eating disorders, obsessive-compulsive disorder, and more.
Because the psychedelic experience can be content-rich and emotionally intense—many people consider it one of the most meaningful experiences of their life—people need good guides for establishing the right mindset for treatment, interpreting the information, exploring their own minds, and integrating new understanding into their lives. Even before they receive the drug, they will find themselves in a comfortable setting conducive to an inner-directed experience. A soothing environment not only maximizes the efficacy of psychedelic agents but also conveys complete safety and minimizes anxiety. In such a setting, patients undergo several sessions of preparatory therapy to set expectations for the possibility of real benefit.
Patients typically receive a moderate to large dose of psychedelic drug in each of two or three extended sessions spaced over several weeks. During the sessions, which may last as long as six hours, they may listen to instrumental music that has been carefully selected and clinically tested to help guide people through phases of the drug experience, facilitating introspection, peak experience, emotional release, and return to calm. The therapeutic guide, present at all times, helps patients stay open to feelings and attentive to thoughts and memories and provides non-directive support from start to finish.
Studies of MDMA show that along with perceptual changes, especially regarding the passage of time, the agent promotes feelings of well-being. It prompts the release of neurotransmitters such as serotonin and dopamine involved in mood regulation and emotional processing while decreasing activity in the amygdala, diminishing feelings of fear. It also promotes the release of oxytocin, stirring feelings of emotional openness, empathy, and connectedness. It promotes a willingness to discuss emotionally charged memories.
Using moderate to large doses of drug, psychedelic-assisted psychotherapy is not microdosing. Microdosing refers to the ingestion of very small doses of certain psychoactive drugs, most often LSD, psilocybin, or cannabis. Microdoses are known as “sub-perceptual” and are typically one-tenth or even one-twentieth of a standard dose. Although microdosing could occur in a therapeutic setting, it is typically done outside of one.
The aim of microdosing is to trigger a drug’s therapeutic benefits—such as increased creativity or improved mood—without the potentially disruptive effects seen at higher doses, such as hallucinations or dissociation. In recent years, microdosing has gained popularity, fueled in part by its use among Silicon Valley tech workers, many of whom anecdotally report microdosing to increase productivity.
Psychedelic drugs are non-addictive and have few negative cognitive effects. They do not impair memory, nor do they cause stupor or narcosis such as that seen with alcohol or heroin. Neither do they produce excessive stimulation like that experienced with cocaine or amphetamine. Used therapeutically under the guidance of a trained therapist, few drug-related adverse events have been reported in clinical trials.
Psychedelics are powerful mind-altering substances: The user is known to experience mind-expansion, often with spiritual overtones. The agents are known to reopen critical periods of learning. The guidance of a knowledgeable therapist is vital to the outcome of treatment.
Researchers have found that taking psychedelics is not a passive experience: The mindset of the patient matters. Taking the drug opens the mind; therapy helps people through the experience and guides them to do the necessary work of digesting the newly exposed information and, eventually, recalibrating their psychological reality. Therapy allows patients to explore and come to terms with challenging psychological material that is keeping them stuck. It also helps them reorganize their consciousness in the wake of the psychedelic experience.
Therapists prepare patients for the experience by establishing a completely safe and trusting environment and establishing goals for treatment. They provide a reassuring presence even before the drug is administered, during the time it is active, and after the pharmacologic effects have worn off.
Always taking their cue from the patient’s needs and the nature of their uniquely individual experience, therapists guide them through the process. Therapists help patients revisit past events and emotions that have been problematic. They also conduct subsequent debriefing sessions to help patients consolidate insights and establish new ways of seeing themselves in relation to the world.
Given the investigative status of PAP, certification requirements for PAP therapists have not yet been established. However, it is known that, in the U.S., the use of psychedelic therapy will be limited to licensed mental health professionals who have received specific certification in psychedelic-assisted therapy following a course of education in psychedelic agents and clinical training in their use.
Some universities and educational organizations have developed programs to train therapists currently engaged in clinical research and to pre-train qualifying community-based therapists. Such programs provide instruction about the nature and chemical properties of the drugs, therapeutic approaches most effective with psychedelic use, safety and effectiveness procedures, and more. Therapists preparing to work with MDMA may undergo additional training in working with specific populations, such as veterans and military personnel.
As with all professional situations, experience counts: It is advisable to seek a therapist who has extensive training and certification as well as experience using psychedelic-assisted therapy to treat people presenting with concerns similar to yours.
Because the nature of the therapist relationship influences the outcome of therapy, it is important to find a therapist with whom you feel comfortable. Look for someone with whom you can establish clarity of communication and a sense of good fit.
You might ask a prospective therapist such questions as:
- How often have you dealt with problems such as those I am experiencing?
- How do you know whether I am a good candidate for PAP?
- How does PAP work?
- What is a typical plan of treatment, and how long is a typical course of therapy?
- What drug effects can I expect?
- What happens during a psychedelic session?
- How can I best prepare for the psychedelic experience?
- What work will I need to do to benefit from treatment?
- How do you measure the effects of treatment?
- What are the risks associated with PAP?
- What safety measures are in place during therapy?
The promise of psychedelics in ameliorating even longstanding mental health problems has given rise to a demand for treatment through extralegal channels. Many individuals (not all of whom are trained psychotherapists) conduct psychedelic sessions on their own with agents sourced through unknown channels. Others engage in psychedelic tourism, offering participation in “healing journeys,” group trips to countries where psychedelic agents are used ritualistically by religious elders or native healers. Such use has not been subjected to clinical evaluation.