The Current Shape of Psychedelic-Assisted Psychotherapy…
At this stage, most legal psychedelic-assisted psychotherapy takes place as a part of a research trial. Australia’s first psychedelic-assisted psychotherapy trial began in 2020, and none have yet been completed. In most instances, a research trial will employ a specific psychedelic compound - psilocybin, MDMA, Ayahuasca, etc. - and be focussed on treating a particular condition, such as PTSD, Depression, OCD, etc. Furthermore, the trial protocol will typically provide certain parameters around the psychotherapeutic framework being employed. Thus, each psychedelic-assisted psychotherapy trial has three basic elements:
The condition being treated (e.g. Depression)
The compound being used (e.g. MDMA)
The psychotherapy being employed (e.g. ACT: Acceptance and Commitment Therapy)
While the compound and condition are clearly identified in research trials, the nature of the psychotherapy paradigm being employed is often less clearly defined. For example, I am currently working with a team on a trial in Melbourne, Australia, looking at using psilocybin for treatment-resistant depression. In this trial, the treatment protocol is not highly specific when it comes to the nature of the psychotherapy being employed. The therapists working on the trial are a mix of psychiatrists, psychologists, and psychotherapists. Their work with participants on the trial will be informed by their training background and their own - likely eclectic - psychotherapeutic paradigm.
In some other trials, investigators are keen to study a specific type of psychotherapy (ACT, CBT, IFS, etc.) in conjunction with the psychedelic compound, and in such cases the trial protocol is more prescriptive when it comes to the shape of the psychotherapeutic work. One of the most interesting research questions to be tackled going forward concerns this very question: what sort of psychotherapy leads to the best outcomes when employing psychedelics?
Basic Treatment Protocol
For the time being, most psychedelic-assisted psychotherapy trial protocols seem to share certain key elements, regardless of the psychotherapeutic models being employed. For example, in most cases two therapists will be present at all times, and at least one of these therapists will be medically trained.
Standard psychedelic-assisted psychotherapy treatment tends to have the following shape:
Screening
Preparation
Dosing
Integration
Follow-up
Screening: This involves gathering information about the potential participant to ensure that they are a suitable candidate for the study. Do they qualify for the diagnosis being investigated? Are there any contra-indications such as a family history of schizophrenia? Are they well supported and resourced? Etc.
Preparation Sessions: The participant has a number of psychotherapy sessions prior to the dosing session. The shape of these sessions varies from trial to trial, however a typical trial will involve 3 preparations sessions of 1-2 hours, with both therapists present. In these sessions, the therapists will cover a number of bases: building rapport, becoming familiar with the treatment space, identifying key themes/struggles, outlining safety protocols, offering helpful tips for constructively navigating a psychedelic experience, identifying likely/possible types of experience the participant may have, and helping the participant articulate their intention.
Dosing Session: This is the long session in which the psychedelic compound (or a placebo) is taken. In general, the participant will sit or lie in a bed. They will have eye-shades on-hand to encourage an internal focus, and (optional) music will be played to assist them on their journey. Both therapists are present throughout. Standard practice suggests that therapists should be largely non-directive in the dosing session and allow the journey to unfold with minimal intervention. While therapists may seem to be doing very little in these sessions, the dosing session is often the most challenging aspect of psychedelic-assisted psychotherapy, and the participant is depending on the therapists to “hold space”, be present, and offer support in robust yet non-specific ways. The length of this session will depend on the substance being taken. For example, a typical psilocybin journey will take 6-8 hours. In most cases, an entire day will be needed to be dedicated to the session. In some trials there is more than one dosing session.
Integration Sessions: The participant has a number of psychotherapy sessions following the dosing session. The shape of these sessions varies from trial to trial, however a typical trial will involve 3 integration sessions of 1-2 hours, with both therapists present. Integration is a process in which the therapists help the participant to make sense of their psychedelic experience, in light of the condition being treated, their intention, and the themes discussed during preparation. One of the aims of the integration sessions is for the participant to bridge back to their daily life and experience, distilling key take aways from their psychedelic journey.
Follow-up: Each trial ultimately seeks to determine the efficacy of the treatment in relation to the condition being treated. As such, each trial with follow-up with participants at various time points in the aftermath of treatment to ascertain what the lasting impact of the treatment has been.
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Going Forward
When most people hear the phrase psychedelic-assisted psychotherapy, they tend to focus on “psychedelic” and ignore “psychotherapy”. This is understandable, but also misguided. We know that without a sound psychotherapeutic container, psychedelic experiences can be very hit and miss, especially in terms of lasting benefit. In psychedelic-assisted psychotherapy trials, the compound - type and amount - is easy to measure and control. The most interesting and powerful variables to be investigated relate not to the psychedelic, but to the context - the psychotherapeutic container - in which the psychedelic experience is held, sometimes referred to as “set, setting and cast”.
It is my sense that the first wave of research - over the next 5 to 10 years - will have a broad focus, simply seeking to establish psychedelic compounds as having healing potential. Once this is established, I then anticipate a more exciting second wave of research that will drill down into the details and examine the relative efficacy of different types of psychotherapeutic container.
It may be a long road, but my hope is that in the not too distant future, we in the West will have developed a powerful, evidence-based and coherent healing modality with psychedelic medicine at its core. I suspect in turn that this process will fundamentally alter our sense of what the psyche is, and how it can be healed.