Psychedelic therapy

Psychedelic therapy refers to therapeutic practices involving psychedelic drugs such as LSD, psilocybin, DMT, mescaline, 2C-B, and MDMA. In psychedelic therapy, in contrast to the use of conventional psychiatric medication which is taken by the patient regularly or as-needed, patients remain in an extended psychotherapy session during the acute activity of the drug and spend the night at the facility. In the sessions with the drug, therapists are nondirective and support the patient in exploring their inner experience. Patients participate in psychotherapy before the drug psychotherapy sessions to prepare them and after the drug psychotherapy to help them integrate their experiences with the drug.[1][2]

History

Prehistoric use of psychedelic substances

Humans have long consumed psychedelic substances derived from cacti, seeds, bark, and roots of various plants and fungi.[3][4] Since ancient times, shamans and medicine men have used psychedelics as a way to gain access to the spirit world. Though western culture usually views the practice of shamans and medicine men as predominantly spiritual in nature, elements of psychotherapeutic practice can be read into the entheogenic or shamanic rituals of many cultures.[5]

Research in the mid-20th century

Shortly after Albert Hofmann discovered the psychoactive properties of LSD in 1943,[6] Sandoz Laboratories began widespread distribution of LSD to researchers in 1949.[7] Throughout the 1950s and 1960s, scientists in several countries conducted extensive research into experimental chemotherapeutic, and psychotherapeutic uses of psychedelic drugs. In addition to spawning six international conferences and the release of dozens of books, over 1,000 peer-reviewed clinical papers detailing the use of psychedelic compounds (administered to approximately 40,000 patients) were published by the mid-1960s.[8] Proponents believed that psychedelic drugs facilitated psychoanalytic processes, making them particularly useful for patients with conditions such as alcoholism that are otherwise difficult to treat. However, many of these trials did not meet the methodological standards that are required today.[9]

Researchers like Timothy Leary felt psychedelics could alter the fundamental personality structure or subjective value-system of an individual to great potential benefit. Beginning in 1961, he conducted experiments with prison inmates in an attempt to reduce recidivism with short, intense psychotherapy sessions. Participants were administered psilocybin during these sessions weeks apart with regular group therapy sessions in between.[10] Psychedelic therapy was also applied in a number of other specific patient populations including alcoholism, children with autism, and persons with terminal illness.[10]

Regulation and prohibition in the late 20th century

Throughout the 1960s, concerns raised about the proliferation of unauthorized use of psychedelic drugs by the general public (and, most notably, the counterculture) resulted in the imposition of increasingly severe restrictions on medical and psychiatric research conducted with psychedelic substances.[11] Many countries either banned LSD outright or made it extremely scarce, and, bowing to governmental concerns, Sandoz halted production of LSD in 1965. During a congressional hearing in 1966, Senator Robert F. Kennedy questioned the shift of opinion, stating, "Perhaps to some extent we have lost sight of the fact that (LSD) can be very, very helpful in our society if used properly."[12] In 1968, Dahlberg and colleagues published an article in the American Journal of Psychiatry detailing various forces that had successfully discredited legitimate LSD research.[13] The essay argues that individuals in government and the pharmaceutical industry sabotaged the psychedelic research community by canceling ongoing studies and analysis while labeling genuine scientists as charlatans.[13]

Studies on medicinal applications of psychedelics ceased entirely in the United States when the Controlled Substances Act was passed in 1970. LSD and many other psychedelics were placed into the most restrictive "Schedule I" category by the United States Drug Enforcement Administration. Schedule I compounds are claimed to possess "significant potential for abuse and dependence" and have "no recognized medicinal value",[14] effectively rendering them illegal to use in the United States for all purposes. Despite objections from the scientific community, authorized research into therapeutic applications of psychedelic drugs had been discontinued worldwide by the 1980s.

Despite broad prohibition, unofficial psychedelic research and therapeutic sessions continued nevertheless in the following decades. Some therapists exploited windows of opportunity preceding scheduling of particular substances or, alternatively, developed non-drug techniques such as Holotropic Breathwork (however following a 1993 report commissioned by the Scottish Charities Office, concerns about the risk that the hyperventilation technique could cause seizure or lead to psychosis in vulnerable people caused the Findhorn Foundation to suspend its breathwork programme[15]) for achieving similar states of consciousness. Informal psychedelic therapy was conducted clandestinely in underground networks consisting of sessions carried out both by licensed therapists and autodidacts within the community.[16] Due to the largely illegal nature of psychedelic therapy in this period, little information is available concerning the methods that were used. Individuals having published information between 1980 and 2000 regarding psychedelic psychotherapy include George Greer, Ann Shulgin (TiHKAL, with Alexander Shulgin), Myron Stolaroff (The Secret Chief, regarding the underground therapy done by Leo Zeff), and Athanasios Kafkalides.[17]

Resurgence in the early 21st century

Psilocybin session at Johns Hopkins

In the early 2000s, a renewal of interest in the psychiatric use of psychedelics contributed to an increase in clinical research centering on the psychopharmacological effects of these drugs and their subsequent applications. Advances in science and technology allowed researchers to collect and interpret extensive data from animal studies, and the advent of new technologies such as PET and MRI scanning made it possible to examine the sites of action of hallucinogens in the brain.[18] Furthermore, retrospective studies involving users of illicit drugs as voluntary subjects were conducted, allowing data to be collected on how psychedelics affect the human brain while simultaneously sidestepping bureaucratic difficulties associated with providing illegal substances to subjects.[18] The new century also ushered in a broader change in political attitude towards psychedelic medicine—specifically within the Food and Drug Administration. Curtis Wright, then deputy director of the FDA Division of Anesthetic, Critical Care and Addiction Drugs explained a motivation for this change: “the agency was challenged legally in a number of cases and also underwent a process of introspection, asking 'Is it proper to treat this class of drugs differently?'"[18]

As of 2014, global treaties listing LSD and psilocybin as "Schedule I" controlled substances continues to inhibit a better understanding of these drugs. Much of the renewed clinical research has been conducted with psilocybin and MDMA in the United States with special permission and breakthrough therapy designations by the FDA, while other studies have investigated the mechanisms and effects of ayahuasca and LSD.[19][20][21] MDMA-assisted psychotherapy is being actively researched by MAPS. Phase two trials conducted between 2004 and 2010 reported an overall remission rate of 66.2% and low rates of adverse effects for subjects with chronic PTSD.[22] Only six formal studies on the applications of LSD occurred between 1990 and 2017. No complications of LSD administration were observed.[23]

As of 2016, Johns Hopkins University and New York University have conducted large randomized, placebo-controlled studies.[24] These two studies are some of the first large controlled studies measuring the effects of psychedelic therapy on depression and anxiety in cancer patients.[24] Across clinician-ratings and self-ratings, the psychedelic treatment produced statistically significant lowered anxiety and depression, with sustenance for at least 6 months.[25][26] Importantly, adverse effects from the drugs were not noted.[25][26]

Both studies also attributed the efficacy in part to patients experiencing a “mystical experience”.[25][26] A mystical experience is a very personal introspective experience where some sort of unity or transcendence of time and space is described.[27] More research is necessary to expand generalizability of the conclusions. Also, more research is necessary to understand the biological properties of a mystical experience.[26] According to Robin Carhart-Harris, the head of the Centre for Psychedelic Research at Imperial College London, "the impact of successful psychedelic therapy is often one of revelation or epiphany. People speak of witnessing `the bigger picture´, placing things in perspective, accessing deep insight about themselves and the world, releasing pent-up mental pain, feeling emotionally and physically recalibrated, clear-sighted and equanimous. This is very different from people’s descriptions of the effects of SSRIs, where a contrasting feeling of being emotionally muted is not uncommon."[28]

As of 2021, many new centers for psychedelics research have been launched, including the Centre for Psychedelic Research at Imperial College London,[29][30] the UC Berkeley Center for the Science of Psychedelics,[31] the Center for Psychedelic and Consciousness Research at Johns Hopkins University,[32][33] the Center for Psychedelic Research and Therapy at Dell Medical School at the University of Texas at Austin,[34] the Center for Psychedelic Psychotherapy and Trauma Research at the Icahn School of Medicine at Mount Sinai,[35] and the Psychae Institute in Melbourne.[36]

Applications

Psychedelic substances which may have therapeutic uses include psilocybin (the main active compound found in magic mushrooms), LSD, and mescaline (the main active compound in the peyote cactus).[19] Although the history behind these substances has hindered research into their potential medicinal value, scientists are now able to conduct studies and renew research that was halted in the 1970s. Some research has shown that these substances have helped people with such mental disorders as obsessive-compulsive disorder, post-traumatic stress disorder, alcoholism, depression, and cluster headaches.[37] Some of the well known particular psychedelic substances that have been used to this day are: LSD, DMT, psilocybin, mescaline, 2C-B, 2C-I, 5-MeO-DMT, AMT, ibogaine and DOM. In general, however, the drugs remain poorly understood. Their effects are strongly dependent on the environment in which they are given and on the recipient's state of mind (set and setting).

In alcoholism

Studies by Humphry Osmond, Betty Eisner, and others examined the possibility that psychedelic therapy could treat alcoholism (or, less commonly, other addictions). One review of the usefulness of psychedelic therapy in treating alcoholism concluded that the possibility was neither proven nor disproven.[38] Another thorough meta-analysis from 2012 found that "In a pooled analysis of six randomized controlled clinical trials, a single dose of LSD had a significant beneficial effect on alcohol misuse at the first reported follow-up assessment, which ranged from 1 to 12 months after discharge from each treatment program. This treatment effect from LSD on alcohol misuse was also seen at 2 to 3 months and at 6 months, but was not statistically significant at 12 months post-treatment. Among the three trials that reported total abstinence from alcohol use, there was also a significant beneficial effect of LSD at the first reported follow-up, which ranged from 1 to 3 months after discharge from each treatment program."[39]

In terminal illness

During the early 1950s and 1960s the National Institute of Mental Health sponsored the study of psychedelic drugs such as psilocybin and LSD to alleviate the debilitating anxiety and depression patients with terminal diagnoses may feel.[40] While these early studies are hard to find, the resurgence of interest in psychedelic drugs to treat humans end of life mindset has led to some small studies in the 21st Century. The more recently published research strengthens the findings from the 1950s and 1960s showing the drug is extremely effective in reducing anxiety and depression in this patient population once carefully screened and has few adverse effects when administered in a psychotherapy setting and under medical supervision. The psychologists leading psychedelic drug therapy trials found that end of life patients often suffer from the emotional turmoil of dying more than the physical aspects. This mindset makes it difficult for patients to find meaning and enjoyment in life during their last few months or years. While all patients have completely different experiences on these mind altering drugs the research subjects interviewed all expressed they had, "heightened clarity and confidence about their personal values and priorities, and a renewed or enhanced recognition of intrinsic meaning and value of life."[40] More recently, researchers have argued that psychedelic therapy is beneficial for these patients because it may specifically reduce their fear of dying.[41]

In post-traumatic stress disorder (PTSD)

The Multidisciplinary Association for Psychedelic Studies (MAPS) is conducting studies seeking to understand how MDMA could be helpful in the treatment of post-traumatic stress disorder. The Phase 2 trials of these studies, conducted in the U.S., Canada, and Israel, consisted of 107 participants who had chronic, treatment-resistant PTSD, and had suffered from PTSD for an average of 17.8 years. Out of the 107 participants, 61% no longer qualified for PTSD after three sessions of MDMA-assisted psychotherapy two months after the treatment. At the 12-month follow-up session, 68% no longer had PTSD.[42] As of 2021, MAPS is continuing their research in Phase 3 trials which, despite setbacks caused by COVID-19, are expected to be completed in 2022. Potential approval by the FDA may happen as early as 2023.[43]

It is important to note that given the difficulties with appropriate blinding in trials of MDMA- and psychedelic-assisted psychotherapy the results are likely overestimated.[44][45] Furthermore, there are no superiority or non-inferiority clinical trials comparing MDMA-assisted psychotherapy to already existent evidence-based treatments for PTSD, but given the effects reported in clinical trials of MDMA-assisted psychotherapy for PTSD there is no reason to believe that this treatment modality is more effective than existent trauma-focused psychological treatments.[46]

In depressive and anxiety disorders

In 2019, the FDA approved the use of esketamine for intranasal use for Major depressive disorder (MDD), and Treatment-resistant depression (TRD), in conjunction with an oral antidepressant.[47] This designation, known as “breakthrough therapy,” fast-tracks the study of drugs where clinical evidence shows that their use will demonstrate a 'substantial improvement' over the therapies that are already available.[48] Later that year, the FDA approved the use of psilocybin for these types of depression as well.[49] These designations are significant, since they provide a blueprint for potential new psychedelic therapies going forward.

In cases of major depressive disorder (MDD), there is evidence that psilocybin-assisted psychotherapy can result in lasting antidepressant effects. A randomized clinical trial showed that of those participants who received the treatment, 71% continued to experience a clinically significant response at the 4 week follow-up session.[50] These long-term effects may be advantageous when compared to the use of traditional pharmaceutical drugs, such as escitalopram which often require daily administration and cause worse side effects.[51] Interestingly, trials utilizing Ayahuasca have shown evidence of both antidepressant and anxiolytic effects as well,[52] which scientists have recognized as an important area that warrants further research.

Methods

The effects of psychedelic drugs on the human mind are complex, varied and difficult to characterize. As a result, many different "flavors" of psychedelic psychotherapy have been developed by individual practitioners. Published accounts of methodologies are discussed below.

Psycholytic therapy

Psycholytic therapy involves the use of low to medium doses of psychedelic drugs, repeatedly at intervals of 1–2 weeks. The therapist is present during the peak of the experience to assist the patient in processing material that arises and to offer support. This general form of therapy was mostly used to treat patients with neurotic and psychosomatic disorders. The name psycholytic therapy was coined by Ronald A. Sandison,[note 1] literally meaning "soul-dissolving", refers to the belief that the therapy can dissolve conflicts in the mind. Psycholytic therapy was historically an important approach to psychedelic psychotherapy in Europe, and was also practiced in the United States by some psychotherapists, including Betty Eisner.

Psychedelic drugs are useful for exploring the subconscious because a conscious sliver of the adult ego usually remains active during the experience.[8]: 196  Patients remain intellectually alert throughout the process and remember their experiences vividly afterward.[8]: 196  In this highly introspective state, patients are actively aware of ego defenses such as projection, denial, and displacement as they react to themselves and their choices.[8]: 196 

The ultimate goal of the therapy is to provide a safe, mutually compassionate context through which the profound and intense reliving of memories can be filtered through the principles of genuine psychotherapy.[54] Aided by the deeply introspective state attained by the patient, the therapist assists him/her in developing a new life framework or personal philosophy that recognizes individual responsibility for change.[8]: 196 

In Germany Hanscarl Leuner has designed a psycholytic therapy, which was developed officially, but was used also by some socio-politically motivated underground therapists in the 1970s.[55][56][57]

Psychedelic therapy

Psychedelic therapy involves the use of very high doses of psychedelic drugs, with the aim of promoting transcendental, ecstatic, religious or mystical peak experiences. Patients spend most of the acute period of the drug's activity lying down with eyeshades listening to nonlyrical music and exploring their inner experience. Dialogue with the therapists is sparse during the drug sessions but essential during psychotherapy sessions before and after the drug experience. There are two therapists, one man and one woman. The recent resurgence of research (see § Early 21st Century Resurgence above) uses this method.[1] It is more closely aligned to transpersonal psychology than to traditional psychoanalysis. Psychedelic therapy is practiced primarily in North America. The psychedelic therapy method was initiated by Humphry Osmond and Abram Hoffer (with some influence from Al Hubbard) and replicated by Keith Ditman.[58][59]

During psychedelic therapy, the focus is on psilocybin and ayahuasca, as patients are provided with high doses of the drug. During the trials, one must analyze both Cognitive Behavioral Therapy (CBT) and/or Motivational Enhancement Therapy (MET). Within a structured CBT intervention and a dose of psilocybin, patients are given the opportunity to experience cognitive and emotional states that are altered. With these psychedelic effects, cognitive reframing of detrimental schemas and self-identity can be modified positively. In a MET environment, patients are able to reflect on their own behaviors to make changes in problematic manners, such as alcohol use disorder. Additionally, it could potentially enhance motivation to change and decrease possible ambivalence about behavioral changes. Within psychedelic drug session, through a reevaluation of the concept of self and reconnecting with core beliefs and values, this can be achieved.[60]

Other variations

In Czechoslovakia, psychiatrist Stanislav Grof developed a form of treatment that appeared to bridge both of these main forms. He analyzed the LSD experience in a Freudian or Jungian psychoanalytic context in addition to giving significant value to the overarching transpersonal, mystical, or spiritual experience that often allowed the patient to re-evaluate their entire life philosophy.

After LSD was outlawed in most industrialized nations, Grof developed an alternative method to induce psychedelic experiences. A method of rapid breathing called Holotropic breathwork allows people to tap into non-ordinary states of consciousness. People have related experiences ranging from releasing buried childhood trauma, reexperiencing birth and even transpersonal events. [8][61]

The Chilean therapist Claudio Naranjo developed a branch of psychedelic therapy that utilized drugs like MDA, MDMA, harmaline and ibogaine.[8]

Anaclitic therapy

The term anaclitic (from the Ancient Greek "ἀνάκλιτος", anaklitos – "for reclining") refers to primitive, infantile needs and tendencies directed toward a pre-genital love object. Developed by two London psychoanalysts, Joyce Martin and Pauline McCririck, this form of treatment is similar to psycholytic approaches as it is based largely on a psychoanalytic interpretation of abreactions produced by the treatment, but it tends to focus on those experiences in which the patient re-encounters carnal feelings of emotional deprivation and frustration stemming from the infantile needs of their early childhood. As a result, the treatment was developed with the aim to directly fulfill or satisfy those repressed, agonizing cravings for love, physical contact, and other instinctual needs re-lived by the patient. Therefore, the therapist is completely engaged with the subject, as opposed to the traditional detached attitude of the psychoanalyst. With the intense emotional episodes that came with the psychedelic experience, Martin and McCririck aimed to sit in as the "mother" role who would enter into close physical contact with the patients by rocking them, giving them milk from a bottle, etc.[61]

Hypnodelic therapy

Hypnodelic therapy, as the name suggests, was developed with the goal to maximize the power of hypnotic suggestion by combining it with the psychedelic experience. After training the patient to respond to hypnosis, LSD would be administered, and during the onset phase of the drug the patient would be placed into a state of trance. Levine and Ludwig found the combination of these techniques to be more effective than the use of either of these two components separately.[61]

Shamanic or Non-Clinical Setting

Psychedelic therapy has been conducted in the setting of spiritual healing for thousands of years. There is evidence of indigenous shamans working with naturally occurring psychedelic substances in many shamanic cultures, including peoples of Mexico, Peru and Brazil. In the Shamanic setting, there is a psychedelic facilitator who is a shaman, or one who communicates directly with the plant spirits to conduct healing, and the person participating in this experience is said to obtain healing in both physical and spiritual form. From Maria Sabina in Mexico [62] to the Shipibo people in Peru,[63] there is even one legal Psilocybin Church in the United States, known as Sacred Heart Medicine Sanctuary, working with the naturally occurring psilocybin mushroom to conduct spiritual healing in a non-clinical setting.[64]

Public interest

The resurgence of psychedelic drug therapy in the 21st century has to do largely with renewed public interest including articles in the New Yorker, The New York Times and the Wall Street Journal.[40] A New York Times article titled "How Psychedelic Drugs Can Help Patients Face Death" was published on April 20, 2012, and led to an increase in interest from the public regarding psychedelic drugs and their use in medicine.[65] Since then there have been many mainstream publications that have published articles regarding this topic and brought attention to the positive findings in research conducted back in the 1950s and 60s. The New York Times has continued to cover new research in the field including an article published in the Health Edition titled, "My Adventures With the Trip Doctors," published on May 15, 2018.[66]

Psychedelic tourism

The first article to bring attention to the uses of psychedelic drugs for mental health was titled, "Seeking the Magic Mushroom," written by Robert Gordon Wasson and published in 1957 by TIME magazine. It detailed his experience traveling to Oaxaca, Mexico and taking "magic mushrooms" (psilocybin) within the cultural practices that started the "trip" experience. Since that time there has been growing interest within the United States to travel for these unique psychedelic experiences. The market for psychedelic tourism is currently growing rapidly. While typically the vacation destinations for psychedelics are based in Central and South America there is a rise in western culture taking over their traditional practices. In the Netherlands there are psychedelic society retreats that range from $500–1200 that center on a ceremony in which tourists take magic mushrooms and trip together for around six hours.[67] There are also underground psychedelic "guides" popping up around the United States that include leaders who claim to assist people through their trip similar to shamans in other cultures. A Guardian article titled, "Welcome to the trip of your life: the rise of underground LSD guides" details various styles of guides that can be found within the United States.[68]

See also

References

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Notes

  1. ↑ Ronald Sandison first referred to the psycholytic model in 1955 in a speech to the American Psychiatric Association, and used the term ‘psycholytic therapy’ at the 1960 'European Symposium on Psychotherapy Under LSD-25' at Göttingen University convened by Hanscarl Leuner. In 1964 Leuner formed the European Medical Society for Psycholytic Therapy.[53]
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