What does good psychedelic therapy look like?

Psychedelic therapy is on its way to becoming a mainstream medical treatment in mental health care. In 2020 and 2022, residents of Oregon and Colorado voted to legalize the use of psilocybin, the psychoactive ingredient in hallucinogenic mushrooms, and the Food and Drug Administration is expected to approve it and MDMA, or Ecstasy, to treat depression and post-traumatic stress disorder by 2024.

While there is mounting evidence that psychedelics could offer much-needed new treatments for intractable mental illness, stories of abuse or trauma have also emerged – which have more to do with the therapists than the drugs.

Some cases involve clear instances of sexual assault. With others, the therapist may have had good intentions but still caused more harm than healing. In one recent clinical trial, which found that psilocybin could offer relief for treatment-resistant depression, three participants reported having suicidal thoughts and harming themselves in the weeks following the therapy.

Twenty years of research has standardized the dosage of the drugs used in clinical trials, but the therapy part has not received similar scrutiny. Instead, therapists’ work is often based on tradition rather than empirical evidence, said Dr. Charles Raison, director of clinical and translational research at the Usona Institute in Wisconsin and a professor of psychiatry at the University of Wisconsin.

The lack of scientifically backed best practices has prompted researchers, clinicians and former patients to call for a more critical look at the therapeutic component of psychedelic therapy.

“I’m really concerned about the ways in which well-meaning therapists can do harm,” said Sarah McNamee, a licensed psychotherapist and research coordinator at the School of Social Work at McGill University.

Because people are so emotionally vulnerable while they’re on psychedelics, there is a greater risk for psychological injury, particularly by inept or inexperienced practitioners. “It could be easy to make someone worse,” said Janis Phelps, director of the Center for Psychedelic Therapies and Research at the California Institute of Integral Studies, which offers degrees in psychology and counseling.

Here’s what currently happens in many psychedelic therapy sessions, and where red flags might appear.

Choosing a therapist

In most of the country, the only way to legally try psychedelic therapy using psilocybin or MDMA is to enroll in a clinical trial. (Ketamine can be administered in clinics or can even be sent to your home, but experts strongly urge that it be used only in conjunction with therapy.)

The practitioner you work with should be a mental health professional, ideally specializing in your condition, and certified in psychedelic therapy, for which there are now several training programs. Amy Lehrner, clinical director of the Center for Psychedelic Psychotherapy and Trauma Research at the Icahn School of Medicine at Mount Sinai, recommended that people assess a potential psychedelic therapist as they would any other mental health provider: Ask about the person’s training, professional certifications and expertise.

Underground options have also existed for decades, some administered by professional therapists, others by amateurs. Experts advise against using such providers because there is even less oversight. Vetting the practitioner is doubly important if you are seeking psychedelic therapy outside a clinical trial.

In any setting, it is crucial that you feel safe and comfortable with the therapist, which is one reason that preparatory sessions are so important for developing trust and rapport.

Preparatory sessions

Before you take the drug, the clinician should meet with you for several hours over a few days to explain what the treatment will entail, especially regarding the drug’s physical and psychological effects. The therapist should ask about your history and symptoms, as well as your goals and intentions for the treatment.

The therapist might advise you to adopt a certain frame of mind during the session or teach you breathing or meditation techniques to use if you are faced with an uncomfortable emotion or physical sensation while on the drug.

“We teach them to be excited and curious about what they don’t know yet, what’s going to come out of them, and to welcome it, even if it’s disturbing for a few moments – or an hour, if that’s the case,” Phelps said.

A critical purpose of these sessions is to obtain informed consent for what might happen during the drug session, especially regarding touch. Because it is not normally part of talk therapy, the role of touch in psychedelic therapy is contentious.

Some experts say that it can be helpful for someone on a psychedelic trip to receive a reassuring touch. Others say it could create an opportunity for boundaries to be crossed. Most agreed that the touch should be limited to holding hands or a hand on the shoulder; anything involving full-body contact, including a hug, could be interpreted as sexual.

Drug session

For most of a drug session with MDMA or psilocybin, the patient is typically lying down, eyes closed, listening to music. The experience generally does not involve much talking and is more internal for the patient.

If the patient starts to feel anxious or is encountering a traumatic memory or vision, the therapist might offer reassurance or guidance through a breathing exercise. In those instances, the goal is not for the patient to avoid or be distracted from the experience. “The therapist role here is to try to help people stay with it,” Raison said. “If you fight the experience, you tend to have bad outcomes.”

Therapists should never push a certain experience on a patient; they are there to follow the patient’s direction, not to lead, Lehrner said. “It is never about intruding or directing by pushing somebody” past their limits.

However, McNamee, who has participated in psychedelic clinical trials, said that uncritically encouraging patients to go through the pain could cause more harm than good. In psychedelic therapy, therapists often push people “to confront the distress,” she said, when sometimes “it might be a good idea to turn away from distress, to soothe, to regulate, to distract.”

It’s not about whether a practice is good or bad, she added, but determining in what contexts it can be helpful or harmful.

Integration sessions

The integration sessions, when the patient processes the experience in the days and weeks after the trip, look the most like traditional therapy. The exact number of sessions varies, but four hours spread over two or three weeks is typical, although some experts say that isn’t long enough.

The therapist helps the patient try to make sense of the feelings, insights and memories that emerged while on the psychedelic. The most common tactic, Raison said, is to ask open-ended questions and let the patient guide the conversation.

For example, a therapist might ask: How did the experience shift your relationship with yourself? The goal is to take those lessons and incorporate them into the patient’s life, the philosophy being that “the patient has their own wisdom, the psychedelic experience has its own wisdom,” he said.

Some researchers are starting to experiment with alternative therapeutic approaches, such as cognitive behavioral therapy or acceptance and commitment therapy, that encourage patients to reexamine beliefs about themselves, potentially aided by insights made during the psychedelic session.

To Lehrner, what researchers should be working to standardize now are general therapeutic principles while they continue testing whether the treatment as a whole is safe and effective. “Afterwards,” she said, “people may investigate: ‘Well, what if we tweak it like this? What if we change it like that?’”

McNamee disagreed. “I worry about how the field might be moving too quickly,” without sufficient research into what constitutes safe and ethical practice, she said. “That we may standardize things that are problematic, I think, is something that’s worth thinking about.”

This article originally appeared in The New York Times.