Long-Term Psychological Effects

Q&A: Long-Term Psychological Effects

The psychological impact of psychedelics can be profound. How people process the experience afterward is central to understanding what happened during the experience, how it relates to their lives, and how they can continue to benefit and learn from it.

Mary Cosimano

Mary Cosimano directs guide/facilitator services at the Johns Hopkins University Center for Psychedelic and Consciousness Research, where she is responsible for training and supervising session facilitators. She has conducted more than 450 study sessions. She has also taught in the Psychedelic-Assisted Therapies and Research program at the California Institute of Integral Studies.


BCSP

What is integration?

Mary Cosimano

“Integration is when someone has an experience and then brings it into their daily life. The experience itself is just an experience. Unless they integrate it and change, they go right back to the same way of living. I’ve heard integration defined as weaving the mystical into the practical. I like that, although it’s not always true, because people don’t always have mystical experiences.”


BCSP

Does someone need to be in therapy or part of a group to integrate their experience?

Mary Cosimano

“Certainly some people can and do integrate their experience alone, but they’re more likely to integrate it into a meaningful experience if they have a well-structured program or plan. It can be in a group. It can be with your therapist. It can be with a friend or friends who really know this territory and know you. Of course, if you’re in a clinical trial, that’s part of the protocol. But if you don’t have the intention of integrating it and some kind of a plan, it’s going to be much easier to dismiss your experience and to have problems with things that came up in a difficult session.”


BCSP

When you talk about an integration plan or program, what does that actually look like? What activities might be included in that?

Mary Cosimano

“You want to make it concrete. I can give some examples from prior volunteers. Meditation or a mindfulness practice is a big one. People have done artwork, written poetry, made sculptures. We had one volunteer who would go back to a chunk of clay at different times, think of an experience, and shape it to that. If you listen to music during the experience, going back to that playlist can bring the experience back. Nature is one of the best ways for integration. Everyone has their own way that’s going to work for them. 

In our sessions, we set goals so that they have something to concretely work toward. What are a few ways that you will integrate your experience this week, until we meet again next week? It doesn’t have to be big, it just has to be intentional. They might say, ‘OK, I’m going to meditate for ten minutes three times this week,’ or ‘I’m going to journal every night.'”

“The experience itself is just an experience. Unless they integrate it and change, they go right back to the same way of living.”


BCSP

How long does integration last?

Mary Cosimano

“Integration should last a lifetime. I just talked with somebody who found a book that helped her incorporate something from her session 25 years later. It’s ongoing, and it’s very individual.”


BCSP

How long will the positive or negative feelings that come out of an experience last?

Mary Cosimano

“That’s individual, too. Some people have already integrated them by the end of their session, just on their own, although I still wouldn’t say the work is done. Give yourself time. 

We had one volunteer who traveled so far out in his experiences. They weren’t necessarily difficult, but it was difficult to come back here and make sense of the daily routine of his life. He realized that for him he needed space. It was really hard because he had a family, but he knew he needed it because the experience was so expansive and so difficult to come back from. We met with him more, talked more, and found ways that he could take the time to make sense of it. There’s not one answer. It just depends on you and how you’re integrating it.”


BCSP

How do you manage disappointment? How do you integrate an experience that wasn’t what someone wanted?

Mary Cosimano

“That happens a lot, because people read about others’ experiences and expect the same. Talking about expectations is a huge part of our preparation.  After witnessing experiences for all these years, I believe that your experience is exactly what you were supposed to have at this time in your life to go forward. So it certainly may not be, and often isn’t, the ‘big-lights-all-is-one’ experience, but it’s exactly the area that you needed to work on. People will say that a lot: ‘It wasn’t what I wanted, but it was what I needed. I see that now.'”


BCSP

How can someone hold onto the good feelings or insights they had during their trip?

Mary Cosimano

“It’s just the nature of the experience that a powerful positive feeling is going to dissipate. But the more that you incorporate a new practice into your life, the more that you bring it into your every day. That integration is gradual. It’s the micro steps. It’s understanding that that big experience, that big joy, fun, and beauty, is going to dissipate.”


BCSP

Can a user stop other mental health supports like therapy or SSRIs after taking psychedelics?

Mary Cosimano

“At our center we never say that, because psychedelics aren’t a cure-all. That’s not what we’re looking for them to be. It’s whatever works for you. I think it’s the same as with therapy. Some people will have formal therapy the rest of their life and others will have it for a few months.”

This interview was edited for length and clarity.

Long-Term Physical Effects

Q&A: Long-Term Physical Effects

Currently, the long-term effects of psychedelics are poorly understood. It’s quite rare for people to become addicted to most psychedelics, but using these substances does affect the body. Symptoms can range from fatigue and grogginess to reports of recurring perceptual changes that can last for days, and sometimes weeks or years, after the experience. 

Brian Anderson

Brian Anderson

Brian Anderson is a psychiatrist, assistant professor, and researcher at the University of California, San Francisco. He is an investigator with BCSP. For over a decade, he has conducted both ethnographic and clinical research related to psychoactive drug use, including studying ayahuasca-using religious groups in South America and psilocybin therapy for people with serious medical illnesses.


BCSP

Do psychedelics cause hangovers?

Brian Anderson

“There are reports of people feeling hungover, fatigued, or a little foggy the day or a couple of days after taking some psychedelics. There is also a real difference between stimulant-based psychedelics, like MDMA, that have psychedelic effects, versus the classic psychedelics like psilocybin and ayahuasca. MDMA-like drugs can lead to side effects such as feeling hungover in different ways. But certainly, people can feel tired and foggy-headed with a number of different psychedelics. 

In psilocybin research, one of the most common side effects that people report in the days after treatment is fatigue. They report that even after taking psilocybin during the daytime (meaning they are not staying up all night because they took the drug late in the evening). Headaches can also be a lingering side effect after psilocybin.”


BCSP

Can MDMA withdrawal cause fatigue and depression?

Brian Anderson

“When people use drugs that they call ‘MDMA’ in community settings, there are often other substances mixed in with them, both potential impurities and other drugs. They may be having some of these adverse effects from the other substances. 

It’s also important to emphasize that whenever a substance is used in a way that changes someone’s sleep-wake cycle—for instance, if someone takes a psychedelic drug like MDMA and stays up all night—then feeling fatigued, hungover, or like they’re ‘coming down’ in an uncomfortable way over the next few days may in large part be due to losing a night of sleep. That’s one reason why, when these substances are used in clinical trials in a therapeutic setting, it’s often done during the day. We try to make sure people have time to sleep and recover afterward.

Also, it’s worth mentioning that one participant in the recent Phase 3 trial of MDMA-assisted psychotherapy for PTSD (published in Nature Medicine) did withdraw from the study in part because they experienced depressed mood following an MDMA treatment session. But there isn’t conclusive evidence that the ingestion of pure MDMA in clinical settings leads to blue Mondays in users.”

“It’s not just about taking a substance. The work that unfolds between sessions is thought to be really important in terms of how a substance may actually help people.”


BCSP

What is Hallucinogen Persisting Perception Disorder?

Brian Anderson

“Hallucinogen Persisting Perception Disorder, or HPPD, is when people experience perceptual distortions long after using a drug, like a psychedelic. People report seeing ‘trailers’—meaning if they move their hand in front of their face, it’s almost like they can see afterimages of their hands slowly moving across their visual field or colored lights or shapes out of the corner of their eye. 

It’s not just about seeing things afterward, even though that’s probably the most common problem. People also seek clinical care after using psychedelics and other drugs for auditory or somatic sensations that are unusual, distressing, and impairing.

Unfortunately, there aren’t great treatments for it.
The prevalence of HPPD is still unclear. One large survey of psychedelic users found that 4.2 percent experienced distressing persisting visual experiences after psychedelic use.”


BCSP

Do people need to eat special foods, vitamins, or supplements before or after taking a psychedelic substance?

Brian Anderson

“There are different opinions on the proper ways to prepare for, recover from, and make the most use of psychedelic experiences. You’ll find a number of different opinions out there on special foods or diets, or the use of supplements, vitamins, and herbs. I don’t know if there is a solid, reliable body of evidence that many people would agree upon. 

But with ayahuasca, and some other psychedelics like 5-MeO-DMT, the idea of combining those drugs with certain other compounds is thought to be dangerous. Specifically, combining different psychedelics with compounds that are monoamine oxidase inhibitors (MAOIs) has led to people having very strong, overwhelming psychological reactions to the psychedelics.

Sometimes this contributes to severe medical outcomes or even death. There’s been a number of cases where people will combine ayahuasca or ayahuasca-like substances that have MAOIs in them with smoking 5-MeO-DMT or related compounds in non-clinical settings, and there have been fatalities. Whether it is safe to combine different psychedelics needs more careful study.”


BCSP

After a trip, do users need to wait a significant amount of time to take psychedelics or other drugs again?

Brian Anderson

“If someone takes a psychedelic drug like LSD or psilocybin every day, the drug will quickly lose its psychoactive effects because of tolerance. There are always risks when someone takes a psychedelic, so safety is an important consideration here. The optimal interval between uses of a psychedelic depends on why someone is taking the drug in the first place. It’s worth asking, ‘What good is it doing for people?’ If they’re approaching it to give them insights for well-being or personal enhancement, how much psychological work can you really get done if you wait only a week between dosing sessions? There are teachings out there about spacing out the use of the substance and trying to optimize the work and growth you do in between.

It’s not just about taking a substance. The work that unfolds between sessions is thought to be really important in terms of how a substance may actually help people.”

This interview was edited for length and clarity.

Resources for Sitters

Q&A: Resources for Sitters

Sitters (or guides or facilitators) are people who support others while they’re taking psychedelics. This can be an intense experience for both the person using psychedelics and the person present with them. It’s important that both users and sitters are comfortable, have communicated beforehand about preferences and goals for the experience, and have created a plan in case something goes wrong or extra support is needed.

Vilmarie Narloch

Vilmarie Narloch

Vilmarie Narloch is director of drug education for Students for Sensible Drug Policy, where she oversees the peer-education program. She is also a clinical psychologist and director of the psychedelic therapy clinic Sana Healing Collective.


BCSP

“How should a sitter prepare for the experience?”

Vilmarie Narloch

“You have to start simply: Who is the person who has asked you to be a sitter for them? How well do you know them? Why are they considering this experience? Why did they reach out to you to be a sitter? You want to understand any sort of medical, behavioral, or psychological risks that might be present. You want to know what kind of experience this person is hoping to have, and have some knowledge and understanding about the particular substance they’re going to use: how it works in the body, contraindications regarding any medications the person might be on, and potential psychological risks.

Understand what the legal risks might be in your community: Is it decriminalized or legalized? Make sure you understand what the potential risks are if you get caught. Are you a therapist? If so, is your license on the line if you do something like this? What are your own boundaries around this kind of situation?

Make sure that, to the best of your ability, you and that person can ensure that whatever they take is in fact what they intend to take. If possible, check the drug through reagent testing from an organization like DanceSafe or Bunk Police or Dosetest. Understand how things like fasting may impact an experience. Understand where this experience is going to take place and how you can ensure safety as much as possible in the setting, including factors like whether they have roommates or could get to a hospital easily.

Also, what is their plan for integration afterwards? Will you be involved? Do they have a therapist to help integrate? Are they involved in a local psychedelic community where they can get some integration support?”


BCSP

“Does a sitter need to be alert for the whole experience or can they bring things to read, listen to, or watch?”

Vilmarie Narloch

“You absolutely have to be alert for the whole experience, which you should check in with yourself about. Are you ready to sit with that person for potentially eight hours? That can be exhausting. The energy in the space can shift really subtly at times, but for the person in the experience it may be very impactful. You want to be attuned to that person as much as possible, so it can be useful to have something with which to write down notes about what you’re observing of the other person, even if they’re just chill and relaxed. Being able to keep notes is also helpful for their integration later. Maybe there are a couple of people that are sitting for someone, which can be useful for safety, relationship balance, or so that you can step out if you need to use the restroom or take a break.”

“People may get anxious, emotional, or really scared. It’s important for the person that’s taking the drug to be prepared for those things themselves, but also to understand how you, as a sitter, are going to support them.”


BCSP

“What should a sitter do if someone is getting upset or scared during their trip?”

Vilmarie Narloch

“You should have a plan in place that you’ve developed with that person– a set of strategies that you’ve both agreed to in advance. People may get anxious, emotional, or really scared. It’s important for the person that’s taking the drug to be prepared for those things themselves, but also to understand how you, as a sitter, are going to support them.

That will look different for each individual. It can look like checking in with them verbally or providing a secure touch.

It’s really important to discuss consent for touch beforehand. People have lots of different feelings about whether or not they like to be touched and how. Particularly when you’re in a vulnerable state like this, it’s exceptionally important to make sure that you’ve had those conversations and agreements ahead of time. It’s never OK to increase the amount of touch in the moment, when they cannot consent to it because they’re under the influence of drugs.

The person having an experience can ask for the sitter to hold their hand, or establish beforehand that the sitter can offer that. Remind them of any sort of agreements that you’ve discussed, like breathing through it or mantras.”


BCSP

“When does a sitter need to call 911?”

Vilmarie Narloch

“That’s usually because of a biological issue. You would call 911 if they’re experiencing chest pain, having trouble breathing, or if their temperature goes up really high. It’s important to have some basics on hand to keep tabs on that, like water and maybe a thermometer. If they start to vomit a lot in a way that’s not just a psychedelic purge and you’re concerned that they may be dehydrated, that would be a time to call 911. Being out in the woods or out in nature is usually really appealing to folks, but having access to medical care is important as well.”


BCSP

“Can a sitter get in legal trouble for helping someone who has taken illegal drugs?”

Vilmarie Narloch

“It’s super important to know the laws and your rights in your state and municipality. Some places have good Samaritan or medical amnesty laws. Some don’t. The penalties will certainly be worse if that person dies, so the most important thing is to make sure that they get medical care as soon as possible.”


BCSP

“If the sitter calls 911, can that get the people they’re watching in trouble?”

Vilmarie Narloch

“That’s going to vary from state to state and sometimes municipality to municipality. In some places, some of these substances have been decriminalized or deprioritized. Some locales have medical amnesty policies. Some protections are only for the person that’s having the medical emergency and some include the person who is calling. It really is going to depend on where you are.”

This interview was edited for length and clarity.

The Importance of Culturally Attuned Care

Q&A: The Importance of Culturally Attuned Care

Because psychedelic experiences are highly variable, it’s important that care providers and participants understand how personal identity can affect the set, setting, and a feeling of safety during a psychedelic experience. This is especially true for people who identify with groups that may be traditionally underrepresented in clinical research, including BIPOC (Black people, Indigenous people, and people of color) and gender nonconforming people.

Pilar Hernandez-Wolfe

Pilar Hernandez-Wolfe

Pilar Hernandez-Wolfe is a licensed therapist with over 25 years of experience. She is also a professor and co-director of the Lewis and Clark Graduate School’s Entheogen Assisted Psychotherapy and Integration Training Series. Her work on decolonization and mental health integrates Indigenous and Western approaches to healing.


BCSP

“What should BIPOC consider when deciding whether to experience psychedelics in a clinical setting?”

Pilar Hernandez-Wolfe

“It’s not about being nice and gentle and having a nice office. People have to understand that BIPOC and gender nonconforming populations might carry with them trauma-based or other terrible reactions in medical settings. Clinical settings can also be off-putting because it’s an office and because there’s no community around.

If you have suffered abuses and misuses of power as a minority, that might be at play, too. There’s also the impact of intergenerational trauma, as well as trauma in that particular person’s life related to abuse. Sometimes people have learned to mistrust professionals, to mistrust police officers, to mistrust people who are authority figures, to mistrust people who have degrees. Sometimes that’s in the general ideology of a community, but oftentimes that is rooted in real experiences of abuse that people have suffered. That’s not just the abuse somebody suffers in their family, but all the other abuses that happen in somebody’s life just because of their social position.

To pursue a clinical experience with psychedelics, I would suggest finding a mental health professional that you know and trust, who is aware that a person might come in with traumatic experiences related to risk, race, class, gender, and sexual orientation.”


BCSP

“How can ethnicity, race, gender, or religion affect someone’s experience with psychedelics?”

Pilar Hernandez-Wolfe

“Gender, class, sexual orientation, and race shape our lives. There’s no way to get away from that. It’s going to play out differently in different social contexts, in different countries, in different geographies. For example, some people who identify as female have fears of going into a psychedelic experience because they’re afraid that men could harm them. If someone doesn’t feel safe, it doesn’t necessarily mean that the setting that the practitioner has put in place is unsafe — it could mean that the person has a higher level of caution. A clinician needs to pay attention to that.”


BCSP

“What should clinicians keep in mind about offering culturally attuned care?”

Pilar Hernandez-Wolfe

“It’s important to ask people: Do you feel comfortable with me — as a woman, as a man, as a nonbinary person — being the provider or the facilitator? Would it be better to have two people co-facilitate? 

There has to be a level of attunement to what people specifically bring into a space. It’s important to ask people: ‘What do you need? Is this safe enough for you? How do you feel with the people who are here? How do you feel with the people who are facilitating? Is anything a red flag for you?'”

“Providing culturally attuned care means that you are aware of what you need to do to build a relationship with that person.”


BCSP

“What is culturally attuned care and how can it help BIPOC clients before, during, and after a psychedelic experience?”

Pilar Hernandez-Wolfe

“From my perspective, culturally attuned care refers to a clinician’s ability to pay attention and relate to a client, both verbally and nonverbally, in a way that’s attentive to their social location. [A term developed by the scholar Kimberlé Crenshaw, “social location” describes how different aspects of identity including race, religion, gender, and sexual orientation intersect with social structures to position individuals in a community, determining who is oppressed, by whom, and how those shifts based on factors like culture, location, history. Although these positions are structurally determined, they also play out in interpersonal relationships.]

There is a level of violence that people from marginalized locations have to deal with in their everyday life that people who have privilege don’t have to deal with. We carry in our bodies a level of cumulative trauma that, in general, people who have privilege do not. When you enter a psychedelic space and you’re not aware of the implications of your privilege and you’re not conscious about your actions and the implications of your actions, you might end up hurting people in many different ways because you have not done your homework. It’s very easy for people of color to come into a psychedelic space and be exposed to microaggressions in a place where they are seeking healing because they have to deal with the ignorance of people who have privilege. This is also true for gender minorities and sexual minorities. 

Providing culturally attuned care means that you are aware of what you need to do to build a relationship with that person. Sometimes that means a more personal chat so they can feel you out and you can feel them. 

For me, for example, it’s very important to ask people about what experiences of marginalization they’ve suffered because of their social location.”


BCSP

“How can non-Indigenous people use traditional psychedelics like ayahuasca or peyote respectfully and without engaging in cultural appropriation?”

Pilar Hernandez-Wolfe

“The Native American Church has been very clear that they really want to protect peyote, and it should be for them. All of us who are not native to this land are basically benefiting from the genocide of the First Nations peoples, so I think that if Indigenous people say, “This is ours,” we have an obligation and responsibility to respect that and not touch it.

With yagé or ayahuasca I would say educate yourself first. Look at the geography. Learn about the people who traditionally use the substance, and what issues their communities face. Educate yourself about the impact of local governments on Indigenous peoples, the impact of capitalism on Indigenous peoples, and ways to help protect the land where these substances grow. Sometimes that means donating, sometimes it means joining a project, but there needs to be a way to circle back. Get away from this mindset of thinking of extraction and think instead about reciprocity. Many Indigenous peoples want to share, but it needs to be done in a respectful and responsible way. You have to think: What’s your impact when you go there? What can you do to give back?”

This interview was edited for length and clarity.

The Role of Place and Mindset

Q&A: The Role of Place and Mindset

There are many factors that can affect a psychedelic experience, and there’s no way to predict exactly what will happen. Being mindful of the physical and emotional environment and preparing to change those influences as the psychedelic experience unfolds are important ways to mitigate risk and manage challenging emotions that might come up.

Hanifa Nayo Washington

Hanifa Nayo Washington is an artist, healer, and activist. She is a cofounder and director of strategy at the Fireside Project, a psychedelic risk reduction organization that offers a peer support line, provides educational resources, and facilitates research into psychedelics.


BCSP

“What does it mean when people talk about ‘set and setting,’ and how can those things affect the experience of being on a psychedelic?”

Hanifa Nayo Washington

“Your set and setting will play a really important role in your psychedelic experience. ‘Set’ is about your inner world: What’s happening on the inside? How are you feeling? What are your personal beliefs, your history, your current emotional state?

‘Setting’ is what’s happening in the external world. Where are you? Where is your physical location—indoors or outdoors, at your home or a friend’s home? Are you at a show or a ceremony or camping? Are there a lot of people or few people there? Setting includes the art on the walls, the temperature in the room, the colors that might be around you, and whether you’re familiar with the people present. It’s important to understand that the things that impact your senses can have really large impacts on your psychedelic experience as well.”

“Often, when we are in challenging experiences, we can change what’s happening in our setting.”


BCSP

“How should users prepare ahead of time to have the desired experience?”

Hanifa Nayo Washington

“You can change or calibrate what an experience may look like depending on where you are and how safe that place makes you feel. Often, when we are in challenging experiences, we can change what’s happening in our setting. We could grab a blanket or move from outdoors to indoors. We could turn the music up or down. We could light a candle and change the scent.

If you want to cultivate a calm state of mind leading up to your journey, which I would suggest, you can use whichever practices feel best for you. That might look like time in nature, meditation, yoga, journaling, making art, or speaking to the people you trust and love.

Honestly, it’s about knowing the type of experience you want to have and also remembering that these medicines and substances are going to do what they’re going to do. It’s important to think about what you want to explore beforehand, so you can cultivate that inner set, but it’s also important to have an open mind. You can have a really clear intention, but then the medicine takes you somewhere very different.

When people have challenging experiences, it’s often because they had a vision of what they wanted to feel, but the medicine is taking them elsewhere, and they’re resistant to it. When we’re resisting, that’s when we’re often creating what we might call a ‘bad trip.’ Consider a practice of surrender within an experience, regardless of what your intention was. That practice of surrendering could really help to transform what one might consider bad into an experience of learning and growth.”


BCSP

“What kinds of equipment or resources should a user have when taking a psychedelic inside?”

Hanifa Nayo Washington

“I think that having tools with you and around you is wonderful, but also keep an open mind that the journey is not necessarily going to follow a set track. Music is a phenomenal tool and influence on our consciousness, our bodies, and our minds, with psychedelics and without them. So you may want to have a favorite playlist handy, although you don’t need it. There’s a lot of stuff that we just don’t need, because there’s so much that this is happening internally, and often we can get distracted by these other external things.

Intentions—and I recommend setting them—will influence what you might want to have around you. Music and art supplies are wonderful, depending on where you want to go. But again, there’s not a lot that you need to have beyond the basics.”


BCSP

“In most studies, psychedelics are administered inside. Is it safe to take psychedelics outside?”

Hanifa Nayo Washington

“Being outdoors and having a psychedelic experience has a different set of risk factors. I think that having someone who can trip sit and keep tabs is particularly important when you’re outdoors, because you might not be attentive to risks in the environment while you’re in an altered state of mind.”


BCSP

“What special equipment and resources should a user have outside?”

Hanifa Nayo Washington

“Use your common sense to prepare for being outside for a particularly extended amount of time. Depending on what substances you’re working with, a journey can be anywhere between four and twelve hours. So ask yourself some questions ahead of time: How long are you going to be outdoors? Do you intend to be outdoors all the time? 

Water is always a really important thing to have. Are there some yummy snacks that make you feel good that you might want to have, particularly things that don’t need preparation, like dried fruits or nuts? 

Then you want to think about being physically comfortable. You should be able to regulate your body temperature. Layer, layer, layer—I always preach that. That way, you can add a layer on or take a layer off to adjust your body temperature, which can fluctuate quite quickly when you’re having psychedelic experiences. 

Having a charged phone or way to communicate is also super important.”


BCSP

“What about going on a trip alone?”

Hanifa Nayo Washington

“I highly recommend never going solo on journeys. That’s not something I recommend at all. If you’re going to go solo, have a game plan for support. I’m a cofounder of Fireside Project, and I always want people to have the app on their phone so if they need to call or text, it’s right there. If you don’t want to do that, have somebody who knows that you are doing this and have them on speed dial.”


BCSP

“Can someone die from drinking too much or too little water while on MDMA?”

Hanifa Nayo Washington

“There is a very slim possibility that somebody could die from drinking too much water while on MDMA, but it’s more likely that someone would die or have a physically difficult time from not drinking enough water. That’s what we see more often, especially when we’re talking about outdoor raves and music events where people are on MDMA, dancing for hours and hours, and unaware of what’s happening with them internally.

If you’re going to be partaking of MDMA, prepare beforehand to drink some extra water. Throughout the day or before you ingest, drink a couple more glasses of water than you would normally. Then definitely have a water bottle on hand with you, or just know that there is access to water wherever you’re going.”

This interview was edited for length and clarity.

Setting Up and Managing Expectations

Q&A: Setting Up and Managing Expectations

Preparing for a psychedelic experience involves setting an intention. This process can include reflecting on why you’re interested in having a psychedelic experience and how you would like your experience to feel, but experts stress that the best way to prepare is to be open to the unexpected.

Rajan Grewal

Rajan Grewal

Rajan Grewal is a psychiatrist and a clinical assistant professor at the University of Arizona, where she is co-investigator on a clinical trial investigating the use of psilocybin for obsessive-compulsive disorder.


BCSP

“There are so many extravagant claims about the benefits of psychedelics. Will taking these substances make a user happier? Or more creative and productive?”

Rajan Grewal

“There’s evidence that psychedelics can help with some psychiatric conditions, like depression and PTSD. Those are things that we have some evidence for, in carefully designed contexts. Psychedelics are different from a lot of substances—the context is hugely important in determining the outcome, so we can’t really talk about what the psychedelics do without talking about for whom, in what context, in what situation and what the person is already dealing with at baseline. It’s very case-by-case, and each person needs to have an individual analysis comparing potential benefits and risks, when taking a psychedelic in a specific time and place and social context.”


BCSP

“How can someone manage their expectations about a psychedelic experience?”

Rajan Grewal

“It generally helps to go in without very specific expectations about what’s going to happen. That’s how we approach it even in research settings. People come in with a hope that this will be helpful, but ultimately we don’t know the outcome, and that’s what we’re studying. Part of the expectation for each session is to come in with openness to having a new experience that unfolds in a way that may not be predictable or expected. There’s a really wide range of different experiences that people can have, even in research settings. We control for a lot of variables, but we can’t control for them all.”


BCSP

“How can someone determine which drug will deliver the outcome they want?”

Rajan Grewal

“I don’t think it works quite that way. If it does, we don’t have the sophistication to know that yet. There’s a lot of variability in terms of how people respond, even dose-to-dose with the same exact substance. Maybe someday, with more data and knowledge, we’ll be able to predict that better. But with different doses and different contexts, we can’t guarantee an exact outcome to a specific drug.”

“People are in a lot of vulnerable situations in healthcare, like getting surgery or a physical exam. This is different, because it’s physical but also deeply psychological. Feeling trust and a sense of safety with the person becomes much more important.”


BCSP

“How can a user find the right therapist and avoid the wrong one?”

Rajan Grewal

“There’s currently no legal way in the U.S. to practice as a psychedelic therapist or guide outside of legal research settings, so we don’t have an infrastructure established to support people who want to have psychedelic experiences with a guide or therapist. (Ketamine is the exception.) But I can say that it would be necessary to be with someone who was trustworthy, reliable, emotionally supportive, and able to look out for the person’s safety.

All of the criteria that would apply in finding a therapist generally would also apply in finding a psychedelic therapist. I think you would also want someone who has particular knowledge about the substances themselves.

There’s also the issue of vulnerability in that context. People are in a lot of vulnerable situations in healthcare, like getting surgery or a physical exam. This is different, because it’s physical but also deeply psychological. Feeling trust and sense of safety with the person becomes much more important.”


BCSP

What questions should a user ask a potential therapist or guide about touch?

Rajan Grewal

“When someone comes to me in a research setting in preparation for having a potential psychedelic experience, we talk about touch before any drug is taken. That conversation is in the broader context of getting to know the person and what their past experiences have been. It means asking what comfort looks like to them and explicitly saying, “Is touch OK with you? If so, what kind of touch? Can you demonstrate what that would be?” It could be something like a hand on a hand or on their forearm or holding hands. It needs to be explicitly talked about and demonstrated and agreed upon: This is what comfort looks like to me, and this is a way that I feel comforted.”


BCSP

How should a user ensure they get what they want out of the experience?

Rajan Grewal

“The word ‘ensure’ is what makes this really hard to answer. There’s a lot that people can do to set themselves up for the best possible experience or the most comfortable experience for them, but I don’t think it’s really possible to ensure it. 

I think it’s probably more helpful to come to it with thoughtfulness, a spirit of openness and curiosity, and a desire to learn about themselves, rather than an expectation of having a mystical or transformative experience that’s going to cure them. In that case, preparation should include tempering expectations and having a support system, so that whatever happens during the experience can be processed afterwards.”

This interview was edited for length and clarity.

Understanding Your Risk Factors

Q&A: Understanding Your Risk Factors

In addition to purity, dose, intention, and environment, the unique physiology and psychology of each individual user affects how their body and brain react to a psychedelic substance. Research shows that some psychedelics can be used to treat mental health conditions, including anxiety and depression, but there’s also evidence that these substances can exacerbate certain psychiatric conditions and react badly with certain medications.

Sylver Quevedo

Sylver Quevedo

Sylver Quevedo has been a physician for over forty years, specializing in internal medicine, nephrology, and integrative medicine. He’s currently one of the principal investigators of the Phase 3 MDMA study at the San Francisco Insight and Integration Center and co-therapist at the Phase 3 site at UCSF. He’s a professor at UCSF and Stanford and a co-founder of the Polaris Insight Center, which offers ketamine-assisted therapy.


BCSP

Can psychedelics exacerbate pre-existing physical or psychological conditions?

Sylver Quevedo

“The short answer to the question is yes. That’s true for all drugs, even aspirin. The important question to ask is: What conditions are particularly high-risk for the use of psychedelics? 

Who should not use psychedelics casually, or without looking into this? Anybody with a history of mania, bipolar disorder, psychosis, or suicidal ideation. It’s not to say that psychedelic agents aren’t effective in depression—they are. But these are areas where we carefully assess people for risk. Anybody that has anything suggesting psychotic ideation or ongoing psychosis should not be doing psychedelics. 

There’s a soft contraindication of hypothyroidism for psychedelics, because hypothyroid states are stimulant states, and adding to that could put somebody into a clinical situation called hyperthyroid toxicosis.

There may be cardiovascular risk with psychedelics, too. In general, psychedelics raise cardiac output about 20 to 30 percent. I’m talking about a person who is at risk for heart failure or who couldn’t do moderate exercise for a half hour: people with cardiac arrhythmias, congestive heart failure, high blood pressure that’s not controlled. These would be relative contraindications, as opposed to more absolute complications from the situations I mentioned earlier.

Anyone who is at risk for cerebrovascular events, like strokes or aneurysms, is at an elevated risk because of the increased cardiac output and increased pulse. If someone elderly is reporting that they have vascular headaches associated with stroke symptoms, there’s definitely a question mark about whether they’d want to use psychedelics.”


BCSP

“How do psychedelics interact with other medications?”

Sylver Quevedo

“The big category to be concerned about is monoamine oxidase inhibitors, or MAO inhibitors, which are used as antidepressants in psychiatry. (Some common MAO inhibitors are Nardil, Emsam, Parnate, and Marplan.) They put people at risk for serotonin syndrome, a clinical syndrome characterized by a flooding of the nervous system with serotonin. It occurs with certain drug interactions and in anesthesia. It’s life-threatening and has been reported with psychedelics, although it’s probably very rare. But it is a real thing, and it can happen to people who are on drugs that increase serotonin levels and change with serotonin metabolism, such as MAO inhibitors and SSRIs. People can have seizures, anxiety, hypertension, and stroke, and they can die from it. 

Similarly, the major tranquilizers that are used for depression, the antipsychotics, and all of the major psychiatric drugs are probably not a good idea to have with psychedelics.”

“There’s a lot of information that suggests that the classic psychedelics are virtually not addictive, which is rather remarkable.”


BCSP

“Should someone stop taking selective serotonin reuptake inhibitors (SSRIs) before doing psychedelics?”

Sylver Quevedo

“Just stopping these drugs without medical supervision is risky, because people are on them for a reason. And if you self-taper, it can be problematic. For example, depression can get worse. Generally speaking, it takes at least a couple of weeks to taper off of SSRIs, and some of them have very long half lives.”


BCSP

“Can users become physically addicted to psychedelics?”

Sylver Quevedo

“There’s a lot of information that suggests that the classic psychedelics are virtually not addictive, which is rather remarkable. In terms of whether or not a specific psychedelic is addictive, I like to think about a few different categories. 

First is the tryptamines: LSD, psilocybin, and anything else with the tryptamine nucleus. Unlike traditionally habit-forming substances like nicotine, cocaine, and caffeine, which trigger dopamine receptors, tryptamines work directly on serotonin receptors. Although it’s possible to develop a tolerance for tryptamines, it’s unlikely for people to become physically dependent on them, because they don’t deliver the dopamine rush triggered by other chemicals.

Then there’s the phenethylamines: MDMA, mescaline, peyote. These drugs have a lot of different names in pharmacology, but they’re often referred to as attenuated amphetamines. They do work on dopamine receptors, although they do so more slowly. They raise cardiac output, heart rate, and blood pressure, and if the dosing is wrong, they can have the effect of amphetamines. We really don’t know if they’re addictive. I’ve been suspicious about MDMA because it’s an amphetamine and we absolutely know from methamphetamine that amphetamines can be addictive. I wonder about MDMA, although most of the reports are that it’s not addictive.

The third category is the ones that are atypical, like ketamine. It does have psychedelic properties and antidepressant properties, but it’s different. Ketamine does have a well-defined abuse pattern and use disorder. People get into bad relationships with it. Ironically, ketamine has also been studied for addiction, and it does seem to help. It can be used in addictive disorders, very similarly to the way that things like suboxone or other agents are used.”


BCSP

“Can users become psychologically dependent on psychedelics?”

Sylver Quevedo

“In the addiction world, that dichotomy is debated a lot. What can seem like a ‘physical addiction’ has psychological underpinnings or a psychological component. The short answer is that we don’t function as a mind or a body separately. They’re quite integrated—physical problems typically have a psychological component and vice versa. I have heard of people that are absolutely addicted to doing too much psilocybin or too much LSD, because they’re really addicted to the peak experience.”


BCSP

“What about treating addictions with psychedelics?”

Sylver Quevedo

“Psychedelics and addiction really need to be approached with special caution. Addiction is such a serious, difficult problem that even if people have an improvement short-term with psychedelics, it doesn’t necessarily mean that they’re in recovery. I usually tell people that in order to treat addiction, they have to actively become involved in a recovery program and be substance-free for at least some time — at least a month or more. To me, those things are best done in a structured or semi-structured program. You need psychosocial support, social connections, and therapy.”

This interview was edited for length and clarity.

Understanding the Substance

Q&A: Understanding the Substance

The effects of a psychedelic substance can vary considerably depending on a number of factors, including the user’s expectations, the amount taken, possible impurities, and the setting in which it’s taken. While fatally overdosing on a pure psychedelic is extremely rare, some substances may be adulterated. Someone taking an adulterated substance faces an increased risk of having a stronger and/or a different experience than they intended, and there are even reports of deaths attributed to adulterated psychedelics. Taking a very high dose of a psychedelic, no matter how pure, is associated with a higher likelihood that the experience will be upsetting, jarring, or traumatic. 

As a class, the classic psychedelics are regarded as having very low toxicity to the body’s organs. However, when under the influence of any psychedelic, there is a risk of behaving in ways that could harm oneself or others.

David Nichols

David E. Nichols

David E. Nichols began studying the structure of psychedelics and how they act in the brain in 1969. Since then, he has become a world-renowned expert in the medical chemistry of hallucinogens. He is an emeritus professor of pharmacology at Purdue University, a current researcher at the University of North Carolina-Chapel Hill, and the founder of the Heffter Research Institute, which promotes the scientific study of psilocybin and other classic psychedelics.


BCSP

“Can the strength of synthetic drugs vary from lab to lab?”

David E. Nichols

“In general, if they’re pure substances, you’d expect them to have a similar effect. Although if someone takes a certain dose of pure LSD on a certain day and takes the very same dose of LSD from the same batch two weeks later, the change in set and setting could change their response.”


BCSP

“If someone buys drugs illegally, how do they know that the substance isn’t adulterated?”

David E. Nichols

“Beyond knowing and trusting the source of recreational drugs, drug testing is useful. In most countries that practice harm reduction, including the United States, you can get pill-testing kits, which tell you if the substance is what it’s supposed to be or if there are some adulterants. The recreational scene has a lot of variability, because you don’t really know — for instance, there have been cases of drugs laced with fentanyl. Those experiences can be very disruptive, disorienting, and even fatal. For example, you rarely get pure MDMA on the black market — it can contain all kinds of other compounds.”

“In most countries that practice harm reduction, including the United States, you can get pill-testing kits, which tell you if the substance is what it’s supposed to be or if there are some adulterants.”


BCSP

“Are there best practices for how people can figure out dosage and the strength of a substance?”

David E. Nichols

“Start low and go slow. If you purchased some paper blotters that you believe to be LSD, for instance, you could cut one of those blotters into four pieces, take one, and say, ‘OK, I’m going to see what a fourth of one of these does.’ Then a week later, you could say, ‘OK, now I’m going to take half of one and see.’ You’d get to a point where you know the kind of experience you’re looking for. That’s harder with tablets, although you could buy tablet cutters in a pharmacy and cut tablets in half. Capsules of powder would be a little more difficult, but you could dump it out, draw it down into a line, and cut it in half or fourths.”

This interview was edited for length and clarity.

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