The Past and Present of Psychedelics and Therapy

In the 1950s and 1960s, when psychoanalysis was the predominant form of therapy in the United States and Europe, some practitioners began to experiment with adding psychedelics to talk therapy.

Over the course of multiple sessions, patients would take small to moderate doses of psychedelics during a session, a practice labeled “psycholytic” therapy by British psychiatrist Ronald Sandison. (The term combines the Greek word word for soul—psycho—and “lytic,” derived from the Greek for loosening or breakdown.) This therapy understood psychedelics as tools that could give patients greater access to their subconscious. Other models that emerged during this era included the psychedelytic approach, incorporating multiple low dose sessions that eventually culminated in a high dose session, or an initial high dose administration along with intermittent low dose sessions with psychotherapy to integrate material.

Simultaneously, other therapists practicing psychedelic therapy experimented with allowing patients to experience a psychedelic without talk therapy, using subsequent sessions to discuss their experience and its meaning. These experiments almost completely stopped when the Controlled Substances Act and the United Nations Convention on Psychotropic Substances took effect in 1971.

Current research combining psychedelics and therapy can vary depending on what issues participants and providers want to address. Smoking cessation studies, for example, have tested psilocybin sessions in structured settings in combination with cognitive behavioral therapy (CBT).

Generally, most psychedelic-assisted therapy is divided into three stages.

The Three Stages of Psychedelic-Assisted Therapy

Preparation: Patients work with a therapist or a team of people to help explore why they’re taking the psychedelic, what issues they hope to address, and to build trust and rapport. Therapists will also brief the patient on the physical and psychological effects they might experience and give them tips for navigating the possible terrains.

Medication: This is when patients will take the psychedelic under the supervision of their therapist or team of providers. Usually, a course of treatment includes one to three medication sessions separated by some weeks, each of which last from six to eight hours. The psychedelic is administered in a comfortable environment. Patients lie on a bed or couch and may use eyemasks and/or use headphones to listen to music. How facilitators manage this part of therapy varies. Some may sit with, observe, and listen to patients while maintaining a neutral, non-judgmental stance. Others may encourage patients to confront or move through difficult issues that may come up during the experience.

Integration: In subsequent non-drug sessions, therapists work with patients to unpack what they experienced, interpret what happened, and use those insights to restructure a patient’s narrative or understanding of their inner self, relationships, and circumstances. Often these integration sessions happen during the “afterglow” phase when patients may have increased brain plasticity, making them more open to new ways of thinking and acting.

Reports of Abuse

Patients under the influence of a psychedelic can be uniquely vulnerable to abuse. In addition to the power imbalance between the therapist and the patient, taking substances like MDMA can heighten sexual openness, affect judgement, and create greater intimacy in an already close relationship. Feelings of openness and trust can also make patients more susceptible to sexual pressure from their therapist. The American Psychological Association’s Ethics Code states that psychologists should not have any sexually intimate relationships with their current clients and discourages relationships with any of their clients even after their therapy has ended. 

At least since the 1980s, research protocols have specified that psychedelic-assisted therapy should be conducted with two session monitors, traditionally one male and one female (although these gender norms are now being challenged), to prevent sexual abuse. Still, there are numerous reports of sexual abuse by therapists, shaman, guides, and other providers in Canada, Germany, Ecuador, the United States, and elsewhere.

The MAPS Code of Ethics for MDMA-assisted therapy specifies that practitioners shouldn’t “engage in sexual intercourse, sexual contact, or sexual intimacy with a participant, or a participant’s spouse or partner, or immediate family member, during the therapeutic relationship or after termination.” But many psychedelic guides are not licensed therapists, making it difficult for any licensing body or professional group to enforce these rules.

You can read more about abuse in the psychedelics field here. The Understanding Risk section has more information about how to navigate touch and the importance of trust in  psychedelic-assisted therapy. More specifics on consent, ethical codes, and finding the right therapist are below.