Psychedelic assisted therapy, a clinical psychologist and trauma experts' views
As an adjunct to my Instagram post. Not specific clinical advice.
Disclaimer: This is general information only to help translate the clinical literature about psychedelic assisted therapy into a more accessible format. It is not clinical advice, and any specific advice should only be provided by a trained medical professional who has consulted directly with you.
Psychedelics are a new form of treatment for mental health disorders. At present, MDMA is being trialled for PTSD, and psilocybin (a hallucinogen) and ketamine (a dissociative anaesthetic) for treatment-resistant depression (TRD).
MDMA works by reducing inhibitory barriers and the fear response, thereby allowing people to reduce the instinctive fear and avoidance response, and thus talk about and process trauma. It’s provided in dosing days, with therapeutic support through the days and integration sessions after.
With psilocybin (for TRD) people can access psychedelic effects and experiences of awe and wonder, though this does not seem to be necessary for an anti-depressant effect. It’s a serotonin agonist (basically amplifying the impacts of serotonin). Ketamine helps people dissociate from their bodies and allows exploration of a range of threatening internal states (anger, fear, sadness) - it is glutamatergic in nature and does not work with the usual serotonin/norepinephrine/dopamine receptors.
Different protocols for TRD are being tested, including microdoses and larger dosing days accompanied by psychotherapy.
At present, psychedelic assisted therapy (PAT) is still nascent and experimental treatment in Australia. PAT has promise, but it is early days in terms of research. There’s a huge push to bring this into the market quickly, and it’s important to understand that this is partially economically driven with investors wanting to capitalise on people’s desperation for mental health cures and are thus pushing to bring these drugs to market. Link in comments for more info re the financial drivers (and Gina Rinehart is one of the investors *cough*).
This treatment is also very expensive ($30,000 +) at present. It has promise in terms of effectiveness, but like every mental health medication, will never be a magic cure for everyone.
MDMA therapy for PTSD
Let’s take a closer look at MDMA for PTSD through a psychological lens. Leaving aside the physiological impacts on the brain (not my field!), psychologically, MDMA for PTSD promises to be most useful for those who find themselves with strong anxiety and fear based responses and avoidance of trauma reminders.
MDMA assisted therapy necessitates trained psychological practitioners, and it seems important that any psychologist working with PTSD have first-line trauma treatment training (EMDR, CPT, TF-CBT) and either schema or IFS training for complex trauma (or some form of psychodynamic systems training).
At present, there is no standardisation around what type of trauma therapy training is required to facilitate MDMA assisted therapy.
PTSD has other symptom clusters and not everyone presents with avoidance. Some people can talk and think about the trauma freely without distress, but feel stuck in rumination about it, or have developed difficulties like problematic personality traits (e.g., dependence, avoidance). It’s unclear whether PAT will work well for people with these presentations, or when there are issues like blocking beliefs (‘this trauma is too big to ever move past’) or secondary gains (advantages which occur secondary to illness, such as access to care or pensions).
When trauma has generalised out significantly (i.e., changed how people think and feel on a global level), then longer-term psychotherapy is likely to be essential, even though PAT may accelerate the healing process for some.
A lot more research is needed, and most of this research will be funded by pharmacological companies who will want a certain outcome — this worries me.
Existing PTSD therapies
Remember that there are excellent psychological therapies already available for PTSD. Cognitive processing therapy and EMDR are two I use myself, and I have clients who have achieved symptom-free status (i.e., remission) without any form of medication.
These therapies are not really discussed, largely because a. slow therapy work to recover isn’t sexy, b. all the people prominent in this space (van der Kolk, Mate) are psychiatrists, not psychologists, and clearly have limited knowledge about psychological therapies, and c. these therapies don’t work for everyone (like any therapy, including PAT I would say) leaving some people very distressed.
A lot of PTSD is created by the social conditions around us (e.g., sending people into brutal wars) and I am curious about the impetus to traumatise people beyond repair and then treat them medically, and the financial nexus between the military industrial complex and the pharmacological industry (I realise I sound like a conspiracy theorist here, I promise I’m not, but it’s useful to learn to explore and question the paradigm).
Safety
It’s important to remember that PAT will be contraindicated for many for physical health reasons, and for those with family histories of certain mental health illnesses. If used incorrectly and without safeguards, it may also cause harmful impacts given these are potent psychoactive drugs.
People undergoing psychedelic assisted therapy are very vulnerable (e.g., fully immobilised on psilocybin) and it’s essential that this form of therapy is delivered in a safe, clinical environment with excellent oversight and no capacity for anything traumatic to occur (e.g., sexual touching). There’s been a history of this with psychedelic therapy, and this is abhorrent.
Safety must be paramount, and it’s important to carefully assess who is providing the therapy and check credentials.
For those with histories of serious mental illness, I’d recommend licensed programs led by medical professionals. Dosing yourself is not recommended at all (and remember these are schedule 8 drugs). Some questions to ask possible providers might be:
Some questions to ask might be:
Who is prescribing, do they have any complaints against them or any professional body regulation/disciplinary action underway?
Who will be providing the therapy, what are their qualifications?
What training will the therapists have with working with trauma? Are they trained in first-line trauma therapies? Which ones?
Has this clinic received any complaints?
What are your exclusion criteria for treatment? (there should be some, lack of any is a huge red flag)
How will you ensure my safety while I am under?
What support do you offer after dosing days?
If I want to withdraw from treatment, can I?
How will you manage any adverse effects I might have?
If you have PTSD, I’d strongly recommend trialling other established first-line treatments first, and if they don’t work, having really honest conversations with your providers about why, and what psychological factors might be preventing recovery.
If you decide on psychedelic assisted therapy, don’t assume it will be a magic cure-all or fix your life. Remember that you will still have some hard therapy work to do to understand and fix patterns.
References:
Financial investments: https://www.afr.com/companies/healthcare-and-fitness/would-you-pay-30-000-to-treat-your-depression-20230606-p5def2
Ketamine for TRD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6102096/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243034/
Psilocybin for TRD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10375870/#:~:text=Randomised%20controlled%20trials%20(RCTs)%20of,studies%20have%20included%20psychological%20support.
https://www.nature.com/articles/s41386-023-01648-7
MDMA for PTSD: https://www.nature.com/articles/s41591-023-02565-4
Caveat Emptor (Adverse experiences with PAT): https://www.abc.net.au/news/2022-09-07/psyched-up/14046384