An overview
Jean Schulthess Watt
Psychotherapie-Wissenschaft 14 (2) 2024 53–56
www.psychotherapie-wissenschaft.info
https://doi.org/10.30820/1664-9583-2024-2-53
Abstract: After a hiatus in research into the application of psychedelics in the treatment of psychological disorders, there has been a form of renaissance since 1990s with treatment results proving safe and effective particularly when combined with psychotherapy.
Keywords: history of psychedelics, psycholytic psychotherapy, neural plasticity, antidepressant, substance addiction, post-traumatic stress disorder
There are numerous developments in psychotherapy, much of which are the result of ongoing research into this field. The focus of this overview is to provide a historical context to the use of psychedelics, moving onto current research findings and potential applications with clients/patients in conjunction with psychotherapy. In this regard it is useful to review some of the main trends emerging of basic research as well as studies administering psychedelics to patients with certain diagnoses.
A brief overview of their application over time is given placing the field of psychedelic usage in perspective. Historically, naturally occurring psychedelics such as ayahuasca and psilocybin (magic mushrooms) have been used in religious rituals, for medicinal and healing purposes, especially in parts of south and central America dating back thousands of years. In Peru and in certain European countries ayahuasca ceremonies and retreats are still being organised offering the participants emotional healing.1
Since 1950s, research into the therapeutic use psychedelics has had a bumpy record. One of the most important psychedelic compound in terms of its application as an emotional healer, is Lysergic acid diethylamide (LSD). In 1938, when working for Sandoz, Hofmann synthesized lysergic acid diethylamide (LSD), which was based on psylocibin. His findings, based partly on his own personal experience with LSD, heralded a new era in the exploration of psychedelics and went on to influence a number of psychiatrists to experiment with LSD as a psychotropic medication treating a variety of psychiatric conditions.
Hofmann’s discovery generated serious and less serious research into LSD and other psychedelics. In the USA many of the studies were what is referred to as «psychedelic» (one or two high-dose sessions for «personality-transforming mystical experiences»; Passie et al., 2022). In Europe the research method tended to be what is referred to as «psycholytic»; repeated administration of small doses of a psychedelic (mainly LSD) in the context of ongoing inhouse or outpatient psychotherapy. The psychotherapy was predominantly psychoanalytically oriented. The differences in the psychological effects between the two methods are clearly outlined by Passie et al. (2022). A large single dose of a psychedelic is associated with long lasting effects on the personality of the individual in particular impacting on ego structures. There is, therefore, a greater risk involved in terms of the possibility of a psychotic-like effects. However, small doses of a psychedelic like LSD or psilocybin over a period of time maintains ego structures and can enhance the efficacy of psychotherapy.
Some early European studies, starting in 1930s, could be referred to as «sleeping beauties»: early useful research studies that somehow have been forgotten or at least only remembered by a few, in particular, the work done primarily by psychiatrists who in many cases were also psychoanalysts.
On such person was the German psychiatrist and psychoanalyst; Hanscarl Leuner, who, starting in 1950s, experimented with many of the psychedelics (LSD, Mescaline, Psilocybin, etc.) on neurotic patients and normal persons in a structured hospital environment as part of psychotherapeutic interventions. He and his team administered small doses of mainly LSD over a period of time as a useful adjunct to ongoing psychotherapy. His detailed records of over 1.000 LSD sessions, are useful, however, one needs to remember that his interpretations were in terms of psychoanalytic theory at the time. Writers, such as Passie et al. (2022) are of the view that his research hasn’t achieved the attention it deserves perhaps, as his publications are only available in German. Leuner went on to found the European Medical Society for Psycholytic Therapy (EPT) in 1964, which was disbanded in 1971, and in 1985, he established the European Collegium for Consciousness Studies (ECBS).
In the United States of America (USA) there was serious and less serious research. According to Nutt (2024) there were thousands of studies in 1950s producing evidence that psychedelics were effective in treating certain disorders. In 1960s Leary, who was affiliated with Harvard center for Personality Research, conducted a number of research projects however their research was often not scientifically rigorous. He and colleague Richard Alpert (alias Ram Dass) left the academic world and became gurus of the new counter culture. Fears were expressed in many countries concerning the uncontrolled use of LSD and psilocybin and so in 1970 psychedelics were classified as Schedule 1 drugs and it became very difficult to obtain permission to conduct research.
However certainly since the 1990s there has been large numbers of studies into the application of psychedelics as a potential adjunct to psychotherapy in treating psychological distress. In most cases special permission from the authorities was required for these research projects. This surge in numbers of publications has been referred to by some, as a renaissance in this field.
Since the 2000s there has been a loosening of legislative controls allowing more world-wide research into the use of psychedelics in the treatment of a variety of psychological conditions including Post Traumatic Stress Disorder (PTSD), addictions, existential anxiety in individuals suffering from a terminal illness, and treatment resistant depression (Agrawal et al., 2023). In Switzerland in 1985, the Schweizerische Ärztegesellschaft für Psycholytische Therapie (SAEPT) was formed and obtained special exemption from the Schweizerischen Bundesamt für Gesundheit (BAG) to experiment with substances such as MDMA and LSD in psychiatric practices and clinical settings.
This trend is also reflected in increased funding for research in this area, for example by the European Unition (EU) (Greenacre, 2024), and the United States of America Food and Drug Administration (FDA) has providing draft guidelines on psychedelic drug trials showing that it is an area to be monitored and observed (Brooks, 2023).
The question can be asked about what the relevance of psychotropic medication for the psychotherapist? As with other psychotropic medication, the psychotherapist needs to know what medication the patient/client is taking and liaise with the psychiatrist concerning the impact and efficacy when necessary.
Certain psychedelics could form a valuable addition to psychiatric medication as they are not addictive and side effects are minimal (Passie et al., 2022). Nutt (2024, p. 11) predicts that they will «become widely approved in western medicine». There are two categories of psychotropic drugs currently prescribed by psychiatrists where psychedelics could provide a beneficial alternative or adjunct.
Patients suffering from treatment resistant depression appear to benefit from psychedelics like ayahuasca (Palhano-Fontes et al., 2018). Similar results have been obtained with trials using psilocybin (Daws et al., 2022). Unlike the current SSRIs where the effects include emotional blunting, psychedelics encourage emotional release (Carhart-Harris & Goodwin, 2017). With a debate about the general efficacy of SSRIs, issues around the discontinuation syndrome and other unpleasant side effects of SSRIs, it might prove useful having workable alternatives. Ketamine has also been used as part of the treatment of severely depressed individuals. It is primarily a sedative, very different in its effect on the brain than the other psychedelics with mild hallucinogenic effects and is referred to as a psychedelic-related compound (Grieco et al., 2022). The administration of ketamine can already be legally prescribed.
In the treatment of PTSD and anxiety conditions, it would be advantageous to have something other than benzodiazepines as these anxiolytics as they lose their effectiveness over time and are highly addictive.
It is unlikely that psychedelics will provide an alternative or adjunct to Neuroleptics. Generally researchers have selected out individuals who have been diagnosed with a personality disorder or a history of psychosis or have a family member with a history of schizophrenia. In a review of naturalistic studies Marrocu et al. (2024) pointed out that individuals diagnosed with personality disorders in particular borderline personality disorders are more likely to have a «bad trip» or later problems related to the psychedelic administration. Many researchers are of the view that in the case of schizophrenia taking psychedelics could loosen already weak ego structures further.
With administration of psychedelics, those working in this field speak of the importance of the «set» and the «setting». The set refers to the mindset of the individual before the drug is administered. The person needs to be prepared emotionally and cognitively for the psychedelic experience. The role of the support person preparing the individual is crucial as it has been demonstrated to influence whether the individual has a so-called good or bad trip (ibid.).
The patient, or person taking part in a research study needs to be prepared for the experience by someone specifically trained for this role, as particularly in cases where there is a single administration of a large dose of a psychedelic, it is not without risk – Marrocu et al. (2024) suggest that the therapeutic support clearly influences the chances of positive outcomes. In fact Grieco et al. (2022) mention that the support prior and during the drug administration may contribute to why the psychedelic is more effective than conventional anti-depressants administered without psychotherapy. In addition, support person needs to communicate safety and security (Passie et al., 2022).
The qualities required of the support person preparing the person for the intake of psychedelics, are similar to the qualities that have been demonstrated to be present in effective psychotherapists, leading to greater therapeutic success, namely; empathy, positive regard, genuineness and communicating hope (Miller & Moyes, 2021; Truax et al., 1966). As psychedelics are what has been labelled as «agitative» (Marrocu et al., 2024), it means that the person taking the psychedelic medication is likely to feel unsettled for some time and needs support not only during the administration, but subsequently as well. There are clear roles for psychotherapists in this regard. In many cases a psychotherapist is involved in the preparation, the dosing session and the follow-up integration of the experience. A good example of this is provided in the Yale Manual for Psilocybin-Assisted Therapy of Depression (Guss et al., 2020).
The setting is the environment in which the drug administration is made and needs to be conducive for relaxation and introspection.
In continental Europe the psycholytic (small doses over a period of time) administration of psychedelics in conjunction with psychotherapy is already taking place in certain hospitals and clinics and is likely in time, to become a standard treatment option. This presents exciting opportunities for psychotherapists. This will be discussed in more detail later when looking at the neurological effects of psychedelics.
Perhaps the major potential of psychedelics for psychotherapy is due to the fact that the compounds encourage greater emotional release (Carhart-Harris & Goodwin, 2017) and what has been referred to as «openness» and extraversion (Grieco et al., 2022).
At a neurological level this is reflected in greater neuroplasticity: «the growth of new neuronal processes» (Nutt, 2024, p. 15). These processes include an increase in the dendrite branching and increased synaptic connections (Grieco et al., 2022). Even small doses of a psychedelic administered over the period of weeks leads to greater neural connectivity, flexibility and brain neural integration.
What is particularly relevant is that similar neural changes are also brought about by psychotherapy and are indicators of greater emotional wellbeing (Cozolino, 2014). «From the perspective of neuroscience, psychotherapy can be understood as a particular kind of enriched environment designed to enhance the growth of neurons and the integration of neural networks» (Cozolino, 2002, p. 27).
This has profound implications for psychotherapy. It could facilitate the therapeutic process through greater emotional openness and flexibility.
«The increase in physiological connectivity was mirrored by subjective reports of the patients who often commented that after the psychedelic, their thoughts were more flexible and adaptable and the negative thought loops so characteristic of depression were gone or less dominant» (Nutt, 2024, p. 14).
Most researchers in the field are generally of the view that psycholytic treatment is not a stand-alone process for treating certain emotional disorders but needs to be accompanied by psychotherapy (Marrocu et al., 2024). In addition, psycholytic therapy may contribute to the effectiveness of psychotherapy and also perhaps shorten the therapy time (Carhart-Harris & Goodwin, 2017).
Since the 2000s there has been a loosening of legislative controls allowing more world-wide research into the use of psychedelics in the treatment of a variety of psychological conditions including Post Traumatic Stress Disorder (PTSD), addictions, existential anxiety in individuals suffering from a terminal illness, and treatment resistant depression (Agrawal et al., 2023).
According to Nutt (2024, p. 14) the use of psychedelics has been done over a lengthy period of time for a variety of reasons from understanding the mind, a providing a sense of mystical connection to the world and to psychological healing and that the ban on their use from 1970s was the «worst censorship of clinical treatment in history». Other writers express the view that it is a matter of time before psychedelics form an integral part of psychotherapy for certain individuals. As an example: «In my opinion, if science is allowed to progress without the kind of political interference that has hindered it in the past, psilocybin (PwPS) with psychological support, will become an early option in the treatment of depression» (Carhart-Harris & Goodwin, 2017, p. 4). The safety and effectiveness of these compounds administered under controlled conditions as part of ongoing therapy has been repeatedly demonstrated. With serious research being conducted which is delivering positive results, it is only a matter of time before that psychedelics form a part of psychiatric and psychotherapeutic treatment.
The challenge will be how best to integrate their administration in order to optimise the efficacy of psychotherapy.
In conclusion we are on the brink of a new era regarding the therapeutic application of psychedelics and in this regard it would be timeous to take stock of the research findings to date, the current use of psychedelics in hospital settings and how to integrate low dosage psycholytic therapy with psychotherapy in psychotherapy outside of a hospital/clinic setting.
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Brooks, M. (2023, 23.06.). FDA Issues Draft Guidelines on Psychedelic Drug Trials. Medscape. https://www.medscape.com/viewarticle/993624
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Greenacre, M. (2024). EU launches landmark €6.5M study on use of psychedelics to treat mental disorders. https://sciencebusiness.net/news/drug-development/eu-launches-landmark-eu65m-study-use-psychedelics-treat-mental-disorders
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L’uso degli psichedelici come coadiuvante della psicoterapia
Una panoramica
Riassunto: Dopo una pausa nella ricerca sull’applicazione degli psichedelici nel trattamento dei disturbi psicologici, a partire dagli anni ’90 si è assistito a una forma di rinascita, con risultati di trattamento che si sono dimostrati sicuri ed efficaci, in particolare se associati alla psicoterapia.
Parole chiave: storia degli psichedelici, psicoterapia psicolitica, plasticità neurale, antidepressivi, dipendenza da sostanze, disturbo post-traumatico da stress
Biographical note
Jean Schulthess Watt, MA, is a clinical Psychologist and state approved Swiss Psychotherapist. She is holding a Diploma in Analytical Psychology of the C. G. Jung Institute. She is working in private practice and teaching at the C. G. Jung Institute in Küsnacht/Zürich.
Contact
Jean Schulthess Watt
Herrenweg 16 CH-5734 Reinach
jean.watt@bluewin.ch