The Limitations of Psychedelic Therapy
Psychedelic therapy involves a psychedelic session in which an individual takes a psychedelic while being supervised by one or more trained therapists. It is the combination of the psychedelic experience with psychotherapy. However, psychedelic therapy, as traditionally understood, is not simply therapy with the adjunct of a psychedelic; it specifically involves a single high dose of the psychedelic in question, with the aim of inducing a mystical or transcendent experience, based on the principle that such an experience is where the most potential therapeutic value lies. The psychiatrists Humphry Osmond and Abram Hoffer developed this form of therapy in the 1950s.
Psychedelic therapy is distinct from psycholytic therapy, another form of psychedelic-assisted therapy developed in the 50s by the British psychiatrist Ronald Sandison. Psycholytic therapy involves administering small to medium doses of a psychedelic at regular intervals, such as every one or two weeks, during therapy. Since the ego is more intact during psycholytic therapy, such psychedelic sessions tend to involve mainly introspection, whereas psychedelic therapy may also feature introspection, but often leads to ego dissolution experiences too.
Based on the more intense nature of psychedelic therapy, there is not much dialogue between the patient and the therapist during the session itself — the role of the therapist is more to offer emotional support, empathy, and a hand to hold if necessary. Dialogue does take place, however, in sessions before and after the experience, with prior sessions being about preparation and intention-setting and post-journey sessions giving the patient space to make sense of their experience in a constructive manner. This contrasts with psycholytic therapy, whereby dialogue will take place as the psychedelic experience is occurring, which is more manageable since the ego is more intact. Sandison believed that small doses of LSD would help to enhance the process of psychoanalysis.
Psychedelic therapy additionally contrasts with the practice of microdosing, whereby an individual takes tiny, sub-perceptual doses of a psychedelic in order to achieve a mental health benefit. Microdosing is done even more regularly than psycholytic therapy, usually every few days, and may be relied upon as an antidepressant, for example, in the long-term.
The Benefits of Psychedelic Therapy
Most of the current research being carried out on psychedelic-assisted therapy today is centred on psychedelic therapy, so high doses of psychedelics. And the results of such research are incredibly favourable. Psilocybin-assisted therapy, for instance, achieves rapid and long-lasting antidepressant effects in patients suffering from treatment-resistant depression. The benefits and implications of psychedelic therapy cannot be extolled and celebrated enough. Clinical depression affects 300 million people worldwide and a large proportion of sufferers are treatment-resistant, meaning that traditional forms of treatment (such as psychotherapy and psychiatric medication) do not provide substantial relief or help the depression to go into remission.
The advantages of psychedelic therapy over traditional treatments are manifold. Having one or two psychedelic sessions is less time-consuming and cheaper than regular psychotherapy and medicating; there are none of the unpleasant side-effects associated with antidepressant medication; and psychedelics appear to work by connecting patients to their emotions, rather than numbing their feelings in the way that many people find antidepressants do. However, I do also believe that media coverage of psychedelic therapy and public opinion sometimes reinforce the view that such therapy is a cure for a given mental illness, a panacea, or that the advantages of psychedelic therapy mean it should make psychiatric medication and non-psychedelic therapy obsolete. There are some important limitations of psychedelic therapy that are worth underlining, which indicate that psychedelics are often not the ‘miracle cure’ we think them to be.
Depression Often Returns After Psychedelic Therapy
It should firstly be noted that the antidepressant effects of psychedelics, while quick, substantial, and long-lasting, do eventually seem to dissipate. This is a point many media outlets did not mention in their reporting of such studies, for example, using headlines such as ‘Magic mushrooms can ‘reset’ depressed brain’. Rosalind Watts, a psychiatrist involved in the Imperial College London studies on psilocybin and depression, has emphasised that such sensational reporting has contributed to some misconceptions about what psychedelics are able to achieve (the notion of a ‘brain reset’ was based on subjective descriptions from a few participants in the 2017 Imperial study on psilocybin).
The brain is, in some sense, ‘reset’ after a high dose of psilocybin, in that the brain becomes more highly connected and flexible, which researchers believe helps to unstick people from rigid depressive states, such as ruminative thinking. But it would be misleading to claim that such a reset is permanent, that the brain becomes impervious to the kind of depression the patient has long experienced. As Watts is keen to emphasise, psychedelic therapy is not this simple; the relationship between psilocybin-assisted therapy and recovery from depression is, in her eyes, more of a journey — and it’s mistaken to think of psychedelic therapy as offering a singular, epiphanous experience that flushes out depression for good.
In the 2017 Imperial study, 19 participants with major depression were recruited and were given two doses of psilocybin, a low dose (10mg) and a high dose (25mg). Of those 19, no patients received additional treatments within the 5 weeks following their high dose experience. Their depression had abated sufficiently that further treatment was not considered necessary. Nine patients had significant reductions in depression at week 5, while six experienced remissions at week 5.
Six patients began taking antidepressants after 3 months, five received some form of psychotherapy shortly before or after 3 months, and five obtained psilocybin (not under guidance from the research team) between 3 and 6 months following the session. Out of the nine patients who experienced reduced depression at week 5, three relapsed into depression at the 6-month mark. Here we can see a mixed picture. It’s important to first of all note that psilocybin offered all these patients a degree of relief that they have never experienced before. On the other hand, we can see that depression returned for most patients, motivating them to seek therapeutic relief, in the form of medication, therapy, or psychedelics again.
Why Do Mental Health Issues Return Following Psychedelic Therapy?
There are multiple reasons we can offer as to why depression returns for many patients enrolled in psychedelic therapy studies. The first reason relates to the limitations of the studies themselves. As a case in point, in the 2017 Imperial study, there was limited integration and follow-up support. It may be that to really sustain the therapeutic benefits of psychedelic therapy, much more psychological support is needed following the high dose experience. To maintain mental health benefits, it might also be necessary for a patient to have follow-up psilocybin sessions, perhaps even on a regular basis. Some patients might be comfortable — or at least more comfortable compared to other options — with having continual psychedelic therapy in their lifetime. Yet for others, the prospect of having multiple or many mystical experiences is quite daunting. Let’s not forget how powerful and emotionally taxing a mystical experience can be. One such experience may be enough for one person, regardless of whether depression returns.
Another key point raised by Watts is that for those participants who sustained relief from depression longer than others, they also made positive changes to their life. So in a way, the psychedelic experience, in increasing more flexibility and perspective shifts, helped to catalyse the process of other changes that entailed mental health benefits, such as changing jobs, for example. But not all participants experienced such major life shifts; many — and many people who undergo psychedelic therapy in general — will return to their habitual lifestyle that may have been contributing to their depression in the first place. This may include a stressful or unfulfilling career or unhealthy habits, such as excessive drinking, social isolation, toxic relationships, poor sleeping habits, poor nutrition, and so on. Indeed, psychedelic therapy is not a magic bullet.
But it would also be unfair to say that it is all up to the individual to improve on themselves following their psychedelic experience and that those who do not recover from depression, say, have only themselves to blame — they simply did not integrate well enough. This attitude can come across as judgemental and over-assign responsibility to the individual, all while ignoring the very real social roots of mental illness. This includes the prevalent difficulty in pursuing meaningful work and work-life balance, the normalcy of precarious and toxic work, economic deprivation, inequality, the feeling of isolation living in a congested city, and all kinds of discrimination that impact mental health, such as sexism and racism. It’s no wonder, then, that so many people become anxious and depressed again after psychedelic therapy. When people return to the same sociopolitical conditions that carry a risk of depression and anxiety, we should be unsurprised if mental health issues return. I’m reminded here of a passage from Aldous Huxley’s Brave New World:
The real hopeless victims of mental illness are to be found among those who appear to be most normal. “Many of them are normal because they are so well adjusted to our mode of existence, because their human voice has been silenced so early in their lives, that they do not even struggle or suffer or develop symptoms as the neurotic does.” They are normal not in what may be called the absolute sense of the word; they are normal only in relation to a profoundly abnormal society. Their perfect adjustment to that abnormal society is a measure of their mental sickness. These millions of abnormally normal people, living without fuss in a society to which, if they were fully human beings, they ought not to be adjusted.
In this vein, returning to depression following a ‘brain reset’ from psychedelic therapy seems totally normal and expected. Unfortunately, psychedelics cannot — nor should we want them to — make people well-adjusted to a profoundly sick society. Perhaps they can make one less affected by external sociopolitical factors (in the way that meditation can), but for many people, psychedelics are not anaesthetising substances — they do not accommodate us to a dysfunctional society, like the drug soma does in Huxley’s dystopian vision of society in Brave New World.
Psychedelic therapy — much like other forms of therapy and medication — cannot remove the sociopolitical issues that wear us down on a daily basis. It might be unfair to characterise this as a glaring limitation of psychedelic therapy since this limitation applies essentially to all forms of therapy. However, I think it’s crucial to highlight this, as many people assume that psychedelic therapy can ‘fix’ mental health issues by working on the individual alone, whereas social, economic, and political solutions are also needed. We cannot expect a psychedelically reset individual to somehow maintain their positive outlook and mood in the face of anti-human forces.
A further limitation of psychedelic therapy is that alleviation of suffering depends on the quality of the experience, in that the therapeutic benefits only emerge — or emerge in the way a patient would prefer — if the experience is of a specific character, such as low in dysphoria and high in measures of mystical features (e.g. egolessness, transcending time and space, bliss, sacredness, a feeling of unity or oneness, and so on). Subsequent research demonstrated that emotional breakthroughs and attaining psychological insight during the acute psychedelic experience are other key components of positive psychological outcomes. Now, while psychedelics can reliably result in mystical experiences, emotional breakthroughs, and psychological insights, they don’t happen for everyone, so such patients might need to keep repeating psychedelic sessions until they have the experience they are looking for. This might not appeal to a lot of patients. Moreover, patients who do not have a positive mystical experience may have a dysphoric or unpleasant experience that puts them off from trying to journey again.
There may undoubtedly be ways to better increase the chances of patients having the acute psychedelic experience strongly associated with positive mental health outcomes, but currently, one limitation of psychedelic therapy is that the element linked to positive mental health is by no means guaranteed. This may be unsatisfying for some patients to place their hopes on and disappointing if their experience does not turn out to be mystical and transformative.
Then there’s also the problem that a significant proportion of patients with depression might not be willing to try psychedelic therapy, although interestingly, a 2017 YouGov survey found that the majority of Americans would be willing to try psychedelic therapy if it was shown to be safe and effective. The stigma and law surrounding psychedelics no doubt influences many people’s hesitancy about these compounds, so claiming that this is a limitation of psychedelic therapy would be misplaced; it is more a limitation of cultural attitudes. Nevertheless, leaving psychedelic stigma and the law aside for a moment, I believe it is also unlikely to expect a large portion of patients to opt for psychedelic therapy, that is, to take a high dose of a psychedelic, in the knowledge of the intense experiences that can occur, be they positive or negative (ego-dissolution, while perhaps ultimately beneficial, can still be an unattractive prospect for many people).
There might be a tendency to judge such patients as not willing to dive into their shadow and do the important work of exploring the uncomfortable aspects of the self that need to be explored. But this only further stigmatises patients and it is unrealistic to expect patients with no experience with psychedelics to dive headfirst into a high dose experience. There is nothing wrong with advocating the need to work with disturbing psychological material, while wanting to avoid doing so during an intense psychedelic experience.
Another limitation of psychedelic therapy, then, is the fact that it might not attract a significant number of patients. After all, if you take the point of view of someone with a mental illness, the condition may involve a high degree of emotional pain and distress, and so the risk of experiencing states of anxiety, paranoia, panic, dysphoria, or terror may be especially off-putting. This limitation of psychedelic therapy, though, can be remedied to a large degree by combating the stigma surrounding psychedelics, promoting understanding of the psychedelic experience, and improving psychedelic therapy (which is in its early stages and already showing impressive results).
Psychedelics Should Not Be Used to Treat All Mental Health Conditions
A final and vitally important to raise in regards to the limitations of psychedelic therapy is that psychedelics do not help to treat all mental health conditions; in fact, psychedelics can exacerbate many mental health conditions or trigger the onset of them (in the case of the latter, the condition would be latent, meaning the individual is already predisposed to it. There is no evidence that psychedelics can cause a psychiatric condition in and of themselves.) Most experts in the field agree that conditions such as a psychotic disorder (e.g. schizophrenia), bipolar disorder, borderline personality disorder, or mania generally do not mix well with psychedelics. Those with a family or personal history of such conditions or a genetic propensity towards them are advised to avoid psychedelics and are screened out of any studies on psychedelic therapy.
Research conducted by Robin Carhart-Harris from Imperial has demonstrated that psychedelics lead to a more ‘chaotic’ brain. In formulating what he calls the ‘entropic brain hypothesis’, Carhart-Harris proposes that psychedelics achieve many of their effects — including their therapeutic ones — by causing more entropy (chaos, disorder, or unpredictability) in the brain. In other words, the brain becomes more flexible under the influence of psychedelics. Areas of the brain that don’t normally communicate with each other start to do exactly that. But what we can see in the brain of a depressed patient is a brain characterised by rigid, fixed brain activity (brain activity that is of low entropy, to use Carhart-Harris’ terminology). Such rigidity is associated with certain conscious states, in the repetitive, negative thinking — the rumination — that a depressive constantly wrestles with.
By encouraging a higher degree of entropy, psychedelics can help free the depressed patient from their neural prison and the evidence illustrates that such a patient will have more psychological flexibility for months following their psychedelic therapy, which predicts positive mental health outcomes. Yet in the case of psychotic disorders, to take an example, Carhart-Harris underlines that these disorders are marked by high brain entropy at the outset, that their symptoms follow from entropy that is too high, and so to amp this with psychedelics would be very unwise; it would go against harm reduction. For this reason, there are some mental health conditions in which a specific form of psychotherapy or medication would likely be much more helpful and restorative than psychedelic therapy would be.
As we can see, there are various limitations of psychedelic therapy that should help us resist the temptation to hail psychedelics as a universal and permanent solution to mental health issues. Watts’ point is worth reiterating: psychedelic therapy needs to be part of a much broader journey of personal growth.