Often associated with a party scene, substances like ketamine and MDMA are taking on another life.
For decades, the establishment’s message on drugs was clear and simple: Just say no. In recent years, however, the psychiatric and psychological communities have become increasingly interested in the potential of certain kinds of drugs — psychedelics, to be exact — to aid in treatments and therapies for various mental health disorders.
Again and again, clinical trials have come up with encouraging data indicating the efficacy of psychedelics in the treatment of conditions like PTSD, depression, anxiety, and even, curiously, substance abuse. Oregon was the first state to legalize supervised psilocybin (commonly known as “magic mushroom”) sessions led by trained, licensed facilitators. In November, Colorado followed suit. The question now is not so much if psychedelics are entering the mainstream, but when.
They’re coming sooner rather than later
Some substances still need to be legalized before they’re available for use in treatment, but there are signs that this may occur sooner rather than later. In May, a letter from the U.S. Department of Health and Human Services indicated that the Biden administration is considering implementing a task force to explore the implications of approving MDMA for the treatment of PTSD and psilocybin for the treatment of depression. Given the proliferation of mental health issues among the population, demand for new treatments is likely to be high.
The therapeutic community is already readying itself. The CIIS Center for Psychedelic Therapies and Research in California offers accredited training for a certificate in psychedelic-assisted therapies and research. This involves 150 hours of instruction and in-person training in research design; the scientific, historic, and multi-cultural underpinnings of psychedelics’ efficacy in treatment; guiding people from diverse backgrounds through alternate states of consciousness; as well as relevant aspects of neuroscience, neuropharmacology, and psychopharmacology. Students include licensed therapists, physicians, and psychiatrists, and ordained or commissioned clergy and chaplains are also eligible to study.
Practitioners are increasingly excited about them
For many practitioners, the prospect of a new avenue of research and treatment represents an exciting upheaval of their preconceived ideas.
“I became interested in psychedelics and their use in therapy in 2017 after following the work of Gabor Maté, a Canadian author and psychotherapist known for his work on trauma and addiction,” says Rebecca Hendrix, a licensed psychotherapist based in New York City who is trained to provide MDMA-assisted psychotherapy once it’s legal and currently offers ketamine-assisted psychotherapy.
“I saw [Maté] speak whenever he came to NYC, and noticed him mentioning ayahuasca as helpful for healing, so I became more open to these medicines,” she explains. “I grew up in Nancy Reagan’s ‘just say no to drugs’ era, so it was a big leap. I took a course called Psychedelics 101/102 for Clinicians offered by Fluence, and I was hooked because they provided a new way to work with mental suffering.”
Hendrix explains that psychedelics are thought to connect us to our body’s innate knowledge to heal itself, an idea that resonated with her training in spiritual psychology at the University of Santa Monica. There, she was taught that we all have the inner resources to deal with whatever comes up that gets in the way of our healing, but that those resources may get “blocked” by the effects of trauma, and the ways we learn to cope and interact with the outside world.
“Skilled therapists can give tools and help us express the feelings we stored away and to parts of ourselves we deemed not good enough or unlovable,” she says. “Psychedelics tend to be an accelerator for this process.”
There’s still stigma — but medics are increasingly positive
The therapeutic potential of psychedelics is still a point of contention within the psychotherapy community. Some practitioners continue to lump them together with cocaine and heroin, see them as a slippery slope into more dangerous drugs, or dismiss clinical findings that have demonstrated their efficacy. That being said, respected figures like the author Michael Pollan, presenter of the Netflix docuseries How To Change Your Mind, have used them effectively and are promoting a fresher perspective. Increasingly, the outlook is favorable.
“It’s always difficult to get a consensus among medical experts, especially about a topic such as psychedelic medication, which is freighted with all sorts of cultural and legal significance,” says Houston-based psychiatrist Dr. Faisal Tai. “Having said that, I feel that the majority of doctors now believe that these psychedelics, which have long existed on the periphery of society, offer real treatment options for millions of Americans who struggle with mental illness.”
MDMA could be a useful option to treat PTSD
A recent study found that talking therapy using MDMA was twice as effective in treating PTSD versus talk therapy alone. For Dr. Tai, this makes sense. “We already know that the most effective treatment for anxiety and depression is often a combination of talk therapy or cognitive-behavioral therapy and antidepressant medications,” he says.
Thanks to its use as a party drug, MDMA comes with some major baggage attached — but this is looking increasingly surmountable.
“MDMA is nearing its legalization process after many years of successful clinical trials proving that it’s efficacy for PTSD when used therapeutically,” Hendrix says. “Once the medicines are legalized, the stigma will lessen and psychotherapists and then their patients will become more open to their use.”
Hendrix says that because it decreases the fear response and increases serotonin and dopamine, as well as comforting, prosocial feelings, MDMA is thought to help patients “delve deeper” into the roots of past trauma, without experiencing the overwhelming fear or mistrust that can so often stop them in their tracks. But as is true of any medication, psychedelics may not be suitable for everyone, and once legalized, they’re subject to the same checks and balances as other pharmaceutical drugs.
So, how does the prescription process work?
“As a psychotherapist, I do not prescribe ketamine, so I refer my clients to a prescriber to be assessed for treatment,” explains Hendrix. “If clients are approved for treatment, they’re prescribed ketamine for their diagnosis.” Some diagnoses and the use of some medications are contraindicated, and Hendrix uses her judgment when making referrals.
“When I am thinking of presenting KAP (ketamine-assisted psychotherapy) to a client who may benefit, I consider whether the client might be open to this type of alternative medicine,” says Hendrix. “Set and setting” — that’s your mindset and the setting where you take the medicine — “is a high indicator of effective treatment, so it’s important that the client is open. I also consider where the client is in their personal work, as KAP can provide insights and awarenesses that can be overwhelming. It’s important to make sure the client has access to ongoing support from their medical team and from friends and family.”
As with all drugs used to treat mental health conditions, psychedelics like ketamine may have varying success depending on the patient. In some cases, the neuroplasticity (the brain’s ability to form connections) that the use of ketamine promotes can help patients to get unstuck when they’ve felt trapped in the same pattern of thinking for a long time. This can allow them to become open to seeing things differently.
“A therapist I know worked with a client who had anxiety from growing up with a narcissistic parent who constantly criticized her,” says Hendrix. “She was able to do a lot of work in therapy, but was still plagued by bouts of anxiety. She tried ketamine-assisted psychotherapy, and in one of her journeys [supervised sessions using ketamine], she saw her younger self being unfairly reprimanded by her mother. She was able to have compassion for her mother — who herself grew up without a mother — and her little girl. She then went through a visual process of rebuilding her little girl physically and mentally. After a few of these journeys, she felt capable to choose not to go down the pathway of anxiety in her day-to-day life.”
It’s crucial that a trained and capable therapist is able to work effectively with the client after their journey. During this time, the therapist and client can make use of the neuroplastic window and the anxiety and depression-reducing effects of the treatment to deploy therapeutic methods while they might be most effective. It’s important to note that even under the best of circumstances, not everyone can expect a revelatory — or revolutionary — experience. The relaxation experienced during sessions doesn’t always translate to everyday life, and it may take some people more sessions than others to see a shift in their wider thinking.
What about the risk of addiction?
Another key consideration, unsurprisingly, is a patient’s susceptibility to addiction. A person who has a history of addiction shouldn’t be able to access unlimited amounts of ketamine, as it has addictive properties. But again, there are subtleties at play that are often ignored by those who out-and-out dismiss the use of psychedelics.
“Because psychedelic experiences can be psychologically challenging, rarely does one wake up the next day saying they want to do it again, as they might with cocaine or heroin,” says Hendrix. “So they are not known to be addictive. Ketamine is the exception due to its dissociative qualities.”
Under the right circumstances — and with the correct use of the drugs — there is, remarkably, evidence that some psychedelics may even be useful for treating addiction.
“The largest study of its kind, which was undertaken by the Langone Center for Psychedelic Medicine at NYU earlier this year, showed that psilocybin, along with psychotherapy, assists patients with alcoholism,” says Dr. Tai. “It really does offer hope for many people suffering from alcoholism. Over 80 percent of those who were given the psychedelic treatment had drastically reduced their drinking eight months after the study started, compared to just over 50 percent in the group given a placebo.”
Are there any challenges yet to be addressed?
It’s vital that patients have an effective support network available while they’re in treatment or carrying out therapeutic work with the use of psychedelics. Navigating the aftermath of a particularly challenging psychedelic experience alone can aggravate existing symptoms and lead to panic attacks. Patients need integrated support, both within the healthcare system and in their personal lives, to cope with the thoughts and feelings that the therapeutic use of psychedelics can bring up.
Of course, all this is assuming that patients can get access to psychedelic treatments in the first place. For many, the cost alone will prove prohibitive.
“A unique challenge is their cost and access,” explains Hendrix. “Even when and if they are legalized, they will be expensive. If legalized via the medical model, the average cost of treatment — if done similarly to the protocol used in the clinical trials — might be at least $11,537 per person. Insurance companies are not used to paying such a large sum upfront for mental health care, so it will take a while for them to come on board. This will mean that initially, the treatment is available only to those who can afford to pay out of pocket.”
