Psychedelics – A tool for therapy?

18 July 2017

Classic psychedelics, such as LSD, psilocybin and DMT, lead to profound experiences, ego dissolution, feelings of compassion and connectedness to self, others and the universe, in addition to possessing hallucinogenic qualities. When used in conjunction with psychotherapy these substances may have powerful therapeutic effects for a range of conditions including treatment resistant depression, anxiety, trauma, bipolar, couple therapy, palliative care and addiction. Other psychedelics include ketamine, which has found to be effective for treating alcohol addiction and severe depression. MDMA, the active substance in ecstasy, has been used as a treatment for Post Traumatic Stress Disorder (PTSD).

Dr Ben Sessa, a child psychiatrist, is leading two MDMA studies in the UK. One in Cardiff uses brain imaging to look at the mechanism by which MDMA may work in treating PTSD, and one in Bristol with Dr David Nutt uses MDMA psychotherapy to enhance post detox type therapy for patients with alcohol dependence. This will be the world’s first 'MDMA assisted psychotherapy for alcoholism' study. Sessa explains that the current tools used in psychiatry are outdated, stating that ‘current relapse rates for detox for alcoholism are 90% over 3 years… this is not good enough after 100 years of modern psychiatry and we need a new way forward’. With mental illness estimated to cost £100 billion per year in the UK, a better treatment is needed.

Optimistically, research in the United States has shown highly effective results in treating PTSD with MDMA assisted therapy. Rick Doblin, founder of the Multidisciplinary Association of Psychedelic  Studies (MAPS), has recruited 107 treatment resistant PTSD patients that were treated in Israel, Canada, Switzerland and the United States (pending publication). One year after the last MDMA session, two thirds of the sample no longer met the DSM-5 criteria for PTSD and the rest had reduced symptoms. This study had an effect size of 0.9 – the therapy greatly reduced symptoms.

Dr Julie Holland, a psychiatrist in New York City and medical monitor for MDMA assisted therapy research in the United States, expressed that this research is ‘quantum leaps ahead of anything else for PTSD’. She explained that '0.9 is an effect size that you do not get in psychiatry’. The two FDA approved SSRI’s for PTSD, sertraline and paroxetine, have small to medium effect sizes (0.31-0.37 and 0.45-0.56 respectively), and require daily dosage.

Holland believes conventional SSRI’s are maintaining the disorder. They mask the symptoms so people stay on these medications longer than they were designed for, and suffer unpleasant side effects as a result. It is perhaps not surprising that many patients still meet diagnostic criteria for PTSD when using SSRI’s. MDMA assisted therapy targets the problem head on… ‘psychotherapy is painful, it is slow, it stops and starts, you feel like you are getting somewhere and then the patient disappears for a long time and become defended’. She continues ‘MDMA assisted therapy allows patients to be more open to the process, it is less painful. MDMA activates a catalyst to make the therapy go faster and more efficient to get to that malignant thing that needs to be taken out and examined in a more peaceful environment with more acceptance and more integration.’

Other research has looked in the therapeutic effects of psilocybin, the active substance in magic mushrooms. Robin Carhart-Harris and the research group at Imperial College London conducted the first investigation into the safety and efficacy of psilocybin as treatment for major depression, and found depressive symptoms had significantly reduced when measured at one week and at three months after last dose. The team are now conducting a randomised control trial using psilocybin assisted therapy for depression. The unpublished data has found a single dose of psilocybin reduced depression strongly after five weeks, and this was extremely significant at all time points. Leor Roseman, a PhD student in the team, is conducting research on the amygdala changes during the peak experience. It was found SSRI’s reduced amygdala activity to negative stimuli whereas psilocybin increased amygdala activity. Based on the neurological findings and subjective responses it seems that SSRI’s achieve their therapeutic effect by numbing and suppressing emotions. Comparatively, psilocybin confronts and works with the emotion and allows the person to be open and compassionate to oneself leading to lasting and transformative mental health improvements.

Researchers in the field are aware that these effects are not solely due to the drug, but are a supplementary tool to psychotherapy. Rick Doblin said ‘I realised psychedelics don’t work by themselves, I think that was one of the delusions of the 60’s… It's about the context, the integration, the preparation’. Roseman noted that there are many mediators that contribute to the therapy and more research is needed to elucidate what influences the process. An important component is the mindset and setting, thus a lot of preparation work occurs pre-treatment. What defines the right setting is less clear but the researchers have explored music, lighting, and support from therapist during treatment.

One of the most important subjective feelings documented both anecdotally and from the research has been connectedness. Rick Doblin explained the peak or mystical experience during psychedelic trips can lead to feelings of connection. For those experiencing severe depression they usually report feelings of disconnect from themselves and relationships with others. Researchers have pinned this as being one of the foundations of healing and can be extremely conducive to the therapeutic alliance. Dr Rosalind Watts interviewed participants with treatment resistant depression in the psilocybin study at six-month follow up to assess their perceptions of the use of psilocybin as treatment. Participants reported since the psilocybin dose they felt more acceptance rather than avoidance, reconnection to self and universe. Whilst previous treatments reinforced avoidance behaviours they reported that psilocybin induced emotional openness.

Research is still in its infancy, but it is suggestive that psychedelic assisted therapy can be more efficacious and powerful than SSRI’s and current talking therapies. To date these studies have focused on treatment resistant patients, so it is possible the effect size would be higher with normal variety PTSD and depression. Despite public concern over the safety of these substances there have been no adverse effects from any of the studies. This is partly due to ‘careful, methodical, thoughtful, [and] extremely evidenced based science’ (Ben Sessa), but also that the substances are ‘non toxic [and] non addictive’ (Bill Richards). There is an opportunity here to step away from daily dosing and help a whole array of disorders on levels not seen before that is accessible to all. This surge in research has come at a perfect time when the world could do with a bit more compassion. You cannot help but get caught up in the excitement.

- Rebecca Samuels is an Assistant Psychologist.

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See also our September 2014 edition on hallucinogens