The big issue: Is working with psychedelics the future of therapy?
Therapy Today, July/August 2023

With demand for treatment relentlessly rising, mental health services, including therapy, are under greater pressure than ever before. With no sign of services increasing capacity or getting enough additional funding, the search for new and more effective treatments is becoming increasingly urgent. And the pressures that we know lead to mental breakdown are getting worse.

While Government spending on mental health services is going up, it isn’t keeping pace with the demand, according to the British Medical Association (BMA) – in fact, it’s going up less than overall NHS expenditure. The 2019 NHS long-term plan pledged to create a new, ring-fenced investment fund worth at least £2.3 billion a year by 2023/24 to increase access to mental health care. But the BMA has estimated that the amount needs to be doubled to £5.2 billion if services are to meet demand.¹

Meanwhile, there are millions of long-term users of antidepressants – drugs that are only really intended as short-term measures. According to the latest population estimates from the 2021 census, published on 28 June 2022, 14.7% of the population in England and Wales – 56.5 million people – received at least one prescription item for antidepressant drugs in 2021/22.²

And talking therapies too have never been more in demand. The annual BACP Mindometer survey, released in September 2022, found that 70% of therapists reported a rise in referrals from first-timers to therapy over the previous two years, and 50% said the demand for therapy was over capacity – up 11% on the previous year. Moreover, 88% of those who said mental health had declined in the previous year cited cost of living concerns as a reason for this, and 57% reported an increase in clients presenting with relationship issues.³

The unavoidable fact is that medical science has failed us dismally when it comes to tackling mental ill health. Antidepressants, hailed as a miracle cure-all in the early days of Prozac, have proved useful for some; a cure for a few, and at best a palliative for most. And, despite NHS Talking Therapies making access to counselling more widely available (in England), people are stuck on waiting lists or paying for private treatment because they can’t get help when they need it.

Psychedelic healthcare

According to the growing number of its advocates, psychedelic-assisted psychotherapy offers the answer to tackling some of the most intractable and disabling mental health conditions – and we are getting much closer to this becoming an accepted and legal option in the UK.

In May MPs debated the legalisation of psilocybin, the psychoactive, naturally occurring substance found in ‘magic mushrooms’, for prescription for treating mental disorders. Crispin Blunt MP of the Conservative Drug Policy Reform Group argued that psilocybin should be recategorised as a Schedule 2 drug rather than Schedule 1, meaning doctors could prescribe it. The UK was ‘trailing behind Australia, Canada and the United States’, he said, with the Home Office imposing ‘disadvantage on our prestigious universities and research companies’. Labour’s Charlotte Nichols made a powerful personal plea, summarising a key argument, based on her own experience of PTSD. ‘PTSD is a condition that I can expect to live alongside potentially indefinitely, and that can only ever be managed,’ she told MPs. ‘It is a condition that has, for me, proved almost fatal. I manage it through a combination of a powerful serotonin and norepinephrine reuptake inhibitor, Venlafaxine, taken daily, benzodiazepines taken for sleep and to stave off a dissociative episode if I am triggered by something, and regular therapy, following an almost month long period as a psychiatric inpatient, having been sectioned in 2021 for my own safety. It feels like institutional cruelty to condemn us to our misery when there are proven safe and effective treatment options if only the Government would let us access them.’

Although psychedelic-assisted therapy is perhaps the most exciting emerging field for the talking therapies professions, the irony is the research currently progressing towards getting psychedelic substances off the Class A and B lists of banned drugs and into the international psychiatric formularies is built on discoveries made in the 1960s, before the 1973 Misuse of Drugs Act halted research into their medical use. Research into medical applications of the hallucinogenic drug LSD flourished from the early 1950s to mid-1960s. It was prescribed as treatment to more than 40,000 patients, reportedly including film star Cary Grant, who was given LSD with psychotherapy to treat depression.

Today, researchers worldwide are steadily progressing psychedelic substances including psilocybin and MDMA, both Class A drugs, and ketamine (Class B) through the stages of trials required to get approval for mental health usage from the drug licensing authorities in the US, Europe and Australasia. This would open up a psychedelic healthcare industry predicted to be worth £8.4 billion by 2028.⁴ Widespread access to psychedelic therapy has been predicted to become a reality within three to five years.⁵

There is confidence that MDMA will be licensed by late 2024 in the US, with UK licensing possible not long after. Australia has licensed MDMA and psilocybin for medical use from 1 July this year, although the rest of the world is a couple of years behind with psilocybin. Ketamine is already licensed in the US and Europe and can be prescribed off-licence in the UK to treat depression.

Licensing by the UK’s Medicines and Healthcare products Regulatory Agency does not, of course, mean automatic roll-out into the NHS for UK citizens – NICE still has to give its approval, but those with money to pay for private treatment will be able to take advantage of what is seen by its advocates to offer the holy grail of ‘cure’.

Says David Nutt, Professor of neuropsychopharmacology and Director of the Neuropsychopharmacology Unit in the Division of Brain Sciences at Imperial College London, and a long-time advocate for the use of psychedelics in mental health treatment: ‘In five years’ time the picture will be very different. But getting it on the NHS is going to be much more challenging. The NHS offers nothing to people with severe depression. That’s partly why I now work part-time in the private sector, having worked in the NHS all my life. It’s the only way we can provide access to a therapy for which there is now a massive amount of evidence of effectiveness and that isn’t available to most people.’

It is, he says, immoral: ‘We have 40,000 patient accounts saying these drugs are helpful and safe. So why would you deny people access to something that works simply because a drug company hasn’t come along and done a trial that NICE can approve?’ That moral and ethical imperative is, he says, precisely why Australia has accelerated licensing MDMA and psilocybin for psychiatric use.

Changing the brain

So how do psychedelics work and why are they considered by a growing number of researchers to be so effective? The effects are, of course, different for the different kinds of psychedelic, but essentially they work by changing the way the brain works. ‘They change the way you think,’ says Nutt. ‘Everyone who treats people with severe disorders knows it’s very hard for them to think differently. Psychedelics allow people to get out of thought loops, whether they are thought oops of guilt and depression, or ruminations about trauma, or PTSD flashbacks, or cravings in addiction. And they stay disrupted for up to three weeks and that’s a huge opportunity to think differently. It can be very hard for some people to even engage with psychotherapy because they can’t detach themselves from their inner thoughts and listen to what the therapist is saying and think about it. After psychedelics, they can do that.’

Psychiatrist Ben Sessa has been involved in psychedelic research since the early 2000s, drawn to it by his personal interest in 1960s psychedelic culture and its literature and music. He runs his own psychedelics research enterprise in Bristol and has been involved in the Imperial College research led by David Nutt.

The treatment is 50-50 drug and psychotherapy, he says. ‘I have always been equally interested in psychopharmacology and psychotherapy. Generally they are regarded as completely distinct, but in psychedelic therapy we bring them together, which in my experience is much more effective than either alone. Because you are boosting the psychotherapy effect with the drug.

'It’s the antithesis of current prescribing in psychiatry,’ he continues. ‘Current prescribing is what we call maintenance prescribing – you take this antidepressant day in, day out for weeks, months, decades, which has the effect of masking symptoms but not treating the core illness. That’s how most psychiatric drugs work; they just hold back the symptoms. Whereas cure, if we use the “cure” word, which strangely we don’t in psychiatry, only comes from psychotherapy. It only comes from tackling the trauma that is the root cause of most chronic unrelenting mental disorders. So you only need to take the psychedelic one, two or three times, depending on which type, or a maximum of four or five with ketamine, plus the psychotherapy, and then you are better, and you’ll have done the psychotherapeutic work and resolved the issues that were holding you back and you don’t need a daily antidepressant just to stand still. So, although people look at psychedelics therapy as a new drug, it’s really a drug to come off other drugs.’

The effects of the drugs are very different. Sessa has been able legally to try these substances himself as a research participant, as is common in this field: ‘MDMA is a very easy compound, very warm, gentle. It suppresses the fear instinct and allows you to engage with your own feelings and the feelings of others. It boosts the sense of empathy and theory of mind, which allows you to see situations from different positions far better than you would in ordinary waking consciousness, so you can see how helpful this is for trauma-based disorders. It allows you to recall and process fearful memories that you would normally suppress or avoid. With MDMA you have this capacity to go there, look at and think and talk about these things.

‘Psilocybin is very similar to LSD – a classic psychedelic, which is much more of an ego-dissolution disturbance experience, in which your usual boundaries of self and the world around you are dissolved. It is a mystical, spiritual experience that is highly profound and can be an amplification of all emotions and feelings. So while MDMA is much more of a 100% positive experience – you can’t really have a bad trip – psilocybin can emphasise difficult emotions as well as positive ones. That doesn’t mean it can’t be used clinically; it just means it requires a lot of care and attention and support while you are having the experience because the profound breakthroughs you can make with psilocybin are really life-changing. When you think most chronic mental disorders are about a sense of stuckness – depression, anxiety, addictions particularly – what psilocybin does is wipe the slate clean in terms of those narratives of failure and self-blame. You get to actually question those narratives and contemplate other ways of looking at things.

‘Ketamine is different again. It’s licensed as an anaesthetic and has been licensed as such since the 1970s. It’s very safe, and at lower sub-anaesthetic doses it has a psychedelic effect. Like psilocybin, it’s outside of normal waking consciousness in a very profound way. But it’s hard to describe. One of the hallmarks of the psychedelic experience is this word “ineffable” – it cannot be described in words. What I sometimes say to my patients is, imagine if you were walking through the woods one day and you found an object on the ground and it was a new colour – one you’d never seen before. You know it’s a new colour, but you have no frame of reference to describe it. It’s unique, and it can be very shocking and fear-inducing.’

Integration

Given the potential for these drugs to create such powerful experiences, specialised and skilled therapy is essential for all psychedelics. What Nutt and others are researching is very specifically psychedelic-assisted psychotherapy: ‘What is truly remarkable is your brain is more flexible after taking a psychedelic, and particularly when your brain is very inflexible, as it can be in depression or OCD or anorexia. When we take an image of the brain, you can see all the multiple different circuits chugging away all the time, but they often chug away in silos. After psychedelics, the integration of the networks is greater. Patients tell us, “It’s like I’ve defragged my hard drive. I’m no longer locked into a thought process I know is wrong. I can see other sides to the argument”.’

The quality of the therapeutic relationship and feeling safe, held and contained are vital in psychedelic-assisted psychotherapy, says Sessa: ‘The skill of the therapist is to hold this space and provide that solid, containing space for the patient to undergo this intensive experience. But it will be challenging as well. It is not a walk in the park. As RD Laing said, you have to break down to break through, and just because it’s difficult and challenging, it doesn’t mean it isn’t the right thing to do.

Practising psychotherapist and retired medical doctor James Hawkins borrows a metaphor from Imperial College researchers. It’s like a ski slope, he says; the patient is the skier locked into the ruts they’ve made skiing down the slope of life repeatedly using the same path. The psychedelics are like a deep fall of snow – the tracks are covered and the pristine slope is opened up to the skier to go any way they choose. And here is where the therapist comes in; they become the mountain guide, preparing the patient for the experience and then helping them find their own, new ways across the fresh terrain, while keeping them safe and emotionally contained.

In the MDMA-assisted studies, typically the patient has 12 standard psychotherapy sessions and three MDMA-assisted sessions, which last around four to five hours. The standard pattern is one MDMA session after every three psychotherapy sessions, with a final three therapy sessions to finish off after the last MDMA session. With psilocybin and classic psychedelics, on the whole the therapist is less active. With MDMA, there is more active psychotherapy going on as the quality of the ‘trip’ itself is less intense. ‘One of the predictors of good outcomes is how the person goes into the experience, how safe they feel with the therapist, if they have a really good therapeutic alliance where they are prepared to go deep,’ says Hawkins.

In the session itself, it will vary a lot with the experience and the person: ‘In some, there’s not much conversation goes on – the experience is more internal to the client – but in others, they may know their abusive history is a key factor and they have asked the therapist to go digging deeper in the cellar,’ says Hawkins.

But what if the NHS, having adopted the treatment, decides to do what it generally does and try to cut costs? Surely the psychotherapy – the most costly part because of the time and the human involvement – will go? Sessa doesn’t believe so. ‘It wouldn’t work as well. This is essentially psychotherapy. It’s the quality of the psychotherapy that makes it work. And the economic argument is very strong. There is,’ he points out, ‘nothing more expensive than the untreated psychiatric patient.’

Risks

While the risk of overdose and addiction in psychedelics is known to be low, no drug is without risk, and we know that recreational use of psychedelics can trigger a psychotic or manic episode in people with a family history of schizophrenia or bipolar disorder. Psilocybin and ketamine raise blood pressure and heart rate, so those with heart conditions, high blood pressure and arrhythmias are advised not to take them. Given that the drugs change brain activity, there may also be a risk they trigger a seizure in someone with epilepsy, or increase pressure in people who have suffered a traumatic brain injury. So if these drugs are to become widely used in a therapeutic context, it’s vital that practitioners – including therapists – have access to the right training, to ensure they are used safely and effectively.

The Australian Government is taking this very seriously and has set up a new training programme for doctors, nurses, pharmacists and psychotherapists in using psychedelics to treat mental disorders, which Ben Sessa is leaving the UK in July to lead. In the UK, independent providers are filling the gap. Hawkins is the founder of the Psychedelic Health Professionals Network, an independent body that offers education and training in the use of psychedelics across the range of health applications. These include legal psilocybin retreats in the Netherlands, online workshops in orientation and integration, and a one-year postgraduate certificate in psychedelic facilitation, which starts this September. Exeter University used the sixth biennial international multidisciplinary ‘Breaking Convention’ conference on psychedelic consciousness in April this year to announce the launch of an online postgraduate certificate in psychedelic studies, based in its faculty of Health and Life Sciences. The event, hosted by the university, featured more than 200 presenters.

‘In terms of therapist training, we need to get our skates on,’ says Hawkins. ‘Even if we have no interest as therapists in using this ourselves, we are going to have clients asking for our opinion, and just as I would expect a decent therapist to know about the potential of exercise for depression, I would expect them to know about psychedelic-assisted therapy for depression. It’s a part of being competent.’

Liz Lilley, a BACP registered humanistic psychotherapist and breathwork facilitator, is involved in training people to facilitate psychedelic-assisted therapy. Breathwork can induce similar mental states to a psychedelic journey, she says, and can be used to simulate the effects. ‘With psychedelic substances we can have a very somatic experience and perception changes, and repressed content may come up. It can be very powerful and profound, and if not supported thoroughly it could be very unsettling. In clinical research we may be working over a short period of time with people, so if the therapist has a similar lived experience of what people might go through, they may feel more confident and could be better prepared to support them. That is the idea of using breathwork as a preparation tool.’

Given that it’s early days in terms of research, and that many of the studies carried out so far have been small-scale, it seems wise to retain an element of scepticism about some of the more evangelical-sounding claims about psychedelics – if the sorry tale of global antidepressant overuse has taught us anything, it’s that no drug offers a miracle cure when it comes to mental ill health. But it’s also important that the psychotherapy professions don’t miss the boat in getting involved in what increasingly looks like an important emerging treatment. ‘Clients come to this from extremely vulnerable places, and it feels important that qualified therapists support this process,’ Lilley says. She would like to see the talking therapies professional bodies showing more active, supportive interest in the field.

Scientific knowledge about the brain’s plasticity and the ability to demonstrate that through imaging confirms what psychotherapists have long known – that the brain can change how it works, whether through physical interventions or through changing thought patterns. Psychedelics are one of the oldest and the newest known ways of creating that change. And, unlike so many other mental health innovations, at the moment, psychedelics are designed to work with therapy, rather than replace it. But to ensure it is a safe and effective treatment, we are going to need highly skilled psychotherapists with specialist training to deliver the treatment. The question is, are the counselling and psychotherapy professions in a position to react quick enough to get on board?