Psychedelics, entactogens and Psychotherapy
Psychedelics are known since remote times in human history, as well as their ability to alter conscience and promote transcendent states that might influence the subject’s core beliefs. However, it is only in the recent years that they have been contemplated as potential agents to improve or aid psychotherapy, specifically in the field of positive psychology. This is an atypical chapter since the evidence in this regard is still scarce, so our aim will be to point towards future opportunities and possibilities and the actual state of the art, rather than to inform about current indications to use them in our psychotherapy practice.
Brief historic overview
`Some plants (mainly mushrooms and cactuses) have been widely used by indigenous cultures because of their psychedelic properties, that is, their ability to induce expanded states of consciousness and spiritual experiences. MDMA, was first discovered as a chemical molecule in the early 1900s, but its properties were not well understood, and it was rapidly forgotten. In 1956, LSD was discovered, and it was then when psychedelics began to attract the scientific community, thus giving birth to several trials aiming to alleviate depression and existential suffering.
In 1970, Alexander Shulgin rediscovered MDMA and introduced it for the first time as an aid for couple counselling, as he found it induced a “loved up” state that allowed to break down barriers between couples. However, because it had originally been patented in Germany in 1914 and was no longer patentable, no pharmaceutical company was interested in sponsoring an investigation, so the drug didn’t gather their attention, and no proper Randomised Control Trials were conducted.
In 1980, in California at least, drugs that were not yet available commercially could be used within a physician’s practice if they were manufactured by the physician or by a pharmacist. Hence, several experiences introducing them in clinical psychotherapy settings took place. The primary purpose of the project was to assist the subjects in achieving their particular and varied goals for having the sessions, rather than treating any specific disorder. However, due to the psychedelics link to the hippie culture, and their theoretical secondary effects and life-hazardous risks in the event of an overdose, several active principles, including MDMA, were soon banned in most countries, and only a few researchers were given permission to conduct experiments with such substances. No wonder that, in the meantime, the interest developed by artists grew exponentially.
Mithoefer was the first researcher, in 2011, to design a particular set of psychotherapy plan for an specific disorder, involving psychedelics, aiming to alleviate PTSD symptoms. It consisted in two sessions of MDMA-assisted psychotherapy with a two-week gap between them. He found it helped recovering 83% of resistant-PTSD subjects that were involved in his research.
Several other studies have also been conducted in order to show potential positive effects in healthy individuals and in treating several other disorders such us substance use
When we talk about “entactogens”, we generally refer to MDMA and some other similar substances, such as 2-CB. The term refers to their ability to enhance sensorial perception, although their mechanism of action is also similar to the substances that fall under the term of “psychedelics” (for the purpose of this chapter, we will only talk about LSD, psylocibin and ayahuasca, being the most studied principles of this category). Both psychedelics and entactogens act via serotoninergic receptors, although there are subtle differences that account for their variable effects. Regarding this, and according to studies related to brain imaging that show a global increased brain activity (aside from several concrete effects in different regions that exceed the purpose of this chapter), the “entropic brain hypothesis” has been posed, that accounts for a dissolution of the ego and enhancement of the default mode network that allows new learning and circuits to be made, and may help in lessen other feedback loops that are involved in PTSD, or substance use disorders.
Psychedelics and entactogens have mostly been studied from the field of positive psychology: “the scientific study of positive human functioning and flourishing on multiple levels that include the biological, personal, relational, institutional, cultural and global dimension of life”. In doing so, there are several properties that have been discovered to be induced by these drugs and that might help in several psychotherapy settings. These properties have been found to last up to 12 months after a single use, and have been correlated with alterations in neural activation in brain imaging studies:
POSITIVE EFFECTS OF PSYCHEDELICS AND ENTACTOGENS
Emotional processing and prosocial attitudes
- Enhancements in personality trait openness
- Self reported mood and self steem may be less influenced by social rejection
- Increased self-compassion and decrease self-criticism
- Long term increases in openness
Social cognition, empathy and prosocial behaviour
- Enhancement in perceived closeness to others, prosocial behavior, and explicit and implicit emotional empathy
- Enhance prosocial feelings and interpersonal empathy in social interactions
- Increased reactivity to happy facial expressions and reduced amygdala reactivity to angry faces
Cognitive flexibility, creativity and problem solving
- Ayahuasca - cognitive flexibility through divergent thinking
- Psilocybyn - creativity, and aesthetic appreciation
*Acute influence of psychedelics might worsen performance, but those effects might be facilitated through repeated exposure
No effects have been found so far
Changes in life-values and orientation
- Spirituality and concern for others
- Less appreciation of financial prosperity
- Reductions in addictive behaviours
- Increased pro-environmental behaviours
No effects have been found so far
Psychospiritual experiences and mindfulness-related capabilities
- Increased level of self-trascendence
- Increased mindfulness-related capabilities (self-compassion and decentering)
- Mystical experiences that correlate with changes in well-being and life satisfaction
No effects have been found so far
Main uses (indications)
As mentioned above, there is not enough evidence yet that allows a safe use of psychedelics in any particular environment. However, there have already been various studies and experiences that show their potential usefulness in positive psychology, aiding the individual to achieve his or her particular goals for wellness and happiness. Also, taking into account their mechanism of action, they have been used by some professionals, rather off-label or for researching purposes, mainly for the following cases:
Mindfulness – psychedelics ability to potentiate decentering (capacity to observe thoughts and emotions as transitory mental events without being trapped by them) and self-compassion might help in progression through a mindfulness therapy
PTSD – MDMA has successfully been proven to help in PTSD therapy; it has been theorized that it might be due to its effect in reducing amygdala activation to negative stimuli. However, the externa validity of the data available is still relatively small
Substance abuse disorder – some researches have been made regarding LSD and alcohol use disorder with promising results. Also, it has been shown in several studies that psychedelics and entactogens lessen addictive behaviour. Ayahuasca is currently being used in several clinics in different countries to aid in use disorder therapies. However, no strong evidence has been gathered so far.
Only PTSD therapy involving MDMA has shown relatively strong efficacy; the difficulties surrounding the research of psychedelics because of legal and safety issues have slowed down the advance of knowledge on this matter. Because of that, no psychedelic or entactogen substance is indicated to be used in any specific therapeutic environment. However, as it is mentioned above, their properties and action mechanisms show a huge potential that needs to be addressed and investigated.
Challenges, safety, ethical issues
Psychedelics and entactogens are substances that have been widely used for decades in the recreational and ceremonial field; however, they are not extent of risks:
MDMA is linked to roughly 50 deaths every year in the US, and its secondary effects involve hyperthermia, dehydration, hypertension, and even cardiac arrest.
LSD is not linked to any death yet, and its overdose effect remains unclear; however, acute secondary effects involve anxiety, fear, and activation or exacerbation of psychotic disorders. Also, it might induce alterations in perception in a delayed way: days, weeks or even months after the substance usage.
Luckily enough, it has been proven that their potential harmful effects decrease greatly within a safe, medical supervised environment.
Most of these substances are subject to legal banning in most countries, so their use in the therapeutic and research field might even be object of legal prosecution.
Comment from an expert
" The search for a relationship with the universal reality about us is one of the most important goals in human life. It has to be conducted by two entirely distinct processes which, while concurrent, are totally different. The passage through your lifetime of eighty to a hundred years (give or take a few decades) involves learning relationships -- giving and taking -- with those who share your journey on this planet. And, at the same time, you play a role at this moment of human history. Living your own personal life in the immediate present, you are also, to an often unknowable extent, a contributor to the structure of the world about you.”
Comment from a trainee
There is no trainee in this modality yet, however we had an enthusiasm to write about this therapy and we expect there will be trainees in just a few years.
Links to Societies
Multidisciplinary Association for Psychedelic Studies (MAPS) - https://maps.org/ - Founded in 1986, is a non-profit research and educational organization that develops medical, legal, and cultural contexts for people to benefit from the careful uses of psychedelics and marijuana.
Heffter Institute - https://heffter.org/ - promotes research of the highest scientific quality with the classic hallucinogens and related compounds (sometimes called psychedelics) in order to contribute to a greater understanding of the mind leading to the improvement of the human condition, and to alleviate suffering.
Byock, I. (2018). Taking Psychedelics Seriously. Journal of Palliative Medicine, 21(4), 417–421.
Walsh, Z., & Thiessen, M. S. (2018). Psychedelics and the new behaviourism: considering the integration of third-wave behaviour therapies with psychedelic-assisted therapy. International Review of Psychiatry, 30(4), 343–349. https://doi.org/10.1080/09540261.2018.1474088
Rougemont-Bücking, A., Scheidegger, M., Jungaberle, H., von Heyden, M., Thal, S., Aicher, H., & Zeuch, A. (2018). Positive psychology in the investigation of psychedelics and entactogens: A critical review. Neuropharmacology, 142, 179–199. https://doi.org/10.1016/j.neuropharm.2018.06.034
Mithoefer, M. C., Wagner, M. T., Mithoefer, A. T., Jerome, L., & Doblin, R. (2011). The safety and efficacy of±3, 4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: the first randomized controlled pilot study. Journal of Psychopharmacology, 25(4), 439-452 https://journals.sagepub.com/doi/abs/10.1177/0269881110378371
M.J. Stolaroff, Thanatos to Eros: 35 Years of Psychedelic Exploration by Myron J Stolaroff, Foreword by Alexander and Ann Shulgin,Thaneros Press, Lone Pine, CA, 1994.
G. Greer, P. Tolbert, Subjective Reports On The Effects Of MDMA In A Clinical setting, J. Psychoact. Drugs 18(1986) 319–332
Carhart-Harris, R. L., et al (2015). The effects of acutely administered 3, 4-methylenedioxymethamphetamine on spontaneous brain function in healthy volunteers measured with arterial spin labeling and blood oxygen level–dependent resting state functional connectivity. Biological psychiatry, 78(8), 554-562.
F.G. Graeff, F.S. Guimaraes, T.G. De Andrade, J.F. Deakin, Role of 5-HT in stress, anxiety, and depression ,Pharmacol. Biochem. Behav. 54 (1996) 129–14
Chapter written by Óscar Soto Angona, Psychiatry Trainee from Vall d’Hebron University Hospital – Department of Psychiatry – Barcelona, Spain
Revision Thomas Gargot, Pitié-Salpêtrière Hospital, Paris, France