Psychedelics and Psychotherapy: The Healing Potential of Expanded States

By Tim Read (Editor), Maria Papaspyrou (Editor) and Gabor Maté

• Examines the therapeutic potential of expanded states, underground psychedelic psychotherapy, harm reduction, new approaches for healing individual and collective trauma, and training considerations

• Addresses challenging psychedelic experiences, spiritual emergencies, and the central importance of the therapeutic relationship

• Details the use of cannabis as a psychedelic tool, spiritual exploration with LSD, micro-dosing with Iboga, and MDMA-assisted psychotherapy for PTSD

Exploring the latest developments in the flourishing field of modern psychedelic psycho-therapy, this book shares practical experiences and insights from both elders and newer research voices in the psychedelic research and clinical communities.

The contributors examine new findings on safe and skillful work with psychedelic and expanded states for therapeutic, personal, and spiritual growth. They explain the dual process of opening and healing. They explore new approaches for individual inner work as well as for the healing of ancestral and collective trauma. They examine the power of expanded states for reparative attachment work and offer insights on the integration process through the lens of Holotropic Breathwork. The contributors also examine the use of cannabis as a psychedelic tool, spiritual exploration with LSD, microdosing with Iboga, treating depression with psilocybin, and MDMA-assisted psychotherapy for PTSD.

Revealing diverse ways of working with psychedelics in terms of set, setting, and type of substance, the book concludes with discussions of ethics and professional development for those working in the field as well as explores considerations for training the next generation of psychedelic therapists.

• Language: English
• Publisher: Inner Traditions/Bear & Company
• Release date: Sep 7, 2021
• ISBN: 9781644113332

Gabor Maté

A celebrated speaker and bestselling author, DR. GABOR MATÉ is highly sought after for his expertise on a range of topics, such as addiction, stress, and childhood development. Dr. Maté has written several bestselling books, including the award-winning In the Realm of Hungry Ghosts: Close Encounters with Addiction; When the Body Says No: The Cost of Hidden Stress; and Scattered Minds: The Origins and Healing of Attention Deficit Disorder. He is also the co-author of Hold On to Your Kids: Why Parents Need to Matter More Than Peers. His works have been published internationally in more than thirty languages.

Book preview

1

On the Therapeutic Stance during Psychedelic Psychotherapy

Andrew Feldmar

The meaning of the word parrhesia, which first appeared in Greek literature by Euripides, implied telling the truth to power and at the same time apologizing for the telling. The apology was to protect the speaker from the wrath of power—from being burned at the stake or beheaded. It can be translated as free speech, and I think the word can also refer to the psychoanalytic notion of free association, as used by Freud. According to Michel Foucault (1983), etymologically, ‘parrhesiazesthai’ means ‘to say everything’—from ‘pan’ (everything) and ‘rhema’ (that which is said). The one who uses parrhesia, the parrhesiastes, is someone who says everything he has in mind: he does not hide anything but opens his heart and mind completely to other people through his discourse.

In this chapter I attempt to tell my truth to the powers that are forming during these heady days of psychedelic renaissance. More and more training programs are springing up, but I think that the skill of the psychedelic therapist can be transmitted only through apprenticeship. It’s a very complex task to actually be there with someone who is in an altered state of consciousness. The possibility of alienation, the possibility of making things worse, is enormous. So, the gains are high, but the dangers are also great. I think the only way to make sure that in the future, when these substances will be legal, that they will not cause harm is to focus not on the drugs themselves but on the relationship between the therapist and the patient.

In 2001, my paper Entheogens and Psychotherapy, in which I explored the potential therapeutic uses of psychedelics and described my own experiences with LSD, was published, and I was punished for it in the summer of 2006 when I was googled at the border between Canada and the US and denied entry (read about it in Solomon 2007). Because of the politics of fighting for the acceptance and legalization of psychedelics, plant medicines, entheogens, and empathogens, I am afraid that an ethos has developed that will consider these exceptional substances just like common pharmaceuticals. The emphasis is on the power of the substance, not on the relationship between the patient and the therapist. Protocols are being manufactured, as if the interactions could be standardized and controlled. Experts are created, selection criteria are invented, optimal musical backgrounds are offered, as if these were scientific matters. Psychotherapy has nothing to do with psychology nor with psychiatry or medicine. Aristotle already knew that what he called the practical sciences, such as ethics and politics, had nothing to do with the productive (medicine or architecture) or theoretical (mathematics or physics) sciences. We are making a terrible category mistake when we pretend that psychotherapy is productive or theoretical in any way. There are no blueprints for who I should be at the end of therapy, and the encounters are fully in the here and now, which have to be negotiated situation by situation, moment by living moment. Psychotherapy is ethics (how we treat each other) and politics (the art of accruing and maintaining sufficient personal power so I can do what I want and not what I don’t want, power to not power over).

R. D. Laing defined psychotherapy as an obstinate attempt of two people to recover the wholeness of being human through the relationship between them (1965, 63). Treatment is how we treat each other. The introduction of a psychedelic, entheogen, or empathogen into the therapeutic relationship will heighten awareness of the other, awareness of how much we flow into and through each other. The therapist cannot hide; any attempt to do so will be noticed, as well as any oneupmanship, power game, falseness, tone of certainty, fear, desire, distancing, objectification, persuasion, coercion, or criticism. The therapist needs to cultivate and practice desirelessness, just listening, love, spontaneity, and candor. There cannot be a protocol to follow, programmed music played, orders given. The therapist should feel at home within the altered state of consciousness of the patient during the session. The therapist, if moved and guided by previous experience, needs to feel free to partake of the sacrament offered to the patient and still honor the responsibility of containing the patient in a safe, secure, and trustworthy manner.

Love takes delight in the other as the other is, in his or her is-ness. Love desires nothing. Love is a relating behavior that allows the other to be a legitimate other, with whom one can coexist. You know you are loved when you feel freer in the company of the other than when you are alone. Love is opening to the possibility of enhancing the life of another. It is not just a feeling, an attitude or thought, a sentiment. Love confers survival benefits on the other, makes the other’s life easier and richer, as judged by the other. The proof of love is in the recipient. Love lets the other be, with some care and concern.

The patient wants to know if the therapist is benevolent or malicious. Friend or foe. The healing moment can be the one when I am defenseless, at your mercy, and you could kill me, hurt me, shame me, humiliate me—but you don’t. Trust cannot be created by fiat. It’s the result of shared experience. Trust can never be earned. It has to be advanced. It can be broken by promises not kept, by betrayal, by lies. The worst traumas are caused by betrayal. The disaster of feeling captured and tortured (enduring unwanted, unchosen experiences), all trust broken, feeling forsaken, any hope of justice, love, and care annihilated, this cataclysm leaves alarms ringing in the background of the rest of the innocent victim’s life. They are locked into constant high arousal. They are not really living; they are in survival mode.

Judith Lewis Herman (1992) thinks, and I agree completely, that all so-called mental illnesses are varieties of terror left behind by having been betrayed, unprotected, hurt, tortured, and silenced. She talks about the first phase of therapy, which she calls establishing some measure of safety, security and trust between the therapist and the patient, and she emphasizes that this takes as long as it takes, sometimes minutes, at times years. MDMA, with its propensity to bring one into the present, to exit shame, and to open the heart, is useful in shortening this phase of therapy if, and only if, the therapist happens to be genuinely loving and trustworthy. In altered states I find it’s best to be guileless, no tricks, no deception, for any falseness, manipulation will be perceived and, if denied, could retraumatize the patient. The aim of the therapist cannot be to help. If the patient finds the encounter helpful, that’s a bonus, but it’s best if the therapist isn’t helping intentionally. Keeping company, containing, ensuring safety and connection when sought for, paying careful attention, and surrendering to what the situation calls for—these are worthy goals for the therapist.

Moments of communion—blessed moments when, for example, two dancers surrender to the music and move like one, neither leading nor following, experiencing themselves as parts of something greater than either of them—are hoped-for moments of fusion. Destructive shortcuts to oneness—for example, let the two of us be one and let that one be me!—are to be avoided. It’s best if both the therapist and the patient heed Marion Milner’s (1950) dictum: the only proper function of the will is to will not to will. Visualize the will as a snake, and make it bite its own tail (as in the symbol of the ouroboros).

All of the above applies to psychotherapy in general; it’s just that in psychedelic psychotherapy, any deviation from this radical or back-to-the roots approach (as in radic, meaning root) could cause deep hurt and panic, especially if deviations are not immediately acknowledged and remedied. The choices of the patient must be honored without judgment by the therapist: whether the patient becomes silent or converses with the therapist, wants music or silence, or physical contact or distance. The therapist follows, accompanies, supports; the therapist never leads. The model is that of the midwife rather than the obstetrician. Receptive, maternal support rather than active, expert heroics.

Sophisticated biochemical, genetic, and surgical treatments induce patients to yield decisions about their suffering to experts. We have to be careful not to add to this list psychedelic treatments. To appear all-knowing, the expert, the therapist promotes transference rather than resolving and helping to end it. Transference is the mistaken belief that the other knows. Children think their parents know. The end of transference is when we realize that nobody knows. A sad and painful and frightening moment, but it helps in the emancipation of the patient (Rancière 1991).

An Argentinian psychotherapist, Juan, proposed to climb Cerro Aconcagua, over twenty thousand feet high, with his patient Miguel (Lingis 2018). Dangerous. Juan had attempted the climb twice before and had been unsuccessful, the climb incomplete. Hippocratic oath: first do no harm.

Juan and Miguel took four weeks off work. It took four months of preparation. Their progress was difficult; Juan wondered if Miguel would survive. The summit was visible. It began to snow, and they came to a halt. They decided to turn back. It took them four days to descend to base camp. The therapist said nothing of what happened to them. No talking cure. No interpretation. No explication. The mountain drove them off. Impassioned states, that totally fill and throb in mind and body, disconnected from, disconnecting the experience and knowledge and enterprises of the past (Lingis 2018, 65). Such states can be transformative. Psychedelic psychotherapy is comparable to Juan’s and Miguel’s adventure. Nothing is certain. There are dangers.

Perhaps it’s best if the therapist partakes of the sacrament of the psychedelic as well as the patient. A psychedelic-assisted session is a trip, not unlike the one Juan and Miguel went on. A joint undertaking of two into the unknown, uncontrollable, unpredictable, dangerous, and exciting. Two equals an us. At most, the therapist is the more experienced Sherpa, perhaps the lead climber. How could the patient move toward emancipation if the therapist exempts himself from sharing the altered state of consciousness? If the therapist is cold sober, the patient might feel observed, objectified, manipulated. If both the therapist and the patient ingest LSD, it’s OK if the therapist has half the amount of the patient or less. After all, the therapist has the role of containing the patient. The patient has no responsibility for containing the therapist. Inevitably, there occur these very human moments when the patient looks into the therapist’s eyes and says, Are you for real? or Do you care? or Will you hurt me? What is the therapist going to say? Whatever the therapist answers, it won’t matter. Words are not going to persuade anybody of anything. There are issues of shame, there are issues of trust, there are issues of betrayal that I think only come to surface, can only be resolved, when the therapist risks everything by being unabashedly himself.

Sándor Ferenczi, one of the, to me, most palatable, sympathetic psychoanalysts, said you need only two qualifications to be a good therapist: you have to have zero ambition and a lot of time. Well, I say that that’s precisely what the psychedelic therapist needs: zero ambition and a lot of time. Because the moment the patient feels that it’s the therapist who is driving the session, the whole session is derailed. It’s absolutely essential that the therapist follows the patient rather than the other way around. Any guide with therapeutic zeal can do untold harm. One of the pseudoscientific questions that arises in psychedelic therapy is: How do you select your patients? What are the selection criteria? Well, as far as I have been able to ascertain, there aren’t any. Self-selection, I would say, is probably the best criterion. I have never suggested to anybody to do an LSD session. I only respond to people who say, I’m going to do one. So self-selection. Because anything else, any other criterion or restriction, basically shows the therapist’s fear, his need to cover his own ass, to avoid being held responsible by the authorities. Actually, what’s going to happen is totally unknown and unpredictable. Coming into psychology from the sciences, I was astonished by the misuse of statistics (Bakan 1967) and the misguided scientism that was the order of the day. It was stated that the aim of psychology was to control and predict human behavior (Johnson 1971). Good luck! I will tell two little stories that illustrate the dangers of pretending to know selection criteria. Under current prejudices, neither of the two patients in my stories would have been allowed LSD psychotherapy.

Mary was a roughly fifty-year-old woman, very depressed. She was in a mental hospital when there were still mental hospitals in Vancouver. And she was in a locked ward. She received several courses of electroconvulsive therapy, and she was on major antipsychotics. She had attempted suicide four times. Her psychologist at the hospital, who was a patient of mine, for some odd reason thought that she could benefit from seeing me. So, it was the psychologist who transported this woman to see me twice a week for fifty-minute sessions. For three long months, this woman came in, sat down, didn’t move a muscle, never looked at me, and just sat there. Three months, twice a week. Who am I to say anything to her? I thought at first. I welcomed her and there we sat. After a while, I began to notice that I’m thinking things that I probably wouldn’t be thinking if I were alone, if I wasn’t in her presence. Now, those thoughts, which I thought arose because I was with her, I started to verbalize. I even joked that she was my analyst because she was quiet and I was speaking. She didn’t crack a smile. To cut a long story short, her first words to me were spoken after three months and totally surprised me because by then I expected that she would never speak. She said, I’m afraid of you. I said, What could I possibly do that would be harmful to you? She said, You might take my freedom away from me. I said, How? She said, I’m afraid I won’t feel free to commit suicide if I continue this. I didn’t think that was such a bad thing. So that’s how it began.

We engaged in regular, unassisted psychotherapy for about three years, during which time she weaned herself off all medication. What we came to was that she lived in a 24/7 soap opera. From the time she was born, she wanted to be the good child of her parents, be the good student at school, and then the good wife to her husband. Then she said she didn’t want any children, but her husband insisted, so she had to be the good mother to her children. She was very keenly aware that no one was interested in her. Everybody was interested in the mother, in the daughter, in the wife. I had to make very sure that I didn’t expect her to be a good patient. It would have been one more load on her shoulders. Clearly, her attempts at suicide were to escape the 24/7 soap opera. I mean, imagine yourself having to perform 24/7, and there is no way out, no way to get offstage, except, she thought, by offing yourself. I could understand. The only alternative I could offer her was that maybe there is a way to be authentic and not have to play anything or anybody without having to kill yourself. I wasn’t sure, but at least it seemed to me worth trying before she really annihilated herself.

And then she had the bright idea that she was going to take LSD. I thought she was either brave or foolhardy, but I was willing to accompany her into the unknown. First session, absolutely nothing happened. She got even gloomier than before. A month later, she said, I’m doing it again. I say OK. It works, she cried. She had a horrendous experience of abandonment. She saw me walking away from her. She said, All I see is your back, and you’re leaving. Now, that opened something up. That opened up a trauma that she hadn’t talked about before. She was three years old, in Germany, where her family was stationed, when they got the order to go back to Canada, and her parents suddenly thought, We haven’t even seen Europe. So, she was three years old and they put her with a German nanny. In her words, they parked me like luggage. The older children and the parents went off for a six-week tour of Europe. Of course, the German woman who looked after her didn’t want any crying, didn’t want any tears, so, from that moment on, she felt she was a piece of shit because gold you take with you, shit you leave behind. She got the message. She thought I, too, would leave her sooner or later. It was a very dark, sad, traumatic LSD session.

A month later, I thought she was going to kill herself for sure. It was clear between us that suicide prevention wasn’t my job, and it was clear even between her husband and me that if he wanted to protect her he would have to keep a twenty-four-hour vigil. I couldn’t do that. She informed me that she was doing a third and last LSD trip before ending her life and—guess what?—she came out of that episode smiling and laughing. In terms of Stanislav Grof’s four stages of birth—bliss inside, no exit, bloody battle, bliss outside—she came out in bliss outside, and she conceived a way of being where she didn’t have to play any roles, and she wasn’t too frightened that her husband wouldn’t have anything to do with her, her children wouldn’t have anything to do with her. Because that was her fear, that unless she performed the roles, no one would tolerate her. Now, this was over ten years ago, and she is still perfectly well. She is living a very creative and happy life. She performs occasional grandmother functions, which she used to dread but now embraces because she is in control of it. She doesn’t play the grandmother; she is the grandmother. Once a year, she sends me a little note: Love you, and hate you!

• • •

The second story illustrating the uselessness of selection criteria is about Lana, a woman I worked with for at least four years. She was diagnosed with multiple personality disorder. She was a fifty-five-year-old woman who would suddenly, in front of my eyes and ears, turn into a seven-year-old boy.

I thought she was pulling my leg. Around that time, I was going around saying and teaching that multiple personality disorder was iatrogenic. Patients just performed that to entertain their therapist. But it wasn’t so. So, I wanted to look up the literature on what to do with somebody who is so split. And then I resisted the urge, and I thought she’s going to teach me. Her multiple personality disorder is not like anyone else’s.

So that’s how we proceeded. The little boy taught me everything. The little boy knew everything. He was the repository of all the memories of torture and sexual abuse that she went through in her childhood. She knew nothing about the boy. She remembered nothing of the abuse. Occasionally, she would come in as the woman. She would say hello, the boy would come out, and at the end of the session, she would come out and write the check and sign it and ask, What did we do? But, of course, when I offered to tape-record the session, she would have none of it. It took a while, but magically, the two personas integrated.

Physiologically she manifested some very interesting phenomena. She wore glasses with a very strong prescription. When the boy came out, the boy took the glasses off, and he had perfect vision. She was allergic to peanut butter. The boy could polish off half a bottle of peanut butter and show no symptoms. If she had a cold and took aspirin, he would call me up and say she was overmedicating him. After he disappeared, blended into her, because she was slowly able to receive all the information that he was the repository of, she had to change her glasses; her new prescription was half as strong as the original.

After that, for about five years, she was fine and lived her life and worked. And then she phoned me up and said she was going to do some LSD. I thought, What if the boy comes out again? But that was my worry, not hers. I mentioned it to her, but she said, Well, then we’ll deal with him. Her reason was that she thought that her life was a little bit gray, not enough color in it. She felt that some creativity in her could be loosened up, that there was still some stultifying fear. Again, to cut a long story short, she had a very deep LSD session. At one point she was crying, and there was snot and tears all over her face, and I, without thinking, wiped her nose with my handkerchief. She later identified that moment as life changing. She said nobody had ever done that for her. This allowed her to feel the grief of never having been cared for, of never having been loved. It’s the smallest things that can make the biggest difference, and these actions cannot be programmed. They somehow have to happen. One has to allow for them.

Often, when either a patient or therapist plan for programmed music during a session, they never get to it; they find they don’t want it. Silence seems to be much more important during an LSD session than music. The music is, I think, for the sake of the therapist. It keeps you the expert. I once proposed to a gathering of psychedelic therapists that, if they felt they needed music during a session, they ask the patient to bring his or her music instead of programming it themselves or, if the session is being done in the patient’s home, they let patients select what they want to listen to. The answer was something like, But most people we work with have such poor musical education. They wouldn’t know what to select. How supercilious, how stultifying.

R. D. Laing wrote:

We are afraid of our souls, of our souls becoming alive. We are psycho phobic. I submit that until we experience our selves, and our world, as one, we are terrified to do so. What we call our consciousness, what we call our mental states, are nothing else than our experience of the world, or the world of experience, or, just simply, our experience. Schizoid minds create a schizocosmos. As long as we remain in this state of apartness from ourselves, from one another, from the cosmos, we can only yearn for the healing of the mind/ body, subject/object, self/other, self/cosmos splits and cut-offs which characterize our schizoid experience. Real health is characterized by the realization of the fact that all is one, that all is in each, as each is in all. (1987, 78–79)

Psychedelic psychotherapy, at its best, can heal both therapist and patient. We are all in the same boat; there is no us and them, the painful illusion of being skin-encapsulated egos.

2

Ayahuasca and Psychotherapy

Rachel Harris

Years ago, in a land far away, I was talking with a Jungian analyst about his female client whose mother had died when she was a child. It seemed clear to me, a young therapist at the time, that this woman should have a female therapist. I blithely made my point with the kind of confidence only an inexperienced therapist is naive enough to express. The older therapist, steeped in the wisdom that Jungians attain after listening to thousands of dreams, patiently responded, Yes, it will be the woman in me who heals her.

After decades in private practice, I often reflect back upon this snippet of conversation that turned out to be formative. The analyst exemplified how it’s the relationship that heals as opposed to the specific therapeutic technique (Wampold 2015), and it’s what we bring from our personal depths to that relationship that makes all the difference.

At some level, this is the essence of psychedelic psychotherapy. As therapists, we have to be able to meet our clients in those mysterious realms that both open from within and also blast into outer space. We have to know how to access these mystical territories within ourselves in order to connect with our psychedelic clients who are exploring these otherworldly worlds. We have to know in our bones what they’re talking about. It’s the mystical traveler in ourselves that we must bring to the therapeutic relationship.

Does this mean the therapist has to have personally attended an ayahuasca ceremony? Does the therapist have to be in her own healing process with this psychedelic medicine, attending regular ceremonies? Yes and no. Is this absolutely a requirement? No. A therapist can gain access to these states of consciousness in a variety of ways. Does it make a difference if the therapist has her own personal relationship with the spirit of ayahuasca? Yes.

We have now officially left the realm of evidenced-based treatments.

The spirit of ayahuasca may be referred to in different ways depending upon context—as a generic unseen other, as Grandmother Ayahuasca, or as a cosmic serpent. When I asked in a study of ayahuasca use in North America, Do you have an ongoing relationship with the spirit of ayahuasca? 74 percent of people reported yes (Harris and Gurel 2012). If both the therapist and the client have such a relationship with this mysterious plant spirit, the whole nature of the therapeutic alliance is qualitatively