Do Psychedelic Treatments Always Require Psychotherapy? Well, We Need To Look 'Beyond Reductionism'

The question of whether psychedelic treatments always require psychotherapy is one hotly debated among researchers, and answers -as well as backstories- vary throughout the whole spectrum.

For instance, on a recent edition of the Psychedelic Safety Seminars organized by philosopher and researcher Jules Evans, COMPASS Pathways CMPS's chief medical officer Dr. Guy Goodwin stood with a no, while on the opposite end, MIND Foundation's head of therapy and training Dr. Max Wolff said yes. 

Note: Opinions below contemplate psychedelic therapy as provided within a clinical environment, not real-world, unsupervised use.

The Drug’s Effect

Dr Goodwin has previously argued (see article in the American Journal of Psychiatry) that the proven benefits of psilocybin were studied when the substance was paired with “psychological support” and not traditional psychotherapy. 

Particularly when high doses are being delivered, he said, “it is not really possible for a patient to interact very meaningfully with a therapist” given their inward state. And even preparation and integration sessions, in his view, need not be done by a licensed psychotherapist.

For Goodwin (and the management and team at COMPASS), one of the reasons supporting the opinion that psilocybin’s clinical effects owe more to the drug than to the psychotherapy is that the substance provides a very clear dose-response relationship: the higher the dose, the larger the effect.

“I think the psychedelic-assisted psychotherapy is a too pervasive expression,” he added. “And while we're far from understanding how serotonergic drugs work, we should use more neutral terminology and not anticipate the outcomes we may desire but cannot prove.”

On the other hand, Goodwin acknowledged that COMPASS’ trial design -as others do- takes base on the experience of underground practitioners who were psychotherapists and provided treatment outside the law for many years.

It was also the FDA’s concern over “unscrupulous” therapists that led the company to take in psychotherapists who were “highly professionally” qualified, he said. 

“I think we need a certain amount of humility about how much we know. I don't think we know that we need a psychotherapist to help people get the best out of a psychedelic experience. I think the drug does most of the work. These drugs produce profound changes in brain connectivity that are not produced other than by a psychedelic drug. So this argument that is all psychotherapy is weird, because you're throwing out the very striking effects of the drug,” Goodwin concluded.

Process & Therapy

On the opposite end of the spectrum, Dr. Wolff argued that effective psychedelic treatments always involve psychotherapy. A view he expands on in his latest co-authored paper published in The Lancet Psychiatry.

During the discussion, Wolff noted that COMPASS’ own trial protocol emphasizes the importance of the therapeutic process, through definitions around preparation -“establishing the therapeutic alliance between therapist and participant (...)-” and integration -“to reflect on the experience and generate insights following the psilocybin session-”. This, in Wolff's view, sounds “a lot like psychotherapy.”

Plus, the biotech’s trial protocol states that  “all therapists must be healthcare practitioners with a professional license in good standing” and “must have demonstrated clinical experience in areas required for psychotherapy or mental health counseling,” Wolff found.

He is part of a large group of researchers and practitioners who believe it is “impossible” to separate drug effects from context effects in such treatments.

“I would consider psychotherapy mitigates harm from the treatment. But also, and much more often, patients feel like the minimal psychological support model (...) is just not enough to make proper use of these tremendously valuable experiences that they've had. And then they just seek psychotherapy to improve, to extend and augment the positive effects of the treatment,” said Wolff. 

To end, he warned the audience about biological reductionism [restricting psychedelic experiences and therapeutic effects to biological mechanisms] and psychosocial reductionism [seeing treatments through the lens of psychotherapy alone]. “We shouldn't fall for either,” he concluded.

See Also: Three Johns Hopkins Psychedelics Professors Call The Shots On Live Q&A: Knowns, Unknowns, Regulations & Hopes

Photo: Benzinga edit with photo by Serrgey75 and fizkes on Shutterstock.