By Sean Lawlor
The role of therapy in psychedelic therapy has been underexplored in mainstream articles that focus more on neuropharmacology and the psychedelic medicine experience. Without therapy, however, results from clinical trials would be no more significant than if the substance was studied in a recreational setting, and the fact that there is such a difference is central to the growing appeal.
As our companion article on psychedelic therapy explained, numerous therapeutic approaches used in psychedelic therapy converge on an inner-directed, relational approach. In psychedelic sessions themselves, therapists take more of a back-seat role, encouraging clients to focus inward and engage in an authentic process facilitated by their “inner healer” and refraining from interpretation. Still, complications can arise in psychedelic sessions, such as an upsurge of trauma, and if therapists lack the skills to respond, they risk leaving clients stuck and unresolved, potentially re-traumatized from improper care in a vulnerable state.
While therapeutic training is essential in case overwhelming content arises, the bulk of therapy work occurs during preparation and integration sessions. Across numerous clinical trials and clinics offering ketamine and cannabis-assisted psychotherapy, psychedelic therapists are using many therapeutic approaches to help their clients heal. Here are some of the most common.
Internal Family Systems
One of the most consistently referenced models used in psychedelic therapy is internal family systems (IFS). Developed by Richard Schwartz in the 1980s, IFS views the psyche as an amalgamation of interrelated personalities, or “parts” that often conflict with one another. IFS brings clients’ attention toward three main parts of the psyche: Exiles, Managers, and Firefighters. When these parts are in conflict, they prevent people from grounding in their core Self.
Exiles are related to psychological trauma, often from early childhood. They are the parts that have been cast away- buried beneath shame, fear, or pain that has not been expressed or accepted. In psychoanalytic terminology, they have been “repressed.” Managers keep the Exiles in control, relegating them to their shadowy domain so they do not disrupt overall function. Still, Exiles sometimes break through Managers’ control, at which point Firefighters take over, putting the system on high alert and inciting reactive behaviors to avoid encountering the Exiles. All of these parts create the “internal family,” and IFS helps clients center in the Self, which transcends all the parts, to create a loving inner container for intrapsychic balance and communication.
“The goal of IFS is to first acknowledge these protected and wounded parts within a person, and then to foster this reconnection with the higher Self,” explained Jason Sienknecht, who practices ketamine-assisted psychotherapy in Fort Collins, CO. “Ultimately, the Self is put into a position of a manager so the other parts can fall in line behind the Self’s guidance, instead of monopolizing a person’s consciousness. We want the Self to monopolize the person’s consciousness.”
Sienknecht is a MAPS-trained MDMA-assisted psychotherapist and a lead trainer for ketamine-assisted psychotherapy through the Psychedelic Research and Training Institute (PRATI). In his psychedelic therapy work, Sienknecht regularly uses IFS. “The reason I gravitate toward IFS is because ketamine aligns the client with their higher Self, or inner healer, very naturally,” Sienknecht said. “The Self doesn’t need development- it’s the root of love and wisdom within each of us. Some people have lost sight of the Self through years of identifying with the protected or wounded parts of themselves.”
Sienknecht added that clients’ subpersonalities also naturally arise under the influence of ketamine, and IFS helps them make sense of the confusing content. As such, it is more a framework of integration than an intervention used in psychedelic sessions. “When you’re engaged in dialogue in a medicine session, you don’t want to give your client linear, logical reflections that their left brain can attach to,” Sienknecht said. “You want to encourage their non-linear state of consciousness to continue, rather than connecting them back to their thinking mind. I generally don’t bring my understanding of IFS into the dialogue of a medicine session.”
As a tool for psychedelic integration, IFS provides a powerful means to restructure one’s relationship to one’s inner reality for lasting healing to occur.
Gestalt therapy preceded internal family systems as a predominant modality focused on internal parts. Created and developed by Fritz and Laura Perls in the 1940s and 1950s, Gestalt therapy helps clients enhance their present moment awareness through acute sensitivity to internal responses to stimuli. “Gestalt is a way to identify inner polarities within a person, or inner parts, and encourage dialogue between those opposing parts or beliefs,” explained Sienknecht.
Those dialogues can take the form of the “empty chair technique,” in which clients converse with a part of themselves as if that part is sitting in the empty chair beside them. Clients are encouraged to feel and express the emotions that arise. Through the process, therapists help them expand their self-awareness and take more responsibility over their way of being in the world.
Sienknecht recently facilitated ketamine therapy for a man suffering from alcoholism. A part of this man wanted to stay in a comfort zone and keep emotional pain at bay, which he did through binge drinking, while another part wanted to free himself from that addiction. Sienknecht helped him become aware of the polarity between these opposing parts, and from that awareness, the client could move toward resolving the conflict.
Psychedelics can enhance clients’ awareness of the relationships and dichotomies between internal parts of themselves. Therapists have found that models based on accepting and balancing those parts can significantly enhance the healing potential from that newfound awareness.
Somatic therapy refers to body-focused psychotherapy. Somatic therapy is a relatively recent development without much research on its efficacy, yet it has still recently come to be regarded as one of the most effective approaches for healing trauma. Its foundational premise is that trauma is stored in the nervous system, and listening to the body’s messages is the ideal inlet to healing trauma’s lasting effects.
The two most prevalent somatic methods are sensorimotor psychotherapy and somatic experiencing. Rafael Lancelotta, a psychedelic therapist and researcher practicing in Denver, CO, helped elucidate the differences. “Somatic experiencing is highly relational and has a ton of emphasis on resourcing,” he said. “Sensorimotor is more based on movement. It’s a little less relational; more let’s go into your body and see where these incomplete movements are. It’s more physical in nature.”
The somatic style used by Innate Path, a psychedelic therapy clinic where Lancelotta worked for two years, is called trauma dynamics. Trauma dynamics uses elements of both approaches but focuses more on challenging clients outside of their window of tolerance. Lancelotta explained that while challenging clients can be effective, sometimes it can be too challenging and push clients too far outside their comfort zone. “I’ve found it most helpful to use pieces of all of these to find something that can be more fluid from one person to the next,” he explained.
Since somatic therapy involves focusing on the body, it can be a helpful intervention in psychedelic sessions themselves. If therapists notice that clients appear stuck in their processing, they can invite the client to focus on their body and notice what arises. From there, new content can become conscious, allowing the client to move toward the point of stuckness and continue processing through it.
Many psychedelic therapists reject the efficacy of cognitive-behavioral therapy (CBT) and claim it does not lend itself well to psychedelic work. Nevertheless, one of Johns Hopkins University’s most significant psilocybin studies to date uses a framework of CBT- a study using psilocybin-assisted psychotherapy for smoking cessation.
Dr. Matthew Johnson is the study’s principal investigator. While he explained that the psilocybin sessions themselves (which typically involve the synthetic equivalent of a Terence McKenna “heroic dose”) proceed with a non-directive, supportive approach, the many weeks of preparation and integration are CBT-focused.
“In terms of the CBT, my thinking is that any number of empirically validated forms of therapy can be brought to bear here,” Johnson said. “If a tool tends to work for the disorder of focus, my bet is we can combine it with psychedelics and make it work. When you’re talking about smoking cessation, most of the programs and a lot of empirical support are based in CBT.”
CBT is among the most widely practiced therapies; used for depression, anxiety, PTSD, and addiction. Therapists help clients identify distorted thought patterns and then replace these cognitive distortions with new, healthier thought patterns, which correspond to better emotional regulation and healthier behavioral patterns. CBT has no interest in psychoanalysis and the unconscious mind. It is an action-oriented, solution-focused approach, and Johnson has found it particularly effective during the “afterglow” of a psychedelic experience.
“We have a lot to figure out [about] what that afterglow is, but there’s probably some neuroplasticity lingering- this window of increased agency,” Johnson said. “If we then establish a new normal with boring, bread-and-butter techniques like CBT, it’s probably going to help.”
In the study’s ongoing second iteration, 59% of participants who received psilocybin were confirmed as abstinent from smoking in the one-year follow-up, as compared with 27% who received a nicotine patch. Such powerful results suggest that even modalities unconcerned with psychological depth can enhance psychedelics’ healing properties.
Mindfulness involves directing one’s open attention to present moment awareness. While this may seem like a given in therapy, many therapeutic approaches encourage interpretation and recounting of past experiences, both of which can impede awareness of the present. Mindfulness-based approaches to therapy, such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction, foster present-moment awareness as a path to healing.
Sienknecht has found that mindfulness-based approaches align well with ketamine-assisted psychotherapy. “Ketamine quickly and effectively helps someone transition from the thinking self to the observing self,” he explained. “It just so happens that meditation does the exact same thing. Meditation mimics the activity of the higher Self, which some people refer to as the eternal witness. You’re not walking down the street, you’re aware of yourself walking down the street. It’s one step back from the ego. Mindfulness-based psychotherapy can help teach the skills needed to move more fully into this observing self.”
In order for people to move more fully into the witnessing Self, both inside and outside the psychedelic session, it is important they develop a daily mindfulness practice. “I find that people who practice daily throughout the course of a two-month ketamine treatment program are more able to move in the natural direction of the medicine as it moves you away from your thoughts and into an observing self,” Sienknecht explained.
A daily mindfulness practice does not have to be seated meditation. The practice can involve journaling, painting, exercising, or simply walking through the woods, as long as it is intentional time taken to practice awareness and receptivity to what arises within and without.
The Hakomi Method
The Hakomi Method is a mindfulness-based somatic approach that is often discussed alongside psychedelic therapy. Developed by Ron Kurtz in the 1970s, Hakomi focuses clients on their present-moment experience and understands that the body is the harbinger of messages from one’s inner workings. Hakomi clients are encouraged to focus on mental content that arises alongside embodied sensations, such as images and memories.
Hakomi therapists use “probes” to gather information on a client’s internal process. These probes often aim at clients’ core beliefs that structure their relationships to their self and their world. For instance, a hakomi therapist might encourage a client to close their eyes, focus on their breath, and notice what arises as they say, “You are lovable exactly as you are.” It does not matter whether a client experiences elation and lightness, or bitter, self-defeating thoughts and constriction of the stomach- what matters is that the client notices what happens, because the response contains all the information needed to then work with the core content.
Psychedelic sessions can cast new light on core stories while also showing clients that other stories are possible. Skilled Hakomi therapists help clients restructure and heal those stories’ ongoing impact on their present moment experience.
Another present-focused approach is experiential therapy. Sara Reed spoke to the approach’s efficacy in her work with ketamine-assisted psychotherapy at the Behavioral Wellness Clinic in Connecticut, as well as her work in MAPS’ Phase II trials for MDMA-assisted psychotherapy for PTSD. “What that therapy is about is really focusing on what’s happening in the here and now,” Reed explained. “Often clients come in flooded with a lot of different things, and experiential therapy can help clients slow down and be present with what’s happening in the here and now.”
Experiential therapy can take many forms; those forms are united in that therapists involve clients in real, present-focused processes to gain insight into their thoughts, feelings, and emotional responses. Examples include art therapy, animal-assisted therapy, adventure therapy, and psychodrama.
Michelle Hobart, a specialist in psychedelic integration, uses psychodrama with her clients. She described psychodrama as “an embodied enactment of certain scenes from life,” thereby allowing clients to engage creatively with their experience. “Creativity is a really important way of working with the material that arises,” Hobart explained. She often helps clients work with their psychedelic experiences as if they were dreams, focusing less on analytical processing than on “embodiment and active imagination.” This approach becomes especially important when psychedelic experiences cannot be rationalized or interpreted at all.
Transpersonal Psychology and Spiritual Emergence
While transpersonal (meaning “beyond the personal”) psychology is not a modality, it is a broad wave of western psychology that embraces the validity of non-ordinary states of consciousness and understands humans as inherently spiritual. Academic programs in transpersonal psychology, such as those offered at Naropa University and Sofia University, are among the most popular programs for students interested in working with psychedelics. Understanding the expansive frameworks through which it views people can help therapists support clients through their most challenging internal experiences.
An important topic within transpersonal psychology is “spiritual emergence.” Developed by Stan and Christina Grof, spiritual emergence refers to experiences in which individuals suddenly expand far beyond their established understandings of themselves into a broader perspective on the universe. When this process becomes too overwhelming, it can incite a “spiritual emergency,” which the western diagnostic model can misinterpret as psychosis.
“Spiritual emergency is when something comes up that’s so expansive that it’s not able to be metabolized or integrated,” explained Hobart, who specializes in spiritual emergence in her integration work with clients. “Sometimes that opening is very ecstatic and blissful, and sometimes it’s terrifying and devastating. If we don’t have a framework for how to work with and hold spiritual emergence and emergency, then when that process happens; whether it’s catalyzed by medicines or happens spontaneously as through kundalini awakening or near-death experience, people may think it’s a mental illness or psychosis. Then people get sent into hospitalization, thrown into the pathology paradigm and forcibly medicated, and it’s not understood as what is actually happening.”
In honoring clients’ overwhelming experiences, Hobart helps clients integrate those experiences and adjust into a society that does not understand or appreciate their profound transpersonal expansion. “I hold it in terms of awakening to spiritual gifts,” she explained.
Hobart also suggested that the potential for spiritual emergency in a psychedelic session heightens the need for therapists to be highly skilled and trauma-informed. “Some people who have been activated into these states have not been held properly in medicine spaces,” she said. “To be able to hold spiritual emergence and emergency, and for that matter, entheogenic work, people need to have attunement and the capacity to hold emotional and energetic space. And they need to be trauma-informed. That’s a huge piece.”
If anyone told you that being a psychedelic therapist is easy, that person lied to you. While specific regulations and training requirements are sometimes hazy and differ between medicines, psychedelic therapy calls for both responsibility and a diverse skill set for therapists to bring out optimal healing potential for their clients.
These therapeutic approaches and frameworks do not comprise a complete picture of the approaches currently being practiced in psychedelic therapy. As Johnson suggested, it is possible, if not likely, that psychedelics can enhance any therapeutic specialty. Regardless, a robust therapeutic tool kit will help any psychedelic therapist meet clients’ specific needs. There is always more to learn, and psychedelic work has never been about staying within an established pattern or comfort zone.
About the Author
Sean Lawlor is a writer, certified personal trainer, and Masters student in transpersonal counseling at Naropa University, in pursuit of a career in psychedelic journalism, research, and therapy. His interest in consciousness and non-ordinary states owes a great debt to Aldous Huxley, Ken Kesey, and Hunter S. Thompson, and his passion for film, literature, and dreaming draws endless inspiration from Carl Jung, David Lynch, and J.K. Rowling. For more information or to get in touch, head to seanplawlor.com, or connect on Instagram @seanplawlor.