TCPR: What typically happens during psychedelic-assisted therapy?

Dr. Guss: I have been involved in a number of psilocybin trials, including studies on major depressive disorder and on alcohol use disorder, as well as a trial of MDMA-assisted therapy for complex PTSD. In all the studies, the therapy started with preparatory sessions, in which we developed a therapeutic alliance and encouraged the participant to tell their story in their own way. We also introduced the concept of a personal healing experience: “You’re going on an inward journey and the medicine is going to reveal a healing process. We don’t quite know exactly what it’s going to look like, but it will be rooted in your personal struggle with [alcohol, depression, or PTSD]. It is our hope that the experience will bring about new perspectives on your feelings, thoughts, and behaviors, and that this will help you live differently.”

TCPR: How do you prepare patients for what to expect from the drug?

Dr. Guss: We tell them about the range of experiences that they might have, including the possibility of joyous or blissful moments, terrifying moments, perhaps sad or angry feelings, or experiences of awe. We establish the parameters of consent for touch during the session, including a preference for no touch. In our studies, physical touch was limited to holding their hand or placing our hand on their shoulder.

TCPR: What kinds of experiences might patients have during the dosing session?

Dr. Guss: They might have sensory changes, like intense colors or sounds that feel strangely meaningful. There may be a very vivid recall of past events; heightened emotions; or intense reactions to relationships as well as thoughts of conflict, grief, loss, or profound attachment to people, places, or the world. There may be mystical experiences where the sense of self is quieted and there is a deep connection to humanity, nature, or a divinity. Many kinds of psychiatric suffering involve the feeling of being apart, disconnected, or emotionally deadened, so that type of connection can be very healing. As a psychodynamic therapist, I’m also interested in how unconscious conflicts and affects emerge and how the barrier between conscious and unconscious shifts.

TCPR: What do you tell individuals just before they take the psilocybin?

Dr. Guss: “Accept everything that comes up with curiosity. Lean into it. Allow the medicine to show you something about yourself and allow yourself to learn from it.”

TCPR: What negative experiences do you warn about?

Dr. Guss: There may be moments of paranoia where they don’t trust the environment around them. In our studies, these were short lived (Studerus E et al, J Psychopharmacol 2011;25(11):1434–1452). The intense emotions and transient loss of the familiar, narrative self can be frightening. On the physical side, psilocybin can cause nausea and hypertension, which we monitor for.

TCPR: What about hallucinations?

Dr. Guss: Hallucinations are not essential to the treatment. They generally are not like the persecutory hallucinations in schizophrenia, although sometimes they can be frightening, such as visions of large creatures. More typical is a visitation from a guiding entity or a family member coming to help. Some people see complex geometric patterns, bright illuminations, or zigzag images.

TCPR: I understand the therapist is also there for safety. What could go wrong?

Dr. Guss: It’s rare, but people can behave unsafely as their ability to navigate the outside world is decreased. The therapist is there to stop anything harmful, such as notions of being able to fly and attempting to jump from a window. Nothing like that has happened in the trials that I’ve been a part of.

TCPR: In emergency psychiatry we learn to talk people down from a “bad trip.” Is that anything like what goes on?

Dr. Guss: No. In our studies, we strive to talk through, not talk down. We avoid the term “bad trip” because we see painful or disruptive feelings as part of a therapeutic process. We try to see difficult experiences as a break-through, not a break-down. Our job is to be with the participant as they move through it. It’s the same principle in traditional psychotherapy. When a patient starts to cry in your office, you don’t try to stop them. You help them go into the affect and face what has been so hard to bear. “Stay with this emotion. Tell me what’s going on right now.”

TCPR: Do you see risks with overuse of psilocybin?

Dr. Guss: All kinds of people are going to seek psilocybin—healthy people, traumatized people, narcissistic people, and people seeking spiritual or creative growth. Some will have great experiences, and a few will have troubled ones. Having a clear intention, planning the experience carefully, and having a trustworthy, knowledgeable guide helps prevent bad outcomes. Unfortunately, not every person has such a guide. Underground practitioners vary greatly in wisdom, training, and ethics.

TCPR: Oregon now allows high school graduates to become psilocybin facilitators. What is your opinion on that?

Dr. Guss: I have some trepidation, because the decision to use psilocybin will be largely in the hands of the consumer. Some facilitators will have no experience in providing mental health care. I’m concerned that some people may use mushrooms unwisely or excessively or seek them out to relieve conditions that are in fact made worse by taking a psychedelic, such as psychotic disorders (Barber G et al, Am J Psychiatry 2022;179(12):892–896).

TCPR: Who should not receive psilocybin-assisted therapy?

Dr. Guss: The exclusion criteria in all the trials I’ve been a study therapist in excluded anyone with a personal history of psychosis or bipolar ­disorders, as well as anyone with a history of those in a first-degree relative. Dissociative symptoms were not an automatic exclusion, but dissociative identity disorder was a hard no. Occasional cannabis was not an exclusion as long as they didn’t meet criteria for cannabis use disorder. Also, we did not enroll people who had taken a psychedelic within the past five years.

TCPR: For those who have tried psychedelics in the past, how does their experience differ in the therapeutic setting?

Dr. Guss: Well, most recreational users take psychedelics with an intention to have fun and enjoy themselves, or out of curiosity or a desire for personal or spiritual growth. For example, some people take MDMA while attending a rave, and they might enjoy a glorious tribal experience of connecting with friends and dancing all night, hopefully in a safe space where people can guide them and watch out for them. When used in Indigenous cultures, such as an ayahuasca ceremony, there is considerable preparation beforehand, management during the journey, and integration work afterward, much like we do in the psychedelic therapy I’ve been describing.

TCPR: But not everyone has that structure.

Dr. Guss: True. In the 1960s people took LSD without knowing the need for support and careful preparation. Some took acid alone and had good experiences, but others had terrible experiences. Psychedelics require a coherent context to make the experience meaningful, creative, and safe. Without that, they can be disorganizing.

TCPR: How so?

Dr. Guss: The psychedelic experience involves some degree of ego dissolution—the emergence of primary process functioning and the loss of boundaries between self and other. It is a state of profound suggestibility. I believe a psychiatrist, psychologist, or skilled psychotherapist should be present if the intention is psychedelic therapy.

TCPR: Tell us more about ego dissolution.

Dr. Guss: The ego functions, that is, our defenses—the structures we use to navigate everyday life—dissolve a bit. They are not erased entirely. In fact, most people retain the memory of their psychedelic journey. But the day-to-day self that we construct as “me” is put on pause for a while. The defenses are reduced, and it is the defenses that organize our perception: what we see or don’t see, feel or don’t feel, remember or don’t remember. Right now, you and I are seeing the world through the filter of our defenses. When that filter is down, we perceive more. Psychedelics lower that filter, and they also reduce predictive processing.

TCPR: What is predictive processing?

Dr. Guss: It is a theory of consciousness that suggests that we are always predicting what is going to happen and then paying attention to see if we’re right. If you have too much prediction, the world feels boring—no surprise, no curiosity. This is part of the depressed state of mind (Kube T et al, Biol Psychiatry 2020;87(5):388–398). Breaking down that cognitive rigidity is part of how psychedelic-assisted therapy may serve to improve depression.

TCPR: Is that part of how psilocybin-assisted therapy works—by increasing cognitive flexibility?

Dr. Guss: That’s a good way to look at it. Cognitive flexibility is a broad concept, and it carries in it the idea of flexible adaptation to whatever comes, open-mindedness, seeing things from multiple perspectives, and decreasing avoidance of difficult emotions and ideas. These are common factors in many therapies.

TCPR: How do people retain that flexibility after the psychedelic experience is over?

Dr. Guss: That is what we work on in follow-up sessions, the “integration” sessions. The therapist helps them turn the insights gained from the psychedelic experiences into action in the real world. We ask them to connect the new feelings and ideas with the problems they first presented with. The new feelings may not be pleasant, but we encourage our participants to hold them in mind. For example, we might say to someone who regrets losing touch with their family, “Now that you are feeling sadness because you lost contact with your sister, is there anything you feel ready to do about that?”

TCPR: The depression trials used acceptance and commitment therapy (ACT) during the integration sessions. Why was that chosen?

Dr. Guss: ACT is transdiagnostic and is not tied to any particular theory, so it can be learned by therapists of any kind of persuasion for many types of maladies. I believe it is a natural fit with psychedelic therapy, but I try to avoid saying which model is “best” because that depends on so many factors: which therapist, what kinds of problems, what setting, etc. ACT offers beneficial interventions for psychological rigidity, helping it to soften and become more flexible (A-Tjak JGL et al, Psychother Psychosom 2015;84(1):30–36).

TCPR: You were also involved in psilocybin-assisted therapy for cancer-related existential distress. What was that work like?

Dr. Guss: When people get a cancer diagnosis, they sometimes become preoccupied with cancer, relapse, and their own death. Their life shrinks down to their chemotherapy, their tumor markers, and patienthood. Often, things that are meaningful in life fall away. They feel like a “thing” with cancer rather than a person.

TCPR: How did you use therapy there?

Dr. Guss: In our study, we tried to restore old sources of meaning and foster new sources of meaning. The therapy was a combination of logotherapy (based on Viktor Frankl’s Man’s Search for Meaning), relational psychoanalysis, and palliative care supportive therapy, which helps people live more fully as a person with cancer and, in time, prepare for death—learning to live in the present with gratitude for what they have and reviewing their life with respect for what they have done (Ross S et al, ACS Pharmacol Transl Sci 2021;4(2):553–562).

TCPR: Sounds like challenging work.

Dr. Guss: It was sometimes a challenge to stay empathically attuned to the emotions of the participant. When I was with people in that study, I wanted to fix their pillows. I wanted to call their doctor and change their meds. I had to practice being fully present to the terror, rage, and hopelessness—the things they themselves needed to express—rather than always being positive and optimistic. Being in that study gave me new respect for cancer and palliative care.

TCPR: Thank you for your time, Dr. Guss.