Elizabeth M. Nielson, Ph.D.

Elizabeth M. Nielson, PhD, is a Psychologist at the Psychedelic Education and Continuing Care Program and therapist on clinical trials of Psilocybin and MDMA-assisted psychotherapy.
Elizabeth M. Nielson, Ph.D.

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Jeffrey Guss, MD

Jeffrey Guss, MD is a psychiatrist, psychoanalyst, and researcher . He was Co-Principal Investigator and Director of Psychedelic Therapy Training for the NYU School of Medicine’s study on psilocybin-assisted psychotherapy in the treatment of cancer related existential distress. He maintains a private practice in New York City.
Jeffrey Guss, MD

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Considering the clinical outcomes of researchers’ and clinicians’ personal relationships with psychedelic compounds

Self-experimentation with psychedelic compounds by researchers and therapists played an important and largely undocumented role in the psychedelic therapy and research of the European and North American psychiatric mainstream from the 1950s through the early 1970s. Often cited by researchers as the very source of inspiration to study psychedelics in the first place, there was a substantial concern that the first-hand experience had contaminated the objectivity of the researchers (Mangini, 1998). Academically sanctioned research and clinical work with psychedelics, sometimes referred to as above ground work, were disrupted by increasingly restrictive laws that emerged in the mid-1960s and culminated in the passage of the Controlled Substances Act of 1970. These laws were created in response to the warning regarding the use of psychedelics in recreational and non-medical settings and criminalized use of psychedelics outside of sanctioned research settings and placed stringent restrictions on their use in sanctioned research settings. Although research on psychedelic-assisted psychotherapy was technically still legal and possible, a second trend toward increasing focus on double-blind trial design, for which psychedelic assisted therapy was a poor fit, coincided with the changing drug laws such that the research was effectively stopped for some 20 years (Oram, 2012). The influence and centrality of psychedelic therapists’ and researchers’ personal experience with psychedelics was a controversial point and consensus on the topic was not reached.

the influence of first-hand experience with psychedelics on those who conduct clinical research and therapy with them remains underexplored and undertheorized.

Sanctioned research on the effects of psychedelics in humans was reinitiated in 1990 by [Rick] Strassman (2001), who studied the effects of intravenous dimethyltryptamine (DMT) on healthy volunteers at the University of New Mexico. Numerous FDA-approved clinical trials followed and we are now 25 years into the second wave of academic psychedelic research; however, the influence of first-hand experience with psychedelics on those who conduct clinical research and therapy with them remains underexplored and undertheorized. With this paper, we seek to open an academic dialogue on the role of researchers’ and clinicians’ personal experience with psychedelic compounds (be it as part of a training program, religious/shamanic ceremony, alone, or with a peer group) by asking what may be the impact of this experience on therapeutic outcomes. We propose that this should now be an askable and researchable question, and as such it should be moved from theoretical debate to a subject of formal inquiry. We will explore the history of personal use of psychedelics by researchers and psychotherapists who work with these compounds and then focus on the role of personal experience in therapist preparation and training among contemporary therapist training programs. The parallels and divergences from psychoanalytic training and mindfulness-based interventions will be a part of our discussion.

History of Direct Experience Throughself-Administration by Psychedelic Researchers and Therapists

Some researchers and clinicians during this era stressed the value of direct experience with a psychedelic compound in order to function successfully as a psychedelic researcher and psychedelic therapist in particular 

Interest in psychedelic therapy rapidly grew after the discovery of LSD’s psychoactive properties in 1943 and Sandoz’s production, distribution, and program to supply LSD to researchers and clinicians (Hofmann, 2005). Some researchers and clinicians during this era stressed the value of direct experience with a psychedelic compound in order to function successfully as a psychedelic researcher and psychedelic therapist in particular  (Blewett & Chwelos, 1959 ; Leary, Metzner, & Alpert, 2000 ). The idea, which Hofmann (2005, p. 76) wrote, was that the first-hand experience would “provide the doctors with direct insight, based on first-hand experience into the strange world of LSD inebriation, and make it possible for them to truly understand these phenomena in their patients, to interpret them properly, and to take full advantage of them.”  This experience was thought to engender compassion, understanding, and insight into the lived experience of psychosis, as well as that of patients undergoing an LSD session.

among early psychedelic therapists, those who had not taken psychedelics themselves were considered by colleagues and critics to carry skeptical or uninformed attitudes toward the psychedelic experience, and that some writers speculated that these attitudes negatively influenced their patients’ outcomes

Some early US-based researcher/clinicians disclosed their personal use of LSD as a potentially relevant factor in their preparation to provide psychedelic therapy (Frederking, 1955; Smart, Storm, Baker, & Solursh, 1966). Recent retrospective research has found that psychedelic researchers in the former Czechoslovakia had also found value in their personal use of LSD when conducting research between the 1950s and 1974, while it was prohibited there (Winkler & Csémy, 2014; Winkler, Gorman, & Kočárová, 2016). Mangini (1998) documented that among early psychedelic therapists, those who had not taken psychedelics themselves were considered by colleagues and critics to carry skeptical or uninformed attitudes toward the psychedelic experience, and that some writers speculated that these attitudes negatively influenced their patients’ outcomes (Oram, 2012). Despite many arguments for and against such experience, the relationship between therapists’ personal experience of psychedelics and patient outcomes remains unknown as quantitative empirical study has not yet been conducted.

The field of contemporary psychiatry currently maintains that the direct experience of a psychotropic medication is neither necessary nor detrimental in effectively treating patients with that medication. Unfortunately, this area has not been explored in the literature: as of June 2018,we were unable to locate a single study on the relationship between psychiatrists’ personal use of pharmaceutical substances, their prescribing practices with psychotropic medicines, and/or effects on patient outcomes. This scotoma was rendered more starkly for psychedelic therapy research with the emergence of randomized controlled trials (RCTs), which isolate treatments from the human beings who prescribe them or receive them. In the mid-1960s, RCTs became the gold-standard for efficacy of pharmacological treatments demonstrating direct biological link between the medicine and the pathology being treated (as in the case of antibiotics). Psychiatric medicines, psychotherapy, and psychedelic therapy in particular (which combines a pharmacological treatment with a psychotherapeutic intervention) have been poor fits for RCT research methods (Oram, 2012).

in psychoanalytic research and training, subjective personal experience of the method is a valuable and respected source of information that may inform research, without risk of invalidating it.

The idea that the researchers’ and clinicians’ first-hand experience with psychedelics could impact objectivity and ethical conduct of their work represents a conflict between two paradigms of research. On one hand, contemporary psychopharmacologic research values scientific objectivity in which personal experience is irrelevant and excluded as a source of knowledge (no one asks if those doing research with selective serotonin reuptake inhibitors (SSRIs) either take them or do not take them). On the other hand, in psychoanalytic research and training, subjective personal experience of the method is a valuable and respected source of information that may inform research, without risk of invalidating it. Controversy regarding the relevance, importance, and danger of self-experimentation in the current psychedelic research emerges from this dual nature: psychedelic therapy is an unprecedented blend of pharmacological and psychotherapeutic approaches that, as we will later discuss, do not neatly fit into one or the other category, carrying elements of both.

 Regardless of one’s position on the question of objectivity, we can confidently state that variation in therapists’ personal experience with LSD and psilocybin introduces a potential confound to research efforts to demonstrate the efficacy of psychedelic therapy in a rigorous way. The nature of this confound is, in fact, an unaddressed empirical question: no contemporary studies have systematically studied whether or how therapists’ first-hand experience with psychedelics affects clinical outcomes in psychedelic therapy.

In the mid-1960s, researcher Herb Kleber came closest to doing so, when he designed a study to compare the outcomes of patients treated with LSD by a therapist who had not used LSD themselves versus one who had (with himself being the therapist in the study and taking his first dose of LSD between treating the two comparison groups). Unfortunately, the recall of LSD interrupted his work and the study was not completed (White, 2013). Even though it is methodologically quite complicated, empirical exploration of these questions is vital, and that question is rendered outside the scope of inquiry, if academic psychedelic research remains wholly embedded in the epistemology of objective psychopharmacologic research.

The Importance of Personal Experience with one’s Therapeutic Method

Due to the protean nature of the psychedelic experience, and its well-known sensitivity to influence by set and setting (Hartogsohn, 2016), the skillful psychedelic therapist needs to approach the patient with certain clinical positions in place. These include a self-aware and non judgmental attitude regarding the content and processes that emerge during sessions, valuing the aspects of experience that are beyond conventional notions of the self (i.e., states of ego dissolution, mystical states, and emotional flooding), a radical acceptance of highly emotional states and disordered thought (transient psychosis), sometimes a confidence in containing chaotic and transient changes in ego functioning, and a coherent stance regarding the relationship of this experience to integrative work. This is quite distinct from a traditional psychopharmacology model, in which the patient’ s diligent compliance with the prescribed regimen alone is expected to predictably reduce painful symptoms and improve functioning. In our current restrictive environment, and because of lack of empirical research on this topic, it is a challenge to know whether and how direct experience is relevant to offering safe and effective psychedelic therapy.

What makes therapists’ personal experience with psychedelics difficult to discuss

As we have described, the use of psychedelic medicines by those providing them to others for healing and personal growth in religious contexts, and therapists’ personal experience with other therapies that employ alternative states of consciousness such as mindfulness based therapies and psychoanalysis are standard practice in each of those fields. Even so, it would not be defensible to simply presume that psychedelic clinical research must follow suit; there is theoretical and empirical work that need to be done on this question. There are two further key issues that must also be considered.

First, the result of the legal status of the psychedelic compounds currently being researched is that most therapists – including those who practice in federally sanctioned clinical research studies – now do not have legal access to these compounds for personal therapy or training purposes. Seeking and using any use of these compounds outside of the few sanctioned exceptions mentioned above would identify the researcher to colleagues, regulators, and funders as one who is engaged in illicit activity, to be of suspicious character, and stigmatized integrity, putting their ability to act responsibly when charged with clinical duties in question.

Second, the stigmata of hedonism and dangerousness remain attached to psychedelic use. Currently, the American mainstream associates psychedelics with 1960s counterculture use outside of medical settings that contributed to the passage of the Controlled Substances act of 1970 (Lander, 2014 ; Lattin, 2010). Although current research on psychedelics in academic settings follows rigorous regulatory guidelines, psychedelic therapy is often associated with the questionable behavior of some 1960s researchers regarding the widespread use outside of therapeutic and research settings, and unsubstantiated claims as to their safety and effects (Lattin, 2010). For this reason, today’ s clinical researchers, especially those who are working with psilocybin, create distance from many of our predecessors and cultivate an image of cautious, respectable, conscientious, and sober scientists (Langlitz, 2013). This distancing is understandable, significant problems did arise. However, we suggest that a thoughtful inquiry into the best training practices for psychedelic therapist must reopen the question of the role of personal experience, with all the concern for intellectual rigor and safety that are central to the current research.


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Note:

Excerpt from “The influence of therapists’ first-hand experience with psychedelics on psychedelic-assisted psychotherapy research and therapist training” by Elizabeth M. Nielson and Jeffrey Guss, originally published in the Journal of Psychedelic Studies, July 26 2018. Edited by Sophia Rokhlin. Used with permission of the authors.



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