Psychologists and psychedelic-assisted therapy

Exploration in an emerging field

Australians are struggling. In 2021, 15% of Australians (and more women) experienced high or very high levels of psychological distress. Since the start of the pandemic, 88% of psychologists have seen an increase in demand for services. Statistics highlighting Australia’s mental health crisis are increasingly talked about in the media and political circles. Perhaps less well known is the statistic that despite the availability of evidence-based treatments, possibly up to 30% remain ‘treatment resistant’^3–5.

Some Australians are taking matters into their own hands, turning to psychedelic substances to ‘self-medicate’ to treat symptoms of mental health disorders and emotional distress¹². With the growing considerations around psychedelic-assisted (psycho)therapy in Australia and internationally, the APS developed a position statement to outline key recommendations based on psychological evidence.

While at this stage we don’t endorse the widespread use of psychedelic-assisted therapy, we acknowledge its potential and support ongoing research in this growing field. This article gives a summary of the issue and more detail on our stance.

Our full position statement can be found here.

The history of psychedelics

Using psychedelic substances for spiritual or therapeutic practices is not a recent phenomenon. They have been used by Indigenous and First Nations peoples for thousands of years^14–17. Investigations into potential therapeutic benefits in Western cultures, however, is far more recent. The documenting of psychological effects of psychedelics appeared in the mid-1940s, with research into their potential therapeutic benefits taking off in the 1950–60s.

This came to an abrupt halt in 1967, due to the worldwide classification of psychedelic substances in Schedule I of the United Nations Convention on Drugs¹². It is only in the past 15–20 years that there has been a renewed focus into psychedelic research, triggered by the need to consider alternative treatment options.

The situation in Australia

In Australia, psychedelic substances are currently classified as Schedule 9 (prohibited) substances by the Therapeutic Goods Administration (TGA)⁹. They are considered to have a “high propensity for dependency and abuse” which means that they are not available for clinical use outside state- or territory-approved clinical research trials²⁰.

The grounds, however, are shifting. In September 2021, the TGA released the final report from independent experts who concluded that MDMA and psilocybin may show promise in highly selected populations when administered by professionals under clinical supervision. Whilst MDMA and psilocybin were not moved to Schedule 8 (controlled) substances, in some states and territories, psychiatrists may apply to the TGA to prescribe on a case-by-case basis.

The situation internationally

The USA Food and Drug Administration (FDA) has classified psychedelics as illegal Schedule 1 substances which have “no currently accepted medical use and a high potential for abuse”10. In the UK, psychedelics are classified as Class A drugs, which strictly prohibits their sale and possession25, 26. Similarly, psychedelics are currently Class A controlled drugs in New Zealand27, except ibogaine (used to help with heroin addiction) which is a prescription medicine^{28, 29}.

What the research says about psychological and therapeutic effects

Psychedelics are typically separated into four groups: (1) classic psychedelics, (2) empathogens or entactogens, (3) dissociative anaesthetics and (4) other hallucinogens. To understand psychology’s role within the use of psychedelics, we first need to understand their effects on psychological processes and mental health disorders.

Our position statement focuses on the first two classes and the effects. The table above right gives our summary based on current research.

“To understand psychology’s role within the use of psychedelics, we first need to understand their effects on psychological processes and mental health disorders”

Psychedelic-assisted therapy: what we know so far

Currently, the largely accepted view is that psychedelics are not a viable treatment in and of themselves⁸. This is because current evidence suggesting promising effects are almost solely in conjunction with psychotherapy.

So, how do they work in a psychedelic-assisted psychotherapeutic setting? It is thought that psychedelics enable the surfacing of previously unavailable emotional material which can then be processed and integrated³⁸.

Research suggests that central to the approach is:

• the importance of set (i.e. psychological)expectations
• setting (i.e. physical environment)
• having a trust-based therapeutic clinician–patient relationship.

So far, the typical psychotherapeutic approach has been non-directive – facilitating rather than directing the experience. Very few psychedelic substances are given, and there are several sessions:

• Preparatory: Understanding the patient’s history and intentions, and educating the patient on the likely experience during the active session
• Active: This session can be very challenging due to the emotional material that may surface. Patients are accompanied by another therapist, and the two therapists are not the same gender
• Integration: Arguably the most important step. The issues are interpreted and there is integration of this experience into long-term positive change.

The FDA requires that the two therapists:

• “are mental health care practitioners and (have) a professional licence in good standing”62
• have demonstrable clinical psychotherapy or mental health counselling experience
• have a masters’ level qualification.

Many who conduct psychedelic-assisted therapy believe that undertaking the experience themselves in personal practice is needed to fully appreciate the approach.

Known risks and side effects

High-risk individuals – such as patients with personal or family history of psychosis, or those with a personal history of mania, suicidality and other physical and mental conditions – should be carefully screened.

The following is a summary of side effects in controlled clinical settings. The full detail is available in our position statement.

APS position

Our position is based on psychological evidence. It is important to note there are limitations to the current research, including knowledge of appropriate dosage protocols, the fact results are limited to participants who are open to psychedelic experiences and very small sample sizes.

Given all this, the APS:

• welcomes the emergence of safe, evidence-based treatment options to address the shortcomings of currently available medication options for individuals with mental health disorders
• is encouraged by the emerging evidence which has led to the FDA ‘breakthrough designation’ for MDMA-assisted psychotherapy to treat PTSD, and psilocybin-assisted psychotherapy to manage treatment-resistant depression
• recognises that the psychological processes of change underlying the observed benefits is limited
• believes there is currently insufficient evidence for the APS to endorse the widespread adoption of psychedelic-assisted therapy, or other therapeutic options involving psychedelic substances
• requires positive evidence from Phase 3 clinical randomised control trials for this position to change
• requires data regarding the efficacy, safety, potential for abuse and tolerability of these substances in vulnerable patient populations.

With the recent surge in interest in this field, however, the APS anticipates that it may reconsider the position on a regular basis as additional evidence becomes available.

Supporting further research

The APS supports ongoing systematic research investigating the therapeutic applications of psychedelics. Future research should investigate the issues of tolerance, and physical and psychological dependencies, to better understand and monitor the risks and side effects.

The role of psychologists

The specific role of psychologists in psychedelic-assisted therapies will evolve as the therapeutic potential of psychedelic substances continues to increase in Australia. We assume that if psychedelic-assisted therapies were to become available, a similar approach to the FDA will be taken – namely, that only highly trained, experienced and presumably regulated mental health professionals should be providing this therapy.

Given our evidence-base, experience and training in working with vulnerable patient populations, our psychological expertise must be utilised in the development of this emerging field.

Next steps

The APS will be working collaboratively with the Royal Australian New Zealand College of Psychiatrists (RANZCP) and other health professionals’ peak bodies to determine how treatment is developed and regulated in Australia.

Part of this will include the training and professional development needed to ensure evidence-based approaches are adopted, that strict treatment protocols are followed and patient screening is undertaken.

We look forward to keeping psychologists updated on developments in this field in the coming months and years.