When you walk through the sleek glass doors of Nushama, located on Madison Avenue in bustling midtown Manhattan, you are greeted by piano music and a friendly but soft-spoken receptionist. The lobby is meant to be a nearly silent, soothing space, with a sign asking visitors to “keep noise to a minimum.” Patients waiting for their appointments are free to help themselves to fruit-infused water or lattes from the lobby’s Nespresso machine. Personalized snack trays with Kind Bars and fruit sit on the counter, labeled with visitors’ room numbers. The walls are decorated with images of cherry blossoms saturated in pinks and blues. White and pink faux flowers dangle in vines from the ceiling. A shelf full of carefully displayed, propped-up books displays apt titles including Think Like a Monk and The Power of Habit. Island, a utopian novel in which citizens regularly take a psychedelic drug to enhance their well-being, is prominent. In front of the shelf sits a cushy leather couch and accompanying marble tables.
If you didn’t know any better, if you had just stumbled into this oasis, you’d probably look around at the lit candles and staff wearing scrubs and think that you were about to receive a deep tissue massage or a facial behind the closed doors of one of the treatment rooms. Behind those doors, though, are patients hooked up to IV bags full of ketamine receiving treatment for anxiety, depression, eating disorders, and substance abuse issues.
To start their journey, clients meet with Nushama staff to go over their medical history, including mental and physical health, and their treatment goals. The cost of an intake session and six rounds of ketamine infusions, each complete with preparation and integration sessions to help patients get the most out of their experiences, is $5,150. Alcohol use disorder treatments are priced higher, at $9,950. Ketamine itself is not covered by insurance, but some of Nushama’s services like IV treatments or consultations may be eligible for coverage.
Founded in 2021, Nushama is one of a rapidly growing number of psychedelic therapy treatment centers nationwide. In the state of New York, ketamine is the only psychedelic drug approved so far – but that might change soon. In 2020, Oregon voted to legalize psilocybin (the primary ingredient that gives “magic mushrooms” their “magic”) for use by licensed providers with adults 21 years or older. Legislators cited high rates of mental illness and addiction in Oregon and the proven efficacy of psilocybin in treating these issues.
In 2023, lawmakers in at least 11 states made efforts to change the rules around the use of psychedelics, whether through decriminalization or medical legalization. That same year, Australia became the first country to allow doctors to prescribe MDMA (commonly known as ecstasy or molly) and psilocybin for psychiatric treatment.
Gone are the videos of fried eggs entitled, “This is your brain on drugs.” Instead: documentaries like Have A Good Trip: Adventures in Psychedelics, a film on Netflix featuring interviews with celebrities like Sting and Carrie Fisher sharing their craziest psychedelic experiences. Despite initial excitement, experts worry that sloppy, rushed patient safety measures could cause irreparable damage to individuals, and set back the psychedelic movement as a whole.
This is Your Brain on Psychedelics
Unlike some pharmacological treatments, most psychedelic drugs are relatively nonaddictive, but this doesn’t mean they come without risk. “Bad trips” are the downside of the casual experimentation that has been going on for years. As psychedelics move into the mainstream, more and more people are engaging with them – whether they’re seeking out treatments in professional clinics like Nushama or opting for more affordable underground experiences. In 2021, 8% of young adults reported the use of psychedelic drugs, a record high not seen since 1988. New research is promising, but most experts agree that it is critical to first build a foundation for this new field – one based on clinical trials, careful regulation, and solid legislation.
Whether they’re in a dorm room or a clinic, people using psychedelics are vulnerable. They are in an intoxicated state and may not be able to advocate for themselves or affirm consent. Even in controlled clinical trials, patients have been assaulted and mistreated. Others have found that their providers completely abandoned them after the course of their treatment. Some have even unknowingly been given psychedelics laced with other drugs. All of these incidents demonstrate a need for a thoughtful, intentional foundation for psychedelic-assisted therapy – one that keeps patients safe.
Ketamine therapy happens to be at the forefront of this new era. When the United States established a drug scheduling system in 1970, they set out to categorize drugs into five “schedules” based on their perceived medical use and potential for addiction. The Drug Enforcement Agency, along with the Food and Drug Administration. named psilocybin, LSD, and MDMA Schedule I drugs. This meant they had no legally accepted medical use and a high potential for abuse. Ketamine was put into Schedule III: medically useful, with a moderate potential for abuse. This allowed practitioners around the United States to administer ketamine to patients in medical settings and gave rise to ketamine-assisted therapy practices.
Ketamine and other psychedelics, even those in the same Schedule, are not interchangeable. “Classic” psychedelics include psilocybin, LSD, 5-MeO-DMT (commonly known as Toad), mescaline, and DMT. These “classic” psychedelics impact serotonin receptors in the brain, along with the central nervous system. Some, like psilocybin, feel the most impactful at around four hours on average while others, like LSD, can last up to 12 hours. All can cause sensitivity to light and sound, visual and auditory hallucinations, and, in unfortunate cases, paranoia and dissociation.
Ketamine is classified by most as a “non-classic” psychedelic, as it does not interact with serotonin receptors. Though the exact way ketamine works is unknown, some believe that the drug has an impact on a neurotransmitter that regulates mood. For years, it has been used as a sedative or anesthetic for both animals and humans, as well as a recreational drug for partygoers and clubbers. Like psilocybin, it can cause hallucinations and affect the drug-taker’s perception of reality, but the effects tend to dissipate quicker, and drug-takers are left more sedated than euphoric.
“MDMA and psilocybin have amazing properties, but there are going to be a lot of limitations in how they are used,” said Steven Radowitz, M.D., chief medical officer at Nushama. “The nice thing about ketamine is that people don’t have to come off their antidepressants, which is a really big benefit.” Since classic psychedelics like psilocybin and LSD impact serotonin production in the brain, they can’t be taken with antidepressants impacting the same areas. Ketamine doesn’t interfere with serotonin receptors, so patients can typically undergo ketamine-assisted therapy without disrupting their medication routines.
The effects of ketamine typically last around an hour, so ketamine-assisted therapy, unlike sessions with LSD, requires far less manpower to conduct, and doesn’t put a strain on the provider, time-wise. Officially facilitated LSD trips, for example, would likely require providers to take legally mandated breaks throughout the 12-hour trip, which could create confusion for someone in an intoxicated state.
Clinic-based ketamine-assisted therapy has garnered a passionate fan base over the past few years. In 2021, Chase Chewning, a military veteran and host of a health and fitness podcast, visited one of those practices: Field Trip Health in Los Angeles, California. He was fed up with the inconsistent treatment he received from the Veteran’s Association healthcare system and found the therapy he received there to be fruitless as he bounced between providers.
His treatment at Field Trip Health, he said in a 2022 interview, “felt like years of work, compressed into a one-hour experience.” To begin the session, Chewning donned an eye mask and settled in under a weighted blanket before a provider injected him with ketamine.
“I was detached from my body,” he said, “I was just my pure energetic being of light, flying through space and time. I was reunited with my father and, you know, not in any kind of body form, but I knew it was him. He knew it was me and we got time together in ways that I never had before when he was sick. And just a true knowing at the end of it, that he’s okay, that I’m okay.”
He gained, as he put it, a “a clear understanding of what moving on looks like.” Chewning speaks positively of the experience in YouTube videos and Instagram posts to his following of over 20,000. He has since used ketamine again. Some estimates suggest that the ketamine-assisted therapy industry will gross $6.9 billion between 2023 and 2030.
Turn on, Tune in, and Drop out
Experts agree that the modern era of psychedelic science began not with ketamine, but with LSD. In 1938, Swiss chemist Albert Hoffman synthesized and took LSD while working for a pharmaceutical company. This discovery sparked decades of research in the 1950s and 1960s as scientists wondered: what could this magic drug do? Could LSD be used to help patients in psychiatric wards? To help people quit drinking? Or to control minds?
In 1953, over a decade later, psychiatrists in Canada began prescribing LSD to treat alcoholism. In one Canadian mental hospital, researchers believed that watching someone trip on LSD could give you a window into their mind. Since many of these trips induced hallucinations, they thought LSD could briefly mimic the feeling of psychosis in mentally unstable patients, giving researchers a better understanding of what causes psychosis. In an overhaul of previously neglectful policies, psychiatrists sought to improve the patient experience during this period of research. They trained nurses and hospital staff to deal with frightened patients under the influence of psychedelics.
Meanwhile, in the 1950s and early 60s, in the United States, the Central Intelligence Agency (CIA) was experimenting with psychedelics as a tool for mind control in a project now known as MK-Ultra. The CIA spent hundreds of thousands of dollars on LSD and dispersed the drug to research facilities including prisons. One prisoner with schizophrenia, for example, was given LSD every day in what he was told was a medical trial. In reality, predatory researchers were trying to understand how consistent, frequent doses of LSD could impact the mind and body, using subjects like prisoners, whom they viewed as disposable.
In many trials, researchers were seeing promising results. “This was a tremendous deepening and acceleration of the psychotherapeutic process, and compared with the therapy in general, which mostly focuses on suppression of symptoms, here we had something that could actually get to the core of the problems,” said Stanislav Grof, a prominent psychedelic researcher of the 1960s, in a 2014 interview with NPR.
Some estimates suggest that, between 1950 and 1965, up to 40,000 patients were given psychedelics to treat a range of mental health issues.
When the U.S. government classified most psychedelics as Schedule I drugs in 1970, public perception of psychedelics began to shift. U.S. President Richard Nixon directed government funding toward anti-drug policies and named drug abuse “public enemy number one.” President Ronald Reagan followed in his footsteps, focusing on making arrests and prosecuting nonviolent drug crimes. Funding for psychedelic research dried up almost entirely until the 1990s when psychedelics were slowly welcomed back into the good graces of public opinion.
Now: a psychedelic fervor, evidenced by Silicon Valley techies taking mushrooms to cope with burnout, ravers enhancing their party experiences with MDMA, and moms microdosing with LSD before taking their children to a Disney movie or the local park.
Tripz, a licensed psilocybin service center in Newport, Oregon, offers “A Friends Night Out,” for groups of up to five seeking a psychedelic-enhanced experience complete with a sing-along. Participants looking for a more impactful experience can opt for a “Hero Dose Session,” a guided 6-8 hour psilocybin experience, marketed towards those seeking “a journey to the core of self-awareness and transformative growth.” The founder of Tripz, who goes by Willy T, first engaged with psychedelics in underground psilocybin sessions before getting certified at the Changa Institute, a psilocybin facilitator training service based in Oregon.
This modern-day psychedelic craze isn’t random or unfounded. One study by the nonprofit, California-based Multidisciplinary Association for Psychedelic Studies (MAPS) found that MDMA-assisted therapy resulted in “statistically significant improvement in PTSD symptoms” after just three sessions. Another found that a few psychedelic sessions were enough to help two-thirds of smokers quit for a year, making psychedelics the most effective treatment for cigarette addiction ever studied. MAPS also reported that LSD could reduce anxiety in patients with life-threatening conditions.
Mind Manifesting
Despite the proven benefits of psychedelic-assisted therapy, these treatments are not one-size-fits-all. Lola*, a mother of two living in California, heard about psychedelic-assisted therapy, as many do, from a friend. Her dad passed away in 2008, an experience that traumatized her and to her felt untreatable with traditional psychotherapy.
In August of 2021, after a few preparatory talk therapy sessions, Lola began sessions with MDMA. “What ended up happening was that my grief, it was so severe that it opened the genie’s bottle,” she said. “I actually ended up not just crying in a session with a doctor but rather non-stop.” Lola compared this experience with trauma-focused psychedelic-assisted therapy to opening a pack of cookies. The first session was like taking off the wrapper: a first step in a long journey.
Heartened by that progress, Lola decided to try a different psychedelic treatment after she lost another friend in 2022. Her therapist suggested she try ketamine. She went to a doctor who was legally qualified to administer the drug and she talked through the process with her regular therapist. Ketamine put her into a dream state, where she could voice her thoughts, visualizations, and feelings aloud as her therapist took notes for later discussion.
As she continued to figure out what worked for her, she tried Toad. It felt, to her, like a lighter version of MDMA. Toad is quicker – inhaled, the effects of the drug only last around 20 minutes on average, while MDMA, typically taken orally, has effects lasting up to four hours on average. MDMA releases chemicals, including serotonin, that play a role in elevating a person’s mood and activating the body’s fight-or-flight response. Toad binds with receptors in the brain that are also key to the functioning of antidepressant drugs. Both drugs can deliver a reality-altering, uplifting experience.
But ketamine, a sedative, and still a great tool to learn about the psyche, had not been sufficient to release Lola from her grief. Now, she has a routine: one week, a session of Toad, where she delves into her emotions – “I’m crying it out,” she said. The next week, a low dose of ketamine helps her begin to process those emotions.
Lola does not want to be in psychedelic-assisted therapy forever — it’s a strenuous process, both physically and emotionally. She acknowledges the impact it has had on her life, though. She described it this way: talk therapy uses your brain, but grief, for her, is about feelings.
Safety Not Guaranteed
Even licensed, seemingly-qualified providers cannot ensure that patients won’t have a “bad trip.” Psychedelic enthusiasts and experts associate bad trips with paranoia, negative feelings and hallucinations, and dissociation. Bad trips can happen when users take too high of a dose, trip alone, don’t prepare (ie. hydrate and eat) properly, or start a trip in a bad mood. As a preventative measure, the psychedelic community has agreed upon the importance of set and setting when tripping: your mindset, and the setting you choose to trip in, taking into account location and the people around you.
Even licensure, unfortunately, cannot guarantee patient safety. After surviving a 2008 terrorist attack in Mumbai, Michael Pollack was seeking relief from post-traumatic stress disorder. He sought out an opportunity to take psychedelics with a licensed clinician (though this type of treatment was not legal at the time) after a successful first trip with an unlicensed provider, whose lack of qualifications made him wary. This new clinician seemed highly educated and appropriately qualified, so, after a brief screening call, Pollack met her in a hotel room for a guided, therapeutic psychedelic experience.
The clinician promised Pollack a cocktail of MDMA and psilocybin, ingested via a pill and a brownie. Both drugs – MDMA in particular – are understood to make users feel euphoric, but Pollack quickly fell into fits of panic as the clinician badgered him with excessively personal questions. Unable to leave, Pollack was forced to endure a bad trip with only a reckless facilitator to guide him.
He wrote of the experience in Slate; “As I struggled to come down from the effects of whatever it was that Sarah [the clinician] had given me—I was fairly certain it wasn’t MDMA and psilocybin—it became clear that she did not have a healthy approach to using psychedelics as therapy, and she certainly did not have the knowledge to prescribe them to others. There was no plan to help me cope afterward.” He suffered through sleepless nights, continuously trying to reach out to the clinician for help. He never got a response.
Pollack later found out that he had taken methamphetamine with a little bit of MDMA mixed in. Despite surviving this laced dose, Pollack was then saddled with the burden of the trip’s impact: “Still high, my mind racing, I madly typed 35,000 words that I believed would help integrate what had happened to me. All of it felt insightful and real, but in the sober light of day, I saw it was fairly incomprehensible gibberish. In desperation, I called my regular therapist, who told me to throw out the writing and helped walk me back off the edge. Without him, the experience could have led to irreparable harm.”
True believers still herald psychedelics as nonaddictive alternatives to antidepressant and antianxiety medications like Lexapro or Wellbutrin. “I’m not saying there’s no place for them but we should be using them with greater responsibility,” said Dr. Radowitz, referring to those drugs, which affect a person’s mental state. “Hopefully there will be more studies in using psychedelics in children, rather than going to psychotropic medications, which I think is unethical.”
Though traditional antidepressant drugs are effective, long-term (3-15 years) users have reported negative side effects like weight gain, emotional numbness, sexual issues, and even an addiction to their antidepressants. “I think it’s dangerous, much more dangerous than putting people through ketamine. [With ketamine], you’re not going home on any drug, there’s no side effects, you’re not taking away their sex drive,” Radowitz said.
In clinical trials and controlled environments, psychedelic use can be safe and effective. Many underground psychedelic enthusiasts have used these drugs safely for years, despite illegality, but not every recreational user is so careful. In 2022, The American Journal of Psychiatry published a case study: a 32-year-old unnamed woman visited a psychiatrist, complaining of impaired mental function. The woman had been on antidepressants and in psychotherapy for the past decade.
Less than a year earlier, she had taken psilocybin mushrooms with friends, none of whom had adverse effects. Despite showing symptoms of mania just hours after taking the mushrooms, she enjoyed the trip so much that she decided to take mushrooms again just the next day. She soon felt symptoms of paranoia, which lasted for months.
In the weeks ahead, she experienced depression, mania, social isolation, a lack of sleep, and a sense of dissatisfaction with her life. Her psychiatrist recommended she stop taking the antidepressant she was on at the time. When the manic and psychotic symptoms settled down, depressive feelings took over; “nothing in life carried any valence, positive or negative. All emotions—happiness, sadness, passion, disappointment—became foreign,” the study authors noted.
Tests came back normal. Sleep medication, anti-anxiety medications, and other pharmaceutical treatments failed to help her snap out of it – as did therapy. She began to lose hope. She was able to keep her job but the endless stream of ineffective treatments was draining her bank account. Eventually, doctors turned to pramipexole, a drug that targets the nervous system. With the right dosage, her quality of life began to improve and she found hope once again.
Though some may herald psychedelics as a miracle cure-all, many experts still urge caution. “A promising psychiatric treatment risks getting swept up in a broader cultural moment—a dynamic that could lead to compromises in quality and reduce the efficacy of psychedelic therapies,” wrote the authors of the article, adding that, “today, we find ourselves in the unprecedented position where the safety and efficacy of medical treatments are being decided by popular opinion.”
Seeking Serenity
In South America, ayahuasca, a brew of psychoactive plant parts typically consumed in tea, has been used for thousands of years by the tribal peoples of Amazonia. The efficacy of ayahuasca ceremonies has been proven – and often accredited to the sense of community, support, and protection afforded by traditional environments. “Shamans are the world experts on psychedelic-assisted therapy,” wrote the authors of an article in Nature Mental Health.
Traditionally, the indigenous spiritual leaders known as shamans (named as “the one who knows”) serve as facilitators of ayahuasca ceremonies, guiding participants through a psychedelic experience and, hopefully, ensuring their safety.
Tourists, locals, and thrill seekers alike have been seeking such experiences for decades outside of the United States. Unfortunately, sexual harassment by facilitators and shamans is not unknown.
One indigenous woman in Puerto Maldonado, Peru, who visited a local shaman for an ayahuasca experience, spoke in an interview with anthropologist Daniela Peluso, Ph.D. “He said that I was very ill and in danger of dying, that people had done terrible things to me with daño (intentional harm). He put my boys in a separate room and then prepared a blanket for me to lie on. I immediately felt that his intentions were not good, that they were sexual.”
“I gave it some time but every sign imaginable was there telling me that he was going to force himself on me: the tone of his voice, the way he looked at me, the way he touched me, and then separating me from my children. I never drank [ayahuasca] with him because I left before anything could happen,” she said.
In many parts of the world, there are few systems in place to protect women from “healers” who aim to take advantage of their vulnerable state. Peluso noted that some shamans intentionally chose to have sex with women who could provide them with something: money, connections, or new clients. Others choose to incorporate herbs or “spells” into their rituals that are said to make women more suggestible to sex. Ayahuasca alone is known to increase feelings of excitement and connection.
Another interviewee, a young woman in Puerto Maldonado who said she was the only non-native in her ayahuasca ceremony, said, “I was so delighted that the shaman placed me next to him and that he began to pay special attention to me. When he began to rub my body I had no way of knowing what he intended but it soon became obvious when he … [she gestures where he placed his hands] … I pushed him away but felt extremely sad and confused and even wondered if it was part of my vision. I also felt somewhat frightened as the visions had only just started setting in and I felt abandoned by the person meant to guide my experience.”
Oregon Trailblazers
In Oregon, lawmakers have attempted to curb risks through legislation. A January 2022 draft posted by the Oregon Health Authority appeared to outline a series of ethical principles for facilitators. The document addressed a need for confidentiality, maintaining a gentle approach with patients, and the potential use of touch during sessions. Most importantly, the draft addressed the vulnerability of psychedelic therapy patients, even in the care of a professional.
Facilitation and licensing guidelines are set out by the Oregon Health Authority, but facilitators need only hold a high school diploma, be over 21 years old, be an Oregon resident (though this requirement expires in 2025), pass a background check, and complete a licensing program and state-issued exam. The Health Authority offers a list of 24 approved licensing programs, ranging in duration from two to 12 months.
Despite best efforts to mitigate risk, any therapeutic dynamic inevitably begins with a power imbalance. In seeking some sort of help, the client must choose to share parts of their lives with a practitioner, giving power to the therapist. Therapists are expected to use this information to help the client, and an appropriate relationship between therapist and client can be influential in the process of healing if treated correctly.
Psychedelic drugs are known to heighten experiences and connections, and the therapist-client relationship is no different. Intoxicated patients, particularly those taking MDMA, feel euphoric, excited, and sometimes even aroused. They can be disoriented or disconnected from reality, completely in the care of their practitioner.
“There’s a reason to think it does alter the relationship,” said Gillinder Bedi, D. Psych, a psychedelic researcher who has worked with MDMA for years. “If you feel this very strong kind of pharmacologically-influenced sense of loving towards someone, how does that impact your relationship with them? Two weeks down the track, we just don’t know, and there’s a lot of vulnerability, I think, in that kind of equation.”
Guidelines promulgated by MAPS (the Multidisciplinary Association of Psychedelic Studies) encourage the use of touch, when consensual and prompted by the patient: “Any touch that has sexual connotations or is driven by the therapist’s needs, rather than the participant’s, has no place in therapy and can be counter-therapeutic or even abusive. By the same token, withholding nurturing touch when it is indicated can be counter-therapeutic and, especially in therapy involving non-ordinary states of consciousness, may even be perceived by the participant as abuse by neglect.”
Examples of the use of touch during psychedelic-assisted therapy, as outlined in the MAPS MDMA manual, include holding hands with a patient, hugging, or putting a hand on a patient’s arm during the session. “Nurturing touch that occurs when the participant is deeply re-connecting with times in life when they needed and did not get it can provide an important corrective experience,” wrote contributors to the manual, including MAPS founder and president Rick Doblin.
Others disagree. Bedi does not implement touch in her own trials: “that’s partially because we have real concerns about how that feeds into autonomy and consent,” she said, adding that “we just don’t think there’s compelling evidence to support the fact that this [use of touch] is important.” Many ketamine therapy clinics do not employ the use of touch in their practices either, despite the presence of spiritual rituals like intention-setting.
In her research studies, Bedi makes an effort to emphasize the importance of boundaries and clarify the roles of everyone involved. She says she errs on the side of caution and order, making sure trial participants know that these drugs may alter their relationship with their therapist. Therapists are trained to address these issues, and all practice is based on research.
Unfortunately, not all researchers implement the same protections. In a video published by The Cut, Meaghan Buisson, a former skater and current wilderness guide, sits on a white, twin-sized bed situated under a stained-glass window. Behind her is a box of tissues, a clock, and some sort of canned beverage. Next to her are Donna Dryer, a psychiatrist, and Dryer’s husband Richard Yensen, an unlicensed therapist. Yensen hands her a turquoise bowl, which holds a single pill.
Buisson takes the pill, marking the beginning of a phase-two clinical trial with MDMA, intended for patients with treatment-resistant PTSD and organized by MAPS. Setting up a camera for these clinical trials was standard procedure, but the footage reveals a plethora of clear misconduct.
Yensen is shown holding Buisson down as she appears to thrash around on the bed, with Dryer beside them on the floor. In other clips, both Yensen and Dryer are seen lying on the bed cuddling with Buisson during her trip. Yensen strokes her face. Yensen lays his body over Buisson and even sits in between her straddled legs as Dryer struggles to hold onto her arms. At points, both therapists are on the bed, holding Buisson in between them.
Yensen asks Buisson: “Do you want to maybe lie down? And spread your legs and forearms.” In response, Buisson jerks into a fetal position with her head resting on her knees as she sways back and forth. Buisson sought out psychedelic-assisted therapy as a treatment for post-traumatic stress disorder and past experiences with sexual assault.
Later in the video, Yensen is briefly shown standing over the bed, seemingly attempting to force Buisson’s forearms down as he leans over her. After the trial, feeling worse but still attached to Dryer and Yensen, Buisson moved to an island where her two therapists lived and began an intimate relationship with Yensen. She later reported him to the police. Today, Yensen and Dryer have faced multiple lawsuits from past psychedelic-assisted therapy patients, and Dryer has resigned her license.
In March, Buisson published a paper in collaboration with two mental health professionals entitled “Studying Harms Is Key to Improving Psychedelic-Assisted Therapy—Participants Call for Changes to Research Landscape.” It details the potential dangers of psychedelic-assisted therapy including suicidality, provider abuse, paradoxical response, and patient dependency on providers. The paper recommends that further psychedelic research be conducted, with researchers who don’t have any personal or financial connections to the work.
Vicky Dulai, board chair at MAPS, noted the importance of taping sessions and said that, typically, having two therapists should serve to reduce risk; “you have to learn from your mistakes and put things in place to minimize that.”
Ultimately, much of the burden will fall on the U.S. Food and Drug Administration to protect patients. “The prescription is MDMA-assisted psychotherapy, it’s not just MDMA – and the FDA has never regulated therapy before. The FDA is ultimately going to be the one that makes the rules,” Dulai said.
Trip sitting: safety first
Lucy*, a psychology and theater student at Wesleyan University, was a teenager when she first started taking psychedelic drugs. She has since taken them more than nine times. At 19, she took a high dose of magic mushrooms – around four grams – alone in her childhood bedroom. Her goal was to have a therapeutic experience, but coming down from the high was brutal.
“I convinced myself that I was stuck in a permanent trip and that I would never be normal again,” she recalled, adding that she burst into tears “because I was like, I will never be able to have real connections with the people in my life that I love anymore because I’m stuck in this altered state. I won’t be able to reach them because they’re on a different plane of reality than I am.”
During her bad trip, Lucy debated seeking help from her parents or even going to a hospital. She felt as though she was stuck in a loop until her phone rang—her friends were calling, asking her to hang out. It was then that she snapped out of that negative mindset. Later, she concluded that if someone had been there to support her throughout the trip, she never would have had those scary thoughts.
Trip-sitting, wherein someone sober watches over a psychedelic user over the course of their experience, is a time-honored tradition. It’s a role similar to that of a designated driver, but perhaps with more responsibility. Trip-sitters ensure drug-takers are physically safe and can help curb negative thoughts before they become all-consuming.
In one self-reported study, researchers found that taking psychedelics with “trusted friends” was the most helpful harm reduction method in ensuring a safe and healthy experience during participants’ trips.
In the field of psychedelic-assisted therapy, the trip-sitter role is filled by doctors, nurses, and integration coaches, who help patients incorporate psychedelic insights or experiences into their daily lives. “With psychedelics – you can go to many people who can give you a drip of ketamine, or whatever it is, but I think the key is: how do you create a safe space for people to open themselves up?” said Dr. Radowitz. “Our job is to create that safe space.”
Have a good trip
In psychedelic-assisted therapy practices, patients, along with providers, should be vetted thoroughly. Michael Cooper, M.D., is a medical director at Innerwell, an at-home ketamine therapy service with in-person appointments in New York City. Innerwell provides patients with a digital hub: they can chat with their team of psychiatrists and therapists, track their moods daily, play music, schedule appointments, and set their intentions for each session, all through an interactive app. Patients receive either eight or 24 doses of ketamine, taken orally.
Before taking on patients, Dr. Cooper’s team at Innerwell evaluates a slew of psychological and physical factors: why are clients seeking out this treatment? What do they hope to get out of it? The Innerwell teams ask about [so as not to repeat “evaluate”] past medical and psychiatric history, educate the patient about the full scope of the treatment, and typically start them out with a low dose to get familiar with the medicine before increasing the dosage if needed.
“Our patients come in with a variety of preconceived notions about psychedelics,” said Dr. Cooper, “Some could care less about having a psychedelic experience. They just want to feel better, they want a way to get over their depression or their anxiety. Other patients are looking to have more of an introspective experience where they can understand aspects of their life or their history a bit more.”
Before starting each ketamine treatment, the Innerwell app prompts patients to confirm the presence of their “sitter” – someone trusted, who can support, supervise, and observe them through the trip. No matter where they take the ketamine, they must never be alone. They are prompted to check their blood pressure, and then the app walks them through the session: taking the ketamine, letting it dissolve in the mouth, putting on an eye mask and, after the ketamine begins to wear off, reflecting on the experience, and checking for any signs of depression, anxiety, or other psychological impacts.
Innerwell’s professionals support their journey: “for the psychiatric clinicians, they have to be nurse practitioners, physician’s assistants, particularly ones that have a history of doing psychiatric work, and psychiatrists, if they’re MDs. For the therapy side, we only recruit licensed psychotherapists LCSWs, LPCs, PhDs, PsyDs,” said Dr. Cooper, adding that Innerwell prefers to hire therapists who already have experience with psychedelic-assisted therapy, particularly with ketamine.
Dr. Radowitz takes a slightly different approach. One of the integrators at Nushama, an intern, had just completed divinity school at Columbia University and was going on to begin the social work program there, too. Integrators are tasked with helping psychedelic-assisted therapy patients incorporate what they’ve learned in a session into their real lives. “She’s a great integrator because she’s using some of her divinity,” Dr. Radowitz said. “If I can hire from that – from divinity school – that’s who I would hire. They don’t even have to do psychedelics, but have a more spiritual, more open approach to seeing the world.”
Dr. Radowitz’s team includes a wide range of backgrounds, including social workers, registered nurses, medical assistants, a psychiatrist, and doctors nurse practitioners. This wide, all-encompassing approach is reflected in the decor of the space and the kind nature of the staff. The experience is not meant to be just medical – it can be spiritual, and comfortable. Modern-day ketamine clinics toe these lines constantly.
Others have different ideas, including Bedi: “There’s this idea, with MAPS, that there’s this inner healing process and that the drug somehow kind of unlocks [it], and then you’re just really a witness. You’re basically allowing, or guiding to some extent, this process,” Bedi said “I’ve heard someone actually call it a form of faith healing because there is the idea that you have to trust the process, and you have to go through the process, and no matter what happens in the process it’s all good.”
Her approach is more therapeutic and clinical, with strict guidelines and boundaries for all parties involved, including the patients. She does not subscribe to the idea of the inner healer – “that’s not how we’re thinking about this. We’re thinking: this particular drug, what do we think is happening? Why are we putting it together with psychotherapy?” she said.
Many psychedelic-assisted therapy providers have faced the challenge of balancing the rich spiritual history of psychedelics with increasingly precise scientific methods and legal hurdles. Bedi and Dr. Radowitz represent two sides of a challenge facing the psychedelic-assisted therapy space: shaping the industry as business owners, researchers, and legislators trek forward together toward widespread legalization.
The business of psychedelics
At the Sequoia Center in Portland, which provides both psilocybin services and ketamine-assisted therapy and claims a mission of “making psychedelic-assisted therapy accessible in Oregon,” a whole treatment plan, from consultation to integration sessions, costs around $5325, with insurance eligible to potentially cover everything except the ketamine sessions.
A 24-dose treatment plan at Innerwell costs a total of $1398, but this number can be as low as $81 per treatment with insurance. The populations that psychedelic-assisted therapy legislators aim to help – veterans, single mothers, and essential workers – often cannot afford to shell out a month’s rent on these services.
In December 2023, MAPS applied for FDA approval of MDMA-assisted therapy for the treatment of post-traumatic stress disorder – the decision is still pending today. MAPS’ application was given “priority review status,” with the FDA intending to take action by August 11, 2024.
Just a few months after submitting this application, in June 2023, The Wall Street Journal reported that the MAPS Public Benefit Corporation was planning to sell $85 million in private shares, though founder Rick Doblin expressed a strong desire to stay true to MAPS’ mission of accessibility.
“MAPS wants to have a robust patient assistance program, so once we have FDA approval we can provide this to people who need it,” said Dulai, who added that “we want to set a good example – a high, ethical, moral example so that other people can follow us.”
Mental illness disproportionately impacts those with lower incomes. One study linked lower household income to a higher rate of mood disorders, including lifetime mood disorders and suicide attempts. Low-income people already have difficulty accessing health services due to costs associated with insurance, treatment and medication, and even transportation to and from appointments.
Cost is also a factor in determining access to the training programs that will facilitate the licensure of those helping to administer MDMA, ketamine, and psilocybin to patients. Currently, the Oregon Health Authority only lists 24 approved training programs, ranging in cost from $11,600 to $4,500.
Ambiguous rules like Oregon’s leave space for interpretation of what exactly these programs are training for. State-approved psychedelic experiences can be anything from a fun night out to something resembling a traditional talk therapy session.
Some training programs only require a high school diploma, while others, like the UC Berkeley Facilitation Certificate Program, are limited to applicants who are certified religious professionals, or healthcare workers with a degree and an active license or certification. Berkeley’s program is focused on ketamine, MDMA, and psilocybin facilitation.
The program takes up 200 hours and lasts nine months – most of which applicants spend in virtual and in-person learning groups. The rest of the program is made up of practicum hours, where facilitators to-be apply their knowledge in the field. Berkeley’s program also incorporates indigenous knowledge and addresses the connection between psychedelics and faith, with one of its core focuses being spiritual care. They encourage indigenous students to apply.
Despite the rigorous and costly nature of these training programs, they’re essential to patient safety and comfort. “You have to make sure the person you’re allowing into your space while you’re under the influence of a brain-altering, mind-altering drug is the right person,” said Dr. Radowitz.
Benjamin Kagedan, who has a doctorate in psychology is the director of clinical training and psychedelics services at Brooklyn Somatic Therapy, completed his training at the Integrative Psychiatry Institute. “Most of it was completed online. It was a combination of courses featuring professionals across the psychedelic field, inclusive of researchers, clinicians, people who are embedded in MAPS,” he said, “we did a good deal of lectures and workshops or seminars that were more participatory and collaborative, also online. We’re learning different clinical skills and how they apply to psychedelic therapy.”
Kagedan’s training also included an experiential portion: flying to Boulder, Colorado, in smaller groups to both receive and administer ketamine therapy to his classmates. “That way people got ‘en-vivo’ experience,” Kagedan said. This element is not typically required for psychedelic-assisted therapists to obtain a license, but many professionals in the industry have had their own psychedelic experiences, whether above board or below ground.
“When I’ve done work outside, it’s all been done in groups, whether it’s ayahuasca, psilocybin, or MDMA, in a group setting, we’ve had our journey – it was very personal,” recalled Dr. Radowitz of his own experiences.
“No one was allowed to talk. You had to be: eye mask on, on the mat, music, and you went into the journey, whether it was five hours, six hours, and no integration happens until the next day,” he said. This kind of silent practice would be hard to find in today’s established, licensed clinics, where patients are encouraged to talk through experiences as they are happening if they so desire.
Though not all facilitators have partaken in a psychedelic experience, the field is primarily made up of professionals who truly believe in the substances they’re administering. “There’s a strong, and I think very appropriate, belief in the field that it’s not a good idea to be administering these substances if you haven’t experienced them yourself,” said Kagedan.
Kagedan says that the psychedelic-assisted therapy industry is largely made up of people who truly believe in the work they’re doing, often because of their own experiences with psychedelics. Their passion has the potential to fuel a legitimate, well-researched push for legalization, but it also has the power to propel psychedelic-assisted therapy into widespread legalization before the legislators, providers, and regulators are ready to tackle this challenge thoughtfully.