Psilocybin and Trauma

What do we know, and what are we learning?

Ceremonial altar with ayahuasca, tobacco, mushrooms, cacao — Jamaica. photo by author, copyright 2023

Disclaimer: this is opinion, not medical advice, and I am not a doctor, and do not advocate using illegal substances. Remember to floss, do your homework, call your mother, etc. etc.

Among the many repeated memes about psilocybin, there’s an oft-repeated phrase about how psilocybin is good for “depression, anxiety, and PTSD/trauma.” Articles in Portland’s Willamette Week bolster such claims: “Rigorous academic research shows that psilocybin can help with depression, alcohol abuse, and post traumatic stress disorder.” No research is cited in the above article.

Many of my students in the Synaptic psilocybin facilitation program come to this work because they feel called to treat trauma. In a recent class, I pointed out the bad news: there is no clinical evidence to support that psilocybin can work for PTSD (Henner & Keshavah, 2022; Khan et al, 2022). There is good clinical evidence that MDMA-assisted psychotherapy and ketamine-assisted psychotherapy (KAP) can be effective for PTSD, but that is of little help for my students, who spent 6 months and many thousands of dollars to become psilocybin facilitators in Oregon. Note: if you’re feeling impatient, skip to the end for my checklist on how to decide whether to treat trauma.

Note: I’m being purposefully sloppy here, and talking about trauma, complex PTSD, and PTSD as if they are all the same. Not all trauma is the same, but for the sake of simplicity, from here on out I’m going to use the umbrella term “trauma.”

In class recently, one of the students wanted to know how they could best approach trauma with psilocybin. This article is my effort to clarify this for myself and my students. As is so often the case, it depends. What I’m hoping is that over time I’ll be able to grow this article, refine it, and offer a better understanding to the psilocybin community – our service centers, facilitators, and clients — so that we have some common understanding of how we can help.

Clinical Evidence is not the Only Word

Psilocybin does not get a lot of attention in research, in the same way racemic ketamine does not get a lot of attention: ketamine is out of patent, and you cannot patent a mushroom that pops out of the ground almost everywhere in the world. There are no scientifically rigorous clinical trials that support the use of psilocybin with trauma, in part, because people haven’t figured out how to make money with it.

There are many able, caring people who have worked in the psychedelic underground over the past 50+ years who would assert that you can work with trauma and psilocybin. Their underground experience matters, and over time I hope to those voices here. For now, I’ll share my own experience providing psychedelic integration therapy and ketamine-assisted psychotherapy (KAP).

A Case Study

I worked with a client’s trauma using EMDR technique for many months before he took a mushroom trip. His trip was like a great many experiences: he was with a friend who had the drug, they had time, and he took a big dose, but did not know how much, and hung out at a beach. I had no idea he was planning on this, and learned about it a week later.

His trip was mildly unpleasant, because he had pressing pain in his chest as soon as the effects came on. The pain persisted through his trip. The next week in session he mentioned the pain. In our session, we used EMDR techniques to understand what that pain was manifesting. It came from a trauma that he’d experienced some ten years before, something he’d never brought up in session. We worked to process this trauma together, and he later reported that his depression had improved.

What went well here? He was stable. He suffered from moderate depression, and had some substance abuse issues in the past. He had already had some practice with EMDR, so he had a broad window of tolerance, which made it easier to handle the psilocybin. Other resources, like stable family, regular exercise, and access to nature were readily available.

This is an n=1, which is the fancy way of saying anecdotal, but I would feel comfortable working with psilocybin and trauma if I knew the client had good resources and a recent history of productive therapy.

How does the trauma manifest?

Here we are going to wade into the diagnostic soup: PTSD, complex PTSD, DID, OCD, or the dreaded “Borderline” label. How does this person’s trauma present? In the case study above, my client’s experience of trauma was mostly depression. If someone is highly dissociative, if they report their own borderline diagnosis, or are highly suicidal, experience severe anxiety, this might not be the right medicine. Psilocybin could make things worse.

A note on diagnosis: there is no requirement for psilocybin facilitators in Oregon to understand diagnosis. I teach diagnosis for the Synaptic program, but it is a short survey, and does not replace years of clinical diagnosis experience. It would not be ethical or legal for a psilocybin facilitator to say “hey I think you have dissociation.” On a positive note: over the past decade people have become fluent in psychology-speak. They understand the acronyms, and very often will disclose their diagnoses without hesitation.

In the article I mentioned above, the authors discussed treatment of secondary illnesses: “Though there is no clinical data on the effect of psilocybin on PTSD directly, this diagnosis is highly co-morbid with major depressive disorder (Henner and Keshavan, 2022).” There is an argument to be made that if the individual’s biggest issue with trauma is depression, psilocybin could be incredibly effective. Early research shows that a single dose of psilocybin can help treat depression, even without therapy, and some clients do not experience the same “blunting” effect as they do with traditional antidepressants.

Severe Anxiety

Hypervigilance is a symptom that manifests from trauma: it can look like generalize anxiety, or something very specific. Years ago, in couples therapy, I saw one partner had a very long checklist of everything their partner was doing wrong. Perhaps a client is losing sleep each night checking over and over on their perfectly healthy sleeping toddler, or are hyperfocused on all aspects of their teen’s life. This can be hypervigilance.

Other people with trauma experience severe anxiety: the kind that includes frequent panic attacks, interrupts sleep, or keeps them from interacting with the world.

Psilocybin and anxiety are like a magnifying glass on an ant on a sunny day. Horrifying. Most people will experience some anxiety caused by the medicine itself. If they manage severe anxiety, this might not be the medicine for them.

Mild, Moderate, or Severe Trauma

These are very open, wiggly terms; Let’s make them smaller: mild to moderate, and moderate to severe. We want to understand how this person reacts to their trauma. What would happen if they were in an altered state and believed they were reliving the trauma? How hard would that be? There is no standard way to assess this: you’ll need to pay attention to your experience of the client, listen to your intuition, ask colleagues, and ask the client. “On a scale of one to ten, how difficult is it to manage life with your trauma?”

Mild to moderate (1-5)

They might have frequent nightmares, depression, hypervigilance, they get overwhelmed when considering the traumatic experience, but they do a pretty good job of holding it together.

Moderate to severe (6-10)

When I think of severe, I imagine a level that interrupts clients’ ability to work or study, and/or prevents them from maintaining relationships with family and/or romantic partners. Highly distressed veterans for example, who are deeply suicidal, experience a severe reaction to trauma.

High Comorbidity

Does the person disclose that they are managing a full alphabet: Bipolar 2 + PTSD + ADHD + PMDD + depression and/or anxiety? Sometimes that’s a sign of an overzealous psychiatrist, or they spend too much time taking online psych quizzes. It could also indicate that this client has a serious set of mental health challenges, and psilocybin might not be appropriate.

What are their resources?

If someone tells me that they exercise a few days a week, they spend quality time with friends/family, they volunteer or have a job, they have good external resources. When I start EMDR with clients, I’ll ask them who they are going to call if things get bad. When someone tells me they have no one, we’ll work together to build a support network before we start EMDR.

What about internal resources? How do they handle distress? Do they have prior experience with psychedelics? How often can they push themselves out of their comfort zone? What happens when they do? If a person appears to have a good window of tolerance, I’ll be more likely to go ahead with a treatment like EMDR or ketamine-assisted psychotherapy. In either the case of KAP or working with psilocybin, I expect my clients to be established with a therapist.

Find a specialist or Continue with Caution

You might contact a specialist. In mental health work, there are plenty of conditions I do not work with, and refer people out all the time. In my role, I have spent years and bought many cups of coffee networking and developing a resource list. In your own exploration as a facilitator, you might also find colleagues who have a specific area of knowledge. There might be an underground provider in your community who has a decade or more of experience working with psilocybin and borderline personality disorder, for example.

What I’ve tried to impart on my students is “start with a lower dose, with simple presentations.” As a new facilitator, perhaps work with someone who has mild/moderate depression, and work in a lower psychedelic range, such as 2-3 grams. If you decide to take on someone with particularly challenging trauma reactions, you’ll have to spend extra time helping this person feel resourced: doing some safety planning, and understanding their plan for care in the hours and days after the session.

Know yourself, aka Sit Down, Be Humble

In becoming healers, we take risks at some point. When I started in community mental health, as a new therapist, I was frequently working with cases I had no business with because my services were charged to Medicaid. Most people in community mental health are just out of graduate school, the pay is poor, and the least experienced therapists work with the most intense cases. I benefited from weekly supervision and consultation with peers. Find your community and keep in conversation.

Trauma can cause serious, devastating consequences on people’s lives. You might be the only provider of psilocybin services within 500 miles. But we can never be the only option in a client’s life, and this is not the only modality. Physician Dr. Gabor Maté, who is a huge booster of psychedelics, reported that yoga was the single most important modality for managing his trauma.

Every caregiver has the responsibility of non-maleficence: above all, do not add harm. There is always a risk of harm with psychedelic work. If you choose to work with someone with severe trauma, understand that this is a risk, and do whatever you can to mitigate danger. If you can, spend some time apprenticing with a more seasoned clinician. Keep talking to others, build community, and understand your limits.

My checklist

• Is the client well resourced?
  If no, refer out or proceed with caution
  

• Many comorbidities (3+ clinical conditions, such as Depression + PTSD + dissociative disorder + ADHD)
  If yes, refer out or proceed with caution
  

• Client ranks their trauma as severe

  Refer out or proceed with caution
  

• Complex presentations (cPTSD/Borderline, severe anxiety disorder, hoarding, severe OCD, severe dissociation, highly suicidal, comorbid substance use disorder)

  If yes, refer out or proceed with caution

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*Another recent article: “No study to date has investigated psilocybin or psilocybin-assisted psychotherapy (PAP) as treatments for PTSD (Khan et al., 2022)”

Ketamine and PTSD:

https://shamynds.com/is-ketamine-with-psychotherapy-kap-really-effective-for-ptsd/

Reference(s)

Henner, R. L., Keshavan, M. S., & Hill, K. P. (2022). Review of potential psychedelic treatments for PTSD. Journal of the Neurological Sciences, 439, 120302.

Khan, A.J., Bradley, E., O’Donovan, A., Woolley, J. (2022). Psilocybin for Trauma-Related Disorders. In: Barrett, F.S., Preller, K.H. (eds) Disruptive Psychopharmacology . Current Topics in Behavioral Neurosciences, vol 56. Springer, Cham. https://doi.org/10.1007/7854_2022_366

Mitchell, J. M., Ot’alora G, M., van der Kolk, B., Shannon, S., Bogenschutz, M., Gelfand, Y., ... & MAPP2 Study Collaborator Group. (2023). MDMA-assisted therapy for moderate to severe PTSD: a randomized, placebo-controlled phase 3 trial. Nature Medicine, 29(10), 2473-2480.

Ragnhildstveit, A., Roscoe, J., Bass, L. C., Averill, C. L., Abdallah, C. G., & Averill, L. A. (2023). The potential of ketamine for posttraumatic stress disorder: a review of clinical evidence. Therapeutic advances in psychopharmacology, 13, 20451253231154125. https://doi.org/10.1177/20451253231154125