TW – this piece includes discussion of trauma and self-harm.
People are confused about what psychedelic integration is, and I like to explain it like this: in integration therapy, I help people pack their bags before their trip, and unpack them after. Both are critical. In the pre-journey phase, I teach grounding skills and we create intentions together. Positive set and setting are a huge influences that can create a good trip, and we do our best to create the best set and setting we can. Integration therapy is also a chance to offer harm reduction: who is your trip sitter, and how well do you trust them? Do you trust the medicine you’ll be using? Do you know where it came from? Is this a safe choice given your medical history, and current substance/medicine use?
If nothing else, psychedelic trips offer two profound effects: they show people some sort of message, and in the weeks after a trip, they give the energy to act on that message. In my own trips, I’ll notice a burst of creativity: I have a lot of ideas, and after the trip I have the energy and focus to write and edit. Sometimes the message we receive isn’t very clear, and integration therapy can help tease it out.
The integration phase pulls meaning and homework after a psychedelic voyage, and I spend a lot of time with clients working to understand what happened. Most of the medical literature so far highlights the importance of integration. It’s not just the trip itself, but it’s the meaningful work you do afterward, when your brain is at its most neuroplastic, that helps move you out of whatever keeps you stuck. Integration can mean a lot of different things: talk therapy, expressive arts, time in nature, journaling, singing, connecting with others, sharing in group circles.
Here are three case studies from my private practice over the last six years of integration work.
I did mushrooms, but I didn’t stop smoking.
This individual had taken a heroic dose on a weekend, and reported back after our next session. They had no plans or preparation before. In our session they told me: “I heard psilocybin can help you quit smoking.”
How true is that?
There is one small study from Johns Hopkins about smoking cessation. A year after receiving three doses of psilocybin, two thirds of the study participants had been abstinent. Sounds magic, right? There are some stories out there that suggest psilocybin can be a potent tool for treating addiction, but it doesn’t work by itself. I appreciate studies like the Johns Hopkins paper, but highlights from the popular press don’t tell people the whole story.
This study involved only fifteen participants. Phase three clinical trials, which are what is required to pass the FDA’s muster, involve hundreds if not thousands of patients. I hope they conduct larger studies, but this paper isn’t what we call statistically significant, so we cannot prove that the benefits for these fifteen people aren’t just as likely to do with psilocybin as with random chance, expectancy effect, or placebo effect.
This Johns Hopkins study also highlights how much therapy is involved: all 15 individuals had been enrolled in a specific smoking-cessation cognitive-behavioral therapy (CBT) program, which involved 4 preparation therapy sessions, and 9 sessions after.
I would have loved to help this person stop smoking, but there’s a lot of hard work before and after the psychedelic experience. I cannot say for sure that if they had come to me for both preparation and integration, that they would have quit smoking. This client chose a different method, as if psilocybin were an anti-smoking pill. That already exists, and it’s called Wellbutrin. Preparation and integration would have given this client a specific intention to examine during their journey, and might have provided some insight around their tobacco use, which we then could have examined in the integration phase. As it was, they were disappointed by the psilocybin, which ended up being our therapeutic focus.
“We had sex!”
When I was a graduate student I worked with a middle aged hetero couple at one of my internship sites. They were incredibly stuck, and had worked with different student therapists for over three years. Both of them were entrenched in their positions: they could identify and understand their negative interaction patterns, but neither of them would move in a different direction. The marriage and the therapy were frozen, like the end of a Tarantino film, or for my Portland locals, cars stopped at a 4-way intersection.
Almost eight months into our work together, they came in one evening, and everything was different. Their affect had changed, their bodies moved in different ways. They looked relaxed. When the session started, I mentioned this difference in presentation, and the woman smiled and said, sotto vocce, “we had sex.”
The couple hadn’t been sexually active in at least a year, and this was a complaint that recurred throughout their sessions. “How did that happen?” I asked. It turned out, over the weekend, they had gone camping with a group of friends, and took some MDMA.
The story could have ended there; the couple could have made the realization that they could have MDMA if they wanted to be intimate. It’s not a great strategy, as the drug makes it difficult to perform. It’s also a first-order change, continually putting on bandaids without asking why you are stepping in front of a wheat thresher.
In therapy, we looked at the positive interactions patterns the couple experienced during their MDMA use. The man was able to be vulnerable and soft, which helped the woman trust him. In the subsequent sessions, they started to use a different language with each other, based on connection, trust, and vulnerability, which made sexual intimacy easier. “I realize I can’t be an asshole to get what I want,” the man said of their trip.
A month or two later, they concluded therapy with me, and the relationship was in a much better place than where we started. I don’t know that it was just the MDMA, but it helped them learn and act out these positive interaction patterns, not to fear connection, and to trust each other.
I couldn’t breathe.
One of my clients took a large mushroom dose with a friend, and they noticed an uncomfortable pressure in their chest throughout their entire experience. They reported they felt like they couldn’t breathe. It was one of the many times when I didn’t get to work in preparation with this client – they had an opportunity to use mushrooms, so I supported them as well as I could after it was over.
The client told me about the pressure, and I asked them to “float back,” which comes from EMDR. In a float back, we ask clients to remember an earlier time when they had the same body experience, looping thoughts, or strong emotion.
In their float back, the client noted the pressure in their chest, and traveled back to an extreme physical trauma. They had been in a high profile sports accident which caused them to struggle to breathe. This person was a community figure, and had spoken about this incident many times in the past. Their cognitive self could work with the trauma. This is true of many people: we dissociate, recite a traumatic story from rote, but don’t let it touch our emotional selves. It’s a valid strategy, and offers some protection, but doesn’t prevent or ameliorate symptoms of post-traumatic stress.
In this case, we used EMDR techniques to work through the accident. This individual had been quite depressed in the years after the accident, and engaged in multiple suicidal gestures of hanging over many weeks. This self-harm then caused a spiral of shame, which increased depression, and then they would continue harming themselves.
In the EMDR work after the mushroom experience, the client made a connection between the involuntary breathing struggles of the accident with the self-imposed breathing restrictions of self-harm. They were able to process this buried trauma, and contextualize later self-harm, which fostered deep healing.
One integration resource I like to share is After the Ceremony Ends by Dr. Katherine Coder. Psychedelic societies offer integration circles, or you might find a therapist who is trip-friendly. Sometimes psychedelics kickstart lasting change, and other times it’s just a weird story you tell your friends. Some form of integration can make a big difference, creating change, offering meaning and protection for these big experiences.