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Psychedelic-Assisted Therapy
The Role of the Therapist in Psilocybin Therapy
Integral to therapy and as important as the psychedelic substance itself
Posted February 8, 2021 Reviewed by Hara Estroff Marano
By Sarah Bateup
Psilocybin has been attracting growing attention for its potential to treat a range of mental health challenges, such as depression and addiction. Psilocybin therapy is still at the clinical research stage, but researchers already understand that the therapy element in psilocybin therapy—the psychological support provided—is as important as the psychedelic substance itself. But what exactly is this support and how is it different from other forms of therapy?
I have worked in mental health and in the evidence-based psychological therapy world for many years, in and out of the clinic. One thing I have learned is that therapists often have an urge to tell you what you should do. This can be difficult to avoid. It’s human nature for all of us, but particularly health professionals, to want to take away hurt and suffering. As therapists we sometimes want to put on our metaphorical white coats and fix problems; why shouldn’t we help a patient by imparting advice, giving instructions, telling them what they need to do?
But the best therapists aren’t overly didactic and they don’t make assumptions. They use their skills to draw out information and effect behavioural change, rather than dictating it. The importance of this approach is particularly significant in psilocybin therapy, where therapists provide psychological support to the patient during their psychedelic experience, giving them gentle reassurance or encouragement and helping them to deal, during the experience, with difficult or emotional feelings that can emerge. This is quite different from delivering an intervention or guidance, as is common in more traditional forms of therapy.
Describing the therapy aspect of psilocybin therapy as “support” can make it sound less important than the taking of the psilocybin substance itself. Don’t be misled. This psychological support is an integral element of psilocybin therapy and is what distinguishes psilocybin therapy as a potential treatment for mental health illnesses from a recreational magic mushroom experience.
Psychological support in psilocybin therapy
In current clinical trials investigating the potential of psilocybin therapy, a patient takes a capsule of the psychedelic substance, psilocybin, in the presence of one or more specially trained therapists. The patient is encouraged to lie down on a bed in a calm and ambient room, put on eyeshades and listen to a carefully curated music playlist. Therapists remain present throughout the entire session, which usually lasts six to eight hours. Before the session, patient and therapist will have spent time together building a therapeutic alliance, talking about what to expect and preparing for what might happen.
Psilocybin effects can be positive or negative and are different for each individual. They can include elevated mood or euphoria, creativity, ego dissolution, altered perception of the environment and time, and increased sensitivity to external stimuli. Preparing for the session will include practising self-directed inquiry—for example, “Why is this happening? What can I learn from this?”
The therapist’s role during the psilocybin session is to establish psychological safety, to minimise any anxiety by maintaining a calm and reassuring presence, and to encourage openness to whatever the patient may encounter. Psychedelic experiences can be intense, and therapists practise supportive techniques with patients in the prep sessions.
Often, during the psilocybin session itself, therapists don’t say a great deal throughout the experience; they do not lead the patient in any way. Having that support there means the patient is able to explore, to accept what is happening, and sometimes to confront uncomfortable or anxiety-provoking things they might otherwise avoid, including deep-seated memories of past trauma.
The best therapists will help a patient to engage with all aspects of their experiences including challenging emotions. They refrain from intervening with the patient’s experience, unless required for safety reasons. And they must overcome their natural urge to take away any unpleasantness experienced by the patient, instead supporting the patient to stay with their thoughts and feelings until they have passed or evolved.
In the days after the psilocybin session, therapists hold integration sessions to help patients process the experiences facilitated by psilocybin, and to generate insights that might lead to cognitive and behavioural change. The experiences can be profound. In a Johns Hopkins study in 2016, more than two-thirds of participants ranked psilocybin therapy among the top five most meaningful experiences of their lives.
Developing a new therapeutic model
The model of “medicine plus psychological support” relies heavily on the skill and expertise of specially trained therapists to deliver the support in the right way. We have developed a formal therapist training programme, described in a recently published paper in the Frontiers in Psychiatry journal. The training is part of a rigorous framework put in place to ensure psychological support of the highest quality and consistency, with minimal variation between therapists.
The programme builds on the work of early pioneers in psilocybin therapy and includes contributions from experts in mental health and psychedelic research. It will continue to evolve as we learn more from our own clinical trials as well as the work and experience of collaborators and partners. In time, I hope there will be official professional recognition for psilocybin therapists, and we are working on the development of a certification process to deliver this.
We do require our therapists to have specific professional and educational backgrounds. All must be registered mental health professionals, such as mental health nurse practitioners, clinical psychologists, and psychiatrists with experience in counselling or psychotherapy. The most important qualities in a psilocybin therapist, however, are openness, empathy, and compassion. These may be "soft" attributes, but they form part of a new model of care that is focused on the patient and the patient experience, while being evidence-based and steeped in science and clinical data.
Early research efforts into psychedelics in the 1950s paved the way for potential breakthroughs in mental health. Now, the re-emergence of that research, being pursued using 21st century technology and with scientific rigour, offers a real opportunity to prove the potential of compounds that many had consigned to the history books. As we clarify the role of the therapist and ensure consistent delivery of psychological support, I believe we will begin to realise the potential of psilocybin therapy for patients.
Sarah Bateup, RMN, BSc (hons), PGCE, BABCP Accredited CBT Therapist, MEd, Prof Doc, is Head of Therapy Research and Training at COMPASS Pathways. Sarah has spent her entire career in mental health, as a clinician, lecturer, clinical leader and researcher. She founded one of the first primary care cognitive behavioural therapy services in the UK and has taught at a number of universities including Exeter University and Kings College London, UK.
