Abstract
There is a developing dialogue between the psychoanalytic and psychedelic fields of psychotherapy. This paper contributes to this emerging collaboration by applying Winnicott's concept of transitional experience to psychedelic clinical work. By analyzing two Ketamine-Assisted Psychotherapy (KAP) cases, we explore in depth how transitional experience facilitates psychedelic transformation. We review clinical touch and introduce hand-holding as a transformational experience that can occur in the amplified relational field of the psychedelic space. Applying these ideas will deepen clinicians' theoretical understanding and experiential practice of KAP.
Introduction
The purpose of this paper is to explore how the psyche-soma regression and the amplification of perception that occurs during psychedelic states in clinical practice can create a transitional experience. These types of transitional experiences can be directed toward transformation and healing. To provide context to these processes, this manuscript begins with a brief history of psycholytic therapy and reviews the current psychedelic research of the last two decades. The second half of this paper describes the development and model of Ketamine-Assisted Psychotherapy (KAP) and presents two clinical cases. Ultimately, this paper extends Fischman's (2023) application of Winicott's concept of transitional experience to KAP that includes supportive touch, specifically hand-holding.
The first integration between psychedelics and psychoanalysis occurred in clinical experiments of psycholytic therapy in the 1950’s and 1960’s (Busch & Johnson, 1950; Frederking et al., 1955; Sandison, Spencer, & Whitelaw, 1954). These experiments with relatively normal functioning participants revealed that using low doses of Lysergic Acid Diethylamide (LSD) (30–150 mcg) or psilocybin (3–15 mg) evoked useful psychodynamic processes, such as catalyzing regression, softening defenses, deepening transferences,1 initiating catharsis, and surfacing spontaneous childhood memories2 (Leuner, 1959, 1967, 1971, 1977, 1984; Eisner, 1997; Eisner & Cohen, 1958; Passie, Guss, & Krähenmann, 2022). These experiments revealed that psycholytic therapy could be highly effective with people who struggle with anxiety and depression (Alnaes, 1964), obsessions and phobias, feelings of emptiness and isolation (Abramson, 1956; Cohen & Eisner, 1959; Chandler & Hartman, 1960; Dahlberg, 1963) and depersonalization and suicidality (Waltzer, 1972).3 Practiced primarily in Europe,4 psycholytic therapy became the first treatment to use psychedelics within a psychoanalytic framework. European clinicians embedded psycholytic therapy into long-term analytic treatment and utilized familiar psychotherapeutic processes while the ego remained intact (Passie et al., 2022). As a respected clinical method, more than thirty European clinics utilized psycholytic therapy until the mid-1970’s when legal prohibitions of psychedelics took effect. The research on psycholytic therapy from the mid-1900s could have been of better quality, including small sample sizes, and a lack of rigorous control groups. However, there was some evidence for long-term psychological benefits for typical functioning participants and minimal risk of major psychological complications (see Table 4 & 5, Passie et al., 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9755513/).
In the last twenty years, there has been a renaissance of scientific research on psychedelics and psychedelic-assisted therapies. This developing body of research is beginning to empirically demonstrate that psychedelics have the potential to accelerate, deepen, and assist therapeutic processes. Carhart-Harris (2019) hypothesizes that psychedelics can bring unconscious material into conscious awareness. His research supports that psychedelics can loosen or remove secondary process thinking and connect a person to deeper primary process experience (Cahart- Harris & Friston, 2010). Several researchers explore how psychedelics can soften boundaries of the self (Nour, Evans, & Carhart-Harris, 2017), generate regressive styles of cognition (Carhart-Harris et al., 2016a; Roseman, Leech, Feilding, Nutt, & Carhart-Harris, 2014), and produce deep and meaningful emotional states (Carhart-Harris et al., 2016b; Preller et al., 2017). Psychedelics can increase openness (Erritzoe et al., 2018; MacLean, Johnson, & Griffiths, 2011) and cognitive flexibility (Carhart-Harris & Nutt, 2017), and simultaneously provide an opportunity to revise negative fixed perspectives and self-beliefs (Carhart-Harris & Nutt, 2017). Subjects of psychedelic research consistently report a “marked reduction in defensiveness,…increased feelings of acceptance,…[and] an enhanced sense of connectedness” (Fischman, 2023).
Psychedelic states in clinical practice
Theories are emerging from research combined with observations made by some therapists working with psychedelic states of mind (Carhart-Harris & Friston, 2019; Letheby & Gerrans, 2017). Psychedelics are non-specific amplifiers that can magnify sensory perception, emotional experience, and cognitive processes (Grof, 1979). They bring forth a “heightened suggestibility”5 that can be used therapeutically to direct patients inward or towards interpersonal dynamics (Cohen, 1959). Psychedelic states exist on a continuum (Richards, 2017) and can facilitate access to repressed conflicts, affects, fantasies, and memories (Passie et al., 2022). During milder forms of psychedelic states, a partial ego dissolution can occur. Defenses, boundaries, and previously fixed beliefs about the self and the world soften, but conscious awareness stays relatively organized and contained by autobiographical memories and self-representations (Fischman, 2019). During more extreme psychedelic states, a complete dissolution of the ego occurs when a person no longer feels bound to the body or mind (Fischman, 2019). Psychedelics can generate experiences of deeply felt love, compassion, empathy, creativity, openness, peace, and/or sacredness that one can use to heal (Dore et al., 2019; Kolp, Friedman, Krupitsky, & Jansen, 2014). Psychedelics can also reduce the effects of negative self-concepts and promote new and positive ways of seeing oneself (Waltzer, 1972).
Psychedelic states and regression
we could think of what happens in a psychedelic experience as a kind of breakdown, surrender or regression- a loosening up of reality as it is normally perceived, allowing one to enter a state of deep emotion (primary process) and understanding where the narrativization of experience through language is not core and the emotional states themselves become mutative (Barret, 2022).
Fischman (2019) offers a model of psychedelic transformation by means of regression, where defenses are deactivated and perception becomes amplified. With a partial dissolution of the ego, the predictive coding that previously defined self-representation is disabled. As a result, the disruption of prior expectations that occurs during moderate-level psychedelic states directly deactivates psychological defenses (Fischman, 2023). Child-like perception and primary-process thinking dominate awareness. Attention shifts from that of a spotlight that uses “top down predictive coding based upon prior self-experience,” to that of an “open floodlight” or “lantern consciousness” (Fischman, 2019). A person's perception is amplified and one can perceive the world again for the first time. Without predictive processing, one can observe defenses and self-structures with a greater perspective and creatively restructure them (Fischman, 2019).
In more extreme forms of psychedelic states, complete ego dissolution can occur. A person may experience openness, mysticism, and boundless love (see Fischman, 2019, pp. 59–67). Fischman (2023) states that the most remarkable feature of complete ego-dissolution is how it parallels infant consciousness. He highlights that both ego dissolution and infant consciousness occur without the context of autobiographical history, continuity of time, physical cohesion of a body, and a sense of self (Fischman, 2023). Fischman states that one experiences psychedelic ego dissolution as a unitive feeling that resembles the omnipotence of early infancy. During the first phase of life, “there is no distinction between inner and outer, or subjective and objective experience; it is all one” (Fischman, 2023).
Psychedelic states as a transitional experience
Psychedelic states of regression can evoke a feeling of infant omnipotence (Fischman, 2023). In the state of infant omnipotence, the young child (infant) is under the illusion that an external object is his creation and omnipotently under his control and only gradually becomes aware of its separateness (Spitz, 1961). The change process from this state draws upon Winnicott's (1971) concept of transitional space, an intermediate area of experiencing between subjectivity and objective reality. In a psychedelic state, a person experiencing infant omnipotence may have a transitional experience that begins with a unitive feeling and a sense of awe (Yaden et al., 2017).
It is characterized as “smallness within vastness (transiently restored omnipotence), oceanic feelings of connectedness [Freud, 1929, 1930], global coenesthetic experience, and feeling ‘authentic’” (see Fischman, 2023, pp. 229–231). From start to finish, it is a process of “illusion-disillusionment” (Fischman, 2023; Winnicott, 1971). During the medicine's peak, a person may have the illusion of magically creating a subjective reality. As the effects of the medicine fade, they have a disillusionment experience of gradually surrendering omnipotence and returning to objective reality.
I suggest that psychedelic-assisted psychotherapy enables a regression…and in various stages of re-integration through states like awe, enables the creation of an area of transitional experience, in which the illusion-disillusionment process may be worked through…By not questioning the “reality” of such experience, psychedelic-assisted psychotherapy affords a transitional space…[and the] process may be thought of as a transitional experience…the therapist, in providing a transitional space, allows the subject the paradoxical experience of both creating and finding her objects…The psychedelic subject [adapts] the content of her experience to external reality spontaneously, a process that recapitulates and compresses the maturational scale [of infancy] into a matter of days or weeks…Psychedelic-assisted psychotherapy, in reducing defensiveness, enhancing connectedness and acceptance, helps restore a sense of authenticity. (Fischman, 2023)
During the integration phase of psychedelic psychotherapy, a person engages in a reflective process that provides a bridging function between their remembered psychedelic experience and their current objective reality (Nayak & Johnson, 2020). In Winnicott's (1971) theory of transitional phenomenon, he links infant omnipotence to creative expression in adult life. Transitional experience is a paradoxical process of creation-discovery (Ogden, 2021; Winnicott, 1971). In psychedelic psychotherapy, the “illusion” experience of omnipotence that takes place during psychedelic states is manifested through subjective creation. The “disillusionment” experience of gradually surrendering omnipotence manifests a discovery of the same experience, but felt in objective reality. The paradoxical quality of both creating and finding the same experience, allows the person to spontaneously adapt the content of their psychedelic state to external reality (Fischman, 2023). This is why it is common practice in psychedelic integration for patients to utilize art, music, poetry, dance, spirituality, connections to nature, and other mediums to extend the psychedelic experience into their everyday lives (Bathje, Majeski, & Kudowor, 2022).
Ketamine as a psychedelic medicine
During a ketamine-induced state, a person may experience vivid dreams, memories, or visions of the future (Kolp et al., 2014). Re-experiencing birth is common and contact is frequently made with deceased ancestors and mythical, extraterrestrial, or archetypal figures. Experiences of reliving one's entire life including death and rebirth also commonly occur. At lower “psycholytic” doses of ketamine, a person enters an “empathogenic experience” or trance state, where one's body relaxes and ego defenses loosen. The person feels an increased love, compassion, and empathy towards oneself, similar to the effects of a standard therapeutic dose of methylenedioxy methamphetamine (MDMA) (Dore et al., 2019; Kolp et al., 2014). Since the ego remains intact, ketamine-induced psycholytic states are useful to relationally process traumas and developmental arrest. A person may enter a state of “new mind” that is creative, open, and free of obsessional burdens (Wolfson, 2016). The effects of higher doses of ketamine are similar to the effects of moderate to high doses of LSD, psilocybin, or ayahuasca. The person enters a “transformational state” that has dissociative and disembodied effects (Dore et al., 2019). These doses may completely dissolve the ego including the boundaries between self and other, past and present, and inner and outer. These experiences come with a “rectification of narcissism” by balancing a person's personal and universal proportions. During psychedelic integration, an individual can leverage these experiences to increase cognitive and emotional flexibility and reduce negative or inflated ego functioning (Wolfson, 2016).
Ketamine-Assisted Psychotherapy (KAP)
more than 10,000 published reports describe ketamine’s high level of effectiveness and its confirmed biological safety…[and] clinical studies have generally detected no long-term impairment of behavior or personality functioning as a result of ketamine use (Kolp et al., 2014).
The most recent meta-analysis on ketamine, as a standalone intervention for depression, demonstrates efficacy (Calder et al., 2024). However, Dore (Dore et al., 2019) notes “that some patients are sickened by ketamine and a subset (<5%) cannot tolerate the nausea and vomiting experienced even with preventative medication.” In addition, the current research and clinical experience with ketamine demonstrates that some individuals do not receive any benefit from the standard dose of ketamine (Miller, Afshar, Mishra, McIntyre, & Ramanathan, 2024). More investigation is needed to determine whether these non-responders could benefit from higher doses, repeat doses, or treatment with ketamine in combination with psychotherapy (Drozdz et al., 2022; Wilkinson et al., 2021).
Since ketamine has an established history of clinical safety in medical settings (see Wolfson & Vaid, 2024, p. 2), providers transitioned to using ketamine for patients with a variety of diagnoses as an adjunct to psychotherapy in non-medical office settings (See Dore et al., 2019, p. 190). A recent systematic narrative review (See Drozdz, 2022, Discussion and Conclusion) of the current KAP literature demonstrates that KAP is effective in the reduction of symptoms for individuals with anxiety, depression and substance use. Despite these advantages, studies also show that KAP may lack long-term effectiveness with certain diagnoses and personality structures. The published evidence of KAP is limited by small sample sizes, heterogeneous populations, concurrent treatments, and absence of blinding and randomization (Drozdz, 2022). Some research participants report relapse and the reemergence of long-term mental health symptoms. These findings demonstrate that, “those [participants] with rigid personality structures, such as those with severe OCD or personality disorders and perhaps severe PTSD, find entering the trance state difficult and are not able to sustain the benefits they experience during the actual sessions” (Dore et al., 2019).
The model and practice of KAP
The KAP model has emerged over the last decade by clinicians adapting parts of the MDMA-assisted psychotherapy model from the Multidisciplinary Association for Psychedelics Studies (MAPS) but substituting ketamine for MDMA (Dore et al., 2019). The ad hoc emergence of the KAP model has resulted in a lack of a clear protocol and a dearth of research. The KAP model combines biological, psychological, and transpersonal elements (Krupitsky & Grinenko, 1996; Krupitsky et al., 2007; Wolfson & Vaid, 2024). Before the preparation sessions, clinicians obtain informed consent, conduct psychological and medical evaluations, and review safety protocols. The preparation session(s) are focused on reviewing and developing resources, exploring treatment expectations, intentions, and reviewing types of touch (safety, supportive, and therapeutic). Typically, there are three to six ketamine medicine sessions often attended by the same clinician. Integration sessions that focus on exploring the patient's ketamine-induced experiences follow each KAP medicine session. The patient and clinician may adjust the number of medicine sessions as clinically indicated. The route of ketamine administration varies, including intramuscular, intravenous, or sublingual. In the clinic, KAP medicine sessions are approximately 3 h long. The ketamine sessions can occur weekly or biweekly or can be separated by weeks or even months. The cadence is determined by the length of treatment, the presenting issue, level of functioning, severity of symptoms and other practical factors. Clinicians may offer this protocol with a patient who is already in weekly psychotherapy with the same provider, as in Omar's case presented below. Alternatively, clinicians can provide KAP as a stand alone treatment, such as adjunct support to a weekly psychotherapy, as in Fey's case discussed below. The two in-person cases presented in this paper use the sublingual route of administration, the effects of which typically last 1–2.5 h in duration and peak around 15–40 min after administration is complete. Although oral administration is the most convenient and commonly utilized practice for KAP in outpatient private practice settings, there is very limited research on the efficacy of sublingually-administered KAP treatments. This can but does not always include some at-home unsupervised sessions with sublingual ketamine (Zydb & Hart, 2021). The emergence of telehealth clinicians offering oral ketamine as well as group-based KAP interventions are also emerging but not well-researched treatments variably influenced by the KAP model (Hull et al., 2022; Robison et al., 2022).
the ethical ketamine clinician has received special training and or mentorship in working with therapeutic ketamine. A comprehensive training includes substantial education in the following domains: medical, psychological, and psychedelic (Bennett, 2020).
KAP training programs address the topics of set and setting, the therapeutic container, psychoactive effects unique to ketamine, and the process of working with psychedelics (Ryan, 2020). Training programs encourage didactic continuing education, supervision, mentorship, and personal experiences with the medicine.
Most current KAP training programs offer immersive training retreats with ketamine-induced states for clinicians-in-training. Although not everyone holds the position that personal experience with the medicine is necessary to become a KAP provider, most KAP training programs believe that personal experience is essential. It helps clinicians become familiar with the arc of a ketamine journey and the different types of experiences a person can have during ketamine-induced states. People describe visiting the intergenerational space of ancestors, the evolutionary space of biology, and the mystical space of spirituality and the cosmic (Polaris Insight Center, training modules).
The use of touch in KAP
touch in psychotherapy is a legitimate and valuable modality when used skillfully with clear boundaries, sensitive application, and good clinical judgment…therapists should have training and supervision in the use of touch, that touch is never utilized to gratify the personal needs of the therapist, and that sexual touch is never part of therapy (Dvir & Hull, 2024).
Clinicians should assess four areas before engaging in touch: context, intent, consent, and competence (MAPS Training Manual, Integrity, 2020). Somatic psychedelic therapists can engage in touch to facilitate a transformation that unlocks stored traumas, memories, and unsymbolized experiences of the body (Gold, 2024). Psychedelic therapists who do not have training in somatic work should only use touch to establish safety and connection, and to communicate acceptance, presence, and support (MAPS Training Manual, 2020).
provided careful informed consent was obtained during the preparatory session. Interestingly, every psycholytic therapist in the past was in favor of marginal physical touch (e.g., holding a hand) as an occasionally necessary component of psycholytic therapy (Passie et al., 2022).
Since the psychedelic experience can be akin to the emotional experience of infancy (Fischman, 2023; Grof, 1979, 1988), supportive touch may be necessary in some instances to facilitate safety and psychological holding (Dvir & Hull, 2024; Gold, 2024). One can interpret psychedelic states as a form of psyche-somatic regression affecting tactile sensations, somatic experiencing, physical and mental boundaries, and the experience of time (Fischman, 2019, 2023; Groff, 1979, 1988). Psychedelics can create a feeling of boundarylessness, where the psyche-soma is unprotected and not mediated by any barrier. During these psychedelic states, Winnicott's concept of the “limiting membrane” (Winnicott, 1960), the barrier usually experienced at the skin that develops to delineate the position between “me” and “not-me,” has partially or completely dissolved. Winnicott also describes the infant's experience of timelessness, where time is experienced solely based on the infant's physical and psychological rhythms, rather than by some objectively agreed upon reality (Stern, 1985; Winnicott, 1962). Psychedelics create a similar experience of time, where it can be distorted, condensed, stretched, traveled through, or disintegrated completely (Grof, 1979).
an adult in a state of ego dissolution is prone to fear of death…or other terrifying images/thoughts unmitigated by defense mechanisms. One wonders if terror in such cases may be traced to the infant’s annihilation fears…The parallel between the two states of consciousness suggests that in psychedelic-assisted psychotherapy a terrified patient may be experiencing something like the “annihilation” of infancy and may explain on a dynamic level how the “holding” presence of an empathic, supportive therapist may help to stabilize the patient’s fears. (Fischman, 2023)
These moments require a type of infantile holding which may include reassuring touch (Dvir & Hull, 2024; Gold, 2024). The therapist must thoughtfully yet quickly decide to make physical contact with a patient who is having this type of psychedelic experience. The clinician should retrospectively process the moment of touch to determine whether it facilitated or encumbered the therapeutic process (Fossage, 2000).
Touch as a transformational experience
The therapist should consider the decision to touch and its effects in the context of a greater relational process (Herzberg & Butler, 2024). Since psychedelics can amplify the therapeutic relationship and transference, they can provide opportunities for relational healing that might not be realized in a weekly psychotherapy. In some cases, psychedelics will reduce fear and distrust, thereby amplifying a positive transference or neutralizing a negative transference. Therapists can leverage an amplified positive transference to maximize transformation through processes of internalization, reparation, and the reconfiguring of internalized objects (Herzberg & Butler, 2024). I will demonstrate this in the first case example below. Conversely, psychedelics can also increase feelings of fear and mistrust, thereby amplifying a negative transference that may not be realized in a weekly psychotherapy. If clinicians can adequately contain the amplified negative transference, it can become an opportunity for patients to safely revisit and process traumas and early failures (Herzberg & Butler, 2024).
Magnified therapeutic holding and touch has great transformative potential (Dvir & Hull, 2024; Gold, 2024; Herzberg & Butler, 2024). During a KAP medicine session, a patient who was holding my hand described, “a feeling of being held more closely and completely than I [he] could ever remember being held before.” He later described to me, “a feeling of being centered and having perfect clarity,” and that this opened him to new potential ways of being. With a different patient, who was in a similar regressed state during a KAP medicine session, I made the decision not to touch him. During his integration, when we discussed my decision to not provide supportive touch, he expressed to me that he was surprised. He experienced me having my arms around him, holding him, and bearing the weight of his upper body completely. These patients, who were experiencing a psyche-somatic regression akin to infancy, could feel the deeply primitive and universal human need for physical and psychological holding. The first patient's experience of touch and the second patient's imagined experience of holding are “transformational experiences” (Rundel, 2022) where “structural and dynamic transformations take place [between] patient and analyst” (Cancelmo, 2009, 2019).
Case examples
In the KAP cases that follow, we use the concept of transitional experience (Fischman, 2023) to refer to the entire process of “illusionment-disillusionment” (Fischman, 2023; Winnicott, 1971) that occurs in the course of a KAP treatment. This process begins during the KAP medicine session and continues through integration. In both case examples, we explore how hand-holding is crucial to forming an opening for “transformational experiences” (Rundel, 2022) for these two patients.
As examined in detail below, psychotherapist disclosure, reverie (Bion, 1962), and the unconscious communication (Ferenczi, 1919) between the dyadic pair, can be important parts of the process of transitional experience. We use the term “reverie” to describe the therapist's private subjective experience such as fantasy, feelings, somatic experiences. Clinicians can use these experiences to receive and metabolize patients' raw mental, emotional, and bodily sensations (Bion, 1962). We use the term “unconscious communication” to describe an unconscious dialogue between the patient and therapist that conveys symbols and meaning to each other (Ferenczi, 1919; see Ferenczi's clinical diary, Dupont et al., 1998). The unconscious communication that occurs in the amplified psychedelic field can have a strong and lasting effect on the psychotherapists' fantasies, reveries, countertransference, and even dreams (Butler, Herzberg, & Miller, 2023).6
These case histories are written from the perspective of JL based on his observations and reflections. In the first case discussed below, Omar's transformation occurs primarily through internalization of a positive paternal transference. His case is remarkable because it illustrates how transformation can occur suddenly during a ketamine-induced psychedelic state during a short period of hand holding. Omar and I also co-create a shared psychedelic space that emerges from our parallel ketamine journeys. To provide context, my journey occurred during a training retreat that was a part of my ongoing experiential KAP training. Coincidentally, Omar and I both took psychedelic trips to the redwoods. We ultimately create a psychedelic space that helps Omar reimagine a new relationship with his father.
Omar
Omar is a 45-year-old cis-gender, heterosexual man who identifies as Lebanese American and works in biotechnology. As a weekly psychotherapy patient, he entered treatment to recover from a breakup that had thrust him into a deep depression. Omar consistently perseverated on the heartbreak. He was convinced that he would never find anyone he could love or be as sexually satisfied with as he was with his former partner. In our work together, we came to understand that his breakup made him feel a similar powerlessness and vulnerability that he felt as a child. Omar's father was abusive and he grew up during the civil war in 1980’s Lebanon. The part of himself that identified with his abusive father and his hypervigilance from being a child of war oppressed Omar. Three years into his treatment, Omar decided to have a stand alone KAP session with me. He formulated his psychedelic journey's intention as wanting to explore his relationship with his father.
During our preparation phase, Omar shared a fantasy of visiting his favorite place on earth. He described standing on a cliff overlooking the sea in Greece and feeling liberated. He then asked me about my favorite place on earth; I told him the redwoods. Omar lit up and encouraged me to visit the redwoods since they are so close to San Francisco. In contrast to Omar's usually negative and restricted view of the world, Omar expressed a newfound enthusiasm.
Omar's curiosity and enthusiasm about my favorite place inspired me to continue my own psychedelic integration process. The next Sunday morning, I wandered through Muir Woods by myself. In our following preparation session, I expanded upon my original disclosure and shared my Muir Woods experience with Omar by showing him photographs of the visit. My intention in sharing was to build upon the candor that we had developed in the previous session. However, I consciously made the decision not to disclose my personal KAP experience to him. Nor did I share that my KAP journey was about repairing my relationship with my mother. Although I did not know it at the time, I retrospectively realized that Omar and I were preparing for a deepening of our transference relationship. We were already engaged in a process of unconscious communication (Ferenczi, 1919; see Ferenczi's clinical diary, Dupont et al., 1998) that helped deepen our preparation process. This set the conditions for Omar to have an important transformational experience during his KAP medicine session. During his experience, I was equally affected with powerful feelings of countertransference and rich reverie.
During Omar's KAP session, we did not speak until the effects of the medicine faded. A half hour into the session, Omar began crying inconsolably. I felt an instinctive desire to hold his hand. Although he gave consent, I wondered how he would receive my touch. He accepted my hand and gripped it tightly; I intuited that he was having a breakthrough moment. When he stopped crying, he let go of my hand and began to have his own separate experience. I then surrendered to my own thoughts about Omar in Greece. In my reverie (Bion, 1962), I imagined Omar free and surrounded by the magnificent beauty of a deep blue sea contrasted by towering rocky cliffs and a hot bright sun tempered by cool winds.
I made the decision to hold Omar's hand and I believe my touch was therapeutically beneficial. We established a solid therapeutic alliance that I felt could withstand any negative reaction that Omar might have to my holding his hand. I considered that Omar might experience my hand holding similar to the touch of an abusive father. Alternatively, I worried that not holding his hand would become a missed opportunity for repair. After a swift internal debate, I felt that my hand would be comforting and if he indicated that it was unwelcome, I would be able to repair my intrusion. When he accepted my hand and held it tightly, I understood that my touch was welcome.
As we held hands, I was able to more closely feel his overwhelming sadness. Then I felt him emotionally calm and open up to receive all of my support and care, along with transferential paternal love. In other words, I believe that our hand holding in the amplified relational field created the opening for a transformational experience that resulted in the internalization of the therapeutic relationship. I interpreted that Omar was experiencing a partial dissolution of his ego, had become regressed and felt as if he was omnipotently creating this experience.
When Omar calmed, he released my hand. The session shifted at this point from us having an interpersonal experience to us having independent subjective experiences of the psychedelic space. To my surprise, Omar later told me that his journey took place not in Greece, but in the redwoods. My sacred space of healing with my mother had now become our sacred space, where Omar would repair his relationship with his father. During our long moment of silence, I believed that my KAP journey to the redwoods, where I had repaired my maternal relationship, influenced Omar's repair of his paternal relationship.
“I was in the forest and I was with my dad the entire time. When you held my hand, I felt him coming through you. I was sending a prayer through your hand to him and he was sending one to me. When I was a kid, my dad was a serious man and I very rarely saw him laugh, smile or play. I couldn't ever reach him. But in the journey, I got what was missing in my relationship with my father. We were finally having fun together. He was loving and playful. At one point, my dad and I spot you through the redwood trees praying in a yogi pose. You were peaceful. My dad and I invited you to have dinner with us at my uncle's house. These dinners are the only memories I have from childhood where I was allowed to be a happy and silly kid.”
“I was young, maybe 5 or 6 years old, and we were driving to my dad’s work. We entered a large underground parking lot and I remember we were well beneath the ground when we parked. When we got out of the car, the power went out and we were in complete darkness. It was pitch black and I could sense his concern. We were lost, but he held my hand the whole time. I remember feeling like I wasn’t sure if he was going to be able to get us out of there, but he eventually did.”
The transitional moment of us holding hands mirrors Omar's actual childhood memory of feeling his father's care and protection in the parking garage. I believe his hand-holding experience and his rediscovery of this memory serve as the “illusion-disillusionment” experience (Fischman, 2023; Winnicott, 1971). Together they allow him to simultaneously create and discover a new relationship with his father.
Omar's treatment outcome
A year and a half after his journey, Omar continues to build a positive relationship with his father and himself. Omar is showing signs that he is healing from his childhood experiences of abuse and oppression. He reports that he no longer has obsessional thoughts about his ex-fiancé and is open to a new romantic relationship. However, feelings of loneliness have surfaced and he is beginning to recognize patterns of sexual compulsivity. In our current work which included another KAP session approximately one year later, Omar is exploring his relationship with women and how he uses them to manage his insecurities and feelings of loneliness.
Case example – 2
Fey is a 41-year-old who identifies as a Chinese-American, cis-gender woman. She has an MBA and is a talented writer. Her treatment goals were to resolve her lifelong depression and to work through her attachment wounds. Since entering mid-life, she began to experience passive suicidal ideation which primarily manifested as a desire to not exist. During our intake, I learned that when she was two years old, Fey's parents immigrated to the United States from China and left her behind with her grandparents. It was not until she was five years old that she traveled by herself to New York City to be reunited with her parents. Fey's four KAP sessions took place approximately one to two weeks apart and we engaged in several preparation and integration sessions. I describe sessions 3 and 4 below to demonstrate Fey's process of transitional experience.
Sessions 3 and 4
“I had a thought this morning about my journey to the United States. I had to take the flight by myself and I had no idea what to anticipate. My grandparents and I were so sad at the airport. The beginning of my medicine session was that flight. It was restorative to have you next to me to take my hand and bear witness to my feelings during take off and landing. In my visions, I saw outer skies and clouds and aerial views of a city. I think that was me landing in New York City for the first time.”
In her state of partial omnipotence, Fey's transitional experience of illusion-disillusionment began in the transformational moment of us holding hands. She was able to create the illusion of safety, while moving through the terror associated with the traumatic immigration memory. As she recounted her psychedelic experience to me, Fey reconstructed the original traumatic memory and reformulated its meaning. She stated in an empowered way, “in order for me to feel safe right now, it is helpful for me to identify the safety that I emotionally needed in the past.” In the state of disillusionment, Fey was able to face the painful reality that she felt very unsafe during her immigration journey, and she realized that she was entitled to safety as a child.
Fey: I’m in a village. I don’t know why I’m here. I’m sliding backwards – not falling. It was very blue and now it’s turning all black. I’m somehow being powered into the ground. Did I go back to sea? Or did I go back to sleep? What’s inside this box? Is it me? Is it time to go? [She is coming out of the experience.]
Therapist: No, we have plenty of time. [She slides back into the experience.]
Fey: Why did you bring me here? I’m in a dark place. I don’t know how to explain it, but I’m being sent out to sea. I think I’m dead. It’s dark and we have been sent out to sea. What are we now evolving into?
[Time passes in silence. I have a fantasy of my six-year-old son transforming into a grown man. I am at his wedding. He is beautiful and full of nerves. I notice his angular face, similar to my own. He no longer has his boyish cheeks. I am excited that he has his entire life ahead of him. I feel deep love for him.]
Fey: Do you see yourself there?
Therapist: No. Where am I?
Fey: You’re in a caramel café. You’re examining the art.
Therapist: How do I seem?
Fey: Quizzical (laughs). I see colors and they keep changing from salmon to orange and now to deep red. You are with me the whole time helping me unlock a future that I can now see.
[After the effects of the medicine have worn off]
Fey: The beginning of my journey was in complete darkness. I felt that I was dead and sent out to sea, a Nordic funeral of sorts. This journey was all about my life, not my parents' lives. In contrast to my previous journeys that were entirely in darker colors, this one bloomed into vibrant red and orange colors. It was calm, peaceful, and beautiful.
I literally interpreted Fey's question, “is it time to go?” as meaning, is the session finished. However in retrospect, I now understand that she may also be asking a figurative question, is it time for me [Fey] to die. I responded, “no, we have plenty of time.” The session had recently begun and we had ample time left. However, my response also may have given Fey permission to further explore being dead and what happens afterwards.
I think her other question, “what are we now evolving into?” was a pivotal part of the session. Instead of searching for an answer to her question, she fell into a deep silence and explored death from a position of omnipotence. Her question catalyzed my reverie about my youngest child transforming into a man and getting married. I saw a vision of my son's face that was similar to my own, but it was clear to me that he would supersede me in his life. My son's wedding and hope for his future life symbolized a new beginning. I could feel the passing of life transgenerationally.
In contrast to my previous journeys where I observed scenes from my past, in this journey I imagined new vignettes. I saw a bright yellow light with vibrant blues similar to a Van Gogh inspired painting of a lighthouse. There was a house with a backyard and views of trees and the ocean. I think it was about my life that is yet to come.
In contrast to Omar's sudden transformation, Fey's transformation occurs more gradually over the course of four KAP medicine sessions. Similar to Omar's case, holding hands forms an opening for Fey to have a transitional experience. In a state of partial omnipotence, Fey unearths an early traumatic childhood memory. In a state of “age regression,” (Fernandez-Cerdeno & Leuner, 1965) she relives immigrating to the United States alone, at the age of five years old. I believe hand holding in the amplified relational space provided Fey with an important experience of holding (Winnicott, 1960, 1962). It allowed her to process her trauma on a deeper somatic and emotional level; a level she previously did not have access to in her weekly therapy. The resulting internal sense of safety she establishes helps her catalyze another important transformational experience. In this experience, she faces an unconscious fantasy of being dead.
Fey's treatment outcomes
In the case of Fey, the lasting benefits and positive outcome of her treatment are not yet clear. We engaged in two more KAP sessions approximately six months and eight months later respectively, after the first four meetings. When Fey returned for these sessions, she reported that she had made some gains regarding her depression and suicidality. However, I observed that our connection had changed and she was distant and did not bring the same investment to the work. These two KAP sessions surfaced for her an ambivalence about her treatment, as well as a negative transference towards me. Despite there being significant integration and follow up after the initial four KAP sessions, I worry that she felt overly exposed and inadequately supported. I further explore these issues below.
Discussion and Conclusion
Freud's “talking cure” began as a therapeutic practice of meaning making, linguistics, and interpretation. The integration of psychedelic clinical work into the analytic frame offers many innovations (Guss, 2022; Rundell, 2022). This collaboration can move psychoanalysis toward becoming a deeper relational, somatic, and experiential practice (Fischman, 2019, 2023; Barrett, 2022; Rundel, 2022). Psychedelic therapists utilize several methods that involve focused attention, breath, movement, supportive touch, and body work; Sensorimotor Psychotherapy, Somatic Experiencing, Holotropic Breathwork, and Hakomi release sensations, pains, emotions, and memories (Brennan & Belser, 2022; Holas & Kamińska, 2023). Many therapists are influenced by the theoretical “inner healing intelligence” model that relies on an individual's innate wisdom to self-repair by connecting and finding meaning from psychological symptoms, somatic experiences, and physiological states (Aday et al., 2024; Mithoefer, 2015). The incorporation of psychedelics and these techniques into psychoanalytic treatment will provide patients with new perspectives and a “direct experience of seeing [oneself] in a new way” (Dore et al., 2019).
The clinical use of psychedelics changes how therapists create the “facilitating environment” (Winnicott, 1962). This will be a departure from how most psychoanalysts, even those from the intersubjective and relational schools, approach the clinical situation. A classical analyst assumes a position of neutrality and creates the environmental setting of a blank canvas. In contrast, the attention to set and setting in psychedelic work puts the therapist in the role of not only being a container, but also a curator of experience (Guss, 2022). Creation of the setting includes the incorporation of music and other creative, artistic, and spiritual elements into the space. This gives the therapist more stewarding control over the environment and more creative influence in the construction of the psychedelic space. This results in a more active approach to holding the patient and developing a facilitating environment.
While psychedelic therapists may gain more control in the development of the setting, the patient assumes a more significant position of power in the therapeutic relationship, influenced by the model of the patient's “inner healing intelligence” (MAPS Handbook, Inner Healing Intelligence). By empowering the patient to lead the direction of treatment, the patient gains more agency and the therapist-patient relationship is more egalitarian. The amplification and speed of transformation in psychedelic work (informed by the model of “Inner Healing Intelligence”) requires the therapist to have a greater capacity to tolerate the unknown, to trust the process, and to believe in the patient's inner wisdom. During medicine sessions, the psychedelic therapist is often simply bearing witness to the patient's self directed healing process.
In Omar's case, he was a long-term weekly psychotherapy patient; we had already tested the therapeutic alliance and the transference mainly was benign. He tolerated the vulnerability that comes with doing psychedelic work and he trusted that I would support him throughout. Our bond facilitated the adjustment of boundaries and the therapeutic frame. The traditional KAP model fits well within a weekly psychoanalytic therapy, and it was effective in accelerating and deepening Omar's therapeutic process.
The standard KAP model was also used when working with Fey. However, in contrast to Omar's case, she was a short-term patient. In retrospect, it has become clear that Fey did not feel supported enough after the KAP process completed. There is the possibility that using the KAP model with short-term patients with underlying attachment issues may not be effective. Perhaps the treatment would have been more successful if Fey's KAP sessions had been provided in the context of a longer-term psychoanalytic therapy similar to Omar's. Upon Fey's return after her initial four KAP sessions, Fey seemed overwhelmed by feelings of vulnerability and fears of abandonment. This manifested as ambivalence towards the KAP treatment and a negative transference towards the therapist. Perhaps a longer-term psycholytic model, with its slower pace and lower dose sessions, would be a better fit for Fey. It could help her focus on her attachment issues and the negative transference without overwhelming her, and it could be embedded into long-term weekly psychotherapy.
Adverse effects and contraindications of psychedelics and psychedelic-assisted therapies
There is an emerging strand of research that finds more adverse experiences and long-term side effects than previously reported (Schlag, Aday, Salam, Neill, & Nutt, 2022). Hallucinogen Persisting Perception Disorder (HPPD) is a short-term or chronic condition that can occur after psychedelic use, particularly with high doses of LSD. HPPD is a re-experiencing of perceptual distortions, as in “flashbacks”or intense dissociative symptoms (Halpern, Lerner, & Passie, 2018). Breeksema et al. (2022) recently conducted a systematic review of adverse experiences reported in clinical psychedelic trials. This research concluded that 40% of adverse events went unreported in trials of esketamine. These studies conclude that psychedelic research and practice must further develop its ethical standards to assure safety and reduce side effects.
Research suggests that psychedelic psychotherapy can be effective in the treatment for mental disorders caused by mental rigidity, such as addiction, depression, and obsessions (Barrett, 2022; Carhart-Harris & Friston, 2019). Conversely, it is contraindicated for patients with psychosis or an unsturdy sense of self (Barett, 2022). Therapists should take great caution with people who have bipolar conditions, dissociative disorders, severe trauma, thought disorders, and intense transferences (Rundel, 2022). In addition, preventive strategies and continued training is necessary to reduce the risk of therapist boundary violations (Meikle, Carter, & Bedi, 2024).
Conclusion
The collaboration of psychoanalysis and psychedelic psychotherapy has the potential to develop conceptual terminology and a unifying language that can support psychedelic work. Psychoanalytic therapists can use the concept of transitional experience (Fischman, 2023; Winnicott, 1971) to understand the processes that occur during psychedelic psychotherapy. During psychedelic work, a transitional experience occurs in a complex process that involves an interaction between the medicine, touch, the amplified relational field, and the therapeutic relationship. This kind of clinical work is one of illusion-disillusionment that engages the patient in a process of creation-discovery.
Conflict of interest
No potential conflict of interest was reported by the authors.
Acknowledgements
We are grateful for Harvey Schwartz, PhD who helped formulate the ideas at the beginning stage of writing this paper. Eric Seinknecht, PsyD., Rebecca Rothberg, PsyD., and Raquel Bennett, Psy.D. provided invaluable research assistance. Finally, a special thank you to Roxanne Hoegger Alejandre, Esq., and Jacqueline Lichtenstein, M.D., for helping with the editorial process. We would not have been able to complete this paper without their support.
References
Abramson, H. (1956). LSD 25 as an adjunct to brief psychotherapy. The Journal of Psychology, 41, 199.
Aday, J., Horton, D., Fernandes-Osterhold, G., O’Donovan, A., Bradley, E., Rosen, R., & Woolley, J. (2024). Psychedelic-assisted psychotherapy: Where is the psychotherapy research? Psychopharmacology, 1–10 2024.
Alnaes, R. (1964). Therapeutic application of the change in consciousness produced by psycholytica (LSD, psilocybin, etc.). Acta Psychiatrica Scandinavica, 40, 397–409.
Balint, M. (1952). Primary love and psycho-analytic technique. London: Tavistock, 1965.
Barrett, K. (2022). Psychedelic psychodynamics: Relational knowing and the unthought known. Psychoanalytic Dialogues, 32(5), 484–496. https://doi.org/10.1080/10481885.2022.2106141.
Bathje, G. J., Majeski, E., & Kudowor, M. (2022). Psychedelic integration: An analysis of the concept and its practice. Frontiers in Psychology, 13, 824077. Published 2022 Aug 4. https://doi.org/10.3389/fpsyg.2022.824077.
Bennett, R. (2020). Ethical guidelines for ketamine clinicians. Journal of Psychedelic Psychiatry, 2(4), 19–20. https://www.journalofpsychedelicpsychiatry.org.
Bion, W. R. (1962). Chapter twelve. Learning from experience. In Seven servants (Vol. 3, pp. 31–37). New York: Aronson. 1977.
Breeksema, J., Kuin, B., Kamphuis, J., van den Brink, W., Vermetten, E., & Schoevers, R. (2022 Oct). Adverse events in clinical treatments with serotonergic psychedelics and MDMA: A mixed methods systematic review. Journal of Psychopharmacology, 36(10), 1100–1117.
Brennan, W., & Belser, A. B. (2022). Models of psychedelic-assisted psychotherapy: A contemporary assessment and an introduction to EMBARK, a transdiagnostic, trans-drug model. Frontiers in Psychology, 13, 866018. Published 2022 Jun 2. https://doi.org/10.3389/fpsyg.2022.866018.
Buchborn, T., Kettner, H. S., Kärtner, L., & Meinhardt, M. W. (2023 Oct 6). The ego in psychedelic drug action – Ego defenses, ego boundaries, and the therapeutic role of regression. Frontiers in Neuroscience, 17, 1232459. PMID: 37869510; PMCID: PMC10587586. https://doi.org/10.3389/fnins.2023.1232459.
Busch, A. K., & Johnson, W. C. (1950). L.S.D. 25 as an aid in psychotherapy; preliminary report of a new drug. Diseases of the Nervous System, 11, 241–243.
Butler, J. A., Herzberg, G., & Miller, R. L. (2023). Integral psychedelic therapy: The non-ordinary art of psychospiritual healing. Taylor & Francis.
Calder, C. N., Kwan A. T. H., Teopiz K. M., Wong, S., Rosenblat J. D., Mansur, R. B. … McIntyre, R. S. (2024 Jul 1). Number needed to treat (NNT) for ketamine and esketamine in adults with treatment-resistant depression: A systematic review and meta-analysis. Journal of Affective Disorders, 356, 753–762. https://doi.org/10.1016/j.jad.2024.04.039.
Cancelmo, J. (2009). The role of the transitional Realm as an organizer of analytic process. Psychoanalytic Psychology, 26(1), 2–25.
Cancelmo, J. (2019). Unconscious communication in the intersubjective analytic field at times of separation, loss, and termination. Psychoanalytic Inquiry, 39(3–4), 198–212.
Carhart-Harris, Muthukumaraswamy, S., Roseman, L., Kaelen, M., Droog, W., Murphy, K. … Nutt, D. J. (2016a). Neural correlates of the LSD experience revealed by multimodal neuroimaging. Proceedings of the National Academy of Sciences of the United States of America, 113, 4853–4858. https://doi.org/10.1073/pnas.1518377113.
Carhart-Harris, R. L., Kaelen, M., Bolstridge, M., Williams, T. M., Williams, L. T., Underwood, R. … Nutt, D.J. (2016). The paradoxical psychological effects of lysergic acid diethylamide (LSD). Psychological Medicine, 46(7), 1379–1390. https://doi.org/10.1017/S0033291715002901.
Carhart-Harris, R. L., & Friston, K. J. (2010). The default-mode, ego-functions and free-energy: A neurobiological account of Freudian ideas. Brain, 133, 1265–1283.
Carhart-Harris, R. L., & Friston, K. J. (2019). REBUS and the anarchic brain: Toward a unified model of the brain action of psychedelics. Pharmacological Reviews, 71(3), 316–344. https://doi.org/10.1124/pr.118.017160.
Carhart-Harris, R. L., & Nutt, D. J. (2017). Serotonin and brain function: A tale of two receptors. Journal of Psychopharmacology, 31, 1091–1120.
Chandler, A., & Hartman, M. (1960). LSD 25 as a facilitating agent in psychotherapy. Archives of General Psychiatry, 2, 286.
Cohen, S. (1959). A pharmacological approach to the study of the mind. Illinois: Charles C. Thomas.
Cohen, S., & Eisner, B. (1959). Use of LSD in a psychotherapeutic setting. Archives of Neurology & Psychiatry, 81, 615.
Dahlberg, C. (1963). LSD as an aid to psychoanalytic treatment. In Science and psychoanalysis (VI, pp. 255–268). J.H. Masserman.
Dore, J., Turnipseed, B., Dwyer, S., Turnipseed, A., Andries, J., Ascani, G. … Wolfson, P. (2019). Ketamine Assisted Psychotherapy (KAP): Patient Demographics, Clinical Data and Outcomes in Three Large Practices Administering Ketamine with Psychotherapy. Journal of Psychoactive Drugs, 51(2), 189–198. https://doi.org/10.1080/02791072.2019.1587556.
Drozdz, S. J., Goel, A., McGarr, M. W., Katz, J., Ritvo, P., Mattina, G. F. … Ladha, K. S. (2022). Ketamine assisted psychotherapy: A systematic narrative review of the literature. Journal of Pain Research, 15, 1691–1706. https://doi.org/10.2147/JPR.S360733.
Dvir, S., & Hull, J. (2024). Chapter 7. Relational touch in psychedelic-assisted psychotherapy. In Integral psychedelic psychotherapy (pp. 128–144). Taylor and Francis Group.
Eisner, B. (1997). Set, setting and matrix. Journal of Psychoactive Drugs, 29(2), 213–216.
Eisner, B., & Cohen, S. (1958). Psychotherapy with lysergic acid diethylamide. Journal of Nervous and Mental Disease, 127, 528–539.
Erritzoe, D., Roseman, L., Nour, M. M., MacLean, K., Kaelen, M., Nutt, D. J., & Carhart-Harris, R. L. (2018). Effects of psilocybin therapy on personality structure. Acta Psychiatrica Scandinavica, 138, 368–378.
Ferenczi, S. (1919). Further contributions to the theory and technique of psychoanalysis. London: Hogarth Press. New York: Basic Books.
Ferenczi, S. edited and translated by Balint, M., Dupont, J., & Jackson, N. Z. (1998). The clinical diary of Sandor Ferenczi. Cambridge, MA: Harvard University Press.
Fernandez-Cerdeno, A., & Leuner, H. (1965). Das Erleben der oralen regression unter Einfluß von Halluzinogenen (LSD-25 und Psylocybin). Zeitschrift für Psycho-somatische Medizin, 11(1), 45–54.
Fischman, L. (2019). Seeing without self: Discovering new meaning with psychedelic-assisted psychotherapy. Neuropsychoanalysis, 21(2), 53–78.
Fischman, L. (2023). Psychedelic-assisted psychotherapy in 3-D: Acceptance, connectedness, and defensiveness. Neuropsychoanalysis, 25(2), 217–236. https://doi.org/10.1080/15294145.2023.2255991.
Fossage, J. (2000). The meaning of touch in psychoanalysis. Psychoanalytic Inquiry, 20(1), 21–43.
Frederking, W. (1955). Intoxicant drugs (mescaline and lysergic acid diethylamide) in psychotherapy. The Journal of Nervous and Mental Disease, 121, 262–266. https://doi.org/10.1097/00005053-195503000-00010.
Freud, S. (1910). The Origin and development of psychoanalysis (21 no. 2). University of Illinois Press.
Freud, S. (1929 (1930)). Civilization and its discontents. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (1981 ed, Vol. XXI, pp. 59–145). The Hogarth Press.
Gold, V. (2024). Chapter 6. A somatic approach to psychedelic-assisted psychotherapy. In Integral psychedelic psychotherapy (pp. 103–127). Taylor and Francis Group.
Grof, S. (1979). Realms of the human unconscious: Observations from LSD research (1st ed.). Viking Adult.
Grof, S. (1988). The adventure of self-discovery. Dimensions of consciousness and new perspectives in psychotherapy and inner exploration. SUNY Press.
Guss, J. (2022). A psychoanalytic perspective on psychedelic experience. Psychoanalytic Dialogues, 32(5), 452–468. https://doi.org/10.1080/10481885.2022.2106140.
Halpern, J., Lerner, A., & Passie, T. (2018). A review of hallucinogen persisting perception disorder (HPPD) and an exploratory study of subjects claiming symptoms of HPPD. Current Topics in Behavioral Neurosciences, 36, 333–360.
Herzberg, G., & Butler, J. (2024). The heart of the work: Relational psychedelic-assisted therapy. Routledge.
Hoffer, A. (1967). A program for the treatment of alcoholism: LSD, malvaria and nicotinic acid. In H. Abramson (Ed.), The use of LSD in psychotherapy and alcoholism (pp. 343–406). New York, NY: Bobbs-Merrill.
Holas, P., & Kamińska, J. (2023, Dec). Mindfulness meditation and psychedelics: Potential synergies and commonalities. Pharmacological Reports: PR, 75(6), 1398–1409. https://doi.org/10.1007/s43440-023-00551-8.
Hull, T. D., Malgaroli, M., Gazzaley, A., Akiki, T. J., Madan, A., Vando, L. … Paleos, C. (2022). At-home, sublingual ketamine telehealth is a safe and effective treatment for moderate to severe anxiety and depression: Findings from a large, prospective, open-label effectiveness trial. Journal of Affective Disorders, 314, 59–67. https://doi.org/10.1016/j.jad.2022.07.004.
Kolp, E., Friedman, H., Krupitsky, E., & Jansen, K. (2014). Ketamine psychedelic psychotherapy: Focus on its pharmacology, phenomenology, and clinical applications. International Journal of Transpersonal Studies, 33(2), 84–140. https://doi.org/10.24972/ijts.2014.33.2.84.
Krupitsky, E., Burakov, A., Dunaevsky, I., Romanova, T., Slavina, T., & Grinenko, A. (2007). Single versus repeated sessions of ketamine-assisted psychotherapy for people with heroin dependence. Journal of Psychoactive Drugs, 39(1), 13–19.
Krupitsky, E. M., & Grinenko, A. Y. (1996). Ketamine psychotherapy: Results and mechanisms. International Journal of Transpersonal Studies, 15(2), 5.
Letheby, C., & Gerrans, P. (2017). Self unbound: Ego dissolution in psychedelic experience. The Neuroscience of Consciousness, 2017(1), nix016. https://doi.org/10.1093/nc/nix016.
Leuner, H. (1959). Psychotherapy in modellpsychosen. In E. Speer (Ed.), Kristische psychotherapie (pp. 94–102). München, Germany: J.F. Lehnmans.
Leuner, H. (1967). Present state of psycholytic therapy and its possibilities. In H. Abramson (Ed.), The Use of LSD in psychotherapy and alcoholism (pp. 101–116). New York, NY: Bobbs Merrill.
Leuner, H. (1971). Halluzinogene in der psychotherapie. Pharmakopsychiatrie & Neuropsychopharmakologie, 4, 333–351.
Leuner, H. (1977). Guided affective imagery: An account of it developmental history. Journal of Mental Imagery, 1, 73–92.
Leuner, H. (1984). Guided affective imagery. New York, NY: Wiley.
Little, M. (1966). Transference in borderline states. The International Journal of Psychoanalysis, 47, 135–154.
MacLean, K., Johnson, M., & Griffiths, R. (2011). Mystical experiences occasioned by the hallucinogen psilocybin lead to increases in the personality domain of openness. Journal of Psychopharmacology, 25, 1453–1461.
MAPS Public Benefit Corporation (2020). MAPS Handbook – Integrity (pp. 10–35).
Meikle, S., Carter, O., & Bedi, G. (2024). Psychedelic-assisted psychotherapy, patient vulnerability and abuses of power. Australian & New Zealand Journal of Psychiatry, 58(2), 104–106. https://doi.org/10.1177/00048674231200164.
Miller, E., Afshar, H. T., Mishra, J., McIntyre, R. S., & Ramanathan, D. (2024 May). Predicting non-response to ketamine for depression: An exploratory symptom-level analysis of real-world data among military veterans. Psychiatry Research, 335, 115858. Erratum in: Psychiatry Res. 2024 May 16;:115965. https://doi.org/10.1016/j.psychres.2024.115858.
Mithoefer, M. (2015). A manual for mdma-assisted psychotherapy in the treatment of posttraumatic stress disorder. MAPS.
Nayak, S., & Johnson, M. W. (2020). Psychedelics and psychotherapy. Pharmacopsychiatry, 54(4), 167–175. 2021 Jul. https://doi.org/10.1055/a-1312-7297.
Nour, M., Evans, L., & Carhart-Harris, R. (2017). Psychedelics, personality and political perspectives. Journal of Psychoactive Drugs, 49, 182–191.
Ogden, T. H. (2021). What alive means: On Winnicott’s “transitional objects and transitional phenomena”. The International Journal of Psychoanalysis, 102(5), 837–856. https://doi.org/10.1080/00207578.2021.1935265.
Passie, T., Guss, J., & Krähenmann, R. (2022). Lower-dose psycholytic therapy – A neglected approach. Frontiers in Psychiatry, Published online 2022 Dec 2. https://doi.org/10.3389/fpsyt.2022.1020505.
Preller, K. H., Herdener, M., Pokorny, T., Planzer, A., Kraehenmann, R., Stämpfli, P. … Vollenweider, F. X. (2017). The fabric of meaning and subjective effects in LSD-induced states depend on serotonin 2A receptor activation. Current Biology: CB, 27, 451–457. https://doi.org/10.1016/j.cub.2016.12.030.
Richards, W. A. (2017). Psychedelic psychotherapy: Insights from 25 years of research. Journal of Humanistic Psychology, 57(4), 323–337. https://doi.org/10.1177/0022167816670996.
Robison, R., Lafrance, A., Brendle, M., Smith, M., Moore, C., Ahuja, S. … Strahan, E. (2022). A case series of group-based ketamine-assisted psychotherapy for patients in residential treatment for eating disorders with comorbid depression and anxiety disorders. Journal of Eating Disorders, 10(1), 65.
Roseman, L., Leech, R., Feilding, A., Nutt, D., & Carhart-Harris, R. (2014). The effects of psilocybin and MDMA on between-network resting state functional connectivity in healthy volunteers. Frontiers in Human Neuroscience, 8, 204.
Rot, M., Collins, K., Murrough, J., Perez, A., Reich, D., Charney, D., & Mathew, S. (2010 Jan 15). Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression. Biological Psychiatry, 67(2), 139–145. https://doi.org/10.1016/j.biopsych.2009.08.038.
Rundel, M. (2022). Psychedelic psychoanalysis: Transformations of the self. Psychoanalytic Dialogues, 32(5), 469–483. https://doi.org/10.1080/10481885.2022.2106139.
Ryan, W. (2020). Ethical guidelines for ketamine clinicians. Journal of Psychedelic Psychiatry, 2(4), 19–20. https://www.journalofpsychedelicpsychiatry.org.
Sandison, R. A., Spencer, A. M., & Whitelaw, J. D. (1954). The therapeutic value of lysergic acid diethylamide in mental illness. Journal of Mental Science, 100, 491–507. https://doi.org/10.1192/bjp.100.419.491.
Schlag, A., Aday, J., Salam, I., Neill, J., & Nutt, D. (2022). Adverse effects of psychedelics: From anecdotes and misinformation to systematic science. Journal of Psychopharmacology, 36(3), 258–272. https://doi.org/10.1177/02698811211069100.
Spitz, R. A. (1961). Some early prototypes of ego defenses. Journal of the American Psychoanalytic Association, 9(4), 626–651. https://doi.org/10.1177/000306516100900403.
Stern, D. (1985). Interpersonal world of the infant: A view from psychoanalysis and developmental psychology. Basic Books.
Waltzer, H. (1972). Depersonalization and the use of LSD: A psychodynamic study. The American Journal of Psychoanalysis, 32, 45–52.
Wilkinson, S. T., Rhee, T. G., Joormann, J., Webler, R., Ortiz Lopez, M., Kitay, B. … Sanacora, G. (2021). Cognitive behavioral therapy to sustain the antidepressant effects of ketamine in treatment-resistant depression: A randomized clinical trial. Psychotherapy and Psychosomatics, 90(5), 318–327. Epub 2021 Jun 29. PMID: 34186531. https://doi.org/10.1159/000517074.
Winnicott, D. W. (1954/1975). Mind and its relation to the psyche-soma. In Through paediatrics to psycho-analysis (pp. 243–254). Hogarth Press and the Institute of Psycho-Analysis.
Winnicott, D. W. (1960). The theory of the parent-infant relationship. International Journal of Psychoanalysis, (41), 585–595.
Winnicott, D. W. (1962/1984). Ego integration in child development. In The maturational processes and the facilitating environment: Studies in the theory of emotional development (1st ed., pp. 56–63). Routledge. https://doi.org/10.4324/9780429482410-4.
Winnicott, D. W. (1971). Transitional objects and transitional phenomena. In Playing and reality. Tavistock Publications Limited.
Winnicott, D. W. (1974). Fear of breakdown. International Review of Psycho-Analysis, 103–107.
Wolfson, P. (2016). Opportunities and strategies for a ketamine psychotherapeutics (KAP). In The ketamine papers (pp. 339–359). Saline, MI: MAPS.
Wolfson, P., & Vaid, G. (2024). Ketamine-assisted psychotherapy, psychedelic methodologies, and the impregnable value of the subjective—a new and evolving approach. Frontiers in Psychiatry, 15, 1209419. https://doi.org/10.3389/fpsyt.2024.1209419.
Yaden, D. B., Haidt, J., Hood, R. W., Vago, D. R. & Newberg, A. B. (2017). The varieties of self-transcendent experience. Review of General Psychology, 21(2), 143–160. https://doi.org/10.1037/gpr0000102.
Zydb, T., & Hart, M. (2021). Efficacy of oral ketamine combined with psychotherapy for treatment resistant depression. European Journal of Medical and Health Sciences, 3(4), 106–108.
Transference (Freud, 1910) is a term used in psychoanalytic treatments to describe a process by which a patient may re-experience the qualities of a relationship often with a caretaker from their childhood. This is elaborated later on page 16.
It was generally believed that these memories were not necessarily historically accurate, but they contain emotionally meaningful content (Passie et al., 2022).
For a detailed review on the history and practice of psycholytic therapy, see Passie et al., 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9755513/
In North America the common practice of that time was psychedelic therapy (which utilized higher psychedelic doses to catalyze ego dissolution and mystical experiences, and was relatively short-term) (Hoffer, 1967)
A “heightened suggestibility” is useful to help direct clients toward internal processes or interpersonal dynamics (Cohen, 1959). It also means patients may be especially vulnerable to therapist's exploitation or abuse of power. In the MDMA-assisted therapy protocol, two therapists are required to reduce these risks.
Countertransference refers to the therapist's subjective experience of the patient which to some extent is always influenced by the therapist's own autobiographical history.
