Why psychedelics are a more ‘compassionate’ way to treat trauma
A therapist explains what it’s like to give psychedelic-assisted therapy.
Dr. Elizabeth Nielson is a psychologist and psychedelics researcher. She’s a therapist on FDA-approved clinical trials of psilocybin-assisted treatments of alcohol use disorder, treatment-resistant depression, and MDMA-assisted treatment of PTSD. She’s also the co-founder of Fluence, an independent training institute for the integration of psychedelic experiences in clinical settings.
Inverse recently spoke with Nielson about what it’s like to be involved in this type of work, the future of psychedelic-assisted therapy, and the hurdles ahead.
How and why did you become involved in the world of psychedelic-assisted therapy?
I was really interested in finding and developing better, more humane, and more compassionate ways of helping people who were struggling with both addictions and trauma. Psychedelics offered a really good way to work toward these goals. I got involved just as I was finishing my doctoral degrees.
I had looked at several kinds of empirically supported treatments, like harm reduction and mindfulness-based interventions. Psychedelic-assisted therapy really offered a next step toward potential improvement of what the clinical therapy could offer.
What has it been like to see a change in opinion on the therapeutic use of psilocybin since 2014 when you started your research?
I think there has been growing acceptance of the possibility over the course of these years. When I first became involved, it just seemed like something that people were less familiar with. And, to his credit, the author Michal Pollan’s book, How to Change Your Mind, really put this on the map for a lot of people.
There’s overall been growing familiarity with the whole idea of psychedelic-assisted therapy and the potential of psychedelics to effectively work this way.
How has your confidence in psychedelics' potential to aid changed over time, especially now that there’s supporting clinical research?
When I came into this, I was already very familiar with the history of psychedelics in terms of how they had been used in both indigenous settings and shamanic practices, as well as in medical settings in the United States and Europe, especially in the 1950s and ‘60s.
So I guess you could say I’m not surprised. What’s more surprising to me is to see the adoption of what sometimes we refer to as the “mainstreaming” of psychedelics: the bringing of them into our existing institutions, clinical research worlds, and potentially into our clinics in ways they may be available to the public. That process has really been interesting to watch.
There’s a lot of focus on the psilocybin part of psilocybin-assisted therapy. Can you please expand on the role of the therapist? What is their primary role?
Therapists have a primary role in establishing the physical and psychological safety of the participants and getting them through their session experience. In psychedelic-assisted therapies in general, the subjective experience is a critical part of the way that we think these therapies may work. The role of the therapist is really helping to create the relational and emotional environment in which the experience takes place.
In general, during psychedelic-assisted therapy — it’s important to note specific trials are all a bit different and have their own procedures and protocols — a participant is seen through that experience by, usually, a co-therapist pair. They are asked to spend the bulk of their time focusing on what their internal subjective experience is. Whether or not there are conversations about specific things or a specific manner depends on the protocol, the treatment diagnosis, and the therapeutic approach, because all the studies have different therapeutic approaches.
Why are there two therapists?
There are a couple of reasons for the two therapists model. One is the safety of the participants should one therapist be needed to attend to the participant. Another, for instance, is if one needed to attend to some other aspect of the environment or interact with the rest of the team in some way. The other reason is the sessions are often quite long, so it’s somewhat easier from the therapist's standpoint if one needs to briefly exit the session at some point.
That seems practical. How long are the sessions?
Pretty much across the board in psychedelic therapy sessions in the United States, they are eight hours long.
Something your new paper really digs into is the need for specially trained therapists who can provide high-quality care to participants in clinical studies. But if regulatory approval is on the horizon, is there also a need for therapists who are ready to go once this type of therapy is actually legal?
Yes, definitely. We, as a field, don’t know what the regulatory requirements will be for becoming a provider of any of these therapies if they are approved. That is something that is unknown at this time.
What I can say is that from the perspective of a researcher who is providing this therapy, the need for specialized and specific training is essential to being able to provide this therapy in a way that is ethical, safe, and has the potential to demonstrate the kind of results the studies may show. And I’m using “may” specifically because we don’t have those results yet.
But if we do have positive results from the studies and we want to be able to generalize those in non-research settings, we really need to address the training piece.
Something I’ve been generally curious about is whether or not there were already plans to create some sort of infrastructure that would support this therapy if it is approved — so that’s really interesting to know.
Interestingly, Fluence was started in order to build that infrastructure now, because, as research therapists and clinicians, my co-founder and I could see that this could potentially be a major rate-limiting factor: the training of therapists.
When we were going through our own training, we were both incredibly impressed with the complexity and the need for real attention to the specifics of doing this kind of work. We were also simply appalled by the thought of how on Earth will our field meet the challenge of training the number of therapists that would actually be needed to provide this to the public? We started this project in order to build the infrastructure to help meet that need.
What has it been like for you, personally, to work in this space?
It’s different every day. What I really like about working in this space is that it is challenging; it requires creativity. It requires a lot of problem-solving, and it requires building programs and solutions from the ground up. You have to figure out how to do things that are not necessarily clear from the outset.
"It’s going to be a field of its own, and to some extent, it is already."
I think for myself and probably a lot of people in my cohort of trainees and clinical researchers, it’s been about learning how to be very flexible, adaptable, and being able to respond enthusiastically to challenges. When I say cohort, I mean people who came to it around the same time and from the same level of training.
To start in 2014 as a trainee therapist on a research trial to now, in 2021, being the co-principal for the MAPS New York City private practice research site is really seeing the result of a lot of sticking with it.
Looking to the immediate future — let’s say one to five years from now — what are you most eager to see happen?
I’m really excited about therapist training. Part of the reason I’m excited about it is because I think therapists in general are just a wonderfully compassionate group of people. They have amazing skill sets they can bring to this work. I meet so many that are really passionate and motivated to get involved.
I’m really looking forward to more research and more development of therapist training programs in this field. It’s going to be a field of its own, and to some extent, it is already.
Psychedelic therapies, in general, have the potential to address some of the existing disparities that we see in healthcare, especially in mental healthcare. Therapist training programs are the optimal place to bring education to bear on that process.
This interview has been edited and condensed for brevity.