State of Mind

What Happens When Psychedelic Treatment for PTSD Turns Into a Bad Trip

A capsule split open with multicolored psychedelic rivers spilling out of the two halves
Photo illustration by Slate. Photos by Vectordivider/Getty Images Plus and Viktoria Ruban/Getty Images Plus.

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I lay flat on my back, pouring sweat and heart racing, in a hotel room with a woman who had just overdosed me.

Let’s call her Sarah. To be clear: Neither of us was here to party. Sarah, in fact, was a therapist, a licensed clinician. Outside of her office hours, she offered patients like me psilocybin and MDMA, for PTSD and treatment-resistant depression. She did this at fairly extreme risk to her career, because, as she said, she believed in it. This was my second time trying a guided, high-dosage cocktail of psychedelics to address my ongoing PTSD, a result of my surviving the 2008 terrorist attack on the Taj Mahal Hotel in Mumbai.

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The goal with such an experience is to “go inside” yourself, surrender the trappings of the ego, and through that process transcend or soothe damage caused by a fundamental trauma. The idea is fairly simple: By letting go of yourself (commonly known as ego loss, or ego death), you become one with everything else. Put another way, you can experience a sense of wholeness that transcends yourself, and that wholeness can be very healing. In conversations with underground practitioners, I learned this was achieved through taking a combination of “medicines.” (For example: MDMA, the main ingredient in what is commonly referred to as ecstasy, paired with psilocybin, otherwise known as magic mushrooms.) But equally important, they said, was the guided support for the experience itself, followed by integration (processing of the experience) with that same guide. My first trip had been very positive and had resulted in a sense of peace and calm with respect to the particular anguish I had been experiencing for years. Indeed, recent scientific research increasingly supports the potential for MDMA-assisted psychotherapy to be “an innovative, efficacious treatment” for PTSD.

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There was just one problem: My first guide had had no medical background or psychiatric credentials. This had made me uncertain about continuing with her. I came from the Wall Street world, where qualifications matter. (Believe me, at the time, the irony of being driven by my ego in pursuit of letting it go was entirely lost on me). So I kept up my inquiries, thanks to an acquaintance who had given me a short list of psychedelic practitioners. Finally I talked to Sarah, who on paper was extremely qualified, with degrees from great schools. Her demeanor on the phone made me feel confident that she was qualified to do this.

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When we finally met in the hotel room, I was ready to continue therapy that would ease my PTSD. After some awkward small talk, she asked me to sit on the bed. I watched as she weighed out crystals on a cheap-looking scale, explaining that for my trip she was going to administer a dose of clinical trial-grade MDMA, along with psilocybin. She inserted a quantity of the crystals into a gel cap, and I washed the pill down with a glass of tap water. She then gave me a small brownie, which contained the psilocybin. I lay back, and she covered me in a blanket and handed me a sleeping mask.

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Very quickly, I knew something was wrong. Whatever I had taken was already bringing on a rush of anxiety. I tried to listen to Sarah’s brief guided meditation, then the ambient music that was playing, but it was no use. I tore off the mask and the blanket covering me, and I told her it wasn’t working. I watched as the hotel room seemed to shrink around me, and my shuddering heart grew larger and larger inside my chest. There was no “going inside.”

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“OK,” she said. “Let’s talk.” But her questions felt invasive, inappropriate. Too aggressively, she asked about my childhood, my marriage, and my anxieties. Suddenly I felt vulnerable—and defensive. We argued about what was happening.  Far from feeling safe, this “qualified practitioner” had created a dangerous environment, and all I wanted to do was leave. Except I couldn’t. The idea of going anywhere in the state I was in was next to impossible.

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In the aftermath, as I struggled to come down from the effects of whatever it was that Sarah had given me—I was fairly certain it wasn’t MDMA and psilocybin—it became clear that she did not have a healthy approach to using psychedelics as therapy, and she certainly did not have the knowledge to prescribe them to others. There was no plan to help me cope afterward. Back home, as my sleeplessness mounted from one night, to two, and finally three, I repeatedly tried reaching out to her. No response. I was being ghosted. Still high, my mind racing, I madly typed 35,000 words that I believed would help integrate what had happened to me. All of it felt insightful and real, but in the sober light of day, I saw it was fairly incomprehensible gibberish. In desperation, I called my regular therapist, who told me to throw out the writing and helped walk me back off the edge. Without him, the experience could have led to irreparable harm.

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This was, to say the least, a learning moment. It was January 2019, and access to “aboveground” treatments involving any kind of psychedelics was extremely limited, usually through clinical trials or experiments. (This has now changed in some states.) Because of draconian drug scheduling laws, many other promising drugs remained largely unavailable (among them mescaline, psilocybin, LSD, ayahuasca, and MDMA). So, like many others, I went “underground” to find help, which is how I ended up in a hotel room out of my mind.

And no wonder: Ultimately, when I finally managed to reach her, Sarah admitted that what I had thought was a trial-grade dosage of MDMA had been a bit more “speedy.” In fact, she said, the crystals had turned out to be largely methamphetamine, cut with a bit of MDMA—what on the street might be sold to a rave kid to stay up all night. (I was so high on speed I hadn’t even felt the psilocybin she’d given me.) In such a case, “legitimate psychedelic treatment” can feel like a contradiction in terms. But the underground looks poised to change.

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Today, ketamine-assisted psychotherapy remains the only “psychedelic” treatment you can access at a clinic aboveground. While doctors have been prescribing it as an antidepressant for years, Johnson & Johnson’s March 2019 Food and Drug Administration approval for a nasal delivery form of ketamine (called esketamine) marked the first time the drug was given specific governmental clearance to be prescribed for mood disorders. Many studies, including government-led research, suggest that ketamine can offer rapid lifting of symptoms in otherwise treatment-resistant forms of depression. But as is frequently reported, most research has not looked into the long-term effects of ketamine treatment, and many insist that more studies are needed. On top of all this, the jury remains out on whether ketamine (and its reported dissociative or out-of-body effects) should properly keep company with other “classic” psychedelics like LSD or psilocybin.

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While MDMA and psilocybin treatments are only legally available via clinical trials, wider accessibility may not be so far off, if they follow a similar trajectory as ketamine. So far, dozens (perhaps even hundreds) of ketamine centers have popped up all around the country. Individual treatments range from $400 to $1,000, and typically clinics recommend up to six treatments, sometimes followed with regular maintenance. In look and feel, the website branding for these commercial enterprises can exude a spa-treatment type of vibe. Meanwhile, access to other psychedelics remains either underground (in the U.S.) or as part of the now-booming psychedelic tourism industry—an industry that promotes psychedelic “retreats” around the world, echoing much of the wellness jargon you read about with the ketamine clinics.

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Many centers and professionals in the psychedelics industry offer a veneer of qualified expertise, but it is difficult to verify their credentials or the safety and efficacy of their practices. Major investment in psychedelics has generated a rush to normalize use in culture at large. The success of the recent Hulu miniseries Nine Perfect Strangers, starring Nicole Kidman as a glamorous if unstable psychedelic guru, ultimately seems to suggest psychedelic tourism is a good thing, that an ad hoc, instinctual approach to treatment can work just as well as clinical treatment. But that’s dangerous. What most conversations around the use of psychedelics as a treatment for PTSD, depression, or anxiety fail to acknowledge is that the beneficial effects come from a high-dosage experience. This is decidedly not the same as a recreational trip with a few college friends in the desert. It is something else. Its effects can be lasting, deep, and unpredictable. And it needs to be done right. That makes the recent emergence of startups like Mindbloom and TripSitter, which offer self-administered at-home ketamine therapy delivered in the form of lozenges (along with online access to “virtual guides for processing the experience), all the more concerning.

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As the collective marketing muscle that pervades America touts “psychedelic wellness” and “unleashing your inner healer,” one critical piece of protocol is too often overlooked: the container. The “container” is basically everything surrounding your psychedelic experience, to make sure that it is beneficial, safe, and integrated into your life. The container is not the same as “set and setting,” a common phrase used in the psychedelic community relating to where you trip and whom you trip with. Nor is it simply about having a guide who assists and supports you through whatever challenges the trip may present. Rather, the container is a combination of agreements—primarily with yourself, about your intentions for such a treatment. The container also includes the person or people who accompany you before, during, and after your experience, as well as the therapeutic work you yourself have done to prepare for taking a high dosage of a psychedelic drug, and the work you will do afterward, to integrate it with your life in a meaningful way.

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Without the right container, people who seek substantive treatment for serious mental health conditions could easily find themselves in a dangerous place, unsupported, as I did. The best metaphor for a high-dose psychedelic experience may be that of a scalpel: It cuts straight through your psychological armor, taking you to the formative physiological experiences that define your sense of self. A scalpel in the hands of a trained therapist can be remarkably healing, helping you to find transcendent comfort in your darkest places. However, that same knife can be devastating in the hands of an ill-prepared, inexperienced, or even predatory guide, in which a user’s experiences on the drug are not integrated with their actual life (causing disruption, disassociation, or trauma); or sometimes, even worse, the experiences can be used to disempower or exploit vulnerabilities.

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Even before the pandemic placed a tragic and terrifying spotlight on our collective sense of isolation and disconnection, it seemed like our society was facing a fundamental crisis of meaning. Among other things, the internet had fractured reality into an infinite collection of disaster loops and self-interest bubbles. No wonder that, even as the COVID era was just beginning in 2020, 1 in 5 American adults reported experiencing mental illness, amounting to well over 50 million people. Considering such an environment, unregulated, misguided, or reckless distribution of high-dose psychedelics does not necessarily mean a positive result, especially for those most vulnerable.

After recovering from my run-in with Sarah, I have since had a handful of successful experiences in the so-called psychedelic underground. But they happened because I was able to seek out and establish the right container. Whether through psychedelics, traditional therapy, or other means, there are no shortcuts to healing. Likewise, in order for psychedelic treatment to work effectively in our society, it must be able to function within a larger and effective framework for treating mental health. Without that, a therapy with profound potential benefits may lose its opportunity to truly emerge from the underground. In the end, it’s all about acknowledging the importance of the container.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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