The Impact of Psychedelic Therapy: The Fourth Wave of Psychotherapy

So before starting, I just want to remind you that this essay here represents my personal opinion on the impact of psychedelic therapy for the future of psychotherapy. No part of these essays should be construed as a recommendation to use any illicit or illegal substances, nor should the information here be used as medical or psychological advice.

With that out of the way, what does it mean to say that psychedelic therapy will be this 4th wave of psychotherapy. You can think of a wave as a technological progression. Like a phone that comes out as 3rd generation, only to be supplanted by the 4th generation. Phones will have “generations,” therapy appears to come in waves.

The first wave was basic behavioral therapy. To train toddlers you attach an alarm to a moisture detector in the bed. When the bed is wet, the moisture detector sets off the alarm, the kid wakes up, and very soon associates a full bladder with waking up, and no more wetting the bed. Or you pair relaxation with a fearful stimulus, which results in behavioral extinction – a reduced feared response. Pretty basic behavioral therapy.

The 2nd wave added a cognitive component. Hence CBT being cognitive-behavioral therapy. Pioneered by Doctor Aaron Beck, the focus turned to cognitive distortions and automatic thoughts. A stressful situation occurs, you have these unhelpful thought patterns, which leads to avoidance, which makes the situation worse. With CBT, you learn to question these automatic thought patterns. That in turn can then lead to healthier behavior patterns.

The third wave shifted the focus from the content of thoughts to the process and function of experience. The focus becomes less about symptom reduction in favor of a holistic approach towards life goals and values. Hence, we shift away from questioning automatic thoughts and towards noticing, accepting, and allowing them to be there. The emphasis is placed on transcending these thoughts to focus on valued living.  

So if someone has an anxious thought, the first wave approach would be to simply teach a relaxation technique. The second wave approach would be to identify and question the automatic negative thoughts that pop up along with those feelings. The third wave approach is to focus on allowing those thoughts to be there. Realizing that they are simply thoughts and don’t represent reality. And making the choice to turn your attention towards your goals, or your values, or just what’s important.

I would consider the Pentabelt ™ program as using much of the third wave approach in the green and orange belts. It’s also designed to integrate the 4th wave, which will likely be Psychedelic therapy.

In other words, in a relatively short period of time, the use of  substances like ketamine, psilocybin, the psychoactive component of magic mushrooms and especially MDMA will represent a revolution in the field of psychotherapy.

What penicillin did for the medical sciences, psychedelics will likely do for the psychotherapeutic sciences.

 With all that being said, here are 5 reasons that psychedelics will likely constitute that 4th wave of psychotherapy.

 First reason: Psychedelics Appear to Have Significant Anti-Addictive Properties.

I used to help people quit smoking all the time as a hypnotherapist in Los Angeles. During that time, I would be happy to have a 40% success rate in helping people quit smoking. It is a challenge, believe me. Talk to these people who struggle with cigarettes and they’ll often tell you quitting smoking is harder than quitting drinking, even quitting heroin. The gold standard for quitting smoking, the medication Chantix combined with behavioral therapy, only results in about a 35% success rate at 6 months.

So what they did at Johns Hopkins University is they gave people who wanted to quit smoking psilocybin-- the active ingredient in “Magic Mushrooms.” Not just the substance but as part of a therapy program. With plenty of preparation and integration.

The results? Astounding! An 80% success rate after 6 months. And really all it took was three sessions where the substance, the psilocybin was involved. The side effects were minimal, compared to traditional pharmaceutical medications.

Similar studies suggest that the protocol the researchers used could be applied to other addictions. To help people quit drinking, for depression, and trauma with the use of MDMA.

 In fact, the FDA has designated psilocybin, for depression and MDMA for trauma respectively as break through therapies. That’s a pretty big deal.

Now keep in mind, these are amazing results that we’re just getting started formally observing in a scientific manner. For years, it was very difficult to get any sort of study on these substances simply because it’s so difficult to study something that’s federally banned. For years, many in the medical establishment consider cannabis as having no health benefits. This was primarily because the only way to get grants to study cannabis was to get it approved by the government. And they were not in the business of painting cannabis in a good light. So all the research focused on the potential downsides. Once cannabis became legalized and we had the societal shift, well, now considerable benefits have started to come to light. I wouldn’t be surprised if psychedelic substances follow a similar trajectory. That if these substances can really resolve addiction and trauma, they could easily revolutionize the field of mental health.

Additionally, and I’ll discuss this more in the next section, these substances, when taken in a controlled environment, appear to be pretty safe. Compared to other drugs we take, psychedelics have been described by a Johns Hopkins professor as “freakishly safe”.

 These substances can provide significant benefit, often without the side effects of traditional anti-depressants. Plus, you’re not waiting weeks or months seeing if the medication works, titrating the dosage, and trying other medication combinations.

 This isn’t to disparage psychiatric medication. But if these results hold up, we’re looking at a major, major revolution in the treatment of a diverse spectrum of psychological conditions. As well, new research suggests that psychedelic therapy can be safely combined with psychiatric medication (under the guidance & supervision of a medical professional).

Second reason: The Dodo Bird Verdict

In the early 90’s researchers compared the various types of therapy to see which type worked best. To their surprise, they concluded that many types of therapy are all pretty much equally effective. They named this effect the Dodo Bird Effect from Alice in Wonderland, where “Everybody has won, and all must have prizes.”

To be sure, some types of therapy, the 2nd and 3rd waves of CBT and ACT do tend to have a greater therapeutic effect, especially with phobias and anxiety. Overall, though, there appears to be common factors that subsume all types of therapy, that lead to that therapeutic effect.

One of the biggest of those common factors is, simply put, the therapeutic alliance. The connection between therapist and client. If there’s a rapport, if there’s trust, if there’s confidence in the therapy sessions, you’re likely to have better results in therapy, regardless of what the specific therapy ends up being.  

Of course, there’s a problem with that. Many people go into therapy because they lack that trust, that connection. Clients put up walls, they put up barriers. There’s shame, embarrassment. Or just a lack of trust. After all, if you grew up in an abusive home, if you could never trust anyone or even rely on anyone, it’s not going to be easy to suddenly trust a stranger with a fancy degree and a comfortable sofa.

I’ve worked with some people for months sometimes even a year before they’ll disclose something fundamental about themselves. This happened, even when we had a good rapport, a good connection, simply because of their fear of rejection. Their sense of shame. But part of good therapy is sharing yourself and then to be told, “you’re okay.” That sense of  “welcome to the human race” moment that can be transformative. But that can be really difficult with people.

It seems that substances like MDMA can remove those barriers, take down those walls. Before MDMA became known as “Ecstasy,” it was known as “Empathy.”

By boosting the sense of connection & rapport with a given therapist, it may fundamentally enhance a key element of successful therapy, whatever that therapy may entail.

Third reason: it’s Transformative.

There are few events that can really fundamentally change who we are. Becoming a parent, for example, very transformative in terms of how you see the world. Traveling. If you travel with the intention of growing and learning about others, you can really shift how you see your life. And the covid-19 pandemic. Being forced to work from home, shifted people’s concepts of what they really wanted out of life, fueling the great resignation.

In both traveling and working from home, you’re getting a break from your traditional life. In the process, you get a better perspective and see where things need to change.

A good, therapeutic psychedelic therapy session can provide that same distance, that same perspective. You can get a bit of that by traveling, sober, to the state & national parks. Getting away from it for a few days. Asking yourself some key questions. But with these substances, you’re going inward and it can be even more transformative.

When they ask participants of studies using psilocybin in a therapeutic context, they consistently rank the experience as among the most spiritual and meaningful of their lives.

And you know what? That meaningfully adds to the therapeutic message. If you want to quit smoking, it’s one thing to have friends and family pester you about your habit. But if, through a psychedelic experience, God or the Universe just asks, “hey, what are you getting out of this smoking thing? Seems pretty dumb to me.” That simple message can be quite transformative.

Fourth reason: It’s Novel.

If you are a smoker, there are a few methods to quit. Vaping, medication, cold turkey, hypnosis. You try those things and if they don’t work, and often they don’t work, you can simply shrug your shoulders and say “I’ve tried everything.” Same thing with depression. There are a variety of psychiatric medications. But you might try 2 or 3, don’t like the side effects, and just sort of resign yourself to being untreatable. But psychedelics? That represents something really novel. Something you may not have tried before.

Let’s say a friend engages in psychedelic therapy. And the friend talks about how amazing it was, how transformative it was. It piques your curiosity. You want to try it out. You’re also a smoker. You’ve been thinking about quitting. You’ve developed a really nasty cough. Your new partner really doesn’t like it. Okay, you’ll give it a shot. When you pick an issue to work on, sure, let’s tackle smoking cessation.

Notice the shift. As a psychologist, I hate having people book appointments only when their issues become so great, they have to seek out the services of a professional. I would way rather help someone as their issues are first developing or even better, to focus on prevention.

With psychedelic therapy, we can allow people’s natural curiosity to bring them in, and we can reinforce the important skills and insights to ideally prevent future addictions and heal past trauma.

And the 5th reason? It does feel pretty good.

This is a huge, huge, component that sets psychedelic therapy apart from other therapies. As clinicians, we have this concept that therapeutic breakthroughs necessarily involve struggle and tears and brave steps. Yet I would argue that significant therapeutic growth doesn’t need to necessarily involve such struggle and turmoil. It doesn’t have to be painful.

These substances of the 4th wave, particularly MDMA, can make personal growth and psychological breakthroughs, enjoyable. Difficult at times, but often enjoyable, rewarding, and with positive aftereffects that can have enduring effects.

And to show how important this is, let’s look at three different hypothetical people. First example, we have Kevin. Kevin was in the army. Saw action in Iraq. And has agreed to participate in an MDMA session with his friend, who has significant trauma. PTSD. Kevin himself also has some difficult memories. And he’s finding he relies upon alcohol more and more to help forget, both the memories and the stress of his life. But he’s not attending these sessions for himself. No, he doesn’t think his condition is all that bad. Compared to his friend, at least. But he’s there. He takes MDMA. He feels connected. And he feels good. During the session, he still may not say anything. But, Let’s say there is another session down the road. Maybe a few months later. Again, Kevin is feeling relaxed. He’s feeling good. He’s likely to just spontaneously talk. Go over what happened. Process it a little. Or process it a lot. He may do these events once or twice a year. Not necessarily for the therapy. But for the connection. The bonding. It feels good. As the years go by, he talks more and more about not just the difficult memories but his reliance on alcohol. At one event, he may make peace with the beer and decide he no longer needs it each day. Maybe it’s just a weekend thing.

Then we have Victor. No traumatic memories. Usually feels good. But generally isn’t a touchy-feely sort of guy. Has a wife. But she sits on the sofa, he’s on the recliner. He loves her, but intimacy was never his strong point. Like Kevin though, he attends a therapeutic MDMA event, maybe 2 or three times a year. It’s a couples event. Victor has two buddies, they and their wives get together and talk about their goals, their struggles, their challenges. But you know, during these events, he sits close to his wife. And it feels good. Very good. There’s that warmth from having his wife in his arms. They go outside and just chat for an hour. Have a heart-to-heart. Victor mentions what he loves about his wife and she does the same for him. After the event, not too much has changed. But maybe they sit closer together, both on the sofa. Maybe he’s just a bit more likely to say “I love you.” Or “I appreciate you.” Maybe he’s more likely to change the cat litter, even though it’s not even his cat. These little things? They add up. It’s these little things that can make or break a marriage. And so just a few events where they reconnect, remember what brought them together, feel the warmth of each other’s company, can keep the relationship going, prevent a difficult separation, protect the entire family.

Finally we have Erica. Erica doesn’t have any traumatic memories and a great, warm, loving relationship with her significant other. In her past, Erica, has had bouts of sadness. Not quite major depressive disorder but enough to make some health changes, maybe when she was in college. She was in track and field. The running made her feel better. And when she finished college she picked a good job, good career that was much less stressful. But as she progressed in her career, she rose in the ranks and some of that stress came back. Nothing debilitating. But she has been having some, let’s just say, noticeable sadness in her life. She participates in the MDMA session. Again, like Victor and Kevin, a few times a year, in a group therapy setting.

She doesn’t have to work through anything traumatic. There’s really nothing in her life to cry over. But she may just have one through: “You know, running in college really helped me a lot. I think maybe I’m sitting too much all day.” After the event, she dusts off the old running shoes, and starts a daily jog. And maybe half-a-year later she has another “ah-ha.” I need to set better boundaries at work. I shouldn't be expected to cover for my boss, certainly not at my current salary. Maybe, this leads to being more assertive. Maybe it means finding a job with a better balance. Now, in this scenario, Erika is doing these events as it’s helpful to get some insight in various life challenges. And it’s good to bond with friends. But it also feels good. Otherwise, she might not continue with them. After all, why take a day off to go to what is essentially a group therapy program when she’s not officially depressed?

But as we see, for all three of these individuals, they do it because of the connection and because it feels good. Yet with all three, the insights gained can help prevent more serious psychological conditions in the future. Erica could very well be on a path to significant depression. That insight that running helped, may reinforce that cardio is an important element of self-care. Victor, who would normally never, ever, go to a traditional couples retreat, will spend the day, when, for the most part, he feels really good and connected. But that amounts to a significant reminder of what he has with his wife. That alone can help prevent separation and divorce. And Kevin? Going to these events helps him admit things to himself he’d never consider otherwise. But he’s not doing these events because he likes therapy. He’s doing them because they are generally enjoyable.

Now, that’s not to say that psychedelic therapy is supposed to be only positive, only enjoyable. A psilocybin or MDMA session may certainly involve processing difficult feelings. But you can have a few of them, and then have sessions that are more enjoyable that can reinforce and expand upon what was learned during those difficult first sessions. And those experiences can be very enjoyable, rewarding, and connecting.

 And this opens up therapy to a wide range of people, who otherwise would never even step foot into a therapist office. Sometimes, you have people who want to explore issues of life with a therapist. But the majority would only seek out therapy as almost a last resort. When their issues become so overwhelming that they need the services of a professional.

 For all these reasons, psychedelic therapy may very well constitute a 4th wave, a complete revolution in the field of therapy. But that’s not all. In the next section, I’ll argue that if used properly, we could then see a 5th and perhaps final wave in the field of psychotherapy. A transition of clinical psychology from a focus on treatment towards a focus on prevention and initiation.

 On to Section 4