The Adult Initiation Ritual: Three Reasons Prevention is the Future of Psychotherapy

What do I mean by the 5th wave in therapy? Well just to review, the first wave, simple behavioral therapy. Second wave, the well-known CBT: cognitive-behavioral therapy. Third wave is where many clinicians are right now, integrating mindfulness, acceptance & commitment into CBT. The forth wave will add in psychedelic substances into the process. We see this happening already with ketamine assisted psychotherapy. Other substances down the line will be psilocybin, & MDMA. As we discussed in the last section, this is all to heighten the therapeutic alliance, drive anti-addictive processes, determine our core values, and have a cathartic release of past trauma. All of this is progressing to the fifth and perhaps final wave in psychotherapy.

What will that 5th wave be? A shift. A big shift from psychotherapy as a treatment and towards psychotherapy as prevention.

Right now what happens when you turn 18, is basically, “you’re an adult, off you go into adulthood.” Then, when you develop some mental health issues, you see a psychotherapist until your issues no longer reach “clinical significance.” In the future, the primary purpose of psychotherapy will essentially be seen as an adult initiation ritual. As you turn 16, or 18, or graduate high school, you learn the techniques of the prior 4 waves of psychotherapy as prevention. There will still be traditional therapy, when things go wrong, as they tend to do from time to time. But a major focus on therapy will be resilience training to prevent issues from occurring in adulthood. In other words, the focus will be on the prevention of anxiety, depressive, and addictive disorders.

What makes me think this is the future of therapy? Three primary reasons.

First: Mental Health Issues are universal.

They are exceptionally common. According to Johns Hopkins University about a quarter of all Americans have some form of mental disorder in a given year. About 10% of Americans have a major depressive disorder in a given year. And almost 20% have an anxiety disorder, again, in any given year.

Suppose I’m speaking to a room full of 30 year olds, I could have everyone stand up. And then say, “sit down if you’ve had a major depressive episode. Sit down if you’ve ever had a panic attack. Sit down if you’ve struggled with addiction, or have thought that you should cut down on your drinking or quit smoking cigarettes. Sit down if you’ve had a traumatic memory or event that you don’t feel like you’ve quite processed. Sit down if you feel like you have no clue how to date or function in a relationship.”

I don’t think you’d have a lot of people standing. And we’re not even talking about people who have relationship issues. Sit down if you’ve felt like you’ve been taken advantage of, by a date, a significant other, or a boss, or family.

I’d say, as a clinician, the more I’ve practiced, the more I’ve come to see mood disorders and related conditions as well, trauma responses. Even events that are pretty common place today such as divorce can lead to mental health issues. And for these issues to be resolved, the trauma needs to be addressed, often directly. 

You would think then that with trauma being so prevalent, we wouldn’t wait for it to manifest in failed marriages and unfulfilling careers. We would work to directly confront the trauma in very early adulthood.

Yet a preemptive approach almost never happens. Most people go into therapy already in a damaged state. They have to learn skills when they can barely get out of bed. Or in between panic attacks.

In general, life is so much more complicated compared to 50 or even 20 years ago. Back then, you got into the same job as your parents, you married the high school sweetheart and the friends you had in middle school are the same ones that attend your retirement party. We now shift careers, date online, and move away from home, from our community. Meanwhile income is stagnant and the cost of living rises each year. This adds up to a mountain of stress, that most young adults are woefully unprepared for.

So if I’m a psychologist in a small town it doesn’t make sense for me to just exist to treat acute mental health issues as if I’m some sort of car mechanic fixing people when they break down. There are too many cars, with too many issues. And as they say in medicine, an ounce of prevention is better than a pound of cure. So my focus would be on outreach at an early age, at young adulthood. Teaching skills to help buffer against the inevitable life challenges that are going to occur.

The second reason psychotherapy will focus on prevention? The relative safety of psychedelics.

A survey of global drug use suggests that of the “recreational drugs” psilocybin is the least likely to lead to hospital visits. And a scholarly review, titled: “Can psilocybin be safely administered under medical supervision? A systematic review of adverse event reporting in clinical trials” came to a similar conclusion. The study states as part of the review, “… 27 publications documented the administration of psilocybin on over 800 occasions to 550 individuals… reported no serious and/or significant adverse events, positive drug tolerability, and/or overall safe administration of psilocybin.”

Think of it like a vaccine. In figuring out if you should take the covid-19 vaccine, one on hand you consider the chances of catching Covid and on the other, the safety the vaccine. The safer the vaccine, the more it makes sense to take it. Especially if it’s effective and the chance of catching Covid is high.

Well, unfortunately, it seems as though the chance of catching depression or a major anxiety, is pretty high right around now. If Psilocybin and MDMA are shown to be as safe as researchers suggest, perhaps it’s time to consider their use as a prophylactic mechanism.

That’s not to say that taking these substances are without risk. Anything taken has some risk associated with it. People have died taking psychedelics, if they end up falling or going into traffic. Of course, the same can be said of alcohol. Hell, the same can be said of caffeine.

There was a fitness trainer who wanted to add a dose of caffeine to his morning supplement routine. He used a wrong scale setting and ended up taking the equivalent of 200 cups of coffee and unfortunately he died from a caffeine overdose. 

So, any medication or substance needs to be taken with care and caution. With psychedelics, certain mental health conditions, those with bipolar disorder or those who have a severe psychiatric illness should be extremely careful and probably avoid their use entirely. Those with a close family member with such a condition should also be very cautious. On the whole though, it seems as though psychedelics may be appropriate for general use.  

And this couldn’t come at a better time. As a clinician, I’ve seen first-hand that we are going through a mental health crisis in our country. According to the CDC in 2021, “22% of high school students seriously considered attempting suicide during the past year.” Clearly, what we are doing right now is just not enough.

I think back on when I had newborns. My wife and I researched how to prevent SIDS, or sudden infant death syndrome. A very long time ago, a physician named Dr. Spock wrote a very popular guide to childrearing. There were reports that some kids, when they went to sleep on their back, would throw up and some would even choke on that. So the recommendation was to make sure they slept on their stomach. Seems to make sense. Unfortunately, that lead to a big increase in SIDS, as they would suffocate and not breathe properly.  

I remember visiting SIDScalculator.com, where the default risk of SIDS was about 1 in 2,942. Taking a few basics steps, ensuring the kids slept on their back, in their own crib, sleeping in the same room as their parents, reduced the risk to about 1 in 12,500! And so, those recommendations we followed, religiously.

And yet, on that same site, I saw the glaring statistic: that there’s a 1 out of 35 chance there will be an “attempted suicide requiring medical attention between the ages of 15 and 18.” Think about that one out of thirty-five teenagers. And that statistic is now out of date.

As per the CDC, again, for the people in the back, 22% of high school students seriously considered suicide in one year alone.  

So the question becomes, with all the attention we place preventing SIDS in our children’s first year of life, what steps should we be taking to prevent suicide in their first few years of early adulthood? Once they’re out into the real world?  

Assuming a strong safety profile of psilocybin, of MDMA, perhaps, once they hit 18 years, we should determine if such substances, given in a therapeutic context, can possibly prevent not just suicide but future episodes of deep depression, debilitating anxiety, and the feelings of profound loneliness that often subsume these conditions. That have now become quite common conditions.

Then there’s trauma. By the age of 18, 1 in 5 girls and 1 in 13 boys will experience sexual abuse. Left untreated, the trauma that comes from that abuse can have a devastating impact on future relationships and just overall emotional well-being. If as a society, if we fail to protect our kids, the least we can do is standardize a system to help resolve the trauma as they enter adulthood. It makes little sense to wait until the 2nd divorce, the failed business plan, the suicide attempt to begin treatment. Perhaps it’s time to assume, that by early adulthood, most will have some sort of trauma that needs to be processed. This could be the adult initiation ritual we so sorely need today.  

Now, there’s no formal research on the best age. Studies show that the brain hasn’t quite fully developed until the mid-20’s. And exposing substances like cannabis early in life appears to be correlated with cognitive issues later on, according to various studies. Yet we’re still trying to determine if it’s causation or correlation. In other words, the same issues that lead kids to try cannabis at a young age also lead them to other health issues later in life.

And again, if psychedelic therapy can dramatically reduce the likelihood of self-harm, that really needs to be considered in the equation. As with infants, you have to pick a side. Place them on their stomach or place them on their back. In early adulthood, we need to do something, pick an intervention because this mental health crisis we’re facing isn’t just going to go away. It’s not going to get better.   

That’s why I believe that, if psychedelics really are as safe & effective as the research suggests, that they will become integral to psychotherapy and the field will then shift from fixing something broken in middle aged adults to building resilience in young adults.

And that process might just happen right in or shortly after college.

The third reason psychotherapy will focus on prevention? The need for community.

This really isn’t discussed as much as it should, but from what I’ve seen, I believe that psychedelic therapy can be used to cultivate a sense of community in a special way that’s needed, now more than ever.

In recent years there’s been a deeper appreciation for the role of the community in the healing process. Johann Hari has made that famous statement: that the opposite of addiction is not sobriety, it is human connection. Unfortunately, human connection has been gradually broken down through years.  

A few decades ago most peopled lived where they grew up. Their lives focused around church. You worked at the same place throughout your life, building deep connections. Nowadays, especially in California, we’re more likely to move a distance away from where we grew up. And change jobs multiple times in our lives. Churches have become politicized. Many Californians look at the mega-churches in the other states and they don’t like what they see. But that need for community, it’s still there.

Psychologists are increasingly sounding the alarm about the dangers of feeling isolated, feeling alone. Surveys suggest the percentage of men with at least 6 close friends has fallen by half since 1990. Today, men are also about five times more likely to report not having a single close friend, compared to thirty years ago. And researchers are increasingly finding that being alone can be bad for your health, with one study finding prolonged isolation having the equivalent health risk as smoking 15 cigarettes each day.

And yet, from what I’ve seen, what I’ve experienced in working with people after having had a group psychedelic experience, that they come away with a deep bond with the other participants. Imagine hearing others talk about their struggles. Deeply identifying with those words. Feeling that sense of connection. That you’re not alone. Others share your struggles. You tend to end up bonding with that group.  

In the fifth wave of psychotherapy, the goal of the therapist is first and foremost to provide a safe space for their clients to resolve past traumas, generally through the use of psychedelic substances. Integral to this process is a focus on establishing self-care practices, developing a value system to drive their focus, and developing a sense of assertiveness along with healthy boundaries. These are all standard practices you might find currently in the field of psychotherapy today, albeit adjusted for use in psychedelic therapy. That’s what Pentabelt™ is all about.

Yet there is a final objective that needs to occur in this 5th wave: to assist their clients in finding their own community, their own tribe. Possibly, depending upon logistics and legality, to use such substances as MDMA and psilocybin with their close friends and family under therapeutic supervision.

Both as a means for growth & development but also because the connection that manifests from this therapy is healing & transformative.

It’s highly likely that most individuals will want to engage in psychedelic therapy throughout their lifespan. Traversing adulthood brings with it heartache, career changes, relationship transitions, and unexpected loss. Again, assuming a favorable safety profile, young adults may want to experience psychedelic therapy perhaps several times throughout their 20’s and 30’s. And not just with a therapist! With their partner, with a family member or two, and with others in the community. There simply aren’t enough therapists in the world to cover all of these sessions and the costs would be prohibitive.

Thus it appears as though a primary purpose in this 5th generation of therapy is to empower the client to form their own community, their own tribe. Educate the client not just on safe, therapeutic practices of psychedelic therapy but on how to manage this new-found community. And to serve as a counterbalance, a resource for the individual through providing an outside prospective. 

 In the next section, we’ll explore the trends that may well lead to focus of therapy on prevention. The integration of therapy into an adult initiation ritual.

On to Section 5