Must psilocybin always “assist psychotherapy”?

A cynic might argue that this paper by Guy Goodwin & colleagues is designed to boost Compass Pathways shareholder value. They write: "Drugs such as psilocybin and many other serotonergic agents can produce a powerful psychedelic experience. It is now commonplace to hear the expression “psychedelic-assisted psychotherapy” or “psychedelic-assisted therapy” when their use in treating mental health conditions is described. Are we clear on what we are trying to describe? Take the definition of psychedelic-assisted therapy offered by a new European organization for psychedelic access and research (1): The fundamental therapeutic benefit of PAT [psychedelic-assisted therapy] comes from the combination of psychedelic medicine and therapy. The drug is a catalyst for treatment, not a treatment in itself.… In other words, psychedelics’ novel therapeutic value stems from their role as enhancements to a psychotherapeutic process, grounded in a relationship-centered approach, that views mental health through a biopsychosocial lens.  The statement that the drug is a catalyst for treatment, not a treatment in itself, is grounded in an odd dualism. The drug as a medication presumably works on the brain (as a “catalyst”), but there is a separate psychotherapy that it facilitates. That psychotherapy is “relationship centered,” which has usually meant nondirective counseling (Table 1). Ironically, there is no evidence that the conditions being targeted by psychedelics (severe depression, posttraumatic stress disorder [PTSD], and substance use disorders) are effectively treated by nondirective counseling. More importantly, the statement fails to recognize that the psychological support provided in recent studies of psilocybin is primarily directed to safety—specifically, the preparation and safeguarding of vulnerable people who are submitting to a potentially disorienting experience. They will also be participating in a clinical trial, which requires informed consent and a measure of equipoise. They do not typically receive evidence-based psychotherapy as it is usually understood. Staff with therapy backgrounds may be an excellent choice of personnel to provide the necessary and essential support, but it is an open question how far their efforts enhance efficacy rather than simply ensuring, as is intended, psychological and physical safety. Such safety creates optimal conditions for patients to be immersed in the psychedelic experience."

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