Written by Dr Sara Tookey
A True North Psychology Publication
The recent surge of interest in psychedelic-assisted therapy has shone a spotlight on the profound potential of substances like psilocybin, LSD, and MDMA in treating mental health conditions that have been resistant to conventional treatments. While these substances have been used for centuries in various indigenous cultures, their application in modern psychiatry is relatively new. Stories of individuals overcoming decades of debilitating depression, PTSD, and anxiety after psychedelic experiences have captured public imagination, offering hope to many who have struggled to find relief.
However, amidst this "psychedelic renaissance," a concerning narrative has emerged that overhypes psychedelics as a panacea while minimising some very real potential risks and challenges. This has prompted prominent psychedelic research teams to publish material that offers a more balanced perspective on the potential risks and benefits of psychedelic-assisted therapy. Like this short youtube public announcement created by Johns Hopkins University’s Psychedelic Research team, addressing the issue of risks associated with psychedelic-assisted therapy.
As a psychologist working in psychedelic research and supporting individuals with challenging experiences, I aim to provide a balanced perspective on this nuanced topic.
If you like this article you might enjoy reading our other psychedelic-assisted therapy related articles:
Table of contents:
Understanding Context in Psychedelic Research:
At True North Psychology, we focus on providing reliable information from current psychedelic research for educational purposes only. It's crucial to distinguish between different contexts when discussing psychedelic use and associated risks:
Clinical Research Trials of Psychedelic Therapy: Controlled studies with careful screening and professional support, most commonly conducted to investigate the safety, feasibility and effectiveness of using psychedelics for treatment of medical and/ mental health conditions (psychedelic therapy), reporting low risks.
General Public Use: Research often based on anonymous surveys across various settings (recreational, spiritual, self-treatment), without always distinguishing between contexts.
This distinction matters because clinical settings aim to minimise risks. Both contexts inform our understanding of potential risks and best practices as psychedelic-assisted therapies develop.
Risks of the "Psychedelic Miracle"
The allure of the "psychedelic miracle" stems from powerful anecdotes of spiritual awakening and seemingly miraculous healing. Yet this oversimplified view overlooks the nuanced processes involved in psychedelic-assisted therapy - requiring careful screening, preparation, skilled facilitation, and comprehensive integration support. It is not a quick fix or one-size-fits-all solution; each individual's journey is unique, with outcomes varying depending on factors like mindset, environment, and personal history.
While the physical and medical risks of psychedelics are generally reported to be low (Schlag et al, 2022), the psychological risks should not be underestimated:
Challenging Experiences: Psychedelics can induce intense emotional and perceptual states during the acute phase of the experience (typically lasting 4-12 hours, depending on the substance). These acute challenging experiences may include fear, grief, feelings of insanity, paranoia, isolation, sensations of dying, physical distress, and confusing or troubling visions (Carbonaro et al., 2016; Durante et al., 2020; Barrett et al., 2016. While often temporary, these experiences can be overwhelming and distressing, even with professional support. Factors that may increase the likelihood of challenging experiences include past trauma, mental health difficulties, unsupportive environments, high or unknown dosages, lack of preparation or psychological support, and negative mindset (Evans et al., 2023; Simonsson et al., 2023).
Exacerbation of Existing Conditions: Psychedelics may increase the risk of triggering or exacerbating psychotic disorders in individuals with a personal or family history of these conditions (Roth & McClure-Begley, 2022). Recent research challenges previous assumptions about bipolar disorder and psychedelic use. While emerging evidence suggests potential benefits of psychedelic-assisted therapy for people with bipolar disorder, results are mixed and studies have been too limited to draw definitive conclusions about effectiveness versus risks. This highlights the need for more comprehensive investigation in this area (Aaronson et al., 2023; Morton et al., 2023).
Prolonged Adverse Effects: Some people may experience challenging after-effects that can include existential distress, mood difficulties, heightened sensitivities, or feeling generally unsettled. Although rare, some may experience prolonged adverse effects like derealization, anxiety, social disconnection, continued visual distortions, or suicidal ideation long after acute psychedelic effects have subsided (Evans et al., 2023; Simonsson et al., 2023).
Recent research into psychedelic use in the general public highlights these rare but potentially debilitating prolonged negative effects:
Anxiety and Mood Disturbances: Anxiety has been reported as one of the more common forms of prolonged adverse effects from psychedelics in recent studies (Bouso et al., 2022; Evans et al., 2023; Simonsson et al., 2023). The Imperial College London study found that 87% of respondents reported new or worsened anxiety symptoms following their psychedelic experience (Bremler et al., 2023).
Psychosocial Difficulties: In a survey of 608 people who experienced extended difficulties after psychedelic use, 33% reported problems lasting over a year, with 17% experiencing issues for more than three years. Common issues included anxiety, social disconnection, derealization, existential struggles (Evans et al., 2023).
Functional Impairment: A public survey found that 8.9% of respondents reported being unable to carry out certain functions in their daily lives, following a difficult psychedelic experience, and lasting for at least one day following the experience. Of these, 2.6% sought professional help in the following days or weeks (Simonsson et al., 2023).
Worsened Mental Health: Functional impairment refers to limitations due to the illness, as people with a disease may not carry out certain functions in their daily lives (Bremler et al., 2023). Another study investigating negative experiences from a pool of 807 naturalistic, observational prospective studies found that for 16% of participants, psychedelic use worsened their mental health in a measure that was clinically significant (Marrocu et al., 2024).
Persistent Perceptual Changes: 12% of respondents in Evans et al.'s (2023) survey reported persistent visual disturbances, including visual snow syndrome, visual perceptual distortion, seeing tracers, and extreme sensitivity to light. Reports from this study align respondents reported visual experiences with that of Hallucinogen Persisting Perception Disorder (HPPD) - a non-psychotic, post-hallucinogen intoxication disorder (though is not exclusive to psychedelics). Given this is a largely under-researched condition, prevalence is largely unknown, estimates suggest roughly 1 in 20-24 lifetime psychedelic users experience such disturbances, with 4.2% reporting symptoms severe enough to consider seeking treatment (Baggot et al., 2011).
Re-experiencing Phenomena: 80% of respondents from Bremler et al.’s study (2023) who had experienced long-term negative effects reported experiencing something akin to 'flashbacks' or 'emotional flashbacks', with some reporting re-experiencing physical symptoms felt during their psychedelic experience. Nearly half (46.7%) of the participants described feelings of disconnection and isolation, having derealization experiences (including out-of-body experiences and an altered sense or loss of connection with reality) (Bremler et al., 2023).
Positive Interpretations of Challenging Experiences
When discussing the risks and challenges associated with psychedelic use, it's crucial to consider the complexity of how individuals interpret their experiences. Research shows that the perception of psychedelic effects, even challenging ones, can vary widely and evolve over time.
Interestingly, many individuals who report prolonged effects from psychedelic use don't necessarily view these effects negatively. For instance, in a global survey of ayahuasca users, while 55.9% reported lasting mental health effects, 88% of these viewed these effects as part of a positive growth process (Bouso et al., 2022). Similarly, Evans et al.'s (2023) study found that despite experiencing prolonged negative effects, almost 90% of participants maintained a positive view on the therapeutic benefits of psychedelics.
Some researchers suggest that overcoming difficulties may actually catalyse the integration process for some individuals ([Bathje et al., 2022)). There's evidence that experiences involving major personality changes or confrontations with repressed trauma, while challenging, can ultimately be perceived as healing (Gomez-Sousa et al., 2021; Guthrie, 2021).
The interpretation of psychedelic experiences often depends on individual appraisal and context. What one person might view as an expected and welcome phenomenon, another might find unsettling. This appraisal can even change for the same individual over time (Evans et al., 2023).
Prevalence of Positive Reflections:
Several studies have found that a majority of participants view their challenging psychedelic experiences positively in retrospect:
78.6% of participants in Simonsson et al., (2023) study reported being glad they had used psychedelics, even after difficult experiences.
84% in Carbonaro et al. 's ,(2016) study reported benefiting from their challenging trip, even when it was one of the most difficult experiences of their lives.
67% of participants in Johnstad’s (2021) study reported long-term positive consequences from their worst psychedelic experience.
Continued Use and Perceived Benefits:
Evans et al. (2023) found that 55% of participants who experienced negative effects from psychedelic use continued to use psychedelics, and 90% agreed that psychedelics can be helpful and worth the risks if taken in supportive settings. However, it's important to note that almost half the participants no longer engage in psychedelic use, and some reported feeling significantly harmed by their experiences.
These findings underscore the complexity of psychedelic experiences and the importance of considering individual interpretations when assessing risks and benefits. While many users find value even in challenging experiences, the potential for harm remains real for some individuals. This nuanced understanding is crucial for researchers, clinicians, and policymakers as they navigate the evolving landscape of psychedelic use and therapy.
Risks in Clinical Settings: Psychedelic Therapy Research
While the majority of reported adverse effects are not observed in regulated medical contexts, it's important to note that even in controlled clinical settings, some risks remain. As described in Schlag et al. (2022) review, many of the persistent negative perceptions of psychological risks are not supported by much of the current scientific-findings from controlled clinical settings. Nevertheless, careful consideration of the potential risks, even if rare, is crucial for responsible clinical practice. Some notable findings from clinical trials include:
In Compass Pathways' clinical research trial investigating psilocybin as a treatment for treatment-resistant depression, approximately 5% of patients experienced treatment-emergent serious adverse events including intentional self-injury and suicidal ideation. The company noted these events "are regularly observed in a treatment-resistant depression patient population," but occurred more often in the 25mg group than in the 10mg or 1mg groups (Compass Pathways, 2021).
McNamee et al., (2023) cited evidence from trials using MDMA and psilocybin (Goodwin et al., 2022) that shows an increase of suicidal ideation and self-injury in approx. 7% of participants.
These findings underscore the potential for long-lasting psychological effects from psychedelic use, even beyond the immediate experience. They emphasise the need for careful screening, preparation, and follow-up care in both clinical and non-clinical settings to mitigate potential risks.
Potential Risk Factors
Studies have identified several potential risk factors for negative experiences following psychedelic use:
Pre-existing Conditions:
Prior trauma or major life events (Evans et al., 2023; Simonsson et al., 2023)
Prior psychiatric diagnosis of anxiety, psychosis (Bremler et al., 2023; Simonsson et al., 2023), or personality disorder (Marrocu et al., 2024).
History of tinnitus, eye floaters, or concentration problems (for HPPD; Halpern et al., 2018)
Substance-Related Factors
High or unknown dosage (Bremler et al., 2023; Irvine and Luke, 2022; Simonsson et al., 2023).
Co-use of lithium or other mood stabilisers (Simonsson et al., 2023)
Use of ayahuasca, DMT, or LSD (associated with longer-lasting difficulties; Evans et al., 2023)
Set and Setting:
Unsafe or complex environments during or surrounding the experience (Bremler et al., 2023; Bouso et al., 2022; Simonsson et al., 2023)
Lack of preparation or psychological support (Irvine and Luke, 2022; Simonsson et al., 2023)
Negative mindset going into the psychedelic experience (Simonsson et al., 2023)
A highly challenging psychedelic experience (Bremler et al., 2023; Carbonaro et al., 2016; Evans et al., 2023).
Demographic Factors:
Being female, unmarried, or having a pre-existing anxiety condition (for adverse outcomes after ayahuasca use; Bouso et al., 2022)
Taking ayahuasca in a non-religious setting (Bouso et al., 2022)
It's worth noting that Evans and colleagues (2023) found no significant association between prior psychiatric diagnosis and prolonged difficulties following psychedelic use, highlighting the complex nature of these risk factors.
Navigating the Path Responsibly
As psychedelic-assisted therapy gains mainstream acceptance, a deep sense of responsibility and commitment to harm reduction is paramount:
Comprehensive Screening and Preparation: Thorough screening processes should identify individuals at higher risk for adverse reactions, and comprehensive preparatory support should ensure participants are fully informed and emotionally ready.
Ethical Guidelines and Professional Standards: Clear ethical guidelines and professional standards must protect participants' well-being and autonomy, with protocols for informed consent, confidentiality, and appropriate therapist-client boundaries.
Skilled Facilitation and Integration Support: Psychedelic experiences in therapy should be facilitated by trained professionals providing a safe, supportive environment. Equally crucial is comprehensive integration support for processing insights and supporting people experiencing lingering difficulties.
Ongoing Research and Dialogue: Rigorous research must continue expanding our understanding of psychedelics' mechanisms, risks, and potential applications. Open, honest dialogue within therapeutic communities is vital for addressing challenges and sharing best practices.
Public Education and Harm Reduction: As psychedelics enter the mainstream, the public needs accurate information addressing both potential benefits and risks, accompanied by widely disseminated harm reduction strategies.
Conclusion & Summary:
The emergence of psychedelic-assisted therapy represents a promising frontier in mental health treatment, offering hope for those who have found little relief through conventional methods. However, as we navigate this "psychedelic renaissance," it is crucial to maintain a balanced perspective that acknowledges both the potential benefits and the risks associated with these powerful substances.
The risks of psychedelic use, even in controlled clinical settings, range from acute challenging experiences to prolonged adverse effects that can significantly impact an individual's well-being. These risks underscore the importance of careful screening, thorough preparation, skilled facilitation, and comprehensive integration support in any psychedelic therapy context.
It's equally important to note that many individuals report positive outcomes from challenging psychedelic experiences, often viewing them as catalysts for personal growth. This complexity highlights the need for nuanced, individualised approaches to psychedelic therapy with an emphasis on integration processes.
As we move forward, the field must prioritise:
Rigorous research to better understand the mechanisms, risks, and potential applications of psychedelics
Development and adherence to ethical guidelines and professional standards
Comprehensive public education and harm reduction strategies
Ongoing dialogue within the therapeutic community to address challenges and share best practices
By maintaining a responsible, evidence-based approach that neither overhypes nor unduly stigmatises psychedelic therapy, we can work towards harnessing its potential while minimising risks to participants. The path forward requires a delicate balance of open-mindedness, scientific rigour, and an unwavering commitment to patient safety and well-being.
Note: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified mental health professional for personalised guidance.
We welcome your thoughts and reflections on this article.
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Harm Reduction resources and support:
The Psychedelic Participant Advocacy Network (PsyPAN) - a non-profit organisation connecting aimed at connecting psychedelic participants, improving patient safety and wellbeing, and building best practices across all levels of the global psychedelic sector.
Psychedelic Support is a website that provides information about psychedelic-assisted therapy and FREE courses on integration.
F.I.V.E, is an organisation providing necessary education for individuals to make informed decisions when considering taking 5-MeO-DMT, has provided key resources to learn more about red flags and what to look for in a safe facilitator and how to engage with the integration process.
PsyCareUK: Provides welfare and harm reduction services at music festivals and events throughout the UK and internationally.
Resources on Adverse Experiences or Spiritual Emergencies, by Jules Evans
Maudsley Psychedelic Society Integration circle (monthly in-person, South London)
Want to learn more about HPPD?
Perception foundation blog: What is HPPD?
Do you think you might have HPPD? Take this self-test provided by The Perception Restoration Foundation and access specialist support today.
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References
References from research cited:
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Baggott, M. J., Coyle, J. R., Erowid, E., Erowid, F., & Robertson, L. C. (2011). Abnormal visual experiences in individuals with histories of hallucinogen use: A web-based questionnaire. Drug and Alcohol Dependence, 114(1), 61-67. https://pubmed.ncbi.nlm.nih.gov/21035275/
Barrett, F. S., Bradstreet, M. P., Leoutsakos, J. M. S., Johnson, M. W., & Griffiths, R. R. (2016). The Challenging Experience Questionnaire: Characterization of challenging experiences with psilocybin mushrooms. Journal of Psychopharmacology, 30(12), 1279-1295. https://pubmed.ncbi.nlm.nih.gov/27856683/
Bouso, J. C., Ona, G., Dos Santos, R. G., Sánchez-Avilés, C., Tapia, D., Maeso, J. M., & Hallak, J. E. (2022). Long-term mental health of ayahuasca users: A systematic review and comparison with the general population. Journal of Psychopharmacology, 36(11), 1253-1265. https://pubmed.ncbi.nlm.nih.gov/36962494/
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Compass Pathways. (2021). COMPASS Pathways announces positive topline results from groundbreaking phase IIb trial of investigational COMP360 psilocybin therapy for treatment-resistant depression. [SEC] https://www.sec.gov/Archives/edgar/data/1816590/000162828021022397/exhibit991-compass6xk.htm
Durante, M., Yamamoto, T., Crockett, M., & Heifets, B. D. (2020). Qualitative analysis of challenging experiences during psychedelic-assisted therapy. Frontiers in Psychiatry, 11, 592199. https://journals.sagepub.com/doi/10.1177/20503245241238316#bibr21-20503245241238316
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