Psychedelic Psychodynamics: Relational Knowing and the Unthought Known

ABSTRACT

After a two-decade moratorium on psychedelic research in the United States, new studies on psychedelic assisted psychotherapy have shown promising results in the treatment of psychiatric disorders and the betterment of well people. Little has been written in contemporary psychoanalytic journals about the possible use of psychoanalytic theory as an underpinning for this research. This paper examines three concepts from psychoanalytic thinkers that may contribute to an understanding of what is curative in psychedelic assisted psychotherapy. First, I examine the possibility of psychedelics as a catalyst in changing a patient’s implicit relational patterns. Second, I use the work of Winnicott and Christopher Bollas to explore the psychedelic experience. Finally, I look at the role of mystical experience in psychedelic assisted psychotherapy.

What is striking about this whole line of clinical research is the premise that it is not the pharmacological effect of the drug itself but the kind of mental experience it occasions – involving the temporary dissolution of one’s ego – that may be the key to changing one’s mind

- Michael Pollan, How to Change Your Mind

Introduction

The patient steps into what appears to be a conventional psychotherapy office. Art and artifacts adorn the walls. Rather than a couch, they lie on a bed and ingest capsules of psilocybin – the main active compound in psychedelic mushrooms. A playlist of classical and ambient music begins as the medication takes effect. Over the next 5 to 6 hours, the patient will go on an inner journey which some participants have described as years of psychotherapy in a matter of hours. There are two therapists present for the session. Their role is not to interpret the experience, but to encourage the patient to explore whatever comes up – even if the content is painful or frightening. The therapists have met with the patient for several weeks in preparation for today, and following this experience, will meet again for several sessions for what, in the field of psychedelic-assisted psychotherapy, is referred to as integration.

Prior to 1965 there were over one thousand scientific papers published on psychedelic therapy, but in the wake of controversy over LSD, the counterculture, and figures such as Timothy Leary, the Federal Drug Administration essentially stopped all psychedelic research in 1966. Psychedelic therapy continued underground during the 1970ʹs and 80ʹs, but the first sanctioned studies since the shut-down in the United States did not begin until the 1990ʹs (Pollan, 2018). These studies on the effectiveness and safety of psychedelic-assisted psychotherapy for the treatment of psychopathology and the betterment of well people have allowed psychedelics to emerge from the counterculture and gain a seat at the table of legitimate scientific research. One of the most compelling lines of study has focused on the treatment of anxiety and depression in terminally ill cancer patients. These studies found that a single moderate to high dose of psilocybin combined with psychotherapy led to rapid, substantial, and enduring decreases in depression and anxiety, as well as improvements in cancer-related demoralization and hopelessness (R. R. Griffiths et al., 2016). Follow-up studies have shown lasting effects in the patients who are still living. (Agin-Liebes et al., 2020).

Pilot studies have shown promising results in treating alcohol and nicotine dependence (Bogenschutz et al., 2015; Johnson et al., 2014) and treatment-resistant depression (Carhart-Harris et al., 2018). As the research moves forward and the culture becomes more open to the healing potential of these substances, there is much to be explored theoretically around why these experiences are helpful for a wide range of problems in living as well as improving the lives of generally well people. “What is striking about this whole line of clinical research,” writes Michael Pollen in his 2018 book How to Change Your Mind, “is the premise that it is not the pharmacological effect of the drug itself but the kind of mental experience it occasions – involving the temporary dissolution of one’s ego – that may be the key to changing one’s mind” (p. 11).

Despite enthusiastic talk in the psychedelic literature of the role of the ego in psychopathology, little has been written in contemporary psychoanalytic journals about the possible use of psychoanalytic theory as an underpinning for this research. The contributions of psychoanalysis to the field of psychedelics seem to stop with Freud, but there are ideas through the history of psychoanalytic thinking that offer ways of understanding the psychedelic experience. In this account, I examine what contemporary relational psychoanalysis as well as independent thinkers such as Winnicott and Bollas have to offer to our understanding of psychedelic experiences.

The study of non-ordinary states of consciousness such as dreams, psychosis, and hypnotic states were integral to the beginnings of psychoanalysis (Carhart-Harris & Friston, 2010), and the study of non-normative states of consciousness induced by psychedelics offers a new way for psychoanalysis to observe the mind. Psychedelic medicine and psychoanalysis could each benefit one another. Like psychoanalytic psychotherapy, psychedelic assisted psychotherapy seems to work across a wide range of diagnostic categories and offers new opportunities to reconsider diagnostic systems and the way that we conceptualize psychic pain and mental well-being. Meaningful change in psychoanalytic therapy often takes many years, and psychedelics could act as a catalyst for change during periods of therapeutic impasse. Here, I examine three areas in which psychoanalysis and psychedelic research can contribute to a deeper understanding of and enhance the effectiveness of each other. While I have separated these categories for the purpose of this paper, there are many areas of overlap between them in the psychedelic and psychotherapy processes.

Implicit relational knowing

Why is it that we continue to struggle with the same relational patterns throughout life? One theory proposed in cognitive neuroscience suggests that the brain is a prediction machine that “evolved to process the environment as precisely as possible by finessing its representations of the world so that surprise and uncertainty (i.e., entropy) are minimized” (Carhart-Harris et al., 2014, p. 7). Our top-down predictions often override our bottom-up sensory input leading us to see what we expect rather than what is actually happening, or in other words, “perception is a controlled hallucination” (Seth, 2016). The concept of implicit relational knowing, introduced by the Boston Change Process Study Group (BCPSG), is a way of describing the brain’s set of predictions and expectations in one’s relational world. One way of defining implicit relational knowing is as “the intuitive sense, based on one’s history, of how to be with another” (Bruschweiler-Stern et al., 2007, p. 845). This knowing begins to be internally represented early in infancy, operates throughout life, and resists explicit efforts to change it. While these patterns can guide us in navigating relationships, they can also keep us trapped in a way of being that doesn’t fit the present context.

Many writers from the relational school of psychoanalysis have elaborated on the intransigence of relational patterns and the process through which relational change can occur. (Aron, 1996; Harris, 2009; Mitchell, 1995). Paul Wachtel (2014) offers a particularly clear model in his concept of cyclical psychodynamics. Wachtel proposes that we enter into all new relationships with certain implicit expectations about how the other person will perceive and react to us, often acting in ways that lead to confirmatory responses in the other. For example, if I grew up in a household where my caregivers ignored or reacted harshly to expressions of emotion, I am likely to expect that others will have no interest in my emotional states. I am then likely to approach new relationships with a hesitancy to express emotion that may, in turn, lead the other person to experience me as affectively empty or boring. This could elicit a real response of disinterest from the other thus confirming what I already implicitly “knew” about myself.

These patterns are frequently reinforced intrapsychically and interpersonally. New relational experience, such as that which one finds in psychotherapy, offers a chance to shift these expectations and patterns. The BPCSG describes one kind of new relational experience as “moments of meeting” between therapist and patient which shift “the relational anticipations of each partner” (Lyons‐Ruth et al., 1998, p. 282). These shifts can allow for greater flexibility in how we perceive ourselves and others and behave interpersonally. Put another way, when the patient learns through experience that their transference expectations of the therapist were inaccurate, they can begin a process of shifting their expectations of others creating a virtuous circle of change inside and outside of therapy. This change process in psychotherapy is often long and arduous. If we are fortunate, we have a few hours per week to change patterns that aren’t challenged by new experience in relationships outside of the consulting room.

Carhartt-Harris and Friston (2019) offer a neuroscientific model of relational change they call Relaxed Beliefs Under Psychedelics (REBUS), theorizing that the entropic effect of psychedelics on higher-level brain functioning relaxes “over-weighted priors” (p. 19) by increasing surprise and uncertainty. We can think of over-weighted priors as encoded predictions about the self, others, and the world that are resistant to being altered by experience and sensory input. They give one example of an over-weighted prior as “the belief that one has a particular personality and set of characteristics and views” (p. 319). This brings a neuroscience lens to the work of Philip Bromberg (1996) on multiplicity of self and the healthy illusion of a unitary self. I would argue that these “over-weighted priors” also include our implicit relational models that influence the transference someone brings into a new relationship. With a relaxing of implicit relational models and the brain’s predictive functioning during a psychedelic experience, the patient is able to question their habitual way of viewing important people or relational experiences in their lives.

With the relaxing of weighted-priors, psychedelics seem to induce a state of mind more receptive to bottom-up processing of new information that may have previously been dismissed as it did not conform to prior schemas. In this state of mind, the person is able to take in new emotional information from lower-level brain systems in a way that can expand their view of themselves in relation to others. This could be a catalyst for untangling the relational knots of enactments which lie at the heart of the change process in relational psychoanalysis (Aron, 2003; Bass, 2003; Schwartz Cooney, 2018). With a “disruption of the usual neural connections that enable binding of self-experience” (Fischman, 2019, p. 59), one is able to see themselves from outside themselves and with the same empathy with which another person would view them. Carhartt-Harris’ REBUS model suggests that the neuroplasticity of these entropic brain states allows for some changes to endure even after the brain returns to its normal predictive processes.

Beyond the domain of this intrapsychic psychedelic experience, the process of psychedelic assisted psychotherapy is itself an intensive new relational experience. As one descends into a drug-induced regression, there is the presence of the safe other, the therapist, who knows how to guide and care for the patient through this experience. The therapist will at times offer reassurance or a hand to hold as the patient experiences difficult emotions or confusion. A therapeutic psychedelic experience offers new ways of seeing oneself in a relational surround, and it is the role of psychotherapy to integrate these new ways of seeing into the patient’s life.

The psychedelic experience is often inherently relational. In a qualitative study of participants in two clinical trials of psilocybin-assisted psychotherapy, researchers found that “nearly all participants reported having an experience of love and joy, and these exalted experiences arose primarily through a specific human relationship with another person, whether it was a parent, child, or partner (Belser et al., 2017, p 363).” Psychedelics may catalyze a loosening up of relational expectations. One of the reported experiences of people who have taken psychedelics is that of reexperiencing old relational patterns with fresh eyes.

One patient reports on his experience of an internal relational shift in a therapeutic psilocybin session:

Toward the end of the session, I took out the family photo the guide had asked me to bring and noticed for the first time a distant sadness in my dad’s eyes. As a child I was always trying to keep him from falling asleep while we were together. I learned recently that he watched his own father die when he was only fifteen. I often felt like he was somewhere else when we were together and I was always trying to “wake” him. Somehow seeing this sadness in him for the first time during my psilocybin trip allowed me to let go of an unconscious feeling I carried that I wasn’t enough to keep him awake and interested. His sadness wasn’t about me.

The REBUS model offers an explanation of what may have happened for this patient. It is often hard to see the “essential others” (Galatzer-Levy & Cohler, 1993) in our lives as they really are rather than as projections of our memories and expectations of them. With his brain in an entropic state and his priors relaxed, this patient was able to notice his father not as he always saw him, but as a person with his own source of pain.

Accessing unconscious material

Beyond shifts in current relationships, many participants in psychedelic research report revisiting and mourning losses from the past, some traumatic, and reaching a place of acceptance and peace around them. The most prominent experiences reported were of events that were either difficult or impossible to convey in words (Belser et al., 2017) and some experiences that were never before symbolized. In his interpretation of Christopher Bollas’s (1987) concept of the unthought known, David Wallin (2007) states that “what we ‘know’ but do not (or cannot) think about is also what we cannot talk about. Enormously influential because it registers outside conscious awareness, unverbalized (or unverbalizable) knowledge plays a crucial role in psychotherapy as well as in childhood” (p. 115).

In Fear of Breakdown (Winnicott, 1974), Winnicott offers a look at the way patients suffer from the unthought known. He wrote about patients plagued by a fear of something happening in the future, which has, in fact, already happened – yet not been experienced (symbolically) by the patient. For Winnicott, this fear was of a presymbolic traumatic break in the parent-child attachment that was unable to be integrated. Without narrative memory, insight and healing through language were impossible. The only way to put this experience in the past and not go on fearing its happening in the future was to experience it in the present with the analyst. “All of this is very difficult, time-consuming, and painful,” writes Winnicott (p. 105). But what if psychedelics could be a catalyst for a controlled breakdown? I am not referring here to a drug treatment alone; Winnicott adds that “the solution is not good enough if it does not include analytic understanding and insight on the part of the patient” (p. 105). We should think of psychedelics not as a traditional pharmacological agent, but as a medication that facilitates an experience that can lead to insight and change.

Similarly, patients in current psychedelic research are not given the drug and left to the experience alone. The presence of a known therapist and the integration of the experience in continued therapy sessions are considered key to facilitating positive outcomes and minimizing harm. Many people have had recreational experiences on psychedelics that have not led to healing or may even have led to an increase in anxiety or distress. The content of a psychedelic experience (just like the accessing of traumatic memory in the normal psychotherapy process) can be confusing and overwhelming. Psychedelic assisted psychotherapy may offer a way for someone to safely experience a felt sense of early failures in the facilitating environment (Winnicott, 1980) in a way that puts these experiences rightfully in the past.

This failure may be relived as an internal experience or can be brought to life in the therapeutic relationship during the psychedelic session. The patient may experience the therapist as overbearing, unable to meet their needs, or as an idealized rescuer. What happens between the therapist and patient in a psychedelic session can be a kind of concentrated dramatic dialogue (Aron & Atlas, 2019) – an internal object relation brought to life.

Christopher Bollas’ description of his work with patients in breakdown in Catch Them Before They Fall (Bollas, 2012) offers a parallel to the work of therapists and guides sitting with patients in psychedelic sessions. Noticing this parallel was my initial inspiration for this paper. When Bollas notices a patient entering a state of breakdown, he offers containment in which he works with patients in all-day sessions for multiple days until the person begins to emerge from this state.

It may help to look at Bollas’ work with a particular patient in breakdown. Years into her analysis Anna arrived to a session disheveled and unable to provide a coherent narrative around what had happened to leave her in this state. She was silent and tearful for the entire session. Suspecting that she was heading toward a breakdown, Bollas extends the session for several hours and discovers the event that brought it about. He told her that he thought she was in a state of breakdown, that they would set aside the following day from 9AM to 6PM to talk about it, and if they gave it the attention it needs, she should get through it. Bollas talks about the importance of time boundaries even in these extended sessions as “the fear of infinity is an immediate consequence of the onset of any breakdown” (p. 50). This is similar in psychedelic sessions. With the relaxing of some ego function as well as a distortion of time perception, one role of the therapist in a psychedelic session is to remind the patient that they are moving through time and that the psychedelic state will come to an end. Otherwise, panic about the trip going on forever can dominate the session.

In Anna’s first extended session, she spends two hours in silence, shifting in her seat, clenching her hands together “as if she was trying to find her body first, before words could come” (p. 53). In time, she is able to describe in detail the event that precipitated the breakdown. Bollas provides her with an interpretation of how this event had shattered the false sense of self that had protected her from some painful realities of her early life. She arrives on the third day in distress telling him that the night before she had shit herself. Bollas views this as part of the regression and says “I think it would be a good thing if you had a little more shit on yourself than you do” (p. 56). This brought about 10 minutes of laughter from Anna. These extended expressions of emotion – laughter and crying – are a hallmark of intense psychedelic sessions and a large amount of time is needed to allow for these extended internal experiences. “Hours can pass with the patient in this state of mind” (p. 76). Bollas describes these as moments when “the sudden arrival of overwhelmingly powerful emotion preempts the analytic pair’s exploration of recent and past history” and “the unthought known that is being released in the here and now cannot be historicized” (p. 80).

[Patients] say it was akin to wakeful dreaming, with occasional hallucination-like visions, or eidetic memories, interspersed with passing lucid views of themselves, their mothers or fathers, or their life. They felt they were inside a moving process. It never occurred to them to speak whilst inside it, nor did they expect me to say anything. (p. 77)

Bollas describes the patient’s emotional experience during this time as “a dream without manifest content; a poem without words; the wind moving through a landscape and animating the natural world.” (p. 83) The internal experience of the patient becomes the force of cure. No interpretation is needed and would most likely just get in the way. In guided psychedelic sessions, the therapist is a witness – there to reassure if needed, not to investigate or interpret. We could think of what happens in a psychedelic experience as a kind of breakdown, surrender or regression- a loosening up of reality as it is normally perceived, allowing one to enter a state of deep emotion (primary process) and understanding where the narrativization of experience through language is not core and the emotional states themselves become mutative.

Bollas (2012) describes the healing that takes place in the analysis of breakdown as “a fundamental shift in a person’s view of the world and their positioning of the self” (p. 100). This is exactly what is on offer when one consumes psilocybin mushrooms under the right conditions.

Carhart-Harris et al. (2014) propose that psychedelic states (along with REM sleep and onset-phase psychosis) are dominated by “primary states,” a regressive style of cognition more present in infancy and early childhood (p. 6). Returning to this state of primary consciousness might allow one to finally experience the traumatic breakdown one experienced in infancy, but which could never be symbolized and brought into consciousness.

Though Bollas argues that this type of breakdown offers a chance for deep healing and change, he does not suggest regression as a goal.¹ One reason a therapist would not pursue this type of regression in treatment is that patients have to carry on with life, work, and family. Few people are able to take a six-week break from the demands of life to do intensive psychotherapy in a regressed state. Psychedelic-assisted psychotherapy may offer a safe way to facilitate a regression or series of regressions that bring to life unconscious and pre-symbolic material on an experiential level and could predictably end within 5 or 6 hours allowing the regular work of life and therapy to continue.

Mystical experience

Many participants in psychedelic trials have rated the experience as one of the top three most meaningful of their lives, and there is a strong correlation in the research between the patient’s report of mystical experience and lasting positive change (R. Griffiths et al., 2008). The works of Carl Jung (1938) and William James (1902) have provided a framework for the research into mystical experience as a mutative factor in psychedelic assisted psychotherapy. Fischman (2019) suggests that ego dissolution – a blurring of the boundaries between the self and the outside world – plays a part in the mystical experience of psychedelic states. “The key phenomena of ego dissolution in this state – particularly the sense of heightened significance or new meaning, and enhanced connectivity – may be explained as a reversal or undoing of the ego’s ability to modulate the affective intensity of its relationships with loved objects” (p. 54). Much has been written about the neurological processes that mediate these states (Carhart-Harris et al., 2014; Fischman, 2019), but I want to focus on the descriptive rather than technical aspects of the research.

Writing about the subjective experience of a psychedelic session is difficult and the narratives can take on a platitudinous quality, but a few sentences from Michael Pollan (2018) on his own ego dissolution offer a vivid description of this much-discussed experience in high-dose psychedelic sessions:

“I” now turned into a sheaf of little papers, no bigger than Post-its, and they were being scattered to the wind. But the “I” taking in this seeming catastrophe had no desire to chase after the slips and pile my old self back together. No desires of any kind, in fact. Whoever I now was was fine with whatever happened. No more ego? That was okay, in fact the most natural thing in the world. And then I looked and saw myself out there again, but this time spread over the landscape like paint, or butter, thinly coating a wide expanse of the world with a substance I recognized as me. What had always been a thinking, feeling, perceiving subject based in here was now an object out there. I was paint (p. 236)!

Another important aspect of mystical experience is accessing a state of primary consciousness, opening up a mode of experiencing “marked by timelessness, an absence of logic, and of negation” (Fischman, 2019, p. 61). Returning to Bollas’ description of patients’ subjective experiences of analysis during breakdown, we see the proliferation of primary process material. Bollas writes that in remembering extended sessions in a state of breakdown his patients have recalled the importance of the physicality of the room and feeling “bathed in light and sound.” Bollas wonders if this could be an experience of rebirth, a dive into the unthought known and somatic memory of prenatal and early infantile life “when light and sound were experienced as phenomena-in-themselves” (p. 83).

Otto Rank (1924) speculated that the experience of birth itself is traumatic, and remnants of the experience contribute to some forms of psychopathology. The violent physical and psychical experience of separation from the mother, he claimed, was a blueprint for all future anxiety. Wilfred R. Bion (1977), focusing on the psychic experience of birth, suggested that infants are born into confusion awash in undifferentiated feeling states.

Some patients who have been through a psychedelic experience have described sensations akin to rebirth. It is, of course, impossible to know if these felt experiences reflect true memories, but this is a problem in psychotherapy in general. Much of the meaning making, historical connections, and narratives co-created in the therapy process are “useful, but ultimately constructed” (Nayak & Johnson, 2021). The metaphors and meaning making in psychoanalytic psychotherapy are moving toward an ultimate reality – something akin to W. R. Bion’s (1965) ineffable “O” that can be experienced, but never known. What moves these experiences from biographical to mystical is the move from experiencing one’s own developmental history to experiencing the evolutionary history of humankind (ontogenetic to phylogenetic).

Sandor Ferenczi’s 1924 book, Thalassa (1938), when viewed as a creation myth, offers an ontogenetic and phylogenetic view of evolution, birth, and sex. Ferenczi theorized that “the birth of man is marked by trauma: a catastrophe whose fragments of lost history are preserved as hieroglyphics in the psyche and in the body” (Sguazzi, 2019). Moving from the ontogenetic to the phylogenetic, he suggests that there is a history within our cells of our own evolution – that within us is a desire to regress to an undifferentiated state – to return to the womb or to a previous evolutionary stage when we dwelled in the sea. As one reviewer of Thalassa wrote; “Why, in the heat of summer, do we all cluster by the seaside, as naked as the customs of the age will permit? What do we seek? What do we secretly long for? Could it be to merge with one another and return to the source from whence we came?” (2013). Similarly, Michael Pollan proposes that one reason humans use drugs is to transcend the ego and return to something larger than the self (Harris, 2021).

Notice the parallel between Ferenczi’s words about regression to an undifferentiated state and Bollas’s (2012) concept of breakdown:

I do believe that, in breakdown, analysands experience the basic elements of being human, the thing-in-itself of their existence. Hence their absorption in the essentials of existence: sound, light, colour, scent and images. These are not moments for rolling insights, the hubbub of dialogue … transference or countertransference. Indeed, it is as if these ordinary features of analysis become mere asides, as self opens up to the most fundamental dimension of being (p. 83)

Could psychedelics not only provide a regression into the unthought known of early undifferentiated states in infancy, but to an even deeper, mystical regression into our evolutionary history? Patients under the influence of psychedelics have described taking on the form of plants or single-celled organisms as well as unitive or oceanic feelings of connection with the universe. Perhaps these experiences are evidence of the imprint of Jung’s collective unconscious on our DNA. Jung (1982, as cited in Carhart-Harris et al., 2014) proposed that both our ontogenetic and phylogenetic histories are present in the unconscious mind and that fragments of those histories emerge into consciousness during altered states such as dreams and psychosis. “The brain is inherited from its ancestors; it is the deposit of the psychic functioning of the whole human race. In the brain, the instincts are performed, and so are the primordial images which have always been the basis of man’s thinking” (Jung, 1982).

Bollas’ conclusion to his 1987 work, The Shadow of the Object, touches on the mystical and harkens back to Ferenczi’s emphasis on regression to an undifferentiated state:

Is it not possible that by eventually developing a limited relation to the unthought known in ourselves, we can then address the mysteries of our existence, such as the curious fact of existence itself, particularly the legacy of our ancestors carried as it is through the generations via the idiom of the inherited disposition? In thinking the unthought known we ponder not simply the kernel of our true self, but elements of our forebears. (p. 283)

Areas for further inquiry

The current research on the use of psychedelics for the treatment of both psychopathology and the “betterment of well people” is promising (Pollan, 2018, p. 45), but there is still much research to be carried out to determine what categories of people and what types of psychic suffering may be helped through psychedelics. The REBUS model presented earlier in this paper suggests that many common mental disorders, such as addiction, depression, and obsession, are linked by mental rigidity (Pollan, 2018) and an overweighting of high-level priors (Carhartt-Harris & Friston, 2019), and that part of the mutative function of psychedelics is a relaxation of the predictive mechanisms of the brain that play a part in seeing the past in the present. With that in mind, psychedelics may be most helpful for those disorders marked by low entropy and high rigidity in the predictive functions of the brain. This loosening up of the predictive function, however, would be unnecessary and potentially harmful for someone whose integration and sense of self is already tenuous. We can think of McWilliams’s (2011) continuum between supportive and uncovering therapies. Patients at the psychotic level of organization could be harmed by an attempt to uncover and work through intrapsychic conflict. What is needed, McWilliams writes, is “an approach that emphasizes active support of the patient’s dignity, self-esteem, ego strength, and need for information and guidance” (p. 87). Likewise, psychedelics as a catalyst for radical uncovering may be inappropriate for patients with a more fragile self-organization.

Given the current legal status of psychedelic substances, I am not suggesting that therapists recommend psychedelics to patients. One might ask, then, why psychoanalytic clinicians should care about the subject of psychedelics. In the past three years, major cities such as Denver, Oakland, and Washington D.C. have voted to decriminalize some psychedelics, and the state of Oregon is working on a legal framework for psilocybin therapy centers which could open in 2023 (Cormier, 2020). Psychedelic use is becoming more common and many of our patients have had or will have a psychedelic experience. Whether or not one has interest in the potential use of these medications as a catalyst for the psychotherapy process, being familiar with and having a psychoanalytic framework for psychedelic experience will help us make meaning of these experiences with our patients in a similar way we make meaning of dreams, fantasies, and wishes. Like any new and promising treatment for mental suffering, the hype can lead to headlines about breakthrough cures. New breakthrough or “miracle” treatments soon enough become another tool that helps some people some of the time. As psychoanalysts and psychotherapists, it is up to us to follow developments in diverse fields “trying to determine what is valid, sensible, and useful in light of the realities of everyday practice and the concrete particularities of the clinical situation” (Borden, 2021, p. 20).

Conclusion

There was an understanding decades ago that psychoanalysis offered a solid theoretical background for the use of these substances in a therapeutic setting (Grof, 1985), but contemporary psychoanalysis has had limited involvement in this new wave of research. In this paper, I have described the ways in which concepts from relational psychoanalytic theory offer an understanding of how a shift in implicit relational knowing brought about in a psychedelic experience can lead to relational change. I also examined the concept of breakdown as formulated by Winnicott (1974) and Bollas (2012) and the possibility that psychedelic assisted psychotherapy offers a structured and time-limited breakdown that gives patients access to presymbolic trauma and experience of unconscious material. Experiencing these states in the context of a therapeutic relationship, allowing the formulation and integration of previously unformulated experience (Stern, 1983) with narrative memory offers a way to put them in their rightful place in the past (Winnicott, 1974).

Finally, I have examined the correlation between mystical experience and positive outcomes in psychedelic assisted psychotherapy. Psychoanalysis may refer to this as the oceanic feeling, a connection to the collective unconscious, or the dissolution of the ego which allows one to feel at one with, and in love with, the world (Fischman, 2019). There is much overlap in the three categories I examined in this paper and there are many other concepts which psychoanalytic theory could offer in an effort to conceptualize the psychic processes underlying psychedelic experience. Carhart-Harris et al. (2014) suggest that psychedelic research offers a path to integrate cognitive neuroscience with psychoanalytic theory, allowing psychoanalysis to establish itself as the science of the mind Freud hoped that it would become.² There is room in the research for a shift away from a model where psychotherapy is an adjunct to the psychedelic experience, offering preparation and integration, to one in which psychotherapy remains primary and psychedelics are used as a catalyst for deepening the therapeutic process. I hope others will continue to think about what psychoanalytic theory can offer the burgeoning field of psychedelic-assisted psychotherapy and what psychedelic research in turn can offer to our understanding of the mind.

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Additional information

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Kevin Barrett

Kevin Barrett, AM, LCSW is a psychoanalytic psychotherapist in private practice in Chicago. He is a lecturer at the University of Chicago Crown Family School of Social Work, Policy, and Practice and a Clinical Associate Faculty Member at the Chicago Center for Psychoanalysis.

Notes

¹ Winnicott’s work on regression has been debated in the analytic literature (Quagelli, 2020) and Bollas cautions against a regression to dependence in his work with patients emphasizing the importance of keeping the patient’s own assets and ego strength as a presence in the room and the work. Quagelli describes regression to dependence as a way of regaining contact with “ahistorical, a-temporal areas of the mind” that seems to describe the places accessed by Bollas’ patients in breakdown as well as patients under the influence of psychedelics (p. 461). A thorough examination on the theoretical and technical debate around regression is beyond the aim of this paper, but it is my opinion that the time-bound nature of a regressed state accessed with psychedelics offers an advantage over the more unpredictable nature and length of regressive states in psychotherapy.

² There is ongoing debate on the relevance of neuroscience within psychoanalysis. Addressing this debate is beyond the scope of this paper, but I resonate with the clinical pragmatism of Borden (2021) when he writes that “the nature of human experience and the practical concerns of clinical practice require a multitude of explanatory concepts bridging scientific and humanistic domains of understanding” (p. 35) and that one can draw on neuroscience without falling into a reductive materialism.