Book review: Psychedelic Integration by Marc Aixala

This valuable book explores a range of adverse psychedelic experiences which are barely researched, and indeed are often denied by an industry desperate for mainstream acceptance, writes Jules Evans

How common is it for people to experience adverse effects of psychedelics in the days, weeks or months after a trip, what sort of difficulties do people report, and what is the best intervention for such cases? These are precisely the questions that our Challenging Psychedelic Experiences project seeks to answer. At the moment, there is hardly any research in this area, but an exception is the work of an NGO called ICEERS (The International Center for Ethnobotanical Education, Research, and Service). Its head of clinical support is Marc Aixala, who has just published a new book, Psychedelic Integration: Psychotherapy for Non-Ordinary States of Consciousness, which is the best work yet on psychedelic integration and adverse psychedelic experiences.

The book draws on Marc’s work over the last 12 years running ICEERS’ support service, which offers 10 free integration therapy sessions for people who have psychological difficulties after a psychedelic experience. He has worked with over 700 people through that service, and he draws on this experience in his wise, humane and intelligent book.

The book begins by outlining a history of the term ‘psychedelic integration’. As I and others have discussed, despite all the current emphasis on the importance of integration for a ‘good trip’, there is no settled definition of the term. As Marc explores, the concept of ‘integration’ originated in psychoanalytic therapy, especially Jungianism, where it referred to the integration of different aspects of the psyche.

In psychedelic psychotherapy, Marc suggests that British psychiatrist Ronald Sandison makes ‘perhaps the first implicit reference to integration’ in 1954, when Sandison wrote:

It seems almost certain that a more or less prolonged period of mental rehabilitation will be required after the course of treatment by LSD has been concluded. The patient may be tempted to make major alterations in his environment and way of life during the more disturbing phase of treatment. It is wise to allow the patient to make at least some experiments in readjusting his life but any major alterations, particularly where these involve the question of marriage, marital separation, or divorce, should be decided on only after the LSD phase of treatment has been concluded. We have found that about one-half of our cases required extensive rehabilitation involving the establishment of a new set of conditioned social responses.

Pioneering psychedelic therapist Betty Eisner was also an early voice insisting on the importance of follow-up integration sessions, especially if trips were difficult, despite the scepticism of her colleague Sidney Cohen. She wrote of her own personal experience of LSD:

After the second LSD I ended up, not in chaos and confusion but with the blackest depression that anyone could dream up. Depression had never been a symptom I suffered from. […] In profound physical and psychological distress, I walked to the corner to a pay phone, forced myself to wait in line, and called, finally reaching Sid. He refused to take me seriously, saying to get a good night’s sleep and all would be well in the morning. I clearly remember telling him that it wouldn’t look good for the research if the psychologist who was the subject committed suicide. He was unimpressed.

Eisner, ‘eventually managed to overcome that period through a curious intervention for that era: reading the writings of St. John of the Cross in the Dark Night of the Soul’, Marc writes.

The first author to use the term ‘integration’ with reference to psychedelics was Stanislav Grof, in 1980. He suggested that clients who undergo psychedelic psychotherapy could work to integrate the insights or breakthroughs that arose during trips through conversations with their therapist, meditation, drawing, dream analysis and so on.

How does Marc define ‘psychedelic integration’? He tells me he deliberately refrained from trying to provide a short definition (as, for example, Gorman has done), and instead offers several different metaphors for what takes place during integration, such as ‘roots and branches’, ‘pieces of the puzzle’, ‘chaos and order’, ‘navigating a storm’ or ‘developing a photo’. He also offers seven dimensions along which integration can happen: emotional, cognitive, behavioural, physical, social, spiritual and time. (One might add – is there such a thing as ‘political integration’? This, and the possibility of ‘political bypass’ through psychedelics, is something discussed by Benjamin Ramm).

Marc notes that social integration – ie the integration back into one’s society after a trip – is little discussed but presents a challenge for westerners coming back into a culture that is rather ignorant and suspicious of non-ordinary states of consciousness. He writes:

In shamanic societies, the concept of integration is not necessary; the use of psychoactive plants that grant access to non-ordinary states or the spiritual dimensions of existence is already integrated into their worldview….If, after an experience with a healer or shaman, someone is somewhat disoriented or needs a period of recovery, no one is surprised or requires further explanation…

A similar situation in any Western society today is unimaginable. Imagine someone who, after a difficult experience on a Saturday night, has to return to the office on Monday morning. This person will likely make every effort to ensure that nothing unusual or strange is noticed and that her bosses and colleagues do not suspect that something out of the ordinary had occurred over the weekend. Even if her bosses and colleagues were open-minded, it is unlikely that they would be able to offer much understanding. Furthermore, they might even be somewhat judgmental or try to warn her about the danger of these practices…

Ideally, in the future we will not need integration as discussed in this book. The future of integration, if we get it right, is that there is no need for integration. If the day comes when these experiences and practices are part of our customs and ways of life, and we develop the language and the spaces needed for this phenomenon to be adequately understood, then integration as such will likely be unnecessary.

While Marc doesn’t offer a narrow definition for psychedelic integration, he does try and construct a theoretical framework for it. He usefully distinguishes it from normal psychotherapy, which is often an open-ended deep-dive into one’s psyche lasting years. Psychedelic integration, by contrast, is shorter-term. If an experience has been largely positive, then integration can consist of self-care practices like journaling, to help a person maximize the benefits. If an experience has led to a person’s cognitive or emotional state worsening, then Marc suggests integration psychotherapy is more likely to help than self-care practices. He suggests that a short course of integration therapy (like the 10 sessions offered for free by ICEERS) is usually sufficient to help resolve issues.

The challenge of offering a theoretical model for psychedelic integration is that clients come to Marc with so many different worldviews – secular, Buddhist, shamanic, Christian, conspiracist and so on. These worldviews may play a role in their adverse experiences – for example, he says it’s quite common for people to feel they have been attacked by a negative energy or entity during an ayahuasca experience. How can an integration therapist work with such profoundly different worldviews?

The model Marc offers is constructivism, based on the approach of the Mental Research Institute of Palo Alto, and especially of the constructivist psychotherapist Paul Watzlawick. In this modality (as far as I understand it), humans experience the world through the construction or prism of their beliefs, and the task of the therapist is not to change that construction or worldview but rather to work within it to find better ways of coping with life difficulties, while maintaining what Marc calls a ‘radical respect’ for people’s worldview. But the integration therapist may still face tricky situations, as Marc discusses.

Integrating difficult psychedelic experiences

As mentioned above, Marc suggests that positive experiences can best be integrated by self-care or peer-group methods, such as mandala-drawing, journaling, tarot, dream-work, singing, meditation, sharing circles and contact with nature. Integration coaches can also help people ‘maximize the benefits’ from their trip. But Marc notes that, even if an experience is largely positive, there are some risks from failing to integrate the experience wisely, such as spiritual bypassing, attachment or addiction to ecstatic experiences, ego-inflation, or simply not taking full advantage of the possibility of self-growth.

What about more challenging experiences, where a person feels in a worse mental or emotional state than they did before the experience? Marc provides a review of the existing research on difficult experiences (concentrating particularly on the work of Sidney Cohen) and offers his own cartography of adverse experiences, based on his work with ICEERS’ support service. He categorizes them into seven categories, each with recommended therapeutic pathways:

Lack of preparation or context

Unresolved difficult experience

Traumatic dissociative experiences

Emergence of a previously unknown traumatic memory

Abuse by the facilitator/ shaman and interpersonal difficulties

Seeking out repeated experiences without proper integration

Previously existing mental disorder

Lack of preparation or context

Marc suggests that most of the cases he has dealt with arose because of lack of preparation, either by the person or by the therapist or centre where they take psychedelics. He gives one example of an 18-year-old woman who took LSD at a festival and was unprepared for her ego-boundaries to dissolve to the extent where she felt she was about to disappear. Thankfully, she got support at Kosmicare, an organization where Marc has volunteered, which provides psychedelic harm reduction services at festivals.

 He writes:

Those who participate in a session must be informed beforehand of the dynamics and types of interactions that will take place between participants or facilitators, whether any specific practices will be carried out during the session, and the proposed boundaries. Taking these issues for granted can lead to very complicated and potentially harmful situations when participants discover, once they have already taken the substance, that nudity or sexual intercourse are allowed or encouraged during the session or that the therapeutic methodology consists of getting a high dose and staying alone in an abandoned building. As outlandish as they may sound, these are real cases that have actually happened.

Unresolved difficult experience

Marc distinguishes between milder and more traumatic difficulties that arise during trips and then continue for days and weeks afterwards. This category refers not to psychotic breaks but to anxiety or depression which might arise and then last beyond the trip. He tells me:

It can be as mild as someone getting in touch with a deep sadness, which then doesn’t resolve, and spills over into the next weeks and months. It’s not incapacitating, but it’s like the lens is tinted. People go on with their lives, but their attention is always drawn to the sadness. Or it could be intrusive thoughts, worrying about death for example.

These cases usually have an easier resolution. It can be as easy as having another non-ordinary experience, maybe through Holotropic Breathwork. That’s a breathing technique that can induce a non-ordinary state of consciousness, but in a more controlled way than psychedelics. Or it could resolve through 5 to 7 sessions of therapy.

One method Marc recommends comes from the Mental Research Institute at Palo Alto. He suggests that, if a person had a scary experience, they can try to bring back the memory of it and experience it for 21 minutes a day, as a form of controlled exposure: ‘You’re trying to achieve a state where instead of the person running away from the experience they willingly go towards it. It’s a change in their inner attitude to ‘alright, I want to do this’.

This probably works best in therapy or a group setting rather than on one’s own. It reminds me of Acceptance and Commitment Therapy, whose founder Steven Hayes speaks of his own transformative experience of the moment he stopped running from his panic attacks, stood his ground, and opened himself to the experience.

Traumatic dissociative experiences

These are similar but more powerful adverse experiences, which may involve temporary psychotic breaks. He writes:

I observed that people typically approached me a few days or weeks following a session, not because of what occurred during the session but instead due to the symptoms they developed post-session. These symptoms often included insomnia, feeling startled, distress, intrusive thoughts, the feeling of re-experiencing the effects of the substance (especially when the lights were off or right before falling asleep), flashbacks, feelings of dissociation, depersonalization and derealization, low moods, and avoiding certain situations that may be reminiscent of the experience (leaving the house, being with the lights off).

The list of symptoms that people reported matched quite precisely what the DSM-V describes as “acute stress disorder,” a disorder that can occur after experiencing traumatic situations and that can turn into post-traumatic stress disorder if a series of diagnostic conditions are met, including the persistence of these symptoms for more than a whole month. In this particular case, what we have is a traumatic experience that takes place during a non-ordinary state of consciousness: a trauma induced by a psychedelic experience. As paradoxical as it may sound nowadays, even though psychedelics such as MDMA and ayahuasca can be used to treat trauma, they can also induce it.

Some people have ironically proposed a new diagnostic category: PSSD, or Post-Shamanic Stress Disorder, and it is even the title of a psytrance music album.

He says that such traumatic dissociative experiences seem particularly common after ayahuasca (indeed, I had an experience like this after an ayahuasca retreat). I wonder if it emerges partly from the ontological or cultural shock of westerners being plunged into powerful non-ordinary states in such a totally different culture as Amazon shamanism. In addition, westerners can feel themselves attacked or possessed by negative entities. Marc writes on possession experiences:

This phenomenon, which deserves a whole other book, is much more common in the context of the use of ayahuasca, particularly when embedded within Indigenous worldviews such as the Shipibo or the syncretic Santo Daime churches. However, it can also be found amongst people who experiment with smoked dimethyltryptamine (DMT). This complex phenomenon has sparked many fierce debates among proponents of the different worldviews. Beyond the debate regarding the ontological reality of such situations, the fact is that these phenomena are becoming the quintessential spiritual emergencies of our time, and they pose a real challenge for clinical practice.

In my experience, these cases are difficult to treat for multiple reasons. They can be understood as a combination of some of the profiles that I have previously described, including repeated experiences without proper integration, the emergence of a memory (in this case, something that happened during an experience: possession), and a potentially traumatic dissociative experience. In a traditional Indigenous context, these situations must be resolved by an experienced shaman who can expel the entities and restore balance. However, the situation is more complex when the affected person is a Westerner who constructs their reality based on Western cultural parameters, and they may or may not partially agree with the animist/ spiritist worldview. This means that treatment by shamanic means is often only partially effective and can sometimes even be quite harmful. Frequently, seeking more experiences with ayahuasca or DMT does not improve the problem but instead worsens it (this coincides with the profile of seeking repeated experiences without proper integration).

An alternative treatment would typically include elements described in the usual literature (Grof & Grof, 2001; Kornfield, 2001; Nelson, 2008) designed to help the person settle down, as described in the corresponding section. However, the resolution of a possession experience often requires some work under non-ordinary states. In my experience, such cases are best handled in the context of Holotropic Breathwork, where manifestations of demonic possession are not judged, and their expression is supported, whereas in ceremonial contexts these types of experiences can be disruptive…

From a constructivist point of view, I guess, a therapeutic response to the attitude ‘I have been possessed by a negative entity’ might be to practice agnosticism on whether this situation is really real, and instead consider how best to support the client to deal with it. In some ways, the modern psychotherapeutic relationship to ‘mental illness’ is a secular version of the animist idea of possession by demons. The CBT course I did for social anxiety taught me to tell myself ‘I won’t be bullied by social anxiety any more. I choose not to give it my attention or energy’. A negative energy, like a mental illness, only has the energy and attention which we give it. It ‘feeds’ on our fear, avoidance and self-loathing, and we can starve the parasite of energy by training ourselves in the psychic self-defence of mental control and self-care.

Emergence of a previously unknown traumatic memory

This is similar to the previous category in that it raises the ontological question – is this really real? Occasionally in psychedelic experiences, people have visions of traumatic events apparently from their past, such as child abuse. They are then faced with what Marc called a double-bind: either the memory is real, in which case they are a victim of abuse, perhaps by a family member, or the memory is not real, in which case what sort of imagination produces such a vision?

Marc gives two examples in his book. One is of a person who took part in a clinical trial of psilocybin for depression, during which they had the memory (real or imagined) of a parent trying to smother them. This memory made their depression worse, not least because they became obsessed with the question of whether the memory was real, and they wanted Marc to resolve the question.

Of course, the question of the veracity of memories of abuse that surface during therapy is not confined to psychedelic therapy. Sigmund Freud faced precisely this question in the early years of psychoanalysis, when patients often reported memories of child abuse. Then, during the 1980s ‘Satanic panic’ in the United States, many people reported memories of having been subjected to Satanic Ritual Abuse in their childhood – this led to huge investigations, which didn’t uncover any evidence of this supposedly widespread ritual abuse. That episode led to research into ‘false memory syndrome’, in which hypnotized patients get groomed to visualize lurid events by over-eager therapists.

Another example Marc gives is of a client who uses psychedelic therapy to try and uncover their earliest memory of trauma (much as Stanislav Grof suggests psychedelic therapy can help people process birth trauma). In this case, after repeated psychedelic sessions, the client felt they were processing trauma from previous lives, going back and back, further and further. This regression to past lives was sometimes reported in early psychedelic therapy sessions in the 950s, by the way. But, as Marc points out, where does the search for the original trauma end?

To both these situations, he suggests therapists can take a constructivist approach – not taking a side on whether a memory is real or not, but trying to help the person deal with the ambiguity of perhaps not ever knowing for sure, and instead thinking about how can they cope here in the present.

Abuse by the facilitator/ shaman and interpersonal difficulties

The situation here involves the tension between the need for wellness and the demand for justice. A person who has recently endured abuse by a facilitator – particularly if it is a well-known facilitator – may want to expose them and seek retribution and accountability, while still in a traumatized state. The integration therapist’s role here is not, Marc suggests, primarily to help them attain justice, but rather to support them to find psychological stability in the short-term, thereby putting them in a stronger position if they want to seek justice and retribution in the medium term. ‘Revenge is a dish best served cold’, as the saying goes.

Seeking out repeated experiences without proper integration

Marc tells me he sees this scenario quite often, where a person seeks rapid healing, and takes ayahuasca often – say once a month – with other psychedelic and ecstatic experiences in the weeks in-between.

They get into a dynamic where the experiences become more and more intense and enlightening, but less and less related to their personal situation. And they lose touch with their original intention. That can become problematic. They stop caring about their work or relationships, and their focus goes into the experiences. They become far out, start thinking about entities, energies. They may start having delusional thoughts, that someone is trying to do the evil eye on them. It can become magical delusional, conspiracy thinking. The person is losing touch with daily reality and are drifting in the transpersonal.

Here the recommended treatment is to encourage the person to slow down and stop seeking non-ordinary states of consciousness for a bit, so as to integrate some of these experiences, and perhaps strengthen their ego somewhat rather than endlessly seeking to dissolve it.

Finally, there is the category of previous mental disorders becoming worse after a psychedelic experience, such as PTSD or psychosis.

In conclusion, Marc’s book is cause for optimism – he suggests that, while psychological difficulties can arise after psychedelic experiences, in his experience they are often resolved via short-term integration therapy. The great value of his book is to shine a light on a range of experiences which are barely discussed or researched, and indeed are often denied by an industry desperate for mainstream acceptance. We need to normalize the fact that sometimes difficulties arise after psychedelic experiences, to reduce the fear and stigma that people may feel.

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