Building a psychedelic safety network

An interview with a pioneering clinic for post-psychedelic difficulties

Our monthly post-psychedelic difficulties peer support group is meeting online this Sunday at 6pm UK time. If you’d like to attend, email contact@challengingpsychedelicexperiences.com

The conversation around psychedelic harm has shifted a lot in the last two years since we launched the Challenging Psychedelic Experiences Project in September 2022.

Back then, there wasn’t a great deal of research on psychedelic harms or post-psychedelic difficulties, or evidence-based support in place for those who experience post-psychedelic difficulties.

Today, there are several psychedelic researchers working on this topic and producing papers –  this is not by any means a complete list, but just to name a few, there is David Yaden and his team at Johns Hopkins, Otto Simonsson and Peter Hendricks, Abigail Calder and her colleagues, Roman Palitsky and the team at Emory, Gillinder Bedi and her group at the University of Melbourne, Tomislav Majic and his group in Berlin, Max Wolff and his team at MIND Europe, Joost Breeksema and the team at OPEN Foundation, Ingmar Gorman and the team at Fluence, Marc Aixala and the team at ICEERS, Jacob Aday and Daniel Kruger at Michigan, Robin Carhart-Harris and the team at Imperial, Matthew W. Johnson at Sheppard Pratt, Nese Devenot and the team at Psymposia, the psychedelic ethics teams at Baylor, Yale and HOPE - and a lot of others, too many to mention them all (apologies if I left you out!) who are producing research on psychedelic harms.

Slowly, there is also more evidence-based support available for people experiencing psychedelic or post-psychedelic difficulties. Fireside Project has been flying the flag for online support for many years. There’s festival harm reduction organisations like Psycare, Zendo, Safe Shore and Kosmicare. There’s the psychedelic difficulties clinic at the Charite hospital in Berlin (I interview two therapists who work there below), Ricarda Evens’ clinic at Humboldt, Aryan Sarapast’s clinic at OHSU, the SHINE Collective and PsyAware for survivors of psychedelic abuse, ICEERS’ support centre, and a new clinic Psychedelic Experience Centre in London - I’m speaking at their online launch event tomorrow (tickets here).

These various different teams and organisations are connecting, their work is increasingly featured at psychedelic conferences, and there are plans for two gatherings next year - one in Berkeley co-organized by a new organization called the Psychedelic Safety Institute, and another at Emory.

There isn’t much funding out there for this work, but there’s some. Key will be opening the taps of government funding - SAMHSA is funding a project on psychedelic risk communication run by OHSU. It would be great if Veteran Affairs, NIH and others funded work in this area. The Psychedelic Caucus in Congress recently put out a call for more information on psychedelic risks and safeguards.

What we need to build is a learning culture.

Psychedelic harms occur and will continue to occur, but does the field learn from harms and improve its practices? If it doesn’t, there is no learning, people merely suffer in silence or go to the press.

One suggestion is the evolution of a psychedelic harm network, formal or informal, to connect researchers, clinics, retreats, churches, training schools, underground guides, dispensaries and consumers - to learn from harms through surveys, case studies and consumer complaints, share that information and try to learn from it. For example, below I interview two therapists from the psychedelic difficulties clinic in Berlin who share that in their experience, anti-seizure medication has sometimes been helpful for people with HPPD - that’s useful info that the rest of the field could learn from.

This sort of network already exists in an informal sense but it could be more joined up. What would that look like in practice? It could be as informal as a mailing list to share articles and case studies, or the creation of some working groups, or more ambitiously it could be the establishment of some sort of jointly-run online registry of harms.

The potential issues for this greater connectedness and joined-up learning are: 1) how to react if someone reports harm from a particular person or organisation, and what if that person or organisation is part of the network? Could some sort of mediation process be developed? 2) competition for funding and prominence could get in the way of collaboration. And finally 3) politics could get in the way - people might have directly competing visions of how the field should look (decriminalized vs medical, profit-driven vs social-driven). Or they might just have beefs with others in the network - this is a small field with a long history of in-fighting!

In the spirit of ‘learning from harms’, here’s an interview with Dario Jalilzadeh Masah and Derin Marbin, two psychiatrists and psychotherapists in training who have worked for four years at the psychedelic difficulties clinic at Charité Universitätsmedizin Berlin.

Derin Marbin and Dario Jalilzadeh Masah

What’s the aim of the clinic?

DERIN 

I believe the main goal is to connect with people who are experiencing ongoing difficulties related to their psychedelic experiences and to offer support. The range of patients we see in our clinic includes those with acute symptoms following a psychedelic experience, as well as individuals who have been dealing with these symptoms for a longer period of time.

DARIO

Our supervisor, Tomislav Majic, identified a gap in medical care for users of psychedelic substances who need treatment. In our clinic, we frequently encounter patients who have previously seen other psychiatrists, where they were misdiagnosed and had negative experiences. This is often due to the persistent stigma surrounding the use of psychedelics. We aim to alleviate the shame, anxiety, and fear that patients feel about their experiences.

DERIN 

Especially the fear of having brain damage. The tools we have are very individual and very multifaceted, because we are psychiatrists, but also psychotherapists, thus using a variety set of tools, with integrative, psychotherapy, psychiatric aspects if needed

How much does it cost?

DARIO 

If you're based in Germany, treatment is covered by public health insurance. We have patients from all over the world. The first consultation is free, and any further treatment depends on individual circumstances.

Is there a typical number of sessions?

DERIN 

It could be anything between one and 25 sessions to an individual. It really depends on what the patient needs. If they need more than that we would recommend they see a psychotherapist on a regular basis.

DARIO

When we prescribe medication, such as for patients with HPPD, the majority are based in Germany because it is covered by insurance. We cannot send medication to the US, the UK, or even neighboring countries like the Netherlands or Poland.

How many clients might you see in a month or a year?

DERIN 

I have the feeling there’s a seasonal rush, especially throughout spring and summer. But I would say, in the last two years I saw 70 or 80 patients.

DARIO 

Yes, I would estimate the same, between 80 and 90, while Tomislav Majic handles slightly fewer cases because he is busy with research and has additional responsibilities.

The seasonal aspect - is that because of festivals?

DARIO 

Partly, yes, and perhaps it's also the invitation from nature to have the experience outdoors. Additionally, more retreats tend to take place in the summer.

What’s the most typical kinds of problems that people come to you with?

DERIN 

I think we can break it down to two or three syndromes. For the first would be DDD or dpdr. This is a syndrome consisting of depersonalization and derealization. So the feeling of being cut off from your own emotions, or being cut off from the surroundings with feeling of alienation, which can can cause heavy suffering, because people affected to not feel like themselves anymore and cannot take part in their everyday life like they used to.  And the other one would be HPPD.

DARIO 

That’s similar to persistent visual alterations. A third group might have had a difficult experience with psychedelics or MDMA, and they want to discuss it in one or two sessions to gain a better understanding of what happened.

Do you ever get people who feel harmed by someone else's actions during the trip?

DARIO 

I had one patient who attended a psychedelic retreat and felt that his guide wasn’t creating a safe space. He was struggling during his trip, and the guide seemed indifferent, leaving him alone with his emotions. Afterwards, he developed a really negative feeling about both the guide and the experience overall.

DERIN 

I had a patient once who was on a retreat, and there was like a circle, and the patient reported that he or she did not start with the trip until the circle was clearing up and they said the ceremony was finished. They said it's over, we cannot accompany you on your trip. And this was the start of a very bad trip experience, and the patient is suffering up until now.

How do you help the people coping with these different issues?

DERIN 

There’s no one size fits all. When people with DDD approach me, I always try to use more psychotherapeutic approaches, and I try to understand the trip experience, and to see what kind of topics and emotions arose, and then to understand and to be curious about the question, what function does the DDD have? Being cut off from oneself or from the surroundings could be some kind of protection mechanism. It is one way of explaining things. There are many other explanations, but I try to use this approach in order to really go into a further dive with the patients, also in their biographical history –did this kind of feelings occur throughout childhood or adolescence? Do they know this feeling of being cut off, and what kind of function could it have now? And this is something I try to work with so that people get more insight and more understanding.

DARIO 

I think what we do is create an environment where our patients feel safe and free from judgment, allowing them to share their stories. We try to understand what happened during the trip that triggered their difficulties. Often, patients come to us saying, "I’ve damaged my brain, and it’s irreversible. I’m never going to be the same, I did something really bad and shameful." We work to remove that sense of shame. For our patients who live in Germany, we always offer MRI or EEG scans to ensure everything is physically normal. This brings a lot of relief, as people realize that what they’re experiencing may not be unique, that others go through similar challenges. They no longer feel alone or unseen; instead, they feel validated and not boxed into a diagnosis.

For example, someone with HPPD might be misdiagnosed as having psychosis by other colleagues, but it’s not psychosis—it’s something different.

Sometimes we see people who have been to other psychiatrists and were prescribed antipsychotic medication. When used for the wrong indication, this can cause significant side effects, making them feel even more disconnected from themselves and potentially worsening DDD symptoms.

What kind of outcomes do you see? To what extent do people recover from HPPD or DDD or other post psychedelic difficulties?

DERIN 

I have seen the whole range, to be honest. But when it comes to HPPD, we have people who recover pretty fast. I think in half of the cases, there's a full recovery. And there's also a percentage with persisting symptoms. And for those, I think the similar approach applies as for, say, chronic pain patients, where it is important to decenter the symptom and to decrease this hyper vigilance and this observation of this visual phenomenon all the time. What happens when something disturbs us is we look out for it all the time, and it becomes bloated, and is more present and prominent. And what we try to work on is to decenter those symptoms, to help them say it doesn't annoy me anymore, and I can function again.

DARIO 

With DDD, those experiencing it in an acute phase often find that it improves after a few sessions of conversation. However, for those who have had it for a longer time, the process can be more challenging. In these cases, we often recommend proper psychotherapy, which we cannot provide for everyone, as our service consists of just three people.

You sometimes prescribe medication as well. Do you sometimes find that helpful for people?

DARIO 

In the case of HPPD, we have observed some really good results with medication, particularly with Lamotrigine, which is an anti-seizure medication used for epilepsy. All of the treatments we use are off-label, as there is currently no evidence-based medicine or clinical trials in that field.

That’s interesting – I recently encountered another case where a person was having disturbing vibrations after an ayahuasca experience, and was helped by anti-seizure medication.

DERIN 

There is theory that HPPD creates some kind of network alterations in a similar sense to epileptic conditions.

DARIO 

You don’t see any alterations in the EEG, but somehow Lamotrigine works for some of our patients. We also see many people who experience tinnitus after a negative psychedelic experience.

I’ve also encountered such cases. What helps them?

DERIN 

That is very complex, because I think the reasons behind tinnitus are also multifaceted and very complex.

How difficult is it sometimes to understand what are post psychedelic difficulties and what might have been pre existing difficulties?

DERIN 

I think it is very important to get to know the patient and to really scan for possible conditions throughout childhood, teenage years, adolescence, and then also to really have a closer look at the trip experience. I mean, sometimes there might have been things which were there already, but not visible, and it might be that the psychedelic experience just made it visible.

DARIO 

Often, our patients are the experts, and they tell us that their difficulties started with the trip. Some might say that the trip triggered something that was already inside them but had not been addressed for a long time.

DERIN 

A lot of people having had difficult experiences, they talk about a lot of childhood memories coming up after or during the trip. And this I find very interesting as a psychotherapist to work with.

Do you ever get people coming to you who've had psychotic breaks?

DARIO 

Our service is not for people experiencing a psychotic break. When we do encounter such cases, we talk to them but refer them to other parts of our clinic that specialize in treating psychotic episodes.

DERIN 

I also have seen them in the emergency department through more acute psychiatric work, but not in the outpatient clinic.

There is a debate ongoing about what are difficulties or adverse events and what are part of the healing process with psychedelics. How can you tell the difference?

DARIO 

I would say that if someone takes psychedelics just for fun and has a bad experience afterwards, it’s not a healing experience; it’s simply a negative experience from which they are trying to recover. However, if your motivation was healing and something challenging arises, then wanting to integrate that experience could be part of the healing process.

DERIN 

If  someone does it for fun, lead with the fun. But if there's a profounder motivation of diving deeper and experiencing then it might also be worth to take a different approach.

What would you like to happen with the clinic?

DARIO 

A sister clinic in Oregon contacted us, which is great. I believe it's really important to connect with other services that do similar work to gain expertise on how to help people who have had negative experiences with psychedelics.

DERIN 

We have almost the same wishes as our patients - not to be alone In this field and to feel connected

I suppose, what could be useful as well is connecting information, new studies, case studies…

DARIO 

Yes, that’s what we’re actually planning to do—perhaps publish some case reports and case studies, and potentially conduct more research.

What would you like to see happening in psychedelic culture more broadly?

DERIN 

A more honest discussion about differentiated effects. And also being able to contextualize the media hype, which goes along with it.

DARIO 

Some people believe that psychedelics are entirely beneficial, while others see them as purely harmful. I think there needs to be an open discussion about this topic. We must talk about both the potential benefits and the risks of using psychedelics because only then can we responsibly offer them to patients who want to use them for depression. It’s crucial to understand the contraindications and know when it’s not suitable for someone. Just like with any other medication, we always need to know when it shouldn't be used, as well as when it should.

DERIN 

Everyone is talking about psychedelic treatment at the moment, but I think it is also worth a look for services for those people who had difficult experiences and are suffering from ongoing symptoms.

After the paywall, some links just for paid subscribers, including Putin’s apparent obsession with shamans, and is Silicon Valley experiencing a backlash against psychedelics?