🫠 Psychonaut POV

Welcome to Tricycle Day. We're the psychedelics newsletter that smells like teen spirit. Take a whiff. 😶‍🌫️

Stacey Armstrong is about to have “the talk” with Mom and Dad. (Relax, this newsletter won’t be about the birds and the bees.) After publishing the first U.S. psilocybin trial for vets with treatment-resistant PTSD, now she wants to know what parents of struggling teens make of psychedelics.

We asked Stacey why veterans improved before they ever got a dose, how to do adolescent psychedelic research right, and what parents need to hear before they decide. 

Bad trips are hard. But you know what’s harder?

Going back to your “normal” life after an eye/heart/soul-opening psychedelic experience and carrying on as if nothing ever happened.

0/10 would not recommend.

So tomorrow, have we got a treat for you. Our head of community, Martyna, is dropping in with Otto Maier, one of our all-time favorite integration specialists, to offer some grounding practices and tips for when a journey leaves you confused or unsettled.

It’s free to attend. Plus you’ll get a first look at Althea’s new small-group integration program, led by Otto.

My path wasn’t traditional, though I’m not sure a traditional path exists yet in this line of work. I trained as a child and adolescent psychologist and started working with people of all ages who’d experienced trauma. After graduating, I did a two-year internship at a traumatic stress center in Akron, Ohio. I was a full-time clinician there, delivering our gold standard treatments, like cognitive processing therapy and prolonged exposure, to civilians and veterans. 

After those two years, I was burnt out from the repeated disappointment that our treatments weren’t working for more people. Many of the people in my office had already seen multiple providers and tried multiple medications, and they were still profoundly impaired in their daily lives. If I felt disappointed, they had to feel devastated. 

So I decided to take a break and go into academia for a couple of years. The whole time, I kept tracking what was happening with psychedelics. Then a colleague reached out about a trial at Ohio State treating veterans with treatment-resistant PTSD using psilocybin. They needed someone with trauma therapy expertise. 

I joined in 2021 as a postdoc at the Center for Psychedelic Drug Research and Education, right as the trial was starting to move more quickly. Ours was the first Schedule I human subjects trial at Ohio State, so I helped get it off the ground as we established the university’s process for this sort of research.

Over the years at the center, I’ve learned I’m as passionate about rigorous science as I am about trauma work. We need high standards to find answers for the people who need them.

These veterans had all tried at least six months of psychotherapy and medication, including SSRIs and SNRIs, and still had significant symptoms. So the 75 percent response and remission rate surprised me. The sample was small at 12 participants, and the trial was open label. Those conditions tend to produce higher percentages. Even so, some veterans reported no PTSD symptoms at all by the end. 

Expectancy (or lack thereof) was interesting, too. Everyone knew they would receive psilocybin twice, so we asked what they expected from their dosing sessions to see if hope was driving the results. From what we captured, expectancy effects didn’t predict outcome. 

What did predict outcome was the impact of the preparation phase. We saw PTSD symptoms drop significantly during those first eight hours of psychotherapy, before any psychedelic was ever administered. And the more symptoms dropped there, the better people did at the end. That makes sense in some ways, since people with the deepest rapport with their therapist tend to have the best outcomes. But I still find it surprising because these veterans had likely worked with other therapists before.

My suspicion is that preparation helps establish therapeutic rapport, and then the interaction between the therapeutic relationship and a potent psychedelic lets people move into the work in a profound way. This was a safety and feasibility trial, though, so we can’t say for sure. We’ll need placebo-controlled trials, blinded to the extent we can manage, to find out.

It was mixed. For some veterans, the experience was clearly tied to combat. Others had trauma unrelated to their service, and there didn’t seem to be any rhyme or reason to who had what experience or why.

Some veterans felt confused afterward. They’d ask what they were supposed to make of the experience and how they could fold it into their lives. Integration mattered most for the ones who felt caught off guard. We told everyone ahead of time that a session might relate to combat or might not. We wanted them to know that an unexpected experience didn’t mean we couldn’t do great work with it.

I remember one veteran who came out of his first dosing session and told us he’d seen nothing at all. It was black, with no visuals. As we talked it over, we were able to tap into what he’d felt in his body and the emotion that was showing up for him. We helped him make meaning of that experience and bring it into his life ahead of his second session, which did end up being much more visual.

My lens is always developmental, so I think about depression, PTSD, and anxiety by asking when they started. There’s a huge pediatric mental health crisis right now, and a significant number of young people experience treatment-resistance. We have very few resources to handle it. Once the FDA approves any of these treatments for adults, it triggers a mandate to explore them in pediatric trials. So we may need to confront this question whether we want to or not.

I worry we’ll take a cut-and-paste approach with psychedelics and assume what works for adults will work for adolescents. That’s risky, because adolescents aren’t little adults. They live in different systems and have different neurobiology. The earliest trials will probably be fine, since they’ll involve 17-year-olds. But as we move to lower ages, we’ll need to think more systematically about how to involve parents, school counselors, social workers, pediatricians, and pediatric psychologists and psychiatrists. 

I wish we took this approach with adults, too! Medicine often cuts someone out of their life, puts them in a treatment setting, and then puts them right back into what are often very toxic systems. If the system is sick, why develop new treatments just to return someone to it?

Of course, treating the fish is easier than replacing the water in the fish tank, even if it’s less effective. Cleaning the water gets daunting fast once you think about healthcare, governments, war. We can’t give up on it, though. Adolescents are so interconnected with their systems that they can’t just be removed and put back. That makes them our opportunity to push on the bigger issues and broaden these treatments beyond the individual.

The FDA has been quite reserved about approving adolescent trials, though I’ve seen a handful of adolescent trials registered on clinicaltrials.gov. If the FDA is approving them, I hope they are approving them with the thought that these treatments may likely be approved for adults anyway, which will open the floodgates for adolescent trials. At present, however, nearly all of the evidence for psychedelic-assisted therapy comes from adult populations, and many important questions about safety, development, family involvement, and implementation in youth remain unanswered.

There’s still so much stigma and fear among parents who feel desperate because their kid is really struggling. I want to talk to those parents, especially the ones with adolescents in high levels of care. Nobody’s really asked them what they think about psychedelic treatments, and they’re the ones who’ll be deciding. Some parents may be ready, but I suspect many aren’t. 

I don’t want them making this decision out of desperation, because desperation means fear and being uninformed. I’m a mother, and I think about what it would be like to decide on such a treatment for my child when I’ve been told since D.A.R.E. in elementary school that psychedelics scramble your brain. Starting transparent conversations with parents now is the most clinically appropriate and ethical thing we can do.

Among many questions, one I find interesting is whether parents could join their kids in a session, though this has not been systematically studied and would require careful research. Preparation would look very different and take a lot more time, because parents would need the skills to hear a trauma narrative and tell their child they love them no matter what. But there is a risk that things derail. If I saw my child struggling, my instinct would be to go into mama bear mode and rescue them. So we’d need protocols for a parent spiraling mid-session and ways to keep everyone safe. The biggest key is being ready for those challenges. It can feel like standing at the bottom of a giant mountain, but I’m excited to start climbing.

Follow Ohio State’s Center for Psychedelic Drug Research and Education.

That’s all for today, Cyclists! Whenever you’re ready, here’s how we can help.

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DISCLAIMER: This newsletter is for educational and informational purposes only and is not intended as a substitute for professional medical advice. The use, possession, and distribution of psychedelic drugs are illegal in most countries and may result in criminal prosecution.