Do Psychedelics Heal Even Without Therapy?

Since antiquity, people have taken psychedelics without ever debriefing with a therapist. Even today, people often participate in intense psychedelic ceremonies that end without so much as a sharing circle, let alone a structured integration or therapy session. Yet, in its unsuccessful bid for FDA approval of MDMA-assisted therapy for PTSD, Lykos Therapeutics insisted that psychotherapy be given in conjunction with the empathogenic drug. It raises the question: To what extent do the therapeutic effects of psychedelics hinge on adjunct therapy? Or are psychedelics healing by themselves? 

For Rick Doblin, the founder of the Multidisciplinary Association for Psychedelic Studies (MAPS), which birthed Lykos Therapeutics, it's a no-brainer. “It's clear that when you combine psychedelics with therapy, the outcomes are better,” he says, referring to both preparation and integration therapy, and mid-MDMA trip guidance if desired by the patient. “That's what we should be focused on.” Referring to published studies on ketamine, he adds: “When you take ketamine without therapy, the results are not as durable as when you take it with therapy. The results fade, and then lo and behold, you need more ketamine.”

The debate over whether psychedelics require therapy to yield lasting mental health benefits has intensified, especially after the FDA approved Spravato, a ketamine-derived nasal spray, as a standalone therapy for depression this past January. That means patients do not have to be taking an antidepressant alongside Spravato anymore, though they must have tried one previously. Despite these changes, patients must still go to a brick-and-mortar clinic to self-administer Spravato under supervision, but they do not receive therapy as part of that experience.

“People need to talk about their experiences,” says neuroscientist Dr. Manesh Girn, from the University of California, San Francisco. “To do that in more of a formal way with talk psychotherapy can be really useful for making sense of their experience, uncovering insights and deriving concrete things that they can do [to improve their lives].” But Girn is also aware that talk therapy techniques may bypass other key dimensions of the human mind and body — not least the nervous system. “We also need to recognize that, often, deep healing is not done at the level of talking and verbalizing alone,” he says. “Cognitive and talk-oriented approaches should be complemented by more somatic, embodied, and trauma-informed approaches, which are equally, if not more impactful.”

Girn is supportive of a non-directive approach to the psychedelic session itself, wherein the therapist or guide is there to offer compassionate and empathic support for the natural unfolding of the experience without actively trying to engage the patient in psychotherapy. However, he adds that the needs of a patient may change depending on what psychedelic they have taken. “Psychotherapy during the experience may play a larger role with MDMA, which often induces a state of emotional openness and willingness to express that may be capitalized on by the practitioner to facilitate deeper emotional processing.”

For Michael Petegorsky, former chief strategy officer of the at-home ketamine therapy company Mindbloom, “psychedelics on their own can have significant benefits in improving mental health, but preparation and integration between sessions magnifies those benefits and makes them last longer.” He adds that people benefit from structures to support preparation and integration, “but we don’t think that has to be in the form of psychotherapy.”

At Mindbloom, clients are paired with a “guide” who coaches them throughout the program. Petegorsky says that Mindbloom considered using therapists instead of guides, but chose not to. “A lot of people come to psychedelic medicine because psychotherapy hasn’t worked, and they’ve had bad experiences with therapists,” says Petegorsky, who was in post when he spoke to DoubleBlind in March. “Therapists also cost more than coaches, and we need to make psychedelic therapy affordable to as many people as possible.”

For its FDA application for psilocybin for depression — which will likely be considered in 2027 — Compass Pathways designed its protocol to encourage a more inward journey during the trip, ultimately offering limited preparation and integration sessions. By contrast, Lykos Therapeutics plans to offer around 12 therapy sessions woven around just three MDMA doses.

Psychedelics may achieve changes to patients’ “emotions, beliefs or behavior … without anyone else present at all, so evidently psychotherapy is not integral to the psychedelic experience,” says Dr. Guy Goodwin, chief medical officer of Compass Pathways. “However, in healthcare settings, having supportive trained staff is likely to be essential for monitoring and safeguarding patients during what can be a demanding experience. We do offer support from a trained health care professional before, during, and after the psychedelic experience.”

The experience of high-dose psilocybin, Goodwin adds, “is incompatible with much interaction with a therapist” and “would be more likely to hinder rather than help the patient achieve the desired intense subjective effects.” Explaining further why Compass has opted to apply to the FDA without a therapy component for its psilocybin candidate, he says: “It may also make the goal of regulatory approval by FDA more attainable because it simplifies the task of appraising the benefit directly attributable to the drug.”

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