Prolonged adverse effects from repeated psilocybin use in an underground psychedelic therapy training program: a case report

Abstract

Background

Psychedelic-assisted therapy has gained growing interest to improve a range of mental health outcomes. In response, numerous training programs have formed to train the necessary workforce to deliver psychedelic therapy. These include both legal and ‘underground’ (i.e., unregulated) programs that use psychedelics as part of their training. Prolonged adverse experiences (PAEs) may arise from psychedelic use, though they are poorly characterized in the clinical literature. Thus, understanding the potential harms related to psychedelic use is critical as psychedelic therapy training programs consider strategies to potentially integrate psychedelic use into therapy training.

Case presentation

We present the case of a psychologist who underwent psychedelic therapy training that involved repeated high doses of psilocybin-containing mushrooms and subsequently developed prolonged adverse effects including severe sleep impairment, anhedonia, and suicidal ideation requiring hospitalization. Despite worsening symptoms, her psychedelic therapy trainers advised her against seeking psychiatric support, delaying treatment. Ultimately, the patient’s symptoms resolved after a course of electroconvulsive therapy (ECT).

Conclusions

This case highlights the tensions between legal and underground psychedelic use within psychedelic therapy training programs, psychiatry and neo-shamanism, and the use of psychiatric interventions (i.e., ECT) and energy medicine to address prolonged adverse effects from psychedelics. Clinicians should be aware of these potential conflicts between psychiatric conceptualizations of PAEs and frameworks maintained in psychedelic community practices and their impacts on patients’ presenting symptoms, decision making, and emotional challenges.

Background

Psilocybin is a psychedelic substance that has gained renewed public interest, including a growing body of research suggesting beneficial properties for a range of concerns for individuals experiencing mental health challenges and for healthy adults [1–4]. This interest has corresponded with increased use in the community [5], as well as an increase in challenges associated with such use [6]. Prolonged adverse effects (PAE), for example, can persist well after the acute psychedelic experience, and have not been well characterized in the literature [7].

Psychedelic use is sometimes accompanied by formal facilitation or guidance, which is the recommended approach in therapeutic applications [8]. Training programs for psychedelic therapists or facilitators, both legal and “underground”, typically focus on preparing individuals to support others in the ceremonial, therapeutic, or explorative use of psilocybin [9–11]. Such programs sometimes involve the administration of psilocybin to trainees. Below we describe the case of a psychologist with no prior psychiatric history who was admitted to an inpatient psychiatric unit for symptoms associated with PAEs that developed after repeated doses of psilocybin as part of traineeship in such a program, and successfully treated with electroconvulsive therapy. This case report was derived from clinical notes taken during treatment, followed by an interview with the patient, as well as corroboration of this account by the patient in a collaborative synthesis.

Case presentation

A 71-year-old female clinical psychologist with no prior personal or family psychiatric history, Dr. A, was admitted to an inpatient psychiatric unit. Her chief complaint was "I'm stuck in a loop." She described an evolving and unremitting constellation of psychiatric symptoms over four months following repeated ingestion of high doses of psilocybin-containing Psilocybe cubensis mushrooms as part of a psilocybin facilitator training. Her symptoms on presentation comprised severe sleep impairment, racing thoughts, uncontrolled anxiety, hopelessness, irritability, depressed mood, anhedonia, passive suicidal ideation, and unintentional weight loss of 25 lb. Her speech was pressured and she paced restlessly as she spoke. Her medical history was notable only for well-managed hypothyroidism and mild chronic sciatica. She endorsed a short history of LSD use in the 1960s, which she stopped after experiencing an “existential crisis” precipitated by taking two unspecified doses within hours of each other. She reported first using psilocybin three years prior to her hospitalization as part of a guided experience, with multiple uses since. Four months prior to admission, she had been functioning at her usual high level as a private practice psychotherapist working on several psychedelic clinical trials, and mother of three adult children. She maintained a life-long meditation practice and had recently celebrated her 50th wedding anniversary.

She connected the onset of her initial and progressively escalating symptoms of insomnia, anxiety, depression, and agitation to her participation in the later phases of the psilocybin facilitator training as a trainee. In the month prior to admission, she had sought outpatient medical care for her symptoms and saw a sleep specialist. She was briefly started as an outpatient on a series of medications, including clonazepam, alprazolam, eszopiclone, daridorexant, mirtazapine, zolpidem, and escitalopram, but reported lack of efficacy and concern about side effects. She ultimately self-discontinued all of them after brief trials. After one month of outpatient treatment without relief, she sought inpatient admission.

Her presentation and history were noted to be atypical. DSM-5 diagnoses applied by her treating clinicians included unspecified mood disorder with manic features and hallucinogen use not meeting criteria for use disorder. Her work-up for organic causes was negative, encompassing serum chemistries, complete blood count, ethanol, thyroid screening, folate, vitamin B12 level, urine drug screen, urinalysis, and head computerized tomography scan. During her first week of inpatient admission, she was prescribed brief trials of medications, which she frequently declined due to concern about side effects, including quetiapine, valproate, gabapentin, hydroxyzine, mirtazapine, and clonazepam. Given her disinclination to psychiatric medications and the severity of her distress, her treatment team recommended a course of electroconvulsive therapy (ECT). She completed seven ECT treatments (See Table 1), with her symptoms improving rapidly following her second treatment. She was discharged following the third treatment, with all following ECT treatments performed as an outpatient. At a follow-up visit four weeks later, she reported returning to her functional baseline with near resolution of all symptoms but endorsed persistent mild impairment to her concentration.

Table 1.

ECT course

Electroconvulsive therapy (ECT) course
Parameters	Right unilateral, ultra brief pulse, pulse width 0.3 ms, amplitude 60 Hz, stimulus duration 8 s, total voltage 800 mA
Anesthesia	Methohexital and succinylcholine
Treatment course	7 total treatments (3 inpatient, 4 outpatient), with significant subjective improvement after second treatment in racing thoughts, psychomotor agitation, and positive affect reactivity
Measures		Pre-ECT	After third ECT treatment	Post-ECTa
	Beck Depression Inventory-II:	28	18	14
	Generalized Anxiety Disorder-7:	18	4	2
	Montreal Cognitive Assessment:	28	-	-
	Clinical Global Impressions (CGI) Scale:
	• CGI-Severity:	6	5	2
	• CGI-Improvement:	-	3	1
	Sheehan Disability Scale:	28	11	5

^aFour weeks after last treatment

After completing her course of ECT, Dr. A provided an extended interview on the details of the events at the facilitator training that preceded her admission. She reported that after a positive first guided experience with psilocybin in 2021, in 2022 she traveled to Costa Rica to a psilocybin retreat hosted by a US-based psychedelic therapy training institute (henceforth referred to as “The Institute”) led by an American husband-and-wife team (henceforth referred to as “the leaders”). In their own promotional materials, the leaders described having learned traditional plant medicine healing from “revered Shamans in far-flung lands” and characterized their work as a “combination of shamanic healing, plant medicine, energy medicine, guided meditation, and transpersonal psychology.” Dr. A described her experience at the retreat as “beautiful.” Afterwards, she was motivated to enroll in the formalized psilocybin facilitator training provided by the Institute due to her belief in psilocybin’s therapeutic potential, and also by a belief in “the transformative power of mushrooms to alter human consciousness” and “concern for humanity’s political and environmental trajectory.”

The Institute’s training program involved a total of six weekend-long psilocybin retreats over six months (clinical history in reference to the timeline of this training is depicted in Fig. 1). It was open to both licensed and non-licensed therapists and was intended to be applicable in all practice settings, both legal and underground. In addition to trainees, non-trainee clients also attended these retreats and were generally treated no differently than trainees. The leaders stated that the program’s use of psilocybin was legally protected through their ordination by a non-denominational church that offers free ordination to those who wish to join. The program primarily consisted of attending these weekend retreats during which participants would ingest psilocybin-containing mushrooms of various strains. The following day, trainees and clients would share their individual experiences during a group session facilitated by the leaders. Both trainees and clients were expected to process (i.e., “integrate”) the experiences on their own between the monthly retreats by using a self-directed therapeutic manual, written by the leaders, that incorporated techniques from cognitive-behavioral therapy and transpersonal psychology. The stated rationale for the Institute’s training method was that trainees would undergo their own personal transformative process, which in turn would enable them to effectively facilitate the healing of others. The first three weekend retreats each involved one dosing session. Each of the final three retreats involved one to two dosing experiences.

Fig. 1.

Clinical Timeline Corresponding to Psilocybin Dosings

Dr. A reported that dosage was decided by the leaders based on their assessment of each trainee’s or client’s individual potential to benefit from high-dose experiences. The exact dosage of psilocybin mushrooms was not made known to trainees, however Dr. A estimated that “low dose” experiences were approximately 1.5 g and “high dose” experiences were up to 4.0 g. During low dose experiences, trainees would also assist in a facilitation role. Dr. A reported being assessed as having “high potential” due to her prior experience with psilocybin, training as a psychologist, and meditation practice. Her initial relationship with the leaders was positive and she described them as “very charismatic.” She described her dosing experiences at the first three retreats as “intense.” She described being highly unsettled by the leaders abruptly ending the dosing sessions and ushering the trainees out of the ceremony four hours after dosing, despite still experiencing the psychoactive effects of psilocybin. After the third retreat she reported mild anxiety, restlessness, concentration difficulty, and growing apprehension about participating in the 4th retreat. She asserted that at the 4th retreat she did not want to take mushrooms but described feeling pressured by both peer trainees and the leaders to proceed. She additionally feared the leaders would lose confidence in her as a future facilitator if she did not participate, and therefore apprehensively proceeded with both the low and high dose sessions.

She reported that during her fourth retreat’s high dose session she experienced a protracted challenging experience characterized by many disturbing visions of “man’s inhumanity to man.” That night she was unable to sleep due to intrusive flashbacks of these visions and felt highly anxious. The leaders described challenging experiences as a necessary part of the healing process and directed her to pursue more self-directed integration by journaling about her experience. She elaborated that “the message I concluded [from their teaching] was that some of your negative experience was your own fault. I was told I did not do the work to integrate and that’s why I had the negative experience, but at the same time there was no real guidance or instruction in integrating.”

She reported that in the weeks between the 4th and 5th retreat she experienced impaired concentration, difficulty sleeping, and significant anticipatory anxiety that she might have another challenging experience. During this time, she again expressed opposition about proceeding to the leaders, who again presented reasons for her to continue with the training and that her distressing experiences were “part of the process.” Reassured, she chose to participate in both the low and high dose sessions during the 5th retreat. During her high dose session, she described the experience as very intense. This session was ended abruptly by the leaders while she was still experiencing the psychoactive effects of psilocybin. She also noted a significant exacerbation of her chronic sciatic nerve pain during this time. She began to deliberately avoid the recommended practices the leaders suggested for integration, out of fear of engaging with the thought content from dosing sessions.

She again expressed apprehension to the leaders about proceeding with the sixth retreat given her distress but was told that this session “would turn it all around and give [her] the final answer.” Reluctantly she decided to participate in the high dose session, “I was so out of my mind, I didn’t know where else to go.” In hindsight she felt coerced and that “they did not my have my best interest in mind.” She reported poor recollection of the details of the retreat or the dosing experience, beyond recalling an overwhelming feeling that she had died, and further worsening sciatic pain. Collateral information obtained from another trainee at the ceremony described her as appearing to lose consciousness and being difficult to rouse, minimally responsive, and with marked pallor. The other trainee also reported that Dr. A did not appear to sleep that night, was highly agitated, and experienced multiple panic attacks, though Dr. A did not recall these details herself. She did not participate in the subsequent low dose session offered during that retreat.

After the sixth and final retreat Dr. A’s symptoms continued to intensify and were sufficiently impairing that she took leave from seeing patients. She turned to the leaders for support, who provided individualized guidance and energy healing for additional financial cost ($5000, in addition to the $25,000 payment for the training program). They advised her specifically to not seek psychiatric intervention or medication as it could impair the process of “rebirth” following her “ego death” and would prolong her symptoms. Her confidence in the leaders declined as her symptoms persisted and, despite their objections, she began to seek guidance from medical professionals. She briefly trialed psychotropic medications as described earlier, but largely continued to prioritize the leaders’ guidance. This deference diminished when she reported to them her loss of appetite with significant unintended weight loss, and was told, “that’s part of the medicine perfecting you.” Later, after one of the leaders told her to “stop acting like a victim” when voicing her concern about the extent of her functional impairment, she cut ties with the Institute, no longer believed her psychiatric and physical symptoms were part of a healing or transformative process, and became fearful that she had done irreversible harm to herself, which lead to passive thoughts of suicide and the psychiatric hospitalization three months after the sixth retreat.

Discussion and conclusions

This patient’s experience of a profound worsening of mental health associated with repeated psilocybin use during a 6-month training program reveals risks associated with psychedelic use, factors that may shape patterns of use associated with prolonged adverse events (PAEs), and the role of psychiatric interventions in treating patients with similar concerns. Importantly, Dr. A’s lack of individual or family psychiatric history, her age (over 60), her education and long career, and her multiple prior positive psychedelic experiences, indicate that PAEs need not result from an underlying psychiatric vulnerability exposed by psychedelics, and that PAEs can occur in those with multiple psychological, social, and environmental protective factors. Therefore, we focus our discussion on exploring the relationship of repeated high doses of psilocybin with extra-pharmacological risk factors, including contextual and sociocultural considerations that may have shaped her experience, decision making, progression of symptoms, and treatment response. Lastly, we discuss various diagnostic challenges this case presented and the role of ECT in treating PAEs by drawing upon prior case reports.

In addition to the psychoactive effects of a compound, the phenomenology and impact of psychedelic dosing are often attributed to a combination of the individual’s intention, the local environment, and broader cultural context of the individual (often referred to as drug, set, setting, and matrix) [12]. Dr. A’s repeated monthly use of back-to-back, high-dose psilocybin-containing mushrooms is likely to be the prime causal factor for her psychological decompensation. High doses of psychedelics have been identified as a risk factor for adverse events in naturalistic studies on PAEs [13]. Additionally, high frequency of use and back-to-back daily dosing has been identified as a potential risk factor in other case reports of psychedelic PAEs [14–17]. These pharmacological considerations should be understood in the context of Dr. A’s immediate set and setting. She described the negative experience of being abruptly removed from the local environment after four hours (in clinical research environments, the acute dosing session lasts a minimum of eight hours) [8] by the leaders while still experiencing acute dosing effects and identified this as the major cause of her anxiety and apprehension going into the fourth retreat, which progressed into distress and confusion by the sixth retreat. Apprehensive, preoccupied, and confused mental states, consistent with Dr. A’s history, are known risk factors for challenging experiences and poor outcomes [18–20].

This case also presents an opportunity to identify contextual factors of the broader set and setting that contributed to this use pattern and perpetuated it by denying, obscuring, or reframing harms, despite the patient having recurrent and escalating distress [7, 21]. From her initial positive experiences with psilocybin, she concluded that psychedelics not only had therapeutic potential but also might induce a global change in consciousness towards political and societal betterment [22]. Osterhold (2023) observed that such idealizations may frame psychedelic use as part of a high stakes mission that proliferates use and obscures harms [23]. Most notably, Osterhold (2023) also remarked that psychedelic experiences, through their “noetic quality” (i.e., sense of imparted knowledge), can significantly inflate self-confidence and thereby embolden charismatic but reckless, and even malicious, leaders who may underestimate risks and over-estimate their abilities to assist those experiencing adverse events.

The harms Dr. A experienced were framed by the leaders, and understood by her, as a consequence of her failing to integrate the experience or, later, as a necessary aspect of "ego death,” a process in which the old self “dies” metaphorically to enable a subsequent “spiritual rebirth.” This can be understood as consistent with a “purification” narrative, which interprets distress to be part of a process through which undesirable elements are eliminated or overcome in order to attain a superior state [24]. In some cultural or religious settings, it is normative to attribute negative experiences to the practitioner’s own errors (i.e., irresponsible or transgressive practice), or to employ purification or redemptive narratives to make sense of negative experiences in light of a broader global worldview [25–27]. Similarly, spiritual emergence/y describes a crisis that involves significant disruption to one’s system of meaning making, causes substantial psychological distress, but is understood as a time of great potential for personal growth [28]. The extent to which such interpretations do, or do not, serve individuals seeking to broadly improve their mental health or personal growth may depend a great deal on their cultural contexts and needs.

The behavior and responses of the leaders were important contributing factors to Dr. A’s experience. On multiple occasions Dr. A’s concerns were deflected, interpreted as a sign of growth, attributed to her own putative shortcomings, or used as a predicate for further dosing sessions or individualized treatment sessions. Experiences of individuals in vulnerable positions, such as Dr. A, have been examined in the context of various forms of institutional abuse. These may be instructive for psychedelic trainings, in which participants may have a heightened degree of vulnerability due to suggestibility induced by psychedelics as well as social factors that may facilitate coercive dynamics [29]. For example, the Deny, Attack, Reverse Victim and Offender (DARVO) pattern describes tactics employed by physical and psychological abusers to avoid accountability [30]. Charismatic leaders can also create the impression that one must join expensive retreats and take psychoactive compounds, in a particular way, in order to be part of a psychedelic vanguard. Notably, the broadly acknowledged need for careful and responsible preparation can be suborned by such leaders to create the impression that untested and unsafe practices are essential for training [31, 32]. Some of the dynamics experienced by Dr. A., such as framing her distress as part of a necessary growth process or isolating her from seeking medical care, may also be understood within the broader context of coercive control (e.g., coercive religious movements, gangs, political movements), and may also highlight problematic aspects of this training program [33].

As Dr. A’s PAEs intensified and persisted, she articulated increasing doubt of the interpretations of her experience as “ego death,” and began to reappraise it as possible mental illness but struggled to navigate the growing tension between the spiritual and medical worldviews these interpretations entailed. This tension resulted in months of delay in seeking treatment, and therefore significantly prolonged the PAEs, making it a potentially significant factor for clinicians to consider. “Ego death” in the western psychedelic subculture is at times a highly regarded aspiration, interpretively adopted from other spiritual traditions [34] and popularized with relation to psychedelics by figures such as Timothy Leary [35]. Notably, Dr. A was specifically advised by the leaders to not seek psychiatric treatment as her experience was conceived of as a necessary feature of an intended purification process, rather than as an adverse effect. Within such narratives, the interruption of a purification or incomplete purification is sometimes considered a major harm or error [24]. After she stopped working with the leaders her concerns included worries about the consequences of ending a purification process, sudden disorientation, feeling foolish, and subsequently fear that the delay in seeking medical treatment would affect her prognosis for recovery.

This case highlights the important role that worldviews can have in psychedelic PAEs, and the importance of assessing and non-judgmentally addressing patients’ spiritual, existential, religious, and theological worldviews in clinical care to address PAEs [36]. Worldviews provide a framework for understanding distressing experiences but also guidance on what to do about them. Westerners in psychedelic use settings may navigate multiple internalized worldviews simultaneously, selectively determining which takes precedence in what situations. Dr. A’s continued ambivalence towards the psychiatric treatment that she sought out after her schism with the leaders may be consistent with her negotiation of conflicting worldviews. Clinicians’ awareness of potential conflicts between psychiatric conceptualizations of PAEs and frameworks maintained in psychedelic use community practices, and how these conflicts may shape patients’ presenting symptoms, decision making, and the emotional challenges patients face in navigating these conflicts, may facilitate better outcomes.

Additionally, this case may be relevant to the current discussion about the role of personal psychedelic experience as a potential component of facilitator training and the respective risks and benefits to both facilitators and patients [37–40]. It is noteworthy that the Institute’s conceptualization of facilitator training overwhelmingly emphasized curated personal experiences as the primary means by which instrumental knowledge of psychedelics was to be transmitted. It must be acknowledged that the necessity of a personal psychedelic experience for facilitators is a matter of informed opinion. Further, without standards for facilitator effectiveness it is difficult to evaluate whether personal experience increases facilitator effectiveness. Personal experience may provide important first-hand knowledge and common ground with patients (as with mental health clinicians with first-hand experience of mental illness) but may also lead facilitators to inappropriately overgeneralize their personal experience to others’ circumstances [31]. Requiring personal psychedelic experience from facilitators may force those with risk factors (e.g., prior mental health history or cardiac conditions) to choose between risking their heath or being formally excluded or marginalized within a professional community [31].

Dr. A’s history and constellation of symptoms present a diagnostic challenge within the DSM-5/ICD-11 frameworks. On the inpatient unit she was diagnosed with unspecified mood disorder with manic features, hallucinogen-induced manic episode, and hallucinogen use not meeting criteria for use disorder. Her symptoms were remarkably similar to those reported in other cases of PAEs, raising the possibility that her presentation may be consistent with a particular PAE phenotype [14, 17]. Cohen and Ditman, psychiatrists who characterized PAEs in the 1960s, proposed four fundamental categories of PAEs related to LSD use based on their clinical experience: prolonged psychotic decompensation, depressive reactions, release of pre-existing psychopathic or asocial trends, and paranoid reactions [41]. Hallucinogen Persisting Perception Disorder was an additional fifth category originally proposed by Rosenthal (1964) [42]. Cohen and Ditman’s description of depressive reactions contains notable similarities to Barber’s (2022) and our cases [17]. Of note is their description of a case of a psychoanalyst experiencing severe “hypochondrial agitated depression” for 8 months following ingestion of 100 μg of LSD, which they provided as an example of a “depressive reaction” to psychedelic use [41].

Alternatively, Dr. A’s symptoms could be conceptualized as a trauma response. She experienced numerous symptoms suggestive of a trauma reaction including recurrent involuntary intrusive flashbacks of her challenging experiences, avoidance behaviors related to integration, numerous negative alterations in cognition and mood, and highly elevated levels of arousal. Trauma reactions to drug-induced AEs have been well described [43]. Because of the degree of distress that intense and prolonged CEs can produce, they may meet criteria for exposure in PTSD. For example, Davies (1979) describes a patient who after ingesting LSD experienced multiple hours of hallucinatory rape and subsequently exhibited symptoms of a severe trauma response, despite being aware after the fact that the experience was hallucinatory [44]. Furthermore, there may be complex interactions between the psychoactive effects of psychedelics and co-occurring traumas independent of these effects, especially those perpetrated by the facilitators themselves [45]. Therefore, clinicians treating a patient experiencing a PAE should evaluate for symptoms of post-traumatic stress and consider not only a psychedelic-informed, but also trauma-informed-care approach to treatment.

Dr. A was ultimately successfully treated with, and rapidly responded to, ECT. Barber and colleagues describe a similar case of a mixed manic episode and later prolonged severe depression after back-to-back psilocybin. The patient was exhaustively evaluated and treated over the course of a year with multiple modalities but not ECT [17]. That patient ultimately responded to 4.5 mg daily of pramipexole. Both cases demonstrate the possible extended duration of untreated PAEs, as well as successful treatment with interventions that are typically reserved for highly treatment-resistant or severe mood disorders. Psychiatrists of the 1960s treating PAEs observed that such occurrences were rapidly and definitively treated with ECT [46–48]. Given this past and present observation based on these cases we recommend that clinicians consider ECT among possible treatments for suspected severely impairing and refractory PAEs.

In summary, this case demonstrates that prolonged and high-acuity adverse events associated with psilocybin use are not limited to those with recognized diatheses or pre-existing mental illness. It highlights the degree of complexity that can surround such PAEs and the important role of social and contextual factors in precipitating, maintaining, and even exacerbating symptoms. Given its success with Dr. A, ECT may be an efficacious treatment in similar instances. Dr. A., upon reflecting on her experience, felt strongly that the current discourse on psychedelics so far had underemphasized the possibility of significant harms, which contributed to her decision-making and risk appraisal during her involvement with the Institute and its psychedelic training program.

Abbreviations

PAE

Prolonged Adverse Experiences

ECT

Electroconvulsive Therapy

Authors’ contributions

John Perna: conceptualization, data curation, writing original draft; and writing—review and editing; Justin Trop, Roman Palitsky, Zachary Bosshardt, Helen Vantine, Boadie Dunlop, and Ali John Zarrabi: equal contributions including data curation, writing—review and editing. Consent for publication: the participant, who is listed as a co-author, provided written informed consent for their personal and clinical details to be published in this study.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

The patient signed a voluntary written informed consent form authorizing the publication. A copy is available if requested.

Competing interests

The authors declare no competing interests.