From “bad trips” to “transformative and potentially therapeutic trips”: harnessing the potential of psychedelics – narrative review

Historical context and cultural perspectives

Psychedelics have historically had a substantial role in various cultures and are often employed in traditional healing practices. Indigenous communities have used these substances in ceremonial contexts, where the integration of both pleasant and undesirable experiences is essential to the healing process. Shamanic rituals frequently acknowledge that confronting fears and emotional pain can facilitate spiritual healing and transformation. While indigenous and historical traditions emphasize the transformative power of such experiences [3], the cultural narratives surrounding psychedelics often dismissed their significance [4].

The way psychedelics are framed linguistically have influenced societal perceptions. In this context, Kendall and Blackmore [5] have studied the conceptual metaphors used in texts on psychedelics and medicine, observing how these metaphors have shaped public and scientific understanding. Metaphors like “journey” and “medicine” tend to emphasize transformation and healing, while “danger” metaphors tend to focus on fear and stigma. Such framing influences the perception of how “bad trips” are culturally defined and understood in both historical and modern therapeutic practices [5].

In the last century, research has started focusing on the therapeutic potential of psychedelics, observing both positive and negative effects. Dr. Timothy Leary and Dr. Richard Alpert advocated for the use of psychedelics to enhance psychological well-being. Nevertheless, the counterculture movement and subsequent criticism led to restrictions and eventually the banning of these substances and the suspension of research for decades [6]. Recently, a resurgence of interest in psychedelic therapy has emerged, as researchers and clinicians begin to reevaluate the significance of “bad trips”, in therapeutic settings.

Dyck and Elcock [7] provide a comprehensive analysis of the historical and cultural narratives surrounding “bad trips,” arguing that confronting fear and trauma during these experiences can lead to significant therapeutic benefits. They emphasize that the interpretation of a bad trip can be reframed positively within a psychotherapeutic context, suggesting that avoidance of fear may hinder the healing process. This perspective is supported by Bienemann et al. [8], who found that self-reported negative outcomes from psilocybin use were often linked to high doses and anxiety management issues. Their quantitative analysis indicates that cognitive distortions during these experiences are significant contributors to the negative outcomes, reinforcing the need for therapeutic frameworks that address these cognitive challenges.

Understanding the nature of a bad trip

A bad trip is characterized by overwhelming feelings of fear, confusion, and distress. From a neurobio-logical standpoint, psychedelics modify brain activity, particularly in regions associated with emotions and perception, such as the amygdala and prefrontal cortex. The same context applies to stimuli that are flashed rapidly on a screen – too quickly for conscious perception – yet still capable of evoking an emotional reaction. This effect can be explained and may be attributed to the sub-cortical sensory input to the amygdala. Even though the amygdala is essential for unconscious emotional responses, the pre-frontal cortex is essential for the conscious experience of emotions and the ability to act in an intentional, organized manner in the aftermath of those feelings [9]. In other studies using functional magnetic resonance imaging (fMRI), the deactivation of the medial prefrontal cortex due to psilocybin is linked to the subjective experiences induced by the drug [10]. Other studies with fMRI support that psilocybin attenuates amygdala activation in response to threat-related visual stimuli [11]. During a bad trip, individuals may confront suppressed memories or unresolved traumas, which can amplify feelings of anxiety and existential fear [12].

Several factors contribute to the risk of experiencing a bad trip, often described by the concepts of “set” and “setting”. The individual’s mental state (set) and the environment (setting) play a significant role in the psychedelic experience [13, 14]. Understanding of the individual differences when dealing with the complexities of bad trips is of paramount importance. Griffiths et al. [15] reported that individual responses to psilocybin could be predicted using baseline psychological factors and personality traits [15]. This predictive capacity is critical for identifying individuals who may be more susceptible to negative effects and tailoring interventions that reduce risks. The interplay between individual characteristics, such as neuroticism, and the risk of experiencing a bad trip is further elucidated by Barrett et al. [4], who demonstrated that personality traits can significantly affect the intensity and frequency of challenging experiences. A supportive and safe setting, in addition to a positive mindset, may reduce the risk of a bad trip. In contrast, a chaotic environment or pre-existing anxiety can increase susceptibility [3].

Moreover, the concept of integration is pivotal in understanding how bad trips can contribute to therapeutic outcomes. Carbonaro et al. [16], found that individuals who reported bad trips with psilocybin often had prior exposure to the substance, indicating that familiarity may influence the perception and integration of bad trips. The authors suggest that repeated use of psychedelics might lead to a deeper perception of one’s psychological setting, which can be beneficial for therapeutic purposes, highlighting the interplay of environmental and psychological factors. This aligns with findings from Johnstad [17] which indicate that experienced users tend to navigate challenging experiences more effectively, suggesting that preparation and context are crucial for mitigating negative outcomes.

Constructive psychotherapy usually postulates alterations in meaning-making. At the outset of psychotherapy, patients often reveal a fragile self-concept, a maladaptive system of meaning rooted in fixations and rigid rules, mechanisms that repress a fertile process of meaning-making. Bad trip stories potentially empower users to overcome fixations, leading to more flexible thinking and meaning-making. There is an increasing body of scientific literature and evidence proposing that such unpleasant experiences may account, in part, for the therapeutic effects of psychedelics [2].

In most studies of patients with treatment resistant major depressive disorder the 3 phases model is used, comprising preparation, support between the dosages, and integration sessions after the psilocybin use but there is also plenty of variety in the psychotherapeutic approach [18]. Furthermore, acceptance and commitment therapy (ACT) was proposed in an article as a therapeutic frame in psilocybin-assisted psychotherapy. This was an attempt to make a protocol for psilocybin-assisted psychotherapy in treatment resistant major depressive disorder, based on the pharmacological profile of psilocybin as well as the phenomenological analysis of the drug experience itself [19].

Regarding patients abusing alcohol, a study utilizing 12 psychotherapy sessions were conducted. The first 4 psychotherapy sessions were held before the first psilocybin administration, following the 4 sessions between the first and the second administration of psilocybin, and 4 sessions after the second administration. The 3 of the total 12 sessions were preparation sessions, the next 7 were based on motivational enhancement therapy (MET), and the last 2 sessions were debriefing sessions. The acute effects of psilocybin along with the psychosocial intervention represented promising results in treating and supporting patients with alcohol dependence [20].

Concerning patients with cancer, a study with 9 psychotherapy sessions was held, including 3 preparatory 6-hour sessions prior to the first drug administration, followed by 3 intermediary 6-hour sessions between the 2 drug administration sessions, and an additional 3 integration 6-hour sessions following the second drug administration. The fundamentals of palliative clinical care and philosophy, existential psychotherapy, attachment theory, mindfulness training, logotherapy, and psycho analytic therapy are the foundations of psychedelic-assisted psychotherapy for patients with advanced stages of cancer [21].

Moreover, in relation to the qualitative evaluation of psilocybin-assisted psychotherapy, a recent interpretative phenomenological study interviewed 13 participants. Five of them were interviewed 1 week after psilocybin administration while 8 at one-year follow-up session. In this study, a semi-structured interview was conducted to explore participants’ cancer-related traumatic experiences, their concerns prior to the intervention, and their perceptions of life before and after the study [22].

This qualitative research approach draws from phenomenological, heuristic, and narrative theoretical frames to systematically analyze the participants’ experiences and explore their understanding of those experiences. The study has reinforced the psilocybin-assisted psychotherapy treatment approach, which is remarkable in its ability to produce quick, significant, and long-lasting improvements in anxiety and depression as well as to trigger profoundly moving experiences and new perspectives for people struggling to accept the existential reality of cancer in their lives. A therapeutically supported psilocybin experience may be a potent intervention for the cancer patient, especially those looking for alleviation through a deeper sense of meaning and comprehension of the emotional and existential implications of a life-threatening condition.

Common themes that characterized bad trips, using the Challenging Experience Questionnaire within bad trips, include ego dissolution, confrontation with death, and the experience of a loss of control [3]. While these experiences can be frightening, they also reflect typical therapeutic struggles that many individuals face in psychotherapy. The parallel between psychedelic experiences and conventional therapy suggests that navigating these challenging emotions could lead to significant personal insights and emotional healing [2].

Therapeutic frameworks for integrating bad trips

The creation of a controlled therapeutic environment is essential to harnessing the therapeutic potential of bad trips. Research indicates that individuals are more likely to experience positive outcomes from psychedelics when supervised by a trained therapist [2]. Bad trips during psychedelic use, particularly with substances like psilocybin, have been proven to elicit a range of acute psychological responses [2]. Barrett et al. [4], highlight that while these experiences can be distressing, they are often benign when participants are adequately screened and supported in controlled environments. The authors emphasize that adverse reactions, such as panic and confusion, can be prevented with proper preparation and therapeutic assistance, implying that the setting in which psychedelics are consumed is critical in determining the outcome of the experience. The role of the therapist is pivotal in providing reassurance and grounding during difficult moments, helping individuals process their experiences [13].

In therapeutic settings, the management of bad trips is often a major challenge. In this context, Carbonaro et al. [11] discuss the use of medications like olanzapine as potential interventions for acute psychedelic crises, indicating that pharmacological support may be required in certain situations. This is important, especially in uncontrolled environments where the risk of adverse reactions is increased [11]. In terms of rescue medications for managing severe adverse psychological effects, a recent systematic review and meta-analysis identified two studies that included per os diazepam (5-10 mg) and per os olanzapine (5-10 mg) within their protocols. Additionally, another study referenced the use of diazepam and risperidone as rescue medications for anxiety or psychosis, though specific dosage ranges were not provided. Another study reported the use of lorazepam (administered per os or via injection) as a rescue intervention for severe panic episodes that posed a risk to individuals after inadequate response to psychological interventions [23].

Several supportive techniques can assist individuals during bad trips. Grounding techniques, such as deep breathing or focusing on sensory stimuli, can help reduce anxiety and facilitate emotional processing. The concept of “surrender” is also significant, as encouraging individuals to let go of their need for control can lead to transforming insights and cathartic experiences [12].

Bad trips as catalysts for psychological insight

The therapeutic utilization of bad trips sets a complex terrain where adverse psychedelic experiences can be re-framed as opportunities for growth and healing. Research indicates that confronting fear and emotional pain during a bad trip can lead to profound therapeutic insights. Stanislav Grof, a pioneer in psychedelic research, proposed that addressing the contents of the unconscious during a bad trip can promote healing. Grof ’s model highlights that the process of confronting difficult emotions and experiences can lead to considerable psychological growth and resolution of past traumas [24].

Anecdotal evidence gathered from those who have experienced bad trips suggests that these moments of fear can act as catalysts for transformation. By confronting deeply rooted fears or painful memories, individuals often emerge with a newfound understanding of themselves, enhanced emotional resilience, and a renewed motivation to make positive changes in their lives [15]. The therapeutic potential of bad trips is underscored by the observation that many individuals report long-term benefits following bad trips, as noted by Johnstad, who found that a significant percentage of participants in a survey claimed to have gained from their bad trips, despite the immediate distress [16]. Gashi et al. [2], observed that users frequently reinterpret bad trips as valuable life lessons, underlining their potential in fostering psychological resilience.

Moreover, when used responsibly, psychedelics can enhance mental health outcomes, and the therapeutic potential of bad trips should not be underestimated [1]. Psilocybin may offer novel possibilities for treating depression, particularly when integrated into therapeutic frameworks that acknowledge and address the complexities of challenging experiences [17]. Fischer and Horvath observed that challenging psychedelic experiences often lead to enhanced meaning-making, which can stimulate personal transformation [18].

Additionally, bad trips can facilitate spiritual and existential breakthroughs. Some individuals report experiencing a profound sense of interconnectedness or understanding of life and death after confronting their fears. Such insights can lead to a redefined sense of self and purpose, emphasizing the potential for personal growth, stemming from even the most distressing psychedelic experiences [18].

Evidence from research studies

Emerging research supports the idea that challenging psychedelic experiences can lead to therapeutic benefits. The therapeutic potential of bad trips has gained more interest in contemporary psychological and medical research and recent literature suggests that these adverse experiences can also serve as pivotal moments for therapeutic breakthroughs and personal growth. Clinical trials investigating the effects of psychedelics in treating PTSD and depression have also acknowledged the role of bad trips. Participants in these studies frequently describe encountering intense emotions, memories, and fears during sessions. These experiences, although distressing, are often integral to the therapeutic process, helping individuals confront and process past traumas, leading to lasting positive outcomes [12]. Ross and Thomas conducted long-term follow-ups on psilocybin-assisted therapy, affirming that integration processes significantly improve therapeutic outcomes [25]. Evans et al. [26] identified instances where individuals faced extended difficulties after psychedelic use, highlighting the necessity of robust aftercare systems [26]. Furthermore, Jaremek et al. [27] demonstrated the effectiveness of psilocybin in combating depression, suggesting that challenging emotions encountered during bad trips could be pivotal to therapeutic success [27].

The potential for bad trips to foster resilience and coping strategies has been documented. Bettmann et al. [28], emphasize the importance of creating a supportive environment for individuals receiving difficult news, drawing parallels to the therapeutic context of psychedelic experiences. The therapeutic relationship established between the individual and the facilitator can enhance the integration process, allowing for a more profound understanding of the experience and its implications for personal growth. This is particularly relevant in the context of veterans and individuals with a history of trauma, as therapeutic adventure programs have shown promise in improving mental health outcomes by providing supportive environments for processing challenging experiences [28, 29].

The therapeutic implications of bad trips extend beyond immediate psychological distress. Research by Krebs and Johansen indicates that psychedelics, including psilocybin, do not cause long-term mental health issues and may even confer protective effects against psychological distress and suicidality. This suggests that the challenging experiences associated with bad trips could serve as catalysts for deeper psychological healing, particularly when individuals are able to process and integrate these experiences effectively [3]. The potential for growth, following a bad trip, is further supported by Barrett et al. [4], who have found that neuroticism is associated with the frequency and intensity of challenging experiences, indicating that individuals with higher neurotic traits may derive more profound insights from their psychedelic experiences.

Moreover, researchers have found that the psychological benefits of psychedelics can persist long after the experience, particularly for those who faced challenging emotions [12]. This suggests that navigating a bad trip can facilitate lasting change and emotional healing.

Challenges and ethical considerations

While the potential for bad trips to serve as therapeutic tools is well recognized, several challenges and ethical considerations must be addressed. Valeriani et al. [30] have raised ethical issues concerning pharmacological interventions during psychedelic crises, advocating for cautious consideration of their use. Evans et al. [25] have stressed the ethical importance of providing long-term support to individuals facing prolonged negative effects after their experiences. Bettmann et al. [28] have found analogies between therapeutic adventure programs and psychedelic therapy, both requiring carefully supervised environments to eliminate risks. The risk of re-traumatization, particularly for individuals with a history of mental illness, cannot be overlooked. Without proper assistance and guidance, bad trips can exacerbate preexisting conditions or cause acute psychological distress [12].

The expertise and training of therapists facilitating psychedelic assisted therapies are of paramount importance. Well-trained professionals can provide essential support, helping individuals navigate challenging moments and process their experiences. Additionally, the importance of after-care and integration support cannot be overstated; individuals must have access to ongoing therapy to help make sense of their experiences and apply insights gained during their sessions [13].

Managing expectations is an important aspect of ensuring positive outcomes in psychedelic experiences. Syed [31] has stressed that clear communication and preparation about the possible range of experiences – including challenging ones – are essential in setting realistic expectations for individuals undergoing psychedelic therapy. This preparation helps reduce the risk of distress caused by unmet expectations and contributes to a safer therapeutic environment.

Informed consent is another vital ethical consideration. Individuals should be fully informed of the potential risks and benefits of psychedelic therapy, including the possibility of encountering bad trips. Creating an environment of transparency and understanding provides a safe space for individuals to explore their emotions and experiences [32].

Psychedelic treatments for mental health and substance use disorders remain in the early stages of development, with significant gaps in the evidence. These include uncertainties regarding whether treatment effects vary based on patient characteristics or disease severity and whether the observed benefits persist over time. Additionally, key unanswered questions involve the reproducibility and scalability of psychedelic treatment protocols in real-world settings, as well as the risk-benefit balance of discontinuing conventional mental health medications to undergo psychedelic therapy.

Future research should also focus on underrepresented populations, including Veterans with combat-related trauma and individuals from diverse racial, ethnic, socioeconomic, and rural backgrounds. Furthermore, it is essential to consider the perspectives of professionals whose critique of psychedelic-assisted psychotherapy focuses particularly on its perceived lack of a robust evidence base and concerns about the potential influence of ritual placebo effects.

Future directions for research

The therapeutic potential of bad trips merits further investigation. Longitudinal studies examining the long-term effects and impacts of challenging psychedelic experiences could provide valuable insights into the mechanisms of change. Identifying ideal candidates for psychedelic therapy, particularly those who might benefit from facing their fears, is crucial for maximizing therapeutic outcomes. As psychedelic-assisted therapy continues to gain acceptance in mainstream mental health practices, it is essential to integrate insights from both positive and challenging experiences into treatment protocols. This balanced approach can help create a more comprehensive understanding of how psychedelics work in therapeutic contexts and the ways in which individuals can be supported through difficult experiences.