Does "Psychedelic-Assisted Therapy" Have Supporting Evidence?
An argument.
Welcome to The Frontier Psychiatrists. This is a media empire—not just a newsletter—dedicated to writing, podcasting, and even video content about human health. Today, I’m tackling one of my favorite topics, in writing, mainly to save myself time in verbal debates. I’m doing the work to evaluate the evidence…for a perplexingly popular treatment modality, given, I will argue, a paucity of evidence.
Many of us have heard about psychedelic-assisted therapy.
And the way humans work, as far as I can tell, is if we've heard a thing enough, we assume it to be true. Taking an idea out of our heads? Difficult.
Here is what ChatGPT says when you ask it the question,
“What data exists to demonstrate the need for psychedelic treatments to include psychotherapy? Is there any? How strong is this evidence?”
It replied (along with many, many more words, when using the “deep research” setting):
“It is important to note that no modern trial has deemed it ethical to give powerful psychedelics entirely without support, so there is no RCT of (for example) psilocybin with zero therapy sessions for direct comparison. The closest analogs are comparisons of different levels or types of therapy, or using therapy versus some minimal control condition. Interpretations must therefore consider that support of some kind (even if just a few sessions or an integration meeting) is always present in clinical research with psychedelics. Within those ethical boundaries, the emerging consensus is that therapy is a critical component for safety and for helping patients integrate the often intense psychedelic experiences.”
Your author disagrees with the last statement— based on the first!—but the training data for LLMs is biased enough to generate the above as part of its answer, presumably on the way back from the metaverse version of Burning Man for Large Language Models experimenting with radical self-sufficiency?
An Argument, Most Disagreeable
Let's start, to make my overarching point, with an absurd idea.
“High-five assisted blood transfusions.”
If, at the beginning of the use of blood transfusions, it was asserted, by enough people, that “high-fives” were necessary to make the blood transfusion work, and every study undertaken of blood transfusions included a robust high-five at the beginning, one could be forgiven for assuming that “the high-five” was an integral part of the blood transfusion magic in helping those suffer massive physical trauma survive. If I were to assert to you that high-fives were necessary today, after having seen enough blood transfusion data absent a high-five, you would be justly skeptical. To be clear, blood transfusions are lifesaving in major trauma.
Regarding treatment for acute post-traumatic bleeding, literature research has considered standardized massive transfusion protocols as a key component to obtain better survival and a low rate of complications and organ failure.1
However, if they had always been administered together, we would be worried about detangling them. Somebody who offered a blood transfusion without a high-five might even be understood as inappropriate or risky. It would take a clinical trial, where individuals were randomized to either blood transfusion with or without a robust high-five, to tease apart the difference. In fact, we can all agree that it would be hard to blind high-five assisted blood transfusions.
You'd have to come up with an elaborate protocol in which the surgeon and the anesthesiologist were placed in some anechoic chamber, wearing virtual reality glasses and fancy headphones, such that they were unaware of whether a high five had been completed or not, prior to the trauma surgery and blood transfusion. We might even give up on the entire process of blinding and accept the common wisdom that high-fives are part of the process. There might even be some who encourage us to high-five more regularly, or high-five for 12 sessions before, as part of the appropriate set and setting of the trauma surgery, and then to have subsequent post-blood transfusion high-fives in our postoperative check-ups. And then those interventions would also need the elaborate blinding protocol to detangle what, I hope we can all agree, is a completely farcical part of a blood transfusion’s claims to efficacy?
The above may sound stupid—because it is. I would argue that's what's happened with psychedelic-assisted psychotherapy. I'm not anti-therapy, I want to make that clear.
One of the problems with the people doing psychedelic therapy, or at least advocating it, is that they lack practical experience in the design of psychotherapy trials that didn't involve psychedelics. I've run clinical trials in psychotherapy—they're hard, the one trial I was a principal investigator on didn't meet recruitment goals, which is what happens when you try to run a clinical trial with no funding. That being said, I'm not the only person in the world who has conducted a psychotherapy study. Other experts have as well, and could be consulted for new trials.
Psychotherapy studies, as a brief aside, are more complicated than biological interventions in one important regard—it's hard to know if the clinical trial participant is getting the intervention you think they're getting. In a drug trial, you don’t have to worry if the person's gonna get a different drug than the one you prescribed. They're getting a placebo, or the study drug. No one is slipping them Advil instead. However, in a psychotherapy trial, you need to evaluate the psychotherapy session with a validated adherence scale, and then audit those sessions for adherence of the therapist to the therapy model. The MDMA – AT trials that MAPS ran did have this adherence rating as part of the study design, but nobody bothered to ask whether the therapy to which they were being asked to be adherent was any good in the first place.
To make a point, one could imagine a high-five adherence scale that rated the quality of the high-fives with the blood transfusions:
“Please rate on a scale of one to five whether there was a loud cracking sound at the completion of the high five?”
1-2-3-4-5
“Were the high-five participants looking each other in the eye during the high five? Please rate eye contact as 1 (for staring in the opposite direction) to 5 (deep, prolonged eye contact).”
1-2-3-4-5
And so on!
There are plenty of ways to make this seem more scientific, but none of them answer the question: is this an appropriate adherence scale to a plausibly effective therapy model? One would need experience in other adherence scales, for related investigations of other therapies, in order to have any sense of whether the adherence manual in question made sense.
I haven't met every psychotherapy researcher in the world, not by a long shot, nor have I met every psychedelic researcher, but I have met a bunch of each kind of individual, and I've never seen them in the same room.
All of which is to say that to study psychotherapy, you need to have a therapy manual that outlines what the therapy will consist of, and a way to measure whether the therapy that you think you're studying is what was delivered. This doesn't mean that the therapy is any good, or even therapeutic. You need to know that an apple is an apple, and an orange is an orange, so that if you're running an apple study, you can be sure that it's because of the apples. If everybody's sitting around having orange juice in your apple RCT, you can't be sure it's because of the crisp apple flavor that people’s blood sugar has been raised!
Drug studies and device studies rarely have this problem! The one exception for this, for the clinical trials in the audience, is the question of adherence to the drugs by the study subjects.2
Returning to the problem of psychedelic-assisted therapy being without any evidence whatsoever. I’m the senior author of the largest scale review of all the data on the topic as of 2024, but to save you 136 or so pages of Volume 31, Issue 2 of the American Journal of Theraputics, here is a quick— and updated—summary:
MDMA: Never Studied Absent Therapy
MDMA has had several trials of MDMA plus “assisted therapy” using the MAPS therapy manual, of which I’ve drafted critical reviews previously:
Now, Everyone Is Interested in Drug Development
Should MDMA-AT Be Saved, Part III
Saving MDMA (and other psychedelic therapies): Part VI
And one prescient podcast appearance before the FDA decision:
The summary of all of that: even if you believe the now retracted data from a number of the MAPS clinical trials, one of the things they never did was study the MDMA absent therapy. The MAPS trials studied, in theory, MDMA plus “AT” and “AT” alone, but never established that “AT” alone was an effective therapy for PTSD. The studies lacked an arm for “assay sensitivity”—this is a third trial arm designed to demonstrate that an already established therapy, in the recruited population, outperformed the placebo in the studied condition. Typically, this design is employed to address situations where both the active agent and the placebo exhibit similar improvement, and the study sponsor wants to suss out if that was because the trial failed (and thus it’s worth doing another one) or if the intervention failed compared to placebo and also compared to treatment as usual.
In the MAPS MDMA trials, this could include an established treatment like Prolonged Exposure Psychotherapy (or venlafaxine), assuming the blind could be preserved.
MAPS went all in on studying a combination of their unproven therapy plus MDMA, making it impossible to determine if the psychotherapy helped or the MDMA helped or the combination helped or…well, depending on your perspective about the trial design, if none of it helped much more than expectation effects would explain. A review of every controlled trial is available here.
Psilocybin: “Psychological Support” And Its Discontents.
There have been some excellent trial designs in the evaluation of psilocybin with “psychological support.”
At this point in the article, I asked the question: What does anyone actually mean when they say psychotherapy? Psychotherapy does not mean a nice person sitting next to you while you have a tough experience—that is psychological support. We have nurses in ICU settings doing that kind of work routinely. We have direct care staff, and mental health technicians, on inpatient psychiatric units, who have spent time on constant observation with individuals who require it, due to the risk to themselves or others, which is also not considered psychotherapy.
The only individuals who can legally administer psychotherapy as an intervention are generally licensed therapists, and these licenses typically fall into one of two categories: master’s level or PhD level, with the occasional MD added for good measure. One of the important things to know about psychotherapists, other than MDs, is that none of them have actual medical training. To be clear, when I say, “No Actual Medical training,” I mostly mean they don't know what to do in a medical emergency.
If your heart stops, unless your therapist has learned basic life support, they'll have no more idea than any other member of the public. Psychotherapists are trained to be good at psychotherapy, not medical crises. Although some of them are allowed to make a mental health diagnosis, their education does not include the comprehensive differential diagnoses and management around general medical conditions that would include: cardiac arrest, delirium, acute intoxication, seizure, serotonin syndrome, heart arrhythmia, you name it—a lot can go wrong with a human body. Most physicians, to be honest, really wouldn't know what to do all by themselves either, because so much of managing medical emergencies is a team sport. We work closely with nurses, our colleagues in other medical specialties, respiratory technicians, pharmacists, and others. Without this collaboration, our patients would never have the outcomes that modern medicine makes possible. However, the very bad things that could happen mid drug exposure could include these medical emergencies, and we'd rather not have psychologists offering empathy mid-stroke.
When individuals take a psychedelic compound, they generally have an altered state of consciousness. The risk medical treatment is trying to manage is only partially around the healing nature of the experience for the psychiatric condition we are targeting. Still, it's probably also about the person not jumping out the window, having a heart attack, attacking someone else in the room, or any number of other things that can happen when people are acutely intoxicated.
And yes, when people take a psychedelic compound, they are often acutely intoxicated.
What is Intoxication, anyway?
The Cleveland Clinic offers the following helpful guide to intoxication (which can happen beyond alcohol). It can include:
Aggression.
Agitation.
Anxiety.
Decreased levels of consciousness, like drowsiness or lethargy.
Euphoria.
Impaired judgment.
Inattention or difficulty focusing.
Increased energy or hyperactivity.
Mood swings (mood lability).
Risk-taking behaviors.
Physical symptoms of intoxication may include:
Balance and coordination issues.
Body temperature changes (hyperthermia or hypothermia).
Flushed face.
Heart rate changes, like tachycardia.
Slurred speech (dysarthria).
Now, when we know what's causing it, like for example, in anesthesia, we don't say someone's high. To be more accurate, we referred to their state of altered consciousness as “under anesthesia.” This is how most ketamine has been administered for most of the time, for example. Anesthesiologists, I’ll note, aren't generally also experts in psychotherapy mid-sedation. They usually wait until the patient returns to a normative state of consciousness to discuss what happened.
Psilocybin
Psilocybin creates alterations of consciousness that are not sedating, like anesthesia, but profound. To argue that's what's happening during that experience is best handled by a psychotherapist is confusing to me, as a physician, because most psychotherapists don't spend their time with people who are in vastly altered states of consciousness. Nurses do, all the time. Walking into any intensive care unit, you're gonna see a nurse dealing with somebody in an altered state of consciousness. It's usually not because they're on a drug, but sometimes it is. We sedate people who are on a ventilator, being very sick causes an altered state of consciousness, for example. Similarly, nurses handle altered states of consciousness in emergency settings daily.
The doctor shows up sometime later to come up with a plan to address the altered mental status. Sometimes we're dealing with a medical emergency. Still, these are not situations with which psychotherapists at the master's and doctoral levels are intimately familiar.
Now, back to the data on psilocybin itself—my readers are unlikely at this point to be surprised by the fact that we've never had a study that teases apart what happens when we add or subtract psychotherapy to psilocybin.
We've had the COMP360 trials, which included psychological support, which is either psychotherapeutic or not, depending on your perspective. However, it doesn't compare a version with “support” to a version without psychotherapy support. This has been argued to be the case for “ethical reasons.”. However, I’d agree— locking someone on a psychedelic in a room with nobody around would be extremely disoriented, it does not follow that what's happening in that room is psychotherapy, more than a nurse at the bedside in the ICU. In contrast, someone who is delirious is performing psychotherapy.
It wouldn't be tough to design a study like this; you could just take someone with no psychotherapy experience and just good sense, like an ICU nurse, and give them literally no instructions. And then you could compare. Individuals are administered a psychedelic compound and given whatever a psychotherapist trained in whatever modality you think is gonna be useful… in the control group, well, that could be the completely untrained (in your theoretical modality) nurses.
This has not happened. There are a range of other psilocybin studies that have been attempted, with results ranging from exciting to pretty good, but all of them failed to tease out this particular question—NYU tackled AUD, for example, and Compass and Veteran population investigators studied PTSD. All of these studies established that psilocybin may be a useful treatment, and all of them chose to have somebody else around while the alteration of consciousness was occurring.
Ibogaine: (head shake)
Ibogaine is so profoundly potent that individuals, during treatment, require telemetry for cardiac stability and an escort to make it to the bathroom, given the profound ataxia it can induce. They have the experience, generally, with an eye mask on, deep in their inner world. This experience may require substantial informed consent, which differs from therapy, and one might want to discuss it afterwards. Still, despite the remarkable promise this compound—perhaps above all others—holds to relieve profound human suffering, it’s really, really hard to argue that the therapy could assist much during the process.
Again, the trial to determine if post-treatment therapy is a helpful adjuvant isn’t hard to design. After ibogaine is administered, have the person talk to a trained therapist, compared to an untrained nurse or even a supportive friend. Then —see which group has better outcomes.
Ketamine: One Glimmer of Hope…If We Use Robots
There is more data to review here, given how long ketamine has been around. Kew, et. al. authored a large review:3
Nineteen studies evaluating 1006 patients were included in the systematic review. A variety of supportive individual and group, manualised and non-manualised psychotherapies were used. The majority of studies evaluated substance use disorders, post-traumatic stress disorder and treatment-resistant depression. Ketamine protocols and sequencing of ketamine/psychotherapy treatment varied substantially between studies.
However, they go on to claim that:
Outcomes were largely positive for the addition of psychotherapy to ketamine treatment.
Which, although true on its face, misses the point for the purpose of this article. Just like the afore-posited high-five assisted blood transfusions, ineffective things given with very effective things are still going to have positive outcomes.
Two of the reviewed studies were by the diligent Wilkinson et al. This team evaluated a sample of “responders to an initial Ketamine infusion,” and saw what happened in a tiny sample of 8 participants, and subsequently, a larger trial. What is more, the sample was chosen from individuals:
Patients who were pursuing ketamine infusion therapy for treatment-resistant depression (TRD) were invited to participate in the study.
Yes, people who already thought “I’d like some ketamine for my depression” and offered more ketamine…plus randomization to CBT or TAU.
And the ketamine treatment…
while all continued to receive intermittent ketamine boosters.
And in those n=8 responders…
Their second study was larger:
Of the 42 patients who signed consent, 28 patients achieved a response and were randomized to CBT or TAU. When measured using the Montgomery-Asberg Depression Rating Scale (primary outcome measure), the effect size at the end of the study was moderate (Cohen d = 0.65; 95% CI -0.55 to 1.82), though the group-by-time interaction effect was not significant.4
The study’s primary outcome (a clinician-rated depression score, the MADRS) showed no statistically significant difference. It showed a difference on a secondary endpoint, which justifies future research.
All of which should be not particularly surprising—severe depression that hasn’t responded to other treatments is a difficult illness to treat, or none of these treatments would be exciting to pursue in the first place. However, spinning “no difference on primary endpoint” to be “it’s better!” because a secondary endpoint (the QIDS) showed benefit (in all of 8 people in a subgroup) does not a compelling paper make.
A better-designed and even larger trial by Grabski et al. (2022)5 conducted a four-arm placebo-controlled trial (N=96) in AUD that explicitly crossed medication and therapy conditions.
Participants were randomized to one of four groups:
(1) ketamine + mindfulness-based relapse prevention therapy (MBRP),
(2) ketamine + alcohol education (minimal psychosocial intervention serving as an active control…exactly what I recommended above, as it turns out)
(3) placebo saline + MBRP, or
(4) placebo + education .
This is a rigorous design; however, it is likely underpowered in a 4-arm trial.
What did they find?
Nothing. Ok, that is not fair. Ketamine is awesome for AUD:
At 6-month follow-up, ketamine (with any psychosocial support) led to significantly more abstinent days than placebo (mean difference ~10% points, p < 0.05). However, no significant difference was found between the two therapy conditions in the ketamine arms: patients who received ketamine + MBRP did not maintain abstinence significantly more than those who received ketamine + “education.”
The addition of an intensive relapse-prevention therapy did not do better than a minimal intervention by a nice enough person.
Ketamine Plus Robots?
In the section of this article most likely to please Sam Altman, we ask the question:
“What happens when we nix the human therapist and replace them with robots?”
It goes well:
Price et al. (2022)6 took a different approach to “psychotherapy” by using a fully automated cognitive training program alongside ketamine.
In this 3-arm RCT (N=154 TRD patients), all participants received a single subanesthetic ketamine infusion (0.5 mg/kg) or placebo (saline) infusion, and were then assigned to either an active computerized therapy (“Automated Self-Association Training”, ASAT) or a sham control program, over the following 4 days.
This design created a
ketamine + therapy (robot) group, a
ketamine + sham (no therapy) group,
Saline + robot therapy control.
Ketamine caused a rapid reduction in depression severity at 24 hours compared to placebo (p < 0.0001) . Those who received the robot's active psychological training after ketamine maintained their improvement over 30 days, whereas the ketamine-only (sham training) group’s depression scores got worse, converging with the placebo group by 1 month .
Statistically, the ketamine+ASAT group had significantly lower depression scores over 30 days compared to the ketamine+sham group (p = 0.0004). The ketamine + sham group showed a “trend” of relapsing depression, losing much of the initial benefit:
By contrast, depression scores following ketamine+sham treatment followed a significant, increasing linear trajectory from 24 hours to 30 days, approaching the levels observed in the saline+ASAT group (group-by-time interaction relative to the saline+ASAT group: β=0.015, 95% CI=0.003, 0.03; t=2.35, df=568).
This well-controlled trial demonstrates that a brief, structured psychological intervention (not a human therapist, a robot) prolonged ketamine’s antidepressant effect.
It provides evidence that a therapeutic something or other can extend the outcomes of a consciousness-altering drug. Set and setting—but don’t let the humans foul it up?
Oh, and of course, the blind was broken with a saline control, but not with the sham therapeutic:
In Summary
I think the experiences we have matter. But given the paucity of data, the risks incurred by having human therapists muck around in the the psychic turmoil of patients in the throes of trauma, reverie, acute intoxication, and subsequent healing, it’s hard to swallow that we shouldn’t seriously explore if psychedelic or ketamine-assisted therapy should bother to be a model—especially during an exposure to the drug. We have dubious or negative data to support this approach, except one trial with a robot therapist. It's vastly more expensive and logistically difficult to pull off, and based on the violations of human subjects' autonomy—alleged sexual misconduct in the MDMA trials themselves, as run by study sponsor MAPS—we have to consider if the substance+therapists in the moment add risk instead of mitigating it.
A few words about the plausibility of psychotherapy after an acute treatment with psychedelics—of course, this is a good idea, generally. Plenty of our existing treatments—prozac, zoloft, etc.—get better outcomes when psychotherapy is paired with the biological agents. All non-psychedelic psychotherapy happens after the fact—something happens in your life, you talk to your therapist about it— you know, to integrate one’s experience—and the hope is that, when the next tricky situation arises, you can respond more adaptively. It is not magic, but it’s effective. I don’t see any reason why post-treatment psychotherapy, when paired with the needs of the patient, should be any less effective than these treatments already are.
We have evidence from Prince et. al. that, at least with the right algorithm, algorithmic brain rewiring can be more potent with a therapeutic tool added to ketamine. This is also true in knee surgery—it’s vital to follow it with physical therapy. The question of whether these effects are additive or “multiplicative” after a psychedelic administration is worth answering. These trials don’t need to be complicated by inventing a whole new therapeutic approach, at least not yet. One could establish that a therapy is effective, give a psychedelic, and then add the therapy. For added science, one could give the psychedelic at the beginning and end of the course of therapy, and see if that is better or worse.
There is work to be done. However, for now, we have no evidence that indicates therapy is mandatory, or the degree to which the “set and setting are crucial.”
These ideas have been presented as fact and orthodoxy. I’m a heretic, perhaps. Either way, well-designed studies will suss out the truth, if we will allow dispassionate science to do what it does best—tease out cause and effect, even when it’s difficult.
Saviano, A., Perotti, C., Zanza, C., Longhitano, Y., Ojetti, V., Franceschi, F., Bellou, A., Piccioni, A., Jannelli, E., Ceresa, I. F., & Savioli, G. (2024). Blood Transfusion for Major Trauma in the Emergency Department. Diagnostics, 14(7), 708. https://doi.org/10.3390/diagnostics14070708
Even deeper down the rabbit hole, I will point out that many drug studies have low adherence rates to the oral medications, because people just don't remember to take their medication daily! Some drug studies have more of this problem than you would think, but what they're not getting is some other active compound that isn't the drug you're studying the effect of!
For more on this topic, I recommend the following articles:
Kew BM, Porter RJ, Douglas KM, Glue P, Mentzel CL, Beaglehole B. Ketamine and psychotherapy for the treatment of psychiatric disorders: systematic review. BJPsych Open. 2023 May 2;9(3):e79. doi: 10.1192/bjo.2023.53. PMID: 37128856; PMCID: PMC10228275.
Wilkinson ST, Rhee TG, Joormann J, Webler R, Ortiz Lopez M, Kitay B, Fasula M, Elder C, Fenton L, Sanacora G. Cognitive Behavioral Therapy to Sustain the Antidepressant Effects of Ketamine in Treatment-Resistant Depression: A Randomized Clinical Trial. Psychother Psychosom. 2021;90(5):318-327. doi: 10.1159/000517074. Epub 2021 Jun 29. PMID: 34186531.
Grabski, M., McAndrew, A., Lawn, W., Marsh, B., Raymen, L., Stevens, T., … Morgan, C. J. A. (2022). Adjunctive Ketamine With Relapse Prevention–Based Psychological Therapy in the Treatment of Alcohol Use Disorder. American Journal of Psychiatry, 179(2), 152–162. https://doi.org/10.1176/appi.ajp.2021.21030277
Price RB, Spotts C, Panny B, Griffo A, Degutis M, Cruz N, Bell E, Do-Nguyen K, Wallace ML, Mathew SJ, Howland RH. A Novel, Brief, Fully Automated Intervention to Extend the Antidepressant Effect of a Single Ketamine Infusion: A Randomized Clinical Trial. Am J Psychiatry. 2022 Dec 1;179(12):959-968. doi: 10.1176/appi.ajp.20220216. Epub 2022 Sep 21. PMID: 36128684; PMCID: PMC9722511.
I think about this topic of psychedelics a lot. My lived experience with treatment resistant depression includes having ketamine play a small role in saving my life.
This was prior to the FDA approved spravato but it was essentially a compound pharmacy version of it. Nasal spray form the exact same way and sent to my house every 3 months.
The benefit for me was it was “prescribed relief”. Simply put, I didn’t feel like dying when I used it. That was a remarkable feeling having that relief and not feeling guilty for getting that relief as it was “prescribed” by my psych was also therapeutic as I didn’t have the guilt of substance abuse. The brain disease of serious mental illness already had my mind ravaged with 1638293 other examples of guilt.
The problem was it wasn’t monitored. I was home so it was incredibly convenient. It involved watching Netflix rather than having to go to a psych office and have a caregiver take off 1/2 a day of work and add yet again another burden to a caregiver of mine.
But that also meant it was easy to abuse. Taking an extra spray meant more relief. It was indicated for every other day or when you are in a recurrence. I was in a recurrence all the time so it was hard to determine if I was using it too frequent or as I should.
I had 4 bad trips on it. My only thought when I came to was I was upset I wasn’t dead. That’s how horrific SMI can be.
I am in remission now purely do to being in a clinical trial for deep brain stimulation surgery that save my life out of Mt Sinai hospital.
I reflect on my medical journey a lot now that I am disease free. My mind races on this a lot. Technically, it helped save my life and I am grateful for that. It was also convenient and cheap which NEVER happens in mental illness care. It was also wasn’t safe for me to manage on my own.
Being able to have the experience that I had with some type of assistance would have been great for me. I had zero resources other than grab it from the mail box every quarter and go take it.
If there was a robot assisting me and jt helped me then awesome. If a robot or therapist made me feel even more relief and it was also a safer experience for me then hell yeah. Let’s go. I don’t need anything validating that other than my own mind and feelings. If it was with a therapist. Awesome. If it was in conjunction with Virtual Reality. Awesome.
There are a million validated treatments. None of them worked for me so it was irrelevant to me in my case if they were or weren’t. I just needed something to save my life.
Now that I am in remission I think a lot about having it one more time but in a therapy guided way. It would be helpful for me to help process the horror I went through and open my mind to a new form of healing.