When Therapy Falls Short: A Qualitative Study of Psychotherapy After Challenging Psychedelic Experiences

Psychedelic use is increasingly occurring outside controlled clinical settings, and earlier research has shown that while many people report benefits, some experience prolonged psychological or functional difficulties afterwards, including anxiety, existential distress, social disconnection, depersonalisation/derealisation, and disrupted views of reality. The introduction argues that existing psychedelic-assisted therapy research offers limited guidance for ordinary psychotherapy with people who have used psychedelics unsupervised, especially when clinicians and patients differ in how they understand difficult experiences. The authors also note debate about whether post-psychedelic difficulties require new frameworks or can be handled within standard psychotherapy with modest adaptation. Simon and colleagues therefore set out to examine how people who experienced challenging naturalistic psychedelic use described subsequent psychotherapy. They aimed to identify the qualities, skills, and practices participants associated with helpful support during integration, and to explore what made therapy feel inadequate, harmful, or poorly matched to their needs. The paper introduces “psychedelic-informed therapy” as an emerging clinical orientation intended to support people who have had psychedelic experiences outside formal treatment settings.

The study used a qualitative design grounded in a phenomenological epistemology, meaning the researchers focused on participants’ lived experience and subjective meaning-making. Reflexive Thematic Analysis was chosen to identify shared patterns across a heterogeneous sample while still attending closely to individual accounts. Participants were recruited from a larger mixed-methods study on extended difficulties after psychedelic use. From an original survey cohort of 608 respondents, 48 agreed to interview, and the present paper analysed the 35 participants who reported engaging in psychotherapy after a challenging psychedelic experience. The sample included 18 women, 16 men, and 1 nonbinary participant, aged 21–58 years. Reported substances included psilocybin, ayahuasca, LSD, and others, and use contexts varied across ceremonial, recreational, solo, and other non-trial settings. Participants had seen a range of providers, most often psychotherapists or counsellors using approaches such as cognitive-behavioural, psychodynamic/analytic, Internal Family Systems, and somatic therapies. Recruitment was voluntary and unpaid, and the Bar-Ilan University Institutional Review Board approved the study. Data were collected through semi-structured interviews conducted between August and September 2023 by secure video or voice call, lasting 60–90 minutes. The interview guide used open-ended prompts to encourage rich descriptions of meaning-making, therapeutic encounters, and recovery trajectories. Interviews were audio-recorded, transcribed verbatim, anonymised, and analysed in MAXQDA 2022. Analysis followed the six phases of Reflexive Thematic Analysis. The research team repeatedly read the transcripts, generated line-by-line codes, and then developed candidate themes through discussion and refinement. Coding began with semantic descriptions and later included latent interpretations of underlying dynamics. Trustworthiness was supported through researcher triangulation, an audit trail, and independent review by three qualitative researchers. The team also described reflexive practices, including noting prior assumptions about psychedelic therapy and using a distress protocol with follow-up resources for participants.

All 35 participants in the analytic sample said they wanted psychotherapy from clinicians who understood psychedelic experiences. However, the quality of care varied markedly. Fifteen participants (42.9%) described therapy as supportive for stabilisation, understanding, or integration, whereas 20 (57.1%) said therapy was unhelpful or only partly helpful. The authors emphasise that the thematic analysis focuses on the latter experiences of mismatch and constraint rather than on estimating the overall effectiveness of therapy. The first theme concerned friction in standard therapeutic settings. Participants often felt clinicians relied on biomedical, diagnostic, or cognitive-behavioural explanations that reduced or pathologised their experiences. Some described subtle or overt judgment after disclosing psychedelic use, which could lead to rupture or ending therapy. Others encountered the opposite problem: therapists were so enthusiastic about psychedelic healing that participants felt pressure to maintain a story of transformation and concealed ongoing difficulties. Shame, embarrassment, and fear of incomprehension also kept some people from disclosing at all. The second theme described the therapeutic qualities participants wanted. Many wanted therapists who could engage altered states without rushing to interpret them as symptoms, and who could help them work through questions of reality, meaning, and the validity of visions or ontological shifts. Several participants said a therapist’s own familiarity with psychedelics would provide safety and reduce the risk of pathologisation, though they usually framed this as knowledge rather than simple peer similarity. The third theme showed that people often turned to self-directed or informal support when professional care felt unavailable or unsafe. Partners, friends, and peers sometimes functioned as “informal therapy”, but these supports also had limits when others lacked comparable experiences. Some participants responded by imagining becoming the kind of practitioner they had needed, suggesting that the experience reshaped vocational goals as well as coping. The fourth theme focused on non-linear recovery and therapeutic fit. Participants frequently described periods of destabilisation, heightened anxiety, or emotional upheaval as part of healing rather than as simple deterioration. Yet in therapy settings oriented towards linear improvement and symptom reduction, these periods could be misread as treatment failure. Some participants later came to see initially frightening or disorganising experiences as meaningful, which complicated simple distinctions between good and bad outcomes. Across the themes, the authors argue that the core pattern was a mismatch between participants’ needs and the kinds of care available. They describe this as involving ontological, temporal, and relational dimensions: clashes over meaning and reality, disagreement about how recovery unfolds, and breakdowns in safety that encouraged concealment. The Discussion frames these patterns as interconnected rather than isolated.

The authors interpret the findings as evidence that psychotherapy after challenging psychedelic experiences is often limited by a mismatch between mainstream clinical frameworks and the forms of distress participants described. They note that more than half the sample found therapy unhelpful or only partly helpful, which is lower than the support success rate reported in a 2025 survey. However, they caution that the two studies are not directly comparable because the survey included broader support types and a wider population, whereas this sample was pre-selected for extended difficulties. Rather than contradicting earlier work, they suggest this study highlights a subgroup whose needs are not well met by routine psychotherapy. Simon and colleagues argue that three forms of incompatibility shaped the therapeutic encounter. Ontological incompatibility arose when clinicians treated participants’ post-psychedelic beliefs or existential crises as cognitive errors or symptoms rather than as meaningful attempts to make sense of anomalous experience. Temporal incompatibility arose when clinicians interpreted temporary destabilisation as deterioration, whereas participants often saw it as part of a non-linear process of reorganisation. Relational incompatibility arose when participants felt judged, dismissed, or pressured to present recovery narratives, leading to concealment and reduced trust. The authors draw on frameworks from contextual behavioural science, critical medicalisation, bioethics, epistemic injustice, and related literature to interpret these patterns. The Discussion also highlights what participants found helpful: a non-judgemental therapeutic space, interpretive flexibility, emotional containment, somatic attention, and the possibility of talking openly without having their experience prematurely explained away. The authors suggest that integration is social and cultural as well as individual, and that informal networks sometimes provided the kind of shared understanding absent in formal care. The paper identifies several limitations. The sample was drawn from people who already reported ongoing difficulties, so it does not represent all psychotherapy after psychedelic use. The data are retrospective, so participants’ current meanings may differ from how they experienced events at the time. The study captures only patients’ perspectives, not therapists’ accounts or reasoning. The authors say future research should include longitudinal designs, therapist-side or dyadic perspectives, and evaluation of community-based support models and clinician attitudes. In terms of implications, the authors propose “psychedelic-informed therapy” as a middle position between creating an entirely new modality and assuming standard therapy needs only minimal adjustment. They argue for competencies in ontological flexibility, temporal sensitivity, exploratory integration, compassion, somatic literacy, and relational safety, and suggest that mental health services may need to work alongside peer and community integration resources. They close by saying that as naturalistic psychedelic use continues to expand, systems will increasingly encounter distress that does not fit existing diagnostic categories or treatment protocols.