Letter to the Editors

“Ketamine-Assisted Psychodynamic Psychotherapy,” by John Cottone, Ph.D., is a welcome contribution to the literature on integration of psychedelic-assisted therapy and psychoanalytic/psychodynamic treatment. Dr. Cottone's case report of a complex patient in analytically oriented treatment receiving ketamine therapy as an adjunct to her ongoing psychodynamic treatment is well described and compelling. However, his critique of current psychedelic-assisted therapy practices is problematic at times, and inadequately referenced.

The author misrepresents ACT (Acceptance and Commitment Therapy) as nonpsychodynamic and disinterested in defense structure and unconscious processes. As two of the authors of the papers he references, we disagree with this claim. A brief “sound bite” correction of this error is impossible; like psychoanalysis (or any complex treatment modality), understanding ACT takes time, attention, and experience. A very specific development in cognitive-behavioral therapy (CBT), ACT is quite a far distance, theoretically, from “first” or “second” wave CBT. As a “third wave” iteration, ACT is embedded in relational frame theory; it recognizes unconscious processes, sees alterations in self/ other representations as central to therapeutic action, and is grounded in “here and now” somatic experience. It holds psychological flexibility as its central axis of effectiveness, which is multiply expressed through a focus on altering defenses, including transference phenomena.

Dr. Cottone's critiques and literature review do not acknowledge recent scholarship on the intersection of psychedelic therapy and psychoanalysis. For instance, he omits a paper that advocates for the use of CBT as a “default” choice for psychedelic therapy (Yaden et al., 2022) and the challenges to this paper (Burton et al., 2022). Instead, he references the Yale manual as the lone example of the use of CBT and ACT in psychedelic therapy and also as an example of how he suggests that psychedelic