Reply to Letter to the Editors

Two fishermen pondered the best way to understand a salmon. The first fisherman said: “We must wait until a school of salmon swims upstream and then catch one in mid-air. We should keep it in a bucket until it stops breathing and then dissect it, examining its brain and each organ closely.” The second fisherman said: “No. Instead, we should jump into the river with the salmon, watch for everything that catches its eye, notice how it interacts with us, observe when it scurries from predators, and follow it when it travels upstream to spawn. Then, and only then, will we be able to understand a salmon.”

The allegory above is illustrative of myriad dialectics: reductionism versus holism; science versus mysticism; left brain versus right brain; and CBT versus psychodynamic psychotherapy. From my perspective, psychodynamic psychotherapy, in contrast to CBT, is an immersive experience. For this reason, I believe that a psychodynamic approach—with its emphasis on the unconscious, the transference/countertransference dynamic, the intersubjectivity of meaning, and the assessment of defense mechanisms—has the most potential of any therapeutic style to take advantage of the unique opportunities available during a psychedelic-assisted psychotherapy encounter.

In their letter critiquing my article, “Ketamine-Assisted Psychodynamic Psychotherapy,” Drs. Guss and Sloshower took issue with my citing their manual (for the Yale study on psilocybin-assisted therapy for depression) as an example of acceptance and commitment therapy (ACT)—an offshoot of CBT—and they argued that I made an “error” by misrepresenting ACT “as nonpsychodynamic.” In their view, I failed to recognize that ACT shares subtle features with psychodynamic psychotherapy, including an assessment of defense mechanisms and other unconscious processes.

Later, Drs. Guss and Sloshower noted that I omitted a paper by Yaden and colleagues (2022) that advocates for CBT to be “the default option for a psychotherapeutic paradigm to