Series: Psychoanalytic Voices on the Issues of Our Time
PSYCHEDELICS ARE everywhere today. Whether it's mushrooms being microdosed for creative work, ketamine on the street, or ritualized ayahuasca retreats in Peru, these substances—first popularized, and then demonized, during the 1960s and 70s—are indeed having a renaissance. They're in the research lab too, now a multibillion-dollar industry primarily looking to address mental health issues like chronic depression and PTSD that are minimally responsive to other treatments.
Psychedelics and psychoanalysis have a kinship: Both have the potential to loosen a person's grip on established patterns of thought and behavior. And their pairing may have far-ranging implications for psychological treatment.
What follows is the first in an ongoing series of interviews with psychoanalysts, psychodynamic therapists, and others about issues of relevance to our times. To discuss psychedelics and their relationship with psychoanalysis, I sat down with John Burton, MD, in his New York City office in Gramercy. Burton is a psychiatrist and psychoanalyst who incorporates Ketamine-Assisted Psychotherapy (KAP) into his practice.
You know, when I went to college, I was sure of one thing, that I would not go to medical school. When I went to medical school, I was sure of one thing, that I wanted to be a “real doctor,” not a psychiatrist. It sounds very conflicted of me, and it was. But, as psychoanalysts, we trust there is a through line to these kinds of conflicts and indecisions.
I was pretty disillusioned by how medicine was actually practiced in a tertiary medical care center, which was very biological and mechanistic. I was working with brilliant people, but patients were kind of housed in the hospital waiting for their labs, no one was really seeing them. Psychiatry itself was in the “Decade of the Brain,” believing that if we can understand the functioning of the brain as well as possible then we can give a person the right biological treatment and we don't need to know anything else. People were just bodies that either worked or didn't. There was little consideration of the human experience that was in those bodies.
Except for the dynamically oriented psychiatrists. It seemed to me that they had a kind of x-ray vision to see things going on that no one else was seeing. Understanding people on that level was absolutely necessary to be able to help and heal them. Otherwise, to me anyway, what was the point of getting healed physically if your psyche was miserable? My friends and classmates would probably disagree with me, but that's how I felt. I was always drawn to what was underneath, holding uncertainty, not putting things in boxes. I didn't want to simplify and reduce people. That's what drew me to psychoanalysis, and that's what drew me to working with psychedelics.
When I first read Michael Pollan's 2015 New Yorker article on the psychiatric research on psychedelics going on at the time, I recognized a couple people I trained with and thought, “Wow, I did not see this coming!” I read How to Change Your Mind and continued to look for information and training, especially during Covid when I had the chance to sit still and learn more. I got excited and realized that this is the same thing I've been looking for, the appreciation of what lies underneath, that drew me to psychiatry and then to psychoanalysis. Researchers were working in a model that is neurofunctionally based, but coming back to defense mechanisms and repressed material. Even though most of them are not psychoanalysts, I saw an overlap for the first time between biological psychiatry and psychoanalytic thinking in ways that were exciting and not conflictual. On top of that, it also added something to my psychoanalytic framework: mystery and awe, joy and wonder. I started to think, what is the role of that in psychological health? Early on, Freud, Reich, and Jung were radicals. They were disruptors. And that's what psychedelics have the potential to do in our field.
That's right. Two years ago I completed training in KAP and I have been doing ketamine sessions with psychotherapy patients since then. Ketamine is what is legal and available for use. On average, I arrange for a KAP session in my office a couple of times a month at the most.
Ketamine is used for numerous psychiatric indications, such as PTSD and treatment resistant depression, and is also being actively studied as an intervention for addiction and other psychiatric diagnoses. In my practice, as a psychoanalytically oriented psychiatrist, I am using ketamine solely within the context of psychodynamic psychotherapy and psychoanalysis. If I felt that someone might benefit from ketamine treatment for depression primarily, I would refer them to an infusion clinic that provides ketamine using the schedule and dosing that has been developed to alleviate symptoms of depression.
In contrast, I use ketamine exclusively with patients who have ongoing therapeutic relationships with me, where we see the potential for a KAP session to move the process forward in a way that augments the psychotherapy itself. Some patients have initiated the consideration of a KAP session themselves. Sometimes I will suggest it to patients. It seems to be particularly helpful for patients who find themselves caught in a cycle of rumination, rigid behaviors, or maladaptive defenses that continue despite thorough analysis and insight. Since KAP is an experiential intervention, it often allows for breakthroughs that do not come from the verbal, intellectual work of psychotherapy. It is in many ways analogous to the use of the couch which fosters free association. The couch, by the way, can be thought of as a “nonordinary state of consciousness” itself.
It's definitely not the only thing. What I do want to emphasize is that there's something uniquely powerful about psychedelics in a psychoanalytic context with a therapeutic alliance and the ability to understand transference and countertransference as part of the work and meaning making as part of that. So certainly other things are just useful for people to do, like meditation.
And with some patients, many in fact, we have considered it and decided not to do a KAP session. I feel like this
happens especially with patients who are using the couch in a more traditional four-times-a-week analysis. We have agreed very clearly that ketamine was not something they needed at the time and that it would actually be disruptive to the ongoing deep analytic work that they were doing. The more powerful experiences I have had were with patients who felt like they kept coming to these insights of awareness but there was something holding them back. They were not able to get a handle on it or not able to translate it into meaningful life change in their relationships or ways of doing things. Psychedelics by definition disrupt. As Stan Grof referred to them, they're “nonspecific amplifiers.” I think of them as nonspecific disruptors to the ego. To show you what your perception is like without your ego, or what neuropsychologists call the “Default Mode Network.”
My radical thought is this: How can you effectively work with these substances—with all respect to Indigenous and shamanic traditions which are working in a different framework, more ecologically, or even cosmologically oriented—without thinking psychoanalytically? How can you work with people going through nonordinary states of consciousness and what comes up with that unless you're doing it in the context of a therapeutic alliance? You have to understand what transference and countertransference are. We as analysts have a way of observing the patient's feelings and our feelings coming up and making use of that. Without that framework a lot of potential is being missed and potential harm can be caused. As psychoanalysts we're experts on holding uncertainty and looking for meaning at the same time. It's not that people with a more CBT approach or ACT or IFS—all of which are very popular in the psychedelic space—are not looking for meaning. It's that the way psychoanalysis constructs meaning and understands repressed content especially is unique and, I think, uniquely needed in working with psychedelics.
From an ego psychology perspective, there is a respect for mechanisms of defense that ward off fantasies and feelings. We actually need our ego. The problem is not the ego itself but the over-controllingness of the ego. One of the things that I feel is most helpful in doing psychedelic work is the preparation. As soon as you start talking about doing psychedelics, we're already doing psychedelic psychotherapy because it's stirring up meaning. I'm not just preparing someone safely for their journey, I'm seeing the transferences that are happening to the experience, to the medication, what meaning, hopes, and fantasies for cure are coming up. We're particularly attuned to hearing those things in a session, which makes the preparation phase of psychedelic therapy extremely rich and useful. I've had preparation phases for patients who never went on to have the ketamine session because they decided they didn't need
it, but it stirred up our psychoanalytic process in a way that can only be considered a success. But the other piece is in the integration. After psychedelic experience, what do you do? In psychedelic work you watch your ego disappear or retreat into the background but then when you come out of the journey you can see it much more clearly coming back online, you see your ego reconstructing itself.
You need an ego, but more than that you can see the automaticity of it. That's what I'm trying to emphasize. Because however much regression you get on the couch, you just don't get the same degree of dissolution of the ego that you do on a psychedelic journey. But then as it reconstitutes itself you see it. Yes you need it, but seeing what it's doing to you that you don't need creates a kind of insight and self-awareness that is extremely helpful.
It's really important to acknowledge that to do due diligence, we need to talk about the risks and benefits of the medicine. But we also have to talk about the real power it has. The misuse of ketamine is a testament to the power it has and why it needs to be thought of so carefully. Now that I have sort of a reputation of doing ketamine psychotherapy I've actually been referred some of the worst cases of ketamine abuse I've ever imagined before this, and I'm not an addiction psychiatrist. But, as a psychoanalyst with training in ketamine, I was uniquely positioned to talk to these individuals about their experience and help them feel understood in what they were trying to achieve in their street use. Sadly, for people who have already been abusing ketamine, it would definitely not be the right treatment for them. I have become personally shocked and impressed at how dangerous it can be in the wrong set and setting. That's a psychedelic terminology, “set and setting,” but it's also very analytic. It addresses the two most important factors that make the difference between a profound and therapeutic experience and a damaging one.
Well, there are many ways set and setting can be not right. Not being safe is the first. There are many ways of being unsafe, and being physically unsafe is only one of them. I would say the larger concern is about the interpersonal dimension and social safety. If you have a psychedelic experience in a group of people who are not prepared to tolerate and hold for you what comes up, that is unsafe. You're going to be traumatized by that. I would say that more than the medical issues with
the abuse of ketamine—and there are real medical issues—the possibility of a psychedelic experience being traumatic because of the setting is the biggest danger.
“SADLY, FOR PEOPLE WHO HAVE ALREADY BEEN ABUSING KETAMINE, IT WOULD DEFINITELY NOT BE THE RIGHT TREATMENT FOR THEM. I HAVE BECOME PERSONALLY SHOCKED AND IMPRESSED AT HOW DANGEROUS IT CAN BE IN THE WRONG SET AND SETTING.”
There has definitely been an evolution in my approach to psychoanalytic work. One aspect in particular has been the role that wonder, awe, and what are often called mystical experiences have in healthy psychological functioning. I always felt that psychoanalysis offered a way to see beneath, or beyond, the surface manifestations of psychological suffering into the universal human attempts to make sense and adapt to our world. At its best, psychoanalysis brings a kind of humility to the work. Often, however, psychoanalysis falls prey to the arrogance of certainty that occurs in many areas of medicine and psychology. For me, psychedelics have brought back to the forefront of my psychoanalytic work the role of mystery and surprise that brought me to the field to begin with.
In Psychoanalytic Voices on the Issues of Our Time, Tracy Sidesinger, PsyD, a clinical psychologist practicing in Brooklyn, interviews analysts, psychodynamic therapists, and others on wide-ranging topics that address the struggles and desires of contemporary human life. This interview has been edited and condensed.
First published online June 2025