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by Saj Razvi, Director of Education and Founder at Psychedelic Somatic Institute
Let’s define the sitter model first so we have a common understanding to work from. This abstract from professor David Nutt captures it well:
There are generally two therapists present in the room (ideally one male and one female) who are there to provide reassurance, medical cover, and care. They only talk with the patient if the patient wants them to, which they generally do not. It is important to note that there is no expectation of conversation during the “trip” and no direction by either therapist of the patient’s speech or thought. It is the next day in the “integration” session that the content of the trip is discussed and interpreted and psychotherapeutic benefits derived.
(Nutt, 2019)
Given this definition of the sitter model, here are the ways in which PSIP (Psychedelic Somatic Interactional Psychotherapy) is quite different:
1.) The PSIP therapist is an active participant in the client’s psychedelic consciousness versus the sitter who is a passive holder of space, excluded from the psychedelic encounter which is between participant and the medicine
Whereas the sitter is a passive observer outside of the psychedelic reality of the client, the PSIP therapist is actively engaged with and a participant inside of the client’s altered consciousness. Because this is trauma that the client’s system is trying to excavate, it is typically a nightmare that the client and PSIP therapist are inhabiting together. The therapeutic opportunity here is incredible. Imagine entering into your subconscious mind but instead of being there alone, you are there with a trusted, skilled, caring ally who can help you navigate this space for therapeutic benefit. In fact, the PSIP therapist is trained to provide interventions that specifically deepen the client into their subjective dream state. The PSIP therapist is relying on her own experience in the psychedelic realm and a well honed intuition to enter into the subconscious mind of the client and be able to operate consistent with the rules of that non-ordinary reality.
Because there are a lot of charged memories having to do with relationship that live in the subconscious, the client’s system is invited to project or transfer these historical relational roles onto the therapist as a means to make this implicit layer explicit. The client who was lacking a competent, nurturing, protective, idealized parent will project that role onto the therapist. They will see the therapist in an overly positive light. With even more compulsive charge, the client’s system will need to project painful, fearful, abusive or neglectful historical roles from their relational past onto the therapist. As this negative transference is emerging, the client will expect the same treatment from the therapist as he received from his traumatizing family members. Though it may seem paradoxical, it is therapeutically relieving for this relational programing to become expressed in the session. The client might feel the therapist is being critical or judging him as being disgusting. If the client had a distant, uncaring parent, he may see the therapist as physically distant or hear her voice as being far away. The client may feel he is a burden to the therapist, or that he is wasting her time. He may even feel the therapist is overtly or secretly angry at him. The permutations of how children internalize their abusive family members and how this internalized memory becomes expressed in the psychedelic session is endless.
The expression of this relational programming is essential for symptom resolution and it's a gift. It is an act of generosity by the therapist to allow herself to be seen by the client in these often horrific ways. While it is easy to understand the theory of how negative transference works, to actually be able to allow it without becoming defensive, reactive or dissociative will take years of personal work and training by the clinician. The human psyche is remarkably complex, and it should take years of training and personal work to be able to effectively work with it.
In contrast to this depth and richness of work, the sitter model is a missed opportunity. This layer of relational programming will simply not have an opportunity to express if there is no other person inside of the client’s psychedelic reality. If there is no opportunity for this relational wounding to express because the sitter is non-existent in the client’s consciousness or because the sitter insists on only being a positive loving presence (I.e they unknowingly insist only on positive transference), it does not mean the negative relational roles go away. Let me say that again for clarity sake, these negative relational roles do not vanish simply because they are not engaged in the session. Very frequently, they will express elsewhere in the client’s life, most commonly with their partner. These powerful projections can ruin the client’s relationship as they express themselves at home in powerfully unconscious ways with people who are not trained to work with them, instead of coming forth in the psychedelic container.
2.) Human relational focus is primary in PSIP versus a transpersonal focus in sitter model
PSIP is designed for people who are suffering from mental health conditions such as: anxiety, panic, depression, dissociation, addiction, PTSD and other complex trauma symptoms. According to large scale research such as the ACE study, these conditions do not occur in a vacuum. The seeds of many adult mental health and even physical disease processes are planted in the highly stressful or traumatic events that occurred during childhood. The vast majority of people who enter into psychotherapy, and psychedelic treatment in particular, are doing so because of wounding they have experienced in their own family of origin which means these are complex relational traumas. Attachment, for example, is one of the most profoundly influential forces determining the course of our lives. Wounding that takes place during this sensitive period is a developmental trauma that is completely relational in nature.
PSIP is designed for people seeking psychedelics as a way to treat these mental health symptoms. As such, PSIP is a highly relational container where clients feel attuned to and in relationship no matter where they go in their psychedelic trauma process. Even if they go to a direct felt sense of profound aloneness where they feel they are floating in the empty void of space, they are still communicating the details of that world to their therapist. In so doing, their aloneness is in relationship. The therapist always maintains some level of relational tether to the client in PSIP. The assumption here is that human relational wounding requires human relational healing.
This is in contrast to the sitter model where the primary encounter is an internal one between the client and the medicine. As profound as this contact can be particularly at the transpersonal and existential levels, the lack of a responsive human connection means the process won’t focus on biographical human realm material. A relational key is needed to open the door of relational wounding. By design, this is inherently not part of the sitter container. Furthermore, there are many human realm psychological defense mechanisms that are very active in the client’s system which will not vanish just because they have taken a psychedelic substance. Directive engagement is needed to discern and work with these defenses. Clients can often loop for hours in their psychological defense when not given appropriate support that allows them to notice and move through the defense.
3.) PSIP has interventions based on an understanding of how trauma affects human psychobiology (autonomic nervous system processing, traumatic transference & memory consolidation); it is a comprehensive somatic, trauma therapy model specifically designed for the psychedelic state. In contrast, the sitter model has no interventions during the psychedelic session, no predictive maps or models, it is non-directive, it is not designed to treat any specific ailment or condition, and cannot be considered a form of psychotherapy
As noted by David Nutt, there are no real interventions in the sitter model during the psychedelic session: “there is no expectation of conversation during the “trip” and no direction by either therapist of the patient’s speech or thought.” My suspicion is that the sitter model evolved out of a realization that traditional cognitive behavioral, talk therapy methods were not effective or appropriate for the psychedelic state and so researchers in the 1950’s decided it was better to do nothing than to do something that would interrupt what the psychedelic was accomplishing on its own.
In contrast to this are the orienting maps, predictive modeling and interventions available to us when treating a client’s psychobiological response to trauma. We know trauma, we know what it does to the mind and body of mammals as well as humans. We can build actual interventions based on this understanding. We have biological reference points that we use in PSIP that tell us with predictive reliability what a client’s nervous system is doing, and where it is heading and what can be done to support it. There are a whole host of variables that we are tracking and engaging with in order to support the client’s organism in resolving trauma. We can do so much more than just suggesting to the client to ‘trust the process’ or ‘take more medicine’. We can track the client’s level of resource, their autonomic nervous system state, their level of dissociation, how much they are able to allow relationship or solution to enter into their nightmare, we can track their transference, we can track what secondary and primary conscious management strategies they are using to avoid their material. We can build highly relational interventions based on all of these factors.
4.) PSIP has a focus on dissociation versus the lack of tracking or engagement with dissociation or other defense mechanisms in the sitter approach
PSIP has a unique hyper-focus on dissociation. This is because the most traumatically impactful events that have happened to people live in dissociated states. The heart of a traumatic event lives in dissociation, the pathway to resolution requires directly contacting dissociation, and treatment resistance is a result of dissociation. Psychedelics by themselves do not resolve dissociation. They do make more of our past available to us but the most significant and impactful traumas are deeply hidden away in dissociation, and these will not be unearthed just by taking a psychedelic medicine. The client’s mind is designed to not notice dissociation or see what lies underneath it. The client’s mind cannot engage with what it cannot see. In contrast, we can track dissociation through the client’s nervous system. We can hold a somatic container to help the client stay focused on the sobriety, the blankness, the emptiness, the boredom that is a hallmark of dissociation before it will begin to crack open. We have a much more detailed article on working with dissociation in the psychedelic session here.
5.) Therapeutic benefit in PSIP is primarily derived in the psychedelic session (while we have direct access to subconscious programing), integration has secondary benefits versus the therapeutic benefit in the sitter approach takes place after the psychedelic session (in ordinary consciousness), during integration
The primary agent of transformation in PSIP is the bottom up, psychobiological shift that takes place at the level of the autonomic nervous system during the actual psychedelic session. The new learning, the new visceral reality, is experienced as the client is in his subconscious mind. Often this is a regressed state where the client’s child self is directly processing and experiencing a new reality.
The therapeutic benefit of the sitter model happens during integration, after the psychedelic session, when the client is back in their ordinary consciousness and will typically involve traditional therapy. While integration is very useful and stabilizing for the client in the PSIP model, that is not the area where the primary shifts are accomplished. Resolution at the level of the autonomic nervous system may not have anything to do with insight, it may not lead to any further recovery of memory, or a clear narrative. The shifts in PSIP do not take place in the top 10% of Freud’s iceberg but instead in the non-declarative, embodied, subconscious, bottom 90%.
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