Set, Setting And Self-Compassion In Psychedelic-Assisted Therapy
The overlooked result is not symptom reduction — it is that people stop hating themselves.
- Difficulty
- Advanced
- Time to result
- ~weeks to results
- Steps
- 4
- Confidence
- 93%
Van der Kolk ran the Boston arm of a large MDMA-assisted therapy study, comparing good psychotherapy delivered largely by people he had trained against the same psychotherapy plus MDMA. The therapy alone made a little difference; MDMA vastly changed the situation. But his own emphasis is contrarian: the headline paper — 67% of MDMA-assisted participants no longer meeting PTSD criteria against roughly 30% on placebo — gets quoted, while the secondary-data paper he considers more important does not. That paper describes how the experience changed people's relationship to themselves. Instead of the usual self-hatred and self-blame, participants arrived at deep self-compassion: look what that poor child went through, he was so little, he couldn't defend himself. And then, repeatedly, compassion for the perpetrator too — my poor dad, he never got to enjoy this beautiful child he had. Van der Kolk calls it a compassion-opening drug, which is what has been wanted in so many areas of life. His hard constraint is set and setting: these must be done in very safe conditions with a lot of support, the environment completely supportive throughout. The majority of participants told him afterwards they could not have done it without the team present. His fear is the profit-driven version — one pill, go off by yourself, deal with it.
Origin
Van der Kolk was asked about psychedelics fifty years ago by Rick Doblin and Michael Mithoefer and told them it was a great idea in theory, since traumatised people live in a very constricted world where trauma dominates perception. He also discouraged them, believing they would never get past regulators. They raised the money anyway and asked him to run the Boston side.
Core principles
- 01The medicine does the heavy lifting; the therapy alone moves little.
- 02The overlooked outcome is the changed relationship to the self.
- 03Self-compassion replaces self-hatred; compassion often extends to the perpetrator.
- 04Set and setting are non-negotiable, not optional refinements.
- 05Different chemicals — MDMA, psilocybin, ketamine — appear to produce similar effects.
- 06The real question is whether your heart is open, not whether you tick fewer symptom boxes.
How to run it
- 1
Establish readiness first
Van der Kolk tells some patients directly that they are not ready — that they should do neurofeedback and body practices to live more in their body before anyone blows their mind open.
Pro tip Readiness is judged on capacity to stay present and tolerate being in the body.
Watch out This gate is what the commercial model is most likely to remove.
- 2
Build the container
The environment must be completely supportive and safe and be there for you throughout. He credits the Johns Hopkins studies and all the trials cited with taking very good care of this.
Pro tip The majority of his study's participants said afterwards they could not have done it without the team present.
Watch out He fears we may very well lose this, and calls the alternative — one pill, go off alone — the thing the profit-driven world is looking for.
- 3
Expect pain, not pleasure
Van der Kolk took MDMA as principal investigator expecting a magical, pleasurable experience. Instead all the accumulated pain of the traumatised people he had listened to over decades came back, and he lay in agony for eight hours.
Pro tip His guide's disclosure — that in his own experience every patient who died in his hands came to visit him — was what helped, by creating human connection around the pain.
Watch out Approaching it as ecstasy sets an expectation the experience frequently contradicts.
- 4
Measure the relationship to self, not the symptom list
Van der Kolk's argument is that the real issue is whether you love yourself, whether your heart is open, whether you are open to new experiences — not whether you still tick items on a PTSD scale.
Pro tip He notes his psychedelic research still lacks the inkblot data he wanted: as Michael Pollan says, how to change your mind, but we are not measuring how people change their minds.
Watch out Symptom-count endpoints are what get funded and quoted, which is why the more important finding is ignored.
In the wild
Participants in the MDMA study repeatedly moved from 'this awful thing happened to me' to 'that poor kid, he was so little, he couldn't defend himself' — and then to 'I was such a beautiful child, and my poor dad, he never got to enjoy the child he had.'
→ Van der Kolk calls it a compassion-opening drug and says this, not the PTSD score, is the result that matters and the one that goes unquoted.
Van der Kolk had always dismissed vicarious trauma as not really hurting him. Taking MDMA as part of his role, all the pain of the traumatised people he had listened to over decades surfaced at once.
→ He lay in agony for eight hours and emerged, in his words, a much sadder but somewhat wiser man — more humble and more compassionate. He also notes he learned most of what his quest for understanding trauma had to do with himself after the age of 70.
Common mistakes
Reading the symptom-remission figure as the finding
The 67% versus 30% result is the paper that gets quoted. Van der Kolk considers the secondary paper on changed self-relationship more important, and it is largely ignored.
Removing the support container
He is emphatic that these must be done in very safe conditions with a lot of support. The one-pill-and-go-home model strips out exactly what participants said made the experience possible.
Expecting a pleasurable experience
He assumed MDMA meant ecstasy and pleasure. His own session was eight hours of agony that nonetheless changed him — the expectation was the error, not the outcome.
Is it for you?
Best for
People evaluating psychedelic-assisted therapy, and clinicians designing protocols where set and setting are the variable at risk.
Not ideal for
Chronically agitated people who cannot yet tolerate being in their body — van der Kolk actively defers them.
From the transcript
“you get this very deep sense of self-compassion instead of the usual response of self-hatred and self-blame”
“the real issue is do you love yourself is your heart open are you open to new experiences”
“the majority of the people in our study said to us the study was over I couldn't have done this if you guys hadn't been…”
From the episode
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Bessel van der Kolk