Psychedelic-assisted therapy will soon be approved for adults. If the history of adult psychiatric drugs is any guide, adolescents will not be far behind — which makes the question of how they should be included in research an urgent one. That question has typically been framed through the lens of autonomy, and specifically through the adolescent’s capacity to consent to participation. We argue that for psychedelics, an equally important dimension of autonomy lies in what happens afterward: in the adolescent’s capacity, or lack of capacity, to shape the environment in which therapeutic change has to take root.
The last time a major class of depression drugs was approved for adults, adolescents received it through off-label prescribing long before the rigorous testing required to determine the risk-benefit profile in that population. SSRIs reached millions of young people this way: not through malpractice, but because the absence of paediatric trials leaves clinicians with adult-licensed drugs and adolescent patients in distress, and a difficult choice between prescribing off-label or not prescribing at all. This means safety and efficacy questions for paediatric populations get answered in clinical practice rather than in the context of research trials. Indeed, a network meta-analysis found that only one of fourteen antidepressants had a favourable risk-benefit balance in young people, and that some were associated with increased suicidality.
Adolescent mental health is in a worse state now than when SSRIs emerged. Clinicians, parents, and suffering young people are looking for better options – and psychedelic-assisted therapy (P-AT), with its promising adult results, will be a tempting one. But the felt urgency to respond to this need must not lead us to repeating the mistakes we made with SSRIs. The sentiment that children and adolescents are not just “little adults” is well-worn, but it bears repeating: we need sensitivity to differences not just in their biology, but in their psychology and social context.
Getting that sensitivity right requires adolescent-specific evidence that, at present, we simply do not have. Khaleel Rajwani and Brian Earp have argued that this needs to change. If P-AT is licensed for adults but no adolescent trials follow, the SSRI pattern will repeat. This means we need P-AT trials in adolescents. But what should they look like?
At least in part, the answer comes from taking adolescent autonomy seriously – but in a way that the existing bioethical conversation has not yet foregrounded. The protection and promotion of patient autonomy is, for many, the foremost among bioethical principles, and a central concern in paediatric research ethics. Adolescent decision-making capacity develops unevenly, perhaps especially in risk evaluation, future orientation, and susceptibility to authority. It makes sense, then, that the familiar challenges around adolescent autonomy in research ethics foreground the decision to participate – whether a young person can meaningfully consent to being enrolled in the first place. As we argue in a newly published paper, there is reason to think that adolescent autonomy is just as ethically salient after the drug has been administered. The reason has to do with how psychedelics seem to work.
Psychedelics appear to create a time-limited window of enhanced plasticity: a period in which entrenched, harmful, or counterproductive patterns become more open to being reshaped. Preclinical research provides robust evidence that psychedelics enhance structural and functional neuroplasticity. Confirming this directly in living human brains is not yet possible. But if psychedelics temporarily make the brain more open to being reshaped, then what it is that does the reshaping probably matters: not just any psychological support or psychotherapy that follows the drug session, but also the person’s relationships, daily circumstances, and the quality of support available to them.
The plasticity-enhancing effects of psychedelics are often lauded as a straightforwardly positive thing, and not without cause: enhanced openness to change is one of the reasons psychedelics are thought to be transdiagnostically effective. But plasticity is not inherently good or bad: inasmuch as psychedelics support the reshaping of patterns of thought or behaviour, it follows that adverse influences during this window could be actively counterproductive to recovery, perhaps even harmful. In one study of people who experienced prolonged difficulties after naturalistic psychedelic use, key risk factors included stressful circumstances, lack of social support, and young age. If we take seriously, as many do, the idea that post-psychedelic psychotherapy is particularly effective because it acts during a period of heightened plasticity, then we must take equally seriously that adverse environments during this same period could undermine or reverse therapeutic gains.
But people don’t need to be passive recipients of their environments. In our research, some of the most successful adult P-AT patients renegotiated or restructured their lives following treatment: pruning draining relationships, investing in nourishing ones, pursuing long-suppressed interests. This active reshaping of one’s social environment during the post-treatment window may be part of how therapeutic gains consolidate. The acute experience generates insight and renewed motivation; adult autonomy allows the patient to turn that into lasting change.
The autonomy of adolescents – or rather, the relative lack of autonomy of adolescents, complicates this process. The developmental trajectory of adolescence is precisely the gradual gaining of influence over one’s own social environment. But relative to a typical adult, teenagers have far less ability to select, avoid, or seek out the social inputs that shape their recovery. Their daily lives are largely determined by the norms of the family home and the routines of schooling.
In short, we should think very carefully before giving adolescents plasticity-enhancing drugs, and then returning them to the very environments in which their distress first emerged.
We argue that taking these considerations seriously has concrete implications for how adolescent P-AT should be designed, at least at first: it invites approaches that attend to the family and relational world the adolescent will return to, not just the individual sitting across from the therapist. “Readiness for treatment” should encompass not only the patient but also the environment they will return to.
Adult psychedelic trials already ask about family history, typically to screen for first-degree relatives with psychosis as an exclusion criterion. This is sensible. But for an adolescent patient, the family is more than a source of inherited risk. It is also a large part of the relational environment the patient will return to during the period of heightened sensitivity discussed above. A family history limited to parental psychiatric diagnoses may suggest biological vulnerability, but on its own tells you little about the emotional climate the adolescent will return to, the capacity of caregivers to absorb and support change, or the relational patterns that may have contributed to their difficulties in the first place. Adolescent P-AT needs a sense of the family the adolescent is going back to, not just the family they are descended from.
Concretely, attending to the post-treatment environment the adolescent returns to might include psychoeducation for caregivers about the post-treatment sensitivity window, assessment of family functioning to identify where additional support is needed, and access to brief, evidence-based family interventions with demonstrated effects on both caregiver self-efficacy and child mental health outcomes. It would also likely involve integration support that extends well beyond the protocol-defined number of sessions developed for adult trials.
And it might, in some cases, look stranger still: it is conceivable that the best application of P-AT to improve at least some adolescents’ mental health could be its judicious use in one or both parents, with integration involving a mix of family and individual therapy. This is not without precedent in spirit, if not in modality: family systems approaches have long recognised that treating the relational context around the patient can be more effective than treating the patient alone, and brief family interventions already have a strong evidence base in adolescent mental health. This is more work and more expense for an already resource-intensive modality. But the alternative is the pattern that produced the SSRI story.
The logic here is not confined to adolescents. Anyone whose environment is both adverse and resistant to individual modification may face a version of the same problem. There are early signals that the population-level benefits of psychedelics are diminished in groups facing structural disadvantage. If the post-treatment environment is part of the mechanism, not merely a backdrop to it, then attending to that environment is not an optional extra but a core design question. Psychedelics might loosen entrenched maladaptive patterns. They cannot, by themselves, alter the circumstances that produced them.
Eddie Jacobs, DPhil (@eddietalksdrugs) is a postdoctoral fellow in psychedelic science at the Center for Psychedelic and Consciousness Research, Johns Hopkins and Associate Director of the Hub at Oxford for Psychedelic Ethics
Bryony Insua-Summerhays, DClinPsych is a Senior Clinical Psychologist in the NHS