Six years ago, on a work trip to London, James suddenly couldn’t read the text on his computer screen. It wasn’t just a glitch; looking around, he realized his whole visual field was filled with static. When he went to the hospital, he told a nurse that he had taken psychedelic mushrooms in Amsterdam with a friend the week before. “She said, ‘This is why we don’t do drugs,’” James said, now 31 and using a pseudonym to protect his privacy. Her response “made it clear that most doctors I would see wouldn’t have much help to offer”, he said. After researching his symptoms online, James suspected he had hallucination persisting perception disorder, or HPPD. In HPPD, a person’s visual perception changes in ways that negatively impact their mental health for months or years after taking a psychedelic substance. Over the next year, his only recourse was to search for advice or interventions on forums and websites. As researchers explore how psychedelics might help people with mental health conditions, psychedelics like LSD and mushrooms are losing much of their former stigma and more people are becoming curious about these mind-altering drugs. Psychedelics have different risk profiles than other drugs; for example, mushrooms have a low risk for physical dependence or overdose. But there are still potential side effects like derealization, anxiety or difficulty making sense of a psychedelic experience. And because these drugs are largely legally restricted all over the world, there are limited resources for help with physical symptoms or overwhelming emotions related to psychedelic use. James, however, found a rarity: Ambulanz psychedelische Substanzen, a psychedelic outpatient clinic that is part of Charité, a university hospital in Berlin. He went to the clinic about a year after his vision started to bother him and met an assistant doctor, Dario Jalilzadeh-Masah, who had encountered similar cases and could diagnose James with HPPD. Unlike his visit to the hospital, James said his meeting at the clinic was nonjudgmental and empathetic. There is potential for psychedelics as a medical intervention, and people also use these substances for spiritual, religious and recreational purposes. But social discussion and media coverage can focus on the more exciting facets of psychedelic use. James said he had only heard about the positive effects. “I was never aware that something like [HPPD] could happen,” he said. “There are a lot of patients who suffer from psychedelic-related problems,” said Tomislav Majić, a psychiatrist who created the clinic in 2018. “They don’t have anywhere to go.” What does the clinic treat? HPPD, depersonalization, derealization syndrome, psychosis and anxiety are the most common reasons people seek out the clinic. Sometimes, a patient struggles to make sense of a traumatic psychedelic experience. Majić has seen people who had panic episodes on drugs like LSD or ayahuasca, then experienced repeated panic attacks afterward. The clinic operates from a psychedelically informed and a harm reduction perspective, Majić said. Its medical staff don’t tell people never to use psychedelics again, but try to help them pinpoint what is leading to their difficulties, and find the right treatment. The clinic has about 10 to 15 patients a month, and a couple of dozen virtual clients. Once a doctor determines what the issue is, they direct a user to next steps, which might include medication, psychotherapy or simply validation. Most people arrive at the clinic desperately seeking some understanding of what’s happening to them. “We haven’t done any advertising,” Majić said. “Still, people are coming all the time.” What do we know about persistent side effects from psychedelics? Many people know about, and are wary of, the “bad trip”: seeing frightening visions or having strong, negative emotions while taking a psychedelic drug. But only recently has research turned to difficulties that persist after a trip. In October 2023, one study from researchers involved with the Challenging Psychedelic Experiences Project described some such difficulties based on reports from 608 people. About a third of the people surveyed had been dealing with their symptoms for more than a year. The most common issue was emotional difficulties. For example, one person wrote: “For about 18 months, I awoke with the sun every morning full of a feeling of absolute terror … Sometimes my anxiety would be so high in the morning that I would physically shake from the energy.” Others felt extremely isolated, like one person who reported dropping out of high school, giving away their possessions and becoming “withdrawn, untrusting, disengaged from friends”. Richard, a 24-year-old based in Berlin using his first name only, also developed HPPD. His visual disturbances started after a DMT trip. For years, he has had sensitivity to light from screens or lightbulbs, which remain in his vision as an afterglow. “It really freaked me out to have a layer between my eyes and the world,” he told me, saying his vision is “basically never clean”. In the months after his DMT trip, Richard started to have a kind of anxiety that Majić said is referred to as existential confusion or ontological shock. “I was confronting the realization that I am a person, that I am a form of life that evolved over time, that some part of me somehow decided to put me in the relationships I was in, in the city I moved to, to make the decisions I had made until that point,” Richard said. “And that now I have to be here with them, and face the conditions or position I was in.” This type of experience is not a psychiatric disorder, but rather a state that can be hugely disruptive. “They say it’s difficult to make sense of it, and it has been so overwhelming – positively or negatively – but it’s too big,” Majić said. “It’s too otherworldly to know how to bring this into everyday life.” Are there other options for treating psychedelic side effects? For those who can’t make it to Berlin, Jules Evans, director of the Challenging Psychedelic Experiences Project, runs an online peer support group for psychedelic difficulties. Fireside Project is a psychedelic peer support hotline for anyone having difficulties with psychedelics, either while on the drug or later, and there are a number of groups dedicated to psychedelic integration – the way people process their experiences and make sense of them in their daily lives – in-person or online. The International Center for Ethnobotanical Education, Research and Service has a support center that offers six free therapy sessions for those struggling after a psychedelic trip. But psychedelic integration is not a well-defined construct, and there is huge variability in what support exists and how hard it is to find. Majić thinks that psychologists and psychiatrists need to be more informed about psychedelics. There are a number of training programs for therapists who want to learn more about psychedelics, but these vary in content matter. Overall, there aren’t many satisfying options for people with psychedelic difficulties. “If they go to their conventional psychiatrist, they will be told to go to the addiction clinic and get sober, but this is not the problem,” Majić said, since typically a person’s problems are not specifically related to continuing psychedelic use or substance use disorder. Majić has often found himself between two poles: those who say that psychedelics are safe because they are non-addictive and nearly impossible to overdose on, and those who say that psychedelics are only dangerous. In addition to running the clinic and seeing patients, he conducts other psychedelic research: for instance, a study on psilocybin for treatment-resistant depression, and another on 5-meO-DMT. “They can be beneficial,” Majić said. “But they’re also harmful for some.” For Richard, it was hard to imagine bringing his existential anxiety to a traditional physician. “It’s difficult to find somebody to talk to about that and not think you’re crazy or psychotic,” he said. He is grateful for the recognition he found at the outpatient clinic. “I was overwhelmed, unable to manage my life and my health, but I was at least capable of reaching for help, and I was lucky that the help was very accessible to me,” he said.