How should psychotherapy proceed when adjoined with psychedelics?
Over the past few years, research and public interest in psychedelic agents – such as psilocybin and 3,4-methylenedioxymethamphetamine (MDMA) – for mental health purposes has skyrocketed. The therapeutic approach to the use of these agents involves three components: preparation, drug administration, and integration. This bundled treatment has been termed psychedelic-assisted therapy (PAT). The basic assumptions and methods of PAT, however, have remained unchanged since the 1950s, despite notable advances in the treatment of mental disorders.
The preparation phase involves building rapport between the patient and therapist(s), providing education about the psychedelic experience, and establishing a therapeutic intention (i.e., a set of goals) for the drug session. These practices are thought to facilitate a positive response to the drug and reduce the likelihood of adverse events (e.g., a “bad trip”). In the empirical literature, preparation has been described with consistent practices but wide-ranging durations, from two to eight hours over one to three sessions1.
The drug administration session has been the most consistent practice in empirical studies. The participant is monitored by two clinicians with little interruption for 6-8 hours. During this interval, patients lay on a couch with eyeshades, listen through headphones to a pre-determined playlist of classical music, and are encouraged to be as introspective as possible. These sessions typically entail minimal involvement from the therapists, except to provide emotional support, safety monitoring and, when appropriate, therapeutic touch.
The most inconsistent offering within PAT has been the integration phase, which has ranged from an individual telephone call to nine psychotherapy sessions1. Integration sessions have traditionally involved various forms of non-directive, unstructured psychosocial support. The theoretical basis behind this approach is that the psychedelic drug assists patients in identifying what they need to heal. The integration sessions have been culled from various traditions, including classic psychoanalysis, Rogerian person-centered therapy, Maslow's theory of self-actualization, and inner healing intelligence2.
Many questions remain about how the psychotherapy components of PAT produce meaningful benefits above and beyond the drug itself. Some experts claim that the current integration practices contribute little (if any) value beyond the drug's immediate psychiatric benefits, whereas others claim that it is the therapy enhanced by the drug that leads to psychiatric change1, 3. While the psychedelic drugs have received the bulk of the attention, the psychosocial treatment components of PAT have not been studied to measure their relative benefits for symptomatic and functional improvements.
To advance the field further, it is important that the psychotherapy adjunct be updated and optimized from its 1950s origins through rigorous scientific testing. We recommend testing the efficacy of adjunctive psychosocial treatments with a strong evidence base for the psychiatric indication of interest. Cognitive-behavioral therapies (CBTs) have robust empirical bases across the core emotional disorders being approached with psychedelics (i.e., mood, anxiety and stress-related disorders). CBTs are most notable for their enduring effects in terms of symptom improvement and relapse prevention4. Importantly, these treatments are manualized, reducing the variability in treatment delivery and making the testing of treatment fidelity possible. Additionally, CBT can be disseminated safely and effectively by community clinicians, as shown by the Improving Access to Psychological Therapies (IAPT) programme in the UK5.
Examining the comparative contributions of the drug and the accompanying psychotherapy is also critical to our understanding of the mechanisms of psychedelic treatment. The core emotional disorders have shared etiologies and psychological processes, including poor emotion regulation that leads to emotional and behavioral avoidance of negative stimuli. Psychedelics have a range of acute effects on consciousness, including sensory and physical experiences; sense of self, time and space; and emotions and cognitions6. The changes in an individual's emotions and cognition help to foster greater social connectedness and self-esteem and may clarify priorities and values. Additionally, psychedelics appear to reduce patients’ emotional sensitivity and cognitive rigidity in reaction to emotionally-laden stimuli, allowing them to approach emotional and cognitive content that they would otherwise avoid. For example, a patient can feel more able to undergo imaginal exposure to a previously avoided trauma. This can also be facilitated by the effects of the drug on the individual's perception of time and space through what can feel like actual movement through a trip or journey. Thus, psychedelics can help patients regulate their emotional sensitivity, appraise and approach stressful situations more flexibly, and connect to their social environment.
Structured empirically-based psychotherapies seek to modify these same psychological mechanisms of emotional regulation, cognitive flexibility, and prosocial engagement. Changes in cognition and behavior can also be tested as mediators of the impact of CBTs on symptomatic or functional outcomes. When combined with psychedelics, we expect psychosocial treatments to work synergistically with the drug to catalyze immediate and longer-term changes in thinking, feeling and behavior7.
PAT has had varying lengths of treatment response, ranging in major depression from as little as a few weeks to as long as one year8, 9. Helping patients make sense of the cognitive, affective and physiological changes produced by the drug through CBTs may instill longer-lasting benefits. Further, working with patients to concretely apply these insights into real-world cognitive and behavioral changes seems critical to producing deep-seated, durable improvement. For example, the effects of psychedelics on feelings of social connectedness may serve as catalysts for changes in thoughts and behaviors that foster social engagement. While the drug may motivate change initially, working with the patient to create behavioral activation plans, holding him/her accountable in making these changes, and solving problems that arise in the implementation of these plans may prolong the duration of the drugs’ benefits.
To examine the effects of structured psychotherapy on psychedelics (and vice versa), it will be important to vary doses of the therapy in the preparation and integration phases. What is the minimal number of preparation sessions that are necessary to safely administer a psychedelic? Does a longer preparation phase magnify the psychedelic experience, facilitate therapeutic alliance, or increase opportunities to practice newly acquired skills (such as cognitive restructuring)? Would preparation be different for psychedelic-naïve participants compared to those who have prior experience with the drug? Do integration sessions gradually improve psychiatric outcomes and functioning, or are the majority of clinical benefits apparent shortly after drug administration? How many integration sessions are optimal? Seeking to identify the treatment ingredients necessary for effective and safe delivery of psychedelics can help to update therapeutic practices. Furthermore, determining whether more than one participant can be served at one time (be it in a group setting or in adjoining rooms), and how the addition of other co-patients affects the delivery of adjunctive psychotherapy, are questions ripe for investigation.
In our ongoing trial of a psilocybin-assisted CBT for patients with major depression7, we are already impressed by the synergy between the psychotherapy and drug treatments. Our preliminary observations are that CBT skills can be leveraged during the drug experience and can increase the individual's accountability for behavioral change following the drug administration. Additionally, the psychedelic appears to increase prosocial emotions and cognitions to help enact behavioral change following the drug session.
The next generation of studies on psychedelics should consider the impact of the psychotherapeutic context of drug administration, which may prove to be as important for clinical change as the drug itself.
