Psychedelic Therapy – A Beginner’s Guide – Highlights from RCPsychIC 2019
This article is based on the talk by Dr Johnny Martell at the RCPsychIC 2019.
1.Psilocybin is a 5-HT2A agonist which renders the subject sensitive to their environment; contextual and extra-pharmacological factors are significant.
2. ‘Set’ (beliefs/expectations/mental state of participants) and ‘setting’ (broader cultural environment of the work in addition to the physical environment in which the therapy happens) are key factors to consider in the context of treatment and how this shapes an individual’s experience.
3. Within the ‘setting’ of psychedelic therapy, music is played from a playlist devised by the clinical lead, which is mainly classical, world, sacred/Indian, and ambient in style. A study revealed that music plays a central therapeutic role in psychedelic therapy. [Kaelen M et al., 2018]
Correlation analyses showed that patients’ experience of the music was associated with the occurrence of “mystical experiences” and “insightfulness.” Crucially, the nature of the music experience was significantly predictive of reductions in depression 1 week after psilocybin, whereas general drug intensity was not.
4. Current studies are designed to gain legitimacy with regulatory bodies, and as such, there may be a tendency to downplay the role of culture as well as the influence of ritual beliefs and expectations in shaping participants’ experiences. [Lifshitz et al., 2018]
5. Preparation for treatment begins the day before with a guiding pair of therapists, usually a male and female pair, and lasts for a couple of hours. Patients with a history of sexual abuse might ask for two female guides. This session is used to review the mental state of the patient, deepen rapport, and relieve anxiety about what content may emerge from the therapy.
6. Administration of psilocybin occurs at 9 am the following morning. Effects of psilocybin last 4-6 hours – the therapist remains in the room with the patient during this time to provide a quality of presence.
7. Challenging experiences (vs ‘bad trips’) can be beneficial if they lead to insight and catharsis, and participants are provided with grounding and focusing techniques by the therapist to allow letting go of mental control and surrendering to the felt experience. Level of interaction depends upon what emerges from the patient, and if they need to share their experience.
8. Integration and aftercare the following morning is based on a psychotherapeutic model (Accept, Connect, Embody – ACE), similar to that of Acceptance and Commitment Therapy (ACT), in line with neuroscientific mechanisms and anthropological literature on healing. [Hinton D & Kirmayer L., 2017]
9. A qualitative analysis of participants’ experiences in the pilot study revealed two changed mechanisms:
- a movement from a sense of disconnection from themselves and others in the world around them to a position of greater connection
- a movement from a sense of emotional avoidance to one of emotional acceptance.
10. This treatment is a hybrid psychotherapy/drug therapy, which is synergistic. Future research needs to test the hypothesised primacy of context, which is a considerable challenge.