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Recommended Readings 5 | Integration2022-05-18T07:08:18+02:00

RECOMMENDED READINGS 5
INTEGRATION IN PSYCHEDELIC THERAPY

This list was made by Floris Wolswijk in cooperation and co-published with Blossom.

Psychedelic-assisted therapy entails several stages that are considered essential in order to gain the best possible therapeutic outcomes. Most commonly the preparation, dosing session, and integration are recognized. Though surrounding that there is also patient referral & screening beforehand and after-care procedures (Gründer & Jungaberle, 2021). Here we will focus on the integration that happens after a dosing session.

Following a psychedelic therapy session, further therapy sessions are needed to make sense of the insights gained during the experience. This phase is known as the integration phase, which Tehseen Noorani (2019)  defined as “the catch-all term for a range of ways of understanding the work required to bring the meaning and fruits of the psychedelic experience to bear upon one’s life in the aftermath of the acute drug effects.”

During the first wave of psychedelic research in the 1950s and 1960s, the importance of integration was not fully recognized. Some studies do mention the need for follow-up discussions after the psychedelic experience however, the necessity of this phase is ill-defined. Robin Carhartt-Harris (2018, 2019) proposed the comprehensive REBUS and the Anarchic Brain model on how psychedelics work in the brain and on cognition: through binding to serotonin receptors, psychedelics can cause us to revise our high-level priors or ‘beliefs.’ If carefully mediated, belief-relaxation can lead to improvements in mental health.

In this sense, psychedelic therapy has the potential to remediate aberrant or abnormal beliefs which may have become engrained as a result of trauma. Thus, the integration phase is essential for helping people assess and successfully employ the changes to their beliefs they experienced while under the influence of psychedelics. This integration work has been studied in most detail on the individual level, though upcoming research also highlights the importance of peer-support as an important factor of integration (Amato, 2021 [editor’s note: this link leads to Maria Amato’s research talk at INSIGHT 2021 conference]).

Today, modern researchers recognize the importance of the integration phase. They are continuously exploring the potential of various models for facilitating integration in the best possible way. Additionally, there is a lack of empirical evidence thus far on integration in particular contexts such as group therapy, as well as the overall cost-effectiveness of the approach. Past and present research into this particular aspect of psychedelic science is discussed below.

PSYCHEDELIC HARM REDUCTION AND INTEGRATION: A TRANSTHEORETICAL MODEL FOR CLINICAL PRACTICE 

Ensuring that patients gain the full therapeutic benefits of psychedelics when undergoing psychedelic-assisted therapy is a priority for researchers and therapists alike. Ingmar Gorman and colleagues (2021) provide a framework for minimizing potential harm and facilitating the integration of the insights gained during the experience. In ‘Psychedelic Harm Reduction and Integration: A Transtheoretical Model for Clinical Practice‘ they offer insights as to how therapists can help their patients to make sense of their experience in the integration process. Dealing with phenomena such as challenging experiences, ego-dissolution, and unmet expectations, among others, is also discussed.
Albert Garcia-Romeu and William Richards (2018) offer further perspectives on the importance of integration in their review article. The authors deem integration to be an essential part of the therapeutic process, serving as “a crucial means to bridge the session experience with everyday life.”

Gorman I, Nielson EM, Molinar A, Cassidy K, Sabbagh J. Psychedelic Harm Reduction and Integration: A Transtheoretical Model for Clinical Practice. Front Psychol. 2021 Mar 15;12:645246. doi: 10.3389/fpsyg.2021.645246. PMID: 33796055; PMCID: PMC8008322.

Psychedelic Harm Reduction and Integration (PHRI) is a transtheoretical and transdiagnostic clinical approach to working with patients who are using or considering using psychedelics in any context. The ongoing discussion of psychedelics in academic research and mainstream media, coupled with recent law enforcement deprioritization of psychedelics and compassionate use approvals for psychedelic-assisted therapy, make this model exceedingly timely. Given the prevalence of psychedelic use, the therapeutic potential of psychedelics, and the unique cultural and historical context in which psychedelics are placed, it is important that mental health providers have an understanding of the unique motivations, experiences, and needs of people who use them. PHRI incorporates elements of harm reduction psychotherapy and psychedelic-assisted psychotherapy, and can be applied in both brief and ongoing psychotherapy interactions. PHRI represents a shift away from assessment limited to untoward outcomes of psychedelic use and abstinence-based addiction treatment paradigms and toward a stance of compassionate, destigmatizing acceptance of patients’ choices. Considerations for assessment, preparation, and working with difficult experiences are presented.

Garcia-Romeu A, Richards WA. Current perspectives on psychedelic therapy: use of serotonergic hallucinogens in clinical interventions. Int Rev Psychiatry. 2018 Aug;30(4):291-316. doi: 10.1080/09540261.2018.1486289. Epub 2018 Nov 13. PMID: 30422079.

Humans have used serotonergic hallucinogens (i.e. psychedelics) for spiritual, ceremonial, and recreational purposes for thousands of years, but their administration as part of a structured therapeutic intervention is still a relatively novel practice within Western medical and psychological frameworks. In the mid-20th century, considerable advances were made in developing therapeutic approaches integrating administration of low (psycholytic) and high (psychedelic) doses of serotonergic hallucinogens for treatment of a variety of conditions, often incorporating psychoanalytic concepts prevalent at that time. This work contributed seminal insights regarding how these substances may be employed with efficacy and safety in targeted therapeutic interventions, including the importance of optimizing set (frame of mind) and setting (therapeutic environment). More recently, clinical and pharmacological research has revisited the effects and therapeutic potential of psychedelics utilizing a variety of approaches. The current article provides an overview of past and present models of psychedelic therapy, and discusses important considerations for future interventions incorporating the use of psychedelics in research and clinical practice.

Keywords: LSD; Psychedelic therapy; hallucinogens; psilocybin.

LSD-ASSISTED PSYCHOTHERAPY AND THE HUMAN ENCOUNTER WITH DEATH

During the first age of psychedelic research in the 1950s and 1960s, little attention was given to helping patients integrate their experiences. Nevertheless, researchers like William Richards and colleagues (1972) who studied ‘LSD-Assisted psychotherapy and the human encounter with death’ saw the value in post-session interviews to help people make sense of their psychedelic experience. The integration sessions offered in the study focused on applying insights to everyday living insofar as was possible.

Richards, William; Grof, Stanislav; Goodman, Louis; Kurland, Albert A. (1972) LSD-Assisted Psychotherapy and the Human Encounter with Death. Journal of Transpersonal  Psychology 1972 4(2) 121-150.

Enthusiasm and optimism are not enough for starting an LSD program. As a caution to those who may attempt psychedelic psychotherapy with cancer patients, we definitely would not advise its use without specialized training under supervision from those already familiar with the reactions facilitated by this powerful psychoactive drug. With adequate training, however, our clinical experience thus far suggests that skilled use of the psychedelic procedure can be a relatively safe and promising approach in an area that has been most discouraging up to the present.

PSILOCYBIN-ASSISTED THERAPY OF MAJOR DEPRESSIVE DISORDER USING ACCEPTANCE AND COMMITMENT THERAPY AS A THERAPEUTIC FRAME

Now, nearly 50 years later, different therapeutic frameworks have been proposed to facilitate the integration process. Jordan Sloshower and colleagues (2020) make a case for using Acceptance and Commitment Therapy (ACT) as an overarching therapeutic framework. In ‘Psilocybin-assisted therapy of major depressive disorder using Acceptance and Commitment Therapy as a therapeutic frame’ they suggest ACT and psilocybin-therapy act in unison to possibly amplify a person’s response to psilocybin, leading to longer-lasting therapeutic outcomes. The benefits of using a contextual behavioral science (CBS) model such as ACT are reiterated by Jason Luoma and colleagues (2019).

Sloshower, J., Guss, J., Krause, R., Wallace, R. M., Williams, M. T., Reed, S., & Skinta, M. D. (2020). Psilocybin-assisted therapy of major depressive disorder using Acceptance and Commitment Therapy as a therapeutic frame. Journal of Contextual Behavioral Science, 15, 12-19.

Psychedelic-assisted therapy is based on the premise that psychedelic substances can act as catalysts or adjuncts to psychotherapeutic processes. Recent clinical trials involving psychedelic-assisted therapy have generally employed a similar three-part structure consisting of preparation, support during the dosing sessions, and subsequent “integration.” However, the content of these sessions and the frame through which the therapists approach participants and understand the clinical process has thus far been inconsistent among studies. In designing a manualized therapy protocol for a small clinical trial of psilocybin-assisted therapy for major depressive disorder, our group sought to delineate an explicit and replicable, evidence-based model that intentionally builds upon both the neurobiological actions of the medication and the phenomenology of the drug experience. Having identified considerable concordance in proposed mechanisms of change between Acceptance and Commitment Therapy (ACT) and psilocybin therapy, we employed ACT as an overarching psychotherapeutic framework. We hypothesize that the psilocybin experience can provide direct experiential contact with ACT processes that increase psychological flexibility, and that these deeply felt experiences may in turn be reinforced during ACT-informed follow-up therapy sessions. In this paper, we describe the rationale for selecting ACT, areas of potential synergism between ACT and psilocybin-therapy, the basic structure of our treatment model, and limitations to this approach.

 

Luoma, J. B., Sabucedo, P., Eriksson, J., Gates, N., & Pilecki, B. C. (2019). Toward a contextual psychedelic-assisted therapy: perspectives from acceptance and commitment therapy and contextual behavioral science. Journal of Contextual Behavioral Science, 14, 136-145.

After two decades of quiescence, clinical psychedelic research re-started in the 1990s and is rapidly accelerating. Early evidence for effectiveness is promising, but understanding of the psychological processes of change underlying observed benefits is limited. This paper outlines contextual behavioral science (CBS) as an ideal framework for understanding psychedelic experiences and the psychological processes of change involved in psychedelic assisted therapy. This paper argues that CBS-based therapies, such as Acceptance and Commitment Therapy (ACT), can contribute to deepening and maintaining the often profound acute effects of psychedelics. The paper begins by briefly outlining the current state of clinical psychedelic research. It then progresses to outlining why CBS may be uniquely positioned to potentially increase the efficacy of psychedelic-assisted therapy, how this scientific model fits with existing data on psychedelic-assisted therapy, as well as with leading neuroscientific theories such as the entropic brain theory. Finally, it concludes by suggesting avenues for future research on how CBS could contribute to psychedelic science, and vice versa.

The use of the psychological flexibility model to support psychedelic assisted therapy

Another model, presented and discussed by Rosalind Watts and Jason Luoma (2020), is named Acceptance, Connect and Embody (ACE). This psychological flexibility model is currently being used in a psilocybin trial for depression, with accompanying positive outcomes (Carhart-Harris et al., 2021). The model uses the six psychological flexibility processes outlined below to better integrate the revelations of the psychedelic experience into everyday life. ‘The use of the psychological flexibility model to support psychedelic assisted therapy’ is divided into two triads, the acceptance triad (defusion, present moment focus, willingness) and the connection triad (self as context, values, committed actions). Psychological flexibility is identified as a possible key to facilitating positive change.

Watts, R., & Luoma, J. B. (2020). The use of the psychological flexibility model to support psychedelic assisted therapy. Journal of contextual behavioral science, 15, 92-102.

Psychedelic assisted therapy comprises three stages: Preparation, Psychedelic Session, and Integration. Preparation is key for maximising the potential of a beneficial psychedelic experience and integration is important for prolonging improvements. The psychological flexibility model (PFM) appears to be a promising one to guide psychedelic preparation and integration. This paper proposes a model that utilises the PFM as informed by a previously published qualitative study of patient accounts of change processes in psilocybin therapy that identified themes of acceptance and connection as associated with positive outcomes. This new model, the ACE (Accept, Connect, Embody) model presents the six psychological flexibility processes, renamed and rearranged in an acceptance triad (defusion, present moment focus, willingness) and a connection triad (self as context, values, committed action). This paper describes the ACE model and how it is being used in an ongoing trial of psilocybin treatment for major depression. It also describes qualitative evidence supportive of the idea that psychological flexibility may be key to characterizing the processes of change involved in psilocybin assisted therapy for depression. These and other results suggest that psilocybin may be specifically increasing psychological flexibility and point to the possibility that psychotherapy approaches incorporating the PFM may serve as a means to deepen and extend the benefits of psilocybin treatment, thus bridging the experiential gap between a potent inner experience and an outer life better lived.

Carhart-Harris, R., Giribaldi, B., Watts, R., Baker-Jones, M., Murphy-Beiner, A., Murphy, R., … & Nutt, D. J. (2021). Trial of psilocybin versus escitalopram for depression. New England Journal of Medicine, 384(15), 1402-1411.

BACKGROUND

Psilocybin may have antidepressant properties, but direct comparisons between psilocybin and established treatments for depression are lacking.

METHODS

In a phase 2, double-blind, randomized, controlled trial involving patients with long-standing, moderate-to-severe major depressive disorder, we compared psilocybin with escitalopram, a selective serotonin-reuptake inhibitor, over a 6-week period. Patients were assigned in a 1:1 ratio to receive two separate doses of 25 mg of psilocybin 3 weeks apart plus 6 weeks of daily placebo (psilocybin group) or two separate doses of 1 mg of psilocybin 3 weeks apart plus 6 weeks of daily oral escitalopram (escitalopram group); all the patients received psychological support. The primary outcome was the change from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR-16; scores range from 0 to 27, with higher scores indicating greater depression) at week 6. There were 16 secondary outcomes, including QIDS-SR-16 response (defined as a reduction in score of >50%) and QIDS-SR-16 remission (defined as a score of ≤5) at week 6.

RESULTS

A total of 59 patients were enrolled; 30 were assigned to the psilocybin group and 29 to the escitalopram group. The mean scores on the QIDS-SR-16 at baseline were 14.5 in the psilocybin group and 16.4 in the escitalopram group. The mean (±SE) changes in the scores from baseline to week 6 were −8.0±1.0 points in the psilocybin group and −6.0±1.0 in the escitalopram group, for a between-group difference of 2.0 points (95% confidence interval [CI], −5.0 to 0.9) (P=0.17). A QIDS-SR-16 response occurred in 70% of the patients in the psilocybin group and in 48% of those in the escitalopram group, for a between-group difference of 22 percentage points (95% CI, −3 to 48); QIDS-SR-16 remission occurred in 57% and 28%, respectively, for a between-group difference of 28 percentage points (95% CI, 2 to 54). Other secondary outcomes generally favored psilocybin over escitalopram, but the analyses were not corrected for multiple comparisons. The incidence of adverse events was similar in the trial groups.

CONCLUSIONS

On the basis of the change in depression scores on the QIDS-SR-16 at week 6, this trial did not show a significant difference in antidepressant effects between psilocybin and escitalopram in a selected group of patients. Secondary outcomes generally favored psilocybin over escitalopram, but the analyses of these outcomes lacked correction for multiple comparisons. Larger and longer trials are required to compare psilocybin with established antidepressants. (Funded by the Alexander Mosley Charitable Trust and Imperial College London’s Centre for Psychedelic Research; ClinicalTrials.gov number, NCT03429075. opens in new tab.)

HUMAN HALLUCINOGEN RESEARCH: GUIDELINES FOR SAFETY

Therapists are an essential component of psychedelic-assisted therapy as they help patients prepare for the experience, guide them through the experience, and integrate the insights gained during the experience. In their 2008 publication ‘Human hallucinogen research: guidelines for safety’ Matthew Johnson and colleagues at Johns Hopkins emphasize the importance of developing a strong patient-therapist relationship. Developing trust and rapport with the patient helps to facilitate the therapeutic process overall.

Ensuring therapists are adequately equipped to monitor and guide a psychedelic experience is of the utmost importance. Janis Phelps (2017) discusses the six core competencies any psychedelic therapist should possess as well as offering guidelines for training future therapists.

Additionally, whether a therapist should have firsthand experience with psychedelics remains an open question. The history of therapists using psychedelics is discussed by Elizabeth Nielson and Jeffery Guss (2018). The authors also suggest a study is needed to explore how the use of psilocybin by therapists may influence how they approach therapy and integration for patients.

Johnson, M. W., Richards, W. A., & Griffiths, R. R. (2008). Human hallucinogen research: guidelines for safety. Journal of psychopharmacology, 22(6), 603-620.
There has recently been a renewal of human research with classical hallucinogens (psychedelics). This paper first briefly discusses the unique history of human hallucinogen research, and then reviews the risks of hallucinogen administration and safeguards for minimizing these risks. Although hallucinogens are relatively safe physiologically and are not considered drugs of dependence, their administration involves unique psychological risks. The most likely risk is overwhelming distress during drug action (‘bad trip’), which could lead to potentially dangerous behaviour such as leaving the study site. Less common are prolonged psychoses triggered by hallucinogens. Safeguards against these risks include the exclusion of volunteers with personal or family history of psychotic disorders or other severe psychiatric disorders, establishing trust and rapport between session monitors and volunteer before the session, careful volunteer preparation, a safe physical session environment and interpersonal support from at least two study monitors during the session. Investigators should probe for the relatively rare hallucinogen persisting perception disorder in follow-up contact. Persisting adverse reactions are rare when research is conducted along these guidelines. Incautious research may jeopardize participant safety and future research. However, carefully conducted research may inform the treatment of psychiatric disorders, and may lead to advances in basic science.
 
Phelps, J. (2017). Developing guidelines and competencies for the training of psychedelic therapists. Journal of Humanistic Psychology, 57(5), 450-487.
Research since the 1950s has shown that psychedelic-assisted psychotherapy has had significant positive effects in reductions of specific clinical symptoms and increases in quality of life as measured on a variety of indices. The intensity of focus on evidence-based outcomes, however, has resulted in a paucity of active discussions and research on the core competencies of the therapists themselves. The context of the history of psychedelic research reveals how this neglect of therapist variables occurred. With current discussions of Phase 3 and expanded access research programs for psilocybin-assisted and MDMA-assisted psychotherapies, there will be a great need for competent therapists trained in this clinical specialty. This is particularly the case if less restricted, legal medical use is approved within the next 6 to 10 years. This article is the first review and compilation of psychedelic therapist competencies derived from the psychedelic literature. These six therapist competencies are empathetic abiding presence; trust enhancement; spiritual intelligence; knowledge of the physical and psychological effects of psychedelics; therapist self-awareness and ethical integrity; and proficiency in complementary techniques. A further contribution of this review is a delineation of the 12 fundamental curricular domains of study for the training and development of these therapist competencies. As current legal restrictions evolve, aspects of these training guidelines will develop accordingly.
 
Nielson, E. M., & Guss, J. (2018). The influence of therapists’ first-hand experience with psychedelics on psychedelic-assisted psychotherapy research and therapist training. Journal of Psychedelic Studies, 2(2), 64-73.
Clinical research on psychedelic-assisted psychotherapy is rapidly advancing in the USA, with two drugs, psilocybin and MDMA, progressing through a structure of FDA-approved trials on a trajectory toward Drug Enforcement Agency rescheduling for therapeutic use. Researcher’s and clinician’s personal use of psychedelics was cited as a potential confound in psychedelic research studies conducted in the 1950s and 1960s, a concern which contributed to the cessation of this research for some 20 years. Currently, there is no empirical research on personal use of psychedelics by current academic researchers and clinicians; its influence is undocumented, unknown, and undertheorized. This paper explores the history of personal use of psychedelics by clinicians and researchers, the potential impact of personal use on psychedelic-assisted psychotherapy and research, and the rationale for opening an academic discussion and program of research to investigate the role of personal use. We propose that there are factors unique to psychedelic-assisted therapy such that training for it cannot neatly fit into the framework of modern psychopharmacology training, nor be fully analogous to psychotherapy training in contemporary psychological and psychiatric settings. We argue that scientific exploration of the influence of therapists’ first-hand experience of psychedelics on psychedelic-assisted therapy outcomes is feasible, timely, and necessary for the future of clinical research.
DEVELOPMENT OF A PSYCHOTHERAPEUTIC MODEL FOR PSILOCYBIN-ASSISTED TREATMENT OF ALCOHOLISM

As we progress through the Psychedelic Renaissance, it is likely that disorder-specific psychotherapeutic models will be developed. In ‘Development of a Psychotherapeutic Model for Psilocybin-Assisted Treatment of Alcoholism’ Michael Bogenschutz and Alissa Forcehimes (2016) discuss the therapy model ‘Motivational Enhancement and Taking Action (META)’ they are trialing in a psilocybin study for alcohol use disorder. Therapists use the META model to discuss how the psychedelic experience has affected the patient’s relationship toward alcohol and their desire to change drinking behavior.

Bogenschutz, M. P., & Forcehimes, A. A. (2017). Development of a psychotherapeutic model for psilocybin-assisted treatment of alcoholism. Journal of Humanistic Psychology, 57(4), 389-414.
 
Research activity on the potential clinical value of classic hallucinogens and other psychedelics has increased markedly in the past two decades, and promises to continue to expand. Experimental study of hallucinogen-assisted treatment, and any future clinical use, requires the development of psychotherapeutic models that are appropriate to the disorder being treated and effectively integrated with the pharmacologic component of the treatment. To provide a framework for thinking about possible treatment models, we provide an overview of the history of psychedelic-assisted treatment, review what is known about the therapeutic mechanisms of these treatments, and consider the various purposes of psychotherapy in the context of both research and clinical use of psychedelic-assisted treatment. We then provide a description of a therapy model we have developed and are currently using in a trial of psilocybin-assisted treatment for alcoholism. Finally, we discuss advantages and disadvantages of a range of alternative models, emphasizing the need for research to determine the most effective treatment models for any indications for which efficacy becomes established.
SURVEY STUDY OF CHALLENGING EXPERIENCES AFTER INGESTING PSILOCYBIN MUSHROOMS: ACUTE AND ENDURING POSITIVE AND NEGATIVE CONSEQUENCES

Integration should also be a key concern when it comes to challenging experiences. Theresa Carbonaro et al. (2016) conducted a ‘Survey study of challenging experiences after ingesting psilocybin mushrooms’ and found that the single worst difficult experience (‘bad trip’) was associated with acute and long-term negative outcomes. The survey found enduring psychotic symptoms, but conversely also that the experience helped others, with 84% of respondents indicating they benefitted from the experience.

Challenging experiences can arise from improper use without guidance, but also from an inappropriate setting. María Gómez-Sousa et al. (2021) reported on the ‘Acute Psychological Adverse Reactions in First-Time Ritual Ayahuasca Users’ and found the lack of screening and poor guiding skills as two reasons contributing to the occurrence of challenging experiences.

Carbonaro, T. M., Bradstreet, M. P., Barrett, F. S., MacLean, K. A., Jesse, R., Johnson, M. W., & Griffiths, R. R. (2016). Survey study of challenging experiences after ingesting psilocybin mushrooms: Acute and enduring positive and negative consequences. Journal of Psychopharmacology, 30(12), 1268-1278.
 
Acute and enduring adverse effects of psilocybin have been reported anecdotally, but have not been well characterized. For this study, 1993 individuals (mean age 30 yrs; 78% male) completed an online survey about their single most psychologically difficult or challenging experience (worst “bad trip”) after consuming psilocybin mushrooms. Thirty-nine percent rated it among the top five most challenging experiences of his/her lifetime. Eleven percent put self or others at risk of physical harm; factors increasing the likelihood of risk included estimated dose, duration and difficulty of the experience, and absence of physical comfort and social support. Of the respondents, 2.6% behaved in a physically aggressive or violent manner and 2.7% received medical help. Of those whose experience occurred >1 year before, 7.6% sought treatment for enduring psychological symptoms. Three cases appeared associated with onset of enduring psychotic symptoms and three cases with attempted suicide. Multiple regression analysis showed degree of difficulty was positively associated, and duration was negatively associated, with enduring increases in well-being. Difficulty of experience was positively associated with dose. Despite difficulties, 84% endorsed benefiting from the experience. The incidence of risky behavior or enduring psychological distress is extremely low when psilocybin is given in laboratory studies to screened, prepared, and supported participants.
 
BACKGROUND

In recent decades, ritualistic use of ayahuasca has spread throughout the world. Retrospective studies have suggested a good psychological safety profile, but prospective studies involving ceremony ayahuasca-naive participants are lacking.

METHODS

We conducted the study using a subsample from a previous study, for which first-time ceremony ayahuasca participants were recruited. The subsample consisted of 7 subjects who experienced acute and challenging psychological reactions. The semistructured Mini-International Neuropsychiatric Interview and psychometric questionnaires were administered before participants attended the ayahuasca ceremony and at 1 and 6 months after exposure. Subjective experiences were also recorded.

RESULTS

Seven subjects from a sample of 40 reported having experienced intense challenging psychological effects during the ayahuasca ceremony. Four of those 7 subjects met the diagnostic criteria for 1 or more psychiatric disorder before the ayahuasca ceremony. One month after the ceremony, 2 of those subjects no longer showed psychiatric symptoms, whereas the symptoms of the other 2 were reduced considerably. Those results persisted at the 6-month follow-up. Inappropriate setting/context (poor guiding skills and screening) contributed to some of the challenging reactions. Most of the participants (6 of 7) did not take ayahuasca again during the study period.

CONCLUSIONS

Based on the cases reported here, we suggest that although it is possible that participating in ayahuasca ceremonies may entail acute psychological negative reactions, those challenging experiences can also have positive long-term effects. Prospective research on the safety profile of ayahuasca and how it is affected by the context of different practices and safety strategies is therefore necessary.

THE POTENTIAL SYNERGISTIC EFFECTS BETWEEN PSYCHEDELIC ADMINISTRATION AND NATURE CONTACT FOR THE IMPROVEMENT OF MENTAL HEALTH

Integrating psychedelic experiences does not only happen through talk and reason, the setting in which it happens may prove to be just as important. In ‘The potential synergistic effects between psychedelic administration and nature contact for the improvement of mental health,’ Sam Gandy and colleagues argue that there is a synergy between nature contact and psychedelics for the improvement of mental health. Although still only hypothesized, so not formally researched, they argue that integration sessions in nature, with accompanying exercises, could enhance integration processes.

Gandy, S., Forstmann, M., Carhart-Harris, R. L., Timmermann, C., Luke, D., & Watts, R. (2020). The potential synergistic effects between psychedelic administration and nature contact for the improvement of mental health. Health Psychology Open, 7(2), 2055102920978123.
 
Therapeutic psychedelic administration and contact with nature have been associated with the same psychological mechanisms: decreased rumination and negative affect, enhanced psychological connectedness and mindfulness-related capacities, and heightened states of awe and transcendent experiences, all processes linked to improvements in mental health amongst clinical and healthy populations. Nature-based settings can have inherently psychologically soothing properties which may complement all stages of psychedelic therapy (mainly preparation and integration) whilst potentiating increases in nature relatedness, with associated psychological benefits. Maximising enhancement of nature relatedness through therapeutic psychedelic administration may constitute an independent and complementary pathway towards improvements in mental health that can be elicited by psychedelics.
DEPRESSION, MINDFULNESS, AND PSILOCYBIN: POSSIBLE COMPLEMENTARY EFFECTS OF MINDFULNESS MEDITATION AND PSILOCYBIN IN THE TREATMENT OF DEPRESSION

Both psychedelics and mindfulness meditation are two ways through which depression may be treated. In ‘Depression, Mindfulness, and Psilocybin’ Kirstin Heuschkel and Kim Kuypers (2020) compare the mechanisms through which both methods work. Most importantly, they argue that mindfulness meditation may increase or prolong the positive effects after psilocybin-assisted therapy.

A similar argument is made by Jake Payne and colleagues (2021) who make the analogy that psychedelics can provide a compass, the direction, and mindfulness the vehicle, the integration. In ‘Combining Psychedelic and Mindfulness Interventions: Synergies to Inform Clinical Practice’ they build further on earlier research that showed the benefit of combining mindfulness meditation and CBT.

Heuschkel, K., & Kuypers, K. P. (2020). Depression, mindfulness, and psilocybin: Possible complementary effects of mindfulness meditation and psilocybin in the treatment of depression. A review. Frontiers in psychiatry, 11, 224.
 
Depression is a major public health problem that affects approximately 4.4% of the global population. Since conventional pharmacotherapies and psychotherapies are only partially effective, as demonstrated by the number of patients failing to achieve remission, alternative treatments are needed. Mindfulness meditation (MM) and psilocybin represent two promising novel treatments that might even have complementary therapeutic effects when combined. Since the current literature is limited to theoretical and empirical underpinnings of either treatment alone, the present review aimed to identify possible complementary effects that may be relevant to the treatment of depression. To that end, the individual effects of MM and psilocybin, and their underlying working mechanisms, were compared on a non-exhaustive selection of six prominent psychological and biological processes that are well known to show impairments in patients suffering from major depression disorder, that is mood, executive functioning, social skills, neuroplasticity, core neural networks, and neuroendocrine and neuroimmunological levels. Based on predefined search strings used in two online databases (PubMed and Google Scholar) 1129 articles were identified. After screening title and abstract for relevance related to the question, 82 articles were retained and 11 were added after reference list search, resulting in 93 articles included in the review. Findings show that MM and psilocybin exert similar effects on mood, social skills, and neuroplasticity; different effects were found on executive functioning, neural core networks, and neuroendocrine and neuroimmune system markers. Potential mechanisms of MM’s effects are enhanced affective self-regulation through mental strategies, optimization of stress reactivity, and structural and functional adjustments of prefrontal and limbic areas; psilocybin’s effects might be established via attenuation of cognitive associations through deep personal insights, cognitive disinhibition, and global neural network disintegration. It is suggested that, when used in combination, MM and psilocybin could exert complementary effects by potentiating or prolonging mutual positive effects, for example, MM potentially facilitating psilocybin-induced peak experiences. Future placebo-controlled double-blind randomized trials focusing on psilocybin-assisted mindfulness-based therapy will provide knowledge about whether the proposed combination of therapies maximizes their efficacy in the treatment of depression or depressive symptomatology.
 
Payne, J. E., Chambers, R., & Liknaitzky, P. (2021). Combining psychedelic and mindfulness interventions: Synergies to inform clinical practice. ACS Pharmacology & Translational Science, 4(2), 416-423.
Psychedelic and mindfulness interventions have been shown to improve mental ill-health and wellbeing, with a range of clinical processes and effects in common. However, each appear to contain specific challenges in the context of mental health treatment. In this Perspective, we focus on a set of distinct affordances, “useful differences”, within psychedelic and mindfulness interventions that might address common challenges within the other intervention. Accordingly, we propose a set of applied synergies, indicating specific ways in which these two promising interventions might be combined for greater benefit. Metaphorically, on the journey toward mental health and wellbeing, we propose that psychedelic treatments may serve the role of Compass (initiating, motivating, and steering the course of mindfulness practice), with mindfulness interventions serving the role of Vehicle (integrating, deepening, generalizing, and maintaining the novel perspectives and motivation instigated by psychedelic experience). We outline a set of testable hypotheses and future research associated with the synergistic action of psychedelic and mindfulness interventions toward improved clinical outcomes.
ETHICAL AND LEGAL ISSUES IN PSYCHEDELIC HARM REDUCTION AND INTEGRATION THERAPY

Therapists who provide psychedelic (integration) should have two goals in mind for their patients. The first is to maximize the benefits of therapy. The second is to reduce the risks of harm. ‘Ethical and legal issues in psychedelic harm reduction and integration therapy’ by Brian Pilecki and colleagues (2021) tackles these issues and provides guidance for therapists on how to help clients and navigate the legal landscape.

Pilecki, B., Luoma, J. B., Bathje, G. J., Rhea, J., & Narloch, V. F. (2021). Ethical and legal issues in psychedelic harm reduction and integration therapy. Harm Reduction Journal, 18(1), 1-14.
Psychedelic-assisted therapy may represent an upcoming paradigm shift in the treatment of mental health problems as recent clinical trials have demonstrated strong evidence of their therapeutic benefits. While psychedelics are currently prohibited substances in most countries, the growing popularity of their therapeutic potential is leading many people to use psychedelics on their own rather than waiting for legal medical access. Therapists therefore have an ethical duty to meet this need by providing support for clients using psychedelics. However, incorporating psychedelics into traditional psychotherapy poses some risk given their prohibited status and many therapists are unsure of how they might practice in this area. This paper explicates such risks and describes ways in which therapists can mitigate them and strive to practice within legal and ethical boundaries. A harm reduction approach will be emphasized as a useful framework for conducting therapy around clients’ use of psychedelics. It is argued that therapists can meet with clients before and after their own personal psychedelic experiences in order to help clients minimize risk and maximize benefit. Common clinical scenarios in this growing clinical area will also be discussed.

 

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