Psychedelic Psychotherapy

Question 1

The following is taken from these sources:

Answer 1

Yale Manual for Psilocybin-Assisted Therapy
of Depression
- http://uczesieact.pl/wp-content/uploads/2020/01/Yale-Psilocybin-Depression-Therapy-Manual_Oct-2019.pdf

A Manual for MDMA-assisted Psychotherapy in the Treatment of Posttraumatic Stress Disorder (from MAPS)
- https://maps.org/research-archive/mdma/MDMA-Assisted-Psychotherapy-Treatment-Manual-Version7-19Aug15-FINAL.pdf

Manual for Psychedelic Guides
- https://uploads-ssl.webflow.com/5f7390dfac8708fbb8e78a8c/5fb9cd63019a29942351bce5_Psychedelic-treatment-manual-jan-7-2019.pdf

Human Hallucinogen Research: Guidelines for Safety
- https://pubmed.ncbi.nlm.nih.gov/18593734/

Question 2

What is psychedelic-assisted psychotherapy?

Answer 2

The use of psychedelic substances to facilitate - both on a biological and experiential level - a therapeutic relationship

Process involves multiple sessions including:

• Preparation = beginning with the establishment of a traditional therapeutic relationship and psychoeducation on the nature of the treatment
• Support = a supported psychedelic experience(s)
• Integration = debriefing/follow up sessions post treatment reflecting on the content of the experience

The preparation and integration phases differ between trials but there are core features:

• The need for all 3 stages
• Set and setting emphasis during support
• Maintenance of a strong therapeutic alliance

Question 3

Generally speaking, what is necessary in the preparation phase?

Answer 3

Development of therapeutic rapport

Gather information about participant and history

Provide psychoeducation on the nature of the psychedelic experience and the therapeutic approach to be used

Practical considerations for the support phase:

• Expectation clarified
• Logistics (duration, use of music/make a playlist, eye masks, other things of comfort/support)
• Delineate acceptable boundaries of the interaction between therapist and participant during the session(s)

Question 4

Generally speaking, what is the typical role of the therapist during the support phase?

Answer 4

Largely nondirective

• Participants encouraged to have an inward directed experience during dosing sessions
• Emotional support and encouragement to engage with difficult thoughts, sensations or memories
• Ensure safety and immediate needs met (e.g. water)

Question 5

Generally speaking, what are the features of the integration phase?

Answer 5

Usually begins the day after the dosing session

Includes a thorough review of the participants experience during their dosing +/- application of therapeutic techniques (of a given modality) to reinforce particular aspects of the experience so that positive changes are encouraged to persist

Question 6

What is ‘set’?

Answer 6

Mindset of the participant and intention of the individual prior to the experience

Beliefs, hopes, fears, traumas, personality, temperament; expectations and fantasies about the psychedelic experience

+/- Participants attitude toward the research setting, medication, therapists; expectations for relief of symptoms

Question 7

What is ‘setting’?

Answer 7

Physical space and environment in which one has the psychedelic experience

Inhabitants (therapists/guides), music, artwork, safety equipment (incl. basic observations monitoring like HR, T)

Question 8

What are some differing approaches to the types of psychotherapeutic support provided throughout psychedelic psychotherapy?

Answer 8

The main debate is between modality-specific vs. non-specific supportive approaches

Some studies utilise evidence based psychotherapies that have already been shown to work in certain conditions e.g. motivational interviewing for alcoholism, and simply adapt these to a psychedelic context

Others e.g. Carhart-Harris (2016) opt for some general core supportive principles e.g. safety, containment, clear guidelines etc
- Therapists here are known as sitters/guides/monitors

There are many reasons to opt for one or another:

• Research aims e.g. isolation of the therapeutic effects of the drug itself (as opposed to drug + therapy)
• Uncertainty as to the types of therapy to apply in given contexts, for different conditions
• Uncertainty as to whether the healing potential is contingent on ‘internally self-generated repair’ i.e. self-healing is a natural consequence of the use of these substances and the process should thus be minimally interfered with

More research will likely elucidate greater understanding, but is somewhat reminiscent of the dodo-bird verdict in the context of psychedelics

Question 9

What things are required to prepare the physical setting?

Answer 9

Basics:

• Private, free from interruption, minimal external stimuli
• Comfortable, not overly clinical, places to sit and lie down, good ambient temperature, availability of blankets
• Nice items of interest/comfort e.g. fresh flowers, artwork, creative materials, warm colours, personal shrine with images of friends/family/meaningful objects etc
• Eye masks are useful, to facilitate inward exploration/contemplation
• Easily digested food and drinks of persons preference available should they desire to eat/drink; ensure adequate hydration during experience
• Availability of medical monitoring and resus if needed

Music:

• Goal to provide guidance and a sense of motion throughout session
• Music may be obtained online from existing protocols or in some instances chosen by patients
• Playlist may be crafted in a way to complement psychedelic experience; thinking about transitions between songs and periods of silence might be important too
• Headphones are ideal, may be linked up with external speakers to play same music quietly, to allow some connection with therapist

Question 10

What is important when considering the relationship to therapist as part of setting?

Answer 10

Must commit adequate time - incl. prep/during/debrief/follow-up

Must agree boundaries regarding touch, including refraining from sexual advances, avoid harm to self, others and property

Must have at least one sitter in the room at all times (bar breaks for bathroom etc)

Question 11

What exercises might be encouraged during the support phase?

Answer 11

‘Going in’

• Is going to be the key focus, hence use of eye mask and headphones
• Not attempting to control external world beyond what is making you seriously uncomfortable i.e. a song you are listening to is scaring you witless
• Being curious and open with kindness, to all the experiences as they unfold

Expressing oneself:

• Through any means that feel appropriate to them: vocally (laugh, cry, animal noises, chant etc); physically (dance, shake, spin, stretch etc); with creative media (paints, pencils etc)
• Without the need to explain to anyone

Breathing exercises:
- esp. breathe into the experience, or letting the breath ground you

Bodywork exercises:
- esp. exploring sensations, going with what the body wants to do, befriending your physical form, being encouraged to release pain

Question 12

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Answer 12

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Question 13

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Answer 13

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Question 14

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Answer 14

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Question 15

What are some useful (non-directive) phrases to guide the support phase?

Answer 15

To start the session or when confronted with fear responses:
- e.g. “trust, let go, and be open” (W. A. Richards, 2015)

To expand on verbal discussion:
- e.g. “Would you like to say any more about that?”

To direct attention to non-verbal/indirect communication:
- e.g. “I just noticed your voice changed, what is going on for you right now?”

To invite the individual to focus inwards:

• e.g. “Would you be willing to experiment with being silent for a few minutes just to see what you might discover?”
• “Maybe it would be a good idea to put the eye mask and headphones back on and go back inside for a period of time to let the medicine help you with this?”

To explore bodily responses:

• e.g. “where do you feel that in your body?”
• “Why don’t you try just going with that energy for a little while”
• “You might want to try breathing into your experience right now”
• “I encourage you to be as present a possible with that feeling, feel it as fully as you can, and express it in any way that might come”
• “Any visions or bodily sensations associated with what you are saying?”
• “let those tears come” “its okay, you can let go”

To reassure:

• e.g. “you are in a safe space, what is happening now is part of the healing process”
• “remember your breathing”
• Asking if they want a pre-agreed nurturing touch e.g. hand or shoulder touch

Question 16

What things are encouraged in the time following the supportive phase? (excluding the formal integration sessions)

Answer 16

Journaling
- Making time to reflect and record physically, the insights gained during the psychedelic experience

Creative expression

• Similar to journaling, a creative project relating/not-relating to the experience might prove useful for sustaining insights
• Drawing, painting, singing etc

Physical activity:

• After such intense mind-work, being in the body can be a way of beginning to live the changes and integrate the learning physically (possibly especially important in cases where problems have arisen from physical trauma/abuse)
• Breathing exercises, yoga, dancing, other exercise; sex with loved one

Being in nature:
- Psychedelic experiences often bring people closer to the natural world, and can help ground people - reinforcing this in a calming natural environment afterwards can be beneficial

All of these activities are aiming to reinforce or assist the integration process, in order to retain memories of new insights and develop new coping strategies to previous problems

Question 17

What might be covered in the formal integration sessions?

Answer 17

General, non-directive discussion of whatever the person wants to bring to the session since their experience

• This way we can elicit what is most meaningful to them
• We can then guide into several important areas should they not be covered:

Tolerability:
- How the session was tolerated - emotional, intellectual, physical response to it

Symptoms:
- What the impact on the individuals symptoms/problems has been since/how their perceptions of themselves, others and the world have changed

Ongoing changes:

• Changes catalysed by these experiences are likely to continue for a long period, often occurring in ‘waves’ - where memories, insights or emotions arise that have not been addressed or experienced previously
• Some may be pleasant, some may be difficult and challenging
• Time must be made for ongoing reflection during daily life
• Signposting for issues that come up that the individual is struggling with
• Having a rough time doesn’t mean you’re failing or haven’t made progress, healing is long and requires lots of love and patience but you are on this journey and doing well
• Re-reading the reflections can be a great way to see what is possible

Problem management:
- Processing of any emotional distress or cognitive dilemmas that may have arisen

Relationships:

• Work with relationship issues and develop tools for healthy connections (including to nature)
• Encourage people to stay connected to their support system

Coping mechanisms:
- Reinforce activities e.g. journaling, creative expression, physical activity etc that contribute to ongoing healing and self-awareness

Validate any affirming experiences

Determine any possible contraindications for subsequent therapeutic sessions ; explore efficacy of your role as a guide and things that could be done differently next time

Bodywork therapy techniques:
- May be introduced/taught for those managing ongoing emotional or somatic distress they are unable to move through

Question 18

What are the 6 core competencies of a good guide? (Phelps, 2017)

Answer 18

Empathic abiding presence

Trust enhancement

Spiritual intelligence

Knowledge

Proficiency in complimentary techniques

Question 19

What does an empathic abiding presence involve?

Answer 19

Composure, evenly
suspended attention, mindfulness, empathetic listening, “doing by non-doing”,
responding to distress with calmness, equanimity, relaxed but engaged, honest - about not having answers

Active/empathetic listening is:

• Minimal encouragement, verbal and non-verbal
• Invitation rather than direction
• Asks questions and explores without prying
• Paraphrasing
• Reflecting
• Emotional labelling
• Validating
• Reassurance and waiting
• Allowing participants to come to conclusions themselves

Strong developed sense of interoception and ability to self-reflect and understand ones own projections

The goal is to offer a loving presence,
witnessing of the mystery of life unfolding under the influence of psychedelics

Question 20

What is trust enhancement?

Answer 20

3 components:
- The participants view of the guide as a trustworthy guide
- The participant’s
trust in their own inner healing capacity
- The ability to reliably normalise for the
participant that paradoxical transformations and radically unexpected moments in
sessions are to be expected, and thus trusted as part of the process

These aspects of
trust-enhancement capacities enable the guide to support the participants’ engagement
in making meaningful sense of their lives and inner healing processes

Question 21

What is spiritual intelligence?

Answer 21

Guides possess knowledge and values that go beyond traditional/conventional psychological understanding, including:

• Our individual relationship to the transcendent/each other/the earth/all beings
• Abilities to calm ones internal dialogue and bodily responses with meditation; especially important as trips can last several hours and can be ‘boring’ for the guide and the participant requires attention (even if it is not reciprocated) as they are highly sensitive in these sates

Question 22

What is knowledge?

Answer 22

A degree of competency in anatomy and physiology, neurobiology, pharmacology, drug disposition, interactions and effects of psychedelic drugs (and the brain/mind at large)

Familiarity with the normative effects of different psychedelic drugs at certain doses is also informative

See psychedelic medicine deck

Question 23

What is guide self-awareness and ethical integrity?

Answer 23

Requires:
- A self-awareness for the personal motives of the work
- Integrity in protecting boundaries with the
participants
- Well-developed capacities for building therapeutic alliances
- Skills in
attachment theories and transference-countertransference analysis
- Personal selfcare

Question 24

What is proficiency in complimentary techniques?

Answer 24

Can be various techniques from all modalities e.g.
- Somatic-oriented techniques, such
as Holotropic breath work
- Stress inoculation
- Therapeutic body work and touch
- Techniques of eye-gazing at a mirror or with the guide
- Somatic experiencing and sensorimotor therapies
- Formal forms of psychotherapy e.g. ACT, trauma-informed

Basically anything in your toolkit, but the more competent and diverse, the more capable..