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Healing A Troubled Mind: A Personal Perspective On Victoria’s Stagnant Mental Health System

Person standing near lake

The Royal Commission’s report on the Victorian mental health system sent shockwaves throughout the State, one of which landed squarely on a patient of mine. They noted that Victoria’s mental health system is “not geared for…change”. Just to ensure we got the message, and despite a Federal Government TGA approval, my request to treat my traumatized patient with MDMA-assisted therapy was declined by our state’s regulatory authority.

To be clear, my disappointment lies not with the state government regulators, nor with the medical opinions suggesting MDMA-assisted therapy should not be used for treatment of traumatized patients (despite excellent emerging evidence that it works with little risk). I understand these opinions, though I certainly do not agree with them.

My issue is a more troublesome one. Underlying these opinions is a problem with how we practice psychiatry, which in turn reflects the alienated community in which we live. Mental health paradigms are always a reflection of the society which supports them. You see, us Australians are alienated both intra-personally (from our own emotional worlds) and inter-personally.

Our current paradigms tend to view mental illnesses in a biologically reductive way. In other words, mental illnesses are both understood and treated primarily as biological diseases (which they are not). The posters at your doctor’s rooms will teach you – depression is just like any other medical disease, such as heart-failure or emphysema. In this paradigm, entities such as addictions and depression are seen as distinct phenomena. They are treated in our current system as totally different diagnoses by entirely different teams. The alienated individual who suffers from depression and addiction is labeled with the alienating and erroneous term ‘dual-diagnosis’, which enshrines the division. Furthermore, if addictions are understood (as they are) as inherited conditions (which they are not), and primarily as brain diseases based in dysfunctional dopamine rewards circuits, they will be primarily treated as inherited brain diseases, by doctors with medications.

But what if we have got it all wrong (which we do). You see, addictions are heritable but not inherited (there is a big difference, I recommend looking it up), and the chemical dopamine in no-way explains addictions. Rather, it is the human experience of dopamine (along with numerous other chemicals) which explains addictions, suggesting that addictions are rooted in difficulties with the human experience of life, rather than the neural correlates of those experiences.

The events which lie at the root of illnesses such as addictions and depression are those which overwhelm the mind’s ability to process and integrate. We know that the presence of adverse childhood experiences is present in the majority of (if not all) people with addictions and chronic depression. But rather than seeing these conditions as consequences of trauma (which they are) and treating the underlying emotional issues (which would help), our society mistakes the symptoms (depression and anxiety) for the disease itself. We treat depression as depression and addiction as addiction and all the while we are missing the forest for the trees. The real disease is the high prevalence of trauma, alienation, and neglect in our society. After all, it is these conditions which twist and distort the mind into the contortions which fill the latest catalogues of mental illnesses.

Which brings me back to my patient. Traumatized when young, she has suffered from every diagnosis a psychiatrist’s finger can point at. She has had every treatment a medical guideline can fathom. Yet her trauma remains in place, because no-one has been able to reach it. Suddenly, on the horizon, a change is coming. Treatments like MDMA-assisted therapy appear to touch the root of the trauma, allowing individuals to process the unintegrated parts of their minds, and offer the chance of real healing. But we don’t change. Our outlooks have ossified, our diagnoses have desiccated. And all the while we suffer in our own blindness. People continue to kill themselves, and my patient will continue to suffer in silence until the Victorian Government allows me to access a new treatment which may finally bring peace to a troubled mind.

Dr Eli Kotler

MBBS MPM FRANZCP Cert. Old Age Psych. AFRACMA

Eli is a consultant psychiatrist, holds an academic position at Monash University through the Alfred Psychiatry Research Centre, and is the medical director of Malvern Private Hospital, the first addiction hospital in Australia. He is a member of the Australasian Professional Society on Alcohol and other Drugs (APSAD). Clinically, Eli is interested in the deep connections between trauma and addiction and works within a neuro-psychoanalytic framework. Eli has overseen the development of a clinical program for addictions focused on trauma, particularly developmental trauma. This has led to an interest in medication-assisted trauma therapy. Eli worked for many years researching neurodegenerative diseases and was the principle investigator on numerous trials for novel therapeutics. He is founding member of the Melbourne Neuropsychoanalytic Group and welcomes new members. Through involvement with Monash University, Eli oversees the addiction rotation for medical students.

Utilizing Eye Movement Desensitization and Reprocessing Therapy to Help Process Challenging Experiences with Psychedelics

EMDR

The last twenty years has arguably led to a renaissance of scientific investigation into the therapeutic benefits and risk of a range of psychedelics. LSD, ecstasy, psilocybin and ayahuasca that are increasing in popularity as alternative therapies used to address a host of mental health challenges [1] [2] [3]. These include anxiety, depression, trauma, addiction [4] [5], existential fear, relationship issues, addiction, obsessive compulsive disorder, and post-traumatic stress disorder [6] [7].

Psychedelics can cause profound shifts in consciousness, personal belief structures, relationships and alter the trajectory of one’s life [8]. Although psychedelics may provide you with 10 years of psychotherapy in one night this does not necessarily equate to 10 years of practical insights that can be translated and integrated easily into one’s daily life. Many people require psychological support and a range of integration practices to process these profound states of consciousness [9].

High quality psychedelic integration can help facilitate deep exploration and processing of the bio-psycho-social-cultural-spiritual and political domains of the individual. Examples of these can be found across multimodal and complementary therapies such as somatic experiencing, movement, music, nature, exercise, nutrition, acupuncture, massage, yoga, breathwork, art and creative forms of expression, rituals, prayer, meditation and psychotherapies [9] [10].

 

What is EMDR and how can it help people integrate their psychedelic experience?

The writer is the National Practice Manager at Mind Medicine Australia Psychological Support Services. One of the writer’s psychedelic integration tools in her tool kit is Eye Movement Desensitization and Reprocessing (EMDR) therapy. EMDR can be used to support psychedelic assisted psychotherapy as an integration tool. Clients safely confront material that arose during the psychedelic experience and continue to process meaning, body sensations, emotions, blocked and challenging content.

EMDR was originally designed to reduce the distress associated with traumatic memories [11]. There have been more than 30 controlled outcome studies with positive results conducted on EMDR therapy. Some of the studies show that 84%-90% of single-trauma victims no longer have post-traumatic stress disorder after only three 90-minute sessions. It is now recognized as an effective form of treatment for trauma by organizations such as the American Psychiatric Association, the World Health Organization and the Department of Defense and Australian Medicare system.

For a detailed outline of the EMDR phases and results of clinical trials refer to www.emdr.com/frequent-questions.

EMDR had expanded beyond trauma and is often used to help clients access new perspectives, improve self-esteem and to shift and expand rigid belief systems [12]. The writer has utilized bilateral stimulation, which is a left and right repetitive eye movement technique with clients requesting psychedelic integration. The client follows the therapist’s fingers and is assisted to concentrate on a distressing memory, emotion and/or challenging and dynamic psychedelic content whilst moving their eyes rapidly back and forth [13].

People naturally do bilateral stimulation every night in during REM sleep. The left to right eye movement is believed to be storing our memories from the day [14]. Retrieving a traumatic memory and following eye movements requires more working memory capacity than is available and subsequently the clients working memory is taxed. Consequently, the client is able to experience the distressing content with fewer associations with fear, anger or sadness.

As the process unfolds, the client often taps into somatic experiencing (e.g., crying, shaking, sensations in their gut, throat etc.) and one’s natural ability to locate helpful beliefs, perspectives and anchors to process and integrate the challenging experience emerge. Clients often report a sense of experiencing new insights and downloads (e.g., information, shifts in core beliefs, a new way to interpret and experience the psychedelic content). Furthermore, clients can process any left-over tensions, emotions and energetic blocks from the previous psychedelic experience; this often results in clients feeling more relaxed, grounded and a sense of ease with the psychedelic material.

Bilateral movements also happen when we walk, run, write, read, cook, play music, and when we are making art. Therefore exercise, hobbies, creative arts, and expressive arts are effective ways to help people with trauma healing and integrating challenging psychedelic experiences.

 

Can EMDR be used to support Hallucinogen-Persisting Perception Disorder?

HPPD is a very rare condition which causes a person to keep reliving the visual element of an experience caused by psychedelics. Little is known about why HPPD occurs and the specific mechanisms behind the experience. However, it should be noted that HPPD does not cause people to have full delusions [15]. HPPD flashes are typically characterized by seeing bright lights, circles, blurry patterns and various size and shape distortions [15]. Due to the persistent nature of these flashbacks and the persons inability to stop them from occurring randomly people can experience agitation, fear and anxiety [15].

 

There are two types of HPPD

Type 1: This is where people experience HPPD in the form of random, brief flashbacks.
Type 2: People with this kind of HPPD experience ongoing changes to their vision, which may come and go.

[16].

The writer has also utilised EMDR to help people who are experiencing HPPD to confront the distressing visual content, and the associated emotions and physical responses. Throughout the session the client visualizes the hallucination and what this image means for them in regard to associated negative beliefs, fear and anger. Clients can organically construct a more meaningful narrative (whilst releasing somatic movements, sounds and sensations) and often reported seeing the visual/hallucination in a new light. In so doing, clients often make the commitment to have a different relationship with the imagery post sessions (e.g., as a reminder to ground, a teacher, a cue to slow down etc.) thus integrating the psychedelic experience and overcoming anxious and fear-based states.

To date there is little research regarding the efficacy of EMDR, psychedelic integration, and/or treatment of HPPD. Future research could explore how the mechanisms of bilateral stimulation (left and right repetitive eye movement technique) and strong therapeutic rapport can support these clinical experiences.

If you would like to know more about psychedelic integration and EMDR please email alana@mindmedicineaustralia.org

 

References

[1] J. Daniel and M. Haberman, “Clinical potential of psilocybin as a treatment for mental health conditions”, Mental Health Clinician, vol. 7, no. 1, pp. 24–28, January, 2017. doi:10.9740/mhc.2017.01.024

[2] Curtis, R, Roberts, L, Graves, E, Rainey, HT, Wynn, D, Krantz, D & Wieloch, V 2020, “The Role of Psychedelics and Counseling in Mental Health Treatment”, Journal of Mental Health Counseling, vol. 42, no. 4, pp. 323–338, October, 2020. doi:10.17744/mehc.42.4.03.

[3] J. Sarris et al. “Ayahuasca use and reported effects on depression and anxiety symptoms: An international cross-sectional study of 11,912 consumers”, Journal of Affective Disorders Reports, vol. 4, 100098, pp. 1–8, 2021. doi:https://doi.org/10.1016/j.jadr.2021.100098

[4] M. Winkelman, “Psychedelics as medicines for substance abuse rehabilitation: evaluating treatments with LSD, Peyote, Ibogaine and Ayahuasca”, Current drug abuse reviews, vol. 7, no. 2, pp. 101–116, 2014. doi:10.2174/1874473708666150107120011

[5] A. Loizaga-Velder and R. Verres, “Therapeutic Effects of Ritual Ayahuasca Use in the Treatment of Substance Dependence — Qualitative Results”, Journal of Psychoactive Drugs, vol. 46, no. 1, 63–72, doi:10.1080/02791072.2013.873157

[6] M. Ot’alora et al. “3,4-Methylenedioxymethamphetamine- assisted psychotherapy for treatment of chronic posttraumatic stress disorder: A randomized phase 2 controlled trial”, Journal of Psychopharmacology, vol. 32, no. 12, pp. 1295–1307, 2018. doi:10.1177/0269881118806297

[7] M. Mithoefer et al. “Durability of improvement in posttraumatic stress disorder symptoms and absence of harmful effects or drug dependency after 3, 4-methylenedioxymethamphetamine- assisted psychotherapy: A prospective long-term follow-up study”, Journal of Psychopharmacology, vol. 27, pp. 28–39, 2013. doi:10.1177/0269881112456611

[8] R.R Griffiths et al. “Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial”, Journal of Psychopharmacology, vol. 30, no. 12, pp. 1181–1197, 2016. doi:10.1177/0269881116675513

[9] A. Garcia-Romeu and W.A. Richards, “Current Perspectives on Psychedelic Therapy: Use of Serotonergic Hallucinogens in Clinical Interventions.” International Review of Psychiatry, vol. 30, no. 4, pp. 291–316, 2018. doi:10.1080/09540261.2018.1486289.

[10] J. Guss, R. Krauseand and J. Sloshower, “The Yale Manual for Psilocybin-Assisted Therapy of Depression (using Acceptance and Commitment Therapy as a Therapeutic frame)”, 13th August 2020, [Online], Available: https://psyarxiv.com/u6v9y/

[11] F. Shapiro, (1989). Eye Movement Desensitization: A New Treatment for Post-Traumatic Stress Disorder. Journal of Behavior Therapy and Experimental Psychiatry [Online]. 20(3), pp. 211–217. Available: https://www.sciencedirect.com/sdfe/reader/pii/0005791689900256/pdf

[12] Griffioen, B.T. Van Der Vegt, A.A. De Groot, I.W and De Jongh, A, “The effect of EMDR and CBT on low self-esteem in a general psychiatric population: A randomized controlled trial” Frontiers in Psychology, vol. 8, 1910, pp. 1–12, November, 2017. doi:10.3389/fpsyg.2017.01910

[13] F. Shapiro, “Efficacy of the Eye Movement Desensitization Procedure in the Treatment of Traumatic Memories” Journal of Traumatic Stress, vol. 2, no. 2, pp. 199–223, 1989. doi:10.1002/jts.2490020207

[14] F. Shapiro, Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press, 2001.

[15] J. Halpern and H. Pope “Hallucinogen persisting perception disorder: what do we know after 50 years?”, Drug and Alcohol Dependence, vol. 69, no. 2, pp. 109–119, 2003. doi:10.1016/S0376–8716(02)00306-X

[16] L. Orsolini et al. “The ‘Endless Trip’ among the NPS Users: Psychopathology
and Psychopharmacology in the Hallucinogen-Persisting Perception Disorder. A Systematic Review”, Frontiers in Psychiatry, vol. 8, pp. 1–10, November, 2017, doi:10.3389/fpsyt.2017.00240

Dr Alana Roy

Ph. D Psychology, B. A Social Work (MHSW)

Dr Alana Roy is a psychologist, social worker and therapist and has spent the last 13 years working in mental health, suicide prevention, trauma, sexual abuse, family violence and the disability sector. Alana has worked with borderline personality and dissociative identity disorder in various roles in the community such as: Rape Crisis Centres with victims of ritual abuse, childhood and adult sexual assault, supporting women in the sex industry, survivors of human trafficking and now as a psychedelic integration specialist.

Alana focuses on harm minimisation, community and connection. She is dedicated to psychedelic-assisted psychotherapy and plant medicines. She has engaged with, and provides integration therapeutic support services for communities across Australia. Alana works at several universities as a Research Fellow and supervisor of students on placement. Alana passionately advocates for public policy, community education and legislative changes so that these treatments are regulated and supported by a strong, connected and skilled sector.

Psychedelic Healing Stories: Michael Raymond

Abstract

 

My name is Michael Raymond. I served in the Airforce for 16 and a half years, serving initially as an Avionics Technician, working on Fighter Jets such as the F-111 and F/A18F Super Hornet. 10 years into my career I commissioned to become an Electrical Engineer Officer and worked on a number of projects, as well as what many refer to as the Australian version of the Pentagon near Canberra. As a side job I also became a Motorcycle Instructor and by the end of my Defence career was regularly coaching the fastest rider group at the Sydney Motorsport Park racetrack. My other passion was martial arts: training and fighting in Boxing, MMA, Shaolin Kung Fu and Brazilian Jiu Jitsu.

In late 2018, I was medically retired after battling with mental and physical illness, including, Major Depression, Anxiety Disorders and Post Traumatic Stress Disorder. I had been in a state of suppression following some near-death experiences both in and out of service, one including an engine explosion during a flight with the US Airforce, narrowly avoiding impact with the ground and involving an evacuation of Waikiki beach, Hawaii. I managed all my struggles by working myself harder, training harder, pushing my limits more on the motorcycle and drinking on the weekends to blow off the steam. I was also prescribed antidepressants and sleeping medication, some of which I later found out was above the recommended maximum dosage.

Prior to my personal research and experiences with Psychedelic Therapies, I held many negative assumptions and judgements regarding the use of psychedelics which deterred me from any consideration of their healing qualities. I believed they were for party goers or drug abusers who had little interest in being a productive member of society or successful within the professional workspaces. I also had a preconceived notion that they were dangerous, addictive, or may even cause a mental breakdown. It is funny to look back on now.

I also had little understanding of my own sub-conscious behaviours and beliefs, which prevented me from exploring potential avenues for healing, self-love, self-growth and acceptance. I was able to keep everyone at an arm’s length, avoid truly dealing with my deepest fears, traumas, lack of self-worth and unknowingly perpetuate a decline into depression and anxiety, to the point of feeling like suicide was my only reprieve. It was in that darkness and in a failing relationship, my partner at the time convinced me to investigate psychedelic plant medicines and their success with helping people recover from severe depression, as well as other mental illnesses. I was intrigued enough to max out the credit cards and book my flights to South America the next month.

My first introduction to Psychedelic Plant Medicines was Ayahuasca and San Pedro at a healing retreat. We had to follow a regimented routine of preparation both mentally and dietary in order to prepare for the ceremonies with the traditional South American Shaman. This included stopping my anti-depressant medication which had terrible side effects, and I was severely dependent on them for mental and emotional stability. I was very sceptical from the start and held little hope for anything significant to change.

Taking Ayahuasca was life changing for me. I was humbled and vulnerable in the ceremony. The medicine seemed to have a mothering energy, disciplining me with cold hard and undeniable truths but also holding me and supporting me through the emotions which inevitably followed when having them highlighted. I had always struggled to cry and could not understand why a man would show what I perceived as weakness. In these moments of nausea and confronting truths, I let go of my grip of control and had a much-needed release of deep sadness I had been holding for far too long.

The next day I felt renewed. I found my sense of humour which my friends and partner had missed. I was laughing and felt joy and peace with the world for the first time in years. It felt like the weight of the world was no longer on my shoulders. The following ceremonies offered me healing beyond what I could have imagined, they all felt like I was conversing with the wisest parts of myself or some spiritual teacher such as Eckhart Tolle or Alan Watts. It was truly life-changing, and my depression seemed to evaporate. I could see the beauty in living and my self-worth no longer felt conditional. Someone had pressed the reset button on my brain. I was more present and felt this peace within me, the type I only ever glimpsed after riding motorbikes on the racetrack at full speed. My ADHD mind was silenced! It was as if I had defragmented my mind and it was now running beautifully again.

Like any healing modality there is no magic pill to instantly resolve chronic and complex traumas; rather, the healing process is often in layers. On my return from South America this proved true as I faced new and emerging layers of my trauma. Thankfully, I was free from my dependence on anti-depressants after 10 years on them and had shifted the stigma around psychedelic plant medicines. I also now knew I had a way to shift my perspective when my internal program of pessimism, lack of hope and/or purpose had run me into a dead negative dead-end once again. Journeying with plant medicines had revealed my intrinsic worth purely from my existence, and that life is worth living.

After my initial experiences I started to understand that taking the psychedelic plant medicines was only one aspect of the healing. The integration, support, intention and understanding of the medicine all contributed to the success of my recovery from cannabis dependence and mental illness in the long term. When combined with exercise, purpose, community engagement, diet and other healthy lifestyle choices, the results were drastically improved, and I was astonished at how powerfully healing these journeys were.

Having experienced both the Western medicine (anti-depressants, talk therapy psychotherapy) and Psychedelic Plant Medicine approach to my mental health, I reflected on the results. I cannot speak for everyone of course, but for me the difference was significant to the point of wanting to share my story.

If we were to imagine myself as a sick tree, the anti-depressants solution would be in line with building a greenhouse around the tree. It is an externally dependent relationship that did not improve my resilience and only sheltered me from feeling the full brunt of life’s weather patterns. The Psychedelic Therapies approach, however, felt like diving deep into the soil to uncover the origin of what may be causing the sickness; then finding that fundamental issue and taking action to improve the soil and health of the roots system. In doing so improving its resilience. I felt exactly this, more resilience and self-empowerment to take on what life throws at me.

With my community of friends and three of my bothers having served in the military, I am aware there will be many barriers to shifting the stigma around Psychedelic Therapies. I do, however, believe that therapeutic use of Psylocibin and MDMA are a godsend for Veterans who may be dealing with complex traumas, such as PTSD and other mental health issues. If rescheduled, I have no doubt about the positive effects organisations such as Mind Medicine Australia will have on the mental health of so many of those who are suffering within the veteran and wider community. So that they are no longer just surviving life, they are thriving.

On the Need for a Bioethics of Psychedelic Psychotherapy: A Few Preliminary Challenges

Psychotherapy assisted by psilocybin, a naturally occurring compound in ‘magic mushrooms’, has recently received ‘Breakthrough Therapy’ status from the FDA, in recognition of the substantial benefits witnessed in clinical trials investigating treatment-resistant depression. A number of trials of psilocybin-assisted therapy are also underway for major depressive disorder, one of the most significant causes of disability worldwide (1), and the modality has the potential to support the long-term cessation of tobacco- addiction to which kills some 5,000,000 people per year – more effectively than any other available treatment (2). As such, it seems certain that therapy assisted by psilocybin and other psychedelics will receive significant interest from the biotechnology sector, psychiatry research and public health policy over the coming years.

However, for all its apparent promise, psychedelic-assisted psychotherapy remains extremely under-researched from a bioethical perspective. This is a serious shortcoming, and with licensing around the corner, it is now also an urgent problem. Against the backdrop of regular healthcare, the experience of psychedelic-assisted psychotherapy, its mechanisms of action, and its downstream consequences, are all pretty unusual. So perhaps unsurprisingly, pre-existing bioethical accounts of mental health treatments are challenged by this new treatment along a number of directions.

A full account of potential ethical challenges embedded in psychedelic-assisted psychotherapy, and a clear articulation of the clinical and policy choices that can defuse these challenges, will be a vital component in establishing psychedelic-assisted psychotherapy within the mainstream of healthcare.  The clinical promise of psychedelics is only part of the story – the success of a technology or treatment depends not just on its efficacy, but also on a slew of social facets of the culture it is embedded in. Not only do we want to have our ethical house in order before there is widespread uptake of psychedelic psychotherapy, but getting the ethics right will also facilitate widespread uptake.

Suppose we forge ahead without deep, critical ethical engagement, and we overlook something that we could have fixed, that leaves patients feeling let down, violated, or otherwise not properly considered. Not only would that amount to a failure of a physician’s duty of care, it would cost the psychedelic psychotherapy movement itself: maybe the loss of the public goodwill that has been so hard to build, maybe a series of litigation actions that make treatment providers, insurers, and decision-makers in other jurisdictions considerably less enthusiastic about facilitating psychedelic psychotherapy, ultimately meaning that many other people who could benefit would miss out. By seeking out potential problems now, and thinking about how to manage or accommodate them, we thereby minimise these risks.

A useful prism through which to understand some of these bioethical challenges is the tranche of unusual, non-clinical ‘side-effects’ of psychedelic experiences. Alongside the target clinical effect, psychedelic experiences can increase prosocial disposition, affect attitudes towards death, enhance aesthetic appreciation and improve patients’ sense of personal well-being and life satisfaction (3,4,5,6). Perhaps most interestingly, they can induce mystical experiences of long-lasting spiritual significance (7), and produce robust changes to religious belief (8) and personality (9,10). Such experiences appear to be a feature, rather than a bug, of psychedelic psychotherapy, with the intensity of the mystical experience correlating with the extent of clinical benefit. Of potentially wider significance, they might cause long-term changes to political values and, perhaps, behaviours (3, 11).

The focus on the therapeutic potential of psilocybin-assisted therapy has meant that the significance of these non-clinical outcomes has been underestimated. But their importance could hardly be overstated: even where psilocybin-assisted psychotherapy proves an effective treatment, participants can report this clinical success as one of the least important effects of the experience, when compared to the other changes (6). Given the unique power that this treatment has to influence facets of a patient’s character that cut to the very core of their identity, it is imperative that the breadth of its potential impact is carefully and critically examined. With the knowledge of these changes, clinicians who conduct psychedelic-assisted psychotherapy are knowingly changing people in a fundamental sense, far beyond the bounds that are usually seen within medicine.

The reflexive response to such ‘side-effects’ from some strains of medical ethics would be to square them away by appeal to the dominance of autonomously given, informed consent: so long as a patient is adequately briefed of the possible consequences of a treatment, their decision to continue with a treatment is conclusive. But the intuitive understanding of informed consent faces a number of challenges with psychedelic-assisted psychotherapy. The superficial challenge is that the very nature of the mystical experience induced by psychedelics runs contrary to the mainstream understanding of informed consent. A core characteristic of mystical experiences is that they are ineffable – inexpressible or incomprehensible in linguistic terms. Insofar as patient briefing takes place linguistically, securing informed consent will not be straightforward.The deeper problem with understanding informed consent in the context of psychedelic medicines, is to find a secure standpoint from which to make judgments of autonomy.  Commonplace advice to people considering whether to undertake a medical intervention, is to choose whichever option leads to a better quality of life, all things considered. But judgments about quality of life are necessarily dependent on a system of values, and values themselves can be changed by psychedelic-assisted psychotherapy. If you know your perspective on life may radically change following psilocybin, how do you adjudicate between your current evaluation of prospective quality of life after psilocybin, and your likely post-psilocybin evaluation of quality of life after treatment? (12) This is not a mere philosophical puzzle. How might we counsel a prospective patient considering psilocybin-assisted therapy who has debilitating depression and is a fervently proud, card-carrying materialist atheist. From this patient’s perspective, coming out of treatment believing in God or some sense of Ultimate Reality may be more horrendous to consider than continued clinical suffering. But, were this patient to proceed with treatment and have a religion-inducing ‘God-encounter experience’ (8), they would not have nearly as negative an evaluation of this newfound belief, after the fact.

With the non-clinical changes following psilocybin administration come questions of authenticity, self-conception, and self-development. Psychedelics are far from the first treatment to challenge these notions in psychiatry. The expansion of SSRI prescription in the 1990s led to worries about ‘cosmetic psychopharmacology’ and patients ‘losing themselves’ to Prozac (13,14) . The personality characteristics and outlooks that develop in users of SSRIs do not truly belong to them, it is argued, given their lack of connection to the patient’s overall narrative arc and  environment (14). Prima facie, some drivers of change seem more authentic than others. Changes that come about from slower-acting, experiential factors (a period of missionary work, the raising of a child) seem intuitively more plausibly ‘authentic’ than those that come about by faster acting, exogenous, artificial factors clearly linked to neurological disruption (a railroad spike through the left frontal lobe, a six week course of SSRIs). But psychedelic-assisted psychotherapy refuses categorisation under this schema. Although the changes are detectable rapidly, and come about following the administration of a drug with a dramatic acute and post-acute effect on brain function (15,16), psychedelic experiences are, nonetheless, experiences. Indeed, they are experiences that tend to be ranked among the most meaningful in a patient’s life (3), making them more credible candidates for authentically cohering with, or indeed shaping, the narrative arc of a patient’s life. Further exploration and elaboration of these ideas, as well as being philosophically interesting, can usefully feed into public narratives about the meaning and significance of clinically administered psychedelic experiences: it is a strange medical treatment indeed that returns patients to their loved ones not only freed from their tobacco addiction, but also with a perceptibly different personality, a penchant for spending time in nature and art galleries, and a newfound spirituality (2, 6). A clear articulation of the authenticity of these changes, if they can be understood as a natural and comprehensible expression of continuity, rather than an exogenously-imposed transfiguration, could serve to assuage suspicion or mistrust of psychedelic medicine among patients’ loved ones, and the wider public.

These are just a few of the surprising ethical quandaries that lurk within psychedelic medicine. While some of the challenges may seem theoretical or philosophical, the sharp end of each of them is to be found in the clinic, requiring sincere and critical reflection on the part of the psychedelic research community, and perhaps ultimately incorporated into the soon-to-be-expanding training programmes for therapists.

 

By Eddie Jacobs

 

References

1.     https://www.who.int/news-room/fact-sheets/detail/depression

2.     Johnson, M. W., Garcia-Romeu, A., & Griffiths, R. R. (2017). Long-term follow-up of psilocybin-facilitated smoking cessation. The American journal of drug and alcohol abuse, 43(1), 55-60.

3.     Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D., …& Klinedinst, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of psychopharmacology, 30(12), 1181-1197.

4.     Ross, S., Bossis, A., Guss, J., Agin-Liebes, G., Malone, T., Cohen, B., … & Su, Z. (2016). Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. Journal of psychopharmacology, 30(12), 1165-1180.

5.     Garcia-Romeu, A., R Griffiths, R., & W Johnson, M. (2014). Psilocybin-occasioned mystical experiences in the treatment of tobacco addiction. Current drug abuse reviews, 7(3), 157-164.

6.     Noorani, T., Garcia-Romeu, A., Swift, T. C., Griffiths, R. R., & Johnson, M. W. (2018). Psychedelic therapy for smoking cessation: qualitative analysis of participant accounts. Journal of Psychopharmacology, 32(7), 756-769.

7.     Doblin, R. (1991). Pahnke’s “Good Friday experiment”: A long-term follow-up and methodological critique. Journal of Transpersonal Psychology, 23(1), 1-28.

8.     Griffiths, R., Hurwitz, E. S., Davis, A. K., Johnson, M. W., & Jesse, R. (2019). Survey of  subjective” God encounter experiences”: Comparisons among naturally occurring experiences and those occasioned by the classic psychedelics psilocybin, LSD, ayahuasca, or DMT. PloS one, 14(4), e0214377.

9.     MacLean, K., Johnson, M., & Griffiths, R. (2011). Mystical experiences occasioned by the hallucinogen psilocybin lead to increases in the personality domain of openness. Journal of Psychopharmacology, 25(11), 1453-1461.

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