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Psychedelic Hedonism — The Ethics Of Psychedelic Therapy

Psychedelic trip

INTRODUCTION

Psychedelic-assisted psychotherapy is a novel approach to treating mental illness which has recently been (re)gaining significant public and scientific attention. Current clinical trials are demonstrating promising results which suggest that not only might these medicines be effective at treating a wide array of mental illnesses[1], but in some instances they might be more effective than currently available treatments[2]. However, despite the growing body of empirical work regarding the efficacy of psychedelic-assisted psychotherapy, the socio-cultural history of these compounds along with their unique psychological effects raises a host of normative ethical questions which need to be addressed to ensure that the return of psychedelics to western psychiatry is done in a responsible and ethically sound manner. “Prescribing Meaning: Hedonistic Perspectives on the Therapeutic Use of Psychedelic-Assisted Meaning Enhancement”[3] is a paper which aims to begin the task of addressing the ethics of psychedelic-assisted psychotherapy. The paper does so by applying the moral theory of Hedonism to analyse the ethical justifiability of psychedelic-assisted psychotherapy.

 

HEDONISM

Hedonism is a well-known type of consequentialist moral theory. In other words, Hedonism is a moral theory which places moral value in the outcomes of actions[4]. This means that for an act to be considered moral, said act must produce outcomes which are of moral value. So then, according to Hedonism, what outcomes are of moral value?

Hedonism or Hedonist moral theories are moral theories which place moral value in the outcomes of pain and pleasure[5]. That is to say that according to Hedonism, an act is morally good if it produces more pleasure than pain, or morally bad if it produces more pain than pleasure. There are some nuances of Hedonism which are explored further in the paper, and which subdivide Hedonist moral theory further into Qualitative Hedonism, Quantitative Hedonism, Hedonistic Utilitarianism, and Hedonistic Egoism.

 

PSYCHEDELICS AS MEANING ENHANCERS

It has been suggested that psychedelics exert their effects via a phenomenon known as the meaning-response[6]. The meaning-response refers to the body’s ability to respond physiologically to perceived meaning or symbols in the environment. For example, when someone takes a pill believing it will heal them — even if it has no pharmacologically active component (e.g. a sugar pill) — the body responds in such a manner which is in turn conducive for healing, as the very act of taking a pill is symbolically active[7]. That is to say that even though there are no chemically active ingredients in the pill, the very action of taking a pill carries certain symbolic connotations which lead to physiological changes in the body that change the body in ways which lead to health. This ability of the body to heal itself via mere symbols of healing might initially sound far-fetched, however it is a very well recognised phenomenon, so much so that the scientific community controls for this effect in its research designs — where it is perhaps better known as the placebo effect.

An important thing to note here is that the proposed mechanism of psychedelics as meaning enhancers is not saying that the effects of psychedelic-assisted psychotherapy are merely due to placebo. But rather the same mechanism which gives rise to the placebo effect also underlies the therapeutic effects of psychedelic-assisted psychotherapy. So how is this possible? It is proposed that during psychedelic states of consciousness the perception of meaning is enhanced. That is to say that psychedelics alter the world such that there is a general increase of ‘meaningfulness’ in the things which are experienced. This extra meaningfulness, when experienced in a therapeutic set and setting, results in an increased perception of therapeutic meaning (i.e. symbolically active meaning which is conducive for healing). This enhanced perception of therapeutic meaning leads to a stronger meaning-response, such that the body/mind of the person undergoing psychedelic-assisted psychotherapy will respond with a host of physiological/psychological sequalae conducive for healing. In other words, psychedelic-assisted psychotherapy heals by increasing the ‘meaningfulness’ of experience in such a way that leads to a dramatically increased meaning-response.

 

ETHICS

This is all very academically interesting, but how does this relate to the ethics of psychedelic-assisted psychotherapy? Well, the proposed mechanism of psychedelics as meaning enhancers raises the following ethical question: is it ethically justifiable to pharmacologically enhance the perception of meaning in order to heal patients?[6]. As was explored above, Hedonism would justify pharmacologically increasing the perception of meaning in order to heal patients so long as doing so led to more pleasure than pain. As is explored in greater deal in “Prescribing Meaning: Hedonistic Perspectives on the Therapeutic Use of Psychedelic-Assisted Meaning Enhancement”[3] the current literature on the effectiveness of psychedelic-assisted psychotherapy, its relative safety, as well as the epidemiology and morbidity of mental illness, would suggest that the introduction of psychedelic-assisted psychotherapy to psychiatry would produce more pleasure than pain.

But what if there is more to morality than pain and pleasure? This is the question that Robert Nozick asks people to consider when he presents his famous anti-Hedonist thought experiment: The Experience Machine[8]. To put his thought experiment simply, Nozick invites readers to imagine a machine which creates a completely realistic simulated reality. Before entering the Experience Machine people are allowed to select to kinds of experiences they want to have. Once inside, people become unaware that they have been wired up to the Experience Machine. According to Nozick, if pain and pleasure were the only relevant moral consequences, people would be morally obliged to enter the Experience Machine forever and live a life full of simulated pleasures. Nozick assumes that most readers would find this conclusion unappealing. Hence, Nozick argues that there is more to morality than just pain and pleasure. Nozick suggests that what also matters in determining morality is contact with an actual reality[8].

It has been suggested that psychedelic states of consciousness are analogous to the Experience Machine in Nozick’s thought experiment, and therefore represent a false reality. This analogy of psychedelic states representing a simulated false reality poses a further ethical challenge: are the effects of psychedelic-assisted psychotherapy ethically justifiable if they are produced by contact with a false reality? Two responses are suggested to such a question. Firstly, emerging research on the neuroscience of psychedelic states of consciousness could suggest that psychedelic states do not represent a false reality, but rather a different way of experiencing actual reality. Secondly, even if psychedelic states do represent a false reality, the use of psychedelic-assisted psychotherapy can still be justified in cases of extreme suffering, where concerns about contact with an actual reality are outweighed by extreme reductions in pain — e.g. treatment resistant patients.

 

CONCLUSION

The psychedelic renaissance is providing hope for many who have not responded to currently available psychiatric treatments. However, along with this hope comes a significant burden of responsibility for those researching and advocating for the medicalisation of psychedelics. Those living with mental illness are among some of the most vulnerable patient populations in society. Therefore, it is of utmost importance that the field of psychedelic science proceed with critical reflection to ensure that the work being done is ethically sound and not detrimental to those it is trying to serve. It is hoped that by beginning the process of applying moral theories to the experience of psychedelic-assisted psychotherapy, more discussion will ensue regarding some of the ethical challenges that this promising new paradigm presents.

 

REFERENCES

1. Reiff CM, Richman EE, Nemeroff CB, Carpenter LL, Widge AS, Rodriguez CI, Kalin NH, McDonald WM, Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research. Psychedelics and psychedelic-assisted psychotherapy. American Journal of Psychiatry. 2020 May 1;177(5):391–410.

2. Davis AK, Barrett FS, May DG, Cosimano MP, Sepeda ND, Johnson MW, Finan PH, Griffiths RR. Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial. JAMA psychiatry. 2020 Nov 4.

3. Miceli McMillan R. Prescribing meaning: hedonistic perspectives on the therapeutic use of psychedelic-assisted meaning enhancement. Journal of Medical Ethics Published Online First: 04 November 2020. doi: 10.1136/medethics-2020–106619

4. Sinnott-Armstrong W. The Stanford encyclopedia of philosophy: Consequentialism. Available: https://plato.stanford.edu/entries/consequentialism/

5. Moore A. The Stanford encyclopedia of philosophy: Hedonism, 2019. Available: https://plato.stanford.edu/entries/hedonism/

6. Hartogsohn I. The meaning-enhancing properties of psychedelics and their mediator role in psychedelic therapy, spirituality, and creativity. Front Neurosci 2018;12:129.

7. Moerman, D. Meaning, Medicine and the “Placebo Effect”. Cambridge; New York, NY: Cambridge University Press, 2002.

8. Nozick R. Anarchy, state, and utopia. New York: Basic Books, 1974

Medically Assisted Psychotherapy in a Global Context

 

World from space

Written by Amelia French and Dr Alana Roy

Psychedelics and plant medicines have been used around the world since early humanity for spiritual, ritual, divination and recreational purposes.[1] Indigenous cultures used plants as medicines for millennia and many cultures carry on this tradition today.[2] Despite the growing evidence for use of psychedelics by humans as modern-day medicine for mental health disorders, they were abruptly made illegal to supply and possess by the United Nations convention in 1971 as a result of President Nixon’s War on Drugs.[3] Studies suggest psychedelics could be a breakthrough therapy for mental health issues including depression, anxiety, addiction, Obsessive Compulsive Disorder, and Post Traumatic Stress Disorder through their ability to work on a deep emotional as well as biological level. [4] Currently statistics of Mental Health in Australia is one in four people.[5] Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease.[6] There needs to be innovation and change for the treatment of mental illnesses. MMA are advocating for the therapeutic use of Psilocybin and MDMA to support people with treatment resistant depression and Post traumatic stress disorder, respectively.

Current pharmacotherapy treatments for depression and anxiety work in 20–40% of cases.[7] Psilocybin has been shown to alleviate depression in 67% of patients within one to two doses even where standard treatments have failed.[8] Current pharmacotherapy has even lower efficacy in the treatment of PTSD with success rates of around 20%, MDMA has been shown lead to remission from PTSD in 78% of cases where standard treatments have not worked.[9] Current treatments such as antidepressants must be taken every day for months, often years. With medicine-assisted psychotherapy, patients frequently experience long-lived reductions in symptoms within a few single dose sessions.

Around the globe we are seeing countries take the lead in medically assisted psychotherapy with the legalization or decriminalization of psychedelics with logical, research-based, and tolerant policies on psychoactive substances. There are currently no countries in which psychedelics are regulated and approved medicines. Also, psilocybin is legally available in the Netherlands and both psilocybin and MDMA are decriminalized for personal use in Portugal, Czech Republic and several countries in South America.[10] When we explore the research into countries with decriminalization of MDMA and Psilocybin from across Europe there is statistics to show the positive outcomes for mental health.

“When delivered safely and professionally, psychedelic therapy holds a great deal of promise for treating some very serious mental health conditions.” Dr Robin Carhart-Harris Head of the Centre for Psychedelic Research

Portugal allows the use of psychedelic drugs through the decriminalization of drugs since 2001 and opted for a harm minimization approach to drug use.[11] Portugal have found that removing criminal penalties for personal drug possession did not cause an increase in levels of drug use but rather drug use is dependent on social and cultural factors and trends.[12] Decriminalization allowed space for research into mental health, supporting those with addictions better access to services by reducing the taboo and shame around drug use.[13] The Dutch drug policy is also driven by the idea that each person should make informed decisions on matters of their own health and recognize that drug policy is also a social issue.

The Dutch are world-renowned for their more logical, research-based, and tolerant policies on psychoactive substances. However, this does not mean psychedelics are completely legal in the Netherlands. Just like many other countries, the Dutch government classifies some drugs, including certain psychedelics, as illegal substances however the use of psychedelics is regulated. Drug policy in the Netherlands is guided by the principle that suppressing drug use and having a blanket ban on all drugs does not make mental health illnesses associated with drug use disappear but quite the opposite, makes mental health outcomes worse.[14] This is reflected in literature that mental health issues become far more difficult to minimize and control without appropriate education and prevention of drug abuse disorders is one of the most effective ways to reduce the impact of mental health on individuals and wider society, this is done through education, effective treatments and reducing cultural stigma or shame around mental health. Mental health disorders are exacerbated through lack of recognition to research and suppression through drug policy.[15] Psychedelic assisted therapies can positively impact mental health outcome and has shown to be safe in therapeutic contexts.[16] The Netherlands are embracing medically assisted psychotherapies through clinics, which are leading a movement to transform the way people approach emotional, cognitive, and spiritual well-being, through safe and legal medically assisted psychotherapy backed by research.[17]

Switzerland have allowed the legal therapeutic use of LSD and MDMA for treatment of post-traumatic stress disorder and depression when used alongside non-drug psychotherapy sessions with an experienced practitioner.[18] In Switzerland, limited medical use of non-registered drugs, or compassionate use is available from psychiatrists to prescribe MDMA for therapeutic use in conjunction with talk therapy for the treatment of trauma disorders.[19] Subjects with chronic, treatment-resistant posttraumatic stress disorder experienced clinically meaningful improvements and no evidence of harm after participating in a Swiss study evaluating MDMA-assisted psychotherapy.[20] The field of medicine-assisted psychotherapy needs to be driven by evidence-based studies to inform policies and law. Through evidence-based research we can effectively improve the quality of people’s lives and to promote healthier societies through policy reform of medicine-assisted psychotherapy. Mind Medicine Australia are advocating for clinical changes to bring these new innovative mental health treatments to Australia. Law is socially constructed by the culture and social influence, and it is ever changing with new research and knowledge emerging. Psychedelics have been shown to have significant therapeutic potential which is seen to outweigh ill-informed anti-drug laws.[21]

There is significant evidence to support the safe use of medicine-assisted psychotherapy when used in a clinically controlled space and appropriate screening is conducted.[22] Research suggests that there is no link between the use of psychedelics and the development of mental illnesses.[23] Further to this, there has been no negative health outcomes associated with the use of psychedelic medicines.[24] However, psychedelic use is highly context dependent and we only advocate for clinical use of psychedelics.

Mind Medicine Australia is an Australian registered charity (with DGR-1 status) seeking to broaden the treatment paradigm available to medical practitioners and their patients and improve treatment effectiveness by establishing, safe, accessible and effective Medicine-Assisted Psychotherapy in Australia for major Mental Illnesses.

 

References

[1]. Nicola Bragazzi et al., ‘Ancient Shamanism and Modern Psychotherapy: From Anthropology to Evidence-Based Psychedelic Medicine,’ Cosmos and History: The Journal of Natural and Social Philosophy 4, no. 1 (2018): 142, https://cosmosandhistory.org/index.php/journal/article/view/688; David Smith, ‘The Role of the Journal of Psychedelic Drugs in the Evolution of Psychedelic Medicine,’ Journal of psychoactive drugs 51, no. 2 (December 2019): 98–101, https://doi.org/10.1080/02791072.2019.1589607

[2]. Richard Doblin, Merete Christiansen, Lisa Jerome, and Brad Burge, ‘The Past and Future of Psychedelic Science: An Introduction to This Issue,’ Journal of psychoactive drugs 51, no. 2 (April 2019):93–97, https://doi.org/10.1080/02791072.2019.1606472; Smith, ‘The Role of the Journal of Psychedelic Drugs,’ 98–101; Michael Winkelman, ‘Shamanic guidelines for psychedelic medicine,’ in Psychedelic medicine: New evidence for hallucinogenic substances as treatments, ed. Thomas Roberts (Connecticut: Praeger Publishers, 2007), 143–168, https://www.academia.edu/4165474/Shamanic_Guidelines_for_Psychedelic_Medicines

[3]. Doblin, Christiansen, Jerome, and Burge, ‘The Past and Future of Psychedelic Science,’ 93–97; Smith, ‘The Role of the Journal of Psychedelic Drugs,’ 98–101

[4]. Tanya Calvey and Fleur Howells, ‘An introduction to psychedelic neuroscience,’ Progress in Brain Research 242, no. 1 (2018): 1–23, https://doi.org/10.1016/bs.pbr.2018.09.013

[5]. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of Results. Canberra: ABS, 2008. https://www.abs.gov.au/statistics/health/mental-health/national-survey-mental-health-and-wellbeing-summary-results/latest-release

[6]. World Health Organization. Prevention of Mental Disorders Effective Interventions and Policy Options. France: WHO, 2004. https://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf?ua=

[7]. Courtney Hutchison and Sara Bressi, ‘Social Work and Psychedelic‑Assisted Therapies: Practice Considerations for Breakthrough Treatments,’ Clinical Social Work Journal (January 2020), https://doi.org/10.1007/s10615-019-00743-x

[8]. Mind Medicine Australia. A new paradigm for mental health. Australia: MMA, 2020. https://mindmedicineaustralia.org/wp-content/uploads/2020/10/Mind-Medicine-Australia-EBook-09102020-small.pdf

[9]. Smith, “The Role of the Journal of Psychedelic Drugs,” 98–101

[10]. Jeff Lebowe, ‘A Global Guide to Where Magic Mushrooms and Psilocybin Are Legal or Decriminalized,’ Mary Jane, May 29, 2020, https://merryjane.com/culture/a-global-guide-to-where-magic-mushrooms-and-psilocybin-are-legal-or-decriminalized

[11]. David Bronner, ‘The Unified Field Theory of Psychedelic Integration and Portugal Style Decriminalization,’ Multidisciplinary Association for Psychedelic Studies 30, no. 1 (2020): 14–19, https://maps.org/news/bulletin/articles/439-bulletin-spring-2020/8126-the-unified-field-theory-of-psyhedelic-integration-and-portugal-style-decriminalization

[12]. Linnae Ponté, ‘Decriminalization and Harm Reduction in Portugal: An Interview with Dr. João Goulão,’ Multidisciplinary Association for Psychedelic Studies 25, no. 1 (2015): 18–21, https://maps.org/news/bulletin/articles/387-bulletin-spring-2015/5671-decriminalization-and-harm-reduction-in-portugal-an-interview-with-dr-jo%C3%A3o-goul%C3%A3o

[13]. Scott Bernstein, Emily Amirkhani, Dan Werb, and Donald MacPherson, ‘The regulation project: Tools for engaging the public in the legal regulation of drugs,’ International Journal of Drug Policy 86, no. 1 (December 2020):102949, https://doi.org/10.1016/j.drugpo.2020.102949

[14]. Bronner, ‘Unified Field Theory’

[15]. Bernstein, Amirkhani, Werb, and MacPherson, ‘The regulation project,’ 102949; WHO, Prevention of Mental Disorders

[16]. Calvey, and Howells, ‘Intro to psychedelic neuroscience,’ 1–23.

[17]. Bernstein, Amirkhani, Werb, and MacPherson, ‘The regulation project,’ 102949

[18]. Peter Gasser, ‘Psychedelic Group Therapy in Switzerland,’ Multidisciplinary Association for Psychedelic Studies 27, no. 1 (2017): 28–29, https://maps.org/news/bulletin/articles/420-bulletin-spring-2017/6622-research-update-psychedelic-group-therapy-in-switzerland

[19]. WHO, Prevention of Mental Disorders

[20]. WHO, Prevention of Mental Disorders

[21]. David Nichols, ‘Psychedelics,’ Pharmacological Reviews 68, no. 2 (April 2006):264–355, https://doi.org/10.1124/pr.115.011478; Tingying Chi and Jessica Gold, A review of emerging therapeutic potential of psychedelic drugs in the treatment of psychiatric illnesses,’ Journal of the Neurological Sciences 411, no. 1 (Jan 2020): 116715, https://doi.org/10.1016/j.jns.2020.116715

[22]. Jacob Aday et al., ‘Long-term effects of psychedelic drugs: A systematic review,’ Neuroscience and Biobehavioral Reviews 113, no. 1 (June 2020): 179–189, https://doi.org/10.1016/j.neubiorev.2020.03.017

[23]. Teri Krebs and Pål-Ørjan Johansen, ‘Psychedelics and Mental Health: A Population Study,’ PLoS ONE 8, no. 8 (August 2013): 1–9, https://doi.org/10.1371/journal.pone.0063972

[24]. Krebs and Johansen, ‘Psychedelics and Mental Health,’ 1–9

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 and 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 Centers 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.

Alana utilises a range of therapies such as emotion focused therapy, Eye Movement Desensitization and Reprocessing (EMDR), cognitive-behavioural therapy, acceptance and commitment therapy and mindfulness and meditation approaches.

In Alana’s spare time she is kept busy by her young sons, her love of travelling the world, and connecting with the diverse and creative medicine community.

Amelia French

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.

10.  Erritzoe, D., Roseman, L., Nour, M. M., MacLean, K., Kaelen, M., Nutt, D. J., & Carhart‐Harris, R.L. (2018). Effects of psilocybin therapy on personality structure. Acta Psychiatrica Scandinavica,138(5), 368-378.

11.  Lyons, T., & Carhart-Harris, R. L. (2018). Increased nature relatedness and decreased authoritarian political views after psilocybin for treatment-resistant depression. Journal of Psychopharmacology, 32(7), 811-819.

12.  Schick, F. (1997). Making choices: A recasting of decision theory. Cambridge University Press.

13.  Kramer, P. D., & Kramer, P. D. (1994). Listening to prozac. London: Fourth Estate.

14.  Elliott, C. (1998). The tyranny of happiness: Ethics and cosmetic psychopharmacology. Enhancing human traits: Ethical and social implications, 177-188.

15.  Carhart-Harris, R. L., Erritzoe, D., Williams, T., Stone, J. M., Reed, L. J., Colasanti, A., … & Hobden, P. (2012). Neural correlates of the psychedelic state as determined by fMRI studies with psilocybin. Proceedings of the National Academy of Sciences, 109(6), 2138-2143.

16.  Carhart-Harris, R. L., Roseman, L., Bolstridge, M., Demetriou, L., Pannekoek, J. N., Wall, M. B., … & Leech, R. (2017). Psilocybin for treatment-resistant depression: fMRI-measured brain mechanisms. Scientific reports, 7(1), 13187.

 

Common Views and Attitudes Towards Psychedelic Medicines and Therapies

 


Psychedelics have a rich history, from use amongst indigenous people, guided by ancient knowledge passed on through centuries of traditional practices, to their discovery by modern science leading into a hampering period of criminalisation and finally through to a resurgence of research into uses in modern psychological treatment. A brief insight into the research, past and present, shines a light on the profound potential of psychedelics. Many studies have perfected the formula for safe therapeutic use, right dose and setting with skilled facilitators. This combination, with few treatment sessions, has provided sufferers of treatment resistant major depressive disorder, depression and anxiety associated with diagnosis of terminal illness, severe posttraumatic stress disorder (PTSD) and substance use disorder, with exceptional enduring therapeutic benefits (Bright & Williams, 2018; Carhart-Harris et al., 2018; Daniel & Haberman, 2017).

The state of mental health is at a tipping point, on the verge of further decline with exacerbation from an imminent economic depression and the increased psychological distress experienced due to the COVID-19 situation. A new approach to mental health treatment is an impending necessity, to help curb future burdens associated with increasing levels of mental distress. Psychedelic research has provided promising results, making psychedelic medicine an obvious candidate for the progression into a new paradigm for treating mental illness. Given the significant benefits of psychedelic medicines, relaying this information to the general public effectively is an important step towards the acceptance and integration of psychedelic-assisted therapy.

This exceptional period of rapid change that we currently find ourselves in has exposed a deep divide in understandings, views and opinions amongst individuals, communities, governments and within institutions. The COVID-19 situation, which is both symbolic and symptomatic of this complex time, has on the one hand produced an enormous amount of conflicting information coming from multiple sources, while on the other hand has not produced a single authoritative position, making it hard for most to differentiate fact from opinion and science from politics. These tensions are not unfamiliar to researchers in the area of psychedelic medicines; however, the scale of the current crisis changes the way we see the problem and directs us to new ways of responding. The COVID-19 situation has shown that when deciphering information, there is an obvious disparity between and within, science, medicine, politics and industry.

Information from highly influential sources leading to impulsive decision-making, has the capacity to produce unforeseen undesirable implications. We have seen an example of this recently with the initial predicted COVID-19 death rate — later found to be highly inaccurate — resulting in the instantaneous introduction of new policies worldwide. With the implementation of these policies, we are now witnessing a rise in mental illness, substance abuse and suicide risk (Wesley Mission & Suicide Prevention Australia, 2020). In hindsight the inadequacies and long-term implications of these policies are becoming visible, highlighted by new and upcoming research (Atkeson et al., 2020; Kaplan et al., 2020; Madhi, et al., 2020; Miles et al., 2020).

The complexity and tensions inherent within the COVID-19 situation present a unique opportunity for reflective research in that it surfaces, in a very explicit way, the challenges associated with the delivery and receipt of information. Learning from the COVID-19 situation, more focus can be placed on the fundamentals of the spread of information within the area of psychedelic medicines and how information flows impact on consensus and associated behaviour and attitudes.

The public perception of psychedelic medicines, relates back to the criminalisation of psychedelics in the 1960’s. The residual effects of this classification, including stigmatisation, rejection and fear, is central to the continuous spread of confusing and incorrect information within the public domain (Belouin & Henningfield, 2018; Bright & Williams, 2018; Sessa, 2016). The spread of this information has both created serious limitations for scientific research, and the uptake of the medicines and therapies themselves (Belouin & Henningfield, 2018; Bright & Williams, 2018; Sessa, 2016).

The way in which information is delivered can either be, a shortcoming for the distribution of correct information, or a catapult for the distribution of incorrect information, leading to a myriad of challenges for policymakers and public health. The dissemination of information in the COVID-19 environment has brought into focus the associated challenges, highlighting how advancements in the use of psychedelic assisted therapy may be curtailed. It is an important consideration when making informed decisions regarding the delivery of information, to examine and understand the sources, intended purposes behind, and the interpretation.

Misinformation can be described as information that originates from an absence or lack of supporting empirical or factual evidence. History tells us that the current scheduling of psychedelics follows on from the criminalisation of LSD in 1966 (Belouin & Henningfield, 2018; Sessa, 2016). LSD was completely banned for any use, including research purposes, on the basis that it posed a danger to the public, despite thousands of studies on the therapeutic use of LSD during the 1950’s and 1960’s deeming LSD, when used in controlled settings, to be “overwhelmingly safe and effective” (Sessa, 2016, p. 8). Based on this, the criminalisation and stringent scheduling of psychedelics is not supported by empirical evidence and based on misinformation.

In understanding the roots and propagation of misinformation, it is important to examine the sources. A study by McCright and Dunlap (2017) discusses the origins and spread of political misinformation and outlines that it is; often based on ideological agendas, deeply ingrained and mutually reinforced by the public, and cohesively promoted through collaborative relationships with industries and media outlets. This study highlights the disregard for accuracy in the delivery of highly influential information and also the difficulties in rectification at this level.

Research suggests that information is often selectively chosen, skewed or sensationalised for entertainment purposes (Klin & Lemish, 2008). With the media driven stigma of a ‘dangerous party drug’, ecstasy is an unregulated drug found to often not contain MDMA at all (Rickwood et al., 2005). MDMA, the psychedelic component in what’s been classified as breakthrough treatment for PTSD (Doblin et al., 2019) is often misleadingly referred to as ecstasy. This demonstrates the potential for incorrect terminology to exacebate misconceptions. However, becoming aware of misleading terminology allows for intervention to expose and correct it, helping to conteract misconceptions.

Aside from understanding and acknowledging the origins of information and misinformation, it is equally important, to recognise and understand how it is received and absorbed. Deciphering whether information is correct or incorrect involves not only the way it is delivered but also how it is interpreted, transferred into knowledge and beliefs, and interacts with prior knowledge and beliefs. Amongst the general population there are many misconceptions associated with psychedelics as a result of misinformation, such as, they are dangerous, toxic and addictive physically, psychologically and/or socially (Belouin & Henningfield, 2018; Byock, 2018). These misconceptions have been refuted by the large amount of research that has taken place since psychedelic medicines were discovered by scientists in the 1890’s (Bright & Williams, 2018; Nichols, 2016; Sessa, 2016), but the obvious dilemma is that such research is not readily available to, or accessed by the general public.

Misconceptions and misinformation are difficult to counteract, as they become imbedded in beliefs and attitudes. The “war on drugs” campaign, led by politics and propagated by mass media has left an unfortunate legacy. The campaign established psychedelics position as an enemy and threat to society. In establishing this position, knowledge was tactfully directed, shifting and cementing the general public opinion of psychedelics. In a study reviewing literature on cognitive biases that influence social perceptions, Marks and Miller (1987) found that values and beliefs held by individuals are often influenced by social groups and the selective exposure to biased samples of information that agrees with and maintains a desired or already held position.

It has been proposed that individuals generally only seek new knowledge when it is necessary or vitally important to do so (Thon & Jucks, 2017), and when it comes to acknowledging new information — whether it is evidence based or not — an individual’s prior knowledge and beliefs are often defended and upheld (Pennycook, 2020). Clearly, prior knowledge and beliefs play a significant role in the adoption of new information, exemplifying the difficulties in shifting firmly held beliefs and gaining trust and acceptance.

The “war on drugs” has been described as, a war on “sovereignty over consciousness” (Hancock, 2015, p. 3). In the current media climate we are witnessing an increase in censorship and a polarisation of information, which similarly to the “war on drugs” can be described as a war on sovereignty over knowledge. Ideally there should be accountability for ingenuousness within sources of information, but it is instead, left to the individual to firstly identify misinformation and secondly rationally and logically question it. Awareness leads to change and begins with acknowledgement and acceptance. Acknowledging and accepting the dilemmas within the delivery and uptake of information, will therefore bring about awareness necessary for change.

Misinformation is somewhat complicated and incorporates many variables from all parties including the sources of information and the intended audience, and many aspects that influence the interpretation and accommodation of information. Misinformation has effectively sustained misconceptions and stigmatisation surrounding psychedelics. It is therefore relevant to investigate and understand in order to move forward and create a model for initiating and establishing positive views and attitudes towards psychedelic medicines and therapies. Further research is needed to explore the barriers surrounding misinformation, to aid successful advocation for psychedelic medicines and promote their place in therapeutic, psychological and clinical practice.

By Candice Folkard

 

References

Atkeson, A., Kopecky, K., & Zha, T. (2020). Four stylized facts about COVID-19. NBER Working Paper №27719. https://doi.org/10.3386/w27719

Belouin, S. J., & Henningfield, J. E. (2018). Psychedelics: Where we are now, why we got here, what we must do. Neuropharmacology, 142, 7–19. http://doi.org/1016/j.neuropharm.2018.02.018

Bright, S., & Williams, M. L. (2018). Should Australian psychology consider enhancing psychotherapeutic interventions with psychedelic drugs? A call for research. Australian Psychologist. https://doi.org/10.1111/ap.12345

Byock, I. (2018). Taking psychedelics seriously. Journal of Palliative Medicine, 21(4), 417–421. https://doi.org/10.1089/jpm.2017.0684

Carhart-Harris, R.L., Bolstridge, M., Day, C.M.J. et al. (2018). Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology, 235, 399–408. https://doi.org/10.1007/s00213-017-4771-x

Daniel, J., & Haberman, M. (2017). Clinical potential of psilocybin as a treatment for mental health conditions. Mental Health Clinician, 7(1), 24–28. https://doi.org/10.9740/mhc.2017.01.024

Doblin, R. E., Christiansen, M., Jerome, L., & Burge, B. (2019). The past and future of psychedelic science: an introduction to this issue. Journal of Psychoactive Drugs, 51(2), 93–97. https://doi.org/10.1080/02791072.2019.1606472

Hancock, G. (2015). The devine spark, psychedelics, consciousness and the birth of civilization. London: Hay House UK Ltd.

Kaplan, G., Moll, B., & Violante, G. L. (2020). The great lockdown and the big stimulus: tracing the pandemic possibility frontier for the U.S. NBER Working Paper №27794. 1–53. https://doi.org/10.3386/w27794

Klin, A., & Lemish, D. (2008). Mental disorders stigma in the media: review of studies on production, content, and influence. Journal or Health Communication, 13, 434–449. https://doi.org/10.1080/10810730802198813

Madhi, S. A., Gray, G. E., Ismail, N., Izu, A., Mendelson, M., Cassim, N., Venter, F. (2020). COVID-19 lockdowns in low- and middle-income countries: success against COVID-19 at the price of greater costs. South African Medical Journal, 110(8), 724–726. https://doi.org/10.7196/SAMJ.2020.v110i8.15055

Marks, G., & Miller, N. (1987). Ten years of research on the false-consensus effect: an empirical and theoretical review. Psychological Bulletin, 102(1), 72–90.

McCright, A. M., & Dunlap, R. E. (2017). Combatting misinformation requires recognizing its types and the factors that facilitate its spread and resonance. Journal of Applied Research in Memory and Cognition, 6, 389–396.

Miles, D. K., Stedman, M., & Heald, A. H. (2020). “Stay at home, protect the national health service, save lives”: A cost benefit analysis of the lockdown in the United Kingdom. The International Journal of Clinical Practice, 1–14. https://doi.org/10.1111/ijcp.13674

Nichols, D. E. (2016). Psychedelics. Pharmacological Reviews, 68(2), 264–355. https://doi.org/10.1124/pr.115.011478

Pennycook, G. (2020). Belief bias and its significance for modern social science. Psychological Inquiry: An International Journal for the Advancement of Psychological Theory, 31(1), 57–60. https://doi.org/10.1080/1047840X.2020.1722577

Rickwood, D., Crowley, M., Dyer, K., Magor-Blatch, L., Melrose, J., Mentha, H., & Ryder, D. (2005). Perspectives in psychology: substance use. Melbourne: The Australian Psychological Society Ltd.

Sessa, B. (2016). The history of psychedelics in medicine. In M. V. Heyden, H. Jungaberle, & T. Majić, Handbuch Psychoaktive Substanzen (pp. 1–26). Berlin: Springer, Berlin, Heidelberg. https://doi.org/10.10.1007/978-3-642-55214-4_96-1

Thon, F. M., & Jucks, R. (2017). Believing in expertise: how authors’ credentials and language use influences the credibility of online health information. Health Communication, 32(7), 828–836. http://dx.doi.org/10.1080/10410236:2016.1172296

Wesley Mission & Suicide Prevention Australia. (2020, June). Policy and Advocacy. Suicide Prevention Australia: https://www.suicidepreventionaust.org/policy-advocacy

Psychedelic-Assisted Therapy For Criminal Offenders — A New Paradigm For Rehabilitation?

I have a lifelong interest in decreasing violent crime and imprisonments rates. For 21 years I was a proudly activist judicial officer seeking to reduce both — definitively a barbed-wire fence proposition.

I have a more recent interest in the treatment of mental health issues by the use of psychedelic assisted therapy. At first glance, it may appear that these two interests are disconnected. The purpose of this short blog is to explain that they are intricately linked, and thus my excitement at being on the advisory panel for Mind Medicine Australia.

I have personal experience of vicarious trauma detailed in my Tristan Jepson Memorial Foundation lecture[1], and am happy to disclose that I have been flirting with the idea of psychedelic assisted therapy for myself.

So, let’s play ‘what if’ for a while.

1. What if psychedelic assisted therapy could make a real dent in the numbers of those suffering from substance abuse disorder, PTSD and depression/anxiety?

2. What if a substantial proportion of those who commit crimes and are imprisoned are suffering from those conditions?

3. What if there was broad availability of these treatments for violent offenders?

4. What if there was broad outspoken support from the criminal justice sector?

As to the first ‘what if’, having read the research, I am comfortably satisfied that psychedelic assisted therapy including psilocybin and MDMA has great results in treating conditions such as substance abuse disorder, PTSD and depression/anxiety. The phase three trials will undoubtedly cement psychedelic assisted therapy as a key treatment to these ailments. However, I notice that much of the recent research has been on those perceived to be worthy — those dying of terminal illness, Vietnam veterans, AIDS survivors, anorexia patients and the like. There are some studies of those with substance abuse disorders, but having read that research it is notable that violent offenders are not the target tested group.

Yet, and this answers the second ‘what if’, those suffering abuse disorder, PTSD and depression/anxiety are responsible for much of the violent crime in Australia.

I know it’s academically sound to start with the empirical evidence-based studies, however sometimes anecdotal evidence has more punch. As a children’s court magistrate, I noticed something very quickly — there were no repeat violent offenders who had not witnessed or been the victim of violence in the home. None, zero. Every sentencing report detailed PTSD from living in fear as a child. Every single one. All of these kids I had to lock up had experienced seeing their mum beaten up, or been abused themselves.

And with violent women offenders, it soon became apparent that the vast majority had been victims of sexual abuse and suffered from PTSD or substance abuse disorder as a result. For men, the picture was more complex with a range of diagnoses — until the Royal Commission. Suddenly, it became acceptable for men to admit to the abuse they had suffered and a PTSD diagnosis became more and more common. For most violent male criminals, alcohol abuse disorder was a regular feature.

This anecdotal evidence is, unsurprisingly, supported by the research. For women prisoners, two thirds had a mental health condition, and one third for men. A third of women had a history of self-harm. A quarter of all entrant prisoners were taking medication for a mental health condition[2]. This is a world-wide phenomenon — for example, the prevalence of psychosis in a London prison population was found to be more than 20 times that of the general community, and almost 70% of people in prison had more than one mental health disorder[3].

The figures don’t distinguish between violent and other offenders, and nor do they inform of the type of mental illness. I plan to dig deeper on these issues, however my hypothesis is that the research will conform with my observations –the vast majority of violent offenders have mental health issues that lend themselves to psychedelic treatment. There are two important caveats to this hypothesis worth keeping in mind — firstly, the vast majority of those who have mental health conditions are not violent. Secondly, those with mental health conditions are much more likely to be victims of violent crime.

And to the third ‘what if’ — imagine if there was broad availability of psychedelic assisted treatment of these violent offenders. I’m not suggesting we lace prison water with LSD a la Timothy Leary, however surely psychedelic therapy holds more likelihood of rehabilitation than the rigid discipline of time behind bars and a lifetime of psychiatric medication. I opine that violent offenders ought to be the first for whom this treatment is available — because there is a sure and clear test of effectiveness. They either re-offend or they don’t.

And finally, to the fourth ‘what if”. There certainly are some barriers to getting criminal justice support for psychedelic therapy — there are deeply entrenched views that mimic those of Mr Mackey in South Park — all drugs are bad. Of course, the logical flaws in that approach are obvious but should not be discounted as it is the dominant hegemony. Such views are shared by the majority of police, judges and lawmakers in the country. Medicinal cannabis has faced decades of prohibition until very recent times in this country, and still the barriers are significant. Legitimising psychedelics is a hurdle that may take some time and effort.

The other hurdle is that psychedelic treatment will not of itself impact on the sociological causes of crime for which treatment of individuals is but a small part. Chronic inequality, institutionalised racism, toxic masculinity and a lack of rehabilitation services all contribute to rising crime. There are no magic bullets for these. However, if the focus is on violent crime — particularly domestic and family violence — then criminal justice system support may be easier to garner.

So, if we are serious about decreasing the prison population and reducing violent crime the criminal justice system ought support psychedelic therapy availability. The current law and order ‘solutions’ to violent crime — more police, longer sentences, tougher prisons — demonstrably are not working. It is time to try a more scientific approach.

By David Heilpern

References
[1] https://www.judicialcollege.vic.edu.au/sites/default/files/2019-07/Helipern%20%282017%29%20TJMF%20Lecture%20-%20Lifting%20the%20Judicial%20Veil.pdf

[2] https://www.aihw.gov.au/getmedia/2e92f007-453d-48a1-9c6b-4c9531cf0371/aihw-phe-246.pdf.aspx?inline=true

[3] Bebbington P, Jakobowitz S, McKenzie N, Killaspy H, Iveson R, Duffield G & Kerr M 2017. Assessing needs for psychiatric treatment in prisoners: 1. Prevalence of disorder. Social Psychiatry and Psychiatric Epidemiology 52(2):221–9. doi: 10.1007/s00127–016–1311–7

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