Dr Sara Tai is a Senior Lecturer in Clinical Psychology, Director of the Psychoactive Substances Research Unit at the University of Manchester (PSRUUM), and Lead Investigator of Clerkenwell Health’s Manchester-based trial. Dr Tai’s twenty years of clinical practice and academic research are key to advancing the therapy component of psychedelic-assisted therapies.
Psychedelic drugs such as psilocybin, used in combination with talking therapy, are opening new avenues of possibility within mental health care by offering a very different mechanism of treatment from existing psychiatric medications. By inducing a unique state of consciousness, these drugs temporarily alter people’s perception of themselves and their experiences.
This altered state of consciousness creates a window of opportunity by allowing thought processes and perceptions to occur in novel ways, which can enable people to approach their problems from a new perspective. Creating the right conditions for people to confront their distress, so they can generate new solutions for resolving their problems, is what separates psychedelic drugs from the way in which we use other medications, which may only provide short-term relief. Expecting psychedelic drugs to do all the work on their own, however, is not helpful for the advancement of mental healthcare; it is the talking therapy which targets psychological reorganisation that must be focused on.
- See also: 'Rules for living - what is Cognitive Behavioural Therapy?'
- See also: 'The examined life and the work of psychoanalysis'
Psychedelics may be the catalyst, but therapy is the drive behind recovery
Mental health difficulties are not caused by biochemical imbalances in the brain. Our mental health is multifaceted and influenced by numerous factors, such as chronic stress, historic trauma, levels of social support, and the meaning we make of it all. Working with mental health issues, therefore, is not just about creating changes to receptors in the brain; it is about having a multifaceted approach to dealing with the very idiosyncratic issues that lead to people becoming distressed.
Due to the complexities and idiosyncrasies of the mind, the conversation around mental health is complex, but is often portrayed as a simple progression from a problem occurring, a remedial drug being taken, and unwanted symptoms subsequently being removed.
A drug-centred, dose-response approach in psychedelic research may, misleadingly, communicate that mental health issues are simply the result of some deficit that needs to be rectified and the drug alone is the vehicle of change.
There is no evidence that psychedelic drugs, by themselves, can create the changes required for resolution of mental health issues.
Losing focus on the role of therapy risks overplaying the importance of neurological mechanisms that contribute to mental health, whilst underplaying social, cognitive, emotional, and behavioural processes underlying mental distress.
It might be dangerous to regard psychedelic drugs as silver bullets that can directly solve mental health problems. This is a reductionistic understanding of the problems that affect people’s mental health and one that could give false hope to those who seek help. Early-stage clinical research indicates that psychedelics could be an important component of what must be a multifaceted approach, where emphasis on psychological processes is, at least, as important as what is happening biologically.
Psychedelic drugs may help people experience their problems in ways that they haven’t been able to before, leading to novel insights which potentially allows new solutions to be generated. In this respect, the drug is more of a catalyst that can enable people to develop awareness of the root causes of their difficulties. To quote the director of the Multidisciplinary Association for Psychedelic Studies (MAPS), Rick Doblin in the New York Times, “It’s not the drug — it’s the therapy enhanced by the drug”.
Psychological support provided during psychedelic-assisted therapies, whether it is non-specific support or shaped by a therapeutic model, is designed in three phases: preparation, dosing, and integration. In preparation, the therapist builds a therapeutic alliance with the participant and prepares them for what to expect. The drug is administered in the dosing session in which the therapist(s) supports the participant for the duration of the drugs’ effects. The integration phase focuses on making sense of the experiences the participant had during dosing and on helping them incorporate the insights and lessons learned into their daily lives.
It is widely posited that the integration phase plays an important part in generating insights from psychedelic experiences and facilitating the chance of meaningful long-term change. Yet, clinical research into what the specific mechanisms of change are and the most efficacious methods for facilitating such change is limited. A clear, empirically sound framework of understanding is needed, which provides a coherent understanding of individuals’ mental distress and informs a clear set of principles on which interventions can be based.
People who seek treatment from mental health services often experience multiple and varied issues, yet current practice usually involves providing a problem specific intervention based on a diagnosis. For example, there are hundreds of problem-specific talking therapies, which can be confusing for service users and unduly expensive when training mental health service providers in hundreds of approaches. We therefore need approaches that place the individual at the centre and can deal with the varied problems they face from their perspective.
- See also: 'Psilocybin, depression and a new era of treatment'
- See also: 'Could DMT be the answer for treatment resistant depression?'
Clerkenwell trial – Perception Control Theory
Our upcoming trial, a collaboration between the University of Manchester and Clerkenwell Health, aims to investigate the impact of talking therapy alongside two different doses of psilocybin. The therapy is informed by Perceptual Control Theory (PCT), which understands mental health issues as the result of a person having reduced or loss of control over the things they value in life, usually because there are two or more competing goals that are mutually incompatible.
PCT provides an empirical framework of understanding that helps to integrate findings from across the mental health literature and informs clinical practice by identifying and capitalising on key principles common to many effective psychotherapeutic interventions. This framework advocates helping people develop their own solutions to problems by mobilising their attention to different aspects of their experiences in order to evaluate them from different perspectives.
There is an emphasis on helping people develop awareness of important values and goals so that they can work out new ways to balancing competing needs. In this respect, psilocybin may serve a useful role in helping an individual redirect their awareness to what is most salient for them, as opposed to other more directive therapeutic approaches.
A number of other therapeutic approaches are emerging for psychedelics, including the Psychedelic Harm Reduction and Integration framework used by MAPS, which has yielded promising results in early research trials. Research in this field is still in its infancy, yet what is becoming increasingly clear, is that service users must be at the centre of psychedelic-assisted therapy and the therapist’s role should be to guide rather than instruct.
In the Clerkenwell Health trial, psilocybin is understood as temporarily reducing our use of strategies to control experiences, including those that may be counterproductive like worry and rumination. This enables us to be exposed to emotions and wider experiences that we might not have been able to identify or focus on before.
Psilocybin is known to ‘downregulate’ receptors involved in such cognitive and emotional processing so that thinking may become more flexible. The role of the therapy is to assist us in imagining different solutions which may then lead to realisation of what is important to us and resolution of distress.
In conclusion, we cannot expect the drug to do all the work on its own. We need more focus on the therapy, which creates the conditions required for people to get themselves better. If we want to improve clinical practice for those who seek help, a principles-based, theoretically driven approach, which builds on what is known to be useful across different psychotherapies is essential. This needs more clinical research. Developing best practices through clinical research, and more importantly, sharing these practices, is crucial for psychedelic-assisted therapy to be incorporated into mainstream clinical practice.