Toward a contextual psychedelic-assisted therapy: Perspectives from Acceptance and Commitment Therapy and contextual behavioral science

In this theory-building paper (2019), the authors outline how contextual behavioural science (CBS) based therapies are ideal for understanding the psychedelic experience. The authors argue that therapies such as Acceptance and Commitment Therapy (ACT) are uniquely positioned to increase the efficacy of psychedelic-assisted therapy and provides avenues for future research on the topic.

Abstract

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

Authors: Jason B. Luoma, Pablo Sabucedo, Johan Eriksson, Nathan Gates & Brian C. Pilecki

Notes

Author highlights:

• “Clinical psychedelic research re-started in the 1990s and is rapidly accelerating.

• Understanding of the psychological processes of change limited.

• Contextual behavioral science can be used to understand psychedelic assisted therapy.”

Summary

Clinical psychedelic research re-started in the 1990s and is rapidly accelerating. This paper argues that contextual behavioral science (CBS) can help explain the psychological processes of change involved in psychedelic assisted therapy, and how ACT can contribute to this process.

Scientific research into psychedelics is undergoing a renaissance, with preliminary efficacy and safety being demonstrated across a range of clinical presentations. Contextual behavioral science provides an ideal framework for understanding psychedelic experiences, and ACT may offer unique avenues to potentially deepen and maintain therapeutic effects.

At least two ongoing trials are currently using methods based on CBS to help patients with psychedelic-assisted therapy, and this paper explores how CBS may contribute to psychedelic science and vice versa.

1. Psychedelics and psychedelic-assisted therapy

Classic psychedelics include lysergic acid diethylamide (LSD), psilocybin, mescaline, and dimethyltryptamine (DMT), and are derived from plants or fungi that create perceptual disturbances. They are illegal in most countries, but have been used for ceremonial, religious, and healing purposes for millennia.

Modern clinical trials of psychedelic-assisted therapy incorporate supportive psychotherapy, but the therapies have not been specifically studied enough to claim empirical support. CBS may offer a way to guide psychedelic-assisted therapy that is grounded in a rigorous, tested and cohesive theory of human behavior.

2. History of clinical research into psychedelics

The first wave of psychedelic research was marked by the discovery of mescaline by Western science, and the second wave was marked by the synthesis of lysergic acid diethylamide (LSD) and psilocybin. Clinical research on psychedelics was substantial, but shared the methodological weaknesses that were common at the time.

The contemporary revival of psychedelic research began with three studies of healthy volunteers conducted in Germany, Switzerland, and the United States. Several clinical trials have now demonstrated preliminary efficacy and safety of psychedelic-assisted therapy in treating a wide range of mental health difficulties.

Contemporary clinical trials of psychedelics began with an uncontrolled proof-of-concept study of nine patients with treatment-resistant obsessive-compulsive disorder, and have shown promising results for smoking cessation and alcohol use disorder.

Four clinical trials have used psychedelic-assisted therapy to treat depression and anxiety related to life-threatening medical diagnoses. The studies showed significant symptom reduction in 80% of participants at 6-month follow-up.

In Brazil, six patients with recurrent depression were piloted for the use of ayahuasca, and 20 patients with treatment-resistant depression were treated with psilocybin. Both groups showed significant reductions in depression symptoms.

Studies have shown that the intensity of mystical experiences elicited by psychedelics predicts therapeutic outcomes, including changes in depression, alcohol consumption, trait openness, smoking cessation outcomes, negative affect, and end of life depression and anxiety.

Psychedelic use has been central to Native American religion and spirituality for millennia, and observational studies on religious communities who consume ayahuasca sacramentally in Brazil have shown lower rates of psychopathology and higher performance in neuropsychological tasks versus non-users.

3. The need for a scientific model to guide psychedelic-assisted therapy

Psychedelic-assisted therapy seems to have potential benefits for a variety of psychiatric diagnoses, but further research is needed to understand the psychological processes mediating this type of intervention.

Psychedelic-assisted therapy has a psychotherapy component, but the psychotherapy portion is often not well-described, measured, or controlled for. A cohesive and testable model of change could be used to guide the psychotherapy component of the intervention to maximize its effectiveness.

3.1. Why contextual behavior science is an ideal fit for psychedelic-assisted therapy

Contextual behavioral science is an approach to science grounded in the pragmatism of James, Dewey, and Peirce. It seeks to identify contextual variables that allow influence over any and all actions of an organism, including internal activities such as thinking and feeling.

Psychedelic-assisted therapy appears to be highly dependent upon the context in which the drug is ingested, and the nature of the person’s experience during these hours appears to be greatly influenced by the context in which the drug is ingested. The context in which psychedelics are administered is well established and has its roots in shamanic use. The context can influence the person’s expectation before the session and meaning-making after the experience.

Data from early clinical studies suggest that setting and psychological preparation are important to ensure safety and efficacy in psychedelic research. Additionally, the occurrence of mystical experiences is strongly associated with outcome and may be particularly important to study and influence.

Context may impact the efficacy of psychedelic-assisted therapy through the conceptual frameworks patients use to understand their psychedelic experiences. A conceptual framework may influence how the psychedelic experience is expressed through the course of subsequent daily living.

The way a person understands their psychedelic experience is filtered by their prior experiences and the reaction of their social environment. A socio-cultural context that gives great meaning to psychedelic experiences is likely to lead to more action based on the insight gained during psychedelic use.

Psychedelic experiences can change a person’s sense of self, which can be leveraged therapeutically. CBS can help explain how psychedelic experiences alter a person’s sense of self.

Psychedelics have different effects depending on the context in which they are administered, including the context of therapy. CBS can help determine which variables may be modified to optimize beneficial effects.

4. CBS and the psychological flexibility model

CBS is well-positioned to contribute to clinical psychedelic research because it offers a scientifically well-supported theory of human language and cognition, is phenomenologically congruent with the psychedelic experience, and offers novel therapeutic techniques for psychedelic-assisted therapy.

CBS encompasses a broad range of scientific research from basic to applied, and uses different levels of theory, including a middle level of theory called psychological flexibility. This middle level of theory is used in clinical work and clinical research.

Psychological flexibility is typically broken down into six processes, including acceptance, cognitive defusion, present moment awareness, flexible perspective-taking, values clarity, and committed action. These processes are often packaged using the term Acceptance and Commitment Therapy (ACT), but are also part of a larger model of psychosocial intervention development.

5. The psychological flexibility model as an organizational rubric for processes of change in psychedelic-assisted therapy

We describe six flexibility processes that can be used to describe the psychedelic experience and guide the preparation, guiding, and integration stages of psychedelic-assisted therapy.

5.1. Self-as-context/flexible perspective taking

Steven Hayes wrote the first paper on ACT, which argued for a naturalistic understanding of mystical experience. This paper also discussed the potential importance of mystical experience in human functioning and well-being.

Relational Frame Theory (RFT) explains how a sense of self emerges, including the self-concept, and how a transcendent sense of self called self-as-context is thought to be largely adaptive in fostering disentanglement from self-focused evaluative thinking and reason-giving that unhelpfully constrain behavior. The role of self-experience in the psychedelic experience is central, and the default mode network is less active during psychedelic states, suggesting that our ordinary sense of self may drop away at times or become reduced. A psychological flexibility model perspective suggests that changes in brain activity may index decreases in deictic framing, which could explain why people report experiencing “fresh” experiences after psychedelic therapy.

Decreases in deictic framing could account for phenomena such as ego death, ego dissolution, and ego-disintegration that have been described as part of intense psychedelic states.

Psychedelic-induced mystical states are characterized by a sense of dissolution of the self into a larger whole, an interconnectedness with the universe, and a decrease in one’s sense of self-importance. There is a striking similarity between reports from psychedelic therapy and descriptions of the self-as-context phenomenon within CBS, including the idea that the self-as-context phenomenon does not have any qualities or content that can be observed, but is instead the place or perspective from which observation happens. Other indications of perspective-taking shifts include reports of contacting an “inner teacher”, encounters with loving beings or “guiding spirits”, and contact with a part of the self capable of great love and compassion.

People who have experienced psychedelic experience often feel more interconnected with others, with the natural world, or with the world itself. The psychological flexibility model can help explain how this sense of interconnection could be therapeutic.

Psychedelics may cause a loosening of attachment to the conceptualized self through direct action on the regions of the brain that are central to the sense of self.

5.2. Acceptance

Psychoactive drugs can cause intense and aversive experiences, including visual hallucinations, aversive bodily sensations, intense emotions, loss of the sense of self, and a sense that one is dying. Acceptance may be one of the routes through which psychedelics have therapeutic effects.

Studies have shown that intake of Ayahuasca and psilocybin in a supportive context increases self-reported acceptance among healthy volunteers, and that psilocybin experiences lead to increases in openness to experience, which overlaps with the openness to one’s own experience that is part of acceptance.

5.3. Flexible, fluid, and voluntary present moment awareness

Qualitative data suggest that psychedelic-assisted therapy may increase present moment awareness, including decreased ruminativeness of the past and increased curiosity and aesthetic appreciation.

Three studies of people attending Ayahuasca retreats measured mindfulness before and after meetings. Two of these studies showed no increases on subscales of the Five Factor Mindfulness Questionnaire, but one study demonstrated increases on a different measure of mindfulness.

5.4. Cognitive defusion

Cognitive fusion is the dominance of narrow cognitive and language-based ways of responding to stimuli over more fluid and flexible ways of responding to stimuli. Psychedelics disrupt ordinary language and cognitive processes, and this may be related to cognitive defusion.

A study of 25 participants taking ayahuasca showed improvements on a measure of decentering, which is similar to defusion. However, a second study with 10 participants did not replicate this finding.

Studies indicate that individuals under LSD respond in ways that are less in accordance with more typical or predictable ways of responding to verbal stimuli, and instead increase more remote or non-obvious associations to verbal stimuli.

The potentially therapeutic alterations in linguistic processing often associated with the psychedelic experience could be conceptualized as facilitating cognitive defusion through a number of pathways, including the failure of words and language to adequately capture the experience, and the opportunity to choose more helpful or functional “stories” or words to help integrate the experience.

Incorporating cognitive defusion techniques common in ACT into the psychedelic-assisted therapy integration phase may help deepen and sustain the benefits of the psychedelic experience, and reduce the rate at which patients fall back into older, more dominant ways of thinking and responding.

5.5. Values

Clinical trials of classical psychedelics demonstrate that revised life priorities and “reconnecting with core values” are common experiences during clinical trials. This increased contact with a sense of meaning and purpose in one’s life seems to be central to the mystical quality reported in the most therapeutically beneficial psychedelic experiences.

Psychedelic experiences may result in values-related shifts that improve mental health. These shifts may also be helpful at a societal level.

ACT strategies and exercises could be helpful in a variety of ways for people who are experiencing psychedelic-assisted therapy, including helping them articulate their values and working through conflicts that may occur.

5.6. Committed action

Historically, psychedelic use was embedded in sacramental contexts that supported their use. However, in most Western countries there is a cultural bias against psychedelic use and mystical or non-ordinary perspectives in general, making it difficult for people to translate their experiences into meaningful change.

The ability to translate insights gained during a psychedelic experience into real-life goals is likely an important mechanism of action, and ACT strategies could be used to help clients achieve meaningful positive change.

5.7. Convergence between the entropic brain theory and CBS

The psychological flexibility model of mental health and dysfunction is consistent with the entropic brain theory, which proposes that over-constrained cognition is the root of much (but not all) psychopathology and that most psychopathology arises from an over-abundance of order (low-entropy) in brain dynamics.

While active psychedelic administration induces high entropy states, the brain will resolve to moderate or low entropy states after acute effects wear off.

The entropic brain theory explains how variability is induced in the brain, but it does not specify how changes are selected for retention over others. This is why environmental inputs are so important in psychedelic-assisted therapy.

Psychedelic states might push people out of locally adaptive peaks, thereby allowing them to shift to new, more adaptive patterns of organization. This is analogous to a species that has adapted to living on a certain mountain top and is unable to survive at lower altitudes.

6. Recommendations and considerations for psychedelic-assisted therapy and research

Psychotherapy components should be systematically varied in order to study the effects of the psychedelic experience. Measures of psychological flexibility should be included in the studies to examine the relationships between psychological flexibility variables and brain-level variables. Studies could examine whether incorporating acceptance-focused techniques into the preparation phase or into the integration sessions could improve outcomes, or whether therapeutic alliance-promoting interventions from Functional Analytic Therapy could enhance the therapy relationship. – Increase the participation of minorities in future research, especially people of color and ethnic minorities, to counterbalance the disparities and inequalities at play in both research participation and design. To develop psychedelic-assisted therapy, researchers are utilizing behavioral tasks informed by Relational Frame Theory, conducting assessments before, during, and after dosing sessions. These tasks may be integrated with brain imaging technologies to elucidate links between basic psychological research and brain functioning.

We recommend further conceptual analyses of how CBS might inform the way that psychedelics alter one’s sense of self, including the study of psychedelic-assisted therapy and more basic CBS concepts.

After years of dormancy, psychedelic-assisted therapy is undergoing a renaissance that includes more rigorous methodologies, increased caution in interpreting data findings, and the integration of more evidence-based paradigms of psychological dysfunction and therapy.