A Paradigm Shift in Mental Healthcare

Author: Iain Burgess is the lead researcher at Blossom. He studied Global Health (MSc) and Physiology (BSc) and has researched the various scientific, societal, cultural and political dynamics that have shaped our understanding of psychedelics throughout history.

Psychedelics have come a long way in recent years. These psychoactive substances are now on the verge of being medicalised in some form, thanks to the so-called psychedelic renaissance.

Research papers on the therapeutic potential of psychedelics are emerging on what is now a daily basis. Accompanying these papers are articles and, even appearances by prominent figures in the field, in nearly every popular media outlet you can think of.

Although the field of psychedelics is not without its flaws, the research and coverage it is receiving are overwhelmingly positive. Psychedelics are now poised to be a paradigm shift in viewing and treating mental health disorders. But what exactly is the paradigm psychedelic medicine is set to replace?

The Biomedical Model

The lens through which Western society views mental health, and health in general, reflects a particular way of thinking which dates back to the nineteenth century; this lens is known as the biomedical model of health. In the simplest sense, this model reduces the cause of illness to aberrations in a person’s physiological processes [1].

At the time of its inception, the advent of ‘germ theory’ and the subsequent realisation that microorganisms were the causal factors of diseases such as typhoid, cholera and smallpox allowed for illness to be explained as having a single cause, an assumption that has come to dominate the biomedical model [2].

While it is true that this model has led to the advent of life-saving medicines such as antibiotics and vaccines, proving beneficial for millions across the globe, we now know that many diseases cannot be attributed to a single cause. For example, the role of lifestyle factors such as physical activity and diet in the cause of diseases like diabetes emphasise some of the shortcomings of this model.

Through this biomedical gaze, medical knowledge is placed above all else, disregarding the lay-opinion of patients and the public alike. Therefore, diseases are reduced to a set of observable symptoms in which the single underlying cause is identified and targeted therapeutically. In reality, disease is complex, with genetic, environmental and lifestyle factors all contributing to the onset and subsequent pathogenesis [3].

This model is rooted in the philosophical idea of reductionism because higher-level phenomena like medical and social processes can be explained at lower-level such as the biological, chemical or physical nature of the process [1]. While it is true that disease is, in part, a physiological phenomenon, it is also socially constructed with a myriad of factors involved in how both patients and medical professionals perceive and understand health and illness. This is all the more true when we think of mental health.

The Biomedical Model of Mental Health

In the context of mental health disorders, although the biomedical model has proven beneficial for an array of cases, the reductionist underpinnings of this model continue to fail a large number of people living with mental health disorders by reducing the causes (aetiology) and symptoms of complex disorders like depression and PTSD to nothing more than the imbalance of chemicals in the brain [4].

In this respect, if it is possible to identify a biological cause, such as an imbalance of chemicals, it is possible to create a drug to target that cause. Consequently, the drug-based paradigm of psychopharmacology began with the advent of the antipsychotic drug chlorpromazine to treat schizophrenia in 1955 [5].

In the years that followed, chlorpromazine was shown to act by inhibiting the activity of the neurotransmitter dopamine in the brain, which shed light on synaptic transmission as being both electrically and chemically mediated [6]. More neurotransmitters like serotonin and norepinephrine were gradually discovered and provided sustenance to the argument that biochemical factors underlie mental illness.

This biomedical understanding of mental health quickly gained popularity and was endorsed by major organisations like the American Psychiatric Association and the U.S. National Institute of Mental Health, allowing the biomedical paradigm to assert its dominance in the realm of mental health science, policy, and practice [4].

On a side note, this is the very same era when research with psychedelics really began to emerge for the first time. While the timing may have been right to integrate psychedelics into this new paradigm, the escape of these substances from the laboratory coupled with ethical and methodological flaws throughout psychedelic research saw these substances become political artefacts. As a result, psychedelics were rendered Schedule I substances as opposed to viable therapy options.

Today, psychiatric medications like antidepressants, anxiolytics (anti-anxiety) and antipsychotics remain the preferred method for treating mental health disorders. Many of these pharmacological interventions are used in tandem with psychotherapy, a way to help people with various mental illnesses. Psychotherapy is a collaborative treatment method grounded in dialogue, allowing a patient to talk through their problems with a psychiatrist or psychologist in a supportive environment [7].

Through dialogue, psychotherapy allows patients and their psychotherapists to better understand the psychosocial nature of their illness by addressing patterns of thoughts and behaviours. Various types of psychotherapy exist, such as cognitive-behavioural therapy (CBT) and acceptance & commitment therapy (ACT), with the kind of therapy often depending on the needs of the patients.

Nevertheless, several issues remain surrounding the effectiveness of psychopharmacological interventions, even when used in tandem with psychotherapy. Many of these drugs come with unwanted sides effects and, in some cases, can even increase the risk of suicidal thoughts. Furthermore, many require long-term daily use to produce the desired results, and a considerable number of patients prescribed these medications remain unresponsive to their effects, even after prolonged use [8].

Thus, these findings, and more, raise several questions surrounding Western societies dependence on the biomedical model and the lens through which we view the nature of mental disorders and how we design and implement treatment strategies. With severe side effects, somewhat limited, efficacy and more accompanying many of these preferred methods of treatments, how have we become so reliant on these substances and the biomedical model?

A paradigm shift is needed, and despite the inflexibility of the biomedical discourse, is arguably underway, as Western science and society have rekindled their relationship with psychedelics and their therapeutic potential.

Psychedelics as Medicine

Psychedelics have had a relationship with Western science and society like no other pharmacological agent. The use of plant-derived psychedelic medicines by an array of cultures across the globe predates written history. Long before their introduction into Western science and society, the healing potential of psilocybin-containing mushrooms and the psychedelic brew ayahuasca has long been understood by various cultures across the Americas and beyond.

Today, the broad class of psychedelics has come to encompass classic psychedelics like psilocybin, ayahuasca, LSD and other non-plant derived psychoactive substances like MDMA and ketamine. Research with these substances is taking place across the globe as science and society are beginning to realise the therapeutic potential of these substances. However, researchers working with these substances must do so within the dominant framework of Western biomedicine. While these researchers are having success, many of the practical and theoretical underpinnings of the proposed psychedelic-assisted therapy (PAT) model stand at odds with the current biomedical framework.

Firstly, drugs must undergo the now gold-standard testing procedures: randomized-controlled trials (RCTs). While conducting placebo-controlled RCTs have become somewhat of a necessity for ensuring drug safety and reducing harm to public health, they have also become a barrier for certain drugs, like psychedelics, where extra-pharmacological processes play an important role in eliciting drug effects [9].

These extra-pharmacological factors relate to the now well-known theory of set and setting. Set and setting theory has been a long-recognized component of the psychedelic treatment model. Ido Hartogsohn offers a simple description of this theory, “the set and setting hypothesis holds that the effects of psychedelic drugs are dependent upon set (personality, preparation, expectation, and intention of the person having the experience) and setting (the physical, social, and cultural environment in which the experience takes place)” [10]. Thus, the PAT model not only focuses on the pharmacological factors but also the psychological and sociocultural.

While Timothy Leary may have popularised the theory, the original vanguards are the Indigenous groups who have used psychedelic substances for thousands of years. These groups have historically emphasised the importance of the environmental context, and psychological factors brought to the experience through practices like having a clear intention and an open, enquiring attitude and the importance of ceremony, ritual, and song [9].

In terms of clinical trials involving PAT, the physical environment of these trials is straightforward to control. Dosing sessions are conducted in aesthetically pleasing settings free from extraneous medical or research equipment that may cause psychological distress to the patient. Patients often listen to music while wearing eyeshades and are instructed to look inward [11].

Moreover, given that the psychedelic experience is highly subjective, ensuring patients are psychologically prepared presents difficulties and is time-consuming, consisting of numerous preparation sessions with a psychotherapist to develop trust and rapport between the patient and the medical professional. Integration sessions are needed after the experience and are essential for patients to make sense of the experience and gain full therapeutic benefit [11].

These therapy sessions emphasise the subjective psychological nature of mental illness, something which contrasts with the reductionist approach of the current biomedical model. In doing so, it allows for a more holistic understanding of mental health disorders and approaches to treatment.

Furthermore, the subjective nature of the psychedelic experience imposes constraints on generality within clinical trials utilising psychedelics, a significant problem for regulators and drug developers. Drug developers need their drugs to possess generality in order to bring drugs to market and to turn a profit, all while regulators like the FDA require extensive scientific evidence from clinical trials to inform them of drug safety and suitability for medical application.

Given the potency of these compounds, blinding and randomisation is difficult in clinical trials. At the same time, sample sizes in most published psychedelic research are currently small. Research has also proven difficult to reproduce, and given the profound effects, once psychedelics are consumed, research is still ongoing to uncover a suitable placebo [12].

Some Final Thoughts

The ability of psychedelics to alter states of consciousnesses is well known [13]. What remains unknown is whether or not the so-called revolution that psychedelic research is experiencing will lead to a collective change in consciousness amongst society, health professionals, and politicians regarding how we view and treat mental health disorders. 

This change will encompass taking a more holistic view of mental healthcare and placing psychosocial factors and the subsequent social construction of illness to the fore in terms of a person’s mental well-being. The current model of PAP is one such model allowing for this holistic view. Psychosocial and environmental factors are addressed through therapy and the overall emphasis on the theory of set and setting. 

Embracing different forms of knowledge rooted in more traditional views of health and illness is also necessary to realise the full therapeutic potential of psychedelics. Indigenous communities have long known the healing potential of these substances, and therefore, biomedicine could learn a lot from their teachings and practices.

Ultimately, with the global rate of mental health disorders at an all-time high, psychedelic-assisted therapy might be the exact paradigm shift necessary to address this increasing rate of human suffering and view mental health disorders in a new light.

References:

1. Rocca, E., & Anjum, R. L. (2020). Complexity, reductionism and the biomedical model. In Rethinking Causality, Complexity and Evidence for the Unique Patient: A CauseHealth Resource for Healthcare Professionals and the Clinical Encounter https://doi.org/10.1007/978-3-030-41239-5_5 
2. Russel, L. (2013). Biomedicine. Sociology for Health Professionals. https://www.sagepub.com/sites/default/files/upm-binaries/59005_Russell.pdf
3. Craig, J. (2008). Complex Diseases: Research and Applications. Nature Education. https://www.nature.com/scitable/topicpage/complex-diseases-research-and-applications-748/ 
4. Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review. https://doi.org/10.1016/j.cpr.2012.09.007
5. Whitaker, R. (2005). Anatomy of an Epidemic: Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. Ethical Human Psychology and Psychiatry. https://freedomcenter.org/pdf/anatomy_of_epidemic_whitaker_psych_drugs.pdf
6. Ban, T. A. (2007). Fifty years chlorpromazine: A historical perspective. Neuropsychiatric Disease and Treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655089/
7. Ching, J., Londoño-McConnel, A., Ducharme, E., Gock, T., Lonning, B., Molitor, N., Polowczyk, D., & Ritz, M. (2020, July 31). Understanding psychotherapy and how it works.https://www.apa.org/topics/psychotherapy/understanding
8. Harmer, C. J., Goodwin, G. M., & Cowen, P. J. (2021). Why do antidepressants take so long to work? A cognitive neuropsychological model of antidepressant drug action. The British Journal of Psychiatry. https://doi.org/10.1192/bjp.bp.108.051193
9. Carhart-Harris, R. L., Roseman, L., Haijen, E., Erritzoe, D., Watts, R., Branchi, I., & Kaelen, M. (2018). Psychedelics and the essential importance of context.
10. Hartogsohn, I. (2018). Constructing drug effects: A history of set and setting.
11. Johnson, M. W., Richards, W. A., & Griffiths, R. R. (2008). Human hallucinogen research: Guidelines for safety. 
12. Fejer, G. (2020, August 30). The biggest challenges for psychedelic science today – ICPR 2020. Interdisciplinary Conference on Psychedelic Research. https://icpr-conference.com/the-biggest-challenges-for-psychedelic-science-today/
13. Nichols, D. E. (2004). Hallucinogens.