This hypothesis paper (2021) puts forth several solutions to the challenges of psychedelic-assisted therapy. Whitfield builds further on Acceptance and Commitment Therapy (ACT) and Contextual Behavioural Science (CBS). The various constructs of ‘Self’ or self-models and ways of integrating new perspectives on this concept are discussed.
Abstract
“Psychedelic-assisted therapy research for depression and PTSD has been fast tracked in the United States with the Food and Drugs Administration (FDA) granting breakthrough designations for MDMA (post-traumatic stress disorder) and psilocybin (major depressive disorder). The psychotherapeutic treatments accompanying these psychedelics have not been well-studied and remain controversial. This article reviews the challenges unique to psychedelic-assisted therapy and introduces a newly optimised psychological flexibility model that adapts Contextual Behavioural Science (CBS)/Acceptance and Commitment Therapy (ACT) to those multiple challenges, including ego inflation, traumatic memories, and the perceived presence of entities. A methodology aligned with biological mechanisms, psychological processes and therapeutic contexts may be advantageous for improving outcomes. This model expands ACT by integrating practises and data from psychedelic-assisted therapy research into a Contextual Behavioural Science framework, allowing both fields to inform each other. Psychological flexibility processes are questioned and adapted to a psychedelic context, and interventions that operationalise these processes are considered. The principle through-line of the paper is to consider varied constructs of Self, as understood by these fields, and integrates respective elements of varied self-models, interventions and data into a Spectrum of Selves model for psychedelic-assisted therapy. Secondly the paper examines how to select and retain new self-perspectives and their corresponding behaviours systemically, drawing from evolutionary science principles. A case example of such behavioural reinforcement is provided, as well as a psychedelic integration checklist to guide the practical implementation of such an approach. This method can enable a coherent therapeutic framework with clear operational relationships between (1) problematic behaviour patterns that an individual wishes to address (2) the guided psychedelic experiences of that individual, and (3) the barriers to maintaining any changes, thus increasing theoretical-practical coherence, broadening treatment benefits and reducing relapse in psychedelic-assisted therapy. Research questions for further developing a CBS-consistent psychedelic-assisted therapy are offered.”
Author: Henry J. Whitfield
Summary
INTRODUCTION
Psychedelic-assisted therapy is a psychopharmacological intervention combining a psychedelic compound with a therapeutic context, and usually comprises three distinct phases of treatment: (1) psychotherapeutic preparation before medication session (2) a guided psychedelic medication session with psychological support (3) a psychotherapeutic integration therapy.
Psychedelic-Assisted Therapy
Preparation is needed before administering a psychedelic for therapeutic purposes. Psychoeducation and experiential exercises are often employed to help the participant trust the process.
Regarding guided medication and integration (phases 2 and 3), there is more debate. One study favoured an “open, flexible, humanistic approach” over a “structured, directive approach” and another study employed a “supportive stance” with “no significant ACT interventions or feedback provided” during the medication phase.
Psychedelic somatic interactional psychotherapy (PSIP) and flexible humanistic approaches can be helpful throughout all three phases of psychedelic therapy, and context-sensitive interventions during the medication phase are probably important for certain situations.
There is some consensus that psychological barriers can undermine the gains of psychedelic-assisted therapy, but research is lacking regarding the role of therapeutic interventions in preventing relapse.
This paper considers what CBS can offer psychedelic therapy, how it can be used to integrate different modalities, and how its processes can be adapted to address known challenges.
Why Is Acceptance and Commitment Therapy Appropriate to a Psychedelic Context?
Acceptance and Commitment Therapy (ACT) is a psychological intervention that offers empirically supported treatments for anxiety disorders, depression, addiction, somatic health. ACT is also able to cater to many psychedelic-therapy aspects, such as the crucial importance of context, accommodating spiritual and religious perspectives, and measuring self-transcendence.
The Importance of Somatic, Non-cognitive Approaches
Psychedelic-assisted therapy can use non-cognitive techniques to access the implicit, automatic or subconscious aspects of self. Holotropic Breathwork, PSIP, Focusing, and Hakomi are examples of therapies often used with psychedelics to help access the implicit.
Whilst second wave cognitive approaches have been criticised for focusing on cognitive, reflective awareness, third wave approaches such as ACT employ mindfulness processes to allow the body and its emotions to “speak” and open participants up to inner experiencing.
Debating the Self Within CBS Research
ACT is in a process of development, particularly regarding the Self, and Hayes et al. have criticised the ACT Hexagon model for oversimplifying and underrepresenting the ACT core processes of Self.
The ACT model of self is a dichotomous representation of the six psychological flexibility processes. More CBS research has been done into how Self processes are measured and understood, and the newer CBS understandings of self neglect the present moment experiencing self.
Experiences of Changing Sense of Identity
Participants in psychedelic-assisted therapy for cancer diagnosis distress and smoking cessation experienced a vivid change in their sense of identity. This change increased one participant’s ability to live the life she wanted.
MacLean et al. (52) found lasting increases in openness to experience after administering Psilocybin, and a cross sectional study of recreational MDMA found lasting increases in openness to experience.
“Ego-Dissolution” —A Dissolving Self
Researchers have suggested that distortions in the subjective experience self or ego are “central” to the psychedelic experience, and that ego-dissolution is so common that an Ego Dissolution Inventory has been validated expressly for a psychedelic neuroscience context.
Millière (58) highlights that ego-dissolution can occur with three different types of psychedelics, each acting on different brain receptors. These experiences can be positive or negative, and may need further psychological support.
Mystical Experience Beyond the Self
Psychedelics can often lead to an experience of a dissolving-self, which can be measured by the Mystical Experience Questionnaire. This questionnaire includes items related to self, such as freedom from the limitations of your personal self and a unity with what was felt to be greater than your personal self.
Confusion Around a Multiplicity of “Selves”
MDMA-assisted therapy for PTSD can lead to the experience of different “parts” of the patient, which can be confusing for the therapist. This may require addressing inner conflict between the varied selves that the patient perceives they have.
Inflated “Ego” and the Narcissistic Self
The Ego Dissolution Inventory (EDI) includes a subscale for measuring Ego-inflation, and this inflation was also associated with psilocybin. Narcissism may also be more pronounced after psychedelic experiences than would be expected, considering the immediate effect of psychedelics is commonly a reduced sense of “ego”.
Othered Selves: Meeting Entities Which Can Be Considered Hallucinations or Actual “Sentient” Beings From Another Realm
Participants in psychedelic studies of various substances often report meeting what appear to be autonomous “beings” offering guidance or other communication. These entities can be experienced as aspects of self, and may point to neglected values, new behaviours or inner avoided experiences.
Unresolved Trauma Informs Self-Storey
During psychedelic treatment, traumatic memories often surface, perhaps due to the enhanced psychological flexibility or lowering of psychological defences occasioned by psychedelics. The EBI predicts emotional breakthrough, which is the strongest predictor of long term outcomes of psychedelic therapeutic process.
In trauma research, the Centrality of Events Scale has been used to measure how central a traumatic event is to a person’s identity and life-storey. The results suggest that facing traumatic memories can be an important component of psychedelic therapy process.
Psychedelic treatments can access traumatic memories that were unexpected to both patient and clinician. Psychedelic therapists should be prepared to help participants open up to traumatic memories during the medication phase, and to continue trauma work during the integration phase.
In sum, the phenomena selected due to their relevance to self-perspective suggest that psychedelic-assisted therapy models should be responsive to trauma and rapidly changing senses of self.
A PSYCHOLOGICALLY FLEXIBLE SELF MODEL, OPTIMISED FOR PSYCHEDELIC-ASSISTED VARIATIONS OF SELF
This paper presents a spectrum of seven selves as an alternative model to ACT’s six dichotomous processes of psychological flexibility.
A new psychological flexibility model is proposed to accommodate a wide range of self-experiences encountered in a psychedelic context. It places self-perspective as the central uniting process and emphasises self-as-process as the first container of self-content.
The extensive empirical support for self-as-hierarchy informs the model and features throughout, and the model ranges from the most rigid fears inherent in unprocessed trauma, broadening through critical voices that have broader behavioural repertoires than a traumatised self, opening to more compassionate values-aware perspectives.
Self as Traumatised
The traumatised self is at the lower extreme of the continuum, and may be locked in involuntary dissociative responding to knowingly or unknowingly avoid such experience. This behaviour can be assessed in terms of whether it is moving away from a trauma-related experience, or other aversive experience.
In a psychedelic context, many different experiences of self can potentially emerge. Internal Family Systems (IFS) offers perspectives and therapeutic tasks to highlight common functions and relationships between such parts, and can facilitate self-compassion and a more nuanced perspective of self.
ACT therapists are already familiar with inner “parts” or “voices”, and Internal Family Systems (IFS) highlights common functions and relationships between the parts to enable deeper acceptance, more self-compassion and less conflict.
If an inner critic contains the child, it suggests alternatives to the child’s behaviour, and if the child contains a trauma, it serves to deny or make up for the wound. Parts work has some empirical support for treating borderline personality disorder and post-traumatic stress disorder.
These categories help to explore different self-perspectives, including trauma, child and critic. Entities can also be considered as parts.
Self as Compassionate Adult
A Compassionate Adult perspective, which contains the self-trauma-wound, the child and the critic, can be assumed after stepping into Self-as-Process and bridging towards self-as-perspective. This perspective can help to increase effect sizes when self-stigma and shame are relevant across many diagnostic categories.
Self-As-Experiencer—I Here Now
The self-as-experiencer is less identified with any particular view of self, and is more open to experiencing bodily feeling without recourse to cognitive descriptions.
Self as Pure Perspective
As psychological flexibility increases, a sense of self-as-perspective is more easily accessed, and the habitually supressed parts of a person’s psyche are allowed to emerge. This may enable radically new views of past, present and future, as well as the ability to understand the perspectives of other people.
Self as Unity
At the top of Self-as-Context, Self as Unity is the ultimate all-containing perspective in which experience is least influenced by syntactic language. Participants may only remember non-verbal ineffable aspects of such an experience, but the journey there and back may offer new perspectives on life.
fMRI imaging has detected increases in brain activity in both spatial and temporal domains, suggesting changes in here-there and now-then perceptions occur even at medium doses of LSD. Clinical implications include assessing whether such an experience could be too destabilising for some populations.
The five non-self core processes can be mapped as axes of different selves across the spectrum. This exercise fosters awareness of self-perspective throughout a person’s experience, and allows them to be in touch with two or more self-perspectives at once.
Finding Hidden Barriers to Growth
The reverse compass metaphor can be used to explore up and down the heuristic spectrum, without defence or bias. This approach aligns with a classic psychedelic therapy technique of in and through, in which a participant is instructed to look a demon in the eye. Encouraging an awareness of the function of any mode of self may help to increase psychological flexibility throughout the spectrum.
This spectrum of selves model is configured to assess for and respond to traumatic self-storey events, normalise and respond to multiple selves, place self-perspective taking as the central process, and prepare for altered-states of consciousness.
Ram Dass argues that as one individual changes, the system changes, and that methods for retention of new behaviour are important. How might newly emergent self-perspectives and corresponding new behaviours be successfully reinforced during integration?
Psychological Flexibility
There is preclinical evidence for increased neuroplasticity following medication of psilocybin, and clinical opinion suggests that the timing of the integration phase can be optimised to take advantage of a temporary “afterglow”. This model suggests that reinforcing new behaviours in a timely fashion may reduce relapse.
Psychedelic-Assisted Behaviour Change
Psychedelic-assisted psychotherapy may have greater effect sizes than known psychotherapy or pharmacological interventions to date for PTSD, anxiety/depression associated with a life-threatening illness, unipolar depression, and social anxiety among autistic adults. However, a greater increase in psychological flexibility may invite a higher degree of behaviour change.
A systemic approach to behaviour change has already emerged in CBS (31) that integrates the evolutionary meta-processes of variation, selection and retention through multiple levels of behaviour: physiological, social and cultural. This article will consider what systemic, sociocultural barriers to change may need to be addressed.
In psychedelic literature, the importance of socio-cultural support during integration is commonly emphasised. This paper considers how to systematically foster helpful behaviour change.
Reinforcing New Self Repertoires Through Multiple Levels of Cooperation
Bourzat and Hunter (78) explore and encourage change broadly, through four domains of (1) Self-care (2) Relationships (4) Community, and (5) Environment. It is helpful to keep track of the new self-perspectives and the barriers they meet, as they can be forgotten.
Figure 3 shows an anonymized example of a multilevel grid that can be used to identify barriers to change and reinforce self-sustaining behavioural paths to long term change.
Coherence as a Reinforcer for Change
A participant received four integration sessions during which the content of Figure 3 was collected and formulated. The red, orange and yellow boxes represent behavioural paths of self-as-storey patterns that may have become clearer during the psychedelic medication or integration sessions.
This model allows for mapping behaviours from left to right and up and down, and also allows for mapping behavioural coherence between levels. For example, meditation can contribute to multiple domains of a person’s life.
A systemic incoherence is a situation where behaviours are out of alignment with a person’s most important values across these four domains. A consciously chosen cross-domain functional coherence can increase a person’s awareness of reinforcing contexts to cultivate, and reduce the effects of punishing contexts that need to be addressed.
A woman with a history of childhood sexual abuse could use the value of breaking the mould to inform her behaviour throughout all four domains, including increased acceptance of older selves.
Cultivating Contexts to Reinforce New Selves
The bottom right green box, Self-care “Self as compassionate adult”, may be of particular importance if it can have the multiple functions of increasing the ability to remain present and potentially extend the afterglow, as well as increasing likelihood of addressing the situations.
Action Implications
This grid can either guide case formulation with a supervisor or be actively shared with the participant as an interactive spreadsheet. It can be used to help integrate new and old behaviours, and can help maintain capacity for self-compassion.
When neuroplasticity and psychological flexibility are heightened by psychedelic compounds, new habits can be intentionally shaped in the light of the participant’s new perspectives.
DISCUSSION
This paper has considered how to integrate recent contextual behavioural science research with psychedelic-assisted psychotherapy, to help people live a better integrated life. This model aims to dovetail with both ends of a psychedelic experience, and so a deeper preparation phase could contribute to a deeper therapeutic process during the medication phase, which can be continued and consolidated during the integration phase systemically.
The introduction to this paper touched on the debate regarding when and how to be directive, and how to do so whilst respecting the participants experience. This model may make such directive decisions easier, if the participant is acquainted with their inner critic and reverse compass during the preparation phase.
The functional view of positive self-perspectives can contribute to the debate in psychedelic therapy research regarding whether acute positive mystical experience is a key mediator of long-term success in psychedelic therapy, or conversely whether willingness to face emotionally difficult feelings/trauma is essential to therapeutic progress.
This Spectrum of Selves model suggests that there are different levels of psychological flexibility, which could be related to different faculties of neurobiological functioning. This could inform future studies that attempt to discern the less common, yet therapeutically useful properties contained in a fuller spectrum of psychological flexibility.
There are many therapeutic modalities that can aid the development of psychedelic-assisted therapy, and CBS has a unique package of precise lab-tested definitions of self, an understanding of how context influences and sustains behaviour change, and a functional analytic framework for integrating therapeutic modalities.
LIMITATIONS
The author of this article attempted to set a coherent theoretical foundation for a CBS-consistent psychedelic-assisted therapy, but it is likely that the seven modes of self can be better defined and more closely aligned with neurobiology, Relational Frame Theory and mystical experiences of self.
The new approach here described has only been tested with Psilocybin and is likely to be less helpful with psychedelics that have a different neuroreceptor profile.
FUTURE DIRECTIONS
Longitudinal, high-density idionomic series data could help to clarify how different elements of this model perform in different contexts and populations, and could be coupled with randomised double-blind placebo-controlled trials to investigate subgroup processes.
Specific hypotheses such as whether increased coherence and alignment between personal, relational and communal domains predict lasting changes in behaviour and well-being, and whether preparative self-perspective taking exercises during the preparation phase increase the extent of perspective taking during the psychedelic experience. Psilocybin may increase the effectiveness of trauma-focused imaginal exposure during the afterglow period, and a trauma-ready model may increase access of aversive memories during the medication session and/or integration phases. A tracking of the function of positive self-storeys during integration may reduce narcissism.
Participants could capture data regarding whether somatic work improved outcomes. This could be measured quantitatively, qualitatively and longitudinally.
CONCLUSION
This article aimed to integrate psychedelic science and contextual behavioural science in a way that can inform therapeutic interventions for multiple psychedelic therapy challenges. It offers a workable approach for fostering variation in self-perspective throughout the three phases of psychedelic-assisted therapy.
A containing awareness of behavioural function can be helpful in psychedelic therapy, especially during the integration phase. Active-directive interventions can help participants reconnect with their inner experiences, and person-centred approaches can help them transcend barriers to reaching the integration phase.
Ongoing psychedelic neuroscience findings may suggest a broader spectrum of psychological flexibility, which could be useful to optimise functional psychological flexibility throughout the three phases of psychedelic therapy.
ETHICS STATEMENT
The studies involving human participants were reviewed and approved by the Psychology Research Ethics Committee, and written informed consent was obtained from the participants.
ACKNOWLEDGMENTS
This manuscript was influenced by many people, including David Gillanders, Hattie Sharpe, Robert Krause, Louise McHugh, Rosamond Watling, Maria Luca, Kim Kuypers and Larry Leeman. It also includes the work of Lucyne Pearson, Karlie Shelley, the reviewers, Fiona Kennedy, Bruce Stevenson, Vanessa Gomes, Brandon Samford and Darren Whiteman.