Ethics and ego dissolution: the case of psilocybin

This theoretical paper (2020) argues the case for an updated consent process for people undergoing an experience with psilocybin. The paper touches upon the novel risks, the differences with consent for other psychiatric medications, and that between clinical research and mainstream use in psychiatry.

Abstract

“Despite the fact that psychedelics were proscribed from medical research half a century ago, recent, early-phase trials on psychedelics have suggested that they bring novel benefits to patients in the treatment of several mental and substance use disorders. When beneficial, the psychedelic experience is characterized by features unlike those of other psychiatric and medical treatments. These include senses of losing self-importance, ineffable knowledge, feelings of unity and connection with others and encountering ‘deep’ reality or God. In addition to symptom relief, psychedelic experiences often lead to significant changes in a patient’s personality and worldview. Focusing on the case of psilocybin, we argue that the peculiar features of psychedelics pose certain novel risks, which warrant an enhanced informed consent process–one that is more comprehensive than what may be typical for other psychiatric medications. We highlight key issues that should be focused on during the consent process and suggest discussion prompts for enhanced consent in psychedelic psychiatry. Finally, we respond to potential objections before concluding with a discussion of ethical considerations that will arise as psychedelics proceed from highly controlled research environments into mainstream clinical psychiatry.“

Authors: William R. Smith & Dominic Sisti

Summary

AbstrAct

Early-phase trials with psilocybin- assisted psychotherapy, 3,4-methylenedio xmethamphe tamine (MDMA), lysergic acid diethylamide (LSD) and ayahuasca have shown promising results for treatment-resistant depression, cancer-related depression and anxiety.

Psychedelics induce peculiar, so-called ‘mind-manifesting’ experiences in the subjects that benefit, including a sense of new, ineffable knowledge, feelings of unity and connection, and encounters with ‘deep’ reality or God.

Despite its recent renaissance, psychedelic psychiatry has attracted very little attention among medical ethicists. The most pressing questions regarding psychedelics concern the established and growing work in psychiatry pointing to the potential for widespread use and benefit.

We fill a gap in ethical analysis by focusing on psilocybin, one of the most well- researched psychedelics, and recommend guidance for informed consent in both research and clinical contexts.

Before proceeding, two clarifications about terms are necessary. First, we will use the term psychedelic to refer to all substances with ‘mind-manifesting’ properties, and second, our analysis generally applies to other interventions with serotonergic psychedelics.

Second, we will use the term personality broadly to refer to the narrative features and values of an agent that make them a distinctive (type of) person. This broad sense of personality is common in lay English discourse, even if less specific than some usage in the psychology literature.

PErsONAliTy ChANgE ANd NEurObiOlOgy Of PsilOCybiN-AssisTEd PsyChOThErAPy

Psilocybin’s therapeutic benefits have been best studied in the cases of anxiety and depression in terminal illness as well as TRD. It is associated with feelings of internal and external unity, sacredness, positive mood, transcendence and ineffability, and with the realization that life and death are part of one circle.

Using validated instruments, researchers have found that psilocybin increases conscientiousness, extraversion and openness and decreases neuroticism. However, therapeutic psilocybin appears to induce personality changes beyond those clearly measured by the NEO PI-R .

Psilocybin increases subjects’ sense of connection, including feelings that people, animals, and trees are all connected. They also feel more emotionally open to significant others.

The mechanisms of psilocybin’s effects remain under investigation, but neuroimaging suggests that it may involve acute decreases in functional connectivity of metacognitive centres, such as the default-mode network. This may explain reported enhanced sensory experience and a sense of openness and connection.

Psilocybin may have therapeutic effects by increasing cognitive flexibility and mindfulness-related capacities, or by making subjects more suggestible.

Why ENhANCEd CONsENT?

Psilocybin may require enhanced consent processes beyond those typical of many informed consent discussions.

There is consensus among ethicists and legal scholars that providers must disclose information about a treatment to a reasonable patient. The standards vary according to context and the intervention in question.

Most psychiatric interventions can be covered in a few minutes, and can include common side effects as well as severe ones. The provider can then invite any questions and direct patients to informational handouts if they find these helpful.

The rationale for simple informed consent for SSRIs and antipsychotics stems in large part from the fact that a reasonable person can be expected to care mostly about the most common and most severe effects.

disClOsurE TOPiCs iN ENhANCEd CONsENT

Psilocybin therapy may cause unexpected shifts in values and personality, rare mental health side effects, and therapeutic touch.

shifts in values and personality

Two risks regarding change in values and personality are worth noting. First, some patients may be troubled by the development of a newfound sense of spirituality or belief in God.

Psychedelic experiences are ineffable, and patients may not appreciate that they too could have intense spiritual experiences. Enhanced consent may increase the probability of patients appreciating the possibility of personality change.

Mental health risks

While ‘transient anxiety’ is often considered ‘mild’ or ‘moderate’, severe anxiety could become more common with clinical psilocybin use outside of the tightly controlled experimental environment.

Psychosis is a mental health risk with psilocybin use, but clinical trials have reported no episodes of psychosis. However, screening may relax as psilocybin transitions to clinical practice.

Some authors suggest that concerns about the negative psychological effects of psychedelics are unfounded, but a survey found 3 self-reports consistent with enduring psychosis after psilocybin use. Additionally, a lifetime history of use, complicated by substance-induced psychosis, would not necessarily correlate with recent symptoms.

There may be psychosis-related risks other than acutely inducing psychosis, such as a risk of violent behaviour in individuals with schizophrenia. Enhanced consent should address these risks.

The third mental health risk is that of trauma re-exposure. Clinicians will have to inform subjects about this possibility as well as be prepared to address it.

Therapeutic touch

Psychedelic psychotherapists have expressed ethical concern about the use of therapeutic touch in psychedelic therapy, but current protocols require therapists to work in pairs and ensure the presence of a consultant and witness.

When patients change their minds about whether they would or would not like therapeutic touch during the psychedelic experience, it is particularly challenging to assess their decision-making capacity.

Even if such assessment is impractical, ethical guidance can be offered. In particular, therapists must respect autonomy when a patient rejects therapeutic touch.

In the second scenario, a patient may become agitated and may need redirection or restraint. This is different from therapeutic touch.

In some cases, patients who initially decline therapeutic touch during the consent process change their mind and ask to be touched. In these cases, therapists may provide therapeutic touch despite the initial declination.

Additional research is necessary to determine the frequency with which patients change their preferences for therapeutic touch and how they feel about various policies and practices regarding touch. Legal and ethics scholars should help develop standards for therapeutic touch.

ENhANCEd CONsENT ANd CurrENT PrACTiCE

Current research practices for psychedelic research may not meet the demands of enhanced consent, particularly during the sessions designed to prepare research participants for psychedelic psychotherapy.

The authors detail preparatory sessions, which are intended to introduce subjects to logistics of treatment sessions, build a therapeutic relationship with participants, and provide guidance on how to address challenging experiences. However, they believe that these sessions should also be considered part of informed consent.

is PsilOCybiN rElEvANTly diffErENT?

The chief concern about our argument is that psilocybin is different from standard psychotropics, like SSRIs. However, psilocybin is not the first psychotropic to raise concerns about changes to patients’ personalities.

There are critical differences between psilocybin and conventional psychiatric treatments. First, the personality changes effected by psilocybin are different in both kind and degree from those of conventional psychiatric intervention, and second, patients may lack the time to revisit the disclosure process to informed consent.

Psilocybin appears to induce changes in personality that are not explained by changes in the five factor model. These changes are at least as ethically salient as changes to the five factor model.

suggEsTibiliTy ANd CAPACiTy TO CONsENT

Two objections must be addressed: enhanced consent might limit psilocybin’s power to induce suggestibility, and research concerns might arise about difficulties in controlling for this disclosure- related effect.

Given the discussion above, it may be material to discuss with patients whether psilocybin makes them more suggestible to certain beliefs they would not otherwise endorse. Additionally, enhanced consent may result in a smaller effect size for psilocybin.

The final objection charges that patients cannot consent to psilocybin- assisted psychotherapy if the experience is ineffable. Yet, we take consent to traditional psychotherapy as authoritative despite effects on personality and worldview that subjects cannot fully appreciate before therapy.

ThE EThiCs Of gOiNg MAiNsTrEAM

There has been a long history of concerns about personality-changing interventions beyond the concerns about SSRIs’ effects on personality noted above. However, many of these concerns have been proved to be unfounded, and many transplants have proven successful without evidence of such problems.

This history reminds us of the importance of caution in drawing conclusions from initial research. If psilocybin induces personality changes that are not well-accounted for on the Five-F actor Model, we may need new instruments to assess how participants understand changes to personality.

Psilocybin is like other novel therapeutic modalities in that ethical challenges arise because of limited knowledge of mechanisms, safety and further benefits. Therefore, it is important to develop careful policy safeguards for the most obvious risks.

Third, therapists believe that intense psychotherapy is necessary for benefit or safety when using psychedelics including psilocybin. However, no trials have been conducted to demonstrate that such psychotherapy is necessary or to assess how much is necessary.

Participants had profoundly positive feelings about the experience, and the risk-benefit analysis of psychedelic intervention seems favourable for those who are screened as having low-risk for psychosis.