Exploring the Use of Psilocybin Therapy for Existential Distress: A Qualitative Study of Palliative Care Provider Perceptions

This qualitative interview study (n=5) examines the attitudes of palliative care workers towards the use of psilocybin therapy for death anxiety and identified common themes concerning the perceived barriers of treating existential distress and their uncertainty about the risks and benefits of psilocybin.

Abstract

“Introduction: There is a growing body of research suggesting that palliative care patients coping with existential distress may benefit from psilocybin. However, there is a large gap regarding the perceptions of palliative care providers who may provide education, counseling services, recommendations, and/or prescriptions for psilocybin if it is decriminalized, commercialized, and/or federally rescheduled and legalized. The aim of this study was to explore the experiences and perceptions of interdisciplinary palliative care providers regarding existential distress and the use of psilocybin therapy.

Methods: Five (n = 5) health care providers from a hospital-based palliative care team completed a semi-structured interview related to their experiences supporting patients with existential distress and their beliefs and attitudes related to psilocybin as a possible treatment modality.

Results: A qualitative descriptive approach was used to identify key themes which included: 1) multiple barriers to addressing existential distress at the cultural, institutional/organizational, relational, and individual levels, 2) the duality and power of presence, 3) suffering as an intrinsically subjective phenomenon, and 4) uncertainty about the risks and benefits of psilocybin.

Discussion: To inform an inclusive, safe, and holistic approach, more research is needed regarding the possible integration of psilocybin therapy within palliative care for the treatment of existential distress.”

Authors: Coryn E. Mayer, Virginia T. LeBaron & Kimberly D. Acquaviva

Summary

Five palliative care providers were interviewed regarding their experiences supporting patients with existential distress and their beliefs and attitudes related to psilocybin as a possible treatment modality. The study identified several key themes including: multiple barriers to addressing existential distress and uncertainty about the risks and benefits of psilocybin.

Introduction

Psilocybin is a naturally occurring psychedelic compound found in certain species of mushrooms. It is considered illegal under Federal law, but some research indicates that it may have therapeutic benefits.

In recent years, decriminalization initiatives regarding psilocybin have gained momentum. Oregon became the first state to decriminalize psilocybin use and legalize psilocybin therapy for commercial medical use in November 2020.

Addressing existential distress is a foundational element of providing quality palliative care, and PT can be used to alleviate existential distress in patients coping with a chronic and/or life-limiting illness.

Psilocybin therapy (PT) is the use of psilocybin in a highly controlled manner to minimize risk for adverse effects and encourage therapeutic outcomes. It may offer patients with life-limiting illnesses hope in finding greater meaning in dying.

While psilocybin may become more mainstream, much remains unknown regarding the perceptions of palliative care providers regarding existential distress and psilocybin as a possible treatment modality.

Participants

We recruited participants from an academic medical center palliative care team using a purposeful sampling strategy. The participants were informed that the goal of the study was to explore provider perceptions of PT.

Measures

A semi-structured interview guide was designed to explore providers’ experiences caring for patients with existential distress.

Procedures

After providing informed consent, providers were invited to participate in a semi-structured interview. The interviews were conducted over Zoom.us video conferencing software by CM, lasted approximately 45 minutes, were audio recorded with permission, and were transcribed using Zoom.us transcription software.

Data analysis

Transcripts were verified against the raw audio files, cleaned, and scrubbed of all participant identifiers. An inductive, descriptive qualitative approach was used to analyze the data, and a concept map was created.

Results

Five interdisciplinary palliative care professionals participated in the study. The main themes were: the duality and power of presence, suffering as an intrinsically subjective phenomenon, and uncertainty about the risks and benefits of psilocybin.

Theme 1: Multi-level barriers to exploring and addressing existential distress

Participants described a cultural lack of expectation for existential and spiritual care in the health care domain, and the dominant curative and commercial paradigm in Western medicine that focuses on prolonging life, avoiding death, and relying on “pills” to fix problems rather than time, energy, and people.

Participants described how miscommunication about treatment plans may contribute to existential distress, as well as relational barriers, professionalism, and personal discomfort talking about death and dying with patients.

Theme 2: The duality and power of presence

Every participant discussed presence as an essential element of providing quality palliative care. Presence can be healing or harmful, and requires vulnerability and trust from both the provider and the patient.

Some providers described the harmful force of presence if the individual lacks a grounded presence, is unaware of their own power, or crosses boundaries inappropriately.

Theme 3: Suffering as an intrinsically subjective phenomenon

Participants discussed different characteristics of suffering, including universal, collective, interdimensional, transferable, and individual suffering, as well as suffering coexisting with love.

The universal nature of suffering was described as being a part of the human experience, regardless of individual differences. Some providers described suffering as interdimensional, influenced by personality and emotions, and manifesting with intractable symptoms, incongruent emotions, and a desire for hastened death.

Providers described how suffering can affect someone who is not experiencing the illness or the dying, and how everyone experiences suffering in their own unique way, internally.

Theme 4: Uncertainty about the risks and benefits of psilocybin

Familiarity, attitudes, and openness/support of psilocybin varied among providers, and perceptions of psilocybin as a treatment for existential distress varied widely. Providers expressed divergent views regarding the necessity, novelty, fruitfulness, accessibility, and applicability of psilocybin, which were reflective of their individual scopes of practice and expertise.

Participants questioned the integration of PT into mainstream practices and if it should be a new specialty or integrated within existing interdisciplinary practices.

Discussion

This research explores how psychedelics can be used to address existential distress in patients near the end of life, and how health care professionals can improve their presence to adequately address patients’ existential distress.

Palliative care team members reported multi-level barriers to exploring and addressing existential distress, which raises the question if psychedelic therapy could integrate within the health care system without first improving barriers to treating existential distress.

From the interviews, it was found that presence was a significant role in providing quality palliative care. An “empathetic abiding presence” was identified as a key competency for psychedelic guides.

The nurse participant shared that the most important factor in shaping patient experiences is who accompanies the person during PT. Non-judgmental rapport and partnership are important for therapeutic outcomes, but there are risks of a harmful presence.

It is not uncommon for patients to idolize health care professionals, and psilocybin increases suggestibility, so there is heightened risk for coercion and abuse during PT. In addition, 25% of psychiatrists consider psychedelics as unsafe, even under the control of health care professionals.

Our sample of palliative care providers discussed many competencies for a psychedelic practitioner, but three were unfamiliar with PT for existential distress, which underscores the importance of educating health care professionals on the physical, psychological, and existential effects of psychedelics.

Our findings reiterate the subjective nature of suffering, healing, and spirituality. Although some progress has been made, the question of how psychedelic clinical research will integrate within mainstream health care practice and to diverse populations remains.

Participants compared psilocybin to medical cannabis and medical ketamine as possible routes for legal medical psilocybin use, and two expressed concern over accessibility and cost. However, many unknowns remain, including who will be involved in the provision of PT, how facilitators will be trained, and who will have access.

Our sample of providers emphasized the need for a team-based approach to address existential distress, but psilocybin-containing mushrooms remain a Schedule 1 substance.

This paper presents many parallels between comprehensive palliative care and PT, including the potential ability to overcome suffering. Additionally, it reaffirms the importance of training health care providers to foster a meaningful presence with patients.

A study of palliative care professionals’ perceptions of PT for existential distress can inform future research and help develop inclusive, trauma-informed, patient-centered, and safe existential care models.

The study was limited to one academic institution and included only male, white, health care providers with significant experience in palliative care and working with patients coping with existential distress.

Psilocybin therapy is a possible approach to address patient existential distress, but palliative care professionals are generally unfamiliar with it. Additional research is needed to better understand its benefits.