Learning to Let Go: A Cognitive-Behavioral Model of How Psychedelic Therapy Promotes Acceptance

This model-building article (2020) argues that psychedelic-assisted therapy works to relax beliefs and increases acceptance via operant conditioning. This leas to less avoidance, more learning, and positive psychological outcomes.

Abstract

“The efficacy of psychedelic-assisted therapies for mental disorders has been attributed to the lasting change from experiential avoidance to acceptance that these treatments appear to facilitate. This article presents a conceptual model that specifies potential psychological mechanisms underlying such change, and that shows substantial parallels between psychedelic therapy and cognitive behavioral therapy: We propose that in the carefully controlled context of psychedelic therapy as applied in contemporary clinical research, psychedelic-induced belief relaxation can increase motivation for acceptance via operant conditioning, thus engendering episodes of relatively avoidance-free exposure to greatly intensified private events. Under these unique learning conditions, relaxed avoidance-related beliefs can be exposed to corrective information and become revised accordingly, which may explain long-term increases in acceptance and corresponding reductions in psychopathology. Open research questions and implications for clinical practice are discussed.“

Authors: Max Wolff, Ricarda Evens, Lea J. Mertens, Michael Koslowski, Felix Betzler, Gerard Gründer & Henrik Jungaberle

Notes

This paper is included in our ‘Top 10 Articles Introducing Psychedelic-Assisted Therapy‘

Summary

INTRODUCTION

Several early-phase clinical trials have shown that classic serotonergic psychedelics may occasion substantial and often sustained symptom reductions in patients treated for depression, psychological distress related to life-threatening illness, obsessive-compulsive disorder, and substance use disorders. The psychological mechanisms underlying these effects remain unclear.

Promoting Acceptance in Cognitive Behavioral Therapy

Many symptoms of mental disorders can be interpreted in terms of avoidance, such as passivity, withdrawal, rumination, intoxication, obsessive-compulsive disorder, washing rituals, etc. However, these avoidance strategies come at an immense longer-term cost.

The role of avoidance in psychopathology is recognized by all major schools of psychotherapy, but is especially emphasized in the so-called third wave of CBT. Acceptance is considered a core mechanism of positive behavior change in third-wave CBTs.

CBT aims to facilitate lasting change from experiential avoidance to acceptance by revising avoidance-related beliefs, which can be changed via Socratic dialogue, metaphors, decentering or psychological distancing, defusion exercises, etc.

Avoidance-free exposure is applied in classical CBT of anxiety disorders to induce corrective experiences with otherwise avoided private events. Acceptance-based CBT commonly pursues exposure through mindfulness-based exercises, which resemble classical exposure treatment of anxiety disorders in that a stimulus is openly attended to while desisting from avoidant responses.

Motivational interviewing techniques and metaphors can be used to reduce avoidance motivation, and experiential methods can be used to demonstrate the futility of avoidance.

Avoidance and Acceptance in Psychedelic Therapy

Psychedelic therapy involves administering one to a few moderate or high doses of a classic serotonergic psychedelic under carefully controlled conditions in a professional clinical setting.

The positive long-term effects of psychedelic therapy are mediated by the quality of the acute psychedelic experience. Avoidance and acceptance are often central themes of patients’ psychedelic experiences, and challenging experiences are often characterized by extreme fear or panic. Psychedelic therapy is often associated with emotional breakthrough experiences, which are commonly described as insightful and rewarding. This article presents a conceptual model according to which psychedelic therapy can facilitate the same acceptance-promoting learning process as that targeted by CBT interventions.

The Relaxed-Beliefs Account of Psychedelics’ Acute Brain Action

A theory of psychedelics’ psychopharmacology was proposed that explains their various psychotropic effects as the result of psychedelic-induced belief relaxation. This theory is based on the concept of predictive processing, arguably the leading unified account of brain and mind function.

The brain’s ability to form new beliefs and change existing ones is assumed to be guided by the principle of prediction error minimization. However, the sensitivity of beliefs toward ascending prediction errors may vary, and heavily-weighted high-level beliefs may exert far-reaching constraining effects.

The relaxed-beliefs account states that psychedelics reduce the weight of higher-level beliefs, which leads to a less constrained, more flexible state of mind. This state is characterized by increased context sensitivity, and is the cause of phenomena like visual-auditory synesthesia.

A COGNITIVE-BEHAVIORAL MODEL OF HOW PSYCHEDELIC THERAPY PROMOTES ACCEPTANCE

In this section, we describe some possible corollaries of belief relaxation that can explain how psychedelic therapy promotes lasting change from experiential avoidance to acceptance.

Operant Conditioning of Acceptance

In psychedelic therapy, acceptance is conditioned instead of avoidance, and an avoidant response (running away) would have been punished. This can explain how a patient can learn to accept a terrifying creature instead of running away.

Avoidance Sensitivity

In the anarchic brain, increased bottom-up information flow from limbic into higher cortical areas may allow avoidance-related processes to infiltrate and distort perception in ways that resemble synesthetic phenomena. This may lead to the emergence of threat-related perceptual content.

Due to avoidance sensitivity, psychedelic states may be characterized by an intrinsic tendency to punish avoidance and reward acceptance. However, avoidance may be intensified in psychedelic therapy by the patient’s lying down body position and the absence of well-defined sensory input.

Shaping Acceptance

The patient may use overt avoidance behaviors to seek distraction and tune down the intensity of aversive experiences, but due to avoidance sensitivity, the attempt to exert control over the flow of events will likely aggravate aversive features of the experience, leading to an even stronger avoidant response.

As soon as the patient spontaneously shows a minimum of acceptance toward an aversive aspect of the experience, an automatic form of shaping may begin. This process may allow the patient to rapidly achieve high levels of acceptance toward challenging psychedelic experiences.

Psychedelic therapy requires the patient to assume an accepting attitude toward the psychedelic experience, and to be encouraged to “trust, let go, and be open”. The purposefully created atmosphere of support, safety, and trust is also necessary.

Psychedelic-induced belief relaxation may lead to exceptional openness to previously “hidden” or “suppressed” feelings during dosing sessions. This may be because the top-down constraints on emotional, mnemonic, and perceptual processes are dissipated.

Psychedelic therapy sessions usually last several hours, and patients sometimes report a sense of being drawn into or guided towards “necessary experiences”, bearing the notion of an “inner therapist”. It is possible that periodic returns to avoidant responding drive the flow of private events towards what the patient most vigorously avoids in everyday life.

In the controlled context of psychedelic therapy, sensory deprivation in the visual, tactile, and proprioceptive domains will enhance the elicitation and intensification of private events, and music will enhance the personal meaningfulness of psychedelic experiences.

Relaxation of Avoidance-Related Beliefs

Pathological avoidance patterns are sustained by avoidance-related beliefs that motivate avoidant behavior and impede corrective experiences. Psychedelic therapy may open a temporary window of plasticity through which these beliefs may undergo revision.

When exposure to a multitude of greatly intensified private events is enabled by operant conditioning of acceptance, large prediction errors may often contradict negative expectancies, leading to highly generalized acceptance beliefs. Psychedelic therapy may be similar to fear exposure treatment in CBT, in that it may facilitate the revision of implicit expectancies and reduce threat responses to private events through mechanisms related to extinction learning. Psychedelic experience may induce negative expectancies about the outcomes of desisting from avoidance, but actual outcomes are often strongly rewarding, thus violating negative expectations.

Psychedelic experiences that involve breakthrough experiences and episodes of relatively avoidance-free exposure to otherwise avoided private events may profoundly transform the patient’s way of relating to private events.

Measuring Acceptance-Related Processes in Psychedelic Therapy

The proposed conceptual model of psychedelic drug action assumes that long-term responses to psychedelics are predicted by relevant aspects of the acute drug response. This model is currently being tested in qualitative studies, but quantitative studies are needed to test and further develop this model. Assuming that acceptance is a central factor in psychedelic therapy, decreases in experiential avoidance should be expected to partially mediate positive clinical outcomes.

Examining the Role of Challenging and Breakthrough Experiences

Previous studies have found mixed results regarding the long-term effects of challenging psychedelic experiences, with some studies finding positive effects and others finding negative effects.

Therapeutic benefits of psychedelics may be due to the personal insight and emotional catharsis that follow the relevant experience(s) of psychological struggle. However, the therapeutic value may also lie in the preceding shaping of acceptance, subsequent exposure to otherwise avoided private events, and corresponding changes in avoidance-related beliefs. From the learning perspective presented here, challenging experiences in a second or third dosing session might be reduced, but the patient may still undergo therapeutically valuable exposure.

Examining the Role of Ego-Dissolution Experiences

Most evidence supporting the EP model’s core assumption that acute responses to psychedelics predict longer-term outcomes relates to acute ego-dissolution. We propose that covert and overt avoidance behaviors may impede the disruption of self-related high-level beliefs, and thus prevent blissful ego-dissolution.

A conceptual model for psychedelic use suggests that mystical-type experiences are a highly rewarding consequence of letting go of avoidance strategies. This view is supported by evidence that mystical-type experiences are followed by long-term reductions in psychopathology, greater well-being, and increased openness.

Integrating Psychedelic Interventions Within Cognitive-Behavioral Treatment Models

According to the proposed model, psychedelics can promote the same acceptance-promoting learning process as CBT interventions. This suggests that psychedelic therapy can be fruitfully integrated within acceptance-based CBTs, most notably ACT, but also CBT more generally4. Future clinical studies with psychedelics should investigate the effects of systematically varying psychological interventions, and whether these effects are moderated by patient characteristics.

Acceptance should not be seen as an end in itself, but rather as a requirement for living in accordance with one’s chosen values. Psychedelic therapy protocols that include values work could optimize treatment outcomes.

Direct Implications of the Model for Clinical Practice

A hypothesis presented here is that psychedelics can transiently compromise the effectiveness of avoidance strategies for reducing aversive states, and that this has important ethical implications for clinical practice.

According to our model, the patient must first show a minimum of acceptance toward an aversive aspect of the experience at some point. This may inform therapeutic strategies for dealing with challenging experiences, such as supporting the patient’s decision for avoidant responding before encouraging acceptance again.

The proposed model of psychedelic therapy explains increases in acceptance in terms of revised avoidance-related beliefs. The long-term outcomes of the therapy depend on how enduring the newly established acceptance beliefs are, and how the patient’s social environment responds to the changes.

Clinical Targets

Psychedelic therapy may have positive effects in mental disorders that are typically characterized by excessive experiential avoidance, but may have less promise in conditions where avoidance is not considered a central factor, such as attention-deficit/hyperactivity disorder (ADHD) or psychotic disorders.

If a patient’s patterns of experiential avoidance are too inflexible to make use of challenging psychedelic experiences, the therapy may have no therapeutic value or even aggravate avoidance-related beliefs. Further research is needed to determine criteria for psychedelic treatment eligibility. State measures may eventually emerge as more robust predictors of treatment outcomes.

Applicability to MDMA-Assisted Psychotherapy

Although not a classic psychedelic, MDMA is applied in therapeutic interventions following protocols which closely resemble those used for psychedelic therapy. MDMA-assisted psychotherapy shows remarkable promise as a treatment for PTSD, and may parallel CBT in promoting motivation for acceptance, avoidance-free exposure, and the revision of avoidance-related beliefs.

CONCLUSION

Psychedelics’ therapeutic effects appear to depend on psychological processes that are evoked by synergies between their pharmacological action and the context in which they are administered. A CBT model was proposed that demonstrates the usefulness of the relaxed-beliefs account as a basis for building theories of psychedelic drugs’ therapeutic effects.