Psilocybin-assisted therapy of major depressive disorder using Acceptance and Commitment Therapy as a therapeutic frame

This theory-building paper (2020) argues for the synergy between Acceptance and Commitment Therapy (ACT) and psilocybin-assisted therapy, describes the process, and limitations to using this framework.

Abstract

“Psychedelic-assisted therapy is based on the premise that psychedelic substances can act as catalysts or adjuncts to psychotherapeutic processes. Recent clinical trials involving psychedelic-assisted therapy have generally employed a similar three-part structure consisting of preparation, support during the dosing sessions, and subsequent “integration.” However, the content of these sessions and the frame through which the therapists approach participants and understand the clinical process has thus far been inconsistent among studies. In designing a manualized therapy protocol for a small clinical trial of psilocybin-assisted therapy for major depressive disorder, our group sought to delineate an explicit and replicable, evidence-based model that intentionally builds upon both the neurobiological actions of the medication and the phenomenology of the drug experience. Having identified considerable concordance in proposed mechanisms of change between Acceptance and Commitment Therapy (ACT) and psilocybin therapy, we employed ACT as an overarching psychotherapeutic framework. We hypothesize that the psilocybin experience can provide direct experiential contact with ACT processes that increase psychological flexibility, and that these deeply felt experiences may in turn be reinforced during ACT-informed follow-up therapy sessions. In this paper, we describe the rationale for selecting ACT, areas of potential synergism between ACT and psilocybin-therapy, the basic structure of our treatment model, and limitations to this approach.”

Authors: Jordan Sloshower, Jeffrey Guss, Robert Krause, Ryan M. Wallace, Monnica T. Williams, Sara Reed & Matthew D. Skinta

Summary

Abstract

Psychedelic-assisted therapy is based on the premise that psychedelic substances can act as catalysts or adjuncts to psychotherapeutic processes. This paper describes the rationale for selecting Acceptance and Commitment Therapy (ACT) as an overarching psychotherapeutic framework, the basic structure of our treatment model, and limitations to this approach.

1. Introduction to Models of Psychedelic-assisted Therapy

LSD, psilocybin, DMT, and mescaline are classical psychedelics, which alter cognition, perception, and emotion through agonist of serotonin 5HT-2A receptors in the brain. They have been shown to have therapeutic potential in a variety of mental disorders.

Most researchers and therapists assume that the subjective and experiential effects of psychedelic substances play an important role in therapeutic outcome, in addition to their direct pharmacologic effects. Set and setting are important factors in maximizing safety, reducing the risk of harmful experiences, and enhancing therapeutic response.

Psychedelic-assisted therapy involves three parts: preparation, support, and integration. The preparation sessions aim to accomplish several important tasks, including developing therapeutic rapport with the participant.

The preparation phase involves discussing logistics for the dosing session, delineating acceptable boundaries of interaction between the participant and the therapist, and assisting the participant in setting intentions for their dosing session. The support phase involves providing emotional support for engaging with difficult thoughts, sensations, or memories that arise.

Most clinical trials of psychedelic therapy have followed a basic model, but the content of the preparation and integration sessions has varied considerably among protocols, based on the condition being treated and the therapeutic orientation of the researchers and therapists.

Some large-scale clinical trials of psilocybin treatment for major depressive disorder are employing nonspecific models of “psychological support”, because it is not clear how best to integrate the psychedelic experience into treatment models designed to have specific therapeutic effects.

We feel that a condition-specific treatment modality should be employed in the overall course of psychedelic therapy for moderate to severe diagnosed mental disorders, and that a non-specific, supportive psychosocial container is the best method to address such a complex clinical situation.

Failure to outline a coherent therapeutic approach with standardized therapy procedures presents a problem for controlled research, as therapists are likely to employ their own intuitive therapeutic modalities at different times and in different ways with different participants.

We agreed with the NIH that research should be guided by a hypothesis about why the behavior exists and how best to change it. We decided on several empirically studied depression treatments.

2. Selection Process of Therapeutic Modality

Weissman and Klerman’s Interpersonal Psychotherapy, Frankl’s Logotherapy, Mindfulness-Based Cognitive Therapy for Depression, and Acceptance and Commitment Therapy were studied in the process of constructing a therapy manual for psilocybin-assisted therapy of depression.

We outlined the etiology of depression, therapeutic mechanisms, targeted outcomes, and therapeutic approach for each modality, including how each modality may relate to psychedelic and “mystical-type experiences”.

We chose Acceptance and Commitment Therapy as our modality of choice because it contains elements of Mindfulness-Based Cognitive Therapy and explores personal values (often lost in depression) and values-based action (also often deficient in depression).

3. Overview of Acceptance and Commitment Therapy

ACT was developed through the integration of radical behaviorism with experiential and existential approaches to target transdiagnostic drivers of psychological distress. It is based on the idea of an observer mind, or transcendent self, that can be experienced through amplified contact with the verbal relations I-you, here-there, and now-then.

The central treatment target of ACT is the development of psychological flexibility, which is cultivated through six core processes. Psychological inflexibility can be seen as functionally related to a range of psychological problems, including depression, anxiety, substance disorders, and eating disorders. ACT can be used to treat depression and is equally effective to traditional cognitive behavioral therapies.

4. Rationale: Why ACT in Psilocybin-Assisted Therapy of Depression

In this section, we will discuss how ACT principles are complementary and synergistic with those of psilocybin therapy, and how ACT and our conception of psilocybin therapy share several key differences from traditional pharmacological approaches to depression.

ACT engages the participant in the process of recovery, and does not explicitly set out to ameliorate symptoms of depression. Instead, it aims to increase psychological flexibility, which may indirectly lead to a reduction in depressive symptoms.

We believe that psilocybin-assisted therapy can confer more meaningful and longer lasting benefits when thoughtfully infusing ACT principles into the course of psilocybin therapy. This is especially true when working with chronic depressive pathology characterized by deeply ingrained rigid self-criticism, hopelessness, experiential avoidance of pain, and abandonment of valued actions.

We constructed our therapy protocol according to the theory that moderate to high doses of psilocybin can provide direct experiential contact with the ACT processes known to increase psychological flexibility, and that these deeply felt experiences may be reinforced during ACT-informed therapy sessions. Psychedelic experience may allow the experience of self-transcendence, in which the self is perceived as distinct from the thoughts that arise in the mind. This may assist people in gaining clarity of their values and priorities in life.

The study participants with long standing depressive disorders may have particularly entrenched problems of psychological inflexibility, so multiple psilocybin sessions may be optimal for the treatment of major depressive disorder. Additionally, preparatory and follow-up psychotherapy sessions are important to support the effects of the psychedelic experience.

We propose that psilocybin therapy may enhance the response and lengthen duration of improvement from depression by actively engaging the participant in making changes to his or her patterns of thinking and behavior.

5. constructing the Therapy Manual: How ACT is Incorporated into the Structure of Psychedelic Therapy

The ACT model is used to understand depressive thoughts, feelings, and behaviors, as well as participants’ responses to psychedelic experiences. ACT-based clinical formulation occurs throughout all therapeutic encounters with the participant, guiding therapeutic approach and assessment of progress in an iterative manner.

5.2. ACT-based Clinician Intervention

A therapist can use an ACT formulation of the participant’s difficulties and values to provide feedback and use other interventions to target particular areas of the ACT hexaflex that need more attention, such as values-based goal setting, defusion from unworkable negative thought constructs, and overcoming experiential avoidance.

The therapist teaches ACT principles to the participant during preparatory sessions and follow-up sessions. This helps the participant to solidify understanding of ACT principles for self-directed, ongoing work toward psychological flexibility.

5.2.2. Experiential Exercises

We used psilocybin to help participants experience psychological flexibility on a deeper level, and also used ACT consistent metaphors, mindfulness practices, and worksheets to help participants clarify their values and discover how their internal experiences impact their ability to engage in values driven actions.

Once the therapy manual was completed, we devised a training program for study therapists that consisted of pre-assigned didactic videos and readings, followed by four day-long sessions that consisted of close reading and discussion of the therapy manual, didactic teaching, and role plays.

7. Discussion

This model represents our best attempt to design a rational and effective therapy protocol for psilocybin-assisted treatment of depression. A different concept than conventional combination therapy, psychedelic-assisted therapy combines an antidepressant medication with a course of evidence-based psychotherapy. The two elements cannot be separated, and the protocol we designed would not make sense without the medication.

7.1. Limitations

While our limited experience using this treatment protocol with research participants suggests that it holds promise, there are a number of important limitations to our approach. We are however collecting qualitative data and self-report measures to determine which aspects of our therapy protocol are effective or helpful to participants. Our protocol does not include the full range of possible ACT interventions, and the number of therapy sessions was constrained. Additionally, we accept that there are alternative, possibly superior ways that ACT could be integrated with psychedelic therapy.

7.2. Cultural considerations of ACT-facilitated psychedelic therapy

The approach outlined here is untested culturally, and while the behavior analytic roots of ACT do not preclude a deep understanding of cultural contexts and histories of clients belonging to oppressed or stigmatized groups, ACT needs to be utilized with caution.

To use ACT effectively with people of color, therapists must be aware of cultural taboos, mental health literacy, and self-stigma of help-seeking. At the onset of treatment, clients of color may expect therapists to provide expert advice to help them resolve urgent problems. A non-directive approach may be perceived as frustrating, unhelpful, and invalidating, so therapists should take care to use the language of ACT flexibly.

Caution must be used when introducing mindfulness exercises, such as meditation, as this may be misconstrued as engaging in a competing religious practice, resulting in ambivalence or refusal to engage in such activities.

The ACT therapeutic frame permits participants to make contact with difficult internalized experiences, like racism, but therapists should be well practiced and comfortable discussing issues of racism and oppression with clients.

8. Conclusion and Future Directions

Psychedelic-assisted therapy has the potential to be helpful across a range of psychiatric conditions and may even be able to render certain treatment resistant conditions more responsive to intervention.

Psychedelic-assisted therapies have been found to have positive outcomes in trials of different conditions, including obsessive compulsive disorder, autism spectrum disorder, and anorexia nervosa. This paper suggests that increased psychological flexibility may mediate the relationship between mystical-type experiences and therapeutic response.

We hope this paper offers a cogent starting place for a discussion about how to combine psychotherapeutic processes and other healing modalities with medicinal cannabis.

Psychedelics: where we are now, why we got here, what we must do. Carhart-Harris, Leech, R., Hellyer, P. J., Shanahan, M., Feilding, A., Tagliazucchi, E., et al. (2016) studied the effects of psilocybin on the brain in patients with treatment-resistant depression and found that the effects were similar across races and ethnicities. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. Engel, G. L., Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. A., & Geller, P. A. (1980). Garcia-Romeu, Griffiths, Richards, W. A., McCann, U., & Jesse (2006) reported that psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance.

Harris, R. (2009), Acceptance and Commitment Therapy Made Simple. New Harbinger Publications; Hayes, S. C. (2002), Buddhism and acceptance and commitment therapy; Johnson, M., Richards, W., & Griffiths, R. (2008); Klerman, G. L., & Rounsaville, B. J. (1994); Leary, T. Ly, C., Greb, A. C., Cameron, L. P., Wong, J. M., Barragan, E. V., Wilson, P. C., et al. (2018) found that psychedelics promote structural and functional neural plasticity. McCracken, L. M. (2005). Contextual cognitive-behavioral therapy for chronic pain. McHugh, Stewart, I., Almada, P., and Michaels, T. I. (2018) reviewed the literature on psychedelic-assisted psychotherapy and psilocybin-induced neuroplasticity in the treatment of major depressive disorder.

A number of authors have written about the use of psychedelics to treat psychiatric distress, including Parker, G., Polk, K. L., Schoendorff, B., Ross, S., Ryan, R. M., Huta, V., Deci, E. L., Schulenberg, S. E., Nassif, C., & Rogina, J. M. The Altered States of Consciousness Rating Scale (OAV) is a psychometric tool for assessing altered states of consciousness and is used in the treatment of depression and anxiety.