Psychedelic Harm Reduction and Integration: A Transtheoretical Model for Clinical Practice

This paper (2021) introduces the Psychedelic Harm Reduction and Integration approach to working with patients in regards to psychedelics.

Abstract

“Psychedelic Harm Reduction and Integration (PHRI) is a transtheoretical and transdiagnostic clinical approach to working with patients who are using or considering using psychedelics in any context. The ongoing discussion of psychedelics in academic research and mainstream media, coupled with recent law enforcement deprioritization of psychedelics and compassionate use approvals for psychedelic-assisted therapy, make this model exceedingly timely. Given the prevalence of psychedelic use, the therapeutic potential of psychedelics, and the unique cultural and historical context in which psychedelics are placed, it is important that mental health providers have an understanding of the unique motivations, experiences, and needs of people who use them. PHRI incorporates elements of harm reduction psychotherapy and psychedelic-assisted psychotherapy, and can be applied in both brief and ongoing psychotherapy interactions. PHRI represents a shift away from assessment limited to untoward outcomes of psychedelic use and abstinence-based addiction treatment paradigms and toward a stance of compassionate, destigmatizing acceptance of patients’ choices. Considerations for assessment, preparation, and working with difficult experiences are presented.”

Authors: Ingmar Gorman, Elizabeth M. Nielson, Aja Molinar, Ksenia Cassidy & Jonathan Sabbagh

Summary

INTRODUCTION

Psychedelic Harm Reduction and Integration (PHRI) is a clinical model for working with people who have used psychedelics, and incorporates principles of harm reduction psychotherapy, psychedelic-assisted therapy, mindfulness-based modalities, and psychodynamic therapy. It is intended to be used by practitioners whose scope of practice includes psychotherapy.

PHRI is an approach to working with people who use drugs that draws upon harm reduction.

Approaches to Working With People Who Use Drugs

Over 30 million people in the US have used psychedelics in their lifetime, and the rate of lifetime psychedelic use was greatest among people aged 30 – 34. Past-year LSD use grew by 56.4% between 2015 and 2018.

Moral Model of Addiction

Although psychedelic use has changed, clinical therapeutic approaches to working with people who use psychedelics have remained stagnant. The moral model of addiction remains among the dominant ways of understanding drug use.

Disease Model of Addiction

Some addiction treatment programs can contribute to shame and stigma through adoption of non-disease models and an abstinence-only approach, and a resulting reluctance to employ empirically supported treatments.

In clinical settings, pathologizing concepts can be misapplied to psychedelic use, which can result in people being stigmatized or turned away. An integrative model is needed for working with psychedelics.

Harm Reduction

Harm reduction is an alternative to both the moral and disease models, and focuses on reducing the harm caused by substance use, sexual activity, and video gaming. It may be appropriate for psychedelic users, who may not experience the same negative consequences of substance use as traditional drug treatment programs.

Harm Reduction Psychotherapy

Harm Reduction Psychotherapy is a cutting-edge framework that applies harm reduction principles to psychotherapy. It emphasizes a non-judgmental stance toward substance use and a non-stigmatizing and non-pathologizing approach to the use of drugs, including psychedelics.

IHRP incorporates techniques from relapse prevention and explores the meanings of substance misuse for the patient. It provides a framework for working outside of an abstinence-only paradigm.

Psychedelic-Assisted Psychotherapy

Psychedelic-assisted psychotherapy is a treatment that involves the administration of a psychedelic compound in the context of a psychotherapeutic environment and relationship. The theoretical orientation with which therapists approach their work with patients and its relationship to the treatment diagnosis has varied widely.

Attitudinal Orientation Toward NOSCs

Mindfulness-based treatment modalities teach meditation practices and skills to reduce stress and distress, including distress associated with mental health and drug use problems. Psychedelic realism therapy draws on this orientation and asks patients to develop the same sense of non-judgmental curiosity to their psychedelic experiences.

A Framework for Understanding the Benefit of Loss of Sense of Self

Traditional psychotherapeutic approaches have considered healthy, strong ego functioning to be the central goal of successful therapy, but mindfulness-based modalities view ego-dissolution and related experiences as a stage of development beyond which one can ideally move.

Inquiry

Inquiry is a component of mindfulness-based interventions that involves the application of non-judgmental curiosity to communication. It involves focusing on understanding rather than agreement, taking turns in listening with an open mind, actively practicing non-harming speech, and using mirroring techniques.

Non-directive Approach

Non-directive psychotherapies employ patience and guidance rather than instruction, and are a core principle of psychedelic-assisted therapies. They enable patients to adopt an uncritical approach concerning their own psychedelic experience(s) and engage in self-directed insight-finding and meaning-making processes.

Inner-Directed Approach

The inner-directed approach is a psychotherapy approach that encourages the patient to look into their inner experience for insight and solutions.

Psychodynamic Psychotherapy

Early psychedelic-assisted therapy was strongly influenced by psychoanalytic theory. Psychoanalytic theory offers many perspectives that can be helpful when working with individuals who use psychedelics.

Psychedelics may function by dramatically reducing or shifting an individual’s defense mechanisms. Understanding a patient’s transference to a psychedelic and their subsequent alleviation of symptoms can be useful in understanding both the patient’s distress and the therapist’s practice.

Defining and Differentiating PHRI

PHRI is a paradigm for psychotherapy that focuses on people who use psychedelics outside of legal psychedelic-assisted therapy contexts.

PHRI involves supporting exploration and enhancing understanding in patients who develop a relationship with psychedelics without encouraging the use of psychedelics or providing therapy during the psychedelic experience.

Psychedelic-assisted psychotherapy practices, IHRP, relational-psychodynamic theory, and mindfulness-based interventions can all be incorporated into PHRI, which is consistent with features commonly found across diverse psychotherapeutic orientations.

Who Might Benefit From PHRI?

People who have used psychedelics on their own, or who have taken them accidentally, may benefit from PHRI. It is helpful to structure sessions as preparation sessions and integration sessions accordingly.

PREPARATION

Psychedelic-assisted therapy can be conceptualized in three stages: preparation, psychedelic experience, and integration. A therapist does not administer or be present with a patient during the psychedelic experience.

Assessment

Although it is necessary to utilize the DSM-5 for differential diagnosis, it can be useful to pose questions specific to PHRI, such as whether a patient’s psychedelic experiences were spontaneous or planned, and whether the patient has drawn any meaning from them.

A therapist should not presume that psychedelic use indicates a drug use problem, but rather should seek to understand a patient’s relationship with psychedelics, including their motives for use and any resulting overwhelming experiences.

Community Involvement

The integration therapist must understand the patient’s connection to a community of psychedelic users, and the impact of creating a therapeutic relationship within that context.

Goals and Obstacles

The therapist can assist the patient in integrating meaningful psychedelic experiences by identifying goals and obstacles for integration, and gauging how the patient defines successful integration.

Patients Seeking Access to Psychedelic Compounds

A patient seeking a psychedelic experience may wish to discuss where to obtain psychedelics with a licensed therapist. However, in the US, most psychedelics remain designated as Schedule I drugs under the US Drug Enforcement Administration.

Motivation, Knowledge, and Psychoeducation

In PHRI, preparation for a psychedelic experience is guided by the patient’s reasons for using a psychedelic. This helps the therapist provide appropriate clinical care and address misinformation, dispel myths, and supply necessary education about psychedelics.

Psychedelic experience preparation involves assessment of the patient’s level of knowledge about psychedelics and providing appropriate information and resources. This is done through a psychoeducational approach that aims to increase the patient’s knowledge of and insight into the issue at hand.

Working Within the Scope of One’s Practice During Preparation

When providing PHRI, it is paramount to work within the professional scope of one’s practice.

Person-Centered and Non-judgmental Approach

In the initial discussion, PHRI patients are given ample information regarding the potential risks and benefits associated with psychedelic use. The therapist helps the patient consider alternative options and provides a supportive and non-judgmental container for their exploration.

Psychedelics as a Non-specific Amplifiers and the Importance of Set and Setting

Preparation for psychedelic use should include introducing the idea that psychedelics are a non-specific amplifier, that they intensify mental phenomena and amplify their significance, and that the quality of the experience is largely contingent on the set, setting, and cast of the experience.

Psychedelic experiences can enhance meaning and creativity, and decrease self-inhibition and self-criticism. However, the meaning of the resulting creative achievements can also be amplified while under the influence of psychedelics or shortly thereafter.

Self-Regulation Tools and Expectation Management

Preparation work for a psychedelic experience should include mental readiness for life after the experience, identifying signs that may indicate the patient’s need for more help, and preparing a detailed re-entry plan.

To help the patient manage trauma symptoms, equip them with self-regulation tools such as mindfulness practice, yoga, reflection, journaling, and guided meditation, and grounding practices and self-care. This will help them shift their focus from trauma symptoms to self-reflective processing.

Managing Expectations

Expectation management is particularly important in preparation, as any disappointment felt by the patient can inform their perception of the entire psychedelic experience. A mystical experience is a commonly sought-after NOSC, but not every instance of psychedelic use will result in a mystical-type experience.

Adverse Psychedelic Experiences and Experiential Processing

When using psychedelics, an individual may have a difficult experience such as panic, anxiety, and psychotic-like reactions. However, most individuals who have a challenging psychedelic experience recognize a long-lasting positive effect on their well-being.

When discomfort arises during a challenging psychedelic experience, it is helpful to stay with the discomfort and remain curious to what is arising. A therapist can help the patient move through the adverse reaction.

Diagnosis of Adverse Reactions

The DSM-5 recognizes psychedelic use only as it pertains to Hallucinogen Persisting Perception Disorder, hallucinogen use disorders, and hallucinogen-induced disorders. It does not capture adverse reactions to psychedelics.

INTEGRATION

Psychedelic integration occurs in the clinical consultation room and is supported by the PHRI therapist. The therapist must consider several considerations for this stage of therapeutic encounter.

Working With Challenging Experiences

Patients and clinicians may experience anxiety and distress after a psychedelic experience. Clinicians should avoid premature conclusions about psychological symptoms and stay informed about psychedelics, their effects, and their risks.

Long-Term Mental Health Outcomes

Studies have not established a link between lifetime psychedelic use and negative long-term mental health outcomes. However, persisting symptoms such as insomnia, disorientation, anxiety, and depression indicate a patient in need of further psychotherapeutic support.

Traumatic Experiences

Some patients who seek PHRI have experienced negative or even traumatic encounters with psychedelics, when used outside of clinical trials. Clinicians can help these patients by reassuring them that others have encountered similar experiences and recovered from them.

In the integration process, patients may experience increased psychological distress while simultaneously experiencing a decrease in experiential avoidance. These experiences should be validated and met with compassion by the integration therapist.

Challenging Experiences With Positive Outcomes

Over one-third of individuals who had an adverse experience with psilocybin outside of clinical trial contexts reported positive, long-term outcomes, but 84% reported negative, long-term outcomes. Therefore, PHRI may provide extra support to individuals who are struggling to make use of challenging experiences.

The patient may appear to be in crisis, but it may be a temporary worsening of symptoms. Psychedelic integration providers can provide support.

Addressing Fear

Fearful reactions to psychedelics may be understood within the processes of the ACT framework, and acceptance, rather than experiential avoidance, is aimed at increasing psychological flexibility. This flexibility is associated with higher rates of psychopathology and lower overall quality of life.

Clinicians should keep in mind that the fears experienced during an encounter with psychedelics are a reflection of an individual’s biopsychosocial factors, including biographical history, wishes, and desires, as well as individual mindset, as well as physical and cultural environmental influences.

Many individuals find it difficult to understand their psychedelic experiences, and may not realize the potential for therapy to help them grow from them.

Ego Dissolution

Psychedelics can trigger cognitive phenomena such as ego dissolution and ontological shock, which can incite or exacerbate fear responses. Clinicians should pay mind to the extant drug, setting, and individual interaction when encountering patients who have experienced these phenomena.

Increase in Sensitivity

Individuals can be seen as adopting psychologically inflexible processes to avoid discomfort within certain contexts. Psychedelics may help individuals become aware of the ways they have historically coped with stressors in their environment.

Psychedelics are hypothesized to increase psychological flexibility by activating mindfulness, acceptance, commitment, and behavior change processes. However, increased vulnerability can lead to increased fear and anxiety, requiring therapeutic assistance to navigate.

The Unfolding Process

After a psychedelic experience, new personal meanings develop progressively over time, with each meaning building on previous meanings. In vertical unfolding, new, radical personal meanings emerge extemporaneously.

After the acute pharmacological effects of the psychedelic have worn off, patients may experience increased vulnerability, sadness, and anger, as well as a body/mind knowing. They may turn to an integration therapist for help.

The unfolding process is a contextual behavioral perspective that involves sitting with experiences and accepting affective responses. It may be helpful to pay particular attention to the body.

Other Challenges During Integration

When patients expect a mystical experience, they may feel disappointed when they do not obtain it. This disappointment can be addressed by cultivating openness to all/actual experiences and setting aside expectations for specific experiences.

The emotional impact of disappointment may be extreme, and therapists’ relational support, understanding, and compassion for patients in this experience is critical. Psychoeducation can be effective in reframing disappointment, and patients should be made aware that the therapeutic context may differ dramatically from clinical trials.

Spiritual Bypass

Clinicians should be aware of the possibility of spiritual bypass, where individuals attempt to avoid pain or psychological distress by taking psychedelics, meditating, or seeking mystical experiences.

The Role of the Body

Psychological difficulties can be felt in the body, and somatic work can help patients process their emotional, physiological, and psychological responses without judgment or overemphasis on the cognitive aspects of psychological distress.

The clinician can encourage the patient to engage in body-related activities outside of therapy, such as yoga, grounding exercises, and mindfulness practices, to increase body awareness and psychological well-being.

Working With Positive Experiences

Positive psychedelic experiences can be as valuable as challenging ones. Clinicians should refrain from reducing positive experiences to hedonistic fascination and be mindful of their own potentially countertransference reactions.

Afterglow

After a psychedelic experience, some individuals report a subjective positive experience of afterglow. This experience may be related to increased neuroplasticity, which allows the individual to explore new behaviors and ways of thinking.

Sudden Wellness

Patients may be highly motivated to make major life changes following a psychedelic experience, but their family and social network may not accept their new way of being. A therapist can help them navigate family dynamics so that a new homeostasis is reached.

Tools for Maintaining Benefits

The process of constructing meaning out of psychedelic experiences extends beyond the therapy setting and should include journaling, meditation, artistic expression, and any other activity that helps sustain focus on the psychedelic experience.

Extending integration may involve seeking further structure and treatment in another form of specialized or intensive therapy, expanding one’s community, or adjusting one’s career path, diet, or living arrangements to better suit one’s needs.

DISCUSSION

Patients are currently using psychedelics and seeking and receiving psychedelic integration services from clinicians. This paper defines the process.

Summary

Psychedelic-assisted therapy, Mindfulness-based therapies, relational psychodynamic approaches, and IHRP are used in the PHRI model. It offers new perspectives on the decision making and meaning-making processes.

Implications

The PHRI model challenges dominant abstinence-based paradigms by acknowledging the potential for benefit of psychedelic use outside of clinical contexts, and by placing the clinician in the role of supporting and following the patient’s preferences.

As non-clinical psychedelic use increases and psychedelic-assisted therapy gains mainstream acceptance, therapists need a model for working with patients who are considering using or have used psychedelics. PHRI offers such a model.

Limitations

This paper attempts to set a theoretical foundation for PHRI, but there is a dearth of empirical evidence for its effectiveness. Future research should focus on establishing and refining standards, and evaluating the efficacy of this approach.

CONCLUSIONS

This paper has presented a transtheoretical model of PHRI that can be integrated with a variety of psychotherapeutic approaches and treatment goals. It has the potential to reduce psychedelic-related harm and enhance benefit from psychedelic experiences.

AUTHOR CONTRIBUTIONS

IG and EN conceptualized and created the theoretical model for Psychedelic Harm Reduction and Integration, and AM, KC, and JS wrote portions of the manuscript.

ACKNOWLEDGMENTS

The authors acknowledge the mentorship, guidance, and support of many psychedelic researchers, therapists, harm reduction practitioners, research participants, students and patients, and the editing services of Jon Kilner.