Special considerations for evaluating psilocybin-facilitated psychotherapy in vulnerable populations

This report (2022) explores the challenges and opportunities associated with evaluating psilocybin-facilitated psychotherapy (PAP) in vulnerable populations. The authors propose that working with vulnerable populations requires special attention to their context. Recommendations for future research include an emphasis on recruitment strategies, the appropriate communication and assessment of subjective effects, building a therapeutic alliance, multicultural competence, and flexible study designs.

Abstract

“Psilocybin-facilitated psychotherapy shows potential transdiagnostic efficacy for a range of mental health conditions. Though vulnerable populations bear a disproportionate mental health burden, they have been largely neglected in the clinical psilocybin literature. However, if the field is to best respond to the diverse needs of individuals from vulnerable populations, care must be taken to ensure these individuals are represented in the empirical research. This report calls attention to this concern by detailing the challenges and opportunities associated with evaluating psilocybin-facilitated psychotherapy in vulnerable populations. First, we show how working with vulnerable populations must be considered in the context of an often-problematic past and differential exposure to and experience with classic psychedelics. We then provide actionable recommendations for future research testing psilocybin-facilitated psychotherapy in vulnerable populations, including an emphasis on recruitment strategies, the appropriate communication and assessment of subjective effects, building therapeutic alliance, multicultural competence, and flexible study designs. On these premises we call for future work in this area, underscoring that there is vast room for improvement and expansion in this rapidly advancing field of study.”

Authors: Cynthia E. Oritz, Haley M. Dourron, Noah W. Sweat, Albert Garcia-Romeu, Sarah MacCarthy, Brian T. Anderson & Peter S. Hendricks

Authors Highlights

• Vulnerable populations have been neglected in the clinical psilocybin literature.
• Clinical evaluation of psilocybin should be conducted in light of historical abuses.
• Recommendations for evaluating psilocybin in vulnerable populations are offered.

Summary

PSH conceived of the work, CEO drafted the work, HMD, NWS, AGR, SM, and BTA revised the manuscript for important intellectual content, and all authors approved the version to be published.

Psilocybin-facilitated psychotherapy shows potential transdiagnostic efficacy for a range of mental health conditions, but vulnerable populations have been largely neglected in the clinical psilocybin literature. This report details the challenges and opportunities associated with evaluating psilocybin-facilitated psychotherapy in vulnerable populations.

Psilocybin-facilitated psychotherapy may be effective in the treatment of a number of mental health conditions, but vulnerable populations are conspicuously underrepresented in the clinical psilocybin research. This report provides a primer on advancing multicultural competence in this area of study. Vulnerable populations include people experiencing homelessness, racial/ethnic minorities, sexual and gender minorities, older adults, people living with disabilities and chronic health conditions, and individuals in the criminal justice system. Multicultural competence is an increasing topic of emphasis in mental health services.

Psilocybin and other classic psychedelics have been used by humans in ritualized contexts for millennia, but the institutional application of classic psychedelics in the industrialized West had an inauspicious start in the middle of the 20th century. Naturalistic use of classic psychedelics became associated with the intelligentsia of the day and appeared to be largely accounted for by white individuals of higher socioeconomic status, though there are notable exceptions to this trend. Psilocybin was introduced to the Western world by Mara Sabina, a Mazatec healer. R. Gordon Wasson and his wife Valentina participated in a ritual involving the use of psilocybin mushrooms.

Sabina invited the Wassons to participate in the velada under the condition that her privacy was respected, but the Wassons’ subsequent works brought unwanted attention from law enforcement, and desacralized the ritual. The current clinical evaluation of psilocybin should be conducted in light of this diverse historical context. Participants from groups with positive psilocybin-related expectancies, exposure to recent media coverage framing classic psychedelics as game-changing treatments, and those with a history of sacramental classic psychedelic use may have difficulty participating.

Researchers should consider recruiting vulnerable populations in close concert with community partners, and should acknowledge historical trends when recruiting. This approach was used with success in a pilot trial of psilocybin-facilitated group therapy in the treatment of demoralization among gay-identified AIDS survivors. Researchers should inform participants of the subjective effects of psilocybin in accessible language and develop multilingual self-report measures. They should also avoid trivializing religious experiences or attempting to explain them away as nothing more than neurological phenomena. Researchers should avoid exacerbating distressing experiences of powerlessness among vulnerable populations when evaluating psilocybin-facilitated treatments. A psychological state of surrender can be optimized among vulnerable populations when therapeutic alliance is prioritized. In healthcare settings, vulnerable populations may experience hardship, adversity, and maltreatment. Researchers should expect that some participants will struggle during the acute psilocybin experience and should respond with understanding and empathy.

Clinical psilocybin research should consider if and how the meaningful representation of individuals from vulnerable populations can improve research procedures and outcomes. This may be achieved by incorporating scientists and staff from those same populations, as opposed to the current status quo of studies being performed primarily by nonminority, socioeconomically advantaged researchers. Though clients prefer therapists of their own race/ethnicity, there is almost no effect on treatment outcomes from racial/ethnic matching of clients with psychotherapists.

A counselor’s sexual orientation has no effect on treatment retention, and personal experience with a substance use disorder is not essential to being an effective counselor.

A substance use counselor’s assertion that culturally adapted interventions were more effective for some racial/ethnic minorities has since been disproved. However, multicultural competence is a critical factor for all clients, not just those from vulnerable populations. Researchers should consider how to best reduce participant burden while remaining flexible to deviations in study protocols, such as scheduling appointments outside of normal business hours and conducting psychotherapy and assessment partly via mobile technology.

Psilocybin-facilitated psychotherapy has garnered renewed attention in recent years and shows promise as a treatment for a range of mental health conditions. Vulnerable populations are of special concern in this line of research, and recommendations for future research are summarized in Table 1.