Systematized Review of Psychotherapeutic Components of Psilocybin-Assisted Psychotherapy

This review (2021; s=11) found that psilocybin-assisted psychotherapy consisted of three stages; 1) pretreatment sessions, 2) treatment sessions (dosing, non-directive support, music therapy), and 3) integration sessions.

Abstract

“Objective: This systematized review sought to fill a gap in psilocybin research by investigating the structure and format of psilocybin-assisted psychotherapy (PAP), with a focus on the counselling components of the treatment.

Methods: A systematized review of PAP was conducted by using the PubMed and PsycInfo databases to search for peer-reviewed studies of human clinical trials, published within the past 25 years, in which psilocybin was administered with psychological support in a clinical setting.

Results: Eleven articles matched the criteria necessary for inclusion in this review. PAP was found to consist of three stages: pretreatment sessions to prepare participants for psilocybin, treatment sessions in which psilocybin was administered, and posttreatment sessions to integrate the experience with daily life. Conventional psychotherapy was primarily seen in the pre-and posttreatment sessions. Psychotherapies included in PAP differed among studies but most often included music therapy and a non-directive supportive approach to treatment.

Conclusions: This systematized review found important commonalities among clinical trials of PAP published within the past 25 years and revealed key differences among studies in psychotherapy’s incorporation into PAP. Additional research is needed to identify the unique effect of psychotherapy in PAP.”

Authors: David M. Horton, Blaise Morrison & Judy Schmidt

Summary

Research into treatments for mental illness has evolved substantially, and a new wave of research has emerged with the resurgence of psychedelic drugs in the context of treating mental illness.

Psilocybin is one of the most thoroughly studied psychedelic substances in modern clinical research, and psilocybin-assisted psychotherapy (PAP) is an established research protocol for safely administering psilocybin with psychological support as a clinical intervention. PAP has shown clinically significant results in several studies for various psychiatric conditions.

This review summarizes findings from clinical trials of psilocybin-assisted psychotherapy over the past 25 years and addresses the role of therapists in PAP, the general structure of PAP, and psychotherapeutic modalities and techniques integrated into PAP.

METHODS

The authors conducted a systematized review of recent psilocybin literature to determine what is known about psilocybin trials and to establish a rationale for future research.

Eligibility Criteria

This review included human clinical trials of psilocybin published between December 31, 1994, and January 23, 2021. The studies included in this review were also searched on clinicaltrials.gov to confirm they were clinical trials.

Search Strategy

We searched for relevant literature in two databases and attempted to contact study authors when necessary. We also searched the reference lists of studies that might reveal additional relevant studies.

Study Selection

Two levels of screening were performed on the PubMed and PsycInfo databases to determine whether studies relevant to the present review were included.

Recorded Variables, Data Extraction, and Analysis

Data were extracted from studies and organized into data tables and figures created by using Microsoft Excel.

RESULTS

The systematized review process for both databases is illustrated in a flow diagram. In total, 1,058 articles were reviewed, and 146 full-text articles were included in the present review.

Role of Therapists in PAP

All 11 trials included session therapists, who provided psychological support during treatment and facilitated integration of the psilocybin experience into the area of desired change. There were at least two therapists present during psilocybin administration.

All but one study indicated that at least two therapists were present during the treatment sessions. Three studies indicated intentional inclusion of both a male and female therapist during the treatment sessions.

In 11 studies, therapists were trained in facilitating psychedelic psychotherapy and in understanding the treatment. The most common titles were psychologist and psychiatrist, but other titles included chaplain, nurse, shiatsu therapist, and life coach.

Five of 11 studies indicated that therapists served different roles in the study, typically a primary role or an assistant or cofacilitator role. The responsibilities of the therapists hinged on the stage of treatment.

Structure of PAP

Pretreatment sessions were used in all 11 studies to prepare participants to receive psilocybin safely and to help them feel supported while under psilocybin’s effects. The length of these sessions varied among studies, but all involved a discussion of the participant’s life experiences.

Psilocybin was administered to participants in treatment sessions, which typically lasted 52 hours and were conducted in a decorated room intended to make the participant comfortable.

Treatment sessions with psilocybin were conducted in a nondirective and supportive setting. This laissez-faire approach to therapy shares many similarities with MDMA-assisted psychotherapy, which identifies an individual’s inner healing intelligence as the primary mechanism of change in treatment.

All 11 studies directed participants to focus their intention on their internal experience or journey, and provided psychological support in several forms during the session.

At least 10 studies reported having posttreatment sessions to discuss the experience and resulting effects of the previous psilocybin treatment session. The number of posttreatment sessions and length of these sessions varied among studies.

Psychotherapy Modalities Integrated in PAP Studies

All 11 studies used psychotherapy in some way, and the role of the therapist depended on the psychotherapeutic components or modalities incorporated into the PAP.

All 11 clinical trials used music during the treatment sessions. The purpose of including music is to support and foster meaningful experiences during the session, and to achieve therapeutic progress.

All 11 studies included a standardized playlist of music during treatment sessions, and most included a mix of neoclassical, classical, or ambient music with minimal lyrics.

Bogenschutz et al. (10) incorporated motivational enhancement therapy (MET) into the pretreatment and posttreatment sessions, and indicated that 12 sessions of psychosocial interventions were included in the study.

CBT was used in pretreatment sessions for tobacco cessation with a sample of 15 individuals who smoked an average of 19 cigarettes per day. The study implemented four pretreatment sessions of CBT for tobacco cessation, which included a signed contract to quit, program cards, a smoking diary, and motivational statements.

Anderson et al. (9), modified an existing adaptation of supportive-expressive group therapy (SEGT), to include breathing exercises and guided meditations instead of autohypnosis to aid in facilitating group sessions and to reduce death anxiety.

Ross et al. (4) used CBT, supportive psychotherapy, existential therapy, and psychodynamic and/or psychoanalytic therapy in posttreatment sessions for individuals experiencing anxiety and depression in the context of life-threatening cancer.

Ross et al. (4) began the integration process of psilocybin therapy toward the end of the treatment sessions with three 2-hour sessions of psychotherapy, borrowing primarily from supportive and existential therapy.

Psychotherapeutic Techniques Integrated in PAP

Psilocybin studies have incorporated psychotherapeutic components not tied to one specific modality, and the therapeutic relationship is one of the primary goals of the pretreatment sessions. The nondirective supportive approach in treatment sessions aligns with a person-centered therapy orientation.

Body scanning and writing are mindfulness techniques for developing attentive flexibility. Participants engaged in body scanning and open-ended narrative writing at the beginning and end of treatment sessions.

Two studies used guided imagery, one during pretreatment and posttreatment sessions and one in the last hour of the first treatment session. The intended effects of guided imagery were not indicated.

Integration is loosely defined as reflecting on the unusual thoughts and feelings arising from the psilocybin experience and exploring implications of the experience for the targeted areas of change.

Griffiths et al. (13) asked participants to engage in sitting meditation and daily awareness practice before and after treatment sessions, and Nicholas et al. (17) offered opportunities for meditation before and during the final hour of treatment sessions.

Outcomes Across PAP Studies

None of the 11 studies reported serious adverse outcomes attributed to psilocybin, and no participant required rescue medication.

Quantitative outcomes of the clinical trials are displayed in Table 1. All but one study achieved statistically significant improvements in the targeted outcomes.

Seven studies demonstrated large effect sizes for the therapeutically relevant constructs, and four of the five studies measuring depression and anxiety demonstrated clinically significant reductions in these conditions.

Qualitative data can capture valuable information missed by quantitative analysis, especially in the field of psychopathology. Participants in PAP seem to gain novel insights into themselves, their presenting problems, or their relationship with those problems.

The only study in this review that measured the effects of psychotherapy on outcomes included meditation practices, journaling, spiritual practices, and group discussion of the psilocybin experience. The results suggested that individuals with greater psychotherapeutic support throughout treatment exhibited greater short- and long-term effects in domains such as daily life experiences, gratitude, and meaning in life.

DISCUSSION

This article reviewed the psilocybin literature regarding the structure and format of PAP, including the role of therapists and differences among studies in the structure and format of sessions. The results revealed three distinct stages of PAP across all 11 clinical trials: pretreatment, treatment, and posttreatment.

Conventional psychotherapy techniques were used almost exclusively outside of or in the last hour of treatment sessions in psilocybin studies, regardless of the dosage provided to participants. This contrasts with early psychedelic research models, where the therapeutic model used during treatment sessions often depended on the dose administered.

Future psilocybin research should explore which psychotherapeutic modalities and techniques are most appropriate for incorporation into PAP, as well as how to make PAP beneficial for individuals from all cultural, racial-ethnic, and socioeconomic backgrounds.

The present research acknowledges the impact that session structure, context, and setting have on the psilocybin treatment session. This research should explore how to optimize the structure, setting, and components of PAP to enhance the clinical efficacy of psilocybin sessions.

Trials similar to Griffiths et al. (13), in which participants receive psilocybin with minimal supportive, largely nondirective therapeutic support, compared with extensive therapeutic support, could be fruitful in determining the impact of psychotherapy in PAP.

Psilocybin-assisted psychotherapy is based on nonjudgmental listening, empathic support, and a strong therapeutic relationship. Therapists can incorporate their preexisting knowledge and skills along with specific training in PAP to help facilitate immediate and enduring positive changes in the lives of their clients.

CONCLUSIONS

The present systematized review outlined the role of therapists in psilocybin-assisted psychotherapy and consolidated the structure of sessions and range of psychotherapeutic modalities and techniques implemented in this therapy. Therapists can get involved with PAP today by completing PAP training.