The hidden therapist: evidence for a central role of music in psychedelic therapy

This open-label qualitative interview study (n=19) assessed the role of music during psychedelic therapy with psilocybin (25mg) for treatment-resistant depression (TRD). It identified several ways in which music influenced their experience, most frequently related to the intensification of emotions and mental imagery, and the music appeared to be a significant source of guidance, creating a sense of grounding, as well as a sense of carrying the listener into different psychological places.

Abstract

“Rationale: Recent studies have supported the safety and efficacy of psychedelic therapy for mood disorders and addiction. Music is considered an important component in the treatment model, but little empirical research has been done to examine the magnitude and nature of its therapeutic role.

Objectives: The present study assessed the influence of music on the acute experience and clinical outcomes of psychedelic therapy.

Methods: Semi-structured interviews inquired about the different ways in which music influenced the experience of 19 patients undergoing psychedelic therapy with psilocybin for treatment-resistant depression. Interpretative phenomenological analysis was applied to the interview data to identify salient themes. In addition, ratings were given for each patient for the extent to which they expressed “liking,” “resonance” (the music being experienced as “harmonious” with the emotional state of the listener), and “openness” (acceptance of the music-evoked experience).

Results: Analyses of the interviews revealed that the music had both “welcome” and “unwelcome” influences on patients’ subjective experiences. Welcome influences included the evocation of personally meaningful and therapeutically useful emotion and mental imagery, a sense of guidance, openness, and the promotion of calm and a sense of safety. Conversely, unwelcome influences included the evocation of unpleasant emotion and imagery, a sense of being misguided and resistance. Correlation analyses showed that patients’ experience of the music was associated with the occurrence of “mystical experiences” and “insightfulness.” Crucially, the nature of the music experience was significantly predictive of reductions in depression 1 week after psilocybin, whereas general drug intensity was not.

Conclusions: This study indicates that music plays a central therapeutic function in psychedelic therapy.”

Authors: Mendel Kaelen, Bruna Giribaldi, Jordan Raine, Lisa Evans, Christopher Timmermaan Natalie Rodriguez, Leor Roseman, Amanda Feilding, David Nutt & Robin Carhart-Harris

Summary

Recent studies have supported the use of psychedelic therapy for addiction.

Introduction

Psychedelic drugs were used therapeutically in the 1950s and 1960s for depression, addiction, end-of-life care, and post-traumatic stress disorder. Music was introduced within the therapeutic framework as a way to support patients’ experiences non-verbally.

Psychedelic therapy sessions involve listening to music while lying down in a relaxed position. Studies have shown that psychedelics enhance the subjective response to music, but no studies have focused on the therapeutic functions of music in the context of psychedelic therapy.

We conducted interviews with patients who underwent psychedelic therapy for treatment-resistant depression with psilocybin, 1 week after the second of two treatment sessions. We hypothesised that music would promote mystical experiences, which would subsequently predict long-term therapeutic outcomes.

Participants

Nineteen patients with treatment-resistant major depressive disorder were included in the study. Exclusion criteria included current or previously diagnosed psychotic disorders, and current drug or alcohol dependence.

Experiment overview and procedures

This study was part of a larger study assessing safety and efficacy for using psilocybin to treat depression. Patients completed the QIDS patient-rated scale for the severity of depressive symptoms and provided written informed consent.

A subsequent visit functioned as preparation for the session, which included conversations with the therapists about the patient’s personal history, expectations for the sessions, and education about the effects of psilocybin. Patients received two different dosages of psilocybin on two separate subsequent occasions, each separated by 1 week.

Each session included one patient and two therapists and took place in a specially designed therapeutic environment. Patients were ready to leave the research facility approximately 7 h after administration.

Clinical improvement was measured by reductions in depression severity and subjective experience of the music, and the clinical outcomes were reported 1 week after the high dose (25 mg) session.

Therapeutic setting

All sessions took place in a specially designed therapy room within the Clinical Research Facility at Imperial College London. The room was decorated with cushions, plants, art paintings, and artefacts, and the music was played in synchrony and continuously through both channels.

Music selection

In order to control for music as a potential confounding variable, a standardised music playlist was created and used in all patients. One patient strongly disliked the music selection in the first session, so a different music playlist was used in the second session.

Several of the musical works originally included in playlists for psychedelictherapy are very familiar today, so a playlist with predominantly contemporary music was designed to provide a new experience with the music.

Playlist design

The music playlist was designed by Bonny and Pahnke (1972 ), William Richards (2015 ), and the psychedelic therapist Stanislav Grof (1980 ). It was adjusted to the shorter duration of psilocybin’s effects, compared to LSD, and only played during peak.

The semi-structured interview

A semi-structured interview was conducted 1 week after the final session to assess how the music influenced the patients’ experience. It consisted of 4 open questions and additional questions to clarify the patients’ responses.

Theoretical approach of interview data analysis

Interpretative phenomenological analysis (IPA) was used to analyse the interviews, and it was found to be an appropriate approach for investigating the benefits of music therapy interventions in cancer care settings.

Interview data analysis: coding

Interviews were transcribed verbatim in Microsoft Word and checked for accuracy. A step-by-step coding analysis of the interview data followed, with at least two researchers coding each transcript.

The authors coded the transcripts into themes, which were then refined and organised into clusters. These clusters were then used to calculate the frequency with which each theme and cluster was present within the total study population.

Ratings for music experience

Three variables were identified from the coding analysis: liking, resonance, and openness. These variables were hypothesized to be predictors for therapy response.

Four researchers rated the liking, resonance, and openness of 19 patients based on their interview transcripts, to ensure inter-rating reliability. The ratings were done via a VAS, with five anchors presented.

Correlation analyses

To reduce the number of comparisons, a principle component analysis was performed on the 11 factors of the 11D-ASC. The three music experience variables (liking, resonance, and openness) were correlated with the first five principal components.

Pearson correlation tests were used to test for a relationship between music experience variables and reductions in depressive symptoms 1 week after the last session with 25-mg psilocybin.

Results

The 19 interview transcriptions were on average 1048 words long. The four different groups were: (1) welcome influences, (2) unwelcome influences, (3) appreciated music styles and playlist design, and (4) unappreciated music styles and playlist design.

The four groups are shown in the figures, and the themes associated with the clusters are presented in separate tables in the Supplementary materials. It is important to emphasise that the identification of a theme in a patient’s experience does not imply that this theme was present in the patient’s total experience.

Welcome influences: intensification

The most prominent cluster in the group welcome influences refers to themes that describe an intensification of the subjective experience by the music, including descriptions of music enhancing or changing emotions.

Themes describing an intensification of imagination were identified in nine out of 17 patients (53%), while eight out of 17 patients (47%) mentioned a general intensification effect of the music, without specifically referring to an intensification of emotionality, imagery, or others.

Welcome influences of the music: guidance

The second most prominent cluster of welcome influences includes themes that depict the music as a source of guidance, psychological support, and being in tune with or in resonance with the person’s intrinsic emotional state.

Five out of 15 patients said the music provided a sense of continuity and direction, making the experience feel driven by the music.

Welcome influence of the music: calming

Ten out of 19 patients described calming effects of the music, with 90% describing general calming effects and 50% describing mental calming effects. One out of ten described feeling more physically relaxed.

Welcome influences of the music: openness to music-evoked experience

Seven out of 19 patients made statements about their own attitude of openness towards the influences of the music, and about the effects of music on their attitude of openness. Six out of seven referred to the importance of being open to challenging experience evoked by the music.

Unwelcome influences of the music: intensification

Five out of ten patients described music to Bintensify emotions they did not want to feel, and four out of ten described irritation as a consequence of the music.

Unwelcome influences of the music: resistance to music-evoked experience

Nine out of 19 patients (47%) described feelings of Bresistance to the music-evoked experience. This contrasts with the cluster of themes describing an openness to the music-evoked experience.

Unwelcome influences of the music: misguidance

Six out of 19 participants made statements about the music providing a sense of misguidance, which contrasts with the welcome influence resonance, when the music was experienced as harmonious, or a good match, with the subjective experience.

Appreciated music styles and playlist features: music styles

All 19 patients mentioned some music styles within the music playlist that they especially appreciated. Most frequent were positive statements about Bethnic music, present in eight out of 19 patients (42% of cluster), such as Indian, BSpanish, or BAfrican music styles.

Appreciated music styles and playlist features: playlist design

Seventeen out of 19 patients made statements reflecting appreciation for the design of the playlist, with the most prominent theme being the music selection. Nine out of 17 patients provided positive descriptions on the way the music was structured into the full playlist.

Unappreciated music styles and playlist features: music styles

Eleven out of 19 patients referred to musical styles that were not appreciated. These themes included music with lyrics, vocal music, piano music, classical or neo-classical music, and cheesy music.

Unappreciated music styles and playlist features: playlist design

Six out of 19 patients referred to aspects of the playlist design that were not appreciated, and a preference for Bown music selection was expressed.

Predictors in music experience for psilocybin experience and therapy outcomes

PCA reduced the 11-ASC to five factors, which explained more than 95% of total variance. Music experience and drug intensity were correlated with these five factors and reductions in depression.

A week after psilocybin, reductions in depression were significantly predicted by the musicexperience variables liking, resonance, and openness, but not by drug intensity. Insightfulness was significantly predicted by music variables resonance, and not by music liking.

Inter-rating reliability and discriminative validity of musicexperience variables

Pearson correlation tests between the three music experience variables demonstrated good inter-rater reliability. Drug intensity did not correlate with any of the music experience variables.

Discussion

This study examined how music influenced the subjective experiences of patients receiving psilocybin with psychological support for treatment-resistant depression. It found that the music intensified emotions and mental imagery, and provided a sense of grounding and carrying the listener into different psychological places.

Under the influence of psilocybin, the music absolutely takes over, and I feel like I have no choice but to go with the music. It took my thinking and experience to uncomfortable places, but I was kind of reassured in the experience.

In contrast to the sense of guidance provided by the music, some patients experienced a sense of misguidance.

The light music took me to a place where I thought I was safe, but then it became unsafe, and I felt duped by the music.

The effects of the music were welcomed, and an attitude of openness towards negative music-evoked emotions was frequently described as helpful in bringing to expression inner psychological conflicts.

I can view the negative moments as positive because they served a purpose, which was to face my demons.

An attitude of resistance to intensification effects was characterized by not wanting the music or its effects.

I worried that I let the music shape this sort of melancholy, because I was afraid to open my eyes.

Music styles and playlist design

The study shed light on how different musical styles and the design of the music playlist were experienced, and how the calming (ambient) music was particularly present during the early and final phases, and at periods during peak.

When strong disliking of the music selection occurred, it was associated with a decrease in the subjective effects of psilocybin and an attitude of resistance.

The music blocked my experience and feelings. I felt torn because I wanted to work with it, but the music didn’t feel real.

Music experience predicts experience and therapy outcomes

As outlined above, notable polarities were observed in the music experience, and these polarities predicted the extent to which patients reported having mystical experiences and insightfulness. Drug intensity also correlated with other aspects of the psilocybinexperience, such as impaired cognition and audio-visual perception changes.

The association between the music experience and mystical experience supports the original motivations to include music in psychedelic therapy, i.e. to promote the occurrence of therapeutically meaningful experiences. The music experience is also associated with reductions in depression 1 week after the psilocybin experience.

Possible therapeutic mechanisms of music in psychedelic therapy

Psychedelics temporarily dysregulate brain mechanisms that normally regulate emotion, which may explain the enhanced emotional responsiveness to emotionally evocative stimuli reported here as well as elsewhere. This may be important for facilitating deeply felt and personally meaningful emotionality in psychedelic therapy.

The present findings show that psychedelic therapy uses music to evoke intense emotional experiences and provide a Bholding environment, which feels Bsafe and secure to express and experience new aspects of oneself.

Implications for the use of music in psychedelic therapy

The therapeutic influence of music in psychedelic therapy has been referred to as being of profound significance. When the music was experienced as dissonant with the unfolding experience, disliked, and rejected, therapeutic outcomes suffered.

The variables resonance, liking, and openness of the music experience correlated with each other, suggesting that they represent a single construct within the music experience that is associated with positive therapy outcomes.

This hypothetical framework holds that an optimal music experience creates an optimal climate for the expression of meaningful therapeutic content, and that the adaptation of the music during psychedelic therapy sessions may be critical to provide adequate therapeutic support conditions.

The therapist may need to clarify the source of the resistance or dislike by the listener to restore music’s therapeutic function, and may need to provide adequate therapeutic support for the patient to feel safe and motivated to engage in exploring and expressing the present challenging feeling states.

Limitations and future directions

This study has a number of limitations, including the lack of a placebocondition and the qualitative nature of the data collected. It hopes to inspire new hypotheses for future studies and assist therapists and researchers in their use of music in psychedelic therapy.

A significant body of empirical work is required to advance the therapeutic use of music in psychedelic therapy. Such work will focus on establishing baseline measures that can reliably predict individual music experiences during psychedelic therapy sessions.

Conclusions

In patients with treatment-resistant depression treated with psilocybin, the music experience was significant in influencing their therapeutic experience, and this influence was predictive of reductions in depression 1 week later.