The psychedelic debriefing in alcohol dependence treatment: illustrating key change phenomena through qualitative content analysis of clinical sessions

This open-label pilot study (n=10) of psilocybin-assisted treatment of alcohol dependence (21mg/70kg) presents a qualitative content analysis of the 17 debriefing sessions conducted in the pilot study, which occurred the day after corresponding psilocybin medication sessions. Participants articulated a series of key phenomena related to changes in drinking outcomes and acute subjective effects of psilocybin.

Abstract

“Background: Research on the clinical applications of psychedelic-assisted psychotherapy has demonstrated promising early results for treatment of alcohol dependence. Detailed description of the content and methods of psychedelic-assisted psychotherapy, as it is conducted in clinical settings, is scarce.

Methods: An open-label pilot (proof-of-concept) study of psilocybin-assisted treatment of alcohol dependence (NCT01534494) was conducted to generate data for a phase 2 RCT (NCT02061293) of a similar treatment in a larger population. The present paper presents a qualitative content analysis of the 17 debriefing sessions conducted in the pilot study, which occurred the day after corresponding psilocybin medication sessions.

Results: Participants articulated a series of key phenomena related to change in drinking outcomes and acute subjective effects of psilocybin.

Discussion: The data illuminate change processes in patients’ own words during clinical sessions, shedding light on potential therapeutic mechanisms of change and how participants express effects of psilocybin. This study is unique in analyzing actual clinical sessions, as opposed to interviews of patients conducted separately from treatment.”

Authors: Elizabeth M. Nielson, Darrick G. May, Alyssa A. Forcehimes & Michael P. Bogenschutz

Notes

This study reports further on Bogenschutz and colleagues (2015) which explains the full proof-of-concept study.

Summary

Introduction

Psychedelic-assisted psychotherapy is a growing field, with psilocybin-assisted treatment of alcohol dependence being tested in an FDA-approved phase 2 clinical trial. The treatment consists of 12 weekly psychotherapy sessions with two psilocybin medication sessions at weeks 4 and 8, as well as a debriefing session.

In clinical research, patients are asked to provide a full account of their experience and reflect on its significance. They are also asked to describe any persisting positive or negative effects that are apparent.

Psilocybin experiences are quite different from ordinary states of consciousness and may be difficult to remember and recall later. A debriefing session may help participants benefit from their experience by consolidating memories, processing emotions, and articulating insights.

Early research on the use of classic hallucinogens for therapy was conducted with LSD, a serotonergic psychedelic similar to psilocybin. The present study focused on psychotherapy surrounding the psilocybin sessions, and found that the change in target behaviors achieved through the overwhelming, peak experience can be consolidated or enhanced through psychotherapy.

Researchers have used ketamine in combination with other drugs to treat alcoholism. This method, called Affective Contra-Attribution (ACA), includes preparatory and integration psychotherapy flanking the ketamine session, but differs in that patients are presented with alcohol while experiencing negative affective states.

In the early 1950’s, LSD researchers proposed that psychedelic therapy with LSD could induce an experience akin to delirium tremens, a dangerous and extreme consequence of alcohol withdrawal. This theory led to 11 studies with 311 patients, 145 of which were considered “much improved” at follow up.

Levine and Ludwig (1967) developed a technique that combined LSD administration with hypnosis to maximize the chances of therapeutic success in treating alcoholics with LSD. This technique is akin to the psycholytic model described above, and the goals of exploring problems, abreaction, and gaining insight are echoed in the present study.

In treatment of cancer-related anxiety with psilocybin, psychodynamic therapies such as logotherapy and meaning-making therapy have been used, as well as cognitive behavioral therapy (CBT) and acceptability and commitment therapy (MET) models.

Undergoing psilocybin-assisted treatment for alcohol dependence in a clinical setting is a rare experience. The post-medication debriefing session is an example of how patients discuss key phenomena related to behavioral change and symptom improvements.

Method

Ten participants met DSM-IV-TR criteria for alcohol dependence and were enrolled in an open-label pilot study of psilocybin-assisted treatment of alcohol dependence. The study included 14 treatment sessions over 12 weeks, including two psilocybin medication sessions at weeks four and eight.

Psilocybin was given orally in a dose of 0.3 mg/kg for the first psilocybin session and 0.4 mg/kg for the second session. The dose range for psilocybin treatment of alcohol dependence is 0.29 – 0.43 mg/kg.

Each participant had a debriefing session with both therapists on the day after each psilocybin medication session. We conducted a qualitative content analysis of all 17 debriefing sessions to illustrate how patients talk about change-related phenomena in this unique context.

Measures

The pilot study included multiple measures of patients’ mood, mental status, physical health, vital signs, and drinking outcomes. A 43 item Mystical Experience Questionnaire (MEQ) was used to determine the presence and strength of experiences that are similar to mystical experiences that may occur spontaneously or in a religious context.

Participants completed the MEQ at the end of each psilocybin session to measure their mysticomimetic experience. Participants whose MEQ subscale scores were above 0.6 were given the option to increase their psilocybin dosage for their second medication session.

We used the Hallucinogen Rating Scale to measure subjective psilocybin effects, and present the intensity subscale data for each participant.

The Altered States of Consciousness (ASC) rating scale was developed by Dittrich (1998) and validated by Studerus et al. (2010). It can be used to measure participant experiences of psilocybin, ketamine, MDMA, and does not detect alcohol intoxication or the effects chlorpromazine as compared to placebo.

Data Analysis

Interview transcripts were analyzed using Atlas.ti qualitative data analysis software. Categories were established by known phenomena of interest and included material related to alcohol/drinking, mysticomimetic experiences, ego-dissolution, interpersonal interactions, intrapersonal insights, motivation, commitment to change, music, stigma, the therapist/participant relationship, and difficult experiences during the session.

The first author created coding categories and completed an initial coding of all transcripts. The third and fourth authors reviewed the categories and coded material, and the first author performed secondary searches using keywords to identify passages that should potentially be included but were missed in the reading process.

Mysticomimetic Experiences

Psilocybin can precipitate mysticomimetic experiences that are personally meaningful. These experiences have been shown to mediate positive change in clinical populations and are regarded as crucial to change by the traditional Alcoholics Anonymous philosophy.

To code transcripts for each of the sub-domains of the MEQ, the researcher reviewed the items comprising each category in MacLean et al.’s (2012) factor analysis and then coded participant utterances that articulated each category.

Ego-Dissolution

Falkenstrom (2003) wrote that the self in psychoanalytic thought is distinct but not incompatible with the self as understood in Buddhist psychology. Hence, experiences of ego-dissolution, which could be considered pathological from the Freudian perspective, might be healing from perspective of Buddhist psychology.

LSD increases global connectivity between brain structures and functional networks, and the strength of these alterations are positively correlated with the sense of ego-dissolution. Psilocybin decreases metabolic activity in the default mode network, which may further contribute to the experience of ego-dissolution.

Primary process thinking is thought to reflect Freudian theory of the pleasure and reality principles, the “Id” and “Ego”, and is more pronounced in altered states of consciousness. Additionally, primary process thinking reflects emotional processes which are a key factor in the subjective experience of psilocybin-assisted therapy.

Relationship to Alcohol

This category was populated with content about drinking gathered by auto-coding interviews for the words drink, drinking, and alcohol. The category title was modified to more accurately characterize this theme.

Motivation for Change

Psilocybin may enhance motivation for change in alcohol use through its subjective experience or via a more basic biological mechanism. In the present study, MET was used to increase the participant’s internal motivation to make positive, healthy behavior changes.

Commitment to Change

We coded the use of key commitment phrases provided in the MET manual to analyze transcripts for examples of strong commitment to make a change.

Dysphoric Experiences and Their Resolution

Recent survey research shows that dysphoric experiences while using psilocybin in non-clinical settings are often associated with lasting increases in wellbeing. Participants were given specific guidance and tools for managing dysphoric experiences, and emergency medications were available.

Stigma

Stigma is a compound issue for psychedelics as potential treatments of addictive disorders. Stigma is a barrier to engagement in any addiction treatment, including conventional methods, and psychedelics are stigmatized medicines by nature of their contentious history and current legal status.

Results

The debriefing sessions were conducted by the fourth author, 12 with the third author as co-therapist, and 5 with a physician co-investigator as co-therapist. The intensity scale mean was 2.43 (SD 1.03) in the first session and 2.0 (SD 1.14) in the second session.

Ineffability

Adam and Michelle discussed their experiences with a mysticomimetic experience, and Michelle’s therapists discussed the possibility of having experienced a direct connection with God.

Ego-Dissolution

The blissful state subscale of the ASC was found to correlate with LSD induced increases in primary process thinking, and corresponding reductions in secondary process thinking, of which ego is a function. Adam, the only participant who reported high scores across all four factors of the MEQ, experienced ego-dissolution.

Stigma

Participants had difficulty sharing their experiences with those who are close to them, as they perceived the experience as just another form of addictive behavior.

Discussion

The present analysis illustrates several concepts in psilocybin-assisted treatment of alcohol dependence, including mysticomimetic experience, which has been shown to account for some, but undoubtedly not all, of the positive mental health outcomes of psychedelic therapy. The excerpts presented here primarily come from sessions with high MEQ scores, yet many debriefing sessions did not clearly articulate the component phenomena of mysticomimetic experiences. This may be because the effects of psilocybin are measurably distinct and unique to classic hallucinogens.

The present treatment model was specifically designed so that therapists who are already trained in the empirically supported MI approach can collaborate with a therapist who has the training to provide the psychedelic preparation and integration sessions.

Other qualitative studies have used interviewing to study participants in psychedelic-assisted treatment trials for smoking cessation, cancer anxiety, depression, and psychostimulant abuse. This study used actual clinical sessions as the data set, and avoided the creation of a separate situation and the introduction of interviewer dynamics.

A potential confound in the analysis of debriefing sessions completed the day after a psilocybin session is alteration in recollection due to delayed recall. In the present study, the therapists may have assisted with recall by reminding the participant and asking about statements or observations made during the session.

Heather had extremely mild subjective experiences during the study, but did change her drinking habits. This may be due to the MET treatment working alone, or to the anti-addictive neurobiological effects of psilocybin.

Limitations

This paper presents the findings of an analysis of 17 debriefing sessions transcribed from recordings made during the pilot-feasibility study of psilocybin-assisted treatment of alcohol dependence at University of New Mexico between 2012 and 2013. The sessions varied in length, content and format, and the analysis did not differentiate between them.