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Psychedelics · 2020

ACE — Accept, Connect, Embody

Change consolidates when the person fully accepts their experience, connects with meaning and values, and embodies those learnings in sustained actions.

ACE (Accept, Connect, Embody) is a psychotherapeutic model developed to guide preparation, support during the session and, above all, integration in psychedelic-assisted therapy, initially within the Psilodep studies for depression at Imperial College London. Rosalind Watts and Jason B. Luoma reorganised the Psychological Flexibility Model into an architecture specially adapted to psychedelic phenomenology and to the qualitative findings of Psilodep 1: an acceptance triad — defusion, present-moment contact and willingness to experience — a connection triad — self as context, values and committed action — and a cross-cutting axis of embodiment that keeps the work anchored in bodily experience. ACE holds that the psychedelic experience can temporarily open a window of flexibility whose therapeutic potential consolidates when the person learns to approach difficult emotions and sensations, to recognise meaning and values, to reconnect with the self, with others and with the world, and to turn insights into concrete ways of living. The model preserves a person-centred, flexible and minimally directive style during the acute experience: therapists follow the emergent process, offer safety, presence and co-regulation, and use the ACE principles as a compass rather than imposing an interpretation or a rigid agenda. Preparation trains openness, trust, willingness, intention and bodily contact; the session favours an attitude of going into and through the experience when there is sufficient safety; and integration organises the material through a funnel that progresses from open narration and witnessing towards meaning-making and, finally, towards actions coherent with what has been learned. ACE thus constitutes a specific framework for translating an intense inner experience into greater psychological flexibility and into sustainable changes in everyday life. (Watts & Luoma, 2020; Watts, 2021).

Theory of change

Change occurs by replacing patterns of avoidance, disconnection and rigidity with a more flexible, embodied relationship with experience: accepting what is difficult, connecting with meaning and values, and integrating the learnings into sustained actions.

Core ideas

  1. The psychedelic experience can open flexibility; integration determines how that openness is carried into life

    ACE starts from the possibility that a psychedelic experience may temporarily produce an emotional, cognitive, perceptual and somatic openness that interrupts rigid patterns. The intensity of that openness may be clinically valuable and at the same time insufficient to sustain changes when the person returns to the same contexts and habits. Preparation and integration create the conditions for navigating the openness and then turning it into new ways of relating to emotions, self, values and behaviour. (Watts & Luoma, 2020, The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy).

  2. Accepting and connecting are complementary movements of one and the same flexibility

    ACE organises change into a complementary polarity: Accept allows the person to approach pain, fear, shame, memories and sensations without being governed by avoidance, while Connect recovers meaning, bonds, values, perspective and action. Therapy avoids turning either pole into a universal solution: a person may need to stop escaping something painful, or may need to come out of a sterile absorption in suffering and turn back towards what makes their life valuable. (Watts & Luoma, 2020, The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy).

  3. Embodiment turns flexibility into a lived and not merely understood experience

    ACE places the body running through the whole map because the psychedelic experience involves intense somatic, sensory and emotional phenomena and because the depressed people described by the authors could be excessively trapped in thought and disconnected from their felt experience. Breathing, interoception, body scan and focusing help them come into contact with what is happening and allow acceptance and connection to be experienced bodily. (Watts & Luoma, 2020, The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy; Watts, 2021, Psilocybin for Depression: The ACE Model Manual).

  4. Pain can signal what matters

    The ACE formulation uses the relationship between suffering and values as a route of exploration: grief may signal love, anger may reveal a violated boundary and fear may show something one is afraid of losing. The clinical function consists in feeling the emotion sufficiently to hear its possible information and then checking which value or need emerges, keeping that reading open and contextual. (Watts & Luoma, 2020, The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy).

  5. The experience belongs to the participant and the therapist accompanies its unfolding

    The model maintains a strongly non-directive position during the psychedelic session. The therapist holds safety, the bond and availability, but avoids selecting in advance the conflict to be worked on or the meaning to be obtained. ACE provides principles simple enough to orient moments of difficulty without replacing the singular trajectory of the experience with an external psychotherapeutic agenda. (Watts & Luoma, 2020, The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy; Watts, 2021, Psilocybin for Depression: The ACE Model Manual).

  6. Preparation modifies in advance the relationship with whatever may appear

    Preparing for a session involves more than conveying information about psychedelic effects. ACE rehearses a psychological stance: openness, reduced control, recognition of avoidance, enough trust to ask for help, the capacity to return to the body and clarity about intentions held lightly. Preparation aims to make those repertoires accessible when the intensity of the experience reduces the usefulness of complex explanations. (Watts, 2021, Psilocybin for Depression: The ACE Model Manual).

  7. Integration begins with witnessing before narrowing towards interpretation

    The ACE funnel preserves a deliberate clinical sequence: first the experience is allowed to be told and witnessed, then connections and meaning are sought, and finally actions are distilled. The wide mouth prevents the therapist from capturing a complex experience too soon within a familiar explanation; the gradual narrowing allows the conclusions that will guide behaviour to rest on sufficiently elaborated material. (Watts, 2021, Psilocybin for Depression: The ACE Model Manual).

  8. An insight consolidates when it changes the way one lives

    ACE attaches great importance to experiences of insight and meaning, but integration culminates in committed action because an intense understanding may lose its force if it does not change decisions and habits. The work helps to translate learnings into small, observable behaviours aligned with values, to review them in the light of their effects and to sustain those that expand the person's life. (Watts & Luoma, 2020, The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy; Watts, 2021, Psilocybin for Depression: The ACE Model Manual).

  9. Connection encompasses self, others and world

    The notion of connectedness that emerged from Psilodep 1 goes beyond an exclusively interpersonal definition. Participants described reconnection with their inner experience, with other people and with broader dimensions such as nature, the world, beauty or a sense of belonging. The subsequent Watts Connectedness Scale empirically preserved these three domains — self, others and world — providing an operationalisation compatible with the Connect component of ACE. (Watts et al., 2017, Patients' Accounts of Increased Connectedness and Acceptance After Psilocybin for Treatment-Resistant Depression; Watts et al., 2022, The Watts Connectedness Scale).

  10. The alliance forms part of the conditions that modulate the psychedelic experience

    In the trial in which ACE was developed, a stronger therapeutic alliance was associated with better rapport before the session, greater emotional breakthrough and mystical experience, and better subsequent depression scores; moreover, breakthrough in the first session was related to a stronger alliance afterwards. These results support a dynamic relationship in which bond and acute experience may influence one another, without turning the observational association within the trial into a definitive causal demonstration. (Murphy et al., 2022, Therapeutic Alliance and Rapport Modulate Responses to Psilocybin Assisted Therapy for Depression).

Influences

  • Psychological Flexibility Model
  • Acceptance and Commitment Therapy (ACT)
  • Contextual Behavioral Science
  • Qualitative findings of Psilodep 1
  • Non-directive tradition of psychedelic psychotherapy
  • William Richards
  • Tim Read
  • Holotropic Breathwork
  • Polyvagal theory
  • London Psychedelic Integration Group

Key references

  • Watts, R., & Luoma, J. B. (2020). The Use of the Psychological Flexibility Model to Support Psychedelic Assisted Therapy. Journal of Contextual Behavioral Science, 15, 92–100.
  • Watts, R. (2021). Psilocybin for Depression: The ACE (Accept/Connect/Embody) Model Manual. Imperial College London.
  • Watts, R., Day, C., Krzanowski, J., Nutt, D., & Carhart-Harris, R. (2017). Patients' Accounts of Increased Connectedness and Acceptance After Psilocybin for Treatment-Resistant Depression. Journal of Humanistic Psychology, 57(5), 520–564.
  • Luoma, J. B., Sabucedo, P., Eriksson, J., Gates, N., & Pilecki, B. C. (2020). Toward a Contextual Psychedelic-Assisted Therapy: Perspectives from Acceptance and Commitment Therapy and Contextual Behavioral Science. Journal of Contextual Behavioral Science. https://doi.org/10.1016/j.jcbs.2019.10.003.
  • Close, J. B., Haijen, E. C. H. M., Watts, R., Roseman, L., & Carhart-Harris, R. L. (2020). Psychedelics and Psychological Flexibility — Results of a Prospective Web-Survey Using the Acceptance and Action Questionnaire II. Journal of Contextual Behavioral Science, 16, 37–44. https://doi.org/10.1016/j.jcbs.2020.01.005.
  • Zeifman, R. J., Wagner, A. C., Watts, R., Kettner, H., Mertens, L. J., & Carhart-Harris, R. L. (2020). Post-Psychedelic Reductions in Experiential Avoidance Are Associated With Decreases in Depression Severity and Suicidal Ideation. Frontiers in Psychiatry, 11, 782. https://doi.org/10.3389/fpsyt.2020.00782.
  • Murphy, R., Kettner, H., Zeifman, R., Giribaldi, B., Kartner, L., Martell, J., Read, T., Murphy-Beiner, A., Baker-Jones, M., Nutt, D., Erritzoe, D., Watts, R., & Carhart-Harris, R. (2022). Therapeutic Alliance and Rapport Modulate Responses to Psilocybin Assisted Therapy for Depression. Frontiers in Pharmacology, 12, 788155. https://doi.org/10.3389/fphar.2021.788155.
  • Watts, R., Kettner, H., Geerts, D., Gandy, S., Kartner, L., Mertens, L., Timmermann, C., Nour, M. M., Kaelen, M., Nutt, D., Carhart-Harris, R., & Roseman, L. (2022). The Watts Connectedness Scale: A New Scale for Measuring a Sense of Connectedness to Self, Others, and World. Psychopharmacology, 239, 3461–3483. https://doi.org/10.1007/s00213-022-06187-5.
  • Carhart-Harris, R. L., Bolstridge, M., Rucker, J., Day, C. M. J., Erritzoe, D., Kaelen, M., Bloomfield, M., Rickard, J. A., Forbes, B., Feilding, A., Taylor, D., Pilling, S., Curran, H. V., & Nutt, D. J. (2016). Psilocybin With Psychological Support for Treatment-Resistant Depression: An Open-Label Feasibility Study. The Lancet Psychiatry, 3(7), 619–627. https://doi.org/10.1016/S2215-0366(16)30065-7.
  • Carhart-Harris, R. L., Bolstridge, M., Day, C. M. J., Rucker, J., Watts, R., Erritzoe, D. E., Kaelen, M., Giribaldi, B., Bloomfield, M., Pilling, S., Rickard, J. A., Forbes, B., Feilding, A., Taylor, D., Curran, H. V., & Nutt, D. J. (2018). Psilocybin With Psychological Support for Treatment-Resistant Depression: Six-Month Follow-Up. Psychopharmacology, 235, 399–408. https://doi.org/10.1007/s00213-017-4771-x.
  • Carhart-Harris, R. L., Giribaldi, B., Watts, R., et al. Protocol for Psilocybin for Major Depression: A Randomized Control Trial, Imperial College London, precursor and protocol framework for Psilodep 2.