Psychedelics · 2016
Psilocybin with psychological support (PSI: Preparation, Support, Integration)
Change is fostered by preparing a safe relationship, holding the psilocybin experience without directing it, and afterwards integrating its emotions, meanings and possibilities for action.
Psilocybin with psychological support, later synthesised by the team itself under the acronym PSI — Preparation, Support, Integration — is a brief psychotherapeutic protocol developed at Imperial College London to accompany the administration of psilocybin in people with treatment-resistant unipolar depression. The clinical structure appeared in the 2016 open-label trial and was made explicit in 2018 as three components of psychological support: preparation, to learn the patient's history, build trust and anticipate the effects; acute and peri-acute support through physical and emotional presence, empathic listening, minimal directiveness and reassurance during the experience; and integration through non-judgemental listening, elaboration of the account, occasional interpretation and support for maintaining positive changes in outlook and lifestyle. In the original protocol, a preparation session of around four hours preceded two psilocybin sessions of 10 mg and 25 mg a week apart, conducted with two clinicians, eyeshades, music and an introspective focus, followed by integration the next day and a week after the high dose. Its psychotherapeutic theory is deliberately light and rests more on facilitating conditions and experiential processes than on a closed doctrinal formulation; later analyses from the same programme associated change with greater emotional acceptance, connection with oneself, others and the world, the quality of the acute experience, the recovery of emotional responsiveness and the integration of meanings. (Carhart-Harris et al., 2016, 2018; Watts et al., 2017; Roseman et al., 2018; Cavarra et al., 2022).
Theory of change
A person can change when a deep psychedelic experience occurs within a framework of trust, openness and low directiveness, allows contact with previously avoided emotion and meaning, and is subsequently integrated into a more connected narrative and life.
Core ideas
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PSI organises psychological support into three complementary clinical functions
PSI's clearest formal contribution is to distinguish preparation, support and integration as distinct but interdependent functions. To prepare means to get to know the patient, build trust and anticipate the experience; to support means to be physically and emotionally present during the acute period with listening and reassurance; to integrate means to listen afterwards to the account, help elaborate meanings and foster the preservation of positive changes. The protocol's efficacy is thus framed as a property of the combined treatment and its context, not of an isolated pharmacological session. (Carhart-Harris et al., 2018, Psilocybin with psychological support for treatment-resistant depression: six-month follow-up).
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Preparation modifies the way the person enters the experience
PSI's preparation devotes hours to the personal history, the understanding of the depression, the relationship with the guides and sensory familiarisation with the forthcoming session. This phase seeks to reduce uncertainty and create enough trust so that, when intense alterations of perception, emotion or self appear, the person can recognise the context as safe and use the therapists as a point of reference without depending on constant direction. (Carhart-Harris et al., 2016, Psilocybin with psychological support for treatment-resistant depression: an open-label feasibility study; Stroud et al., 2018).
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Low directiveness protects the autonomy of the experiential process
During the session the guides minimise thematic intervention and allow a largely uninterrupted introspection, carrying out periodic checks and engaging more actively when distress or a need for support appears. This stance reflects the idea that the therapist should create conditions of safety and availability without imposing a narrative upon a state that is particularly sensitive to expectation and suggestion. Low directiveness is therefore a technical and ethical choice as well as an operational feature of the protocol. (Carhart-Harris et al., 2016, 2018; Cavarra et al., 2022).
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The willingness to accept the experience replaces the struggle to control it
Patients were encouraged to surrender or let go when it was clinically safe to do so, and the later qualitative analysis found that many described their depression in terms of avoiding feelings and memories while characterising therapeutic change as a greater capacity to confront, feel and accept that material. PSI thus treats openness to difficult experience as a condition of processing, while simultaneously maintaining a framework of safety that makes it possible to distinguish acceptance from being overwhelmed. (Watts et al., 2017, Patients' Accounts of Increased "Connectedness" and "Acceptance" After Psilocybin for Treatment-Resistant Depression).
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Connectedness emerges as an experiential marker of emerging from depression
In the follow-up interviews, depression was repeatedly described as disconnection from the body and the senses, from the self, from other people and from the world, while the psychedelic experience was associated with a reopening of those connections. Some patients maintained changes in meaning and a sense of connection even when part of the depressive symptomatology returned, which suggests that the clinically relevant outcome may include transformations not fully captured by a symptom scale. (Watts et al., 2017).
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The quality of the acute experience matters more than its mere intensity
Roseman and colleagues' analysis showed that qualitative features of the 25 mg experience, especially oceanic boundlessness and the relative absence of dread of ego dissolution, were associated with the symptom trajectory at five weeks, while generic sensory effects showed less predictive capacity. This supports the PSI architecture because it compels consideration of how preparation, trust, support, music and psychological disposition may influence the experience that occurs, even though correlational data cannot determine which component caused the outcome. (Roseman, Nutt & Carhart-Harris, 2018, Quality of Acute Psychedelic Experience Predicts Therapeutic Efficacy of Psilocybin for Treatment-Resistant Depression).
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Music functions as a contextual intervention with therapeutic power of its own
The playlist acts as more than ambient accompaniment: patients described how it could evoke significant emotions and images, provide a sense of guidance, increase safety and openness or, when it did not resonate, generate resistance and a sense of being led in an alien direction. The quality of the musical experience was associated with insight and mystical-type experiences and predicted reduction in depression at one week, which is why Kaelen and colleagues called it the "hidden therapist". (Kaelen et al., 2018, The hidden therapist: evidence for a central role of music in psychedelic therapy).
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The treatment appears to facilitate a recovery of emotional responsiveness
Studies derived from the trial observed changes in emotional processing that the team interpreted as compatible with a greater capacity to respond once again to affective stimuli: a greater amygdala response to emotional faces was found after treatment, along with connectivity changes during face processing and an improvement in the speed of emotion recognition associated with reduced anhedonia. These findings remain preliminary and do not allow the effect to be attributed to a single cause, but they converge with the qualitative account of moving from blunting and avoidance to a wider emotional experience. (Roseman et al., 2018, Increased amygdala responses to emotional faces after psilocybin for treatment-resistant depression; Stroud et al., 2018; Mertens et al., 2020).
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The experience may be accompanied by lasting changes in outlook and personality traits
At three months, the cohort showed a decrease in Neuroticism and increases in Extraversion and Openness, with a trend towards an increase in Conscientiousness; moreover, greater insight during the acute experience was associated, exploratorily, with reduced Neuroticism and increased Extraversion. These findings do not demonstrate that PSI directly transforms personality, but they are consistent with the hypothesis that an intense and integrated experience can reorganise relatively stable ways of relating to oneself and to the world. (Erritzoe et al., 2018, Effects of psilocybin therapy on personality structure).
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Integration turns an extraordinary experience into biographical material and everyday action
PSI holds that the psilocybin session requires subsequent work so that emotions, memories and insights can be organised into a narrative and can guide sustainable change. The original formulation of this phase was brief and allowed for non-judgemental listening, occasional interpretation and advice on maintaining positive changes in outlook and lifestyle; the later ACE model of Watts and Luoma developed acceptance, connection, embodiment and committed action far more explicitly. Maintaining this historical distinction makes it possible to describe PSI faithfully without retrospectively projecting onto the 2016 protocol techniques created afterwards. (Carhart-Harris et al., 2018; Watts & Luoma, 2020).
Influences
- Classical psychedelic therapy
- Set and setting
- Person-centred therapy
- Humanistic psychology
- The experiential tradition of Stanislav Grof
- William A. Richards's psychedelic guidance
- The therapeutic use of music by Helen Bonny and Walter Pahnke
- Psychiatry and experimental psychopharmacology
Key references
- 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.
- Watts, R., Day, C., Krzanowski, J., Nutt, D. J., & 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. https://doi.org/10.1177/0022167817709585.
- Roseman, L., Nutt, D. J., & Carhart-Harris, R. L. (2018). Quality of Acute Psychedelic Experience Predicts Therapeutic Efficacy of Psilocybin for Treatment-Resistant Depression. Frontiers in Pharmacology, 8, 974. https://doi.org/10.3389/fphar.2017.00974.
- Kaelen, M., Giribaldi, B., Raine, J., Evans, L., Timmermann, C., Rodriguez, N., Roseman, L., Feilding, A., Nutt, D., & Carhart-Harris, R. (2018). The hidden therapist: evidence for a central role of music in psychedelic therapy. Psychopharmacology, 235, 505–519. https://doi.org/10.1007/s00213-017-4820-5.
- Stroud, J. B., Freeman, T. P., Leech, R., Hindocha, C., Lawn, W., Nutt, D. J., Curran, H. V., & Carhart-Harris, R. L. (2018). Psilocybin with psychological support improves emotional face recognition in treatment-resistant depression. Psychopharmacology, 235, 459–466. https://doi.org/10.1007/s00213-017-4754-y.
- Roseman, L., Demetriou, L., Wall, M. B., Nutt, D. J., & Carhart-Harris, R. L. (2018). Increased amygdala responses to emotional faces after psilocybin for treatment-resistant depression. Neuropharmacology, 142, 263–269. https://doi.org/10.1016/j.neuropharm.2017.12.041.
- Erritzoe, D., Roseman, L., Nour, M. M., MacLean, K., Kaelen, M., Nutt, D. J., & Carhart-Harris, R. L. (2018). Effects of psilocybin therapy on personality structure. Acta Psychiatrica Scandinavica, 138, 368–378. https://doi.org/10.1111/acps.12904.
- Mertens, L. J., Wall, M. B., Roseman, L., Demetriou, L., Nutt, D. J., & Carhart-Harris, R. L. (2020). Therapeutic mechanisms of psilocybin: Changes in amygdala and prefrontal functional connectivity during emotional processing after psilocybin for treatment-resistant depression. Journal of Psychopharmacology, 34(2), 167–180. https://doi.org/10.1177/0269881119895520.
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy—A Systematic Review of Associated Psychological Interventions. Frontiers in Psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255.
- Watts, R., & Luoma, J. B. (2020). The use of the psychological flexibility model to support psychedelic assisted therapy. Journal of Contextual Behavioral Science, 15, 92–102. https://doi.org/10.1016/j.jcbs.2019.12.004.
- Imperial College London. Hammersmith Hospital Campus, Du Cane Road, London W12 0NN; Burlington Danes Building location.