Patient Experiences of Psilocybin-Assisted Psychotherapy : An Interpretative Phenomenological Analysis
Alexander B. Belser, Gabrielle Agin-Liebes, T. Cody Swift, Sara Terrana, Neşe Devenot, Harris L. Friedman, Jeffrey Guss, Anthony Bossis and Stephen Ross
Journal of Humanistic Psychology, 2017, 1 –35
Doi : 10.1177/0022167817706884
The psychological mechanisms of action involved in psilocybin-assisted psychotherapy are not yet well understood. Despite a resurgence of quantitative research regarding psilocybin, the current study is the first qualitative study of participant experiences in psilocybin-assisted psychotherapy. Semistructured interviews were carried out with 13 adult participants aged 22 to 69 years (M = 50 years) with clinically elevated anxiety associated with a cancer diagnosis. Participants received a moderate dose of psilocybin and adjunctive psychotherapy with an emphasis on the process of meaning-making. Verbatim transcribed interviews were analyzed by a five-member research team using interpretative phenomenological analysis. General themes found in all or nearly all transcripts included relational embeddedness, emotional range, the role of music as conveyor of experience, meaningful visual phenomena, wisdom lessons, revised life priorities, and a desire to repeat the psilocybin experience. Typical themes found in the majority of transcripts included the following: exalted feelings of joy, bliss, and love; embodiment; ineffability; alterations to identity; a movement from feelings of separateness to interconnectedness; experiences of transient psychological distress; the appearance of loved ones as guiding spirits; and sharing the experience with loved ones posttreatment. Variant themes found in a minority of participant transcripts include lasting changes to sense of identity, synesthesia experiences, catharsis of powerful emotion, improved relationships after treatment, surrender or “letting go,” forgiveness, and a continued struggle to integrate experience. The findings support the conclusion that psilocybin-assisted psychotherapy may provide an effective treatment for psychological distress in cancer patients. Implications for theory and treatment are discussed.
Keywords : anxiety, psychosocial distress, cancer, psilocybin, psychedelic, hallucinogens, qualitative, spirituality, interpretative phenomenological analysis
In the past 15 years, there has been a renaissance of quantitative research evaluating the safety and efficacy of substances used to alter consciousness, namely those called hallucinogens and psychedelics (Friedman, 2006; Studerus, Kometer, Hasler, & Vollenweider, 2011). One of these studied, psilocybin, is a naturally occurring serotonergic (4-phosphoryloxy-N,N-dimethyltryptamine) compound found in over 180 species of mushrooms that has been used in religious and healing practices in various cultures for centuries (Allen & Arthur, 2005; Stamets, 1996; Wasson, 1980). In a series of doubleblind placebo-controlled trials using quantitative research methods, the provision of psilocybin-assisted psychotherapy was associated with decreased levels of anxiety among cancer patients (Grob et al., 2011), reductions in depressive symptoms among patients with treatment-resistant depression (Carhart-Harris et al., 2016), positive changes in personality, such as increases in openness to new experience (MacLean, Johnson, & Griffiths, 2011), and profound spiritual and mystical experiences (Griffiths, Richards, Johnson, McCann, & Jesse, 2008).
The current study draws from a subsample of participants from a recently completed trial conducted by Ross et al. (2016) at New York University (NYU). In this double-blind placebo-controlled randomized trial, psilocybin-assisted psychotherapy was investigated as a treatment for patients with cancer and concomitant anxiety and depression. The NYU study and a similar trial completed by Griffiths and colleagues at Johns Hopkins University suggest that a single administration of moderate to high-dose psilocybin, when combined with psychotherapy, led to rapid, substantial, and enduring decreases in depression and anxiety, as well as improvements in cancer-related demoralization and hopelessness, spiritual well-being, and quality of life (Griffiths et al., 2016; Ross et al., 2016). In the trial conducted at NYU, the administration of psilocybin generated very large anxiolytic and antidepressant effects, with 83% of participants in the psilocybin-first group, as compared with 14% in the placebo-first group, demonstrating antidepressant response after 7 weeks. These large magnitude effects were enduring: At 6½-month follow-up, antidepressant and anxiolytic response rates were 60% to 80% (Ross et al., 2016). Additionally, more than two thirds (70%) of the study participants rated their experience of psilocybin to be among the top five most spiritual experiences of their lives. Despite the profound and singular experiences reported in these quantitative studies (Griffiths et al., 2008; Griffiths et al., 2011; Griffiths et al., 2016; Ross et al., 2016), we found no qualitative studies of patient experiences of psilocybin-assisted psychotherapy in clinical trials in the published literature.
A review of the qualitative literature regarding subjective psychedelic experiences reveals a variety of studies, although most involve noncomparable participant populations and contexts. Relevant research includes analyses of interviews with substance users in uncontrolled recreational settings (Beck & Rosenbaum, 1994; Comis & Noto, 2012; Pennay & Moore, 2010; Singer & Schensul, 2011), user experience reports found on online message boards (Bersani et al., 2014; Kjellgren & Soussan, 2011), or interviews of participants involved in non-Western treatment settings (Loizaga-Velder & Verres, 2014; Presser-Felder, 2013; Shanon, 2002). Various substances have been investigated using qualitative methods, including ayahuasca (Loizaga- Velder & Verres, 2014; Presser-Felder, 2013; Shanon, 2002), salvia divinorum (Addy, Garcia-Romeu, Metzger, & Wade, 2015); 25C-NBOMe (Bersani et al., 2014), 4-HO-MET (Kjellgren & Soussan, 2011), MDMA (Passie, 2012; Comis & Noto, 2012; Singer & Schensul, 2011; Beck & Rosenbaum, 1994), and polysubstance use (Pennay & Moore, 2010). Other qualitative research with psychedelic substances has focused on religious/spiritual/mystical experiences (Yaden et al., 2016) or self-transcendent experiences occasioned by hallucinogens (Garcia-Romeu, Himelstein, & Kaminker, 2015).
Although there are beginning efforts using qualitative inquiry into the nature of psychedelic experience, rigorous qualitative investigations of the subjective effects of serotonergic hallucinogens in clinical treatment settings are rare. In one trial, Turton, Nutt, and Carhart-Harris (2014) conducted an interpretative phenomenological analysis (IPA) of the subjective experiences of psilocybin as administered via intravenous injection to healthy psychedelic experienced volunteers within a unique setting, an fMRI scanner. In a second study, Gasser, Kirchner, and Passie (2014) conducted a qualitative
content analysis of LSD-assisted psychotherapy for anxiety associated with a life-threatening disease. Finally, in their research regarding the administration of psilocybin to healthy normal volunteers, Griffiths et al. (2008, 2011) have provided excerpted verbatim comments from participants, and they are
currently pursuing qualitative research with psilocybin (Noorani, Garcia- Romeu, Griffiths, & Johnson, 2015).
Current theoretical conceptualizations regarding the psychological mechanisms of action involved in psychedelic-assisted psychotherapy remain underdeveloped. Some have proposed that a psychedelic-occasioned mystical or peak experience is a mediating factor fostering highly salient spiritual/ mystical states of consciousness associated with enduring positive effects in cognition, affect, behavior, and spirituality (Gasser, Kirchner, & Passie, 2014; Griffiths et al., 2008; Griffiths et al., 2011; Griffiths, Richards, McCann, & Jesse, 2006; Pahnke, 1969; Studerus et al., 2011). While there is empirical support for this conceptualization (Griffiths et al., 2008; Griffiths et al., 2016; Ross et al., 2016), alternative hypotheses regarding other possible mediating factors and psychological mechanisms of action have not yet been evaluated.
Quantitative methods are well suited for hypothesis testing, but such methods may be limited by preconceptions regarding the phenomena under study. Alternatively, qualitative methods provide a hypothesis-generating mode of inquiry that is appropriate to address research questions in a nascent field such as psychedelic science where theoretical models are not yet well formed. While both modes of inquiry provide value, qualitative inquiry can complement existing quantitative research regarding psychedelic-assisted treatments as it is well suited to address questions of meaning, inner experience, and behavioral change within complex multidimensional contexts (McAdams, 1999) and may help elucidate underlying mechanisms of action.
Our study is perhaps the first formal qualitative inquiry regarding participant experiences in psilocybin-assisted psychotherapy. Per inclusion criteria, all study participants had elevated clinical anxiety and psychological distress associated with a diagnosis of cancer. The interviews with participants elicited
substantial experiences related to cancer, death, and spirituality that have Belser et al. 5 been analyzed and submitted for other publication (Swift et al., in press), but our current research question is not focused on oncological concerns. In the current analysis, we address research questions regarding the form and content of participant experiences during the psilocybin dosage sessions, descriptions of their subjective experiences of this psychological intervention in context, and their understandings of the embedded meanings of their lived experiences.