Seeking Safety for women in incarceration: a systematic review

PURPOSE

Seeking Safety is an evidence-based treatment for individuals with comorbid posttraumatic stress disorder and substance use disorder. This treatment shows promise to address the unique, unmet needs of women in prison. The current systematic literature review aims to highlight several critical gaps in research on Seeking Safety in forensic settings that need to be filled before Seeking Safety can be implemented in a widespread manner.

METHODS

PsycINFO, PubMed and Google scholar databases were used to identify studies that were published in English, included women in forensic settings, and incorporated Seeking Safety treatment. A total of seven studies met review criteria. The quality of studies was assessed with the mixed methods appraisal tool.

RESULTS

High risk of contamination, inclusion of small, predominantly White samples, high attrition rates, need for dose-response testing, and lack of follow-up data currently limit the ability to assess the efficacy of Seeking Safety in forensic settings. In addition, there is a lack of research on Seeking Safety's ability to reduce symptoms of substance use disorder for incarcerated women and further cultural adaptation may be needed.

CONCLUSION

Seeking Safety has the potential to address the underlying causes of incarceration for justice-involved women, but additional research addressing these identified gaps is needed to facilitate more widespread implementation.

Diminished psychedelic returns on distress: Marital status and household size

Although the use of psychedelics to impact health has seen growth, little research has tested the effects of culture conditions on the relationship. More specifically, how does marital status and family size affect the relationship between psychedelics and health? This study tests the relationship between Lifetime Classic Psychedelic Use (LCPU), marital status, and household size (number of people living in a household) on levels of psychological distress in the past 30 days. This project uses pooled data from the National Survey of Drug Use and Health (NSDUH) (2010 to 2018) (N = 674,521). The Final sample size is determined by the dependent variable, psychological distress in the past month (n = 158,633). The analysis includes a series of nested logistic regression models conducted in Stata 17. Results indicate that LCPU is independently associated with better health, but the association between LCPU and health varies across levels of household size. Larger households are associated with higher levels of distress, which are then exacerbated among psychedelics users. Furthermore, three-way interactions reveal that the negative association between household size and distress gets larger among psychedelic users who are married, divorced, and widowed. Overall, results suggest that household size negatively impacts the association between LCPU and health, with those who are married, divorced, and widowed experiencing the worst outcomes.

Preliminary evidence for the importance of therapeutic alliance in MDMA-assisted psychotherapy for posttraumatic stress disorder

Background: MDMA-assisted psychotherapy (MDMA-AP) is a combined psychotherapeutic and pharmacologic intervention that shows promise in the treatment of posttraumatic stress disorder (PTSD). Although therapeutic alliance has been established as a key predictor across psychotherapies and is emphasised within MDMA-AP treatment manuals, research has not yet examined the relationship between therapeutic alliance and MDMA-AP treatment outcomes.Objective: Examine whether therapeutic alliance predicts changes in PTSD symptoms following MDMA-AP.Method: Twenty-three individuals with chronic PTSD participated in a MDMA-AP clinical trial that included a randomised (MDMA vs. placebo) and open-label phase. The present analyses focused on participants who were administered MDMA over the course of the randomised and open-label phases (n = 22). Therapeutic alliance was assessed using the Working Alliance Inventory at sessions baseline (pre-session 3) and sessions 4 and 9. PTSD symptoms were assessed using the Clinician Administered PTSD Scale and the Impact of Events Scale-Revised.Results: Controlling for baseline clinician-assessed PTSD severity, therapeutic alliance at sessions 4 and 9 (but not baseline) significantly predicted post-MDMA-AP clinician-assessed PTSD severity. Controlling for baseline self-reported PTSD severity, therapeutic alliance at baseline (although this did not survive correction for multiple comparisons) and sessions 4 and 9 predicted post-MDMA-AP self-reported PTSD severity.Conclusions: The present results provide the first preliminary evidence for the relationship between the therapeutic alliance and treatment outcomes within MDMA-AP for PTSD. These findings highlight the important role of psychotherapy, and common psychotherapeutic factors, within MDMA-AP. Replication in studies with larger and more diverse clinical samples remain necessary.Trial registration: ClinicalTrials.gov identifier: NCT00090064.

The illusion of inclusion: contextual behavioral science and the Black community

Anti-racism approaches require an honest examination of cause, impact, and committed action to change, despite discomfort and without experiential avoidance. While contextual behavioral science (CBS) and third wave cognitive-behavioral modalities demonstrate efficacy among samples composed of primarily White individuals, data regarding their efficacy with people of color, and Black Americans in particular, is lacking. It is important to consider the possible effects of racial stress and trauma on Black clients, and to tailor approaches and techniques grounded in CBS accordingly. We describe how CBS has not done enough to address the needs of Black American communities, using Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP) as examples. We also provide examples at the level of research representation, organizational practices, and personal experiences to illuminate covert racist policy tools that maintain inequities. Towards eradicating existing racism in the field, we conclude with suggestions for researchers and leadership in professional psychological organizations.

Single-Dose Psilocybin Treatment for Major Depressive Disorder: A Randomized Clinical Trial

Importance

Psilocybin shows promise as a treatment for major depressive disorder (MDD).

Objective

To evaluate the magnitude, timing, and durability of antidepressant effects and safety of a single dose of psilocybin in patients with MDD.

Design, Setting, and Participants

In this phase 2 trial conducted between December 2019 and June 2022 at 11 research sites in the US, participants were randomized in a 1:1 ratio to receive a single dose of psilocybin vs niacin placebo administered with psychological support. Participants were adults aged 21 to 65 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of MDD of at least 60 days' duration and moderate or greater symptom severity. Exclusion criteria included history of psychosis or mania, active substance use disorder, and active suicidal ideation with intent. Participants taking psychotropic agents who otherwise met inclusion/exclusion criteria were eligible following medication taper. Primary and secondary outcomes and adverse events (AEs) were assessed at baseline (conducted within 7 days before dosing) and at 2, 8, 15, 29, and 43 days after dosing.

Interventions

Interventions were a 25-mg dose of synthetic psilocybin or a 100-mg dose of niacin in identical-appearing capsules, each administered with psychological support.

Main Outcomes and Measures

The primary outcome was change in central rater-assessed Montgomery-Asberg Depression Rating Scale (MADRS) score (range, 0-60; higher scores indicate more severe depression) from baseline to day 43. The key secondary outcome measure was change in MADRS score from baseline to day 8. Other secondary outcomes were change in Sheehan Disability Scale score from baseline to day 43 and MADRS-defined sustained response and remission. Participants, study site personnel, study sponsor, outcome assessors (raters), and statisticians were blinded to treatment assignment.

Results

A total of 104 participants (mean [SD] age, 41.1 [11.3] years; 52 [50%] women) were randomized (51 to the psilocybin group and 53 to the niacin group). Psilocybin treatment was associated with significantly reduced MADRS scores compared with niacin from baseline to day 43 (mean difference,-12.3 [95% CI, -17.5 to -7.2]; P <.001) and from baseline to day 8 (mean difference, -12.0 [95% CI, -16.6 to -7.4]; P < .001). Psilocybin treatment was also associated with significantly reduced Sheehan Disability Scale scores compared with niacin (mean difference, -2.31 [95% CI, 3.50-1.11]; P < .001) from baseline to day 43. More participants receiving psilocybin had sustained response (but not remission) than those receiving niacin. There were no serious treatment-emergent AEs; however, psilocybin treatment was associated with a higher rate of overall AEs and a higher rate of severe AEs.

Conclusions and Relevance

Psilocybin treatment was associated with a clinically significant sustained reduction in depressive symptoms and functional disability, without serious adverse events. These findings add to increasing evidence that psilocybin-when administered with psychological support-may hold promise as a novel intervention for MDD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03866174.

Chasing the Numinous: Hungry Ghosts in the Shadow of the Psychedelic Renaissance

In recent years a renewed scientific, public and commercial interest in psychedelic medicines can be observed across the globe. As research findings have been generally promising, there is hope for new treatment possibilities for a number of difficult-to-treat mental health concerns. While honouring positive developments and therapeutic promise in relation to the medical use of psychedelics, this paper aims to shine a light on some underlying psycho-cultural shadow dynamics in the unfolding psychedelic renaissance. This paper explores whether and how the multi-layered collective fascination with psychedelics may yet be another symptom pointing towards a deeper psychological and spiritual malaise in the modern Western psyche as diagnosed by C. G. Jung. The question is posed whether the West's feverish pursuit of psychedelic medicines-from individual consumption to entheogenic tourism, from capitalist commodification of medicines and treatments to the increasing number of ethical scandals and abuse through clinicians and self-proclaimed shamans-is related to a Western cultural complex. As part of the discussion, the archetypal image of the Hungry Ghost, known across Asian cultural and religious traditions, is explored to better understand the aforementioned shadow phenomena and point towards mitigating possibilities.

Healing Words: Effects of Psychoeducation on Likelihood to Seek and Refer Psychedelic-Assisted Psychotherapy Among BIPOC Individuals

Psychedelic-assisted psychotherapy (PAP) is gaining renewed interest as a treatment for various mental disorders. However, there has been limited Black, Indigenous, and People of Color (BIPOC) representation in PAP clinical trials, signaling the need for culturally consonant communication about the efficacy and safety of PAP. We randomly assigned 321 BIPOC and 301 non-Hispanic White participants to four different modes of psychoeducation (didactic, visual, narrative, hope-based) and tested effects on likelihood of seeking and referring others to PAP using ANCOVAS. The influences of different psychoeducation components on these likelihoods were also tested using hierarchical regression modeling. Regardless of psychoeducation mode, BIPOC participants were more likely to seek PAP than non-Hispanic White participants after psychoeducation. Further, information on physical safety and success rate of PAP uniquely predicted BIPOC participants' likelihood of seeking and referring others to PAP after psychoeducation. Our findings suggest that once provided psychoeducation, BIPOC participants are receptive to seeking or referring others to PAP. BIPOC participants also appear to prioritize physical safety and rate of success of PAP in these decisions. Stigma against PAP is likely not the primary barrier to recruitment of BIPOC individuals into PAP trials. Instead, researchers should conduct more psychoeducational outreach to diversify future trials.

ARC: a framework for access, reciprocity and conduct in psychedelic therapies

The field of psychedelic assisted therapy (PAT) is growing at an unprecedented pace. The immense pressures this places on those working in this burgeoning field have already begun to raise important questions about risk and responsibility. It is imperative that the development of an ethical and equitable infrastructure for psychedelic care is prioritized to support this rapid expansion of PAT in research and clinical settings. Here we present Access, Reciprocity and Conduct (ARC); a framework for a culturally informed ethical infrastructure for ARC in psychedelic therapies. These three parallel yet interdependent pillars of ARC provide the bedrock for a sustainable psychedelic infrastructure which prioritized equal access to PAT for those in need of mental health treatment (Access), promotes the safety of those delivering and receiving PAT in clinical contexts (Conduct), and respects the traditional and spiritual uses of psychedelic medicines which often precede their clinical use (Reciprocity). In the development of ARC, we are taking a novel dual-phase co-design approach. The first phase involves co-development of an ethics statement for each arm with stakeholders from research, industry, therapy, community, and indigenous settings. A second phase will further disseminate the statements for collaborative review to a wider audience from these different stakeholder communities within the psychedelic therapy field to invite feedback and further refinement. By presenting ARC at this early stage, we hope to draw upon the collective wisdom of the wider psychedelic community and inspire the open dialogue and collaboration upon which the process of co-design depends. We aim to offer a framework through which psychedelic researchers, therapists and other stakeholders, may begin tackling the complex ethical questions arising within their own organizations and individual practice of PAT.

The Psychedelic Renaissance in Clinical Research: A Bibliometric Analysis of Three Decades of Human Studies with Psychedelics

Psychedelics were used in the treatment of psychiatric conditions prior to their prohibition in the late 1960s. In the past three decades, there is a revived research interest in the therapeutic potential of psychedelic drugs with expected FDA approvals for treatment of various conditions. Given the exponential scientific growth of this field, we sought to characterize, analyze, and visualize trends in its top-cited articles. Bibliometric analyses are quantitative approaches to characterize a scientific field, including evaluation of the impact of academic literature. The bibliometric analysis and visualizations were conducted with R-tools for comprehensive science mapping. The top-cited 100 articles were cited between 82 and 668 times (median 125; mean 158). Fifty-four percent of the T100 articles were produced in the past decade (2010-2020). Network and author impact analysis highlighted key figures and primary collaboration networks within the top 100 publications. UK, USA, Switzerland, Spain, and Brazil lead the field. Results are discussed in terms of research growth, access, diversity, and the distribution of knowledge and experience in the field. These aggregated data and insights on the second wave of psychedelic research facilitate research evaluation, data-driven funding policies, and a practical map for researchers and clinicians entering the field.

Risks and benefits of psilocybin use in people with bipolar disorder: An international web-based survey on experiences of 'magic mushroom' consumption

BACKGROUND

Psilocybin, the primary psychoactive component of psychedelic 'magic mushrooms', may have potential for treating depressive symptoms, and consequent applications for bipolar disorder (BD). Knowledge of the risks and benefits of psilocybin in BD is limited to case studies.

AIM

To support the design of clinical trials, we surveyed experiences of psilocybin use in people with BD.

METHODS

An international web-based survey was used to explore experiences of psilocybin use in people with a self-reported diagnosis of BD. Quantitative findings were summarised using descriptive statistics. Qualitative content analysis was used to investigate free-text responses, with a focus on positive experiences of psilocybin use.

RESULTS

A total of 541 people completed the survey (46.4% female, mean 34.1 years old). One-third (32.2%; n = 174) of respondents described new/increasing symptoms after psilocybin trips, prominently manic symptoms, difficulties sleeping and anxiety. No differences in rates of adverse events overall were observed between individuals with BD I compared to BD II. Use of emergency medical services was rare (n = 18; 3.3%), and respondents (even those who experienced adverse effects) indicated that psilocybin use was more helpful than harmful. Quantitative findings elaborated on perceived benefits, as well as the potential for psilocybin trips to contain both positively and negatively received elements.

CONCLUSIONS

The subjective benefits of psilocybin use for mental health symptoms reported by survey participants encourage further investigation of psilocybin-based treatments for BD. Clinical trials should incorporate careful monitoring of symptoms, as data suggest that BD symptoms may emerge or intensify following psilocybin use.

MDMA-assisted psychotherapy; Inclusion of transgender and gender diverse people in the frontiers of PTSD treatment trials

Introduction

Transgender and gender diverse (TGD) people experience stigma, discrimination, trauma, and post-traumatic stress disorder (PTSD) at higher rates compared to the general population; however, TGD people have been underrepresented in PTSD research. Clinical trials of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy demonstrate promising safety and efficacy for the treatment of PTSD. Issues related to equitable access, power imbalances in the therapeutic relationship, and vulnerable states of consciousness occasioned by MDMA are magnified when working with people affected by structural vulnerabilities and health disparities, and community engagement in research planning and implementation is essential. To inform the inclusion and safety of TGD people in future MDMA-assisted psychotherapy research, the aims of the current study were to: characterize TGD experiences with trauma-related mental health care, assess openness of TGD people to participate in experimental PTSD research, and to gather specific feedback on protocol design for conducting MDMA-assisted psychotherapy with TGD people.

Materials and methods

We conducted three virtual focus group discussions (FGDs) with 5-6 participants each (N = 17). Eligible TGD participants had a history of receiving trauma-related mental health care. Each FGD was facilitated by two licensed clinicians who identified as TGD. Qualitative data analysis was conducted via an iterative process of identification of recurrent patterns and themes.

Results

We have identified several key issues TGD people face when seeking and engaging in trauma-related mental health care, including barriers to receiving adequate gender-affirming and trauma-informed mental health care and frustration with providers lacking cultural humility. Suggested amendments to MDMA-assisted psychotherapy protocols include: routine collection of trans-inclusive gender identity data, implementing an explicit gender-affirming treatment approach, ensuring a culturally safe setting, and diversifying co-therapy dyads.

Discussion

The inclusion of TGD voices in early conversations about emerging experimental PTSD interventions promotes equitable access, in the context of health and healthcare disparities, and helps researchers understand the needs of the community and tailor research to meet those needs. Through an ongoing conversation with the TGD community, we aim to incorporate a gender-affirming approach into existing research protocols and inform future applications of MDMA-assisted psychotherapy in addressing the effects of minority stress and boosting resilience.

MDMA-Assisted Psychotherapy for Borderline Personality Disorder

Borderline personality disorder is a complex psychiatric disorder with limited treatment options that are associated with large heterogeneity in treatment response and high rates of dropout. New or complementary treatments for borderline personality disorder are needed that may be able to bolster treatment outcomes. In this review, the authors comment on the plausibility for research on 3,4-methylenedioxymethamphetamine (MDMA) used in conjunction with psychotherapy for borderline personality disorder (i.e., MDMA-assisted psychotherapy [MDMA-AP]). On the basis of the promise of MDMA-AP in treating disorders overlapping with borderline personality disorder (e.g., posttraumatic stress disorder), the authors speculate on initial treatment targets and hypothesized mechanisms of change that are grounded in prior literature and theory. Initial considerations for designing MDMA-AP clinical trials to investigate the safety, feasibility, and preliminary effects of MDMA-AP for borderline personality disorder are also presented.

Psilocybin use patterns and perception of risk among a cohort of Black individuals with Opioid Use Disorder

Background and aims

There is growing evidence that psilocybin, a serotonergic psychedelic substance, may be useful in the treatment of substance use disorders. However, there is a lack of data on the beliefs and attitudes towards psilocybin amongst Black individuals diagnosed with Opioid Use Disorder (OUD). This study characterized psilocybin use patterns and perception of risk amongst a cohort of Black individuals diagnosed with OUD.

Methods

Using a convenience sampling approach, patients were recruited from an urban methadone treatment program and paid five dollars to complete an anonymous phone-based survey.

Results

Twenty-eight patients participated (mean age 53.8; N = 28; 35.7% female). Most (N = 23; 82.1%) had "heard of" psilocybin mushrooms before taking the survey, but only five (N = 5; 17.8%) had ever used them. More than 80% perceived a risk or were "unsure" of the risk for sixteen of the seventeen items queried about psilocybin. Approximately half (N = 15; 53.6%) were willing to try therapy incorporating psilocybin and half (N = 14; 50%) said they would be more likely to try if it were FDA approved for OUD. Most (N = 18; 64.3%) preferred to stay on methadone treatment alone, 32.1% (N = 9) wanted to try treatment with both psilocybin and methadone, and only one participant opted for psilocybin treatment without methadone.

Conclusion

Many Black individuals with Opioid Use Disorder perceive psilocybin as dangerous and may be hesitant to try psilocybin treatment. Culturally informed treatment models, educational interventions and community outreach programs should be developed to increase racial/ethnic minority representation in psilocybin research and treatment.

MDMA-assisted therapy for posttraumatic stress disorder: A pooled analysis of ethnoracial differences in efficacy and safety from two Phase 2 open-label lead-in trials and a Phase 3 randomized, blinded placebo-controlled trial

BACKGROUND

Limited ethnoracial diversity in previous ±3,4-methylenedioxymethamphetamine-assisted therapy (MDMA-AT) trials for posttraumatic stress disorder (PTSD) has prompted questions concerning whether Black, Indigenous, and People of Color (BIPOC) also benefit from this treatment.

METHODS

Secondary analysis was conducted using a modified intent-to-treat sample pooled from two Phase 2 open-label trials and a Phase 3 randomized, blinded placebo-controlled trial to compare efficacy and safety of MDMA-AT for PTSD between BIPOC and non-Hispanic White participants. Four subgroups were of interest: MDMA-AT, BIPOC (n = 20); MDMA-AT, non-Hispanic White (n = 63); Placebo-assisted therapy (Placebo-AT), BIPOC (n = 17); and Placebo-AT, non-Hispanic White (n = 27). Planned comparisons tested subgroup differences in changes in Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) scores from baseline to primary endpoint, controlling for study type and baseline scores. Adverse events (AEs) on the day of (day 0) to 2 days post-dosing were reported for each subgroup.

RESULTS

In the MDMA-AT group, no significant ethnoracial difference in CAPS-5 change scores was observed. In the Placebo-AT group, BIPOC participants trended toward greater reductions in CAPS-5 scores than non-Hispanic Whites. Among non-Hispanic Whites, MDMA-AT was accompanied by significantly greater reductions in CAPS-5 scores than Placebo-AT. No treatment difference emerged among BIPOC participants. AEs were mostly rated as mild or moderate across subgroups.

CONCLUSIONS

These findings provide preliminary support for the efficacy and safety of MDMA-AT for treating PTSD across ethnoracial groups. There was also a trend toward greater efficacy with Placebo-AT among BIPOC participants. There was an imbalance in subgroups, highlighting the need for culturally responsive recruitment strategies to diversify future studies.

Models of Psychedelic-Assisted Psychotherapy: A Contemporary Assessment and an Introduction to EMBARK, a Transdiagnostic, Trans-Drug Model

The current standard of care in most uses of psychedelic medicines for the treatment of psychiatric indications includes the provision of a supportive therapeutic context before, during, and after drug administration. A diversity of psychedelic-assisted psychotherapy (PAP) models has been created to meet this need. The current article briefly reviews the strengths and limitations of these models, which are divided into basic support models and EBT-inclusive therapy models. It then discusses several shortcomings both types of models share, including a lack of adequate attention to embodied and relational elements of treatment, and insufficient attention to ethical concerns. The article then introduces the EMBARK model, a transdiagnostic, trans-drug framework for the provision of supportive psychotherapy in PAP clinical trials and the training of study therapists. EMBARK was designed to overcome challenges that prior models have had in conceptualizing therapeutic change in psychedelic treatment, incorporating elements of non-psychedelic evidence-based therapies, incorporating therapists' prior skills and clinical orientations, delimiting therapist interventions for research standardization, and determining specific factors that contribute to treatment outcomes. The article explains EMBARK's six clinical domains, which represent parallel conceptualizations of how therapists may support therapeutic benefit in PAP treatment, and its four care cornerstones, which reflect therapists' broad ethical responsibility to participants. The article describes how these elements of the model come together to structure and inform therapeutic interventions during preparation, medicine, and integration sessions. Additionally, the article will discuss how EMBARK therapist training is organized and conducted. Finally, it will demonstrate the broad applicability of EMBARK by describing several current and upcoming PAP clinical trials that have adopted it as the therapeutic frame.

The Therapeutic Potential of Psychedelic-assisted Therapies for Symptom Control in Patients Diagnosed With Serious Illness: A Systematic Review

CONTEXT

People affected by serious illness usually experience suffering in its various dimensions, not only in the physical but also in the psychosocial and spiritual aspects. The interest in psychedelic-assisted therapies as a potential new therapeutic modality has increased since evidence suggests a significant impact of their use on the outcomes of patients with serious illness.

OBJECTIVES

To systematically review the available evidence on the effects of psychedelic-assisted therapies for symptom control in patients diagnosed with serious illness.

METHODS

The protocol of this systematic review has been prepared according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. This review included randomized and non-randomized controlled trials published in peer-reviewed scientific journals. A comprehensive search for studies was carried out in the main scientific databases, including Web of Science, Scopus, Cochrane Library, PsycINFO, PubMed, CINAHL, and EMBASE. There were no limitations regarding the year or language of publication.

RESULTS

The sample was composed of 20 studies. The results suggest positive effects of psychedelic-assisted therapies for symptom control in patients diagnosed with serious illness, with considerable safety of use. Most studies have been conducted with lysergic acid diethylamide, psilocybin, and N,N-dipropyltryptamine in cancer patients. The adverse effects reported were of physical and/or psychological nature and of mild to moderate intensity, transient, and self-resolutive.

CONCLUSION

The evaluated evidence suggests positive effects of psychedelic-assisted therapies for symptom control in patients diagnosed with serious illness, especially regarding symptoms of psychological and spiritual nature.

Being an anti-racist clinician

Racism is a pervasive problem in Western society, leading to mental and physical unwellness in people from racialized groups. Psychology began as a racist discipline and still is. As such, most clinical training and curricula do not operate from an anti-racist framework. Although most therapists have seen clients with stress and trauma due to racialization, very few were taught how to assess or treat it. Furthermore, clinicians and researchers can cause harm when they rely on White-dominant cultural norms that do not serve people of colour well. This paper discusses how clinicians can recognize and embrace an anti-racism approach in practice, research, and life in general. Included is a discussion of recent research on racial microaggressions, the difference between being a racial justice ally and racial justice saviour, and new research on what racial allyship entails. Ultimately, the anti-racist clinician will achieve a level of competency that promotes safety and prevents harm coming to those they desire to help, and they will be an active force in bringing change to those systems that propagate emotional harm in the form of racism.

Key learning aims

(1)

Therapeutic Alliance and Rapport Modulate Responses to Psilocybin Assisted Therapy for Depression

Background: Across psychotherapeutic frameworks, the strength of the therapeutic alliance has been found to correlate with treatment outcomes; however, its role has never been formally assessed in a trial of psychedelic-assisted therapy. We aimed to investigate the relationships between therapeutic alliance and rapport, the quality of the acute psychedelic experience and treatment outcomes.

Methods: This 2-arm double-blind randomized controlled trial compared escitalopram with psychedelic-assisted therapy for moderate-severe depressive disorder (N = 59). This analysis focused on the psilocybin condition (n = 30), who received two oral doses of 25 mg psilocybin, 3-weeks apart, with psychological preparation, in-session support, and integration therapy. A new psychedelic therapy model, called “Accept-Connect-Embody” (ACE), was developed in this trial. The primary outcome was depression severity 6 weeks post treatment (Quick Inventory of Depressive Symptomatology, QIDS-SR-16). Path analyses tested the hypothesis that therapeutic alliance (Scale To Assess the Therapeutic Relationship Patient Version, STAR-P) would predict depression outcomes via its influence on the acute psychedelic experience, specifically emotional-breakthrough (EBI) and mystical-type experiences (MEQ). The same analysis was performed on the escitalopram arm to test specificity.

Results: The strength of therapeutic alliance predicted pre-session rapport, greater emotional-breakthrough and mystical-type experience (maximum EBI and MEQ scores across the two psilocybin sessions) and final QIDS scores (β = −0.22, R² = 0.42 for EBI_Max; β = −0.19, R² = 0.32 for MEQ_Max). Exploratory path models revealed that final depression outcomes were more strongly affected by emotional breakthrough during the first, and mystical experience during the second session. Emotional breakthrough, but not mystical experience, during the first session had a positive effect on therapeutic alliance ahead of the second session (β = 0.79, p < 0.0001). Therapeutic alliance ahead of the second session had a direct impact on final depression scores, not mediated by the acute experience, with a weaker alliance ahead of the second psilocybin session predicting higher absolute depression scores at endpoint (β = −0.49, p < 0.001)

Discussion: Future research could consider therapist training and characteristics; specific participant factors, e.g., attachment style or interpersonal trauma, which may underlie the quality of the therapeutic relationship, the psychedelic experience and clinical outcomes; and consider how therapeutic approaches might adapt in cases of weaker therapeutic alliance.

Clinical Trial Registration: This trial is registered at http://clinicaltrials.gov, identifier (NCT03429075).

Top Ten Tips Palliative Care Clinicians Should Know About Psychedelic-Assisted Therapy in the Context of Serious Illness

Psychedelic-assisted therapy (PAT) is a burgeoning treatment with growing interest across a variety of settings and disciplines. Empirical evidence supports PAT as a novel therapeutic approach that provides safe and effective treatment for people suffering from a variety of diagnoses, including treatment-resistant depression, substance use disorder, and post-traumatic stress disorder. Within the palliative care (PC) field, one-time PAT dosing may lead to sustained reductions in anxiety, depression, and demoralization-symptoms that diminish the quality of life in both seriously ill patients and those at end of life. Despite a well-noted psychedelic renaissance in scholarship and a renewed public interest in the utilization of these medicines, serious illness-specific content to guide PAT applications in hospice and PC clinical settings has been limited. This article offers 10 evidence-informed tips for PC clinicians synthesized through consultation with interdisciplinary and international leading experts in the field with aims to: (1) familiarize PC clinicians and teams with PAT; (2) identify the unique challenges pertaining to this intervention given the current legalities and logistical barriers; (3) discuss therapeutic competencies and considerations for current and future PAT use in PC; and (4) highlight critical approaches to optimize the safety and potential benefits of PAT among patients with serious illness and their caregivers.

MDMA-Assisted Therapy for Posttraumatic Stress Disorder: A Mixed-Methods Case Study of a Participant of Color From an Open-Label Trial

MDMA (±3,4-methylenedioxymethamphetamine)-assisted therapy (MDMA-AT) was shown in previous clinical trials to have promising efficacy and safety for alleviating treatment-resistant posttraumatic stress disorder (PTSD). However, due to low ethnoracial diversity, the question remains as to whether ethnoracial minority participants would benefit similarly. Thus, a mixed-methods case study was conducted on a participant of color from an open-label trial of MDMA-AT for PTSD to provide a culturally informed lens on symptom recovery with this treatment approach. An additional aim was to elucidate mechanisms of change underlying this treatment for the participant. A case profile was provided, documenting quantitative improvement in PTSD symptoms. This was followed by an interpretative phenomenological analysis (IPA) of effects and mechanisms of action for this participant, based on integration session transcripts. Results of IPA indicated recurrent themes related to psychological mechanisms of symptom change, reduced PTSD symptoms, and additional effects (positive and negative) beyond PTSD symptom reduction. These themes were discussed and recommendations for attuning to culturally relevant material during MDMA-AT were provided.

Therapeutic setting as an essential component of psychedelic research methodology: Reporting recommendations emerging from clinical trials of 3,4-methylenedioxymethamphetamine for post-traumatic stress disorder

Research of psychedelic assisted therapies is at an all-time high, though few studies highlight extra-pharmacological factors that may affect treatment efficacy. One critical set of attributes includes the therapeutic setting itself, which describe the physical and socio-cultural environments in which the drug-assisted session occurs. Despite enduring consensus of the influence of setting, recommendations for establishing and reporting key setting variables remain sparse across clinical trial protocols and published research methodologies. The purpose of this paper is to: (1) present what is known of the influence and implications of setting to psychedelic-assisted therapies, with a particular focus on 3,4-methylenedioxymethamphetamine (MDMA); and (2) propose a set of reporting guidelines for operationalizing and reporting key setting variables in clinical trials of psychedelic-assisted therapies, based on recommendations emerging from clinical trials of MDMA for PTSD. In fact, recommendations should be expanded to "set" - the subject's mood, expectations, and broader psychological condition - once this is more fully developed in the field. The proposed reporting guidelines offer a means of increasing the volume and variability of data necessary for future empirical examination of key setting attributes influencing treatment efficacy, while preserving practitioner and patient autonomy to co-construct adaptive therapy settings according to their respective needs and expertise.

Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review

BACKGROUND

In the past two decades, subanaesthetic doses of ketamine have been demonstrated to have rapid and sustained antidepressant effects, and accumulating research has demonstrated ketamine's therapeutic effects for a range of psychiatric conditions.

AIMS

In light of these findings surrounding ketamine's psychotherapeutic potential, we systematically review the extant evidence on ketamine's effects in treating mental health disorders.

METHOD

The systematic review protocol was registered in PROSPERO (identifier CRD42019130636). Human studies investigating the therapeutic effects of ketamine in the treatment of mental health disorders were included. Because of the extensive research in depression, bipolar disorder and suicidal ideation, only systematic reviews and meta-analyses were included. We searched Medline and PsycINFO on 21 October 2020. Risk-of-bias analysis was assessed with the Cochrane Risk of Bias tools and A Measurement Tool to Assess Systematic Reviews (AMSTAR) Checklist.

RESULTS

We included 83 published reports in the final review: 33 systematic reviews, 29 randomised controlled trials, two randomised trials without placebo, three non-randomised trials with controls, six open-label trials and ten retrospective reviews. The results were presented via narrative synthesis.

CONCLUSIONS

Systematic reviews and meta-analyses provide support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust, but suggests similarly positive and short-lived effects. The conclusions should be interpreted with caution because of the high risk of bias of included studies. Optimal dosing, modes of administration and the most effective forms of adjunctive psychotherapeutic support should be examined further.

Enhancing equity-oriented care in psychedelic medicine: Utilizing the EQUIP framework

Psychedelic-assisted therapies are experiencing a re-emergence in mainstream medicine and mental health contexts. A wide variety of psychedelic-assisted therapy modalities are being utilized to address mental health issues such as substance use disorders, end of life anxiety, treatment-resistant depression, suicidality, PTSD and other conditions. The novel and inchoate acceptance of psychedelic-assisted therapies into mainstream medical and therapeutic realms raises questions of equity. Concerns have been raised that individuals and communities facing structural inequities are perhaps least able to access these treatments including Black, Indigenous and people of colour (BIPOC) as well as people who use drugs. Psychedelic-assisted therapies may exemplify the inverse law of care whereby services are most inaccessible to communities with the most need, especially if these therapies are regulated into the private sector. As legalization and wider implementation of these therapies appears to be imminent, now is a critical time to consider how health equity may be promoted within psychedelic medicine. This paper examines how the EQUIP Health Care approach (https://equiphealthcare.ca) may inform the development and provision of equity-oriented psychedelic-assisted therapies. The EQUIP approach seeks to reduce the effects of structural inequities on people's health, the impacts of discrimination and stigma, and the mismatches between usual approaches to care and the needs of people most affected by health and social inequities. Key dimensions of the EQUIP intervention include cultural safety, harm reduction, trauma and violence-informed care, and contextual tailoring.

Exploring the Use of Psilocybin Therapy for Existential Distress: A Qualitative Study of Palliative Care Provider Perceptions

There is a growing body of research suggesting that palliative care patients coping with existential distress may benefit from psilocybin. However, there is a large gap regarding the perceptions of palliative care providers who may provide education, counseling services, recommendations, and/or prescriptions for psilocybin if it is decriminalized, commercialized, and/or federally rescheduled and legalized. The aim of this study was to explore the experiences and perceptions of interdisciplinary palliative care providers regarding existential distress and the use of psilocybin therapy. Five (n = 5) health care providers from a hospital-based palliative care team completed a semi-structured interview related to their experiences supporting patients with existential distress and their beliefs and attitudes related to psilocybin as a possible treatment modality. A qualitative descriptive approach was used to identify key themes which included: 1) multiple barriers to addressing existential distress at the cultural, institutional/organizational, relational, and individual levels, 2) the duality and power of presence, 3) suffering as an intrinsically subjective phenomenon, and 4) uncertainty about the risks and benefits of psilocybin. To inform an inclusive, safe, and holistic approach, more research is needed regarding the possible integration of psilocybin therapy within palliative care for the treatment of existential distress.

Research abuses against people of colour and other vulnerable groups in early psychedelic research

There is a growing resurgence in the study of psychedelic medicines for the treatment of mental health and substance use disorders. However, certain early investigations are marred by questionable research methods, abuses against research participants, and covert Central Intelligence Agency financial involvement. The purpose of this study was to understand how and to what extent people of colour and other vulnerable populations, specifically, individuals who were incarcerated or incapacitated due to mental health issues (inpatients with psychotic disorders), were exploited during the first wave of psychedelic research in the USA (1950-1980). To do so, we reviewed available empirical publications according to current ethical standards. Variables of interest included race and ethnicity of participants, population vulnerability, drug administration conditions, informed consent and undue influence. Our findings draw attention to the history of research abuses against people of colour in Western psychedelic research. In light of these findings, we urge a call-to-action to current psychedelic researchers to prioritise culturally inclusive and socially responsible research methods in current and future studies.

Probing the Future of Psychedelics for Mental Health

Mounting evidence suggests that psychedelics may be useful for treating a range of different neuropsychiatric conditions that currently have limited treatment options. On May 4-6, 2021, leaders from academia and industry discussed a variety of issues related to the development and adoption of psychedelic drugs for different conditions during the virtual Psychedelic Therapeutics and Drug Development Conference. Selected topics from the conference are presented below.

Ethical and legal issues in psychedelic harm reduction and integration therapy

Psychedelic-assisted therapy may represent an upcoming paradigm shift in the treatment of mental health problems as recent clinical trials have demonstrated strong evidence of their therapeutic benefits. While psychedelics are currently prohibited substances in most countries, the growing popularity of their therapeutic potential is leading many people to use psychedelics on their own rather than waiting for legal medical access. Therapists therefore have an ethical duty to meet this need by providing support for clients using psychedelics. However, incorporating psychedelics into traditional psychotherapy poses some risk given their prohibited status and many therapists are unsure of how they might practice in this area. This paper explicates such risks and describes ways in which therapists can mitigate them and strive to practice within legal and ethical boundaries. A harm reduction approach will be emphasized as a useful framework for conducting therapy around clients' use of psychedelics. It is argued that therapists can meet with clients before and after their own personal psychedelic experiences in order to help clients minimize risk and maximize benefit. Common clinical scenarios in this growing clinical area will also be discussed.

Ensuring the psychedelic renaissance and radical healing reach the Black community: Commentary on Culture and Psychedelic Psychotherapy

Similar to much of the mental health field, psychedelic-assisted psychotherapy has failed to center the needs of people of color. Monnica Williams and colleagues demonstrate the harm faced by Black women and other people of color when working with psychedelic-assisted psychotherapists that are unaware of and ill-equipped to address sensitive topics related to race. Here I discuss the benefits and limitations of Functional Analytic Psychotherapy training for therapists that have not engaged in deep and reflective processes to understand their personal engagement in racism, privilege, and oppression. I call on leaders in the field of psychedelic-assisted psychotherapy to adhere to a new standard of intersectional cultural humility for anyone preparing to provide these services. Finally, I highlight the need to significantly increase the number of therapists of color trained to offer psychedelic-assisted psychotherapy to begin to address racial disparities to access to these radical treatments for trauma.

Dr. Valentina Wasson: Questioning what we think we know about the foundations of psychedelic science

Equity and diversity are essential to the development of inclusive psychedelic research. However, oversights and misattributions are common, particularly when it comes to accounts of important psychedelic moments and key figures. Dr. Valentina Pavlovna Wasson is an important early contributor to the growth of Western psychedelic science but remains under-recognized. Psychedelic researchers must continue to address the glaring need to ask questions and examine the foundations of what we think we know about psychedelic studies—to question our assumptions with a critical and intersectional eye to resist replicating social and cultural inequalities in psychedelic research and history.

Culture and psychedelic psychotherapy: Ethnic and racial themes from three Black women therapists

Psychedelic medicine is an emerging field of research and practice that examines the psychotherapeutic effects of substances classified as hallucinogens on the human mind, body, and spirit. Current research explores the safety and efficacy of these substances for mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although current studies explore psychotherapeutic effects from a biomedical perspective, gaps in awareness around cultural issues in the therapeutic process are prominent. African Americans have been absent from psychedelic research as both participants and researchers, and little attention has been paid to the potential of psychedelics to address traumas caused by racialization. This paper examines cultural themes and clinical applications from the one-time use of 3,4-methylenedioxymethamphetamine (MDMA) as part of an US Food and Drug Administration (FDA)-approved clinical trial and training exercise for three African American female therapists. The primary themes that emerged across the varied experiences centered on strength, safety, connection, and managing oppression/racialization. The participants' experiences were found to be personally meaningful and instructive for how Western models of psychedelic-assisted psychotherapy could be more effective and accessible to the Black community. Included is a discussion of the importance of facilitator training to make best use of emerging material when it includes cultural, racial, and spiritual themes. A lack of knowledge and epistemic humility can create barriers to treatment for underserved populations. Implications for future research and practice for marginalized cultural groups are also discussed, including consideration of Functional Analytic Psychotherapy (FAP) as an adjunct to the psychedelic-therapy approaches currently advanced. As women of color are among the most stigmatized groups of people, it is essential to incorporate their perspectives into the literature to expand conversations about health equity.

Co-design of Guidance for Patient and Public Involvement in Psychedelic Research

Within the context of scientific research, patient and public involvement (PPI) is defined as research performed "with" or "by" patients and members of the public, rather than "to," "about", or "for" them. When carried out systematically and thoughtfully, PPI has the potential to strengthen the quality and impact of research by fostering accountability, transparency, and relevance. There exist numerous guidelines, frameworks and tools for supporting PPI, however, these do not account for the unique challenges faced in psychedelic research. This paper describes the co-design of guidance intended to help build, evaluate and improve PPI in psychedelic research. A steering group was formed to design and run a co-design workshop alongside public collaborators. Insights from this workshop were analyzed and refined into a comprehensive and readily usable guide for planning PPI specific to the field of psychedelic research. Core values emerging from the process focused on the essential importance of trust, learning, purpose and inclusivity. It is hoped that this guidance will be a starting point for incorporating PPI in future psychedelic research, so that it can grow and adapt as this burgeoning field of research progresses.

People of color in North America report improvements in racial trauma and mental health symptoms following psychedelic experiences

This study examined how psychedelics reduced symptoms of racial trauma among black, indigenous, and people of color (BIPOC) subsequent to an experience of racism. A cross-sectional internet-based survey included questions about experiences with racism, mental health symptoms, and acute and enduring psychedelic effects. Changes in mental health were assessed by retrospective report of symptoms in the 30 days before and 30 days after an experience with psilocybin, Lysergic acid diethylamide (LSD), or 3,4-Methylenedioxymethamphetamine (MDMA). We recruited 313 diverse BIPOC in the US and Canada. Results revealed a significant (p < .001) and moderate (d = −.45) reduction in traumatic stress symptoms from before-to-after the psychedelic experience. Similarly, participants reported decreases in depression (p < .001; d = −.52), anxiety (p < .001; d = −.53), and stress (p < .001; d = −.32). There was also a significant relationship (R_c = 0.52, p < .001) between the dimension of acute psychedelic effects (mystical-type, insight, and challenging experiences) and decreases in a cluster of subsequent psychopathology (traumatic stress, depression, anxiety, and stress), while controlling for the frequency of prior discrimination and the time since the psychedelic experience. BIPOC have been underrepresented in psychedelic studies. Psychedelics may decrease the negative impact of racial trauma. Future studies should examine the efficacy of psychedelic-assisted therapy for individuals with a history of race-based trauma.

Diversity, equity, and access in psychedelic medicine

Although it is exciting to witness the culmination of decades of drug policy advocacy and clinical research, the psychedelic science movement struggles with many of the same social issues that plague healthcare in general. The healing properties of plant medicines and their derivatives were originally brought to Western consciousness by indigenous cultures from all over the world. These practices are now being adapted to Western models of healthcare, in part, to achieve governmental approval as medical treatments. The current models of psychedelic psychotherapy being utilized in clinical trials are resource-intensive and therefore likely to remain out of reach for the socioeconomically disadvantaged if approved as medical treatments. Moreover, people of color and women are uncommon in leadership positions in the psychedelic research community, and few people of color are included as research participants in psychedelic studies. This piece introduces a special issue with a focus on issues of diversity, equity, and accessibility in psychedelic medicine.