Considerations in the Application of Psychedelic-Augmented Psychotherapy: A Commentary on Clinical Mechanisms

Round 1

Reviewer 1 Report

I found this to be an ambitious paper that left me wanting more depth and less breadth. I think the question of what kind of therapy and what dose will be needed in combination with particular psychedelics is an important question. However, the paper seemed to derail from this thesis when it delved into esoteric aspects of each psychotherapy modality. It attempts to be comprehensive in discussing all the various forms of psychotherapy that might be utilized with psychedelics, but in doing so, especially in such a brief paper, was not able to discuss the pros, cons, and unknowns of each therapeutic modality when used with psychedelics. While I realize that this paper is intended to generate ideas for empiric exploration, it frequently made claims without support (noted in the text). I would encourage this paper attempt to be less ambitious in its aims and by doing so may provide greater clarity on the ideas that it wishes to discuss. 

Comments for author File: Comments.pdf

Author Response

Thank you for your comments. I have now reviewed potential pros/cons of theoretic and praxis relevant to each modality and have aimed to give a more balanced summary outside of the theoretical claims that were previously too detached from the thesis. Empirical data has been fleshed out in more detail and more critically wherever available.

Some of the speculation has been reeled back or substantiated with further references/evidence. Thank you also for the in-text comments; these have greatly helped to enhance the clarity of the paper.

 

Reviewer 2 Report

I wanted to enjoy and admire this paper, as it engages an important and compelling question being asked by many.  However, I was  by the absence of a coherent voice through which the paper and as well as the lack of useful discussion of the problem at hand.  The author doesn’t offer us clarifying ideas about psychedelic assisted therapy, and how it fosters change and transformation.  It is an ambitious undertaking;  he has dipped into a very broad range of disciplines and discourses, but they are not gathered or presented in a way that fosters even interim conclusions or heuristic positions.  There is an absence of the  contemporary neuropsychoanalytic discourse on psychedelic effects on the psyche, neurophysiology of cognition and perception and therapeutic transformation, which seems to be central to the question of therapeutic modalities to used when conducting psychedelic therapy. 

            The author clearly has done a good deal of reading and study, but it does not seem as though he truly understands the research he quotes;  I don’t find a sense, in the paper, of how psychotherapy (and other psychological interventions) works, what psychedelic experience is, and therefore,  what psychedelic therapy is.    At times, the information offered is inaccurate bits of information, out of context, and the overall effect does not add up to coherent engagement with the topic. The author seems fond of neurology and psychology, but appears to be avoidant, even phobic, about clinical psychiatry, a field of medicine that has combined psychotherapy and psychopharmacology for decades.  This paper leads me to wonder if author has actually conducted psychedelic assisted therapy, because the paper has a bit of a “wool gathering” feel to it.  

 

            My major reservation about the paper, however, is that I do not accept the question in the title as a valid one, or even an ethical one.  It is my belief there one is no single “psychotherapy technique” that is “most well suited” to psychedelic assisted therapy.  I question the basic assumption contained in that query.  I am aware that there is currently a jittery search for the “best” platform for psychedelic assisted therapy, and a sense that this question must be answered. And answered by a search through research findings, as published in peer-reviewed journals.  Other research, not engaged by the author  suggests that   the therapeutic relationship is the best predictor of outcome of any therapy.  In light of this long standing “truism”, the question asked in the title would be advanced by examining relationships among the patient, the therapist, and the medicine (and the cultural context in which their work is taking place).   The clamor for a “best” therapy platform for psychedelic therapy reveals a fundamental misunderstanding of the process of psychedelic experience and transformation, and separates out the humans involved, trying to match a technique to a modality instead.  

Author Response

Thank you for your feedback. The theoretic and practical implications for selected therapies have now been discussed in more depth. Speculations have now been qualified and remaining questions have been highlighted more clearly, with the aim toward an overall thesis centred on multidisciplinary future work. I have also expanded discussion of modern neuro-psychoanalytic approaches. More work on the ego-dissolution has also been added to more thoroughly discuss mechanisms of action at both neural and cognitive levels, as well as the mystical elements of the psychedelic experience.

The author acknowledges his expertise in cognitive science and counselling psychology (not psychiatry/medicine) may have limited or even biased some of the discussion; more balance has now been endeavoured towards both medical and social sciences approaches in constructing our understanding of the ‘healing’ aspects of psychedelics. More discussion of the specific psychotherapy techniques (and how they combine with psychedelic therapy) has been added and focus on pure theoretical models has been reduced.

The author agrees this is perhaps the wrong question to ask and thanks the reviewer for this insight. The authors intends to explore the varied ways in which specific philosophies and modalities may be applied, not necessarily whether there is a “right” or “best” therapeutic approach. Notably, a 2022 paper made the argument that CBT-based therapies are the best approach in psychedelic augmented treatment; the author rejects the sentiment that there is an ‘ideal’ approach and poses integrative/eclectic models, as well as attachment/patient-focused models, need to be considered foremost. Thus, the author agrees that the title is misleading in this endeavour. The title has been revised to better reflect the paper’s aims. More commentary on the role of attachment, patient-therapist relationship, and culture has been added in the revision.

Reviewer 3 Report

The topic of this paper is very interesting. The intersection of psychedelics and psychotherapy is a deep area that requires much more academic exploration. However, while this manuscript gives a nice summary of some of the psychotherapeutic contributions to the field of psychedelics, it was difficult for me to glean a cohesive point. 

Some summaries were expressed nicely. I think the section on somatic methods is clear and sound, though it could also include more modern contributions to this area, including somatic experiencing and psychomotor psychotherapy (or even Internal Family Systems). The sections on experiential and psychodynamic frameworks were cursory. For more on psychoanalysis and psychedelics, please see the edition of the journal Psychoanalytic Dialogues from fall 2022, which was entirely dedicated to psychedelics.

Also, this paper seems to privilege cognitive change/insight as the primary mutative psychotherapeutic factor in psychedelic therapy, when in fact, change may occur as a result of action that has been inspired, or a transpersonal or spiritual shift. Of course cognition plays a role in these (as it does in nearly everything), but I think it does not represent the current state of the field to privilege cognitive change over other psychotherapeutic changes that can occur with clinical psychedelic use.

This paper may be of value to be published if the main point of the manuscript is made to be more clear, and if the remainder of the paper supports that main point.

Author Response

Thank you for this valuable feedback. The author has now made substantial revisions to the paper, highlighting a clearer thesis, as well as expanded paragraphs on psychoanalysis and IFS approaches. The overall contributions to the literature, and remaining questions to consider, have been made more apparent in the updated version. A section on the nature of ‘change’ experienced with psychedelic augmented therapy, canvassing behavioural/cognitive, as well as psycho-spiritual considerations, has been added to provide a more balanced viewpoint.

 

Round 2

Reviewer 1 Report

This paper has significantly improved and is getting closer to publication. In general, there are fewer speculations without evidence (while still maintaining that this is a paper intended to fuel discussion rather than prove a truth), however please see marginallia in places where it continues to weaken the arguments of the paper. I would strongly suggest not over-claiming around microdosing (see notes), as the evidence remains thin, and points towards strong expectancy effects, and discussion of placebo/expectancy is not a component of this paper.  There are a few places where fewer words would make for stronger ideas and I have noted those.  I think it's getting closer and I look forward to the completed version.

Author Response

Thank you for your comments on the paper submission. Track-changes addressing these comments have now been made.

Reviewer 2 Report

The revisions are strong and thoughful.  I am attaching some further input that I hope will be helpful.

Comments for author File: Comments.pdf

Author Response

Thank you for your comments on the paper submission. Track-changes addressing these comments have now been made. Major/moderate considerations raised have also been addressed below:

• The wording on ‘best practices’ was originally intended around enforcing a high standard of practitioner care. But the author acknowledges this may have read as though he is suggesting a single best practice… This phrasing has thus now been improved throughout the paper to clarify the intention towards multidisciplinary work around developing clinical frameworks that support effective treatment, rather than preferencing a singular ‘best’ practice.
• The Rogerian/Humanistic section has been re-worked. In clinical psychology within Australian contexts this is a specific way of practicing in the sense that clients may actually seek out a “Rogerian therapist” (which is quite common) as opposed to a “Cognitive therapist”. The author has aimed to acknowledge that person centered care tends to encompass most modern therapies, whilst some practitioners do still choose to specialize as Rogerian therapists, and those counselors may be uniquely placed to support integration experiences due to their specialization in such an approach.
• Likewise, the Gestalt section has been refined in a similar manner and given context within phenomenology and bodywork, which is the historical basis from which it originated (namely, many therapists may likewise incorporate gestalt techniques in less a purist manner such as parts/somatic work as an extension of other modalities). Notably Szummer was cited as he precisely discusses Gestalt psychotherapy and psychedelics. The reference has been discussed in more detail.

Reviewer 3 Report

I appreciate the revisions that have been made to this paper. It is more coherent and a bit clearer what the author is trying to express.

It seems this is an article examining, comparing, and contrasting various psychotherapeutic approaches to psychedelic facilitation.

This article would potentially be of use to the broader community of those interested in psychedelic-assisted therapy praxis. However, it would need to be more comprehensive (e.g. inclusive of other somatic therapies besides Gestalt, perhaps including Somatic Experiencing, Sensorimotor Psychotherapy, or Internal Family Systems therapy), and also more coherent (clearer sense of the purpose of the paper) for the paper to be of good use to the academic community.

Author Response

Thank you for your comments on the paper submission. Track-changes addressing these comments have now been made. Additional somatic therapies and broadened sections of discussion have now been added. A clearer thesis and introductory sections have now been written.

Round 3

Reviewer 3 Report

Thank you for the edits, I believe the paper will be useful to its readers.