In a recent article in Frontiers in Pharmacology, E.E. Schenberg described a significant crisis facing psychiatry: innovation in psychiatric drug development is in decline while mental illness increasingly contributes to the global disease burden.1,2,3 According to Schenberg and others, the halt in psychiatric drug innovation is intertwined with a larger “paradigmatic crisis” in psychiatry, in which brain-based explanations of mental illness along with discrete categorical diagnostics no longer spur innovation in therapeutics, i.e., the development of psychiatric drugs with unique mechanisms of action.1,2
In response to this paradigmatic crisis, Schenberg suggests that some mental health practitioners, researchers, and theoreticians have become increasingly open to new ways of conceiving of mental illness, which, in turn, inform novel diagnostic and treatment approaches. According to Schenberg, this openness may be indicative of a deeper shift in the underlying paradigm of explanation, diagnostics, and therapeutics, creating space for reconsideration of the traditional medical model of mental illness vis-à-vis alternative and novel treatment approaches.
Psychedelic Assisted Psychotherapy as a Novel Treatment Approach and Beyond
Psychedelic assisted psychotherapy (PAP) is a novel treatment for mental illness that involves the therapeutic and supervised use of psychoactive substances, such as ketamine, MDMA, LSD, and psilocybin, among others, in the course of psychotherapy.1 Rather than a prolonged course of psychotropic medication, the PAP therapeutic course includes the therapeutic use of the potent psychoactive substance in a limited number of sessions. The three stages of PAP include: Preparation, Psychedelic Session, and Integration. Preparatory sessions set the stage for the administration of the psychedelic substance, and follow-up sessions are aimed at integrating the therapeutic benefit of the psychedelic sessions while shoring up treatment gains.1,4
Beyond its potential as a novel, safe, and efficacious treatment for mental illness, Schenberg suggests that PAP has implications for shifting the collective attitude toward the widely accepted medical model, including its reliance on brain-based explanations for mental illness and use of discrete diagnostic categories with specific symptoms constellations targeted by longer-term psychiatric drug treatments.
The Medical Model vis-à-vis PAP: Explanation, Diagnostics, and Therapeutics
Conceptual models of mental illness differ in terms of explanation, i.e., how the mental disorder is etiologically explained, diagnostics, i.e., how it is identified and labeled, and therapeutics, i.e., how the illness is treated.
The medical model typically explains mental illness as arising from various organic brain dysfunctions, which are identified and categorized by characteristic symptom constellations and treated with specific drugs, taken over a long period. These drugs are thought to target the underlying brain dysfunction, most commonly a neurochemical imbalance, which is then adjusted, ideally, to asymptomatic levels through prolonged use of the drug.1
This traditional medical approach is brought into question by PAP, as Schenberg points out, which conceptualizes mental illness along the axis of explanation, diagnostics, and therapeutics in a broader, more inclusive fashion. As compared to the medical model, the PAP model advances an explanation of mental illness more inclusive of psychological, social, and cultural variables, as well as adverse life events and trauma, broadly defined as mental injury.1 Furthermore, in terms of diagnostics, the PAP model presents symptoms on multidimensional spectra as compared to grouping symptoms within discrete diagnostic categories.1
Indeed, mental injuries have been shown to correlate with a broad range of negative and trans-diagnostic mental health outcomes, and the PAP model implicitly hypothesizes that broad-based holistic treatments, such as PAP, can bring about experiences that have positive mental health outcomes, spanning diagnostic categories, such as promoting increased “acceptance” and “connectedness” or producing “emotional breakthroughs.” 5,6 As such, rather than considering the efficacy of the drug, the PAP model attends to the efficacy of the experience.
Experiential Efficacy and the Therapeutic Value of PAP
When PAP practitioners and researchers use the term “experiential efficacy,” a term Schenberg attributes to Leor Roseman, they are describing the experiential and phenomenological states that serve as the therapeutic mechanisms of action of PAP. Instead of conceiving of the drug as correcting functional neurochemical imbalances, the PAP model suggests that through mediation and processing of the psychedelic experience via psychotherapy, a patient may experience deeply meaningful and profound insights that bring about emotional, cognitive and behavioral changes across diagnoses and even in “treatment-resistant” cases.1,5
While the therapeutic mechanism of action is not entirely understood, theoreticians are attempting to understand the experiential efficacy of PAP via neuroscience research as well as by drawing parallels to the identified mechanisms of action of various psychotherapy modalities, including Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and psychodynamic psychotherapy.1,7,8
Conclusion: The Potential of PAP
PAP has the potential for shifting the current paradigm in psychiatry via the notion of “experiential efficacy,” which brings into focus and the forefront the subjectivity of the patient experiencing the illness. While not ignorant of the therapeutic neurochemical changes8 that may attend the course of PAP, the primary concern of PAP practitioners is the phenomenology of the treatment experience and its therapeutic value across a broad range of diagnoses, for example, patient reports of cathartic emotional breakthroughs.6
Thus, PAP may offer a way for psychiatry to minimize its risk of “losing the psyche” 9 while also overcoming its current paradigmatic crisis by adopting a broader, more inclusive approach to mental illness explanation, diagnostics, and therapeutics.
David Sugarbaker, PsyD, MPH
Dr. David Sugarbaker is a clinical psychologist and psychotherapist practicing in the Greater Boston area. He is curious about the integration of psychedelic science and psychotherapy, and enjoys writing about clinical and research advances in psychedelic-assisted psychotherapy.