The Gold Standard for Psychedelic-Assisted Therapy?
Exploring the use of Acceptance and Commitment Therapy (ACT)
For most of the 20th Century, Cognitive Behavioural Therapy (CBT) has been the go-to model for talking therapy. Having emerged as a reaction to Freud’s (unscientific) theories, CBT’s solid evidence base placed it as the gold standard in traditional psychotherapy.
Since the turn of the millennium, new ways of thinking about CBT have developed alongside our ever-widening understanding of the human mind. These new models are commonly referred to as third wave CBTs, one of which is the Acceptance and Commitment Therapy (ACT). This new wave progresses psychotherapy from just being about symptom reduction towards living a content and meaningful life.
Acceptance and Commitment Therapy (ACT) is a model based around six key principles for developing psychological flexibility. Psychedelic drugs are also thought to increase psychological flexibility. This article looks to explore the overlap between the two and how they might be used in combination.
The rationale for using psychological therapies alongside psychedelic drugs is based on the hypothesis that psychedelics amplify the effects of the therapy. However, there are many models of therapy, and not enough evidence showing which model is most suitable to be integrated into the psychedelic experience.
While many models of talking therapy may be compatible with the use of psychedelic drugs to produce the desired therapeutic outcomes, it is increasingly proposed that the ways in which ACT leads to therapeutic change are highly synergistic with the subjective, experiential and pharmacological effects of psychedelics.
Clerkenwell Health advocates that combining psychedelic medication with ACT maximises the opportunity for treatment gains by amplifying the response to therapy and lengthening the duration of improvements. The advocates of ACT are growing in numbers globally too. The Yale Manual for Psilocybin-Assisted Therapy of Depression, Imperial College London and Reconnect Labs are also using ACT in their work.
ACT has a strong evidence base as a transdiagnostic therapy model showing that it is an effective intervention for many mental health disorders. It offers a framework for the preparation, dosing and integration sessions allowing therapists to meaningfully engage with patients. But what separates it from other evidence-based and transdiagnostic therapeutic models?
Among all the different models, it seems that ACT conceptually overlaps with psychedelic therapy most harmoniously. How ACT understands the causes of a mental health problem (i.e. psychological inflexibility) and aims to relieve it (i.e. developing flexibility) synergises well with the hypothesis that psychedelics invoke a transient neuroplasticity.
Psychological inflexibility is defined as a state in which behaviour is excessively controlled by one’s thoughts, feelings and other internal experiences at the expense of more meaningful actions. ACT aims to normalise these hard-wired responses and support people to become psychologically flexible by learning six key processes: present moment focus, acceptance, self as context, cognitive defusion, valued direction and committed action. These processes are hypothesised to be facilitated by the core aspects of psychedelic experience such as ego dissolution, transcendence and gaining insights about one’s mental and social lives.
The Hexaflex model of ACT for psychological flexibility and inflexibility.
Present moment focus
When people are not in the present moment they can get stuck ruminating about the past or worrying about the future. ACT helps people learn to notice when this is occurring and come back to the present moment when it does. However, it may be that the present moment isn’t pleasant and therefore people might want to avoid it. A psychedelic experience, sometimes forcefully, brings people directly in contact with the present moment, making them sense everything in great detail and with less interference from rigid thought pathways. This flood of thoughts, memories, emotions and sensations are allowed to flow freely as people become fully immersed in the present moment.
Acceptance
Trying to avoid or control unpleasant symptoms can often make symptoms worse, thereby maintaining the underlying problem. This struggle against experiences prevents people from thinking flexibly and seeing the situation clearly. The idea of “letting go” and “surrendering” is fundamental to psychedelic experience as people cannot escape from the present moment and resisting the experience often leads to “bad trips”. In a way, psychedelics prepare people to tolerate experiences they might not be able to otherwise, allowing feelings to flow through and tension to ease.
Self as context
The way people self-define can become rigid. Instead of perceiving themselves as distinct from the thoughts that arise in their mind, they may view themselves as a collection of stories and beliefs about themselves. An example is the difference between “I’m feeling depressed right now” versus “I’m depressed”. This in turn can prevent them from engaging with behaviours that may help solve their problems.
Realising that they live in their self-constructed world instead of seeing the bigger picture might be more difficult to some people than others. The feeling of transcendence and ego dissolution during the psychedelic experience, which allow people to experience themselves as part of a larger whole, facilitates the process of unlearning these rigid, self-defined narratives. Instead, it allows people to see themselves as the context in which such experiences unfold.
Cognitive defusion
When people are fused with their thoughts, they may believe them to be absolute truths and allow their thoughts to dictate their behaviour. Thoughts and emotions that arise in our minds are difficult to control or change as they tend to be involuntary and follow hard-wired paths laid by years of experience. Instead of trying to change uncomfortable and unhelpful thoughts and feelings, ACT focuses on teaching people how to change their relationship with them. A psychedelic experience can be very helpful in exploring new ways of relating oneself to one’s thoughts and feelings by evoking insights.
Valued direction
Living a full and meaningful life is the main goal of ACT and prioritised over reducing the symptoms of a specific disorder. Exploring one’s values in life is central to identifying behaviours that will lead to a meaningful life. However for some people, what they value in life might not be clear to them, while some others might not even know what matters to them anymore, making it challenging to identify their values. A psychedelic experience can assist people in clarifying their values and priorities by revealing the aspects of their life that have been neglected or can be improved.
Committed action
Executing behaviours to fulfil identified values is central to achieving the goal of living a meaningful life, which may indirectly reduce negative symptoms. ACT has tools to facilitate this process, however, changing behaviours can still be challenging. Psychedelics create a window of opportunity of several weeks, called the afterglow phenomenon, in which people have ‘a relative freedom from concerns of the past and from guilt and anxiety’. This window may allow people to change their behaviours and commit to actions through ACT to bring about long-lasting change as they feel less anxious and risk-averse.
Integration sessions, which help people interpret their psychedelic experiences in a way that might lead to meaningful change, are a key part of almost all psychedelic experiences designed to have a therapeutic effect. The principle of committed action in ACT offers an operational framework to work with, as these sessions remain largely unstructured.
“What I particularly like about ACT is its pragmatic nature. It teaches mindfulness skills which prepare participants to better embrace and learn from their psychedelic experience, and can bring about long-lasting clinical improvement by encouraging behaviour changes which are consistent with personal values.”
Competitive advantage
ACT also differentiates itself from other models by being able to better accommodate different sets and settings, especially compared to more traditional models of CBT. Rather than being prescriptive towards mental processes and thoughts, ACT is more pragmatic and works with what people have. ACT’s less antagonistic nature makes it easier to work with people coming from different backgrounds and having different experiences in life.
The effects of psychedelic drugs appear to complement ACT in a synergistic way, but many questions still remain open. There are no trials showing whether integrating therapy models into psychedelics is more effective than providing psychological support only, or which therapy model is most effective for which condition.
To reliably study this model in comparison with other therapy models and with psychological support only, we need to optimise our approaches to therapist training and also to measuring the adherence of therapists to ACT during all three stages of psychedelic-assisted therapy.
ACT is already embedded in evidence and clinical practice, and this is vital to ensure its ultimate uptake by the healthcare systems following the approval of psychedelic drugs. ACT has the potential to be the gold standard and the first-line treatment in psychedelic-assisted therapy. Therefore, studying ACT in combination with psychedelics is what Clerkenwell Health believe will improve the field and facilitate the integration of psychedelic-assisted therapy into mental healthcare delivery.
