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Intro
I recently told a family member that some researchers were investigating whether psychedelics can improve mental health. She burst out laughing, “drugs are the problem, not the solution.” Even if we do not share this sentiment, most of us are familiar with new age spiritual movement personalities that employ mystical and quasi-scientific language, and these individuals often (though not always) endorse psychedelic experiences. These two attitudes--one that sees traditionally recreational drugs as an ill and the other that sees them associated with a bizarre metaphysics--are likely to make the term “psychedelic therapy” seem less than scientifically and professionally respectable. The aim of this article is to resist this attitude. I do this by arguing that psychedelic effects can be recruited to achieve effects that a therapist typically aims for in a therapeutic setting.
To have confidence in psychedelic therapy, we should have some understanding of the mechanisms behind why and how psychedelic treatments operate and are effective. Much of the empirical data and theory is still forthcoming (but see Letheby, 2021), particularly because research in this area has been taboo or off limits. Nevertheless, I argue that these mechanisms are extensions or enhancements of cognitive behavioral therapy. In other words, cognitive behavioral therapists recruit methods to make changes in the patient’s cognition, perception, associations or values, and we can see psychedelic treatments as continuous with these methods.
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Key Take Aways
We explain human behavior by reference to their physical make up (brain/genetics) as well as their values, perceptions, beliefs, desires, expectations, culture and so forth. I call this our cognitive-motivational profile (CMP).
Therapy is informed by how we explain human behavior (Our CMP). The theory of therapy is built using our explanation of behavior, and these explanations are used during therapy. For example, the belief that traumas cause fears informs our theory of therapy and how therapy is done. Thus, therapy operates by influencing our CMP.
Psychedelics also influence our CMP. I argue that therapy could draw on psychedelic effects to achieve effects aimed for in traditional cognitive behavioral therapy. Some examples include stress reduction, trust building, and mental simulation to bring about behavioral change.
My conclusion is that "psychedelic therapy" is continuous with traditional therapy and thereby rigorous and respectable. When properly controlled, it is not a social \l nor mystical.
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Part 1: General Schema of how we Explain Human Behavior
Imagine the following scenario. You are walking out of Starbucks as they close it behind you for the day. You are texting your friend, you check your phone, and moments later you see someone walk up to the front door of Starbucks. They try to open the door, but they cannot open it. They peak inside, look at the store hours sign, down at their phone, and then they walk away. Can we explain what just happened? We typically think we can. First, the potential customer tried to open the door and noticed it was jammed. They then thought that the store must be closed for the day. To make sure, they checked the store hours and the time. After doing this, they concluded that it was closed, so they could no longer enter the building.
While this is a very simple scenario, it illustrates that to explain human behaviors, we easily postulate beliefs, intentions, motivations, values, desires and the like to explain human behaviors. If we next saw the person dialing a number and then joyfully saying “hey, I am here,” as they wave at someone inside, we would change our explanation. If instead we saw the person later wearing black clothing, sneaking around, and breaking and entering, we would again change our explanation. Each time, we would posit a different set of beliefs, goals, values, motivations, and so forth.
We should also notice that this very simple way of explaining can become very complex. If we saw someone breaking and entering, how could we explain this behavior? Maybe they have an immoral set of values, or maybe they are just anti-capitalism, and they have no respect for these types of companies. Maybe they had a bad upbringing, or maybe society failed to properly instill lawful behavior in them. Maybe they were born with a brain or with genetics different from others. Explaining a very simple behavior can become pretty complex. We need to look at a persons’ genetics and their formed associations, expectations, beliefs, concepts, values, motivations, perceptions, identities, characters, and so forth. For simplicity, call this big list of things our cognitive-motivational profile (CMP). And here is what I want to say in this section: to explain human behavior, we cite facts about people’s CMP. These explanations can be rather simple or rather complex. They can be based on genetics, beliefs, values, culture or all the above and more. With this first idea down, let’s move on to relate it to cognitive behavioral therapy.
Part 2: A Bit on Cognitive Behavioral Theory
Mental health encompasses an increasingly large number of issues including depression, anxiety, addiction, trauma, aggression, and many more. The goal of therapy is to help with these issues. While there are many approaches to doing this, a leading approach is cognitive behavioral therapy. According to the American Psychological Association, cognitive behavioral therapy (CBT) proceeds by identifying problematic thinking patterns, learned behaviors, or coping mechanisms. To address these, it employs methods for improving one’s thought processes, relevant misunderstanding, and values and motivations. It emphasizes strategies for changing unhelpful behaviors, emotions, or perspectives.
It must be stressed that there is no one size fits all approach to CBT. There is no single method, and there is no final fixed set of methods in CBT. A therapist will use different strategies, at different times, and in different circumstances. The approach is both a science and an art. As a science, the field is grounded in objectivity, evidence, well supported theory, and logic. As an art, the practice depends on the circumstance and the practitioner’s informed judgement (Cartwright et al, 2017).
With all that said, we can cautiously draw general ideas (for our purposes) about how CBT operates. One way it operates is by using reasoning. The therapist helps the patient reject faulty beliefs, thought processes, concepts, and perceptions. So, a patient might believe they are unworthy, or they might have learned helplessness. The therapist helps the patient see that these views are mistaken. Another way CBT proceeds is by helping the patient appreciate important values. This can be done by role playing or mental simulation (of which I’ll say more in the next section). For example, someone who tends to use aggression to problem solve can get practice, in a therapeutic setting, using socially acceptable conflict resolution techniques. A third way CBT therapy proceeds is by reworking problematic associations. So, someone who has associated authority with mistrust can be helped by meeting trustworthy authority figures.
We can now state the main claim in this section: CBT works by using reasoning, experience, role-play and simulations to bring about desirable changes in one’s CMP profile. There are two ways this plays out. First, one’s theory of how CMP profiles are formed is used to inform the field of therapy. The belief that childhood trauma can produce irrational fears informs one’s theory of therapy. Second, one’s theory of how CMP profiles are formed plays an active role in the therapeutic setting. By getting the patient to see that their fear is based on trauma, the therapist may hope that the patient sees the fear as less potent.
Part 3: How Psychedelics can be Part of the Therapeutic Process
We saw in part 1 that we postulate various conditions to explain human behavior. I called these various conditions one’s CMP. This includes facts about our cognition, reasoning, associations, values, motivations and so forth. In part 2, I said that CBT uses reason, simulation, and experience to bring about desired changes in our CMP. The ways these are used, I suggested, is influenced by our views formed in part 1. If we think trauma is based on experience, we can reason about our experiences and change them. If we think our issue is genetic, we try a different approach. We are now in a position to ask how psychedelic therapy can fit into this process. I don’t suggest that there is only one way for this to go--much less do I suggest that there is only one way that it should go. Rather, I am asking for one theory of how psychedelic therapy can effectively integrate with what we saw in part 2 and 3. My answer rests on two claims.
Claim 1: psychedelics influence our cognition, experiences, and our mental
simulations (Kalean et al, 2015).
Claim 2: influences on our cognition, experiences and mental simulations have
influences on our CMP.
A lot of details need to be added to these claims. We need more science as to how psychedelics affect our cognition and experiences, and we need more theory about how these in turn affect our CMP. But, however these details turn out, I think claim 1 and 2 are credible.
Now, here is the point of claim 1 and 2. If psychedelics influence our experiences and mental simulations, and these in turn affect our CMP, then psychedelics and CBT both make changes in our CMP. So far this is an uninteresting claim because anything can make changes in one’s CMP. If you hit me on the head with a hammer, and that causes me to be a different person, then your action had an effect on my CMP profile. Alternatively, if I am having deep and personal issues, but you help me reason through them, then you make changes in my CMP. But the latter operates more like CBT, and hammers to the head do not. To make my claim interesting, my third claim is that psychedelics make changes to our CMP profile, and thus can be therapeutically beneficial, in a way similar to how CBT operates. Let me suggest two examples to illustrate it and rationally motivate this.
Example 1. The Multidisciplinary Association for Psychedelic Studies (MAPS) has published a manual for MDMA assisted therapy for post-traumatic stress disorder (Mithoefer et al, 2019). The authors write that MDMA works by first reducing activity in the left amygdala. This in turn reduces stress or fear in the patient as well as alters the patient’s perception of (and response to) positive facial experiences (of the therapist). Notice, these are outcomes that a therapist would strive for without MDMA. That is, during a session, a therapist would need to help the patient reduce fear or stress that would get in the way of the upcoming discussion. Traditionally, a therapist might do this by breathing exercises. Also, the patient would need to trust the therapist, and therapists often have to work for this trust. On the MAPS model, MDMA helps the therapist achieve a similar kind of outcome (reduced stress/perception of trustworthiness) with a somewhat different method (e.g., a drug). I write “somewhat” because there is a sense in which the methods are similar: both techniques would have to find a way to act on stress centers in the brain. Next, to be trusted by the patient, the patient needs to perceive the therapist as trustworthy. To achieve that, MDMA is said to help the patient perceive positive features of the therapist. So again, the method and outcome aren’t entirely distinct, though they are changed. This concludes my first example of why psychedelic effects can be continuous with those aimed for in existing therapeutic approaches.
Example 2. My second example involves mental simulation. Mental simulation has been under-utilized in CBT, probably due to less being known about its effects (Cole et al. 2021). However, due to the flexibility of CBT, there is no reason to bar it from being part of the therapist’s tools. And if psychedelics can positively influence mental simulation, then we have another case of psychedelics being continuous with CBT. This raises questions. What is mental simulation? Does it offer any therapeutic value? How might psychedelics play a role?
In a meta-analysis of research on mental simulation, Cole and colleagues distinguish two dimensions by which to distinguish types of mental simulation: based on what is simulated and how we evaluate the simulation. We can simulate different things, such as a process, performance, or outcome. A process-simulation involves steps. A performance-simulation involves a behavior without necessarily involving steps. And outcome-simulations simulate a desired outcome, such as graduating from college. Along the second dimension, we can evaluate the simulation as inferior, standard, or superior. We can imagine barely graduating, graduating by average measures, or graduating with honors.
Consistent with past meta-reviews on this subject, the authors found a correlation between mental simulation and behavioral change. The authors conclude that “...mental simulation may be a particularly potent behavior change technique…” (Cole et al. 2021). To be sure, this is correlational data, and correlation is not causation. For now, I want to take on the author’s conclusion to make a point about how psychedelics can play a role in simulation. As we proceed, I’ll say a few things about how confident we can be given that the data does not include a mechanistic explanation and so we don’t have a theory about how mental simulation relates causally (if at all) to behavior change.
With that said, how might psychedelics play a role? Since we have less science here than in the first example, this part will be more speculative, but I think some informative points can be made. We tend to think of psychedelics as having a distorting role on cognition and perception. But distortion is only bad when we don’t know how to harness it. Consider magnifying glasses. Magnifying glasses make little things appear huge, but since we know how to use these tools, the distorting effects are not bad. Similarly, psychedelics can distort our cognition and perception. But by analogy, this is bad only if there are no beneficial ways to utilize the distorting effect. Is there some way to harness these effects? In theory, I see no barrier as long as a psychedelic experience can affect a mental simulation in such a way as to beneficially change one’s values, experiences, associations, or reasoning based on that simulation. At least intuitively, if I am able to imagine myself happy when I engage in altruistic behaviors, then having altruistic values will be easier for me (Gamble et al, 2019). If psychedelics can enhance our mental simulations, if therapists can harness this mental boost, and if by doing so, one can change one’s CMP in important ways, then psychedelics can play a role in CBT. This concludes my second example of how psychedelics can be continuous with CBT: via the use of and changes in mental simulation.
A caveat. Now, I haven’t fully argued that this can be done since I didn’t present theories of the underlying mechanisms. Scientists are still investigating how, if at all, mental simulation influences behavior (Conroy and Hagger, 2018). Cole et al. (2021) note that one hypothesis is that when I simulate an activity, I am using the same neuropsychological processes I would use when doing the activity. For instance, when simulating myself surfing well, I may be recruiting the same parts of the brain that would guide me to balance while surfing. While this is a plausible hypothesis, they note, it wouldn’t fully explain how all simulations work. Consider outcome simulations. Here, I imagine a positive outcome such as graduating. These simulations focus on an outcome, not a behavior, so this explanation can’t be exactly the same type as the previous one. One suggestion is that the positive feelings around the imagined outcome make one more likely to perform it. But then why wouldn’t these positive feelings instead give one a false sense of accomplishment and hence make one less likely to act?
So, there are still some gaps to fill in. In part, all this should be expected, as we are still waiting for the science of psychedelic therapy and mental simulation. In another part, I think what I have said is plausible given what we do know. That is, we know psychedelics affect our CMP and that CBT proceeds by changing our CMP. My thesis is that both can proceed in a continuous fashion. My two examples illustrate how this can be carried out.
Conclusion.
As mental health continues to affect many people, as multi-million dollar companies are racing to research and develop therapeutic compounds, as attitudes about such compounds change in society, more and more normative questions will arise (Anderson et al, 2020). At the start of this essay, I brought attention to one such normative question: should our society allow psychedelic therapy? One conservative answer is that psychedelics are social ills. Another answer is that they are a source of mystical belief. My strategy here has been to answer the question by showing that it can help achieve things we already think are worthy of pursuit, e.g., those aims that therapy endorses.
References
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