Trauma-Informed Care in Psychedelic Therapy Research

Neuropsychiatric Disease and Treatment | 2024, Vol. 20, p. 109-135

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Nadav Liam Modlin; The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Michael Creed; The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK;  South London and Maudsley NHSFoundation Trust, Maudsley Hospital, Denmark Hill, London, UK

Maria Sarang; The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Carolina Maggio; The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

James J Rucker; The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; South London and Maudsley NHSFoundation Trust, Maudsley Hospital, Denmark Hill, London, UK

Victoria Williamson; King’s Centre for Military Health Research, King’s College London,London, UK; Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK

Introduction: Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD. However, trials of classical psychedelics in PTSD are lacking. Understanding patients’ experiences of EBPI could help promote safety in PT.

Aim: To systematically review qualitative research on patients’ subjective experience of EBPI for PTSD and of PT and examine areas of overlap and divergence between them.

Methods: Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results: 40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR,CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA, and ketamine for the treatment of substance use disorders,anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion: This study suggests overlap between patients’ experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

Trauma; PTSD; psychotherapy; psychedelic therapy; qualitative, review

“In response to the unmet clinical need in PTSD, and difficult-to-treat mental-health conditions, studies investigating psychedelic forms of therapy have shown promise in so-called “treatment-resistant” patients. Psychedelic therapy (PT) is an umbrella term for interventions administering serotonergic hallucinogens such as 4-phosphoryloxy-N, N-dimethyltryptamine (psilocybin) and lysergic acid diethylamide (LSD) or entactogens such as 3,4-Methyl enedioxy methamphetamine (MDMA) alongside manualised psychological interventions. Despite PT’s favourable safety profile in research settings and advances in understanding of its neurobiological, psychological, and behavioural effects, significant gaps of knowledge remain... As most PT trial participants must be unsuccessfully treated by first-line interventions, understanding the positive and negative experiences of EBPI patients could help optimise PT protocols” (p. 110). 

“A systematic literature search was conducted to identify papers studying patients’ qualitative experiences of either EBPI in PTSD,or PT. Given the paucity of existing qualitative literature on PT for PTSD, an expanded second search was conducted to include studies on PT for any clinical indication, including but not limited to depression, substance use disorders, and anxiety associatedwith life-threatening illness. The search was conducted between January and March 2023… Papers deemed eligible for inclusion were original, peer-reviewed studies presenting qualitative data with an identifiablequalitative research methodology (eg, grounded theory, interpretative phenomenological analysis, etc.), focused onpatient experiences of either EBPI in PTSD, or PT for any indication…Selected papers were assessed for quality using the Critical Appraisal Skills Programme (CASP) criteria” (p. 110-112).

“Overall, the included studies demonstrated that EBPI in PTSD and PT across indications compel the patient tocontend with a range of arduous processes in the service of recovery. In both treatment paradigms, patients highlightedthe intense biopsychosocial nature and heavy demands of treatment. Applying insights from this review, below wee xpand on 5 areas relevant to positive safety outcomes in future PT research and practice” (p. 125).

“An integral finding of this study pertains to the overarching presence of trauma-related psychopathology across indications in PT research. This may be due to higher prevalence of trauma exposure in treatment-resistant patient populations. Correspondingly, researchers have discussed the potential utility of PT to treat PTSD, citing psychedelics’ mechanisms of action, and its hypothesised transdiagnostic utility” (p. 125). 

“Broadly, patients discussed how the treatments encouraged behavioral activation, and catalysed novel insightsand corrective emotional experiences related to their symptoms and beliefs about self and others. While EBPI patients’ narratives were often focused on the impact of treatment on PTSD symptoms, PT patients reported therapeutic processesthat were also linked to obtaining a greater sense of connection to their values, increased meaningfulness, andappreciation of the importance of spirituality.” (p. 126-127).

“Self-narratives may be a consequence of, anda maintaining factor, in trauma-related psychopathology. Broadly, self-narratives construct identities by organisinglife experiences into seemingly coherent stories that define the person’s subjective experience of self… This study highlighted the potential transformative interaction between patient’s self-narratives and experiences elicitedby the psychedelic compound and therapeutic context. Patients reported processes of relatedness and identification withthe compound, significant others, and transcendental states. These intrapersonal processes, supported by the treatment’s non-pharmacological factors and potentially facilitated by the patients enhanced neural and cognitive plasticity, appeared to help participants re-organise damaging self-narratives” (p. 127).

“Factors pertaining to patients’ perceived sense of readiness to engage in treatment contribute to positive outcomes. Readiness in this study refers to the patients’ capacity to tolerate intense negative affect, overcomedefenses, possess an intentional desire to change and admit that one needs support. Despite the lack of empirical data, patients’ lack of readiness for treatment may be associated with poorer outcomes, including adverse reactions such as symptomatic deterioration and suicidality. Correspondingly, there is a lack of standardised best practices across PTstudies, including screening measures evaluating patient’s suitability, rather than medical eligibility, for PT” (p. 127). 

“This review demonstrates how patient burden can conflate both logistical factors and the often-demanding treatmentprocedures. PTSD treatment-specific challenges (eg, exacerbation of existing symptoms) may enhance patients’ sensi-tivity to so-called “real world” barriers (eg, travel, employment, relationships). Correspondingly, real-world difficulties may make it more challenging for patients to utilise interventions that in and of themselves may produce significant distress” (p. 128). 

Traumatic Stress in PT:

• Interpersonal Factors: “Excessive shame, past experiences of betrayal, and moral injury might make it difficult for traumatised patients to request support during intense PT sessions, potentially leading to feelings of isolation and withdrawal. Slipping into traumatic awareness, some patients may experience these occurrences as traumatic reenactments,reminiscent of past experiences of neglect and abandonment. Taken together, clinicians should be mindful of patients’ experiences of interpersonal trauma, associated impact on personality and subsequent capacity to engage in PT, an intervention that may elicit profound regressive states” (p. 126). 
• Intrapersonal Factors: “Traumatised patients may be burdened by demoralising self-narratives often accompanied by persistent negative affect and negatively biased cognitions… To promote psychological safety and trust, this theme demonstrates the need to establish clinical and organisational cultures that promote consent, collaboration, agency,transparency, trustworthiness, and cultural humility in EBPI and PT” (p. 126).

Key Mechanisms of Change: “Clinicians should be prepared to support patients through intense therapeutic processes, initiated and completed in a relatively short period of time. Modelling confidence and purposeful-ness without negating patient safety, clinicians should approach instances of struggle during PT as a potentially valuable component of the treatment process; sensitively conveying trust in the patients’ resources to utilise challenging occurrences during PT. Importantly, clinicians should be prepared to support patients who did not perceive an immediate sense of resolution and treatment non-responders, who may perceive challenging PT experiences as destabilising, potentially reinforcing harmful core beliefs and intensifying negative affect associated with unresolved conflicts” (p. 127).

Re-Organisation of Self-Narratives via Processes of Relatedness and Identification:  “Shifting from “what is wrong with you?”, a self-narrative indicative of cognitive rigidity and blame, to “what happened to you?”; an exploratory and accepting stance towards self. This in turn appeared to support therapeutic gains by promoting curiosity towards entrenched negative autobiographies and increase openness to change. However, PT sessions are inherently unpredictable, potentially catalysing anxious ego-dissolution and intense negative affect that may reinforce patient’s harmful self-narratives… Taken together, on-going therapist training, supervision, and ethical oversight is crucial to mitigate potential risks associated with PT” (p. 127). 

Readiness: “As patients may perceive a discrepancy between their needsand abilities or lack a clear understanding concerning the treatment’s rationale, this review highlights the importance ofaccessible psychoeducation regarding PTs rationale and procedures prior, during and after treatment” (p. 128).

Real-World Barriers: “ It is important clinicians pay attention to the patient’s everyday psychosocial circumstances duringtreatment; failing to situate the patient in the “real-world” or considering the impact of treatment emergent adverse eventson psychosocial functioning may lead to poor outcomes” (p. 128). 

“This study has several limitations. Firstly, we were unable to include papers not written in English. As a result, 37 EBPIin PTSD and 2 PT papers were excluded, which may have provided insight into patients’ experiences. An additionallimitation is that PT studies generally appeared positively biased, often reporting the experience of treatment responders,and rarely discussing adverse events/responses. As psilocybin and MDMA edge nearer towards regulatory approval andrapid-onset, short-acting psychedelics with limited safety data are developed, it is vital that future qualitativestudies target treatment emergent adverse events in PT to ensure patient safety and inform ethical practice guidelines” (p. 128).