Psychedelic Harm Reduction and Integration: A Transtheoretical Model for Clinical Practice

Abstract

Psychedelic Harm Reduction and Integration (PHRI) is a transtheoretical and transdiagnostic clinical approach to working with patients who are using or considering using psychedelics in any context. The ongoing discussion of psychedelics in academic research and mainstream media, coupled with recent law enforcement deprioritization of psychedelics and compassionate use approvals for psychedelic-assisted therapy, make this model exceedingly timely. Given the prevalence of psychedelic use, the therapeutic potential of psychedelics, and the unique cultural and historical context in which psychedelics are placed, it is important that mental health providers have an understanding of the unique motivations, experiences, and needs of people who use them. PHRI incorporates elements of harm reduction psychotherapy and psychedelic-assisted psychotherapy, and can be applied in both brief and ongoing psychotherapy interactions. PHRI represents a shift away from assessment limited to untoward outcomes of psychedelic use and abstinence-based addiction treatment paradigms and toward a stance of compassionate, destigmatizing acceptance of patients' choices. Considerations for assessment, preparation, and working with difficult experiences are presented.

A Spectrum of Selves Reinforced in Multilevel Coherence: A Contextual Behavioural Response to the Challenges of Psychedelic-Assisted Therapy Development

“…Psychedelics are not recommended as purely pharmacological interventions. However, integrated psychotherapeutic frameworks grounded in empirically supported processes throughout the three phases of psychedelic-assisted therapy, are only just beginning to emerge, and mainly focus on the preparation and integration phases (9)(10)(11).…”

Psychedelics, Mystical Experiences, and Meaning Making: A Renegotiation Process With the Challenges of Existence

“…Individuals who use psychedelics often cite curiosity, the desire to seek mystical experiences, and self-medication as reasons for use (Lerner & Lyvers, 2006;Móró et al, 2011) and have also been found to occasionally seek mental health services after particularly challenging experiences (Carbonaro et al, 2016;Davis et al, 2020). In these events, counselors may consider similar approaches as described in the previous paragraph on integration and may further explore aspects of what are known as "set" and "setting," which have significant influence on how psychedelics are experienced (Carhart-Harris et al, 2018;Gorman et al, 2021). Set refers to the clients' intentions, affect, and outlook shortly prior to and during the experience, whereas setting captures the physical context in which the experience occurred and people who may have been present for it.…”

“…Still, counselors are likely to encounter cases in which established clients inquire about or are insistent upon personal use. Thus, counselors may adopt a risk-reduction perspective by accurately providing information about psychedelics, their effects, and common responses (Gorman et al, 2021) and discussing challenges of nonclinical use, such as difficulty in verifying identity or dose of the drug consumed. Risk reduction includes reviewing psychological and safety contraindications for psychedelic use (Gorman et al, 2021), including personal or close family history of psychosis, comorbid borderline personality disorder, current use of antidepressant drugs, and untreated hypertension (O'Donnell et al, 2019), and encouraging clients to also consult a physician prior to engaging in personal use.…”

“…Thus, counselors may adopt a risk-reduction perspective by accurately providing information about psychedelics, their effects, and common responses (Gorman et al, 2021) and discussing challenges of nonclinical use, such as difficulty in verifying identity or dose of the drug consumed. Risk reduction includes reviewing psychological and safety contraindications for psychedelic use (Gorman et al, 2021), including personal or close family history of psychosis, comorbid borderline personality disorder, current use of antidepressant drugs, and untreated hypertension (O'Donnell et al, 2019), and encouraging clients to also consult a physician prior to engaging in personal use. Risk-reduction approaches may also emphasize the importance of having a trusted and sober "sitter" to provide support or intervene in a crisis, given that challenging experiences have been found to last longer without such an individual present (Carbonaro et al, 2016).…”

“…Riskreduction approaches may note the importance of the experience taking place in a setting where the social, spatial, and musical environments are more predictable and controllable, given that being able to change these was also reported as being substantially helpful in stopping challenging experiences. While engaging in discussions related to risk reduction, counselors should frame and set their boundaries appropriately and in accordance with their knowledge, scope of practice, and legal and ethical restrictions (Gorman et al, 2021).…”