Psychedelic-assisted Psychotherapy in 3-D: Acceptance, Connectedness, and Defensiveness

ABSTRACTAs psychiatry weighs a move from a categorical to a dimensionally-based classification system, clinical research and treatment paradigms may shift towards identifying which dimensions of mental health can improve treatment outcomes across a broad range of diagnostic categories. Psychedelic-assisted psychotherapy, which is currently in clinical trials for a wide range of conditions from PTSD to tobacco dependency, holds promise for just such a dimensional approach to treatment. Anecdotal reports and qualitative studies have hinted at its potential for decreasing defensiveness and increasing feelings of acceptance and connectedness. In this theoretical paper, I draw upon ideas and research with psychedelics, infant observation, social psychology, and psychoanalysis to explain why psychedelic-assisted psychotherapy is especially well-suited for addressing these dimensions of mental health. Because studies already support the use of psychedelic-assisted psychotherapy in one dimensionally-based application – the treatment of existential anxiety in patients with cancer – I begin with a look at psychological models of defensiveness in relation to the fear of death. I then use the models of Winnicott, Stern, Carhart-Harris/Friston and others to discuss the experiences of awe, omnipotence, and creativity within ordinary and psychedelic states, and touch on a fourth dimension of mental health, authenticity. I suggest psychedelic-assisted psychotherapy may be viewed as a transitional space ideally suited for working through experiences of disconnection through the process of illusion-disillusionment, allowing gradual acceptance. I conclude with a summary of how acceptance, connectedness, and defensiveness are related to each other and to one’s sense of self.KEYWORDS: PsychedelicAcceptanceConnectednessDefensivenessAuthenticityTransitional space Disclosure statementNo potential conflict of interest was reported by the author(s).Notes1 Despite some differences in proposed mechanism of action and behavioral effects, I have included findings from one study with 3,4-methylene dioxymethamphetamine (MDMA) together with findings using the “classic” psychedelics, as MDMA is often described in the literature as reducing defensiveness.2 Just how it feels to have fears exposed under the influence of psychedelics is extremely relevant, and discussed further below. Studies of subjects in MDMA-assisted psychotherapy who have PTSD often report facing the triggers of their fear without the expected level of anxiety.3 I am intentionally evoking the seminal study by Ainsworth and Bell (Citation1970), which led to inferences about the generative models used by one-year olds in a strange situation.4 There are, of course, many theories about the origins and meaning of the self in psychoanalytic and other literatures. Admittedly, I am selecting those I consider relevant to my purpose.5 This will have implications in understanding the powerful sense of authenticity in psychedelic states.6 Renee’s case made an impression upon Winnicott (Citation1962), too, particularly because of how Sechehaye permitted the transference to develop in a way that allowed Renee to experience her as “mama.” This allowed Renee to “create an object” (p. 60), with which Sechehaye “did no more than enable the object to take apple-shape, so that the girl had created a part of the actual world, an apple” (p. 50). This technique, which Sechehaye termed “symbolic realization,” illustrates Winnicott’s idea about the importance of the mother, or the analyst, waiting for, and responding empathically to the infant’s/patient’s spontaneous gesture, allowing the True Self to develop.7 Synesthesia, a hallmark of psychedelic ego dissolution, like affect attunement, is based on cross-modal sensory convergences. Affect attunement is the primary means of a sense of connectedness during certain stages of infancy (Stern, Citation1985).8 For a fuller explanation, see Winnicott (Citation1960b, Citation1962, Citation1971a). Mother’s “breast” is, in addition to its literal meaning, intended by Winnicott to refer to the entirety of the mother’s holding as a response to the infant’s need, not simply in relation to hunger/feeding. Also, I take “implementing” to mean an empathic recognition and acceptance of the infant’s satisfaction in experiencing relief following her gesture, not a manipulation meant to instill false belief in omnipotence.9 In the present context, the fate of idealizing selfobject needs may be understood as going from an insistence that “there are true heroes who are omnipotent, even if I am not,” to “there are people whose experience in life can assist me in confronting my own lack of power or control over situations.”10 The word “uplifting” is not used by chance. One imagines that the infant’s exhilaration in being joyfully and powerfully lifted high in the air is related to the feeling of smallness within vastness. This literal uplifting may be re-created in the sense of awe.11 While the unfamiliar use of the words “omnipotent” and “creative” in different senses is initially jarring, its use in different senses more than repays the effort to accommodate this, in bridging two or more seemingly disparate ideas, in the same way that looking at a list of words with a common etymological root helps one gain a greater depth of understanding of the concepts they signify.12 Italics in original. I have merely substituted the words “psychedelic subject” for “baby.”13 It is the mother’s “primary maternal preoccupation” (Winnicott, Citation1956) that assures her proper and timely adaptation to the infant’s need for omnipotence, and its closure will also assure her proper and timely frustration of the infant’s omnipotence. It is interesting to consider the synchronicity between the infant’s omnipotence and the primary maternal preoccupation from an evolutionary, or attachment theory, point of view.14 The differential effect of psychedelic drugs on evoked companions and RIGs suggests Stern’s distinction between them is warranted, and that they represent differently wired memory systems; see Chefetz and Bromberg (Citation2004) pp. 416–419. Psychedelics are thought to “unbind” abstract models (i.e., RIGs) used in predictive processing (Carhart-Harris & Friston, Citation2019; Letheby & Gerrans, Citation2017).15 Stern holds that evoked companions never disappear, but remain dormant, and are activated at times of great disequilibrium.16 The idea that a record or trace may be left of the life-as-lived experience outside of the RIG is supported by the idea of the evoked companion as activated through the episodic memory system, while the verbally represented RIG is recorded in semantic memory (Stern, Citation1985, p. 227). Psychedelics may deactivate the mechanisms involved in repression.17 In this and the previous example, it is admittedly difficult to know, without more details, if these are true evoked companions in Stern’s sense.18 Last lines from Keats’s “Ode to a Nightingale”.