ethics and ego-dissolution

abstract

  • psychedelics are coming back to psychiatric research

    • after decades of prohibition

  • psilocybin: shows potential for cancer-related anxiety/depression, alcohol misuse, treatment-resistant depression, and smoking cessation

  • the therapeutic effects are linked to features: loss of self-importance, mystical insights, ineffable knowledge, unity, and an encounter with “deep reality”

  • personality and worldview changes

  • novel ethical concerns (informed consent)

    • trauma re-exposure

    • personality/value shifts

    • spiritual/ineffable experiences

  • the authors make an argument for enhanced consent processes

  • discusses challenges as psilocybin goes to mainstream psychiatry

I. personality change and neurobiology of psilocybin-assisted psychotherapy

  • mostly studied in depression and/or anxiety in terminal illnesses and TRD (treatment resistant dep.)

  • mystical experiences (unity, sacredness, ineffability, transcendence)

  • patients rank it as one of the most meaningful experiences of their lives

  • five factor model

    • less neuroticism

    • more conscientiousness

    • more extraversion

    • more openness

  • unmeasurable traits

    • more spirituality (even in atheists)

    • transcendence in death

    • more sense of connection (people, animals, nature)

  • biological:

    • decreases in the default-mode network connectivity (ego dissolution)

    • reintegration afterwards suggests a reset mechanism

  • hypotheses:

    • restructures cognition like CBT

    • an increase in mindfulness and flexibility

    • heightened suggestibility

    • the mechanism is likely multifactorial

II. why enhanced consent?

  • the authors emphasized that the effects of psilocybin are very different from standard psychiatric medications

  • the experiences are hard to imagine beforehand

    • typical consent (like brief disclosure of side effects and alternatives) is insufficient

  • patients have to understand the profound potential for personality changes before consenting

III. disclosure topics in enhanced consent

  • Shifts in the values and personalities

    • patients may gain spirituality/worldviews that conflict with prior values

      • atheist → spiritual

      • religious patient → disturbed by mystical experiences framed as “biochemical”

    • patients may underestimate the possibility of the profound change because its difficult to convey the intensity

  • some mental health risks

    • severe anxiety

      • up to 39% said the worst trip was among life’s most challenging events

    • psychosis

      • no cases in trials due to careful screening

      • risk could increase without strict oversight in clinical practices

      • there are some self reports of lasting psychosis after psilocybin

    • trauma re-exposure

      • relive or experience new trauma

      • therapists have to prepare and disclose this risk

  • therapeutic touch

    • touch (like hand holding) is controversial

    • challenges include patients changing preferences mid-session and assessing the capacity of the patient during the psychedelic state is difficult

    • recommendations:

      • refusal of touch should be respected

      • develop shared standards (prior discussions to signals and gestures)

IV. enhanced consent and current practice

  • preparatory sessions: often included in current research

    • safety, possible experiences, and coping strategies

  • the author argue that this should be a part of the informed consent, not just therapy prep

  • no systematic review of the protocols exist → practices could vary

V. is psilocybin relevantly different

  • counter argument/objection: SSRIs and psychotherapy also change personality

  • response:

    • psilocybin changes are different in kind and degree (especially in openness and spirituality)

    • the effects are rapid and profound, not gradual

    • produces ineffable mystical realizations that are not typical of SSRIs and CBT

VI. suggestibility and capacity to consent

  • the concern is that the enhanced consent could reduce psilocybin’s therapeutic effect by lowering suggestibility

  • the response:

    • withholding information is a violation of the informed consent standards

    • even if the effect size decreases, the knowledge will advance science

  • objection: the ineffable experiences make true consent impossible because it can’t really be described

  • response:

    • life decisions (like marriage and jobs) are unimaginable (partly) but validly consented to

    • same applies to psilocybin????

      • I personally don’t agree with this because whatttt

VII. the ethics of going mainstream

  • the author reminds us that the data on psilocybin is still preliminary, so ethical caution is required

  • four issues

    • new personality assessment tools may be needed beyond the five factor model

    • policy safeguards must be developed to prevent unsafe practices

    • there is a need to study whether psychotherapy is essential alongside psilocybin

      • for precaution, include it

    • must be emphasized that the strong patient enthusiasm suggests a favorable risk-benefit ratio

3 STATEMENTS: 

  1. psilocybin cannot be ethically consented because you cannot describe the profound effects.

  2. psilocybin is a moral conundrum because it raises the question if it is okay for psychiatrists to essentially change a person’s whole personality 

  3. psilocybin is going to become another drug that had potential but became demonized through misuse and malpractice