Qualitative Interviews With Australian Psychedelic-Assisted Therapy Trial Clinicians

Barber, M., Gardner, J., Liknaitzky, P., & Carter, A. (2024). Lost in translation? Qualitative interviews with Australian psychedelic-assisted therapy trial clinicians. Psychology and Psychotherapy: Theory, Research and Practice, 00, 1–19. https://doi.org/10.1111/papt.12545

Rationale

The study aims to understand the perspectives of clinicians involved in psychedelic-assisted therapy (PAT) trials in Australia. This research is justified by:

What we know:

• PAT shows promise for treating various psychiatric disorders (Barber & Aaronson, 2022; Reiff et al., 2020).
• Australia has recently legalized the prescription of MDMA and psilocybin for certain conditions (TGA, 2023).
• There are concerns about premature implementation and challenges in integrating PAT into existing healthcare systems (Blau & Thompson, 2023; Rossell et al., 2023).

Next step:

• Investigating the views of clinicians at the forefront of PAT research to understand how they conceptualize the therapy and its potential implementation.
• Exploring the therapeutic frameworks used by these clinicians and their perspectives on how PAT interfaces with current mental health care systems.

Method

• Qualitative, semi-structured interviews were conducted with clinicians working on Australian clinical trials of psychedelic-assisted therapy (PAT).
• Interviews were conducted via Zoom or in-person, lasting 30-65 minutes.
• Data was analyzed using reflexive thematic analysis as outlined by Braun and Clarke (2006, 2019).
• The analysis involved data familiarization, collaborative cross-coding, and iterative theme development.

Sample

• 11 clinicians from five different Australian PAT trials participated.
• Participants included five psychologists, four psychiatrists, and two psychotherapists.
• All had substantial clinical experience in mental health (5-30+ years) and formal training in PAT.
• 63% of participants were female.

Results

Four key themes were identified:

1. Therapeutic eclecticism

The theme “Therapeutic eclecticism” reflects clinicians’ diverse approaches to understanding and practicing psychedelic-assisted therapy (PAT).

Clinicians in the study demonstrated a broad and inclusive view of mental health and PAT, drawing from conventional and alternative modalities.

Their perspectives were particularly influenced by psychodynamic, humanistic, and Eastern philosophical lineages.

This eclectic approach included elements from attachment theory, Mindfulness Based Stress Reduction, Internal Family Systems therapies, transpersonal psychology, and somatic psychotherapy.

This quote demonstrates how clinicians integrate concepts from different therapeutic traditions, in this case Jungian psychology, to conceptualize the healing process in PAT.

“The idea that he [Carl Jung] has around romancing shadow, a lot of psychedelic work is about that. It’s about getting to know the darker parts of yourself in a way that’s kind of more loving towards them. You know, if you see the monster, ask it what it has to teach you.”

2. Enhanced reflexivity

The theme “Enhanced reflexivity” highlights the importance that clinicians place on self-awareness, personal development, and experiential understanding in the practice of psychedelic-assisted therapy (PAT).

Participants emphasized that PAT providers should engage in their own deep personal work, including therapy or other forms of introspective practice, to develop a keen awareness of their biases, traumas, worldviews, and limitations.

This enhanced reflexivity was seen as crucial for maintaining therapeutic integrity and avoiding the imposition of the therapist’s own perspectives on the client’s experience. Many interviewees considered this level of self-awareness to be a non-negotiable competency for PAT providers.

This quote emphasizes the importance of therapists understanding their own psychological processes and boundaries to maintain a client-centered approach in PAT.

It highlights the potential risks of therapists projecting their own experiences or interpretations onto clients and underscores the need for deep self-awareness in PAT practice.

“I feel like having done your own deep therapy and so you have a real sense of where your defences are or where your edges are. So you know when you’re being triggered and it’s your own stuff. Because I think that might be a place that could get dangerous if you’re putting your own stuff in. … To be able to really let that person’s experience be their own and not try and imagine that everyone who does it is going to be inducted into the same frame of understanding the world.”

3. Legitimisation of extra-medical perspectives in mental health

The theme “Legitimisation of extra-medical perspectives in mental health” reflects clinicians’ desire to incorporate broader, non-pathologizing understandings of mental health and wellbeing into mainstream practice.

Participants saw psychedelic-assisted therapy (PAT) as an opportunity to validate and integrate psychological, social, cultural, and spiritual perspectives that often fall outside the conventional medical model.

Many interviewees expressed frustration with the current mental healthcare system’s focus on medical diagnosis and intervention, advocating for a more holistic approach.

They viewed PAT as a potential catalyst for generating research evidence supporting alternative understandings of mental health.

This theme is aptly illustrated by a quote from Interviewee 2, a psychologist:

“I have a hope that as this comes more online, not only will it help the individual, but it will help psychology, psychiatry, and the medical field as a whole. Our tendency to separate mind/body will diminish, our medicalisation of misery will become more nuanced and less. We will be much more able to be with people in suffering … Which means we won’t have to have defences, which means we won’t develop symptoms, which means we won’t develop a cluster of symptoms, which means that there’s no such thing as a mental health disorder diagnosis.”

This quote encapsulates the hope that PAT could lead to a paradigm shift in mental health care, moving away from a symptom-focused, diagnostic approach towards a more holistic understanding of human suffering and wellbeing.

It reflects the desire to legitimize perspectives that consider the interconnectedness of mind and body, and the broader context of an individual’s experiences.

What might be lost in translation?

The theme “What might be lost in translation?” captures clinicians’ concerns about how psychedelic-assisted therapy (PAT) might be implemented in mainstream practice.

Despite the perceived opportunities for positive change in mental health care, many interviewees expressed worry that the nuanced, complex, and relational aspects of PAT could be compromised when translated from research to clinical practice.

Participants feared that the pressures of the existing healthcare system, including economic constraints and dominant medical paradigms, might lead to oversimplification or medicalization of PAT.

There were concerns about PAT being misinterpreted as a quick fix or standalone pharmacological intervention, potentially overlooking the crucial role of psychotherapy and the importance of the therapeutic relationship.

This theme is aptly illustrated by a quote from Interviewee 2, a psychologist:

“I’m just worried that the loudest voice and the biggest contingent of people will maybe decide how it does go … we need people to be doing different things so we can find out what maybe works best.”

This quote reflects the apprehension that the implementation of PAT might be driven by dominant voices or interests, potentially limiting the exploration of diverse approaches and compromising the therapy’s integrity.

It underscores the tension between the need for standardization and evidence-based practice, and the desire to maintain the flexibility and depth that many clinicians see as essential to PAT’s effectiveness.

Insight and Depth

This study provides unique insights into how clinicians at the forefront of PAT research in Australia conceptualize the therapy and its potential implementation.

It reveals tensions between current mental health care models and the holistic, relational approach favored by many PAT clinicians.

The research highlights the complex interplay between therapeutic ideals, practical constraints, and systemic challenges in translating PAT from clinical trials to community practice.

The study also sheds light on the broader debate in mental health care between medical models focused on symptom reduction and more holistic approaches that emphasize relationships, meaning-making, and personal growth.

PAT appears to be positioned at the intersection of these perspectives, potentially offering a bridge between pharmacological interventions and psychosocial therapies.

Strengths

• The study captured perspectives from a significant portion of PAT trial clinicians in Australia.
• The qualitative approach allowed for rich, nuanced exploration of clinicians’ views.
• The research addresses a timely and important topic given recent policy changes in Australia.
• The analysis was conducted collaboratively, enhancing its rigor and trustworthiness.
• The study situates PAT within broader debates in mental health care, providing valuable context.

Limitations

• The sample size was relatively small (11 participants).
• Participants were recruited from a limited number of research groups, potentially introducing selection bias.
• The study focused only on clinicians’ perspectives, not those of patients or policymakers.
• Most interviews were conducted before the rescheduling of psilocybin and MDMA in Australia, which may have influenced responses.
• The study did not collect demographic data on participants’ age or cultural backgrounds.

Implications

The results have significant implications for the development and implementation of PAT in Australia and potentially globally:

1. Workforce development: The emphasis on therapist reflexivity and personal experience suggests a need for specialized training programs that go beyond traditional clinical education.
2. Policy and regulation: The tension between clinicians’ holistic ideals and concerns about medicalization highlights the need for nuanced policy approaches that balance safety and efficacy with therapeutic flexibility.
3. Healthcare system integration: The study raises questions about how PAT can be integrated into existing mental health care systems while maintaining its integrity and efficacy.
4. Equitable access: Clinicians’ concerns about PAT becoming expensive and exclusive point to the need for strategies to ensure equitable access if it becomes an approved treatment.
5. Interdisciplinary approaches: The eclectic nature of clinicians’ conceptualizations suggests that PAT may benefit from interdisciplinary collaboration in research and practice.

Conclusion

This study provides valuable insights into how clinicians involved in psychedelic-assisted therapy (PAT). research in Australia conceptualize the therapy and its potential implementation.

It highlights the complex interplay between therapeutic ideals, practical constraints, and systemic challenges in translating PAT from clinical trials to community practice.

The research underscores the need for careful consideration of workforce development, policy approaches, and healthcare system integration as PAT moves toward potential approval and implementation.

The study also situates PAT within broader debates about mental health care models, suggesting that it may offer a unique opportunity to bridge pharmacological and psychosocial approaches.

However, realizing this potential will require addressing significant challenges related to training, access, and integration into existing healthcare systems.

Further research is needed to explore the perspectives of other stakeholders, including patients, policymakers, and clinicians not involved in PAT research. Additionally, studies examining the actual implementation of PAT in community settings will be crucial as the field develops.

In conclusion, while PAT shows promise as a potentially transformative approach to mental health treatment, its successful and ethical implementation will require navigating complex clinical, systemic, and societal considerations.

This study contributes to our understanding of these challenges and opportunities from the perspective of clinicians at the forefront of PAT research in Australia.

References

Primary reference

Barber, M., Gardner, J., Liknaitzky, P., & Carter, A. (2024). Lost in translation? Qualitative interviews with Australian psychedelic-assisted therapy trial clinicians. Psychology and Psychotherapy: Theory, Research and Practice, 00, 1–19. https://doi.org/10.1111/papt.12545

Other references

Barber, G. S., & Aaronson, S. T. (2022). The emerging field of psychedelic psychotherapy. Current Psychiatry Reports, 24(10), 583-590.

Blau, A., & Thompson, G. (2023). ‘Serious concerns’ over TGA’s decision making on landmark psilocybin, MDMA ruling. Australian Broadcasting Corporation.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101.

Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597.

Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., Rodriguez, C. I., Kalin, N. H., McDonald, W. M., & the Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research. (2020). Psychedelics and psychedelic-assisted psychotherapy. The American Journal of Psychiatry, 177(5), 391-410.

Rossell, S. L., Meikle, S. E., Williams, M. L., & Castle, D. J. (2023). Why didn’t the TGA consult with Australian researchers and clinicians with experience in psilocybin-assisted psychotherapy for treatment-resistant major depressive disorder? Australian and New Zealand Journal of Psychiatry, 57(7), 935-936.

Therapeutic Goods Administration (TGA). (2023). Change to classification of psilocybin and MDMA to enable prescribing by authorised psychiatrists.

Keep Learning

Suggested Socratic questions for a college class to discuss this paper:

1. How can the tension between medical models of mental health care and more holistic, relational approaches be navigated in the context of PAT implementation?
2. What strategies could be employed to ensure equitable access to PAT if it becomes an approved treatment, given concerns about it becoming expensive and exclusive?
3. How might the integration of PAT into existing mental health care systems challenge or reshape current conceptualizations of mental health and wellbeing?
4. What are the ethical implications of using substances that can potentially alter one’s personality or worldview as part of mental health treatment?
5. How can policymakers balance the need for safety and efficacy with the desire for therapeutic flexibility in regulating PAT?
6. What role should non-medical perspectives (e.g., spiritual, cultural) play in the development and implementation of PAT, and how can these be integrated responsibly?