Psychedelics and the essential importance of context

Abstract

Psychedelic drugs are making waves as modern trials support their therapeutic potential and various media continue to pique public interest. In this opinion piece, we draw attention to a long-recognised component of the psychedelic treatment model, namely ‘set’ and ‘setting’ – subsumed here under the umbrella term ‘context’. We highlight: (a) the pharmacological mechanisms of classic psychedelics (5-HT2A receptor agonism and associated plasticity) that we believe render their effects exceptionally sensitive to context, (b) a study design for testing assumptions regarding positive interactions between psychedelics and context, and (c) new findings from our group regarding contextual determinants of the quality of a psychedelic experience and how acute experience predicts subsequent long-term mental health outcomes. We hope that this article can: (a) inform on good practice in psychedelic research, (b) provide a roadmap for optimising treatment models, and (c) help tackle unhelpful stigma still surrounding these compounds, while developing an evidence base for long-held assumptions about the critical importance of context in relation to psychedelic use that can help minimise harms and maximise potential benefits.

DMT Models the Near-Death Experience

“…Recent work has consistently shown that the occurrence of mystical-type experiences is predictive of long-term therapeutic benefit from psychedelics (Maclean et al, 2011; Garcia-Romeu et al, 2014; Griffiths et al, 2016; Carhart-Harris et al, 2017, 2018; Roseman et al, 2018) and similar mechanisms may be at play in relation to improved mental well-being post NDE (Moody, 1975; Noyes, 1980; Ring, 1980; Groth-Marnat and Summers, 1998). It is pertinent to ask therefore, what common features shared between these states may be responsible for mediating the apparent long-term psychological benefits that follow them.…”

“…As both psychedelics and the NDE phenomena appear to be strongly influenced by contextual factors (Kellehear et al, 1994; Carhart-Harris et al, 2018), it could be argued that significant differences may exist regarding phenomenological features between both experiences. Nonetheless, considering the strong overlap on the items of the NDE scale, the study of such differences might require the use of other methods addressing nuances not explored here (e.g., the use of questionnaires addressing contextual factors and qualitative studies).…”

“…Both the psychedelic experience and NDEs appear to be sensitive to contextual factors such as prior psychological traits and state (‘set’), the environment (‘setting’) in which the experience unfolds (Metzner et al, 1965; Studerus et al, 2012) – plus the broader cultural context in which they are embedded (Wallace, 1959; Hartogsohn, 2017; Carhart-Harris et al, 2018). For example, controlled research has found that certain personality traits, e.g., ‘absorption’ and ‘neuroticism’ can predict the intensity and quality of a psychedelic experience (Studerus et al, 2012; Carhart-Harris et al, 2015, 2018; Carbonaro et al, 2016; Barrett et al, 2017) while readiness to ‘let go’ and quality of the environment also seems to be predictive of response (Carhart-Harris et al, 2018).…”

“…For example, controlled research has found that certain personality traits, e.g., ‘absorption’ and ‘neuroticism’ can predict the intensity and quality of a psychedelic experience (Studerus et al, 2012; Carhart-Harris et al, 2015, 2018; Carbonaro et al, 2016; Barrett et al, 2017) while readiness to ‘let go’ and quality of the environment also seems to be predictive of response (Carhart-Harris et al, 2018). In a similar fashion, the prevalence and nature of NDEs appear to be sensitive to environmental, demographic and personality variables, such as etiology and prognosis of the NDE, age, absorption and a propensity to report paranormal experiences (Kohr, 1983; Greyson, 2003).…”

“…In a similar fashion, the prevalence and nature of NDEs appear to be sensitive to environmental, demographic and personality variables, such as etiology and prognosis of the NDE, age, absorption and a propensity to report paranormal experiences (Kohr, 1983; Greyson, 2003). Cultural factors are presumed to influence the psychedelic experience (Carhart-Harris et al, 2018) and have been found to influence the content of NDEs, (Kellehear, 1993; Kellehear et al, 1994). …”