"Psychedelic substances induce profound alterations in consciousness. Careful preparation is therefore essential to limit adverse reactions, enhance therapeutic benefits, and maintain user safety."
-DIPP Study Abstract
I stumbled upon a Youtube video today that made me think about what it's like to feel besieged and desperate. The footage captures one of the countless epic wipeouts experienced by surfers at the now-iconic, big wave mecca of Nazaré, Portugal. Everything about Nazaré is extreme: the expertise needed to surf there, the perilous conditions unique to this spot, and, of course, the colossal size of the waves. The video demonstrates what surfers call, getting caught inside—a scenario where you're trapped between the shore and the oncoming waves. Getting caught inside almost anywhere else in the world is an inconvenience and an annoyance, but, at Nazaré, it can be life-threatening. That's why, on big wave days, Nazaré has a highly-skilled rescue team on jet skis to assist.
I imagined that the surfer in this video had an intense sense of desperation that was, at least, somewhat mitigated knowing a lifeline was nearby. And, I surmised, just as the surfer relies on others to survive the treacherous waters of Nazaré, individuals battling mental illnesses often find themselves in need of a lifeline to pull them from the depths of their own perilous circumstances. This brings us to a discussion about an emerging mental health treatment—psychedelic-assisted therapies (PATs)—a groundbreaking approach that offers new hope for those who traditional therapies have fallen short.
I had just finished reading a study on this very subject called, Development of a digital intervention for psychedelic preparation (McAlpine et al. 2024). Now, the video had me equating the sometimes overwhelming nature of mental health struggles to being trapped in the relentless onslaught of giant waves, besieged and engulfed by despair, doubting one's own ability to emerge unscathed. The big difference is that, for most living with mental illness, there is no help in sight. Whether or not my analogy is apt or elegant, here's why studies that help create viable lifelines for people with mental illnesses are so important.
In their World Mental Health Report (June 2022), the World Health Organization (WHO) said that:
1 in 8, or nearly one billion people worldwide, live with a mental health condition,
71% of people living with psychosis do not receive mental health services
14% of the world's adolescents (age 10-19) are living with mental illnesses (2019) and,
"The COVID-19 pandemic has had a severe impact on the mental health and wellbeing of people around the world."
The WHO findings dramatically underscore an ever-intensifying worldwide mental health crisis which translates to a growing demand for effective treatments. In fact, this alarming data raises the stakes and should raise the standard for what constitutes "effective treatments" in this space. For a treatment to be truly effective, it must be accessible and affordable for the vast numbers of individuals worldwide to whom the report refers, not just for the well-insured or the economically well-off*.
*Exact costs for psilocybin-assisted therapy are still relatively unknown, but treatments will most likely be in the thousands of US dollars. Some savings could be found in group rather than individual therapy (E Marseille et al. 2023) but, I suspect, even this will be unaffordable for the large majority.
The study we're discussing today focuses on the landscape of PATs and their three-phase treatment process, with an emphasis on the role of the preparation phase. PATs involve the therapeutic use of potent psychoactive substances—such as psilocybin, LSD, MDMA, and ketamine—that are usually guided in-person by one or more trained clinicians over a period of days or weeks. They are meant to treat a wide range of mental disorders including post-traumatic stress disorder (PTSD), depression, anxiety, and substance use disorders. These therapies are at the forefront of what some have called a revolution or renaissance in psychiatry that could replace or, at least, supplement more conventional treatments. Before they do, each step in the structured three-phase process—preparation, dosing, and integration—must be mapped out and rigorously tested.
Given the starring role of psychedelics in PATs, dosing can overshadow the other phases of this holistic process. Psychedelic experiences typically receive superlative-filled descriptions in media portrayals and personal accounts (both positive and negative), but preparation and integration for psychedelic therapy are essential for achieving enduring healing and transformation from the treatments.
Seeing as how psychedelic-assisted therapies will undoubtedly debut to an eager mental health marketplace (there are huge expectations for this science), there's still a chance to make a good first impression for psychedelic treatment protocols and the process as a whole. This goes beyond an effort to transform once-prohibited, highly-misunderstood substances into champions of mental health, it involves integrating psychedelics as multidimensional threads of a novel treatment that reimagines the very fabric of mental health intervention and care. Success may depend upon how well the three phases of these treatments are woven together.
In this context, psychedelic research studies exploring the pathways to successful implementation, including innovative approaches like Digital Intervention for Psychedelic Preparation (DIPP), are not just academic exercises. They are critical blueprints for a future where mental health treatment aligns with the complexity, dignity, and the uniqueness of human experiences. This study reveals something that could directly enhance the accessibility and affordability of PATs through the use of self-directed preparation strategies that are delivered digitally. The authors note that they've taken cues from indigenous cultures—who have a long history of understanding the value of preparation through ceremony and ritual—in an effort to develop a standardized, self-directed preparation intervention that they believe can reduce the likelihood of psychologically distressing effects.
"There is a pressing need for more rigorous evaluation of the various approaches, techniques and frameworks used to prepare participants, as well as research specifically dedicated to developing instruments to optimise this process."
-DIPP Study
The DIPP study was authored by researchers from the Clinical Psychopharmacology Unit, Clinical, Educational and Health Psychology of University College London in London, UK along with one contributor from the Meditation Research Program, Department of Psychiatry, at Massachusetts General Hospital, Harvard Medical School in Boston, and another from the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet in Solna, Sweden. The study was published in February of 2024.
Its "person-centric approach" is broken down into four strategies (as quoted from the study) that are aimed at enhancing and ensuring:
"Knowledge-Expectation - Refers to activities that participants described as undertaking in order to improve their understanding of psychedelic substances and their resultant expectations regarding the potential immediate and long-term effects.
Psychophysical-Readiness - Describes how participants prepared themselves mentally and physically for navigating the complexities of the psychedelic experience.
Intention-Preparation - Involves thoughtful deliberation on the motivations behind the psychedelic use, such as self-exploration, therapeutic purposes, or spiritual growth.
Safety-Planning - Focuses on establishing a trustful connection with those present during the experience, ensuring the safety of the substance, preparing friends and family for potential changes, and making a contingency plan for possible challenging moments during and after the experience."
These strategies were developed through a phased process involving two studies whose data collection efforts focused on psilocybin* retreat participants. The participants were recruited from attendees of retreats in Mexico and the Netherlands.
Study 1—Initial Intervention Development - This qualitative phase, with 19 participants, is built around in-depth interviews designed to identify essential components for psychedelic preparation.
Study 2—Intervention Component Refinement - This phase engages 28 participants in co-design workshops to build from and refine the information learned in Study 1.
*Psilocybin
Definition: Psilocybin is a naturally occurring psychedelic compound produced by certain species of mushrooms, known as "magic mushrooms."
Explanation: When ingested, psilocybin is converted into psilocin, which affects the serotonin receptors in the brain, leading to altered perception, mood, and thought processes. Its effects can include visual and auditory hallucinations, an enhanced sense of connection to the environment and others, and profound changes in consciousness and emotional state.
Example: Researchers study psilocybin for its potential therapeutic benefits in treating conditions like depression, anxiety, and PTSD, where traditional treatments have been ineffective.
Quote: "Psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance." Dr. Roland R. Griffiths
Glossary of Terms, The Psychedelic Blog
The outcome of this process is DIPP, Digital Intervention for Psychedelic Preparation, a co-produced 21-day digital course. A graphic from the study shows a brief of the preparation protocol, along with a description below it, leading to the dosing phase.
Structure and thematic modules of DIPP. The intervention comprises four primary thematic modules: Knowledge-Expectation (KE) from day 1–7, Psychophysical-Readiness (PR) from day 8–14, and Safety-Planning (SP) from day 15–21, with a concurrent Intention-Preparation (IP) module spanning across the entire period. Each week includes a selection of module specific activities. Each day includes guided meditation sessions and a brief daily mood assessment. aAims to deepen participants’ knowledge of psychedelics and their potential effects and outcomes. bAims to equip participants with tools and techniques to optimise mental and physical readiness for the psychedelic experience. cAims to create a secure environment for psilocybin administration and to facilitate effective post-session integration. dAims to guide participants in defining their motivations and setting clear intentions for psychedelic use.
Here's how cell phone delivery of the DIPP modules looks:
I am convinced that our ability to provide care remotely is crucial for the future of mental health, especially for the vast, lower income segments of the world population in need. Studies like this will help develop protocols to do that. Very soon they may help provide the critical lifelines that, like the Jet Skis at Nazaré, have the potential to save lives.
It's my hope that subsequent versions of this study can include a more diverse representation of participants as reflected in the demographic profile where 74% identified as white in Study 1 and 80% in Study 2. (I understand how the locations of the retreats, from which the researchers recruited participants, would have affected demographic diversity.) I would also be interested in knowing something about the mental health profiles of the participants; if they had been diagnosed with specific mental disorders or for what purpose they had sought a psilocybin experience at the retreats.
Finally, if we aim to reach a larger segment of individuals in need of treatment, should (or will) the preparation and integration protocols be tailored for different audiences based on the severity of their situations, the complexity of their needs, and the resources available to them? Just as a clinician is empowered to adjust dosing as deemed appropriate, based on an informed understanding of the patients and their needs, could we also anticipate these needs through nuanced and variable preparation and integration protocols?
Thanks to the authors for their work. This is obviously just a brief overview, but the study is well-written and worth reading. Another researcher at University College London, Germán Andrés Alarcón Garavito, is the subject of a previous blog. Check it out here.
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