The rebirth of psychedelic-assisted therapy (PAP) has been garnering a great deal of attention lately. Not only in medicine and academia but in the media and the public consciousness at large. Many herald this renaissance after decades of legal embargo, but some have expressed a good deal of skepticism and caution. Is it time to move to a relational therapy approach?
A key concern around current PAP is that the field is being dominated by medical and research institutions (e.g., Imperial college London, John Hopkins University). On the one hand, this is to be expected and accepted to the extent that organized, well-funded empirical work is necessary. On the other hand, it creates an approach organized around the shared commitments and ideologies of the medico-scientific establishment.
The result is that almost all of the current research into and discourse around PAP is cast in terms of individualistic, cognition-centric theory. I will call it the “IC-C framework.”
This isn’t just a problem because it is biased toward one particular way of viewing PAP. Much more importantly, it is a problem because such a view, as I will attempt to show, is based on weak, outmoded and problematic foundations.
The Current Model of Mind: The Dominance of the ICC framework
The lion’s share of PAP research is based on the assumptions and language of cognitive psychology and neuroscience. From this standpoint, mental phenomena are best explained in terms of internal cognitive processing and the neurological systems correlated with such processing.
Following this, the literature is almost exclusively focused on cognitive phenomena. And how beliefs, perceptions and thinking patterns etc — may have become problematic and how psychedelics may change those things. One of the leaders of the field, Carharrt-Harris, suggests that PAP is principally concerned with the “de-weighting of a plethora of maladaptive cognitive/ perceptual schemas or ‘sets’ about self, others and the world” (Carhart-Harris and Brouer, 2021).
Social and interpersonal levels of experience and functioning are largely ignored and our embodied-affective involvement in the world and with others is neglected by design.
In line with this, we find cliche mind-as-computer metaphors widely employed, i.e., ‘rebooting’ or ‘resetting’ ‘malfunctioning’ or ‘distorted’ thinking. It is not at all incidental that computers are devoid of social and interpersonal experience and context.
What we are talking about, then, is clearly cognition-centric and thoroughly individualistic. The focus is on the individual and their thinking abstracted from context.
Unsurprisingly the kinds of psychotherapy currently used in PAP are ones that share consonant assumptions and biases. Namely, the Cognitive-Behavioral group of therapies.
Classic CBT is what we might call the master psychotherapeutic theory of a group of therapies that come under the title of CBT (usually expressed in terms of ‘waves’). The core premise of classic CBT is that emotional and psychological suffering principally follows from irrational or erroneous beliefs, attitudes, or other cognitive structures that the person holds.
For CBT, the broad goal of psychotherapy is to effectively correct the errors in such thinking. The therapist’s role is to challenge underlying beliefs and attitudes and/or use behavioral ‘experiments,’ which seek to interrupt the cycles between thinking, feeling and behavior that are believed to cause the emotional suffering involved.
Acceptance and Commitment Therapy (ACT), part of the so-called “third wave” of Cognitive Behavioral Therapies, currently holds sway at the key institutions (e.g., Imperial college and John Hopkins). While ACT and related mindfulness based ‘third-wave’ models do offer a more nuanced and sophisticated set of assumptions about the individual and what effects psychotherapeutic change, the essential problems of the ICC framework nevertheless remain the same.
In all cases, the issue is understood in or with the individual. The solution is deemed to be found in the corrective power of an otherwise un-implicated therapist. The importance of which will become clear below.
Now, while this may sound like just what therapy is, or is supposed to be, this has much more to do with the power and resources behind these kinds of approaches than anything necessary about their assumptions.
Why the individualistic, cognition-centric framework is flawed
These models are speaking the same language because they assume the same philosophical framework. This framework, however, is not something that is scientifically evidenced. In fact, it is not even something founded upon a well-accepted philosophy. On the contrary, it is essentially based on a set of outmoded enlightenment era assumptions, which have not borne out the test of time.
The largely foreign idea that ‘mind’ is separate from others and the world and the exclusive seat of experience and identity principally arose through the philosophy of Descartes and the British empiricists in the 17th & 18th centuries.
While this fundamental philosophy has been largely abandoned outside of psychology and psychiatry, it has persevered in the psy-disciplines (i.e. psychology and psychiatry). This is mainly due to it being highly convenient for doing the kinds of quantitative, empirical research that gains the acceptance and prestige associated with the ‘hard sciences.’ The psy-disciplines have historically been very insecure in this regard, and as a result, all the more ardent in their identifications with such philosophies.
For our purposes here, there is one key, well-established reason that poses irresolvable problems for this framework. This comes from developmental research.
In its psychological incarnation, the ICC framework has been predicated on the assumption that we come into this world as experientially private, internal subjects with little correspondence to the ‘outside world’ and its key others. This model principally derived from Freud and Piaget, both of whom assumed the same 19th century philosophical background.
The notion of psychological development that arose from this starting point was one concerned with connecting internal experience and otherwise unknowable things outside via internal representations, which had to be centralized to explain the linkage. The whole of western academic psychology and psychiatry more or less followed this.
Consequently, psychology became focused on the individual and their internal constructions, rather than what is going on in their world and with others.
Infant research over the past several decades, however, has conclusively shown these assumptions to be false. In fact, it shows the complete opposite of the assumptions of the ICC model to be the case.
We now know that come into this world aware of, and psychologically attuned to, primary others from the very beginning. Infants and caregivers are shown to engage in intimate intersubjective exchange from the very beginning. And it is this, not internal cognitive processes, that form the basis of psychological development (e.g. Beebe & Lachamn, 1993, 2014; Fonagy et al, 2002; Meltzoff & Moore, 1998; Stern, 1978; Stern et al, 1985; Trevarthen and Hubley, 1978; Trevarthen, 1979, 2010; Tronik, 2007)
We are not the isolated subjects we were assumed to be, but social, experientially open beings that are inextricably bound up with the world and primary others from birth.
The implications of this cannot be overestimated. As prominent infant researcher, Trevarthen, wrote in 2010, “the story of human infancy told by philosophers and medical and psychological sciences has been rewritten.” (2010; p.145).
One might legitimately point out that PAP is not doing research or psychotherapy with babies. However, one’s stance on our basic psychological nature is not just about development. It tells us something vital about our core psychological and experiential selves and represents the core of the subsequent psychology, which all further ideas and theory are built around.
In the present context what this means amounts to the following: if we are not first and foremost private individuals but inherently intersubjectively related beings, then psychological and emotional suffering and what ameliorates it is something that happens between people — not inside the brain or individual mind.
This has obvious implications for PAP and, indeed, all psychotherapy.
The shift to relational therapy
You wouldn’t know it based on the PAP literature, but there has been an explosion of ‘relational’ and ‘intersubjective’ theory and practice in psychotherapy and related disciplines over the past few decades. We see it in the resurgence of psychoanalysis in its relational and intersubjective forms. We see it in the focus in existential, humanistic therapies. As well as the feminist and social justice-oriented therapies on the ‘here and now’ of the relationship. And we see it more generally in the central role that attachment research is enjoying across all (non-CBT) psychotherapeutic theory and practice.
Much of this is based in, or informed by, the developmental shift described above. It is also centrally linked to the repeated finding that the ‘therapeutic alliance’ between therapist and client is the best predictor of therapeutic outcome (see: Horvath et al., 2011).
Outside of institutional psychology and psychiatry there has been a decisive shift away from the internal functioning of the mind/brain and toward a focus on interpersonal processes and dynamics.
The sort of disengaged scientist-at-a-distance focus on internal constructions and use of specific techniques (i.e., challenging thinking patterns, behavioral experiments, interpretations etc.) has been supplanted. It is now the ongoing therapeutic relationship that is understood as the key agent of change. Again, you would have no idea about this based on reading the PAP literature.
It is not what the therapist can do for the client in terms of specific interventions. It is ‘who’ they can be for them in the therapeutic relationship that is. The goal is to develop a particular kind of secure, interpersonally rich and authentic experience. It is the therapist’s ongoing capacity for empathic reflection/exploration, interpersonal regulation of affect and emotion, and deliberate, authentic communication that performs the most important role.
Crucially, these are not actions that one does or takes, so much as ways of being with another. And here we meet the key difference: relational therapy is about facilitating a relationship over time. Something that is in stark contrast to the few sessions of cognitive ‘integration’ that current PAP employs based on the ICC model.
Time for Relational PAP?
Interestingly there is reference to related themes in the PAP literature itself. Watts, who uses a form of ACT, for example, reports, “Feedback so far suggests that the aspect of therapy most appreciated by patients is having been sensitively supported by fully present and respectful caregivers. Themes relating to an absence of accurate empathy in early life emerge for many of our patients.” (Watts & Luana, 2020; p.99)
These are interpersonal, relational concerns. We have to ask ourselves why the models employed in PAP are individualistic, cognition-centric ones that downplay and neglect these factors? We also have to ask, how does or even can only a few sessions of ‘integration’ (the norm in these approaches) come close to responding to these issues?
In short, they can’t.
It is also not at all surprising that the ameliorative effects of using current PAP models have been found to be time limited, to around 6 months (Nutt et al., 2020). From a relational perspective, when one returns to habitual relational dynamics, situations and other people with vested interests in things staying the same, a shift in one’s view of oneself is likely to dissolve in the tide. Indeed, we hear anecdotal reports of exactly this.
An individualistic model used over a very short period is simply not suited for sustained change. We need a relational framework.
Something very different is needed, which goes beyond cognitive or behavioral change. To understand what PAP would be within a relational framework, we need to leave behind the idea that it is one’s cognitions that need to change. We also need to leave behind the idea that people are in need of an external source to provide some sort of solution. Along with this — and here’s the catch — we need to leave behind the idea that meaningful, sustained change should occur quickly.
A relational therapy approach would be using the psychedelic experience to facilitate a different, conceivably deeper, kind of relational experience within an already established therapeutic relationship.
It would have to be this way because there is no ‘quick-fix’ from a relational perspective. Indeed, the search for quick solutions is in some important sense exactly what has already not worked for the person.
If we are principally relational beings and what we are trying to address is primarily at the interpersonal, relational level, then the response needs to be in kind. This cannot be contrived into a discrete experience to be ‘integrated,’ no matter how convenient this may be for research purposes, funding or political expediency. Relational speaking, change only happens incrementally, over time.
If psychedelics could increase ‘relational depth,’ then there is reason to think that employing a relationally framed PAP may indeed provide a much more real, sustained improvement than current PAP seems unable to.
Relational Therapy – In Conclusion
Let’s return to the question of why the ICC dominates. It is important to know that ‘relational models’ have in fact been around since the very inception of psychology and psychotherapy.
There has in fact been a consistent strand of this thinking going back to the Freudian era. And through the work of Ferenczi, Sullivan, and Winnicott — to name but the most influential. What’s more, interpersonal models of mind have also been around in philosophy since early and mid-20th century phenomenology (I.e. Heidegger and Merleau-Ponty).
The brute fact is that all of this has been ignored, denied even, by academic and institutional psychology and psychiatry over the decades simply because of the vested ideological interests in cognitive and biomedical thinking that have dominated.
I will close by pointing out that this isn’t just an academic or practical issue. It is in fact a serious ethical one. If what I have said above is true, then the current set-up in PAP not only fails to get to the roots of the matter but actually serves to further distance people from what is actually helpful.
If now is not the time to enforce a change, then when is?
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Meltzoff, A.N. & Moore, M.K (1998). Infant intersubjectivity: Broadening the dialogue to include imitation, identity and intention. In S. Braten. (Ed.),Intersubjective Communication and Emotion in Early Ontogeny, pp. 47-62, Cambridge, UK: Cambridge University Press.
Stern, D., Hofer, L., Haft, W. & Dore, J. (1985): Affect attunement: The sharing of feeling states between mother and infant by means of intermodal fluency. In: T Field & N. Fox (Eds.) Social Perception in Infants. Norwood, N.J.: Ablex.
Trevarthen, C., & Hubley, P. (1978). “Secondary intersubjectivity: Confidence, confiding and acts of meaning in the first year.” In A. Lock (Ed.), Action, Gesture, and Symbol: The Emergence of Language (pp. 183–229). London: Academic Press.
Trevarthen, C. (1979). Communication and cooperation in early infancy: A description of primary intersubjectivity. In M. Bullowa (Ed.), Before Speech: The Beginning of Interpersonal Communication (pp. 321–347). New York: Cambridge University Press.
Trevarthen, C. (2010) The self born in intersubjectivity: The Psychology of an Infant Communicating. In The Perceived Self: Ecological and Interpersonal Sources of Knowledge. Cambridge: Cambridge University Press.
— Originally publsihed on Healing maps March 14th, 2022 here