Psychedelic experiences in clinical settings | Letters

Although it is refreshing to read a more balanced article on psychedelics (Experts warn of mental health risks after rise in magic mushroom use, 25 December), we must be cautious about accepting the paternalistic notion that the clinical setting is always the most appropriate.

“Set and setting” – one’s mindset and the physical and social environment – are hugely influential on the psychedelic experience, and for some marginalised communities and patient groups, the medical establishment may be associated with difficult or traumatic experiences, and therefore not the ideal setting for taking psychedelics. This is perhaps reflected in the lack of diversity of psychedelic clinical trial participants. Although this is a problem across clinical research as a whole, it is more of a concern for psychedelic trials as the psychedelic experience is very culturally specific.

Furthermore, concerns have been raised about the difficulties of obtaining informed consent for psychedelic experiences in the clinical setting. Positive clinical outcomes for psilocybin-assisted therapy have been linked to generating what is termed a “mystical experience”. One of the core features of a mystical experience is that it is ineffable. If I as a clinician cannot put the experience into words, then how can my patients give informed consent that meets the robust medico-legal standard?

We must also question how much follow-up integration therapy will be offered in resource-driven mental health services, should psilocybin become a licensed treatment. Any model that focuses on preparation and support during the experience, rather than longer-term integration, will leave questions around where patients are to turn should they need additional support following a challenging experience.

It is still not certain that psilocybin will become a licensed psychiatric treatment and, as trials progress, it is important that the above issues with psilocybin in the clinical setting are robustly addressed.
Dr Caroline Hayes
Newcastle-upon-Tyne