Reports of Self-Compassion and Affect Regulation in Psilocybin-Assisted Therapy for Alcohol Use Disorder: An Interpretive Phenomenological Analysis

Abstract

Objective:

The primary aim of this qualitative study was to delineate psychological mechanisms of change in this first randomized controlled trial of psilocybin-assisted psychotherapy to treat Alcohol Use Disorder (AUD). Theories regarding psychological processes involved in psychedelic therapy remain underdeveloped.

Method:

Participants (N = 13) mostly identified as non-Hispanic and White, with approximately equal proportions of cisgender men and women. Participants engaged in semi-structured interviews about their subjective experiences in the study. Questions probed the nature of participants’ drinking before and after the study and coping patterns in response to strong emotions, stress, and cravings for alcohol. Verbatim transcripts were coded using Dedoose software, and content was analyzed with interpretive phenomenological analysis.

Results:

Participants reported that the psilocybin treatment helped them process emotions related to painful past events and helped promote states of self-compassion, self-awareness, and feelings of interconnectedness. The acute states during the psilocybin sessions were described as laying the foundation for developing more self-compassionate regulation of negative affect. Participants also described newfound feelings of belonging and an improved quality of relationships following the treatment.

Conclusion:

Our results support the assertion that psilocybin increases the malleability of self-related processing, and diminishes shame-based and self-critical thought patterns while improving affect regulation and alcohol cravings. These findings suggest that psychosocial treatments that integrate self-compassion training with psychedelic therapy may serve as a useful tool for enhancing psychological outcomes in the treatment of AUD.

Alcohol use disorder (AUD) is among the most prevalent mental health disorders in the United States (U.S.) and is one of most disabling diseases worldwide (Rehm et al., 2009). Nearly one-third of the U.S. population meets AUD criteria on a lifetime basis (Grant et al., 2015), however, only one-fifth of individuals ever seek treatment (Grant et al., 2015). Additionally, while there are several evidence-based Food and Drug Administration treatment options for addiction, they generally fail to produce long-term sustainable changes and tend to yield high relapse rates (Anton et al., 2006; Chikritzhs & Livingston, 2021; Dutra et al., 2008; Sacks et al., 2010; World Health Organization, 2018).

Research into the use of classic psychedelics in addiction treatment has reemerged in recent years as a potential strategy for improving treatment outcomes. A meta-analysis of several randomized controlled trials (RCTs) from the first wave of psychedelic research that employed the classic psychedelic lysergic diethylamide (i.e., LSD) for treatment of AUD demonstrated a medium effect size compared with controls (Krebs & Johansen, 2012). Additionally, recent pilot uncontrolled trials with psilocybin suggest that psilocybin has the potential to promote positive and enduring psychological and behavioral outcomes in the treatment of alcohol and tobacco cessation with large within-group effect sizes (Bogenschutz et al., 2015, Johnson et al., 2014). Several observational studies have also documented reductions in alcohol and drug use following naturalistic psychedelic use outside of treatment settings (Agin-Liebes et al., 2021; Doering-Silveira et al., 2005; Fábregas et al., 2010; Garcia-Romeu et al., 2019; Halpern et al., 2008).

The findings of two recent studies with psilocybin provide preliminary support for the safety and efficacy of psilocybin-assisted therapy for AUD treatment. In a small open-label proof-of-concept study conducted by Bogenschutz and colleagues (2015) (N = 10), both the percent of drinking days and percent of heavy drinking days decreased significantly immediately after psilocybin administration, and improvements were largely maintained at the 6-month follow-up point (Bogenschutz et al., 2015). These promising initial results motivated a larger double-blind RCT that was carried out to investigate efficacy and mechanisms more rigorously, and which represents the largest placebo-controlled study of a classic psychedelic in the treatment of an alcohol and substance use disorder (ASUD) (Bogenschutz et al., 2022). In this primary study (hereafter referred to as the “parent study”), treatment-seeking individuals (N = 95, with 93 included in final analysis) with a diagnosis of AUD were offered a 3-month course of manualized psychotherapy and randomly assigned to receive two administrations of psilocybin or an active placebo (diphenhydramine). In the psilocybin group, the percentage of heavy drinking days (the prespecified primary outcome) and average daily alcohol consumption were found to be significantly lower compared with these outcomes in the placebo group during the 36 weeks of follow-up. Percentage of heavy drinking days among participants in psilocybin group was 41% of that observed in the placebo group. There were no serious adverse events among participants who received psilocybin (Bogenschutz et al., 2022).

Psychedelic therapy consists of a complex interaction of pharmacological and psychological processes. Classic psychedelics exert their effects at the serotonin-2A receptor and activate signaling pathways that lead to increased synthesis of proteins supportive of neuroplasticity and may lead to increased entropic processing (Dourron et al., 2022; Inserra et al., 2022). These states are also typically characterized by changes in perception, altered experience of time and space, and strong activation of emotions and a sense of unity, sacredness, and positive mood (Preller & Vollenweider, 2016). The acute subjective effects of psilocybin typically persist for 4–6 hours. Psilocybin, compared to other psychoactive substances, presents low levels of toxicity and low addiction potential (Nichols, 2016). However, transient increases in blood pressure and heart rate have been documented during psilocybin sessions as well as transient headaches after the acute effects have subsided that typically last no more than a day following psilocybin administration (Bogenschutz et al., 2022; Johnson et al., 2019).

Despite several proposed mechanisms delineated in the literature, theories regarding psychological processes involved in psychedelic therapy remain underdeveloped. Psychedelic-assisted psychotherapy is believed to spur “quantum,” or transformational, change—change that is sudden, intense, and persistent (e.g., Griffiths et al., 2018). Quantum change as a pathway of healing has formed the basis of historically important abstinence-based and spiritual models of alcohol recovery (Miller, 2004). Quantum change experiences commonly involve a heightened clarity about one’s values and priorities and a sense of meaning. Additionally, several studies have evaluated the impact of psychedelics on self-compassion, mindfulness‐related capacities (e.g., acceptance, non-reactivity), and emotion regulation. Preliminary evidence suggests that psychedelics enhance these capacities (Agin-Liebes, 2019; Bogenschutz et al., 2018; Domínguez‐Clavé et al., 2019; Franquesa et al., 2018; Gasser et al., 2015; Malone et al., 2018; Ruffell et al., 2021; Sampedro et al., 2017; Walsh et al., 2018). These psychological outcomes can be likened to those seen after mindfulness and self-compassion training (Chiesa et al., 2014; Neff, 2003). Self-compassion is particularly relevant to clinical populations as it involves mindful awareness of one’s emotions so that distressing feelings are not avoided but rather accepted with gentleness, which allows for adaptive processing of negative emotions (Neff, 2003). Moreover, phenomenological reports suggest that acute experiences of connectedness and awe may overshadow feelings of disconnectedness that characterize addiction (Hendricks, 2018; Noorani et al., 2018). Self-compassion and feelings of connectedness can help individuals cope with difficult emotions and stress by encouraging adaptive coping responses. These capacities appear to play an important role in the recovery from disorders characterized by rumination and emotional avoidance, such as ASUD, depression, and anxiety disorders (Jazaieriet al., 2014; Leary et al., 2007; Phelps et al., 2018).

The primary aim of this qualitative study was to characterize the psychological mechanisms of change attributed to a structured psilocybin-facilitated treatment for AUD. Narrative accounts from participants can complement quantitative data to provide richer understandings of change processes. As clinical research with psychedelics is still in its early stages, these accounts can energize new directions of inquiry in the emerging field of psychedelic research and psychotherapy for AUD.

Method

The parent study was a double-blind controlled trial that randomly administered psilocybin (25 mg/70 kg) or diphenhydramine (50 mg) to participants in two 8-hour medication sessions separated by one month. The dose for the second session was titrated according to the response in the first session (i.e., increased up to 40 mg/70 kg of psilocybin and up to 100mg of diphenhydramine or held at the same dose administered on the first session). Following completion of the double-blind phase of the protocol (at week 36, 32 weeks after randomization) all participants who met safety criteria were offered an additional open-label medication session in which psilocybin was administered. The behavioral intervention program, described in detail in a separate publication (Bogenschutz & Forcehimes, 2016), included motivational interviewing and cognitive behavioral therapy, with the addition of standardized preparation before each medication session as well as debriefing and follow-up after the medication sessions. Participants who had been randomly assigned to the control condition received two double-blinded sessions with diphenhydramine and were subsequently offered one session of psilocybin during the open-label portion of the study (at week 36), while those in the active psilocybin condition received two double- blinded sessions of psilocybin and then offered an additional session with psilocybin during the open-label portion (at week 36).

Eligibility criteria for the parent study included being ≥25 years old, meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR) criteria for alcohol dependence with a desire to stop or decrease drinking, not participating in any formal treatment (e.g., 12-step). Exclusion criteria included medical conditions that would preclude safe participation in the trial (e.g., seizure disorder, significantly impaired liver function, coronary artery disease, heart failure, uncontrolled hypertension) and psychiatric conditions that would preclude safe participation (schizophrenia, schizoaffective disorder, bipolar disorder, current major depressive episode, current post-traumatic stress disorder, current suicidality, or history of medically serious suicide attempt, as well as any other current substance dependence in the past 12 months). Full details of the parent study design, study criteria, and methods can be found in Bogenschutz and colleagues’ (2022) report. Participants were eligible for this qualitative study if they had completed two double-blind drug administration sessions and an open-label session within 18 months, agreed to be contacted for future research when they consented to participate in the parent study, and consented to the release of quantitative data from the parent study for analysis in the qualitative study.

Participants who had completed the parent study (NCT02061293) were contacted by email or telephone and invited to participate in this optional supplementary qualitative study. The timing of the interviews ranged from two to 18 months following participants’ third medication session (i.e., open-label psilocybin session at week 38). We selected a subsample of 13 participants from the parent study for inclusion in this qualitative study based on the date of their final drug administration session. We approached the 14 participants who had most recently completed drug administration sessions (no more than 18 months since their final drug administration session). Of these 14 individuals, 13 agreed to participate in the qualitative study. One participant declined to participate due to scheduling conflicts. All participants in this qualitative study participated in the open-label portion of the study and received three total medication sessions. Included in this qualitative study were six participants who had been randomized to the psilocybin condition (i.e., received two sessions with psilocybin during the double-blind phase and one session with psilocybin during the open-label phase of the study), and seven participants who were randomized to the diphenhydramine control condition (i.e., received two sessions with diphenhydramine during the double-blind phase and one session with psilocybin during the open-label phase).

The qualitative interview guide included several questions about participants’ subjective experiences of the study treatment (see Supplementary Materials for full interview guide). We sought to establish a point of contrast between participants’ pre-study subjective distress and subjective improvements following the treatment. Questions probed participants’ previous and current drinking habits, overall study treatment experiences, experiences of the preparation, debriefing and medication sessions and their therapist teams, coping patterns in response to strong emotions, and mechanisms hypothesized to play a role in drinking reduction outcomes. Additional questions focused on stigma related to their experience of AUD and their participation in an intervention involving a psychedelic substance. Themes related to stigma were not included in the current analysis and will be analyzed in a separate forthcoming report. Two members of the team (EMN and UA) conducted interviews with all 13 participants. This qualitative study was approved by the New York Langone Health Institutional Review Board.

Analysis

We coded all transcripts within Dedoose (2016), a qualitative data analysis software program (SocioCultural Research Consultants, 2016). Dedoose’s interrater reliability testing feature assessed interrater agreement using Cohen’s kappa (κ) coefficient. Final coding began when the pooled (κ) across coders was > 80, indicating consistent code application by all coders and strong level of agreement. Each transcript was reviewed by at least two study members to ensure adequate application of codes. The coding team (GAL, AH, MZ, and KK) met regularly to discuss emergent themes and to ensure continuity of coding.

We analyzed content using interpretive phenomenological analysis (IPA; Smith et al., 2009). In the IPA method, it is generally recommended that sample sizes be restricted to 15 or fewer participants to enable a fine-grained reading of participants’ accounts (Smith et al., 2009). In contrast with other qualitative approaches (e.g., thematic analysis), IPA focuses on understanding the unique characteristics of individuals while also elucidating patterns of meaning across participants. We did not seek out an objective reality; rather, we sought to uncover the lived experiences of these individuals through collaborative inquiry. However, as researchers, we recognize that our interpretations of phenomenological themes were shaped by our personal, cultural, and historical backgrounds and as such believe it is important disclose our positionality and philosophical assumptions. The members of the analysis team (GAL, MZ, KK, AH) all shared a social constructivist value system, identifying with the worldview that individuals develop subjective meanings from the environments in which they live, work, and interact with others (Moustakas, 1994). At the time of the analysis, all members of the analysis team were licensed mental health clinicians (one masters level and three doctoral level therapists). They all identified as trauma-informed and psychodynamic practitioners with a theoretical foundation in attachment theory and had received clinical supervision from supervisors who identified with this theoretical orientation. The analysis team (GAL, MZ, KK, AH) had also received training in psychedelic facilitation, but they did not serve as therapists in the parent study. Additionally, the lead author, a licensed clinical psychologist, had undertaken several years of clinical training in the treatment of alcohol and substance use disorders prior to the study analysis. These positionalities undoubtedly influenced participant reports and the interpretation of these reports, and we cannot assume that our findings would be replicated in teams with different positionalities.

Results

Participants’ demographic characteristics are presented in Table 1. Eligible participants in this qualitative study were between the ages of 28 and 63 at screening. Most individuals identified as non-Hispanic and White, and there were approximately equal proportions of cisgender male and female participants. Compared with the larger parent study sample, there was a greater proportion of White participants in this qualitative study (92% compared with 75% in the parent study). Additionally, the 13 participants in this qualitative study reported higher median income ($145,000 compared with $100,000 in the parent study). The mean age of participants was 48 years old (standard deviation (SD)=11.9 years), and the average age of onset of alcohol abuse was 33 years old. At screening, approximately equal proportions of participants endorsed criteria for mild versus moderate-to-severe alcohol dependence, and participants on average reported having consumed drinks on 81% of all days in the past month. At screening, the 13 participants in this qualitative study were roughly equivalent in severity of drinking related characteristics, however, there were no participants in the qualitative study who met criteria for the “Very high” World Health Organization (WHO) drinking level definition risk category (World Health Organization, 2000) compared with 30% in the parent study sample. Lastly, nearly two-thirds of the qualitative study participants reported at least one first-degree relative with a history of alcohol problems. It is also worth noting that five participants (38%) in this qualitative study reported during their interviews that they had read Michael Pollan’s (2018) book “How to Change Your Mind,” which has substantially popularized psychedelic therapy in the mainstream media. Additionally, several study participants reported, anecdotally, to study staff and therapists that they had viewed media coverage on psychedelics or read Michael Pollan’s book and voiced their desire to contribute to psychedelic science.

Table 1.

Participant Characteristics

	Mean (SD) or %	Range
No.	13
Demographic characteristics
Age (years)	48.1 (11.9)	28–63
Household income, median (range), $	145,000	60,000–500,000
Sex, No. (%)
Female	6 (46.2)
Male	7 (53.8)
Race, No. (%)a
Hispanic or Latinx	1 (8%)
Black	1 (8%)
White	11 (85%)
Ethnicity, No. (%)
Hispanic or Latinx	1 (8%)
Not Hispanic or Latinx	12 (92%)
Drinking-related characteristics
% Drinking days	81 (22.0)	37–100
% Heavy drinking days	53 (27.3)	16–99
Drinks per day	5.4 (2.5)	2.3–10.9
Drinks per drinking day	7.4 (5.3)	2.7–24.0
No. of dependence criteriab	5.5 (1.0)	4–7
Age of onset, years	33.4 (10.1)	18–50
Years dependent	14.7 (9.1)	2–30
Short Index of Problems (total score)	18.5 (6.9)	4–29
WHO risk category, No. (%)c
High	5 (38%)
Moderate	6 (46%)
Low	2 (16%)
Family History of Alcohol Problems
None	39%
1x first-degree relatives (mother or father)	54%
2x first-degree relatives (mother and father)	8%

Abbreviation: WHO, World Health Organization.

^aRace and ethnicity were determined by participant self-report according to standard National Institutes of Health categories to assess the representativeness of the sample.

^bDefined using the Structured Clinical Interview for DSM-IV axis I disorders.

^cWHO risk categories are defined as follows. Abstinence was defined as no risk (level 0), following a recent study evaluating the use of WHO risk levels as a treatment outcome. For men, low risk (level 1) is defined as >0 g/d to ≤40 g/d; moderate risk (level 2) as >40 g/d to ≤60 g/d; high risk (level 3) as >60 g/d to ≤100 g/d; and very high risk (level 4) as >100 g/d. For women, low risk (level 1) is defined as >0 g/d to ≤20 g/d; moderate risk (level 2) as >20 g/d to ≤40 g/d; high risk (level 3) as >40 g/d to ≤60 g/d; and very high risk (level 4) as >60 g/d. Change in WHO risk level was calculated in relation to drinking during the 12 weeks prior to screening.

Drinking outcomes reported by the participants in this qualitative study at screening, week 4 (immediately prior to the first study medication session) and at follow-up (after the two double-blind drug administration sessions) were roughly equivalent to those reported among the larger parent study sample. At the open-label time point at week 38 (the last time point at which quantitative drinking outcomes were collected prior to their enrollment in the qualitative study) participants reported on average 4.5 – 7.6% of heavy drinking days (compared with 55.8 – 57.9% at screening), 18.6 – 19% of drinking days (compared with 77 – 84.4% at screening), and 0.5 – 0.9 drinks per day (compared with 4.9 – 5.9 drinks at screening) over the prior month. (See Table 2 for further details regarding average drinking outcomes by group and Supplementary Materials Table 1 for individual drinking outcomes data.)

Table 2.

Drinking Outcomes

	Mean (SD)
	Diphenhydramine (n = 7)	Psilocybin (n = 6)
% of Heavy drinking days
Screening	55.80 (28.40)	57.93 (34.92)
Week 4a	23.57 (20.29)	22.64 (14.05)
Follow-up b	16.46 (28.88)	6.67 (9.52)
Open-label c	7.61 (9.61)	4.46 (10.09)
% of Drinking days
Screening	77.00 (24.26)	84.42 (20.56)
Week 4 a	35.20 (19.52)	59.52 (19.52)
Follow-up b	28.23 (31.58)	23.23 (23.46)
Open-label c	18.97 (19.27)	18.61 (24.15)
Drinks per day
Screening	4.92 (2.00)	5.91 (3.11)
Week 4 a	1.99 (1.80)	2.32 (0.68)
Follow-up b	1.93 (2.76)	0.74 (0.70)
Open-label c	0.86 (0.94)	0.50 (0.72)

^aRepresents the 4 weeks prior to administration of study medication.

^bRepresents the 32-week double-blind follow-up period.

^cRepresents the open-label period.

We organized thematic findings into temporal categories consisting of ‘before’, ‘during’ and ‘after’ psilocybin treatment to describe psychological processes of change attributed to the psilocybin treatment over time (see Table 3). Participants reported that the psilocybin treatment helped stimulate self-awareness, self-compassion, and feelings of connectedness and belonging. The psilocybin sessions were described as laying the foundation or “template” for the development of adaptive affect regulation in the face of future stressors and cravings, as well as prompting improvements in participants’ interpersonal relationships with close others. These themes are discussed in further detail below.

Table 3.

Qualitative Themes

	Before Psilocybin	During Psilocybin	After Psilocybin
Self-Awareness	Autopilot and avoidance (13)	Spacious awareness and emotional catharsis (11)	Mindful in the face of stress (10)
Intrapersonal	Shame and self-criticism (12)	Self-compassion template (9)	Coping with self-compassion (9)
Interpersonal	Alcohol as surrogate for connection (8)	Interconnectedness (8)	Connection, compassion and belonging (7)

Note: Numbers in parentheses refer to how many participants reported the specific theme during their semi-structured interviews.

Self-medication with alcohol.

Autopilot and emotional avoidance.

A consistent theme to emerge from the interviews was that participants had used destructive coping strategies throughout their childhoods and into their adult lives to manage uncomfortable affects. Alcohol had initially provided participants with an effective tool for managing and reducing distressing feelings and social anxiety. For example, one participant noted, “I used to go into this zombie mode, like drinking or smoking pot or eating” (1013). Another participant noted, “It relaxes you, cheers you up, does a number of things that seem like they’re benefitting you. Anxieties or concerns you might have had, just after a few drinks, seem to melt away somehow” (1010). Two participants also explained that alcohol was effective at self-soothing and self-medicating, such as one participant who stated, “It was an easy soothing mechanism” (1011) and another who conveyed, “I was just medically soothing myself” (1012). One participant reported: “I started to use alcohol as a way to offset social anxiety and to manage stress that I was feeling over financial issues and work pressures” (1007). One participant described a 35-yearlong cycle of drinking: “I was having a lot of depression, and I knew alcohol helped me temporarily, but I knew it wasn’t the answer” (1008).

Despite the short-term benefits of alcohol in relieving psychological distress, participants noted that it also negatively impacted how they related to their emotions and undermined self-understanding, self-awareness, and the processing of painful emotions. “I was deeply covering up a lot of emotional traumas, which was not allowing me to see clearly,” stated one participant (1003). For many, these negative emotional states precipitated their alcohol use, and they struggled to identify and label their emotions. For example, one participant noted:

I never really evolved an emotional vocabulary because I didn’t really need to. When I was upset, I would have a drink. When I was happy, I would have a drink. It never occurred to me that I needed to face my emotions, I needed to face my challenges. (1009)

Another reported, “I would’ve responded to any challenge by drinking. Sadness, anger, boredom, frustration, fear, pretty much anything. My answer would’ve been to drink” (1002). Another participant noted, “It had become an oppressive presence in my life” (1011).

Shame and self-criticism.

Nearly all participants (12) reported ruminative inner dialogues consisting of excessive self-blame, shame, guilt, and resentment toward close people in their lives. Participants described “intrusive destructive thoughts” (1011) and “ruminative thoughts about family” (1011). Several participants reported that they had adopted or internalized the inner critic of their parents or caregivers and had come to believe that their own feelings were invalid. This pattern of negative thoughts and feelings formed core negative self-appraisals of being unworthy and inadequate. “I was stuck in some deep childhood patterns” noted one participant (1011).

The drinking shut off the voices in [my] head. I would often get all these negative voices in my head and downward spiral, and then feel even more depressed. The drinking always helped all that stuff go away, whether it was dad’s voice or my mother’s voice that I had my whole life and the constant self-criticism. (1004)

One participant noted, “My inner voice… how I treated myself. I was really, extremely hard on myself” (1004). Another participant explained: “That voice has always been there, that wants to undercut every bit of progress or growth that I make” (1010). Another participant shared the following reflection: “The drinking was more of a symptom of a set of issues that the drinking was around, like childhood trauma and neglect” (1003).

Alcohol as surrogate for connection.

Most participants (8) indicated that alcohol inhibited a sense of connection with self and others as well as meaning and belonging. “I felt so disconnected from everything, disconnected to other people, disconnected to nature, disconnected to the universe…It was an anesthetic crutch,” noted one participant (1001). Six participants reported that one or more of their caregivers had also struggled with alcohol misuse and noted that the modeling of these coping strategies laid the foundation for their own self-medication with alcohol. “I think I unconsciously reverted to what I knew as a child, what I’d observed my father rely on to manage his stress and his difficulties,” reflected one participant (1007).

Some participants indicated that alcohol consumption served to regulate the distressing emotions associated with feelings of social anxiety or social isolation. “Ninety percent of the social interactions I had were all alcohol related. I started drinking so young that my emotional maturity was about the same as a 15-year-old” stated one participant (1009). Another noted: “I loved to get drunk because then the world was okay. Everything was okay… but it was like a barrier between me and everything. Like all those connections that I thought I made back then, it was all like a kind of phony” (1004). Two participants likened alcohol to a trusted companion: “It was sort of a good friend. It was always there” (1009). Another noted:

[Alcohol] was a friend that helped me, but then I got to see that it’s not really the friend that I thought. It provides like an hour of relief and then there’s 23 hours of recovery, and that’s not worth it. So, this friend is really, it’s not a friend anymore. (1008)

Psilocybin promotes self-awareness.

Spacious awareness and emotional catharsis.

Most participants (11) reported that the psilocybin sessions elicited an intense range of emotions that had been suppressed for long periods of time. Participants described experiences of “catharsis” (1002 and 1007) and “emotional rollercoaster[s]” (1008). Another stated, “I think I was getting anger and emotions out that I was keeping in. I think the medication–it was letting out all the pain I wasn’t able to let out…I realized I have to let out these feelings” (1012). Nearly all participants reported that the psilocybin experience afforded them a mental spaciousness in which they could feel, process, and release feelings, such as shame, that had been repressed. Other participants noted experiencing a mental clarity in which they could perceive the “bigger picture” (1006) and a “grander vision, in a grander view” (1008).

Several participants specifically commented on how psilocybin helped them to process and release emotional pain that had been bound up with their alcohol use. One participant explained: “It takes all the barriers down…and what is laid bare to see if you’re willing to see it and heal it is available. All the barriers and the denials and all the conditioning” (1008). “It was really unpleasant, but I needed to process [difficult emotions] in order to help me live without drinking” (1002). One participant experienced “a really deep well of potential meaning and insight” (1005). “It’s like you get to visit a place where things become apparent,” explained another participant (1001). One participant noted: “I sort of saw all of my behavior in life and all my past experiences and all the people, the players, the characters—I saw it all, sort of as a classical musical piece” (1006). Another reported:

The psilocybin freed up the things that were going on inside of me that made me want to drink, that made me not want to confront my life, what was going on in my life. The psilocybin opened the door so I could get into spaces and see what was going on and do something about it. The fear, anxiety, and other negative emotions that were bound up with my drinking were dissolved by the psilocybin. (1001)

Participants noted that psilocybin helped them develop self-awareness and new understandings about their alcohol use and coping patterns. One participant reported, “It loosened self-destructive patterns and provided a deeper understanding of my life” (1010). “It was like a deep routing, you know like a roto-rooter kind of routing, which needed to be done. I had so much repressed stuff” reported another participant (1008). Another noted: “It was really stepping out of my childhood dynamic into conscious ways of living as an adult” (1007). “I got a very clear understanding that alcohol actually does not do what I want it to do,” noted another participant (1008).

Participants emphasized the importance of the presence of their study therapists and the containment of the study in their therapeutic processes. They explained that their therapy teams were essential elements in facilitating the psychological safety needed to examine and resolve psychological stuck points, as articulated by one participant: “[My therapists] made it possible for me to just always keep moving through the experience. It was just so much security” (1007).

A self-compassion template.

During the psilocybin experience 12 participants reported accessing feelings of security and comfort, which were reinforced by the safety, trust, and rapport they had established with their study therapists. Participants also described experiencing a reprieve from shame and self-criticism as they experienced states of mental spaciousness and connectedness. Another noted that psilocybin helped her separate the harsh, internalized voices from their authentic self-compassionate voices: “Psilocybin gave me the ability to, in a sense, separate out different strains or different voices and identify my voice,” (1007). Several participants (5) also described viewing their loved ones in a new perspective, and these insights allowed them to shift into more expansive feelings of gratitude, love, and forgiveness of self and others. Two participants described:

I said to myself, ‘You’re doing the right thing and just let it be, let it be a bit more easy, like don’t be so hard on yourself … There was a lot of self-judgment…so I was finally able to see that from a place of more compassion and from somebody else’s viewpoint that wasn’t entirely my own – seeing how really hard I could be on myself and that that was a lens or perspective that I had some control over. (1005)

I was just able to have compassion for everything I’ve ever done, even the less than savory choices, it all just made sense in a bigger way. (1006)

One participant recounted accessing states of compassion and self-compassion in relation specifically to her alcohol use: “I had such a tenderness for [my alcohol use]. I realized it was a tool that I picked as a very young person, to protect myself and I really appreciated it” (1008). Another reflected on how the self-compassion she experienced during one of her psilocybin sessions helped her to process and release intergenerational pain:

I had this vision of my father as a little boy, as a child. His whole progression of his life, and his abuse and suffering. [He] started to get this web wrapped around him, and as he walked through life the web wrapped him more and more until he was an old man…I knew that the web was alcohol. The alcohol locked in his problems and suffering, and he lost himself, some of his humanity as a result. And then I had a vision of myself at around 40 walking through the different phases of my life and starting to get the web [of alcohol] wrapping around me. Then I saw myself over the period of the study shaking the web off and sort of reshaping into myself again. When I saw my father, I felt so much compassion. I felt so deeply for him, and I was so touched. And then to see myself in that context - I have a lot of compassion for where I was and the struggles I was dealing with. (1007)

It helped me, oh my god, in opening an awareness of how I treat myself. That really was the gist of a lot of stuff because when it finally flipped, I said, ‘It’s not so dark in here.’ Oh my god it is so absurd the way I treat myself like a piece of shit all the time…The psilocybin brought up that inner critic inner voice, ‘Why am I beating myself up? Why is everything so dark when it doesn’t have to be?’ It’s, like, I’m my own worst enemy. I’m making everything dark myself. (1004)

Participants also described relating to their cravings and urges for alcohol from a place of gentleness and compassion:

I saw myself opening the fridge and wanting a beer. It was a vision, a thought, and I saw that the wanting, the needing, the craving felt like this little weasel-y animal that was like scrabbling and needing and desperate. I remember taking this little animal that I was seeing in my mind and calming it. I pet it, and I calmed it down, and I just pet this weird little alcohol weasel and was able to just calm it down and treat it lovingly. (1002)

Interconnectedness.

Eight participants described a deepening of spiritual insights and understandings during the psilocybin sessions. Participants described a profound sense of spiritual connectedness, which was imbued with a heightened clarity and self-awareness as well as experiences of ‘higher selves’ and realities. For example, one participant stated, “It was like the highest level of reality” (1007). Others reported:

It’s made me feel not only more connected to other people and earth, but it makes me feel connected to the deeper, spiritual fruits of existence…a deeper interconnectedness that would not have even occurred to me to consider before the study. From that deeper perspective, it alters the weight and the mindset of how I perceive the world – to be able to pull back and have more of an overview of what’s happening. (1007)

I saw that we were really interconnected, all one. The human race is all one on some kind of a level, and I had known these things intellectually…but I had, like, a true feeling…It was a knowing, not something I just knew in my brain. I really got this strong sense of what that means, that we’re really just one, and I can carry that through into my normal living world. (1008)

I experienced a tremendous elevation of being connected to some source of beauty, love…it was just being filled with a sense of everything all right, a liberation from normal consciousness where you feel like you’re in contact with something certainly beyond your personality. A feeling of being liberated into the space that was so loving… I was perfectly at peace. (1010)

Some participants noted that this spiritual framework helped them reframe their relationship with alcohol and with painful memories. For example, one participants expressed:

I wasn’t even really having thoughts. I was just in a state of connection… I remember sort of going back to before I was born…I kind of felt like I chose this human body in order to carry out the work that I came here to do in this lifetime—I just saw it all as being perfectly orchestrated, even the alcohol, as being part of it. …it can be really dense in our brains. I think we need these substances to help us remember our place in the world and just our place in the cosmos. (1006)

A couple of participants noted that these spiritual insights ushered in feelings of psychological comfort and belonging. One participant noted: “The understanding that one is left with about what one really is and what one’s place is in the world is beyond words. It’s a complete reset of what life is—of what your life is” (1001). Another participant reported:

I had this beautiful vision of a harp and the strings at the bottom were the past, and the strings at the top were the future and the ones in the middle were the “now” and so it didn’t matter which path or possibility or action you took, the future was open to me… it was a comforting feeling, like, I’m on the right path no matter what I choose to do, that I’m always doing the right thing. Some kind of universal power or life force was revealed to me, the most important of which is that it is endlessly loving, it’s full of love. It’s just unbelievable how full of love it is and completely benevolent and completely accepting and completely non-judgmental. I did not know it before… It set me on a new path of life and a new way of being…To live in a way that acknowledges this presence…I take a moment every night before bed to remember what I saw, to try to be more present and to stop and be aware of the magic that’s all around me… It helped completely change my relationship to alcohol. (1002)

Affect regulation post-psilocybin.

Mindfully present in the face of stress.

After their psilocybin sessions, participants reported developing more mindful ways of responding to stress, strong emotions, and life challenges. Participants commented on their capacity to mentally disentangle from overwhelming thoughts and feelings, which would have previously driven them to drink, and to reconnect with the spacious awareness they had accessed during their psilocybin sessions. “I was able to get that feeling in the session, so that was a template, and I can use that as a template to help myself in this present moment,” noted one participant (1008). Other participants similarly noted, “I try to be patient and understanding and tolerant of negative emotion” (1010), and “I’m more able to manage emotions or tough emotions. I would say I feel more balanced” (1007). Another participant explained: “I just accept that sometimes I’ll have feelings of shame or guilt and let the emotion be there but not let it dictate how I react to it. I acknowledge that I’m feeling them and try not to shut them out” (1005).

For many participants, their appraisals of challenging situations previously regarded as threatening shifted as they built skills for managing difficult emotions. Their attitudes regarding the perceived benefits of alcohol were also updated in this context:

I can contextualize what’s happening much more easily, even if I get caught in something emotionally, I can pull back and look at the big picture, try to tone down the reactivity that may come up. I’m also very aware when I get the feeling like I can’t tolerate the situation. I’m very aware that that’s coming up, and what I would have done in the past with using alcohol, that I now use other tools to manage it, and the awareness that the experience will pass…patience. (1007)

I would’ve responded to any challenge by drinking, sadness, anger, boredom, frustration, fear, pretty much anything. My answer would’ve been to drink. So, in that regard, it’s changed my reactions completely because that is no longer how I respond to strong emotions. Now I just try to process things in a healthier way. I’m trying to be more patient, trying to be calmer, trying to be more loving, trying to be more accepting.” (1002)

Alcohol is not a particularly useful tool for what I was wanting it to do… I don’t have the deep craving that I used to have. My relationship has completely changed….It’s like you broke up, you know? You see it for what it is. I remember feeling some grief, like, ‘Oh my gosh I’m losing this friend that helped me.’ But then I got to see that it’s not really the friend that I thought. It can actually get in the way of real relationships. (1008)

Some participants noted a newfound wisdom and harnessing of courage to face life challenges. “I roll my sleeves up and say, okay, I’m heading in. I’m heading in. I’m going to feel it. It’s not going to kill me. I have way more willingness to do that because I know I can,” stated one participant (1008). Others reported:

I have strategies to deal with the stress now that I didn’t have before. I have, almost like, a slowness in looking at situations, like, what’s the real issue here? Whereas before I might not have had the perception to be like, what’s actually happening versus what’s my emotional reaction to what’s happening here? So, I can actually respond to the situation to get me to where I need to go. (1003)

[I have] more confidence in facing difficulty…It’s definitely helped with a greater perspective of just feeling like everything is going to be okay…It hasn’t turned me into an optimist or anything, but I think it’s alleviated a lot of my tendency to slip into a more depressive state. (1005)

Coping with self-compassion.

The narratives recounted multiple instances in which participants incorporated insights regarding self-compassion and self-love from the psilocybin sessions to create meaningful changes in their lives. One participant stated, “I’ve learned to love myself the ways others love me” (1008). Participants also developed self-soothing abilities such that emotions were regulated simultaneously as they were generated. One participant stated: “Being compassionate with myself makes a big difference in terms of being able to accept what is happening in the moment and giving myself more freedom to process emotions and let them pass through, rather than holding on or getting trapped in them” (1007). Another participant reflected on his ability to regulate feelings of shame:

I would say that shame feels much smaller. It doesn’t obliterate my sense of self. I can contextualize it as a momentary, short-term emotion that’s going to go away, and then I don’t have to be identified with it–that it’s not a character trait, I would say. Just a human feeling that’s passing through. (1001)

Another participant reported:

I have compassion for the dense person who thinks alcohol is going to help her. I gained compassion for the whole process really, and that’s something that’s really carried over… Even if I feel like, ‘Oh, I shouldn’t have drunk that much,’ it’s, like, ‘It’s okay.’ I trust the process more. (1006)

Several participants (8) also reported considerable qualitative reductions in cravings and alcohol use following their psilocybin sessions. However, some participants noted that the cravings for alcohol did not disappear after their sessions, as one participant explained that the psilocybin was not a “magic pill” (1008). Another participant noted: “I started drinking again, and I ran very quickly back up and that was all triggered by work…I got back to my usual routine and fell back to drinking” (1001). This participant explained, however, that after his third medication session he harnessed new motivation and developed skills for coping with pervasive feelings of shame. This, in turn, helped diminish his cravings: “I don’t find myself prey to react to emotions like shame, guilt, humiliation, and since the last session I haven’t had any cravings at all, nor have I touched any alcohol. They disappeared” (1001).

Connection, compassion, and belonging.

Participants (7) noted that the quality of their relationships improved after their psilocybin sessions. They described being able to trust others, experience gratitude, and express their emotional needs more easily. Participants also reported that they were less likely to repress their emotions in the context of their relationships. For instance, one participant noted:

I’m able to cultivate a stronger sense of compassion for people and myself and be able to forgive others…[During one of the psilocybin sessions] I received a really strong instruction. Stay open hearted, don’t harden your heart to people or to kids when you get upset, and that’s something that I have carried through from the sessions. (1008)

Another participant reported: “After the psilocybin session, it changed my sense of social anxiety. It made me feel much more confident and comfortable around other people, and it made me more curious and adventuresome in the world” (1007). This participant had previously reported using alcohol to self-medicate intense feelings of social anxiety. Participants, in general, noted being more open and receptive to support from close others. Participants noted that the feelings of safety and belonging during their psilocybin sessions helped them bolster feelings of acceptance, self-compassion, and compassion for others after the session. One participant noted:

I feel more compassionate towards others, more open-minded and non-judgmental…One day my husband made some snarky comment, and my instinct was like, “That’s ridiculous,” but right away I heard a bigger more important voice…that new voice of compassion, understanding, and non-judgment…It’s very prevalent in my life now. (1003)

I’m much more patient and compassionate with my children… I feel like I have a much better relationship with them, and I am much more loving towards them and able to be way more patient and way less angry. (1002)

Discussion

This study analyzed qualitative interviews from 13 individuals who were interviewed about their subjective experiences in the first RCT of psilocybin-assisted therapy for AUD. The present study expands upon quantitative findings from the recently published parent study paper that reported significant reductions in alcohol consumption following psilocybin treatment compared to the control condition, which persisted for up to eight months (Bogenschutz et al., 2022). Participants in this qualitative study noted that prior to the study, they had consumed alcohol to relieve or avoid experiencing uncomfortable feelings or sensations, including feelings of shame, nervousness, and social anxiety. In addition to alcohol consumption, some participants reported employing other unhealthy coping strategies to mitigate these internal states—including misuse of other substances, overeating, and engagement in reckless behaviors. For many participants, these learned patterns of emotional avoidance had originated in childhood or early adolescence and were reinforced by self-evaluations that were excessively self-critical. Participants noted that they had been able to successfully cope with distressing feelings by drinking alcohol but that it had kept them feeling emotionally stuck on ‘autopilot’, disconnected in relationships, and caught in cycles of shame. They also noted that drinking had inhibited the healthy processing of emotions related to painful past events.

Under the influence of psilocybin, participants reported intense emotional releases and the processing of unresolved feelings such as sadness and anger. They also reported heightened levels of self-compassion, self-awareness, and connectedness. The phenomenological insights and experiences of emotional catharsis that occurred during the psilocybin sessions were described by participants as forming the “template” and foundation from which they could develop more self-compassionate regulation of negative affect and healthier habits for coping with cravings for alcohol and life stress.

Participants consistently reported that the psilocybin-assisted therapy facilitated the development of self-compassion capacities and reduced excessive shame, self-criticism, and self-blame. These qualitative increases in self-compassion are supported by preliminary quantitative studies that have found increases in self-compassion after psychedelic use (Dominguez-Clave et al., 2022; Fauvel et al., 2023). Some theoretical models regarding psychedelics’ psychological effects also comport with these reports. One recent model called the self-entropic broadening theory suggests that psychedelics trigger a style of cognition and psychological plasticity in which stereotyped, self-focused schemas are deemphasized and novel information is accommodated that supports new perspectives and appraisals (Dourron et al., 2022). Another model proposes that psychedelics can help loosen entrenched psychological protective patterns and behaviors that become canalized over time; initially adaptive, these learned coping patterns wear down one’s ability over time to respond to situations in a flexible manner (Carhart-Harris et al., 2022). Like the cognitive-affective actions of mindfulness, psilocybin’s acute effects may have increased participants’ sensitivity to feelings and thoughts undermining maladaptive self-critical beliefs, allowing for the long-term revision of cognitive and emotional schemas (Garland & Fredrickson, 2019; Koban et al., 2021). Psilocybin-induced neural plasticity coupled with feelings of connectedness, self-understanding, and belonging may have helped participants learn more acceptance-promoting and self-compassionate responses to stress and negative emotions. Participants in this study described how accessing warm and supportive feelings during and after the psilocybin treatment helped them to self-soot and face and accept distressing thoughts and emotions in their daily lives, rather than avoiding or resisting them with alcohol or with other maladaptive forms of coping (Neff, 2004).

Interestingly, many participants came to recognize during the psilocybin sessions that their critical inner voices and patterns of destructive thoughts emerged out of the judgments and criticisms they received from others in early formative relationships. Some participants noted that they had internalized criticisms from caregivers during childhood—many of whom held negative self-views of their own—or from others in influential social networks including peers who had bullied them at school. In some cases, participants linked these self-critical schemas to a familial legacy of alcohol use; six participants noted that their caregivers struggled with alcohol misuse and that they were emotionally unavailable, and in some cases verbally abusive. Various psychological models emphasize how social relationships can influence the way one perceives oneself. According to these models, subjective experiences of shame can evolve through relationships with others and become the basis for highly negative and self-conscious self-evaluations (Bowlby, 1969; Gilbert & Irons, 2009). Participants reported that the psilocybin therapy treatment helped them separate the harsh, internalized voice from their authentic self-compassionate voices, as stated by one participant: “Psilocybin gave me the ability to, in a sense, separate out different strains or different voices and identify my voice”.

A handful of participants also articulated that due to patterns of shame, social anxiety, and feelings of insecurity, patterns of self-medication with alcohol over time began to substitute for other meaningful interpersonal relationships. It has been proposed that psychological attachment to alcohol may substitute for interpersonal bonds with trusted others (Flores, 2004; Reading, 2002). This understanding is supported by a body of evidence linking insecure attachment styles with addiction (Massey et al., 2014; Reis et al., 2012; Schinldler et al., 2009), with high prevalence of insecure attachment styles among individuals with AUD compared to normative samples (Wedekind et al., 2013). As their relationships to alcohol shifted throughout the course of the study and in the weeks following the psilocybin sessions, participants noted becoming more emotionally open, receptive, and trusting, and the quality of their relationships with family members and significant others improved. There is preliminary support for the notion that psilocybin-assisted therapy may operate through mechanisms that enhance trait attachment security (Healy et al., 2021; Stauffer et al., 2020). This could be tested in future studies by administering validated self-report measures of adult attachment such as the Experiences in Close Relationships scale (Fraley et al., 2011) before and after psilocybin treatment under controlled conditions. If quantitatively confirmed, this finding would be meaningful, especially because attachment security is considered a relatively stable trait that becomes increasingly resistant to change as development progresses (Pinquart et al., 2013). An intervention that could rapidly and durably shift insecure attachment styles toward more secure attachment would be exciting and would have positive implications for relapse prevention through improving affect regulation and interpersonal functioning (Mikulincer & Shaver, 2016).

Another noteworthy finding was that participants reported developing sustained affect regulation abilities after their study completion including mindfulness, self-compassion, and positive reappraisal skills. Findings from this study are supported by influential psychological models of emotion regulation. According to these models, compulsive substance use represents a coping strategy used to regulate states of negative affect, hyperarousal, and overwhelming emotions or sensations (Dvorak et al., 2014; Estévez et al., 2017; Khantzian, 1997). Internal evaluative processes such as negative self-appraisals may motivate use of alcohol or other substances (Baker et al., 2004). These qualitative results are promising and consistent with the notion that psilocybin facilitates more adaptive regulation of negative affect (Thiessen et al., 2019). More research will be necessary to determine whether self-compassion or other characteristics of the acute psilocybin experience may lead to improved affect regulation abilities and other therapeutic benefits in ASUD patients.

It is important to note that participants emphasized that study therapists and supportive peers were instrumental in reinforcing the self-compassion relearning processes in the weeks and months following their psilocybin sessions. These processes were also reinforced by skills and practices developed during the psychotherapy sessions before and after study medication sessions (Bogenschutz & Forcehimes, 2017; O’Donnell et al., 2022). The MET and CBT sessions focused on eliciting and clarifying participants’ values and intrinsic motivation for change and on implementing specific strategies for meeting those goals. The preparation and debriefing sessions focused on supporting participants in making meaning of the drug administration sessions, including any changes in views of self, relationships, values, and spirituality. The therapeutic gains seen in the diphenhydramine group suggest that these non-pharmacological, psychosocial ingredients are key elements in facilitating positive change in this treatment modality.

It is also important to note that participants did not describe the treatment as a panacea. While most participants reported diminished cravings or urges for alcohol ranging from one week to longer, several described continued struggles in the face of life stressors and triggers. A handful of participants continued to struggle with the integration of their experiences after their psilocybin sessions. Additionally, while craving was consistently described as becoming less frequent and intense, several participants noted that cravings for alcohol did not disappear after their sessions and were frequently triggered by stress and strong emotions. A highly structured setting along with a strong therapeutic alliance, supportive therapy, and community-based aftercare support may be needed to transform rigid coping strategies into vehicles for healing and to manage strong cravings and prevent relapse.

Several limitations should be highlighted. The timing of the interviews varied from participant to participant and ranged from ranged from two to 18 months following participants’ third medication session (i.e., open-label psilocybin session). Second, due to the study design, which involved a double-blind control condition, the quantity of psilocybin medication sessions administered to participants in this qualitative study varied depending on group condition. Participants who were randomized to the psilocybin group (six total participants) in this qualitative study received three psilocybin medication sessions; conversely, those randomized to the diphenhydramine control condition (seven total participants) received only one session with psilocybin during the open-label portion of the study. This may explain why some participants reported more substantial improvements compared with others in the study. Additionally, it is likely that there was participant self-selection bias in the parent study, which may affect the validity and generalizability of the findings. This phenomenon may be accentuated in psychedelic research as the mainstream popularization of psychedelic medicine grows in response to narratives put forth by thought leaders such as Michael Pollan. In fact, over one-third of the participants in this qualitative study cited Pollan’s (2018) book as part of the study’s appeal. Additional biases were also introduced into this study by our positionalities and theoretical orientations as researchers and clinicians. Our positionalities undoubtedly influenced the information that participants reported in the interviews as well as our interpretation of these reports, and we cannot assume that these findings would replicate in teams with different positionalities. Finally, this study consisted of a relatively homogeneous sample, largely consisting of White, well-educated individuals with high socioeconomic status (mean household income in this qualitative study was $144,0000, in the 78^th percentile of households in the U.S.) (U.S. Census Bureau). It is important to note that this highly resourced study sample does not represent the general SUD population or those at greatest risk for adverse outcomes associated with SUDs. Therefore, the generalizability of these findings may be quite limited and may not generalize to other demographic groups, particularly those that have been historically underrepresented in clinical trials generally and in with psychedelics. In psychedelic research studies, Black, Indigenous, and People of Color have been vastly underrepresented even as the multigenerational effects of centuries of racialized policies burden them with high rates of trauma and other mental health sequelae. This presents stakeholders with an ethical imperative to prioritize providing opportunities to individuals from historically underrepresented communities to ensure generalizability and that those who could stand to benefit most are not excluded (George et al., 2020; Michaels et al., 2018).

In conclusion, the present study focused on a subset of qualitative data from 13 individuals with AUD who were interviewed about their participation in the parent study that consisted of up to three therapeutically supported psilocybin sessions and psychotherapy before and after the medication sessions. Participants reported that experiencing insights and emotional catharsis during their psilocybin sessions, which were described as laying the foundation or “template” for developing more self-compassionate regulation of negative affect. The psilocybin-assisted therapy treatment also sparked meaningful improvements in self-awareness, self-compassion, and feelings of connectedness and belonging. The qualitative reports revealed key themes and potential mechanisms of change, contributing to an understanding of the therapeutic process as well as considerations for future research in the nascent field of psychedelic psychotherapy for ASUD and disorders characterized by rumination and emotional avoidance. Our results provide support for the assertion that psilocybin increases the malleability of self-related processing and diminishes, in a potentially enduring way, the impact of self-critical thought patterns and excessive shame on affect regulation and managing cravings for alcohol use. Additional controlled studies are required to establish whether increased self-compassion and affect regulation leads to improved outcomes in AUD. These findings provide a deeper understanding of possible psychological change processes involved in this intriguing treatment approach. Psychosocial treatments that integrate self-compassion training with psychedelic therapy may serve as a useful tool for enhancing psychological outcomes in the treatment of AUD.

Public Health Significance:

This study demonstrated the importance of psychological factors that influence outcomes in psilocybin-assisted therapy for Alcohol Use Disorder (AUD). Our findings showed that psilocybin treatment prompted meaningful and enduring improvements in self-compassion and affect regulation. These psychological processes may help individuals with AUD cope with difficult emotions and stress and prevent relapse by encouraging adaptive coping responses.