Psychedelics and the essential importance of context
The first wave of psychedelic research in the 1950’s and 60’s presents examples of favourable contexts leading to good clinical outcomes as well as adverse contexts leading to poor outcomes, most notably in the controversial US military experiments with LSD in the 1960’s, in which set and setting were intentionally neglected or even manipulated in a negative way. In the last decade we have seen psychedelic therapies being used successfully in clinical trials to treat depression, addiction and post-traumatic stress disorder when set and setting have been carefully controlled. Typically, favourable settings are engineered through the use of low lighting, carefully selected music playlists and aesthetically pleasing decor. A patient’s set is optimised through extensive psychological preparation with trained therapists and therapy ‘guides’ who are present throughout the psychedelic experience (see The Hidden Therapist – evidence for the central role of music in psychedelic therapy Kaelen et al. 2018). Taking stock of this evidence the dependence between the context of a psychedelic experience and its therapeutic benefits seem clear. The question then naturally arises: why is context so important to the psychedelic experience? It is thought that psychedelics enhance the brain’s ability to rewire itself, known as cortical plasticity. Carhart-Harris et al. propose that in this plastic state the brain becomes acutely sensitive to both internal and external influences, in other words the set and setting respectively. Cortical plasticity thus provides the physiological link between psychedelics and the importance of context.
An important corollary of recognising the essential importance of context is that the prevailing societal views around psychedelic use form a ‘cultural set and setting’. During the first wave of psychedelic research, cases of worsened mental health and rare tragedies linked to drug use were aggressively exploited by a conservative media which turned public opinion against psychedelics. Such a negative cultural setting can in turn lead to negative expectations, or a negative set, in a reinforcing feedback loop. The authors warn against a similar media backlash following this ‘third wave’ of psychedelic research and propose that increasing our understanding of how to mitigate against negative drug experiences is the best way to address the cultural bogeyman of the ‘bad trip’.
Studying the effects of specific contextual elements in isolation on the psychedelic experience presents significant practical challenges. Moreover, in testing a variety of contextual conditions, some conditions will necessarily be sub-optimal as compared to others and the provision of sub-optimal test conditions is fraught with ethical issues. Carhart-Harris et al. suggest a possible route around the ethical issues could be to use ‘microdosing’. Microdosing, a phenomenon that has come to attention in popular culture in recent years, involves ingesting subthreshold quantities of psychedelic on a regular basis while everyday life continues. The trick of microdosing would be to give the drug in small enough quantities that the provision of a sub-optimal context becomes ethically justifiable. While this remains a future research direction, the authors make use of more easily obtainable data probing the effects of context on the psychedelic experience. They discuss preliminary results from a survey of individuals who have travelled to specific retreat centres in order to receive a psychedelic in the context of their choosing; in accordance with the literature, their results show a link between a positive set and setting and long-term, beneficial therapeutic outcomes.
Finally, the authors conclude that an increased appreciation and understanding of the essential importance of context to the psychedelic experience may call for a paradigm shift, not only in psychedelic research but in pharmacotherapy more generally. They argue that treatment models should account for the synergy between the effect of taking any drug and the context in which it is taken. While it could be argued that this added source of variability will make treatments too costly, they counter that such a treatment model may in fact by cost-saving due to improved outcomes with greater longevity, delivered over a shorter number of sessions.