Abstract
Anthony P. Bossis, PhD, is a clinical psychologist and clinical assistant professor of psychiatry at NYU School of Medicine conducting Food and Drug Administration (FDA)-approved clinical research with the psychedelic compound psilocybin since 2009. Dr. Bossis was director of palliative care research and coprincipal investigator on the 2016 clinical trial demonstrating a significant reduction in emotional distress from a single psilocybin session in persons with cancer. Dr. Bossis is study director on an FDA-approved clinical trial evaluating psilocybin-generated mystical experience with religious leaders. He is a training supervisor of psychotherapy at NYU-Bellevue Hospital Center and cofounder and former codirector of the Bellevue Hospital Palliative Care Service. He is a guest editor (with Charles Grob, MD) on a special series on psychedelics for the Journal of Humanistic Psychology and has a long-standing interest in comparative religion and on the interface of psychology and spirituality. He maintains a private psychotherapy and consulting practice in New York City. Here, Dr. Bossis discusses FDA-approved clinical research with the psychedelic compound psilocybin in palliative care and implications for clinical practice.
While it is difficult to formally operationalize the concept of spirituality, it is commonly agreed that spirituality and religion refer to a search for meaning and purpose, often through an enhanced understanding and connection with self, nature, others, and to the transcendent and sacred. Undoubtedly, we are seeing an increase in integrating complementary and alternative approaches including spiritual techniques and practice with more traditional psychotherapies. In this regard, the findings and implications from meditation and psychedelic research showing improvements in spiritual and psychological well-being have been intriguing.
Our primary research findings utilizing a single dose of psilocybin in a therapeutic setting with cancer patients demonstrated an immediate, significant, and sustained reduction in depression and anxiety along with an improvement in spiritual well-being. There were also significant reductions in hopelessness and demoralization, which we know from palliative care research are both greatly associated with end-of-life distress. In our NYU study, 70% of participants rated the psilocybin experience as among the top 5 most personally meaningful experiences of their life, including the single most, and over half rated the psilocybin experience as among the top 5 most spiritually significant experiences, including single most of their life. Almost 90% reported improvement in general well-being and life satisfaction. Up to 80% of the study participants sustained these clinical benefits about seven months later. It is important to highlight that the current psilocybin trials are randomized, double-blind, and placebo-controlled studies. And earlier this year in 2020, our group at NYU published a follow-up article interviewing the surviving participants in the study and found that at 4.5 years following their psilocybin session, approximately 60%–80% of those in this follow-up study continued to show reductions in anxiety and depression and improvements in hopelessness, demoralization, and death anxiety.
Many organizations, including the World Health Organization, have called for developing novel and effective treatments for the emotional distress in advanced illness, now identified as a priority in palliative care. We do not die well in America. Many people diagnosed with life-threatening diseases experience anxiety, depression, hopelessness, and severe personal anguish. End-of-life existential and psychospiritual distress has also been linked with a desire to end one's life. While there have been significant advances and a greater acceptance of the fields of palliative and hospice care in America, we still have a paucity of therapies to address the existential and psychological suffering that may be experienced by a person with a terminal illness. For years, death and dying were a taboo conversation in our culture and within health care training. Finally, we are now seeing some improvements in the national conversation about death and dying. And the anxiety and suffering from the coronavirus disease 2019 (COVID-19) pandemic have seemed to have raised global awareness regarding existential issues.
Subjective features of a naturally occurring or psychedelic-generated mystical experience include unity, sacredness, transcendence, ineffability, and an enhanced awareness of positive emotions including that of love. It also includes what is called the noetic quality, the feature that one is encountering ultimate reality. This altered state of consciousness from psilocybin lasts about six to eight hours with the most robust aspect of the mystical experience lasting roughly three to four hours. A major distinction between psilocybin and most medications is that unlike most medications—including antidepressants and antianxiety agents—which are taken daily to produce their desired effects, psychedelic research demonstrates that only one or two experiences generated by psychedelics can produce sustained and positive clinical benefits. So, in a sense, these are not typical drug effects per se, but rather it is the insight and memory of the experience that is associated with the positive outcomes. In research dating back to the 1960s and continuing with the trials with cancer and end-of-life distress, the mystical experience has been shown to be a mediating factor in the beneficial clinical results.
Palliative care research demonstrates that meaning-making and transcendence are helpful in coping with the end of life. Meaning-making, for those with a terminal illness, has been shown to improve spiritual well-being and quality of life and to decrease wishes for a hastened death. The experience of self-transcendence is a potentially powerful human experience. In the psilocybin trials, for the person with a life-threatening illness or facing the end of life, the insight or experience of not solely identifying the self with the body or of cancer is a radical shift in perspective—in consciousness. The possibility through self-transcendence, to not solely identify with the failing body, but to connect with something more enduring, is a profound gift and offers spiritually transformative and therapeutic potential. Often, participants report experiencing themselves in vastly enlarged panoramic fields of consciousness, recalibrating prior assumptions on the nature of self, the body, and death.
It seems that these transpersonal insights from meaning-making and transcendent experiences—occurring naturally or with psychedelics—suggest that humans are wired for meaning. Our search for meaning is an essential aspect of the human experience. And an enhanced sense of personal meaning and transcendent experiences are some of the core findings of psychedelic research. Another remarkable experience we hear is of feelings of forgiveness for others and for self. And volunteers in psychedelic research often speak of profound experiences of love, loving kindness toward self, toward others, and of love of a spiritual or divine nature, what I like to call agape, from the Greek word.
First, there is careful medical and psychological screening of all participants. While the most common adverse physical effects are primarily mild increases in blood pressure and heart rate, it is the potential psychological adverse effects, notably heightened anxiety or panic, that can produce significant emotional distress. For that reason, screening and therapeutic support throughout the study timeline are vital. Following medical and psychological screening, participants engage in a three- or four-week therapeutic preparatory period with two therapists to review their personal background, their response to illness, and their intention for entering the study. The therapeutic rapport and trust between the participant and the therapists are an integral component of this relationship, which significantly helps in mitigating anxiety during the psilocybin session.
The all-day psilocybin session takes place in a living-room-like setting in the medical center. The patient, lying on a couch, will typically wear headphones, which is playing preselected music, and eyeshades to encourage them to direct attention inward to the unfolding changes in consciousness and to distract from any environmental stimuli. Of course, the participants can remove the headphones and eyeshades whenever they wish to speak with the therapists. The therapists are present the entire time, and while there is minimal speaking during the typical psilocybin session, the therapists are there to offer assurance and interpersonal support if needed. Following the experimental session with psilocybin, there is a period of sessions to address and therapeutically integrate the experience. The careful screening, preparation, integration, and interpersonally supported setting have been beneficial in avoiding serious adverse effects in the clinical trials, unlike the risks that can be present when using these substances recreationally. Psilocybin is an illegal drug and is being used only in FDA-approved clinical trials.
Understanding the nature of consciousness or as it is sometimes referred to as the “hard problem” of consciousness has been explored by the fields of neuroscience, spirituality, and philosophy alike. Does the mystical or peak state of consciousness that occurs naturally or generated by psychedelics provide any insights for the scientific study of consciousness? How do states of consciousness from meditation and near-death experiences contribute to this understanding? Mystical experiences have been occurring naturally and cross-culturally throughout human history with surveys showing roughly half of the American population naturally reporting such experiences. The perennial philosophy, as stated by Aldous Huxley, the famous English author and proponent of psychedelics for the dying, states that at the foundation of the world religions and wisdom traditions lies a universal and fundamental truth regarding the nature of self, consciousness, and ultimate reality. This was a key aspect of the writings of Huxley, William James, Carl Jung, and others. This underscores the relevance of spirituality, religion, and spiritual practice in palliative care and other areas of health care. The spiritual care of the dying patient and the inclusion of pastoral care and chaplaincy are an integral part of the palliative care team.
E-mail: anthony.bossis@nyulangone.org
One of the many improvements that has already occurred in palliative care and that so many of the clinicians who care for the dying have achieved is raising awareness on death and dying. Death really is our great teacher and it is inevitable, even though we would like to not believe that. There is still a cultural denial of death even though it is with us all the time. One of the main things that makes this COVID-19 pandemic so difficult is that it really pulls back the veil and reminds us that impermanence, suffering, and death are right there. It is always changing. And so, while there is still a long way to go regarding societal and medical openness to caring for the emotional needs of the dying, things are beginning to hopefully improve.
One of the insights many volunteers from psychedelic research share is that by emotionally turning toward their fear, toward the feelings around death itself, they often felt less anxiety, more compassion and love toward self and others, and cultivated new insights. While difficult, by turning toward suffering, they spoke about experiencing a greater acceptance and openness to the mystery of death. And by doing so, they report being able to live more fully in the present. Over the years, professionals from palliative care, chaplaincy, and teachers from spiritual and contemplative backgrounds have helped individuals and our culture to better understand this. The development of meaning-making psychotherapies, the psychospiritual care of the patient, and early findings from research in psychedelic therapies will all ideally contribute to a more compassionate and attentive care of the dying. By not avoiding, but rather by being with dying, we can live more fully.▪