Psychedelic Therapy is Highly Directive | Can Therapy be Non-Directive ? (3/5)
Reflections on inter-subjectivity, inner healer intelligence, influencing and music in the context of psychedelic therapy
Please note that this article is divided into five parts, which are published sequentially and are ideally read in chronological order:
Part 1
Psychotherapy is never non-directive | Reflections on inter-subjectivity
Part 2
Music is always directive | Reflections on the therapeutic function of music
Part 3
Psychedelic therapy is highly directive | Reflections on the use of music in psychedelic therapy
Part 4
The use of music is not necessary | Reflections on the use of silence
Part 5 (PENDING PUBLICATION)
Healing often requires direction | Reflections on Inner Healer Intelligence
Part 3 | Psychedelic therapy is highly directive
Reflections on the use of music in psychedelic therapy
In the previous sections, I discussed that no psychotherapy can essentially be non-directive due to its inherent intersubjective nature. I explained that incorporating music into therapy sessions will per definition enhance the directive qualities of these therapy sessions.
In this part I will explain how in the context of psychedelic therapy, these arguments become even more relevant.
Not only do psychedelic therapists typically play music, this music is typically emotionally evocative (i.e. forceful in it’s direction), asked to listen to with a blind-fold (i.e. it becomes virtually the only stimulus present), is present for the large majority of the session (i.e. there is direction provided almost continuously), and often packaged with strong explicit verbal suggestions (for example to “surrender to” or “be carried by” the experience).
All of this, while the patient is under the influence of a drug that increases suggestibility.
“Normally when I hear a piece of music, I respond to choice. But under the influence of psilocybin it felt as if I had no choice than to follow the music”, one patient said in one of the clinical trials with psilocybin I was involved in.
There are various angles from which to discuss the mechanisms via which psychedelics act therapeutically. Authors may use terms like psychedelics facilitating “primal processes”, “mental flexibility” or “suggestibility”.
No matter if we look at this from a neuroscience or a psychodynamic perspective,the bottom-line is that psychedelics amplify the usual subjective responses to the non-verbal suggestions embedded in music in very significant ways.
Therefore, not only is it impossible to be non-directive in psychotherapy, the way psychedelic therapy is currently mostly practised, places it arguably amongst the most directive forms of therapy one can imagine.
But let me add some important nuance to these statements.
First of all, I want to invite all therapists who work with music to start thinking of music having varying degrees of force by which it asserts its directive influence over the listener. I often refer to this as the different “degrees of direction” present in music.
On the one end, we have music whose direction is a gentle suggestion, similar to a soft summer breeze. Whereas on the other end we have music that provides direction with immense authority. A stormy gust that catapults the sailing boat forward.
Music will always influence the listener. Music will always provide some direction. Yet the degree of music’s directive properties can vary greatly in its forcefulness. Both ends of this spectrum have unique therapeutic value, with their own unique use-cases and consequences.
Secondly, it is the approach to music playlist design that eventually determines how person-centred the provided musical direction will be. The sequencing of the music in the session dictates what direction is provided, when this is provided, and to my previous point, how forceful this direction is.
Here, the effects of the direction in the music can really only be understood in relation to the patient experience when that music is played.
On the one extreme, we have a predetermined set of songs from start to finish.
An analogy for this approach would be to imagine talk-therapy where the therapist reads a fixed script of reflections and instructions to the client, strictly adhering to vocalise these sentences in only one particular order, in one particular way, and only at specific and precise times in the session.
In this imaginary scenario, a therapist might for example suggest to the care-seeker to think about death exactly at the 01:46 hour time point in the session. But what if the experience of this client in that moment instead centred around her reconnection with feelings of gratitude for a highly significant person in her life?
She is redirected with force into a very different experience. She may try to protect her current state and try to “resist” giving into the demands of the music. But the given direction may be strong and persistent.
This is what I describe as “psychological dissonance” between music and listener. A predictor for negative therapy outcomes. (I have in fact formulated three distinct reasons a careseeker may express resistance, and this “psychological dissonance” between music and listener is one of them)
The lack of feedback loops between music and listener arguably makes this the most directive form of psychedelic therapy. Importantly, not only is this approach very directive, but in-considerate about who the actual person is in therapy, and what they are going through.
For the sake of this exploration, we might refer to this approach from here on as “the non-person-centred approach of psychedelic therapy”.
We must understand that this is one of the legacies we can attribute to clinical research, where this approach is most commonly seen. This stems from the challenge researchers face when needing to control for a complex and often misunderstood variable such as music.
To illustrate this point with an analogy: Many years ago, I volunteered for a clinical trial that required me to stay in a clinic for 10 days to test a new drug. During this time, my usual diet was abruptly replaced with a monotonous rotation of mass-produced sugary bread and overcooked microwave meals of beans and vegetables. After each meal I often found myself with a headache, and at one time, explosive diarrhoea. Although these symptoms were so clearly linked to my aggressive diet-change ,they were attributed as a potential side effect of the drug being studied
When it comes to the use of music in psychedelic therapy, this issue is way more significant.
In psychedelic therapy we give vulnerable individuals one of the most profound subjective experiences imaginable in their lives (i.e. drug-facilitated ego-dissolution), and pair this with one of the most personally and potent pre-linguistic directive stimuli one can imagine (i.e. emotionally evocative music).
There are different ways to control music as an experimental variable in clinical trials. No sane care provider would use the example I gave earlier of a strict script of sentences to read to the patient minute by minute. Yet we must ask ourselves, why do we tend to accept this for music?
Clinical trial reports rarely include measures to track how music affects the patient experiences differently. Typically and at best, the inclusion of music receives one short sentence of acknowledgement in the method section. Some may not even mention their use of music at all.
One of the basic principles I learned as a scientist is that method sections in academic papers need to function like a “cooking recipe”. They should be a complete and sufficient set of details that enable any other researchers around the world to replicate the study in question.
Most academic papers on psychedelic therapies are quite a bit away from this ideal. And this not only concerns the use of music.
I have immense sympathy for the complexities involved in clinical research, having been involved in this for more than a decade by now myself. But we need to be mindful that the current clinical research studies are informing the legal standards for the future implementation of this new form of therapy.
With regard to clinical research, there are pretty simple ways music selection can be protocolised and tracked. This way the variable controlled for is not merely the presence of music, but the effort to ensure that each patient receives the support they require to be safe.
Again, this is an ethical pre-requisite in all clinical research. But researchers and regulators alike so far have turned an almost-blind eye to the impact of music on patient experiences and therapy outcomes. For reasons that we could explore later in more detail.
One alternative approach to standardize the music across trial participants, would be to radically minimize its directive qualities. By keeping the music as non-directive as possible, we will reduce its influence as a "hidden (psycho)therapist," preventing it from interfering with the patient’s experience in an out-of-context or intrusive way.
I do anticipate this approach would result in a less effective overall treatment paradigm and introduce new challenges when applied at scale. However, it would be more congruent when the goal is to minimise psychotherapy-like components. One scenario to surely avoid would be a highly directive, emotionally evocative musical approach, but without the presence of trained psychotherapists to offer necessary support alongside.
To shift this conversation away from the clinical research, back to our discussion on the mechanisms of the therapy process - I've developed a strong suspicion that the directive qualities inherent in psychedelic therapy, especially when coupled with music, may in fact be key to its effectiveness.
Those seeking care are inherently seeking change, and thoughtfully selected music can provide the direction required to access this change.
As I already alluded to, perhaps the crucial question isn't whether psychedelic therapy is directive or not. But rather how therapists can offer the type of direction and the force of this direction in a manner that respects the integrity and safety of individual patients: I usually phrase this as ”the effort to ensure direction is provided in a person-centred way”.
In this approach, therapists won’t adhere to a fixed one-size-fits-all musical structure that catapults each and every individual at each sharp 2 hour time-mark in the session through a confrontation with their mortality, no matter who they are, where they, what they feel - but rather utilises a set of starting and pivoting points for the music selection, tailored to the individuals and their dynamically changing experience.
Music can then instead start to provide a direction that is imbued with empathy.
Music has the ability to meet the listener where they are. To offer a direction that is resonant with the present experience. The non-verbal direction facilitated by music then becomes an integral part of the therapeutic relationship. Evolving like a dialogue, grounded in “unconditional positive regard”.
This is my hope and vision for the future of psychedelic therapy and its use of music.
By no means am I implying this to be a simple task. This might indeed make the development and regulatory approval process of psychedelic therapy slightly more elaborate, but with no doubt vastly more ethical and effective. Recognising the full complexity of working with psychedelics and music therapeutically is truly essential to nurture it into it fullest potential.
To be clear, I understand that the complexity of this situation goes way beyond the undervaluation of music’s potential to either facilitate healing or harm. It includes an ongoing conversation around what qualifications therapists require, judgements of the psychotherapy-related components, the balancing of profit-motives versus effectiveness-motives, and much more.
I argued in this part of the article that the combination of suggestibility-enhancing drugs with potent pre-linguistic stimuli makes psychedelic therapy arguably one of the most directive forms of therapy one can imagine.
My point is not to make a negative value judgement, but for this to be recognised.
Understanding the ways and degrees music provides direction, and how these influences of music can be harnessed in a person-centred way are, as I argued, essential for this method to develop most ethically and most effectively.
In the next chapter, I will continue to deepen this exploration by integrating and analysing one of the arguably most common therapeutic foundations in the psychedelic therapy space - the notion of an Inner Healer Intelligence.
People used to recycle psychelics, by recycling urine. Learn about Urine Therapy and how I discovered it in my personal story in my podcast here: https://soberchristiangentlemanpodcast.substack.com/p/s2-ep-8-my-story-urine-therapy-discovery-4f3