MHM Magazine

36 | MENTAL HEALTH MATTERS | 2022 | Issue 5 MHM In the South African setting psychedelics such as psilocybin, LSD, and MDMA are illegal, hampering efforts to reduce harm while maximising potential benefits. Ketamine and Ibogaine are two psychedelic substances that are legal and can be medically prescribed, creating a valuable avenue for local practitioners to use psychedelic-assisted therapy. Internationally there are innovative approaches to improve access to psychedelic- assisted psychotherapy such as the Oregon Psilocybin Services, the Decriminalise Nature movement, and access to MDMA-assisted psychotherapy through FDA approved Expanded Access Programme with the Multidisciplinary Association for Psychedelic Studies (www. MAPS.org) . Ketamine-assisted psychotherapy models have been developed and training is available through organisations such as the Psychedelic Research and Training Institute (www.pratigroup.org ). Clinical practice guidance on the safe use of psychedelic substances are currently based on accumulated professional experience, early findings from clinical trials, and treatment manuals developed by experts. The three most important considerations for reducing risks and maximising potential benefits in psychedelic-assisted psychotherapy are what is known as “set, setting, and skill.” The “set” refers to the psychological and physical state of the patient prior to the psychedelic dosing session (e.g. screening for contra- indications and medication interactions, psychological preparation, and intention setting). The “setting” refers to the physical setting in which the psychedelic dosing session will occur (e.g. safety, music, lighting, comfort, access to support). The “skill” refers to the personal qualities and competencies of the therapist who will facilitate preparation, integration, and facilitation of the psychedelic dosing session (e.g. adherence to ethical and professional guidelines, psychotherapeutic skills, and assisting the patient in managing challenging experiences). Due to the lack of legal access to therapeutic use of psychedelic substances, patients may indicate their intention to use psychedelic substances on their own in a non-clinical environment with the support of a trusted friend or family member. It’s in this context that health professionals have an ethical duty towards helping patients make informed decisions and provide information following a harm-reduction approach. In a harm reduction approach, the health professional does not advocate for or against the use of psychedelics, but instead focuses on the patient’s goals and welfare. The goals of a harm-reduction approach are to reduce risk of harm, increase the likelihood of positive outcomes, provide patient education about potential risks and benefits, provide information on alternative treatment options, assist the patient in developing realistic expectations, maximise potential therapeutic benefits, and encourage psychological integration and support after the psychedelic experience. In a biomedical model we tend to over-estimate the medical risks involved in the use of psychedelic substances and under-estimate the importance of the non-drug elements such as set, setting, and skill. Contra- indications to psychedelic- assisted psychotherapy include the following: diagnosis of a primary psychotic disorder, current manic or mixed state, severe personality disorders, and a family history of psychotic disorders. Younger age and certain personality characteristics Psychedelic substance Conditions under investigation in clinical trials MDMA (3,4-Methylenedioxy methamphetamine) Post-traumatic stress disorder (PTSD), end-of-life anxiety, social anxiety in autism, tinnitus, alcohol use disorder Psilocybin Treatment-resistant depression, obsessive-compulsive disorder (OCD), migraine headaches, cluster headaches, chronic pain, generalised anxiety disorder, demoralisation in HIV/AIDS, substance use disorder, tobacco smoking cessation, anxiety and depression in patients with life-threatening illness LSD (Lysergic Acid Diethylamide) Anxiety in life-threatening conditions, alcohol use disorder Ayahuasca Treatment-resistant depression, substance use disorders Ibogaine Substance use disorders Ketamine Treatment-resistant depression, PTSD, OCD, substance use disorder