PSILOCYBIN FOR DEPRESSION: THE ACE (ACCEPT/CONNECT/ EMBODY) MODEL MANUAL

Authors:Dr. Rosalind Watts

Contributors:Michelle Baker-Jones

Dr. Jonny MartellAshleigh Murphy-Beiner

Roberta Murphy, MDTim Read

Dr. Graham CampbellGregory Donaldson

James CloseDr. Benjamin WaterhouseDr. Frederico Magalhães

Renee Harvey

Imperial College London Psilocybin for Depression: The ACE ModelCopyright © 2021 by Ros Watts

All rights reserved.Data is available upon request.

First edition: July 2021DOI:

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"The Psilocybin for Depression: The ACE Manual '' describes the structure, procedures, andscripts used in the two Imperial College London studies (Psilodep) researching psilocybintreatment for major depression. The studies utilized the ACE (Accept, Connect and Embody)model as a therapeutic framework. The model is based on six psychological flexibility processes(Experiential Acceptance, Present Moment Focus, Cognitive Defusion, Self as Context, Values,Committed Action) that are the core of the ACT (Acceptance and Commitment Therapy),otherwise called Psychological Flexibility Model (PFM).

To read more about the ACE model and why it was chosen for the Psilodep studies, we refer tothe article by R.Watts and J.B. Luoma.

Watts, R. & Luoma, J. B. (2020) The use of the psychological flexibility model to supportpsychedelic assisted T therapy. Journal of Contextual Behavioral Science (JCBS). Volume 15,pages 92-102

The manual is intended to inform about the steps, procedures, and scripts used in the study andhow the ACE model was incorporated into the protocols. The manual should not be used as aninstruction for studies or clinical trials.

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SCREENING 6

CHECK IN CALL 7

PREPARATION DAY 10

CATCH-UP 11

PSILOCYBIN SESSION TIPS: 12

BE OPEN 12

TRUST the substance, your mind, the therapist. 13

INTENTION 15

IN AND THROUGH 16

GROUNDING 17

IT IS YOUR JOURNEY 18

HOLD IT LIGHTLY 19

PRACTICALITIES AND ANSWERING QUESTIONS 19

4. RUN THROUGH & METAPHOR 20

P-ACE (Preparation - Accept Connect Embody) Script 20

INTENTION 24

SESSION DAY 24

PREPARATION 24

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INTERVENTIONS DURING THE SESSION 25

POST SESSION 26

INTEGRATION 27

INTEGRATION OVERVIEW 27

FOUR FIXED SESSIONS 28

Integration A (morning after session 1) 29

Integration B (call) week after session 1 31

Integration C (morning after session 2) 32

Integration D (three weeks after second dose) 33

6 weeks onwards 34

APPENDIX 35

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SCREENING

● Keep a Database with everyone who writes in enquiring about the study● Conduct a telephone screening with people (a short form)● Conduct a HAM-D (The Hamilton Rating Scale for Depression) with everyone● Skype with the main therapists● Invite in for face to face screening

Skype - the purpose is to assess whether to invite for a face to face screening visit. The callshould include both main therapists (one of whom will be a guide for this person, alongsideanother guide). Call duration: 20 minutes.Script for the call: Suitability Rapport building, answer person’s questions about the study. Geta sense of the main traumas to be discussed further in a face to face meeting.

*****get a sense of how much of the online content they have seen. If they have seen a lot (tedtalks etc) explain that the ted talk looking at our study (connectedness/ acceptance) was basedaround interviews at the 6 month point, people looking back- but they may not have said thatstraight after the session. It’s a process. Psilocybin can open a door, but you have to walkthrough it. Not a magic cure ******Anyone coming in with a purely biological explanation ofdepression- explain that research from our group suggests that having an emotional experienceis a key mediator of effects (can’t bypass this part- it doesn’t just ‘reset the brain’- a more fittinganalogy is that it is like 5 years of therapy in one day - rather than a reset). It’s important thatthey are open to the psychological, therapeutic, emotional aspects of the experience, rather thanthinking they will maintain control at all costs during the session, in the hopes that the brainreset will work anyway.

Face to face screening (3.5 hours)

1) Medical:- With psychiatrist 1.5 hours (full psychiatric screening)2) Therapy:- Meet with 2 guides I.5 hours (with breaks).

Script: Participant’s life story- go into main traumas in detail. Assessment. Rapportbuilding: Self Disclosure. Witnessing. Active Listening. Answering participant’squestions about the study. Building trust

3) Study Lead – Principal Investigator (PI) joins for ten minute chat, remaining time:answer questions, thank them for coming in

Doses: There will be a high and low dose, so you are not guaranteed to have an intensepsychedelic experience. Sometimes high doses do not produce intense effects anyway, and lowdoses can produce intense effects, so we ask you please that we stay away from too muchdiscussion of what your doses are until the final follow-up at 6 weeks when all will be revealed.

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For the sessions themselves, it’s a full day of listening to music and being with yourself, with adose of psilocybin that will influence your experience to a greater or lesser extent. We are thereto support you, but it isn’t a day of talking therapy, it’s a day for you to listen to music and ‘sitwith’ any emotions that arise. You might feel no different to normal; it might be one of themost intense experiences of your life; it might be somewhere in between. Because it isimpossible to predict, we ask you to think very carefully about whether you are willing topartake in something that may not provide you with personal benefit, whilst asking a lot of you.

Motivation: Of all those who have applied, we are careful to select only people who are fullycommitted to continuing even if they do not receive any personal benefit, in order to contributeto an important scientific study. By taking part in this study you would be making a verysignificant contribution to cutting edge scientific research which has the potential to improve thelives of millions of people. It’s the first time in history that the mechanisms of psilocybin and anSSRI antidepressant will be compared in a study. (*Service to others). We are only able toinclude people who are willing to go through something quite tough (lots of time, scans,potential for a difficult session, potential for disappointment, it’s a big investment of time andemotion). The experience can be tiring: regardless of the dose you get, you might have to digdeep at times, and keep going because something really important is at stake ( *Bravery,pioneering spirit). By taking part in the study you are also showing that you are ready forchange, and that is an important thing to recognise: regardless of the dose you receive, you havesome interest in scientific advancements in the treatment of depression, and if you don’texperience a dose that works for you during this study that doesn’t mean that you will neverexperience psilocybin or some of the other of the new depression treatments being developedcurrently. (*Starting a new chapter in your life)

Email & Card: Email from a study lead to say yes (including the whole team) Admin assistantsends dates. Write out a contact card for each person (putting dates on for their visits). Post it tothem.

CHECK IN CALL

Before the call, send them the menus with a short email saying that you will call in a day or so(remind them of the time) to talk through practical stuff before they come in, so if they just havea look over the menus before then and choose lunch for the prep day and session day.

CALL:

1) Check in: How is it going? Withdrawals from medications? Feelings about participation?Questions?

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2) Intentions: (ask the three questions)

What would make the session meaningful for you, regardless of the dose? Why you are doing it(i.e. whatever happens I will (……) do my best to surrender/ I’m contributing to importantresearch/ see it as meditation / a chance to think about my life)

Remember the three points raised in screening : *Service to others *Bravery,pioneering spirit *Starting a new chapter in your life

(If they are finding it hard to think of anything you could prompt them by saying: ‘By takingpart in the study you are also showing that you are ready for change, and that is an importantthing to recognise: you could set the intention that regardless of the dose you receive, you willtake the day to reflect on your life’ )

What is going to give you courage if it gets tough?

I.e., A person, a value, a song…

What do you want to have more of in your life, after the session?

Keep it realistic and emotion-focused if possible

3) Objects: Do you have any small objects/ pictures/photos/ mementos which might represent1) why they are doing it regardless of dose 2) what will give them strength if it gets hard 3)what they want more of in their life . They can have an object for each one. Ask them to bringobjects in with them (no pressure though, it’s not a problem If they can’t think of anything, ordon’t want to do this).

4) The purpose of the music: Music can activate strong emotional states. We use music thattakes you on a journey. We have included music that is particularly tender and that mightencourage you to open up to your deeper emotions, help you feel a sense of support as you fullyexperience whatever comes up. We use the same playlist for everyone, although we can add insome of your own chosen tracks to go at the end. It will all be done in advance, and on the dayyou can relax knowing that the music is taken care of.

Trust us with it. You don’t have to like it all, it’s not about liking, it’s about what the music canhelp you access. If there’s a particular track that (on the day) that you really don’t like, we mightinquire a bit about what feelings it is bringing up, and encourage you to stay with them if youcan. However if a particular piece of music is just not working for you, if it is blocking you sothat you are just thinking ‘I hate this music!!’ we will change it. So it’s good to check out now:

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is there a particular genre that you think might irritate or bother you? Is there any kind of musicyou really hate? (Then talk through the playlist very briefly- it is very beautiful music, describedifferent genres: classical, world music, ambient –(you might need to play them an example),sacred/Indian.

As I mentioned, if there are a few particular pieces of music/ songs that you really like we canadd them into your playlist (at the end). Have a think about whether there is any music close toyour heart that you would like us to include. If so, it would be great to receive those songs overemail in the next week or so. When you send me tracks over email, it would be helpful if youcould send me a little description of what they mean to you, associations etc. Otherwise, we cantalk about it during the prep day.

5) Food: Go through choices for meals on the prep day, and snack/drink preferences forsession day- i.e do they like grapes and dried fruit bars. Ask about allergies. Also let them knowthat they will need to bring in comfy clothes, slippers (very important), and a dressing gown ifthey have one

6) ****** women participants: ask for where they will be on the menstrual cycle for session 1and 2. Info in grey- needs to be sent to admin assistant, info in yellow is for guides’reference/therapeutic.

When did you have your last period – write the date of the first menstrual day (the date of thefirst bleeding day this month). Need exact date- if they don’t know, don’t record. Just get arough idea for therapeutic purposes.

Do you use hormonal contraceptives? Do you have a regular menstrual cycle? What is thelength of it? Do you suffer from PMS or PMDD (premenstrual dysphoric disorder)? How doesit affect your life?

How do you think it might affect the sessions (ie- if they are on their period- hot water bottles ifthey get cramps? Do they have any other concerns (ie- if they will be bleeding heavily, reassurethem that we can have dark washable sheets so that they don’t need to worry in case of anystaining if they can’t change a tampon etc) . If their period experience is more emotional- thenhow can we help them- ie do they need more space, or more reassurance. If they will be havingPMT- what does this look like? What can we do to help? (ie- more tearful/ irritable). Someacknowledgement that if they suffer from it, pmt can add an extra layer. It is very rarelydiscussed in our society- but we recognise its importance, and want to adapt in any way we can.

7) Follow up email: Summarising logistics for their stay

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To do at the check-in stage.

Playlist creation Create a copy of the playlist: Take the baseline playlist: Psilocybin forDepression. Copy and paste it in Spotify, to make a new repeat copy of the playlist, andrename it with the initials of your participant. Modify: Take out tracks that are of any genrereported to be offensive/blocking by your participant, and then ‘fill up’ with some extra tracksfrom the playlist: Extra tracks (these are mellow and non-directive). Add in any chosentracks from the participant at the end (replace existing songs). Currently, the final section (from7 hours to 8 hours after capsules are taken) contains 8 songs with words. The songs are asfollows: Nana, Agua de Estrellas, All Related, Motherland, Follow the Sun, Across theUniverse, Anthem. Familiarise yourself with these songs, and choose which ones to swap withthe choices from your participant. You can choose to take out any songs that you don’t thinkwill resonate with that person.

The songs at the end are interspersed with relaxing music so that each song can be gently andspaciously appreciated without being overwhelming. The relaxing music I have chosen tobook-end each song is ‘chakra balancing music’, starting at the root chakra and going up to thecrown chakra at the end of the playlist. I chose this because it is very soothing. If you thinkyour participant will find the sound of it too ‘new agey’, or if they have expressed stronganti-spiritual viewpoints, you may want to swap these tracks for some relaxing classical musicfrom the ‘Extra Tracks’ playlist. They will receive the playlist and will see the names of alltracks, so a chakra-aversion should be respected!

PREPARATION DAY

Psychology assistant greets participants at CRF (Clinical Research Facility) reception at 8.30.Take them to the participants’ lounge, and get them a cup of tea and any breakfast they need,get their meal orders. Leave them with breakfast while going to make meal orders. Deliversthem to Bruna at CRF for the tasks and scan. Scan, Tasks (9-12.30)

Lunch (12.30-2.30) with both therapists/guides, in the session room. This is an opportunity forinformal connection, a gentle introduction to each other. A sense of occasion- sharing a mealtogether- breaking bread. A human experience. Also a chance for the therapists to ‘take care’and ‘attend’ to the participant. Serving them, in a way. Pouring them water. The message: let ustake care of you.

Prep session with BOTH therapists/guides (2.30-5.30)

Overview: Describe what you will cover today (we have about 3 hours, time for a breakwhenever you need)

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1) Talk about how you’ve been – time to continue the discussion we started last time wemet

2) Some tips, explanations of how things go in psilocybin sessions3) Answer any of your questions4) Practice run where you will lie down on the couch and put the eye-shades on & listen to

the music

At any point, if you have any concerns or questions, please do let me know. If there’s anythingyou think afterwards that you wished you’d asked, you can ask me tomorrow. But bear in mindwe will only have a brief check in before you take the capsules tomorrow. We like to get thetalking done now, the day before, and then tomorrow you can just let go of everything and gowith the flow. There will be lots of information this afternoon. Don’t worry about rememberingit- the important bits will all go in, so don’t worry about writing anything down. There’s no rightway or wrong way to do this. The lesson of this type of work (especially as compared totraditional psychiatry) is: go with the flow. We don’t try to dictate or control, we let theconnection between us develop naturally, we let the conversation go where it needs to go, and inthe psilocybin session we let the medicine and the music do their work with really littleinterference. So, try to just let this information kind of wash over you, hold it lightly.

1. CATCH-UP

a) How have you been since I last saw you: (depression symptoms/withdrawal from meds/anxieties about the study- how are you feeling about tomorrow?).

b) Continue the discussion of their personal history that was started on the screening day. (Forthis, check your notes, so that you can remember significant names/ times/ things they have toldyou, so that they have a sense that you remember them, that you really listened, that you can beentrusted with their deepest most painful information and that sharing things with you is not awaste of time- you are thinking about them and you care).

c) Any things you haven’t got around to mention that you’d like to? Anything that you tend toavoid thinking about but know is there deep down? It’s a safe space. There may be particularthings that you feel worried about, or guilty about, or that you think would make you feel veryexposed and ashamed if they came up? It can be helpful to get it off your chest beforehand, butit’s absolutely fine if you don’t want to talk about anything like this- it’s not necessary, just theoption is there if you want it. (Taboo subjects- sex, death, religion, debt, addictions, shamefulhabits, being unfaithful to a partner etc etc)

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2. PSILOCYBIN SESSION TIPS:

BE OPENto whatever happens (TLO - Trust, Let go and Be Open, Bill Richards- one of the mostexperienced psilocybin therapists in the world trained us, and TLO is his favourite ‘mantra’for use in psilocybin sessions- we use it a lot too).Today we will mainly spend time preparing you for an intense experience, because it’s reallyimportant to be prepared if this happens. Because we are spending so much time today talkingabout the intense experience, we must not forget that there is a chance you will have a gentleday. If so, that is a chance to spend a day listening to music, in this relaxing room, with nothingyou have to do, nowhere you have to be. It’s a chance for you to be with yourself, to exploreyour inner world, with us here to look after you a little bit. Remember that you are taking part ingroundbreaking research, and the contribution of each of the 50 people involved will be equallycrucial. We are very grateful to you for being here. Whatever happens regarding what kind ofdose you receive we can predict the following:

1) You will have a day of listening to music, with all your needs taken care of for the day-the music experience will be augmented by psilocybin, but not necessarily a high dose-so it is possible that you will feel quite normal and possible you will feel quite strange

2) By being here, being open to whatever happens tomorrow, and making a commitment tosee out the study, you are making a very important contribution to the ImperialPsychedelic Research Group, to the scientific study of depression, and to all those whoneed new mental health care treatment options.

Intense and challenging experiences You may have heard of ‘bad trips’ (explain that these areoften about the release of powerful emotions in an environment where they cannot be contained,and thus people resist- it is the resistance which causes the anxiety). Here, if powerful emotionsare released, that is a wonderful opportunity for healing, because you are completely safe, andwe are here to help you fully accept whatever comes up, rather than resist it. So if you receivethe opportunity to face your most painful feelings, welcome it, because our research shows usthat challenging experiences in a therapeutic environment are often seen by those who wentthrough them as providing opportunities for growth, and are often associated with increasedwell-being afterwards. Having said that, when you are in the session it can be hard to gothrough such intense emotion- whether it is sadness or anger or even joy (sometimes peopledon’t feel deserving of good things). So if an intense emotion starts to develop (whatever it is),we’ve seen that the more you embrace it, the deeper you go into it, the better.Don’t worry if you don’t have an intense challenging experience of confronting your deepestemotional pain: it might be intense but pleasurable, or you might not feel anything much at allhappen. If that happens, try to remember that you are contributing to groundbreaking research,and see where the music can take you.

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TRUST THE SUBSTANCE, YOUR MIND, THE THERAPIST.

Substance: non toxic, physiologically well tolerated (used with terminally ill patients),non-addictive, in research studies since 2006- no safety concerns, no flashbacks, no one hasdied from psilocybin. In large scale population surveys, no link between lifetime psychedelicuse and any kind of mental health problems, in fact linked to lower rates of suicide, psychiatricinpatient visits and medication. No side effects found so far apart from sometimes a bit of aheadache afterwards or the next day). However it can feel intense: depending on dose it couldfeel much more intense than drinking alcohol, perceptions can be much more altered. Thepsilocybin can induce some physical effects, maybe some temperature change, or some shaking,or a feeling of pressure/ turbulence. These are all totally safe. Nausea is rare but possible. Tell usas soon as you feel something and we can help you focus on the feeling which usually helps itpass quicker.

Trust that your mind is totally capable of handling this: In the same way that the sky cancontain all different types of weather without being harmed by it, so can you contain whateverthoughts or feelings or images that come up. But us humans want to control every thought orfeeling, we want to stay safe, stay ok, we try to battle our storms, push back the rain clouds. Buttomorrow is a chance to TLO, let it be. If it’s raining, let it rain, no amount of rain can hurt thesky.

Trust the team- you will never be alone. You can trust us, we have a lot of experience doingthese studies, a lot of expertise, we have medics and nurses all around. So although no one hasever died from psilocybin, or had any physical complications, if this was going to be the dayyou had a burst appendix or something else completely unrelated, you are in the best possibleplace, it will be one of the safest days of your life, surrounded by care. I’ll be absolutely withyou every step. One of the analogies we use is that it can be like a journey, exploring a forest(and of course that shouldn’t be too hard to imagine, here), you might be walking through aclear beautiful sunlit path, or you might be walking through the darkness, deep into your pain,maybe some difficult memories. We’ll talk about that more later. But the way you explore thisforest can feel more like a canoe ride than a walk – you might feel like you are being pulledalong, it could even be quite turbulent, but I am there with you in the canoe the whole time.During this ride together, you can say anything, there is nothing that cannot be said, we reallyencourage you to just say anything that is on your mind, no matter if you thought it soundedreally strange. These experiences can be strange and we absolutely relish the strangeness, it ispart of the beauty of it. This is a rare chance to say absolutely anything on your mind.

Two things that come up a lot: sex/ suspiciousness. Both these things could come up and areoften hard to talk about

Sex: Psilocybin can sometimes make people feel a kind of sexual energy. If you feel that,welcome it, it can be very nourishing and healing. There is sometimes a taboo around talking

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about sexual issues, but please feel that whatever your experience, it is welcome in this room. Ifsex was a relevant theme in your experience, you can share that with us. Also, sometimespeople feel romantic feelings towards one of their guides. We think this might be becausepsilocybin sessions can really be very loving and blissful. Although we spend most of the preptalking about the potentially difficult bits, these challenging moments often lead to very positivestates, and it can feel like there is a lot of love in the room. This can be projected onto yourguide. It’s worth mentioning that no guide would ever engage in a romantic relationship withsomeone having psilocybin therapy, and because that is so clear from the start, it’s easier to talkabout any such feelings if they do arise. We refer to this as a ‘heart opening’- it’s nothing to beembarrassed about, and it can lead to positive things if it is seen as your own subjectiveexperience, part of your therapy process, rather than being ‘reality’. Participants in psilocybinsessions ‘project’ all sorts of things onto guides- you may see us as representing people you areangry with (give relevant examples to this particular patient), or people you love very dearly.This can be an important part of the therapy process, and is absolutely healthy as long as it istalked about. If you start to see us as angels or indeed demons, tell us, and we can work itthrough. It won’t be the first time, and we won’t be offended. It’s our honour to be able toreflect these feelings back to you and support you as you learn what these feelings are tellingyou about your own internal world.

Suspiciousness: Linking on from this, psilocybin can sometimes make people feel suspicious, itis usually short lived, but if you suddenly felt you couldn’t trust us, this can be hard to say, butplease do, we can help you through it as we have with others. That could be a really importantmoment that you were able to get in touch with lack of trust and share it with us. You could justsay ‘I’m struggling to trust you right now’.

Sometimes the content of your experience might be about things we often see as taboo, I’vealready mentioned that themes around sex are quite common. Themes about death or violencemay also come up in your experience. We know how to allow you to explore whatever comesup, without compromising safety/boundaries. We would sometimes work as a team here- that’sjust really to make it easier for us. You don’t have to worry about this, it’s our job to help youengage with your experience fully, whilst making sure that all the boundaries are maintained.Any and all of your feelings are ok, and we can contain that experience, respecting yourboundaries. If I did ask you to do something or stop doing something, you can be reassured thatwe are just doing this to keep us all in the safe space that we hold for you here. For example, ifyou felt a strong urge to punch something, we can use pillows and blankets to create a containedspace for you to express that energy, without hurting yourself or us (demonstrate pillow/ blanketexercise). If you did have this feeling, it would be much better to express it than to push itdown and keep it in. Your job is to try to say yes to whatever arises: our job is to support you toengage with your feelings in a way that is safe. That is why we are here. In our own work withpsilocybin we have ourselves really appreciated the support of facilitators to enable us toexpress our own intense feelings without judgement, and with full acceptance. That is what thiswork is all about.

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If you have an experience of going through something horrible, like a painful event or trauma,we are here to support you to go through that experience. In our experience, if something likethis is happening, rather than resisting the experience it really is better to go through it, but forthat you may need the close support of your guides. So you could tell us that you felt you werebeing hurt in some way, and we would sit right by you and just encourage you to remember thatyou are safe now, and that it is ok to fully surrender to the experience, and that you will learn alot from it. It can be helpful for us to hold your hand or your shoulder during something likethat- would you want that? (negotiate reassuring touch during a trauma reliving).

If you have cold feet before the session, please share this: It’s natural to feel nervous, andimportant to share any last minute doubts, and we won’t proceed unless you’re ready. So- youcan relax knowing that I am taking care of you, supporting you so that you can go as deeply intothe experience as possible. You can’t do anything wrong – whatever comes up needs to comeup. Everything is welcome.

Unpredictability Emphasise unpredictability. Three people did not respond to high doses lasttime. Some had strong responses to low doses. Variety of effects (can give a few examples,perhaps of participants in the last study, also some self disclosure, if that feels right. Forquestions about what psilo does (psychological mechanisms), you can focus on themes from thequalitative follow-up last time. For brain mechanisms- DMN deactivation- snowy mountainmetaphor/ shaking snow globe/ reset/ hyperconnectivity-plasticity-flexibility. Overall: increasespsychological and cognitive flexibility.

Also, both sessions likely to be very different from each other

INTENTION

This is time for them to talk a bit rather than listen. What are their expectations? Differencebetween hopes / expectations and intentions. Tourist Vs Traveller.

Go through the three questions (from the check-in call) and their answers (which you wrotedown) and the objects. Lay out items on the table.

Can they form an intention into one sentence? Make it positive rather than negative (ie, I amgoing to take psilocybin in service of exploring………..)

So after this talk today about intentions, tomorrow we try to really let go of any expectation andsurrender to whatever comes up, trust that what comes up is right for you. It might be gentle,intense, challenging, enjoyable, and it could be all of those things at different times. It’s a dayto practice the art of surrender and acceptance, the art of TLO.

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IN AND THROUGH

Often in life we try to suppress pain, or numb pain. But pain is an indicator that somethingimportant isn’t working. Emotional pain can be seen as a navigation system. When it shows upit’s an opportunity to learn about what’s not working, why it matters to you, and how theproblems can be tackled at the very root. But in order for the pain to be helpful, we need to go‘In and Through it’. Resisting pain just prolongs it, maintains it. It’s a fundamental idea of thistype of work that sitting with our pain is how the pain gets healed . But getting to the root of it,sitting with it, learning from it, healing from it: that is easier said than done. Usually in lifethere are two major barriers to this , the first is that accessing pain is hard, a lot of it is storedaway and hidden . We brush it under the carpet- or another way of thinking about it is that wepush it down into the basement and shut the door. The second is that we don’t want to open thatbasement door, because it feels horrible to confront those feelings. But if we don’t confrontthem, they just fester, they don’t go away. Psilocybin can help you open up that basement doorand deal with what’s been lurking there in the basement. That doesn’t mean that we canguarantee that your worst traumas will come up – but if they do it is to be welcomed. Equally, ifthey do come up, it doesn’t guarantee that they will then be healed straight away, sometimes it isthe start of a long journey of healing- and often that journey starts with gaining insights aboutthe roots of the problem, learning about what’s in the basement, and understanding it better.So, during your day tomorrow, you might feel some pain, loneliness, shame, grief, anger, fear.If you do, dive in, go ‘in and through’. In and Through is another of the sayings from BillRichards. Remember pain is your navigational system, and tomorrow if something verypainful comes up, you are encouraged to go towards it, not away from it .

If you're feeling anxious, that often means you're close to something important (warmer colderexercise- when feeling anxiety, good, you’re getting closer, warmer). Say you were to see animage that represented something really painful or frightening, let’s say you saw a fiery dragon.It’s understandable you might want to run away, resist (it feels just too hot, you want to getaway from it to something colder). But that fiery dragon in your mind is there for a reason (itmay represent something you had locked in your basement for years and this is your chance tofinally face it, look it in the eye. Bill suggests you could ask “What are you doing in mymind?’ What we resist, we give energy to: If you run from it you might feel smaller andsmaller and it might get bigger and bigger. It’s more efficient to welcome it and ask what it isthere to teach you. It can’t hurt you or damage you. If you indicate that you need some supportthen I can become more active, I can get alongside you. I can find out where you are, what youare looking at, and help you face whatever it is, go in and through it, open up and make roomfor it.

Maybe for you it wouldn’t be a dragon, it might be _________________(Insert this person’smajor personal demon). If they show up, try to allow it, see what you can learn, In andThrough.

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Dying: If you feel as though you're dying, it's ok to allow that feeling to be. Other people haveexperienced this before, no one has physically died. So even if it feels really real, that you’redying or dissolving, then just go with it- I'll be with you-remember your body will be OK, andafter you’ve ‘died’ you’ll most likely be reborn, after you’ve dissolved you might be propelledinto the most incredible bliss. (If appropriate for this person you can add: ‘These kind ofexperiences are linked to the deactivation of the ego, and we think this might be why psilocybinmight lead to positive effects on the mind’)

Forwards motion Vs Stuckness: Bill Richards talks about ‘collecting experiences’ : keepmoving forwards. If joy comes up, do joy fully and put joy in your basket, move on, see what’scoming next. Maybe it’s a bit of sadness so it would be a great opportunity to explore somesadness. So really get to know that feeling, learn from it and then put it in your basket and moveon. If death comes up, do death! It’s a great chance to practice. Sometimes you might have tobe with something uncomfortable for a while before you can move on to the next part of theexperience, and that’s fine too. We don’t have to rush anything. Let me know that you arefeeling stuck and I will do my best to help us keep moving forwards, together. The music canreally help with that, go into the music and see where it takes you. You might just feel stuckand disappointed and frustrated all day, and if that’s the case, then we accept that as yourexperience, it’s still valid, and you can still learn from it…your basket might be full of stucknessand frustration so you have ‘done’ stuckness fully, and we have the chance to talk through thatexperience and see what you can learn from it. It is ALL learning. And the experience might beof boredom and disappointment- and that can be painful: but remember it’s not in vain- if youhave a boring/disappointing day, it is the most scientifically significant boring/disappointing dayyou’ll probably ever have.

GROUNDING

We will be giving you our undivided attention and so if we pick up that you are feeling somesadness or anxiety then we might instinctively want to offer our hand as a support. Is that ok foryou if we reach out to you if we sense you might appreciate it (and any time you want us tostop, or you need space, you can just pull your hand away). We sometimes take the hand duringthe first part, and then later if you move your hands in any way we can take that as a sign toreach out. Hand holding can provide a sense of grounding, and there can be a physiologicallycalming effect on the body when the hand is held. Do you have any difficulties with that kindof touch- hand hold? What about a hand on the shoulder? We can show you what we meanwhen we do the run through in a moment. But we encourage you to be open to this- it’s fine tochange your mind, just letting you know it’s available, sometimes people say no but then in theexperience they want it. If you would like this kind of support- there are different ways you canindicate to me- if you can’t really speak you can just shoot your hand in the air, or just move inany way, and I will be there beside you and take your hand. You can indicate you’ve hadenough at any point, just move your hand back. Do you find asking for help easy/ difficult?(SELF DISCLOSURE)- how hard it is ‘I have to do it myself’- allowing yourself to be

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vulnerable and needing another human hand, and asking for it, and receiving it, can be a hugepart of the healing.

These experiences can be very physical, at the beginning particularly. You might get a little fightflight response, nothing to worry about, and breathing together can be helpful- we might breatheslowly with you.

Another thing we sometimes do is called focusing, if you have a particular sensation in yourbody this can be a kind of trapped emotion and learning about it can not only unblock it, but canalso hold some really key breakthroughs for people, they gain insight into the way their bodyresponds to certain emotions. In focusing, what we might do is simply ask you to ‘focus onwhere you feel that emotion or sensation in your body’. So, if you said you felt sick (this is veryrare by the way, people are very rarely sick, but it’s not impossible- if you felt nauseous youwould just tell us and we would just get a container and help you, you wouldn’t even need totake your eyeshades off) we might ask you to actually focus on the nauseous feeling, whereveryou feel it. Rather than trying to distract from it or avoid it, we encourage you to dive right intoit, ‘try to make it bigger not smaller’, and by focusing in that way it usually passes. Sometimesit gives you a little insight on the way.

Focusing: 1) where do you feel it in your body? Can you find a label for it (get a handle onit-spiky black hole/ fuzzy mush). Saying hello to it (defusing and getting present), see it issomething separate, not as an annoying part of us that we need to get rid of, open awareness andcompletely experience this as it is rather than trying to change it. Tell it (even an uncomfortablefeeling) that it’s OK for it to be there and you are aware of it.

IT IS YOUR JOURNEY

You don’t have to look after us, please us, entertain us, impress us, include us. You don’t have tothink about our needs in any way. We are here to serve you. You don’t have to constantly reportwhat’s happening. You can indicate ‘not now’ and tell us later. We may check in every now andagain- this is an invitation to say where you are. As you may be listening to music in theheadphones you may not hear me, if so is it ok if I tap you on the shoulder to get your attention?I will ask ‘would you like to tell me where you are?’. Sometimes you will be travelling at a fastpace, imagine being on a canoe going down a fast river: by the time you’ve described whereyou are, the scenery will be different anyway, and sometimes there are no words to describewhere you are. That’s fine. If it will interrupt your flow to start talking, then you can just shakeyour head/ give us a sign that you are ok but not wanting to talk, maybe a thumbs up! We willask you again an hour or so later, and again there is no pressure. However if you are in any wayfeeling a bit lost or confused or in need of some guidance or comfort then please do try toarticulate even a few words expressing what’s going on. It is often hard for people to ask forhelp, but that is why we are here. From our point of view it is quite difficult to know what isgoing on (people might look blissful but be a bit lost, or be crying but actually be crying tears of

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joy) so please if you are lost or struggling in any way, try to reach out, or just say a couple ofwords to indicate you’d like us to lean in a bit, and then we can help guide you through it.

Please feel free to fully express what you are feeling. If you feel angry you can yell at the top ofyour voice, and if you feel joy you can dance and sing! We’ve seen it all before, it’s allwelcome.

If you want to walk around the room, or read books, that’s fine, anytime you want to go to thebathroom we can help you if needed.

HOLD IT LIGHTLY

We have come to trust that psilocybin sessions take people where they need to go. That is notthe same as believing everything you see. If you do see images they might be symbolic, so tryto remember that this is happening in your mind. The mind is full of mystery. Don’t try to graspon to any insights or revelations as hard facts or orders. Hold them lightly. Don’t try tounderstand everything: you never could anyway. We’ll have lots of time afterwards to talk aboutit, think about what it might mean. But on the day, try to let go of needing to understand. Itwon’t stop it from working if you don’t understand everything. In many ways the healingseems to happen on a whole body level in a way that is far beyond our current understanding, sobest to let the psilocybin do its thing, go wherever it takes you, look at even the strangest thingswith the eyes of a child- open, willing, playful. And hold all of the ‘lessons’ and insights lightly.Don’t worry about trying to remember everything, you will remember what is important.

BREAK

3. PRACTICALITIES AND ANSWERING QUESTIONS

Meals: We will eat a meal together at some point, so just say when you’re hungry and we haveour meals delivered. We have water and snacks. Tomorrow morning, please have your porridgepot before 8, have your usual caffeine. Don’t take any meds.

Music: The music is a key part of the experience. Whatever the dose of psilocybin, this is amusic meditation, a chance to be out of your daily life, a luxury really, we want you to feeltotally supported in giving yourself the gift of a full day to look inside, and be with your owninner world. So try to be with each moment of the music as it happens, and be with whatever itbrings up. We will change the music if it’s not really working for you. We might ask you whatit’s bringing up before changing it (i.e, if it’s bringing up sadness, it’s probably good to face it sowe might try and keep it on, but if the music is somehow blocking the experience for you, justtell us and we will change it).

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Mantras (TLO - Trust, Let go and Be Open; In & Through; Open up and Make Room for It;Go Deeper; See if you can you say ‘YES’ to that)

**** women- quick catch up re menstrual cycle – how can we accommodate? Emotionally andphysically.

We’ve given you so much information. How is this all feeling for you, anything you want toask/clarify?

Please let us know if you have any questions

4. RUN THROUGH & METAPHOR

P-ACE (PREPARATION - ACCEPT CONNECT EMBODY) SCRIPT

I invite you to close your eyes, steady your breathing, in and out through your nose,slowly. Bring your attention to the tip of your nostrils and how the air feels cooler here on thein- breath and warmer on the out-breath. Keep your focus on this feeling in your nostrils as youbreathe in and out. Keep breathing slowly.

Imagine a vast ocean early in the morning, the sun is rising over the surface of the sea.You are on the beach, where the waves lap at the sand. You are picking up some divingequipment, you’ve had your diving training and a new adventure beckons. A boat arrives; youare helped aboard and shown your comfortable seat at the front of the boat. The sun is on yourface as you gently sail out to the very middle of the ocean, you feel yourself glide forwardsteadily. Then the boat stops and drops an anchor. You know it is time to disembark. This boatstays here all day, and will be there to take you home when you are ready. You stand up, take adeep breath, look around you, take in the bright blue colours all around: the sea, the sky, somany different shades of blue. When you are ready, you climb down a ladder, and in the glintingsun you lower your body into the waters. The water is warm. You are bobbing up and downthere on the water, ready to take the plunge. When you take the capsules tomorrow you will bechoosing to dive deep into yourself: it’s a bit like diving into that ocean, to learn about what isthere deep down. So, imagine now that you are there bobbing about on the surface of the seaand then you take a deep breath, and you dive deep down. (If you like you can go ahead and liedown on your stomach, with your arms outstretched in front of you in a diving position.)Imagine you are diving down into the warm water. You are completely safe: as you dive downthe water surrounds you and holds you. You can breathe so easily, and you feel held, supportedand warm as you swim down, deeper and deeper. Currents pull you in this way and that way,you just trust, and let go and you swim deeper down. You are on a journey, you are carried bythe current, you don’t have to decide where to go, just let yourself be carried. With eachmoment you surrender yourself more and more, you let go, and allow yourself to glide alongwherever this journey will take you-up, down, sometimes smooth, sometimes turbulent, butalways knowing that you are safe. Let yourself surge down, with force and purpose. You are

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swimming deep into yourself, exploring parts of yourself that you have never explored before,and you can trust that you will be shown all that you need to see, that you will feel all that youneed to feel, without you needing to control anything, or rationalise it, or make sense of it. Allyou need to do is trust, let go, and be open to these waters, see what you might find.

As you dive down towards the sea bed, sweep your attention over your whole body.sweep your awareness over your body from the tips of your fingers down to your toes: the tipsof your fingers, hands, forearms, upper arms, shoulders, neck , face, top of head, back of neck,upper back, chest area, heart area. Stay here for some heart breathing: When you breathe inthrough your nose in a slow in-breath, it’s as if you are breathing into your heart: breathe in,hold the focus there in your heart, and breathe out of your mouth, let it out. And again, breatheinto your heart, hold the breath there, feel the warmth of it, and then exhale, let go. Breathe intoyour heart (breathing through your nose) and then breathe out through your mouth, letting it allgo. Then continue to sweep your awareness to your stomach, thighs, calves, feet, toes. Nowbring attention to the whole of your body, the space inside. Do you feel any tension? Andtenderness? If you have any uncomfortable sensations in your body, don’t try to distract oravoid: instead try to really feel them. They are messages from your body that want to be heard.This is a time for opening up, for learning. If there is an uncomfortable sensation, make spacefor it, allow it to be there, feel it all. Rather than trying to distract your attention away from it,give it your full attention, say yes to that sensation, you might even like to give it permission toget bigger. So in this way, rather than distracting your attention from anything that feelsuncomfortable, go deeper into it. If your chest feels tight, really stay with that feeling. If yourstomach feels knotted, stay with that feeling too.

Now you are diving deeper in the ocean, there are so many different directions you cango in, many things to see. There are bright corals and beautiful exotic fish in some directions,with shafts of sparkling sunlight shimmering down through the crystalline blue waters. Themost beautiful delicate sea creatures putting on the most elegant displays in this magnificentmulticolour wonderland. In places the seaweed is thick and the water is murky. Be carried byyour willingness to experience everything fully. We trust that the currents will take you whereyou need to go. If you see a tangle of weeds, swim straight into the very middle of it, not awayfrom it. “In and through” you go. Right through the middle and out the other side. You have atorch-shine your light on the murkier places, explore everywhere: embrace this opportunity tosee and feel things you’ve never seen before, the tangled seaweeds as well as the bright seaflowers.

At times you may find yourself swimming against strong currents, and be moving veryslowly. Let go of any expectations or requirements of yourself. Let yourself be slow, do“stuckness” fully, let it be just as it is. Can you say yes to whatever is there, to each moment,exactly as it is, without needing to change it? Trust that the learning will come in time, maybeit’s important to feel stuck for a while, meaning will unfold.

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And now you swim down to the sea bed, search your hands through the mud, feel it toits depths. Sometimes what has been hard, and dark and spiky in your life might be waiting foryou here. It can feel like the water gets cooler and shadowy, and then you come across piles andpiles of spiky ugly oyster shells. The fish don’t swim here, the whole place feels uninviting, andyou might want to turn back and find those beautiful fish and shimmering turquoise watersagain. But go on, go forwards. Go right into the pile of shells, let yourself feel them, everyrough angle. The shells are firmly shut, impenetrable, and difficult to open. These oystersrepresent the hardest, spikiest darkest things in your past, that have been kept firmly shut andout of sight. The oysters also represent the heavy feelings, the negative emotions, the feeling ofdepression, of grief, of fear, of loss…..these oysters are the things you want to avoid. So nowthat you are in the realm of dark shells, take this moment to connect to your body, thesensations, are there any uncomfortable feelings? Is there some fear? That it will be challengingtomorrow, that it won’t work for you, that you won’t do it right? Any other painful feelingscoming up because of what we talked about earlier, any difficult memories, or feelings of shameor frustration at yourself? If you can identify a difficult emotion, or maybe there is more thanone, imagine that each one of those difficult feelings is a separate oyster shell. Each shellrepresents a different difficult thing that is there in you right now.

Take some time to really search yourself and list all emotions you can feel. When youhave searched around let me know what emotions are there in you. It’s ok if there are positiveemotions. When you are ready, list them all to me. And then we will take some time for you toreally feel each one (*****they list). (validate all feedback, attend to physical contact needs)

When you make space for these emotions it’s a little bit like prising open the oystershell. Opening it up, even though it feels tight and spiky and like it wants to stay shut. Prise theshell open gently, just a little, open up just a bit to this feeling. Give the feeling more and moreroom to grow. So opening up the first oyster (emotion 1) stay with it….really feel it. Where doyou feel it in your body? And opening up the second oyster (emotion 2), where do you feel it inyour body? Make space for it to be there.

Now when you open up oysters like this, when you search deep into the spiky things thatseem impenetrable at first, sometimes you find a pearl. The way a pearl is formed in an oysterinitially is that a little bit of grit gets inside the shell. And the oyster responds by very slowlycoating that little bit of grit with the mother of pearl. It doesn’t eject the bit of grit, it lets it staythere and it coats the grit in a shimmering beautiful layer that turns that bit of grit intosomething very precious. The oyster accepts the grit and turns it into a treasure. So now that youhave opened your (emotion1) oyster and your (emotion 2) oyster, search them both for pearls,and that means search for the lesson in your pain, the meaning in it. That is the precious gift, thepearl in your oyster. So for (oyster 1): why do you think you have this feeling? What does itshow you about your own needs, about what really matters to you? This feeling is a messageabout something. What is the message? What is this feeling there to tell you? And oyster 2….(ask for a bit of feedback about the essence of the meaning, validate all feedback, attend tophysical contact needs)

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So when you feel your emotions fully and search for the meaning in them it is likesearching through spiky oyster shells on the seabed, prising them open gently, and looking forpearls of meaning. The pearl is the message. Your emotions are always trying to tell yousomething about what really matters to you.

So, you felt (xxxxx) and you felt it until you understood its message (xxxxxx). This is apearl. Hold it in your hand.

And you felt (xxxxx) and you felt it until you understood its message (xxxxxx). This is apearl. Hold it in your hand.

And then, when you have this pearl(s) in your hand, wim up, up through the watertowards the sky. You are swimming with great energy, kicking your legs. As you swim upthrough the surface you can actually turn over on the bed right now, so you are lying on yourback, and sweep your attention over your body from the top of your head down to your toes,and just notice how your body feels. You are gracefully pushing up to the horizon. And thenwith great energy you burst through the water. Suddenly there is great calm, the water is still.The sky is so huge, and it is glowing from the pink sun which is now a few metres above thesurface of the water. As the sun rises you feel it getting hotter and hotter, all over your face andshoulders.

And, then you see the boat. It has been there waiting for you all this time, with itsanchor holding it steady. You climb aboard, putting the breathing equipment away, and sittingon your special comfy chair at the front of the boat. And as you sit there, wrapped up in ablanket, you feel incredibly light and free. You are just gazing at the rising sun. And looking atthe water, still and calm, reflecting pink rays on its silvery surface. Then you open up yourhands and look at the pearls you brought with you from the oyster shells. Remember themessage of the pearls…. (remind them)…they said that (…….) matters to you. So you sit therein your comfy chair, and for the next few minutes while the boat carries you back to the beach,just think a little about the oyster shells you encountered just now and the pearls you found inthem, and think how this experience might inform an intention for the psilocybin sessiontomorrow. How can you honour these feelings? We can talk about it in a moment, but for thenext few minutes let the music carry you along and reflect on your intention for tomorrow.

Ok we’re at the beach, you can open your eyes. Did you have any ideas about anintention for tomorrow?

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INTENTION

Did you learn anything that might add to your intention for tomorrow? (if so- add it in to thesentence, write it down)

(if not, just ask for feedback on the exercise, validate any difficulty, make sure they arereassured that if they didn’t see or feel anything that doesn’t matter because many people don’tand still have very rich and beneficial psilocybin experiences). If they struggled to let go,validate this as important info, make plans for tomorrow, i.e. if they struggle to let go how canthey tell you tomorrow? (They can just say- I’m not letting go’ and you can do a raftvisualization- ie you are floating on a raft, sun on your face, letting it flow- body scan- heartbreathing )/ you can change the music/ hold their hand/ turn the lights completely off/ validatethe stuckness experience as where they are – say yes to it, what does it feel like? Go into thebody. So reassure them that this was useful learning. And then go back to their intentionsentence.

*****again…..if people have seen lots of media about psychedelics, explain that many of thequotes from patients are from the 6 month follow ups-, people looking back- but they may nothave said that straight after the session. It’s a process. Psilocybin can open a door, but you haveto walk through it. Not a magic cure. As you approach the session, let go of needing it to bemystical- magical -wonderful. It might be. But the majesty of it can come in many guises, andit may not all make sense tomorrow. Often meaning unfolds gradually. If it feels like a bit ofsoup of stuckness, that is ok. If it seems to have nothing to do with your intention, that is ok. Ifit seems really banal, that is ok. Let go of all expectations. Just try to say yes to every momentand trust that you will be receiving something important, and that you will learn a huge amountfrom your day tomorrow.

SESSION DAY

Therapist: Dynamic meditation in the room from 7-8

PREPARATION

Therapist prep: discussion about 1) participant’s intentions 2) particular ‘sore spots’ 3) touchand music preferences 4) therapist’s countertransference.Place a new notebook (stack of these in the office) and pencils for the participant at the bottomof the bedside rack.

8.50- 9:00 Music starts, aroma mister filled and turned on, candles and lamps arranged- mainlights turned off. Therapists- quiet sitting meditation to establish the field.

Participant- greeted by Psychology assistant at 8.30, taken to the CRF lounge.

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(A participant has had light breakfast at 7.30 in their accommodation, if they need it- otherwiseno breakfast. Usual caffeine intake is essential to avoid withdrawal headache). Psychologyassistant checks how the participant is feeling, and makes sure they have had usual caffeineintake. Doc does a urine test.

Admin assistant goes to collect psilocybin at 8.30, takes it to CRF staff lounge

After therapist meditation, one of the therapists comes to collect the participant from theparticipant lounge and brings them to the room (9.05 ish). When the participant enters the ante-room, they take off their shoes and coat, take out their phone- turn it off and leave it in a safebox in the ante room. They are given their slippers. ‘Forest Stream’ is playing. Another therapist(in the room) stands up to receive the participant. Settle the participant in. Show them the itemsin the bedside rack- tissues, water in the non-spill water glass with a lid and straw, headphones,eye mask. There are art books and their own notebook and pencils at the bottom of the rack.Explain procedure for bathroom breaks, music adjustments, and that they will be in the suite thewhole day. Time at the object table, looking at what they have brought, but letting go ofspecific intentions/ expectations.

When ready, one therapist goes to collect psilocybin. The capsules are placed in the woodencontainer, and there is a moment of reverence while the participant takes the capsules. Thenguided meditation if appropriate/ wanted. The participant is encouraged to look at the art booksuntil they want to lie back with eyeshades on (encourage this after 30 mins if they have notspontaneously done so).

Therapist writes notes on the form (Appendix 1) only when the participant is ‘insidethemselves’ , autonomous and calm. The therapist can also read during this time, but we willhave no phones in the room. Phones are kept in the ante-room, participant’s one is turned off,guide’s one is on silent and is only to be used in emergency.

INTERVENTIONS DURING THE SESSION

Main rule: Constant presence. If they are engaged, do nothing. If they are not engaged, dosomething.

Check in: How are things going, what’s happening, how’s it going? Later on: If you need help,let us know, if you feel you are getting bogged down or going around in circles.

Check resistance: Is there anything you are resisting, what is hardest to let go of?

Touch: Grounding touch on arm, shoulder (negotiated with each person)

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Guiding: Specific questions around what they are seeing/feeling: What does it look like/ want toshow you?

Breathing together: Ask about any bodily discomfort/ feeling blocked

Focusing Focusing: 1) where do you feel it in your body? Can you find a label for it (get ahandle on it-spiky black hole/ fuzzy mush). Saying hello to it (defusing and getting present), seeit is something separate, not as an annoying part of us that we need to get rid of, open awarenessand completely experience this as it is rather than trying to change it. Tell it (even anuncomfortable feeling) that it’s OK for it to be there and you are aware of it.

Music alterations: Keep to playlist, but deviate to extra playlists to follow strong incongruousemotion.

If they are struggling to let go (thinking too much): 1) Change the music. 2) Body scan 3)Guided relaxation (imagine floating down a stream) 4) Validate that this experience of struggleand resistance is where they are at, and important to be with it ‘There is nothing you can dowrong, it’s all part of the process, let’s just be with this feeling of (……………) and let it be’

Reinforcement/ Suggestions: Well done, you’re doing really well

Boredom: Look at books, altar objects, intentions, values. LUNCH

POST SESSION

Stage 1 integration: witnessing the unfolding narrative, help them stitch it together – nointerpretations. Encourage them to write as much as they can tonight when they get to theaccommodation.

The participant is given their ordered meal if they did not have it for lunch. If they had lunch,they are given a bag with soup and snacks to be eaten in their accommodation.

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INTEGRATION

INTEGRATION OVERVIEW

Integration is based around the Accept Connect diagram- See ACE paper (Watts & Luoma, 2020)- 6 processes of psychological flexibility- Let go (defusion) / Sense (present moment focus) /Feel (willingness to feel) / Self (self

as context)/ Meaning (Values)/ Intention (committed action)

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The participant can record on their phone.

Overall they receive four fixed & up to three flexible sessions.

FOUR FIXED SESSIONS

1. 1 day post session 1 A2. 1 week post B (call)3. 1 day post session 2 C4. 3 weeks post session 2 D

Extra flexible sessions: Up to 3 Skype integration calls with a therapist. Unlimited ‘care calls’with Psychology assistant

Our integration model is ‘funneling’ session content through three stages of integration(see Appendix 2)

● Stage 1 (top of funnel, wide mouth) -unstructured reporting of session content. Therapistwitnesses, no interpretations.

● Stage 2 (middle of funnel, narrower)-making meaning. Making links.● Stage 3 (the neck of the funnel)- distilling actions.

Integration is not therapy. Integration processes the material from psilocybin sessions. Therapyasks people to explore their inner worlds generally. We are comparing psilocybin withescitalopram. Psilocybin comes as a package (prep and session and integration). Escitalopramdoes not come with therapy alongside it. Therefore, we are not providing ‘therapy’ to theescitalopram people, we are helping people who have been through intense psychedelicexperiences process what they have been through. If they have not been through much in thesessions, we will not initiate a separate therapeutic process.

I am referring to low session content vs. full session content (rather than placebo vs. high dose).We are helping people process the material that comes up for them. So people with less sessioncontent will require less integration time. We will record how many of the optional extra Skypesessions each person uses.

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1. INTEGRATION A (MORNING AFTER SESSION 1)– BOTH THERAPISTS

Today (Integration A) unstructured witnessing, no interpretations. Gently moving into stage 2 ifand when they are ready (starting to help them make meaning).

At the end of the session, explain the three levels of support:

Three levels of support

1) Contact with an assistant psychologist in the first part of the call to check if you needanything. If it is general questions about your participation in the study, or you havehad an idea/insight/dilemma and want to talk it through, the assistant psychologist canprovide a supportive listening space. Email the assistant psychologist and she/he willcall you that day or the next day if possible. She/he will pass on all information to theteam.

2) If you need a little bit more support (you need support processing content from thesession/ you want to talk to your therapist, or the assistant psychologist thinks it is agood idea for you to talk to your therapist) the assistant psychologist will contact yourtherapist to arrange a time for a Skype integration session- you have three of these totake).

3) If you are struggling a lot, phone our doctor straight away. And if feeling suicidal,A&E.

Suggested session outline for Integration A

What was your experience? (presence, witnessing, reflecting, validating).

Low session content (ie, they did not experience very much):

You are helping them process THEIR MATERIAL (if not much of a trip, not much processing)

Say: we next will talk in a week, over skype, to see how you are doing. Introduce the simplediagram (accept, allow those inner feelings, connect to the outer world).

Full content (ie, they had an intense experience):Listen to the content. Go through the stages (Appendix 2)

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Say: integration naturally happens in the days, weeks and months afterwards, you may wellhave new ideas, reflections, insights. The work really comes from inside you, we are here tosupport that process if required, but we don’t know what the new directions for you might be,that can only come from you, and it is best to go quite gently and slowly. Baby steps. Youprobably had an intense day yesterday, so the most important thing is to be kind to yourself asyou start the integration process. Give yourself as much time and space to process the changeshappening inside yourself and get the most out of them.

So you and I will be talking in a week for our follow up skype, but if you want one of the extracalls before then that is fine, integration happens in these next days, new insights, up and downtime. We’re here. So we can have three calls at any time from now, would you like a call beforethe week Skype (visit B) ? Many people do use their first call in the first week but it’s optional.

Plan for the next few days- what are they up to? How can they create space for reflection? Askthem to journal generally- no filter, they can share it with us or not. ‘Vomiting it out’, realhonest delving into the most difficult painful stuff. Anything that comes up. Journal also: Whatdo I want to explore next time? If this time was ‘in the cellars’, is there still more to unpackdown there?

Give resources: music playlist , listen back as you journal. Integration Support postcardAccept/Connect Diagram is a simple reminder of the two key directions: what small ways canthey sit with / be with / allow/ accept their inner feelings AND also connect to the outer worldmore? Keep it in a wallet, or stick it on the fridge. You won’t be on your own during the nextthree weeks, the assistant psychologist will be there. Encourage them to start journaling.

*****Remind people: If they have seen a lot (ted talks etc) explain that the ted talk lookingat our study (connectedness/ acceptance) was based around interviews at the 6 monthpoint, people looking back- but they may not have said that straight after the session. It’s aprocess. Psilocybin can open a door, but you have to walk through it. Not a magic cure

Integration Support Postcard

Side 1: (diagram)

Side 2: Integration Support If you require some therapeuticsupport between appointments, please do reach out to the team! Ifyou email the assistant psychologist she/he will call you back andliaise with your therapist to work out whether a call with her/himor your therapist is indicated. If you need more urgent help callthe study doctor (available 24 hours). If you have any suicidalthoughts or urges please go straight to your GP or A&E and askyour care providers to contact our study doctor.

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2. INTEGRATION B (CALL) WEEK AFTER SESSION 1Low content: checking to see how the daily tablets are going, and checking for processing oftrip/session. Disappointment. Hopes for next time.

Full content: Continue funneling (Appendix 2) Stage 1, moving on to Stage 2 (distilling themain lessons). Asking about journaling. Potentially moving to Stage 3.

If they report that they have found the simple Diagram (on the contact card) helpful, you mightask about their experiences in the framework of acceptance/ connection (ie, have there beendifficult or painful feelings? How have you managed them? Have you been able to sit withthem? What has your relationship with yourself/others/nature been like?)

Set up a Skype call. (They’ve got up to three calls to take with your therapist, and the assistantpsychologist is there for you any time)They might want an optional call to happen soon, if so, set this up now. Call with the assistantpsychologist (goals, simple support, moving forward, applying insights: She/he can listen, butnot provide any advice or interpretations, but often that’s not needed anyway- can be nice tohave someone listen when you are mulling over ideas/ dilemmas.) Call with therapist: Anycomplex /troubling content related to the session that still needs processing.

Prompts for expanding journaling (if they have taken to the accept/connect structure and youthink it might be helpful for them to expand on this- writing down times when they have beenaccepting/ sitting with painful feelings AND times they have been feeling ‘connected’ toself/others/nature etc. ) Other prompts on these two themes….. Acceptance: What was difficultto accept- what am I open to accepting now? Do I see anything differently now? Insights,lessons? Does any of your past look different to you now? How? Connection; If new paths areopening up to you, how might you track whether you are keeping to your new path?

Session 2Prep call- arrangeSay: We will call you before the second session to see how you are feeling and go over anythingabout psilocybin sessions that you want to talk about (this is not one of your three calls) This isusually the evening before psilocybin, but could be two days before (get the date in the diary).

Prep call (day before session 1)

Prep for the second dose- how are they feeling, anxieties, anything we want to do differentlythis time?Kahlil Gibran quote: ‘the deeper sorrow carves into your being the more joy you can contain’.Any extra objects that we can add in? Bring an object to represent something you want to let

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go of, and then things you want to bring in, or focus on. Any other objects for what will giveyou courage? Or why are you doing this regardless of psilocybin dose?

Music- how was the playlist last time, any new songs, or songs to take out. More on theSorrow? Anger? More happy or sacred?

For those who had a difficult first session, the idea of going in again may becounter-intuitive and scary. This is why from the very beginning - screening onwards- wereinforce the idea that intense emotional experience is not harmful and of the innerhealing intelligence knowing where it needs to go (if this pain is there in you it is anopportunity to process it, learn something, and experience relief afterwards). Key idea:Where you find values you will find suffering, and where you find suffering you will findvalues.

At the start of the session, go over the metaphor/ visualisation again

3. INTEGRATION C (MORNING AFTER SESSION 2)Low content: Overview of the experience. Processing disappointment and any insights.

Full content: Keep following the funnel. Focus on how they can integrate lessons/insights intotheir daily life. Aim for 3 specific goals (but in a gentle, non-clunky way: ‘in how manydifferent ways could you be a loving father? Is there anything that you might set yourselfto do differently between now and when we next meet in three weeks? Is there anythingelse? Does that feel enough or might there be another new thing, no matter how small, thatyou also want to try to do over this time period?’ Plan for the next skype call, to continue theprocess.

If they want to, they can start a ‘Journal of new things’ (acknowledge all the things they dodifferently between today and the final follow-up in 3 weeks’ time. The assistant psychologist isavailable to talk it through).

Skype Calls

Follow the funnel /reinforce new behaviours

Those who have done a ‘Journal of new things’. Think about which of these new things theywant to keep doing? What might get in the way of sticking to the new paths? If that does comeup, what can they do differently?

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4. INTEGRATION D (THREE WEEKS AFTER SECOND DOSE)Present: Sense of ceremony and gratitude, respect to the participant. No sense of hurry.Be present, be your whole self with them (as always but especially today).

Asking initially how they are feeling, getting an overview of the last three weeks. Do theythink they were on escitalopram? What doses of psilocybin did they think they received ?

Unblinding. Those on escitalopram given the option to continue (we have extraescitalopram).Thank you, goodbye.

Full content: Talk through general progress, journal of new things, goals for next week, month,6 months. Setback plan. Go through the Integration group in Hackney, community resourcesetc. Can contact the assistant psychologist until the end of the year. Consider referral for 1 to 1integration therapy with recommended therapists.

Complex diagram: can be introduced at this point, if appropriate (Appendix 3)- only to the highdose psilocybin group.

Here is a tool which can be a guide for you during this time. It’s a reminder of what psilocybinteaches us. It describes 6 processes that together make up a concept called psychologicalflexibility. They are divided into two halves (accepting and processing pain/ connecting toyourself, others, nature, the world around you). It is a slightly more detailed version of the‘accept/ connect’ reminder diagram you have on your contact card.

There is absolutely no pressure to use this. It might just be useful as a framework, so if you arefeeling stuck at any point, if you are not sure what to do you can pick it up and see if it givesyou any ideas. Is this a moment to accept, or connect? How might I do that? There are sometechniques to get out of your head and into your body and your heart (like you did withpsilocybin). And also ways of clarifying and consolidating values, developing goals, and alsostrengthening any new sense of who you really are. It might help you deal with symptoms ofdepression/ challenging moments. It can be helpful in any moments when you might feel lost,afraid , hopeless or alone. If you want any help with this contact the assistant psychologist.She/he can explain it (it does take a while to get it, she/he can help you with any questions aboutit, and will be happy to hear about your progress using it, but remember she/he is not a therapistand won’t be able to provide more than a listening service. She/he can also point you in thedirection of more support if this is required).

If they want to go through the diagram, the assistant psychologist can spend some time doingthis with them after the follow-up session, in the participant lounge. She/he will be explaining tothem how the diagram works as a tool for accepting pain/ connecting to self/others/nature). The

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assistant psychologist can help each person tailor it to themselves- particular ideas for eachlayer.

Staying Connected After The Study Postcard

Whatsapp Group for participants: if you want to be included in a whatsapp group which hasbeen set up by previous study participants (for sharing experiences, asking questions etc) pleasetext group admin

Psychedelic Integration Group: recommend a free or low cost local psychedelic group.

Individual integration therapy: if you would like to have 1 to 1 sessions with an integrationtherapist we can recommend the following specialists:

(Names and contact details of the integration therapists)

5. 6 WEEKS ONWARDS

They have an appointment with their GP the day after the 6 week follow up appointment - todiscuss medication.

If they need a doctor: they need to contact their usual GP, as the study doctor is no longer anemergency contact.

The assistant psychologist - for non urgent listening/ diagram support/ meditation teaching. Shewill pass on info to the therapist. She can also refer for individual integration

6 months – qualitative interview – how things have been (therapist and next of kin alsointerviewed)

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APPENDIX

Appendix 1.

Observations

1hr

2hrs

3hrs

4hrs

5hrs

6hrs

Resistance: stuck points VS surrender, breakthrough

Painful emotions/memories

Somatic sensations

Key insights

Intentions (why doing this regardless of dose, what want more of in life, what will keep me goingthrough hard bits)

Values, ideas about new things to do

Self- compassion

Connection to others/ nature/ wider world interconnectedness- we are all one

Music

Notes for supervision- write on the back

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Appendix 2

Integration stages

3 stages of integration

1. Disorganised content, welcome the chaotic nature of it, don’t try to make meaning too quickly. Allowthe participant to describe, without any censorship, as much content as possible. Get sensory details.What did it feel like? What was your body doing at that moment? Therapist makes notes. Therapist:unstructured listening, summarizing. Pulling together the narrative. Participants can supplement thisprocess with journaling, without self-censorship, editing, or making sense. No need to think of thelessons now. If the participant starts to ‘funnel’, support this process, but do not initiate it.

The simple Diagram is sometimes given when still in Stage 1: Accept/Connect is a simple reminder ofthe two key ‘directions’: what small ways can they allow and accept their inner feelings and connect tothe outer world more?

2. Starting to distill lessons, insights. Links between session content and personal history. Therapist isslightly more active, but it is still coming from the participant.

3. How will these learnings impact their life? Clarify values, develop goals ( in a non clunky way).Relapse prevention. Can introduce the more complex diagram (the pearl dive, with the 6 integrationprocesses) if you think it is appropriate for this participant . Can introduce some ideas from theory ifthese are relevant. Can suggest relevant books.

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Appendix 3

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Examples of questions to help with each of the processes

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