The journey itself is only one part of the psychedelic experience. But while many people are now recognizing the need for integration—processing, interpreting and incorporating what happened during your trip—fewer are focused on what happens before it starts.
Preparation is just as crucial as integration, if not more so, believes Rosalind McAlpine, a PhD candidate at University College London. Most studies and trials include a preparation stage, but there are no established standards for what that entails, and the people designing and leading research often don’t have firsthand experience. It’s why she helped create the first Psychedelic Preparedness Scale (PPS): Based on feedback from people who actually use psychedelics, it measures the degree to which a person is prepared for a trip.
In societies where plant medicine is part of everyday life, “many aspects of what we might call preparedness are often woven into the fabric of the culture, and the community itself acts as a container,” McAlpine told Filter. But in the Global North, “this is a relatively new construct … [and] there’s an active need to make time and space for adequate preparation.”
“Anything we can do before going in to increase the likelihood of having a safe, meaningful and potentially transformative experience … should be exposed.”
In a presentation at Breaking Convention 2023, she likened it to a day trip to Paris: You don’t have to pack, research, or plan a route; you’ll still have an experience. But you’ll probably end up missing a lot of what you hoped to encounter, and you might even end up in an unsafe situation.
Psychedelics, too, will bring you an experience no matter what—but without familiarizing yourself with the possibilities, you could not only miss the benefits, but potentially suffer real harms.
Challenging experiences are often the most transformative parts of psychedelic journeys, but these can be incredibly intense: from encounters with death or otherworldly entities, to repressed memories resurfacing. People need tools to navigate these moments when they arise.
Blogs and articles provide blanket advice; retreat centers give attendees guidelines; but none of this is standardized or geared toward the clinical setting, and little of what users and practitioners are doing is documented, McAlpine said.
The PPS aims to change that. “From the perspective of harm reduction,” she said, “anything we can do before going in to increase the likelihood of having a safe, meaningful and potentially transformative experience, reducing the risks involved and potentiating challenging experiences as growth opportunities rather than traumatic events … should be exposed.”
The team gathered items for the scale based on feedback from both “learned experience experts” and “lived experience experts.”
McAlpine’s team defines psychedelic preparedness as “a state preceding the session that is conducive to a safe and personally meaningful experience. The state will allow the participant to be psychologically, physically, and socially ready for the content and consequences of the experience, and will most likely involve a variety of extra-pharmacological factors.”
The team gathered items for the scale based on feedback from both “learned experience experts” in psychiatry, philosophy and psychedelic research and, uniquely, “lived experience experts” undergoing psychedelic healing, whose perspective is often missing from scientific literature.
The intention was to “include patient and public involvement [or PPI], throughout the whole process,” McAlpine said, from creating the scale to implementing and optimizing it, in order to reflect “not only the rigorous, hard-science framework, but also the voices of those people who would most benefit.” PPI aims to bring accountability, transparency, and relevance to scientific studies—defined by the authors of a paper that inspired the team as “research performed ‘with’ or ‘by’ patients and members of the public, rather than ‘to,’ ‘about,’ or ‘for’ them.”
The scale was built in a three-study process. This involved collecting feedback through focus groups and interviews to determine which measures should be included; exploratory and confirmatory factor analyses to gauge which measures most impacted preparedness; and preliminary implementation. The scale was then validated by two online samples of psychedelics users (516 and 716 people, respectively), and tested on 46 people attending psilocybin retreats at partnering centers, tracking preparedness levels and outcomes.
Preparedness elements defined by the PPS fall into four categories. These include knowledge expectations, meaning the person had an understanding of the substance itself and what the experience might be like; support and planning, meaning they felt the substance was safe to take and had a supportive physical environment; and psychophysical readiness, or being prepared for the whole range of emotional experiences, from bliss to horror, as well as physical possibilities, like vomiting or urination.
Across the board, participants with higher levels of preparedness had significantly better outcomes than those with lower levels.
The final category was intention preparation, involving measures like journaling, breathwork, and meditation—rated most important by participants. McAlpine’s team plans to pilot a meditation-based preparedness intervention at UCL.
Through meditation, one participant said, “I was able to enter the psychedelic state with a more open and receptive mindset. It helped me shed some of my preconceptions and allow the experience to unfold organically, without trying to control it or impose my own expectations.”
Another noted, “[Meditation] allowed me to approach the experience with a sense of curiosity and exploration, rather than fear or resistance.”
Measures of participants’ outcomes included emotional breakthrough; mystical experience; challenging experience; post-psychedelic growth; the centrality of the event (whether, and how, the experience became central to their identity and a turning or reference point for their life story); wellbeing; relationship attachment style; extraversion; altered states of consciousness (gauging the acute experience); and depression, anxiety, and stress.
“The scale doesn’t prevent difficult things from happening, but it can point you in the right direction to reduce harm and maximize benefit.”
Across the board, participants with higher levels of preparedness had significantly better outcomes than those with lower levels. High preparers had higher scores on positive measures such as unity, spiritual experience, blissful state, and insightfulness than low preparers; they also showed significantly greater reductions in depression, anxiety, and stress. When high preparers did have challenging moments in a trip, they were more likely to turn them into growth opportunities, and they were also more likely to experience positive changes in wellbeing after the experience.
“The scale doesn’t prevent difficult things from happening, but it can point you in the right direction to reduce harm and maximize benefit,” McAlpine said. “If one went into those experiences with no idea that was going to happen, it can be an unnecessary challenge … Even a little bit of psychoeducation [and] expectation management can go incredibly far.”
The PPS “could serve as a valuable screening tool to identify individuals who may require additional preparation or support prior to undergoing psychedelic interventions, thereby functioning as a pre-intervention assessment to pinpoint areas of preparedness that necessitate attention,” the researchers wrote. “Furthermore, the PPS could serve as an outcome measure to evaluate the effectiveness of psychedelic preparedness interventions or to compare the efficacy of different preparation protocols.”
Just because a study is conducted in a scientific setting doesn’t mean it’s safe, as evidenced by allegations of abuse and misconduct in some of the MDMA trials conducted by MAPS. “There needs to be more investigation and reporting of what’s going on in those preparation sessions, specifically within the context of clinical psychedelic-assisted psychotherapy,” McAlpine said.
While the PPS was co-created with people who use psychedelics, the studies behind it focused on clinical settings, limiting researchers to including only people who could legally disclose their psychedelic use—those who had participated in research studies, clinical trials, or retreats. (Only clinical-trial participants contributed to the creation of the scale items.)
“The last thing we want is to be like, ‘We’re the scientists, we’re right.’”
Obviously, this misses a massive swath of the user base, as McAlpine lamented, and vastly underrepresents the Indigenous people who are the original keepers of the largest body of knowledge on the subject. It also impacts the demographic makeup of their samples: The academic contributors, unsurprisingly, were predominantly white men. The lived-experience experts were more diverse by gender and nationality (data on sexual and gender identity were not collected). But respondents were still largely white, educated and well-off, hailing from the United Kingdom (mostly) and other European countries.
The PPS is open-access, and McAlpine encourages everyone to use it. She now calls upon others to pick up where her team’s research left off, capturing a broader scope of lived experience. The scale is currently being used in a DMT neuroimaging study at University College London, and organizations such as the Institute of Psychedelic Therapy have used it for therapist training.
“The aim is to keep it iterative and intuitive, learning from as many sources as possible … to shed light on what works and what doesn’t,” McAlpine said, “[while] giving voice to people who don’t always get it. The last thing we want is to be like, ‘We’re the scientists, we’re right.’”
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