A qualitative analysis of participant expectations and experiences of psilocybin-assisted psychotherapy for methamphetamine use disorder

Methamphetamine (MA) use has risen substantially and is associated with severe individual and societal harms, yet there are no approved pharmacotherapies and psychosocial treatments show only modest effects. Recent clinical research has expanded into psychedelic-assisted psychotherapy, particularly psilocybin-assisted psychotherapy (PAT), which has shown strongest evidence in treatment-resistant depression and preliminary signals in tobacco and alcohol use disorders. The authors note that quantitative measures in PAT trials can under-represent the richness of subjective experience, and that qualitative investigation of phenomenology may clarify therapeutic mechanisms such as shifts from experiential avoidance to acceptance, increases in psychological flexibility, and the roles of trust, safety and therapeutic alliance. J. and colleagues set out to qualitatively describe participants' expectations before treatment and their experiences after participating in a single-arm, open-label pilot study of PAT for MA use disorder. The primary aims were to characterise participant hopes and acceptability of PAT delivered in an outpatient stimulant treatment setting, to map the experiential arc of participation (including acute subjective effects and perceived impacts on MA use, self-perception, relationships and spirituality), and to explore mechanisms—using interpretive phenomenological analysis—to inform future trial design and therapeutic practice.

The embedded qualitative study sampled participants enrolled in a single-arm, open-label pilot PAT trial at an outpatient stimulant treatment programme in Sydney, Australia. Fifteen participants were recruited by self-referral or referral from the clinic; all 15 consented to qualitative interviews and 12 provided both pre- and post-treatment interviews. Eligible participants were aged 25 or older, met DSM-5 criteria for MA use disorder, were engaged in treatment and had used MA on at least 4 of the 28 days before screening. They agreed to abstain from MA and non-prescribed substances for 48 hours before dosing. Exclusion criteria included recent severe psychiatric illness, current or lifetime bipolar I/II or psychotic disorder, recent suicidal ideation, current use of monoamine oxidase inhibitors, mood stabilisers or antipsychotics, first- or second-degree relatives with psychotic or bipolar disorders, certain medical comorbidities (e.g. uncontrolled hypertension, seizures), recent problematic alcohol or cannabis use, recent psychedelic use, and pregnancy or breastfeeding. The PAT intervention comprised three 90-minute preparatory psychotherapy sessions over two weeks, a single 25 mg oral psilocybin dosing session conducted in a living-room style outpatient room lasting about 8 hours, and two 90-minute integration sessions over the following week. Psychotherapy was delivered by a consistent dyad of two therapists (drawn from six clinical psychologists and two psychiatrists). The therapeutic framework combined set-and-setting principles, acceptance and commitment therapy (ACT) and motivational interviewing, and the dosing protocol used eyeshades and a study musical playlist. Qualitative data collection involved two semi-structured interviews per participant: one after enrolment and before the first preparatory session, and a second interview conducted approximately one month after the psilocybin session (as reported elsewhere in the paper). Interviews were audio recorded and transcribed verbatim. The researchers used interpretive phenomenological analysis to foreground participants' self-interpretations while recognising researcher influence. Transcripts were imported into NVivo for coding. One researcher (S.J.) conducted initial coding to identify themes and sub-themes; these were reviewed and discussed iteratively by all authors to achieve agreement and to reflect on the influence of the research team's perspectives. Reporting followed the Standards for Reporting Qualitative Research checklist. The study received ethical approval from the St Vincent's Hospital Human Research Ethics Committee and was prospectively registered.

Twelve participants provided paired pre- and post-PAT interviews. The median age was 44 years; nine identified as men (six of whom identified as gay or non-heterosexual) and three as women (one of whom identified as gay or non-heterosexual). Participants had used MA for a median of 11 years and reported a median of 12 days of MA use in the 28 days before screening. Motivations for MA use included productivity, boredom, loneliness, sexual pleasure and self-medication for anxiety, depression and attention difficulties; many reported early attachment trauma. The qualitative results are organised around participants' expectations, the acute and integrative phenomenology of sessions, relational factors, and acceptability. Expectations: Participants commonly sought cessation or reduction of MA use and broader life improvements (relationships, employment). Hopes were generally positive but tempered and realistic. Many participants emphasised reassurance at receiving psychedelics in a professionally supported environment. Core experiential themes: A prominent theme was the emergence of new and often global understandings—shifts in perspective on emotions, relationships and self-worth, and sometimes broader spiritual or cosmological reframing. Several participants reported embodied emotional shifts (for example, rapidly moving from sadness to joy), vivid reliving of past relational episodes that prompted empathy and apology, or spiritual connectedness that altered self-regard and led to reduced importance of MA. The authors identify an orientation they term "leaning into the obstacle"—a volitional stance of turning toward vividly presented, often challenging psychological material during the psychedelic session. Resolution or compassionate engagement with these obstacles was frequently associated with a reduced salience of MA and diminished desire for use in some participants (illustrated by cases where desire for MA was reported to have gone). Heterogeneity: Not all participants experienced this trajectory. One contrasting case (Martin) described pronounced bodily irritation and anxiety during the session, reliance on breath-focused regulation that may have functioned defensively, an absence of vivid imagery, no broad narrative reframing and no reported reduction in MA use. This highlights variability in experiential depth and apparent therapeutic benefit. Therapeutic relationship: Participants described the therapeutic alliance as reparative and central to positive outcomes. Two factors were emphasised: the unusually concentrated therapeutic contact (described as 7.5 hours of preparation/integration plus an 8-hour dosing day with two therapists) and an intersubjective intimacy or identity-affirming stance that many had not experienced in standard substance use care. This concentrated attention was said to lower anticipatory threat, reduce avoidance during dosing and amplify integration gains. Broader impacts and acceptability: Participants reported changes extending beyond MA use, including reduced habitual chaotic patterns, a softer or more reflective relationship with an inner critic, mourning and integration of attachment traumas, improved relational functioning and mood. Overall acceptability of the intervention was high, though participants differed in preferred intensity of dosing—some wanted gentler entry, others a deeper immersion. Elements of the setting (for example, music) were experienced as grounding by many but intrusive by some. Practical interruptions (e.g. needing to use the bathroom) sometimes disrupted immersion but could also be reinterpreted as acts of agency.

J. and colleagues interpret their findings as indicating that participants' expectations were generally realistic and that PAT was acceptable in this sample. They emphasise that many participants reported therapeutic change arising from new understandings of self, relationships and meaning that often emerged when participants intentionally "leaned into" vividly presented psychological obstacles during the psychedelic session. This orientation—turning toward rather than avoiding distress—aligns with theoretical constructs from ACT (willingness to experience discomfort for valued living) and with prior qualitative and quantitative work showing shifts from experiential avoidance to acceptance, increased psychological flexibility and enhanced connectedness following psychedelic experiences. The authors situate their findings in the broader PAT literature, noting parallels with qualitative reports from PAT for alcohol, tobacco and cancer-related anxiety, where immersive and sometimes distressing acute effects were followed by reductions in substance salience, increased motivation to change, and broader psychosocial benefits. They argue that concentrated, identity-affirming therapeutic contact functioned as a corrective relational experience that may facilitate changes in attachment models and increase attachment security, thereby supporting integration of the psychedelic experience. Limitations acknowledged by the authors include the qualitative study's lack of generalisability, the self-selecting nature of trial enrolment and interview participation, and sample characteristics (participants were relatively highly educated, employed and pre-disposed to interest in psychedelics) that may introduce bias. The authors also note heterogeneity in experiential intensity and response, exemplified by participants who did not report vivid imagery or reduced MA use. For future research, the authors recommend larger, definitive trials of PAT for MA use disorder given the acceptability, feasibility, safety and preliminary efficacy signals reported elsewhere. They suggest considering multiple dosing options or dose escalation and providing more integration psychotherapy to optimise safety and efficacy, particularly because this population may have prior exposure to altered states and differing thresholds for experiential intensity.