Culture, context, and ethics in the therapeutic use of hallucinogens: Psychedelics as active super-placebos?

Following decades of prohibition and widespread concern about their mind-altering properties, there is increasing public, scholarly, and clinical interest in the therapeutic potential of psychedelic substances. Serotonergic substances in particular (DMT, psilocybin, and LSD) are now being tested as treatments for such ailments as depression, anxiety, and substance use disorder. This thematic issue of Transcultural Psychiatry presents articles that investigate the cultural assumptions, political dimensions, and clinical and ethical implications that arise from this renewed interest. After reviewing ongoing debates on therapeutic mechanisms of action and the importance of context, we argue that psychedelics can be conceptualized as "active super-placebos"-that is, substances that enhance ritual, symbolic, and interpersonal therapeutic processes by increasing suggestibility and the influence of extra-pharmacological, "non-specific" factors. Rather than simply freeing up habitual constraints on perception, the articles in this issue support the claim that psychedelic encounters typically entail processes of sense-making, crystallization of meaning, and enculturation into contextually mediated assumptive worlds (or ideologies) and behaviours that necessarily install novel constraints with potentially maladaptive consequences. We highlight the importance of clinical and epistemic integrity in the framing of psychedelic therapies. The importance of structuring and providing oversight for the therapeutic context raises difficult questions about the search for appropriate forms of epistemic authority that are at once respectful of the plural cultural origins of psychedelic rituals and mindful of best practices and standards in clinical care.

A Nudge-Based Intervention to Reduce Problematic Smartphone Use: Randomised Controlled Trial.

Problematic smartphone use is rising across the world. We tested an intervention with ten strategies that nudge users to reduce their smartphone use, for example by disabling non-essential notifications and changing their display to greyscale. Participants first completed baseline measures of smartphone use, well-being, and cognition before choosing which intervention strategies to follow for 2 to 6 weeks. Study 1 ( N = 51 ) used a pre-post design while study 2 ( N = 70 ) compared the intervention to a control group who monitored their screen time. Study 1 found reductions in problematic smartphone use, screen time, and depressive symptoms after 2 weeks. Study 2 found that the intervention reduced problematic smartphone use, lowered screen time, and improved sleep quality compared to the control group. Our brief intervention returned problematic smartphone use scores to normal levels for at least 6 weeks. These results demonstrate that various strategies can be combined while maintaining feasibility and efficacy.

Stuck in a lockdown: Dreams, bad dreams, nightmares, and their relationship to stress, depression and anxiety during the COVID-19 pandemic.

BACKGROUND: An upsurge in dream and nightmare frequency has been noted since the beginning of the COVID-19 pandemic and research shows increases in levels of stress, depression and anxiety during this time. Growing evidence suggests that dream content has a bi-directional relationship with psychopathology, and that dreams react to new, personally significant and emotional experiences. The first lockdown experience was an acute event, characterized by a combination of several unprecedent factors (new pandemic, threat of disease, global uncertainty, the experience of social isolation and exposure to stressful information) that resulted in a large-scale disruption of life routines. This study aimed at investigating changes in dream, bad dream and nightmare recall; most prevalent dream themes; and the relationship between dreams, bad dreams, nightmares and symptoms of stress, depression and anxiety during the first COVID-19 lockdown (April-May 2020) through a national online survey. METHODS: 968 participants completed an online survey. Dream themes were measured using the Typical Dreams Questionnaire; stress levels were measured by the Cohen's Perceived Stress Scale; symptoms of anxiety were assessed by Generalized Anxiety Disorder (GAD-7) scale; and symptoms of depression were assessed using the Quick Inventory of Depressive Symptomatology. RESULTS: 34% (328) of participants reported increased dream recall during the lockdown. The most common dream themes were centered around the topics of 1) inefficacy (e.g., trying again and again, arriving late), 2) human threat (e.g., being chased, attacked); 3) death; and 4) pandemic imagery (e.g., being separated from loved ones, being sick). Dream, bad dream and nightmare frequency was highest in individuals with moderate to severe stress levels. Frequency of bad dreams, nightmares, and dreams about the pandemic, inefficacy, and death were associated with higher levels of stress, as well as with greater symptoms of depression and anxiety. CONCLUSIONS: Results support theories of dream formation, environmental susceptibility and stress reactivity. Dream content during the lockdown broadly reflected existential concerns and was associated with increased symptoms of mental health indices.

Super Placebos: A Feasibility Study Combining Contextual Factors to Promote Placebo Effects.

Background: Ample evidence demonstrates that placebo effects are modulated by contextual factors. Few interventions, however, attempt to combine a broad range of these factors. Here, we explore the therapeutic power of placebos by leveraging factors including social proof, positive suggestion, and social learning. This study aimed to test the feasibility of an elaborate "super placebo" intervention to reduce symptoms of various disorders in a pediatric population. Methods: In a single-arm qualitative study, participants entered an inactive MRI scanner which they were told could help their brain heal itself through the power of suggestion. The sample included 11 children (6-13 years old) diagnosed with disorders known to be receptive to placebos and suggestion (Attention Deficit Hyperactivity Disorder, Tourette Syndrome, chronic skin picking, and migraines). The children were given positive suggestions during 2-4 placebo machine sessions over the span of approximately 1 month. We assessed open-ended treatment outcomes via recorded interviews and home visits. Results: The procedure was feasible and no adverse events occurred. Ten of the 11 parents reported improvements in their children after the intervention, ranging from minor transient changes to long-term reductions in subjective and objective symptoms (e.g., migraines and skin lesions). Discussion: These preliminary findings demonstrate the feasibility and promise of combining a broad range of contextual factors in placebo studies. Future research is needed to assess the causal effects of such interventions.

Social, financial and psychological stress during an emerging pandemic: observations from a population survey in the acute phase of COVID-19.

INTRODUCTION: The negative impacts of COVID-19 have rippled through every facet of society. Understanding the multidimensional impacts of this pandemic is crucial to identify the most critical needs and to inform targeted interventions. This population survey study aimed to investigate the acute phase of the COVID-19 outbreak in terms of perceived threats and concerns, occupational and financial impacts, social impacts and stress between 3 April and 15 May 2020. METHODS: 6040 participants are included in this report. A multivariate linear regression model was used to identify factors associated with stress changes (as measured by the Cohen's Perceived Stress Scale (PSS)) relative to pre-outbreak retrospective estimates. RESULTS: On average, PSS scores increased from low stress levels before the outbreak to moderate stress levels during the outbreak (p<0.001). The independent factors associated with stress worsening were: having a mental disorder, female sex, having underage children, heavier alcohol consumption, working with the general public, shorter sleep duration, younger age, less time elapsed since the start of the outbreak, lower stress before the outbreak, worse symptoms that could be linked to COVID-19, lower coping skills, worse obsessive-compulsive symptoms related to germs and contamination, personalities loading on extraversion, conscientiousness and neuroticism, left wing political views, worse family relationships and spending less time exercising and doing artistic activities. CONCLUSION: Cross-sectional analyses showed a significant increase from low to moderate stress during the COVID-19 outbreak. Identified modifiable factors associated with increased stress may be informative for intervention development. TRIAL REGISTRATION NUMBER: NCT04369690; Results.

Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice.

In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline a framework of questions exploring key cultural and ethical dimensions of mhGAP planning, adaptation, training, and implementation. This framework is meant to guide mhGAP activity taking place around the world. Our approach is informed by recent research on cultural formulation and adaptation, and aligned with key components of the WHO implementation research guide (Peters, D. H., Tran, N. T., & Adam, T. (2013). Implementation research in health: a practical guide. Implementation research in health: a practical guide.). The framework covers three broad domains: (1) Concepts of wellness and illness-how to examine cultural norms, knowledge, values and attitudes in relation to the "culture of the mhGAP"; (2) Systems of care-identifying formal and informal systems of care in the cultural context of practice.; and (3) Ethical space: examining issues related to power dynamics, communication, and decision-making. Systematic consideration of these issues can guide integration of cultural knowledge, structural competence, and ethics in implementation efforts.

Hypnotised by Your Phone? Smartphone Addiction Correlates With Hypnotisability.

Hypnosis and heavy smartphone use are both characterised by absorbed states in which one loses track of time and responds automatically to stimuli. In this pre-registered study, we tested whether there was a relationship between smartphone addiction and hypnotisability: one's tendency to follow suggestions under hypnosis. Over 11 public lectures, we hypnotised 641 student-aged participants; after the hypnosis session, participants completed the Smartphone Addiction Scale (Short Version). There was a positive correlation between hypnotisability and smartphone addiction (r = .17, 95% CI [.09, .24], p < .001) with a magnitude similar to standard predictors of hypnotisability. This correlation was small but unlikely spurious: it was positive in 10 of the 11 samples (including two from psychology courses) and persisted in a follow-up several months later. The addiction scores in this Canadian sample were unexpectedly high (M = 31.41) compared to other countries. We hypothesise that targeting the absorbed, time-distorted, and automatic use of smartphones may promote healthier phone habits.

TTOM in action: Refining the variational approach to cognition and culture.

The target article "Thinking Through Other Minds" (TTOM) offered an account of the distinctively human capacity to acquire cultural knowledge, norms, and practices. To this end, we leveraged recent ideas from theoretical neurobiology to understand the human mind in social and cultural contexts. Our aim was both synthetic - building an integrative model adequate to account for key features of cultural learning and adaptation; and prescriptive - showing how the tools developed to explain brain dynamics can be applied to the emergence of social and cultural ecologies of mind. In this reply to commentators, we address key issues, including: (1) refining the concept of culture to show how TTOM and the free-energy principle (FEP) can capture essential elements of human adaptation and functioning; (2) addressing cognition as an embodied, enactive, affective process involving cultural affordances; (3) clarifying the significance of the FEP formalism related to entropy minimization, Bayesian inference, Markov blankets, and enactivist views; (4) developing empirical tests and applications of the TTOM model; (5) incorporating cultural diversity and context at the level of intra-cultural variation, individual differences, and the transition to digital niches; and (6) considering some implications for psychiatry. The commentators' critiques and suggestions point to useful refinements and applications of the model. In ongoing collaborations, we are exploring how to augment the theory with affective valence, take into account individual differences and historicity, and apply the model to specific domains including epistemic bias.

Tripping on nothing: placebo psychedelics and contextual factors.

RATIONALE: Is it possible to have a psychedelic experience from a placebo alone? Most psychedelic studies find few effects in the placebo control group, yet these effects may have been obscured by the study design, setting, or analysis decisions. OBJECTIVE: We examined individual variation in placebo effects in a naturalistic environment resembling a typical psychedelic party. METHODS: Thirty-three students completed a single-arm study ostensibly examining how a psychedelic drug affects creativity. The 4-h study took place in a group setting with music, paintings, coloured lights, and visual projections. Participants consumed a placebo that we described as a drug resembling psilocybin, which is found in psychedelic mushrooms. To boost expectations, confederates subtly acted out the stated effects of the drug and participants were led to believe that there was no placebo control group. The participants later completed the 5-Dimensional Altered States of Consciousness Rating Scale, which measures changes in conscious experience. RESULTS: There was considerable individual variation in the placebo effects; many participants reported no changes while others showed effects with magnitudes typically associated with moderate or high doses of psilocybin. In addition, the majority (61%) of participants verbally reported some effect of the drug. Several stated that they saw the paintings on the walls "move" or "reshape" themselves, others felt "heavy… as if gravity [had] a stronger hold", and one had a "come down" before another "wave" hit her. CONCLUSION: Understanding how context and expectations promote psychedelic-like effects, even without the drug, will help researchers to isolate drug effects and clinicians to maximise their therapeutic potential.

Thinking through other minds: A variational approach to cognition and culture.

The processes underwriting the acquisition of culture remain unclear. How are shared habits, norms, and expectations learned and maintained with precision and reliability across large-scale sociocultural ensembles? Is there a unifying account of the mechanisms involved in the acquisition of culture? Notions such as "shared expectations," the "selective patterning of attention and behaviour," "cultural evolution," "cultural inheritance," and "implicit learning" are the main candidates to underpin a unifying account of cognition and the acquisition of culture; however, their interactions require greater specification and clarification. In this article, we integrate these candidates using the variational (free-energy) approach to human cognition and culture in theoretical neuroscience. We describe the construction by humans of social niches that afford epistemic resources called cultural affordances. We argue that human agents learn the shared habits, norms, and expectations of their culture through immersive participation in patterned cultural practices that selectively pattern attention and behaviour. We call this process "thinking through other minds" (TTOM) - in effect, the process of inferring other agents' expectations about the world and how to behave in social context. We argue that for humans, information from and about other people's expectations constitutes the primary domain of statistical regularities that humans leverage to predict and organize behaviour. The integrative model we offer has implications that can advance theories of cognition, enculturation, adaptation, and psychopathology. Crucially, this formal (variational) treatment seeks to resolve key debates in current cognitive science, such as the distinction between internalist and externalist accounts of theory of mind abilities and the more fundamental distinction between dynamical and representational accounts of enactivism.

Regimes of Expectations: An Active Inference Model of Social Conformity and Human Decision Making.

How do humans come to acquire shared expectations about how they ought to behave in distinct normalized social settings? This paper offers a normative framework to answer this question. We introduce the computational construct of 'deontic value' - based on active inference and Markov decision processes - to formalize conceptions of social conformity and human decision-making. Deontic value is an attribute of choices, behaviors, or action sequences that inherit directly from deontic cues in our econiche (e.g., red traffic lights); namely, cues that denote an obligatory social rule. Crucially, the prosocial aspect of deontic value rests upon a particular form of circular causality: deontic cues exist in the environment in virtue of the environment being modified by repeated actions, while action itself is contingent upon the deontic value of environmental cues. We argue that this construction of deontic cues enables the epistemic (i.e., information-seeking) and pragmatic (i.e., goal- seeking) values of any behavior to be 'cached' or 'outsourced' to the environment, where the environment effectively 'learns' about the behavior of its denizens. We describe the process whereby this particular aspect of value enables learning of habitual behavior over neurodevelopmental and transgenerational timescales.

Corrigendum: Hypernatural Monitoring: A Social Rehearsal Account of Smartphone Addiction.

[This corrects the article DOI: 10.3389/fpsyg.2018.00141.].

Treating ADHD With Suggestion: Neurofeedback and Placebo Therapeutics.

OBJECTIVE: We propose that clinicians can use suggestion to help treat conditions such as ADHD. METHODS: We use EEG neurofeedback as a case study, alongside evidence from a recent pilot experiment utilizing a sham MRI scanner to highlight the therapeutic potential of suggestion-based treatments. RESULTS: The medical literature demonstrates that many practitioners already prescribe treatments that hardly outperform placebo comparators. Moreover, the sham MRI experiment showed that, even with full disclosure of the procedure, suggestion alone can reduce the symptomatology of ADHD. CONCLUSION: Non-deceptive suggestion-based treatments, especially those drawing on accessories from neuroscience, may offer a safe complement and potential alternative to current standard of care for individuals with ADHD.

A variational approach to niche construction.

In evolutionary biology, niche construction is sometimes described as a genuine evolutionary process whereby organisms, through their activities and regulatory mechanisms, modify their environment such as to steer their own evolutionary trajectory, and that of other species. There is ongoing debate, however, on the extent to which niche construction ought to be considered a bona fide evolutionary force, on a par with natural selection. Recent formulations of the variational free-energy principle as applied to the life sciences describe the properties of living systems, and their selection in evolution, in terms of variational inference. We argue that niche construction can be described using a variational approach. We propose new arguments to support the niche construction perspective, and to extend the variational approach to niche construction to current perspectives in various scientific fields.

Hypernatural Monitoring: A Social Rehearsal Account of Smartphone Addiction.

We present a deflationary account of smartphone addiction by situating this purportedly antisocial phenomenon within the fundamentally social dispositions of our species. While we agree with contemporary critics that the hyper-connectedness and unpredictable rewards of mobile technology can modulate negative affect, we propose to place the locus of addiction on an evolutionarily older mechanism: the human need to monitor and be monitored by others. Drawing from key findings in evolutionary anthropology and the cognitive science of religion, we articulate a hypernatural monitoring model of smartphone addiction grounded in a general social rehearsal theory of human cognition. Building on recent predictive-processing views of perception and addiction in cognitive neuroscience, we describe the role of social reward anticipation and prediction errors in mediating dysfunctional smartphone use. We conclude with insights from contemplative philosophies and harm-reduction models on finding the right rituals for honoring social connections and setting intentional protocols for the consumption of social information.

Cultural Affordances: Scaffolding Local Worlds Through Shared Intentionality and Regimes of Attention.

In this paper we outline a framework for the study of the mechanisms involved in the engagement of human agents with cultural affordances. Our aim is to better understand how culture and context interact with human biology to shape human behavior, cognition, and experience. We attempt to integrate several related approaches in the study of the embodied, cognitive, and affective substrates of sociality and culture and the sociocultural scaffolding of experience. The integrative framework we propose bridges cognitive and social sciences to provide (i) an expanded concept of 'affordance' that extends to sociocultural forms of life, and (ii) a multilevel account of the socioculturally scaffolded forms of affordance learning and the transmission of affordances in patterned sociocultural practices and regimes of shared attention. This framework provides an account of how cultural content and normative practices are built on a foundation of contentless basic mental processes that acquire content through immersive participation of the agent in social practices that regulate joint attention and shared intentionality.