Participants' Music Experiences Associated With Psychedelic-Assisted Psychotherapy for Life-Threatening Illness: Interpretivist Research

The paper addresses a gap in psychedelic-assisted psychotherapy (PAP) research for people living with life-threatening illness: although PAP has shown promising effects for distress, anxiety and depression, there has been limited information about what participants themselves experience in relation to music, and about how music may contribute to therapeutic change. The authors note that music is widely used during psychedelic sessions and is believed to support emotional release, imagery, meaning-making and altered states, but the specific music-related experiences of participants in this setting had not been well characterised. The study therefore set out to examine participants’ music-related accounts of PAP within a randomised controlled trial (RCT) with open-label extension, and to identify participants’ perceived mechanisms of change attributed to music during PAP. The analysis reported here is music therapist-led and uses the same interview data that had also been examined by a psychiatrist-led team, allowing the paper to present a distinct interpretive account of how music functioned in the treatment process.

This was an interpretivist qualitative analysis nested within a broader double-blind RCT with open-label extension conducted in an Australian hospital setting. Participants were recruited from oncology and palliative care departments between January 2020 and January 2023 by clinician referral and self-referral, with recruitment paused at times because of COVID-19 restrictions. Eligibility required adults aged 18-85 with a life-threatening illness, prognostic estimate of 6-12 months, psychological distress, adequate performance status, clinician approval, clinically significant anxiety or depression on the Hospital Anxiety and Depression Scale, and English fluency. Exclusions included psychosis risk, bipolar disorder, recent substance dependence, acute suicidality, certain other psychiatric diagnoses, and inability to consent. Participants taking antidepressants had to taper off them under medical supervision because of psilocybin’s serotonergic action. The trial involved 11 manualised PAP sessions with two therapists. Core therapists were licensed clinical psychologists or consultant psychiatrists, and co-facilitators had relevant mental health or medical training. The paper states that the study used psilocybin and placebo (niacin) in the randomised phase, and that all participants received active drug during the open-label extension. Three drug-ingestion phases were described for psilocybin sessions: initiation, onset, peak experience, re-integration, and return to baseline. Music programmes for the ingestion sessions were part of the overall RCT; one programme included music composed by Australian artists. Participants were interviewed at baseline and again at 3 weeks after dose 1 and 3 weeks after dose 2, while still masked to allocation. The music-related interview questions asked about how music affected the experience, preferred and non-preferred music, associated emotions, memories and imagery, and awareness of new or different perspectives. For this article, the authors analysed transcribed post-dose 1 and post-dose 2 interviews using reflexive thematic analysis informed by grounded theory techniques and a constructivist worldview. The analysis was led by the first author, who coded the transcripts, identified music-related codes, grouped them into categories and then themes, with memo-writing throughout. A qualitative inter-rater procedure was then completed with a psychiatrist and the second author; the psychiatrist did not fully concur with the music therapist-led interpretation, which is one reason the paper discusses two parallel analyses. The software ATLAS.ti was used to manage the data. Participant checking was not done because of the advanced illness context and because some participants had died by the time of analysis.

In the parent RCT, 35 participants were randomised, with 17 allocated to psilocybin-first and 18 to placebo-first. Thirty-one participants contributed at least one interview for the present analysis, and 57 interviews were analysed in total: 41 after psilocybin sessions and 16 after placebo (niacin) sessions. Twenty-six participants were interviewed after both post-dose timepoints, four after post-dose 1 only, and one after post-dose 2 only. The paper reports no serious adverse events in the overall research project. Mean interview duration was 24.8 minutes at post-dose 1 and 35.2 minutes at post-dose 2. Twenty-nine interviewed participants received the researcher-created music programme in both dosing sessions. The thematic analysis generated four themes and 16 categories. First, participants often described music as connecting and integrating with deep multisensory, bodily and mental experience during psilocybin sessions. Music could feel synchronised with mood, imagery, bodily sensations and emotion, or could feel disconnected when lyrics or musical tone did not match the participant’s experience. Negative or negligible responses were uncommon, but some participants found particular music intrusive, controlling, confusing or anxiety-provoking, and occasional panic or discomfort was not resolved simply by stopping the music. Second, music and PAP often catalysed awareness of far-reaching realms of self, including remembered, spiritual, universal and transcendent experiences. Participants described vivid memories, collective connection, spiritual imagery, and strong emotional and physical reactions ranging from sadness and fear to elation, compassion and peace. Music also altered perceived time, place and identity, with some participants describing journeys, transformation into other roles or beings, and altered self-boundaries. Third, music could be experienced as an anthropomorphic or material force. Participants described music as medicine, as penetrating the body, as producing bodily movement or sensations, and as merging with the outside world or with imagery such as flowers, instruments, ancestors or landscapes. Therapists sometimes helped participants work with music by encouraging curiosity, supporting requests to change the programme, or presenting personally meaningful music later in the session. Fourth, music was associated with revelatory messages, lessons and insights, as well as disconnection, fragmentation and fear in a smaller number of cases. Participants reported music eliciting insights about grief, family, identity, spirituality, trust, self-belief and future meaning. Some music was experienced as confronting or emotionally difficult, but still potentially meaningful. After the sessions, ingestion music often evoked embodied memories, and some participants used the programme later to return to the states or insights it had supported. Several reported changed relationships with music after PAP, including more mindful listening, choir participation, renewed piano playing, and in one case a shift from not wanting to live to feeling alive again. The authors emphasise that psilocybin sessions were generally described as more intense and more music-immersed than placebo sessions, though many participants still found the placebo music experience pleasant and meaningful.

The authors interpret the findings as showing that music was a vital part of the PAP treatment milieu for people with life-threatening illness. In their account, music did not merely accompany the psychedelic experience but actively connected, integrated and interplayed with participants’ multisensory, bodily and mental realms, helping to catalyse awareness of what they call the person’s “essence”. They suggest that the music could intensify emotions, support spiritual or transcendental experiences, and help participants process biopsychosocial and existential concerns, sometimes producing insights that were welcome and sometimes revealing experiences that were difficult or fragmenting. They compare this music therapist-led interpretation with the psychiatrist-led analysis of the same interviews. The psychiatrist-led version, grounded in phenomenology, described music as undergoing a metamorphosis into an elemental form that participants encountered within their lifeworld, while the present analysis attributes more agency to the musical programme as it merges with psilocybin to catalyse change. The authors argue that both analyses extend conceptual understanding of music in PAP, but in different ways because of their theoretical and professional backgrounds. The authors also highlight the importance of therapists’ roles in preparation, during ingestion, and in integration. They argue that therapists should be curious about both welcomed and unwelcomed musical responses, should consider the participant’s broader relationship with sound in their formulation, and should use music flexibly to support exploration when participants are ready for it. They describe cases where therapists allowed music changes when participants were not ready, and others where they encouraged continued engagement when challenging music appeared therapeutically useful. They also suggest that music therapists have important contributions to make as co-facilitators in PAP, and that guided imagery and music-informed approaches may be useful before and after ingestion. The limitations acknowledged include not systematically collecting musical background data, difficulty for participants in recalling detailed music-related sensations and imagery, and the possibility that the findings reflect the authors’ own professional and personal backgrounds. The authors also note that participant checking was not feasible in this context. They suggest future research should examine how therapists prepare participants for music use, choose and modify music during ingestion, discuss music in integration, and use post-session observations. They further suggest that music therapy practice and education should adapt to growing psychedelic therapy use, including training psychedelic psychotherapists in music awareness and use.

The authors conclude that their music therapist-led interpretation suggests music can be integral to therapeutic change in PAP for people with life-threatening illness, by connecting with whole-person experience and catalysing meaningful awareness, reflection and more equanimous ways of living while dying. They also conclude that different qualitative approaches applied to the same dataset can yield different but still plausible findings, and that researchers should not feel obliged to force a single inter-rated interpretation.