SPECIAL ISSUE: Do Biofeedback, Neurofeedback, and Neuromeditation Have a Role in Psychedelic-Assisted Therapies?

“Are magic mushrooms the miracle cure for depression we've been looking for?” (Khan, 2021). Attention-grabbing headlines such as this are becoming increasingly common and suggest that psychedelic medicines are some kind of magic bullet. This perception is increased by stories of people who had a single life-changing psychedelic experience that resulted in complete relief of their long-standing mental health concerns.To some degree, this enthusiasm is warranted, as early results indicate that the clinical use of psychedelics including psilocybin, methylenedioxymethamphetamine (MDMA), and ketamine can be effective for treatment-resistant depression, posttraumatic stress disorder (PTSD), addictions, end-of-life anxiety, and obsessive-compulsive disorder (see Andersen et al., 2020). However, it is important to recognize that these benefits are attained within contexts that provide specialized preparation for the psychedelic experience, active support during, and structured integration sessions as follow-up. This process is often referred to as psychedelic assisted therapy (PAT), highlighting the role that nondrug interventions play in the healing process.Perhaps the most used and accepted model of PAT is that standardized by the Multidisciplinary Association for Psychedelic Studies (Mithoefer, 2017). With minor variations, this approach typically includes two to three nondrug 90-minute therapy sessions before the first psychedelic dose. Participants then receive two to three integration sessions with the same team of therapists (one male bodied, one female bodied) after their psychedelic session before repeating the process with one or two additional MDMA sessions (see Figure 1; Mithoefer et al., 2019).Although the psychedelic experience is only one piece of the psychedelic therapeutic approach, it is not clear how much and what type of nondrug therapeutic interventions are best suited to PAT (Reiff et al., 2020). A cursory examination reveals a wide range of wellness and therapy practices incorporated into the PAT process, including cognitive behavioral therapy, acceptance and commitment therapy (Wolff et al., 2020), mindfulness (Dakwar et al., 2019), yoga, aromatherapy, and energy psychology (Dames et al., 2022).Recently, several authors have proposed models to understand the healing potential of psychedelics within the context of traditional mental health treatments (Carhart-Harris & Friston, 2019; Wolff et al., 2020). For example, Carhart-Harris and Friston (2019) advanced the REBUS model, suggesting that much of the therapeutic benefit of psychedelic therapies may be related to the relaxed beliefs that accompany psychedelic experiences. Essentially, the principal action of psychedelics is to temporarily shift neural patterns into a state of increased entropy, leading to a mental state in which previous beliefs about oneself or the world are held with less confidence, thus providing an opportunity for change. This neuroplasticity facilitates new ways of thinking, feeling, and behaving (Carhart-Harris & Friston, 2019), making it an ideal tool to enhance and support other therapeutic interventions.Using this model, it becomes important to (1) prepare and support the brain/nervous system for the shift experienced during a psychedelic session and (2) take advantage of the increased flexibility created by the experience. Based on this understanding, there would seem to be a strong role for technology-based interventions in this process. In the remainder of this article, I will describe ways that biofeedback, neurofeedback (NFB), and neuromeditation may be used in both the preparation and integration phases of PAT.Specific psychological and emotional states including absorption, openness, acceptance, and surrender are associated with having positive psychedelic experiences. Negative psychedelic experiences are more common in persons who tend to be low in openness and surrender and/or high in preoccupation, apprehension, or confusion (Aday et al., 2021). Similarly, two recent studies have found that psychological flexibility, occurring as a result of a psychedelic experience, was a better predictor of treatment outcome than mystical experience (Davis et al., 2021) and, in fact, fully mediated the experience of a mystical state (Davis et al., 2020). These results, in combination with other studies (see DeBeer et al., 2018; Meyer et al., 2019) suggest that psychological flexibility and related constructs may be an important factor contributing to mental health in general and specifically in connection to the therapeutic benefit of psychedelics. Consequently, it is important to offer preparatory sessions with a trained guide to facilitate the desired states and minimize the undesired ones. This is referred to as establishing the set or mindset for the experience.The preparation phase of PATs can be used to assess a client for appropriateness/readiness, to clarify intentions, manage expectations, outline the process, and discuss any fears or concerns they might have about working with psychedelic medicines. In addition, a thorough intake interview, psychological questionnaires, and quantitative electroencephalogram (qEEG) assessment can provide important baseline information. Beyond the benefit of having markers to measure future success, this information can help guide further foundational work and integration. Similar to the approach used in many NFB practices, the data from the qEEG may provide information on clinically relevant patterns that can directly inform treatment. From this perspective, the therapeutic interventions become primary with the psychedelic experience, serving as a tool of neuroplasticity to facilitate and expedite the desired change.B., a 48-year-old man, came to our clinic seeking ketamine-assisted therapy for long-standing depression. He described significant symptoms of anhedonia, feeling stuck in life, and feeling hopeless about the world. B. also reported a history of anxiety and eating-disordered behaviors. His primary goal related to experiencing a range of emotions and feeling happier. He reported a history of trying various medications including Zoloft and Wellbutrin, participating in regular talk therapy, and engaging in Vipassana meditation, none of which has seemed to have had much of an impact.His baseline qEEG analyzed through qEEG Pro revealed high levels of slow-wave activity in the delta and theta ranges as well as frontal alpha (see Figure 2).It was suspected that this pattern may be related to chronic depression, particularly as there was no evidence of any cognitive performance concerns. This hypothesis helped form the treatment plan, which included NFB designed to inhibit delta and theta activity. After B.'s first ketamine session, he reported feeling some immediate relief of his depressive symptoms, which quickly returned. The results of his postketamine qEEG are presented below (see Figure 3).The reduction in midline delta and theta occurring in response to the ketamine session and subsequent reduction in depression appeared to support the NFB approach.Beyond orientation and assessment, the preparation sessions are also designed to establish trust and rapport with the facilitator; experiment with nonmedicine, nonordinary states of consciousness (e.g., breathwork, stroboscopic light, etc.); and introduce practices to enhance psychological/cognitive flexibility. Although this aspect of preparation is often given limited attention, we suggest that it is a critical element to the long-term success of many clients. This notion is gaining support and is clearly articulated in the extrapharmacologic model of PAT. This model emphasizes the importance of client traits and a prepsychedelic state in determining long-term outcomes of PATs (Carhart-Harris et al., 2018). Although there are a variety of techniques available to encourage psychological/cognitive flexibility, this seems an ideal place to incorporate technology-based interventions such as heart rate variability (HRV) biofeedback and EEG neuromeditation.HRV is a measure of cardiac vagal tone that can be quantified through a spectral analysis of beat-to-beat changes in heart rate (Porges, 2007). The resultant values provide an indication of nervous system balance with direct implications for mental health. For example, low resting HRV has been associated with a variety of mental health concerns including anxiety (Friedman, 2007; Hofmann, et al., 2005), stress (Keeney, 2008; Sherlin et al., 2009), and PTSD (Tan et al., 2011; Zuker et al., 2009). Conversely, high resting HRV has been shown to predict self-regulatory strength and reduce negative emotions during acute stress (Khodik, 2013). In short, higher overall levels of HRV are associated with psychological resiliency, behavioral flexibility, and the ability to adapt to changing social demands (Beauchaine, 2001).HRV biofeedback provides a mechanism to allow individuals to directly regulate their nervous system through breath training (Khazan, 2013), feelings of appreciation (Edwards, 2015), or mindfulness practice (Lehrer & Gevirtz, 2014). In short, HRV biofeedback appears to be an effective tool for increasing self-regulation (Segerstrom & Nes, 2007) and self-awareness (Kim et al., 2015). In fact, HRV may be considered a marker of psychological flexibility. For example, a study by Geisler et al. (2013) found that young adults with higher resting-state HRV displayed more adaptive self-regulation. Subjects with higher HRV reported using more engagement strategies when coping with distress and less disengagement when regulating negative emotions. As psychological flexibility is an important aspect of successful psychedelic therapy, incorporating HRV biofeedback into the preparation phase of PAT would seem to be a natural fit.W. is a 76-year-old woman. She is a retired professor in the field of computer science. She sought PAT in conjunction with talk therapy and neuromeditation to address developmental trauma related to parental neglect she experienced as a child. Although W. demonstrated great insight into the dysfunctional patterns of her mother, her therapeutic process seemed limited to cognitive analysis. W. was aware of this, noting that she often feels disconnected from her body, has trouble being present with emotional discomfort, and uses her intellect to avoid the feelings connected to her insights. This therapist used a variety of technology-based and traditional therapeutic modalities to assist the client in learning to be present with, and tolerate, uncomfortable feelings. After two psychedelic experiences, W. reported feeling immediate relief of her anxiety and depression. However, in both cases, the symptoms returned. It was noted that W. had a tendency to talk throughout her psychedelic experiences, resisting prompts to “go inward.” As part of her integration/preparation work, we agreed to focus on increasing cognitive flexibility and openness to experience before she engaged in additional psychedelic sessions. As part of this approach, we began exploring her breathing patterns. It was noted that W. generally had a shallow breath, restricting the movement of her torso and, at times, holding her breath. As this was discussed in session, W. recognized that this tendency was connected to feelings of holding on to control and a general defensiveness. We began HRV biofeedback using Heartmath technology in the office. W. also bought a system for home use and practiced between sessions. W. initially resisted this training, finding it very challenging and frustrating. After adjusting the feedback screen to minimize information and coaching W. through a variety of techniques to slow and relax the breathing, it was discovered that her most successful approach involved visualizing ocean waves or a safe space. Essentially, by taking her mind off the task at hand, and shifting to something that was naturally nurturing, W. was able to have success with the biofeedback. With more success, W. was able to reduce the reliance on visualizations and engage more directly with the feedback. The psychological themes present in her approach to this task (e.g., control, efforting, perfectionism) became helpful in teaching W. skills to manage these tendencies. Three screen captures taken 1 week apart demonstrating her success are presented in Figure 4.The entropic brain hypothesis presents a model for understanding the range of human consciousness in relation to states of system entropy. Based on this model, states of consciousness represented by high levels of entropy become increasingly flexible and random. At the extreme, this state can represent high levels of disorder, such as might be seen in early psychosis. Low entropy implies highly ordered but inflexible cognition, as might be seen in a variety of mental health concerns including depression, obsessive-compulsive disorder, and addictions (Carhart-Harris et al., 2014). According to this model, psychedelics provide therapeutic value by introducing entropy into a rigid system, creating a relaxation of previously held beliefs (Carhart-Harris & Friston, 2019) and a potential opportunity for healing.Interestingly, recent work by Vivot et al. (2020) has demonstrated that consistent meditation practice can also result in increased entropy of brain activity. Consequently, it seems logical that meditative experience may be useful in preparing the nervous system for a PAT. In fact, preliminary evidence supports this idea. For example, experienced meditators who administered psilocybin during a meditation retreat reported higher levels of meditation depth, postretreat trait mindfulness, and psychosocial functioning at 4-month follow-up compared with a control group (Smigielski, 2019). Griffiths et al. (2018) administered psilocybin to healthy volunteers along with spiritual practice that included mindfulness meditation. When compared with an active placebo group, the spiritual practice group demonstrated greater improvements in positive mood and life satisfaction at 6-month follow-up.Unfortunately, meditation is not an easy skill to learn, particularly if you are not feeling mentally well. For example, in a study examining participation and attrition from a 4-week meditation class, it was found that 91% of the participants stopped meditating 1 month after training. In addition, pretest measures of self-esteem and psychosomatic symptoms predicted attrition (Rivers & Spanos, 1981). Combining meditation with NFB may provide a learning strategy helpful to those early meditators and/or persons looking for a secular, science-based approach. As stated by Prestel et al. (2019, p. 272), “A combination of meditation with which the of the activity of relevant brain more enhance the therapeutic of in who have in more by meditation In addition, meditation EEG may be suited to the preparation phase of PAT by to various states of an EEG neuromeditation approach that includes states of consciousness 2020). 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