Abstract
Music is integral to Psilocybin-assisted psychotherapy (PAP), believed to enhance therapeutic outcomes by structuring experiences and facilitating emotional expression. However, the effects of conducting PAP without music are underexplored. This study examines the experiences of two breast cancer patients undergoing psilocybin therapy under Canada's compassionate access program, specifically focusing on sessions that incorporated intentional periods without music. Patients had previously experienced psychedelics in therapeutic contexts but only with continuous music, as is common practice. Here, each patient participated in a 30-min silent period involving mindfulness exercises and therapist discussions. These periods of relative silence resulted in both challenges and benefits. One patient found that the absence of music was difficult initially, but that the relative silence allowed for engagement with mindfulness exercises that were experienced as highly meaningful. The other patient reported that music had evoked challenging past memories early in the dosing session, which were then productively explored with her guides during the subsequent period without music. These findings suggest that integrating silent intervals in PAP can enhance mindfulness practices and therapist-patient interactions, potentially offering distinct therapeutic benefits. Further research is necessary to delineate the differential impacts of music, silence, and guided activities in PAP, given that these three common treatment activities can be understood as both complementary and competing. Finally, we emphasize the importance of more detailed reporting on session components in psychedelic research publications, particularly regarding the balance between patients listening to music and interacting with their guides, which is often not clearly detailed in existing studies.
Introduction
Psilocybin-assisted psychotherapy (PAP) is among psychiatry's most promising new interventions for depression (Cavarra, Falzone, Ramaekers, Kuypers, & Mento, 2022; Pearson, Siegel, & Gold, 2022; Prouzeau et al., 2022) and for existential distress in patients with life-threatening illnesses (Lowe et al., 2021; Nichols, 2016). Over the past two decades, a relatively standard approach to PAP has been shown in multiple clinical trials to yield rapid and generally safe antidepressant effects that may persist for months after treatment (Goodwin et al., 2022; Madras, 2022; Roscoe & Lozy, 2022). These promising results have spurred Health Canada to permit the federal Special Access Program to allow medical professionals to request psilocybin from approved distributors to provide PAP for patients with life-threatening conditions outside of clinical trials (de la Salle et al., 2024). PAP conducted via Canada's compassionate access pathways has less constraints on its non-pharmacological components than typical clinical trial protocols, allowing authorized clinicians some degree of flexibility in how they utilize elements such as music – or its absence, as this article discusses.
We report on two patients with breast cancer who simultaneously received PAP, via Canada's Special Access Program, in Montreal, Quebec. Both patients suffered from existential distress care associated with life-threatening breast cancer diagnoses and were authorized to receive legal access to psilocybin in conjunction with psychotherapy. Treatments took place at the Hope and Cope Wellness Centre, a non-profit community organization affiliated with the Jewish General Hospital. Care was provided by three clinicians: one generalist palliative care physician, one psychotherapist, and one psychiatrist.
As per standard PAP protocols (Guss, Krause, & Sloshower, 2020), patients received preparatory therapy before the psilocybin dosing session including two virtual and two in-person sessions. During preparation sessions, patients were encouraged to voice preferences for the treatment session's music, which were accommodated where possible. Additionally, for both patients, the possibility of including a brief period of around 15–30 min without music was broached and accepted. This variation on standard practices was inspired by our group's experiences in conducting ketamine-therapy sessions without music (Garel et al., 2023; Greenway et al., 2024).
To our knowledge, an intentional period without music has not been incorporated into modern psilocybin clinical treatment protocols. Indeed, all recent psilocybin clinical trials have heavily employed music, with patients spending the majority of their psilocybin experiences listening to music that is played through headphones and/or speakers in the treatment rooms (Goodwin et al., 2022; Luoma, Sabucedo, Eriksson, Gates, & Pilecki, 2019; Rosenblat et al., 2023; Strickland, Garcia-Romeu, & Johnson, 2021; Watts, 2021; Watts & Luoma, 2020). Curated music is thought to provide important benefits, including reassurance and structure, and to improve benefits by facilitating emotional expression (Kaelen et al., 2018).
Little to no research has investigated whether periods without music may also have therapeutic benefits for PAP. However, relative silence has featured in traditional psychedelic healing rituals, including psilocybin and ayahuasca (Labate & Cavnar, 2014; Metzner, 2005), and several articles have suggested potential benefits for periods without music in clinical psychedelic therapy (Garel et al., 2023; Gloeckler, Lehmann, de la Salle, Greenway, & Lucas, 2024; Noorani, Garcia-Romeu, Swift, Griffiths, & Johnson, 2018; O’Callaghan, Hubik, Dwyer, Williams, & Ross, 2020). Relatedly, PAP trials have employed mindfulness and other meditative practices in various ways throughout their preparation and integration phases (Griffiths et al., 2018; Guss et al., 2020). Meditative practices are commonly conducted in relative silence, though may also involve mindful listening to music or sounds. It is not clear whether the incorporation of mindfulness in modern PAP trials involves music.
To our knowledge, we present the first modern report of PAP conducted with intentional periods of silence incorporated into psilocybin experiences for therapeutic motivations.
Patient information
Patient 1
Patient 1 is a female in her 60s diagnosed with advanced-stage breast cancer that reoccurred after treatment. Prior to this report, Patient 1 received three individual, compassionate-access PAP sessions for refractory anxiodepressive symptoms associated with her cancer diagnosis. Beginning with the first session in May 2022, each of these three treatments were conducted at her home by a generalist physician and a psychotherapist. As per standard PAP practices, music was used continuously throughout these sessions.
Following a partial but not complete therapeutic response to these three sessions, the patient was offered the fourth PAP treatment described in this report. For Patient 1, this fourth session differed primarily from her previous three in that it was conducted with a third clinician (in addition to the two that facilitated the previous doses), that Patient 2 also received treatment at the same time, and that it incorporated an intentional 30-min period without music. The same oral dose of psilocybin (25 mg) was used as her previous PAP treatments.
Experience of music
Music is extremely important and also, I should say, during the integration process as well. I listen to the playlists all the time, to remember the emotional states I was in while I listened to it.
Experience of period without music
When we stopped the music, then I felt it strange you know, because I’m not used to it – I had sessions with music wall to wall. But very quickly I got used to it and I could appreciate the silence.
There was a moment where I wanted to eat and was given fresh fruits. And [my therapists] guided a mindfulness session with what I was eating, meaning to be completely present with the sensations. It was extraordinary.
Generally, Patient 1 reported that the incorporated period without music during the psilocybin experience initially felt like a marked departure from her previous PAP treatments. However, she responded positively to the mindfulness-oriented approach of her therapists and later sought more time without music as the session progressed.
Patient 2
Patient 2 is a woman in her 50s who was diagnosed with, and treated for, bilateral breast cancer. Prior to the treatment outlined in this report, she had participated in two group ayahuasca experiences, once in Colombia and another in a Montreal Santo Daime ritual, but had never experienced psilocybin. After her application to Health Canada's Special Access Program to undergo PAP was approved, which was submitted by the same clinical team as Patient 1, she was invited to participate in the psilocybin therapy session with Patient 1 at the Hope and Cope Centre.
Experience of music
I didn't stay long enough for the music to have the full experience, but it works with the visions, somehow. (…) I was transported to a nightclub in the 90s. And I remember that night specifically. But then for me the music got very loud, because of the experience I was having in that club that night. I just wanted to get out, I was - it's almost like I was, I felt - it was too much, I was suffocating, and it was too dark and too many people. And I kept saying, “I want to go home, I want to go home. It's too loud, it's too loud, it's too loud.”
Experience of period without music
We had a mindfulness body scan. [A therapist] guided us, it was nice. I felt very calm and relaxed and open to the experience after that.
I always had the option to put [the headphones] back on, and at one point I was asked if I wanted to put them back on. I said no, I've been too lonely with my thoughts. And in the darkness, I just, I want to have my eyes open […] I needed reassurance. It's almost like I couldn't rest. I wanted desperately to rest, but it's almost like if I rest, something's gonna go wrong. Someone's gonna leave.
So that was very informing of how I’m always trying to make sure […] I can't rest because I need to make sure everything's OK. […] And if I don't, then they will leave, and they won't love me anymore. That's something that I will explore in my [therapy]. We haven't gotten there yet.
Presence was very important, because for a long time, I've been going into my mind to search for answers and then revisiting experiences. But as I close my eyes and I go into these experiences alone, it feels too much, it feels scary, and it makes me anxious. With [my therapists] there, I felt I'm in it, but I'm not alone.
Discussion
This report details the experiences of two participants who underwent PAP, via Canada's compassionate access program, where the dosing session incorporated intentional periods without music. The period without music was intended to facilitate discussion and guided mindfulness exercises by, for instance, removing the directive effects of music and the isolative effects of headphones. Although music, mindfulness, and discussion are all established elements of PAP, the use of intentional periods of relative silence during therapeutic psilocybin experiences has not previously been reported, to our knowledge.
Initial reactions to these music-free periods varied. Patient 1, who had highly positive experiences of continuous music during past PAP dosing sessions, found the shift unsettling. However, she soon after reported unique benefits from the mindfulness exercises that the music-free period permitted her engagement in. Patient 2's experience of music differed significantly – she described a more challenging musical experience that she was grateful to be then able to discuss with her therapists during the period without music. This latter experience might be understood as resistance to the music-psilocybin experience, and subsequently a missed opportunity to cultivate “letting go” and internally “work through” the experience as per current recommendations (Johnson, Richards, & Griffiths, 2008; Richards, 2015). On the other hand, psychedelic experiences characterized by feelings of resistance to musical accompaniment have been associated with less subsequent benefits (Kaelen et al., 2018), suggesting that such experiences may not always prove to be therapeutically productive if music is simply maintained.
Indeed, current protocols for PAP typically feature continuous music accompaniment during dosing sessions, played simultaneously through headphones and speakers (Johnson et al., 2008). Nevertheless, trial participants are reportedly given the option to remove the headphones for some periods to engage in discussion with their guides (Guss et al., 2020; Johnson et al., 2008). Such guiding or talk therapy has been a major component of nearly all published PAP trials (Carhart-Harris et al., 2018; Davis et al., 2021; Goodwin et al., 2022), though the frequency or duration of the periods where music is quieted or headphones removed is not clear. No PAP clinical trial, to our knowledge, has reported the proportions of psilocybin sessions that are actually spent listening to music through headphones or speakers, versus engaging in discussion.
The use of mindfulness in modern PAP trials is likely nearly as common as music and is similarly reported in relatively sparse detail. While most PAP protocols include mindfulness as a preparatory and integrative practice (Guss et al., 2020), such practices remain unstandardized. For instance, it is unclear whether mindfulness exercises are incorporated into the treatment sessions themselves, either alongside or without music. Modern PAP research reporting practices suggest that most or all interventions involve some combination of music-, mindfulness-, and talk-based components, but their relative balance is not reported.
As our two cases demonstrate, these three factors can be understood as both opposing and complementary forces in PAP. For all its described benefits, music may potentially distract from mindfulness exercises or impede verbal exchanges. On the other hand, mindfulness practices could potentially be cultivated through active listening to music, or indeed with dialogue. Verbal exchanges might also aid patients in “letting go” of resistance to the directive influences of music on their emotions or thoughts, allowing them to re-immerse themselves in the psilocybin experience. Alternatively, speaking might negatively distract from music's influences or impede the cultivation of mindfulness.
Given the complex relationships between music, mindfulness, and discussion in PAP, and the general paucity of clear comparative data, there remains much unknown about the advantages and disadvantages of each. Our patients' generally positive experiences suggest that there are potential benefits to incorporating intentional periods without music in PAP, as others have suggested (Kaelen, 2021, p. 202) (Noorani et al., 2018; O’Callaghan et al., 2020). This practice may prove to be a valuable technique in the repertoire of psychedelic therapists seeking to adapt their care to a given patient or to a given moment. However, further prospective research with standardized interventions and larger sample sizes is necessary to explore the generalizability of our preliminary findings. More broadly, PAP research should endeavor to improve reporting practices regarding how music is actually being employed in psychedelic treatment sessions.
Funding sources
None of the authors received any specific funding for participating in this treatment report.
Authors' contribution
SGG: Developed questions and conducted interviews with patient, writing—original draft, and writing—review and editing. JTL: Conducted interviews with patients and writing—review and editing. AL: Writing—review and editing. HF: Administered treatment and was directly involved in the patients' care. KTG: Administered treatment and was directly involved with the patients' care, supervision, and writing—review and editing.
Conflict of interest
Houman Farzin is a trainer for the non-profit organization TheraPsil, and was a volunteer member of their training and ethics committies. He was the Montréal site physician for MAPPUSX, a Phase 3 clinical trial of MDMA-AT for PTSD sponsored by MAPS, and is an investor in Beckley Psytech. The remaining authors declare that they have no conflicts of interest.
Ethical aspects
Our institution does not require ethics approval for reporting individual cases or case series. Written informed consent was obtained for the patient information that is published in this article.
Acknowledgements
The authors would therefore like to thank the patients for allowing us to publish their cases and contributing their invaluable experiences to PAP research.
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