BACKGROUND: Psilocybin-assisted psychotherapy shows promise in alcohol use disorder (AUD), but therapeutic mechanisms remain poorly understood. Previous qualitative studies have described potential processes such as gaining insights, altered self-perception, connectedness, and changes in coping, yet findings remain limited and inconsistent in AUD, and little is known about early markers of therapeutic response.
METHODS: We conducted a mixed quantitative-qualitative analysis of first integration sessions in the Psilocybin Alcohol Depression (PAD) randomized controlled trial. Only participants randomized to the 25 mg psilocybin group were included in this analysis. Recently detoxified patients with AUD and persisting depressive symptoms underwent semi-structured integration interviews the day after dosing. Transcripts were analyzed with IRaMuTeQ software using the Reinart descending hierarchical classification. Associations with abstinence at 3 months were examined.
RESULTS: Twenty participants were included (55% male, median age 49); 55% were abstinent at 3 months. The corpus comprised 127,760 words, with 88% classified into two stable classes. Class 1 (44% of text segments) described sensory and emotional aspects of the psychedelic experience (physical sensations, visual phenomena, emotions, setting) and was predominantly elicited by non-responders. Class 2 (56%) reflected active cognitive processes and inner dialogue, including cognitive restructuring, distancing from habitual patterns, commitment to change, and work on pre-elicited intentions related to alcohol. Abstinence at 3 months was significantly associated with references to family connections, pleasant emotions, adaptive processing of fear, and revisiting alcohol-related triggers with new coping strategies, while non-abstinence was associated with negative emotions, physical pain, disappointment, and suppressive coping.
CONCLUSIONS: Responders were distinguished by narratives of inner dialogue and adaptive coping, while non-responders emphasized sensory and affective descriptions and suppressive coping. Inner dialogue may constitute a distinct therapeutic mechanism, highlighting the importance of preparation and integration in psilocybin-assisted psychotherapy.
