Clinical skills for psyhchedelic therapy with Dr Adele Lafrance

My unofficial Vital Study Zine #17 with observations from Vital Psychedelic Training and recent happenings in the space

From Highlights of the Convergence, a new immersive exhibition for the visually impaired, open now at Meow Wolf, Denver, Colorado

“I want to be a steward for reality,” declares clinical psychologist Dr Adele La France.

The effervescent Dr La France is famously ‘based’.

She cracks off her talk to Vital students about the practicalities – the reality if you will – of psychedelic therapy by explaining how she was generally anti-psychedelic drugs, until she experienced them in a medical context.

Her clinician’s manner is a masterclass in marrying authority, whimsy and vision. She’s the co-creator of Emotion Focussed Family Therapy; her clinical manual on it is published by the notoriously hard-to-please American Psychological Association. Dr Lafrance’s new book What to Say to Kids When Nothing Seems to Work: A Practical Guide for Parents and Caregivers is out now at a family-friendly price.

While toiling at the sharp end of mental health, she’s spoken convincingly (and warmly) about topical issues like taking ayahuasca to heal eating disorders on Emmy Award-winning daytime TV show The Doctors, and video game addiction on CBS. She’s currently working as clinical investigator and strategy lead at MAPS’ study of MDMA-assisted psychotherapy for eating disorders, and as clinical support on Imperial College London’s study for psilocybin and anorexia nervosa.

Maybe because Dr Lafrance has actually been conducting psychedelic therapy while the rest of us are debating its finer points, the softly-outspoken clinician has junked some of the practice’s outdated rhetoric.

“Oftentimes they’ll be rewarded with amazing insights in the bathroom”

Like its reluctance to let voyagers take a pee, lest a break for ‘voiding’ stops them from ‘surrendering to the medicine’. “If they’re doing work that feels really meaningful, clients may get conflicted about going to the bathroom. But my stance is that the meeting of physiological needs is the most important,” she says, “After all, Abram Maslow’s Hierarchy of Needs would say insights are great, but engaging consistently in meeting physical needs is fundamental.”

According to Dr Lafrance there are all sorts of other advantages to be discovered when trippers stumble to the lavatory.

“Oftentimes they’ll be rewarded with amazing insights in the bathroom,” she says, and it’s true ablutions are managed by the right brain, hence Pythagoras’ eureka-in-the-bath moment.

Things clicked for Dr Lafrance – “Adele, please” she urges Vital students – in a ‘patient experience’ she had a while taking part in an MDMA safety trial. 

Dr Adele La France

“It happened to me when I was part of an MDMA study for health controls,” she confesses, “I went to the bathroom to pee. But I was working on something, and I couldn’t wait to finish it up and get back. So I was pee-ing in a pressured way… I can’t believe I’m sharing this… anyways… I realised, for fuck’s sake’s – I couldn’t even pee in peace. I’m so focussed on productivity and getting things done, that I can’t even pee at a rate that is organic! That revelation was life-changing. Now I never want to multi-task ever again. It’s self injury!”

It is indeed. But there’s even more to a mindful tinkle than flushing out the pipes, psychic or otherwise. 

“If we all heal the split between our mind and our body, not only are we more attuned to when we need to void or eat, we’re more attuned to our instincts,” advises the working psychedelic clinician, “and reconnecting with their instincts the greatest gift we can give our clients.” 

Homeostasis for everyone. And, risk of multi-tasking aside, Adele has further intentions: she’s grown psychedelic therapy into a fresh model, ‘theoretically informed’ psychedelic therapy, incorporating her angle of emotion processing.

“A sign of emotional maturity is the capacity to hold anger and love at the same time”

She’ll apparently be presenting this next year in 2023, and gave the Vital cohort a sneak peek.

“I am committed to reality,” she reminds us, “meaning, actively letting go of blame narratives and fantasy as a tool for human relationships. A sign of emotional maturity is the capacity to hold anger and love at the same time, reckoning with the complexity of human relationships.”

Watch Adele talking to Gabor Maté on behalf of Chacruna and more including her talks for MAPS on my New Psychonaut YouTube lecture library type thing.

Here’s what’s in this week’s issue of your frank but friendly Vital Student Zine, themed along Vital Psychedelic Training’s core pillars of study. Air provides an overview of psychedelic use, Fire concerns therapeutic applications, Water covers ‘space holding’ – the art of keeping it together, Earth is where you’ll find medical matters, and Ether discusses integration, the process of bringing psychedelic power into regular life.

The Feeling Theory

Approach

Dr Lafrance mixes up emotion focussed therapy with a ‘theoretically informed’ treatment room style – that involves interacting with the patient

By Nokukhanya Langa showing at Saatchi Yates gallery, London till November 22

“There’s been an evolution in psychedelic therapy, says Dr Lafrance, "I’m presenting all this next year, so you’re getting a sneak preview.” 

Contemporary psychedelic medicine began with ‘experience’ sessions were ‘non-directed’, that is, given as little intervention as possible. (Psycholitic is the name given to experiences where talk therapy takes place). Soon they became ‘inner directed’ encouraging the voyager to get in touch with their ol’ inner healer.

But now, “We’re moving towards a theoretically informed way of being in the treatment room,” Dr Lafrance reports, “especially when the inner healing intelligence is most active.”

If like me you’re wondering what ‘theoretically informed’ means, well, from my Googling I figure it’s an academic term for ‘rooted in reality’ and usually involves some form of research and sense-checking from folks actually doing the thing in question.

For instance: one paper I found, which researched ways to encourage intravenous drug users to be tested for hepatitis C, insisted it employed ‘evidence based and theoretically informed techniques’ gleaned from social workers.

Dr Lafrance later describes herself as “a theory-based person” and I for one will happily accept her theories when it comes to ‘ways of being in the treatment room’, because she’s been a top-flight clinical psychologist for decades. 

“They indulge in maladaptive coping behaviours and problematic relationships to cope… or risk more serious mind fractures” 

The bubbly brainbox is also a renowned expert on Emotion Focussed Therapy (EFT); she’s the author of Emotion Focused Family Therapy: A Transdiagnostic Caregiver Focused Guide, published by the redoubtable American Psychological Association. 

According to The International Centre for Excellence in Emotionally Focused Therapy (ICEEFT) website, EFT is closely related to John Bowlby’s Attachment Theory of Human Relationships. ‘Attachment views human beings as innately relational, social and wired for intimate bonding with others,’ it reads, ‘The EFT model prioritises emotion and emotional regulation as the key organising agents in individual experience and key relationship interactions.’

Dr Lafrance says EFT focusses on emotion regulation and processing: “If they have low skills regulating emotions and stressors, and their resources are insufficient, they have to indulge in maladaptive coping behaviours and problematic relationships in order to cope – or they risk more serious mind fractures.” 

In the EFT model, seemingly destructive patterns like addiction fend off worse outcomes like suicide.

“You get this activated self rising like a phoenix. And it’s freaking awesome”

Addicition’s an example of a coping mechanism that’s arisen to swamp the torturous emotional quagmire within.

“Cross-diagnostically patients have problems with identifying and processing emotions,” says Dr Lafrance, “the symptoms are thought to be emotion regulation strategies. But if we can offer them support, including in strengthening their emotion regulation and processing skills, they receive co-regulation that in turn leads to self-regulation. Then they don’t need the coping patterns. It’s tackling the problem from the inside out.”

“The key term,” says Dr Lafrance, “is self-efficacy,” meaning the power to deal with things yourself. “If you feel it with emotion processing,” she claims, “it’s incredible armour for the challenges of life: both the skills, and the support it provides.”

Our emotional landscapes, though, can be foggy territory. Dr Lafrance has even felt the compulsion to hold free public workshops helping the great unwashed map out their own internal geography. Many of us are simply not literate enough to know that behind the emotion of ‘sadness’ there’s a need for ‘comfort’ from another – the common reaction is to withdraw for time alone instead. 

“Which emotional states do they find most challenging to identify, label, meet and need?” advises Dr Lafrance, “Stick with the sense of helplessness and that turns into ‘it’s not fair!’ And then there’s a healthy rising up of assertiveness. Latch on to something, work with it in specifics ways that help it along, and you get this activated self rising like a phoenix. And it’s freaking awesome,” she says.

As a people we’re so emotionally retarded that Dr Lafrance has found it’s sometimes best to simplify troubled emotions down into two categories.

“In the past when I would’ve said ‘Feel into that space with me’ now I’d just say, let’s not go there if you’re not sure”

‘Anger, resentment and disappointment’ indicate a client who shies away from vulnerability. ‘Anxiety, sadness and despair’ point to low assertiveness.

But “hate and resentment can feel like a comfy blankety” advises Dr Lafrance: “Some people subconsciously live their lives by the mantra ‘I’d rather die than feel’,” she says.

This is where “accessing and understanding the genus of their difficulties” comes in. “One patient told me that their medicine sessions were the first time they’d sat in fear and sadness with memories they were trying to hide from,” she explains, adding that psychedelics can quieten a harsh inner critic that usually directs repressed feelings towards their holder, away from the recognition of painful events. 

But, “EFT is less about the memories than it is about processing,” says Dr Lafrance, “they’re regulating, avoiding or suppressing affective material. Understanding the pattern can diffuse shame and assist in moving through the emotion.”

To quote humanist psychologist Carl Rogers: ‘Once an experience is fully in awareness, fully accepted, then it can be coped with effectively, like any other clear reality.’

Four Times You Probably Should Intervene with the Voyager’s Experience

Therapy

Frontline clinical psychologist answers the big question: when the patient’s tripping balls, when does the therapist definitely need to get involved?

From The Order of the Fool Street Tarot exhibition in Manchester

‘This level of reality should be the new standard being applied to therapy in general’ says a Vital cohort colleague in praise of Dr Lafrance’s theoretically informed approach.

“It’s different to how we were trained!” replied the respected frontline clinical psychologist. Like you can read about in the Approach section this issue, she combines emotion-focussed therapy with a ‘theoretically informed’ style taking cues from lived experiences received in the treatment rooms.

This not only contrasts with bureaucratic doctrine, that favours centralised top-down wisdom… which can take decades to catch up with what’s happening on the ground.

It’s also at odds the non-directive or ‘inner directed’ approach pioneered by Dr Stanislav Grof (for it is he) which insists on more delicate interaction with the therapist during the psychedelic experience itself, to encourage a more detailed internal dialogue. 

“I do warn them in advance that they’ll be more aware than I am”

That’s the the way psychedelic therapy is going though, Dr Lafrance claims.

Those of us who were only just getting the hang of being non-directive may be left a-flutter by this sudden change in er, direction. So Dr Lafrance has kindly detailed the when’s and why’s of sticking your oar in during the voyager’s experience. 

“We still intervene in a relational, emotion-focused, and inner-directed way,” she comments in her Vital lecture profiling the emotion-focused, theoretically informed style. 

Dr Lafrance’s reasons for chipping in? Conflict with parts of the self. Maladaptive emotions like anxiety and self-criticism. Anticipated shame and regret, along the lines of ‘I can’t believe I told you that, it’s supposed to be a secret.’ And, reluctance. 

Each must be handled gingerly, and always in the context of the medicine experience – hence ‘inner directed’ still, prompting the patient to look inside themselves, still.

To confirm if your planned intervention is indeed worthwhile, confer with the handy acronym WAIT – ‘why am I talking?’

“We make a deal in the container that I’m always fine”

For instance: when confronted by the thought of a sober therapist and spangled patient, an old tripping pal of mine asked, “What happens when they realise they’re taking care of you?”

He was offering up a psychedelic riddle-cum-truism. But it does happen according to Dr Lafrance albeit more prosaically. 

“I do warn them in advance that they’ll be more aware than I am,” says Dr Lafrance, “We make a deal in the container [agreed-upon boundaries of behaviour while tripping] that I’m always fine.” Because when patients suddenly start insisting that you go outside for a smoke, grab a coffee, or take some time to yourself “it can be reassuring to just say that you are” says Dr Lafrance.

“But it can be more rewarding to go into that place,” she advises, “is there a process of caretaking that needs looking into?’ Tell them that you’re always comfortable, they don’t need to worry if you’re hungry because it’s been four hours.”

Otherwise, go get that brew now “Or it may feel like a violation.”

Uncharacteristic behaviour can be examined by gently pointing out that “It’s so wonderful to get to know this part of you… feels like it’s a part that really need to show itself?”

That attentive, experience-led vibe seems to be sweet spot of ‘theoretically-informed, inner-led, emotion-focussed therapy.’

Don’t Go There

Space

Dr Lafrance doesn’t insist that patients ‘surrender to the medicine’ when they’re not up for a challenging experience

By Thomas Houseago now showing with… Nick Cave and Brad Pitt at Sarah Hilden Museum, Tampere, Finland till 15 Jan 2023

In her preparatory sessions with clients, Dr Lafrance asks them what level of intensity they’re prepared to face.

“What if a wariness of some feelings is an expression of the inner healer?” the storied clinical psychologist who “aims to be a steward of reality” asks Vital students, in her lecture on frontline applications of psychedelic therapy.

And she doesn’t insist upon ‘surrender to the medicine.’

“Any opportunity for pro-active shame work we will take,” she points out, “but if someone is expressing reluctance about pushing through, we’ll wait. This contrasts with prevailing psychedelic wisdom/gubbins, which practically demands patients stare directly into the eyes of any monsters: “In the past I would’ve said ‘feel into the space with me’ now I’d just say ‘No, let’s not go there if you’re not sure’,” Dr Lafrance reports.

“What if a wariness of some feelings is an expression of the inner healer?”

This ‘self interrupter’ part that forbids examination of traumatic feelings (especially when tripping balls) “was downloaded for a reason,” says Dr Lafrance, “Let’s respect it and go slow because that in itself can be powerful… by helping them be less afraid in the future.”

So she’s fine with patients telling jokes, “which is awesome for people who have problems expressing joy and flexibility.”

Dr Lafrance even gives a pass to ‘spiritual bypassing’ which as far as I can tell means ‘having any sort of trip that isn’t a clinical healing-type one’. 

Those, as Vital students have been repeatedly told by big dogs like Dr Bill Richards, aren’t ever worth banking on anyway. 

“Therapy comes more from process than outcome in the session”

Indeed be wary of any dramatic, sudden, supposed healing advises Dr Lafrance.

“If they realise they’ll feel bad tomorrow for acting out of the ordinary, that’s a sign it might be time to work with the shame. But if they’re throwing all their clothes off and shouting ‘I’m so sick of hating my body!’ it might be worth asking them what ‘Tomorrow You’ is going to think of all this. They realise you’re not trying to shame them. And they’re very grateful.”

Dr Lafrance even assures patients not to feel they have to talk about things they really don’t want to. This is because “therapy comes more from process than outcome in the session,” she explains, “how did they engage with the parts of themselves and the therapist? That creates a different framework for engaging with the world.”

Anger is an NRG

Medical

How to take a (small) step closer to the dark side for more assertiveness and self-compassion

Adam Neate, ‘Retrato’ available from Flurorescent Smogg

The reconstructed self doesn’t take any crap.

“Assertion is a common after-effect of medicine work,” says Dr Lafrance coyly, in her eye-opening lecture to Vital students on hw psychedelic therapy goes down in the real.

Like the article says over in the Approach section of Zine #17 here, Dr Lafrance says therapists see two secondary emotions most commonly in the field.

“Empowerment skills, when they’ve perhaps not been done before, are usually too mousey… or too much”

Those two feelings she hears about the most are sadness, as one might expect from the depressed, and rage.

“Anger is a challenge for many people,” says Dr Lafrance, “but not all anger is destructive. There is healthy anger.”

This more righteous kind of fury can often be confused, shall we say, with assertiveness.

“Culturally we really struggle,” comments Dr Lafrance, “I’ve been in therapy for 20 years working on my capacity for anger, standing up for myself, and asking what I need.”

The rage-fuelled are shying away from vulnerability according to emotion focussed therapy, and it “shows up as these problematic reactions that fuel expression of symptoms,” says the clinical psychologist, somewhat eupehmistically.

“Empowerment skills, when they’ve perhaps not been done before, are usually too ‘mousey’, or too much,” explains the blonde boffin, “plus the most predictable reaction to unexpected criticism is defensiveness.”

Dr Lafrance provides scripted frameworks for the budding bearish buccaneer.

“I always assume user error. You know, because it helps me to cultivate more sophisticated skill”

She’s kind enough to share one with Vital students during the post-lecture Q&A, when I ask about help with my own fermenting… assertiveness.

“I always assume user error. You know, because it helps me to cultivate more sophisticated skill,” she advises. 

“If I'm expressing assertion, especially if it’s in a relationship where it’s kind of a novel experience, and it doesn't go well… then I ask myself: ‘What am I doing or not doing to contribute to this problem?’” 

That’s how she hit on the idea of detailled advice for pateints fumbling their way into self-confidence.

“I was encouraging people to express assertion, and it's not going well. So then I, as a therapist, asked myself ‘How did I contribute to that?’ Like, ‘Oh, shit, we didn't warn them.’ So I wrote, I wrote the script now that I give to all the clients.”

And it goes a little something like this:

‘I realised that I don't always say or tell the truth about how I feel. Or about what I need. It's hurting me.

And I realise that makes it so that I'm not always honest in relationships. Because I'm scared that I'll lose people important to me. Including you.

“Not all anger is destructive. There is healthy anger”

I really want to make a change in this way. I want to be more honest. And I want to have more faith.

Faith that heart-centered motivation is there at the forefront. And faith that this relationship can sustain the changes that are required for it to evolve. 

Would it be okay, if I started, in this relationship, being more honest about the things that hurt?

Or the things that anger me? Knowing that it's really because I want to find a new normal that will serve us both?’

You might as well give it a go, you’ve tried evrything else. Could avoid an ‘Iatrogenic’ – therapist-induced – divorce.

Trip for me babe… trip for you?

View fullsize

Integration

After a fortnight in the jungle, your relationships might never be the same

Soheila Sokhanvari, The Gift, from the exhibition Rebel Rebel at The Barbican, London till 22 Feb 2023

“I’ve a feeling we’re inadvertently harming a lot of family members. If your partner goes for a two week ayahuasca retreat in the jungle, your life is going to change.”

Thus warned Dr Adele Lafrance in her lecture to Vital students about how feedback from the frontlines is informing psychedelic therapy.

And the emotion-focussed therapy expert told the Vital cohort that things can get even more cluster-fucked than that, once psychedelic rhetoric sets in. 

“The concept of blame in psychedelic work is very delicate and potentially dangerous,” she says in her quietly subversive style, “there’s that fundamental belief that ‘we are all one’ and ‘inner conflict is related to outer conflict’.” 

Transcendent resolutions usually only happen in retreat brochures. “Healing can be disruptive,” points out the self-declared ‘steward for reality’ – “We don’t want to throw anyone under the bus.”

If handled correctly, “Holding the healing for the patient’s chosen, natural environment can encourage positive effects, lessen negatives, and evolve relationships,” says Dr Lafrance, improving key connections for the benefit of all concerned. 

“Neuroscience supports the healing power of supportive caregiver-loved one reactions,” she continues, encouraging “Working at letting go of blame narratives and fantasy as a tool, in particular those involving our primary caregivers… as for some reason, at this stage of evolution, humans are strongly affected by the context of attachment relationships.”

Psychedelic culture, its rhetoric at least, is infamous for butting up against reality: from free love to not doing any washing up in the hippy commune and the ‘all conflict is bad, mmm-kay?’ notion referred to by Dr Lafrance above.

“It’s a skill to hold space for absent family members”

And patient-voyagers often come crashing back down to Earth when they head back to the all-too-real environment of the office, family dinner table, or marriage bed.

“As a field we need to think how we’re managing systemic stress,” says the working doctor, “If we foster asymmetry of growth by only treating one person, it can have worse outcomes for the client – breakdown of a marriage, for example. There is a high chance of getting divorced, when if we treated both the relationship could have thrived.”

MDMA-assisted couples’ therapy is still a few years off. What can psychedelic therapists do to keep ‘systems’ like couples and families in union till then?

“It’s a skill to hold space for absent family members. And it can be an especially complex skill to deeply validate the client’s experience while still honouring the family member,” advises Dr Lafrance.

“We don’t want to throw anyone under the bus”

She’s a specialist in Emotion Focussed Therapy (EFT) which has its own branch for next of kin, Emotion Focussed Family Therapy (EFFT).

During Zoom lectures, “I normally have my hibiscus behind me,” says the congenial clinical psychologist, with no further explanation of her favourite flora’s current whereabouts, “I normally point at it while I say this; a client’s lineage makes up the whole plant. So, an example of what I might say [about their family] is, ‘Yes, they were not able – not didn’t care, or didn’t try. Let’s cultivate these experiences, so you can be the first flower in your family lineage to bloom.”

Cod spirituality around ‘respecting the ancestors’ is best kept in mind, rather than hectored at the client. "We don’t have to tell the patient, but it’s important for us to remember the cultural, religious and social influences that changed the directory of their lives.”

Here in the UK, family members have a legal right to a ‘needs assessment’ that can provide additional support, and a study on Multiple disassociation disorder (MDD) Dr Lafrance is consulting for here in Europe involves the family. “This could be a formal process during screening [in the USA] as things get legal, especially if they are under-resourced or unaware,” she says.

Those of us who are wary of social services padding about our home, or feel their help may be superfluous, might also find ourselves cast in a role of responsibility, where certain emotions are unwelcome.

And personally, I’ve seen more women presenting at services usually associated with men, like anger management (see the Kardashian sisters for a celeb example). It’s connected to a sense of overwhelment, usually from satisfying others’ needs before one’s own.

“We don’t want people to taint our experience when it’s so fresh, raw and vulnerable. So we tell the family that they can’t expect to hear all about it”

Says Dr Lafrance, “There are gender differences, unfortunately, that are still true you know, in terms of how we have been culturally conditioned to connect with emotions. Men still struggle more with sadness, fear and shame. Women, because of cultural conditioning, and socio-political movements meant to suppress female assertion, still struggle with healthy anger. So that's why I use this dichotomy: ‘Which one is true for you?’ Because it's not always gender specific, especially as we continue to evolve as a culture around questions related to gender roles.” 

The respected clinical psychologist also recommends discretion around any potent visions and insights voyagers may’ve enjoyed. “At the end of the session we’ll ask the client what they feel comfortable sharing that doesn’t compromise them, their needs, or their integrity, but is still informed by what a couple might need. We don’t want other people to taint an experience when it’s so fresh, raw and vulnerable. So we tell the family that they can’t expect to hear all about it.” Bear in mind that sharing you spoke to an omnipotent mushroom counts for that.

What if, like myself, you sometimes get carried away with the notion that everyone in your family would benefit from a little medicine work? 

“When I was in the jungle what came up over and over again was – you have to be in touch with reality”

In the post-lecture question and answer session, I asked Dr Lafrance how not to share too much with friends and family: “Yeah, in fact, that would be another point of direct intervention, actually. So thank you for bringing that up,” she replied, “If someone in the context of the ceremony, you know, or session says, like, ‘Oh my gosh, I wish my parents would do this, I wish my brother would do that, I wish my sister…’ then I will ask them to look more deeply into that.”

Doing so might enable the patient to “Release themselves, and release that person from, you know, having to be at the same stage of healing,” says Dr Lafrance, “Release self first, release other second. And if that comes up in integration sessions, I would do it the same way – like, ‘Yeah, check in with the part of you that is longing for that. Let's see what it needs. Let's see what it says’.”

Dr Lafrance can certainly tell you what the Grandmother Spirit had to say about her own familial ins-and-outs, during a lengthy ayauasca retreat.

“When I was in the jungle, that was one of the things that came up over and over again – like, you have to be in touch with reality.” 

Which is probably a better tip than ‘You must respect the ancestors.’ But like anything genuinely helpful, it’s not easy to take on board. 

“They are limited in their capacities,” she explains, “And it's not because they don't love you. It's not because they desperately want you to be different, that you're not going to be able to get what you're looking for. And so where else you're gonna get it? Inside. And I cried many tears over that, you know, sprawled out on the earth outside of the maloca. Like, not wanting that to be true.”

Ceremony in Jamaica with Sacred Transitions Retreats and New Psychonaut

Treasure Beach ‘The Cornwall of Jamaica’ is where I’d send anyone close to me pondering a first experience.

Take a look.