Developing Methods for Observing Awe Narration in Psilocybin-Assisted Therapy

Background: Understanding the benefits of psychedelic-assisted therapy (PAT) will require scientific attention to the causal interaction between the therapeutic context and process. Measuring what actually happens during PAT in large-scale studies will be an essential component of this work. Objective: We aim to develop and preliminarily evaluate the feasibility and reliability of a direct observation coding system for narrations of awe experiences during PAT, one hypothesized therapeutic mechanism. Methods: We analyzed 32 PAT clinical trial encounter recordings involving eight participants from a Phase 2 clinical trial study of psilocybin-assisted therapy in advanced cancer. Using a conceptually grounded structured codebook, two human coders independently identified start and stop times for moments exhibiting definitional characteristics of awe narration, including expressions of vastness, need for accommodation and ineffability. We used coder agreement and degree of confidence to refine the coding system. Results: During 16,760 total minutes of video, coders collectively recorded 246 moments of awe narration. Of those moments, 42% (104/246) were identified by one coder and 58% (142/246) by two coders. Coders felt substantially more confident in their judgments about a moment of awe when vastness was present compared to when vastness was absent (OR: 4.3; 95% CI: 2.4, 7.8). Iterative refinement of the coding system led to accommodation being operationalized as two distinct components: an initial cognitive disruption followed by variable engagement in the process of accommodation. Conclusions: Awe narration is directly observable using explicit definitional criteria. This work provides the empirical foundation for scalable coding systems of awe narration during PAT.