Slides and Transcript
Slide 1 of 22
So this is on psychedelic-assisted therapy and I would encourage everyone listening to really not think of psychedelics as drug treatments.
Slide 2 of 22
At present, all of the larger clinical trials that have been conducted with psychedelics have been conducted in the form of psychedelic-assisted therapy and sometimes this is called psychedelics with psychological support. But regardless, there is a fairly stereotyped therapeutic process in which the psychedelic is administered. And this is not only to mitigate the potential harms associated with people getting scared and having challenging or negative experiences from psychedelics but also as I mentioned to really help catalyze therapeutic change, that if there's this neuroplastic state, neuroplasticity in and of itself in a neutral environment is usually not going to mean anything. One has to make a change and take advantage of the neuroplastic state to have that change stick. And so I'll explain a little bit about how the therapy works.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 3 of 22
But first, I want to talk about psychological safety. So as I mentioned for most participants and for most of these psychedelics, medical safety is mostly a given. They're physiologically quite safe. It's really psychological safety that needs to be considered which is kind of unique in terms of research. When I'm submitting something to the IRB, I really need to be thinking about how to protect patients from the psychological effects of psychedelics honestly more than the medical effects. There're not many agents that that's a consideration or at least the primary consideration, right?
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 4 of 22
So you've probably heard the term bad trips. We don't use the term bad trip anymore, one, just because it obviously has some baggage associated with it and, number 2, because we say challenging experiences rather than bad trips because in most cases when people have challenging experiences, this is not the entire duration of the psychedelic session but it can be intense when It happens.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 5 of 22
So what are challenging experiences? So these can occur in a variety of modalities. They can take the form of just simple anxiety to panic or dysphoria all the way up to frank paranoia and delusions. The variety of modalities they can occur in, people can have sensory feelings and illusions, there can be somatic hyperawareness of body processes, distressing personal thoughts about the self and even metaphysical thoughts, fearful thoughts about the world, society, evil forces, cosmic forces, stuff like that.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 6 of 22
Psychologically, when people start fighting with this or try to avoid the psychological experience that they're having, this tends to make it worse. Secondly, it's generally believed that in most cases when a challenging experience occurs, it's kind of the way we think about emotional difficulties in more classic psychotherapy particularly psychodynamic therapy, that this is grist for the mill and is an opportunity for the participant to really dive in to whatever it is, try to trust the process, be open to what's coming up and to feel their way through the experience.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 7 of 22
And this happens with the support of the therapist team, right? So these studies generally have been conducted with not one but with two therapists present. And one of the main roles of the therapist is to assist the participant in the studies when these things come up to help them to kind of trust in the process, to go deeper and to see if they can kind of come out the other side with some new insights into whatever was causing this distress.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 8 of 22
Now, there will be pharmacological agents as backup. They're rarely used but they have been used in some scenarios. So usually, you're going to have a benzo on hand just in case and if not, there's going to be an atypical antipsychotic available for extreme situations.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 9 of 22
There is some screening that needs to be done. So not everybody is thought at least at present based on what we know to be a good candidate for psychedelic-assisted therapy. So people with a personal history of a psychotic episode, personal history of a true manic episode are thought to potentially be at risk of adverse effects from psychedelics and having their condition worsen. Most American studies have gone a little bit further and also screened out anyone who has a family history, who has a primary family member with either a psychotic disorder or a type 1 bipolar disorder.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 10 of 22
So when we think about generalizability of these studies, important to note that these are very, very carefully screened people and all of the studies that you've seen up to this date, they may not be at least at this point very generalizable results given how careful the screening has been.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 11 of 22
What is HPPD? HPPD stands for hallucinogen-persisting perceptual disorder and this refers to something that's been seen going back to the 1950s where people have some kind of persistent perceptual re-experiencing of something that first occurred during psychedelics.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 12 of 22
Now, there's certainly a lot of people out there and I've seen some of them who have this but what's curious is that this has never been seen in any modern clinical trial. So it's unclear if this is a truly organic or brain-related impact of psychedelics or rather this may be more of a traumatic response or maybe both that might be much more likely to occur in recreational use which often is unsupported the way that people have been supported in these studies or perhaps that this may simply be due to the fact that people who develop HPPD are people who are at risk based on factors that have been up to this point screened out of any of our modern clinical trials.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 13 of 22
So how does psychedelic-assisted psychotherapy work? Psychedelic-assisted psychotherapy has three key parts. So there's the psychedelic session in the middle and these are preceded by preparation sessions which establish rapport with the therapist dyad, they collect information about the participant and they help to psychologically prepare the participant to really trust and be open to the psychedelic session. You don't want people coming in to the psychedelic session expecting that this is going to be easy, expecting that there's going to be this amazing euphoric experience with no dark corners. This is really not — Somebody who's thinking like that, they're really not a good candidate for this. And so working with them in the preparation to be able to be a little bit more neutral and open to whatever may come up is really the main purpose of preparation.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 14 of 22
After the psychedelic session, there are a number of what are called integration sessions and this is really just aimed at letting the participant speak to what their experience was, be supported in processing or meaning making of what came up for them during their psychedelic session. It is thought that the integration sessions are really likely key to helping people solidify whatever these changes may be that they're going to get longer term such as reductions in depression or anxiety. But really the opportunity for talking is going to come during the integration sessions and it's thought that the more the person can spend inside with their own thoughts and their own feelings or whatever is coming up, the more the opportunity for therapeutic change there is.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
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Slide 15 of 22
So like I mentioned, the therapist dyad is present but the patients are encouraged to have an internal experience. So the psychedelic session itself usually doesn't have a lot of talking. So you'll see in the picture there, there're some headphones. So people are offered eyeshades and headphones and really instructed to go inside and to just try to sort of calmly be open to whatever is coming up. If they need to talk to a therapist, they're there. But really the opportunity for talking is going to come during the integration sessions and it's thought that the more the person can spend inside with their own thoughts and their own feelings or whatever is coming up, the more the opportunity for therapeutic change there is.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 16 of 22
Set and setting is a term that many are probably familiar with. This goes back to the 1960s. We know that the set which is the mindset that the patient goes in to the psychedelic experience with matters and we know that the external environment also matters. So set and setting refers to an ideal both internal and external environment. So these are not treatments that can be done in very sterile hospital-type settings and so most of these academic hospital centers that have done this research have outfitted their rooms and tried to humanize them as much as possible and make them a little bit more similar to what one might find in a private practice office or even one's living room.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.1901003516
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Slide 17 of 22
Now, having told you this, you might be already thinking that this model probably is going to cost a lot of money. And indeed, at this point, I think things are certainly looking that way. So even for a protocol that might have only one psychedelic session, let's say it has two preparation sessions that might last 90 minutes, psychedelic session lasts eight hours, two integration sessions lasting two hours each. Each one of these sessions has two psychotherapists present. In a lot of these studies, one of them is a psychiatrist. So this is a very resource-intensive paradigm particularly given the fact that up to now at least one and sometimes both of the therapists have been people with doctoral level degrees. So this is going to present a very large challenge for scalability and for cost. I think there's a lot of room for innovation with the therapy itself.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 18 of 22
And as I've alluded to throughout this talk up to this point, there're also some competing medical philosophies that I think will also be a challenge. Indeed, they are a challenge now in kind of explaining how these treatments work. In modern medicine, we tend to be very prescriptive, we tend to mostly tell the patient what to do even if it's just, you know, take sertraline every single day. The idea of psychedelic-assisted therapy is really non-directive. It's simply to be present for the patient and to encourage the patient to have their own process and to determine in a supportive environment but really on their own what is important for them. And so in this way, psychedelic-assisted therapy is more akin to practice-based modalities such as mindfulness than as a treatment per se. And so we're seeing some clashes as these things that are now being researched as treatments are coming to the level of FDA approval and how we're actually going to work with them clinically when I think most of us are really not well versed in thinking of therapeutic change more as something that's the result of a practice or a process.
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Slide 19 of 22
Lastly, as I've mentioned, the idea of the mystical experience, right? This is maybe not a religious term but it hints at it. It's certainly not a purely secular implication when one speaks of the mystical experience. And if it turns out that the mystical experience truly is crucial for therapeutic change in psychedelics, I think it's both a challenge given our hypersecular orientation of modern medicine but also potentially a real opportunity to expand this sphere of scope of practice of what practitioners are doing and what dimensions of human functioning we're really looking at in terms of both treatments as well as ideas of wellness in our patients.
References:
- Cavarra, M., Falzone, A., Ramaekers, J. G., Kuypers, K. P. C., & Mento, C. (2022). Psychedelic-Assisted Psychotherapy-A Systematic Review of Associated Psychological Interventions. Frontiers in psychology, 13, 887255. https://doi.org/10.3389/fpsyg.2022.887255
- Guss, J., Krause, R., & Sloshower, J. (2020). Yale Manual for Psilocybin-Assisted Therapy of Depression (1st ed.). https://doi.org/10.31234/osf.io/u6v9y
- Reiff, C. M., Richman, E. E., Nemeroff, C. B., Carpenter, L. L., Widge, A. S., … Rodriguez, C. I. (2020). Psychedelics and Psychedelic-Assisted Psychotherapy. American Journal of Psychiatry, 177(5), 391–410. https://doi.org/10.1176/appi.ajp.2019.19010035
Slide 20 of 22
So the key points here are that psychedelics are unique in that the primary concern tends to revolve around psychological safety as opposed to medical safety. We know that challenging experiences can occur during a psychedelic session and we emphasize the need for psychological support or therapy prior to, during and after the medicine sessions.
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Slide 21 of 22
Psychedelics are not standalone drug treatments. That could change but that is not the way to think about them now. They are offered in a paradigm of psychedelic-assisted therapy which includes the preparation for psychedelic experience, supportive care during the session and integration therapy following sessions to reinforce and solidify therapeutic insights. Psychedelic-assisted therapy is paradigmatically unique in Psychiatry and as such faces significant challenges ranging from a philosophy that is fairly anathema to biomedical paradigms to substantial upfront costs and related issues of access. These challenges have yet to be solved.
Slide 22 of 22
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