Psychedelic Turf Wars: Where Does Psychiatry Fit In?
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As many of you are probably aware, the mental health space is experiencing a renaissance with the reintroduction of psychedelics. Over the past several years, compounds like psilocybin, MDMA, LSD, 5-MeO-DMT, ayahuasca, peyote, and ibogaine have been at the forefront of headlines for their potential to treat a wide variety of ailments, including treatment-resistant depression, PTSD, anxiety disorders, and substance use disorders. Additionally, these compounds have been noted to improve creativity, openness, and overall well-being.
“... psychedelic use has been a staple of society for thousands of years... nearly every corner of the world has been along for the ride!”
This is an exciting time for researchers because there has been limited ability to formally study psychedelics following the passage of the Controlled Substance Act. Prior to its passage, much work was done in an attempt to understand the applications of psychedelics. From the accidental discovery of LSD’s psychedelic potential by Dr. Albert Hofmann in 1943 to Dr. Humphry Osmond’s and Dr. Abram Hoffer’s work investigating the efficacy of LSD in treating alcoholism in the 1950s, to the Spring Grove Experiments in the 1960s that investigated LSD’s use for a wide variety of mental illnesses, the potential for psychedelics to "break the mold" of mental health treatment has been well documented. However, psychedelic use has been a staple of society for thousands of years. There is evidence of ritualistic and ceremonial use dating back to prehistoric European societies and indigenous cultures in North America, Mesoamerica, South America, Africa, Asia, and Australia – nearly every corner of the world has been along for the ride!
“Because of the presence of well-regarded treatment programs and the mystical nature of psychedelics, many argue that there isn’t much of a role for psychiatrists to play in this arena, favoring therapist or shaman-led treatment programs.”
At present, millions of dollars are being invested in psychedelic research, with MDMA and psilocybin studies leading the way. With FDA approval on the not-too-distant horizon for MDMA treatment for PTSD, many questions are being raised about what protocols should be used and how practitioners should be trained to properly and safely engage in psychedelic-assisted psychotherapy (PAP). An even bigger question that has led to contentious debate is who is best suited to provide PAP. Despite the lack of FDA approval in the United States, places such as Australia have charged forward and allow authorized psychiatrists to prescribe MDMA and psilocybin in clinical settings. There are also several psychedelic retreats around the world where people seek out treatment. Additionally, there are many "underground" centers engaging in treatment.
Because of the presence of well-regarded treatment programs and the mystical nature of psychedelics, many argue that there isn’t much of a role for psychiatrists to play in this arena, favoring therapist or shaman-led treatment programs. As a psychiatrist looking to carve out a niche in the psychedelic space, it’s admittedly difficult to remain impartial on this topic. There are many nuances to treating refractory mental illnesses. Many clients in this category are taking several medications, some of which have significant, clinically relevant interactions with psychedelic compounds. Many also have underlying medical illnesses that require close monitoring and could be absolute or relative contraindications to engaging in PAP. Unfortunately, many providing PAP don’t have the training necessary to comfortably navigate the nuances of treatment-resistant illnesses, which can lead to significant safety issues during preparation, dosing, and integration.
“Without adequate training and (arguably) meaningful personal experiences with psychedelics, it’s likely that PAP will miss the mark and cause more harm, as facilitators won’t be able to properly prepare clients for the experience, guide them, and then help them integrate the insights from their journeys into their everyday lives.”
It's not as simple as weaning off medications prior to treatment—a practice that is common in treatment centers and clinical research but isn’t always warranted in actual practice—or screening for certain disorders such as bipolar disorder or schizophrenia spectrum illnesses, which can be difficult to identify. This is where having a psychiatrist-led treatment program will be extremely valuable. However, one of the limitations of psychiatry training is the lack of robust education on PAP in residency programs, which poses significant issues. Psychedelics are unlike other medications in that they can cause massive shifts in consciousness during and after treatment. During a trip, your senses are significantly altered, and your thought processes shift in ways that are difficult to articulate. Some even experience the classic “ego death” which can be extraordinarily challenging to navigate, even for the most experienced psychedelic users. Without adequate training and (arguably) meaningful personal experiences with psychedelics, it’s likely that PAP will miss the mark and cause more harm, as facilitators won’t be able to properly prepare clients for the experience, guide them, and then help them integrate the insights from their journeys into their everyday lives.
“Despite the turf wars that are underway, I believe that with proper training, appropriate oversight, and a multidisciplinary approach, {psychedelic-assisted psychotherapy} can be safely and effectively provided to those who need it most.”
As we get closer to FDA approval, I believe the best treatment programs will integrate a multidisciplinary approach to ensure safety and efficacy are maximized for clients. Psychiatrists will be essential in regard to helping manage the medical complexity of individuals pursuing treatment for refractory illnesses. We’ll also be essential in less severe cases to ensure compounds are being administered safely and responsibly. The role of therapy can't be understated, and it is essential to have practitioners with adequate training in PAP. This doesn’t necessarily have to be limited to therapists or shamans. As a psychiatrist, I was able to receive PAP training through Compass Pathways which was an invaluable experience and enabled me to provide high quality PAP in clinical settings. I also believe personal experience with psychedelics holds value for those looking to provide PAP. This is a bit harder to facilitate from a legal standpoint, but several training programs have an experiential component that allows practitioners to have an immersive experience and gain further context into these compounds.
Despite the turf wars that are underway, I believe that with proper training, appropriate oversight, and a multidisciplinary approach, PAP can be safely and effectively provided to those who need it most. Sometimes, it just comes down to providers sacrificing our egos and recognizing that we can work together to provide even better outcomes for our clients.
Until next time!
Dr. McCall
References:
Hofmann, A. (1979). LSD: My Problem Child. McGraw-Hill.
Hoffer, A., & Osmond, H. (1967). The Hallucinogens. Academic Press.
Kurland, A. A., Savage, C., Grof, S., & Unger, S. (1972). Psychedelic psychotherapy. In C. A. Fisher, R. E. Hicks, & R. N. Pearson (Eds.), The Psychophysiology of Consciousness. Charles C. Thomas.
Latz, P. K. (1995). Bushfires & Bushtucker: Aboriginal Plant Use in Central Australia. IAD Press.
Riedlinger, T. J. (1994). The Sacred Mushroom Seeker: Tributes to R. Gordon Wasson. Dioscorides Press.
Fernandez, J. W. (1982). Bwiti: An Ethnography of the Religious Imagination in Africa. Princeton University Press.
La Barre, W. (1989). The Peyote Cult. University of Oklahoma Press.
Valdés, L. J., Butler, W. M., Hatfield, G. M., Paul, A. G., & Koreeda, M. (1984). Divinorin A, a psychotropic terpenoid, and divinorin B from the hallucinogenic Mexican mint Salvia divinorum. Journal of Organic Chemistry, 49(24), 4716-4720.
Dobkin de Rios, M. (1972). Visionary vine: Hallucinogenic healing in the Peruvian Amazon. International Journal of Social Psychiatry, 18(4), 256-268.
Sharon, D. (2000). Shamanism and the sacred cactus: Ethnoarchaeological evidence for San Pedro use in northern Peru. Archaeological Papers of the American Anthropological Association, 10(1), 131-142.
Guzmán, G. (2008). Hallucinogenic mushrooms in Mexico: An overview. Economic Botany, 62(3), 404-412.
Schultes, R. E., & Hofmann, A. (1980). The Botany and Chemistry of Hallucinogens. Charles C. Thomas.
Samorini, G. (2002). Animals and Psychedelics: The Natural World and the Instinct to Alter Consciousness. Park Street Press.
