At the Aspen Ideas Festival, Rachel Yehuda, PhD, shares her expertise and research on psychedelics. Once the domain of bohemian culture, psychedelics are now headed into mainstream medicine. As psychedelic therapy becomes easier to study, mounting evidence is informing new clinical models to treat depression, PTSD, and addiction, smooth the end-of-life passage, and make grief easier to handle. Oregon voters have approved the legalization of psilocybin, a "magic mushroom," for use under carefully controlled conditions. And at least one company has expanded worker health benefits to cover ketamine, an anesthetic that can produce hallucinations at the right dose, in tandem with counseling. As the use of psychedelics expands, will mental health care be transformed?Chapters (Click to go to chapter start)
Intentionality Biological Underpinnings of PTSD Policy Realm Training Programs for VA and Community Providers Curative? Potential for Psychedelic Usage Research in Real World Settings
welcome everyone. I am really thrilled to see you all here this evening for what I know is gonna be just a fascinating and really important conversation. I'm dr Shoshana Ungerleider. I'm a practicing internist across over health in san Francisco. I'm the host of the ted health podcast and the founder of End Well, a nonprofit media platform and annual convening dedicated to making the end of life a part of life. And so I'm really excited to start by introducing our experts, Rachel Yehuda, dr Rachel Yehuda on the end is an endowed professor of psychiatry and neuroscience of trauma. She's the director of mental health at the James Peters Veterans Affairs Medical Center, She's a recognized leader in the field of traumatic stress studies, having authored more than 500 academic papers in the field of PTSD and intergenerational trauma. Her research on Cortisol and epigenetic mechanisms has really truly revolutionized our understanding of neurobiology and the treatment of PTSD in 2019 she was elected to the National Academy of Medicine for her seminal contributions. Um in 2020 doctor you had established and now directs the center for psychedelic psychotherapy and trauma research. And next we have dr G Sean chowdhury, I know right, she should have been laughed. G Shaun is co founder and ceo of journey collab, a bio pharmaceutical company, really unlocking the science of psychedelics to build a new model of addiction care. Sean is an M. D. PhD and did his graduate studies and informatics as at Oxford as a Rhodes scholar and he completed the C. I. S. Training course in psychedelics. He's a very seasoned entrepreneur which we're gonna hear all about starting multiple successful companies and as the recipient the recipient of multiple national level research awards. Um Next up we have Andrew Penn Andrews, a psychiatric nurse practitioner and associate clinical professor of community health systems in the school of nursing at the University of California san Francisco. He works on psychedelic studies of psilocybin and M. D. M. A. In the translational psychedelics research and practices at the SAn Francisco. Veterans Administration. Andrew is truly a leading voice in nursing is co founder of the organization of Psychedelic and nurses, really advocating for the perspectives of nurses in psychedelic therapy. So tonight with that we're having a conversation with these incredible experts about the potential for psychedelic medicines to transform mental health care. And I want to quickly set the stage for this conversation to get everybody on the same page about what we're talking about for those of you in the room who are experts on this. This is going to be a little basic but bear with me, I promise we'll get into the juicy stuff. Um we're all aware of the mental health crisis in America. This is a huge burden for people for families for clinicians and our health care system. COVID has only made this worse in any given year. An estimated 18.1% which is 43.6 million U. S. Adults Over 18 suffer from mental illness. We don't have enough psychiatrists and therapists to meet the demand and the treatments? We do have to say the least don't work as well as we would like them to. So how might psychedelic assisted therapy be helpful? Well that's what we're here to talk about. And let's start with just a tiny bit of context in the 50s and 60s. If you didn't live through that period of time, psychedelic research really flourished all over the world and showed great promise for the fields of psychiatry of psychology and neuroscience. But psychedelics leaked out of the research setting and began to be used by the counterculture and by the anti Vietnam War movement And there was a backlash. So in 1970 the us government criminalized all uses of psychedelics and they started shutting down all psychedelic research and this ban really spread all over the world and lasted for decades and it landed us where we are today. And yes psychedelics aside from ketamine are still illegal in this country outside of a clinical trial. So with that said let's dive in here Andrew and no we don't have any samples. No we're not giving it out tonight. Sorry. Andrew right now. Psychedelic assisted therapy is being studied in clinical settings for everything from PTSD to depression, substance use disorder O. C. D. And of life distress prolonged grief and many others. So for people who aren't familiar these clinical settings create a very different scenario than a recreational use of psychedelics. Can you walk us through what it's like to be a trial participant for example and specifically how does the assisted therapy component come into this? Yeah, absolutely. Well I'm glad you talked about that, about this being a therapy focused process. Because really in the press it's the drugs that get a lot of the attention and what these compounds are doing is they're helping to catalyze psychotherapy. And so psychedelics are very contextual drugs. So by that, I mean the experience where you're having the experience with whom you're having, The experience is a significant determinant of what what's going to happen. And if it was just the drug alone, then you know, burning Man would be curative for a large number of people or or Woodstock depending on your your vintage. Um but it's but we know that that that the drug alone doesn't do the work. So, so in our lab and our lab is similar to many others that are doing this work. We begin with several sessions of non drug psychotherapy. And we work with to psychotherapists historically as a male female diet. But we're now eliminating that uh to in two for greater flexibility and also gender inclusivity. Uh and and we'll have uh 232 hour sessions with the subject. Getting to know them, them getting to know us. We're starting to create a container therapeutic container where this can happen safely. We want to know what issues they're coming into the session with what their history is with depression in the studies that we're doing with seven or PTSD and the studies that we're doing with M. D. M. A. What their concerns are, what their fears are about the experience. We walk them through what the day is going to look like. We might rehearse reassuring touch if that's something that the subject is okay with. Um And then we'll have them actually practice lying down on our couch and we have eye shades, we have headphones and then so we do that a couple of times two or three times before we actually have the dosing session. The dosing session lasts all day. They come in in the morning. They've obviously already done their their physical exams, got that all the way so that we know that we can do this safely from a physiologic standpoint. The drug is ingested usually 9:00 AM and then we're there all day. And during the therapy session there may not be a lot of talking going on. So it may not look like when you think of conventional psychotherapy, more of a dialogue happening. This is we often encourage people to direct their attention inward. That's where the eye shades and the music are useful. Um and then afterwards starting the next day so the drug will wear off after 57 hours depending on the drug. Uh And then we begin what we call integration psychotherapy where we start to unpack the experience of the day before I try to make sense out of the experience. Try and identify themes identify opportunities for change because what this may represent is a period of possible neural plasticity openness to change. And we look for opportunities to make actual actionable change in that person's life towards their intentions of healing. Thank you and Rachel Andrew touched on this a little bit, but we hear the concept of intentionality being used and we talk about that their pubic experience with psychedelics and the framework of set and setting. Why is this important? Oh thank you. And it's pleasure to be here. And Andrew did start us off with answering that question. But understanding intentionality and set and setting with psychedelics is probably the most important thing you're going to hear tonight. Um and I'll just elaborate on your example, let's say you have a drug like M. D. M. A. Ecstasy. So if you take it in a recreational context, what is ecstasy or M. D. M. A. Do? It reduces your fear response. It promotes pro social behavior, it makes you less judgmental, it makes you more likely to engage with people or trust them more. So if you're in a recreational context then you might have a really good time meeting people, you might dance or feel less inhibited than usual, you might trust people maybe take them home and continue the evening without if you will. But I don't think there's any documented cases of that? Especially not a burning man, But if you want to use this drug in a recreational in a therapeutic context, sorry, then that those same properties start to work for you in different ways. You harness them. So the reduction in fear becomes more of a a willingness to engage in exploring traumatic memories that are scary. The pro social behavior becomes a connection with the therapist, the building of interpersonal trust. So you basically take the same properties of the of the compound, but you harness them and you harness them in the presence of trained therapists. You can take that same experience and really have a very deep psychotherapeutic process. That's the intention part. The setting part is that you're not at a raven, you're not at a party and you're not at a festival, you're in a room that is safe with people who are going to keep you safe and you are able in that safe room to be able to go very, very deeply into material that usually is not accessible because of the anxiety. The anxiety of what the material is that you'll run out of time that you won't get to say it, that you don't trust the people to listen to it. But this promotes a very different kind of a process. Thank you so much for that. Can you set some more historical context for us? Psychedelics have been around a real long time. There is a very long history of human use of these substances. Can we talk about that a little bit? Yeah, I mean, I think the best. Well, first of all, thank you for having me. It's great to see so many people from the aspen community join us here. I think the best way to describe is that this moment in time that we are living of prohibition is is really an aberration of all human history. Um humans have had a relationship with psychoactive plants like psychedelics for thousands of years. This is not just something that we take from the oral tradition, but there's hard evidence around that. My company works with mescal in which comes from the peyote cactus or the cactus. The earliest evidence that we have of fossilized peyote buttons in specialized burial sites goes back to 5700 Bc. We have similar evidence for ayahuasca for mushroom use. And so we, as humans have have multiple relationships with plants. We use them for food. Obviously we use them for textiles and clothing for structures are lumber and we know that we use them for physical medicines, aspirin or up all the way to new medicine. Like Taxol comes from plants. So the idea that we would not use plants for mental mental health and for psychiatric healing is also an an an an an an aberration. And so we have a long history and almost a universal history of using these types of psychoactive compounds, I think, other than the Inuit where there's just simply not much that grows there. Almost every society that we have encountered has some tradition of using psychoactive substances, particularly for healing. And to what my colleagues here said when we look at those community, it's always been done in a ritualistic setting. It's always been done with intention. And I think there's a lot to learn, not only from the fact that where we are in this forced period of abstinence and we know how forced periods of abstinence usually work out in multiple dimensions um that we have an opportunity to have a relationship again with these substances with these plants and with these with these psychoactive compounds. And I'm really excited about where we're going with that Rachel. I want to come back to you and uh and talk about what you're doing in your lab. It was there that what you were doing some of the very first uh studies to look at the biological underpinnings of PTSD and have studied intergenerational epigenetic transmission of trauma in military veterans in holocaust survivors and PTSD as many people probably know remains very, very difficult to treat. So Rachel, you started out as a skeptic and have really become an advocate of course for psychedelic assisted psychotherapy research. And you now, of course, established and now direct the center for psychedelic psychotherapy and trauma research. So, tell us about that journey. Oh okay, thank you for asking. Well, I would have been skeptical of any claim that anyone had that a treatment in such a very short time can take away somebody's PTSD and scientists are naturally skeptical people. And PTSD is a very difficult are conditioned to treat. And I'm not an advocate for using psychedelics, but I am an advocate for doing the research on it and that and what started to flip my process. Um of course, when the initial study came out, I just thought, what is this? A very large effect size, but a very small study. And I thought I don't really understand this. But as more studies came out, they kept showing pretty large effect sizes. Um, I started to pay more attention. But when the FDA declared M. D. M. A. Assisted psychotherapy, a breakthrough treatment that really changed things for me when the FDA declares something a breakthrough treatment, what they're saying is this is better than anything that we've got going on right now. And so for somebody that really cares about PTSD and wants to study it so that for the purpose of really learning how to treat it, it became an issue of how could you not study it. So, I knew that it was going to be difficult to get more conservative, mainstream academic or community settings to kind of want to look at this, especially in this early stage before it is made legal or approved as a treatment. But I thought these are the populations that really need to be studied the most. And so it really became a moral imperative of sorts. Um you can't look, you can't look at a treatment that is really doing twice as well as the standard of care, I should say twice as well as the standard of care, but still leaving some people with symptoms. So that's very important to not walk away thinking that this is a treatment for everybody. But that that made it even more important, like who responds who doesn't. And we have been studying predict biological predictors and correlates of psychotherapy and other treatments. So, were we were in a good position to kind of take this on. And that's why we established the center at Mount Sinai. Thank you Andrew. I want to talk about an area that's really near and dear to my heart and my work at and well. And it turns out we we don't have the tools to be able to adequately care for people who have existential fear, dread and distress when when diagnosed with a terminal illness and the medicines that we do have for anxiety and pain tend to to blunt the senses and and not allow us to live fully until we die. So tell us why psychedelics might be helpful for patients and and certainly their families who are facing a life limiting illness and what has the research shown to date on that? Yeah. So, so this was one of the very important earlier studies and it's the field is moving so fast that it feels kind of ridiculous to say. Something that was published in 2016 was an earlier study. But it it is. So there was a pair of studies that were done wanted N. Y. U. And one of Hopkins that looked at people with life threatening illness who had anxiety around that diagnosis, whether largely cancer, uh and they were treated with this course of psilocybin assisted therapy, intervention and outcomes were significant. And and they measured a number of things in that. But depression and anxiety around the illness and depression, anxiety in general were measured and vast majority of people had what's known as a response, which is that they got somewhat better. But a significant number of people remitted even at the end of six months of the study period. And some of the people that continued to that didn't pass from their illness that were followed, lasted uh that the effect lasts as long as 4.5 years. And so there was something about this, this shift that was really important and and and it really underscores the need that you pointed out, which is that, you know, we don't die well in this country. We've we've developed incredible medicine to help us live for a very long time, but when it comes to dying despite, you know, the really valiant efforts of people like Cicely Saunders who was a british nurse who started the modern hospice movement and palliative medicine. We do a really good job of managing physical symptoms. We can help people be comfortable as they're approaching the end of their life, but when it comes to their their soul, their spiritual needs, we call the chaplain, usually if you're in a hospital, you call the chaplain and no knock on chaplains. Some of my best friends are chaplains. Um but we really, you know, and it's challenging because we live in an increasingly secular country too. So what are those, what do we give those people? And so whether you're religious or secular, it doesn't matter. You know, the soul needs things like meaning and connection and love and purpose. And what these treatments may allow people to do is to review their life. You know, Goethe said, you know, if you if you haven't died before you die, then when you die, you really die or something like that. You know, he was really concise with his words, but um, but this idea that, you know, we actually get a chance to practice dying um in this, in this kind of treatment. And that maybe it becomes not so frightening because there's this phenomenon that happens, especially with psilocybin and serotonin ergic psychedelics, where, you know, sometimes people call ego death, but this idea of shifting from that, you know, my worries and my story and my concerns are kind of the center of my universe and they preoccupy most of my time. Two stepping back to to what um if you heard the speaker last night talking about a state of awe in the state of something much bigger than ourselves where yeah, we're still part of it and and we still have an importance that we don't disappear but that there's so much more and that if we can connect to that especially as we approach, you know, hopefully we don't have to wait until the end of our lives to connect to that. But if if if that's the case well then so be it. But that's that that may be what's happening. They're powerful. Um Sean I want to talk a little bit about the pathway. So how does a compound like M. D. M. A. Or peyote for example, help to I sort of think about it like clearing a path to healing or to allow a person's innate healing maybe to be activated. How do you think about this? That's a very tough tough question. I will say that we don't know how a lot of things work in medicine. So does anyone use Tylenol here before? If you ask a scientist how Tylenol works, We have some ideas but what we know is it's an empirical story rather than a scientific story. We know a certain dose reduces fever, certainly dose reduces inflammation. Um And now over like 100 years of scientific research and an incredible last few decades of clinical trial research, we know that certain doses of sarah genetic, what we call these classical psychedelics can produce these outcomes. We have some idea of, we have some theories around it. We know at the receptor level that they introduce what we call neural plasticity. So like you'll actually see whether the synapses in the brain like making new connections with FmR FmR I imaging, we know that different parts of the brain talk that we're talking before um and from like a psychological level from the insights that people are able to face with what Rachel was saying, having your fear response reduced to be able to process trauma. So these things are happening in parallel and together. Um what's what's really interesting is this idea that you mentioned this inner inner healer that the brain has. And I've used the analogy that if you cut yourself depending on the severity of the wound, you may need to wash it out. You may need to approximate the wound with sutures, we may put a bandage on, but you don't need to tell your body how to heal it will heal itself. And something seems to happen in the psychedelic state of consciousness when it's done with the right intention in the safe therapeutic setting, not necessarily a burning man um that this this inner healer starts to function and work and people start to work through the traumas, adverse events, the issues that are that are, that are facing in their lives. We often tell people you're, you're not gonna, you may not get the trip that you want, but the trip that you need. And I think that's also a reflection of this, this inner healer that is functioning. Um, and I think it's the awe of the human mind and the human psyche that when given a safe space to be able to process that it can heal itself. I want to switch gears a little bit and I want to start with Rachel and jump into the policy realm. Now this is sort of a question for everybody, but we'll start at the end here. And so we know states like Oregon and maybe soon Colorado are passing legislation to make psilocybin, for example, legal. So what are the pitfalls of fast tracking state level legislation such as in Oregon? And where do you see the potential for issues to arise wealth? That's a complicated question. Um, I was hoping to get the question about how the drug works. Yeah. So we can come back to you on this. Okay, I'll do it. But it's not, it's not gonna necessarily be what everybody wants to hear because I have some real reservations about this. Um, and it's not that I don't think that it should never be legalized or anything like that. And I really take what you have said about like our whole history of the use of plant medicines. And I understand that perhaps the reasons that caused these substances to be banned were political more than anything else? And all of that is true. But I have two sets of concerns. one really involves whether we know enough about the safety of taking psychedelics in this culture, in this time, in this here and now um to be able to um safe as we are saying when we when we bring these bills forward that they're these compounds are perfectly safe now that the compounds themselves are not as dangerous as many drugs that we have that are legal, such as for example, opiates, even alcohol, even alcohol. So we we don't worry so much about the physical properties of the drug or the toxicity or even the addictive nature of it. But psychedelics can increase a lot of psychological vulnerability. And so then the question becomes, who can facilitate what happens if somebody I enough so many times, so many times where somebody is taking a psychedelic for what they think will be recreation or exploration and they'll uncover a memory of a trauma. Mhm. Now the facilitator who does not have a mental health background is not going to be equipped to deal with it. Maybe they can go through that six hour session. Okay. And and have a phone call the next morning, but this might initiate a process. So in a in a stressed mental health system. Um Do these bills build in harm reduction? And do they build in mental health treatment or the influx of more mental health treatment that people will want to have if part of their exploration involves this. So it's not that I don't I think that these these medicines should be legalized, but I think we don't want to walk into this naively without harm reduction and without making sure that our mental health system and the people that work in the communities where this is legal, even if they're not going to ever deal with psychedelic drugs, they're going to have to understand what has just happened to somebody with a facilitator that now ends them on your doorstep. And I just want to make sure that we have the resources for that. So that's one set of concerns. The second set of concerns is really about timing, timing. Is everything right? Is this what we should be doing now? We're on the cusp of perhaps advancing M. D. M. A. And psilocybin as treatments for PTSD and depression? You know, because the FDA has given both of those treatments, breakthrough therapy. What will the impact be? Will that facilitate that by making it easier to study these drugs because they won't be illegal? Or will it undermine it by making this more about business opportunities for having a spot for your brain or see each he was optimizing their performance or will it be in the places where hopefully these medicines can do the most good in community settings and it be a is reimbursable insurable medical. What will the impact be on that? Now, if we've thought about that and we don't think that this will sabotage that the way maybe cannabis did sabotage that, then great. If we can put in harm reduction because we're walking in with our eyes open, great. But to walk in because these are the greatest drugs on earth and there's no problem to them, I think is a problem for me. I'm so glad that you're saying that Rachel. And if I could put a plug in for psychedelic harm reduction, because one of the things that these compounds do, which can be leveraged in a therapeutic setting is they decrease what we call experiential avoidance, which is that people develop all sorts of strategies to not feel their feelings from using substances to any number of different strategies. And what psychedelics tend to do is they tend to put all that right in your face. They can. Um and and so that's why the old adage of you don't know, always get the trip you want. You may get the trip that you need, but that may be very, very difficult. Uh and so I I've done psychedelic harm reduction at burning man, I've been going to burning man since 1998. So uh, anyone else going to burning man any other burners in the room, Rachel's been to Burning man. Yes, I clean up. Well, um, so so I I've worked with them with a offshoot of maps uh, which is the organization sponsoring the M. D. M. A. Work called the Zenda Project Project is is a space where anybody can come to who's having a difficult time emotionally. Sometimes that may involve a psychedelic. It may just be because they've been awake for three nights and they just broke up with their partner. It doesn't matter. They can come and they can, we have trained volunteers who will sit with them for as long as they want if they want to talk, they can talk if they just want to sit, if they just want to sleep, they can sleep, but it's a safe space so that you don't end up uh, in law enforcement or an emergency room when you're having maybe one of the most difficult times of your life. And um, a colleague of mine, josh White is has rolled out an organization called the fireside project, which is actually a, it's a telephone number, you can call it, you can text it. And they have similar trained volunteers to work with people. We're having a difficult experience or have recently had a challenging experience that want to integrate it. So these are the kind of things that we're doing to try and reduce this harm, but to Rachel's point, you know, these are powerful tools and any powerful tool that can have this much positive impact, can have a commensurate amount of harm. It's not the same kind of harm we're saying we're like fentaNYL because people aren't going to, you know, if you're not, you can't take enough LSD to stop breathing like you can with opioids, but you can have very challenging emotional experiences. So this isn't for everyone. And one of the big questions that we, I don't think we've done a good job as a field of identifying who is this not good for, you know, that is something we need to disturb in, just as much as as figuring out who this works for you. I would approach these questions that we have been in this war on drugs and we're moving to like what is what does the piece look like and the war on drugs is a misnomer in that, you know, this is an uncomfortable button, controversial statement to say that the war on drugs is a war on people, it's been a war on brown and black people primarily and the war on the women who have held these traditions alive for so long. And so as we move into the piece, we have lost the people who like, quite literally, we've burned them at the stake and put them in jail. We've wiped out their cultures and their communities that we don't have that cultural context. We do not have the literacy, we do not have the rituals that these other communities, other cultures have had. So we're moving into the piece without these tools, but I do think there's a lot that we can learn from those traditional communities and again, like in those communities, these have always been seen as very powerful tools. They would use the word sacrament, but I think we can say these are powerful tools and there was always a ritual around them. There's always been of reverence and respect to them and how we do that in a secular setting. That is accessible to all. I think that's an open question, but I think there's a lot of ground work that we need to do. I think there are some things on the war on drugs that we can move very quickly which is, you know, the in terms of mass incarceration, expunging people's records, those are things we can do now. But in terms of like what this is going to take for us as a society to integrate, I think we need to learn and spend the time building that infrastructure. Yeah. So this is a question for Andrew and I'm coming to Rachel next on this one area where there's an urgent need and you've touched on this a little bit is for training guides or facilitators of therapy. Right, So given the amount of of demand that's out there and has access will increase. Um where do you see this headed? And can you talk about the role of nursing in this work? Yeah, sure. So there's gonna be a huge bottleneck when this gets FDA approved. We're going to have a few 1000 people maybe at most who have actually been trained to do this work. And as I said at the beginning, this is primarily a psychotherapy process. This is not just giving somebody a pill and walking away. This is you have to train people how to navigate these spaces and how to help people through them. Um And and we're going to have a short we're gonna have a real shortage of people who know how to do this. And we're gonna have a tremendous amount of demand because honestly, that's what happens in psychiatry, right? What happens in medicine, but particularly happens in psychiatry, you know, probably because we have so much unmet need that there's gonna be so many people who are going to be lining up for this and we're not gonna have the therapists for them. And we also have to make sure as Rachel said that that this is covered under commercial insurance. So this doesn't just remain something that is for people that have excess wealth, they can buy this. So, so one of the places that I'm particularly interested in this as a nurse is that a lot of the inherent ethos of nursing line up very nicely with psychedelic therapy. So nursing is about care more than it is about cure, which is largely what we do. It's about presence. It's about spending long periods of time with people. So you know when I tell my therapist friends you know well suicide in session can be eight hours. They say eight hours I do 50 minute sections. I said yeah we do 12 hour shifts in the I. C. U. You know 12 hour shift is somebody who's totally delirious. That's a nice you shift for a lot of people. So um so the idea of being present with with patients for that period of time and allowing this natural healing capacity to manifest is something which is very aligned with nurses and nurses. You know it's often repeated by a very trusted profession and so you know and we're sort of the people so most people know a nurse you know they have sisters, nurse or family member and so you know it's a very naturally aligns it and and it's also a way of getting this into places that are not aspen and that are not san Francisco and not new york because we you know there's people suffering in South Dakota who are gonna need this too. And I'm not sure there's too many psychedelic therapists there in South Dakota. So so in scaling this we really need to think about Workforce development and there's 3.8 million nurses in the United States and so I don't think it would take too much additional training to to get nurses who want to do this kind of work on board with it. Yeah and Rachel. Can you share about your training program for via and community providers? Oh yeah sure. Um So thanks to a very generous philanthropic gift from the bob and Renee Parsons Foundation, we were able to expand a program that we start that started pretty small into a program where we could offer therapists working at and community settings. The free M. D. M. A. Assisted psychotherapy training. We're doing this in partnership with maps, going to certify and credential lists to be trainers and supervisors. Now what I think is important about training isn't just to create people who can work with psychedelics. I think we want to be training all clinicians about what it means to be in an altered state, how to facilitate a process, what it might mean for them if somebody comes to their office saying that they participated or took psychedelics and they had a revelation how they can work more with them right now in traditional settings. If a patient comes and says oh I had the most incredible experience. I took LSD and then I took mushrooms and I really want to talk about it. They would make a consult to the substance abuse program. Probably right and you're laughing but that's what I would have done five years ago I would have said oh boy this is somebody that has a substance abuse problem. So that's the kind of education that has to happen on a fundamental level, we have to start introducing courses in medical schools and graduate schools that talk about what what psychedelic medicines are. Because unlike other medicines in medicine and psychiatry, we've been emphasizing that they're a tool to assist in psychotherapy, Right? So the chemical properties which we know of the receptor actions which we know all of the plasticity, all the things that we know about these drugs don't really quite explain the phenomenon of why these taking these drugs in the presence of psychotherapy occasions, a therapeutic process or an insight that then leads to symptom reduction. So I think um I feel very fortunate that we're able to offer this training for free. There there are a lot of places to get trained in psychedelic assisted psychotherapy, but they're expensive. And so most people make the investment if they want to shift their practice because then they will be in a position to also charge a lot of money for these treatments, which they should because it's a lot of man hours if you're in private practice, you have to recoup that, but a clinical setting, you know, or a community setting, um where people are salaried and there's a great high need might be a place if these therapies are found to really be a game changer in terms of reducing symptoms or getting people to a place where they don't need to keep coming every week for months or years or decades, if there could be like a more intense interaction, the way the way it is when you go to a surgeon, right? You're not, he's gonna work with you very, very intensely. Um, he's going to become the most important person in your life, you know, for the prep and the surgery and the aftercare and then you won't even remember his name next time somebody wants to asks you for a good surgeon, right? You might not even remember who he is or or where you put his phone number. Um, so if these, that's the, that's the promise of this approach that instead of keeping people in for really long periods of time, years and decades that we have something that is intense that is labor intensive. Um, but that may actually cause a breakthrough. Now we don't know yet if that's going to happen. That's why we're doing this research. That's the promise of it. And so we don't want to confuse the potential for this to be a new paradigm of care with the fact that it's a done deal yet. And that's why these forums are so important because public education is so important to you have to know this. We all have to know this and we have to follow the process and kind of be able to separate the hype and the sexy part of the altered state and the drug from really the fact that getting over mental health problems. It's hard work because you have to go to places that are so difficult and if this is something that, you know, kind of is like a chemotherapy or a surgery or one of these really invasive things that you do for a short period of time to come out the other side. Perhaps a little boosters. Now in that then we have now transformed the landscape of mental health treats, wow, I wanna sean I want to go a little bit deeper into this because I maybe it's obvious to you all. But this is something that is sort of just kind of dawned on me. You know, we're talking about the potential for psychedelic assisted therapy to be maybe curative for mental health issues potentially. So you're shifting from maybe treating symptoms to addressing underlying mechanisms. Maybe I shouldn't go as far as say the word cure, Right. But how do you think about this? Yeah. People that deal in mental health don't use the word cure. We never use it. We think about it as maybe a little remission or very long periods of good functioning episodes of care, right? We have a language and in our language, we it belies our belief that, you know, if you have once had mental health problems were on deep surveillance for you to maybe have another episode at another time and that really, really good care is when you can go for a long period of time, in between episodes. Um So this so again, it's it's a hopeful thing now. I think that it, you know, it depends on if you believe that underneath these mental health issues is a trauma, is something that you need to look at is something painful that you haven't dealt with because it's too overwhelming to deal with. And so the promise here is that maybe if you can go there and you can shift your mind about it, you can see the world in a different way. You can get stuck unstuck from being stuck, then maybe you have a chance to go forward. Another event can bring you maybe back, but maybe you'll have better tools to get out of this um quicker. So no, I'm not using the word cure yet. I think we need to do a lot more research and much more longer term follow ups, but that's really where the excitement is coming from, that. You see the possibility in a way that you don't see it for treatments that you have to take a pill every single day for. And if I could put it add to that. Um you know, psychiatry is an interesting field, because you know, 30 years ago we had the decade of the brain, we had some tremendous advances and such as your work with cortisol um and really understanding the neurobiology of the brain, but there was also this idea that that perhaps we could eliminate mental illness through through chemistry and and that's fallen short if we're gonna be honest with ourselves, that's fallen short. We've had tremendous advances and it also hasn't fulfilled its promise. And and so, You know, I think sometimes we in psychiatry we kind of have science envy. You know, we have we have I have oncology envy personally right now because in oncology in the last 30 years they've made tremendous advances right? And so in oncology it used to be there was it was categorical you either had cancer still or or it was eliminated right? And now we define success often as arresting a tumor. We have things like checkpoint inhibitors that arrest tumors from growing. So you can have you can be riddled with tumors for years but you're not dying of it because the cancer is not advancing. You're living with that cancer. Um And and I think when I expand this into mental health, I think this idea of either you're you're sick or you're ill. It doesn't work in psychiatry because the maladies that we treat in psychiatry are really in some ways just the extremes of normal human emotional experience. I mean where where is the line between sad and depressed? We can create one in the D. S. M. But it's an arbitrary line. So this idea that we're going to have, you know that the cured and the sick I think is naive but what I do think might happen is that we change the relationship that the person has with the illness so that, you know, this idea that pain and suffering are not the same thing that suffering is about the relationship that you have to pain. So in psychiatry, the pain maybe your traumatic childhood, but the suffering is the story that you have around that pain. And what I see in the work that we do is that people begin to slowly change the story that they have about their own life experiences and their own illness and that's what alleviates the suffering and they may still have that disease, but that's okay because it's not impeding their life. I think when I was in med school, you basically would look down if you went into psychiatry, it was like the last thing to look at people wanted to be surgeons, they wanted and interventions, they wanted to be able to make a change. Like surgery is attractive because you go in, you do the surgery, it's an acute bundle of care and you make an intervention, but we are ushering in an era of interventional psychiatry with these tools where we're not just watching, we're not throwing the same drugs at patients, like we're actually giving these interventions that are these acute bundles of care that can get patients into what I would say like psychiatric remission for their disease and there may be episodic care that follows after there, but that's that's really exciting and I think the next generation of, like students and clinicians will want to join. Like, I think there is um you know, the workforce issue is is, you know, is a bottleneck. But I am hopeful that with these tools that more and more people will step into these careers and want to join them and I'm excited for what we call this, like, it's a healing economy where these are, these were in a world where many of the jobs that we have will no longer exist, but these are jobs that you cannot outsource and you cannot automate that they can be run by local centers by people who look like the people they're trying to treat. And that is a very vibrant economy that we are headed towards. Love that. Yes, Rachel. Yeah, I love what both of you said, I really do. Um I just think that we want to keep in mind that some um psychiatric conditions and mental health presentations are very biological, and we're going to need all the tools that we've collected in order to really figure out which thing is which, so I think we're psychedelic assisted psychotherapy can help the most is potentially when there is some shift that needs to happen. And someone's thinking, I really love how you framed it around thinking differently about your condition, but we all know people who's who's who's mental health symptoms seem almost organic. Um and and very non experientially based. So we're gonna have to really do a lot of work to figure this out. And ultimately we'll be able to develop an algorithm. And I think a lot of the science we've developed will come in handy as we try to use these science tools to really figure out, you know, what's what. So as long as we don't immediately throw out the old and usher in the new, that's not nuanced, we have an opportunity here to add something in that might explain why we're not helping so many of the people that are not helped by traditional methods, understanding that this also will not be helpful to certain kinds of presentations. So I want to just make sure that we keep the richness of individual differences and the expertise of providers to really know the difference and be able to use their skill set to be able to match people to an approach. There's certainly enough for everyone. We know right now that if you have a history of psychosis or family history of psychosis, like a first degree relatives, like a parent or a sibling or even now like an aunt or an uncle, psychedelics we currently can't treat with. And so we need more tools in the toolbox and to be clear, you know, in sort of a lot of that, the dialogue around this, there's been such effervescent exuberance around psychedelics um, to the point where I'm kind of exhausted by it personally, and I understand where it had come from because we had to overcome the gravitational pull of prohibition. And so in doing so, we've created a lot of, a lot of what I am concerned are unrealistic expectations. And, and you know, we're still going to need conventional psychiatry and psychedelic psych psychiatry, It's not an either or if anything psychedelics teaches you is to appreciate paradox is this is not an either or world. It's a both and, and, and this is and, and we have to keep this sort of meta process here that we have to keep that in mind that this isn't going to eliminate conventional psychiatry, nor should it because they're not for everyone. And conventional psychiatry works for some people, but for those whom it doesn't, let's have this as an option once we have the science to show that it works okay. I think we want to take some audience questions who has questions about what they've heard. Um, well we'll spend about 10 minutes and I just want to say, please phrase your question in the, in the form of a question we'll try to get through as many as we can. And we actually, unfortunately, even though we're all clinicians and scientists, we cannot answer medical questions so and we can offer medical advice. So please keep that in mind as well. Doctors but not your doctor. Okay. Ready? Hey, thanks, my name is James Corbin, I'm an ethicist uh, question is that when marijuana became legal here, people don't want to admit it, but a lot of people were doing it already and they hit the ground running. So we're seeing the same thing in psychedelics right here in Colorado and across the country. So any thoughts on that and guidance for those who are doing it, many of whom you'll meet next year when you're here for the big conference pick up Sandra. Uh, I'll start, I think marijuana and psychedelics are very, very different things. Cannabis is um, can be used as a psychologic tool. I think there's a, you know, we see an established recreational market for it, a social market for it. Um, psychedelics are very, very powerful tools. Um, as again, I'll come back like the only people who have mastered this at scale are traditional indigenous communities and they don't, they don't use it like how we use cannabis psychedelics, Like it's always been used as a ritual in a safe setting. And I think we need to learn from that exclusively. Next question. Hi, thank you so much. It's so exciting to live in aspen for the last six years and have this conversation at the aspen ideas festival awesome. Thank you. Um, as a person individual, not a PhD who is a huge advocate for psychedelics. Deep reverence for ritual set setting admiration and deep respect for the concerns Um completely. And also believes in them so much that I my friend um would love to participate in this as a career. And also like, do you have any advice for somebody in that field in the community who wants it? Absolutely. But there is no guidance yet. So, so like where to like what can I do do tomorrow or the next day? Like what are the initial steps into um, really respecting this and playing the part into bringing it into communities that could be served? And um, do you, do you have any advice for that pathway? So you mean becoming like a facilitator or a guide yourself? Yes. I mean, right now, you know, the two places where this will likely be legal will be in religious context and in medical context. So that kind of creates either a situation where either your doctor or your priests become gatekeepers. Now, places like Oregon where this may, this will soon be legal in a sort of oversight, overseen, facilitated setting, uh, introduce the third way. I mean, to, to your question, I think learning harm reduction, um, and learning temperance, I think is really important. I think one of the places we got in trouble with this last time, was it saying this was for everyone for all all reasons, it's not, It's really not. And if we're gonna do this right this time, we have to learn where it's appropriate and when it's not and how to say no, when it's not appropriate because that that's the nuance that we have to, we have to do better this time than we did 50 years ago. So for folks who are non clinical, they have no background in in medicine and therapy. Is there any pathway for somebody to become trained in in being a facilitator or they're doing that in Oregon? Yes, they are. They do have a pathway for non clinician facilitators. We will see how it works in obstetrics. We've like slowly frustrating and slowly have accepted the role of a doula in, in in in in kind, in a team with nurse is an obstetrician, a surgeon. We don't have that yet. But the idea of a psychedelic duel I think is something that needs to be addressed and who are people who are outside of medical training that can still provide, like in birth and in death, a doula type of experience mental health coursework or experience under your belt. It won't hurt not necessarily towards a degree, but towards understanding it, yep. Next question, I'm really concerned about what you know about mental illness in the family and undiagnosed mental illness within oneself. And whenever psychedelics are discussed, that comes up for me, I'm curious to know anything more about that also, what we're talking about with mental illness. So, you know, if you don't have say schizophrenia or bipolar in your family, in your, you know, within your aunts and uncles? Like how far back are we talking about inside in your family and um what types of mental illnesses are we talking about that can be triggered by um psychedelics. I mean as as I was saying, one of the absolute exclusion criteria has been history of a psychotic illness and that generally definitely include schizophrenia and in some places bipolar disorder. Um in my lab we're about to do a study of bipolar to depression and bipolar. Two people have recurrent depression without full mania. So they generally don't have psychosis as part of their illness but they have a lot of depression. Those people have all been excluded from previous studies. So we're going to do a very small pilot study to see if we can do this safely and if the benefits as effective as it is in uni polar depression. Again that's usually been a rule out for most. In most cases we're going to be doing a study on borderline personality disorder and M. D. M. A. We're very early right like we're dealing with the safest patients. We can the the burdens to doing this research are incredibly high and costly. But with work like this we are advancing and pushing the envelope and and safe away as we can. And and you know, we talk about FDA approval as if that's the finish line that's just one lap. So there's one thing that's gonna be really important and you have to realize that a lot of these phase three studies that we're doing with M. D. M. A. Because the FDA gave breakthrough status, it drastically reduced the number of patients that had to be in these studies. Which is great. From a cost perspective, it's not so great from a data perspective, because if you give a drug to 200 people, you might not have a negative outcome. That happens less than 1% of the time. But you give it to two million people. You're gonna see a lot of those cases. Right? So when we go into what's called post marketing approval or phase four, we really need to be vigilant around this stuff and to be honest about it and and to be able to identify people for whom this isn't working so that we don't get ourselves into trouble with this. Can we do mike up here in the front, make a run all the way across the room, all the way across the room making you run? I'm sorry, I love what you guys doing specifically around PTSD and the benefits that I see potential for us really understanding. I do want to ask a little bit about the difference between research, traditional clinical research and the contextual Ization that you guys really harped on here, um we we will approve a drug effective, Non effective. Right? But we're not really thinking about what is the ecosystem we need to be able to deliver it in and how and and that's not part that's so I think of like this context between research and innovation and what that looks like in terms of workflow and uh an environment and all the other pieces that you need to make something like this work. Tell me how you guys are thinking about that as you go through this process. I mean Rachel, you spoke to us not having containers for these kind of experiences and this idea of where do we in this idea of set and setting in psychedelics, the physical setting and the mindset you're going to. But there's a third thing on Matrix which is the world you've come from and the world you're gonna go back into and and right now the world were set up for is not really well equipped to deal with that. And so there's been some efforts in psychedelic integration circles and things like that where people can talk about their experiences. But you know, we don't have a lot of infrastructure for people to process these very big experiences. And I think for this to be safe and effective, we're going to need to I have one. Yeah, I think it's a very important consideration. So there is an artificiality in the research world and there's no getting around it. Um there are inclusion exclusion criteria which the laymen way of saying that is not everyone can be part of the study so we can't necessarily generalize the findings and we tend to try to, we did pick safe people um the good news about the clinical world is that once you don't have the constraint of a protocol, clinicians will be able to use these drugs and custom customize the solutions more. Maybe you need four sessions or five or maybe, I don't know, but they can customize it more. But this idea of where you're returning the patient to is really very, very important and this is why we have to do so much research and community settings and places like the V. A. We have to know what it what it looks like in real world settings um because the research setting is a little bit artificial, so that's how we're stuck. But I think that we will be able to figure that out. We're going fast. We unfortunately have to leave it there folks. Um I want to thank our panelists, Rachel dish on Andrew my goodness, this was phenomenal. Thank you for all you do
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