June 14, 2023
The adage "magic lies outside your comfort zone" reverberates in this moment in psychiatry, but we need to tread lightly. In a time where psychedelics are not just sparking a renaissance but charting the future of mental health treatment, it's worth exploring the extraordinary potential that lies in these compounds. But it's not all about high doses and instant cures, as our esteemed guest, Andrew Penn, elucidates. Penn is a registered Psychiatric Mental Health Nurse Practitioner (PMHNP), a professor in the Community Health Systems at UCSF School of Nursing. and an Osmind Community Advisory Board member.
He emphasizes the need for new ways of thinking about healing in psychiatry as innovative treatments become more mainstream. According to Penn, "The world is not an either/or—it's both. And so our challenge, I think, is going to be to walk that talk. How do we hold a "both/and" model rather than an either/or?"
In this fascinating discussion, Penn brings nuance to the discussion of psychedelic treatments for mental health. Here's what you can expect to learn:
"Psychedelic therapy offers the opportunity to shift perspectives on conditions such as depression, PTSD, and trauma. It allows individuals to alter their relationship with their illness and gain new insights for healing."
In the world of psychiatry, we often dream of a magic bullet solution - a 'one pill cures all' scenario. But as our guest Andrew Penn suggests, it's not that simple. The truth of psychiatric treatment, especially with psychedelics, lies in changing the relationship patients have with their illnesses.
During an MDMA trial, one of his patients with PTSD found solace through psychedelic-assisted therapy. The therapy did not "cure" her trauma, but shifted her relationship to it. Her trauma was no longer the puppet master controlling her life.
Penn believes we shouldn't view psychiatry as "curing" an illness, but rather as learning to coexist with it and ultimately grow.
Penn believes depression is ultimately a phenomenon of disconection: You feel disconnected from other people and yourself. When you're depressed, you engage in what Penn calls "pathological introspection." You don't really want to be thinking about yourself all the time, but you can't stop yourself from having all these negative thoughts.
The experiences of awe and connectedness during psychedelic journeys can help individuals break free from negative thought patterns. Penn says that through that expereicne of awe, patients can "realize, oh my gosh, I'm just one story in a sea of billions of stories. What a relief. There's so much wonderful stuff out here to connect with like the beauty of this tree, or my partner's smile."
By expanding one's consciousness and fostering a sense of connection, psychedelic therapy facilitates the exploration of meaning in difficult experiences, leading to emotional healing.
In psychedelic therapy, we often overemphasize the big breakthroughs—the heroic doses that ignite the lightbulb in a single session. But as Jack Kornfield says, “after the ecstasy, comes the laundry.” In other words, while large doses can cause breakthroughs and epiphanies, the patient needs to integrate that insight into everyday life for the positive affect to sustain.
There’s no doubt that integration is crucial to any psychedelic-assisted therapy, but there’s debate in the best approach. While more research supports large doses than microdoses in treating major depression and anxiety, there’s debate in the community about psychedelic vs psycholoytic approaches.
The psychedelic approach emphasizes larger doses, creating a psychedelic “trip”, where the integration comes after they come back down to earth, or in a later session altogether. In this approach, psychedelics and therapy are sequential.
The psycholytic approach, on the other hand, emphasizes working with smaller doses, and working with the psychedelic as a way to make the patient feel more open while talking with their therapist - simultaneously.
There’s no settled winner here, and in fact, some patients may do better in one situation over another, or the same patient can try easing in with smaller doses and try a larger psychedelic dose later. These are puzzle pieces researchers and clinicians have yet to place.
But Andrew’s argument is this: real sustained progress takes time. We can and should appreciate glacial change. We can think of progress in the same terms as exposure therapy for phobias; though in this case, rather than confronting a fear of spiders or elevators, the phobia may be all internal, like confronting a buried trauma.
Day one may be a patient being guided through tough emotions with their defenses slightly lowered. Day 5 may be them practicing sitting with those emotions during meditation alone. Day 20 may be them confronting hard emotions in a social context.
Psychedelic research is only scratching the tip of the iceberg. Let’s not downplay glacial change.
"You know, that was the first time I ever felt safe in my life."
This testimony comes from one of Penn’s patients, the first time she tried MDMA-assisted therapy. But she had done MDMA before, recreationally. There’s something more important than the drug itself. At the heart of any therapeutic experience—especially with psychedelics, is a feeling of trust and care. Patients are letting go of much of their physical and emotional agency—it’s a vulnerable place to be.
Penn says, “They need somebody there who they feel like they can trust to be not only physically vulnerable with, but emotionally vulnerable as well, and know that whatever comes up is going to be held with a loving kindness and equipoise and care.”
When we think of set and setting, we often think music, and soft couches, and zen wall art and setting expectations. But don’t forget as a clinician, that your mindset and openness to hold a trusting and loving space matters much more.
As psychedelic treatments become more popular, Penn emphasizes the need to manage expectations for patients. They may come into their first session believing that one treatment is a panacea and will "cure" their mental illness.
"Psychedelic therapy requires managing expectations to avoid overhyping the outcomes. We need to find a balance between realistic expectations and the potential for transformation."
We're still in early days with psychedelics. Andrew cautions against overpromising and underdelivering, underscoring the need for individualized approaches and patient-centered care. Each person's journey is unique and cannot be predetermined.
Financial barriers and out-of-pocket costs associated with psychedelic therapy exacerbate existing healthcare inequities.
Penn notes how treatments like ketamine and psilocybin, though inexpensive to produce, become costly when integrated into clinical settings, often not covered by insurance. This setup renders these therapies inaccessible for many, creating an unfortunate divide.
He highlights a tension between groups arguing for the sanctity of psychedelics, resisting their transformation into pharmaceutical products, and those who believe in their potential as an FDA-approved treatment. For Penn, the latter path aligns more closely with the ideals of equity. If approved by the FDA, these treatments could be covered under Medicare and Medicaid, enabling access for those who can't afford out-of-pocket costs.
Andrew Penn's insights highlight the transformative potential of psychedelic therapies, emphasizing their capacity not for instant cures but gradual growth and self-discovery. This isn't about rushing change, but valuing slow, steady progress and managing realistic expectations.
Penn's focus on the 'both/and' model urges us to reshape mental health discourse and challenges us to consider the sociocultural and economic realities surrounding these treatments. We are invited to navigate healthcare inequities, ensuring that access to these novel therapies isn't confined to those who can afford them.
Ultimately, the transformative power of psychedelic therapy isn't just in its biological impact, but its ability to foster connection, meaning-making, and inclusivity in mental health care. It's a journey towards understanding, compassion, and patient-centered progress, underpinned by principles of trust and safety.
Let's journey together into this new frontier of psychiatry, one patient and one transformative perspective at a time.
Note: The transcript excerpts have been edited for clarity and coherence within the context of the blog post.
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