Bridging the Gap: Psychiatry, Psychotherapy, and Psychedelics

In their joint 2021 Sana Symposium Session, Andrew Penn, MS, PMHNP, associate clinical professor at the University of California, San Francisco and attending nurse practitioner at San Francisco Veterans Administration Hospital, and Saundra Jain, MA, PsyD, LPC, adjunct clinical affiliate at the University of Texas at Austin School of Nursing and a private practitioner, discuss the use of psychedelics as a way to bridge the gap between psychiatry and psychotherapy.

During this session, Penn and Jain take a look at the curative vs carative models of treatment, discuss key components of the therapeutic relationship, and touch on creating the best environment for healing.

Read the transcript:

Andrew Penn:  Hi, welcome to this talk that I am pleased to be joined with my colleague, Saundra Jain. We're going to be talking about this challenging gap between psychiatry and psychotherapy with regards to psychedelic therapies. Here are our disclosures, and here are our learning objectives.

Really what we're going to be talking about here is the psychotherapy relationship in psychedelic therapies. This is where we are right now.

A lot of this probably have been covered already in the conference, but we know that with a lot of our conditions that we treat in mental health that there are a lot of people who are left either not treated at all, which is worse, or even just partially treated.

We saw this from STAR*D, where even after 4 different trials of antidepressants, we saw that there were still a significant number of people who were left untreated.

This has led to this great thrust of interest into using psychedelic therapies, or psychedelic medicines, as adjuncts to psychotherapy, ranging anywhere from major depression to PTSD, and then some more emergent treatment paradigms for things, such as OCD or eating disorders, and also, of course, substance use disorders.

I've been talking about this now to various audiences for about 8 or 9 years. When we first started talking about it, it really seemed far off in the distance. Now, we are much closer to this being a reality in our clinical practices.

It's looking like MDMA-assisted therapy for PTSD can likely be FDA-approved as early as 2023 and psilocybin-facilitated therapy for depression probably somewhere around 2025. Of course, as many of you are well aware, or maybe in practice, esketamine and ketamine, which do certainly have similar effects to psychedelics, are already in widespread clinical use.

Here's the problem is that, for many, many years, we've been siloed into people who provide psychotherapy and people who provide psychopharmacology. The 2, unfortunately, have not always done a great job of talking to each other. This is a wonderful marriage, or reuniting, if you will, of bringing psychotherapy back to psychopharmacology.

The problem is, it's a lot more psychopharmacology than a lot of psychotherapists are familiar with, and it's certainly a lot more psychotherapy than a lot of psychopharmacologists and pharmaceutical companies and regulators, such as the FDA, are familiar with, as Matt Johnson from Johns Hopkins has pointed out here in this tweet.

Most of the time, when we think about psychopharmacology, we don't think about the process of what happens to the person as they get better. We just think about, we add a pill to the mix, and then out comes a reduction in symptoms, and that's usually good enough for most of us.

This challenges that paradigm. What we're doing here is, we're actually very interested in what happens to the person as they get better. The extant model of treatment in psychopharmacology, and in medicine in general, has been this idea that there's a disease that happens to reside inside of a person, and the disease becomes the central focus of attention.

That certainly had its value. We might call this a curative model. The problem with this model is that we often think that we can just eliminate the disease, and the person will get all better.

This old idea that there is pain which is not negotiable, so that might be something as obvious as a cancer diagnosis, or it could be something like a traumatic childhood, cannot be changed. It is a constant.

What can be changed is the relationship to it, and that is referred to as suffering. When we think we can just eliminate the pathology, we get into this fantasy that we can just have these lytic treatments.

Think about it. We have a class of medications called anxiolytics. We borrowed that term from biology, like we could just poke a hole in the middle of that pain, and everything goes away along with it. As we know, that hasn't worked out so well. I often think that a lot of psychiatry is actually quite palliative, and that's OK.

I'm a nurse by training. In nursing, we have a somewhat different perspective. In nursing, we talk about, there's a disease, sure, but that disease happens to live inside of a person, and that person happens to live inside of a context of their entire life.

On that wide field of their existence, this person, who happens to have a disease, also has a family. They also have work. They have love. They have relationships. They have a story. We're a part of that as their clinicians, but we're a small part of it. This perspective on care could be thought of as carative, in contrast to curative.

Psychotherapy has been going on for a long time. We said there's evidence going back more than 3500 years when the ancient Egyptians talked about healing through words. In ancient Greece, there were these places called asclepeions. This is one in Western Turkey that I visited in the town of Bergama. I visited this in 2016.

Inside of these ruins here, you would see these tunnels and these chambers where people would undergo steam baths. They would talk about their dreams and talk about the visions that they experienced as a means of healing them.

We might think, "Well, that's kind of weird." Just think more recently back to Freud and Jung, who talked about interpreting dreams and interpreting the internal world of our patients' lives as a means of helping them get better.

I think about how psychedelic therapy works as changing the experience of suffering that the person has around their illness. That suffering is reduced in the context of this relationship that the person has with their therapist or therapists. That caring, empathic, supportive relationship.

Through that, what I imagine is that there's a shift in the story. There's your pain. There's the thing that's happened to you. Now, instead of having that suffering gobbed on top of it, you've got this wider orbital of suffering, where there can be a little more space between the person's experience of that pain and how they feel about it.

That I call Caritas psychedelic psychotherapy. We're going to expand upon that in the slides ahead. This idea of psychedelic Caritas is meant to be a complement to these emerging models of psychedelic therapy.

There's been exploration, everything from acceptance and commitment therapy, to internal family systems, trying to find a conceptual framework for approaching psychedelic therapy. My idea is that these can be complemented by this way of being with our patients.

What we've done is we've taken a couple of different models and married them together into what is a perspective that is deeply informed by nursing, which is, as I mentioned, my background. Largely based on the work of Jean Watson.

Jean Watson is a nursing theorist who is very well-known within nursing. Not as well-known outside of nursing, which I think is a real misfortune. She has done about 40, 45 years of work, talking about this way of being that we are as nurses. This is not limited to nursing. Certainly, non-nursing professions can learn these modalities as well.

What she's talking about here is if you've ever been a patient, or if you've been a patient in a hospital, or had a loved one who was, you know when there's good care being delivered. That care, she describes it here. We elaborate on this in our paper.

She talks about that the nurse creates this space of healing with the patient. That you collaborate with the patient to help them get better on their own. It's about making a path for the person's own ability to heal to emerge.

We took this idea of Jean Watson's and we married it with work that has been published by Janis Phelps. Janis, as you may well know, is the person who is spearheading the California Institute for Integral Studies Center for Psychedelic Therapies & Research training programs. This is a psychedelic therapist training program.

She talked about what are the competencies of a psychedelic therapist? Talking about things such as empathic, abiding presence, trust enhancement, self-awareness, and knowledge, of course, of the physical and psychological effects of psychedelics. We'll elaborate on this a little more.

It's clear that these models complement each other nicely. That's why we're advancing this idea as a means of starting to have a conversation about, what should the therapy sessions look like? The results are impressive. They speak for themselves.

It's quite clear that this is not just the drug itself. That this is the combination of the psychotherapy, amplified with the psychedelic drug.

I think about this collaboration that the therapist, nurse, or whoever it is that's providing the therapy does with the patient as a collaboration, like you might have with a contractor if you're going to remodel your house.

I think about this container that we're creating as having three parts. There is a physical container. It's done in a safe living room type environment, typically. There's a psychological container. Meaning that the therapists are aware of what the issues that are present for the patient that might come up in the therapy will be.

It's interpersonal. There's been trust created between the patient and the therapist before any drug is ever administered. That triad is what begins to create this house of healing, if you will. I think back to when I remodeled my apartment here in San Francisco a few years back.

I bought this place. It had this very vintage, 1985 interior that was functional, but as you can see, not terribly attractive. We went from that, we went to this. How did we get there? It was messy sometimes, because we were living here, too. In order to get from this point to this point, we needed a guide. This was Pascal. He was our guide. He was our contractor.

Just like in order to get through sometimes the messiness that is psychedelic therapy, you need a guide. Which is why I believe that the interpersonal therapeutic aspect to this is so important. It's not just the drug itself that's doing the work.

With this, I'm going to turn this over to my colleague, Saundra Jain, who's going to talk about what some of these aspects actually look like. Saundra.

Dr. Saundra Jain:  Hello, everyone. Thank you, Andrew. Wow. I have to say, the remodel as a metaphor for the psychedelic experience is brilliant. What I suggest is let's do this. Let's take that metaphor and move forward with it.

Let's spend the rest of our time together talking about, what might we do? How might we decorate this newly remodeled home to create our therapeutic container? What matters most in that process? Here, we see it. Trust, presence, learning. Empathic presence. Ethical, self-aware practice.

How about our own personal spiritual practice? Effects of the psychedelic medicines. Then, of course, creating that healing environment. Let's take the rest of the time together. Let's dig into each one of these a bit more.

Here we go. Continuing with that remodel metaphor, we first have to have an idea that we need a little bit of a change, like Andrew's experience with his kitchen. He and his family decided, "We need an uplift. We need a redo. A remodel." We've done that. Next, we're going to invite someone in, our contractor/therapist.

What's so beautiful about this is that once we've decided we need to change or a change needs to be made, we invite that person in. There's this bi-directional learning, teaching process that begins to occur between the therapist/contractor, the patient/customer.

Always keeping in mind that when the work is done, but of course, I'm not sure the work is really ever done. In this example, we're going to thank our host. We're going to leave. We're not staying around forever.

Let's take a look at what this process is like. Andrew did such a nice job of laying the foundation, if you will, for us to dig a little bit deeper into this process. We've invited the person in. All of a sudden, there's this collaborative exchange. It's also quite creative. As our builder, our guide, our contractor comes in, they're helping us to see the range of possibilities.

That's where that collaboration and creativity comes to life. That builder sits in the living room, the kitchen, on the back porch, they're hanging out to get a feel for what life looks like in that space as it exists now.

I love this idea that some houses can be quite simple. Straightforward, simple floor plan. Then, as we all know as clinicians, other houses have lots of rooms, there are hallways, there are nooks and crannies. There's a lot going on.

In the preparation work, sticking with this metaphor, what we may uncover as we're preparing, we may find things hidden behind the insulation in the walls. We may also uncover and discover things that have been, if you will, pushed into the dark recesses of a person's basement.

Here we go. Let's go back to this idea of the foundation of this remodel. Let's think about trust as that foundation. As we build this therapeutic container, trust really is the foundation. Once established, something quite beautiful happens. It allows space, safety, and security for this inner healing ability to emerge.

I love this idea. It's very heart-opening, heart-expanding. That's where this inner healing, inner wisdom, embodied self, whatever language you like, that's where it resides. Let's turn to a moment for some wise words from Annie Mithoefer. The MDMA studies, she was a principal investigator for the treatment of PTSD. Look what she shared with all of us.

She says, "We often use the analogy in MDMA-assisted therapy of a person with a wound. The doctor or nurse can help by removing obstacles such as gravel, debris, and they can create favorable conditions. But it is always the person's own healing intelligence that does the healing." Beautifully stated.

Long before Annie's wise words were shared with all of us, Florence Nightingale, look what she tells us. "Surgery removes the bullet out of the limb, which is an obstruction to cure. But nature heals the wound." Beautifully stated.

If you don't know Kay Parley, my friends, we, Andrew and myself, invite you to get to know her. She is a wealth of wisdom. I believe she is either in her mid-90s or maybe she's surpassed 95 and continues to grow, learn, and share with all of us.

Kay Parley is a nurse from Canada. She worked quite some time with Humphry Osmond, a psychiatrist. They were interested in LSD for the treatment of alcohol use disorder.

I want to share with you this quote, which I'm sure you've already read, from Kay that was published in the "American Journal of Nursing" in 1964. The title of this article "Supporting the Patient on LSD Day." What she's talking to us about is trust, presence, and learning, emphasizing that trust is the foundation for this creative healing therapeutic container.

Kay tells us, "The nurse-patient relationship during LSD treatment is like that between partners on a mountain climbing team. It's warm, cooperative, intimate, and yet objective."

We'd also like to recommend that you grab a copy of Kay's memoir. It talks about her lived experience with bipolar disorder. It's called "Inside The Mental—Silence, Stigma, Psychiatry, and LSD." We'll revisit some of Kay's words in just a moment.

Once that foundation, that trust, is established, we as the therapist, the guides, the facilitators, we hold empathic presence. The question is, how do we do that? We'll continue to talk about it, but here, look what we're learning.

We achieve that, we do that, through impeccable behavior, through that ever-present, empathic, abiding presence. Those are the building blocks of the foundation of trust. I love this idea of inner subjectivity, that once that trust is there, that foundation is solid.

We then can enter into the frame of our patients. We can begin to see and view the world through their eyes. As that begins to unfold, look what happens. Once we are comfortable in the patient's world, they're comfortable in ours. Then all the teaching and all the learnings are based in just pure creativity.

You'll also notice—I won't go through these, but I'll bring it to your attention—for many of these slides, you'll see in the green text box these different Caritas principles that Andrew referenced earlier. Please be sure to take a look at those. We are back to our wise person, Kay Parley, and she's going to expand on empathic presence.

She sets these words of wisdom in this context for all of us that, no matter what surfaces during these journeys, we hold space. If you'll allow me, I'll just read this for you. "The sitters interest and attention are the subjects lifeline. They have lost their ego. You are it. They have lost their sense of direction, you are their guide.

"They are drifting in space, you are there to bring them back to earth. It is a great growing experience for a sitter, if exhausting. It is the most intuitive and empathic relationship I have ever known." My friends, I cannot add anything to those words from Kay Parley. All right. Let's go back.

I'm going to keep pulling us back to this foundation, because without that foundation of trust, we cannot really successfully create this therapeutic container. I love this formula. Presence engenders trust, trust leads to learning and here's the formula. Presence plus trust, plus learning equals healing.

Let's remember that as humans, we are all naturally inclined towards healing. Let me share a model of existence that comes to us from Martin Buber. He was a biblical scholar, a prolific author, a philosopher. Here's 2 ways he viewed how we live in this world. The first you see it right here, that I-It approach.

Quite objective where we see ourselves and we see others not connected, but completely separate from us. Now, let's take a look at this little bit slow on the animation. Here you see, I-Thou. This is an entirely different approach. This is I see myself in relationship to others. There are no distinct boundaries.

Here you'll see that language we saw just a moment ago, intersubjective space, where I am able through that foundation of trust, to view the world through my patients' eyes. Really beautiful. You'll see the Caritas principles. Here's another one, but I want to bring your attention before we move on—Sorry. We missed one. I want to go back. There it is.

We'll do this I-Thou. This fewer boundaries. This inner subjective space that Buber taught us about. Remembering being very mindful about maintaining appropriate therapeutic boundaries in the process. Here we go.

We know that psychedelic experiences, whether they are in a recreational setting or whether they are in a therapeutic setting, can at times, for many people, be challenging. Let's keep that in mind while we remember this. That no matter what happens, no matter what happens, we, as the clinician, we stay present. That ever-abiding presence.

Lots of questions. Several bullet points. I want you to read through all of them. These are great points, if you will, of self-reflection for our own work as clinicians. Let's touch on a few. That first one is so powerful. How do we embody loving kindness? How do we convey that?

Keeping that in mind, how do we do that so that we can remain present, you'll see this in bullet point 3, to all feelings that will and may arise during a session? That means the good, the bad, and the ugly. All of it. Are we able to maintain that presence in the face of whatever emerges?

Then that idea, can we sit with that, and here's the rub for many of us, without feeling the urge to intervene? Quite honestly, as healthcare providers, particularly in the mental health space, we are fixers. We are problem solvers. We are advice givers. That is probably how many of us, if not most or all of us, were trained.

Now we're in this new therapeutic container that we're talking about today, where we're looking at it differently. We're being present with our clients, our patients, in a different way. This next slide outlines it beautifully.

The question is, that many of us ask, what should we do during the psychedelic session? Pulling from Taoism, a concept you'll see in bullet point 1, wu wei. Doing, not doing. All the way to the last bullet point. Less is more.

Can we be in this space? That's what we're striving for. To be in this space without the need for effort, force, or doing anything. I once saw a slide in one of Andrew's presentations. He had included an acronym, WAIT. Why am I talking?

I think this is a beautiful thing to keep in mind, not just in a psychedelic experience, but also in our experiences in everyday relationships. That oftentimes, when uncomfortableness bubbles up, if you will, whatever the source, we tend to want to fill that with talking, asking questions.

We want to fill up the space. There is that sense of difficulty with sitting in that stillness and simply allowing. Here we go. We are so lucky at Sana this year. I'll tell you why I believe that. That just in this presentation, Andrew and I have the privilege of referencing and talking about the works from Dr Janis Phelps.

In a moment, I'll share with you the work from this slide. The ACE model of psychedelic therapy from Dr Rosalind Watts. Fantastic. They are part of our faculty this year, which makes me smile from ear to ear. If you're not familiar with the ACE model, accept, connect, and embody, Andrew and I encourage you, grab this article, read it. You will absolutely love it.

I wanted to give you a little bit of a teaser. You can see the graphic. That encouragement in the preparation work to quiet the mind and take a deep dive into the ocean. You can see that. Letting go, allowing, surrendering.

When in that journey, as we run across these gifts, these pearls of wisdom, of learning, that we collect them. We bring those back with us as we return to the surface. Then we're able to use that in the integration work. Please, become familiar with the ACE model of psychedelic psychotherapy.

How about this? I don't know if it's true for you. Every time I see this picture, I pull back. It makes me uncomfortable. I think it's true. I'm guessing the same is true for all of us looking at this.

That when suffering or pain bubbles up, we retract. We spend a lot of energy avoiding those feelings. That's just being human. That's all there is to it. Maybe during Q&A, remind me. I'll share an episode story with you from "The Dog Whisperer." An episode about a dog that was a biter.

Here's the takeaway. The teaching is when something uncomfortable happens—Think about it. Psychedelics amplify experiences, memories, emotions, both good and bad. When it is difficult and challenging, we pull back, how I described it. I even did it in my chair, pulling back just now.

In this work, we want to encourage leaning into, not running from. Asking, "What are you here to teach me?" Let me do the animation throughout this so we can take a quick look at this slide and then move on.

To give some context for all the things, while we're on this planet walking through our life, how much stuff are we trying to avoid? Spending time and mental energy, body energy avoiding. Look, we've got grief. It comes from personal life experiences. We must not forget transgenerational traumas, ancestral traumas.

There's a lot that we spend time avoiding. Let me pull that little last piece of animation up to make this point. As we're creating this healing environment, we've got to go back to the words of Timothy Leary around set and setting. You see Florence Nightingale popped up again in another slide.

All those decades ago, she was aware, sensitive, and intuitive about all of this. Tim Leary tells us the nature of the psychedelic experience depends almost entirely on set and setting. That's why this conversation about creating a therapeutic environment, a container, this healing environment, is so important.

Let's go back to Dr. Janis Phelps. You'll see the Caritas principle up there on the right-hand corner. Look, she tells us about the importance of understanding the effects that psychedelic medicines may and can have on the body and the mind. She spends time talking to us about creating a safe environment that is conducive to healing and care.

Maybe during Q&A, Andrew can tell you about this particular photograph. I'll tell you that I've heard him say previously, "This is a funky Airbnb." I'll let him tell you the rest of the story. Dr Phelps tells us one last thing. Andrew referenced this earlier, but worth making the point again.

That as clinicians in this psychedelic space, within this therapeutic container, what other techniques should we, do we want to be proficient in to complement the work? Many come to mind. I'll mention a few. Holotropic breathwork, meditation, acceptance and commitment therapy, ACT, internal family systems, IFS. Honestly, the list is quite long.

Another question about effects of psychedelic medicines. Let me ask you, should therapists have their own psychedelic experiences to increase their capacity for empathy? What do you think? I'll share with you. My thought is this.

I believe having your own personal experiences does enrich connection and empathy. Not everyone believes that. I'm hoping that during Q&A, someone may find this conversation of interest. Maybe we'll explore it a little bit.

Take a look. This was another important element of our design. How we want to decorate that therapeutic container. That is our own spiritual practices. First and foremost, there is no one prescription. There is no one path. Remember that old saying, all roads lead to Rome.

What we want to do is cultivate our spiritual intelligence, our spiritual understanding and mindfulness. Coming from a place of humility and connection. I love this one. Meeting suffering with equanimity and creating meaning-making out of suffering.

I saved this one for last. For many of us, as researchers, as evidence-based practicing clinicians, we may struggle with this one a bit. I saved it for last. That is that we remain open and curious to the mysteries of life and the possibility of miracles. Quiet down that thinking, structured mind and let that one sit with you for a while. See where you land.

Andrew:  Thanks, Saundra. That was a fantastic overview. I'm going to bring home the last couple of points here and bring us up to Q&A. One question I want to ask people, as a nurse, is how does it feel to you when somebody has to take care of you? Is it difficult to accept that care from another person or does it actually feel healing?

This is one of the places where nurses are well-suited to this work. As you can see in this picture, the patient here is having his hand held. Oftentimes, in these sessions, there is going to be physical contact. We're going to have to take vitals. We're going to have to take people to the restroom.

We might even have to help people get cleaned up if they were to have an episode of incontinence. This is honestly where nurses have a lot of native comfort with this. We're used to touching our patients. It's a natural part of our profession.

It is something that is going to require some reflection and thought from our therapist colleagues. So often, they've been told you never touch patients, or at most, you offer a handshake or a tissue. This is something we're going to have to figure out.

Oftentimes, patients need physical reassurance. Which is, of course, agreed upon ahead of time and boundaried. It's going to be a really important part of this therapy. We've put a lot of focus on the psychedelic experience itself.

What I've experienced as a psychedelic therapist working on these studies is that a lot of the healing comes after the fact. It's this integration period where you see how all these pieces fit together in this bird's eye view. That's where the benefit is cemented, if you will. It's not this transient psychedelic experience. It's the lessons that are taken from it.

Finally, coming back to our remodeling here, this our re-housewarming party. This was after the kitchen was done. The house was exactly the same on the outside, but the inside was different. It was reimagined. It was welcoming. I wanted to be there. It was like the windows had been cleaned, and I finally saw what was outside all along.

William Blake talked about, "If the doors of perception were cleansed, everything would appear to man as it is." I want to just close with an excerpt from a poem from one of my favorite poets, David Whyte. This is from a book called "The House of Belonging," and this is the poem by that same name.

He ends the poem by saying, "This is the bright home in which I live. This is where I ask my friends to come. This is where I want to love all the things it has taken me so long to learn to love. This is the temple of my adult aloneness and I belong to that aloneness as I belong to my life. There is no house like the house of belonging."

With that, I thank you for your attention. Saundra and I look forward to taking your questions.