‘Container’ Creates an Ideal Home for Psychedelic Therapy

For years, providers of psychotherapy and providers of psychopharmacology have been siloed from one another, Andrew Penn, NP, associate clinical professor at the University of California, San Francisco and attending nurse practitioner at San Francisco Veterans Administration Hospital, told Sana Symposium attendees on Friday.

“The 2, unfortunately, have not always done a good job of talking to each other,” he said.

With psychedelic-assisted therapy becoming much closer to a reality in clinical practices, Penn and Saundra Jain, MA, PsyD, LPC, adjunct clinical affiliate at the University of Texas at Austin School of Nursing and a private practitioner, discussed the path to bridging that gap.

MDMA-assisted therapy for post-traumatic stress disorder (PTSD) could be approved by the US Food & Drug Administration as early as 2023, while psilocybin-facilitated therapy for depression could be cleared by FDA as early as 2025, Penn said. Ketamine and esketamine, meanwhile, are already in widespread clinical use.

Currently, therapeutic use of psychedelic medicines in combination with psychotherapy is being researched to treat the following: major depressive disorder, bipolar depression, PTSD, obsessive-compulsive disorder, eating disorders, cancer-related depression and anxiety, smoking cessation, and substance use disorders.

Both Penn and Jain likened the collaboration between patient and caregiver in psychedelic-assisted therapy to working on a home remodeling project. With the therapist serving as a contractor, the 2 parties create a container that has 3 components:

• Physical: A safe environment, such as a living room
• Psychological: An awareness of issues present for the patient that could surface in therapy
• Interpersonal: A trust between patient and therapist before any drug is administered

Building ‘the container’

Jain extended the home renovation metaphor to describe what is needed when constructing a therapeutic container:

Trust, presence, learning. The therapist must be invited in by the patient, and after a learning-teaching process occurs, it is time for the therapist to leave, Jain said.

Empathic presence. Once trust is established, therapists hold an empathic presence with patients. That is achieved through impeccable behavior and maintaining an abiding presence. Therapists can then enter the frame of the patient to learn how they see the world. “Once we are comfortable in the patient’s world and they are comfortable in ours, we can be creative in teaching and learning,” Jain said.

Healing environment. Therapy should have a private, safe, protected, comfortable and quiet place, Jain said. As noted psychologist Timothy Leary said, the nature of the psychedelic experience depends almost entirely on set—the preparation of the individual, including personal structure and mood at the time—and setting—the physical location.

Effects of psychedelic medicines. Therapists must know how drugs impact both body and mind, as well as what constitutes a safe, conducive environment for care. Therapists should also be proficient in several techniques that complement therapy, such as holotropic breath work, meditation, acceptance and commitment therapy, and internal family systems. Should therapists have their own psychedelic experience to build empathy? Jain said she believes personal experiences do enrich connection and empathy, but she recognizes that opinions vary on this topic.

Personal spiritual practice. While there is no single prescription for spiritual practice, therapists should aim to cultivate spiritual intelligence and mindfulness, as well as humility and a sense of connection. They should also remain open to mysteries and miracles, meet suffering with equanimity, and find meaning in suffering, she said.

Reference

Jain S, Penn AD. Psychedelics-bridging the gap between psychiatry and psychotherapy. Presented at: Sana Symposium; September 17-19, 2021; Virtual.