Integrating Psychedelic Medicines and Psychiatry: Theory and Methods of a Model Clinic

This book chapter (2018) examines how the integration of psychedelic medicines within psychiatry may shift the focusses of clinical symptoms and the underlying neural biomarkers of mental disorders towards a multidimensional perspective of human beings and their suffering, and engages in a more holistic healing process that includes spiritual and existential domains.

Abstract

“The past two decades has seen a significant increase in both popular and scientific interest in psychedelic substances and plants as therapeutics for mental illness, addictions, and psychospiritual suffering. Current psychiatric practice privileges a biological paradigm in which the brain is considered the locus of mental illness and symptom-focused treatments are delivered to patients as passive recipients. In contrast, a psychedelic healing paradigm, constructed through examination of different ontologic understandings of plant medicines, is based on a complex multidimensional perspective of human beings and their suffering. This paradigm actively engages the sufferer in addressing root causes of illness through healing on multiple levels of existence, including spiritual and energetic domains. Numerous theoretical, methodological, and ethical challenges complicate the integration of the psychedelic healing paradigm into psychiatric practice. These include developing coherent therapeutic narratives that account for the complex processes by which psychedelic healing occurs and overcoming reductionist tendencies in the medical sciences. Tasked with overcoming such challenges, a model clinic is proposed that seeks to implement and study the psychedelic healing paradigm in a critical, interdisciplinary, and reflexive manner. Such “critical paradigm integration” would employ multimodal patient formulation and treatments, as well as a range of knowledge generation and sharing practices. Outcomes-oriented research would seek to establish an evidence base for the model, while critical dialogues would advance understandings of psychedelic substances and plants and related practices more generally. The clinic would serve as proof of concept for a new model of studying, conceptualizing, and treating mental illness.“

Authors: Jordan Sloshower

Summary

Jordan Sloshower

The past two decades have seen an increase in interest in psychedelic substances and plants as therapeutics for mental illness, addictions, and psychospiritual suffering. A new model clinic is proposed that seeks to integrate the psychedelic healing paradigm into psychiatric practice.

Introduction

This chapter attempts to provide preliminary answers to questions about how psychedelic substances and plants can help alleviate human suffering. It discusses key differences between current psychiatric treatment and a proposed paradigm of psychedelic healing.

Psychedelic Medicines in the Era of Biological Psychiatry

My training in psychiatry at Yale University has emphasized a biopsychosocial approach to diagnosis and treatment, which includes medications, evidence-based individual and group psychotherapies, and social interventions. Unfortunately, this approach is too often not the case due to resource limitations and an overprivileging of biological perspectives and technological interventions.

In the current era of biological psychiatry, mental illnesses are primarily conceptualized as brain diseases resulting from aberrant neural circuitry and chemical imbalances. Pharmacotherapy is the most common treatment, but evidence-based forms of psychotherapy are too often unavailable, unaffordable, or not sought out by people suffering with mental disorders.

Currently, most psychiatric treatments target symptoms, rather than root causes, and are based on categorical or descriptive diagnoses, which cluster symptoms into disorders. This leads to chronic drug administration, associated side effects, partial treatment effectiveness, and patient dissatisfaction.

Different Ontological Understandings of Psychedelic Medicines

Psychoactive plants have been in relationship with humans for thousands of years, and there are numerous different ways that psychedelic substances and plants are understood and characterized by different groups of people and academic disciplines.

Ayahuasca is a plant spirit used by indigenous peoples, as well as in a variety of cultural, spiritual, and scientific contexts. It alters brain network connectivity and neuroplasticity and may bring about insights and change.

Ayahuasca is often considered an “entheogen” or “sacrament” by spiritual or religious perspectives, or an “evolutionary tool” by contemporary users wishing to highlight their healing effects.

From Ontologies to a Psychedelic Model of Healing

Although different ontologic understandings of psychedelic plants may be based on different modes of knowledge, I would argue that they reflect different “mechanisms of action” by which psychedelic medicines exert their effects on the human organism.

The next task is to translate the psychedelically informed perspective of human existence into a healing paradigm. This can be achieved by revising and expanding the biopsychosocial model.

Mental suffering may arise in any of the layers of existence and may be propagated through them in complex ways. For people experiencing profound suffering, psychedelic medicines may need to be guided through one or more of the layers of existence and outward into interpersonal and social domains.

Psychedelic integration refers to the process of continuing to heal after an acute experience, whether through ongoing practices such as psychotherapy or meditation, or through changing one’s daily habits, interpersonal relations, living environment, and relation to society and nature.

Psychedelic healing is a multilayered healing process that targets deep-seated pathological patterns and processes. This helps explain the popularity of psychedelic healing and the profound therapeutic benefits seen thus far in clinical trials.

Theoretical, Methodological, and Ethical Challenges to Paradigm Integration

The field of psychedelic science needs to develop deep understandings of how psychedelic substances and plants operate at each ontological or existential level, and how these levels and processes interact. This integration is likely to be contested at multiple sites of knowledge production.

Theoretical issues in psychedelic healing include articulating a coherent narrative or model for psychedelic healing, and negotiating different idioms and paradigms to convey concepts to different audiences.

It is challenging for clinicians and researchers to translate the psychedelic healing paradigm into clinical trial protocols, as the principles and interventions are foreign to traditional drug development research.

A clinical trial protocol may include liquid ayahuasca instead of freeze-dried capsules, or may incorporate esoteric healing practices that are foreign to most clinical trials, such as the use of music during experimental sessions.

A research protocol to investigate the therapeutic potential of psilocybin in the treatment of depression was difficult to prepare because the research grant was grounded in a biological framework that left little room for psychological or spiritual mechanisms of action.

The drive to conduct clinical trials with psychedelics with utmost scientific rigor is commendable, but it must not come at the expense of losing sight of what distinguishes psychedelics and the psychedelic healing paradigm as distinct from a pharmacology-first treatment model.

Ketamine therapy may be improved if other ontologic understandings were brought to bear on its use, such as capitalizing on its subjective effects or integrating it with psychotherapy.

Methodological issues are critical in this early and resurgent time for psychedelic science, because treatment guidelines are generally based on evidence produced in clinical trials.

The scientific method and typical clinical trial methodology are not well suited for the study of psychedelics, because of the tendency to isolate individual variables and characterize their specific (biological) effects, rather than looking at systems as a whole. The reductionist tendency in clinical trial design does not allow for the study of complex interactions between psychedelic medicines and metaphysical healing components like music, dieting, praying, being in nature, and other aspects of shamanism. In what setting and with whom should a person ingest psychedelic-assisted therapy? Does it matter if the therapists have personal experience with the medicine being given?

A methodological problem related to reductionism is the historical tendency of biomedical science to isolate and study single molecular compounds as medicines, rather than looking at combined effects of multiple chemical compounds. However, the entourage effect is an understudied phenomenon of nature.

The more widely discussed problem of blinding psychedelics in placebo-controlled trials is examined more closely by Katherine Hendy (2018).

Psychedelic scientists are challenged to adapt scientific tools and methods to adequately study the phenomena of psychedelics, rather than packaging them into artificial units that are more conveniently studied by existing scientific methods.

A discussion of the ethical issues surrounding the expansion of plant medicines outside of their original ethnocultural and ecological contexts is beyond the scope of this chapter. However, I would like to briefly acknowledge a number of risks inherent to the work of integrating plant medicines into more mainstream medicine.

The use of psychedelic plants and medicines in the treatment of patients carries certain inherent risks to their physical and psychological health. This is especially true when working with people suffering from significant medical or psychiatric illnesses.

Psychedelics currently occupy a tenuous space in society and are considered Schedule I illegal drugs in the United States. Psychedelic science is currently one of the primary mediators between governments, policymakers, and the public on the regulation of these substances.

Theory and Practice of a Model Clinic: Overview

A model clinic for psychedelic healing is proposed that would endeavor to implement and test a model of care based on the psychedelic healing paradigm. This clinic would seek to impact thought leaders and policymakers in the health sector and related fields.

The clinic would need to engage in the following essential activities: clinical practice, research, knowledge sharing, policy and advocacy, and funding generation. To fulfill its mission, it would need to have an overarching ethos or unifying theoretical orientation.

Clinical Approach Based on Multimodality and Interdisciplinarity

A clinical approach based on multimodality and interdisciplinary collaboration is proposed, which includes the administration of psychedelic substances and plants as one potential component of a multifaceted approach to healing.

Multimodality applies to the process of clinical formulation, in which a team of clinicians with different theoretical perspectives and orientations conceptualizes a person’s problem or situation. This could be accomplished in different ways, such as team-based interviewing or using a sequential stratified approach.

A narrative approach can be used to integrate different clinical perspectives and ontologic understandings into a coherent therapeutic narrative, which can then be used to determine how various treatments can address the problems.

Clinicians can work with patients to formulate a customized, multimodal treatment plan that targets different domains of the person’s existence, drawing on different ontologies of psychedelics and plant medicines as organizing principles.

Psychedelic psychotherapy includes acceptance and commitment therapy, mindfulness-based therapy, logotherapy, and psychodynamic psychotherapy. It aims to help people face, accept, and cope with their difficulties and existential situations, rather than avoid them.

When psychedelics are clinically indicated, the clinic should be able to facilitate psychedelic-assisted therapies using different medicines as well as different session formats. These therapies should be contextualized within the broader treatment plan and involve preparation and integration processes before and after.

Although recent clinical trials have been implemented in highly clinical settings, I believe it is critical to incorporate ceremonial context in this proposed model for several reasons, including to generate an evidence base around the ceremonial use of psychedelic medicines.

Collaboration with indigenous healers, group and family therapy, medicines, art, music and nature therapy, and social, economic and political engagement and empowerment may be useful in psychedelic psychotherapy.

A hybrid outpatient and residential facility would be structured to facilitate therapeutic experiences in nature and would utilize principles of “biophilic design” to incorporate natural elements into the aesthetic of the clinic.

A clinic using psychedelic substances and plants could be implemented in contexts where they are illegal by conducting clinical work exclusively through research protocols.

Knowledge Generation and Dissemination Across Paradigms

The clinic would use an interdisciplinary approach to generate and share knowledge, and would be guided by core values of reflexivity, transparency, and openness.

The clinic’s central aim is to implement and study an integrative treatment model based on the psychedelic model of healing, and its primary research objective is to conduct outcomes-oriented clinical research aiming to demonstrate the effectiveness of the model. The outcomes research proposed here would center on the model of care, not the substance, and would involve observing patients and then randomizing them to either the psychedelic model of care or conventional psychiatric care.

This form of outcomes research would demonstrate the safety and efficacy of psychedelic substances and plants, and could pave the way for their use in legal contexts.

While treating patients and collecting outcomes data, the clinic could simultaneously collect real-time data on treatment variables, set variables, and setting variables. This would allow for the refinement of the treatment model and increase the quality of evidence behind psychedelic therapy.

As a clinic founded on paradigm integration, qualitative and participatory forms of research would complement quantitative empirical research in order to understand the subjective experience of treatments and identify areas for improvement.

The clinic would aim to engage in research that furthers its mission of paradigm integration, such as research into the neurobiology of consciousness and non-ordinary states. This would help open up the neurobiology of consciousness as a legitimate treatment target.

A model clinic would seek to engage in critical dialogue with shamans, academics, policymakers, and other stakeholders, and would seek to rethink its design, practices, and protocols based on feedback and critique, and to advance understandings of the uses of psychedelics and plant medicines more generally.

A psychedelic clinic’s final aspect of its mission would be to promote indigenous rights, environmental justice, and drug policy reform.

Conclusion

This chapter has discussed how psychedelic substances can be used to treat mental health issues in a more holistic way, by bringing into focus our profound existential condition as impermanent beings intimately connected with all other forms of life, matter, and energy.

The model clinic proposed here would integrate different healing modalities and modes of knowledge generation in order to bring about deep healing.