Psychedelics Use Outside of the Clinical Setting

Saundra Jain, MA, PsyD, LPC, adjunct clinical affiliate, University of Austin School of Nursing, Austin, Texas, presented a session at the 2021 Sana Symposium, entitled "Working With Patients Who Use Psychadelics Outside the Clinical Setting," in which she discusses the best path forward and "what could potentially be a clinical dilemma or possibly a clinical opportunity."

Her session takes a deeper dive into psychedelic-assisted therapy as it pertains to the client-patient relationship; 5 options for clinicians to best serve their patients; and the resources available to clinicians for those 5 options.

Read the transcript:

Dr Saundra Jain:  Hi, everyone. I'm so glad you joined me today. Let me start by asking you this question. As a practicing clinician, have you yet had your patients ask you about psychedelics?

Maybe they want to know if you're in support of it. They want your opinion about it. Maybe they want to have a psychedelic experience and have asked you for your help in connecting them with someone. The questions are varied.

If you haven't been asked those questions yet, let me share with you. Based on the research, based on everything that's appearing across social media, in mainstream media, the documentaries that are now available, if you haven't been asked those questions yet, rest assured, you most likely will be in the very near future. Where does that leave us as clinicians?

These plant-based substances, the synthetics, they are schedule 1. They are illegal. We must consider what is our best path forward.

I would suggest this, that we take the rest of our time together today and talk about what could potentially be a clinical dilemma or possibly a clinical opportunity. Let's get started.

No disclosures to share. Learning objectives. Very straightforward, we're simply going to explore that current intersection between mental health and psychedelics. How that pertains to our relationships with our patients and their relationship with us.

During our time together, I'm going to offer 5 different options that we as clinicians can utilize to help us best serve our patients' needs. Then, with each of those options, I'll share a variety of resources.

Let's think about this. I know that, as a clinician, all of my colleagues and friends who joined us today, we take care of patients who sometimes just don't get better, or they respond to treatment, but it doesn't stick. These are difficult patients to take care of. They struggle a lot.

In that process, it's no surprise that many are willing to step outside of mainstream treatment to try to find relief. I would offer this, that we know that psychedelics were scheduled in the early 1970s, and in that process, everything went underground.

Even today, we refer to practitioners in that space as underground sitters, guides, facilitators, therapists. The language varies a little bit.

As I began preparing for today's presentation, I thought about what you see here on the slide, prohibition from the 1920s, and I wondered, "OK. How well did that really work?" I ran across this quote that I want to share with all of you. "For every prohibition you create, you also create an underground."

As we think about this conversation with our patients, I want to present it to you from this point of view—3 windows into psychedelics. Let me just share that with you. There's some overlap between the windows, but I do believe that we as clinicians approach the conversation about psychedelics the same way as our patients do.

We either come to it from a place of support or a place of opposition. We're not in agreement. Of course, overlap between the 2, some uncertainty, is a possible window as well. I would say this. Whether we come to the table from support or from opposition, don't forget about that third window into psychedelics, which is curiosity.

I would go so far, my friends, as to call it radical curiosity, that if we approach the conversation, no matter what our position. Just interested in what our patients bring to the conversation, we're in a better place.

What can we expect? This is silly, but it does portray. Our patients are going to knock on our doors. They're going to come into our offices, and we all know that they are going to have lots and lots of questions.

The dilemma that we as clinicians may potentially face is this. You can see this graphic. We have ongoing, trusting relationships and dialogues with our patients, that therapeutic relationship.

In the space of psychedelics, we may hear these questions. "I'm interested in taking a psychedelic substance. I've read the studies. Can you give me a psychedelic substance, or you can help me find some?"

Here's a potential response from us as clinicians. "No. I can't help you with this. What you're asking for is illegal. As a therapist, my number one concern is being mindful of any risks for us both."

I would say this. This is really about us as clinicians deciding on the risk/benefit. How much risk are we willing to take when we engage in this conversation? I'm hoping that in the time that we have left today, this is what we're going to address. How we may be best prepared for this conversation.

As we approach what may be potentially a dilemma, or I'm going to go with a clinical opportunity, I love this Walt Whitman quote. "Be curious, not judgmental." Think about it. If we as clinicians come to the conversation. We're not certain, but we're leaning towards opposition. We've not decided yet.

We may inadvertently convey some judgment. When our patients say, "Hey, what do you think about this?" I love Walt Whitlam's saying. Let's be curious. Avoid the judgement. What I believe is if we go back to that window of opportunity into psychedelics, the one of curiosity, we can listen openly, we can learn together, and we can grow together.

I ran across this from Albert Einstein. I loved it. I had to share it with you. I think most of us when we think of him, we think of genius, quite remarkable. Listen what he tells all of us. "I have no special talent. I am only passionately curious." I had to share that with all of you.

Again, no matter which window into psychedelics you're approaching this conversation from, please remember, caution is the rule. Be prepared. Consider how you want to handle the conversation before it happens.

Always keep in mind. Other than ketamine, which you're going to learn a lot about during Sana, these substances are still illegal.

Let me share with you that in our clinical work we've done or we're doing an online anonymous survey in the space of psychedelics and wellness.

In the process of doing this online anonymous survey, we've received many, many emails from participants who have reached out. I want you to know. I know you already know this, but the need is great. There are many personal stories of tragedy. If I may, if I could share, I'll select one from this list of 3.

Here's one story, partially edited, from a veteran. "Multiple IED blast. Best friend shot in the head standing next to me. Many years, no treatment at all." You can take a look at the other 2. They are the common stories that we hear from our patients.

The question that we're all confronted with is what can we, as clinicians, offer? That's where we turn to the 5 options that I mentioned earlier. How can we help our patients when these questions surface? Here's the first option, join a clinical trial.

We must give credit to those who paved the way. The forerunners if you will, in the world of clinical trials. Here, you see academic institutions, corporations, we see different organizations. This is not an exhaustive list. There are others.

Just to give you some idea of those who have invested lots of time, energy, money, to bring evidence-based data to all of us. We also have to say that the history is far-reaching. It reaches long before clinical trials were on the scene.

This is a beautiful graphic. I do realize it's difficult to see. I would encourage you to click on that link and check it out because in larger format, it's quite impressive. You can see some of the things that they're sharing with us that clearly tell us psychedelics have been part of the human experience for a very long time.

An archaeologist has shown through fossil evidence that psychedelic medicines have been part of the human experience for 10,000 plus more years in ritual ceremonies. Here's another person we're all familiar with. A renowned mystic and psychonaut Terence McKenna. He has an interesting theory of his own, which he calls the stoned ape theory.

This is what he's proposing or what he proposed. That the evolutionary leap between the Homo erectus and Homo sapiens was a result of a surprising addition to the human diet. That was magic mushrooms.

I would encourage you if you're not familiar with this theory, read about it. Then you'll have to decide on your own what you believe. It's important for us as clinicians that we do know what's happening.

Here, you see a sampling of research that's ongoing in the US as well as in Europe. Be familiar with that. These conversations will come up.

I would strongly encourage you, check out clinicaltrials.gov. Not that it's better. It is where most of us as researchers are registering our ongoing clinical trials. Be sure. Survey the landscape. Here's another resource, psychedelic.support, where you can go in and research different psychedelic clinical trials, their database, they've put together.

You can research the substance, the condition, the status of the trial. They offer it in list format, which I think is a little bit boring. I love the way they portrayed it here as a resource. Each of the different color bubbles that you see on the map indicate a different research study. You can click on that and learn all the details.

Let's go to option 2, psychedelic integration. This is where meaning-making happens. This is what happens after the psychedelic experience. Let's talk about it briefly. Many of us believe that through the psychedelic integration process, that this is where cementing of the actual experience occurs.

You can see basic definition of integration. I won't go through that. I love the graphic. I love this animation. Many report that during psychedelic experiences, there are little puzzle pieces or little bits of information that will bubble up. Sometimes during that experience, it's hard to make sense of it.

The psychedelic integration provides that safe space that work with someone else to create meaning out of these individual pieces. Honoring the experience. Refers to the process. This is a beautiful quote.

"By which the material that's accessed, the insights that are gained, and the entheogenic experience, they're incorporated over time into one's life in a way that benefits the individual and their community."

One more quote, if I may, from Alan Watts, a British writer, and speaker. Simply beautiful. "Strictly speaking, these drugs do not impart wisdom at all, any more than the microscope alone gives knowledge. They provide the raw materials of wisdom and are useful to the extent that the individual can integrate what they reveal into the whole pattern of behavior and the whole system of knowledge."

Honestly, there's not much more I could possibly add to that. Please, be familiar with different psychedelic integration resources now. Certainly, this is not an exhaustive list. I wanted you to see a sampling. Know that many of these sites, many of these organizations are offering provider databases. Great resources for all of us.

Let's talk about harm reduction. Please know that during Sana, the Zendo Project will be presenting a session on harm reduction. I'm going to quickly go through this because you've got a deep dive in that other session.

A basic definition. Reducing negative consequences associated with drug use. Also, this social justice movement to develop respect for the rights of people who use drugs. A little bit of history about harm reduction. I think it's important that the term was coined in the '80s. There were medical writings as far back in 1926.

Harm reduction is the antithesis, the opposite of just say no, zero tolerance, the war on drugs. Those abstinence-only approaches. Let me share this with you. I will say this before I do. This is only one person's opinion, a journalist.

They say, "The US government must stand down and loosen these legal barriers to research and treatment with psychedelics, or else it directly harms thousands of patients, both in the US and across the world each year." Maybe you agree and maybe you don't. In doing this research, I ran across this the statement, "Know where you stand knowingly."

Honestly, no matter which window into psychedelics you approach this conversation from, support, opposition, I'm not sure, curiosity. Knowing where you stand. Be clear on your previous experiences. Know what you bring to the table for this conversation.

Know the harm reduction resources. I have several listed here. Zendo Project already mentioned Erowid dance site. Fireside Project is a very cool helpline for people who may be currently in the throes of having a difficult experience or post the experience they're having trouble with the meaning-making. It is a free resource where people can call in and have someone available to help them.

Here, I couldn't not share with you the 4 tenets of psychedelic harm reduction from the Zendo Project because they're just beautiful. Create a safe space. It's about sitting, not guiding. Talk through, not down. Remember, difficult is not the same as bad.

Tips for us as clinicians, takeaways that I think are critical. Know the law. Know what's happening in your state. You may want to consult an attorney to help you understand what's going on. Know what your license board, what their position is.

Know your context. Do you live and practice in a conservative or liberal setting? Be sure to know how much risk you're willing to take individually. I love the last one. Be educated and prepared. Seek out consultation, education, stay current and find a mentor or mentors.

Let's look at option number 4. Legal psychedelics. Let's talk about ketamine, psychedelic tourism, as well as churches as options. Ketamine. Again, during Sana, you're going to have access to some top-notch education about ketamine, which is the only legal psychedelic at this point.

Ketamine is not a classic psychedelic, as I know you're aware of. It is not a 5HT2A agonist like psilocybin and LSD. It, in fact, is an NMDA receptor agonist. Know this, it can produce mystical experiences. It's also FDA-approved for TRD. There's off-label use for several mental health conditions.

Then the various routes of administration, which you'll learn more about in other sessions during Sana. Please, know the landscape. There are so many trainings about ketamine. Not only ketamine but also, this form of psychotherapy that is specific to ketamine, which is called KAP. Ketamine-assisted psychotherapy.

I've provided for you a number of different groups that are offering top-notch education and training for KAP certification. If you're not familiar with that, but the work in the psychedelic space speaks to you, but you want to do it in a legal setting, outside of clinical trials, ketamine is the path forward at this point.

I hope these resources will be helpful to you. Now, what about psychedelic tourism? We know this is alive and well. I want you to know, I had a colleague text me last week, a story from I believe it was the "Bloomberg Business Wire," an online magazine.

It was an article about psychedelic tourism and the title was something like this. "All-Inclusive Magic Mushroom Retreats, The New Luxury Trip." Great marketing, but this is what our patients are reading about, and it's what they're going to be asking us about.

The question is this, keeping in mind, illegal substances, but they are legal in other parts of the world. When our patients come to us and ask, "Hey, do you know about this retreat center?" Or, "I'd like to go to a retreat center. A friend of mine just came back. Do you know about a specific one? Is there one you would recommend?"

We must be prepared in advance for these questions. The best advice I can give you, and the advice that I follow myself is this. Tread lightly and proceed with caution. Be fully aware of how much risk you as an individual, as a clinician are willing to shoulder.

The challenge, the worry is this, that we make a recommendation or we're supportive of our patients following the route of psychedelic tourism. What happens if they go there and something bad occurs while they're at the retreat center? What is our legal liability? This is a clinical dilemma. We do want to help our patients, particularly those who are really suffering.

There is this tug at the heart to help them and to tell them what we know and to be honest and connect them in any way we can with resources. This one, we may want to step back and reconsider. Again, I think the question that will be a deciding factor is, how much risk are we willing to shoulder?

Here are the risks, some of them, not all, that are associated with psychedelic retreat centers, but the potency and purity of the medicine is unknown. If you haven't read, please know the articles and the accounts of sexual assault have happened and had been written about.

It's important that our patients be aware of that, and that we know about it. This one got my attention, accessibility due to high cost. These are not moderately priced retreats, they are quite expensive. It's not available to everyone. We also must keep in mind, reciprocity, sustainability issues.

We've already talked about permission liability. For some reason, I'm not sure my friends why I listed cost for 2 bullet points. Probably because it just caught me off guard, when I really started digging in and looking at the associated cost.

I actually ran across one retreat center that offered an 18-month residence, which to me, that's a very long time. Pricing for those retreats started at $30,000. Something to keep in mind. Then also, we want to be aware, we want to know, we want our patients to know to research and be aware of what is their protocol.

What are the credentials of the people who own the retreat centers who are running the retreat centers, their training, etc.? As clinicians, we always want to be informed no matter what disease state we're dealing with.

In psychedelic tourism, I want you to know, there are platforms where you can go in. Here's an example of one. Retreat Guru.

You can put in the country, you can put in information about the psychedelic substance that you're interested in. You can search for sites, different locations. It's quite remarkable because it really mirrors. If you were planning a trip to Hawaii and you went to KAYAK.

Just be aware that there are platforms like this, that our patients are visiting and checking out what's available. Finally, the legal path via a church. I want you to know that in the United States, there are three different churches. You can see them here.

I would encourage you, check into each one, read about them, because again, our patients, my patients, they know about each and every one of these. They are recognized in the United States as legitimate churches, and they use different psychedelic substances as part of their religious sacraments.

Then option 5, other past and non-ordinary states of consciousness. Until FDA makes a ruling about approval for these psychedelics, we are in a bit of a holding pattern, it's quite uncertain. Just be aware, there are other paths to non-ordinary states of consciousness, including breath work, and also meditation.

I love the title of this slide because it seems so true in most situations. All roads lead to Rome. There are other options available, and we just want our patients to know about it. With that said, I thank you for your kind attention and joining me today to have this conversation about how do we handle these conversations when our patients bring these questions to our office.

I hope that our time together, I hope you've found it interesting, useful. I hope it piqued your curiosity, and that we're all going to lean in with radical curiosity moving forward. I'm very excited to join you in a moment for live Q&A. I'll see you there shortly.