Horizons 2010: JEFFREY GUSS MD "The NYU Psilocybin Cancer Anxiety Research Project’s Psychedelic…"

Horizons 2010: JEFFREY GUSS MD "The NYU Psilocybin Cancer Anxiety Research Project’s Psychedelic..."



I am thanks so much for having me here today to talk about the NYU training program in psychedelic psychotherapy I want to thank that Kevin and Neil for bringing everyone here together and all the people that have helped in this and also all the therapists and other people at NYU that have contributed to our program I'm going to talk today about a training program that's affiliated with an academic research program and working with people who have cancer so this is not a talk about training to become a psychedelic psychotherapist for a broad population of people or for a non clinical and non research population we trained to do a very specific thing in a very specific setting I'm Jeffery Gus I am an investigator and the director of psychedelic psychotherapy training at the NYU psilocybin in cancer anxiety project today I'm going to divide my talk into three sections the first is a little bit of a overview and the thought piece about what psychedelic psychotherapy is who does it how people train to become one and where it is in our Western culture the second is the structure of the NYU training program and the third and last part the goals of the training program you might think that the goals would come first but actually the goals for the training program evolved over the first year that we were doing the training and doing the research because it wasn't entirely clear what we needed to learn and what we needed to do until we actually started to do it with subjects so to begin who does psychedelic psychotherapy today what happens for a therapist and a patient during a psychedelic psychotherapy session and what are the theories are there theories that we could say underlie a psychedelic psychotherapy process and what does the person do in order to become one so in thinking about how to address this question I just decided to work with four different kinds of therapists or people who engage in a therapeutic way with participants or subjects or seekers or individuals that offer some kind of psychedelic psychotherapy and there are four categories that I'd like to talk about the shaman the Neo shaman the meditation adept and the palliative care psychotherapist or the psychodynamic psychotherapists I'm going to talk about each category and each one of these categories as I'm sure the people in this room know is a very diverse complicated group of people and it's really wrong to say hey shamans are this way or neo shamans are that way so I'm going to offer some generalizations which may even sound like stereotypes to some people but I ask you to bear with me because I'm going to try to bring out some principles about what it is that we are training people to do at NYU the limitations that we have the opportunities that we have and how we are different and in some ways similar to each of these four categories shamanism is humankind's earliest as longest-lasting healing psychotherapeutic and religious tradition the core function and one of the core theories underlying shamanism is communication with the spirit world the shaman interacts with unseen mysterious forces so right off the bat we have a kind of discourse which is prohibited in Western medical settings if you say to someone I want to help this patient by giving them this medicine or I'm going to take this medicine which is going to allow me into their into the spirit world or I can communicate with spirits and help solve their problem you're not going to get very far you're not going to get any referrals and you're really going to be considered to be not even a fringe player in an academic medical setting you're going to be considered a kook and you're not going to be taken seriously and I'm going to repeat again and again we are an academic research program in a medical setting we have our little a place that we've that we've landed and we're trying very hard to make certain that we continue to be welcomed and taken seriously in that setting so we can't be all things to all people and I think that there are certainly ways that some psychedelic psychotherapists would say what we're doing is you know misses the mark in terms of what the general practice would be but we're doing what we're doing where we're doing it the shaman enters a trance state in an altered state of consciousness sometimes with the drug other times without the shaman experiences soul or soul or spirit leaving the body and journeying into other realms and this is quite a literal use of language within shamanism that the soul leaves journeys does something communicates it doesn't make some kind of a deal negotiates or retrieves the soul and brings it back the shaman commands intercedes and communion with spirits for the benefit of the individual or possibly for the tribe so again we're quite distant from the way the Western medicine thinks about psychotherapy and particular medical therapy there is a commonality though between the shaman and the psychoanalyst both suffer from a malady which is defined by and cured by a particular practice everybody who becomes a psychoanalyst has a condition which is by definition if not healed certainly treated and ameliorated by the practice that the psychoanalyst is learning himself or herself and the same is true for the shaman so the shaman and the psychoanalyst shared the wounded healer paradigm I had many many slides before this one and in the interest of time I paired them down but I wanted to include this one because it brings quite a profound aspect to bear which I'm going to talk about through today's talk and that is a culmination of the shamanic quest shamanic training program is a very extensive program usually takes a number of years occasionally it's brief but commonly takes a number of years there was a confrontation with death and this is experience quite literally as a death of the individual a death of the soul a death of the body with transformation and rebirth these themes are not heard very often in how medicines work with people who are suffering from anxiety but for the NYU therapists our training involved turning our attention to the theme of death and transformation again and again and again because so much in our psychotherapy training we think of the patient as leaving us and having a long life to live leaving us with a open-ended potential for using what they've learned and using the transformations that have happened to them in our work but in order to be therapists in this study we had to learn to face death think about our own death and think in a very unblinking way about the deaths of people who came to us for help and people who had cancer now don't need to tell people in this room that they're often our psychedelic plants that are part of shamanic training the training may involve taking psychedelic medicines and may involve taking a lot of psychedelic medicines and the practice may be either I mean the sacrament the psychedelic may be taken by the shaman or the patient or both in the healing process and there was already has been a question about who takes the substance and who knows what in shamanism sometimes the shaman sometimes the patient take the medicine but certainly in training the shaman takes it a similarity between shamanic training and Western training is that there are culturally bound narratives of illness and healing in other words a shaman may be a marginal figure in society but they are a well-recognized figure like a neurosurgeon not that many people actually go to a neurosurgeon but we all know what a neurosurgeon is we know what a certain neurosurgeon does and there might come a time in which we need one so it's actually a fringe person in most people's lives but a idea or some presence in lives and again there's a highly ritualized strong respect for tradition in secular shamanism plants coops are considered gift of the Gods they're either the mediator between human beings and gods or the the psychedelic plant maybe the God itself or himself or herself and the plants contain spirit power in psyche in psychedelic research in psychiatric research molecules are considered inert substances they're dangerous they are in danger we have an 800 pound safe that protects the psilocybin in our study and it's always curious to me like whether it's protected it's being protected from us or we're being protected from it but we've one case or another this huge safe is required to keep this tiny bottle of medicine and in that's the way it is on First Avenue 26th Street but in other places they grow out you know in the wild for anybody who wants to go pick them and take them so this is a summary of what the indigenous shaman brings the neo shaman is somebody who's more member of a contemporary Western society and the cortex tonio shamanism is Michael Horner's the way of the shaman the neo shamanic beliefs include direct contact with the spirit world including entering altered states through psychedelic medicines there's skepticism towards monotheistic religions there's skepticism towards traditional allopathic medicine in particular psychiatry and usually a good bit of skepticism towards the scientific method as a way of knowing the psychedelic sitter or the neo shaman is generally naturally emerging self selected as opposed to a shaman who is sort of selected by the community or whose qualities as a shaman are emergent and there isn't always a voluntary choice for each person that's called into shamanism the validity to function is in the OR shaman or a psychedelic sitter is based on personal experience with psychedelics and often a little more and there is a lack of a formal widely accepted culturally bound apprenticeship process the Neo shaman is often allied with the yoga chakra healing Chinese medicine or acupuncture astrology or a broad variety of other non traditional healing mechanisms the new shaman or the psychedelic sitter is a culturally bound a culturally deviant identity if you are a psychedelic sitter you may be able to talk about that in a room like this but there are many many worlds in which if you talk about that you're going to be held in question and I like this picture because you know this woman could be at Burning Man in a tent or she could be a junior league a participant or she could be both and she could be a psychedelic sitter and a neo shaman you can't tell by looking at her and in most shamanic in most cultures that have shamanism as a central healing mechanism the shaman is not a hidden identity we have a bridge between neo shamanism in psychiatry and that is stan grof well I thought I'd put his two books in looks like I didn't and Stan Grof varieties are very very interesting and he brings forward the idea of death and rebirth his perinatal matrices being in the womb the contractions prior to birth enter exiting through the birth canal and then being born apply in a metaphorical way to four discreet processes in human transformation that he that he uses when he does psychedelic work but again we see the theme of death and rebirth coming forward being a neo shaman is a prohibited discourse in medical circles in other words you really can't talk about being a psychedelic sitter if you want to be taken seriously as an academic researcher or as a participant in academic research and this is one of my pet peeves if you get the pun this is a PET scan it's much more comfortable for people to think about scans like this although it by opinion a PET scan is just the slightest bit less metaphoric about how the mind works then chakra healing or acupuncture meridians so then we have a review of near shamans mindfulness the mindfulness adept or the meditation practitioner the meditation teacher offers something very specific that we used in our study and that is the skill of mindfulness meditation teaches a technique for developing mindfulness which is characterized by two main qualities the self-regulation of attention and the focus on the immediate experience the focus on the immediate experience carries with it a particular kind of orientation and that is an orientation of curiosity openness and acceptance working against the absence of curiosity oh I've already seen that I already know that openness no I don't want to feel that and acceptance no I can't bear feeling that each one of these habits of mind is countered through the technique of mindfulness mindfulness is not listening out and having only good thoughts it is a kind of a relationship with one's own thoughts and this is a central technique that the therapist uses in the research program mindfulness is a core practice in our medically based psychedelic psychotherapy the mindfulness practitioner recognizes that altered states of consciousness have a capacity to facilitate a transformation however in many advanced meditative practices there is a deep skepticism of drug-induced altered states of consciousness as less legitimate as not leading to a religious life just a religious experience and just being not kosher in some important ways so this is a review of some of the qualities of mindfulness and the same and the fourth I'm going to talk about is the palliative care therapist and the psychodynamic therapists we have in our study three two-hour preparatory sessions before the first psychedelic or placebo session then there's seven weeks during which there's six more hours of therapy and after the second session another six hours and we had to come up with some clarity about what we were going to do during all that time when we were working with people with cancer related anxiety and if you look at the palliative care literature one of the core processes that is in addition to mindfulness is the development of meanings and narratives regarding illness cancer and death and this is it was a great asset when I discovered it in the palliative care literature because it was new to me when I started working with this project there is a similarity between the original radical idea of psychoanalysis that Freud brought it has been so changed and so so so developed in so many different ways that some people forget that Freud's hovering free-floating attention is actually quite similar to the meditative mindfulness but I spoke about you know just a couple of minutes ago also in Freud's original psychoanalysis there was a search for truth authenticity noetic awareness and surrender and noetic awareness of the truth is knowing and feeling the truth without a need for objective proof or external validation mindfulness in palliative care anchors the individual in reality in immediacy and groundlessness which includes the inevitability of change letting go and the tolerance of intense emotions one of the qualities between palliative care and psychoanalytic therapy shamanism is the intense focus on self observation by the therapists of their own feelings thoughts breath and bodily sensation in terms of maintaining presence and also being able to be most therapeutic to the patient the therapists own psychotherapy is an integral part of the training process and importantly this is quite consistent with Western medical ethical norms and standards and is easily accepted and we have a two slides of review so I'm gonna go on to talk about the structure of the program I modeled the the training program on the psychoanalytic training which is composed of three essential components the first is I'd active coursework in psychoanalytic training you have years of articles chapters books and discussion studying the writings of other people you have three four or five carefully supervised control cases and a personal psychoanalysis so if you think about modeling psychedelic psychotherapy training on this we have a problem the problem is that personal work with psychedelic medicines in a supervised regulated way is not something which at this stage in the evolution of the psychedelic research Renaissance that we can have there is no legitimate way that we can require therapists to undergo psychedelic psychotherapy and really no legitimate way in which we can even talk about it so it is a prohibited discourse and all I can say is that it leaves this aspect of our training program incomplete there are some substitutes that we considered we couldn't have encouraged our therapists to undergo secret and theage and experience and not talk about it and that seems really bogus to me we talked about holotropic breathwork but this is not really the same thing as psychedelic work and we wanted our therapists to feel free to pursue whatever kinds of meditative spiritual transformative experiences that they chose to pursue their own spiritual path and not set a certain kind of standard for what it should be also as I'm sure many of you know in August 2010 Maps was successful in developing a program by which the therapists in an MDMA study for PTSD were will be allowed to take MDMA as part of their training as a study program looking at the psychological effects on healthy volunteers but this is really not part of our agenda at NYU at this time so I thought about what I might substitute for it and what I found what I developed actually doesn't really substitute for direct experience with psychedelics in terms of what that might offer therapists but it does offer something which I think is of real value to people and that is the experiential Diet sessions now some of you may know but all you may not know that the therapy that we do with with subjects in the study is done by Sarah teams each person in our study is assigned a therapy diet usually that's been a male/female diet although we say we have had a male-male diet and we wondered what the communication process with the development process for the therapy diet you know should look like and would be so I developed these dyadic sessions and so this well this is an overview of the three components of the nyu training program didactic reading classes articles the experienced retired sessions and supervision and I'll talk about each of these individually the didactic first the didactic coursework occurred over a nine-month period all the therapists participated in it there are 18 sessions over about nine months for many of us it was a crash course in sight in palliative care psychotherapy only tawny bosses who is a palliative care specialist and a pain medicine specialist had been working with individuals who have cancer who have pain and so he was well experienced in palliative care but it was new for all the rest of us and it was a quite eye-opening to me to study palliative care to find articles that I thought would allow the therapists to quickly get up to get up to speed in the methods techniques and theory for it we read one academic journal article or book of procession and in class we talked about how to apply what we were learning about palliative care therapy to what we imagine psychedelic therapy would be because our training occurred before we actually had started working with our subjects and it happened here in our study room so we started reading our abhi ox article the meaning and value of deaths and this is actually one of the most moving and touching sessions I think that we had this brought forward so many reactions in the therapists of things that we had not thought about not talked about and discovered that we had in a way like so many other therapists had a subtle and maybe not so subtle denial of the impact and meaning of death or our own death the death of our said of our patient and the roll of death and the denial of death in the therapy that we do I had never learned to take a spiritual history and so we read a couple of articles on that in particular Christina for Chomsky's article on spirituality and the care of patients at the end of life and we each practiced doing spiritual histories and taking them on one another we read bill Breitbart article which gave a very nice introduction to existential psychotherapy with his focus on freedom and death at the denial of freedom and death as well as logotherapy by Victor Frankl we studied the historical perspectives on the work that we're doing reading stan grof and Joan Halifax chapter the history of psychedelic therapy with the dying and Peggy's classic article a psychedelic mystical experience in the human encounter with death there was a number of interesting articles that we read that I looked at and this is one of the best looking at spontaneously occurring or evoke mystical experiences with people who have cancer and Ellison vitta I think is how you should pronounce this her name works in palliative care does not work with psychedelics but looked at spontaneously occurring and evoked mystical experiences with people who have cancer trying to help figure out what makes them happen what facilitates them what shuts them down and most importantly what's important about integrating them into the overall psycho therapeutic approach to the individual with cancer we studied mindfulness and breathing practices again this article by an Bruce focuses not just on learning how to teach a breathing practice to your patient but how to participate yourself in the palliative care work as a form of meditation tracking your own awareness and mindfulness as well as that of your patient and realizing that the separation between your mindfulness and your attention to your patients mindfulness that the barrier between subject and object you know begins to break down and I think we see here a bit of a connection to the breakdown between the subject and object that we saw in traditional indigenous shamanism when I studied palliative care about a third of the articles that I found or about burnout and I learned how quickly people who practice palliative care burnout and find the work unbearable there are a lot of articles about preventing burnout and how to maintain yourself as a practitioner in order to figure out what to do during those long sessions I mean those long therapy sessions in between the first and second experimental medicine sessions we used two forms of therapy two kinds of structured therapy one meaning-making therapy and the other life review therapy both of these helped look at the person's life as a whole beginning with birth moving to cancer and then when that a person imagines their death is going to occur looking at how they coped goals disappointments strengths coping strategies vulnerabilities creating a new and different narrative about this to help the person cope with both their present and what they were going to do with the the remainder of their life and the life review interviewing guide by Beecham was a really great article and really really interesting in terms of how to work with the stories that were being given not just to hit take them in in a kind of empathic attunement to them but also how to work with them and give something back to the to the patient or the subject that really felt useful and creative and not simply holding what they were telling you we had some guest lecturers bill Richards from Johns Hopkins came and spent a weekend with us and we still refer to the notes from from that weekend is really quite a brilliant and moving and touching experience spending time with him I learned a great deal about how to conduct the sessions how to interpret what happens how to deal with problems how to prepare ourselves for it was really a great inspiring experience Scott Kellogg from the Department of Psychology at NYU gave us a talk on transformational chair work and Oliver Williams and Emily Horowitz gave us a guest lecture on holotropic breathwork so next I'm going to talk about the experiential dyad sessions there were six experiential dyad sessions there are eight therapists in the study there are four diets and each dyad was was fixed they were invited and actually required to complete these six sessions the sessions lasted one I have two two hours and only the therapists were present during the experience with Diet sessions each session had a had a defined theme although a free-flowing discussion occurred afterwards after between the beginning with the theme of the session and we certainly did in mind and I think it did in other people's diets too after the third and the sixth session there was supervision with the person who was designated to be the supervisor I was not the supervisor for all of the Dhyana processes because there was just too many too much supervision to do and we felt that it'd be useful for people to talk you know in a way that felt comfortable and in a structure that was had some flexibility for who wanted to work with whom the goal of the dyad sessions was to establish a close communication and close connection between the therapists and to discover similarities and differences not just in their Theory creative styles but also what they what they thought and felt about the afterlife about heaven and hell and so forth you know I when I was selecting the pictures for this I didn't think that much about this particular one and it seemed a little cutesy but just last night when I was reviewing my notes I I noticed that you know when you played this game of speaking with a tin can who's listening and who is speaking is very well defined these people cannot have a you know a conversation who's listening and who speaking is defined and this actually was one of the ways that the sessions were so I invited the therapist to speak as if they were the patient or the subject I keep calling the patient the subject in the study talking about their internal experience and for the other to function as a therapist and practice kind of active listening skills that we were going to be using with our subject the first session was about early memories as well as contemporary experiences of death and losses I invited people to talk about whether as a child they had family members that died pets friends patients parents that had died also early memories of awareness that you yourself are going to die when that first came about and the reaction or the defense or the denial or whatever it is that came up around that really frightening awareness the second session was to talk about experiences with profound spiritual mystical States and entheogen experiences now many of the people in the room here will probably easily recognize what this is a picture of these are people from North America or Europe who have traveled to South America to engage in ayahuasca retreat and have experienced with that that sacrament and in that that healing system this was a place in the privacy of the dyad sessions people were free to talk about what they had done what they had not done but they were afraid of what they wanted what they didn't have what they did have so that this in this you know private and confidential setting there was a freedom to be quite open I also invited each therapist to talk about their experiences as a sitter if they had done psychedelic therapy with people or if they had experienced them psychedelics and work with the sitter what that was like what they didn't like how it worked how they understood it and how their role in the study was different or similar to what they experienced themselves and also to talk about you know where they work with shamans the third session the therapists were invited to talk about their experience of pain and suffering and family members friends and patients this is different from death and loss this is about being in the presence of ongoing anguish pain and suffering also for each person to talk about experiences with their own cancer or family members or friends patients that had cancer or other terminal conditions as well as disfigurement and body failure I have not been worked had not worked in the inpatient unit for many many years before working with this and although in my medical training and in my residency I saw a lot of very very sick people it had been a long time since I've been with somebody who was really quite ill and often as a doctor when you work with somebody who's really quite ill there is a technological or diagnostic or or treatment intervention that stands between you and real empathic immersion with what the patient is going through you're prescribing something you're relieving pain with the pill you're diagnosing what's making him hurt so much in trying to relieve it and the the job of empathic immersion with your subject who might be in agony or and some kind of anguish required a kind of tolerance that brought a new sort of brought a new a challenge to me and I think a number of the the therapists in the study the fourth session was focused on near-death experiences whether the therapist had ever had a suicide attempt or had suicidal ideation whether they had in their spiritual practice had ever had experience of dying body d'etat t decomposition and transformation including these experiences that might have occurred through entheogen also I encouraged people to talk about being ill or having an accident or having any kind of near-death experience so that the the the therapist would know what the what their partner was really about when it comes to these real life-and-death issues the fifth session was devoted to personal beliefs about heaven some of our therapists believed quite literally in a certain kind of afterlife others had absolutely no belief or no sense that any conscious the consciousness lives on in any way after you know we stopped living encouraged them to talk about their religious history work that they'd done with religious or deeply spiritual patients and what happened to them growing up whether they were alienated or estranged or perhaps even it's still a deep practitioner of some kind of organized religion and the succession was devoted to personal experiences with extreme emotional states during psychotherapy whether we had the therapist and work with people who are terrorized grief-stricken rageful people who had bizarre altered somatic state somatic elucidation z– or agitated states and experiences and friends loved ones family members that had been in such states we did not experience this we really anticipated that there might be quite quite extreme behavior coming from the subject in the study and there certainly has been crying fear anger a lot of intense emotion but we've not had any disruptive experiences which in any way felt you know anxiety provoking to the therapist and it's quite the contrary the emotional outbursts have been deeply moving and really I think very healing for the for the subjects and really profound for the therapists as well so the lived experience of the experiential dyad sessions the topics that I set up were really just a starting off point and people went in all different directions in their diet sessions the supervision was necessary in order to track how the dyad was doing and whether they were progressing along and what was required but there was a subtle intrusiveness I think at times by the suit okay by the supervisor and it does not adequately parallel the personal analysis that simple the psychoanalytic training so I'm going to close by reviewing the goals of the training program the first goal developing core competence in the methods of tally ative care psychotherapy in individuals with advanced cancer the second developing a close trusting flexible bond between the co theorists third the development of the capacity to support a mystical or spiritual experience in the subject and relate these to the illness and the mortality that's facing the individual this was really something quite new for me although I had I have been involved in spiritual practice for a long time working with it in patients and applying it to transformation in their life was something that was new for me something with for which I'd had a kind of distance in terms of the practice that I had of psychotherapy and what I was doing myself learning how to recognize it and support it in patients and use it creatively and like opened up a new way of talking and helping the patient and we had to not only learn how to do that but also related to cancer and the fact that the individual was going to be dying of cancer and perhaps in the near distance in the near future we wanted to develop skills and how to respond in a very specific way to difficult complicated or disruptive experiences we talked for long periods of time about touching whether it was right to touch someone or not touch them and we need to ask them for permission during the sessions and after all the talking that we did about it I think there's been a significant amount of hugging that's going on when people were in extreme states and I think that everybody is all the better for it so we developed these skills but I think that people did what came naturally in terms of caring about people when they were in in rough shape or in extreme states and it's not been it's not been a big problem the one other goal was to integrate personal experiences with mystical States and your identity as a spiritual seeker or an entheogen user with your identity as a palliative care and transpersonal therapist there was a surprising amount of countertransference that emerged both in our work group and in sessions with actually it's not surprising that it occurred but there was a lot there there was a lot of it that occurred and we'd like to work with that and lastly developing acceptance of the restrictions imposed by the fact that this is a research protocol as I said at the beginning this is a training program in psychedelic psychotherapy for people with cancer in an academic research program there are many things that you would not do if this were outside of a research setting or if the individuals didn't have cancer so you know when you become a psychoanalyst you're free to go out and treat all kinds of people and you're not trained to be a psychoanalyst for this particular kind of condition but I wanted us to focus on what these subjects needed in this setting at this time and that's the the training program that that we developed there are a number of things that we had to do that felt intrusive into what would ideally be the most impactful II crafted psychedelic therapy session for patient there are also things that we that we couldn't do that we would would like to have done all of these had to be tailored in order to maintain the integrity of the research program because in a way we had we had subjects in our study but the most delicate the most fragile subject of all turns out to be the study itself the study itself requires a tremendous amount of caretaking tender loving care attention sometimes it seems like it almost needs life support to keep going because of all the challenges that come to it and so there's really not much not many days go by that we don't have to remember that we're not just psychedelic therapists we are researchers in an academic setting I brought a lot of this together in a training manual which has you know the didactic components the experiential components describe the preparatory sessions but the subject in the family the experiential of experimental sessions with the subjects and some guidelines on how to conduct integrator sessions with the subject and family so some long-term questions include questions that are the kind of things that are asked in departments of psychiatry and academic medicine whenever you offer a new form of therapy if you offer a new form of therapy you have to define what are the core processes that define that therapy what makes that a particular form of therapy that's distinct from other therapies is it possible to establish standards of practice you know that phrase may sound very boring and foreign to people who are not involved in academic research settings or academic training settings but it's all over the place and Department of Psychiatry how do you say okay this person is trained as a psychedelic psychotherapist and they've met the standards of practice they're doing what a competent psychedelic therapist should do and this person isn't this person is behaving outside those boundaries and setting those boundaries in deciding like who's meeting the making the cut and who's not is what training programs these are questions that you have to answer we need to think about whether kind of transference is understood in any way that's different than any other form of therapy our two therapists really necessary free for this process it's a male/female diet tradition one that's valid and should be maintained is it possible to evaluate the clinicians spiritual maturity you know we trained to be an analyst your supervisors will say yes this person seems to have that you know achieved an analytic process they know how to handle it and they're mature in an analytic way is it possible to say that about another person's spirituality because it seems to me that spiritual maturity should be a prerequisite of corrective but an accompaniment of being a psychedelic therapist a big question that intrigues me is how character structure affects response to psychedelics and psychedelic therapy and how do the therapists values and psychological orientation theories affect their work so as I guess you can see I really like looking at images and because I think that they convey some something that the words can't when I saw this picture I was really quite quite funny and captured something about the way that I think many people see see our program ours is not a sight a psilocybin research study it is a palliative care study that is assisted by one dose of psilocybin the person has to experimental sessions one is placebo and one is active drug so the concept that this is all about what happens inside this molecule is you know really not not accurate because there's so much work that happens with each subject that does not involve the actual ingestion of the substance on the other hand psilocybin pervades every aspect of the study it gives us the way to build a bridge and to enter a medical discourse with psilocybin on our lips to talk about it to bring up the topic to explain to doctors and nurses and social workers why we think this might be helpful to them we go into the most traditional of Western medical settings and talk about it so before I talked about a prohibited medical discourse this study is a way that we are making psilocybin and psychedelic therapy part of an accepted medical discourse so as I mentioned before there are very few actual encounters between the human being and the psychedelic agent and yet the spirit of the agent pervades all aspects of the of the process from the initial phone call throughout the entire process with us and even the follow up afterwards I also just found this this very funny slide last night and wondered whether the brain was generating God and Adam or God and Adam had generated the brain or whether these were just two among many metaphors that we can use to think about you know what happens up here but the goal of this project and the goal of the training is to bring together and to create a discourse between these two worlds the worlds of academic medicine and the world of psychedelic medicines in a particular the suffering that's caused by cancer death and dying and the themes of the altered narrative that we tried to bring to the subjects also I think have come about for all of the therapists in the study and that is the importance of having a sense of contribution to other people the importance of forgiveness and acceptance of each other and ourselves for all of the challenges and mistakes and hardships and difficulties that come our way the sacredness of life in each moment of life preparing for experiences of death and rebirth and a moment to moment appreciation of each moment of life and with that I'll bring it to a close [Applause] [Applause] questions thank you Jeff beautiful questions this my name is dr. Deborah Goldberg and a while ago and this board as a medical oncologist and I'm also a medical hypnotist so that's my framework and my I'm really glad you guys are doing this study I think it's really important that it be done but my question has to do with is psychoanalytic training in this whole thing a surrogate for maturity and discipline or is there something about psychoanalytic training that's really necessary that you in your opinion to be able to be somebody to evaluate this data to train somebody to to evaluate the psychoanalytic training a necessary part of looking how to do this kind of therapy we're using the testing the possibility of using psilocybin to treat cancer and near-death anxiety do you need the psychoanalytic training quad training or do you need it because you get the right people out of doing it that's really my question I think it's a great question I don't think you need psychoanalytic training per se but I do think that you need extensive training as a psychotherapist I think you need to know how to work with all kinds of people in all kinds of extreme states how to work with transference and countertransference having a sense of your own of yourself as a therapeutic instrument and working with people we have people who are social workers psychologists family therapists some people working in a family network you know strategic structural family therapy model others are more psychodynamic it isn't what the training is as much as having had experience and sitting with a lot of people in pain over time and knowing who you are and the process that you believe in because if you know the distinction between psycholytic and psychedelic psychotherapy I think our subjects have a combination of both in many ways they have a loosening of the defences and the kind of aggression that Groff and others wrote about in terms of psycholytic psychotherapy and when those defenses loosen then the person is in a kind of a psychodynamic session with you you have to know what you're doing why you're doing it how to take a person from here to there and the theory that you have doesn't matter as much as your confidence and ability to do that so you have to spend a lot of time as a therapist and I don't think just doing a lot of psychedelics yourself makes you able to do that it might make you able to interpret in one session something or know how to understand or identify with what your subject is going through but you know as I said so much of what happens is about palliative care therapy so it's mostly about being settled as a therapist and being ready to understand and work with what happens in sessions other questions please just to go along with what you're just discussing what sort of people have entered the program and succeeded like what were their backgrounds as far as the people that have been trained in the palliative care program the therapists yes there is all of the therapists are either psychologists social workers family therapists psychiatrists so everybody's been through a training program in some kind of psychotherapy and had extensive experience and working with people outside of psychedelic psychotherapy so this is sort of an integration of an interest in the belief in psychedelics with pre-existing identity as a therapist does that answer your question okay room yes wondering if you followed your subjects until that did you follow your subjects all the way through till to their death yes not all of them have died but all of them have been followed and some treatment I mean the research itself ends at nine months and if it appears clinically indicated there's no rule against the therapists and the person continuing to see each other in some form but there is a structured interaction with them and there's also a compassionate clause in which we're able to see people in ways that seem you know clinically indicated we had one subject that lived in California who flew to New York for his sessions and about like three or four weeks before he died we were really fortunate enough because a very generous person that at blue stone supported his cause is they're pissed which was me and my crew therapist and our research coordinator to fly out there and see him in his home so we were able to see him just a few weeks before he died I've got a couple of yeah mm-hmm so I have a couple of questions could you tell us other kinds of doses of psilocybin you were giving and also I was wondering how you were going to be assessing the quality of their psychedelic experience it was thirty four milligrams particularly for milligrams per kilogram so it's done on a milligram per kilogram basis and each person gets the exact same dosage in in their session people are extensively evaluated through a broad variety of questionnaires before during and after they're given the apz questionnaire and a number of other instruments on skin I can't list them all for you so sorry other questions excuse me did you pass this down so you mentioned that there was a bit of counter transference and you also mentioned that you have a an agent of somebody who goes with the patient throughout the process from the beginning to the end and I was wondering if you examined at all the therapeutic alliance and if your thoughts on that and its role within psychedelic research it's a big question examined yes studied in a research way no all of our studies are focused on the experience of the subject even the person even the family members that we work with are observing the subject in the study so we have no systematic way of looking at what therapists are going through or what the family members or loved ones of the subject are going through but examined yes that's something that we work at work with in supervision and the transference and countertransference for the most part is similar to other proper ways that transference and countertransference emerge the patient's can see you is via their father or mother their kids there since there's two therapists there often is a kind of split and one person becomes a warm and caring the other one is cool and distant you know all kinds of processes like that happen the one of the subjects that I worked with with young and he was younger than I am and he's a gay man who was very muscular and throughout the time I worked with him you know I saw him shrink and shrink and we know watching this happen I think evoked a reaction in me that was different than if my subject had been a 75 year old woman with cervical cancer because my identification with him was so much stronger and you know in one of our sessions he had to catheterize himself and seeing that being present for that and seeing the pain and anguish and suffering of this this process was wrenching it was really painful to watch that and for him to not do that alone but to do that was somebody that he had a relationship with it was a complex transference countertransference event for does that answer your question I'm sorry can't hear you okay yeah Jeff I have a question I think your therapist training program is fantastic and so I I wonder though do you videotape your sessions and is there some way for you to kind of verify or give feedback on whether people are following the principles that you've tried to teach them and then secondly in the MDMA PTSD therapy training program we've gotten as you know permission from FDA to give MDMA to therapists as part of their training are you going to be exploring trying to get permission like that to administer psilocybin to your therapists teams okay so let me see if I could remember all the questions no we don't have any videotaping of the process we've considered that but we decided it would be too intrusive for the subject and the idea that they were being recorded without any knowledge of what would happen to that recording would have a detrimental and profound effect upon their freedom to be say do whatever it is that they were going through I know often you know people will say well I forgot about it after five minutes I certainly you know heard that from patients when I used audio taping during my analytic training but as a group we just decided to put that off and to answer the second part of your question no we do not have a plan in mind to develop research similar to the MDMA research it's not a way that we're that we're leaning in terms of how they want to devote our resources time and energy right now it's not that I don't think it's important I do but you know we're all volunteers and we have limited resources and limited time and it's just not not made it to the top of the list in terms of projects that we want to pursue so no I don't have any way of validating that people are following the principles except to the Supervisory process this is something which is you know just beginning and you can't do everything all at all at the beginning it took I think it would take training you know more people and treating more subjects to really know more about you know what psychedelic therapy is what these particular patients need what therapists need and so forth it was a challenge to develop a training program for a kind of therapy that was not really very much in existence yet so it sort of like giving the not the cart before the horse for getting the saddle before the cart and the horse because you gotta like figure out exactly what it is that you think you're going to need before you actually need it and we've been evolving it over time more subject to be treating thank you I think we're really out of time for questions right now and please help me thank Jeff Gus [Applause]

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