The subject of psychedelic assisted therapy may not be the main or only hot topic at the 2024 annual meeting of the American Psychiatric Association in New York City. Maybe this whole scene of psychs-and-Shrooms/psychs-and-LSD/psychs-and-Ecstasy/psychs-and-Special K, is just my own peculiar fetish.
But man! Stephen Ross, M.D. sure did draw a crowd on Saturday!
Dr. Ross ran a featured session at 10:30 AM entitled, "The Leading Edge of Psilocybin Therapeutics: Psychiatric & Existential Distress in Advanced Cancer, Alcohol Use Disorder, and Major Depression." The room was filled to capacity with about 300 people.
Dr. Ross started with a summary of the history of psychedelics which was fully in tune with the way "Psychedelic Renaissance" people usually present the story. He commented as a preface that he loves history, and said the history of psychedelics "...is a very important part of our field (in psychiatry), which has been sort of erased." He went over the traditional use of psychedelic drugs for millennia by indigenous peoples, Albert Hoffman's 1943 bicycle ride, the 60's, Timothy Leary, and Nixon's war on drugs. He seemed to have a pretty good command of the Twentieth Century narrative.
At several points Ross reminded his audience that these drugs have occasionally been used in very unethical ways, like by the CIA, and by Charlie Manson. (He never mentioned any unethical use by psychiatrists, of course; psychiatrists from NYU/Belleview/NIMH are the good guys!) The audience could have detected a hint that Ross thinks those bad old, unethical things could happen again, because the current enthusiasm, the Renaissance, "is almost moving too quickly now. There are real risks, and there's way too much hype." Drug companies want to hop on board this enthusiasm, with shorter-acting versions of shrooms and acid that could just be prescribed, and wouldn't need any therapists.
Dr. Ross categorically asserted, "We must have a therapy model." In other words, Big Pharma's wet dream of gazillions in profits from just selling these drugs to a mass market is impossible. Doctors are never going to tell patients to just trip. Ross seemed a little too casually dismissive of such scenarios, though like, oh of course everyone there in the room would agree with him, because he's the top expert and they were professionals always dedicated to following his opinion and obeying his every advice.
He did seem very confident in reeling off details from a large number of studies, and more raw data than anyone could remember or evaluate. There were occasional gem-quality, if disjointed, comments, e.g., "Psilocybin is really about the search for a good death;" and a slide which detailed the "Psychological Safety Profile" of Psilocybin which included "acute psychological distress, fear, panic, psychosis, acute dangerous behavior, suicidality, violence, persisting adverse psychological sequelae, hallucinogen persisting perceptual disorder (HPPD), and hallucinogen misuse/abuse;" or for treating alcohol use disorder, "Religiomania is the best cure for for dipsomania;" and "MDD is the most problematic brain based illness" but "data suggest that the mystical experience really matters in treatment."
One of my favorite APA guys is Paul Appelbaum, M.D., from Columbia University. He and Jeffrey "freak-of-nature" Lieberman (also an erstwhile Columbia professor) were back-to-back APA Presidents, in the days when they could imagine that psychiatrists would soon be the powerful captains of mental health treatment teams, with the closest access to brain science enabling high status and huge money. Now Dr. Appelbaum is in the thrall of psychedelics, because everything else psychiatry has done failed. He gave his talk from 1:30 to 3:00 PM Sunday, about "Challenges in the Use of Psychedelic Compounds for Psychiatric Treatment."
Psychedelics are "compounds" (rather than "drugs" or "medicines") for Dr. Appelbaum, and I failed to wonder why, until hours after his session. Now I think maybe it's a more neutral term (not to mention more technical/chemical), which wouldn't tip his hand about whether he approves or disapproves of this trend in his profession. His opening question for an audience of at least 500 people was, "What accounts for the rapidly growing interest in psychedelics?"
Appelbaum had two considerably younger co-presenters, both of whom were perhaps far more into psychedelics than he wanted the audience to believe he was. These were Dr. Natalie Gukasyan, M.D., of Columbia, and Dr. Amy McGuire, Ph.D., of Baylor College of Medicine. Dr. Gukasyan mumbled a lot, so she was hard to understand although she mentioned a couple scary downsides: anyone who is on lithium is at high risk for seizures with psychedelics; and boundary violations (sexual or financial abuse) are a very important problem, because people taking psychedelics are so suggestible.
Nevertheless, Dr. Gukasyan was certainly there to testify about the upside of psychedelics. She's too young to believe the truth, that psychiatry has simply failed and it has no hope.
Dr. McGuire was an interesting case, too. She has actually run a psychedelic retreat herself. Her specific points were that due to the expense of doing psychedelic assisted therapy "correctly" (with a substantial therapy component, hours of counseling before and even more hours of counseling after tripping), there will be enormous incentive for unregulated use of the drugs, and for an increasing number of retreats that cannot be closely supervised. They will be branded/marketed as "alternative health" and "religious" retreats, and only rarely as actual medical care.
All three presenters in this standing-room-only session emphasized the dire importance for mental health professionals to get themselves educated in the issues involved, because the demand for psychedelic drugs and psychedelic assisted treatment is already huge, and increasing rapidly beyond their control. Although Appelbaum and his cohorts were admittedly shell-shocked by the magnitude of this development, they seemed to have no sense of any solution to an obvious looming danger, other than just their continued presumption that "science" as they have always understood it is the necessary, and the only possible, answer.
Paul Appelbaum gave the final portion of the presentation. He expanded on the difficulties of informed consent in psychedelic therapy. For example, how can a patient be "informed" by a therapist, about possible experiences and phenomena that are really ineffable? How can a therapist explain or warn about things (like "oceanic boundlessness," or "dissolution of ego," or apparent communications with "higher powers and spiritual entities") which are simply not understood at all?
Advanced planning for interventions when therapy gets difficult is also very hard. A patient might say before a psychedelic session that he or she does not want to be touched by the therapist, but then want such reassurance desperately if they are terrified by experiences on the drug. Once a psychedelic session has begun, it is very difficult to stop.
Many people who want psychedelic therapy have unrealistic expectations of benefits. The media often contribute to this problem.
Appelbaum's basic position seemed to be, "We know little or nothing about psychedelics, we cannot predict what they will do to any person or to society. But we sure are going to use them anyway."
Stephen Ross said, "I have become comfortable with spirituality."
For him and for psychiatry, that is surrender.
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