The NYU Training Program for Psychedelic Psychotherapy – Jeffrey Guss

It is really an honor, and so much fun, to be here and it’s been a lot of fun preparing this talk. Each time I give this talk, things change, and I learn more about about the training program. You know, I’ve been a psychiatrist for 25 years, and when I first trained, I did an anxiety disorders fellowship and I started teaching about anxiety and anxiety disorders and that was a hard topic to, like, get a big picture of and to do in an interdisciplinary way and then I started working with addictions and teaching about that, and then gender and sexuality, and each one had its own challenges in terms of how to teach residents and fellows about how to practice in some way that was not just cookbook and, you know, cookie cutter about – “this is how you treat this problem in this way” but I think that psychedelic psychotherapy training has been the most challenging thing that I have ever undertaken and it continues to teach me a lot about doing therapy and being with patients, and in teaching. So I’m going to try to cover a number of different topics in my talk today. I wanna ask the question: What is psychedelic psychotherapy? And in particular, What is psychedelic psychotherapy that we do at NYU with our participants in the cancer anxiety study? I answered this question by looking at who was doing psychedelic psychotherapy today who actively participates in offering and in consuming psychedelic therapy and also with some of the methods and techniques that are important even if psychedelics are not involved. I’m gonna show a little bit about what it is that we actually do with participants that are in our study what kinds of experiences they actually undergo when they go through the work with us I’m going to talk to you about how we train our therapists, what kinds of experiences we put them through, what kind of teaching we do, and how it is that we conceive of their going from one place to another. I wanna ask the question: Why do we call it therapy? And a theme that you’re gonna hear me address throughout the talk today is why this is therapy and why we are not guides, or monitors, or sitters, but we are therapists who are doing therapy with patients. We call them “participants” or “subjects”, but, for the clinical work that we are doing, it is really therapists who are very well trained who are sitting with human beings that are suffering, and we’re doing a short-term therapy that has Psilocybin sessions that are part of it. And I’m gonna close by asking What are the goals of our training program? What do we really hope to accomplish in training people to work in the study? So what is Psychedelic Psychotherapy? It is a collection of psychotherapeutic processes that are facilitated by psychedelic agents. So the important part here is that psychedelic therapy has, as its basis, a therapeutic process which already exists in the mind of the therapist, and in many ways, in the mind of the participant, when they come in, all of the experience, all of the training that they’ve had – that patients or the participants experience in therapy – all of this comes to bear on what happens to people when they enter our research project. And in this way, it’s distinct from psychedelic agents as neuroscientific probes into the function of the brain and the mind, and it’s also different in some important ways from psychedelic journeys that are undertaken for a recreational purpose, or for a spiritual purpose, or for artistic creativity, or individually. So this is very specifically therapy that’s done with people who are suffering from a certain condition. So what we do is not shamanic healing, it is not neo-shamanic healing, however, it does absorb many of the core teachings and the wisdom that come from those traditions. Psychedelic therapy is deeply embedded, and inextricably embedded in the knowledge systems of the subject and the guide. Here we see Copernicus looking at the sky with a very primitive telescope and what Copernicus saw, the data that he gathered, how he interpreted it, was all very much based in what he knew about the heavens, and what he thought was going on in the heavens. Now he may have seen things that surprised him – that caused him to revise what he thought, but basically what happened with that telescope was profoundly influenced by what he expected to see, what he was surprised by, and the basic knowledge base that was going on in his culture at that time. 300 years later, we have a much fancier instrument looking at the sky but it’s more or less the same sky, and more or less the same kind of instrument but the way the data was gathered, the questions that were asked, the way the data was manipulated and interpreted, and the kinds of impressions that were drawn from it was very different. However, same kind of instrument and same kind of sky So this shows how deeply it is… in the mind of the observer and the looker and the person that’s participating in the experience that the catalyst or the technology, which in our case is psychedelics, you know, has to be understood. So I want to reintroduce the idea of psycholytic therapy. Psycholytic therapy is much referenced, but not that much talked about anymore. It’s a kind of therapy that was done in the Fifties and Sixties, it was existed more in Europe than in America although there was quite a bit of psycholytic therapy that happened here, but in the modern psychedelic research Renaissance, there’s much more emphasis on psychedelic therapy, which is, if you wanna be, and this is quite reductionist, though to say that psychedelic therapy has ego death, brought about by the agent, followed by a peak spiritual or mystical experience. So this tends to be more unitary in concept, that is – it’s more or less the same for everyone, and in fact, all of you have probably seen the nine – the list of nine criteria, that define the mystical experience, and in our study, we, like, measure people to say how many of them they’ve accomplished, you know do they get three, or four, or five? And if they get nine, then they’ve had a complete mystical experience. So in this way, the idea is towards a kind of a universal experience, and this is seen as having somewhat magical properties to heal. It brings about decreased death anxiety, and transformation in character, which is seen, and it’s sort of a goal that people look for in research. However, it is a goal which is deeply bedded in contextualization. It’s more likely to happen with someone who’s prepared for it, and who knows how to experience it. It’s not like it never happens in unprepared people, but in our study, people who are experienced meditators and have worked with ego death as it occurs in meditation retreats – that kind of person is more likely to experience ego death followed by a spiritual or mystical experience. And this… quasi-religious preparation is, you know, more likely to bring this about for this kind of individual. And in this case, the therapy supports the medicine experience, so the goal of the therapist in the context is to support this profound and shattering medicine experience. Psycholytic therapy, on the other hand, is more biographical and more psychodynamic. It’s more individualized, and has more to do with that individual’s time on the earth, their experiences in childhood and adulthood, and it’s also deeply embedded in the relationship with the therapists who are in the room. In this way, the medicine supports the therapy experience, and there’s a lot of writing that happened about psycholytic therapy that advanced whatever kind of therapy that patient and that therapist were doing in the Fifties and Sixties, if they were Jungian therapists, if they were Freudian therapists, or Rogerian or relational therapists the psychedelic experience, used in a psycholytic manner, advanced that particular kind of therapy. In our study, we measure and we look for a mystical or spiritual experience, but many people have a combination of a psycholytic and a psychedelic experience, and some people have only a psycholytic experience and this falls, then, of course, to the therapists to interpret this and help the patient – the, ah, participant work with it in a meaningful way, To make this point one more time, Anaïs Nin said “We don’t see things as they are, We see them as we are” So why is this point so important? Why do I hammer away at this point? Because when you teach a certain kind of therapy, you’re called upon to explain much of the basis of that therapy – how it works, why it works, what you’re doing, what distinguishes it from other kinds of therapy and these are very difficult questions to answer about psychedelic therapy for many reasons. One is that it’s not been done very much in the last forty years, in an overground, above-board way and secondly, because there are so many different forms of psychedelic therapy but when you wanna teach something, especially in a rather traditional setting like we have at
NYU you have to have a matrix or a structure in which you’re setting out to teach a body of knowledge to therapists who don’t have it. So you have to decide: What is the body of knowledge? What are we doing? Why are we doing it? Most people would agree that we are opening up something inside – so: What are we opening up to, with psychedelics? Why are we opening up to this? Why do we think it’s a good idea to unleash or open up these kinds of restrictions that happen in the brain naturally, for a period of six or eight or ten or twelve hours? Why was it closed in the first place? What are we looking for? And are we instead opening up to something outside the self, rather than inside the self? And these are all questions which it’s easy to ask, but when you teach it, it’s important to have some answers and yet these are answers we don’t really have immediately at hand. So an important question: How do we develop new narratives out of being involved in the study? That is: How do the people who come to us for help come away feeling better, feeling like their life is more meaningful, less afraid of death, and deeper engaged with the life that they have, and able to know and experience that, and speak of it? What can help these changes become long-lasting? All of these are questions which go into teaching psychedelic therapy, and they’re questions which I wouldn’t say that I have all the answers to, which makes it especially hard to teach. And when you work at NYU or any academic setting, you really have to make certain that what you’re doing fits into quite a traditional model of education. So part of the goal that we’re grappling with is how to develop a coherent model for teaching psychedelic-assisted therapy to conventionally trained therapists. All of the people that have been through our training program are trained and have extensive experience in working with patients, either as psychiatrists, as psychologists, nurses, social workers, or family therapists. So they’re all fully trained therapists. And how do we teach this additional method? Or this additional kind of intervention? Or how do we teach therapists that know how to work with patients then to use this new kind of experience, using their own unique skills and abilities, and, in some way, trying to bring about a coherent treatment? Because if you’re saying “This is psychedelic psychotherapy,” you’re defining it as something specific. You’re saying “This is a certain kind of therapy. This is what it is, and this is what it isn’t,” and those kind of boundaries, which are problematic in – if you think about things in a holistic way, or a non-dual way, that isn’t the way that psychiatry works. You know, if you’re defining a certain kind of a therapy and you wanna, say, have a fellowship in psychedelic psychotherapy, then the chairman is gonna say, “Well, what is that? And how do you know it’s something? And how do you know when someone’s doing it? And how do you know when someone’s doing it well? And how do you know if somebody’s not doing it, but it looks like they are?” And these are all questions that you have to have at least practical anwsers to. You also wanna answer questions like: Who can become a psychedelic therapist? Who should become a psychedelic therapist? And who shouldn’t? We tried to answer the question: How is our work different from the psychedelic therapy that’s done by underground workers? Of which hundreds, if not thousands of sessions are – ah, you know, happen every year. And how do we integrate our training with the therapists’ existing approaches? And how do we bring our responsibilities as, you know, trained, professional therapists to the psychedelic therapy setting? So this is the title of our study: “Effects of Psilocybin-Assisted Psychotherapy on Anxiety and Psychosocial Distress in Cancer Patients” This therapy occurs in a very specific context. It occurs in Manhattan, at NYU. This is our research center, in the upper right-hand corner, the Bluestone Center for Clinical Research. People walk around with white coats on and stethoscopes around their necks, and so the people who come are, for the most part, very mainstream individuals who have cancer, some of them quite advanced cancer. Some people are not too ill, but many people are quite ill, and they’re involved with traditional cancer regimens with scans, radiation, chemotherapy, and these are the patients who come to us and enter our study, by and large. These are the members of the NYU team: Steve Ross, who I think might be here in the room – Steve? Over there. And Tony Bossis, who spoke on the first day of the conference. Gabby Agin Liebes, who might be here also – over there And Carey Turnbull, ah, director of development, Alexander Belser, who might be here – Alex? No, and Effie Nulman, another consultant and somebody who helps us with development. And this is an overview of our study, for those of you who aren’t familiar with what it is we are doing, I thought I would show you what it is that the therapists do in our study, and what it is that we’re preparing them to do. There are two dosing sessions: Dosing A and Dosing B. They’re separated by a seven week period. Before Dosing Session A, there are three preparatory sessions. These are about two hours long. Then there’s Dosing Session A, which is either placebo or active drug. No one knows, not the participant, or the therapist, or the PI, or anybody. The only person who knows is the compounder, who actually makes up the pill, on a milligram per kilogram basis, and puts it into a special envelope and then a special bottle, and it’s all very special (audience laughter) After Dosing Session A, there’s a seven week period, and then there are integrative psychotherapy sessions. Now, if the person received placebo, or it appears to everyone that they got a placebo, then those next three sessions tend to be more continued preparation, because the experience with Psilocybin is definitely the high point of the experience so they either have, in essence, six preparatory sessions, and three integrative, or three preparatory, and six integrative sessions. And there’s a subtle, well, you know, not-so-subtle dynamic differences that happen when a person is disappointed if they didn’t get active drug first, but everyone knows that by the end of the study, they will have received a dosing session in both conditions. So after the Dosing Session B, then there is a period of about four weeks or five weeks, during which there are three more integration sessions. So we have nine therapy sessions and two dosing sessions. Who are the psychedelic therapists of today? In order to think about what we needed to learn, what we needed to do, I asked myself the question: “Who is doing work with psychedelics, and who is doing work that feels related to psychedelic therapy?” And I came up with four categories: The Shaman, the Neo-Shaman, the Meditation Adept, and the Palliative Care Therapist and Psychodynamic Therapist of today. And I’m going to go through each one and talk a little bit about what we learned from them and what I think we needed to incorporate from these different disciplines. The shaman is the earliest and longest-lasting… longest-known psychotherapist in recorded history. A core of shamanism is communication with the spirit world. This occurs quite concretely. It’s not metaphor, it’s not an aspect of the mind, it is a literal communication with spirits, and the ability to work with unseen and mysterious forces and to intercede for the benefit of the sufferer is a core activity of the shaman. The shaman enters a trance state, voluntarily, either with or without psychedelics, and experience their soul or spirit leaving the body or journeying or traveling on behalf of the individual who is suffering. The shaman interacts with spirits, and will command, intercede, or commune with them in some way, in order to bring about a benefit for the individual who is in the ceremony, or for the tribe or community as a whole. There’s quite a similarity between shamanic training and psychoanalytic training. In both, the individual, by definition, suffers from some kind of malady – some kind of unhappiness, frustration, or fear, or anguish – some kind of suffering, which is both defined by and treated by a particular knowledge system. In order to become a psychoanalyst, you have to be, you know, upset, neurotic, troubled in some way (audience laughter), seek treatment with an analyst, and undergo a genuinely therapeutic psychoanalytic process. And anybody who doesn’t do that is probably not going to be very much good as a psychoanalyst, because enthusiasm for the method is a requirement for practicing it effectively. And also, you learn a great deal about what it means to be a patient, and what it means to be a therapist, from working with your own analyst. So, the analyst, as well as the shaman, suffer from some kind of malady, and often both are, you know, marked at a very early age, as headed towards a particular career. This is true for many therapists. And so this malady is cured or ameliorated in some way by shamanic practices or by psychoanalytic practice and this is the embodiment of the wounded healer paradigm, in which the person who’s conducting the ceremony or conducting the analysis is not expected to be perfect or flawless, but in fact is expected to be someone who lives with a spirit wound and is working at healing it, or has had it healed in some way and developed a compassion and a unique ability to relate to other people as a part of that process. Part of the culmination of a shamanic quest – and this is quite different from pschoanalytic training – is a confrontation with death. This confrontation with death, which often is accentuated in psychedelic experiences, is a catalyst for moving to a different stage of being, without the encounter with death and the experience of dying, either in a trans state – you know, non-psychedelic induced, or with medicine – the reaching out, the hunger, the need, the expansion and extension of oneself, to find a new way of relating to life, to oneself – it doesn’t happen. And so it is this very terror and reaching through the sense of groundlessness and shattering that transformation and rebirth can occur. And this is one of the things that is most important, I think, for therapists to be able to work with participants in this study. And in order to approximate this, we have a great deal of emphasis in the training process on confrontation with one’s own mortality, fears about death, and experiences of death and mortality in friends and family and in patients. The shamanic practitioner may take medicines, and, as I’m sure everyone here knows, the practice may be that the shaman takes the medicine, and not the seeker or sufferer in their culture. That is not what happens in our study – in our study, it is the person with cancer anxiety who takes the medicine, and the therapists in the room with him or with her are quite sober, although there is sometimes a kind of contagious experience of entering trance with them but we’re all sober, pharmacologically-speaking. And in shamanism, psychedelic plants are considered gifts of the gods. They are mediators between the gods and humans, and may carry special communicative potential, and it is the – also, some believe that it is the plant itself that is the god, or the plant contains the spirit power. Mushrooms are found widely available in nature, if you know where to look, and you know when to look They are not secreted away, and they are not expensive – you just need to know what to do with them, where to find them, and how to use them. In research, the molecules of Psilocybin are considered to be inert, and to not have spirit within themselves, and yet they’re considered to be very dangerous, and we had to install a very expensive and huge safe in order to protect a relatively small amount of Psilocybin. It’s weighed every day, and there is some kind of danger that exists with the human beings around the Psilocybin because it needs this much protection. So – while these mushrooms are available growing in cow dung in certain places, when they arrive at First Avenue and 25th St., we need a big safe, to keep everybody feeling okay about it. (audience laughter) Now the shaman is a person who exists at the margins of society, but that doesn’t mean that he or she is a counter-cultural agent, because those who exist at the margins are very much a part of culture very much a part of society, in fact, the center can’t define itself if there isn’t a margin against which it can say, “Well, we are not that, but we’re glad that person is here, because we can find what we don’t have in ourselves in them, or we can hate them, or we just need them in some way.” But the shaman, perhaps a person marginalized in society, is a very well-known and respected and valued person in society so there are culturally-bound narratives of illness and healing that the shaman knows and that the other members of the community know. So even before a person goes to a shaman, what’s wrong, how it gets better – all these are cultural narratives that exist, you know, as a part of the culture. There’s a highly ritualized training process with a strong respect for tradition, so although working with psychedelics is counter-cultural and edgy and kind of outlawish in the underground circles in the Western world, I think within indigenous cultures, it’s not that way at all. There’s a training program – there’s an apprenticeship, which I’ll talk about in a little bit, and it also may be a part of the shaman’s job, in ceremony, to reinforce pro-social values and social regulation, and in fact, it’s this function that’s thought to be significant in the ways that certain psychedelic-based religions facilitate recovery from alcoholism and other addictive disorders. Okay, so we’ve covered the indigenous shaman – now I want to move on to the Neo-shaman, or Psychedelic Sitter The training and practice for the Neo-shaman is much less well-defined. The practitioner may know of yoga, may have a meditation practice, may do Chinese medicine or acupuncture, and uses intuition and many concepts from Transpersonal Psychology that are brought together as part of his or her method for doing psychedelic sitting or guiding. The neo-shaman is generally naturally emergent or self-selected. A person says, “I would be willing to sit for you, and I believe that I have the credentials to do that,” or an individual may say “I want you to do it.” And there’s little training or apprenticeship program that empowers the sitter or the guide to know what they’re doing, except their own direct experience, and reading and observing other people. The neo-shaman, again, has direct contact with the spirit world, enters into spirit reality through altered states, and often in neo-shamanism you see skepticism towards monotheistic religions, allopathic medicine (especially psychiatry) and overvaluation of the scientific method, which is known as “scientism,” which is the irrational overbelief in the scientific method, and the belief that scientific knowledge is somehow harder or firmer or more powerful or more important or more reliable than other kinds of truth. I’m not sure why this -ism is capitalised – it shouldn’t be. Neo-shamanism is a descendent of the ideology of American Transcendentalism, which I’ll talk about in just a minute. Another distinction, and this is of course a generalization, that shamanism – there is generally a greater emphasis on searing pain, hardship, and terror than you see, you know, by and large, in Neo-shamanism. The Neo-shaman theory and methods are generally prohibited – prohibited discourse in medical circles, you know, when you are talking to oncologists or nurse practitioners at the cancer center, and you start using the language of shamanism, you can see people start to roll their eyes and glaze over, and stop listening to you. And so since we’re trying to persuade them to refer patients to us, and to take what we’re doing seriously, you know, this whole discourse is prohibited, even though it may have a great deal of value in communicating with the subject in the study. And so the Neo-Shaman – this discourse is not preferred in medical science, PET scans are preferred. And yet we have a – many people who are bridges: Stan Grof famously bridged psychiatry and Neo-shamanism, and no course or lecture on psychedelic therapy would be complete without giving credit to James Fadiman, who’s written this extremely useful guide, The Psychedelic Explorer’s Guide, and Neal Goldsmith, his book, Psychedelic Healing, and numerous others. So – the mindfulness adept – ah, it was clear to us early on that many of the practices and teachings within meditation are important for us as practitioners and for the participants to know how to do. Meditation is a technique for developing the skill of mindfulness – focusing on self-regulation through careful attention, focusing on immediate experience, and developing curiosity, openness, and acceptance. One of the underlying themes that happens in existential anxiety is that there’s little context to speak about the terror, rage, disappointment that occur after the development of a cancer diagnosis or cancer treatment and the looking away, the encouragement to cope, the encouragement to fight, the encouragement to be positive all of these draw attention away from the most difficult, painful, searing, hard questions and processes that need to occur and this capacity of curiosity, openness, and acceptance of what is that is central in mindfulness is something that I thought was quite important to bring to training. Mindfulness and meditation is an established technique for entering altered states of consciousness with the idea that entering them can be inherently transformative, and bring about an improvement in outlook, mood, and connection to other people. Non-judgemental/radical self-acceptance are also important in meditative practice, something which we bring to bear with each person as they prepare for their psychedelic experience. And the Psychodynamic Therapist: There are many, many things that we could say about what a psychodynamic therapist knows how to do, but much of it is embedded in his or her own training. One thing that I think cuts across all schools of psychotherapy is that we help the patient develop alternative meanings and narratives about life. We do that in different ways, we do that in different – with different techniques, but we all hope to help someone have a better sense of what their life means, and how they can speak to themselves and understand themselves in it, and in particular, here, cancer, illness, and death. And Narrative therapy is a particular form of therapy in which truth is not just something which is discovered objectively, it is something which is constructed in the development of a narrative between the speaker and the listener, and this is a theme that I think comes up again and again when trying to understand how to use psychedelics in working with cancer-related anxiety. Like the shaman and the neo-shaman, the psychodynamic therapist believes in unseen forces. We don’t call them spirits or ancestors that exist in the spirit world; we call them the Ego, the Superego, the Id, internalized object relations, internalized schemas – many, many of these metaphors, I believe, are for the similar processes that occur. But again, the psychoanalyst and the psychodynamic therapist is trained to work with these forces, and just like the shaman, to intercede on the patient’s behalf, in order to try to make things better. Within psychodynamic therapy, there is a deep commitment to a personal healing journey, extensive work towards self-knowledge, and understanding of transference and countertransferece. All of these are invaluable in working with patients in our study. And there’s a long history that’s not hidden to the people who are here in this room, but certainly hidden within traditional psychiatric and psychoanalytic circles, of using LSD and other psychedelics to facilitate psychotherapy and here are three books: This one in the right-hand corner I’d never seen before and I was kind of intrigued to see it showing up in my Google Images search: “My Self and I” with its nice 60’s graphics. Now, psychodynamic therapy is very consistent with Western norms, medical/ethical norms and standards, so it fits in comfortably with what we’re trying to do. So before telling you about the structure of our program, I wanna do one more theory-based excursion, and talk about set and setting. We often think about set and setting as the set being the participant’s intention, and the setting where the therapy occurs. And in some ways, this is our setting: Manhattan streets, Bluestone, this is the couch that the sessions occur on, but I’d like to suggest that there are two other contexts that are deeply influential in the work that we do, and these are existential psychotherapy and American Transcendentalism In particular, we work with Victor Frankl’s Logotherapy. Logotherapy – I’m gonna try to reduce it to just a few soundbytes, has as its core that life has meaning under all circumstances, even the most miserable ones, and this biography of Frankl, showing this concentration camp march, at the top, and then this very thoughtful image of him as a young man, I think says volumes about how he came to develop this philosophy. He believes that our main motivation for living is our will to find meaning. And that when the search for meaning is blocked, there is psychological damage that occurs. According to Frankl, we discover this meaning in three different ways: As earlier today, Steve talked about meaning-making therapy, which is a kind of a practical technique for bringing these philosophical ideas to bear in the clinical situation. So meaning is discovered in three different ways: by creating a work or doing a deed, by experiencing something or encountering someone, or by the attitude we take. So by creating, experiencing, or taking an attitude, Frankl says that everything can be taken from Man but one thing: the last of human freedoms – to choose one’s attitude in any given set of circumstances. This is his famous book, “Man’s Search for Meaning,” and I wanna point out now that Logotherapy is not a psychology of mind; it’s not about the Id, the Ego psychology, internalized object relations, developmental stages, perinatal matrices. It’s not about, oh if you look, this is what we find, like you’re making a map. It is a therapy of action about the creation of meaning – the intention, choice, and the creation of meaning. And Irving Yalom can’t be left out. American Transcendentalism is a philosophy, and a form of literature, which had its origins in the 19th century, and in some ways lives on today in the New Age movement. American Transcendentalism holds in the inherent goodness of both human beings and nature. Now this is quite different than Freudian psychology of the late 19th century and 20th century, who said that the inherent nature of human beings is filled with steaming cauldrons of Id and rage and libidinal energy that needs to be modified and modulated in order to fit with the demands of society. It’s quite different than American Transcendentalism, which says that the individual is pure, and it is society that is corrupting. American Transcendentalism is an inherently optimistic philosophy. There is a great deal of belief in the self, and in the self identity, in creativity and infinite possibilities of the human soul, there’s a belief in spiritual progress, and the interconnection of all beings, the immense grandeur of the soul and that the interior is a source of goodness and wisdom. So I’d like to come back down to Earth now and tell you about the structure of the training program that we have, and this is the structure that we have used just in our last year of training, which is the third cycle of training that we’ve offered. This is Shira Schuster, who is soon to be a PhD, and has been my co-instructor in the course for this year, and has been a tremendous help and creative force in putting the training program together. So there are three core aspects to the training program: a one-year mentorship with one of the three investigators in the study – Steve Ross, Tony Bossis, or myself, a didactic series and work with two study subjects. This is the schedule with which we began last year. It unfortunately was blown to bits by Hurricane Sandy, but by about February, we started to recover and get back on track to all the papers that we wanted to discuss, and I’m going to talk about the didactic first. I don’t have all of the didactic papers here summarized, but just a few of them. We start off with this fabulous paper by Matt Johnson and Bill Richards and Roland Griffiths, on the safety and basic medical knowledge of psychedelics. This paper covers what ten other papers would be needed, in order to convey the information about who is eligible, who shouldn’t be taken into treatment, what are the risks, what are the basic techniques. It’s a great paper and offered a tremendous amount of information in a quick, ah, not a quick, but in a concise way to people who were going through training. The next is a wonder article by Alison Witte (no relation to Stephen, who’s organizing our conference today) This is a paper that I found in a journal on holistic nursing. She worked with nurses who had worked with people who were seriously ill in Eastern Kentucky – in Appalachia and she looked at who had spontaneous mystical experiences while they were in the hospital – what contexts led to their arising, what nurses did that facilitated people being able to have mystical experiences, being able to talk about them, and what kinds of things the nurses learned about how to help the person utilize that mystical experience in their life afterwards. She also, interestingly, talked about the impact on the nurse that was doing the listening , and participating in the creation of this shared experience. So this is a really useful article, nothing to do with psychedelics, but really about how do you occasion a mystical experience? What do you do that enhances the likelihood of that happening? We did some historical papers, looking at the LSD-assisted psychotherapy and the human encounter with death, by Bill Richards, Stan Grof, and others, and Pahnke’s groundbreaking article on the transcendental mystical experience in the human encounter with death. We studied contemporary scholarship in psychedelic research – Roland Griffiths et al’s paper on Psilocybin occasioning mystical experiences, and we took a crash course in Yalom and Frankl by studying this paper by Bill Breitbart – “Psychotherapeutic Interventions at the End of Life – A Focus on Meaning and Spirituality” So here, I think you’re hearing again the ongoing theme of establishment of meaning as a core process that we encourage our therapists to bring to people in the study. So that’s the didactic series. If you want a copy of it, I’d be happy to send it to you by email. The next part I want to describe is the mentorship program. The mentorship program is defined as just that, and not as a supervsion. We used the idea of supervision at first, but decided that mentorship is better for several reasons. A mentor is more of a guide, a friend, a supporter – there’s more equality in a mentoring relationship than in a supervisory relationship. And since all of the people that are trainees in our program are fully trained therapists, we felt that they were actually enhancing or developing or extending their skills, rather than learning something from scratch. So we use the term “mentorship.” Also, there’s a certain amount of teaching that comes back the other way that can be really quite profound, and I’ll tell you a little bit more about that later. The mentorship relationship is confidential. The mentor doesn’t say anything, and holds the material found in the mentorship sessions with equal confidentiality to what you would hear in therapy. The intention of the mentorship is an integration of all aspects of the experience. The trainee is encouraged to discover new aspects of him or herself and others through the relationship, in other words, How does my existing identity as a therapist change, grow, transform? What do I leave away, what do I do more of, how am I changed in this experience in learning how to do work with psychedelic therapies? And a core part of the mentorship is dyad training. Now, when you work with two study subjects, which is a third part of the program, you work with your mentor for at least one of the sessions. So each therapy team – each therapy dyad – has to do dyad training. And the dyad training, which I’m going to tell you about in a second, is the central part of the mentorship relationship at the beginning. So you meet for these six two-hour sessions, doing dyad training, and by that time usually you’ve gotten started working with your first patient. your first participant. So at that point, you’re doing clinical work, you’re talking about what’s going on, you’re talking about what’s happening in the reading. But the dyad training is a central way that the mentor and the trainee get to know each other. The dyad sessions occur six – there are six of them. They’re about one to one and a half hours and only the therapists are present, so it’s a group of two, and what happens in there also is confidential. Each session has a defined theme, even though you’re encouraged to do free-flowing discussion, and talk about anything that arises that you think is going to be relevant to working together as a dyad team. And we used to have supervision after the third and sixth sessions, but I think that’s pretty much fallen by the wayside. So the goal is establishment of a close relationship. If you’re going to be a dyad team, you have to really know one another as therapists, you have to understand how somebody thinks about life, death, suffering, and when I first picked this picture, I thought that it was just kind of cutesy, but I realized that one of the times I’ve given this talk before, that there’s something quite similar between this tin can string telephone – and that’s that you either are listening or speaking, and in order to change, you have to change your position. And the dyad sessions occur in the same way – when you’re speaking, a person is expected to say what they have to say, to describe their experience, and the other person listens. It’s not a therapy session. You’re not expected to ask questions to deepen the experience. But it’s a practice of a certain kind of meditative listening. The first session – early memories and contemporary experiences of death and losses. Family members, pets, friends, patients that have died. Each person is invited to talk about their life from their earliest memories to the present time – of what death and mourning has been like for them. This is also the time to talk about early memories of awareness, of your own mortality, and thoughts and feelings about your own death, and the death of loved ones. The second dyad session is an invitation to talk about a profound mystical or spiritual experiences, including experiences with entheogens. So the confidentiality is also a part of the protection of this, because speaking openly about entheogenic experiences or psychedelic use in a context like this brings about certain kinds of ethical and legal anxiety in people, so only with confidentiality, I think, are people really free to speak openly about what they’ve done, what they’ve not done, what it has meant to them, and the part of them that they’re going to bring to their dyad work, which is the work with the participant, that relates to their own experience or lack of experience with entheogens. They can speak about their experience as a sitter and as a guide, with shamans or guides, or meditation teachers that they might have had and this allows a basic kind of groundwork to be established between the dyad as they’re getting ready to sit with someone who’s going to enter into a state which is rather unpredictable, in terms of what they’re going to be confronted with holding. The third session involves looking at pain and suffering in family members, friends, and patients, and experiences with cancer, or other terminal conditions, including experiences in working with patients who are disfigured, and whose bodies are failing, and the impact that this has – ten minutes? okay so session four: near death experiences. Session five: (audience laughter) beliefs regarding heaven and hell, and religious history. Session six: extreme states in psychotherapy, but actually, by session six, everybody’s pretty much done and we’ve talked about everything there is to talk about. So that’s the one year mentorship, and I’m going to skip over that and talk about the study and what actually happens during the sessions. So I presented this slide before, but I’m going to go over it again: you’ve got three prep sessions, a dosing session, three more sessions, a dosing session, and then three more. So there’s nine therapy sessions, and two dosing sessions. The three preparatory sessions: this is the study room, this is what it looks like, this is a model pretending to be in session, and the first prep session. So, during the first prep session, it’s really divided into two parts: there’s education to the participant, regarding goals, the purpose of the study, time tables, expectations, and education regarding the range of possible effects of the medication, side effects, rescue medications that we have on board, what we’re going to do to try to help them through a difficult experience, and after that then we do a history, during which we take a psychosocial history, in particular a cancer narrative, we talk about family, relationships, hobbies, work, political social religious affiliations, experience of psychedelics, meditation practice, and anything that you would want to do to get to know somebody and develop a trusting relationship with them. The second session is a life review – in this, we do a rather structured exercise, which I’ll show you an example of in just a minute, but you go over much of the same material – you go over where you were born, growing up, where you went to school, when your dad transferred to another state, what happened when your grandmother died, you know, if you had to go into the service, like, whatever these important turning points are in your life. We talk about them literally on a timeline, and examine the meaning of those events in the individual’s life, in order to see how their life has come to have meaning, how events were made meaning of, how catastrophe or disappointment or anger or exaltation moments were given meaning and came to structure the way their life worked. In particular, in the life review, we look at the cancer narrative, which has to do with how you reacted to the diagnosis, what the diagnosis meant, and the relationship between cancer, spirituality, and how the individual found meaning. So this is a life review exercise – on the left hand side you can see birth, about two thirds of the way across you can see now (this is a man in his late forties) and at the very right hand side, he writes his death. So you can see between birth and now, there’s many, many events, and I’ll give you a closeup in just a minute, and about half-way through you can see that he didn’t leave enough space, which is like the the proportion wasn’t right, so he wrote a little u going down to write in some more information. And this is a closeup of what he wrote. At the bottom, he wrote his regrets, loss of friends, he had to care for his mother when he had pneumonia, he was mean to Scott when he was a kid, and did well in school and became a quarterback – all of these were things that he felt were important, and just getting this information, writing it here, and taking this time was really a profound experience for him. And each person that we work with says “You know, I’ve never done anything like this before,” and it’s quite illuminating to have these memories sought in this relatively structured way. And then the third is taking a spiritual history – in order to take the spiritual history, we use these two mnemonics: the HOPE and FICA, and I’m gonna skip over this because I’m running out of time, but these, you know, information about these is easily available online. The spiritual history – What are your beliefs? More about the spiritual history, more about the spiritual history. The dosing sessions. Now I’m not going to say a great deal about the dosing sessions, because what we do is not vastly different than what is written about quite extensively – how we handle people in various kinds of situations, what we expect, what we invite them to do, how we handle crises – this is quite extensively covered by many, many people, and what we do isn’t terribly different from it. We have headphones with music, the therapists take a supportive role and respond actively if necessary, we have an opening ritual that focuses on internal direction, and immersion in the inner experience, the therapists are invited to watch, listen, and be attuned, and very careful listening to the first post-journey narrative – usually around two or three, the person sits up, takes off their headphones and eyeshades, and starts talking about what they’ve been through, and this first narration of the experience is really quite important, and listening to it in a careful way, I think, sets the ground for how you’re gonna work with it in subsequent sessions. Then you have a closing ritual. So the integration sessions – these are the least-well-defined part of the process, and they vary considerably from one dyad team to another, and while there is an effort in academic research to have uniformity, and to have a manualized approach to things, I think that these integration sessions are a place where it’s going to be quite a challenge to do this, because what the person brings, what happened to them in their session, and who the therapists are, and the bond that they’ve tied, the bond that they’ve made, the tie that’s happened among the three of them, is really going to define what happens in the integration sessions. So again, making meaning of a psychedelic experience, and incorporating that meaning into one’s perspective on yourself and in the world is an essential part of what we’re trying to do. Now this is Reverend Mike Young, and this is a slide that I didn’t know about this quote, and it was Cody Swift, actually, that turned me on to this wonderful quote, and this is, in some ways, the idealized experience in which the ego, which is constructed by memory, and determines what we think, under Psilocybin, you transcend this ego – it’s not who I am, and the loss of self is not as distressing as it was before. So this is kind of the idealized experience, and this is a picture actually of Marsh Chapel, where the Good Friday experiment happened, and people praying, in that very same chapel, but not everybody has this full experience. Some people have a much more biographical experience, and I don’t think I’ve read a description of what you need to do better than what came forward, quite recently, in this lovely small monograph by Torsten Passie, describing what kinds of things can happen in session, and I don’t think that much of what’s here is going to be new to anyone here, so I’m not going to go through this, in the interest of time, and again, well, one point that I wanted to make about this is that Sometimes you hear, you know, when people are talking about Katherine MacLean’s report on openness, that 14 months later, openness was found to be increased by a single psychopharmacological event. And when that phrase is used, it really reduces the experience to the drug itself, and I think that the mystical experience is sometimes seen as kind of like the magic that brings about some kind of transformation without being contextualized in a certain kind of therapeutic process. And I’d like to suggest that it really isn’t quite this way, and that even when a full mystical experience occurs, the way that it is held, the way that it is worked with, the way that it is applied and connected to the individual’s life is very much a part of a therapeutic process that occurs. So: what have we learned from working with our trainees? This came out of a discussion that I had with Steve Ross and Tony Bossis a month ago and I’ve got nine points that I wanna make and that will bring me to the end of my talk for today. There is a complex relationship between spiritual states, the cancer narrative, and experience with altered states. Now we hear these words, and these words are said a lot, but actually sitting with people and trying to figure out what their cancer narrative means to them, what their life meant and how life has meaning, how cancer affected the meaning in life, and the relationship of those two to this one psychedelic experience these are like bridges that need to be made, and they need to be made actively. Just sitting back and saying “So how was it for you?” is not really going to bring about a very powerful connection unless it’s already happened. So this complex relationship I think has much to be found and discovered about it, but it’s quite important. Secondly, that there’s a great variety in the way that spiritual distress and existential anxiety present themselves. In general, the greater the mystical experience, the less active integration is needed. So this is what, you know, some of our mentors have felt, that when there’s a more full mystical experience, the integration sort of happens on its own, or kind of happens naturally. When it’s less, and there’s more of a biographical or psychodynamic, then more dynamic work is needed. Number four: involvement as a therapist in a study brings about deep personal changes in the relationship to cancer, death, and therapeutic stance. For me, this had to do with facing patients who were dying and talking about dying, looking at my own feelings about death, illness, pain, cancer pain, my mother’s death from cancer – all of this got activated in me, and I realized how much I had been living, you know, once or twice removed from these very deep existential issues, because when you work with addictions, you’re almost always working with somebody who’s going to have a new birth, and a new life in sobriety, and there’s much of a hopeful perspective, so this reduction in lifespan and the threat of dying from cancer brought about a change for me. On the other hand, I work with – in my therapy dyad – with somebody who’s been working in cancer care for 15 years, and her attunement to defenses, denial around cancer, cancer anxiety, diagnosis anxiety, the way that somebody clearly hears or doesn’t hear information that they’ve got, is very, very refined and for her, imagining this new technique – this new way of helping a certain kind of suffering that she was so familiar with, was really quite different for her. For her, it is like What is a psychedelic experience for this particular patient going to do for this very familiar form of cancer care that she’s done? Number five, and you know, this is like beating a dead horse – the centrality of the construction of meaning healing existential anxiety due to cancer, core processes that were necessary for the therapist is the cultivation of authentic presence, meditative attention, balance between overactivity and overinvolvement – usually caused by anxiety in the therapist, or detachement, which can be caused by an overvaluation of a certain kind of calm or a certain kind of meditative observation, when a more engaged or forward-leaning approach might be helpful, and the skills helpful in bringing about a mystical experience. Each therapist’s trajectory is embedded in his or her own past and path, and that there’s a great value, when you’re doing short-term therapy like this, to know how to work with patients, to know about transference and countertransference and skill, about what to open up, what to leave closed, how to work with things that emerge, how to work with crises that arrive, how to handle the subtle things that are important that you might not recognize or you might not notice if you weren’t well trained there’s a great deal of value in being a well-trained therapist. And number nine – the unquestioned value of personal experience with entheogens in working with integrative sessions, especially in working with difficult passages during dosing sessions. So I’m going to sum up with two slides. So I want to talk about the goals of the training program. There are two sets of goals: One are the goals for the therapist, so you know the goals that go in, and the other are goals that go out. The goal of the training program for therapists is to develop the capacity to support spiritual and mystical experiences in the subject, and to relate these to illness and mortality and existential anxiety. So to conduct short-term therapy work that integrates spiritual experiences, and facilitates psycholytic work. So these are a lot of words to encapsulate what I think is really the core task of what we’re trying to do and that is be both psychedelic therapists and psycholytic therapists, and short-term dynamic psychotherapists. The therapist’s goal is to become a safe, skilled, and knolwedgeable in all aspects of the process, meaning: patient selection, patient preparation, handling the session and whatever occurs in the psychedelic session, and the integration that happens afterwards, whether that’s three or six sessions, or for several years, which can occur you know, one of the people who was in our research study stayed in treatment with her dyad for several years, because it was just clinically the best thing to do. So being able to know when to do what is a very important part of adding this kind of technique to your work. And lastly, to support each therapist’s talent, maturity, and individuality, and to practice therapy that is creative, adventuresome, and unknowing, and by that I mean where the therapist is comfortable with not knowing what’s going to happen, not knowing what should happen, but having an open mind and an open heart to be ready to respond to what does happen. And the external or the far-reaching goals for the training program – these are out for the community. First, to define a training process and evaluate its effectiveness in an ongoing way. So we had to develop a training program before, or, you know, without any training ourselves, and without actually having done very much psychedelic psychotherapy in this particular context. So we sort of hit the ground running, and now, by the third round of training, and we’ve done twenty-five subjects in the study, I’m starting to have some preliminary ideas about what’s effective in training, what’s important, what’s not so important So creating a training process was an essential part of what I was trying to do, and in order to do this I just started with one that I thought up and did it and said “Okay, how is this working? What’s important and what’s not?” The next is to provide education and a normalization of psychedelic discourse, within the highly traditional medical setting. So in this study, information goes out to departments of psychiatry, departments of oncology, we have a journal club, the PGY-4’s sometimes come to our lectures, and the fellows in addiction psychiatry and in other fellowships are invited to attend. So there’s a place where psychedelic medicine is being taught and talked about, and when we go to the cancer center, we talk about this. So even though only twenty five people have actually enrolled in our study, and received dosing, hundreds and hundreds, if not thousands of people in the NYU area have heard about the study and are seeing psychedelic medicines being taken seriously, and being studied in a rigorous academic way, thereby creating a conversation for reintroducing these agents into our discourse. Third is to prepare the needs for a Phase III study in which we would be doing two or three or even four hundred subjects in the study, so we’d need a lot of therapists for that and third, to establish at least one model for a post-rescheduling world, in other words, if we were going to have Psilocybin offered as a form of therapy, and therapists were going to offer it, how will they be trained? What will that therapy look like? How will we know when someone’s a good psychedelic therapist, and somebody’s not pulling their weight or not doing a good job? And with that, we’ll bring it to the end. Thank you very much.

2 Replies to “The NYU Training Program for Psychedelic Psychotherapy – Jeffrey Guss”

  1. Currently in the process of getting a degree (masters eventually) for psychology. My dream is to work primarily with mindfulness and psychedelics as tools for my clients. Love that this stuff is coming out now, I look forward to watching the integration of these amazing tools into a therapeutic in a western, therapeutic paradigm.

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