CIIS Public Programs Podcast

transcript

 [Cheerful theme music begins] 
 

This is the CIIS Public Programs Podcast, featuring talks and conversations recorded live by the Public Programs department of California Institute of Integral Studies, a non-profit university located in San Francisco on unceded Ramaytush Ohlone Land. 

In this episode, clinician and CIIS professor Gisele Fernandes-Osterhold has an illuminating conversation with UCSF psychiatrist Brian Anderson on the benefits, risks, and therapeutic applications of psilocybin-assisted psychotherapy. 

This episode was recorded during a live online event on May 6th, 2021. A transcript is available at ciispod.com. To find out more about CIIS and public programs like this one, visit our website ciis.edu and connect with us on social media @ciispubprograms. 

[Theme music concludes] 
 

Giselle: Good evening, everybody. Good evening, Brian. It’s so nice to be here with you. Welcome. 

Brian: Thanks for having me Gisele it's great to see you. 

Giselle: Yeah, so our conversation today, we're talking about psychedelic mushrooms, and we know that they grow in many parts of the world in North and South America, in Europe, and Asia, and Africa, and Australia. Actually, in all continents, except Antarctica. And there are findings of prehistoric rock art offering a hypothesis that mushrooms were used in religious rituals 6,000 years ago.  

Psilocybin mushrooms have been used in ceremonies in Mexico and Central America as a sacrament for thousands of years, and it was first introduced to the United States here in the late 50s by Gordon Watson and his wife Valentina after they came back from Oaxaca, and it became news in local magazines. And today, as we're here, to talk about the therapeutic use of psilocybin for the treatment of anxiety and depression. But before we get into the details of what the research shows and of your work in this field. How about we set the frame of our conversation by first clarifying, the differences between magic mushrooms used in specific cultural and ceremonial contexts versus the psilocybin used in research here in the US.  

Brian: Yeah, great. So, yeah, it is I think, really important, as you already mentioned to recognize that the use of psilocybin mushrooms has a long-standing tradition in a number of communities throughout the Americas and elsewhere and that this really predates sort of the very initial knowledge that we have of this in biomedicine. So, a lot of the clinical trials that we see today are building off of research that was Initiated in the 1950s 60s and 70s, and even that medical research, you know, initially took a lot of information from Indigenous communities that have long-standing wisdom about how to use these as tools for spiritual healing and other purposes. So, I think it's a really important framing, certainly for us to start with. 

Giselle: Mhm, and also the way that the mushroom is prepared, right? So, in these ceremonies, they would, you know, many times cultivate the mushrooms and get them in nature and use it in a natural form. And in the research, when we are discussing here today, we're going to be talking about psilocybin-assisted psychotherapy. It's not exactly the mushroom that these communities used is that correct? 

Brian: Yeah, exactly so in the clinical trials that we’re mostly going to be talking about today, the investigators have used just a pure synthetic version of psilocybin, which really is just one of the psychoactive compounds that you can find in psilocybin mushrooms. And so yeah, this question does come up a lot, you know, do you ever give mushrooms to participants in research? I'm only aware of one study that actually happened in Brazil. Maybe about 10 Years ago, in a psychology department, where psilocybin mushrooms were harvested, they're chemically characterized and they were given to healthy, volunteer, participants to assess the effects. But beyond that, all the other studies going back to the 50s and 60s were- was all pure synthetic psilocybin. 

Giselle: Yeah so, the psilocybin and its related compounds are referred to as being hallucinogens because they promote a change in perception and an internal visionary experience. They are known as being psychedelic because it's mind manifesting, and they're also known as entheogen, becoming God or divine within. So, these terms are often used interchangeably because they speak of the different dimensions of the magic mushrooms. Would you like to elaborate on the effects that psilocybin may produce on the mind, body, and soul when taken in high doses?  

Brian: Sure. And you know, you listed three sort of key terms that we see a lot in the medical literature, hallucinogen, psychedelic, and entheogen. You know, I imagine that depending on the research setting and what people were volunteering for that could certainly change the outcome that people would report. What are the effects, right?  

I think it's also really notable that modern research with psilocybin, starting in the, in the 2000s. You know, the first study that really kind of put on the map a lot of This research was not a clinical treatment study. It was actually assessing the mystical type and the spiritual type affects, right. As we know the study out of Johns Hopkins by Roland Griffiths, Bill Richards, Bob, Jesse, and that team. They specifically looked at what might be called sort of transcendent effects, sort of feeling outside of oneself, connected to the larger universe around you, beyond space and time and, you know, at higher doses this certainly is seen in a number of studies, effects like that.  

And yet, you know, there's a number of different traditions that we can look at in the literature that look at lower doses as well. Moderate doses, like is used in a lot of the studies today. When we're talking about higher dose, studies, you're right. There is these kind of entheogen-like effects or you know, what people are starting to associate more with this idea of a psychedelic, mystical type effects are the sort of stepping outside of the self for looking, at the, at the core root of the word, ecstasy, sort of being outside of self. These are the effects that I think we hear most about in the news today. and seem to be associated with actual therapeutic benefit when we're looking at treating patients in these trials. 

Giselle: Yeah, it's a very interesting because if we go back to the 1960s and in Boston and that famous Good Friday experiment, which was one of the first studies that scientifically evaluated the potential of psilocybin, right? Was conducted by a Walter Pahnke and- and Timothy Leary and Richard Alpert were at Harvard at the time, and I think they actually lost their jobs there and because of this, because they were overseeing the study. That study- W- do you want to talk about that a little bit? and- and how it links to the current studies, you know, on this idea that the mystical experiences are really key, in fact. 

Brian: Sure. yeah, I mean that- so that the controversy about how Timothy Leary and his colleagues ended up leaving Harvard is complex an- and I'll leave that for someone else who maybe knows that better. I don't think it was because they particularly did, the Good Friday experiment. But certainly, some of the- what happened after that, was involved with their leaving the institution. But the Good Friday experiment was one of the studies that they conducted at Harvard along with their Concord prison experiment and others where they were examining, with the tools that were available to psychology at the time. What are the outcomes of high-dose psilocybin experiences?  

And what I think of is really notable about that study and really commendable is that they weren't just looking to see, is it a treatment? They were, and not just looking to see, does it cause psychosis like a lot of other investigators were wondering about psychedelics at the time but they- they wanted to assess can psychedelics like psilocybin when taken in a really supportive setting amongst people with a predetermined set. So, they were just working with seminarians or people who already have a spiritual and religious background. If given in a setting where they might be primed to have a mystical-type experience. Could they- could they elicit, or could they occasion what would be quantified with scales as being akin to the types of experiences that saints from the Judeo-Christian tradition had talked about in the sort of, in older texts of being in touch with a higher being, leaving oneself, and extreme states of bliss or deep knowledge. And they did find that high dose psilocybin led to those experiences more than- than people who had a control substance. And importantly they also found that sometimes people had really challenging experiences with high-dose psilocybin and that didn't actually come out in the original papers. Thanks to some of the research that Rick Doblin had done, and I think in the 90s going back and evaluating. What were the outcomes? It then came out later that some people had a very hard time with that, and so I think we need to, you know, as we talk about all these studies really keep in mind, what might be really good sounding effects, transcending of self and having a state of bliss. And then also what are the challenging and hard parts about this work that we really need to be transparent about too.  

Giselle: Yeah, and we're going to get there tonight. So, but before we go into the hard aspects of the work. So here we’re establishing that, you know, both from the research in the 60s and the research and the 2000s, like the ones you mentioned at Johns Hopkins. The- the investigation if psilocybin is conducted in a setting that is safe and that there is enough preparation and integration there are this possibility of mystical type of experiences and- and that has paved the way to look into applications in the treatment of psychological suffering, especially related to cancer and end-of-life illnesses.  

And so here in the United States, we know of NYU and Johns Hopkins, University of Maryland, UCLA, UCSF. A lot of these studies are connected to palliative care and the treatment of anxiety in the face of cancer diagnosis. And some other studies investigating the treatment of depression. So would you like to expand a little bit and talk about some of these studies, the overall research frame, discuss some of the therapeutic outcomes and also bring in a little bit of your work and research that you have been involved in. 

Brian: Yeah great. I mean the applications of psychedelics like psilocybin in palliative care is something I think is a really rich area that I think our patients could really benefit from having more rigorous information available. As you said there's been research on how to treat distress and for instance patients with cancer, going back to you know many decades the some pioneering work also from Walter Pahnke and Bill Richards in Maryland in the 1960s and 70s, as well as Eric Cast using LSD and Sydney Cohen, really laid the groundwork for some foundational studies that came out, as you mentioned, Charlie Grubbs work at UCLA that came out and around 2010 soon, followed by two studies at NYU and Johns Hopkins, that were double-blind, randomized controlled trials, comparing either psilocybin to its full dose combined, with psychotherapy. Comparing that to such a small dose of psilocybin, that it shouldn't have an effect as they did at Johns Hopkins, or an active control. Like, like niacin.  

There were large effects that were seen in really, sort of gold standard measures of depression, anxiety, and this has really, I think opened up the field for more research like this pilot study, we did at UCSF. But, you know, the big picture that I keep on coming back to you with this work is that, you know, even with this with the substance, like an SSRI, you know, something like fluoxetine or Prozac that we call an antidepressant. It may be good for depression and may help but it also probably helps some other things anxiety and other conditions. And so just because psilocybin may help depression, doesn't just mean that it's an antidepressant. And so, as we've seen some initial really positive early findings of how psilocybin therapy can help mood and anxiety in cancer patients. It's also I think telling that these studies have found measures of death transcendence, you know, change with high-dose psilocybin and there's anecdotal reports of patients find it easier to just open up and talk with their loved ones, sometimes after these treatments. And so, there's a lot of sort of interesting early data that we can follow to see how this might be a possibly an important treatment to offer people towards the end of life. 

Giselle: It's my understanding from reviewing most of the research that the focus on palliative care that addresses the psychological, the existential, the spiritual distress experienced by the dying. It has tremendous positive outcomes with psilocybin because it's described as the, the demoralization syndrome, right? That patients experience, at the end of life, and they feel hopeless and helpless and the meaninglessness. It's really an existential distress, that is at the core of the suffering, there in palliative care and- and psilocybin then brings in this enhanced sense of existential and spiritual well-being. That then it's looked at as a key factor in the improvement of psychological and social functioning to deal with that distress. Now, when you're talking about depression, then there's other components there, such as the need for psychotherapy, and I can't help but to remember this article that just came out now last month by the Imperial College of London that compares the use of antidepressant, I think Lexapro, with psilocybin. And do you want to mention something about that study? 

Brian: Yeah, the- so the study you're referring to the lead author was Robin Carhart Harris who, he and his team at Imperial College performed what is the first modern trial where they compared psilocybin therapy, meaning two doses of moderate, high dose psilocybin with psychological support. They compared that to a head-to-head comparison with escitalopram or Lexapro. Their primary outcome measure of depression didn't actually show that the two were significantly different after six weeks of the intervention but they did have a number of other measures that did show that that psilocybin treatment group seems to be doing better in terms of their depression. You know, it's great to see more trials happening. More patients having an experience with psilocybin and- and starting to ask some of these real-world questions. You know, if you have a patient that you want to consider, should I send them to a research study to try this? Or if this is an approved medication, would I, you know, refer this versus something else? It's great to see that sort of research start to attempt to answer those questions.  

And again, you know, it's not clear to me that psilocybin is necessarily an antidepressant, even though it may certainly help with depression in some patients at the same time. Something you were talking about how psilocybin might be helpful in palliative care is, you know, people who are facing a life-threatening illness may be having a sort of a sense of hopelessness or a loss of meaning in life. That can be really traumatic too. And so, to what extent, you know, should we be thinking about psilocybin as a- when combined with talk therapy as a way to treat trauma, and trauma-related disorders. You know, this is something I know that you're very familiar with this is addressing trauma. And I, you know, I really appreciate the insights of one of my colleagues, Dr. Alicia Danforth, who likes to say that, you know, any psilocybin session can become a trauma session. So how, you know, if we're treating depression but sort of traumatic experiences come up, psilocybin therapy needs to be able to address all that safely. If we're going to ask participants and patients to undergo these experiences with us. 

Giselle: Yeah, so that's the importance of, you know, assessment of the patient. Just see what is the presenting problem. What are the symptoms? You know, what are the conditions in which this person may have what kind of previous experiences they might have had with altered states of consciousness and how do we prepare them for that? And even when an experience with psilocybin or any other entheogen, or hallucinogen can be very powerful and it can induce mystical-like experiences and healing and bring about an overall sense of well-being. How was that integrated? How is that sustained? And so, we already have I think at this point in the field the- the it's established that psychotherapy is a crucial and essential part of the healing, right? Because just the medicine alone, which offers tremendous potential and awakens this innate healing capacity, that sometimes has been dormant in itself is not alone, so it does need to have a whole support system around even how these medicines are taken. With a preparation before, the right setting during, and an integration after for these to have the right effect and for some people it may not be the best type of treatment, right? And so, my question to you now is what are the counter indications or dangers in this kind of treatment modality? What are the risks or side effects? Besides a person potentially being traumatized by a journey.  

Brian: Yeah well, I mean speaking of screening, right? That's- you- you said it and I totally agree, this is, this is a key, key part of this is, is who should these treatments or these experiences not be offered to. And I think we have a fair idea. It seems like there's a fair bit of agreement in the field about there's some people who have pre-existing psychotic conditions you know bipolar disorder. People who are in extreme states of crisis already, you know, probably would not benefit very likely, could be harmed by going through these experiences and we know that for better or worse because these medicines, these drugs like psilocybin, LSD were given to a lot of different types of people in the mid-century. And so, the guidelines that we have today were sort of found by trial by fire, and it's great that we follow them. And yet, because a lot of the clinical trials are- are conservative, especially early on in a field. This is typical. There's a number of people who- patients with particular conditions who have not been exposed to psilocybin and other compounds. And so, we actually don't have that great of an idea of some of the safety parameters you know in particular again thinking about palliative care, you know how sick, how frail, might someone be that you wouldn't want to offer them, these treatments? What types exactly of heart conditions are appropriate and not, before undergoing psilocybin therapy, you know? Are there ways to use other treatments to sort of prevent a bad outcome? I think a lot of these questions still need to be asked and as we treat sicker and sicker patients for- we will, you know with informed consent and doing the best job we can to make sure it's safe, start to learn some of these parameters but you know, in general, I do worry about people with pre-existing heart conditions. This has been screened out of all the current studies, all the current trials and yet we don't have a great sense that if someone had maybe like a heart attack, two or three years ago, but they're doing pretty well today. You know, how appropriate is it to give them a high dose psychedelic session? So, we just don't actually have a lot of information on that. 

Giselle: And I can't help but just think about Stan Grof, back in Maryland when he was taking the cases that, you know people with severe mental illness, that weren't getting better with other types of psychiatric treatment, and he would take those to try out psychedelics. And so, it's pretty far out what he did there, and then nowadays, and the research, if a person has been diagnosed with bipolar, they are automatically not qualifying. So, the in inclusion and exclusion criteria for participants has changed quite a bit in these controlled trials. Any other exclusion criterias that you see?  So, heart conditions, bipolar, psychotic symptoms. Any other exclusion criterias that you would like to mention? 

Brian: One thing. I mean patients with bipolar disorder. There's at least a couple studies underway, or preparation for treating patients with bipolar 2. So, patients, who haven't had full manic episodes in the past but who do suffer from really severe hard to treat depressive episodes so that is being investigated now. And I think we'll learn more about the safety and efficacy certainly from some initial studies.  

You know, something that you and I have talked about before and I think is important, as you know, again, going back to the issue of trauma, is, you know, how do we safely work with people who have trauma histories, who maybe have dissociation as part of their condition. That, you know, it seems like that, that can be very challenging and not always beneficial for people. And yet at the same time, you know, it's a different molecule but it was really just really good to see the data that just came out about MDMA and treating PTSD, severe PTSD, including people with dissociation. So, some psychedelics might be more appropriate, and some types of psychotherapy might be more appropriate. But thinking about classic psychedelics like psilocybin. Yeah, people with severe trauma backgrounds. This- this may be very powerful, and it may you know, they may need to make modifications to the treatment protocols. Maybe lower doses, maybe more sessions of psychotherapy before and after in order to make it appropriate for people with significant trauma histories 

Giselle: What are the main challenges in conducting research with psilocybin? Has people had you know, difficult experiences. I mean it- really negative experiences. Is it difficult to- to set up a study? What are- yeah. What are the challenges there?  

Brian: Yeah, I mean I think that depends a lot on- on when you're talking about you know, if you look at some of the really pioneering work that was done 20 years ago. I think there were many more hurdles as far as concern from ethics committees, difficulty with fundraising, and a real hesitation from regulatory agencies like the FDA to see this work move forward. But thanks to the careful work of people like the team of Johns Hopkins, Charlie Grob at UCLA, the team at NYU and elsewhere. You know, this work has been- people have been able to show proof- proof of concept that you can do this safely right? Which is so important here.  

These days, there's a real blossoming of the field with people investigating, in particular with psilocybin. Its application for treating addictions, certainly mood, anxiety disorders, other things like eating disorders and OCD. And so, you know, you can do it but the many regulatory steps and just the real cost of conducting the research is significant. And there's always the question of, you know, how do you train your clinical team? I think that comes up a lot, if someone wants to start doing this work and they haven't done it before. Where do you get good supervision? Where do you get mentorship? Where do you get good oversight? Of how to train your staff to really be able to do well by the patients who are going to entrust their well-being to the- to the investigative team.  

And so I think that's a real hard part is getting a good team together who feels comfortable, especially when people are having challenging experiences and who at least have the possibility of getting supervision and learning through these experiences in a constructive way, is- is a really important part and that takes to- sort of really,  time and study and getting to know the field. 

Giselle: Yeah. And I’m assuming here we're talking about multidisciplinary teams, right? With doctors, with psychotherapists, and with usually a whole staff to be able to support patients in this long, because usually some studies are just with one journey, some studies have more, right? But it's in- any way a big holding in order to complete a treatment. And when you think about the parameters of the research, you know, including the multidisciplinary team, sometimes two therapists in the room with the patient, long hours for the sessions. You know, a thorough assessment, a lot of psychotherapy before, during, and after… doctors and you know, how do you see this kind of treatment being transferable to a mainstream offering of psilocybin assisted psychotherapy? 

Brian: Yeah. I mean Gisele, I think you did a great job there just characterizing a lot of the details that we need to be very transparent about when we are reporting the outcomes of this research, you know, who is in the room? What is the training of the people doing this work? How many hours of psychotherapy were involved in the study and did the investigators even call it psychotherapy? You know, is it enough to call it psychological support? Is that really different in nature than having a trained psychotherapist who will, you know, meet with people for multiple sessions before and after?  

There's a lot of questions I think, as a field we're to be able to start to answer. You know, how much preparation is really necessary? And for what types of patients, right? And it may be that one laboratory conducts a study and it shows that, you know, the- the headline might be “psilocybin wasn't helpful for this condition”, but it's not just psilocybin. It is psilocybin plus all of these components of really complex behavioral intervention, that if the hours of psychotherapy before, or after are different or the clinical stance of the facilitators is rather different. That may explain things far more than the dose of the of the medication. And so, I think we'll start teasing that out. But we'll have to pay really close attention to the types of details you just listed off. 

Giselle: And those details, you know, changes the results of the study and how you understand the effects of the psilocybin. And- in- so because there's always the placebo. Right? And so that's an interesting thing too because some studies that you see an improvement some of some of the MAP studies. Of course, there is a big difference and you really see that the people who did take the MDMA improved significantly and you know they have a very thorough way or following through and looking at the results after. But some people with placebo actually get better, that under certain conditions of care, that includes a psychotherapy and includes a certain holding and includes a certain way that the person can get in contact with themselves and with their trauma, they may feel better even without the medicine. And so, it's a, it's an interesting paradox. While we look at these medicines as being so, transformative, and so kind of like, like a beam of hope, you can also look at the other side, there's some sort of elements that may be healing just by itself, with a- with what gets activated for the patient. But if we're thinking about most of the clinical trials, we know that they have been focused on individual treatment and we know that it's been very expensive to run that kind of treatment. What are the possibilities for this kind of treatment to eventually become more affordable, accessible? Do you think that at some point we’ll be able to have group therapy? Or health insurance and things like that for psilocybin assisted psychotherapy? 

Brian: Yeah, you're touching on some really big themes, you know, what if this gets approved and it's not really accessible to people. What if, what if this is available but like a lot of things in mental health and healthcare only benefit some members of our communities? Is it really going to be transformative anymore? Certainly, an issue, you know, moving beyond questions of- of economics. I think, you know, when people bring up group therapy or at least group preparation and integration, if not also group administration of the medications, it may be important for us to get to the point where we can think about that as far as health care delivery and how to make it more economically affordable.  

But it- my bet is it will certainly change the intervention itself, it  will change the type of care that we can provide with psychedelic assisted psychotherapies, because of the importance of the group especially probably in integration, you know, one thing I was thinking about earlier today was how so many of the studies that we have are short, as is common in biomedical research that we don't know what the real outcome is of these treatments. Do we need to have people come back every three or six months? What is the best way to have whatever benefits people may gain, have them really endure? And you know something that is a sort of tried-and-true lesson from the communities where psychedelics have been used for a long time is that the people around you are an important part of the integration.  

So we were, we were really excited to have the opportunity at UCSF in 2018, to conduct our group therapy study with- with psilocybin and demoralized, long-term AIDS survivor men. And I think it was really powerful that the participants got to connect with each other during the study, we had group therapy before, and as part of the preparation, all of the medication sessions were conducted individually. So, the participants were by themselves with their clinicians and then we had group therapy afterwards to integrate and to sort of anecdotally…it was, it was very powerful to see the participants being there for each other, hear them talk about how they were looking forward to getting through the psilocybin experiences. Even when they were really challenging in order to be part of the group and process in a group. And frankly, sometimes the experiences with psilocybin were really hard either during the day. And even sometimes for days after people had, were still processing through some really challenging memories or visions or experiences that they had. And being able to receive support in a group from people who they thought were like them and had been through similar challenging experiences or sometimes just unusual experiences seem to be a great comfort. Especially for a group of people that are rather traditionally marginalized, gay men, and rather, isolated, long-term AIDS survivors is, you know, it's a community that was hit very hard by the epidemic, and- and have, they've lost a lot of loved ones. And so, to get to see long-term survivors, connect with one another and really open up emotionally, you know, psilocybin or not, was very powerful. But certainly, going through these experiences together was also I think a very important part of whatever benefits they may have had from the study. 

Giselle: Wonderful, that was a wonderful study that you were involved in. I love the aspect of the group work and that sense of community and- and strengthening one another and the shared space, and the commonality also of experiences and- and the possibility of being accessible. So, I do hope that in some way, you get to reproduce that in your work with UCSF. And yeah, because it's- it's a great model.  

Brian: Yeah. 

Giselle: And- and- as we're talking about the clinical trials and MDMA for PTSD is in a phase 3. We just saw the news this week, right? From MAPS of revolutionary contribution to psychology and psychiatry. Where's the development of the research with psilocybin in this moment?  

Brian: So, psilocybin clinical trials. There's been a lot of small studies. So single-site studies, phase one or early phase two. There's currently now two industry-funded studies, both looking at different types of depression. And there's also a psilocybin study for alcohol use disorder that finished recently. The results, hopefully, will be published soon out of NYU and then it looks like psilocybin assisted psychotherapy for alcohol use disorder will probably be the first clinical trial, that's sort of a phase 3 for that drug. So, you know if MDMA is first indication that go to the FDA is probably going to be severe PTSD. For psilocybin is likely to be a type of depression or possibly even alcohol use disorder before that. 

Giselle: And it's entering phase 3. 

Brian: Yeah, they're planning the phase 3 trial now.  

Giselle: Mmm-hmm. Now last November, 2020, the state of Oregon voted on measure 109. A ballot issue known as the Oregon Psilocybin Service Act, and that approved, the legalization of the use of psilocybin for adults, in controlled clinical settings for treatment of mental health issues. And so, they are planning the clinics in the state of Oregon. So, let's talk a little bit about that because that is- is happening. And what I'm curious to hear from you is that even though this measure was an incredible conquer, both the American Psychiatric Association and the Oregon Psychiatric Physician Association, opposed the measure. What- what are your thoughts on what's happening in Oregon with the clinics? 

Brian: Well, it's very pioneering for certain. I'm not surprised that this comes out of Oregon, which has also really led the way in- in this country on other, sort of controversial health issues like medical aid in dying, or death with dignity was really pioneered in Oregon. As well as, you know, the regulation of cannabis for use by adults, that happened in Oregon before it even happened in California. So, with- with Oregon legalizing psilocybin therapy, or I should say therapy with psilocybin mushrooms, going back to what we started talking about this is not going to be psilocybin that comes in a capsule form that's sold and approved by the FDA. It actually is- doesn't change anything about federal regulation of pure synthetic psilocybin as a medicinal product, but some form of psilocybin mushrooms will be available for use, like you said in a controlled clinical setting. And, you know, I look at that as a, it's part of the laboratory of the United States, where states actually, states regulate medical practice, and, you know, medical care, the FDA regulates the interstate commerce of medical products and if the state of Oregon chooses to legally produce forms of psilocybin mushrooms and make them available as a type of treatment, it's very innovative. It's very experimental. I don't know how the federal government is going to respond to that. They may choose to not interfere. They may choose to interfere. The clinics might not actually happen. We'll have to see, but I do think it's a very, again, pioneering way of providing these still experimental treatments to people, patients or people who don't have mental health diagnoses.  

But to do it well and do it safely, the state of Oregon has a lot of work in front of it. It needs to define clearly how they're going to certify facilitators, think through, what are going to be safe protocols, how often should people do this? Is it, is it okay to do a treatment once a week? Should it be no more than once a month? And importantly, I think when things don't go well, what is going to be the response, not just of the Oregon Health Authority, but also the community of providers. How are they going to learn from adverse events and train people to do better and try to prevent that moving forward? A whole sort of culture of care and science of treatment needs to be developed. So, Oregon has a lot of work to do, but I hope that we can learn a lot from what they do accomplish.  

Giselle: Yeah, it's an incredible task. So, the Oregon Health Authority is going to decide and who is going to be licensed as a facilitator, they will determine qualifications, education, training and like you mentioned, creating a code of professional conduct for these facilitators so that hopefully people can learn from it and- and sustain a ethical and liable, use of psilocybin. What are the essential skills that you think? And you mentioned that in relationship to the research too, you know, what are the essential skills that you think facilitators should have when guiding people through psilocybin sessions?  

Brian: You know, you mentioned interdisciplinary teams earlier Gisele. So, I think, I think that's really important is the if anyone wants to take sort of, take on the responsibility and onus of providing these experiences in a safe way, is first recognizing that, I don't think any one sort of professional group or any one sort of class of practitioners knows all the answers and knows what to do.  

So, if anything, I would start with good communication between people of different experience levels so that we can learn from each other. And when we don't know what to do, that we know when to refer to other providers or to get consultation. When, for instance, there may be very serious medical contraindications, that you're not sure if perhaps it's safe for someone to undergo this. And who do you look to for, you know, with humility, who do you look to for guidance on whether or not to even proceed with the treatment in the first place? I would start there.  

And then something else I think you know has been highlighted a lot in the field is it's really important to be able to build trust with people as part of the preparation to make sure that you can safely work with them and help them get through, what may be beautiful, very helpful experiences. Also challenging experiences which can be helpful, but take sort of more work to get through. And if someone is present, warm, and able to build a strong connection with people before the experiences. And really, ideally, make the experience in the treatment about that healing connection, and not just about the drug or the experience itself, that seems to be a really foundational piece. Now, how do we do that, and how do we work with people of different backgrounds, and different communities is- is a huge question.  

So, there's no, you know, one practitioner that's best for everyone. And especially when people come with different needs - isolation, experiences of stigma, you know and actually you know even distrust of the medical field. You know, how do you work with people who are seeking help but maybe have a really hard time building trust in the first place. Again, it comes back to, for me, a lot of its communication, supervision, and a good ability to learn and understand that you're going to get it wrong sometimes too is a very foundational piece. 

Giselle: Yeah, so the idea of multidisciplinary team and the knowledge of- of the both physical and psychological effects that these medicines may bring about, you know, knowledge and mental health, and the ability to support people through trauma, being experienced in diversity and inclusion and understanding people's walks of life and ways in which they, their experience has not been held right by the medical system and how to validate that. How to have, also different cultural elements represented whether that is race or, or sexuality, or gender identity, social economics. So that people can feel like “I can be myself here. I can be understood here”, right? Then we have to think also about, you know, familiarity of the professionals with these mystical states of consciousness, their- their ability to- to cultivate equanimity and acceptance. You know, in intense moments in moments of change, ability to support somebody and make meaning on an existential level of what may emerge and so there's a lot of different qualities and we're here you know representing and in some way a mainstream field you as a doctor and me as a clinician as a mental health practitioner, do you think that there's space for non-licensed clinicians and alternative healers in this field in this idea of a multidisciplinary team?  

Brian: Yeah well -I mean you know stepping back and just thinking about is -is the medical model -is treatments in medical clinical settings the -the only place that these types of experiences can and should happen, and I don't think so. I think there's you know, many traditions and use outside of medical treatment that need to be sort of respected and sort of revered for, you know, the knowledge that they have cause I just want to start by saying that.  

You know, to be focused on this question of, if these are medical treatments, particularly in the United States, if these are medical treatments, what is the role of people of different levels of credentials? You know, certainly having a medical degree, you know, graduate training in psychotherapy is- I think could probably be very helpful but is not always -definitely not sufficient and it's not always necessarily the best training. You know, I can share briefly, there was- there was one clinical trial treating patients with a mental health condition and an investigator who was sitting for participants in that study so that there was a psychiatrist sitting with him and the reaction of the patient to the psychedelic that they took in the trial was so unusual. So different from what the psychiatrist was used to, they literally got up and said that they could not stay, and they walked out of the room and made a comment about how they were not trained to deal with these types of responses.  

And so, you know, it's again, goes back to who's the team and how comfortable do they feel with the unusual responses or the maybe unusual for mainstream mental health but actually are pretty usual and not, you know, abnormal or bad for psychedelic responses and experiences and how do we get people comfortable being able to support the person for whatever they're going through? Respecting what they're going through, their process and support them even if it's not something that you yourself have experienced, even if the clinician has either had or not had psychedelic experiences. You may sit for someone who is undergoing something very, very different from what is, you know, your usual frame of reference and how do you make it about them and making sure that they feel safe and supported throughout. That's I think a lot of people would agree is pretty fundamental. 

Giselle: Yeah but I can’t help but to make a point, don't you think it is important for people who will be holding space to be familiar with those states themselves. In other words, the question is, if people interested in working in the field of psychedelic assisted psychotherapy, should they themselves have experienced personally with altered states of consciousness?  

Brian: I think the way you put it is important, you know, having experience with altered states of consciousness, whether or not someone has ever taken a psychedelic, there seems to be things about different states of mind and the body that can be reached perhaps through meditation and other sort of very intensive, focused practices that are likely to be helpful for preparing people to sit for others. I don't personally say that it should be requirement that someone has prior experience with psychedelics in order to sit for someone. But again, this is where, you know, who's the co-facilitator in the room if there is someone, you know, what's that person's experience?  

And- and I think these can be paired questions that we can -we can assess with time. Who seems to be a better guide? Is it someone who's had many sessions themselves and if you haven't had many experiences or any, are you able to listen to people who have and learn from them about how to do this in a really safe and appropriate way? You know, I'll say personally before I was even a physician and I was doing participant observation-based research and I had gotten to become friends with people who were participants in Ayahuasca churches, that were, you know, legally drinking, Ayahuasca, as a sacrament in different settings. It was very profound for me to learn from people with a lot of life experience, you know, working with these substances and I, and I personally also, I drank Ayahuasca. I've had those experiences. It's very informative for me to reflect on how, you know what, it might mean for someone to go through an experience like this and how you know, not making it about me, but making it about how can I if I'm a clinician be as supportive and helpful, as I can, my prior experiences were helpful for me, and those reflections. And so, I think it's important that people have those opportunities in ways that are safe and appropriate if they are going to take on the again, the responsibility that comes with being a facilitator. 

Giselle: Yes. So, this leads us into, you know, alongside research, alongside medicalization of psychedelics, alongside the measure in Oregon, is the -it's the other one is that instead of measure 109 it's 110, right? The decriminalization of possession and personal use of drugs. And so we know that is very important from a social-political standpoint because of the war on drugs, because of mass incarceration, and racism in this country and how a lot of people have not been able to use their own medicines and have been persecuted and put in prison because of that. So, we know Denver became the first city to decriminalize psilocybin mushrooms in 2019 and then Massachusetts, Oakland, Santa Cruz, and Harbin, Washington DC. How about California? You know? Where are the efforts to decriminalize psychedelic plants here?  

Brian: Yeah, so you know right now in the California legislature, there is a bill that's being considered to decriminalize or actually make lawful the possession and use of psychedelic substances including in small group settings, it's not a piece of legislation that would authorize the sale and distribution of psychedelics, but it would make it, you know, no longer punishable by as a criminal offense to possess and use. You know, I think there's as you're saying, a lot more recognition that many people in this country feel it's not right to put people in jail or to incarcerate people for using substances. We should -that we should treat these things as health issues, public health issues and address them accordingly. And also think about them as sort of larger social issues like you're -like you're bringing up like what are the actual -the costs of, of incarceration, of particular communities that have suffered so much because of drug laws?  

So, in California, it's interesting that there's interest of decriminalizing lots of different types of drug use, making you know for instance there's been an attempt to make safe injection sites available not for psychedelics but for other substances in order to take a harm reduction approach to public health but also for psychedelics there's there is a push to follow in the steps of some other cities like are right here in Oakland, California. There's we've had decriminalized psychedelics actually for -for some time now. Thanks to the local efforts of a number of people who, you know, worked really hard to make that happen with the Oakland city council and we may follow at a state level, but if we do again, all these issues of training, supervision, learning and again, safety all the safety around this is going to become far more important if many people feel that they might want to do start doing this or they become, you know, interested in learning more about it, we're going to need a lot more education about how to do this safely if it's, -if it can be safe, you know, and it's not probably safe for everyone, which we should also be-we should be talking about. 

Giselle: Yeah, sometimes I, you know, I like to look at examples in other places in the world and how they're doing it. And, you know, and so Portugal shows up as an example, the Netherlands, you know, Austria and Jamaica, where, you know, psilocybin is legal. And in Portugal specifically, when they really decriminalized all the drugs there was excellent results, you know, you had overdose was less, prison overcrowding was less, addiction rates fell, and cases of disease related to drug injection also dramatically fell. So, they had like an overall including yeah, so people becoming less addicted. You know, and so they had very positive results overall, the only thing is that they had more homicides because the gangs thought, you know, it was all free for all and it was a lot of encounters with the police. But other than that, on a social level and on a health level, it was better in every aspect. So, it's, you know, something for us to see how much the society would hold and how much the ethics and the -and the therapeutics would come together, if the decriminalization, you know, passes and people are allowed to, then, you know, design ways in which people can explore the safely.  

Brian: I mean, I think part of the success in Portugal was also really making available social services and health services for people who did have, you know, sometimes issues with using substances in ways that were not healthy or you know very helpful for them. And you know, I think that comes back to this issue of what are the structures that come into place. I think I always come back to this reference and my life is, you know, Brazil and how they've treated Ayahuasca churches there, you know, now and saying that they were going to be allowed to function as part of the cultural patrimony of Brazil going back many years initially, starting in the -in the 80s and then sort of that being ratified more around 2010 and it's not just that, you know, anyone goes and just makes Ayahuasca wherever they want and they drink it whenever they want. There's a very strong culture of ritual and respect of tradition, and teachings, and -and having oversight and I think it's incredibly powerful to think about how communities can organize around responsible, safe, very respectful use, and the communities can hold their own members accountable, and make sure that within themselves without the intervention of medical professionals without the intervention of legal sanctions that they enforce their own standards of safe practice. This is a very powerful way for us to think about what can be appropriate for substance use and, you know, I'm curious to see what types of traditions and social norms and social controls, you know, can be created or already have been created in the United States that we're going to start to learn more about as the, as decriminalization and regulations happen more and more in this country with psychedelics, and potentially open up new possible of forms of cultural forms, and ways of making this hopefully safe for use here. 
 

Giselle: Well said. So the larger structures, you know, like you mentioned with Portugal, it's true, their social services and programs, and therapy, and all of that and as well as the example from Brazil, communities and connection to land into culture and to your community. And so, there is an accountability and there's a support there and -and it's an accessible and available to everybody who wishes to partake in that. So, we're coming kind of to the end of our time today. But for you personally, what -what have been some of the major influences that led you to this work? 

Brian: You know, I started you know, learning about psychedelics and wanting to research them, you know years and years ago before it was much of a field and actually when many of my mentors warned me, that it was a very hard field to be in and or didn't really even exist yet, and they -many people at that time were discouraging young people like myself from even getting involved, but I found it very compelling for the reason that as a number of people have said in this field, that psychedelics seem to be compared to other forms of treatment that we have in at least in modern medicine today, they seem to be meaning-making medicines. They seem to be interventions that help people find meaning and purpose, or at least that leave people with the sensation that they've been in touch with something very meaningful. Even if, as I think we know, sometimes after psychedelic experiences, it might be hard to articulate what exactly that meaningful piece of information or that insight was but the experience of being in touch with something very profound, something that seemed to happen over and over again with psychedelics. And for me that's something that either through my work and in social sciences and anthropology, or as a psychiatrist working with patients, something about helping people find meaning in their life and in their experiences is such a fundamental I think need of people. I mean Victor Frankel said this, many people in humanistic psychology have said this and I don't know of too many other interventions that can so powerfully and potently give people an experience of really intense meaning. And so for me that underlies, it and also underlies my interested in things like demoralization and people finding meaning and purpose when they struggle with significant illnesses and I think this is a great tool for potentially addressing a lack of meaning in life and hopelessness. And I really hope, I would feel very fortunate to get to continue doing this work and see how reliably and safely we can use these tools to help people find meaning again. 

Giselle: And you're currently connected at UCSF. I know that they're bringing some special people over from Europe, but I also know that you are going to be connected to a center here in Berkeley. So, what is your vision for your work? Where are you going, what's coming in terms of your own manifestation and your vision for this work? 

Brian: Yeah, at UCSF there's a number of investigators there’s a really rich community here of people studying psychedelics both to look at sort of the mechanisms of how they maybe work in the brain but also how they can be used as treatments and it's exciting to be part of that community. But also, you know being affiliated with the new center at the University of California, Berkeley. The Center for the Science of Psychedelics. It's been a really awesome opportunity to get to work with an interdisciplinary group of researchers to think through how this center could be used for conducting human research in this area. Also, doing what I think is really important is the sort of public education around these substances and the potential impact of the research as well as working with colleagues, at- in different schools at UC Berkeley and at the neighboring institute, The Graduate Theological Union to think about how we can do really good training for becoming a facilitator and providing these experiences for a diverse set of people, whether they be patients, or just sort of healthy volunteers in research, or even religious and spiritual care professionals. It's been very rich to see a strong interest from Berkeley and GTU and people elsewhere and thinking through how these, you know, these core elements of this work – research, training, and education can all come together. So, I'm excited to see what, you know, what, we're going to be able to do there as well. 

Giselle: Fantastic. It sounds like a wonderful project and when do you think that will come into manifestation, into fruition?  

Brian: That- the UC Berkeley Center launched last year, and we hope to start our research studies early in 2022. So -so look out for that. 

Giselle: Thank you Brian, so much. It's been wonderful to talk to you tonight. And I hope that the audience received a lot of good information and feel stimulated by your presence here with us today. Do you have any final comments, anything else that you wish to say before we end our time together?  
Brian: Thanks, thanks for having me Gisele, it's a pleasure to get to chat with you. And I'll just say, you know, this is a very exciting time for the field. It seems like a lot is happening and a lot of new sort of endeavors with psychedelic medicines are coming forward and, you know, this is just a really small tip of the iceberg. All the medical research and the focus on and companies and science. I really feel is a very sort of pale comparison to a lot of knowledge that’s been in the different communities that have used these substances, some for Generations, if not centuries, and it just it's good for us to keep that in mind and keep some humility about this work. It's very exciting. And it's very promising and yet at the same time, people like myself, who do research. We're just beginning, just beginning to learn about this field and I think we should keep that in mind. And think about the people who came before us and the communities that still do this work and probably will do it, you know, for many generations to come.  

Giselle: Thank you, wonderful.  

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Thank you for listening to the CIIS Public Programs Podcast. Our talks and conversations are presented live in San Francisco, California. We recognize that our university’s building in San Francisco occupies traditional, unceded Ramaytush Ohlone lands. If you are interested in learning more about native lands, languages, and territories, the website native-land.ca is a helpful resource for you to learn about and acknowledge the Indigenous land where you live. 
 
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