The Psychedelic Gadfly

19 May 2023

It’s a good feeling when things start falling into place after watching them fall apart for so long.

One of the things that has been generated by all the enthusiasm associated with the so-called psychedelic renaissance, is the tendency to lump psilocybin and MDMA together as if they were similar drugs – psychedelics – that did similar things.

Now everyone working in the field knows that that is just plain wrong and as events unfurl and important decisions are made about how we can, and cannot use these drugs in psychiatric practice, the time to look at practicalities has arrived. 

The facts are that MDMA is a synthesized empathogen, not a psychedelic, which encourages relatedness and emotional openness and at the same time promotes a non-sedating mood elevating, relaxation effect. Research, predominantly coming out of the MAPS trials, convincingly supports its use in the facilitation of verbal and non-verbal reprocessing of traumatic memories for sufferers of PTSD.

On the other hand, the picture painted by psychedelic drugs like psilocybin, DMT and LSD, requires a much broader canvas where boundaries are more diffuse, colours and imagery more intense, and the overall effect more potent, powerful and unpredictable. Despite this and despite limited research, the TGA, in its wisdom thinks it’s OK for psychiatrists to prescribe psilocybin under certain circumstances which has sent those involved clinicians and bureaucrats amongst us, who are expected to make important decisions about how these drugs should be used in clinical practice, racing to lay down some necessary rules.

Although I have my doubts about whether we are ready for the psychedelics in clinical practice, I’ve been convinced for a long time that MDMA assisted psychotherapy for PTSD is going to help a lot of people and we are now ready for the sensible introduction of MDMA-assisted psychotherapy into clinical practice in Australia.

During my career assessing and managing PTSD sufferers including veterans, first responders, accident, and bushfire victims, as well as victims of physical, sexual and psychological violence, I became increasingly frustrated at how so many PTSD sufferers were not being significantly assisted by conventional treatments. Time and time again traumatised individuals with high levels of anxiety could not go back and work through, or reprocess their trauma, and successfully move on. Rather they remained stuck in their painful memories, nightmares and overwhelming anxiety. Of course, some recovered but many did not.

So when I was introduced to Rick Doblin the founder of MAPS through my friends at PRISM, Martin Williams and Steve Bright, in Melbourne all those years ago, it was the beginning of a great adventure for me. But it hasn’t all been smooth sailing especially for someone who suffers from the disease of impatience.

I can remember returning from my MAPS training in Tyringham in the UK run by Michael Mithoeffer and his wife Annie in 2014, so full of boundless enthusiasm and keen to get things happening in Australia. Martin Williams and I proposed a proof-of-concept MDMA assisted psychotherapy for PTSD study, sponsored by MAPS at Deakin University where I had an academic position. The night before the protocol was to go before the ethics committee it was rejected by the Vice-Chancellor of research on the grounds that suggested that MAPS was a corrupt organisation which promoted illegal and anti-social activities.

Soon after that I attended a PTSD forum in Brisbane run by the Queensland RSL where a key recommendation which came out of the conference was that “support for research and initiatives dedicated to adjunct/second line therapies in the management of PTSD is vital”. But my experience at the forum was disheartening because at that stage no-one wanted to hear about psychedelic drugs, let alone include them as part of a therapeutic process. 

I won’t bore you with the rejections that I and my colleagues continued to face. My way of dealing with it all was to write a novel, “The Asylum Seekers” about how the lives of many people can be harmed when only one person they are all close to, suffers trauma that remains untreated.

Despite these various setbacks over the years, I have remained firmly determined to initiate an MDMA for PTSD trial in Melbourne. So several years ago I finally got my chance to sponsor such a trial at Monash University. But again, I’ve had to deal with incredible delays which have continued to provoke my interminable impatience.

So I write this with the knowledge that finally the trial is about to proceed. As part of the trial MAPS has already generously trained 18 qualified local clinicians with a wealth of healthcare experience free of charge, which is a first for Australia. These therapists will complete the practical side of their MAPS training in the upcoming trial, working in supervised dyads in psychotherapy and dosing sessions.

It's an open label trial with 25 patients, looking at the safety and effectiveness of MDMA-assisted therapy for severe PTSD. Each patient will have the opportunity to participate in 2 dosing sessions.

You may have heard that at the same time Monash is hosting a further in-person MDMA-assisted therapist training for mental healthcare professionals, delivered by MAPS in Melbourne which will train another 60 or so therapists.

These are exciting developments I’ve been waiting for, for a long time. In my personal opinion, and I’m not saying this in any official capacity, the MAPS training should be the recognised or accredited training course for MDMA-assisted psychotherapy in Australia. But that is not a decision for me to make.

However, the fact that by years end we will have a reasonable number of MAPS trained therapists in Australia will mean that increasing numbers of PTSD sufferers will have the opportunity to benefit from this reliable and well- established treatment process. At this stage I would not recommend any other training program for MDMA-assisted therapy for PTSD in Australia. And I will be telling that to anyone who asks my advice.

I am proud to be part of this development and optimistic that for at least some long-term sufferers of PTSD, help may be on the way. Personally, I have already selected a patient with PTSD along with my co-therapist Renee Harvey, and we are beginning to navigate the challenging legal and bureaucratic requirements that treaters will need to meet before treatments can commence after July 1. More on that later.

Currently, the cost to the Australian community of managing and looking after severe PTSD victims who have not responded to treatment must be enormous. If we can show organisations such as Workcover, the TAC, and the Department of Veterans Affairs that this treatment is effective in the long term, especially for first responders, accident victims and veterans, then the cost of this treatment, which will be expensive if carried out appropriately and safely, may be significantly underwritten by such organisations.

Of course, all of this is conjecture at this stage, but I remain optimistic and look forward to developments in the coming months and years.

In the meantime, psilocybin-assisted psychotherapy for treatment resistant depression has also been legitimised by the TGA decision, and this treatment too will be available under controlled circumstances after July1 2023.

But are we ready for it?

On the one hand I’m delighted that Australia has become a world leader in the therapeutic use of psychedelic medicines but on the other hand I’m not completely convinced we know enough about such things as who is suitable for this treatment, what are the human and personality factors that are important attributes of a good and effective psychedelic psychotherapist, and is the current psychiatric approach to depression a good starting place for the introduction of these drugs into the healing professions?

To answer these questions, I want to raise some points that I’ve written about before. 

First here is a quote from the book “The Varieties of Psychedelic Experience”, by R.E. Masters and Jean Houston:

“When it finally happens that psychedelic research – left sufficiently free to realise potentials – is permitted, then that freedom must include an agreement that under no circumstances must it be monopolised by psychiatrists. Psychologists, philosophers, theologians, anthropologists, artists, scientists, engineers – those from many disciplines and fields – must be allowed to contribute to the body of knowledge that will be generated. Given the range and diversity of the psychedelic experience – and truly nothing human is alien to it – investigation must be multidisciplinary if it is not to be warped and stunted". And we must understand and agree that this work will be exploration, not subject to the kinds of restraints imposed if it were to be more narrowly defined.”

In other words, restricting psychedelic research to a psychiatric model, although the safest way to proceed at this juncture, is going to be problematic eventually if we do not rapidly and carefully expand our horizons and our understanding of what these drugs can potentially offer human consciousness.

Psychiatric diagnoses, although widely accepted and utilized are not scientifically valid and tell us little about the individuals who are receiving these drugs in our trials. Therefore, individual differences, cultural contexts, and idiosyncratic responses to the medicines are not what our trials are necessarily concerned with. Outcomes are determined by whether the psychedelic assisted psychotherapy brings about an overall improvement for the majority of people suffering from the psychiatric condition being studied.

I understand that in Australia currently it is a good thing that the research is finally underway and psychedelic therapists are being trained through these trials. But it is also important to realise that so many other factors apart from diagnoses will determine outcomes in the individuals being investigated, and these other factors are not necessarily being considered in the current research.

So on the one hand I’m all for psychedelic research, but on the other hand I think we need to remain cognisant of the fact that scientific reductionism and limited attention to phenomenology may not be the best basis for developing our understanding of psychedelics. By this I mean that what seems to be happening as we psychiatrists play a major role in how this program is to be played out, is that there is great emphasis on measurement and too little emphasis on the creative, philosophical and entheogenic aspects of psychedelics, all of which may prove to be more potent and influential than the therapeutic aspects.

In particular, psychiatrists are not trained in entheogenesis, or in other words the spiritual dimension of the human psyche. Yet this is an important and frequent outcome of the psychedelic experience, be it a healing or challenging one. So it is a no-brainer that a good and effective psychedelic psychotherapist not only have a good grasp of psychodynamic psychotherapy, but also be at peace with their own soul, not be a proselytiser, or a purveyor of self-constructed meaning, and be open to, and be able to work with, the spiritual experiences and beliefs of others, whatever they may be.

It seems to me that currently academic psychiatry in Australia is a long way from appreciating or exploring much if not any of this. That’s no-one’s fault but when it comes to the entheogenic effects of psychedelics we are left with myriad questions that are not really in the contemporary medical or psychiatric domain, even though they need to be. Carl Jung spent most of his career attempting to shift psychiatry and the mental health professions away from the dominant materialistic orientation of the medical model to a more psychological and spiritual orientation. Some of his complex concepts of the psyche serve in my opinion as a very useful model for integrating the entheogenic effects of psychedelics into the psychiatric framework, but Jung, along with Freud, is generally held in contempt by modern psychiatry as was recently demonstrated by the RANZCP rejecting psychodynamic psychotherapy as a recognised psychiatric treatment for depression.

Perhaps instead of calling this work psychedelic assisted psychotherapy, a better title would be based on etymological considerations. Let’s not forget that the psych in psychiatry, psychology, and psychedelics, derives from the Greek word psyche, meaning soul, and nurse happens to be one of the early meanings of the Greek word therapeia.

So I propose that in order to take into consideration all aspects of this work we rename it “Care of the Soul” (to borrow the title of Thomas Moore’s wonderful book).

Let’s see how comfortably that fits with our contemporary studies.

By Dr Nigel Strauss