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 2019 Summer issue of The Los Angeles Psychologist

Sex, Drugs, and Psychology

 

The Renaissance of Psychedelic Therapy

Stephanie Knatz Peck, Ph.D.

 

Psychedelics are experiencing a renaissance in psychiatry (Nichols, 2016). Recent studies of psychedelic therapy have demonstrated safety and promising results for depression (Carhart-Harris et al., 2016), substance use (Johnson et al., 2014), end-of-life distress in cancer (Grob et al., 2011), post-traumatic stress disorder (Oehen et al., 2014), and obsessive-compulsive disorder (Moreno, Weigand, Taitano, & Delgado, 2006). Furthermore, interest in applying and testing psychedelic therapy to other psychiatric illnesses is growing and funding proposals are underway (Rucker, Iliff, & Nutt, 2018). Classic serotonergic psychedelics include 5HT2A agonists psilocybin (the active ingredient in what are commonly known as magic mushrooms), lysergic acid diethylamide (LSD), mescaline, and dimethyltryptamine (DMT). Scientific interest in these treatment models including these drugs have substantially increased over the last few decades (Nichols, Johnson, & Nichols, 2017), with a particular focus on the study of psilocybin therapy. Additionally, further research is underway to understand the therapeutic impact of the more broadly defined class of hallucinogens/psychedelics which includes drugs with other mechanisms of neurotransmission including ketamine, MDMA, and Ibogaine among others.

 

Awareness about the therapeutic use of these drugs in both the mental health field and popular culture is rapidly increasing in large part due to media attention covering therapeutic studies and Michael Pollan’s recent book, How to Change your Mind (Pollan, 2018). However, despite recent excitement and ongoing support and study from the scientific community, psychedelics are still outgrowing their long-fraught reputation. The collective societal associations we have unwittingly inherited of psychedelic drugs as artifacts of the 1960s countercultural movement and recreational drug usage though diminishing, remain alive in mainstream culture and even the mental health field. Though an alluring story, the recreational use of psychedelics is a small—and arguably frivolous—aspect of a much deeper medicinal history beginning with ancient medicinal purposes amongst indigenous populations; progressing to the use and study of these drugs in Western psychiatry in the 1950s; and finally, to the revival and advancement of scientific inquiry championed by highly reputable academic and funding organizations concerning the potential of psychedelic therapy for a range of psychiatric disorders (GarciaRomeu & Richards, 2018). Though more research is needed to prove efficacy and effectiveness, scientific studies are continuously emerging showing these drugs as safe and potentially efficacious for a range of psychiatric illnesses.

 

A Brief History

Recorded usage of naturally occurring hallucinogenic plant medicines date back to ancient indigenous populations (Richards, 2015; Metzner 1998). In Western medicine, scientific inquiry concerning the medicinal uses of serotonergic psychedelics grew throughout the 1950s, primarily with the study of LSD after the drug was fortuitously synthesized by Swiss chemist Albert Hoffman. These studies, though lacking in scientific rigor by today’s standards, demonstrated safety and pointed to positive outcomes for various psychiatric issues. However, research was abruptly halted as psychedelics were criminalized through the Controlled Substances Act in the mid-60s in the context of socio-political factors that characterized that era. The psychedelic movement was forced dormant and pushed underground until their study was revived in the 1990s with systematic investigation of biological and psychological effects in healthy control subjects first, followed by studies investigating their therapeutic impact in psychiatric illnesses (Garcia- Romeu & Richards, 2018).

 

Applications of Psilocybin-Assisted Therapy to Psychiatric Illnesses

Clinical investigation of a variety of psychedelic treatments for psychiatric illnesses are currently underway (Clinicaltrials. gov; Multidisciplinary Association for Psychedelic Studies, 2019). Much of the contemporary research on serotonergic psychedelics has focused on psilocybin-assisted therapy. Clinical studies of psilocybin include treatments for depression, end-of-life anxiety in late-stage cancer, obsessive compulsive disorders, and alcohol and tobacco addiction. Although further research is needed to prove efficacy, preliminary results are promising and have demonstrated good safety and feasibility (Johnson & Griffiths, 2018). In a pilot study targeting distress in end stage cancer, participants reported marked reductions in both anxiety and depression symptoms up to six months following the psilocybin session (Grob et al., 2011). Treatment included a single administration of either a medium or high dose of psiThe Renaissance of Psychedelic Therapy locybin preceded by preparatory sessions focused on building rapport with a therapist and providing education on potential effects of the drug. In a small case series paper investigating psilocybin for OCD, Moreno et al. (2006) showed a reduction in obsessive compulsive symptoms immediately following the psilocybin session across a variety of doses ranging from low to high. These results proved to be durable, with decreased scores reported up to two weeks after the session. Further studies are ongoing, including a double-blind, placebo-controlled trial, to investigate the efficacy of psilocybin in reducing symptoms of OCD (Clinicaltrials.gov; Moreno, 2017; Kelmendi, 2017).

 

Psilocybin has also been tested in small trials for alcohol and tobacco addictions. One study showed a reduction in drinking behavior and cravings in alcohol dependents after a single administration (Bogenschutz et al., 2015). In a small trial in tobacco users, 80% of participants were abstinent at six month follow-up (Johnson, Garcia-Romeu, Cosimano, & Griffiths, 2014). A randomized controlled trial is currently underway investigating the effects of psilocybin treatment on drinking in alcohol dependence (Clinicaltrials.gov, Bogenschutz, 2014). Results of these open label studies are promising, though preliminary, due to the small scale and non-randomized design of these studies.

 

Though the results cited above are limited by size and study design, the application of psilocybin to unipolar depression is advancing. An international, multi-site randomized controlled trial funded by Compass Pathways is currently underway to investigate safety, efficacy and therapeutic dosage of psilocybin in individuals with treatment refractory depression (BusinessWire, 2017). Compass Pathways, an organization devoted to improving access to effective treatments received a “Breakthrough Therapy” designation from the FDA. This designation allows for expedited reviews by the FDA which would result in a swifter timeline for expanding access to this treatment if therapeutic impact is shown. (Trials for MDMA-Assisted Therapy for PTSD led by the Multidisciplinary Association for Psychedelic Studies; MAPS, is currently advancing on the same trajectory). Preliminary results from an open label study, which helped pave the way for the current depression trial, are promising. Participants who received a low dose and a high dose of psilocybin in a supportive setting with non-directive psychological support provided before and after, demonstrated meaningful reductions in depressive symptoms up to three months following the treatment (Carhart-Harris et al., 2016).

 

What Does Psilocybin Therapy Involve?

There has been no systematic study of treatment models surrounding psychedelic administration. Despite this, it is generally well-accepted that psychological support surrounding a psychedelic trip is an important element (Garcia-Romeu & Richards, 2018). The integration of psychotherapy with the administration of psychedelics represents a first move in psychiatry towards integrating “the brain” and “the mind” and a shift away from a dualistic view of psychiatric medicines and psychotherapy as separate spheres of treatment (Schenberg, 2018). Though the mechanisms of action are not fully understood, neuroimaging data suggests that psychedelics disrupt functional connectivity producing an entropic brain state and increase neural plasticity (Carhart-Harris et al., 2017; Carhart-Harris, 2019). Phenomenologically, these brain state changes may promote new insights and learning, enhance meaning, and disrupt dysfunctional and rigid styles of thinking, all of which may lead to new beliefs and behavior change (Hartogsohn, 2018).

 

Psychological support varies somewhat across studies, ranging from a short-term model of nondirective psychological support to structured therapies delivered as an adjunct to psilocybin. However, all models focus on optimizing “set and setting,” referring to a patient’s mindset and the external context (Carhart-Harris et al., 2018; Johnson, Richards, & Griffiths, 2008) features that are widely believed to be imperative to ensuring a therapeutic experience. Models of treatment are typically short-term and nondirective, borrowing from models forged in the earlier decades of study. Psychological support is delivered by a provider in a three-step model which includes preparatory sessions, followed by psychological support during the psychedelic trip, and integration sessions that follow the dosing session (Garcia-Romeu, 2018).

 

As the swift course of study of psychedelic therapy continues, our culture and healthcare communities are undergoing an important tide shift in re-shaping the popular attitude towards psychedelics as safe psychiatric medicines with the potential for significant therapeutic impact. This work will likely impact the mental health field in providing more opportunities for treatment non-responders and for mental health professionals interested in eventually participating in this work. Psychedelic therapy represents a unique paradigm of psychiatry involving the marriage of the biological and psychological. Though mechanisms of action are not yet fully understood and the role of adjunctive therapy is not yet clear, lead Hopkins researcher Matt Johnson describe the therapeutic potential as a biological effect of the drug that results in psychological opportunities for change. This integrated model denotes an opening for mental health professionals to be trained to provide therapeutic support during a psychedelic trip and therapy focused on maximal preparation and the integration of insights and experiences post-administration. This is an exciting prospect for those of us interested in participating in new and potentially more robust treatments at a time in which our currently available behavioral treatments are proving to be limited in improving mental health outcomes (Insel, 2015). ▲

 

Dr. Stephanie Knatz Peck is a clinical psychologist at UCSD, where she is a therapist on the Compass Pathways sponsored trial investigating psilocybin for treatment refractory depression.

 


 

 2018 Spring issue of The Los Angeles Psychologist

 Working with Orthodox Jewish Clients: What You Need to Know to Be a Culturally Sensitive Therapist

 

 Increasing Cultural Competence with Orthodox Jews:
A Primer for Mental Health Clinicians

Lauren Wecker, Psy.D.

 

 

Orthodox Jews face many of the same mental health and relational challenges that other people face. However, they may avoid treatment out of fear that their culture and value system will not be understood, accepted, or respected (Sublette & Trappler, 2000). This article aims to increase clinicians’ cultural competence with this population in order to improve quality of care and outcomes by presenting a brief overview of what Orthodox Jews believe. There are four topics which are common religious and cultural issues that may be encountered in the clinical setting: laws pertaining to modesty, laws pertaining to speech, family values, and holiday observance. I will also present possible accommodations to ease cultural differences and help clients feel more comfortable. Please note that while I am a religiously-observant Jew, I am not a rabbi or expert in Jewish law or philosophy. Readers are encouraged to seek consultation with a competent rabbi familiar with Orthodox Judaism for clarification on any of the concepts presented herein.

 

Orthodox Jews believe that the Torah (Five Books of Moses) was given to them by God on Mount Sinai approximately 3,300 years ago. The Torah comprises a complex set of laws that cover every aspect of life from business practices, charity, and diet, to holiday observance, marriage, and sexuality. Orthodox Jews feel that their lives are enhanced by the observance of these laws (Wikler, 2001). It is important to note that while differences may be imperceptible to outsiders, there are many variations within Orthodoxy (e.g. Modern Orthodox, Hasidic, Yeshivish) and subgroup members take differences very seriously (Wikler, 2001).

 

Laws pertaining to modesty:

Judaism posits that human beings are created in God’s image and people should therefore conduct themselves with dignity and focus on the inner qualities of a person as opposed to physical appearances. These values are manifested in the laws of tzniut, often translated as modesty, covering several areas of Jewish law such as conduct between sexes, dress, and behavior.

 

Orthodox Jews observe tzniut by avoiding physical contact between members of the opposite sex outside of the immediate family, including common social norms such as hand shaking or a supportive pat on the back. Spouses may refrain from public displays of affection, including hand holding. Clothing for both men and women that is provocative or demeaning is avoided and women typically cover their hair, and wear skirts that fall below the knee and blouses that cover the collarbone and elbows. Eye Increasing Cultural Competence with Orthodox Jews: A Primer for Mental Health Clinicians Lauren Wecker, Psy.D. contact may be minimal, especially for men who encounter women who are immodestly dressed. Finally, Orthodox Jews strive to guard themselves against vulgarity, immorality, and situations that can lead to sexual temptation.

 

Clinicians wishing to demonstrate cultural sensitivity in the area of tzniut may do so by refraining from initiating physical contact with clients, particularly with clients of the opposite sex. Female clinicians are encouraged to avoid wearing short skirts or sleeveless or low-cut tops (Schnall, 2006). Clinicians may consider exploring a client’s comfort level meeting with a clinician of the opposite sex, or consider having a same-sex clinician to limit anxiety, facilitate the therapeutic alliance, and avoid the prohibition of seclusion with a member of the opposite sex (Greenberg & Witztum, 2012; Margolese, 1998). Clinicians may also leave the office door ajar or unlocked (Margolese, 1998; Sublette & Trappler, 2000). With couples, clinicians should be cautious about utilizing interventions that encourage hand holding or hugging.

 

Laws pertaining to speech:

Jewish law prohibits lashon hara (literally, “evil speech”), which includes all forms of derogatory speech, gossip, and slander. Nevertheless, under certain conditions, negative speech may be sanctioned if it serves a constructive purpose. The laws of guarding speech encourage character refinement and foster positive relations between people.

 

Clinicians may notice clients’ reluctance to verbalize complaints against others or they may be hesitant to discuss subjects they perceive as sensitive in order to avoid transgressing these laws. Additionally, children may feel uncomfortable or believe it is immoral to say negative things about their parents, even if they are abusive (Keieger, 2010).

 

Clinicians may demonstrate cultural sensitivity in the area of speech by being empathic with clients who appear reluctant to speak negatively about others and by helping clients communicate their thoughts and feelings in a purposeful and constructive manner. Clinicians are cautioned not to confuse reluctance to share with resistance in therapy in this matter.

 

Family values:

In Judaism, family is the central social unit and marriage is strongly encouraged (Krieger, 2010; Margolese, 1998). In addition to helping people achieve their fullest potential in life, Judaism views the purpose of marriage as twofold: to increase peoples’ sense of responsibility for one another and procreation (Krieger, 2010). Orthodox Jews are encouraged to marry young and parents often assist in finding spouses for their children. Dating only occurs for the purpose of finding a spouse and engagement periods are generally short. Couples observe laws that guide intimacy and sexuality and endeavor to maintain peace in the home. Couples strive to not only have a loving and fulfilling marriage, but to also provide a home environment conducive to the development of well-adjusted and emotionally healthy children.

 

Clinicians may notice high levels of enmeshment within families (Wieselberg, 1992) and well-defined member roles, with parents holding authoritative positions (Krieger, 2010).

 

Clients may present with fear and anxiety that mental health issues will negatively impact one’s (or a family member’s) prospects for marriage (Greenberg, Buchbinder & Witztum, 2012; Margolese, 1998; Sublette & Trappler, 2000). Infertility may be particularly emotionally devastating and stigmatizing for couples. Furthermore, financial resources may be scarce due to large family size and because some choose religious study, clergy, or teaching as their primary occupation (Schnall, 2006). In addition, clinicians may be called upon to provide information and guidance to the client, parents, potential in-laws, and rabbis during the dating process or for any other issues (Greenberg & Witztum, 2012).

 

Judaism is a collectivistic culture and significant value is placed on each member’s responsibility for one another. Thus, a systems approach is recommended for treatment (Keieger 2010; Margolese, 1998). Collaboration and consultation with family members and rabbis may help reduce a client’s reluctance to engage in treatment, assist in determining whether behavior is within normative bounds, and provide valuable insight into the client’s personal, professional, and communal life. Lastly, being vigilant and judicious about confidentiality is especially important, given the sensitivity to privacy in the community (Margolese, 1998).

 

Holiday observance:

The most important day on the Jewish calendar is the Sabbath, which begins each Friday at sundown and concludes Saturday at nightfall. Many holidays have a status similar to the Sabbath, are often two days in duration, and begin at sundown and end at nightfall. In order to maintain the spirit of these special days, Jewish law prescribes activities designed to enhance joy and spiritual awareness, such as festive meals, prayer, and learning Torah, while prohibiting mundane activities such as conducting business, driving a car, and using electrical devices. Therefore, inviting clients to consider how they would manage a crisis on the Sabbath or a holiday may be necessary.

 

Final thoughts:

In addition to the suggestions presented above, clinicians are encouraged to maintain open dialogue about cultural issues and ask clients to share insights into unfamiliar practices. It is advisable for clinicians to seek consultation from colleagues familiar with the culture and/or from Orthodox rabbis, and utilize personal psychotherapy and consultation to address issues of countertransference. And finally, relish the opportunity and challenge of working with a new population and appreciate the beauty of human diversity. ▲

 

Lauren Wecker, Psy.D. (PSY23365) offers evidence-based therapies for the treatment of trauma, relationship crises, addiction, depression anxiety, grief, and bereavement. When working with couples, Dr. Wecker employs Gottman Method Couples Therapy. She is also a clinical supervisor at Chabad Residential Treatment Center in Los Angeles. When she is not in session with clients or supervisees, Dr. Wecker is an avid reader and hosts the quarterly LACPA Book Club in West Los Angeles. She can be reached at Lauren@DrLaurenWecker.com. References are available on request from the LACPA office, lacpa1@gmail.com.

 

 

 

 

 

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