Integrating Psychedelic Medicines and Psychiatry : Theory and Methods of a Model Clinic, Jordan Sloshower, 2018

Integrating Psychedelic Medicines and Psychiatry : Theory and Methods of a Model Clinic

Jordan Sloshower

Chapter 7, In : Labate B., Cavnar C. (eds) : Plant Medicines, Healing and Psychedelic Science,  2018

© Springer International Publishing AG 2018

DOI: 10.1007/978-3-319-76720-8_7



The past two decades has seen a significant increase in both popular and scientific interest in psychedelic substances and plants as therapeutics for mental illness, addictions, and psychospiritual suffering. Current psychiatric practice privileges a biological paradigm in which the brain is considered the locus of mental illness and symptom-focused treatments are delivered to patients as passive recipients. In contrast, a psychedelic healing paradigm, constructed through examination of different ontologic understandings of plant medicines, is based on a complex multidimensional perspective of human beings and their suffering. This paradigm actively engages the sufferer in addressing root causes of illness through healing on multiple levels of existence, including spiritual and energetic domains. Numerous theoretical, methodological, and ethical challenges complicate the integration of the
psychedelic healing paradigm into psychiatric practice. These include developing coherent therapeutic narratives that account for the complex processes by which psychedelic healing occurs and overcoming reductionist tendencies in the medical sciences. Tasked with overcoming such challenges, a model clinic is proposed that seeks to implement and study the psychedelic healing paradigm in a critical, interdisciplinary, and reflexive manner. Such “critical paradigm integration” would employ multimodal patient formulation and treatments, as well as a range of knowledge generation and sharing practices. Outcomes-oriented research would seek to establish an evidence base for the model, while critical dialogues would advance understandings of psychedelic substances and plants and related practices more generally. The clinic would serve as proof of concept for a new model of studying, conceptualizing, and treating mental illness.

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How can the use of psychedelic substances and plants1 help alleviate human suffering? What are the barriers to these medicines becoming part of mainstream mental health treatment? What models could be used to both treat mental disorders with psychedelics and conduct research on their therapeutic uses in a meaningful and ethical way? This chapter attempts to provide some preliminary answers to the above questions. First, it will discuss key differences between current psychiatric treatment and a proposed paradigm of psychedelic healing. Next, it will examine relevant theoretical, methodological, and ethical challenges in integrating the two paradigms. Lastly, it will outline how an integrative psychedelic healing approach could be implemented in a model clinic utilizing “critical paradigm integration.”

Psychedelic Medicines in the Era of Biological Psychiatry

My training in psychiatry at Yale University has emphasized a “biopsychosocial” approach to diagnosis and treatment (Engel, 1980), in which biological, psychological, and social factors are thought to contribute to a person’s mental illness or suffering. Accordingly, treatment interventions are meant to address problems in each of those domains. The model is fairly comprehensive and often quite effective
when a person is able to access and make use of the various possible treatments, such as medications, evidence-based individual and group psychotherapies, and social interventions. Unfortunately, this is too often not the case due to resource limitations and, I would argue, to an overprivileging of biological perspectives and technological interventions in the field of psychiatry in recent decades (Bracken et al., 2012). This shift has occurred for several reasons, including (a) helping psychiatry take its place among other specialties of medicine grounded in the biological sciences; (b) destigmatizing mental illness and addictions by reframing them as chronic treatable illnesses, like diabetes or heart disease, rather than as moral failings or resulting from weak character; and (c) promoting pharmaceuticals as the primary means of addressing mental illness and alleviating everyday suffering (Carlat, 2010; Moynihan & Cassels, 2006).

In the current era of biological psychiatry, mental illnesses like depression and schizophrenia, as well as addictions, are primarily conceptualized as brain diseases resulting from aberrant neural circuitry and chemical imbalances. To address brain-based pathology, psychiatrists commonly prescribe medications and deliver other interventions, such as electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS), that primarily target brain circuits and neurotransmitters.2 The sufferer is largely a passive recipient or consumer of such treatments and, without additional psychotherapy or lifestyle modification, is positioned as a relatively helpless victim of a diseased brain. Evidence-based forms of psychotherapy, which conversely require the active engagement of the sufferer in his or her own healing, are too often unavailable, unaffordable, or not sought out by people suffering with mental disorders. This is largely due to the current structures of insurance coverage and financial incentives for mental health practitioners in the United States and has resulted in a rise in the proportion of patients receiving
pharmacotherapy only (Olfson & Marcus, 2010).

Moreover, most pharmacological treatments currently available in psychiatry target symptoms, rather than root causes of psychiatric illness. This is due, on the one hand, to a lack of understanding of the precise biological etiologies of mental illnesses and, on the other, to the inability of conventional pharmaceuticals to address psychological, social, and spiritual or energetic3 causes of suffering. Symptoms also constitute the focus of most psychiatric or “medication management” patient encounters. This reflects the way in which mental health service provision and reimbursement are currently based on categorical or descriptive diagnoses, which cluster symptoms into disorders. In such a system, mental health providers must elicit symptoms from patients in order to make a diagnosis (as is generally required for reimbursement) and focus treatments on diminishing those symptoms. The result of this approach is often chronic drug administration, associated side effects, partial treatment effectiveness, and patient dissatisfaction (Goff et al., 2017; Samara et al., 2016;Warden, Rush, Trivedi, Fava, & Wisniewski, 2007). This in turn has led to the rise of new paradigms, such as the recovery movement and strengthsbased or resilience-based approaches, and to a rapid expansion of complementary and alternative medicine (CAM) in the West (Tindle, Davis, & Phillips, 2005).

Different Ontological Understandings of Psychedelic Medicines

Psychoactive plants have been in relationship with humans for thousands of years (El-Seedi, Smet, Beck, Possnert, & Bruhn, 2005; Torres, 1995), playing various roles in society, culture, religion, and medicine over time. Reflecting this complex historical relationship, there are numerous different ways that psychedelic substances and plants are understood and characterized by different groups of people and academic disciplines. Before outlining tenets of a psychedelic healing paradigm, I will first consider these different “ontologic understandings” (Tupper & Labate, 2014) in order to shed light on different possible ways that psychedelics may exert their therapeutic effects.

Ayahuasca will make a useful example here, given its long history of use among indigenous peoples and more recent expansion into a variety of cultural, spiritual, and scientific contexts. An anthropological or indigenous perspective of ayahuasca may view the brew as a “plant spirit” or “teacher” with which a person or shaman interacts to bring about a desired effect (Luna, 1984). Meanwhile, ayahuasca could be described in strict biomedical terms as a collection of alkaloids and other chemical compounds, primarily a serotonin 2A receptor agonist and monoamine oxidase inhibitor (MAO-I), which alter brain network connectivity and neuroplasticity (Domínguez-Clavé et al., 2016). Perhaps between these views are psychological perspectives of the brew as a “psychedelic” or “cognitive tool” (Tupper & Labate, 2014) capable of eliciting non-ordinary states of consciousness, manifesting aspects of the subconscious, and bringing about insights and change.

There are multiple other ways of conceptualizing ayahuasca that continue to evolve as its use becomes more widespread. Spiritual or religious perspectives may classify it as an “entheogen” or “sacrament,” capable of catalyzing profound spiritual or mystical experiences (Richards, 2015). More recent discourses consider ayahuasca to be an “evolutionary tool” that can help our species evolve or live more harmoniously with nature. Finally, ayahuasca and other psychedelic plants are often endearingly called “plant medicines” by contemporary users wishing to highlight their healing effects.