Good Life Project - Leading Integrative Psychiatrist | The Truth About Ketamine, MDMA and Psilocybin Assisted Therapy

Episode Date: September 16, 2024

Could psychedelics revolutionize mental health care? Psychiatrist Dr. Will Van Derveer openingly discusses his exploration of psychedelic-assisted therapies after becoming disillusioned with conventional treatments. He details remarkable results using ketamine, psilocybin, and MDMA for conditions like PTSD and depression. With the FDA's imminent decision on rescheduling MDMA, Van Derveer provides an inside look at these groundbreaking medicines' therapeutic potential. For those struggling with mental health issues, this candid conversation may reveal new hope.You can find Will at: Website | Higher Practice Podcast | Episode TranscriptIf you LOVED this episode you’ll also love the conversations we had with Adam Gazzaley about cutting-edge research he’s leading in this field.Check out our offerings & partners: Join My New Writing Project: Awake at the WheelVisit Our Sponsor Page For Great Resources & Discount Codes Hosted on Acast. See acast.com/privacy for more information.

I think the biggest message I can offer is a message of hope that the things that people are out there suffering with that seems so impossible to overcome, there are new tools being developed that hopefully will become available widely. In the case with MDMA, hopefully this year and with psilocybin next year on the federal level. It's really devastating to be dealing with a chronic illness of any kind that you, in good faith, try everything there is to try and you still don't get much return for your investment and effort. And I want people to know that these things are not for everybody. They're not a panacea, but there's an incredible opportunity here. These tools are very powerful, and they're not to be played around with lightly, but they have incredible potential.

So that's where the art of the practice comes in, is to try to discern, like, what does this person really need? So these days, you're probably seeing more and more headlines in the media about the potential of psychedelic assisted treatments. Psilocybin from quote magic mushrooms, MDMA and ketamine being explored as novel therapies for mental health conditions like depression, PTSD and anxiety. We have had a number of guests on to talk about various aspects from the research to the underground of psychedelics. But beyond the initial intrigue, I have become deeply curious. How much do we really understand about what these substances

truly are, how they work therapeutically, and the real world impacts concerns and applications for the future of mental health care? Which is why I am so excited to share this frank, science-based and practice-based conversation about this kind of nebulous world of psychedelics. My guest today is Dr. Will Vanderveer. Will is a psychiatrist, researcher, and educator, and co-founder of the Integrative Psychiatry Institute, which offers comprehensive training for mental health professionals in the application of psilocybin, MDMA, and ketamine-assisted psychotherapy. In addition to his clinical work and teaching, he's also been involved in several pioneering

clinical trials, including investigating MDMA-assisted psychotherapy for chronic treatment-resistant PTSD. Will's also a dear friend who I found over the years to be just incredibly well-educated and also frank and grounded and honest and real about this rapidly evolving and often wildly misunderstood and confusing landscape. So I wanted to get very detailed, very granular and drill down into the truths, the myths, the science applications, concerns and red flags, history, and the future of the three leading substances in this landscape of psychedelic-assisted therapy, ketamine, psilocybin, and MDMA. So we explore the profound

mental health impacts already being uncovered in the research and in practical application, the critical role of therapist guidance and integration work, as well as the personal and cultural shifts required to really embrace these powerful but highly misunderstood medicines in an intelligent and safe way. If you or someone you care about has struggled to find real relief from depression, anxiety, trauma,

or other stubborn mental health challenges, this eye-opening discussion offers a refreshing lens of both truth and possibility. So excited to share this conversation with you. I'm Jonathan Fields, and this is a Good Life Project. The Apple Watch Series 10 is here. It has the biggest display ever. It's also the thinnest Apple Watch ever, making it even more comfortable on your wrist,

whether you're running, swimming, or sleeping. And it's the fastest-charging Apple Watch ever, making it even more comfortable on your wrist, whether you're running, swimming, or sleeping. And it's the fastest-charging Apple Watch, getting you eight hours of charge in just 15 minutes. The Apple Watch Series X. Available for the first time in glossy jet black aluminum. Compared to previous generations, iPhone XS or later required, charge time and actual results will vary.

Well, it's so much fun to be hanging out and having conversation with somebody who I consider a true expert in a field that I am fascinated by and that has received a whole lot of conversation in a lot of different ways, good, bad, all the things, and also who's a dear friend of mine. So I'm excited to dive in with you today as we explore the exciting, the confusing, the world of psychedelic substances in the context of genuine therapeutic applications. So excited to go there with you. One of the things I'd really love to sort of like tee up out of the gate is you have this very long background as a practitioner, as a psychiatrist in the field out there working with clients for years and years and years. And you have made this really profound shift in originally it was in your own practice. And now it's actually, you know, in the context of really becoming a leading voice in this emerging field. So take me back to before you really ever had any exposure, before psychedelics was a part of your vocabulary, especially in a therapeutic modality.

What was going on with you and with your practice also that made you say, something's got to change? It's great to be here with you too, Jonathan. I think the first thing I'll say is that I was one of those kids who was very nerdy and very bookie and I took refuge in academics and was not in any way, shape or form interested in psychedelics as a kid, which is different from a lot of people I meet these days who, you know, have a different path. The closest I ever got to a psychedelic in college was I was looking for a friend of mine in the dorms and I heard a bunch of people laughing behind a door and I knocked and everybody got really quiet. And then my friend

says from behind the door, Will, we're on MDMA. Come back later. And then let's see, that was probably 1991 or earlier actually. And then it was a couple, you was probably 1991 or earlier, actually. And then it was a couple, you know, a few decades before it even became something on my radar. So, you know, I went to med school, got, I think, a pretty solid medical education at Vanderbilt and doing my residency in psychiatry. And still there was no word of any of that stuff at that point in time. And then I got into practice and I started doing what psychiatrists do, you know, offering FDA approved conventional traditional treatments, therapy, medication. And within a couple of years, it became really obvious how limited the tools were that I was using. And I was very discouraged.

I had poured a lot of time and effort into getting trained. It was, you know, a 10-year journey after college for me of education and, you know, a lot of hours. And I just got increasingly depressed. And about two and a half years after I had finished my residency, I quit psychiatry in despair because everything was not working the way it was promised to work. And so my career turned around when I met a former patient of mine who, after I quit psychiatry, he went and saw a naturopathic doctor. This was a guy who had crushing anxiety, terrible panic attacks, great guy. I could tell he had so much potential, but he couldn't get out

of the house. He couldn't date, he couldn't travel. And I treated him with an SSRI and cognitive therapy. And I was living the dream. I was doing the thing that you're supposed to do as a psychiatrist. And he didn't get much better. But after I quit and he saw the naturopath, he was tested for celiac disease and came back positive. Celiac is a very strong wheat allergy is probably the best way to say it for people who don't know what that term is. But as soon as he stopped eating wheat, his anxiety gradually melted away. And then he went off his medications and still had no anxiety. So that was about 20 years ago that that happened. And it was such a huge gift because it showed me that there was so much more to brain function and the link between the gut and the brain, which was not something I'd ever heard of before. So that was the beginning of a turning point for

me. And I started to get better results as I had more integrative medicine tools in my psychiatry practice. But I still had people with bad trauma who still didn't get better, even with all the integrative tools that I learned. And that's when I was kind of tapped on the shoulder by a friend of mine in town who asked me if I was interested in getting involved in an MDMA research project. And that was in 2011. And I said, isn't that the stuff that causes holes in the brain? I was very skeptical. And the guy, his name is Rick Doblin, who runs MAPS. I don't know if your audience is familiar, Multidisciplinary Association for Psychedelic Studies, done a lot of the sponsorship of MDMA research, flew out from the East Coast and kind

of talked me off a cliff and said, look, you know, there's a good research here. Look at the papers. I read the papers and being the academic nerd I was, I saw the results and I said, well, this is way better than anything I can promise my patients. So I got involved and I watched what can happen when people get MDMA-assisted therapy for chronic trauma and what happens after. It's just quite incredible as a practitioner to see a tool work so much better than what I had before. It's fascinating, right? Because as you said, 10 years of education and you're doing all the things, everything that you've been taught to do, you're doing. And still, it's just so often, it's not working. I've often wondered, right? From the standpoint of a patient or a client, it's got to be just incredibly brutal depending on why you're showing up, especially to just try thing after thing after thing and feel like, is this just the way it's going to be? There's no hope. But I think a lot of people probably often don't wonder about what it's like for the

practitioner, for the professional on the other side to experience that and say, I'm doing everything I've been taught to do. I'm using everything that I feel like I have available to me. And it's still nowhere near close enough to helping people get back to where I wish they could be and they wish they could be also. And it sounds like for you, a certain moment, it became existential in terms of almost leaving the career. Exactly. Exactly. It's so devastating when you care so much about what you're doing. And it doesn't have to be healthcare, but in my case, providing excellent care and getting good results with people is such a huge priority and existential fulfillment. When it happens,

to not have that experience is just crushing. And I think there are a lot of, I meet a lot of psychiatrists who are out there feeling that right now. When you get involved eventually, and you start to see what's happening with MDMA-assisted therapy, and we'll go into, for folks listening, we're going to go into some sort of like the three major substances that are being researched and used in a therapeutic setting, especially in clinical settings. It sounds like a light bulb really goes on for you. And you're like, this has to be a part of what I do.

But it also sounds like there was an earlier light bulb for you, which was the one where you described that patient coming to you and you're saying, okay, so this is this whole other thing that I was never taught, the relationship to the gut and the microbiome and how that can literally affect somebody's mental health. It sounds like you're already tracking in that direction. Like I need to actually step outside of the confines of what normally is practiced. When you get exposed to the research and then the practice around this therapy, how do you go from there to then completely changing around your practice and then eventually collaborating with some others to

launch an institute to really study, to go deeper into this, and then to start to understand how do we spread the word in a really intelligent, well-thought-out, science-backed way and begin to train professionals in actually being ready so that when this becomes more popularly available, we can hit the ground running. As I started to see what was happening in the clinical trial I was a part of here in Boulder on MDMA-assisted therapy for PTSD, it started to gradually dawn on me the existential problem of, wait a second, I, you know, using that patient we talked about earlier as an example, I worked with him for a year and a half and saw him once a week and, you know, we had very little show for it. And it becomes an ethical dilemma too of, wait a second, I just saw people on average,

the participants in that study had more than 29 years of PTSD symptoms entering the study. And at the 12 month follow-up, fully two thirds of those people no longer met criteria for PTSD. So I was watching something happen that I didn't have access to because MDMA, as we'll talk about later, is still scheduled on schedule one, you know, so it's considered by the DEA to be as dangerous as heroin or crack cocaine and so forth. But I didn't feel great about taking people's money for my time, you know, in my practice, offering them something that would take maybe two or three or four or who knows how much longer than what MDMA therapy promised if they had access to that. So at that point in time, I had started to hear about ketamine for depression and trauma. And I started going to

trainings and conferences about that and learning about it and began to incorporate that in my practice. And ketamine is very different from MDMA. We can get into that. But that was sort of the first thought was, okay, well, it's going to be a while before MDMA gets reviewed by the FDA and hopefully enters the mainstream. We've got to do something that's more effective and time efficient and cost effective for people. You've talked about ketamine and MDMA, you've named these things. So let's just dive into some of these substances because so many people have heard this, and people haven't heard the actual MDMA as a name. They've probably heard its other names for that one particular substance. So ketamine is one of these things. Why don't we

start out with ketamine? And we'll progress from there through, I think, psilocybin and then MDMA. So we can really understand what these are. And I think ketamine is a good launching off point also, because as you said, this became a really central part of your practice and then your practitioner training. But also ketamine, it's different in the others in that it has a very different status in terms of its available use and approval through the FDA. So what actually is ketamine? Right. Ketamine was developed, this is an interesting little anecdote about ketamine, that it was developed as an anesthetic drug. And its development was built out of an intention to delete the downsides of PCP as an anesthetic.

So PCP, for some people may not know that that was actually an anesthetic that was used in the 60s. The downside of PCP, which you will see when people are intoxicated on it, it's not very popular anymore, but in the 70s, it was more popular. People get very combative and violent when they're coming off a PCP. And in recovery rooms after surgery, that's not a great situation. You've got a wound with sutures and you've got staff who get injured and so on. So they develop ketamine to have the benefits without the drawbacks. And its main personality, I would say, quality is dissociation. So it causes you, it's really hard to describe in words, it causes you to feel like you're disconnected from your body for a period of time, not very long. It's pretty short acting. And it was not

known to have any applications in mental health until really the 1980s and 90s. But even then, it was very quiet and fringy to use ketamine for depression or trauma or psychotherapy. It wasn't until a paper came out in the year 2000 that showed research connecting relief from depression from ketamine. And that led into interest at the National Institutes of Mental Health. A big study that was done in 2006 that showed remarkable decreases in depression scores within 24 hours of a ketamine infusion. And that led into a great deal of interest in research. Looking at analogs to ketamine that could be useful led to the FDA approval of a form of ketamine called Spravato that's a nasal spray, and it

led to the proliferation of ketamine clinics all over the country for the treatment of depression, anxiety, PTSD. Ketamine is, as you said, not illegal, So it's widely available, fully legal, and it definitely has a role to play, I would say, in the toolkit of someone like me. But it also has significant drawbacks that we should probably get into that are quite different from the other two drugs we're going to talk about today. And I want to get into those drawbacks, but I want to fill in a couple of holes here along the way too. So to make sure I understand, it was originally developed as an anesthetic and I guess it's still used. It's still a very popular anesthetic. So when you described it as being dissociative, it can be dissociative to the point where there's a complete absence of

consciousness where, you know, in the more therapeutic use that we hear about now, the dissociation is often described, and maybe this is why it's often bundled under the, you know, the umbrella of quote psychedelics as you know, like you, you leave your body and you go on a journey. Right. Explain what's actually happening there more to me. Very important point you're making is that the depth of the ketamine, we'll call it dissociation or the journey that you're on is very much dose dependence. If you're dealing with depression or trauma and you go to a clinic, you're likely to get a dose roughly equivalent to half a milligram per kilogram of your body weight. That's what's been studied in the research for depression.

If you're getting ketamine for procedure in the emergency room, like sewing up a cut from an accident on your face, for example, really common use for ketamine. The dose is more like four milligrams per kilogram, so eightfold higher for the full anesthetic kind of dose. So that alone is interesting because it creates kind of a rainbow of different applications for ketamine based on the dosing. To make things even more complicated with ketamine, and we can decide how complicated we want to get in the research is intravenous ketamine, ketamine infusion. And in general, that's how it's used when you get it at the emergency room for an anesthesia

experience. It's also what a lot of clinics provide for depression. But there's also the opportunity to use ketamine intramuscular, where you just have a shot and it goes right in the muscle. It's a very different experience from intravenous. We could talk about that. But it's really practical for combat medics to carry ketamine in the combat theater where they can knock someone out with ketamine who's had a terrible injury and put them on their shoulder and carry them out of there. So that's an important element. And then you have intranasal ketamine,

which I mentioned earlier, a form of which has been FDA approved for depression. And then you also have sublingual ketamine. So we now have online prescribing organizations that will, for a 10-minute interview online, you can get a supply of ketamines into your house, and you can take it sublingual, unsupervised. Maybe you can tell I have opinions about that. Yeah, the tone of your voice has changed pretty dramatically there. And so I'm curious about these four different modes of administration. It sounds like intravenous and intramuscular, probably pretty fast-acting, right? And it sounds like you have a reasonable amount of control because you're administering an exact dose over a specific

amount of time. Intranasal, longer to actually take action? Correct. Longer, messier, less precise with the dosing. Right. And the lozenges or the sublingual, similar to intranasal in terms of less control, stuff like that. That's right. And with the sublingual, there's a very unpredictable range of how much gets absorbed into your body. So that's part of what makes it really difficult to know what the right dose is for someone to take on any given treatment day. Yeah. Now you also just described that there are certain ways where now you can actually get this literally sent to your house after a 10 minute consult or something like that. And clearly this is not something that in love with as an option, which I think brings us into

the concerns around not just the substance, but also the various ways that people access. So why don't we head into that conversation? Yeah. I think this for me starts with a fork in the road where on down one side of the road, you have more of the philosophy that I was taught in medical school where the medication is, if not the whole treatment, it's most of the treatment. So the molecule does something to you, you put the molecule in your mouth and you're good to go. You know, it's a promise of a chemical, a radical chemical shift in you from taking something in your mouth. On the other fork, down the other fork of the road,

which is what I've come to understand is for me a much more robust effect if we can follow it, is the fork in the road where the chemical is a catalyst to open things up that you need to look at. Injuries or the traumas or the problems in childhood or whatever the thing is that is underneath psychologically driving the symptoms that you're experiencing. So the benefit of the sublingual, going back to that for a moment, is that you could take a sublingual tablet to your therapist's office and you can have what I just described on the second fork in the road. You could have a deep healing process looking at your traumas, working through things with the support and the

opening that happens from ketamine. That can also happen with the other routes of administration, but it's more of a medical setting typically where, you know, if you're going to get into needles or IVs, you've got a whole medical staff and set up in a clinic. So from the perspective of accessibility, the sublingual can make a lot of sense. From the point of view of safety and control over dosing and so on, it's probably going to be an IV or intramuscular route. The thing I'm most concerned about is people having an experience with ketamine at home or anywhere else where difficult things are coming up, but you're by yourself and there's no one to help you. And, you know, I'm not interested in sort of taking this paternalistic,

I'm going to scare you to death kind of perspective. I don't think that really is very useful, but I know so many people, both patients I've treated who had scary experiences without enough support and then had to come to us to now they've got another layer of trauma to deal with. Or friends who took psychedelics in a non-medical setting by themselves in the woods or somewhere and had really scary experiences and thought about killing themselves out of the blue. You know, it was like a brand new experience for them. So these tools are very powerful and they're not to be played around with lightly, but they have incredible potential. And we'll be right back after a word from our sponsors. I knew you were going to be fun. Tell me how to fly this thing.

You know what the difference between me and you is? You're going to die. Don't shoot him, we need him! Y'all need a pilot? The Apple Watch Series 10 is here. It has the biggest display ever. It's also the thinnest Apple Watch ever, making it even more comfortable on your wrist,

whether you're running, swimming, or sleeping. And it's the fastest-charging Apple Watch, getting you eight hours of charge in just 15 minutes. The Apple Watch Series 10, available for the first time in glossy jet black aluminum. Compared to previous generations, iPhone XS or later required, charge time and actual results will vary. Thank you, Terry. practice, there seems like, and this is starting to be a little bit of what you're referencing, is there's a little bit of a divide in this world. There's the, quote, underground of psychedelics, and then there's the, I don't know, what's the opposite of that? Above ground world? Yeah, above ground. Which is sort of, you know, like the science-based, clinically-based, research-focused

world. And on the one hand, you know, it's easy to have a knee-jerk reaction and say, like, this is clearly better than the other. But what I've learned through conversations with you, with her, and through many others is it's not quite so clear. Part of what we lose in a purely clinicized approach to these substances is what has been described to me as the knowledge that comes with a lineage of having, you know, use these substances in very different settings, but often in therapy, we're not talking about using it as a party drug and as a therapeutic modality for sometimes hundreds or thousands of years and the people who have passed on the wisdom of how to do this in a safe and

intelligent way. So talk to me a little bit more about like, let's open this door about this conversation about these two different worlds and how to explore them in an intelligent way. Great question. I would like to add a third realm. We have, as you said, the clinical, and then we have what I would call the ceremonial, which is this deep and longstanding human tradition of choosing to alter our consciousness with a substance. That goes back many, many thousands of years, as far as we can tell. And then I would say the third category is recreational use. So we don't really need to

spend a lot of time on that today, but there is a big world of folks using substances to have a fun time with their friends. And I'm not here to be a party pooper either. I know that people have a lot of fun and can get a lot of value of those experiences too. It's just that when you're in a non-contained environment, and I would say the ceremonial and the clinical both are contained environments in different ways. There's people there with you whose job is to help you navigate difficult situations. So I think that I'm not a professional anthropologist, so I'm not an expert in ceremonial use. I've had the privilege of getting to participate in ceremonial experiences with ayahuasca and peyote. And I think that's the extent of it actually for me. But what I personally

experienced I can speak to is that there's a different set of intentions and a different framework of understanding of what's actually happening in the experience. To be more specific, the experiences I had in ceremony have been deeply meaningful around reconnecting my sense of connection with the universe and with nature, with plants, with the other inhabitants of planet earth and so on. Really deeply meaningful. And the leaders of those ceremonies that I met were not, so to speak, trauma-informed. They weren't carrying this clinical toolkit. They weren't seeking, they weren't prepping people for ceremonies saying, hey, we're going to work on your trauma tonight. It was more like, hey, you're going to relate to

your own experience. You're responsible for yourself. We're here for an emergency, but you need to sit with your experience and see what comes up. So more of a spiritual context and intention than, hey, we're going to be working on this diagnosis with you, right? So, there's sort of like, I think of the spiritual work differently from the let's go after this, maybe you could say medical condition that we think that you're dealing with. Now, in psychiatry, it's funny because we have, well, it's not funny for a lot of people, but we have this dilemma of, is this a spiritual illness that is in front of me, or is this a medical illness, right? And often I find as a psychiatrist, there's a lot of overlap between the deep despair, especially since the pandemic. I mean, this has been a massive hockey stick kind of curve

situation with isolation and loneliness and all the intensity in the political realm right now. But we also see biomarkers that are of inflammation, and we see gut-brain axis issues coming up. And the subjective experience of depression might feel similar for someone dealing with either more of a spiritual type of illness or more of a physical illness. So that's where the art of the practice comes in, is to try to discern, like, what does this person really need? That makes so much sense to me. One of my curiosities also, and I'll probably ask this about each of the substances, is, is there a fairly, quote, standard experience that is associated with a particular substance? Or is it really just completely span the gamut of who somebody is, like what they show up trying to work on, what their history has been, what the dosage is, who's with them when they're doing it?

Is it just completely unique? Or is there some sort of generalized narrative arc of the experience? There can be a narrative arc of the experience, but more commonly, and I'm speaking mostly from our experience with ketamine-assisted therapy for depression, the nature of the drug experience is radically different from one session to the next, even within one person. It's just so unpredictable. It's quite interesting. With the MDMA work that I did, experience is radically different from one session to the next, even within one person. It's just so unpredictable. It's quite interesting. With the MDMA work that I did in clinical trials, I saw more of an arc. The protocol we were working on had only three MDMA sessions. And it was interesting, and they were one month apart. So you would see,

you know, sort of a beginning, a middle, and an end to the three-part series. And it seemed like the medicine often supported people to go deeper later. After one or two sessions, they're pretty deep into the earliest experiences of their life. So that's just kind of a gestalt that I have about those experiences. They can be way across the board. You, towards the beginning of describing ketamine, you described how it is dissociative. And for people who don't understand what that means, my understanding is effectively it's the feeling that you're literally dissociating from your physical body. I've had people describe it to me as they

were sort of like floating above or out there. Is that kind of right? I think that's a fair attempt to describe it. There's an old Woody Allen movie, Annie Hall, where there's a scene where Annie Hall rises up above her body while she's having sex with Woody Allen and she's kind of on the ceiling looking down at what's happening. And I think that's a pretty decent visual attempt to describe what it's like to be out of your body and watching from a different point of view. You could also have a deeper experience where it's hard to find your point of view or hard to find your body for a period of time. If that happens, it can be pretty scary or it could actually feel really blissful for someone who has chronic pain, for example, which actually brings up another piece about ketamine that we haven't touched on that probably is important to mention is that people do get into trouble with ketamine. Ketamine has addictive qualities to it. And I think that's under described about ketamine. So I think it's important. The Matthew Perry case at the end

of the year, his unfortunate death at home in a hot tub on ketamine, I don't know much about his life, but I know that he struggled with addiction from his memoir quite a bit. And I think that for people with chronic pain like him, the relief that's promised by ketamine can be very compelling. Which really brings us to the notion of who is this not okay for? Let's start with ketamine. Ketamine is probably not a great idea for someone who is prone to dissociation or who's already dissociated enough to be unable to really function well in their life. So putting your thumb on the scale of dissociation is not a great idea if it's already there. There are folks who have cardiovascular situations that are a little too dangerous for ketamine. Ketamine increases your heart rate and blood pressure for the time it's in your body. Not significantly for a healthy person, but there are people who should not take it for that reason.

And then someone with a past history of ketamine addiction, I would be very reluctant to offer ketamine too, just to spark off cravings and renew a pattern that they've put behind them. Yeah, that makes perfect sense. And by the way, for everyone listening, I think it's probably clear, but just to make it abundantly clear, nothing we're talking about here. Will is not playing the role of a medical provider. There's no advice being given. There's no prescription. This is really an exploration of

what are these things? How do they work? So we can just understand what's happening in this world in a more grounded and practical vetted way. Unless there's something that you feel like we've missed in the conversation on ketamine, I think why don't we move on to, I think we'll wrap up with MDMA, but why don't we drop into to, I think we'll wrap up with MDMA, but why don't we drop into the middle, just a little bit of psilocybin. So let's start out with that same question, which is when we're talking about psilocybin, what are we actually talking about here? Psilocybin is a molecule that's found in a variety of so-called psychedelic mushrooms, about 20 different species that are known to contain psilocybin. And these mushrooms have been in continual ritual ceremonial use for many thousands

of years all over the world, ranging from the Mayans and other tribes in Central America to Siberia and all over the place. So they're very traditional, you could say, over the course of human history, and they've proven to be, from a medical standpoint, extremely safe. There's very few stories of a medical problem on psilocybin. So with psilocybin, the bigger danger is the psychological danger, And we can go deeper into that. But in recent years, through the work at Johns Hopkins, Roland Griffiths recently passed. Other groups, New York, San Francisco, have produced a body of research that's very compelling around psilocybin being used for chronic depression. And it's also been studied for a bunch of other things like obsessive compulsive disorder, eating disorders, end-of-life anxiety,

cancer anxiety, and even PTSD. But the main conversation with psilocybin in the medical context is around depression. So psilocybin has been on the DEA Schedule 1 since 1970 under Richard Nixon, the Controlled Substance Act that also made LSD illegal and a few other things. phase three studies on psilocybin for depression that could result eventually, it's going to be at least a year before we hear about this, but it could become an approved treatment for depression. Now, the states have started to sort of take things into their own hands with psilocybin. So that's a whole nother complexity here where Colorado and previously Oregon and have passed measures. And then you have other states, about 20 other states have bills in various stages of being considered at the state level. So it's an interesting time for this vast landscape of different compounds and different

jurisdictions and different pros and different cons and different access for different people. It sounds like with psilocybin, the traditional use was ceremony for thousands of years, potentially. It still is not available. It's not FDA approved. It's still Schedule 1 to this day, from what I understand, even though certain states, as you said, there's this kind of strange patchwork on a federal level, not okay. On a state by state level, and we're seeing this with different substances now, there's a whole wide landscape of what is or is not allowed. And you said the research is showing a whole bunch of different uses, but really for depression and from what I understand, anxiety, it can be incredibly effective too. And that's where a lot of the focus has been. I think a lot of the early work that I had seen was, I think this is what came

out of Johns Hopkins was end stage cancer patients who are really struggling with an existential anxiety and depression and angst. And it was, am I right in that the research said that it was literally one session that profoundly changed this for many of them? One session, and people often described their one psilocybin session as one of the top five most deeply meaningful experiences of their lives on par with the birth of a child. So deeply meaningful experiences for folks. And in many cases, diminish the fear of death to a point where a person could walk across that threshold, or maybe not walk, but pass across that threshold of death without the fear that is so common for almost all of us about what's on the other side there. I wonder if you're aware of any research, So we do know that with conditions like this, especially if it's end stage or terminal three, that a person's psychology can play a substantial role in the state of their physiology and in how their physiology responds to the presentation of a disease. Sometimes to the extent of,

you hear stories about these miraculous stories of spontaneous remission, which from what I know, nobody's really understood what's happening there. But if you accept the fact that when you're struggling with something that's really challenging your physical body, that your psychological state will have a profound effect

on how your physical body relates to this intruder, invader, disease, illness, does it stand to reason also that not only might it help somebody really just shift the way that they process what they're moving through psychologically, but would it potentially prime their system to be able to actually fight this thing more effectively? Well, there are a number of different mushrooms that prime the immune system to support people to fight off the invader, whether the invader's a virus or bacteria or cancer. As far as the psychological impact on the disease progression, and specifically what you're asking. I don't know of any evidence that shows that psilocybin bends the arc of the disease, of the cancer process itself. But

there are always anecdotal reports that you hear about of people making peace with what's happening inside their body. And that seems like a very good idea for a number of different reasons, whether it's spiritual, psychological, or physiological. The stress chemicals in our body that get activated when we're in fight against something are not great for long-term health. You know, they're fine for fighting off an acute invader. But if I had a cancer diagnosis, I would try all of it, all the different ways to try to find the lever to move the world, to move the psychological, the spiritual, and the physical. Is the nature of an experience with psilocybin meaningfully different from what you've seen from the nature of an experience with, say, ketamine?

I think it's very different. The content can overlap for sure, but the experience of psilocybin, and we're running a center in Oregon under the Oregon rules where we have students coming through and having psilocybin experiences all the time. So we're also seeing a lot of people move through that center and sharing their experiences. And I would say that the psilocybin experience is a bigger experience for most people. It's longer, it's deeper. It can be a lot harder to navigate than ketamine. Ketamine can feel hard to navigate for a few minutes and then it's over. But with psilocybin, you're in for a six-hour experience. And so it's sometimes said by experienced guys that you're done with the medicine before the medicine's done with you. So these experiences, deep connection with oneself, with others, with our families, with deeper essence of meaning, these are more consistently experienced with psilocybin, I would say, than ketamine.

Ketamine more consistently has this dissociative effect that has this benefit of sometimes seeing the forest for the trees, or sometimes people will describe floating up above the forest so they can see what's going on in their mind or in their lives. But that's a pretty different subjective experience from feeling the sense of camaraderie with the trees around the center where you're taking the psilocybin, for example. It sounds like also the duration of this is a really big difference, six hours versus anywhere from minutes to an hour or two with ketamine, depending on the dosing. You also brought up something which we haven't really touched on directly, but let's actually touch on it, which is you earlier, this is what we were taught to do in psychiatry. Like here's the pill, here's the thing that you put in your mouth and you're on your way. And you know, again, six weeks, it either does or doesn't work. These substances are different in that they're pretty, well, I guess with the exception of some of the circumstances, the home uses you described, but really in a more directed therapeutic way, you don't just take the thing and then it just works. There is an experience that goes along with this.

And often this is something that is intelligent to be an experience that's guided by somebody who knows what they're doing. These are what we call evocative treatments rather than suppressive treatments. So when I prescribe an SSRI for depression, I'm suppressing the symptoms of depression with the SSRI and the suppression of the symptoms continues for as long of depression with the SSRI, and the suppression of the symptoms continues for as long as you take the SSRI. And then if it works well, it does a good job. But then when you stop it, the suppression is gone. So people often have recurrences of depression after they stop. The evocative approach, and this also was applicable to this MDMA protocol I

mentioned earlier with three MDMA sessions. With psilocybin, the research is showing remarkable long-term changes in depression symptoms after either one or two session protocol. And those sessions can be sometimes really challenging because you have all this material from your unconscious mind coming forward on digested experiences, traumas, and so on, and sequencing that the body wants to do in those sessions that need support to move to completion. So an effective guide is really important to someone who's well-trained and knows how to support you through that, but also someone who has a really deep comprehension of ethics, of holding space with a person who's in an altered consciousness, who's really vulnerable, not just vulnerable to boundary violations, very overt problems like that, but they're also more suggestible. So the things that you do, the things that you say, or the things that you choose not to say, have a huge impact on a person who's with you or the people who are with you and the setting. I know Adam Wazali, who's over at UCSF, has an entire lab. He's partnered up with Robin Carhart.

And a lot of the work that they're doing, I mean, they're trying to study intensely, like what actually is set and setting? Like what are the elements that matter? What are the elements that don't? What's just mythology? And can we actually isolate these things? Because if we can, that would help in being able to create, to replicate the things that are truly effective so that you could potentially scale the impact of this with more consistency. So the guide, I guess, would be a part of that conversation around this thing called set and setting. Would that be right? A hundred percent.

A hundred percent. The set, well, setting I think is obvious, right? You want to have a quiet, protected, mellow environment to have your experience and have a person there who you trust who can support you, but not over-support you to make a lot of room for you to have your experience. The set is oftentimes referred to as the set of intentions or beliefs that the participant or, you know, person who's going to take the psilocybin has. But what's often forgotten is that there's also the set of expectations,

the set of training, the set of ethical standards, and so on of the guide, and also the depth of the experience of the guide. So what I love about Adam's work and Robin's at UCSF is Adam's really interested in, we had a conversation with him last year about this, that trying to, as you said, scale the availability of this work, recognizing that a guide who has 20 years of experience is really different from a guide who has, you know, 20 minutes of experience. An online certificate. Exactly. So how do you help these folks? It seems to me there's plenty of people who want to do the guiding, and then there's a lot of excitement, which is wonderful.

But there's also a very different landscape when you're supporting a participant in the terrain inside of that can get very intense. The places inside of us can be dark and scary, or they can be beautiful. I like to think about the Princess Bride, like you've got the fire swamp with the rodents of unusual size. It can get really scary in there. So having someone who doesn't freak out when you're having a difficult experience is super important. But that ability to hold one's seat and not panic as a guide, it doesn't come immediately for people. It has to be practiced. Yeah, and I would imagine also to find the line between ensuring that the person is safe, but not trying to stop them from having the experience that they need to have for it to actually be therapeutic, which may involve scary moments.

100%. And this is one of the biggest questions that comes up in our training for therapists who want to be psychedelic guides is, when do I call 911? When do I call for backup or help? Because you can really cut off a process that's essential for someone to move through something, but it could look and feel very intense for a guide. And one great example, I have a friend who's a very experienced guide in California, and she was telling me this story recently about working with a large, physically large man patient in her office. And he reached out and grabbed her and pinned her down

on the couch. And as I said, my friend's extremely experienced, but she also holds the view that an experienced person holds, which is like, hey, this is probably part of the therapeutic process. I'm going to keep an open mind. I'm going to call for help, which she did, and then got the help. And then there was a whole process of, well, what happened there? And he was holding on for dear life in a literal way, right? The metaphor became literal. And so there was this beautiful opportunity to look at, well, let's look at how you're holding on for dear life in the life that you're living. How can we help you loosen the grip?

I think that also brings up the conversation around this other phrase that you often hear, which is integration. So after the example that you just shared, or somebody has, they have a session, it shakes some serious cobwebs loose. It's not like you come out of that and you're like, wow, that was really brutal. I am so glad it's over. I'm good. Right. It's Miller time. Let's crack a beer. Right. Oftentimes there's stuff that you really need to process and maybe stuff that you've actually compartmentalized for years or decades. And you've kind of like been going through life and saying like, I think I'm okay. And this kind of pries open those compartments. And now it's

not a matter of it. It doesn't automatically make it all good. Now you're at a state where you're like, oh, this is actually on the surface now. Now there's an integration and a processing that often has to happen after. Absolutely. I can think of a number of examples of the hard work that is involved in integration, you know, where, for example, you might wake up to in the midst of a psilocybin experience that you have a lot of self-hatred and it shows up in the form of eating fast food every day. And the question might come up of, wait a second, do I really love myself? Why am I treating my body like trash? You know, why am I being so cruel to myself?

And then in the integration period, the question can come up is, well, am I going to continue doing that? And fast food can be extremely addictive. You know, there are chemicals in there to make you want to go back and get more of that Taco Bell and so on. So the actual rubber hits the road when behaviors start to change and new habits form that become your new reality of that support, the wellness that you've been wanting for the rest of your life. You have to keep investing, right? You don't get to just cross the finish line and then, okay, you're good now. And we'll be right back after a word from our sponsors. The Apple Watch Series 10 is here. It has the biggest display ever. It's also the thinnest Apple Watch ever,

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charge time and actual results will vary. Mayday, mayday. We've been compromised. The pilot's a hitman. I knew you were going to be fun. On January 24th. Tell me how to fly this thing. Mark Wahlberg.

You know what the difference between me and you is? You're going to die. Don't shoot him, we need him. Y'all need a pilot. Flight risk. Coming full circle on psilocybin then, and then we'll jump into MDMA to bring this home. I'll ask the same question I asked about ketamine. Are there people where they should just really, this is strongly contraindicated as something to even consider even in a therapeutic setting?

Well, it's been said that the intense risks with psilocybin are more psychological, so not so much medical. So it does modestly increase blood pressure and heart rate, but the bigger concern is for people who might have a tendency toward a condition that we call, the label we have for it is psychosis, but it's people who are not as connected with ordinary reality as an average bear. So there's a, can be a kind of a tenuous quality of living in a reality that may not be very grounded in the physical reality we all share. And so there are plenty of cases of people who take a traditional psychedelic like psilocybin or LSD who, so to speak, never come back. These are case reports of mostly people in their 20s who maybe have a predisposition or a risk towards schizophrenia or that kind of long-term psychotic

mental illness. It's sometimes hard to predict who those people will be, but there's a risk period where people develop schizophrenia in late teens, early twenties. So if I had a patient who had a family history of schizophrenia and they were not tied down very well into this reality and they were in that risk period, I probably wouldn't recommend psilocybin to that person. For older people, people who are pretty stable in the world that they live in and don't have those risk factors, I wouldn't be concerned about it. There could be difficult integration periods, but over a period of time, definitely doable to make that journey. I think that brings us to MDMA. Of the three that we've talked about,

my sense is this is the one that has most become known as a quote party drug. When I was a kid, this was ecstasy. In the generation after me, this is Molly. There are probably a whole bunch of other names for it. This was the rave drug in the 80s and 90s. And now, as you described earlier in our conversation, you're starting to see some stunning therapeutic applications for this. So I'll ask that same opening question. What actually is MDMA? MDMA is a molecule that was first developed in 1912 by, I think it was Dow Chemical. It was a chemical company. And it wasn't developed for humans as anything a human would consume. And it sat on a shelf for, I think, 60 years-ish. And then there was a kind of renegade pharmacologist named Sasha Shulgin in the Bay Area in California

who had had a distinguished career as a pharmacologist and got very interested in psychedelics. And he re-synthesized MDMA. He took it himself, which was a common practice in the 70s when you're cooking up chemicals. It's a different practice now. And he thought, wow, this could be really useful for therapy. And then he offered it to his wife and they took it together and thought, wow, this is incredible. They offered it to their inner circle of friends, including a bunch of therapists, which led to a proliferation to the point where it's estimated about 5,000 therapists were using it in the 70s and early 80s, primarily for couple therapy. So we could talk about that too. We have time, but as you said, it went on, it became illegal in the mid 80s because it got really

popular in the rave scene and people were worried that, you know, too many people were taking it. We didn't know enough about it and so on. So it's a chemical. It's synthesized in the lab. It looks a lot like, just like psilocybin looks a lot like serotonin. MDMA has the same sort of two ring structure that looks like serotonin, but it has a lot of amphetamine-like qualities because, and its name reflects that. So the amphetamine qualities include things like elevated temperature, heart rate, blood pressure, sweating. People can have jaw clenching really strongly. So it comes with a host of sort of more chemical side effects, I would say, than psilocybin. banned. It goes on schedule one. What's bringing it back in sort of like modern therapeutic

scenarios where people are starting to say, no, no, no, we need to revisit this. Like, what are the possibilities attached to it now that are so compelling that people are like, okay, we can't just ignore this and pretend it doesn't exist anymore. Well, I think the mental health epidemic is probably driving a lot of it. We have rates of PTSD that are, as I said before, a hockey stick, especially since the pandemic across the board, suicides and teenagers up, you know, dramatically. It's hard to put your mind around how serious the mental health epidemic globally is. 350 million people with depression globally, 12 million people in this country with PTSD. And so part of that epidemic is that the tools that we currently have

available are not effective enough, like we talked about in the beginning. So if the tools we had were effective enough, I don't think this conversation would be on the table because there would be no reason to entertain something with this much political baggage. So when we look at MDMA, it sounds like the thing that you keep going back to, maybe one of the differentiators between ketamine and psilocybin is its application in PTSD. Right. If I had all the tools available to me, or maybe I should say when I have all the tools, if I'm optimistic, I think MDMA is going to be the tool of choice for PTSD. It's just hard to describe, you know, as a therapist, what it's like to be in the room and watch people do accelerated recovery from trauma and do the integration work too.

But MDMA is a more supportive experience than psilocybin or ketamine. And ketamine, of course, has this drawback of the benefits wear off pretty quickly, which is very different from psilocybin and MDMA. So I think there's a role for all three. I think they're different, but they're not all going to be used for the same things yeah and you also reference and i've heard this from a number of people both on the practitioner side and also um partners who have gone who have done mdma assisted couple therapy partner therapy and experienced stunning things some just brought a level of love and connectedness that that they never knew existed even though they felt that they were deeply connected. able to process it while interacting with this substance in a therapeutic setting, they

described it as this just incredibly open, honest, and almost beautiful conversation where the outcome was truly peaceful that they could never have imagined before. Is that an outlier or is this the type of thing that you see fairly often? It's not an outlier at all. The stories you hear about how much connection people feel in MDMA, that's the common description. And part of why this therapy, MDMA therapy works so well for PTSD is that when you're working with a person with long-term trauma as a therapist, you're investing weeks, months, sometimes years just to get the trust to be able to talk about the traumatic memory. And one important thing about

MDMA that's very unique is that through a secondary, through a serotonin pathway, there's a secondary effect of a spike in the hormone oxytocin. And oxytocin is the social connection hormone. It makes us feel safe with one another. It causes us, it's so fascinating to me that research on oxytocin shows that when you look at someone's face on oxytocin, you make a different kind of mistake. You mistake a neutral face for a friendly face on oxytocin. But what happens with people with trauma when their oxytocin levels are high, they see friendly faces that they never see because they're always seeing threatening faces because their fight or flight system is so activated. So you get this boost of oxytocin,

you feel warm and connected. You're trusting the people in the room with you. Sometimes to an extent that later on feels really unnerving and weird. I can't believe I poured my heart out to these people. I just met them. And so that can be an important thing to integrate. But the point being that there's an opportunity with the effect of oxytocin on your fight or flight apparatus in your brain to drop the defensiveness that we don't even know that we're living inside of all the time. And so our hearts can connect with other people in ways that are oftentimes quite shocking and beautiful. Yeah, I mean, so powerful, especially you look at the state of the world right now, and you're like, we need more hearts connecting with other hearts.

We need to see ourselves on that level more readily than rather just seeing how absolutely opposite we are. When you talk about MDMA-assisted therapy, if you talk about that session experience compared to psilocybin and then ketamine, again, qualitatively different? Very different. If you think about the hormone oxytocin and what it does, it makes you feel not only more relaxed around connecting with others, but wanting to connect with others more. So in an MDMA session, there tends to be a lot more interaction with the therapist. The psilocybin experience, on the other hand, is oftentimes,

it can be almost entirely internal, where you have eye shades on and you have music on headphones, and you might be in her landscape for five or six hours, almost entirely. But people on MDMA, they usually want to talk and connect and reflect on the places where they're stuck or traumas that they experienced, having a new perspective. This can happen spontaneously with MDMA, which is, I think, really interesting. Does that sense of wanting to connect, does it end when the substance is no longer active in you? Or is there, beyond some therapeutic effect, is there any sort of longer term openness to connection? Or is it really when the oxytocin starts to diminish, that kind of goes

with it too? Well, that speaks to integration. On the MDMA, you might get a glimpse of maybe what it feels like outside of your PTSD or outside of your depression. Experiencing the desire to connect is something that's very unusual within chronic cases of depression or PTSD. So after the oxytocin and MDMA wear off and you begin to have this kind of awkward, weird experience of coming back into your point of view, which can be very contracted and isolated and maybe fearful or a little suspicious about other people, you have that contrast of that reference point that you just experienced with the MDMA. And so it becomes something that pulls you forward toward the possibility that could be achieved through integration of, okay, I moved up to the mountains, isolated myself for 30 years. I need to get on a

meetup group or I need to join a CrossFit gym or I need to go do yoga or something with people and challenge myself and, you know, say hello to someone, you know, at the yoga class. And it becomes a practice orientation toward that felt sense that you had on the MDMA of, wait, it didn't feel that bad. It actually felt kind of good to connect with people. Yeah. So it's almost like it opens the door to the possibility of you experiencing something even remotely similar, but just out in the world. We're having this conversation at a really interesting moment in MDMA's history too. Like as we record this conversation, it's early July, just a couple of weeks ago, MDMA has been, I guess, going through a potential approval process to get the FDA to reschedule it so that just a lot more research can be done, a lot more

practitioner work can be done to really understand this better. There was an advisory decision that actually said, based on what's been presented, we don't recommend that the FDA approve this, but the actual panel decision, the final panel decision, will happen from what I remember you telling me, actually, about a month from when we're having this conversation, maybe a little more. What's your take on what's going on right now? What may happen here? What the future,

the near-term future at least, holds for the wider scale availability of this? You're absolutely right. It's a delicate moment for MDMA and the final decision will be made on the 11th of August. And my sense is that the FDA is having a hard time and the advisory committee members having a hard time wrapping their head around something that's never been done before. To have a medicine that you take that alters your consciousness, that you have a therapist with you, and that effectively treats PTSD for most people who go through the protocol. I mean, it's very radical. And then there's all of the history of, you know, the war on drugs and, you know, all of the politics around concerns about what happens when people alter their consciousness and maybe they learn to think for themselves, or maybe they have a different experience that's less placid. And it was threatening to Richard Nixon, for sure. I don't know if it's the same situation

today, but the point is that there's a lot of political energy around this. I don't mean along Democrat and Republican lines, but I mean around who gets to control your consciousness and who gets to have experiences that could cause you to think for yourself. What we're looking at with these critiques or these concerns with MDMA research, the biggest one that I saw in the advisory committee a month ago was the issue that you can't really blind effectively a research protocol on a psychedelic. So in the MDMA research in the phase three trial, I think the number I saw was 90% of the participants guessed correctly, whether they got the placebo or the MDMA. And the problem with that from a research

point of view is that when someone knows what they got in a research study, there's a thing called expectancy bias, where if you think that you're going to get a good result, then you're more likely to get a good result. It's kind of related to the placebo response. So I think there are valid questions around that. I wanted to go back and look at the fentanyl and opiate research that led to the approval of those compounds to see ifing was actually done with those research projects. Because I'm not sure if MDMA is being singled out as a, you know, more of a canary in the coal mine kind of situation where MDMA is the first to come through the FDA process, and then you're going to have psilocybin and potentially other things. It's a little hard to be in the first position of going up to the plate.

Yeah, I would imagine you have to, there's a lot of friction there on every level. If we zoom the lens out, it's so fascinating. Like I think I've learned, even though you and I have talked about like these things a whole bunch, I've just learned so much about these three different substances and also just generally the state of psychedelics

in medicine and therapeutic use these days. For somebody listening to this and they're kind of like, huh, what do you most want people to know about these substances, their potential application, the potential availability? Like if somebody's kind of like curious at this point, what do you want them to know? I think the biggest message I can offer is a message of hope that the things that people are out there suffering with that seems so impossible to overcome. There are new tools being developed that hopefully will become available widely in the case with MDMA, hopefully this year and with psilocybin next year on the federal level. It's really devastating to be dealing with a chronic illness of any kind that

you in good faith, try everything there is to try and you still don't get much return for your investment and effort. And people get very discouraged. You know, people kill themselves. People do all kinds of things that from my point of view, makes sense when you're that disturbed and that desperate for something that can actually impact your life. So I want people to know that these things are not for everybody. They're not a panacea, but there's an incredible opportunity here. So stay tuned and hopefully we will have an update. Maybe you and I can talk about this in a year from now or something. Yeah, that would be pretty incredible. Feels like a good place for us to come full circle as well. So I always wrap with the same question, which is in this container of Good Life Project,

if I offer up the phrase to live a good life, what comes up? For me to live a good life means to have deep connection with other people and to spend my time doing meaningful projects. Thank you. Thank you. Hey, before you leave, if you love this episode,

it's safe, but you'll also love the conversation we had with Adam Ghazali about cutting edge research he's leading in this field. You'll find the link to Adam's episode in the show notes. This episode of Good Life Project was produced by executive producers, Lindsay Fox and me, Jonathan Fields, editing help by Alejandro Ramirez, Christopher Carter, Crafted Air Theme Music, and special thanks to Shelley Adele for her research on this episode. And of course, if you haven't already done so, please go ahead and follow Good Life Project in your favorite listening app. And if you found this conversation interesting or inspiring or valuable, and chances are you did since you're still listening here, would you do me a personal favor, a seven second favor and share it maybe on social

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making it even more comfortable on your wrist, whether you're running, swimming, or sleeping. And it's the fastest-charging Apple Watch, getting you 8 hours of charge in just 15 minutes. The Apple Watch Series X. Available for the first time in glossy jet black aluminum. Compared to previous generations, iPhone

XS or later required. Charge time and actual results will vary. Mayday, mayday. We've been compromised. The pilot's a hitman. I knew you were gonna be fun. January 24th. Tell me how to fly this thing. Mark Wahlberg. You know what the difference between me and you is?

You're gonna die. Don't shoot him, we need him! Y'all need a pilot? Flight Risk.