Critical to the research is a stable and responsible workforce. Nurses scope of practice has this covered but needs to be sanctioned by professional organizations to protect us legally. The research had some issues that can be overcome with good practice and REMS. Thanks for keep this ball moving!!!
I appreciate the fact that people like, Andrew, are attempting to find ways to get healthcare systems and the professionals to work together to facilitate psychedelic therapy. It’s not a simple task. You need vision. You need an ability to understand logistics, the system, costs, personnel, etc. As someone who suffers from complex PTSD though, I would not be open to administration of MDMA - an extremely powerful drug with only RN and/or doctor present.
Many healthcare professionals, including RNs and psychotherapists are very excited about working with a population with extreme mental health challenges in the psychedelic field. Yes — it’s going to be great!!! I’m sure it’s very ego satisfying to feel like you’re part of something that’s going to transform the way mental health services are going to be provided in this country. I’m sure it’s very ego gratifying to think you’ve got the special skills to be selected to do this work. No doubt it is a calling.
I’d prefer a more sober, cautious and deliberate consideration of the issues here. The way professionals have jumped on the psychedelic bandwagon, eager to do their 150 hours of PAT or KAT training concerns me. It might respresent career advancement for many individuals who feel otherwise disengaged with their current work. But, as they say, just because you can, doesn’t mean you should. Anyone out there that wants to consider this work, please think long and hard.
I’m sure many nurses are fine people, highly skilled and compassionate. I think nurses have one of the hardest jobs in the world. However, most all of them, in my experience, know little to nothing about complex PTSD and its treatment. I have been retraumatized by nurses in hospital settings because of this lack of understanding.
In this plan, I read that psychotherapists that would be brought in from outside would require PAT training before they would be allowed as part of the team. What about the RNs? Are they going to be required to take advanced psychotherapeutic course work in complex PTSD? They have a seven month course for $499 at Bessel van der Kolk’s non profit organization, Trauma Research Foundation. That would be a start. For more info: https://traumaresearchfoundation.org/programs/certificate-program/.
The problem with MDMA approval process is in part, in my mind, is connected to MAPS lack of sensitivity to the needs of a complex trauma population. There were stories of individuals in the research being simply abandoned once the research was conducted. People who became suicidal. No warm hand off there. There was a SF psychotherapist who held down a woman (restrained her) during treatment while under the influence of MDMA. You don’t think that could happen to another patient? You do think that someone could become traumatized from the experience of MDMA itself — especially if those in the room have not worked with this population?
Treating a veteran with PTSD is not the same as treating someone with complex PTSD. If you haven’t been there, you don’t know. There’s a concept of a ‘warm hand off’ — yeah — it doesn’t work that way when you’re processing trauma. It’s not a hospital setting where you’re whisking a patient off after a procedure to do X-rays or to see a specialist or back to their room for recovery.
My greatest concern is how a field of highly skilled professionals who specialize in complex PTSD — people who have worked for decades honing their craft and have spent considerable time, effort and money for advanced training, how are they going to be embraced by the psychedelic community? And how are people like myself going to find a clinic that can meet my needs?
Ketamine clinics have done a pretty crappy job with staffing as if it’s just a matter of inserting an IV or shot. I didn’t feel ‘held ‘by the experience because the person didn’t feel comfortable holding my hand. I’m sorry if you can’t be present with someone with their suffering — it’s going to be an issue — possibly retraumatizing. I’ve experienced this ‘warm hand off’ as been suggested here. Doesn’t work so well because the ‘after care’ requires a continuity of care in terms of the psychotherapeutic experience. Healing from complex PTSD involves attachment and relational repair. It often involves transference/countertransference. This means whoever is sitting with the patient ‘in treatment’ should be the person providing folllow up psychotherapy and checking in with a person. Integration is not ‘trust your inner healer’ and your on your own sitting in your room contemplating the universe. There needs to be professional guidance and opportunity to do EMDR or Internal Family Systems, mindfulness or somatic work that will move recovery forward. ‘Trust your inner healer intelligence’ is an excuse for poorly trained psychotherapists. It’s absolves them of ethical responsibility to get advanced training in a highly specialized field.
Having a RN, someone who does not have a mental health license, sitting with a patient (taking notes to give to psychotherapist later?) is not going to work too well. In my experience with ketamine, it just doesn’t translate. The psychotherapist who later treats the patient will not understand what happened during the session. It became very confusing (especially when you’ve been in an altered state of consciousness) as I was tasked with translation of my experience. Most professionals simply don’t have hours to spend consulting with each other.
Please consider soliciting the input of professionals who work with complex PTSD on a daily basis as well as their clients.
And nurses are wise to consider liability issues because you’ll definitely need additional coverage.
Also, I just want to be perfectly clear that I don't think all nurses would be good at PAT (I also don't think that most therapists or psychiatrists would be good at it either... it takes a certain kind of clinician to do this work). Just as I COULD work in an ICU, I really shouldn't as it's not my forte or skill set. And fortunately, no one is MAKING me work in an ICU - I self selected. The same will be the case for nurses working in PAT.
To some nurses, the idea of sitting with someone in a semi-catatonic state on psychedelics for 8 hours sounds like the most boring thing ever, and they probably would not select it as a place to work. But for those who are called, I still think the native intelligences of nursing and core skills of care, presence, and safety are well matched to PAT.
Sep 17·edited Sep 17Liked by Andrew Penn, MS, PMHNP
😂 — I could see it being a little boring myself — it does require a certain presence of mind and patience and an ability to sit with uncertainty. Some people are more suitable to this kind of thing. Not me! I’m compassionate, but I’d be a horrible nurse or even psychotherapist! What’s why it’s great that there are so many kinds of people in the world.
Hi Anna, thanks for taking the time to read and respond. As someone who has worked in mental health for 30 years with some of the most challenging populations (highly traumatized children, combat vets, and severely mentally ill), I have some appreciation for the needs of this population.
I think you'll find most of these concerns addressed in the piece:
• Yes, all personnel (including the nurses) would need to be trained in working with people on psychedelics.
• All personnel will need to be certified in PAT (probably by their respective professional organizations as it is increasingly looking challenging to complete an omnibus certification exam for all professions).
• The reality is that in a medicalized setting, psychedelic treatments have become a procedure (for better or worse, we can discuss if that's a good idea or not) and in medical settings, procedures are handled by different types of professionals along the process.
• Ethical transgressions can come from any profession (the abuse you reference that happened in phase 2 MDMA in Canada came from a licensed physician and her psychologist husband who had let his license lapse), both of whom had considerable experience in working with people in non ordinary states and still did substantial harm. However, this said, the number of reports of these kinds of transgressions coming from nurses (especially when compared to the sheer number of patients treated by nurses each year) is remarkably low.
• I agree that we will have to build time and resources (i.e. people will need to be compensated for their time) for this warm handoff. Technology can also be leveraged (as a means of increasing safety, sessions should be videotaped) to highlight key sections of the session for the receiving therapist.
• I think the biggest question that this piece does not answer (and you appropriately critique) is if this model maintains the relational container needed to treat PTSD, let alone C-PTSD. I don't think we know the answer to this, because only one model of using MDMA in PTSD (i.e. MDMA + the MAPS therapy protocol) has been empirically tested. Irrespective of what model is used, the combination of MDMA + therapy in a new drug application will continue to stymie the FDA, since the regulation of psychotherapy is outside of the FDA's scope.
Thank you for your thoughtful response, Andrew. I appreciate your consideration of my thoughts. And yes — the biggest question. We are working with FUD — fear, uncertainty and doubt. Lots of unknowns and that can be unsettling. I think it’s important that trust needs to be established in the survivor community as this is a big shift in the way that treatment is being delivered.
The FDA is going to need to figure out the psychotherapeutic component. As was suggested in recent Reagan Udall Conference that discussed advanced treatments in PTSD — there seems to be a need for coordination across various governmental and state agencies (not only the regulation of the drug and administration itself, but licensing of practitioners, ways of consumers to report unethical practices, etc). I realize it’s a huge task. It will take concerted time and effort to get agencies on board to roll out whatever programs are established.
It would be good to see input from all stakeholders including more involvement by psychiatrists who, largely, aren’t up to speed with latest trauma treatments. Diagnosis is always a sticky point. So, yeah… lots of work to be done. More conversations, more brainstorming, more thinking.
And thanks for providing a forum for discussion of these important issues.
Thanks for participating in the discussion, Anna. There are a lot of bombs thrown in this space without opportunity the discourse that we're engaging in here. I appreciate the conversation.
There are certainly a lot of unknowns in PAT, and even more now following the FDA decision, and I could see how that uncertainty must be really unsettling for people with PTSD who were optimistic for treatment. That is the group that has really been hurt the most by this setback.
I don't think it's realistic to ask for the FDA to figure out how to regulate psychotherapy. If the FDA starts trying to wander into regulating medical practice, that will likely trigger lawsuits from medical stakeholders (e.g. AMA) to make them stick to their charter.
In my opinion, one of the conceits of the "psychedelic movement" (such that there is one) is that they are going to get to both use the system (i.e. push MDMA through a regulatory framework/FDA) and get to change the system (i.e. make the FDA opine on psychotherapy) at the same time. I don't think you get both. If you want to use "the system" to change things, one has to a certain extent, play by its rules. If the referee kicks you out of the game for not following the rules, you can't really cry foul. What concerns me the most is that in the aftermath of this denial, I see a lot of people in the "psychedelic space" talking about going back underground, or using the poorly regulated religious exception as a way of having personal access to psychedelics. I don't see a lot of advocacy for the patients who still need treatment. I want to be wrong on this one, but time will tell.
This is all very nice and good. Thoughtful, but not thorough. The United States of America was founded on important, no, essential principals, that bear on this matter directly: The first amendment, the separation of church a state. "There is a genius to our constitution." Psychedelic drugs are one of the oldest, ubiquitous, safest, continuously used means of attaining direct experience of the divine. There should be no institutional, governmental, interferences put between a responsible person and their use of them. So, fine, if you and other members of the scientific community want to research them, and apply them to your kinds of psychotherapy or healing. But if those rules you make for your profession interfere or take precedent over mine or anyone else whose motives for using them are spiritual or religious, they are unconstitutional. The first thing those of us who appreciate these drugs should do is petition our legislators to rescind the Controlled Substance Act. All the psychedelics are wrongly classified, and most importantly, the CSA grants the authority to determine a drug's value to the DEA, not to scientists, or philosophers, but to the police, who, as we well known, run a disgustingly corrupt institution. By redefining psychedelics properly as sacraments, it takes the business out of them, as it should be. Sacraments belong to the universe of god seeking human beings, not to greedy people, like MAPS founder Rick Doblin, or any of the other profiteers of this corrupt renaissance.
Critical to the research is a stable and responsible workforce. Nurses scope of practice has this covered but needs to be sanctioned by professional organizations to protect us legally. The research had some issues that can be overcome with good practice and REMS. Thanks for keep this ball moving!!!
This is so awesome! I love the proposal, everything about it. Makes me so proud and excited to be a nurse.
I appreciate the fact that people like, Andrew, are attempting to find ways to get healthcare systems and the professionals to work together to facilitate psychedelic therapy. It’s not a simple task. You need vision. You need an ability to understand logistics, the system, costs, personnel, etc. As someone who suffers from complex PTSD though, I would not be open to administration of MDMA - an extremely powerful drug with only RN and/or doctor present.
Many healthcare professionals, including RNs and psychotherapists are very excited about working with a population with extreme mental health challenges in the psychedelic field. Yes — it’s going to be great!!! I’m sure it’s very ego satisfying to feel like you’re part of something that’s going to transform the way mental health services are going to be provided in this country. I’m sure it’s very ego gratifying to think you’ve got the special skills to be selected to do this work. No doubt it is a calling.
I’d prefer a more sober, cautious and deliberate consideration of the issues here. The way professionals have jumped on the psychedelic bandwagon, eager to do their 150 hours of PAT or KAT training concerns me. It might respresent career advancement for many individuals who feel otherwise disengaged with their current work. But, as they say, just because you can, doesn’t mean you should. Anyone out there that wants to consider this work, please think long and hard.
I’m sure many nurses are fine people, highly skilled and compassionate. I think nurses have one of the hardest jobs in the world. However, most all of them, in my experience, know little to nothing about complex PTSD and its treatment. I have been retraumatized by nurses in hospital settings because of this lack of understanding.
In this plan, I read that psychotherapists that would be brought in from outside would require PAT training before they would be allowed as part of the team. What about the RNs? Are they going to be required to take advanced psychotherapeutic course work in complex PTSD? They have a seven month course for $499 at Bessel van der Kolk’s non profit organization, Trauma Research Foundation. That would be a start. For more info: https://traumaresearchfoundation.org/programs/certificate-program/.
The problem with MDMA approval process is in part, in my mind, is connected to MAPS lack of sensitivity to the needs of a complex trauma population. There were stories of individuals in the research being simply abandoned once the research was conducted. People who became suicidal. No warm hand off there. There was a SF psychotherapist who held down a woman (restrained her) during treatment while under the influence of MDMA. You don’t think that could happen to another patient? You do think that someone could become traumatized from the experience of MDMA itself — especially if those in the room have not worked with this population?
Treating a veteran with PTSD is not the same as treating someone with complex PTSD. If you haven’t been there, you don’t know. There’s a concept of a ‘warm hand off’ — yeah — it doesn’t work that way when you’re processing trauma. It’s not a hospital setting where you’re whisking a patient off after a procedure to do X-rays or to see a specialist or back to their room for recovery.
My greatest concern is how a field of highly skilled professionals who specialize in complex PTSD — people who have worked for decades honing their craft and have spent considerable time, effort and money for advanced training, how are they going to be embraced by the psychedelic community? And how are people like myself going to find a clinic that can meet my needs?
Ketamine clinics have done a pretty crappy job with staffing as if it’s just a matter of inserting an IV or shot. I didn’t feel ‘held ‘by the experience because the person didn’t feel comfortable holding my hand. I’m sorry if you can’t be present with someone with their suffering — it’s going to be an issue — possibly retraumatizing. I’ve experienced this ‘warm hand off’ as been suggested here. Doesn’t work so well because the ‘after care’ requires a continuity of care in terms of the psychotherapeutic experience. Healing from complex PTSD involves attachment and relational repair. It often involves transference/countertransference. This means whoever is sitting with the patient ‘in treatment’ should be the person providing folllow up psychotherapy and checking in with a person. Integration is not ‘trust your inner healer’ and your on your own sitting in your room contemplating the universe. There needs to be professional guidance and opportunity to do EMDR or Internal Family Systems, mindfulness or somatic work that will move recovery forward. ‘Trust your inner healer intelligence’ is an excuse for poorly trained psychotherapists. It’s absolves them of ethical responsibility to get advanced training in a highly specialized field.
Having a RN, someone who does not have a mental health license, sitting with a patient (taking notes to give to psychotherapist later?) is not going to work too well. In my experience with ketamine, it just doesn’t translate. The psychotherapist who later treats the patient will not understand what happened during the session. It became very confusing (especially when you’ve been in an altered state of consciousness) as I was tasked with translation of my experience. Most professionals simply don’t have hours to spend consulting with each other.
Please consider soliciting the input of professionals who work with complex PTSD on a daily basis as well as their clients.
And nurses are wise to consider liability issues because you’ll definitely need additional coverage.
Also, I just want to be perfectly clear that I don't think all nurses would be good at PAT (I also don't think that most therapists or psychiatrists would be good at it either... it takes a certain kind of clinician to do this work). Just as I COULD work in an ICU, I really shouldn't as it's not my forte or skill set. And fortunately, no one is MAKING me work in an ICU - I self selected. The same will be the case for nurses working in PAT.
To some nurses, the idea of sitting with someone in a semi-catatonic state on psychedelics for 8 hours sounds like the most boring thing ever, and they probably would not select it as a place to work. But for those who are called, I still think the native intelligences of nursing and core skills of care, presence, and safety are well matched to PAT.
😂 — I could see it being a little boring myself — it does require a certain presence of mind and patience and an ability to sit with uncertainty. Some people are more suitable to this kind of thing. Not me! I’m compassionate, but I’d be a horrible nurse or even psychotherapist! What’s why it’s great that there are so many kinds of people in the world.
Hi Anna, thanks for taking the time to read and respond. As someone who has worked in mental health for 30 years with some of the most challenging populations (highly traumatized children, combat vets, and severely mentally ill), I have some appreciation for the needs of this population.
I think you'll find most of these concerns addressed in the piece:
• Yes, all personnel (including the nurses) would need to be trained in working with people on psychedelics.
• All personnel will need to be certified in PAT (probably by their respective professional organizations as it is increasingly looking challenging to complete an omnibus certification exam for all professions).
• The reality is that in a medicalized setting, psychedelic treatments have become a procedure (for better or worse, we can discuss if that's a good idea or not) and in medical settings, procedures are handled by different types of professionals along the process.
• Ethical transgressions can come from any profession (the abuse you reference that happened in phase 2 MDMA in Canada came from a licensed physician and her psychologist husband who had let his license lapse), both of whom had considerable experience in working with people in non ordinary states and still did substantial harm. However, this said, the number of reports of these kinds of transgressions coming from nurses (especially when compared to the sheer number of patients treated by nurses each year) is remarkably low.
• I agree that we will have to build time and resources (i.e. people will need to be compensated for their time) for this warm handoff. Technology can also be leveraged (as a means of increasing safety, sessions should be videotaped) to highlight key sections of the session for the receiving therapist.
• I think the biggest question that this piece does not answer (and you appropriately critique) is if this model maintains the relational container needed to treat PTSD, let alone C-PTSD. I don't think we know the answer to this, because only one model of using MDMA in PTSD (i.e. MDMA + the MAPS therapy protocol) has been empirically tested. Irrespective of what model is used, the combination of MDMA + therapy in a new drug application will continue to stymie the FDA, since the regulation of psychotherapy is outside of the FDA's scope.
Thank you for your thoughtful response, Andrew. I appreciate your consideration of my thoughts. And yes — the biggest question. We are working with FUD — fear, uncertainty and doubt. Lots of unknowns and that can be unsettling. I think it’s important that trust needs to be established in the survivor community as this is a big shift in the way that treatment is being delivered.
The FDA is going to need to figure out the psychotherapeutic component. As was suggested in recent Reagan Udall Conference that discussed advanced treatments in PTSD — there seems to be a need for coordination across various governmental and state agencies (not only the regulation of the drug and administration itself, but licensing of practitioners, ways of consumers to report unethical practices, etc). I realize it’s a huge task. It will take concerted time and effort to get agencies on board to roll out whatever programs are established.
It would be good to see input from all stakeholders including more involvement by psychiatrists who, largely, aren’t up to speed with latest trauma treatments. Diagnosis is always a sticky point. So, yeah… lots of work to be done. More conversations, more brainstorming, more thinking.
And thanks for providing a forum for discussion of these important issues.
Thanks for participating in the discussion, Anna. There are a lot of bombs thrown in this space without opportunity the discourse that we're engaging in here. I appreciate the conversation.
There are certainly a lot of unknowns in PAT, and even more now following the FDA decision, and I could see how that uncertainty must be really unsettling for people with PTSD who were optimistic for treatment. That is the group that has really been hurt the most by this setback.
I don't think it's realistic to ask for the FDA to figure out how to regulate psychotherapy. If the FDA starts trying to wander into regulating medical practice, that will likely trigger lawsuits from medical stakeholders (e.g. AMA) to make them stick to their charter.
In my opinion, one of the conceits of the "psychedelic movement" (such that there is one) is that they are going to get to both use the system (i.e. push MDMA through a regulatory framework/FDA) and get to change the system (i.e. make the FDA opine on psychotherapy) at the same time. I don't think you get both. If you want to use "the system" to change things, one has to a certain extent, play by its rules. If the referee kicks you out of the game for not following the rules, you can't really cry foul. What concerns me the most is that in the aftermath of this denial, I see a lot of people in the "psychedelic space" talking about going back underground, or using the poorly regulated religious exception as a way of having personal access to psychedelics. I don't see a lot of advocacy for the patients who still need treatment. I want to be wrong on this one, but time will tell.
This is all very nice and good. Thoughtful, but not thorough. The United States of America was founded on important, no, essential principals, that bear on this matter directly: The first amendment, the separation of church a state. "There is a genius to our constitution." Psychedelic drugs are one of the oldest, ubiquitous, safest, continuously used means of attaining direct experience of the divine. There should be no institutional, governmental, interferences put between a responsible person and their use of them. So, fine, if you and other members of the scientific community want to research them, and apply them to your kinds of psychotherapy or healing. But if those rules you make for your profession interfere or take precedent over mine or anyone else whose motives for using them are spiritual or religious, they are unconstitutional. The first thing those of us who appreciate these drugs should do is petition our legislators to rescind the Controlled Substance Act. All the psychedelics are wrongly classified, and most importantly, the CSA grants the authority to determine a drug's value to the DEA, not to scientists, or philosophers, but to the police, who, as we well known, run a disgustingly corrupt institution. By redefining psychedelics properly as sacraments, it takes the business out of them, as it should be. Sacraments belong to the universe of god seeking human beings, not to greedy people, like MAPS founder Rick Doblin, or any of the other profiteers of this corrupt renaissance.