Who will staff the psychedelic resurgence? Erika Dyck, Professor and Canada Research Chair in History of Health & Social Justice from the University of Saskatchewan, provides an intriguing answer to this question
On 6th February 2024, a research team at Le Grau-du-Roi Hospital in the south of France, led by addictologist Amandine Luquiens, put their first subject through a clinical trial with psilocybin to investigate its therapeutic value for people with alcohol use disorder and depressive symptoms.
This was the first psychedelic trial conducted in that country in 58 years, which now adds France to a growing list of places investing in psychedelic medicine after decades of prohibition. However, overturning half a century’s worth of regulations and attitudes is not trivial.
Researchers here and elsewhere have faced an uphill battle to secure research funding, identify consistent supplies, and select appropriate trial subjects, not to mention demystify psychedelics’ reputations to regulators, ethics boards, and trial participants. Nonetheless, in 2024, with dozens of trials underway in Europe, North America, and Australia, the ground seems to be shifting.
Patient trials for psychedelic-assisted therapy
Trials are bringing the number of people receiving psychedelic-assisted therapy into the hundreds. At the same time, media reports and social media threads suggest that the demand for these interventions is rising steadily.
Are we ready to effectively scale up psychedelic science to meet the growing demand? And who is qualified to provide psychedelic therapy?
The scientific evidence on psychedelics is limited. While individual reports and celebrity testimonials have contributed to what Johns Hopkins researchers described as “psychedelic hype”, the science remains more cautious. Some trials have produced significant results, leading to bold pronouncements and breakthrough therapy designations in the United States. But others warn that we do not yet have clear enough evidence. Trial sizes have remained relatively small, and selection criteria have been rigid, meaning that trials cannot be generalized to the broad population. It seems, therefore, that the hype and the science may be out of sync.
Running a trial itself is no small task. Beyond the financial and administrative hurdles, there is a significant shortage of staff trained to work with psychedelics. Historically, psychedelic therapy appealed to reform-minded clinicians who recognized the potential for both therapeutic and administrative efficiencies in psychedelic medicine, claiming that psychedelic therapies were equivalent to months and even years of non-psychedelic psychotherapy.
However, the context for applying psychedelic therapies was very different. In the earlier psychedelic therapy heyday, psychiatrists ran trials in hospital settings or private practices, and most patients with major psychiatric disorders were treated while living in large custodial facilities.
Who will staff the psychedelic resurgence?
Nursing staff frequently sat with patients undergoing psychedelic treatments. Qualifications for these positions as psychedelic “sitters” came mainly from experience, intuition, and, for some, specialized training in psychiatric nursing.
Most psychedelic sitters from this era had also accumulated their own psychedelic experiences, even if only once. Psychiatrists administered the psychedelics, and in some cases, psychologists or social workers were present to interact with patients and trial subjects. Still, nurses often sat with people for eight or more hours of active treatment.
Today, the situation is quite different. The era of self-experimentation appears long gone. Psychiatrists, psychologists, and nurses typically do not include protocols that formally incorporate self-experimentation into their training. Moreover, due to the decades of prohibition on psychedelic research, a new generation of staff needs to be trained to handle the administration, sitting, and therapeutic interactions with patients, amidst a very different culture of psychiatric care compared with the 1950s.
Patients qualifying for trials today predominantly live in the community; not mental hospitals, and most patients meeting the selection criteria have a considerable history of using SSRI medications, something that was not yet a feature of the 1950s mental health care complex, yet might affect clinical outcomes today. The need for qualified staff to first study, then administer and monitor, psychedelic therapies is perhaps now even more specialized than in the past.
The science of psychedelics: Where are we?
With the science of psychedelics still being worked out, the need for qualified therapists and nursing staff is growing without clear indications of what psychedelic therapy might look like. Several training programs have emerged in recent years. Still, despite the proliferation of programs, there is no consensus, regulation, or certification where professional bodies have agreed upon the skillset required for psychedelic staff, whether therapists or sitters.
Some of the clinical optimism surrounding psychedelic therapy comes from a belief that these substances when taken in a therapeutic context, can help people confront a host of psychological traumas and problematic behaviours in a concentrated manner, equivalent to months or even years of psychotherapy. The cost savings in that projection are significant.
However, the current state of psychedelic research and capacity building amongst therapists seems poised to keep these therapies out of reach for the majority of potential patients, with costs to offset sessions ranging from $2,000 to 8,000 USD. The limited supply of qualified staff presents a significant challenge for psychedelic therapies from now on.
How do we deliver psychedelic therapies at scale?
To deliver psychedelic therapies at scale, new investments in training are vital. It seems that in 2024, the focus remains on developing their scientific validity, while only a few institutions are beginning to turn their attention to the looming challenge of training nurses and therapists. In a profession that is already stretched and suffering from pandemic burnout, and seemingly ever-increasing demand for mental health interventions, the option of psychedelic nurse training may be a mixed bag.
Despite the claims of mind-blowing and life-changing experiences, psychedelic sitting requires a disposition and skillset that combines patience with sensitivity, intuition, and the ability to be present for often long periods of time, sometimes with limited interaction. Historical and current research indicates that these guides or sitters are critical for therapeutic safety and outcomes. Indeed, patients historically described these nurse- sitters as one of the most important features of the session, crediting these attentive guides with helping to anchor the experience, often just by being there.
A more sustainable future for psychedelic therapy?
Beyond the science gathered from these clinical trials, these caring features of psychedelic therapy are poised to make a substantial contribution. Indeed, they can make the difference between another relatively short-lived psychedelic moment, and a more sustainable future for effective and replicable psychedelic therapy.
