What Happens in Psychedelic Therapy with Dr. Jason Luoma

In part 2 of the conversation with Dr. Luoma, he and Dan discuss the complexities of psychedelic research, including the regulatory hurdles and safety requirements that can complicate and increase costs. Dr. Luoma explores the promising psychedelics currently under investigation, such as psilocybin and MDMA, and emphasizes the importance of integration in making psychedelic experiences meaningful. Finally, Dr. Luoma gives an overview of the Portland Institute for Psychedelic Science, which aims to advance research and therapy in this field.

Dr. Jason Luoma is a researcher, practitioner, and co-founder of the Portland Institute for Psychadelic Science; the Portland Psychotherapy Clinic, Research, and Training Center; & host of the Research Matters Podcast.

Special Guest: Dr. Jason Luoma
https://jasonluoma.com/

The Portland Institute for Psychadelic Science
https://www.pipsinstitute.com/

Jason's Research Matters Podcast
https://jasonluoma.com/researchmatters/

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Transcript

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[Music] Once you start taking psychedelic assisted psychotherapy seriously as a clinical intervention, the obvious questions show up fast. Who is this actually for? What does the treatment look like in practice? And how do different substances change the process? In this second part, my guest gets much more concrete. We talk about why this probably shouldn't be a first line treatment. What clinicians need to understand about screening, preparation, dosing, and integration? How MDMA differs from psilocybin in the therapy room? And what kinds of change processes may actually be doing the heavy lifting? If you're a practitioner, curious about what this work looks like beyond the headlines? This conversation is a great place to start. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology. Rise it down with leading researchers to pull out practical insights, peek behind the curtain, and hopefully have a little bit of fun along the way. If you're getting value from the show, do me a huge favor and subscribe on your podcast player, or if you're watching on YouTube, hit like and subscribe. It's one of the simplest ways to support the podcast and keep these conversations coming. This episode begins with my guest responding to my question about what psychedelic assisted psychotherapy actually looks like from a clinician's point of view. So without further ado, it's my pleasure to welcome my very special guest, Dr. Jason Luoma. Well, there's ketamine, which some people consider a psychedelic. It's more of a dissociative, but has some amount of psychedelic effects when those at certain levels. I'm not involved with that. I don't really follow that literature. I think it's pretty different. But there is a body of literature on ketamine delivery, not much with ketamine assisted psychotherapy though, but that's one of the big ones. The biggest one in the classic psychedelic that is most talked about where the bulk of the research is on psilocybin. So that's the main substance in psilocybin, cubensis mushrooms, or like magic mushrooms. There are well over 100 clinical trials that currently under way or in planning. So there's a lot of research ongoing. There's going to be a lot more data in the next five years that's going to come out. There are quite a few studies across a number of conditions. A lot of it's with depression as often happens with truck development because there's where the most people are and can make the most money. And maybe have the biggest public health impact. So a lot of it's with depression. There's some good studies with substance use disorders there. End of life, like you mentioned, anxiety and depression around end of life. I feel like I'm missing one of the categories there. But that's the biggest bulk of research. And that's when people think about psychedelics, they're usually thinking about psilocybin, the kind of effects that psilocybin has. And then the third biggest one would be MDMA. And again, you might think of it more as an empathogen or intactogen rather than a psychedelic, but some people call it part of this broader psychedelic class. But it's not a classic psychedelic. And its effects are different than quite a bit different than psilocybin. And they have more to do with it has this kind of co-main types of effects on the one hand, it's a stimulant. So like any other stimulant like tobacco, you know, nicotine or caffeine or cocaine or any of those things. Not a super strong, but it has it. And then the thing that it's known for is this effect that has to do with creating feelings of safeness, empathy, connection with people. It's this social bonding kind of facilitating effect that it has, seems to involve things like oxytocin, vasopressin, these neurahornomones that are involved in bonding that are released, you know, at birth or when a mother's nursing. And so it's known for creating those kinds of effects. And so it's often been used in the treatment of problems, disorders that have strong social components. Like PTSD where there's, you know, safety and safeness and also interpersonal pieces and self-judgment are really really key or things like social anxiety disorder. But where for couples relationships or families or couples I would say. And that's the third biggest one. And I would say that there's one more that's kind of rapidly growing. And that's five MEODMT, which is sort of a classic psychedelic. They called it a typical classical classic psychedelic. But it's somewhat unusual in that it has very rapid effects, very rapid onset offset. And often very, very, very powerful effects that are the sense of self can be extremely disrupted. And you know, so people are blasted into the stratosphere and then come back 10 minutes later. And it tends to have very powerful subjective effects. And it's being used by quite a few farm companies or have it in the pipeline. I think partly because it's very short acting. And so it's more convenient. You can have somebody come in and send them home two, three, four hours later instead of eight hours later with MDMA or so Sibon. And so that's probably the most common. And then I guess the last one would be Iowaska or DMT as the NNDMT. So not five MEODMT, but DMT as part of Iowaska. But that's not as Iowaska is not studied as much in the clinical context. It's not really studied much at all in terms of psychotherapy context. But there is a inhaled or injected form of DMT that's also being studied. So the five MEODMT, what's like the more colloquial, is there more colloquial street name? Toad. Sometimes we call toad. It's the one that comes from one of the origins is from a what's called the Sonoran Desert Toad, which is this toad that is from the Southwest United States. And they take the glands and they excrete them and make a crystal that was smoked. And the lore behind this is that it has some sort of indigenous roots, but it doesn't appear to have any indigenous roots. It's purely like a modern thing with this manufactured story to sell it as if it were indigenous. But yeah, so that's that's the kind of some of the history of five MEODMT. So the ones that you have the most like have done the most work with are psilocybin and MDMAs, are right? Yeah. Okay. So good. You know, one of the things that I would be really curious about is like what that like is if you could sort of walk us through that process of like and you can sort of, you know, pick whichever one you think would be, you know, you want to chat about or we could even do both. Like what do you see in a client where you might think, oh, this might be valuable. And then how do you have those conversations? Then what does it just sort of like what you know what I mean? Like what that actual sort of clinical process looks like? The first thing I want to say just before we go into this is this is a whole area to learn about that people, if someone wants to get involved with PAT, there's a lot to learn and there's a lot to manage. It's not like it's not like something you, it's not like if you're a psychotherapist, like it's like you would pick up a new therapy. You know, you don't know psychodynamic therapy and you're just going to get like trained. And so it's not like that. So you know, there's a lot that has to be taken, learned about the regulations, a lot about safety. There's a there's a very great care paid to safety because there can be harms from these. You know, there's much more risk, I would say, than you know, standard psychotherapy. So there's a lot to be managed. But in terms of, was your question primarily about how would you identify a person that was a good candidate? Just like anything about the process, I think that most people, many folks have no idea, right? Like what this would even look like. So imagine that you're talking to, you know, a therapist who's in practice and they do, you know, traditional, whatever their approach is. And they've sort of like heard about this on the periphery, but like, have no idea, you know, like what this actually, how this might unfold. Does that make sense? Yeah, I will try, I will try in a few minutes to get this cross. Yeah, and obviously all of these are very 30,000 foot. But I think that like in a lot of ways, and you know, at the end of this, I'll ask you for specific references and I'll link to them for folks who want to get into it and learn more. And you know, I feel like folks who are in, anybody who's listening can go and read some systematic reviews and meta analyses to like catch up on the effect sizes for different. So we can talk about that some, but I'm more interested in talking to you about like as an expert in this field, right? You know, your sort of, your experiences, your learnings, your intuitions based on those experiences, integrating with, but you're also a scientist, right? So integrating with that, I think that's like, that's what is more difficult for people to access. Yeah. And one of the first things I would say in terms of thinking about who is that, you know, this, this really, you know, generally shouldn't be a first-line treatment. It's expensive, it has more risks associated with it. And so it really makes more sense for people who, if we're talking about a mental health context, right? It makes sense for people who've already tried other things and not found that they were helped or helped sufficiently. I mean, that's mostly who it's for, not that other people can't access it and that they would have a right to, but, you know, generally that's who it's going to be for. So I would think about clients who have been not responding to treatment, they're not making progress. And, and those are probably the candidates that are going to make more sense. And then I would probably tend to go towards maybe some of what the clinical trials seem to show where there's some evidence space of things like depression, you know, certain concerns, existential concerns, like around end of life. And there's growing evidence space for other things. So I think when you're starting to get farther out, you just have to start to recognize that. But then we could also think about some of the processes of change involved with psychedelics. And so from a neuroscience standpoint, I think the thing we know confidently about how psychedelics work in the brain, classic psychedelics. I'm not going to talk about MDMA, but classic psychedelics is that the thing they do is they create chaos in the brain. They primarily target five HD2A receptors, five HD2A receptors are broadly spread throughout the brain. They're in all kinds of areas of the brain. They're also located in your body as well outside the brain. And they basically create a large wide scale excitation inhibition in all kinds of ways in the brain. And the typical, and a modularity of the brain where you have different regions or kind of modules of the brain talking to each other in four or eight ways, that breaks down and becomes very chaotic. And so you have these very chaotic brain states. And those seem to be associated with this kind of experience of having new weird experiences. So, you know, in the brain, like sometimes they analogize it to like shaking up a snow globe. You know, the brain is like getting shaken up. So your normal ways of thinking are temporary disrupted. Your normal ways of perceiving are temporarily disrupted. Your normal ways of emoting are temporarily disruptive. Your normal ways of behaving are temporarily disrupted. And so the, I think one way to think about this is that if there are folks who have rigid and inflexible patterns of thinking, behaving, you know, those are folks who maybe are going to be some of the better candidates for these because psychedelics create this state of temporary disruption and flexibility and randomness that then when paired with good integration where you can then basically kind of take the new stuff and hopefully reinforce it and strengthen it, you then can start to have new patterns emerge. And so that's some of the, I think, the idea behind where psychedelics might be helpful. I think for folks who are already more dysregulated and chaotic, those folks are probably more at risk for heterogenic outcomes. So people who are, you know, bipolar disorder or borderline personality disorder or those sorts of organizations where people are, you know, really chaotic environments in their life. Those folks are probably not great candidates because this is a disruptive substance when at least given in this context, it's this disruptive substance. So for people who are already disrupted and kind of chaotic, it may just very well add more chaos. And in that way, maybe less likely to be helpful. We don't have any evidence for this. And we do have some evidence that some of those folks I alluded to maybe more likely to have heterogenic outcomes and things like that. But I would say it's very strong evidence. But I think that's some of the ways I would tend to think about maybe making some of the choices about who the best candidates are. It's probably part of the answer you were looking for. What else would be good for me to talk about? So the idea of the sort of brain is being in a chaotic state. That makes intuitive sense to me, and that makes sense to me, is the idea that you're like, you're introducing the stimuli, like some sort of stimuli while creating this chaos. So that the like a new learning or new experiences, new relationships with those, I'm using the word stimuli very broadly here, obviously. That's the integration process is bringing in new stimuli, bringing in new experiences. What the therapist says, how the therapist encourages the person to do new things and have new experiences during the integration period, as they're returning from that more chaotic state. And how they make sense of the experiences that they had in that chaotic state, the weird thoughts and the unusual feelings. And how do they just discard it? And again, it becomes that way integrated. Or do they take those and have those become more part of a new way of being in the world? So I'd say the idea is more that the stimuli are happening during the integration, and that typically in the psych, this is in classics like Alex, typically during the dosing session, the person is more directed in word. They put, I'm asked on, they listen to headphones, and they're largely not interacting with the therapist. They're largely interacting with their own internal world. And having new experiences with their own internal world, they're viewing their thoughts in different ways. They're having new emotions, they're viewing their emotions in different ways, and having different ways of relating to their ongoing experience. So in the psyched up accession itself, it's usually very, very much an internal kind of introspective kind of experience. It may feel very interpersonal, you may feel credibly connected to others, but you're doing it while wearing eye shades and headphones are on. That's the typical and a way which it's unfolds. And so you've done research with psychedelics and social anxiety, right? Yes. So like what would you do? What's that? That's with MDMA. So like what would be some of those, but that would adhere to what you're saying, where folks would be have like, I mean, it's gone ahead for a while. Not so much. Less so. Yeah. Yeah. So yeah, I can talk more about that research. So MDMA is more of this, we're talking very loosely, but it's much more of a social, socially kind of enhancing substance. It's not as dysregulating. If you go in and you try to talk to somebody who's on a high dose of a classic psychedelic and you try to have a conversation with them, it'll often be just like go off in the stratosphere or it will make sense that they can't track it. That kind of stuff, you talk to somebody on a high dose of MDMA. Sometimes people can have some hard difficulty with an frontal lobe functioning, but for the most part, they can have a coherent conversation. They can be more linear. They're more coherent. Their sense of self is intact, but they're opened up. Often their heart is more open. They feel safer. The experience of others, the way others are related to them kind of have more impact. They feel like there's an empathic resonance that people typically have when MDMA is active. Again, especially depending on the therapeutic context that supports that. And so there's a lot of preparation that of course you do typically in our trials, we do three sessions of preparation, so three 90-minute sessions. And then there's the dosing day. In our trial, we have two dosing experiences, two MDMA experiences. And those with social anxiety, at least in our study, tend to have a much more of a balance of periods of introspection, eyes closed, you know, your headphones on. And also periods of more of interaction with the therapist. And those periods can look a lot more like standard psychotherapy. And with resin, with the classic psychedelic, even when the person has their eye shades off, often a lot of what you normally do in therapy kind of just doesn't land. But you can often do a lot of that with the MDMA during the interactive periods. And the way we thought about social anxiety was that those interactive moments, or we consider those potentially very important because, you know, this is a problem where central problem is you have a hard time being yourself around strangers. It's kind of like if you wanted to put it in a nut shell, that's the core problem of social anxiety disorder is you have a hard time being yourself around strangers. You're afraid that if you just let yourself be yourself, let them see or the authentic you without all of the masks and the performance and the preparation and the rehearsal and all of that, if you were just let them see you, people wouldn't like you, people would judge you, they would reject you. And that's the core fear of social anxiety. And so part of what happens, it seems like with MDMA is that it can help people, people go into, you know, people with them with social anxiety sort of go into situations with expectations. They have this expectation that if I'm my authentic self, I will be judged, I'll be ostracized. So what happens with MDMA, and I say this is part of probably most effective treatments is people have those expectations violated that something else happens except besides what they expect. And with MDMA, it can heighten that expectancy violation. So you're in the session, you feel safe. And so you can reveal that authentic self without having to hide it because you feel safe now. And you just drop, you just naturally just drop all of the protection and all of the hiding and that rehearsal and all of that. And the person can be themselves. And then because of the heightened empathy and all of these kind of interpersonal things, they're more likely to experience the therapist responses as non-rejecting as, you know, that the person cares about them. And in the context of being seen as their authentic self, and that can happen repeatedly over many hours. And so we think of that as like a very salient expectancy violation, which then allows those, and of, you know, expectations to be updated so that people that really strong expectancy that if I do this, people are going to reject me and they're going to judge me, can start to become more, you know, reduced and people have less of that expectancy. And so the interpersonal reactions are a key part of that. So people can have a new experience of being authentic and feeling safe, being authentic and feeling not just not rejected, but being authentic and feeling cared for and valued. And MDMA kind of can make that more salient. And kind of a stronger experience. So if we think about, you know, one of the most typical things you do and say social anxiety sort of treatment is exposure therapy, you have a person go out and like face fearful situations. And generally if you do that, like the best thing, the best outcome is the person does the thing. They do the public speech and they don't get heckled. They don't get ostracized, right? The bad thing doesn't happen. That's the best thing that can happen usually in terms of an expectation violation. But what happens with MDMA, the analogy would be you go and you give the public speech and it's not just that you don't get heckled. It's like you give the public speech and all the people come up afterwards and they're like, oh, that was so fantastic. You know, and oh, I was so touched and, you know, I love that. And you know, it was like, uh, and you know, I just, you really moved me and it's not just that they say it, but you can actually feel it. You don't just hear it, you actually feel it and it like gets into your bones and that's when MDMA can create that sort of a possibility and that sort of experience for at least I think a good number of people. And so it's not just you not reject it, but it's almost like you get the opposite of rejection. And that I think can create these really salient learning moments. So that's at least how I think about how MDMA might be helpful for social anxiety disorder. So how is it difficult to keep patients from after the fact saying, oh, yeah, that was just the drug? It can happen some, but we have an encounter that a whole lot. I think really, okay. It doesn't feel, I think people who they talk to may say that, right? If they share their experiences, like, oh, you were just high, but from the inside out, it doesn't feel like that. It doesn't feel like you're not you in that situation. It feels like you, it just like feels like you having different experiences. And in you learn from them. And at least that that's been that's been our experience. Yeah, well, I mean, I think about it like, you know, when we talk about some of the limitations of other psychiatric medications, right? One of the sort of the the typical pushback from a psychotherapist will be, you know, patients can sort of get dependent on it or can think like, oh, this is just because I'm on this medication I can do this. So the students like go off the medication. Right. Yeah. Yeah. It's back to normal. But I think the difference here is that, you know, with that, you're kind of taking this external thing each day and you know, expecting that to change you. In this case, you take a you take a drug and you have an experience. And it's the experience that changes you. It's not the drug that changes you. Right? And so you have this new experience and you learn from it. And that's the thing that changes you. At least subjectively, I think. Yeah. I mean, there's probably biological level things happening as well. But from the phenomenological level, that's the experience of it. Not like this drug changed me. Like this experience changed me. You talked about in the context of social anxiety, how, you know, you can sort of have this fear of rejection that you get this disconfirming evidence for that. What does that look like for something like psilocybin when there isn't this interpersonal component that sort of quote unquote new learning that happens? Yeah. I think there's lots of things that can happen. So we're writing a book like a a primer for therapists on psychedoxys therapy. And in that book, we tried to make sense of what the psychological literature says about the processes of change. And they're, you know, there's not a huge literature at this point. But they're they're do seem to be a number of pathways through which change happens. And to simplify the best way that we could come up with to kind of characterize the main pathways, it uses an acronym that we say is called epic. So E-P-P-C, we pronounce it epic. And E refers to embodiment. And so this is the idea that psychedox often create experiences of embodiment of being able to have, it often involves intense somatics sensations, intensive motions. Oftentimes the ones that you most might be scared of experiencing can sometimes come up. And so people will have these experiences of being with emotions and sensations in their body in a way that they don't normally experience. And that's a, you know, that's a core problem for many forms of psychological difficulties. People can't be with their feelings. And so psychedox create these powerful experiences around that that then people can carry into their lives. And that that's the embodiment component. And then the this the first P is perspective. So psyched out classics, psyched out S can create all kinds of shifts in perspective from these profound mystical experiences where your sense of self may completely dissolve. And it's just the world as it is with no separation. That's a shift in perspective to having a sense of yourself as still intact, but you're part of something larger whether it's the universe or a family or, you know, nature, but there's this sense of interconnection that's not only there, that's a perspective shift. There's also perspective shifts in the sense of people kind of have these experiences of seeing their their their their life and their narrative in the context of some larger purpose. So that's again a perspective shifts you kind of see this bigger picture of the bigger perspective of what you know, meaning that your life is embedded in. So these there's these shifts in perspective of which some, you know, those are examples that will relatively frequently happen, happen, you know, in psyched out scissored therapy. The third P, the second P third letter is purpose. And that has to do with again, I mentioned that meaning part, but oftentimes people find these experiences as profoundly meaningful. They're often arrayed them as amongst the most meaningful experiences their lives. And they often find themselves connecting with their sense of what what it is that they really care about, who they want to be, what they want their life to stand for. That there can be shifts in priorities that can be about sometimes those can be quite disruptive. And also they can be, you know, quite meaningful and life-affirming. But there's often shifts in people sense of purpose and priorities. So that's the third P, or the third letter. And then there's the the C which is connection. And often people have really profound experiences of connection. Whether that's connecting with their bodies, connecting with that larger vision, but also just interpersonal connection, people will feel connected to others in ways and in a depth that they don't typically feel in their ordinary life. And we know from large and very large amounts of research that feeling interconnected, feeling like you belong, and that you're connected to others is one of the most key factors for having a good life. And so psychedelics can kind of create those experiences that then as I've talked about with integration and intentionality afterwards, these temporary, strong experiences can then become integrated into your life so they become part of your behavior, part of how you think and part of how you act and part of how you feel over time. And so that there's a lot more to it. I would say then it's not only those four processes, but I think those four processes are a good way of kind of giving you an overview of the bulk of the types of things that happen with psychedelics that tend to be helpful. And then there's all kinds of things that happen with psychedelics that are just weird or just experiences and they may not actually lead towards productive outcomes, but they might be interesting or fun or scary and not productive. If we're going to bring a productive, kind of western productive type frame to this, but there are lots of other reasons to value psychedelics beyond whether they foster greater mental health, but we've been talking about the psychotherapy context. So that's really the context that we're talking about. Before I let you go, I want to give you an opportunity. You started this Portland Institute for Psychedelic Science, which I will link to in the show. I just want to give you the opportunity for 30 second, 45 second, just the overview of what you all are doing there. And then also if there's any other resources or things you want that I can point my listeners to for folks who are more interested in your work or learning about this generally. So anyway, so yeah. Well, people can look on Google Scholar for my name and find the things we're writing about and the resources there. We are writing this book that will be how it will be about to submit it to the publisher with Gille Ferd. So if people listen to this in a year and 2027, it'll be out. But Pips, we're a research and research center and clinic and training center and essentially trying to advance the science of psychedelics and develop psychedelic psychotherapy approaches in particular that are more grounded in the evidence space. And that's really our central task is to both develop those. As we develop them, train them and deliver those. And so we provide, in terms of delivery side, we provide psilocybin assisted therapy through in combination with a nonprofit that we're affiliated with that creates this seamless and of psilocybin assisted therapy service that's like pretty analogous to what you get in a clinical trial. And that's the main thing that we offer clinically through our organization. And then yeah, we run clinical trials. We finished an MDMA trial. We're about to start a psilocybin trial for women with chronic pelvic pain. And then we have our next MDMA trial plan to start next year. And then we're involved in other psychedelic science projects and studies of various sorts internally and externally as well. But our core goal it our core focuses these these clinical trials and trying to develop the psychotherapy approaches. Yeah, at some point I'd love to talk to you more about this, like the model that you all have set up, which is this, you know, this nonprofit organization that is deliver services to the community, but also does research, you know, and to do that in an on academic context. And it seems like most of the financial resources for doing that come from the revenue that you bring in for the clinical services. So I think it's pretty pretty uncommon and pretty cool. Yeah, but thank you for this. I can't tell you how much I appreciate it. It's been incredibly enlightening. Cool. Yeah, I hope it's helpful. I hope it's helpful for the listeners. And you know, if anybody wants to shoot me an email or something as a follow up, I'm not hard to find online. So feel free to connect with me and happy to help people find their way if they're interested in this field. That's a wrap on our conversation. As I noted at the top of the show, be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time.[Music]