Understanding the Therapy Part of Psychedelic-Assisted Therapy - Dr. Mary "Bit" Yaden, Assistant Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University

Shiv Gaglani: Hi, I'm Shiv Gaglani. We've been careful on Raise the Line to use the term psychedelic-assisted therapy because, as we've heard from our guests, these compounds are best administered in the context of a therapeutic relationship in a safe, controlled setting. 

Today, we're going to focus more on the therapy part of the equation with Dr. Mary “Bit” Yaden, an assistant professor of Psychiatry and Behavioral Sciences at Johns Hopkins University, who contends that administering psychedelic-assisted therapy is vastly different for professionals used to conventional mental health treatments. She co-authored an article in JAMA Psychiatry in 2021 entitled Psychedelics and Psychiatry, Keeping the Renaissance from Going Off the Rails, with her Hopkins colleagues, Dr. Roland Griffiths and Dr. David Yaden, who was a previous guest on the podcast and who also is her husband. 

Dr. Yaden earned her medical degree at Thomas Jefferson University in Pennsylvania and did her residency in psychiatry at the University of Pennsylvania Health System. As a side note, she's also my preceptor at Johns Hopkins in my return to medical school, so I really appreciate her taking the time out of her schedule to be on the podcast and also to mentor me as I'm returning to med school. 

So, Bit, thanks for taking the time to be with us.

Dr. Yaden: I'm so delighted to chat. I'm looking forward to it.

Shiv: So, we always like to begin by asking our guests in their own words to tell us what got them interested in a career in medicine and, in your case, ultimately psychiatry.

Dr. Yaden: Wow, that's a great one. So, it's interesting because I grew up in a family of physicians, which I think is one of those really common things. I think medicine is one of those professions where a lot of people have family members or other close folks that, you know, you kind of get to see exemplars of medicine that really shape your thinking and for me, I actually grew up really interested in the arts and other disciplines and it was only really until college and after college that I recognized that I could have a career in medicine but also create space for other areas of my passion. I felt like psychiatry in particular allowed for a really interdisciplinary practice and that I can combine different areas of my own interest into my clinical work and it doesn't take away from my medicine but rather makes me a better, I think, doctor. I'm especially finding that in what I'm doing right now. 

But, yeah, I think many paths led me here and I'm certainly grateful to have made it to the other side.

Shiv:  Absolutely and, well, you have a pretty interesting background because you also have an interest in, you know, we've talked about everything from Buddhism to the work you did at Penn in positive psychology. So, for our audience, can you fill them in a bit about maybe the positive psychology, what drew you to that and your experience at Penn?

Dr. Yaden: Absolutely. When I was in college, actually, I went to NYU and I was in a program that allowed you to create your own major, which is kind of the opposite of the medical school experience. You have a carte blanche to say I want to learn about very specific things. For me, my interest at that time was really looking at the intersection of well-being studies...things like what makes us happy and also things like Eastern religion in particular. It was a great college and that way is so wonderful in that you can really be very clear about what makes you curious about the world and being a human and growing up. For me, that was about exploring Eastern spirituality and evidence-based well-being practices. 

So, that's when I was first exposed to the work of a well-known psychologist named Martin Seligman, who is probably in your psychology textbooks for having defined something called ‘learned helplessness’ which is part of the theory of what causes depression. Specifically, that when you experience failure or have thoughts that are particularly distressing about your future potential or who you are as a person or what the world is like, that it can inspire in us this kind of apathy or lack of motivation that then looks a lot like depression, both in models of animals as well as adult people.

Somewhere into his career, he said, actually, I'm really done studying what makes people unwell and I want to get really curious about what science tells us about what allows people to flourish. And he really created space for a field to grow, to ask scientifically what are the practices or things that we can be doing that allow us to live better, kind of regardless of whether or not we're dealing with psychiatric illness or otherwise? I found that really compelling and had the opportunity to get a master's degree at Penn to learn about the existing literature and to try to kind of expand it and envision ways to expand it in the future. So, that was such a great opportunity and really was my first introduction into psychology, but also a lot of the same themes that make psychedelics interesting to me now.

Shiv: Yeah, absolutely, and I definitely share that interest because I think so much of medicine is focusing on getting people from an “abnormal” quote-unquote state to a normal state, but everyone seems to exist on a spectrum. We talked about this actually just last week in Denver at the Psychedelic Science Conference. People who may have been flourishing, like healthcare professionals, can go to moral injury and burnout within years if not months. They move up and down that spectrum depending on circumstances in their life. Was it at Penn with Martin Seligman and with David that you got into the study of psychedelics or was that more after residency? Like, when did that happen? 

Dr. Yaden: That's a great question. So, it was actually at Penn. You know, I have a great memory. I was just telling this story recently. David was a colleague of mine at Penn. We were both in graduate school and we're both kind of interested in spirituality and we're both meditators. We were in the library at some point and he passed me a paper. I just have this very visceral memory of him passing me the 2006 article that Roland Griffiths had written saying that psilocybin can occasion mystical experiences, which is one of the first big articles in psilocybin research that came out and I was just totally blown away. 

I was into mystical experiences and spirituality but I was not interested in psychedelics. I didn't grow up as a part of that subculture of being really exposed to it. But I thought, wow, this is so interesting and then I think in future years, just seeing the opportunity as clinical trials started flowing out that showed efficacy for things like tobacco use disorder, alcohol use disorder, major depression, treatment of existential distress in patients with cancer... I was just like, wow, this has incredible merit and incredible potential, it would seem. I think it's been really fun to see that field develop.

Shiv: So, let's get into the psychedelic-assisted therapy. I've been looking forward having you in the podcast because I've had the privilege to interview a lot of the other Center for Psychedelic and Consciousness Research faculty at Hopkins and everyone I think I've spoken to has come from a very interesting background -- whether it's Fred Barrett as a neuroscientist or Al Garcia-Romeu as a psychologist, or obviously David Yaden as a very well-established, impressive researcher. You're the first clinician, especially the first MD, I've had on the podcast from CPCR talking about psychedelics. 

So, having both diagnosed and treated people with say conventional psychiatric medications and therapies, you know...now you're starting to delve into the psychedelic aspects. What are some compare and contrasts that maybe we should be aware of? 

Dr. Yaden: Yeah, that's a great, great question. I'll start by way of just saying that I love being a psychiatrist. I'll use any opportunity to shout out psychiatry because I think it is such a deeply meaningful field. I think that regardless of the kind of approach you're taking to treatment that our patients are suffering and they're suffering in a way that is oftentimes ignored or underappreciated by other fields of medicine.  

Psychiatry not only allows us to address mental illness, but also I think some of the deeper questions and challenges about what it is just to be human. So, before even talking about how we begin to approach those things -- whether they be illness or just the human condition -- I just have to shout out the field of psychiatry in general, because even while it is an imperfect field, I think it has great potential and it has done some very good things historically...and maybe some other things that are not so good. I think that there is a real promise in psychedelic-based treatments, or I certainly hope so. I'm investing my career in that area. So, I'm very hopeful, but I also am always wanting to be as aligned with the evidence as much as possible and so we're certainly at the infancy of this field. 

So, with that preamble over, let’s go back to your question, which is, okay, psychiatry does things one way, how is psychedelic-assisted treatment different? Our lab, specifically, at Johns Hopkins, works primarily with the medicine called psilocybin which is the active ingredient in hallucinogenic mushrooms, which I think a lot of people are familiar with. Psilocybin has had some compelling evidence for several different indications, but one I think that is very interesting for a psychiatrist is depression, or even kind of some of the depression that happens when really bad things happen, like cancer diagnoses or end-of-life treatment, etc. 

As a psychiatrist, there are a few things that I can do if a patient comes to me and they're depressed. The first thing, I love to recommend -- and I feel like psychiatrists often aren't thought of as therapists, but we do get lots of good therapy training -- is that therapy is good for anyone, whether or not you're suffering from depression, anxiety, or just, again, a human who is dealing with the trials of being a human. I think having a good therapist is always kind of solution number one. 

The other thing that we offer are medications, and I think psychiatric medications can seem kind of intimidating to other providers and also, you know, maybe have some negative reputations, and yet we have good evidence to suggest that there are a lot of safe psychiatric

medications that treat depression. The most common ones we hear about are, of course, SSRIs -- selective serotonin reuptake inhibitors -- and they are pretty commonly prescribed for patients whether that be in a primary care setting or in a true psychiatric setting. 

These are kind of our tools, and things like SSRIs are medicines that you take every day, and you take them like a vitamin. We know that over periods of four to six weeks, we see changes in people's moods that are often very subtle, and yet we can see remission of illness, ideally in a lot of patients. So, that's the traditional model and for a lot of folks, that is effective and for some other folks, it's not. 

I think the question of how do we best serve people if that kind of daily pill solution or standard psychotherapy solution is not working -- like, what other things can we offer them -- I think the psychedelic-assisted treatment model is really unique in that it's different from this. Whereas we talked about taking medicine every day and seeing a therapist once a week, psychedelic-assisted psychotherapy or treatment structures are time-limited. These are often happening over a period of three months and again, I'm talking about this in the context of what we are seeing in our clinical trials, because at this point, psilocybin is not something you can go down to your pharmacy and get. It's not legal in our country and yet we're exploring this treatment structure in a clinical trial setting. So, in that context, treatment is usually around two to three months. 

A lot of these studies are taking the shape that -- again, I'm giving a generalization -- where you are meeting with therapists. The idea here is that the medicine that you'll be receiving is linked to your relationship with these therapists who are supporting the work you're starting together and for about three to four sessions before you even take this medicine, you're just meeting with these two providers. In our case, we use two therapists for every one patient, really just to ensure ultimate safety, because this is an experimental treatment, to really get to know participants, and that can include different kinds of psychotherapy. 

I'm going really in the weeds here, but you can stop me at any point if you want me to be less specific.

Shiv: No, this is great. I appreciate that.

Dr. Yaden: I just think it's so weird that you kind of have to go a little bit deep into it. For the first three to four weeks, a lot of this psychotherapy -- and I'm going to call it a supportive psychotherapy structure -- is really just about understanding who the participant or patient is, their life story, regardless of if they're there for depression or another indication. It's just trying to get to know you so that you can build that trust that is essential to any kind of psychiatric treatment. So, whether you're doing psychedelics or otherwise, that trust is kind of key, no matter what. Then after this three or four weeks of trust building and psychotherapy, we bring people into a kind of a living room-like space in our lab and administer this medicine, psilocybin. Th subjective effects last around six to eight hours, most intensively around six. 

It’s another conversation to talk about what those subjective effects are like, but for many people, it feels like an altered state of consciousness. This is a different way of experiencing themselves, the world, and their relationship with other people. We often put people in blindfolds and have them listen to classical music, which in and of itself is kind of weird in a therapy context and yet, this can allow people in many cases to think about their life and make connections or meaning-making in a different way. The two therapists that they've gotten to know very well are there to support them should any scary things come up or any unsettling experiences, or they want to talk or have a handhold. So, it's a very safe space, so to speak. 

Then following that, we integrate the experience with more psychotherapy. So, the next day, we'll have a session and talk about what sort of interesting things came up during that experience. Then some of these protocols will say, okay, after a few psychotherapy sessions integrating the first dosing session, we'll have another dosing session and kind of see where things go. Sometimes we use a slightly higher dose or a lower dose and then have another, let's say, three to four weeks of psychotherapy to integrate that second experience and that will close treatment. That's when we start measuring whether or not this discrete three months of psychotherapy and two dosing sessions of psilocybin work or not for something like depression or demoralization or another kind of target.

That was a very long-winded response, but I think the takeaways are, this is not taking a pill every day; this is taking a pill twice. This is not maybe you have psychotherapy or not; this is treatment that has psychotherapy as integral to its success. This is not kind of maybe I feel better today taking an SSRI, but I'm not quite sure; this is deliberately taking a medicine that changes your mental state in a way that is not ordinary, that can involve feelings of connectedness, sometimes can involve scary things or feelings of fear, and sometimes can involve full-blown mystical experiences. But yeah, I would say this is not normal psychiatry and yet, maybe this is a new normal for psychiatry in the future for some folks who do want to practice this. So, it's exciting.

Shiv: That's a really helpful compare and contrast because it's the first time we've heard it on this podcast. So, thank you for that. Actually, this reminds me of a conversation I had last week with a guy named Jeeshan Chowdhury at Journey Colab. They're trying to build psychedelic-assisted therapy on top of existing rehab infrastructure. I met him alongside David as well, and he says maybe this is less psychedelic-assisted therapy and more like psychedelic surgery or psychological surgery just in terms of the actual procedure where it's this pre-op, this operative time, eight hours in an operating room or a psychedelic room and then, the integration or the post-op being extremely important, whether that's physical therapy or some sort of rehab. I'm just curious, what are your reactions to that way of thinking?

Bit: I love that. I love that framing and I think that within psychiatry, the place where we put psychedelic-assisted treatments is in what is thought of as interventional psychiatry. In some ways, when we think about interventions, we do think about surgery and I think that there's a lot of overlap. There's far more overlap between the surgical specialties and the psychiatric specialties than anybody gives us credit for. A funny thing is that a lot of times, you'll meet medical students who are deciding between the two and you can't imagine more radically different worlds, and yet, there can be an intensity to both. 

But I think that to your point, surgery itself is something that has a lot of ritual involved in it. There is, as you said, pre-op. There are a lot of pre-op screenings. There's a lot of kind of setup to a day when you're going to go in. And before you're, quote, put under, you're one way and then, you're not sure what's going to happen afterwards. There's this kind of letting go of control. Then, you wake up, presumably somehow different afterwards. So, in that same way, psychedelic-assisted interventions are similar. You walk into a building, you take a medicine, you don't know what's going to happen -- you're surrendering that kind of control -- and at the end of it, you may be different in some way afterwards. So, just in terms of procedurally, it's similar. 

Then, I think that there are also these questions of how do psychedelic-based experiences vanquish aspects of our -- I want to be careful in how I say this -- but I think that there is this sense of things that we can let go of during psychedelic experiences that we would have trouble letting go of during other kinds of experiences that, in that way, mirrors this idea of ‘I go into surgery, and I have a cancer that I take out.’

To give a good patient example -- it's a doctorly thing to just give you a patient example -- I had a lovely woman who we were treating in one of our studies and we were actually looking at OCD. She was not thinking about grief as part of her diagnosis, but after her session she reflected on having grieved the loss of a loved one during the experience. She really felt like after having this six hours with us in a room with eyeshades on, where we said absolutely nothing to her and listened to classical music together, she said, “Oh my gosh, I feel like I grieved the loss of this parent in a way that I am truly different having had this experience.” She didn’t say I'm thinking about grieving it or I'm starting to grieve it, it was like ‘I went there in this experience in a way that now has made me feel very differently about that loss.’ I thought that it's kind of interesting that way...the things that we let go of during these procedures. 

Shiv: That's fascinating. By the way, I love specifics. So, if any of those come to mind...

Dr. Yaden: I'll give you all the specifics!

Shiv: It's just such a good way of bringing something that's super abstract into the real world and making it tangible when you can cite different patients and studies, etc. 

I love the mind-body connection and it made me think as you were talking that just earlier this year, the Surgeon General's office released a report about this epidemic of loneliness and feeling disconnected. People don't have best friends or friends alone, which is paradoxical because, you know, we're more connected than ever via the internet and Twitter and Instagram and Facebook, but feel lonelier. What the Surgeon General's office concluded in this eighty-one-page report is that severe loneliness could be as bad as smoking fifteen cigarettes a day in terms of the cost to someone's health. 

I don't think loneliness is an outcome variable for psychedelic studies as far as I've seen, but maybe you can give our audience a bit of an overview of what gets you most excited as far all the different things psychedelic-assisted therapy could be used for. We’ve heard about depression, anxiety, OCD, eating disorders, but then also human flourishing and spiritual experiences. 

Dr. Yaden: Well, I'm going to answer both your comments and agree with you and say why I think that's such a brilliant point to bring up, and then I'll think out loud about what makes me most excited because there's a lot of things that I think are exciting. 

But I think your point about loneliness is so well taken, and I think one of the most compelling outcomes in the literature exploring the phenomenology of psychedelic-based experiences and some of the outcomes people have afterwards is this increased feeling of connectedness. Again, we're not going in there and saying, “Okay, you're walking out the door with more friends than you came with.” It's not like that. That's not the outcome, but rather that there is something about psychedelic experiences and the container that psychedelic-assisted psychotherapy supports that can for many of our participants – and I have heard this – change how they feel in terms of reaching out to their community. 

I had another patient, a lady who came in, again, in a totally different context -- she was not looking to feel more connected. She was presumably pretty well-connected in her community and had kids and was lovely. She remarked after her experience that she felt more willing or more comfortable showing parts of her own heart to other people. Before, she had sought out friendships that were good and helpful, but that she had never been able to show vulnerability in her connections with different people and that something about the psychedelic-based experience and going through that kind of therapeutic process allowed her to feel safer and to feel more willing to be vulnerable and intimate with friends, and that was not what we were treating her for. That was not the outcome that we were measuring and yet, that was the one that she kept saying had the most meaning for her and was so important in her life and she talked about wanting to strengthen her marriage and these other things. 

This is not uncommon for many of our participants to really walk away saying, sure, maybe I'm less depressed, but really I just love my family and want to spend more time with them or care about my friends. You know, if that's what this treatment does, or if that's a big so-called side effect, then I will take it. So, that's an aside. 

But, to your question about what's most exciting, I think this is a two-part answer. I'll give you the one that I think is most exciting for medicine more broadly. Some of the most compelling evidence, specifically with psilocybin, has been around smoking cessation and our lab is going to hopefully at some point publish a study that some of my colleagues have done on outcomes related to tobacco use disorder, which we know is huge in the category of preventable causes of death and illness. Any doctor will tell you that we shouldn't be smoking and yet, it's so hard to quit and there's a lot of well-meaning folks who encourage quitting and there's medications that we have that are not necessarily that effective. 

I think the outcome potential with psilocybin and psychedelic-assisted treatments are really cool. I don't want to, like, ruin the results of this future research, so I'm not going to speak to it very directly in specifics, but I will say that seeing that data come out around tobacco use disorder and other substance use disorders for me is just heartening across the field of medicine. I'm really excited to see that work continue to develop. 

When I came to medicine and psychiatry, I did so because I wanted to kind of deeply connect with other people. I thought a lot about being a chaplain and was a meditation teacher and really valued that kind of bedside time when it's not just about you being the doctor and someone else being the patient, but what it is to be with another human in moments that are incredibly challenging or incredibly meaningful. and to be with others in that way. I think, for me, psychedelic-based treatments provide a really powerful vehicle by which we can experience the human condition with other people and hopefully see them flourish in new ways that are aligned with their values. 

So, I think that part is so exciting and thinking about things like end-of-life care...you know, I can't give you an SSRI that is going to truly take away the loss and the pain of what it is to say goodbye to your family at the end and yet, it feels like such a privilege to be a part of helping to facilitate experiences whereby individuals can find peace and meaning with the hardest parts of what it is to be alive. So, that to me just feels meaningful and it makes me excited to continue to do this work in the future. 

Shiv: Absolutely. Each one of those are very interesting threads to pull on and, again, I echo why I'm excited about the work and being able to learn and work with you all. 

Before we go into workforce considerations around scaling up psychedelic-assisted therapy, which is super important, one of the people we had on the podcast last year was James Fadiman, who wrote The Psychedelic Explorer's Guide and is well known as the father of microdosing and really advocates for the citizen science approach, which many of us have heard examples of, you know, tech founders out in Oakland being on these protocols of microdosing psilocybin or LSD. As a psychiatrist yourself, I'm just curious, what are your thoughts on that approach? Obviously, self-administered psychedelic therapy is not so much what you described as what's clinically being studied.

Dr. Yaden: Yeah, this is an awesome question. I'm so glad you asked it because I am a psychiatrist and so I favor safety and medical monitoring and I have a lot of humility about what we know about these medicines and what we don't. So, I'll just kind of rattle off a few things. I think that as excited as I am to learn more about psychedelics and the treatment of disorders as well as, as you alluded to, this idea of human flourishing, I think we have to be really careful. I remember I had a great residency or med student mentor who was like, powerful things have side effects. Like, if things work, they have side effects. That's the kind of good and bad of things. 

So, I think that we need to be honest and open about the idea that a medicine can have a lot of potential and it's powerful and can do some things that maybe we don't want it to do. And so, having seen people have really powerful positive experiences on psilocybin, for instance, I've also heard a ton of stories about folks in unsupported environments having really scary, challenging experiences that were maybe destabilizing for them. I only know the evidence for what's been done in clinical trials and those are highly, highly regulated environments with very trained providers and highly screened patients.

I'm jumping up and down excited about the results of these studies, and that's all I can be excited about. You know what I mean? I really can't encourage my patients to do things that I don't know are safe. And that's my job. It's kind of the doctorly thing, I think. It reflects my own journey of becoming a physician... recognizing that our number one job is to keep people safe in many ways. So, I think that I would be really hesitant to recommend things outside of the research model at this point.

I think you brought up something very interesting, which is microdosing in particular. There have been some preliminary studies of microdosing that have not necessarily shown overwhelming evidence that it's effective for some of the things that people are targeting when they're doing it. I also want to highlight one of the interesting kind of specifics about microdosing in particular, is that psilocybin -- and I hope I don't misquote this, this is not my area of research -- but psilocybin, like a few other substances, can act on very specific receptors that are in the brain, but also in other parts of the body, like the heart. We know that with psilocybin in particular, it can act on a receptor in the heart that can make it more likely with persistent exposure that you develop structural heart disease or valvular disease. 

This is not something unknown for a lot of medicines. Like, we give people medicines that can cause this. Something like cabergoline, which is a dopamine agonist, is another example of something that can work on heart valves in this particular way that can make it more likely for you to develop things like aortic stenosis and we monitor these patients that need this medicine very closely with echocardiograms just to make sure that they can take this safely. So, that's a known risk and we know that psilocybin acts on the same receptor and could also put people at risk for this kind of valvular disease. 

Daily dosing of something like psilocybin may not be a good idea for us. We don't know that.

We haven't done those studies specifically looking not just at does it make people feel better or not, or make them more productive or not, but does it put them more at risk for heart disease? I don't think we know that. I think we have compelling evidence that two doses of this medicine in a three-month treatment is probably not dangerous. But again, things like microdosing, where you're potentially taking a medicine every day, I don't have evidence to say that that's effective. I also don't have evidence to say that that's safe. So, that's my hesitation about it, just from a very psychiatric medical doctor standpoint. 

Shiv: That's great. Thanks for sharing that. And I think it's important that our audience listens to this because I think this is also one of the points from your JAMA psychiatry paper is how do we avoid being in peak hype cycle? David shared this last week at the great talk he gave, which is maybe psychedelic researchers -- and frankly, the organization that put together that conference, MAPS -- maybe give out what he called a wet blanket award. Let's celebrate the studies that actually reduce all the hype that's coming around. 

For example, like, can psychedelics lead to solving climate change as well as make everyone eliminate wars and things that in the 60s and 70s wound up, I think, ultimately leading to them being banned...just the peak hype around it. So, maybe you can comment a bit about that. How do we avoid going back into a banned period over the next several decades?

Dr. Yaden: I love that. David is not a wet blanket, even though you were mentioning a point he makes about really encouraging people to not get overly excited or kind of oversell psychedelics as the answer to world peace and suffering and all of the things. Sometimes that makes us out to feel like wet blankets and that is not the intention. Yet, I think the idea there is so important that we don't have to make this the solution to all of the problems for this to just be a good solution for a few of them. You know what I mean? I think that humility in medicine is so important and that it will be such a boon if we know that psychedelic-assisted therapies treat a few things. That's a great success. 

For this to be meaningful and worthy of research, it doesn't need to answer all of the questions. It's good that we're asking many of these questions. Yet, I think that a great tragedy of this kind of movement to support this kind of therapy and to support research in this area could be that there is so much overblown hype that we become disenchanted too early or that we start allowing for practices that are not safe just because there is widespread enthusiasm and support in a more cultural sense as opposed to in an evidence-based way.

I think that one of the fun things about being a doctor is that you like a treatment until you read a better study that says that you shouldn't. I think that we are constantly challenged to re-examine the literature and to continue to learn. It is a field of lifelong learning. In that way, I hope we can all continue to keep learning about psychedelics and not just be sold that they're the answer to something because we never know that for sure. I think there's great

promise and lots of opportunities for us to learn over the next several decades.

Shiv: Yeah, totally. Going into workforce issues, you mentioned that one thing you were exploring was being a chaplain, and a meditation teacher. We know that we already have a shortage of tens of thousands of healthcare professionals and mental health professionals in particular, especially with all the mental health challenges that have come as a result of COVID and being socially isolated, as we discussed, not just from COVID but from social media. 

The counterpoint is there's also just a lot of scope of practice concerns across every field, right? My sister and brother-in-law are dentists in Chicago. They have six dental practices and there’s the issue in that field of dental assistants versus hygienists versus dentists. What do they do? What's the scope of practice? We see that with PAs and NPs. We see that with psychologists, social workers, psychiatrists.

Can you comment a bit about what you see as a psychiatrist as being important workforce considerations when it comes to actually scaling out psychedelic assistance therapy? As someone who's trained alongside social workers and psychologists -- because you've gone through a lot of training yourself -- how has the reception been as a psychiatrist from Hopkins, maybe top of the totem pole as far as the hierarchical system?

Dr. Yaden: Well, I think your first question really speaks to your point about access, which is that there aren't a lot of psychiatrists. There's a shortage of psychiatrists. There's a shortage of so many important healthcare practitioners across disciplines. Realistically, it's not going to be two psychiatrists in a room with a patient facilitating this kind of therapy outside of clinical trial context. In many cases, it will likely be that social workers, other kinds of licensed therapists, psychologists will be conducting more of the psychotherapy associated with this, and that there will be an overseeing psychiatrist who may be involved for consultations or medical monitoring as part of this rollout of care. 

I think that there will also be -- and I very much hope because, again, I'm a psychiatrist who loves being a therapist -- psychiatrists who do take a more active role in the actual psychotherapy involved in this work. I think that I will say in thinking about things like burnout, there's both burnout that we get because we're working too much, and there's burnout that we get because the work we're doing doesn't feel meaningful. I know for me, I actually think about my psychotherapy hours that I spend with my patients as feeding my soul as much as it is caring for other people. 

I think that there's an opportunity for psychiatrists to safeguard that space for ourselves that we can continue to advocate for and provide that care as we are able. There are different structures that make this challenging, like reimbursement, and it's complicated, and at the same time, I think that there's a role for psychiatrists in many areas of psychedelic-assisted therapy work, and I hope that that will continue into the future. That's point one. 

Then point two, it's funny about how in some ways, psychedelic-assisted treatments in psychiatry is natural and is a thing that psychiatrists across the world are rejoicing that we get to use these medicines again and be curious. I will share a funny fact that early research into psychedelic substances actually allowed for the discovery of serotonin as a neurotransmitter. Scientists in the 50s and 60s were beginning to understand these medicines, and that then led them to ask questions about other chemicals in the brain that then led to the development of things like SSRIs. This is not so “other” from what we have been immersed in for the last century in our field, and yet there was this big shift away from looking at psychedelics as having important potential both in research domains or clinical domains because of this prohibition by the government and a lot of fear around recreational use. I think that that fear really biases a lot of psychiatrists against them. 

I think we are protective of our patients, and we get scared when we know our patients have substance use disorders, and it can be hard to differentiate between the abuse potential of things like psychedelics and the abuse potential of things like opiates. I think that can lead a lot of psychiatrists to be fearful and cautious, and yet I've been really reassured by the data that shows that for psilocybin, for instance, this is not a medicine that people are using on a daily basis. This is not a medicine that you become physically dependent upon. This is not a medicine that inspires the kind of suffering that is typical in the context of things like opiate use disorder or cocaine use disorder. This has a different profile, and in that way, I think many psychiatrists are coming around to the idea that these may not be drugs in the way that we think about recreational drugs, but rather could be seen as medicines again and hopefully will be in the future.

Shiv: Wow. That's, again, a very nuanced and interesting answer, especially because so many of our audience are finishing up medical school or they're finishing up residency and they may be interested in careers like yours, but also kind of pushing the frontier in psychedelic-assisted therapy. For those people listening, what advice do you have for them about meeting this moment in their careers, not just about psychedelics, but in general. What advice would you give them?

Dr. Yaden: That's a great one. It was so funny...I was talking to another member of our research team at Hopkins, and we were appreciating how different the landscape even is in five years. I remember I was interviewing for residency at Hopkins, and I ultimately chose to do residency at Penn because that's where my husband was finishing his PhD. I actually loved being a resident. This is an aside that people will scare you about being a resident. I loved it. It was so hard, and it totally is exhausting. You learn so much. This is just an aside, don't be scared about residency. It can actually be wonderful. 

I remember I was at an interview, and I knew that Hopkins had this psychedelic research. At the time, it was not necessarily something that many people were talking about. It was years ago. It was not as popular on people's radars. It was in hushed voices. We were like, “Hey, what's up with that psychedelic stuff you guys are doing?” It was like, “Oh, yeah, that stuff's really exciting.” It was clear that Hopkins was really a leader in this area already. Then nowadays, when I was a chief at Penn, it was like there were a ton of people interested in psychedelics. All of these resident applicants were super excited to talk about it and asking questions really openly. I think it shows you that in even just a few years, the culture around ‘is it okay to talk about this or not’ really changed. 

I think the advice I would give is that don't be scared to talk about what you find interesting. I think that there are so many cool frontiers in medicine and psychiatry. Seek out people who are willing to have conversations about those things. Don't be discouraged if people tell you that they think that this is too ‘out there’ because ‘out there’ things become standard of care pretty quickly. That's why being a doctor is so cool, because we get to watch the field change. 

Shiv: That's great advice. I think that's pretty unique advice too, after 400 episodes: just being authentic to yourself. People say follow your passions, which implicitly I think talks about being genuine or authentic to yourself, but I'll say this resonates with me not only in the field of psychedelics, but also interrupting med school to start a company and still being entrepreneurial. A lot of people will say residency program directors or clerkship directors may not be very supportive of that. It's true. A lot of them are not, but I don't want to necessarily close my passions and interests based on what other people want. You start hiding things about yourself or burying them. I think that's a recipe for burnout, moral injury, not being happy... whether that's your professional interest or personal interest. 

Dr. Yaden: Ifeel like that is such a great point. I think that you're a prime example of that. If everybody who told you that that was maybe not the best idea had encouraged you not to start a company, your life would have looked very different. Clearly, this has gone quite well. I was lucky that my residency program was led by warm and loving people that let me be myself as much as I wanted to be. That way, it was the same thing. Good residency programs are like good parents. They love you no matter how you are. I definitely had that experience. I've taught meditation. I did all sorts of weird stuff that maybe some other folks would have discouraged me against, but they just allowed me to flourish. Then I would publish. You get to meet these other extrinsic metrics just because you're excited to do what you're passionate about, as you said, but also to show up with who you really are. I think that that matters most. 

Shiv: I love that. Good residency programs are like good parents. That's a great way to look at it, too. Hopefully, many of our audience can be fortunate to find one like you did at Penn with their psychiatry program. 

Dr. Yaden: I should just shout out my residency training director and my associate program director. One was named Cabrina Campbell and one was named Kristin Leight.They were my family. They did such a wonderful job. I could tell stories about them, but I won't. I will just say that I felt so blessed to really feel like -- not that they weren't asking me to do call or hard things or stay up all night and all of the other stuff -- but that I was truly safe and well cared for as a person and not just as a worker in a program. I hope everybody finds leadership like that.

Shiv: That's awesome. Really great. I want to be respectful of your time, so I only had one last question for you, and it's very open-ended, which is basically, is there anything else about you, about CPCR, the educational programs you're helping to develop, anything you want to share with our audience before we let you go for the day?

Dr. Yaden: I think psychedelic education. We've talked about the field of psychedelic research, which is just like we're doing studies, and soon we're going to have -- and some people would argue that ketamine can be used in a psychedelic-assisted therapy model, and it can be -- but soon we'll have more medicines like MDMA or psilocybin in a therapeutic, clinical context. I think the third frontier is thinking about how do we as psychiatric educators think about teaching about psychedelic-assisted therapy. I think that that presents new, exciting questions in teaching. 

It's, like, how do we prep medical students for an integration session with a patient after a psychedelic experience to talk about mystical experience, because that's the thing that we actually measure. It's not just this rando thing that's really out there that maybe a patient says one day. It's like, no, we know that if we give this medicine in a certain proportion of patients, they report transformative or mystical-like experiences. As a psychiatrist, nobody gave me a lecture on how to talk about that in a grounded way or in a way that is evidence-based or that's wild. 

Yet, that is one of the more interesting things that we have to prepare providers for in the future is how to have conversations that are not just about headache side effects or other things, but also about things like what happens if you just want to call your grandmother afterwards, or you just are tearful, or have these different feelings about the world and the meaning of life. How do we begin to unpack that? I think as educators, we get to help our students think about those things, too, and that, for me, sounds really exciting. I hope that you're all exposed to good educators in the psychedelic space, and I'm sure that there will be good things on the horizon. 

Shiv: I'm positive as well, especially because you're the one leading it at Hopkins. With that, Bit, I really appreciate you taking the time to be on this podcast and sharing what lessons you've learned and wisdom you have from your career as a psychiatrist and now going into the space of psychedelics, but more importantly, the work that you've done to, as we say, raise the line and strengthen our healthcare system.

Bit: Well, thank you. It's really nice to chat. This is so fun, and I appreciate it. Thank you for having me. 

Shiv: Awesome, and with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.