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Merging biology and psychotherapy within psychiatry

An Interview with Collin Reiff, MD

Colin Reiff, MD

While psychedelics try to find their place within psychiatry, psychiatry is still trying to find its place in society.

In the MIND Bioblog series, we present personalities who have influenced the development of psychedelic therapy, research, and the culture surrounding the psychedelic experience. Collin Reiff, MD, is an assistant professor of psychiatry at the New York University Grossman School of Medicine, where he specializes in treating trauma and substance use disorders in the Steven A. Cohen Military Family Clinic. He has co-authored numerous book chapters and peer reviewed publications on psychedelic compounds. His first author publication, Psychedelics and Psychedelic-Assisted Psychotherapy, which he wrote with the Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research, was recently published in The American Journal of Psychiatry. The following conversation covers Reiff’s thoughts on the psychedelic renaissance as it pertains to psychiatry.

Saga Briggs (SB): Some like to say psychiatry has not progressed as a field of medicine relative to others for decades, and that psychedelics could do for psychiatry what the microscope did for biology. Do you feel like this is a fair assessment?

Collin Reiff (CR): Psychiatry is different from other specialties within medicine in that there’s still a lot we don’t know about the mind and the brain and how it works. It started out originally with anatomy back in the late 1800s. In time, it evolved into psychotherapy. Then it went back to anatomy and biology. Egas Moniz won the Nobel Prize for the lobotomy, thinking that changing the anatomy and structures of the brain would have an impact on the mind. Now we think, “That was a horrible thing, how could we do that?” Then things went in the direction of psychotherapy. In the eighties and nineties, it went back towards biology again, with this idea of neurotransmitters working on certain receptors, and not having enough of one neurotransmitter in the brain or too much of another leading to depression or psychosis. Parts of that are true. In and of itself, though, it is a little reductionistic.

But if you think about it, psychiatry involves a lot of things we’re not talking about, which I think are easy to glance over, such as do we have meaning and purpose in life? I don’t think many diagnostic assessments ask about that. Do we think about the history of the world and what needs of humankind are being met at a specific time and how they’re changing? Is there a reason we see so many people getting diagnosed with ADHD today? Is it because of the pressures that are put on people to sit down at a desk and work at a computer for long hours? I think we are seeing more diagnoses because more people are saying, “Hey, I’m having a hard time adapting to a world that is ever changing at faster speeds.” We might think of psychiatry as a practice that eases people’s suffering, allows people to lead lives that are more fulfilling and more in harmony with their desires, and helps tune the mind. Psychiatry is evolving with society. I’m excited to learn what psychedelics will teach us about our minds.

SB: How are psychedelics playing into this currently? Do you see them encouraging us to pay closer attention to some of these deeper questions within psychiatry and medicine more generally?

CR: I don’t think we necessarily have the measures to capture what’s happening right now. We are forcing psychedelics into measures that might not be capturing the full psychedelic experience, and its benefits and risks. In a way, psychedelics are going to force psychiatry and psychology to evolve. Whenever you’re kind of stuck with, “Hey, we’re not sure what’s happening,” it’s prudent to observe. I’m always struck that our depression inventories in psychiatry–the PHQ-9, BDI, HAM-D, and MADRS–don’t ask about patients having meaning, purpose, or structure in life. The question is, do psychedelics have a place in psychiatry and medicine? For a select group of patients, they might. The evidence right now suggests that MDMA does serve a purpose for the treatment of PTSD. Psilocybin appears to be helpful for people who struggle with depression, existential distress around chronic illness, substance use disorders, and burnout and demoralization. By no means does this mean that everyone should be taking psychedelics.

SB: How exactly do you see psychiatry evolving, perhaps with the help of psychedelics?

CR: It may be useful to think about psychiatry historically, in terms of treatments that are perhaps not “psychiatric” in nature. Take the Turkish bath, for example, where you’re heating up the body. There’s evidence that a hyperthermic experience can elevate someone’s mood. That’s probably why saunas and Turkish baths have persisted for so many years in Europe and the Middle East. If we look at something like meditation: does it treat depression? I don’t know, but there’s a reason it has existed for so long. The same could be said for psychedelics, which were used in shamanic practice in Central and South America, and in Africa. They have an impact on the mind, but there’s also a physiological component. I very much believe there is a mind-body connection. I don’t know if we pay enough attention to the body in psychiatry; we tend to focus on the mind. If you look at an illness such as bipolar I disorder, for instance, you see that, when someone is in mania, they tend to have increased energy. Sometimes people can do a physical exercise beyond what is considered normal for them. People can go extended periods of time without sleeping. The mind is driving a physical response. They’re connected. I’m saying this because I think psychiatry in general could benefit from zooming out more, and in my opinion pay more attention to history. Thinking of it simply as neurotransmitters is reductionistic. We did that in the nineties. SSRIs haven’t proven to be nearly as effective as we thought they would be. They work for some people, but they didn’t solve the problem and we’re still trying to figure it out today. So why not explore psychedelics with curiosity?

SB: Though we could be saying the same thing about psychedelics in a decade or two as well…

CR: True, there’s a psychedelic exuberance right now. And this is human nature, to put something on a pedestal. Then what we do is, in time, we knock it off the pedestal. Realistically, with psychedelics, we’re going to find a middle ground. I believe that. They’re going to be effective for some things and probably not for other things, and there probably will be contraindications in time. Very rarely is it that the one thing works for everybody. That’s a red flag–if there’s one “panacea” that works for every ailment. My guess is they’re going to end up being efficacious for certain ailments in psychiatry and medicine.

SB: How important do you think it is to understand the mechanisms underlying that efficacy?

CR: Recent neuroimaging studies suggest that psychedelics are correlated with enhanced cognitive flexibility. There is really exciting work happening and it’s as if pieces of the puzzle are slowly coming together. Enhancing our understanding of neuroscience is very important, but for me right now, it’s more about figuring out if these compounds can improve and prolong people’s lives. Something that is a big restraining force for psychedelics right now is that there’s not a universally accepted approach to psychotherapy. A lot of what’s happening in psychotherapy now is non-directive, which is based on therapies that were used in the 1960s. That approach seems to work…

SB: But there’s no basis for comparison.

CR: Exactly. What would happen if we tried different approaches? What would happen if you gave them MDMA with prolonged exposure therapy or put it in the framework of a psychodynamic or psychoanalytic treatment where someone takes one of these compounds several times a year throughout their treatment with the therapist they’re doing ongoing work with? And what happens if we use these compounds to enhance already established evidence-based psychotherapies? Can we use them as catalyst for psychotherapy? I’m wondering what these therapies are going to look like if and when they become available to the general public. Maybe psychedelics are just a part of treatment for some people.

SB: Do you think there’s a risk of psychedelics leading us toward a more reductionist understanding of diagnosis?

CR: We’re not getting more reductionist. We’re getting more sophisticated. We’re asking questions. We’re curious. These compounds are making us ask questions about how the mind is working, about neuroscience, about our treatments…

SB: I think the thinking behind the question was in terms of where we’re placing the focus. For example, when we hear psychedelics may work to treat not only PTSD but also substance use disorder, we tend to think, “There must be something special about psychedelics” rather than “What’s the connection between PTSD and substance use disorders?” Obviously, you know there is a connection. But this isn’t necessarily the message being conveyed to the general population.

CR: Neuroimaging studies by Robin Carhart-Harris et al. suggest that psychedelics enhance connectivity in certain regions of the brain during a psilocybin session, and for up to three weeks after. They are working via a different mechanism of action than SSRI’s. From a neuroimaging perspective, this is part of what’s special about psychedelics, and this might explain why they are considered “universal amplifiers” by Stanislav Grof.

One of the biggest challenges that limits care in psychotherapy and psychiatry is that quality care is often time and labor intensive. It requires listening and working with a patient to figure out what isn’t working in their life. And then to come up with a plan on how to resolve the conflict, negative cognitions, or feelings. Part of what makes psychedelics interesting and important is that they can alter perception in a way that enhances curiosity and opens psychic boundaries. From a Systems-centered perspective, they can help a patient get out of survivor role and enter explorer role relatively quickly. Also, if we look at them through a psychoanalytic lens, we might say they lower resistance and allow the patient to explore challenging thoughts or feelings that are normally repressed or suppressed. For example, they can allow guilt or shame to surface from the undercurrent of the mind, and be processed relatively quickly. Psychedelics also seem to facilitate transference, which is a key principle used in psychotherapy. It’s paramount in psychoanalysis, and dynamic treatments. This also means that therapists should be well trained and have impeccable boundaries so that no boundary violations occur.

SB: So while some aspects of this therapy might be more efficient, other aspects will require even greater attention and care, and potentially place an even greater emphasis on the individual.

CR: In a way, we might say that psychedelics allow psychiatry to be incredibly individualized. If you think about psychoanalysis, it was a treatment designed for well-to-do or affluent men in Europe. It was really not accessible to most. Anti-depressants, mood stabilizers, and antipsychotics have provided treatment for depression, anxiety, bipolar disorder, and psychosis. They can be very helpful and have helped psychiatry evolve while improving the lives of many people. With that said, we need to continue evolving, and we should remain curious. I’m guessing in time psychedelics are going to have an important place in medicine and psychiatry.

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