5 Questions for Rajan Grewal and Megan Frost
In 2020, a group of nine therapists, nurses, and doctors who call themselves the Medicine Midwives were watching the rapid growth of the psychedelic field — and decided it was time to start a professional group for psychedelic practitioners. From there, they launched the American Psychedelic Practitioners’ Association, or APPA. Over the last few months, the group has been focused on establishing what they call, “self-governance in a rapidly evolving field.” With legal psilocybin-based therapy set to roll out in Oregon by 2023, and multiple claims of psychedelic therapy abuse coming to the forefront in recent months, one of APPA’s working groups has focused on developing a code of ethics to guide current and future practitioners’ work.
Rajan Grewal and Megan Frost are the chairs of APPA’s ethics committee. Grewal is a psychiatrist and a clinical assistant professor at the University of Arizona, where she is co-investigator on a current clinical trial investigating the use of psilocybin for obsessive-compulsive disorder. Frost is a general surgeon who specializes in breast cancer and is also a prescribing provider in the state of Oregon for the Death with Dignity Act. The Microdose spoke with Grewal and Frost about the process and challenges of developing ethical standards in a quickly changing landscape.
How has the APPA ethics committee kicked off its conversations?
Grewal: Our process so far has been getting a sense of what guidelines and practices are already in existence, synthesizing them, and then having discussions. We’re asking a lot of questions: What needs to be added? What needs to be modified? Where do we need help? Where are there unresolved questions? When do we need an expert to come in and share their perspective?
Frost: Right now, we’re drawing on guidelines from the American Psychiatric Association, the American Psychological Association, MAPS’ guidelines, and the Hakomi Institute. North Star has also put up some ethical guidelines.
What challenges have you run into as you’ve started work on this ethics committee?
Frost: While it feels like a brand new field, it's not. It's been around in a therapeutic sense for decades. It's been around in indigenous cultures for centuries. So speaking for myself, coming in, I feel like an imposter — and my biggest problem has been not creating an opinion on something without really digging deep and seeing as many perspectives as possible. Our goal as a working group is to not rush this, to realize that we can take time with it and get as many perspectives and resources as possible. It's going to be an evolving process. We might come up with a rough draft and then a final draft and then in a year, change it and then in a year change it. This process includes our entire psychedelic community and not just those of us sitting on this working group.
Grewal: One of the biggest obstacles has been how overwhelmingly large the task is. We've got our small piece that we're working on, but what are the boundaries of what the ethics committee is versus what the standards of care working group is doing or what the accountability working group is going to look like, or what the legal structure is going to be — what psychedelic therapy will look like in this country is still very much unformed. It’s been hard to figure out the limits of what we're doing and how to accomplish something meaningful while also taking into account all of the other things that need work.
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It feels like many of the topics you’re grappling with might have some precedent in therapy and medicine, but of course the unique experience of being on psychedelics adds a new dimension. How are you all thinking about existing concepts, like giving consent?
Frost: As a surgeon, I ask for informed consent all the time with people prior to a surgery — and even that's really variable. There are some people that are really bright; you can lay out all of the evidence-based medicine for them and they can give really informed consent; they can really weigh everything. But then there are people that don’t understand evidence-based medicine. I can give information to them, but they can't take all of that information and really make that same informed consent. In any field, it is difficult to say what is required in the information that you give to a patient that suffices as “informed consent.”
What makes for informed consent is going to be different in literally every provider-client relationship. With psychedelics, there isn’t even a consensus yet on what consent means. Drawing that out in ethical guidelines is very difficult; you're going to have different opinions about it. We are in a very difficult place in the psychedelic field; there's a lot of gray area here. How do you standardize something that kind of lives in the gray area?
Grewal: I definitely agree. There are certain elements that comprise what we think of as informed consent, but every single case is complicated and nuanced. It's always a case-by-case discussion in any field of medicine, and the field of psychedelics is no exception.
Another common point of discussion in psychedelic therapy is whether touching between practitioners and clients or between participants should be permissible. That also seems like a topic that might be difficult to set general guidelines for. What have conversations on the ethics committee looked like? And how do you, personally, feel about using touch in therapy or treatment?
Grewal: We haven't come to any firm conclusions. It's still an ongoing conversation about what the guidelines would be around that. Just from my personal experience in the research world, the general practice that I've seen is having a conversation during preparation about what comfort looks like to that person, and coming up with a variety of ways to demonstrate comfort. If some of those ways involve touch, we would get pretty detailed about what that means. Is that a touch on the forearm? Is it okay to tap your shoulder? What about a hand on the lower part of the leg? You get pretty specific about what comfort looks like for that person. If that involves touch, what does that touch look like? You need a shared understanding among everybody in the room about what's okay and what's not okay prior to going into the session. During the session, if somebody changes their mind about that and revokes consent for touch, we definitely respect that. If it's the opposite — if I said that I didn't want to be touched, but now I do — our practice has been to not go along with that, to err on the side of caution.
Frost: It’s just like any consent process: it’s an ongoing discussion. You definitely cover it in a preparation phase — that is obviously a very big part of informed consent — but it's also about frequently checking in. If they say yes to touch in the preparation phase before you touch them in the actual session, you ask again: Is it okay if I put my hand on your shoulder? Does this touch feel okay?
In my personal opinion, I feel like touch is a really important part of human relationships for a lot of people. I see that in my practice, the amount of people that just want to hug at the end of an appointment. While I've never been myself in a therapeutic relationship outside of my surgical relationships with people, I can imagine that in therapy, the desire for some touch is very important for people, and that may even be elevated with the psychedelic experience. We're in a scary place because there's a lot of gray area, but that's why it should almost feel silly how much you have to check in with someone. I feel like constant communication is the safest way to go about things.
You’ve both mentioned “gray areas” multiple times in our conversation. What recourse do clients, patients, or study participants have if they feel they’ve been wronged in the course of psychedelic therapy?
Frost: One of the other working groups that we're going to have down the road is an accountability working group, because you can have ethical guidelines about providing informed consent, but there's still going to be a gray area with some situations. Those situations need to be evaluated by an accountability working group, who will look at whether or not those ethical guidelines were upheld.
Grewal: We've had discussions on the level of “we need to come up with a way to do this,” but the specifics haven’t been figured out yet.
Frost: We're still trying to figure out if we would be the true accrediting body — that's one of our biggest goals, but it’s still in the development phase. For me, I report to the Oregon Medical Board, and so there should be some similar accountability body, whether it's by the state or federal government, that holds practitioners accountable, just like any other field, like psychiatry or psychology.
I think we should also be having these discussions to let our clients know who to reach out to, because it's not always easy to go to, say, a medical board to report practitioners. As a community, we're early on in this discussion because so far everything's been underground. And while there's definitely downsides to the medicalization of psychedelics, one of the upsides is accountability. We need these kinds of accountability structures, to hold people accountable and to provide some way to screen out people who are not well-suited for being in positions of power in psychedelics. If that doesn't exist, there's a lot of potential for abuse.
This interview has been edited and condensed for clarity and length.