Developing guidance for psychedelic therapy: 5 Questions for the APA’s Lynn Bufka

Bufka discusses how the APA and its members are responding to psychedelics’ rising popularity, and how the organization makes decisions about issuing guidance to its members.

The American Psychological Association (APA) is one of the largest psychology organizations in the world. With 145,000 members, the group represents licensed psychologists and researchers, and provides clinical treatment and practice guidelines for the profession. As the idea of psychedelic-assisted therapy gains traction, professional organizations like the APA have the power to influence best practices and standards for mental health practitioners. 

Lynn Bufka, a licensed clinical psychologist, has worked at the APA for two decades. As the associate chief of practice transformation, she helps develop guidelines and statements based on current science research. The Microdose spoke with Bufka about how the APA and its members are responding to psychedelics’ rising popularity, and how the organization makes decisions about issuing guidance to its members.

What kinds of questions have you been getting from APA members about psychedelics — and has the organization issued any statements directly addressing those questions?

For some members, there's been an initial skepticism towards psychedelics: what is this all about? There's also concern about what this means for practice, and how clinicians can determine which patients might benefit from psychedelic treatment. Fundamentally, people who go into clinical practice do so because they want to help people. For those working with people who have long histories of trauma or treatment resistant depression, which are very promising areas for psychedelic intervention, they're curious whether there’s something here. Many also want to know what their role is if they’re not trained in psychedelic-assisted therapy. We’ve provided consultations with psychologists in states like Oregon and Colorado with psychedelic services to explain the existing evidence. 

We don't have answers yet, and we have not made any formal statements on psychedelics. But we can provide members with up-to-date information so they can begin learning and assessing what’s appropriate. We want to ensure that our members are informed so that if a patient is asking these questions of them, psychologist members will at least be able to help guide them to quality information. 

The FDA could approve MDMA or psilocybin in the next year or two — but the FDA doesn’t regulate therapy, so some experts have suggested that guidelines set by states and professional organizations will determine standards for psychedelic-assisted therapy. Has the APA discussed any such guidelines?

It’s a conversation that’s been had, but nothing has been decided. It’s actively in development. If you check back with me in a year, the answer might be different. There might not be best practices about this yet, but there are pretty consistent recommendations in the scientific literature based on clinical trials about how best to use psychedelics. These trials are in a controlled environment; people aren’t just given MDMA without supervision. The risk for any intervention is that if it’s not delivered appropriately, it doesn’t work, and psychedelics could fit into that category. If someone tries it under the wrong conditions and it doesn't work, then they might feel they have even fewer options. 

What might trigger the creation of such guidelines?

FDA approval, definitely, or perhaps if there were an increasing number of businesses or practices in the psychedelic arena. We typically do not issue policy statements unless there’s clear science in an area or a clearly identified need to mark some boundaries.

If governance groups in the APA felt we needed to address it — like if committees are finding that members and the public are asking a lot of questions about psychedelics — that might create some impetus to develop something short of policy, like a position statement. 

What does the process for developing new guidelines look like, and who makes such decisions? 

We’re always trying to look at the science behind an issue. We connect with experts in different areas and identify key content before formulating a position, and policy recommendations always come through the work of our members. We have panels that include people with clinical backgrounds but also individuals with lived experience, and colleagues in related disciplines like psychiatry, primary care, and nursing. When we develop guidelines, we try to be as transparent as possible; there’s a public comment period which is open to anyone, and we typically receive hundreds of emails.

We also try to examine our panel for potential conflicts of interest. We need to know not only what their financial conflicts of interest might be, but also their intellectual ones. We want to have people who know the science that can represent the science, but we also need to understand where their potential biases are. In the case of psychedelics, if I’m a researcher whose life work is on, say, interventions using psychedelics, and I serve on a panel, what am I going to say? Of course I’m going to want that to go through. So we have to figure out how to balance that. One of my colleagues uses the term “adversarial collaboration”: we want to create a group where not everyone has the same way of thinking about an issue. 

You mentioned that guidelines are created if there’s clear science for an issue. What standards does the APA use, and where do psychedelics stand?

For clinical practice guidelines, there needs to be sufficient quality and quantity of randomized controlled trials, as well as systematic reviews. We measure the quality of the existing studies and reviews: were there sufficient controls and appropriate blinding? And what do we know about applicability across different groups? For instance, we know there have been studies using psychedelics to treat PTSD in combat veterans, but how applicable is that research to other traumas and populations? Are there significant differences between how psychedelics work in men and women, or people of different races? We need to see this information from different groups to make recommendations about how to structure psychotherapy, like the amount of time clinicians should allocate for sessions and the number of preparation or follow up meetings. Also, we don’t want all studies to come from the same institutions. If a lot of the research comes from, say, Johns Hopkins, then we have to ask if there could be biases we’re not privy to. 

Currently, there aren’t enough quality studies to set those guidelines. But we still do want to communicate with the public and our members about the latest. We don’t want to shy away from innovation, but we want to ensure safety and maximize potential for positive outcomes, and to help people be realistic about what psychedelics can do. We will be keeping an eye on developments in psychedelics and mental health treatments. I think this all shows how mental health care delivery is rapidly changing.

This interview has been edited and condensed for clarity and length.