For the month of February, we interviewed Dr. Hayden Rubensohn, a PGY-5 Palliative Care Medicine Resident, on the topics of the of use of psychedelics in palliative care, as well as for treatment of PTSD. Happy reading!
In 2018, you gave a presentation called “Far Out Therapies: Psychedelics in Palliative Care”, and remain passionate about the potential of psychedelics as a way to manage existential distress at the end of life. Could you tell us a bit about what drew you to this specific topic?
Indeed, it was really an honour to be able to give this presentation to the Division of Palliative Care. I was drawn to palliative medicine in my clinical training because of its significant focus on maintaining dignity and humanity in people facing life-limiting conditions. Palliative medicine does a superlative job of providing symptom relief to patients, and I appreciated that relief from suffering could be seen so rapidly. However, I noticed that the psychospiritual aspects of suffering, and the existential challenges that arose didn’t have quite the same treatment offerings. Social work and spiritual care provide incredible supports, and psychiatry can offer useful therapy, but still I found that many patients face psychological distress that can’t easily be dealt with.
The more I learned about psychedelic medicines, the more I realized that they might provide the answer. These medicines can engender powerful mystical experiences that result in shifts in how people come to understand and relate to concepts such as life and death. Studies are mounting to demonstrate that through these experiences people are finding peace in the face of life threatening illnesses such as cancer. I strongly feel that these tools are unprecedented in what they can provide, and fill a gap in our currently available therapies. So it was in this context that I wanted to spread the word and drum up some excitement about this emerging field.
The Division of Palliative Care at UBC is staffed by incredible physicians who, like myself, are curious about new therapeutics and opportunities to help people at the end of their lives find peace and meaning. The division has been remarkably supportive of me and my interest in psychedelic medicines and we hope to bring this research to Vancouver in the coming years.
You’ve mentioned that you hope to do clinical psychedelic research one day. What would you say has inspired you—and continues to—in remaining passionate in this pursuit?
When people hear that I am doing training in palliative medicine the response is almost ubiquitously a comment about how hard it must be, but I don’t see it that way. For me palliative medicine isn’t marred by sadness surrounding the death of many of my patients. Rather, it’s about respecting personhood, about maintaining dignity, about helping people manifest themselves in the time that they have left; and I find that uplifting. Palliative medicine is about people coming into themselves and into union with their loved ones. It’s beautiful to watch people shine as their facades came away, their adherence to imposed social norms fades away, and they get to be their true selves. It is experiences like this, and being a facilitator of such experiences that inspires me.
The challenge comes when patients are overcome by depression, fear, worry, concern, apprehension, and can’t have meaningful death experiences. Being able to sit with patients and create a safe space for them to explore their distress is quite a privilege, especially if it helps them reach the freedom I mentioned before. However, that’s not always the case, and that’s why I think that psychedelic medicines are so important. Right now psychedelics are classified as controlled substances in Canada and can’t be accessed for medical use. Clinical research into the use of psychedelics has increased in volume in the past decade, but all of the work using psychedelics in palliative settings has taken place in the USA and Europe. I think that Canadians should have access to these medicines, and that Canadian researchers should contribute to the data attesting to these medicines’ utility in palliative care. Being involved in that has continued to motivate and inspire me.
You have also been involved in research on the use of MDMA-Assisted Psychotherapy for PTSD. Did your interest in this stem from your work in palliative care, or from elsewhere? What has this involvement been like, and how does MDMA compare to the use of psychedelics?
When I first found out that research was being done utilizing MDMA, I thought it was a joke. Up to that point I’d only known MDMA to be a recreational drug and something that causes hyponatermia! However, the more I looked into it, the more I realized that the research was legitimate. MDMA is simply a substituted amphetamine, falling into a class of substances called empathogens, which increase interpersonal trust and decrease fear and anxiety. This makes it a potent tool for augmented psychotherapy. Luckily for me, this research was being planned in Vancouver in 2012 when I went through CaRMS. In fact, I chose to rank Vancouver so that I could hopefully be involved in this work.
Through a series of events I was offered the chance to work alongside Dr. Ingrid Pacey who is an exceptional trauma therapist in Vancouver. Together Dr. Pacey and myself treated several participants in a Phase II clinical trial. I was subsequently invited to participate in the Phase III clinical trial that will further explore this interesting new medicine for people with PTSD (https://maps.org/ ). My involvement in this research has been extraordinarily meaningful and it has been a true honor to be involved in such groundbreaking work. I also feel like my career has been fast-forwarded by about 30 years, as I didn’t think I’d be directly involved in this sort of research until much later in my career. Having kept my ear to the group and met and liaised with the right people has completely changed my early career.
MDMA is a serotonin releaser and is not considered a classic psychedelic. MDMA typically creates strong feelings of interpersonal trust, and working with people on MDMA is very relational. On the other hand, psychedelics are serotonin 2A agonists and their power lies in their ability to create transcendent mystical experiences by transiently altering neuroconnectivity. People undergoing psychedelic therapy still require strong support, but often their most powerful experiences take place internally. Suffice it to say, these two classes of medicine are similar but require different approaches and skills.
The academic lead-up to where you are now is rather unique, as well: you studied psychology for your undergrad, completed med school with a match to Psychiatry, and switched during your third year into Internal Medicine, where after four years of General Internal Medicine, you moved on to do a two year palliative medicine subspecialty fellowship—where you are, now? What was the experience like, learning the different specialties, and what experience would you say has influenced you most in regards to your interests and pursuits right now? What are your plans for the future?
That’s right! Although I’m only allowed to call myself an R5 right now, I am actually in my 7th year of residency. It was challenging for me to decide on a specialty at the end of medical school because so many areas of medicine were interesting. I did medical school in Calgary, so we also had to decide pretty early on what to apply for, and I never had clinical exposure in Palliative Medicine until R1. When I found out that the new Royal College Palliative Medicine Subspecialty would not be available to Psychiatry residents, I decided to switch course and do Internal Medicine. After four years of General Internal Medicine, I am now happily in my fellowship and should finally finish my training in 2020.
A lot of people ask me if I feel like I lost or wasted two years when I transferred programs. True, I did have to go from an R3 salary to an R1 salary, but the knowledge and skills I gained in my first R1 and R2 years was invaluable. I truly don’t believe that there is any wasted time in medicine, and the more you learn about another specialty the better off you’re likely to be as a physician. The switch was very easy to do and both my outgoing and incoming program directors were very supportive.
The truth is that Palliative Medicine really is the happy medium between Internal Medicine and Psychiatry. There is really fascinating medicine to consider in malignant palliative care, and the field of non-malignant palliative care is evolving and is certainly well suited for an internist. There is also an undeniable relational component to good palliative care, and I often think about my fellowship as being a communications fellowship. This works out well for me, because the stories our patients have and the lives that they lead are truly fascinating to learn about.
In the future I hope to marry all of my interests by practicing some internal medicine, some palliative care, working on a Post-discharge Advanced Care Planning Clinic, helping to establish some non-malignant palliative care clinics, and, of course, finding a way to use some far out therapies in palliative care!