Are hospitals the best setting for psychedelic medicine?
The Swiss psychedelic medicine programme considers some patients' complaints
This is a guest-article by Sarah Zeines, a journalist in Switzerland
Switzerland’s legal psychedelic-assisted therapy (PAT) programme has been praised as revolutionary, but some patients have complained about the medicalized setting. We asked the psychedelic community - patients and practitioners - if and when hospital settings are conducive to effective psychedelic treatments.
In the spring of 2021, Gary * (not his real name) found himself panicking in a sterile white room at Geneva Hospital (Hôpitaux universitaires de Genève – HUG), which harnesses one of Switzerland’s most prominent PAT programs. In the hope of ending a decades-long depression, Gary had ingested 200 micrograms of LSD an hour or so earlier – his first-ever experience taking a psychedelic.
It was one of the most terrifying experiences I have ever been through. At first, there were the monstrous hallucinations. Then, excruciating intestinal issues. In the end, I felt a sense of emptiness, like my mouth was connected to my anus and my body was swallowing itself. I died and was reborn many times that day.
During the session, Gary’s long-term psychiatrist and a practitioner from the hospital held his hand or offered soothing words during his bouts of agony. However Gary says that he was also often left without guidance, amplifying his anguish: “There was another patient in the room screaming and sharing intimate details about his life. There was just too much going on.”
When “the unnecessarily high dose of LSD” finally wore off, many hours later, Gary was questioned by the team for research purposes. “I underwent a proper interrogation, although I was exhausted. The doctors at the hospital want to talk to people when they're most affected. I just wanted to go home.”
Over the following weeks, Gary’s anxiety peaked. His intestinal issues also continued. He questioned the program's methods. “I was not well at all. Why hadn’t anyone warned me that I could go mad following the treatment? During my only follow-up consultation, the doctors told me that the more I suffered during the session, the more effective the therapy would be. I disagree.”
Several months later and feeling like himself again, Gary opted to try psychedelic medicine in a different setting. “I decided to continue my psychedelic endeavors with my psychiatrist in a rural group setting with MDMA and psilocybin. When the right substance is administered correctly, and, in my case, at lower doses, these medicines can work miracles. My depression went from extreme to severe to moderate. Currently, after two years of sessions every few months, I believe that I am mostly healed.”
Other testimonials of bad hospital experiences have trickled into Swiss psychedelic circles. One social worker active in Geneva’s substance awareness scene tells us that a handful of bewildered hospital patients have requested support at one of the city’s public forums for drug users. “The HUG have a responsibility to evolve their protocols in order to avoid experiences like Gary's”, insists Laura Tocmacov, co-founder of Psychedelos, the Swiss association of PAT patients. “Some of our members have had negative experiences with the hospital program, while others have been reassured by the medical framework.”
Medical versus ‘living room’ versus nature settings for PAT
A total of 1051 medical authorizations were given for psychedelic treatments in Switzerland between 2016 and 2023 (351 for MDMA, 338 for LSD, and 362 for psilocybin). Since 2014, Swiss federal law has authorized compassionate use of Schedule 1 controlled substances for patients with complicated medical backgrounds, making Switzerland the first country in the world to offer treatment with LSD, MDMA and psilocybin. Several Swiss hospitals run psychedelic programmes, as do some psychiatrists in private practice. The settings for these treatments vary. At the national level, Geneva and Basel Hospital’s psychedelic programs offer similar settings (though Basel patients have access to a garden), while clinical settings in Fribourg, Zurich, and Bern prefer “living room” settings with cozier decors.
Currently, no comparison data exists for these different settings and protocols. “Initial retrospective results on HUG's patient cohort should be published or presented at a conference soon” notes Gabriel Thorens. There has been a recent Cambridge survey conducted by researchers from Basel Hospital and a private practice in Solothurn, which gathered responses from 39 patients of LSD therapy between 2017 and 2021. Two of the 39 criticized the medical setting and the guide / therapist interaction.
“Overall, the feedback was positive,” conclude the researchers. “Predominantly negative feedback was given by two participants (one participant dropout reported an insufficient match with their therapist, and another reported that the second treatment with LSD interrupted their constructive inner processes that were started with the first experience; this participant also reported that they did not like the setting at University Hospital Basel).”
In response to the mixed feedback, Swiss psychedelic medicine practitioners co-authored a 48-page document that establishes recommendations and best practices in the field. “A specially equipped and supervised room is generally recommended to carry out psychedelic treatment safely and effectively," list the guidelines. “The constant attendance of the therapists with their presence and therapeutic mindset is also an important part of the setting. Experience has shown that it can be helpful, especially in regressive states and also for safety reasons, if therapists of both sexes are present.”
One question now facing the Swiss psychedelic field is whether there should be one standardized protocol governing things like setting, dosage and therapist / guide interactions, or diversity. A local doctor with a private practice claims that Geneva’s hospital representatives are promoting a “one protocol fits all” approach in local training circuits, adding that the suspected high number of bad psychedelic experiences at the hospital has a lot to do with the fact that the medical setting breeds anxiety and that patients generally have more severe diagnoses upon arrival.
Dr. Gabriel Thorens, Associate Physician at the HUG’s Addictology Department, denies this: “A plurality of acceptable approaches is desirable, similar to traditional psychiatric care.” Laura Tocmacov is hopeful patients’ preferences will be listened to. “We all share the same concern: improving patients' mental health,” she says. “Today, all over the world, protocols are evolving towards the active integration of patients in all approaches. I'm certain that, in a field as crucial as mental health, if there's one department that's going to move fully towards patient empowerment and the integration of their expertise, it's psychedelic-assisted therapies.”
What do you think - are hospitals an appropriate setting for psychedelic experiences?
Considering how crucial ‘set and setting’ are thought to be to psychedelic experiences, it’s surprising how little research has compared different settings, such as hospital rooms versus living rooms versus outdoors. A scoping review (Golden et al 2022) looked at 43 psychedelic studies which all emphasized the importance of setting:
However, this consensus has yet to generate consistent, prospective, rigorous tests of setting and its complexities. As a result, the field continues to lack understanding or agreement regarding the effects of various specific elements of setting, the mechanisms by which they affect outcomes, for whom these effects occur, under what circumstances, given what conditions, and other critical factors.
In the absence of hard data, we asked the psychedelic community on X, Bluesky and LinkedIn ‘are hospitals a good setting for psychedelic treatment?’ and received responses from therapists, psychiatrists and patients including Yale’s Jamila Hokanson, KCL therapist Amy Durden, Dr Bianca Sebben in Australia, Tehseen Noorani in Auckland, Susan Ousterman of Vilomah Foundation, Kevin Mikkelsen in Denmark, Michael J Tarver at University of Colorado, David Drapkin of Vital and others - plus patient experiences from Jennifer, Becca Kacanda and artist Andrea Khora. Thanks everyone!
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