Terence Ching, PhD. April 2024

April 29, 2024

Title: A Primer for Culturally Attuned Psychedelic Research

Description: Psychedelic research with diverse populations is necessary for inclusiveness, representativeness, and generalizability. Cultural attunement may be key to facilitating equitable research. In this presentation, Terence reviews prevalent psychological and pragmatic barriers to diversity – as part of set and setting – in modern psychedelic research. He also proposes potential strategies for the culturally attuned recruitment, assessment, and retention of diverse participants.

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00:00Is now being recorded and 1st I just
00:04want to apologize to the group we
00:05did not have this meeting didn't
00:07happen in March and that was simply
00:08because I wasn't able to get the get
00:10my ducks in a row to make it happen.
00:12So I apologize for any confusion that that
00:14created but we're glad to be back today.
00:17Our speaker today is Terence Ching.
00:19Terence is an Associate Research
00:20Scientist here at Yale,
00:21working with Ben Kilmendi and me
00:24with a long history of psychedelic,
00:27psychedelic science in his in his
00:30graduate work with Monica Williams,
00:32and then when he came and joined us about,
00:34what is it, four years ago now,
00:363 three years, 3 1/2 something?
00:41And Terence has expertise in
00:43a number of different areas.
00:44He's worked both with MDMA and psilocybin,
00:47but one thing that he's written
00:49about and spoken about eloquently
00:52is the challenges that we face in
00:55making sure that our work in this
00:57space is representative and is
01:00appropriately positioned to benefit
01:01everyone who we could bring it in.
01:04And. And we all know that the studies
01:06that have been done thus far have
01:09been woefully inadequate in their
01:11representation of people other than wealthy,
01:14educated white people,
01:15mostly who's been studied in
01:16most of their work.
01:18So that's something Terence has
01:19has worked on a lot and he's gonna
01:22share his thoughts with us today,
01:23both about the challenges that
01:25we face and about paths forward.
01:27Terence,
01:27thank you for being with us and for
01:28speaking on this important topic.
01:30Thank you, Chris, for inviting me.
01:33Let me go ahead and share my screen.
01:39And it's a real pleasure to do this
01:42for the Yale community, especially
01:45the psychedelic medicine community.
01:46And I've given this talk in various
01:51iterations of this talk several times,
01:54and I'll try to keep within the time
01:56allotted just so that we could make our way
01:59to the auditorium for the film premiere,
02:03which ties in a little nicely to some
02:06of what we're gonna talk about today.
02:09I've titled this talk A Primer
02:12for Culturally Attuned Psychedelic
02:14Research and I'll endeavour to
02:16make some of these terms a little
02:18bit more obvious and well defined.
02:21And yeah, really excited to dive
02:24into these topics with everyone.
02:27Here are some of my disclosures and really
02:30jumping quickly into learning objectives.
02:33Hopefully by the end of my presentation,
02:35everyone has A at least a beginning
02:39idea of the state of diversity
02:41and modern psychedelic research.
02:43You're able to recognize some of the
02:46barriers to accessing psychedelic trials
02:49among primarily today we're talking
02:52about Bipoc and queer communities.
02:55You're able to situate these barriers
02:57as components of set and settings.
02:59So these are very commonly used
03:02terms in our work and these are also
03:06inclusive of of some of these barriers
03:08to access among these populations.
03:13Hopefully at the end of today you're
03:15you're beginning to think a little
03:17bit more about some of the things
03:18you want to start asking your own
03:20research about diverse participants,
03:21just so that you have a more holistic
03:25picture of what it's like to take part in
03:28a psychedelic trial for someone of color or
03:31or someone who identifies as queer broadly.
03:36And just whenever I get
03:38presentations like this,
03:39I always want to be super sure and
03:42clear about what I'm presenting.
03:44Like I myself have my own blind spots.
03:47I identify as a cisgender gay,
03:50immigrant man of Singaporean Chinese descent.
03:55So that necessarily colors a lot of
03:57what I think about and talk about.
03:59And in a way,
04:01hopefully there's models for everyone
04:04in this room just how we wanna
04:06think about these things, right?
04:08Like we may have some viewpoints
04:11about certain topics,
04:12and with those viewpoints we certainly
04:15run into some blind spots as well.
04:17So we wanna be talking about these
04:19things in broad strokes as opposed to
04:22being super prescriptive about that.
04:27So we're gonna start off with
04:30really highlighting the state of
04:32diversity in psychedelic research.
04:34So far as Chris has mentioned,
04:37we we as a a community,
04:40the psychedelic research community
04:42have not particularly done a great
04:46job of of being super inclusive
04:49and representative in our samples.
04:51We've done a great job of of of
04:54gathering data that shows advocacy
04:57and safety preliminarily for for
04:59psilocybin and MDMA for example,
05:02for the major indications.
05:05What this paper here shows is
05:07that when we look at psychedelic
05:10studies in the recent decades,
05:12we actually find that a lot
05:14of these participants were,
05:16as Chris described, non Hispanic white.
05:18They tend to be prosperous.
05:20They tend to have
05:23significant levels of education as well.
05:26We don't see are actually folks who identify
05:30as African American of Latinx origin,
05:34Asian or indigenous origin,
05:35as well as all of the other wonderfully
05:40diverse ethnoracial groups that
05:43are present in the United States.
05:47For for this particular research
05:51group that not only did they
05:53look at psychedelic studies,
05:54they also looked at just just ketamine
05:57studies And then that's like a big
05:59part of our work here at Yale as well.
06:02And what they did find was pretty much
06:04the same thing right Across studies
06:07of ketamine that were conducted
06:09over the past several decades,
06:13they'd found that overwhelmingly
06:1773.7% of the pulled sample
06:20identified as non Hispanic white.
06:23So this really, you know,
06:24helps us understand just where
06:27the what the obvious barriers to
06:30accessing psychedelic research may be.
06:32Or if you identify as a person of color,
06:35it probably is the case that
06:37you're not going to get into
06:39a psychedelic clinical trial.
06:41And what are some reasons for that
06:45When we look at the MDMA
06:48research program for PTSD,
06:50things are looking a little
06:52bit more optimistic.
06:54They just completed two phase
06:56three clinical trials and the the
07:00the inclusion of participants of
07:05color were were improved from the
07:09first phase three trials that
07:12they did to the point that when
07:15they looked at their second phase
07:18three trial more than half of the
07:20recruited participants identified
07:23as Bipoc and this was actually
07:27oversembling if we looked at
07:30PTSD patient population by race.
07:33While this is a a a sign of
07:35good things to come,
07:36we still need pretty systemic
07:39diversification of psychedelic research.
07:42We need this to happen also
07:44in Academy studies.
07:45We also need this to happen in
07:48psilocybin programs as well.
07:53If we look at other limitations
07:55that exist in psychedelic research,
07:57some of these are pretty obvious
07:59and and you know probably has been
08:01discussed in the seminar series.
08:04Studies often fail to report certain
08:08demographics sexual orientation altogether.
08:09Not only do they fail to report it,
08:12I think the the the limitation
08:16extends prior to that they fail
08:18to collect such information,
08:19so they couldn't report it when they
08:22published their primary outcomes paper.
08:24Other studies tend to report these
08:27demographics, not intersectional.
08:30Intersectional they they don't consider
08:34how participants not only just identify
08:38as a particular ethnoracial group,
08:41they might also be queer as well,
08:43and we just don't get the the
08:46sample breakdown in that way.
08:48So it's really hard to think about how
08:50these findings might generalize or not.
08:52Psychedelics are often discussed also in
08:55umbrella categories like illicit substances.
08:58A lot of the research that is done
09:03with queer populations tends to
09:05have a skew toward problematic
09:07substance use or addictions.
09:09That's often how psychedelic
09:10use is discussed in that frame,
09:13and it really makes it hard to
09:15generalize some of these findings
09:17to the non addicted majority.
09:21OK,
09:23what that? So with all of these findings,
09:26that really just seems to to indicate
09:29that perhaps you know the reason why
09:32folks of color or queer folks aren't
09:34in psychedelic clinical trials.
09:36It might be they're not interested.
09:38But what we do see is actually with more
09:42recent data coming out of large scale
09:45epidemiological studies of people who've
09:49ever used psychedelics in their lifetime,
09:52we we see some really
09:54interesting trends here.
09:56We see here that more than half of
10:00multiracial and Hispanic males reported
10:03lifetime psilocybin or LSD use.
10:05Another interesting thing,
10:07perhaps not too surprising,
10:09is, you know,
10:10Native American males reporting
10:12the highest lifetime peyote use,
10:15Pacific Islander males reporting
10:17the highest lifetime mescaline use.
10:21But what was like most surprising for me,
10:23especially personally speaking,
10:24it was just seeing how Asian females
10:27reported the highest lifetime
10:29use of any psychedelics.
10:31So as an immigrant
10:36who is also of of of Asian descent,
10:40the messages I got were that, yeah,
10:43like Asians don't take psychedelics.
10:45So this was in stark contrast to
10:47all of these messages that are
10:50inherited from generations before me.
10:53Which opened my eyes to the
10:56fact that Bipoc populations are
10:59interested in psychedelic views,
11:02and that psychedelic views is
11:04increasing across racial and ethnic
11:07groups in recent years as well.
11:09But here we have some clarifying information.
11:11Yeah, yeah, folks of color are
11:15actually interested in psychedelics.
11:17What we do see when we look more intently
11:20at what happens when folks of color
11:24receive information about psychedelics
11:26relevant to or similar to what they
11:30receive in psychedelic clinical trials.
11:33We see here,
11:35particularly in this study,
11:36that when bipoc individuals
11:40receive education,
11:41they actually are more likely
11:44to seek or or endorse higher
11:48likelihoods of seeking psychedelic
11:51assisted psychotherapy than their
11:53non Hispanic white counterparts.
11:55So we see here a significant
11:58difference across the different modes
12:00of reporting or or educating them
12:04about psychedelics across the board,
12:06they're just more interested than
12:08their non Hispanic white counterparts.
12:10So that's really interesting,
12:11right?
12:12Like,
12:13not only are are are people of color
12:16interested in psychedelics when you
12:19give them perhaps accurate or or clear
12:24information about what psychedelics are,
12:26they're actually quite interested in
12:28the promise of psychedelics for healing
12:33when when we talk about
12:35queer populations as well.
12:37I just want to highlight the this
12:39very nice study that was done by
12:41Chris Stauffer's group where they did
12:44focus group discussions with trans
12:47and gender non conforming and other
12:50queer individuals about the promise of
12:53MDMA for PTSD among their community.
12:56A lot of them actually said,
12:57oh, I've actually tried MDMA,
12:59you know, I've had a lot of my own
13:01personal experiences with that.
13:02These have been profoundly moving
13:05and life changing.
13:07Others are, you know,
13:08a little bit more hesitant,
13:11but they still see the promise of
13:13it for others like them, right?
13:15I I still see it as being really
13:18beneficial for people in general.
13:20So we see here a lot more clarifying
13:23information about whether people of color,
13:25whether queer folks,
13:26are interested in psychedelics.
13:28We know, Yeah, they are.
13:31And when they're educated about it,
13:33they are actually more likely
13:35and more interested to take part
13:37in psychedelic clinical trials.
13:41The clearest information we have at
13:44this point about the intersection of
13:47psychedelics and diversity was this research.
13:51So we looked at the MAPS data or MDMA
13:57for PTSD and we actually found that
14:00for people that were randomized to
14:03the MDMA group that folks of color
14:07benefited to the same extent as their
14:10non Hispanic white counterparts.
14:13A very interesting finding was
14:15that for folks of color that were
14:17randomized the placebo group,
14:19they actually almost, you know,
14:22trended towards more improvements
14:25than there are non Hispanic white
14:28counterparts in the placebo group.
14:30So this really speaks to the power of
14:33the psychedelic experience itself,
14:35the idea of it being a total package.
14:39Not only do you have the dosing
14:41sessions itself,
14:41but also the prep and integration
14:43sessions that can be so helpful,
14:46especially if you're identifying
14:48as part of the bipod community.
14:51Basically what we're taking from
14:53from these findings is that when
14:55we get people of color into trials
14:57at least for MDMA or PTSD,
14:58they might benefit to the same extent
15:01and it would be so helpful even if they
15:04were randomized to the placebo group.
15:06So just to really summarize the state
15:09of research among diverse populations
15:12here it it is an indictment of
15:15of us basically as a psychedelic
15:17research groups that we really should
15:20do a lot more to recruit diverse
15:22samples to improve generalizability.
15:26This is such an urgent need because
15:30folks of color and queer folks are
15:32also very interested in psychedelic
15:34use and if we do get them in,
15:36there's a chance that they might
15:37benefit to the same extent,
15:39perhaps a little bit more than their
15:41non Hispanic white counterparts.
15:43What this really highlights is that
15:46there are some patient level access
15:48barriers that we as researchers
15:50need to learn and mitigate and a lot
15:54of our own therapist or research
15:56for level problems that we need
15:59to recognize and address.
16:01And really it's it's the onus is on
16:03us to conduct psychedelic research
16:06in a culturally attuned manner
16:09because not doing so may be harmful.
16:12So how do we even start doing this right?
16:16Well,
16:16let's start with a working definition
16:19of what I mean by culturally
16:22attuned or cultural attunement.
16:24For me it really cultural attunement
16:27is an active process of of knowing,
16:31of being aware,
16:32of,
16:32of being able to recognize and pay
16:35attention to and also collaborate with
16:38with the goal of empowering diverse
16:42individuals as intrinsically cultural
16:45beings with unique intersectional identities.
16:49So in all the way,
16:51a lot of ways,
16:52this really parallels what is discussed by
16:56by Crenshaw in intersectionality theory.
16:58Cultural attunement is also highly similar
17:02to what we think of as cultural sensitivity,
17:06maybe some component of cultural competence
17:09that has evolved into this notion of
17:13culturally informed and responsive care.
17:15And ultimately,
17:16you know,
17:17the idea of cultural humility,
17:19the idea that being able to
17:23work with diverse individuals
17:25is a continual learning process,
17:28the one that we need to be open to.
17:30And that's a lot of what we ask of
17:32people in psychedelic sessions.
17:34So it it it behooves us to do the same
17:36for ourselves with our participants as
17:42well. Let's also define SAD.
17:44I mean, I'm not going to
17:45spend too much time on this.
17:46Everyone in this group really
17:48has a clear idea of what SAD is.
17:51As I mentioned, you know,
17:52SAD is the constellation of
17:55internal factors that that a
17:57person brings with them into
18:00a psychedelic dosing session.
18:02If we expand that and and necessarily
18:04so given what we've just discussed,
18:07it also involves all of these
18:09different access barriers that we
18:11are are talking about as well.
18:15I like to think of some of these
18:18barriers in the psychological
18:19sense as well as a pragmatic sense.
18:22So let's first work on the
18:24psychological barriers.
18:25A lot of these form part of people's
18:28set as they enter the psychedelic space.
18:31There can be actually intergenerational
18:34stigma about drug use.
18:36I I've given my own personal examples,
18:39but we hear a lot about how folks of
18:43color talk about drug use as a a a
18:47gateway to addiction a a sure path
18:49down to death or imprisonment, right?
18:52We hear a lot about how folks of
18:55color think about using drugs
18:57as highly threatening.
18:59So this really involves the concept of
19:03stereotype threat as a person who's
19:06violating social norms by taking
19:09drugs for for Bipoc individuals is a
19:12very common theme of of psychedelic
19:15use or other illicit substance use
19:18as invoking the idea that they
19:21are deviant drug users, right?
19:23For other populations such as gay men,
19:26there's the the intrinsic idea that anyone,
19:31any gay men who uses drugs uses drugs to
19:36for for chemically altered sex or camp sex.
19:40There's also the idea and and you know,
19:44actual history of the racist war on
19:47drugs where where black Americans are
19:49arrested and charged at with drug
19:52related offenses at higher rates,
19:54they they are punished to a
19:56more severe extent.
19:57They have harsher sentences,
19:59longer incarceration than their
20:01non Hispanic black counterparts.
20:04So think about all of these different
20:06messages that folks of color inherit,
20:09that that queer populations inherit,
20:11and how that really forms part
20:14of their expectations their.
20:15Assumptions and their goals as
20:17they even contemplate doing
20:19a psychedelic clinical trial.
20:24When we look at the idea,
20:27when we look at the reality
20:28that a lot of these trials are
20:29happening in hospital settings,
20:31we begin to think about some of the other
20:34stereotypes that are triggered or activated.
20:37When we talk to, for example,
20:38bipod communities about
20:40doing psychedelic research,
20:42we all know about the Tuskegee
20:45Syphilis study.
20:46What we don't really pay a lot
20:49of attention to is actually this
20:52long history of really abusive
20:55psychedelic research on Ipoc and
20:58incarcerated populations that really
21:00breeds mistrust of medical systems.
21:03So just want to highlight this really,
21:06really important essential research
21:11by Monica Williams and John
21:14Sloshower and and their colleagues
21:17Dana Strauss and Sarah de LaSalle,
21:19where they reviewed early psychedelic
21:23research based on today's standards of
21:26ethical care and and conduct of research.
21:30And it actually turns out that a
21:33lot of early psychedelic studies
21:36were heavily recruiting from
21:38highly vulnerable populations.
21:40These were folks in prison,
21:42folks were serious mental illnesses or both,
21:45and they were subjecting them
21:48to really risky, highly abusive,
21:50unethical, you know,
21:52dosing schedules where they consumed
21:55really high doses of psychedelics.
21:57The dosing frequency was
22:00extraordinarily frequent, right?
22:02Like they were dosed more than once a week,
22:04more than five times overall.
22:07Often they were dosed with multiple
22:09drugs with no clear rationale for why.
22:12So evidently little thought as to,
22:16you know,
22:17drug drug interactions and and the
22:20potential for medical risk in that sense.
22:23It turns out that also a lot of
22:25folks that were recruited in these
22:27early psychedelic studies were
22:29differentially treated based on race.
22:32They were unduly influenced
22:33into staying in the study.
22:36So a very jarring example is
22:40how folks that were addicted to
22:44heroin or promised heroin in order
22:47to be dealt with a psychedelic.
22:50So that was the the compensation for for
22:53taking part in this psychedelic trial.
22:55So that would not fly today.
22:57And this was really the,
22:58you know,
22:59the fabric of early psychedelic research
23:02that was built on the foundation of
23:04research abuses against folks of
23:06color and other vulnerable groups.
23:09So that's what we reckoned with.
23:10That's,
23:11you know,
23:11the history of psychedelic research.
23:13That's what people bring into
23:16the psychedelic space.
23:18Every time we think about
23:20recruiting diversely,
23:20that's what we have to to to grapple with.
23:26We also know that in Korean trans
23:29communities there are so many levels
23:32of oppression that it would be not
23:34easy to to go into detail with them.
23:36But these include, you know,
23:38the the governmental refusal to
23:41acknowledge the early HIV epidemic.
23:44You know,
23:45really stigmatizing healthcare
23:47practices in many different
23:48parts of the country today.
23:51Transition of related bureaucracy,
23:54no insurance coverage for transition,
23:57transition related medical procedures,
24:01a lot of gatekeeping and once
24:04again you know like we don't
24:06really talk a lot about this,
24:08but the idea that psychedelics have
24:12been used to assist with conversion
24:16therapy for career populations.
24:22When people I'm going to spend a
24:26little bit time on not not as much
24:29time on this slide but it's the idea
24:32that you know even in that focus group
24:35discussion conducted by Christopher's
24:38group they were consistently
24:40expressing frustration with having
24:43to educate their providers on on the
24:48actual terminology have having to
24:50keep them up to date with what they
24:52mean when they say dad name right.
24:54What they mean when they say trans
24:58so or or when they use the word sis
25:01right Like to the extent that a lot
25:04of these participants had to and
25:06chose to conceal their identity.
25:08So going back in the closet again,
25:11really traumatizing,
25:12really threatening to their self worth
25:15and their identity and these are the
25:18things that queer populations grapple
25:19with when they enter medical settings.
25:24So really, jumping right into the
25:27back to the idea of psychedelic
25:30assisted conversion therapy,
25:32I really wanna highlight this
25:34book Querying Psychedelics.
25:36It's an anthology published
25:37by the folks at Chacruna.
25:40Alexander Bowser was a fellow here
25:42at Yale who's gone on to become the
25:46Chief Political Officer at Siben.
25:48And he continues to advocate
25:52for making sure that, you know,
25:55that history does not repeat itself,
25:56basically, that psychedelics aren't used
26:00for for anything that might threaten
26:04the integrity and reality of great lives.
26:09So in this book,
26:10they did mention how, you know,
26:12one of the early uses of psychedelics was,
26:14you know, explicit attempts to cure
26:17homosexuality and this really outdated term
26:21here that I would not pronounce or say.
26:25And a lot of these took place in
26:27and out of hospitals in England,
26:30in in Canada, North America,
26:31really.
26:32And they spent three decades and was
26:36discontinued shortly after the international
26:39prohibition of psychedelics in 1971.
26:42So this was really recent.
26:45This is,
26:45you know,
26:46when we think about bringing queer
26:47folks into psychedelic research,
26:49this is necessarily some of the
26:50things we need to grapple with.
26:52To us researchers
26:56talking about pragmatic bears really quickly,
26:59there's a lot of research out
27:02there showing how, you know,
27:04one of the ways in which accessing clinical
27:08trials or or studies in general, right,
27:11not even psychedelic trials, is the idea
27:14that transportation is a huge barrier.
27:17It is a a larger barrier,
27:19especially among lower income
27:21or uninsured populations.
27:23And we know that the this tends to correlate
27:26strongly with marginalized status.
27:28When we talk about transportation,
27:29we also talk about, you know,
27:31who's gonna take care of my children
27:34for me to make these study visits?
27:36Who's gonna pay me for me to
27:39make these study visits?
27:40Is my my job at risk here?
27:44My job isn't really secure or stable.
27:46I work a shift I don't even have.
27:50I didn't even sign a contract.
27:51A lot of this is under table money, right?
27:54Like, so there's no security here for me
27:58and I'm struggling with depression or PTSD.
28:01How can I make sure that I can feed my family
28:08two weeks from now after I do this trial?
28:11Will this make me so destabilized
28:14that I cannot work anymore and
28:18thereby endanger the likelihood,
28:20my likelihood.
28:22You know,
28:23my family's ability to meet their
28:25basic needs.
28:26So these are all really important
28:28pragmatic barriers that we also
28:30as research groups need to
28:32be actively thinking about.
28:36OK, so we're gonna move on into the
28:39idea of setting right and and I'm not
28:42gonna spend too much time defining it,
28:43but really it's the constellation of
28:47external factors that a person navigates
28:50as they enter the psychedelic space.
28:54And it is my contention that adjusting
28:58elements of the setting is actually a
29:02very realistic and and maybe not easy,
29:06but a realistic way to positively
29:10influence components of participants.
29:12That and this is really important
29:15not only for recruiting people into
29:17a a psychedelic clinical trial,
29:19but also keeping them in the
29:22clinical trial retention.
29:24If we don't create a therapeutic space that
29:27really affirms people's diverse identities,
29:30we're perpetuating harm in that way.
29:32We're we're perpetuating color blindness.
29:34We're perpetuating a closeting
29:37of their authentic identities.
29:39And when we think about all the power
29:42of set and setting as it informs
29:45the psychedelic dosing experience
29:47and our desired outcomes,
29:49we're really putting our
29:50own research at risk, right?
29:52We're diminishing the healing potential.
29:54Psychedelics may even cost harm.
29:57So we we don't want to do that.
29:59We want to be prepared to to
30:01meet people where they are.
30:02We want to be pretty proactive actually,
30:05about making sure that people are entering
30:08a a space that feels safe for them.
30:11How do we do this?
30:12So I just once again really want to
30:16highlight Monica Williams's work.
30:18This was pivotal.
30:19They talked in in their publication
30:22about the many design issues that they
30:25tried to mitigate in trying to bring
30:28folks of color into an MDMAPTSD trial.
30:31So I'm gonna build upon that
30:33foundation and expend it to queer
30:37related recommendations as well.
30:39So the first thing really that comes
30:40to mind is we need to make sure
30:43that everyone on the study team
30:47is representative of the diversity that
30:50we want in our study sample, right.
30:53Intentionally diversifying your study
30:56team may have a benefit of of making
31:00minoritized participants feel more
31:02invested and comfortable participating.
31:05It really is a very outward
31:09signal to participants that we
31:12care about your preferences,
31:13for whom you want to work with
31:16through these study sessions,
31:18and internally for the team itself.
31:20It really helps you understand appreciate
31:23some of the culturally relevant concerns
31:25people might have about participating.
31:28So we all have our blind spots,
31:29as I said from the start.
31:31So having a diverse team is perhaps
31:34a great way of highlighting what
31:35the blind spots are and making
31:37sure that there are checks and
31:39balances in place internally.
31:44Often times in psychedelic research,
31:46we rely on a male female therapist diet,
31:50so two people working with two
31:52facilitators or therapists
31:54working with a single participant.
31:56We contend when you know that
31:59this is gender essentializing.
32:00Basically this borrows from the
32:05psychoanalytic tradition that if we
32:07have a man and a woman serving as
32:11facilitators in the psychedelic space,
32:14this is our archetypically the parental
32:17image that we want to present here, right?
32:21This is the platform from which people's
32:24psychedelic experiences grow and sprout.
32:27It might offer a corrective
32:28experience for people who,
32:30you know, didn't have really great
32:32relationships with their parents.
32:34But it is gender essentializing.
32:36Because people can be gender diverse.
32:39They can be raised in households with single
32:41same sex or gender diverse parents, right?
32:44So we need to be responsive.
32:47We need to expand beyond the binary.
32:50We need to have pretty diverse gender
32:54pairing options that are responsive
32:57to what participants prefer.
32:59So if they say,
33:01you know what,
33:02actually I want two men working
33:04with me and I'm a woman where
33:06we can be open to that as well
33:12using culturally responsive
33:14recruitment strategies and materials.
33:16So a point, the, the biggest point here
33:19is that a lot of the time when we want
33:22to recruit for our clinical trials,
33:25we rely a lot on Flyers.
33:28And this is not a critique at all.
33:31But truly, like a lot of the time,
33:33these Flyers are very minimal in
33:36terms of information about the study.
33:39You usually don't even have any
33:43information about whom the person
33:44is going to be working with.
33:46In the study on that flyer,
33:50you usually only have a single mention of
33:53the indication of interest depression, PTSD.
33:55Do you have symptoms of schizophrenia?
33:57Etcetera.
33:58Consider this study, right?
34:01So when we think about how
34:06education about mental health and
34:09mental illness might be desperate,
34:11that then becomes an inequitable
34:14recruitment tool, right?
34:17And we contend that it it may be
34:20worthwhile to talk about racial trauma,
34:23to to talk about common to rare side
34:26effects of psychedelics on your flyer,
34:29to even have pictures and information
34:31about your study staff on these Flyers.
34:34So here is an actual flyer that we used at
34:39the MGMAPTSD study to recruit folks of color.
34:42So I wouldn't spend too much time on this,
34:44but but at first glance,
34:48I think we all can agree that this is
34:50way more information than you would
34:52typically see on a study flyer, right?
34:54You wouldn't even see pictures
34:56of the study step.
34:57But here we have that because we want people
35:01to know who they're going to be working with.
35:03We want to engender trust
35:06in this process proactively.
35:08So therefore we put our faces on on these
35:10Flyers so that people know ahead of
35:13time who they're going to be talking to.
35:15They might, you know,
35:16do some research on the Internet.
35:18Who is, you know,
35:19like Terence Chang, Who, who is he?
35:21So they'll,
35:22they'll pull up information about me
35:24and then they'll learn about me, right.
35:26And that's the transparency and trust
35:28that we want to model for people.
35:31And they're able to do that when they
35:33have that information on the flyer here.
35:35On this flyer, I also want to
35:37highlight this is a PTSD trial.
35:38First and foremost.
35:40We want to be super clear
35:42that racial trauma is real.
35:45People can have trauma due to
35:47racism and discrimination.
35:48We put that up there at the top really
35:51as an obvious way to tell people that,
35:54hey, yeah,
35:56we know that what you've
35:58experienced is trauma.
36:00We know that you're you're experiencing
36:02symptoms of trauma due to these racist,
36:04discriminatory experiences.
36:07And this is a trial for you.
36:10So really making sure that people get the,
36:13the message that they're eligible
36:15for a clinical trial because often
36:17times people just think about how,
36:20yeah, this doesn't apply to me.
36:21Why would it apply to me?
36:23Oh, turns out that,
36:24you know,
36:25discrimination can lead to trauma.
36:27Maybe I can consider this
36:31and one of the the biggest things here.
36:34Another big thing to highlight is that
36:37we have a lot of information about
36:40common to rare side effects here.
36:43The the the most common thing that
36:46we've heard in this trial when we
36:49screen people for this study was will
36:51this leave a hole in my head? Right.
36:54So this is a matter of debunking a
36:56lot of these myths and the the first
36:58point of contact is often the Flyers.
37:00So that is a great chance for people to
37:02to already have that question answered.
37:07OK, I know I wasn't gonna spend
37:08too much sad I wasn't gonna spend
37:10too much time there, but I did.
37:13So when you have this wonderful flyer,
37:17you got to think about, well,
37:18where am I going to put this fire, right?
37:21Where am I going to put this fire that
37:24will have the most impact for reaching
37:27the groups that I want to reach?
37:29And this is where, you know,
37:31creating a fire is only the first step.
37:34A lot of times, you know,
37:35running a clinical trial is really hard.
37:39We do however need to go above
37:41and beyond the level of effort
37:42needed to run a clinical trial to
37:45reach diverse groups and that is
37:47often the under appreciated thing.
37:49This is a whole job in itself,
37:52you know, outreach and and recruitment.
37:54When you have a wonderful, wonderful flyer,
37:56you want to reach out to folks in
37:59the community that are leaders.
38:01All of these gatekeepers to help you
38:05disseminate accurate study information.
38:07Where do you find these people?
38:09You know these are not just people
38:13hanging around campus, right?
38:14Like, these are people in churches.
38:17These are leaders and and people
38:19who do your hair, who do your nail,
38:21who cut your hair, right?
38:22Like who serve you in restaurants, right?
38:25Who go on radio shows and the
38:27radio shows that you listen to,
38:29who are there at the pride centers,
38:33the rainbow Centers for your
38:35peer support sessions, right.
38:38And these are just such great
38:41underutilized avenues for us to
38:44disseminate information about the trial.
38:46Word of mouth is really powerful.
38:50Often times you can,
38:53you can speak at, you know,
38:55your intended group as long as you want.
38:59But what they really want to hear
39:01is that the person that they trust,
39:03who is the the gatekeeper,
39:05the community leader,
39:07if they gave them the green light
39:09to go forward with doing this study,
39:11that's what they need, right?
39:13You can, they can listen to you all day long.
39:16They actually just wanna hear whether
39:19their pastor says this is a go.
39:22So a lot of times we need to leverage
39:25all of these community bridging resources
39:27to really get our message across,
39:29get study information across as well.
39:34OK, so I was gonna hot play this video,
39:36but I don't think I will
39:37for in the interest of time.
39:38But we have such a wonderful resource here
39:41with the Yale Cultural Ambassadors Program.
39:44Our group in the OCD clinic
39:46is actively talking to them.
39:48We've been trying to build a relationship.
39:49It's all about the relationship
39:52here and it it takes time.
39:54So I would strongly encourage people
39:56to to use this available resource
39:58as much as you can. You know,
40:00they've been pivotal with the COVID trials,
40:02with the cancer trials, etcetera.
40:06Why not, you know,
40:08branch out into psychedelics as well,
40:13OK. So let's say you're you're
40:16able to get people into the study
40:18to even consider the study,
40:21you bring them in for a consent call.
40:24We don't want to scare people off with
40:27certain language in the consent form, right?
40:33Our suggestion here is to consider
40:36replacing certain words such as
40:38investigation or experimental
40:40session with study session or or
40:43just study your overnight session.
40:46A lot of times,
40:47a lot of these particularly
40:50loaded terms have a high risk
40:53of activating implicit stigma
40:55and negative stereotypes against
40:58medical research and drug use.
41:04When we talk about language too right,
41:06we also want to be super responsive
41:09to how people refer to themselves.
41:11We want to mirror some of the terminology
41:14that queer folks use to self identify.
41:17This really helps us avoid conflating
41:19sex and gender for example,
41:22and really reduces the
41:24likelihood of microaggressions.
41:26So this here is a gender bred person.
41:29They continue to update similar
41:32infographics like this that really
41:35helps us stay up to date with
41:39evolving terminology for for sexual
41:41and gender diverse individuals.
41:45I also want to highlight here a good
41:47resource for clinician education here.
41:49This is UCS FS Center for
41:52Excellence on Transgender Health.
41:54This is a very accessible open
41:58source self training module or
42:02course that they offer and you
42:08can easily access that and they're
42:10just like very not time consuming,
42:13very easy to to complete modules that
42:17really highlight the the diversity
42:20of how people who are sexual and
42:24gender diverse self identify,
42:27really paying attention to
42:29how words matter basically.
42:33OK, so I put this point
42:36here really the idea that
42:40a lot of time, a lot of these clinical trials
42:42are are are conducted in English, right?
42:45Like that's even a inclusion criterion.
42:47They need to be able to understand
42:51study materials in English and that
42:54certainly rules out a huge part of our
42:58Connecticut population at least, right?
43:00We have a lot of folks who don't have,
43:04who don't speak English
43:05as their first language,
43:06who do suffer from mental health problems and
43:09should have access to psychedelic trials.
43:13So I I put this up here as food for thought.
43:17For us to consider how feasible
43:20it can be to translate materials,
43:23to hire translators,
43:24to hire study team members who can work
43:28effectively through psychedelic sessions
43:30in a different language than English.
43:33And this is really something to
43:35consider given how intensive and time
43:37consuming study procedures can be.
43:39Psychedelic trial, OK,
43:44when we talk about language
43:45other than English,
43:46we also talk about immigrant status, right.
43:49And one thing that we,
43:53that I think you know,
43:54we don't pay a lot of attention to is the
43:57the idea of of this fear of deportation.
44:00We need to establish participants
44:03safety beyond the physical and
44:06psychological or physiological.
44:09When we talk about a
44:11schedule one trial right,
44:13it is understandably natural for for
44:18certain individuals to be extremely hesitant
44:22and apprehensive about taking part.
44:24They believe you know that.
44:26You know when I take a psychedelic,
44:30immigration officers are gonna bust
44:32through the door and deport me,
44:34right?
44:35So we we it behooves us to think
44:38really intentionally about what our
44:40study policies are about the non
44:43reporting of undocumented immigrants.
44:46How can we work with community
44:50based groups to really improve
44:53trust among migrant communities?
44:56How can we use them to help guide
44:58these conversations if that's
44:59something that we
45:02really want to do? And that's also, you know,
45:09the, the related point is
45:13that immigrant communities,
45:15undocumented immigrant migrants have a
45:18higher risk for all of the different
45:20mental illnesses that we're interested in,
45:22in psychedelic trials. So.
45:26So that's just something to think about.
45:28You know, like how ethically
45:31are we proceeding by,
45:33by running a trial that excludes
45:35a subset of the population here in
45:38the United States or in Connecticut
45:40that are actually suffering
45:42the most from the mental health
45:44problems we're most interested in.
45:48All right. So here we also talk about
45:52how providing equitable incentives might
45:57be a way to bring more folks of color,
46:01more diverse folks into our clinical
46:05trials utilizing convenience enhancing
46:07technology offering rideshare credits
46:10to improve access to participation.
46:13While this may target the idea
46:15of transportation as an access
46:18barrier and not necessarily
46:22may not always
46:26solve the issue of, you know,
46:29who do I turn to for childcare, Etcetera.
46:31But I think it is a a nice
46:34first step that we can think
46:36about more carefully together,
46:38about how compensation schedules
46:40can be put on a sliding scale and
46:43what how can we determine who has a
46:45greater need than the other person.
46:50OK, so let's say you got them in,
46:52you know they're here for for their
46:54first study visit, it's a prep visit.
46:57They enter the the study room.
47:00I think every step of the way we need
47:03to be thinking about how we can be
47:06culturally attuned to participants needs.
47:08So a great way to think about that is how
47:11we can introduce diversity and artwork,
47:14some of the decorations here
47:15and how we select music for the
47:18dosing sessions themselves.
47:20It's really important to understand,
47:21you know, the cultural roots of such decor
47:24that we incorporate them respectfully,
47:26that we're not doing it in a
47:30culturally appropriative way.
47:31There are really obvious ways in which we can
47:35do to to queer and diversified dosing space.
47:39Fried flags, for example.
47:41Art depicting same sex
47:43relationships for example,
47:45employing queer office staff,
47:47making sure that people
47:49have access to single stall,
47:51gender neutral bathrooms.
47:52All of these are essential ways of making
47:56sure that every moment that a participant
47:59spends in our at our study site is is,
48:03you know,
48:04situated in a feeling of safety and comfort,
48:07right?
48:08That they're not feeling only
48:11safe in the room and then micro
48:13grasped against when they leave
48:14the room to use the bathroom.
48:19This is a point about music.
48:21A a lot of the times the playlist
48:23that we use in dosing sessions
48:26can be pretty standardized.
48:27They they're highly instrumental and they
48:30are evocative of a particular spiritual
48:33experience for some people, right?
48:37So given the invalidating and potentially
48:40traumatic experiences that many queer
48:43folks have with religious institutions,
48:46it might be a moment to pause
48:48and think about, you know,
48:50just what what is happening
48:52here for this person.
48:54And a great way to prevent potential
48:57re traumatization of of certain
49:00folks is to have them here.
49:02And that samples of intended music playlists.
49:06So this is just another way to
49:08to be queer affirming in your
49:11collaboration with the participant.
49:14OK, I I'm gonna make the hour mark here.
49:20We're gonna round the corner and
49:22talk about assessments, right?
49:23So we highlighted how assessment
49:26procedures are an integral part
49:29of of the study process in a
49:31clinical trial for psychedelics.
49:34The the choice of assessments is
49:37also so important to signal to
49:39participants that you really care
49:42about their diverse identities and
49:45the the how in which you conduct
49:47your assessment is also so important.
49:48So all of that also feeds into
49:51the idea of retaining them in the
49:54psychedelic trial because if if a
49:57person starts feeling micrograss during
49:59an assessment interval every time
50:01they have to come in for a study visit,
50:03they're probably not going
50:04to want to stay in the trial.
50:06So first of all, right,
50:09before we even conduct any assessment,
50:12I think it behooves us as as clinicians
50:15and researchers to to work with the
50:18understanding that certain experiences
50:20typically not considered criterion A,
50:22for example,
50:23can still lead to symptoms of depression,
50:26anxiety or PTSD.
50:27So what I'm specifically referring to
50:30are the many different ways in which
50:33identity based stress and trauma can
50:35manifest through microaggressions,
50:36through hate crimes,
50:38through racially motivated violence or
50:42or sexual or gender motivated violence.
50:47For I I contend that to do,
50:52to conduct assessment in
50:54a culturally attuned way,
50:55we really need to be highly
50:58educated about minority stress.
51:00We need to know and and recognize
51:02the reality that all of these
51:05identity related stressors often
51:07result from existing in a system
51:11that really endows certain other
51:13identities with power and privilege
51:16and oppresses others, right.
51:18We need to recognize how all
51:20of the isms permeate modern
51:23healthcare and that we're working
51:25actively to to keep that in check.
51:28So I I certainly do encourage people
51:31to continue educating themselves,
51:33to continue referencing and referring
51:35back to all of the professional
51:38guidelines and standards we
51:39have for working with folks of
51:41color and queer folks as well.
51:46And through this process,
51:48this continual process of self education,
51:51we begin to know and understand
51:53more about what could be asked when
51:56we conduct that first psych eval.
51:59For someone that we screened
52:01for a psychedelic trial.
52:03There are a lot of, like,
52:04really great queer affirming intake
52:07protocols that we can integrate into our own
52:12assessment procedures first of all, right?
52:14Like giving open-ended quest
52:16options for how a person wants
52:18to identify for their gender,
52:20for their sexual orientation, etcetera.
52:23When people see that on your iPad or your
52:27paper that you hand over to them to fill out,
52:31that really is a way to signal,
52:33you know, like we trust that how you
52:37identify is your reality and we wanna,
52:41you know, be on the same page as that.
52:43So tell us exactly how you identify.
52:46That is such an empowering way and
52:49affirming way for participants to
52:51to be brought into the study and
52:53it's so easy to to integrate that
52:56into your assessments too as well.
53:01So really the the point of this is that
53:09you know there there could be
53:10pressure for someone to try to
53:12do it right and that's what I
53:13talked about on the next slide.
53:15It's all about balance, right,
53:16like we're we're not over or
53:19under focusing on identity.
53:20We're open to making mistakes along the way,
53:23but we're always trying to to
53:25correct that for ourselves.
53:27We're not assuming that how people
53:29wanted all clients want to talk
53:31about their diverse identities.
53:33It may have nothing to do with
53:35some of their presenting concerns
53:38and we're not asking invasive
53:40questions just out of curiosity.
53:41So just out of curiosity,
53:43what are you right like that would
53:45be super micro aggressive for a
53:47participant to receive from from
53:49someone that they should trust in this
53:52highly vulnerable therapeutic process.
53:55So you know at this point in time usually
53:57is when people start feeling like,
53:59oh like I'm I'm confused like
54:01what are you saying really?
54:03You know we want to be attentive and
54:05led by the patient in understanding
54:08their identity development because
54:09it it ranges on the spectrum.
54:11People are maybe at point A at one
54:14point in time at point B the next
54:17day or the next month or year.
54:20We need to do our own homework and
54:22learning more about identity diversity.
54:24And I strongly encourage people
54:26to be super warm,
54:28non judgmental and compassionate
54:30and accepting of their sharing
54:32and having you know,
54:35the the the capacity to own
54:39up to my progressions.
54:41Even if it was unintentional.
54:43And for you to apologize,
54:46quickly own it and and then move on,
54:50which really signals to the participant
54:52that you're able to take this in stride,
54:56that you can stand to be corrected.
54:59You can tolerate that and that you
55:01trust that they will continue to
55:03do that if it comes up for them.
55:05So what better way to build trust and
55:08rapport than being super transparent
55:10and honest in that way as well?
55:12OK,
55:15The next few slides really
55:16highlight all of the different
55:17options that we can consider.
55:19These are not exhaustive at all
55:22and and certainly more interviews
55:24and self report measures continue
55:27to be released over the years.
55:30Let's remain curious and open to
55:32what what these measures could do
55:34for us in in helping us understand
55:36a a person more holistically as
55:38we bring them through our trials.
55:40So the cultural formulation
55:42interview certainly is a a great
55:46assessment to integrate in.
55:47In working with participants.
55:49It helps you understand how they understand
55:52their problems from a cultural lens.
55:56What are some of their culturally
55:59sanctioned ways of working through
56:02mental health problems that could
56:04be brought into the healing
56:06process in a psychedelic trial?
56:09I just want to highlight EU Conn
56:10racial ethnic stress and trauma,
56:12survey the unrest.
56:13Basically it's a a cultural or
56:17racialized version of the Caps
56:205 and it allows you to assess
56:24for incidents of racial trauma,
56:27racial discrimination that informs the
56:30person's presentation of PTSD symptoms.
56:35There are a few self-reports that
56:37I'm just gonna breeze through.
56:39This is the general ethnic
56:41discrimination scale really helping
56:43you understand in a very easy way
56:47people's experiences with ethno,
56:50racial discrimination and racism.
56:53Basically this is a self report measure
56:57of intersectional microaggressions that
57:00have occurred to queer folks of color.
57:05Basically, this is a self report
57:09measure of internalized model
57:12minority stereotypes among Asians.
57:14So this is a group specific measure.
57:18It's something that I'm fond of and
57:21that I think a lot about 'cause you
57:25can imagine how certain Asians who
57:28have internalized the model minority
57:31stereotype could become super stoic,
57:33standoffish,
57:34or or adopt more of a people pleasing
57:40approach through a healing process.
57:42That is meant that can be meant to be,
57:44you know, pretty,
57:46vulnerable and and expressive and
57:49how that really shapes how they
57:51show up during a dosing session.
57:53So it might give you a lot of
57:56information that you can then
57:58collaborate with the participant
58:00to work through if it makes sense.
58:03There are also similar measures
58:05for internalized racism,
58:06internalized sexual and gender stigma too.
58:09So strongly encourage people
58:11to check all of those out.
58:14This is the the last self
58:15report that I'll talk about.
58:17This is the barriers to
58:19access to care evaluation.
58:20What you get from this very easy to
58:24administer self report is a lot of
58:27responses that talk about things that
58:30highlight certain access barriers
58:31that people might not talk about
58:33when they show up for study visits.
58:35Oh,
58:36turns out I don't have time to
58:38take off work for the study visit.
58:40So I I basically skipped work to
58:42come to this study visit and that was
58:44something that was not discussed.
58:46But if you administered this
58:48self report measure,
58:49you're able to get that information and
58:52bring it up and start thinking about,
58:55oh,
58:55maybe we need to have a protocol
58:57amendment for certain groups that
58:59we want to bring into the study.
59:01So you know,
59:02just a great way to to get a
59:04lot of that information, really.
59:07OK.
59:07So as a conclusion,
59:09we really understand how hopefully
59:12people understand how these different
59:14barriers interact as part of set
59:17and setting to dissuade diverse
59:19participation in psychedelic trials.
59:21And as such,
59:23any strategies to address these
59:25barriers need to be attuned to
59:27the culturally relevant factors
59:29involved in their formation.
59:31So we've talked about many culturally
59:34attuned ways to recruit to assess
59:36and hopefully retain diverse
59:38people in psychedelic research,
59:39and none of these are meant
59:41to be prescriptive.
59:42I only ask for folks in this call
59:44and people who are listening to
59:47to consider and perhaps adapt and
59:50enact these recommendations as
59:52appropriate and feasible in your
59:54own psychedelic clinical trial.
59:56So with that, I'll, I'll,
59:58I'll conclude and stop here and
01:00:02I just highly, you know,
01:00:03wanna thank Ben,
01:00:04Chris and the rest of the OCD clinic,
01:00:08the Enac lab,
01:00:09all of the other organizations that
01:00:12have contributed in some way or another
01:00:16to to these slides here. Thank you for that.
01:00:22Thank you, Terence for being
01:00:23with us today and sharing this
01:00:25perspective and and material.
01:00:26It's really an important one.
01:00:30We are at a little after 430 and I know
01:00:32that I couple of us need to, it's fine.
01:00:34We started a little late.
01:00:35So your time and control was perfect.
01:00:37We just started late.
01:00:39But maybe if there's one or two
01:00:40questions we could take them
01:00:42briefly and then we'll close.
01:00:43I know some of us want to get over
01:00:45to the film screening at 5:30.
01:00:52Well, that's easy hearing. None.
01:00:54Thank you, everyone, for being with us.
01:00:56Have a great weekend. Take care.
01:00:59Thank you. Thank you.