Laura Berg
Laura Berg's article "Notes from a Research Nurse" appeared in MAPS V.5 no.1, Summer 1994
Sarah lies back upon the hospital bed, and I help secure the black satin eye shades over her eyes. Around Room 531 of the Clinical Research Center (CRC), she has positioned special stones and fetishes, and her resting form is draped with a colorful cotton blanket from home: her "trip blanket," which has provided safety and comfort in other journeys to altered states. Sarah also has recited a prayer for guidance and balance.
My stopwatch is set to zero, and the rack of blood sampling tubes, ice and syringes are ready near the bedside. A "Do Not Disturb" sign is placed prominently on the door. The tapestry of abstract blues and purples has been unrolled from the closet and hung, and Rick's stepdaughter's painting of butterflies and Amanita mushrooms, brightly colored, is also on the wall.
Rick Strassman, Sarah and I now take a few moments to sit in silence. This morning Sarah will receive 4 intravenous injections, one half hour apart, of a high dose of N,N-dimethyltryptamine (DMT), a potent hallucinogen she describes as "a warp speed conveyor belt into the psychedelic buzz saw." Sarah breathes deeply several times, "I'm ready," she whispers.
Perspectives
As the psychiatric nurse clinician working with the UNM psychedelic studies between March 1993 and May 1995, I've been closely involved with the contemporary renewal of psychedelic research. Our research design at UNM has been primarily psychopharmacological and quantitative, focusing on the measurable variables of neuroendocrine pathways and psychological parameters. However, the larger research environment contains the lived experiences of the research team and the research volunteers, and the phenomenon of our work encompasses many experiences that can only be known in relationship and context, through qualitative perspectives. While quantitative methods emphasize such techniques as randomized design, endocrine measurements, paper and pencil objective tests and statistical analyses, qualitative methods include ethnography, case study, in-depth interviews, and participant observation (Cook & Reichardt 1979). Qualitative approaches focus on naturalistic presentation of phenomenon, contextual, subjective, and embodied meanings, and enlargement rather than reduction of the variables of experience (Munhall & Oiler 1986). In psychedelic work, this type of approach is an useful counterpart to formal, reductionistic methods.
Both perspectives are valid. Here in my second article for MAPS, I acknowledge both qualitative and quantitative perspectives, and will combine narrative description from a selected study day and case study with background information on my day to day work activities as a nurse in psychedelic research, including my closing perspectives. In doing so, I seek to tell more of the important "story behind the study" (Sandelowski, 1991).
Sarah checked in to the CRC yesterday. All women volunteers' studies take place only in the first 10 days of their menstrual cycles, when potentially confounding levels of progesterone and estrogen are at their lowest. Sarah's cycles are irregular, so she called me as soon as her menses began. Another CRC patient was discharged from our designated research room, so Sarah is able to come in. A pregnancy test and brief physical assessment measures were obtained by the unit nursing staff, and she then checked out on an overnight pass.
Two months ago, Sarah had her test dose administrations of DMT: 0.05 and 0.4 mg/kg level, allowing us to assess her cardiovascular and psychological response to DMT. Importantly, these also allowed her to measure her own response to the medicine within the research setting. She had very strong feelings of death and rebirth.
One month ago, she came in for the first day of her double-blind DMT tolerance study. At 7:30 AM that morning, I picked up 4 pre-filled syringes from the research pharmacist; neither Rick nor Sarah nor I knew whether these would be DMT or placebo. We prepare as for DMT, but within 30 seconds Sarah lets us know: it's saline placebo. Our protocol continues through 3 more precisely-timed injections of saline, as we chat informally. through 2 hours of blood sampling, blood pressure readings, and rating scales. Sarah has now had a month to prepare for her second day, knowing that it will be DMT.
Sarah returns early this morning, and preparations for the tolerance study have taken around 2 hours. Today, again, she is fully poked, prodded, lines and probes inserted, subject to the full array of technical procedures as she undertakes the DMT journey. I've started 2 intravenous (IV) lines: one in her right hand, a heparin lock (a small capped plastic catheter placed in a vein) for DMT administration; and in her left arm, an antecubital (inner arm) line attached to a slowly-infusing saline solution. I'll be drawing blood samples at 2 to 15 minutes intervals for several hours. I've made and set-up a heating pad to cover her left arm IV site; this will be more comfortable for her, and, by reducing some of the widespread vein constrictions caused by DMT, ease the blood sampling process.
I've also gathered the syringes and laboratory tubes for this day's study, arranging technical apparatus as unobtrusively as possible, and setting up things to prevent untoward sounds and movements. I've also placed a flexible rectal thermometer, a thin rubber-coated sensing wire, humorously and infamously known to the volunteers as The Probe, and connected it to a small, transistor-radio-sized recording device. The monitor will record Sarah's core temperature changes, for later downloading into our database. We have grimaced and we have laughed. Somewhere in all this, we've kept humor, sensitivity and the human touch, knowing that set and setting are key aspects of the experience. And amidst the apparatus, Sarah has composed herself, and recited her invocations. We honor the silence. This moment is precious. There is a timelessness in the silence before DMT administration. For me, the surreal and the real, the quantitative and the qualitative, mingle there in a unique way.
My nursing work with the UNM studies began with pilot studies in DMT tolerance, continued throughout 2 subsequent studies of DMT, and into initial pilot work with psilocybin. The psychedelic research nursing role has included many complex professional responsibilities. The relatively more circumscribed aspects of my psychiatric nursing role have included recruitment and formal psychiatric screening with prospective volunteers; study scheduling; liaison and training with UNMH pharmacy, nursing, laboratory and CRC staff; study set-up and technics; and participation in protocol development and team meetings. These general duties are consistent with responsibilities commonly incurred in the management of many other research projects within the field of psychiatry.
However, recruitment and psychiatric screening took on many new attributes in the conduct of a psychedelic study, as did orientation and liaison with hospital staff. Recruitment of experienced hallucinogen users was accomplished exclusively through word of mouth and needed to be managed with special sensitivity. The population of experienced hallucinogen users had a wide range of characteristics and histories on psychiatric screening: predominantly, a history of experimentation with a wide range of psychoactive substances, and in many cases, histories of experimentation with other altered states through non-drug means including non-Western or Eastern spiritual practices.
Research-based interviews
Our formal research-based psychiatric interview codified symptoms according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Although our volunteers may have had problems with Major Depression, Adjustment Disorder, or Psychoactive Substance or Alcohol Dependence in the past, persons with current or recent problems were not eligible to participate. Abuse of a substance, in general, is coded only if there is impairment in social, relational or physical spheres or hazardous use. As such, many volunteers with histories of extensive psychedelic experimentation did not meet DSM-III-R diagnoses.
Over the course of my project involvement, I expanded my interview to include assessment of other significant areas not included on the formal interview, including birth experience (type of delivery and mother's labor, birth order), family, developmental and relationship history, and a more thorough discussion of difficult psychedelic experiences, with special focus on set and setting and how the prospective volunteer handled anxiety that may have arisen. Interviews also came to include further preparation and discussion of the protocols themselves and anticipated DMT or psilocybin sessions. Volunteers were also given forms to complete before the first session: an extensive drug history and a personality inventory.
Before my psychiatric interview, Rick already had met twice with prospective volunteers: once to meet and discuss the study work, and once for medical screening and physical examination. The screening interviews with Rick and myself gave us an opportunity to develop trust and rapport with volunteers. In the midst of our assessing them, they also had the opportunity to assess us. For each volunteer, the decision to participate was not taken lightly.
Of perhaps 70 persons screened, around 1 in 6 had medical, situational or psychological factors that excluded them from continuing into formal studies. One person has enrolled in all studies to date, and several more have participated in multiple studies. Approximately 1 in 3 or 4 participants has been a woman.
Sarah is in her early 40's, now in her second marriage, and has 3 children. She holds a BS and is a successful freelance writer. She initially heard about the psychedelic research project at a conference where we happened to meet. I described the studies, and she was very enthusiastic about the chance to take part. The studies had remained quite low-profile and had generated nearly no publicity; Sarah, as most local people, was astonished to hear that psychedelic research was happening at all, much less in her own city. Sarah and her husband, who was also interested in the research, then met with Rick to discuss their prior experiences with psychedelics, and to discuss the UNM studies in more detail. She then underwent and passed her screening medical history and physical examination.
We then met for her psychiatric assessment. Unlike most other volunteers who began their experimentation with psychedelics at an early age, she began her use in the late 1980's, when she was in her late 30s. Since then, she has taken psychedelic substances around twice a year, and describes her use as a "tool on my spiritual path." Her use has been in a "ritual" context with a small group from which she now is estranged. She has had experience with mescaline and peyote, but no other psychedelic substances.
Sarah is a practitioner of Wicca, which she describes as "the old religion of Celtic and neo-pagan roots." She describes "communication with spirit guides and nature spirits." As I more closely assess her thought processes, I find no evidence of a formal thought disorder or psychotic thinking that would warrant DSM-II-R diagnoses. She, as do many other volunteers, reports a range of non-drug induced alterations of consciousness. For the most part, these experiences are cultivated by the volunteers and occur in meditation, ceremony, or long walks in nature. For Sarah, these experiences are accepted and encouraged by her peers, her family and her spiritual circle. And most significantly, they have not interfered with her functioning in day-to-day activities and responsibilities: a critical element in differentiating the nature of "psychiatric symptoms."
The psychedelic sessions
The more complex responsibilities associated with the UNM project have revolved around the psychedelic sessions themselves: volunteer preparation for each session, support during sessions themselves ("sitting"), and follow-up over ensuing days to months. These were skills requiring on-the-job training. Preparation for sessions included provision of written background materials, discussion of the range of expected effects, hopes and fears, and the anticipated timeline of the studies. As my experience at the bedside grew, enhanced by ongoing follow-up interviews, I was able to provide better preparation and sitting for volunteers. With the shift from DMT to psilocybin sessions occurring last summer, a new constellation of skills and aptitude for empathic and effective sitting was required. Work with psilocybin entailed major changes, for both volunteers and the research team.
The psilocybin experience is markedly longer than that of DMT; our UNM psilocybin sessions ran from around 8 am to 4 pm. Because of its length, and the gradual rise and decline of peak effects, different psychological and physiological responses took place. While cardiovascular effects are much less robust than with DMT, the length of time spent in a hospital room and/or hospital bed evoked restlessness for some volunteers. As well, the team needed to remain quiet, relaxed and attentive for longer periods. Rick initially recommended a simple meditation practice for me; over time, I found it easier to sit comfortably and with less distraction. Psychologically, the psilocybin effects at larger doses seem to release more personal and unconscious material, in contrast to the relatively more transpersonal or chaotic attributes of the DMT experience. The volunteers' experiences of psilocybin seems to have a undulating motion whereas DMT is more piercing and explosive. I await the results of Rick's rating scale data analyses to confirm or modify these subjective impressions. The images and emotions encountered with psilocybin seem to be more directly associated with personal issues or relationships for the volunteers. As well, attributes of transference are heightened, and elements of trust and rapport with the research team take on an even greater significance than with DMT.
The work evolves
The structure of psilocybin sessions was modified over time, as we became more familiar with the effects of the drug and received volunteer feedback. We continued to structure and support an inward journey. Volunteers were asked to bring in 3 selections of music, to be played during the onset, ascending period, and coming down period of psilocybin effects. For the time of peak effects, volunteers were asked to keep silence and lay prone for 90 minutes. There were several breaks to complete rating scales and to check in with the team, and use the bathroom if necessary.
Initial attempts to have volunteers complete the HRS on medium or high doses during peak effects were found to be impractical; volunteers would either laugh (sometimes wildly) or become too distracted or frustrated in reading and thinking over the HRS descriptors. After several sessions, we also began to invite significant others to be present for all or part of the day. We also found it helpful to offer gentle massage during especially difficult parts of the session, and to rearrange furniture so to provide more floor space for volunteers to do stretching or seated meditation. For the psilocybin work, blood pressure readings were obtained on a half- hourly basis. For some some studies, ear thermometer temperature checks were obtained at the same interval. However, no IVs or blood drawing were necessary. Blood sampling and endocrine assays were a component of the planned formal protocol, but the UNM work was stopped before any of these procedures took place. The double-blind, dose-response protocol was designed to incorporate 5 randomized study days after 2 non-blind test doses at the low and high levels. One of the 5 days would be placebo and 4 days would be psilocybin across a range of doses.
Several volunteers, all experienced in the DMT studies, joined us in the pilot psilocybin work. We thank them. Most of them, after pilot and test dose work, chose not to enter the formal protocol because of the rigor of the hospital setting.
Sarah, second DMT session of 4 for the tolerance study. The hum of the automatic blood pressure machine inflating. The slight clink of glass tubes. Steam arising from the UNM hospital smokestack in the distance. The garnet color of blood.
Sarah breathes deeply. At 2 minutes, she murmurs, "Tell me where you want me to go." Glancing eye contact between Rick and me; she's not speaking to us. At 6 minutes she sighs deeply. At 7 minutes she presses her hands over the eye shades, and resettles her body. She joins her fingertips and wets her lips with her tongue. Five more minutes pass, my stopwatch recording the seconds. She lifts and removes the eye shades, makes contact with Rick and me, raises and shakes her head, smiles, and says, "I'm back."
Rick quietly takes notes, as she describes her DMT experience: I was in deep space this time. There were beings. It wasn't scary, they were expecting me. They were observing me. They told me: "We are in a different universe. We mean you no harm. We embrace peace."
At 15 minutes post-injection, I step quietly out of the room to deliver the iced blood samples to the research lab, and to check with the CRC nursing staff on our study progress. I am not able to hear the full story of her DMT experience, and try to return as quickly as I can. Rick will take full notes of her narrative, and will later provide copies to Sarah. My own notes will focus on the technics of the study and her overall response. As I return, Sarah is sitting up and completing the HRS, which will quantify the DMT effects. Today, she is completing a shorter version of the questionnaire, since she will be receiving her fourth dose of DMT 30 minutes after the last administration, which is only 10 minutes away.
Follow-up
Follow-up contact with volunteers is an essential component of psychedelic studies, and these responsibilities were another key aspect of my nursing role. In conjunction with Rick, I provided day-after phone contact to volunteers after DMT and psilocybin sessions, and arranged ongoing phone or 1-to-1 assessment of volunteer needs. I also conducted formal follow-up interviews after 1 year with all DMT study participants in the first 2 protocols. These semi-structured interviews reviewed insights and memories from DMT sessions, taking into account the full range of possible DMT responses, and assessed changes in lifestyle patterns and psychological variables, including the presence of flashbacks and effects on subsequent psychedelic experiences during volunteers' own self-experimentation. I hope to complete further interviews with participants in subsequent DMT and psilocybin studies and to provide an overview across studies.
According to one author: "Professional practice in Nursing seeks to promote symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field, and to direct and redirect the patterning of the human and environmental fields for realization of maximum health potential."(Rogers, 1970, p 122). Through the nursing role, I became a voice for the volunteer group as a whole; adding elements of comfort to the study room, expanding the preparatory discussions to include previous volunteers' reports, communicating and integrating critique and suggestions into ongoing conduct of the study.
Reflecting back
Over time, I heard many volunteers speak of an isolation in their experiences. While they had peers or friends with psychedelic experiences, few of their friends had ever had any experiences with DMT. Fewer still had ever had psychedelic experiences in a hospital setting as a research volunteer. There appeared to be a strong need share their stories, to reflect on the meaning of their experiences with others who had been there. Responding to this need, Rick and I began offering quarterly technical review meetings, where volunteers were able to meet with the team and each other. These round-table meetings have been well-received and, I feel, provide an important element of continuity for both volunteers and the team.
Follow-up evolves into a circle and becomes preparation, enfolding experience. For the UNM volunteers, the constraints of the hospital setting became more difficult under the full effects of psilocybin. Our setting had been effective for the DMT work, but the length and breadth of the psilocybin experiences taxed our resources further. Sensitivity to the physical and interpersonal environments is heightened, even when a focus on an inner-directed experience is encouraged. As comfortable as we could make the room and experience, there were significant limitations: a small room that was crowded when a spouse/partner or art therapist joined us; noises from the hallway; one sealed window overlooking the hospital dumpster and loading zone; and a door onto a hospital hallway which lead to rooms with people experiencing pain, loneliness or fear. A short walk in a natural setting or a breath of fresh air would have been very welcome at several points throughout the day during psilocybin sessions.
Sarah's fourth dose of DMT is completed. She describes an experience of "communication with beings from another solar system. I was pouring light, pink light, from my hands into them." She is blissful, excited, but exhausted. I disconnect all technical apparatus, and set up her lunch as we discuss her experience more fully. We will be in touch over the next day and following weeks.
Sarah later returns for further studies, both DMT and psilocybin. We have a difficult time starting her IVs for several sessions. Her husband also enrolls in the DMT study, but has a very difficult DMT test dose: his blood pressures goes very high, and blood pressure machine alarms go off at 2 minutes, during the peak effects, creating a very chaotic environment for the DMT experience. He was dropped from further participation in the studies because of his blood pressure response. They had hoped to participate together, and the dichotomy creates some brief stress within the relationship, requiring some couples counseling from Rick.
Sarah, 1 year post-study, said during her follow-up interview: "It was a powerful tool for self-exploratoin and exploration of all the invisible dimensions. It's about being stripped to your soul essence - having everything of the material world peeled away." She also speaks of the terror of the 0.4 mg/kg dose and the IVs and about a fall during a rock climbing trip, (when I saw how I would die and it was so much like the DMT space.)
Her experiences with DMT, and her later experiences with psilocybin, were not unusual. "Seeing" and "interacting" with "entities"," "beings," or "creatures" are reported by nearly one third of our DMT study participants. In another setting, her story would be labeled psychotic, her participation classified as reckless and deranged. Yet she returns home to maintain a responsible and productive lifestyle and persona, as writer, mother, wife, neighbor, friend and citizen.
Thank you Saray, and many thanks to all UNM volunteers, for contributing both endocrine markers and human spirit toward the endeavors of the UNM psychedelic team.
References
Reichardt, C. & Cook, T. (1979) Qualitative and quantitative methods in evaluation research. Sage, Beverly Hills, CA.
Newman, M. (1986) Health as Expanding Consciousness. CV Mosby Co. St. Louis.
Munhall, P. & Oiler, C. (1986) Philosophical foundations of qualitative research. (pp 47-64) IN Nursing Research: a qualitative perspective. Appleton-Century-Crofts. Norwalk, CN.
Rogers, Martha (1970) An Introduction to the Theoretical Basis of Nursing. FA Davis Co. Philadelphia.
Sandelowski, M. (1991) Telling stories: Narrative approaches in qualitative research. Image, The Journal of Nursing Scholarship. 23, 3, pp 161-166.