A psychiatric renaissance?
In this fairly short article, I share some thoughts about psychedelics that I hope will be both interesting and useful – within the broader context of reimagining
psychotherapy. I have woven together a personal story that has deeply affected my work as a psychotherapist and also a bigger picture highlighting how psychedelicenhanced psychotherapies are giving hope to many people whose suffering is ineffectively treated by our current psychological and pharmacological interventions. As the psychiatrist Ben Sessa put it in his talk at the recent Interdisciplinary Conference on Psychedelic Research in the Netherlands, ‘Everyone is talking about the psychedelic renaissance … Let’s change this, I think we should be talking about a psychiatric renaissance. Psychedelics are excellently placed to change the whole paradigm with which we look at mental health. We must disregard categorical diagnoses. I have been a psychiatrist for twenty years. I have never met a patient with depression or anxiety or schizophrenia or bipolar or an eating disorder or an addiction. I have met thousands of idiosyncratic clusters of people who require bespoke personalised care plans in which they teach the doctors what they need to do. We need care plans to be designed around needs, around social and psychological issues, not diagnoses that have been fabricated by pharmaceutical companies to sell particular products that are rubbish and don’t work and mask symptoms. This is a renaissance of psychiatry, not a renaissance of psychedelics.
This article shares some of my personal journey with psychedelics. I then go on to point out how poor we have been for some decades – with both pharmacotherapy and psychotherapy – at improving our ability to help people. I briefly outline the various classes of psychedelics and look at exciting emerging research demonstrating very clearly that we need to take the promise of psychedelics seriously. I will also say something about safety issues. Intriguingly, it’s well worth noting that improved outcomes from using psychedelics involve both the relief of suffering and enhanced wellbeing. Again, I’ll say something about personal experience here. I will then close with a few where-from-here suggestions.
Immersion in an emerging field
So, let me start with a personal story. It’s December 2018 and I’m reading a book that I’ve been given – Michael Pollan’s How to change your mind: The new science of psychedelics. I had taken LSD a dozen or so times as a student in the late 60s and early 70s and then put psychedelics behind me. I shifted to meditation, dance and yoga and changed subjects from philosophy to medicine. Now, 50 years later, I was aware that the long psychedelic research ice age had begun to thaw and that fascinating new studies were emerging, but – until I read How to change your mind – I wasn’t paying this new work much attention. Reading the book was a strange experience for me. It was as if an old, very dear friend knocked on the door and came in after being away for decades. I could feel a whole-body response: ‘Yes, this is where I want to channel much of my energy now.
To swim into this field again I initially did three things – update my knowledge, join the conversation about psychedelics, and update my personal experience. First, I dived into the research literature and have continued to do so. If I search right now on the keyword ‘psychedelics’ in my personal Endnote database, up come 504 articles of which three-quarters have been published in the last three years. I also attended a couple of psychedelic conferences and enrolled on a series of online workshops, classes and discussion groups covering different aspects of psychedelics.
A growing conversation
Secondly, I wanted to ‘join the conversation’ by sharing what I was learning. I began writing blog posts about this work – see under ‘Psychedelics’ in the ‘Good Knowledge’ section of the website goodmedicine.org.uk. Within a few months I had also written an article for the main Scottish counselling journal, Psychedelic-enhanced psychotherapy: time for a Scottish special interest group? and we now have the UK-wide Psychedelic Health Professionals Network If you visit the group’s website, you can sign up for the free newsletter linking through each week to emerging research, join the monthly orientation/integration groups, and apply for one of the experience retreats we are running in the Netherlands from summer 2021.
The Psychedelic Health Professionals Network’s main aims are education, connection, support and advocacy. So we are contacting other health organisations where new research suggests psychedelics may have something useful to offer. Currently this covers trauma, depression, severe end-of-life anxiety, substance use problems, and meditation/ mindfulness. Eating disorders, migraine and other pain problems, and anxiety disorders including OCD are likely to follow. The slides from a talk I and a medical colleague gave to a group of drug and alcohol workers are on the psychedelicnetwork.org.uk website, as too are the slides and recording of another talk to the main Scottish psychological trauma treatment centre. I’ve also recently attended a workshop planning future developments in Scottish palliative care and I’ve already written to the convenor discussing the possible part psychedelics could play here. A senior figure in the mindfulness world has begun writing a research protocol involving meditation and psychedelics that I hope we can collaborate on and a younger doctor has come forward to look at researching the potential for helping pain problems with psychedelicenhanced therapies.
I am aware of the contradiction of highlighting the importance of working with patients as individuals rather than simply grouping them under diagnoses, while at the same time discussing the relevance of psychedelics for general disorders rather than for specific people. It’s noteworthy that in the recent paper Psychedelic treatments for psychiatric disorders: A systematic review and thematic synthesis of patient experiences in qualitative studies, the authors specifically highlight that ‘Patients frequently report on clinical effects beyond their own psychiatric diagnosis, which may be indicative of the cross-diagnostic
action of psychedelic drugs’ ’(Breeksema et al, 2020).
So, both personally and more generally in the Psychedelic Health Professionals Network, we are continuing to educate ourselves and sharing what we learn. The third area I dived into last year was to revisit psychedelic experience as a participant, but before I talk more about that, what has the research been saying?
Conventional treatments disappoint
I think it’s useful to remind ourselves just how stuck both pharmacological and psychotherapeutic interventions have become. So a recent major review of antidepressants, Analysis of time-course, dose-effect, and influencing factors of antidepressants in the treatment of acute adult patients with major depression, concluded that: Amitriptyline showed the highest drug efficacy. The remaining 18 antidepressants were comparable or had little difference’ (Cheng et al, 2019). OK side-effects may be a bit worse with amitriptyline than more modern antidepressants, but it’s shocking that in the 60 years since amitriptyline was first introduced, we haven’t been able to come up with a widely available, well-tolerated, more effective alternative medication. And the situation seems similar with psychotherapy. Smith, Glass & Miller performed a meta-analysis of psychotherapy’s helpfulness back in 1980. They came up with an average 0.85 effect size (Smith et al, 1980). This is pretty good … but … the hundreds of psychotherapy meta-analyses over the next 40 years since have not shown any reliable improvements on this initial effect size estimate. In fact, if anything, better statistical methods suggest we have been over-estimating how helpful we are as psychotherapists (Driessen et al, 2015). Of course, new types of psychotherapy emerge all the time like waves out of the ocean. Claims are made that they are more helpful than previous types of therapy but, again and again, when independent researchers compare outcomes the new kids on the block turn out to produce very similar outcomes to the old kids (Cuijpers, 2015). As an aside, I would comment that when it comes to comparing outcomes between different counsellors and psychotherapists (rather than different schools of psychotherapy), then one does routinely find significant variations in effectiveness.
Not only does a clear look at the lack of improvement in the helpfulness of psychotherapies and pharmoco – therapies show a depressing lack of progress, similarly adding psychotherapy and pharmacotherapy certainly does not produce a one plus one equals two outcome benefit. Sometimes there is some increase in helpfulness if one combines these two approaches to relieving psychological suffering, but it’s typically only a slight improvement in outcome.
And this is where it looks like psychedelics can provide something very different from previous attempts at combining treatments to improve psychotherapy outcomes. For example, the pooled results from six phase two trials of MDMA-assisted psychotherapy for treatmentresistant post-traumatic stress disorder of average 18 years duration showed very large effect sizes of 1.4 after two MDMA sessions and 1.9 after three (Mithoefer et al, 2019). Dropout rates were less than half the level usually reported for PTSD treatments. In some ways even more remarkable was the difference in effect size of 0.8 between the genuine MDMA-assisted intervention and the very extensive psychotherapy provided for those in the active control group. The US Food and Drug Administration (FDA) has designated the treatment a ‘breakthrough therapy’ and we await with very considerable interest the outcomes of two phase three trials (the first of which reports this autumn).
Reiff and colleagues published a major review, Psychedelics and psychedelic-assisted psychotherapy in May’s edition of the American Journal of Psychiatry (Reiff et al, 2020). They stated: ‘The most significant database exists for MDMA and psilocybin, which have been designated by the U.S. Food and Drug Administration (FDA) as “breakthrough therapies” for posttraumatic stress disorder (PTSD) and treatment-resistant depression, respectively.’ They also wrote, randomized clinical trials support the efficacy of MDMA in the treatment of PTSD & psilocybin in the treatment of depression and cancerrelated anxiety’ and ‘research supporting use of LSD & ayahuasca in the treatment of psychiatric disorders is preliminary, although promising’. This is encouraging – and the review only looked at studies up to the beginning of July 2019, so plenty has been published since then. The clinicaltrials.gov website lists completed, active and recruiting studies around the world. When I looked recently, 49 studies mentioned using psilocybin, 28 LSD, 86 were using MDMA and many more ketamine and other substances.
Classes of psychedelic
Psychedelics as a term means ‘mind revealing’ and it was introduced by the British psychiatrist Humphrey Osmond in the 1950s. Grinspoon and Bakalar in their widely cited 1981 paper The psychedelic drug therapies (Grinspoon & Bakalar, 1981) state that a psychedelic is ‘A drug which, without causing physical addiction, craving, major physiological disturbances, delirium, disorientation, or amnesia, more or less reliably produces thought, mood, and perceptual changes otherwise rarely experienced except in dreams, contemplative and religious exaltation, flashes of vivid involuntary memory, and acute psychosis’. One useful way of categorising these compounds, described by the Maastricht researcher Kim Kuypers, is to put them into four groups – the classic psychedelics (psilocybin, LSD, DMT/ayahuasca and mescaline), entactogens/empathogens (for example MDMA, MDA, MMDA, 2C-series), dissociatives (ketamine, salvia
divinorum, PCP and NO2), and unique substances (for example THC/CBD, ibogaine, mad honey and various sponges). Research into the therapeutic potential of each of these psychedelic groups opens doorways into fascinating overlapping beneficial possibilities. So much is already understood about these compounds but much, much more waits to be discovered.
Risks and safety
At the start of this article I said that I would share some of my personal journey with psychedelics, go on to highlight how poor we have been historically at improving therapy outcomes, look at some of the very encouraging emerging outcome research and briefly outline the various classes of psychedelics. I will now say something about safety issues, comment on how psychedelics can increase wellbeing in addition to reducing suffering, say a bit more about personal experience, and close with a few where-fromhere suggestions.
What are the risks? David Nutt is a professor of neuropsychopharmacology and a widely respected voice of sanity in the debate on drugs – see, for example, his
helpful book Drugs without the hot air. He has written: Although a bad LSD trip can be extremely frightening and distressing, psychedelics overall are among the safest drugs we know of … It’s virtually impossible to die from an overdose of them; they cause no physical harm; and if anything they are anti-addictive.
So, the first point I want to make about the risks of classical psychedelics (eg DMT, LSD, mescaline and psilocybin) is that in terms of direct physical damage to
users, damage to non-users, and costs to society – these drugs are very safe compared with alcohol and tobacco. However, the second point I want to make is to contrast the care taken when using these substances in traditional sacred/healing rituals around the world – or when administering them in health professional settings – with the potentially considerably more risky practice of casual recreational use. Carbonaro and colleagues from John Hopkins ran a survey asking about psychedelic users’ ‘worst “bad trip”’ (Carbonaro et al, 2016). They reported 1,993 individuals completed an online survey about their single most psychologically difficult or challenging experience (worst “bad trip”) after consuming psilocybin mushrooms. Thirty-nine per cent rated it among the top five most challenging experiences of his/her lifetime. Eleven per cent put self or others at risk of physical harm; factors increasing the likelihood of risk included estimated dose, duration and difficulty of the experience, and absence of physical comfort and social support’.
Eleven per cent (during their worst “bad trip”) put self or others at risk of physical harm.’ This isn’t good. Why would anybody want to risk experiencing these kinds of reactions? Well actually the authors comment that, ‘A substantial majority of participants (84%) rated that they benefited from the challenging portions of their (worst bad trip) sessions. Almost half (46%) endorsed that they would want to repeat their chosen session and all that had happened in it, including the difficult or challenging portions of the session.’ Intriguing, and it is clear that these kinds of occasional difficulties are hardly even a pinprick when compared with the explosion of damage produced by, for example, alcohol which has been shown in recent major research to be the leading risk factor for death in 15–49-year-olds worldwide (Global Burden of Disease – GBD – 2016 Alcohol Collaborators, 2018).
It’s well worth noting too that besides improved outcomes – with little in the way of side-effects – from using psychedelics to relieve a variety of difficult-to-treat forms of suffering, there is also clear evidence of enhanced wellbeing when these substances are used by the ‘normal’, healthy general population. In his recent article Psychedelics and potential benefits in ‘healthy normals’: A review of the literature (Gandy, 2019) author Sam Gandy comments, ‘We are in the midst of a
psychedelic research renaissance. With research examining the efficacy of psychedelics as a treatment for a range of mental health indications still in its early stages, there is an increasing body of research to show that careful use of psychedelics can yield a variety of benefits in “healthy normals” and so lead to “the betterment of well people. Psychedelics have been found to modulate neuroplasticity, and usage in a supportive setting can result in enduring increases in traits such as well-being, life satisfaction, life meaning, mindfulness, and a variety of measures associated with prosocial behaviours and healthy psychological functioning. The effect of psychedelic experience on measures of personality trait openness and its potential implications is examined, and the potential role of awe as a mediator of the benefits of the psychedelic experience is discussed. Special attention is given to the capacity of psychedelics to increase measures of nature relatedness in an enduring sense, which is being correlated with a broad range of measures of psychological well-being as well as a key predictor of pro-environmental awareness and behaviour. The effects of particular classical psychedelic compounds on healthy people are discussed, with special attention given to the mystical-type experiences occasioned by high doses of psychedelics, which appear to be an important mediator of long-term benefits and psychotherapeutic gains.
My own experience
Having taken a dozen or so LSD trips in the 60s and early 70s, I was aware what psychedelic experience might involve. However, I had not tried the current standard approach which is to take a comparatively high dose and then go inwards – lying down, often with an eye mask, listening to a carefully curated musical playlist. Also nearly all my student experience had been with LSD, while now the research has mainly focused on psilocybin and MDMA.
In March of 2019, almost exactly 50 years since my first LSD trip, I travelled to the Netherlands to take two highdose psilocybin truffle ‘journeys’. In their paper Classic psychedelics: An integrative review of epidemiology, mystical experience, brain network function, and therapeutics (Johnson et al, 2019), the John Hopkins researchers discussed their ‘further analysis of psilocybin-occasioned mystical experience in 119 healthy volunteers by collapsing data …. On the MEQ30 completed on session days, 57% of participants met criteria for a “complete” mystical experience …. In retrospective follow-up ratings, most participants rated this session experience in the top five most personally meaningful (66%) or spiritually significant (68%) in their lives, with 70% rating moderate or greater positive behaviour change that they attributed to the session experience.’ And that was what I found too – the March trips were the most profound spiritual experiences of my life, until I returned in July and went even deeper. I have written more fully about these experiences – see under ‘Psychedelics’ in the ‘Good Knowledge’ section of the website goodmedicine.org.uk. Here is some of what I wrote about that first trip in 50 years: Surrendering to liquid night – Welcoming dissolution – A path of music – To love’s lessons – In a sky of being.
Into the mystic
Gosh … I’ve been skirting round writing this descriptionof-the-experience blog post. I scored identical, high 83% scores on the widely used mystical experience questionnaire (MEQ30) for each of the two psychedelic trips I took. One of the characteristics of these states is ‘ineffability’, which an online dictionary tells me means ‘incapable of being expressed or described in words; inexpressible: ineffable joy. not to be spoken because of its sacredness; unutterable: the ineffable name of the deity’. And this feels right … both that descriptions tend to crashingly fail to honour the power of these experiences and that also in some ways I feel uncomfortable talking about things that have such a deeply sacred quality. I’m not a religious person, in that I don’t belong to any formal faith. I don’t even believe in a God. However, I do see myself as deeply spiritual and I have extensive experience of many spiritual paths (so, for example, I have been meditating and practising yoga for nearly 50 years … and have taught both). Despite this and, earlier in my life, a whole series of meditation retreats and stays in ashrams and monasteries … the two internal ‘voyages’ I took last week felt the most profound spiritual experiences of my life. As I’ve said already, I use the words ‘most profound’ rather than ‘most important’ quite deliberately as how important’ the experiences are won’t become evident until I see how much they have affected my life in the weeks, months and years ahead. Despite my caution about trying to talk about what happened … not to say a bit about it would leave (what else I’ve written) feeling like an extensive description of the scientific study and practical care of say elephants without ever getting round to actually describing an elephant to you.
Integrating the psychedelic experience
In trying to ‘integrate’ what happened, I’ve been using a number of methods – see the goodmedicine.org.uk > good knowledge > psychedelics >lessons from current personal experience – suggestions blog post for more on integration, dose, guides, and so on. One integration ‘tool’ I’ve used has been to draw each of the trips. Despite not being an artist at all, these drawings illustrate key points pretty well. Here’s the drawing for the first trip (right). OK, I know this picture is kind of confusing, but it does illustrate the territory I explored. I’’d gone into the trip wanting to open more to love, wonder and gratitude … and I received this in great bouquets. If I was to try to do the experience justice, I would write for pages and this isn’t what I want to do here. I would, however, like to give some flavour of it … and it’s important, I feel, for the flavour’ to give a sense of the deep emotional colouring of trip experiences. Without this emotional colour, talking
about a trip is a bit like trying to tell you about the taste of wine by waving an empty glass bottle in front of you. To try to give this flavour, I’ll share something I found difficult and something that I’m deeply grateful for about each of the two trips.
So … a difficulty of the first trip. Mm …. this is only partly relevant to trip flavour, but it was the biggest difficulty I found myself facing. At least for our first two meetings, I didn’t feel particularly in tune with my two trip-sitters. This was hard … a bit like preparing for a space flight with the astronaut feeling that they weren’t really on the same page as their ground control team. We had exchanged emails and had a Skype call between Scotland and the Netherlands beforehand. I wasn’t particularly comfortable with how this had gone but decided to go ahead with the trip anyway. There’s a basic therapy principle that the therapeutic alliance is central to the effectiveness of therapy. I try to give my clients the session rating scale’ towards the end of each meeting (at least in our early sessions). This scores each of four aspects of the alliance – feeling understood/respected, agreement on goals, agreement on methods, and overall session – on 0–10 scales. For helpful therapy, one would hope for all four scale scores to be at least up at 8, and preferably at 9 or 10. I was nowhere near that. Ouch. My sense was that they saw my interest in more transpersonal issues like love, wonder and gratitude as avoidance of nitty-gritty psychological problems … and that I was an intellectual, caught in my head, who was in denial about my probable gut-level emotional difficulties. This was understandable … they didn’t know me. I voiced my concerns about this mismatch, but I didn’t feel we really connected well until after the first trip … not at all ideal.
And my feelings around this? Unease. A background sense that the deeper water of the trip itself might be safer than the shallows where I would potentially be more in dialogue with my guides. Knowing that I hadn’t visited this psychedelic space since student LSD experiences nearly 50 years earlier, I was concerned about my ‘rustiness’ … like facing a difficult mountain walk feeling I needed to be fairly self-reliant but I hadn’t been in the hills for a long time. A paradox here is that if I had been plagued by psychological difficulties, research strongly suggests that a deep ‘mystical experience’ would … far from being an avoidance of the problems … actually be one of the best predictors of good outcome (Russ et al, 2019).
A larger sense of self
And something I’m deeply grateful for? That I went ahead with the trip … swam and was carried by the current deep out into the ocean … explored, learned about love in ways that felt heart-meltingly helpful. Images and feelings imprinted in my body. I think the small-mind of our everyday ego is a great evolutionary development that helps us navigate and survive in this complex world. But like the tree of knowledge’s apple in the bible Genesis story, I think this ability to plan, remember, worry, regret, get lost in past and future … also in a sense throws us out of the garden of Eden. During the trip, the ego’s resting default mode network in the brain is disrupted. We can open into big-mind/big-self. This shift from what could be thought of as small-self to big-self could be terrifying … a kind of ego death … but it can also be deeply wonderful, at times dissolving into bliss, into infinite gratitude, into a kind of ecstasy. And the big-self wasn’t particularly interested in coming back into this world … it yearned much more to move up and away into some kind of no-self, to fully dissolve into the universe. Heart opened like a flower. A sense of love flowing through us like a great current … and our choice to surrender and open and channel this as best we can … or not. Huge. Extraordinary. Unforgettable. Like floating out in the depths of space surrounded by infinite stars. And coming back, like a humble pilgrim returning from a mountain peak. Quiet, blessed, reflective, at peace.
Where do we go from here?
In this article, I’ve said a bit about psychedelic classification and safety. I have highlighted that both psychotherapy and pharmacotherapy have got stuck in their attempts to relieve suffering more helpfully. There is growing evidence that psychedelics can respond to this need with improved outcomes – and this can be done cost-effectively (Marseille et al, 2020). In addition, psychedelics may strongly contribute to ‘the betterment of well people’, as partly illustrated in my own personal story.
So, where do we go from here? How do we – particularly those of us who are healthcare workers – want to respond to this growing wave of new research on the
potential value of psychedelics for people suffering with psychological difficulties? At minimum it seems of value to stay reasonably well informed about these developments. Extrapolating from US prevalence data, it’s likely that very approximately a million people in the UK take some form of (mostly illegal) psychedelic each year. Many of these experimenters will also have some psychological symptoms. Making sense of and integrating the psychedelic experiences into their lives can be of real importance. We as therapists can make ourselves available, ask about such events and offer help with integration when appropriate.
Also, as increasing numbers of people are realising it’s legal to travel to the Netherlands (or elsewhere abroad) and take psilocybin ‘truffles’ (compact masses of hardened fungal mycelium that also contain the psilocybin found in the illegal above-ground mushroom ‘fruiting bodies’) or other forms of psychedelic. Online websites like ‘tripsitters.org’ provide links to experienced ‘trip-sitters’ who can help with orientation, support and acute safety issues. However, for UK residents, early pre-session orientation and later post-session integration is likely to be better done by therapists in the UK who can provide a more ongoing framework. Additionally, a number of organisations, including our own Psychedelic Health Professionals Network offer regular guided retreats in the Netherlands and elsewhere. It’s such an interesting and hopeful time as encouraging research continues to emerge highlighting the value of these special substances.
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