Psychedelic Polemic 1

“We rationalise, we dissimilate, we pretend: we pretend that modern medicine is a rational science, all facts, no nonsense, and just what it seems. But we have only to tap its glossy veneer for it to split wide open, and to reveal to us its roots and foundations, its old dark heart of metaphysics, mysticism, magic and myth. Medicine is the oldest of the arts, and the oldest of the sciences: would one not expect it to spring from the deepest knowledge and feelings we have.”

                                         Oliver Sachs, Awakenings

The recent decision by the professional and academic advisers to the American Food and Drug Administration which basically panned the MAPS trials supporting the use of MDMA assisted psychotherapy for the treatment of PTSD, came as no surprise to me. I’ve been saying for a long time that trying to fit psychedelics into psychiatry and psychology, is the same as pushing a square plug into a round hole. No matter how hard you try it just won’t fit.

That’s not to say that the FDA won’t ultimately allow this treatment as the TGA has done in Australia, but there are a lot of researchers out there who are not happy with the available evidence supporting this treatment in both Australia and the US.

Their well-known gripe involves the problem of blinding with psychedelics and MDMA. You can’t blind psychedelic drugs because their effects are so potent. That means that this so-called gold standard of contemporary drug research cannot be met in most cases of psychedelic research.

Those of us who have been doing this research for some time freely acknowledge that fact which always makes me wonder why some researchers persist in carrying out double blind psychedelic studies. But that’s another story.

The point is that just because you can’t effectively blind psychedelics, doesn’t mean they are not potentially helpful or effective in the treatment of certain psychiatric conditions.

What it does suggest is that it’s now time that the research community who see no alternatives to RCT’s, take some chill pills, step back a few paces and stop acting as if scientism is more important than science itself.

Gold standards, absolute certainty, no-room to move, are not what science is supposed to be all about. Science is about possibilities and probabilities, about hunches and imagination. That’s not to say that science should lower its standards and accept every crank or crazy theory or idea that comes along. But too much rigidity, too much certainty, should be the enemy of science, which as a product of the human mind would do better to follow the wisdom of its master, and accept, as its guide, the moral virtue of moderation. Or as Plato described it: “Moderation is the harmony between reason, spirit and desire.”

On the other hand there is no doubt that in the contemporary world of psychedelic studies spirit and desire are chomping at the bit, as was seen in last year’s TGA’s decision to legitimise psychedelic treatment in Australia.

On that point only time will tell whether the TGA’s decision will have beneficial or unfortunate consequences.

This decision was made not because of reason or scientific evidence, but rather because of the influence of a powerful lobby group with second-to-none public relations expertise and plenty of cash. Or in other words spirit and desire. (Interestingly the same scenario is now in progress in the US where several PR companies have apparently been hired to influence the upcoming FDA decision referred to above).

But getting back to moderation and sensible psychedelic research, where reason, spirit and desire are largely in agreement, let us consider the following.

Firstly no-one can deny that psychedelic drugs can have a profound effect on consciousness. Every function in the mind under the influence of a psychedelic is potentially heightened or deepened, as the case may be. Cognition, affect, perception, judgement, insight, orientation and memory can all be profoundly disrupted or altered by these powerful substances.

Secondly these drugs are psycho-pharmacological chameleons (PPC). They in themselves carry no message, or story, or commandments from the gods, but rather help accentuate or embellish the stories or narratives we humans provide, along with the drugs. In other words, they act like psychological catalysts – they precipitate changes in consciousness (potentially both positive and negative) which are ultimately determined or orchestrated by the narrative provided.

For example, the term psychedelic assisted psychotherapy implies that the narrative is all about healing or psychiatric or psychological treatment.

Indigenous use of these substances has always been interwoven with powerful shamanistic belief systems and stories, rituals and symbols.

Timothy Leary, the counterculture guru who actively promoted the use of psychedelics to bring about cultural change, used the slogan “Turn on, tune in, drop out”. That narrative ostensibly resulted in so much social disruption, that the enraged Richard Nixon purportedly banned any further scientific research into the stuff.

Charles Manson, the notorious cult leader and sadistic murderer told an evil story to his followers who under the influence of psychedelics, committed heinous crimes.

In other words, the narrative is always a key factor in psychedelic outcomes. And that is why we must never forget the old psychedelic mantra of set and setting.

You simply should not take the psychedelic out of its set and setting. And the best evidence for this is giving some innocent, psychedelically naïve person a strong dose of a psychedelic in a whitewashed room without telling them or preparing them, and then leaving them there to their own devices. Watch what happens to them over the next several hours. They have no narrative, no set or setting, just a pumped-up brain with no-where to go. No point of reference, no soothing journey with signposts along the way.

So thankyou Timothy Leary. Despite your current status as a psychedelic pariah, you were the one who popularised this essential concept which even now is overlooked by the RCT adherents.

To sum up, however the psychedelic is administered, whether it be sacramental, therapeutic, hedonistic, or manipulative, the expectations of the subject, as derived from the set and setting, will always have a significant effect on outcomes on the basis that the psychedelic is a psycho-pharmacological chameleon.

Of course, what we are describing here is the placebo effect or meaning response, as it is also known. In medicine placebo responses depend on the meanings that people attribute to diseases and cures, and these vary from culture to culture.

One of my favourite quotes comes from the much-maligned anti-psychiatrist Thomas Szasz which sums up my point very well:

“Formerly when religion was strong and science weak, men

mistook magic for medicine; now, when science is strong

and religion weak, men mistake medicine for magic”.

As an experienced clinician I urge all doctors, healers, therapists and treaters to fully exploit the placebo. Give me one good reason why one should not?

The placebo explains why a good relationship, not the theoretical technique, is what makes psychotherapy effective. Placebo is why medication rarely comes in black capsules. Placebo is why the vitamin industry is so successful. And so on.

Researchers on the other hand, in their reductive approach to medicine, want to get rid of placebo effects, so they can judge the effectiveness of the physical treatment they are investigating. Hence RCT’S.

But psychedelic assisted psychotherapy is not a physical treatment. It is a psychological treatment where the placebo, the set and setting, is an integral component of the whole box and dice.

It is this gap between what researchers want to determine, and what treaters hope to achieve, which so irritates conservative researchers and leads to accusations that MAPS is a cult, and that in the MAPS trials expectations were so high that outcomes were distorted by these expectations.

Yes, Rick Doblin has become a sort of psychedelic guru and champion. Yes, MAPS has at times exhibited the trappings of a cult. And certainly, there were some problems with the way it conducted its trials. But overall, one can only congratulate Doblin and his crew for their amazing persistence, tenacity and genuine desire to make a difference. I have no doubt that whatever the FDA decides next month, MDMA assisted psychotherapy will eventually help a lot of people if provided ethically, judiciously and inexpensively. The results of the MAPS trials, when all factors are considered were profoundly positive, and that cannot be denied.