A Turning Point for Psychedelics?
(originally published on Psych Congress Network Blog, Fall 2018)
Michael Pollan, author of The Omnivore’s Dilemma and The Botany of Desire, has turned his spotlight of curiosity onto the subject of psychedelics with his new book How to Change Your Mind. Suddenly, what was once a subject of obscure query [TA1] within a small circle of psychiatric researchers and a somewhat larger number in the psychedelic subculture, was being projected into living rooms with appearances on The Late Show with Stephen Colbert and out of car radios with interviews on Fresh Air. After a marathon week of reading, I have finished all 465 pages to offer this review.
No more than 3 days after the release of the book, a new patient asked me how to get treatment with psilocybin-assisted therapy for her lifelong depression. To her disappointment (and mine), I had to remind her that these drugs, as promising as they may be in current phase 2 studies, remain Schedule I substances, subject to the strictest sanctions. It will be at least 3 to 5 years before enough phase 3 research has amassed for the US Food and Drug Administration to consider approval.
Which leads me to ask, is this too much, too soon?
The ease with which Pollan spoke of his own psychedelic experiences, which he sought out in researching the book, seemed to belie the difficulty with which they are obtained, currently requiring travel to a country where they are legal or working with underground therapists who guide these experiences at great legal risk to themselves.
While people with depression reading his book may be disappointed to hear that the mushroom-with-a-difficult-to-pronounce name—psilocybin—is not yet available from their psychiatrists, Pollan has done a great service by illuminating the important and groundbreaking work that has been going on quietly for nearly 2 decades (and for 30 years before that, prior to the interregnum of the 1971 Controlled Substance Act). Researching how to harness these “meaning making molecules,” as New York University (NYU) researcher Dr. Tony Bossis has called them, to catalyze psychotherapy has delivered some of the most compelling findings in a generation of psychiatry.
Psychiatry has been locked in a dualistic view of how to treat mental illness for too long. In the years when psychoanalysis was dominant and neurobiology was an undiscovered continent, psychiatry was brainless. As biological models of illness guided pharmacologic interventions in recent decades, an interest in consciousness was lost and we became a mindless science.
Psychotherapy and psychopharmacology are often delivered to the same patient by different providers who come to the problem with different priorities, perceptions, and treatment plans. Our training tends to be siloed and biased towards the brain or the mind, but rarely both. Psychedelic-assisted psychotherapy marries these two elements in a way that enhances both modalities and improves outcomes. Therapeutic goals can be reached more quickly, and the handful of times that medications are used minimizes the exposure to the noxious side effects of long-term medication.
As Pollan notes, the need for a fresh approach was endorsed from the very top of our profession, with Dr. Tom Insel, former director of the National Institute of Mental Health, stating that our field is “broken,” and Dr. Paul Summergrad, former president of the American Psychiatric Association, writing a supportive editorial to accompany the publication of recent trials of psilocybin-assisted therapy carried out at Johns Hopkins and NYU.
Pollan’s book has significant shortcomings, which is unfortunate for a history that will undoubtedly be widely read. He overlooks the contributions of many women in the history of psychedelics and contemporary research. During a time of increasing awareness of how women and people of color are left out of the narrative, this omission was deeply disappointing. Additionally, he gives short shrift to the indigenous cultures that discovered the ceremonial and therapeutic benefits of psychedelic compounds for hundreds, if not thousands, of years before their discovery in the Western world. When he does mention indigenous ritual in the delivery of psychedelics, it is written with, at best, an awkward tone, if not a mocking one. The issue of cultural appropriation is hardly breached.
Probably the most glaring omission from the book is a scant discussion of MDMA- assisted therapy for post-traumatic stress disorder (PTSD), choosing to focus almost entirely on the “classic” 5HT2A-agonist psychedelics: psilocybin, LSD, 5MeO-DMT, and ayahuasca. While no book on such a large subject can ever hope to be comprehensive, this omission leaves out not only an entire area of related research, but also the need for developing more effective treatments for PTSD. I would have been interested in reading less about Timothy Leary’s apocryphal antics in favor of hearing more from social worker and therapist Mary Cosimano, who by Pollans’ own report has probably led more psilocybin sessions at the Johns Hopkins lab than anyone else, or more about Dr. Katherine MacLean’s findings that psilocybin experiences can increase the personality trait of openness, which is typically well cemented in place by adulthood.
Pollan has attempted and mostly succeeded at a difficult task, that is to wrestle with the inevitable ineffability of a psychedelic experience that highlights the profundity of the experience and its ability to catalyze positive change. The cynic may quote the Tao Te Ching when it says“Those who know do not talk. Those who talk do not know,” but by risking his own credibility by speaking publicly about his experiences with psychedelics, he brings a seriousness and legitimacy to the conversation that was eclipsed by the moral panic of the 1960s’ misadventures with these compounds. By bringing a complex, nuanced, adult conversation into American living rooms, perhaps at last, we can let the 1960s fade into the rearview mirror and begin to fully appreciate the potential of this novel therapeutic modality.