Protecting people from the side effects of psychedelic therapy

The psychedelic market is big and getting bigger. One company, Compass Pathways, which plans to offer magic mushroom therapy, listed on the Nasdaq in November with a $1 billion valuation. New funds like Atai are raising hundreds of millions to invest. New companies are listing, new training programmes for therapists are launching, new states are preparing to legalize or decriminalize psychedelics.

It’s both an exhilarating and a slightly queasy time for long-term psychedelic practitioners, like a nervy, fast come-up. What if it all spins out of control?

Some of the early signs aren’t great — new actors are flooding into the market, looking to make a fast buck. Some of the investors are not the groovy liberals one might expect — two of the biggest are Rebecca Mercer of Breitbart and Peter Thiel, both prominent funders of Trump’s 2016 presidential campaign. Several of the new listings are re-purposed mining company listings (see this piece for all the links between psychedelic and mining companies). Some don’t seem to have any product at all, beyond a brand-name and a press release. Everything is being commodified — one company calls itself ‘Eleusis’, another ‘Alan Aldous’ (after Alan Watts and Aldous Huxley).

Then, to make matters worse, the Qanon shaman led an insurrectionist mob into the Capitol building, while loudly promoting psychedelic therapy. You could see the fear grip psychedelic practitioners: the freaks are emerging, it’s the Sixties all over again!

Things will go wrong. Companies will go bust, investors will lose money, therapists will misbehave, people will have difficult experiences, some people will commit suicide, and there will be a media and regulatory backlash, just as there was in the Sixties. We can expect this. And the field should prepare for it now.

Companies can prepare by investing in public affairs and public relations companies to plan for the backlash. But that’s not enough. The field should also prepare by investing a lot more in researching how psychedelic trips can cause psychological difficulties, and providing support for people when they do.

Hardly any investment in protecting people

How much is invested in this at the moment? Practically zero.

There is an assumption in the field: ‘Yes, in the Sixties there were acid casualties, but they weren’t as careful as we are. If the set and setting are good, people don’t have difficult experiences. Or if they do, the experiences are still ultimately life-enhancing.’

This is a false assumption. People can still have difficult experiences — experiences of emotional disturbance and / or quasi-psychotic disorientation lasting several days or weeks — in very ‘held’ settings.

I personally experienced a week of profound dissociation, in which I thought I was either dead or in a dream, following a 10-day retreat at one of the best ayahuasca centres in the world. The actual retreat was very well run, but I still got into difficulties in the days after the retreat, and the centre provided little in the way of support. Luckily my friends did, but it could have gone much worse.

I also have a friend who got into an extended manic state for a month or so, requiring hospitalization and anti-psychotics, following a university’s psychedelic trial. Anecdotally, I hear about other people who got into psychological difficulties following participation in clinical trials. Not loads, but some.

Difficult trips can happen to novices, but they can also happen to experienced trippers. Tim Read, a psychiatrist who consulted for Imperial’s psychedelics lab, and the co-editor with me of a book on spiritual emergencies, tells me:

There is a tendency for people to access the really difficult layers of psyche (where healing potential is greatest) after some initial openings. Even quite experienced psychonauts may open in a safe setting to the point where they access their deepest wounds — and this can be overwhelming. These deeper layers are difficult and can feel hopeless or impenetrable.

Psychological problems following difficult experiences can last a while. In a Johns Hopkins survey, of 1339 participants who reported a ‘bad trip’ a year or more in the past, 24% said they experienced psychological difficulties (depression, anxiety, paranoia) for a week or more after the bad trip, and 10% reported these symptoms lasted longer than a year.

How to help them? We don’t yet know

How can clinics or therapists best support people in the days, weeks, months and years after a difficult experience?

The answer is, we don’t yet know.

Matthew Johnson, one of the lead researchers at Johns Hopkins’ psychedelic research team, tells me:

I don’t think there is any research on this at all. I believe everything that is known really just falls into the category of clinical observation — basically what doctors have reported in case reports. A common thing is administration of anti-psychotics and/or benzos depending on symptoms. While I won’t say that is never called for, my impression is that these are way over used.

Tracy Cheung, chief communications officer at Compass Pathways, says:

We still don’t know enough about how [difficult] experiences are integrated; there is definitely a need for more research, in clinical trials and through the collection of data from real world evidence.

While there is a lack of research on how best to support people after difficult trips, there is a lot of real-world experience, particularly among therapists working on ‘psychedelic integration’. One of the most experienced integration therapists is Michelle Baker-Jones, who co-founded the Psychedelic Integration Circle in London. It meets once a month to help people process psychedelic experiences. Michelle tells me:

The current thinking is that difficult psychedelic experiences can generally be still useful unless happening in unsafe spaces where a re-traumatisation rather than healing of trauma occurs. In cases of spiritual emergency or ontological shock, again it is felt that with the right help, holding and acceptance of the experience these too can be beneficial. For the people that come to our integration groups…the group process really helps people to feel less stigmatised, alone and supported with these experiences.

Matthew Johnson agrees:

My impression is that for the vast majority of people…what is needed is deep processing of the experience, basically a lot of discussion with a good therapist who does not just pathologize the fact that they took a psychedelic or had a challenging experience (I think that can really make things much worse). A therapist who knows psychedelics is likely important, but most others will pathologize the entire thing. I think it should be handled the way that trauma is best treated, with methods such as prolonged exposure therapy, cognitive processing therapy, or similar, which are really just different ways to encourage the person to discuss the experience and their difficulties rather than trying to psychologically bury them.

Investing in the infrastructure of integration

Right now, the field does not have the support infrastructure in place to support the people who will inevitably have difficult experiences.

This is what I have found, so far. There is the TRIPP Network of therapists who are experienced in psychedelic integration work — this is 29 UK therapists, mainly in London and Brighton, who obviously have limited time and capacity to take on clients. MAPS lists 300 therapists who offer psychedelic integration on its websites. There are four UK psychedelic integration groups, all in London and Brighton. I found 15 or so other such groups in North America, via the website Psychedelic Support.

So there is zero clinical research on how to support people after difficult psychedelic experiences, and perhaps 20 psychedelic support groups in the UK and North America — and these are largely non-profit and run by volunteers. Compare that to the billions of dollars being poured into the upside of psychedelics — the miracle cure, the mystical experience, the ‘quantum healing’ you can expect over a weekend.

The field is investing entirely in the psychological upside of psychedelics, and barely investing a dollar in protecting people from potential negative effects.

Similar failures in other healing markets

One sees a similar dynamic in other wellness markets.

Take anti-depressants, a $30 billion global market. It’s been going since 1987, and now 17% of the British adult population takes anti-depressants regularly (other developed countries have similarly high usage rates). Yet it was only last year, 33 years after SSRIs were launched, that the Royal College of Psychiatrists admitted anti-depressants can often lead to long-term dependency and nasty withdrawal symptoms, and recommended patients be advised of this.

And how much support is there for people who want to come off long-term anti-depressant use? How much have governments, psychiatrists and pharmaceutical companies invested in it? Zero. There’s not even a support line yet. There is now a movement for big pharma companies to pay a levy to support people coming off anti-depressants. They may also face class action law suits if it’s shown they knew about the risks and intentionally downplayed them.

Or take the mindfulness market, now worth an estimated $2 billion in apps, training courses, academic research, corporate wellness programmes and so on. What percentage of the approximately 1000 mindfulness research papers a year explore the difficult or negative experiences people sometimes have to meditation? Less than 5%. What percentage of the $2 billion which the market makes from meditation does it invest into supporting and protecting people from the negative side-effects of meditation? Basically zero. There’s one person at Brown University trying to support the thousands of people who get into difficulties when they accidentally exit their habitual ego. Shouldn’t the people making fortunes from mindfulness invest some of that money into protecting people from the unfortunate occasional side effects?

The Greek word for medicine — pharmakos — is also the word for poison. Every medicine has unintended side effects. A responsible healing modality is aware of those side effects, doesn’t deny them, and actively seeks to mitigate them.

But that is not how the wellness world typically acts. Instead, healing or transformation programmes focus entirely on the incredible recovery stories, the Quantum Healing. You feel better? Tell your friends! Sign them up!

And if people get into psychological problems? Not our responsibility. You were probably messed up to begin with.

The psychedelic therapy market has a chance to be better than these other healing modalities. It has a chance to be more caring, empathetic and responsible. Honestly, if you’re offering any sort of medicine and you’re not aware of and prepared for the side effects, should you be offering that medicine at all?

Possible steps — invest at least 1% in integration

Investing in a proper infrastructure of integration could mean companies committing at least 1% of their capital to integration research and services, particularly for difficult experiences. If the market is worth roughly $5 billion, that means investing 1% — $50 million — in support for and protection against negative side effects.

There are already examples of this sort of responsible psychedelic investment. Tim Ferriss, for example, didn’t just invest in the upside, he also invested in Zendo, a psychedelic harm reduction collective, and volunteered to be a sitter at Burning Man. Cody Swift, one of the heirs to the UPS fortune, also invested in Zendo via his Riverstyx foundation.

You could use that $50 million for:

• Investing in more psychedelic integration circles.

• Supporting peer-to-peer training programmes to train laypeople how to run such circles (Zendo is launching such a programme this year).

• Retreat and therapy centres investing a lot more in integration training and provision, and honestly sharing their results with the field (Synthesis Institute hired Ros Watts as their clinical director to develop their year-long integration programme).

• Supporting psychedelic support lines and web services (the first of which is launching this year).

• Supporting research to gather, analyse and share people’s personal accounts of what difficult experiences were like, and what helped people integrate them (the book I co-edited with Tim Read, Breaking Open, is an early example of this sort of work — we did it without research funding.

• Supporting research into the variety and similarities of difficult experiences, and the best ways of supporting people to integrate them. (It’s great to see the first academic conference on this topic happening this month, again, without funding).

Finally, and this is the hardest part — we need a cultural shift in our attitude to the ecstatic. At the moment, psychedelic therapy offers westerners a doorway to ecstatic experiences, but within a culture that is almost completely ignorant of such experiences, and prone to either rejecting them, or fetishizing them. People are going through that doorway with their incredibly elaborate and well-defended western egos, and unsurprisingly for some people the journey through the door and back is hard.

Ros Watts, clinical lead at Imperial’s trial on psychedelics for depression, and co-founder of the Psychedelic Integration Group, told Rebel Wisdom:

The current protocols we have are very short term. People experience a huge opening, they see themselves differently, they feel more connected and thin-skinned, life affects them more. Then they go back into their old life and they don’t have support. And it can be really hard for them, really destabilizing. We’re learning that this way of working needs such a solid interpersonal container and strong network of support, and we don’t have that in place yet.

Michelle Baker-Jones agrees:

Ultimately it would be great if each city had a psychedelic integration group that could be attended, and funds were available to assist in this rather than being reliant on volunteers to provide a such a crucial service. These groups will become incredibly important if our hopes for psychedelic assisted therapy manifests not only for the help they provide in integration but for the potential they hold to create community and connection — perhaps one of the fundamental antidotes to the mental health crisis that we are currently experiencing.

We’re a long way from that quilt of support groups yet. At the moment, psychedelics offer a very modern sort of religion — long on ‘experience’, short on community. That risks exacerbating the loneliness and isolation that cause a lot of our suffering in the first place.