Abstract
The fields of psychology and psychopharmacology have developed along surprisingly divergent historical trajectories, given their shared clinical endpoint. The subsequent schism between drug and psychotherapeutic treatments is artificial, and exaggerated by continued ignorance on both sides of the debate. In fact, such distinctions are relatively contemporary. There exists a rich history of shared psychotherapeutic-drug assisted clinical practices in pre-history and non-Western cultures using the psychedelic (hallucinogenic) drugs. These practices were re-invented in the 1950s and 1960s in Western medicine and are now enjoying a renaissance in contemporary research. It is postulated in this article that further development of psychedelic drug-assisted psychotherapy offers a bright future for the fields of psychology and psychiatry alike.
Introduction
But we are here concerned with therapy only in so far as it works by psychological methods, and for the time being we have none other. The future may teach us how to exercise a direct influence, by means of particular chemical substances, upon the amounts of energy and their distribution in the apparatus of the mind. It may be that there are other still undreamt of possibilities of therapy. - Sigmund Freud (1938)
There exists in psychiatry a fundamental rift between our understanding of mental states (psychological processes) and brain states (organic or neurobiological processes). The Cartesian model (Descartes 1641) drives both professionals and the general public to erect an immovable barrier between the mental and the physical. Despite decades of research into the neurophysiology of the brain, modern psychiatry’s continued pursuit of the pharmacological quick fix maintains this dualistic schism.
This essay will postulate a resolution of these contrasting models through the use of discrete, targeted, drug-assisted psychotherapy using specific pharmaceutical agents (the psychedelic drugs) that directly enhance the psychotherapeutic experience. A brief history of these drugs, their usefulness, their limitations and the state of modern research with psychedelics will be discussed in this paper.
The trouble with pharmacology
Throw physic to the dogs; I'll none of it - William Shakespeare
Despite their limitations, many of the drugs available to today’s psychiatrist are effective at relieving some of the symptoms of mental disorder. This is well-documented by scientific studies and supported by regulatory bodies such as the National Institute for Clinical Evidence (NICE) that make evidence-based recommendations for doctors to use as part of their clinical practice (http://www.nice.org.uk/guidance/CG).
Nevertheless, the multiple factors (from genetics and the environment) that cause mental illnesses shape the vast range of treatment options available. Although drugs may have a role, they alone are insufficient to resolve problems. Combination therapies (psychotherapy alongside medication) are often the most effective. And there are always risks when prescribing medication. The incidence of iatrogenic illness increases year on year and is illustrated particularly in psychiatry (Degner 2004). Despite the efforts of the NICE, there are sceptical voices about the ethics of drug trials that are financed and run by the pharmaceutical industry - who clearly have a product to sell (Melander 2003).
Dissenting voices are growing within the medical profession (Healy 2003), with professional bodies becoming progressively more cynical about drug company influences. It is not only the financing of research that is concerning, but also the insidious induction of doctors’ confidences through the sponsorship of conferences, gift offerings and—of course—the endless supply of office stationary (HoC 2005).
It is clear that purely academic institutions, such as universities, could never compete with the budgets offered by drug companies. Objective research that potentially challenges the drug-treatments, therefore, does not get a fair chance at being developed. There are areas of medicine with important potential that are going un-researched. Examples include the ‘alternative therapies’, psychotherapy in general and, of course, psychedelic psychotherapy.
What is psychotherapy anyway?
There thus appears to be an inverse correlation between recovery and psychotherapy - the more psychotherapy, the smaller the recovery rate. - Hans Eysenck 1957
Like drugs, psychotherapy is effective at reducing symptoms and improving the quality of life for patients. And clinical trials—whilst less numerous than those that champion drugs—robustly demonstrate these effects (Janowsky 2000). Psychotherapy is therefore recommended, often in combination with drugs, by the NICE. In some cases psychotherapy has been shown to be more effective and better tolerated than drug treatments (Leff 2000).
The term ‘psychotherapy’ has come a long way since Freud’s conception of psychoanalysis. There is little provision for this kind of lengthy treatment in today’s NHS (Wilkinson 1986). And attempts have been made to shorten psychoanalytical psychotherapy into more clinically manageable packages - such as Psychodynamic Psychotherapy (Malan 1999). Driven partly by economics, the last 50 years has seen the development of increasingly brief and structured therapies. Some, e.g. Interpersonal Therapy (Klerman et al 1984) and Cognitive Analytic Therapy (Ryle 1990) bear some resemblance to their analytical roots. Whereas others, particularly in terms of structure and method, seem very far removed, e.g. Cognitive Behavioural Therapy (Beck 1975) and Dialectical Behavioural Therapy (Linehan 1999).
There are newer versions of psychotherapy appearing all the time. Their effectiveness is often dependent upon the skill and training of the therapist delivering the model and evaluating the different types can be difficult. Frequently no such differences can be observed (Sheffield et al 2006). It has also been postulated that the ‘psychological mindedness’ (Conte 1990), personality traits (Conte 1991) and intellectual level (Bender 1993) of the patient can have effects on the efficacy of the treatment.
Despite the proven efficacy of psychotherapy, doctors are still over-prescribing medication for many mental disorders because of the relative ease and cheapness of doing so (Pomerantz 2003).
From Schism to Stigma
The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. - Plato
Both Descartes, and more recently Ken Kesey, author of ‘One Flew Over the Cuckoo’s Nest’ (Kesey 1962), have a lot to answer for. Their works have had a lasting effect on how the public understand mental illness and psychiatry. The negative attitudes towards psychiatric patients and their doctors appear early in the medical training (Ken Hausman 2003). Many people see such patients as lazy and weak-willed-frequently having brought problems upon themselves (Trute et al 1999), and many see psychiatrists as eccentric and not quite ‘proper’ doctors (Walter 1989). Much work has been done in recent years both from within the profession and from external, user-lead pressure groups to tackle this problem (Byrne 1999). Central to stigmatisation is the schism between mind and body, and how we, ‘the well’, justify our own mental health through polarising ourselves against those we label as unwell.
What has psychiatry become?
We are at the point now in the evolution of psychiatry that general medicine reached over a hundred years ago. At the turn of the 20th century our skills as doctors in recognising and categorising the epidemiology of physical illnesses was finely tuned. But we still had no idea how to defeat the great killers - the infectious diseases. We thought these diseases could never be beaten, but in fact the invention of antibiotics was just around the corner.
Similarly in mental health today we have become experts at skilful diagnosis and identification of the problems our patients have. But how effective are we really at treating disabling conditions like anxiety and depression?
Flattered and seduced by the possibility of a chemical quick fix we pursue the idea of a simple solution. This is the ultimate act of repression; blaming our psychological experiences on our hapless biology. This situation is analogous to our attribution of obesity to our ‘metabolism’, ignoring our gluttonous lifestyles and looking for a pharmaceutical wonder drug—the illusive ‘slimming pill’—that will allow us to continue our greedy way of life.
It is only through demanding re-visitation of those memories that we can reprogram the psychological processes into their appropriate pigeonholes. There is no easy and non-toxic solution. It was the chronic, relentless experience of human relationships that gave us these neuroses - and only through careful examination and re-visiting of these memories with psychotherapy can we begin to untangle the mess. No, there are no wonder pills. And there are no stomach staples or frontal lobotomies either.
Partial resolution of this schism with drug-assisted psychotherapy
In relation to the division between biological and psychological models of mental illness and treatment, a necessary shift could perhaps come from combining the psychotherapeutic experience with an acute drug experience designed to enhance the psychotherapy. This differs, of course, from the current practice of using a course of drugs (such as SSRIs), taken daily over many months or years, to improve somatic and psychological factors—either alongside a course of psychotherapy or (as more often occurs), without any added psychological input.
Drug-assisted psychotherapy, as will be described here, involves the patient undergoing a short, time-limited course of psychotherapy, during which some of the sessions (perhaps as few as just two) are enhanced by the acute action of a drug that has specific properties conducive to improving the efficacy of the psychotherapy. There is a class of powerful psychoactive substances—the hallucinogenic, or psychedelic, drugs—that characteristically boost important factors present in the psychotherapeutic experience.
What are psychedelic drugs?
There are several ways in which to define these substances (Sessa 2006). Many psychiatrists may define them as psychotropic agents that produce profound alterations in consciousness, and may induce perceptual distortions as part of an organic psychosis. However, the psychedelic experience has significant differences from the psychotic episode. Firstly, in the psychedelic experience the perceptual distortions and the changes in thinking are extremely fleeting and dynamic - abnormal beliefs are rarely held with the rigid and unshakable quality of psychotic delusions. And secondly, crucially, in almost every case the informed user of a psychedelic drug has full insight into their experience as being secondary to intoxication with a drug.
Some different types of psychedelic drugs:
The ‘Classical’ psychedelics:
- LSD-25 (Lysergic Acid Diethylamide)
- Mescaline (3,4,5-trimethoxyphenylathylamine)
- Psilocybin (4-hydroxy-N,N-dimethyltryptamine)
- DMT (dimethyltryptamine)
The Entactogens or empathogens:
- MDMA - ‘Ecstasy’ (3,4-Methylenedioxymethamphetamine). There are many other drugs in this group - mostly based around the structure of phenethylamine
The Dissociative Anesthetics:
- Ketamine
- Phencyclidine
Some researchers may also class the psychological effects of cannabis (tetrahydrocannabinol) as psychedelic at high doses.
Characteristics of the Psychedelic Experience that may enhance the Psychotherapeutic Experience
The material emerging under LSD, far from being chaotic, reveals, on the contrary, a definite relationship to the psychological needs of the patient at the moment of his taking the drug. - Cutner 1959
Psychedelic drugs produce a variety of mental phenomena. The effects on perceptions are particularly well recognized. But perhaps the most interesting effects of the psychedelic experience are those that can facilitate psychotherapy. It is postulated these drugs can improve the depth and speed of psychotherapy, through making therapeutic use of regression, abreaction, transference and symbolic drama (Grinspoon and Bakalar 1986). And the newer drug MDMA is often credited with the ability to increase empathy and shared understanding between the patient and therapist (Sessa 2007).
Another feature of the experience is the presence of eidetic images, which are seen ‘in the mind’s eye’, with the eyes shut. They range from simple geometric shapes to complex figures involved in scenarios that have an intense personal meaning. These images often have an archetypal element and may represent relevant material from the patient’s unconscious (Masters and Houston 2000). In the therapeutic environment offered by a skilled psychedelic therapist, the meaning of the images can be interpreted and explored to reveal otherwise inaccessible parts of the psyche. If Freud called dreaming ‘the royal road to the unconscious’ then this internal visual element of the psychedelic experience is more like a Technicolor super-highway to the unconscious.
The nature and the quality of the hallucinatory experiences are identical with the dreams of some patients during the course of analysis (Sandison 2001). But like dream-work analysis in traditional psychotherapy, one must be cautious to not interpret all the content of such experiences in its entirety - the real value lies in using these images as a springboard with which to free-associate and access repressed parts of the unconscious.
This can be particularly helpful in the recall of painful memories that, unlike dreams, can then be worked through with the therapist in real, waking time. The patient under the influence of a psychedelic drug, accompanied by an experienced guide, may therefore revisit past traumatic experiences with great clarity. Many patients, who had previously been disabled by unremitting neuroses were able to benefit from this approach (Grof 2001a).
The therapeutic effects of a drug like LSD do not come entirely from the drug’s pharmacological properties. The drug acts as a catalyst that, in combination with extra-pharmacological factors, such as the patient’s pre-existing attitudes, personality and expectations (mindset), together with the structure of the environment in which the drug is taken (including the quality of the relationship between the user and their guide) - the setting - determines the quality and nature of the experience (Leary 1963a). This accounts for the extreme variability of the experience. But when taken in a clinical setting, the material revealed is of such personal relevance to the patient that if interpreted wisely, it can be of significant value.
What evidence do we have that psychotherapy and psychedelics can be combined?
- a) The ancient use of drug-assisted ‘psychotherapy’.
The historical human use of hallucinogenic plants and fungi is diverse and varied throughout the world. Some researchers even credit hallucinogens as the catalysts that fuelled the development of humans from non-sentient primates to spiritually aware beings (McKenna 1992). Today there are few cultures that have no historical use of such substances and many modern religions can trace their origins back to the influence of these drugs.
Some cultures in the developing world still perform psychotherapeutic ceremonies involving the use of these ‘sacred plants’. Examples include the Native American Indian use of the peyote cactus (containing mescaline), the Mexican Indian use of magic mushrooms (containing psilocybin), the Amazonian use of Ayahuasca (containing DMT), the West African use of the root Iboga (containing Ibogaine), and the use of cannabis for religious purposes in India, the West Indies and East Africa.
These cultures use the drugs in varied ways, but common to all of them is the concept of healing–for both physical and mental health issues–and is often called Shamanism. The drug is usually taken in a group, lead by a highly respected member of the community, the Shaman, who acts as both a doctor and a spiritual guide. Through the use of the drug and also incense, tobacco, chanting and dancing–all aimed at altering the level of consciousness–the guide helps the patient to explore, confront and overcome their personal issues.
For these fragile societies, these ceremonies are important traditions that have enormous cohesive purpose. They are not linked to an increase in recreational drug use - indeed, in some of these cultures (for example the Native American Indian use of peyote and the West Africa use of Iboga) this shamistic use of psychedelics is heralded as a major factor in reducing alcoholism, and empowering the community to resist other harmful, mono-cultural influences of the West.
- b) The rediscovery of drug-assisted psychotherapy
The Swiss chemist, Dr Albert Hofmann first discovered the psychoactive effect of LSD in the 1940s whilst working for the pharmaceutical company Sandoz (Hofmann 1977). LSD was disseminated to psychiatrists throughout the world in the 1950s. Initially thought to be useful as a psychotomimetic (for therapists to take themselves to help them understand the experience of psychosis) it was later used extensively to assist in psychotherapy.
Britain has a rich history of LSD-assisted psychotherapy from this time. Dr Ronald Sandison at Powick Hospital, Gloucestershire, pioneered the use of ‘psycholytic’ (mind-loosening) psychotherapy when he combined low doses of LSD with ongoing psychotherapy and found the drug to be useful in helping patients to progress who had previously become ‘stuck’ in the traditional psychoanalytical therapy (Sandison 1954). Between 1950 and 1965 LSD was used safely and with good success by psychiatrists throughout the world. Some 40,000 patients were treated with LSD and over 1,000 papers were written on the subject. Even though the drug was often being used on only the most resistant and chronic patients, the results were overwhelmingly beneficial (Grinspoon and Bakalar 1979).
Many case studies were examined with meta-analyses (Mascher 1967, Cohen 1960, Bhattacharya 1966, Malleson 1971). The number of adverse incidents was low and doctors were developing an increasingly sophisticated method for achieving the most comfortable and productive psychedelic sessions–which were often informed by Eastern tradition–with elements of meditation, chanted verses and a relaxing environment (Leary 1963b).
But psychedelics leaked from the scientific community to a wider audience. By 1966 LSD misuse had become a major social problem and its possession was made illegal. Despite the promising results of the preceding research, the scientific community was forced to distance itself from interest in the drug. Governments clamped down on research licenses and increasing reports of adverse drug reactions to psychedelics taken recreationally - as opposed to in controlled, scientific circumstances (which remained safe)--appeared in the publications. As a result, research use ceased while illicit use remained, fueled by a growing criminal distribution system.
Modern objections to psychedelic drugs
Concerns surrounding the phenomena of Drug Abuse
Since the rise, and subsequent collapse of psychedelic psychotherapy, the legacy of the dangers of illicit, non-medical abuse of these drugs has remained with us. Successive governments since the 1960s have adopted the strict War on Drugs policy - which includes demonising the psychedelic drugs alongside harmful and addictive drugs such as heroin and cocaine. It is noted, however, that unlike the psychedelics, both heroin and cocaine (in their various forms) have managed to retain their roles in medicine as essential parts of any hospital’s formulary. Nevertheless, psychedelics have disappeared from view - with even their place in psychiatric history erased from the curricula of medical student’s teachings (Sessa 2005).
Concerns Surrounding the Contentious History of Clinical LSD Research
There is no doubt that these drugs have a history littered with abuse and danger. And not only from the unsolicitered use by the poets and pop-stars of the 1960s - there was also misuse from within the medical profession. By the late 1950s many lay-therapists began offering expensive, private treatments. Some of these had little regard for the safety considerations involved in such therapy, and even began to mix research with recreational use, holding parties at their homes in which they shared LSD with their friends (Novak 1998).
The psychiatrist Sidney Cohen was initially a firm advocate of the new LSD research at the beginning of the 1950s, but as the decade wore on he could not ignore the improper use of the drug by some professionals. An editorial accompanying one of his articles criticised LSD investigators who ‘Administered the drug to themselves… became enamoured of the mystical hallucinatory state’ and were thus ‘disqualified as competent investigators’, whose research was corrupted ‘due to unjustified claims, indiscriminate and premature publicity and lack of proper professional controls’ (Grinker 1963).
The most famous clinician of the 1960s to abuse LSD was Timothy Leary, the Harvard psychologist whose research began legitimately with clinical experiments using psilocybin-assisted psychotherapy. Leary’s massive personal use of psychedelics was followed by unsolicitered distribution to Harvard undergraduate students, and he was expelled from the university. His subsequent rise into notoriety as a self-appointed leader of the growing drug culture in the United States is well documented (Greenfield 2006). For those genuine psychedelic therapists working at the time, Leary’s damaging public profile was extremely frustrating - and it certainly played a part in the subsequent severe restrictions on further medical research with psychedelics (Sandison 2005).
Concerns surrounding addiction and dependence
There is no evidence to suggest psychedelic drugs are addictive. Whilst tolerance develops quickly (after four days of continuous use, LSD becomes ineffective, even at high doses) no recognised physical withdrawal syndrome occurs. In animal models of drug abuse, reliable self-administration does not occur (Griffiths et al 1980, Fantegrossi et al 2004). In fact, because of the intense nature of the psychedelic drug experience, most recreational users have had only very few experiences with the hallucinogenic drugs, and their use tends to decrease or stop spontaneously over time (National Institute on Drug Abuse 2001). As recently demonstrated clinically, although the majority of users found the psychedelic experience to be intensely profound and valuable, very few had aspirations to repeat the experience again (Griffiths 2006).
Concerns surrounding the lack of robust clinical research
Despite the sheer number of patients treated with LSD, and the generally positive results obtained, the studies quoted from the 1950s and 60s hold little more than anecdotal value compared to the rigorous standards expected by modern research trials. They were subject to a selection bias, usually lacked control groups and had little or no long-term follow-up (Grob 1994). But then this goes for just about any psychiatric research that is now 50 years old… and some would argue is still true for psychotherapy today.
Concerns surrounding Toxicity
The ‘classical’ psychedelics such as LSD and psilocybin are remarkable safe. During the early stages of the intoxication there are mild and transient autonomic effects, but no severe physiological reactions have been demonstrated (from many thousands of monitored clinical trials) and no deaths solely from LSD have ever been recorded. The largest known overdose with LSD was 40mg (400x greater than the average clinical dose) and the subject survived (Grinspoon and Bakalar 1979).
There have been several recent physiological studies with psilocybin, in which subjects under the influence of the drug, and in follow-up, had repeated measurements of physical parameters such as heart rate, respiratory rate, blood pressure, blood hormone, electrolyte, liver function and glucose analysis. No significant differences from controls were observed and no subjects reported any adverse drug reactions (Passie 2002, Carter 2005).
However, the physiological toxicity concerns surrounding the drug MDMA are more significant (Sessa 2006b). Some users most likely have a genetic predisposition to the potential harmful physical and psychological effects of MDMA, which then interact with certain environmental factors (Soar 2006).
There are two major ways in which recreational ecstasy users (e.g. at a rave) can suffer acute toxicity: The first is through hyperthermia secondary to not consuming enough water. The sequalae include liver and kidney failure, cerebral oedema, rhabdomyolysis and disseminated intravascular coagulation (Nimmo 1993). High temperature has also been demonstrated to further exacerbate the risk of longer-term neurotoxicity (Malberg and Seiden 1998).
The second cause of acute toxicity is hyponatreamia. In vulnerable individuals with a genetic predisposition for the condition, MDMA can cause an impairment of the kidney’s normal water homeostasis mechanism via an increase in arginine vasopressin (ADH) that can lead to excess water retention (Wolff, K. et al 2006). When this is combined with excessive water consumption (as has sometimes occurred because users have been over-vigilant about the risks associated with dehydration) there can be associated decreased serum sodium, which in turn leads to nausea, weakness, fatigue, confusion, seizures and coma.
So in summary, when ecstasy is taken in uncontrolled circumstances, in extreme heat and with vigorous exercise, there may be problems associated with either drinking too much or too little water. Despite these very real physiological risk factors associated with recreational consumption of MDMA in a non-clinical setting, it is important to stress that these problems due to temperature and water consumption can easily be controlled in a clinical setting. This has been demonstrated by the Phase One trials for the contemporary MDMA psychotherapy studies. They did not record any significant changes in temperature and no associated abnormal water homeostasis reactions occurred - suggesting that severe toxicity reactions associated with uncontrolled recreational ecstasy use do not analogise accurately to proposed clinical applications with MDMA.
Objections to the theoretical value of psychedelic psychotherapy
A pill does not construct character, educate the emotions or improve intelligence… in fact, the LSD state was a completely uncritical one, with the great possibility that the insights are not valid at all and overwhelm certain credulous personalities. - Cohen 1968
Many psychotherapists oppose the proposition that the psychedelic experience can be of any use in psychotherapy. Notable in his rejection of the psychedelic drugs, was Carl Jung in a letter to Victor White (Jung, 1954):
The LSD-drug, mescaline: It has indeed very curious effects – vide Aldous Huxley! – of which I know far too little. I don't know either what its psychotherapeutic value with neurotic or psychotic patients is. I only know there is no point in wishing to know more of the collective unconscious than one gets through dreams and intuition. The more you know of it, the greater and heavier becomes your moral burden, because the unconscious contents transform themselves into your individual tasks and duties as soon as they become conscious. Do you want to increase loneliness and misunderstanding? Do you want to find more and more complications and increasing responsibilities?
Other commentators have been sceptical of the claims that the psychedelic experience is similar to the religious experience. The philosopher RC Zaehner (1972), who wrote extensively on religion and mysticism, was opposed from a Christian point of view to the idea that drugs could offer a ‘quick ticket to God’. He was also rejecting of the LSD-culture’s interest in describing the psychedelic experience as something akin to the Eastern religion’s appreciation of God - refuting the idea that it shared similarities with the Buddhist or Hindu state of enlightenment.
Since the 1960s, psychedelics have continued to be embraced by the New Age culture, where there remains a lot of unempirical crossover between science and mysticism. It remains difficult, therefore, for a clinician to find dispassionate, evidence-based information on the medical potential of psychedelic drugs, as the subject is so often littered with unhelpful references to individuals’ anecdotal hedonistic experiences. This undoubtedly scares off genuine interest from enquiring doctors.
Nevertheless, if the natures of these substances are to be explored and understood by doctors, then doctors must develop a meaningful language with which to describe these unusual mental states. Words like “Bliss”, “Enlightenment” and “Cosmic-oneness” have so far been very much the dispensation of the religions. They tend to make many scientists feel uncomfortable. But whether God can be found in a bottle or not (and certainly the Bwiti tribes of West Africa and the Mazatec Indians in Mexico believe it to be so), the psychedelic experience at least feels similar to a mystical or religious one - and this warrants closer examination by scientists interested in the psychological capabilities of our brains in their entirety.
A new renaissance in Psychedelic Research
After a hiatus of almost 40 years, there are now multiple new psychedelic drug research projects occurring. The ethical considerations associated with this kind of research are immense. These projects have taken decades of planning, and authorities are rightly cautious about enquiries involving drugs that have a history of abuse. However, medical research methods have changed a lot in the 50 years since these compounds were first used on patients. Modern day studies are subject to strict and rigorous ethical conditions that ensure patients are fully informed and consenting to these trials.
How best to re-introduce psychedelic therapy to sceptics
LSD does indeed have the ability to induce a state of panic in those people who have never taken the drug. - Timothy Leary
As far as discredited treatments go, the psychedelic drugs, particularly LSD, suffer with perhaps the greatest image problem of all past medical research. Indeed, perhaps LSD itself is beyond retrieval. Those very letters puts fear into the minds of physicians, politicians and parents alike. The future for these substances therefore requires some serious re-branding. The word psychedelic itself, coined by Dr Humphrey Osmond in communication with Aldous Huxley in the 1950s (Huxley 1956), might best be superseded by an alternative. Sandison’s (1957) suggestion of a better word, ‘psycholytic’, might not only be more acceptable to the public, but also be a more accurate description of the drug’s properties.
LSD may best be superseded by newer drugs such as MDMA or less publicised drugs such as psilocybin - both of which are shorter acting and more clinically manageable than LSD. Of course MDMA has a significantly different psychotropic effect to both LSD and psilocybin, being less classically ‘psychedelic’. Some would argue that this further makes MDMA more clinically useful (Grinspoon and Bakalar 1986).
In order for sceptics to embrace a fresh look at these drugs it is important to stress the risk-benefit argument. All medical treatments (especially those involving drugs) carry risks - but this must be balanced against potential benefits. If risks can be reduced to a minimum through careful, controlled applications in a facilitative environment, and benefits can be as great as offering a breakthrough for patients with previously unremitting mental illnesses, then this equation can be justified. After all, medicine is littered with examples of invasive treatments that are justified in terms of the outcome gains they give, e.g. chemotherapy for cancer treatments. And of course, there is no suggestion that psychedelic therapy is by any means as risky or noxious as chemotherapy. In fact, perhaps the greatest problem is that of the public perception and stigma associated with these drugs.
A way forward for this therapy is through encouraging the public to vote with their feet. The current environment of ‘user-driven practice’ favours patients who make choices. The drive for alternative treatments can motivate legislators to re-open access for research into the psychedelic compounds.
It is essential in developing psychedelic therapy to ensure any research proposals are rigidly scientific and avoid clichés. Only by adopting a clear, dispassionate and ‘non-Leary-esque’ stance can we best convince legislators of the possibility of re-visiting this research.
An important factor in the history of psychedelic-drug assisted psychotherapy, and of vital importance for selling this kind of research to people in the future, is that despite the tendency to concentrate on the drugs themselves, this subject is principally one of psychotherapy - and not psychopharmacology. All of the current projects underway involve just a few sessions with a drug, alongside non-drug psychotherapy, followed by the prospect that the patient can thereafter make real progress and then not have to continue on the daily, lengthy treatment with drugs such as the SSRIs. For this reason, it seems unlikely that the massive pharmaceutical companies—in their present form—are willing to show enthusiasm for such treatments. After all, why would they wish to sponsor research that offers a patient the chance to resolve their problems without the long-term use of drugs?
Conclusion
The many opinions about the relative usefulness or contrasting worthlessness of psychedelic drugs appear to be as numerous and varied as the effects of the drugs themselves. Examining only the negative points of view about psychedelic drugs, the politicians, physicians and journalists of the future are bound to be sceptical of these substances. But by exploring more widely and objectively they can make new conclusions based on a broader body of evidence.
The persisting split between mind and body, maintained by the continued insistence on the long-term pharmacological treatments, is selling both the patients and the psychiatric profession short. Now is the time, therefore, to examine new possibilities and novel treatments. But new researchers in this field must be careful to stay true to the concept of evidence-based medicine, keep in mind the risk-benefit argument and steer well clear of the quackery that invades this subject at all levels.
Psychiatry and psychotherapy have always been uncomfortable bed-partners. Perhaps through the development of targeted, safe, clean and efficient drug-assisted psychotherapy we will remember the 21st century as the point at which there was a true integration of these theoretical models.
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This article first appeared in the Psychedelic Press XV journal.
Sessa, Ben: Ben is one of the five co-founders of Breaking Convention, the UK’s only psychedelic conference, and the author of several novels and non-fiction books, including The Psychedelic Renaissance. He is a paediatric psychiatrist and is coordinating Britain’s first MDMA/PTSD study. He began publishing in medical journals on the subject of psychedelics as a trainee and since then has spoken nationally and internationally to doctors in a campaign to see these fascinating substances return to the mainstream pharmacopeia where their lives began. In 2008 he became a Research Associate under Prof. David Nutt at Bristol University, where he consulted for the ACMD on MDMA before working on the UK’s only human hallucinogen study in modern times – being the first person to be legally administered a classical psychedelic drug in this country for 33 years. He is the author of the novel To Fathom Hell or Soar Angelic.
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