The Coming Pivot in Psychedelic Medicine
Our society may soon switch from having too little access to psychedelics to having too much.
Last week in the newsletter, I talked about the various and sometimes-diverging capacities shared by meditation and psychedelics. Each modality, I observed, has the capacity to dramatically improve mental health, to perhaps contribute to a better society, and to occasion profound spiritual transformation. Sometimes these align, and sometimes they’re in tension with one another.
At the end of the piece last week, I noted that there’s at least one major difference between these two modes of contemplative practice: psychedelics can cause a lot more harm. That’s where I’d like to pick up this week.
1.
Because of the results of the election, I think psychedelics may be at an inflection point. Specifically, I think we may quickly pivot from too little access to psychedelics to too much.
Whether RFK Jr. is confirmed to lead the Department of Health and Human Services or not—I think, because of the close relationship between Big Pharma and the GOP, he will not be—there is obviously a strong appetite in the new administration for deregulation in general, deregulation of ‘alternative’ medicines in particular, and deregulation of psychedelics specifically.
To take one example, last June, Kennedy criticized an FDA advisory committee’s rejection of MDMA-Assisted Therapy as a treatment for PTSD. (The FDA followed the committee’s non-recommendation, and turned down the application in August.) Not only that, he blamed Big Pharma for the decision, saying on Twitter:
MDMA treatment for PTSD and other mental illnesses has a big drawback — a single treatment is effective. That means small profit potential compared to lifetime treatment with conventional pharmaceuticals. Maybe that’s why an FDA advisory committee shot it down. One of the committee members actually works for Johnson & Johnson.
When I’m President the FDA will serve the public, not industry. Then we can start getting to the root of this nation’s mental health crisis.
Even this radical claim may just be a deck chair on the Titanic. Will the FDA even exist in its current form a year from now? Will the collection of pseudoscience and anti-science that Elon Musk regularly promotes soon become government policy? I have no idea. But even a modest shift in policy could have seismic implications.
Moreover, if psychedelics are approved for one mental health condition, they will likely soon become available “off-label” for others. This happens all the time; one of the nation’s biggest-selling pharmaceuticals, Abilify, was initially only approved for schizophrenia, but was frequently dispensed for depression before eventually gaining approval for that condition as well. And unlike MDMA-AT, which, because of the therapeutic component, costs thousands of dollars per person, there are other psychedelic medications that are as simple as taking a pill, and in an accelerated process might be readily accessible within the year.
Meanwhile, if the Musk/RFK wing of the Trump regime prevails, there are good reasons to worry that the “move fast and break things” ethos the Telsa/SpaceX founder is known for may also seep through the governmental regulatory bodies—not to mention Musk’s penchant for bullying, which, as
just discussed, now includes singling out individual civil servants for termination, trolling, and harassment, with the obvious intention of getting them to simply quit. If Musk intimidates actual scientists into leaving, it's quite foreseeable that psychedelics, as well as many other medicines, will enter the market without any of the safeguards that every responsible scientist knows are essential.(As
pointed out in a fascinating recent piece, the pro-Trump psychedelic crowd is actually made up of two very different factions: back-to-nature nostalgists like Kennedy and transcend-nature futurists like Musk and Peter Thiel. For our purposes here, though, their alliance of convenience still holds.)
Fortunately, the psychedelic field—businesses, investors, nonprofits, philanthropists, activists, scientists, scholars, and practitioners—has, especially in the wake of the FDA decision on MDMA-AT, become much more interested in safety and ethics: monitoring adverse events, reducing harm, clarifying risks, and preventing abuse in psychedelic-assisted therapy (PAT) and other contexts.
Unfortunately, this effort is really just getting started. We barely even have standards for tracking adverse events, let alone preventing them, and some are quite serious: disorientation or dissociation that lasts for weeks or months, suicidal ideation, extreme suggestibility, and countless others (actually, 54 others, according to my Emory colleague Roman Palitsky’s recent work proposing standard methods of evaluating and measuring such events).
And whether the specific allegations against MAPS (still the leading psychedelic organization) were well-founded or not, there have, over the years, been at least some instances of abuse, some under-tracking of adverse events, and some degree of missionary zeal in play that led some people to sweep problems under the rug. I don’t think the rate of irresponsibility was any higher than in other fast-developing fields (certainly not as high as at Tesla) but the potential for harm is worse.
So is the field really prepared for widespread dissemination of psychedelics? I don’t think so. Not yet, anyway. Nor are governments prepared for the investments that will be necessary to protect the vulnerable and treat the affected. After decriminalization of psychoactive mushrooms in Oregon and Colorado, calls to poison control centers skyrocketed, and almost three quarters of those callers required medical attention.
Psychedelics aren’t like meditation; they can cause profound harm on the very first use, even at generally appropriate dosage levels. And unlike simple medications, the effects of psychedelics depend on (in the classic formulation) your mindset (including intentions, propensities to dissociation, trauma history, etc.) and and setting (which includes a safe physical space, a reliable trip-sitter or mental health professional, et cetera). A lot of people don’t know that, and couldn’t create conducive settings if they wanted to.
The field may need to pivot quickly, away from advocacy touting the benefits of these compounds and toward harm reduction and ensuring that they are being administered as safely as possible. If ‘move fast and break things’ replaces ‘first do no harm’, it’s not things that will break, but people.
2.
Nor is there unanimity in the field about the world we want to live in. Indeed, any utopian dreams one might have about psychedelics saving the world are not borne out by evidence.
The term ‘psychedelic’ literally means ‘mind-revealing’ (perhaps ‘mind-manifesting’) and that is what these compounds do. Go into a psychedelic journey with intentions of discovery, loving-kindness, and healing, and you’ve got a good chance of experiencing those things. Go in with the belief that because you made money at PayPal, you know a lot about ethics, human flourishing, and science — and you might just believe those things even more strongly.
The mutability of psychedelics is not some new discovery. In indigenous cultures, plant medicines were used not only for communing with benevolent entities in the spirit realm, but also for placing curses and summoning malevolent forces. Westerners may have a different cosmology today, but the events the cosmology is describing are at least analogous. Psychedelics may be used not just for healing, harmony, or transcendence, but also to further one’s own egoic pursuits, to grow into some trans-human superintelligence, to generate new ideas for technological innovation or self-enrichment, and, of course, to just get away from it all, ignore one’s issues and problems, and dissociate.
True, sometimes the medicine helps despite the patient’s desires. But sometimes it just gives into them, magnifying the ego with a supercharged intensity that will be familiar to any student of messianism.
So, no, you can’t just give your least favorite person some mushrooms and assume they’ll stop being bad. On the contrary, there are bad people who have used psychedelics to be even worse, like Charles Manson. And there are people who use and boost psychedelics today who are in it for the money or ego or power. And there are people, including some of the most powerful people in the country today, whose psychedelic use seems only to augment their own sense of importance, and who take commercial and political actions that increase the net suffering of the world, perhaps justifying their actions with some half-baked Ayn Randian “beyond good and evil” self-mythology that wouldn’t be out of place in Alfred Hitchcock’s Rope.
It is a very mixed bag.
There’s a great AI video that a friend-of-a-friend of mine made about Donald Trump drinking ayahuasca. It’s hilarious and you should watch it. It starts out fulfilling our fantasies about Trump: he sees within himself “demons, dark entities, everything I’d buried.” It’s also eerily accurate, from the New Age cliches that post-medicine Trump traffics in to his sweaters and facial expressions. And then, spoiler alert, it knowingly depicts how Trump remains a narcissist, only now in the spiritual milieu rather than the political one. “They say I’m the greatest shaman now,” Enlightened Trump says. “Nobody does it better. Maybe they’re right.”
Brilliant.
3.
So, am I a hater now? No. On the contrary, I think I’m a better believer.
First, as we should all know from failed love affairs and poor life decisions, we don’t see clearly when we’re still flushed with enthusiasm. The zeal of the converted is a dangerous thing: we can’t or don’t want to see the imperfections in the new cause, the new religion (see, e.g. J.D. Vance), the new person, the new miracle thing. Our happiness is bound up with it; we have found something wonderful and don’t want to be disappointed. We experience a kind of blindness.
Over time, this enthusiasm can harden into identity. At some point, we are no longer merely fascinated; now we define ourselves in terms of this relationship, community, ideology, or belief. Now it is almost impossible to dislodge; we refute all evidence that contradicts this fundamental organizing principle of our lives.
Disillusion is salvation from toxic certainty. We see that our idols have feet of clay and so we no longer worship them. Our self-worth is not at stake in the same way. We are no longer fundamentalists. Our sense of ourselves and the world no longer depend on certain propositions being true.
And then, if we choose, we might cultivate a more sophisticated relationship with the object of our love, belief, or sense of communal belonging — a second naivete, as Ricoeur describes. We appreciate it for what or who it is while not losing sight of its faults. Our faith is mature.
Disillusion is salvation from toxic certainty.
Personally, I’ve undergone this process in the contexts of Jewish spirituality, the Buddha Dharma, and in relationships, ideologies, and spiritual communities. I’ve been disillusioned many, many times, and I’m better for it. In the case of psychedelics, as it happens, I was never a true believer; I knew too many burnouts, assholes, addicts, and flakes to believe that these drugs always make people better. And yet, they can sometimes offer profound healing and transformation. This is reality. Both/And, I guess?
Having said all that, I do think psychedelics (and meditation) improve the odds of positive transformation. There are some principles intrinsic to the psychedelic experience — letting go, listening, seeing clearly, questioning certainties, and above all, encountering a pervasive sense of the numinous so profound as to shake loose the stuck habits of the mind — that, if they are integrated, tend to lead to a more heartful and awake way of life. Not all the time, to be sure. But, in my personal experience, in the experiences of my friends, and in reams of clinical data on treatment for mental health conditions, more often than not. There is more wisdom than folly, more Stings than Mansons. (Sting credits his decades of environmental activism to encounters with ayahuasca in the 1980s.)
And given the conundrum of the human condition, which has just recently unleased a calamity we are only beginning to experience, I’ll take those odds. If psychedelics make just 10% of experiencers 10% more compassionate, then the activism, the scientific study, the lobbying is all worthwhile. The psychedelic omelet still isn’t worth breaking the eggs of people’s personal safety. But our species desperately needs some way to rise above the base, tribal, greed/hatred/delusion instincts that currently drive our politics, some way to defeat all this denial and conspiracy theorizing and increasing meanness and vulgarity. And psychedelics are, still, one arrow in that quiver.
So, no, I am not a hater. I only wonder how this nascent and fast-morphing field will confront what may be its biggest challenge yet: not failure, but success.
Thanks again for reading. I’ve gotten some supportive feedback on these psychedelic pieces and I’m delighted to be sharing some of my last two years of work with you.
What am I reading? I’ll tell you what I’m not reading: election takes. Practically every pundit I know is busy confirming their priors: it was anti-wokeness, it was elite culture, the Dems went too far left, the Dems went too far right. No — it was the economy, stupid. Okay, enough of that. Here are some pieces I have liked lately:
First, on the above point,
says what I just said, but a lot funnier. If you know an I-Told-You-So centrist/liberal/conservative/anyone who’s making a close election into a gigantic rejection of things they already hated, send them this piece.did a great piece a few weeks ago looking at evolutionary biology, nationalism, multiculturalism on the fringes, and Star Wars. Check it out.
I mentioned Jules Evans’s fascinating analysis of pro-Trump psychedelic folks. It’s not just simple conspirituality anymore, for sure.
The one bit of bad news that I think is worth reading is
’s piece on Elon Musk’s bullying as a means of purging the government (and anywhere else) of people he doesn’t like. This is brownshirt stuff, people. I’ve experienced it a little in the last few weeks and it definitely sucks. I think it’s now one of the two or three things I’m most concerned about in the coming year.
See you later this week for a guided meditation on the obscure perception that Buddhists call “vedana.” How’s that for a cliffhanger.