Selling psychedelics - to government, policy makers and a sceptical public

One of the big things on many people's horizon as 'the next big thing' in mental health is the use of psychedelics. Although the label 'psychedelic' has largely replaced the old word  'hallucinogen' (for reasons of technical inaccuracy), its literal meaning - as 'mind revealing' - is also true for Ketamine and MDMA, which are also known as a 'dissociative anaesthetic' and an 'empathogen', respectively - but they are not hallucinogens. Therefore I use 'psychedelic' to cover them all. 

To reduce it to the usual diagnostic straitjackets I will simplify the reasons for which they are thought to be therapeutic. The list that follows is in order of current and likely future legalisation. 

 

K-hole

Ketamine for 'TRD' (Treatment Resistant Depression') - a controlled drug already prescribable off-label by anesthetists and maybe others, and prescribable on-label as the absurdly expensive separated S-enantiomer called 'esketamine' and marketed as a nasal spray (Spravato). Only a handful of UK clinics exist, charging about £5000 or more per treatment, including preparation and integration psychotherapy sessions before and after the medicine dosing. There is a much wider range of formats in USA and overseas - from wholly biomedical IV infusions, through IM, sublingual lozenges and oral sustained release resin-pearls (which have imperceptible psychological effects).

Smiley

MDMA for PTSD - with excellent studies and high quality evidence, particularly from the US East Coast. There are initiatives to develop new formats of therapy in at least Europe and USA (eg couples, families and groups) but it is only legal to do so as part of fully registered clinical trials. MDMA's professional therapeutic use is nearly always as a facilitator of psychotherapy. The onerous requirements for research trials entail a great deal of burdensome bureaucracy. It is therefore likely that much informal / underground / illegal therapeutic work is already taking place. Smart money is on UK approval for medical use within about 2 years - although details of how this will work are unknown.

Magic

Psilocybin for Depression, 'End of Life Anxiety' and addictions. Psilocybin is the most 'natural' of these three, being likely to have been used for several thousand years in religious and ceremonial settings. However, the formulation used for clinical trials must be synthesised de nove in the laboratory and adds vast costs to the administrative, clinical and practical hurdles of running rigorous research trials. Despite these difficulties, some very good randomised trials have been run - with impressive outcome results. However, they have had their credibility questioned by pedantic academic requirements concerning the choice of 'primary outcome measure'. Nonetheless, psilocybin holds out much promise for being an effective medicine of the future (and long-distant past, probably). Licensing for medical use is probably at least 3 years away in the UK.

Others currently in the frame include DMT or 5-MeO-DMT for very short and intense psychedelic experiences (much more convenient for administering in clinical settings) - for similar indications to psilocybin. Ibogaine is a more hazardous substance, with another long history of ceremonial use, with early research indications of likely effectiveness for addictions. Ayahuasca is a herbal concoction with probably as long a history of cultural use as any of the other natural psychedelics, particularly in South America: it is unlikely to gain clinical recognition in the west as it requires variably potent natural ingredients and shamanic expertise in brewing it. LSD is - at least in modern western circles - the granddaddy of them all, and is a powerful and very safe psychedelic. It was intensively and extensively researched in the 1950s and before 'the War on Drugs', but probably now carries too strong a taint or stigma from its widespread countercultural use in the 1960s. Of course, there are many others both natural (such as mescaline) and synthetic (a vast range of 'designer drugs' - particularly tryptamines and phenethylamines) - but they are much lower down the list of medicines likely to gain approval for clinical use.

 

BUT (1)...

Perhaps the true place of psychedelics is not in the treatment of what we call 'mental illness', but more in a well-being and preventative role perhaps in the context of a safe and benevolent community of users of mixed age and experience - to include the wisdom of elders and those with special experience. The danger of the field being taken over by medicalisation (including psychotherapy) is that far too much dominance will be given to the vary narrow view of effectiveness as researched by modern 'evidence-based medicine'; the numinous, ineffable, spiritual and mystical aspects (which are so often cited as transformative factors) could be lost in the world of highly-qualified and highly intelligent boffins.

 

BUT (2)...

Even more persuasive than the power of massed biomedical academics is that of venture capital. The language is of 'startups' and 'incubators', as well as 'return on investment' and 'leverage'. A long way indeed from human needs, relationships, emotions and distress - also from 5HT receptors and synapses, neuroplasticity, the default mode network and glutamate systems. The only driver behind this very powerful force of change is money, and a very great deal of it. I find that rather worrying

 

BUT (3)...

Many many people, myself included, are disillusioned and almost despairing about the state of the world, and how humankind appear to be destroying it. Hence the vigor of activist movements such as Occupy, Me Too, Black Lives Matter and Extinction Rebellion. Last week, I went to a 'Seeds' talk in Swindon with the title 'Science of Psychedelics', given by a speaker who clearly knew his stuff, and could communicate it vividly and passionately. But more influential than the facts he presented was his manner and milieu. The 200+ audience could have come straight from Swindon shopping centre once they had bought their Eventbrite tickets. When I arrived the setting looked much more like a rock concert than the sort of professional lecture I am used to - and had a long queue to the bar and a faint aroma of patchouli oil. The speaker - with very respectable academic credentials - looked for all the world like a bass guitarist without his bass guitar - strutting up and down the stage with the sort of cool and sex appeal that no clinicians that I know could do or would dare to attempt! 

Where's your bass guitar?

Just a few quick reactions: 

• it is great that science and new information are being publicly disseminated so effectively
• this is picking up on a much wider disagio diffuso - like the better known activist movements that want to change the world
• it takes too long to change public opinions and demands by professional medical research
• it feels sad that it is all becoming so commercialised and managed by PR experts.
• there isn't a single mastermind behind all these mechanisms for publicising psychedelics, and selling the potential importance of them, but many very committed, determined and intelligent individuals who are often working together.
• Are they missing something? (I have a feeling they are, but I don't know what it is!)

Taking a step back: looking with a third eye

Just three months ago...

Time to get back in the saddle after being grounded by covid for over two and a half years: where better than to than Zafferana Etnea in Sicily for the latest Italian LLE (Living-Learning Experience)?

Having forgotten most of what one has to do to travel on an aeroplane, never mind the extras since the pandemic, I was rather worried that I wouldn't be allowed on board because I had forgotten something. That is as well as feeling quite guilty about going back to having a hefty carbon footprint - the climate crisis seems quite a lot worse than it did when I was flying before 2020. Nevertheless, Heathrow was easier than I ever remember - then I got three seats to myself to Rome and onto Catania - and Fiumicino had clearly had a make-over, though the walk from the London plane to the Sicily one was as long as ever, but past some very flashy shops of (or to be precise, through the middle of them). Al Italia no longer exists with its friendly green and red stripes, and the ITA Air planes were glittery metallic blue. Passport control dead easy both ways - through the e-gates. My phone even worked contactless for a beer while I was waiting to be picked up - I was expecting more Brexit trouble than that!

The Mediterranean in front

Three of us were driven from the B&B the next morning, arriving almost but not quite late at the venue. Which was a modern three-storey building with about four bunk beds in every upstairs room and many Catholic icons, crucifixes and pictures - and an altar in the community meeting room (which we tucked out of sight behind some screens). However, the view was spectacular - Etna peeking through its very own clouds behind, and seeing all along the coast to the Italian mainland at the front. 

Etna behind

Working out what to do with the rooms was a bit of a problem, as the bunk beds were not moveable. So after discussing and agreeing several different solutions and changing our minds several times, with everybody disagreeing but not quite saying so, it took about half an hour to sort it out in the Italian way - just get on with it and move the furniture where we needed to. It meant that two of the three small groups were in different parts of the garden and the staff group happened in a top floor corridor. The garden groups were a new departure, which some of us found a bit worrying; and the staff room ended up being rather crowded when we were all in it.

The participants came from all over Italy - only one from Sicily, and groups of others from Rome, Tuscany, Sardinia, Venezia and Piedmont. The staff team was also bigger than usual - Veronica and myself from UK as supervisors (or so we thought when we arrived), David an LLE staff trainee from Florence; Amelia, Rosanna and Giuseppe as three local group therapists to conduct the small groups; Carmelo the administrator, and Simone the organiser. We started with a little friendly rivalry between us all about the number of LLEs we had attended. As I have been there since the very beginning, I have clocked up over fifty and Veronica about half that. Simone claims 14, and the small group conductors all single figures. David was quite early in the process, and this was his third, or possibly fourth. Cue much talk about parents, grandparents and transmission down the generations.

The fun really began when we talked through the amended timetable and started working out our roles. Simone was going to be the supervisor of the group therapists, and they would meet alone for most of the staff meetings. Veronica, David and I were 'the research group', and we would meet once each day by ourselves and once each day with the other staff. This soon made us feel a bit unwelcome in the staff room, though we soon got over it. Our task, loosely defined, was to observe and reflect on the overall group processes. It also meant that we didn't get involved in the discussions after all the groups, so only had a vague idea of what was going on for other people, except what we saw in the community meetings and in the social time together. 

Two other noticeable differences from most previous LLEs were the length of the community meetings, and the separation of 'free time' and 'community time' on the second afternoon. The community meetings were seriously longer than I have ever done before - two for 60 minutes, and four for 90 minutes. It is hard to know what difference this made to the process and to the experience for participants, except it made the 'downtime' between groups less - 15 minutes instead of 30, usually. We weren't in a position to observe how the separation of  'free' and 'community' time worked, as we were in our research group at the time - but it is a good thing for the staff team to think about in future.

Our first meeting of the research group was all over the place, to say the least: how Italians might see authority - never ending groups - generational transmission of pearls of wisdom - rivalry - Italian regions - South American countries - cultural adaptations for LLEs - therapists being provocative - boundaries (surprise, surprise!) - democracy which 'might be an illusion' - happy cohesive staff groups - how we might be helpful to the rest of the staff team -  and 'what's the research question anyway?' 

Subsequent meetings were often more personal, but also widely systemic. This included thinking about the Mafia and global organised crime - climate change - covid - language - aplologising - gratitude - warmth - trust - containment - unexplainable medical events - illness - death -and, running like a golden thread through everything we covered, relationships. Relationships between each other, between members of the community, between different groups, between staff and non-staff members, between staff members themselves, and between all of the above and the world outside. As often happens in good groups, I was left with a sense of the numinous: impossible to precisely describe or pin down in words, and only present in the space between us.

Practically, this research group was rather more satisfying and relaxed than supervising in the normal staff meetings: less rushed, more spontaneous and open to any subject any of the three of us wanted to raise. Although we allocated ourselves an hour for each of the research meetings, we usually over-ran, sometimes until the other small groups ended. We were our own small group, and quite proud of it! Our combined meetings with the staff group were quite like the usual after-groups from previous LLEs - but mainly focussed on the group processes in the community, and not individuals. There was no space, opportunity or indeed willingness to bring any details of our own discussions in the research group to the wider staff team. Similarly to how small group members often value their small group experience very highly, we treasured ours and felt the whole staff plus research group had a very different atmosphere (and task). We did do the 'one word feelings check' at the end of each of the staff meetings, led by Simone.

For me, I felt rather isolated and somewhat lonely as the only person there who did not speak Italian. Although it was absolutely clear that everyone was friendly and welcoming, I could never communicate freely. It was helped - a little bit - by the god Google, which does a very impressive job of translating live speech on one's phone; and rather more by a small number of community members who spoke good English and sat next to me in community meetings to convey at least the essence of what was going on. Many thanks to them. And even without the full comprehension of what was being said, I certainly heard, thought and felt that there was some therapeutic magic going on close to me - perhaps in the way we were with other, and how that changed over the three days.

Unfortunately, I made a mistake for the second evening's 'community time' - partly due to this feeling of isolation. After a few nice conversations with various people over dinner and afterwards, I felt it was time for retiring: my usual routine of reading then bed. So I went upstairs to the second floor bedroom zone (next to the 'staff group space' in the corridor), for the night. I learned the next day that I had just missed participating in the lively, funny, silly Italian song session that for which everybody else sat out on the veranda. The staff started to be seen as humans, and the 'us and them' quality of the relationships was well-dismantled. And I had been grumbling to the research team how there didn't seem to be much space for playfulness or fun in this community! How wrong I was, and how sorry to miss it. Maybe I should just put it down to my age.

For reasons of confidentiality, I am not going to mention any personal details of what happened in the community meetings, but I do want to convey something of the positive, but realistic, tone of the closing community meeting. One lovely analogy somebody made was to the clouds - how sun and warm blue sky can quickly change to dark clouds and torrential rain. How it can suddenly get cold, and then have us back in sunshine a in few minutes (or hours, or days). I always like weather analogies, because of their link to chaos and complexity theory - and how relevant that is in human emotional development. There was also discussion of the limits to what is possible in the LLE format, which was something of a recurring theme (and often comes up in LLEs - often in the form of 'it's amazing how far we have come in three days' or 'I wonder how to continue this afterwards'). In the final moments we had a go-round for check-out, and we did it as 'what ingredient would you be if the community was a cake we were making together?'. Another favourite for me, as I often think and talk of groups as a pudding to which we all add our own unique flavours or ingredients.

So it feels like the research group was worthwhile - and a good addition to the 'super-supervisory' arrangements for the international LLEs, though some tweaks are probably needed. The longer groups and shorter breaks certainly need to be thought about, and a few typos or timing errors on the agenda and timetable need to be corrected: but these are minor and separate matters. The research group could interestingly include academic or clinical or lived experience 'outsiders', as well as the grandparents, senior old fossils and therapists training to be LLE staff members (as we had in Etna). 

But as always, thank you so much to everybody involved for making such a rich, fascinating and emotional experience!