بخش 101

EPILOGUE

In Praise of Neural Diversity

IN APRIL 2017, the international psychedelic community gathered in the Oakland Convention Center for Psychedelic Science, an every-few-years-or-so event organized by MAPS, the Multidisciplinary Association for Psychedelic Studies, the nonprofit established by Rick Doblin in 1986 with the improbable goal of returning psychedelics to scientific and cultural respectability. In 2016, Doblin himself seemed stunned at how far and fast things had come and how close to hand victory now seemed. Earlier in the year, the FDA had approved phase 3 trials of MDMA, and psilocybin was not far behind. If the results of these trials come anywhere near those of phase 2, the government will presumably have to reschedule the two drugs, and then doctors will be able to prescribe them. “We are not the counterculture,” Doblin told a reporter during the conference. “We are the culture.”

What had been as recently as 2010 a modest gathering of psychonauts and a handful of renegade researchers was now a six-day convention-cum-conference that had drawn more than three thousand people from all over the world to hear researchers from twenty-five countries present their findings. Not that there weren’t also plenty of psychonauts and legions of the psychedelically curious. Between the lectures and panels and plenaries, they browsed a sprawling marketplace offering psychedelic books, psychedelic artwork, and psychedelic music.

For me, the event turned out to be a kind of reunion, bringing together most of the characters in my story under one roof. I was able to catch up with virtually all the scientists I’d interviewed (though Robin Carhart-Harris, with a baby on the way, had to skip), as well as several of the underground guides with whom I’d worked.

Everyone, it seemed, was here, scientists rubbing shoulders with guides and shamans, veteran psychonauts, a large contingent of therapists eager to add psychedelics to their practice, plus funders and filmmakers and even a smattering of entrepreneurs sniffing out business opportunities. And although I picked up snippets of concern about the new attorney general’s efforts to rekindle the drug war, on the whole the mood was unmistakably celebratory.

When I asked conferencegoers which session they deemed most memorable, almost invariably they mentioned the plenary panel called “Future of Psychedelic Psychiatry.” What was most noteworthy about this panel was the identity of the panelists, which, at a psychedelic convention, was cause for cognitive dissonance. Here was Paul Summergrad, MD, the former head of the American Psychiatric Association, seated next to Tom Insel, MD, the former head of the National Institute of Mental Health. The panel was organized and moderated by George Goldsmith, an American entrepreneur and health industry consultant based in London. In the last several years, he and his wife, Ekaterina Malievskaia, a Russian-born physician, have devoted their considerable energy and resources to winning approval for psilocybin-assisted therapy in the European Union.

It was clear to everyone in the standing-room crowd exactly what the three men on the panel represented: the recognition of psychedelic therapy by the mental health establishment. Insel spoke of how poorly the record of mental health care stacks up against the achievements of the rest of medicine. He pointed out that it has failed to lower mortality from serious psychiatric disorders and spoke of the promise of new models of mental health treatment such as psychedelic therapy. “I’m really impressed by the approach here,” he told the group. “People don’t say, simply, we’re gonna give psychedelics. They talk about ‘psychedelic-assisted psychotherapy.’ . . . I think it’s a really novel approach.” Insel tempered his enthusiasm, however, by noting that such a novel paradigm may bedevil regulators accustomed to evaluating new drugs in isolation.

George Goldsmith asked both men what advice they would give to the researchers in the room, men and women who have been working diligently for years to bring psychedelic therapy to patients. Without hesitating, Insel turned to the audience and said, “Don’t screw it up!”

“There may be lots of promise here,” Insel said, “but it’s really easy to forget about issues related to safety, issues related to rigor, issues related to reputational risks.” He suggested that psychedelics would probably need to be rebranded in the public mind and that it would be essential to steer clear of anything that smacked of “recreational use.” He and Summergrad both warned that a single sloppy researcher, or a patient with a disastrous experience, could poison the well for everybody. Nobody needed to mention the name Timothy Leary.

• • • HOW CLOSE ARE WE to a world in which psychedelic therapy is sanctioned and routine, and what would such a world look like? Bob Jesse was in the audience when the former head of NIMH took his swipe against “recreational use,” and though I didn’t see it, I can picture his grimace. And what exactly is wrong with re-creating ourselves? Bob Jesse worries that the “medicalization” of psychedelics these men were advocating as the one true path would be a mistake.

Not that medicalization will be easy. Several steep regulatory hurdles will first need to be overcome. Phase 3 trials involve multiple sites and hundreds of volunteers; they can cost tens of millions of dollars. Normally Big Pharma foots the bill for such trials, but thus far the pharmaceutical companies have shown scant interest in psychedelics. For one thing, this class of drugs offers them little if any intellectual property: psilocybin is a product of nature, and the patent on LSD expired decades ago. For another, Big Pharma mostly invests in drugs for chronic conditions, the pills you have to take every day. Why would it invest in a pill patients might only need to take once in a lifetime?

Psychiatry faces a similar dilemma: it too is wedded to interminable therapies, whether that means the daily antidepressant or the weekly psychotherapy session. It is true that a psychedelic session lasts several hours and usually requires two therapists be present for the duration, but if the therapy works as it’s supposed to, there won’t be a lot of repeat business. It’s not at all clear what the business model might be. Yet.

Several of the researchers and therapists I’ve interviewed nevertheless look forward to a time, not far off, when psychedelic therapy is routine and widely available, in the form of a novel hybrid of pharmacology and psychotherapy. George Goldsmith envisions a network of psychedelic treatment centers, facilities in attractive natural settings where patients will go for their guided sessions. He has formed a company called Compass Pathways to build these centers in the belief they can offer a treatment for a range of mental illnesses sufficiently effective and economical that Europe’s national health services will reimburse for them. Goldsmith has so far raised three million pounds to fund and organize psilocybin trials (starting with treatment-resistant depression) at multiple sites in Europe. Already he is working with designers at IDEO, the international design firm, to redesign the entire experience of psychedelic therapy. Paul Summergrad and Tom Insel have both joined his advisory board.

Katherine MacLean, the former Hopkins researcher who wrote the landmark paper on openness, hopes someday to establish a “psychedelic hospice,” a retreat center somewhere out in nature where not only the dying but their loved ones can use psychedelics to help them let go—the patient and the loved ones both.

“If we limit psychedelics just to the patient,” she explains, “we’re sticking to the old medical model. But psychedelics are more radical than that. I get nervous when people say they should only be prescribed by a doctor. I imagine a broader application.”

In MacLean’s words it’s easy to hear echoes of the 1960s experience with psychedelics—the excitement about their potential to help not only the sick but everyone else too. This kind of thinking—or talking—makes some of her mainstream colleagues nervous. It’s exactly the kind of talk that Insel and Summergrad were warning the community against. Good luck with that.