Backlash against the wider biomedical availability of psychedelic drugs is likely at some point. However, we may take steps that minimize causes of a potential backlash. One of these steps is to avoid overreaching. Any failure to maintain intellectual rigor and honesty in such a highly controversial field will not serve the research community well when media coverage turns negative for any reason. The worst thing we can hear is: “You were not honest in portraying benefit and risk.”
I see at least three phenomena related to the biomedicalization of psychedelic drugs where overreach could come back to haunt us.
1) Renaming psychedelic drug adverse effects as “challenging experiences”;
2) Non-clinicians advocating for policy changes with clinical implications—specifically attempts to re-schedule psychedelics;
3) Homogenizing widely disparate religious traditions by proposing that they all share a “common mystical core.”
In my last post, I presented arguments against the one-size-fits-all approach to spiritual experience, but did not explicitly address its potential to generate backlash. All religious traditions take serious umbrage to those outside their fold telling them what their tradition is really based on. They see such attempts as theologically untenable at best, and heretical or blasphemous at worst. We will be on much firmer, and more honest, ground by maintaining a clear-eyed appreciation of the varieties of (that is, the differences among) religious experience. Fundamentalism, even of an “all-is-one” variety, inevitably begets angry backlash.
Non-clinicians advocating for changes that affect clinical practice is the topic of my next post.
In today’s post, I suggest that renaming adverse effects of psychedelic drugs as “challenging experiences” minimizes, almost trivializes, their negative effects. While doing this provides less fodder for negative media coverage and reduces stigma in those suffering from them, it is misleading. It may result in under-diagnosis and under-treatment of serious psychiatric side effects, and provide the bases for negative media coverage and restrictive regulatory decisions.
During the first wave of widespread psychedelic use—within and outside of the medical community—negative reactions were called “adverse effects” and “bad trips,” respectively. These were highly distressing and maladaptive reactions to the drug experience.
Before I began my DMT research, I knew that any request to administer DMT would be met with concerns about safety. Could people be given psychedelic drugs without adverse effects resulting? Anticipating this response, in 1984 I published a review summarizing the findings of hundreds of reports of adverse reactions to psychedelics in and outside of the research setting: doi:10.1097/00005053-198410000-00001. I concluded that in the research environment, volunteers who were carefully screened, supervised, and followed up suffered very few serious adverse reactions.
However, in the general population, hundreds of thousands of people were using psychedelics of unknown quality, combining them with alcohol or other drugs, in states of pre-existing psychiatric instability. Here, many serious problems occurred in many people. These were severe psychiatric syndromes triggered or worsened by ingesting a psychedelic drug: psychosis, mania, depression, suicide attempts or completions, many times requiring psychiatric hospitalization and medication. (Later, flashbacks [now called PHPD or post-hallucinogen perceptual disorder] joined the list. These were unbidden, unexpected, usually less intense re-experiencing of certain elements of a previous psychedelic drug experience; for example, perceptual or emotional effects.) I further noted the utility of characterizing these effects along a timeline—acute, subacute, and chronic.
“Bad trips” were defined in a more holistic but nevertheless realistic sense of the degree of impairment one might experience. Acute panic, fear, confusion, depression and suicidality, grandiose and/or paranoid thoughts and behaviors. “Talking down” was the most common remedy offered, and when combined with tincture of time, was generally effective for mild to moderate reactions.
Horror stories of bad trips in the setting of uncontrolled use appeared in the media during the 1960s and early 1970s. These reports riveted readers with accounts of murders, suicides, and other severe and highly disruptive reactions to the psychedelic drug state. This emphasis on rare but alarming events convinced regulators that a public health emergency was underway and required immediate action. This, despite reassuring data coming from research centers regarding overall safety and promising clinical utility.
Now, both research and non-research doses of psychedelics being used are substantially lower than those previously taken or administered. This necessarily reduces the frequency and intensity of adverse effects. In addition, the critical roles of set and setting are much better understood, appreciated, and systematically applied. In the field, more sophisticated psychological first-aid has evolved and is more readily available.
However, this does not mean that serious adverse effects to psychedelics have gone away. Believing that they have gone away may result from renaming adverse psychedelic drug reactions as “challenging experiences.” This notion is evolving and spreading with little resistance. For example, we now see the development, use, and publication of data generated by a “challenging experience questionnaire.”
The data utilized in developing this meme, and the rating scale measuring it, came from online survey responses from a sample of self-selected psychedelic drug-users. These respondents described negative experiences’ nature, prevalence, severity, management, and impact. While relatively common, most negative reactions were brief and minor. Those that weren’t were often the impetus for “personal psychological growth.” Hence, the idea of “challenging experiences” was born. However, I am concerned that this attempt to mainstream negative effects—just as attempts to mainstream positive ones—may be a case of gilding the lily. It may cause unintended consequences down the road. This is because it lacks the rigorous honesty required in this controversial field.
We all can relate to the notion of challenging experiences. Challenging experiences are understandable and not especially threatening. Who doesn’t encounter them nearly every day? It is a mainstream and demystified notion. A flat tire is a challenging experience. When applied to adverse effects of psychedelic drugs, it drains much of the fear and confusion from something so ominous. However, would we also call a heart attack caused by a prescription drug a challenging experience? This is where the problem lies.
In the case of a negative reaction to psychedelics, when is a challenging experience only challenging? Short-lived mild anxiety? Inconsolable crying? Several hours of hyperkinetic dancing and whirling in someone out of touch with their environment? Being curled up in a ball refusing any contact? And how long until challenging becomes adverse? 10 minutes? An hour? A day? A week? While it is true that many mild adverse effects can be managed without recourse to medication or psychiatric hospitalization, how many people are being under-diagnosed and under-treated because their reactions are called challenging rather than adverse?
In addition, concluding from online survey data that adverse effects to psychedelics may lead to personal growth gives a false impression. While it is certainly true, it also relegates reports that do not align with the goal of mainstreaming psychedelic drugs. Neither are such online survey data representative of the real world of psychedelic drug use.
I regularly receive a small but steady number of emails from relatives and friends of those whose ill-advised or over-use of psychedelics has led to psychological reactions and/or behaviors that required imprisonment, hospitalization, or both. Such individuals would neither have heard of nor been able to answer such an online survey. In other words, those whose adverse effects resolved are much more likely to have responded to such a survey than those whose adverse effects did not.
We already have a well-established, consensually-validated, useful clinical term that extends throughout every discipline of clinical medicine: adverse drug effects. They occur in cardiology, immunology, dermatology, and psychiatry. There is no need to invent a new term. The risks associated with trivializing serious negative reactions to psychedelics outweigh any benefit associated with mainstreaming such effects for the media or reducing stigma in those who suffer from them.
It may be relevant to note that the notion of challenging experiences has been conceived of and promulgated by research psychologists rather than psychiatric MDs. Research psychologists have less clinical experience dealing with adverse medical effects of any type of drug. They thus may not fully appreciate the hazardous impact of conceptually conflating serious with less serious adverse drug effects.
As I noted above, there are treatment implications of renaming adverse reactions to psychedelics as simply challenging. Neither caregivers nor those for whom they are caring may want to treat (or accept treatment for) a state that is simply challenging, rather than, say, “briefly psychotic.” Nor will someone on their own seek the help they may need if they mislabel a serious adverse effect as simply challenging. In all these cases, the result may be delayed diagnosis and appropriate treatment, and more serious and difficult to treat conditions.
The reframing of adverse reactions to psychedelics as challenging experiences is well-intentioned in that the ultimate goal is wider availability of the psychedelic drug state in a regulated biomedical model. However, I see this apparent downplaying of adverse effects as a potential weak link in the effort to mainstream psychedelics and protect them against backlash. Renaming adverse drug effects will not change their prevalence nor their need for treatment. Sowing conceptual and clinical confusion appears to me ill-advised. Under-diagnosis and under-treatment may lead to more serious negative outcomes and media coverage. This will then draw more scrutiny from already skeptical regulators regarding psychedelics’ wider accessibility.