Abstract
Sean M. Viña on the potential of therapeutic psychedelics.
The extensive evidence that psychedelics are a viable treatment option for various health issues, including depression, anxiety, suicidality, PTSD, drug dependency, and behavioral addictions, has led to significant changes in the legal and cultural landscape surrounding their use. The Food and Drug Administration (FDA) has expedited research on two therapies, psilocybin and MDMA, granting them “breakthrough” therapy designations. States like Oregon, Colorado, and Hawaii have begun legalizing the medical use of psychedelics, while others, like Colorado, Connecticut, New Jersey, California, Washington, Utah, and Texas, have decriminalized them for research. The use of psychedelics among the general population doubled to about 9% between 2019 and 2021, and, according to a recent NPR report, groups we do not typically associate with drug use, like middle-class White mothers, are turning to microdosing with “magic mushrooms” outside of clinical settings to cope with parental stress.
Amid these rapid changes, on October 24, 2023, the case of commercial pilot Joseph Emerson raised high-profile concerns. Emerson, a standby employee passenger, engaged in an in-flight altercation with fellow pilots while in the cockpit of an Alaska Airlines jet. During this altercation, Emerson attempted to pull the handles of a fire suppression system, which could have caused engine failure and a potential crash. Investigators discovered that Emerson had been self-administering psilocybin mushrooms to cope with six months of severe depression, instead of seeking traditional medical treatment. He later claimed that he was trying to wake up from a dream during the incident. With commentators questioning whether Emerson’s case is an isolated incident, it is fair to ask if the rapidity of cultural shifts around psychedelic use will negatively impact public health.
Stigma and Diminished Psychedelic Returns
This incident revived pressing issues in current psychedelic research and policy debates. A fundamental problem is that the nearly religious fervor of some researchers trying to prove the benefits of psychedelics has, for instance, downplayed the impact of social forces, or completely ignored cultural differences. In their 2018 review, Timothy I. Michaels and colleagues found that over 80% of current clinical research participants are White men. This lack of diversity is evident in studies such as a phase 2 trial on psilocybin for treatment-resistant depression, which included 92% White participants, and another study on MDMA, which had approximately 90% White participants.
The consequence of the White biases in research cannot be overstated, considering growing evidence that the benefits of psychedelics may not be widely shared. National data reveals that while psilocybin and MDMA use improved health outcomes for White users, the same effects were minimal or non-existent for users from racial or ethnic minority groups, particularly Black Americans. Moreover, there is significant variation in the benefits depending on factors such as educational status, income, marital status, household size, employment status, gender, and even criminal history (see, for instance, Sean M. Viña and Amanda L. Stephens’s 2023 Frontiers in Psychiatry article).
Moreover, research is finding that the efficacy of psychedelics is dependent upon positive social and psychological resources that can be accessed throughout the trip (before, during, and after feeling the effects of the substances), including living in spaces with less stress so that beneficial outcomes are maintained. In other words, it makes a difference whether a patient has the time and positive support to maximize the benefits of a psychedelics trip or if the patient is saddled with systemic racism, sexism, or other inequalities that limit the ability to heal.
For Emerson, the social force that drove his episode was stigma. Many scholars agree that the stigma attached to mental illness is the main obstacle to treatment, accounting for more than half of the estimated 28 million American adults not receiving care for mental health issues (here I recommend Bernice A. Pescosolido’s 2013 article, “The Public Stigma of Mental Illness”). This stigma also pushes individuals toward unhealthy coping mechanisms like excessive drinking and substance abuse. Indeed, preliminary evidence suggests that individuals who have used self-administered psychedelics—the psychological benefits of which can give users a false sense of control during times of distress—are less likely to seek formal mental health treatment when experiencing heightened distress or perceiving more stigma. Consequently, instead of seeking professional care, they are driven further into potentially harmful behaviors compared to those who have never tried these drugs—exactly the circumstances faced by Emerson.
Emerson, in particular, was deterred from seeking professional help due to the Federal Aviation Administration’s regulations on mental health for pilots. These rules dictate that if a pilot seeks mental health treatment, they are immediately grounded; evidence shows that it could take over three years to regain their position, often at a reduced salary. Fearing the loss of his livelihood, Emerson avoided formal treatment and instead turned to self-administered psychedelics.
What can be done to continue this important research and to ensure the medical benefits for more people?
Continuing Decriminalization and Reducing Stigma
First, we must continue decriminalization efforts. Psychedelics, such as mushrooms and LSD, have a low risk of overdose and the benefits they offer outweigh the potential harm. These substances have been found to have positive effects on mental health and may indirectly impact physical health, cardiovascular health, behaviors, and addiction. Some researchers argue that psychedelics are “anti-addictive” because they can lead to a decrease in negative behaviors like excessive drinking, which is a leading cause of death in America and is rising among all demographics, especially among women. Decriminalization can be a small step toward righting the wrong of the war on drugs that has harmed so many.
It is important to note that Emerson’s actions cannot be attributed to psychedelics. He had consumed psilocybin mushrooms more than 18 hours before the incident; these drugs are typically metabolized within 6 hours. Further, if he experienced hallucinations during his attempt to hijack the plane, it was not due to psychedelics but to his 40 hours of sleep deprivation. His case instead illustrates that stigma and working conditions—which dissuaded him from seeking professional mental health treatment and led him to self-administer psilocybin in the hopes of some relief—played dominant roles in this incident.
Cultivating Culturally Centered Research
Finding that the current clinical research shaping policy mainly involves middle-class, White, and male populations, many organizations are taking a culturally sensitive approach, including MAPS (the Multidisciplinary Association for Psychedelic Studies) which has offered MDMA therapy training specifically for communities of color. Future research funding should follow this model and explicitly require a well-defined plan to recruit and retain marginalized individuals who need to be overrepresented in samples. Additionally, policies should not be influenced by research that overlooks race and ethnicity, or at the very least, the impact of White-centered research on policymaking should be minimized.
Of course, a culturally sensitive approach is still fundamentally flawed because it centers on a White/psychiatry model and attempts to fit diverse populations into it. A truly culturally centered approach prioritizes the original Indigenous custodians who nurtured this spiritual medication knowledge (for discussions of Indigenous psychedelic history, I suggest a pair of 2019 Journal of Psychedelic Studies articles, one by Evge-nia Fotiou and the other by Jamilah R. George and colleagues). This approach is important for two reasons. First, most of the original Indigenous knowledge was created in communal spaces. Given that social resources are integral to psychedelics’ efficacy inside and out of the clinic, a communal approach is necessary. And second, although this Indigenous knowledge comes from communal practices, some were created more recently than others. For instance, the Santo Daime religion was established in 1930. In less than a century, this religion developed significant rituals around Ayahuasca use that have been documented to provide profound health and spiritual benefits for its congregants.
Thus, instead of exclusively relying on a White psychiatric model to administer drugs in a clinical setting, policies need to promote the development and empowerment of cultural knowledge across different communities. How, for instance, would Black women in the inner city, Latinos in border towns, or Evangelical groups create their own communal psychedelic practices that catered to their beliefs and needs? With appropriate health oversight, communities can develop their own cultural practices that enhance their health and well-being, rather than see psychedelic use dictated (and potentially dampened) by White psychiatrists.
Prioritizing Social Solutions for Mental Illness
A driving force of psychedelic research is to aid wounded warriors, which is a crucial endeavor. However, we must be cautious not to reach a point where the consequences of perpetuating war are not influenced by the toll it takes on human lives, simply because it is cheap to administer drugs to soldiers or civilians after witnessing atrocities.
Pharmacology cannot replace good social policies based on high quality research. It is misguided and potentially dangerous to suggest (as some researchers do), that psychedelics can help minorities cope with the effects of sexism and racism, potentially addressing culturally ingrained trauma. Others have suggested that psychedelics may help people manage inner turmoil and help them get to treatment. Some have even suggested psychedelics will provide the basis for secular spirituality, replacing old religious institutions. Psychedelics alone cannot solve deep-rooted issues like racism, stigma, and inequality, because this approach does not address the underlying problems. Worse, this perspective places the burden on marginalized individuals to overcome social problems, perpetuating the bootstrap myth. Even more disturbing, it suggests that marginalized individuals should simply use drugs to numb themselves from discrimination, which is unacceptable. Psychedelics show promise for therapeutic use, but they are not a cure-all solution to the ills of society.