Are Psychedelics Too Risky?
We are constantly weighing risks versus benefits in every action we take. Whether it’s getting out of bed in the morning or engaging in much riskier activities like driving an automobile, we implicitly decide the benefits outweigh the risks.
When something new comes along, the calculations become difficult. Some of us who are more conservative view the new thing wish suspicion and decide the unknown risks likely outweigh the potential benefits, while those of us more open to new experiences, fall into the first stages of the “Gartner Hype Cycle” for new technologies, and are overly optimistic about this new thing.
There are five stages to this hype cycle:
Technology Trigger: First, a new thing pops up and it’s cool (i.e., it works in some way, is different, or is engaging or fun).
Peak of Inflated Expectations: More people try it out and agree it’s cool! This new cool thing is going to change everything! Salvation is upon us.
Trough of Disillusionment: Even more people try the new thing and they do it in many different contexts or for many different purposes, and they come to see that it’s not going to change everything and that salvation is not, in fact, upon us.
Slope of Enlightenment: The hype-seeker and fad-followers fall away. Serious people continue narrowing in on the risks and benefits and the real-world utility of the cool new thing.
Plateau of Productivity: The cool new thing is ready for primetime and mainstream adoption. Steady growth in its use lies ahead.
In the world of therapeutic psychedelics, we’re probably somewhere in the middle of stage of 2 with bits of stage 3 showing up. Just in the last 6 months we’ve seen the potential risks of psychedelics in high-profile news stories about an Alaska Airlines pilot who tried to down an airplane days after a therapeutic psilocybin session, actor Matthew Perry’s death from ketamine overdose, and Elon Musk’s erratic behavior being blamed on abusing various psychedelics.
Others like journalist Jules Evans and anti-psychedelic watchdog Psymposia (which I won’t link to because I think they’re way too partisan and sensationalist) have emerged to call attention to potential risks of psychedelics and abuses in the psychedelic space.
I can see the “trough of disillusionment” on the horizon as people realize that psychedelics are not without risks and that they cannot cure everything. But I believe that if we remain clear-eyed about the risks and benefits AND take seriously the best practices around psychedelic safety, then we can move pretty quickly into the the “Slope of Enlightenment” and the “Plateau of Productivity.”
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First, let me give you my take on the risks of psychedelics. I believe that the clinical trial data to-date show that psychedelics such as psilocybin, MDMA, ketamine, and LSD are very safe when administered in a controlled setting and given to people who have been screened for serious health conditions.
This recent overview of bad reactions (“adverse events”) to psychedelics in the Journal of Pharmacology finds that:
medical risks are often minimal, and that many – albeit not all – of the persistent negative perceptions of psychological risks are unsupported by the currently available scientific evidence.
It’s pretty clear to me that the benefits outweigh the risks when psychedelics are done in a safe and therapeutic setting. So, the question then becomes not whether psychedelics are safe or if the benefits outweigh the risks, but rather how do we create these safe and therapeutic settings?
After years of studying the history of psychedelic-assisted therapy and the current clinical therapeutic protocols, as well as directly observing and participating in individual and group therapeutic psychedelic sessions, I’ve come up with the Seven Steps of Psychedelic Safety. I believe the data so far has shown that when practitioners follow these steps, psychedelic medicine is overwhelmingly safe and beneficial for a wide range of conditions.
Assessment: Psychedelic safety begins with the question: Is this person a good fit? Currently, clinical trials and responsible practitioners take a very conservative approach to answering this questions. In some clinical trials, even having a second-order family member diagnosed with schizophrenia will cause a person to be excluded from the trial. Other exclusion criteria include certain medications a person is on or certain mental and physical health conditions. Many responsible practitioners will also screen for things like the level of social support a person has in their life or inflated expectations.
Preparation: Clinical trials have varying degrees of preparation in the form of therapy and information sessions, typically around two sessions. Some practitioners will require more than this.
Dose: Clinical trials first go through a phase of “dose finding” so that they can land on a dose that is safe and effective. Responsible practitioners will know the precise dose to give and how that dose will serve the aims of the therapeutic psychedelic session.
Setting: The importance of setting during a psychedelic experience has been known for over 70 years. In clinical trials, the research team does their best to create a comfortable, relaxed, and visually appealing environment. It’s not always easy when done in university and hospital settings, but they try! Every responsible practitioner will do their best to create a physical environment that contributes to a sense of safety, welcoming, and beauty. This serves to put the participant at ease and allow them to turn their attention inside.
In-session monitoring and guidance: Most clinical trials and therapeutic practitioners use a non-directive approach during the medicine session. This means that participants are invited to turn their attention inside and have an inward experience. If the participant wants to engage, the therapist or practitioner will do so through active listening. There are studies and practitioners who will give lower doses of psychedelics, what is referred to as a psycholytic dose, and do different forms of talk therapy. Regardless, a key to psychedelic safety is having a practitioner who is experienced, intentional, and clear about their approach to in-session monitoring and guidance. Oh, and this should go without saying, but the practitioner(s) should be sober! It’s rare but some underground guides will take at least some of the medicine with the participant. This is obviously not a safe practice.
Post-Session care: The episode with the airline pilot shows how important the 24-48 hours after a psychedelic session can be. Immediately, after it’s essential that people have a chance to gently come down from the medicine and talk about what they experienced. They also need to be monitored for any sleep problems are other behavioral irregularities. They should be followed up with the next day as well, with no work or other obligations planned.
Integration: In the 2-4 weeks that follow the psychedelic session, people should have scheduled therapy/coaching sessions aimed at processing the material that came up in the journey and also any feelings or thoughts that have arisen since the journey. Most clinical trial have at least two integration sessions scheduled.
The questions for most people will move from the degrees of safety and benefit of psychedelic medicine to how to ensure a particular practitioner is delivering the medicine in a safe and responsible way.
To that end, I’ve designed the Yes Collective Root Work program as well as my own private 1:1 coaching to follow these steps closely. This comes from a profound respect for the medicine, but also a clear-eyed recognition that deep inner work, emotional healing, and personal growth cannot happen without the context of real safety.