Illustration by Tate Overton
What did William Blake, Aldous Huxley, and Jim Morrison have in common? The answer can be found in this line of poetry: “If the doors of perception were cleansed, everything would appear to man as it is, infinite.” This quote from Blake's eighteenth-century Marriage of Heaven and Hell provided the title of Huxley's influential book The Doors of Perception (1954), which reflects on his experience with the psychedelic mescaline and advocates for psychedelic-assisted psychotherapy. Jim Morrison and his band named themselves “The Doors” after reading Huxley. Were they alive today, these three visionaries would feel right at home with the current renaissance of psychedelic research, brought to public attention, for instance, by Michael Pollan's 2018 book How to Change Your Mind.
Animal Magnetism, The Magic Finger.
Leigh Woods, 1892.
I want to make a clear statement about psychedelic-assisted psychotherapy for PTSD and other disorders: if large, well-designed, independently replicated research shows that these treatments are safe and effective, then they should be employed. There is no reason to wait until we fully understand the mechanism of this treatment. We rarely ever know the first principles by which our treatments succeed. That said, clinicians must grapple with the what, how, and why of what they do. What follows is my best effort to live up to this obligation, while offering some historical perspective.
The roots of these unorthodox practices are deep. Many will remember W. H. R. Rivers as a psychiatrist portrayed in Pat Barker's Regeneration trilogy of historical novels about shell shock among British officers during World War I, but fewer are familiar with his actual career. After completing medical training in 1886, Rivers, aged twenty-two, founded Britain's first experimental psychology laboratory at Cambridge University. In 1898, he sailed to the Torres Strait (an area comprising northern Australia and islands in and around New Guinea) to study the sensory functions of the Melanesians. There he was drawn to anthropological fieldwork. In later life, Rivers reflected on health and illness in his book Medicine, Magic and Religion (1924):
One of the most striking results of the modern developments of our knowledge concerning the influence of mental factors in disease is that they are bringing back medicine in some measure to that cooperation with religion which existed in the early stages of human progress.
Rivers speaks from first-hand experience with the healing practices of Melanesian shamans. Shamans are regarded as having access to, and influence in, the world of good and evil spirits. They typically enter a trance state during a ritual, which allows them to practice divination and healing. While this practice may seem quaint to medical clinicians, hundreds if not thousands of combat veterans now seek care for war-related mental health problems from shamans at ayahuasca retreats across Central and South America. In addition, many clinicians now seek out those shamans for instruction.
Medical psychotherapy also emerged out of older traditions of trance states and ritual healing. Father Johann Gassner (1727-1779) successfully employed Catholic exorcism rites to treat physical illnesses. In 1775, Franz Anton Mesmer (1734-1815), a University of Vienna-trained physician, delivered an invited presentation to the Munich Academy of Sciences on Gassner's exorcisms in which he reported that, while Gassner believed he was casting out demons, his miraculous cures were achieved through “animal magnetism.” Medical historian Henri Ellenberger cites the intersection between Gassner's religious view of healing and Mesmer's secular approach as the point of emergence of modern psychiatry.
Mesmer's own magnetic treatments often proved effective when contemporary medicine had failed. Consequently, he was in such demand that he had to optimize the number of patients he could treat in a single session. By holding metal rods inserted into tables or baths, he could “magnetize” large groups of people simultaneously. Alternatively, he could link them by ropes to a “magnetized” tree.
Eventually, disgruntled members of the French medical society demanded that King Louis XVI investigate Mesmer. Louis charged Benjamin Franklin (in France as a representative of the American colonies) with leading a scientific commission which demonstrated conclusively that there was no magnetism in mesmerism. Thus discredited, mesmerism remained suppressed for a century.
Franklin was an expert on magnetism but he wasn't a clinician. This may be why his report didn't focus on the fact that many of Mesmer's patients achieved significant improvement which they had not attained through conventional treatment. Looking back, we could accuse Franklin's commission of throwing the baby out with the (magnetized) bathwater. We don't want to repeat that mistake now.
It was only through the authority of Jean-Martin Charcot (1825-1893), father of neurology, that a form of mesmerism reentered French medicine as hypnosis. In 1885, Sigmund Freud, then a recent medical graduate, traveled to Paris to study neuroanatomy. As he watched Charcot demonstrate that hysterical symptoms could be manipulated through hypnosis, Freud remembered a case described to him by his mentor, Josef Breuer. As Breuer treated a young woman for hysteria, he noted that she could spontaneously enter trance states. It occurred to Breuer that he might be able to probe her thoughts by hypnotizing her. To both doctor's and patient's surprise, once hypnotized, she became able to trace each of her
symptoms back to specific traumatic experiences—and, as she did, each symptom disappeared. This was the original form of psychoanalysis.
Freud did his best to apply Breuer's model, but he eventually abandoned hypnosis. As he shared in his Five Lectures,
… to this day I cannot understand how it can be supposed that by merely holding up a finger and saying once “go to sleep” I had created in the patient the peculiar psychical state in which her memory had access to all her psychical experiences. I may have called up the state by my suggestion but I did not create it, since its features—which are, incidentally, found universally—came as such a surprise to me… . I soon came to dislike hypnosis, for it was a temperamental and, one might almost say, a mystical ally.
It would be helpful to reflect on what Freud meant by “a mystical ally.” Mysticism can be defined as the belief that communion with the infinite, or knowledge not otherwise accessible to the intellect, may be attained through a transcendent state of mind and spirit. Altered mental states play an important role in mystical experience and can be attained in many ways including ingestion of natural substances (e.g., peyote, mushrooms, ergots) or synthetic drugs, meditation, sleep deprivation, isolation, or even mortification of the flesh.
Two methods of producing altered mental states, hypnosis and sodium amytal, were highly effective in relieving psychiatric symptoms among WWII veterans as documented by military psychiatrists Roy Grinker and John Spiegel in their 1945 report, Men Under Stress. Their success prompted the establishment of departments of psychiatry across the US after the war. It also secured the dominance of psychoanalysis in American psychiatry because of their dramatic demonstration that psychological trauma could be relieved by overcoming repression.
Another World War II psychiatrist refused to jump on that bandwagon: Jerome Frank chose to explore “nonspecific” factors which he believed were essential in all forms of healing. In the third and final edition of Persuasion and Healing (1991), Frank concluded that
Cultural hostility toward certain drugs limits their use in psychotherapy… . Little attention has been paid to the potentially beneficial use of substances that induce abnormal states of consciousness… . Widespread prejudice against “psychotropic hedonism” (Klerman, 1972) may be as much to blame as concern over the unreliability of the drug's effects.
This statement is highly relevant to recent consideration of psychedelic-assisted psychotherapy. Frank believed that all healing practices restore morale in those who lack a “sense of inner freedom, self-efficacy and satisfaction with life.” Psychological trauma can be understood as a paradigm for loss of morale. He suggested that all therapies, including “those involving various rituals of medication, prayer, and, sometimes, mind-altering drugs—that are intended to provide experiences of direct contact with transcendental healing powers” have in common the restoration of morale. This is largely accomplished within and through the therapeutic relationship.
MDMA, psilocybin, mescaline, ayahuasca, and ketamine are just a few of many substances capable of eliciting a profound sense of receptivity and connection. This experience, while short-lived physiologically, may nonetheless provide an
enduring psychological buffer against cognitive and emotional distress previously associated with traumatic memories. Following Frank, such experiences may work primarily by restoring morale through a revelatory experience akin to those described by psychologist and philosopher William James in The Varieties of Religious Experience: A Study in Human Nature (1902). James focuses on spontaneous conversion experiences (which tend to be sudden and dramatic) but also mentions that conversions were observed “in an extraordinary degree” with the anesthetic agents of his time. By “conversion” James did not mean the adoption of a religious belief but rather a transformation in an individual's character or personality. James's contemporary Mary Baker Eddy founded Christian Science after receiving medical treatment by a mesmerist. Christian Science's motto is “Heal the sick, raise the dead, cleanse the lepers, cast out demons.” This implies a deep link between healing and mystical experiences. It also brings us back to Gassner's exorcisms.
With this truncated history in mind, can we tease out the role played by altered states (exorcism, mesmerism, hypnosis, psychedelics, and others) in achieving therapeutic goals? When psychedelic-assisted psychotherapy succeeds, are the effects primarily pharmacologic or psychological? What role might its unique therapeutic relationship play? Could these components be intrinsically linked? To answer these questions, we'll need to know a great deal more about neuroscience and human nature. We may also have to reappraise our core beliefs as well as some lessons our teachers taught us.
William Blake, quoted at the outset, had an intellectual and spiritual predecessor, the inventor and scientist Emanuel Swedenborg (1688-1772). Both Blake and Huxley allude to Swedenborg's book, Heaven and Its Wonders and Hell From Things Heard and Seen (1758). Swedenborg described a transformative experience he termed “vastation” and claimed that confrontation with dark and ominous forces prompts a renewal or purification through purgation. Like Swedenborg, Henry James Sr., the father of writer Henry James and William James, reported his own spiritual and intellectual transformation through vastation.
In The Varieties of Religious Experience, William James provides numerous examples of historical figures who attained enlargement of both mind and soul through perceived confrontation with “the infinite.” He held that, while such incidents might have “morbid origins” in brain pathology (e.g., temporal lobe epilepsy) or intoxication, and may seem irrational to observers, they are, in general, positive because valued ideas and insights often remain with that person for the rest of their life (as was true of James's father).
James believed that these experiences could restore physical and mental health and that such cures could be equal or superior to those obtained by medical means. It's not that James was dismissive of standard medical practice; he simply recognized that some people require a different path to health. Regarding mechanism of action, James suggested that, through mystical experience, people come to perceive both sickness and evil as illusions and, thereby, overcome them.
The idea that purgation can lead to health is ancient. Aristotle adapted the contemporary medical term catharsis to explain the power which theater holds over its audience. It's important to note that ancient Greek theater was regarded less as an entertainment than as a mystical experience associated with the worship of Dionysus and other deities. In Achilles in Vietnam (1994), Jonathan Shay suggests that Greek theater was deliberately employed as psychological and moral treatment for Athenian warriors as they readjusted to civilian life. Breuer and Freud followed this tradition in their “cathartic treatment,” which Freud refined to develop psychoanalysis. In doing so, he followed a principle which James emphasized: the importance of applying rigorous and objective attention to subjective experience as an essential component of the scientific approach to human nature.
Another point of agreement between Freud and James appears in “The Uncanny” (1919), which Freud wrote in the aftermath of World War I and the 1918 influenza pandemic. He defined uncanny experience as regression to
the old animistic conception of the universe … characterized by the idea that the world was peopled with spirits of human beings; by the subject's narcissistic overvaluation of his own mental processes; by the belief in the omnipotence of thoughts and the technique of magic based on that belief; by the attribution to various persons [e.g., mesmerists] and things [e.g., psychedelics] of carefully graded magical powers or ‘mana’; as well as by all the other creations with the help of which man, in the unrestricted narcissism of that stage of development, strove to fend off the manifest prohibitions of reality.
Freud is describing merger with the infinite as an attempted return to the safety of primary narcissism in the face of extraordinary challenges. Such regressions can include mental reorganization in which “word presentations” (defined in Freud's 1915 paper “The Unconscious”) devolve into representations of
the things themselves. This opens the door to merger of the self with those external things. Note that, as Huxley describes his mescaline experience, he repeatedly emphasizes that everything in his surroundings (from people to inanimate objects) became “the things themselves” rather than the words which normally symbolized them and that he came to the realization that both he and they were (and always had been) one with the infinite. This experience of cosmic unity was at the heart of Huxley's enduring psychedelic revelation of universal harmony and peace.
Following James and Freud, and taking Huxley's insights into account, might the therapeutic action of psychedelic-assisted psychotherapy stem from similar perceptions? Janoff-Bulman defined psychological trauma as disruption of basic assumptions about oneself, other people, and the universe. Perhaps the psychedelic experience of resonance across these spheres can realign that posttraumatic imbalance in a new and enduring configuration. This might also provide opportunities for posttraumatic growth.
While psychedelics may help create conditions conducive to therapeutic change, it is also important to address the psychotherapy component of psychedelic-assisted psychotherapy. The therapist must skillfully assist the patient in developing a positive mindset and provide an optimal physical and social environment called “set and setting”—a term popularized by Timothy Leary in his 1960s Harvard experiments. This requires a series of carefully orchestrated meetings to prepare the patient for the psychedelic experience, instill positive expectations, and build a supportive therapeutic alliance that will facilitate the patient's progress.
A recent experience left me concerned that the lack of exposure to psychoanalytic theory and technique among recent mental health trainees might limit their ability to provide such treatment. While attending a presentation by psychiatry fellows on psychedelic-assisted psychotherapy, I noted that, although they described each agent's chemical structure, putative sites of action, and potential adverse effects in detail, they gave short shrift to the “-assisted psychotherapy” component of treatment. Thirty years after the onset of the “Decade of the Brain,” newly minted psychiatrists may have trouble seeing beyond the biomedical reductionism of our time. If psychedelic-assisted psychotherapy is validated as clinical practice, psychoanalytically trained clinicians should have an important role to play in training its practitioners.
Another concern is that clinicians who lack experience with psychoanalytic principles fail to perceive countertransference pressures that often emerge in the treatment of trauma. The history of psychiatry is replete with examples of brilliant clinicians who employed altered states to overcome intractable mental disorders and ended up getting lost in the phenomena they helped promote. Among these were Mesmer, the British academic physician John Elliotson (1791-1868), Charcot, and Breuer. Each was brought to grief once they realized that singular (and sometimes remarkable) responses to their efforts which they had thought were entirely under their control and rooted in objective science were, in fact, subjective phenomena which primarily operated at the level of the unconscious: their own as well as their patients'. Without an understanding of how psychological trauma may manifest in transference and countertransference, clinicians are especially susceptible to the temptation to “do magic.” And, although they may achieve stunning therapeutic successes along the way, they may ultimately find themselves in the same regrettable position as did Mesmer and Charcot.
While psychedelic agents may be safe as prescribed in treatment trials, once they are approved for prescription there is no way to regulate their off-label use. Research trials have strict criteria which usually exclude subjects with schizophrenia, bipolar disorder, or dissociative disorder; but given recent experience with off-label use of ketamine, it
is likely that psychedelics will be prescribed for a range of conditions despite the absence of any evidence base and in a wide variety of doses and frequencies. There is also a critical need to develop training and standards for those who will attend patients during psychedelic experiences—especially as nonmedical facilitators may be trained to supplement the limited mental health workforce.
“If psychedelic-assisted psychotherapy is validated as clinical practice, psychoanalytically trained clinicians should have an important role to play in training its practitioners.”
Definitive evidence for or against the efficacy and safety of psychedelic-assisted psychotherapy in controlled settings can be expected in the near future, but a clear understanding of its mechanism of action is farther off. That said, we should not repeat the Franklin Commission's mistake of throwing out the baby with the bathwater even if it were shown that the clinical efficacy of this approach has more to do with the patient's subjective experience than with the psychedelic itself. As William James concluded, no matter how it might be achieved, “union or harmonious relations with the higher universe [result in] a process wherein work is really done … and produces effects psychological or material, within the phenomenal world.” These may include what he describes as “a new zest which adds itself like a gift to life … An assurance of safety and a temper of peace.” James presages key ideas which Freud will later articulate in “The Unconscious” and “The Uncanny.” For example, James writes,
so long as we deal with the cosmic and general, we deal only with the symbols of reality, but as soon as we deal with the private and personal phenomena as such, we deal with realities in the completest sense of the term … The world of our experience consists at all times of two parts, an objective and subjective part … The cosmic objects [of science] are but ideal pictures of something [while the subjective is] the very experience itself; its reality and that of our experience are one.
For these reasons offered by James and Freud, it is unscientific to reject the reality of a therapeutic effect simply because it stems from the patient's subjective experience. Subjectivity needs to be studied, understood, and accepted as integral to human existence and our shared reality. Psychedelics may or may not have direct pharmacological effects on discreet mental disorders, but if they can be rigorously shown to promote enduring positive effects on mental life when applied in combination with psychotherapy, we can't afford to reject them. We will, instead, need to enlarge our understanding of human nature and of the paths to health made possible by cleansing the doors of perception.
Harold Kudler, MD, trained in psychiatry at Yale. He co-led development of joint VA/Department of Defense clinical practice guidelines for PTSD, advised Sesame Street's Talk, Listen, Connect series for military families, and cochairs APsA's Service Member and Veterans Initiative.