This article appeared in the July/August 2021 issue of Discover as "The Future of Psychotherapy?" Subscribe for more stories like these.
A lot has changed since the 1990s. That’s when Alex Belser, then an undergrad at Georgetown University, first found a book about LSD psychotherapy.
Back then, hardly anyone was talking positively about psychedelics. The U.S. had recently passed a string of strict anti-drug and crime bills, extending the war on drugs that President Richard Nixon started in 1971. By the late 1990s, medical and industry investment in the field was virtually nonexistent.
Two decades — and several degrees — later, Belser has read far more about psychedelics in medicine. He’s also published his own peer-reviewed papers, guided dozens of patients safely through medically sanctioned trips and advised corporations that are suddenly pouring millions of dollars into the promise of psychedelic-assisted therapy. A recent market report from Financial News Media projected the industry in North America will exceed $6.8 billion by 2027.
The business surge in psychedelics has followed a tidal shift in academic research. Since 2006, researchers at Johns Hopkins University alone have published more than 60 peer-reviewed papers on psychoactive compounds found in magic mushrooms and other plants. In late 2019, the university opened the first-of-its-kind Center for Psychedelic and Consciousness Research. Around the same time, the U.S. Food and Drug Administration (FDA) granted “breakthrough therapy” classification to psilocybin, the so-called “magic” compound found in psychedelic mushrooms. That FDA status helps fast-track the approval of promising pharmaceuticals in trial phases. And Oregon made history in November when the state voted to legalize psilocybin for medical use.
Belser, who holds a doctorate in psychology, has made many contributions to this potential medical renaissance. He’s the founding president of Nautilus Sanctuary, a nonprofit dedicated to psychedelic assisted psychotherapy. He also currently works as chief clinical officer at Cybin Inc., a biotech company focused on psychedelic therapeutics, like using a sci-fi looking helmet that shows real-time blood flow, oxygen levels and other brain activity during a psychedelic experience.
He recently met with Discover over video chat to explain the current state of magic mushrooms, psilocybin and hallucinogenic medicine — and the unlikely academic path that brought him here.
Q: We’re talking about medicine. But terms like psychedelics and magic mushrooms can still sound provocative, or edgy and mystical. Is that language misleading?
A: It’s so hard to know what word to use. This is one of our favorite debates: What do we call these medicines? Psychedelic means “mind-manifesting.” They’re not properly hallucinogens. The medical literature uses that term, but that term doesn’t really help describe them. Other people have used terms like entheogen, which is “manifesting the spirit within,” because people do have very powerful spiritual experiences under these medicines. Some people prefer the term plant medicines.
Q: How do you assess and interpret a spiritual experience, both medically and scientifically?
A: My research has been focused on interviewing people in-depth, asking “What is it that happens for you when you use these medicines?” We also do pre- and post-measures. And we use something called the Mystical Experience Questionnaire and the Hood Mysticism Scale that have been used in scores of trials.
But we consistently find that when people have a spiritual or mystical experience with psychedelic medicine, that predicts whether or not they get better in terms of the symptoms they are having for depression, anxiety or something else. This is incredible because it suggests that it’s not just a biomechanical medicine. It’s not just happening in the physiological level. It suggests that people are also having something really important happening in their mind, in their memory and their identity or their history. It’s their relationship to being alive, in the human body and the world. That helps them get better, and that’s independently predicting their treatment outcome.
Q: Interesting. That sounds a bit more like religion, or an existential belief system, than medicine.
A: This is a different model than the traditional “take a pill a day and call me later” approach. It really requires a lot from the person who’s taking the medicine to navigate internally what comes up for them. And it also requires a lot from the people they work with, the clinicians.
When people say, “I felt a profound experience of unity, and an interconnectedness with all things,” it’s not the same as a blood draw or getting a level on your blood pressure. It’s not a metric like that, but it is a way for people to tell you what they’re experiencing and to get at what’s happening internally. If we only paid attention to what we could obviously measure, we would lose everything that happens internally for people in their own minds and their own inner experience, which is the vast majority of what people experience in their lives. This is especially true when you’re dealing with things like depression and addiction and end-of-life distress.
Q: What other symptoms or conditions does this type of treatment work well for?
A: For many psychedelic medicines, they are medicine in search of a condition. So, with psilocybin, it’s potentially effective for a variety of things, including anxiety, major depressive disorder, treatment-resistant depression, obsessive compulsive disorder, smoking cessation, alcohol-use disorder, even potentially other areas like anorexia and eating disorders. I believe that the future of psychiatry will find psychedelic medicine at its heart. That’s because our old drug classes may not have worked well to begin with and are sort of petering out.
Q: How do you describe the shift in this field over the past decade or so?
A: There’s just been an explosion of research in psychedelics. It used to be that when a new study would come out, we would parcel it out word-for-word, paragraph-by-paragraph, because there was so little research coming out. It was a trickle. Now it’s become a torrent of clinical research studies being initiated and papers being published, demonstrating very promising results for a variety of psychedelic medicines for any number of psychiatric conditions. It’s incredible.
There’s also been this massive interest from the public — from Michael Pollan’s book, How to Change Your Mind, to any number of media outlets that have covered these stories in different ways. It’s because when you talk with patients and when you talk to people doing this work, you realize that the experiences can be beautiful and powerful. The effects for people can be really not only intense, but healing, and in ways that don’t work the same way as our conventional medicines work.
Q: And Oregon legalized psilocybin in the November 2020 election. In application, what does that mean immediately and in the near future?
A: They have created a two-year development period. It’s not like the legislation passed, and then, overnight, psychedelic-assisted psychotherapy is legal. The measure is specifically about psilocybin, the active compound in magic mushrooms. These are mushrooms that grow on the six inhabited continents of the world and have been used by human civilizations and peoples in documented anthropological literature for a long time. We expect this is going to be a rulemaking period, and then, psilocybin-assisted psychotherapy treatment for certain conditions will be legal to do by licensed clinicians in the state of Oregon only. And that sort of work may serve as a model for how other states or municipalities could potentially pursue this sort of clinical track. The Oregon approach is like a state-by-state legalization pathway. But psilocybin is still an illegal drug to use from a federal-statutes perspective.
Q: It sounds like the same path we’ve seen with legalizing cannabis in states around the country. Are there a lot of parallels to marijuana?
A: Well, I think it’s an experiment in federalism. In 1970, Richard Nixon signed the Controlled Substances Act into law, and it’s been an exemplar law, not just for the U.S., but for countries around the world. But, when states like Oregon can change their state laws regarding how we can return to these medicines, it opens up a new field. And these medicines do show medical and psychiatric benefit for people, and the evidence suggests they are not addictive or dependence-causing.
But there’s an important distinction from cannabis: Cannabis is sold, even if it’s prescribed, as a product without supervision or without working with a facilitator. Psychedelic medicines are a very different class because nobody is seriously proposing that people should just be prescribed psilocybin for at-home use as we do with cannabis —at least not at significant doses. This is really a combination treatment. It would be a medicine that would be prescribed by a person who has specific training in doing psychedelic-assisted medical intervention work.
Q: That’s where practitioners like you come in — in your case, with 20 years of experience. But how did you get here, given the lack of activity in the field when you were in college?
A: I was a kid, an undergrad at Georgetown in the ’90s, and I read a book called LSD Psychotherapy: The Healing Potential of Psychedelic Medicine by psychiatrist Stanislav Grof. I just was so fascinated by these medicines and I flew to my first psychedelic conference and met all of the psychedelic leaders in the field at the time. The research movement [that gained momentum in the 1960s] had largely stalled out, but the traditions were alive and a lot of people knew that these could be promising medicines. I wasn’t even pursuing psychology at that time. I was doing prison-reform work, working in jails and prisons in D.C., Maryland, Virginia, and then I moved to the United Kingdom for a master’s in criminology.
I tacked from there to working with LGBTQ+ people. My dissertation in psychology was on how to prevent suicide among lesbian, gay and bisexual teenagers. Because in that group, a lot of people feel like they want to end their lives in part because of the shame and stigma that they’ve received. We started a psychedelic research group at NYU in 2006, when I was just a graduate student. I got to help run a number of studies at NYU. I did my clinical research fellowship at Yale. And there I worked on a number of psilocybin studies. I’ve also worked on MDMA therapy studies for people with severe PTSD, including a vet from Afghanistan who had been pinned down in multiple firefights.
Q: That seems like an atypical path, especially for someone now working in pharmaceuticals. How does that foundation inform your work today?
A: I think it’s important to have a social justice framework when working in medicine, broadly and specifically in psychedelic medicine. There’s no way to do this work without attending to our participation in structures that might oppress people and our ability to make changes so that we can treat each other with compassion, dignity and deep respect. Our practice of medicine should mirror and amplify that for the betterment of all people.
Q: You mentioned earlier that psychedelic treatment isn’t really a pill-a-day model. Can you elaborate on that and how it fits into the current system of modern medicine?
A: I think that these are medicines for the whole person, and I think it’s important that we understand them as such. It’s not going to work to try to fit psychedelic medicine and practice into old models. We have to think differently about how we work with these medicines. When I say the whole person, I really do mean not just the body, but the mind and the person’s experience of their spirit and how they make meaning of their lives.
There is a long lineage of psychedelic plants and medicines being used by people across the planet. Western medicine kind of fell asleep on it for the last 100 years. And not all of those practices are still alive, and maybe not all of them will be helpful for us today. But the psychiatric possibility of this sort of medicine is really a different way of asking, “What could healing be?” I think that psychedelic medicine and the research suggests we should think very deeply about how we practice medicine.
This interview has been edited and condensed for clarity.
How Psychedelic-Assisted Psychotherapy Works
In most clinical studies with psilocybin, MDMA and other psychedelics, the medicine is used alongside talk therapy. Psychologist Alex Belser says most of the trials he has helped facilitate play out something like this: After a thorough screening process, an approved patient works with two or more facilitators — at least one of whom is a licensed psychotherapist. Before interacting with any psychoactive medicine, that patient has three sessions, minimum, of talk therapy. This preparation time helps both the patient and therapist set goals and intentions while also building trust and understanding. That foundation is vital before introducing any psychoactive substances, which can stir up momentary fear, confusion, panic or paranoia in the human brain.
When the time comes to try the medicine — often in a pill, though oral strips are now in development — that session lasts several hours or a full day, sometimes with overnight care. Clinicians create a safe, comfortable spa-like setting for the patient. They might bring in stones and flowers or other natural objects. Calming music plays through speakers or headphones, and the patient might wear eyeshades or lie down to immerse themselves in the experience.
They often encounter vivid visions, poignant emotions and memories over the course of a few hours. Many people say they have interactions with deceased relatives or loved ones. The therapy team remains present the entire time. “Therapists can hold out a hand, the patient can grab their hand, take a few breaths, and get back in touch with what’s going on,” Belser says, noting that rescue medications like benzodiazepines have never been needed to calm a patient during his sessions. “It’s very intense. There’s often crying, and it can often be very motivating for them.”
After the experience, integration work involves at least a few more talk therapy sessions in the following days. These address what happened mentally and emotionally, how to make sense of it and what the patient wants to learn and integrate into their psyche and life. Belser says that lasting effects often occur after just one use of a psychedelic medicine. A study he was part of at New York University recently showed lasting results in patients four years after treatment. — T.M.
Timothy Meinch is features editor at Discover.