Addiction psychologist Michael P. Bogenschutz currently works at the Department of Psychiatry at NYU. Prior to New York, he worked at the Department of Psychiatry and Behavioral Sciences, University of New Mexico.
Much of Bogenschutz’s work has involved searching for new applications of existing treatments for addictions. The OPEN Foundation talked to him to learn more about his research on psilocybin-assisted treatment for alcohol dependence, the first trial of its kind.
Could you briefly describe your career, and what led you to pursue psychedelic research?
My career has focused on clinical treatment and, particularly in the last 10-15 years, clinical research on treating addictions. I have always been deeply interested in how people change and how we can facilitate change in problematic behaviours.
Working with patients, you’ll find people who will tell you they came to a point where they just quit suddenly, while some gradually become abstinent or the problem diminished over time, and others have relapse episodes for years, never improve, or get worse. There is a very real and not uncommon phenomenon of sudden and categorical change in behaviour, which is not unique to addiction. I find that interesting scientifically, psychologically and clinically. Why does this happen to some people and not to others?
I really became interested in research with psychedelics shortly after joining the faculty at the University of New Mexico (UNM) in 1994. At that time, Rick Strassman was doing work with the intravenous administration of DMT. Dr. Strassman left UNM not long afterwards and as I was a junior faculty member, it didn’t seem realistic to pursue my own research in that area. I didn’t think much about it again until I saw Roland Griffiths’ 2006 paper on the effects of psilocybin on healthy volunteers.
I was immensely impressed with both the findings and the fact that it was possible to do these kinds of studies. In that paper, the authors describe the acute effects of psilocybin in volunteers and the relatively high frequency of mystical types of experiences. More importantly, from a clinical perspective, there was a report of the persisting change in attitudes, emotional states and relationships. The follow-up paper two years later documented the persistence of these effects on the basis of a single experience with relatively high doses. I found it immensely interesting and it made sense to start investigating the clinical potential of these types of drugs myself.
Addiction obviously has a huge public health impact. Why are you interested in alcohol-related issues and treatments in particular?
I’m interested in addiction in general but for me alcohol, which is a very common, devastating addiction throughout the world, was a logical place to start. As I learned when I started investigating the topic, a considerable amount of research on the use of psychedelic treatment (mainly LSD) and alcohol had already been conducted in the late 1950s.
In the United States, the Alcoholics Anonymous (AA) philosophy is prevalent in addiction treatment. It’s a philosophy that emphasizes the spiritual component of the addiction process and the importance of becoming healthier spiritually in order to recover. This also interests me.
What are the benefits of using psilocybin over LSD in a study?
Psilocybin has two practical advantages. For one, the duration of action is significantly shorter, in the order of six hours instead of ten with LSD. This makes psilocybin easier to use in an outpatient model. In other words, you can administer it in the course of a normal workday, whereas LSD sessions could easily continue late into the evening. Another important reason is that there is much more stigma attached to LSD. Many people think of LSD as a very dangerous and frightening drug. Certainly in the 1960s, there were many adverse reactions to LSD. Much of this had to do with taking extremely high doses of a substance with unknown potency, as well as a lack of understanding at the time about how important setting was in determining an experience’s outcome. Clinically speaking, both LSD and psilocybin appear to be very safe when used under carefully controlled research conditions. Also, even though the psilocybin we administer is actually a synthetic version, people often think of the substance as “mushrooms” or a naturally occurring compound, which is reassuring to some people.
Could you generalise about what types of persons were interested in joining this trial?
We recruited from the community, using advertisements aimed specifically at people who were not engaged in treatment. We wanted this to be a stand-alone treatment. We required people to be alcohol dependent, in general good health, and not suffering from any serious psychiatric illness. In our Albuquerque study, participants were working and had some intact social structure or support. They had been alcohol-dependent for an average of 15 years, the mean age was 40, and there were six men and four women. Some had limited amounts of experience with psychedelics in the past, but we excluded those with extensive use.
One concern was that people might volunteer because they wanted a psilocybin experience. We wanted to attract those seriously interested in changing their drinking and open to the possibility of novel treatments.
Can you describe the setting you provided for your patients?
The outpatient clinic was set up to look as much as possible like a comfortable living room with a large couch. We asked participants for most of the session to wear eyeshades and headphones – there was a standard program of music – and instructions were to focus on their internal experience, to accept and explore whatever came up. We prepared them for what they might experience during sessions, what the possible range of experiences could be, and advised them to manage those experiences in order to make the most of them. We believed that setting an intention was important. In this context, the general intention might have been to use the session to learn or experience something to help them make a positive change in drinking or other issues related to drinking they wanted to explore. There was very little direct intervention. Two therapists provided support and were available to intervene when needed, otherwise they checked in every 30 minutes to an hour to make sure the participant was doing okay. At the end of that session, the participants could start talking about what they had experienced. (The volunteers received psilocybin in one or two supervised sessions; this was in addition to Motivational Enhancement Therapy and therapy sessions devoted to preparation for and debriefing from the psilocybin sessions, ed.)
In some of the initial LSD trials, the therapists’ aim was to recreate an experience akin to delirium tremens (DT), a severe withdrawal symptom sometimes experienced by alcohol-dependent patients. These DTs were often a turning point for alcoholics, and they felt LSD could have similar consequences. What they found was that some participants had mystical, transcendent experiences that affected their long-term behaviour. Could you describe how peak experiences affected the patients in your study?
On a psychological and biological level, we don’t have theories, let alone data to explain these phenomena. In the context of a person trying to address a problem and make a kind of change, what we’ve seen is that participants often have an experience of oneness, the hallmark of a mystical experience. They have a sense of unity with all of creation or the universe or God, and they also have a very powerful experience of love and connection on a deep emotional level. This includes self-love and self-compassion, that feeling of being okay. This sounds almost trivial, but for some of these folks who’ve experienced a lifetime of feeling unloved, it’s a very powerful experience. In some cases, they told us their drinking had been motivated by the lack of feeling loved or lovable, and that this experience made them feel less like they needed to drink for that reason.
Other changes accompany this kind of experience. People emerge with a sense of optimism that change is possible, that life can be different because they have experienced something that is so different from anything they could have imagined. We’ve seen people spend a lot of time during sessions thinking about family and relationships, about the grief, guilt and harm their drinking has brought to others, as well as themselves. People emerge from sessions talking about pro-social values like being a good parent or contributing to society. We’ve measured significant decreases in craving and an increase in confidence that they will be able to make a change in their drinking.
How can taking a drug once or twice cause lasting behaviour change? What evidence speaks to this question?
I don’t really have an answer. Clearly things are going on in the brain and we are beginning to conduct studies that look at brain function using MRI scans before and after the psilocybin sessions. But we can’t say yet why a single acute experience can produce such lasting changes.
The best analogy we have come up with is Post Traumatic Stress Disorder (PTSD), in which a single traumatic event can impact someone’s day-to-day experience. These traumas can be of a purely psychological nature, though they often involve physical violence as well. PTSD is an example of how an acute event can cause persistent psychological and measurable biological changes in brain function and structure. Maybe what we are seeing with psilocybin is something like the opposite of PTSD—an experience so powerfully positive it can actually make lasting impact on one’s psyche and brain.
Addiction is a misguided search for spirituality. Can you comment on this or elaborate?
Carl Jung is really the person who expanded on this idea, which was that through intoxicants people (in some limited way) were able to experience connection, unity, a sense of wellness and being loved. You can think of it as a misguided search for mystical or human connection, a way to experience a reliable emotional attachment to something external in order to receive comfort. This can be a useful way of understanding and reframing people’s struggle with addictive substances as not simply seeking hedonistic pleasure, but a genuine desire for wholeness. Though if this isn’t found in healthier ways, it can readily become a trap.
The outcome of your study seems to be very promising: all of the patients experienced a definite improvement. However it was a small sample. Do you have plans to do another clinical trial?
This was a small trial without a control group, done to demonstrate the feasibility of conducting such a study. We were able to demonstrate clinical improvement, and the degree of improvement correlated with the strength of the subject’s experience during sessions. It is suggestive and by no means conclusive or convincing evidence. We need to do much larger controlled trials. Our current trial aims to recruit 180 alcohol-dependent patients, which will provide a much more rigorous test of efficacy. This will take a few years—we estimate five—to complete the trial.
Do you think there may be obstacles other than scientific that might bring psychedelic research to a halt all over again? Or do you think it will evolve into standard practice?
We understand these drugs better scientifically than we did in the 1960s, in terms of effects, potential dangers, and how to minimise those dangers in a clinical research setting. The people doing clinical research with psychedelics now are serious, experienced scientists who approach their work cautiously and with scientific rigour. The general public also has a much better understanding of psychedelics than it did 50 years ago. We need to stay balanced in our approach and avoid extrapolating beyond the data, guard against exaggerated claims and expectations, and remind people of the significant risks that exist with these drugs when used outside of structured and controlled settings.
While I and others in the field are hopeful that what we discover will lead to important advances in addiction treatment, no drug is a magic cure. There are limitations to any treatment. Addiction is a complex, chronic disorder and you cannot cure everyone in one or two sessions, nor reduce the risks to zero. But it’s reasonable to hope that we will be able to demonstrate reproducible benefits, and learn a lot about the psychology and biology of behaviour change in the process.