PHYSIOLOGICAL SAFETY
On a foundation of many years of experience in indigenous cultures and in modern psychotherapy suites and medical laboratories, the physiological safety of the major entheogens has been quite firmly established. Various studies over several decades have declared them essentially nontoxic as well as physically nonaddictive. They are not considered drugs of dependence since compulsive drug-seeking is not associated with them. Neither reliable self-administration in animal studies nor any detectable withdrawal syndromes have been observed.
The sensationalistic publicity surrounding the death of a seven-thousand-pound elephant called Tusko in the Oklahoma City Zoo, who in 1962 was given an intramuscular injection of 297,000 mcg of LSD, has finally quieted down. Subsequent investigations concluded that in all probability it was not the LSD, but other medications subsequently administered that caused the elephant’s death. And though LSD alone has since been administered allegedly to elephants in equally excessive dosage without causing death, the amount administered in this bizarre story was approximately 660 times the typical high dose of LSD (450 mcg) that would be prescribed for a human volunteer. That this event was ever referenced to attempt to document the alleged dangers of LSD is now in retrospect a thought-provoking indicator of the irrational climate present in that period of our history.
Similarly, at that period in time, in the wake of the Thalidomide tragedies that had resulted in birth defects, it was alleged that LSD might cause chromosome damage. Taking this concern seriously, the staff at the Maryland Psychiatric Research Center conducted a carefully designed FDA-approved study, double-blind and controlled, using pure LSD in collaboration with Joe-Hin Tjio, a biochemist at the National Institutes of Health. Blood samples were obtained from thirty-two subjects who participated in our ongoing psychotherapy research studies before and after LSD administration and were transported to a laboratory in Bethesda, Maryland, for microscopic examination. Also, blood samples were obtained from five black-market users who agreed to take pure LSD at the center as well as from eight normal volunteers and staff members who had received pure LSD in the recent past, including myself. The laboratory technicians did not know which samples were drawn before LSD administration and which were obtained afterward. The results of this study, published in 1969 in the prestigious Journal of the American Medical Association (JAMA), stated that “there is no definite evidence that pure LSD damages chromosomes of human lymphocytes in vivo as studied from 72-hour cultures.” Yet, again as an indicator of the irrational climate at the time, this study and its results received almost no press coverage and well-meaning antidrug warriors persisted in calling attention to the ephemeral specter of chromosome damage.
In 1971, Norman Dishotsky and his colleagues critically surveyed nine “in vitro” (that is, in test tubes) studies that claimed chromosome breakage after LSD and twenty-one “in vivo” (that is, in living human beings) studies that had reported conflicting results. The scientists concluded that “chromosome damage, when found, was related to the effects of drug abuse in general and not, as initially reported, to LSD alone. We believe that pure LSD ingested in moderate dosages does not produce chromosome damage detectable by available methods.” They also addressed allegations that LSD might cause cancer or birth defects and found no credible evidence in their review of the literature, but noted that “while there is no evidence that pure LSD is teratogenic in man, the use of any drug during pregnancy requires that its potential benefits significantly outweigh its potential hazards.” Ethical guidelines in research projects with most any drug today would disqualify any pregnant woman from participation as a precautionary measure. Our own review at Johns Hopkins of the literature on major entheogens relevant to issues of safety, published in 2008 (by Johnson, Richards, and Griffiths), arrived at similar conclusions.
Clearly the finding of the apparent physiological safety of pure LSD does not automatically generalize to other major entheogens, either in their pharmacologically pure forms or in their manifestations in natural plants or fungi. Many opportunities for carefully implemented research studies await us to supplement and clarify the findings already in the professional literature. It is conceivable, for example, that some of the 180 or more species of mushrooms that contain psilocybin or some of the ingredients occasionally put into ayahuasca preparations could cause some adverse responses in humans.
There are many unknowns to consider when dealing with substances harvested in nature—for example, one never knows for sure if a raccoon urinated on the mushrooms one is harvesting or not or whether such an event would make any difference. However, in light of the long history of the indigenous use of these sacramental substances in religious ceremonies, it is reasonable to consider it improbable that any acutely toxic compounds are to be found. To circumvent the unknowns of the natural growth of psilocybin-containing mushrooms in the open air, often in pastures on cow dung, some people today, with precise instructions easily found via the Internet, order the mushroom spores online. They then inject the spores into vermiculite and brown rice flour with distilled water in sterile wide-mouth mason jars and grow their own supplies. Although growing psilocybin mushrooms, even in the privacy of one’s own home for one’s own use, is still illegal and, if apprehended, carries harsh penalties in many parts of the world, ordering and possessing the spores, presumably for microscopic examination, remains legal with few exceptions.
Another concern has focused on what has come to be called “hallucinogen persisting perceptual disorder (HPPD),” more commonly characterized by the term “flashbacks.” These perceptual changes, sometimes claimed to constitute a recurrence of drug effects in the days or months after the substance is presumably no longer present in the body, appear to be quite rare. They are welcomed by some people and cause distress in others. In almost two decades of research with psychedelic substances at the Spring Grove Hospital and Maryland Psychiatric Research Center, I am aware of no reports of this phenomenon, perhaps because it wasn’t expected and volunteers were not questioned about it during follow-up interviews. Researchers at present are inquiring about the phenomenon, so more definitive information should be available in the near future.
It appears that “flashbacks,” though rare if existent at all in well-managed research settings, may be more common among people who frequently use a variety of psychoactive drugs and especially among those who do not administer the substances with religious or psychotherapeutic intent. One theory of their origin often suggested proposes that they are more probable when one is seeking a pleasant experience and unresolved conflicts emerge instead, especially if one seeks to avoid the emotional content awaiting confrontation and expression. A significant psychotherapeutic opportunity is presented and, due to lack of motivation or insufficient therapeutic support, the invitation is essentially rejected. The person typically walks around and talks with open eyes, trying to regain control rather than allowing himself or herself to move though the emerging distress toward resolution and healing. Finally, the drug wears off, but the conflict that has been awakened remains just below the threshold of awareness. Then, when the person is under stress or sleep-deprived, so goes the theory, the material that has been triggered and inadequately confronted is understood to reemerge into conscious awareness, essentially offering a second opportunity to deal with the difficult emotional content within.
Another factor to consider in weighing reports of “flashbacks” is that unusual mental states before taking a psychedelic substance tend to simply be viewed as “unusual experiences,” but when they occur afterward, their appearance sometimes, rightly or wrongly, may be attributed to a prior psychedelic experience. Alternative states of consciousness have always been known to occur spontaneously, perhaps triggered in part by our own biochemical and psychological processes. In summary, the available information at this point in time supports the fundamental physiological safety of the major entheogens, especially in their pharmacologically pure forms.
It should be noted that, in the medical screening of volunteers for most ongoing research projects with psychedelic substances, there are criteria for excluding people who may be at greater risk than others. For example, as noted earlier, pregnant women, or women intending to become pregnant in the near future, routinely tend to be screened out, a usual and routine precaution in all psychopharmacological research. Similarly, for a person with an acute cardiovascular condition, the risks entailed might well exceed the potential benefits. If one shouldn’t ride a rollercoaster or finds it physically dangerous to encounter intense emotions, it well may be unwise to take an entheogen, though I am aware of no well-documented instances of death from intense emotion alone. Nonetheless, both intense psychological pain and intense joy can be downright exhausting. Elderly terminal cancer patients without severe cardiovascular problems have tolerated emotional expression well; even though weary at the end of the day, they have typically expressed gratitude for the experience as a whole.
Most research projects would screen out anyone with a brain tumor, significant neurological metastases from cancer, or a seizure disorder such as epilepsy, both for ethical reasons in wanting to maximize the probability of benefit when there is the presence of unknown factors and for methodological reasons in wanting to standardize the characteristics of the sample of people being studied. In most contemporary studies there are also strict disqualifying standards for people who consistently produce high blood pressure readings. Initial findings at Hopkins indicate a slight rise in blood pressure for most people during the action of psilocybin, and cardiovascular arousal often rises and falls with the emotions being experienced. Further, due to possible unknown factors, people currently taking antidepressant medications such as Prozac, Zoloft, Celexa, or Paxil, which are understood to bind with the same brain receptors as psychedelics, would be well advised to successfully discontinue those medications if possible and appropriate prior to considering participation in psychedelic research.
These, of course, are the guidelines typically followed in controlled medical investigations, usually in university settings. The standards observed in indigenous religious communities may differ, perhaps posing more risks to some participants, but also providing more flexibility for others who may choose to accept those risks. So far as I know, baseline blood pressure readings are not obtained from church members who receive peyote, psilocybin mushrooms, or ayahuasca in their religious services. Whether or not the current screening procedures in research operations represent an overly cautious determination to ensure maximum safety, along with the necessity of reassuring concerned medical colleagues and members of Institutional Review Boards, will become clear in time with increased experience and the accumulation of more substantial caches of data. Most current researchers who are working with psychedelic substances would rather err on the side of being overly cautious, even overprotective, than risk any potentially adverse event that might conceivably necessitate pausing or halting research while investigations are conducted. Although these policies are sometimes very disappointing to highly motivated research volunteers who apply to participate in various studies with entheogens, at this time in history they tend to be considered prudent and necessary.
PSYCHOLOGICAL SAFETY
The psychological safety of entheogen use requires a more complex answer since it depends both upon who the person about to receive the psychedelic substance happens to be and upon the knowledge and skills of the people who may administer the substance and who are present to provide companionship and support as may be needed.
With our present knowledge, anyone with a family or personal history of psychosis would be wise to opt for methods of personal and spiritual growth that do not include entheogens. There appears to be a significant risk for such people that an entheogen may trigger the onset of a prolonged reaction, that is, of unwanted alternative states of consciousness that continue for days or months after the psychedelic substance would normally have been metabolized, thereby returning the person to the baseline awareness of everyday life. For people without genetic tendencies toward psychosis, this risk appears to be minimal and perhaps nonexistent. In a survey of investigations that included a total of twelve hundred research volunteers who had received either LSD or mescaline, none of them classified as “patients,” the psychiatrist Sidney Cohen found only one report of alternative states of consciousness lasting more than forty-eight hours. This person turned out to have been the identical twin of a schizophrenic patient who, in most research programs today, would have been excluded during the initial medical evaluation.
Insofar as entheogens may trigger or accelerate the onset of psychosis in people who are already genetically vulnerable, it has been suggested that in time these same people might well manifest psychotic symptoms even if they do not ingest these substances. Thus, it has been reasoned that a psychedelic experience might speed up their entry into treatment or even prevent psychosis by addressing conflicts that have been intensifying over time or by the therapeutic cultivation of increased ego-strength. This raises fundamental questions about timing, motivation, values, and how one conceptualizes the purpose of human life. Is one’s goal to “remain normal” or is it to struggle with and through one’s conflicts in a process of human personal and spiritual growth? And of course, this raises the question of what struggles may be necessary and of constructive value and which may constitute unnecessary detours in life and are best avoided completely.
At the very least, it is clear that for anyone only interested in so-called recreational use or getting high, the major psychedelic substances are poor choices. As repeatedly affirmed, these molecules do indeed appear to be intrinsically sacred, can trigger unanticipated experiences, and can be incredibly powerful. They may lead one through excruciating personal pain, which, though perhaps potentially meaningful in the big picture of human development for some, also can be very disruptive at the time. In the poignant words of Huston Smith, “Ecstasy is not fun.”
Some of the reports of psychedelic use outside of medical or religious contexts reflect an alarming lack of knowledge. There are young people who have taken entheogens and then wandered through shopping centers or walked aimlessly through different landscapes without any intention beyond “seeing what might happen,” and sometimes without the presence of any companion to help to ensure safety. One young man took pride in watching horror films on his television set and expressed a special fondness for Alfred Hitchcock’s
Psycho. With low dosage, some people may get away with such behavior, at least on some occasions, and label their experiences as “cool.” Eventually, however, if they persist, the seriousness of their misuse of these intrinsically sacred substances is likely to become apparent to themselves as well as others. Confrontation of fears is always in order, but there is ample grist for the mill within each of us and there is no need to supplement it with potentially distracting or disturbing stimuli from the environment or from the fantasies of other people.
The saying “it’s not what happens to you but how you respond to it that matters” is exceptionally true during psychedelic sessions. As noted in the earlier chapters, the safe and productive exploration of consciousness demands a high degree of trust, courage, openness, and interpersonal grounding. If one seeks control or tries to evade emerging experiences, anxiety will build and paranoid thought processes will often occur. Paranoid people can misinterpret environmental cues and act in ways that they would view as reckless or simply stupid when their normal faculties of good judgment are functioning.
The presence of an alert and knowledgeable companion or guide is of critical importance in ensuring safety. Genuine hallucinations, though extremely rare, sometimes do occur and, however briefly, seriously impair reality testing. I recall a man in our study of LSD-assisted therapy for narcotic addiction at the Maryland Psychiatric Research Center who, when sitting up on the couch during his psychedelic session, suddenly stared wide-eyed at the vacant black leather chair opposite him. Then, suddenly, he darted for the door, intending to yank it open, run down the hallway, and sprint out of the building. As if in a football game, I tackled him at the door and held him tightly. Panicking, he pointed to the chair and informed me that we had to quickly escape from the coiled cobra in the black chair that was threatening him. Firmly, I continued to hold him and directed him to look directly into the eyes of the cobra. As he did so, he burst into tears as he experienced the cobra transforming into his mother. His body relaxed as he tumbled through emotions that he attributed to her constricting influence on his life.
This became a pivotal therapeutic experience for him and in time he came to explore even deeper meanings of the cobra, relating it to the rising of his own spiritual energy, called
kundalini shakti in Eastern meditative disciplines. Had this man been alone or without competent supportive companions, not only would he have missed a valuable therapeutic opportunity, but while running away with impaired judgment he could have injured himself or others. As with the nocturnal nightmares most of us can recall, when one runs away from psychological conflicts the threatening specter grows bigger and one feels weaker, smaller, and increasingly anxious, often awakening in a cold sweat; when the frightening image is courageously approached and confronted, one grows stronger and insights awaken.
As has been repeatedly stated, one’s intention during the action of an entheogen is of critical significance. If one genuinely seeks personal and spiritual growth, one is also motivated to confront material that may initially appear frightening or dark. We encourage an intention to “follow the arc” of the entheogenic reaction regardless of any anxieties encountered, akin to trusting the arc of an Australian boomerang that, when thrown, circles widely but returns dependably to its point of origin. With practice, one can even arrive at a point of welcoming the appearance of a dragon or similar symbolic manifestation and, like a skilled athlete, enjoy the challenge of “looking him directly in the eye” and the adventure of tumbling through whatever emotions and insights may occur during the subsequent confrontation. In illustration of this principle within consciousness, a man under the influence of ayahuasca described a visionary sequence of going deeper and deeper into the earth, moving through various dark tunnels, past crypts, roots, spider webs, and slithering insects until, somewhere in the despicable depths, he finally arrived at an ancient door. He grasped the handle, opened the door, and discovered himself at the top of a mountain with warm sunlight and blue sky above him. The mind often works like that. A helpful mantram to silently repeat during psychedelic sessions is “in and through.”
In preparing volunteers for psychedelic sessions, we sometimes suggest a fantasy of opening the door to the “basement of one’s life” and announcing, “I’m coming down!” One then descends with firm footsteps, carrying a bright searchlight. Intentionally, one seeks out the darkest corners one can find in the basement and shines the light into them. Sometimes this process can continue by opening a trapdoor in the basement floor and penetrating still more deeply. When this process is grounded in the relationship with the companion or guide, there is nothing that cannot be “seen for what it is.” One may affirm an inherent right to know what is going on within one’s own mind. Ultimately this intention leads to the resolution of anything within that has potential to engender anxiety and an awareness that it is safe to relax and genuinely to be at peace. With this intention and interpersonal grounding during the action of a psychedelic substance, it is common to hear the report, “There is nothing to fear.”
The safety record during the past fifteen years of research at Johns Hopkins has been consistently positive. Though some people have indeed experienced difficult episodes of anxiety during their psychedelic sessions, sufficient new insights and perspectives have also emerged so that in retrospect the experiences are viewed as constructive and meaningful. To my knowledge, no person to date who has completed participation in a study has reported regret at having volunteered or any adverse impact on his or her personal or spiritual life.
This situation may well be attributed to the careful medical and psychological screening that all volunteers undergo, and also to the interpersonal climate in the research unit. Volunteers are welcomed as valued participants and colleagues on an important frontier of knowledge rather than labeled as “patients” or “experimental subjects.” A similar therapeutic climate and safety record prevailed in earlier research at the Spring Grove Hospital and Maryland Psychiatric Research Center and at many, if not most, other sites, past and present, where studies with entheogens and normal volunteers or persons seeking psychotherapeutic treatment have been conducted.
Further, once a person is accepted into a study and signs an informed consent document, he or she usually participates in a minimum of eight hours of relationship-building time with the guide or therapist who will be present during the period of entheogen action. Typically during this period, spread over at least one or often two or three weeks, one’s life history is shared in confidence, including important relationships, career developments, religious or nonreligious history and present orientation, travel experiences, and any unique traumas or accomplishments that have occurred thus far in life.
On the day before the entheogen session is scheduled, the guide surveys the varieties of experiences that could occur with the participant, insofar as words can communicate, thereby offering the best wisdom we have available on the art of maximizing opportunities for safety and benefit. This always is done in person to provide opportunities for discussion and interaction, thereby further solidifying the relationship. Listening to a generic video on how best to respond during the action of an entheogen would not be the same. Also, each volunteer becomes familiar with the room in which the entheogen will be administered, lying on a couch, listening to music with sleepshade and headphones, often also exploring his or her own mental imagery, akin to a waking dream without the assistance of an entheogen. This becomes a “dress rehearsal” for the upcoming psychedelic session.
Another important factor in ensuring safety is the provision of trained and skilled guides. Although ideally all would have had training experiences themselves that included personally receiving entheogens, this is not always possible in the current legal-political climate in the United States and in many other countries. At a minimum, all guides in the Hopkins studies have personal experience in meditative techniques and are familiar with some alternative forms of consciousness. They have also worked in an apprentice relationship with more experienced guides, are emotionally stable and centered, and are cognitively open to the potential value of nonordinary states of awareness. Thus, they are not inclined to be fearful of unusual speech or other atypical behavior. Were a guide to become tense or worried that a person is “going crazy” and might “get out of control,” that anxiety easily could become contagious, disruptive, and counterproductive.
Part of a new guide’s orientation at Johns Hopkins entails becoming familiar with the supportive music used in a particular research study and the rationale for its selection. We have learned that in high-dose sessions, especially during the onset and intense period of entheogen effects, the supportive structure of the music is more important than either the guide’s or the volunteer’s personal musical preferences. In states of ego transcendence, the everyday self as the perceiver of music may no longer exist, having entered into a unitive awareness that is claimed to be quite independent of whatever sonic frequencies are coming into the ears through the headphones or loudspeakers. As the ego approaches its dissolution and when it begins to be reconstituted, however, the nonverbal structure of the music may provide significant support. Thus, sensitivity to the therapeutic potential of carefully selected music may be an important factor in enhancing psychological safety.
One playlist that has been carefully developed through trial and error and has been found to work well with many different people over time is included at the end of this book. It includes a significant amount of classical music, symphonic and choral, as well as some Hindu chant, in the intense portions of the session and lighter selections near the return to everyday reality at the end of the day. We discovered in early research in the 1960s, notably with some alcoholics who had never appreciated classical music, that Brahms symphonies and similar works resonated deeply within them and proved highly effective in providing nonverbal structure and support. Many of those people not only discovered an appreciation of classical music within themselves, but went out and purchased records, tapes, or compact disks to facilitate the continuing integration of their experiences and for future enjoyment. It may be noted that, as consciousness is returning to ordinary awareness after intense experiences of a mystical, visionary, or psychodynamic nature, most any style of music can be explored with delight. At this time, one’s personal favorite selections may be enjoyed with fresh appreciation.
Still another important consideration in ensuring psychological safety is the provision of continuing opportunities for the integration of the psychological or spiritual content that was experienced during the action of the entheogen. In most research studies, participants who receive entheogens are encouraged to write a description of their experiences, or at least an outline or initial rough draft, on the evening of the session or early the following morning to freshly capture the essence of their insights in their own words. This helps to launch the integrative process, provides an important research document, and ensures that each volunteer has a souvenir that often remains of value in future years. With report in hand, volunteers return to the research center on the day immediately after their sessions for an appointment with their guides, initially to talk through whatever happened. The process of interpersonal sharing and discussion, including the full spectrum of thoughts, emotions, and insights, appears to solidify the benefits obtained.
Sometimes there are traumatic memories from childhood that have never been shared with anyone that need to be discussed honestly. Sometimes there are spiritual experiences beyond what the person ever conceived as being within the realm of possibility that need to be acknowledged. There are times when volunteers may be groping for words or concepts and the guides are able to normalize their experiences by articulating ways of thinking that others have found helpful or by suggesting readings from the writings of mystics from years past or of more recent explorers of the mind. Research protocols usually provide several hours for integration after a psychedelic session occurs to help to ensure safety and to continue to solidify potentially beneficial responses. Yet the process of integration for many people continues for months, years, and even decades as psychological and spiritual growth advances.
In religious contexts outside of the structures of psychopharmacological research, psychological safety is promoted by the traditions, behavioral guidelines, and interpersonal context of the spiritual community. Religious elders often fulfill the role of guides and the community as a whole provides the respectful acceptance required to integrate both psychologically painful and spiritually ecstatic experiences. In one study, Paulo Cesar Ribeiro Barbosa and his colleagues surveyed fifteen publications that had evaluated emotional, cognitive, or physical health responses reported after the acute effects of ayahuasca had subsided. While noting possible methodological biases in some studies, they concluded, “The accumulated data suggest that ayahuasca use is safe and may even be, under certain circumstances, beneficial.” Two other recent small studies of the religious use of ayahuasca have similarly supported claims of fundamental safety, one by John Halpern of thirty-two members of a branch of the Santo Daime Church and one by Charles Grob of fifteen male members of the União do Vegetal. In both cases procedures of preparation and social support were provided within the community context.
LEGAL CONSIDERATIONS
In considering questions of safety and potential benefit, obviously possible legal consequences must also be weighed when people choose to use psychedelic substances outside of the scientific research projects, religious organizations, or other circumstances currently approved in a particular country. If one is fined or imprisoned, the psychological or spiritual benefits may well continue, but one’s life can be adversely impacted.
As we thoughtfully recover from the hysteria of the 1960s, especially if present and future research projects continue to support the basic safety of the major entheogens when they are appropriately and responsibly used, it is reasonable to anticipate gradual changes in the drug laws of various countries and of their individual states or provinces. As with marijuana at the present time (2015), federal and state laws may contradict each other. For example, in the State of New Mexico in 2005 an appeals court ruled that growing psilocybin mushrooms for personal use could not be considered “manufacturing a controlled substance,” but psilocybin still remains illegal in that state under federal law. The laws tend to be complex, sometimes with subtle differences between natural and synthetic forms and varying with the assumed intent associated with cultivation, transport, sale, or possession. There rarely appears to be a category of “responsible use”; possession alone is usually assumed to imply “abuse.” Fortunately, the Internet provides fairly up-to-date information on current laws in different locales.