A Fateful Turn

A key advance in the corporate takeover of psychological suffering came with a very well-meaning piece of legislation. In 2008, Congress passed the Mental Health Parity and Addiction Equity Act, which required insurers to cover mental health conditions in the same way as other medical conditions. Former president Barack Obama’s Affordable Care Act, meanwhile, increased the number of people with health insurance, including young people who could be covered by their parents’ insurance until age twenty-six.

More insurance coverage was a good thing, of course, as was greater mental health care coverage. But absent a public health system, these reforms also meant a deeper well of potential insurance payouts from insurers on behalf of newly covered patients. Those payouts did not go unnoticed by investors.

With this influx of cash, the corporatization of behavioral health took off. At first, it was mostly about addiction recovery, a field subject to little of the oversight applied to psychiatric institutions. One glaring example of this unregulated growth was the massive development of “sober homes” — residential settings, unlicensed at the time, which often offered cheap rent while garnering most of their profits through kickbacks from drug treatment programs and testing sites, an arrangement that would be glaringly illegal if the programs were regulated as medical establishments.

As the opioid crisis brought addiction to epidemic proportions, private equity rushed to buy up treatment sites, from detoxes and day programs to hospital and sober housing, branding them with flashy marketing and cutting costs to make them more profitable. At a 2016 investor conference, one such treatment center chain’s CEO described the increased rate of heroin use as a “favorable industry tailwind.”

The results were disastrous. A 2020 Vox investigation documented the “Florida shuffle,” in which treatment centers employed brokers to recruit patients who had good insurance. These brokers sought out patients everywhere from twelve-step meetings to hotlines claiming to offer help to those suffering from addiction. Potential patients were bribed with cash, clothes, or even drugs in order to achieve enrollment. The goal was to maximize profits by keeping as many people in the system as possible.

Some cycled through corrupt centers for years until they overdosed or gave up. In an ugly and telling twist, the urine of addicts became a hot commodity at this time, since many treatment centers made most of their profits from large insurance payments for drug and alcohol tests as opposed to actual treatments. Patients were nicknamed “thoroughbreds” and treated as cash cows (to mix farm animal metaphors) rather than as the focus of therapeutic care.

When insurance companies and regulators caught wind of these tactics, they intervened — the former restricting the interventions for which they would pay, the latter shutting down some particularly abusive programs. The remaining treatment centers sought new legitimacy and a much larger market by developing conglomerates that offered a continuum of care for all manner of behavioral concern, shifting from addiction treatment solely to mental health care in general.

While the more unethical shenanigans of early corporate treatment may have diminished, the sales pitch mechanism of pathology and quick fixes has only grown stronger: a one-two punch in which certain experiences of mind and mood are defined as “sicknesses” by experts who then offer a cure — an already-growing tendency in psychiatry in the United States that shifted into overdrive when behavioral health became a hot commodity.

Sick in the Head

“Stop the Stigma” is the central campaign of the National Alliance on Mental Illness (NAMI), the largest advocacy group in the United States for individuals who have been diagnosed with mental illness and their families. NAMI’s main strategy in fighting stigma is to educate the public about the science behind mental illness as a brain disease, a similar approach to the one taken by advocates for individuals engaged in addictive behaviors, in which the source of a certain behavior is framed as a disease of the mind instead of a moral choice.

Such approaches are laudable and match society’s larger view that diagnoses liberate individuals from stigma. They are also sociologically naive.

Stigma was developed in cultures for many reasons, but one clear purpose of stigma is to ostracize sick people by removing them from the body politic and keeping a distance from them in order to protect against infection. That means that calling people “mentally ill” may not really remove stigma but is, in fact, stigmatizing. More important to our discussion, the narrative of a brain disease does not free individuals from moral judgment: it shifts the site of their morality to decisions they are making about getting better.

The famous sociologist Talcott Parsons defined “the sick role” as divided, like all social roles, by both rights and responsibilities. When one is sick, they are freed from the typical obligations we assign to “well” individuals, like attending school or going to work. But they are also assigned new responsibilities having to do with seeking out medical care and complying with expert courses of action — to recover promptly and get back to school or work, in other words. When those who are sick don’t demonstrate that they are seeing the right professionals in order to heal, we tend to view them as not doing their part in meeting the responsibilities of their role, typically seeing them as irresponsible, lazy, and deviant.

There’s some obvious logic to such negative sentiments. We should want people who feel sick, whether mentally or physically, to get better. But psychiatry and behavioral health have a history of often getting it wrong more than right.

They also work in areas that, say, an orthopedic surgeon doesn’t: spiritual, existential, and social suffering — experiences that exist on a continuum in all of us. You can’t solve a broken leg by seeing a cleric or shaman, striking up a new friendship, developing greater social support, a sense of purpose, more economic or educational opportunity, or falling in love. But you can solve a lot of behaviors psychiatry defines as abnormal in these ways.

That’s why clinical psychology is not the only social science; rigorous research in sociology and social psychology shows that many behaviors are less psychological traits and more related to social states. In this light, the message that medicines and sanctioned therapies are the only cures for psychological pain can be understood as more of a monopolistic grab on psychological well-being than a solid truth about the best or even only way for people to build better lives for themselves. And, whether intentionally or not, this monopolization is aided by society’s general belief that individuals who do not choose the medically sanctioned way to get better are doing something deviant.

The story of psychedelics as a miracle cure participates in a deeply disempowering approach to healing, one that implies a moral choice (who, in their right mind, would refuse a miracle?) regarding treatment in which the righteous decision is to place one’s recovery solely in the hands of professionally legitimized others. In this mode, psychological transformation becomes something you purchase or submit to in order to become more “normal,” while refusals to take your medicine are seen as ill-advised, amoral, or even part of the illness (i.e., “denial” or “resistance” in “professional” psychological terms). In this medical hegemony, people start to sound like machines to be fixed with just the right screwdriver or wrench for what ails them.

We’ve Got the Very Best in Store for You!

The medicalization of psychiatric suffering has increasingly led to a segmenting of therapeutic treatments designated as “evidence-based best practices” to treat specific diseases of mind and mood: cognitive behavioral therapy for depression or dialectical behavioral therapy for borderline personality disorder, for example. These are the models sold by treatment centers today, a menu of cures for particular ailments that mimic in many ways the panoply of cosmetics at your local CVS, each a way to remove or cover this or that blemish.

Psychedelics as magic pills for depression, PTSD, and addiction fit within this approach. This new segmenting of illness and remedy might be all well and good, if it worked. Yet there is scant evidence that it does.

Decades of what is called “common factors” research in psychotherapy shows that only 15 percent of change in therapy is the result of any particular model, while the effect of a patient’s social experience and their willingness to change is almost triple that, and the effect a warm and collaborative relationship with the therapist is double. (The remaining 15 percent of cure is due to the placebo effect.) Basically, this research is about what Leary called “set and setting” (something he attributed as more important than psychedelic compounds in a person’s awakening), the complicated but curative space between two people in which one comes with their own capacities to metabolize care and another does their best to make the space hospitable for change.

When Yaden, Yaden, and Griffiths suggest that we integrate “psychedelic treatments into existing evidence-based psychiatric paradigms,” they are lauding the smallest element in therapeutic change, while minimizing the much more important common factors that are actually at work when change occurs. When Angermayer describes the ingestion of psychedelic compounds as “10,000 hours of psychotherapy into four hours,” he’s doing the same and to the extreme, claiming human agency and human contact are a waste of time.

By selling a brokenness that only experts can fully see, define, and remedy, the exuberant proponents of the new, medicalized version of psychedelics are “iatrogenically” participating in a particular kind of social sickness — one that has become pandemic in our culture but is less and less likely to be recognized due in large part to the pathologizing of human behavior. This sickness is what sociologists call “alienation,” a malady in which a person “does not experience himself as the center of his world, as the creator of his own acts,” instead feeling “estranged from himself,” as Erich Fromm described it.

Psychedelics are not palliatives swallowed to instantly eradicate psychopathologies (and neither are any of the pills your psychiatrist might prescribe, for that matter). They are liberating medicines which, when used in a supportive context, can enable people to fathom and deal with their suffering on their own terms. Used correctly, they can enhance our sense of our agency in the world. These chemicals work in a beautifully inefficient way, with the imprecision of poetry. And like poetry and art in general, they bring us back to what it’s like to be human here on earth.

Can psychedelics help with those forms of suffering psychiatry labels as depression, PTSD, and addiction disorders? Yes, they can, in remarkable and even revolutionary ways. But their ability to help with specific kinds of psychological suffering has to do with what they do in general: free our minds from repetitiveness and rumination. Forcing them into the sterile cast of a psychotropic pill that supposedly cures a pathology automatically, as a kind of “one weird trick,” carries the real danger of crushing that expansive effect, since it removes human agency and human connection from the scene.

When psychedelics work (and they don’t always work), their specialness lies in their ability to open our minds not only to ourselves but to the world around us. In doing so, they not only help us question personal narratives that may keep us stuck but social narratives that might hold us back. When used correctly, these substances are not quick-fix cures for illness but consciousness raisers — and raised consciousnesses tend to find the public causes for personal pain. This, too, is the danger in the current medicalized approach to psychedelics: a profound reductionism that doesn’t only reduce individuals into clusters of complaints but brands compounds that can help us see outside ourselves and comprehend the effects of social forces on our lives and the lives of others into just another little pill for skull-bound ailments.

The current mood around psychedelics is one of exuberance, but the changes that mood can bring also give us reasons for hope. Oregon is the first state to make psilocybin legal for therapy, and two omissions in the law there are particularly important: you don’t need to be labeled with a psychiatric diagnosis to enter therapy, and mushrooms will not need to be prescribed by a doctor. Perhaps that’s a sign that there will be room in this new renaissance for more than one approach to psychedelics: a way of seeing things more fluidly, with more openness and plasticity.

Like all cures, this will take human effort, since any attempt to decommodify psychedelics as magic pills for pathologized problems threatens to weaken a remarkably eloquent and powerful sales pitch. The most conscientious of healers and the most dedicated investors have one ethic in common: a commitment to place the needs of their constituents above their own. The current renaissance would do well to protect the Hippocratic mission of the former group. That doesn’t mean a complete abandonment of the latter, many of whom are opening their pocketbooks for altruistic reasons. But it does mean a prioritizing of “do no harm” over profits. And to get there, doctors and scientists would do well to welcome the elements in the psychedelic space that are focused on expansiveness, a heightened sense of encounter with the world, a connection to something bigger than us, sacredness, and even something as unscientific as “universal love.”

Despite the best efforts of the war on drugs, the psychedelics movement never actually died — it went underground, spreading fungally through nightclubs and warehouses, and in the apartments, homes, and offices of a growing number of therapists, “space holders,” and trip sitters willing to risk their own freedom to help others. This group, made up of individuals with decades of experience in the use of these medicines, holds an antidote to the current trend of pathologization in service of sales.