The Broken Paradigm

Today, one in three Americans suffers from anxiety, depression, or both (globally, that number is about one in twenty), and one in six Americans is on a psychiatric medication. These numbers reflect the broader trend that about half of all mental illnesses go untreated.

The sources of the current mental health crisis are numerous and varied, but two causes must be mentioned in any serious account. The first is the current fragile state of American society. In the last fifty or so years, incomes have stagnated, personal debt has skyrocketed, politics and culture have become hyperpolarized, and communal life has collapsed, leaving Americans materially insecure, fearful, and atomized — all feelings exacerbated of late by the COVID-19 pandemic. Naturally, these social conditions take a toll on people’s mental health.

The second is the dysfunctionality of mental health care itself, a component of the broader practical absurdities of the American health care system, but also a problem with its own particular history. In the last half century, Americans have fallen prey to what medical historian Edward Shorter calls “neurotransmitter chatter.” Psychiatrists agree that troubled human beings are, from their professional perspective, no more than broken brains. Patients have adopted this outlook too. As Joseph E. Davis argues in Chemically Imbalanced, many have so thoroughly absorbed the language of the biological revolution that they now explain their own conditions in terms of dopamine and synapses, as though this vocabulary were adequate to the task of describing human interiority. The convenient result for pharmaceutical companies and insurers is that the solution to every psychiatric problem is a pill, typically taken on a regular basis.

This model of care is reductive, callous, and existentially insulting. And to make matters worse, the drugs aren’t even good. This is partially the result of a misguided preference for site-specific drugs (like SSRIs and SNRIs) over so-called “dirty” drugs with less specific actions. It’s also partially the result of the industry’s entire drug development model, which prioritizes chronic (i.e., moneymaking) over curative treatment. The case of Prozac is illustrative: in a majority of double-blind studies, sugar pills equal or outperform Prozac and similar antidepressants. Prozac also causes a small but significant number of people to become violent and suicidal, and users for whom it is effective sometimes get addicted and develop a tolerance to it. The drug that is virtually synonymous in the public imaginary with the profession of psychiatry is about as smart as the whole paradigm that has elevated it as a miracle cure.

The insufficiencies of this model have grown more glaring with each passing decade, and psychiatry no longer enjoys the hegemony it once had. Many Americans know they need help, and they know the prevailing mode of psychiatric care is deeply flawed. This is what distinguishes the psychedelic renaissance from previous moments when America’s dominant regime of “punitive prohibition” was relaxed. Americans like cocaine and marijuana. Today, from the sociological and psychopharmacological perspectives, they seem to need psychedelics.

A Fork in the Road

Things don’t always go as planned. Maybe certain Big Pharma executives decide they don’t like the threat of market disruption and proceed to muddy the waters of psychedelic research. Maybe psychedelics are absorbed into the culture war, and a Republican president with Republican control of both houses goes on the offensive. But these are increasingly less likely scenarios than that of medical legalization and cultural mainstreaming. The social situation, in combination with the failing mental health care system, almost recalls William Burroughs’s description of “the algebra of need” in Naked Lunch: leave a sick junkie in charge of drug policy and only one result is possible.

Psychedelic researchers and enthusiasts are fully aware that they are speaking to the current moment, and that, when it comes to legalization, the winds are blowing decisively in their favor. For them, however, a different kind of threat to the psychedelic renaissance is looming, one that promises not a new enlightenment but a return to medieval darkness.

In Ascani’s view, there are two tracks currently being laid for the psychedelic rollout. The first track is the one that he is on, a track devoted to a “fidelity to relationships, consciousness, exploration, and transformation.” For him, the existing psychiatric model is essentially a suppressive one: “You can maybe be a little bit more comfortable, not suffering, but you’re still not better. You care less, perhaps.” In his effusive description, characteristic of what he calls the “whole psychedelic movement,” the emerging model is almost diametrically opposed to this existing one. It’s about using psychedelics not as maintenance medications but in combination with talk therapy to transform “people’s lives through their own inner healing intuition and creativity.” It’s not about acclimating oneself to the existing world but about being open “to other realities and paradigms of living and being in the world.” It’s about “leaving behind this capitalist model” for one that is “true to what psychedelics are.”

The second track, by contrast, involves “going along with the institutions that are already in place and co-opting this technology to fit the existing system.” After decades of drug development stagnation in the realm of psychopharmacology, the legalization of psychedelics promises something truly innovative for pharmaceutical companies to sell. The ketamine nasal spray Spravato, prescribed as an antidepressant, is perhaps a harbinger of things to come. Think of microdosed psilocybin prescriptions doled out in the same fifteen-minute sessions psychiatrists are already accustomed to. Think of boomers dropping acid once again, but this time out of paper cups in their nursing homes. Think of Peter Kramer doing a “find and replace all” and rereleasing Listening to Prozac as Listening to Ecstasy.

Even more than the drugs that psychiatrists use, it’s this reductive psychiatric paradigm that psychedelic practitioners reject today. While often dismissive of the excesses of the ’60s as having set back psychedelic medicine by a generation or two, they still maintain a certain countercultural ethos in imagining their practice as almost the exact opposite of the dominant model of psychiatric care. They know, however, that the same historical opportunity for a paradigm shift in mental health care also provides an occasion for revitalizing the existing paradigm with much better drugs.

The Psychedelic Gold Mine

Sadly, for psychedelic practitioners, these two tracks will likely have to coexist for the foreseeable future. One might be potentially transformative, but the other is ruthless and resourceful.

A combination of traditional pharmaceutical companies like Johnson & Johnson and large market disruptors like MindMed and Compass Pathways are ready to capitalize on legalization. Peter Thiel–backed Compass Pathways has been aggressively cornering certain parts of the psychedelics market, including patents on synthetic psilocybin. Some estimate that the psychedelics market will grow to $69 billion by 2025, about two-thirds the size of the global craft-beer market today.

The traditional path also has many valiant defenders claiming the mantle of responsibility. In a 2021 article for the Journal of the American Medical Association, David Yaden, Mary Yaden, and Roland Griffiths warn that psychedelics in psychiatry might be “going off the rails.” They see the first path as one of “exuberance, utopian thinking and uneven clinical approaches,” and the latter “a more careful and systematic one” involving “the appropriate integration of psychedelic treatments into existing evidence-based psychiatric paradigms.” Therapists Ross Ellenhorn and Dmitri Mugianis responded recently in Jacobin that it is precisely absorption into this existing paradigm that is the biggest threat to psychedelics.

No doubt the flame wars are just beginning. In the coming years, there will be countless articles bemoaning a movement betrayed, lamenting the commodification of a once spiritual, transformative practice. For some, leading lights like Rick Doblin of MAPS have already sold out. In a 2018 interview, he publicly defended Compass Pathways as follows:

The other concern you have with for-profit development is this sort of critique of capitalism, that it’s all about profit maximization and that it doesn’t take into account human needs — it’s all about making money. I think that’s not the case. From all that I know about Compass and what they’re trying to do, I think they have both financial and humanitarian motives. . . . So I think we’re in a terrific situation, and the easy criticism of “Oh capitalism is bad, for-profit companies are bad and they are trying to do evil things with psychedelics to monopolize the market” — I don’t think that’s really happening. I think we all have to give each other the benefit of the doubt and just watch what people do and watch what happens.

Still, one could argue that from a macro-historical perspective, all of these are good signs for psychedelics. Drugs tend to be prohibited when powerful actors within the ruling class decide that the masses should not have them, and legalized when the opposite is the case. You can think Peter Thiel is an awful person but nonetheless be happy that he is a psychedelics investor.

And indeed, it’s precisely what psychedelic practitioners despise that offers the most convincing evidence that psychedelics will soon be legal. It’s not the studies on post-traumatic stress disorder and depression that promise to usher in a new era of transformative medicine. It’s the possibility of capitalizing on the current mental health crisis at a low moment for existing psychiatric practice. New kinds of therapy will undoubtedly emerge on the first, more transformative path of psychedelic development, but they will be predicated on the old structures renewing themselves and remaining in place.

In brief, psychedelics today are first and foremost a business opportunity embedded in a failing system, not unlike Medicare Part C plans. A depressing conclusion, perhaps, but it’s probably best to stay grounded in that fact in anticipation of the surreal marketing to come.

Of course, it seems callous to toss aside the psychonauts as incidental to the movements of structural forces and large corporations. The psychedelic movement has demonstrated a commitment, patience, and discipline that most movements can only dream of. Where does credit for their dogged efforts lie in the present moment?

Purveyors of “The More”

The United States is notoriously a country of hucksters and charlatans, of quack cures and flimflam. All culture circles around a funnel draining inevitably toward “One weird trick.” As a result, the United States is also a country of committed paranoids, always on the lookout for scams and lies — a tendency stoked and gratified in the partisan culture war. Anthropologist Joseph Dumit describes the contemporary patient’s approach to making informed medical decisions as “objective self-fashioning for the rationally paranoid.” The phrase teems with broader significance.

But as much as we don’t want to be dupes, we also want to be taken in; we want to believe; we want what William James famously described simply as “the more.” American capitalism desperately seeks to cater to this desire, but its promises ring hollow and its visions do not compel. When it’s obviously business all the way down, no amount of dressing up the latest technology can inspire genuine belief. Thus, despite their psychotic enthusiasm for “innovation,” biotech executives are not going to give us “the more,” and neither are their billionaire backers like Peter Thiel.

But people like German Ascani can. Talking with Ascani, I found his enthusiasm and authenticity enlivening. I saw no reason to doubt that his own life had been transformed by psychedelic medicine, and that he was completely earnest in his belief that psychedelics could similarly transform the lives of his patients. In his cogent characterization, psychedelic-assisted psychotherapy promises a form of insight, healing, and transcendence almost wholly unavailable in existing models of psychiatric care. I, for one, was sold.

Herein lies the uneasy contribution of participants in the psychedelic movement to the present renaissance. Their unwavering faith in the consciousness-raising and emancipatory value of psychedelics, while paving a new and transformative path for psychotherapy, is also one of Big Psych’s greatest assets. Compass and MindMed could not ask for better marketing copy than the genuine and inspiring endorsements that earnest psychedelic practitioners provide. Thanks to them, psychedelics can float above the sea of snake oils, buoyed by the liberatory characterizations of the true believers. It is such believers who, by their own characterization, hold the “antidote to the current trend of pathologization in service of sales” — and thus it is they who will ultimately depathologize and destigmatize the sale itself.

The psychedelic renaissance is undoubtedly hurtling toward enlightenment, but it’s an uneasy enlightenment, fueled by a powerful mythology that speaks to a country desperately wanting to believe. It’s unclear what could alter this dynamic at this point. As Rick Doblin said, it’s time to “just watch what people do and watch what happens.”