If psychedelics are going mainstream will they be accessible to everyone?

As some places in America begin to decriminalise psychedelic drugs for medical treatment, ethical questions are being raised about whether those who really need the treatments will be able to get them, writes Whitney Joiner

‘To me, that’s something that has been part of my mission in this work – to help more people of colour to be human, to relax. When presented in the right container, that is the power and the potential of this medicine’ (Getty)

On a sweaty Sunday morning in August of last year, Jamilah George was on the 16th floor of the historic Brown Hotel in Kentucky, leading a spiritual service of sorts. George, a doctoral candidate in clinical psychology at the University of Connecticut who also holds a master’s degree in divinity from Yale University, asked the audience to shout out the names of ancestors or people they admired. With each name, George performed a libation ritual, pouring water into a leafy green plant, stationed at the front of the podium, as a gesture of thanks. “Maya Angelou,” called out one audience member. “Mama Lola,” called another. The names kept coming: Toni Morrison. Audre Lorde. Mahatma Gandhi. Harriet Tubman.

George, who had been part of a team at UConn running the only clinical trial to study the effects of the psychotropic drug MDMA on post-traumatic stress disorder with participants of colour, wanted the audience to connect with its cultural lineages before she started her presentation – a bracing call for inclusion and social justice within the burgeoning world of psychedelic healing. It’s a world that holds great promise but is overwhelmingly white and economically privileged. Part of the problem, as George sees it, is that academia has lost its connection to the histories of these consciousness-altering substances (also known as entheogens), many of which have been used by indigenous cultures for physical and psychological healing for thousands of years.

“It’s up to us to find ways to disseminate resources and stop leaving them at the top, in the most elite research institutions,” she said to the small audience of psychotherapists, who were there to learn how psychotropic substances like methylenedioxymethamphetamine (MDMA) and psilocybin, the active ingredient in hallucinogenic (“magic”) mushrooms, could be used to heal mental and emotional distress. “We have to find ways to take this information and bring it down so it’s accessible,” she continued. “MDMA – you can’t even pronounce it! We have to find ways to make this information translatable. It’s like speaking another language.”

The next day, the public part of the inaugural Psychedelic Medicine & Cultural Trauma Workshop ended and the psychotherapist training began. Fifty therapists of colour had been accepted into the week-long training, hosted by Maps, the Multidisciplinary Association for Psychedelic Studies. In the training, therapists would learn best practices for using the entheogen MDMA to treat PTSD in their patients.

MAPS is currently studying MDMA-assisted psychotherapy as a method of treating PTSD. The clinical trials are in phase 3 – the last stage before approval from the US Food and Drug Administration – and Maps, which has been working toward this moment since its inception as a research and advocacy organisation in 1986, has been preparing for a post-approval world. Before the Cultural Trauma workshop in Kentucky, Maps had trained 285 therapists, with the idea that – while they can't legally practice yet – they will be ready to open their doors once approval is final. But fewer than 10 per cent of those trained were people of colour. If Maps wanted therapists to treat clients of colour, they would need to train therapists of colour.

Last year, there were at least 20 conferences in the United States covering the latest developments in psychedelic science and medicine. It’s a conference-happy community, which makes sense: most of the substances discussed at these events are labeled as schedule 1 or 2 by the US Drug Enforcement Administration, so, outside of clinical research, their use is illegal. (Schedule 1 drugs are considered to have the highest potential for abuse, with “no currently accepted medical use.” MDMA is a schedule 1 drug, as is cannabis, and is ranked as more dangerous than oxycodone and cocaine, which are both schedule 2.) Conferences are one of the few places where researchers, clinicians, advocates and the curious public can learn about developments in the field and meet other psychedelic proponents. Compared to a huge event like New York City's Horizons: Perspectives on Psychedelics conference, which has convened every autumn in New York for 13 years and last year brought in over 2,800 attendees, the two-day public workshop in Kentucky was tiny, with fewer than 100 participants and very little attention from a media that energetically covers psychedelic developments.

But the gathering – which featured talks on drug legalisation and systemic racism, presentations on indigenous healing methods, experiential group exercises, and even a dance performance – was groundbreaking. It was historic not only because it was the first such training for therapists of colour, but because it marked a turning point in the mainstreaming of psychedelics. Many of the organisers and presenters are part of a larger effort to diversify the world of psychedelic healing. They are pushing back against the popular narrative that psychedelics originated in white, mid-century countercultural movements and, perhaps most significant, fighting to ensure that the new field of psychedelic medicine – often touted as a miracle for long-standing and deep-rooted struggles like treatment-resistant depression, addiction, anxiety and PTSD – will be accessible to all. This includes black and non-white communities that have been historically over-policed and heavily incarcerated for possession or sales of some of these substances. (White people and black people are equally likely to use illegal drugs, a 2009 Human Rights Watch report found, but black people are arrested for drug offences at much higher rates than white people.)

George, who is black, spoke directly to these inequities at the climax of her talk. While white people might see psychedelic use as edgy or controversial, there is little legal risk in white use of these substances. “Western researchers have taken some of these indigenous religious traditions, using them outside of their spiritual context ... and then take it for ourselves and go to a rave and jump around and flash the lights,” George said. “We go in the mountains and have a self-discovery kind of experience.” Her voice rose as audience members clapped in agreement. “All of that is amazing. Let’s do that. But let’s bring others with us. Let’s find ways for those who have been oppressed for generations to experience the same freedom that some of us in this room have on a Saturday morning because they feel like it. Not on a Tuesday night when they’ve had to take off work and find a babysitter to take care of the kids so they can come to the clinic and participate in this research and pray that it frees them, so they can keep their families and keep their jobs.”

I had a boyfriend in high school who used LSD once or twice, and I don’t remember any remarkable transformations happening as a result

Monnica Williams, clinical psychologist

She continued: “Lives depend on us. You see what I’m saying? When you really think about it, when you break it down like that, lives depend on us.”

There is little legal risk in white use of psychedelic substances. But black and non-white communities have been historically over-policed and heavily incarcerated for possession or sales of some of these substances.

It would be hard to avoid coverage of what’s been called “the psychedelic renaissance”: it’s everywhere. In a recent episode of 60 Minutes, Anderson Cooper reported on successful clinical trials at Johns Hopkins and New York University that found psilocybin can help with, respectively, smoking cessation and binge drinking. Gwyneth Paltrow's Netflix show The Goop Lab dedicated an episode to following Goop employees at a healing psilocybin retreat in Jamaica, where mushrooms are legal. And, of course, there’s science journalist Michael Pollan's No 1 New York Times bestseller How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence. The politics around psychedelics are changing as well: with great effort from advocates, various measures to decriminalise possession of certain entheogens have passed in California, as well as Denver, and similar campaigns are under way in Chicago and other cities. In November, this movement will come to Washington, DC, when residents will vote on whether to decriminalise magic mushrooms.

Entheogens like peyote and ayahuasca have been used within indigenous cultures for thousands of years, but this latest wave of research has mostly focused on two substances: MDMA, a derivative of the sassafras tree, which was first synthesised in a lab in 1912 and used in therapeutic settings throughout the Seventies and early Eighties before being labeled a schedule 1 drug in 1985; and psilocybin, added to schedule 1 in 1971. Psilocybin is found naturally in some mushrooms and has been used in indigenous cultures all over the globe; mushroom iconography has been found in prehistoric cave paintings.

In the late 1990s, a handful of researchers started to take up the work that had been dropped when these substances were criminalised. (Dropped, at least, in aboveground situations; therapists continued, and still continue, working underground.) Now the field has exploded: when George says that “lives depend” on therapists learning to use these modalities, she’s not being dramatic. The numbers would impress anyone. In the Johns Hopkins smoking-cessation study, conducted in 2006 with a small group of participants, 80 per cent of long-term smokers stopped smoking for at least six months after their psilocybin treatment. After a year, 67 per cent were still nonsmokers. Nine years later, Johns Hopkins published the results of another trial in which psilocybin was used successfully to treat depression and anxiety in cancer patients, with the changes lasting in 80 per cent of participants after six months. The university has invested so much in the field that it launched a stand-alone Centre for Psychedelic and Consciousness Research last year and is working on studies to use psilocybin to treat addiction, anorexia and many other issues.

Meanwhile, in 2017 the FDA granted “breakthrough therapy” status to MDMA-assisted psychotherapy to treat PTSD, after privately funded Maps studies found that 56 per cent of participants experienced significant relief – so much so that they no longer met the requirements for PTSD. (The FDA can’t discuss ongoing trials, a spokesperson told me over email.) Breakthrough status is given to therapies that have shown great promise, with the idea that they will be given priority within the FDA approval process, and Maps predicts MDMA-assisted psychotherapy will be available sometime in the next few years. I’ve experienced the treatment myself: after editing a story about MDMA-assisted psychotherapy many years ago, I connected with a highly skilled underground therapist to address the lingering effects of my father’s death when I was 14, effects that talk therapy and meditation hadn’t relieved. While it was difficult and painful to face the trauma that I’d buried, I greatly benefited from the work.

But as study after study showed positive outcomes over the years, one thing was constant: there was little diversity among both the study leads and the participants. In 2015, Natalie Ginsberg, Maps’ director of policy and advocacy, came across the name of Monnica Williams, a clinical psychologist then at the University of Louisville. Williams, who is black, studied obsessive-compulsive disorder, anxiety and the effects of racism, and her work excited Ginsberg, who wrote to Williams to ask if she might be interested in working with Maps. “Social marginalisation compounds trauma,” Ginsberg told me via email. Regardless of the origin of their trauma, which could stem from any number of causes, including sexual assault, childhood trauma and military service, “people who experience the highest rates of trauma are those most marginalised from society, which in the US includes people of colour”.

Williams had no previous experience with psychedelics. “I had a boyfriend in high school who used LSD once or twice, and I don’t remember any remarkable transformations happening as a result,” she told me. It took some convincing. “It kind of seemed like maybe the fad of the week, you know?” recalls Williams. “Where they say, you know, you drink a glass of water with vinegar and lemon juice and you lose 50 pounds. Like, yeah, right. But actually reading the research, seeing the videos of the participants getting better ... when you do this work, you can look at people and you can tell: that person is really ill. And then you see that same person later and they’re smiling and their face is bright. And they’re making eye contact and they’re talking about the future. Seeing that whole progression on a videotape, that’s kind of what convinced me.”

In 2016, Maps invited Williams to join its clinical trials to study MDMA for PTSD, but her trial would be unique: it would include only participants of colour and mostly therapists of colour. There was no reason to believe that MDMA would not work as well with people of colour, but there was so little data that Maps and Williams had no way to tell.

Jamilah George researched anxiety and racial trauma, and came aboard the study after meeting Williams at a conference. George was initially wary. “I’ve always seen drugs as dangerous, leading to violence and incarcerations,” George told me. “Never something that I saw as a means to healing, certainly not for exploration or fun. Learning more about psychedelics was strange for me: I was around all white people, talking about their experiences with these substances and how they’d changed their lives and how much they’d learned about themselves. It was so foreign to me and really difficult to wrap my mind around. A world in which you can use an illegal substance and aren’t at risk for being arrested? It was like, where am I?”

The team spent two years preparing, using the guidelines set out by Maps. First they went through their own training, including a required MDMA-assisted therapy session of their own, called MT-1, so they could relate to and understand their participants’ experiences. They also had to find the right lab space at the University of Connecticut. Since MDMA alters consciousness, rendering participants more open and vulnerable – a state that allows for safe exploration, and then reprocessing, of trauma – the protocol requires them to spend the night after a treatment, which adds more regulatory issues and staff hours.

Trying to put the treatment into words – how does it work, exactly? – is a challenge, since psychedelic experiences are often ineffable, and people will respond differently depending on their unique circumstances, their brain chemistry and the setting in which the experience takes place. A note of caution, however: the research about psychedelic-assisted psychotherapy stems from therapeutic settings, where clients are carefully supervised, with adherence to protocols around usage and dosage – not a recreational one where multiple variables could be at play, like the purity of the substance and the surrounding environment. The few scientific voices expressing concern focus not on the research, but on the quick expansion of the field as a whole and the lack of research in non-medical settings. “If these drugs are approved as therapeutic treatments, will pharmacological-grade drugs become easily available and used and abused recreationally?” asked Washington University psychiatry professor Eugene Rubin in a 2018 Psychology Today article.

To describe the treatment, Maps therapists will often use the analogy of the body, says Sara Reed, a therapist in and study coordinator of the UConn trial. “The Maps language of the treatment approach is that there’s an intelligence that our body has, that wants to move towards healing,” says Reed, who is black. “When you get a cut on your arm, as long as you are in a pretty healthy, functioning body, your body’s going to know what to do to heal itself, to stop the bleeding and create the scab. We believe that the psyche also has that same property. The psyche wants to move towards healing, but sometimes there are barriers that get in the way of that healing process. Our philosophy in this treatment is to create a container where some of those barriers are removed, so folks can process traumas in their own way, at their own time.”

The therapy “helps you look at the bigger picture,” says Terence Ching, a doctoral student in clinical psychology at UConn and a therapist in the trial, who is Singaporean Chinese. “It almost feels like your life before was just zooming in on the puzzle pieces. Now you’re taking a step back – a few steps back – to see how things fit in. ... I can easily see how, for a person with PTSD who hasn’t responded to talk therapy, cognitive behavioural therapy or even medical marijuana, that this might be the thing that they might need to push things along so it clicks. And they can begin to enjoy their lives again.”

Despite the researchers’ optimism after their own experiences with MDMA-assisted psychotherapy, they soon faced obstacles. Williams quickly realised that the Maps protocol for how to recruit participants, and then how to take them through treatment, was not going to work. “We were basically trying to take a study that had already been designed for white people and make it work for people of colour,” she says. “The therapy has to make sense and feel like a good fit for the person getting it. And what may feel like good therapy for a white person may not necessarily resonate with somebody from a different ethnic group.”

This discrepancy showed up in recruitment. It seemed almost impossible to find participants. “The other clinics had long waiting lists of people trying to get into the study,” George says. “Our waiting list was empty.” The team realised they’d need to make some small but highly significant changes, like making sure they used the words “participant” and “study” in their materials, instead of “subject” and “experiment”. “We’re pretty aware of the history of medical atrocities committed against communities of colour in the United States,” Ching told me. “We really wanted the language, at least, to reflect that we’re aware of that. We want to be more inviting, because there’s already that layer of stigma and mistrust of the medical system that communities of colour have.”

Education during the recruitment period was different, too. “People of colour needed more support in the screening process,” Reed says, to combat the cultural stigma associated with seeking mental health help, as well as fears that using psychedelics, even in a clinical setting, might lead to a harmful outcome. “What are psychedelics? What is MDMA? Am I coming here to get high? Could you tell me about what the overnight session is going to be like? Am I going to be safe? So we had to spend a lot of time educating participants and providing the language throughout the screening process, from informed consent to enrolment.”

“‘I would be your therapist’,” George recalls telling potential participants. “‘Me, a black woman. The other person in the room will be a person of colour. There’s a whole team committed to make you feel safe.’ Then you have to make them feel safe enough to want to hear more, then provide education about what the drug actually is. You have to get them to want to do the study.”

Once participants did enrol, the team had to tweak Maps’ protocol further. Maps was on board, George says: “Like, ‘Hey, we hadn’t thought about any of these things, and thank you’.” During MDMA-assisted psychotherapy sessions, participants listen to music through headphones – often relaxing, instrumental pieces that you might hear in a spa or a yoga centre. The UConn team wanted to curate these playlists to allow for music that would match each participant’s cultural background and intersecting identities.

The physical space also allowed for more cultural representation. “The paintings on the wall, the magazine on the table, the coffee mug we had – we were just really intentional that anything that our participants would come in contact with would only further their feeling of safety and that they belong,” says George. “We wanted folks to come in and say, ‘This is familiar. I recognise this artwork. I see people who look like me.’ We were explicit about cultural representation in our individual presentation as well. Maybe I’d wear a kente cloth head wrap. Making sure that we ourselves represented our own culture as a means to model that behaviour for our participants so they can be fully themselves and let all their pain come forth – which is really difficult to do in a new space with new people, especially if you’ve never talked about that pain before.”

“What may feel like good therapy for a white person may not necessarily resonate with somebody from a different ethnic group,” says Monnica Williams, who led the trial.

Are we going to make it accessible to some of the most vulnerable populations that need it: people of colour, black folks, trans folks, trans women of colour particularly?

Sara Reed, therapist and study coordinator

Each enrolled participant was a small victory, a product of hours of psychoeducation. Reed says Maps wondered why things were different with their team. “They would ask questions like, ‘You are spending a lot of time with your participants. What’s this about?’ It wasn't like, ‘You need to stop,’ but it was just more of a curiosity. ‘What’s the difference in need at the site as opposed to other sites?’ The difference was that people of colour needed more support during the onset of the screening process and this treatment, so we could actually retain them. There were some participants who, if there weren’t active engagements with them during this introductory process, the participants got overwhelmed and would leave or withdraw from the study prematurely.”

Time was another issue. The current protocol for MDMA-assisted psychotherapy includes 42 hours of therapy over 12 weeks. This includes multiple sessions with therapists before the actual dose of MDMA. Then, there are three dosing sessions spaced a month or so apart, and each dosing session lasts a full day (MDMA’s most intense effects last around four to six hours) with an overnight stay. In between, participants are supposed to see therapists regularly to explore what came up in the dosing sessions, with a series of sessions after the final dose. Some of the potential participants in the UConn trial, however, found this time commitment to be insurmountable. The team wondered: could they combine appointments? “We were trying to accommodate, but it was really impossible for a lot of people to commit to it,” says George. The obstacles continued: potential participants had trouble convincing their families and partners that the treatment was worthwhile and safe. “[MDMA] is not a form of treatment that we’d typically experience,” says George. “It’s too foreign and scary for people.”

After two years of work, one participant made it all the way through: a client working with Sara Reed. The participant had “endured many experiences of trauma from his childhood, race-related trauma, trauma where his body was violated,” says Reed. “He carried so much in his body. In his first dosing session, [my co-therapist and I] saw his body relax in profound ways. He was laughing in such a way that I absolutely believe it was part of the release. He kept saying, ‘I feel so relaxed,’ and [my co-therapist and I] were looking at each other, witnessing his process of being able to relax for the first time in a long time – or ever, as an adult in this body, with all of its histories and complexities and memories. For him to be human: he wasn’t a person of colour, he wasn’t a person who had traumatic experiences; he was someone who got to be human. It reminded me of my own experience of MT-1, where I felt freedom for the first time in my body. Of course we need more research to back this up, but I’ve found that people are able to experience some sense of freedom in their body with this medicine. To me, that’s something that has been part of my mission in this work – to help more people of colour to be human, to relax. When presented in the right container, that is the power and the potential of this medicine.”

But after losing the prescribing psychiatrist on her team – the only member legally able to prescribe MDMA – Williams was forced to shut down the clinical trial altogether. It was a crushing disappointment, but also not surprising considering the obstacles they faced. “I think it’s more symbolic in a lot of ways,” Williams says of their research. Even if they’d successfully completed treatment for the 10 participants they’d originally planned for, it still wouldn’t have been enough data to say for certain how MDMA-assisted psychotherapy works with people of colour versus their white counterparts. “I think the bigger value is the amount of attention that this effort has gotten” within the psychedelic research community, Williams says. “And how that's been able to bring more changes, much more than we could have gotten out of the study itself.”

The training conference in Kentucky was a direct result of their partially completed study: The obstacles and the systemic issues pointed out by Williams and her team got the attention of Maps and, crucially, its donors. (Donors to Maps, a tax-exempt, charitable organisation, span the political spectrum and include Dr Bronner’s soap company, author Tim Ferriss and the Mercer Family Foundation; the Kentucky workshop was funded by the Open Society Foundations, Libra Foundation and the RiverStyx Foundation, among others.) “If you want this [treatment] to be accessible to people of colour, you can’t use the same strategies that marginalised them in the first place,” says George. Marcela Ot’alora, a Colorado-based psychotherapist who has been involved in Maps’ MDMA work since the organisation’s inception, helped lead the therapy training in Kentucky. “There are so many places where marginalised communities have to put up with going to a practitioner that is white and is not going to treat them the same way, or is not going to understand, and is going to maybe do things that are harmful in some way without knowing it,” she says.

Even with a new focus on inclusivity within psychedelic-assisted psychotherapy research, questions remain around issues of access. If and when the FDA approves MDMA used for PTSD, it will not be widely available; it will be an option only for people with a formal clinical diagnosis of PTSD. It will also be incredibly expensive: estimates range from £10,000 to £12,000 per treatment round, and it’s not clear what might be covered by health insurance. The cost is not about the substance; it’s the therapeutic hours that will be required – the 42 hours of therapy, including three overnights – and the fact that therapists work in teams of two, a measure taken for patient safety. Clinicians are trying to figure out how to bring that immense cost down. Fewer appointments? Can the work be done in a group, so multiple clients can work together at the same time? (This is often how entheogens are used in traditional and indigenous settings.) A sliding scale? Pro bono?

As lengthy as the process to FDA approval has been, there’s still a lot on the line for clinicians and activists. They want to see these treatments available, but they want to get them right. To this end, Maps is launching a health equity initiative this autumn to benefit marginalised clients, including therapist and supervisor scholarships and patient access funds. “It’s important to really slow down and really think about what – if we move towards mainstreaming psychedelics using psychotherapy – what implications does this have,” says Reed. “Is this going to be an elusive form of medicine, where there's going to be a select few who have the luxury to take the time off to get the treatment, or who have the funds to purchase the treatment? Or are we going to make it accessible to some of the most vulnerable populations that need it: people of colour, black folks, trans folks, trans women of colour particularly? ... Who are we really targeting in psychedelic medicine? That’s a huge question.”

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