Therapeutic Psychedelics
Psychedelic-assisted therapy is showing promise in reducing cancer-related anxiety and depression and post-traumatic stress disorder. Why? The answer seems to include our human need to find meaning and connection.
Wendy Dubin describes having ovarian cancer as not only a physical challenge but an existential crisis that robbed her, in her words, of her soul. After two occurrences of the cancer, with associated surgeries and rounds of chemotherapy, Dubin was in a “disease-free state” — physicians don’t use the term “remission” for a cancer that is considered incurable, which Dubin’s is.
But the normally vibrant, active woman was in constant pain, frightened, and demoralized. “I was getting from day to day, but I didn’t feel like I was living,” she says. “I was enduring.”
When she heard about a clinical trial being run at Emory involving psilocybin — the mind-altering compound in “magic mushrooms” — she jumped on it.
So one day in February, Dubin lay down on a twin bed in a cream-colored room with a gray fur rug and several potted plants within the Emory Brain Health Center. Two therapists sat in comfortable chairs facing her, and two physicians stood nearby as she took a pill containing 25 mg of psilocybin.
Dubin embarked on an experience she describes as spiritual, emotional, and life changing. “Yes, I still have blood work every six weeks, and I still have to go in for MRIs every six months, but I’m living with this very differently now,” she says. “I don’t ruminate on it constantly. I’ve stopped crying myself to sleep every night. If my pain scale used to be a six or seven, now it’s maybe a two. I feel 10 years younger, and I got my spirituality and my connection to God back.” (For more on Dubin’s story, see “One Patient’s Experience with Psilocybin-Assisted Therapy,” following this article.)
Dubin was participating in the first clinical trial run out of the Emory Center for Psychedelics and Spirituality. With the center, which launched in August 2022, Emory joins a burgeoning field of institutions studying psychedelic-assisted therapy to treat depression, anxiety, post-traumatic stress disorder (PTSD), and despair associated with serious medical illness. Indeed, after decades of stigmatization, psychedelic medicines now are being hailed as the most promising new mental health treatments in a half-century.
Boadie Dunlop and George Grant of the Emory Center for Psychedelics and Spirituality, in the room where patients receive psychedelic-assisted therapy.
Boadie Dunlop and George Grant of the Emory Center for Psychedelics and Spirituality, in the room where patients receive psychedelic-assisted therapy.
The Emory Center for Psychedelics and Spirituality, however, is one of just a handful of the centers that are studying psychedelic medicines while attending to the spirituality of the patient. That’s likely because spirituality is usually considered to fall outside the bounds of science. This despite the fact that spiritual experiences — not necessarily religious, although they can be — are often a key part of a psychedelic experience and a big component of its therapeutic value.
“Historically, to get to the place where psychiatry was respected as a scientifically valid component of medicine, spirituality had to be left behind,” says Boadie Dunlop 01MR, co-director of the ECPS and director of the Mood and Anxiety Disorders Program in the Department of Psychiatry and Behavioral Sciences. “However for millennia, spiritual health — which I define as the human search for meaning and connectedness to something greater than the self — has been integral to many people’s mental health. Psychedelics enable you to activate spiritual material. Why would we not want to look for ways to incorporate that into the healing psychotherapy of the patient?”
And at Emory, spirituality is considered scientific. It is studied as such in the Department of Spiritual Health in the Woodruff Health Sciences Center. The department maintains a robust research program focused on developing and testing novel, evidence-based interventions that harness the power of spirituality to enhance human health and well-being.
“Emory is unique in bringing together rigorous biomedical psychiatry with formal expertise in religion and spirituality,” says Charles Raison, director of research in Emory Spiritual Health as well as professor of psychiatry at the University of Wisconsin-Madison. “Emory has real expertise in both of these realms, which really sets the work that is going on here apart.”
A Brief History of Psychedelics
Humans have been ingesting psychedelic compounds, presumably for the mystical states they induce, for thousands of years. In a cave in Algeria, a mural dating back 7,000 to 9,000 years depicts a shaman with mushrooms sprouting out of his body. Strands of hair dating back 3,000 years found inside a cave on an island off the coast of Spain tested positive for a number of psychoactive drugs.
Psychedelic compounds, particularly psilocybin and LSD, began to be examined for their therapeutic value in treating alcoholism in the 1950s and 1960s. The hippie counterculture, though, was embracing magic mushrooms, LSD, and other psychedelics at the same time, leading to a backlash. In 1970, the Controlled Substances Act classified psychedelics as Schedule I controlled substances, ending research on the drugs for the next several decades.
Study resumed within the past two decades. In 2016, Johns Hopkins Medicine and New York University’s Langone Medical Center concurrently released findings showing therapies involving psilocybin could safely and effectively relieve anxiety and depression in people with cancer, launching the next era of psychedelic-assisted therapy studies. In 2018, the Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA) classified psilocybin as a “breakthrough therapy” for depression, paving the way for more studies and, potentially, for the eventual approval of the drug as a treatment for mental health conditions.
The video pictured above, "Psychedelics" on Your Fantastic Mind, is available at the end of this article.
How Psychedelics (May) Work
Researchers are not completely sure how psilocybin and other psychedelics work. They know psychedelics are serotonin agonists, which means they powerfully turn on a subtype of serotonin receptor that some drugs used in psychiatry block. Either through this or some other mechanism, psychedelics enable parts of the brain that don't typically communicate to develop cross-talk and new connections.
“The brain functions through specialized networks consisting of different regions of the brain that act in synchrony when performing certain mental functions. These networks tend to have a lot of activity within themselves, but don’t communicate much with other networks,” says Dunlop. “With psychedelics, it’s like the brain is having a big block party, and all of a sudden everybody is talking with everybody else. That is why some people experience synesthesia — where colors have textures, for example — and likely why people have mystical or spiritual experiences.”
Regardless of how psychedelics work, studies show they do, at least for some. About 30 percent to 50 percent of people who take a high dose of a psychedelic have a mystical experience. Although each psychedelic experience is unique, there are some hallmarks of these experiences. People may feel connected to the universe, to a higher power, and/or to people who came before them or will come after. They may feel themselves in the presence of a divine power. They may feel their sense of being a separate self dissolve. They may gain a third-person perspective, looking back over their lives and beliefs from a more detached point of view. Even if a person does not achieve a spiritual experience, they often have an emotional breakthrough, a catharsis or insight that allows them to reframe their thinking around the roots of their depression and anxiety.
“We know these compounds work for many,” says Raison. “You take people who are really depressed and give them a high dose of psilocybin in a clinical setting and the antidepressant effect is rapid, profound, and sustained. A single pill can produce weeks and weeks — sometimes months and months — of powerful relief from depression. That is so unusual. The field is not going to abandon it.”
From Naysayer to Proponent
Dunlop was a reluctant convert to psychedelic-assisted therapy. “Around 2016, one of my residents kept telling me I needed to start reading about psychedelics,” he says. “We had a years-long discussion that always ended with me saying, ‘No, these are drugs of abuse. We are not going there.’
“I’m an NIH-funded researcher, a clinical trialist, and a psychopharmacologist — that’s who I am,” Dunlop continues. “But I do treat patients, and I recognize the limitations of our existing treatments. It took a while, but once I started to understand how these drugs could open people up to process emotionally powerful material that might be impossible to achieve in other ways, I reluctantly began to give it a bit of credence.”
Charles Raison, director of research, Emory Spiritual Health.
Charles Raison, director of research, Emory Spiritual Health.
Dunlop and colleagues in the Department of Psychiatry and Behavioral Sciences started to act as investigators in clinical trials involving psychedelic-assisted therapy. Dunlop collaborated with Barbara Rothbaum, associate vice chair of clinical research in the psychiatry department, in her study using MDMA (also called ecstasy or molly) to enhance the speed of overcoming learned fears, which is directly applicable to the treatment of PTSD.
He led the Emory portion of a multisite psilocybin study by COMPASS Pathways, a biotechnology company. “In the COMPASS trial, I saw patients with treatment-resistant depression — which as the name implies is notoriously hard to treat — who didn’t need to go on an antidepressant a year after treatment,” says Dunlop. “And this is after a single dose of psilocybin. They talked about how they saw the world differently, how they re-conceptualized their suffering.
“Compare that to the medications I’ve prescribed for decades that basically numb the pain as well as other emotions,” continues Dunlop. “This was different. This was transformative. At that point, I was thinking this is a real thing that we need to be studying and figuring out how to use properly and safely.”
In other words, Dunlop stopped giving psychedelic-assisted therapy just a bit of credence. He embraced its possibilities.
The Science of Spirituality
George Grant doesn’t mince words when he talks about spiritual health at Emory. “With regard to training, research, and service, we have the strongest spiritual health department of its kind in the world,” says Grant, the other co-director of the center and executive director of Spiritual Health. “And what is truly unique is that the department operates within the Woodruff Health Sciences Center, which includes the schools of public health, nursing, medicine, and Emory Healthcare.”
That was by intent. When Grant stepped into the department in 2014, it was one of the largest health care chaplaincies in the country, but it was purely hospital-service focused and not seen as a part of the total academic medical center enterprise. Grant wanted to change that. He immediately replaced the department’s name — Pastoral Services — with its current moniker, Spiritual Health. He began referring to chaplains as spiritual health clinicians.
Grant succeeded in incorporating the department “as a discipline among disciplines” within the Woodruff Health Sciences Center, and perhaps most important, he embarked on scientific study in a field not typically viewed as scientific.
“We reconstituted to be a health science discipline, so we needed to conduct studies and develop evidence-based interventions,” says Grant.
He did just that. Grant, along with expert clinicians, educators, and spiritual health researchers developed Compassion-Centered Spiritual Health.
This intervention, in fact, builds off another developed at Emory in studies led by Raison and Emory College’s Lobsang Tenzin Negi — Cognitively-Based Compassion Training, a meditation system that has its roots in Tibetan Buddhism but was developed by Negi as a secular program to cultivate compassion.
Compassion-Centered Spiritual Health is used to train chaplains to sustain compassion and improve resiliency, and to develop bedside interventions spiritual health clinicians can deliver to patients, family members, and medical staff experiencing distress. The team has widely published its findings in peer-reviewed journals.
The Center for Psychedelics and Spirituality
Buoyed by the success of applying scientific rigor to methods for improving spiritual health and well-being, Dunlop and Grant brought together an interdisciplinary team from the Department of Psychiatry and Behavioral Sciences and the Department of Spiritual Health to form the Emory Center for Psychedelics and Spirituality. Within its first year, the center put on the inaugural Science on Spiritual Health Symposium, drawing more than 1,000 participants online and 200 in person to demonstrate how the center is incorporating spirituality into the study of psychedelic-assisted therapy. The center’s scientists published a conceptual paper in JAMA Psychiatry on the same topic. And the center launched its first clinical trial.
Led by Ali John Zarrabi, assistant professor in the School of Medicine’s division of palliative care and program director for palliative and supportive care in the Emory Center for Psychedelics and Spirituality, and funded by Emory’s Winship Cancer Institute, the trial has recently concluded dosing 10 people with cancer who suffered from demoralization and chronic pain.
“I was motivated by the pretty remarkable findings from early studies showing dramatic improvement among many — but not all — patients with anxiety, depression, and other psychiatric distress as a result of living with a serious medical illness,” says Zarrabi. “I also wanted to look at the potential for relieving physical pain. There is a great deal of overlap between psychological and physical pain, and in this pilot we are exploring whether a dosing session can also influence your perception of pain and how you cope with it.”
Ali John Zarrabi, assistant professor of palliative care at Emory School of Medicine and program director for palliative and supportive care in the Emory Center for Psychedelics and Spirituality.
Ali John Zarrabi, assistant professor of palliative care at Emory School of Medicine and program director for palliative and supportive care in the Emory Center for Psychedelics and Spirituality.
Each participant is paired with a licensed mental health clinician and a spiritual health clinician, and the small team meets for three two-hour sessions before the psychedelic session. The same team is together for the eight-hour psychedelic session and then meets for three two-hour sessions after the experience.
In the preparation sessions, the mental and spiritual health clinicians prepare the participants for what they are going to experience, ask how they want to be comforted should they become anxious during the psychedelic experience, and help them set clear intentions for the session. A therapeutic alliance is formed in the triad relationship. Life history, culture, and current life happenings are discussed, and a trustworthy bond develops.
Both therapists stay with the participant during the day-long psychedelic session. They provide comfort when needed and, in the event of distressing or scary periods, encouragement to remain engaged and intentional. Inner work is accompanied by a music track or conversations with the therapists. Extensive notes are taken by the clinicians to be used in subsequent sessions.
In the post-psychedelic integration sessions, the therapists help the participant talk through what they experienced and how it relates to the intentions they set. These sessions take advantage of a change in the brain induced by the psilocybin. “These drugs increase synaptic plasticity, allowing new connections between neurons to form,” says Dunlop. “Those connections are not necessarily strong — they grow, and they can recede. The integration sessions make use of those new synaptic connections to strengthen them and make them more durable. So those old ways of thinking about feelings or events now become shapable, moldable in new ways because of what the medicine is doing biologically.”
Caroline Peacock, director of spiritual health at Winship Cancer Institute and a spiritual health clinician at the center.
Caroline Peacock, director of spiritual health at Winship Cancer Institute and a spiritual health clinician at the center.
Having highly trained therapists, including those with spiritual health competency, for the entire process may be critical to the outcome. “During the psychedelic session, people often experience non-ordinary states of consciousness, perhaps where they feel one with the universe, or connected to the divine, or they meet deceased ancestors,” says Caroline Peacock, director of Spiritual Health at Winship and a spiritual health clinician in the Emory Center of Psychedelics and Spirituality. “Spiritual health clinicians are used to being with people in altered states of consciousness. We’re with people when they are in profound grief, and when they are dying. Many of us have personally experienced nonordinary states of consciousness as part of our training, perhaps through hours of sitting in meditation or prayer. We have the unique clinical expertise to help people handle the complex spiritual material they might encounter.”
Results of the current trial have not yet been released, but Zarrabi says while several participants had a transformative experience, such as Dubin’s, some did not. Zarrabi will follow the participants for 90 days postdosing to gauge the treatment’s effectiveness in relieving pain and demoralization. He expects to publish his findings in the spring.
“There is a long road ahead with many unanswered questions, but our study is laying the groundwork,” says Peacock. “In decades to come, I want people to receive spiritual health services as part of psychedelic-assisted therapy. For that to happen, we have to be able to demonstrate this type of care is evidence-based and effective.”
Going Forward
Are there personality characteristics that can predict who is likely to benefit from psychedelic-assisted therapy? Are religious people more likely to have transformative experiences than atheists? Would some people benefit from two or three doses of a psychedelic instead of just one? How often should a person have psychedelic-assisted therapy? These questions and more remain unanswered, and the center’s team is hoping to chip away at them.
The team would like to continue testing its triad model — a mental health clinician, a spiritual health clinician, and a care seeker — in future clinical trials and is considering opening the therapy to a broader array of participants, perhaps people suffering from chronic neurological diseases such as ALS (amyotrophic lateral sclerosis or Lou Gehrig’s Disease).
Dunlop, Grant, and the center’s team also are working on what they see as a large part of the center’s mission — defining harms or adverse events. They are painstakingly documenting various ways people might be harmed from this therapy — physically, emotionally, socially, spiritually. “Whenever you have a powerful treatment in medicine, there is always risk for harms,” says Dunlop. “With all the hype surrounding psychedelic-assisted therapy, the field urgently needs an understanding of harms that can result: what they are, who is most likely to suffer them?”
Training future therapists—spiritual health clinicians and mental health clinicians—in psychedelic-assisted therapy is another part of the center’s mission. Grant envisions a two-year intensive training program, perhaps a certificate or master’s program, where members of other health care disciplines can get didactic, hands-on clinical training.
All of this work is gearing up for FDA approval of psilocybin for therapeutic use, which experts predict could come around 2026. Already, Oregon and Colorado have legalized the therapeutic use of psilocybin. And experts predict MDMA will be approved to treat PTSD sometime next year.
“It’s right on our doorstep,” says Grant. “When FDA approval for these medicines comes, we want to be able to have a brick-and-mortar clinical service for persons in need of this unique healing and to provide a world-class training ground for future leaders in the field of psychedelic medicine. Our mission is to continue our important research in treating major depressive disorder, PTSD, neurodegenerative disorders, end-of-life distress, and many other associated health distress concerns.”
Dubin hopes Grant and his colleagues are able to do just that. “I’m a 69-year old woman, mother of two and grandmother of six,” she says. “I’m also a psychotherapist, my experience with drugs has been limited to dealing with clients suffering the harms of habitual abuse. So I’m not the person you would think would raise her hand and say, ‘Yes! I want to do this!’ But I am so glad I did. For me, the experience was transformational.”
‘You Don’t Have to Be Afraid’
One Patient’s Experience with Psilocybin-Assisted Therapy
Wendy Dubin was 61 with a thriving psychotherapy practice in Dunwoody, Ga., and two new grandchildren when she was first diagnosed with ovarian cancer. Surgery and chemotherapy rid her of the cancer, but it returned three years later, as the doctors had warned her might happen. Her cancer was considered recurrent, possibly incurable.
Living with a life-threatening disease changed her psyche even more than her body. Dubin continually felt bad, with chronic pain and fatigue. She had to stop counseling patients — although she was eventually able to start back with a smaller telehealth practice. She could only plan her life in six-week increments, between the blood tests that told her if the cancer had returned.
She felt isolated, demoralized, and brokenhearted. She sometimes carried a stone she found with a crack in it, symbolizing her broken heart. She also carried a tremendous sense of guilt. “My daughter and daughter-in-law were having their children, so this was supposed to be a time of joy, and I was making everyone worry about me,” she says.
As a therapist, Dubin knew the tools to deal with anxiety and despair. She took therapy of her own. She did yoga, exercise, meditation, and ceremonial rituals. “I was actively pursuing a way to feel better, but nothing worked,” she says. “I was so angry with God and cancer. Losing my connection to a higher power was a big part of what I was struggling with. I was going through all this without feeling grounded.”
So when Dubin heard about Emory’s clinical trial using psilocybin-assisted therapy to treat cancer patients with chronic pain and demoralization, she knew she wanted to take part. “I wanted to do the dosing right away,” she says, about her first meeting with her psychologist and spiritual health clinician. “There wasn’t an ounce of me that was anxious or fearful, and I was ready to get on with it.”
The therapists, however, helped her to slow down and properly prepare for the psychedelic session, including setting her intentions. “They suggested using words like acceptance, but that didn’t work for me,” she says. “I did feel comfortable with the idea of integration. So the intention we ended up with was to integrate everything that was happening — the medical trauma, the guilt, the broken heart. They pulled it together in a language that worked for me.”
One day in February, Dubin went to a room in the Emory Brain Health Center for her psychedelic session. She brought with her a blanket, a picture of her family, her cracked stone, and printed copies and a recording of her daughter singing the Jewish Prayer of Healing. Her two therapists and two physicians sang along to the prayer the best they could. “At one point, I looked up and they were singing with me,” says Dubin. “There wasn't a dry eye in the house.”
Then her spiritual health clinician read back her intentions, and Dubin took the pill containing 25 mg of psilocybin, donned an eye mask, and lay down to begin her journey.
The medication, says Dubin, had a feminine voice and presence. “The first thing she said to me was, in the kindest, most compassionate, loving, and gentle way, ‘You don't have to be afraid. You're not alone. You can let go.’”
Then the medication asked permission to enter her brain. “I said yes, and it was only at that point that I could feel the medicine entering into my brain,” says Dubin. “It was a bit colorful, like tiny mosaics. I was observing it and experiencing it at the same time, and I thought, ‘My brain is getting rewired. That’s pretty cool.’”
A second presence then materialized: God. “Both God and the medicine had a voice and a physical presence — not in the sense of a body, but in a spiritual sense. God told me, ‘I’ve always been here for you. You’ve never been alone.’ Then he told me he was going to take the burden of guilt I had been carrying and I didn’t need to carry it anymore. He enveloped me with love, compassion, gratitude, and kindness while my pain was eased.”
She describes the experience itself like labor in childbirth: “There's the calm before the contraction, but you know it's coming. Then there's the buildup, the intensity, and the coming back down on the other side. You get a period of calm again before the next one. Well, that's how this was for me.”
Many of her experiences involved difficult periods from her life and from the lives of others. “I understand now that the medication finds these unresolved traumas and gives you an opportunity to view them in a way that helps you heal,” says Dubin. “For me, it wasn’t just my traumas. The theme was very much intergenerational trauma.”
She experienced her own birth and reexperienced the strong connection she felt with God as a young child. She relived a traumatic miscarriage that happened when she was 22 and newly married. She experienced having ovarian cancer twice.
“Then the medicine asked me if I was ready to meet someone,” says Dubin. “I thought I was going to get to meet the spirit of the child I lost in the miscarriage. But then another presence came and said, ‘I’m Mollie. I’m your grandmother.’ That blew me away because I did not anticipate that. I had never met her. She died when my father was seven.”
Dubin says she learned things from Mollie that she hadn’t known. Mollie was beaten almost to death by her drunk husband, and Dubin’s father, as a child, witnessed it. Mollie died a month later in the hospital, but Dubin’s father was never taken to visit. Ultimately, he ended up living in an orphanage.
Dubin learned from Mollie why Dubin’s daughter couldn’t give up on having a third child, even after several miscarriages. “This soul, this baby, needed to be born, because her birth closed the circle of trauma for me and my son,” Mollie told her. Then Mollie looked at my rock with the crack in it and said, ‘Wendy, that's not your broken heart. That's mine. You've been carrying my broken heart. Now that the baby’s been born, you don’t need to carry it anymore.’”
Psychedelic sessions typically last a maximum of eight hours, but Dubin was not ready to leave her altered state when her therapists started nudging her back. She asked them for more time, and they gave her some. Even after the session was over and she was back home, she continued her journey. “My dad showed up that night, I could feel him,” she says. “He just said, ‘Thank you for what you did for my mom.’”
Five months after her psychedelic session, Dubin says she still feels the effects. “I feel like the different parts of my brain can talk to each other still,” she says. “The gift of psilocybin has kept on giving. I think that’s because of the three sessions I had after the dosing to integrate the whole experience.”
“I got my spirituality and my connection to God back,” she says. “I feel more empathetic and compassionate. I know I still have potential for a recurrence, but I don’t worry about it as much. I have more joy and less fear.”
Originally appeared in the Spring 2024 print issue of Emory Medicine Magazine.
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