Chris Letheby, PhD
Lecturer in Philosophy at the University of Western Australia and Postdoctoral Researcher at the University of Adelaide
Dr Chris Letheby is a Lecturer in Philosophy at The University of Western Australia who specializes in the philosophy of mind and cognition.View full profile ››
- 7 minutes
- 18 března, 2022
- Philosophy & Consciousness
- Psychedelic Therapy
Psychedelic-induced mystical-type experiences may be therapeutic “not primarily because they change people’s beliefs about the ultimate nature of reality, but because they enable people to revise their self-conceptions in healthier ways, changing how they see themselves and how they relate to their own minds and lives.”
Recent clinical trials suggest that one to three supervised psychedelic sessions can durably reduce symptoms of anxiety, depression, and addiction.1 As Stephen Ross said, it is “simply unprecedented in psychiatry that a single dose of a medicine produces these kinds of dramatic and enduring results.”2 Assuming that this is a real and robust effect, the obvious question is: how does it work?
To this obvious question, there is a seemingly obvious answer: it works by changing patients’ beliefs about the nature of reality. This answer, which I call the Metaphysical Belief Theory of psychedelic therapy,3 seems obvious in light of one of the most consistent findings in psychedelic research: that lasting psychological benefits (reductions in psychiatric symptoms, or positive personality change in healthy volunteers) are predicted by the occurrence of a “mystical-type experience” (MTE) during drug action. 3
In light of this finding, and an intuitive association between mysticism and religious belief, it is natural to speculate that psychedelics cause lasting psychological benefits by promoting uplifting metaphysical beliefs in a transcendent “Divine Reality” or “Ground of Being”— what Alan Watts called a “Joyous Cosmology.”4 This speculation has caused concern among those partial to a physicalist, materialist, or naturalist worldview, including Michael Pollan, who wondered: “Is psychedelic therapy simply foisting a comforting delusion on the sick and dying?”5 I think that the answer is “no,” and that this view does not accurately portray the underlying cause of psychedelics’ therapeutic benefits. A more plausible explanation, in my view, focuses on changes to the narrative self.
Mystical-Type Experience Without Metaphysical Conversion
Psychometric questionnaires define the MTE in terms of a set of experiential features. These include a sense of unity, transcendence of time and space, a “noetic” feeling of gaining knowledge about reality, and a deeply felt positive mood.6 Again and again, across multiple studies and populations, the volunteers who tick the boxes for this type of experience are those who experience the greatest lasting benefits.
The Joyous Cosmology view, AKA the Metaphysical Belief Theory of psychedelic therapy, is prompted partly by psychometric findings such as these. But there is other evidence too. As Wayne Glausser7 has noted, this idea seems to be suggested by the first-person accounts of some patients, such as Rachael Petersen, who wrote that receiving psilocybin in a clinical trial for depression “cured [her] of [her] atheism.”8 The theory is especially tempting when we consider the best-studied therapeutic indication of psychedelics: the treatment of anxiety and depression accompanying terminal illness. Clearly, an experientially-backed conviction in the existence of an eternal, transcendent realm could provide significant comfort to those deeply distressed by their own imminent mortality.
While psychedelics do sometimes instill metaphysical beliefs in a Joyous Cosmology, and it would be hard to deny that this has psychological benefits when it occurs,9 qualitative interviews with successfully treated patients reveal a more nuanced picture, showing that some can tick all the psychometric boxes for a “complete” MTE without undergoing any metaphysical conversion.10 Instead, these criteria can sometimes be satisfied by transformative experiences featuring profound feelings of connectedness, acceptance, emotional catharsis, and psychological insight—with no Joyous Cosmology in sight.11 A good example of this is furnished by Michael Pollan’s own psilocybin-induced experience, which satisfied the definition of a complete MTE:
“I could easily confirm the ‘fusion of [my] personal self into a larger whole’, as well as the ‘feeling that [I] experienced something profoundly sacred and holy’ and ‘of being at a spiritual height’ and even the ‘experience of unity with ultimate reality’… provided, that is, my endorsement of those loaded adjectives doesn’t imply any belief in a supernatural reality … It had been my objective to have [a mystical experience], and at least according to the scientists a mystical experience I had had. Yet it had brought me no closer to a belief in God or in a cosmic form of consciousness or in anything magical at all.”12
So, how does psychedelic therapy work, if not (mainly) by changing metaphysical beliefs? In my view, the reason the MTE—as psychometrically defined—is so consistently therapeutic is because it facilitates profound changes to the “narrative self.”
Psychedelics and the Narrative Self
The term “narrative self” refers to the complex set of beliefs and representations a person has of their own identity, personality, and autobiography. It is standardly distinguished from the “minimal self,” the mere feeling of being an embodied subject of experience in the here and now, irrespective of any specific personality traits or biographical features.
Why think that changes to the narrative self are the real story underlying the correlation between MTEs and therapeutic outcomes? For one thing, the sense of unity is regarded as the cardinal feature of the MTE, and a corollary of this is a profound disruption to the ordinary sense of self.13 For another, it is known that conditions such as addiction and depression feature deleterious changes to the narrative self, such as negative “core beliefs” about oneself, and that changing these can be therapeutically beneficial.14,15
Besides these general considerations, there is evidence from psychedelic science that supports this hypothesis. At least one study has found that measures of psychological insight predict therapeutic outcomes more strongly than measures of MTE, and the relevant types of insights almost all involve changes to the narrative self.16 Therapeutic effects have also been linked to increased mindfulness-related capacities17 and psychological flexibility,14 both of which involve changes to the felt relationship between the experiencing subject and their own thoughts and feelings—including the thoughts and feelings that comprise the narrative self.3 The apparent involvement of changes to the Default Mode Network in the brain is important, too, since this system is implicated in narrative self-representations by a large body of evidence.18
Finally, many reports from successfully-treated patients fit well with this idea. Consider, for example, the following report by someone who received psilocybin-assisted therapy for tobacco addiction:
“For a few seconds, it was just like ‘I’m me, and there are no defining characteristics!’ . . . that made me realise that I’m not a ‘smoker’.”19
It seems clear, at least in this case — and there are many examples like this — that part of what psilocybin has done is free the patient from the grip of the core belief that “I am a smoker,” enabling them to see the contingency of this belief and revise it for the better. This is consistent with the idea that psychedelic-induced MTEs are therapeutic, not primarily because they change people’s beliefs about the ultimate nature of reality, but because they enable people to revise their self-conceptions in healthier ways, changing how they see themselves and how they relate to their own minds and lives.20
The Narrative Self vs. Minimal Self
Why single out the narrative self, as opposed to the minimal self, in trying to understand the therapeutic process? In part, this depends on exactly how one characterizes and distinguishes the two phenomena. Drawing this distinction more clearly in relation to psychedelic therapy could be an important topic for future research. On the one hand, the minimal self is often linked to, or identified with, some form(s) of bodily self-awareness, and clearly changes to bodily self-awareness can be involved in psychedelic therapy. On the other hand, parts of the narrative or autobiographical self can include, or make reference to the body. Indeed, as I have defined the narrative self here, it includes anything that goes beyond the mere sense of being a subject of experience, to identify one as a specific individual – and this includes representations of the appearance, history, and significance of one’s body.
It may be that some of our current conceptual schemes do not map neatly onto the psychological realities here. But while the acute psychedelic experience, like psychotic states, can feature definite changes to minimal self-awareness – dissolution of bodily boundaries, and the loss of a sense of “ownership” over mental states and bodily parts – these typically subside with the acute effects of the drug. What can be changed dramatically and durably, in successful cases, is not the mere sense of “being someone”21 in the here and now, but the sense of who one is — which (kind of) someone — and how one relates to the thoughts, feelings, perceptions, objects, people, and situations in one’s life.
Terminal Illness and the Narrative Self
There is one lingering worry to address. Perhaps, one might think, the mechanism of disrupting and revising the narrative self is plausible when it comes to depression or substance use disorders – but can this really be the main mechanism for psychological distress in terminal illness? As I noted above, this is the use for which the Metaphysical Belief Theory seems most plausible. It is hard to see at first glance how changing the narrative self could alleviate anxiety and depression brought on by impending mortality. Here, however, it is important to appreciate just how deeply our narrative self-representations pervade our experience of the world, via their influence on attention, emotion, and perception.
In Switzerland, a team led by Peter Gasser conducted the first clinical trial of LSD-assisted psychotherapy in 40 years.22 The population? Patients with anxiety and depression relating to a terminal illness. LSD-induced experiences led to lasting reductions in anxiety and depression, but the researchers noted that patients typically underwent emotionally- and existentially-oriented “peak” experiences, rather than classical mystical experiences or metaphysical epiphanies. The main themes that emerged from qualitative interviews with patients about their psychedelic experiences were “facilitated access to emotions and catharsis,” “de-schematizing and viewing experiences in another perspective”, and “changes of basic emotions.”23 One patient commented:
“I had the opportunity to relax. I rather connected to my inner world. Closed eyes. It was less about my illness. I was able to put it into perspective … Not to see oneself with one’s sickness as centre. There are more important things in life … The evolution of humankind for example … Your Inner Ego gets diminished, I believe, and you are looking at the whole … you are indeed starting to build relations with plants or with the entire living world around. You think less about yourself, you are thinking – across borders.”
This is just one example, of course, but it provides a proof-of-concept that apparent encounters with a “Divine Reality” are not necessary to cope with impending death. Instead, the existential distress attendant on imminent mortality might be reduced by profound changes to the narrative self, and to the perspectives, priorities, and patterns of emotion and attention that it underpins.
- Andersen, K.A., Carhart‐Harris, R., Nutt, D.J. and Erritzoe, D., 2021. Therapeutic effects of classic serotonergic psychedelics: A systematic review of modern‐era clinical studies. Acta Psychiatrica Scandinavica, 143(2), pp.101-118.
- Quoted in Schiffman, R., 2016. Psilocybin: a journey beyond the fear of death? Scientific American. https://www.scientificamerican.com/article/psilocybin-a-journey-beyond-the-fear-of-death/. 26 January 2022.
- Letheby, C., 2021. Philosophy of psychedelics. Oxford University Press.
- Watts, A.W., 1962. The joyous cosmology. New York: Pantheon.
- Pollan, M. 2015. The trip treatment. The New Yorker. https://www.newyorker.com/magazine/2015/02/09/trip-treatment. 26 January 2022.
- Barrett, F.S. and Griffiths, R.R., 2017. Classic hallucinogens and mystical experiences: phenomenology and neural correlates. Behavioral neurobiology of psychedelic drugs, pp.393-430.
- Glausser, W., 2021. Psychedelic Drugs and Atheism: Debunking the Myths. Religions, 12(8), p.614.
- Petersen, R., 2019. Taking mushrooms for depression cured me of my atheism. The Outline. https://theoutline.com/post/7367/taking-mushrooms-for-depression-cured-me-of-my-atheism. 2 February 2022.
- Timmermann, C., Kettner, H., Letheby, C., Roseman, L., Rosas, F.E. and Carhart-Harris, R.L., 2021. Psychedelics alter metaphysical beliefs. Scientific reports, 11(1), pp.1-13.
- Bogenschutz, M.P., Podrebarac, S.K., Duane, J.H., Amegadzie, S.S., Malone, T.C., Owens, L.T., Ross, S. and Mennenga, S.E., 2018. Clinical interpretations of patient experience in a trial of psilocybin-assisted psychotherapy for alcohol use disorder. Frontiers in pharmacology, 9, p.100.
- Breeksema, J.J., Niemeijer, A.R., Krediet, E., Vermetten, E. and Schoevers, R.A., 2020. Psychedelic treatments for psychiatric disorders: a systematic review and thematic synthesis of patient experiences in qualitative studies. CNS drugs, pp.1-22.
- Pollan, M., 2018. How to change your mind: the new science of psychedelics, p. 284. Penguin.
- Nour, M.M., Evans, L., Nutt, D. and Carhart-Harris, R.L., 2016. Ego-dissolution and psychedelics: validation of the ego-dissolution inventory (EDI). Frontiers in human neuroscience, 10, p.269.
- Dozois, D.J. and Rnic, K., 2015. Core beliefs and self-schematic structure in depression. Current Opinion in Psychology, 4, pp.98-103.
- McConnell, D. and Snoek, A., 2018. The importance of self-narration in recovery from addiction. Philosophy, Psychiatry, & Psychology, 25(3), pp.E-31.
- Davis, A.K., Barrett, F.S. and Griffiths, R.R., 2020. Psychological flexibility mediates the relations between acute psychedelic effects and subjective decreases in depression and anxiety. Journal of contextual behavioral science, 15, pp.39-45.
- Mian, M.N., Altman, B.R. and Earleywine, M., 2020. Ayahuasca’s antidepressant effects covary with behavioral activation as well as mindfulness. Journal of psychoactive drugs, 52(2), pp.130-137.
- Davey, C.G. and Harrison, B.J., 2018. The brain’s center of gravity: how the default mode network helps us to understand the self. World Psychiatry, 17(3), p.278.
- Noorani, T., Garcia-Romeu, A., Swift, T.C., Griffiths, R.R. and Johnson, M.W., 2018. Psychedelic therapy for smoking cessation: qualitative analysis of participant accounts. Journal of Psychopharmacology, 32(7), pp.756-769.
- Amada N, Lea T, Letheby C, Shane J. Psychedelic Experience and the Narrative Self: An Exploratory Qualitative Study. Journal of Consciousness Studies. 2020 Jan 1;27(9-10):6-33.
- Metzinger, T., 2003. Being no one: The self-model theory of subjectivity. Cambridge, Mass.: MIT Press.
- Gasser, P., Holstein, D., Michel, Y., Doblin, R., Yazar-Klosinski, B., Passie, T. and Brenneisen, R., 2014. Safety and efficacy of lysergic acid diethylamide-assisted psychotherapy for anxiety associated with life-threatening diseases. The Journal of nervous and mental disease, 202(7), p.513.
- Gasser P, Kirchner K, Passie T. LSD-assisted psychotherapy for anxiety associated with a life-threatening disease: a qualitative study of acute and sustained subjective effects. Journal of Psychopharmacology. 2015 Jan;29(1):57-68.