This interview is about the following publication: Yaden, D. B., Berghella, A. P., Regier, P. S., Garcia-Romeu, A., Johnson, M. W., & Hendricks, P. S. (2021). Classic psychedelics in the treatment of substance use disorder: Potential synergies with twelve-step programs. International Journal of Drug Policy, 98, 103380.

Treatment for people with substance use disorders is often based on classical psychotherapeutic principles, such as cognitive-behavioural therapy. However, two unorthodox approaches have existed since the 1950s that, at first glance, seem to incorporate opposing principles: 12-step abstinence-based programs and psychedelic therapy. In this interview, I exchange with David Yaden, PhD, who recently published a paper with his colleagues from John Hopkins University, in which they discuss potential synergies between these two treatment modalities.

L: For our readers who may be are unaware of this concept, could you shortly explain what 12-step programs are?

D: 12-step programs are peer-support groups that follow a guiding set of principles to help members maintain sobriety. Alcoholics Anonymous (AA) was the first 12-step program, and probably the one that most people are familiar with. Nowadays, there are 12-step groups intended to help with most addictive drugs as well as behaviors like gambling.

12-step groups sit a little uneasily with mainstream addiction treatments. While many clinicians encourage their patients to seek out 12-step groups as an adjunct to evidence-based therapies or treatments, 12-step programs are not themselves considered part of medical or clinical treatments. Moreover, many 12-step programs do not allow members to participate in some evidence-based drug treatments such as medication assisted treatments (e.g., methadone), which is considered a controversial practice among evidence-based clinicians and researchers who see this as preventing effective treatment. Lastly, a large Cochrane review showed that there is evidence suggesting that 12-step programs are effective for some people.¹ There are a complex set of dynamics at play here.

L: What do you think is the broad appeal of 12-step programs? Why has this program been able to spread successfully across the whole globe?

D: 12-step programs benefit from its members, who are often extremely engaged and can provide social connection and support to people who are often lacking it in their lives. The social support that many 12-step programs provide goes well beyond the amount of time that clinicians can provide due to the constraints of their schedules. For example, 12-step program members are teamed with another 12-step program member, who plays the role of a “sponsor.” New members can generally call their sponsor at any hour, day or night, if they are tempted to relapse or if they simply need someone to talk to.

Additionally, the 12-steps themselves are very easy to understand, and provide as their name implies, a step-by-step process to regain sobriety and remain sober.

Finally, 12-step programs are usually easily accessible and free, while healthcare resources can sometimes be inaccessible and/or difficult to afford in the US.

L: The 12-step programs explicitly mention spiritual experiences as catalysts of change. Could you elaborate on what is meant by that?  What is considered a spiritual experience in 12-step programs and how does this experience differ from or is similar to experiences induced by psychedelic substances?

D: The 12-step programs stem from Bill Wilson’s writings. Bill Wilson (b. 1895 – d. 1971) co-founded Alcoholics Anonymous (AA) after he achieved sobriety during a moment that he considered a “spiritual experience.” Here is Bill Wilson describing his experience:

“Slowly the ecstasy subsided. I lay on the bed, but now for a time I was in another world, a new world of consciousness. All about me and through me was a wonderful feeling of Presence. A great peace stole over me and I thought, “No matter how wrong things seem to be, they are all right…” (quoted by Ernest Kurtz²)

Notably, Bill Wilson was being treated with a substance called Scopolamine, which some consider a psychedelic (though it is not a classic psychedelic like psilocybin or LSD). He was undergoing treatment for alcoholism in a New York City hospital under the care of a physician who was attempting a new form of treatment. Most people are unaware that Bill Wilson’s first spiritual experience occurred under the influence of a psychedelic-like substance!

Spiritual experience plays a prominent role in 12 step programs. After all, it’s part of the 12 steps. The 12^th and final step reads: “Having had a spiritual experience as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.”³

L: With regards to your paper: What led you to think that synergies between psychedelic use and 12-steps programs could exist?

D: The spiritual experience that Bill Wilson described as prompting his sobriety is very similar to the subjective effects reported by many people taking psychedelics.  Bill himself made this point. Later in his life, Bill tried LSD (a classic psychedelic) under the care of a physician. He appeared to benefit from these psychedelic treatments, and Wilson provided a positive endorsement:

“It is a generally acknowledged fact in spiritual development that ego reduction makes the influx of God’s grace possible If, therefore, under LSD we can have a temporary reduction, so that we can better see what we are and where we are going – well, that might be of some help. The goal might become clearer. So I consider LSD to be of some value to some people, and practically no damage to anyone.” ⁴

Wilson’s endorsement of psychedelic treatments may surprise people – it certainly surprised us when we learned about it. According to one scholar, Joe Miller, who wrote US of AA, this fact may have even been actively suppressed by the board of AA.

L: So, what actual synergies do you see? Do you believe there is a benefit to combining the two approaches?

D: I want to be very clear on this point – in the paper, we are neither advocating nor denouncing the combination of psychedelics with 12-step programs.

However, we can’t help but notice the substantial similarities between psychedelic treatments, which many people report resulting in a spiritual-type experience, and the aims of 12-step programs, which aim to provide a kind of spiritual experience as a result of working the steps.

We thought it was interesting that 12-step programs tend to disallow members from participating in medication assisted treatments (MAT) because they are seen as “swapping one drug for another.” This can be unfortunate considering that MAT has been shown to be among the most effective ways of keeping people who have substance use disorders alive.

We were curious as to whether some 12-step programs might make an exception for treatments with psychedelics. Indeed, while they are drugs or kinds of medication, they provide experiences that are similar to (or identical to in some cases) the spiritual experiences that are at the heart of 12-step programs. Meanwhile, the founder of AA advocated combining 12-step programs with psychedelic treatments – and it could be that knowing about this endorsement from AA’s founder might be impactful or at least interesting to some members of 12-step programs.

L: Regarding the integration of psychedelics into 12-steps: What would the actual practice look like? How could psychedelics be integrated into a 12-step program?

D: We could imagine a few different possibilities – call the possible models initiatory, intermittent, or culmination. An initiatory model would suggest undergoing a psychedelic experience toward the beginning of the 12-step process in order to provide more motivation during what may be a difficult period of transition. An intermittent model might involve periodically engaging in psychedelic treatments over the course of the 12-step process, maybe once every few months or so, in order to maintain the momentum of treatment and sobriety. Lastly, a culmination model might involve having the psychedelic treatment along with the 12^th and final step as a kind of capstone to, and opportunity to reflect on, the entire process.

Again, these are just some possibilities, we don’t really know how this integration might look in the real world. It’s a topic that’s worth studying and would require interdisciplinary teams to do the research well. Let me reiterate that both here and in the paper, we are neither advocating or denouncing the combination of psychedelics with 12-step programs, but merely considering the subject.

L: What do you think the next steps would look like for this line of research? What are important aspects about this combination that need to be explored?

D: We’re launching some research projects to study groups that are apparently already engaged in integrating psychedelics into the 12-step process. Yet again, I want to reiterate that we’re not supporting or condoning integrating psychedelics into 12-step groups (it is currently illegal in the US and therefore legally risky). But we do want to learn more about this practice – the potential safety issues that come up, whether it’s effective, and how the integration fits with 12-step philosophy as well as with current mainstream evidence-based treatments. There are a number of interesting and important psychological, medical, legal, and anthropological questions to address in this framework.

L: Finally, what would the best possible care for patients with substance use disorders look like? What do you envision the ideal future of treatment to look like?

D: I am a psychological and psychopharmacological researcher, so I study psychological and pharmacological interventions. I think there is a great deal of progress that can be made on both of these fronts. It’s important to note that there are treatments currently available for people who suffer from substance use disorders, and I encourage this population to take advantage of these existing evidence-based treatments.

Learn more about substance use disorders on MIND’s Elements of Science.

At our lab at Johns Hopkins, the Center for Psychedelic and Consciousness Research, we are conducting studies and collecting promising data on the potential efficacy of psychedelics for the treatment of substance use disorders. We need more and better research to follow-up on preliminary findings (something that researchers like Matt Johnson, Albert Garcia-Romeu, and Peter Hendricks are currently working on), but it does seem that psychedelics have the potential to help treat some patients with substance use disorders. On the other hand, community-based peer support groups like 12-step programs also appear to be effective, as the recent Cochrane review showed.

Ultimately, though, several larger social forces and policy-related issues need to be addressed to allow people with substances use disorders to obtain access to the services and resources they need.

To summarize, “the best possible care for substance use disorders” would likely involve the integration of access to economic resources and social services. The same goes for psychological and pharmacological treatments. There are no easy or simple solutions here.

The aim of our paper was to highlight a somewhat complicated situation – integrating psychedelics into 12-step programs – and to try to understand their dynamics a little better. I think we probably succeeded more in raising questions than we did at providing concrete answers.

1. Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database Syst Rev [Internet]. 2020 [cited 2021 Sep 30];(3). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012880.pub2/full
2. Kurtz E. A.A.: The Story by Ernest Kurtz. Harpercollins; 1988.
3. Alcoholics Anonymous. Alcoholics Anonymous Big Book. 4th ed. Hazelden; 2001.
4. Hartigan F. Bill W.: A Biography of Alcoholics Anonymous Cofounder Bill Wilson. Thomas Dunne Books; 2000. 256 p.

“Researchers are coming to a shared understanding of how it can be that one person’s LSD trip feels disruptive, while another is mystical and transformative.” (Ada Jaarsma)

Viewed through the lens of placebo research, “set and setting,” a phrase coined decades ago by Timothy Leary, applies not only to first-hand, embodied experiences but to psychedelic science as well.

As a philosopher who studies placebo effects, I was delighted to interview Dr. Ido Hartogsohn about his recently published book, American Trip: Set, Setting, and the Psychedelic Experience In the Twentieth Century, which explores the genealogy of psychedelic research as it relates to personal bias.¹ The convergence of psychedelics and placebo research is at the heart of Hartogsohn’s central argument: “set” and “setting” play crucial roles in the experience of psychedelic trips as well as in the scientific research surrounding them.

In our video-conversation, you’ll learn how these terms, set and setting, have emerged as newly critical concepts in psychedelic research.  You’ll also hear our reflections on the importance of these concepts, not only for advancing medical treatment and resolving longstanding mysteries related to psychedelics, but also for existential transformation.

In this post, I draw out the philosophical implications of Dr. Hartogsohn’s approach to psychedelic research—namely, one anchored in first-person, embodied experiences and passions—and turn to philosopher of science Prof. Isabelle Stengers’s work on placebos to elaborate upon this approach.

Passion and Interest in Scientific Inquiry

Dr. Hartogsohn’s description of his own book echoes the philosophy contained within it. In our video conversation, Hartogsohn and I talk about how psychedelics and psychedelic research are not static objects of inquiry that stand apart from Hartogsohn’s own experiences.  Rather, they are tangled up with Hartogsohn’s own embodied interests, including his interests in art and in existential transformation. Moreover—and this is one of the key takeaways of his book-length study—the more we learn about the workings of psychedelics, the more we discover the relevance of the experiences of scientists and clinicians to the findings of psychedelic research. In his book, for example, Hartogsohn traces the shifting definitions and methodologies of scientists over decades, examining key events in the study of hallucinogens and related phenomena that connect with broader societal shifts in the meaning of medicine, art, and embodied experiences. From Timothy Leary, who first coined the term “set and setting,”² to an array of contemporary researchers, Hartogsohn draws on Science and Technology Studies to examine the interplay between scientific insights and scientists themselves.

What I find telling about Hartogsohn’s philosophy is how well it aligns with Prof. Isabelle Stengers’s descriptions of scientific inquiry more generally. Stengers is a feminist philosopher of science, and during my conversation with Hartogsohn about his book, I kept thinking about Stengers’s claim that passion and interest are essential for emerging and significant scientific research.

Here’s how Stengers puts it in one of her influential essays about the workings of scientific research: “The emperor is wearing clothes.”³ This claim is characteristic of Stengers’s  philosophical prose, and it packs a punch because it stands in explicit contrast to mainstream, conventional stories about science.

It can be tempting, even at times compelling, to imagine scientists as disembodied minds to underscore the efficacy of their methodologies: there they are, we might imagine, working in their labs, deploying protocols and undertaking statistical analyses and striving, above all, to produce findings that are duplicable and generalizable. (You might hear a version of this story in the video-essay, when I muse about mysteries that have long perplexed both placebo and psychedelic researchers. It is only when the fantasy of disembodied scientists is replaced by engagement with particular research practices that these mysteries give way to rich, exciting new understanding.) This temptation is not worth indulging, Stengers maintains. The emperor is wearing clothes! There is a comedic spin to Stengers’s metaphor here, since it inverts the familiar tale of an emperor who marched proudly in public, passing as clothed while not wearing any clothes at all. In Stengers’s version, it is the scientist qua emperor who enjoys the conceit of passing as naked, all the while wearing professional attire.

It is vital, on Stengers’s account, to engage with different styles of scientific research—and to affirm or question the methods and conclusions devised by scientists, as members of the public. To take up this task well means finding ways to resist the entrenched modern story about science, in which “the emperor has no clothes.” According to this modern story about science, Stengers explains, nature must be described by an “ideal, godlike spectator,”⁴ instead of by the clothed, embodied persons who undertake the collaborative tasks of research.

Research as a Love Song

“My book is a love song to LSD.”  (Ido Hartogsohn)

I first began studying placebos and placebo effects because of Stengers’s philosophy of science. Consider the white coat, often worn by medical doctors and researchers. This is an example of how clothing itself, associated with expertise, can convey authority: this white coat is a well-documented placebo, drawing out placebo effects in patients or research participants.

In my own work, conducted collaboratively with psychiatrist Suze Berkhout, I’ve become struck by the import of these kinds of placebos, especially for thinking about disability⁵ and race,⁶ precisely because they highlight the embodied interplay between the “emperor’s clothes” and the researcher, consumer, client, patient, or citizen. Science—and specifically medicine, in this case—wields such placebos that our very bodies and minds anticipate and manifest their curative powers.  We might get better in part because we visit the doctor’s office.  As an early publication in Placebo Studies puts it, “diagnosis is treatment,” ⁷ and wide-ranging research affirms the significance of how we receive these diagnoses.  Our treatments will likely work more effectively when our clinicians infuse their instructions with enthusiasm. And our symptoms might worsen or treatments fail to work when doctors address us with disinterest.⁸  Given how medicalized our social contexts tend to be, saturated as they are with messages about new and improved scientific treatments, scholars in Science and Technology Studies point out that there is actually no such thing as “no treatment.”⁹ Extending far beyond the bounds of visits to the doctor or brand-names on a pill, placebos are all around us.¹⁰

This is key to Hartogsohn’s analysis. What American Trip adds in particular to our understanding of psychedelic research is sustained exploration of the role of “set and setting” and placebos more broadly in psychedelic experiences. I’m fascinated, myself, by this line of thought—that the very environments in which we find ourselves (the sounds, sensations, and designs of spaces) might hold import for how our bodies and minds experience psychedelic trips.  This is in part what “setting” refers to, and as Hartogsohn points out in our conversation, including things like the doctor’s white coat.

In turn, the term “set” refers to the mindset, expectations, and conditioning that a person brings to a psychedelic experience. These ingredients are also essential to the dynamics by which placebo effects emerge.¹¹

It’s striking, then, when a researcher like Hartogsohn acknowledges that their book project is a love song to the very phenomenon being studied—psychedelics, and LSD more specifically in this case. Hartogsohn’s genealogy of psychedelic research, laid out in American Trip, helps me understand more clearly why Stengers is so insistent that scientists draw on their own vested interests and experiences in order to generate new experimental findings. What I hear, in Hartogsohn’s declaration, is an affirmation of Stengers’s point that the emperor is wearing clothes: placebo effects, in other words, are just as relevant to the scientific study of psychedelics as they are to the experiences of hallucinogens themselves. Even more, I hear an invitation to us, as readers and engaged members of the public, to reflect on our own embodied responses to the love songs of researchers.

Stengers can also help us think more philosophically about how “set” and “setting” relate to historical and ongoing research into psychedelics. As part of her scrutiny of the importance of interest and passion for science, Stengers points out, “The etymology of [the word] ‘interest’ is ‘to be situated between.’”¹² This “in between” is precisely what is often missing, when it comes to scientific inquiry. Just as a patient or a user forges a connection with a hallucinogen—in ways that will be utterly specific to them—so too do scientists and science-studies scholars like Hartogsohn forge connections between their own interests and the phenomena being studied.

And when these connections are infused with love, as Hartogsohn describes his own book project, then the outcomes might well be as edifying and transformative as a positive psychedelic experience. 

References

1. Hartogsohn, I. American Trip: Set, Setting, and the Psychedelic Experience in the Twentieth Century. Cambridge, MA: MIT Press; 2020.
2. Hartogsohn, I. American Trip, 123 p.
3. Stengers, I. Another Look: Relearning to Laugh. Deutscher, P., Trans. Hypatia. 2000; 15(4):44.
4. Stengers, I. Power and Invention: Situating Science. Bains, P., Trans. Minneapolis: University of Minnesota Press; 1997. 43 p.
5. Berkhout, S.G. and Jaarsma, A.S. Trafficking in Cure and Harm: Placebos, Nocebos and the Curative Imaginary. Disability Studies Quarterly. 2018; 38(4). Available from: https://dsq-sds.org/article/view/6369/5138
6. Jaarsma, A.S. and Berkhout, S.G. Nocebos and the Psychic Life of Biopower. Symposium: Canadian Journal of Continental Philosophy. 2019; 23(2): 67-93.
7. Brody, H. and Waters, D. B. Diagnosis is Treatment. Journal of Family Practice. 1980; 10(3): 445-9.
8. Friesen, P. and Blease, C.  Placebo Effects and Racial and Ethnic Health Disparities: An Unjust and Underexplored Connection. Journal of Medical Ethics. 2018; 44(11): 774 p.
9. Wilson, Elizabeth A. Gut Feminism. Durham: Duke University Press; 2015, 150 p.
10. Alves, Carlos Alberto et al. It Makes Me Feel So Good: An Experimental Study of the Placebo Effect Generated by Brands. Journal of International Consumer Marketing. 2017; 29(4): 1-16.
11. Blease, C.R. Psychotherapy and Placebos: Manifesto for Conceptual Clarity.” Frontiers in Psychiatry. 2018; 9: 1-5.
12. Stengers, Another Look, 48 p.