Do Psychedelics Just Provide Comforting Delusions?

The elephant, in this case, is the issue of mystical experiences and their role, often presumed to be causal, in how psychedelics act as a valuable treatment option for those with depression, addiction, end-of-life anxiety, and more. “In scientific journals and throughout the halls of any psychedelic conference, researchers and therapists teach the importance of mystical experiences for the efficacy of psychedelic therapies," the authors wrote. 

Many people have transcendent, mystical-type experiences while taking psychedelic drugs. These experiences have been measured using psychological tools like the Mystical Experience Questionnaire, Hood’s Mysticism Scale, and the Altered States of Consciousness Questionnaire. Again and again, it's been shown that people who have these kinds of experiences tend to have better outcomes from psychedelic therapy. 

Yet this prominence and centering of mystical experiences can be contentious. Researchers like Johns Hopkins' Matthew Johnson have cautioned that therapists and guides need to be careful about projecting their own spiritual interpretations and assumptions onto others, and that relying on narrow forms of spirituality and mysticism could be alienating some from seeking out the treatment. The authors of the new opinion piece write that they "are concerned that use of the mysticism framework creates a 'black box' mentality in which researchers are content to treat certain aspects of the psychedelic state as beyond the scope of scientific inquiry."

And within these deliberations lies a larger philosophical dilemma. Let's say mystical experiences do lead to better results in psychedelic treatments. Are there ethical issues when providing substances to people that lead them to change their beliefs about the nature of reality and the universe (as mystical experiences are wont to do) if those newfound beliefs may be untrue? If it makes people feel better, does it matter? 

Michael Pollan addressed this concern in a New Yorker article and in his book How to Change Your Mind. “It’s one thing to conclude that love is all that matters, but quite another to come away from a therapy convinced that ‘there is another reality’ awaiting us after death, as one volunteer put it, or that there is more to the universe—and to consciousness—than a purely materialist worldview would have us believe," Pollan wrote. "Is psychedelic therapy simply foisting a comforting delusion on the sick and dying?”

In a new book being released this August, Australian philosopher Chris Letheby tackles the comforting-delusion quandary. In Philosophy of Psychedelics, he asks whether we should care if psychedelics provide a comforting delusion if that leads to less suffering. Perhaps more importantly, Letheby questions whether or not it really is the mystical experiences causing the dramatic outcomes seen in people who undergo this therapy. They may not be the whole story. 

Motherboard talked to Letheby about mysticism, the importance of truth and knowledge, and why the field of psychedelics, in particular, needs philosophy to help guide it. 

This interview has been lightly edited for length and clarity. 

Motherboard: Why focus your book on mystical experiences, over all the other facets of psychedelic therapy and research? 
Chris Letheby: As a philosopher, I'm very interested in issues around truth and knowledge. And before I was ever interested in psychedelics, I was interested in issues to do with mysticism, mystical state, spiritual practices and so on.

For me, these are very live issues in psychedelics. You've got these states of consciousness and practices that induce them that obviously help a lot of people considerably with psychological suffering and with existential angst. But as a philosopher, an issue naturally arises: Is this increase in wellbeing, is this decrease in psychological suffering, something that is resulting from an accurate insight? Seeing the world as it really is? 

Or, is it resulting from some kind of "comforting delusion"—people getting some kind of reassuring but ultimately false or evidentially unsupported belief about how the world is. 

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The "comforting delusion" is one of the key issues you grapple with. Part of it relates to the fact that the kinds of experiences psychedelics induce can contradict a "naturalist" worldview. What is naturalism, and why does it set up psychedelics to potentially bring about "comforting delusions?" 
Naturalism, like everything in philosophy, is hard to define precisely, but it's very easy to get an intuitive grasp on. It's a view that says the natural world, the world studied by the sciences, is the only world there is. 

This worldview that says mental phenomena—mind, consciousness and so on—are not something that's fundamental in the universe, they’re something that develops. So, reality is made of ultimately "non-minded" things like atoms and subatomic particles, and minds are something relatively recent and complex that gets built out of stuff that is ultimately non-minded. 

You can contrast that materialist or physicalist view with other views like panpsychism, idealism, cosmopsychism, and panprotopsychism. All these views are all variations on the claim that mind, consciousness, or protomind is somehow ubiquitous and fundamental in the universe. It's everywhere and it permeates everything. People who consider themselves naturalists typically deny that. 

Naturalists also typically also deny the existence of non-natural entities; they deny that there's anything like a literal God, literal disembodied spirits, a spirit world, or anything like that. I think it's probably true that most philosophers today consider themselves naturalists in this sense—and I think there are good arguments in support of this kind of view of the world.

But the problem arises simply from the fact that lots of people who take psychedelics and have overwhelming, transformative experiences afterwards claim to have experienced aspects of reality that naturalism denies. In some cases, they claim to have experienced directly the existence of some kind of spirit world, divine universal consciousness, or ultimate reality. 

Then, in the research on psychedelic therapy, you have this specific type of experience, the "mystical-type experience" that stands out again and again as the strongest predictor of good outcomes. It seems that people who have this type of experience are the ones who get lasting benefits from psychedelic therapy. 

When you take a first glance at the mystical experience, in the way mystical experiences have classically been defined, it looks like they are all about apprehending some dimension of reality that flies in the face of naturalism. Huston Smith, the eminent scholar of comparative religion who took psilocybin back in the 1960s,  said the basic message of psychedelics is that there is another reality with a capital R that puts this one in the shade.

In light of this, you get Michael Pollan, who is himself very sympathetic to naturalism, asking:  Is psychedelic therapy simply foisting a comforting delusion on the sick and dying, and making them believe in some comforting but implausible worldview according to which there is another reality, some ultimate or divine reality out there? 

You write that when we are confronted with the notion of the comforting delusion of psychedelics, there are a few different reactions we can have. We could say that those mystical experiences are real—they actually are revealing an ultimate reality. We could also respond by asserting that it doesn't matter if it's real, if that comforting delusion helps people. 

Or lastly, we can decide that this comforting delusion problem is something we should worry about, and set out to do so. You clearly have decided to worry about it, or your book would have ended a few pages in. Why is it that you think we should care? I've heard it said before about psychology: That it doesn't really matter if something is true, if it helps reduce suffering. 
I think one of the reasons why people are attracted to that view is because they want to be tolerant. They don't want to be paternalistic and authoritarian and go around policing people's worldviews, telling them what to believe.

I share that impulse. I think we should be tolerant and pluralistic. I'm not advocating that we stick our noses unduly into people's cognitive and epistemic business. But I think you can hold that view and still think that truth and knowledge are things that matter. And that there is an ethical obligation on us as individuals to actually care about whether our beliefs correspond to reality, and to make efforts to scrutinize them critically.

This is one of those things that is very hard to demonstrate, like all claims about what's morally important. But there are a number of thought experiments that point in this direction. 

One is Robert Nozick's "Experience Machine'', which interestingly, he connected to psychedelics when he first published it back in the 1970s. 

The thought experiment says there's an incredibly advanced virtual reality machine that you can hook yourself up to if you want. You can program it to give you the most rich, rewarding, satisfying virtual reality experiences for as long as you like. You don't have to know it's virtual, it can be subjectively indistinguishable from an incredibly wonderful life in the real world. The question some people ask is psychological one of: would you plug in? But the question is actually the normative one: Should you plug in? Would it be a good decision for you to do that?

Nozick thinks, and a lot of other people have agreed that, no, you shouldn't. Or, at least, that if you did, you would be sacrificing something important—knowledge of reality. The seeming experiences you would be having would all be delusory. People that you would seem to have relationships with would be figments of your imagination, just like when you dream at night.

That's one thought experiment that aims at pumping this intuition that it should matter to us whether our beliefs are grounded in reality, whether our experiences are ones of a real reality, or just something fake or simulated or delusory. 

It's still important to appreciate the nuance. What I'm trying to say here is that truth and knowledge matters. They are things we should take into account in our calculations, in our deliberations. but of course, that doesn't mean that they're the only things that matter. Obviously well-being and happiness and suffering and things like that matter, too.

Even if you accept this idea that we should factor truth and knowledge and epistemic accuracy into our deliberations, it still is possible that it could turn out that the benefits for well-being and for happiness are so great that they outweigh the epistemic risks. 

I've felt fraught about psychedelic mystical experiences—exactly because of this tension. And also because we hear all the time that these experiences are not only helpful, but causal in the healing that occurs, so it seems important to get to the bottom of them. Yet in your book, you suggest that psychedelic therapy might not necessarily work by instilling comforting metaphysical beliefs. It might be something else going on that includes mystical experiences, but isn't exclusive to them. 
If you look at the evidence more closely, I don't think it turns out to be plausible that psychedelic therapy works primarily by inducing comforting metaphysical beliefs. That theory about the causal mechanisms at play in psychedelic therapy doesn't actually withstand empirical scrutiny. 

The first major clue about this comes from a look at qualitative research. People are very into all the quantitative findings, and I am too. But this is an example of how the effort to quantify can sometimes obscure important details.

You have these quantitative instruments, psychometric instruments, like the Mystical Experience Questionnaire (MEQ) that have been developed to quantify this mystical-type experience. And there is this robust finding across all these studies that scores on these questionnaires seem to predict good outcomes. So you think, okay, psychedelic experiences alleviate pathology by inducing these mystical experiences of cosmic consciousness. 

But if you go and look at the qualitative studies in patients with alcoholism, with tobacco addiction, with end of life anxiety, who have been treated by psychedelics, and have been interviewed about the treatment, you find that a lot of people are not talking about encounters with God and encounters with ultimate reality. 

Some people are, but you wouldn't say it's the most prominent or the most overwhelming theme. Instead, what comes out are things like a sense of renewed connectedness, which has been emphasized in work by Ros Watts and others from Imperial [College London]. Connectedness, feeling reconnected to the body, to the senses, to other people, and to various aspects of life.  

You find a lot of talk of acceptance; shifting from avoidance of emotion to its acceptance, or moving from rejection or denial of various aspects of one's life to accepting them. There's talk about psychological insights, having psychodynamic epiphanies, realizations about one's own life history, one's personality, values, priorities, sometimes the deleterious effect of certain behaviors or attitudes. You find a lot of emotional content and bodily content. And then mixed in with it, sometimes you do find people talking about encounters with God or encounters with ultimate reality.  But basically, you don't get the impression from qualitative interviews of people who have seemingly been successfully treated that it's centrally about changes in metaphysical beliefs.

To me that framework is a bit of a relief because we get to avoid some of the epistemic tangles we were facing before. While I don't have a strong feeling either way if people do have a meaningful mystical experience, anecdotally, from talking to lots of folks who've done this, I know these experiences don't necessarily have to involve anything mystical to be very profound. It's almost like a change in the sense of self rather than just a "mystical experience." 
Yes, and that's my positive proposal, that that is really the central factor: changes to the sense of self. 

People have said for a long time that changes to the sense of self are one of the most defining features of the psychedelic state, even when you don't get a classic mystical experience. I think this comes out really clearly in certain cases.

One that I really love is Michael Pollan's description of his psilocybin experience in his book. Even though he didn't take psilocybin in a research setting, he took it in an underground setting with a practitioner. He nonetheless went away afterwards and filled out one of these questionnaires, the mystical experience questionnaire. He found that according to those psychometric criteria, he had had a mystical type experience, as it's defined in the research, a complete mystical type experience. 

But he was very emphatic that the fact that he had assented to all these criteria, the transcendence of time and space, ineffability, sense of sacredness and so on—to him, it didn't mean that there was anything in the experience that caused him to question his naturalism.

Pollan basically is a naturalist. He accepts naturalism, as I characterized it earlier, and none of his psychedelic experiences that he describes in the book led him to question that.

He says, this didn't lead me any closer to a belief in God or cosmic consciousness or anything magical or supernatural. But it was obviously still a very profound, very important and powerful experience for him and one that centrally involved changes to the sense of self. 

There is some growing types of quantitative evidence that reveals that just because we found that this construct of a mystical type experience is a reliable and strong predictor of lasting benefits, doesn't mean that it's the strongest possible predictor. It could just be a clue showing us where to look. 

There are intriguing findings in just two or three studies, and most of them are survey studies. These find another construct predicting the lasting benefits more strongly than the construct of a mystical type experience—and this is the construct of psychological insight. When you look at it, it is all about changes to what they call the narrative self, changes to people's self conception, the autobiographical sense of who they are and what matters to them and what's happening in their life. 

To my mind, this all amounts to a fairly strong circumstantial case that the reason why the construct of a mystical type experience predicts good outcomes so strongly is because it typically goes hand in hand with these changes to the sense of self, particularly the narrative self. 

The philosopher Jules Evans has spoken about how there's a legacy around the importance of the mystical-type experience that comes from Johns Hopkins' Bill Richards, and before that Aldous Huxley and William James. He said we’re always grappling with that legacy of interpretation when we try to explain what these experiences mean, and why they're important. In light of that, do you think we should stop using the mysticism scales, in favor of scales for other aspects, like ones for psychological insight?
I think we should augment rather than replace. There was an interesting paper that came out in the last couple of weeks that generated a lot of discussion, called "Moving Past Mysticism in Psychedelic Research." The two authors argued that this whole discourse around mysticism and the construct of a mystical-type experience is limiting, constraining, and influencing how people are conceptualizing their experiences. 

I should say that there is a real worry there. But on the other hand, I think it very often gets mixed up with some very problematic arguments. For instance: that because mysticism inherently involves reference to the supernatural, it has no place in science. 

That's a basic confusion as far as I'm concerned. That's like saying that you can't scientifically study theistic belief, or belief in God, because it involves reference to the supernatural. In studying psychological events that make reference to the supernatural, scientists don't thereby commit themselves to the existence of the supernatural. 

The other point is, I think from a scientific standpoint, the MEQ and related measures have absolutely demonstrated their value. We should just be expanding the toolkit, paying very close attention and doing a lot more research into things like psychological insight.

It's interesting to me that more people aren’t making a big deal about that. I actually looked back and found in the initial study that they did at Imperial of psilocybin for treatment resistant depression. They used the 11 Dimensions of Altered States of Consciousness scale, and they used this subfactor of unity, spiritual experience and blissfulness as an approximation of a mystical type experience—finding that scores predicted reductions in depression. But scores on the insightfulness subscale predicted it even more strongly. 

That's, of course, the same pattern that you get in those survey studies with this new Psychological Insight questionnaire. So it is surprising to me that people haven't made a bigger deal about these few studies where something seems to predict good outcomes more strongly than a mystical-type experience. I think we should be looking very carefully at that. But I think the way to go is to add to or to augment the MEQ, not to replace it.

If we start thinking about psychedelic experiences as ones that lead to a new sense of self or new psychological insights, why are those not just new comforting delusions that have replaced the other one?
This is especially interesting to me because I have historically been sympathetic to the Buddhist inspired view that there is no self. The sense of self is somehow illusory. 

So yeah, why then, is it any better epistemically to go from one belief about the self to another? Especially if you might have this view on the table that the self doesn't exist. Isn't any belief about the self a comforting delusion?

The jury is out as to whether the sorts of insights people have are typically veridical or not. But some of these psychological insights definitely do have the appearance of learning new facts. People come out and say, "I learned that my depression is due to these unhealthy emotional habits that resulted from this experience in my childhood." Or, "I realized that the reason I keep failing in my relationships is because I'm self sabotaging myself because of this deep seated belief about who I am."

You're right that the epistemic question still arises again. There is this question of truth. Are these insights real or are they just more comforting delusions? From a naturalist point of view, they at least could be true. If you’re sympathetic to naturalism, there is a knockdown argument right from the get go that any beliefs you come out with about a spirit world or cosmic consciousness have a probability of effectively zero. Whereas these sorts of [psychological insights] typically sound plausible enough. 

All that can really be done is for people to try and exercise critical scrutiny after the psychedelic experience with the help of the therapist in the integration and debriefing sessions, in the same way that they would with any other psychological insights they came up with through talk therapy. 

And with the predictive processing theories of how psychedelics work, there are some good reasons to think that they will sometimes induce genuine insights. There are current theories that psychedelics cause an altered state of consciousness by weakening the influence of your prior beliefs. In normal waking consciousness, your ordinary model of who you are, your self story might be good enough for most purposes, but it's probably going to blind you to certain important facts about yourself. By weakening it, by disintegrating it, it seems likely that at least in some cases, psychedelics are going to open your eyes to real facts about yourself that you have been ignoring or you have been blind to. That doesn't mean they're not sometimes going to create false apparent insights or placebo insights.

Even reframing the experience to be rooted in a change in sense of self, we're still operating from the assumption that the experience is causal to the psychological outcome. I'm curious what you think about the attempts to create a non-hallucinogenic psychedelic compound—something that has similar physiological effects, but not the same intense psychological experience? 
I think these attempts are sociologically very interesting in what they reveal about people's reactions. Because some people think that this is obviously the way to go, if you can get rid of the psychotomimetic side effects. And then some people get very upset about these attempts. 

Very upset!
I think there's something fundamentally problematic with that. Both attitudes are anti-empiricist. Both attitudes come from a place of thinking that you've got all the answers prior to scientific inquiry.

My fundamental attitude is, well, let's find out. Let's do the experiments. I strongly suspect, as a lot of other people who work in the psychedelic space, that it's not going to work. I think the most reasonable belief, based on our evidence to date, is that most of the therapeutic effects do come from the experience. And you're not going to be able to get the same therapeutic punch from a variant that doesn't have the experience. But there's no way the evidence we've got to date logically entails that, or guarantees that.

It's definitely an open possibility and we could turn out to be wrong, especially when you consider the methodological problems with blinding and placebo control. It certainly is conceivable that out of these experiments, lo and behold, someone will come up with a molecular variant of psilocybin that has exactly the same therapeutic potential, but none of the altered state of consciousness. 

Obviously it would be good if that happened because then people who don't want the altered state or can't undergo it for some reason could still get the therapeutic benefits. It would also be problematic because it removes one of the main tools of legitimation for the psychedelic state, so that would complicate matters on that front.

When I see people get heated about non-hallucinogenic psychedelics, it reminds me of how something feels different about psychedelics compared to other mental health interventions—maybe because these experiences can be so powerful, and sometimes sacred. It's one of the reasons I believe that psychedelics really needs the field of philosophy, to wrestle with what it all means. 
Mental health in the last 30 years or so has been really interdisciplinary. There's a ton of work by philosophers, psychiatrists, and psychologists on the nature, the taxonomy, and the treatment of mental disorders. In a sense, this is an extension of an existing trend. 

But I agree with you that there's something different and there's something special here. Psychedelic research needs philosophy in a way that is distinct from other areas in psychiatry and in mental health. And a few people have made some comments about this like Nicolas Langlitz, Thomas Metzinger, Benny Shanon; on the fact that psychedelic experiences make people ask philosophical questions.

These experiences somehow raise the sorts of questions that also get addressed in the philosophy classroom, questions about the nature of knowledge, the nature of reality, the nature of the mind, morality, meaning, purpose.

I think a very attractive explanation of this in the REBUS model of [Robin] Carhart-Harris and [Karl] Friston in which says that psychedelics alter consciousness by weakening or relaxing your most fundamental abstract beliefs or assumptions about the world, and then allowing you to experience phenomenal worlds or simulated worlds in which those beliefs don't hold. Where space and time no longer exist, in which the self as an entity distinct from the rest of the world no longer exists, in which contradictions are possible and causes needn't precede their effects and things like that. 

Of course, this is exactly what philosophy does. This is precisely what we do in the philosophy classroom, is we expose these fundamental assumptions about the world that usually go unscrutinized. We do it using the tools of argument and logic and the psychedelic experience does it using these far more dramatic tools of directly modulating your conscious model of reality.

That is perhaps not the only reason, but a really compelling explanation of why psychedelics and psychedelic research needs philosophy— there is something intrinsically philosophical about the psychedelic experience. And so you can't think about this experience and how to regard it without asking philosophical questions about the nature of mind, the nature of reality, the nature of knowledge in these kinds of things. 

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