There is a line you’ll occasionally hear in psychedelic circles, popularized by the researcher Dr. David Nutt: psychedelics are safer than riding a horse. This can be a mic drop statement, and as a statistic about acute physiological risk, it’s roughly fair. But as a guide to how we ought to deal with psychedelics and their full spectrum of possible effects, it falls far short. When you fall off a horse, the people in the emergency room know what’s wrong with you. They can name the injury, treat it, and tell you what it will take to get back in the saddle. On the other hand, for the person who struggles after a psychedelic experience and doesn’t get back up for months, we have almost none of that. No reliable diagnosis. No protocol. Often no clinician who has even heard of what they’re describing. For horse-riding accidents, we have physical therapists and orthopedic surgeons. Psychedelic-related challenges, so far, have a long way to go.
Right now at Emory University we’re working on a study that is built around the people whose psychedelic experience doesn’t fit the tidy narrative of psychedelics as a reliably safe panacea that’s lately been in vogue. The Post-Psychedelic Challenges Project is recruiting eight hundred people who have had, or are currently having a challenging landing after taking a psychedelic. We are studying the experiences of people who struggle during integration, have a difficult time functioning the way they normally would, or have experienced some kind of negative impact. For half of this group we’ll be tracking their progress for a full year, in real time, to understand how to support recovery and, hopefully, thriving after those difficulties.
Don’t get us wrong: we believe psychedelics have remarkable potential to ease suffering and deepen people’s lives. That is precisely why understanding potential harms matters. Psychedelics are powerful agents, and with that power comes some possibility of harm. Those of us who have been around the psychedelic world recognize this as an open secret: sometimes people struggle after taking a psychedelic, and those struggles can get pretty serious. And yet people in real distress, with nowhere to go, are told over and over that what is happening to them isn’t supposed to be possible. Safer than riding a horse.
We fail patients and care seekers if we don’t do our best to care for those who experience difficulties or adverse effects after taking a psychedelic. Not only is this our responsibility to people who take psychedelics, it’s the way to build a robust and healthy psychedelics field. Our project has been under way for almost one year, and we still have several years to go. We believe this study represents the field’s best opportunity so far to understand the nature of psychedelic-related challenges, what helps, and what doesn’t.
At this point we have seen a variety of symptoms. If you or someone you care about is experiencing something that feels difficult or unusual, you are probably not alone. Chances are that we’ve spoken with others who have had similar difficulties. To name a few examples, we have heard from people with perceptual disturbances — visual, auditory, or somatic. These persist for months; unfamiliar flows of energy through the body; sleep problems; episodes that resemble mania or psychosis, but which don’t have certain features that a psychiatrist might expect; and the struggles of coping with meaninglessness and hopelessness. Our study asks about our participants’ experiences in fine-grained detail. We also ask questions that the adverse-event paperwork in a clinical trial never does: what does this experience mean to you, and what do the people around you think it means? We have seen how similar symptoms can be filed under “breakthrough” or “breakdown” depending on who is holding the pen.
To be sure, psychedelics have their cheerleaders and detractors. A cheerleader might say that there is no such thing as a bad trip, and that anything that seems like a harm is really a benefit in disguise. A detractor might say that negative experiences make the entire psychedelic encounter harmful. But we think neither is quite right: benefit and harm are not opposites you trade off on a single dial. They can ride together, the way the things that do us the most good — exercise, love, a hard conversation — are so often the same ones that can leave a bruise. Both harm and benefit can be true at once. What we want to know is more specific, and, we think, more useful than “good or bad.” Our study is trying to identify what helps a hard experience metabolize into growth — and what leaves someone, a year on, still struggling, still alone with it, still waiting for a resolution to their injury.
There are a few reasons why we don’t have this information yet. For one thing, clinical trials often rely on what’s called passive monitoring: this means that adverse effects are not systematically assessed and instead it’s left to the participant to volunteer anything negative. Research suggests that in clinical trials passive monitoring can reduce adverse event detection by a factor of twenty or more. This means we miss many negative impacts, for all sorts of reasons: people think it’s part of the treatment (aren’t I supposed to feel this way?), that it’s not related (I’m feeling aches and pains but that can’t be connected, can it?), or they might be experiencing real benefits and not want to undermine the success of the research (I don’t want to give the impression that this has harmed me in some way). In non-clinical use, if someone gets injured by doing something risk-prone, they might not think their injury counts. (I hurt myself while skateboarding on mushrooms, but that’s not an adverse effect, that’s just a skateboarding accident… right?) For those adverse effects that we do assess, the usual criteria from pharmaceutical trials might not be the right fit for capturing what we see with psychedelics. The checklist that works for an SSRI trial may, for instance, ask about nausea, insomnia, dry mouth, and sexual dysfunction. It does not ask whether someone expected to encounter the sacred and instead found an abyss. It does not ask whether a person came home no longer sure who they are—and whether, six months later, they’re still not sure. These are among the experiences we are now systematically tracking.
By the best available estimates, more Americans are using psychedelics today than at any point in two generations, and more often than not, they’re coming to psychedelics for reasons and in contexts that look nothing like the clinical trials. The profile of a psychedelic user has shifted substantially: where self-exploration and spiritual seeking dominate popular narratives of 1960s-1970s psychedelic use, an increasing number of people, introduced to psychedelics through stories of their clinical research promise, are approaching these substances with explicitly therapeutic goals—to treat depression, to resolve trauma, to get better. In practice, this may mean a different population of psychedelic users entirely, characterized by their own distinct risk landscape. What is true about psychedelic challenges—as well as what predicts them, and what helps people get through them—may not generalize from one cohort to another. As a wider and more diverse set of people take to using psychedelics, a nuanced, pluralistic approach to the study of psychedelic experiences and their impacts has never been more vital.
Our study is recruiting now. We have the privilege of being able to talk to every participant that we screen face to face, and the stories we hear make clear how important it is to provide meaningful support for people having challenging post-psychedelic journeys. The data we gather will generate an anonymized dataset that will be available to the wider research community. This is meant to be a resource for the whole field, not something anyone owns. If you’re having a difficult time after a psychedelic experience, or if the integration has been tough on you, we want to hear from you. You can find us at psychedelicchallenges.org. Your story can help us move the science forward and provide ways to help others in the years ahead.
Josh Lipson and Roman Palitsky are psychologists and researchers on the Post-Psychedelic Challenges Project at Emory University. The study is currently recruiting at psychedelicchallenges.org.
