Abstract
Coinciding with and responding to a growing crisis in the diagnostic, explanatory and treatment systems of psychiatry, the last couple of decades have seen a growing amount of evidence regarding the therapeutic potential of psychedelic drugs to treat a variety of mental health conditions. Broadly, this crisis can be construed as that of “indivi/dualist” approaches which aim to treat patients who are construed as separated from their social and material contexts, which are taken as given. The implicit premise: the self, but not the world, is the site of therapeutic intervention. By contrast, researchers insist that psychedelic therapy functions by on producing an experience of “connectedness” to self, world, and others, which is heavily influenced by context. However, by remaining in an indivi/dualist thoughtspace, neurological and psychological perspectives betray these recurring themes. In this essay, I approach psychedelic therapy for depression through the lens of phenomenological psychiatry to take these themes seriously–a task which passes by considering experience as embodied, and therefore embedded. Starting off from an analysis of depression as a bodily detunement (disconnection), I argue that, through a process of “immersive reflection”, psychedelic therapy transforms not only the self, but patients’ sense of reality. This will allow me to answer several questions pertaining to psychedelic therapy regarding its therapeutic mechanism, why it transforms reality and not only the self, why it transforms and not merely amplifies experience, why its effects last beyond the drugs’ psychoactive duration, and in what their paradigm-shifting potential for mental health consists of.
Arriving at a time of crisis in the diagnostic, explanatory and treatment systems in psychiatry (and therefore also of its profitability) (Rose, 2016), psychedelic substances are slowly proving their capacity to respond to the need for new therapies for a variety of “mental health disorders” ranging from addiction to end of life anxiety, post-traumatic stress disorder (PTSD), and depression (Andersen, Carhart-Harris, & Nutt, 2020; Chi & Gold, 2020). In the first instance, this is a crisis of the medical model of mental illness which treats it as a chemical or neurological disorder in the brain to be treated with drugs designed to target a specific biological mechanism (Whitaker, 2010/2015). Thus, supported by the advances of neuroscience and pharmacology, the medical model of biopsychiatry construes the individual self as the site of illness and therapeutic intervention–rendering a crisis of this model a challenge to its implicit individualism. To this extent, the crisis implies not only biopsychiatry but also extends to the psychological approaches after which such conditions are labeled “mental” to begin with. Construing the mind or the brain as an independent object of reference that can be separated from its living context, neurology and psychology are both dualist approaches which take the latter as given and therefore focus exclusively on changing the former. The outcome–the self must be transformed, not the reality it lives in. If psychedelics seem uniquely suited to address this indivi/dualism, it is because they have consistently highlighted that “a proper acknowledgement of the importance of context and experience would represent a positive paradigm shift in pharmacological care in psychiatry” (Carhart-Harris, Roseman, et al., 2018, p. 727).
In contrast to traditional pharmacological treatments, it is often noted that the effects of psychedelic therapy hinge on the experiences they produce and not only their chemical action. Specifically, research has repeatedly encountered that psychedelic experiences are heavily influenced by their context of use, or “set and setting” (Carhart-Harris, Roseman, et al., 2018; Leary et al., 1968/2008), and that they are characterised by a strong sense of “connectedness” to self, world and others which may be at the root of their broad therapeutic benefits (Carhart-harris, Erritzoe, et al. 2018). From this perspective, many turn to the notion that psychedelics are non-specific amplifiers of experience which sensitize or open us to our particular environments rather than, as believers in their inherent benevolence defend, drugs which universally produce specific ethical or therapeutic transformations (Grof, 2009; Hartogsohn, 2020). However, to the extent that the resurgence of psychedelic research has been made on the back of the scientific legitimacy and cultural intelligibility afforded by neuroscience (Langlitz, 2013), it remains committed to an explanation of psychedelic experiences that reduces them to an isolated brain on drugs. Concomitantly, while qualitative or “phenomenological” psychological research does pay heed to patients’ psychedelic experiences, it mostly sticks to recording and categorizing them into clusters of subjective effects (Belser et al., 2017; Swift et al., 2017; Watts, Day, Krzanowski, Nutt, & Carhart-Harris, 2017). As a result, experiences of “connectedness” can only be conceived in a “mechanistic and subjective sense” (Carhart-Harris, Erritzoe, et al. 2018, p. 549), i.e. either as an increased global neuroconnectivity or as a purely personal feeling of, say, mystical unity with the world, but not as an eminently real connection to one's context or something outside our self-contained individuality. By remaining in this indivi/dualist thoughtspace, therefore, much psychedelic research betrays its central insights about experiences of connectedness shaped by context–for you cannot be locked in your head and “open” to influence.1 To take these themes seriously, then, requires a conception of experience that does not separate it from the environment in which it takes place.
In this article, I analyze a study on psychedelic therapy for depression at Imperial College London (Watts et al., 2017) through the lens of phenomenological psychiatry to transcend indivi/dualist accounts of experience, mental health, and psychedelic experience. As the philosophical tradition that begins from a description of the structures of experience rather than an explanation or inventorizing of subjective effects, phenomenology lends reality to the notions of context and connection by considering all experience as the emergent result of our bodily contact with our environment rather than the product of an isolated brain or mind. This implies, in turn, a reevaluation of “mental health” conditions as embodied expressions of, as Thomas Szasz's famous phrase goes, “problems in living” (1974/2010). In other words, it is the patient's lived world, rather than strictly their self, which is ill and requires care and transformation (J.H. van der Bergh, 1972). Thus, overcoming the dualism between self and world can shift the “target” of psychotherapeutic intervention from individuals to the contexts in which they live. For if different, in this case disturbed, forms of experience arise as responses to certain contexts, it follows that the former can be avoided (or aggravated) by changes in the latter. This notion informs my conclusions, at the end of the essay, that psychedelics’ paradigm-shifting potential is in highlighting the social causation of mental distress – an all too important task in our neoliberal age. Thus, in a more general sense, my argument that psychedelic therapy functions by a transformation of reality rather than merely of the self aims to redress the emphasis on individual responsibility at the expense of social explanations characteristic of this historical moment. More circumspectly, however, it is this deeper change of reality rather than the self which explains the lasting effects of psychedelics beyond their direct psychoactive duration and its neurological, psychological or behavioural effects. The point is not to deny the benefits of intervening on these latter dimensions of mental health but to consider them within the holistic context of the organism in its milieu (Fuchs, 2007/2018b; de Haan, 2020; Rose, 2019).
Besides enabling me to take patient experiences seriously and transcend indivi/dualist assumptions, the perspective of embodiment will also serve to theoretically ground recent attempts to integrate the body into the use of Acceptance and Commitment Therapy (ACT) for psychedelic therapy (Watts & Luoma, 2020) and to answer several key questions pertaining to psychedelic therapy in general:
What is the mechanism of psychedelic therapy?
Why do psychedelic experiences transform reality and not merely the self?
Why do psychedelic experiences often transform our experience of reality rather than merely amplify it?
Why do psychedelics produce changes in well-being that last long after their direct psychoactive effects have worn off?
In order to answer these questions, the first section will begin by looking at depression as an unusual experience of “disconnection” in which self and world become closed off from each other. From this, the second section will draw out some implications about the structures of everyday experience that are overlooked by those with indivi/dualist assumptions–specifically, how the self is a field phenomenon rather than a private “thing” and how reality is constituted by a dimension of possibility. Finally, before concluding with some comments on paradigm-shifting social potential of psychedelics for mental health, I will turn to psychedelic therapy and propose it operates by a process of “immersive reflection” which facilitates an expansion and re-orientation of our boundaries of action.
Depression as disconnection
Fundamentally a generalized condition of “disconnection” (Watts et al., 2017), depression is evocative of the Cartesian universe. By radically separating the thinking, immaterial self from the mechanical, material world, the 17th century philosopher René Descartes also argued for a strict mind-body dualism which also separated thinking from feeling and the subject from its intersubjective social world (Grosz, 1994). So while the inner mind was given total sovereign freedom over itself and the body, the external world was a uniform, static and objective world regulated by an absolute determinism (Coole, 2010). Interestingly, all these separations and themes are found in patients’ descriptions of their depression, who complain about feeling “trapped in their minds” and “detached” from their bodily senses, about being able to think or intellectualize things but incapable of feeling them, and of feeling “isolated” from others (Watts et al., 2017, pp. 526–536) and unable to engage in an abstract world of objects that will never change (Fuchs, 2013; Ratcliffe, 2015). “Thankfully”, writes phenomenological psychiatrist Matthew Ratcliffe, “the mechanistic world is not actually lived in” (2008, p. 292). Far from being the normal state of things, therefore, the Cartesian dream of closed individuality located in the mind is precisely descriptive of depression, and this points towards the therapeutic need to connect the self to something other than itself.
Nevertheless, dominant approaches to depression reproduce Cartesian assumptions and consider it “an ‘inner’, ‘mental’ and individual disorder” (Fuchs, 2013, p. 220). Such approaches view the patient as separated from its context and bodily symptoms as secondary expressions of the primary disorder–understood as neurological, affective, cognitive, and/or mechanistically behavioural. The disturbance of their relations to the world and to others is thus conceived as a consequence, rather than a cause, of the condition. This belies patients’ own accounts, which insist that what is missing is a connection to their own bodies, to others, and the world. Turning to phenomenological psychiatrist Thomas Fuch's concept of corporealization, we can take patient experiences seriously and think about depression as a form of bodily detunement which is expressive of inhabiting a disconnected–or de-realized–world rather than of a deep rooted individual disorder. From this perspective, “the illness is not in the patient, but the patient is in the illness” (Fuchs, 2013, p. 222). By considering depression a form of bodily constriction, we will see that the neurological or psychological “rigidity” that some accounts explain depression as (Carhart-Harris & Friston, 2019; Sloshower et al., 2020) can also be conceived in terms of one's spatial and intersubjective world. The inability of the body to “flexibly” open and extend into the world produces a progressive closure which many patients compare to being locked in a prison, with no possibility of escape (Ratcliffe, 2015, pp. 64–71). Hence, understanding this experience will help us make sense of why psychedelic experiences often feel liberating.
Depression as bodily detunement
To look more closely at corporealization and its link to derealization, we can begin with Ratcliffe's elaboration of Martin Heidegger's concept of “mood”, or what he calls “existential feelings” (2008). Heidegger (1927/1962) understood moods not as mental or internal phenomena, but as emerging from the in-between of body and world as a result of their interaction. In other words, a mood is not in us, but we are, as the colloquial expression has it, ‘in the mood’. Since they are lived as vague atmospheres that “permeate and tinge the whole field of experience” (Fuchs, 2013, p. 224), we often describe moods through words relating to weather–‘bright’, ‘sunny’, ‘foggy’, ‘cold’ or ‘warm’–that reflect the overall tonality of the emotional space we inhabit. This space is composed of “situations, persons and objects which have their expressive qualities” (Fuchs, 2013, p. 222), and we dwell in it through the embodied responses that they give rise to–such as bodily tension, changes in heartbeat and breathing, or tendencies to approach or withdraw from the situation. Whether we are aware of them or not, all our moods are experienced through such “bodily feelings” (Ratcliffe, 2008). Thus, these bodily feelings are expressive of the situation we are attuned to, rather than of an inner self. This theoretical insight, still lacking in recent considerations of the role of embodiment in psychedelic therapy, explains how a “body scan” can in fact reveal meaningful “messages” about what matters in a patient's life, i.e. in their surroundings (Watts & Luoma, 2020, Appendix A). In all, existential feelings couple bodily feelings to ways of finding oneself in the world, and they constitute an overarching background that structures the specific cognitions and behaviours that become possible within that relation (Ratcliffe, 2008). Such is the deeper nature of depression–not merely a set of negative thoughts or harmful behaviours, but an altered and all-encompassing way of being in the world within which the former arise.
As a form of detunement between body and world, depression leads to a progressive closing off of one from the other. On the side of the body, this leads to corporealization, understood as a process of reification whereby it “turns into a heavy, solid body which puts up resistance to all intentions and impulses directed towards the world” (Fuchs, 2013, p. 226). This is reflected in patients’ sense of carrying a great weight or “concrete coat”, of bodily constriction or shrinkage, of being stuck, of “fog”, or of being enclosed or locked “in the most narrow confined space imaginable”, comparable to a cage or prison (Watts & Luoma, 2020; Watts et al., 2017). As some of these “metaphors” already suggest, these bodily feelings are inseparable from a concomitant experience of one's actual, spatial world. Hence, on the side of the world, depression can lead to varying degrees of derealization, whereby the world appears removed and at a distance, unreachable, totally abstract and foreign to one's self–cold, unaccommodating, uninviting or even hostile. The dreary and incapacitating nature of this detached perspective reveals that perceiving the world as neutrally laid out, such that “nothing stands out [and] nothing makes a difference” (Ratcliffe, 2015, p. 185), fails to capture our usual relationship to the world. Forming one single dynamic, the detunement of body and world becomes a self-reinforcing spiral of disconnection, such that each term becomes increasingly enclosed upon itself and thus not amenable to change through interaction (e.g. ruminative, repetitive thoughts). Thus, what is most needed by the patient–connection–is also what feels hardest and furthest away.2 As I will clarify below, depression is to live in a world bereft of possibilities for transformation (Ratcliffe, 2015). To get a closer look at this process and how to find a way out of it, we can consider its intersubjective, social dimension.
Depression as loss of intercorporeality
The fact that most patients, including those at the Imperial College trial, locate their depression primarily in the social sphere, i.e. as a lack or loss of contact with others, points to its being a failure of intercorporeality. With this term, Fuchs captures how, in social interaction, rather than remaining at a distance from each other, “the other's body extends onto my own, and my own extends onto the other” (2017, p. 9). Drawing particular attention to the attunement between infant and caregiver, where we see the development of intercorporeality in its earliest stages, Fuchs describes the acquired ability to establish reciprocity through gestures, facial expressions, and other micropractices through which we form an “intercorporeal dialogue” and establish a shared situation (2017). It is through such bodily “resonance” (Rosa, 2016/2019)–the offering and responding to subtle bodily cues–that mutual incorporation takes place, locking us into a shared ‘vibe’ or ‘wave-length’ through which we flow into one another. Where such resonance collapses, we fail to extend beyond ourselves and slowly shrivel into a hardbound isolation which disturbs and diminishes our capacity to respond to a way out of it. Such is the case in depression, in which a numbed capacity for expressiveness shuts down intercorporeal dialogue–and thus, in more generally, our ability to participate in a shared world.
From a phenomenological perspective, all relationships to the world are always already social, permeated by intersubjective meanings, values, and boundaries. Therefore, the loss of social roles (e.g. employment, moving away) or relationships (e.g. break ups, death) that often onsets depression affect one's overall relationship to the world, sometimes producing a generalized “de-synchronization” (Fuchs, 2001) with others that produces a sense of unbridgeable distance from them. Crucially, this exclusion from a shared intersubjective world implies that attempting to reach or direct patients according to the possibilities of such a world are misguided. This is why asking patients to try to change their thoughts or behaviour in certain ways without acknowledging that distance and establishing a prior intercorporeal flux can make them feel misunderstood at a fundamental level and reinforce their disconnection, for they inhabit a world in which the possibility for such changes is gone (see below) (Ratcliffe, 2018). Thus, attempting to think or behave differently take a huge amount of effort because they do not “make sense” in their depressed world, and failing only underscores their sense of despair and difference from everyone else. Thus, recovering an ability for personal connection is often a crucial pre-condition to work through depression at a more specific level, which explains why “common factors” such as the therapeutic alliance are probably more important than particular treatment approaches (Wampold, 2015). This interpersonal alliance is fundamental to resynchronize patients with a world outside of their depressive enclosure and help them trust that they can extend into it. In the absence of a shared world through which they can gain a new perspective on themselves, the patient “completely equates his self with his current depressed state” (Fuchs, 2013, p. 223) and becomes a depressed object, a self-contained individual, incapable of change – thus confirming the inevitability of the condition and deferring any possibility of recovery.
As drugs that, once ingested, pretty much force you to experience the world – and yourself – from a different angle, perhaps psychedelics are best viewed, as some indigenuous cultures suggest (Fotiou, 2020), as ‘others’ who pull us out of our own point of view and show us that we can still make contact with a larger world that harbours room and reasons for us to be different. Just like other persons, psychedelics can breathe new life into reality when it appears dead and mute, unable to speak to us across an impossible separation.
Phenomenology and the sense of reality
In order to make my main argument that psychedelic therapy alters patients’ world and not merely their “interior” self, it is important to understand that existential feelings constitute what Ratcliffe calls our “sense of reality” (2008). To this end, we can draw from the previous discussion of depression for some insight into what this sense of reality is and how it is susceptible to variation. Two crucial conclusions follow from the definition of existential feeling, which again, clearly defined, is both a bodily feeling and a way of finding oneself in the world that makes some things possible and not others.
First, depression forcefully shows that we are not an isolated mind or brain inside our heads (precisely what patients complain of feeling like), but bodies embedded in a world, and as such, the self is a field phenomenon (Switzer, 2016, p. 262). In other words, the self is fundamentally constituted by the way that our bodies extend into our surroundings according to a particular “orientation” (Ahmed, 2006). This means that we do not face the world as if it were neutrally laid out in front of us, but are, more or less (un)consciously, involved in it in meaningful ways determined by the practical projects into which we are always already “thrown” (Heidegger, 1927/1962). My orientation as “a writer”, for example, gives a particular perceptual salience to my office, books, and computer, while it passes over the paint store and brushes as rather irrelevant. Reverse these perceptions, and I am no longer a writer, but a painter. Thus, orientations carve out our boundaries of action by establishing a set of proximities and distances around us, determining what becomes accessible and what is beyond our reach, bringing some things near us and relegating others to the background–in short, by organizing space in a way that makes sense to us (de Haan, 2020). As the means of our placement within this “familiar” world, our bodies are shaped by its boundaries, as moving along a certain orientation calls forth and requires particular responses to our environment. In other words, these environments become embodied in personal dispositions and competences that are never only of our own making but markers of different social positions (Bourdieu, 1972/1977). While these remarks help us keep in sight the embeddedness of allegedly independent selves–and their neurological, cognitive and behavioural processes–in their particular worlds, they also visibilize a dimension of our experience of reality that is ignored by indivi/dualist discourses.
Thus, secondly, depression reveals that we do not usually confront the world as fixed and static, but in fact experience reality as a dynamic possibility space. Being about what we can do in the world, orientations establish boundaries of action that, like paths that we can follow, lead our bodies beyond what is immediately present in our surroundings. In other words, our perception of what is physically around us in a particular moment includes a reference to what is currently outside of our view–and towards which our agency becomes directed. The road we are on, for example, is not merely a ground for our car, but de facto also the way to our house. Hence, “what is actually given in experience is not all that is given” (Ratcliffe, 2008, p. 131). Phenomenologists call this supplementary structural dimension of experience the “horizon”–an indeterminate set of interconnected possibilities for further perception that constitute and complete our sense of reality. It is important to note that the horizon is not a sort of mental projection onto an otherwise fully determinate world, but that it is a relational fact whereby one and the same environment offers different possibilities to different bodies, who in turn respond to or call forth different aspects of the former (de Haan, 2020, p. 8). As such, two people can be in the same physical environment while inhabiting vastly different senses of reality–without this making their sense of reality “subjective” in the strong sense.
While this dimension of possibility is obscured by scientific discourses which consider reality simply what “is”, it is also easily missed in everyday experience when our expectations of how possibilities will unfold–or “actualize”–are repeatedly met (habit). Such stable forms of experience, however, are not immune to slippages that reveal the contingency of our sense of reality. According to Ratcliffe (2008), an “existential shift” is a rare, encompassing and therefore particularly conspicuous shift in one's sense of reality which often results in a strong feeling of strangeness, novelty, or difference, whereby practically nothing has changed and it looks the same, yet it somehow feels noticeably different. This is because existential shifts are not an “actual” or practical shift in our experience but a change in the structure of the possibility space we inhabit. For example, rather than a switch between being friends with Maisie or Elena (practical), the possibility of trust in general is missing, making any friendship impossible (existential). While, certainly, this loneliness might sediment through asocial behaviours or “negative cognitions” and can be targeted through these processes, these are expressions of a deeper disturbance of the relationship between self and world. Isolated from this relationship, interventions aimed at the individual cannot find a firm footing within the patient's world and can, as many report, intensify their experience of being misunderstood or their guilt for being unable to effect the necessary changes in themselves (Watts et al., 2017).
Overall, my argument is that depression and the psychedelic experiences used to treat it reveal opposing structures of possibility that the world is felt to incorporate–i.e. opposing senses of reality. While the former discloses the world as bereft of possibilities because you are disconnected from any access to them, the latter imbues the world with an expanded sense of possibility by connecting us back to it. It is in this sense that psychedelic therapy transforms reality and not merely the self.
Psychedelic therapy as connection
Looking at the therapeutic mechanisms behind psychedelic “connection” more closely through a phenomenological lens, I would propose that it operates by a process of “immersive reflection” constituted by two simultaneous and interrelated movements. One the one hand, at the very least, psychedelics produce a large and swift experiential shift, or ‘altered state of consciousness’, which radically unsettles one's sense of reality. By breaking the uniform repetition on which our familiar orientation is based, we can access a new perspective through which we can reflect and work on what previously remained inconspicuous about it. In relation to one's previous constitution, this experience of ‘going outside yourself’, of ecstasy, or of crossing some boundary or threshold to ‘another side’, certainly deems psychedelics a poison that produces a kind of ‘death’ or ‘ego-dissolution’. On the other hand, however, I argue that the reflection enabled by this movement is not a function of becoming detached from reality, but on the contrary, of plunging into its multiple possibilities. Therefore, while I align with the notion of psychedelic therapy as a process of “immersion” that some researchers use to guide their patients through the experience (Watts & Luoma, 2020), I differ in that I consider this not a metaphor for an “introspection” into the depths of an inner psyche, but a description of an embodied process of engagement with the world. In other words, it is by responding to the possibilities that exist in our environment that we are pulled out of our previous predicament and into something different. Immersive reflection is this combination of being ‘outside of oneself’ and more ‘engaged’ in the world – i.e. “connected”.3 Moving beyond subjectivist or mechanistic interpretations of psychedelic experience, this notion will allow us to understand how “connection” is able to heal and transform our reality.
Ecodelic boundary-exploration
In order to conceive of the alteration of experience psychedelics induce as bearing on reality, it is useful to think of them as “ecodelics” (Doyle, 2011) instead–as “making manifest” (delos) our environment (eco) rather than our minds (psyche). This shift challenges us to reconsider the traditional view of the unconscious as something that emerges, vertically, from below consciousness, and to consider it horizontally, as a phenomenon of our experiential field–“not at the bottom of ourselves, behind the back of our ‘consciousness’, but in front of us” (Merleau-Ponty, 1964/1968, p. 180). Therefore, if the unconscious evades our grasp, it is not because “it is sealed from us and inaccessible in principle” but because it is “ubiquitous and pervasive” (Switzer, 2016, p. 267)–all too familiar. As that which is constitutive of our experience without being itself visible, we can equate the unconscious with the aforementioned ‘horizon’–that phenomenological structure which completes our sense of reality by filling in the voids of our partial perspective on the world and which determines the assumptions and directions we take for granted in our familiar orientation. Thus, the unconscious delineates a directional possibility space that shapes our field of action, determining where you can go and, perhaps more importantly, where you will not. By altering your experience of this field and loosening its strictures, ecodelics not only render our given orientation conspicuous but also allow us to come up against or even beyond its boundaries in a very real, bodily way.
Quite literally, this means that the exploration of the unconscious takes its form from the bodily exploration of our environment. This is reflected in the language patients use to describe their ecodelic experiences–describing their reconnection to their ‘mind’ in terms of mental ‘space’, ‘agility’, of ‘light’ clearing away the ‘fog’, and of being able to ‘move out’ after having been stuck (Watts et al., 2017). From the perspective of embodiment, such language appears much less a metaphorical rendering of a disembodied mind than a descriptive account of changed relationships to the world (Ratcliffe, 2008, p. 135). This also suggests that it is not, as is often argued in relation to psychedelics (e.g. Huxley 1954/2004), language or thoughts per se that trap individuals and which have to be transcended into a non-cognitive embodied awareness, but that certain forms and uses of language such as metaphor can in fact provide a means to connection. Taking these expressions more seriously, we can also make sense of psychedelic experiences as a journey or ‘trip’ which takes or leads you somewhere, perhaps somewhere you would otherwise not go. Such emotional “places” in fact correspond to zones of taboo or prohibition that warp your lived space and into which you avoid crossing over (Fuchs, 2018a). Again, this is not mere psychological metaphor. One might, for example, avoid going to a bar that reminds them of their former partner because that would trigger an undesirable bodily experience. The crucial point is that avoiding these affectively charged domains, however, does not mean that they are any less part of your overall experience. Since they structure your field, they are always with you precisely as “to be avoided”. How then do we set and maintain a boundary that keeps them at bay even as it simultaneously holds them all too close?
During his psychedelic therapy session, one patient, for example, re-experienced the fear, confusion and shock he felt as a kid when his grandparent passed away, and crucially, how his parents told him that “boys don't cry” (Watts et al., 2017, p. 539). With this spoken proscription, perhaps unwittingly, his parents set down a boundary that would be in place until many years later. By blocking the body's impulse to cry, they were denying the kid's ability to express the mournful world which he then inhabited. In other words, they were not merely calming the inner state of the child, but turning off the resonance between body and world that is the principle of their open exchange. Through this intentional detunement, then, a certain detachment and dissociation between self and world was effected, erecting a hard boundary between them. This established a restriction of responsiveness to situations to which crying might be an appropriate, now suppressed, reaction–situations whose affective valence became taboo and thus were not to be dealt with but avoided. Thus, shutting down a certain bodily response–crying–produced a particular way of moving through the world (masculine, later disconnected and depressed).4 While diminishing the boy's capacity for interaffective response and resonance temporarily pushed the world away, it also carried this disconnection into the rest of his life, enveloping it as a whole.
Based on patients' own reports from this and other studies, researchers have noted that, in stark contrast to other forms of therapy, psychedelic therapy is valuable precisely because it enables facing and accepting difficult experiences and emotions rather than avoiding them (Watts et al., 2017; Zeifman et al., 2020). But if psychedelics are merely amplifiers of experience, as some suggest, should we not be afraid that by making us confront our “negative” experiences, they would only make them worse? How are we to make sense of the idea that allowing ourselves to feel our pain is often necessary for healing? Since the boundaries that block our relation to the world may produce a painful form of withdrawal, the immersive plunging into the world that psychedelics facilitate has therapeutic value insofar as it helps us explore these boundaries–and discover we can redraw them.
Presence as transformation
To think about how the amplificatory quality of ecodelics relates to their transformative effects, we can consider the popular notion of “presence”, often borrowed from eastern traditions such as Buddhism. That we become present is first and foremost a function of the heightened sensory engagement with the world that these substances produce–colours might have richer hues, things might change size and shape or appear to be moving, patterns and figures might emerge from unexpected backgrounds, and so on. Even non-chemical means to presence, such as “mindfulness” meditation practice, are a result of such altered sensory engagements–sitting and staying still, noticing small alterations of the body or the environment–rather than (or at least as much as) a mental effort to silence one's thoughts. As one patient in the depression study put it, his usual state of being stuck in his head is a form of “mindlessness” compared to the “mindfulness” of being present–i.e. sensorially connected to the world and therefore embodied (Watts & Luoma, 2020, p. 95).
This sensory engagement produces (and is produced by) an experiential shift which, as psychedelic users often say, reveals that there is ‘more’ to reality than we normally perceive (e.g. Huxley 1954/2004). In terms of the reciprocal relationship between self and world, we can say that the latter suddenly offers a bounty of new enticements, of new features and details which demand our attention and draw out our response. It is in terms of this increased responsiveness to solicitations that we can think of the expansion of what researchers call “the emotional repertoire” (Watts et al., 2017, p. 554). Instead of as a purely internal amplification, we can conceive it as the expression of an increased range of bodily resonance that is called forth by new worldly offerings. Hence, it is our tendency to respond to our changing environment which enables us to access different bodily feelings. The “intensity” of psychedelic experience corresponds to the degree to which our body's capacity for response is stretched (in-tension) by its new encounters with the world.
In psychedelic therapy, patients are encouraged to “surrender” to the overwhelming generosity of psychedelic perception–to face it and let it affect them, to “let go” of trying to control or turn away from it (Watts et al., 2017, p. 522). This opening up to a new experience of the world viscerally reveals that there is “more” to what is “present” than you could previously access. Thus, to be present is not to simply perceive what was directly in front of you, but to tap into the horizon–the unactualized possibility of a different perception. By bringing about an “expansion” of consciousness, i.e. in one's response to possibilities and capacity for response, ecodelics forcibly suggest that reality is not exhausted by your previous perception, but that alternative possibilities exist therein. It is worth noting how, at least in some buddhist traditions, presence to the empirical world is a means to connect to the impermanence of appearances and being (Gokhale, 2021)–not to an affirmation of their definitive solidity (as in scientific naturalism).
Returning to our aforementioned patient, we can say that psychedelics brought about a transformative expansion of his sense of reality and the possibilities it offered rather than an amplification of his depressive dissociation. Before therapy, the possibility space he inhabited had been constricted by his effort to avoid, specifically, the memory of his grandparent's death, and generally, crying as a bodily response to later situations. In a circular logic, the very effort to avoid pain was responsible for construing the situations to be avoided as inherently painful and thus to be avoided. Despite the constant effort required to sustain it, this avoidance had not served him to transcend the pain of that moment but only to carry it with him and permanently restrict his capacity for response. This, in turn, made it impossible to respond to later situations differently, thereby shrinking his overall experience of reality. In his own words, while he had learnt to “put his feelings in a box”–a perfectly closed and tightly bounded space–“because you can't be upset, you're a man”, his psychedelic experience was like “opening the box” that he “did not know was there”, which gave him “a wider perspective” that helped him “appreciate that the world is a big place, that there's a lot more going on than the minor things that were going on in [his] head” (Watts et al., 2017, pp. 534–536). By surrendering to the psychedelic experience, he was not only relieved of the boundary-sustaining effort of separating himself from his pain but also free to spend that same energy on interrogating and working through it in order to adjust his orientation. Thus, his psychedelic engagement with the world allowed him to immerse himself in the possibilities of the present–to transform–rather than staying imprisoned in–merely amplifying–the past.
Washing over a hard drawn boundary, psychedelics enabled him (at least temporarily) to transcend the agonizing disconnection from the world that is depression and experience the possibility of connection. It is by intensifying the presence of, making us confront, and therefore forcing us to include the parts of our experience that we carry with us despite our attempts to exclude them that psychedelic therapy requires integration.
Integration
From the perspective of embodied subjectivity, integration consists in a re-orientation of our sense of reality that follows its expansion. Once the barriers that separated us from different zones of our world are dissolved, the challenge is to find our ground within the new, multiplied set of relations that we find ourselves amidst. In this way, psychedelics invite us to heal in a holistic way that does justice to our status as “ecological subjects” (Fuchs, 2007/2018b)–embedded in, open to, and constituted by a multiplicity of relations to our environment. Therefore, to heal must not mean to “return” to a narrow and confining orientation simply to “move on” with a “normal” life defined by a disavowal of these relations, but to include, acknowledge, and where possible, mend them. In other words, healing is a transformative, rather than merely restorative, process through which we become connected to our world, not (only or even primarily) to an independent sense of self. Having unlocked our ability to respond to new features of our surroundings allows us to cognitively, affectively and behaviourally extend our bodies into them in ways that previously seemed impossible. Thus, integration is not an internal but eminently embodied and practical process through which we become directed towards a new reality constituted by a transformed possibility space. It is this reorientation of our boundaries of action that grounds the psychedelic experience in everyday life and explains the lasting effects of psychedelics beyond their definite chemical and psychological effects. In other words, beyond their psychoactive duration we inhabit a different reality–after the “high”, “what goes up comes down elsewhere and somehow altered” (Boothroyd, 2006, 67).
By showing that the way psychedelic therapy functions challenges indivi/dualist premises, this whole analysis points to the need to expand beyond them when we think about therapeutic interventions. In terms of integration, perhaps the most important aspect of psychedelic therapy, this implies creating discourses and practices that exceed cognitive, neurological and behavioural logics. While the first two logics are most visible in psychedelic therapy given the “talking cure” and the ingesting of a chemical substance, respectively, researchers have noted the difficulty of producing lasting significant changes in the third. Here, the focus on contextual forces so strongly highlighted by psychedelics reveals their strength as well as their limits. One the one hand, I have argued that psychedelics manage to alter patients’ lived reality in a comprehensive way that extends beyond the encounter in the therapy room. On the other, the revelation that experience in general is influenced by one's material and social context suggests the need for interventions and support (not to mention research) that exceed therapeutic spaces as traditionally conceived. If the problem is that when people “return to their ‘old lives’ […] the [psychedelic] experiences can be forgotten or dismissed by a world that often sees things differently” and this requires patients to struggle “on a daily basis” to “sidestep the well-trodden trails of old that hold constant allure and temptation” (Watts & Luoma, 2020, p. 94, 98), then a consistent approach would aim to intervene on the world and support the formation of new trails therein. This would be the literal meaning of “holding space” for someone during or after a psychedelic experiences. If this phrase refers first and foremost to a safe presence that “gently” (Timmermann, Watts, & Dupuis, 2022) validates the paths discovered by patients during their “trips”, it might also imply, as community psychology suggests (Nelson et al., 2014), including family members or relevant others in the integration process, direct support to deal with other life stressors such as housing or employment, or enlisting community members to collectively transform their existing conditions. Certainly, the goal is not to “do everything” for patients but to help them through changes that make sense to and at a pace that suits them. Taking this possibility seriously amounts to nothing less than a radical reconsideration of psychiatry and psychology as social disciplines rather than purely medical or scientific ones (Rose, 2019), which, as I will end by suggesting, would suppose a paradigm shift in the conception and treatment of mental health issues.
Conclusion
By means of summary, let us briefly answer the key questions regarding psychedelic therapy I outlined in the introduction:
What is the mechanism of psychedelic therapy?
- A process of “immersive reflection” by which our sense of reality, i.e. of possibility, is expanded and transformed.
Why do psychedelic experiences transform reality and not merely the self?
- In the same way that the self is not an isolated individual but a field phenomenon constituted by its relation to the world, so psychedelic “altered” experience is not an inner phenomenon but a worldly one which affects the environment we are embedded in. Thus, a change in our experience is always already a shift in the boundaries of perception and action that the world offers. These boundaries are not only a straightforward matter of the physical environment, but of an unactualized set of possibilities the world contains. Even when the former remains the same, the latter can be transformed.
Why do psychedelic experiences transform our reality rather than merely amplify it?
- While psychedelics certainly intensify our experience of what is in front of us and how we feel, this intensification also produces a shift which makes conspicuous and confronts us with those domains of our experience which we disavow, ignore or otherwise struggle to access. This implies that our reality is not only what is immediately present but is also enveloped by a set of absences that shape our world. Helping us include or become present to what was previously excluded and to unlock new ways of responding to it, our reality takes a different shape.
Why do psychedelics produce changes in well-being that last long after their direct psychoactive effects have worn off?
- Understanding psychedelic therapy as an embodied re-orientation that connects us to new tracks and paths in the world clarifies how the acute experience of ego-dissolution finds its continuation in our daily lifeworld. Since psychedelic experience is a form of engagement rather than detachment from the world, it is never an isolated mental or neurological phenomenon but always already a grounded mode of being-in-the-world that at once extends beyond our head.
To conclude, we might qualify the effects of psychedelic therapy as modestly (although certainly non-trivially) reality-transforming due, in part, to the limitations of its current embeddedness in indivi/dualist approaches. I have argued that dominant neurological and psychological frameworks are constrained in their understanding of the mechanisms and effects of psychedelic “connection” by their methodological assumption that affective disorders are located inside an isolated head which is therefore also the site of intervention. As discussed above, researchers working in this paradigm continue to come up against its limits in their realization that to properly integrate psychedelic experiences would require continued support beyond the confines of the therapeutic setting. Confronted with this limit, some have begun to set up community integration initiatives that extend such support (Noorani, 2021; Watts, 2022) and to call for the implementation of relational approaches to psychedelic therapy (Barnes, 2022). While I have responded to the latter by analyzing psychedelic therapy for depression through the theoretical lens of phenomenological psychiatry and its emphasis on embodied embeddedness, I would suggest that further empirical research should focus on the dynamics of integration within patients’ particular lifeworlds. This could take the form of ethnographies of the previously mentioned community integration groups or through case studies which track the difference (or lack thereof) that psychedelics make in the larger context of a patient's life. In contrast to isolated reports of subjective psychedelic effects, this would allow us to form a more complex “formulation” (Rose, 2019) of the aetiology of mental illness (how it came to be, its past before psychedelic therapy) that includes patients’ own understanding of it, and of how different factors contribute to its development (what comes after), including how and to what extent different therapeutic discourses are taken up by patients and with what effects. Only such a move away from indivi/dualism will allow us to understand and secure (to stabilize and make safe) the potential of psychedelics to help those who feel stuck–as well as to fully capture their “paradigm-shifting” promise.
A useful way to make sense of this promise is to emphasize that indivi/dualist knowledges and practices regarding “mental illness” emerge within particular cultural and historical contexts themselves. The lens pioneered by Michel Foucault (1975/1991; 2004/2008) is of utmost relavance here, enabling us to perceive how, since the advent of modernity, the “psy” disciplines have facilitated the “responsibilization” of individuals for social problems, a dynamic which has only intensified with the general retrenchment of “the social” in our era of neoliberal capitalism (Adams, Estrada-Villalta, Sullivan, & Markus, 2019; Cosgrove & Karter, 2018; Rose, 1996, 1999). The result is a form of what psychotherapist David Smail calls “magical voluntarism”–the idea that, regardless of your personal circumstances, “with perhaps the expert help of your therapist or counsellor, you can change the world you are in the last analysis responsible for, so that it no longer causes you distress” (2005, ch1). When psychedelic therapy focuses exclusively on changing the self to the detriment of social factors under the guise of scientific neutrality, it certainly partakes of this process (Gearin & Devenot, 2021), even if we admit that this also produced by the exigencies of the evidence regimes it must submit itself to and considerations of cost (Noorani, 2020; Oram, 2014). Nonetheless, psychedelics and psychedelic therapy are still considered harbingers of a great hope in their insistence on the contextual nature of experience, thereby opening the door to a much needed and stronger consideration of how “social adversity factors” contribute to affective disturbances (Rose, 2019).
As I have suggested with regards to depression, to consider such factors in embodied terms implies looking at such “adversity” factors as literally pushing back against the intentions and movement of patients. Depression might be triggered or expressed by interpersonal (e.g. childhood trauma or loss of social roles) or other contextual “disconnections” (e.g. lack of or meaninglessness at work), but what characterizes it is a certain of blockage of patients extension into the world that becomes incorporated and translated into other domains of their lives. Taking things further, as many cultural commentators suggest (albeit in different forms), as a failure of the extension of bodies into their lifeworlds, depression stands as a sign of our larger contemporary predicament – as a lack of “resonance” produced by social and economic acceleration (Rosa, 2016/2019), a form of powerlessness and self-blame produced by norms of infinite self-determination in a society characterized by inequality (Fisher, 2012a, 2012b, 2014; Ehrenberg, 1998/2010; B. van der Bergh, 2012; Han, 2017), a disconnection from meaningful work, status, nature, and others (Hari, 2018), and so on (see also Rogers-Vaughn, 2014). Thus, it is not only our knowledges about mental health conditions that are historical, but the conditions themselves. Thus, to address the current increases in these conditions requires new forms of knowledge that aim at their social contexts and the powerful forces that shape them.
It is from perspective that we can see the “opportunity” many see in psychedelics, as much to raise “collective questions about the increasing prevalence of mental illness in our societies” (Noorani, 2020, p. 38) as to “acknowledge and resist the replication of existing structures of power” (George et al., 2019, p. 12). The point is to acknowledge that indivi/dualist discourses regarding “mental health” are not the only neutral, scientifically validated options but caught up in larger social contexts that can themselves be changed, and that psychedelics make us wonder whether it's once again time that the “diagnosis was social” (Staub, 2011) – a question that phenomenological psychiatrists such as Ronald D. Laing (1960/2010), who had also experimented with psychedelics in his practice, were once at the forefront of asking.
This is not to say that biopsychiatry or psychology are “bad”–clearly they continue to help many, and they have indeed rendered many debilitating conditions amenable to intervention–but to remain critical about how, in the attempt to lend reality to, legitimize, and address the plight of those suffering mental distress, they have de-realized the latter's contextual and relational character in ways that have larger social consequences. For it is within these contexts that the overly rigid “egos” that psychedelics dissolve were constituted and are to be recreated for the better. From a critical standpoint, we might thus hope that psychedelics can springboard a “super therapy” (Gilbert, 2017) aimed not at merely coping with an existing reality by trying to fit into its established norms, but at bringing about a new health through the latter's transformation. This will only occur, however, to the extent that we focus less on mental health, and more on its conditions.
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As an exemplary case of the individualisation of contextual relations, we can consider research conducted by MacLean, Johnson, and Griffiths (2011) that found that mystical experience induced by psychedelics enhanced the “character trait” of “openness”. In fact, openness describes a certain relation between self and world, and not an inner quality of a person–a personality “trait”. Turning a mode of relation into an attribute of a person, this is a great example of the hypostatization of individuality that Michel Foucault saw as one of the main normative, epistemological and ontological functions of the “psy-” disciplines.
Once this self-reinforcing dynamic is set in motion, it becomes impossible to determine its initial cause (which in any case, is possibly and probably plural, i.e. causes). This can give the impression that indeed it is the person who is responsible for the continuation of the depression due to a lack of response to new environments. As I mention below with reference to Bourdieu, however, we can view bodily dispositions and competences of response as incorporated environments–in other words, our bodies carry our past environments with us. In this sense, it remains possible that two people currently in similar contexts can feel differently about them–it does not follow from this that depression is not contextual (one reality, two “minds” – an eminently modernist assumption rather than a universally valid one).
Eschewing the scientific assumption that the physical world remains the same beyond subjective experience and the spiritual assumption that change is either mental or occurs in (or from) an altogether different and perhaps immaterial metaphysical domain, the transformation of immersive reflection functions on the performative operation (Butler, 2006/2006): “the same but different”. In other words, the same world becomes different by repeating it differently, which is possible because the world is not a static given but is “enacted” (Varela et al., 1991/1993) moment to moment by the subjects who shape it through their engagement with it. This enactivist, performative, or “emergent” view of the material world helps us transcend the impasse between scientific and spiritual accounts of psychedelic experience.
I am not trying to suggest a logical or necessary relationship between masculinity and depression, especially considering that depression is known to affect women at a higher rate than men (Grigoriadis & Robinson, 2007).
