Introduction

The world of psychedelic research is abuzz with enthusiasm as compounds such as psilocybin are approaching licencing for a range of psychiatric conditions. Although media coverage of the so-called psychedelic renaissance would suggest that these are incredibly promising treatments (Yaden, Yaden, & Griffiths, 2021), there are a growing number of opinions from within the industry that raise concerns that this may not be the full picture (Yaden, Potash, & Griffiths, 2022). More unusual still, is a voice from outside the small echo chamber of psychedelic research. The short story, Cornutopia (Okojie, 2019), by British-Nigerian writer Irenosen Okojie gives an important insight into how psychedelic research may be perceived by those from an ethnic minority background, and holds a number of important messages from which the sector can learn.

The arts provide an invaluable insight into human experiences, and the public can often form opinions of psychiatric treatments based on what they may see or read in the media. An example of this is electroconvulsive therapy, where negative portrayals still have an impact on patient and carer views of the treatment (McFarquhar, 2008; Walter, 2002). It is therefore important that those working in developing psychedelics as medicines are aware of how they are being depicted in popular culture.

Cornutopia

Cornutopia is from Okojie's collection of short stories, Nudibranch, which was published to critical acclaim in 2019. The title is a combination of the words ‘Cornucopia’, meaning a horn of plenty which overflows with abundance, and ‘utopia’, an imagined place in which everything is perfect. This perhaps alludes to the overly positive coverage psychedelic-assisted therapy has received.

We meet the protagonist whilst she is in the throes of what seems to be a depressive episode, “aching, rolling, gnawing and howling” (Okojie, 2019) with pain. She is supported by her “ally” (Okojie, 2019) and “ex-boyfriend” (Okojie, 2019), Edwin, who is sceptical when she expresses that she wants to enrol on a clinical trial.

The protagonist takes us back to her past when she and Edwin were dating. She had said goodbye to him after a date and set off walking home when she was the victim of a “vicious, random attack” (Okojie, 2019) by a stranger in a subway. He slits her throat and runs off, leaving her with a “permanent necklace” (Okojie, 2019) of scar tissue which acts as a “certificate of near death” (Okojie, 2019).

The reader is brought back to the present where the protagonist is at the hospital with the other participants about to begin the trial. Not long after she has taken the “pills shaped like small capsules” (Okojie, 2019) she notes that her “pain had waned” (Okojie, 2019) and that it had been “reduced to a molecule, a glimmer under a telescope” (Okojie, 2019) as if now she has some perspective and is able to examine her psychological pain. This appears to refer to the idea behind the “Accept, Connect, Embody” model of psilocybin therapy, which uses the increased psychological flexibility that can be generated by psilocybin, towards generating new connections and acceptance (Watts R., 2020). That it is a psychedelic clinical trial is further alluded to in the imagery; “Bright purple mushrooms sprang from the floor” (Okojie, 2019) and “the walls became silvery waterfalls” (Okojie, 2019).

Things take a sinister turn as the trial progresses and the effects of the drug “crashed out, levelled off” (Okojie, 2019). The protagonist reports that “Eden had gone” (Okojie, 2019), and the positive experiences of the trip have been replaced by more ominous images. We are told that “the walls were shedding their layers to reveal scar tissue” (Okojie, 2019) and “damaged, misshapen bloody hearts were beating in sick pans” (Okojie, 2019). This tells us how raw and exposed the patients' pain has become, leaving the protagonist a “wreck” (Okojie, 2019).

Despite raising concerns, the protagonist is told that she is unable to leave the trial. Whilst staff are on their lunch she goes through their desk, “not knowing exactly what I was looking for” (Okojie, 2019). She goes through patient notes in the filing cabinet to find that the “staff on the wing were former patients” (Okojie, 2019). She flees into the disabled toilet to call Edwin, speaking in a “rush of garbled panicked breaths” (Okojie, 2019).

The story ends with the protagonist and Edwin sat in the park. The reader finally learns that her name is Amel Dyani, although she feels that the name “belonged to someone else” (Okojie, 2019). Her pain is completely exposed, to the extent that “people were skidding” (Okojie, 2019) on it and it “slid up the trunks of trees” (Okojie, 2019). This suggests that now the pain has been spilled so extensively she may be unable to gain any kind of control, and this leaves the reader with a sense of her hopelessness.

Cornutopia is a work of fiction, though representing the views of an individual, is incredibly valuable as it can offer a fresh perspective on how psychedelic research may be experienced by those from an ethnic minority background. This is important as lack of diversity has been widely highlighted as an issue in psychedelic clinical trials (Carter, 2023; George, 2020), and Okojie highlights a number of potential barriers and concerns around participation.

Historical research abuses against people of colour

It is crucial for those working in clinical research to be aware of the historical mistreatment of people of colour during clinical trials conducted by the medical establishment. Perhaps the most famous example is the Tuskegee Study, an observational study in which around 400 African American men were not told they had syphilis and were not offered any treatment or counselling around how to prevent spread of the disease. It ran for forty years and became the longest non-therapeutic human experiment in medical history (Corbie-Smith, 1999). It is thought that the lasting impact of this can be seen in the continued poor recruitment of people of colour into clinical trials (Corbie-Smith, 1999).

There were also numerous abuses of people of colour in the first wave of psychedelic research, which often focussed on vulnerable populations such as incarcerated people, who were disproportionately people of colour (Strauss, de la Salle, Sloshower, & Williams, 2021). In one 1956 study Black participants received double the dose of LSD relative to their White counterparts, and whilst White participants were dosed for 8 consecutive days, Black participants had to endure up to 85 days of chronic administration (Belleville, Fraser, Isbell, Logan, & Wilker, 1956). There are many such examples of ethical violations against people of colour in the name of psychedelic research, leading to calls for current psychedelic research to be culturally inclusive and socially responsible (Strauss et al., 2021).

Okojie perhaps alludes to this mistrust of the medical establishment when Amel “wondered if they'd tested it on animals yet” (Okojie, 2019), suggesting that she feels that those running the trial do not value her safety particularly highly. This idea of suspicion is reiterated when she meets the doctors and nurses running the trial. She describes their faces as “masks of congeniality” (Okojie, 2019), as well as a nurse who had “make-up slathered on as if to hide something” (Okojie, 2019). It is abundantly clear that the clinical setting is not a place where the protagonist feels safe. This raises questions around the extent to which this feeling unsafe may impact the carefully managed set and setting when psychedelic-assisted therapy is delivered in a clinical context.

Continued health inequalities

There remain significant health inequalities between those from a minority ethnic background and the White majority. This has been highlighted most recently by the Covid-19 pandemic which had a disproportionate effect on Black and Asian populations in the UK. This was a result of a combination of biological and social factors generating increased exposure, reduced protection and increased severity of illness (Patel, 2022).

With regards to mental health, those from a Black Caribbean background are more likely to be compulsorily admitted to hospital compared to White ethnic groups, as well as being more likely to be readmitted to hospital (Barnett et al., 2019). Mental health services are also less frequently accessed by those from a minority ethnic background due to fear of discrimination, restraint and seclusion if they try to seek help (Patel, 2022). It is important that readers consider Cornutopia in the context of these on-going health inequalities for people of colour.

Diversity in psychedelic clinical trials

Lack of diversity is a common problem across all clinical research, and psychedelic clinical trials are no exception. Sellers et al. (Sellers, Romach, & Leiderman, 2018) describe psychedelic trial participants as ‘Often mainly Caucasian, highly educated living in major urban centres with access to tertiary medical care.’, and it has also been noted that in 70.6% of psilocybin studies, 75% of all participants were white (George, 2020). Another review article found that of 18 studies looking into psychedelic-assisted therapy 82.3% of participants were non-Hispanic White (Michaels, Purdon, Collins, & Williams, 2018). This does not necessarily reflect the population who are most likely to suffer from depression, which is often associated with lower socio-economic status (Carles Muntaner, 2004). This is a serious issue – one study showed that around 20% of newly-approved drugs demonstrate differences in exposure and/or response across ethnic groups (Ramamoorthy, Pacanowski, Bull, & Zhang, 2015). The positive results generated by trials lacking in diversity simply may not be applicable to a wider population (Michaels et al., 2018) – a significant issue when those from minority ethnic backgrounds are at increased risk of poor mental health, with racial trauma being a contributing factor (Carter, 2023; Nazroo, Bhui, & Rhodes, 2020). Additionally, the psychedelic experience is very culturally specific (Dupuis, 2022; Neitzke-Spruill, 2020), meaning that lack of diversity is a much more pressing issue within psychedelic research than in other fields. It is therefore incredibly important for those running clinical trials to try and recruit a more diverse range of participants, not only to be more representative of the population, but also to establish whether or not positive results would apply to a more diverse patient population.

Patient vulnerability

Okojie effectively portrays Amel's suffering and her desperation to get better. She expresses her “need to try something else” (Okojie, 2019), and describes the sign directing her to the drug trials department as “bracing itself for keen hands” (Okojie, 2019). In promising a “new anti-depressant that could take the pain away” (Okojie, 2019) Okojie is suggesting that the pharmaceutical company is perhaps taking advantage of the desperation of those who are so unwell as to go to any lengths to get better. This makes them very significantly vulnerable to exploitation (Mermet-Bouvier & Whalen, 2020), particularly when patients are often left dissatisfied by the antidepressant medication they may have been offered first line (Baune et al., 2021). One recent study showed that over 40% of patients with moderate depressive disorder failed to achieve remission with the initial treatment offered and around half of those taking antidepressants were dissatisfied with their treatment (Ohayon et al., 2023). The appeal of a treatment that promises to be radically different is all too understandable.

A recent analysis of internationally recognised core documents around human research protections highlighted fifteen ways in which someone could be vulnerable. “Those that may be unduly influenced by the expectation, whether justified or not, of benefits associated with participation” as well as “ethnic and racial minorities” are both on the list (Mermet-Bouvier & Whalen, 2020). It has been suggested that patient expectations of psychedelic-assisted therapy can be beyond what current data suggests is realistic, likely due to uncritical media outlets promoting the benefits of psychedelics (Yaden et al., 2021). One study looking into perceptions of psychedelic assisted therapy amongst Black Americans found that Black American participants reported more positive views than White participants after psychoeducation, and that Black participants who reported a greater severity in their depressive symptoms had more positive views of psychedelic-assisted therapy and expressed more interest (Carter, 2023). As well as highlighting a greater need for novel treatment within the group as the authors suggest (Carter, 2023), it is important to bear in mind that this creates a greater risk of exploitation. Those working on psychedelic clinical trials must be mindful when recruiting patients of their background and expectations, and the ways in which these factors make them vulnerable in the research setting.

Okojie also alludes to the vulnerability of patients whilst they are under the influence of psychedelics when she describes the “man whose robe had come undone had his tongue pressed against a trolley wheel, eyes closed in bliss” (Okojie, 2019). This leaves the reader with an overwhelming sense of how easily this man could come to harm. Psychedelic-assisted therapy puts patients in a much more vulnerable position than conventional treatments such as medication and psychotherapy owing to the significant influence the therapist has over the new insights a patient generates, the relatively short time in which the insights are generated, and the lack of benefit to the patient in resisting the treatment (Villiger & Trachsel, 2023); you can choose to stop taking a tablet or attending a longer course of psychotherapy but it is difficult to reverse a psychedelic once it has been taken. This “special vulnerability” (Carhart-Harris & Goodwin, 2017) in combination with mistrust of the medical profession alluded to by Okojie may represent a significant barrier to inclusion to those from an ethnic minority background.

Potential for bias

A recurrent theme in the text is one of mistrust of the doctors and nurses staffing the clinical trial. One nurse is described as having a “fox-like” (Okojie, 2019) face with “make-up slathered on as if to hide something” (Okojie, 2019), as if the staff are preying upon participants. It is also suggested that the staff's positivity is unwavering even in the face of the protagonist's suffering. Okojie describes the nurses' “fixed smiles” (Okojie, 2019) and that they “batted away my concern like a pro” (Okojie, 2019), hinting that this may be something the staff do on a regular basis. The protagonist eventually makes the discovery that the “staff on the wing were former patients” (Okojie, 2019), which causes her to panic – a “chill hit” (Okojie, 2019) and her “body shook” (Okojie, 2019) - this cannot possibly be a fair and unbiased trial, and leaves the reader with questions as to the motives of the staff.

Questions have been raised about whether the personal use of psychedelics amongst psychedelic researchers creates the potential for bias (Forstmann, 2020; Kious, 2022). One recent study showed that, amongst medical students, those with personal experience of psychedelics reported more positive attitudes and beliefs around psychedelic-assisted therapy. They also demonstrated that these positive attitudes and beliefs made students more willing to recommend psychedelic-assisted therapy (Pagán, 2023). Additionally, a survey study by Aday et al. of therapists in one phase II study of psilocybin for major depressive disorder showed that 88% of those who responded had personal experience with psychedelics, though this study was limited by a low response rate and notably lack of diversity amongst respondents (Aday, 2023). There is no evidence to suggest that those with personal experience of psychedelics are any more competent than those without (Hendricks, 2023), however, it has been noted that personal experience of psychedelics amongst those working in the field may create an expectancy bias, or at the very least a perceived one (Kious, 2022).

In raising questions around the motives of the trial staff in Cornutopia, Okojie has highlighted how this perceived conflict of interest may perpetuate feelings of mistrust of the medical establishment carrying out psychedelic research, and how this may disproportionately impact people of colour.

Transiency of positive impact

Whilst under the influence of the study drug, the protagonist describes the positive impact it seems to be having on her. She is “light, happy, the ache inside me dulled” (Okojie, 2019), and in contrast how the clinical setting has previously been portrayed the ward now seems “tropical, warm” (Okojie, 2019). This air of positivity seems to shift, however, as the study drug wears off the imagery begins to suggest that this relief from patients' suffering may have been short-lived.

Nurses come round handing out “bruised pears” (Okojie, 2019) and fruit with “teeth-marks” (Okojie, 2019) whilst patients still seem to be enjoying the positive effects of the study drug, perhaps foreshadowing the harm that the protagonist will feel has come from her participation in the trial.

There is a growing body of evidence that there is potential for psychedelics to do more harm than good for some (Marrocu et al., 2024), however, this may not always arise from a negative experience during the trip itself. Depression is more than a headspace; it has a significant impact on lifestyle and functioning. Psychedelic-assisted therapy aims to change someone's mood in the space of a few hours, however, if someone has been unwell for a long time they may struggle to make the lifestyle changes required to maintain their improved mood, such as regular meals, exercise and a consistent sleep routine. This may result in their mood deteriorating not long after dosing. We must ask whether this rapid improvement followed by a swift return to depression may be more distressing and destabilising than if they hadn't had any psychedelic-assisted therapy at all (Hayes, 2024; Jacobs, 2023).

At the end of the story the protagonist describes the “pain stretched before me” (Okojie, 2019), that it is “crawling, crawling, crawling” (Okojie, 2019) beyond her control. It seems that her distress has spilled out and she is unable to gather it back again. She is a “carcass that had finally stopped tricking people into thinking it could breathe” (Okojie, 2019). She has undoubtedly came away from her psychedelic experience more unwell than when she signed up for the trial.

Potential impact of mistrust on psychedelic-assisted therapy

It is well-documented that context and expectations can have a significant impact on the psychedelic experience (Carhart-Harris et al., 2018; Dupuis, 2022). Questions have been raised about the impact of expectancy bias on the results of clinical trials – if participants are expecting a positive outcome this can artificially inflate the effect of the treatment group relative to the placebo group (Muthukumaraswamy, Forsyth, & Lumley, 2021). What if, much like Okojie's protagonist, expectations were negative as a result of not feeling adequately safe within the medical establishment? It would be reasonable to hypothesise that these negative, or perhaps not so positive, expectations might have an impact on clinical outcomes of psychedelic-assisted therapy. It has been hypothesised that race may play a role in the set and setting of a psychedelic experience (Neitzke-Spruill, 2020), and so further investigation is warranted to see whether this potential impact would be significant enough to see a measurable difference in response between the white majority of trial subjects and those who are from an ethnic minority background.

Culturally sensitive therapy (CST)

In his 2001 paper, Hall discusses the concept of CST, the limitations of delivering existing Eurocentric therapy models to a more culturally diverse population, as well as the difficulties of undertaking research in this area. Current research asks participants their ethnicity, but ignores factors that create significant variation within these groups, such as immigration history, language skills, acculturation, racial identity, perceived minority status, experiences with discrimination, religious or spiritual beliefs and socioeconomic status (Hall, 2001) to name a few. He also points out the limitations of simply including participants from ethnic minority backgrounds without considering modifications to the models of therapy to make them more culturally relevant. These models have likely been developed by middle class European-Americans, and will therefore be most useful for ethic minority persons who are most similar to European Americans, namely those who are acculturated, speak English, are educated and not socioeconomically disadvantaged (Hall, 2001). It may be these individuals who are most likely to partake in research, meaning there is limited generalisability and external validity to the data generated (Hall, 2001). It is therefore crucial that those working on psychedelic clinical trials are mindful of the rich variation within ethnic groups, and aim to make therapy models as culturally sensitive as possible.

Beyond psilocybin

The focus of this article has been psilocybin, as that is the substance alluded to in Okojie's short story. There will, of course, be variations on the impact of cultural context between psychedelic substances due to the differing cultures surrounding their naturalistic use. A useful example to consider would be ayahuasca, which has an extensive history of use amongst indigenous populations in South America, but has undergone a process of globalisation through its commodification for use by mainly non-indigenous people (Tupper, 2009), as well as being investigated in clinical trials to treat mental health conditions (Palhano-Fontes et al., 2019; Zeifman, 2020). Concerns have been raised about the appropriation of traditional knowledge, the impact of increased demand on limited natural resources, and how these processes unfairly reward those individuals responsible for appropriating (Tupper, 2009). When considering cultural competence, it is important to be aware of how aspects of the psychedelic renaissance are perceived as colonial (Ens, 2020), and how this may impact how someone from an ethnic minority may view psychedelic research.

Conclusion

Although Cornutopia is the view of an individual and a work of fiction, Okojie gives us a valuable insight into how psychedelic research may be perceived by those from an ethnic minority background outside the psychedelic research bubble. It is also important to be mindful of the unconscious bias that may arise in the author's interpretation of Okojie's work as someone of a White British background who has previously worked on a clinical trial involving psychedelics; this represents a limitation of this article.

It is crucial that those who work on psychedelic clinical trials are aware of the impact of the lack of diversity amongst trial participants and make active efforts to recruit a more diverse study population (Hayes, Wahba, & Watson, 2022) as a starting point, recognising that this alone is not sufficient (Hall, 2001). An excellent example is being set by the Multidisciplinary Association for Psychedelic Studies (MAPS) whose efforts to increase participation of people of colour led to a doubling of ethno racial diversity amongst participants of its phase III trial looking at MDMA for post-traumatic stress disorder, in which people of colour made up 53% of participants (Leighton, 2022). Greater awareness amongst researchers is needed around the barriers to participation, as well as the limitations of current Eurocentric research models in capturing the variation within ethnic minority groups.

Additional research is also required around whether or not there is any variation in clinical outcomes for psychedelic-assisted therapy between people of colour and White majority participants when controlled for other variables, as well as follow-up of those who did not benefit regardless of ethnicity. Although at this early stage psychedelic-assisted therapy seems to be showing promise as a clinical treatment, voices such as that of Okojie can give a valuable insight into broader views on the so-called psychedelic renaissance, and the particular subjective experiences that may partly determine the treatment outcome.

Funding sources

This article received no funding.

Conflict of interest

Dr Caroline Hayes was a sub-investigator on the Compass phase IIb trial looking into psilocybin for treatment-resistant depression. She has no current involvement with psychedelic clinical trials.

Author contribution

Dr Caroline Hayes – conceptualisation, writing original draft, editing.