Psychedelic Psychotherapy Is Coming: Who Will Be Included?

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Recently, there has been much excitement in the potential of psychedelic-assisted psychotherapy to address a multitude of mental health conditions, including depression, post-traumatic stress disorder, addiction, end-of-life anxiety, and other conditions. The non-profit organization Multidisciplinary Association of Psychedelic Studies (MAPS) has been at the forefront of these efforts, funding studies to demonstrate the efficacy of psychedelics for mental health, including MDMA-assisted psychotherapy for people with PTSD. As a result, FDA approval of MDMA for the treatment of PTSD may soon become a reality. However, not everyone has been included or represented in this momentous process.

The crowd is cheering as the psychedelic train pulls into the station, its inviting doors flung wide open. One by one, people with a multitude of ailments are stepping onboard – people with PTSD, anxiety, depression, and many other conditions. Yet, though there are many who need seats, the only people holding tickets are White.

As noted by Dr. Nicholas Powers, the dominant, pervasive image of the psychedelic community is that of White affluence. This is thought to be rooted in the glorification of 1960s and 70s White hippie drug use as a “counterculture” as opposed to an illicit act. People of color have not been meaningfully included in this community. Other factors uniquely impacting people of color include prohibitive costs and lack of access to substances, negative stereotypes about people of color and drug use, and criminalization of people of color through the War on Drugs.

However, the use of non-ordinary states of consciousness for medicinal purposes is neither novel nor modern, and actually dates back thousands of years to the spiritual practices of indigenous communities all over the world. For many indigenous people, psychedelic use is considered a both a sacred and healing act — something that requires the guidance of a highly trained spiritual leader (shaman), and entails psychoactive rituals that bring humans closer to the spiritual world, in an effort to treat both physical, psychological, and spiritual ills. Understanding the indigenous roots of psychedelic medicine within the historical origins of psychedelic-assisted psychotherapy is an crucial reference point, given that modern psychedelic medicine has struggled to include people of color and is only now beginning to acknowledge the importance of their inclusion.

The psychedelic train is pulling out of the station, and people are giddy with excitement, waving as the train beings to move. The train itself is painted with bright colors, but there is little color within. White faces are pressed against the windows from the inside while everyone else watches from afar. Black and brown people, including the elderly, young people, veterans, and the disabled are left standing on the platform as the train chugs away.

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Western medicine’s exploration of psychedelics for treatment purposes can be divided into two distinct periods, the “first wave,” occurring between 1950 and 1985, when synthetic psychedelic compounds were just being discovered, and the “second wave” beginning around the late 1990s and continuing to today, with a renewed focus on high quality research.

The initial “rediscovery” of psychedelics as medicine by Western science first occurred during a period in which biomedical options in psychiatry were limited, as psychopharmacology had not yet become mainstream practice. Newly synthesized psychedelics were not considered controlled substances, and therefore their clinical and research use was fairly unrestrained. Given that psychoanalysis was a mainstay of treatment, initial research on psychedelic medicine examined whether psychedelic drugs could improve the process of psychotherapy, accelerating the treatment of psychological disorders. Yet ultimately, the widespread use of these substances, serious ethical violations (i.e., administration to physically-restrained subjects, sexual abuse between therapists and clients), major methodological flaws in research, and concerns over safety led to defunding of research and eventually the designation of psychedelics as illegal substances. While many researchers and patients continued to espouse the therapeutic benefits of psychedelic-assisted therapy, this area of investigation was shut down for decades.

Several important factors contributed to the resurgence of psychedelic medicine in the late 1990s. Foundational research during the second wave was conducted, consisting of animal and basic science studies. With the creation of MAPS by Dr. Rick Doblin in 1986, researchers were no longer reliant upon government funding and could pursue FDA drug development. The medicinal potential for scheduled substances was also no longer novel, given that research into both cannabis and ketamine had been underway since 1975. Coupled with the fact that many psychiatric illnesses still lacked effective drug treatments, these factors paved the way for today’s second wave of psychedelic research.

Yet despite promising initial results, research has often been limited to small, mostly White samples, limiting the generalizability of findings and excluding people of color from potential therapeutic benefits.

To determine if the existing data on psychedelic treatments is sufficiently applicable to all people of color, we conducted an international review of inclusion across ethnic and racial groups in current published psychedelic-assisted psychotherapy studies, spanning the second wave of studies from 1993-2017.

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As reported in this month’s issue of BMC Psychiatry, we found that the White-centric focus of psychedelic drug use continues in medical research, with extremely low rates of participation by people of color in studies worldwide. Of the 18 studies of psychedelic-assisted psychotherapy that met criteria for inclusion in our investigation (n = 282 participants), 82.3% of the participants were non-Hispanic White, whereas only 2.5% were Black/African American, 2.1% were of Latino/Hispanic origin, 1.8% were of Asian origin, 4.6% were of indigenous origin, 4.6% were of mixed race, 1.8% identified their race as “other,” and the ethnicity of 8.2% of participants was unknown.

These numbers are low when compared to the proportional amounts needed to represent the population, even when considering country-specific differences, making it unclear if current psychedelic-assisted psychotherapy protocols are effective and safe for people of color. The inclusion rates are low even compared to national rates for minority participation in US biomedical research.

One factor contributing to low representation is the lack of cultural inclusivity within the research community itself. Historically, psychedelic research has been predominated by White men and there have been few people of color in positions of leadership. This is not only an issue of representation within the field but also of acknowledging the contributions of indigenous people and people of color in advancing the field, and directly involving these communities in the design, recruitment, and implementation of clinical trials. Only by including researchers with specific expertise in culturally-informed methods will we be able to improve representation and better understand the specific issues relevant to those communities that are resulting in their exclusion from research and the broader psychedelic mental health community.

Given the long history of discriminatory drug enforcement practices in the United States, the stigma of drug use itself must also be addressed. White people have the privilege of publicizing psychedelic use with lesser consequences than people of color. Even if the psychedelics are administered in a legal, health-oriented setting, people of color may still feel they are playing out the stereotype of being drug users that engage in questionable or illicit activities. Further stigmatization may arise from within those communities, as people of color seeking psychedelic therapies may be criticized for engaging with the White medical establishment.

While several efforts are currently underway to address these concerns, it will take the acknowledgement and efforts of both those without and those with privilege and power to change the field. Psychedelic psychotherapy is coming and we all need to be onboard.

Dr. Monnica Williams was part of the MAPS-sponsored multisite MDMA-assisted psychotherapy trial for PTSD, serving as Principal Investigator at the University of Connecticut, one of 17 study sites in North America.

MAPS is hosting a week-long conference and training this August. The purpose of this event is to make sure that MDMA therapy will be available to communities of color by training therapists who serve people of color and to expand thinking about PTSD to include racial trauma. Please consider donating to this effort. Your donation is tax deductible and will help to build equity and inclusion for this important new healing modality.