🫠 Psychonaut POV

Welcome to Tricycle Day. We’re the psychedelics newsletter that’s not obsessed. Not at all. We’re just moderation-challenged. 🙃

Roman Palitsky was told studying mysticism was career suicide. (Reader, he did it anyway.) Now he leads spiritual and existential research at Emory's psychedelic center, where the work often entails sitting with people through their dark night of the soul.

We asked Roman why mystical experiences might be overhyped, what the largest-ever study of post-psychedelic difficulties is starting to show, and how to recover when a journey leaves you more rattled than healed.

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I always knew I wanted to be a psychologist and have spirituality connected to what I did. I went to divinity school before my clinical psych PhD, and throughout my training I was told by well-meaning mentors not to go near mysticism or psychedelics, because there was no career in those fields. That was probably good advice. Today, I am amazed and consider myself incredibly lucky that I get to do this work.

With my divinity background, I kept gravitating toward existential issues. Most of my clinical training was in behavioral medicine, providing psychological care to patients also facing serious physical conditions like heart transplants, cancer, or severe chronic pain. A hospital can't help but be the site of a lot of existential turmoil. So even though I use modalities like ACT and CBT, my orientation tends to be existential, really facing the limits of our experience.

At my postdoc at Brown, I worked with Willoughby Britton, who did groundbreaking research on meditation-related adverse effects, and at Cheetah House, which supports people experiencing difficulties from meditation. That was world-opening. Then I got to Emory just as it opened its psychedelic center, and all my training in spiritually responsive care suddenly had the right place to be used.

In college I was moved by the spiritual emergency narrative and its intersection with the anti-psychiatry movement. A key idea there is that people who'd be recognized as mystics or shamans in more enlightened societies get labeled here as mentally ill, and we harm them through our own pathologizing. So I got a fellowship to go to India and roam the mountains interviewing Sadhus and Babas, doing psychological interviews. My expectation was that these spiritual virtuosos would get flagged as pathological. I was completely wrong. They did not seem diagnosable in that way. There were people among them who were struggling, but these were the ones the community was taking care of.

So my view shifted. I haven't found that framework as uniformly useful as I expected, because if used unskillfully it creates a false dichotomy. Either you're on a spiritual journey, or you're dealing with something pathological. That means people with serious diagnoses like schizophrenia don't get to be mystics. Why not? Why can't they have profound mystical journeys while also recognizing they might need their medication?

I also got clued in early that the possibility of encountering serious difficulties is an open secret among communities doing intensive meditation, much like it is in the psychedelic world. People can fall through the cracks on both sides. Biomedical clinicians often lack a toolkit for these situations, and spiritual communities can be so focused on love and light that people become flummoxed when someone has a hard time. Meditation and altered states are powerful, often for the good, but they can also be dangerous, even if you're careful. And as these contemplative traditions get translated into Western society, the parts about the danger often get left out.

Focusing on mysticism as a measurable construct is relatively new, and a lot of it traces to William James. He described a transient experience characterized by timelessness, access to knowledge, and a sense of union with reality. It's a very positively valenced picture. But if you read the mystics of any tradition, there's pathos in there too. There's union, sure, but there's also fear and trembling in the face of God (although of course God is not always part of the picture or the theology).

The Mystical Experience Questionnaire (MEQ) is measuring something, and it's predictive, but it's not clear it points at a mechanism. If we're talking about the spiritual relevance of psychedelics to people and their communities, you have to ask how relevant a single type of experience really is. The MEQ doesn’t do justice to the diversity of mystical experiences, or the rich contexts in which mystical experiences have historically operated. It’s like singling out a single flower that is usually part of a complex local ecosystem.

So we've adopted a broader framework that encompasses the Spiritual, Existential, Religious, and Theological (SERT) components of psychedelic experiences. The advantage is that it doesn't hinge everything on one peak moment. We already know from psychotherapy that insight alone isn't enough to precipitate change. Everything around the experience matters, too: the relationships, the behaviors, the communities, the way you make sense of it afterward.

My other concern, in our current zeitgeist where psychedelics are bundled with medical science, is that overemphasis on mystical experience has set up a bar to be cleared, almost like a gold star for doing the therapy right. That could cause problems.

The study plans to enroll 800 people who've had difficulties following a psychedelic experience. We have enrolled about a quarter of that number, but it is already the largest sample of its kind, and we're still in our first of three years. Half of the total 800 will be recent-onset cases, and we are following these over a full year. The reason we track people prospectively, in real time, rather than asking them to look back, is that people who recover tend to credit whatever they happened to be doing as the thing that helped. We also have a comparator arm of meditators who've had similar difficulties, which lets us isolate what role the chemical itself plays, because the phenomenology of the difficulties often overlaps.

We haven’t analyzed the data yet because we are still in the process of collection, so nothing here is definitive. But in what we are seeing so far, sleep has come up consistently, and I'm starting to think it might be an important warning sign. Circadian disruption is barely reported in clinical trials, so we're doing a dedicated case series on it. Beyond sleep, the more common clusters of difficulties include heightened anxiety and depressed mood. There are some less common symptoms that are still important. These include dissociation, somatic effects like burning energy sensations and bodily pains, and (less commonly) even harmful encounters with entities.

We can't speak to how common these adverse effects are in the general population, only relative to one another, because people self-identify into our study. However, another recent study found that 6.4% of naturalistic psychedelic users reported difficulties lasting longer than a day and 1.3% for more than a year.

Good support is incredibly valuable. Stay connected with folks who are understanding and willing to take whatever comes up. Don’t rush the process. Get the help you need. There's a tendency in a difficult integration process to think, I shouldn't take medication, or I shouldn't treat this as a problem. Well, why not? There's nothing wrong with any path that offers some relief.

For those who are preparing for an experience, there are some wonderful resources out there. Before You Trip has a great trove of knowledge. Know your dose. We hear “I didn't know what I took or how much” from time to time, and I think that responsible facilitators should make sure that people know what they are taking. I've heard abhorrent stories of facilitators springing a surprise second dose, sometimes even a different medicine, on someone mid-experience. Please don’t do that.

When people are integrating something hard, they often pour all their energy into making it make sense, or “making meaning.” But we don’t need to rush meaning; it will come. But maybe you don't need to do all of it right away. For now, focus on the basics. Maybe have a cheeseburger with someone you love and take care of yourself however feels good. The meaning can come later.

And if you're having a hard time, know that you're not alone, and that it does get better. There's a common fear that you can't “unring the bell” or that you've somehow broken your mind. But that’s not what we see. That might be how it feels right now. By and large, people tend to recover. It will get better.

Find out if you’re eligible to participate in the Post-Psychedelic Challenges Study.

That’s all for today, Cyclists! Whenever you’re ready, here’s how we can help.

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DISCLAIMER: This newsletter is for educational and informational purposes only and is not intended as a substitute for professional medical advice. The use, possession, and distribution of psychedelic drugs are illegal in most countries and may result in criminal prosecution.