By Daniel Villiger.

Last year, the German crime series Tatort, which belongs to the most watched television shows in Germany, Austria and Switzerland, aired an episode that takes place in the psychedelic underground. In his mansion, a spiritually-oriented psychiatrist hosts psychedelics sessions for his patients or, rather, his followers. Little surprisingly for a crime story, events turn out as fatally as possible. In the end, almost everyone is dead and viewers are left with the impression that using psychedelics in mental health care is something dangerous.

While the episode is not based on a true story, it was likely inspired by real-life cases where psychedelic underground sessions turned out deadly. A closer look at the German-speaking psychedelic underground scene brings to light one specific name: Samuel Widmer. Widmer was a Swiss psychiatrist who, in 1986, got a special permit from the Swiss Federal Office of Public Health (FOPH) to use psychedelics for research purposes. Due to malpractice, the FOPH revoked the special permit seven years later. Yet Widmer continued to use psychedelics in his therapeutic work and founded a cult-like community called Cherry Blossom Community, leading to a network of underground practitioners. At this, reports of community escapists and former patients indicate that psychedelics got used to manipulate patients and make them dependent.

Psychedelics’ mechanisms of action reveal why they are ideal for exerting impact on patients. According to the REBUS hypothesis, patients become highly suggestible and sensitive to context during a psychedelic session, amplifying therapeutic influence. Of course, this is usually a good thing since it can amplify therapeutic effects, however, it can also become a bad thing when practitioners misuse their enhanced influence. Additionally, research suggests that patients do not benefit from fighting back the psychedelic experience and that already a single session can have a major effect, which again can be good or bad. Taken together, we can see that when undergoing a psychedelic session, patients put themselves in a very vulnerable position that can easily be exploited (also unintentionally). This is the dark side of psychedelic’s power, as portrayed in the Tatort episode and the reports of Cherry Blossom Community escapists.

So far, the dark side of psychedelics’ power has received relatively little attention in psychedelic research. But there is an urgent need to address the issues and concerns that arise from it as psychedelic interventions begin to be used outside the research context. At this, two aspects are of particular importance: (1) Patients need to be informed about the loss of control and increased influence of practitioners in psychedelic interventions as well as about possible security measures to protect their vulnerability. Without this information, patients are not in a position to give informed consent to a psychedelic intervention. The article by Manuel Trachsel and myself provides a detailed account of this argument. (2) The general public needs to be informed about the dark side of psychedelics’ power and how it gets controlled. That way, public concerns, reinforced by cases of malpractice highlighted in the media, are taken seriously and the public understands that these practitioners are bad apples who breach ethical guidelines and that there are safeguards in place to prevent such cases. Such proactive communication can dispel unwarranted doubts about, and promote public acceptance of, psychedelic interventions in mental health care.

Psychedelics are said to have great potential to change mental health care in a major way in the coming decades. In order for these changes to be overwhelmingly positive, we should explore and discuss not only the bright side of psychedelics’ power, but also the dark side. I hope that our article has made a contribution to this.

Paper title:
With Great Power Comes Great Vulnerability: An Ethical Analysis of Psychedelics’ Therapeutic
Mechanisms Proposed by the REBUS Hypothesis

Authors: Daniel Villiger 1, Manuel Trachsel 2

Affiliations:
1 Institute of Philosophy, University of Zurich, Zurich, Switzerland

2 Clinical Ethics Unit of University Hospital Basel and Psychiatric University Clinics Basel, Basel
Switzerland

Competing interests: None declared