Combining Psychedelics and 12-Step Programs for Substance Use Disorders
An interview with David B. Yaden, PhD, by Lukas Basedow, M.Sc., for the MIND Blog.
This interview is about the following publication: Yaden, D. B., Berghella, A. P., Regier, P. S., Garcia-Romeu, A., Johnson, M. W., & Hendricks, P. S. (2021). Classic psychedelics in the treatment of substance use disorder: Potential synergies with twelve-step programs. International Journal of Drug Policy, 98, 103380.
Treatment for people with substance use disorders is often based on classical psychotherapeutic principles, such as cognitive-behavioural therapy. However, two unorthodox approaches have existed since the 1950s that, at first glance, seem to incorporate opposing principles: 12-step abstinence-based programs and psychedelic therapy. In this interview, I exchange with Dr. David Yaden who has recently published a paper with his colleagues from John Hopkins University, in which they discuss potential synergies between these two treatment modalities.
L: For our readers who may be are unaware of this concept, could you shortly explain what 12-step programs are?
D: 12-step programs are peer-support groups that follow a guiding set of principles to help members maintain sobriety. Alcoholics Anonymous (AA) was the first 12-step program, and probably the one that most people are familiar with. Nowadays, there are 12-step groups intended to help with most addictive drugs as well as behaviors like gambling.
12-step groups sit a little uneasily with mainstream addiction treatments. While many clinicians encourage their patients to seek out 12-step groups as an adjunct to evidence-based therapies or treatments, 12-step programs are not themselves considered part of medical or clinical treatments. Moreover, many 12-step programs do not allow members to participate in some evidence-based drug treatments such as medication assisted treatments (e.g., methadone), which is considered a controversial practice among evidence-based clinicians and researchers who see this as preventing effective treatment. Lastly, a large Cochrane review showed that there is evidence suggesting that 12-step programs are effective for some people. There are a complex set of dynamics at play here.
L: What do you think is the broad appeal of 12-step programs? Why has this program been able to spread successfully across the whole globe?
D: 12-step programs benefit from its members, who are often extremely engaged and can provide social connection and support to people who are often lacking it in their lives. The social support that many 12-step programs provide goes well beyond the amount of time that clinicians can provide due to the constraints of their schedules. For example, 12-step program members are teamed with another 12-step program member, who plays the role of a “sponsor”. New members can generally call their sponsor at any hour, day or night, if they are tempted to relapse or if they simply need someone to talk to.
Additionally, the 12-steps themselves are very easy to understand, and provide as their name implies, a step-by-step process to regain sobriety and remain sober.
Finally, 12-step programs are usually easily accessible and free, while healthcare resources can sometimes be inaccessible and/or difficult to afford in the US.
L: The 12-step programs explicitly mention spiritual experiences as catalysts of change. Could you elaborate on what is meant by that? What is considered a spiritual experience in 12-step programs and how does this experience differ from or is similar to experiences induced by psychedelic substances?
D: The 12-step programs stem from Bill Wilson’s writings. Bill Wilson (b. 1895 — d. 1971) co-founded Alcoholics Anonymous (AA) after he achieved sobriety during a moment that he considered a “spiritual experience.” Here is Bill Wilson describing his experience:
“Slowly the ecstasy subsided. I lay on the bed, but now for a time I was in another world, a new world of consciousness. All about me and through me was a wonderful feeling of Presence. A great peace stole over me and I thought, “No matter how wrong things seem to be, they are all right…” (quoted by Ernest Kurtz)
Notably, Bill Wilson was being treated with a substance called Scopolamine, which some consider a psychedelic (though it is not a classic psychedelic like psilocybin or LSD). He was undergoing treatment for alcoholism in a New York City hospital under the care of a physician who was attempting a new form of treatment. Most people are unaware that Bill Wilson’s first spiritual experience occurred under the influence of a psychedelic-like substance!
Spiritual experience plays a prominent role in 12 step programs. After all, it’s part of the 12 steps. The 12th and final step reads: “Having had a spiritual experience as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs”.
L: With regards to your paper: What led you to think that synergies between psychedelic use and 12-steps programs could exist?
D: The spiritual experience that Bill Wilson described as prompting his sobriety is very similar to the subjective effects reported by many people taking psychedelics. Bill himself made this point. Later in his life, Bill tried LSD (a classic psychedelic) under the care of a physician. He appeared to benefit from these psychedelic treatments, and Wilson provided a positive endorsement:
“It is a generally acknowledged fact in spiritual development that ego reduction makes the influx of God’s grace possible If, therefore, under LSD we can have a temporary reduction, so that we can better see what we are and where we are going — well, that might be of some help. The goal might become clearer. So I consider LSD to be of some value to some people, and practically no damage to anyone.”
Wilson’s endorsement of psychedelic treatments may surprise people — it certainly surprised us when we learned about it. According to one scholar, Joe Miller, who wrote US of AA, this fact may have even been actively suppressed by the board of AA.
L: So, what actual synergies do you see? Do you believe there is a benefit to combining the two approaches?
D: I want to be very clear on this point — in the paper, we are neither advocating nor denouncing the combination of psychedelics with 12-step programs.
However, we can’t help but notice the substantial similarities between psychedelic treatments, which many people report resulting in a spiritual-type experience, and the aims of 12-step programs, which aim to provide a kind of spiritual experience as a result of working the steps.
We thought it was interesting that 12-step programs tend to disallow members from participating in medication assisted treatments (MAT) because they are seen as “swapping one drug for another”. This can be unfortunate considering that MAT has been shown to be among the most effective ways of keeping people who have substance use disorders alive.
We were curious as to whether some 12-step programs might make an exception for treatments with psychedelics. Indeed, while they are drugs or kinds of medication, they provide experiences that are similar to (or identical to in some cases) the spiritual experiences that are at the heart of 12-step programs. Meanwhile, the founder of AA advocated combining 12-step programs with psychedelic treatments — and it could be that knowing about this endorsement from AA’s founder might be impactful or at least interesting to some members of 12-step programs.
L: Regarding the integration of psychedelics into 12-steps: What would the actual practice look like? How could psychedelics be integrated into a 12-step program?
D: We could imagine a few different possibilities — call the possible models initiatory, intermittent, or culmination. An initiatory model would suggest undergoing a psychedelic experience toward the beginning of the 12-step process in order to provide more motivation during what may be a difficult period of transition. An intermittent model might involve periodically engaging in psychedelic treatments over the course of the 12-step process, maybe once every few months or so, in order to maintain the momentum of treatment and sobriety. Lastly, a culmination model might involve having the psychedelic treatment along with the 12th and final step as a kind of capstone to, and opportunity to reflect on, the entire process.
Again, these are just some possibilities, we don’t really know how this integration might look in the real world. It’s a topic that’s worth studying and would require interdisciplinary teams to do the research well. Let me reiterate that both here and in the paper, we are neither advocating or denouncing the combination of psychedelics with 12-step programs, but merely considering the subject.
L: What do you think the next steps would look like for this line of research? What are important aspects about this combination that need to be explored?
D: We’re launching some research projects to study groups that are apparently already engaged in integrating psychedelics into the 12-step process. Yet again, I want to reiterate that we’re not supporting or condoning integrating psychedelics into 12-step groups (it is currently illegal in the US and therefore legally risky). But we do want to learn more about this practice — the potential safety issues that come up, whether it’s effective, and how the integration fits with 12-step philosophy as well as with current mainstream evidence-based treatments. There are a number of interesting and important psychological, medical, legal, and anthropological questions to address in this framework.
L: Finally, what would the best possible care for patients with substance use disorders look like? What do you envision the ideal future of treatment to look like?
D: I am a psychological and psychopharmacological researcher, so I study psychological and pharmacological interventions. I think there is a great deal of progress that can be made on both of these fronts. It’s important to note that there are treatments currently available for people who suffer from substance use disorders, and I encourage this population to take advantage of these existing evidence-based treatments.
At our lab at Johns Hopkins, the Center for Psychedelic and Consciousness Research, we are conducting studies and collecting promising data on the potential efficacy of psychedelics for the treatment of substance use disorders. We need more and better research to follow-up on preliminary findings (something that researchers like Matt Johnson, Albert Garcia-Romeu, and Peter Hendricks are currently working on), but it does seem that psychedelics have the potential to help treat some patients with substance use disorders. On the other hand, community-based peer support groups like 12-step programs also appear to be effective, as the recent Cochrane review showed.
Ultimately, though, several larger social forces and policy-related issues need to be addressed to allow people with substances use disorders to obtain access to the services and resources they need.
To summarize, “the best possible care for substance use disorders” would likely involve the integration of access to economic resources and social services. The same goes for psychological and pharmacological treatments. There are no easy or simple solutions here.
The aim of our paper was to highlight a somewhat complicated situation — integrating psychedelics into 12-step programs — and to try to understand their dynamics a little better. I think we probably succeeded more in raising questions than we did at providing concrete answers.
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References appear in the original article.