#478 — The Psychedelic Mind
Sam Harris interviews Robin Carhart-Harris, a UCSF researcher, about the current state of psychedelic science and therapy. They discuss the FDA denial of MDMA therapy approval, the importance of therapeutic context, quality control concerns, and contraindications for psychedelic use. The conversation covers both the promising clinical results and the significant risks and challenges facing the field.
Summary
Robin Carhart-Harris, a consciousness scientist at UCSF, discusses the current state of psychedelic research with Sam Harris. He describes the field as having ridden a hype wave following Michael Pollan's 2018 book, followed by a market correction and regulatory setbacks. The most notable setback was the FDA's denial of MDMA-assisted therapy for PTSD, submitted by MAPS/Lycos, which Carhart-Harris attributes to data quality issues in adverse event reporting, non-traditional clinical settings, and the FDA's confusion over approving a combination drug-therapy treatment rather than a standalone pharmaceutical.
Carhart-Harris emphasizes that psychedelic therapy is fundamentally a combination treatment where the drug induces neuroplasticity and the therapeutic context shapes that plastic state. He discusses his ongoing research controlling for contextual variables such as therapist quality, music (which he calls a 'hidden therapist'), and aesthetic environment, comparing 'enriched' versus 'unenriched' therapeutic conditions. He argues that context is not separable from the drug's efficacy and is actively testing this assumption.
The conversation addresses quality control concerns in psychedelic therapy, particularly around therapist influence on vulnerable subjects. Harris raises concerns about recovered memory — drawing parallels to the hypnosis-induced false memory crisis — and Carhart-Harris acknowledges this has occurred in major research sites including his own. He describes the therapeutic approach as deliberately non-directive, emphasizing that therapists should neither endorse nor deny the veridicality of recovered memories but instead work with them therapeutically regardless of their truth status. He shares two contrasting case studies: one ambiguous case of possible recovered memory of parental harm that worsened a patient's symptoms, and one case where a patient with a documented history of paternal abuse underwent a transformative emotional experience during a psilocybin session.
On the question of who benefits and who is at risk, Carhart-Harris notes that clinical results across numerous small trials have been remarkably consistent and positive across depression, PTSD, addiction, eating disorders, OCD, and anxiety. However, he identifies key risk groups: individuals with a history of personality disorders (particularly borderline) showed four times greater likelihood of adverse outcomes in naturalistic settings, while those with a history of psychotic illness showed twice the risk. He notes that clinical trials typically screen these individuals out, which he acknowledges is a form of cherry-picking more resilient populations. He also distinguishes MDMA from classic psychedelics like psilocybin and LSD, noting MDMA is less context-dependent, less likely to produce extreme experiences, and functions more as a 'heart opener' enabling conventional talk therapy, making it somewhat safer across varied settings.
About this episode
<p>Sam Harris speaks with Robin Carhart-Harris about psychedelic research and its therapeutic potential. They discuss the current state of the field, the FDA denial of MDMA-assisted therapy for PTSD, the critical role of set and setting, risks for vulnerable populations, the REBUS model of how psychedelics work on the brain, the default mode network and ego dissolution, microdosing, the neuroscience of consciousness, DMT entities, and other topics.</p> <p dir="ltr">If the Making Sense podcast logo in your player is BLACK, you can SUBSCRIBE to gain access to all full-length episodes at <a href="http://samharris.org/subscribe" rel="noopener" target="_blank">samharris.org/subscribe</a>.</p> <p> </p>
Key Insights
- Carhart-Harris argues the FDA rejection of MDMA therapy was partly due to the regulator's conceptual difficulty in approving a combination drug-therapy treatment, since the FDA is structured to approve drugs, not psychotherapy protocols.
- Carhart-Harris claims that psychedelics induce neuroplasticity and that the therapeutic context is what shapes that plastic state — meaning the drug and the therapy are not separable, and stripping context risks undermining or inverting therapeutic outcomes.
- Carhart-Harris identifies music as a 'hidden therapist' in psychedelic sessions, noting it can be emotionally overwhelming and that its presence or absence is a significant variable he is actively controlling in current research.
- Carhart-Harris warns that psychedelics could function like 'hypnosis on steroids' with respect to recovered memory, acknowledging the phenomenon has occurred in multiple major research sites including his own at Hopkins, and that legal exploitation of this dynamic is a foreseeable future problem.
- Carhart-Harris found that individuals with a history of personality disorder diagnosis were four times more likely to fall into the worst outcomes bracket in naturalistic psychedelic use data, while those with a history of psychotic illness were twice as likely — yet both groups are routinely screened out of clinical trials, raising questions about how generalizable the positive trial results are.
- Carhart-Harris argues that the consistency of positive results across nearly all psychedelic therapy trials — covering depression, PTSD, addiction, eating disorders, OCD, and anxiety — is itself meaningful evidence of reliability, even if individual trials are small and underpowered.
- Carhart-Harris distinguishes MDMA from classic psychedelics by characterizing it as a 'heart opener' rather than an ego dissolver, noting it enables more conventional verbal therapy during sessions, is less context-dependent in producing positive outcomes, and is less prone to extreme negative experiences.
- Carhart-Harris contends that the therapeutic protocol in psychedelic sessions is deliberately non-directive — therapists are trained not to guide or interpret patient experiences, including possible recovered memories — and that the correct clinical stance is to work with the material therapeutically regardless of its factual accuracy.
Topics
Transcript
You're listening to Making Sense with Sam Harris. This is the free version of the podcast, so you'll only hear the first part of today's conversation. If you want the full episode and every episode, you can subscribe at samharris.org. There are no ads on this show. It runs entirely on subscriber support. If you enjoy what we're doing here and find it valuable, please consider subscribing today. I am here with Robin Carhart-Harris. Robin, thanks for joining me again. Thanks for having me on. So remind people where you are doing your research on psychedelics. I'm at the University of California, San Francisco. I have my lab there. And what's the focus of your research at this point? It's…
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