Psychedelic Projections: Hidden Narratives Shaping Psychedelic Medicine

Psychedelics can evoke powerful projections not only for those under the influence of these substances but also for those who study them. As Timothy Leary once quipped, “LSD [is a psychedelic drug that] occasionally causes psychotic behavior in people who have not taken it.”¹ This speaks to how the idea of psychedelics can be polarizing, political, and often poorly defined. While psychedelic substances are mere molecules, “psychedelic” as a concept is a blank canvas onto which all manner of biases, agendas, and beliefs can be projected. Consequently, psychedelics often mean different things to different people.  

Exploring these “hidden meanings” helps explain the charged debates over psychedelics playing out in media, academia, and public discourse. Drawing from my work as a psychiatrist studying psychedelics, I will examine the idealistic, often unacknowledged, beliefs and aspirations projected onto these substances. By bringing these hidden meanings to light, I argue we can better navigate the current psychedelic landscape and perhaps rescue the field from itself. 

Psychedelics are in the zeitgeist largely due to their potential psychiatric benefits. How did it come to be that after three decades of relentless propaganda about psychedelics causing permanent mental illness, they are now suddenly embraced as potential medicines for psychiatry’s most vulnerable patients? The answer lies in the overall clinical landscape. Following a generation of federal obstruction, clinical research on psychedelics only began to garner widespread institutional interest in the late 2010s. The remarkable return of psychedelics bears a striking correlation with what a 2013 New York Times op-ed described as “a dry pipeline for psychiatric drugs.”² 

While favorable attitudes among psychiatrists toward psychedelics are rapidly increasing, this shift is disproportionately composed of younger psychiatrists³ who came of professional age at a time when few other new psychiatric treatments were on the horizon. Older psychiatrists, who lived through a golden era of psychopharmacology when anxiolytics, antidepressants, and antipsychotics first hit the market, tend to hold more reserved opinions on psychedelics. The increasingly favorable attitudes that many clinical researchers hold toward psychedelics may, therefore, owe more to the broader context of psychopharmacology’s stagnation than to the clinical benefits of psychedelics per se.

However, for many researchers, psychedelics represent something more than just a medical treatment. Defining this unexpressed “something more” could illuminate the truth behind Dr. Leary’s famous quip by explaining how psychedelics provoke intense reactions and serve as a mirror for fears and aspirations that often have little to do with pharmacological effects. This dynamic, which Michael Pollan calls the “irrational exuberance” driving overly optimistic takes on psychedelics, underscores the need to clarify the deeper values and ideals being attached to these substances.⁴ Doing so may also help explain the charged debates within the psychedelic space and foster more grounded perspectives on their medical applications.  

To uncover what that “something more” may be, let us interrogate what it means to depict psychedelics as “treatments.” There is a current debate among researchers between those who believe psychedelics are biological agents that require only “psychological support” from a technician—making them more similar to surgical procedures than psychiatric treatments—and those who believe psychedelics represent a paradigmatically different treatment, called psychedelic-assisted therapy (PAT). Hidden within the idea of PAT is a clinical-philosophical worldview that contrasts with the prevailing biomedical worldview. PAT emphasizes the value of a patient’s subjective experience and agency, as well as the relational processes between the therapist, environment, and sociocultural milieu in which the therapy occurs. This raises a question: if these are the hallmarks of a PAT worldview, are psychedelics required to uphold these principles in the first place? 

In a widely circulated commentary published recently in the American Journal of Psychiatry, authors representing a company pursuing FDA approval of “psilocybin with psychological support”⁵ questioned whether PAT could even be called therapy. They argue that the effects of psychedelics are due to a biological process, and therefore, the term “psychedelic-assisted therapy,” as currently conceptualized, is inappropriate. The paper ignited considerable controversy, leading the Journal to publish an unprecedented six letters to the editor in January 2024.⁶ All six letters strenuously challenged the article’s logic. Clearly, strong feelings were aroused. 

But what provoked these strong feelings? Most responses argued that discounting the psychotherapeutic framework would lead to ineffective treatments at best and harm patients through poorly assisted psychedelic psychotherapy at worst.⁷ However, these responses also reflect a deeper unease about reducing the effects of psychedelics to mere biological mechanisms, which risks dismissing the broader values integral to PAT.  Personal conversations and published qualitative reports of psychedelic researchers’ opinions reveal that these tensions stem from longstanding debates about the direction of psychiatry itself—about the role of subjective experience, relational dynamics, and sociocultural context in healing. These tensions, neither new nor unique to the psychedelic space, highlight competing visions of psychiatry that have shaped its history.⁸

The history of psychiatry is inseparable from its critiques regarding power dynamics, societal norms, and the pathologization of human experiences. For example, in Madness and Civilization, philosopher Michel Foucault examines how psychiatry reinforces societal power structures.⁹ Similarly, psychiatrist R.D. Laing argues that mental illness often reflects existential struggles rather than pathology and calls for greater attention to patients’ lived experiences and relational dynamics.¹⁰ More recently, the rise of biological psychiatry—models of mental illness based on neuroscience, coupled with a shift away from psychotherapy and toward medications—has sparked a different critique. The field’s abrupt biological turn in the 1970s has been impugned for embracing a reductive conception of mental suffering, leading to shorter visits, a reliance on prescriptions, and a disregard for the sociocultural and environmental contexts in which the patient’s suffering occurs.    

This historical context and the recent dominance of biological psychiatry are fueling disappointment among many psychiatrists and a desire for alternative approaches to psychiatric care. These factors are, I argue, behind much of the enthusiasm for psychedelic treatments. Most advocates I encounter are drawn to psychedelics because they represent a shift away from perceived biological reductionism and toward a more holistic and contextually appreciative approach to patient care. This perspective resonates most strongly with clinicians disillusioned by psychiatry’s perceived neglect of relational and environmental factors in healing. For example, researcher Tehseen Noorani recently observed:  

Psychedelics inspire a secondary hope, that the care over establishing safe and efficacious containers in emerging paradigms of psychedelic medicine will offer templates for a much more contextually sensitive psychiatry in general.  This hope contains a redemptive promise, to rectify psychiatry’s over-embrace of acontextual drug-based remedies since the mid-twentieth century neurochemical turn.¹¹  

Noorani here seems to have identified the primary aspiration underlying much psychedelic idealism: those enthusiastic about psychedelic medicine may actually be yearning for a new psychiatry, freed from the shackles of bio-reductionism, with or without psychedelics. 

The cultural narratives surrounding psychedelics go beyond competing visions of psychiatry and extend into broader critiques of science itself. For example, George Lukács, a founder of Western Marxism, was among the first to examine how scientific rationality reinforces economic inequities and power structures.¹² Similarly, philosopher Theodore Adorno’s work explores how Enlightenment philosophy fostered a disenchanted worldview, dismissing as unreal anything not objectively quantifiable.¹³ These critiques resonate strongly with many psychedelic researchers, whose resistance to bio-reductive explanations of transformative experience parallels a broader rejection of trends in medicine that devalue subjective experience and culturally held forms of knowledge.  

Scholars in critical and Indigenous studies and decolonial theorists have shown how existing knowledge systems perpetuate colonial structures and uphold a white and Western epistemic hegemony.¹⁴ This analysis is encapsulated in the concept of the “cognitive empire,” which highlights how the Global North dominates global knowledge production¹⁵ and promotes a distinctly Western form of biological materialism. Recognizing, for example, that psychedelic use arose in the Global South underscores how the criminalization of these substances was deeply entwined with colonial oppression.  

Today, knowledge once suppressed by these colonial systems is being appropriated to advance what has been rebranded as a Western medical invention.¹⁶ While scholars in critical and Indigenous studies raise important concerns about how Western psychedelic science rests on knowledge taken from other cultures and imposes Western epistemes upon them, psychedelic researchers have largely avoided these issues. The broad field of psychedelic studies may superficially acknowledge this history or naively assume that medicalization will undo these colonial legacies. Unfortunately, empty gestures and utopian visions are unlikely to change drug policy, challenge materialist paradigms, or address the enduring harms of colonialism. While specific solutions to these problems exceed the scope of this paper, at minimum, psychedelic researchers must not mistake psychedelic regulatory approvals as substitutes for the activism and political work needed to dismantle the very structures that criminalized psychedelics in the first place.

Unlike the prescriptive nature of the Western medical model, the psychedelic therapist neither directs nor interprets but rather supports the patient’s experience and meaning-making process. It is this ethos that many believe is essential to psychedelic therapy, more so than even the psychedelic drug itself. However, this underlying truth is often obscured in debates in psychedelic research. For example, discussions about non-psychotropic “psychoplastogens,” which are psychedelic receptor agonists that are highly sought after in contemporary pharmaceutical research, reveal a deep uncertainty. Psychoplastogens would, theoretically, eliminate the psychedelic experience while still producing the clinical benefits of current psychedelics.  

While many in the psychedelic medicine space dismiss psychoplastogens outright, their potential success would force an uncomfortable question: what if the psychedelic experience is not necessary for drug efficacy? Would proponents of psychedelic therapy still argue that “the trip matters?”¹⁷ I believe they should, but not on the basis of clinical outcomes alone. Arguments that frame the psychedelic experience as critical only because of its measurable efficacy miss a larger point. The more compelling—and honest—argument is that the subjective psychedelic state has intrinsic value, regardless of its role in producing statistically significant improvements on psychometric scales. This challenges the field to defend the ethos of psychedelic therapy as an end in itself, not merely a means to clinical success. 

Mindfulness is a useful example of the importance of subjective experience qua subjective experience. Both mindfulness and the meditation practices aimed at cultivating it have steadily entered Western healthcare over the last two decades and, in the process, have been stripped from their social and spiritual contexts to become more “generalizable.”¹⁸ However, these surrounding contexts (e.g., Buddhist moral and ethical precepts) are the very things that many argue are essential.¹⁹ In an effort to mold meditation for randomized control trials and the secular medical setting, something fundamental to the practice may well be lost. This, I argue, is the same thing that psychedelics face when the subjective experience is stripped from the neurochemical function. 

Additionally, many meditation practices emphasize direct, personal experience as well as ongoing practice for its own sake.²⁰ As such, meditating to reach a specific outcome, such as reducing anxiety, instrumentalizes meditation and, therefore, misses the essence of meditation itself. In a noninstrumentalized view of meditation, benefits are regarded as byproducts that arise naturally when one surrenders to the practice without seeking them. Critiques of so-called McMindfulness programs that transform practices for the exploration of consciousness and the achievement of bliss into an “intervention” aimed at reducing scores on clinical scales reveal striking parallels with contemporary psychedelic debates.²¹ Much like meditation, the benefits of psychedelics may be best realized when the psychedelic state is valued for its own sake rather than as a treatment.

Clinical trials, so fundamental to Western medicine, replicate a bias against subjective experience by prioritizing changes on rating scales over a person’s actual experience. Quantitative measures take precedence over qualitative factors in the design of psychiatric research. This also reflects the modern West’s tendency to privilege ordinary, waking consciousness over non-ordinary states.  Dreams, for example, are considered interesting but are rarely considered sources of genuine knowledge. Drug and trance states may have tangential benefits but are not, in and of themselves, a source of insight and, in fact, may be pathologized. Philosopher Sarah Ritchie describes this view as “an insidious and totalizing physicalism that reduces extraordinary conscious experiences to mere neurological events.”²² That is, extraordinary conscious states, despite feeling profound, are seen as lacking epistemic value. 

This is also reflected in the clinical world. I have had patients describe clinics where they were told that ketamine—a drug with psychedelic-like effects—would help them, but they would have to endure the hallucinogenic side effects to receive the benefit. And we continue to hear debates from “experts” as to whether the subjective psychedelic experience is, in fact, valuable. Rather than spin through these tired debates, a more discerning question would be valuable for what or for whom? Clearly, the subjective experience is valuable for some patients, and perhaps research would yield richer insights if it embraced the psychedelic experience as an essential component of healing rather than a side effect to be eliminated.

While psychedelics may catalyze shifts in psychiatry, they alone will not fundamentally transform the field into one that honors subjective experience, displaces biological reductionism, or embraces contextually sensitive approaches to care. Achieving these shifts requires intentional, systemic change. Yet, within psychedelic spaces, there is often an implicit belief that these ideals are intrinsic to the substances themselves—that psychedelics will inevitably entrench systems of oppression or restore humanity to a more harmonious state. This belief obscures an important truth: “psychedelic aspirations,” such as decoloniality, epistemic diversity, and the re-centering of subjective experience in medicine, are not inherent properties of psychedelics but values projected onto them. To realize these aspirations, we must recognize them as independent goals that demand deliberate action rather than leaving them hidden behind the rhetoric of their transformative potential.

To make progress, psychedelic researchers and advocates must engage in broader academic and societal conversations about anti-imperialism, post-coloniality, critical psychiatry, and neoliberalism. Psychedelics alone are not a panacea; meaningful change requires the hard work of theory, cross-cultural collaboration, and activism. By disentangling the substances from the values they amplify, these endeavors would be approached with greater honesty, clarity, and efficacy.