Encountering the Divine: Pyschedelics and End of Life

I’m Dr. Stephen Ross. I’m an addiction psychiatrist at the NYU School of Medicine, at Bellevue Hospital, and I’m a psychedelic researcher.

When I was 14 years old, my mom invited me to accompany her to a hospice where she was volunteering. This was in the mid-’80s in Los Angeles, and this was one of the first hospices in Los Angeles. My mom, being the beautiful person that she is, volunteered to go to hospice.

When she asked me to go, I jumped at the opportunity. I had wanted to be a doctor since I was age six, and I thought this would be a really interesting opportunity.

And so, for a couple of years, I went on a bunch of occasions to this hospice in the Valley in Los Angeles. It was really a life-changing experience for me.

What I got to witness in this hospice setting were people having good deaths. They were surrounded by friends and family members. They were not getting chemo or any treatment anymore for their cancer. The staff was helping them deal with existential problems in their lives, and they were happy. They were smiling.

At the end of this process, people had these really amazing experiences where they would die with family members, friends and hospice workers in the room. It was incredibly moving and an amazing experience.

Fast forward to my medical training. Over a decade of training, I was a medical student at UCLA, I did my general psychiatry training at Columbia, and I did my addiction training at NYU Bellevue.

And I got something completely different during my experience in medicine. I saw the opposite of good deaths. I saw bad deaths.

I was very interested in oncology and spent a lot of time on the cancer wards, in particular as a medical student in my fourth year and then as an intern. I spent about four months on an inpatient oncology ward, and what I saw there were bad deaths.

Patients were separated from their families, terrorized and terrified that they were dying of the disease process, and they were continuing to get chemotherapy up until the very end. The doctors never stepped back to say, “Hey, wait a minute. What are we doing here? Should we be thinking about this in a different way?”

And I don’t blame the doctors. It was a kind of lacuna in medical training. They did not train doctors in palliative care. It’s gotten better over time, but when I was a trainee, I don’t remember getting any courses on palliative care.

There was nothing about how to think about helping somebody who’s dying and how to increase psychological, emotional and spiritual well-being.

Doctors are trained to save lives and to never give up. That was, like, in our DNA, and that’s what we did. But it really was not helping the patients.

And it was really interesting how different it was compared to this hospice experience that I had with my mom.

So now fast forward to 2006. I’d been at Bellevue and NYU for six years. I was running the substance abuse division. It was an administrative role. I had a teaching role.

And one of my supervisors, Jeff Guss, started talking to me about LSD.

And I got really curious. Why is he mentioning LSD?

He said he was going to Switzerland to commemorate the birthday of Albert Hofmann. And I thought, why would anyone commemorate Albert Hofmann? Like, what did he do exactly?

And Jeff said, “Well, he was the inventor of LSD, and it was a big part of psychiatry. You should really check it out.”

So I was curious, and I started to check it out. And kind of, like, it blew me away.

Hidden in plain sight, and completely absent from any of my training, was this huge body of research from the ’40s to the ’70s. It was kind of like the first wave of psychedelic research, and it was a huge part of psychiatry.

There were over 40,000 research participants studied. And what piqued my interest was that the most studied and promising indication by far was the use of LSD treatment, LSD-assisted psychotherapy, for alcohol use disorder.

And being an addiction psychiatrist, that really got my interest.

But I also learned that the second most studied and promising indication was the use of psychedelics, essentially LSD-assisted psychotherapy, to help terminally ill cancer patients who were having anxiety, depression and existential distress.

And I got really interested in this body of research. The more I looked, the more interested I got in it.

Thinking about the history, there were two great research programs in this area.

The first was this amazing psychiatrist I’d never heard of named Eric Kast. He was a pain researcher, and he heard about LSD in the ’50s. Not knowing anything about its unique psychological effects, he decided to order some up.

He got LSD from Sandoz and decided that he was going to test it to treat pain in end-of-life cancer patients who were dying on an inpatient ward at the University of Chicago.

What he found was remarkable.

He was a great scientist, so his first study was a comparative efficacy study of single-dose LSD versus two opioids. What he found was that LSD led to rapid reductions in pain within the first several hours that persisted for three weeks after one dose.

That was really interesting to him. But even more interesting than that, patients started to talk about having these profound philosophical insights and mystical experiences. A lot of them said they were no longer scared to die.

He called this a kind of peculiar disregard for death, that they were not traumatized by dying anymore, that they had accepted it. He also reported decreased depression and anxiety.

Kast went on to do this in 200 people.

That work led to the kind of dream team of psychedelic research in the ’60s. This was at Spring Grove, and they included Stan Grof, Walter Pahnke and Bill Richards, who is still doing psychedelic research at Hopkins.

They initially were going to study psychedelics to treat alcoholism, but one of the nurses developed metastatic breast cancer and was dying. They decided to completely repurpose their research to study LSD-assisted psychotherapy to help dying cancer patients.

They ended up treating about 70 individuals, all with terminal cancer. This was an outpatient setting, and here it was the model of two therapists, preparation beforehand, an eight-hour, or with LSD, longer, 12-hour dosing day, and integration afterward.

They found similar findings to Kast: decreases in depression, anxiety and fear of death were the main findings.

So this set the stage for the next phase, which was going to be randomized controlled trials in this area.

But before that could happen, the music came to an abrupt stop.

Psychedelics had escaped from the lab in the ’60s, and they quickly went from wonder drugs that were going to transform psychiatry into demonic drugs. There were bad outcomes that started to happen, people using them in uncontrolled settings.

And they spilled into the counterculture and became a kind of threat to the political establishment.

At the time, we were at war in Vietnam, and ultimately Richard Nixon declared Timothy Leary the most dangerous man in America and said, “We need to put a stop to this.”

So the war on drugs was declared, essentially against these drugs and what they were doing. And in 1970, Congress enacted the Controlled Substances Act, which really, as an addiction psychiatrist, has been a horrible thing.

It has led to addiction being criminalized. It has led to us being the biggest jailer in the world. We take a neurological illness and we put people in jail and punish them for it, which is really bad.

So back to 2006. I’m having this meeting with Jeff Guss. Suddenly, I’m interested in psychedelics. I’d never thought about them.

And very quickly, Jeff Guss, Tony Bossis and myself formed the NYU Psychedelic Research Group. In fact, we were a reading group at first. We didn’t know what we were going to do. We didn’t think research was possible.

But I was introduced to Charlie Grob. He was completing a trial of psilocybin-assisted psychotherapy, a small pilot trial in patients with terminal cancer who had depression, anxiety and existential distress.

His daughter was an NYU student, and he said, “Why don’t you do this at NYU?”

So kind of out of nowhere, we decided to do a trial, which took about 10 years to do.

What was really amazing about this trial is that it reconnected me to these early experiences I had with my mom in the hospice. The whole point of the trial was to help dying people face death with dignity and to have increased psychological, emotional and spiritual well-being.

So I loved the idea of doing that.

But I was scared. I was scared of giving psilocybin to people who were very anxious, who were dying, who had cancer. I was worried they would have terrible experiences.

But after about half of the participants were treated, about half of the 30 or so, I started to think there must be something wrong, that people must be making up that they had cancer, making up their symptoms.

Because everyone kept describing, very rapidly, by the end of the day, feeling so much better. Their depression had melted away. Their anxiety had melted away. They just felt so much better.

And I started to think there really may be something going on here.

When we finished the study and analyzed it, the data bore that out.

We found that psilocybin-assisted psychotherapy in patients with advanced cancer, depression, anxiety and existential distress produced rapid reductions in depression.

For instance, one day after getting psilocybin, 80 percent of the participants no longer met the criteria for depression in cancer.

There were rapid anti-anxiety effects, which we saw 24 hours afterward. And the really astonishing thing is that when we ran the experiment until the end, at six and a half months, those improvements were sustained.

So we found that a single dose of a medication led to rapid reductions in anxiety and depression that lasted at least six and a half months.

We also found short-term reductions in existential distress, decreased demoralization and decreased hopelessness. We found improved quality of life.

We found that the mystical experience, in some ways, mediated the therapeutic outcomes, and that suggested it might be a psychological mechanism of action.

We did a long-term follow-up of up to five years. About half of the participants were still alive. And at five years or so, the participants continued to report sustained antidepressant and anti-anxiety effects.

It’s very hard to say that that was due to the psilocybin. But qualitatively, almost all of them said, “That experience changed my life, changed my orientation to cancer and reconnected me to a meaningful life.”

These drugs are meaning-making medications. They’re very unique in that way.

Cancer is not the only advanced medical illness, and there’s no reason to think psilocybin or psychedelics would only work in that population.

So there are efforts now to go beyond cancer. For example, Charlie Grob and Tony Bossis are leading a multicenter trial, and NYU will be a site, using psilocybin-assisted psychotherapy to help people who have depression, anxiety and existential distress in any end-of-life advanced illness.

Beyond cancer, it can be end-stage heart disease, end-stage kidney disease or pulmonary disease.

So that’s a really interesting area to continue. We’ll see what happens with that.

In particular, we’re looking at how these experiences create new meaning and help people who are stuck, where they feel like life is no longer worth living, there’s no more meaning, and they’re detached from sources of love, hope, connection and spirituality.

And my biggest sort of hope on the translational end of this, if it works, is that I’m imagining cancer centers having a psilocybin dosing room, that if you are sick and you’re at a cancer center, this treatment would be available.

But actually, it wouldn’t be the first available treatment.

I’d like to see medical education do a much better job of training physicians, in general, in end-of-life distress, so that we could have a very robust algorithm of care to detect existential and other kinds of distress at the end of life, and to provide a whole algorithm, including existential psychotherapies and other things, before you get to psilocybin.

But I think psilocybin would be a great tool in the armamentarium.

And ultimately, this is getting back to my hospice experience, I would like to see these medications available and helping patients in hospice settings approach death with dignity, surrounded by family members, able to prepare for their death, able to still find meaning and live their lives fully, and approach death with enhanced psychological, emotional and spiritual well-being.

It is extremely exciting to me, and I’m very hopeful that this is a treatment modality that really could help a lot of people in the future.