Expectations: When You Enter a Psychedelic Experience

In the interesting book Talking to Strangers, Malcolm Gladwell describes the journey of a graduate student in anthropology to the mestizo people in the heart of South America (Bolivia, Montero). During the 1,5 year stay, the student, his wife, and many local people get drunk on rum every weekend. Through a western lens, you would expect drunken fights, hook-ups, and many other bad behaviours that we’ve come to expect when people drink too much.

But in this case, there are no fights, no hookups, just drunk people who are put in a corner to rest when they’ve had enough (or too much). “There was no social pathology—none. No arguments, no disputes, no sexual aggression, no verbal aggression. There was pleasant conversation or silence. The drinking didn’t interfere with work… It didn’t bring in the police. And there was no alcoholism either.”

The ritual around drinking, the social context, or our expectations has a large influence on how we experience an altered state of consciousness.

This applies at least as much to psychedelics as to alcohol. The type of experience you prepare for (or fail to do so), heavily influences the subsequent ordeal. This article explores how expectations influence a psychedelic experience. It looks at the context, the dosage, individual experiences, and microdosing.

“As a review of 1950s and 1960s LSD research demonstrates, the same drug can create anxiety or relaxation, fear or joy, cognitive enhancement or retardation, suspiciousness or intimacy, depending on how it is used” (Hartogsohn, 2016)

Our expectations, the guide (or lack of one), the warmth of the room you’re in, and everything about your own mind has influence over the psychedelic experience. It’s much more than just the substance you take.

Placebo, Set, and Setting

A placebo is typically an inert substance that has no therapeutic value. In many cases, this is a sugar pill. But sometimes researchers use ‘active’ placebo’s. In the case of psychedelics, this means giving people speed (methamphetamine), Ritalin (Methylphenidate) or another psychedelic or a lower dose.

Outside psychedelic studies, placebo surgery has been used to show that some medical interventions were nothing more than the expectancy of participants of getting better that made them better. (see this interesting 5 minute BBC Documentary).

You would maybe think that placebo doesn’t really have much of an effect on psychedelics. It’s notoriously difficult to blind people to which condition they are in (i.e. the participants know they have taken psychedelics). Early studies from MAPS reported that 100% of researchers and 95% of participants (19 out of 20) knew in which condition they were. But the effects of a placebo go further than knowing if you have taken a psychedelic.

The setting also has a strong placebo effect. A ‘positive approach’ in general-practice consultation raises patient improvement rates by 25% (Thomas, 1987). The study showed that 64% of those with a positive consultation got better, only 39% of those with a negative consultation. The attitude of the general practitioner had a larger effect on health outcomes than what they actually did (treatment or not).

If someone comes into a psychedelic experience expecting to just have a good time, then that is most likely to happen. This is how many (if not most) people use them recreationally. But if you come there to work on trauma, actively think about it, and discuss it before and after the experience, you will have centred your experience around this.

Psychedelics can be seen as meaning enhancers. They amplify the feelings and thoughts that you bring into the experience. Hartogson (2016) describes this as follows: “At the same time, the placebo response may help clarify some of the mechanisms by which psychedelics exert their effects. Psychedelics have often been described as amplifiers or magnifiers of consciousness (Grof, 2008; Lee and Shlain, 1992; Metzner, 2011). They also increase suggestibility (CarhartHarris, 2014; Middlefell, 1967; Sjoberg and Hollister, 1965). If placebo response is understood as meaning response, and if psychedelics magnify the perception of meaning (Savage et al., 1966), it may be that psychedelics augment meaning response. If psychedelics are understood as meaning-response magnifiers or as hyper-active placebo catalysts, which set the stage for particularly powerful placebo response, this may help explain the anecdotal yet frequent reports of healing associated with their use in ritualistic settings and other meaningful settings.“

Psychedelics are thought to open the mind and make new connections possible. If you are guided to think about processing something that happened in the past, you might be able to do so while in an altered state of mind. Couple that with an encouraging psychiatrist/guide/researcher and it starts to make more sense why psychedelics look so promising for treating mental disorders.

(see Carhart-Harris & Friston, 2019 for more discussion about the changes in your brain).

One note should be made that the expectation effect might be dampened over time. Partly because the general public still has very little experience with psychedelics (e.g. someone who goes to an (es)ketamine clinic will not have tried it recreationally without any transformative effects). And partly because the person giving the psychedelics might become less enthusiastic (which helps strengthen the placebo effect) about them. The average psychiatrist might not be as encouraging as the leading researchers at this time.

In a way, this effect has been shown with antidepressants. When a new class of them was introduced, to treat the same condition, the efficacy of the older drug fell from 72% in 1975 to 64% in 1981 (Moerman, 2000). The molecules in the medicine didn’t change, but the attitude of the doctors (who were probably more enthusiastic about the new drug) did change.

During the psychedelic experience, the actual setting also has a strong influence on the experience. Researchers generally stick to putting people in an aesthetically furnished laboratory session room (Studerus, Gamma, Kometer, & Vollenweider, 2012). And this setting is more conducive to having a good experience than being in a PET scanner (laying down and being confined to that space).

Letting participants choose the activities they wanted to do was also more conducive to having a positive experience. An interesting study that changed many variables while studying people on LSD, showed that that being free to do what you want during the experience (versus following set instructions from the researchers) led to more positive ratings (Hyde, 1960 – quoted in Hartogson, 2016).

The integration of a psychedelic experience is also important. Someone should be able to make sense of what has happened and have a supportive environment to enable changes to be made and the experience to be related to. Here the research is still developing and I struggle to find experiments where the amount of follow-up is varied.

Microdosing and Expectations

Microdosing psychedelics (mostly psilocybin and LSD) is the use of a low, sub-perceptual, dose (usually a 10th of a normal dose) that doesn’t impair the normal functioning, is done multiple times (e.g. every 4th day), with the intention of improving one’s well-being and enhance cognitive and/or emotional processes (see Kuypers et al., 2019).

The positive effects are anecdotally described as having “higher levels of creativity, more energy, increased focus, and improved relational skills.“(ThirdWave) And the practice of using them to improve one’s well-being is reportedly widespread in Silicon Valley and other early adopter circles (also see this article in The Cut).

This is in part due to the advocacy by the hands of James Fadiman and his description of the ‘Fadiman protocol’ of microdosing every 4th day in The Psychedelics Explorer’s Guide. “Sub-doses of 10 to 20 micrograms [LSD] allow me to focus, open my heart, and achieve breakthrough results while remaining integrated with my routine.” (a practitioner of microdosing from the book)

And it’s true that physiological effects are present at the microdosing level (see Hasler et al., 2004). “Slight drowsiness and increased sensitivity and intensification of preexisting mood states were most prominent effects at this dosage level.” But, are all the effects that people in the wild report an effect of psychedelics, or of their expectations?

Alas, there is only one study I could find that has tested this in a double-blind, placebo-controlled, randomized setting. In ‘The effects of microdose LSD on time perception…’ Yanakieva and colleagues (2019) describe effects on time-perception, but no “robust changes in self-reports indices of perception, mentation, or concentration.” (do also see this talk by George Fejer)

In response to the article by Kupyers and colleagues (2019), Fadiman himself acknowledges the lack of scientific study and the status of the research into microdosing being (for now) confined to self-reports. More work needs to be done to discern if microdosing really has any of the positive effects, or if it’s just our minds that expected and gotten the better response.

Expectations Influence the Psychedelic Experience

This article has explored several ways in which expectations influence the psychedelic experience. A large part of it can be ascribed to the placebo effect and this comes both from the participant as the person guiding the experience. Both the (mind)set and setting are also influential in having a meaningful experience, but that doesn’t take away that psychedelics are active in the brain and our expectations mostly shape the direction the experience takes us.

I think psychedelics are powerful tools to help people with mental disorders and let people experience all that life has to offer. They should be used with caution and the expectations should be realistically managed (e.g. don’t tell someone that one session will heal a life of trauma). Because of the wide variety of experiences someone could have, guidance is paramount.

Research with a larger group of participants (and/or meta-analysis of current research) will hopefully shed more light on what parts have the strongest effect on the psychedelic experience. The way participants are guided beforehand (how their expectations are managed) and afterwards (what level of guidance and amount of check-ins is needed) will be very interesting. Here we should not forget that much has already been learned from experience in the ‘real world’ and examples could be taken from there.

Lastly, the research into expectations and microdosing is only just starting and it would be interesting to see under which conditions microdosing has a significant effect over placebo.