#26 – What Psychedelics Ask of Those Who Lead

Introduction: Psychedelic Medicine and the Evidence Gap 0:00

[music] >> Welcome to the Trip Lab, kitchen table conversations about integrative medicine and psychedelics. [music] I'm your host and attending physician, Dr. Mariela Wood. Welcome back, everyone. In today's episode, I want to talk about something that I've been noticing in the psychedelic space and some questions that it's been leading me to ask. And not just about psychedelics, but about medicine more broadly. So, this field, psychedelic medicine, is moving fast. Really fast. And at the same time, maybe actually not fast enough. Public interest and use of psychedelics has far exceeded what medicine can currently offer in a clinical setting. The data is growing rapidly, but our ability to prescribe, recommend, or legally support psychedelic experiences, specifically in a therapeutic way, is still pretty slim. Now, changes are happening. Right now, outside of clinical trials, there really only two places in the US where people can legally access psychedelic therapy. Oregon and Colorado. Everywhere else, interest and use has far outpaced what medicine and policy can reasonably support. And beyond that, these substances are still schedule one. And just to say it out loud here, I don't think that they should remain classified in that way as the new data emerges, but that is a conversation for a different podcast. What is happening right now is this.

People are using these molecules. They're sourcing them in different ways. They're microdosing on their own. They're doing full journeys on their own. Or they're finding underground or ceremonial spaces to work with them. And I want to be clear, I actually don't think this is inherently bad. I'm definitely not in the camp that these medicines should only be available to people who meet strict DSM criteria for a mental health diagnosis. When you really take a step back and look at the DSM, it puts people into boxes. You miss one criterion and you don't qualify. You meet one more and you do. And that's just simply not how mental health works. But I'll leave that there for now.

Alongside people using these molecules, something else is happening. A whole group of people are becoming {quote} experts. They're offering education, microdosing protocols, training courses for facilitators, clinicians, and guides. And here's the thing that we don't talk enough about. Right now, there are no real regulating bodies for this emerging field. So, people can complete a course, receive a certification, whether you're a medical professional or not, and then suddenly you have authority in the field. You're giving guidance about incredibly complex medicines. Now, that's, again, not necessarily wrong, but it is worth slowing down and really

Microdosing, Protocols, and Who Counts as an Expert 2:37

looking at. Because a lot of the training and recommendations being offered are based on extrapolated data, presumed mechanisms, theories about how these molecules should work, rather than solid clinical evidence. And to be fair, that evidence is emerging. We're getting more and more of it every day. But there is at least one area where we actually don't have good data at all, and that's microdosing. Most of the research to date suggested microdosing performs just about as well as placebo. So, my obvious question is, where are all these microdosing protocols coming from? And the answer is actually largely from personal experience. So, experience that gets passed along slowly turns into knowledge and then becomes something that other people experiment with, and eventually more protocols are created. Which brings me to another question that keeps coming up for me. Who are the experts here?

How do you become an expert in psychedelics? Is it taking a course? Completing a training program? Just reading enough of the literature? Personal experience or self-experimentation? I think probably a mix of all that, but the boundaries are very blurry. So, in this episode, I want to dive into all of this. We'll also look at parallels in medicine throughout history, including psychotherapy, where public interest actually outpaced the data and experience formed before evidence fully caught up. I think therapy is a perfect example about how this is not bad, it's actually a good thing. But I do want to explore this a little bit more. We'll also come back to a question that I touched on in a recent episode. How much evidence is enough evidence to recommend something? If you want to check out that episode, it's titled Is Modern Medicine Still Evidence-Based? Reclaiming Evidence, Restoring Clinical Wisdom. Because I want to dive a little bit deeper into what I posed in that episode and use psychedelics as a case study to help us understand medicine and the world in general. So, let's zoom in on psychedelics, and then we'll zoom out and think about the future of this space and what this could mean for how we can shape medicine and the world. So, first I think it's worth briefly mentioning what we do and do not know about psychedelics, because I think this is where things get pretty interesting. I recently did a full episode on updates in psychedelic science, if you really want all the nitty-gritty neuroscience, which is in episode 25. But at a high level, we actually do know a lot more than people sometimes realize. For full-dose psychedelic experiences, we have a growing body of research showing pretty consistent patterns in the brain.

So, changes in network connectivity, modulation of the default mode network, increased neural flexibility, and now emerging evidence that these experiences also affect the body. So, inflammation, stress physiology, and even immune signaling. And clinically, the data are generally promising, especially for depression, anxiety, addiction, end-of-life distress, and PTSD. So, not perfect data, not final answers, but enough rigorous findings to really take this field seriously. But of course, we certainly do not know everything, which means that not all psychedelic use is equally supported by the evidence. I think microdosing is the clearest example of this. As I mentioned earlier, when you actually look at the research we have so far, microdosing has not been shown to outperform placebo. Across multiple studies, people do feel better, but so do the people taking placebo. And I think that tells us something really important. That expectation, meaning, narrative, and context are actually playing a huge role. So, I personally think that this does not mean microdosing is useless, but I do think we should be more honest about what's driving the effects. So, despite the very little evidence that we have that microdosing alone impacts outcomes, rather than just a therapeutic experience of taking the microdose, there are very confident microdosing protocols everywhere. We have specific schedules, doses, claims about focus, creativity, mood, and productivity.

And again, it's coming from experience, extrapolation, and plausible-sounding theories about how these molecules should work. There's a great paper that I recently read. It's called The Illusion of Knowledge in the Emerging Field of Psychedelic Research, and it talks a lot about this in a more clinical way. The authors make the case that in fast-moving, high-excitement fields like this, we often confuse compelling narratives with actual understanding. We build clean explanations on top of very early data.

And we speak with a level of certainty that isn't quite justified yet. Not because people are being dishonest, but because humans are really good at filling in the gaps, especially when something feels meaningful. And this paper is actually not anti-psychedelic at all. If anything, it's a call for humility. It points out how easy it is in an emerging field to mistake coherence for truth. To believe that because something makes sense, it must be proven. And this is where things start to shift from science into culture. Because once ideas start circulating through podcasts, courses, trainings, protocols, they begin to take on a life of their own. They feel established. They feel vetted. They feel safe.

Clinical Evidence, Uncertainty, and Integrative Medicine 7:31

Even when the evidence underneath them is still pretty thin. And this is the moment that I think we're in right now. Not a moment of fraud or bad actors, but a moment where structure starts to masquerade as validation. And I want to talk about that next. So, this is the part where things can get a little bit uncomfortable, and I want to be really clear that I'm actually including myself in this questioning. Because once you start noticing how fast ideas harden into protocols, the next obvious question is, who exactly gets to be an expert in an emerging field like psychedelic medicine? And I personally really had to examine this. I talk about psychedelics a lot on this podcast. I talk about them in the clinic.

I do a lot of counseling around them, mostly harm reduction counseling, which is what legally is allowed right now. And I have read a lot of the research papers that have come out in this space. And I have a clinical background that helps me translate research into the person actually sitting in front of me. So, does all that make me an expert? Maybe, maybe not. What I haven't done, and I'll be completely honest, is I have not completed a psychedelic certification course. I really like the idea of doing one, but right now, it just doesn't make sense for me yet. Not because I think these programs are bad, but because many of them are taught by people essentially doing the same thing that I'm doing. So, reading the literature, synthesizing it, and trying to make it relevant to real humans. And because I do live and work in a modern medicine setting where board certifications, licensure is extremely important and really does give you credibility, and I just haven't found a course that I think gives me that same level of credibility. Now, I actually do think that there are some programs out there that look pretty credible, because they are connected to academic institutions and are transparent about what is evidence-based, what is experiential, and what is still speculative. For example, there's programs associated with universities like CIIS, training organizations like Fluence that are deeply embedded in research and clinical translation. And of course, MAPS, particularly around MDMA-assisted therapy, where there are very specific research-driven protocols tied to FDA trials. So, what I think makes these ones more credible is not that they're perfect, it's that they're closely tethered to data, ethics, and clearly defined scopes of practice. But here's the big point in all of that.

There is no external regulating body that certifies psychedelic training programs. No equivalent of medical school accreditation, residency standards, fellowship requirements, board exams. And in medicine, those structures exist precisely because we decided, collectively, that expertise shouldn't be self-conferred. Now, again, I want to pause here and say something else that I think is really important. I personally don't believe that you need letters after your name to have an authority or expertise in a field. A perfect example of this is patients. I actually want and highly encourage my patients to become experts in their own bodies and in their own health conditions, and I think they absolutely can be. They don't need to be an MD or a DO to understand their lived experience in a way no clinician ever fully could.

And I think the same principle applies in the psychedelic space. There are people without, quote unquote, formal medical credentials who really do have deep insight, careful judgment, and a level of experiential knowledge that genuinely does matter. So, that shouldn't be dismissed, and I'm not dismissing that. But, what I do want to point out is that I do think it's fair to say that rigorous clinical training does shape how someone integrates new information. So, medical training doesn't just teach facts. It trains pattern recognition, risk assessment, differential thinking, and an appreciation for how complex and interdependent human physiology really is. You simply can't compress the years of clinical immersion. And when I say years, I'm talking 4 years of pre-med, 4 years of medical school, 4 to 8 years of residency and fellowship. And during residency and fellowship, you're working 100-hour weeks. And I know it's legally 80-hour work weeks, but we all know that that's [ __ ] But, essentially, you can't compress all of those years of training into a short course. And of course, that's not what the courses are intending to do. I'm just pointing out that having that clinical background can help you understand physiology a little bit better, and then take information about psychedelics and apply that to the person sitting in front of you. So, I don't think you need to be a physician to be an expert in psychedelics, but I do believe having a deep clinical background can help when it comes to situating powerful experiences and emerging data within the broader context of human health.

Especially when risk, vulnerability, and complexity are involved. And I actually think that non-medical, non-doctor, however you want to say it, psychedelic leaders can really partner to push this field forward. We have different experience, different expertise, different backgrounds, and I think you need all of that in psychedelic medicine. So, my point with all of that is not about who gets to be an expert, who doesn't. It's just about being honest about the different kinds of expertise that exist, and about the responsibilities that come with offering guidance in a space that's this powerful. What we need to acknowledge is that psychedelic medicine does not have regulating bodies or standard tools to accredit training programs.

And to be fair, the field is far too young to have this yet. Now, there are actually some important exceptions to this that I think are worth naming here. Ketamine is different. It's legal. It's already being used clinically. There are research-based protocols, continuing education standards, and medical oversight. MDMA is also different. It's not legal yet, but it has gone through an unusually rigorous research pathway. MAPS has spent decades developing structured, reproducible protocols to prepare clinicians for MDMA-assisted therapy when and if it's approved. So, those ones are examples of expertise being scaffolded by data. The classic psychedelics, so I'm talking psilocybin, LSD, DMT, mescaline, aren't there yet.

And I think this is especially relevant with microdosing, because as we talked about, the evidence just isn't there to show that it's better than placebo. Again, I think that's still a notable finding, but just something to point out. But, there are microdosing protocols everywhere. And I think most modern microdosing protocols can be traced back to a mix of the following. So, there's really popular book like The Psychedelic Explorer's Guide. There's early anecdotal reports. People are extrapolating full-dose psychedelic research and how that works.

And then people experiment themselves and then pass along what works, what doesn't. And I think this is how human knowledge often develops at the edges. Experience comes first, meaning follows, and then structure comes later. But, I think what I'm uncomfortable with is when personal experience starts to sound

Lessons from Therapy, Biofeedback, and HRT 14:00

like a medical recommendation, especially in a field involving very powerful psychoactive substances. So, I think we need to be really clear about that, because if we don't, then confidence will fill the gap. And confidence, especially when it's wrapped in certifications and protocols, can look a lot like medical expertise, even if the evidence is just not there yet. Which brings me to the next question, and one [clears throat] that we spend a lot of time with in integrative medicine. How much evidence is enough evidence to recommend something?

So, to backtrack a little bit, integrative medicine, which is what my specialty is, is an actual medical specialty with a board certification that blends modern conventional medicine with evidence-based therapies that were once labeled, quote unquote, alternative. And it's certainly a lot more than this. Integrative doesn't just mean blending alternative medicine with modern medicine. It also involves integrating full patient care, giving patients tools and power, working with other providers like psychotherapists, pharmacologists, nutritionists, to best serve the patients in front of us. But, going back to my point, in integrative medicine, we live in a world of emerging data on therapies that have been used for thousands of years, and also some new ones when we talk about more innovative and longevity-based therapies. But, anyone in this field works daily to try to parse out what works and what doesn't and what the evidence shows.

So, the question we often grapple with, or at least should grapple with, is when is the evidence strong enough to bring something into clinical practice? In some areas, like nutrition, we actually do have a lot of data. Not perfect data, but enough to make thoughtful, evidence-informed recommendations. In other areas, especially spaces like longevity, metabolic health, and prevention, the ideas are still very emerging, promising, biologically plausible, but not settled yet. So, in integrative medicine, we've had to develop a different kind of clinical reasoning, one that does not abandon evidence, but also does not wait for perfect data before doing anything at all.

Because the reality is, people want to try these therapies despite the limited data. Or because someone on Instagram has claimed the data where there isn't, but a topic for another day. So, in integrative medicine, instead of only asking, is there a large, randomized controlled trial, we ask more questions. Like, is the proposed treatment mechanistically sound when we look at human biology and physiology? Does it make sense based on what we know about how the body actually works? Could it plausibly cause harm, short-term or long-term? What is the risk-benefit ratio, especially compared to doing nothing at all?

And importantly, is the patient interested? Does this treatment align with their values, goals, and lived experience? So, all those questions matter when you're practicing medicine in areas where the evidence is still forming. And psychedelics deserve that same level of scrutiny. And I actually do think that this scrutiny is happening in psychedelic medicine. Many leaders in this field are careful to talk about risks alongside of promise, about screening, preparation, integration, and the reality that these experiences can be destabilizing for some people.

But, because psychedelics specifically have gained so much traction, in a beautiful way, they're actually inviting us to look more closely about how we practice medicine in general, especially in all emerging fields. How comfortable are we with uncertainty as clinicians? How honest are we with patients about what we know versus what we're extrapolating from the data? What else in medicine are doctors recommending with such figure that we actually don't have enough evidence on? And how do we balance curiosity and caution without becoming either reckless or paralyzed? And if we really look at medicine, it has actually never been practiced with perfect information.

Even if many doctors speak with such authority as though the information is perfect. The truth is, we've always made recommendations under conditions of uncertainty. The difference is whether we're willing to name that uncertainty, or whether we hide behind it in protocols, credentials, and confident language. And that, I think, is one of the deeper things psychedelics are asking of all of medicine right now. But, psychedelics are actually not the first to do this, and they certainly will not be the last.

Medicine has been here before, many times. In fact, we've been through almost the exact same process with something we now consider one of the most foundational treatments in mental health, and that's psychotherapy. Early therapy was actually not mainstream medicine. It was not in guidelines. It was not universally accepted. And for a long time, it was actually viewed as fringe, unscientific, or even indulgent. So, Freud, psychoanalysis, talk therapy, these ideas actually lived in the margins of medicine rather than inside it. There was a lot of deep skepticism about whether talking could meaningfully change biology, symptoms, or outcomes. So, over time, of course, that has dramatically changed. As different therapeutic modalities developed, like CBT, interpersonal therapy, trauma-informed approaches, the data really started to accumulate. Slowly at first, unevenly, and not always cleanly, but eventually, psychotherapy actually did move from the margins to the center.

Today, it's actually even hard to imagine a mental health guideline that doesn't include therapy as a core recommendation, actually even before medication. And that shift actually was not scientific, it was cultural. But, I will say, even a few decades ago, therapy did carry a stigma. When I was growing up, being in therapy often meant something was wrong with you. It was not framed as proactive care or self-understanding. It was framed as failure or pathology. That cultural narrative has changed dramatically. Therapy is now widely understood as part of taking care of your health, not evidence that you failed to do so.

We've also seen similar patterns in other areas of medicine. Think biofeedback is another good example. So for years biofeedback and neurofeedback lived on the edges used by a small group of clinicians often viewed with skepticism and sometimes lumped in with things that were alternative or quack medicine or not really scientific. And I will say the early evidence was mixed. The mechanisms weren't always clear and protocols like psychedelics varied widely. But again, over time biofeedback found its place and now it actually is used in mainstream medical settings for conditions like migraines, chronic pain, ADHD, pelvic floor dysfunction and anxiety. Often as an adjunct not a replacement but still a legitimate tool nonetheless. Moving away

Indigenous Wisdom, Humility, and the Future of Medicine 20:38

from mental health, I think actually hormone replacement therapy is another instructive example. Though I will say probably a more humbling and arguably more complicated one. So for a long time HRT was widely prescribed based on a strong physiological reasoning and early observational data. Which made sense. Estrogen affects the bones, cardiovascular health, cognition and mood and many women experienced dramatic improvements in quality of life when they took hormone replacement therapy. Then came the Women's Health Initiative which fundamentally shifted public and medical perception of HRT. Framing it as dangerous, associated with cancer and cardiovascular risk. And the response was swift and severe.

Prescriptions dropped, fear took completely over and almost an entire generation of women was told that a therapy that had helped the woman before them was now too risky to consider. So that was a major setback and a disservice to a lot of women. Because now we revisited that data and discovered flaws in the reasoning. The women that were studied in the Women's Health Initiative were on average well past the onset of menopause. And age alone significantly changes baseline cancer and cardiovascular risk.

Also the hormones used were largely synthetic not bioidentical and timing, formulation and individual risk were not adequately parsed out. So those important nuances were not meaningfully communicated to the public or even to many clinicians. So the result was widespread fear around a therapy that for many women is genuinely life-changing when used appropriately. And now years later we've swung back to a more balanced understanding. HRT is no longer abandoned. It also is not recommended to everyone. So our practice has been refined. We talk about timing, formulation, individual risk assessment and benefits alongside of risks. So that's what maturation looks like.

Not blind adoption, not wholesale rejection but learning and in this case sometimes painfully how to hold complexity. So I think it's crucial that we keep talking about things like this. It applies to psychedelics and other aspects of medicine and life. So early adoption often does pave the way for foundational treatments. But overconfident language can actually slow progress especially when later data forces course corrections. And psychedelics are moving through this arc right now. We have early enthusiasm or I guess re-early enthusiasm because they were used many many years ago. Rapid cultural uptake, growing but incomplete data and a field learning in real time how to talk responsibly about what it knows and what it does not. So seeing that pattern doesn't mean that we should pull back in fear. It means acknowledging that the field is still maturing and naming expertise in an emerging field requires a lot of thought. So as we start to close I want to zoom out for a moment because I don't think this episode is really just about psychedelics.

I think that psychedelics are acting as a mirror showing modern medicine something about itself. These molecules are showing us how we behave when the science is promising but incomplete. How we talk when experience runs ahead of data. And how quickly authority forms when structure, story and hope all come together at once. And there really is something genuinely beautiful about this field. These are molecules that come from the earth. They've been in relationship with humans for a very long time and many people, so researchers, therapists, guides, artists, indigenous communities have devoted their lives to understanding them and long before mainstream medicine was paying attention. So that alone deserves respect. You don't need to be a physician to hold deep wisdom about these medicines. You don't need an academic appointment to have insight that matters especially when we talk about indigenous wisdom.

Indigenous communities have held, protected and transmitted understanding of these medicines across generations and not as interventions but as part of a broader worldview that integrates healing, meaning, community and responsibility. And unfortunately that wisdom was dismissed for a very long time. Now it is being rediscovered and respect is being given. Sometimes imperfectly, sometimes clumsily but I think it does matter deeply that we name where this kind of knowledge comes from. So ultimately I don't want to draw hard lines about who can teach about this plant wisdom and who can't. I just want to ask better questions. Where is this information coming from? What kind of knowledge is this? Is it data, inference, experience, indigenous wisdom or tradition? And how honestly are we naming the uncertainty that still exists? To me real expertise especially in emerging fields looks less like certainty and more like diligence. Diligence is reading the data, listening to lived experience, honoring indigenous wisdom without appropriating or flattening it. And it's saying this is promising but not settled. I think it also means resisting the temptation to sell protocols as truth when the evidence is still forming. And this isn't unique to psychedelics. We see the same pattern right now in in longevity medicine.

Longevity is exciting. It's sexy. There's fascinating biology, real insights into metabolism, aging and resilience. But same as psychedelic medicine there is no board certification in longevity medicine. There's no standardized pathway that defines expertise and yet in parallel there are very confident claims, supplements, protocols and strong opinions everywhere. So this doesn't mean it's an illegitimate field. It just means it also deserves the same careful scrutiny, the same humility and the same honesty about what we know, what we're extrapolating and what's still unknown. So I think maybe that's what psychedelics are really asking of those who lead.

Not that we slow everything down. Not that we wait for quote unquote perfect evidence. But that we learn to hold promise without inflating certainty. Because the future of medicine does not depend on how fast we adopt new tools. It depends on whether we can stay honest, humble and human while we do so. And I think that's what makes this moment in psychedelic medicine so exciting. Not just the molecules themselves which are very exciting but the invitation that they're offering us to practice medicine a little bit more wisely. Psychedelics are teachers. Let's let them teach. Thanks for listening to the Trip Lab. If you liked this episode please subscribe and share so we can get the conversation started about integrative medicine and psychedelics to destigmatize it and fully explore what this could mean in the world.

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