Abstract
I chewed on the mushrooms, pulled on an eyeshade, and settled in the couch for my journey. “Journey” is the term used by my guide, the person with whom I had arranged this psilocybin experience. I wasn't sure where I would be taken, however. I had no prior experience with psychedelics. I had never even smoked a joint.
But I did have an intention. As an oncologist and palliative medicine physician, I have faced many times the raw fear of patients near death, and felt incapable in the face of it. The studies about the use of psilocybin-assisted psychotherapy for existential fear intrigued me. I do not have anything in my therapeutic pocket that is remotely as impactful as what these studies and anecdotes describe. But I felt that I needed to take a journey myself before discussing it seriously, much less recommending it to a patient.
The mushrooms tasted earthy. Although I had no idea what to expect, I didn't have to wait long. Dashes of light appeared, kaleidoscopic, as if the raw output of my visual cortex was being spilled out on a black screen. I began to shake, as if someone had put their hands on my shoulders to emphasize a point, but it felt kindly rather than violent. As if a grandmother had put her hands on my shoulders to make a point. Then, without warning, my familiar sense of “me”—my preferences, my body, my history—dropped away, all at once, and what became palpable was an oceanic sensation of being unified with everything: the music, the bells, and the trees outside. It wasn't alarming or frightening. In fact, there was a sense of being complete belonging, of having a profound connection to the earth, and of having access to an energy in the universe that normally was hidden. It was exhilarating. The usual me seemed small and banal—not gone, just distant—with concerns that appeared, from this oceanic perspective, as quotidian and insignificant. My small self, it turns out, isn't necessary.
As my psilocybin journey ended six hours later, there was an interesting transition period between the sense of having dissolved into everything and the return to my usual me. I became aware that someone was talking and talking: it was my small self, busily making sense of what just happened. My small self was spinning narratives, posting explanations, and generally taking charge. I speculated on the grandmother. I had a theory about my body. I had an idea about where to go for dinner. Clearly, my small self was eager to be back in the driver's seat.
Yet my small self is now driving with a new companion: this ineffable sense of the Beyond. I'm no longer in it, but I know it's there, in a way that my small self can't quite distract me from recalling. It has altered the way I think about dying, and how I talk about it with patients.
Much of my work in communication has emphasized talking to patients about what they are hoping for, what kind of medical care they want, and how their values might inform all this. I now see that my prepsilocybin approach, which consists of attempts to bolster, reinforce, and reassure the small self in the face of death, might be reifying the wrong thing.
Until now, I've assumed, having listened to many patients, that they would find it easier to die if their small self could remain intact. Many of my patients fear the crumbling of their body and the weakening of their mind, because they intuit that the end of the small self must be catastrophic. For some patients, it's their motivation to pursue medically assisted dying. What has changed is that I know now that it is possible to allow the small self to dissolve in a way that feels exhilarating. When my small self dissolved, it wasn't a loss, it wasn't about letting go. I gained access to something alive and potent. Could there a way to talk to patients about goals that leaves this possibility open, that doesn't restrict me to the realm of the small self?
I've been trying this out; it's a work in progress. Not long ago I saw a humble man with cancer. He's lost 50 pounds since I met him 9 months ago. He's gaunt, he moves slowly, and he's quite aware: his will is done and his do-not-resuscitate status settled. He's laid out some modest hopes for the next month, so that he has something to look forward to. I congratulated him on being ahead of the curve. And yet, as prepared as he was, there was an undercurrent of unease.
Instead of drilling down on the consumerist details of what he was hoping for, I asked whether we could talk about what in his life is bigger than himself. He looked up, and said “Well, my life has been about service.” He told me about his church, his family, his profession. “Tell me, I said, “what is your service now?” We talked about the way John McCain continued to serve right through his funeral. He gave me an interested look.
Could I serve my patients more fully if I paid more attention to what lies beyond their small self? Is the inner work of dying not about deciding how you want things arranged but instead about learning how to allow the small self to dissolve? This territory isn't completely unheard of—spiritual teachers and wisdom traditions both refer to it, using different terms. But it is one thing to read that, theoretically, one's small self could be dissolved, and another to experience it. My small self, though firmly in the driver's seat, can't shake off a new awareness: that the Beyond is no further off than the seat next to me and that the journey isn't necessarily about the road that my small self can see.