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Gabor Maté meets with Dr. Josep María Fabregas to learn more about his studies of the effects of the longterm use of ayahuasca. The conversation also covered the philosophical implications of addiction treatments involving psychedelics.

GABOR: So you’ve done studies on the long-term safety and effects of ayahuasca?

FABREGAS: Yes, I had the possibility to assess people of the Santo Daime [Church] in Brazil. We assessed them using standarized tests for neuropsychological, and psychological, and perhaps – for me – the most important was the ASI: Addiction Severity Index. It’s an instrument to score what is the capacity to create addiction in the use of ayahuasca, and the results are zero: it is not a substance that creates dependency.

GABOR: So you found no addiction with the ayahuasca despite long-term use.

FABREGAS: No addiction. This is an standardized instrument in Europe and the results are clear: ayahuasca does not create addiction.

GABOR: You also found there was diminished use of other substances, is that right?

FABREGAS: Yes, this is also an important fact: because the people who regularly use ayahuasca have lower levels of use of other substances, like alcohol. But the problem is this is a result that is difficult to generalize, because the people we studied live in the middle of the rainforest jungle, and perhaps they are not representative. So we made a control group in a town very near to Ceu do Mapia: the Daime community where we based our study. We found a group of people with similar living conditions who were not using ayahuasca, then we could make a proper comparison.

GABOR: So they asked a group who is in the jungle, and a control group who is in the city?

FABREGAS: Yes, but also a group in Rio Branco: the capital of the Acre state in Brazil, where you have the Barquinha [Church], the Uniao do Vegetal, and Alto Santo – a group of the Santo Daime. All were urban groups, with members that had been taking ayahuasca for many years. The study was on members who have drank ayahuasca for 15 years, minimum, a minimum of twice a month. It was a study of the effects of long-term use, and the results were clear on this case: the people who drink ayahuasca did better or equal to the control group in all scores & measurements.

GABOR: And you studied neuropsychological effects?

FABREGAS: Yes.

GABOR: And what did you find there?

FABREGAS: There are 7 different measurements: we scored addiction, neurological functions, and a list of assessments published in the Alcohol and Drug Dependence Review.

GABOR: So you’ve used some very standard tests of frontal lobe functioning?

FABREGAS: Yes, we did a series of assessments with a number of measuring instruments. We were fortunate to have at our disposal a very large group of long-term ayahuasca users. We ran a series of tests to measure if (ayahuasca) had altered their neuropsychological and cognitive functions. Because very often, in addicted persons, or long-term users of any drug, these functions have been altered.

We used internationally validated standard tests such as Stroop, Wais, Wisconsin. Our objective was to see if these functions had been altered. We found the long-term users did not score lower, in some measurements they actually scored higher than the control subjects.

We also wanted to measure psychosocial satisfaction using BIEPS: a test that measures the degree of satisfaction one feels with their own life and with their relationship with others.

And, also, some tests for spirituality and life purpose, called SOI.

We also used SCL-90, a test to assess psychopathology, it’s 90 questions: often used a filtering diagnosis, to see if there are psychopathological disorders. The results were surprising & allowed us to prove that there is no presence of added psychopathology in long-term ayahuasca users.

We know that people who suffer a psychotic crisis experience measurable alterations in certain abilities. We wanted to see what was taking place in long-term ayahuasca users. In the past, scientists have theorized that these substances provoke a type of reversible, transitory psychotic state. We wanted to see if we could find the ayahuasca users the same damages that one can measure in psychotic patients. We found no such correlation, nor could we find any of those damages.

We are still parsing the data, but the preliminary results show clearly that ayahuasca doesn’t cause these problems.

GABOR: But I have seen one person develop a psychotic break after an ayahuasca experience.

FABREGAS: Yes, this is possible because in cases where the structure is not very good. Any extreme situation, like drinking ayahuasca, has the capacity to induce a psychotic state.

But, if you have a proper filtering criteria, this possibility is very, very low

GABOR: Now how long have the people been followed for? How many years?

FABREGAS: I know people here drinking ayahuasca for about 18 years, and the hypothesis is about the possibility to introduce the use of ayahuasca in psychotherapy.

But, in the beginning, it is very difficult to understand this capacity of the ayahuasca: that of an altered conscious state providing solutions to psychiatric problems. But now the science is approaching this capacity: to understanding this possibility.

GABOR: You’ve established the relative safety of the ayahuasca. Are you working to establish the value of it? In other words, we know relatively that it is safe over a long-term. The really interesting question is now that we know that it is safe, is it also helpful? Is it useful?

FABREGAS: Ayahuasca is a new substance for science, it has been used for many, many years, but not knowing the way it works in the brain. We know now that for some problems – it is a very good solution.

GABOR: For example?

FABREGAS: For example post traumatic stress, cases of sexual abuse in young people. Sometimes psychiatry is not the solution for this, we only treat the symptom, but with the ayahuasca you have possibility to revive /re-live this situation with the same feeling – and the same pain – but with the capacity to change this situation. This is a treasure.

GABOR: You mean a safe environment; people can go back to the experience, but in a safe environment?

FABREGAS: Yes, but to be clear, we also know in some cases it is a very bad solution. For psychosis, for example.

GABOR: Or for the manic depressive?

FABREGAS: Yes, manic depression. Some people do not agree regarding OCD, obsessive-compulsive disorder. Some people say it’s good, some people say not, it is not clear, but in some places it is good, in some places it is bad. We need the science, have the time, have the resources, & the possibility to study. Ayahuasca is not a panacea to solve all problems, that is for sure, but why not have the possibility to study? To study, not to blindly accept, but to allow the opportunity.

GABOR: And are you doing such studies?

FABREGAS: Yes, but it is not myself only. It is some people in the US, Brazil, Germany, Switzerland, Spain, all have studied the effects of ayahuasca and the possibility to introduce it in therapy.

GABOR: I’ve had one patient specifically, I wouldn’t call her a patient, she’s a long-term addict. She came to ceremony, coupled with the counseling that she got that night, said it was worth more than 10 years of psychotherapy.

FABREGAS: This is a way to explain what happens with ayahuasca. [I have to] agree absolutely with this impression your patient had. The treatment of drug addictions are an opportunity with ayahuasca. I understand that perhaps it is not easy to accept. You utilize a drug to change a drug addiction. But for many years, people who have had poor results in traditional detox clinics in Europe go to the ayahuasca church or have therapy with ayahuasca in Brazil or Ecuador or Colombia, and have very, very good results.

GABOR: Actually when you said that it is good for post-traumatic stress, most of addiction is a result of post traumatic stress, it is a self medication

FABREGAS: I agree, absolutely, but in science it is different: what you ‘believe’ and what you ‘know’. Now it is necessary to study what is happening.

GABOR: Personally I see it on two levels. Individually, personally I can see that it works, and I can also see why it works. But proving it to colleagues: that’s another question entirely. Do you also work on two levels of what personally intuitively you know but you also have that scientific mind that has to provide the double bind proof.

FABREGAS: Science has the hypothesis, and has to prove it has happened in a relationship between cause and effect. But in ayahuasca use, the problem is that some of the variables are not possible to control. That is the difference: you know and you see and you feel, but sometimes it is very very difficult to prove. Because: it is not the ayahuasca, it is the ritual use of the ayahuasca. The ayahuasca is not the same as other drugs: to take a pill and you feel better. The ayahuasqueros know the way to administrate, but for this to work, he needs to control the environment. And science now has limitations around this: it is not the same drinking ayahuasca in a hospital or in a laboratory.

GABOR: I agree too, I just don’t want to wait twenty years until it is all proven. I mean I believe I can go ahead and use it now and wait for the studies to catch up, rather than to wait, because usually you have to wait for the studies, and that would be waiting for a long time yet.

FABREGAS: [in Spanish] in the study we had to overcome some limitations. One was that when you compare a group of long-term drinkers with a control group that doesn’t drink, we didn’t have studies made of the user group before they took ayahuasca for the first time. So even if the results in the scores are better in people who have been drinking ayahuasca for 5 years, science could interpret the result as: perhaps these people were vastly superior before they began drinking, and through their use they may have even diminished their capacities!

So, between 1 and 2 years, we had to repeat the tests on the same subjects. In order to see if the results remained constant or there were changes. The results remained constant, and in some cases improved. There are some tests that measure the capacity of subject to learn from their mistakes, it’s called persistence of error. In long-term ayahuasca users it was lower, and the ability to learn from errors was higher.

But to extrapolate this, to mean it would happen in any life situation, outside a very precise laboratory test, should be done with prudence.

Another problem that science has is that since we cannot control many of the variables, the study can be criticized. I’ll explain; since our users drink ayahuasca within a very particular context, inside a church, we must separate to which degree it was influenced by the ayahuasca, and to which degree it was influenced by life in community, etc.

GABOR: So for that you’d need 2 groups, one with the same community, the same interactions, one with ayahuasca and one without it, but you could never get that.

FABREGAS: Exactly, you are a professional in science, and you understand that sometimes the results only can be read in the environment. It is not easy, and maybe we cannot extract all results – but what we can definitely prove is that there hasn’t been a worsening. This had not been measured before. The group is large enough – 60 people – and the ayahuasca use is relatively long – 15 years – and the frequency of use is high – between 2 and 4 times per month, sometimes more – and the range of tests taken is broad enough to touch on many functions.

From this point on, we know that continued use of ayahuasca does not produce a deterioration. From there to being able to prove that ayahuasca is actually ‘good’ is some distance away. But I believe this was the first step necessary in order to be able to move forward with other studies. If in this study we would have proved that that ayahuasca had toxic effects, it would have been very complicated. But from this study we know that ayahuasca is not damaging.

Now we can begin to see what it might be useful for.

GABOR: As a psychiatrist why were you interested in even looking at it? Are you frustrated with the limitations of western medicine?

FABREGAS: In the past 50 years medical science has had spectacular advances. With new non-invasive diagnostic tools, today, we can look inside the brain in real time. We have much better, more exact instruments. There have been great advances in surgery, traumatology, genetics. But in psychiatry which is my field, things have not moved in such a hurry.

GABOR: Or it has become very narrow, it’s all about drugs, what they call biology-based psychiatry, but it is a very limited biology.

FABREGAS: [in Spanish] For example, to treat depression, we use the same therapeutic approach that we used 30 years ago: Prozac and SRIIs have been in the market for 30 years. We are still using antipsychotics from 40 years ago, anti-anxiety drugs such as valium are still in pharmacies. Many of the new medicines are just improved derivatives of these molecules.

So we try these same 40 year old drugs in psychiatry only to change the symptoms – not [treating] the cause of the problem.

And perhaps the altered conscious state opens a window, an opportunity, a possibility to get very deep in the reason for the problem and change the problem.

GABOR: I am going to argue with you a little bit, because although in certain areas of medicine like traumatology and specific things there have been great advances…

But overall, when it comes to chronic illnesses, cancer, arthritis, and neurological disease, there has been very little progress in the past 40 or 50 years, and I think it’s for the same reasons, because many of these diseases also are related to emotional factors, the mind and body not being separate, and Western medicine separates the two, and I think that ayahuasca could actually be used to help to people with many conditions. Personally as a medical doctor, that’s what I think.

FABREGAS: What’s happened is that we have spent a lot of time and effort modifying or nullifying symptoms. But we haven’t been able, in many cases, to solve the source of the problem. We talked earlier about PTSD or victims of extreme violence. In psychiatry we treat them with years of psychoanalysis, psychotherapy, and drugs to diminish the anxiety or depression. But it is extremely rare that patients have the chance to re-live their trauma; with the same pain, anguish and suffering as the first time that it happened, but now with the chance of modifying the impact of that memory. I mean, what is past is past, but the way in which we understand it or hang on to memories can change. If at 35 we re-experience something that happened when we were 5, it may be the same situation, but now understood through the capacities, the experience, the structure of a 35 year old. That might give us a chance to reposition the experience. Why wouldn’t we work with this? Why not open that possibility? So often in our work we are faced with the impossibility of going through the barriers the patients build to avoid pain- If there is a tool that allows us to do this, I think it is imperative we use it.

And perhaps the altered conscious state opens a window, an opportunity, a possibility to get very deep in the reason of the problem and change the problem.

GABOR: Now you look at the research of Jordi Riba; the brain studies, and how the limbic system – the emotional memories – are triggered or activated, it goes along with the psychotherapeutic. That is exactly where you want to go: that is exactly where you want to take people.

FABREGAS: This is the way to prove via research about these ways of working.

GABOR: Are you using ayahuasca yourself to treat people?

FABREGAS: In Europe, it is not accepted

GABOR: That wasn’t my question..

FABREGAS: In Brazil I supervise the groups that use ayahuasca, but not here.

GABOR: Do you have conversations about it here? What is the response to your interest in the plant? How do your colleagues see or respond to what you do?

FABREGAS: In the beginning, they thought it was a wrong path. Today the evidence has changed that.

I have full respect for my colleagues, I understand there are some prejudices, and information that pushes people away from it.

I work in an addiction treatment clinic. We don’t use ayahuasca or talk about using it, it is not a possibility. I began with this because I was in an NGO in Brazil, treating malaria in the Amazon jungle, there I met some shamans, and I saw, as you said ‘I saw.’ From there came the interest in turning that seeing into knowing.

That is why I gave it a chance.

People have asked me what would have happened if my research findings had been the opposite – what would have been my position. I am certain I would have gone on to defend the non-use of ayahuasca.   I don’t have an interest. I’ve merely observed. I think if you observe something that you think might be a positive hypothesis for the use of certain substance, there is a responsibility to a least devout enough time to confirm, or to see if it doesn’t work. If in our studies we would have found negative results, I would have published them.

FABREGAS: This is something pharmaceutical companies often don’t do. Sometimes people who have a vested interested when the results of research are not what they expected, they hide these results. My interest is, if ayahuasca works, to try to know why, and if it doesn’t – to explain what we have found.

I’ve had to retract myself in a number of things in life, for example, on the effects of cannabis, I have a different opinion today than I did 30 years ago. Because science has proven a number of correlations between the use of cannabis in early ages, with some psychiatric and psychological problems later in life. And that is how it is.

So, I’m neither in favor nor against substances, but rather in favor of science.

GABOR: So, do you see then a future for ayahuasca in western medicine?

FABREGAS: Yes. In San José California, at the MAPS conference, there were more than 200 psychiatrists interested in this, including psychiatrists from the US Navy for the PTSD studies. Now it has opened this opportunity to study. And when the US accepts the studies it has opened the opportunity for the rest of the world.

GABOR: That is life, yes, but this why I am not going to wait, you know, for the studies.

FABREGAS: Yes!

GABOR: I’d be dead.

FABREGAS: This is the problem with ‘safe’, this happens with many many things in life, the ‘safe’ option sometimes hinders the speed of development. Sometimes it is to protect, because in the history we have some bad experiences about the people who believe, therefore they make studies.

GABOR: True.

FABREGAS: Some 7 years ago in Rio Branco, the Brazilian state organized a meeting of the practitioners of different uses of ayahuasca in the world, in order to try to make a regulation of the use of ayahuasca. Three groups of users came together, the traditional users- shamans, taitas, of the ethnic groups who use ayahuasca, the religious groups, and the scientific, medical or therapeutic community. I was invited, we met and tried to generate a document to regulate the use of ayahuasca.

It was very complicated: the shamans said we are the true repositories of this knowledge and we should be the ones to say who and how. The religious groups said this is a holy thing and we have the possibility to properly access it. The doctors said they don’t know what they are saying and we should be the ones to handle this substance.

They fought for 3 days, it was very very complicated. At the end we had a document that regulated traditional and religious use, and that encouraged studies for therapeutic applications. Nowadays in Brazil, there is list of researchers who have been authorized to work with ayahuasca. They are publishing their results. That is the road. If one believes one can jump over rules, mistakes will be made.

FABREGAS: The problem is that, when it comes to a substance that right now is not legal,there is a use by neo-shamans, urban shamans, and there is a possibility that since there are no protocols of use- no filters – something bad might happen eventually. And that can inhibit the evolution of the process.

Studies have their own speed, they can’t go any faster.

Perhaps if one of the substances wasn’t on list 1 of the Vienna convention it would be easier to research it, but being on list 1 makes getting research permits more difficult. Let’s hope that science gets the space, gets the time, and gets the opportunity to study ayahuasca.

GABOR: Do you work with shamans? Or do you just give the substance?

FABREGAS: I work with shamans and with the church who uses ayahuasca. There are 3 different churches who use it; the UDV, the Barquinha, & the Santo Daime.

GABOR: Which brings up the next question. Dr. Jordi Riba does the studies on brain function, it is all about which centers in the brain get activated: prefrontal lobe, frontal, limbic, amygdale, hippocampus. The shamans, and in the church context, it is an spiritual experience, they are not about brain functioning. Brain functioning is involved, but they are making the spiritual connection. And actually, when you talk about addiction, that is an important connection, the spiritual one. What is your take on that?

FABREGAS: In my work with addiction I can’t generalize, but there have been theories that, behind some drug addictions was the search of a mystical experience, and that the only way to effectively heal them was through a profound mystical experience. Some people have published the theory that behind the addicts’ use of substances is a necessity to transcend.

In these cases, the use of ayahuasca could be a valid option.

In the studies that Riba is doing in the San Pau hospital, maybe we will arrive at the understanding that some mystical experiences – whether or not induced through substances- might have therapeutic connotations, provoking changes. What is good is to have the opportunity to investigate and go deeper into the effects of these experiences and these substances.

FABREGAS: And so we are back to the same problem: one of the difficulties studying ayahuasca is to know to what degree it is the ayahuasca, and to which is the altered stated produced by the ayahuasca, or the context in which it takes place.

What produces the change?

Today it is still difficult to separate these things, that is why it is good that studies are being made that are based purely on the pharmacological action of the substance, in order to see up to which degree the substance itself is responsible, and at which point other environmental factors have influence.

In the pharmacology when we study medicines this separation is easy, we have double-blind with a placebo. In ayahuasca it is not possible to do a double-blind study with a placebo. The person who has taken ayahuasca knows very well they have taken it, the person who got the placebo knows it. That makes the scientific approach that we have difficult. That is why the road has been through the subjective effects, that is, to see what changes took place in the people who took ayahuasca. It is always a subjective impression “I feel better because I took this”.

After that we have the toxicity studies, to determine that the substance is not neurotoxic or detrimental, and then to see if we can make studies with control groups of healthy volunteers, who take a ayahuasca so we can measure how this has modified some of their parameters.

FABREGAS: The problem will be to differentiate – as we’ll remain locked in the substance itself – while we know there are other environmental factors at play.

I don’t think it is ayahuasca itself: MAOI plus DMT, but rather the state it provokes that allows for access to the subconscious, and breaks some of the subconscious defences, and that allows of the self-analysis of these contents.

I make a distinction between psychotherapy and the techniques that use visionary substances. In psychotherapy one tells the therapist what they believe happened to them, or what they want the therapist to believe happened to them, or what the patient is able to accept as what happened to them. It’s not necessarily what happened, but a way for the patient to explain what they believe happened to them. The therapist listens to that explanation, as best they can, according to their training and capabilities, then the therapist will elaborate on that, find an interpretation, and try to put it into wording that the patient will understand. Out of this explanation the patient will receive what they can, or hear what they want to hear… it is very complicated. It is a very long road, where information travels through many distorting filters.

In ayahuasca – one is alone with oneself.

That ability to be able truly see oneself – unfiltered – eliminates some of the intermediate steps. Sometimes that information can then be interpreted by a person with experience. I think this is a plausible way to understand the psychotherapeutic effect of ayahuasca. This is where, as you said, sometimes a session of ayahuasca can be like many years of psychotherapy. This is the subjective impression of many people who have gone thorough it and this could be a way of trying to explain the effect.

GABOR: Finally, people who have worked with LSD have often asked, what is the difference? People have done psychotherapy with LSD. Shamans would say that LSD is chemical and ayahuasca has a spirit. But that’s not a scientific answer. So as a psychiatrist, how would you talk about the difference between a synthetic substance like LSD, and a natural one like ayahuasca?

FABREGAS: As a scientist I don’t feel capable of making this differentiation. I will explain why: I have friends who have some sessions with shamans where they replaced traditional ayahuasca, by equivalent pharmacological substances – an MAOI with DMT. The shaman couldn’t tell the difference. Some friends who are anthropologists, gave LSD to some shamans, the shamans found it was a substance fully capable of being used to work. They didn’t make that difference between natural and synthetic. At the end everything is chemistry, all is chemistry. I might have a reductionist view of ayahuasca. To me it’s an MAOI together with a DMT additive, which the MAOI makes orally available, and this produces some changes.

Others will think that in ayahuasca there is a spirit or a force, it depends how one want to look at it. For example, the effect of dietary restriction, the presence of women in their period. I think a double blind study where, without the shaman’s knowledge, 100 women, 30 one their period. I believe the shaman wouldn’t be able to tell the difference, but that is just my opinion. But the tradition says menstruating woman cannot participate, and indigenous people are very strict about that. I have seen women hide their state to the shaman and no one seemed to notice.

This is one of the advantages of science: it tests our beliefs – to determine if what we believe really takes place, or we merely believe it does.

LSD was used in medicine for many years, there were many studies on its effects on alcoholism. Then it was made illegal, many authors had made studies of its use, and gotten results that seemed impressive, the investigation was full of hope, but then it was drastically cut. Ayahuasca is having its chance now. But I was recently at a congress in Mexico about the use of peyote in therapy. Ibogaine is being tested now for opiate addictions, apparently with good results even though it is substance that must be used with care because it cardio toxic, so it can have fatal consequences if it is not handled with due caution.

FABREGAS: But I don’t think it is just the ayahuasca that does it, but visionary substances: and the altered states of consciousness that they bring, that can help in therapeutic work.

GABOR: Thank you and well…we’ll see, I mean. They’re doing this film, you know? The whole country will see it and we’ll see what happens. Maybe we’ll all be in jail in a year!