The Blind Leading the Double Blind

Psychopharmacology simplified

Hey, let’s take a minute to talk about science. People get precious and weird about it, but its not hard to understand. My mom was a junior high science teacher, so I think I’m fully qualified to talk about a couple of basic things. Because I’m just a simple country guy, I’ll illustrate my science talk with a woodcutting metaphor.

One thing that people doing science a lot is an experiment. This is a way to test something through controlled trial and error, more or less. Let’s say you were chopping wood, and you wanted to know what angle on your axe or maul head works better. You’d have to first have the head you always use, and a new one with a different angle to test against. Then, to make sure you were actually testing the maul head, you’d want to make sure everything else about the work you are doing is the same.

You’d ensure that the handle is the same, and that despite the difference in angle the heads weighed the same and had the same shape. You’d be chopping the same number of logs, of the same size, from the same species that have been aged the same length of time. You’d probably alternate from one to another, perhaps, so fatigue didn’t play a factor- only testing one maul head after you were already worn out.

You’d make sure you had a consistent way to measure “better”- say the amount of time it takes on average to cut a log into eighths- or maybe you would just do number of swings.

Even then you’d only know which angle head works better for a particular type of log- maybe its better for pine but you might get different results with a hardwood like oak.

One other potential variable you might need to consider- what if you liked one of the heads more? You think one of those heads is sexy as hell and really believe that it will just split like crazy. It’s ENTIRELY possible that you’d actually perform better when wielding a maul that your EXPECTED to perform better. You’d then unintentionally influence the results of your experiment simply by improved performance.

To mitigate against this possibility you could use a technique called blinding. In this case, all you’d need to do is blindfold yourself so that you could not see which head you were using. NOW you can be reasonably confident that any difference in the split wood will be a direct result of the angle of the particular head in question, and nothing else. We can safely assume that it will make no difference to the block of wood, which need not be blindfolded- no need for double-blinding.

Now if you have a mental image of a blindfolded woodsman swinging wildly at a block of wood, you probably have a fairly accurate picture of the current state of modern psychopharmacological research. The absurdity of imagining blind wood chopping isn’t that dissimilar from so myopically focusing on the manipulation of brain chemistry that it becomes somehow rational to exclude all other aspects of treatment. It also treats a subject as little more than an inert block of wood.

This absurdity is deepened in the realm of psychedelics, in which critics of psychedelic research have expressed deep concerns that double blinding can’t be experimentally maintained. Turns out, shockingly, that when a person is given psilocybin, they KNOW they’ve been given psilocybin. So do their attendants.

It is completely spreadsheet-brained to think that the impossibility of blinding is a problem with psychedelics rather than a problem with modern research methods. Rather than treat this as a criticism of psychedelics, which it plainly is not, maybe we should view this as an indictment of double-blind myopia in psychopharmacology. After all, it’s been a pretty long time since we got any new psych meds that are really worth a damn without undergoing statistically significantly tortured statistics.

Perhaps its just completely and totally wrong to think that there is any meaningful treatment at all that can be offered to someone plagued with psychological suffering that offers ONLY a chemical intervention. Maybe, just MAYBE, humans are too complicated for the type of facile reductionism that imagines that a PILL can operate predictably on a BRAIN which will then make someone durably BETTER.

This IS the logic of the double blind placebo controlled pharmacological approach to human suffering. Fancy statistics and big words shouldn’t be allowed to obscure the fact that the assumption at play is that a person is little more than their brain chemistry. Not only that, but for double blinding to be effective, the person must know nothing of their true treatment. As far as the researchers are concerned, their subject may as well be a stump. Don’t be fooled by lip service to “biopsychosocial” approaches- the record indicates that’s not where the time, money or interest goes.

This assumes no agency on the part of the subject, and implies that the subject needn’t be, and ideally wouldn’t be, part of their own treatment. Take this pill, let us know with this itemized questionnaire how you are feeling. In no way is the subject asked to make sense of their experience, engage in self examination (other than a survey), or understand their place in the world. This is jaw-droppingly paternalistic and condescending.

This is all implied simply by the experimental design! Again, by design, the only important things in the experiment are: a) drug or placebo given and b) outcome measure. Everything else is a confound.

You know the old saying “when you are holding a hammer, everything looks like a nail”. The tools we use often dictate the actions we take, whether or not they most effectively serve the function we are in need of. If you have at your disposal a double-blind placebo controlled trial, well- everyone looks like an object in need of chemical tweaking.

It’s remarkable how an entire institution filled with very smart people have ended up in such a simpleminded dead end. Simpleminded is the correct word. Because if you strip away all of the circularly reinforcing references, the fancy statistics, the big words, and the arguments from authority, you are left with a modern philosophy of suffering that has nothing to offer but brain chemistry. Your average pothead has as much practical experience managing suffering via chemical modifications. It’s pathetic.

So the fact that psychedelics don’t fit easily into placebo controlled double blind trials is a feature, not a bug. The effects of psychedelics are so wide ranging, strange and obvious that pretending our empirical research methods are capable of making meaningful sense of the experience is laughable. Good. Our collective sensemaking apparatus in the realm of “mental health” in our current cultural context is more or less busted. It’s perfectly inadequate to the challenges of modern malaise, cultural and ecological collapse, economic precarity, mass oligarchic hoarding, and resource scarcity. We need tools that challenge us to integrate complexity and uncertainty into our thinking, tools that force us to adapt rather than to conform.

We don’t need to wedge new treatment approaches into the double-blind model, we need to ditch it altogether. Put the really smart academics at the high dollar institutions to work coming up with something actually useful for a change, rather than something conceptually familiar, highly profitable and functionally useless.