JOURNAL OF PALLIATIVE MEDICINE
Volume XX, Number XX, 2018 Personal Reflection
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2018.0561
What Psilocybin Taught Me About Dying
Anthony L. Back, MD
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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 grand-
mother 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 pro-
found connection to the earth, and of having access to an
energy in the universe that normally was hidden. It was ex-
hilarating. 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.
Department of Medicine, University of Washington, Seattle, Washington.
1
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 exhil-
arating. 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 for-
ward 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 at-
tention to what lies beyond their small self? Is the inner work
 2 PERSONAL REFLECTION

of dying not about deciding how you want things arranged journey isn’t necessarily about the road that my small self
but instead about learning how to allow the small self can see.
to dissolve? This territory isn’t completely unheard of—
Address correspondence to:
spiritual teachers and wisdom traditions both refer to it,
Anthony L. Back, MD
using different terms. But it is one thing to read that, the-
Department of Medicine
oretically, one’s small self could be dissolved, and another
University of Washington
to experience it. My small self, though firmly in the driv-
Seattle, WA 98104
er’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 E-mail: tonyback@uw.edu
Downloaded by Wegner Health Science Information Center/ University of South Dakota multisite from www.liebertpub.com at 11/11/18. For personal use only.