Ethical and legal issues in psychedelic harm reduction and integration therapy

This policy paper (2021) examines the ethical considerations one needs to take into account to reduce harm and help integrate psychedelic experiences as are now, or will soon, be offered by therapists. Legal and ethical boundaries regarding preparation and integration work are considered, with a focus on reducing harm for clients who are using psychedelics (unsupervised).

Abstract

“Psychedelic-assisted therapy may represent an upcoming paradigm shift in the treatment of mental health problems as recent clinical trials have demonstrated strong evidence of their therapeutic benefits. While psychedelics are currently prohibited substances in most countries, the growing popularity of their therapeutic potential is leading many people to use psychedelics on their own rather than waiting for legal medical access. Therapists therefore have an ethical duty to meet this need by providing support for clients using psychedelics. However, incorporating psychedelics into traditional psychotherapy poses some risk given their prohibited status and many therapists are unsure of how they might practice in this area. This paper explicates such risks and describes ways in which therapists can mitigate them and strive to practice within legal and ethical boundaries. A harm reduction approach will be emphasized as a useful framework for conducting therapy around clients’ use of psychedelics. It is argued that therapists can meet with clients before and after their own personal psychedelic experiences in order to help clients minimize risk and maximize benefit. Common clinical scenarios in this growing clinical area will also be discussed.“

Authors: Brian Pilecki, Jason B. Luoma, Geoff J. Bathje, Joseph Rhea & Vilmarie F. Narloch

Notes

As a direct result of the increased visibility of psychedelics as therapeutics, thanks in part to the clinical studies of the last 20 years, more people are using psychedelics as therapeutics. This paper tackles the ethical and legal issues that are become ever more relevant for therapists who have clients that use psychedelics. The paper discussed this with the context of US regulations but lessons can generalize to other countries.

Therapists (should) have two goals in mind for their clients. The first is to maximize the benefits of therapy. The second is to reduce the risks of harm. A place where these values are already being incorporated, with regards to psychedelics use, is Psychedelic.Support (a website that features therapists).

The paper then explores the history of psychedelics use and recent clinical trials.

Harm reduction

Harm reduction puts the focus on reducing negative consequences of drug use, not the elimination of use. In the context of psychedelics, this means that a client is encouraged to be open about their use and the therapist provides information to reduce harm (and conversely increase benefit as Carl Hart has reframed the approach).

Therapists could provide information about the use of psychedelics (what to expect) and what alternatives are available (e.g. ketamine as a legal alternative to other psychedelics). Although not mentioned directly at this point, therapists can play a key role in dampening or grounding exuberant expectations.

With regards to the question of going off medication, a therapist should refer to someone who has more knowledge on that topic. Or in other words, stopping medications or evaluating their interactions with psychedelics is not the role of therapists.

Another part of harm reduction is to consider the environment the client is in. This includes the environment where they will take a psychedelic, and also their network that can support them. Another way to reduce harm is to advise drug checking to know if the substance is what is advertised and if it doesn’t contain adulterants.

Finally, clients should be made aware of the lack of regulatory oversight for current underground guides.

Risks for therapists

There are no specific laws that prevent clinicians from working with clients who use psychedelics. But licensing boards may be more stringent and unfamiliar with the benefits or low-risk profile of psychedelics. A negative experience on psychedelics, that was not discouraged by a clinician, may lead to complaints (read: litigation for malpractice) from clients or their kin.

Therapists should not be under legal trouble when it comes to discussing intentions or integrating experiences. They should refrain from discussing sourcing or referring them to underground guides.

Finally, the risk for the reputation of the therapists among peers is something to consider. One, of course, hopes that the risk of not being open to this type of work will soon be the norm.

Several steps are suggested for reducing these risks. First, a therapist should not provide any space where psychedelics could be used or sourced via them. Second, they should refrain from working with underground guides. Third, they should be clear in their advertisement that they only do preparation and integration work. Fourth, they should be aware of their boundaries and possibly engage with continued education. Fifth and finally, they should stay up to date with the current literature and its limitations.

Diversity, equity, and inclusion

Much of the recent research on psychedelics has been done within a Western context. This should not take away from the roots and experience that has been accumulated over thousands of years. It should be something that clinicians take into account when generalizing from the populations that have been studied to their specific patients. One example is the mistrust that many people have against the ‘medical system’ which should be carefully considered.

Personal inquiry

The paper ends with several questions a clinician could reflect on. These are as follows:

• “What are my reasons for doing work that relates to psychedelics?
• Am I comfortable with psychedelic content?
• What is my level of competency in working with psychedelics and harm reduction? What might I do to develop competency?
• What level of risk am I comfortable taking on?
• What is my personal level of experience?
• What is my privilege and how safe is it for me to practice HRIT?
• What is my level of support?“

Summary

Psychedelic-assisted therapy may represent an upcoming paradigm shift in the treatment of mental health problems. This paper will discuss the risks involved in incorporating psychedelics into traditional psychotherapy and how therapists can mitigate these risks and strive to practice within legal and ethical boundaries.

Background information on psychedelic therapy, harm reduction, and integration

Psychedelic use has thrived for thousands of years in Indigenous cultures and underground subcultures, but is now being encountered in the mainstream in countries around the world. This is evidenced by the increase in media attention on the therapeutic use of psychedelics and the increase in volunteers for clinical trials.

There is a growing need for education about psychedelics within the mental healthcare field so that clinicians can meet clients’ current needs. This paper explores ways that therapists can ethically meet this demand inside current legal and ethical regulatory contexts in the USA.

Traditional psychedelics include lysergic acid diethylamide (LSD), mescaline, dimethyltryptamine (DMT), and psilocybin. They are often grouped together with 3,4-methylenedioxymethamphetamine (MDMA) and ketamine because they can result in profound shifts in states of consciousness.

Psychedelics are widely consumed throughout the world, with 32 million lifetime psychedelic users in the USA. Many people want to use psychedelics for therapeutic purposes, but there is no clear legal path toward this use.

Therapists can provide psychotherapy before and after a client has a psychedelic experience, though they cannot prescribe psychedelics or serve as a guide during psychedelic experiences.

We argue that a harm reduction approach is ideally matched to the context of psychedelic use, and that it includes the possibility for psychotherapy after psychedelic experiences to help clients process the experience, clarify gained wisdom or insights, provide support for challenges that may have occurred, and translate their experience into meaningful long term change.

Background and history of psychedelic use and scientific research

Psychedelics have been used for spiritual purposes, healing, and growth for thousands of years, likely as far back as prehistoric times. Western/European research on psychedelics began in the late nineteenth and early twentieth centuries with the discovery of LSD in 1943.

Clinical research was proliferating on psychedelics, but they were classified as a Schedule I drug in the USA in 1970 and subsequently around the world in 1985. However, they continued to be used in the “underground” for therapeutic, exploratory, and recreational purposes.

Researchers have conducted nine rigorous placebo-controlled trials of psychedelic-assisted therapy and found a “very large” between-groups effect size of 1.21 (Hedges g). The strongest evidence for psychedelic-assisted therapy is in the treatment of post-traumatic stress disorder (PTSD), depression, end-of-life distress, addiction, and social anxiety in adults with autism.

The role of psychotherapy in psychedelic medicine

There is consensus on the need for psychotherapeutic support for people undergoing treatment using psychedelics. This support typically takes the form of preparation sessions, therapeutic support during dosing sessions, and integration sessions after each dosing session.

In trials, participants listen to instrumental music, wear eyeshades, and are encouraged to focus on their internal experience. Therapists are trained to respond to difficult experiences, such as fear, confusion, uncomfortable somatic experiences, or attachment issues.

In clinical trials, integration sessions are nonstructured and focus on helping participants make sense of their experiences, including any challenging or confusing aspects. Participants may use creative modalities, practice yoga, or spend contemplative time in nature during integration sessions.

This model of psychedelic experimentation takes care to maximize safety, comfort, and aesthetics, and participants are supported by two professionals with developed trusting relationships. Participants in clinical trials are able to plan for their psychedelic experience and are provided with support during administration. This is in sharp contrast to the way psychedelics are often taken in less controlled or recreational settings, where experienced professionals are usually unavailable to provide support.

Harm reduction and psychedelics

Many therapists offer therapy services in the area of psychedelic medicine, but many are hesitant to engage directly in providing components of psychedelic-assisted therapy. A harm reduction approach can be used instead.

History of harm reduction

Harm reduction approaches focus on reducing the negative consequences of drug use, rather than focusing on eliminating the use of the drug. They are often integrated into psychotherapy approaches for treating individuals engaging in risky behavior.

One common criticism of harm reduction programs is that they condone risky behavior. However, the evidence suggests that harm reduction programs are effective in preventing HIV and increasing treatment entry.

Applying harm reduction to psychedelics

A harm reduction approach to psychedelic use does not permit therapists to legally attend or facilitate dosing sessions.

In contrast to the preparation work usually provided in clinical trials, harm reduction sessions before psychedelic use focus more heavily on safety and education. They help clients make informed choices about psychedelic use and focus on helping them determine for themselves what behaviors will lead them toward the life they desire.

Clinicians can help clients have informed consent for psychedelic use by providing resources, asking clients to do their own research, and providing space for clients to synthesize information they encounter. They can also directly educate clients about psychedelics if they choose to do so.

The therapist should provide information on risks that the client doesn’t discover on their own, such as the emergence of avoided problems, memories, or emotions.

Clients often ask about the potential interactions between psychedelics and medications they are currently taking. Therapists can help clients find online resources to learn more about these potential risks and benefits, and can refer them to local medication providers knowledgeable in psychedelics.

If clients decide to pursue psychedelic use, clinicians can help them think through plans, ensure they are in a safe environment, and promote the use of drug checking, which can help reduce medical risks associated with taking drugs that may be adulterated or mixed with other dangerous chemicals.

Clients seeking services from underground guides may be unaware of the risks of trusting another person while in a vulnerable state during psychedelic experiences. Clinicians can help clients assess the safety and trustworthiness of underground guides and decide whether to proceed with services or report a guide to legal or regulatory authorities.

A harm reduction approach may also maximize the potential benefits of psychedelics by focusing on safety and on a growth-oriented lifestyle. This approach is compatible with the dualistic model of passion, which suggests that psychedelic use may be experienced as positive and not necessarily associated with negative outcomes.

The benefit-to-harm ratio of psychedelics is more likely to be weighted more toward the benefit side compared to some other mind-altering substances, and harm reduction approaches may be more effective.

reduction and integration therapy

Therapists who wish to offer psychedelic harm reduction and integration therapy may hesitate to provide this service due to potential risk.

The largest domain of risk relates to licensing boards. Because of the novelty of psychedelic therapy, less familiarity with harm reduction principles, and stigma against drug use, it is possible that a licensing board may disapprove of therapists who are not explicitly trying to prevent people from using prohibited substances.

Some licensing boards prohibit psychologists from engaging in intention setting or other strategies aimed at maximizing benefit, and others prohibit psychologists from taking public positions on controversial issues.

No licensing boards in the USA have taken disciplinary action against clinicians in relation to harm reduction therapy around psychedelics, but some boards may want to know what education or training experiences have prepared the therapist to offer HRIT.

Another area of risk for therapists is criminal prosecution, which includes local, state, and federal levels. The First Amendment protects healthcare practitioners from anticipatory offense or accomplice liability, but does not apply if a therapist assists in the attainment of prohibited drugs.

In Oregon, a defense attorney discussed the risk of prosecution based on peer-group actions. This may be especially true in the context of the lack of clear guidelines about HRIT from licensing boards.

Another type of risk involves potential litigation of malpractice. Therapists should consider three different grounds for civil suits, including failing to protect the client from harm and violating standards of care.

Another type of risk involves professional reputation amongst peers and communities. Clinicians should think through these risk factors and consider other forms of risk that may be unique to their own personal circumstances.

Steps to mitigate risk

Although harm reduction approaches for substance use disorder treatment are well-established and evidence-based, there are some activities that clearly increase risk that one should be aware of.

To avoid legal risk, clinicians should not facilitate access to psychedelics or prohibited substances in any way, and should refrain from suggesting clients take psychedelics before a session and come to session under the influence.

Referring a client to an underground guide creates greater legal risk than simply facilitating access to prohibited substances. Receiving referrals from an underground guide entails less legal risk than consulting with an underground guide on an ongoing basis, but doing so increases the risk of a licensing board sanction if a client claims their use of a prohibited drug was because of interaction with the therapist.

Therapists can reduce risk by carefully considering the language used on advertising, forms, and in documentation. This includes avoiding terms such as “preparation” or “guide”, and clearly specifying boundaries of practice in all verbal communication.

Obtaining adequate training and access to consultation resources is an important risk reduction strategy. There is currently no consensus on minimal training standards, so clinicians may be frustrated by the lack of clear pathways to increase education.

A clinician should investigate their local contexts before offering HRIT therapy, including learning about the local licensing board, laws related to controlled drugs, and community attitudes about psychedelics.

It is recommended that clinicians become familiar with the empirical support for psychedelic-assisted therapy, including both strengths and limitations, so they can talk to clients about psychedelics from an informed, balanced, and evidence-based perspective.

Know the law and know thyself: common decision points encountered by therapists

Below we outline common situations that often occur in HRIT therapy relating to psychedelics, and recommend factors to help clinicians in decision-making.

Clients who seek HRIT may have underground guides who provide them with psychedelic substances and be present with them during their experience. A therapist may need to assert professional boundaries and decline to speak with their guide.

Therapists should provide information about the risks and benefits of psychedelics to their clients and should spend some time developing their own resource list. They should also provide a wide range of informational sources, such as websites, books, or podcasts.

Clients who have financial resources may ask a clinician’s opinion about traveling to other countries where psychedelic retreats are legal. However, it is recommended that clients familiarize themselves with guidelines for reducing risks associated with traveling to other countries, such as traveling with trusted companions and conducting thorough research.

Clients sometimes ask clinicians about their prior experience with psychedelics. Clinicians may feel reluctant to answer questions regarding their own use of psychedelics, but one option is to provide a vague answer that affirms one’s prior experience without going into detail.

Diversity, equity, and inclusion in harm reduction and integration therapy

Psychedelic-assisted therapy is embedded within a White-dominant medical framework, and there is a significant lack of diversity within the field of psychedelic researchers. This lack of diversity stands in stark contrast to the fact that psychedelics have been part of the spiritual practices of Indigenous people throughout the world.

This paper highlights the role of psychotherapy in reducing risk and maximizing benefit in relation to psychedelics, but Indigenous, spiritual, or religious cultures have been using psychedelics long before psychotherapy existed.

When psychedelic-assisted therapy becomes legal, it will likely be expensive and inaccessible to individuals of lower socioeconomic status, resulting in an active underground use of psychedelic medicines.

Psychedelic medicine presents an opportunity to diverge from existing systems of oppression and promote values associated with DEI. Clinicians are encouraged to do their own personal work around cultural humility. Clinicians should adapt their therapy approach to clients who identify as people of color or who have other marginalized identities, and should spend more time in initial screening to counteract potential mistrust toward the medical system and to formally assess racial trauma and institutionalized oppression. Clients from less advantaged backgrounds will likely experience higher risk of criminal prosecution for their involvement with psychedelics.

Personal inquiry and conclusion

We recommend that clinicians think through their potential interest in psychedelic medicine, clarify their values, assess their competency, and pursue additional training and education.

Psychedelic-assisted therapy has been touted as a potential paradigm shift in the treatment of mental health problems. Therapists should become better educated and prepared to incorporate psychedelic experiences into their practice, and should consider advocacy work to reduce the stigma associated with psychedelic use.

Appendix: Personal inquiry for clinicians considering psychedelic Harm Reduction and Integration Therapy (HRIT)

Clinicians should clarify their own set of values that draws them to work with individuals engaged in psychedelics, and think through what aspects of practicing in this area might be difficult or aversive.

If you are not comfortable with psychedelic content, reflect on recent encounters with clients who have brought up similar topics and decide whether you are comfortable discussing them.

There are few professional arenas for obtaining education and training in working with psychedelics and harm reduction, though this is likely to change as psychedelic-assisted therapy becomes more widely disseminated. Clinicians are encouraged to read research articles or media about psychedelics and to read trip reports to better understand the use of psychedelics in treatment.

HRIT involves some level of legal and regulatory risk, and clinicians should consider their own unique situations, local laws and guidelines, and their level of comfort in discussing psychedelics with clients.

Many clinicians who are new to psychedelics are curious as to whether or not they need to have their own prior experiences with psychedelics. It is not necessary, but it is advantageous to have experience with non-ordinary states of consciousness.

Depending on where you live, practicing HRIT may be considered controversial by colleagues and peers. Some therapists may be less comfortable practicing HRIT than others, but it is hopeful that more professionals will speak out and work toward counteracting stigma.

If you are considering practice in HRIT, consider the level of support you have from other clinicians, paid consultation, or a professional listserv.

Therapists with training and background in harm reduction can play an important role in shaping and advancing public policy related to psychedelics and other drugs.