A Qualitative Exploration of Relational Ethical Challenges and Practices in Psychedelic Healing

In this qualitative interview study (n=23) practitioners who have administered MDMA and psilocybin to clients in underground healing contexts were interviewed about their experiences. Common themes experienced by the practitioners were identified (both descriptive, e.g. use of touch, and prescriptive, e.g. grounding) and the implications for training future psychotherapists are discussed.

Abstract

“As both 3,4-methylenedioxymethamphetamine (MDMA)- and psilocybin-assisted psychedelic psychotherapy near U.S. Food and Drug Administration (FDA) approval and gain acceptance as efficacious clinical approaches, concerns have been raised about the likelihood of sexual violation of a client and other relational boundary transgressions. In the current study, 23 practitioners who have administered MDMA and psilocybin to clients in underground (i.e., extralegal) healing contexts were interviewed about their experiences navigating multiple relationships, nonsexual touch, and sexual boundary-setting in their work. Of these practitioners, 12 had undergone formal, graduate-level training in psychotherapy, 10 identified as female, and 13 identified as male. A phenomenological research design was used to assess what unique relational challenges they have faced in this work and what practices they have found helpful in doing so. Two sets of themes addressing these two questions were developed from the data. Descriptive themes represent the unique challenges that psychedelic practitioners have encountered in their work, and prescriptive themes are made up of the practices they have found most useful in confronting these challenges. Some themes are unique to psychedelic work (e.g., client nudity, the use of touch, the belief that therapists must continue to have their own psychedelic experiences), while others represent a psychedelic-specific take on standard ethical considerations (e.g., transference, supervision, staying within one’s scope of competence). Discussion of these results includes implications for the training of psychedelic psychotherapists and other regulatory decisions facing the field.“

Authors: William Brennan, Margo A. Jackson & Katherine MacLean

Summary

As psychedelic psychotherapy approaches near FDA approval, concerns have been raised about the likelihood of sexual violation of a client and other relational boundary transgressions. 23 practitioners were interviewed about their experiences navigating multiple relationships, nonsexual touch, and sexual boundary-setting in their work.

MDMA and psilocybin have shown efficacy in treating posttraumatic stress disorder symptoms, treatment-resistant obsessive – compulsive disorder, major depressive disorder, alcohol dependence, and treatment-resistant depression. They are likely to gain approval as therapeutic adjuncts within the next few years.

Given the apparent therapeutic efficacy of these substances, we must now consider how psychedelic psychotherapy will be integrated within existing models of psychotherapeutic care. We must develop ethical practices that address the unique therapist – client dynamics that arise in psychedelic sessions.

The current study examined the experiences of underground psychedelic practitioners in navigating relational ethical challenges, particularly around sexual boundary-setting, therapist-client touch, and non-sexual multiple relationships. The results suggest that these practitioners’ experiences predict those that will soon be faced by practitioners of legal psychedelic psychotherapy.

Three types of boundary concerns were chosen for their particular pertinence in psychedelic psychotherapy relative to talk therapy. Despite the more cautious approach adopted by the current wave of psychedelic research, therapist sexual abuse has already occurred in an FDA Phase III study on MDMA-assisted psychotherapy.

Psychedelic psychotherapy uses touch as a second distinguishing feature that can lead to increased relational ethical risks relative to talk therapy. However, inappropriate uses of therapist – client touch may adversely affect clients.

Nonsexual touch can be more harmful in psychedelic work because client autonomy is impaired, and therapists must take special precautions to protect the welfare of clients with impaired autonomy.

Fischer (2015) draws from her experience providing psychedelic group therapy to illustrate the role flexibility found between therapist and client.

The apparent innateness of this relational boundary flexibility in psychedelic work may have adverse consequences for clients in traditional Western psychotherapeutic contexts.

Common and Distinctive Features of Psychedelic Psychotherapy and Guidework

A psychedelic medicine session consists of two therapists attending to a client under the influence of a psychedelic substance for 5 to 10 hours. Therapist-client interaction is allowed, though limited in favor of having an inner-directed experience.

Underground psychedelic work looks very similar to psychedelic psychotherapy, but with several notable differences, including the use of shamanic or bodywork techniques and working without legal or institutional permission to use the controlled substances they employ.

Ethical Status of Underground Guidework

There is no clear answer to whether underground guidework violates the APA’s (2017) Ethical Principles. Participants claimed to accept the legal risk entailed by their work out of a sense of ethical responsibility to provide its benefits to their clients.

Standard 2.01 allows practitioners in emerging areas without legally recognized credentialing to make a good faith effort to obtain the education, training, supervised experience, consultation, study, or professional experience needed to protect their clients from harm.

Even if the participants’ work were in violation of the APA code, the authors feel that it is important to examine their experience of striving to uphold the ethical standards that are most relevant to this study.

Participants and Recruitment

All participants were at least 18 years old and had provided underground psychedelic work for a minimum of 2 years. They had served at least 10 clients.

To preserve participant anonymity, only gender and professional background were collected. Of the 23 participants, 10 identified as female and 13 identified as male, and 13 had received at least 1 year of formal training and/or mentorship in the therapeutic use of psychedelic substances.

All 23 participants reported having provided one-on-one psychedelic sessions to clients as part of their practice, but none had ingested as much as the client when working with MDMA or mushrooms.

Interview Questions

Each interview began with the collection of personal data, and then a set of subquestions was used to ensure that each participant spoke to the three ethical domains under study.

Procedures

The recruitment protocol for the current study was drawn from the work of Dr. Kim Hewitt, who conducted interviews with psychedelic users who required anonymity. Participants were recruited through a link provided in a recruitment email, and verbal consent was solicited at the start of each conversation.

Data Analysis

The principal investigator used a phenomenology methodology to analyze the transcripts of the participants’ conversations about ethical relationship and boundary-setting in their psychedelic work.

Results

Themes identified through a phenomenological analysis of the interview transcripts are summarized in Table 1. Descriptive themes are derived from participants’ descriptions of the ethical challenges they have faced.

Descriptive Themes

All participants stated that psychedelic work requires more authenticity and role flexibility, but that it is important to balance this with the need to remain the person who is holding the container for the work.

Participants noted that psychedelic work gives rise to greater transference and countertransference than talk therapy, especially in cases involving sexual desire, boundary-testing, or guru projections.

Clients may experience strong feelings in their bodies during a psychedelic session, remove some or all of their clothing, or touch their bodies in a sensual or sexual way. This can be therapeutic for some clients, but may also inappropriately activate the therapist’s desires.

Participants described a greater intimacy than talk therapy, which they felt was a result of various elements of psychedelic work. However, they also noted that this intimacy has led to ethical boundary challenges.

Many participants felt that psychedelic sessions can foster a bidirectional flow of love and affection between them and their clients. They felt that this love is important for clients’ healing and that it is acceptable as long as it is free from romantic intent.

Participants stated that touch is an essential part of their work, but highlighted the possibility of retraumatization through misattuned touch or the potential slippery slope from appropriate touch to sexual touch.

Participants felt that greater self-disclosure was required when working with clients undergoing psychedelic work. However, poor use of self-disclosure may lead to inappropriate shifts in the dynamics of the relationship.

Participants felt that the impaired autonomy of a client in an altered state of consciousness made it necessary for them to hold firmer boundaries than usual and made in-session solicitations of consent impossible.

Participants felt the need to be available to their psychedelic clients outside of sessions, but found that this could put stress on the practitioner or add confusion to the relationship.

Some participants felt that psychedelic practitioners need to attend to a level of nonphysical, non-verbal “energetic” communication with their clients, and that if this communication is neglected, harm can be done to both practitioners and their clients.

Participants observed among their peers a pervasive permeability of relational boundaries, where practitioners often take on friends as clients, begin a full friendship with a client over the course of their work, or exist in community with clients.

Participants spoke of clients regressing to a younger developmental stage in order to work through an earlier trauma, and how this presents an ethical challenge.

Participants stated that clients under the influence of psychedelic substances are more sensitive to the inner experience of the practitioner.

Prescriptive Themes

Participants spoke to the importance of self-awareness in helping them remain ethical with their clients, including engaging in a regular meditative practice, adequate self-care, and getting one’s needs met elsewhere.

Participants felt that seeking supervision or consultation was important when grappling with ethical challenges.

Many participants found it helpful to discuss the boundaries of the therapeutic relationship with clients at the outset of psychedelic work, and to discuss any background dynamics that had arisen between client and practitioner.

Participants felt that practitioners should do their own work to reduce their susceptibility to transgressions. This work should include healing their own unconscious, disavowed psychic material, and understanding their sexuality.

Participants emphasized the importance of therapists having their own experiences with psychedelics, and many added that this experience should be an ongoing relationship.

Participants discussed the value of long-term relationships and repair in psychedelic work. Some participants felt that this would minimize relational harm and turn boundary transgressions into valuable therapeutic “grist for the mill”.

Participants noted that working within a community of practice has helped them remain ethical toward clients.

Participants spoke about the importance of being attuned and responsive to the client before and during touch. Some participants taught self-attunement to clients to participate actively in determining the rightness of touch.

Participants reported using a two-stage process of consent for touch, in which they discussed the forms of touch that may be used with the client.

Some participants discussed the importance of staying within one’s scope of competence when offering psychedelic work to clients. They recommended getting additional training in touch and energetic work.

Participants used redirection to help clients heal from a problematic practitioner – client dynamic, by encouraging them to use sexual feelings toward the practitioner as a springboard for self-insight.

Many participants have shared nonromantic, nonsexual love with clients, and have cited their love for their clients as an important part of what grounds them ethically in their work.

Some participants have grounded their ethicality in a spiritual orientation that dissuades them from doing harm. This sense of sacredness is often inspired by their own experiences with psychedelics.

Some participants felt their grounding in a specific lineage of psychedelic work informed their ethicality.

Participants discussed the idea of an adjudicating body to oversee boundary violations, but most favored restorative justice-based approaches that might instead mandate personal healing for transgressors and support their monitored return to psychedelic work.

Discussion

23 underground psychedelic practitioners provided descriptive and prescriptive themes about their experiences with maintaining ethical relationship and boundaries with their clients. These results provide a substantive answer to the central research question of how these practitioners have navigated ethical relationship and boundary-setting around sexual contact with clients.

The current study demonstrated that embodied phenomena such as nudity and sexual expression are likely to arise within a psychedelic session and require fuller consideration if therapists are to respond to them ethically.

Participants believe that the exchange of love feelings between the therapist and client is part of how psychedelics heal, but previous ethical literature views such beliefs as a precursor to boundary transgressions.

A third topic warrants further attention: the tendency toward the formation of psychedelic communities that cut across the therapist – client divide. Some participants suggested that this could contribute to therapeutic outcomes.

The prescriptive themes suggest several practices for expanding the ethical capacities of psychedelic psychotherapists, including two-stage consent for touch, enhanced skills for working with transference, and strong relational psychotherapy skills.

Some prescriptive themes suggest shaping the inner life of the practitioner, while others emphasize the importance of undergoing one’s own personal therapeutic work. These suggestions challenge how psychotherapeutic ethics are currently inculcated and governed.

Unresolved narcissistic needs are the most common antecedents of therapist sexual abuse, and the most effective way to minimize this source of relational ethical risk may thus be to insist that the practitioner “do their own work”.

Participants’ insistence that practitioners must have their own psychedelic experiences speaks to a long-standing conversation about the necessity of this practice.

The results of the current study point toward novel avenues of future research, including hypotheses about the relational elements of a psychedelic session and ethical practices that could be further explored from clients’ points of view.

The lack of gender effects found across participant responses may be an effect of the gender of the principal investigator (male), who conducted all interviews.

Two participants mentioned the importance of cultural factors in relational ethics, despite their documented role in determining one’s sense of what is ethical in clinical relationships. This silence may reflect the cultural homogeneity of the field.

The results of the current study surprised the investigator because there was no sharp divergence in perspectives between participants.

The current study was practitioner-focused, and therefore did not include perspectives from clients. Future work would benefit from obtaining clients’ perspectives.

The authors of the current study were unable to collect more extensive demographic data to protect participants’ anonymity. This limited the depth of understanding and interpretation found in the results section.

A third limitation stems from the possibility that there are gaps between underground psychedelic guidework and FDA-approved psychedelic psychotherapy. The results of the current study may not be considered relevant to psychedelic psychotherapists.

Conclusion

This study explores the experiences of underground psychedelic guides navigating ethical relationship and boundary-setting in their work. The findings support the contention that psychedelic psychotherapy is rife with unique ethical challenges.