Developing Guidelines and Competencies for the Training of Psychedelic Therapists

This article (2017) lays out guidelines and core competencies for psychedelic therapists in training, which include empathetic abiding presence; trust enhancement; spiritual intelligence; knowledge of the physical and psychological effects of psychedelics; therapist self-awareness and ethical integrity; and proficiency in complementary techniques. It also highlights 12 domains of curricular training that include knowledge of history, neuropharmacology, best practices in set and setting, as well as therapeutic strategies and boundaries.

Abstract

“Research since the 1950s has shown that psychedelic-assisted psychotherapy has had significant positive effects in reductions of specific clinical symptoms and increases in quality of life as measured on a variety of indices. The intensity of focus on evidence-based outcomes, however, has resulted in a paucity of active discussions and research on the core competencies of the therapists themselves. The context of the history of psychedelic research reveals how this neglect of therapist variables occurred. With current discussions of Phase 3 and expanded access research programs for psilocybin-assisted and MDMA-assisted psychotherapies, there will be a great need for competent therapists trained in this clinical specialty. This is particularly the case if less restricted, legal medical use is approved within the next 6 to 10 years. This article is the first review and compilation of psychedelic therapist competencies derived from the psychedelic literature. These six therapist competencies are empathetic abiding presence; trust enhancement; spiritual intelligence; knowledge of the physical and psychological effects of psychedelics; therapist self-awareness and ethical integrity; and proficiency in complementary techniques. A further contribution of this review is a delineation of the 12 fundamental curricular domains of study for the training and development of these therapist competencies. As current legal restrictions evolve, aspects of these training guidelines will develop accordingly.”

Authors: Janis Phelps

Summary

The history of psychedelic research reveals how the focus on evidence-based outcomes has resulted in a paucity of active discussions and research on the core competencies of the therapists themselves. This article is the first review and compilation of psychedelic therapist competencies derived from the psychedelic literature.

Setting the Stage for Psychedelic Research

Psychedelic psychotherapy was developed in the early 1950s as a tool to better understand how the brain itself works.

The research literature on therapist competencies and therapeutic alliance-building has gone relatively unsystematized and unresearched due to political climate changes in the United States.

In the clinical setting, psychedelic substances were initially used to induce elements of psychosis and reveal underlying psychodynamic processes. However, soon interest shifted to their potential as catalysts for therapeutic healing.

Researchers proposed various qualities for therapists, including empathy, objectivity, calmness, awareness of reactions, and transference analysis. However, there is only clinical case studies and self-reported, anecdotal discussion of therapist qualities.

Researchers in the 1950s and 1960s discovered that psychedelics could catalyze transformative, breakthrough experiences. They began convening conferences where they could share their findings and discuss the potential implications of them.

The Dark Ages and the Renaissance in Psychedelic Research

In 1970, the federal government made psychedelic-assisted therapy illegal. In the mid-1970s, MDMA was introduced to the therapeutic world by several therapists, but stayed largely under the radar of the mainstream culture until they were placed on Schedule I status in 1985.

In 1986 Rick Doblin founded the Multidisciplinary Association of Psychedelic Studies, and in 1993 the Heffter Research Institute was cofounded by David Nichols, George Greer, Dennis McKenna, Mark Geyer, and Charles Grob. In 1990 the FDA allowed Rick Strassman to conduct clinical trials with DMT.

After Strassman’s research approval coup and the pivoting of the two federal agencies, MAPS and Heffter started up psychedelic research programs again in earnest. These organizations focus on MDMA for the treatment of posttraumatic stress disorder and psilocybin for the treatment of anxiety in patients with advanced-stage cancer. The FDA has approved clinical trials for MDMA and psilocybin for treatment-resistant PTSD and end-of-life distress and major depressive disorder, respectively, in the past 20 years.

Present-Day Research With Psychedelics

The momentum of the current renaissance period has occurred through the dedication, persistence, and wisdom of several dozens of researcher clinicians. Three organizations are helping to underwrite clinical studies of psychedelic-assisted therapy. The tireless efforts of all these organizations have led to greater interest in this field, as evidenced by the publication of the New Yorker article, The Trip Treatment, and the books Healing with Entactogens and Manifesting Minds.

A lack of direct research on therapist qualities and competencies has been contextualized by recent research data on psilocybin and MDMA poised to move into Phase 3 drug trials.

Current Psilocybin-Assisted Therapy Outcomes

Researchers at Johns Hopkins University found that psilocybin-assisted therapy could induce mystical-type experiences. The participants rated the experiences as having substantial personal meaning and spiritual significance.

Psilocybin-assisted therapy pilot study on smoking cessation found that 12 out of 15 participants were abstinent from tobacco, and 67% remained abstinent at 12-month follow-up. Bogenschutz (2015) is currently conducting a study on the effects of psilocybin on alcohol dependence.

Researchers found that psilocybin reduced anxiety in patients with advanced-stage cancer. The effects lasted for 6 months and 80% of participants still endorsed the high-dose psilocybin session as having moderately or greater increased life satisfaction/well-being.

In a related study, psilocybin-assisted therapy produced rapid, robust and enduring anti-depressant and anxiolytic effects on 29 patients with cancer-related psychological distress.

Current MDMA-Assisted Therapy Outcomes

In 2011, Mithoefer et al. found that 83% of participants who received MDMA in conjunction with psychotherapy no longer qualified for a PTSD diagnosis two months post-treatment. All participants who received MDMA maintained both statistically and clinically significant symptom relief in a comprehensive follow-up study.

Subjective Experiences of Participants in Psilocybin and MDMA Clinical Trials

The following discussion focuses on the clinical results of psychedelic- and entactogen-assisted therapy for relationship and quality-of-life improvements, including occasioned mystical states and experiences, openness, improved quality of life, and enhanced experiences of love, empathy and meaning-making.

A pilot study looking at psilocybin for the treatment of tobacco addiction found a significant correlation between mystical experience measures and smoking cessation outcomes.

MDMA and psilocybin can both facilitate the experience of love, which is one of the core reasons why MDMA is so effective in facilitating therapy.

In clinical trials focused on psilocybin and mystical experiences, participants experienced greater empathy, which remained stable 14 months later. This empathy may help patients with addictions to acknowledge and change their behavior.

Psilocybin-assisted therapy can increase the capacity to make meaning of one’s experience, which can catalyze the healing process.

The Competencies of the Therapist Guide for Psychedelic-Assisted Psychotherapy

The benefits of psychedelic-assisted therapy have become clear with each successive study, but discussions about the desired qualities and competencies of the therapists themselves have remained limited. The time has come to have serious conversations and inquiry dedicated to psychedelic therapist competencies and training.

There are three terms used in contemporary discourse to describe a mental health or medical professional who is present and facilitating a psychedelic therapy session: sitter, guide, and therapist.

The therapist facilitates the participant’s sense of trust, safety, encouragement, and fortitude through witnessing and acknowledgment, and helps the participant move through three phases of treatment: preparation, medicine session, and integration.

The literature on psychedelic therapist competencies is sparse, but reveals fundamental agreement on the core knowledge, attitudes, and skills of a therapist in this specialization. These competencies include an empathetic abiding presence, trust enhancement, spiritual intelligence, knowledge of the physical and psychological effects of psychedelics, and proficiency in complementary techniques.

Competency 1: Empathetic Abiding Presence

A properly trained psychedelic therapist has the capacity for empathy, which is a hallmark of humanistic therapies. This empathy is cultivated into a calm, abiding presence during psychedelic therapy, which is evidenced in the therapist during preparation, the session itself, and integration meetings.

Empathetic abiding presence is a key component of Holotropic Breathwork, a widely known form of non-psychedelic means of inducing a non-ordinary state of consciousness. It is characterized by composure, evenly suspended attention, mindfulness, empathetic listening, “doing by non-doing”, responding to distress with calmness, and equanimity. Researchers have commented that ways of listening with empathy and presence are more impactful than engaging the participant in dialogues and inquiry.

Empathy is the skill of being attentive, supportive, and becoming ground to the figure of the participant’s own process. This skill is akin to the stalwart analytic practice of evenly suspended attention.

Empathetic abiding presence is crucial for ease during psychedelic sessions and for potentiating a corrective emotional experience for the participant. This equanimity can be seen as consistent with Taylor’s (2007) statement that a guide develops the skills for “a balance of protection, permission and connection” (p.133).

Therapists are best suited to this work if they themselves have experienced transformative, nonordinary, or alternate states of consciousness. This is because they can embody an empathetic abiding presence and tolerance for moments in psychedelic sessions in which the participant is experiencing paradoxical, intense emotional and physical states.

Competency 2: Trust Enhancement

A therapist’s empathetic abiding presence, skill in enhancing trust, and ability to reliably normalize paradoxical transformations and radically unexpected moments in sessions are key to creating safety in the treatment sessions, building the therapeutic relationship, and supporting the participant’s increased trust.

For psychedelic therapy to be effective, the therapist must be open to various ontologies and embody multiple ways of knowing. This is accomplished by consistently responding in ways designed to enhance the participant’s trust in their own inner healing process.

A guiding therapist’s trustworthiness is essential for a participant’s willingness to endure the challenges of making meaning from psychedelic sessions, and for a participant’s sense of renewal, greater self-awareness, personal growth, and greater compassion for others.

Recent studies have shown that psilocybin and LSD ingestion enhances meaning making and relevance attributions. A trust-enhancing therapist can help participants cultivate multifocal viewpoints for making sense of what may reveal itself as meaningful.

Competency 3: Spiritual Intelligence

Therapists who are competent in psychedelic-assisted therapy have a spiritual intelligence that goes beyond conventional psychological development. This intelligence is evidenced by knowledge of the process of entelechy and familiarity with mystical states of consciousness.

The descriptions of experiences within transpersonal and mystical realms of consciousness by Passie (2012), Bossis (2014), and Richards (2014) reveal descriptors of spiritual intelligence in the competent therapist, such as the ability to open up toward inner awareness, feeling free to accept oneself, and experiencing love.

Therapist guides with this competency have an awareness of the spiritual dimension of consciousness, its indestructible nature, its interconnectedness with all human beings and perhaps all life forms, and its incredible, awesome beauty.

Competent psychedelic therapists embody spiritual intelligence, which is woven with an appreciation of the mystery of realms of transpersonal consciousness. This appreciation correlates to positive clinical outcomes.

Competency 4: Knowledge of the Physical and Psychological Effects of Psychedelics

Psychedelic-assisted therapy has benefited from knowledge of ancient and contemporary indigenous practices of ceremonial use of plant medicines, which have time-honored sets and settings. Psychedelic scholars have noted the need for guides in psychedelic-assisted therapy to have in-depth, theoretical, and experiential knowledge of the cross-cultural roots of the global use of plant medicines.

Researchers reiterate that therapists need to be thoroughly knowledgeable in all aspects of current best practices for creating appropriate set and setting for safe and optimal outcomes when using psychedelic-assisted therapy.

Psychedelic therapists need to be astute in theories of child and adult development, and need to know how to persuade volunteers to stay onsite, refrain from destructive acts to self, other, or property, and from sexual activities, and follow therapists’ instructions for safety.

Psychedelic therapist guides should have knowledge in anatomy and physiology, neurobiology, pharmacology, drug disposition and interactions, and neuropharmacology of psychedelic drugs, as well as clinical narratives on the normative effects of different psychedelic drugs at varying dosages in a variety of sets and settings.

In the 1990s, when research began again under FDA approval, scholars debated whether or not to promote this valuable competency-based training. Grof (1980) stated that a therapist must have first-hand experience with psychedelics to understand their clients’ reactions. Swiss and German health authorities require therapists in psychedelic studies to take the drug, and the Czech model required five personal sessions and 30 sessions as a guide. MAPS gained FDA approval to allow training therapists to take MDMA.

Competency 5: Therapist Self-Awareness and Ethical Integrity

A core competency of psychedelic therapists is the capacity to wisely reflect on one’s motives while simultaneously working with participants’ attachment and transferential processes. Transferential issues are likely to arise more often in higher dose treatment, depending on the emerging unconscious processes.

Researchers have highlighted the need for therapists to scrutinize their responses in countertransference with participants in each step of the treatment, particularly during the psychedelic sessions. This is particularly important because the therapist can all too easily be drawn into acting out with a patient.

The therapeutic alliance building aspects are thoroughly supported by the first four competencies of the therapist guide: empathetic abiding presence, trust enhancement capacities, spiritual intelligence, and knowledge of and skills in safe, informed sets and settings.

Self-awareness of power dynamics and the ability to self-reflect are important when supporting the sense of safety felt by participants from underrepresented populations. This is in addition to the guide’s self-care skills and an adoption of and acting within guidelines in relevant ethical codes.

The Code of Ethics for Spiritual Guides from the CSP is a milestone in the crucial period of the FDA’s agreement for psychedelic research to begin anew in the 1990s. It has nine foci: intention, serving society, serving individuals, competence, integrity, quiet presence, not for profit, tolerance, and peer review.

Cooper (2014) and her team adapted the CSP code and professional codes for the Usona Guide Manual for an FDA-approved study on the pharmacokinetics of psilocybin, and the Interprofessional Professionalism Collaborative created a list of values and ethical behaviors for use in multi-disciplinary care-giving teams in medical settings.

Competency 6: Proficiency in Complementary Techniques

A toolbox of complementary therapeutic methods is used by guides in various phases of the therapy and research, including stress inoculation, therapeutic body work, and touch, eye-gazing, felt sensing and focusing, and somatic experiencing and sensorimotor therapies.

Psychedelic therapists use guided affective imagery, meditation, psychoanalysis, the Bonny Method of Guide Imagery and Music, expressive arts therapy, logotherapy, existential and narrative therapy, posthypnotic suggestions, hakomi, gestalt, voice dialogue and psychosynthesis, and shadow work.

Horizons of Psychedelic Therapist Training

There is a consensus that therapists, clergy, and medical professionals should be trained in psychedelic-assisted psychotherapy. Further evidence of the need for skilled therapists, clergy, and medical professionals can be found in the 2015 national survey data that 1.2 million people over age 12 reported taking a hallucinogen in the past month.

Academic professional programs in psychedelic therapy and research provide training in the six therapist competencies and include didactic, practical, and experiential training. Senior Heffter researchers conduct the training for new medical teams receiving Heffter funding for psychedelic research.

The Usona Institute has created a thorough and astute Guide Manual for training therapists in research on the pharmacokinetics of psilocybin, and the CIIS has pioneered the first academically accredited certificate program in Psychedelic-Assisted Therapy and Research for training clergy, medical, and mental health credentialed professionals.

Twelve Domains of Training in Psychedelic-Assisted Therapy

The 12 domains of study for training in psychedelic-assisted psychotherapy are: scientific foundation, clinical psychology, clinical social work, marriage and family therapy, pastoral counseling, and ethics. These domains enhance the development of several of the six therapist guide competencies.

Psychedelic-assisted therapy is based on the use of psychoactive drugs. It is also used in combination with other therapeutic techniques.

Co-therapy methods, interprofessional skills, current models of consciousness, ceremonial use of psychedelics, individual and group clinical supervision, and personal experience of being guided.

In the absence of or as an adjunct to the legal use of psychedelics, training programs can improvise many sources of inductions of nonordinary, alternate states of consciousness in their curriculum, including Holotropic Breathwork, drumming and rattling inductions, solo wilderness journeys, isolation tank immersion, prolonged meditation retreats, and work in harm reduction or medical centers.

The established training programs of Heffter, MAPS, GTT and CIIS have much to teach us about how to educate trainees in these 12 areas of study and how to evaluate a training program’s effectiveness.

Renewed Psychedelic Therapy Training Conversations

As more training programs are developed for therapist guides, these six core therapist guide competencies will be essential in the expansion into areas of new research designs, clinical methods, and pastoral care in medical and community-based centers.

There is no doubt that the most interesting work will be done by therapists who will utilize and adapt wisdom from the analytically-oriented, psycholytic research and from the more humanistic, client-centered frames of current clinical trials.

Conclusions

Psychedelic-assisted psychotherapy can increase capacities for coping and making meaning, increase empathy, lessen anxiety and other symptomologies, evoke life-affirming transpersonal/mystical experiences, and enhance the quality of life. However, therapist effectiveness and competence variables have not been a contender as an area of focus in double-blind clinical trials.

This review has compiled and elucidated identifiable trends in terms of 6 core competencies, 12 curricular domains of study, and guidelines for therapist training. This work is important because freedom of religion and spiritual practices utilizing psychedelics has been suppressed in the United States.