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?

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