May 3, 2023
Abstract: The use of psychedelics in therapy may benefit both the client and the facilitator, and there is a debate about whether facilitators should have personal experience with the substance. While some traditions expect the facilitator to partake in the same dose as the participants, modern medicine expects the facilitator to remain sober. Facilitator sobriety is important to attend to the risks associated with psychedelic use, while communal use of the substance may increase empathy and compassion. Further research is needed to determine the circumstances in which facilitator sobriety or communal use is appropriate.
Psychedelics1 are part of a special class of drugs in which it can be beneficial for both the client and the facilitator to partake. This differs sharply from many allopathic drugs. For example, it would be absurd for a doctor to self-administer a course of antibiotics to herself in preparation to prescribe antibiotics to treat a bacterial infection in a patient. Psychedelics are different, and this is reflected in how we talk about their subjective experience. We talk about a psychedelic journey or trip as if we are going on a visit to a historical site like the Taj Mahal. Just as we have tour guides or docents for historical sites or museums, there is a growing conversation about whether facilitators who work with psychedelics should have personal experience with the substance, and how much experience. In modern medicine, there are mainly two different traditions: Psychedelic-assisted psychotherapy training programs often include an experiential learning component (i.e., a medicine use practicum) while training programs for psychiatrists often do not.2 In both cases, however, the facilitator is expected to remain sober during an administration session with a client.3
Psychiatry is one extreme, keeping medicine at arms length. At the other extreme, in many ayahuasca ceremonies and the Santo Daime, the facilitator is not merely expected to have experienced the medicine in the past, but is expected to take approximately the same dose of the medicine as other participants. If not working as volunteers, are facilitators getting paid to get high? In my opinion, this question belies a false premise. Whether paid or unpaid, a therapist’s job includes remaining level-headed, observing subtle cues from the client, closely monitoring reactions to the projections of the client (i.e. countertransference), and remaining relatively free of distraction from the therapist’s own internal material. Why should these responsibilities be suspended as the facilitator journeys through an altered state? This may seem like a high bar given the dire shortage of skilled psychedelic facilitators, but it is worth discussing the aspirations of our field. For example, Zendo and the Fireside Project are admirable, but we can aspire to offer trippers more than peer support by sober, supportive volunteers who listen from a place of non-judgment.
In the Santo Daime, guardians fully partake and are trained to simultaneously provide peer support. A similar kind of community peer support was envisioned in Jon Dennis’s Community Practitioner Framework proposal. In an altered state, a facilitator is regarded as best able to guide the journey in the same way that a museum tour is best conducted by a docent who is fully present and participating. Perhaps one reason for this arrangement is that serotonergic psychedelics increase empathy and compassion.4 A sober facilitator may be felt by the client as out-of-step with the psychedelic journey, hindering the client’s engrossment in the experience and overall comfort.
On the other hand, facilitator sobriety is more important when there is heightened probability of an emergency that is not of the emotional nature. For example, a 2009 MAPS protocol for a clinical trial with psilocybin allowed for the administration of intravenous lorazepam (1 - 3 mg) in the event that extreme acute anxiety cannot be addressed by verbal support and reassurance. The same protocol also anticipated the possibility of unspecified adverse events, such as stroke or heart attack, that may or may not be related to psychedelic use.5 These risks are well understood. In comparison, researchers are just beginning to understand how serotonergic psychedelics affect empathy. It makes sense to attend to the risks that we understand best. However, it would be an act of hubris to be confident of our choice. The probability of serious adverse events is low6 while the empathic drag of a sober facilitator may be a constant detriment on each and every journey. More research is needed. It may be the case that sobriety is indicated in some circumstances while the empathy gained by the communal use of the psychedelic is superior in other circumstances. Of course it is not always necessary to choose one or the other. With a lavish budget, a medical professional could be stationed nearby, but outside of the administration room, ready to leap into action. However, I suggest that extra medical staff should usually be regarded as a luxury, not as an ethical imperative.
Aday, J. S., Skiles, Z., Eaton, N., Fredenburg, L., Pleet, M., Mantia, J., … & Woolley, J. D. (2023). Personal Psychedelic Use Is Common Among a Sample of Psychedelic Therapists: Implications for Research and Practice. Psychedelic Medicine, 1(1), 27-37. ↩︎
There is no dispute that this is the correct approach for substances like MDMA, which must be used sparingly due to neurotoxicity, intravenous ketamine infusion, which requires supervision by a physician or registered nurse, or Ibogaine, which causes ataxia. ↩︎
Pokorny, T., Preller, K. H., Kometer, M., Dziobek, I., & Vollenweider, F. X. (2017). Effect of psilocybin on empathy and moral decision-making. International Journal of Neuropsychopharmacology, 20(9), 747-757. ↩︎
Kumar, S., Mithoefer, M., Mojeiko, V., & Doblin, R. (2009). Psilocybin-assisted psychotherapy in the management of anxiety associated with stage IV Melanoma. Clinical Trials. gov). Retrieved from http://www.clinicaltrials.gov/ct2/show/study/NCT00979693 ↩︎
Breeksema, J. J., Kuin, B. W., Kamphuis, J., van den Brink, W., Vermetten, E., & Schoevers, R. A. (2022). Adverse events in clinical treatments with serotonergic psychedelics and MDMA: A mixed-methods systematic review. Journal of Psychopharmacology, 36(10), 1100-1117. ↩︎