Psychedelic Ethics: How to Gain Consent in Psychedelic Therapy
Psychedelic experiences can be surprising, even for seasoned psychonauts. We can’t predict what a trip will be like. We also can’t predict if or how a psychedelic experience will change us. Any trip can be transformative, possibly changing how we view ourselves, our relationships, what we value, or how we think of reality as a whole.
Psychedelic therapy seeks to harness this transformative potential to help alleviate or resolve things like depression, anxiety, PTSD, and existential distress. But this same potential and unpredictability make getting (or giving) informed consent for psychedelic therapy less straightforward than for other therapies.
What is Informed Consent and Why is It Important?
Normally, for medical, psychiatric, or psychological interventions, doctors or therapists seek informed consent from their patients or clients before treating them. Informed consent is simply where a person fully understands what they are agreeing to. The flipside is that if you don’t understand what something will do to you, you can’t really agree to it.
Informed consent is important as it’s part of what helps protect autonomy – the principle that, within reason, people get to decide what happens to them. For patients, it means that they generally have the last word on interventions and cannot be treated or experimented on without their permission. This might seem obvious. But, prior to the mid-20th century, medical research had a dark history when it came to respecting autonomy and other human rights.
What is the Issue with Psychedelic Therapy?
“Psychedelic therapy” encompasses a range of therapeutic approaches. Some, like the LSD psycholytic therapy Cary Grant undertook, relied on lower doses. But modern psychedelic-assisted therapy (PAT) typically involves doses of psilocybin that produce full-blown psychedelic effects, involving profoundly mystical or visionary experiences or ego-dissolution (ego death). While MDMA-assisted therapy isn’t strictly psychedelic, patients can still experience radically altered emotional responses and thought patterns.
Exactly what these experiences are like can’t be predicted. And, unless you’ve had them before, they really can’t be understood. Will it be glowing and divine or dark and challenging?
More importantly, how this experience might change you can’t be predicted or understood beforehand. Maybe you’ll become more open, or more environmentally aware, or more spiritual and less religious. Or, if you’re unlucky, you’ll be in the estimated 20-30% of people that PAT doesn’t seem to significantly help.
Mind-blowing experiences or ongoing personality changes are things that we can’t truly understand what they’re like for us before they’ve happened. And yet, for psychedelic therapy, this is exactly what patients are asked to consent to.
This isn’t the whole story, though. There’s one more complication: touch.
Boundaries of Touch During Psychedelic Therapy
We know that touch is both essential and beneficial for people (or most of us, at least). But what about during psychedelic therapy?
One of the key debates around consent and psychedelic therapy is about touch between therapists and clients. Specifically, should therapists or other sitters/guides touch clients or offer touch during dosing sessions?
It’s not a huge surprise that psychedelic experiences for people undertaking PAT can be challenging. Even MDMA-assisted therapy can be tough, particularly for PTSD, as participants may re-experience events that trigger trauma responses. When these people show signs of distress, therapists supervising them may feel they should provide reassurance, including through appropriate non-sexual touch.
On that note, in my considered opinion, touch that’s sexual or even just strongly intimate should be off-limits for PAT. And it should never (ever) have any element of coercion. The kind of touch Richard Yensen and Donna Dryer deployed in the MAPS MDMA clinical trial is utterly unacceptable and is not what we’re talking about here.
The complication with consent, even for appropriate touch, is that it’s fluid and changeable. During preparation sessions, a client might agree that some touch is OK for them. But once they get into the experience, even appropriate touch from a therapist can feel invasive.
Under normal circumstances, a skilled therapist can make a better assessment of when a person will be OK with being touched. But someone in the peak of a therapeutic psilocybin or MDMA experience may not be able to express themselves clearly. Their cognitive and executive functions might be impacted in ways that alter their capacity for informed decision-making. They may also ask for contact that is inappropriate in a PAT context, e.g., contact that’s too intimate or overtly sexual.
Even if the therapist asks, “Is it OK if I place my hand on your arm?” and the client can voice a coherent answer, the combination of therapist/client power imbalance and psychedelic state means that a client could feel like they can’t say no, even if they wanted to.
A majority of practitioners in PAT settings consider appropriate touch to be positive, but this doesn’t extend to bodywork and especially not full-body contact. Research (currently in peer review) suggests that many PAT clients feel touch is valuable or positive, noting also that there isn’t yet much scientific investigation of whether touch is safe and effective in PAT.
So, just to throw another complication into the mix, not only is consent for touch during PAT complex, but there isn’t much scientific evidence to say if it’s beneficial or if a lack of touch at key points in the process is harmful. At this point in time, there is limited consensus between clinicians/researchers on what the best balance is. Influential pioneers, such as Michael Mithoefer in the MAPS MDMA therapy manual, advocate for a more permissive attitude to touch that includes focused bodywork, where therapists provide “resistance for the participant to push against”. Alternatively, some contemporary researchers like Neşe Devenot are in favour of a more precautionary approach, arguing that the basis of views like Mithoefer’s is more opinion-based than scientific.
How Can Psychedelic Therapists Gain Consent?
Despite all this, there are steps psychedelic therapists can take to be as diligent as possible in gaining consent from PAT clients, for both the therapy in general and for specific interventions like touch.
Enhanced Informed Consent
Discussion of unpredictability of experience and transformation should be part of the therapist-client conversation around consent during the preparation phase of the PAT treatment. You can’t get someone to imagine what they literally can’t imagine. But you can make them aware of the possibilities of what they might experience, how they might change, and the odds that the treatment will be successful. This process is typically longer and more involved than gaining informed consent for mainstream psychotherapy, taking place over multiple preparation sessions, rather than as a brief discussion during an initial session.Clinicians should be cautious regarding touch and always fully discuss all possibilities and boundaries with clients during preparation.
Checking in during integration, to ensure the client felt safe and that their autonomy was respected during their psychedelic experience, is also a good practice. If everything went well, it reinforces the experience. If the client feels that some aspect wasn’t in line with what they consented to, it creates the opportunity to address this sooner rather than later.
Ongoing Consent
Ongoing consent is the idea that consent is not a checkbox or one-and-done deal but is constantly renewed over time. Importantly, ongoing consent means that consent can change and can be withdrawn at any stage.For PAT, this means that a client can change their mind about pretty much anything they’ve consented to, at any stage of the process, though this is obviously limited by safety, professional boundaries and what’s possible (there isn’t much point in saying that you revoke consent to be tripping once the drug has kicked in).
In practical terms, this applies to things like touch. As a PAT client, you might have agreed that some touch was OK, but once you’re in the experience, you don’t feel that way. Ongoing consent means that therapists should respect this, even if you agreed to it during preparation.
Advanced Directives
All PAT involves some level of decision-making about how the dosing session will go before it happens. Some ethicists have suggested that preexisting agreements could be helpful for times when a client is unable to express what they need or want, much in the way advanced care directives are used in conventional medicine.I think an agreement that “touch is ok no matter what I say” would be unhelpful and potentially damaging. But agreements that set out the limits of things like touch and when it will be used, e.g., “if you seem distressed or you ask for it, we will place a hand on your forearm” or “we will only physically intervene for your own safety” are more likely to be helpful. If nothing else, they are a good place to start the discussion between therapists and clients.
On Touch: Considerations for Psychedelic Practice, a live collaborative document hosted by EPIC, includes examples of touch agreements that practitioners (clinical or otherwise) might find useful and informative.
Professional Boundaries
In order to protect client autonomy and well-being, PAT practitioners should have clear professional boundaries that prohibit inappropriate or unethical conduct at any point. For example, if a client asks for or attempts to initiate excessively intimate or sexual contact, the therapist will gently redirect them and, if appropriate, remind them that they agreed such behaviour was off-limits. (Boundaries work best with protocols to limit risk, such as therapeutic dyads, and where therapists have accountability to professional associations, but that’s a discussion for another day.)Consent is Key
If consent isn’t informed, it’s not really consent. And without consent, we can’t exercise autonomy and make our own decisions. Autonomy is fundamental to what it means to be human. But it’s also a key part of why access to psychedelics is important, because people should have the autonomy to decide what kind of experiences they have. When psychedelic therapy does informed consent well, it doesn’t just help keep patients safe, it affirms our humanity and the values that underpin resistance to the War on Drugs.
Samuel is one of our community bloggers here at Chemical Collective. If you’re interested in joining our blogging team and getting paid to write about subjects you’re passionate about, please reach out to Sam via email at [email protected]