The Main Ethical Issues in Psychedelic Therapy

Progress is being made towards making psychedelic therapy available to people experiencing various forms of mental distress. North America, in particular, is making significant progress: psilocybin therapy for certain conditions is available in Canada and the state of Oregon, the number of ketamine clinics in the US is estimated to be anywhere between 500 and 750, and the US could soon legalize MDMA therapy. 

Despite some setbacks in the field of psychedelic therapy, the desire for psychedelic therapy remains strong and global. The liberalization of laws regarding it, and the subsequent opening of related clinics, means that this form of treatment will soon become available to many people struggling with (often severe) emotional distress.

However, the push to legalize psychedelic therapy cannot be wisely done without consideration of ethical practice. Many in the field worry that this is being neglected. Without proper consideration of ethics in psychedelic therapy, patients will be exposed to risks that are unique to psychedelics. The ethical issues involved in this type of treatment are, therefore, also unique. Let’s outline the main concerns that many in the industry have.

A Lack of Aftercare and Integration

The writer and researcher Jules Evans has raised concerns about how there is “practically zero” investment in protecting people who undergo psychedelic therapy. There is a lot of investment in clinics, PR, and public affairs, but little in aftercare and integration. Evans warns that this lack of support means that people who experience psychological difficulties after a psychedelic session could suffer unnecessarily. He writes:

“Investing in a proper infrastructure of integration could mean psychedelic companies and research labs committing at least 1% of their capital to integration research and services, particularly for difficult experiences. If the psychedelic market is worth roughly $5 billion, that means investing 1% — $50 million — in support for and protection against negative side effects.”

He suggests that this $50 million could go towards:

Therapists Imposing Beliefs on Patients

One ethical issue that can arise in psychedelic therapy sessions themselves is therapists imposing beliefs on clients. This risk is heightened due to the fact that psychedelics enhance people’s suggestibility. In an article for ACS Pharmacology & Translational Science, the psychedelic researcher Matthew Johnson raised concerns about psychedelic investigators and clinicians inappropriately expressing their religious or spiritual beliefs during sessions. He notes:

“Just as with the practice of secular clinical psychology or psychiatry, a patient can certainly bring up religious beliefs and concepts in therapeutic discussion, e.g., Buddha, Christ, kundalini, and plant spirits, but it is not the role of the clinician or scientists to introduce such concepts.”

Johnson also argues that “scientists and clinicians should not include religious icons in the session room or other clinical space”. He adds:

“It has unfortunately become fashionable and commonplace for statues of Buddha to be present in psychedelic session treatment rooms…. [T]he introduction of such religious icons into clinical practice unnecessarily alienates some people from psychedelic medicine, e.g., atheists, Christians, and Muslims. It will ultimately interfere with the mainstream adoption of these treatments”.

Violations of Patient Autonomy

The therapist-client relationship can involve other risks. As already stated, psychedelics can enhance suggestibility. This not only makes it easier for therapists to impose beliefs on patients, but it also means therapists could potentially control psychedelic sessions how they see fit. This might involve forcing their interpretation of what certain subjective effects mean. This can occur not just during the session itself but also during the preparation and integration stages. In addition, a therapist might try to steer a psychedelic experience in a particular direction (rather than simply encouraging clients to ‘let go’ and accept the trajectory of their experience).

When patients aren’t given the freedom to explore what their experiences mean to them, it can be considered a violation of patient autonomy. On the other hand, input from therapists can often be key to helping clients clarify and integrate insights or confusing experiences. Moreover, many psychedelic therapists apply a particular approach to psychotherapy (e.g. cognitive-behavioral, somatic, mindfulness-based, psychoanalytic, Jungian, existential, etc.)

Many clinical trials, as a paper in Frontiers in Psychology points out, have sought to use a “non-directive, non-judgmental and empathetic approach to therapy.” The fundamental idea here is to recruit the patient’s ‘inner healing intelligence’, i.e. their innate ability to heal their emotional wounds. This non-directive kind of therapy is maintained during the integration phase and while the therapist’s interpretations are allowed, it is recommended that they are minimized. Many see this approach as the best way to respect a patient’s autonomy.

Gaining Informed Consent

Informed consent in psychedelic therapy has been another contentious issue. The effects of psychedelics can be unpredictable. The nature and prevalence of risks, as well as how to best treat extended difficulties, is uncertain at this stage. It is also possible that the experience will create rapid, significant, and lasting changes in someone’s personality or metaphysical beliefs. All of this makes gaining informed consent tricky. 

The researcher Edward Jacobs is currently exploring this very topic. In a paper published in Frontiers in Psychology, he argues that “the idealized [emphasis added] conception of meaningfully informed consent” cannot be obtained. This is because:

“of two features of the psychedelic experience: first, the epistemically transformative nature of the acute drug effects, which can be of so radically different a nature to previous experience as to be fully comprehensible only by experiencing it. More crucially, clinical evidence supports the thesis that PAP [psychedelic-assisted psychotherapy] can be of a personally transformative nature.”

However, this doesn’t mean such a treatment cannot be consented to, nor does it mean that psychedelic practitioners are being deceptive or coercive when offering treatments. Someone can still voluntarily choose to have a mysterious, ineffable, and potentially transformative experience, even if this potential “makes truly informed consent impossible.” Furthermore, Jacobs believes that though informed consent is central to contemporary medicine, psychedelic therapy can still be practiced ethically with a non-standard form – or lower threshold – of consent in place.

William R. Smith and Dominic Sisti have proposed that an ‘enhanced consent process’ can be applied to psychedelic therapy. This involves discussing with clients some of the possible changes that may occur during or after treatment, such as ego dissolution, interconnectedness, unity, a deeper connection with nature, or becoming more spiritual. Patients should ultimately be made aware that they could have one of the most meaningful experiences of their lives, and that this is not always experienced positively.

Transgressing Professional Boundaries and Sexual Abuse

The possibility of psychedelic therapists transgressing professional and sexual boundaries is of particular concern to many in the field. This issue became much more widely discussed after footage from a 2015 clinical trial of MDMA therapy for PTSD emerged, showing therapists spooning and pinning down trial participant Meaghan Buisson.

MAPS, the organization that ran the study, issued a statement in 2019 – after Buisson went public about allegations of sexual assault – acknowledging that the therapist, Richard Yensen, had an “inappropriate and unethical” sexual relationship with her while she was enrolled in the clinical trial.

The problem of sexual abuse in psychotherapy is not a new one. However, since psychedelics can put someone in a vulnerable and suggestible state – and a highly trusting state in the case of MDMA – this further increases the risk of sexual transgression. This requires unique solutions (such as having two therapists not of the same gender present during the session). 

More attention is being paid to setting and respecting sexual boundaries in psychedelic therapy and how best to approach the subject of non-sexual touch.

Biopiracy

Biopiracy is the practice of commercially exploiting biological materials (e.g. plants) and indigenous knowledge. And the growing psychedelic industry has been accused of doing precisely this. Patenting compounds that are found in nature and used by indigenous groups – without acknowledging, compensating, or giving back to indigenous communities – can be seen as a form of biopiracy. Marlena Robbins, an Indigenous member of the Diné (Navajo) Nation in Crystal, New Mexico, told The Daily Beast:

“Psychedelics being the new gold rush for a lot of these corporations is limiting access for those who need it most: for communities of color, for Indigenous people, for BIPOC communities, and making it financially inaccessible.”

However, the negative effects of biopiracy are not an inevitable consequence of the psychedelic industry. As Robbins adds:

“I think that a psychedelic company can have indigenous reciprocity initiatives that help support the cross-cultural relationship between indigenous nations to share in culture and knowledge, and trade medicine and ceremony.”

One company respecting these concerns is Journey Colab, which wants to use psychedelics to treat addiction. It filed a patent for the use of lab-made mescaline in the treatment of alcohol abuse disorders. But in December 2022, the company published a patent non-assertion pledge, which is a commitment not to sue Indigenous communities or practitioners using peyote (they technically could do so for patent infringement). This was the first psychedelic company to make such a pledge.

As we have seen, the ethical issues involved in psychedelic therapy are varied – they relate to investment, therapist training, regulations, guidelines, and the ethos and practices of clinics. All of the above concerns need to be addressed to ensure that patient safety and well-being are respected. Ethics will ultimately be crucial to the success and viability of psychedelic therapy.