By Samuel Hatfield
Psilocybin and MDMA were recently rescheduled in Australia for clinical use, leading many mental health professionals to question how psychedelic therapy will work in practice. As part of a research team at the University of Sydney, I recently interviewed as number of experts in the field, with the aim of developing a comprehensive taxonomy of matters relating to psychedelic therapy that are or could be regulated. We also sought to identify where there was uncertainty or disagreement about the implementation of these matters. One point of contention was the provision of ongoing psychotherapy by the psychedelic therapist beyond the formal integration phase — which, given the vulnerability and suggestibility of patients undergoing psychedelic therapy, may give rise to important ethical considerations. With practitioners from a range of professions likely to act in the role of psychedelic therapist, this is an issue with cross-disciplinary relevance.
In most modern clinical trials of psychedelic therapy, the post-dosing integration phase usually consists of a set number and schedule of psychotherapy sessions delivered by the lead psychedelic therapist. Integration therapy is said to provide an opportunity for the patient to revisit and perhaps reconceptualize their psychedelic experience, to relate it to any intentions or therapeutic goals set during the preparatory phase, and to devise strategies to incorporate any newfound insights to their daily lives so as to maximize the therapy’s putative benefits.
Notably, there is scant evidence that points toward any particular type, amount or frequency of integration therapy to maximize efficacy or safety, or even that integration therapy is required at all. Nonetheless, it is widely held that integration is key to the therapeutic process, with many holding it is the most important component for achieving sustained treatment success. Given it has formed part of all modern trials, it seems that, for at least the immediately foreseeable future, the inclusion of integration psychotherapy in some form is likely to be considered a professional obligation, if not mandated by regulatory standards.
Among the interviewees who participated in our study, it was relatively uncontentious that greater flexibility in relation to the integration sessions should be accommodated in a real-world clinical setting, particularly when it came to scheduling variables such as dates, location, and perhaps even the precise number of sessions. It was also generally thought that ongoing psychotherapeutic support beyond the formal integration sessions was highly desirable, and that standard referral/handover mechanism (preferably to a psychologist or counsellor with a pre-established relationship with the patient) should be an essential part of the post-treatment discharge process.
However, divergent opinions surfaced regarding whether continuing psychotherapy could (or perhaps ideally should) be continued with the same lead therapist who delivered the integration therapy. Some contended that this arrangement could potentially yield greater therapeutic effects in terms of deeper insights and sustained personal transformation. However, others were concerned that such an approach might unacceptably blur the well-defined therapeutic boundaries established by the structured therapy protocols. Additionally, there were apprehensions as to whether such an arrangement might constitute a conflict of interest, particularly if patients were directed to a therapist’s private practice outside the clinic or hospital where the psychedelic therapy took place.
Some experts took a middle path, suggesting that it might be appropriate and desirable for a subset of patients to receive ongoing support from the lead therapist, but that this would require careful consideration and supervisory input. They felt the potential conflict of interest could be appropriately managed through open disclosure of this referral option at an early stage (prior to dosing), noting that other medical specialists routinely refer hospital patients to their own private consultation practice after hospital treatment.
Given the vulnerability and suggestibility often induced by psychedelics, we suggest that a higher threshold of caution should be exercised, and that it would not be appropriate for a psychedelic therapist to routinely self-refer patients to their own private practice. However, we would also not want unnecessarily rigid rules to preclude patients from accessing enhanced care, and believe there might be a case for ongoing psychotherapy by the lead therapist in some circumstances, as long as there was sufficiently independent input and oversight. This might include seeking a second opinion, providing patients with a range of referral options (including to alternative psychotherapists), and documenting the steps taken to ensure a patient was not unduly persuaded into any arrangement.
As with much of what we currently view as “standard” practice in psychedelic therapy, decisions about what is appropriate in the conduct of the psychotherapy are currently being made based on consensus opinion and professional judgment. The evidence base for a wide range of clinical variables simply does not yet exist and will take many more years to properly accumulate. While some issues are somewhat analogous to those in other clinical practices, there are particularly unique qualities of psychedelic therapy that often make these issues more salient or problematic. Self-referral for further psychotherapy beyond the scheduled integration sessions is a case in point: in other contexts the same ethical considerations may not be so significant (think of hospital doctors who routinely refer inpatients back to their own private consulting practice for follow-up) — but in the context of the highly suggestible state induced by the psychedelic experience, the ethics of this practice become more acute. There is an intuitive belief that there must be a tight perimeter around the psychedelic therapy experience, so as to facilitate the putatively therapeutic effects of that very suggestibility while also protecting the patient against the risks this entails. Perhaps standing in the long shadow of the first psychedelic wave, we fear the consequences of stepping outside that boundary. It remains an open question whether that fear is well-placed.
Samuel Hatfield is a former practicing lawyer, has worked for the University of Melbourne, and is currently completing the Sydney Medical Program at the University of Sydney.
