Therapeutic Stance

Inner-directed therapy requires the health professional to relax into uncertainty of what is unfolding, or about to unfold, within a client’s present moment process in psychedelic-assisted therapy, and to support this appropriately. Needs and opportunities for healing and learning are met skilfully as they arise emergently, rather than through a pre-planned health professional-directed process. This therapeutic stance was first introduced formally as “Non-Directive Therapy” into the psychedelic field by MAPS and later recoined as “Inner-Directed Therapy.” This stance is encompassed within mindfulness-based and embodiment-oriented psychotherapeutic modalities which is why a background in such modalities is considered an asset for training as a psychedelic health professional.

Unconditional positive regard, coined by humanist psychologist Carl Rogers, involves showing abiding recognition of a person’s inherent human worth irrespective of the person’s espoused values and actions. Rogers (1942) asserts that when one is fully acknowledged and supported as they are, without judgment, resistance to change lessens. With less resistance, one can more readily step into the change process. Any health professional judgement of a client’s behaviours or emotions as ”good” or ”bad” are not to impinge on positive regard for the person of the client.

Agapic love is something that is often encountered in psychedelic experiences, (Phelps, 2017) and can be a mutual experience within the intersubjective field of the health professional and client. It is important for health professionals to have lived experiences with agapic love to be able to empathically resonate and meet a client in that state and to be comfortable experiencing this natural human state within frameworks of professionalism.

Agape

Altruistic and selfless love

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Eros

Sexual love or desire

The notion of agape is often confused with eros. In Buddhism, a form of agapic love is described by metta. Considered an ‘immeasureable’ and boundless quality, it is the opposite of clinging and attachment and facilitates the expansion one’s capacity for experience, eventually transforming into wisdom. Agape and metta contain the wish for everyone, everywhere, to have happiness and freedom and to be free of suffering and its causes. As health professionals holding space for healing and relief of suffering of our clients, we might look to what can be learned through these ancient traditions and spiritual practices as we begin to open once more to the presence and power of love in our personal healing and growth and the healing work we participate in with our clients.

Empathetic abiding presence refers to an unwavering, unconditional, and attuned whole-person practice of being with someone in a way they can feel and trust and into which they can yield and receive support and care just as they are (Phelps, 2017).

Components of empathetic abiding presence include evenly suspended attention, mindfulness, empathetic listening, “doing by non-doing,” and responding to distress with calmness and equanimity.

Being physiologically and energetically grounded, self-regulated, and aligned is essential when working with individuals in altered states of consciousness and with those who have experienced significant traumatic stress. It requires a well-honed capacity to self-monitor and consciously modulate one’s nervous system, emotional state, and mental formations at will. It also supports the open, non-judgmental stance of empathetic abiding presence.

Therapeutically, a phenomenological orientation concerns itself with unfolding the subjective “inner” experience of the client, including their thoughts, emotions, body sensations, behaviours, or impulses to act. This orientation is fundamental to mindfulness- and somatic-based therapeutic modalities as well as being complementary to inner directed therapy.

A therapeutic stance grounded in relationship-centered care is based in mutual self-inquiry, shared understanding, and collaboration. Attention to the quality of the therapeutic relationship is always prioritized with an understanding that desired therapeutic outcomes will naturally follow, in keeping with the contextual model of psychotherapy. Relationship-centered care acknowledges that quality care happens when there are strong reciprocal and interdependent relationships among everyone involved in care (APA, 2019; DeAngelis, 2019; Soklaridis et al., 2016; Murphy et al., 2022).

Appreciation for human suffering acknowledges that suffering exists, that it is subjective, and that all people experience it to some degree (Cooper, 2016).

Compassion is the ability to suffer with another, not by pretending to know their unique suffering, but rather by turning toward the other as they contact painful experience and empathically resonating with them as they do. Many clients presenting for deep healing work did not experience caring adults holding them through painful experiences in childhood. True compassionate presence, made possible through appreciation for human suffering, is an aspect of the healing potential of the therapeutic relationship.

Psychedelic experiences can open deeply painful content and attending emotions that clients had hitherto avoided or repressed. In alignment with inner-directed therapy, health professionals are reminded to trust the client’s inner healing process during such moments, to refrain from attempting to ‘help’ by removing or palliating their experience, and to instead encourage them to lean into the experience while providing skillful and loving support.

Health professionals self-awareness, long-identified as a critical component of psychotherapy (Mattison, 2000; Strong, 1970; Uhlemann & Jordan, 2012; Ehrlich, 2001), involves self-knowledge or self-insight and emphasizes the importance of knowing one's own issues, biases, strengths, and weaknesses. Health professionals self-awareness has been shown to be inherently positive (Coster & Schwebel, 1997), necessary for ethical practice (Rubin & Amir, 2000), and critical for skilful psychotherapeutic work (Edwards & Bess, 1998).

Due to the unique ethical risks of psychedelic-assisted therapy, self-awareness demands particular emphasis as an element of therapeutic stance for psychedelic-assisted therapy health professionals: knowing oneself and maintaining curiosity and healthy vigilance toward oneself must be a prioritized personal value to engage in this work. Self-awareness includes investigating and challenging one’s implicit biases, understanding one's motives for providing psychedelic-assisted therapy, maintaining appropriate boundaries with participants, establishing a strong and trustworthy therapeutic alliance, and appropriately identifying and managing countertransference.

Using the model of the brain as a hierarchical information processor, top-down or long-route processing versus bottom-up or short-route processing refers to the area (or level) of the brain which is dominant in guiding the processing that is occurring.