Ethics in Psychedelic-Assisted Therapy
Ethics are crucial in healthcare as they serve as a framework to ensure the safety and wellbeing of clients, which ultimately fosters therapeutic alliance and trust.
Within the field of psychedelic-assisted therapy, there are some additional nuances to ethics due to the high suggestibility of clients under the effects of the medicine and the close relationship developed between clients and health professionals.
Activity
At Numinus, many of our courses use cases to help learners apply what they've learned in class to a realistic scenario. Experiential learning is woven throughout our certification pathway as well.
Using what you've learned so far, read the following case study and try to brainstorm what key ethical consideraitons may be important for a therapist to consider?
Note: the themes of this case may be activating for some people. Please take care to progress through the content at your own pace, take breaks, and chat with a trusted support person as needed.
Meet the Therapist
This therapist is masters-educated, heterosexual, and non-religious but spiritual. She's female and grew up in, went to school in, and continues to live in a predominately white western state in the United States.
Meet the Client
Black, female identified, single heterosexual, Christian client with diagnosis of anxiety and history of physical abuse while growing up in a Southern United States state in poverty. Client states she has nine older siblings, some of whom are doing “well”, some are in prison, and some are struggling with addiction.
The client is coming to see you for prep, dosing (not sure what medicine works best for this client), and integration for her anxiety.
Preparation Session
During Preparation, the therapist and client establish rapport. The client hints at traumatic childhood, experiencing current day micro-aggressions from white authority figures at work, during interactions with the medical community, from the mother of her white wealthy partner, and generally while living in her current community. She expresses that she is dating two people: a white extremely wealthy yet controlling, non-religious male (Andrew) and a black, working-class man who deeply identifies with his Christian black community (Marcus). The client expresses confusion about who she really wants to date and eventually marry. She states she loves to sing, especially hymns and that singing hymns helped her survive her childhood.
Medicine Session
About 1 hour into the dosing session, the client pulls up her eye shades, takes off her headphones and states “You white people have the worst taste in Music”. The therapist asks the client to bring curiosity to why she is struggling with the music. She resists this suggestion and during a back and forth between the client and therapist: the client crosses her arms, her shoulders tense and rise up to her ears, and eventually a grimace appears on her face.
After about 5 minutes, the client agrees to try and listen to the music again.
After about 10 minutes of going inward, the client assertively states “you are not hearing me, this music is by and for white people only. I dare you to look up the skin color of these artists”. At this point, the therapist agrees to let the client choose her own music. With the new music list the client then gets up, sings and dances – expresses joy.
After about an hour, the client is still enjoying her music, singing and dancing, a young white MD knocks on the door, the therapist lets him in without telling the client. Although the client had met the MD previously and had been told he would be doing a medical exam that afternoon, the client jumps and looks scared as soon as she sees him. She expresses surprise and then anger at the doctor for interrupting her experience for his own needs. The doctor apologizes, and the client hesitantly complies with the medical evaluation.
The therapist notices she looks very scared and guarded, again crossing her arms with eye contact down and away from the MD and the therapist. During the exam, the white MD stands over her while she is seated. He touches her appropriately, as required; the therapist notices that the client jumps and recoils from the touch.
After the MD leaves, the client engages again with the therapist: asking her, who she should date and maybe marry, Andrew or Marcus? The therapist decides to get engaged because she does not want to get into another power struggle like the one she had with the client over the music and she does not want to upset the client after seeing her anger and recoil from the MD. The therapist asks the client questions about who she feels safer and more comfortable with, with whom she can be her true self, how her emotions show up in her body, thoughts, and emotions when she is with each partner.
At the end of a long day, as the client is preparing to leave, she expresses her confusion about which man to date and the therapists whispers in her ear so no one else in the room can hear: “it sounds to me that you and Marcus have a safer more comfortable relationship”.
Ethical Considerations
Some areas of this case that need improvement include:
- The therapist not considering how race and culture may be an important part of the client's setting while under the effects of the medicine
- The therapist selected music that brought up negative emotions for the client
- The MD came into the room unannounced while the client was under the effects of the medicine
- The physical positioning of the MD in the room
- The therapist participated in a major life decision while the client was still coming down from their dose
What are some of your key takeaways from this case? Jot them down in your notes.
References
Barber, G. S., & Dike, C. C. (2023). Ethical and Practical Considerations for the Use of Psychedelics in Psychiatry. Psychiatric Services, 74(8), 838-846.
Pilecki, B., Luoma, J. B., Bathje, G. J., Rhea, J., & Fraguada Narloch, V. (2021). Ethical and legal issues in psychedelic harm reduction and integration therapy. Harm Reduction Journal, 18, 40.