Assessment

Assessment in the context of psychedelic-assisted therapy is primarily concerned with safety, risk, and harm reduction. As a regulated or unregulated health professional, you may or may not be directly involved in assessment. However, from a harm reduction perspective, it is essential to address safety, and discern whether it is within your scope to be working with this client, and the degree of risk to the client taking these medicines.

Note

As a harm-reduction health professional, your role is to help ensure the client is as safe as possible and to minimize risks associated with non-clinical ingestion and procedures. It is not within your role to suggest, condone, or recommend illegal use of these substances.

Those who have a professional designation will be expected to engage in formal assessment and record keeping as per their clinical practice and governing body.

Health Professional Tip

How should I assess a client’s preparedness for psychedelic-assisted therapy?

A central principle guiding assessment is to determine the degree to which the client has psychological flexibility and stability, tools for managing dysregulation, and a willingness to be with what arises internally and externally (environmentally and interpersonally).

You are trying to assess the following:

  • Is it relatively safe for the client to do this work?

  • Is the person stable and/or in remission from a mental health or other medical condition?

  • Is the person ready and do they have the tools for psychedelic work?

  • Do they understand the potential risks?

  • Does the client have the resources (internal/external) and ability to manage triggers?

  • Do they understand that their mental and emotional states and interactions with the environment may be significantly disrupted, requiring significant integration work?

  • Do the client’s psychosocial circumstances support this work? For example, do they have a support network, relatively stable employment, and/or housing?

Key Considerations for Assessment

When determining the eligibility of your client for psychedelic-assisted therapy, consider the client’s set, the setting of the therapy, contraindications, consent, client expectations, and a support strategy for the client after therapy finishes.

Please ensure that you read through all items before proceeding by selecting each title.

Contraindications

The relative and absolute contraindications will depend on the medicine that is being used. Some typical contraindications include medications and supplement interactions, past or present mental health conditions (whether formally or self-diagnosed), and a history of relational trauma or adverse childhood experiences. Health professionals should also consider how the client manages or has managed any of these conditions.

Social Suports

Outside of the therapeutic relationship, clients should have social supports in place to assist them during and after psychedelic-assisted therapy. Ongoing support is crucial to the success of this therapeutic modality.

Sufficient social supports include:

  • A support network - family, friends, therapist etc.
  • Meaningful work or volunteer activities
  • Accessible internal resources

Managing Client Expectations

The client should identify realistic, yet hopeful expectations. For example, the client should not anticipate a long-standing chronic condition to disappear in one or two sessions, if at all.

Informed Consent

Part of planning the psychedelic journey includes ensuring that the client is fully informed regarding the process and potential adverse effects. They should also be aware that these may be part of the process.

Later in the course, we will learn about some ways to ask for informed consent.

Set and Setting

within a scientific research setting in the 1950s and 1960s, the importance of psychological and environmental factors was quickly appreciated, known as set and setting or known together as context (Leary, 1961).

Video: What is Set and Setting?

11:19

In this video, Dr. Joe Flanders explains what we mean by set and setting.

Set

Set refers to the client’s internal environment and state. This can be influenced by

  • Current circumstances influencing wellbeing: environment, social, financial, work, physical, mental health, and others.
  • Internal resources: capacity and ability to manage, turn toward and regulate challenging mind and mood states
  • Intentions or goals for the process
  • Coachability and willingness: to be actively engaged, accountable and take responsibility for their therapeutic work. Understanding that this is an active and engaged process is essential.
  • Timing: Does the client have the availability and support to manage dysregulated states and for their life to be potentially disrupted? The Perceived Stress Scale may be a helpful tool to explore their threshold for increased stress.
  • Experiential avoidance (desperation) - Commonly the client’s unconscious or undisclosed intention is that they want the suffering to be eliminated and don’t understand that these medicines can be catalytic but are neither a panacea nor a quick fix. They do not realize that paradoxically wanting to get rid of a state may make it worse.

Setting

The setting is the physical environment and container for the psychedelic experience. Components of the setting include:

  • Facilitator: Level of experience and personal fit for the client
  • Space: Group versus individual therapy - what setting would be optimal for the client?
  • Length of time: retreat (multiple experiences) versus one-day session
  • Safety assessment - what medicine might work well for their presenting concerns and intentions (e.g. MDMA versus Ayahuasca for PTSD)

Additional Factors for Readiness

When a client’s current personal condition or life circumstances makes this an inappropriate time to engage with psychedelics, the following may support them:

  • Therapy - increasing skills (insight, mindfulness, somatic awareness, cognitive/emotional awareness, behavioural) and increasing window of tolerance
  • Increasing their support network
  • Developing some practices and tools for self-regulation or managing triggers
  • Breathwork as an alternative to psychedelics

In order to be eligible for psychedelic-assisted therapy, clients should have:

  • Tools, practices, and frameworks that facilitate turning toward, staying with or exposure to what is occurring versus engaging in avoidance
  • Previous experience with psychotherapy or other personal work
  • Openness to collaboration with and feedback from the health professional
  • Subjective experience of readiness and enough stability

Resource

Consider downloading this Assessment Quick Reference to help guide you through the key components of assessment from a harm reduction approach.

References

Johnson, M., Richards, W., & Griffiths, R. (2008). Human hallucinogen research: guidelines for safety. Journal of Psychopharmacology, 22(6). 603-620.

Leary, T. (1961, September 6). Drugs, Set, and Suggestibility [Paper presentation]. 1961 American Psychological Association annual meeting.

Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., ... & Doblin, R. (2021). MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine, 27(6), 1025-1033.

Romeo, B., Hermand, M., Petillion, A., Karila, L., & Benyamina A. (2021). Clinical and biological predictors of psychedelic response in the treatment of psychiatric and addictive disorders: A systematic review. Journal of Psychiatric Research, 137. 273-282.

Silveira, J., & Rockman, P. (2021). Managing Uncertainty in Mental Health Care. Oxford University Press.