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The Ethics and Importance of the Role of Therapists in Working in Non-Ordinary States

Psychedelics

We would like to say something about the ethics and importance of the role of therapists in working in non-ordinary states. Nigel has personally worked in this space for 35 years in various forms including many decades in Holotropic Breathwork. We are often working with patients or clients who carry with them deep personal trauma.

This trauma can manifest in many ways and can express in completely unexpected symptoms. In working with many survivors of complex trauma, including ritual abuse, clergy abuse, intra family abuse, cult abuse, warfare, and other crimes, it is so important that we as therapists and the staff that support therapists, keep a willing and open mind to people’s suffering.

The average report time from first crime to first report for survivors of Institutional sexual abuse, for instance, is 33 years. Often this abuse has been ignored or actively repressed. It is incumbent on us all to hold the importance of the voice of survivors and to give them our belief and support.

Working with non-ordinary states and medicines can raise many deeply buried issues and traumatic experiences can manifest from many different sources, some from biographical memories, others from other symbolic processes. Projection onto therapists in this space during and immediately after sessions is not uncommon. This is one reason why, consistent with world best practice, we recommend 2 therapists always be present during trial and special access sessions, and, when rescheduling occurs, therapy sessions.

It is important that we are making ourselves and our clients safe and maintaining the most ethical and clear containers to allow this work to unfold as we develop greater clinical knowledge and skill.

Therapists who do transgress boundaries and behave in an unethical manner should be appropriately managed under legal and professional codes. Therefore, it is important that anyone working in this field be registered in a professional governance system such as AHPRA or PACFA.

Transgressions against patients in this field, like all others, should not be tolerated or accepted. The only way to create healing is to build trust and safety for all. Working together, openly supporting ethical behaviour and outing all forms of abuse and those who collude with it, it imperative.

Warm regards,

Nigel Denning & Dr. Tra-ill Dowie

Directors, Mind Medicine Training and Education

Nigel Denning

MA, MPsych

Nigel Denning MA, MPsych is a Counselling Psychologist, AHPRA registered supervisor and Managing Director of Integrative Psychology a Psychology/Psychiatry practice in East Melbourne.  He is a former Family Violence Co-ordinator for Relationships Australia and is currently the Former Deputy President of the In Good Faith Foundation, an organisation that supports Institutional Abuse and cult survivors. Nigel is also a registered Neuro-psychotherapy supervisor with IAAN.

Nigel has been involved in Transpersonal Psychology and consciousness studies for over thirty years.  He has studied extensively under Stanislav Grof MD and worked closely with Tav Sparks and Grof Transpersonal Training to develop training approaches to Holotropic breathwork and therapy influenced by this modality. Nigel also conducted one of the few peer reviewed research studies on HB.

Nigel teaches and has presented at numerous national and international conferences on state change technology, including medicine work. Nigel also has an established practice in Tibet Bon Dzogchen meditation under the guidance of Dr Daniel Brown of Harvard Medical School.

Dr Tra-ill Dowie

PhD

Dr Tra-ill Dowie is the Head of the Faculty of Psychotherapy at Ikon Institute Australia. Dr Dowie is the Chair of the Australian Counselling Association (ACA) Panel for Trauma Standards & Practice. Dr Dowie is a practising psychotherapist, supervisor and public speaker. Dr Dowie’s academic life and public lectures cover a broad range of interdisciplinary topics that relate to the human condition: psychiatry, psychotherapy, trauma, continental philosophy, philosophy of mind, anthropology, health and wellbeing, and human optimisation. He holds dual PhDs, receiving a PhD in Psychiatry from Monash University and a PhD in Philosophy from the University of Melbourne.

Psychedelic Hedonism — The Ethics Of Psychedelic Therapy

Psychedelic trip

INTRODUCTION

Psychedelic-assisted psychotherapy is a novel approach to treating mental illness which has recently been (re)gaining significant public and scientific attention. Current clinical trials are demonstrating promising results which suggest that not only might these medicines be effective at treating a wide array of mental illnesses[1], but in some instances they might be more effective than currently available treatments[2]. However, despite the growing body of empirical work regarding the efficacy of psychedelic-assisted psychotherapy, the socio-cultural history of these compounds along with their unique psychological effects raises a host of normative ethical questions which need to be addressed to ensure that the return of psychedelics to western psychiatry is done in a responsible and ethically sound manner. “Prescribing Meaning: Hedonistic Perspectives on the Therapeutic Use of Psychedelic-Assisted Meaning Enhancement”[3] is a paper which aims to begin the task of addressing the ethics of psychedelic-assisted psychotherapy. The paper does so by applying the moral theory of Hedonism to analyse the ethical justifiability of psychedelic-assisted psychotherapy.

 

HEDONISM

Hedonism is a well-known type of consequentialist moral theory. In other words, Hedonism is a moral theory which places moral value in the outcomes of actions[4]. This means that for an act to be considered moral, said act must produce outcomes which are of moral value. So then, according to Hedonism, what outcomes are of moral value?

Hedonism or Hedonist moral theories are moral theories which place moral value in the outcomes of pain and pleasure[5]. That is to say that according to Hedonism, an act is morally good if it produces more pleasure than pain, or morally bad if it produces more pain than pleasure. There are some nuances of Hedonism which are explored further in the paper, and which subdivide Hedonist moral theory further into Qualitative Hedonism, Quantitative Hedonism, Hedonistic Utilitarianism, and Hedonistic Egoism.

 

PSYCHEDELICS AS MEANING ENHANCERS

It has been suggested that psychedelics exert their effects via a phenomenon known as the meaning-response[6]. The meaning-response refers to the body’s ability to respond physiologically to perceived meaning or symbols in the environment. For example, when someone takes a pill believing it will heal them — even if it has no pharmacologically active component (e.g. a sugar pill) — the body responds in such a manner which is in turn conducive for healing, as the very act of taking a pill is symbolically active[7]. That is to say that even though there are no chemically active ingredients in the pill, the very action of taking a pill carries certain symbolic connotations which lead to physiological changes in the body that change the body in ways which lead to health. This ability of the body to heal itself via mere symbols of healing might initially sound far-fetched, however it is a very well recognised phenomenon, so much so that the scientific community controls for this effect in its research designs — where it is perhaps better known as the placebo effect.

An important thing to note here is that the proposed mechanism of psychedelics as meaning enhancers is not saying that the effects of psychedelic-assisted psychotherapy are merely due to placebo. But rather the same mechanism which gives rise to the placebo effect also underlies the therapeutic effects of psychedelic-assisted psychotherapy. So how is this possible? It is proposed that during psychedelic states of consciousness the perception of meaning is enhanced. That is to say that psychedelics alter the world such that there is a general increase of ‘meaningfulness’ in the things which are experienced. This extra meaningfulness, when experienced in a therapeutic set and setting, results in an increased perception of therapeutic meaning (i.e. symbolically active meaning which is conducive for healing). This enhanced perception of therapeutic meaning leads to a stronger meaning-response, such that the body/mind of the person undergoing psychedelic-assisted psychotherapy will respond with a host of physiological/psychological sequalae conducive for healing. In other words, psychedelic-assisted psychotherapy heals by increasing the ‘meaningfulness’ of experience in such a way that leads to a dramatically increased meaning-response.

 

ETHICS

This is all very academically interesting, but how does this relate to the ethics of psychedelic-assisted psychotherapy? Well, the proposed mechanism of psychedelics as meaning enhancers raises the following ethical question: is it ethically justifiable to pharmacologically enhance the perception of meaning in order to heal patients?[6]. As was explored above, Hedonism would justify pharmacologically increasing the perception of meaning in order to heal patients so long as doing so led to more pleasure than pain. As is explored in greater deal in “Prescribing Meaning: Hedonistic Perspectives on the Therapeutic Use of Psychedelic-Assisted Meaning Enhancement”[3] the current literature on the effectiveness of psychedelic-assisted psychotherapy, its relative safety, as well as the epidemiology and morbidity of mental illness, would suggest that the introduction of psychedelic-assisted psychotherapy to psychiatry would produce more pleasure than pain.

But what if there is more to morality than pain and pleasure? This is the question that Robert Nozick asks people to consider when he presents his famous anti-Hedonist thought experiment: The Experience Machine[8]. To put his thought experiment simply, Nozick invites readers to imagine a machine which creates a completely realistic simulated reality. Before entering the Experience Machine people are allowed to select to kinds of experiences they want to have. Once inside, people become unaware that they have been wired up to the Experience Machine. According to Nozick, if pain and pleasure were the only relevant moral consequences, people would be morally obliged to enter the Experience Machine forever and live a life full of simulated pleasures. Nozick assumes that most readers would find this conclusion unappealing. Hence, Nozick argues that there is more to morality than just pain and pleasure. Nozick suggests that what also matters in determining morality is contact with an actual reality[8].

It has been suggested that psychedelic states of consciousness are analogous to the Experience Machine in Nozick’s thought experiment, and therefore represent a false reality. This analogy of psychedelic states representing a simulated false reality poses a further ethical challenge: are the effects of psychedelic-assisted psychotherapy ethically justifiable if they are produced by contact with a false reality? Two responses are suggested to such a question. Firstly, emerging research on the neuroscience of psychedelic states of consciousness could suggest that psychedelic states do not represent a false reality, but rather a different way of experiencing actual reality. Secondly, even if psychedelic states do represent a false reality, the use of psychedelic-assisted psychotherapy can still be justified in cases of extreme suffering, where concerns about contact with an actual reality are outweighed by extreme reductions in pain — e.g. treatment resistant patients.

 

CONCLUSION

The psychedelic renaissance is providing hope for many who have not responded to currently available psychiatric treatments. However, along with this hope comes a significant burden of responsibility for those researching and advocating for the medicalisation of psychedelics. Those living with mental illness are among some of the most vulnerable patient populations in society. Therefore, it is of utmost importance that the field of psychedelic science proceed with critical reflection to ensure that the work being done is ethically sound and not detrimental to those it is trying to serve. It is hoped that by beginning the process of applying moral theories to the experience of psychedelic-assisted psychotherapy, more discussion will ensue regarding some of the ethical challenges that this promising new paradigm presents.

 

REFERENCES

1. Reiff CM, Richman EE, Nemeroff CB, Carpenter LL, Widge AS, Rodriguez CI, Kalin NH, McDonald WM, Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research. Psychedelics and psychedelic-assisted psychotherapy. American Journal of Psychiatry. 2020 May 1;177(5):391–410.

2. Davis AK, Barrett FS, May DG, Cosimano MP, Sepeda ND, Johnson MW, Finan PH, Griffiths RR. Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial. JAMA psychiatry. 2020 Nov 4.

3. Miceli McMillan R. Prescribing meaning: hedonistic perspectives on the therapeutic use of psychedelic-assisted meaning enhancement. Journal of Medical Ethics Published Online First: 04 November 2020. doi: 10.1136/medethics-2020–106619

4. Sinnott-Armstrong W. The Stanford encyclopedia of philosophy: Consequentialism. Available: https://plato.stanford.edu/entries/consequentialism/

5. Moore A. The Stanford encyclopedia of philosophy: Hedonism, 2019. Available: https://plato.stanford.edu/entries/hedonism/

6. Hartogsohn I. The meaning-enhancing properties of psychedelics and their mediator role in psychedelic therapy, spirituality, and creativity. Front Neurosci 2018;12:129.

7. Moerman, D. Meaning, Medicine and the “Placebo Effect”. Cambridge; New York, NY: Cambridge University Press, 2002.

8. Nozick R. Anarchy, state, and utopia. New York: Basic Books, 1974

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