Icons, gurus, and boundaries: Professional risks in psychedelic therapy settings

Prof. Dr. Matthew Johnson looks at the challenges posed to psychedelics science professionals by patients' experiences and experimental settings.

In the context of the INSIGHT Conference 2023, Prof. Dr. Johnson gave a lecture titled “Preparing of Approved Psychedelic Medicine: Dangerous Trajectories in Psychedelic Science”.1 In it, he addressed some of the most complex questions that the psychedelic scientific community confront regarding the existential questions patients face in therapy sessions, the role of icons, symbols & belief systems in therapeutic settings, and the importance of autonomy in how patients lead their therapy processes. He also discussed the role of the therapist, the risks of power dynamics with patients, and the importance of empirical rigidity in psychedelic scientific observations.

About Prof. Dr. Matthew Johnson: Prof. Johnson’s work with psychedelics has spanned over 17 years, and has included the first psychedelic therapy for tobacco addiction, safety guidelines for psychedelics applications, recommendations on their controlled substance classification, and publications including safety, behavioural change, and Major Depressive Disorder aspects of psychedelics therapy. He is the Susan Hill Ward Professor of Psychedelics (Johns Hopkins University School of Medicine).

The big questions come up

Prof. Johnson started with one of the key features of psychedelic therapy. As a patient reacts to the psychedelic experience, they often come out of it with big questions. These touch upon philosophical, spiritual, metaphysical, and even semantic issues. “Patients may ask, what is the nature of reality? What is meaning? Does anything mean anything?  Does a god or anything like it exists?”, Prof. Johnson recalls.

Compared to the average day of any person, someone exposed to a high dose of psychedelics is more likely to be confronted by such questions. For Prof. Johnson, there is some value in grappling with these dense issues: “our ancestors may have pondered with this when staring at the stars. There may value in just contemplating these”.

And yet, the fact that such questions come up in therapy settings, has prompted a growing concern over the last decade in psychedelics research: when patients grapple with these big questions, it is important that a model is built to allow medical professionals, psychologists, psychiatrists, nurses, and even individual users of psychedelics, how to best help those involved in the therapy setting in their role and tools to best address the questions and situations that arise.

When iconographies enter the therapy space

As a norm, Prof. Johnson explains, clinical professional frameworks need to be conscious about what inputs and information medical professionals and therapists present to patients. One example is that of the presence of religious icons in therapy spaces. Some locations may feature statues of Buddha, Hindu gods and deities, or crucifixes. But in such settings, neither the experts or the context is there to suggest or tell a patient what to believe or not to believe.

A great model for this, is to leave it up to the patient to bring their iconography. They can bring family pictures to a session, bring explicit religious symbols, even reference meta symbols, says Prof. Johnson. The items they bring range from dream catcher, amulets, statues, religious figures. And likewise, people may come to a session without iconographies, and they take all the value and benefits they need from the experience.

The patient drives the bus

One of the core approaches is therefore to let the patient, client, or research participant to “drive the bus” of the questions that come up in the therapy, and the stimuli (visual, spiritual, etc) that they want to include in their experience. Prof. Johnson recalls adding this approach as a commentary in a paper he published. The feedback included people that were grateful because these questions “had been a concern”, but there was also some push back, from people that misunderstood this approach as a way of “imposing materialism on a patient”. 

A psychedelic therapy may take the form of metaphysical insights, or not. In certain communities and settings (for example if a patient is Black American, from the US “deep south”, or belongs to the Baptist churches), references to Jesus Christ often come up. An individual draws meaning as a patient from their own belief system, and the therapist is there to provide a caring professional support to that person regardless of the spiritual dimension they bring. Such a dimension may include references to Jesus, heaven, or even there may be no visual references to it. Prof. Johnson places importance on having a trusting relationship with the patient, and to let the patient lead the way through their own experience.

Scepticisms towards psychedelics therapy

An important point Prof. Johnson made was on the concern over which groups do not showing up in psychedelics research. Some religious communities would associate the psychedelic experience as “something of the devil” or see press coverage on this research and develop scepticism, despite the medical successes that the therapy can offer. But this scepticism is by no means only present in religious communities. 

All insights can contribute to empirical observations

The religious, metaphysical, or philosophical questions that arise in psychedelic experiences are intriguing and complex, and just like discussions on the problem of consciousness, they fall beyond the realm of empirical science. But this should not deter scientists from taking these insights into account for research. Prof. Johnson argues that when a patient contemplates questions and concepts, and engage in discussions helped by the icons, or references available to them, this in itself is important: “As a scientist, I am also interested in that engagement as a data point. It doesn’t prove a ground truth, but it is worth recording that it came up”.

The Guru complex

Professionals that have participated in psilocybin-therapy sessions as a guide, or councillor are aware of the intensity the patient may manifest as the psychedelic effects wear off. At times a patient may explain that they had just been through “the most meaningful experience in my life”. But how does that relate to the expert? Prof. Johnson calls on the importance of grounded professional ethics. The entire network of doctors, social workers, nurses, and all professions relevant to the psychedelics therapy process benefits from setting clear standards and boundaries that can enable medical professionals to provide relevant support to a patient. 

Prof. Johnson is aware that there can is a risk of power dynamics between the professionals that facilitate the therapy, and the patient. The potential rituals and social hierarchies that may unfold demands that professionals are aware of boundaries, of advice, of adding their own subjective approaches to a therapy. 

Also, in such settings, dispensing spiritual advice or personal opinions may not be as unimportant as it seems. Prof. Johnson recalls a case in which a patient shared a specific experience from the psychedelic session with a medical professional. In response, the professional noticed similarities with the “kundalini experience”.2  The patient did extensive research on the topic and came across literature that suggested a risk of death in kundalini experiences. This was a cause of concern for the patient, as this was not in the therapy’s disclosure forms. 

Details that may seem minor, could have wider implications in a psychedelic therapy setting. And Prof. Johnson calls on professionals to be aware of the risks in going beyond their roles and training that are pertinent in that context.

Psychedelic exceptionalism

Some of the experiences patients describe appear transcendental. This can feed into the argument of a “psychedelics exceptionalism”. At times, people working in psychedelics research encounter people stating that “this work will save the human species”. Such statements, Prof. Johnson points out, risk supporting a belief that “anything is justified”. He reminds us that the exceptionalism approach overlooks the lessons from 1960s psychedelic research, recalling that while academics like Timothy Leary did important work, he also did some things that cannot be repeated in scientific psychedelic research.3

Prof. Johnson underlined the importance of honesty, facts, openness to criticisms, and humility in the scientific work, adding some final thoughts for those involved in the development of psychedelics medicine:

Notes and sources
  1. INSIGHT Conference 2023. 1 September 2023, 09:30-10:00. Lecturer: Prof. Dr. Matthew Johnson. Session: “Preparing of Approved Psychedelic Medicine: Dangerous Trajectories in Psychedelic Science”. Track 1: Therapy.
  2. Author’s note: Also known as a “kundalini awakening” this concept derives from some Hindu schools of thought, and describes an intense psychophysical experience that occurs after extended engagement with certain spiritual, emotional and physical practices.
  3. Author’s note: The Harvard University’s Department of Psychology page on Timothy Leary states for example critiques over the lack of methodological rigour in his research, safety issues for patients, or his active promotion of recreational use of psychotropics.