How Should Clinicians Share Decision Making With Patients Interested in Using Psychedelics to Feel Psychologically Safe?

Case

FG is a 33-year-old transgender man who uses the pronouns they/them and has a history of unipolar depression and alcohol use disorder. Through their employer-sponsored health insurance, FG initiates alcohol use disorder treatment. FG also reports that combined selective serotonin reuptake inhibitors and psychotherapy with their psychiatrist, Dr P, have helped, but that their depression symptoms remain debilitating.

Recently, after watching a show about psychedelic mushrooms and cannabinoids and noticing sensory deprivation chambers at their local mall, FG wonders how these approaches could help them find peace of mind more often and more regularly.

At their most recent session with Dr P, FG expressed interest in trying psychedelic mushrooms. “I want more control over my ability to generate peace in my life and in my experiences,” FG says.

Dr P, a 60-year-old, cisgender woman who uses the pronouns she/her, considers how to respond.

Commentary

For almost 2 decades, there has been a call for health care practitioners (HCPs) to ask patients directly about their use of complementary and alternative medicine (CAM)—defined by the National Institutes of Health National Center for Complementary and Integrative Health as “a non-mainstream approach” that is either “used together with conventional medicine” or “in place of conventional medicine”¹—before prescribing traditional medications (TMs) and making recommendations aimed at preventing adverse drug interactions and better supporting their patients’ health choices.^2,3  In particular, HCPs might have patients who report using herbs, body-based treatments, mindfulness meditation, or spiritual practices to support their well-being.^3,4 Given media reports suggesting that psychedelics can help to alleviate symptoms of depression, anxiety, and posttraumatic stress disorder,⁵ HCPs might also see patients who are using or considering using psychedelics to complement their TMs or as an alternative to TMs due to side effects or lack of effectiveness. Psychedelics can be considered CAM in that they are also plant-based medicines (eg, psilocybin, ayahuasca, peyote), and some psychedelic practitioners, based on their orientation, view the work and taking of psychedelics as a spiritual practice or intervention and, as such, include spiritual components such as ritual and prayer in their practice. We believe that the therapeutic use of psychedelics to support well-being—which, at this time, is not considered TM—is a CAM that is growing in popularity.

In 2022, Forbes reported the results of a study that found that 65% of Americans who identified as having mental health conditions wanted access to psychedelic medicines.⁵ Therefore, it is incumbent on HCPs to educate themselves on the risks and benefits of psychedelic use for patients seeking improved mental health, support with substance use, and relief from chronic pain exacerbated by depression, anxiety, or trauma histories.^6,7

FG, like the respondents in the aforementioned survey, is exploring CAM to support their mental health. Increasingly, HCPs like Dr P are treating patients interested in psychedelics—such as 3,4-methylenedioxymethamphetamine (MDMA), psilocybin, and ketamine—to improve their mental health.⁸ When FG shared their desire to use psychedelics with Dr P, they took the risk of having Dr P judge and shame them for wanting to use illicit substances to feel better. Such circumstances give HCPs like Dr P the opportunity to practice their harm reduction^7,9,10 and shared decision-making ^11,12,13 skills. The National Harm Reduction Coalition defines harm reduction as “a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use [and] … is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”¹⁰ Elwyn et al define shared decision-making as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”¹³ Both frameworks require HCPs to exhibit a patient-centered manner by providing information about risks and benefits of different treatments, listening to patients’ concerns nonjudgmentally, and including patients in decision-making while being mindful of patients’ cognitive and emotional capacities.¹¹ In particular, a harm reduction approach is useful when discussing psychedelic use with patients because it enables HCPs to discuss the potential risks of various substances (both illicit and licit) without shaming patients and while honoring their agency to make an informed decision.

Before Dr P responds to FG’s expressed interest in trying psilocybin, it would be helpful for Dr P to consider the following: (1) any potential biases she may hold regarding legal and illicit psychedelic use, (2) how her and FG’s respective social locations as well as the power dynamics in the patient-HCP relationship might affect FG’s interpretation of her response, and (3) how to respond to FG’s desire for more agency in cultivating peace in their life using a harm reduction and shared decision-making approach.

Relational Power Dynamics

When patients broach subjects that are stigmatic or taboo with their HCPs, it is important that HCPs understand how their opinions and attitudes can impact the patient due to the social power that they hold. This understanding supports the development of psychological safety in the patient-HCP relationship so that patients feel heard, seen, understood, and confident that HCPs’ recommendations can be trusted. We understand psychological safety as part of the co-created dynamic between the HCP and the patient, in which the HCP creates a safe space by acknowledging the power dynamics, especially with patients who hold oppressed identities related to, for example, gender, race, class, immigration status, sexual orientation, religion, or age. Psychological safety is further supported by HCPs and patients having a direct conversation about their individual social locations and the ways that their identities are similar and different in terms of the privileges and oppression that they experience. It is important for HCPs to explore how similarities and differences in social locations might affect patients’ comfort in disclosing their psychedelic use as well as how patients’ experiences of social stigmatization and oppression related to their identities might impact their mental and physical health.¹⁴

If Dr P has not explored with FG how their similar and different social identities affect their relationship, including transphobic beliefs that FG might project on Dr P due to Dr P’s social position, the potential for a rupture in the relationship is increased, particularly when the two discuss topics that might make FG feel vulnerable. FG might easily feel judged or dismissed by Dr P, given her cisgender identity or her other identities that carry privilege. If these subjects have not been previously discussed, Dr P might respond in the following ways:

• I’m imagining this was not an easy topic to bring up with me, your psychiatrist, whom you might perceive as… (Dr P would list several self-referring social locations).
• I’ve been wondering how it has felt to tell me about your difficulties with depression, considering I do not necessarily deal with some of the stigmas and oppressions that you do.
• Are there parts of your experience that you feel like you can’t share with me because I’m your doctor and I identify as… (Dr P would mention one or two social identities that afford Dr P privilege or differ from FG’s identities).

A Harm Reduction Approach

Narratives about the “drug-seeking” patient are prominent in medical forums, along with the perception that psychedelics can lead to subsequent psychiatric disorders.^15,16 Given the stigma surrounding drugs and drug use among HCPs and the resulting tendency of patients to conceal their drug use, Dr P could begin the discussion by reassuring FG that it is safe and appropriate to discuss the use of psychedelics in order to dispel any fear or discomfort.⁷

Peace could denote any number of experiences, including a sense of feeling less affected by gender identity stigma, relief from alcohol cravings, and reprieve from depression. 

As with any medical intervention, we find that it is useful for an HCP to get an understanding of what the patient is seeking and the motivation behind the question in order to guide the conversation to an outcome that would be useful to the patient. In this case, the patient is seeking “control over my ability to generate peace.” Dr P could ask FG about what having peace in their life would entail. Peace, for FG, could denote any number of experiences, including a sense of feeling less impacted by gender identity stigma, relief from alcohol cravings, and moments of not feeling depressed, to name a few.

Depending on how FG answers this question, Dr P could then speak to potential risks and benefits of individual substances, such as psilocybin and ketamine, as well as to FG’s underlying desire to access the therapeutic benefits gained through nonordinary states of consciousness (NOSC). In using a harm reduction approach, Dr P would adopt a nonjudgmental attitude towards FG’s desire to use psilocybin while also providing information and resources that would minimize potentially negative consequences of psilocybin use. For instance, perhaps after Dr P asks what peace in their life would entail, FG responds that peace involves feeling moments of relief from symptoms of depression. In that case, Dr P could affirm FG’s desire for relief from depression, provide psychoeducation about the use of psilocybin to address depression symptoms based on the results of recent clinical trials, and discuss the potential risks and benefits of using psilocybin and psychedelics in general.

Dr P could also explain that psychedelics are powerful medicines with potential to destabilize people during and after use and that psilocybin, although it might not be legal where FG lives, might be accessible through participation in a clinical trial.^6,7 However, if FG still wants to proceed even if there is no opportunity to serve as a research participant, Dr P should stress the importance of working with an experienced and skilled psychedelic practitioner because, even with support, many people find that they experience some level of psychological distress.^16,17 Among psychedelic practitioners, there exists a spectrum of experience and professional training. Some psychedelic practitioners are licensed mental health practitioners, clinicians, chaplains, or body workers who have undergone therapeutically based training programs, and other psychedelic practitioners may not be licensed professionals but have completed training programs either in the United States or abroad that are not restricted to licensed professionals. Psychedelic practitioners may be allowed to work in specific districts, cities, and states that have decriminalized plant-based psychedelics but have regulations specifying the volume of plant-based psychedelics that individuals can possess, the purpose for which the plant-based psychedelic is being used, the type of facility in which the psychedelic-assisted therapy is being administered, or the type or level of training that the psychedelic practitioner must have.¹⁸ In addition, both trained professionally licensed and trained unlicensed psychedelic practitioners may be working as psychedelic practitioners in places where the use of  psychedelics is deemed illegal. Criminalization of most psychedelics creates conditions that can make it difficult for many psychedelic practitioners to find trainings with experiential components that enhance skill development and learning and for patients to find skilled and well-trained psychedelic practitioners. Therefore, the risk of psychedelic-assisted therapy is dependent on where the patient lives, what types of psychedelic practitioners they have access to, whether the patient can travel to cities that have a pool of skillful psychedelic practitioners, and other contextual factors.

Dr P could inquire whether FG has the resources to be able to take time off if needed after a session and whether they have supportive people in their life whom they could lean on in case of destabilization. Given some of the risks of psychedelics, such as adverse medical reactions, and the difficulty of accessing psilocybin in a clinical setting that would provide medical screening and monitoring, Dr P could suggest alternative medical and nonmedical means of accessing NOSC, such as ketamine-assisted therapy or mind-body approaches (eg, breathwork) that could fulfill FG’s desire to access NOSC benefits. Although further research is needed, several studies suggest that mind-body approaches can produce comparable shifts in consciousness and that they can have a range of therapeutic effects, including enhanced self-awareness and spiritual well-being.¹⁹

Dr P could also help manage FG’s expectations of what psychedelics and, by extension, NOSC, can actually do by giving FG a sense of what is required in terms of preparation and integration. Integration is a process in which patients implement and incorporate the key insights gained in the NOSC experience in their day-to-day lives.²⁰ Dr P can explain that, unlike pharmaceutical medicines that can have a biomedical impact regardless of the patient’s intent, the effectiveness of NOSC, whether induced by psychedelics or mind-body approaches, is significantly influenced by the patient’s active engagement in both preparatory sessions (during which the patient gains clarity on their intentions) and integration sessions. Although patients can experience an abatement in symptoms and immediate positive effects after the experience, ongoing integration is necessary to internalize the insights gained in the NOSC and to make lasting change.

Finally, Dr P could provide suggestions on how to find an appropriate psychedelic practitioner. For example, Dr P could direct FG to online resources that detail what questions to ask potential psychedelic practitioners.⁷

Conclusion

For many, NOSC facilitate connection with a sense of peace, self-compassion, love, and connectedness, which often mitigate symptoms related to depression, anxiety, and trauma. Dr P’s patient, FG, is exploring the use of psilocybin in combination with psychotherapy in the hope that this alternative treatment will alleviate their symptoms of depression without the side effects often experienced when using selective serotonin reuptake inhibitors. FG wants to feel more agency when it comes to feeling at peace and hopes that the use of psilocybin, in combination with psychotherapy, will offer them the control that they are seeking. When FG, who continues to feel debilitating depression, broaches the topic of using psilocybin during the therapy session, Dr P has an opportunity to employ both harm reduction and shared decision-making skills to support FG in examining their desire to use psilocybin in combination with psychotherapy to gain more peace in their life and in their experiences.

To make sure that Dr P responds to FG’s statement in a way that supports FG in their exploration and does not make them feel judged, Dr P needs to first explore any biases or stigma that she has regarding psychedelics and psychedelics’ medicinal uses. Then Dr P can explore with FG how they feel about sharing their interest in psilocybin use with her in light of the similarities and differences in their social locations and the privileged role that she occupies as an HCP. If Dr P can navigate the conversation with FG regarding their interest in psilocybin, providing FG with time to discuss what they know about the risks and benefits of psychedelic-assisted therapy and providing resources so FG can learn more, it would create the opportunity for Dr P and FG to build more trust and for FG to feel more in control of their mental health care.