Psychedelic-Assisted Therapy Training: An Argument in Support of Firsthand Experience of Nonordinary States of Consciousness in the Development of Competence

Abstract

Introduction:

This perspective on experiential training delves into the potential benefits and counterarguments related to integrating firsthand experience of psychedelic-assisted therapy (PaT) to enhance the competency of trainees.

The Case for Experiential Training as a Core PaT Competency:

Experiential training serves a dual purpose: promoting therapists' mental wellness and refining their skills in facilitating healing in nonordinary states of consciousness. With a rising demand for PaT amid a growing mental health crisis, therapists are increasingly seeking PaT training, including experiential training from underground sources. Educators actively strive to establish formal PaT competencies and training standards, recognizing the need to consider both perspectives in this discourse.

Counter Arguments:

The emergence of differing opinions on the therapeutic value of firsthand exposure to PaT and concerns about potential bias underscores the necessity for further research to substantiate claims on both sides.

Access:

Whether or not consensus is achieved, the persistent demand for experiential training remains. Offering this form of training in regulated settings has the potential to reduce reliance on illicit sources for this sought-after form of training, ensuring a more controlled and ethical approach.

Introduction

Our team of authors advocates for the integration of personal experience in nonordinary states of consciousness (NOSC) before supporting others who are going through psychedelic-assisted therapy (PaT). We argue that firsthand subjective experience of PaT is a crucial training element for PaT practitioners, hereafter referred to as “therapists” or “providers.” We acknowledge that in the absence of a randomized control trial exploring the impact of both experienced and naive PaT therapists on treatment outcomes, these arguments remain anecdotal and open to criticism. Those with firsthand PaT or NOSC experience may face scrutiny for bias, while those without experience may be criticized for a lack of understanding. While our review leans toward supporting the hypothesis that firsthand experience holds significant value, we remain open to empirical evidence challenging this perspective.

Positionality statement

This review is informed by the experiences and perspectives of three of the lead authors who are active educators in Vancouver Island University's PaT Graduate Certificate Program, a year-long, accredited training program in British Columbia, Canada. Informed by feedback from PaT students and guest lecturers, we recognize the importance of firsthand experiences, where personal psychedelic encounters shape the intuitive foundation and coherence required for competency in PaT. While the university does not directly offer experiential training, students have the autonomy to pursue such experiences, aligning with their self-assessed needs. Additionally, five of the seven authors/reviewers are also leaders in two Canadian PaT organizations, providing PaT treatment. One of these organizations, a nonprofit operating as Roots to Thrive, also offers experiential training for those unfamiliar with psychedelics—enabling those training in the field to gain a felt sense experience of NOSC by partaking in PaT themselves.

The lead author's doctoral work, published in a health care-focused textbook, explores factors promoting resilience and thriving amid trauma-laden work environments.¹ As is reflected in this research-informed text, a core factor that informs professional confidence is one's degree of “sense of coherence,” a concept coined by Antonovsky,² emphasizing one's ability to find meaning, understanding, and predictability in navigating life's challenges. In this case, we believe firsthand experiences in PaT significantly contribute to the development of this sense of coherence in PaT therapists, enabling a greater understanding of how to navigate NOSC, and the confidence to serve as a guide when challenges arise. Acknowledging potential biases from personal experiences, we recognize their impact on objectivity. Simultaneously, we assert that these lived experiences enrich our insights into the crucial role of experiential training.

Our overarching intention is to present a comprehensive argument in favor of the integration of experiential training in PaT, while very briefly addressing some of the arguments against such integration.

Background

Canada is in the throes of a growing mental health crisis, recently exacerbated by the COVID pandemic. With the increasing prevalence of mental health diagnoses, the health care field needs to explore and incorporate novel, evidence-based treatments, to expand and improve therapy options for individuals with mental health conditions.³ Traditional therapies are failing many of the growing number of Canadians struggling with mental health challenges.⁴ Fifty percent of the general population will have a mental health condition by the age of forty, with higher rates among health care professionals.⁵ As the term “treatment-resistant,” indicating an insufficient response to conventional mental health treatments, is increasingly seen in 20–40% of cases, depending on the condition,⁶ there is an urgent demand for innovative treatment alternatives.

PaT is showing significant promise in the treatment of several clinically challenging conditions, including treatment-resistant depression, anxiety, posttraumatic stress disorder (PTSD), substance use disorders, and end-of-life distress.^7–13 While precise mechanisms remain ill-defined, viewed through the lens of complex system theory, the effects of psychedelics appear to destabilize entrenched patterns of thinking and behavior, creating the potential for meaningful change.¹⁴ This potentiating destabilization occurs when experience with a NOSC creates new awareness, challenging ordinary, or conditioned patterns.¹⁵

Psilocybin, the psychoactive prodrug, found in magic mushrooms was classified as a breakthrough therapy by the U.S. Food and Drug Administration in 2019, setting the stage for future approvals.¹⁶ In 2023, Australia became the first country to approve psilocybin and the related compound MDMA (3,4-methylenedioxymethamphetamine) for clinical use. With increasing awareness of the limited efficacy of mainstream first-line treatments, there is growing public interest in psychedelics as promising adjuncts, or alternatives. This increase in demand is creating an impetus to forge legal and regulated pathways to access treatment and firsthand experience as an aspect of one's PaT training.

Traditional mental health training does not prepare clinicians to work in NOSC, which requires specialized training to provide safe and effective care. Few health care providers are qualified to deliver PaT, and in the absence of standardized PaT training programs, there are a few accredited avenues to train therapists in the delivery of these breakthrough therapies. Those training centers that do exist in North America, which is leading the way in training standards, such as Vancouver Island University (VIU), California Institute of Integral Studies (CIIS), and the Multidisciplinary Association for Psychedelic Studies (MAPS), recommend that trainees have firsthand experience with NOSC as a basic competency standard for PaT therapists, as evidenced in their competency standards and published literature.^17,18 Yet, there are currently few legal and feasible PaT access points, with many therapists facing the ethical dilemma of complying with existing regulations, versus doing what they believe best supports their professional development, and consequently, best outcomes for their patients.

In 2020, Health Canada granted 17 health care providers access to psilocybin for training purposes.¹⁹ Following this initial approval, dozens of applications have been subsequently rejected. Despite extremely limited access and an onerous access pathway, Health Canada now requires that providers enroll in clinical trials as a condition for granting access.²⁰ Conversely, the FDA in the United States granted MAPS permission to provide an experience with MDMA for therapists in training.²¹ Such policy aligns with seminal experiential training theory, whereby accurate empathic reflection is acquired by the therapist's ability to engage in a quasi-therapeutic process, enabling them to process their own personal experience as clients.²²

Before discussing the role of experiential training in PaT, we will describe the key factors that promote long-term benefits of PaT:

• Mystical experiences during PaT positively correlates with posttreatment well-being.²³

• Having clear intentions for PaT correlates with higher rates of mystical experiences.²³

• Those with a positive mindset and clear intention appear less likely to experience challenges during PaT.²³

• The participant's capacity for acceptance and flexibility.²⁴

• The participant's absorption capacity and higher doses of the psychedelic substance were associated with more profound experiences, including mystical experiences, challenging experiences, and visual effects. Absorption capacity pertains to one's capacity to become deeply engrossed or immersed in sensory or cognitive experiences.²⁵

• Degree of rapport between the therapist and the patient.²³

• Prompt integration support following PaT promotes the durability of benefit and behavioural change.^25,26

These findings highlight the importance of nonpharmacological factors in shaping individual treatment responses, providing a valuable foundation for objectively evaluating the benefits of experiential training.

The Case for Experiential Training as a Core PaT Competency

It is crucial to acknowledge the fundamental distinctions between PaT and traditional pharmacology. These differences underscore the necessity for specialized training and distinct therapeutic pathways. Differences include mechanism of action, the nonordinary landscape, therapeutic approach, transpersonal aspects, and the regulatory environment. It is also crucial to note that accessing NOSC does not necessarily require psychedelic consumption. Alternatives like hypnosis and holotropic breathwork exist as viable options. Experiential training, where trainees undergo a psychedelic substance experience, stands as the most reliable method for gaining profound understanding of NOSC, aligning closely with the patient's PaT journey.

The role of experiential training in western medicine is novel and still evolving, with further research needed to determine the impact of personal experience on therapist competence and patient outcomes. Western medical trainees are not required to have personal experience with the medications they prescribe as part of their training. However, PaT differs significantly from traditional psychopharmacology, as PaT is experienced in a nonordinary state, where benefits extend beyond biological manipulation, to incorporate potentially transformative psycho-spiritual experiences.

Facilitating therapy in NOSC is more comparable to cultural immersion, where firsthand experience improves awareness, knowledge, and skill in multicultural competency.²⁷ This also aligns more closely with indigenous ways of knowing, recognizing the importance of going beyond intellectual knowledge to incorporate direct experience. Knowledge is recognized as intellectual and abstract, whereas knowing is internal or embodied. Many indigenous communities have utilized psychoactive substances to promote wellness and healing, consistently incorporating an apprenticeship component. In these cultures, the medicine holder or spiritual elder undergoes years of specific experiential training, enhancing and ensuring their capacity for supporting others in the same experiential space.^28,29

Contemporary discourse among influential experts and researchers highlights a growing recognition of the potential positive impact of personal transformative experiences with psychedelics on therapy outcomes, as suggested by historical precedents and anecdotal accounts provided below. Conversely, a lack of understanding and confidence, leading to a low sense of coherence (defined earlier) as a PaT therapist, might instill fear of the unknown, potentially having the opposite effect.

Before the political ban on psychedelic research in the 1970s, therapists were often participants in various experiences and studies where this phenomenon was noted. Mangini's³⁰ historical analysis implies that researcher bias, whether positive or negative, might significantly impact the results of lysergic acid diethylamide (LSD)-assisted therapy. Skepticism and uninformed attitudes appeared to predispose a negative bias and influence the study outcomes. Similarly, Oram suggests that historical outcomes seemed to correlate with researchers' appreciation of psychedelics' transformative potential. This appreciation enables researchers to demonstrate confidence in the therapeutic process, resulting in predominantly positive outcomes.³¹

Despite the absence of direct research and a unanimous consensus, before the prohibition, psychedelic research reviews suggest that, in specific instances, researchers believed that undergoing a personal experience with d-LSD enhanced the ability to support patients during LSD-assisted psychotherapy.³² Some European countries required physicians to experience LSD-assisted therapy personally before offering LSD to their patients.^17,33 Notably, Grof, a psychiatrist with over 60 years of psychedelic research experience and a prominent figure in transpersonal psychology, asserts that “it is impossible for the future LSD therapist to acquire a deeper understanding of the process without first hand exposure.”³⁴ Grof further emphasizes, “I tried personally all the psychedelic substances we worked with before I gave them to others. That is the only way; there is no other possibility. One cannot learn the effects of psychedelics from reading books, no matter how sophisticated they appear to be.”³⁵

More recently, leaders in modern psychedelic research in North America seem to align with this sentiment. This alignment is illustrated by the launch of a study by MAPS, which allows health care providers to obtain MDMA for training purposes.³⁶ Despite limited peer-reviewed research on the value of experiential training in the last two decades, a MAPS trainee reflected on the experience, stating, “My complete immersion in the session allowed me to leave with a clearer image of how to be present with and for a client during their experience, and I felt more prepared to respond to what I would encounter as a therapist in an MDMA study.”³⁷

Leading organizations today echo sentiments akin to preprohibition PaT researchers. The Medical Director of TheraPsil, a Canadian nonprofit facilitating psilocybin access for treatment and experiential training, emphasizes, “You would not expect a guide to take any journey over any terrain with which the guide was not familiar. When it comes to psychedelics, the terrain is so unusual and outlandish that it is imperative that the therapist has familiarity with the realms of the human unconscious visited under psychedelics, guiding the patient through situations that might seem utterly bizarre, even psychotic to an untrained therapist.”¹⁹ Phelps, the founder and director of the CIIS, reinforces this perspective in a review of competencies for psychedelic therapists, highlighting the value of firsthand exposure to PaT.¹⁷

Firsthand experience to promote competency development

Continuing from the exploration of the significance of firsthand experience in PaT, we now delve into how such experiential engagement serves as a pathway to enhancing each of the competencies outlined by Phelps.¹⁷

Competency 1: Empathetic Abiding Presence: Firsthand experience with PaT can help therapists cultivate empathetic abiding presence,¹⁷ which is a form of empathy that is crucial in PaT. It requires a deep relationship with the context in which they are working to cultivate qualities such as composure, even attention, mindfulness, and equanimity.

Competency 2: Enhancing Trust: Firsthand experience with PaT enhances trust by providing therapists with an intimate understanding of the psychedelic states participants may encounter, equipping them with the ability to adeptly convey the normalization of subjective states as they prepare their clients for the nonordinary terrain. This enhanced familiarity with the terrain reinforces therapists' trustworthiness, particularly in guiding participants through potentially paradoxical transformations and unexpected moments within sessions.¹⁷

Competency 3: Spiritual Intelligence: Directly encountering mystical states of consciousness and transpersonal experiences seems to enhance clinical outcomes.³⁸ When PaT therapists have personally undergone these experiences, they can connect with patients at a profound level, engaging with a resonant richness that surpasses what could be achieved without such firsthand understanding.

Competency 4: Knowledge of the Physical and Psychological Effects of Psychedelics: It is logical that the more intimately one knows the nature and texture of their environment, the more predictable the PaT therapist's orientation and context will feel. The more confident the therapist feels in their ability to intuitively navigate challenging PaT experiences, the more likely they are to intuitively promote a similar sense of confidence and security in their patient's ability to navigate such challenges.^17,39,40

Competency 5: Self-Awareness and Ethical Integrity: By the therapist fostering self-awareness of their own inner processes and patterns through a direct experience with PaT,¹⁶ improved discernment between their own experiences and those of their clients can be achieved, thereby mitigating the risk of projecting their own issues onto the client.

Competency 6: Proficiency in Complementary Techniques: Experiencing PaT firsthand enhances one's relationship with and proficiency in complementary techniques, fostering adaptability and personalized integration into one's therapeutic approach.

Fostering therapeutic efficacy and mental wellness in PaT therapists

Research emphasizes the impact of a therapist's unwavering belief in a patient's capacity for change, cultivating a positive therapeutic alliance.^39–41 Contextual familiarity is essential for developing predictability, confidence, and self-efficacy in navigating anticipated challenges. Efficacy goes beyond understanding fixed circumstances; it involves cultivating intuition through a learned, generative capability that integrates cognitive, social, and behavioral skills into cohesive courses of action.⁴² Nursing is just one discipline that explicitly recognizes intuition as the integration of forms of knowing through sudden realization, providing impetus and surety for meaningful action,⁴³ and understanding without rationale.⁴⁴ These qualities contribute to a primary resilience factor, referred to as the sense of coherence, which encompasses self-efficacy, meaning-making capacity, and the understandability of one's context.¹

Finally, an in-training PaT experience can serve a dual purpose, supporting professional development and providing mental wellness and resilience benefits to the trainee. Unfortunately, accessing PaT as a treatment modality, particularly with substances like ketamine, poses challenges due to legal restrictions tied to obtaining a qualifying mental health diagnosis. This may result in stigma, affecting employability, insurance eligibility, and deterring therapists from seeking any form of psychological support, despite having an eligible diagnosis or disabling condition.⁴⁵

Counterarguments to Requiring Personal Experience as a Core Competency in PaT

The evolution of psychedelic substances from their traditional roles within diverse cultural and religious practices to their current applications in medical practice prompts inquiries into potential cultural, moral, and philosophical implications.⁴⁶ Traditional practices have often emphasized a personal relationship with the healing substance, which diverges from the shorter history of the contemporary Western approaches. Therefore, it is imperative to recognize that there are varying perspectives, both with relevant points, regarding whether firsthand experience in PaT consistently leads to improved outcomes.

• 1.In addiction studies, Culbreth discovered that a therapist's personal knowledge of addiction does not consistently link to improved treatment outcomes.⁴⁷
• 2.Matching therapists and patients on demographic factors such as race, ethnicity, gender, or sexual orientation does not appear to exert a significant influence on treatment outcomes.^48–53 To the contrary, gender matching between patient and therapist may have limited, or even negative, effects on treatment retention.

While these comparisons contribute to the discussion, they are not entirely analogous. To draw a parallel, it is akin to suggesting that in PaT, therapist familiarity with the specific condition being treated, such as PTSD, or resonance with a similar identity, might be more relevant than emphasizing familiarity with the process of navigating NOSC in PaT. Moreover, recent research among PaT therapists indicates a substantial number with personal experience, potentially influencing their preferences or biases and, thus, possibly confounding therapeutic priorities.⁵⁴ A parallel concern is raised regarding potential bias if a PaT researcher demonstrates excess enthusiasm for PaT, stemming from their positive personal experiences.⁵⁵

Access to a Psychedelic Experience

Legal barriers to PaT have spawned a growing underground psychedelic movement. The regulatory climate notwithstanding, many seeking competency with PaT will continue to pursue psychedelic experiences, driven by individual values and needs for professional development. This is analogous to our experience with abortion and with cannabis before legalization, where a growing number of Canadians will circumvent a law they view as either arbitrary, disconnected from science, and/or lagging shifts in the broader culture. With PaT, we have returned to a place of moral distress, where therapists seeking personal experience with PaT feel obliged to break the law to become more effective therapists. At this time of unprecedented inadequacy of mainstream treatments, we are called to support, not obstruct, therapies with demonstrated positive outcomes.

There is an urgent need for establishing legal training and practice options, bridging the underground with best practices, with all therapists operating within a regulated and ethically accountable framework. Such a proactive strategy would mitigate the risks associated with unregulated training in a field with relatively few guidelines for developing competency.

There are currently five options for access to PaT:

• 1.Leave one's country: The therapist is required to travel to areas such as the Netherlands, Costa Rica, or Jamaica that provide legal access to PaT. This option is expensive, not always feasible for therapists with families, and potentially unsafe.
• 2.Breathwork: While certain breathwork techniques might briefly induce NOSC, this modality might not do so as consistently as the specific psychedelic substance.⁵⁶ This option does, however, afford the advantage of not requiring a formal diagnosis or a comprehensive medical evaluation as conditions for access.
• 3.Illegal procurement of psychedelic substances: This is not a feasible or safe long-term solution. Unregulated, illegal access to psychedelics for self-use will continue to be an ongoing public safety concern.⁵⁷ Given growing public acceptability, much as was the case for cannabis, there will be multiple routes for underground procurement, with low risk of prosecution in many jurisdictions.
• 4.Clinical trial enrollment: For those meeting eligibility criteria and in areas where trials exist, it is possible to gain access to PaT for training purposes, or as a patient with a defined mental health diagnosis. With few/no studies in progress and narrow eligibility criteria, this option is not readily accessible to most therapists.
• 5.Ketamine-assisted therapy for treatment purposes: This is feasible where ketamine is prescribed as a therapy adjunct for those meeting eligibility criteria. Given very limited public funding and availability, cost is a relative barrier for this eligible subgroup.

Therapist Wellness Benefits

While the majority of health care providers struggle with mental health conditions,⁵⁸ many forgo seeking treatment. In a study involving 639 allied health professionals, 54% met the criteria for diagnosable conditions, yet only 14% indicated a willingness to seek support.⁵⁹ In a study of 5829 physicians, 40% expressed reluctance to seek mental health care, fearing potential implications for their licensure and malpractice insurance.⁶⁰ Highly stressful health care environments predispose developing secondary mental health diagnoses, further complicating their reluctance to seek care due to concerns for career and livelihood.⁶⁰ Given that many diagnosed with a primary mental health disorder will have co-occurring conditions,⁶¹ and given the concern for stigma, selecting an eligible, yet relatively benign diagnostic code might be the preferred option.

PaT is showing promise for treating the mental health challenges common among health care providers, including depression, generalized anxiety, and posttraumatic stress disorder.⁶² As demonstrated by studies on “healthy normals,” a PaT experience provides wellness benefits beyond the treatment of overt psychopathology,^63–65 with many indigenous cultures using psychedelic substances to support spiritual and psychological health.⁶⁶ This is aligned with the World Health Organization's view of health as being far more than the absence of disease.

When PaT is incorporated as an experiential component of training, trainees shift between patient and therapist roles, realizing the combined benefits of enhancing clinical competence while supporting their personal wellness. Further, a personal PaT experience might enhance self-awareness and mental wellness among “healthy” trainees. Improved self-awareness reduces the risk of unconsciously projecting one's emotional states onto their patients, or failing to recognize when one's own unconscious patterns or needs threaten to derail the therapy process.⁶⁷ Collectively, these benefits offer hope and promise at a time of unprecedented care–provider burnout and absenteeism.⁶⁸

Acknowledging the potential benefits of firsthand exposure to PaT for gaining experience in NOSC, it is premature to mandate such experience as a requirement for therapists entering this field. Therapists should have the autonomy to choose evidence-informed training modalities that align with their career paths and learning needs, embracing an individualized approach similar to patient care standards. These standards include thorough screening, a meticulous assessment of risks and benefits, careful consideration of ethical and safety concerns, and an informed consent process that clearly describes the potential for adverse effects.

Further research is needed to better evaluate PaT therapist effectiveness and to understand how a personal experience with PaT might enhance professional competence and support better patient outcomes. Whether or not therapists engage in experiential training—potentially serving a dual purpose in one's own healing process, it is imperative that they maintain their own wellness practices.⁶⁹ This proactive/primary prevention strategy could improve well-being and resilience, reducing secondary mental health consequences for patients and therapists.^70,71 Cultivating a culture of self-care within the mental health field should be an overarching priority for training programs and professional organizations, without which we are left with broken people in support of broken people. Current rates of burnout, absenteeism, and early retirement suggest that we are already on that trajectory and should serve as a call to action.

Authors' Contributions

S.D.: Chair of Psychedelic Programming at Vancouver Island University (VIU) and Innovation and nursing lead for the Roots to Thrive Society for Psychedelic Therapy (RTT), conceived of, provided the literature review for, authored the first draft of the manuscript, and responded to revision requests. C.W.: Overseeing Psychiatrist of Psychedelic Programming at VIU and RTT, made substantial contributions to the writing, provided multiple reviews and editing. P.K.: Physician and Medical Chair of Psychedelic Programming at VIU and RTT, contributed to a major revision, and editing.

P.A.: new graduate nurse from VIU and research assistant, assisted with reviews, editing, and references. M.G.: visiting researcher at VIU and PhD candidate with the University of British Columbia, assisted with reviews, editing, and references. V.W.L.T.: psychiatry resident, leading researcher for the RTT, and leading board member for QI Integrated Health Clinic made contributions to the writing with reviews and editing. W.T.: Experiential Training lead for RTT and Master's student with VIU contributed to editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.