Understanding Psychedelic-Assisted Psychotherapy Providers’ Perspective and Insights: A Qualitative Analysis

Abstract

Background:

There is increasing interest in the use of psychedelics for therapeutic and recreational use. Research has been hindered by federal prohibition, put in place in 1970. Despite the regulatory difficulty, research has rapidly expanded in the past decade. Multiple states and cities have drafted their own policies regarding the use of psychedelics. Assuming interest in psychedelics continues to expand; every opportunity should be explored to better understand how psychedelics may be helping or harming people.

Objective:

This study examined underground psychedelic-assisted psychotherapy providers’ protocols and perspectives, to better inform policy and public health, as psychedelics increasingly are used in the United States.

Methods:

Transcripts of interviews were examined through qualitative content analysis.

Results:

The following four themes were identified: (1) personal experiences and self-healing motivated sharing and promotion of the positive effects of psychedelics as an expression of altruism, (2) guides articulated consistent, yet flexible processes, (3) guides believed that the client benefit was actualized through their own intrinsic ability to heal themselves, and (4) guides expressed an overwhelming sense of dissonance regarding psychedelic legalization, not only desiring increased access and decreased risk but also expressing concern about potential negative impacts on provider flexibility, and depersonalization that could come with standardizing this field of practice.

Conclusion:

In order for current research and policy to be best informed, information must be gathered from both clinical trials and observational studies of current practice. This study identified themes within the latter to provide perspectives, practices, and insights of current underground practice, so it can be used to inform research and policy moving forward.

Introduction

The use of psychedelics for therapeutic purposes and psychedelic-assisted psychotherapy has gained significant interest, leading to an increase in clinical studies.¹ The use of psychedelics among adults in the United States is on the rise, and efforts to legalize these substances are gaining momentum in several states.^1–4 Many Americans are already engaging in “self-medication” with psychedelics, and as positive media coverage regarding their use continues to grow, public interest in the health benefits of psychedelics is expected to increase further. As research into the use of psychedelics for medical and psychological applications gains traction, legal and ethical challenges have become apparent. Amid this evolving context, a unique phenomenon has emerged—the presence of underground psychedelic providers who offer guided psychedelic experiences outside established medical and legal frameworks. As can be seen in the results of this work, people providing these psychedelic experiences have diverse backgrounds, yet nearly all refer to themselves as “guides.” We will, therefore, refer to this group of people who provide underground psychedelic experiences as “underground psychedelic guides” throughout this article. While there is a growing body of research exploring the attitudes and beliefs of participants in psychedelic research,^5–9 recreational users,^5–7 psychiatrists,⁸ psychologists,⁹ and health-care trainees,¹⁰ exploration of the experiences of underground providers has yet to be studied.

The emergence of underground psychedelic guides introduces a complex array of legal and ethical challenges that intersect with their role as facilitators of psychedelic experiences. These providers operate within a legal gray area, as their activities violate existing drug laws and regulations. This poses a significant risk not only to the providers themselves but also to the clients seeking their services. Law enforcement’s stance on underground psychedelic practices varies widely, leading to an environment of uncertainty and potential legal consequences for both parties involved.^11,12

Ethical considerations further complicate the landscape for underground psychedelic guides. One of the central ethical dilemmas revolves around the principle of informed consent.^13–18 Clients seeking psychedelic experiences are often in vulnerable states and ensuring that they possess a comprehensive understanding of the potential risks and benefits is challenging in an unregulated environment.^19,20 In addition, questions arise regarding the qualifications and expertise of these providers. The absence of recognized standards for training and credentials raises concerns about client safety and the potential for inadequate preparation and guidance during psychedelic sessions.^19,21 This ethical gray area extends to the providers’ own moral and philosophical justifications for their activities—balancing the desire to help individuals with the potential harm and legal repercussions associated with their services.

Navigating these legal and ethical challenges requires a delicate balance between the desire to provide support and the responsibility to prioritize client safety and well-being. The underground psychedelic community finds itself grappling with these issues as it seeks to establish ethical guidelines, harm reduction strategies, and potential pathways for legal recognition within a landscape that is rapidly evolving. Addressing these challenges is crucial not only for the providers themselves but also for the broader conversation surrounding responsible psychedelic use, harm reduction, and the ongoing shift in public perception of these substances.

The current use of underground psychedelic guides poses both legal and ethical challenges. Given the legal status of most psychedelics, these guides are operating outside the traditional medical system, further fragmenting care.²² Survey data suggest that many users of underground psychedelics are not disclosing their use to their medical providers, which may complicate care. Ethically, the use of underground psychedelic guides poses concerns about potential exploitation or boundary violations of patients seeking care.²⁰ The prohibitionist approach taken by many governments clashes with a growing body of research suggesting the therapeutic potential of these substances. Consequently, some individuals have become providers out of frustration with the slow pace of change within traditional medical systems. Some view their role as a form of civil disobedience or a way to directly challenge the established norms and perceptions of psychedelic substances. This phenomenon highlights the tension between public sentiment, evolving scientific understanding, and regulatory frameworks.

To bridge the gaps in understanding, practice, and law, this study intended to complete the following aims: (1) describe procedures surrounding underground psychedelic sessions, (2) capture the lived clinical experience of underground psychedelic guides, and (3) harness the knowledge of current guides to bolster research-based preparation for upcoming state and potential federal legalization of psychedelic-assisted psychotherapy.

Methods

Participants

We conducted purposeful sampling of underground psychedelic guides with diverse backgrounds and experiences. Participants were invited to participate through a list serve for our research center and snowball sampling through people who engaged in the study.

Study design

Individual, semistructured interviews (n = 13) focusing on each participant’s experiences, practices, challenges, and ethical perspectives were conducted using Zoom software. Qualitative content analyses of interviews with underground psychedelic guides revealed their insights into this novel therapeutic substance. To promote anonymity and confidentiality, we took into account additional ethical considerations and steps. Participants were encouraged to use proton email accounts and leave video off to increase their security, and a certificate of confidentiality was obtained for the study. Interviews lasted approximately 1 hour and were completed after participants engaged in consenting procedures with study staff and filled out a brief demographics and background survey. Each participant was provided a $40 gift card as gratitude for their participation.

Measures

Demographic information gathered included age, race, ethnicity, sex, gender identity, and highest educational level completed. Additional survey questions asked participants about the number of years of experience they had providing underground psychedelic sessions, whether they had personal experience with psychedelics, what state they provided underground psychedelic sessions in, and how they characterized themselves with respect to psychedelic therapy practice. In our qualitative interviews, we asked participants to tell us about their personal experience with psychedelics, the procedures surrounding psychedelic sessions, the process and detail of psychedelic sessions, and what they thought next steps for research and policy should be.

To address our first aim of understanding psychedelic session procedures, we asked participants to tell us about the diagnoses they targeted with their underground psychedelic sessions, dosages, typical number of sessions, client recruitment, session planning, follow-up, and the reasons behind their choices for each of these. We also asked about contraindications they were aware of and how they learned about the procedures they described. For aim 2 of the study, we gathered information on the process and details of the psychedelic sessions. To gather information on this, we asked participants to describe the experience of sitting with or guiding people during psychedelic sessions. We also asked about how they monitored people during the sessions, whether the sessions were combined with other types of therapy, whether their process changed based on diagnosis or goal of the person they were working with, how they measured progress/outcomes, and what obstacles they have run into in their practice. Finally, targeting our third aim, we hoped to learn what next steps for research and policy underground psychedelic guides felt would be most useful. To gather information on this, we asked what underground psychedelic guides wished they knew but did not. We also asked what they felt needed to be studied, and what changes they would like to see in policy.

Qualitative content analysis

A qualitative descriptive approach²³ with content analysis methods based on recommendations made by Schreier^24,25 was used to analyze interviews with (n = 13) Underground Psychedelic Assisted Psychotherapy (PAP) Providers. This method of analysis involves combining concept-driven and data-driven analysis approaches to the text. An audit trail, detailing analysis decisions and process, was kept throughout the analysis process to document thematic and coding decisions made by the team to promote transparency and reliability. The analysis team (which involved all authors, but J.R.) met 9 times. Each person read all transcripts independently, made marginal notes independently, and identified potential categories for the data independently. We then met to discuss, combine, and refine categories. Transcripts were then split among the group and coding was completed by placing quotes into the categories. When this was completed, the analysis team met to discuss any quote that fit multiple categories or appears not to fit the coding structure. After coding was finished, the team met to create themes from the categories based on the quotes within each.

Results

Participant characteristics

Participants were 13 adults, 18 years of age or older, who provided underground psychedelic sessions in the United States. All participants practiced in Washington state, 1 also practiced in California, another in Oregon, and another in Canada. Six of our 13 participants (46.2%) stated that they had received some sort of training in psychedelic-assisted psychotherapy. All but 1 of our participants referred to themselves as a guide or facilitator, with the one exception referring to himself as a Shaman. Along with the title of guide or facilitator, most participants also referred to themselves as various types of coaches or therapists. Every participant had used psychedelics. One participant indicated that they had used psychedelics 5 times, 6 indicated between 15 and 49 times, 2 between 50 and 100 times, three indicated hundreds of times, and 1 indicated that they had used psychedelics more than I can count” (note: participants did not indicate whether these were macro or micro dose sessions). All participants indicated that they had used psilocybin in their lifetime, 11/13 (85%) indicated that they had used lysergic acid diethylamide (LSD) in their lifetime, and 10/13 (77%) indicated they had used 3,4-Methylenedioxymethamphetamine (MDMA) in their lifetime. Many participants had jobs other than guiding, including being counselors, managers, students, software engineers, life coaches, and musicians. Additional descriptive statistics for the sample can be found in Table 1.

Table 1.

Descriptive Statistics

Variable name	N = 13 N (%) or mean (SD)
Demographic characteristics
Age	51.69 (14.65)
Biological sex assigned at birth
Male	6 (61.5%)
Female	4 (30.8%)
Not disclosed	3 (23.1%)
Gender
Male	7 (53.8%)
Female	6 (46.2%)
Race
White	13 (100%)
Ethnicity
Hispanic	1 (7.7%)
Not Hispanic	12 (92.3%)
Marital Status
Married	8 (61.5%)
Single	4 (30.8%)
Divorced/separated	1 (7.7%)
Highest education
Associate’s degree/2 years college	2 (15.4%)
Bachelor’s degree	4 (30.8%)
Master’s degree	7 (53.8%)
Years providing PAP	6.19 (10.51)

Themes identified

Analyses indicated that, although providers are unique in their preparation, dosing, administration, and follow-up process, each is consistent, yet flexible as they tailor their process and dosing to each client. Four themes describing participants’ perspectives and insights on underground psychedelic session provision emerged from the data.

These themes include (1) personal experiences and self-healing motivated sharing and promotion of the positive effects of psychedelics as an expression of altruism, (2) guides articulated consistent, yet flexible processes, (3) guides believed that the client benefit was actualized through their own intrinsic ability to heal themselves, and (4) guides expressed an overwhelming sense of dissonance regarding psychedelic legalization, not only desiring increased access and decreased risk but also expressing concern about potential negative impacts on provider flexibility, and depersonalization that could come with standardizing this field of practice.

Theme 1: Personal experiences and self-healing motivated sharing and promotion of the positive effects of psychedelics as an expression of altruism

Every guide we spoke with (13/13) said they were inspired by their own transformative experiences and the self-improvement they found through the use of psychedelics, driving them to become underground psychedelic guides, wherein they could share the experience with others and promote the positive effects. All the guides we spoke with described having experiences with psychedelics that resulted in life shifts or changes that were beneficial. They also explained that they enjoyed being able to help others through their psychedelic guiding.

I guess I discovered on one of my trips that what I was about was service. Now that I was retired, I could be of service. That’s where my joy came from was from providing some benefit to others. […] What I’m more interested in is facilitating others so that they could have the experience—positive experience that I’ve had.- Participant #5

By the end of a—so for me, it’s an experience of joy for me, gratification to see other people, to see their eyes open to different things, new possibilities to let go of unforgiveness, to let go of pain, to embrace spirit. The experience for me, I feel like, you know, there’s a sacred responsibility aspect to all this. I’m getting to be witness to someone’s rebirth, kind of. - Participant #4

Not only was I feeling it in my own healing, but I was automatically thinking about all of the opportunities within the trauma caseload that I had, that could benefit from it. - Participant #2

Theme 2: Guides articulated consistent, yet flexible processes

Although process varied across guide, each guide (13/13 participants) articulated a standard core set of processes, involving screening, dosing, planning, and follow-up, which formed the foundation of their client care, from which they individualized, based on client-level factors such as experience with the psychedelics, intention, medical and mental health, and history. Substantial differences were identified between providers in methods of screening, with some using 3rd party medical professionals to evaluate clients with in-depth safety checks, and some using a cursory medical history looking for contraindications. Multidisciplinary Association for Psychedelic Studies (MAPS) guidelines were referred to frequently across the transcripts, but often dosing was based on the provider’s personal experience.

It’s always individualized, but there’s a general template. I don’t diagnose. The person may be coming with a certain symptom, but that may not be their core issue. […] That is through a long process of intake and preparation with the client, even up until the day of the session. I’m determining what they are ready for based on their preparation, intention, experience, health, being fear-based. Those are a few of the criteria. - Participant #6

After about a week or so, I reach out just to see if they have any other questions coming up and check in with them. If they’re in a green light, we go ahead and schedule. Scheduling usually we schedule an all-day session. Then we schedule a bubble around it—a therapeutic bubble, which would be three to four—At least, three-to-four-hour long therapy prep sessions and a few integration sessions to follow as well. - Participant #3

Screening practices for potential contraindications varied across providers; however, each person described a standard process they used for screening. Nearly all the providers worked with medical providers or asked their clients to consult with a medical provider if they had any concern about contraindications.

I absolutely need them to consult their doctor and to tell their doctor they are planning on taking the medicine called ayahuasca and make sure their doctor knows about that and can clear them, so that’s if they take any prescription medications, if they have cardiovascular disease, including heart attacks, any infections, communicable diseases, diabetes, high or low blood pressure, any mental illness, recent surgery, past or recent physical injuries, including fractures and dislocation, glaucoma or retinal detachment, epilepsy, or asthma, and pregnancy and breastfeeding as well. - Participant #9

I have a really complex intake that is a medical professional’s intake. I can’t pretend to know all of the nuances of the questions. What I do do is every single person I work with who has any sort of abnormality in their medical intake, I will work with a medical professional. I like to know enough to know why. -Participant #2

[…] strongly recommending that people see their doctor before they take on a course of psychedelics. – Participant #13

Personalization of dosing was discussed by all participants in the study. Many of them began with a somewhat standard dose, based on their experience, education (e.g., reading the MAPS protocol), and client focus factors such as previous experience with the psychedelic. Guides then added “booster doses” until they felt they had reached an optimal dose (at times with input from the client). They noted that dosing for mushrooms varied based on the strain; however, typical doses noted ranged from 2 to 6 g and providers often noted starting with a dose near the lower end of the range and then adding smaller doses after approximately an hour depending on response. Dosing for MDMA was guided largely by the MAPS protocol, which was frequently referred to during the interviews. Most providers started with a 125 mg dose and then added boosters. Final doses of MDMA across a session ranged 125–400 mg. Ketamine, LSD, Mescaline, N,N-Dimethyltryptamine (DMT), and Ayahuasca use were also described, however, in less frequency and consistency, and therefore, they will not be described in detail in this study.

Participants spoke about personalization of dosing in general.

Well, the psychoactive substances are catalysts, and this work is not dose dependent. The reasons for the choices are based on their health; their experience; their state of being, their intention. - Participant #6

Participants spoke about personalization of dosing with mushrooms.

If they’re doing mushrooms only, then I—two and a half grams at the beginning, and then an hour later, another gram or more if they wanna go deeper.- Participant #7

Then for psilocybin, I start on the lower end with people who’s—again, I’m looking at what their experience is and everything taken into consideration starting somewhere around two or two and a half. Then either boosting or not boosting. Then going up to, I think, the most I’ve given anyone so far is seven grams of psilocybin. -Participant #8

[…] the real magic occurs at a deeper—a higher dose. Somewhere around three, three and a half, four, or five grams, depending on what people are asking for or where they wanna go with it. - Participant #13

Participants spoke about personalization of dosing with MDMA.

I’m also looking at their history with any medications, including these. I’m looking at how sensitive they are to medications. I’m looking at do they have any experience with these medicines. Then I adjust the dose based on all of that.

Then like intuition, which I know is totally scientific. I would say the range—if I had to give you a range would be somewhere between 130 on the low end up to, say, 250 on a high end. Most people are somewhere between 150, 175 total, maybe. -Participant #8

MDMA would be, I’d say, 125 milligrams plus the option for a booster dose, which would be half of that, aligned with the MAPS protocol, MDMA protocol. - Participant #10

Theme 3: Guides believed that the client benefit was actualized through their own intrinsic ability to heal themselves

Underground psychedelic guides described that much of what they are attempting to encourage and inspire is the same healing and introspection that they themselves experienced from the use of the psychedelics. Ten out of 13 of our participants explicitly described a self-healing process that was prompted by the use of psychedelics.

Descriptions harkened to the training and Carl Rogers’ therapeutic approach,^26,27 wherein the provider ‘gets out of the way’ and allows the client to heal themselves. The focus of the therapy is on the client’s intrinsic ability to heal self.

It’s really powerful to witness people discover the divine nature of themselves. That’s how I think of it. To watch people heal themselves—like I said, I don’t do a lot to get in the way of the process. It’s like watching someone discover spirituality for the first time in an embodied way. That’s incredibly powerful and life-affirming for me and validating of my own beliefs and the own healing that I’ve done. Yeah, it’s incredibly life-affirming work. - Participant #10

Also, there’s something meaningful in the fact that this profoundly helps a lotta people. Can’t help everybody, but man, just wish I could just show you a little documentary of all these different people that have come to see me. It’s not me really helping them. It’s just me gettin’ the fuck outta the way so they can help themselves with the medicine. - Participant #1

I am an attachment-oriented trauma therapist who happens to have extensive training in certain plant medicine allies that have incredible capacities to help you heal yourself ‘cause that’s what you’re doing. You’re healing yourself - Participant #2

Theme 4: Guides expressed an overwhelming sense of dissonance regarding psychedelic legalization

Underground psychedelic guides not only expressed a desire for increased ease of access and decreased risk associated with providing psychedelic sessions but also described a hesitance and worry about the effects these changes could have on the freedom and flexibility of individual providers and a fear of the depersonalization that could come with standardizing this field of practice (10/13 participants explicitly described both interest and concern). With this standardization, they expressed concerns about the risk of undermining the value system that is intertwined with the process currently.

It’s good and bad that there’s no gatekeeping, and then it’s gonna be good and bad when there is gatekeeping because there’s no restraints, and there’s no accountability on other people in this space. There’s some really screwed up people that get into this stuff for purposes of their own ego and their own gratification. - Participant #1

I think from a social justice standpoint and also kind of a public opinion standpoint, I’m really hopeful that those efforts will move forward. I think that the investment in educating people about making informed decisions about the risks and benefits of these medicines we need investment in that so that people can make their own decisions. - Participant #2

I think there is a pressing need for normatized, standardized ethical guidelines. I mean, I don’t spend a whole lot of time worrying about this, but I’m certainly aware of it, and it concerns me at times that we are in the Wild West, so to speak, in terms of underground therapy, there’s a lot of really good underground therapy. Then the need for some kinds of, you know, modified systems of ethics, obviously, are going to, as time goes on the need for those is going to increase. […] I know some, like <State>, are hoping that maybe having some licensure will help—that’s one step. Although my one anxiety around that is, there are people doing work like I have done in a community-based way, without licensure that have been doing really good work for a long time. -Participant #4

Discussion

The study, which builds on previous research exploring spiritual health practitioners’ contributions to psychedelic-assisted therapy,²⁸ explores the experience of underground psychedelic guides identifying four key themes: (1) the influence of providers’ personal experiences and motivations on their practice, (2) the need for a consistent yet adaptable process to meet patient needs, (3) the widespread belief in the innate healing ability of individuals, and (4) complex feelings surrounding the legalization of psychedelics. To our knowledge, this is the first qualitative study exploring themes derived from underground psychedelic guides.

Psychedelic psychotherapy occupies a unique and challenging position in the field of mental health, where patient interest and demand are outpacing the current scope and speed of clinical research. This burgeoning interest is driven by anecdotal reports and preliminary studies suggesting significant therapeutic benefits for conditions like treatment-resistant depression, Post Traumatic Stress Disorder (PTSD), and addiction. However, the rigorous, systematic research is necessary to fully understand and safely integrate these treatments into mainstream psychiatry lags. This disparity is due to several factors, including historical stigmatization of psychedelics, regulatory barriers, and the complexity of conducting controlled studies with psychoactive substances. Consequently, while there is a growing public enthusiasm and a push for wider access to psychedelic therapies, the scientific community is racing to provide comprehensive, evidence-based guidelines on their use, safety, and long-term efficacy. This gap presents both a challenge and an opportunity for researchers and clinicians to navigate integrating psychedelic-assisted treatments into current clinical practice.

The study highlights the evolving landscape of psychedelic-assisted psychotherapy, particularly in the underground sector, where providers are adapting their practices in response to the unmet needs of patients. These providers are driven by a combination of personal experience, altruistic motives, and dissatisfaction with current medical frameworks. Their approaches, which vary in terms of screening, dosing, and planning, are tailored to individual client needs and are based on a mixture of medical and spiritual perspectives. This flexibility allows them to address a range of mental health issues, suggesting the potential for PAP to fill gaps in conventional treatment modalities, especially for patients not adequately served by traditional therapies.

The study also underscores the need for a nuanced understanding of psychedelic-assisted psychotherapy in shaping future research and policy. Guides’ experiences point toward the necessity of developing ethical and legal frameworks that accommodate the unique aspects of psychedelic-assisted psychotherapy, including its potential for personalized healing and introspective growth. Moreover, the findings raise important considerations for the potential legalization and regulation of psychedelic substances, highlighting the balance between accessibility and maintaining the integrity of the therapeutic process. As psychedelic-assisted psychotherapy continues to gain interest, these insights are vital for policymakers and healthcare professionals in creating supportive structures that ensure safe, effective, and ethical use of psychedelics in therapy.

Strengths and limitations

This study is strengthened by our ability to capture the lived experiences of an extremely difficult to reach group of underground psychedelic guides in the United States, where current underground practices are working in parallel, and in some places, in advance of the current legal landscape. Through qualitative interviews, participants were able to provide detailed information on their experiences, processes, beliefs, and perspectives.

There are limitations to this study, however, that should be emphasized. Due to our sampling techniques, many of our participants were from the Pacific Northwest, limiting our geographic and racial/ethnic perspectives. Underground psychedelic guides in other areas of the United States or people with different racial/ethnic backgrounds may have different experiences. In addition, all data collected were through self-report. These reports may have been influenced by social desirability, wherein participants may have responded in the manner they believed we wanted them to. Our sample was also diverse in the number of psychedelic sessions each person had administered and the length of time participants had been providing psychedelic sessions. This limits generalization, but also provides data that may characterize themes present even among this diverse group of psychedelic guides. In addition, although our team put many safeguards into place and notified participants of these safeguards, conversations may also have been influenced by fear of legal repercussions.

Conclusion

Discussions with underground psychedelic guides allowed us to garner information on the state of the practice of using this novel therapeutic underground in the United States. Results suggest that the approach used currently in the underground may be substantially different from that which is being developed through research and conventional practice. This information allows us to discuss experiential administration practices and suggestions for future research from the underground field.

Authors’ Contributions

C.L.S.: Conceptualization, formal analysis, funding acquisition, methodology, project supervision, visualization, writing—original draft, and writing—reviewing and editing. N.S.: Conceptualization, formal analysis, visualization, writing—original draft, and writing—reviewing and editing. B.C.S.: Data curation, formal analysis, investigation (data collection), project administration, writing—original draft, and writing—reviewing and editing. V.D.: Data curation, formal analysis, and investigation (data collection). E.W.R.: Data curation, formal analysis, investigation (data collection), writing—original draft, and writing—reviewing and editing. J.R.: Funding acquisition, project supervision, and writing—reviewing and editing.

Author Disclosure Statement

None of the authors or their spouses or partners have had a personal, commercial, political, academic, or financial interest or relationship that might potentially bias and/or impact the content of this article.

Funding Information

This study was funded by Washington State University’s Elson S. Floyd College of Medicine Research Funds.