Psychedelic Therapist Sexual Misconduct and Other Adverse Experiences Among a Sample of Naturalistic Psychedelic Users

Abstract

Introduction:

Psychedelic substances have been used for centuries in various cultural and religious contexts, and more recently, in clinical research and therapy. There is a surge of interest in psychedelics, and psychedelic-assisted psychotherapy is becoming increasingly accessible. However, most individuals using psychedelics do so outside of therapeutic contexts. It is important to understand the adverse experiences that may occur with psychedelic use, as well as adverse events that may happen even in therapeutic contexts.

Materials and Methods:

We conducted an anonymous online survey of individuals who self-reported past psychedelic use. We asked about the frequency of experiencing 12 different adverse experiences when using psychedelics, and if they or someone they know was the victim of inappropriate sexual contact by a psychedelic sitter, guide, or practitioner. Participants could also describe other adverse experiences.

Results:

Among 1,221 participants, most reported having adverse experiences such as being frightened (74.3%), sadness (58.6%), feeling their body shake or tremble (54.3%), and loneliness (51.6%) during their psychedelic experiences. About half of participants reported having some other adverse experience, and one in ten participants had adverse physical reactions. About one-third of participants knew someone who was arrested for possession or use of psychedelics; 8% reported that they or someone they know was the victim of inappropriate sexual contact by a psychedelic sitter, guide, or practitioner; and one-quarter of participants knew someone who experienced a severe adverse event other than inappropriate sexual contact or arrest.

Conclusion:

Despite beneficial effects, psychedelic experiences can also be challenging, distressing, or even harmful. Adverse events can increase the risks of psychological harm, legal problems, stigma, and public health issues. Therefore, it is essential to prevent, identify, manage, and treat adverse events during psychedelic experiences to ensure the safety and well-being of the participants and the facilitators, and create opportunities for “integration” even with unguided sessions.

Introduction

Classical psychedelics (e.g., psilocybin, Lysergic acid diethylamide [LSD]) and related compounds (e.g., 3,4-methylenedixoymethamphetamine [MDMA]) are increasingly studied for their potential health benefits, particularly when paired with psychotherapy.^1,2 Although numerous clinical trials have yielded generally positive efficacy and safety outcomes primarily for the treatment of depression, posttraumatic stress disorder (PTSD), and substance use disorders, disagreement and uncertainty remain regarding the potential for adverse effects related to the drugs and concomitant psychotherapy treatment.³ The ‘moral panic’ and War on Drugs that followed the first wave of psychedelic research in the mid-20th century fueled myths and misinformation about risks related to psychedelics.⁴ More recently, enthusiasm around the therapeutic potential of psychedelics has caused both patients and researchers to downplay the adverse effects, which have been argued to be understudied.⁵ These concerns are highlighted by a recent report from the Institute for Clinical and Economic Review (ICER),⁶ in which they argued that this bias led to flawed research design in the clinical trials for MDMA-assisted therapy, which may have favored recording positive outcomes, while failing to capture serious adverse events. Nonetheless, as psychedelic therapy becomes increasingly accessible through voter-initiated ballot changes and potential U.S. Food and Drug Administration (FDA) approval in the future,^7,8 a more thorough and transparent characterization of the potential adverse effects of psychedelics is needed to inform potential users of risks and develop strategies to address them. There are concerns with the current scarcity of research on the adverse effects of psychedelics and calls for more studies,⁵ a concern highlighted by comments to the FDA advisory committee related to insufficient safety reporting in the review of MDMA.⁶

In terms of established risks, classical psychedelics have well-known effects on peripheral physiology, such that heart rate, body temperature, and blood pressure increase acutely, while under the influence of the drugs.⁹ Because of this, cardiovascular conditions are often listed as exclusion criteria in psychedelic clinical trials.¹⁰ There have also been naturalistic reports of seizures among patients with epilepsy,¹¹ so these individuals are usually excluded as well. Beyond this, psychedelics have not been shown to pose serious medical risks and are low in abuse potential and toxicity.^12,13 The primary risks that have been associated with psychedelic use are psychological, including the capacity for a psychologically challenging experience (i.e., “bad trip”), which can be highly distressing and potentially destabilizing for some individuals.¹⁴ These experiences can include fear, grief, paranoia, isolation, death, physical distress, confusion, troubling visions, and feelings of insanity.^15,16 Long-term negative effects may persist well after the acute psychedelic experience,¹⁷ including re-experiencing adverse mental or physiological states (e.g., nausea).¹⁸ The most common persisting adverse mental states include anxiety and fear, existential struggle, social disconnection, depersonalization, and derealization, sometimes persisting for years.¹⁷

In addition, although psychedelic use is associated with reduced suicidality at the population level,¹⁹ there is concern that some may be at increased risk of suicide after psychedelic experiences. Whereas individual risk factors for suicide have thus far been elusive, rates of suicidal behavior were higher in the treatment groups (10 and 25 mg) compared to the control group (1 mg) in a recent clinical trial of psilocybin for treatment-resistant depression.²⁰ Despite this finding, the treatment groups still demonstrated a robust antidepressant effect compared to the control—underscoring the wide variability in treatment outcomes and uncertainty regarding safety at the individual level.²¹ There are also concerns with the underreporting of adverse events in clinical trials.²² Finally, Hallucinogen Persisting Perception Disorder (HPPD), which is characterized by persistent alterations in perceptual processing, following the use of a psychoactive drug, is an additional risk, but prevalence estimates vary widely.^23,24 Some hypothesize that HPPD may be a form of anxiety⁴ or traumatic anxiety disorder similar to PTSD.²⁵

As psychedelics can induce a state of suggestibility and increased vulnerability,²⁶ there is also an emerging discussion in the field regarding the potential for therapist abuse and sexual misconduct from providers.²⁷ Indeed, there have been sporadic reports of misconduct from ‘underground’ psychedelic therapists for years,^27,28 and even in the confines of a highly regulated clinical trial, there has already been at least one case of serious boundary violations during and after treatment with MDMA-assisted therapy.⁵ Although this is a problem shared with traditional psychotherapy, the increased suggestibility and vulnerability induced by psychedelics make it a particularly important issue to address before these treatments are disseminated more widely. Understandably, there is a high incidence of previous trauma, including sexual trauma, among those taking psychedelics in therapeutic settings.^27,29,30 To our knowledge, only one other project has measured the prevalence of inappropriate sexual contact among those using psychedelics. About half of those participating in Peruvian ayahuasca ceremonies and retreats heard about an incident of sexual abuse in ayahuasca settings or experienced it themselves.³¹

In this study, our goal was to describe the frequency of a wide variety of possible adverse experiences with psychedelics, including inappropriate sexual contact, among individuals who use psychedelics naturalistically. We hypothesized that psychedelics would generally be well-tolerated physically, but that some participants would report psychological adverse events or inappropriate contact from companions who were present before, during, or after their experiences.

Materials and Methods

This study was designed to capture the prevalence of a variety of possible adverse experiences with psychedelics, including inappropriate sexual contact, among individuals who use psychedelics naturalistically. All study procedures were approved by the University of Michigan Health and Behavioral Sciences Institutional Review Board (protocol HUM00205639). Participants were not compensated and could withdraw at any time.

We developed an anonymous, confidential, online Qualtrics survey to investigate the naturalistic use of psychedelics. This study, which is part of a larger multicomponent survey, reports on the subset of measures targeted at psychedelic-related adverse effects. Participants were recruited in person at Entheofest, a psychedelic advocacy event in Ann Arbor, Michigan, on September 18, 2022, as well as through email listservs and social media platforms (e.g., Reddit, Facebook) for psychedelic interest groups from September 18 to November 05, 2022. The “Prevent Ballot Box Stuffing” setting in Qualtrics was used to prevent duplicate responses. Survey items were collaboratively designed by academic researchers experienced in survey design with input from various stakeholders in the psychedelic community, including therapists and psychedelic advocacy groups. Items related to adverse experiences with psychedelics were inspired by case reports, naturalistic studies, cross-sectional research, and clinical trial outcomes noting negative outcomes.³² Adults 18 years of age and older, who had taken a psychedelic substance and had not previously completed the survey, were eligible to participate in the study.

We asked, “Do you know anyone (including yourself) who has been the victim of inappropriate sexual contact by a psychedelic sitter, guide, or practitioner?” and followed up with details about who engaged in the inappropriate behavior with response options: Therapist in a medical clinic, Support staff in a medical clinic, Therapist in a clinical or research study, Support staff in a clinical or research study, “Underground” therapist or guide, Friend or acquaintance, Family member, Participant at a retreat, or Other. Next, we asked, “Do you know anyone (including yourself) who was arrested for possession or use of psychedelics?” and “Do you know anyone who experienced a severe adverse event (e.g., psychosis) because of the use of psychedelics? (other than inappropriate sexual contact or arrest)” (Response options: Yes, No). Those who responded affirmatively to the latter question were asked, “Did the person who experienced a severe adverse event have guidance from someone who was knowledgeable about psychedelics…” with items “…before the experience,” “…during the experience,” “…after the experience,” and response options were as follows: Yes, No, or Don’t Know.

In the next section, we asked “How often have you experienced the following when using psychedelics?” with the following response options: Never, Rarely, Sometimes, Often, Very Often, or Always. Items were as follows: Being frightened, Despair, Experience of antagonism toward people around you, Experience of isolation and loneliness, Fear that the state you were in would last forever, Fear that you might lose your mind or go insane, Feel as if dead or dying, Feel body shake/tremble, Feeling that people were plotting against you, Panic, Pressure or weight in chest or abdomen, Sadness, and Other adverse experience. Those who selected “Other adverse experience” were asked to explain what the experience entailed.

A coding scheme was developed to quantify content in the “Other adverse experiences” description. The team developed major categories and subcategories after reviewing the raw data. Two coders independently assigned categories to participants’ content and resolved discrepancies to generate a final set of codes. Descriptive statistics were utilized to quantify proportions for qualitative items, as well as major categories and subcategories.

Results

Overall, 2151 surveys were initiated and 1287 were completed (59.8% completion rate). Individuals who reported never taking psychedelics (n = 66) were excluded, resulting in a final sample size of 1,221. Participants reported hearing about the survey through social media (57.2%), email (26.5%), at the Entheofest event (7.9%), and some other mechanism (7.8%); 17.1% of participants reported attending Entheofest. The median time to complete the survey was 25.0 min.

The participant sample predominantly identified as White (84.6%), with other respondents identifying (inclusively) as Hispanic or Latino/a/x (6.1%), Native American (4.3%), African American or Black (3.2%), Asian (2.8%), Native Hawaiian or Pacific Islander (0.4%), and Other (4.8%). Respondents identified as women (48.2%), men (46.5%), nonbinary gender (2.1%), transgender (0.5%), gender fluid (0.3%), and some other gender identity (1.9%). Participants were 39 years of age on average (SD = 12) and had 15 years of education (SD = 2). Most participants (96.0%) lived in the United States, predominantly in Michigan (62.1%), with 30.9% in 42 other states.

We found that 7.9% of participants reported knowing someone (including themselves) who had been the victim of inappropriate sexual contact by a psychedelic sitter, guide, or practitioner (Table 1). Among these participants, the most common sources of these boundary violations were “underground” sitters or guides (46.3%), friends or acquaintances (21.1%), “underground” doctors or therapists (7.4%), and shamans/guides at retreats (6.3%). About one-third of participants knew someone who was arrested for possession or use of psychedelics and about one-quarter of participants knew someone who experienced a severe adverse event because of the use of psychedelics, other than inappropriate sexual contact or arrest (Table 1).

Table 1.

Proportions of Participants Reporting Adverse Events (n = 1221)

Item	Proportion (%)
Do you know anyone (including yourself) who has been the victim of inappropriate sexual contact by a psychedelic sitter, guide, or practitioner?
Yes	7.9
No	92.1
The person who engaged in inappropriate behavior was a…
“Underground” sitter or guide	46.3
Friend or acquaintance	21.1
“Underground” doctor or therapist	7.4
Shaman/Guide at a retreat	6.3
Therapist in a clinical or research study	4.2
Family member	2.1
Participant at a retreat	2.1
Therapist in a medical clinic	1.1
Support staff in a medical clinic	1.1
Other	8.4
Do you know anyone (including yourself) who was arrested for possession or use of psychedelics?
Yes	31.0
No	68.8
Missing	0.2
Do you know anyone who experienced a severe adverse event (e.g., psychosis) because of the use of psychedelics? (other than inappropriate sexual contact or arrest)
Yes	24.5
No	75.3
Missing	0.2
Did the person who experienced a severe adverse event have guidance from someone who was knowledgeable about psychedelics…
Before the experience [% Yes]	39.1
During the experience [% Yes]	30.1
After the experience [% Yes]	44.0

Most participants reported being frightened (74.3%), sadness (58.6%), feeling their body shake or tremble (54.3%), and loneliness (51.6%) during their psychedelic experiences (Table 2). Nearly half of participants experienced panic (50.0%), despair (48.7%), and fear that the state they were in would last forever (48%). At least a quarter of participants experienced pressure or weight in their chest or abdomen (37.8%), feeling as if they were dead or dying (37.7%), fear that they might lose their mind or go insane (36.5%), and antagonism toward people around them (32.3%). Nearly one-quarter reported feeling that people were plotting against them (23.8%). Most of the participants who reported these experiences had them only rarely or sometimes when using psychedelics. The most frequently reported adverse experiences (reported as often, very often, or always) were feeling their body shake or tremble (10%), being frightened (7%), and sadness (6%).

Table 2.

How Often Have You Experienced the Following When Using Psychedelics?

Experience	Never	Rarely	Sometimes	Often	Very often	Always	(Missing)
Being frightened	25.7	37.7	29.2	5.0	1.4	0.4	0.7
Sadness	41.4	28.3	23.5	4.1	1.6	0.2	0.9
Feel body shake/tremble	45.7	21.4	22.0	7.4	1.9	0.8	0.8
Isolation and loneliness	48.4	28.3	18.8	2.5	1.0	0.3	0.7
Panic	50.0	32.7	14.7	1.1	0.2	0.3	1.0
Despair	51.3	30.5	15.1	1.3	0.7	0.1	1.1
Fear that the state you were in would last forever	52.0	26.4	17.0	3.3	0.5	0.2	0.7
Pressure or weight in chest or abdomen	62.2	20.3	12.7	2.9	0.9	0.2	0.7
Feel as if dead or dying	62.3	19.0	13.2	3.1	1.6	0.2	0.7
Fear that you might lose your mind or go insane	63.5	22.8	10.8	1.8	0.3	0.1	0.7
Antagonism toward people around you	67.7	22.0	7.9	1.1	0.3	0.1	0.8
Feeling that people were plotting against you	76.2	16.8	4.9	0.9	0.2	0.1	0.9
Other adverse experience	48.1	10.5	11.2	4.0	2.5	2.0	21.7

About half of participants reported having some other adverse experience (51.9%, Table 2). The most common theme, mentioned by one in ten participants, was for adverse physical reactions during one’s psychedelic experience (Table 3). Muscle tension, stomach pain or cramping, and issues with temperature regulation (feeling chilled, sweating, etc.) were the most common experiences of this theme. The next most common theme, experienced by nearly one in ten participants, was for mental health issues during one’s psychedelic experience. Anxiety, dissociation, and paranoia were the most common experiences of this theme. Some participants noted that adverse experiences are part of the healing process, others explicitly mentioned positive experiences, despite the framing of the question. Very few participants (0.2%) mentioned adverse experiences or conditions persisting beyond the period of trip.

Table 3.

Proportions of Participants Noting Other Adverse Events and Experiences

Type	Proportion
Physical reactions during psychedelic experience	9.9
Muscle tension	3.5
Stomachache/pain/cramping	1.1
Temperature regulation (feeling chilled, sweats, etc.)	0.8
Mouth dryness	0.4
Heart palpitations	0.3
Bladder/urination issues	0.2
Diarrhea	0.2
Headache/migraine	0.2
Nausea	0.2
Fainting	0.1
Other physical reaction	2.0
Mental health issues during psychedelic experience	8.9
Anxiety	1.8
Dissociation	1.1
Paranoia	0.8
Confusion	0.6
Mental thought loop	0.6
Ego death (with adverse reaction)	0.4
Insomnia	0.3
Social anxiety	0.3
Catatonia	0.2
Crying	0.2
Delusions	0.2
Alteration in perception of time	0.2
Other mental health-related experience	2.1
Positive experiences	1.2
Enjoyment	0.3
Happiness	0.3
Spiritual experience	0.2
Euphoria	0.2
Enlightenment	0.2
Properties of psychedelic experience	0.7
Bad/inappropriate setting	0.3
Bad trip—no elaboration	0.2
Excessively intense high/overdose (nonlethal)	0.2
Adverse experiences are part of the healing process	1.6
Adverse experiences or conditions persisting beyond period of trip	0.2
Adverse behaviors during psychedelic experience	0
Adverse consequences	0
Other experience adverse events and experiences	1.2

Note: Major themes are listed in italics with the proportion of participants expressing content related to each major theme. Specific themes nested within each major theme are listed below each major theme with the proportion of participants expressing content related to each specific theme.

Discussion

Despite growing enthusiasm surrounding the potential therapeutic applications of psychedelic drugs, it is important to carefully characterize and understand their potential adverse effects to minimize harm, as is routinely done with all approved treatments and medications. A small (8%) portion of participants reported knowing someone who was the victim of inappropriate sexual contact by a psychedelic sitter, guide, or practitioner. The offending individuals were primarily underground sitters or guides and friends or acquaintances. As the use of psychedelic drugs is scaled up from research trials to clinical practice of psychedelic-assisted therapy, the potential for abuse must be carefully considered.

Although sexual abuse is an issue shared with traditional psychotherapy, it is particularly concerning with psychedelics, given the acute vulnerability and increased suggestibility that accompany the subjective effects induced by these drugs.²⁶ Psychedelics may also affect therapeutic alliance between client and provider,³³ arguably to a fault in some cases, putting the patients at even greater risk of suggestion. Indeed, McNamee et al.⁵ describe the case of an MDMA-assisted psychotherapy study participant who was inappropriately touched during an MDMA dosing session, developed an extreme bond and dependency with the (married) therapist dyad, and subsequently moved in with them after the study ended, while the sexual misconduct continued. The journal Psychopharmacology recently retracted three articles based on this clinical trial due to unethical conduct and failure to disclose conflicts of interest.^34–36

Four out of five participants in Peruvian ayahuasca ceremonies or therapies were aware that sexual abuse is an issue in ayahuasca settings, even if they did not know anyone affected.³¹ The Chacruna Institute released the Ayahuasca Community Guide for the Awareness of Sexual Abuse to raise awareness of the issue and promote safety guidelines,³⁷ which have led to more cautious behavior in about one-third of ayahuasca ceremony participants surveyed.³¹ The Multidisciplinary Association for Psychedelic Studies developed a code of ethics for psychedelic psychotherapy, which prohibits sexual touch and mandates consent for therapeutic touch.³⁸ The use of multiple therapists during dosing and video-recording sessions might buffer against some of these instances of inappropriate behavior, but even with these safeguards implemented in the context of a tightly controlled and regulated clinical trial, it is evident there is still the potential for ethical misconduct. Therefore, stringent licensure and close regulatory oversight of psychedelic treatment providers will be critical to reduce the risk of possible harm and abuse for patients.³⁹

As the commercialization and medicalization of psychedelic treatments approach,⁴⁰ it will be crucial to characterize the range of potential adverse experiences one could be exposed to throughout the course of psychedelic treatment to identify and implement effective harm reduction strategies. Our study found several acute and persisting adverse experiences that were most often rated as “rare” or “uncommon,” but it is important to note that “rare” and “uncommon” does not mean “never.” Even if certain side effects are not experienced by most patients, they can cause considerable personal and societal harm. Therefore, careful screening and monitoring of patients, along with proper vetting, training and oversight of providers will be essential if psychedelics are implemented more widely in clinical practice.

Limitations

Although this study provides valuable information regarding potential risks that can occur during or following psychedelic use, there are several limitations that should be noted and addressed with future research. First, the retrospective nature of the survey is subject to recall bias and potential misremembering. Our study also combines effects from a wide number of psychedelic drugs (e.g., LSD, psilocybin, MDMA, etc.), and it may be the case that certain substances confer higher or lower prevalence of specific adverse effects. For instance, the “empathogenic” and social bonding properties of MDMA could theoretically raise the potential for boundary violations or ethical misconduct relative to other psychedelics. We asked specifically about the adverse events and experiences found in Tables 1 and 2, although the broader range of other adverse events and experiences found in Table 3 were generated by participants in response to an open-ended question. It is possible that the proportions of participants reporting these specific experiences would be higher if they were asked about directly. Finally, the study utilized a convenience sampling approach, which allowed us to capture a large sample of participants, but is not representative of the general population using psychedelics.

Conclusion

To conclude, we surveyed a large sample of individuals reporting naturalistic psychedelic use regarding the occurrence of adverse experiences with psychedelics, including acute and persisting effects, as well as inappropriate sexual contact by a psychedelic sitter, guide, or practitioner. We found that almost 1 out of every 12 participants (7.9%) indicated experiencing or knowing someone who experienced sexual violations in the context of psychedelic use. Several other serious adverse mental and physical health side effects were reported as well, with most being uncommon. Future controlled trials and nationally representative survey studies with psychedelics should continue monitoring these potential side effects to facilitate informed risk/benefit assessments and to develop improved harm reduction practices.

Authors’ Contributions

D.J.K. contributed to the creation of the project, analysis of data, significant contributions to the article, and final approval. J.S.A. made significant contributions to inference of data, drafting and revising the article, and final approval. C.W.F. and N.K. contributed to the analysis of data, critical revisions of the article, and final approval. N.G.G., J.B., M.H., and K.F.B. were involved in creation of the project, critical revisions of the article, and final approval.

Author Disclosure Statement

K.F.B.’s effort on this publication was partially supported by the National Institute on Drug Abuse of the National Institutes of Health under K01DA049219. N.G. owns stock in Cybin Inc., Mind Medicine Inc., Numinus Wellness, Revive Therapeutics, Braxia Scientific, and Compass Pathways. K.F.B. has received grant funding from Tryp Therapeutics for protocol development and sits on a data safety and monitoring board for an ongoing clinical trial with Vireo Health (unpaid). J.B. is the Founder/President of the Michigan Psychedelic Society and is a Psychedelic Integration and Music Therapist at Blue Sage Health Consulting.

Funding Information

No funding was received for this article.