By Neşe Devenot, Emma Tumilty, Meaghan Buisson, Sarah McNamee, David Nickles, and Lily Kay Ross
Amid accelerating interest in the use of psychedelics in medicine, a spate of recent exposés have detailed the proliferation of abuse in psychedelic therapy, underscoring the urgent need for ethical guidance in psychedelic-assisted therapies (P-AT), and particularly relating to touch and consent.
Acknowledging the need for such guidance, McLane et al. outline one set of approaches to touch in a recent Journal of Medical Ethics blog. However, we find their piece at odds with the available information in the fields of P-AT and psychotherapy. We explain three major concerns: consent and autonomy, risk mitigation, and evidence and reasoning. In our view, these concerns merit a precautionary approach to touch in P-AT, given the current state of research on touch-based interventions.
Consent and Autonomy
McLane et al. attempt to complexify the notion of consent in altered states by presenting contradictory assertions that patients can be more authentic in altered states (enhanced capacity for consent) and that they can become regressed (increased need for touch but impaired capacity for consent). This is presented as a dilemma for clinicians who must weigh both possibilities equally; however, neither assertion has been adequately investigated in the P-AT literature, and the notion of “enhanced capacity” in altered states is neither supported by evidence nor by legal definitions of consent.
Conditions for autonomous decision-making rely on the ability to comprehend and weigh information. Some research has shown that psychedelics impair cognition, executive function, and memory in ways that could undermine informed decision-making. Further, the client-therapist(s) relationship in P-AT presents greater vulnerabilities than the typical power imbalance in psychotherapy, due to psychedelic-induced suggestibility — increasing susceptibility to manipulation — and memory impairment. We agree that the numerous reports of therapist transgressions (sexual and non-sexual) require proactive approaches, but we argue that this should focus on greater boundary definition and maintenance, not less.
McLane et al. also equate the therapeutic harms of refusing to provide touch with the risk of harms related to unwanted or inappropriate touch. They provide no evidence to support this claim. Potential harm from a refusal of touch in trauma therapy can be successfully mitigated by skillful therapist responses. Given allegations of inappropriate sexual and non-sexual touch in P-AT, resulting in serious and lasting harms, we are concerned this may be a false equivalency.
Because touch may exacerbate pre-existing traumas at a time when client vulnerability is increased, a precautionary principle approach seems more appropriate. The precautionary principle advocates that in the absence of evidence (for benefit of touch or harm of denied touch) alongside knowledge of potential threats (unwanted sexual/non-sexual touch and sequelae), a risk-averse approach should be taken.
This is particularly relevant given historical and current patterns of abuse by psychedelic therapists (see for example: here, here, here and here). Avoiding a risk of harm is more justified than an ad hoc approach in a setting where such harms are known to occur. While we do not endorse a slippery slope argument regarding touch (i.e., that all touch leads to sexually inappropriate touch), we recognize that an environment that lacks defined boundaries provides shelter for predatory behavior as well as increased opportunity for unintentional transgressions.
To ensure clear and safe boundaries, therapists should prioritize non-touch methods of comfort. We are concerned that the uncritical promotion of touch as an integral part of the P-AT healing process may lead to an overreliance on touch to the detriment of therapeutic interventions that help build clients’ self-soothing capacities. While brief non-sexual touch may be helpful in alleviating severe distress or providing nurturance, it may also carry unidentified risks and should be researched, theorized, and debated before widespread dissemination as a valid therapeutic tool.
Importantly, current processes of accountability for both training standards and practice standards in this area are nascent. In the emerging psychedelics industry, the institutions and actors that require oversight and regulation are positioning themselves as regulators. This raises significant concern regarding regulatory capture and conflicts of interest, and may result in the type of “ethics washing” that has been discussed in other industries.
Evidence and Reasoning
Lastly, we have observed a pattern of uncritical transmission of information about best-practices and methodologies within the P-AT field. When tracing back references in the literature that justify interventions like touch, one often finds they are opinions from first-wave researchers, repeated so often and uncritically that they have become accepted as fact despite little empirical investigation. This is not an acceptable level of evidence given the degree of patient vulnerability and the need to address serious and widespread records of harms. The phenomenon of citing anecdotal evidence as if it is scientific evidence appears across training materials, research articles, and general discussions by stakeholders (e.g., Mithoefer & Haden). We call on those promoting psychedelic therapies to uphold the field and patient safety ethically and effectively through rigorous evidence generation, improved training, evidence-informed standard setting, and external licensing/practitioner oversight.
Neşe Devenot, PhD is a Postdoctoral Associate at the Institute for Research in Sensing (IRiS) at the University of Cincinnati and the Medicine, Society & Culture Research Fellow at Psymposia. She teaches Psychedelic Bioethics at The Ohio State University, and she previously completed a postdoctoral fellowship in the Department of Bioethics at the Case Western Reserve University School of Medicine.
Emma Tumilty, PhD is a bioethicist and lecturer in the School of Medicine at Deakin University. She does research, publishes, teaches, and consults in the areas of research ethics and clinic ethics and is an Associate Editor for the journal Progress in Community Health Partnerships and a Book Review Editor for the International Journal of Feminist Approaches to Bioethics.
Meaghan Buisson, BSc, is a professional wilderness guide who manages risk in challenging, complex terrain. An advocate for ethical research with human subjects, she has worked as a research assistant on multiple clinical trials and conducted extensive research into clinical drug trials.
Sarah McNamee, MSW, is a mental health clinician whose work focuses on helping people heal from relational trauma and helping professionals better understand the complex sequelae and treatment needs of trauma survivors. She divides her time working directly with survivors of interpersonal violence, training therapists and other helping professionals, and doing research on the development, implementation and evaluation of trauma-informed practices.
David Nickles is Managing Editor of Psymposia, a non-profit media organization that operates as a watchdog and think tank, engaging with critical issues at the intersection of drugs, politics, and culture. He has contributed to public psychedelic research and harm reduction efforts through a variety of organizations and outlets since 2009.
Lily Kay Ross, MDiv, PhD has been taking a feminist approach to theorizing psychedelic ethics since 2009, especially with regard to sexual misconduct, abuses of power, and gendered violence. She works to advance best practice prevention and evidence based institutional policies for sexual harm.
Disclosures: Dr. Devenot is an unpaid board member of Psymposia, a 501c3 nonprofit research organization. Ms. Buisson and Ms. McNamee have both participated in previous MAPS trials.