Psychedelic workers of the world, unite!

Guides are shouldering the expectations generated by massive hype, but are underpaid, under-celebrated and sometimes exploited.

A new type of worker is emerging in the western world – people who sit with other people while they trip. There are different roles with different names, different training and different belief systems – guides, facilitators, psychedelic therapists, trip-sitters, chaplains, shamans. It’s important to know the differences between these roles. But they involve some of the same work and same challenges. While the magic chemicals are celebrated as otherworldly saviours (‘Fantastic Fungi’, ‘the God molecule’ etc), the people sitting with other people while they’re on these drugs are under-appreciated, under-paid and exploited.

Here's one example. A therapist with prior experience and training in psychedelic therapy embarked on a career in above-ground psychedelic facilitation. He worked at one retreat centre which went bust, then was hired by another psychedelic retreat centre in a developing country. He says:

I knew right away it was a mistake. We’d work 16-18 hour-long days, for 5 days in a row, in suboptimal conditions, while we lived in very modest accommodations. Living there for extended periods of time was very challenging, away from family, away from friends, and we were not allowed to bring our partners to live with us, while single team members were not allowed to form relationships with other staff members either – the bottom line was that the management wanted people to be single or unattached. It felt isolating. Sometimes retreat participants with trauma histories were not able to integrate the effects of high doses of psilocybin and would destabilize and left with limited follow up. Some dosing locations were not optimal, as people could jump into the pool or other body of water if left unattended. Even though the retreat facilities were extravagant, sometimes it was difficult to distinguish whether the retreat was a healing retreat or a resort that served alcohol between dosing days. Many young people would agree to come and work for free in exchange for the learning experience, or "training", however the "free training" offered in exchange for the "hard labour" was unstructured and questionable. It was exhausting and unsustainable.

That wasn’t the half of it, but their account has been toned down to protect them (and us).

Of course, different contexts have different challenges. But there are also some shared challenges. Here are six.   

1)      Lack of elders and lack of experience

Rosalind Watts was the lead therapist in Imperial’s psychedelics trials and is now the founder of Acer Integration. She recently wrote:

So much of what I see happening in the psychedelic space is because we are lacking the checks and balances that come when we have a circle of wise elders, who have let go of their personal ambitions for power, and are instead able to provide direction, counsel, guidance, conflict resolution, transformative justice, learning…The Western psychedelic field is young, bold, determined, laden with treasures too powerful for naive hands to hold. Big dreams, big hype, a lot to prove, a lot to heal, a world to save, so much at stake, so much to win: power, money, status, popularity, being special, and *being seen as a healer*. So........ Ego inflation. Problems brushed under the carpet. Stress. Pressure. Polarisation. Projection. Denial. Manipulation. Factions. Everyone calling everyone else a narcissist. Competition. Scapegoating. Ruptures without repair. We need help!  And no wonder...we are cut off from our roots, we lack lineage and apprenticeship and spaces for reflecting and acknowledging mistakes and course correcting and laughing and crying together.

Although westerners have been doing ‘psychedelic work’ (therapy etc) since the 1950s, there was a good 50-year hiatus when the work was entirely underground and not very active. Since the psychedelic renaissance began in 2006, public interest has grown hugely, many companies have been set up, there are hundreds of psychedelic retreat centres, and thousands of freelance guides and trip-sitters working in the underground. But this is still a very young endeavour.

Jeronimo Mazarrasa is the social innovation coordinator at ICEERS, which is a plant medicine NGO based in Spain. He says:

The main issue is that culturally speaking the psychedelic experience is very new and unknown to Western culture. This is part of what you call ecstatic illiteracy. We have very little in terms of maps, tools, techniques to manage and accompany these states to the best possible outcomes. This is because it’s very new, and we are bad at things we are new at. It takes time and practice to get good at them. We have doctors, we have universities, we have degrees and education, but next to nothing in most medical training when it comes to a type of active care you need when you sit with people during psychedelic experiences. Indigenous and shamanic cultures are much more skilled at this, they have hundreds of years of accumulated experience. Our doctors are trained to give people drugs to make symptoms go away. They’re not trained to accompany them while their symptoms temporarily increase. Our psychologists are used to talking to people after something has happened to them, not being with them while it’s happening. All of the challenges and difficulties emerge from this fact: that this is very new and we’re not very good at it yet.

‘All of the challenges and difficulties emerge from this fact: that this is very new and we’re not very good at it yet.’ - Jeronimo Mazarrasa, social innovation coordinator at ICEERS

There are of course a few elders in the field, in the sense of older people with power, but they don’t always behave well– everyone is adjusting to the new modishness of psychedelics and some elders are falling prey to the temptations of sex, money and power. There are some training programmes as well, but they’re also still pretty young and untested – one therapist told me about a course with a stellar faculty, where for the in-person component students were given multiple drugs then encouraged to hug and kiss each other. There’s a lack of supervision in the field, a lack of apprenticeships, and a lack of experience. Rachel Harris is a therapist and author of new book Swimming in the Sacred: Wisdom from the Psychedelic Underground, in which she interviews several female elders who have worked with psychedelics for decades. She says:

The women elders who I interviewed spent years on their own work. They were in apprenticeship with supervision for years. I know we don’t have time for people to be trained like that anymore. But the new practitioners have to realize this is the history.

Carolina worked for an ayahuasca a centre in Peru where she apprenticed with a Shipibo shaman. She says:

It takes a really long time to be good at this. And I keep saying to people, the definition of a practitioner in this field is someone who's put in the years of practice. This is why I really don't believe in the validity of three-month training programmes. Part of the problem is that the people who are interested in doing this work are typically very young. Most of the people coming to be retreat facilitators are in their early 20s, with next to no life experience. By the time someone makes it to your age or my age, we want to get married, have kids and have a more comfortable life.

2)     Transference and counter-transference

All the guides I spoke to mentioned transference and counter-transference as a major issue that comes up during ‘the work’.  These are terms from psychoanalysis, in which a client may develop strong feelings for the therapist during the months or years of analysis, which arise from projecting certain roles onto them – good mother, bad mother, good father, bad father, sibling, lover, angel, demon, and so on. Counter-transference is when the therapist gets triggered by that and projects their own issues onto the client. Therapists and guides say this dynamic gets amplified and intensified during the hours of a psychedelic session. You’ve heard the ’10 years of therapy in a night’ hype-line for psychedelics. Perhaps it should be ‘10 years of transference in a night’.

Rachel Harris says:

The biggest psychological issue is counter-transference. What in the practitioner’s psyche gets stimulated and how do they recognize and deal with it. That’s a function of their own inner work. There’s a quote I like from Laura Huxley:  ‘The most challenging aspect of being a guide is to keep yourselves out of clients’ journeys.’’

Bruce Poulter is Faculty at the Center for Psychedelic Therapy & Research at California Institute of Integral Studies (CIIS) and was one of the lead therapists on MAPS’ Phase 2 and Phase 3 trials of MDMA for PTSD. He says:

There are different challenges working with different substances. LSD is hard because it lasts 12 hours or more, so that’s a long night. MDMA has its own challenges because it’s so relational. It amplifies transference and countertransference. I get put into being either the good father or the bad father. And either one is fine, I'll move wherever I need to go in service of what needs to unfold with that participant. You can work with it and not take it personally for good or bad, to the best of your ability.  

Carolina says of her time working at the ayahuasca centre in Peru:

Sometimes I'd be on a pedestal and then I'd fall off the pedestal from the same guest in the same week several times over. And they’d be like, ‘oh, you're an angel, I saw wings on you’. And I‘d be like ‘I’m just a person cleaning up vomit’. I think a lot of people newer to the work feel like in order to be respected, they have to appear perfect, and it is fucking exhausting.

This transference / counter-transference amplification can create the potential for interpersonal issues, for ego-inflation and for boundary-breaches and inappropriate sexual relations with clients. Carolina adds: ‘I've seen typically male facilitators have a penchant for thinking that they're now irresistible and they ended up serially dating clients and other guides.’

In one survey, 12% of male mental health professionals said they’d had a sexual relationship with a client (compared to 3% of women). We don’t yet know how often that happens in psychedelic work, but we do know of several instances where prominent therapists and guides got into unethical relationships with clients – like Richard Yensen, a therapist on MAPS’ MDMA trial, who got into an unethical and abusive relationship with a participant in the trial, Meaghan Buisson (covered in the Psymposia Power Trip podcast).

Even with well-trained and well-intentioned guides, transference raises challenges. Daan Keiman is a Psychedelic and Buddhist Chaplain, co-founder of the Communitas Collective and former lead facilitator at Synthesis. He says:

Let's say you work with a client that has quite a powerful experience and starts to undress themselves - which has happened to two different practitioners I know, during group ceremonies…Let's say you handle it in the best way possible and the client might even acknowledge that. But now the client says: “in the preparation you didn’t say this could happen’…or they say “you didn't do the right thing”. And let’s say there's no one else there that has witnessed what has happened. This is when things can go wrong really quickly. And not just for the client - the risk for abuse is obvious - but also for the facilitator. So I wonder what is best for the client and I'm also thinking what is best for the facilitator? I think unfortunately the number of facilitators that don't know how to handle this well, due to poor training and supervision, is much larger than we would like to think. But I also know well-trained facilitators that still ended up in disputatious situations.

In an informal online survey I conducted of 29 psychedelic workers, 44% said they had to deal with transference and counter-transference issues a lot, and 48% said they only felt moderately equipped to deal with it.

3)     Adverse events and concerns about safety and screening

Experienced guides and therapists know that adverse psychedelic events happen and people sometimes get harmed. Therapists tend to be much less boosterish than entrepreneurs and much more open about the fact people can get harmed taking psychedelics, even under clinical settings. There are physical adverse reactions (heat exhaustion, heart failure and so on) and mental adverse reactions (very bad trips, dangerous acting out, psychotic breaks and so on).  Sometimes there are genuine emergencies which require professional medical support, but inexperienced guides won’t recognize that and will tend to spiritualize everything as ‘part of the process’.

This month, there are inquests looking into two accidental deaths in the Australian New Age scene, both involving ‘kambo ceremonies’ (where people get dosed with poison from a frog) and one also involving ayahuasca. In neither case were emergency services called promptly. In the ayahuasca ceremony, when medics did arrive, they were told by facilitators they were interfering with the person’s aura.

Admitting there’s an emergency means admitting the situation is beyond your expertise (and some guides pretend to be perfect avatars of wisdom) and can mean taking a risk with the law. Rachel Harris says: ‘One of the guides I interviewed for my book had to take a client to the ER in the US. That was taking a lot of risk. She walked them in to ER but luckily she had a sympathetic doctor.’

Guides hope that screening will spot people with physical or mental risks, such as a history or family history of psychosis. But screening is far from perfect at many retreat centres (at some it’s non-existent) and sometimes clients will hide or minimize potential vulnerabilities. One guide tells me of a person who came on a retreat, and didn’t disclose that their doctor had suggested they might have bipolar disorder. After the retreat, they went into a manic state and were sectioned. The guides went through a lot of soul-searching about what they could have done better, and decided that they need to be able to spot ‘yellow flags’ as well as red ones, if a client is at risk of becoming unmoored during or after a retreat.

The psychedelic renaissance has created massive hope among the unwell, but not yet given them safe places to get professional psychedelic therapy. What does this mean in practice? People who are desperate will roll the dice and take their chances in the underground or with unregulated decriminalized providers in states like Colorado. Guides with good intentions but without therapeutic training will have cases of people with suicidal depression, complex trauma or unstable personalities taking psychedelics and having powerful abreactions. It’s going to be messy – for the client, above all, but also for the facilitator.

4)      Legal and financial risks

People doing this work shoulder the weight of the continued criminalization of psychedelics, and of operating in a twilight world without a safety net. Daan Keiman says:

to my knowledge there are no insurance companies that are actively insuring either individual practitioners or organizations for any harm that might come from accidents that occur during ceremony - while clients are under the influence of a psychedelic. You have a lot of responsibility that you're carrying. So from the moment someone ingests a psychedelic all the way to the end, because there is no clear legal precedent on liability…we're in this weird twilight - which puts a certain pressure on you as a facilitator. 

I interviewed two British General Practitioners who have run psychedelic retreats and are part of an organization called Psychedelic Health Professionals Network, for British health workers (GPs, therapists, nurses etc) interested in working with psychedelics. One of their main concerns was the lack of legal clarification about their work and the lack of insurance coverage. One GP says: ‘I’m used to working in a way where I feel protected legally and insurance-wise if something goes wrong. We have run retreats in Holland, which were legal, but if something went wrong, could our licences to practice in the UK be revoked? It isn’t clear.’

Many guides may not themselves know what is or isn’t legal, and what consequences they could potentially face. Adriana Kertzer is the founder of the Plant Medicine Law Group. She says:

We had a potential client who wanted to set up a trip-sitting company after taking a course with Mount Tam. During our zoom, he discovered this wasn’t legal. He was absolutely furious. There’s a lot of legal uncertainty around, from the different decriminalization bills in various states, and just from the culture at large. And guides are often white, so they can be naïve about the potential consequences if they were arrested – they could face jail time, they could lose their home if they work from there, they could even lose custody of their children.

Guides can be naive about the potential consequences if they were arrested - they could face jail time, they could lose their home if they ran sessions there, they could even lose custody of their children. - Adriana Kertzer, Plant Medicine Law Group

We have already seen a civil case brought against Zendo Project, MAPS’ festival harm reduction organization, after someone died in their care at a festival. And there was one instance of complaint against a licensed therapist who provided mushrooms and cannabis to a client, who then decided to divorce his wife (it may have been the wife who lodged the complaint). In addition, three veterans sued a Bay Area psychiatrist for unethical behaviour, including spiking one with ayahuasca, having sex with another, and making treatment decisions based on astrology. She lost her license. We’re likely to see more such cases going forward.

5)     Clashes with management

In the last few years, mental health has become the new frontier for venture capital. On the one hand, this has meant that billions of dollars in funding have gone into an area that traditionally has been the ugly sister to physical healthcare. But it’s also meant that therapists have been subjected to the market pressures of working for VC-funded start-ups desperate to grow quickly (see the stories of burnout at Better Help, the VC-funded online therapy platform, for example).  

Psychedelics are an exotic play for venture capitalists, so it’s attracting an unorthodox brand of risk-loving, drug-taking, shoot-for-the-moon investor and founder – and some of them are hippies, bullshitters, or straight-up grifters. Very few psychedelic founders have a background in therapy or healthcare. You can find people from luxury yacht sales, marketing, mining, cosmetic surgery, event management, even (in the case of Synthesis) a former professional poker player. What many have in common is their youth, their relative lack of management experience, and their certainty that psychedelics will save the world and solve the mental health crisis, so their businesses should be scaled up as quickly as possible. They are typically taking psychedelics themselves, and can be subject to ego inflation.  One therapist who worked at a retreat company says: ‘The founders were psychedelic cowboys. They had no idea how to work with trauma. Their solution to everything was ‘increase the dosage’. They saw the facilitators as ‘fungi functionaries’.’

CEOs often see therapists or guides as an expensive nuisance. One therapist worked at Field Trip, a psychedelic company founded by a former mining executive, which aimed to open 100 psychedelic clinics around North America, starting with ketamine. It went bust earlier this year, along with several other fast-growing ketamine companies. The therapist tells me:  

My manager would say ‘we’re bleeding cash’. But that wasn’t the therapists, that was the interior design and marketing. Each clinic cost $1 million to build and furnish. They spent $20,000 on a carpet, and there were a lot of carpets in the clinic. They spent $7000 on these ‘zero gravity chairs’. The pillows cost $150. But the therapists were seen as too expensive, so they were always trying to cut corners – have one therapist floating around while several clients were on ketamine in rooms with the doors closed. I told them ‘people come here for therapy, not for the pillows’, but they were obsessed with branding and marketing. They brought in an executive from Peleton to help with the marketing.  [NB the estimated cost of the carpets has been questioned by another therapist who worked there!]

A Field Trip clinic. That rug really ties the room together.

They wouldn’t be the first psychedelic entrepreneur to try to mimic the fitness industry – one prominent philanthropist supporter of MAPS suggested that to meet the demand of ‘training at scale’ it could train up fitness instructors from SoulCycle. 

One of the fastest growing psychedelic companies is Mindbloom, founded by 35-year-old Dylan Benyon, who previously founded a legal restitution website. Mindbloom grew rapidly during the pandemic by offering ketamine telehealth, spending big on design and marketing and low on human support. You get ketamine lozenges delivered to your door in a designer package, then log in to receive 30-minute zoom from a facilitator (who doesn’t need to have any medical or therapeutic training) before your experience and 30-minutes integration after it. One guide says:

They pay $25 an hour, which is a ridiculously low amount of money for that work, and want people to work in four-hour shifts with a 30-minute break in between. So they want you to see eight clients a day for $100. There was a lot of training, but it was all about the systems and scripts you need to follow. And you’d be jumping from zoom to zoom trying to prepare one client then ‘integrate’ another.

Benyon, like other psychedelic entrepreneurs, is adamant that psychedelics can ‘solve the mental health crisis’. Entrepreneurs and media have massively hyped people’s expectations, and therapists and guides are the ones shouldering these expectations. Psychedelic corporates are asking guides to shovel up the world’s shit, to clean the Augean stables of human suffering, without offering them proper support or pay. And because guides are often young, naïve, altruistic and quite spiritual, they are easily taken advantage of and gaslit. Carolina says:

A lot of us are very idealistic about certain things. I think I've matured in that I don't work for free. I want to get paid well and that's unusual. I think there is an abuse of the empathy of the people who can actually do this work. I don't know that it's intentional, but it's definitely present. It's definitely endemic.

The lack of appreciation for therapists is not just an issue in psychedelic clinics and retreats by the way. In academic trials and drug trials, therapists are often under-celebrated, underpaid or not paid at all – some of the most prominent psychedelic research clinics don’t pay the therapists on their trials, because they are desperate for the experience. And this injustice is gendered – the therapists are often women, and the CEOs or heads of research centres are often male.

One therapist tells me:

A lot of the employment conditions around psychedelic work is precarious - e.g. zero hour contracts, late payment, reduced fees, trial cancellations go unpaid etc…This is some of the most difficult therapuetic work – it’s like playing the psychotherapy game on extra hard level. That means practitioners need more support than usual, but what we see is organisations trying to take advantage of the hype and cutting costs.

Some companies are looking to do without therapists altogether. For example, GH Research, one of the biggest psychedelic companies, is trialing a treatment using powerful hallucinogenic 5meoDMT for treatment-resistant depression, without any therapy. That would be cheaper, and perhaps easier to get FDA approval – the FDA has said it doesn’t have much experience in approving therapeutic protocols. But it’s obviously higher risk for the patient, blasted out into hyperspace without a guide.

Some companies like Woebot are already looking at replacing human therapy with AIs, other companies are using AIs to analyze trip reports, or developing apps and VR programmes to support people in their preparation, experience and integration. With several of the leading researchers at Open AI (the company behind ChatGPT) also investing in psychedelics, it seems likely that ChatGPT or similar programmes will soon be trialed as a replacement for human psychedelic therapists. So much cheaper!

6)     Burnout

All of these problems can add up to exhaustion and burnout. I spoke to several therapists and guides who reported having to spend weeks or months in bed, with chronic physical or emotioonal problems. I wondered how common this was so sent round an informal survey. In a survey of 29 guides and therapists, 60% said they felt some degree of burnout, and 27% said they felt a lot. The main contributing factor was the intensity of the work, but 16% mentioned difficult work conditions, 12% mentioned working with a difficult client, and 8% said dealing with an adverse experience (their own or a client’s) was the hardest aspect.

Those queuing up to re-train as psychedelic facilitators, and spending tens of thousands on online training courses, should be aware this is hard work. Especially for those working in retreats in developing countries, which honestly sounds like a cross between Fear Factor, Love Island and Hunger Games. Carolina says of her time working in the Peruvian Amazon:

Sometimes I was on call 24/7 for a month-long retreat. And let’s say you have a really challenging guest, but you don't really have any support, you got to work it out. And people might need help at night. Sometimes in between retreats, people needed to get medical help for an ear infection and you'd end up taking them to the hospital. No one's paying me for that. That was my only two days off that month. You're severely malnourished for prolonged period of time. No access to supplements, no access to healthcare.  You got parasites, you get malaria, you get dengue, you have hormonal issues. You're severely sleep deprived. There's just no support. So you might be having a nervous breakdown at lunchtime.

Daan Keiman had some experience of burnout, because of difficult work conditions and interpersonal challenges while working at Synthesis (I’ve written previously about the troubles at Synthesis, which partly arose from inexperienced management, and partly from the fact the company took on venture capital funding and then had to ramp up retreats, cut time-off for facilitators, and lower its screening thresholds). Daan says: ‘I think there is a risk when companies who are juggling different interests, including very big financial interests, are consciously or unconsciously setting their facilitators up for burnout.’ He adds the risk is greater when guides feel they lack control over their schedule:  ‘All the challenges that I've just been talking about pertain primarily to facilitators who are not in charge of their own caseload, who are working for organizations that are setting the pace.’

Bruce Poulter agrees: ‘Folks doing underground work can pace themselves. If you don’t have that ability, it creates vulnerability.’ He says he is at the moment dealing with a different form of burnout – working on a years-long MAPS clinical trial, and dealing with clients’ disappointment when they have severe mental illness, sign up for a trial, and they get a placebo. He says:

Eventually I said I can’t do this anymore. And that was OK.  I could say ‘I’m not going to do this’ and MAPS was fine with that. Had it been an issue where I didn’t have a choice for some reason – financial, institutional – that’s where therapists and researchers get in trouble. That’s really dangerous. If you feel stuck, that’s when people get burnout.

While organizational factors certainly contribute to burnout, there may be some occupational hazards to this work that we don’t even fully understand yet. Katharine MacLean is a former researcher and lead guide at Johns Hopkins psychedelics lab and the author of new memoir Midnight Water. She says her work at Johns Hopkins took a toll on her mind and body:

I had no idea how sick I would get. I had one volunteer who had a really terrible dissociative experience during a trial. I ended up using my hand to help ground the person – I put my hand on their chest and got them to breathe in. We talked about it the next day, as it was a boundary violation. But it worked. That night, I got really sick, I had a high fever, and I got pneumonia. I didn’t get better for a year. When I spoke to shamanic people they said ‘why did you touch the person when they’re in that state?’ I said what do you mean? They said ‘when a person’s spirit is not in their body, you don’t know what’s in their body, and you don’t want to be a conduit for that energy’. There’s no medical way that makes sense, yet I experienced it. We don’t talk about that – it verges on the paranormal. Curanderos say they would purge for someone who is really sick. They would see the sickness, and then the healer would take it on and purge it. What the hell is that?

‘I had no idea how sick I would get.’ - Katherine MacLean, former guide at Johns Hopkins and author of Midnight Water.

Solutions

If this all sounds negative, we should remember what Jeronimo Mazarrasa said at the start of the article. Western culture is new to psychedelic work, and when you’re new to something you’re not very good at it, you make mistakes, and you learn, grow and get better. After the paywall, some expert advice for guides seeking support. Lesson one: get paid properly!