Ethics in Psychedelic Therapy: The Promises and Pitfalls of Enhanced Suggestibility

suggestibility and psychedelic ethics

Psychedelics are known to enhance suggestibility – in other words, the quality of being inclined to accept and act on the suggestions of others. (Interestingly, those who score high in trait conscientiousness – or being careful, diligent, efficient, and organised – are the most sensitive to this effect of psychedelics.) Psychedelic users are well aware of this effect; for example, when tripping amongst a group of people, what others say or do can easily influence your state of mind. 

Within the field of psychedelic-assisted psychotherapy, this reliable effect of psychedelics has significant ethical implications. This is because what a psychedelic therapist brings to the sessions can create dramatic shifts in a person’s experience, in both positive and negative ways. Moreover, the assumptions, beliefs, and psychotherapeutic background of the therapist may influence not just the psychedelic sessions but also the way a patient interprets and integrates those sessions, perhaps altering their own beliefs and worldview in the long term.

The increased suggestibility induced by psychedelics, therefore, entails promises and pitfalls. The sub-field of psychedelic ethics – relevant to both the fields of ethics and psychedelic therapy – has to confront the phenomenon of enhanced suggestibility. This will place obligations and standards on psychedelic therapists, whose influence on patients is distinct from standard psychotherapists, owing to the deeply vulnerable place that patients find themselves in. Under these conditions, the expectations of the therapist are much more likely to be fulfilled by the patient.

Enhanced Suggestibility as a Driver of Therapeutic Change

The ability of psychedelics to increase suggestibility has important implications for their uses as adjuncts to psychotherapy, where suggestibility plays a major role. It is precisely this kind of effect that allows hypnosis to be efficacious (even among people who are not highly suggestible). Once a person is put in a hypnotic state, and thus made more likely to be influenced by the direction of the hypnotherapist, people can more easily beat various addictions, lose weight, and experience the alleviation of physical pain and emotional distress. 

Likewise, being in a more suggestible state in the context of psychedelic therapy can help drive therapeutic changes. If a therapist encourages healthier perspectives on a patient’s sense of self during and after sessions, then these new attitudes could be more likely to stick, thereby improving mental health outcomes. According to the philosopher Chris Letheby, it is these alterations to the sense of self that drive the therapeutic benefits of psychedelics. 

In an interview with philosopher Joseph Earp, Letheby states, “People can get very harmful, unhealthy, negative forms of self-representation that become very rigidly and deeply entrenched.” He adds:

Psychedelics unbind the self model. They decrease the brain’s confidence in a belief like, ‘I am an alcoholic’ or ‘I am a smoker’. And so for the first time in perhaps a very long time [addicts] are able to not just intellectually consider, but to emotionally and experientially imagine a world in which they are not an alcoholic. Or if we think about anxiety and depression, a world in which there is hope and promise.

Now, based on the added ability of psychedelics to enhance suggestibility, therapists will be able to work with patients to encourage healthier (as well as realistic) models of the self: beliefs that one is not destined to be an addict or a depressed person, for instance. People under the influence of psychedelics would be more responsive to all sorts of positive suggestions and ideas expressed by therapists.

The potential of LSD to enhance suggestibility was first observed by clinicians working with the substance in the 1950s. In a 2015 paper showing that LSD leads to non-placebo increases in suggestibility (in 80% of participants), Robin Carhart-Harris et al. write:

The importance of prior expectations (‘set’) and environment (‘setting’) in determining the nature of an individual’s psychedelic experience is often emphasised (Johnson et al. 2008), and this is likely to be related to these drugs’ seemingly robust suggestibility-enhancing effects.

The authors add that in clinical trials on psychedelic therapy:

Whether explicitly exploited or otherwise, the influence of suggestions is likely to have played an important role in these study’s outcomes. Indeed, given the growing support for cognitive and behaviourally oriented psychotherapies, it may be interesting to isolate this as a variable in future trials to specifically investigate the influence of LSD on therapeutically motivated conditioning and deconditioning techniques, as such are used in addiction treatment for example. Such methods may supplement rather than replace the less prescriptive psychoanalytically oriented approach that encourages a patient to allow his/her inner experience to unfold ‘naturally’ or spontaneously.

The Risks of Increased Suggestibility in Psychedelic Therapy

Increased suggestibility following psychedelic intake can be considered a risk (just think of Charles Manson’s use of LSD to influence cult members). While the prospect of psychedelic therapists indoctrinating patients into cults is probably not a high-priority risk, enhanced suggestibility during these sessions does involve other morally relevant considerations.

For instance, Robin Carhart-Harris et. al underscore that increased suggestibility can interact with whatever psychotherapeutic model a therapist brings to the sessions:

Also relevant to both set and setting is the manner in which a psychedelic experience is theoretically interpreted. In the 1950s and 1960s, the majority of psychedelic-assisted psychotherapy adhered to a psychoanalytic/psychodynamic model (Abramson 1967; Josiah Macy and Abramson 1960), i.e. it was believed that psychedelics lower ‘ego defences’, thereby providing the ideal conditions for an emotional release/catharsis and personal and/or existential insight (Cohen 1964; Grof 1980; Sandison and Whitelaw 1957). It was even claimed that “Observations from LSD psychotherapy could be considered laboratory proof of the basic Freudian premises”(Grof 1980). While there may well be some substance to the psychodynamic interpretation of the psychedelic experience (Carhart-Harris et al. 2014), it is important to consider the role that suggestion plays here. For example, it was noted by therapists working with LSD in the 1950s and 1960s that patients appeared to be even more inclined than normal to endorse experiences consistent with their therapist’s own theoretical allegiances, e.g.patients treated by Jungian therapists would report self-transcendent experiences under LSD, whereas those treated by Freudians would be more likely to report recollections of childhood memories (Josiah Macy and Abramson 1960). Thus, although it would be unfair to discount reports of phenomena such as ‘ego dissolution’ and personal and philosophical insights as mere products of suggestion, it is important to consider how the interpretation or framing of these experiences is influenced by suggestion. Similarly, the influence of suggestion in reports of psychedelic-induced mystical or religious experiences should be further investigated since the same neurobiological state may be subjectively interpreted as profound yet secular by one individual but mystical by another.

All of these considerations raise a crucial ethical question: Should a therapist avoid framing an individual’s highly personal experience in terms of a specific therapeutic model? As pointed out earlier, the authors of this paper suggest specifically using conditioning and deconditioning techniques – instead of being non-commital in one’s allegiance to a particular model, as seen in many clinical trials – as this may offer therapeutic advantages. Other researchers and writers believe other approaches are more beneficial (the psychotherapist James Barnes, for instance, makes the case for why relational therapy – and not cognitive-behavioural models – is optimal).

Other proposed approaches to be used in psychedelic therapy include transpersonal therapy, somatic therapy, and acceptance and commitment therapy (ACT). All of these approaches can be relevant to aspects of the psychedelic experience. Relational therapy complements the common theme of connectedness (often to others) that manifests in psychedelic states; transpersonal therapy may help make sense of transcendent experiences; somatic therapy ties into how psychedelics can connect patients more with their bodies and the emotions ‘stored’ there, as well as encourage a release of them through crying, shaking, or shivering; and finally, ACT matches the common psychedelic wisdom that says to accept whatever thoughts or feelings arise during the experience. A more integrated therapeutic approach can, of course, be used as well, with a specific framework applied whenever it is deemed relevant.

But if a therapist’s commitment to a particular model comes into conflict with a patient’s self-chosen interpretation of their experience, and the former becomes what sticks, does this not disrespect the patient’s autonomy?

A similar problem arises when it comes to the metaphysical beliefs of psychedelic therapists. Aspects of the psychedelic experience can lead people to reject certain metaphysical positions while accepting others (see this paper on how psychedelic use shifts people away from physicalism and towards panpsychism). However, these shifts should ultimately be the choice of the patient (irrespective of whether they entail therapeutic benefits). If a therapist encourages a specific metaphysical interpretation of a patient’s experience, whether due to their own belief in such a worldview or the idea it could help the patient, this again could be considered unethical. 

The moral problem is magnified due to what Letheby calls the Comforting Delusion Objection: the concern that psychedelic therapy works by foisting implausible metaphysical beliefs on the sick and dying. The journalist Michael Pollan raised this issue in an article titled “The Trip Treatment”, published in The New Yorker. These beliefs (the implausibility or falsity of which are by no means certain) may include the belief in an afterlife or the existence of God, spirits, or other supernatural entities.

Therapists who support comforting falsehoods, which may solidify in a person’s mind due to the effect of increased suggestibility, can be seen as exerting too much power and influence, as well as deceiving people in the process. This encouragement of falsehoods can be thought of as an epistemic harm and an epistemic wrong.

Letheby, nonetheless, rejects the Comforting Delusion Objection. Firstly, he argues psychedelic therapy does not work centrally by changing metaphysical beliefs, but by altering the sense of self (as we have already seen). Moreover, he adopts the notion of “epistemic innocence” from the work of philosopher Lisa Bortolotti, which is the belief that some falsehoods can actually make us better epistemic agents. He states:

Even if you are a naturalist or a materialist, psychedelic states aren’t as epistemically bad as they have been made out to be. Sometimes they do result in false beliefs or unjustified beliefs … But even when psychedelic experiences do lead to people to false beliefs, if they have therapeutic or psychological benefits, they’re likely to have epistemic benefits too.

To make this case, he draws attention to what the mind of a depressed or anxious person is like. Such a person commonly retreats from the world and talks less to their friends and family, which can lead to epistemic harm; if you don’t engage with people, then you have fewer opportunities to (1) find out you’re wrong, (2) discover reasons to update your beliefs, or (3) search out new experiences. As Letheby puts it:

If psychedelic states are lifting people out of their anxiety, their depression, their addiction and allowing people to be in a better mode of functioning, then my thought is, that’s going to have significant epistemic benefits. It’s going to enable people to engage with the world more, be curious, expose their ideas to scrutiny. You can have a cognition that might be somewhat inaccurate, but can have therapeutic benefits, practical benefits, that in turn lead to epistemic benefits.

In a sense, this kind of discussion highlights the tension between utilitarian and deontological perspectives in psychedelic ethics. If the interaction between a therapist’s assumptions and increased suggestibility leads a patient to adopt implausible or inaccurate beliefs, but this entails greater psychological and epistemic benefits, is this approach therefore justified? On utilitarian grounds, it would appear so. As chemist David Nichols opined in an interview with Science, “If it gives them peace, if it helps people to die peacefully with their friends and their family at their side, I don’t care if it’s real or an illusion.” But from a deontological point of view, this end may not justify the means.

It is also possible that patients will have experiences that can feel like a memory of an event, sometimes a traumatic one, such as sexual abuse. In some cases, these experiences could pertain to true memories, but at other times, they may be false memories. There may be some visions or states of ‘remembering’ that a patient might not want to interpret literally, since they may not be literally true. Instead, these could be symbolic expressions (of feeling states from childhood, for example). This kind of emotionally laden material can be highly ambiguous, however, which can be challenging for both patients and therapists to work with.

However, if a therapist leads a patient to accept the truth of a supposed memory (in all its details), rather than letting them decide the veracity of it for themselves, this could be harmful. As Dee Dee Goldpaugh writes in an article for Chacruna, “By positively confirming recovered memories as factually true in the form in which the survivor remembers them, therapists potentially cause great harm to survivors themselves, families, and communities impacted by these revelations.” If a psychedelic therapist motivates a participant to believe they accessed repressed traumatic memories, when other explanations may exist, this could also cause them severe emotional distress. Furthermore, an epistemic harm and epistemic wrong may result if the memory was false in such an instance.

Another risk of increased suggestibility following psychedelic use, which I touched on in an article on MDMA therapy, is the crossing of boundaries, including sexual transgressions. Enhanced suggestibility in psychedelic sessions widens the power imbalance that already exists in standard psychotherapy. It is crucial then for psychedelic therapists to have extremely high levels of self-awareness and ethical standards. Increased suggestibility is something that could be easily exploited; harm could result from this effect combined with poor psychotherapy practices or predatory therapists.

Concluding Remarks

The ability of psychedelics to increase suggestibility show how these substances are truly a pharmakon: a term from philosophy and critical theory denoting something that can act as both a remedy and a poison. Everything that a therapist brings to a psychedelic session can dramatically change it, which can either end up improving or worsening a patient’s well-being. This kind of influence may also lead to specific, long-lasting changes in the patient as well. 

Psychedelic therapists, then, face ethical dilemmas of a degree that is unique, and these questions have become even more prominent, given that these treatments are on track for legalisation. Shannon Carlin, Director of Training and Supervisions at the Multidisciplinary Association for Psychedelics Studies (MAPS), emphasises that a person in a highly suggestible state:

introduces an even greater need for client-centered approaches, therapeutic skill in navigating transference and countertransference, and professional boundaries in psychedelic therapy. Psychedelic psychotherapy heightens the importance of trust, trustworthiness, and safety.

Many of the risks associated with increased suggestibility can be mitigated when the therapist avoids directing or interpreting unconscious material and instead respects the participant as the authority of their consciousness, only offering the kind of guidance that supports the participant in navigating their experience. When clinicians act as facilitators or ‘empathic witnesses’ in these sessions, power dynamics are disrupted, and the participant has the freedom to discover their own wisdom and self-healing capacities.

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