Ethical Principles of the ISSP
Authors: Members of the Board and Advisory Board of the ISSP
The relationship between patient and therapist in psychotherapy aims to enable patients to have new experiences of themselves in the context of a therapeutic relationship, as well as exploration of life-history, current experiences and the future, with the aim of reducing the burden of illness and improving quality of life.
Substance-assisted psychotherapy has the potential to enhance such creative endeavors. However, it is not a uniform type of treatment modality. Different approaches to treatment, a broad variety of substances and settings can be applied and will need to be explored for this type of work (e.g. psycholytic therapy, psychedelic therapy, and MDMA-assisted psychotherapy).
It is a core belief of the ISSP that substance-assisted psychotherapy is in essence a form of psychotherapy, and needs to be performed by skilled psychotherapists. Psychoactive substances (currently mainly LSD, psilocybin, and MDMA) are researched or used as tools for enhancing the psychotherapeutic process.
Sound training and experience in a recognized psychotherapeutic method is a prerequisite for any therapist engaging in substance-assisted psychotherapy. In addition, the acquisition of a comprehensive expertise in the functioning of the Central Nervous System, the effects and side effects of psychoactive substances, and their psychotherapeutic management is required for their proper application, including recognition and handling of clinical emergencies.
It is each therapist’s responsibility to select the correct indication, assessment of motivational readiness, the patient preparation, to establish and maintain the setting, the selection of substance and dosing. Careful education of the patient regarding the benefits and risks of psychoactive substances is ethically required, including full transparency about the effects and dose of the drug administered. Other responsibilities include maintenance of a proper therapeutic attitude, including the exploration of countertransference, and careful attention to possible after-effects.
Pressure by a therapist for a patient to undergo substance-induced experiences is unethical. Autonomy and informed consent are central to the skillful, ethical practice of substance-assisted therapy.
It is the therapist’s responsibility to conduct patient education as an ongoing process in the treatment, including necessary documentation. A Patient’s Bill of Rights is available to the patient.
As substance-assisted psychotherapy is psychotherapy, the use of psychoactive substances should not start before a trustworthy and stable therapeutic relationship has been established in a conventional psychotherapy setting.
The ethical therapist has realistic expectations of treatment, shares these with the patient and gently confronts unrealistic hopes or expectations.
Strict observation of agreed upon boundaries is a crucial requirement of substance-assisted therapy. The ethical therapist is aware of the asymmetry or power imbalance inherent in the psychotherapy situation (by expertise, experience and authority). Asymmetry requires special attention as it is sometimes heightened through the effects of psychoactive substances (alteration of ego functions, increased suggestibility, and regressive states).
Competent and empathic practice of substance-assisted therapy requires: maturity, authenticity, openness, integrity and reliability, honesty, self-reflectiveness, humility and collaboration.
The therapist has done, and continues to be mindful of personal vulnerabilities, blind spots, traumas, affective disruptions, blind spots, areas of preoccupation and dissociation. The ethical therapist seeks collegial support through ongoing peer inter-/supervision and is open to seek professional consultation and therapy when needed.
Psychotherapists working with substance-assisted therapies ideally will have self-experience with psychotherapies and controlled self-experience with substance-induced states of consciousness, preferably in therapeutic settings and usually with those substances that are to be used in each case. Five controlled self-experiences have been suggested as a minimum by North American and European experts in substance-assisted psychotherapy.
The ethical therapist will not take any psychoactive substance himself immediately before or during the course of a patient’s substance-assisted session. This may be different with indigenous healers.
Personal views related to substances, if not scientifically based, should not be incorporated into the therapy or offered to the patients. Likewise, political or religious influencing of patients is to be avoided. The introduction of religious symbols, images or figures into treatment rooms, as well as the use of rituals, exercises or techniques that are not directly related to therapy should be critically considered regarding clinical appropriateness. Treatment rooms should be designed to be home-like and sheltering, while avoiding a clincial/technical atmosphere as well as an overtly religious one.
The support of an autonomous substance-assisted experience, free from coercion or any manipulation is central to the ethical practice of substance-assisted therapy.
In order to ensure the free development of the therapeutic process in the patient, the therapist will hold a quality of openness and acceptance of any type of experience for his/her/their patient. The therapist does not aim to produce a specific type of experience (e.g., "positive") in the patient or direct the patient towards a confrontation with inner materials.
Substance-assisted therapies require a greater than usual amount of attunement and tolerance for episodes of high affective arousal as well as the management of the after-effects of treatment. The ethical substance-assisted therapist is familiar with destabilization and weakening of the ego or ego dissolution processes that may emerge, as well as after-effects in patients/clients, and is prepared to manage such events skillfully, safely and effectively.
The ethical therapist is prepared to witness (and be a part of) profound experiences of death and rebirth, agitation or terror, seductiveness or hostility or aggression. He/she/they strive toward equanimity and an empathic containment of all that emerges, maintaining professionalism and appropriate boundaries at all times.
The states of consciousness induced by psychoactive substances imply changes in integrative ego functions leading to increased suggestibility and vulnerability. During such states, decision-making and competence are reduced. Consent cannot be established during an ongoing substance-treatment session; consent can only truly occur during preparatory sessions. The appropriate and therapeutically beneficial handling of these states, including adequate proximity-distance regulation, requires specific education and experience.
Sexualization, of any kind, is harmful in psychotherapy. Sexual and seductive behavior by the therapist is forbidden in substance-assisted therapy, including a period of time after the conclusion of the therapy. The ethical standards and rules of the respective countries are authoritative in explicating the details of these facts.
The past has taught us that narcissistic self-aggrandizement and boundary violations may occur with some therapists. These qualities or actions may lead to injuries, re-traumatization or emotional/sexual abuse of patients. If treatment is not conducted in a multi-professional clinic setting, the safety must be guarded through professional supervision and consultation.
Psychotherapists using substance-assisted therapies are especially required to actively perceive and reflect on their countertransference, especially regarding issues of dependency, extreme suggestibility, latent hostility and power dynamics. This requires appropriate training, as well as ongoing professional supervision and consultation.
Therapeutic touch (e.g. holding a hand) can be a helpful or sometimes therapeutically necessary component of substance-assisted therapy, which requires careful negotiation of boundaries and consent, including documentation. Consent can be withdrawn by the patient in an altered state of consciousness, but it cannot be granted or increased. In the therapeutic situation, explicit consent for the respective touch must always be obtained before any touch can be performed.
Licensed therapeutic bodyworkers are permitted to work within their own scope of care, in terms of physical touch during substance-assisted sessions. Other psychotherapists are limited to minor supportive therapeutic touch as agreed upon between therapist and patient in advance.
Membership in ISSP does not constitute any type of authorization to perform therapies with psychoactive substances. Membership in the ISSP does not reduce the need for relevant training in certified programs, in accordance with all local and national legislation and registration boards.
Compliance with the professional standards of ethical clinical care (as defined by the relevant professional regulating licensing board) is required for all members of the ISSP. In other words, membership in ISSP offers no exemption from city or state laws or scope-of-practice guidelines within any profession, and any violation of city or state laws in this respect may be grounds for expulsion from ISSP.