Given the increased demand for psychedelic medicine and the importance of psychological support in producing good outcomes, many therapists have begun offering therapy services in this area. However, because the use of psychedelics in clinical practice, with the exception of ketamine, entails illegal activity, most therapists are hesitant to engage directly in providing components of psychedelic-assisted therapy. A harm reduction approach has long been established as an ethical and legal means for working with people who use substances and are not interested in or capable of complete abstinence . We will now describe a harm reduction approach and outline its application to people seeking therapeutic support in using psychedelics for personal growth or healing purposes.
History of harm reduction
Harm reduction approaches refer to a focus on reducing the negative consequences of drug use, rather than focusing on eliminating the use of the drug . Harm reduction grew in response to limitations of abstinence-only approaches to drug use, the US war on drugs, and the acquired immunodeficiency syndrome (AIDS) epidemic where needle exchanges were observed to reduce risk among injection drug users . While harm reduction can refer to a public health or social justice movement , it has been integrated in psychotherapy approaches for treating individuals engaging in risky behavior [37,38,39]. Harm reduction assumes that it is better to provide space for clients to be honest about their substance use with a therapist who is nonjudgmental and has their best interests in mind, rather than establishing a situation in which clients need to either terminate therapy or hide their use or lack of commitment to abstinence to avoid judgment or treatment rejection. In harm reduction approaches, therapists adopt a non-coercive stance and help clients identify the risks and benefits of their behaviors. Clients are treated with dignity and respect and are empowered to make their own choices. If abstinence is not a client goal, clients may instead be encouraged to alter the route of administration, use a safer substance, change other behaviors surrounding use, or reduce the frequency and intensity of substance use .
One common criticism of harm reduction is that by adopting a stance acknowledging that substance use can have both risks and benefits and providing a place for clients to openly discuss their drug use, therapists are condoning risky behavior and increasing the potential for harm to occur. However, the evidence suggests that harm reduction interventions have been effective in various areas  including preventing HIV in people who use drugs  needle exchange programs , opioid substitution therapy , and alcohol misuse in college students . Further research has shown that harm reduction programs do not increase drug use and simultaneously increase treatment entry .
Applying harm reduction to psychedelics
It is important to be clear that a harm reduction approach to psychedelic use does not permit therapists to legally attend or facilitate dosing sessions, something that is often called “guiding.” In the section below, we only have space to outline the basic principles and strategies involved in the application of harm reduction therapy in the context of psychedelics and refer readers to other sources [39, 47] for a more complete understanding of the harm reduction approach.
In contrast to the preparation work usually provided in clinical trials, harm reduction sessions before psychedelic use are oriented more toward helping clients make informed choices about psychedelic use and focus more heavily on safety and education. Clients who seek professional guidance in relation to psychedelics often have little experience or knowledge with these substances and are unsure whether psychedelic use is a good idea for them. In a harm reduction approach, the therapist does not advocate for or against the use of psychedelics, but instead focuses on the client’s goals and welfare and attempts to help the client determine for themselves what behaviors will lead them toward the life they desire. Consistent with this aim, the therapist often begins with helping the client clarify reasons for seeking an illicit psychedelic experience and may suggest alternative pathways for achieving desired goals, such as suggesting that a client seeking relief from depression first consider more established approaches such as psychotherapy, antidepressants, FDA approved psychedelic clinical trials, or ketamine treatment. From a harm reduction standpoint, these options would be presented to facilitate an informed choice.
Education about psychedelics, including their risks and benefits, is an important part of clients having informed consent as well as reducing risks associated with their use. In today's age, there is a large amount of information and misinformation on psychedelics that can be overwhelming to sort through. Clinicians can help in two ways. First, clinicians can provide resources, ask clients to do their own research, and provide space for clients to synthesize information they encounter. Clinicians can play a role in encouraging clients to critically evaluate information that they obtain on their own and help clients distinguish between fact and fiction. This may be especially important with psychedelics as informal information passed along by peers may be more trusted than information from healthcare resources. The situation may be similar to communities of people using performance-enhancing drugs, such as how growth hormone continues to be used by athletic communities despite strong evidence that it does not improve physical performance . Second, clinicians can directly educate. The benefit of having clients do their own research is that clients may more clearly experience their therapists as objective if therapists do not provide information that could be perceived as approving or disapproving of psychedelic use. This may support client autonomy but may also be frustrating or confusing for clients who are seeking professional guidance and want direct information without needing to conduct their own research. Even if a therapist attempts to avoid appearing in favor of or against psychedelics, there still may be a need to provide information on risks that the client doesn’t discover on their own. For example, clients may think psychedelics are a “magic bullet,” unaware of the potential for challenging experiences or the emergence of avoided problems, memories, or emotions.
One common topic about which clients seek information is the potential interactions between psychedelics and medications they are currently taking. Unless the therapist is a prescriber, therapists should generally coach clients to bring such questions directly to their medical provider or assist clients in obtaining a psychedelic-friendly provider that would be willing to provide relevant information. Therapists working with clients considering withdrawing from medication should generally advise them to do so under the supervision of a prescriber. At minimum, clients can be helped to find online resources so that they can understand potential risks and benefits. While most psychedelics appear to have fewer unwanted side effects than many drugs , there are potential interactions between psychedelics and psychotropic medications. Some dangerous combinations are known such as the potentially lethal consequence of serotonin syndrome when using a serotoninergic substance such as Ayahuasca and certain antidepressants . Clients should be aware that an absence of evidence does not guarantee safety, and that they may be taking on some risk if using psychedelics while on medications. Therefore, therapists are encouraged to network with local medication providers knowledgeable in psychedelics so that potential referrals can be made.
If clients decide to pursue psychedelic use, clinicians can be helpful in promoting safety by helping clients think through plans. Will they have support from someone they trust? Will they be in a safe, familiar environment where they won't need to drive? Will their physical needs be properly looked after, including diet and hydration? In addition, because psychedelics are prohibited substances, they are commonly purchased from sources that may be of questionable quality. While clinicians cannot facilitate access to psychedelics, they can encourage clients to be safe, including promoting the use of drug checking (also sometimes referred to as pill testing or reagent testing). Drug checking refers to the use of commercially available products that are legal in most countries and easily available for consumers to purchase in order to test the chemical makeup of various substances and identify whether what they purchased may be adulterated or actually another substance. However, clinicians should be aware of local laws since drug checking kits are considered paraphernalia in some jurisdictions, and their possession may be criminalized. While drug checking can help reduce risk, it may be subjective or imprecise and does not guarantee safety . However, there is evidence to suggest that drug checking, when conducted in a laboratory by qualified staff (not using home-based testing kits), is helpful in reducing medical risks associated with taking drugs that may be adulterated or mixed with other dangerous chemicals .
Finally, harm reduction principles may be applied to helping clients who seek services from underground guides. Clients may be unaware that there is no regulatory oversight of underground guides or may fail to understand the risks of trusting another person while in a highly vulnerable state during psychedelic experiences. Clients can be informed about these potential risks and, if they choose to pursue obtaining an underground guide, clinicians can help clients assess the safety and trustworthiness of the guide. Clinicians can collaborate with clients to develop a set of questions to ask underground guides so that clients feel empowered to make a choice that is right for them. Clients may also benefit from encouragement to “trust their gut” if an underground guide does not feel safe and that they have the right to decline to proceed with a guide’s services at any point during the process, even if they have already committed time or money. Clients who experience harm from guides may also benefit from therapist assistance in determining whether or how to report a guide to legal or regulatory authorities as a means to prevent future harm to others.
Besides focusing on safety, a harm reduction approach may also serve to maximize the potential benefits of psychedelics. For decades, psychedelics have been used by individuals who value their beneficial effects and have integrated their use into a growth-oriented lifestyle. Using the dualistic model of passion, it is possible to view such use of psychedelics as a type of harmonious passion, or ongoing engagement with an activity that enhances life, rather than obsessive passion, which is a type of engagement with an activity that can interfere with other life domains . This passion model offers an alternative to the abstinence-only or "all drugs are bad" approach that, instead of pathologizing the use of psychedelics, considers that their use may lead to positive emotions and psychological well-being. The passionate model has been applied to MDMA  and marijuana [55, 56] suggesting that some patterns of regular use may indeed be experienced as positive and are not necessarily associated with negative outcomes. A focus on benefit maximization in harm reduction therapy appears even more acceptable in the case of classic psychedelics given their well-documented low potential for dependence or physical harm . In other words, because classic psychedelics are typically non-addictive and physically safe, the benefit-to-harm ratio is more likely to be weighted more toward the benefit side compared to some other mind-altering substances. Therefore, clinicians may be less inclined to focus on elucidating the potential harms of classic psychedelics and freer to consider that use of these substances is potentially beneficial for clients. Harm reduction approaches allow clinicians to make space for clients to discuss positive consequences of the use of psychedelics and integrate them into their lives. Finally, harm reduction work may also entail psychedelic integration that is similar to therapy sessions in clinical trials which involve helping clients maximize benefit from their experiences.
Risks associated with conducting psychedelic harm reduction and integration therapy
Many therapists who wish to offer psychedelic harm reduction and integration therapy (HRIT) are unsure of the potential level of risk involved and may therefore hesitate to provide this service. The following section will outline some of the most common types of risk associated with this emerging clinical area but is by no means an exhaustive account of all forms of risk that are possible. In addition, types and degrees of risk will differ depending on local regions, professional licensing boards, and dispositions of local law enforcement.
Perhaps the largest domain of risk relates to licensing boards. Even though a clinician may not engage in behavior that violates the law, a licensing board has greater latitude to assess and determine if a clinician is acting outside of the boundaries of acceptable professional practice. For example, guidelines in many US states include holding that licensed practitioners should not act in an unprofessional, unethical, or negligent manner. Due to the novelty of psychedelic therapy, less familiarity with harm reduction principles, and stigma against drug use, it is possible that any given licensing board may disapprove of therapists who are not explicitly trying to prevent people from using prohibited substances. Because licensing boards may receive complaints from clients, other clinicians, or general members of the public, there are multiple ways that they may become aware of a clinician’s actions. For example, a client's family could discover that the client has been meeting with a therapist for HRIT and perceive that the therapist has encouraged the client to use illicit drugs. Or a client may experience an adverse event during a psychedelic experience, such as physical injury or extreme psychological distress, and communicate this to another provider who knows that psychedelics have not been advocated against in therapy. Such a situation might trigger a report to be made, especially in states that require reporting of perceived unethical or unprofessional behavior by colleagues. In addition, a licensing board may consider it a violation to engage in intention setting or other strategies aimed at maximizing benefit as those might be perceived as encouraging clients to engage in illegal activities. Finally, some boards have guidelines that prohibit activities that may lead to negative perceptions of the profession by the public. For example, psychologists in the USA who are taking public positions on controversial issues are encouraged to consider potential negative consequences that may result from public perception of their profession . As a parallel, the personal conduct of US medical physicians is also considered to be relevant to their professional role and reflective of the field in general .
To the authors’ knowledge, no licensing boards in the USA have taken disciplinary action against clinicians in relation to harm reduction therapy around psychedelics , but this does not mean that following a harm reduction approach will guarantee protection. Though ethical codes may differ between disciplines (e.g., psychology, counseling, social work), they all emphasize the importance of practicing within boundaries of competency. For example, a licensing board may want to know what education or training experiences have prepared the therapist to offer HRIT. Unfortunately, most licensing boards will not provide clear guidelines about practicing in this area. At the very least, complaints, even if without merit, may lead to stress and inconveniences, such as having to indicate that you have been previously investigated for unethical behavior when applying for malpractice insurance or insurance panels.
Another area of risk is criminal prosecution, which in the USA includes local, state, and federal levels. First Amendment protections for free speech extend to healthcare practitioners and discussion of information around drugs, such as when it was found that doctors could discuss the benefits of cannabis to their patients in California before cannabis was legalized . This case found that discussion of marijuana would not constitute an anticipatory offense or accomplice liability, thus suggesting that therapists might be equally permitted to engage in discussion of psychedelics with their clients. However, if a therapist assists in the attainment of prohibited drugs or refers a client to an underground guide, this protection would no longer apply and could implicate one in racketeering, conspiracy to commit a crime, or aiding and abetting unlawful acts. Some therapists attempt to skirt laws by allowing clients to come to session under the influence of psychedelics that they have taken on their own and then conduct therapy with them during the experience. However, this would not be protected under the First Amendment and could be perceived as conspiracy in committing a crime or a violation of drug house laws which prohibit the provision of space to consume controlled drugs. In a conversation with a defense attorney in Oregon, a general rule pertaining to controlled substances was discussed, namely that “the more involvement you have and the more intrinsic your involvement is, the more risk you have of prosecution” (A. Margolis, oral communication, August 2020). It is generally not recommended to infer risk levels based on peer-group actions, which may be especially true in the context of the lack of clear guidelines about HRIT from licensing boards. In other words, just because a lot of peers are doing something, that behavior could still be sanctioned if reported to a licensing board or prosecuted if presented to legal authorities.
Another type of risk involves potential litigation of malpractice. If a client were harmed while using psychedelics, we can imagine three different grounds for civil suits that therapists may want to consider when making decisions about risk. First, the therapist could be sued for failing to protect the client from harm. In addition, lawsuits might be filed under the grounds that psychedelic HRIT is a new treatment that lacks sufficient scientific evidence. Finally, it could be argued that the therapist has violated standards of care by not taking a more conventional approach to treatment. Any of these grounds could also be a part of a licensing board decision.
Another type of risk involves that of professional reputation amongst peers and communities. This risk likely differs widely based on factors such as geographic location and type of workplace. This may be especially true in more conservative regions or traditional therapeutic contexts such as abstinence-focused substance use disorder treatment. If clinicians perceive that publicizing HRIT services might jeopardize their income or employment, it may limit the accessibility of this type of therapy for the public. In addition, some agencies might not support or permit this type of practice. Clinicians interested in providing psychedelic HRIT therapy are encouraged to think through these risk factors and consider other forms of risk that may be unique to their own personal circumstances.