Psychedelics in Western medicine

Psychedelics have been used in traditional indigenous contexts for centuries for emotional health, spiritual purposes, and personal growth, but are now re-emerging in Western medicine for their potential in reducing symptoms of some of the most disabling mental health conditions. Therapeutic experimental research of psychedelics dates back to the 20th century, with drugs like Lysergic acid diethylamide (LSD), psilocybin, mescaline, and 3,4-methylenedioxymethamphetamine (MDMA) being used for a variety of indications (Costandi, 2014; Passie, 2018). Current clinical research is exploring the safety and efficacy of psychedelics for mental health disorders, such as posttraumatic stress disorder (PTSD), mood disorders, substance use, and end-of-life anxiety (Brown & Alper, 2018; Ross et al., 2016; Ot'alora G et al., 2018). These drugs have been explored as stand alone treatments, such as intravenous ketamine infusion therapies (Zarate et al., 2006), and as adjuncts to psychotherapy (Mithoefer et al., 2018; Rodriguez et al., 2016; Wilkinson et al., 2017). However, very little of this research has focused on people of color, and there are no accounts that represent the experience of Black women. The purpose of this paper to report the personal accounts of three African American female clinicians who ware administered a psychedelic substance in a psychotherapeutic clinical setting to help advance our understanding of the use of psychedelic-assisted psychotherapies in different populations.

In Western clinical paradigms, psychedelic substances and traditional psychotherapy have been combined to create mental health treatments that are curative and support psychic expansion through non-ordinary states of consciousness, where the effect is potentiated by the presence of an experienced healer, therapist, or guide. For example, psilocybin is being used in combination with Acceptance and Commitment Therapy (ACT) for the treatment of Major Depressive Disorder (Sloshower et al., 2020). Ibogaine is combined with behavioral therapy in the treatment of opiate dependency (Brackenridge, 2010). Likewise, MDMA is being used in combination with psychotherapy for PTSD to facilitate trauma processing and create a context for healing within a participant's mind, body, and spirit (Mithoefer, 2015). Although psychedelic-assisted treatments are showing promise in Western medicine, researchers and clinicians must begin to examine the applicability of these protocols cross-culturally.

Indigenous practices

Most of the existing literature on psychedelic therapy is from a Eurocentric, medicalized perspective, often omitting indigenous use or discussing its origins in a detached historical manner (George, Michaels, Sevelius, & Williams, 2020). However, many substances currently used for psychedelic medicine are derived from plants that are considered to have sacred healing properties by indigenous groups, and are still being used by those communities today. Even manufactured psychedelic substances are derived from plants, some of which have been prized for their health benefits by indigenous peoples, such as sassafras and similar spice trees, which produce safrole oil, the source of MDMA (Kemprai et al., 2020).

Cultural groups around the world make use of psychedelic healing traditions, which include the clinical management of psychedelic medicines in a spiritual context. These traditions are repositories of millennia-old medical experience and knowledge regarding best practices in the use of these substances. Such indigenous traditions constitute their own form of clinical science that provides important guidelines relevant to Western applications of psychedelics in medicine and therapy (Winkelman, 2007).

There has been much written about the indigenous use of plant medicines from Mexico and South America, but psychedelics have been used across cultures and eras. The psychedelic Soma was a central part of ancient Indian (Vedic) religiosity, and psychedelics appear to have been used in Biblical times to facilitate divine encounters by anointing priests and kings (Nemu, 2019). They have also been used for thousands of years in African culture and traditions. When Black people were enslaved in North America, Yorba women from West Africa engaged in healing practices using their knowledge of plant medicines derived from Africa (A. Williams, 2018). In Ethiopia, all plants are believed to possess some degree of medicinal usefulness, and medicinal plants occupy a central place in their traditional health care system (Doffana & Yildiz, 2017). This includes an array of flora for medical purposes and important psychoactive plant medicines for psychological problems and more psycho-spiritual problems, such as warding off evil influences and misfortunes; Çaate (Katha edulis), buncho (Coffea arabica L.) and ţaddo (Rhamnus prinoides) are examples of some of these plant medicines (Doffana & Yildiz, 2017).

The iboga shrub (Tabernanthe iboga) has been used for centuries in healing ceremonies and cultural rites by traditional communities in West Africa, for example among members of the Bwiti religious groups in Gabon, Cameroon, Equatorial Guinea and the Congo (Brackenridge, 2010). It is a mild stimulant in small doses, but in larger doses causes an intense psychedelic state. Iboga is the source of ibogaine, a powerful psychoactive alkaloid. Researchers in the West, found that ibogaine can significantly reduce withdrawal symptoms from opiate dependency and eliminate cravings (e.g., Brown & Alper, 2018). This has resulted in several noteworthy clinical trials and thriving international and underground ibogaine treatment centers for opiate addiction (Labate, 2014).

In southern Africa, there is widespread reliance on ubulawu as psychoactive spiritual medicine among practitioners of traditional medicine in many communities, including the Xhosa and Zulu, to communicate with their ancestral spirits and to treat mental disturbances (Sobiecki, 2012). Ubulawu is composed of the roots of a variety of plants (e.g., Silene and Dianthus species) that are ground and made into a cold water infusion, churned to produce healing foam. Further, Bantu traditional healers use the ubulawu as part of their ritual initiation process and as a training tool for their shamanic work. It has been noted that factors such as psychological attitude, familiarization with the process, correct plant combinations, and a compatible relationship with the healer are all critical influences in the effectiveness of ubulawu (Sobiecki, 2012). The Bushmen of Dobe in Botswana use the hallucinogenic plant kwashi (Pancratium trianthum) for spiritual and healing purposes (Schultes, Hofmann, & Ratsch, 2010). As of 2002, over 300 plants with psychoactive uses have been identified in South Africa alone, many with psychedelic properties (48 listed as visionary plants for inducing altered states of consciousness; Sobiecki, 2002).

There are many other psychedelic medicinal traditions in Africa, but most of these have not yet been sufficiently researched to enable Westerners to fully understand or appreciate their potential. What is clear, however, is that Africans have had a long tradition of healing with psychedelic plants, used in accordance with traditional practices and experienced healers.

Stigma surrounding psychedelics in Black communities

Despite great public interest in the use of psychedelics for mental health, and traditional uses among indigenous groups, people of color in the US have shown less enthusiasm for this repopularized modality. In terms of African Americans specifically, reduced interest is evidenced by the fact that very few Black people have been included as research participants in studies of psychedelic therapy (2.5% worldwide; Michaels, Purdon, Collins, & Williams, 2018) and our own observations in regards to the small number of Black researchers involved in psychedelic medicine. Further, although Black and White people in the US use drugs at similar rates, recreational use of hallucinogenic drugs is far lower for African Americans than White Americans (Shalit, Rehm, & Lev-Ran, 2019).

False stereotypes about African American drug use causes many to have increased fears about even considering psychedelics as a mode for healing and growth. Consider that Black youth use drugs at lower rates than White or Hispanic youth (Wu, Woody, Yang, Pan, & Blazer, 2011), and Black Americans are less likely to suffer from substance use disorders than White Americans (Grant et al., 2016; Lacey et al., 2016). Nonetheless, Black Americans are 3.5 times as likely to be arrested for drug-related offenses and are 7 times more likely to be incarcerated for using drugs compared to White Americans (e.g., US DOJ, 2016; Hinton, Henderson, & Reed, 2018).

These differential rates of punishment are not an accident. According to University of Virginia historian, Douglas Blackmon, the criminal justice system was designed to bring justice to White people and injustice to people of color (Anderson, Blackmon, Elzie, López, & Lowery, 2017). Slave patrols were the forerunners of our police force, hired by landowners to catch runaway slaves and punish them (Turner, Giacopassi, & Vandiver, 2006), and law enforcement today continues to carry out a version of its original mandate. Laws against drug use in the Nixon-era were intentionally designed to target Black people, as they were seen as a serious threat due to their push for Civil Rights. “Hippies” were also targeted as their opposition to the Vietnam War was attributed to the use of substances like LSD. However, drug laws were never applied evenly across racial groups, with Black Americans targeted by law enforcement and receiving longer and harsher sentences for identical violations of the law as compared to White Americans (e.g., Beckett, Nyrop, & Pfingst, 2006). The rising perception that drugs were a Black problem fueled negative stereotypes about these communities that Black people were eager to dispel, resulting in stronger negative attitudes about drug use overall in Black communities.

The Black Church was motivated to find solutions to the crack epidemic and aligned itself with the Reagan-era “War on Drugs” as a potential solution. However, the War on Drugs became an excuse for long and harsh sentencing of Black Americans found guilty of drug infractions. Crack cocaine penalties were much more stringent than penalties for powdered cocaine use, the only difference being that Black people were more likely to use crack and White people were more likely to use cocaine. Through this process, African Americans became falsely stereotyped as addicts and dealers who were committing crimes to feed unconstrained drug habits (Williams, Gooden, & Davis, 2012). So, the War on Drugs became a vehicle for the mass incarceration of Black Americans accused of drug infractions, and US prisons became filled with Black and Brown bodies (Alexander, 2012). There was little interest within the Black community for drugs as a means of expanding consciousness or personal growth. The focus was on preventing and reducing drug use to keep people safe, well, and out of jail.

There is no scientific literature on African Americans and psychedelics, beyond demographic correlates of usage and treatment-seeking patterns (e.g., Palamar, Mauro, Han, & Martins, 2017). The limited research on MDMA among African Americans indicates that the drug has gained a small measure of increased popularity among Black youth, amidst much misinformation and misperception about the benefits and dangers of use. Rather than facilitating self-discovery or improving mental health, users believe MDMA can alter the effects of other drugs or potentiate sexual experiences (Rigg, 2017; Rigg & Lawental, 2017).

African American racial and cultural trauma

Historical trauma refers to the cumulative emotional harm of an individual or generation caused by a profound traumatic experience or event. The trauma experienced by prior generations continues to result in harm to subsequent generations. The historical trauma response may include depression, substance abuse, suicidal ideation, anxiety, low self-esteem, anger, and emotional constriction (Brave Heart, 2003). Examples of historical trauma include acts of genocide, such as what happened to Native Americans and Indigenous Canadians, and to Jewish people during the Holocaust. One of the most salient examples of historical trauma in the United States is the experience of Black people in America who were kidnapped from their homes in Africa, and forced into a lifetime of servitude. These individuals were subjected to an agonizing Middle Passage, enslavement of themselves and their children, forced separation of families when children were sold, physical and sexual abuse, and forced extermination of their culture and languages. Once slavery was no longer legal, African Americans continued to experience oppression in the form of segregation, Jim Crow laws, and the unequal application of the criminal justice, which included lynchings (Alexander, 2012; DeGruy, 2007). At every level, the criminal justice system is heavily biased against Black people compared to White people (e.g., Beckett, Nyrop, & Pfingst, 2006; US DOJ, 2016), and although Black Americans are 13% of the population, they comprise 35% of male inmates and 44% of female inmates (Hinton et al., 2018).

Cultural trauma occurs when members of a cultural group have been subjected to a horrendous event that etches permanent marks upon their group consciousness, marking their memories forever and changing their future identity in fundamental and irreversible ways (Alexander, Eyerman, Giesen, Smelser, & Sztompka, 2004). Given the traumatic history of African Americans, combined with current problems such as racial profiling, mass incarceration, unchecked police violence in mass media, and daily discrimination, it should be unsurprising that cultural trauma persists (Alexander, 2012; Becket, 2006; Bor, Venkataramani, Williams, & Tsai, 2018; Chou, Asnaani, & Hofmann, 2012). Traumatization exists at the intersection of race and gender as well. African American women experience high rates of PTSD, which can be explained in part by the high number of traumas they experience. The National Survey of American Life found that almost half of all African American women had been assaulted, which included 17% having been raped, 20% having been sexually assaulted, and 16% having been stalked; additionally, 17% experienced a life threatening car accident, 14% had a life threatening illness, and 12% had a child with a life threatening illness (Ching, Williams, & Taylor, 2018). Given these grim numbers, it seems clear that Black women carry a great deal of pain associated with life in America, from both past and present traumas.

The combination of historical and cultural trauma in African Americans can lead to what Dr. Joy DeGury (2007) has termed “Post Traumatic Slave Syndrome”—loss of self-esteem, anger, and internalized racism. Correspondingly, current research indicates that the experience of ongoing racism can indeed result in stress, traumatization, and even a formal diagnosis of PTSD. When racism causes or contributes to traumatization, we call it racial trauma (Williams & Leins, 2016; Williams, Printz, Ching, & Wetterneck, 2018).

African Americans and medical research

African Americans also have these traumas surrounding medical research, including psychedelic research. There is evidence that the risks of early era psychedelic research unduly rested on the backs of African Americans and other vulnerable populations. In examining these early studies, comparing the treatment received by White research subjects to what was experienced by people of color, inequities become evident. The Addiction Research Center (ARC) in Lexington KY, run by Dr. Harris Isbell, shared the campus with the Federal Bureau of Prisons. The research subjects were inmates, one-third White, a third “Negro” and a third “Mexican.” While most people have some knowledge of the Tuskegee Syphilis Study of Untreated Syphilis that targeted Black men, few know about the facility dubbed the “Narco Farm” in Kentucky (Campbell, Olsen, & Walden, 2008).

One study describes two groups that received LSD, one was “Negro” males convicted on drug charges who were recruited from prison and provided coercive incentives to participate in dubious LSD experiments, and the comparison group was professional White people at Cold Spring Harbor, living freely, who were not coerced but given LSD in the principal investigator's home “under social conditions designed to reduce anxiety” (Abramson, 1960). Knowing the profound influence of set, setting, and intention, these two groups undoubtedly had very different experiences. According to Edward Flowers, an African American subject in ARC experiments while incarcerated, “They used my ass and took advantage of me, you know, being a young kid and all…” (Campbell & Stark, 2017).

There were over 500 published studies that came out of ARC from 1935 to 1975, testing the limits of human tolerance for psychedelics, opiates, and amphetamines on prisoners (NIDA, 1978). Dr. Isbell's studies included dangerously high and prolonged doses of LSD on his subjects. In the 1970s, ARC moved to Baltimore and became the National Institute on Drug Abuse (NIDA), after a nationwide ban on the use of federal prisoners as research subjects. These studies violated well-established guidelines for the ethical conduct of biomedical research (e.g., Nuremberg Code, Declaration of Helsinki, Belmont Report) that has never been publicly acknowledged. African Americans individually may not know the details of the crimes committed against Black communities, but the cultural memory remains (Suite, La Bril, Primm, & Harrison-Ross, 2007).

Psychedelic experiences for training of therapists

Psychedelic-assisted psychotherapy, as practiced currently in academic research settings, involves the use of a psychedelic compound in conjunction with a specified sequence of therapy sessions that are intended to inform, shape, and support the psychedelic experience. Studies typically include three types of sessions: preparatory, medication, and integration sessions (Bogenschutz & Forcehimes, 2016). These prepare clients for psychedelic sessions and establish the therapeutic alliance, to guide them safely during the experience and assist in the critical process of translating their experience into lasting change. Sessions generally utilize medium to high doses of a psychedelic substance during 1–3 sessions, with the intention for the client to have an intense and insightful experience supported by the therapists and further explored during integration (Nielson & Guss, 2018).

Therapists and researchers who work with psychedelics are often questioned regarding their own use of psychedelics, with a concern that a lack of direct experience might compromise their effectiveness as therapists (Nielson & Guss, 2018). Such experiences may be difficult to obtain given the legal prohibition against psychedelic substances, and even more so for African Americans for the reasons described previously. To facilitate instructional psychedelic experiences, the Multidisciplinary Association for Psychedelic Studies (MAPS) received US Food and Drug Administration (FDA) approval to proceed with a separate study for healthy volunteers. As part of the training to become an MDMA therapist, clinicians were able to receive one dose of MDMA along with psychotherapy in the same manner in which a participant would. The study was not designed to investigate the effect of the MDMA experience on clinicians, but rather to provide the opportunity for therapists in training to experience MDMA in a therapeutic setting, while collecting safety data in healthy volunteers. Some therapists have published their own individual accounts (e.g., Ching, 2020; Halberstadt, 2014), but as previously noted, there have been no accounts from African Americans and their corresponding cultural issues published in the professional literature, making this an important new area of inquiry. Women of color are among the most stigmatized groups of people in North America, where much of this work is taking place, therefore it is essential to incorporate these perspectives into the literature to expand conversations about psychedelics and health equity.

Participants and study procedures

At the University of Connecticut Health Center (UConn), our team participated in a multisite MAPS-sponsored, FDA approved, Phase 2 open-label study for PTSD. This work focused on culturally-sensitive and respectful treatment approaches for people of color, taking into account the impact of culture and the possible need to adapt MDMA-assisted psychotherapy to culturally-specific traumas (Williams et al., 2018; Williams, Reed, & Aggarwal, 2020).

At the UConn site, most study clinicians participated in the separate study to further their clinical training, “Phase I Placebo-Controlled, Double-Blind Crossover Study to Assess Psychological Effects of MDMA when Administered to Healthy Volunteers” (MT-1; ClinicalTrials.gov identifier: NCT01404754). MT-1 was a randomized, double-blind cross-over study, whereby all participants received MDMA during one drug session and placebo at a second session. Three MT-1 participants were Black women. Each participant had an initial preparatory visit at the investigators' offices for screening, followed by two day-long drug sessions, each including an overnight stay with a night attendant in a nearby room. Participants had an integrative session with the therapists the next morning after drug sessions, and a phone call to check in the day after. Each participant worked with two therapists, a male and a female. Between the three therapist participants, there were a total of four facilitating therapists, three of whom were White Americans and one who was a Columbian American. The study was approved by the Copernicus Institutional Review Board, and all participants provided informed consent.

Methodology

To arrive at critical themes, an iterative thematic analysis process was utilized (Vaismoradi, Jones, Turunen, & Snelgrove, 2016). The objective of this approach is to generate themes related to the phenomena under study that might point us toward a broader cultural experience as witnessed through a smaller number of eyes and life experiences (the phenomena-in-context). The goal is to acquire a felt sense of the experience through accounts described by different participants. To that end, each participant wrote about her experience, with a focus on the parts that felt most salient, and then condensed the accounts to approximately 950 words. An iterative process was utilized to identify themes, whereby the subjects of the study were themselves co-creators of the themes. Each participant read each account and generated themes, revising the final list until there was agreement.

What follows are the written accounts of three female African American therapists from the UConn site that participated in MT-1 in 2017 in Denver, Colorado.

Psychedelic experiences

Major themes

All three of the MDMA-assisted experiences included cultural themes relevant to the experience of Black women in America. A main theme from Therapist 1 focused on healing deep, racialized intergenerational wounds. On one hand, she was able to experience a blissful reality beyond her race and gender; however, she also had to learn how to sit with these political realities in an unfiltered way. She notes, “As a Black woman, I had to learn the language of this White American world, the mannerisms, and the performance. I've straightened the coils from my hair and denied parts of myself just to feel like I belonged. Those defenses that became a necessary part of my social development and helped me survive in the only world I knew no longer worked.”

The themes from Therapist 2 focused on the paradoxical need for human connection and dependence, in contrast to perceived need to be strong, efficient, and self-sufficient to “survive and thrive in a perilous and often hostile racist society controlled by White men and women.” She found the idea of being vulnerable too threatening to tolerate, which cut her off from the vulnerable parts of her personality and interfered with important relationships.

The themes from Therapist 3 included transcendence, moving above the oppression and pain of everyday life to a higher plane, from which she could reach down and help others to also transcend. She was able to situate herself simultaneously within her ancestral community and her current African American experience, and thereby draw strength from her family, past and present. Nonetheless, she continued to feel a need to be vigilant and a lack of safety. She notes, “It has become apparent to me that we must be preoccupied with helping clients of color, Black clients in particular, to feel an immense sense of safety.”

The primary themes emerging across the varied experiences include strength, safety, connection, and managing oppression/racialization. Challenges with vulnerability also cut across the narratives. Growth from the experience centered on understanding that having needs and experiencing feelings does not equate to weakness (prominent in narratives 1 and 2), and a renewed sense of duty to provide help and healing to one's community (prominent in narrative 3).

Experience as a training exercise

All three therapist participants found the process of having a session of MDMA-assisted therapy, in the same manner that a client would experience it, to be helpful for better understanding the research protocol and the client experience. Navigating cultural and racial material during the MDMA sessions was also an important reminder that all participants are a product of their culture to various extents, which becomes reflected in the psychedelic experience, including past and present experiences of oppression.

The lived racial experiences and training of the facilitating therapists was salient to participant experiences, as it influenced their ability to respond to material as it was unfolding. Of the four therapists who facilitated sessions, two made statements that were culturally insensitive or microaggressive during the MDMA session, and this directly impacted two of the three Black therapist participants (Williams & Halstead, 2019). This underscored the need for multicultural training and extreme sensitivity on the part of therapists to refrain from contributing to a participant's cultural trauma by reenacting social patterns of oppression that occur in everyday interactions outside of the treatment space (Williams et al., 2020).

Psychedelic-assisted therapy for Black women

The material that emerged from the MDMA-assisted psychotherapy sessions was filled with themes that are particularly salient for Black women in America, including cultural trauma, spiritual connection to ancestors, care for community, and the Strong Black Woman archetype – an intersectional conceptualization of Black womanhood. This archetype derives from slavery, when Black women had to be strong in order to survive and protect their children in a brutal environment of forced physical, emotional, and sexual servitude. The Strong Black Woman has become “a cultural ideal that portrays Black women as strong, self-reliant, nurturing, resilient, and invulnerable to psychological or physical challenges” (Baker, Buchanan, Mingo, Roker, & Brown, 2015, p. 53). Black women may struggle with how much to identify with this ideal due to its conflicting positive and negative and characteristics. Although a focus on inner strength can be empowering, adopting this archetype perpetuates problems such as being overworked, undertreated for mental health needs, neglectful of self-care, and cut-off from nurturing from others. It can also interfere with the emotional vulnerability needed to forge deep, mutually reciprocal relationships.

One important avenue for understanding some of the other themes may lie in cultural differences in approaches to understanding the self. The North American concept of the person centers on individualism, where each person is considered autonomous and uniquely deserving the free pursuit of their own private goals; this “egocentric” notion of the person leads individuals to think about their identity primarily in terms of personal history and achievements (Kirmayer, 2007). However African cultures typically have more of a “cosmocentric” sense of self, and may therefore narrate their identity in relation to ancestors, spirits, or larger cosmic forces. Of course, the different ways of construing the self are not mutually exclusive, as egocentric and cosmocentric views may exist simultaneously (Kirmayer, 2007).

Nonetheless, as noted by Kpanake (2018), African cultures generally have a more spiritual and relational-oriented perspective of the self, in which an individual manifests “personhood through connections to three distinct forms of agency: (a) spiritual agency, including God, ancestors, and spirits that influence the person; (b) social agency, including the family, the clan, and the community, with extension to humanity; and (c) self-agency, which is responsible for the person's inner experience” (p. 198). These three forms of agency were all apparent in one or more of the narratives provided by participants, reflecting their meaningful and important connection to African culture.

Understanding the self from the perspective of a Black woman requires consideration of intersectionality as well. Black women often experience oppression by being both Black and a woman. They may not be able to separate these two facets of their identity into distinct pieces, but rather conceptualize themselves holistically. Without this framework, one can misunderstand or misinterpret important aspects that are salient to her experience.

Dangers of culturally uninformed therapy

When therapists are unable to make use of cultural material it can represent a lost opportunity for healing, but it is much worse when therapists actively cause harm. It has been recognized for some time that racially charged materials can provoke violence from clinicians in the form of microaggressions or other harmful actions or inactions, as therapists struggle to manage their own psychic woundedness around issues of race (Comaz-Diaz & Jacobsen, 1991; Kanter et al., 2020). Race relations in the US, Canada, and many other Western nations operate within a system whereby people of color are expected to maintain White comfort by remaining silent about past and present experiences of racial oppression (DiAngelo, 2011; Kanter et al., 2019). This expectation often extends into the mental health care frame, and it is thought to represent a major barrier to treatment for people of color, as good therapy requires an open trusting dialog. Further, in a typical outpatient mental health setting, if an African American client is harmed by a therapist, the client can use their generally well-developed defenses against racism and choose to engage at a superficial level or not at all, or even walk out. In contrast, when under the influence of a psychedelic, the client may not leave the session for several hours and may not be able to access their typical defenses to protect against emotional harm. Further, the heart-opening properties of MDMA specifically may make clients who are seeking healing from racial traumas particularly vulnerable to further emotional injury. This represents at least two distinct kinds of abuse, abuse of authority and abuse aided by an intoxicating substance (Dawson, 2019). This could be compared to the devastating experience of a client seeking healing from the trauma of rape only to be subjected to sexual advances from a therapist while in a physically vulnerable or even helpless state.

Training for therapists and guides

Because of the extreme vulnerability of patients during psychedelic-assisted psychotherapy, all therapy providers and supervisors should have basic competencies in working ethically and skillfully with people of color. As noted by Williams et al. (2020), essential skills include, the ability to (1) identify normal cultural variations in the expression of psychopathology and personality, (2) recognize trauma related to the experiences of racism and other forms of oppression, (3) develop good rapport with people of color by appropriately expressing caring, empathy, and respect, (4) comfortably engage in discussions about racial topics, and (5) identify and examine personal biases as they relate to ethnic and racial differences, with an ongoing action plan to address any areas of difficulty. All therapy providers conducting psychedelic therapies should be competent in these areas prior to working with people from different ethnic groups. Skill in cross-racial work is critical given the very limited number of psychedelic therapists of color.

Functional Analytic Psychotherapy (FAP) is a therapeutic approach rooted in the contextual behavioral tradition (Hayes, Barnes-Holmes, & Wilson, 2012) that focuses on the therapeutic relationship as the agent of change to improve relationships (Tsai et al., 2009). FAP promotes intrapersonal awareness as well as interpersonal awareness between the client and therapist equally for a strong and authentic connection. This approach prompts FAP therapists to take interpersonal risks by experiencing, processing, and disclosing reactions to the client as they occur in-session in the service of client growth, and it prompts therapists to encourage their clients to do the same. When the client engages in courageous self-expression in FAP sessions, the therapist in turn responds with genuine feedback to increase the intimacy of the exchange. This vulnerability and immediacy serves as a model to help the client improve connections with others, which is an important trans-diagnostic outcome (Wetterneck & Hart, 2012).

In this context, inadvertent insensitivities and microaggressions committed by therapists present a barrier to fundamental and necessary intimate, trusting, and safe transactions. Within FAP this could become an opportunity for therapist growth around racial anxieties and client growth in successful assertion of needs, which would ideally lead to a celebration of a client's expression of their full self as an ethnic and cultural being. FAP is particularly well-suited for culturally-sensitive practice because of its focus on the relationship as a primary change mechanism, and FAP is flexible enough to be used for understanding behaviors across cultures and ethnicities (Vanderburghe, 2008). Therapists are allowed to admit that they do not have all the answers and may not fully understand the experience of racial oppression, which paradoxically bolsters trust and genuine connection with the client. And, as therapists are able to confront their own assumptions and biases, they become more culturally sensitive and attuned to feedback from their diverse clients (Miller, Williams, Wetterneck, Kanter, & Tsai, 2015). Thus, FAP may be well-suited for MDMA-assisted psychotherapy with people of color, given the focus on establishing a quality emotional connection (Luoma, Sabucedo, Eriksson, Gates, & Pilecki, 2019; Williams et al., 2020).

Since the accounts described in this paper occurred, MAPS has made efforts to further the cultural competence of its therapists, including a series of trainings for independent raters, that was recorded and subsequently made available to study therapists (Reed, 2019; Williams et al., 2020). Further, in August 2019, two of the authors organized and co-led a community conference and special training for therapists of color, which was grant-funded by the Open Society Foundation and other donors and implemented by MAPS (Williams & Labate, 2020). These are essential early steps in improving treatment for people of color, however important gaps remain. For example, at MAPS there are almost no approved supervisors able to provide culturally-informed oversight to new therapists who might require guidance in this area. Apart from MAPS, we are aware of no other sponsors or research teams attending to this aspect of the work (Williams et al., 2020), however one of the only certified training programs for psychedelic therapies, the California Institute of Integral Studies, had put some successful measures in place to increase admissions for trainees of color.

Addressing misgivings

Some may be concerned that exposing people to psychedelics may be simply introducing a new approach for escaping from problems as opposed to working through them in a clinical setting. People may fear this process encourages potential drug misuse among patients and clinicians by trying psychedelics in a clinical setting. Indeed, the therapist participants featured here each had private reservations about participating in MT-1 for a variety of reasons. It is important to understand that all medications have the potential for healing or abuse, depending on how they are used, and psychedelics are no exception. That being said, the data indicate that compared to other substances, psychedelics are generally safe, with low addiction potential, and even recreational use is correlated to few negative outcomes (Johansen & Krebs, 2015).

Further, psychedelic-assisted therapy is hard work and should not be considered an escape or shortcut to healing. All three therapists spent considerable time and effort processing their experiences alone and with others to integrate what was learned into their lives for personal growth and individual healing from racial stress and trauma.

Reclaiming our cultural birthright

As described previously, there is a rich tradition of plant medicines and spirituality in Africa, and African spiritual themes were prominent in two of the three narratives. As such, people from the African diaspora may especially benefit from psychedelics within a culturally-appropriate framework. Two of the participants have started providing culturally-informed psychedelic-assisted psychotherapy as a means of treating racial trauma in an outpatient mental health clinic. In our experience, many African Americans are fearful of psychedelic medicines and the vulnerability that comes with being in an altered state. Certainly, these treatments can be unsafe without skilled providers or caring therapists to guide clients on their journeys. But these medicines are part of our cultural birthright, and African Americans deserve the same access to the healing potential of psychedelics that our ancestors have benefitted from and continue to benefit from in Africa today.

Limitations and future directions

Because this study chose to focus on the voices of African American women, the experiences described cannot be assumed to generalize to African American males or even Black people worldwide. More research is needed to amplify the voices of people from other racial and ethnic groups and those with other marginalized identities to better understand psychedelic experiences cross-culturally. As more narratives become available, it would be interesting and important to compare them across populations to better understand how culture influences the psychedelic experience.