Abstract
Similar to much of the mental health field, psychedelic-assisted psychotherapy has failed to center the needs of people of color. Monnica Williams and colleagues demonstrate the harm faced by Black women and other people of color when working with psychedelic-assisted psychotherapists that are unaware of and ill-equipped to address sensitive topics related to race. Here I discuss the benefits and limitations of Functional Analytic Psychotherapy training for therapists that have not engaged in deep and reflective processes to understand their personal engagement in racism, privilege, and oppression. I call on leaders in the field of psychedelic-assisted psychotherapy to adhere to a new standard of intersectional cultural humility for anyone preparing to provide these services. Finally, I highlight the need to significantly increase the number of therapists of color trained to offer psychedelic-assisted psychotherapy to begin to address racial disparities to access to these radical treatments for trauma.
As a clinical-community psychologist, I have been vocal about the many ways in which psychological science must change or risk being irrelevant to the masses (see Buchanan & Wiklund, 2020). The field has failed to train the clinicians necessary to address the needs of a rapidly diversifying population. Not only is the psychology workforce and trainee pipeline largely White (APA, 2018), but their training continues to focus almost exclusively on treatment paradigms, theories, and models that center Whiteness to the exclusion of understanding the needs and worldviews of people of color. Despite having competency benchmarks for professional psychology addressing individual and cultural diversity (Fouad et al., 2009), regulating bodies, such as the American Psychological Association do not hold training programs accountable for demonstrating cultural competence. Even their most recent multicultural guidelines (APA, 2017; Clauss-Ehlers, Chiriboga, Hunter, Roysircar, & Tummala-Narra, 2019) are not enforceable, rendering them optional for most training programs.
The psychedelics renaissance has not extended to Black America. Black people continue to use psychedelics at lower rates than Whites (CBHSQ, 2018) and like much of the mental health field, psychedelic-assisted therapy has failed to center the needs of people of color (Williams & Labate, 2020). Over 80% of participants in treatment trials are White and less than 3% are Black (Michaels, Purdon, Collins, & Williams, 2018). Across the globe, only two investigators for MDMA-assisted psychotherapy studies are women of color, Marcela Ot'alora, M.A., L.P.C. (Latina) and Monnica Williams, Ph.D. (Black) and trainees in psychedelic-assisted therapy programs remain overwhelmingly White. Notably, in August 2019, the Multidisciplinary Association for Psychedelic Studies (MAPSs) welcomed its first and only cohort of approximately 40 Black, Latinx, Asian, and Indigenous trainees.
The absence of people of color means that protocols, procedures, and training are often developed with little to no input from diverse scholars (Williams, Reed, & Aggarwal, 2020) and participants of color do not have the benefit of having therapist teams that reflect their cultural backgrounds. The consequences of these oversights are painfully articulated in Culture and Psychedelic Psychotherapy: Ethnic and Racial Themes from Three Black Women.
The authors are three Black women who recount their experiences with a single session of MDMA1 through a Food and Drug Administration (FDA) approved clinical trial and exercise as part of the MDMA-assisted psychotherapy training. This article provides guidelines for therapists providing psychedelic-assisted psychotherapy and argues that Functional Analytic Psychotherapy (FAP) will be useful for therapists working with clients of color in altered states.
As articulated in their article, during psychedelic-assisted psychotherapy, clients are emotionally vulnerable, stripped of their defenses, and physically unable to leave during sessions. This raises the standards for clinicians' cultural awareness and competence in discussing sensitive concerns related to race and its intersections with other key identities, such as gender and sexuality.
While I agree with the authors that FAP offers promise, I am less enthusiastic about its potential for getting therapists ready to see clients of color, especially when working with psychedelic medicines. Functional Analytic Psychotherapy enhances interpersonal awareness to create a strong connection with clients and allows space for therapists and clients to take risks and discuss cross-cultural missteps (Luoma, Sabucedo, Eriksson, Gates, & Pilecki, 2019; Williams et al., 2020). Therapists that have already engaged in a sustained and deeply personal process of learning and have grown in their awareness of race, privilege, and oppression, will be well positioned to use FAP to responsibly work with clients of color. Unfortunately, too few therapists are trained to value the ongoing work involved in understanding these concerns and their individual roles in maintaining oppression (Buchanan & Wiklund, 2020). Without such a focus, therapists are prone to committing microaggressions in therapeutic settings and fail to create an environment where clients can have challenging conversations about therapist enactment in oppression. While damaging in any therapeutic relationship, such an experience when one is in an altered state and unable to leave furthers client trauma and limits the healing they deserve.
With this in mind, the first requirement for psychedelic-assisted psychotherapists needs to be a vigilant practice of intersectional cultural humility (Buchanan, Rios, & Case, 2020; Tervalon & Murray-Garcia, 1998). Intersectional cultural humility acknowledges that we cannot reach a point where we fully understand another culture. Instead, we must engage in ongoing efforts to better understand our privileged identities, how they complicate our ability to work effectively with others, and that experiences are dependent on the matrices of identities one holds (race, gender, sexuality) and their particular historical and contemporary context. Intersectional cultural humility pushes past the limitations of cultural competence models, which assume an essentialism of different races/ethnicities that can be understood through the careful observation of group members' traits and behaviors. Cultural competence models imply that one can acquire expert status with enough training on a different cultural group and at that point there is no need for ongoing learning. In contrast, intersectional cultural humility establishes that this learning is lifelong and changes based on contemporary events, such as our current worldwide protests against police brutality against Black people in the United States.
Race-related contextual factors are important components of set and setting (Neitzke-Spruill, 2020). Williams and colleagues highlight a number of themes the authors experienced during their MDMA sessions that were specific to their life experiences as Black women. These themes were not fully explored with their therapists, potentially because of the nature of the one-session trial. However, it is likely that such topics would not be fully explored because of the therapists' lack of familiarity with the cultural meanings and importance of these themes among Black people, and Black women in particular. Lack of understanding of the themes could be overcome with a therapist that has an appropriate framework related to intersectional cultural humility. However, this is impossible and the session is potentially harmful for clients due to the presence of microaggressive behaviors and comments on the part of the therapists.
Therapist lack of understanding and engagement in racist behaviors during treatment sessions highlight the urgent need to increase the number of therapists of color trained to provide psychedelic-assisted psychotherapy. Given the power of race-related contextual factors in establishing set, setting, and safety, I imagine the treatment sessions reported by the authors would have been far more powerful if they were led by therapists that were also Black women. Matching client and therapists on their race and gender is a strategy for improving cultural congruence because they are more likely to share values and worldviews (Presnell, Harris, & Scogin, 2012), understand gendered and raced coping responses (Buchanan, Settles, & Langhout, 2007) and experience fewer cultural barriers, microaggressions (Cabral, 2017; Hook et al., 2016) and cultural mistrust (Whaley, 2001).
At the time of this writing, trauma among the Black community is palpable. Most of the United States is under shelter-in-place orders to reduce the number of deaths during the coronavirus global pandemic (COVID-19). Black people are a disproportionate number of the coronavirus deaths, up to 80% in parts of the country, despite being only 15% of the population. There have been peaceful and violent protests across the nation in response to the hundreds of unarmed Black men, women, and children murdered by police in the last decade. News is rife with images of Black people brutalized and murdered with little to no provocation and White nationalists are openly calling out for a race war. There have been a wave of Black men, women, and teens hung from trees and nooses (a commonly used symbol of racial terrorism; Bledsoe, Dowd, & Ward, 2020) have been anonymously placed around the country. These recent events are layered on top of a legacy of cultural and historical trauma (Alexander, Eyerman, Giesen, Smelser, & Sztompka et al., 2004; Barlow, 2018; Yu, 2016), financial strain, and unacceptably high rates of trauma among Black people. Specifically, Black women experience high rates of forced and coerced sex across all ages (McCauley, Campbell, Buchanan, & Moylan, 2019), an increased risk of being targets of violence in their homes, disproportionate rates of sexual and racial harassment at work (Buchanan, Bergman, Bruce, Woods, & Lichty, 2009), and inequities in healthcare that increase their risk of death from any range of conditions from childbirth to cancer, to cardiovascular disease (Baker, Buchanan, Small, Hines, & Whitfield, 2011; Baker, Buchanan, Mingo, Roker, & Brown, 2015; Baker, Buchanan, & Spencer, 2010; Belgrave & Abrams, 2016). Current levels of racial trauma (Williams & Leins, 2016) among Black men, women, and children are incredibly high as is the need for collective healing.
Psychedelic-assisted psychotherapy stands at cross-roads with the potential to be a therapeutic method that centers social justice and embodies healing justice. Cara Page, from Kindred: A Southern Healing Justice Collective is a Black, queer woman that developed the healing justice framework in 2007 and advocates for its use around the country (Piepzna-Samarasinha, 2016). Healing justice demands that we make healing a political act of resistance against oppression, that we conceptualize healing as a facet of social justice, and that we make the work of healing accessible for all people.
Psychedelic-assisted therapy cannot live up to its potential without addressing systemic injustice inherent in its current enactment. Having primarily White researchers, working with primarily White clients robs communities of color from the radical healing psychedelics promise. These medicines originated among communities of color and were then criminalized and denied to these same communities. We cannot allow the healing that accompanies our modern psychedelic renaissance to continue to overlook their trauma and their right to heal.
Conflict of interest
I have no known conflicts of interest to disclose.
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MDMA (3,4-methylenedioxy-methamphetamine) is a synthetic drug that is chemically similar to both stimulants and hallucinogens. MDMA acts primarily on three neurotransmitters, Dopamine, Norepinephrine, and Serotonin to produce a sense of emotional connectedness, empathy, arousal, and elevated mood (see NIDA (2020) MDMA (Ecstasy/Molly) DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/mdma-ecstasymolly).
