Abstract
Psychedelic-assisted therapy (PAT) is currently undergoing a resurgence of clinical interest for several mental health ailments. We propose that philosophers can play a significant role in PAT in both the preparation and integration phases of PAT. Philosophers can aid in the former phase by offering philosophical preparatory insights and in the latter phase by providing the conceptual language to articulate the complex philosophical aspects of a psychedelic experience.
“The mind was primarily concerned, not with measures and locations, but with being and meaning.” (Huxley, 1963, p. 20)
Introduction
A growing body of evidence supports the use of psychedelic medicines to treat mental illnesses, including PTSD (De Gregorio et al., 2021), depression (De Gregorio et al., 2021; Ko, Kopra, Cleare, & Rucker, 2023), addiction (Bogenschutz et al., 2015), and social anxiety associated with autism spectrum disorder (Markopoulos, Inserra, De Gregorio, & Gobbi, 2022). Along with decriminalization and legalization in several states, public interest has dramatically increased over the last 15 years. After decades of prohibition, psychedelic research is booming, with recreational use also becoming socially acceptable and mainstream (Pilecki, Luoma, Bathje, Rhea, & Narloch, 2021; Schenberg, 2018). The second renaissance of modern psychedelic-assisted therapy (PAT) has created opportunities for addressing scientific, ethical, and practical questions that had been left unanswered in 1970, when psychedelics were essentially banned in the US under the Controlled Substances Act. The scientific questions related to the biological mechanisms of psychedelic substances and their therapeutic potential are being investigated on many fronts, with frameworks ranging from neurological to psychological to spiritual, proposed to conceptualize the psychedelic experience (Neitzke-Spruill, Devenot, Sisti, Averill, & McGuire, 2024). However, unanswered questions remain about the efficacy of various psychotherapeutic modalities employed in PAT, lagging behind clinical research on the psychedelic experience itself.
Psychedelic practitioners—like all clinicians—are ethically obligated to employ treatment modalities to maximize benefits and minimize risks to patients. Medical risks associated with psychedelics may include psychosis-like symptoms, particularly in patients who have a personal or family history of bipolar disorder or psychosis spectrum disorders like schizophrenia. In contrast, non-medical risks include epistemic transformations and “ontological shock”—a confrontation with fundamental questions about the validity of one's worldview and reality— that may accompany psychedelic experiences (Sanders & Zijlmans, 2021).
Indeed, transformations in consciousness and thinking are often the central aims of psychedelic-assisted therapies aimed at relieving symptoms of trauma, depression, or addiction. For such experiences, standard procedural models of informed consent may prove inadequate. Evidence indicates that patients who undergo PAT may undergo ego dissolution, changes in metaphysical beliefs, and experience a deep unity with the divine (Timmerman et al., 2021). These are complex and intense intrapersonal experiences, difficult to describe (Breeksema, Niemeijer, Krediet, Vermetten, & Schoevers, 2020; Kahużna et al., 2022), experienced as completely “real” or noetic, and while often positive they may potentially lead to distressing feelings such as “ontological shock” (Sanders & Zijlmans, 2021).
Ancient philosophers and spiritual leaders—from Greece to the Far East to the Americas—likely used psychedelic substances in rites and rituals (George, Hanson, Wilkinson, & Garcia-Romeu, 2022). Drug-induced mystical and psychedelic experiences appear to have been pivotal in the work of European philosophers including Nietzsche and Schopenhauer (Sjöstedt-Hughes, 2016). By the 19th and 20th centuries philosophers were describing a new kind of metaphysics explicitly linked to chemically-induced nonordinary states and psychedelic experiences. William James described his use of nitrous oxide in revealing a fundamental reality—“depth beyond depth of truth”—which was an epiphany that persisted throughout his life (James, 2009, p. 292). Walter Benjamin described the psychedelic effects of hashish, opium, and mescaline, revealing deeper truths and aesthetic impressions that he otherwise could not sense (Benjamin, 2006; Sjöstedt-Hughes, 2016). Huston Smith, mystic and philosopher of religion, investigated psychedelic use and their connection to religiously significant experiences (Smith, 1964). Indeed, progress in neuroscience and interdisciplinary research of the mechanisms of psychedelics reflects the philosophies of consciousness found in James, Freud, and other prominent thinkers (Carhart-Harris et al., 2014).
Sjöstedt-Hughes has compellingly argued that competent integration of different branches of philosophical thought, such as metaphysics, in the integrative step of PAT can produce more fruitful therapeutic outcomes (Sjöstedt-Hughes, 2023). Building off of this view, we discuss the possibility that philosophers themselves may play an important clinical role in PAT during both the preparation and integrative stages of PAT, and we sketch what an operationalized role for philosophers in PAT might look like. We limit our discussion to medical settings, leaving aside the question of psychedelic experiences in nonmedical settings, such as psychedelic retreats or in supervised use settings like those created by the state of Oregon, where there exists a state-run program that is explicitly nonmedical and facilitators need not be licensed clinicians.
Applied psychedelic philosophers
Philosophers, particularly those who specialize in the philosophy of mind, metaphysics, epistemology, phenomenology, ethics, and the philosophy of religion, are trained to think critically about and carefully conceptualize theories about the nature of existence and reality and make normative claims. For the past 60 years, philosophers have taken clinical roles in healthcare, applying their analytic skills to real-world problems in healthcare policy, research ethics, and clinical ethics (Toulmin, 1982). Indeed, philosophers now work across a range of clinical and biomedical research contexts, serving as clinical and research ethics consultants, roles that involve the identification and articulation of ethical values in conflict. Also, philosophers are involved in informing scientific research on psychedelics. For example, Walter Stace, a philosopher of religion who specialized in mysticism, directly influenced the development of Ralph Hood's mysticism scale, commonly used to measure mystical experiences in psychedelic medicine (Hood, 1975).
Philosophically trained clinical ethicists may be helpful at two junctures of PAT: in describing potential philosophical benefits and harms during preparation, and in facilitating a more comprehensive integration process, when patients process what they have experienced in sessions with their therapist. Typically, integration begins shortly after the experience and may continue for several weeks or months.
Psychedelic experiences explored in integration often raise questions examined by philosophers. For example, psychedelics can lead people to question their everyday reality (Hood, 1975), as well as catalyze a significant shift from secularism to animism or theism (Timmermann et al., 2021). It is likely that some patients grapple with deep ontological questions because of PAT, particularly those patients who have experienced shock or confusion. This may be amplified by latent trauma or mental illness for which the patient is in therapy. Thus, there exists the potential for a novel kind of iatrogenic harm: one that alters a person's worldview, commitments, values, and sense of self in ways that are undesirable or uncomfortable.
PAT may also leave some patients without the support and tools to fully integrate deeper, longer-term transformations in relationships, reality perception, and shifts in beliefs. In such cases, PAT may expose patients to a kind of philosophically-based risk, deserving of attention and mitigation.
If philosophers help psychedelic patients understand and explain their deep experiences and thoughts, they can guide patients in discussing complex philosophical aspects like their views on identity, reality, and beliefs, which may have long-term beneficial outcomes (Sjöstedt-Hughes, 2023). Engagement with a philosopher might be especially useful in providing a conceptual scaffold for patients during integration and may bring clarity to experiences that were otherwise not fully comprehended by the patient. Given this, patients should be afforded the option to consult with a philosophically trained therapist or a clinically trained philosopher.
Psychedelic use has been guided by philosophers qua healers throughout time. Indigenous healers are themselves philosophers and often share perennial wisdom with analytical and continental mystical philosophers. They are seekers of knowledge who investigate and explain the world around them using cultural and theoretical frameworks to engage with the topics of consciousness, epistemology, and religion. Both indigenous healers and philosophers trained in the analytic and continental traditions seek truth and offer their own type of healing in their own unique social contexts. “Each holds out the regenerative potentiality for image (shaman) and concept (philosopher)…The shaman often has a significant role in the reformulation of traditional cosmological concepts; the philosopher turns his (sic) attention to what he considers to be moribund and unresponsive in society's accepted and habitual assumptions and paradigms” (Glass, 1974, p. 182).
Indigenous healers gain and then share their knowledge with members of their community, and conceptualization and articulation of philosophical concepts appear to shape how healing practices are generated. Consider Anne Christine Taylor's analysis of the philosophy of the Achuar People of Ecuador and Peru and how their philosophy of selfhood influences shamanic healing practices. Taylor describes the Achuar's philosophy of selfhood and how these concepts correspond to their healing practices (1996). Taylor explains that selfhood for the Achuar is heavily influenced by community perceptions, “…therefore the image of the self, in so far as it is based on the attribution of others' images of it, is necessarily suffused with the memory others have of you.” (1996, p. 206). Such a state of personal identity can be “highly unstable” (Taylor, 1996, p. 207) because of the importance of interpersonal perception. Death of loved ones and events that fragment a community, such as intertribal feuding, can lead to a shattering of the self, and these events are common for the Achuar (Taylor, 1996, p. 207). Taylor acknowledges that this type of psychic breakage leads to the Achuar conception of illness, and healing can take place through the use of shamanic care and psychedelic care (1996, p. 207–208). Such care aims to enhance the self, returning a state of ambiguity into an enhanced state or “hyper-selfhood” (Taylor, 1996, p. 209).
The Achuar conceptualize the philosophy of selfhood and act upon this conceptualization for healing purposes. Such a conceptualization appears to be necessary to lay out a plan of care for the Achuar patient. The Western medical paradigm should integrate this knowledge in developing ethically robust frameworks for PAT. Competency in working with philosophical topics including selfhood could be critical for effective care, especially given that psychedelic states can open new phenomenological understandings of selfhood (Girn & Christoff, 2018) or potentially risk depersonalization— characterized by persistent feelings of detachment and disconnection from one's self, others, and the world (Columbia University Irving Medical Center, 2023).
Generally speaking, indigenous healers appear not to use the detached methodology characteristic of Western philosophers, particularly in mainstream academic philosophy. Yet this difference in methodology should not discount the similar roles both might play in psychedelic interventions. Both healers and philosophers “…claim a special insight and manifest that insight through the curative capacities of a public ‘statement’ –for the shaman the curative function often occurs in public ceremony, for the philosopher, her insight is transmitted by way of the visibility of her ‘word’” (Glass, 1974, p. 183).
Moreover, experiential knowledge allows indigenous healers to generate unique answers to philosophical questions that may not be easily accessible to some analytical and continental methodologies. Indigenous healers integrate and apply this knowledge to offer physical, psychological, and spiritual healing. The expertise of indigenous healers in guiding psychedelic experiences shows that philosophical knowledge and articulation of such knowledge may be antecedent to positive outcomes. Our proposal recognizes this and hopes to incorporate a system of analytical and continental philosophical engagement that respects, acknowledges, and integrates wisdom offered by the healing practices of Indigenous Peoples who use spirit medicines.
A role for philosophers in PAT preparation
A bedrock of contemporary medical ethics, informed consent serves as the starting point for examining potential philosophical benefits and risks of PAT. Patients will bring a wide range of expectations about and experiences with psychedelic substances. Philosophically trained psychedelic clinicians could play an important role in communicating important facets of PAT that are otherwise left unaddressed. For example, a psychedelic ethicist might aid therapists in the construction of informed consent procedures by providing appropriate language to discuss psychedelic medicine (Beswerchij & Sisti, 2022), and developing ethical guidance for a comprehensive informed consent process (Dowie et al., 2023; Smith & Sisti, 2020). Further, psychedelic ethicists would advocate on behalf of the patient while being guided by culturally and structurally informed approaches to psychedelic use (Celidwen et al., 2022).
Philosophers may also help address therapeutic misconceptions and expectancy bias. This particular challenge is not uncommon in other areas of medicine. In psychedelics, it may be characterized by a patient who may be so desperate for relief from psychological pain that they do not fully consider other aspects of the psychedelic experience that might broadly impact their personal identity and subjective worldview. A patient could emerge with a new sense of self or a fundamental shift in perspective of reality, such as a belief in a deity where prior they were atheist. If a patient goes through PAT without preparation for this possibility, the patient (or her family and friends) might reasonably feel like they were “harmed” in some way if they emerge a theist. It is therefore critical to address the philosophical risks of transformative experiences during a comprehensive informed consent process.
These questions about how best to obtain informed consent for transformative experiences have been increasingly discussed in the bioethics literature. Some have argued that valid informed consent is impossible to obtain (Jacobs, 2023) in the context of psychedelic therapy, others have argued that transformative experiences are not new to medicine and offer practical recommendations for fully adequate informed consent (Kious, Peterson, & McGuire, 2024).
We agree that valid informed consent is possible, but an enhanced process is warranted in the context of PAT. Therefore, a psychedelic ethicist could ensure that transformative experiences and their potential outcomes are explained clearly to the patient. We are not contending that psychedelic clinicians who provide PAT fail to capture these potential risks when meeting with patients. Rather, we recognize that many outcomes of PAT are philosophically complex, and a philosophically trained ethicist might assist in the disclosure process. In some cases, patients may be overwhelmed by aspects of the consent process; a psychedelic ethicist with philosophical training could help support the patient in understanding what might happen to them. They might help patients develop questions and explore potential risks and benefits, outlining important philosophical aspects of the psychedelic experience, such as possible ethical, phenomenological, and ontological changes. Having a philosophically trained psychedelic ethicist consult with a patient prior to dosing could provide the patient with additional clarity about the journey they are about to embark upon.
A role for philosophers in psychedelic integration
Post-experience integration is a critical aspect of PAT (Bathje, Majeski, & Kudowor, 2022). Integration sessions can happen over the span of weeks or months (Gorman, Nielson, Molinar, Cassidy, & Sabbagh, 2021). Providing clarity and alleviating confusion about aspects of the psychedelic experiences likely require a strong grasp of both philosophical concepts and the ability to translate them into comprehensible language. This is where a philosopher can offer clinical support. We now examine conceptual issues that philosophers might help conceptualize with patients during PAT integration.
Preventing and relieving ontological shock
Psychedelic experiences are powerful and can fundamentally and irreversibly alter metaphysical beliefs by shifting one's understanding of the world from “hard materialism” towards beliefs of panpsychism, a separate realm of supernatural existence, and ontological transcendence (Timmermann et al., 2021, p. 1). These experiences can be intense, occasionally forcing users to confront and question their fundamental worldview, leading to what some have called “ontological shock” (Sanders & Zijlmans, 2021, p. 1253). A patient may find it helpful to have a philosopher interlocuter assist in examining and processing aspects of ontological shock. One risk is that if these questions and experiences are not identified and addressed clearly the patient could be left feeling confused, as if the session was incomplete, or worse, feeling harmed, as if their reality was transformed and they must navigate this transformation alone. At the same time, the patient is deprived of maximum benefit in PAT, as failing to properly integrate these experiences and newfound beliefs could rob the patient of therapeutic benefits.
In general, therapists who provide PAT are typically not trained in philosophy and therefore may miss opportunities to attend to a patient's rapidly shifting values, beliefs, and ontology more fully. Berkeley's Certificate Program in Psychedelic Facilitation program spans 160 h of instructional training across eight core domains: 1) Spiritual Care 2) Psychotherapeutic Methods 3) Ancestral Entheogenic Traditions 4) Clinical Science and Research 5) Diversity, Equity, and Inclusion 6) Contemplative Science and Practice 7) Ethics 8) Reciprocity and Ecological Awareness (Psychedelic Facilitation Certification Program – UC Berkeley BCSP, 2023). While cores 1 and 7 may involve some philosophical questioning, most domains attend to other aspects of PAT.
The cross-cutting nature of philosophical issues was measured in a recent study of metaphysical belief change after psychedelic use: ontological and supernatural transcendentalism, dualism, idealism, materialism, solipsism, panpsychism, the primacy of other realms, non-naturalism and naturalism, internalism about consciousness, virtual self theory, and the enactivist approach to consciousness (Timmerman et al., 2021, p. 2). Similarly, the concepts in Sjöstedt-Hughes's Metaphysical Matrix offer starting points for conversations about spiritual changes. These include monotheism, polytheism, panentheism, pantheism, deism, and animism (Sjöstedt-Huges, 2023, p. 17). Sjöstedt-Huges recognizes the importance of philosophical knowledge as well in PAT, saying “Psychedelic-assisted psychotherapy has been the province of psychologists, psychiatrists, and other counselors who, as such, have not been trained in metaphysics” (Sjöstedt-Huges, 2023, p. 13).
“I became simultaneously all the people (and other intelligent beings) who ever lived, are alive, and will ever live in the universe. I realized that there is only one Actor playing all the parts – it is God, and I am him” (Strassman, Wojtowicz, Luis Eduardo, & Frecska, 2008, p. 149)
To elaborate on this experience and engage the patient in further dialogue, it would be useful to introduce concepts and vocabulary to discuss pantheism and personal identity.
There is a pragmatic benefit to having a philosopher in this role. A philosopher alleviates some of the burden of the therapist. The therapist is primarily trained in guiding the emotional and psychotherapeutic process of the patient. Having to attend to philosophical belief change, particularly in areas that may be quite subtle, in conjunction with regulating the emotions and psychological safety of a patient on a psychedelic journey, is taxing. The philosopher then helps alleviate some of the pressure on the therapist, who can focus on using their expertise in a psychotherapeutic capacity instead.
“A true master shaman does not challenge the validity of anybody else’s experiences, although less capable and less humble shamans may. The master shaman will try to integrate even the most unusual experiences into his total cosmology, a cosmology based primarily on his own journeys” (Harner, 1980, p. 57).
To demonstrate the further need for philosophical versus psychotherapeutic clarification, take these two statements that arose during PAT and how they could fit into separate domains of inquiry.
“[I] became myself at age 7, after my [grandparent] had died. I totally was back there, so vivid, so real, I had the emotions that I would have felt at the time: fearful, why did this happen, the naivety, the shock and confusion. I was getting overly upset and my parents were saying ‘boys don't cry’” (Watts, Day, Krzanowski, Nutt, & Carhart-Harris, 2017, p. 539)
“[During the dose] I was everybody, unity, one life with 6 billion faces, I was the one asking for love and giving love, I was swimming in the sea, and the sea was me.” (Breeksema et al., 2020, p. 936–937)
The first statement represents a traumatic memory, while the other is a mystical or philosophical reflection. The first statement relates to emotions and trauma, two aspects of the psychotherapeutic experience that a therapist is professionally trained to examine and provide insight into. The second statement seems different. It is concerned with a shift in ontological perception, with hints of idealism, not emotion or trauma. If this statement led to philosophical inquiry from the patient, a philosopher might complement the therapist with questions to bring forth the patient's experience of the Whole. These experiences may be extremely difficult to put into words, however, we believe that due diligence is required on the part of the PAT team to attempt to answer the questions of PAT patients as well as possible. Table 1 illustrates this point, pairing relevant quotes from various psychedelic trip reports with corresponding areas of philosophy. A central feature of psychedelic integration may therefore involve philosophical questioning.
Qualitative psychedelic experiences
| Branch of philosophy | Psychedelic experience quote(s) | Broader philosophical concepts |
| Metaphysics | “I could only very dimly perceive the givers of these thoughts: giant reptilian creatures reposing sluggishly at the lowermost depths of the back of my brain, where it met the top of the spinal column.” (Harner, 1980, p. 5) “… what is real…? what is reality…? what is universe…? what is GOD…?” (Tokolosi, 2018, p. 1) |
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| Philosophy of Mind | “The dose helped me realise why I felt the pain in my chest, I saw it visually and felt it emotionally, then I felt so much lighter, like something had been released. It was an emotional purging, the weight and anxiety and depression had been lifted” (Watts et al., 2017, p. 541). “Some people talk of 'egodeath.' I guess that's what I felt: I literally had no conception of myself. What in hell do I possibly say to convey to someone what exactly that means?” (Just Some Guy, 2016, p. 1) |
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| Epistemology | “that music was really how everything was conveyed to me, it all came through the music…like everything that I experienced did not really happen in the English language, it kind of happened through the music, like the music was the conduit for this experience to happen” (Belser et al., 2017, p. 373) “And I started asking ayahuasca questions. Questions I think most people think about, like: why is there life on earth, what happens after you die? Questions you can never normally have an answer to. And I felt those questions were just answered immediately. The answers were kind of implanted into my brain. I remember just lying on my mat, thinking: how can this possibly be?” (Wolff, Ruffell, Netzband, & Passie, 2019, p. 302) “I stood on an alien street in some glowing symmetrical reality. I wondered where the people who lived here were. But as I thought of that, they too began emerging from the light. They were strange trans-dimensional beings that were basically indescribable. They spoke to me in a strange, telepathic language and told me the essence of being.” (Strassman et al., 2008, p. 160) |
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| Phenomenology | “For a better example, I think of my first girlfriend. When I was with her I thought myself thoroughly in love. Now I hardly see that as even possible. And yet how can I challenge the reality of previous perception based on what persists just due to its persistence? What evidence is there that the persistence of perception is equal to its reality?” (Brown, 2008, p. 1) “Things look different even now. I would look over at the park and it would be so green, a type of green I'd never experienced before. Being among the trees was incredible, like experiencing them for the first time, so vibrant, so alive” (Watts et al., 2017, p. 531). |
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| Philosophy of Religion | “…It was the absolute unity of everything, ultimately, it was only one thing. Everything and Nothing AT ALL. It was one thing. One thing. ONE thing. All of life, all of death, all of infinity, all of eternity. It was ONE. What was this one thing? God?” (I AM, 2011, p. 1) “Then I felt the presence of God: I have always thought that he was a man because of the way I was raised, reading the bible, but it felt like a female energy” (Watts et al., 2017, p. 535). |
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| Ethics/Moral Philosophy | “The fact is, I am depressed. I did not want to admit that to myself, but it now seems unavoidable. I am sad. Is this 'the Human Condition?' Or can something be done about it?” (Navi, 2001, p. 1) “A shift in values. … To take time to listen to music, to listen to music consciously. Maybe that material values were not that important anymore. That other values have priority…” (Breeksema et al., 2020, p. 938) “I got a wider perspective, I stepped back. It helped me appreciate that the world is a big place that there's a lot more going on than just the minor things that were going on in my head” (Watts et al., 2017, p. 534). |
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| Aesthetics | “[After the dose] When I went outside, everything was very bright and colourful and it felt different. I noticed things I didn't notice usually, the leaves on the trees and the birds, small details” (Watts et al., 2017, p. 530). “I was sobbing and I remember looking at the trees and looking at the leaves on the trees and [they] were so beautiful and I was just mesmerized by each leaf on the tree and understanding the parts that make up the whole…” (Earp, 2022, p. 16). |
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To our knowledge, no training programs or active practitioners utilize a professional philosopher on-site for the integrative step of PAT. There have been calls to implement metaphysical integration questionnaires and matrices into PAT, which have the potential to guide patients in the integrative step of therapy (Sjöstedt-Huges, 2023). This is a step forward that could lead to better therapeutic outcomes and one that can be potentially enhanced by a philosopher consultant.
A. Conceptualizing mind, metaphysics, and phenomenology
As noted by Johnson (2021), “It is not uncommon for people having psychedelic sessions to touch on what I call the “big questions,” e.g., the nature of reality and the nature of self” (p. 580). The patient's conception of their own personhood is a line of philosophical inquiry that may arise during or after a psychedelic experience. Long-examined concepts such as personhood and the self are often perceived as philosophically complex within the framework in PAT (Gorman et al., 2021) and altered perceptions of the self are characteristic of psychedelic experiences (Gorman et al., 2021). Ego-dissolution, or, a compromised sense of self (Nour, Evans, Nutt, & Carhart-Harris, 2016), is a particularly interesting phenomenon of psychedelic experiences that has drawn considerable attention (Gearin & Devenot, 2021; Smith & Sisti, 2020). Psychedelic marketing and culture practically invite philosophical questioning about this topic.
For example, a philosopher of mind could properly reference relevant philosophical topics such as the relation between mind/body in personal identity and features of consciousness such as qualia. Providing this lexicon and on-the-spot explanation may be beneficial to patients at a loss for words. Failing to articulate a newfound belief regarding personal identity could be a lost opportunity for a patient in integration.
Important changes in perception expand to the fundamental nature of reality as well. If a patient experiences a reality shift that dictates that mentality is fundamental in the natural world (Goff, Seager, & Allen-Hermanson, 2023, p.1), panpsychism, or, believes the world is a projection of their mind, idealism, both of which are two noted belief shifts after psychedelic use (Timmerman et al., 2021), a skilled metaphysician could relay coherently what panpsychism and idealism is to the patient. These concepts are complex, and, when combined with the intensity of “ontological shock” that may occur, having an outlet to conceptualize and understand these experiences philosophically may be of substantial benefit to that patient.
A philosopher could further articulate the phenomenon of perception and the conscious experience of a psychedelic experience. Consider how the articulation of the psychedelic perspective in general, when enhanced with the language of phenomenology could be useful in describing difficult phenomenological experiences. Having access to language that describes the subtle investigations of mental phenomena, especially if experiencing hallucinations that the PAT practitioner would not be sharing with the patient, may provide the patient with a nimbler way of interacting with phenomena produced by psychedelics. Philosophers have engaged in this specific domain already and could be useful in synthesizing a patient's experience with philosophical inquiry (Letheby, 2021). Further phenomenological theories, such as Fuchs and Schlimme's embodiment theories (2009) and Zahavi's analysis of self-awareness (2020) could be useful when articulating introspective phenomena. Such investigation may lead to phenomenological and existentialist-inspired theories of psychotherapy, such as Carl Rogers' person-centered psychology and therapeutic concepts of positive regard (1951). Such patient-centered therapy, carried out by understanding critically phenomenological and existential language and conceptualization, yet, remaining non-judgmental of the patient's experiences, seems to fit well as a model for PAT.
Contact with seemingly divine entities is not unheard of for those who use psychedelics (Winkelman, 2018). Philosophical concepts such as noumena and phenomena may provide new insight into how these deities can be conceptualized (Winkelman, 2018). Such language may aid in how entity encounters during psychedelic experiences are conceptualized and provide patients with a new way of thinking about the reality behind psychedelic entities.
B. Conceptualizing epistemological concerns and mystical experience
No doubt, the epistemological aspects of psychedelic experiences is of interest to philosophers (Langlitz, 2016; Letheby, 2019). The knowledge received from a psychedelic experience may come from perceiving outside entities or from a deeper core of a patient's own subconscious. Philosophers may discuss with patients ideas related to truth to help patients decide for themselves if this knowledge gained from a psychedelic experience is useful.
Philosophers of religion can aid in conceptualizing mystical/religious experiences for those who use a religious system as a framework for understanding their PAT session to aid in knowledge acquisition.
“Identification as a “Non-believer (e.g., atheist)” changed from 35.8% Before to 13.0% After. Identification as “Agnostic” changed from 35.3% Before to 28.2% After. Identification as a “Believer (e.g., in Ultimate Reality, Higher Power, and/or God, etc.)” changed from 28.8% Before to 58.8% After… (Nayak, Singh, Yaden, & Griffiths, 2023, p. 85)”
Newfound beliefs may breed new questions. Philosophers of religion come not just with philosophical training in analyzing the phenomenon of mystical experiences, but, additionally, are armed with historical knowledge of the religion(s) and culture(s) that they specialize in. Further, philosophers of specific schools of religion may provide a comfortable introduction to a patient's newfound belief system.
This coincides well with contemporary calls from the psychedelic chaplaincy community, which similarly understands the necessity of articulation of profound religious experiences in psychedelic therapy. As noted by Beachy and Petersen (2022) in a paper examining spiritual care and its beneficial role in psychedelic therapy, “For many mental health clinicians, discussions of religion and spirituality have been mostly omitted from clinical training” (p. 94). This leaves opportunities open for those philosophically and spiritually trained to fill the gap, which patients may want to help them integrate the spiritual dimensions of psychedelic experiences (Cole-Turner, 2022, p. 12). This push appears to be happening already, with institutions like Naropa University's Master of Divinity program noting that alumni have served in psychedelic-assisted therapy (Naropa.edu, 2023).
C. Conceptualizing changes in values and aesthetics
Changes in values and aesthetics have been noted to occur after a psychedelic experience (Kähönen, 2023). As seen in Table 1, questions regarding “The Good Life” and how one ought to live their life can arise from psychedelic experiences. This is certainly the domain of a philosopher, who can guide discussions to better help a patient connect with an existing, or newfound, system of values.
The use of MDMA in couples' therapy provides a glimpse of how values can change. Such therapy may rekindle partnerships for some couples, but others may find that what they truly value in life was revealed through the drug and this altered the course of their life and relationship (Earp & Savulescu, 2020, p. 86–87). In sum, patients may seriously question what is truly significant in their lives.
Such experiences may bring about a discussion of authentic values. Some philosophers who examine authenticity for patients in psychiatric care, such as Carl Elliot (2004), have called attention to how medicines could influence whether we are acting authentically. This could be important for PAT patients to consider when engaging in a therapy that could alter personal properties philosophers associate with authenticity, such as beliefs and desires (Varga & Guignon, 2023). Access to philosophers from Kierkegaard through Charles Taylor would be useful here to unpack the various schools of thought regarding authenticity, such as self-creation and self-discovery, or even question whether an authentic self exists in the first place. Conceptualizing authenticity through the lens of a self-discovery account in PAT, where patients uncover deeply held, intrinsic values, would yield different results than a self-creation account.
These ideas extend to aesthetic judgments. According to Yaden and Newberg, “Aesthetic experiences describe mental states that usually involve a perception of deep beauty or the sublime.” (2022, Chapter 13, p. 1). Aesthetic theories could be applied to examine and conceptualize psychedelic experiences (Sjöstedt-Hughes, 2016). Sublime landscapes have been described in psychedelic experiences, such as technological space stations and galaxies (Strassman et al., 2008, p. 65–67, 89, 151). Having access to language that can conceptualize the sublime may provide patients with a newfound capacity to describe profound experiences more impactfully. When aesthetics and values are synthesized, patients may discover a new calling. A newfound love of nature (Kettner, Gandy, Haijen, & Carhart-Harris, 2019), or perhaps a greater connection to animals (Pöllänen, Osika, CUD, & Simonsson, 2022), may relate to engaging in environmental ethics and transforming perceptions of what is beautiful.
Structure and future directions
In practice, we see two ways philosophers could enter this role. The first involves an on-the-scenes philosopher who is there alongside the clinical team. They would participate in the informed consent stage and/or the integrative stage. (We do not see a reason for the philosopher to be there during the actual dosing.) In this capacity, the philosopher would be able to work alongside the clinical team and patient. The philosopher would work directly with the patient and clinical team.
Another approach envisages the philosopher in consultant role. A patient who has been given PAT and is dealing with philosophically-based questions or shock could be referred for correspondence to a philosopher who specializes in the desired area of inquiry. Further, the philosopher could be called upon by the therapist to aid them with questions regarding informed consent or integration. This latter option may be efficient for telehealth services. Regardless, opportunities arise for both inpatient and outpatient services.
The use of a philosopher in these roles could be studied in ongoing clinical trials of PAT. Empirical evidence would be necessary to obtain a consensus on if a philosopher could contribute clinically. Given the booming interest in PAT, we believe this is possible. As PAT becomes more of a norm, it would be useful for philosophers and philosophically trained ethicists to get exposure in both these settings.
Philosophers have entered the clinical space of medicine before, such as becoming members of clinical ethics consultations (CECs). A critique leveled at CECs involves an imbalance of authority (Agich, 1995). Philosophers aiding in PAT must ensure that:
Their goals align with the patient and therapists.
They do not enforce their personal views or values onto the patient or providers.
They communicate effectively in a manner that is accessible to patients and therapists.
Further, CECs have been critiqued for believing they have moral authority over those perceived as morally vulnerable (Fiester, 2014). Philosophers engaging in consultation in PAT must ensure they do not fall into this trap. The philosopher should be sure to not imply that being a philosopher grants “metaphysical authority” over the patient. Ultimately, the patient's experience is most important, and the philosopher is there to help articulate the experience, not impose authority on what the experience should have been or should have meant. Conflict with religious beliefs has been noted in CECs too (Evans & Colgrove, 2022). Philosophers working in PAT should be aware that supernatural or divine experiences are sometimes an important feature of psychedelic experiences, as well as the cultural plurality that is engaged in psychedelics.
Not all philosophers will be equally skilled in psychedelic integration, just as not all therapists will be skilled in facilitating a PAT compared to conventional therapy. If necessary, the philosopher should be used if the therapist or patient believes that having this feature would be beneficial. Further, just as therapists engage in continuing education to hone their craft, continuing education programs may need to be created for philosophers who consult on PAT. As novel questions arise as PAT progresses onward, it will be important for all those clinically involved to be as up-to-date as possible in the developments of psychedelic medicine.
Conclusion
In PAT, addressing patients' philosophical and ethical questions is crucial. We recommend involving a philosopher who can help to frame and examine these questions during preparation and integration. While research is needed to confirm its effectiveness, the inclusion of a psychedelic philosopher could enhance patient experiences and advance both the field of PAT and philosophy, offering philosophers fresh insights and perspectives through direct engagement with individuals who have had transformative experiences.
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