The journey to becoming a guide

The remaining five practitioners reported using psilocybin as part of their healing journey with little or no prior recreational experience with mushrooms. One practitioner waited almost 15 years until their children were older before first trying psilocybin as a potential healing tool for multiple complex health problems. Soon after “I left my job like a free fall, like I can't do the same work that my body's in total rebellion against […] I came to life to be part of a solution and part of health” (P15).

From these personal histories of use, which were commonly marked by both highly difficult and profoundly healing experiences in recreational and therapeutic contexts, 13 practitioners further described when and how they “heard the call to guide” other people in their psilocybin journeys. Six practitioners explained that they initially had no intention to serve as a facilitator for other people, for example, “I wasn't like, ‘Oh I'm going to be a psychedelic sitter,’ but it's just sort of unfolded over time […] I started getting invited to medicine ceremonies [and then] I was asked to be a support person” (P10). A practitioner who had been working with herbal medicines and psychedelics for multiple decades described how, before there were guidelines on how to curate a positive psychedelic experience, they were invited to give talks on the topic and “then there would be people who would ask me if I would be a guide with them or trip with them.” In time, they decided “I really wanted to dedicate at least some of my life to helping to teach people how to use these plant medicines in a safe, sacred way so that it’s beneficial” (P4). Another five practitioners expanded their personal use of mushrooms to a professional practice by offering to facilitate sessions for their friends or supporting clients who were already using micro or macro doses of mushrooms, for example, “Being in the [mushroom] space myself gave me a window into the needs of other people in the space. So, I started reaching out to people and just offering that I would do this, that I would hold space for them” (P3). Only a couple of practitioners described experiencing a great insight or epiphany about working with psilocybin mushrooms as a professional calling and set out with intention to develop a practice as a professional psilocybin educator and guide.

Relationship and trust with the medicine

The role of the guide or facilitator was described generally by most practitioners as “holding safe space” for others to “go within.” That “safe space” was a quality of physical and energetic space wherein the practitioner played a significant role. Most important from the perspective of nearly all practitioners in this sample was their personal relationship with the medicine, practices of the guide to stay resourced and grounded, and trust in the mushroom itself to carry its own wisdom.

All practitioners described having “a personal relationship with the medicine” of psilocybin mushrooms and centering that relationship as an essential part of their providing safe and ethical spaces for others. Practitioners found it critical to “connect with the sacredness of the medicine [for themselves] and really be guided by the medicine” (P1). The personal relationship with the mushroom was also perceived as supportive of quality control, “If you haven't done that exact medicine, don't give it to others […] Don't give somebody stuff that you haven't done yourself” (P11).

With this reverence for the mushroom that is gained through repeated direct experience, practitioners lamented “amateur-type of scenarios, where the facilitator is trying to get you to feel something and direct your experience and how damaging that is” (P11). Rather, the role of a practitioner is to “kind of just get myself out of the way [because] the medicine has an agenda [and] it's a lot more intelligent than my present personality is” (P3). In practice, this might mean following “whatever instinct or impulse is showing up in someone. Just letting what wants to happen, happen. And saying yes to whatever shows up” (P1) or “breathing with them and encouraging them” (P4).

Uses of psilocybin mushrooms

The expected “personal work” that precedes clients' readiness for psilocybin mushrooms might include traditional talk therapy, yoga, meditation, and other healing modalities that support self-awareness. As other practitioners explained, “I look for people who have already done work” (P12) and have “come to a plateau where I've taken myself as far as I can take myself” (P2) and “feel like there's something deeper that they need to get to” (P10).

In this way, clients are able to explore a variety of existential and interpersonal terrain, including grief, fear of death, relational attachments, vulnerability, personal boundaries, joy, and life meaning, all of which can move clients toward “deeper relationships with yourself, the universe, with others” (P1).

Essential practices

The majority of practitioners (88.2%) placed a high degree of importance on spirituality, energy, or meditation as essential practices for their mushroom work with clients. The client session was deemed “a sacred space” (P1) where practitioners found it essential to “honor the allies from other dimensions” (P17), “honor the indigenous roots of working with the mushroom” (P1), and teach clients “that ritual delineates that this space is different than regular everyday life” (P3). Meditation, prayer, breathwork, ritual practices, invocation, and “moving energy” (P4) were all routinely employed by practitioners for this purpose.

Other essential practices specifically named by multiple practitioners included music (curated playlists, drumming, live instruments or singing; 14 practitioners), formal therapeutic practices (Internal Family Systems, Cognitive Behavioral Therapy, Gestalt; 11 practitioners), somatic practices (massage, Hakomi, body scan, somatic experiencing, dance, stretching, somatic expression; 9 practitioners), and nature-based practices or access to outdoor areas (7 practitioners).

Screening

All 17 practitioners described a referral and screening process that operated primarily by word-of-mouth and through trusted referral sources of colleagues, friends, and former clients.

Due to the illegality of the work, one practitioner explained, “I don't promote it [mushroom work] […] If people text me or email me about psilocybin, I don't hardly even respond. On my website, I do not sell or have any affiliation with these medicines themselves” (P6). All practitioners reported meeting with potential clients ahead of time with varying screening practices. Most described extensive screening and intake processes that included a person's personal history, medical history, psychiatric history, family history, current medications, prior experience with psilocybin, their intention and purpose for the psilocybin experience, and their support system and any ongoing practices they have for their own inner work. In general, practitioners found that screening and preparation is “about learning about the client, their history, where they're coming from, and what's happened to them. Are they healthy? Do they have a support system? Can they hold themselves together [following ceremony]?” (P7).

Risks and contraindications during screening mentioned by clinical and non-clinical practitioners alike included a history of psychosis, dissociative identity disorder, bipolar disorder, borderline personality disorder, and narcissistic characteristics, the latter two described by one practitioner as not amenable to psychedelic work. Not all practitioners automatically screened potential clients out for past psychosis, but rather for a couple of practitioners, a person's history of psychosis “would just inform how I practice and what we do” (P1). Similarly for a history of severe trauma, “that would be an indication for me to go really slow with psilocybin and start with something else” (P1) to build up “enough emotional resources to meet it [the mushroom]” (P11).

Other risks that warranted caution for practitioners included the general impression that a client “is really imbalanced in a way that they don't know how to bring themselves back into balance” (P17), “has done no internal work and doesn't have any tools to help guide them through the process” (P2), and/or has no outside support system and is highly isolated. As one practitioner explained, “I think [clients] should have some stable tools […] because this does require a lot of surrender […] Those that are not prepared to look in the dark closet should not take something that's going to make them look in the dark closet” (P2). The decision to screen a client out of a psilocybin experience further involved the practitioner's sense of how serious a potential client is about “doing the work” as opposed to a client who is “just wanting to have an experience” (P7), “looking for the magic bullet” (P13), or “in a hurry, like they're looking for a quick fix” (P16).

Dosing and getting started

All practitioners reported arriving at dosing decisions based on a variety of factors, including the client's prior experience with altered states and psychedelics, the client's present manifestation of trauma symptoms and their trauma history, and the strain and strength of mushrooms. While six practitioners noted they are willing to facilitate macro dose journeys of 5 or more grams of dried mushrooms, other practitioners remarked they felt it unnecessary to consume macro doses to achieve therapeutic aims. Average dose ranges used by practitioners were 0.5–4 g. Nine practitioners further described supporting clients in micro dosing (0.25 g or less) as part of preparation and/or integration of higher dose mushroom journeys.

Nearly half of practitioners explained that they may not start a new client with mushrooms, preferring to introduce other altered states first. Many practitioners (41.2%) initiated altered states work with clients through MDMA, and more than a third of practitioners started with ketamine (35.3%) or micro dosing mushrooms prior to a higher dose session (35.3%). Upon screening and preparation, practitioners assessed clients' readiness for psilocybin deeming higher dose mushroom sessions as “more complex, it strips away all the defense mechanisms so that can be jolting to a person” (P7). For clients who have little or no prior altered states experiences with psychedelics, are not internally resourced, and/or have unresolved trauma, practitioners would more often “move into psilocybin” slowly over time. Consensus emerged, in particular, that “the starting place (for trauma) really needs to be elsewhere” (P10).

Preparation

Practitioners reported a general protocol involving a range of one to three preparation sessions before the medicine journey and a range of one to three integration sessions following the medicine journey. Within that, however, practitioners reported a variety of strategies for moving clients through the process. Most intensively, the cycle of preparation, medicine journey, and integration continued as a multi-year process with weekly non-medicine sessions and quarterly medicine sessions. The regularity of this pace was contrasted with clinical studies where “they do one or two sessions working on a specific trauma. But you still have the rest of your life…there are deeper and more interconnected layers to it. It's not a compartmentalized process” (P7). Several practitioners outlined protocols involving microdosing as part of the preparation process, perhaps further increasing to low “psycholytic” doses before moving into a macro dose journey. As one practitioner explained, this protocol can “clear off the first layer of gunk on a mirror before you go into a deeper session” (P10).

Education, preparation, intention, and clear boundaries and agreements were described as essential components of the pre-medicine process. Education might include giving clients a general understanding of psilocybin mushrooms' actions on the brain and body or learning about basic mindfulness techniques and body scan exercises that can help prepare for the experience. Preparation involved preparing a person's body through a healthy diet and exercise in anticipation of the medicine experience, clearing their work schedule and ensuring that all their usual daily activities were covered, and discussing the practical logistics of the medicine experience. Several practitioners emphasized their intent in the preparation phase for clients to be “sovereign” and “self-sufficient” so that they are empowered with education and fundamental skills to continue their medicine and non-medicine work of healing and growth on their own (P3). Trust, or at minimum a strong familiarity, between the practitioner and journeyer was deemed highly important alongside a clear sense of a client's intention, or “Why do you want to do this? […] really getting into the person's why” beyond simple curiosity (P2).

Despite the illegality of their work with mushrooms, many practitioners still used written informed consent agreements and liability waivers in their practice because “you want to have really clear boundaries” and put the responsibility on the client for making the “adult choice” to use mushrooms (P4). The primary boundary practitioners described discussing in advance with clients was regarding the use of touch agreements, which varied across practitioners. Some practitioners delineated to clients different types of appropriate touch, such as “nurturing touch” which could include holding their hand, stroking their head, or hugging, and “intervention touch” which could include shaking, massage, or energy work. Other practitioners reported having open-ended conversations with clients to explore “When you go in there [mushroom space], how do you want to handle touch? Do you want to have some healthy touch? Do you not?,” and emphasized the importance that clients understand that “they have power about their consent” (P11). Finally, one practitioner reported the tightest boundaries around touch, which involved no touch to journeyers outside of a hand or shoulder hold, with the added explanation that the purpose of their ceremony was solely for clients to have a safe space for an altered state experience with psilocybin, without outside intervention.

Integration

Integration was emphasized as another essential component to the overall process. Integration is a dialogue where practitioners ask “what happened, what did we learn from it, what did we get out of it, what are we doing about it, what's the action we are going to take?” (P7). Another practitioner described integration as “relevancy,” meaning “how we take that more expanded potentiation [from the mushroom experience] and ground it into our bodies and make it relevant in the 3D space” (P3). For example, clients may “have a big opening, like ‘ok, well, I fundamentally know God,’ and then what does that actually look like in your relationship with your intimate partner? And what are the challenges there?” (P10).

Even with screening and preparation, most practitioners recalled unusual difficult scenarios when a dose was too high for a person or the experience was very difficult resulting in a high degree of support required during the session and in the weeks following. In some instances, practitioners described highly rigid or controlling personality types of clients who experienced elevated levels of fear, panic, and anxiety during their mushroom session. The “massive upheaval of emotions” that followed the session sometimes required months to integrate and, according to one practitioner who has guided individuals through such difficult experiences, “this is where healing can become trauma” (P2). Other practitioners also described instances of intense mushroom experiences where clients felt ungrounded, “get stuck in a loop of a very dark place” (P17) or otherwise get so scared that “sometimes people in that case run away from it. They don't want to do it anymore” (P7). Sometimes such experiences were described as due to practitioners or clients “shortcutting” the process, for example by taking too high a dose or moving on a quick timeline because the client requested it for financial or other reasons. Other times, the practitioners viewed the difficult experience as a necessary part of the client's larger healing process, in which case appropriate follow-up was essential for the positive integration of that experience.

Concerns about practice

Relatedly, because of the illegal nature of mushroom work, practitioner isolation, silos, and an “element of secrecy” (P6) posed significant risks for both practitioners and clients to maintain safe and ethical practice. The lack of “communities of practitioners that have open exchange and open dialogue” (P10) and are “checking in with each other” (P17) for accountability and supervision was described as feeding an environment of poor ethics and risks of abuse.

Finally, the fourth primary area of concern centered on the possibility of psilocybin mushrooms being shaped as a profit-driven “pharmacological drug” that becomes overly expensive considering the fact that “you can pick it from a cow patty and eat it” (P3). A concept of the “pop up shaman” also fell into this category of concern, referencing newly entering practitioners who have “no substance, no skill, no training, just sort of like [culturally] appropriative knowledge and they just started a [mushroom] company” (P15).

Priorities for regulation

Practitioners' concerns connected to their stated priorities for the evolving policy environment. Issues of safety, ethical guidelines, and a basic understanding of trauma were clear forerunners as targets of education and regulation for new legal markets. Participant 16 explained that “this work requires a level of personal and spiritual maturity and experience with [mushrooms] that is pretty essential,” as participant 10 elaborated how, because of this fact, “sending everybody through the psychedelic guide mill [of education and training]” will not ensure effective practitioners. As practitioners themselves oriented their work with mushrooms in myriad ways, they acknowledged there is “no one right way” nor “one standardized training program” that could sufficiently ensure effectiveness (P3, P4). In reality, “standardization is a word that doesn't even fit in the experience. It's kind of like trying to fit an ocean in a postage stamp. You can't” (P17). One point of unanimous agreement regarding training was that it is “imperative that practitioners themselves have experiences with these medicines…many many experiences” (P6) as there is “no way to theoretically know this” (P7).

While practitioners were mostly unable or unwilling to articulate specific policy recommendations within the various policy initiatives unfolding nationwide, a few broad principles clearly emerged (see Table 3). Practitioners considered psilocybin to be “an Earth medicine” with the foundation of good practice based in “respectful reciprocity,” which entailed a personal connection to natural and mystical worlds, and for some practitioners, financial compensation to indigenous and allied groups. Issues of professional control, commodification, access, and equity were central to practitioners' concerns and priorities for all forms of evolving regulation. No one existing profession, according to this sample of practitioners, has the skill, paradigm, or expertise to “take ownership over” mushroom work, but rather the field needs to define a new profession marked by “cross functional learning between these different groups” in order to effectively adopt a new way of engaging therapeutic or healing work (P10). In contrast to professional territorialism and bureaucratic rules, practitioners expressed a preference for communities of learning, opportunities for mentorship, and councils of elders that can sustain the relational and mystical essences of mushroom work, alongside written guidelines to provide basic guardrails for safety and ethics.