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Supervision on Acid: fortifying clinical supervision guidelines for new psychedelic therapists

To Gatekeep or not to Gatekeep- is that the question?

Psychedelic-assisted psychotherapy requires an advanced skill set on behalf of the clinician and even more so, from whom they learn (Phelps, 2017). The practice of including psychedelics in psychotherapy adds an immediate physiological component to the original therapeutic practice; even more, psychedelics introduce a psychological tenderness during which clients enter increased states of emotional vulnerability (Krediet et al., 2020). Therefore, supervision in psychedelic-assisted psychotherapy maintains the preceding guidelines by which supervisee growth is assessed (APA, 2015), including working alliance, integration and openness to feedback, and theoretical and clinical skill set development, in addition to a higher standard of ensuring competent and ethical therapeutic care. This review argues for maintaining a higher standard when granting access to psychotherapists interested in providing psychedelic-assisted psychotherapy and, by proxy, the assessment of their growth by clinical supervisors.

Supervision in Psychology

As it is custom in mentor-novice dynamics, the variable of mentee growth exists as a factor by which higher-level practitioners gatekeep access to their field. In the very same way, the field of psychology has adopted clinical supervision as an influential model to ensure ethical and proficient practice amongst new practitioners (Homrich, 2009). Although supervisors inhabit a critical role in the preparation and preservation of the values of their field, the intricacies of what entails “good” supervision are nuanced and theoretically dependent. To detail the factors by which supervisee growth can be evaluated, a developmental theoretical lens will be reviewed because it includes relational, professional, and clinical skill set factors regarding supervisee growth.

Levels of Supervisee Development

The developmental model of clinical supervision highlights the importance of supervision that is catered to the clinical level of the supervisee. Supervisors must accurately decipher supervisee’s skills so that their feedback matches the supervisee’s developmental level (Smith, 2009; Stoltenberg et al., 2014). Thethree levels of supervisee development are detailed through an integrative lens (Stoltenberg, 1997): level one is the entry level, during which supervisees are high in motivation and fear of evaluation from supervisor(s) and peers; level two is marked by an increased sense of confidence with clients and fluctuating levels of motivation- with this, supervisees will often link their own mood to their success with clients; at level three, supervisees showcase a more stable and secure sense of motivation. As the supervisee continues to remain motivated in their sessions with clients, they are able to cater to an inner sense of objectivity balanced with accurate empathy.

According to Stoltenberg (1997) and Stoltenberg et al. (2014), the major areas a supervisor will focus on regarding their supervisee’s growth include assessment of working alliance, integration and openness to supervisor feedback, and theoretical and clinical skill development. From a developmental lens, these critical areas coalesce to form a well-rounded evaluation of relational and professional appropriateness, and clinical skill set.

Working Alliance

Working alliance is originally a psychotherapeutic concept in which the relationship between a client and a counselor influences therapeutic progress and change (Sterner, 2009). In supervision, the working alliance is similarly grounded in the mutual agreement of tasks to reach developmental goals. The essence of the supervisory working alliance is for the supervisor to encourage change processes within the supervisee (Bordin, 1983); as such, the working alliance is a starting point by which change processes can be either supported or weakened (Sterner, 2009). Even more, the supervisory working alliance reveals a trickle effect by which positive alliances have been found to positively influence supervisee-client dynamics (Park et al., 2019).

Integration and Openness to Supervisor Feedback

As Ronnestad and Skovholt (2003) report in their review, optimal learning and professional development are shaped by a counselor’s self-reflective abilities. As clinical supervisors present corrective feedback, the supervisee’s ability to remain open to and integrate such feedback influences their professional growth. However, preexisting factors, such as the supervisee’s attachment style and their level of cognitive distortions (Rogers et al., 2019) can negatively influence their professional growth (Ramos-Sánchez et al., 2002). For example, the likelihood that a supervisee feels challenged by supervisor feedback can be similarly reflected in the client-counselor dynamic. Therefore, it is critical that the supervisor continues to gauge the supervisee’s openness and integration of feedback as a marker of supervisee growth and competency.

Theoretical and Skill Development

Throughout the supervisory process and from the supervisory working alliance, supervisees are exposed to new information and counseling techniques. While supervisors are appropriately matching their feedback to supervisee development level, they also consistently “scaffold” the mark of satisfactory competency (Zimmerman & Schunk, 2003). This scaffolding process encourages the supervisee to use prior academic knowledge to shape their clinical skills and produce inspiration for new skill development. As it is encouraged for supervisees to review theoretical underpinnings that match their own counseling techniques and professional style, similarly, supervisors solidify this skill development through the scaffolding process.

Supervision in Psychedelic-Assisted Psychotherapy

Psychedelic-assisted psychotherapy refers to the implementation of psychedelics as a form of medicine to assist with the psychotherapeutic process (Cavarra et al., 2022). This assistance generates an alternate state of consciousness for the client (Icaza & Mashour, 2013), oftentimes described as experiencing an increased sense of vulnerability through the sedation of egoic barriers along with changes in physiological mechanisms and neuronal pathways in the brain system. This is to detail that psychedelics increase one’s openness to the exploration of their own self and cumulative life experiences. Even more, psychedelics induce a “window of neuroplasticity” by which the brain is “plastic” and neuronal pathways can be strengthened or weakened depending on reinforced behaviors, actions, and thoughts; this timeframe of increased neuroplastic activity in the brain can last up to four weeks following a single psychedelic dose (Calder & Hassler, 2022). Therefore, psychedelic-assisted psychotherapy can facilitate client access to previously uncharted or fear-inducing depths in the psyche.

In addition to the immediate neuroplastic implications of psychedelic-assisted psychotherapy, other areas of focus that are fortified when compared to non-psychedelic-related care include, ethical therapeutic rapport (Murphy et al., 2022), consistent monitoring for physical safety, management of unprocessed phenomenon emerging from the client’s psyche (Pilecki et al., 2021), safety in mindset and setting (Leary et al., 1964; Neitzke-Spruill, 2019), and accurate empathy during states of emotional vulnerability. Therefore, the therapeutic integration of psychedelics into psychotherapy calls for a nuanced clinical skill set that reinforces positive change for the client. By proxy, it is then required that supervisors evaluate several factors: the supervisee’s ability to maintain a positive working alliance with their client to promote safety in the client’s mindset regarding the psychedelic experience and the setting within which it will take place; the supervisee’s ability to integrate feedback to ensure that psychological harm is avoided, especially during windows of neuroplasticity; and lastly, a theoretically informed approach for the integration of the psychedelic experience, which includes exploratory and process rooted interventions that sustain newfound client insights and meaning making.

Culturally Competent Psychedelic-Assisted Psychotherapy

Intersectional Lens and Psychedelia

As it is matched with diversity literacy and ethical concerns, psychedelic-assisted psychotherapy calls for a set of nuanced and advanced clinical skills on behalf of the practitioner (Anderson et al., 2020). Such diversity literacy and adherence to ethical guidelines are implicated from whom the practitioner learns. Therefore, therapeutic practice and clinical skills, especially when performing psychedelic-assisted psychotherapy, call for a theoretical and historical understanding of the intersection of client demographics and psychedelia. When approaching sessions from an intersectional framework marked by cultural humility, supervisees and supervisors must remain cognizant of accurate empathy tempered by objectivity in recognizing social privilege and historical implications that coincide with the reintroduction of plant medicines into Western therapeutic models of healing and practice.

Historical and Practical Cognizance

The societal rhetoric surrounding psychedelics and to whom it targets, supports, and criminalizes highly influences how perceptions of psychedelics and the self are shaped. As most individuals are exposed to media and news, as well as required to oblige national law, the history of psychedelia is intricately linked to criminalization of marginalized populations (Noorani, 2020). As the inclusion of psychedelics in psychotherapy upholds accessibility to care as a value, the processes by which marginalized populations have been dehumanized can be expected to emerge when such marginalized populations are within states of vulnerable consciousness (George et al., 2020; Williams et al., 2021). Therefore, expecting issues of race, culture, and historical influences to emerge during psychedelic states and subsequent integration sessions heavily calls on practitioner ability to hold space through proper set and setting (Neitzke-Spruill, 2020), express accurate empathy, and remain open to processing issues of race, diversity, and dehumanization through appropriate cultural humility (Pilecki et al., 2021). As this may pose as a challenge to some clinicians, the guidelines by which one provides supervision for professionals interested in psychedelic-assisted psychotherapy need to be increasingly comprehensive and restrictive. From this, the field of psychology, and most notably counseling psychology, holds an ethical responsibility to integrate psychedelics with meticulous sensitivity to cultural consideration and clinician training through thorough gatekeeping and supervision practices.

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