What motivates spiritual health practitioners in psychedelic-assisted therapy? A qualitative study and implications for facilitator training practices
Spiritual health practitioners (SHPs), also known as healthcare chaplains, are increasingly involved in facilitating psychedelic-assisted therapies in clinical trials and community settings. Although the motivations of therapeutic practitioners are known to impact clinical decision-making and treatment outcomes, little research has investigated what drives SHPs to pursue this work. This qualitative study examined n = 15 SHP's (60% female; MAge = 46.57) who were involved in legal administration of psychedelic-assisted therapy. An inductive-deductive qualitative analysis approach yielded two major themes: (1) Initial Motivation for Practicing PAT, and (2) Ongoing Sources of Meaning and Fulfillment. The SHPs in this study often cited personal experiences as key motivations for entering this field, frequently linked to a significant personal encounter with psychedelic use. The most common Ongoing Sources of Meaning and Fulfillment included witnessing healing in others and experiencing positive personal impacts from facilitating psychedelic-assisted care. This article addresses the substantial role that personal psychedelic experiences appear to play in SHPs’ motivations to pursue this area of practice. Such experiences provide valuable first-hand knowledge of the unique phenomenology of psychedelic treatment, although they can also potentially introduce biases and reduce objectivity. Training and certification guidelines set by the Association for Clinical Pastoral Education (ACPE) may help address these risks for SHPs through heavy emphasis placed on self-literacy and reflective learning components. Guided by these findings, we introduce a novel reflective learning exercise, as well as several existing ACPE learning components that may support psychedelic facilitators and facilitators-in-training from any professional background.
Introduction
Psychedelic-assisted therapy (PAT) involves the administration of a psychedelic compound (e.g., classic psychedelics such as psilocybin or lysergic acid diethylamide as well as MDMA and other compounds) together with therapeutic support (1–3). Evidence for the benefits of PAT for addressing several difficult-to-treat conditions (PTSD, treatment-resistant depression, demoralization among cancer patients) is mounting (4–6), and correspondingly, the utilization of PAT interventions is growing. In the United States, legal frameworks for supervised use of psilocybin have been enacted in Oregon and Colorado (7, 8), although most psychedelic compounds remain federally illegal. Recent state-level legal changes and the growing mental health crisis have sparked burgeoning research on the therapeutic use of various psychedelic compounds, as well as a rapid expansion of certification and training programs for PAT facilitation.
Among evidence-based psychosocial treatments, a distinctive feature of PAT is that it is simultaneously a pharmacological intervention and a clinician-facilitated therapy (9). PAT facilitators therefore play a key role in the experience that clients’ have during preparation for their psychedelic dosing session, during the dosing session itself, and in integration of the experience after the acute effects of the psychedelic agents have worn off (10, 11). Several attributes of PAT make it a unique treatment to facilitate, compared with existing evidence-based therapies. These include the intense phenomenology of a psychedelic experience (which typically involves marked perceptual, affective, and cognitive changes, including hallucinations); the duration of these experiences (which can last 4–48 h); and their immediate and enduring sequelae which often involve changes in the patients’ worldview (9, 12). Research characterizing the best therapeutic practices for PAT facilitation and the training components that adequately prepare facilitators to implement them is, therefore, important for the optimization of PAT. To date, very little research has characterized the attributes of PAT facilitators or investigated the role of facilitator attributes in providing effective care (2).
Spiritual health practitioners (SHPs; i.e., healthcare chaplains) have increasingly played roles in PAT facilitation in clinical trials and community practice contexts. SHPs are healthcare professionals who are employed in approximately two-thirds of all hospitals in the United States (13, 14) and trained to work on integrated care teams to recognize and respond to emotional, psychosocial, spiritual, religious, existential, and moral concerns (15, 16). SHPs training involves 1600 hours of clinical training in an accredited, year-long clinical residency, and additional professional certification requirements including published scholarship and committee appearances (17). Given the prevalence of spiritual and existential themes reported by those who have undergone PAT (18, 19), and the potential mediating role that these experiences may play in PAT benefits (19, 20), the training and professional expertise of SHPs is a natural fit for PAT. SHPs are ideally equipped to engage the spiritual dimension of biopsychosocial-spiritual models of care (21, 22) and are uniquely qualified to respond to spiritually impactful experiences that may arise for patients, including spiritual distress (19). In a prior qualitative study, these authors investigated the roles that SHPs play in PAT and the competencies they identified with as members of PAT treatment teams. Results indicated that training and formation (the ongoing internal and communally based development of the person as a spiritual care provider or clergy person) assist in SHPs being able to hold space, accompany persons in non-ordinary states of consciousness, and respond to spiritual, existential, religious and theological material that emerges in PAT. SHPs also discussed how they contribute to PAT teams by noticing and attending to power dynamics associated with identity characteristics that may confer vulnerabilities for patients (23).
The present study is motivated by recent calls to optimize the “psychotherapy” components of PAT (9, 24–26), as well as prior work indicating that clinicians’ underlying motivations for practice impact therapeutic choices made during treatment and, correspondingly, treatment outcomes (27). This research is a novel, secondary analysis of qualitative interviews previously completed with SHPs who have worked on PAT treatment teams in legal settings (for further detail on the primary study, see ref. 23). The current secondary analysis focused on identifying the motivations that drew SHPs to this unique scope of practice and the factors that sustain their motivation to continue to provide this modality of care. Understanding the backgrounds and motivations that SHPs bring to treatment teams supplements a growing research base on the attributes of PAT facilitators and the facilitator-level factors that may contribute to effective care. Methods are detailed at the end of this article, after the Discussion section.
Results
Two overarching themes were identified in this analysis: “Initial Motivation for Practicing PAT,” which included descriptions of what initially drew participants into this field of work, and “Ongoing Sources of Meaning and Fulfillment,” which included descriptions of what provided SHPs with a sense of ongoing meaning or fulfillment that motivates their work presently. Initial Motivation for Practicing PAT was found to have five subthemes: (1) experience with trauma/adversity and healing through psychedelics, (2) psychedelic care as a component of one's spiritual-vocational path, (3) desire to alleviate suffering in others, (4) unplanned exposure to the field, and (5) multilayered motivation. Ongoing Sources of Meaning and Fulfillment had four subthemes: (1) appreciation for the patterns commonly associated with psychedelic experiences, (2) witnessing the alleviation of suffering, (3) mutuality of the facilitation experience, and (4) personal impacts of facilitating PAT.
Theme 1: Initial Motivation for Practicing PAT
Subtheme: Personal Experience of Healing Through Psychedelics
The most frequently endorsed subtheme of Initial Motivation for Practicing PAT was participants’ own experiences with healing experienced through psychedelics. Some participants spoke of “healing” in broad terms (i.e., not associated with a specified ailment), while others described more specific healing from physical pain, illness, and or traumatic experience. Ten of the 15 participants spoke of this theme. As an illustrative example, one participant described experiencing physical pain from a bicycle accident, eventually leading them to seek PAT, which they found to provide surprising relief from pain that had not been responsive to physical therapy. In response to the prompt, “What led you to this work?”, this individual responded:
“Well, in one word, pain … I had a bike accident a few years ago and multiple breaks. I was dealing with pain and doing rigorous physical therapy, with a great therapist for like a year. I was on her table, we're doing dry needling and my shoulders, which is where I seem to hold a lot … and finally, my therapist said, you know there's nothing structurally problematic about your body anymore. I think that you have trauma. And I've worked with a lot of – I mean, I've been the chaplain at a domestic violence shelter and in a trauma 1 hospital. So, I'm like, “No.” Out of respect, I would say I've had hard things happen to me, but not trauma. Well, my whole definition of what that means has been completely undone. And I went to see someone who offered somatic therapy and … amplified with psychedelics, and I began a process of my own healing. And at first, I thought I was just carrying pain. I felt pain in my body. I felt pain in my heart. I felt heavy. I just felt weighted. And that was my beginning – my own healing. I started to experience the benefit of what was happening, and my whole understanding opened up to the fact that my nervous system held pain, held stories, held traumatic experiences even vicariously. And through this work, I was able to release it. I started to feel better in every way.”
Similarly, another participant described personal experience of the benefits of psychedelics in the management of their chronic illness as motivating their entry to work in the field:
“So I have chronic illness. Chronic Lyme disease, I also have a form of muscular dystrophy, and in my healing journey, I was just intuitively drawn. I'd heard about a therapist using specifically MDMA and psilocybin and just knew that's what I needed, and it has been an incredible healing support on all levels for me. And so, after several years of doing that work for myself and experiencing incredible benefits, I decided that I wanted to go into the field.”
Other participants spoke about psychedelic experiences that they found to be personally transformative:
“The bottom line is that I had my own experiences with ayahuasca, and it was deeply healing for me in ways that I just couldn't even imagine, and I kind of had a sense and a feeling that it was going to be part of my life in some way, but I didn't really know how.”
Subtheme: A Component of One's Spiritual-Vocational Path
Other participants described impactful spiritual experiences from psychedelic use that guided their vocational path. One person described how an experience with psychedelics became central to their spiritual life:
“Twenty-five years ago, I had the experience of working with both MDMA and psilocybin in more ceremonial and healing capacities, and one was with a native American Chicano man who studied in Mexico, who also was coming out of the Mazatec tradition in southern Mexico. And it was profound for me … It was the thing that helped me focus on my spiritual path, which has been Buddhism, for many years. I was studying and practicing Buddhism, working for many years in end-of-life care, spiritual care, and palliative care. And then kind of came back around full circle to the medicine again for my own healing.”
As illustrated by the above quote, this theme sometimes co-occurred with psychedelic experiences that were also described as “healing.”
Subtheme: Desire to Alleviate Suffering in Others
Several participants expressed a desire to alleviate the suffering in others as a primary motivation for entering the field of psychedelic care. For example, one participant described the challenging emotional experience of witnessing their grandmother's cancer journey and subsequent death. Their familiarity with psychedelics helped them understand that different experiences were possible for people who were suffering. They shared:
“She was at home, not even talking about dying until two days before she died and then went to the hospital and died there two days later and was fully alert to the moment that her spirit left her body, eyes wide open, sitting up gripping our hand, just totally fighting this thing. And that experience really is what brought me into chaplaincy-experiencing the feeling like I know there's a better way that this can happen, and I want to find out what that is. … It doesn't need to be that way, but it still is for so many people … So for me, the tool of psychedelic care allows us to support people in their transformative process at the time in their lives that they're being called to instead of waiting for life to happen to them and, like crossing our fingers that it'll be good. So that's how I hold it- not in any way believing that it's a cure all or that magically people are transformed from just one experience, but some people are. And other people need a hand to hold for a long time. They need a particular form of care in an expanded timeline that allows them to kind of work through one piece at a time, depending on how much they're carrying.”
Subtheme: Unplanned Exposure to the Field
Some participants spoke of an unplanned encounter with the field of PAT that sparked their interest in entering this area of practice. For some, these experiences came from their personal lives; for others, they were unexpected professional experiences. One participant described working as a chaplain for an institution that initiated a clinical trial of PAT. In this context, they were invited to participate in a legal psychedelic experience to prepare for being a facilitator. They shared the following:
“I would consider myself a somewhat conservative evangelical Christian. And certainly those roots don't necessarily overlap well with the history of psychedelic substances, whether it be in the context of a study or just the cultural revolution that we experienced in the 50s and 60s and the drug wars in the 70s and 80s and kind of where we are today. And so I was really kind of uncomfortable, to be honest. I didn't know if I had a place in this and I didn't know if morally I could participate in such a study, so this really took me through a soul-searching process on a lot of levels, not that I'm completely done processing or completely done with the journey … Part of this journey that has drawn me is not just in the process of how do I as a chaplain create a safe space and hold space for people under medication and to prepare them and to help them integrate these processes, but I think chaplains also bring us a particular angle on the practice of medicine and the studies that we have to offer to the bigger conversation of what exactly are we doing with psychedelics and what exactly are we measuring.”
Another participant shared about a situational opportunity to participate in a clinical trial themselves. They had an impactful spiritual experience which ultimately led them into the work of facilitation:
“My introduction to this field occurred in (country elided) when I was a 23-year-old theological student. And I volunteered to help test some new drug I had never heard of … derivatives of psilocybin they were studying. And so, I lay there, open and trusting and curious. And then, this incredibly beautiful transcendental state of consciousness opened up in my mind. And I was one very starstruck young theological student. And in a way, I could say my life has never been the same since … in a positive way … This incredibly beautiful transcendental state of consciousness opened up in my mind. In Methodism, there's an emphasis on conversion experiences, especially in early adolescence – giving your life to Jesus and being saved in an experiential sense of belonging … I had always had a profound appreciation for nature. But I had never come close to experiencing what happened in that first psilocybin experience. It's beyond words- basically a unity, a state of consciousness, inner beauty, and meaning that felt more real and fundamental than the state of consciousness we're in. Like a homecoming and awakening. A remembering of what is. You know a real rediscovery of the eternal dimension of consciousness.”
Several participants described exposure to PAT through educational or continuing education programs. For example, one participant spoke of hearing a researcher talk about the suitability of chaplaincy skills in PAT, which was an influence that led to their choice of making this a focus of their scope of practice.
“When I was getting my masters in psychology and religion at (seminary name elided) in (city elided), I was in the Psychology and Religion program, and we had [name elided], who's doing the psilocybin research in end of life context at (institution elided), he came in to talk to aspiring chaplains at the seminary and again that just got me really excited in the possibility of kind of utilizing my background and spiritual care … so I would see those were kind of my introductions to the field, so that when opportunities came up later through [company elided] I knew that my skills were relevant, I was excited about the field. I had a lot of just kind of intellectual knowledge about the field that's really kind of how I made the transition from chaplaincy to check it out.”
Subtheme: Multilayered Motivations
Notably, for most participants, motivations to enter the field were multifaceted. Rates of co-occurrence between the above categories were high, with nearly all participants endorsing more than one of the above themes. While some participants were primarily driven by one factor, others described more blended motivations. For example, one participant succinctly described a motivation that included the promising results of recent research, the healing they had personally experienced from psychedelics, and a desire to help others experience similar healing. This participant shared:
“Having witnessed a lot of suffering from trauma in people who weren't really finding much relief and support. Then, in terms of end-of-life care … some of the psilocybin studies that have shown that people are really able to work through existential distress and other challenges of the end of life – that also connected with my vocational path. And then, on a personal note, having gone through some childhood trauma myself, I found psychedelic therapy to be really beneficial for myself. Those are the main reasons that I started to look at this. And then had some opportunities to become involved in the research, which I'm grateful for.”
This participant came to PAT as an area of practice after encountering existing research on psychedelics and observing their own positive psychedelic experiences. Other participants shared different constellations of precipitating factors. For example, one participant identified challenging or difficult experiences with psychedelics:
“I then had an experience that was very, very difficult, very painful, very disorienting during a psychedelic journey … that essentially sidelined me for the next decade. It scared me very badly. I believed that I was sort of manifesting some kind of mental illness that I was going to lose my mind – that my sense of self was going to fragment. That never happened but what did happen is that one particular instance manifested what I now know to be anxiety that I had to deal with for years after that. And that I still deal with. Because of that anxiety, I was on the sidelines. My community and my friends continued to experiment, and I therefore took on more or less inadvertently the role of babysitter or a guide.”
Another participant described an experience with psychedelics early in life that led to a transformative spiritual awakening, leading them into chaplaincy. Much later, an opportunity arose to train as a facilitator.
“I did a lot of psychedelics in my teenage years. I had a very powerful experience that was more spiritually based and had a very solid intention when I was 19. And that changed the course of my life and helped me experience something much deeper – a much deeper reality, if that makes sense, and I also experienced a lot around death and dying, and from that experience, I was called first, into a spiritual path that led me into meditation that then kind of took me into the calling of ordained ministry, as well as chaplaincy work, specifically with those who are dying. And then I stopped psychedelics; I didn't do psychedelics for 20 years, actually, after that really powerful experience, and I was approaching non-ordinary states of consciousness more through meditation, contemplative prayer, things like long extended retreats. But then I had an opportunity to go through the (program name elided) in the first cohort, as it was a pilot project. So, I took that opportunity, and that's kind of what then led me to begin facilitating psychedelics.”
Theme 2: Ongoing Sources of Meaning and Fulfillment
Subtheme: Appreciation for the Patterns Commonly Associated with Psychedelic Experiences
Several participants described deriving ongoing appreciation and fulfillment from witnessing certain experiences or themes that commonly accompany psychedelic experience. For example, one participant described a global sense of connectedness experienced by many who have taken psychedelics:
“Seeing the similar experiences of participants in studies … creating new stories but also coming into a sense of being part of something larger … that to me is spiritual however anyone defines their spiritual journey or their religious practices … the feeling of being part of something larger than ourselves.”
Similarly, in another participant's words:
“Something that just seems to consistently emerge with psychedelic therapies and that seems to be a beneficial emergence for the people that are experiencing it … to see this pattern again and again and again feels very spiritual and very affirming. I don't have to label it or know exactly what it is, or put ABC lists to it, but that there is something that connects us all, connects us to the planet, connects us … whether we call that God's spirit, the universe, humanity, earth, whatever, … it's a very spiritual experience for me to witness again and again these same patterns, these same experiences for different people.”
When SHPs spoke of the patterns that emerged across facilitating psychedelic experiences, words such as “connectedness” came up frequently. SHPs described witnessing these experiences as personally meaningful, inspiring, and an important contributing factor to their motivation to continue in this field.
Subtheme: Witnessing the Alleviation of Suffering
Participants also described the satisfaction they experienced in witnessing the alleviation of suffering during PAT. This theme commonly co-occurred with the “desire to alleviate suffering” subtheme of Theme 1 (Initial Motivation for Practicing PAT), as witnessing the alleviation of suffering created ongoing motivation for persons initially drawn to PAT facilitation with this aim. Several participants described deriving satisfaction from seeing others heal and grow through psychedelic use. In one SHP's words:
“The deepest place where I access meaning is through being of service to the healing process of others. That comes through in this work because it's very client centered. It's very focused on redirecting individuals to their own inner wisdom, inner spiritual voice … It feels like that is the greater purpose … It gives me meaning – the feeling of being in alignment with life's path happens when I am holding space for others actually to sit within their relationship to their own inner guide … It's being of service. It's also assisting folks and moving into what I would call their spiritual alignment. Whether that's religious or not, or whether it's atheist … that's what gives meaning.”
Other participants described the rewarding nature of witnessing improvement for clients who have had limited success with other forms of treatment:
“A lot of the folks that are coming to our treatment model, in particular, have been dealing with treatment-resistant depression, anxiety, or PTSD. They've been having really severe symptoms or symptoms that they just haven't been able to get a hold of for a really long time. And just really seeing this rapidly acting transformation that begins to happen in just a few sessions. I think it's just really always exciting for me … Seeing people's hard work come to fruition. … being able to use my chaplain skills and to acknowledge how difficult it is to open up at that moment. So I think that's another thing that's really fulfilling for me is that a lot of people come into treatment, maybe already having partially given up or seeing this is their last resort, so to speak. So just being able to grow that kind of breakthrough treatment for people, I think, is exciting as well.”
Similarly, another participant described hopefulness for PAT in addressing concerns typically characterized as “subclinical,” such as burnout. They shared:
“I think there's hope in it. Other therapies haven't worked. Other things haven't spoken to people. There's too much that's unidentified living in people. That you know it's if they had access to it or knew what to do with it, they would have done it already, it would have been dealt with, you know people are not lazy or stupid, and so they can't get to it … I worked through the whole COVID in the ICU. We lost 80 nurses who have resigned from that unit over the course of the pandemic. And I'm still talking to them and hearing them say, ‘I'm dead inside.’ That's a quote – ‘I am dead.’ We're not going to talk you out of that. I don't think we're gonna bubble bath you out of that.”
Participants also discussed finding meaning in helping people experience a connection to the sacred, coupled with the capacity of PAT to treat mental health conditions:
“I wouldn't be doing it if it didn't give me so much meaning. Psychedelics for me are an extremely powerful tool for people to experience the sacred, the divine God, I mean whatever language … we know that's kind of ineffable … all different words to describe that. Also, from a mental health perspective, the data, the statistics that are coming out, and the results that I see in the participants that I facilitate compared to more traditional tools in the mental health world like talk therapy and pharmaceutical drugs … just such an amazing success rate with the use of psychedelics if done correctly, I really, really strongly believe that.”
Subtheme: Mutuality of the Facilitation Experience
Some participants spoke about finding meaning in the mutuality of the facilitation experience. Participants who had their own, personally impactful lived experiences with psychedelics often described an appreciation for the aspects of shared experience that accompanied facilitating psychedelic experiences for others. For example, as one participant put it:
“… seeing people heal – like really seeing people heal – is so satisfying. To have that and my own experience, knowing where I am in my journey because of this work, and I wouldn't be here without this work and the way that I am today, and I see that it changes people's lives.”
Another participant spoke of a similar experience of mutuality in the context of having a chronic illness:
“As I've worked with my chronic illness and as I've reframed my narrative, it makes me feel less isolated, less alone, part of society, part of the world. Even if I'm in pain, even if I'm still not feeling well, I can still be part of this larger fabric of the world and accept my limitations … Psychedelics have helped with symptoms, helped heal some of my chronic illnesses and helped me step more deeply into relationships with others and with this whole ecosystem that we're part of and feel more in connection with the divine. There's a plan for my life. There's a reason I came in with the challenges … But I've got ground that I can support others with now because I found this ground within myself … psychedelic therapies can support us all to recognize that we are all connected … can help us find ground and then therefore kind of be able to move from that ground. Even though I may still have symptoms, I may still not feel good some days. I still have pain, but I can still step into the world with all of myself and find a place that's meaningful for me and allows me to have joy.”
Not all participants described mutuality in terms of healing. Other participants spoke of a spiritual process that began with their own experience of taking psychedelics and is now enriched by facilitating psychedelic experiences for others. In another participant's words:
“Personally, sitting with the medicine requires a deep commitment to my own spiritual development, and my own inner healing work. That has been, in some ways, amplified and, in some ways, really does come to the forefront to see and to be as clear as possible for others. To offer that service working within the structures within my life has been extremely important. Encountering all my biases, healing my own stuff, and doing the inner work. The more I do that, the more clarity I have and the less of my own stuff I bring into the room with others … To hold space for folks having mystical experiences, there's also been a change within me to access those states where the opening is stabilized between sessions. And a lot of my development leans into various spiritual lineages that are not necessarily using medicine work but are encouraging and are using ancient practices to establish those same openings but maybe access them in more of a stable day-to-day expanded way. So, twofold: it's been heavy-duty spiritual practice that has amplified it in my life and our work. I think it's two sides of the same coin.”
In addition to mutuality with their clients, participants also spoke to impactful experiences of mutuality with other members of clients’ care teams. For example:
“Personal experience with medicine working in therapeutic and ceremonial contexts and how profoundly that has impacted me, my spirituality, my healing, my sense of connection in the world … I mean, relative to other work contexts, this team has felt like I have a real sense of kinship and that we are in alignment with the model in a more holistic approach. Yeah, and just how from my own experience and from what I hear of others how, potentially, not inevitably, but potentially supportive medicine work can be for not only healing, particularly healing around trauma, but spiritual growth and self-awareness of connection in the world.”
Subtheme: Personal Impacts of Facilitating PAT
This subtheme described experiencing personal impact from engaging in PAT that sustains participants’ vocational motivation. Although this sometimes included the personal impacts of the prior theme, mutuality, participants also spoke to several personal impacts independent of shared experiences. One participant described being inspired by the commonalities in psychedelic experiences that they have witnessed over years of facilitation:
“I've certainly been reinforced in my view of the world, in my spiritual life, in my psychological theory. I've had the great honor of being with several hundred people in their psychedelic sessions, and to me, that's a lot of evidence. People from different races, different educational levels, different careers, different physical health situations and the human mind seems to function pretty much the same with all of them. And that's inspiring …”
Another participant spoke of the personal impact of working in a group/peer support model and the power of watching group members build trusting relationships with one another:
“This group model is more about peer support, and it is more about cultivating tools for presence, for grounded spacious awareness, for what it is that is emerging within us that we can accept, be with, and possibly allow for some processing simply by being present to it with compassion, and then people being witnessed by the group and feeling the sense of support and safety and trust that ideally is deepened over the weeks from the group. Seeing people who have, in this case, significant trauma histories, some of whom have been really isolated either for various reasons, socially or because of the degree of their anxiety (not comfortable leaving their house, especially in the context of the last few years) even in a short period of time, feeling a sense of bond kinship, safety. Feeling ‘I'm not alone’ with each other. Being able to relax and feeling a natural heartfulness, joyfulness, compassion, and inner healing wisdom emerge within that space. That to me is beautiful to witness.”
Another participant described fulfillment in the intimacy of psychedelic-assisted care:
“I would say things have kind of changed me about this work …. I think in some ways, like the psychiatric context, in some ways, like the hospice context, it's a very intimate setting. The medicine, in some ways, really helps people take their defenses down and be more engaged with the work, maybe to stay present with more difficult activating material. I think the sessions are really intimate, and I think there's some transformation just in seeing this kind of spiritual revelations that people have. I think just being able to witness that, being able to observe that, support that. I think it really just opens my eyes to the complexity of humans in our spiritual lives.”
Discussion
As the evidence base for PATs continues to expand, optimizing the facilitation of these unique treatments has become increasingly important (25). In the context of the spiritual and existential experiences that often accompany psychedelic experiences, SHPs are increasingly recognized as playing vital roles on PAT care teams (19, 23). Understanding the roles that SHPs can play on PAT care teams, and how training for PAT facilitation can be optimized, requires an understanding of the motivations that draw SHPs to PAT facilitation in the first place, as well as the factors that sustain their ongoing work in this field. The major themes identified in this research highlight the deeply personal nature of PAT facilitation for the SHPs in this study, a finding which has valuable implications for PAT facilitation training.
This study found that personal psychedelic use was a strong motivator for SHPs practicing PAT—a finding consistent with a recent investigation of psychedelic use among therapists from a phase 2 clinical trial of psilocybin for major depressive disorder that found that the majority of therapists had experience with at least one psychedelic substance, most commonly psilocybin (25). Many SHPs in our study described their psychedelic experiences as “healing”; others described their experiences as spiritually “transformative,” as opening new spiritual awareness, enhancing their existing sense of spirituality, or increasing their understanding of their place in the world. Notably, SHPs predominantly described personal benefits associated with their past psychedelic experiences, although psychedelic experiences are not exclusively experienced as beneficial and are sometimes experienced as challenging in the general population (28, 29).
With respect to factors that provide SHPs with ongoing sources of fulfillment and motivation for this work, witnessing others experience healing was described as particularly significant. Many participants in this study reported deriving a deep sense of meaning from the mutuality of the experience—that is, guiding someone else through an experience that they had found to be so powerful and personally impactful. Many participants also spoke to interconnectedness as a sustaining factor. Interconnectedness was sometimes described as experienced with clients, sometimes described as experienced with other members of a PAT care team, and sometimes described as drawing from repeated witnessing of themes that commonly emerge during a psychedelic experience.
These findings are aligned with prior research on the motivations that draw practitioners to psychological healing professions more broadly. Studies examining the motivations of mental health providers (including therapists, psychologists, and social workers) have found that therapists frequently describe personal experiences of adversity and healing as significant factors in their motivation for their vocation. Specifically, personal adversities, lived experiences of social and cultural marginalization, and one's own experience of receiving therapy are common motivators for vocation (27, 30, 31). The limited existing literature characterizing general vocational motivations of SHPs finds, similarly, that many come to the profession with a history of personal trauma and adversity in their families and communities (32, 33). SHPs are also likely to cite disillusionment with religious institutions as a motivator for working in chaplaincy (33). Having lived experience with symptoms and experiences reported by patients has been noted in the psychotherapeutic literature to have both advantages and drawbacks. It has been suggested that personal experiences of adversity may confer empathy and an enhanced capacity to understand human complexities (33), leading to a greater capacity for sitting with others in times of distress (24, 34). Conversely, personal experiences can increase the risk of inaccurate projection of one's own experience onto the patient (24) and may interfere with objectivity in assessment and treatment planning (35).
The question of whether personal psychedelic experience should be a prerequisite for providing psychedelic facilitation remains one of the most debated topics in the field of PAT facilitation training (24). This study adds an additional data point to an accumulating finding that, much like mental and spiritual health professionals who are motivated by their own experiences of adversity and healing, psychedelic facilitators are frequently motivated by personal experiences with psychedelic use. However, our findings also raise the possibility that firsthand psychedelic experience may not, in itself, lead to more effective care. Because personal psychedelic experiences were frequently described as key sources of motivation to provide this kind of care, it may be that motivation—rather than the experience itself—is a more immediate and influential factor in facilitating effective therapy. While no research to date has examined whether facilitators with prior psychedelic experience are more efficacious, we suggest that, even if such an association were found, it could be attributable to increased motivation rather than any inherent benefit of the psychedelic experience (or other encounters with non-ordinary states of consciousness) itself. Given this, we recommend that PAT facilitation training programs acknowledge personal psychedelic use as a potential motivational factor and explicitly address this in training. Regardless of whether programs choose to offer psychedelic experiences to trainees, it is essential for trainees to recognize and thoughtfully engage with prior psychedelic experiences that are brought into training.
When the Professional is Personal: Implications for PAT Facilitation Training
Results of this research found that for most SHPs, working in the field of PAT is deeply personal. Many reported experiencing their own transformation and healing through psychedelic use and now seek to offer others support through similar methods. On one hand, this level of personal experience can be beneficial: experiential knowledge may equip SHPs to skillfully respond to the unique phenomenology associated with psychedelic agents (24, 36). A facilitator's lived experience with and belief in the effectiveness of psychedelics may also constitute common factors of treatment effectiveness. Psychotherapy research on common factors has found that therapist empathy alone exerts large effect sizes on treatment outcomes (d > 0.8), and expectations have smaller but still significant effects (d > 0.2), independent of any specific components of treatment (34).
Conversely, personal experiences can also introduce biases that hinder the ability to provide objective care. Facilitators who are strongly motivated by personal experience run the risk of “experiential encapsulation”—a term we adapt from cultural encapsulation, which is used to describe a clinicians’ application of their own culture-bound experience and worldviews to those of a client without regard for important differences (37, 38). Experiential encapsulation occurs when facilitators assume that their own psychedelic experiences, the timelines of these experiences, and their frameworks for interpreting these experiences, are universally applicable. This can lead facilitators to overlook the unique and deeply personal ways in which different individuals may experience psychedelics during PAT. Just as culturally encapsulated therapists are at risk of failing to consider cultural differences between themselves and their client and imposing their own values on care (37, 38), an experientially encapsulated facilitator may fail to recognize variations in how individuals experience psychedelics and the meanings that are ascribed to these experiences. Any facilitator of PAT (whether an SHP or from another profession) whose approach is overly shaped by personal psychedelic experience runs the risk of oversights when working with someone who has a markedly different experience. Such oversights can lead to ineffectiveness, or at worst, treatment harms (9).
For SHPs, training requirements set by the Association for Clinical Pastoral Education (ACPE) may help buffer against this risk (24). The preparatory training to become an SHP through ACPE places a heavy emphasis on self-literacy. Self-literacy training occurs in the context of the Common Code of Ethics for Chaplains, Pastoral Counselors, Pastoral Educators and Students, which sets forth several standards pertaining to cultural humility and respect for autonomy in the worldview and beliefs of others in all professional activities (e.g., Standard 1.3: “Demonstrate respect for the cultural and religious values of those they serve and refrain from imposing their our own values and beliefs on those served.”) (39). ACPE training standards also include several outcomes and indicators that ask SHPs-in-training to reflect upon their motivations to engage in the work of spiritual care, the orienting system behind their spiritual care choices with clients, and their understanding of personal, social, and cultural location that impacts their way of being in the world and work (39). For example, learning outcomes include “Identify formative and transformative experiences in one's narrative history and their significance to one's spiritual journey” (IA.1) and “Demonstrate an awareness of implicit and systemic bias including cultural and value/belief-based prejudice and its impact on spiritual care” (IA.7). This reflective learning aims to aid SHPs in bringing awareness to factors that motivate their actions in spiritual care encounters. In the context of PAT, this training may also aid SHPs in sensitively approaching a participant's experience without expectations, regardless of the SHPs’ relationship with psychedelics. While the personal history of transformation through psychedelics may be a significant motivator for many SHPs engaged in this work, the learning outcomes and ethical guardrails of SHPs may assist in maintaining a practice that centers the experience of the client.
Standards set forth by professional ethics codes for mental health providers (e.g., the American Psychological Association Ethics Code; the Code of Ethics for Social Work) articulate comparable practice standards with regards to respect for clients’ autonomy and refraining from imposing one's own values (40, 41). However, these standards for training and practice do not explicitly address reflection on one's own narrative and psychospiritual history. In the absence of such standards, training programs for clinical mental health professions often dedicate minimal time to experiential self-literacy training as an integrated component of training. Findings from this research suggest that when it comes to PAT, training competencies associated with self-literacy of one's narrative and psychospiritual history and motivations may be particularly important. In the context of ongoing discussions about training guidelines and requirements for PAT that cut across professions, we suggest that ACPE's reflective learning model for acquiring self-literacy be considered an element of training that can benefit all PAT providers, regardless of their profession. Further, as practitioners engage in PAT, continual reflection on these learning outcomes as part of continuing education can benefit providers’ work.
Guided by findings from this study and the ACPE reflective learning model, we suggest a self-literacy exercise that can be completed by PAT facilitators and facilitators-in-training coming from any professional background (Figure 1). These questions aim to balance the value of personal experience with the need for clinical objectivity and the importance of reflecting on how personal experiences and motivations can confer both strengths and gaps in awareness. The nine self-reflection questions provided in Figure 1 can be assigned as a written, narrative exercise during psychedelic facilitation training, so that trainees can practice reflectively without being required to disclose about personal experience beyond their comfort level. Practicing facilitators may be benefit from revisiting these questions annually, as motivations (and personal experience) may change over time.
Citation: Psychedelics 2025; 10.61373/pp025r.0008
Limitations and Researcher Positionality
A primary limitation of this work pertains to recruitment and the sample of participants represented. Participants in these interviews were recruited through a national professional network (Transforming Chaplaincy) that was originally co-convened by this study's principal investigator (PI). This could have led to bias such that the views of participants were similar in nature to each other and the PI. Participants in this study had a variety of chaplaincy training experiences, not all through ACPE. Relatedly, only those practicing PAT in legal settings were included. This means that our results may not generalize to the numerous practitioners working in underground settings and traditional religious/spiritual settings. Providers practicing in those settings have unique experiences facilitating PAT, and may have different motivations and sustaining factors for their work. Our results also may not generalize to legal PAT practitioners from non-SHP training backgrounds (e.g., psychiatry, clinical psychology, social work). Broadly speaking, educational pathways and practice environments impact the experiences and motivations of practitioners. Future research should reach a broader network of providers to ensure more generalizability and understand to what extent experiences may differ.
Additionally, the vast majority of participants in this study were white (80%) and North American (93%). This poses limitations on the generalizability of this work to the populations at large. Individuals from other racial, ethnic and cultural backgrounds may approach psychedelic experiences differently, leading them to have different perspectives than those represented here. For example, participants in this study expressed an orientation toward personal healing. Communal dimensions of healing are central to many traditions of psychedelic use around the world (42) and are under-represented here.
This qualitative study should also be interpreted in light of author positionality. All authors of this study reside in the United States and work in primarily academic contexts, with settings spanning a large academic medical center, a School of Public Health, and a School of Theology. The authors include SHPs (chaplains), clinical psychologists, a clinical social worker, and a graduate student in public health. All authors have professional experience with PAT; some authors have provided PAT facilitation, while others have served research-focused roles on PAT trials (e.g., investigator, data analyst). Our training backgrounds inform the lens through which we approached these analyses and their interpretation, and individuals with other training or professional backgrounds may have generated different coding categories or drawn different conclusions than those represented here. We acknowledge that our perspectives do not represent the perspectives of all PAT facilitators or recipients of these treatments.
Conclusions and Future Directions
As the field of PAT continues to expand and the potential for FDA approval of psychedelic agent(s) appears on the horizon, it is a critical time for professional disciplines to systematically evaluate what constitutes appropriate preparation for those working in PAT. Understanding the motivating factors for SHPs who are already engaged in this work allows those within and outside the field of spiritual care to consider the complex dynamics at play within a PAT facilitation experience from a unique perspective.
A core finding from this study was that personal experiences substantially informed participants’ initial and ongoing motivations for working in this field. We do not draw conclusions regarding whether experience with psychedelics is necessary to be an effective PAT facilitator. However, awareness of motivations—whether related to one's own psychedelic experiences or not—can assist the facilitator in bringing an objective approach to the work that is centered on the experience of the person seeking care. Results of this study suggest that training programs for PAT would benefit from curricula components that invite trainees to explore personal motivating factors so that insight into these can be cultivated and any resulting biases can be addressed. With a careful and self-aware approach, therapists of any discipline may be able to provide care that is sensitive to power dynamics and non-imposing of personal experience and perspective.
Methods
The present study is a secondary analysis of a qualitative study that aimed to identify the role that SHPs play on PAT teams (23). This secondary analysis was motivated by the emergence of two themes that were inductively identified during our original qualitative analyses for the primary study. These themes fell beyond the scope of that research, and therefore were not examined or reported: (1) the factors that initially brought participants to PAT facilitation, and (2) the factors that motivate their continued practice of this profession.
Participants
Participants in this research had experience facilitating PAT and also met at least one of the following criteria: (1) one or more units of Clinical Pastoral Education (ACPE), (2) ordination or status as a religious leader, (3) a Master of Divinity or other advanced theological degree, or (4) specific training in spirituality within psychedelic work, above and beyond what is offered in standard PAT certification programs. Recruitment occurred between March 2022 through June 2022. “Experience with PAT” was defined as experience facilitating PAT in settings where it was legal, including both ceremonial and/or retreat settings, as well as clinical research environments.
All participants (n = 15) in the parent study are represented in the present study. Participants had an average age of 46.57 (SD = 13.38), identified as 60% female (40% male), and were 20% Hispanic/Latinx and 80% White. The vast majority (93%) were North American, with 6.67% being South American. The most common context of PAT experience was within clinical trials (46.67%), with the next most common being retreat/ceremonial (40%), and private practice, clinic, and remote/virtual being the least common (6.7%). The most commonly used psychedelic in PAT interventions reported by participants was psilocybin (66.67%), followed by ketamine (46.67%), ayahuasca and MDMA (both 13.33%), and LSD, cannabis, and kambo (6.7%).
Procedures and Measures
SHPs were interviewed via the Zoom telehealth platform, except for one SHP, who was questioned via a written email exchange due to poor internet connectivity and inability to engage via Zoom. All SHPs were queried using a semistructured interview guide of 14 standard questions, reported in the originally published study (23). Interview questions included items asking SHPs to describe various aspects of their professional activities, their motivations for engaging in PAT, their view of the importance of personal experience with psychedelics, ethical concerns related to PAT, spiritual outcomes of PAT, and views of the building field of SHPs engaging in PAT.
Two previously unanalyzed questions were the analytic focus for the present investigation: a motivation question, asked to all participants (“What motivated you to work in this field?”), and a meaning and fulfillment probe (i.e., “What brings you meaning or fulfillment in this work?”). The meaning and fulfillment probe was included in the interview guide as an optional follow-up probe, and therefore not asked of all participants. Information yielded in response to this probe, when it was included, was related to the motivation theme and was therefore included in the present analysis. All interviews were video and audio recorded and transcribed using the autotranscription feature of Zoom. Transcripts were subsequently manually deidentified and corrected following the automated transcription for any errors or lack of clarity (via comparison with live recording) by two researchers.
Data Analysis
The data analytic strategy for the primary analysis is described elsewhere (23). During that process two themes emerged inductively, which did not fall within the scope of the primary analysis. These two themes were (1) participants’ descriptions of their initial motivations for facilitating PAT, and (2) their current sources of ongoing motivation and fulfillment in their work. These themes were determined to be unrelated to the aims of the primary study, which were to characterize the roles and activities of SHPs on PAT treatment teams, but of sufficient scientific importance to warrant their own dedicated systematic investigation.
The present secondary analyses employed a hybrid inductive-deductive approach (43) to rapid qualitative analysis of these two themes. A rapid qualitative approach was selected because of the shifting regulatory environment of psychedelics, and ongoing discussions about the role of SHPs in psychedelic care, to which this analysis may provide directly germane, though time-sensitive, information. In the secondary analysis, our first step was to generate a codebook of subthemes, which was created by two investigators with content expertise in chaplaincy and psychedelic facilitation. The codebook was created by reviewing all transcripts, and then identifying (1) pre-existing themes that were deemed important to examine in a deductive step (e.g., the existing unexamined categories that emerged in the prior analysis that motivated the present investigation), and (2) a set of themes relevant to these two original themes, which were recognized and noted separately by the two investigators. These were discussed and consolidated into one codebook. That codebook was then refined by having the two expert coders code a subsample of transcripts independently, and then resolve disagreements by consensus, modifying and adding categories as needed. The resulting codebook was then treated as a finalized version. These codes were deductively applied by a single coder using MAXQDA version 22.2.00 qualitative analysis software. This method of rapid qualitative analysis has the advantage of taking less time than double-coded methods, and the limitation that coding may be subject to biased detection, with intercoder reliability of the full dataset not possible to establish (44). This limitation makes researcher positionality particularly important to describe and report as part of data interpretation (see Discussion for this reporting).
Data Availability
Data cannot be shared publicly because of concerns about identifiability, and the need to preserve privacy and confidentiality of participants. Because the topics discussed may incur legal or social sanctions the data are held on protected and encrypted university servers at Emory University. Data may be made available for researchers who meet the criteria for access to confidential data by contacting the Emory University Institutional Review Board at irb@emory.edu or the corresponding study author.
Acknowledgments
The authors would like to thank the participants in this research for sharing their experiences and perspectives with us.
Author Contributions
C.P. collected and analyzed reported data. D.M.K., I.P., and C.P. wrote the first draft of this manuscript, with input from R.P., J.C.S., J.M.P., and G.H.G. Revisions to this article were completed by D.M.K. and I.P., with input by C.P., R.P., J.C.S., J.M.P., and G.H.G. All authors reviewed and approved the final version of this manuscript. All authors take full responsibility for data and text and approve the content and submission of this article. No related work is under consideration elsewhere.
Funding Sources
This research was not funded by external sources. Personnel time dedicated to preparation of this article was generously supported by Emory Spiritual Health.
Author Disclosures
D.M.K. has served as a consultant for the Mind and Life Institute and the Oxford Research Encyclopedia of Global Public Health, and has received research support from the NIH, the Georgia CTSA, the Tiny Blue Dot Foundation, the Sarlo Family Foundation, and the Vail Health Foundation. R.P. has received research support from the Tiny Blue Dot Foundation, the Jim Joseph Foundation via Shefa Jewish Psychedelic Support, the Sarlo Family Foundation and has consulted for the Harvard Divinity School Center for the Study of World Religions. J.M.K. has received consulting payments from COMPASS Pathways and Ostuka and receives support from the Wounded Warrior Project (WWP) and Multidisciplinary Association of Psychedelic Studies.
Self-literacy reflection exercise for psychedelic facilitators.
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