Considerations of providing care around difference in identity and cultural knowledge  

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Ethical Tension
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Max, a 41 year old white heterosexual man, has an initial screening with Chris, a 46 year old Puerto-Rican heterosexual male psychedelics guide. Max identifies as transgender. He has come to see Chris wanting to explore whether psychedelics could help him work through intimacy issues within his primary relationship. Max and Chris have excellent rapport; it’s easy for them to get along well together. Chris specializes in couples work but he is cis-gender and doesn’t have familiarity with the trans experience.

Ethical Themes: Diversity and difference, screening and rightness of fit/scope of practice; guide consultation; transgender care

Specific Tension: When a guide’s life experience or identity is different from that of a client, should the guide refer the client to another guide with lived experience?

  1. What actions are in the client’s best interest?
  2. Is good rapport enough to do deep work with a client despite different backgrounds and lack of certain specialized education?

Guides will continuously face the challenge of not entirely understanding or sharing a client’s life experience. This is expected to some degree; after all, we live in a world filled with diversity.

Early in the process, it is the guide’s responsibility to recognize differences and acknowledge their educational limitations to determine whether the guide’s background and training may limit the quality of their work.

In this case example, we see that Chris is unfamiliar with the trans community and potential special considerations and needs during psychedelic sessions, preparation and integration. For instance, does Chris have familiarity with terminology common to the transgender community, and how the use of improper pronouns may have a profound impact? Is Chris aware of how touch is (and isn’t) engaged might affect a transgender individual differently? Is he familiar with how hormone therapy (and related emotional states of mind) may interact with the psychedelic modality or timing of psychedelic sessions?

During the initial consult meeting, Chris should bring up the difference in identity and his lack of familiarity with the/a trans experience to open a dialogue with Max. Chris should ask Max how he feels about this difference, and explore whether Max would like a referral to a guide specializing in psychedelic support for transgender clients. 

He could say, “I’m not trans, and I don’t know much about what that experience is like, and I’d like to open the door for you to share with me whatever is comfortable for you. My main priority is helping you feel fully supported, whether by me or another guide more versed in the/a transgender experience.”

This open discussion is rooted in collaboration and transparency, and will help Max gain awareness of Chris’ views and perspectives and whether he feels “seen” enough by Chris to engage in impactful, psychologically well attuned work together.

Chris may also propose to Max that he educate himself and seek supervision while working with Max in parallel, and allow Max to gauge this as an option. However, Chris needs to be realistic about his ability to prioritize additional training and reflection in time for Max’s needs. 

While our Commentary is limited to the issues described above, this case raises other ethical tensions such as considerations unique to rural geographic areas. Within rural areas, there may only be a few psychedelic guides, so it is less likely to find a “perfect match” between client and guide. Mental health and medicine in rural areas have distinctions from urban/suburban medicine, and psychedelics work follows a similar dynamic; like rural clinicians, rural guides will be called upon to exercise creativity, collaboration, and honesty when responding to their clients’ needs. 

None of our cases or commentaries constitute medical or legal advice; see our Disclaimers for more information.

Gather Well values a multi-pronged approach to ethics which includes organizational ethics, ethics education, and personal reflection.  

In this case we especially see the value of personal reflection. Guides must be honest with themselves about their “kneejerk” responses to their clients’ personalities, attributes, and values. For example, when a guide notices feelings of hostility or defensiveness arising during client sessions, the guide should make immediate efforts to see if those feelings can be addressed and overcome. Peer counseling, ethics education, ethics consultation services, and mentorship are all viable approaches. If the guide is unable to work through their knee-jerk response, they are ethically obligated to refer the client to another guide.

Gather Well prioritizes the quality of clients’ care. This means guides consider not just their skill in what they do but their capacity to meet or resonate with a client on the human level of lived experience. Frameworks, methodologies, or theoretical concepts are a part of the guide’s education, but each guide brings with them their own lived experience, familiarity, and comfort with people who identify in distinctly different ways from themselves. There is certainly education to be gained on difference, diversity and creating a culturally sensitive practice, and yet sometimes the client may need to feel their guide inherently understands an aspect of their identity from an embodied, or lived experience. This is not always the case, as many clients and guides who differ greatly in some ways find many points of connection, shared life experience, values and interest in other ways, and may even celebrate what comes of difference and contrast. It should be up to the client to define this, and the guide’s responsibility to raise the dialogue early in the relationship. 

It may be the case that the best course of action is a referral, and taking this action requires humility, honesty, and integrity. At Gather Well we strive to develop strong networks, a sense of community, and open channels of communication amongst professionals and guides so referrals can be made for the benefit of clients. 

We strongly advocate for anyone in the helping professions to gain education on how to do their particular work in such a way that is inclusive and attuned to a wide range of diverse experiences, particularly across  race, gender, sexual orientation, socioeconomic experience, religion, and mental and physical ability, along with customs and norms of diverse cultures. In Gather Well programs we place significant attention on cultivating a capacity to stay present when faced with fear and discomfort. We pay special attention to staying attuned and present, with an open heart and mind, especially relating to differences of identity. This is not easy work, but we believe this capacity building is critical to the overall transformation and wellbeing of the collective. 

Every client has a dynamic system of beliefs and influences in their lives that relate to their upbringing and life experience. This extends far beyond formative experiences in their childhood. It also involves culture, customs, and beliefs; societal position, privilege and oppression; and exposure to caring community and the natural world. The guide cannot possibly educate themselves on every possible experience, so we educate in presence and embodied capacity building as fundamental, upon which theoretical learning about difference or a particular identity’s experience can be built. 

As an organization we, too, are continuously growing our capacity. While growth is not always a smooth process, we know we will continue to learn immensely from those we engage with in meaningful ways.  

None of our cases or commentaries constitute medical or legal advice; see our Disclaimers for more information.