Revelation of sexual trauma during sessions/ “bad trip” presentation

During a psychedelic session, Mo reveals sexual trauma that did not come up in preparation sessions with Sasha, her guide. Mo is a 47 year old white lesbian identified cis-woman, and Sasha is a 31-year old white hetero identified cis-woman. Mo is dysregulated, feeling afraid, experiencing what is colloquially called a “bad trip.” Mo’s presentation scares Sasha and throws her off-center. Sasha is frustrated with Mo since her client’s lack of disclosure prevented Sasha from being prepared for this moment.

Ethical Themes: Client safety, trauma informed care, client’s sexual assault history; guides’ moral erosion & burnout, preparation/integration, screening and rightness of fit/scope of practice.

Specific tension:  How should Sasha balance the conflict of responding to her own personal needs and feelings (e.g. wishing to distance herself in response to her fears and frustrations) with upholding her duty to provide a supportive, collaborative “container” for her client?

1. How can Sasha respond to Mo’s presentation to reclaim her guide role and support Mo, making her best efforts to transform Mo’s “bad trip” into a healing opportunity?
2. Is there something in the preparation sessions that was missed?
3. How will the guide address this within integration sessions?

During the Session:

It is the guide’s responsibility to “hold a container” that provides a safe physical environment – and a psychological sense of safety – throughout the session. This means the guide must work with whatever psychological material the client evokes. 

To the extent possible, the guide should welcome the client’s presentation with love and compassion. The guide should also exercise caution. Touch must comply with the consent agreement made prior to the session but also be approached with extra care. Because of her trauma history, Mo may misinterpret physical actions by Sasha, so while Sasha intends to support and heal, her touch could cause Mo additional harm.

In this instance, the guide should ask themselves “what’s going on for Mo?” (instead of “what’s wrong with Mo that she’s acting this way?!”). This nonjudgmental inquiry refocuses the guide’s response on empathic, safe actions to promote the client’s emotional safety during the remainder of her psychedelic session.

Sasha also needs to address her own fears arising during the session. She will need to draw on her own self-resourcing skills during the session to stay grounded and present for the client. If another guide is present, she can consider whether she needs to take a short break to recenter.

Post-Session Steps for the Guide:

After the session and before follow-up integration sessions with Mo, Sasha should meet with her mentor and reflect on how to best support Mo and meet her with nonjudgmental regard and collaboration.  

Sasha should also explore with her mentor what aspects of Mo’s session were triggering for her. With support, this case can help Sasha grow into a wiser and more experienced guide.  Without support, this case has the potential to result in Sasha’s burnout, possibly becoming inappropriately distant or unattached to future clients in order to protect her own emotional well-being.  Being a guide will challenge guides in unexpected ways, but with the right guidance, growth is entirely possible.

The guide can also connect with their mentor to more generally explore whether there are ways to better facilitate rapport with clients. We encourage lengthy and detailed intake and assessment prior to a psychedelic session, and a preparation phase that allows for trust and comfort between a guide and client, but clients are sometimes unwilling or unable to disclose their trauma history. 

Guides can also reach out to a rape crisis center for free and confidential guidance on how to approach these kinds of cases. Rape crisis centers have expert counselors who understand the unique nuances of surviving a sexual assault. Sasha could find resources through RAINN, the national sexual assault hotline. 

Integration:

Sasha should ask open-ended questions and allow Mo to set the parameters for how deep their integration sessions will discuss the assault. 

It is important to remember that survivors of sexual assault can process their trauma in a number of ways, and denial of previous trauma is a protective action which should not be criticized or blamed. It may have been helpful for Sasha to know about Mo’s trauma, but Mo’s self-protective behaviors have more ethical weight than Sasha’s need to know about the trauma. 

Guides should understand that sexual assault is never the fault of the survivor; that nothing the survivor did (e.g. clothing they may have worn, or alcohol they may have consumed) justifies what the perpetrator did; and that sexual assault is always wrong. If a guide is unclear on any of these points, they should seek out resources and support to understand the complexities of rape trauma.

If there is a window of opportunity during time with Mo, Sasha should underscore to Mo how she understands that sexual assault is always wrong.

Expecially if the guide has no experience in rape crisis counseling, Sasha should be very clear with Mo about the immense benefits of working with a specially trained rape crisis counselor. Sasha should provide resources to local or national rape crisis centers and hotlines, such as RAINN, the national sexual assault hotline. 

While our Commentary touches upon many aspects of the case, the case raises several ethical tensions which could prompt additional inquiry and exploration. For instance, because of the intensity of psychedelics work, guides are at risk for moral distress, moral erosion, and burnout, which should be addressed by debriefing challenging cases with mentors/peer support, self-care, education, and pacing client experiences to allow for self-healing. Additionally, the ethics of preparation and integration are complex and only briefly addressed within this Commentary. As our casebook grows, we may be able to explore those concepts in greater detail.

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

At Gather Well, we recognize that some clients may not feel ready to disclose their trauma history to their guides. We also understand the importance of undertaking guided sessions only when clients are ready to work with their traumas. 

Client readiness should be determined by both client and guide; both must feel the client is ready before a psychedelics session is scheduled. The client should feel ready to work with their trauma, and the guide should also assess that psychedelic work would not destabilize, but would be likely to bring about healing and closure.

Our philosophy is to remember we are a part of a broader community of healers; sometimes clients need months or years in other healing modalities before a psychedelic experience is appropriate. We support survivors of all trauma wherever they are on their healing journey 

We also consider the notion of a “bad trip” to be intrinsically tied to the preparatory sessions, set (mindset of the client), and setting (the surrounding environment, people, room).

During preparatory sessions, the guide must take proper measures to screen, prepare, and inform the client. This includes a careful screening and informed consent process, including the identification of medical, psychiatric and psychological contraindications. This also includes extensive discussion about the range of possible experiences and collaboration on a plan in the event of an especially disorienting or scary experience.  Guides should also inform clients that if they withhold aspects of their trauma history, the guides are less able to prepare the client and themselves for the session. These discussions should be handled with great sensitivity, emphasizing the importance of building rapport with clients – and informing clients of the risks of failing to disclose. Guides should assure clients that sometimes there isn’t the “perfect fit” between a client and guide – which is no one’s fault! – and if the client is feeling any hesitation in sharing their history, it’s perhaps an indicator of needing another guide – or needing to work through the issue with another experienced mental health professional as a precursor to a session.

With respect to setting, organizations are ethically obligated to provide a safe environment, including ample experienced guides within group settings to attend to all clients, and pre-planned safety measures in case tensions arise.

If the environment is physically or situationally unsafe, or if other people in the room do not have everyone’s well-being as a priority, a client can experience heightened distress which can predispose a client to a “bad trip.” 

With respect to set, we understand how work within non-ordinary states of consciousness can feel disturbing and uncomfortable. Indeed, a feeling of extreme discomfort is sometimes the nature of this kind of healing work. The disorganization of old patterns we wish to shed and the forming of new “healthier” patterns can be experienced by some clients on a range from deeply disorienting to life- affirming; a session’s conditions are not entirely predictable. 

Within the setting of psychedelic healing approaches that have a foundation in ethical care, we believe the goal is not to always pull away from or avoid experiences that may be considered hard, disorienting, or scary – but to find a way to navigate through the experience with open-mindedness, care, and empathy since these kinds of experiences are sometimes catalysts for the change the client desires. During a “bad trip,” a client might only be willing to try to “get through” the experience with distraction and avoidance. But another client may desire to face their fears. Gather Well teaches students how to proceed gently, never “push” the client toward a certain outcome, always with the client’s best interests in mind, and teaches how to distinguish between various levels of client presentation.

We encourage guides to work within their scope of practice and to assess their capacity to stay present to the client’s history and presentation. Though it’s difficult to know how a client might express themselves in a session, there are often elements such as historical events or present client traits revealed during an intake and preparation phase that can indicate the likelihood or possibility of presentations in a psychedelic session. 

In our programs we educate prospective guides to create positive conditions for a clients experience and also help guides to cultivate the capacity and practical skills to assess the potential for, and to navigate, a session in which a client is having a difficult experience. This kind of experience can present in many ways and we intend for our graduating guides to feel confident and well supported in their ability. In our Psychedelic Guide Apprenticeship Program, apprentices will observe live group sessions, participate in staff roles, and debrief with seasoned guides to integrate the theoretical knowledge they gain in the program with real life session presentation. 

While it’s impossible to predict every “bad trip,” guides trained by Gather Well learn to synthesize information collected during the intake and preparation phases and extrapolate to assess an expected range of client presentations. Guides can therefore make determinations of whether they are personally and professionally equipped to support their client during a session.  

Additionally we encourage guides to maintain self-care practices and have a personal and professional support network. Guides should develop long-term mentoring and supervising relationships with senior guides to help them through their continual learning experience. We all have our own challenges in life, and will be triggered by various client presentations.  Staying engaged in a continual inner process of self awareness and development, paired with formal ethics education, will help us all on our learning journeys.

Please remember that caring for yourself is essential to providing meaningful and empathic guided experiences, and that attending to yourself is a sign of a mature guide who understands these complexities.

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

TBD