Facilitating the Sacred: The Role of Chaplains in Psychedelic Law and Policy

The law and policy surrounding psychedelic substances in the United States is in its infancy.  At the time of writing, two states, Oregon and Colorado,¹ have passed laws that create legal access points for regulated psychedelic substances and do not require a doctor’s recommendation or prescription for access.² Several psychedelic substances are also being researched by pharmaceutical companies in the United States within the Food and Drug Administration’s (FDA) drug approval process. Additionally, there is federally permitted religious and spiritual use for certain psychedelic churches, as other authors in this volume discuss. Whether as a possible medicine at the federal level, a quasi-medicine/recreational substance at the state level or as a sacrament used in a spiritual community, psychedelics are administered in what I describe as a “facilitated use model.” In this model, an individual is given a psychedelic substance in a controlled setting under the supervision of a trained facilitator or clinician.³ As of now, there are no other models for access to regulated psychedelics in the United States outside of a “facilitated use model.”  

The requirements for a facilitator within this model vary greatly. In an FDA context, facilitators must be medical doctors. In states such as Oregon, in contrast, regulations require that a facilitator have a high school diploma and complete a licensed training program.⁴  These variable requirements raise concerns about the standard of care and support of patients, especially regarding possible spiritual aspects of a psychedelic experience.⁵ It is common for people taking a psychedelic substance to report experiences they consider spiritual, existential, religious, or theological (SERT).⁶ These SERT experiences give rise to unique challenges for facilitators who are unlikely to be adequately prepared to support the person having them. Consequently, as I argue in this essay, trained spiritual care providers, such as chaplains, are an ethically necessary part of psychedelic facilitation and education in a facilitated-use model. However, as I will address first, the policies surrounding facilitated psychedelic use do not currently recognize or, in some cases, even allow chaplains as legally sanctioned facilitators.

The law and policy of including chaplains in facilitated use models differs depending on whether research and regulation is state or federal. At the federal level, the FDA has released guidance related to psychedelic facilitation. In June 2023, the FDA provided a document highlighting issues for sponsors to consider when conducting research on psychedelics. Related to the length of experiences in psychedelic sessions, the FDA recommended patients be observed for the entirety of their session by two monitors.⁷ The FDA recommends that these monitors be health care practitioners. Included in their recommended roles were psychologists, social workers, and licensed marriage and family therapists. The FDA did not include chaplains in its recommendation. Following this decision, a group of chaplains and other spiritual care providers submitted written comments to the FDA arguing for the inclusion of chaplains as monitors.⁸ The FDA has yet to respond to these comments or update its recommendations. 

At the state level, in Oregon, psychedelic facilitators can be any person who has graduated high school and completed a facilitator-education program.⁹ Importantly, healthcare professionals in Oregon are restricted from offering psilocybin services under the authority of their medical license. The state of Colorado issues different licenses for psychedelic medicine with differing requirements and restrictions. One license type is a clinical license that allows medical professionals to use existing healthcare licenses to become facilitators with the completion of additional education and an application. Colorado’s other license has requirements similar to Oregon’s. Additionally, a bill similar to Oregon’s was recently introduced in California and subsequently withdrawn. It was critiqued for creating a costly new category of licensed professionals to facilitate psychedelic treatment rather than allowing access to psychedelic medicine through existing providers.¹⁰  

Thus far, regulators generally require that facilitated use models for psychedelics create a new classification for licensing facilitators rather than allowing individuals to utilize existing licenses. Regardless of the specific licensing structure, it is important to ensure that existing and future models of psychedelic facilitation include professional chaplains. Equally important is ensuring that spiritual care is part of training program curriculums for psychedelic facilitators. 

Individuals under the influence of psychedelics are highly suggestible¹¹ and particularly sensitive to their internal mindset and external environment, which is why the concept of “set and setting” is central to psychedelic use.¹² Ensuring that mindset (“set”) of the individual and the surrounding environment (“setting”) are conducive to a positive experience is a key principle for minimizing risks and enhancing the therapeutic or transformative potential of psychedelics. In the facilitated-use model, the facilitator plays a significant role in shaping the environment and influencing the user’s experience. Researchers, such as Matthew Johnson, have raised concerns that facilitators may unintentionally (or intentionally) impose their own beliefs or viewpoints on psychedelic users, especially when users have not explicitly consented to such influence. ¹³ This is particularly problematic when facilitators project spiritual or religious ideas onto users in a non-religious context. This ethical issue is one chaplains are well suited to address, as clinical chaplains undergo specific training to avoid inappropriately imposing their own viewpoints when interacting with patients and clients. 

Researchers from the Center for Psychedelic Spirituality at Emory University argue chaplains are well suited to support the SERT aspects of psychedelic experiences.¹⁴ In a research study of spiritual health practitioners (SHPs) with experience facilitating psychedelic therapy, Peacock et al. identified five unique contributions of SHPs in psychedelic therapy settings: (1) competency to work with spiritual material, (2) awareness of power dynamics, (3) familiarity with non-ordinary states of consciousness, (4) holding space or creating and sustaining an environment for sacred experiences, and (5) providing a counterbalance to the biomedical perspective. They also identified two general contributions of SHPs in these settings: (6) the use of a generalizable therapeutic repertoire and (7) the contribution to interdisciplinary collaboration by providing patients with useful tools such as meditation.¹⁵ Additionally, chaplains are trained to prevent religious countertransference and restrict, especially through awareness of language, the imposition of their own religious view on their patients.¹⁶ These qualities identified by Peacock et al. further support the case that chaplains are well suited to support psychedelic experiences, which the law would do well to recognize. 

Thinking more granularly about the role of the chaplain as a psychedelic facilitator, it is helpful to consider where and how their training could support patients. There are three stages of psychedelic use in the facilitated-use model: preparation, administration, and integration.¹⁷ The exact requirements around psychedelic use in legal models depend significantly on who is regulating the sessions, but the three-stage framework is consistent across all settings. Preparation in facilitated psychedelic use may include medical screening, collecting a user’s background information, developing a relationship with the facilitator, and discussing the intentions and goals of the psychedelic experience. During the administration stage of the psychedelic substance, which includes the experience itself, a facilitator may employ a variety of techniques. For example, a facilitator may act like a ‘trip-sitter,’ remaining in another room, ready in case a user needs support. Alternatively, some facilitators employ a variety of therapeutic approaches such as therapeutic touch, music, and other verbal guidance. Integration is a stage following the psychedelic session, where a facilitator and user can discuss anything that came up during the psychedelic experience. Integration aims to help illuminate any insight gained during the psychedelic experience so that it can be brought into the user’s life after the psychedelic experience.  

Chaplains have a role to play in all three aspects of the facilitated use model. In the preparation stage, a chaplain can administer a spiritual assessment to assess the patient’s spiritual history, needs, and goals. Since psychedelics may occasion SERT experiences, it is helpful for a care team and facilitator to be familiar with the religious history of the psychedelic user to be better equipped when providing care. Chaplains also have an important role in the informed consent process, which is often required in both medical and non-medical contexts. People being given treatment have the right to be warned of its possible risks. However, obtaining informed consent from a patient prior to using psychedelic medicine can be difficult, particularly because the “subjective psychedelic effects are difficult to describe, comprehend, or predict.”¹⁸ One such subjective effect is experiences described as mystical or divine. The chaplain here can impress upon the patient the possible spiritual or religious effects of a psychedelic experience from a religiously informed perspective.  

During the administration stage, chaplains’ training in “hold space” and providing a therapeutic and calming presence makes them valuable support for patients during the acute effects of psychedelic medicine.¹⁹ Likewise, chaplains are trained to support individuals having existentially challenging experiences due to severe or terminal illness or grief. This training can easily transfer to patients experiencing similarly existentially challenges with psychedelics. Finally, chaplains are well suited to be part of an ongoing integration practice, particularly for those who have intense SERT experiences. Chaplains may be able to point patients to specific spiritual, religious, or communal resources to help them on their healing journey. 

Beyond direct patient care, chaplains’ unique experience and knowledge make them well-suited to be educators and consultants in facilitator training programs. For example, chaplains might create religious literacy resources and develop standards of care for responding to those patients who undergo intense SERT experiences and seek guidance and support. 

Many questions need to be assessed for facilitated-use models in psychedelic medicine. Some important questions that will dictate the role of chaplain facilitators in the future include the following. What informed consent process should a facilitator deploy, especially if they are not a licensed health care professional? What does malpractice look like for facilitators who are not licensed healthcare professionals? Will licensure as a facilitator in one state allow for licensure as a facilitator in other states automatically, or will changing states require different educations?  

These questions and many like them will impact whether spiritual care can be provided to psychedelic patients. As a first step in answering these questions, chaplains and other spiritually trained care providers should be included in the planning and regulatory process around psychedelics. This small step can help ensure that policymakers do not overlook the vital spiritually tuned care that chaplains can provide.