The Ethics of Touch in Psychedelic Therapy

One of the main ethical issues in psychedelic therapy is the use of touch. Therapeutic touch can feel incredibly helpful during a psychedelic journey. It can help to ground a person and let them know that someone is there who cares about their well-being. But when does therapeutic touch cross a professional boundary and become an ethical violation rather than a form of help?

“Touch must always be used with a high level of attention and care, with proper preparation and communication, and with great respect for the participant’s needs and vulnerabilities.”

— Michael C., Mithoefer, M.D. (MAPS Manual for MDMA-Assisted Psychotherapy in the Treatment of Posttraumatic Stress Disorder)

This question can be a difficult one to answer. Sometimes, the answer depends on individual circumstances: what one client has expressly consented to. However, there are more apparent cases in which the use of touch in psychedelic therapy is a sexual transgression. Guidelines around non-sexual, therapeutic touch are one part of the puzzle that aims to prevent abuses of power in this form of psychotherapy.

What is Therapeutic Touch?

In the context of psychedelic therapy, therapeutic or nurturing touch refers to non-sexual touch that acts as a form of support and care. Since psychedelic journeys can bring up anxiety and past trauma, touch can have a reparative effect. It can help dissipate or reduce negative or overwhelming emotions. In addition, the MAPS Manual for MDMA-assisted psychotherapy for PTSD states that the “mindful use of touch can be an important catalyst to healing during both the MDMA-assisted sessions and the follow-up therapy.”

However, touch is not ordinarily present in non-psychedelic psychotherapy. Moreover, many people who seek MDMA- or psychedelic-assisted therapy have experienced childhood or adult sexual abuse. This background may make someone acutely uncomfortable with physical touch, particularly from someone they don’t know well. This discomfort is why a therapist and client need to establish trust; otherwise, touch may feel invasive and carry negative connotations. And, of course, if touch in psychedelic therapy becomes sexual or is unwanted, this can worsen someone’s mental health, especially if they have PTSD related to sexual abuse. This situation could re-traumatize patients.

The MAPS manual adds:

“Touch must always be used with a high level of attention and care, with proper preparation and communication, and with great respect for the participant’s needs and vulnerabilities. Any touch that has sexual connotations or is driven by the therapist’s needs, rather than the participant’s, has no place in therapy and can be counter-therapeutic or even abusive.”

These complications may make psychedelic therapists hesitant about using any kind of touch. However, depriving clients of touch when they need it most could replicate past experiences of neglect or abandonment. The MAPS manual underscores that “withholding nurturing touch when indicated can be counter-therapeutic.” Caring touch for patients who have experienced childhood neglect can act as a corrective experience.

What Does Nurturing Touch Look Like (and Not Look Like)?

Typical forms of nurturing touch in psychedelic therapy include placing a hand on the shoulder of the client or holding their hand. Hugging can be viewed in MDMA- and psychedelic-assisted therapy as another form of nurturing touch. This kind of embrace can feel deeply supportive and compassionate for many clients. Yet clinicians have also discussed the merits of cuddling clients as a way to mend the wounds of childhood neglect. Cuddling is not the same as hugging. It is much more intimate. It often carries romantic and sexual connotations. For many clients, this would not feel nurturing or therapeutic.

If a client feels that the touch is sexual and is uncomfortable with it, then this clearly won’t be experienced as nurturing. Psychedelic therapists should never deny the client’s experience during a session, which underground practitioners have done. Sexual touch would include touching another person’s intimate parts: genitals, anus, buttocks, groin, or breast. This touch can be skin-to-skin or through a person’s clothing. However, touching other parts in certain ways, such as stroking the client’s thighs or rubbing their back, may feel sexual and too invasive. Kissing would also be a clear violation of professional boundaries.

Two MAPS therapists—Richard Yensen and Donna Dryer—engaged in unacceptable intimate contact during a study on MDMA therapy for PTSD. Video footage shows the two cuddling, spooning, and pinning down trial participant Meaghan Buisson. Buisson entered treatment with trauma as a result of being sexually abused and assaulted.

Gaining Consent for the Use of Touch

The Issue with Gaining Consent During a Session

A group of psychedelic researchers criticized a Journal of Medical Ethics blog post, partly due to the views on consent expressed. McLane et al. argue that patients can be more authentic in altered states in that blog post. Based on this, they believe this enhances their capacity for consent. However, they make a contradictory claim, too: psychedelic therapy clients have an increased need for touch alongside an impaired capacity for consent. Crucially, neither claim has been sufficiently explored in the scientific literature [1]. Criticizing the blog post, Devenot et al. state that “the notion of “enhanced capacity” in altered states is neither supported by evidence nor by legal definitions of consent.” They add:

“Conditions for autonomous decision-making rely on the ability to comprehend and weigh information. Some research has shown that psychedelics impair cognition, executive function [2], and memory [3] in ways that could undermine informed decision-making. Further, the client-therapist(s) relationship in P-AT presents greater vulnerabilities than the typical power imbalance in psychotherapy due to psychedelic-induced suggestibility [4] — increasing susceptibility to manipulation — and memory impairment [5].”

Why Consent Should Happen Before the Session

The above factors highlight why touch needs discussing before the psychedelic session is necessary. Therapists and clients need to establish precisely the kinds of touch that the client feels comfortable with. If, in an altered state, a client requests a form of touch not previously consented to in a sober state, it is prudent for the therapist not to provide this touch. However, they should deliver this refusal tactfully and compassionately to ensure that the client does not feel rejected. The risk of providing touch without sober consent is that the client could, in hindsight, feel they weren’t clear-headed enough to make that decision. There is always a chance for a client to consent to a form of touch in a future session, which they didn’t receive in the first session.

It appears that MDMA particularly heightens the possibility of requests for non-agreed forms of touch during the session. This tendency is because MDMA increases prosociality, feelings of trust, affection, intimacy, and love [6]. Therapists should inform clients of these potential effects. These effects also demand stronger boundaries and maintenance of those boundaries.

Minimizing Risks Related to Touch

Risks and Precaution

In their blog post, McLane et al. claim that the risks of refusing touch are equal to those associated with unwanted or inappropriate touch. Devenot et al. take issue with this claim, saying there is no evidence to support it. They point out that therapists can minimize the risks of refusing touch by developing skillful responses [7]. Serious harm has resulted from sexual and inappropriate non-sexual touch in psychedelic sessions. Devenot et al. believe this gives us less reason to equate this harm with refusals of touch. They write:

“Because touch may exacerbate pre-existing traumas at a time when client vulnerability is increased, a precautionary principle approach seems more appropriate. The precautionary principle [8] advocates that in the absence of evidence (for the benefit of touch or harm of denied touch) alongside knowledge of potential threats (unwanted sexual/non-sexual touch and sequelae), a risk-averse approach should be taken.”

An Evidence-Based Approach

Devenot et al. are not arguing that all touch carries a risk of becoming sexual. But, they do believe having a more precautionary approach to touch is the most effective way to minimize harm. They add:

“To ensure clear and safe boundaries, therapists should prioritize non-touch methods of comfort. We are concerned that the uncritical promotion of touch as an integral part of the P-AT healing process may lead to an overreliance on touch to the detriment of therapeutic interventions that help build clients’ self-soothing capacities. While brief non-sexual touch may be helpful in alleviating severe distress or providing nurturance, it may also carry unidentified risks and should be researched, theorized, and debated before widespread dissemination as a valid therapeutic tool.”

The use of touch in psychedelic therapy, moreover, has to be evidence-based. There can be a tendency for psychedelic therapists to follow ‘best practices,’ which have become widely accepted but not yet empirically investigated. Anecdotal evidence is not the same as scientific evidence.

Many would argue that the legalization of psychedelic therapy is occurring without adequate attention paid to the ethics of touch. States and countries considering making medical psychedelics legally available need to take a more evidence-based and harm-minimization approach when it comes to this practice.

References

1. Smith, W. R., & Sisti, D. (2020). Ethics and Ego Dissolution: The Case of Psilocybin. Journal of Medical Ethics, 47(12), 807–814. https://doi.org/10.1136/medethics-2020-106070
   
2. Barrett, F. S., Carbonaro, T. M., Hurwitz, E., Johnson, M. W., & Griffiths, R. R. (2018). Double-Blind Comparison of the Two Hallucinogens Psilocybin and Dextromethorphan: Effects on Cognition. Psychopharmacology/Psychopharmacologia, 235(10), 2915–2927. https://doi.org/10.1007/s00213-018-4981-x
   
3. Healy, C. J. (2021). The Acute Effects of Classic Psychedelics on Memory in Humans. Psychopharmacology/Psychopharmacologia, 238(3), 639–653. https://doi.org/10.1007/s00213-020-05756-w
   
4. Carhart-Harris, R. L., Kaelen, M., Whalley, M. G., Bolstridge, M., Feilding, A., & Nutt, D. J. (2014). LSD Enhances Suggestibility in Healthy Volunteers. Psychopharmacology/Psychopharmacologia, 232(4), 785–794. https://doi.org/10.1007/s00213-014-3714-z
   
5. Regan, A., Margolis, S., De Wit, H., & Lyubomirsky, S. (2021). Does ±3,4-Methylenedioxymethamphetamine (Ecstasy) Induce Subjective Feelings of Social Connection in Humans? A Multilevel Meta-Analysis. PloS One, 16(10), e0258849. https://doi.org/10.1371/journal.pone.0258849
   
6. Dalenberg, C. J. (2000). Therapy as a Unique Human Interaction: Management of Boundaries and Sexual Countertransference. In American Psychological Association eBooks (pp. 199–239). https://doi.org/10.1037/10380-008
   
7. Resnik, D. B. (2004). The Precautionary Principle and Medical Decision Making. The Journal of Medicine and Philosophy, 29(3), 281–299. https://doi.org/10.1080/03605310490500509