Managing Risk in Psychedelic Assisted Therapy: Lessons from Adventure Sports

I spent twenty years working as an adventure sports guide.  In my early twenties, I was a whitewater guide on rivers like the Zambezi and White Nile in Africa. In my thirties I worked as a mountain leader, guiding trekking expeditions to Kilimanjaro,  Everest base camp, the Andes and the Himalayas. While it may seem that those working in such fields may be risk-takers, and it may have been true about me in my early twenties, the reality is adventure sports guides are constantly assessing risk, and are in some ways hyper-attuned to risk.

For the past six years, as a psychotherapist and co-founder of Inwardbound psilocybin retreats in the Netherlands, almost a thousand people have come through our retreat processes. This article explores my perspective on risk from these differing viewpoints. While it may seem that these are very different worlds, I believe there are a lot of similarities between managing risk in adventure sports and in psychedelic assisted therapy.

My own personal story is one of outward bound to inward bound- at the age of about thirty due to a series life crises (heartbreak, injuries and tragedies I witnessed in the outdoors) I began to look at more inward self-reflective practises such as meditation, yoga and therapy, which slowly and over time, led me to the work I am doing now, not in a planned way, but through the path of my own lived experience.

As my time working as an outdoor guide was coming to an end, I began to be much more interested in adventure therapy than adventure sports. ‘Being in nature’ rather than ‘doing in nature’. This period coincided with my training as a psychotherapist and moving towards psychedelic assisted therapy.

Since I was a child, there is something in me that was drawn to exploring the boundaries of my known world, and to going first, more by accident than design, whether that was the first descent of a whitewater river in Iran, or setting up Ireland’s first psychedelic therapy organization. Why that is, I am not sure, but it is in my nature, and I enjoy helping others explore their own personal limitations too and to grow beyond the boundaries of their known world. I do this work with psychedelics motivated by a belief, from my own lived experience and from what I have witnessed, that this work has the potential to relieve human suffering and improve people’s lives.

On the Nature of Risk

Life is inherently risky. We make decisions every day to take risks, and few would like to live in a zero risk world. Often, the most significant and rewarding achievements in our lives involve a degree of risk – whether falling in love or starting a business. But today we live in a very risk averse society. In other societies and cultures, through necessity, a higher degree of risk can be seen as acceptable.

It is also true to say that as adventure sports guides or as psychedelic assisted therapists, we have an ethical duty of care to our clients. And so we also must protect ourselves and our clients, especially people who are vulnerable, from taking on too much risk.

1. Psychedelic-assisted therapy is inherently risky.

There are certain risks with psychedelic assisted therapy that do not come, or are greatly lessened, in other forms of therapy. These risks include the risk of psychosis or spiritual emergency (kundalini awakening), Hallucination-Persistent Perception Disorder, headaches, nausea, anxiety, dissociation, having a disappointing or underwhelming trip, the increase levels of transference and projection, ontological shock, the altering of metaphysical beliefs or spiritual beliefs, and the risk of being traumatized by a very challenging psychedelic experience. The more serious risks listed here are rare, but they do exist.

Psychedelic-assisted therapy also has the potential to be, perhaps, more rewarding and beneficial than other forms of therapy. Therefore, we need to create a model of access that minimizes risks and maximizes benefits. We also need to take a critical attitude to what Timmy Davis of Psilocybin Access Rights calls “a hypertrophied risk aversion”.

We witness this frequently on our retreats, where sometimes people have emotional breakthroughs and  process traumas that have been unprocessed for years or decades,  processing the ‘frozen present ’of trauma as Dr Ivor Browne called it. We often see incredible transformations on our retreats. Physical transformations- literally people looking different afterwards, like a heavy weight had been lifted off them. The stories of transformation and rebirth and redemption. The deep, real, authentic gratitude. Giving voice to those whose voice had been lost or forgotten. An inner change from ” a sense of hopelessness to a sense of hope”, as one of our clients put it on a recent integration call.

The question, then, is how best to balance the risk/ reward ratio?  If psychedelic assisted has potentially life-changing therapeutic benefits,  what level of risk is ethically tolerable?

2. We need, as a field, to accept the reality of these risks, not deny them or hide them, and to learn how best to mitigate them.

There is sometimes a tendency in the ‘psychedelic renaissance’  for proponents of psychedelic assisted therapy to be messianical. It would be more prudent for us to acknowledge and accept the reality of these risks and take steps to mitigate them. We need, as a field, to be more open about talking about adverse experiences. Our job as those working in the field is to define, acknowledge, communicate and mitigate risks as best we can.

3. The difference between risk and consequences

Researchers such as Professor David Nutt have demonstrated that psilocybin, for example, has a very low harm score compared to other drugs. While the risks involved in working therapeutically with psychedelics may be low, the consequences may, on rare occasions, be high. It is important to distinguish between the likelihood or probability of a risk occurring, and the consequence or severity of that risk, which may be minor or major.

In adventure sports environments, risk assessments fall within several broad categories, known as the risk likelihood/ severity matrix. This framework may be helpful for the field of psychedelic assisted therapy when thinking about risk. It is also important to consider potential benefits when talking about risk, and to consider the difference between perceived risk, and actual risk. There is also a clear distinction in risk assessment when making personal decisions, and when leading a group in the outdoors.

Risk Likelihood/Severity Matrix

a) The first category is low risk likelihood and low consequences. We could say micro-dosing falls into this category. Teaching novices in an adventure sports environment should fall into this category. In terms of the difference between perceived risk and actual risk, sometimes beginners learning a sport may perceive a high level of risk in a situation where the actual risk is extremely low, learning to climb on an indoor climbing wall, for example. Likewise in psychedelic assisted therapy, sometimes participants can present with increased levels of perceived risk, fear of the unknown. Managing people’s fears, anxieties and expectations is a vital part of guiding in the outdoors, as it is in psychedelic assisted therapy.

b) The second category is low risk and medium or high consequence. I would put most psychedelic assisted therapy, when done in a carefully controlled set and setting, in this category. Guiding a group on Kilimanjaro would fit into this category. Statistically, Kilimanjaro is a very safe mountain for an almost 6000m peak, but, on rare occasions, the consequences can be high (heart attack or high altitude pulmonary or cerebral edema, which can be fatal).

c) The third category is high risk likelihood and low consequence. For example, climbing a challenging bouldering problem where the likelihood of falling is very high, but the consequences, falling a few meters on a protective bouldering mat, very low, at most causing a sprained ankle.

c) And the fourth category is high risk likelihood, high consequence. This last category is usually reserved for people at the peak of their ability taking personal responsibility for their decisions who want to challenge their limits. This last category is unsuitable when guiding a group in an adventure sports environment, unless guiding at a very high end, such as guiding an expedition to K2, and would be unsuitable for psychedelic assisted therapy.

4. On the importance of screening

Careful screening can lessen the likelihood of certain risks occurring. Screening and preparation was also very important in adventure sports, especially when guiding treks to remote high altitude locations, making sure people had the required level of fitness and no major health contraindications. On our psilocybin retreats we have recently been turning away approximately 60% of applicants. While this is necessary and makes sense from a risk management perspective, it is challenging from a business perspective, and also leaves a significant group of people in need of help without a therapeutic pathway. But we do this to reduce the possibility for ourselves, and our clients, from taking on things that we or they cannot handle.

We work with what we call the ‘walking wounded’, the average human being with their hopes and fears and traumas, not with people in deep psychological distress or who are very unwell. Such individuals may be better off served in a medical model with more specialized care. It is also important for us to be aware of our limitations.

However, careful screening is not foolproof, as sometimes clients do not disclose, or perhaps are unaware of,  or are in denial about, relevant psychological or medical issues. People sometimes can lie, even to themselves, especially if they are in deep need of help.

Sometimes participants present on a retreat in a very different psychological mindset they presented with during screening and preparation.  We have found other factors than the usual contraindications to be relevant, such as presenting with an overwhelmed nervous system or in the midst of a major life crisis.

One of the challenges of working with psychedelics is dealing with the unknowns of the unconscious. By definition, we do not know the contents of our unconscious mind. Despite careful preparation, sometimes people have experiences that they did not expect or were unprepared for.

It may be that certain substances such as 5 meo DMT or iboga have higher risk profiles than, say, psilocybin. It may also be that certain substances have greater potential benefits for high risk cohorts of people,  such as iboga/ibogaine for severe addiction, and ketamine for suicidality,  which means the risk-benefit equation is different for those substances.

I believe that the risk of being traumatized by a challenging psychedelic experience can be mitigated by skillful and dedicated integration. I have found that helping people find meaning in their suffering can change what was previously seen as a very negative experience into a positive therapeutic one. One senior therapist in the US  told me that he believed almost anything could be held therapeutically, depending on the capacity of the therapeutic team and the strength of the therapeutic container. While this may be true, it does not take into account just how challenging it can be to hold very difficult therapeutic processes for the therapists and participants involved.

5. Informed consent

One part of managing risk is making sure clients are aware of, and give their consent to taking on, the risks involved. One challenge is that it is difficult to fully communicate the changes that may occur as a result of a psychedelic experience to those who have never had a psychedelic experience. Perhaps some form of standardized consent procedure could be worth developing.

6. We also need to acknowledge that sometimes there will be consequences as a result of those risks, and come up with ways of dealing with those consequences.

As a field, we need to accept that despite careful screening and preparation, on occasion things may go wrong. The parallels with adventure sport are prescient. In the outdoors, despite careful management of risks, occasionally things go wrong. Over a 20 year period of working as an outdoor guide, especially in the dynamic environment of whitewater rivers, I saw a lot of things go wrong directly and indirectly. This naturally leads to increased risk aversion over time.

This can perhaps be best illustrated by the following story. I am not a very experienced offshore sailor, but on one occasion, I crewed a catamaran sailing from the Azores to the UK. Halfway across the passage, 1000 km offshore, we hit some heavy weather. I noticed that the skipper,  an incredibly experienced sailor who had circumnavigated the globe several times, including the Cape of Good Hope, was nervous, more nervous than I was as a novice sailor. When I asked him about it he told me that on his first transatlantic crossing, as a relatively novice skipper, he had felt no such fear. I understood why. From his vast experience, he had become more aware of what could go wrong than I was as a relative novice.

Overtime, you become more aware from lived experience of what can go wrong and the possible consequences. Things do not always go as planned. Often accidents in the outdoors occur, not in high risk situations when people are pushing their limits and very focused, but often in situations where the likelihood of a risk occurring was not particularly high. When you witness and have to deal with the consequences of serious accidents in the outdoors, it changes something in you.

7. Consequences I have witnessed in low risk situations

On two occasions I have witnessed people having experiences that could be described as spiritual emergencies which can look very similar to psychosis. Neither case involved a high dose psychedelic experience. One case occurred after a vipassana meditation retreat on Maui. No psychedelics were involved, but other powerful practices, such as kundalini yoga, were. The second case involved a low dose of psilocybin, not at one of our retreats, but at an indigenous style ceremony.

In both cases, although the behavior involved was quite bizarre at times (such as talking to trees and persistent shaking and twitching over several days) these people could be held in a supportive and loving environment in nature for several days which was enough to ground them and bring them back to consensus reality.  Sometimes people need more time to come back from ‘between the worlds’ after powerful psychedelic experiences.

8. My own experience

In my own lived experience, I recall having persistent hallucinations, double vision, dizziness and vertigo for a week after a Bwiti iboga initiation. The experience was one of the most transformative therapeutic experiences of my life, processing layers of shame I never thought possible. Even at the time, I understood the difficulties were a part of the process. Sometimes the most rewarding things in life are not easy. That said, I was very glad when my eyesight and balance returned to normal!

It is also important to recognize that these risks are ones we all face, whether in a clinical trial, a legal retreat setting or an indigenous ceremonial setting. The fact of the matter is that any of us working in this field face these same risks. Some of the most difficult and dangerous adverse reactions I have heard about occurred at ayahuasca retreat centers in Peru.

My point is that extended difficulties after a psychedelic experience could equally easily occur on a clinical trial at Johns Hopkins, Imperial College London, at a legal psychedelic retreat setting,  an underground ceremony, or an indigenous ceremonial setting in the Amazon.  The sooner we collectively acknowledge these risks and potential consequences,  and are able to talk about them openly without shame or fear of judgment, the better. Otherwise, a culture of secrecy, shame, blame and judgment could emerge. What is not in the light, will be in the shadows, as it were. We need to create a culture of self reflection, acknowledging that we can all make mistakes. We need, as a field, to be more open about talking about adverse experiences.

8. On the power of belief and focus

When running a large whitewater rapid, we would spend as much time as necessary looking at the line and the risks involved, all of the consequences and potential worst case scenarios. Then a careful assessment would be made, based on all relevant factors including river water level,  skill level, the team and the safety set up involved, on whether to run the rapid, or not.

But, and this is the important part, once a decision has been made to run a whitewater rapid, that decision was taken in full commitment, focussing fully in confidence on the desired outcome, with no focus on the worst case scenario. In other words, completely focusing on where you want to go, not where you do not want to go. Focusing on what can go wrong when running a whitewater rapid is an almost certain way to ensure a negative outcome.

Perhaps this mindset has some parallels with psychedelic assisted therapy. In the early stages of screening and preparation it is important to address, communicate and acknowledge the risks involved, assessing if it is the right course of action for an individual to embark on.

Once a decision has been made, in consultation with the participant, that the therapeutic process is suitable for the individual involved, then it is important to move forward with as little doubt as possible, creating the right mindset for a positive outcome. At a recent conference in the Netherlands, “Unveiling the mind: Convergence of Hypnotic and Psychedelic realities”, many speakers emphasized the power of suggestion and belief.

For this reason, it is important to prime the participants mindset carefully, creating an atmosphere conducive to a positive therapeutic outcome. This can include preparing them in advance for difficult feelings to arise, and emphasizing the normality and purpose of these feelings. Acknowledging that while the process may be challenging, there is a reason for undertaking it. In my experience, once a meaning can be found in suffering, it can allow even the most challenging psychedelic experience to be seen from a positive therapeutic perspective. I often tell my clients that I don’t do this work because I enjoy watching people suffer, but because a light can be found at the end of the tunnel. Sometimes the most challenging psychedelic experience can be the most therapeutic ones.

It is also important to be mindful that the pressure of making the right decisions can be a heavy responsibility for those working in the field, so creating multidisciplinary spaces for open discussion and supervision is essential.  I am sure I am not the only person in the field who feels this, very deeply at times.This is not something I hear talked about too often, just how challenging this work can be for the therapists involved.

To conclude, as a field we need to acknowledge the risks and consequences of psychedelic assisted therapy, to agree on how best to communicate, address and mitigate them, to consider what levels of risk are ethically acceptable, to address how to manage consequences, and to consider the possibility of standardized screening and informed consent procedures. In this, we can learn lessons from other fields such as adventure sports.

This piece was first published in Jules Evans Estatic Integration substack https://www.ecstaticintegration.org/

Feature Image: An Ethiopian woman crossing a class 6 rapid on the Blue Nile with a new-born baby wrapped in her shawl. A fall here would have meant certain death for both of them.