Spiritual health practitioners’ contributions to psychedelic assisted therapy: A qualitative analysis

Psychedelic-assisted therapy (PAT) is an emerging treatment approach showing early promise for conditions such as treatment-resistant depression, post-traumatic stress disorder and substance use disorders. PAT pairs administration of a psychedelic compound (for example psilocybin or MDMA) with psychotherapeutic support, and dosing often produces spiritually and existentially meaningful experiences. Despite the frequency of spiritual material in PAT and a history of spiritual practitioners participating in ceremonial and clinical contexts, there is little consensus about who should facilitate PAT or what competencies spiritual health practitioners (SHPs) bring to such teams. The absence of clearly specified roles for SHPs complicates development of practice guidelines and may leave important aspects of care unaddressed. Peacock and colleagues set out to characterise how SHPs who have facilitated PAT conceptualise their roles, the competencies they apply, and the activities they perform across preparation, dosing and integration phases. The study used interviews with SHPs practising in legal contexts to identify thematic domains of contribution that could inform team composition, training, and future guidelines for PAT delivery and research.

This was a qualitative interview study of spiritual health practitioners with experience facilitating PAT in legal settings. Recruitment occurred from 20 March to 15 June 2022 via outreach to a professional network (the Transforming Chaplaincy Psychedelic Care Network) and snowball sampling. The institutional review board at Emory University approved the study and participants provided written informed consent. Sixteen SHPs consented but one was excluded for not meeting inclusion criteria, leaving 15 participants. Inclusion required SHPs to have facilitated PAT and to meet at least one of the following: (1) at least one unit of Clinical Pastoral Education (CPE: 300 clinical and 100 educational hours), (2) ordination or status as a religious leader, (3) a Master of Divinity or another post-baccalaureate theological degree, or (4) specialised training in spirituality in psychedelic work beyond PAT certification programs. Participants practised in North and South America and had experience in clinical trials, retreat/ceremonial settings and other clinical environments. Data collection used a 14-item semi-structured interview guide administered primarily by Zoom (one interview by email due to connectivity issues). Interviews were auto-transcribed and then manually de-identified and corrected by two researchers. Analysis employed thematic analysis in MAXQDA v22.2.00 using both deductive (study-driven) and inductive (data-driven) coding. One investigator developed an initial codebook; a second coder independently applied it, after which code definitions were revised and the dataset was re-coded. The team judged that thematic saturation was reached after analysing the 15 interviews. One principal theme, "Contributions and Perspectives of SHPs with respect to PAT," was further sub-analysed to derive seven subthemes reflecting unique and general contributions. The coding process and emergent subthemes were reviewed with the multidisciplinary author team to establish concurrence and refine the thematic structure (initially six themes were revised to seven).

Fifteen SHPs were included in the analysis; fourteen practised in North America and one in South America. Reported practice settings overlapped and included clinical trials (n = 7), retreat/ceremonial contexts (n = 6), private practice (n = 1), virtual PAT (n = 1) and clinic-based practice (n = 1). One participant held dual licensure as a mental health professional. Thematic analysis yielded seven subthemes grouped into two domains: unique contributions (themes 1–5) and general contributions (themes 6–7). These themes were described across the preparation, dosing and integration stages of PAT. Unique contributions 1) Competency to work with spiritual material (identified in 11 interviews). SHPs described specialised training and formation for responding to spiritual and religious content that commonly arises in PAT, including supporting participants with positive spiritual experiences and those with difficult or traumatic religious histories. Several SHPs emphasised a pluralistic, non‑sectarian stance and attention to participants' own language and meanings. 2) Awareness of power dynamics (also present in 11 interviews). SHPs highlighted sensitivity to interpersonal and systemic power, including care with language, respect for participant autonomy, explicit discussion of physical touch and boundaries during preparation, and attention to cultural humility and concerns about cultural appropriation of Indigenous practices. 3) Familiarity with non‑ordinary states of consciousness (NOSC) (reported by eight SHPs). Participants linked their prior experience with contemplative practices, end‑of‑life care and other contexts involving altered or peak states to comfort and competence in witnessing and normalising NOSC during PAT, while also resisting premature interpretive closure. 4) Holding space (nine SHPs). SHPs characterised "holding space" as creating a ritualised, present, and stabilized interpersonal environment that allows participants to engage with intimate or mysterious material without pressure to "fix" it. Holding space was described as distinct from active intervention during dosing and as conducive to safety, consent and later integration. 5) Counterbalance to biomedical perspectives (eight SHPs). SHPs reported that they complement biomedical teams by making room for spiritual registers of participants' experiences, recognising meanings that fall outside conventional scientific terminology, and acknowledging indigenous practice histories while cautioning against appropriation. General contributions 6) Use of generalisable therapeutic repertoire (eleven SHPs). SHPs described employing common clinical skills such as assessment (screening for stability, substance use, safety), psychoeducation about the PAT process, teaching grounding and coping skills, providing a calming presence during dosing, and assisting in narrative and ritualised integration that involves family, community and worldview. 7) Interdisciplinary collaboration (eleven SHPs). Many SHPs reported routine collaboration with physicians, psychiatrists, nurses and therapists, describing documentation practices, safety communication, and team assessments. Examples included multidisciplinary grief retreats and comparison to palliative care models where spiritual care is integrated into comprehensive assessments. Across themes, SHPs offered concrete examples: handling a participant whose music triggered trauma linked to a religious setting while later encountering a benevolent divine figure; preparing participants for boundaries around touch; and contributing to study design or team deliberations about equity, recruitment and relations with Indigenous rights‑holders. The analysis emphasised that themes could overlap for a single SHP and that SHPs often blended specialised spiritual competencies with shared clinical skills.

Peacock and colleagues interpret the findings to mean that SHPs possess both specialised and generalisable competencies that are relevant to safe and responsive PAT. They argue that SHP training—formation in ritual, contemplative practices, CPE and attention to power, cultural humility and ethics—maps onto the themes identified and equips SHPs to address spiritual content, NOSC, and interpersonal and systemic power dynamics in PAT. SHPs' familiarity with powerful affective states (for example in end‑of‑life care) was presented as complementary to handling NOSC and "ego‑death" phenomena in psychedelic sessions. The authors position SHPs as natural collaborators within interdisciplinary PAT teams and recommend a model in which a licensed mental health clinician and a SHP form a dyad that leverages overlapping skills while drawing on distinct expertise: mental health clinicians managing assessment, therapeutic technique and safety; SHPs offering spiritual assessment, holding space, attention to power dynamics and ritual/integration support. They also propose that SHPs can inform study design, interpretation and community engagement, including liaison roles with Indigenous practitioners and raising questions about cultural appropriation and equitable recruitment. Limitations acknowledged by the investigators include the qualitative, retrospective design which precludes causal inference and effectiveness claims; potential sampling bias owing to recruitment via a network co‑convened by the principal investigator; restricted generalisability because participants practised only in legal settings and were predominantly white and Western‑hemisphere based; absence of perspectives from community/"underground" practitioners; lack of member checking; and that economic and scalability questions (costs of including SHPs on teams) were not examined. The authors recommend further research with more diverse and broader samples (including underground and traditional practitioners), exploration of cost and scalability, and continued refinement of role definitions for SHPs in PAT.

The authors conclude that spiritual health practitioners bring distinct and valuable skills to psychedelic‑assisted therapy that complement biomedical and psychological care. As PAT moves toward broader clinical implementation, inclusion of SHPs on interdisciplinary teams can help address spiritual, existential and cultural dimensions of participants' experiences. Peacock and colleagues recommend that training and certifying bodies consider SHPs among clinicians eligible for PAT training and that standards of care ensure spiritual, religious and theological concerns are not neglected in treatment delivery.