Part 1: The Power of Holding Space
Why Holding Space Matters in Psychedelic Therapy
Pope Francis famously said:
“Truth may be vital, but without love, it’s unbearable.”
This is a useful lens through which to explore the discipline of holding space: the act of creating an opening for someone to be present with their experience while providing support as a compassionate witness to their process. Given that psychedelics ‘manifest our minds to ourselves,’ we might view them as radical self-truth agents. But who among us is ready to fully confront their own mind?
Only someone thoroughly screened, carefully prepared, and most importantly, helped to feel safe.
Indeed, all the historical records, phenomenological reports, recreational accounts and scientific studies with psychedelics show that their effects are almost entirely context-dependent. This has been known by shamans for thousands of years.
Set & Setting - The Context that Shapes the Journey
The terms “set and setting” were popularized by Timothy Leary in the 1960’s to capture this. He defined “Set” as the pre-existing psychological factors one brings to a psychedelic experience including personality, preparation, expectations, assumptions, and intentions.
He defined “Setting” as the environmental context, including physical, social (for example one's guides (shamans, therapists) and the group individuals who will be in your vicinity during a journey), and cultural elements, including public opinion, media representation, legal and regulatory stances within which the psychedelic experience occurs.
Part 2: Building a Safe and Supportive Environment
Crafting the Ideal Setting - From Music to Meaningful Objects
So powerful is setting in determining outcome, that in one study, LSD-induced changes in brain dynamics associated with changes in personality traits were observed only under conditions where participants were listening to music (Lebedev et al., 2016).
Mendel Kaelin, professor of neuroscience at Johns Hopkins calls music ‘the hidden therapist.’ It plays an integral role in the setting for a journey:
It holds and contains the experience by providing an ‘anchor;’
Lowers the probability of difficult experiences, and
Makes difficult experiences more tolerable.
Music has also been found to catalyze healing by softening defense mechanisms, eliciting underlying emotions like sadness and grief, and facilitating the recollection of early memories.
On the other hand, when contextual factors are neglected, psychedelic experiences have been found to be clinically ineffective (Carhart-Harris et al., 2018). Indeed, if this weren’t true, everyone who takes LSD at a trance party would return home healed and recovered, with their trauma processed and integrated. Of course, this never happens! Unsurprisingly, when setting is manipulated in a negative way, as in the military experiments in the 1950s, psychedelics are injurious to our well-being.
The ideal setting is therefore safe, private and non-clinical, with careful attention given to aesthetics, such as lighting, smell, nature, flowers, images and meaningful objects, such as photographs of loved one’s, treasured ornaments or special items of clothing.
Psychedelics have thus been called meaning-response magnifiers, or hyper-active placebo catalysts: they intensify mental phenomena and amplify their significance. Hence the need to prime our mindset during the preparation phase. This includes careful screening, thorough history taking, working through our autobiography or Life Story, setting clear and meaningful intentions and cultivating practical mindfulness-based skills centered around non-reactive, open awareness to navigate the journey confidently.
The Therapist-Guide - An Empathetic Anchor and Trustworthy Companion
Crucially, setting isn’t only concerned with the physical environment during the journey, but the physical and emotional presence of the therapist-guide.
In traditional therapeutic settings, decades worth of clinical literature has tried to distill the core factors that lead to positive outcomes. One factor seems to trump all: the depth and quality of the therapeutic relationship (Orlinksy, 2017). In the absence of a relationship premised on trust, kindness, expertise and integrity, therapeutic tools and techniques lose efficacy. As the great couples therapist Harville Hendrix said:
“We are wounded in relationship, and we heal in relationship” (Hendrix, 1988).
Dr Janis Phelps of Berkeley University has elucidated the core competencies of psychedelic-assisted therapists which allow one to feel held, contained and free to relinquish control during a journey.
Such practitioners-
have an empathic, abiding presence,
are trust-enhancing,
have a degree of spiritual intelligence - in other words, openness to transcendent experiences
have self-awareness
have ethical integrity, as well as
demonstrate proficiency in complementary mindfulness practices.
These are the characteristics that create a holding space, allowing people to surrender their defense mechanisms and confront truths that may otherwise be unbearable.
The therapist-guide is also judicious with how and when to intervene. For example, on one of our retreats, we covered a participant with a blanket during a journey. Afterwards, he said this moment brought tears to his eyes, because he felt neglected as a child. In his hyper-neuroplastic and regressed state, that simple gesture was transformative for him.
Guides also need some experiential knowledge by being acquainted with the phenomenology of the psychedelic experience through personal journeying. It’s as if they’re inviting their participant to venture into a dark forest with them. While they might not know this particular forest, they know something about forests in general, and may thus be a useful companion on the journey.
Part 3: Navigating Challenges and Fears
Facing the Void with Curiosity - Fear of Death and Insanity
An attuned, holding presence is also necessary as two core fears may arise the journey - fear of death and fear of insanity. Both are protests of the ego: one for immortality and the other for control.
Albert Hoffman offered a famous description of these fears during his first LSD trip:
“Every exertion of my will, every attempt to put an end to the disintegration of my ego, seemed to be a wasted effort. I was seized by the dreadful fear of going insane. I was taken to another world, another place, another time. My body seemed to be without sensation, lifeless, strange. Was I dying?”
But with rigorous preparation, we’re trained to move towards these fears with curiosity. For example, during a journey, a retreat participant once said to us: “I think I’m dying.” Our first impulse was to help him slow his breathing to activate his parasympathetic (rest and recovery) system. Instead, we said: “That’s great. You go ahead and do that. It’s safe to let go. See what happens.”
He snapped out of his distress, looked up at us and said: “therapists can be really weird!” An astute guide is thus capable of helping participants trust that their fear and discomfort are an invitation:
What they need most is where they least want to look.
Mindfulness Training - Observing with Kindness and Compassion
Preparing the requisite mindset thus enables us to observe with kindness and compassion as thoughts, memories, sensations, images, emotions and internal dialogue arise and pass. This is where mindfulness training truly shines. To paraphrase the philosopher Nietszche, if we stare into the void for long enough, we eventually see the light.
Ethical Considerations - Respecting Vulnerability and Boundaries
Finally, holding space raises unique ethical concerns:
Physical Touch
Issues of physical touch become pertinent, especially where there’s a history of sexual abuse. Sometimes patient’s need help getting up and being guided to the restroom. They may even reach out for a supportive hand or a hug during a difficult moment. How the guide responds must be discussed before a journey, and there should always be more than one guide present.
Indeed, a discerning and skilled guide is warm and responsive, but has boundaries of steel, and will never intrude into the patient’s space.
Dosing & "topping up"
Relatedly, issues of dosing and real-time top-up doses need to be discussed beforehand. It can be disconcerting for a participant if a guide recommends more medicine and this was never a prior consideration.
Beneficence, respect and confidentiality
Since, by definition, the individual is likely to lose touch with reality during a psychedelic journey, they may regress to a childlike state, have less control over their physical body, relive a trauma or confuse a guide with someone else, including a loved one. With our defenses radically disabled, we are extremely vulnerable during a journey. Guides therefore need to be sensitive to principles like beneficence, respect and confidentiality.
Given how powerful and transformative psychedelics can be, the therapist-guide ought to be mindful not to overvalue their role while appointing themselves spiritual guru or healer. Unfortunately, the psychedelic space can attract evangelists and people with unchecked ‘spiritual narcissism’ who view psychedelics as a panacea, often sacrificing safety and therapeutic rigor for expediency.
Finally, we want to advocate for humility in the presence of a person’s innate healing capacities. As in traditional therapy, we believe the therapist-guide merely opens a space within which the participants inner healing resources may come to the fore. In this regard, we fully concur with Maps founder, Rick Doblin (in Valentino, 2020), who said:
“Our therapeutic system is inner-directed… Once we give someone MDMA, they are the ones who produce the content. We follow and support where they are going.
Our hypothesis is there is an inner healing intelligence. We all know that's true for our bodies. If you get a scratch or break bones, your body has a mechanism to heal itself… We think there is something like that for the psyche.”
Please feel free to reach out to us and share your experiences or ask our clinical team a question - we'd be very happy to hear from you!
Contact us to find out whether psychedelic-assisted therapy is the right option for you.
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DISCLAIMER: This article was written for educational purposes only, and is not intended as advice. Psychedelic-assisted therapy is not helpful or indicated for everyone, and professional, trusted advice from a qualified healthcare professional should always be sought before entering into any new form of treatment. Similarly, we advocate for the safe, legal use of psychedelics in a therapeutic setting, guided and administered by qualified professionals.