Beyond the Journey: A Qualitative Analysis of Therapists’ Perspectives on Psychedelic Integration Challenges

Beyond the Journey: A Qualitative Analysis of Therapists’ Perspectives on Psychedelic Integration Challenges | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond the Journey: A Qualitative Analysis of Therapists’ Perspectives on Psychedelic Integration Challenges Christina Chwyl, Odin S. Elvenes, Andrew S. R. Kleven, Eric W. Kongshaug, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6874539/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Psychedelic integration is widely acknowledged as essential, yet limited empirical data exists on challenges faced during integration. Objective To explore therapists' perspectives on post-psychedelic integration challenges and their approaches to supporting clients. Methods Online interviews were conducted with a purposive sample of licensed mental health professionals who had provided psychedelic integration support to at least 15 clients using classical psychedelics or 3,4-methylenedioxymethamphetamine (MDMA). Data were analyzed with Systematic Text Condensation. Results Participants ( N = 20, 90% white, 70% cisgender women, modal integration clients: 25 − 30) used a wide range of integration frameworks and practiced in diverse settings. Ten key integration challenges emerged: 1) Unearthed Trauma, Suppressed Emotion, and Long-Avoided Pain; 2) Destabilization and Psychological Crisis (subtheme: Emergence/Exacerbation of Psychosis or Mania); 3) Re-Adjusting to Daily Life Demands amidst New Insights and Heightened Sensitivity; 4) Relational and Systemic Harms from Boundary Violations, Misattunement, Objectification, or Abuse; 5) Making Sense of Chaotic or Confusing Experiences; 6) Identity and Worldview Crisis; 7) Overwhelmed by the Magnitude of Change Needed to Integrate Insights; 8) Relationship Examination, Disruption and Distance; 9) Hope, Hype and the Aftermath of Disappointment; and 10) Seeking Escape and Solace in Psychedelic Use. Conclusions Findings reveal core integration challenges and practical strategies that can inform training and preparation for clients and providers: beginning integration in preparation, setting realistic expectations, creating safe, attuned therapeutic environments, bolstering coping and social support resources, using trauma processing techniques, facilitating client-led meaning-making, and supporting gradual, values-guided life changes. psychedelics psychedelic-assisted therapy qualitative integration challenging experiences Introduction Psychedelics have garnered significant attention for their potential to aid in the treatment of mental health conditions, such as depression, post-traumatic stress disorder, addiction, depression, eating disorders, and anxiety disorders (Yao et al., 2024 ). Psychedelics comprise a class of psychoactive substances with the capacity to induce acute neurobiological effects, primarily through 5-HT2A receptor agonism, such as neuroplasticity, and acute psychological effects, including altered cognition, emotion, and perception, and sometimes feelings of interconnectedness, mystical and self-transcendent experiences (van Elk & Yaden, 2022 ; Yaden et al., 2024 ). These physiological and psychological effects are thought to synergistically promote wellbeing and mental health improvements (Yaden & Griffiths, 2021 ). Beyond the acute effects of psychedelics, the ‘integration’ period following psychedelic use is widely considered to be critical for reducing risks of harm, maximizing benefits and deriving therapeutic value from psychedelic experiences (Aixalà, 2022 ; Bathje et al., 2022 ). Approaches to integration have been conceptualized and practiced in wide-ranging ways and are shaped by varying theoretical and cultural frameworks (e.g., Indigenous, medical/psychological, Western perspectives). Bathje, Majeski and Kudowor ( 2022 ) described integration, based on a synthesis of 24 definitions of integration found in the literature, as an active, ongoing process of making sense of and applying lessons from psychedelic experiences to foster internal (mind, body, and spirit) and external (lifestyle, social relations, natural world) balance. Similarly, Earleywine et al. ( 2022 ) define integration as a bridge from the psychedelic experience to daily life, facilitating lasting change and a sense of wholeness. Integration practices span multiple domains, including introspective, creative, somatic, health, relational, nature, mindfulness, ritual, and spiritual practices (Bathje et al., 2022 ). Despite the presumed importance of psychedelic integration, it remains under-researched, with limited empirical data. In qualitative studies, participants frequently highlight the importance and value of integration sessions (Breeksema et al., 2020 ). Quantitative findings suggest integration practices (e.g., meditation, yoga) may predict positive outcomes (Amada & Shane, 2022 ; Griffiths et al., 2018 ; Perkins et al., 2021 ; St. Arnaud & Sharpe, 2023 ), though most studies are cross-sectional and lack comprehensive or validated measurement of integration. A validated psychedelic integration measure was recently proposed (Frymann et al., 2022 ), but its application appears untested. Very little empirical work has specifically examined integration challenges, though studies on challenging psychedelic experiences—especially those that persist beyond the acute phase—offer insight into difficulties people may face during integration. Compared to research examining acute challenges (e.g., difficult perceptual, emotional and physical experiences; Barrett et al., 2016 ; Johnstad, 2021 ; Koslowski et al., 2023 ), relatively few studies have examined persisting challenges after psychedelics—the issues most relevant to integration. While most people appear to have positive psychedelic experiences, a subset report persisting psychological distress—ranging from days to years—leading some to seek professional or medical support (Bouso et al., 2022 ; Bremler et al., 2023 ; Carbonaro et al., 2016 ; Evans et al., 2023 ; Kopra et al., 2023 ). Below, we review data on persisting challenges after psychedelic use. Challenges Following Psychedelic Use A variety of challenging persisting after the acute psychedelic experiences have been identified in the literature. Emotional and psychological difficulties are among the most commonly reported. These include fear, anxiety, grief, depressive symptoms, and trauma-related symptoms, such as sleep disturbance/nightmares, or derealization and depersonalization (Barrett et al., 2016 ; Bouso et al., 2022 ; Bremler et al., 2023 ; Evans et al., 2023 ). Some people perceive the psychedelic experience itself as traumatic (Johnstad, 2021 ), potentially precipitating trauma-related symptoms, such as flashbacks of the psychedelic experience (Bremler et al., 2023 ). Others report persisting fears of going insane (Barrett et al., 2016 ) or cognitive difficulties (e.g., poor concentration, distractibility) (Bremler et al., 2023 ; Evans et al., 2023 ). For a small subset, elevated suicidality, self-harm or addictive behaviors (Bremler et al., 2023 ) are observed following psychedelic use. Manic and psychotic episodes following psychedelic use also appear rare, but are documented in several case reports and qualitative studies (Bremler et al., 2023 ; Carbonaro et al., 2016 ; Evans et al., 2023 ), particularly, though not exclusively, amongst people with a personal or familial history of psychosis or mania (Dos Santos et al., 2017 ). Social and interpersonal difficulties, such as feelings of disconnection, loneliness, isolation, or stigmatization are commonly reported among the persisting challenges following psychedelic experiences (Barrett et al., 2016 ; Bouso et al., 2022 ; Bremler et al., 2023 ; Evans et al., 2023 ). Disconnection and isolation can arise when a person finds themselves at odds with the values prevailing in a society, such as materialism or rationalism (Grof & Grof, 2010). Sanabria and Tófoli ( 2025 ) explain that the greater the gap between societal beliefs and psychedelic insights, the greater the need for integration. These insights can lead to foundational changes in beliefs about oneself, the world, and spirituality, which can create an ‘ontological shock’—a foundational change in one's sense of reality or existence (Gorman et al., 2021 ). Persistent ontological and spiritual difficulties have been reported following psychedelic use (Evans et al., 2023 ) and Axialà (2022) introduced ‘ontological integration’ to describe the process of assimilating these new metaphysical or existential understandings. Such foundational changes can disrupt personal equilibrium, leading to significant life changes, such as relational challenges (Gorman et al., 2021 ). Other persisting difficulties following psychedelic use reported in the literature include perceptual alterations, such as feeling attacked by the spirit world or experiencing persistent visual distortions (Bouso et al., 2022 ) such as occurs in Hallucinogen Persisting Perception Disorder (Ford et al., 2022 ). Others report ongoing time perception and auditory processing distortions (Evans et al., 2023 ). Somatic difficulties, including physical distress and physiological symptoms such as fatigue, headaches, crying episodes, and weight fluctuations, have also been documented (Barrett et al., 2016 ; Evans et al., 2023 ). Integration Challenges To our knowledge, only two empirical studies have specifically examined the challenges people encounter during the integration process, rather than general difficulties associated with psychedelic experiences. In one study, during a qualitative interview following a psilocybin retreat, a subset of participants spontaneously reported integration challenges (Lutkajtis & Evans, 2023 ). Another qualitative study analyzed the integration experiences of ayahuasca drinkers (Cowley-Court et al., 2023 ). Notably, no studies have investigated integration difficulties in the context of psychotherapy, or examined the integration challenges that facilitators observe in their work with clients. Consistent with findings on persisting challenges after psychedelic experiences, during integration, participants have reported emotional, psychological, social, and somatic difficulties, such as re-experiencing the sensation of having birth, or persistent trembling, interpreted as a “transient cathartic after-effect” (Cowley-Court et al., 2023 ; Lutkajtis & Evans, 2023 ). People also reported “post-ecstatic blues” arising from a disconnection from the peak psychedelic experience and heightened sensitivity or feeling “raw” (Lutkajtis & Evans, 2023 ). Others reported needing time to re-adjust to daily life, aligning with recommendations from integration frameworks for people to plan for time to rest and recuperate after a psychedelic experience (Gorman et al., 2021 ). Aligning with the finding that people often experience ontological shifts after psychedelics, some participants following a psilocybin retreat experienced difficulties going back to their “old life” with new understandings (Lutkajtis & Evans, 2023 ). Integration frameworks also describe the importance of working with potential feelings of disappointment and unmet expectations during integration (Gorman et al., 2021 ), as people may view psychedelics as a “panacea” (Earleywine et al., 2022 ) and therefore become disappointed when difficulties are not resolved. Expectation management is key to addressing potential feelings of hopelessness and self-deficiency following underwhelming psychedelic experiences (Gorman et al., 2021 ), especially as people may be accustomed to a medical model in which medications work via a more passive process, as opposed to someone actively healing themselves with the aid of a psychedelic (Marcus, 2023 ). Current Study An improved understanding of the potential challenges following psychedelic experiences, and how these challenges can be overcome, is key to minimizing psychedelic harms, maximizing therapeutic potential, and advancing integration frameworks, which are currently not evidence-based (Greń et al., 2024 ). However, to our knowledge, only two empirical studies have evaluated integration challenges, and no studies have examined how therapists address these challenges, despite the recognized importance of integration therapy (Aixalà, 2022 ). This gap is particularly relevant as psychedelic use continues to rise, yet education on safe and effective use remains limited. The current study seeks to address these gaps by exploring the integration challenges therapists encounter in their work with clients. Specifically, the research aims to: 1) identify and investigate therapists' accounts of challenges clients face during integration therapy, and 2) examine the strategies therapists use to help clients navigate and address these challenges. Methods Study procedures were approved by both the Institute of Psychology at UiT (The Arctic University of Norway), and the Behavioral Health Research Collective's Institutional Review Board and the ethics committee, approval number 051, in accordance with the Declaration of Helsinki. Recruitment and Enrollment Participants were recruited through a purposive sampling strategy involving invitations to potential participants or to online networks consisting of psychedelic integration therapists. Eligibility criteria were holding a current, active license as a mental health professional and having provided psychedelic integration support for experiences with classic psychedelics (e.g., psilocybin, ayahuasca, or lysergic acid diethylamide (LSD)) or 3,4-methylenedioxymethamphetamine (MDMA) to at least 15 clients. Ketamine was excluded because of the high degree of variability in the way that ketamine therapy is delivered (Heifets & Olson, 2024 ) and potential different integration challenges. Data Collection Open-ended, semi-structured interviews were conducted via Zoom by team members (ASRK, EWK, OSE) between September 2023 and November 2023, with each interview planned to last approximately 55 mintues. Prior to commencing the interview, participants provided written informed consent then completed a demographic survey. Interviews were conducted using a guide developed by the study team for this project through consensus, which is presented in full in the Supplementary Online Materials. Interviews questions centered on two main themes: (a) a description of integration challenges participants experienced with their clients; and (b) how they addressed those challenges. Interviews were digitally recorded and transcribed verbatim with the help of Microsoft 365. Quotations reported below are corrected for punctuation and repeated or filler words are removed to enhance readability. Data Analysis Data on integration challenges were analyzed with Systematic Text Condensation, a descriptive and explorative method for cross-case thematic analysis of qualitative data (Malterud, 2012 ). This iterative process involves several stages, including data familiarization, initial coding, theme development, and refinement. The initial six transcripts were coded, and an initial coding framework was developed by ASRK, EWK, and OSE, in consultation with BP, JL, and ETN. Another team member (CC) then coded the remaining 14 transcripts in consultation with JL in batches of seven and refined these codes. Within each theme, key integration approaches and strategies employed by providers are discussed in the “Provider Approaches” sub-section. Participants, referred to as “providers,” are identified using the notation [p#]. Results Participants Participants ( N = 20) were primarily white (90%) and cisgender women (70%) with diverse sexual orientations, utilizing a wide range of integration frameworks. Table 1 details participant characteristics. Table 2 provides an overview of themes and sub-themes. Table 1 Participants characteristics ( N = 20) Sample Characteristic N (%) Gender Cisgender woman 14 (70%) Non-binary/genderqueer/genderfluid 4 (20%) Cisgender man 3 (15%) Prefer not to say 1 (5%) Sexual Orientation (more than one choice permitted) Straight/heterosexual 7 (35%) Queer 5 (25%) Pansexual 4 (20%) Bisexual 4 (20%) Asexual 2 (10%) Prefer not to say 1 (5%) Race/Ethnicity (more than one choice permitted) White 18 (90%) Hispanic or Latinx 3 (15%) Black or African American 2 (10%) Ashkenazi Jewish 1 (5%) Jewish 1 (5%) Indigenous 1 (5%) Psychedelics Experienced with Integration (more than one choice permitted) Psilocybin 20 (100%) MDMA 20 (100%) Ayahuasca 13 (65%) Ketamine 13 (65%) LSD 10 (50%) 5-MeO-DMT 6 (30%) Mescaline/Peyote/San Pedro 5 (25%) Cannabis 1 (5%) Salvia divinorum 1 (5%) Approximate Number of Integration Clients (excludes ketamine, ranges reflect participant-provided estimates and may not cover all possible values) 18–20 5 (25%) 25–30 8 (40%) 40–60 5 (25%) 75–100 1 (5%) 550+ 1 (5%) Experience with Indigenous Psychedelic Practices 3 (15%) Formal Psychedelic Training Program 18 (90%) Mental Health License Licensed Professional Counselor 7 (35%) Licensed Clinical Social Worker 5 (25%) Licensed Marriage and Family Therapist 4 (20%) Psychologist 3 (15%) Licensed Mental Health Counselor 1 (5%) Licensed Professional Counselor 7 (35%) Theoretical Framework for Integration (more than one choice permitted) Psychedelic Harm Reduction and Integration 18 (90%) Internal Family Systems 16 (80%) Somatic Experiencing 10 (50%) Existential Therapy 6 (30%) Psycho-Spiritual Integration Process 6 (30%) Acceptance and Commitment Therapy 5 (25%) Emotion Focused Therapy 4 (20%) Psychodynamic Therapy 4 (20%) Sensorimotor Integration 3 (15%) Nature Contact 3 (15%) Cognitive Behavioral Therapy 3 (15%) Holistic Model for a Balanced Life 3 (15%) EMDR and Related Therapies (EMDR, EMDR resourcing, AF-EMDR and Dreamwork) 3 (15%) Visionary Plant Medicine Integration 2 (10%) Psychedelic Inclusive Model of the Psyche 2 (10%) Psychological Flexibility Model 2 (10%) Gestalt Therapy 2 (10%) Expressive Arts Therapy 1 (5%) Guided Imagery 1 (5%) SAFETY (security, accessible, fluidity, empowering, transformational, yours) 1 (5%) LSD = lysergic acid diethylamide; EMDR = Eye Movement Desensitization and Reprocessing; AF-EMDR = Attachment Focused EMDR. The following section describes each integration theme, including direct quotes from providers, followed by a section describing approaches that some providers offered in how to respond to each integration theme. [Insert Table 1 Here] Table 2 Overview of Integration Challenges Themes and Sub-Themes Themes Theme 1 : Unearthed Trauma, Suppressed Emotion and Long-Avoided Pain Theme 2 : Destabilization and Psychological Crisis Subtheme : Emergence/Exacerbation of Psychosis or Mania Theme 3 : Re-Adjusting to Daily Life Demands amidst New Insights and Heightened Sensitivity Theme 4 : Relational and Systemic Harms from Boundary Violations, Misattunement, Objectification or Abuse Theme 5 : Making Sense of Chaotic or Confusing Experiences Theme 6 : Identity and Worldview Crisis Theme 7 : Overwhelmed by the Magnitude of Change Needed to Integrate Insights Theme 8 : Relationship Examination, Disruption and Distance Theme 9 : Hope, Hype and the Aftermath of Disappointment Theme 10 : Seeking Escape and Solace in Psychedelic Use Theme 1: Unearthed Trauma, Suppressed Emotion and Long-Avoided Pain Providers described how following psychedelic experiences clients found it “impossible to ignore” [p14] painful emotions, grief, or trauma that had long been avoided, suppressed or minimized. Confronting previously unacknowledged content could lead to challenging emotional experiences, such as sadness, fear or confusion, especially given the swiftness and intensity of psychedelic-assisted healing: “It's like there's been a natural disaster. And now it's calm. But I'm looking around and I'm seeing all the wreckage and the rubble that I have to clean up.” [p08] One provider, for instance, described the experience of veterans who believed they had successfully suppressed painful memories, only to have them resurface: “It comes back in – an experience where it becomes real again. So often they'll present with fear this is coming back. Is this how it's always going to be? Why is this happening? Why do I have to go back there?” [p12] Providers described how, oftentimes, there has been longstanding “repression of feelings” [p06] such as anger, sadness, grief or passion. One provider, for instance, spoke to a client in his 30s experiencing anger for the first time: “Now he has access to anger, and not in a bad way. The anger was never welcome and now he feels like he's sensitive and gets angry easily.” [p06] Psychedelic experiences were also discussed as bringing clarity to the “depth of harm” [p01] caused by self-criticism or maladaptive coping behaviors (e.g., problematic substance use): “Suddenly they recognize that their substance abuse is a way that they've been dissociating from a tremendous amount of trauma and pain... They can no longer ignore the harms their coping strategies create anymore.” [p01] Provider Approaches to Address Challenges Providers emphasized the importance of first creating a sense of safety, validation, and normalization when clients uncover pain or re-experience traumatic memories, which can help reduce feelings of anxiety, shame, guilt, and fear of judgment. One provider explained that while some people can worsen mentally and emotionally: “…There's a large majority of people that just need that contextualization of why? Why am I feeling worse?” [p10] Many providers advocated for a gradual and staged approach to integration, beginning with strengthening a person’s coping abilities, distress tolerance, and internal and external resources. Some providers suggested psychoeducation on concepts like the “window of tolerance” (Siegel, 1999 ) allowing therapists and clients to collaboratively monitor arousal levels and ensure grounding throughout the process. Once distress is in a manageable range and the client has developed sufficient coping mechanisms, therapists facilitated meaning-making and processing of previously unaddressed pain, emotions, or trauma. This was accomplished using various psychological frameworks, often internal family systems (IFS) therapy, somatic work, and Eye Movement Desensitization and Reprocessing (EMDR). Additionally, some providers emphasized the importance of healthy emotional expression through practices like journaling, art, emotion identification and labeling, and cultivating mindful awareness of emotions and their physical sensations. Theme 2: Destabilization and Psychological Crisis While the last theme relates to clients who are experiencing challenges or some degree of disruption from confronting pain or previously unacknowledged thoughts or emotions, the current theme refers to cases where the client is in an acute crisis or significant episode of dysfunction. Providers noted that many clients fear such lasting negative changes from psychedelic experiences. As one provider described: “She's afraid that if the psychedelics show her the trauma that she has so skillfully pushed down out of consciousness for her whole life... then she will be unable to function.” [p16] While these fears are often not realized, a subset of clients do become overwhelmed or destabilized. One provider highlighted a dichotomy between clients who “ really make a lot of meaning, and they have all kinds of really supportive and compassionate insights” and those who become “ stuck in that trauma, trauma-memory, trauma-experience. ” [p03] Another provider highlighted the impact of processing intergenerational or collective trauma, which can lead to “prolonged periods of terror, anxiety, despair.” [p02] In some cases, clients experienced somatic disruptions. One provider described a client experiencing “ a pretty consistent shaking experience” [p19] following psychedelic use, rendering the client temporarily unable to work. Providers also observed cases where a crisis state emerged following psychedelic use, such as for a person who took psilocybin alone and felt she was in a “void” and “eternal blackness,” leading to depression and post-traumatic stress disorder (PTSD) symptoms (e.g., hypervigilance, anxiety, anger outbursts, sleep disruptions) [p17]. While her symptoms reportedly improved over the following year, she continued to struggle with her mental health and connecting with others: “ The trauma of that strong dosing experience continued to linger in her.” [p17] Subtheme 2a: Emergence/Exacerbation of Psychosis or Mania Some providers noted mania or psychosis emerging after psychedelic use, particularly in clients with a family history of bipolar disorder or psychosis or when the experience was “just too much, too fast.” [p17] Some noted that unresolved trauma can mimic psychosis at times. One provider described a client who believed they were experiencing psychosis after a psychedelic experience, though the provider attributed their symptoms to PTSD flashbacks. Another provider described a man in his 40s who had experienced significant developmental and recent trauma who had the emergence of psychosis-like symptoms after ayahuasca, interpreting it as the development of spiritual powers: “He interpreted it as a kundalini awakening shamanic thing, that he was developing spiritual powers… so spiritual delusions. Or at least a spiritual or magical framework is what he used.” [p16] Provider Approaches to Address Challenges. Providers observed that when an individual does not have the necessary resources to navigate pain, they can turn to unhealthy coping mechanisms, such as problematic substance use, compulsive spending, self-destructive behaviors, risky behaviors, “dopamine seeking behavior to make pain go away” [p10], and, in the worst-case scenario, self-harm or suicide. As one provider explained: “… the issue I have with unskilled facilitators prescribing high dose psychedelics is that sometimes, it can outstrip a clients window of tolerance and outstrip their existing coping strategies.” [p02] Crisis management, entailing helping clients regain emotional safety, providing skills-based support, and assisting clients in returning to baseline, was reported as essential. One provider underscored the need to approach destabilization as “both as a spiritual event and a mental health slash medical event.” [p18] While some providers believed all psychedelic experiences, even difficult ones, could offer valuable insights (i.e. “there is no such thing as a bad trip”), others cautioned against dismissing the potential trauma of a negative experience: “I think there's very much such a thing as a bad trip and validating clients in that experience is really important when a client says ‘that was chaos’… rather than moving straight towards like, well, is there anything you could learn from it?” [p18] Providers saw strong preparation work as one of the most effective ways to reduce the likelihood of post-experience integration challenges. To mitigate the likelihood of destabilization or psychological crisis, providers overwhelmingly emphasized the need for preparation and harm reduction steps, such as going low and slow and ensuring a safe, supportive environment. Providers emphasized the importance of proper screening in the preparation phase (e.g., psychosis and mania histories), and cautioned that psychedelics are not suitable for everyone: “… these are safe medicines when used safely, but they are powerful. We're entering into the realm of the unknown, and there should always be that humility going in.” [p02] Providers also stressed the importance of identifying additional supports before psychedelic use and referring to higher levels of care when necessary, sometimes including hospitalization. Theme 3: Re-Adjusting to Daily Life Demands Amidst New Insights and Heightened Sensitivity Providers highlighted the challenges of balancing healing and integration work with work, family and daily responsibility demands/obligations. Many clients struggle with having new insights or feeling better after a psychedelic experience, only to return to the same life stressors: “The work of integration is, how do I go back into a job or a relationship when I have all these new insights about myself and about my life and the rest of the world is still the same?” [p14] “I've had this big experience, but I'm right back in my box. How can I make myself safe enough to continue exploring?” [p03] While providers reported that many clients wish for more time to readjust to themselves, relationships, professional responsibilities, and financial obligations often force them to “get back to the rhythm of their life… earlier than they would like.” [p04] Heightened sensitivity, which could range from days to a year following psychedelic use, could exacerbate difficulties returning to daily life. One provider described a common feeling of “having shed a layer of skin, making you more sensitive” [p06], with some clients struggling to return to their routines: “They just need more space… just feeling like I can't just get back in this system I've been part of. I can't just work 50 hours a week and do all this other stuff I'm doing.” [p06] Relational demands also add to integration challenges. One provider described a parent of young children struggling to take alone time: “She literally goes and sits in her closet with noise cancelling headphones on as many people with autism want to do. But then she feels like she's not allowed to do that.” [p08] Additionally, clients in an “open, vulnerable state from the session” [p09] may be more affected by their external environment, and in some cases, this heightened sensitivity can lead to “spiritual crises”: “Just feeling very open for an extended period of time and connecting to spiritual entities.” [p04] Provider Approaches to Address Challenges To help clients navigate readjustment difficulties, often amidst heightened sensitivity, providers encouraged proactive preparation—setting aside space and time for integration, for example by taking time off from work, whenever possible. However, many acknowledged that not all clients have the privilege to do so and that these challenges are, to some extent, unavoidable. Several therapists linked the difficulty of re-adjusting to daily life to a clash between the slow process, emotionally intense process of healing (see Theme 1) and the fast-paced demands of capitalistic society. One practitioner contrasted the deep work of integration with the realities of survival, stating: “You have to go to work every day. You don’t have time to just sit and journal and feel things.” [p16] Theme 4: Relational and Systemic Harms from Boundary Violations, Misattunement, Objectification, or Abuse Providers described how harms arise from relational ruptures (where the client felt unsafe with the facilitator), boundary violations, systemic oppression, and insufficient or mis-attuned support during psychedelic experiences often led to prolonged distress in the integration process. Clients often sought integration support following psychedelic experiences marked by cultural misattunement or a lack of responsivity to their specific needs. For instance, one provider described a client who had a positive MDMA experience but struggled with an integration process that emphasized spirituality when they preferred a secular approach. Another provider shared the experience of a musician who felt pressured to listen to “ a very particular kind of music that was just not resonant at all,” during a psilocybin session, leading him to later seek integration support in which “he could be held with a bit more spaciousness… he could be trusted to make some of his own choices in a medicine space.” [p18] Providers also recounted instances of neglect and abuse during psychedelic sessions, which left clients distressed and seeking integration support to process the harm. For example, a provider recounted an ayahuasca experience in which the facilitator “behaved inappropriately… didn't respect her boundaries and didn't understand the way in which she was asking for her help and ended up causing more harm.” [p15] Systemic oppression was discussed as amplifying harms for people with marginalized identities. One provider described a Chinese woman who felt threatened during an ayahuasca ceremony, where she was prevented from leaving or contacting her mother. This experience left her in a distressed state, unable to sleep or eat. Both racial and gender dynamics heightened the client’s distress, as she perceived a power imbalance in the retreat setting and later sought a female integration therapist for support. Providers also spoke about the challenges of integration amidst racialized trauma: “BIPOC self-identified folks… feel a sense of othering in community and society, and sometimes in their psychedelic work… How can we integrate an experience like that where someone may really not feel safe in their body or safe in community?” [p03] Provider Approaches to Address Challenges To minimize relational harm, providers emphasized the need for thorough preparation, including discussions about trauma history, relational patterns, and trust. Providers also emphasized the importance of establishing a good fit between provider and client, particularly around “safety or cultural resonance” [p08]. Special care was recommended for clients with trauma histories, as ruptures in therapeutic relationships can reinforce negative core beliefs. Creating a safe space with clients was described as essential. For clients integrating psychedelic experiences amidst racial trauma, one provider emphasized moving “really slowly” [p03], recognizing the added challenges of navigating identity and community. Theme 5: Making Sense of Chaotic or Confusing Experiences While providers spoke of some clients who gain significant clarity on their path forward following psychedelic experiences, others feel “completely freaked out and confused” [p12], by the experience or unable to understand it: “It felt random or it felt chaotic. And so they're a little confused about what to do with it afterwards, right? So it challenges them in that it's not some straight answer or they don't just suddenly feel better.” [p17] Participants specifically highlighted the challenge of making sense of trauma, often involving the difficult task of navigating complex emotions such as anger, grief, confusion and blame directed toward parents, caregivers, or other authority figures. Several providers described cases where repressed experiences of abuse resurfaced, leading to significant turmoil and confusion about the authenticity and meaning of the experience. For example, one provider described a client who had a “very, very vivid sense of having been molested as a child by his father” after an ayahuasca ceremony, which especially distressed him because he had an “amazing relationship with this father” throughout his life. After this experience, the provider explained: “He spent two years in a state of utter confusion… because it didn't fit the narrative or lived experience of his life… But he couldn't shake the thought right. He had this idea that was this a repressed memory.” [p18] Provider Approaches to Address Challenges To help clients navigate confusion around identity and meaning following psychedelic experiences, providers shared the importance of supporting clients in arriving at their own conclusions, facilitating reflection through open-ended questions, and adopting an exploratory stance rather than imposing interpretations. Some providers highlighted the value of embracing ambiguity and acceptance around uncertainty: “People want closure. I've done it, fixed it and let go. But to be open to this non closure, it's continuing.” [p11] When clients encounter possible abuse memories during sessions, providers stressed the importance of a sensitive, non-directive approach, recognizing that such memories could be authentic/literal or symbolic: “Integration has to be seen through the lens of understanding that the mushroom speaks in in symbolic language…” [p02] Providers also suggested helping clients contextualize psychedelic insights within their life histories for clarity. One provider shared an example of a client who came to realize that an emergent memory of sexual assault likely symbolized a feeling of being trapped rather than a repressed event. Another described how recalling a childhood abuse memory helped one client “put the puzzle pieces together” : “It explains symptoms they have manifested over the decades, such as suicidal ideation, non-suicidal self-harm, eating-disorders, depression, anxiety, difficulty with sexual intimacy…” [p12] Theme 6: Identity and Worldview Crisis Providers described clients grappling with existential questions and shifts in worldview and identity. Psychedelics could highlight incongruencies between a client’s current life or between their current and authentic self, often causing distress: “… that chasm, that gap between their authentic life and self-expression and the life that they're living can become a great source of pain once it's in awareness.” [p01] Integrating insights around identity and worldview can be especially challenging when material from the psychedelic experience contradicts a person’s cultural values or “concept of who they are” [p15]. In these instances, people may experience an “ existential or identity crisis” [p19] , or struggle to “redefine who that person is” [p07]. For several clients, integration work encompasses questioning and working through sexual orientation and gender identity. One provider, for example, highlighted the challenge of working with internalized biases and systems of oppression, such as heterosexism, xenophobia, antisemitism and sexism: “I grew up in the Bible Belt in America so… why would I ever accept that I could be gay? Really helping people work with that deep pain of systems of oppression that they've internalized has been really challenging....” [p10] Clients often also re-examine their religious or spiritual beliefs. One provider described a client who had a “ big God opening experience, realizing there is meaning” [p17]. However, in the months that followed, they struggled with how to reshape their life to align with these newfound beliefs. Another provider described a client whose psychedelic experience shattered his beliefs about the afterlife, leaving him feeling that his past choices were based on a “wrong assumption” [p09]. This triggered a crisis of him wanting to change everything about his life, including his parenting, relationships, and business: “He was in a state of depression, despair, and conflict in his environment.” [p09] Provider Approaches to Address Challenges Providers emphasized the need for strong support when psychedelic insights radically shift self-understanding or worldview. One provider described a client confronting unacknowledged abuse, underscoring the importance of guidance through the shattering of their relationship beliefs and the potential loss of the “narrative of their life.” [p09] Theme 7: Overwhelmed by the Magnitude of Change Needed to Integrate Insights Insights gleaned from psychedelic experiences were described by providers as often daunting and overwhelming for clients, as they can call for major life changes, such as working through addiction, changing jobs, moving locations, or changing relationships: “ A psychedelic sends the message to the client that ‘hey, you need to be responsible… You can't keep drinking. You can't keep cheating on your spouse. You need to get out of this soul sucking job.’” [p02] Providers described clients as often unprepared for the lasting effects catalyzed by the psychedelic experience. One provider shared how a client was overwhelmed by the realization that a 6-hour psilocybin experience would take “months and weeks to make sense of.” [p10] For some clients, there can be a feeling of urgency or necessity to implement changes, as “once it's conscious, then it suddenly there is a necessity to start working with it” [p01]. Another provider described how after the initial “excitement” and “positive effects of the journey” [p09] fade, people confront the reality of their unresolved issues. They shared the example of a client who had been depressed for 20 years suddenly feeling that their depression is lifted, then experiencing regret, telling themselves the following: “‘I haven't paid my taxes for 20 years’, ‘I wanted to have kids, but I didn't’, and ‘now I'm not able to have kids anymore’. ‘I haven't spent time with my family, and I cannot take it back.’” [p09] Provider Approaches to Address Challenges When insights from psychedelic experiences call for major changes in peoples’ lives, providers noted that people often face fear, “ambivalence… inner conflict” [p16], or avoidance, which can cause integration work to “come to a standstill.” [p10] In contrast, another key challenge mentioned by several providers was slowing clients down from making major life changes when they feel an urgency or excitement to make major changes quickly: “I found it very challenging to work with—the level of anxiety and urgency that they had. And a lot of the things that I was recommending just were not landing well because they didn't work immediately.” [p20] Some providers recommended that participants refrain from making big decisions for a period (e.g., a month) following a psychedelic experience. Others advised focusing on small, gradual, values-aligned actions instead of quick large-scale changes. At the same time, providers recognized the need to balance patience with leveraging the “window of opportunity” [p11] post-psychedelics, as insights can “get diluted” [p14] if not acted upon soon after psychedelic experiences. As one provider described: “Drawing on that joy is what gives people the ability to keep moving forward, right? But slowing it down means that it's not going to be harmful. You don't want someone packing up their house and leaving their family just because that's what their experience suggested they do.” [p12] Theme 8: Relationship Examination, Disruption and Distance Several providers described clients gaining awareness of relationship issues and unhealthy relational patterns following psychedelic experiences, making these challenges difficult to ignore any longer. One provider compared the experience of returning from a psychedelic journey to returning from an alcohol rehabilitation treatment center: “They feel like they've made the changes, they've got a system in place, but the partner at home or the family at home still sees or responds to the old person.” [p11] Some providers described how feeling misunderstood or perceived doubt by others in one’s transformation could lead to distress or hopelessness. Clients often faced difficulties—including relationship conflict, difficulty sustaining personal changes, or feeling misunderstood—when they changed, but those around them do not. As one provider described: “… they would go home to this family system that put them in the role of the dysfunctional scapegoat person and they would go back to the behaviors because that was the only way they were getting attention.” [p07] Psychedelics were also described as often prompting people to re-evaluate relationships. As a result, many clients sought integration support for making relational changes, such as leaving partners or redefining family relationships. One provider described a person deeply engaged in self and spiritual work who could no longer stay in a relationship with his partner, which he found “devastating” [p15]. The provider explained that the integration work centered on grieving his divorce and navigating this major life transition. Several providers spoke of clients experiencing feelings of loneliness or difficulty connecting with others following a psychedelic experience. One provider, for instance, described loneliness stemming from a client who couldn’t share a meaningful experience due to differing religious beliefs and stigma around psychedelic use. Another described a client who derived significant meaning from an LSD experience, yet felt unable to articulate their experience with others, explaining: “The more often he journeyed, the less able he felt to connect with people here.” [p17] This “loneliness in healing” can also stem from a lack of shared understanding, with one provider explaining: “Having people or loved ones… that are not on that that same path or don't see the value in shifting perspectives and oppressive of practices of life that keep people stuck or cause harm to other people, intentionally or unintentionally.” [p04] One provider noted that clients may experience “survival guilt” [p09], feeling they have escaped pain while others have not. Provider Approaches to Address Challenges Providers overwhelmingly encouraged clients to connect with others or build a supportive community following psychedelic experiences—whether through loved ones or peer support groups—to foster a sense of understanding, connection, and support, helping to prevent feelings of isolation. Sometimes, however, clients experienced barriers to establishing social support, as exemplified by the following quote: “ If there's barriers to cultivating community, then I would address the barriers. Barriers would be like social anxiety or certain phobias, insecurities.” [p04] While providers highlighted the value of sharing meaningful experiences with others, they also stressed that clients need to recognize that not everyone in their life will understand or accept their changes. One provider cautioned against sharing personal changes too soon, especially with those who may not understand: “There's a little bit of undermining that change, and so I think if we speak too early about our change… it can be a problem.” [p11] Several providers emphasized teaching clients mindfulness or self-regulation skills to enhance their internal resources for building relationships. Theme 9: Hope, Hype and the Aftermath of Disappointment Many providers noted that sensationalized media portrayals often create unrealistically high expectations, leading to disappointment and frustration when psychedelics do not provide a “magic bullet” solution. Some clients felt underwhelmed that “nothing happened” [p13], while others experienced some benefit but not to the degree they hoped: (“... there was progress, but not complete alleviation of their distress” [p05]). One client with treatment-resistant depression, for example found relief six months later: “ it didn't meet their expectations in the time frame, but within 1/2 a year it did.” [p04] Disappointment in psychedelic experiences was described as sometimes leading to hopelessness, self-disparagement, and reinforcing beliefs that one is “broken” [p18] or that “ there's something wrong with me” [p20]. Providers described how these feelings can be particularly intense if people have found insufficient or no relief in prior healing methods: “Many people are coming to these medicines after decades of being poorly treated by the mental health community… so they're looking to psychedelics often as their last hope.” [p02] Provider Approaches to Address Challenges While clients often expected healing to be linear, immediate, and “one and done” [p03, p13], providers described healing as a “zig zag” [p09], “spiral” [p08] or “nonlinear process” [p05]. To minimize the likelihood of disappointment providers emphasized setting realistic expectations in preparation, including around the non-linearity of healing and unfolding nature of integration. Several providers highlighted the importance of helping clients remain open during the psychedelic experience, reminding clients that its specific course can’t be controlled: “You're receiving something that has inherent wisdom, and it's not doing your bidding. It wants you to heal, it wants you to evolve, but it must be treated with respect, and it must be honored.” [p02] When disappointment arises, providers emphasized the need for empathy and psychoeducation around integration requiring “patience, time and attention” [p03]. Several shared the viewpoint that even disappointing or underwhelming experiences can offer valuable insights or foster deeper self-understanding. They discussed the importance of empathy, recognizing “subtle shifts” [p07] and exploring the meaning of the disappointment to the client, as it often reflects “a theme within the person's life that's amplified” [p13]. Others stressed the need to support clients in managing hopelessness, self-criticism and shame which can be reinforced by a disappointing psychedelic experience. Theme 10: Seeking Escape and Solace in Psychedelic Use Providers spoke to a subset of clients who have positive experiences with psychedelics but feel unable to heal without them, leading to a sense of dependency and grief. Some believe that psychedelics are the “only way that they can access spirituality” , self-love, or “feel OK with the state of the world. [p01]” This was described as sometimes leading to a “ transference to the medicine… as the source of power and healing. [p08]” One provider described a client who, after an MDMA experience, felt deeply connected to their partner but was now grieving the loss of that feeling of connection. Additionally, providers noted instances of 'spiritual bypassing,' where psychedelics were used by participants not to process pain but to avoid confronting it. Providers reported that some clients may repeatedly use psychedelics without adequately integrating their experiences. For instance, one provider explained that without proper integration: “Maybe they would come to believe the only way that they'll ever feel that love is by for themselves is by taking MDMA, which could result in compulsive use… creating another strategy to avoid pain.” [p01] Provider Approaches to Address Challenges Several providers emphasized the importance of supporting clients in confronting and working through painful content that surfaces during psychedelic experiences, rather than suppressing, "bypassing," or reengaging in old patterns. One provider explained the difference between using psychedelics for “vacation” versus “travel”: “Vacation is when you kind of draw away from your challenges into the familiar comfort of less responsibility and stress. Travel is where you go out and you learn something... It may be hard... But you may bring back a new understanding that makes you a more capable human being...” [p05] To address the idealization that clients can have around psychedelics, providers reported empowering clients to cultivate similar feelings or qualities through other modalities, while providing psychoeducation that psychedelics are not “the solution” [p18] or “the right tool for everyone at all times” [p18] . One provider, for instance, shared: “… if you can feel something on the medicine, you can experience a version of it. Maybe not the exact same, but that gives you something to work towards. Like if you want more intimacy, there's a hundred ways of developing more intimacy with your partner.” [p10] Discussion This qualitative study aimed to address gaps in understanding post-psychedelic integration challenges by exploring therapists' perspectives on these issues and the approaches they use to support clients. Research on integration remains limited, but prior studies on navigating existential distress and integration following psychedelic use highlight a range of helpful strategies, including grounding, spiritual and other personal practices, interpersonal support, having an interpretative framework (e.g., philosophical, scientific) for meaning-making, and creating space to actively integrate and apply insights (Argyri et al., 2024 ; Cowley-Court et al., 2023 ). Similarly, providers in our study highlighted the importance of fostering interpersonal support, offering frameworks and strategies to interpret and make sense of psychedelic experiences, and helping clients translate insights into actionable steps. Participants used a range of theoretical frameworks to guide their integration work (see Table 1 ). Most used Psychedelic Harm Reduction and Integration, which is a transtheoretical and transdiagnostic clinical approach that provides a framework for therapists to work compassionately with patients who are using or considering using psychedelics, without providing the actual psychedelic experience as part of treatment (Gorman et al., 2021 ). The majority also utilized Internal Family Systems therapy in their integration work, an approach that involves identifying and engaging with different “parts” of the self to cultivate a more balanced and harmonious “internal system” (Schwartz & Sweezy, 2019). Around half of providers used Somatic Experiencing to guide integration work, emphasizing attention to internal bodily sensations as a way to facilitate a “discharge process” in which the nervous system releases stored tension—particularly from past trauma (Kuhfuß et al., 2021). It is unknown to what degree the prevalence of these theoretical approaches generalizes to the general public, as our sample may not be representative. Across several themes, providers highlighted that integration challenges often arise when psychedelics surface difficult emotions, memories, or challenging insights related to oneself, one's worldview, or relationships. This aligns with research showing that psychedelics can lead to heightened emotions, resurfaced trauma, and new existential, relational or spiritual insights (Argyri et al., 2024 ; Cowley-Court et al., 2023 ; Evans et al., 2023 ; Johnstad, 2021 ). Providers in our study viewed painful surfaced content as often important to an person’s healing process, though they also identified the risk of clients becoming destabilized after challenging psychedelic experiences, potentially leading to a ‘crisis’ characterized by severe anxiety, trauma symptoms, psychosis, or mania, aligning with some past research (e.g., Dos Santos et al., 2017 ). Providers suggested that these risks could be mitigated through careful screening and harm reduction strategies before use, as well as gradual, cautious integration work that strengthens psychological resources (e.g., social support, coping skills) before confronting painful content. In crisis situations, providers emphasized the importance of helping people return to baseline and providing higher levels of support as needed. Difficulties with somatic responses were also observed, consistent with some limited prior psychedelic research (Barrett et al., 2016 ; Evans et al., 2023 ). One provider observed a client experiencing a “consistent shaking” experience, whereas another recounted a client attributing their experiences to a “kundalini awakening”— a spiritually transformative energetic experience (Woollacott et al., 2021 ). Though under-researched in the psychedelic field, such experiences have been documented as related to meditation (Lindahl et al., 2017 ) and as part of ‘spiritual emergencies’ in which states of heightened distress, often with a somatic component, are considered a part of the natural development process of spiritual growth and healing (Evans & Read, 2020 ). Many clients described by providers in the current study underwent a process of relationship examination, oftentimes experiencing loneliness, misunderstanding, or disruptions in relationships. This aligns with recent past work (Barrett et al., 2016 ; Bouso et al., 2022 ; Bremler et al., 2023 ; Evans et al., 2023 ) and the longstanding phenomenon of reintegration struggles after ecstatic experiences, such as Plato’s observation that ‘illuminated mystics’ often felt alienated from society (Bloom & Kirsch, 1968 ). Therefore, providers in this study often focused on helping clients build support systems, overcome barriers to connection, and reconnect with existing or new communities as essential aspects of integration. The finding that some clients struggled to understand the meaning of content from their psychedelic experience during integration aligns with past research indicating that having an interpretative framework (e.g., psychological, spiritual) can aid in integration (Argyri et al., 2024 ; Cowley-Court et al., 2023 ). It also echoes observations that Western participants may lack the cultural references necessary to understand and process the complex, abstract, and symbolic aspects of experiences like ayahuasca (Loizaga-Velder & Pazzi, 2014 ). In the current study, providers shared nuanced accounts of clients confronting previously unacknowledged memories of abuse or discovering that recollections of abuse represented symbolic emotional distress (e.g., feeling trapped). These findings build upon and provide further insights into the well-documented history of people sometimes feeling that they are vividly re-living past abuse or spontaneously recalling childhood memories during psychedelic use (e.g., Busch & Johnson, 1950 ). Providers recommended supporting clients in arriving at their own interpretations—whether literal or symbolic—while helping them understand how content from the psychedelic experience may fit within the broader context of their life. This non-directive approach in which clients lead the interpretive process is critical to trauma treatment and aligns with best practices for trauma-related conditions (Foa et al., 2007 ; Herman, 2023 ; Herman, 1992 ; Resick et al., 2024 ). Additionally, providers indicated that some people spontaneously recovered memories of abuse during psychedelic experiences, and came to understand these memories as true over time, which aligns with research on dissociative amnesia and the recollection of traumatic memories after a period of forgetting (Freyd, 1994 ; MacIntosh et al., 2016 ). Several themes in the current study emphasized the importance of thorough preparation, not only for the psychedelic experience itself but also for the integration phase afterward. While positive expectations can enhance outcomes in psychedelic trials (Aday et al., 2022 ), the current research suggests that excessively high expectations can become an obstacle to therapeutic growth, leading to disappointment or self-disparagement. Consistent with past research, providers noted that clients often have unrealistic expectations about psychedelics and the integration process (Earleywine et al., 2022 ), underscoring the need for realistic discussions about psychedelics, including the variability of its effects, and the potential for challenging experiences, such as resurfaced trauma, identity shifts, or disappointment—topics often overlooked in informed consent processes (Harrison, 2023 ). Setting realistic expectations can help clients prepare for these challenges and manage them more effectively during integration, which may require time and ongoing effort, particularly when significant life changes are involved. Several providers emphasized that even disappointing or underwhelming experiences can provide valuable insights and promote deeper self-understanding, while others cautioned against invalidating negative experiences or subscribing to the belief that “there is no such thing as a bad trip.” Recommendations for realistic integration expectations included aftercare plans and preparation for potential heightened sensitivity or emotionality when returning to daily life, consistent with prior literature (Gorman et al., 2021 ; Johnstad, 2021 ). Providers emphasized the need to inform clients that psychedelics may reveal the need for difficult life changes, such as ending relationships or quitting jobs. Those unable to make significant changes, commit to long-term integration, or seeking a "quick fix" may struggle more with integration. Providers highlighted the tension between helping clients seize a unique "window of opportunity" and advising caution to avoid impulsive decisions. The pace of integration can also be influenced by factors like privilege, time, and identity, with one provider highlighting the importance of a slower, more careful approach for BIPOC clients facing integration challenges related to racialized trauma. Providers in the current study observed that some clients may use psychedelics compulsively or to avoid challenges, aligning with the concept of “spiritual bypass”—using spiritual practices to avoid confronting psychological or emotional issues (Welwood, 2002 ). This finding aligns with other reported instances of spiritual bypass occurring within integration work (Aixalà, 2022 ; Gorman et al., 2021 ; Lutkajtis & Evans, 2023 ). While the prevalence of spiritual bypass is unknown, one ayahuasca retreat center owner estimated that 10% of people exhibit an “obsessive-compulsive relationship with the medicine,” likely due to insufficient integration (Marcus, 2023 ). Providers in the current study emphasized the importance of helping clients confront painful content and avoid idealizing psychedelics as a permanent solution, instead encouraging alternative modalities for healing and growth. The current study highlights the critical role of set and setting in determining outcomes, particularly the importance of a safe, trusting relationship with sitters or guides. It also underscores how boundary violations, or even subtle power dynamics, can significantly impact psychedelic experiences and cause harm. The risk of boundary violations, especially due to the vulnerability associated with psychedelic states, has been recognized in both psychedelic-assisted therapy (e.g., Meikle et al., 2024 ) and naturalistic use (Kruger et al., 2024 ). This risk emphasizes the need for therapists and facilitators to be trained in trauma-informed care, ethics, and cultural humility to prevent harm. The current study’s results must be interpreted within its context and limitations. This study focused on integration challenges during psychotherapy, a critical area given that adverse experiences are often under-reported in clinical and psychedelic trials, (de Laportalière et al., 2023 ; Ona et al., 2022 ). However, providers also highlighted numerous positive experiences and noted that difficulties were often seen as positive and valuable to the client’s healing process, aligning with past research (Bouso et al., 2022 ; Carbonaro et al., 2016 ; Cowley-Court et al., 2023 ; Lutkajtis & Evans, 2023 ), and frameworks that view challenging experiences as foundational to healing and spiritual growth (Evans & Read, 2020 ). Finally, although themes are presented as distinct in the results, they are often inter-connected; for instance, making sense of chaotic or confusing experiences (Theme 5) may interface with unearthed trauma (Theme 1). Our qualitative approach allowed for in-depth exploration of integration challenges and therapists’ strategies for addressing them. However, these findings are not exhaustive of all integration challenges, are influenced by the characteristics of the participant sample (predominantly white) and do not capture the frequency of various challenges. Since data were gathered from providers rather than clients, the findings reflect providers' interpretations, which may not fully align with clients' experiences. Quantitative research could complement these insights by systematically measuring the prevalence and impact of these challenges. Furthermore, to our knowledge, no research has examined how integration challenges may vary by use setting (e.g., ceremonial, therapy session, independent use, social environment)—examining how set and setting influence the challenges people face in integration represents an important future direction. Conclusions Integration challenges identified in this study—such as confronting unacknowledged pain, destabilization, struggles with daily life, integrating new beliefs, translating insights into action, re-examining relationships, loneliness, unmet expectations, and using psychedelics for escape—can guide training and preparation efforts for both clients and providers. To help develop an evidence-based psychedelic integration framework, further research should explore other integration challenges with diverse samples of clients and providers, identify core integration components, and evaluate their efficacy. Declarations Declarations Ethical Considerations Study procedures were approved by both the ethics committee at the Institute of Psychology at UiT (The Arctic University of Norway) and the Behavioral Health Research Collective's Institutional Review Board, approval number 051 in accordance with the Declaration of Helsinki. Consent to participate: Written informed consent was obtained for all participants. Consent for publication: Not applicable. Declaration of conflicting interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding Statement Internally funded. Author Contribution AK: data analysis, writing, study design, data collection; literature review; BP: feedback on study design and analysis, writing (editing); CC: writing (initial draft), data analysis; literature review; EK: data analysis, writing, study design, data collection; methods selection; literature review; ETN: feedback on study design and analysis, project supervision; JBL: feedback on study design and analysis, writing (editing); OE: data analysis, writing, study design, data collection, administrative/project coordination Acknowledgement During the preparation of this manuscript the authors used ChatGPT in order refine text and proof the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Data Availability Due to the sensitive and confidential nature of the data, full transcripts and raw data are not publicly available. 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J Psychopharmacol (Oxford England). 2023;37(7):733–48. https://doi.org/10.1177/02698811231158245 . APA PsycInfo®. Koslowski M, de Haas M-P, Fischmann T. Converging theories on dreaming: Between Freud, predictive processing, and psychedelic research. Front Hum Neurosci. 2023;17:9. https://doi.org/10.3389/fnhum.2023.1080177 . APA PsycInfo®. Kruger DJ, Aday JS, Fields CW, Kolbman N, Glynos N, Barron J, Herberholz M, Boehnke KF. Psychedelic Therapist Sexual Misconduct and Other Adverse Experiences Among a Sample of Naturalistic Psychedelic Users. Psychedelic Med. 2024;3(1). https://doi.org/10.1089/psymed.2024.0011 . psymed.2024.0011. Lindahl JR, Fisher NE, Cooper DJ, Rosen RK, Britton WB. The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoS ONE. 2017;12(5):e0176239. Loizaga-Velder A, Pazzi AL. Therapist and Patient Perspectives on Ayahuasca-Assisted Treatment for Substance Dependence. In: Labate BC, Cavnar C, editors. The Therapeutic Use of Ayahuasca. Berlin Heidelberg: Springer; 2014. pp. 133–52. https://doi.org/10.1007/978-3-642-40426-9_8 . Lutkajtis A, Evans J. Psychedelic integration challenges: Participant experiences after a psilocybin truffle retreat in the Netherlands. J Psychedelic Stud. 2023;6(3):211–21. https://doi.org/10.1556/2054.2022.00232 . MacIntosh HB, Fletcher K, Collin-Vézina D. As Time Went On, I Just Forgot About It: Thematic Analysis of Spontaneous Disclosures of Recovered Memories of Childhood Sexual Abuse. J Child Sex Abuse. 2016;25(1):56–72. https://doi.org/10.1080/10538712.2015.1042564 . Malterud K. Systematic text condensation: A strategy for qualitative analysis. Scand J Public Health. 2012;40(8):795–805. https://doi.org/10.1177/1403494812465030 . Marcus O. Everybody’s creating it along the way’: Ethical tensions among globalized ayahuasca shamanisms and therapeutic integration practices. Interdisc Sci Rev. 2023;48(5):712–31. https://doi.org/10.1080/03080188.2022.2075201 . Meikle S, Carter O, Bedi G. Psychedelic-assisted psychotherapy, patient vulnerability and abuses of power. Australian New Z J Psychiatry. 2024;58(2):104–6. https://doi.org/10.1177/00048674231200164 . Ona G, Kohek M, Bouso JC. The illusion of knowledge in the emerging field of psychedelic research. New Ideas Psychol. 2022;67:100967. https://doi.org/10.1016/j.newideapsych.2022.100967 . Perkins D, Schubert V, Simonová H, Tófoli LF, Bouso JC, Horák M, Galvão-Coelho NL, Sarris J. Influence of Context and Setting on the Mental Health and Wellbeing Outcomes of Ayahuasca Drinkers: Results of a Large International Survey. Front Pharmacol. 2021;12(April):1–13. https://doi.org/10.3389/fphar.2021.623979 . Resick PA, Monson CM, Chard KM. Cognitive processing therapy for PTSD: A comprehensive therapist manual. Guilford; 2024. https://books.google.com/books?hl=en&lr=& . id=P4ABEQAAQBAJ&oi=fnd&pg=PP1&dq=CPT,+cognitive+processing+therapy,+5th+edition&ots=H2sdFLE9VK&sig=mT6Aq0jR-BDBxRJAy9aQX4X7dnI. Sanabria E, Tófoli LF. (2025). Integration or commodification? A critical review of individual-centered approaches in psychedelic healing. Journal of Psychedelic Studies . https://akjournals.com/view/journals/2054/aop/article-10.1556-2054.2024.00411/article-10.1556-2054.2024.00411.xml Schwartz, R. C., & Sweezy, M. (2019). Internal family systems therapy . Guilford Publications. https://books.google.com/books?hl=en&lr=&id=ScqYDwAAQBAJ&oi=fnd&pg=PP1&dq=internal+family+systems+therapy&ots=84qnc3-xCL&sig=b_6TPpQKgs3znG1C_bKeQpuDf5c Siegel DJ. The developing mind: Toward a neurobiology of interpersonal experience. Guilford Press; 1999. Arnaud S, K. O., Sharpe D. Contextual Parameters Associated with Positive and Negative Mental Health in Recreational Psychedelic Users. J Psychoactive Drugs. 2023;55(1):30–9. https://doi.org/10.1080/02791072.2022.2039815 . van Elk M, Yaden DB. Pharmacological, neural, and psychological mechanisms underlying psychedelics: A critical review. Neurosci Biobehavioral Reviews. 2022;140:104793. Welwood J. Toward a psychology of awakening: Buddhism, psychotherapy, and the path of personal and spiritual transformation. Shambhala; 2002. Woollacott MH, Kason Y, Park RD. Investigation of the phenomenology, physiology and impact of spiritually transformative experiences–kundalini awakening. Explore. 2021;17(6):525–34. Yaden DB, Goldy SP, Weiss B, Griffiths RR. Clinically relevant acute subjective effects of psychedelics beyond mystical experience. Nat Reviews Psychol. 2024;3(9):606–21. Yaden DB, Griffiths RR. The Subjective Effects of Psychedelics Are Necessary for Their Enduring Therapeutic Effects. ACS Pharmacol Translational Sci. 2021;4(2):568–72. https://doi.org/10.1021/acsptsci.0c00194 . Yao Y, Guo D, Lu T-S, Liu F-L, Huang S-H, Diao M-Q, Li S-X, Zhang X-J, Kosten TR, Shi J, Bao Y-P, Lu L, Han Y. Efficacy and safety of psychedelics for the treatment of mental disorders: A systematic review and meta-analysis. Psychiatry Res. 2024;335:115886. https://doi.org/10.1016/j.psychres.2024.115886 . Additional Declarations No competing interests reported. Supplementary Files supplementaryonlinematerialspitch.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6874539","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494697603,"identity":"a9ef6f05-2ead-4e35-b239-1ac80f69604e","order_by":0,"name":"Christina Chwyl","email":"data:image/png;base64,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","orcid":"","institution":"Portland Institute for Psychedelic Science","correspondingAuthor":true,"prefix":"","firstName":"Christina","middleName":"","lastName":"Chwyl","suffix":""},{"id":494697604,"identity":"e84c3e2d-657c-42e9-80c7-ee311942ecb0","order_by":1,"name":"Odin S. 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Psychedelics comprise a class of psychoactive substances with the capacity to induce acute neurobiological effects, primarily through 5-HT2A receptor agonism, such as neuroplasticity, and acute psychological effects, including altered cognition, emotion, and perception, and sometimes feelings of interconnectedness, mystical and self-transcendent experiences (van Elk \u0026amp; Yaden, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Yaden et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These physiological and psychological effects are thought to synergistically promote wellbeing and mental health improvements (Yaden \u0026amp; Griffiths, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBeyond the acute effects of psychedelics, the \u0026lsquo;integration\u0026rsquo; period following psychedelic use is widely considered to be critical for reducing risks of harm, maximizing benefits and deriving therapeutic value from psychedelic experiences (Aixal\u0026agrave;, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bathje et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Approaches to integration have been conceptualized and practiced in wide-ranging ways and are shaped by varying theoretical and cultural frameworks (e.g., Indigenous, medical/psychological, Western perspectives). Bathje, Majeski and Kudowor (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) described integration, based on a synthesis of 24 definitions of integration found in the literature, as an active, ongoing process of making sense of and applying lessons from psychedelic experiences to foster internal (mind, body, and spirit) and external (lifestyle, social relations, natural world) balance. Similarly, Earleywine et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) define integration as a bridge from the psychedelic experience to daily life, facilitating lasting change and a sense of wholeness. Integration practices span multiple domains, including introspective, creative, somatic, health, relational, nature, mindfulness, ritual, and spiritual practices (Bathje et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite the presumed importance of psychedelic integration, it remains under-researched, with limited empirical data. In qualitative studies, participants frequently highlight the importance and value of integration sessions (Breeksema et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Quantitative findings suggest integration practices (e.g., meditation, yoga) may predict positive outcomes (Amada \u0026amp; Shane, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Griffiths et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Perkins et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; St. Arnaud \u0026amp; Sharpe, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), though most studies are cross-sectional and lack comprehensive or validated measurement of integration. A validated psychedelic integration measure was recently proposed (Frymann et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), but its application appears untested.\u003c/p\u003e\u003cp\u003eVery little empirical work has specifically examined integration challenges, though studies on challenging psychedelic experiences\u0026mdash;especially those that persist beyond the acute phase\u0026mdash;offer insight into difficulties people may face during integration. Compared to research examining acute challenges (e.g., difficult perceptual, emotional and physical experiences; Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Johnstad, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Koslowski et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), relatively few studies have examined persisting challenges after psychedelics\u0026mdash;the issues most relevant to integration. While most people appear to have positive psychedelic experiences, a subset report persisting psychological distress\u0026mdash;ranging from days to years\u0026mdash;leading some to seek professional or medical support (Bouso et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Carbonaro et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kopra et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Below, we review data on persisting challenges after psychedelic use.\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges Following Psychedelic Use\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA variety of challenging persisting after the acute psychedelic experiences have been identified in the literature. Emotional and psychological difficulties are among the most commonly reported. These include fear, anxiety, grief, depressive symptoms, and trauma-related symptoms, such as sleep disturbance/nightmares, or derealization and depersonalization (Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bouso et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Some people perceive the psychedelic experience itself as traumatic (Johnstad, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), potentially precipitating trauma-related symptoms, such as flashbacks of the psychedelic experience (Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Others report persisting fears of going insane (Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) or cognitive difficulties (e.g., poor concentration, distractibility) (Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor a small subset, elevated suicidality, self-harm or addictive behaviors (Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) are observed following psychedelic use. Manic and psychotic episodes following psychedelic use also appear rare, but are documented in several case reports and qualitative studies (Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Carbonaro et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), particularly, though not exclusively, amongst people with a personal or familial history of psychosis or mania (Dos Santos et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSocial and interpersonal difficulties, such as feelings of disconnection, loneliness, isolation, or stigmatization are commonly reported among the persisting challenges following psychedelic experiences (Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bouso et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Disconnection and isolation can arise when a person finds themselves at odds with the values prevailing in a society, such as materialism or rationalism (Grof \u0026amp; Grof, 2010).\u003c/p\u003e\u003cp\u003eSanabria and T\u0026oacute;foli (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) explain that the greater the gap between societal beliefs and psychedelic insights, the greater the need for integration. These insights can lead to foundational changes in beliefs about oneself, the world, and spirituality, which can create an \u0026lsquo;ontological shock\u0026rsquo;\u0026mdash;a foundational change in one's sense of reality or existence (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Persistent ontological and spiritual difficulties have been reported following psychedelic use (Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and Axial\u0026agrave; (2022) introduced \u0026lsquo;ontological integration\u0026rsquo; to describe the process of assimilating these new metaphysical or existential understandings. Such foundational changes can disrupt personal equilibrium, leading to significant life changes, such as relational challenges (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther persisting difficulties following psychedelic use reported in the literature include perceptual alterations, such as feeling attacked by the spirit world or experiencing persistent visual distortions (Bouso et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) such as occurs in Hallucinogen Persisting Perception Disorder (Ford et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Others report ongoing time perception and auditory processing distortions (Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Somatic difficulties, including physical distress and physiological symptoms such as fatigue, headaches, crying episodes, and weight fluctuations, have also been documented (Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntegration Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo our knowledge, only two empirical studies have specifically examined the challenges people encounter during the integration process, rather than general difficulties associated with psychedelic experiences. In one study, during a qualitative interview following a psilocybin retreat, a subset of participants spontaneously reported integration challenges (Lutkajtis \u0026amp; Evans, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Another qualitative study analyzed the integration experiences of ayahuasca drinkers (Cowley-Court et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Notably, no studies have investigated integration difficulties in the context of psychotherapy, or examined the integration challenges that facilitators observe in their work with clients.\u003c/p\u003e\u003cp\u003eConsistent with findings on persisting challenges after psychedelic experiences, during integration, participants have reported emotional, psychological, social, and somatic difficulties, such as re-experiencing the sensation of having birth, or persistent trembling, interpreted as a \u0026ldquo;transient cathartic after-effect\u0026rdquo; (Cowley-Court et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Lutkajtis \u0026amp; Evans, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). People also reported \u0026ldquo;post-ecstatic blues\u0026rdquo; arising from a disconnection from the peak psychedelic experience and heightened sensitivity or feeling \u0026ldquo;raw\u0026rdquo; (Lutkajtis \u0026amp; Evans, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Others reported needing time to re-adjust to daily life, aligning with recommendations from integration frameworks for people to plan for time to rest and recuperate after a psychedelic experience (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Aligning with the finding that people often experience ontological shifts after psychedelics, some participants following a psilocybin retreat experienced difficulties going back to their \u0026ldquo;old life\u0026rdquo; with new understandings (Lutkajtis \u0026amp; Evans, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIntegration frameworks also describe the importance of working with potential feelings of disappointment and unmet expectations during integration (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), as people may view psychedelics as a \u0026ldquo;panacea\u0026rdquo; (Earleywine et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and therefore become disappointed when difficulties are not resolved. Expectation management is key to addressing potential feelings of hopelessness and self-deficiency following underwhelming psychedelic experiences (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), especially as people may be accustomed to a medical model in which medications work via a more passive process, as opposed to someone actively healing themselves with the aid of a psychedelic (Marcus, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eCurrent Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAn improved understanding of the potential challenges following psychedelic experiences, and how these challenges can be overcome, is key to minimizing psychedelic harms, maximizing therapeutic potential, and advancing integration frameworks, which are currently not evidence-based (Greń et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, to our knowledge, only two empirical studies have evaluated integration challenges, and no studies have examined how therapists address these challenges, despite the recognized importance of integration therapy (Aixal\u0026agrave;, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This gap is particularly relevant as psychedelic use continues to rise, yet education on safe and effective use remains limited. The current study seeks to address these gaps by exploring the integration challenges therapists encounter in their work with clients. Specifically, the research aims to: 1) identify and investigate therapists' accounts of challenges clients face during integration therapy, and 2) examine the strategies therapists use to help clients navigate and address these challenges.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Study procedures were approved by both the Institute of Psychology at UiT (The Arctic University of Norway), and the Behavioral Health Research Collective's Institutional Review Board and the ethics committee, approval number 051, in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecruitment and Enrollment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants were recruited through a purposive sampling strategy involving invitations to potential participants or to online networks consisting of psychedelic integration therapists. Eligibility criteria were holding a current, active license as a mental health professional and having provided psychedelic integration support for experiences with classic psychedelics (e.g., psilocybin, ayahuasca, or lysergic acid diethylamide (LSD)) or 3,4-methylenedioxymethamphetamine (MDMA) to at least 15 clients. Ketamine was excluded because of the high degree of variability in the way that ketamine therapy is delivered (Heifets \u0026amp; Olson, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and potential different integration challenges.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOpen-ended, semi-structured interviews were conducted via Zoom by team members (ASRK, EWK, OSE) between September 2023 and November 2023, with each interview planned to last approximately 55 mintues. Prior to commencing the interview, participants provided written informed consent then completed a demographic survey. Interviews were conducted using a guide developed by the study team for this project through consensus, which is presented in full in the Supplementary Online Materials. Interviews questions centered on two main themes: (a) a description of integration challenges participants experienced with their clients; and (b) how they addressed those challenges. Interviews were digitally recorded and transcribed verbatim with the help of Microsoft 365. Quotations reported below are corrected for punctuation and repeated or filler words are removed to enhance readability.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData on integration challenges were analyzed with Systematic Text Condensation, a descriptive and explorative method for cross-case thematic analysis of qualitative data (Malterud, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This iterative process involves several stages, including data familiarization, initial coding, theme development, and refinement. The initial six transcripts were coded, and an initial coding framework was developed by ASRK, EWK, and OSE, in consultation with BP, JL, and ETN. Another team member (CC) then coded the remaining 14 transcripts in consultation with JL in batches of seven and refined these codes. Within each theme, key integration approaches and strategies employed by providers are discussed in the \u0026ldquo;Provider Approaches\u0026rdquo; sub-section. Participants, referred to as \u0026ldquo;providers,\u0026rdquo; are identified using the notation [p#].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20) were primarily white (90%) and cisgender women (70%) with diverse sexual orientations, utilizing a wide range of integration frameworks. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e details participant characteristics. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides an overview of themes and sub-themes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eParticipants characteristics\u003c/b\u003e (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSample Characteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCisgender woman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (70%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-binary/genderqueer/genderfluid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCisgender man\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrefer not to say\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSexual Orientation\u003c/b\u003e (more than one choice permitted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStraight/heterosexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQueer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePansexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBisexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrefer not to say\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace/Ethnicity\u003c/b\u003e (more than one choice permitted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (90%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic or Latinx\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack or African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAshkenazi Jewish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJewish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndigenous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePsychedelics Experienced with Integration\u003c/b\u003e (more than one choice permitted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsilocybin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMDMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAyahuasca\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (65%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKetamine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (65%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5-MeO-DMT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMescaline/Peyote/San Pedro\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCannabis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalvia divinorum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eApproximate Number of Integration Clients\u003c/b\u003e (excludes ketamine, ranges reflect participant-provided estimates and may not cover all possible values)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e75\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e550+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExperience with Indigenous Psychedelic Practices\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFormal Psychedelic Training Program\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (90%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMental Health License\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLicensed Professional Counselor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLicensed Clinical Social Worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLicensed Marriage and Family Therapist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychologist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLicensed Mental Health Counselor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLicensed Professional Counselor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheoretical Framework for Integration\u003c/b\u003e (more than one choice permitted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychedelic Harm Reduction and Integration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (90%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternal Family Systems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (80%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSomatic Experiencing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExistential Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsycho-Spiritual Integration Process\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptance and Commitment Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotion Focused Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychodynamic Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSensorimotor Integration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNature Contact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive Behavioral Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHolistic Model for a Balanced Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEMDR and Related Therapies (EMDR, EMDR resourcing, AF-EMDR and Dreamwork)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVisionary Plant Medicine Integration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychedelic Inclusive Model of the Psyche\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological Flexibility Model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestalt Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExpressive Arts Therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGuided Imagery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSAFETY (security, accessible, fluidity, empowering, transformational, yours)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLSD\u0026thinsp;=\u0026thinsp;lysergic acid diethylamide; EMDR\u0026thinsp;=\u0026thinsp;Eye Movement Desensitization and Reprocessing; AF-EMDR\u0026thinsp;=\u0026thinsp;Attachment Focused EMDR.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe following section describes each integration theme, including direct quotes from providers, followed by a section describing approaches that some providers offered in how to respond to each integration theme.\u003c/p\u003e\u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e Here]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverview of Integration Challenges Themes and Sub-Themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 1\u003c/b\u003e: Unearthed Trauma, Suppressed Emotion and Long-Avoided Pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 2\u003c/b\u003e: Destabilization and Psychological Crisis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSubtheme\u003c/b\u003e: Emergence/Exacerbation of Psychosis or Mania\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 3\u003c/b\u003e: Re-Adjusting to Daily Life Demands amidst New Insights and Heightened Sensitivity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 4\u003c/b\u003e: Relational and Systemic Harms from Boundary Violations, Misattunement, Objectification or Abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 5\u003c/b\u003e: Making Sense of Chaotic or Confusing Experiences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 6\u003c/b\u003e: Identity and Worldview Crisis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 7\u003c/b\u003e: Overwhelmed by the Magnitude of Change Needed to Integrate Insights\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 8\u003c/b\u003e: Relationship Examination, Disruption and Distance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 9\u003c/b\u003e: Hope, Hype and the Aftermath of Disappointment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTheme 10\u003c/b\u003e: Seeking Escape and Solace in Psychedelic Use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c2\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Unearthed Trauma, Suppressed Emotion and Long-Avoided Pain\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders described how following psychedelic experiences clients found it \u0026ldquo;impossible to ignore\u0026rdquo; [p14] painful emotions, grief, or trauma that had long been avoided, suppressed or minimized. Confronting previously unacknowledged content could lead to challenging emotional experiences, such as sadness, fear or confusion, especially given the swiftness and intensity of psychedelic-assisted healing:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's like there's been a natural disaster. And now it's calm. But I'm looking around and I'm seeing all the wreckage and the rubble that I have to clean up.\u0026rdquo;\u003c/em\u003e [p08]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne provider, for instance, described the experience of veterans who believed they had successfully suppressed painful memories, only to have them resurface:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It comes back in \u0026ndash; an experience where it becomes real again. So often they'll present with fear this is coming back. Is this how it's always going to be? Why is this happening? Why do I have to go back there?\u0026rdquo;\u003c/em\u003e [p12]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eProviders described how, oftentimes, there has been longstanding \u0026ldquo;repression of feelings\u0026rdquo; [p06] such as anger, sadness, grief or passion. One provider, for instance, spoke to a client in his 30s experiencing anger for the first time:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Now he has access to anger, and not in a bad way. The anger was never welcome and now he feels like he's sensitive and gets angry easily.\u0026rdquo;\u003c/em\u003e [p06]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePsychedelic experiences were also discussed as bringing clarity to the \u0026ldquo;depth of harm\u0026rdquo; [p01] caused by self-criticism or maladaptive coping behaviors (e.g., problematic substance use):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Suddenly they recognize that their substance abuse is a way that they've been dissociating from a tremendous amount of trauma and pain... They can no longer ignore the harms their coping strategies create anymore.\u0026rdquo;\u003c/em\u003e [p01]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders emphasized the importance of first creating a sense of safety, validation, and normalization when clients uncover pain or re-experience traumatic memories, which can help reduce feelings of anxiety, shame, guilt, and fear of judgment. One provider explained that while some people can worsen mentally and emotionally:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;There's a large majority of people that just need that contextualization of why? Why am I feeling worse?\u0026rdquo;\u003c/em\u003e [p10]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMany providers advocated for a gradual and staged approach to integration, beginning with strengthening a person\u0026rsquo;s coping abilities, distress tolerance, and internal and external resources. Some providers suggested psychoeducation on concepts like the \u0026ldquo;window of tolerance\u0026rdquo; (Siegel, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) allowing therapists and clients to collaboratively monitor arousal levels and ensure grounding throughout the process.\u003c/p\u003e\u003cp\u003eOnce distress is in a manageable range and the client has developed sufficient coping mechanisms, therapists facilitated meaning-making and processing of previously unaddressed pain, emotions, or trauma. This was accomplished using various psychological frameworks, often internal family systems (IFS) therapy, somatic work, and Eye Movement Desensitization and Reprocessing (EMDR). Additionally, some providers emphasized the importance of healthy emotional expression through practices like journaling, art, emotion identification and labeling, and cultivating mindful awareness of emotions and their physical sensations.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Destabilization and Psychological Crisis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile the last theme relates to clients who are experiencing challenges or some degree of disruption from confronting pain or previously unacknowledged thoughts or emotions, the current theme refers to cases where the client is in an acute crisis or significant episode of dysfunction. Providers noted that many clients fear such lasting negative changes from psychedelic experiences. As one provider described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;She's afraid that if the psychedelics show her the trauma that she has so skillfully pushed down out of consciousness for her whole life... then she will be unable to function.\u0026rdquo;\u003c/em\u003e [p16]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile these fears are often not realized, a subset of clients do become overwhelmed or destabilized. One provider highlighted a dichotomy between clients who \u0026ldquo;\u003cem\u003ereally make a lot of meaning, and they have all kinds of really supportive and compassionate insights\u0026rdquo;\u003c/em\u003e and those who become \u0026ldquo;\u003cem\u003estuck in that trauma, trauma-memory, trauma-experience.\u003c/em\u003e\u0026rdquo; [p03]\u003c/p\u003e\u003cp\u003eAnother provider highlighted the impact of processing intergenerational or collective trauma, which can lead to \u003cem\u003e\u0026ldquo;prolonged periods of terror, anxiety, despair.\u0026rdquo;\u003c/em\u003e [p02] In some cases, clients experienced somatic disruptions. One provider described a client experiencing \u0026ldquo;\u003cem\u003ea pretty consistent shaking experience\u0026rdquo;\u003c/em\u003e [p19] following psychedelic use, rendering the client temporarily unable to work.\u003c/p\u003e\u003cp\u003eProviders also observed cases where a crisis state emerged following psychedelic use, such as for a person who took psilocybin alone and felt she was in a \u003cem\u003e\u0026ldquo;void\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;eternal blackness,\u0026rdquo;\u003c/em\u003e leading to depression and post-traumatic stress disorder (PTSD) symptoms (e.g., hypervigilance, anxiety, anger outbursts, sleep disruptions) [p17]. While her symptoms reportedly improved over the following year, she continued to struggle with her mental health and connecting with others: \u0026ldquo;\u003cem\u003eThe trauma of that strong dosing experience continued to linger in her.\u0026rdquo;\u003c/em\u003e [p17]\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubtheme 2a: Emergence/Exacerbation of Psychosis or Mania\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome providers noted mania or psychosis emerging after psychedelic use, particularly in clients with a family history of bipolar disorder or psychosis or when the experience was \u003cem\u003e\u0026ldquo;just too much, too fast.\u0026rdquo;\u003c/em\u003e [p17] Some noted that unresolved trauma can mimic psychosis at times. One provider described a client who believed they were experiencing psychosis after a psychedelic experience, though the provider attributed their symptoms to PTSD flashbacks. Another provider described a man in his 40s who had experienced significant developmental and recent trauma who had the emergence of psychosis-like symptoms after ayahuasca, interpreting it as the development of spiritual powers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;He interpreted it as a kundalini awakening shamanic thing, that he was developing spiritual powers\u0026hellip; so spiritual delusions. Or at least a spiritual or magical framework is what he used.\u0026rdquo;\u003c/em\u003e [p16]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges.\u003c/b\u003e Providers observed that when an individual does not have the necessary resources to navigate pain, they can turn to unhealthy coping mechanisms, such as problematic substance use, compulsive spending, self-destructive behaviors, risky behaviors, \u0026ldquo;dopamine seeking behavior to make pain go away\u0026rdquo; [p10], and, in the worst-case scenario, self-harm or suicide. As one provider explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; the issue I have with unskilled facilitators prescribing high dose psychedelics is that sometimes, it can outstrip a clients window of tolerance and outstrip their existing coping strategies.\u0026rdquo;\u003c/em\u003e [p02]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCrisis management, entailing helping clients regain emotional safety, providing skills-based support, and assisting clients in returning to baseline, was reported as essential. One provider underscored the need to approach destabilization as \u003cem\u003e\u0026ldquo;both as a spiritual event and a mental health slash medical event.\u0026rdquo;\u003c/em\u003e [p18] While some providers believed all psychedelic experiences, even difficult ones, could offer valuable insights (i.e. \u0026ldquo;there is no such thing as a bad trip\u0026rdquo;), others cautioned against dismissing the potential trauma of a negative experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there's very much such a thing as a bad trip and validating clients in that experience is really important when a client says \u0026lsquo;that was chaos\u0026rsquo;\u0026hellip; rather than moving straight towards like, well, is there anything you could learn from it?\u0026rdquo;\u003c/em\u003e [p18]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eProviders saw strong preparation work as one of the most effective ways to reduce the likelihood of post-experience integration challenges. To mitigate the likelihood of destabilization or psychological crisis, providers overwhelmingly emphasized the need for preparation and harm reduction steps, such as going low and slow and ensuring a safe, supportive environment. Providers emphasized the importance of proper screening in the preparation phase (e.g., psychosis and mania histories), and cautioned that psychedelics are not suitable for everyone:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; these are safe medicines when used safely, but they are powerful. We're entering into the realm of the unknown, and there should always be that humility going in.\u0026rdquo;\u003c/em\u003e [p02]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eProviders also stressed the importance of identifying additional supports before psychedelic use and referring to higher levels of care when necessary, sometimes including hospitalization.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Re-Adjusting to Daily Life Demands Amidst New Insights and Heightened Sensitivity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders highlighted the challenges of balancing healing and integration work with work, family and daily responsibility demands/obligations. Many clients struggle with having new insights or feeling better after a psychedelic experience, only to return to the same life stressors:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The work of integration is, how do I go back into a job or a relationship when I have all these new insights about myself and about my life and the rest of the world is still the same?\u0026rdquo;\u003c/em\u003e [p14]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I've had this big experience, but I'm right back in my box. How can I make myself safe enough to continue exploring?\u0026rdquo;\u003c/em\u003e [p03]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile providers reported that many clients wish for more time to readjust to themselves, relationships, professional responsibilities, and financial obligations often force them to \u003cem\u003e\u0026ldquo;get back to the rhythm of their life\u0026hellip; earlier than they would like.\u0026rdquo;\u003c/em\u003e [p04] Heightened sensitivity, which could range from days to a year following psychedelic use, could exacerbate difficulties returning to daily life. One provider described a common feeling of \u003cem\u003e\u0026ldquo;having shed a layer of skin, making you more sensitive\u0026rdquo;\u003c/em\u003e [p06], with some clients struggling to return to their routines:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They just need more space\u0026hellip; just feeling like I can't just get back in this system I've been part of. I can't just work 50 hours a week and do all this other stuff I'm doing.\u0026rdquo;\u003c/em\u003e [p06]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRelational demands also add to integration challenges. One provider described a parent of young children struggling to take alone time:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;She literally goes and sits in her closet with noise cancelling headphones on as many people with autism want to do. But then she feels like she's not allowed to do that.\u0026rdquo;\u003c/em\u003e [p08]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, clients in an \u003cem\u003e\u0026ldquo;open, vulnerable state from the session\u0026rdquo;\u003c/em\u003e [p09] may be more affected by their external environment, and in some cases, this heightened sensitivity can lead to \u0026ldquo;spiritual crises\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Just feeling very open for an extended period of time and connecting to spiritual entities.\u0026rdquo;\u003c/em\u003e [p04]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo help clients navigate readjustment difficulties, often amidst heightened sensitivity, providers encouraged proactive preparation\u0026mdash;setting aside space and time for integration, for example by taking time off from work, whenever possible. However, many acknowledged that not all clients have the privilege to do so and that these challenges are, to some extent, unavoidable. Several therapists linked the difficulty of re-adjusting to daily life to a clash between the slow process, emotionally intense process of healing (see Theme 1) and the fast-paced demands of capitalistic society. One practitioner contrasted the deep work of integration with the realities of survival, stating:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You have to go to work every day. You don\u0026rsquo;t have time to just sit and journal and feel things.\u0026rdquo;\u003c/em\u003e [p16]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 4: Relational and Systemic Harms from Boundary Violations, Misattunement, Objectification, or Abuse\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders described how harms arise from relational ruptures (where the client felt unsafe with the facilitator), boundary violations, systemic oppression, and insufficient or mis-attuned support during psychedelic experiences often led to prolonged distress in the integration process.\u003c/p\u003e\u003cp\u003eClients often sought integration support following psychedelic experiences marked by cultural misattunement or a lack of responsivity to their specific needs. For instance, one provider described a client who had a positive MDMA experience but struggled with an integration process that emphasized spirituality when they preferred a secular approach. Another provider shared the experience of a musician who felt pressured to listen to \u0026ldquo;\u003cem\u003ea very particular kind of music that was just not resonant at all,\u0026rdquo;\u003c/em\u003e during a psilocybin session, leading him to later seek integration support in which \u003cem\u003e\u0026ldquo;he could be held with a bit more spaciousness\u0026hellip; he could be trusted to make some of his own choices in a medicine space.\u0026rdquo;\u003c/em\u003e [p18]\u003c/p\u003e\u003cp\u003eProviders also recounted instances of neglect and abuse during psychedelic sessions, which left clients distressed and seeking integration support to process the harm. For example, a provider recounted an ayahuasca experience in which the facilitator \u003cem\u003e\u0026ldquo;behaved inappropriately\u0026hellip; didn't respect her boundaries and didn't understand the way in which she was asking for her help and ended up causing more harm.\u0026rdquo;\u003c/em\u003e [p15]\u003c/p\u003e\u003cp\u003eSystemic oppression was discussed as amplifying harms for people with marginalized identities. One provider described a Chinese woman who felt threatened during an ayahuasca ceremony, where she was prevented from leaving or contacting her mother. This experience left her in a distressed state, unable to sleep or eat. Both racial and gender dynamics heightened the client\u0026rsquo;s distress, as she perceived a power imbalance in the retreat setting and later sought a female integration therapist for support. Providers also spoke about the challenges of integration amidst racialized trauma:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;BIPOC self-identified folks\u0026hellip; feel a sense of othering in community and society, and sometimes in their psychedelic work\u0026hellip; How can we integrate an experience like that where someone may really not feel safe in their body or safe in community?\u0026rdquo;\u003c/em\u003e [p03]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo minimize relational harm, providers emphasized the need for thorough preparation, including discussions about trauma history, relational patterns, and trust. Providers also emphasized the importance of establishing a good fit between provider and client, particularly around \u003cem\u003e\u0026ldquo;safety or cultural resonance\u0026rdquo;\u003c/em\u003e [p08]. Special care was recommended for clients with trauma histories, as ruptures in therapeutic relationships can reinforce negative core beliefs. Creating a safe space with clients was described as essential. For clients integrating psychedelic experiences amidst racial trauma, one provider emphasized moving \u003cem\u003e\u0026ldquo;really slowly\u0026rdquo;\u003c/em\u003e [p03], recognizing the added challenges of navigating identity and community.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 5: Making Sense of Chaotic or Confusing Experiences\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile providers spoke of some clients who gain significant clarity on their path forward following psychedelic experiences, others feel \u003cem\u003e\u0026ldquo;completely freaked out and confused\u0026rdquo;\u003c/em\u003e [p12], by the experience or unable to understand it:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It felt random or it felt chaotic. And so they're a little confused about what to do with it afterwards, right? So it challenges them in that it's not some straight answer or they don't just suddenly feel better.\u0026rdquo;\u003c/em\u003e [p17]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants specifically highlighted the challenge of making sense of trauma, often involving the difficult task of navigating complex emotions such as anger, grief, confusion and blame directed toward parents, caregivers, or other authority figures. Several providers described cases where repressed experiences of abuse resurfaced, leading to significant turmoil and confusion about the authenticity and meaning of the experience. For example, one provider described a client who had a \u003cem\u003e\u0026ldquo;very, very vivid sense of having been molested as a child by his father\u0026rdquo;\u003c/em\u003e after an ayahuasca ceremony, which especially distressed him because he had an \u003cem\u003e\u0026ldquo;amazing relationship with this father\u0026rdquo;\u003c/em\u003e throughout his life. After this experience, the provider explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;He spent two years in a state of utter confusion\u0026hellip; because it didn't fit the narrative or lived experience of his life\u0026hellip; But he couldn't shake the thought right. He had this idea that was this a repressed memory.\u0026rdquo;\u003c/em\u003e [p18]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo help clients navigate confusion around identity and meaning following psychedelic experiences, providers shared the importance of supporting clients in arriving at their own conclusions, facilitating reflection through open-ended questions, and adopting an exploratory stance rather than imposing interpretations. Some providers highlighted the value of embracing ambiguity and acceptance around uncertainty:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;People want closure. I've done it, fixed it and let go. But to be open to this non closure, it's continuing.\u0026rdquo;\u003c/em\u003e [p11]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen clients encounter possible abuse memories during sessions, providers stressed the importance of a sensitive, non-directive approach, recognizing that such memories could be authentic/literal or symbolic:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Integration has to be seen through the lens of understanding that the mushroom speaks in in symbolic language\u0026hellip;\u0026rdquo;\u003c/em\u003e [p02]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eProviders also suggested helping clients contextualize psychedelic insights within their life histories for clarity. One provider shared an example of a client who came to realize that an emergent memory of sexual assault likely symbolized a feeling of being trapped rather than a repressed event. Another described how recalling a childhood abuse memory helped one client \u003cem\u003e\u0026ldquo;put the puzzle pieces together\u0026rdquo;\u003c/em\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It explains symptoms they have manifested over the decades, such as suicidal ideation, non-suicidal self-harm, eating-disorders, depression, anxiety, difficulty with sexual intimacy\u0026hellip;\u0026rdquo;\u003c/em\u003e [p12]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 6: Identity and Worldview Crisis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders described clients grappling with existential questions and shifts in worldview and identity. Psychedelics could highlight incongruencies between a client\u0026rsquo;s current life or between their current and authentic self, often causing distress:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; that chasm, that gap between their authentic life and self-expression and the life that they're living can become a great source of pain once it's in awareness.\u0026rdquo;\u003c/em\u003e [p01]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIntegrating insights around identity and worldview can be especially challenging when material from the psychedelic experience contradicts a person\u0026rsquo;s cultural values or \u003cem\u003e\u0026ldquo;concept of who they are\u0026rdquo; [p15].\u003c/em\u003e In these instances, people may experience an \u0026ldquo;\u003cem\u003eexistential or identity crisis\u0026rdquo; [p19]\u003c/em\u003e, or struggle to \u003cem\u003e\u0026ldquo;redefine who that person is\u0026rdquo;\u003c/em\u003e [p07]. For several clients, integration work encompasses questioning and working through sexual orientation and gender identity. One provider, for example, highlighted the challenge of working with internalized biases and systems of oppression, such as heterosexism, xenophobia, antisemitism and sexism:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I grew up in the Bible Belt in America so\u0026hellip; why would I ever accept that I could be gay? Really helping people work with that deep pain of systems of oppression that they've internalized has been really challenging....\u0026rdquo;\u003c/em\u003e [p10]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eClients often also re-examine their religious or spiritual beliefs. One provider described a client who had a \u0026ldquo;\u003cem\u003ebig God opening experience, realizing there is meaning\u0026rdquo;\u003c/em\u003e [p17]. However, in the months that followed, they struggled with how to reshape their life to align with these newfound beliefs. Another provider described a client whose psychedelic experience shattered his beliefs about the afterlife, leaving him feeling that his past choices were based on a \u003cem\u003e\u0026ldquo;wrong assumption\u0026rdquo;\u003c/em\u003e [p09]. This triggered a crisis of him wanting to change everything about his life, including his parenting, relationships, and business: \u003cem\u003e\u0026ldquo;He was in a state of depression, despair, and conflict in his environment.\u0026rdquo;\u003c/em\u003e [p09]\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders emphasized the need for strong support when psychedelic insights radically shift self-understanding or worldview. One provider described a client confronting unacknowledged abuse, underscoring the importance of guidance through the shattering of their relationship beliefs and the potential loss of the \u003cem\u003e\u0026ldquo;narrative of their life.\u0026rdquo;\u003c/em\u003e [p09]\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 7: Overwhelmed by the Magnitude of Change Needed to Integrate Insights\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInsights gleaned from psychedelic experiences were described by providers as often daunting and overwhelming for clients, as they can call for major life changes, such as working through addiction, changing jobs, moving locations, or changing relationships:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eA psychedelic sends the message to the client that \u0026lsquo;hey, you need to be responsible\u0026hellip; You can't keep drinking. You can't keep cheating on your spouse. You need to get out of this soul sucking job.\u0026rsquo;\u0026rdquo;\u003c/em\u003e [p02]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eProviders described clients as often unprepared for the lasting effects catalyzed by the psychedelic experience. One provider shared how a client was overwhelmed by the realization that a 6-hour psilocybin experience would take \u003cem\u003e\u0026ldquo;months and weeks to make sense of.\u0026rdquo;\u003c/em\u003e [p10]\u003c/p\u003e\u003cp\u003eFor some clients, there can be a feeling of urgency or necessity to implement changes, as \u003cem\u003e\u0026ldquo;once it's conscious, then it suddenly there is a necessity to start working with it\u0026rdquo;\u003c/em\u003e [p01]. Another provider described how after the initial \u003cem\u003e\u0026ldquo;excitement\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;positive effects of the journey\u0026rdquo;\u003c/em\u003e [p09] fade, people confront the reality of their unresolved issues. They shared the example of a client who had been depressed for 20 years suddenly feeling that their depression is lifted, then experiencing regret, telling themselves the following:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026lsquo;I haven't paid my taxes for 20 years\u0026rsquo;, \u0026lsquo;I wanted to have kids, but I didn't\u0026rsquo;, and \u0026lsquo;now I'm not able to have kids anymore\u0026rsquo;. \u0026lsquo;I haven't spent time with my family, and I cannot take it back.\u0026rsquo;\u0026rdquo;\u003c/em\u003e [p09]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhen insights from psychedelic experiences call for major changes in peoples\u0026rsquo; lives, providers noted that people often face fear, \u003cem\u003e\u0026ldquo;ambivalence\u0026hellip; inner conflict\u0026rdquo;\u003c/em\u003e [p16], or avoidance, which can cause integration work to \u003cem\u003e\u0026ldquo;come to a standstill.\u0026rdquo;\u003c/em\u003e [p10]\u003c/p\u003e\u003cp\u003eIn contrast, another key challenge mentioned by several providers was slowing clients down from making major life changes when they feel an urgency or excitement to make major changes quickly:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I found it very challenging to work with\u0026mdash;the level of anxiety and urgency that they had. And a lot of the things that I was recommending just were not landing well because they didn't work immediately.\u0026rdquo;\u003c/em\u003e [p20]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome providers recommended that participants refrain from making big decisions for a period (e.g., a month) following a psychedelic experience. Others advised focusing on small, gradual, values-aligned actions instead of quick large-scale changes. At the same time, providers recognized the need to balance patience with leveraging the \u003cem\u003e\u0026ldquo;window of opportunity\u0026rdquo;\u003c/em\u003e [p11] post-psychedelics, as insights can \u003cem\u003e\u0026ldquo;get diluted\u0026rdquo;\u003c/em\u003e [p14] if not acted upon soon after psychedelic experiences. As one provider described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Drawing on that joy is what gives people the ability to keep moving forward, right? But slowing it down means that it's not going to be harmful. You don't want someone packing up their house and leaving their family just because that's what their experience suggested they do.\u0026rdquo;\u003c/em\u003e [p12]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 8: Relationship Examination, Disruption and Distance\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral providers described clients gaining awareness of relationship issues and unhealthy relational patterns following psychedelic experiences, making these challenges difficult to ignore any longer. One provider compared the experience of returning from a psychedelic journey to returning from an alcohol rehabilitation treatment center:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They feel like they've made the changes, they've got a system in place, but the partner at home or the family at home still sees or responds to the old person.\u0026rdquo;\u003c/em\u003e [p11]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome providers described how feeling misunderstood or perceived doubt by others in one\u0026rsquo;s transformation could lead to distress or hopelessness. Clients often faced difficulties\u0026mdash;including relationship conflict, difficulty sustaining personal changes, or feeling misunderstood\u0026mdash;when they changed, but those around them do not. As one provider described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; they would go home to this family system that put them in the role of the dysfunctional scapegoat person and they would go back to the behaviors because that was the only way they were getting attention.\u0026rdquo;\u003c/em\u003e [p07]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePsychedelics were also described as often prompting people to re-evaluate relationships. As a result, many clients sought integration support for making relational changes, such as leaving partners or redefining family relationships. One provider described a person deeply engaged in self and spiritual work who could no longer stay in a relationship with his partner, which he found \u003cem\u003e\u0026ldquo;devastating\u0026rdquo;\u003c/em\u003e [p15]. The provider explained that the integration work centered on grieving his divorce and navigating this major life transition.\u003c/p\u003e\u003cp\u003eSeveral providers spoke of clients experiencing feelings of loneliness or difficulty connecting with others following a psychedelic experience. One provider, for instance, described loneliness stemming from a client who couldn\u0026rsquo;t share a meaningful experience due to differing religious beliefs and stigma around psychedelic use. Another described a client who derived significant meaning from an LSD experience, yet felt unable to articulate their experience with others, explaining: \u003cem\u003e\u0026ldquo;The more often he journeyed, the less able he felt to connect with people here.\u0026rdquo;\u003c/em\u003e [p17]\u003c/p\u003e\u003cp\u003eThis \u0026ldquo;loneliness in healing\u0026rdquo; can also stem from a lack of shared understanding, with one provider explaining:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Having people or loved ones\u0026hellip; that are not on that that same path or don't see the value in shifting perspectives and oppressive of practices of life that keep people stuck or cause harm to other people, intentionally or unintentionally.\u0026rdquo;\u003c/em\u003e [p04]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne provider noted that clients may experience \u003cem\u003e\u0026ldquo;survival guilt\u0026rdquo;\u003c/em\u003e [p09], feeling they have escaped pain while others have not.\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders overwhelmingly encouraged clients to connect with others or build a supportive community following psychedelic experiences\u0026mdash;whether through loved ones or peer support groups\u0026mdash;to foster a sense of understanding, connection, and support, helping to prevent feelings of isolation. Sometimes, however, clients experienced barriers to establishing social support, as exemplified by the following quote:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIf there's barriers to cultivating community, then I would address the barriers. Barriers would be like social anxiety or certain phobias, insecurities.\u0026rdquo;\u003c/em\u003e [p04]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile providers highlighted the value of sharing meaningful experiences with others, they also stressed that clients need to recognize that not everyone in their life will understand or accept their changes. One provider cautioned against sharing personal changes too soon, especially with those who may not understand:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There's a little bit of undermining that change, and so I think if we speak too early about our change\u0026hellip; it can be a problem.\u0026rdquo;\u003c/em\u003e [p11]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSeveral providers emphasized teaching clients mindfulness or self-regulation skills to enhance their internal resources for building relationships.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 9: Hope, Hype and the Aftermath of Disappointment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMany providers noted that sensationalized media portrayals often create unrealistically high expectations, leading to disappointment and frustration when psychedelics do not provide a \u0026ldquo;magic bullet\u0026rdquo; solution.\u003c/p\u003e\u003cp\u003eSome clients felt underwhelmed that \u003cem\u003e\u0026ldquo;nothing happened\u0026rdquo;\u003c/em\u003e [p13], while others experienced some benefit but not to the degree they hoped: \u003cem\u003e(\u0026ldquo;... there was progress, but not complete alleviation of their distress\u0026rdquo;\u003c/em\u003e [p05]). One client with treatment-resistant depression, for example found relief six months later: \u0026ldquo;\u003cem\u003eit didn't meet their expectations in the time frame, but within 1/2 a year it did.\u0026rdquo;\u003c/em\u003e [p04]\u003c/p\u003e\u003cp\u003eDisappointment in psychedelic experiences was described as sometimes leading to hopelessness, self-disparagement, and reinforcing beliefs that one is \u003cem\u003e\u0026ldquo;broken\u0026rdquo;\u003c/em\u003e [p18] or that \u0026ldquo;\u003cem\u003ethere's something wrong with me\u0026rdquo;\u003c/em\u003e [p20]. Providers described how these feelings can be particularly intense if people have found insufficient or no relief in prior healing methods:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Many people are coming to these medicines after decades of being poorly treated by the mental health community\u0026hellip; so they're looking to psychedelics often as their last hope.\u0026rdquo;\u003c/em\u003e [p02]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile clients often expected healing to be linear, immediate, and \u003cem\u003e\u0026ldquo;one and done\u0026rdquo;\u003c/em\u003e [p03, p13], providers described healing as a \u003cem\u003e\u0026ldquo;zig zag\u0026rdquo;\u003c/em\u003e [p09], \u003cem\u003e\u0026ldquo;spiral\u0026rdquo;\u003c/em\u003e [p08] or \u003cem\u003e\u0026ldquo;nonlinear process\u0026rdquo;\u003c/em\u003e [p05]. To minimize the likelihood of disappointment providers emphasized setting realistic expectations in preparation, including around the non-linearity of healing and unfolding nature of integration. Several providers highlighted the importance of helping clients remain open during the psychedelic experience, reminding clients that its specific course can\u0026rsquo;t be controlled:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You're receiving something that has inherent wisdom, and it's not doing your bidding. It wants you to heal, it wants you to evolve, but it must be treated with respect, and it must be honored.\u0026rdquo;\u003c/em\u003e [p02]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen disappointment arises, providers emphasized the need for empathy and psychoeducation around integration requiring \u003cem\u003e\u0026ldquo;patience, time and attention\u0026rdquo;\u003c/em\u003e [p03]. Several shared the viewpoint that even disappointing or underwhelming experiences can offer valuable insights or foster deeper self-understanding. They discussed the importance of empathy, recognizing \u003cem\u003e\u0026ldquo;subtle shifts\u0026rdquo;\u003c/em\u003e [p07] and exploring the meaning of the disappointment to the client, as it often reflects \u003cem\u003e\u0026ldquo;a theme within the person's life that's amplified\u0026rdquo;\u003c/em\u003e [p13]. Others stressed the need to support clients in managing hopelessness, self-criticism and shame which can be reinforced by a disappointing psychedelic experience.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 10: Seeking Escape and Solace in Psychedelic Use\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders spoke to a subset of clients who have positive experiences with psychedelics but feel unable to heal without them, leading to a sense of dependency and grief. Some believe that psychedelics are the \u003cem\u003e\u0026ldquo;only way that they can access spirituality\u0026rdquo;\u003c/em\u003e, self-love, or \u003cem\u003e\u0026ldquo;feel OK with the state of the world. [p01]\u0026rdquo;\u003c/em\u003e This was described as sometimes leading to a \u0026ldquo;\u003cem\u003etransference to the medicine\u0026hellip; as the source of power and healing. [p08]\u0026rdquo;\u003c/em\u003e One provider described a client who, after an MDMA experience, felt deeply connected to their partner but was now grieving the loss of that feeling of connection.\u003c/p\u003e\u003cp\u003eAdditionally, providers noted instances of 'spiritual bypassing,' where psychedelics were used by participants not to process pain but to avoid confronting it. Providers reported that some clients may repeatedly use psychedelics without adequately integrating their experiences. For instance, one provider explained that without proper integration:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe they would come to believe the only way that they'll ever feel that love is by for themselves is by taking MDMA, which could result in compulsive use\u0026hellip; creating another strategy to avoid pain.\u0026rdquo;\u003c/em\u003e [p01]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProvider Approaches to Address Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral providers emphasized the importance of supporting clients in confronting and working through painful content that surfaces during psychedelic experiences, rather than suppressing, \"bypassing,\" or reengaging in old patterns. One provider explained the difference between using psychedelics for \u0026ldquo;vacation\u0026rdquo; versus \u0026ldquo;travel\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Vacation is when you kind of draw away from your challenges into the familiar comfort of less responsibility and stress. Travel is where you go out and you learn something... It may be hard... But you may bring back a new understanding that makes you a more capable human being...\u0026rdquo;\u003c/em\u003e [p05]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo address the idealization that clients can have around psychedelics, providers reported empowering clients to cultivate similar feelings or qualities through other modalities, while providing psychoeducation that psychedelics are not \u003cem\u003e\u0026ldquo;the solution\u0026rdquo; [p18]\u003c/em\u003e or \u003cem\u003e\u0026ldquo;the right tool for everyone at all times\u0026rdquo; [p18]\u003c/em\u003e. One provider, for instance, shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; if you can feel something on the medicine, you can experience a version of it. Maybe not the exact same, but that gives you something to work towards. Like if you want more intimacy, there's a hundred ways of developing more intimacy with your partner.\u0026rdquo; [p10]\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study aimed to address gaps in understanding post-psychedelic integration challenges by exploring therapists' perspectives on these issues and the approaches they use to support clients.\u003c/p\u003e\u003cp\u003eResearch on integration remains limited, but prior studies on navigating existential distress and integration following psychedelic use highlight a range of helpful strategies, including grounding, spiritual and other personal practices, interpersonal support, having an interpretative framework (e.g., philosophical, scientific) for meaning-making, and creating space to actively integrate and apply insights (Argyri et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Cowley-Court et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Similarly, providers in our study highlighted the importance of fostering interpersonal support, offering frameworks and strategies to interpret and make sense of psychedelic experiences, and helping clients translate insights into actionable steps.\u003c/p\u003e\u003cp\u003eParticipants used a range of theoretical frameworks to guide their integration work (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most used Psychedelic Harm Reduction and Integration, which is a transtheoretical and transdiagnostic clinical approach that provides a framework for therapists to work compassionately with patients who are using or considering using psychedelics, without providing the actual psychedelic experience as part of treatment (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The majority also utilized Internal Family Systems therapy in their integration work, an approach that involves identifying and engaging with different \u0026ldquo;parts\u0026rdquo; of the self to cultivate a more balanced and harmonious \u0026ldquo;internal system\u0026rdquo; (Schwartz \u0026amp; Sweezy, 2019). Around half of providers used Somatic Experiencing to guide integration work, emphasizing attention to internal bodily sensations as a way to facilitate a \u0026ldquo;discharge process\u0026rdquo; in which the nervous system releases stored tension\u0026mdash;particularly from past trauma (Kuhfu\u0026szlig; et al., 2021). It is unknown to what degree the prevalence of these theoretical approaches generalizes to the general public, as our sample may not be representative.\u003c/p\u003e\u003cp\u003eAcross several themes, providers highlighted that integration challenges often arise when psychedelics surface difficult emotions, memories, or challenging insights related to oneself, one's worldview, or relationships. This aligns with research showing that psychedelics can lead to heightened emotions, resurfaced trauma, and new existential, relational or spiritual insights (Argyri et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Cowley-Court et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Johnstad, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Providers in our study viewed painful surfaced content as often important to an person\u0026rsquo;s healing process, though they also identified the risk of clients becoming destabilized after challenging psychedelic experiences, potentially leading to a \u0026lsquo;crisis\u0026rsquo; characterized by severe anxiety, trauma symptoms, psychosis, or mania, aligning with some past research (e.g., Dos Santos et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Providers suggested that these risks could be mitigated through careful screening and harm reduction strategies before use, as well as gradual, cautious integration work that strengthens psychological resources (e.g., social support, coping skills) before confronting painful content. In crisis situations, providers emphasized the importance of helping people return to baseline and providing higher levels of support as needed.\u003c/p\u003e\u003cp\u003eDifficulties with somatic responses were also observed, consistent with some limited prior psychedelic research (Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). One provider observed a client experiencing a \u0026ldquo;consistent shaking\u0026rdquo; experience, whereas another recounted a client attributing their experiences to a \u0026ldquo;kundalini awakening\u0026rdquo;\u0026mdash; a spiritually transformative energetic experience (Woollacott et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Though under-researched in the psychedelic field, such experiences have been documented as related to meditation (Lindahl et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and as part of \u0026lsquo;spiritual emergencies\u0026rsquo; in which states of heightened distress, often with a somatic component, are considered a part of the natural development process of spiritual growth and healing (Evans \u0026amp; Read, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMany clients described by providers in the current study underwent a process of relationship examination, oftentimes experiencing loneliness, misunderstanding, or disruptions in relationships. This aligns with recent past work (Barrett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bouso et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bremler et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and the longstanding phenomenon of reintegration struggles after ecstatic experiences, such as Plato\u0026rsquo;s observation that \u0026lsquo;illuminated mystics\u0026rsquo; often felt alienated from society (Bloom \u0026amp; Kirsch, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1968\u003c/span\u003e). Therefore, providers in this study often focused on helping clients build support systems, overcome barriers to connection, and reconnect with existing or new communities as essential aspects of integration.\u003c/p\u003e\u003cp\u003eThe finding that some clients struggled to understand the meaning of content from their psychedelic experience during integration aligns with past research indicating that having an interpretative framework (e.g., psychological, spiritual) can aid in integration (Argyri et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Cowley-Court et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It also echoes observations that Western participants may lack the cultural references necessary to understand and process the complex, abstract, and symbolic aspects of experiences like ayahuasca (Loizaga-Velder \u0026amp; Pazzi, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the current study, providers shared nuanced accounts of clients confronting previously unacknowledged memories of abuse or discovering that recollections of abuse represented symbolic emotional distress (e.g., feeling trapped). These findings build upon and provide further insights into the well-documented history of people sometimes feeling that they are vividly re-living past abuse or spontaneously recalling childhood memories during psychedelic use (e.g., Busch \u0026amp; Johnson, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1950\u003c/span\u003e). Providers recommended supporting clients in arriving at their own interpretations\u0026mdash;whether literal or symbolic\u0026mdash;while helping them understand how content from the psychedelic experience may fit within the broader context of their life. This non-directive approach in which clients lead the interpretive process is critical to trauma treatment and aligns with best practices for trauma-related conditions (Foa et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Herman, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Herman, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1992\u003c/span\u003e; Resick et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Additionally, providers indicated that some people spontaneously recovered memories of abuse during psychedelic experiences, and came to understand these memories as true over time, which aligns with research on dissociative amnesia and the recollection of traumatic memories after a period of forgetting (Freyd, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; MacIntosh et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSeveral themes in the current study emphasized the importance of thorough preparation, not only for the psychedelic experience itself but also for the integration phase afterward. While positive expectations can enhance outcomes in psychedelic trials (Aday et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), the current research suggests that excessively high expectations can become an obstacle to therapeutic growth, leading to disappointment or self-disparagement. Consistent with past research, providers noted that clients often have unrealistic expectations about psychedelics and the integration process (Earleywine et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), underscoring the need for realistic discussions about psychedelics, including the variability of its effects, and the potential for challenging experiences, such as resurfaced trauma, identity shifts, or disappointment\u0026mdash;topics often overlooked in informed consent processes (Harrison, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Setting realistic expectations can help clients prepare for these challenges and manage them more effectively during integration, which may require time and ongoing effort, particularly when significant life changes are involved. Several providers emphasized that even disappointing or underwhelming experiences can provide valuable insights and promote deeper self-understanding, while others cautioned against invalidating negative experiences or subscribing to the belief that \u0026ldquo;there is no such thing as a bad trip.\u0026rdquo;\u003c/p\u003e\u003cp\u003eRecommendations for realistic integration expectations included aftercare plans and preparation for potential heightened sensitivity or emotionality when returning to daily life, consistent with prior literature (Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Johnstad, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Providers emphasized the need to inform clients that psychedelics may reveal the need for difficult life changes, such as ending relationships or quitting jobs. Those unable to make significant changes, commit to long-term integration, or seeking a \"quick fix\" may struggle more with integration. Providers highlighted the tension between helping clients seize a unique \"window of opportunity\" and advising caution to avoid impulsive decisions. The pace of integration can also be influenced by factors like privilege, time, and identity, with one provider highlighting the importance of a slower, more careful approach for BIPOC clients facing integration challenges related to racialized trauma.\u003c/p\u003e\u003cp\u003eProviders in the current study observed that some clients may use psychedelics compulsively or to avoid challenges, aligning with the concept of \u0026ldquo;spiritual bypass\u0026rdquo;\u0026mdash;using spiritual practices to avoid confronting psychological or emotional issues (Welwood, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). This finding aligns with other reported instances of spiritual bypass occurring within integration work (Aixal\u0026agrave;, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Gorman et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lutkajtis \u0026amp; Evans, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). While the prevalence of spiritual bypass is unknown, one ayahuasca retreat center owner estimated that 10% of people exhibit an \u0026ldquo;obsessive-compulsive relationship with the medicine,\u0026rdquo; likely due to insufficient integration (Marcus, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Providers in the current study emphasized the importance of helping clients confront painful content and avoid idealizing psychedelics as a permanent solution, instead encouraging alternative modalities for healing and growth.\u003c/p\u003e\u003cp\u003eThe current study highlights the critical role of set and setting in determining outcomes, particularly the importance of a safe, trusting relationship with sitters or guides. It also underscores how boundary violations, or even subtle power dynamics, can significantly impact psychedelic experiences and cause harm. The risk of boundary violations, especially due to the vulnerability associated with psychedelic states, has been recognized in both psychedelic-assisted therapy (e.g., Meikle et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and naturalistic use (Kruger et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This risk emphasizes the need for therapists and facilitators to be trained in trauma-informed care, ethics, and cultural humility to prevent harm.\u003c/p\u003e\u003cp\u003eThe current study\u0026rsquo;s results must be interpreted within its context and limitations.\u003c/p\u003e\u003cp\u003eThis study focused on integration challenges during psychotherapy, a critical area given that adverse experiences are often under-reported in clinical and psychedelic trials, (de Laportali\u0026egrave;re et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ona et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, providers also highlighted numerous positive experiences and noted that difficulties were often seen as positive and valuable to the client\u0026rsquo;s healing process, aligning with past research (Bouso et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Carbonaro et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Cowley-Court et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Lutkajtis \u0026amp; Evans, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and frameworks that view challenging experiences as foundational to healing and spiritual growth (Evans \u0026amp; Read, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Finally, although themes are presented as distinct in the results, they are often inter-connected; for instance, making sense of chaotic or confusing experiences (Theme 5) may interface with unearthed trauma (Theme 1).\u003c/p\u003e\u003cp\u003eOur qualitative approach allowed for in-depth exploration of integration challenges and therapists\u0026rsquo; strategies for addressing them. However, these findings are not exhaustive of all integration challenges, are influenced by the characteristics of the participant sample (predominantly white) and do not capture the frequency of various challenges. Since data were gathered from providers rather than clients, the findings reflect providers' interpretations, which may not fully align with clients' experiences. Quantitative research could complement these insights by systematically measuring the prevalence and impact of these challenges. Furthermore, to our knowledge, no research has examined how integration challenges may vary by use setting (e.g., ceremonial, therapy session, independent use, social environment)\u0026mdash;examining how set and setting influence the challenges people face in integration represents an important future direction.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIntegration challenges identified in this study\u0026mdash;such as confronting unacknowledged pain, destabilization, struggles with daily life, integrating new beliefs, translating insights into action, re-examining relationships, loneliness, unmet expectations, and using psychedelics for escape\u0026mdash;can guide training and preparation efforts for both clients and providers. To help develop an evidence-based psychedelic integration framework, further research should explore other integration challenges with diverse samples of clients and providers, identify core integration components, and evaluate their efficacy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclarations\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003cp\u003e Study procedures were approved by both the ethics committee at the Institute of Psychology at UiT (The Arctic University of Norway) and the Behavioral Health Research Collective's Institutional Review Board, approval number 051 in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained for all participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest\u003c/strong\u003e\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003cp\u003eInternally funded.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAK: data analysis, writing, study design, data collection; literature review; BP: feedback on study design and analysis, writing (editing); CC: writing (initial draft), data analysis; literature review; EK: data analysis, writing, study design, data collection; methods selection; literature review; ETN: feedback on study design and analysis, project supervision; JBL: feedback on study design and analysis, writing (editing); OE: data analysis, writing, study design, data collection, administrative/project coordination\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eDuring the preparation of this manuscript the authors used ChatGPT in order refine text and proof the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDue to the sensitive and confidential nature of the data, full transcripts and raw data are not publicly available. Anonymized excerpts supporting the findings are included within the article. The interview guide is available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAday JS, Heifets BD, Pratscher SD, Bradley E, Rosen R, Woolley JD. Great Expectations: Recommendations for improving the methodological rigor of psychedelic clinical trials. 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Efficacy and safety of psychedelics for the treatment of mental disorders: A systematic review and meta-analysis. Psychiatry Res. 2024;335:115886. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.psychres.2024.115886\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2024.115886\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"psychedelics, psychedelic-assisted therapy, qualitative, integration, challenging experiences","lastPublishedDoi":"10.21203/rs.3.rs-6874539/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6874539/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePsychedelic integration is widely acknowledged as essential, yet limited empirical data exists on challenges faced during integration.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo explore therapists' perspectives on post-psychedelic integration challenges and their approaches to supporting clients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eOnline interviews were conducted with a purposive sample of licensed mental health professionals who had provided psychedelic integration support to at least 15 clients using classical psychedelics or 3,4-methylenedioxymethamphetamine (MDMA). Data were analyzed with Systematic Text Condensation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParticipants (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20, 90% white, 70% cisgender women, modal integration clients: 25 \u0026minus;\u0026thinsp;30) used a wide range of integration frameworks and practiced in diverse settings. Ten key integration challenges emerged: 1) Unearthed Trauma, Suppressed Emotion, and Long-Avoided Pain; 2) Destabilization and Psychological Crisis (subtheme: Emergence/Exacerbation of Psychosis or Mania); 3) Re-Adjusting to Daily Life Demands amidst New Insights and Heightened Sensitivity; 4) Relational and Systemic Harms from Boundary Violations, Misattunement, Objectification, or Abuse; 5) Making Sense of Chaotic or Confusing Experiences; 6) Identity and Worldview Crisis; 7) Overwhelmed by the Magnitude of Change Needed to Integrate Insights; 8) Relationship Examination, Disruption and Distance; 9) Hope, Hype and the Aftermath of Disappointment; and 10) Seeking Escape and Solace in Psychedelic Use.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFindings reveal core integration challenges and practical strategies that can inform training and preparation for clients and providers: beginning integration in preparation, setting realistic expectations, creating safe, attuned therapeutic environments, bolstering coping and social support resources, using trauma processing techniques, facilitating client-led meaning-making, and supporting gradual, values-guided life changes.\u003c/p\u003e","manuscriptTitle":"Beyond the Journey: A Qualitative Analysis of Therapists’ Perspectives on Psychedelic Integration Challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 19:11:11","doi":"10.21203/rs.3.rs-6874539/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c604a566-aa9d-41a8-8aad-f57964d32516","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T09:57:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 19:11:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6874539","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6874539","identity":"rs-6874539","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}