Autonomy and autoheteronomy in psychedelically assisted psychotherapy

Psychedelically assisted psychotherapy (PAP) is becoming a common treatment for serious mental health problems, and the market for therapist training and credentialing is expanding rapidly. Concerns about potential abuse in PAP have been framed as failures to respect patient autonomy, but such concerns require a fundamental reconsideration of autonomy's role in psychotherapy. This chapter begins with practitioner-focused guidance, reviews the history of autonomy in geopolitics and ethics, and examines its place in psychotherapy generally and PAP specifically. It concludes that while protecting autonomy is central to medical ethics, autonomy does not capture the phenomenology of the psychedelic experience, which is better described as 'autoheteronomy'. The chapter shows that PAP exposes longstanding cultural uncertainties about how psychotherapy has fostered patient autonomy.

Study at a glance

Abstract

Psychedelically assisted psychotherapy (PAP) looks set to become a common remedy for a range of serious mental health problems. The market for providing PAP, including a secondary market for the training, credentialising and monitoring of therapists, is expanding rapidly. Concerns have been raised recently by actors in that secondary market about the potential for abuse in PAP, which have been framed in terms of a failure to respect patient autonomy. Such concerns cannot be adequately addressed without a fundamental reconsideration of the role of autonomy in psychotherapy. Discussing what autonomy means in psychotherapy and thence especially in PAP is the aim of this chapter, which starts from practitioner-focused guidance, before reflecting on the history of autonomy in geopolitics and ethics and finally returning to consider its place in psychotherapy generally and PAP specifically. The conclusion reached is that while protecting autonomy is the primary concern of medical ethics today, autonomy is not equal to the phenomenology of the psychedelic experience, which is better characterised in terms of ‘autoheteronomy’. The chapter’s contribution to the emerging ‘psychedelic humanities’ is to show that PAP brings to crisis longstanding cultural compromises and uncertainties around the way in which psychotherapy has been thought to foster patient autonomy.