Inclusion of people of color in psychedelic-assisted psychotherapy : a review of the literature
Timothy I. Michaels, Jennifer Purdon, Alexis Collins and Monnica T. Williams
BMC Psychiatry, 2018, 18, 245
Background : Despite renewed interest in studying the safety and efficacy of psychedelic-assisted psychotherapy for the treatment of psychological disorders, the enrollment of racially diverse participants and the unique presentation of psychopathology in this population has not been a focus of this potentially ground-breaking area of research. In 1993, the United States National Institutes of Health issued a mandate that funded research must include participants of color and proposals must include methods for achieving diverse samples.
Methods : A methodological search of psychedelic studies from 1993 to 2017 was conducted to evaluate ethnoracial differences in inclusion and effective methods of recruiting peopple of color.
Results : Of the 18 studies that met full criteria (n = 282 participants), 82.3% of the participants were non-Hispanic White, 2.5% were African-American, 2.1% were of Latino origin, 1.8% were of Asian origin, 4.6% were of indigenous origin, 4.6% were of mixed race, 1.8% identified their race as “other,” and the ethnicity of 8.2% of participants was unknown. There were no significant differences in recruitment methodologies between those studies that had higher (> 20%) rates of inclusion.
Conclusions : As minorities are greatly underrepresented in psychedelic medicine studies, reported treatment outcomes may not generalize to all ethnic and cultural groups. Inclusion of minorities in futures studies and improved recruitment strategies are necessary to better understand the efficacy of psychedelic-assisted psychotherapy in people of color and provide all with equal opportunities for involvement in this potentially promising treatment paradigm.
Keywords : Psychedelic-assisted psychotherapy, Ethnic differences, Minority recruitment, People of color
The promise of psychedelic medicine
The use of altered or non-ordinary states of consciousness for medicinal purposes is neither novel nor modern, but rather dates back thousands of years to the spiritual practices of indigenous communities across the world. For indigenous peoples, psychedelic use is considered a both a sacred and healing act, that requires the guidance of a highly trained spiritual leader (shaman), and entails psychoactive rituals that bring humans closer to the spiritual world, in an effort to treat both physical and spiritual ills . While the full history of indigenous healing practices has been covered elsewhere , understanding
its roots within the historical origins of psychedelic-assisted psychotherapy serves as an important reference point, given that modern psychedelic medicine has struggled to include marginalized
communities, especially people of color, in this movement, and is only now beginning to acknowledge the importance of their inclusion [3–5].
Western medicine’s exploration of psychedelics for treatment purposes can be divided into two distinct periods, with the first occurring between 1950 and 1985 (herein referred to as the “first wave,”), when synthetic psychedelic compounds were just being discovered, and the second (herein referred to as the “second wave”) beginning around the late 1990s and continuing to this day . This periodic distinction has been observed by others. The “rediscovery” of psychedelics as medicine by Western science first occurred during a period in which biomedical therapeutic interventions in psychiatry were limited, as psychopharmacology had not yet become mainstream practice . Newly synthesized psychedelics were not considered controlled substances, and therefore their clinical and research use was relatively unrestrained. Given that psychoanalysis was a mainstay of treatment, initial research on psychedelic medicine examined whether psychedelic drugs could facilitate the process of psychotherapy, thereby accelerating the treatment process of psychological disorders . Yet ultimately, the combination of widespread use of these substances, serious ethical violations (i.e., administration to physically restrained subjects, sexual abuse between therapists and clients), major methodological flaws, and concerns over safety led to defunding of research and ultimately the scheduling of psychedelics as controlled substances [8, 9]. While many researchers and subjects continued to espouse the therapeutic benefits of psychedelic-assisted therapy for the treatment of depression, addiction, and other disorders, this area of investigation lay dormant for several decades.
Several important factors contributed to the resurgence of psychedelic medicine in the late 1990s following a several decade-long hiatus. Instead of launching into therapeutic investigations, early research during the second wave consisted of pre-clinical animal and basic science studies that were carefully conducted to establish the pharmacological properties and safety of these substances [2, 8]. With the creation of the Multidisciplinary Association of Psychedelic Studies (MAPS), a non-profit pharmaceutical organization, by Rick Doblin in 1986, researchers were no longer reliant upon government funding and could pursue FDA drug development . The medicinal potential for scheduled substances was also no longer novel, given that research into the healing properties of both cannabis [11, 12] and ketamine  had been underway since 1975. Coupled with the fact that many psychiatric illnesses still lacked effective pharmacological treatment, these factors paved the way for the second wave of psychedelic research.
Recent renewed interest in psychedelic-assisted psychotherapy has benefited from avoiding the mistakes of the past by focusing explicitly on ethical, methodological and clinical safety issues. It has also taken a careful and gradual approach to re-introducing this controversial area of study, working closely with regulatory bodies and federal agencies . Indeed, initial results from second-wave (2000-present) psychedelic research has demonstrated the efficacy of psilocybin [14–16] for the treatment of depression, addiction, and OCD, LSD [14, 17–19] in the treatment of depression, anxiety, and substance use, ayahuasca [20, 21] for the treatment of depression and addiction, and MDMA [22, 23] in reducing trauma symptoms. Yet these promising findings have often been limited to small, predominantly White samples, limiting the generalizability of findings and excluding people of color from potential therapeutic benefits. Beyond a broad lack of representation of people of color in psychedelic-assisted psychotherapy studies, the conceptualization of psychopathologies rarely include important cultural considerations such as the importance of including race-based trauma when recruiting participants of color for MDMA-assisted psychotherapy for PTSD . In the United States, this lack of inclusion goes directly against federally mandated efforts to report and recruit diverse samples in clinical trials.
The following study aims to provide a comprehensive review of inclusion and recruitment across ethnic/racial groups in current (1993-present) psychedelic-assisted psychotherapy studies, in an effort to characterize the scope and importance of this issue while identifying areas for growth. To provide the necessary context around these issues, we first review the prevalence and presentation of psychopathology in people of color and the importance of cultural considerations in the design and implementation of clinical trial research. Upon reporting findings on the rates of inclusion and recruitment strategies in psychedelic studies, we conclude by summarizing current efforts to acknowledge diversity issues in the field and provide considerations for future directions.