PSI Psychedelic Harms Case Book

Psychedelic Harms Case Book

Psychedelic Harms Case Book

with entities perceived as benign or malevolent are not uncommon

One of two cases of extended difficulties after Braxia’s psilocybin TRD trial

episode of mania following ingestion of psilocybin mushrooms in a woman previously not diagnosed with bipolar

and physical trauma in an underground psychedelic ceremony

absence of essential healing elements in the therapeutic container may have exacerbated the outcome of a perceived crisis

Therapist and Participant Identities in Psychedelic-Assisted Therapy................................63

Therapists sharing one or more intersectional identities with a participant may impact their sense of safety

Terence McKenna’s Bad Trip 64

The selective portrayal of an influential figure in the psychedelic community

Introduction

This Case Book represents a small number of types of harm or potential harm from psychedelic use, and is not exhaustive.

Examples are needed that represent the experiences of indigenous people, LGBTQ+ folks, veterans, and people seeking psychedelic sessions to treat addiction.

More examples are needed that represent persisting adverse events (derealization, depersonalization, etc. spanning months or years).

For facilitated or guided sessions, more descriptive examples are needed that delineate the omission of critical attributes in the practitioner and/or the omission of essential healing elements in the therapeutic container (in the relationship between practitioner and client) before, during, and after a psychedelic session. Alternately, examples where attunement, caring, trust, and presence improved outcomes and minimized safety issues are welcome additions to this casebook.

Reach out to summit@psychedelicsafety.institute to suggest cases.

Version History

4.0 - Mar 17 2025 - Added three case studies

3.0 - Mar 16 2025 - Added three case studies

2.1 - Mar 15 2025 - Added two case studies; updated Introduction with email address

2 0 - Mar 14 2025 - Added one case study and Introduction; annotated table of contents, copyedited, regularized formatting

1 0 - Mar 7 2025 - First draft

Complications from Chocolate Products Marketed

as Containing Mushrooms1

Unregulated adulterated “mushroom” edibles capitalize on the popularity of psilocybin

Year: 2024

Substance/Dose – Primary: Adulterated “Mushrooms” edibles

Confidence level of identification: Low

Case Study Source: U.S. Food and Drug Administration. “Investigation of Illnesses: Diamond Shruumz-Brand Chocolate Bars, Cones, & Gummies (June 2024).” U.S. Food and Drug Administration, Updated 15 Nov. 2024, https://www.fda.gov/food/outbreaks-foodborne-illness/investigation-illnesses-diamond-s hruumz-brand-chocolate-bars-cones-gummies-june-2024

Summary: People who became ill after eating Diamond Shruumz-brand products reported a severe symptoms including seizures, central nervous system depression (loss of consciousness, confusion, sleepiness), agitation, abnormal heart rates, hyper/hypotension, nausea, and vomiting. FDA analyses of samples identified the presence of 4-acetoxy-DMT, Psilocin, Pregabalin, kavalactones found in the kava plant, muscimol found in the Amanita muscaria mushroom.

Case Study:

Total Illnesses: 180 – The case definition used by state health departments for the reported illnesses is as follows: Illness with moderate or major clinical effects, or death, occurring in a person who ate any Diamond Shruumz product (chocolate bars, cones, gummies or other) or another chocolate product marketed as containing mushrooms, during January 1, 2024, through the present.

● Number of cases among people who reportedly ate a Diamond Shruumz product: 118

● Number of cases among people who reportedly ate a mushroom chocolate bar of an unspecified brand: 36

● Number of cases among people who reportedly ate a mushroom chocolate bar of a non-Diamond Shruumz-brand: 26

1 Summary adapted from https://www fda gov/food/outbreaks-foodborne-illness/investigation-illnesses-diamond-shruumzbrand-chocolate-bars-cones-gummies-june-2024

Serious Adverse Events after Legal Ketamine

Treatment in a Clinical Context2

The crucial role of provider and patient education

Year: 2020s

Substance/Dose – Primary: Ketamine, varying doses

Case Study Source: Bennett R, Yavorsky C. Mind the Ketamine Education GapBetter Training Can Prevent Adverse Outcomes in Psychiatric Patients. MedPage Today (2021). Available online at: https://www.medpagetoday.com/psychiatry/depression/91719 (accessed June 1, 2021).

Summary: Adverse outcomes associated with legal, off-label ketamine treatment for mood disorders in a clinical context have not been well documented, though copious research exists around the physical and psychological risks of illicit ketamine use.

Case Study (Excerpted from published op-ed):

Since October 2020, [the authors] became aware of multiple serious adverse events (SAEs), including death, that occurred during or following legal ketamine treatment in a clinical context:

● Patient A received ketamine lozenges in the mail from a company that is selling "psychedelic experiences" online. The patient took the ketamine lozenges while alone, and then completed suicide by asphyxiation while under the influence of ketamine (and possibly other intoxicants).

● Patient B was receiving psychiatric and psychological services in an out-patient psychiatry clinic connected with a medical school at a public university. The patient completed suicide over the weekend (in between ketamine infusion sessions) during their induction series.

● Patient C was being treated for PTSD, anxiety, and depression by a psychiatrist in the clinician’s private practice. The psychiatrist administered injectable ketamine to the patient. Later that same day, the patient attempted suicide at home, which resulted in a psychiatric hospitalization.

● Patient D completed suicide after receiving multiple ketamine infusions from an emergency department physician at a ketamine clinic. The patient was also receiving concurrent psychotherapy from a licensed therapist.

2 Full text of op-ed: https://www medpagetoday com/psychiatry/depression/91719?trw=no

● Patient E arranged for a physician-assisted suicide in Europe and died by suicide there. The patient had previously received multiple ketamine infusions and psychological care from a psychiatrist at a ketamine clinic.

● Patient F died as result of injuries sustained in a fire. The victim was under the influence of multiple intoxicants, and in possession of a very large quantity of ketamine lozenges that had been prescribed for them, illicit ketamine, alcohol, and other drugs.

In addition, multiple SAEs occurred recently in the context of ketamine infusions for pain management, where the ketamine was administered by an anesthesiologist or nurse anesthetist (CRNA):

● Patient G received a 750 mg bolus of intravenous ketamine, had a cardiac event, and required ICU care.

● Patient H was an older adult with a history of hypertension. During a ketamine infusion, the patient’s blood pressure increased to 180 systolic, the provider elected not to treat the elevated blood pressure, and the patient had a stroke.

● Patient I completed suicide at home. The patient was receiving maintenance infusions for pain, anxiety, and depression.

● Patient J was a young adult who completed suicide in a bizarre way after receiving multiple high-dose ketamine infusions for refractory headache.

Out of these 10 cases with egregious outcomes, it would appear that three of the suicides – Patient B, Patient D, Patient E – can likely be attributed to the patients having severe and protracted psychiatric illnesses; there is no suggestion of provider malfeasance. It is worth noting that all three of these patients had received a combination of conventional oral medication, intensive psychotherapy, and ketamine treatment. Sadly, suicidal ideation is frequently seen in the population of patients who present for ketamine treatment. Therefore, it is essential to have a clinician on the treatment team who has strong skills for assessing and treating patients with refractory depression and active suicidal ideation.

In the remaining cases, the SAEs may be the result of provider error. Common provider errors include: not having a rigorous and comprehensive intake process for prospective ketamine patients; not providing adequate psychological preparation for ketamine treatment; not providing adequate psychological support during ketamine administration; not providing adequate follow-up care to ketamine patients; and medical malpractice. Note these cases and investigation do not consider FDA-approved ketamine products.

See also (ketamine-related court cases):

Struck v. Jason Duprat CRNA, P.C., Case No. 1:20-cv-01026-KWR-JHR (D.N.M. Dec. 16, 2020)

Valdes v. Brooks, 19-cv-617 (JGK) (S.D.N.Y. Oct. 13, 2021)

PTSD, Medication, and an Unsupported Environment

Marine Corps veteran experiences psychotic break after taking mushrooms

Subject identity details: 33-year-old man, Marine Corps veteran Year: 2023/4

Substance/Dose – Primary: “high dose” of Psilocybe mushrooms

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: unspecified “medication”

Case Report Source: Barmann, J. (2024, February 9). Man who rampaged naked shooting gun in Richmond District had psychotic break on mushrooms, attorney says. SFist, https://sfist.com/2024/02/09/man-who-rampaged-naked-shooting-gun-in/

Summary: Veterans face conditions that make approaching psychedelic work difficult, such as high rates of PTSD and suicidality, the concurrent challenge of forming a new civilian identity once out of the service, and coming from a culture that is not very emotionally available and historically removed from psychedelic-friendly circles. Taking psychedelics in an unsupported context and alongside psychiatric medication can heighten risk of complications. This may have been the case with a combat veteran who experienced a psychotic break in San Francisco in early 2024.

Case Study:

A combat veteran who had served in Afghanistan experienced a psychotic break after consuming psilocybin mushrooms on New Year's Eve. Reportedly, he "had received a double dose of an unspecified medication he takes for PTSD two days earlier". Armed and naked, the man fired multiple rounds into vehicles and a home in San Francisco’s Richmond District. His wife testified that he became delusional, threatened her and their baby, and demanded she strip, believing they were in the Garden of Eden. He also threatened his landlord and allegedly tried to lure him outside by shooting at his car Police intervened before anyone was harmed.

His attorney described him as a decorated veteran struggling with PTSD. A judge ordered him into a veterans’ rehabilitation program rather than pre-trial detention, citing his clean record and the circumstances of his breakdown.

Power Imbalances and Use of Touch During MDMA-AT

As PAT goes mainstream, former patient warns of danger of sexual abuse

Subject identity details: Woman in her 30s

Setting: Clinical Trial

Year: 2015

Substance/Dose – Primary: MDMA, dose unspecified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Multiple sources have reported on this incident, e.g.:

Lindsay, B. (2021, March 18). As psychedelic therapy goes mainstream, former patient warns of danger of sexual abuse. CBC News. Retrieved from https://www.cbc.ca/news/canada/british-columbia/bc-sexual-abuse-psychedelic-therapy1.5953480

Transcript of the June 4, 2024 Meeting of the Psychopharmacologic Drugs Advisory Committee (PDAC), U.S. Food and Drug Administration Center for Drug Evaluation and Research, pp 314-317. Retrieved from https://www.fda.gov/media/180703/download

Case Study:

A woman alleges she was sexually abused during an MDMA-assisted psychotherapy clinical trial in British Columbia. In 2015, she participated in a Phase II clinical trial for MDMA-AT for complex post-traumatic stress disorder (PTSD) under the guidance of a husband and wife team of therapists. During sessions, what the trial subject described as inappropriate physical contact occurred, including instances where she was pinned down and spooned. Subsequently, the participant moved in with the couple and entered a sexual relationship with the husband. In 2018, she filed a civil lawsuit against him alleging repeated sexual assault; the case was settled out of court. Upon learning of these ethical violations, the organization that sponsored the trial severed ties with the therapists, reported the incident to health authorities, and implemented a new code of ethics explicitly prohibiting sexual contact between therapists and participants. This incident has raised significant concerns about the potential for abuse in psychedelic therapy settings and underscores the necessity for stringent ethical standards and oversight.

“Now I Only Buy From Trusted Sources”

Expecting MDMA, an experience turns unsettling

Subject identity details: 21-year-old man

Setting: Dance Club

Year: 2013

Substance/Dose – Primary: Unknown (misrepresented as MDMA), 250 mg

Confidence level of identification: Low

Substance(s)/Dose(s) – Secondary: Alcohol, dose unspecified

Case Study Source: Erowid Center3

Summary: A 21-year-old man experienced an intense state of dread, anxiety and dissociation after consuming 250mg of powder purported to be MDMA. Negative effects persisted into the next day The author now only buys from trusted sources or waits for others to test material first.

Case Study:

An experience report author reports a harrowing experience with what was supposed to be MDMA but turned out to be an adulterated or misrepresented substance. The person had prior experience with MDMA and expected the usual effects of euphoria and stimulation, but instead endured an intensely distressing and dissociative state.

The author recounts the events leading up to the experience, beginning with purchasing the substance from an unverified source and consuming 200mg initially, followed by an additional 50mg when the expected effects did not materialize. Initially, there was mild stimulation and euphoria, but soon, the experience turned deeply unsettling. The usual pleasurable effects of MDMA were absent, replaced by a sense of profound dread, disconnection from reality, and slowed perception reminiscent of ketamine, but without the pleasurable dissociation.

As the night progressed, the author felt increasingly detached, trapped in an overwhelming sense of anxiety and despair Attempts to engage socially, including dancing and conversing with friends, failed; he felt devoid of joy or desire despite the

3 Case Report adapted from first person narrative: akurenji “Drowned in Eternal Psychosis Awaiting Death: An Experience with Unknown (sold as MDMA) & Alcohol (exp100138)”

Erowid org Nov 2, 2024 erowid org/exp/100138

vibrant club environment. Eventually, realizing something was seriously wrong, they left the club early and struggled through a night of mental torment, repetitive thoughts, and auditory disturbances while attempting to sleep.

The psychological distress continued into the morning, with the author still feeling the lingering effects well into the next day. Despite finally coming down by the evening, the experience left a lasting impression, reinforcing the dangers of consuming untested substances. The author concludes with a strong warning about the risks of street MDMA, urging others to use reagent testing kits or at least verify the substance's quality through trusted sources before consumption.

Ultimately, the experience serves as a cautionary tale about the unpredictability and dangers of misrepresented drugs, emphasizing that anyone can fall victim to a “bad batch” if they do not take precautions.

Complications from Compounded Oral Ketamine4

Patients may not receive important information about potential risks

Year: 2023

Substance/Dose – Primary: Ketamine (buccal), dose unspecified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: U.S. Food and Drug Administration. “FDA Warns Patients and Health Care Providers About Potential Risks Associated with Compounded Ketamine Products, Including Oral Formulations, for the Treatment of Psychiatric Disorders.” U.S. Food and Drug Administration, 10 Oct. 2023, https://www.fda.gov/drugs/human-drug-compounding/fda-warns-patients-and-health-car e-providers-about-potential-risks-associated-compounded-ketamine.

Summary: The U.S. FDA issued a warning regarding the risks of compounded ketamine products, particularly oral formulations, for psychiatric treatment. The FDA highlighted safety concerns, including serious adverse events such as sedation, dissociation, and increased blood pressure. Unlike FDA-approved ketamine products, compounded versions lack regulatory oversight, leading to potential inconsistencies in potency and quality.

Case Study:

In April 2023, FDA received an adverse event report of a patient who experienced respiratory depression after taking compounded oral ketamine outside of a health care setting for the treatment of PTSD. The patient’s ketamine blood level appeared to be twice the blood level typically obtained for anesthesia.

Patients who receive compounded ketamine products from compounders and telemedicine platforms for the treatment of psychiatric disorders may not receive important information about the potential risks associated with the product. Safety concerns that may be associated with ketamine products include, but are not limited to,

4 Summary adapted from https://www fda gov/drugs/human-drug-compounding/fda-warns-patients-and-health-care-provid ers-about-potential-risks-associated-compounded-ketamine

risks of sedation, dissociation, psychiatric events or worsening of psychiatric disorders, abuse and misuse, increases in blood pressure, respiratory depression, and lower urinary tract and bladder symptoms. At-home administration of compounded ketamine presents additional risks because a health care provider is not available onsite to monitor for serious adverse outcomes resulting from sedation and dissociation.

Suicide Attempt One Week after Ketamine Infusion

The crucial role of comprehensive follow-up and psychosocial interventions

Subject identity details: 75-year old South Asian woman

Setting: Ketamine infusion therapy clinic5

Year: 2023

Substance/Dose – Primary: Ketamine, dose unspecified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported / Unclear

Case Study Source: Ahuja J, Leontieva L. Ketamine Therapy in Complex Cases: A Cautionary Tale of Exacerbated Personality Traits and the Crucial Role of Comprehensive Follow-Up and Psychosocial Interventions. Case Rep Psychiatry 2024 Jun 17. DOI: 10.1155/2024/2143372.

Summary: A 75-year-old woman with treatment-resistant depression underwent ketamine infusion therapy, anticipating relief from her depressive symptoms. Contrary to expectations, she experienced an increase in suicidal thoughts following the treatment.

Case Study:

Adapted from published case report, edited for length

A 75-year-old female presented to the emergency department (ED) after a suicidal attempt via laceration to her wrist. The patient has a past psychiatric history of unspecified depressive disorder and a past medical history of breast carcinoma in remission. Her complex medical history included psychosocial stressors, a genetic predisposition to depression, and personality traits that may have influenced her adverse reaction to ketamine. The patient reported that this was her second suicide attempt within 45 days. Between the two suicide attempts, the patient had received four cycles of ketamine infusion therapy which had not resolved their symptoms of depression and suicidal ideation. Her penultimate ketamine treatment was one week before her presentation to the ED during which time she had experienced intense emotional flooding, increased suicidal thoughts, and unresolved feelings of worthlessness and despair. She did not have any follow-up from her ketamine treatment provider.

5 Case Study: https://pmc ncbi nlm nih gov/articles/PMC11208781/

It Kept Getting More Intense

Misidentified substances in unregulated markets carry risks

Subject identity details: 18-year-old man

Setting: Small group at home

Year: 2009

Substance/Dose – Primary: Bromo-dragonfly (sold as 2C-B-fly)

Confidence level of identification: High

Case Study Source: Erowid Center

Summary: The death of an 18-year-old after consuming misidentified Bromo-dragonfly underscores the risks of unregulated psychedelics. The decedent, with preexisting health issues, suffered severe adverse effects within hours. Others experienced prolonged distress, emphasizing the need for substance verification.

Case Study:

Adapted from: Reported Deaths Related to 2C-B-Fly: Misidentified Substance is Most Likely Bromo-dragonfly Retrieved March 3, 2025, from Erowid.org/2cb_fly/2cb_fly_death1.shtml

An 18-year-old man died after ingesting 9 mg of Bromo-dragonfly misrepresented as 2C-B-fly, both uncommon psychedelics with only a short history of human use. He was not on any medication that his family was aware of, although he did have multiple preexisting medical conditions.

The decedent began having a difficult trip at two hours after ingestion. At three and a half hours after ingestion he began having what appeared to be seizures but could have been strokes or a heart attack, or a combination of those. 911 was called. He died approximately four hours after ingestion. The decedent’s brother and the brother’s girlfriend were also present and also ingested the same material. The brother experienced “intense gastrointestinal disturbances” and was still experiencing effects at 30 hours after ingestion. He and his girlfriend both reported extremely strong experiences and were taken to the hospital in restraints after paramedics/police arrived.

At least two other serious adverse events on another continent were reported in connection with the misidentified material, which was sold online. Its identification as Bromo-dragonfly was confirmed by laboratory analysis conducted by Energy Control (Spain) and Drug Detection Laboratories (California) on behalf of Erowid Center

Suggestibility in Retreat Settings

Ethics codes and complaints procedures for retreats

Setting: Psychedelic Retreat Centers

Case Study Source: Challenging Psychedelic Experiences Project

Summary: An ayahuasca retreat center uses aggressive marketing tactics to maximize profits. A facilitator feels a strong attraction to a client at a psychedelic retreat and initiates a relationship with the client, which lasts for months. Are clients in suggestible states susceptible to exploitation, and what can be done to mitigate risk?

Case Study:

An ayahuasca retreat center uses aggressive marketing tactics to maximize profits. Its online marketing promises that the vast majority of customers experience “miraculous breakthroughs”. During its week-long retreats, it seeks to upsell customers to expensive stem cell injections and even offers them the opportunity to buy condos nearby The retreat center, like many, videos participants on the final day of their retreat giving glowing testimonials, and also encourages them to leave five-star reviews in the days after the retreat.

When clients are under the influence of psychedelic drugs they can be more suggestible to cues from their environment, including from facilitators and staff at retreat centers. This suggestibility can last for 48 hours after a ceremony Should there be ethical guidelines to protect consumers from being exploited while under the influence?

To take another example from another ayahuasca retreat: a facilitator feels a strong attraction to a client at a psychedelic retreat and starts to pay them a lot of attention. In the days after the retreat he begins a relationship with the client, which lasts for some months. Then the client decides this was an inappropriate relationship and reports the facilitator to the retreat owner. The owner says they have a “two strikes and you’re out” rule – if a facilitator starts one relationship with a client they get a warning, if they start two relationships they are fired. The facilitator is still working at the retreat center.

Very few psychedelic retreat centers have ethics codes or complaints procedures to protect consumers. Some retreat centers or underground ceremonies don’t even have websites. How could standards be improved in the retreat industry or the underground?

Accidental High-Dose MDMA Ingestion

Implications for substance safety and issues of consent

Subject identity details: 30-year-old, sex and gender unspecified

Setting: Small group experience at home

Year: 2022

Substance/Dose – Primary: MDMA, 300 mg

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: 50 mg Quetiapine, 400 mg Lamotrigine, 5-HTP

Case Study Source: Erowid Center

Summary: An individual accidentally ingested 300 mg of MDMA, three times their typical dose, after mistaking it for 5-HTP. The unexpected intensity caused panic, severe teeth grinding, and prolonged effects lasting 24 hours. Their hosts provided trip-sitting support. Despite explicit consent being affirmed before engaging in intimate activities, the individual acknowledged the risks of drug-facilitated decisions. They later experienced a delayed serotonin crash and hypomania.

Case Study:

A 30-year-old individual traveled to visit their partner and their partner’s partner (metamour) and decided to bring the remainder of their MDMA in a discreet manner They crushed 300 mg of MDMA, measured with a precision scale, and concealed it within a capsule placed in a bottle with 5-HTP. The plan was for each individual to consume approximately 100 mg at some point during the visit, followed by a 5-HTP supplement 24 hours later to mitigate any potential crash.

However, the individual did not separate the MDMA capsule from the 5-HTP after arrival, believing they would recognize the difference. They later reflected on their overconfidence in being able to differentiate the capsules, especially under conditions of low lighting, fatigue, or stress. On the night of the incident, they and their hosts consumed a small amount of low-THC cannabis and engaged in a necessary but emotionally challenging discussion.

The individual reported that their typical MDMA dose was 100 mg, as higher doses in the past had led to distressing physical reactions, including convulsions. However, that night, they unintentionally ingested the 300 mg MDMA capsule along with their usual medications, which included quetiapine, lamotrigine and 5-HTP for bipolar disorder, anxiety, and insomnia.

The effects set in rapidly, and within moments, they reported dizziness and lay down. When the sensations intensified, they experienced an overwhelming sense of alarm, initially fearing an unexplained medical emergency. As the effects continued to escalate, they struggled to comprehend what was happening, feeling a mix of familiarity and terror. Their partner confirmed that the MDMA capsule was missing from the 5-HTP bottle, verifying that they had mistakenly taken it. Despite the unexpected nature of the situation, their hosts remained calm and prepared to support them through an intense night of trip-sitting.

Physically, the individual exhibited teeth chattering and shaking, and they bit their tongue excessively in an effort to avoid grinding their teeth. To mitigate this, they improvised a pacifier Though they later took 800 mg of magnesium, it had little effect at that stage.

The remainder of the night was spent in their metamour’s bedroom, as it offered the most space. As the peak effects settled in, the person experienced heightened emotional connectivity Although the finer details became hazy, they recalled feeling deeply connected to the other two people and requesting to cuddle, which later evolved into intimate interactions with their metamour for the first time. Their partner observed and encouraged the experience.

Recognizing the individual’s altered state, their hosts prioritized explicit consent, verifying that the desires expressed under the influence were pre-existing. They acknowledged past MDMA experiences where they had been around people they would not have engaged with while sober, reinforcing the need for caution. Ultimately, all parties felt comfortable proceeding.

After approximately five hours, the hosts fell asleep, while the individual remained awake with eyes closed, still feeling the lingering effects. By morning, they continued to experience a mild rolling sensation, fully coming down around the 24-hour mark.

They reflected on the fortunate timing of the event, recognizing that on a different night, the experience could have been highly distressing. Additionally, they acknowledged the potential complications of accidentally consuming MDMA alongside 5-HTP

The aftermath included a significant “serotonin crash”, though it was delayed by two days due to an intervening LSD trip. Initially feeling well, they proceeded with the trip without considering the strain on their neurochemistry. The LSD experience itself was not overwhelming but induced sadness regarding unrelated personal matters. The following day, they experienced intense distress, followed by three days of hypomania.

Ten days post-incident, they reported feeling back to their baseline level of well-being.

“That’s Part of the Medicine Perfecting You”

Prolonged adverse effects from repeated psilocybin use in an underground psychedelic therapy training program

Subject identity details: 71-year-old female clinical psychologist6

Setting: Guided underground sessions for psilocybin facilitator training Year: 2022

Substance/Dose – Primary: Psilocybe cubensis mushrooms, “high” doses, unspecified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Perna, J , Trop, J , Palitsky, R et al Prolonged adverse effects from repeated psilocybin use in an underground psychedelic therapy training program: a case report. BMC Psychiatry 25, 184 (2025) https://doi org/10 1186/s12888-024-06303-z

Summary: A psychologist underwent psychedelic therapy training that involved repeated high doses of psilocybin-containing mushrooms and subsequently developed prolonged adverse effects including severe sleep impairment, anhedonia, and suicidal ideation requiring hospitalization. Despite worsening symptoms, her psychedelic therapy trainers advised her against seeking psychiatric support, delaying treatment Ultimately, the patient’s symptoms resolved after a course of electroconvulsive therapy (ECT)

Case Report Summary adapted from Case Presentation:

A 71-year-old female clinical psychologist, Dr A, with no prior personal or family psychiatric history, was admitted to an inpatient psychiatric unit with severe psychiatric symptoms following repeated ingestion of high doses of psilocybin mushroom She reported persistent sleep impairment, anxiety, depression, irritability, anhedonia, and passive suicidal ideation, along with significant weight loss. Her symptoms had progressively worsened over four months, and she linked their onset to her participation in a psilocybin facilitator training program

Initial Psilocybin Exposure and Enrollment in Facilitator Training

Dr A had her first guided psilocybin experience in 2021, which she found profoundly positive Motivated by its perceived therapeutic potential, she enrolled in a formal psilocybin facilitator training program in 2022. The program, run by a U.S.-based therapy training institute in Costa Rica, was led by a husband-and-wife team who promoted a blend of shamanic healing, plant medicine, and transpersonal psychology. The training spanned six months and involved six weekend retreats, with both trainees and non-trainee clients ingesting psilocybin mushrooms in group settings The Institute claimed legal protection for its use of psilocybin through a religious ordination model.

6Adapted from Case Presentation of the original paper, see original for full case report

Training Program and Escalating Symptoms

Trainees, including Dr. A, underwent multiple psilocybin experiences, with leaders selecting dosages based on their assessment of each individual’s potential to benefit from high-dose experiences. Deemed to have “high potential” due to her background, Dr. A received escalating doses over the sessions The first three retreats involved one high-dose session each, which she found intense but manageable However, she became increasingly uneasy as the sessions progressed. She reported distress at the leaders’ practice of abruptly ending sessions while participants were still experiencing psychoactive effects

Following her third retreat, she experienced anxiety, restlessness, and concentration difficulties. By the fourth retreat, she no longer wanted to take psilocybin but felt pressured to continue, fearing that withdrawal would impact her credibility as a future facilitator During the high-dose session at this retreat, she had overwhelming visions of violence and reported an acute increase in anxiety Despite her distress, she was advised that such experiences were part of the necessary healing process

Between the fourth and fifth retreats, her symptoms worsened, including impaired sleep and heightened anticipatory anxiety Despite expressing concerns, the leaders reassured her that continued participation was necessary for personal transformation. She proceeded with another high-dose session, which exacerbated her physical discomfort Her ability to engage in integration practices diminished, as she feared further engagement with her experiences

Deterioration and Final Retreat

By the sixth retreat, Dr A was in significant distress but was persuaded to continue, believing the final session would resolve her struggles. However, she later described feeling completely disoriented, experiencing a state of near-complete dissociation with minimal recollection of the event Witness reports suggested she lost consciousness, was difficult to rouse, and experienced multiple panic attacks. Following this retreat, her psychiatric and physical symptoms became debilitating, forcing her to take medical leave from her practice

Post-Retreat Decline and Hospitalization

Seeking support, Dr A turned to the leaders, who charged an additional $5,000 for individualized guidance and energy healing They discouraged her from seeking psychiatric care, claiming that medical intervention would interfere with her “rebirth” process. As her symptoms worsened - including further weight loss - the leaders dismissed her concerns, telling her the medicine was “perfecting” her The breaking point came when she was told to “stop acting like a victim.” She severed ties with the Institute and, fearing irreversible damage, developed passive suicidal thoughts, leading to her psychiatric hospitalization

Conclusion

This case highlights the psychological risks associated with high-dose psilocybin use in unregulated settings, particularly when facilitators discourage medical intervention and fail to provide adequate support. Dr. A’s experience underscores the need for structured, evidence-based approaches to psychedelic therapy, ethical facilitation, and informed consent regarding potential adverse outcomes

Distressing Hallucinations Lead to Emergency Department Visit

Black out and violent outburst during LSD experience, then HPPD

Subject identity details: 21-year-old African-American man

Setting: Unknown Year: 2010s

Substance/Dose – Primary: LSD

Confidence level of identification: Medium to High Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Kurtom M, Henning A, Espiridion E D (February 14, 2019)

Hallucinogen-persisting Perception Disorder in a 21-year-old Man. Cureus 11(2): e4077. DOI 10.7759/cureus.4077

Summary: A young man experiencing an episode of flashbacks was hospitalized for evaluation. The symptoms were linked to a prior LSD experience that had resulted in a blackout and altercation leading to legal consequences and ongoing stress. Unable to work due to injury, he faced the threat of eviction and felt isolated without support. He reported concentration and sleep difficulties but denied suicidal thoughts. Despite presenting as sad and guarded, he exhibited fair cognitive function and insight. A short hospital stay with clonazepam treatment stabilized him, and he was referred for outpatient care. Clinicians discussing this case believe the man was experience hallucinogen-persisting perception disorder (HPPD).

Case Study:

Adapted from published case report, edited for length

A 21-year-old African-American male presented to the emergency department at the local community hospital after an episode where the patient was reported to have flashbacks with hallucinations. He reported that the hallucinations were “tactile in nature” and that he could “still feel the cold breath” come out of him. Upon admission to the behavioral health unit, it was discovered that he took an unknown quantity of LSD seven months prior, and he claimed he was having flashbacks to that night, where he “blacked out” and then shortly after became aware of his surroundings to discover he was beating the man who had given him the LSD. There was, reportedly, “blood everywhere.”

Because of the altercation, the patient was arrested and is serving two years of probation with community service. The patient injured his hand at the time of the assault and is unable to work, so he is physically unable to fulfill the community service requirement. The patient is under significant distress because of the position he is in and reports that he does not want to go back to work as a lumberjack. Because he is currently unemployed, his stepfather has been threatening to evict him if he does not find a new job.

The patient admits he has symptoms of poor concentration, memory problems, sleeping difficulties, and is feeling isolated without a good support system. There are no prior psychiatric hospitalizations, and additional history was benign other than the incident he had seven months prior, after taking LSD.

The patient denied a history of suicidal thoughts and attempts. He denied alcohol use but admitted to marijuana abuse. He has never been married and has no children. Upon exam, the patient looked appropriate for his stated age. There was no psychomotor agitation or retardation. He maintained eye contact and spoke with coherence. The patient was sad and his affect was constricted. Immediate retention and recall, recent memory, remote memory, and fund of knowledge appeared to be fair. There were no referential or paranoid ideations. He denied any thought broadcasting, insertion, or withdrawal. He denied any delusions but admitted to visual hallucinations. He was paranoid and guarded. There were no suicidal or homicidal ideations, intents, or plans. He denied any problems with concentration. Insight and judgment were fair, but impulse control was poor by history. The patient was not taking any prescription, over-the-counter, or herbal medications.

On completion of the interview, the patient was observed in the behavioral health unit, and a decision was made to place the patient on clonazepam 1 mg four times a day. The patient fully recovered after four days, and he was then referred to a private local mental health center for follow-up.

K Confessions

Chronic ketamine use and its psychological effects

Subject identity details: 42-year-old man

Setting: Alone at home

Year: 1998-1999

Substance/Dose – Primary: 25-100 mg intramuscular Ketamine

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Erowid Center7

Summary: A 42-year-old male developed a near-daily ketamine habit over 18 months, transitioning from infrequent high doses to regular low-dose IM administration. While maintaining functional relationships and employment, he experienced deep cognitive and existential shifts, including reality reorganization and perceived omniscience. His wife detected behavioral changes, prompting him to reduce use to weekends. He acknowledged psychological dependence and questioned the validity of his experiences. While avoiding overt psychosis, prolonged dissociation raised concerns about reintegration into reality His case underscores the need for awareness of ketamine’s long-term cognitive effects, balancing its therapeutic potential against risks of dependency and altered perception.

Case Study:

A 42-year-old male with extensive experience using various psychoactive substances developed a habitual ketamine (“K”) use pattern over 18 months. Initially, his use was limited to infrequent high-dose intramuscular (IM) sessions (75-100 mg) that elicited profound experiences. Over time, he introduced lower-dose IM administration (20-30 mg per dose, spaced hourly) as part of his evening routine, likening it to a ritual that enhanced focus and relaxation. Despite near-daily use, he reported no significant withdrawal symptoms or physical dependence when abstaining for brief periods.

The man described his professional life and personal relationships as stable, maintaining a corporate job and a marriage, despite his secretive use. However, his wife, perceiving behavioral changes under the influence of ketamine, disapproved of its effects and was ultimately able to detect even subtle signs of use. This led to a

7Case Report adapted from first-person account: Legofeel "K Confessions: An Experience with Ketamine (exp2731)" Erowid org Aug 10, 2000 erowid org/exp/2731

confrontation regarding his escalating consumption. As a compromise, he agreed to limit usage to weekends but expressed internal conflict over maintaining control over his intake. While he recognized his psychological dependence, he found no immediate compelling reason to discontinue use aside from concerns about long-term health effects.

His ketamine sessions often took place in a controlled home environment, accompanied by electronic music and visual stimuli. He described the effect of ketamine as a "consciousness filter" that reduced sensory input while enhancing cognitive clarity. He noted that at low doses, he could maintain full functionality, with an increased ability to process financial and philosophical concepts.

Recurrent motifs in the man’s experiences included:

● A perceived breakdown and reorganization of reality, where all external stimuli could be rearranged into novel, meaningful associations.

● A sensation of transcending conventional reality, encountering a universal "meta-reality machine."

● A crisis state where he believed he was approaching the dissolution of self, sometimes interpreted as physical death.

● Moments of perceived omniscience, where he felt connected to a vast informational network.

● A struggle to reintegrate into baseline reality, often requiring cognitive reconstruction to dismiss anomalous perceptions as hallucinations.

Following prolonged ketamine use, the man began questioning the sustainability of his habit. While he did not report overt psychotic symptoms outside of acute intoxication, he acknowledged a psychological dependence, describing ketamine as a fundamental tool for structuring his perception of reality. Despite this, he recognized the need to moderate his use, largely in response to interpersonal strain with his spouse and concerns about long-term cognitive effects.

He also expressed uncertainty regarding the legitimacy of his experiences, questioning whether they provided genuine insights or were merely elaborate constructions of the mind. While he remained deeply engaged in philosophical contemplation about consciousness and reality, he also acknowledged the potential risks of persistent dissociation and the blurring of boundaries between subjective experience and objective existence.

This case highlights the complexities of chronic ketamine use. While ketamine is recognized for its dissociative and psychedelic effects, prolonged use at both low and

high doses may contribute to shifts in perception, existential re-evaluation, and potential difficulties with reintegration into baseline reality.

Although the man maintained social and occupational functioning, the psychological impact of long-term dissociation and altered cognition warrants further investigation. His case underscores the need for greater awareness of the nuanced effects of ketamine, particularly among users engaging in frequent self-administration outside of clinical settings. Additionally, the psychological dependence described in this case reflects a growing concern regarding ketamine’s potential for habitual use, and raises important questions about the balance between the therapeutic potential of ketamine and the risks of chronic use in altering self-perception and existential frameworks.

LSD at a Festival

Varying accounts of emergency that resulted

in death

Subject identity details: 20-year-old woman

Setting: Festival8

Year: 2017

Substance/Dose – Primary: LSD

Confidence level of identification: High (unknown dose)

Substance(s)/Dose(s) – Secondary: Uncertain

Case Study Source: Composite (media sources, Erowid Center, Lucid News)

Case Study:

On May 28, 2017, Baylee Gatlin, a 20 year-old-woman, was transported to Twin Cities Community Hospital and declared deceased, after being taken to psychedelic peer support services at an outdoor festival. The San Luis Obispo County Coroner’s Office ruled the death to be caused directly by the low level of LSD detected in her blood. Medical experts who have studied LSD criticized the finding, saying that the low level of LSD found in her blood could not have killed her and those involved in the investigation must have failed to identify substances that were more likely to have caused her death.

The Coroner’s Report states that a “Complete Drug Screen” was performed on blood samples and vitreous fluid, but it is not clear what this entailed beyond the assays for LSD, “bath salts”, GHB, “Psilocin (metabolite of Psilocybin) and Synthetic Cannabinoids (‘Spice’)”, U-47700, Buprenorphine, Ethyl Alcohol and Lidocaine that are specifically mentioned. Apparently the coroner did not order tests for any NBOMes, which have been misrepresented as LSD and caused dozens of deaths in the last decade. As of August 2017, no NBOMes appeared on the Drug List available in the Coroner & Medical Examiner section of the testing facility that performed the toxicological analysis.

Further, in September 2017 it was reported that the medical examiner responsible for declaring the death to be from “acute LSD poisoning” was removed from his position at the Coroner’s office due to both private conduct (a DUI) and his controversial reports in two deaths, those of Andrew Holland and of Baylee Gatlin.

8Erowid Summary: https://www erowid org/chemicals/lsd/lsd death shtml#2017-baylee-gatlin Lucid News Coverage: https://www lucid news/tag/baylee-gatlin/

Wasn’t Sure if He Would Continue to Hurt

Himself or Others

Client becomes combative, reasonable effort to resolve situation fails

Subject identity details: Male, age not specified

Setting: State-licensed Psilocybin Service Center (Oregon)

Year: 2024

Substance/Dose – Primary: Psilocybin, “B+, 34 mg [psilocybin equivalent] in pre-packaged apple”

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Oregon Health Authority’s Oregon Psilocybin Services (OPS)

Summary: Male client exhibited erratic and aggressive behavior, including self-harm, physical altercations with staff, and property destruction. Attempts to calm him through verbal reassurance and environmental adjustments were ineffective. Emergency services were called, but the client was not transported.

Case Study:

Oregon’s OPS rules require Psilocybin Service Center representatives to fill out an Emergency Services Contact Report if anyone on the licensed premises requires emergency medical care due to an immediate or potential life threat. The following details were gleaned from a redacted incident report submitted in December 2024.

After masturbating, taking off his shirt and asking the service worker if he “wanted to some of this” (as if preparing to fight, not have sex), the client banged his head against the front door “a couple of times”, punched it, threw punches at the service worker and grabbed the shirt, sweater and necklace of the facilitator He would not let go and ripped it open. He also ripped blinds from one window, and pulled down the microwave and refrigerator The client had a cut on his forehead from hitting his head against the door’s peephole, and the facilitator wasn’t sure if he would continue to hurt himself or others.

Prior to contacting emergency services, the facilitator and service worker made attempts at redirecting the client to his intention, and changed the music to [be] even more quiet and calm. The facilitator said client’s name over and over and reminded him he was safe and that we were there to support him. Client was not engaging verbally with facilitator or service worker.

Client Wanting a “Big Experience” To Get Him on the “Right Path”9

Physical aggression, safety concerns and legal consequences

Subject identity details: 55-year-old man (composite)

Setting: State-licensed Psilocybin Service Center (Oregon) Year: 2020s

Substance/Dose – Primary: 30 mg then 20 mg psilocybin equivalent after one hour

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Healing Advocacy Fund

Summary: A man with a history of substance use and childhood trauma sought a facilitated psilocybin session to reset his life. Choosing a high-dose experience, he initially enjoyed the effects but soon became agitated and paranoid. Feeling unsafe, the client tried to leave the center, and when staff intervened, he became confrontational. De-escalation efforts failed, necessitating emergency intervention. During an EMS assessment, the client struck a responder, prompting police intervention. After calming down, he opted to stay at the center until the effects subsided. The EMS worker later pressed battery charges, and the client is now awaiting trial.

Case Study:

Note: This case study, while informed by real stories, is hypothetical and intended for discussion purposes only

Case Study: Physical Aggression and Facilitator Safety

A 55-year-old man sought psilocybin therapy through Oregon’s state-regulated program for substance use issues with alcohol. The client had struggled with substances most of his life and had experienced physical and emotional abuse as a child. He committed to and was able to do the preparation session sober, and maintained sobriety for 24 hours before his session without entering withdrawal. He decided on an initial 30mg dose with a 20mg booster due to some previous experience with psychedelics, and wanting to have a “big experience” to get him on the “right path.”

One hour after consuming the 30mg, the client was not feeling anything and consumed an additional 20mg dose. Very shortly after, he began feeling the substance. The first 20 minutes, he enjoyed the experience, but then his anxiety grew as the psilocybin took

9 This case study, while informed by real stories, is hypothetical and intended for discussion purposes only

effect, and he began to accuse the facilitator of controlling him. His behavior became erratic, and he grew increasingly distressed, citing his discomfort with the facilitator’s presence and the session environment.

As his agitation increased, the client tried to leave the session, expressing that he didn’t feel safe. The facilitator remained calm, reminding him of the guidelines and reassuring him that he was in a secure space. However, the client’s distress continued to intensify, and he began to raise his voice and demand to be left alone. When the facilitator attempted to redirect him, he became physically confrontational, knocking items off of shelves, and approaching the facilitator while yelling at them. The client was significantly larger than the facilitator and starting to become more physically antagonistic, jolting towards the facilitator.

The situation was escalating, and recognizing the need for additional support, the facilitator signaled for assistance from the onsite service center worker. The service center staff arrived promptly and positioned themselves at a distance, offering non-threatening communication to help calm the client. The client ended up punching a wall, and at that point, the staff became concerned with their safety, and they determined they needed to call emergency services. They notified the client they were going to call for assistance to have their hand evaluated. The client started to become more responsive and aware of their surroundings.

EMS and police were dispatched to the scene. The service worker stepped outside and it was decided that EMS would go into the administration room to evaluate the client’s hand, but the police would stay in the reception area so as not to escalate the situation. The client was initially cooperative, but when EMS tried to evaluate the client’s hand, the client grabbed and struck the EMS worker. The police came in to restrain the client, and after about 15 minutes, the client had calmed down and was fully cooperating.

The client was given the option of staying at the center or going to the hospital to have their hand examined further They decided, with agreement from the facilitator, to stay at the center until the effects had fully worn off.

The EMS worker decided to file a battery charge against the client and they are awaiting trial.

Generational Trauma and Facilitator Training

Facilitator did not follow program rules, failed to reach out to client to offer an integration session

Subject identity details: 28 (composite)

Setting: State-licensed Psilocybin Service Center (Oregon)10 Year: 2020s

Substance/Dose – Primary: Not specified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Healing Advocacy Fund

Summary: A Canadian client sought a facilitated psilocybin session to address depression, anxiety, and inherited trauma. While past psilocybin therapy had been effective, this session proved challenging. During intense trauma processing, the facilitator provided little guidance beyond urging the client to “trust the medicine,” leaving them feeling unsupported. Seeking reassurance, they turned to friends outside the session, via phone. Post-session, the facilitator failed to provide integration support due to a personal emergency, and the service center did not reach out to the client, leaving them to feel abandoned. They ultimately sought therapy independently, feeling that the lack of structured follow-up underscored gaps in facilitator training and accountability.

Case Study:

Note: This case study, while informed by real stories, is hypothetical and intended for discussion purposes only

Case Study: Generational Trauma and Facilitator Training

A 28-year-old client from Canada sought psilocybin therapy to address lifelong struggles with depression, anxiety, emotional numbness, and an underlying sense of dread that they could never fully explain. Despite years of traditional talk therapy and medication, they continued to experience deep-seated fears and relationship difficulties. The individual had experience with psilocybin therapy in the past, and it was very effective.

10 This case study, while informed by real stories, is hypothetical and intended for discussion purposes only

The individual’s family had a history of surviving extreme hardship, loss, and displacement due to historical trauma. Though family members rarely spoke about their experiences in detail, they grew up in an environment shaped by inherited trauma. The household was marked by isolation, hypervigilance, emotional suppression, and an unspoken fear of loss and instability. These dynamics deeply affected their sense of safety, emotional expression, and ability to trust others.

After extensive research and consultation, the individual participated in a therapeutic psilocybin session in a controlled setting with a trained facilitator in Oregon. The facilitator they selected had stated they had a “trauma informed approach” but did not hold any other healthcare licenses. During the experience, the client reported accessing memories and emotions that had previously felt inaccessible, gaining insight into the fears and survival mechanisms that had shaped their family’s history

However, during the highest moments of intensity around trauma response, the client reported that the facilitator present was not equipped to deal with the situation. The facilitator remained largely inactive, providing minimal reassurance or intervention, continuously telling the client to “trust the medicine” and “surrender.” The participant, feeling acutely unsafe, resorted to seeking support from two friends outside the session via phone. While the psilocybin experience did bring them to the depths of emotional processing they had hoped for, it also revealed serious limitations in the training of this facilitator. This lack of adequate facilitator intervention contributed to feelings of isolation and insecurity during critical moments.

Following the session, the individual reported mixed results. There was a lingering feeling of isolation compounded by the fact that the facilitator did not follow program rules in reaching out to the client to offer an integration session due to a “personal emergency.” No one from the service center reached out, and the client felt incredibly alone.

The client ended up finding their own therapist and support through their family and friend network, without any direction from the facilitator

Oh My God, Demons Are a Thing

Encounters with entities perceived as benign or malevolent are not uncommon

Subject identity details: 37-year-old woman with complex PTSD

Setting: Alone

Year: 2020-2022

Substance/Dose – Primary: 100 grams fresh home-grown Psilocybe mushrooms11 Confidence level of identification and dose: High

Substance(s)/Dose(s) – Secondary: 100 μg LSD; 300 μg LSD (separate experiences)

Substance(s)/Dose(s) - Secondary – Confidence level of dose: Medium

Case Study Source: Challenging Psychedelic Experiences Project

Summary: Chloe, a 37-year-old dominatrix with complex PTSD, turned to LSD for self-healing during the pandemic. Initially, she experienced profound inner transformation. After nine months of weekly trips, she took a break to integrate Six months later, a high-dose mushroom trip plunged her into a nightmarish struggle with what she perceived as a parasitic demon She spent 18 months struggling alone before seeking peer support from a spiritual awakening group and sharing circle In the midst of her struggle with the demon, she had a 300 microgram LSD trip, which led her to abandon her former life and join a Buddhist monastery.

Case Study:

-Chloe was a 37-year-old dominatrix from London with complex PTSD stemming from a challenging childhood During the COVID-19 pandemic, Chloe turned to psychedelics, specifically LSD, as a means of self-healing She embarked on weekly 100-microgram trips, utilizing Pete Walker's re-parenting techniques to address her trauma. This process led to significant personal growth, including feelings of rebirth and a newfound sense of spirituality

After nine months of consistent psychedelic sessions, Chloe decided to pause and integrate her experiences Six months later, she consumed a substantial dose of magic mushrooms, which led to a distressing encounter with a perceived parasitic entity. She described this entity as a purple blob with tentacles, each representing various distractions like alcohol and social media Chloe felt that this demon fed off individuals' traumas, laying eggs that perpetuated harm. This confrontation left her feeling deeply shaken and led to ongoing efforts to purge the entity from her being

Such encounters with entities – perceived as benign or malevolent - are not uncommon during psychedelic experiences, and have been documented in various cultural and historical contexts. Rick Strassman, during his DMT research in the 1990s, noted frequent reports of contact with

11 Further details: https://www ecstaticintegration org/p/encounters-with-negative-entities

beings, some of which were perceived as malevolent These experiences raise questions about the nature of such entities and their origins, whether they are manifestations of the psyche or encounters with external forces

Internal Family Systems (IFS interprets these entities as sometimes being parts of the self that have become extreme due to trauma, but also sometimes ‘unattached burdens’ – external malevolent entities which need to be ‘exorcised’ Some clients report this process to be helpful if they believe they have ‘unattached burdens’ within them However, other clients report finding it disturbing if their therapist tells them they have an entity within them that needs to be removed

A majority of psychedelic guides say they believe in entities, benign or malevolent, and think people can be brought into contact with them during psychedelics Most psychedelic guides also feel they do not have sufficient training to deal with entities. Within traditional shamanic ceremonial healing settings, shamans from various traditions may also subscribe to the view that entities are real and can be malevolent and need to be carefully addressed by qualified shamans

Red Flags, yet for Some Reason, We Stayed

The psychedelic retreat from hell

Subject identity details: British woman in her 40s, psychotherapist

Setting: 17-day psychedelic facilitator training course12

Year: ~2022

Substance/Dose – Primary: 5-MeO-DMT (“Bufo”) / Unspecified high doses

Confidence level of identification: Unclear (either 5-MeO-DMT, or 5-MeO-DMT-containing toad secretion)

Substance(s)/Dose(s) – Secondary: Syrian Rue seed tea, Sananga, maybe Kambo

Case Study Source: Challenging Psychedelic Experiences Project

Summary: Julia, a psychotherapist, sought spiritual and professional growth at a Bufo (5-MeO-DMT) facilitator training in Mexico Despite glowing online reviews for the psychedelic retreat center hosting the training, she endured a harrowing experience. From the start, Julia encountered unethical practices, coercion, and psychological abuse The lead facilitator administered large doses of psychedelics daily and subjected her to non-consensual treatments. Over the course of a week, she descended into terror, paranoia, and suicidal thoughts She fled the retreat early with the friend to had accompanied her Back in the UK, she faced months of physical and emotional recovery

Case Study (adapted from Doubleblind article):

Julia is a British psychotherapist in her 40s who has been exploring and working with psychedelics for eight years In 2022, she read glowing reviews about a psychedelic retreat center in Mexico called Sowilo. She and her friend, who’s a psychotherapist, signed up for a 17-day Bufo facilitator training course for $5,000

Sowilo was based at a beautiful farmhouse outside Merida, in Yucatán, Mexico It was run by a Frenchman named Bruno Cluzel, who calls himself Gabriel, and his wife Aymeline They lived there with their three children. They offered Bufo (5-MeO-DMT) ceremonies that cost a few hundred dollars and multi-week facilitator training for thousands of dollars Some people found healing from addictions and other issues, ultimately choosing to stay at the retreat and become employees or followers

But Julia and her friend had bad vibes from the start When they arrived, Gabriel was mid-ceremony He eyed them strangely and muttered what sounded like incantations, then produced startlingly accurate information about them. “It was weird,” said Julia. “There were all these red flags, yet for some reason, we stayed ”

12 Further details: https://doubleblindmag com/sowilo/

Sowilo began each day with what Gabriel said was a “low dose” of 5-MeO-DMT, which was not small by any normal metric. Then there would be an even higher dose in the afternoon, or sometimes a magic mushroom or Syrian Rue ceremony Julia noticed Gabriel was smoking a lot of Bufo, causing him sometimes to fall over. Guests fell over, too, burning themselves with the pipe or banging their heads on the ground. The facilitators offered kambo and Bufo on the same days One time, Gabriel forcefully grabbed Julia’s head and, without consent, put drops of sananga (eye drops made from a shrub found in Latin America that often elicits a burning sensation) into her eyes

Gabriel was an odd mixture of a guru with Messianic pretensions and a former Miami real estate salesman with slicked-back hair who often spoke about money and how successful he’d been in his previous job. He told Julia he was a “walk-in spirit” called Gabriel (which is his middle name), and sometimes that he was Lucifer

From the first Bufo session, Julia felt in a state of permanent terror “Every time I almost fell asleep, I felt myself fall into hell,” she said. “Lost souls energetically around me lining up to be released through me, back to the light At different times during the night, my body jolted as a malevolent spirit entered my body Gabriel’s remedy was to serve me more Bufo to release them. I felt in a drugged state the whole time. My energy field was blasted open, and I didn’t know what was real or not anymore I lost myself and I lost my mind ”

One day they were served Samadhi, or Syrian Rue, seeds Julia could hear Gabriel whispering to his assistant, “Make sure she drinks it all

Gabriel lay next to her during the ceremony and said, “You’re so boring, you’re such a victim ” He also tried to get her friend to mock her for being pathetic. She felt like Gabriel was trying to break her spirit

“I experienced an overwhelming, all-consuming paranoia of wanting to kill myself,” she said “I had this tiny bit of rational mind that was still there, which was able to say, ‘Please, can you move these pipes because if you don’t, I’m going to slash my wrist ’ In the garden, a hammock rope was hanging from a tree I walked to it, compelled to put a loop in it and wrap it around my neck. Thankfully, someone came so I wasn’t left alone.”

Finally, Julia and her friend mustered up the courage to leave the retreat center 10 days early, get to Merida, and find a way back home to the UK

“I spent six weeks physically recovering after returning home with chronic diarrhea and nausea,” she said. “Mentally, I had no energy or concentration for conversation. I was terrified to be alone and slept with the light on. The night terrors lifted after four weeks. It took over four months to recover and feel whole again ”

Julia was not the only person to endure severe harm during their time at Sowilo

Right From the Beginning, There Were Issues

One of two cases of extended difficulties after Braxia’s psilocybin TRD trial

Subject identity details: Adult female, age not specified13

Setting: Clinical Trial / small with no windows, plants or natural light

Year: Multiple sessions, 2021 to 2022

Substance/Dose – Primary: Psilocybin / Unspecified dose

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Challenging Psychedelic Experiences Project

Summary: Heather had battled treatment-resistant depression since adolescence and joined a psilocybin clinical trial with high hopes During her participation, she faced numerous challenges. Required to taper off SSRIs quickly, she received inconsistent therapist support, and felt unsupported during sessions After initial improvement, she developed severe anxiety, vision disturbances, and depersonalization Despite seeking help, she felt dismissed by trial staff and resorted to underground therapy, worsening her symptoms. She was later diagnosed with PTSD, GAD, and Hallucinogen Persistent Perception Disorder (HPPD) While some symptoms improved with neurorehabilitation and psychotherapy, others persist. The trial results omitted long-term adverse effects, raising concerns about research transparency

Case Study:

Heather is one of two participants in Braxia’s psilocybin trial for treatment-resistant depression who reported that they encountered prolonged challenges following their involvement They attributed these difficulties to the conditions of the trial and felt that their experiences were inadequately represented in the published results The individuals eventually connected with each other and shared their stories

The trial aimed to assess the efficacy of psilocybin in treating depression unresponsive to conventional therapies While some participants reported positive outcomes, these two individuals experienced adverse effects that persisted beyond the trial’s conclusion. They believed that certain aspects of the trial’s design and implementation contributed to their prolonged difficulties

Both participants felt that the trial conditions did not adequately prepare them for the intensity of the psychedelic experience They reported a lack of sufficient psychological support during and after the sessions, which they believed exacerbated their challenges. Additionally, they expressed concerns about the integration process, feeling that it was insufficient to help them process and make sense of their experiences

13 Further details: https://www ecstaticintegration org/p/two-cases-of-extended-difficulties

Upon reviewing the published results of the trial, the individuals noticed that their adverse experiences were not thoroughly documented. They felt that this omission presented an incomplete picture of the trial’s outcomes and potentially misled others about the risks involved This lack of comprehensive reporting prompted them to share their stories publicly.

Through sharing their experiences, the participants highlighted the importance of comprehensive support systems in psychedelic research They advocated for more thorough preparation, monitoring, and integration processes to ensure participant safety and well-being. Their stories serve as a cautionary tale for future trials, emphasizing the need for transparency and the inclusion of all participant experiences in reported outcomes.

The experiences of these two individuals underscore the complexities involved in psychedelic research for mental health treatments Their accounts call for a reevaluation of current protocols to better address the potential risks and ensure that all participant experiences are accurately represented By doing so, future research can be more ethically sound and provide a clearer understanding of both the benefits and challenges associated with psychedelic therapies.

How can trial participants and, eventually, patients receiving psychedelic medicine, be properly prepared for psychedelic treatments, informed about the range of possible outcomes, and best supported during and after sessions?

Left Feeling Confused and Abandoned

Transference and dual relationships in therapeutic psychedelic facilitation

Subject identity details: mid-30s BIPOC individual with significant childhood trauma, religious abuse, childhood neglect and ADHD

Setting: Sessions with Underground Facilitator14

Year: 2020s

Substance/Dose – Primary: Multiple sessions / MDMA and Psilocybin (separately), doses unspecified

Substance/Dose - Primary - Confidence level of identification High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: SHINE Collective

Summary: A mid-30s individual with childhood trauma, ADHD, and C-PTSD sought MDMA-assisted therapy to heal familial relationships and religious shame The facilitator, an underground provider, failed to maintain boundaries, engaging them socially and personally Over four months, they participated in multiple psychedelic sessions and community ceremonies, becoming deeply attached to his facilitator Encouraged by her, they pursued psychedelics professionally and socially. After experiencing major grief events, they sought support but were met with blame and aggression Feeling abandoned and confused due to their multiple relationships, communication became strained, though the facilitator continues sporadic and cryptic outreach.

Case Study:

A mid-30s BIPOC individual with significant childhood trauma, religious abuse, childhood neglect and ADHD was seeking therapeutic treatment for C-PTSD Client was referred to an underground facilitator through an online referral network, local to their region, who could provide MDMA-Assisted Psychotherapy. The client was specifically seeking treatment to heal the strained relationship with their mother and to process shame and guilt around religious upbringing. The facilitator was a long-practicing medicine facilitator, who was of similar age to the client’s mother.

From the onset of the therapeutic relationship, the facilitator failed to maintain professional boundaries The facilitator engaged in inappropriate conversations around personal life and romantic life, spoke of other clients she’s worked with and facilitated sessions from her home, requiring all clients to stay overnight in her private residence.

14 Case studies are all based on actual reports given to SHINE Collective staff The names and locations have been anonymized The survivors have reviewed and given consent for SHINE Collective & PSI to utilize this information for educational purposes

The client participated in three MDMA sessions and one Psilocybin session over the course of four months, with frequent but sporadic contact through phone calls and text messages

The morning after the first MDMA session, the facilitator engaged in conversations that involved her personal and professional goals to open up a healing center Client was in a highly suggestible state and enamored with the idea. Client wanted to support his facilitator in any way possible and offered to help and be involved

The conversations continued to evolve throughout the treatment time and the facilitator began inviting the client, who was seeking community and integration support, to psychedelic gatherings at her home and began getting involved socially and meeting other clients that she was working with.

In the subsequent months, the facilitator hosted multiple community ceremonies with small groups and the client participated in four medicine groups in four months

Client was struggling to fully integrate back into work/life and was attending more psychedelic events and beginning to experiment in the psychedelic recreational space with other substances Client was enamored with the psychedelic community and began developing friendships and romantic partnerships, with aspirations to go into psychedelics professionally and with the on-going encouragement of his facilitator The client reported feeling extremely attached to the facilitator and was willing to do anything she encouraged them to do.

Several months later, the client experienced several grief events (mother passed away and romantic breakup), became dysregulated, and reported to their facilitator that they were in crisis The facilitator became aggressive and accusatory towards the client, claiming that they were to blame for their own misfortune The client felt confused and abandoned, especially given the multiple dual relationships that were created by the facilitator, including professional, social and psychotherapeutic. Communication between client and facilitator has been strained, but facilitator continues to reach out sporadically and cryptically to the client

Pleasant and Mystical, then Complications

An episode of mania following self-reported ingestion of psilocybin mushrooms in a woman previously not diagnosed with bipolar disorder

Subject identity details: 21-year-old woman, history of anxiety, depression and PTSD

Setting: Unspecified / Recreational Year: 2020s

Substance/Dose – Primary: Psilocybe cubensis mushrooms / “substantial amount”

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Hendin HM, Penn AD An episode of mania following self-reported ingestion of psilocybin mushrooms in a woman previously not diagnosed with bipolar disorder: A case report Bipolar Disord 2021 Nov;23(7):733-735 DOI: 10 1111/bdi 13095 Epub 2021 May 18 PMID: 33934465

Summary: NT, a 21-year-old woman, was hospitalized after experiencing her first manic episode, which she believes was triggered by psilocybin use Despite a family history of bipolar disorder, she had never experienced mania before. Her mental health history includes anxiety, depression, and PTSD, with treatment involving SSRIs, rTMS, and ketamine After her psilocybin experience, she developed paranoia, racing thoughts, and severe distress, leading to involuntary hospitalization. Diagnosed with bipolar disorder, she was stabilized on lithium and aripiprazole before transitioning to lamotrigine Since then, she had one brief mixed episode but has not experienced further psychotic symptoms

Case Report15 (Edited for length):

NT is a 21-year-old female identifying woman who came to the office of her outpatient psychiatric provider a month after a hospitalization for a brief psychotic episode, later diagnosed as mania, that she believes was triggered by consuming a substantial amount of Psilocybe cubensis mushrooms that she had taken recreationally. While she has a positive family history (father and paternal grandmother) of bipolar disorder, she herself had never had a manic episode or been diagnosed with bipolar disorder before this hospitalization She notes that over the past 4 years she had been diagnosed with and treated for anxiety that had later developed into depression and PTSD following rape Psychotherapy and SSRI medications were beneficial but did not lead to remission Eight months prior to her manic episode, she was hospitalized for depression and suicidal ideation. She was placed on fluoxetine in the hospital and released after her acute symptoms resolved about a week later A few weeks following the hospitalization and still on her fluoxetine, she sought treatment with rTMS (standard 6 weeks, 5 treatments per week) for treatment-resistant depression. At the facility that provided rTMS, she also received

15 Adapted from original paper, see original for full case report

adjunctive ketamine infusion (6 infusions over 2 weeks offered at initiation of her rTMS treatment) to help with depressive symptoms. The ketamine did produce short-lived (e.g., hours to days) antidepressant benefit, but the rTMS resulted in remission of her depression Following completion of her course of rTMS, the SSRI was discontinued.

NT had never previously consumed psilocybin and reports the psilocybin experience was pleasant and mystical Drug effects resolved about 5 hours after ingestion, and she describes having had a positive “after-glow” effect for a 1–2 hours following the end of acute drug effects.

About 36 hours after ingestion of the psilocybin, NT’s thoughts began racing She noted an irritable mood and was observed to have pressured speech. She was confrontational with family and required only 2–3 hours of sleep each night These symptoms persisted for 4 days and then, in addition to her original symptoms, she also began to feel fearful of being sexualized by others. She stopped eating. After 3 more days of these symptoms, her boyfriend and family became concerned about her welfare and called the police NT was placed on an involuntary psychiatric hold for 48 hours. She notes that at the time she felt she had special powers that allowed her to read and respond to other people's energies, and that she could communicate with people through telepathy She became fearful that her boyfriend and family were intending to harm her, and tried to run away, but was sedated and restrained with haloperidol and olanzapine She remembers akathisia following the administration of these antipsychotics, and she remembers calling out “Kill me, kill me, kill me” several times

The inpatient psychiatric team diagnosed NT with a bipolar disorder because she met DSM-V criteria in both duration and symptoms for a manic episode (that was most likely psilocybin induced). She was admitted to an inpatient behavioral health unit and stabilized on lithium and aripiprazole After 1 week she was transferred to a partial hospitalization program, and then to outpatient care Because of adverse effects, we reduced and stopped lithium and aripiprazole and started lamotrigine monotherapy. She has not had any further psychotic symptoms; however, she has had one more period of an irritable mixed episode of mania lasting about a week that has since resolved with an increase in lamotrigine dose [ ]

It should be noted that NT had abstained from cannabis for several months prior to ingesting the psilocybin, and that she was not using cannabis when she consumed the psilocybin mushrooms The likelihood of proximal effects of cannabis on the trajectory of her manic episode appears to be minimal. When substance use is present in bipolar episodes, multiple substances are often used and establishing clear correlation between mania and a single substance is difficult, at best, and causation almost impossible

In the months prior to her manic episode, NT’s depression had been treated with fluoxetine as well as rTMS [ ] NT reported no symptoms of hypomania immediately following these interventions. Her last rTMS session and her last use of fluoxetine were 4 months before her manic episode, reducing the likely temporal relationship between these interventions and the emergence of mania

Client Became Dysregulated and Physically Violent

Legal and physical trauma in an underground psychedelic ceremony

Subject identity details: Retired female law enforcement officer16

Setting: Underground therapy session in short-term rental, two sitters and two clients

Year: 2020s

Substance/Dose – Primary: 5+ grams of ground Psilocybe mushroom, encapsulated

Confidence level of identification: High

Substance(s)/Dose(s) - Secondary – MDMA, dose unspecified; no prescribed medications or other substances reported

Substance(s)/Dose(s) - Secondary - Confidence level of identification: Medium-high

Case Study Source: SHINE Collective

Summary: This case study explores the legal and physical trauma of a retired law enforcement officer seeking psychedelic-assisted therapy for PTSD. After engaging a self-proclaimed practitioner through an online directory, the client underwent an unregulated ceremony involving psilocybin and purported MDMA. Severe dysregulation led to police intervention, excessive restraint, and hospitalization for substance-induced excited delirium. Blood tests revealed methamphetamine, and the client faced felony charges. The facilitator evaded responsibility, and despite reporting, remains listed online. This case underscores critical gaps in psychedelic therapy regulation, practitioner accountability, and the risks of unregulated underground ceremonies.

Case Study: Legal & Physical Trauma in an Underground Psychedelic Ceremony

A retired law enforcement officer of 22.5 years service, was seeking alternative treatments to help relieve her PTSD symptoms that developed throughout her career Without finding effective treatment or relief from her on-going symptoms and reading countless articles about the potential of psychedelics, her curiosity around psychedelics began a deep search of finding a safe and reliable psychedelic practitioner to help her find relief and heal her PTSD. She had never taken any psychoactive substances prior to this.

16 Case studies are all based on actual reports given to SHINE Collective staff The names and locations have been anonymized The survivors have reviewed and given consent for SHINE Collective & PSI to utilize this information for educational purposes

She used a well-known online directory of “vetted providers” and selected a provider who had a Master’s Degree in Psychology, who works as a coach and claimed to have “more than 10 years of experience working with individuals and couples.” The practitioner presented herself as a trusted, trained psychedelic provider through her website, social media & provider referral list.

The practitioner travels to various locations throughout the US and Mexico and utilizes vacation rentals & AirBnB’s as ceremony spaces. A couple of days prior to the session, the practitioner informed the client that they had to change locations and that there would be one additional participant along with a helper in attendance. The client trusted the practitioner's guidance and expertise

At the start of the ceremony, the participant was given 2 grams of dried psilocybin mushrooms in a steeped tea, along with a capsule of what the client was told was pure MDMA, intended as a "heart-opener." During the ceremony, the client was given at least 3 more grams of dried psilocybin mushroom, in capsule form. Several hours into the ceremony, the client became severely dysregulated and physically violent, which was later attributed to the intense effects of the substances. Unaware of her actions and in an uncontrolled altered state, she damaged the property rental and broke several items in the home.

The facilitator lacked the proper experience and training to manage such a situation and called law enforcement for assistance. When the police arrived, they found the participant naked, bleeding, and unable to respond to basic commands. First responders utilized excessive force to sedate and restrain her, deploying bean bag rounds, causing the client extreme physical injuries, bruising, and pain. She was transported to a hospital trauma unit, where she was hospitalized for substance-induced excited delirium. At the hospital, laboratory tests of her blood were positive for methamphetamine. During the interaction with law enforcement, the facilitator blamed the client for the incident and filed a police report against her.

The facilitator blocked the client, shut down her social media and left the country She did not offer any follow up support or refunds for services rendered. The client reported the incident to the online directory from which she found the facilitator, but the provider is still active on their site.

The client was charged with felony vandalism and was re-diagnosed with PTSD after the incident. The client spent months in court, attempting to save her pension and avoid criminal charges. Nine months after the ceremony, the client was granted admittance into the mental health diversion program with the court system and must follow the court's orders, including on-going therapy, as part of the program for at least one year. After that time, at the court's discretion, the case may be closed with no plea entered.

Training Programs and their Role as “Gatekeepers”

When a psychedelic facilitation training program questions a student’s suitability for the role

Setting: Psychedelic Facilitation Training Programs

Case Report Source: Healing Advocacy Fund

Summary: Psychedelic facilitator training programs assess students’ suitability for safely holding space for clients. Problematic behaviors observed during training may escalate post-graduation, leading to client complaints. Programs risk retaliation if they revoke certification, and denied students may transfer elsewhere. In a field where attunement, caring, trust, and presence are essential to the safety of clients experiencing nonordinary states, what are the unique safety issues?

Case Study:

The trainers in psychedelic facilitator training programs have the opportunity to form opinions on a student’s suitability for the role of facilitator or guide. They may see red flags, and consider whether or not to graduate people who show signs of problematic behaviors. What if a student seems to lack critical attributes necessary for safely holding space for clients?

Similarly, after a graduate begins working with clients, what were mild problematic behaviors in the training setting may escalate, leading to clients complaints. A training program may be exposed to possible retaliation from students if they document the issues and decide to revoke their participation in the course (with reimbursement of fees). In such a case, a person denied graduation – or having certification revoked – at one program may simply transfer to another program and still end up becoming a licensed (or unlicensed) facilitator, which presents safety issues.

These issues are relevant for a number of professions. How might they manifest in particularly problematic ways in a field where attunement, caring, trust, and presence are essential to the safety of clients experiencing nonordinary states?

30 Hours Back to Baseline

Trusting experienced sitters prevents a client from escaping session

Subject identity details: 29-year-old woman

Setting: Underground facilitated session / Two clients and two sitters

Year: 1999

Substance/Dose – Primary: 250 ug LSD & 2 75 g Mushrooms

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Erowid Center17

Summary: A client underwent a high-dose psychedelic session with experienced co-sitters, following a months-long preparation Around 4-5 hours into the experience she panicked, attempted to flee, and was gently restrained. She struggled with integration, requiring extensive post-session work with the lead sitter’s support over months Through caring presence and the trust established between client and sitter prior to the session, a potential emergency was avoided.

Case Study:

A client engaged in a high-dose psychedelic session facilitated by an experienced sitter and co-sitter Preparation included completing a lengthy biographical questionnaire months in advance, required by the lead sitter. The night before, the client met with the sitters for dinner, discussing the upcoming experience She felt reassured by the sitters’ guidance

The session took place in a structured setting with bedrolls, eyeshades, and music During the session, the client initially experienced mild anxiety but maintained a sense of security. However, around 4-5 hours in, she entered a difficult state, losing all reference points and experiencing intense disorientation. Panic escalated, culminating in a moment where she attempted to run from the room The sitters intervened, gently restraining her and providing reassurance The lead sitter encouraged her to return inward, stating, “There’s nothing out here, go back inside.”

Throughout the peak, the client repeatedly called out for familiar figures, seeking grounding The sitters maintained a steady presence, offering her reminders to breathe and validating the experience The other client in the room, witnessing her distress, moved closer but was reminded that they, too, had their own journey The client vacillated between feelings of detachment and existential insight. She worried that she might not return to her familiar identity. As the session waned, and into the next day, she still was not grounded, couldn’t drive, and

17 Case Report adapted from first-person account: Samanthe "30 Hours Back to Baseline: An Experience with LSD & Mushrooms (exp9764)" Erowid org Oct 4, 2001 erowid org/exp/9764

could barely talk After the trip, integration was arduous, involving support from the lead sitter through multiple phone over many months.

This experience underscores the critical role of attuned, experienced sitters in holding space for a client’s extreme psychological state, including through her attempt to flee the session on foot.

“This Body Needs Help”

The absence of essential healing elements in the therapeutic container may have exacerbated the outcome of a perceived crisis

Setting: State-licensed Psilocybin Service Center (Oregon) Year: 2024

Substance/Dose – Primary: Psilocybin, dose unspecified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Oregon Health Authority’s Oregon Psilocybin Services (OPS)

Summary: A client experienced breathing difficulties and requested medical help, despite his facilitator’s attempts at soothing him. EMTs arrived, provided oxygen, and transported him to the hospital per his request. The presence of essential healing elements in the therapeutic container before and during the session may have improved the outcome of this perceived crisis.

Case Study:

Oregon’s OPS rules require Psilocybin Service Center representatives to fill out an Emergency Services Contact Report if anyone on the licensed premises requires emergency medical care due to an immediate or potential life threat. The following details were gleaned from a redacted incident report submitted in 2024.

Client was having difficulty breathing. After being supported by his facilitator and a service center representative, he requested medical help, citing “This body needs help,” and “I feel like I can’t breathe,” and “I want to call an ambulance.” Five EMTs arrived approximately 10 minutes later, took client’s vitals, and administered oxygen to him. Despite the EMTs recommendation that the client was not at risk for having a medical emergency due to decreased oxygen, the client still requested to be transported to the hospital.

Prior to calling emergency services, the facilitator requested support from a service center representative. Together, they sat on either side of the client and engaged in slow inquiry using supportive language. They breathe deeply and slowly to co-regulate and emphasized that they were there and wouldn’t leave his side. They also provided a blanket as client expressed that he felt very cold, and they talked him through feelings of nausea and his self-administration of his inhaler.

Client’s Distrust of Facilitator and Staff

Heightened Risk

When in crisis, client’s relationship with friend superseded relationship with facilitator

Setting: State-licensed Psilocybin Service Center (Oregon) Year: 2024

Substance/Dose – Primary: Homogenized powder, 49.64 mg of psilocybin

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Oregon Health Authority’s Oregon Psilocybin Services (OPS)

Summary: A client became paranoid, left the service center, refused to return, and threatened to step into traffic. Facilitator and staff attempted de-escalation techniques, contacted emergency services, and ultimately relied on the client’s emergency contact to secure the client’s safety

Case Study:

Oregon’s OPS rules require Psilocybin Service Center representatives to fill out an Emergency Services Contact Report if anyone on the licensed premises requires emergency medical care due to an immediate or potential life threat. The following details were gleaned from a redacted incident report submitted in 2024.

Client became convinced that service center staff and their facilitator were up to something. They asked to speak to their emergency contact. Staff called the emergency contact, who was also the client’s transportation for the session. Staff allowed the client to speak to their emergency contact on a staff person’s mobile phone. The client decided to leave the service center out the back door. Service center staff all attempted to de-escalate the situation and talk the client in to returning to the center.

Client refused, and would step into the road if staff got within a few feet of them, but stepped back on the sidewalk when staff backed up. Due to the danger of the high-traffic road, 911 was called. Police dispatcher advised that as long as the client stayed out of the road, there was nothing they could do, and asked that the service center call them back if client stepped back into the road. Staff continued to keep client within sight, but stayed at a distance, so as not to spook them into stepping into the road. Client’s transportation showed up and client got in the car with them.

Client refused to return to the center and refused to return the center staff person’s phone. Client’s emergency contact agreed to take them home and keep them safe until acute effects wore off.

Prior to contacting emergency services, the service center staff had attempted deep breathing, grounding techniques, engaging the client in conversation, offering water and snacks, and distraction techniques, as well as allowing the client to obtain reassurance by phone from a friend.

MDMA-induced Hyponatremia

A less commonly reported complication

Subject identity details: 45-year-old man

Setting: Various Year: 2020s

Substance/Dose – Primary: MDMA

Confidence level of identification: Medium to High

Substance(s)/Dose(s) – Secondary: Regular use of caffeine, nicotine, synthetic cannabinoids (K2, spice), cannabis, and various psychedelics

Case Report Source: Dorsen, C., Penn, A., Carew, N., & Lloyd, M. (2023). A rare case of MDMA-induced hyponatremia The Journal for Nurse Practitioners, 19(2), 104484 https://doi.org/10.1016/j.nurpra.2022.10.013

Summary: Although rare among users of MDMA, hyponatremia is one of the most common causes of MDMA-related deaths or serious injuries This case describes a non-fatal case of MDMA-related hyponatremia in a 45-year-old man.

Case Study18 (adapted from published case report):

A 45-year-old man with a history of heavy substance use presented to primary care with fluctuating blood pressure and cognitive disturbances following a high-dose MDMA session He had long been a regular MDMA user and recently made a significant dietary change eliminating his usual 5-10 liters of Diet Coke daily and replacing it with an equivalent amount of water This shift, combined with MDMA's antidiuretic effects, led to acute hyponatremia.

MDMA promotes antidiuretic hormone (ADH) secretion, impairing the body's ability to excrete excess water. Simultaneously, the patient’s high Diet Coke consumption had previously provided a substantial sodium intake (800-1600 mg/day), which was suddenly lost when he switched to water The combination of water retention from MDMA and reduced sodium intake resulted in an electrolyte imbalance, likely exacerbating his symptoms of confusion, altered speech, and anxiety

The patient’s condition improved with fluid restriction and electrolyte replacement, and he was managed as an outpatient His case highlights the dangers of excessive water intake in MDMA users, especially those accustomed to high-sodium beverages This case underscores the need for harm reduction strategies regarding hydration and MDMA use, particularly in non-clinical psychedelic settings

18 Adapted from original paper, see original for full case report.

LSD “Addiction” Leading to Fatal Accident

Perceived institutional endorsement may contribute to risk in vulnerable people

Subject identity details: 19-year-old man

Setting: Various

Event Year or Year Range: 2020s

Substance/Dose – Primary: LSD

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: Cannabis, Mushrooms

Case Report Source: Anthony Back

Summary: People may rely on popular media that omits discussion of the potential harms of psychedelics. Especially when they are used outside the context of a clinical trial or session facilitated by an experienced guide, perceptions of safety may lead to concerning misuse, with sometimes devastating outcomes.

Case Study:

A 19-year old man with anxiety and depression who self-medicated with cannabis, mushrooms, and then LSD, developed a substance use problem with LSD and participated in treatment with a therapist. His parents report that he justified his use by citing research, reporting “Johns Hopkins says psychedelics are safe”, but he used LSD exclusively in unsupported situations. He was aware that his use was causing harm but “loved” the experiences according to his mother and father (a physician), and “could not stop”. During a solo LSD trip, he died after being run over by a log truck while playing his guitar naked in the middle of a freeway

Wanting to Make Sure They Were Able to “Go Deep”

Dosing decision and navigating a challenging experience

Setting: State-licensed Psilocybin Service Center19 Year: 2020s

Substance/Dose – Primary: 35 mg psilocybin equivalent

Substance/Dose – Primary – Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Healing Advocacy Fund

Summary: A person with treatment-resistant depression sought relief through a facilitated psilocybin session in Oregon, taking a 35mg dose to achieve a deep experience. Instead of the anticipated euphoria and insight, they endured intense nausea, distress, and physical discomfort. Post-session, they struggled with uncertainty, questioning their reaction. While the facilitator reassured them, they felt isolated hearing others’ positive experiences. Seeking support, they found their long-term therapist unfamiliar with psychedelics but received referrals for integration specialists. Despite the difficulties, they remained hopeful about psilocybin’s potential but emphasized the need for clearer dosing guidance, especially given the session’s significant financial burden.

Case Study:

Note: This case study, while informed by real stories, is hypothetical and intended for discussion purposes only.

Background: An individual seeking relief from depression participated in a facilitated psilocybin session in Oregon (including 2 preparation sessions, 1 administration, and 2 integration sessions). They had hopes of experiencing greater insight, intense joy, euphoria, and heightened sensory perception. The person struggled with treatment-resistant depression and had been seeing a therapist for the majority of the past 10 years with little helpful result. The individual repeatedly commented on how expensive the psilocybin care was and decided to take a 35mg dose, aiming for a deep experience.

19 This case study, while informed by real stories, is hypothetical and intended for discussion purposes only

Contrary to their expectations and hopes, the session proved to be one of the most difficult and painful experiences they had ever endured. Instead of joy or insight, they were overwhelmed by intense nausea, discomfort, and a rapid heartbeat. They spent most of the session on the floor of the bathroom, crying and struggling to find relief. Rather than the anticipated mystical or transcendental moments, the experience was dark and distressing. In the aftermath, the individual was left with lingering physical discomfort, including a persistent headache and an unsettled stomach. They expressed concerns about the dosage, wondering if they had taken too much and whether a lower dose (such as 20mg) might have provided a more manageable and meaningful journey.

Two days after the experience, the individual continued to process what had happened in an integration session. They questioned whether they had done something wrong and whether such reactions were documented in clinical studies. Their facilitator reassured them that plant medicine often brings what is needed for healing, and that breaking down can be part of the process. However, the individual remained uncertain, feeling as though they had missed out on the positive aspects of psilocybin therapy due to the intensity of the session. Hearing others express their positive feelings about the experience only left the person feeling isolated, and like something was “wrong with them.”

They expressed a desire to connect with others who have navigated similar negative experiences and sought guidance on whether their reaction was normal. They reached out to their long-term therapist, but the therapist stated that they weren’t familiar with psychedelics and the individual felt the conversation was not productive. The facilitator provided the client with names of individual providers/therapists with knowledge on psychedelics. Despite the challenges, the client still believed in the healing potential of psilocybin but wished for more clarity on what had transpired and how to integrate the experience.

An additional integration session was scheduled for the following week, with the hope that further reflection and discussion would provide insight and meaning.

The individual remained open to sharing their story after more time had passed but emphasized the need for facilitators to provide clearer guidance on appropriate dosing, particularly for first-time participants. They also spoke about the significant financial burden of the session and the role finances played in wanting to make sure they were able to “go deep,” driving their higher dosing decision.

Long-Lasting Trauma after Ayahuasca

Struggle spanning five years after ceremony

Subject identity details: 31-year-old man

Setting: Ayahuasca ceremony

Year: 2004

Substance/Dose: One cup ayahuasca

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Erowid Center20

Summary: The author recounts a five-year struggle following an ayahuasca ceremony, during which he experienced profound psychological and physiological distress. His experience would become a prolonged ordeal rather than a spiritual awakening. He develops multiple problems including persistent sleep disturbances, vibrating/tingling sensations in his face, difficulty concentrating, intense fear of death, derealization, and the inability to work.

Case Study:

Initially drawn to ayahuasca through extensive research and testimonials, a 31-year-old man viewed it as a transformative tool for healing and self-discovery However, his experience would become a prolonged ordeal rather than a spiritual awakening.

The ceremony included not only ayahuasca but also kambo. Despite persistent doubts and an internal warning urging him to leave, the man was pressured by organizers and fellow participants to stay, reinforcing the idea that fear was an obstacle to be overcome.

During the ceremony, after consuming ayahuasca, the author initially experienced a sense of clarity and euphoria, and profound realizations about consciousness and self-awareness. However, the session took a dark turn when the shaman emitted a piercing scream, triggering a sensation of something breaking inside him. While others engaged in communal drumming and celebration, the author felt increasingly uneasy That night, he struggled to sleep, feeling deeply unsettled. The real decline began after he returned home, marking the start of a long-term deterioration.

20 Case Report adapted from first-person account: Jhi-dou "Long-Lasting Trauma: An Experience with Ayahuasca (exp104149)" Erowid org Aug 6, 2015 erowid org/exp/104149

In the immediate aftermath, the author felt mentally disconnected at work, unable to focus. He soon developed fever, fatigue, and a red mark on his neck, which he initially dismissed as an allergic reaction. At one point he smoked a light joint given to him by another participant. That night, the ayahuasca revelations returned in an intrusive and overwhelming way. He suffered from night sweats and extreme anxiety, waking every 30 minutes in distress. Over the next several days, the symptoms worsened, including persistent sleep disturbances (waking drenched in sweat, unable to rest), vibrating/tingling sensations in his face, severe difficulty concentrating, and overwhelming emotional sensitivity

Seeking medical help, he visited a doctor who ordered tests but found nothing conclusive. The doctor, unfamiliar with ayahuasca, prescribed tranquilizers, which didn’t help. As his mental state worsened, he experienced intense fear of death and derealization, making him feel as though he were under a spell or curse.

Desperate, he reached out to the original ceremony organizer for help. Instead of support, he was told to either return for another session (which required another payment) or “just do some yoga.” When he persisted, the organizer dismissed his suffering, saying, “We’ve done thousands of ceremonies, and everyone’s fine—this is your fault.” He later learned that other participants had also reported severe negative experiences, some even filing complaints against the facilitators.

Unable to find relief through conventional medicine, he turned to alternative healing methods, including Reiki, daily prayer (despite not being religious), and a drumming ceremony led by a shaman. Despite these interventions, the man's sensitivity to other people’s emotions intensified, making public transportation unbearable. The concept of time became distorted, with days feeling impossibly long. He quit his job, as he was unable to function. Fortunately, his employers were understanding and agreed to formally terminate the contract so he could receive financial support.

Two years after the initial experience, he started working again, albeit in a different field with reduced hours. While he never fully understood what had happened, he speculated that he had experienced a violent Kundalini awakening.

Five years later, the man was grateful to have regained his stability but insists that, given the chance to redo it all, he would never have taken ayahuasca. The psychological and emotional toll was simply too great.

Veteran Seeking Integration Following Therapeutic Mushroom Experience

Despite initial therapeutic benefits, anxiety symptoms were beginning to resurface

Subject identity details: Military veteran

Setting: Text-based support call/helpline

Year: Not specified (Recent)

Substance/Dose – Primary: Psilocybin mushrooms, dose unspecified, used several months prior

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Support call log from helpline volunteer

Summary: A military veteran reached out via text for integration support several months after a positive psilocybin mushroom experience that initially alleviated his PTSD symptoms. Despite initial therapeutic benefits, he was experiencing a resurgence of anxiety and contemplating returning to combat zones as a contractor.

Case Study:

A military veteran contacted a psychedelic support service via text seeking integration assistance for a psilocybin mushroom experience that had occurred several months prior The veteran described his psychedelic experience as positive, inducing feelings of gratitude for life and providing significant relief from his PTSD symptoms.

Despite these initial therapeutic benefits, the veteran reported that his anxiety symptoms were beginning to resurface. When offered space to discuss his psychedelic journey or current anxiety, the veteran was reluctant to engage deeply with these topics. Instead, he shifted the conversation toward his consideration of returning to war zones as a military contractor in Europe.

The support volunteer attempted to explore this significant life decision with the veteran and tried multiple times to redirect the conversation back to his psychedelic integration needs and anxiety symptoms. Throughout the exchange, the veteran remained

reserved in his communication. The conversation included brief sharing about military experiences between the veteran and the volunteer.

Before concluding the conversation, the veteran was deeply pondering whether they would choose "military contract work or freedom". The interaction highlights the complex interplay between therapeutic psychedelic use, PTSD, identity tied to military service, and the challenges of integration when underlying psychological needs remain unaddressed.

Transgender Individual Seeking Support

While Processing Emotional Distress

Contacting a psychedelic support service while crying and in emotional distress during a psilocybin mushroom journey

Subject identity details: Transgender individual who works as a peer supporter

Setting: Support call/helpline

Year: Not specified (Recent)

Substance/Dose – Primary: Psilocybin mushrooms, dose uncertain

Confidence level of identification: Low

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Support call log from helpline volunteer (first-time volunteer)

Summary: A transgender individual called a psychedelic support helpline in an emotionally distressed state while on psilocybin mushrooms, experiencing intense feelings and seeking space for processing. Through empathetic support, breathing exercises, and validation, the caller was able to move from a state of distress to feeling sufficiently grounded to rest. Suicidal ideation was mentioned but assessed to not require involvement emergency services.

Case Study:

A transgender individual contacted a psychedelic support service while crying and in emotional distress during a psilocybin mushroom journey The caller was seeking a supportive space and empathetic presence during a difficult emotional experience. When the caller mentioned experiencing suicidal ideation, the volunteer conducted a safety assessment. The caller confirmed they were not actively suicidal and were already engaged with appropriate mental health care resources.

During the call, the volunteer offered breathing techniques, which they practiced together in silence. The caller specifically requested that the volunteer not count the box breathing method out loud, demonstrating self-advocacy about their needs. This shared breathing exercise appeared to be grounding for both participants.

The conversation included moments of emotional range, from tears to laughter The volunteer celebrated the caller’s proactive approach to mental health, their authenticity

as a transgender person, and their willingness to engage deeply with difficult emotions. A connection formed when the caller revealed they also work as a peer supporter, creating a sense of solidarity.

The volunteer provided integration circle links and psychedelic resources via text. The call concluded when the caller expressed feeling tired and ready to rest, suggesting a transition from acute distress to a more regulated emotional state.

This case highlights the importance of creating safe, affirming spaces for LGBTQ+ individuals in psychedelic support contexts, the value of simple grounding techniques in moments of emotional intensity, and the power of authentic human connection during vulnerable states.

Persistent Depersonalization and Derealization Following Single LSD Use

Significant distress and uncertainty about ever reconnecting with the pre-psychedelic sense of self

Subject identity details: N/A

Setting: Support call/helpline

Year: 2025 (Approximately five years after the psychedelic experience)

Substance/Dose – Primary: LSD, single use, dose unspecified

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Support call log from helpline volunteer

Summary: An individual sought support for persistent depersonalization, derealization, and identity disturbances that began following a single LSD experience approximately five years prior. The caller expressed significant distress about these lasting effects and uncertainty about whether they would ever feel like themselves again.

Case Study:

An individual contacted a psychedelic support helpline seeking assistance for persistent psychological symptoms that began after a single LSD experience approximately five years ago. The caller described experiencing ongoing depersonalization, derealization, and profound shifts in their sense of identity since that experience.

The caller expressed significant distress and uncertainty about whether they would ever reconnect with their pre-psychedelic sense of self. Their experience was characterized by a persistent feeling of disconnection from their identity and reality The caller indicated they had been unprepared for the psychedelic experience and lacked adequate education about potential risks and outcomes.

During the support call, the volunteer provided validation, reassurance, and a nonjudgmental space for the caller to express their fears and confusion. The supporter normalized the caller’s experience, reinforced that such reactions, while distressing, are not uncommon, and explored the caller’s feelings without imposing conclusions. The

supporter introduced the concept of psychedelic integration and provided resources for ongoing support.

This case highlights the importance of proper education, harm reduction practices, and support systems for individuals using psychedelics. The supporter noted similarities to another recent caller who experienced persistent psychological difficulties years after an ayahuasca ceremony, further emphasizing the critical need for preparation and integration services for psychedelic experiences.

License Jeopardized by Underground Side Gig

A licensed therapist faces losing his license and possibly facing legal consequences

Subject identity details: Composite21

Setting: Private Practice Year: 2020

Case Study Source: National Council for Psychedelic Education

Summary: A licensed practitioner with a secret underground role as a sitter accepts to offer a psilocybin mushroom session to a client at their request. After the client has a difficult experience, they report him to his licensing board. He faces losing his license or worse.

Case Study:

Luca had benefited from having had positive, therapeutic experiences with psychedelics and MDMA. Interested in helping others to experience similar healing, he studied to become a licensed marriage and family counselor, in the hopes of eventually working with these materials legally with clients. He chose this career specifically because it appeared that FDA approvals would come, and regulatory changes would pave the way for legal access to psychedelic-assisted psychotherapy.

Luca established his practice, working in compliance with his license. As a side gig, separate from his licensed practice, he sat for a separate set of clients, holding space for their psychedelic experiences.

At one point, a regular client in his licensed practice, learning of his secret role as an underground psychedelic sitter, requested such a session. Against his better judgment, due to complex circumstances, Luca sat for this client, whose first experience was very positive and uplifting. The client assertively requested a second session, and again, Luca reluctantly complied.

The second session was harrowing. The client was so upset, they reported Luca to his licensing board. Luca then faced several stressful years of review and sanction, eventually relinquishing his license to avoid a more serious outcome, such as a criminal legal investigation.

21 Composite case study based on circumstances reported to NCPE.

Therapist and Participant Identities in Psychedelic-Assisted Therapy

Therapists sharing one or more intersectional identities with a participant may impact their sense of safety

Subject identity details: Gay; Veteran

Setting: Clinical Trial

Year: 2020s

Substance/Dose – Primary: Psilocybin, 25 mg

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: SNaP Lab

Summary: A clinical trial therapist disclosed their status as a Veteran during their introduction, in an attempt to connect with a participant—who was also a Veteran—during the preparation period. The participant, who was gay, had had harmful experiences from his military service during the Don’t-Ask-Don’t-Tell era related to his sexuality. He identified much more strongly during the trial with his gay identity as opposed to his Veteran identity. Therapists sharing their invisible identities with participants can potentially compromise the therapeutic container.

Case Study:

The individual, a military veteran, was participating in a clinical trial investigating the efficacy of psilocybin-assisted psychotherapy in the treatment of a substance use disorder Both of the therapists facilitating the sessions were also veterans.

One of the therapists, as part of their process of establishing rapport with the participant during the initial preparation session, shared with the participant unprompted that both therapists were also veterans. In some circumstances, this choice may have supported the therapeutic rapport, e.g., if the participant had asked. However, in this case, the participant, who was gay, did not feel that knowing their therapist was a veteran helped the therapeutic process, and felt it in fact inhibited his sense of safety within the clinical trial experience. He had harmful experiences in the military related to being gay, and identified more with his gay identity than his veteran identity

Terence McKenna’s Bad Trip

The selective portrayal of an influential figure in the psychedelic community

Subject identity details: Terence McKenna

Setting: Private, unspecified

Year: late 1980s

Substance/Dose – Primary: Psilocybe mushrooms, unspecified dose

Confidence level of identification: High

Substance(s)/Dose(s) – Secondary: None reported

Case Study Source: Ecstatic Integration22

Summary: In the late 1980s, Terence McKenna underwent a mushroom experience so frightening it caused him to stop taking mushrooms and reassess his previously unreserved endorsement of psychedelics. Despite the persistence in popularity of McKenna’s writings and talks, this significant event has been largely absent from mainstream narratives about his life and work.

Case Study:

Terence McKenna, a prominent advocate for psychedelic substances during the 1980s and 1990s, is renowned for his extensive discussions on the benefits and transformative potential of psychedelics. However, less known is an intense personal experience he had in the late 1980s that profoundly affected his perspective on these substances.

During this period, McKenna underwent a particularly challenging mushroom trip that left him deeply unsettled. The specifics of this experience are not widely documented, but it is noted that the ordeal was severe enough to cause McKenna to reassess his previously unreserved endorsement of psychedelics. This incident introduced a more cautious tone in his subsequent discussions, acknowledging that such substances could lead to unpredictable and potentially distressing experiences.

Despite this significant event, accounts of McKenna's difficult trip have been largely absent from mainstream narratives about his life and work. This omission raises questions about the selective portrayal of influential figures in the psychedelic community and the potential consequences of not fully acknowledging the risks associated with psychedelic use.

McKenna's experience serves as a reminder of the complex and unpredictable nature of psychedelics.

22 https://www.ecstaticintegration.org/p/terence-mckennas-secret-bad-trip