Ayahuasca research

1. Introduction

Version followed: the psychotherapy and safety frame of the Natal (UFRN/Onofre Lopes University Hospital) randomized placebo-controlled trial in treatment-resistant depression (Palhano-Fontes et al., 2019, Psychological Medicine; NCT02914769), supplemented by the Ribeirao Preto/UFRN open-label studies (Sanches et al., 2016), the Canadian retreat observational study (Thomas et al., 2013), and ICEERS harm-reduction and integration guidance (Good Practice Guide 2013/2014; Towards Better Ayahuasca Practices, Londono, Mazarrasa and Aixala, 2019; ICEERS Support Center / El Faro pages). No drug quantities, preparation, sourcing, routes or schedules of administration are given anywhere in this guide.

Source status. Peru's heritage declaration comes from RDN 836/INC (24 June 2008) in an English translation; US and Canadian status from ICEERS country pages (US page published 2022 with legal events to 2011; Canada content updated May 2019); the PHRI model from the abstract and a summary of Gorman et al. 2021; Aixalà's integration approach from ICEERS summaries of his 2022 book and 2024 chapter, not the book itself; trial session conduct, debrief, blinding and follow-up from the Palhano-Fontes preprint methods. Still [uncertain]: the book's step-by-step method, PHRI's detailed procedures, any trial touch policy (none published in the sources cited), handling of placebo participants, and US local decriminalisation measures.

What it is. "Ayahuasca research" is not a single therapy with a treatment manual. It is a body of clinical studies (mainly Brazilian, with Spanish and Canadian contributions) plus a harm-reduction and integration practice developed by ICEERS (Barcelona). There is no licensed ayahuasca medicine anywhere, so for a practising psychotherapist the usable parts are: (a) the screening, consent, setting, monitoring and follow-up frame used in trials, which you would only deliver as staff on an approved research protocol; and (b) harm-reduction and integration work with clients who attend ceremonies or retreats elsewhere [source: Palhano-Fontes 2019; ICEERS 2019; ICEERS Support Center].

How change is thought to happen. The trial frame itself is minimally psychotherapeutic: participants were asked to rest with eyes closed and attend to body, thoughts and emotions, with staff nearby but not conducting therapy, and the authors tested a rapid antidepressant effect measured over the following week [source: Palhano-Fontes 2019]. ICEERS frames benefit and risk as depending heavily on setting, preparation and integration ("The setting and adequate preparation and integration are key to reducing the risks") and treats integration as the person making their own sense of the experience, reconnecting it to everyday life and community [source: ICEERS Good Practice Guide; ICEERS, The Art of Integration, 2025].

Legal and regulatory status (as of the sources' dates; check current law). [source: Labate and Feeney 2011/2012; ICEERS 2019; ICEERS country pages for the USA and Canada; Instituto Nacional de Cultura, Resolución Directoral Nacional 836/INC (2008); Assemblée nationale written question 39644 (France); ICEERS Netherlands and Germany pages; BtMG Anlage I; Wikipedia legal-status page (secondary, UK item only); Thomas 2013]

International: DMT is in Schedule I of the 1971 UN Convention; a 2001 INCB letter stated that plant preparations such as ayahuasca are not under international control, but countries may and do ban them; courts have disagreed on this reading.
Brazil: CONAD Resolution No. 1 (25 January 2010) permits use only within religious ritual and prohibits commercial distribution, therapeutic use, tourism and advertising; it encourages scientific research on therapeutic potential. Brazilian clinical trials therefore run as approved research (ethics committee, written consent).
USA: DMT is in Schedule I of the Controlled Substances Act, so importing, possessing or distributing ayahuasca is federally illegal; the Native American Church's peyote exemption does not cover it. Two religious exemptions rest on RFRA: the UDV (Gonzales v. O Centro Espírita Beneficente União do Vegetal, 546 U.S. 418, Supreme Court, 2006), which may use its sacrament in services once registered with the DEA; and Santo Daime (CEFLURIS) churches (Church of the Holy Light of the Queen v. Mukasey, D. Or. 2009, partly vacated by the Ninth Circuit in Church of the Holy Light of the Queen v. Holder, 2011), limited to named congregations (Oregon and Los Angeles per ICEERS) operating under DEA registration, inventory and permit conditions. These exemptions cover those churches' religious services only; no clinical or therapeutic use is authorised [source: ICEERS, United States of America page, published 2022, latest legal events 2011]. Some cities deprioritised enforcement of entheogenic plants from 2019 onwards; this does not change federal law or make clinical use legal [uncertain: local measures and any post-2011 changes not verified in a primary source].
Canada: DMT, harmaline and harmalol are Schedule III under the Controlled Drugs and Substances Act (1996), and ayahuasca counts as a controlled preparation. Health Canada has granted section 56 exemptions for religious use only: Céu do Montreal (Santo Daime) and the UDV on 5 June 2017, and three further Santo Daime churches (Montreal, Val-David, Toronto) in May 2019, five groups in all as of that update; use in any other context is not covered. In 2011 Health Canada's Office of Controlled Substances told Dr Gabor Maté to stop using ayahuasca in addiction treatment, and an exemption request for the related First Nations programme was refused [source: ICEERS, Canada page, content updated May 2019; Thomas 2013 addendum]. Exemptions or therapeutic-access routes after May 2019 were not verified [uncertain].
Europe: France: an arrêté of 20 April 2005 added Banisteriopsis caapi, Psychotria viridis, Peganum harmala, Diplopterys cabrerana, Mimosa hostilis and Banisteriopsis rusbyana, together with harmine, harmaline, tetrahydroharmine, harmol and harmalol, to the national list of narcotics (stupéfiants); the brew itself is not named [source: Assemblée nationale, written question no. 39644, 22 June 2021]. Netherlands: the Supreme Court (Hoge Raad) has held that the Opium Act's ban on importing ayahuasca takes precedence over religious freedom, ending the earlier recognition of Santo Daime churches' sacramental use; ICEERS dates the ruling to October 2019 in one place and 2018 in another [uncertain: exact date] [source: ICEERS, legal status of ayahuasca in the Netherlands, 2023]. Germany: DMT is listed in Annex I (non-marketable narcotics) of the Narcotics Act (BtMG), so DMT-containing brews are illegal; ICEERS reports that B. caapi on its own is not explicitly controlled and that people running shamanic or therapeutic ceremonies face a high risk of prosecution [source: BtMG Anlage I; ICEERS Germany page, 2017]. UK: reported as illegal, with DMT a Class A drug [source: Wikipedia] [uncertain: secondary, unverified; check national law]. Spain: status not clearly defined; ICEERS reports that participation is not a criminal offence but that offering it to others may carry liability [source: ICEERS 2019]. Peru: the National Institute of Culture (INC) declared the "knowledge and traditional uses of Ayahuasca practiced by the native Amazon communities" Cultural Heritage of the Nation by Resolución Directoral Nacional No. 836/INC of 24 June 2008, to protect traditional use and the ritual's sacred character as distinct from out-of-context, consumerist and commercial Western uses [source: RDN 836/INC, English translation by Takiwasi, bialabate.net]. It is a cultural-heritage measure, not an authorisation of clinical or tourist use [synthesis].
Religious and Indigenous ceremonial use is outside this guide; see Domain XI/XIII entries. Authority over ceremony rests with the religious organisations (e.g. UDV, Santo Daime) and Indigenous practitioners and communities, not with clinicians.

2. Framework

A. Trial frame (Palhano-Fontes 2019, double-blind RCT, Natal, Brazil) [source: Palhano-Fontes 2019]

Phase 1, referral and screening. Referral from outpatient psychiatrists or media advertising; full clinical evaluation by a trained psychiatrist with structured diagnostic interview; screening for mania/bipolarity. 218 assessed, 35 eligible, 29 analysed. Goal: confirm treatment-resistant unipolar depression and exclude risk. Move on when eligibility is confirmed and written consent given.
Phase 2, medication preparation. Antidepressants were withdrawn before the session under psychiatric supervision, with timing set by the psychiatrists according to the drug; benzodiazepines were permitted as supportive medication. This is a medical decision made by prescribers, never by the therapist [source: Palhano-Fontes 2019; synthesis on role boundary].
Phase 3, pre-session briefing (same day): reminders of possible effects and strategies for managing difficult moments.
Phase 4, experimental session, about 8 hours, daytime, in a quiet living-room-like room (bed, recliner, controlled temperature, dim natural light), eyes closed, inward focus, optional pre-selected playlist; at least two investigators in an adjacent room available throughout. Acute ratings at intervals.
Phase 5, closing. After acute effects resolve: final psychiatric evaluation, debriefing, post-session questionnaires; discharge home with a relative or friend; four participants with more complex conditions stayed on the ward for a week.
Phase 6, follow-up at days 1, 2 and 7 (primary outcome HAM-D at day 7; MADRS at days 1, 2, 7). New treatment could start after the day-7 assessment window. Assessors were different psychiatrists from those present at the session (blinding) [source: Palhano-Fontes 2019]. Version note: the 2017 bioRxiv preprint of the same trial also describes participants being encouraged to describe their experience again the next morning, a new antidepressant scheme proposed at day 7, and further follow-up at day 14 and monthly to six months [source: Palhano-Fontes preprint 2017].
Psychotherapy-relevant contacts: a screening/evaluation pathway, a same-day briefing and debrief, and three follow-up visits. Structured psychotherapy was not part of the protocol [source: Palhano-Fontes 2019]; preparation and integration were brief.

B. Open-label frame (Sanches et al., 2016; earlier Osorio et al., 2015 report): inpatient psychiatric unit; acute ratings (CADSS, BPRS, YMRS) and depression scales at days 1, 7, 14 and 21 [source: Sanches 2016 repository record]. Setting details and exclusion criteria are not given in the record [uncertain].

C. Retreat-plus-group-therapy frame (Thomas et al., 2013, British Columbia): four days and three nights at a First Nations band's longhouse, led by Dr Gabor Mate with a ceremonial team; group talk therapy at intervals, a session on re-conceptualising addiction, breathing and meditation exercises, morning debriefs; group orientation and consent several hours before; follow-ups at 2 weeks, 4 weeks and monthly to 6 months, adverse-reaction monitoring by the band's health office [source: Thomas 2013]. Note this was stopped after Health Canada's 2011 warning; it is described as history, not a model to run.

D. Harm-reduction and integration frame (ICEERS) for clinicians whose clients attend ceremonies elsewhere: before (assessment, contraindication screening, education, choice-of-provider guidance, safety plan, referral for medical/interaction questions) and after (integration: up to five brief sessions in the ICEERS Support Center model; ongoing therapy where needed; check-ins). ICEERS's own organiser guidance recommends follow-up contact around one week and two months after a session [source: ICEERS Good Practice Guide; ICEERS Support Center]. Criteria for moving from "harm-reduction consultation" to ordinary therapy or psychiatric referral are not specified by ICEERS [uncertain]; see section 5 for synthesised criteria.

3. Guiding principles

Work only inside a legal frame. Trial roles exist only on an approved protocol; outside that, your role is harm reduction, assessment and integration, never facilitating, arranging or recommending use [source: CONAD 2010 via Labate and Feeney; synthesis].
Screen conservatively. "If you have any doubts about a person's suitability, it is better not to accept him or her" (ICEERS Good Practice Guide). Practical meaning: when in doubt, advise against and refer.
Set and setting, preparation and integration are the safety system. Practical meaning: spend your time on these, not on the substance [source: ICEERS Good Practice Guide].
Two-person presence and never alone. Trials kept at least two investigators available; ICEERS says never run a group alone and never leave participants unsupervised [source: Palhano-Fontes 2019; ICEERS 2019].
Non-directive presence in session. The participant attends inward; staff stay available rather than steering [source: Palhano-Fontes 2019; ICEERS Good Practice Guide warns against facilitators acting as spiritual guides].
Support without interpreting. Do not impose meaning on someone else's experience; the person finds their own metaphors and pace [source: ICEERS, The Art of Integration].
Psychological autonomy and low dependence. Practical meaning: return authorship to the client and avoid power imbalances [source: ICEERS, The Art of Integration].
Cultural sensitivity, non-pathologising. Do not stigmatise use or treat experiences as psychopathology by default; take the client's cosmological and cultural framework seriously as theirs [source: ICEERS Support Center].
Community rootedness. Integration is also social: reconnecting with community and practice [source: ICEERS, The Art of Integration, citing D. Nickles].
Cautious interpretation of "messages". Do not act hastily on insights; defer major decisions [source: ICEERS 2019].
Stay within competence. Avoid psychological interpretations without qualifications (directed at facilitators); clinicians should equally stay out of medical and pharmacological decisions [source: ICEERS 2019; synthesis].
Safety first, never deny help. "Never deny help to anyone" even with legal concerns [source: ICEERS Good Practice Guide].
Compassionate, destigmatising acceptance of clients' choices. The Psychedelic Harm Reduction and Integration (PHRI) model (Gorman, Nielson, Molinar, Cassidy and Sabbagh, 2021, Frontiers in Psychology; not an ICEERS paper) is a transtheoretical, transdiagnostic approach for clients who use or are considering psychedelics in any context; it combines harm-reduction psychotherapy with psychedelic-assisted psychotherapy, can be used in brief or ongoing therapy, and moves away from assessing only negative outcomes and from abstinence-based framing. Practical meaning: assess, prepare and work with difficult experiences without making abstinence a condition of care [source: Gorman et al. 2021, abstract]. Its detailed assessment, preparation and difficult-experience procedures are not summarised here [uncertain].
Ethical boundaries: no sexual contact or seductive behaviour; protocols for misconduct; regular supervision [source: ICEERS 2019]. Touch: the Natal RCT methods describe staff in the room next door assisting when needed and give no touch policy [source: Palhano-Fontes preprint 2017]; no published touch policy from an ayahuasca trial was found [uncertain]. Practical meaning: on a protocol, follow its written policy; otherwise agree in advance and in writing whether any supportive touch (such as a hand on the shoulder) is acceptable, ask each time before touching, and never touch in a sexual or intimate way [synthesis].

4. Intervention inventory

The published studies describe procedures, not scripted psychotherapy techniques. Items A1 to A8 are the trial frame (for staff on an approved protocol). Items B1 to B9, plus B6a, are harm-reduction and integration work for any licensed clinician. Where sources describe only an aim, steps are marked [synthesis].

A1. Psychiatric eligibility screening (trial)

Purpose / when: before any research session; to confirm diagnosis and exclude those at highest risk.
Steps: (1) structured diagnostic interview confirming unipolar major depression; (2) document treatment resistance (non-response to at least two antidepressants of different classes) and current moderate-to-severe severity; (3) screen personal and family history of schizophrenia, bipolar disorder, mania or hypomania; (4) screen current substance use and suicide risk; (5) confirm no prior ayahuasca use (a design requirement of the RCT); (6) medical and neurological history reviewed by medical staff; exclude pregnancy [source: Palhano-Fontes 2019].
Example language (illustrative): "Before we go further I need to ask about your family's mental health history, including anyone who has had mania or psychosis, because it changes whether this study is safe for you."
Watch for: pressure to be included (minimised symptoms or history); ambivalence about suicide risk. Working: clear, documented decision; excluded applicants receive a referral rather than a bare refusal [synthesis].

A2. Medical and medication review (medical staff responsibility)

Purpose / when: at screening and again before the session.
Steps: (1) medical staff review cardiovascular, neurological and other physical conditions; (2) prescribers decide on and supervise any changes to psychiatric medication; (3) therapist role: make sure the client has raised every medication, supplement and other substance with the medical team, and monitor mood during any medication change [source: Palhano-Fontes 2019; synthesis on therapist role].
Example language (illustrative): "Changes to your medication are a decision for the study psychiatrist, not me. What I can do is check in with you about how you feel while that happens."
Watch for: worsening depression or suicidality during medication changes; report to the medical team the same day [synthesis].

A3. Informed consent

Purpose / when: after eligibility, before any session.
Steps: written consent approved by the ethics committee [source: Palhano-Fontes 2019]. ICEERS's model consent covers purpose, nature of the substance, expected effects, risks (acute panic or psychotic episodes, rare longer-lasting effects), voluntariness and the right to withdraw before the session, the right of facilitators to exclude, confidentiality and anonymised data use, and the duty to disclose health information honestly [source: ICEERS Good Practice Guide]. In a blinded trial, explain that the person may receive placebo and that staff will not know which [source: Palhano-Fontes 2019].
Example language (illustrative): "You can stop at any point before the session starts, and saying no now will not affect your usual care."
Watch for: misunderstanding of blinding or of the chance of placebo; expectations of cure. Working: the client can explain risks and options back in their own words [synthesis].

A4. Pre-session briefing

Purpose / when: on the session day before it begins.
Steps: remind the participant of the possible effects and give strategies for managing difficulties [source: Palhano-Fontes 2019]. Content of those strategies is not specified in the trial paper [uncertain]; ICEERS strategies that fit: slow diaphragmatic breathing, focusing on the music, letting go, asking staff for help at any time [source: ICEERS 2019].
Example language (illustrative): "If something frightening comes up, try slowing your breath and letting it move through. You can call us at any time; someone is always next door."
Watch for: high anticipatory anxiety; offer to review the plan again or to withdraw [synthesis].

A5. Set and setting design

Purpose / when: to reduce risk and support inward attention.
Steps: quiet, comfortable, living-room-style room with a bed and recliner, controlled temperature, dim natural light; optional pre-selected playlist; daytime session of about eight hours [source: Palhano-Fontes 2019]. ICEERS adds: a safe venue that is not too isolated, a tested emergency plan known to the whole team; participants seated, or on their side rather than their back if lying down, to reduce choking risk [source: ICEERS Good Practice Guide; ICEERS 2019].
Watch for: physical hazards (falls, fainting); the ICEERS 2019 guide lists dizziness, fainting, falls and choking on vomit among acute risks.

A6. In-session presence and instruction

Purpose / when: throughout the session.
Steps: (1) before the session, remind the participant of possible effects and strategies for difficult moments; (2) invite them to stay quiet with eyes closed, attending to body, thoughts and emotions, with an optional music playlist; (3) at least two investigators stay in the room next door, offering assistance when needed; (4) do not steer content [source: Palhano-Fontes 2019; preprint 2017]. The trial reports no touch policy and does not describe staff dialogue during the session [source: Palhano-Fontes preprint 2017, methods checked]; for a touch agreement see the ethical-boundaries principle [synthesis].
Example language (illustrative): "Let your attention go inward. Whatever comes, you don't need to do anything with it right now."
Watch for: distress, disorientation, attempts to leave; ICEERS: participants should not leave before the session closes and should never be left alone [source: ICEERS Good Practice Guide].

A7. Acute monitoring and rating

Purpose / when: at set points during the session (trial: before and at intervals up to about four hours after the start of acute effects).
Steps: trained raters administer dissociation (CADSS), general psychopathology (BPRS) and mania (YMRS) scales; medical staff handle physiological monitoring [source: Palhano-Fontes 2019; Sanches 2016]. Instruments are licensed; items are not reproduced here.
Watch for: emerging manic or psychotic features; escalate to the psychiatrist on duty [synthesis].

A8. Closing evaluation, debrief and discharge

Purpose / when: after acute effects resolve.
Steps: (1) final psychiatric evaluation; (2) debriefing; (3) post-session questionnaires (Hallucinogen Rating Scale, Mystical Experience Questionnaire); (4) discharge home with a relative or friend; (5) keep on the ward those whose condition requires it (four RCT participants stayed a week) [source: Palhano-Fontes 2019]. ICEERS: check each participant individually before closing and before they leave; advise rest for several hours before driving or returning to daily tasks [source: ICEERS 2019].
Example language (illustrative): "Before you go, tell me in a few words how you are now, and who will be with you tonight."
Watch for: residual confusion or agitation; effects persisting well beyond the expected period (ICEERS lists this as a rare risk) indicate medical review, not discharge [source: ICEERS 2019; synthesis].

B1. Non-judgemental assessment of use and intentions

Purpose / when: when a client says they have attended, or are considering, an ayahuasca ceremony or retreat.
Steps: (1) express neutral interest without endorsing or condemning [source: ICEERS Support Center, non-stigmatising principle; PHRI abstract]; (2) ask about context (religious group, Indigenous-led ceremony, retreat abroad, informal group), reasons and expectations, prior experiences, other substance use, current treatment and medication; (3) map current psychiatric state and risk; (4) record what you can and cannot help with given your jurisdiction's law and your professional code [synthesis].
Example language (illustrative): "I'm not here to tell you whether to go. I'd like to understand what draws you to it, so we can think together about your safety."
Watch for: expectation of a cure (ICEERS 2019 warns about guides promising cures); attendance under pressure from others, which ICEERS lists as a contraindication.

B2. Contraindication screening and advice

Purpose / when: before a planned experience, or when reviewing a past adverse one.
Steps: go through the contraindications ICEERS 2019 lists, and advise against attending and refer to medical care where any apply. Physical: severe cardiovascular disease, severe hypertension, glaucoma, retinal detachment, recent surgery or fractures, epilepsy or seizures, stroke history, serious liver, kidney, gallbladder or pancreatic disease, certain ulcers or gastritis, digestive bleeding, acute infections, tuberculosis, difficulty vomiting; pregnancy and breastfeeding. Psychological: panic attacks, serious psychiatric disorders (ICEERS names bipolar disorder, schizophrenia, borderline personality), personal or family history of serious mental illness. Severe depression, suicide attempts or self-harm require close psychological supervision [source: ICEERS 2019; ICEERS Good Practice Guide adds osteoporosis and active spiritual emergency]. Trials additionally excluded significant neurological disease and substance use [source: Palhano-Fontes 2019].
Example language (illustrative): "With your history of mania in the family, the published safety guidance advises against this. I'd rather tell you that clearly now."
Watch for: disclosure only after the conversation becomes non-judgemental; revisit.

B3. Interaction education (general terms) and medical referral

Purpose / when: any client on medication or using other substances.
Steps: (1) explain in general terms that ICEERS identifies interaction risks with monoamine oxidase inhibitors and drugs acting on serotonin, many antidepressants and other psychotropics, stimulant-type drugs (risk of hypertensive crisis), and other tryptamine-containing substances [source: ICEERS 2019]; (2) do not advise on stopping or changing medication: abrupt discontinuation carries its own risks, and changes belong to the prescriber [synthesis]; (3) refer medication questions to the prescriber, and note ICEERS runs a separate medical/drug-interaction information service [source: ICEERS Support Center].
Example language (illustrative): "Please don't stop your antidepressant on your own. Talk to your prescriber about this before making any decision."
Watch for: a plan to stop medication without supervision; escalate to the prescriber with consent [synthesis].

B4. Choosing a provider: red flags and green flags

Purpose / when: a client has decided to attend somewhere.
Steps: help the client check for: screening with a health questionnaire and individual interview; written informed consent; an information sheet in advance; small groups or enough trained assistants; a team (never one person alone); a code of ethics and protocols for sexual misconduct; a shared emergency plan; aftercare and integration support. Red flags: promises of cures or results, guru self-presentation, sexual interest in participants, no screening [source: ICEERS 2019; ICEERS Good Practice Guide]. For travel abroad, ICEERS mentions going with an experienced sponsor (padrino/madrina) [source: ICEERS Good Practice Guide]. This is safety information, not a referral: never recommend specific centres (ICEERS itself does not) [source: ICEERS Support Center; synthesis].
Example language (illustrative): "Did they ask about your health and medications before accepting you? If not, that's a warning sign."
Watch for: idealisation of a leader; isolation from usual supports.

B5. Safety plan

Purpose / when: before a planned experience.
Steps: (1) disclose all conditions and medication to organisers; (2) avoid alcohol and other drugs around the experience [source: ICEERS 2019]; (3) during it: stay seated or on the side, do not leave the space without telling the guide, ask for help when needed, use slow breathing and focus on the music in difficult moments [source: ICEERS 2019]; (4) afterwards: rest before driving or resuming tasks, defer major decisions, write the experience down [source: ICEERS 2019]; (5) write down an emergency contact, who knows where they are, and how to reach local emergency services; (6) book an integration appointment in advance [synthesis].
Example language (illustrative): "Let's write down who you'll call if things feel unsafe, and book a time to talk when you're back."
Watch for: reluctance to tell anyone; explore and strengthen supports [synthesis].

B6. Integration: supporting without interpreting

Purpose / when: after any ceremony or trial session, especially in the days and weeks after.
Steps: (1) offer steady presence, attentive listening and containment; (2) invite the client to tell the experience in their own words and metaphors; (3) help them organise the narrative and separate meaningful insights from confusing material; (4) compare insights with everyday reality and decide which need attention or action; (5) support return to stability and responsibility; (6) avoid imposing symbolic or theoretical interpretations [source: ICEERS, The Art of Integration, drawing on M. Aixalà]; (7) encourage journaling and talking with an experienced person, and therapy for major life decisions [source: ICEERS 2019]. ICEERS offers up to five free integration sessions with trained psychologists and therapists [source: ICEERS Support Center; The Art of Integration]. Aixalà's 2024 chapter presents a brief, focused, individually tailored method whose detailed steps are [uncertain]; for what ICEERS reports of his 2022 book, see B6a.
Example language (illustrative): "What does that image mean to you? I don't want to put my reading on it." / "Of everything you saw, what feels most important to bring into your week?"
Watch for: the therapist offering interpretations; client dependence on the therapist. Working: a coherent narrative, more stability, fewer intrusive or confusing elements, decisions taken at a measured pace [synthesis on indicators].

B6a. Aixalà's integration approach: metaphors, dimensions and between-session practice

Purpose / when: integration therapy after an experience in any context (trial, ceremony, other use), especially where material is unresolved. Version followed: ICEERS's published summaries of Aixalà's book Psychedelic Integration (2022) and his 2024 chapter, not the book itself [source: ICEERS 2022 book article; ICEERS, Deepening Psychedelic Integration].
Steps: (1) Treat integration as a varied practice rather than a fixed protocol: Aixalà describes it through 11 metaphors and seven dimensions instead of one definition, and sees it as starting with preparation [source: ICEERS 2022]. (2) Centre sessions on active, empathic listening to the client's own story; offer possible interpretations tentatively, never impose them [source: ICEERS 2022; The Art of Integration]. (3) Link current symptoms to underlying conflicts, traumas and values, on the view that work at one level affects the other [source: ICEERS 2022]. (4) Agree between-session practices the client can continue alone, such as drawing, writing, time in nature and dance [source: ICEERS 2022]. (5) Plan for time: healing and learning unfold gradually; integration is complete when the insight is incorporated into life, not when sessions end, and absence of adverse effects is not by itself success [source: ICEERS 2022]. (6) Help the client find support for healing within their own community [source: ICEERS 2022]. (7) Decide whether the work aims to maximise benefit or to address an adverse reaction, and adapt to the setting of the experience (clinical trial, neo-shamanic, traditional, recreational) [source: ICEERS, Deepening Psychedelic Integration]. The names of the metaphors and dimensions and the book's session-by-session method are [uncertain].
Example language (illustrative): "Before we decide what it means, could you draw or write it this week and bring it next time?" / "The fear that came up in the ceremony: where else in your life do you meet it?"
Watch for: spiritual bypassing and ego inflation, which Aixalà treats as signs that more integration is needed; inward focus that unbalances the rest of life; hasty major decisions based on images that may be symbolic rather than literal [source: ICEERS 2022]. Working: the insight shows in everyday behaviour and relationships, and the client relies less on sessions [synthesis].

B7. Cultural and community reconnection

Purpose / when: throughout integration, especially where the experience took place in a religious or Indigenous context.
Steps: (1) ask what framework the client and their community use to understand the experience; (2) work with the psychological, cosmological and cultural frameworks the client brings, attributing them as theirs [source: ICEERS, The Art of Integration; ICEERS Support Center]; (3) support reconnection with family, community and practice; (4) for religious questions, signpost to the client's own religious community rather than offering ceremonial guidance (see XI/XIII) [synthesis].
Example language (illustrative): "In your church, how would people understand what happened to you? Is there someone there you trust to talk with?"
Watch for: the therapist taking a position on whether spirits or entities are real; stay with the client's experience and safety [synthesis].

B8. Assessment after a difficult experience

Purpose / when: a client presents distressed after ayahuasca.
Steps: (1) assess immediate risk (suicidality, psychosis, mania, inability to care for self) and use emergency services if present [source: ICEERS Support Center directs crisis and suicide risk to emergency services]; (2) identify the pattern; ICEERS's service sees these profiles: lack of preparation, unresolved experiences, difficulties with facilitators, traumatic psychedelic episodes, worsening of pre-existing conditions, surfacing of previously unknown traumatic events, repeated use without integration, feeling attacked or possessed by entities [source: ICEERS, Deepening Psychedelic Integration, summarising Aixala 2024]; (3) screen for delayed harm from acting on session "messages" as literal truths [source: ICEERS 2019]; (4) decide: brief integration, ongoing psychotherapy, or psychiatric referral [synthesis].
Example language (illustrative): "Let's first make sure you're safe tonight; then we'll make sense of what happened, at your pace."
Watch for: psychotic or manic symptoms (ICEERS reports rare psychotic episodes, some without prior history) [source: ICEERS 2019].

B9. Group therapy alongside retreats (historical example, Thomas 2013)

Purpose / when: described for addiction in a First Nations community; Health Canada stopped the practice in 2011. Not for use; included so you recognise the format [source: Thomas 2013].
Steps (as described): group orientation, eligibility and consent; group talk therapy at intervals reflecting on trauma and compulsive behaviour; a session re-conceptualising addiction as something other than personal weakness; breathing and meditation exercises; group sharing; morning debriefs after each ceremony; community follow-up for adverse reactions. Ceremonies were led by a Shipibo practitioner and apprentices and are not described here.
Usable today: the non-ceremonial parts (trauma-informed reframing of addiction, group sharing, follow-up) are ordinary group-therapy practice and can be used without any substance [synthesis].

5. Handling problems

The sources say little about therapy process problems. Items not tagged with a source are [synthesis].

Overwhelm or panic during a session (trial staff). Simple non-medication support: slow diaphragmatic breathing, active listening, calm presence, continued until stable; never leave the person alone; call medical staff for anything beyond this [source: ICEERS 2019; ICEERS Good Practice Guide]. Benzodiazepines were available as supportive medication in the RCT, and their use is a medical decision [source: Palhano-Fontes 2019].
Physical adverse events. Nausea, vomiting, transient anxiety, restlessness and headache were reported in the RCT (nausea and vomiting more often with ayahuasca); vomiting was the only adverse event recorded in 47% of open-label participants [source: Palhano-Fontes 2019; Sanches 2016]. Positioning against choking, fall prevention and medical escalation as in A5 and A8 [source: ICEERS 2019].
Client wants your blessing or a referral to a ceremony. Decline to recommend or arrange; offer harm-reduction information (B2 to B5), stay available, and document the conversation. Where use is illegal, do not provide anything that facilitates obtaining or using the substance.
Client intends to go despite contraindications. State the risk plainly and in writing; involve the prescriber where medication is involved; agree a safety plan anyway (B5); keep the door open for afterwards. Do not end therapy because of the decision.
Non-adherence to medical advice (e.g. stopping antidepressants on their own). Treat it as a safety issue: inform the prescriber with consent, monitor for relapse, withdrawal or suicidality, and run a risk review in line with standard practice.
Acting on "messages" (quitting a job, ending a relationship, stopping treatment). ICEERS warns against harmful literal readings and hasty decisions [source: ICEERS 2019]. Respond by agreeing a pause before major decisions, testing the insight against everyday reality (B6 step 4), and involving trusted others.
Stuck integration (going round in circles, more confusion over time). Narrow the focus to one element the client can act on; ask what is unresolved; check for re-traumatisation or newly surfaced trauma memories (a profile ICEERS sees) and move to trauma-focused stabilisation before any processing [source for profile: ICEERS, Deepening Psychedelic Integration].
Repeated use as avoidance or without integration (an ICEERS profile) [source: ICEERS, Deepening Psychedelic Integration]. Explore function and pattern as with any repeated behaviour; use motivational and harm-reduction approaches rather than ultimatums (PHRI rejects a purely abstinence-based stance) [source: PHRI abstract; synthesis].
Feeling attacked or possessed by entities (an ICEERS profile). Take distress seriously without arguing about the framework; assess for psychosis; if psychosis is absent, work within the client's framework and community resources (B7); if present, refer urgently to psychiatry [synthesis].
Psychotic or manic symptoms, persistent depersonalisation or effects that do not resolve. Urgent psychiatric assessment. ICEERS reports rare psychotic episodes, sometimes without prior history, and rare prolonged effects [source: ICEERS 2019]. Rates of persistent depersonalisation after ayahuasca are not reported in the sources cited [uncertain].
Suicidality. Standard risk assessment and safety planning; ICEERS directs crisis and suicidal-risk cases to emergency services, not to its integration service [source: ICEERS Support Center]. Severe depression, suicide attempts or self-harm need close supervision before any experience [source: ICEERS 2019].
Harm by a facilitator (sexual misconduct, coercion, exploitation, injury). ICEERS lists difficulties with facilitators among presenting problems and requires protocols for sexual misconduct [source: ICEERS 2019; Deepening Psychedelic Integration]. Respond with trauma-informed care, support the client's choice to report to police or authorities, and document; follow your mandatory reporting duties for minors or vulnerable adults.
Rupture: the client feels judged, or idealises the therapist as a guide. Repair with transparency about your role and limits; return authorship to the client ("support without interpreting") to reduce dependence [source: ICEERS, The Art of Integration; synthesis].
Therapist's own position. Clinicians with personal enthusiasm for or against ayahuasca should seek supervision; ICEERS recommends regular supervision for those working in this field [source: ICEERS 2019].
Trial-specific problems. Breaking blind, placebo-related stomach upset, disappointment after placebo, relapse after medication changes. The Natal RCT masked allocation (identical bottles, a placebo mimicking taste and colour, participants with no prior ayahuasca use, allocation held only in the database and by the pharmacy) and assigned different psychiatrists to follow-up; no check of whether participants guessed their allocation is reported [source: Palhano-Fontes preprint 2017]. In the preprint a new antidepressant scheme was proposed at day 7 and follow-up continued to six months [source: Palhano-Fontes preprint 2017]. How participants learned their allocation, and any plan for disappointed placebo participants, are not described [uncertain]. Synthesised response: debrief placebo participants at unblinding, name and normalise disappointment, screen for hopelessness and suicidality, start the new treatment plan promptly, and keep a named contact through follow-up [synthesis].
Legal exposure. Where use is illegal, avoid any act that facilitates it, keep records factual, and seek advice from your professional body or indemnity provider; confidentiality about a client's past use follows ordinary rules [synthesis].

Sources

Sources used:

Palhano-Fontes F, et al. (2019). Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychological Medicine
ICEERS Foundation. Ayahuasca Good Practice Guide (2013/2014)
Londono D, Mazarrasa J, Aixala MB (2019). Towards Better Ayahuasca Practices. ICEERS.
ICEERS (2025). The Art of Integration: How to Support Ayahuasca Experiences
ICEERS Support Center. Integration Sessions for Challenging Experiences
ICEERS Support Center. Assistance with challenging experiences
ICEERS. Deepening Psychedelic Integration (summary of Aixala 2024 chapter)
Thomas G, Lucas P, Capler NR, Tupper KW, Martin G (2013). Ayahuasca-assisted therapy for addiction: results from a preliminary observational study in Canada. Current Drug Abuse Reviews.
Sanches RF, et al. (2016). Antidepressant effects of a yahuasca in patients with recurrent depression: a SPECT study (title abbreviated; UFRN repository record)
Labate BC, Feeney K (2011). O processo de regulamentacao da ayahuasca no Brasil e na esfera internacional. Periferia 3(2)
Wikipedia. Legal status of ayahuasca by country (secondary)
Gorman I, Nielson EM, Molinar A, Cassidy K, Sabbagh J (2021). Psychedelic Harm Reduction and Integration: A Transtheoretical Model for Clinical Practice. Frontiers in Psychology

Further sources:

Also cited: Aixala MB (2022). Psychedelic Integration: Psychotherapy for Non-Ordinary States of Consciousness. Synergetic Press. Aixala MB (2024), chapter on psychedelic integration, Current Topics in Behavioral Neurosciences, doi 10.1007/7854_2024_532. Osorio F de L, et al. (2015), preliminary open-label report, Revista Brasileira de Psiquiatria. Labate BC, Feeney K (2012), International Journal of Drug Policy (English original).

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