1. Competency to work with spiritual material.

Competency to work with spiritual material was a common theme, identified within 11 SHPs’ interviews. This theme refers to addressing, understanding, and responding to spiritual and religious material, such as beliefs, experiences, and practices relating to God, the transcendent, divine, the universe, and other supernatural or sacred constructs. A key throughline across most SHP interviews was that SHPs are specifically trained to respond to spiritual content and experience, which is a frequent experience of participants undergoing PAT. In this regard, SHPs discussed the value of their personal experience offering spiritual care to patients, and its implications for PAT as a site of spiritual care. This included patients’ positive experiences with spirituality, but also knowledge about how to provide support for participants who had difficult histories with spirituality or had to address spiritual challenges in their current experience.

One SHP reflected that spiritual care is the primary role for a SHP in PAT, both because of their training and because of the experience of PAT for participants:

There is no way around acknowledging that there are spiritual care dimensions to this work that are inherently involved, despite whether somebody comes from a faith tradition or not these experiences bring up matters of the spirit, matters of one’s relationship with life, with death, with all matters of just spiritual dimensions of the human experience.

These dimensions of care may require specialized training and aspects of what is called “formation,” or the development of personal characteristics, as part of that training. “Of course my training helps me. And also just my spiritual perspective in general,” said one SHP. SHPs’ clinical training supports a nuanced understanding and appreciation of spiritual and religious content, which enables them to respond to complex spiritually and religiously oriented experiences. One SHP described working with a patient who experienced a traumatic reaction in relation to a song on the music playlist used during dosing, which brought memories of past abuse in a religious setting. Later in the same session, the participant experienced a connection with a benevolent divine figure that was a part of this same religious tradition. Training in spiritual care and theological reflection allowed the SHP to explore the subtleties of both harmful and supportive religious experiences, while also exploring the participant’s core values and beliefs. This SHP noted that the skills of chaplaincy allowed them to navigate this with subtlety and care:

I think it really helped [to] have a chaplain there to just be able to accept all of the dimensions of that religious experience—all of it was welcomed in and then more integrated… Integrating the generative aspects of religious coping and religious experience with the really abusive harmful stuff and being able to…parse it out…kind of pulling apart the threads and looking at each and then being able to weave this more integrated self through the experience, instead of having these sort of splits…I think that was [a] really positive outcome…if I were to document it [I] might call it ‘religious integration’ or ‘spiritual integration.’

Some SHPs described a capacity to be nimble in response to the variety of religious or spiritual scenarios a participant might encounter in a psychedelic experience, including experiences that reflect different, conflicting, or emphatically non-religious worldviews. In fact, knowledge of spirituality was not regarded by SHPs as only knowledge of a specific theological or religious approach, but a knowledge of the nuances of spiritual care, including non-coercive recognition of atheist and non-religious perspectives. Notably, none of the SHPs described exclusionary or sectarian applications of their knowledge. Many shared a pluralistic framework for conceptualizing their expertise in spiritual care, in which the SHP is prepared and able to respond to any type of theological material with the participant in a manner that is respectful of their belief systems and autonomy.

2. Awareness of power dynamics.

SHPs’ awareness of power dynamics refers to SHPs’ attention to interactions that may impose spiritual, religious, or cultural perspectives, which may impinge upon the autonomy of participants, and their awareness of the dynamics of physical touch. It also includes awareness of power dynamics that exist beyond the interpersonal relationship between the participant and clinician, described here as systemic power imbalances and justice-related concerns. These elements were treated as a single theme because they all involve attunement to the power dynamics in the care environment at the different levels where they occur. This theme was present in eleven interviews. SHPs who discussed awareness of power dynamics were cognizant of the many intersecting roles that both the facilitators and the participants in PAT inhabit and referred to the power-related implications of their actions as they fulfilled their roles.

SHPs described an understanding of the role of language in conveying shades of religious connotation and spiritual meaning, which may interfere with a pluralistic support for diverse clients. This enabled attentive and deliberate selection of language, including allowing the patient to introduce their own language around values and beliefs. This care toward language is reflected in a core principle that emerges from spiritual care training: the “living human document.” This is a reference to Anton Boisen’s seminal work regarding hospital-based chaplaincy [28], which highlights the value of honoring the person receiving care, as noted by this SHP:

We seek out what this person is open to, where are they, what do they feel safe with…we are trained to be quiet and to listen and to interact alongside rather than to lead, control, guide, change….the value [of chaplaincy] is of respecting the individual and trying to read the living human document before us.

Non-imposition also involved not intruding upon or invalidating the participants’ emotional experiences, including difficult ones. One SHP said: “when with the family and friends the pain is so evident, and yet we don’t try to change it, we don’t try to numb it, we don’t try to name it, we just hold space and we offer support when we’re acted upon.”

SHPs also described their expertise at conveying their knowledge of power dynamics and allowing it to inform their care, not only during the dosing experience, but during preparation and integration as well. Successfully communicating the SHPs’ role was one way to assure participants that their values, whether religious, spiritual, or not, would be respected. One SHP noted:

My only goal is to help support them in their own meaning making process, whether that’s an atheist, agnostic, spiritual but not religious, religious. What we do in spiritual care is help people deal with the human condition. And I think once you name that and really make it explicit in the preparation stage, people have permission to be and act and interpret however they want. That really empowers them to feel more at ease and then they feel more confident.

Discussion of boundaries around touch in preparation stage was a key element in supporting participant empowerment as discussed by SHPs. Physical touch is commonly used as a support strategy in psychedelic sessions and can risk harm if not approached appropriately [29]. Multiple SHPs talked about the dynamic around physical touch and the importance of employing a strategy during preparation for discussing boundaries and a plan relating to physical touch. Participant autonomy and safety relating to physical touch were priority in several SHP’s interviews.

Cultural humility, a value embedded within spiritual care training and certification programs, was a recurring aspect of SHPs’ attention to power dynamics. Directly stated by one SHP, “we do not impose our de facto belief systems or cultures onto others.” Many references to cultural dynamics were consistent with the principles of cultural humility even when that exact phrase was not used. The values of cultural humility are consistent with attention to the larger context of systemic inequality and historical inequities, including concerns around cultural appropriation of psychedelic medicines. One SHP described chaplains’ contributions of respectfully engaging indigenous traditions while being cognizant of possible cultural appropriation in the context of psychedelic medicine:

I think chaplaincy has a lot to add when it comes to respecting indigenous religious and spiritual traditions that have been using these medicines for millennia. Chaplains can be the champions not only for access but also answering questions about appropriation. That’s where a chaplain’s cultural competency becomes essential. How do we respect the history of these medicines, where they come from, the cultures that they come from? How do we utilize these in a medicinal or spiritual context in a way that is respectful of these things?

3. Familiarity with non-ordinary states of consciousness (NOSC).

SHPs’ awareness of NOSC was discussed by eight SHPs. The topics included within this theme comprise: SHPs’ personal familiarity with NOSC, their awareness of the importance of these states for participants undergoing PAT, and SHPs’ responsiveness to these states. SHPs’ awareness of NOSC was acquired through multiple kinds of experiences, such as care for the dying, and experiences with contemplative, prayerful, and meditative practices. Awareness of and comfort with NOSC was described as a key capacity of SHPs in PAT.

Some SHPs considered familiarity with NOSC to be central to their professional identity and responsibilities. One SHP described chaplaincy as involving “the whole of a person, and innately that includes spirituality in the sense of the meaning and the connections and the relationship that we have to that which is mysterious, transcendent, bigger than ourselves, and deeper than our conscious everyday minds and behaviors.” They saw part of their role as helping to engage with the non-ordinary and building a “bridge” to it, including NOSC.

A variety of experiences beyond PAT were invoked to describe the importance of NOSC in SHPs’ duties and professional experience. Some SHPs described the importance of working with NOSCs while being present with the dying, an important part of their existing professional repertoire that they have been able to learn from and translate to PAT. One SHP described their role in such experiences:

Chaplains have expertise in end-of-life matters when issues of death or experiences of life outside of the present moment, experiences of…we might call them spiritual experiences, peak experiences, religious experiences, experiences of altered consciousness, spiritual visitations, visions.

For multiple SHPs, the appreciation of NOSC as sacred or transcendent was connected to the previous theme of non-imposition. Recognition of the magnitude of such experiences was paired with a hesitancy to foreclose their meanings, and with humility about imposing one’s own lens on such an experience, including within the context of PAT.

SHPs also described how their familiarity with NOSCs helped them to normalize these experiences. Indeed, the SHPs illustrate a kind of complementarity in their accounts of NOSC: on one hand, they describe the importance of treating them with reverence and appreciation. On the other hand, they describe the everyday nature of such experiences, and their willingness to regard such experiences as unique but not unusual. While NOSC may not be ordinary to the participants or to other PAT professionals, they can be ordinary for SHPs without losing their significance or vitality:

…when someone has some sort of weird experience or a deceased loved one they’re grieving comes and visits them in the dosing session, or they need Jesus or an angel. That’s the spiritual care. It’s everything we’re trained for. That’s our bread and butter.

4. Holding space.

For this analysis, holding space refers to the creation or sustainment of an interpersonal environment that affords engaging with intimate, sacred, or existentially meaningful experience. This theme included SHPs’ descriptions of being present with the patient, calmly and with supportive, present-moment awareness, and observing internal and external activity with readiness to respond to what may arise [30]. Holding space is also consistent with ritualized and ceremonial practices that many SHPs are trained in through their religious histories and ordination processes. Although holding space shares elements with other clinicians’ professional activities (e.g., empathic listening), SHPs’ emphasis on contemplative and ritual aspects of this activity singles it out as an area of particular emphasis for them. Nine SHPs provided examples of holding space throughout the PAT process. SHPs described the need to respond in a way that was not merely clinical but also spiritual and even ritualistic. One SHP described it this way:

I feel like chaplains are trained to hold the unexplainable, the mystery, the weird, the liminality. So much about my training as a chaplain is just being with, witnessing, holding, supporting without needing to fix or change or anything… it’s just really a process of allowing. I really see us as doulas in a lot of ways—like there are death doulas and birth doulas—but we are almost like psychedelic experience doulas that can just be present with the experience and support without needing to get in there with any concrete tools.

SHPs described holding space in a way that was consistent with the clinical and therapeutic priorities of the treatment. For example, one SHP’s description of holding space included applications to consent, safety, and planning:

… in the preparatory stage a chaplain engages in a ritualized creation of the container, establishing consent, holding the space, and more or less bringing the elements of intentionality, safety, and a solid plan into existence.

Holding space may manifest in different ways across the continuum of the PAT, but often included an attention to the SHPs’ own experience in order to ensure that they were able to provide a supportive presence for the participant. In this way, holding space was distinct from presenting a ‘blank slate’ or compartmentalizing one’s experience; rather, it involved attending to one’s own experience so that the SHP may show up in a particular way. One SHP’s description of holding space during the dosing conveyed a balance of attuning to their own experience, and ensuring that they were able to actively support the participant’s experience without introducing agitation:

If I’m agitated or moving or hungry and not taking care of my body or thirsty or I have to use the restroom, they’re going to be more aware of that than they would normally, or at least experience that I’m not fully engaged with them…it’s a very dynamic following of energy and attendance. What it’s not for me is “interventions” or trying to produce some results… I might ask a few questions or reflect something back for them. But often I’ll track that and maybe in an integration session bring questions or other things, but in the actual medicine session is just allowing the medicine and the participant to do their magic.

It is thus relevant to note that holding space may be conceptualized as distinct from an intervention or therapeutic technique. It is not done in order to achieve any particular outcome, save the participant having an authentic and safe experience with the treatment. Nonetheless, as this SHP described, the capacity to hold space may enable the participant to have experiences that might subsequently become material for more interventional activities during integration.

One SHP who discussed the ceremonial qualities of holding space went on to describe their relevance to emotional difficulties that can arise during PAT:

When there are challenges that come up in the experience a lot of what I…or what my team would be doing would be trying to assist people through those edges. Sometimes that can take the form of just presence or mindful touch or just making sure somebody knows that there’s somebody there. A lot of times what can be really hard and terrifying really is when you’re in a very challenging space and you feel alone, and you don’t feel like anybody’s there.

This statement also highlights a relational quality to holding space. While careful not to impose on their experience, holding space is an attempt to ensure that the participant does not feel that they are alone, and to convey that someone is with them through their experience.

5. Counterbalance to biomedical perspectives.

Eight SHPs described ways in which their work as members of the PAT team provides a counterbalance to biomedical perspectives patients generally encounter in clinical care. Correspondingly, this theme refers to SHPs complementing other perspectives on the interdisciplinary care team through addressing spiritual concerns which might not otherwise be addressed, through balancing the biomedical approach when needed, through making space for non-ordinary experience, and through honoring the spiritual container that has been held in indigenous practice with psychedelic medicine.

One SHP described how commonly participants’ psychedelic experience is expressed in spiritual language. These spiritual registers may not be captured by the scientific perspectives or terminology that participants might otherwise encounter in medical settings, which may result in leaving important aspects of their experience unaddressed:

…science is still working to try to understand how these medicines work and how people’s experience is expressed, how the positive outcomes are expressed… in the language of the spiritual domain. People draw on cultural traditions to make sense of their experience. It defies certain kinds of measurement and really requires a more holistic approach in how we support and understand and develop this work.

SHPs did not describe excluding any accepted medical strategies; rather, they described their role as offering the PAT team a capacity to integrate more than biomedical approaches might capture on their own. For example, SHPs described addressing connections with ancestors, experiences of feeling one with the earth or universe, or battling powerful spiritual forces. One SHP reflected:

…the nice thing about working with a chaplain is that we are used to a lot of weird, and that’s okay. Chaplains provide a counterbalance to the biomedical approach and also open up the space for some profound and perplexing ideas that may sometimes conflict with some of the underlying assumptions in the biomedical ideology.

One SHP reflected on the importance of this for the participant, who may have an experience deeply rooted in spiritual or religious experience, as well as for the field, which is developing in its understanding of the breadth of impact of these medicines.

We’re starting to explore psychedelics as kind of a medical intervention, but how do we also recognize the spiritual value of these substances, of these medicines, such that it’s not just a medical intervention for sick people, but it’s a spiritual intervention for well people who are exploring particular spiritual goals. I think having chaplains involved in this work introduces that critical distinction of saying this isn’t only a medicalized treatment. There is something else at work here. There’s something spiritual and emotional going on here as well. And I think just having chaplains involved in the work puts some kind of inherent validity on that approach.

The presence of the SHP acknowledges a multitude of ways in which a participant’s life is connected with the sacred—through their spiritual/religious tradition, their personal history, their core relationships, and the other places they find meaning in their life.

An important aspect of counterbalancing biomedical perspectives included recognizing the utility of skillfully applying indigenous approaches to psychedelic healing. This SHP highlighted the historical practice of psychedelic medicine in indigenous communities and recognized how some of these rich practice histories can be appropriately utilized in clinical settings by SHPs:

Traditionally these medicines…in indigenous communities that work with medicine… are always held in a spiritual context and spirituality is never separate from anything else…And I think we really do a disservice to clients if we don’t hold it in a spiritual context because it’s such an important part of the work.

While valuing indigenous practices was highlighted by several SHPs in this study, as previously mentioned in the theme of attention to power dynamics, SHPs also emphasized the importance of avoiding misappropriation.

6. SHPs make use of generalizable therapeutic repertoire when facilitating PAT.

Eleven of the 15 SHPs described a range of activities in PAT that directly relied on a set of generalized, interpersonal therapeutic skills shared among other clinical professionals. These included: assessment, taking a life history, psychoeducation about the treatment process in PAT, teaching and practicing with coping skills, offering a supportive presence, helping patients make meaning, and helping with integration of life experiences and themes.

The initial application of transdisciplinary therapeutic skills often occurred during participants’ preparation, when SHPs were sometimes involved in initial assessments. Assessments included informal evaluations of participant characteristics and histories that could impact their treatment, as well as formal evaluations for SHPs who are trained to conduct mental health evaluations. One SHP described their role in, as well as their rationale for careful assessments of patients considering PAT:

There would be an assessment of the state of mental health, medications that people might be on or not. If you have an active addiction, this wouldn’t be a person who would be safe to go into this experience. If they’re in acute trauma or in the sense of an unsafe intimate partner, this would not be a good time to move into it. Making sure there’s enough stability and preparedness to enter in and enter out because the work by its very nature is going to become somewhat destabilizing and somewhat dysregulating as we’re moving through transition and we’re moving through trauma and we’re even discovering things that we didn’t necessarily identify before.

Another type of activity that often began during preparation was informing participants about PAT and setting expectations. SHPs remarked on the importance of equipping patients to “navigate” the experience and provide information or techniques that could assist them once they began to feel the psychoactive effects of the treatments during dosing. SHPs mentioned specific skills, “We’re also giving participants tools like breathing practices to help ground…We give mindfulness practices or different meditations, so we really try to equip the participants.” Another SHP described the importance imparting specific information:

Preparation also includes just some education—call it psychoeducation or spiritual education. How do you navigate in the internal world? It’s a bit like teaching people how to go skiing or something… There’s the intention to welcome whatever your mind choreographs and presents to you on the particular day when you take the psychedelic.

This informative approach also involved communicating a stance toward experience and a contemplative sensibility. The SHP continued:

And whatever comes, the intention is to meet it, to welcome it, to embrace it, to explore, not to control it, not to label it…So there’s a certain courage and there’s a decision to trust. It’s not just being passive.

Finally, the educational and informative roles of SHPs comprised setting expectations, including maintaining a realistic sense of what PAT might (and might not) achieve.

I think one of the risks is feeling like psychedelics is a silver bullet or magic something that will cure all, which is obviously not true and [we] try to frame this in a much larger context of equipping participants with tools and a bigger picture.

Like many other health professionals, SHPs might cultivate a therapeutic presence that can be used to support participants throughout the treatment. For the day of the dosing session, SHPs described the importance of offering a “grounding presence” to participants and other staff:

As they arrive, many people have high anxiety coming into a ketamine session, so our role is to be a grounded, clear, calm, compassionate presence.

During the integration portion of the treatment, while continuing to include an emphasis on general therapeutic skills, SHPs also paid additional attention to the broader context of integration, which included families, communities, worldviews, and life narratives. Thus, SHPs blended general therapeutic skills with their unique areas of competence, such as guiding participants through rituals to help integrate.

Our work is not simply to comfort the people we work with, but also to really assist in integration and healing through elements of story, through elements of ritual, and through elements of the heart. [What] I would want healthcare administrators to know is that we chaplains really have a discrete tool belt of interventions that can assist in processes that feed directly into wholeness and healing and wellness.

7. SHPs contribute to interdisciplinary collaboration.

Eleven of 15 SHPs described interdisciplinary collaboration on PAT teams. This activity that is common for SHPs is part of a generalized clinical skillset that is shared by many other disciplines, and is also a useful element for PAT. Interdisciplinary collaboration is defined as working with physicians, mental health practitioners, integrative and complementary health professionals, and other clinicians for the benefit of the patient’s experience. Within healthcare environments, SHPs are accustomed to interdisciplinary team work. As noted earlier, it is common for SHPs to round with physicians, social workers, nurses, pharmacists, and other members of the care team. SHPs are often invited to offer their perspective on patient and family concerns from a spiritual health lens. SHPs described the translation of their foundation in collaborative medical care to interdisciplinary PAT teams.

My chaplain training has been absolutely essential, particularly in the hospital context, where I was working on a team collaborating with clinicians… I really do a lot of communicating with the clinicians around kind of particular safety thresholds for the session. But I also take time to write particular […] notes for the clinician after our individual session, so that they really get an idea of how Session One went… I like to fill in the clinician on what the experience is like, how the client is feeling about their treatment process, what the content of the sessions were like, what kind of goals they’re pursuing… Clinicians [in PAT] are a combination of MDs, DOs, psychiatric nurse practitioners, and maybe even some physician assistants.

Interdisciplinary collaboration was also described as a part of retreat/ceremonial contexts, in which six (40%) of the SHPs also had experience. For example, one SHP described group grief retreats for participants whose child has died. These retreats included multidisciplinary clinical teams working together. The SHP emphasized the comprehensive assessments conducted on the retreats, which integrated input and perspectives from various disciplines:

In our team for the grief retreats we have two palliative care physicians who are MDs, one of whom is also a chaplain, which is really lovely. We have a psychiatrist on that team, and I work as a chaplain/therapist. We all consult with one another. Before people ever go on retreat we do a really full comprehensive assessment—physically, emotionally, spiritually, medically for these people, to understand the full complexity of their situation.

SHPs explicitly discussed the positive collaboration and mutual understanding between roles that they experienced on PAT teams, and the factors that contribute to good collaborative relationships. One SHP described the positive nature of their relationship with the other team members. They referred to relationship-building, and recognition of their distinct skillset by other team members, which helped them join together to offer supportive care to their participants:

I would say that I have been able to build a relationship with the doctor and the rest of these licensed therapists. I’m well accepted into the group and they believe that I have something to offer. They acknowledge that the type of pastoral counseling, ethical counseling, moral counseling, the kind of things that chaplains …would interact with is a bit different than the therapy sessions that licensed therapists have. But we all acknowledge that we’re all on the same team we’re all trying to support and equip the patients that we’re working with for healing.

Across multiple examples, SHPs’ also referenced their personal background and experience working on medical teams in order to provide models of successful interprofessional collaboration. For instance, one SHP with experience in palliative care referred to it as an exemplary model for collaborative care.:

I think ideally there’s an interdisciplinary team. Palliative care is a good model. It would be good to have a team that represents all the dimensions of health and well-being–the spiritual, psychological, physical, social dimensions of care. Spirituality should be included in that integrated care plan, and chaplains are specialized in spiritual assessment and meaning making, and should be represented on the team.

Just as their experience in palliative care helped to shape their approach to interdisciplinary care in general, they saw palliative care as a potential model that the emerging field of PAT might draw upon to provide interdisciplinary treatment.