What do we know about the psychedelic underground?: 5 Questions for drugs researcher Crystal Lederhos Smith

Smith discusses a recent qualitative study in which she and her collaborators interviewed underground psychedelic practitioners about their practices and views.

Crystal Lederhos Smith was trained as a prevention scientist, identifying the factors that drive misuse of substances like opioids. In her doctorate program at Washington State University, she first began studying tobacco and opioids; by the time she became an assistant professor at the university and director of the Analytics and Psychopharmacology Laboratory, she grew more interested in studies on cannabis use as well. 

Eventually, she ended up investigating psychedelics. In 2022, a colleague at WSU introduced her to a team at the University of Washington. Researchers at the two universities assessed what was known and unknown in psychedelics research, and decided to undertake a qualitative study to better understand underground psychedelic practitioners’ practices and views. These are the people who guide others through psychedelic experiences outside of a legal and regulated framework. The study is complete but the data have not yet been published; The Microdose spoke with Smith about what the researchers have found thus far. 

How did you find underground practitioners to interview for this study? 

Being in substance use research, it's not abnormal to talk and work with people who are doing illegal things. We made sure to include a ton of precautions to keep people safe, like we set up an encrypted email account and our participants did too. 

My collaborator, University of Washington researcher Nathan Sackett, leads a center where they get lots of inquiries about psychedelics, so he started putting feelers out through email groups and word of mouth. We ended up with 13 people to interview, all of whom have been underground practitioners. Our minimum requirement is that interviewees had guided at least five people, but some had guided hundreds, or even thousands of people.

How did you structure those interviews?

We targeted three main aims. The first was the procedures surrounding psychedelic sessions. We asked whether they recruited participants, and what participants were seeking. What diagnoses did they want to target? What substances did they use? And at what dosages? The second aim was to understand the process of the actual psychedelic sessions. How did they monitor people? What was the experience of sitting with or guiding people like? And how did they measure progress or outcomes? And the third aim was to ask people about the next steps. Where do you think research and legalization efforts should be going? What do you wish other providers knew?

Were there any highlights or themes that emerged from those interviews?

I was very surprised that no one we talked to said that they intentionally recruited. People were always asking, so facilitators were more limited by their own availability than anything else. 

We also saw a few themes. One was that people's personal experiences — their own self healing through psychedelics — was the primary motivating factor for them promoting the use of psychedelics. Another theme was that there was a continuum of beliefs surrounding the mechanism of action of psychedelic-assisted psychotherapy. Some folks referred to the process as a medically focused intervention, but others were really uncomfortable with that, and felt that it’s more of a spiritual intervention. Some felt that if somebody tried to fit psychedelics into a medical model, it would really do a disservice to the substance and take away some of its benefits. 

Some providers also believed that the client benefit was actualized through their own intrinsic ability to heal themselves. Providers said things like, “I just get out of the way.” It’s a pretty common sentiment that it's not so much the person who is guiding or being present, but the substance that allows a person to get past their own stuff. 

What did practitioners have to say about the future of psychedelics access and legalization, and is there anything to learn from their insights?

As we talked with providers about legalization and the politics surrounding psychedelics, there was an overwhelming sense of dissonance. Providers all said they wanted increased access, and for people to be able to use substances and experience the healing they’ve felt. But many were also very worried that if these substances were legalized, regulations would push the experience into a box, and as guides they would lose the ability to tailor experiences to each person. They’re worried it would just become too mechanistic. 

The most insightful thing that came out of this work for me was a conversation I had with a nurse on our team. Given all of the things providers said about wanting to tailor experiences and make sure that it's right for the individual, this nurse said, “You know, that's what we do all day long as nurses.” The general public may have this view of medicine as rigid: you have this issue, you get this dose of this medicine. But this nurse’s explanation was that it doesn’t necessarily happen that way, and that's a lot of what nurses do: as they're interacting with people and communicating with providers, they have the ability to tailor interventions to the person. To me, this shows how important it’s going to be to roll out psychedelics in a way that makes it clear that it needs to be tailored to the individual, and how we need to communicate that to politicians and other people working on this. 

A lot of psychedelic research focuses on clinical trials and quantitative work on outcomes. Why do you think this kind of qualitative work matters?

I’m a biostatistician — I love data! But it only gives you one piece of the puzzle. You're never going to get the depth of information in that data as you do with qualitative work; it’s so valuable for connecting many different puzzle pieces. I definitely would not understand the perspectives and the emotions of the providers if not for this qualitative work. 

This interview has been edited and condensed for clarity and length.