Ayahuasca Beyond the Amazon: the Benefits and Risks of a Spreading Tradition
This commentary (2010) examines how to integrate these spiritual healing rituals into contemporary Western concepts of psychological health and ethical conduct, and calls for an enforcement mechanism of accountability for monitoring the reputations of different ritual leaders to protect the community from predatory practices.
Authors
- Trichter, S.
Published
Abstract
Ayahuasca, a hallucinogenic plant brew from the Amazon basin used as part of healing ceremonies by the region's indigenous people for centuries, is now consumed by growing numbers of people throughout the world. Ayahuasca consumption has moved from strictly being part of indigenous shamanic healing ceremonies, to being a key component of the Brazilian syncretic churches formed in the last century, to most recently being part of New Age rituals conducted throughout the Western world. The discovery of ayahuasca by the Westerners, has resulted in a growing body of research suggesting that participants who take part in ayahuasca ceremonies experience significant spiritual and psychotherapeutic effects. Along with these potential benefits, however, the adoption of indigenous practices into Western cultures brings simultaneous challenges. As participation in ayahuasca ritual spreads into Western cultures, it becomes necessary to examine how to integrate these spiritual healing rituals into contemporary Western concepts of psychological health and ethical conduct.
Research Summary of 'Ayahuasca Beyond the Amazon: the Benefits and Risks of a Spreading Tradition'
Introduction
Trichter frames the paper by noting that ayahuasca, a hallucinogenic plant brew long used in Amazonian healing ceremonies, has spread into a variety of contemporary spiritual contexts worldwide. Earlier research and anecdotal reports suggest that ritualised ayahuasca use can produce powerful mystical and spiritual experiences, which many participants and investigators link to lasting spiritual and psychotherapeutic benefits. At the same time, the transfer of an indigenous shamanic practice into Western cultural settings raises questions about safety, ethics, and cultural fit. This paper sets out to synthesize existing empirical studies, clinical observations, ethnographic accounts, and legal/regulatory examples to examine both the reported benefits of ayahuasca ritual and the risks that accompany its growing use outside the Amazon. Trichter seeks to characterise the kinds of spiritual and psychotherapeutic outcomes observed in prior work, describe medical, psychiatric, spiritual, ethical, and legal challenges encountered in Western contexts, and propose practical measures—education, psychotherapeutic integration, and ethical guidelines—to reduce harm as the tradition spreads.
Methods
The extracted text does not present a formal Methods section or describe a systematic search strategy. Rather, Trichter offers a narrative review and commentary that draws on a mix of published empirical studies, ethnographic and historical literature, clinical case observations, and legal examples. Specific cited sources include epidemiological and clinical investigations of church-affiliated users (notably studies of the União do Vegetal and Santo Daime communities), adolescent comparison studies, EEG research, and qualitative reports of ritual participants. Because the author does not report inclusion/exclusion criteria, search dates, or a formal risk-of-bias assessment, the review should be read as a scholarly synthesis and clinical perspective rather than as a systematic review or meta-analysis. The paper integrates quantitative findings from small empirical studies with qualitative accounts and the author's clinical impressions to address benefits, risks, and implementation challenges of ayahuasca use in Western settings.
Results
Trichter summarises a body of findings that the author groups under spiritual, psychotherapeutic, and safety-related headings. Spiritual benefits reported in the literature include frequent accounts of profound mystical or religious experiences during ceremonies, increased spiritual awareness, and incorporation of peak experiences into ongoing spiritual life. Participants commonly report encounters with sacred beings, enhanced self-awareness, and a sense of access to new sources of meaning. Psychotherapeutic benefits identified across studies and clinical reports include enhanced affective expression (accessing sadness, anger, joy), personal insight, and behavioural change. Historical clinical reports (for example, early work with harmaline) described improvements in a subset of psychoneurotic patients. Research among members of Brazilian ayahuasca churches has documented apparent reductions in alcohol use: one study reported that 11 participants with prior problematic alcohol consumption achieved sustained abstinence after affiliating with the União do Vegetal. Adolescent studies cited found that church-attending adolescents showed similar DSM-IV diagnostic profiles to controls, with some advantages reported in anxiety, body image, attention, and measures of social maturity; the authors of those studies cautioned that changes might reflect religious affiliative processes rather than pharmacological effects. Cognitive assessments of adolescent long-term users reported no evidence of neurocognitive harm in a pilot investigation. An EEG study is summarised as suggesting increased access to unconscious material. Finally, single-occasion ceremony attendees frequently describe short-term increases in empathy, connectedness, gratitude, and peacefulness that they integrate into daily life. On risks, the paper documents medical and psychiatric concerns including potential interactions with prescription medicines (notably SSRIs), the risk of precipitating psychotic states or decompensation in vulnerable individuals, and the possibility that intense material surfacing during ceremonies may overwhelm participants who lack adequate psychological resources or follow-up care. Trichter cites case-based and qualitative reports of severe adverse outcomes in uncontrolled settings, including psychotic reactions. Spiritual and psychosocial risks highlighted include ‘‘spiritual bypass’’—using ritual to avoid psychological work—compulsive, repeated attendance of ceremonies (termed ceremony-craving or spiritual addiction), and tendencies toward spiritual narcissism or social withdrawal from prior roles. Ethical and legal challenges include power imbalances between ritual leaders and participants, sexual exploitation and abuse by some practitioners, commercialisation and ‘‘neo-shaman’’ behaviour in ayahuasca tourism, and the absence of standardised protocols or ethical training. Some factual details reported are that the UDV counts more than 7,000 members in roughly 60 congregations, and that ceremonial fees may range from negligible in indigenous contexts to about $200 USD in the Amazon and up to $500 USD per ceremony in Western settings. The legal landscape is described as mixed: certain religious uses have received legal protections (UDV in the United States is noted), while the active compound DMT remains a Schedule I substance in U.S. law.
Discussion
Trichter interprets the assembled evidence as indicating meaningful spiritual and therapeutic potential in ritualised ayahuasca use, tempered by significant risks when practices move outside their original cultural contexts. The author emphasises that many positive outcomes reported in church settings might derive from a constellation of factors—ritual structure, community support, moral commitments, and the pharmacology of the brew—and that disentangling these influences requires further research. Trichter also notes limits in the current evidence base: small samples, observational designs, possible selection effects from religious affiliation, and the absence of controlled trials to clarify causality. In addressing practical implications, the paper argues that the West-wide spread of ayahuasca calls for precautionary measures rather than unregulated adoption. Three interrelated responses are proposed: public education about traditional uses and medical contraindications; integration of ayahuasca work with Western psychotherapeutic models (including pre-screening, crisis intervention, clinician-supported preparation and post-ceremony integration); and the development of cross-cultural ethical guidelines and community accountability mechanisms for ritual leaders. Trichter points to existing models—such as the Takiwasi centre that combines ayahuasca with psychotherapy and the long-standing ethical structures within some Brazilian churches—as examples that could inform safer practice. The author acknowledges ongoing uncertainties and calls for more systematic research to identify which populations might benefit or be harmed, to better understand medical interactions and psychiatric risks, and to develop standards for training, supervision, and cross-cultural ethical practice. Building intra- and intercommunity dialogue and monitoring reputations of ritual leaders are offered as pragmatic steps to reduce the harms associated with exploitative or uninformed practitioners.
Conclusion
Trichter concludes that while growing evidence points to positive spiritual and psychotherapeutic effects of ayahuasca, the global spread of the practice entails serious medical, psychological, spiritual, ethical, and legal risks if adopted without safeguards. To protect participants, the author advocates three primary strategies: education for the public and practitioners about traditional uses and medical contraindications; psychotherapeutic integration that incorporates screening, preparation, crisis support, and post-ceremony integration by trained clinicians; and the creation of ethical guidelines, community networks, and accountability structures for ceremony leaders. These measures are presented as necessary steps to preserve potential benefits while mitigating harm as ayahuasca rituals move beyond their original cultural contexts.
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INTRODUCTION
Even as modern psychiatry and psychotherapy create space for patients' psychological growth and self-exploration, research has shown that individuals often desire to have their spiritual beliefs and values integrated into clinical settings. Given the importance of mystical and spiritual experience in people's lives, it is not surprising that more and more individuals are turning towards alternative and emergent forms of religion and spirituality in search of healing and fulfillment. In Brazil, and throughout the world, the hallucinogenic plant brew ayahuasca, used in sacred healing rituals in indigenous Amazonian cultures for centuries, has found more recent use in a wide variety of modern spiritual contexts and communities. Its reputation for connecting those who participate in these ceremonies to the spirit world has stimulated the interest of those seeking connection with what they perceive to be ''the divine'').description of the spiritual power of ayahuasca provides a starting point from which to understand this phenomenon: Personally, if I were to pick one single effect of Ayahuasca that had the most important impact on my life … I would say that before my encounter with the brew I was an atheist … and when I returned back home after my long journey to South America, I no longer was one. Likewise, a significant number of informants I have interviewed indicated that the main lesson they received from Ayahuasca was religious or spiritual.The increasing popularity of ayahuasca among Western spiritual seekers, due to its reputation for creating profound spiritual and mystical states of consciousness, has created a necessity to examine how to integrate these spiritual healing rituals into Western concepts of psychological health and ethical conduct. As the use of ayahuasca shifts to use outside of its original cultural context, we must examine how the spread of this healing practice can not only bring the benefits for which it was originally intended, but how its transfer into a new cultural framework potentially can also cause distress and harm.
AYAHUASCA BASICS
Many studies of both the historical and contemporary use of entheogens, a term etymologically rooted in Latin meaning ''generating the divine within,'' have suggested that the experiences they induce can have profoundly positive, even life-changing effects upon individuals, often because they provide insights into possible solutions to psychological dilemmas. Ayahuasca, classifiable as an entheogen, is a psychoactive brew originating in the Amazon Basin region of South America. The ayahuasca drink is made by boiling, in a particular ratio, the pulverized bark of the Banisteriopsis caapi vine together with the leaves of another plant, usually the Psychotria viridis. For centuries, ayahuasca has been used in South America both as a healing tool and purportedly to communicate with plant and animal spirits. The term ''ayahuasca'' is a compound word from the Quechua language meaning ''vine of the spirits''. Widely found in the Amazon cultures, the drinking of ayahuasca was taken up by mestizos (people of mixed European and indigenous, non-European ancestry) living near tribal peoples. This resulted in a number of different movements that have incorporated ayahuasca into their doctrines and activities. Today there are several ayahuasca churches in Brazil that combine indigenous traditional beliefs and practices with Christian and African-Brazilian elements in their patterns of use. The three major churches are the Santo Daime, the Uniao do Vegetal (UDV), and Barquinha. The Church of Santo Daime was founded in the 1930s in the Brazilian rain forest. In its rituals, Daime, their name for ayahuasca, is consumed as a sacrament. The Daime is regarded as a divine being, or even as the ''Divine'' itself, and is believed to be the source of life, vitality, and health, on the one hand, and all knowledge and supreme wisdom, on the other. Another of these churches, the Brazilian UDV, a religious sect that uses ayahuasca (referred to as hoasca) as a sacrament, was founded in 1961. Today, the UDV numbers more than 7,000 members in 60 nucleos or churches. Members care for the Church's sick and elderly, provide food and shelter for women and children, and are actively involved in many ecological projects. Both of these traditions use ayahuasca at least twice monthly in ceremonial use, as does Barquinha (''little boat''), the smallest of the three congregations. Most recently, over the past few decades, another type of setting has developed for the use of ayahuasca that extends from South America to both Europe and North America. These are ceremonies, independent from any centralized organization, which vary in form and in the manner in which they are conducted. Ceremonial leaders use techniques borrowed from both the more traditional and the contemporary expressions of ayahuasca usage. In addition, and of particular importance to this paper, there is an increase in frequency of the occurrence of these rituals in both urban and rural settings throughout the Western world, led by a shaman or by local experienced guides.
SPIRITUAL BENEFITS
Over the past two decades, growing evidence has emerged that drinking ayahuasca in a ritualized context has benefits that are felt to be ''spiritual'' in nature by practitioners. In a study examining those who seek traditional use of ayahuasca,found that the motivations for attending these ceremonies were primarily focused upon ''issues of spiritual relations and development'. He found participants reported that their experiences resulted in an ''increased and enhanced awareness of their own self, having obtained insight into deeper levels of their being'' (p. 214). ''The ideas of contact with a sacred nature, God, spirits and plant and natural energies were expressed by many participants; others emphasized the importance of their personal spiritual development being promoted by the plant experiences'' (p 214). Those who seek spiritual insight through ayahuasca tend to find what they are looking for. Typically, those who drink the brew may feel that they are gaining access to new sources of knowledge and that the mysteries and ultimate truths of the universe are being revealed to them. This is often in addition to a drinker's experience, or encounter with the Divine. The visions encountered with ayahuasca are often reminiscent of those reported in the mystical traditions of different cultures throughout the ages. It is not for nothing that psychoactive plants have been called ''plants of the gods''. Investigators have found that not only do participants in ayahuasca ritual have spiritual experiences, but such experiences tend to shape their ongoing spirituality. The author of this article and his colleagues found that the positive peak experiences that participants experience in an ayahuasca ceremony ''lead to greater incorporation of the peak experiences into one's ongoing spiritual well being''.
PSYCHOTHERAPEUTIC BENEFITS
Along with facilitating access to spiritual domains, and creating states of consciousness felt to be ''spiritual'' by experients, there seems to be great promise for the use of entheogens such as ayahuasca in psychotherapy. It should be noted that these substances are not panaceas, but require work on the part of the user. The value of having entheogens as part of psychotherapy is that the work takes place on a different level. Alanstated that entheogens ''are useful to the extent that the individual can integrate what they reveal into the whole pattern of his behavior and the whole system of his knowledge'' (p.16). Chilean psychiatrist Claudioused harmaline, one component of ayahuasca, in analytic psychotherapy, claiming that 10 out of 30 patients diagnosed as ''psychoneurotic'' exhibited positive changes that would otherwise have been expected only after intensive psychotherapy. The potential found throughresearch led to several decades of exploration by other psychologists curious about the clinical application of ayahuasca in a Western context.reported that the ayahuasca ceremony participants were able to experience sadness, anger, and joy that they typically had difficulty accessing. Additionally, approximately 50% of the participants in thestudy reported experiencing personal reflections and insights. These types of experiences included the participants' examination of personal interactions from their past and reflections on their attitudes and beliefs. The significant and meaningful spiritual and mystical experiences resulting from participating in an ayahuasca ceremony can produce the desired affective expression thatstates patients seek in psychotherapy. Integrating ayahuasca ceremony into the psychotherapeutic process gives the patient an alternate perspective in examining unconscious, unexpressed affect. Examining the psychological effects of ayahuasca, Doering-Silveira et al. () compared ayahuasca-drinking adolescents to those in a control group for psychological symptomatology. Screening tests for major DSM-IV diagnoses were used to assess the participants' mental health. The researchers found that adolescents who drink ayahuasca were comparable in their DSM-IV profiles to those in a control group. Despite finding similar results, the study did show slight differences. Results showed that the ayahuasca group members were characterized by less anxiety, less body image dysmorphia, and fewer attention deficit disorders. In addition, the study found that ''ayahuasca using participants were considered to be more confident, optimistic, outgoing energetic, persistent, reflective, and scored higher than control measures of social desirability and emotional maturity'' (p.132). The researchers acknowl-edged that ''It is still unclear if the reported changes can be attributed to the effect of the substance itself or to the religious affiliating process'' (p. 132). Another study on adolescents and ayahuasca was conducted by Dobkin deexamining differences between users and controls on qualitative measures. Although there were no significant differences between the ayahuasca-drinking adolescents and the control group, the researchers found that the ayahuasca-drinking group seemed ''to be more responsible, respectful, and concerned about the welfare of others…The teens appear to be healthy, thoughtful, considerate, and bonded to their families and religious peers'' (p. 139). A clinical psychological examination of ayahuasca psychiatric diagnostic assessments revealed that, although an appreciable percentage of the long-term ayahuasca-using adult participants had manifested alcohol, depressive, or anxiety disorders prior to their initiation into an ayahuasca church, ''all disorders had remitted without recurrence after entry into the Uniao do Vegetal''. The researchers found that this change was particularly evident in the area of excessive alcohol consumption, where, in addition to the five participants who had diagnoses of prior alcohol abuse disorders, six additional participants reported moderate patterns of alcohol consumption that fell short of achieving actual psychiatric diagnostic status on a formal structured interview. After affiliating with the ayahuasca church, all 11 of these participants with prior involvement with alcohol achieved complete abstinence sustained over many years. The study also found that participants reported that they had undergone radical transformations of their behavior, attitudes toward others, and outlook on life beyond their decrease in alcohol use. Participants were convinced that they had been able to ''eliminate their chronic anger, resentment, aggression, and alienation, as well as acquire greater self-control, responsibility to family and community, and personal fulfillment through their participation in the ayahuasca ceremonies of the UDV'' (p. 94).Although the salutary effects of a strong group support system and religious affiliation cannot be minimized, it is not inconceivable that the long-term use of the ayahuasca itself may have had a direct positive and therapeutic effect on the participants' psychiatric and functional status. (p. 94) In the first report to focus on the cognition of long-term ayahuasca-using adolescents,found that those who use ayahuasca in a religious context did not differ significantly from those in the control group. The study examined adolescents who attended UDV churches in Brazil, comparing their results on various neurological tests to those in the control group consisting of adolescents who had never imbibed ayahuasca. The authors concluded they had found no evidence that ayahuasca has injurious effects on adolescents who participated with their families in ceremonial rituals using psychoactive substances. Furthermore, they stated ''we have been allowed access to study the effects and have found, at least in this pilot preliminary investigation, that ayahuasca did not have a toxic or deleterious effect on adolescent neurocognitive functioning'. In other research examining the psychological effects of ayahuasca, Hoffmann, Keppel-Hesselink, & da Silveiraexamined the effects of ayahuasca consumption on participants' EEG results. Despite being a neurological study, Hoffmann et al. concluded, ''ayahuasca opens up people to their unconscious feelings and memories and gives them an opportunity to explore new psychological insights'' (p. 29). Finally,concluded that those who drink ayahuasca on just one occasion tend to have positive spiritual experiences during ceremonies and afterwards, and then take these positive experiences and integrate them into their daily lives. These ayahuasca ceremony participants tend to, after their experience, be more empathic and feel more connected to others, nature and their sense of god or the divine. They are consistently shown to, in the short-term, feel healed, grateful and peaceful, with an increased sense of responsibility for, and reconciliation with, themselves, others, and the world. The data from this research indicates that these positive measures are clearly linked to experience of an ayahuasca ceremony, and reveals incentive for further investigation into ayahuasca's promise. (p. 133)
AYAHUASCA'S RISKS AND CHALLENGES
Given the many research findings related to the use of ayahuasca, from finding no physical or psychological harm in chronic use, to its benefits in spiritual inquiry and psychological growth, it is of no wonder that increased attention is being given to the brew by Western researchers and seekers alike. Despite these findings and extensive anecdotal reports of healing and transformation, there is concern about how this growing phenomenon could harm those Westerners who partake in the ayahuasca brew, unless guidelines are created to protect their physical, psychological and spiritual health. The movement of ayahuasca rituals from an Amazonian cultural context to a Western one creates the potential for serious risks to participants as this movement gains popularity in the West. It is only within the Amazonian indigenous cultures and syncretic Brazilian churches in which power hierarchies and traditional family-community structure exist that the current models of ayahuasca ritual have thrived. Although there are many aspects of these rituals that would benefit Westerners, it is important to realize how differences in culture are likely to require an adaptation and evolution when applied to new settings. In a detailed look into what is happening in ''ayahuasca tourism,'' Dobkin depointed to the health of Western users who participate in an unregulated and economically challenged Amazon region where charlatans and malevolent practitioners use the hallucinogenic brew to take advantage of high paying Western ayahuasca tourists. They discuss how the growing demand for ayahuasca has resulted in neither shamanistic practitioners nor their brews being regulated to a dangerous degree. They point out that many of these practitioners ''lack the experience, appropriate personality, and requisite training for this traditional healing work…nor are they aware of the important facts about drug interactions'' (p. 76). Going further they state ''at best, they are simply inept and rely on luck so as not to harm their clients. At worse, they fleece them out of substantial cash. Some of the women are seduced, raped, and discarded after their novelty to the healer wears off'' (p. 82). Their work calls for the regulation of the tourism industry centered around ayahuasca, that puts participants' well being at risk as they are actively preyed upon by ''neo-shaman'' looking for sex, money and power. Although their work and similar findings contain important contributions to the literature, I take the position that a significant number of more subtle, yet equally harmful psychological risks are involved in integrating ayahuascabased rituals into Western contexts, even if knowledgeable, trained and respected ceremony leaders are the ones sharing the brew. Ayahuasca rituals over the centuries have adapted to their indigenous cultural context to best serve those communities. With a rapidly growing diversity of people participating in these rituals, the slow refining process used to best suit the people and communities involved is not possible. With the import of the ayahuasca trade to North America, Europe and Australia, those participating in these ceremonies, even with well intentioned and trained ayahuasca ritual leaders, are at risk of harm.
PSYCHIATRIC AND MEDICAL RISKS
Because of the increased consumption of ayahuasca in the West, there is a need to acknowledge the medical, psychiatric, and psychological, risks involved in mixing the psychoactive chemicals of the brew. Psychiatric risks include the risks of combining ayahuasca with prescription medications, particularly the SSRI anti-depressants. In addition, individuals diagnosed with a mental health disorder or at high risk for one are taking a potent psychedelic and are putting themselves at risk for decompensation and the potential for mental and emotional stress. Experiences can bring up past traumas or can bring about new traumatic experiences that participants may not be able have the ego strength or emotional capabilities to work through without causing significant disturbances to themselves, their friends, and their families. Further research is needed in identifying the risks and benefits of different populations, including healthy populations, neurotic patients, and psychotic patients. Dobkin deshowed how ''uncontrolled use of the plants was precipitating [a] woman into a psychotic state'. This kind of experience is not for everyone, just as any psychospiritual practice may not be a good match for everyone. The hallucinogenic properties of the brew allow the ego's defenses to lower, facilitating investigation into oneself; however, this scenario can induce a rush of fear and paranoia, and psychotic states can result. Therefore it is suggested that only healthy people would find the most value participating in an ayahuasca ceremony. Determining who can safely participate in these ayahuasca rituals will continually need to be re-addressed as further research is conducted.
SPIRITUAL RISK
In a time of postmodern and New Age hodgepodge spirituality in which Westerners often reject their Judeo-Christian past, and end up picking and choosing from different religious and mystical traditions to create an idiosyncratic spirituality, it is of great importance that the implications of introducing such a powerful shamanic tool into the West are examined. Often spiritual seekers, in an effort to escape their own psychological challenges and traumas of their past, turn towards spirituality to find answers.explained that a ''genuine encounter with the Ultimate does not guarantee a genuine spirituality. The experience may be authentic, but how authentic their spirituality was depends on what those who had the experience do with it'' (p. xii). John, in his examination of the Eastern religious movement into the West termed the phenomenon ''spiritual bypass,'' explored the idea that people often turn to and get absorbed into an unhealthy relationship with spirituality to avoid examining their psychological issues. He describes spiritual bypass as, the tendency to avoid or prematurely transcend basic human needs, feelings, and developmental tasks…they wind up using spiritual practices to create a new 'spiritual' identity, which is actually an old dysfunctional identitybased on avoidance of unresolved psychological issues -repackaged in a new guise. (p. 12) Welwood's concern about spiritual bypass expresses the sentiment that we are only successful at finding psychological health if we truly unravel our unhealthy personality patterns and/or have a history of positive psychological development. Participating in an ayahuasca ceremony in and of itself creates a risk of falling into old patterns, newly masked. This idea flies in the face of many of those who blindly rush towards the potential spiritual and psychological benefits discussed earlier. As Welwood illuminated, much has been learned from the challenges of the movement of Eastern religions to the West that those seeking enlightenment in ashrams and on mountaintops may sometimes merely push their pain into the unconscious while donning a shiny new spiritual practice veneer. Immersing oneself in a community based on ayahuasca rituals can create many similar blind spots to self-growth and wellbeing. Furthermore, one must acknowledge the possibility that spiritual seekers who pursue ayahuasca rituals may be looking for answers to some of their life's challenges in the bottom of a glass of a hallucinogenic tea. While studieshave shown that profound insights are possible during ayahuasca ceremonies, there are no studies of Westerners to date that show that these insights can be integrated into the patient's ongoing life in order to make the positive changes they are seeking. With no ongoing treatment or continuity of care, not only might patients find it difficult to integrate these insights into their life, but if the ceremony breaks down psychological defenses and results in opening up trauma that is left unresolved, these patients are at risk of developing new or exacerbating old psychological difficulties. Through my clinical work, I have discovered that many Western participants in ayahuasca ceremonies seek out the weekend long spiritual retreats typical in the West, for similar reasons that Fotiou (2010) has found in shamanic tourism -for self transformation, healing, accessing the sacred, etc. They end up depending on the retreats for this type of environment and seek out ceremonies during which they may connect to the medicine, sometimes several dozen times per year. As discussed elsewhere in more detailand seen through my clinical work with patients, some of these individuals often find themselves coming back for more insights, connection with alleged spirits, and alleged spiritual healing in a compulsive way. This ceremony-craving behavior is the result of a co-dependence on the ayahuasca rituals and its components, which is a form of what could be called spiritual addiction. It is a way in which the person uses an external object as a soothing coping mechanism. This will likely fail repeatedly as the patient will become psychologically dependent on the ayahuasca to achieve these visions, feelings, and insights. Despite the sense of connection that I previously reported in many ayahuasca ceremony participants, I have observed in some patients in my clinical practice a sense of spiritual narcissism, a phenomenon similar toobservations when eastern religions moved to the West. Individuals become so deeply involved in the spiritual path with the ceremonies that they become unaware of the impact of their spiritual pursuits. Through my clinical practice I have observed participants who do not have compassion for others who do not share the ideology of the community. Other people have pushed aside their life's work and their loved ones in order to spend more time drinking ayahuasca in ceremony to connect with what they consider to be ''the spirit world.''
ETHICAL AND LEGAL CHALLENGES
One of the greatest challenges of the movement of ayahuasca culture to the West is the movement of a tradition rooted in psychoactive substances and shamanic community leaders to ones with vastly different contemporary and historical cultural values. In a risk similar to the challenges of adopting Eastern guru-based practices in the West, the ayahuasca ritual leader's position of power in combination with the psychoactive brew can create many challenges. An ayahuasca ceremony for the ayahuasca tourist costs from next to nothing in its indigenous setting all the way up to $200 USD in the Amazon and $500 USD per ceremony in Western countries. Ayahuasqueros are in the center of power, of psychoactive substances, and of wealthy and devoted participants who often see the brew as a means of connecting with the Divine. This often leads to participants who idealize the shamanic practitioner, sometimes falling in love and occasionally developing a sexual relationship with him or her. The interpersonal dynamics and energy between the practitioner who is conducting an ayahuasca ritual and the participant can cause significant harm in the participant when not handled appropriately. Ayahuasca ceremony leaders often come from other Amazonian cultural traditions and are rarely trained in the knowledge of transference and countertransference issues -terms used in psychotherapy to describe the unconscious projections of energy between patient and therapist. This knowledge is necessary in order for ayahuasca ritual leaders to navigate these powerful energies within a culturally appropriate Western framework. As discussed in more detail elsewhere, it is not uncommon that well-established and seasoned ayahuasca ritual leaders demonstrate countertransference towards the participants in their circles. The ayahuasqueros may end up superimposing their own agenda on the client, claiming that the client needs to go through certain types of intense experiences, some of them sexual in nature. Some ritual leaders have been known to project erotic fantasies into their work with participants. Although often not consciously wielding their power over the participants in drug induced states, sexual relationships are quite common between healers and participants during rituals and sometimes continue on an ongoing basis. Strong feelings of the ayahuasca ritual leader can emerge in other ways as well. Leaders can be supportive or punishing towards certain of the participants' reactions to their action, the effects of the brew, or the ceremony in general. Ritual leaders may project their feelings of anger, disappointment, shame, or guilt onto participants if they do not act according to expectations. Clients can also idealize the leaders losing their original intention for participating in the rituals by focusing more attention and energy on the leader than on their own growth and development. Regardless of the setting, ayahuasca leaders have been known to be attached to certain ideologies and dogmas that are entwined in their traditions. It is often in these cases that ceremony leaders with little understanding of how their own personal reactions can be psychologically harmful to the participants can do a great disservice to those they attempt to heal. Another challenge to the healing potential of ayahuasca rituals is a concern that it is mainly through suggestion that participants feel any healing benefit. Participants in the ayahuasca ceremonies in thestudy were told beforehand by the ceremony organizers that they were participating in a healing ceremony, so it is not surprising that this was a common theme discussed by participants. Within the contemporary psychotherapeutic context, it is believed that external demand characteristics do not produce psychological growth, but healing comes through self-discovery. It is questionable whether or not the healing that occurs during ayahuasca rituals is generated through selfexploration or merely imposed on the participants during a trance state by the ritual leader. Within the Western framework of psychological healing, the therapist creates a safe container by examining his or her countertransference issues and keeping any idiosyncratic or impulsive feelings from entering the room or the group. A well-developed theory regarding how the ayahuasca ceremony leader relates to participants as part of the healing process would be useful in this exploration. Otherwise, without this relational agreement, negative results can occur, causing pain to the participant. For example, if the ceremony leader prefers hearing about one type of experience and not another, then the result becomes conditioned, and little, if any, growth can occur. A final consideration involves the regulation of ayahuasca. In the countries of the Amazon (principally Brazil, Peru, and Ecuador), the use of ayahuasca, whether in the indigenous context or in the religious contexts described earlier, is legal. In the Western world, the situation is not clear. Although UDV's right to use ayahuasca has been affirmed by the U.S. Supreme Court, Dimethyltryptamine, in itself, remains a Schedule I substance in the United States, which makes it illegal for administration and consumption. Regardless of whether or not there is ambiguous legal status there are no standards (or protocol) of how ayahuasca ceremonies are to be safely and effectively conducted, nor any ethical guidelines for how ayahuasca ceremony leaders should work with their participants in any country. There are many disparate ceremony leaders from various cultural traditions, and different schools of thought, each with idiosyncratic variations on ceremonies that make standards and regulations of ayahuasca ceremonies and ceremony leaders' conduct difficult, if not impossible, to maintain. Furthermore, because of the great variability within ayahuasca ceremonies and ceremony leaders right now, there is no current protocol on how ayahuasca ceremonies could be integrated as a beneficial part of psychotherapy, counseling, or spiritual development.
CONCLUSIONS
The growing evidence of the positive benefits of drinking ayahuasca has led to a surge in use from its original base in South America to ritual leaders traveling worldwide conducting ceremonies with the brew. However, these benefits do not come without serious risks involved. There are many precautions that should be taken on order to insure the protection of ayahuasca ritual participants as this indigenous shamanic tradition makes its way into the Western world. The following list is by no means exhaustive, as it is not meant to make recommendations beyond the author's field of expertise.
EDUCATION
It is of increasing importance that the public needs to be educated about the traditional use of ayahuasca in both church and indigenous settings, so that they can be well-informed about making a decision whether or not to participate in these rituals. Too often participants blindly trust ayahuasca ritual leaders and place their medical and psychological well-being into the hands of strangers. The growing body of knowledge gathered by seasoned ayahuasca communities and academia needs to be utilized to educate naı ¨ve newcomers about the psychological and spiritual risks and benefits of working with ayahuasca. Creating a cross-cultural document about the medical risks involved in contraindicated medicines and foods and sharing the document with pertinent forums and centers could prevent unnecessary hospitalizations and deaths. Additionally, by educating those interested in participating in ayahuasca rituals regarding the traditional uses of the brew, the cultures in which the rituals originated and the cosmology of the traditions, there would likely be an increase in seriousness, reverence, structure, and cohesive community support with contemporary rituals. Simultaneously, education of this sort would likely decrease the use of ayahuasca ritual as ''spiritual recreation,'' as well as the number of unskilled leaders who are not prepared to handle the challenges that manifest during ceremonies.
PSYCHOTHERAPEUTIC INTEGRATION
By combining ayahuasca rituals with Western psychotherapeutic models, participation in these traditions could be brought towards a healthy Western psychospiritual healing practice. Takiwasi, a center that combines ayahuasca and other indigenous healing tools with psychotherapy, is one such model that has been treating patients suffering from severe drug addiction for the past 25 years in Tarapoto, Peru. Through such integration, the psychological health of participants could be safeguarded so that during psychotherapy sessions they could explore potential spiritual bypass and investigate shame or guilt that may have come up in transferencecountertransference issues within the ayahuasca ritual context. Standing alone, the ayahuasca ceremony has the potential of creating meaningful and significant mystical and spiritual states of being; however, combined with psychotherapy, specific qualities of such states can further promote the essential goals that have been proven to be effective in the Western psychotherapeutic modalities. Another benefit of integrating psychotherapy and ayahuasca rituals is that it would allow licensed and experienced mental health professionals to help screen, prepare potential crisis intervention, and work with emerging traumas and post-ceremony integration. The work that can be done with an experienced licensed mental health professional begins with preparing the client with the potential of emotionally challenging material that may come up during the ceremonies. The clinician can also work with the client to prepare an intention as a focusing of the client's psychospiritual needs at the time of the ceremony. Doing so may enable the client to guide the direction of the experience towards gaining insights into pertinent areas that are challenging the client's presenting problem or development. To achieve the greatest benefit from an ayahuasca ceremony, it would be valuable for the client to have participated in therapy for some time. One of the key benefits that could be found in integrating psychotherapy and an ayahuasca ritual would be that the previous therapeutic work could be brought into the ayahuasca ritual for further investigation, the experiences could be further explored, and the interpretation's validity tested in the dreamlike states of the ayahuasca experience. The client could prepare for the ayahuasca ritual work by setting an intention to further explore themes that have come up during therapy and could examine any resistance recognized in the consultation room during the ceremony. The clients who might be working on several themes in their ongoing therapy could determine with appropriately trained clinicians which ones might be most effectively explored during an ayahuasca ritual. During ayahuasca rituals it would be valuable to have a well-trained clinician available for participants who were overwhelmed, agitated, and/or unstable during the experience. It is possible for participants in ayahuasca ceremony to be in crisis due to fear and anxiety over the altered state of consciousness or the psychological material that comes up. One major psychological service that can be employed during these ceremonies is having people trained in crisis intervention available. Often in the Western context, ceremonies have ''sitters'' assisting participants who are confused or disoriented. Sitters could be trained in relaxation techniques, empathic listening, and simply being present to alleviate some of the stressors that occur during these crises. Few sitters are trained in mental health procedures and many are inadequately able to assist the participants or work with the client to use the psychological material that is coming up for the client to their benefit. In the traditional ayahuasca context, the ritual leader, or ayahuasquero uses icaros (songs), native tobacco, and other shamanic tools to assist the struggling participant. However, this is part of a larger context of community support found in the traditional culture. Although these tools can and should be utilized in the ceremony, it is not unheard of that individuals sometime seek more Westernoriented tools to aid in the process during ceremony. A cliniciantrained in integrating spirituality and psychotherapy, is helpful to have on hand to help individuals work through their experience if needed in the moment. Most contemporary psychotherapeutic frameworks state that a therapeutic relationship is necessary for the client to experience sincere relatedness to others and to develop a stronger sense of oneself. Therefore, the sense of interconnectedness that participants feel with this type of work could be supplemented with such psychotherapeutic techniques to create complemen-tary benefits. Although the sense of connection sometimes felt during experiences with ayahuasca can have healing benefits for participants, there is often no ongoing concrete relationship that is deliberately occurring during the group rituals. This causes questions of the sustainable impact of these feelings on contemporary Western psyche. By bringing the feelings of connection to a therapeutic relationship alongside participation in an ayahuasca ritual, they could be further explored and integrated. The integration of ayahuasca ceremony into a framework of ongoing psychotherapy would create a greater sense of safety for the client when participating in an ayahuasca ritual. This would allow the participant to explore a situation that often brings up fear, feeling fully prepared. It would also allow the client to share his or her experiences with the therapist postceremony. Lastly, this rapport would create an opportunity for the therapist to make interpretations more freely while the ceremony experience is more temporally and affectively grounded within the client. After participating in the ceremony, the affective experiences and the insights that may have been obtained through the ayahuasca ritual could be interpreted, worked through, and integrated into the ongoing therapy. In order to avoid the pitfalls of spiritual bypass, numbing distraction, and egocentric self involvement, it is valuable for a trained clinician to work with the participants of the ayahuasca ceremony afterwards in order to help them use the material to interface with their intentions, spiritual growth, interpersonal connections, and psychological development. Welwood's concern about spiritual bypass expresses sentiments similar to the psychotherapy model which states that we are only successful at finding health if we link affective expression and interpersonal connection with reality, not fantasy. When clients participate in an ayahuasca ceremony, psychotherapy creates an opportunity for the therapist and client to work through any of the breakthroughs that occurred during the ceremony to explore whether they are founded in fantasy or reality. As ayahuasca rituals are transferred into a Western culture that does not automatically support them, a means of integration is needed in order for clients to take the lessons from the ritual and incorporate them into their daily life. Because these rituals only happen sporadically in the West and the ritual leaders are often traveling between communities, there is often a feeling of longing for the next opportunity to connect with the experiences attached to earlier ayahuasca experiences. By exploring the insights, wisdom, and healing that have come out of ayahuasca ritual experiences regularly in psychotherapy, the feelings of connection, growth, strength, will, and purpose that are often reported can not only be integrated, but a tendency for dependence on the ayahuasca rituals for such states can be extinguished.
ETHICAL GUIDELINES
In addition to education and integration into Western psychotherapy, individuals would be protected from potential risks if ayahuasca ritual communities created ethical guidelines stating the proper use of the sacrament and conduct of participants and ceremony leaders. The educational movement and the collaboration with mental health professionals will only be possible through building communities and community networks to share knowledge and set standards of care during ayahuasca rituals. This is a departure from the rivalry that is commonplace between ayahuasqueros in the indigenous setting, where shamans speak badly of each other and are sometimes involved in combative sorcery (Dobkin de. The building of these collaborative relationships between Western communities and the ayahuasca ritual leaders with whom they work will allow proper dissemination of the educational materials, as well as medical and psychological screening standards. Ayahuasca ritual leaders in the Western setting need to be held accountable for these outcomes because if they are not embedded in a community in which there is a continuum of feedback and accountability, they can take advantage of and abuse ritual participants and continue on to their next destination unchecked. In a similar vein to Dobkin de Rios and Rumrrill's (2008) work, I am proposing that by setting up intra and intercommunity dialogue around ethics and monitoring the reputations of different ritual leaders the community can be protected from predators. Those ritual leaders who need to work on issues that come up with Westerners can receive the feedback they need in order to obtain further training or do personal work.writes that Eastern religion teachers in the West had ''to deal with the underlying roots of problems in themselves, whether old wounds, cultural and family history, isolation, addiction, or their own grandiosity. In some communities masters have ended up attending AA meetings or seeking counseling. In others, decision-making councils were formed to end the isolation of the teacher'' (p. 264). Setting up ethics for the communities and ayahuasca ritual leaders also would be beneficial so that the powerful temptations of power, sex, and money can be discussed transparently and leaders could be held accountable. Currently, there are no cross-cultural ethical standards by which ayahuasca ritual leaders must abide. They receive no coursework in ethics, nor are they required or advised to go through any type of personal psychotherapy, consultation, or supervision to examine any personal issues that may come up in the work they conduct. Some groups have already begun to explore this idea such as the Montreal chapter of the Santo Daime (Ceu do Montreal Santo Daime Church ofand the Indigenous Doctors Union Yageceros of the Colombian Amazon (Unio ´n de Me ´dicos Indigenas Yageceros de la Amazonia. The UDV also has a 50 year tradition of monitoring the ethical conducts of their leaders (mestres). More dialogue needs to be created not only within communities, but between communities so that those seeking guidance and healing from this plant medicine are adequately protected when entering such powerful and vulnerable states of consciousness. Dobkin de Rios and Rumrrill (2008) make a strong case for the dangers involved in working with inexperienced or charlatan neo-shamans, those who have not studied the depths of the tradition and are solely seeking money, sex, and/or power. Although their investigation is extensive, there is an equally important need for the examination of well established and respected ayahuasqueros and other ayahuasca ritual leaders, whose practices and/or personal beliefs may be in conflict with participants from urban or international cultures, thus causing unintended harm to their patients. A well-developed theory regarding how the ayahuasca ceremony leader relates to participants as part of the healing process would be useful in the exploration of transference and counter-transference issues. If the participant knows that their emotions are accepted within the therapeutic relationship, the client can move from the fantasy that they have been holding onto -that affective expression yields pain and tension -to a realistic observation that connection with others through affective expression can exist. In this global age it is no longer acceptable to claim naivete ´or tradition when intentionally crossing cultural boundaries as a healer. Until we begin to look at all of these challenges in detail, the full range of potential benefits cannot be considered inside a vacuum. The community of those who participate in ayahuasca rituals must take it upon themselves to protect themselves as individuals and a community from potential harms so that they can explore the depth and beauty of the healing potential of the sacred brew.
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