Amazonian vegetalismo and ayahuasca ceremony

1. Introduction

Version followed: the psychotherapist's own culturally responsive work alongside the tradition, built on the DSM-5-TR Cultural Formulation Interview (APA core version), the Chacruna Institute's Ayahuasca Community Guide for the Awareness of Sexual Abuse (first version 19 November 2018, as currently posted), the statement of the Shipibo-Konibo healers' union ASOMASHK with the council COSHIKOX (2019), Peru's National Institute of Culture Resolution No. 836/INC (24 June 2008), and, for vegetalismo, Luna (1986) as summarised in secondary sources.

What it is. This entry is a set of living healing traditions, not a therapy. A psychotherapist does not perform it. The guide covers how to work, as a psychotherapist, with clients who come from, take part in, plan to take part in, or were harmed in these settings.

Vegetalismo is described as a mestizo healing practice of the Peruvian Amazon. Its healers, vegetalistas, say their healing knowledge and power come from plants of the region, and many hold that this knowledge comes through ayahuasca. Many vegetalistas are Catholic. Scholars describe the practice as strongly shaped by Indigenous Amazonian cosmology, but more urban and more focused on individual healing than upper-Amazon Indigenous shamanism. [source: https://en.wikipedia.org/wiki/Vegetalismo, summarising Luna 1986] Edward MacRae's survey of Western Amazonian shamanism, drawing mainly on Luna, likewise describes vegetalistas as mestizo healers who hold that the spirits of certain plants are their teachers, with ayahuasca giving first access to them, and notes that the weight of Christian elements varies between older and younger healers. [source: https://www.neip.info/downloads/edward/chapter1.htm] [uncertain: secondary summaries of Luna 1986]
Icaros are described in this scholarship as healing songs that healers say they receive from plant spirits. Dietas are described as long periods of seclusion and restricted diet through which, practitioners say, a healer builds a relationship of trust with the plants. These are the tradition's own concepts, given here as practitioners and scholars attribute them; this guide gives no songs, schedules or procedures. [source: https://en.wikipedia.org/wiki/Vegetalismo] MacRae, summarising Luna, reports that vegetalistas describe keeping the diet as the road to their knowledge. [source: https://www.neip.info/downloads/edward/chapter1.htm] [uncertain: secondary source]
Indigenous traditions. Many Amazonian peoples hold their own ayahuasca traditions. Peru declared "the knowledge and traditional uses of Ayahuasca practiced by the native Amazon communities" Cultural Patrimony of the Nation in 2008, to protect the "traditional use and sacred character" of the ritual and distinguishing it from Western uses that are "out of context, consumerist" and commercial. [source: https://www.bialabate.net/blog-archive/news/ayahuasca-is-declared-cultural-patrimony-of-peru] The Shipibo-Konibo healers' union ASOMASHK states that ayahuasca and the icaro are cultural heritage of the Shipibo-Konibo nation under that resolution. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019]
Ayahuasca churches (Santo Daime, União do Vegetal and others) are covered in guide 116 of this domain. Psychedelic-assisted therapy and integration in clinical settings are covered in Domain VII.

How change happens, as the tradition holds it. In vegetalismo, healing power is attributed to the healer's relationship with plant and protective spirits, and illness may be attributed to sickness or to harm caused by sorcery. [source: https://en.wikipedia.org/wiki/Vegetalismo] [uncertain: secondary source] These are the tradition's own explanations, neither confirmed nor dismissed here. How change happens in the psychotherapist's work: understanding the client's own explanatory model, keeping the client physically and psychologically safe, collaborating with legitimate community authority when the client wishes, and helping the client make meaning of what happened. [synthesis]

Who holds authority.

Vegetalistas are not tied to one Indigenous people, and no community formally initiates them. They come to the work by personal choice or vocation, and their reputation grows within their community. [source: https://en.wikipedia.org/wiki/Vegetalismo] MacRae, drawing on Luna, also describes initiation as a personal, gradual process without a public recognition ritual, often beginning with a serious illness. [source: https://www.neip.info/downloads/edward/chapter1.htm] [uncertain: secondary source] Practically, there is no licensing body; authority is reputational and local. [synthesis]
Among the Shipibo-Konibo, ASOMASHK (Union of Onanyabos and Traditional Medical Practitioners of the Shipibo Konibo) says it coordinates maestras and maestros, is legally registered in Peru, and acts with COSHIKOX, the Shipibo autonomous governing council. It asks that organisers of ancestral-medicine events not connected with it, especially foreign organisers, obtain its consent. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019]
States: Peru's cultural authority made the 2008 declaration. Legal regulation of the brew varies by country (see the legal-status intervention). [source: https://www.iceers.org/ayahuasca-legal-status/]
No health authority has approved ayahuasca or DMT as a medical therapy. [source: https://www.drugscience.org.uk/drugs/ayahuasca]

2. Framework

The tradition has its own course of healing and apprenticeship, held by its practitioners and not described here. The phases below are the psychotherapist's work. They are a [synthesis] built on the CFI and the community and safety sources cited; no source sets session numbers.

Phase A. Engagement and cultural assessment (1–3 sessions).

Goals: learn what ayahuasca, vegetalismo or a healer means to this client; their community, faith and identity; their explanatory model; past and current help seeking.
Format: individual, 50–90 minutes; core CFI (16 questions) in the first session, with supplementary modules as needed. The CFI is meant for "any clinician" with "any individual in any care setting." [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf] Time needed: the DSM-5 field trial found later interviews "required less time"; a typical duration in minutes is [uncertain]. [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]
Move on when: you can state the client's own name for the problem, their view of its cause, and what help they want, in words the client agrees with.

Phase B. Safety and risk review (alongside Phase A; repeat before any planned participation).

Goals: screen for psychiatric risk (personal or family history of psychosis or mania), medical and medication factors to route to the prescriber, sexual-safety and setting risks, legal exposure, and safeguarding concerns.
Format: within ordinary sessions; with consent, liaison with GP, psychiatrist or prescriber.
Move on when: risks are documented; medical questions are with a prescriber; the client has the information to decide; any safeguarding duty has been acted on.

Phase C. Collaboration (only if the client wishes, and only with community-sanctioned practitioners or organisations).

Goals: coordinate with a legitimate healer, community organisation, church or cultural broker, with explicit consent and clear limits on what is shared.
Move on when: roles are agreed and written in the record, or the client declines.

Phase D. Integration and treatment (variable; often 4–12 sessions, [synthesis]).

Goals: help the client make sense of ceremonial experiences in their own frame; treat any disorder present; process harm if it occurred. Clinical psychedelic integration methods are in Domain VII.
Move on when: the client's functioning and distress are improving on agreed measures, and the meaning of the experience is the client's own, not imposed.

Phase E. Crisis pathway (at any point). Acute psychosis, mania, suicidality, sexual assault, or medical symptoms after a ceremony move straight to emergency assessment and safeguarding (see Sections 4 and 5).

3. Guiding principles

You are alongside the tradition, not inside it. Practical meaning: never offer, arrange, lead, or advise on ceremonies, brews, purges or dietas; your inventory is assessment, collaboration, integration and safeguarding. [synthesis]
Attribute, do not adjudicate. Practical meaning: describe plant spirits, sorcery, icaros and visions as the client and tradition hold them ("in your understanding..."), neither affirming nor dismissing. [synthesis]
Name who holds authority. Practical meaning: for Indigenous traditions, the community and its organisations (for example ASOMASHK and COSHIKOX for the Shipibo-Konibo); for vegetalismo, local reputation; for churches, the church. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019]
Respect what communities ask of outsiders. Practical meaning: the Shipibo-Konibo statement objects to appropriation of ancestral knowledge and asks outside organisers to seek ASOMASHK consent; do not steer clients towards retreats or events, and help clients weigh these concerns if they raise them. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019]
Neither pathologise nor miss illness. Practical meaning: visions and altered states within a broadly accepted ceremonial practice are not by themselves symptoms; trance or possession states that are involuntary, unwanted and outside accepted practice may be disorders (ICD-11 6B62, 6B63). [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]
Psychiatric history matters. Practical meaning: psychotic episodes after ayahuasca or DMT appear rare, but most reported cases involved a personal or family history of psychosis or mania, other drug use, or unsupervised settings. [source: https://www.iceers.org/?p=39998]
Never advise on medicines. Practical meaning: name the interaction concern and route it to the prescriber; do not suggest starting, stopping, tapering or timing any medicine. Drug Science notes that prescribed medication should not be stopped without medical advice. [source: https://www.drugscience.org.uk/drugs/ayahuasca]
Abuse is never the participant's fault. Practical meaning: whatever the setting or the client's choices, respond to sexual abuse as abuse; the Chacruna guide states "Abuse is never your fault." [source: https://chacruna.net/?p=8765]
Power imbalance shapes consent. Practical meaning: in altered states and with a healer "in a position of power and responsibility," apparent consent may not be free; assess, do not assume. [source: https://chacruna.net/?p=113165]
Evidence is preliminary. Practical meaning: present research honestly as investigational; all clinical uses remain investigational, off-label or anecdotal. [source: https://www.drugscience.org.uk/drugs/ayahuasca]
Consent and confidentiality govern collaboration. Practical meaning: contact a healer, church or community organisation only with the client's explicit, specific consent. [synthesis, consistent with collaboration models such as COSIMPO: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]
Touch: none beyond ordinary professional norms; never sexual. Practical meaning: you do not do bodywork or ceremonial touch; if a client describes touch in a ceremony, explore consent explicitly. The Chacruna guide notes healers do not need to touch intimate areas in the healings it names. [source: https://chacruna.net/?p=8765]
Hold the colonial and economic context. Practical meaning: ayahuasca tourism, commercialisation and appropriation affect Indigenous healers and communities; this may be part of a client's distress or ethical questions. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019] [source: https://chacruna.net/?p=8765]

4. Intervention inventory

All interventions below are the psychotherapist's own. None involves conducting, arranging or advising on a ceremony, brew, purge or dieta. Example language is illustrative unless quoted.

4.1 Cultural humility and self-examination

Purpose / when: before and throughout work with any client involved with ayahuasca or vegetalismo; especially when you notice strong enthusiasm or strong scepticism about psychedelics, "shamans" or the Amazon. [synthesis]
Steps: (1) Write down your own beliefs about ayahuasca, Indigenous healing and psychedelics, including romantic images; the Chacruna guide calls seeing shamans as superhuman "erroneous and dangerous." [source: https://chacruna.net/?p=8765] (2) Note what you know only from media or tourism marketing. (3) Identify the client's likely tradition (mestizo vegetalista, a named Indigenous people, a church, a Western neoshamanic or retreat setting) and avoid treating these as one thing; the Chacruna guide lists Indigenous, mestizo, religious, therapeutic, neoshamanic and New Age settings as distinct. [source: https://chacruna.net/?p=8765] (4) Arrange supervision or consultation with a cultural broker if the client is from an Amazonian community. [synthesis]
Example language (illustrative): "I know something about ayahuasca from research and news, but not how it is for you or your family. I'd like you to teach me where I'm wrong."
Watch for: your own urge to recommend or warn off ceremonies; using "shaman" for every practitioner; assuming a Peruvian client uses ayahuasca, or that a European client's retreat was "traditional." Working: the client corrects you readily and brings more detail over time.

4.2 Asking about ayahuasca, healers and ceremonies without judgement

Purpose / when: at intake and whenever help seeking comes up; clients may withhold involvement for fear of disapproval, stigma or legal exposure. Fits CFI past help seeking (Q12) and current preferences (Q14–15). [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: (1) Ask routinely, as you would about any help sought. (2) Ask what kind of setting (family or community healer, urban practitioner, Indigenous community, church, retreat, private ceremony abroad or at home). (3) Ask what it was for and what the client made of it. (4) Ask about plans to go again. (5) Record in neutral language and explain confidentiality and its limits, including on legal matters. [synthesis]
Example language (illustrative): "Many people see healers, churches or plant-medicine ceremonies as well as therapists. Have you, or has anyone in your family? What was it like?"
Watch for: guardedness about legality; shame after a bad experience; idealisation that makes risks hard to discuss. Working: the client volunteers details of healers, settings and plans.

4.3 Core Cultural Formulation Interview (DSM-5-TR)

Purpose / when: first or second session for any client whose problem, help seeking or identity involves ayahuasca, vegetalismo or Amazonian heritage. It clarifies the problem from the perspective of the person and their social network: its meaning, sources of help and expectations of services. It supports clinical understanding and is not meant to be the only basis for a diagnosis. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Steps: follow the APA form's four domains in order, in your own words: (1) cultural definition of the problem (Q1–3); (2) cultural perceptions of cause, context and support (causes Q4–5, stressors and supports Q6–7, role of cultural identity Q8–10); (3) self-coping and past help seeking (Q11–13, including barriers); (4) current help seeking (preferences Q14–15; clinician–patient relationship Q16, e.g. perceived racism or language barriers). Use the official form (free to reproduce for clinical use; modifying or translating needs APA permission). [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] With a family member or friend, use the Informant Version (17 questions). [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]
Example language (illustrative): "In your own words, what has been going on?" ... "What do you think is causing it? What do people in your family or community say?" ... "Is there anything about my background, or the language we're using, that could make it hard for us to work together?"
Watch for: the client describing the problem in spiritual or plant-related terms (e.g. sorcery, a broken dieta, a spirit encounter); write these down in the client's words. Working: you can state the client's own name and cause for the problem and they agree with your summary.

4.4 CFI supplementary modules

Purpose / when: for depth after the core CFI, or as stand-alone tools at first evaluation, later, or repeatedly. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]
Steps: choose from the 12 modules: Spirituality, Religion and Moral Traditions (for Catholic, evangelical, Indigenous, church or neoshamanic frameworks); Explanatory Model; Cultural Identity (mestizo, Indigenous, migrant, mixed identities); Coping and Help-Seeking (healers, churches, retreats, biomedical care); Immigrants and Refugees (for clients from Amazonian countries); Social Network; Psychosocial Stressors; Patient-Clinician Relationship; Level of Functioning; School-Age Children and Adolescents; Older Adults; Caregivers (given to the caregiver). [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf] The core form indicates which module expands each subtopic.
Example language (illustrative): "You mentioned the plants as teachers. Can we spend some time on how your spiritual life and this practice fit together?"
Watch for: overload; spread modules across sessions. Working: the formulation now includes faith, identity and help-seeking networks the client recognises.

4.5 Exploring the explanatory model (Kleinman)

Purpose / when: whenever the client's understanding of illness differs from yours, e.g. attributing illness to sorcery, plant spirits or a ceremony gone wrong. Source: Kleinman, Eisenberg and Good (1978), Annals of Internal Medicine. [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]
Steps: ask, in your own words, the eight explanatory-model questions: what the client calls the problem; what caused it; why it started when it did; what it does and how it works; how severe it is and how long it will last; what treatment they think they should receive; the chief problems it has caused; what they fear most. [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf] Then compare with your formulation and negotiate a shared plan. [synthesis]
Example language (illustrative): "What do you call what happened to you after that ceremony? What do you think caused it?" ... "What are you most afraid of?"
Watch for: fear of sorcery or of having offended a healer or the plants; family disagreement about cause; the client testing whether you will mock the explanation. Working: the plan includes both the client's and your understanding, and the client follows it.

4.6 Cultural concepts of distress

Purpose / when: when the client uses an idiom, explanation or syndrome from their culture. DSM-5-TR says cultural concepts of distress include "idioms, explanations or perceived causes, and syndromes," and revised its examples to avoid stigmatising or generalising language. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]
Steps: (1) Ask what the term means to the client and who in their community recognises it. (2) Check whether it matches a DSM-5-TR concept; for Latin American clients, susto and nervios are among the listed concepts. [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf] (3) Treat local Amazonian concepts of harm by sorcery or spirits as perceived causes in the client's model, not as DSM entities. Specific Amazonian terms are not in the DSM list. [uncertain] (4) Assess separately for any disorder. [synthesis]
Example language (illustrative): "When you say you were given susto, what does that mean for you, and who would know how to help with it?"
Watch for: translating the concept straight into a diagnosis; or ignoring real symptoms because a cultural label exists. Working: you can describe the concept in the client's terms and also state whether a disorder is present.

4.7 Distinguishing ceremonial experience from psychosis, mania or dissociative disorder

Purpose / when: when visions, spirit contact, altered identity or unusual beliefs appear before, during or after ceremonies.
Steps: (1) Establish context: was the experience within a broadly accepted collective practice? Dissociative trance is not diagnosed when it is "a normal part of a broadly accepted collective cultural or religious practice." [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574] (2) Ask whether the state was voluntary and wanted, how long it lasted, and whether it ended as expected; ICD-11 trance disorder (6B62) and possession trance disorder (6B63) require states that are involuntary, unwanted and outside accepted cultural or religious practice, with distress or impairment. [source: https://www.findacode.com/icd-11/code-1807490186.html] (3) Look for persisting features after the acute effects end: disorganisation, persistent delusions, reduced need for sleep, pressured speech, risk behaviour. (4) Ask about personal and family history of psychosis or mania and other drug use; these were the main features of reported cases. [source: https://www.iceers.org/?p=39998] (5) Consult a cultural broker or a community member the client trusts on what is normative. (6) Refer for psychiatric assessment when doubt remains. [synthesis] Note: a DSM-5-TR note on culturally sanctioned beliefs versus delusions is widely cited, but its exact wording is not sourced here [uncertain].
Example language (illustrative): "In your community, would others recognise what you saw that night as part of the ceremony? Has anything changed in how you sleep, think or feel since then?"
Watch for: symptoms continuing days after a ceremony; family saying the person "is not themselves"; manic signs. Working: a clear, shared decision on whether this is normative experience, distress needing integration, or disorder needing treatment.

4.8 Medical and medication factors: route to the prescriber

Purpose / when: whenever a client takes any medicine and is considering, or has recently attended, an ayahuasca ceremony. The brew contains DMT with MAOI-acting harmala alkaloids, and its composition varies widely. [source: https://www.drugscience.org.uk/drugs/ayahuasca]
What clinical sources state (for your awareness, not for advice): SSRIs carry a risk of serotonin syndrome; other MAOIs, antipsychotics, antihypertensives and SSRIs should rule out use or require a doctor's advice first; lithium is to be avoided because of seizure risk; serotonergic drugs such as tramadol and dextromethorphan carry a documented risk of severe serotonin toxicity; amphetamines are singled out, though that combination is not documented in the ayahuasca literature; foods high in tyramine (aged cheeses, cured meats) may interact; heart rate and blood pressure rise, and uncontrolled cardiovascular disease is an exclusion criterion. [source: https://www.drugscience.org.uk/drugs/ayahuasca]
Steps: (1) Ask what medicines, supplements and other substances the client uses. (2) If any may interact, tell the client this is a medical question and help them take it to their prescriber or GP. (3) With consent, write to the prescriber. (4) Do not suggest stopping, starting, tapering or timing any medicine. (5) Record the conversation. [synthesis]
Example language (illustrative): "Some medicines can interact seriously with ayahuasca. That is a question only your prescriber can answer for you. Please don't change anything on your own; can we work out how you'll raise it with them?"
Watch for: a retreat or facilitator telling the client to stop medication; the client planning to do so alone; unexplained fever, agitation, tremor or confusion after a ceremony (send to emergency care). Working: the prescriber is informed and the client's decision is medically informed.

4.9 Psychiatric risk conversation

Purpose / when: with clients who have a personal or family history of psychosis, bipolar disorder or mania, or are currently unstable, and who mention ayahuasca. Schizophrenia, a personal history of psychosis and bipolar disorder are exclusion criteria in most clinical and retreat settings. [source: https://www.drugscience.org.uk/drugs/ayahuasca] The dos Santos, Bouso and Hallak (2017) review advises that people with a personal or family history of psychotic illness or non-psychotic mania avoid these substances. [source: https://www.iceers.org/?p=39998]
Steps: (1) Take a careful history, including family history. (2) Share what the research reports, plainly and without scare tactics. (3) Explore what the client hopes to gain and other routes to it, including within their own faith or community. (4) Respect the client's autonomy; you do not decide for them, and you do not arrange participation. (5) Agree a safety plan and an early-warning-signs plan with the client and, with consent, family. [synthesis]
Example language (illustrative): "Because of your history of mania, the research suggests a higher risk of a serious reaction for you. What are you hoping ayahuasca would give you? Are there other ways we could work towards that?"
Watch for: pressure from partners or facilitators; screening that is only a form; worsening mood or sleep in the run-up. Working: the client can state the risks in their own words and has a plan.

4.10 Setting and sexual-safety psychoeducation (Chacruna community guide)

Purpose / when: when a client says they will attend a ceremony or retreat anyway, or is returning to one; to reduce the risk of sexual abuse. The Chacruna Institute's community guide was shaped with Indigenous and Western survivors, healers, facilitators and researchers, focuses on abuse of women by male healers while noting abuse occurs across genders, and says it does not aim to discourage participation. [source: https://chacruna.net/?p=8765]
Steps: (1) Offer the guide itself (free, in about fourteen languages) rather than your own summary. (2) Go through its main points with the client in your own words: do not drink alone with a healer; bring a trusted companion; consider experienced women or couples as facilitators; research the healer and place through past participants and local women; healers do not need to touch intimate areas; the client may decline or interrupt any individual "special" treatment; sex during or right after ceremony is "not acceptable in Ayahuasca Traditions"; be wary of offers of other substances. (3) Go through its red flags: focus on the client's looks or excessive touching; secrecy or "pacts of silence"; offers of "love magic"; claims that ayahuasca enhances sex; being told one is "special and chosen." (4) Point to its Legal Resource Companion for country-specific help. (5) Agree what the client will do if something feels wrong, and that they can contact you afterwards. [source: https://chacruna.net/?p=8765]
Example language (illustrative): "You've decided to go. There's a guide written with survivors and healers about staying safe from sexual abuse in these settings. Can we look at it together, and plan who you'll go with?"
Watch for: idealisation ("he's a real shaman, he wouldn't"); the guide's own heading puts it bluntly: "He's a Shaman, Not a Saint!" Working: the client has a named companion, knows the red flags and has a plan to leave or report.

4.11 Legal-status awareness

Purpose / when: when a client plans to travel, import, possess or take part; and when a client is anxious about legal exposure after participation.
What sources state: DMT is in Schedule I of the 1971 Convention; the brew itself is not internationally scheduled, a position the INCB has clarified. Peru treats ayahuasca as national cultural heritage and entered a reservation for traditional uses. Religious use by churches is permitted or regulated in Brazil, the United States and Canada. France and Russia treat it as prohibited; in Portugal, Mexico, Israel and Spain the law does not address it explicitly and people have been prosecuted for receiving it by mail or carrying it on planes. [source: https://www.iceers.org/ayahuasca-legal-status/] In the UK DMT is Class A, so the brew is illegal to possess, supply or produce; in the US DMT is Schedule I with religious exemptions following the 2006 Supreme Court ruling for the UDV; Australia and New Zealand prohibit DMT. [source: https://www.drugscience.org.uk/drugs/ayahuasca] Laws change; treat this as orientation. [uncertain: current status may differ by date]
Steps: (1) Tell the client that legal status varies and that you are not a legal adviser. (2) Point them to independent legal resources (ICEERS; Chacruna Legal Resource Companion). (3) Explain your own confidentiality limits clearly. [synthesis]
Example language (illustrative): "The law on ayahuasca differs a lot between countries. I can't advise you legally, but here are organisations that track it."
Watch for: fear of police deterring a client from reporting abuse or seeking emergency care; address this directly. Working: the client seeks legal information from a proper source.

4.12 Collaboration and referral with community-sanctioned healers and organisations (client's wish only)

Purpose / when: when a client from an Amazonian community or a vegetalista family wants their healer, community organisation or church involved in their care, or wants help finding legitimate community support. Collaborative care with traditional and faith healers has trial evidence elsewhere: in Nigeria and Ghana, the COSIMPO cluster trial (Gureje et al., The Lancet, 2020) found collaborative shared care reduced psychosis symptoms more than enhanced usual care and reduced harmful practices. [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839] In a Ghana prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric care lowered symptoms but did not significantly reduce days in chains. [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial] Whether an equivalent trial exists for Amazonian healers is [uncertain].
Steps: (1) Ask whether the client wants collaboration, with whom, and why. (2) Check legitimacy through the client's community: for Shipibo-Konibo matters, the healers' union ASOMASHK and the council COSHIKOX present themselves as the coordinating bodies. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019] For vegetalistas, legitimacy is reputational and local; ask who in the client's community vouches for the person. [source: https://en.wikipedia.org/wiki/Vegetalismo] [uncertain: secondary source] For churches, see guide 116. (3) Obtain written consent specifying what you may share. (4) Agree roles: you handle assessment, therapy and risk; they handle what their tradition holds. (5) Agree a plan for emergencies and for any practice that would be unsafe (e.g. stopping medicines, restraint). (6) Use an interpreter where needed. [synthesis]
Example language (illustrative): "Would it help if I spoke with the person your family trusts, so we're not pulling in different directions? I'd only share what you agree to."
Watch for: retreat operators presented as "community healers"; any advice to stop medication; payment pressure. Working: the client experiences care as joined up and safety rules are agreed.

4.13 Interpreters and cultural brokers

Purpose / when: when the client's first language is Spanish, Portuguese or an Indigenous language, or when terms like icaro, dieta or a local illness concept need careful handling. [synthesis]
Steps: (1) Use a professional interpreter, not family, for assessment and risk. (2) Brief the interpreter on confidentiality and on not editing spiritual content. (3) Where possible, consult a cultural broker from the client's community, with consent, about what is normative. (4) Debrief the interpreter after distressing sessions. [synthesis] CFI Q16 asks about language barriers in the clinical relationship. [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Example language (illustrative): "Please translate exactly what she says about the plants and spirits, even if it sounds unusual. If a word has no English equivalent, tell me."
Watch for: the interpreter's own attitudes to ayahuasca or Indigenous belief; community overlap that threatens confidentiality. Working: the client's own terms appear in your notes accurately.

4.14 Integrating ceremonial experiences

Purpose / when: after participation, when the client wants to make sense of visions, emotions, memories, or a sense of spiritual change. Drug Science notes that past trauma can resurface during the experience. [source: https://www.drugscience.org.uk/drugs/ayahuasca] ICEERS argues that supervision and post-session integration could have prevented some reported deaths. [source: https://www.iceers.org/examining-deaths-ayahuasca/] Clinical integration methods are set out in Domain VII.
Steps: (1) Let the client tell the experience in their own frame first. (2) Ask what it meant to them and what changed in daily life. (3) Separate meaning-making from risk: check sleep, mood, reality testing, suicidality. (4) Link insights to concrete, small changes. (5) Respect the client's interpretations, including spiritual ones; do not reinterpret them as only psychological. (6) If trauma resurfaced, move to trauma-focused work at the client's pace. [synthesis]
Example language (illustrative): "What stays with you most from that night? ... How would you like it to change how you live, if at all?"
Watch for: grandiosity, persisting derealisation, compulsive return to ceremonies, isolation from family; attraction to or dependence on a healer, which the Chacruna guide notes may be temporary or induced. [source: https://chacruna.net/?p=8765] Working: the client's account becomes coherent and their functioning holds or improves.

4.15 Crisis response after a ceremony

Purpose / when: when a client presents with acute psychosis, mania, severe anxiety, suicidality, medical symptoms, or disclosure of assault after a ceremony.
Steps: (1) Assess immediate safety, including suicide risk, using your standard risk assessment. (2) Treat medical symptoms (high temperature, agitation, confusion, tremor, chest pain, seizures, vomiting with weakness) as an emergency and send to emergency care; tell clinicians what was taken, if known. (3) For psychosis or mania, arrange urgent psychiatric assessment. (4) For recent sexual assault, follow your local sexual-assault pathway (forensic and medical care, support services) with the client's consent, and act on safeguarding duties. (5) Inform the client's existing prescriber with consent. (6) Follow up within days. [synthesis] Most reported psychotic episodes occurred in people with prior risk factors or in unsupervised settings. [source: https://www.iceers.org/?p=39998]
Example language (illustrative): "What you're describing needs a doctor today. I'll help you get there, and we'll keep working together afterwards."
Watch for: minimisation by the client or facilitator ("it's just the medicine working"); fear of legal trouble delaying care. Working: the client reaches appropriate care quickly.

4.16 Safeguarding and reporting

Purpose / when: when a client discloses sexual abuse, violence, coercion or exploitation by a healer or facilitator; when a minor is involved; or when someone else is at risk.
Steps: (1) Believe and support the client; the Chacruna guide says a "freeze" response is common and that abuse can be reported later. [source: https://chacruna.net/?p=8765] (2) Explain options: reporting to police in the country concerned, legal advice, support services; point to the Chacruna Legal Resource Companion. (3) Follow your mandatory reporting and safeguarding duties, especially for children and adults at risk; never name minors in records shared outside the service. (4) Do not pressure the client to confront the abuser. (5) Keep careful, factual records. [synthesis]
Example language (illustrative): "What happened was not your fault, whatever the setting and whatever you agreed to beforehand. Let's look at your options together; you decide what happens next, except where I have a legal duty, which I'll explain."
Watch for: self-blame framed as spiritual failure; the abuser's claims that sex was healing; community pressure to stay silent. Working: the client feels believed and has chosen next steps.

4.17 Working with families, communities and churches

Purpose / when: when family members disagree about ayahuasca or a healer; when a client belongs to an ayahuasca church (see guide 116); when an Amazonian family has its own healer.
Steps: (1) Map the family's and community's views (CFI Social Network module). (2) Meet with family members if the client agrees, using the Informant Version where useful. [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] (3) Support communication rather than taking sides. (4) Recognise the church or community as a source of support as well as possible pressure. [synthesis]
Example language (illustrative): "Your mother sees the healer as protection; you're worried about the ceremonies. Can we find out what each of you is afraid of?"
Watch for: coercion in either direction; isolation from family by a group or facilitator. Working: family conflict lessens and the client keeps their supports.

4.18 Addressing extraction, colonial history and ethics

Purpose / when: when an Indigenous or Amazonian client describes grief or anger at the commercialisation of their heritage, or when a non-Indigenous client has ethical questions about taking part.
Steps: (1) Acknowledge the history the community itself describes: ASOMASHK speaks of rapid growth of spiritual tourism, abuse of sacred plants and ancestral knowledge by outsiders, a "cannibalistic Western system" taking Shipibo knowledge, and knowledge not being passed between generations. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019] (2) Peru's resolution distinguishes protected traditional use from consumerist, commercial uses. [source: https://www.bialabate.net/blog-archive/news/ayahuasca-is-declared-cultural-patrimony-of-peru] (3) For Indigenous clients, explore intergenerational and colonial trauma and racism in services (CFI Q16). (4) For non-Indigenous clients, explore their motives without moralising; share that communities have asked outsiders to seek their consent. [synthesis]
Example language (illustrative): "It sounds painful to see your grandmother's medicine sold as a holiday. How does that sit with you?" / "Some Amazonian communities have spoken publicly about outsiders taking their practices. Is that something you've thought about?"
Watch for: the therapist lecturing; the client's guilt or anger becoming the whole focus. Working: the client can hold their own position with less distress.

5. Handling problems

Guidance here is [synthesis] unless a source is given.

Client asks you to recommend a retreat, healer or "good shaman." Decline to recommend, explain why (you are not part of the tradition and cannot vouch for anyone), and offer what you can: the CFI help-seeking discussion, risk review, the Chacruna guide, and contact with legitimate community bodies if the client is from that community. "That's not something I can do responsibly, but I can help you think through safety and what you're looking for." (illustrative)
Client asks whether ayahuasca will cure their depression or trauma. Give the evidence status honestly: a small randomised placebo-controlled trial (Palhano-Fontes et al., Psychological Medicine, online 2018; 29 patients with treatment-resistant depression) found a higher response at day 7 with ayahuasca than placebo (64% vs 27%); remission did not differ significantly. [source: https://repositorio.ufrn.br/items/57fa92d1-fa5a-4915-b3e8-b5ec549e20e2/full] Drug Science describes all clinical uses as investigational, off-label or anecdotal, with no approval by any health authority. [source: https://www.drugscience.org.uk/drugs/ayahuasca] Then offer evidence-based treatment and, if relevant, Domain VII for regulated clinical research settings.
Client plans to stop medication before a retreat (sometimes on a facilitator's instruction). Do not advise either way; urge them to speak with their prescriber before any change and offer to contact the prescriber with consent. Record it. If the client has already stopped, treat as a medical-risk issue and route to the prescriber urgently.
Idealisation of a healer or the plant ("resistance" to risk talk). Do not argue. Use the client's values: ask what a trustworthy healer would do, then compare with the Chacruna red flags. [source: https://chacruna.net/?p=8765]
Overwhelm after a ceremony (flooding of trauma memories, derealisation, panic). Stabilise first: grounding, sleep, routine, support; postpone exploratory work; screen for psychosis and suicidality; refer when symptoms persist (4.7, 4.15).
Spiritual distress framed as sorcery, punishment or a broken dieta. Work inside the client's explanatory model; ask who in their tradition could help; with consent, involve a community-sanctioned practitioner (4.12); treat co-occurring anxiety or depression. Do not tell the client the fear is unreal or confirm it is real.
Repeated returns to ceremonies, with worsening functioning. Explore what each return provides; assess for dependence on a facilitator or group, financial exploitation, and isolation from family; consider substance-use assessment if other drugs are involved.
Non-adherence to therapy because "the medicine does the work." Acknowledge the client's frame; agree on what therapy is for (for example, safety and daily-life change) and review it regularly.
Rupture: client feels judged for taking part, or for not taking part. Name it, take responsibility for your contribution, and return to the CFI clinician–patient relationship question (Q16). [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]
Client discloses abuse but does not want to report. Respect the decision for adults unless a legal duty applies; keep options open; note that reporting later is possible. [source: https://chacruna.net/?p=8765]
Client feels romantically drawn to a healer or fellow participant. Normalise the feeling; share that the Chacruna guide says such attraction may be temporary or induced and suggests allowing time for integration before deciding. [source: https://chacruna.net/?p=8765]
Community conflict over tourism or appropriation affecting an Indigenous client. Validate; support connection with the client's own organisations; avoid speaking for the community (4.18).
Therapist's own enthusiasm or opposition. Bring to supervision; check that your stance is not steering the client (4.1).
Minors. A young person raising interest in ayahuasca, or brought by family, triggers safeguarding assessment and parental involvement as law requires; never facilitate participation.

Harm account

What was actually done

Sexual abuse by healers and facilitators. The Chacruna guide (first version November 2018) documents the patterns it was written to counter: healers focusing on a participant's appearance or being overly "touchy"; claiming their wife does not mind affairs; demanding secrecy or "pacts of silence"; offering to teach "love magic"; claiming ayahuasca enhances sex; telling a participant she is "special and chosen" and offering ceremonial status; arranging individual "special" treatments outside ceremony involving intimate touch, which the guide says the named healings do not require; offering additional psychoactive substances framed as "sexual chakra releases"; and initiating sex during or right after a ceremony with claims that sex can "regain the sacred energy." [source: https://chacruna.net/?p=8765] Peluso (2014) examines sexual seduction and gendered power between shamans, apprentices and participants in the context of rapidly growing ayahuasca tourism. [source: https://kar.kent.ac.uk/37177] A 2022 Chacruna article by Peluso, Sinclair, Labate and Cavnar says incidents of sexual abuse of women are rising "alarmingly" with ayahuasca's popularity, among both Indigenous and Western victims, including through "charm spells" and offers of sex as healing or a route to spiritual power. [source: https://chacruna.net/?p=113165]
Deaths and serious harms linked to ceremonies. An ICEERS analysis (Suárez Álvarez, 2023) of 58 deaths linked by the media to ayahuasca between 2010 and 2022 found: 34 with ayahuasca taken in the hours before death; none of nine public autopsies attributing death to ayahuasca itself; tobacco implicated in four deaths; other plants or substances (scopolamine, possibly Brugmansia, and 5-MeO-DMT taken hours after ayahuasca); hyponatraemia from overhydration; heart attacks, one with a pre-existing condition; drowning, a fatal fall and a neck fracture from convulsions; 14 suicides linked by media, one with ayahuasca in the hours before; eight homicides, two by perpetrators under its effects who had severe psychiatric disorders. [source: https://www.iceers.org/examining-deaths-ayahuasca/] ICEERS writes from a perspective supportive of ayahuasca's therapeutic value; its figures rely on public records.
Psychiatric emergencies. Reported psychotic episodes after ayahuasca or DMT occurred mostly in people with a personal or family history of psychosis or mania, prior or concurrent drug use, or unsupervised settings. [source: https://www.iceers.org/?p=39998]
Violence against healers and exploitation. The Shipibo-Konibo statement (2019) cites the killing of a Shipibo-Konibo master healer by a Canadian tourist and the shooting of another healer in May 2019, alongside abuse of sacred plants and ancestral knowledge by outsiders and events organised without community consent. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019] News reports date the killing to April 2018, in the Ucayali region. [source: https://globalnews.ca/news/4160544/canadian-murdered-peru-indigenous-healer-killed]

How it caused harm

Sexual abuse: exploits the power of the healer role, altered states and participants' hopes of healing; the Chacruna guide calls it "a perversion of the healer-participant dynamic," and notes that many women seek healing for past sexual trauma, making abuse especially damaging; a "freeze" response is common. [source: https://chacruna.net/?p=8765] Expected sequelae include PTSD symptoms, shame, self-blame framed spiritually, and loss of trust in help. [synthesis]
Physical harm: mechanisms reported include tobacco toxicity, other toxic plants, drug interactions, overhydration, cardiac events in people with pre-existing conditions, and accidents in unsupervised settings. [source: https://www.iceers.org/examining-deaths-ayahuasca/] Clinical sources name serotonin toxicity with SSRIs and other serotonergic drugs. [source: https://www.drugscience.org.uk/drugs/ayahuasca]
Psychiatric harm: precipitation of psychosis or mania in people at risk; resurfacing trauma without support. [source: https://www.iceers.org/?p=39998] [source: https://www.drugscience.org.uk/drugs/ayahuasca]
Cultural and community harm: appropriation of ancestral knowledge, commercialisation, violence against healers, and loss of transmission within communities, as the Shipibo-Konibo describe. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019]
Most at risk: women, especially those travelling alone or seeking healing from sexual trauma; people with psychiatric or cardiovascular conditions or on interacting medicines; people in unsupervised settings; and Indigenous healers and communities. [source: https://chacruna.net/?p=8765] [source: https://www.iceers.org/examining-deaths-ayahuasca/]

Recognising it today

In a facilitator or retreat: the Chacruna red flags (above); instructions to stop medicines without a doctor; no screening for psychiatric or heart conditions; no supervision through the night; use of extra plants, tobacco or other substances beyond what participants were told; individual sessions alone with a healer; secrecy; pressure to return and pay. [source: https://chacruna.net/?p=8765] [source: https://www.iceers.org/examining-deaths-ayahuasca/] [synthesis for the list as a whole]
Rebrandings: "traditional" or "Indigenous" labels without any link to a community that recognises the practitioner; events in Indigenous territories without the consent of community organisations. [source: https://www.shipiboconibo.org/asomashk-pronauncement-2019]
In a colleague's practice: a therapist who arranges, leads or profits from ceremonies, refers clients to retreats, advises on medicines, or touches clients in "energy" or ceremonial ways. [synthesis]
How legitimate settings differ: community recognition, clear consent and the right to decline, screening, supervision, companions welcome, no sexual contact, no secrecy, and integration support. [source: https://chacruna.net/?p=8765] [source: https://www.iceers.org/examining-deaths-ayahuasca/]

What to do instead and how to help those harmed

Safer alternatives: for mental-health treatment, evidence-based therapy and psychiatric care; for clients interested in psychedelic treatment, regulated clinical research and the approaches in Domain VII; for those within a tradition, legitimate community pathways (Indigenous organisations, recognised local healers, churches in guide 116). [synthesis]
Assessment of affected clients: CFI and explanatory model (4.3–4.5); trauma, psychosis, mania, suicidality and substance-use screening; medical review where symptoms persist. [synthesis]
Treatment: trauma-focused therapy at the client's pace after sexual abuse; stabilisation then integration after destabilising experiences (4.14); family and community work (4.17). [synthesis]
Ethical, reporting and legal duties: follow safeguarding and mandatory reporting law, especially for minors; support adult survivors' choices about reporting; point to the Chacruna Legal Resource Companion for country-specific laws and contacts; report a colleague's misconduct to their regulator. [source: https://chacruna.net/?p=8765] [synthesis]
Cross-references: Domain VII for psychedelic-assisted therapy and integration; guide 116 in this domain for ayahuasca churches.

Sources

Community, tradition and safety sources

Cultural assessment and collaboration sources

Books and papers cited

Luna, L. E. (1986). Vegetalismo: Shamanism among the Mestizo Population of the Peruvian Amazon. Stockholm: Stockholms universitet, 202 pp. (Smithsonian Libraries record).
Peluso, D. M. (2014). Ayahuasca's attractions and distractions: examining sexual seduction in shaman-participant interactions. In B. C. Labate & C. Cavnar (Eds.), Ayahuasca Shamanism in the Amazon and Beyond (pp. 231–255). Oxford University Press.
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care. Annals of Internal Medicine, 88, 251–258.
Lewis-Fernández, R., et al. (2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview. British Journal of Psychiatry, 210(4), 290–297.
Gureje, O., Appiah-Poku, J., et al. (2020). Collaborative shared care for psychosis in Nigeria and Ghana (COSIMPO). The Lancet.
Ofori-Atta, A., et al. Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial. British Journal of Psychiatry, 212, 34–41 (2018). doi:10.1192/bjp.2017.12
Palhano-Fontes, F., et al. (2018, online). Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression. Psychological Medicine. doi:10.1017/S0033291718001356.
dos Santos, R. G., Bouso, J. C., & Hallak, J. E. C. (2017). Ayahuasca, dimethyltryptamine, and psychosis: a systematic review of human studies. Therapeutic Advances in Psychopharmacology.

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