The Space Between Gatekeeper and Cheerleader (2 of 5)
Updated: 2 days ago
A third clinical stance, and why it can be trained
Neutrality is not the same as presence. One is an absence. The other is a discipline.
In the first essay in this series, I named two failures clinicians default to when a client brings psychedelic or earth medicine use into the room: the gatekeeper, who closes the conversation down, and the cheerleader, who opens it too far in the direction of their own enthusiasm. Most clinicians reading that essay probably recognized themselves somewhere in that tension — sometimes in one camp, sometimes in the other, depending on the client, the circumstances, or how close the material sits to their own history.
What I didn’t say plainly enough is this: the alternative to those two postures is not some neutral middle point where you simply say less. It is not fence-sitting dressed up as clinical restraint. It is a distinct, learnable, teachable clinical competency — and like every other competency in your training, it has recognizable components. I want to name four of them here.
Competency One: Staying Oriented to Function, not Content
The gatekeeper and the cheerleader are both, in their own way, reacting to the content of what the client brings — the substance itself, its legality, its cultural associations, or its risk profile in the abstract. The trained clinician asks a different question first: What is this experience doing for my client, functionally, in the architecture of their life?
Is the ceremony a genuine attempt to encounter grief that years of talking have not reached? Is the microdosing functioning as self-medication for symptoms that deserve fuller assessment? Is repeated psilocybin use becoming another form of avoidance — a spiritualized way of continually seeking revelation rather than doing the slower work that has to happen in relationship, behavior, and ordinary life?
These are clinical questions, not moral ones. And they cannot be answered simply by knowing which substance the client took. They require curiosity about context, intention, pattern, consequences, meaning, and function. They require you to ask what happened before the experience, what happened during it, and perhaps most importantly, what has happened in the client’s life since.
The medicine is part of the story. It is not the whole story.
Competency Two: Risk Literacy that is Specific, not Generic
Neither gatekeeping nor cheerleading requires you to know very much. Gatekeeping can survive on discomfort. Cheerleading can survive on enthusiasm. The third posture requires actual knowledge.
That means understanding that psychedelics and earth medicines are not one interchangeable category with one universal risk profile. Psilocybin, MDMA, bufo, ketamine, ayahuasca, and ibogaine raise different medical, psychiatric, pharmacological, and contextual considerations. Medication interactions have to be understood substance by substance rather than reduced to a generic warning about psychiatric medications. Cardiovascular concerns matter differently across substances. Personal and family histories of certain psychiatric conditions can materially change the clinical picture. Ibogaine raises medical concerns that cannot responsibly be treated as equivalent to those associated with psilocybin.
It also means developing enough literacy to recognize when an unusually difficult post-psychedelic period may be part of a challenging integration process and when what you are seeing requires urgent psychiatric or medical assessment. Those distinctions are not always obvious, and they are not always clean.
You do not need to become a psychopharmacologist. You do need to know what you know, know what you don’t know, and know when another professional needs to be brought into the conversation.
Your caution and your openness should both be grounded in something more reliable than instinct, because instinct alone is where both failure modes begin.
Competency Three: Informed Decision-Making as an Ongoing Conversation
Most clinicians encounter informed consent as something formal: a document reviewed at intake, signed, filed, and occasionally revisited when circumstances change. But when a client is independently engaging with psychedelic or earth medicine work, something adjacent but different becomes clinically important: supporting informed decision-making without quietly becoming the person authorizing, prescribing, or directing an experience outside your role.
Before an experience, that may mean exploring what the client actually understands about what they intend to do. What do they know about the substance? What do they know about their own vulnerabilities? Who will be present? What do they know about the facilitator or setting? What medications are they taking, and have relevant medical questions been discussed with an appropriately qualified provider? What is their plan if something goes wrong?
None of those questions requires you to say, Yes, you should do this.
They require you to stay in the conversation.
Afterward, the conversation changes. What actually happened? What frightened them? What opened? What remains unresolved? What meaning are they making from the experience, and how quickly are they making it? Are they reorganizing their entire life around something they understood during an altered state three days ago? Are they sleeping? Are they functioning? Are they becoming more grounded in their relationships and responsibilities, or less?
This is where harm reduction actually lives clinically. Not in a pamphlet and not in a disclaimer. It lives in a relationship where the client trusts you enough to keep telling you the truth because you’ve demonstrated that you won’t shut the conversation down and you won’t hijack it either.
Competency Four: Knowing the Edge of your Scope, and Having Somewhere to Send them
The trained clinician holds one more piece the untrained clinician often doesn’t: a working map of when the situation exceeds their competence, their scope, or outpatient psychotherapy altogether.
Sometimes the client’s pattern of use begins to look less like intentional exploration and more like compulsive or harmful substance use. Sometimes medical or psychiatric history introduces risks that require assessment beyond the therapist’s expertise. Sometimes what emerges after an experience cannot safely be held by one outpatient clinician seeing someone for fifty minutes a week. Sometimes the most competent intervention is not deeper engagement from you but consultation, coordination, or referral — to a physician, psychiatrist, addiction specialist, emergency service, higher level of care, or another clinician with expertise you do not have.
This is one reason psychedelic competency cannot simply mean knowing more about psychedelics. It also means knowing the surrounding ecosystem of care.
You need colleagues you trust. You need referral relationships established before you are scrambling for them. You need people you can call when the clinical picture becomes ambiguous. And you need enough humility to recognize that being the therapist your client trusts does not automatically make you the professional best equipped to meet every need that emerges.
Knowing your edge, and having somewhere real to send a client when they reach it, is not a failure of competency. It is competency.
Why This Has to be Trained, not Intuited
None of these four things are personality traits. They are not a matter of being a “chill” clinician or a “cautious” one. They are skills, built the way every other clinical skill is built — through structured training, consultation, supervision when appropriate, case discussion, and enough repetition that the third posture becomes increasingly available to you when the unexpected walks into the room.
And there is another reason this has to be trained: psychedelic material has an unusual ability to activate the clinician.
It can activate our fear. It can activate our fascination. It can activate our skepticism, our spiritual beliefs, our personal experiences with altered states, our unresolved experiences with substances, our desire to rescue, and sometimes our desire to be the person who understands something that the client’s other providers do not.
The third posture therefore requires more than knowledge. It requires the capacity to notice yourself while you are using it.
Can I hear my client’s extraordinary experience without needing to explain it away?
Can I hear it without needing to believe every interpretation they have made of it?
Can I remain curious about a medicine that frightens me?
Can I remain discerning about a medicine that changed my own life?
Can I help this client make meaning without making the meaning for them?
That is the space between gatekeeper and cheerleader. Not neutrality. Not approval. Not prohibition. Presence with discernment.
This is what I’m building in the trainings and consultation work coming out of this site. Not a philosophy of openness, but a working competency you can bring into session on a Thursday afternoon when a client tells you something you didn’t see coming.
Some of the deeper clinical scaffolding behind these competencies will be in The Psychedelic Clinician when it’s out. But scaffolding on a page and scaffolding you can actually use under pressure are two different things. The second gets built in a room with other clinicians: studying cases, examining our reactions, practicing difficult conversations, and learning how to recognize the moment when what is needed exceeds us.
The goal is not to become more psychedelic-positive. The goal is to become more clinically competent.
If you want to stop reaching for this stance and start standing in it, that’s exactly what the training is for.
See upcoming trainings and consultation groups →
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