Michael Mithoefer: The Non-Directive Approach Takes Actual Work

Therapists new to the psychedelic psychotherapy space are often uncertain about how to support clients effectively during altered states. Should they remain silent and allow the medicine to do the work, or should they actively guide the session with interventions? Misconceptions about the “non-directive approach” often leave practitioners unsure of their role, leading to either over-involvement or complete disengagement. How can therapists balance presence and intervention?

As a psychiatrist and researcher specializing in psychedelic-assisted psychotherapy, Michael Mithoefer explains that the therapist’s role is not to impose structure but to follow the client’s inner healing intelligence. He outlines three key principles: only intervene when necessary, provide time for natural processing, and always frame suggestions as invitations rather than directives. Additionally, he highlights the importance of relational safety, regular check-ins, and the integration of somatic interventions to help clients navigate difficult emotional and physical manifestations of trauma during their sessions.

In this week’s episode of Living Medicine, Michael Mithoefer, the Senior Medical Director for Medical Affairs, Training, and Supervision at the Multidisciplinary Association for Psychedelic Studies (MAPS), returns to talk with Dr. Signi Goldman about guiding internal-directed healing during psychedelic therapy sessions. Michael discusses the importance of checking in with clients regularly during sessions, how therapist training and personal psychedelic experiences influence psychedelic therapy facilitation, and when to intervene during MDMA sessions.

This episode is brought to you by the Living Medicine Institute.

LMI is a training, resource, and membership program educating providers about the legal and safe use of psychedelic-assisted psychotherapy.

To learn more or participate, visit https://livingmedicineinstitute.com.

Intro 0:03

Welcome to the Living Medicine podcast where we talk about ethical medical use of psychedelic psychotherapy, teaching skills, examining the issues and interviewing interesting people. Now let’s start today’s show. 

Dr. Signi Goldman 0:18

This is Signi Goldman, your host today, and I’m talking to Michael Mithoefer, who most of my audience knows quite well, or knows your work. But for those of you who don’t know who Michael is, I will just say that many of you know that we are in this sort of second psychedelic Renaissance, and certainly kind of like a big psychedelic Renaissance into the awareness of psychedelics for mental health, and that is really changing the landscape for how people think about what mental health treatment will look like. And this, this paradigm shift that we’re in now, rocky as it is right now, is really based on research and Michael, and especially your collaboration with Rick Doblin, I think around 2000 so Michael was one of the lead people that put together the collaborative kind of ft studies with the FDA, the phase two clinical trials, early and, I think 2000 and then after that, quite a few trials. So that research has really sort of opened up the conversation, and was really instrumental in a lot of ways. But one of the other things that you do a lot of, along with your wife, Annie, who was on that, that research team with you, is teaching and training, you know, training therapists to do this work. So you are a trainer, and I’m a trainer. I train therapist, and part of how I learned how to train therapists is because you’re one of the people who I also learned from, and I find myself in these conversations lately a lot about the non directive approach. You’re someone who has been, like, often quoted, as, you know, in reference to that idea or like that phrase. And so I thought I would kind of text you and see how you felt about talking about my concern that that is so misunderstood, and so I really appreciate you coming on. Why don’t we start by like, do you have thoughts on that already, before I reached out to you on sort of this, that concept of the non directive approach, and how people are hearing that?

Michael Mithoefer 2:18

Yeah, yeah. Yeah. I’m really delighted. Thanks for the introduction, Signi. And I’m glad you mentioned Annie, because my wife, Annie, and I have done all these studies that I’ve worked on. We’ve worked on together so and we’re co therapists, so it’s kind of peculiar, even though I’ve been doing clinical research for like, 25 years, 24 years now, I’ve been working on it. I’m not really a researcher. I’m a therapist. I’m a clinician, and he’s a clinician, and we were forced into doing research because we needed a better treatment for the patient. So for us, it’s always been about therapy and the and not about the drugs, but about tools that will catalyze people’s ability to engage in therapy with connection to their own innate healing capacity. So, you know, we originally learned that from Stan Grof. Stan is off Grof and his wife, Christina, because in you know, about 30 years ago, when I for 10 years of practicing emergency medicine, I was looking for a change in my career. It was reading Stan, gross book that had a major a lot was the main factor in my deciding to switch to psychiatry and I train. I did that training with with the graphs over two and a half years while I was doing my psychiatry training so I could see and the graph training was based on what Stan had learned studying LSD psychotherapy. Yeah, many years before, he was one of the primary LSD researchers. And you know, he came from a tradition of academic Biological Psychiatry and Freudian psychology. And when he came upon LSD that was sent around to universities by Sandoz, he was surprised. You know, he didn’t have this framework. But what he quickly realized, sitting with 1000s of people in LSD sessions, the people kept reporting, kept having these unexpected experiences that were tended to be very, very healing if they were handled well, if they were supported and integrated. And these were not coming from the Freudian theory or from doing anything else by law. Psychological and then these, you know, I think a very important point is, after many years of LSD research, when Richard Nixon suddenly made LSD illegal, and Stan Grof was at Johns Hopkins and at the Maryland Psychiatric Research Center, it was going to be a big deal researching psychedelics was a hot topic in psychiatry, and then it was shut down by Richard Nixon in 76 so but what Stan then discovered is he realized that there are other ways of shifting Consciousness in this way that were some of them involved other drugs, Ayahuasca, peyote, Ibogaine. People have known about plant medicines that could shift consciousness like this for 1000s of years. But also people have known about yoga and meditation and prolonged dancing and drumming and sun ceremonies, all these other ways, technologies for shifting consciousness that aren’t even about drugs. So when we train with Stan, he taught us to be facilitate, to do our own and to facilitate others in Holotropic breath work, which combine music and vigorous breathing in a therapeutic sentence, a supportive sentence setting, and people have remarkable shifts and cautious and it’s like they had with LSD or psilocybin or ketamine or MDMA, you know, not the same, but the same phenomenon. Yes. What Stan talks about? Stan drop coined the term Holotropic and hylotropic as two general categories of consciousness and Holotropic. Holotropic means oriented toward matter, which is important to be able to do. We spend a lot of our waking consciousness oriented toward matter, so we don’t drive off the road and things like that. However, what people have realized for 1000s of years is there are ways to shift into what Stan calls a Holotropic consciousness oriented toward wholeness, which has many benefits. So if you can have a way to intelligently and skillfully shift your consciousness to a whole trophic state, it has benefits, healing benefits. And of course, in the ancient cultures and some contemporary cultures, those things go together. Shamans are, you know, shamanism involves healing community life and spiritual life, so they tended to go together. But there was a powerful healing potential, in a way. What Stan summarizes what this is all about, is the healing potential of non ordinary states of consciousness, and how you get there is secondary. Sometimes it’s breath, sometimes it’s dancing, and sometimes it’s medicines that can be very useful. So that’s the I guess. I don’t want to go on too on, but I think that’s an important point. It’s not about the psychedelics, it’s about the tool to shift consciousness we happen to be using these psychedelic drugs, and that involves paying attention to the drug, obviously intelligently, like we do every medicine, and they have to be regulated by FDA to be safe medically. And it’s not mainly about that. It’s about tools for the therapy, so and so and you, you know, you name the the big problem we have once we mentioned, I mean, Stan talks about this concept of the inner healing intelligence, yeah, you know, he says it when you go into a Holotropic state. However you got there. LSD, MDMA, breath work, ketamine. When that happens, he says it’s as if there’s an inner radar that scans for what is important for you. Experience is important for your healing and growth. Yes, that experience and the therapists have no way of knowing ahead of time what that experience is going to be, and the patients or the participants have no way of knowing. But one thing that we’ve seen again and again is it will happen if you don’t interfere. So that’s where the non directive approach comes from. Is the main point is, it’s not that the therapists don’t do anything. You know, many therapy skills that therapists have can be very, very helpful or even essential in these sessions. It’s a matter of how you apply them and what you’re whether you’re applying them with a preconceived agenda. To which is a problem in my mind, because then you may get in the way of that unexpected experience that would come from the person’s inner healing intelligence. That’s the point. So

Dr. Signi Goldman 10:13

this idea of the non directed approach is don’t have an agenda and don’t get in the way of the innate healing instinct that you know the person in that altered state has, but it doesn’t mean don’t talk or don’t engage. Is that

Michael Mithoefer 10:32

exactly that? Because, you know, as soon as we said non directive approach 27 years ago, or Stan had been saying it before that now we’ve been trying to explain what we mean by that ever since, and there’s a great and it’s understandably confusing for people, because it sounds like maybe you’re not doing much,

Dr. Signi Goldman 10:52

yeah. Well, I’m so glad you brought in that history with Stan Grof and all that. A lot of people may not know that that was when you started teaching and training that that that was the background that you had, and that you you already had, that breath work training and that awareness of like, you know, non ordinary states, more more globally, right? Um, and it’s also good for people to know that one of the main psychedelic researchers out there, which is you that I’m talking about right now, you and Annie, and actually the rest of the map seem to but you came out of Holotropic breathwork backgrounds. So altered states achieved in other ways, other than psychedelics, was something that you already understood and had lived experience with, and so and so I, who coined the term non directive, was that you was that Stan? Where did that that term, sort of the non directive approach come from, I know it’s kind of an, it’s an extension of this idea of the innate healing intelligence, but,

Michael Mithoefer 11:48

yeah, well, that’s,

Dr. Signi Goldman 11:53

it’s a mystery. It certainly

Michael Mithoefer 11:55

comes from Stan Grof’s idea. Yeah, Stan ever used those words. He basically talked about the inner healing intelligence, or sometimes inner healer I tend to use inner healing intelligence because I don’t want to anthropomorphize it too much. Yeah, maybe that’s the term I used in in the beginning, when I started writing down in the protocols what we were going to be doing the therapy. I can’t remember if it came from Stan’s ideas. Anyway,

Dr. Signi Goldman 12:25

an interesting term you used in the protocols initially was non directive. Yes, what would be in the MAPS trials? Got it okay. And

Michael Mithoefer 12:32

then we’d say relatively non directive. But then Rick Donald, you know, interestingly, not only did Annie and I train with Stan Grof, but before that, and before we had met him, Rick Doblin, the founder of MAPS, yeah, so we never really talked about the therapeutic approach. We just went and did it. But we were all grounded in the same idea. So Rick had the same idea from Stan,

Dr. Signi Goldman 12:57

yeah, I find myself in a parallel position, and because I’m training, sort of the current generation of therapists that’s coming into the ketamine assisted psychotherapy world, I’m one of many people doing that, but And so having to put words to what that is, because many of these people do not come from a Holotropic breathwork background, so it’s not intuitive. And I think I shared with you, I share with you the fact that I had a background in working with other forms of altered states, and I sort of I already knew that there was an inner hero healing intelligence, and that that was the source of the solution for the client often. And I already sort of understood that the role was to stay out of get, not get in the way of that, and to sort of follow along with that. But I found myself, when I started running a training program, having to put words to it. And really, let’s say this is what this means, because people didn’t, don’t often understand. And so I love that it came from Stan, and that we’re get to kind of name him as a, sort of a pioneer, thought leader in in this concept that we all carried forward of this, of what we’re calling the non directive approach, which, and I use the phrase non directive approach very much in trainings, but then I then have to go on to explain what a lot about what I mean by that, or demonstrate it, or things like that, is what I found. I think we’ve landed at that, the non directive approach that that phrase, because it gets thrown around a lot, but that phrase comes from the idea of respecting the inner healing intelligence. And that inner healing intelligence goes by other names, but, I mean, you know, people call it different things, but it really is the idea that on a psychedelic or in any kind of altered state of consciousness, there is something that arises that doesn’t come from the client’s conscious, rational mind and also doesn’t come from the therapist. There’s something that arises that is healing and that. Knows what to do, is kind of a way of describing that, this idea of the inner healing intelligence for those that just want us, you know, I want to make sure the audience is tracking along with us here. So if we all, if we all agree that that’s happening, and I think anybody who has sat with anyone in altered states for any length of time cannot deny that that is what’s happening. You know, that is the most compelling thing about this work, is that there is an innate healing wisdom that sort of guides the client, that just shows up, right? So then the next piece is, we as therapists need to not get in the way of that. And I that’s where the idea I’m imagine, of of you using the phrase non directive approach, came from. And that is 1,000% the correct stance. And so and then, now I think a lot of people are grappling with, they want to have a non directive approach, but the misunderstanding I see out there, the most, I don’t know if this is what you have run into, is that that means that you you kind of sit mostly silently like you don’t talk to them unless they’re in acute distress. I mean, you sort of, you really holding space and letting them have a psychedelic journey on their own, maybe only stepping in if there’s some sort of acute need. But you don’t, you’re not dialoguing. And then afterwards, when they come out of the medicine, then you integrate it. And so there’s a lot of, there’s, there’s not a lot of verbal exchange happening at all. And so interestingly, a lot of these people have been through MAPS training, as have I, and I, I always my reflection on watching you and Annie work, and because you the MAPS training that I did was with you and Annie, and I know Bruce and Marcella also have I was in the videos. That’s not the case at all. I feel like, yes, there are long moments of silence when the person is in their journey, but there’s also quite a bit of you dialoguing, you, letting them know that you’re present, you, mirroring back the content that’s showing up, reassuring other kinds of things. But that’s, that’s my memory of it. What I just want to know, if you have thoughts on that, like how, I guess the confusion is that non directive doesn’t mean that you’re not in dialog, right?

Michael Mithoefer 17:16

Yes, I think that’s so important, Signi, and you know, I want to add, we’ve never been that happy with the non directed term. And some years ago, it’s been quite a while now, Rick, I was talking to Rick Don about this, and we were all discussing it, Rick said, How about inner directed? So, and we now use inner directed. Mean, it’s directed from inside the the the participant. So that is better, actually, yeah, better. But, you know, the main point is the same. Yeah, it’s we certainly are in dialog with people quite a bit. And of course, that’s where there is a difference between medicines and doses. You know, MDMA is more relational and more conversation, sort of like psychotic doses of ketamine or even other things. So there, but the point, I think it’s more it’s not a point of, do you engage, or do you even use, you know, sometimes elements of other therapies that we’ve experienced in will be very useful in service of what’s happening, but that’s the point. So it’s not that you never have conversations or never give guidance or you never give direction. It’s there are three criteria. Basically, one is it needed. Often it’s not needed. So yeah, shut up and sit there. Yeah, be present, be empathic, but don’t keep your yapper shut if something is needed. So there’s that, you know, because sometimes we can, as therapists, we can either consciously or unconsciously you begin to feel we should be doing something useful.

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