In 2021, the Fireside Project, a psychedelic peer-support hotline, announced a research partnership with the University of California San Francisco. Working with data collected by the Fireside Project between April 2021 and September 2022, UCSF researchers analyzed survey data from over 800 people who used the hotline and published their findings in the June 2023 edition of the peer-reviewed journal Psychedelic Medicine.
Joseph Zamaria, principal investigator for the study and associate clinical professor of psychiatry at UCSF school of medicine, said in an interview with Lucid News that the findings help illuminate the unique moment researchers, advocates, and policy reformers are encountering as efforts to legalize psychedelic-assisted therapy move forward.
Entitled, “Reducing the Harms of Nonclinical Psychedelics Use Through a Peer-Support Telephone Helpline,” the paper presents the first peer-reviewed study to investigate the effectiveness of the Fireside Project’s peer-support phone and SMS hotline services.
Zamaria says the goal of the study was to look at data Fireside gathers from the people they serve and answer some essential questions. “Who’s using it, is it helpful, is it diverting resources from levels of care that are more costly on the system and probably less attuned to the experience of someone who has had or is having a psychedelic experience,” said Zamaria.
Building Cultural Containers to Reduce Risk
Despite the evolution of regulatory policies around psychedelics and advancements in models of psychedelic-assisted therapies, research shows that the majority of people who use psychedelics do so outside of the medical system, and take these compounds in an effort to “enhance well-being.” Due to prohibitive costs, stigma, and other barriers to access, many people will likely continue to seek out and use psychedelics outside of clinical frameworks – even after more substances are decriminalized and the FDA approves more forms of psychedelic-assisted therapy.
In turn, the safety and efficacy of these non-clinical psychedelic experiences will continue to be a public health concern, one that might be best managed by those familiar with psychedelic experience and healing.
Zamaria was only beginning to consider these questions when he first met Joshua White, Fireside Project co-founder, at the Psychedelic Science conference in Oakland in 2013. The two sat next to one another during a presentation from renowned psychedelic scholar Ralph Metzner.
Zamaria was completing grad school at the time, while White, then an attorney with the City of San Francisco, was completely new to the space. After meeting, they did not connect again for 7 years.
By then, the covid pandemic, and the subsequent mental health crisis catalyzed by isolation and grief, had prompted White to focus on psychedelic research. After serving for years as a volunteer counselor with Safe & Sound’s TALK Line, White drew from his experiences with peer-support networks and working with underserved communities and pitched Zamaria the idea of a psychedelic support hotline.
Zamaria says he encouraged White to launch the hotline noting that in non-clinical settings, “cultural containers,” rather than study protocols, must be created to help reduce risks for people using psychedelics. Researchers have found that communities construct cultural containers through collaboration, story-sharing, enforcement of social boundaries, and opportunities for individuation from shared and common values. They are always evolving over time and in relationship with changing social structures and community demographics.
Underground psychedelic communities throughout modern society have developed cultural containers both before and throughout the decades of prohibition, but these models are not accessible or appropriate for every community. Neither are traditional lineages of spiritual practice and modes of healing. Newly formed communities must often develop other ways to create cultural containers and forms of support.
Unlike cultures with millennia of traditional use of psychoactive compounds, Zamaria points out that some cultural containers in modern psychedelic communities can be examined as they are being built out. With escalating decriminalization efforts and increasing access to clinical trials, he believes that these containers are becoming easier to construct in the open, evaluate for efficacy, and incorporate into existing societal structures.
According to Zamaria, who now serves as an advisor to Fireside, the crisis hotline model, which has proven effective across many sectors of society, is a natural next-step in public health efforts to reduce the potential risks of psychedelics. He says that academic institutions like UCSF can help evaluate these emergent cultural containers as they are crafted in real-time. This pilot study is merely one step toward assessing programs like Fireside, says Zamaria.
Measuring Effectiveness Through Post-Call Surveys
Like other peer-support or crisis hotline models found across the public health sector, Fireside is designed not only to support a specific population, but also to reduce impacts on emergency support services that should prioritize physiological emergencies.
According to Zamaria, the study’s first author, Mollie Pleet, was the catalyst for creating a study to examine the impact of Fireside on the community it serves. Pleet is a clinical psychologist in private practice, a former postdoc at UCSF, and is currently working within clinical psychedelic research trials through the Portland-Vancouver VA Health Care System.
Other co-authors of the paper that examined the study include White and Rachel Yehuda, a Professor of Psychiatry and Neuroscience of Trauma at the Icahn School of Medicine at Mount Sinai. Yehuda is also director of the Mount Sinai Center For Psychedelic Psychotherapy and Trauma Research.
The study examined data from call logs created by Fireside’s volunteer peer-support specialists. The hotline also texts post-call surveys to clients within 24 hours of their contact with the hotline and this data was examined in the study as well. The research period includes 17 months of data, from the time of Fireside’s initial launch in April 2021 through September 2022. In that time the organization sent a total of 4,047 surveys to callers and received 848 responses, a response rate of roughly 20%.
Of the respondents, 12.5% said they may have otherwise called 9-1-1, while 10.8% said they may have instead sought help from the emergency room. Importantly, 29.3% of respondents said they may have been “physically or emotionally harmed” if not for the hotlines peer-supporter specialists. Overall, 65.9% indicated they “agreed or strongly agreed” they were de-escalated from emotional, mental, or physical distress.
According to the authors, “to our knowledge these are the first data suggesting that a lack of support during the process of psychedelic integration may lead to harm.” As discussed further in the paper, these positive findings are similar to data drawn from other community mental health support hotlines.
White says that if Fireside has the necessary resources, the organization will conduct longitudinal studies that explore why some people are able to alchemize challenging psychedelic experiences into positive life change. “To me, this is one of the most fascinating, and urgent, questions the psychedelic field faces,” says White. “Our new software system will allow us to conduct this research by auto-sending surveys to consenting callers weeks and months after their psychedelic journeys.”
Evaluating Volunteer-Reported Call Logs
Call-log results filed by Fireside’s peer-support specialists offered another perspective to help researchers understand effectiveness and impacts of the service. Of the 1,630 callers who were actively in a psychedelic experience, 39.9% reported taking the substance alone. Of those, 77% were at home and only 4.3% reported being outdoors in nature.
Further, of the 3,386 that called the hotline to discuss a current or past psychedelic experience, 27.4% mentioned an underlying psychiatric condition, primarily Post-Traumatic Stress Disorder (27.6%), Major Depressive Disorder (26.8%), and Generalized Anxiety Disorder (17.9%). Other conditions included Substance Use Disorder, Borderline Personality Disorder, Attention-Deficit/ Hyperactive Disorder, Obsessive Compulsive Disorder, and Eating Disorder.
Reflecting on these data, the authors suggest “people may be consuming psychedelics in nonclinical contexts to address underlying psychiatric conditions.” This echoes the global trend of people reporting self-treatment with psychedelics for psychiatric conditions and emotional distress as discussed in the 2020 Global Drug Survey. Globally, the most common psychiatric conditions reported are Depression (37.4%) and Anxiety (18.4%), with PTSD accounting for only 4.3%.
The authors further note that the majority of callers using psychedelics in non-clinical settings “do so without the necessary safety precautions.” Call log data reveales that many report a range of difficult emotions, including anxiety (33.7%), overwhelm (24.8%), confusion (13.8%), and fear (22%).
Zamaria notes that, “in clinical settings, these difficult emotions are met with safety protocol and experienced therapists”. But for users of psychedelics who experience psychedelics alone or outside of a group or ritual context, there should be a cultural container in place, not only for the benefit and safety of the individual, but also to offset the burden on emergency services.
According to the researchers, the Fireside Project has been effective in reducing the risks and harms of psychedelic use. Noting the limitations of self-reported data and Fireside’s data collection processes, the authors conclude that there is an “ethical imperative to delineate responsible solutions to reduce the risks associated with naturalistic psychedelic use”.
Addressing the Issue of Accessibility to Psychedelic Therapies
Zamaria says Fireside is just one program that aims to reduce the risk potential of non-clinical psychedelic use, but has several unique aspects.
Similar to other crisis hotline models that support people experiencing a specific type of heightened distress, Fireside provides services to those who are actively experiencing or processing a past psychedelic experience. The organization’s Affinity Peer Integration Support offering’s are designed to help “callers from historically marginalized communities to feel a sense of belonging and safety in the psychedelic field”, specifically “callers who identify as BIPOC, transgender, and military veteran communities.”
Like the Zendo Project, Fireside operates under a volunteer, peer-support model that engages community building and small-groups to review internal systems and best practices. Unlike the Zendo Project, which focuses on in-person peer-support at festivals and larger gatherings, Fireside offers a phone and texting service. By making both crisis support and integration support so accessible, the organization is aiming to reach the greatest number of people possible.
Zamaria believes that in order for psychedelic assisted therapy (PAT) to integrate into modern society, medical models are necessary. He notes, however, that these systems will not necessarily have the greatest impact on the general population. Under current models, he says access to PAT is only possible for those few who are lucky enough to qualify for a clinical trial, or who can afford services from underground therapists and are willing to take the personal and legal risks to do so – plus the necessary time away from work and family to integrate their treatment.
From a public health perspective, this suggests a future destined for a struggle toward equitable access. But, Zamaria believes that if peer-support models like Fireside could prove effective, then communities may have one model for developing sustainable, affordable support networks that can grow into the cultural containers needed in a post-prohibition society.
“Thanks to this study, we know that a psychedelic hotline, like other hotlines, is a high-impact, low-cost way to minimize harms, reduce distress, and provide people with support as they navigate challenging experiences,” says White. But he notes that in the current economy finding funding to make such services sustainable is a challenge.
White says that other hotlines often receive federal, state, and local funding as well as multi-year support from major institutional foundations. “Now that we know that the Psychedelic Peer Support Line delivers similar results, and prevents the very harms that precipitated the current disastrous war on drugs, my hope is that these traditional funding sources will become available to Fireside Project and the other nonprofits that are also foundational to the psychedelic field.”