Chapter 8 - Textbook

Absolute contraindications are conditions that preclude proceeding regardless of participant desire — no exceptions within facilitator scope. These are hard stops. The facilitator does not find workarounds, does not defer the decision to the participant, and does not apply clinical nuance that belongs to a licensed clinician. The absolute contraindications are: personal or first-degree family history of schizophrenia or schizoaffective disorder; current MAOI use; current lithium use; active uncontrolled seizure disorder; severe cardiovascular disease with recent major cardiac event.

Relative contraindications requiring medical clearance are conditions where proceeding may be appropriate — but only after a prescribing provider has been fully informed of what the service involves and has provided written documentation indicating the participant may proceed. These include: controlled cardiovascular conditions (hypertension, arrhythmia); current antidepressant use; controlled seizure disorder; renal or hepatic conditions affecting metabolism; pregnancy or breastfeeding. "My doctor is supportive" is not medical clearance. Written documentation from a fully-informed prescriber — that is clearance.

Monitoring conditions require heightened in-session attention but do not preclude proceeding with appropriate precautions. These are flagged in the intake for the administration facilitator's awareness — not as gate conditions.

MAOIs (phenelzine, tranylcypromine, selegiline) are an absolute contraindication — they create life-threatening serotonin syndrome risk in combination with psilocybin. This is not a clinical judgment call. It is a hard stop. Lithium creates seizure risk in combination with psilocybin — also an absolute contraindication. SSRIs and SNRIs interact with the serotonergic system and require medical clearance. Stimulants create combined cardiovascular effects and also require clearance. Cannabis is not a contraindication but requires a no-use window before the session — specific guidance lives in M11 Administration.

The facilitator equips the participant with a written service description document — a clear, plain-language summary of what psilocybin facilitation is, why certain medications require provider consultation, and what the facilitator is asking the provider to determine. The participant carries that document to, or sends it to, their provider appointment. The provider reads it and makes a written determination. The participant brings that determination back.

The facilitator never contacts a provider directly. This is not bureaucracy — it is scope discipline. The participant owns and delivers their own medical communication. The clinical determination belongs to the clinician who has the full medical picture of the patient in front of them. A facilitator who calls a participant's cardiologist is not being diligent. They are practicing medicine without a license.

The one pharmacokinetic fact relevant to eligibility screening: sessions typically last 4–6 hours, with effects potentially extending to 8 hours. A participant with an inflexible post-session commitment has a logistics problem that must be resolved before proceeding. Flag it here; the full conversation about logistics happens in 08C. What participants experience during a session — physical presentations, expected effects, how to observe and respond — is M11 Administration content and is not covered in this module.

The mindspace assessment is not clinical diagnosis. You are not determining whether someone has a psychiatric condition. You are recognizing stability indicators — observable, functional descriptions of where someone is right now — and making routing decisions based on those indicators. The language distinction is not semantic. "This participant displays features of emotional dysregulation and significant relationship instability" is in scope. "This participant has borderline personality disorder" is out of scope. The content of what you observe may be the same. The professional claim is entirely different.

Absolute Hold — refer to mental health clinician before any further steps: Active suicidal ideation with plan or means (M05 protocol activates immediately); active psychosis; acute manic or hypomanic episode; current severe dissociative episode. These are not situations where a facilitator continues the intake conversation while noting a concern. They require immediate halt and mental health referral.

Hold — not now for a full journey; specific pathway required: Unresolved acute trauma within 90 days; acute grief with collapsed support structures; active substance use disorder in active use phase (particularly stimulants or dissociatives); major acute life disruption; no current clinical support in the presence of significant psychiatric history. A hold is not a rejection. It is a description of what needs to be in place before the conversation about proceeding can happen. The language matters: "not now" is not "never." The door remains explicitly open.

Go with additional preparation: Well-managed depression or anxiety with current stability; processed trauma with active therapeutic support; addiction history in stable recovery; prior difficult psychedelic experience with integration work; borderline features with solid therapeutic structure. These participants can proceed — with specific additional preparation elements identified and built into the preparation plan.

Go with standard preparation: No current psychiatric concerns, adequate social support, no acute stressors, stable psychological baseline.

A hold conversation that simply communicates "I don't think you're ready" is an abandonment — it closes the door without telling the participant where the door is or how to get there from where they are. A hold conversation has three required elements: name the stability condition specifically and in non-diagnostic language; state what needs to be in place before the conversation about proceeding can happen — specifically and behaviorally, not vaguely; and offer the referral that will help get there. Bring your hold conversation template to every readiness conversation. Read it out loud before you use it.

Substance use history is relevant not just as a contraindication concern but as information about how the participant manages difficult states — both a potential resource and a potential vulnerability. Active addiction in the active use phase is a hold. Stable recovery is a go with additional preparation. The distinction is current functioning and support structures, not history alone. A participant who has been sober for three years with a solid recovery community is in a very different position from one in active dependence, even if their history looks similar on paper.

Lifespace maps to what the research literature calls "set and setting" — extended beyond the physical environment of the session to include the participant's entire life context in the period surrounding it. A participant in the middle of a high-stakes work deadline, a family crisis, or a contested custody situation is operating with a full cognitive and emotional load that the experience will not pause. It will often amplify.

• Obligations and responsibilities — who or what depends on this person in the 48–72 hours around the session? Is childcare, eldercare, or any sole-caregiver role covered? Is there a backup plan if the session runs longer than expected?
• Logistics — transportation to and from the session (no driving for 8+ hours post-ingestion), housing stability, financial stability as it relates to the ability to rest without working post-session, no inflexible commitment within 8 hours of session end.
• Support availability — is there at least one trusted person who knows the participant is doing this and can be contacted after the session? Not everyone has this. For isolated participants, the absence of a support person is a significant lifespace gap requiring a specific plan, not a checkbox.
• Work and professional context — can this person take the time they need? Is there any high-stakes professional demand in the days following that will create pressure on integration?
• Calendar and seasonal factors — anniversary dates, upcoming significant events, family obligations that create emotional pressure or timing constraints.

Not all participants have the same access to post-session flexibility. A single parent with limited childcare options, a shift worker who cannot take time off without financial consequence, a participant from a community where this work is stigmatized and who has not disclosed it to anyone — these participants face structural barriers to lifespace readiness that are not individual failings. The facilitator's job is to co-create a plan that acknowledges these realities, not to apply a template designed for a participant who has full professional and financial flexibility. Complex lifespace logistics are not disqualifying. They are factors to plan around collaboratively.

The lifespace conversation also establishes the adverse reaction response plan — a required element of a complete lifespace assessment. Who knows to call if the participant is in significant distress after the session? What is the threshold for seeking medical support? The three-threshold framework: monitor (manage independently with grounding practices); contact facilitator (within stated contact hours, for concerning but non-emergency presentations); emergency (911 or ER, for active self-harm ideation, inability to communicate, chest pain, seizure, or any situation requiring immediate medical attention). Both facilitator and participant sign off on these thresholds before the session proceeds.

Any single absolute stop in any space produces a hold or refer — regardless of how green the other spaces look. A participant who is physically and psychologically ready but whose lifespace has an unresolved critical gap (no transportation, active suicidal ideation trigger on the calendar, no support person at all) cannot proceed. The synthesis decision requires reviewing all three maps and applying the most conservative determination that the full picture warrants. But conservative does not mean defaulting to hold whenever there is any flag. It means accurately reading the flags and making a determination that reflects their combined weight.

The synthesis note is the written record of the eligibility determination — and it is one of the most important documents a facilitator produces. It must contain: what was disclosed in each space (using the participant's words in quotation marks where relevant); the classification applied (go / go with additional preparation / hold with pathway / hold pending clinical consultation); the specific basis for the classification in non-diagnostic language; every action taken (routing, referral, clearance requested, document provided) with date; and any conditions that must be in place before the determination can be revisited. What it does not contain: clinical diagnosis, interpretation of what disclosures mean clinically, the facilitator's prediction of outcome, or language that goes beyond what was disclosed.