Traditional Indigenous medicine in North America: A scoping review

• Nicole Redvers ,
• Be’sha Blondin

• Published: August 13, 2020
• https://doi.org/10.1371/journal.pone.0237531

• Article
• Authors
• Metrics
• Comments
• Media Coverage

• Abstract
• Introduction
• Methods
• Results
• Discussion
• Conclusion
• Supporting information
• Acknowledgments
• References

• Reader Comments
• Figures

Abstract

Background

Despite the documented continued use of traditional healing methods, modalities and its associated practitioners by Indigenous groups across North America, it is presumed that widespread knowledge is elusive amongst most Western trained health professionals and systems. This despite that the approximately 7.5 million Indigenous peoples who currently reside in Canada and the United States (US) are most often served by Western systems of medicine. A state of the literature is currently needed in this area to provide an accessible resource tool for medical practitioners, scholars, and communities to better understand Indigenous traditional medicine in the context of current clinical care delivery and future policy making.

Methods

A systematic search of multiple databases was performed utilizing an established scoping review framework. A consequent title and abstract review of articles published on traditional Indigenous medicine in the North American context was completed.

Findings

Of the 4,277 published studies identified, 249 met the inclusion criteria divided into the following five categorical themes: General traditional medicine, integration of traditional and Western medicine systems, ceremonial practice for healing, usage of traditional medicine, and traditional healer perspectives.

Conclusions

This scoping review was an attempt to catalogue the wide array of published research in the peer-reviewed and online grey literature on traditional Indigenous medicine in North America in order to provide an accessible database for medical practitioners, scholars, and communities to better inform practice, policymaking, and research in Indigenous communities.

Figures

Citation: Redvers N, Blondin B (2020) Traditional Indigenous medicine in North America: A scoping review. PLoS ONE 15(8): e0237531. https://doi.org/10.1371/journal.pone.0237531

Editor: Jon Wardle, Southern Cross University, UNITED STATES

Received: March 31, 2020; Accepted: July 28, 2020; Published: August 13, 2020

Copyright: © 2020 Redvers, Blondin. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) was a pivotal document for the world’s Indigenous Peoples [1]. In addition to being quoted in numerous policy, research, and community initiatives since it was adopted, the declaration is now being used to evaluate the adequacy of national laws; for interpreting state obligations at the global level; and by some corporations, lending agencies, and investors in regards to resource and development opposition on Indigenous lands [2]. Article 24 of the declaration states that “Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals, and minerals” (UN document A/RES/61/295). The World Trade Organization has stated that “traditional medicine contributes significantly to the health status of many communities and is increasingly used within certain communities in developed countries. Appropriate recognition of traditional medicine is an important element of national health policy” [3].

The United Nation’s Economic and Social Council President in 2009, Sylvie Lucas, stated that “[t]he potential of traditional medicine should be fostered. … ‘We cannot ignore the potential of traditional medicine’ in the race to achieve the Millennium Development Goals and renew primary health care for those who lacked access to it … traditional medicine [is] a field in which the knowledge and know-how of developing countries was ‘enormous’—and that was a source of hope for improving the world’s health-care situation” [4].

In November 2008, member states of the World Health Organization (WHO) adopted the Beijing Declaration [5], where they recognized the role of traditional medicine in the improvement of public health and supported its integration into national health systems where appropriate [6]. The declaration also promotes improved education, research, and clinical inquiry into traditional medicine, as well as improved communication among health-care providers [6].

Research into some types of complementary and alternative medicine (CAM) practices has received large amounts of funding. For example, the US National Institute of Health has a division called the National Center for Complementary and Alternative Medicine (NCCAM), which in 2010 had a budget of US$128.8 million dollars [7]. Before the Beijing Declaration, sixty-two countries had national institutes for traditional medicine as of 2007, up from twelve in 1970 [4]. Despite this, there has been a complete lack of acknowledgement of the Indigenous traditional knowledge (TK) currently being used in many CAM professions. In some cases, there has been direct cultural appropriation of traditional medicine and practices by CAM or other biomedical groups in North America [8]. Although outdated, given the lack of scholarship in this area, a 1993 estimate put the total world sales of products derived from traditional medicines as high as US$43 billion [9]; however, only a tiny fraction of the profits were and are being returned to the Indigenous peoples and local communities from where these medicines were derived. In the early 1990s, it was estimated that “less than 0.001 per cent of profits from drugs developed from natural products and traditional knowledge accrue to the traditional people who provided technical leads for research” [10].

So, despite some progress on a global level in CAM research and practice, many Indigenous medicine systems around the world are still often given the back seat when it comes to both acknowledgement and practice within the conventional medical-care setting. The terms and attributes used for traditional medicine, such as ‘alternative’, translates into an epistemological discomfort regarding the identity of these medicines [11] that automatically sets a power differential from conventional care. In 2007, The Lancet published an article in which the authors stated, “[w]e now call on all health professionals to act in accordance with this important UN declaration of [I]ndigenous rights—in the ways in which we work as scientists with [I]ndigenous communities; in the ways in which we support [I]ndigenous peoples to protect and develop their traditional medicines and health practices; in our support and development of [I]ndigenous peoples’ rights to appropriate health services; and most importantly in listening, and in supporting [I]ndigenous peoples’ self-determination over their health, wellbeing, and development” [12].

In his 2008 dissertation, (Gus) Louis Paul Hill noted that there is a paucity of literature on Indigenous approaches to healing within Canada specifically, and little documentation and discussion of Indigenous healing methods in general [13]. With this, there is currently no formal Canadian (or US based) Indigenous health policy framework or national adopted policy on Indigenous traditional medicine [14,15], and no broad application and endorsement of Indigenous ways of achieving wellness markers that are self-determined in an already marginalized community (demonstrated by a lack of funding and accessibility to these services generally).

Despite this being an emerging scholarship area, with a clear lack of reflected national health policy, there is increasing evidence on the use of traditional Indigenous medicine in certain areas of need such as in substance abuse and addictions treatment [16–21]. When Canadian Indigenous communities were asked about the challenges currently facing their communities, 82.6% stated that the most common issue was alcohol and drug abuse [22] and that traditional medicine itself is a critically important part of Indigenous health [23], including in the support of addictions. Due to the often upstream, structural, and socio-political [24] factors driving substance abuse in addition to other health ailments in Indigenous communities, advancing co-production of treatment options such as utilizing traditional medicine that already fits into an Indigenous paradigm may ensure four key steps to wellness occur: decolonization, mobilization, transformation, and healing [25].

The present study

Despite the documented continued use of traditional healing methods, modalities, and their associated practitioners by Indigenous groups across North America, widespread knowledge of this domain is presumed elusive among most Western-trained health professionals and systems. This despite the fact that the approximately 7.5 million Indigenous peoples who currently reside in Canada and the United States (US) are most often served by Western systems of medicine. There is current exploration in the literature on how cultural competency and safety impacts health disparities across diverse populations; however, there is little attention to how traditional Indigenous medicine systems fit into this practice area. Therefore, an account of the state of the literature is currently needed in this area of traditional Indigenous medicine to provide an accessible resource tool for medical practitioners, scholars, and communities in the North American context to better understand Indigenous traditional medicine in the context of current clinical care delivery and future policy making. In addition, having baseline literature on this topic area available for use in cultural safety training, and diversity and inclusion training on or off reservations, is warranted and in need.

Considering the paucity of accessible information on traditional Indigenous medicine, in addition to the lack of cohesive understanding on what traditional healing is within the Western context, the purpose of this present study is–

1. to catalogue the current state of the peer-reviewed and online grey literature on traditional medicine in the North American context by identifying the types and sources of evidence available, and
2. to provide an evidence-informed resource guide for medical practitioners, scholars, and communities to better inform “practice, policymaking, and research [26]” in Indigenous communities.

Methods

The methodology for this scoping review was a mixed-methods approach (Western-Indigenous). The first four steps of the scoping review were conducted within a Western methodological approach as outlined by Pham et al. [27] and based on the framework outlined by Arksey and O’Malley [28] with subsequent recommendations made by Levac et al. [29] (i.e., (1) combining a broad research question with a clearly articulated scope of inquiry, (2) identifying relevant studies, (3) study selection, and (4) charting the data). For the fifth step, as outlined by Arksey and O’Malley [28], (i.e., (5) collating, summarizing, and reporting the results), we utilized a dominant Indigenous methodology that places a focus on personal research preparations with purpose, self-location, decolonization and the lens of benefiting the community [30–32]. Although this research process did include the Western conceptions of collating, summarizing, and reporting the results as per outlined and described by Arksey and O’Malley [28], there was a very clear intent of identifying ourselves, the authors, as being rooted within Indigenous communities, and within an Indigenous worldview. This meant that we were not able to critique or provide commentary to contradictory evidence found in the scoping review process, as it is not culturally appropriate to provide this type of analysis within the topic area of traditional medicine through an Indigenous worldview. As Saini points out, utilizing self-determined Indigenous methodologies is “critical to ensure Aboriginal research designs are not marginalized due to perceptions that they are somehow less valid or sophisticated than their counterparts” [33] at the community or systems level.

The sixth methodologic step in our scoping review, as advanced by Levac et al. [29], incorporates a consultation exercise involving key stakeholders to inform and validate study findings [26] and was done in parallel to all steps of the work. This was another mixed-method bridging step, where one Indigenous Elder who is considered a content expert in their respective community was utilized to ensure placement of the research in the Indigenous context despite the use of Western metrics for the data-collection portion of the work (as opposed to an academic or other institutional stakeholder). It must be noted that Indigenous Elders’ engagement with research is often solely for the purpose of benefiting their community [30–32]. This therefore creates a unique stakeholder engagement process that roots the research not to a specific Western-defined method or process but to a set of traditional Indigenous protocols (unwritten community directives defined through an Indigenous worldview) that must be followed to ensure uptake and acceptance of the work by Indigenous communities themselves. In essence, the ‘validation of study findings’ (as outlined by Levac et al. in their sixth methodologic step [29]) is not culturally malleable and needed to be changed to a process of reviewing the rules and parameters (i.e., traditional protocols) around how traditional medicine should be talked about in the context of research. The authors are both immersed in work with Indigenous communities and peoples and understands the importance of Indigenous research processes to move away from the conformity of Western notions of the scientific deductive process of new knowledge development, and instead to work towards providing space for the translational voices within Indigenous communities and peoples [34]. The review methodology was defined a priori.

Eligibility criteria, procedures, and search terms

Only articles published in peer-reviewed academic journals or easily accessible online reputable organizational documents and dissertation works that were formally published (i.e., online grey literature) were included. No limits were put on the type of research conducted, whether qualitative, quantitative, commentary, or otherwise given the specific nature of the topic and the assumed limited studies available for review. Studies were included if they made reference to traditional medicine, or if they noted specific traditional medicine interventions or practitioners (i.e., sweat lodge, traditional healers, etc.). Ethnobotanical, plant physiology, and reviews of specific Indigenous plants were excluded from this scoping review as they were most often not based on the context of traditional medicine but the function and action of the plant itself. All studies up until June 29, 2020 were included in the review.

The authors did not specify a definition for ‘traditional medicine’ before selecting studies for this review, which was purposeful. There is currently a vast array of traditional medicine modalities, practices, and people across North America who may have varying definitions or interpretations of the terms and practice. This therefore required a broad inductive and immersive approach to allow the community of researchers in this area to provide their own definitions regionally, which therefore made an impact on the breadth of articles found. All the variants of the words for traditional medicine that were used to include articles were based on existing knowledge, a pre-screen of the available literature, and consultation with an Elder (see S1 Table and ‘title and abstract relevance screening’ section).

No restrictions were put on language for the initial search; however, only English language articles were considered for inclusion. This was also due to a complete lack of peer-reviewed articles written in an Indigenous language being noted in prior work, in addition to the prospective difficulties and budget needed to attain translation support. With a multitude of Indigenous languages in North America, there is an unfortunate lack of access to translators for projects such as these. Articles that were outside of the continental US and Canada were also excluded (i.e., Pacific Islanders, etc.), in addition to those from Mexico despite the proximity of traditional lands within and to the US. This was due to differences in traditional medicine practice and agents in those areas. Books and book reviews were not included due to the difficulty in verifying their content. North American Indigenous was defined to be First Nations, Inuit, Métis, American Indian, Alaskan Native or the respective Bands and Tribes within the region. As demographic terminology changes depending on the region of the continent, it was important to ensure complete capture of the eligible literature by utilizing both Canadian and US Indigenous terminologies. A two-stage screening process was used to assess the relevance of studies identified in the search as further outlined below.

The scoping review process and search terms were developed with the aid of a medical librarian (D.O) in discussion with the lead author (N.R.). The search was created in PubMed using a combination of key terms and index headings related to North American Indigenous peoples and traditional medicine (see S1 Table). The search was completed between December 27, 2018 and June 29, 2020 by searching the following databases with no limits on the start date, language, subject, or type: PubMed, EMBASE, PsycInfo, Elsevier’s Scopus, PROSPERO, and Dartmouth College’s Biomedical Library database due to the breadth of databases available in this library. In addition, manual searches of the following websites were completed: Indigenous Studies Portal, University of Saskatchewan [35]; National Collaborating Centre for Aboriginal Health [36]; the Aboriginal Healing Foundation’s archived website documents [37]; and the International Journal of Indigenous Health, which includes archives from the Journal of Aboriginal Health. Google Scholar was searched by inspecting the first two pages of results and then subsequently screening the next two pages if results were identified until no more relevant results had been found. The reference lists of randomly selected articles were manually searched with a “snowball” technique utilized to identify any further literature that may have been missed in the first search round until saturation of the search had been reached.

Title and abstract relevance screening

A title and abstract relevance form was developed by the author (N.R) in a session during the Elder consultation (B.B), mainly by the a priori identification of the search terms used and as listed in the S1 Table. As the goal was to capture as much available literature on the subject as possible, the title and abstract review were non-restrictive other than the stated eligibility criteria and search terms noted above. The reviewer was not masked to the article authors or journal names as this was not a results-based review. Some article titles did not have an abstract available for review and were therefore included in the subsequent full review to better characterize the content relevance to the topic area. If there was a question on the relevance of an article for inclusion, the Elder was brought into the discussion (B.B) as the final authority for the decision on whether to proceed with inclusion.

Data characterization, summary, and synthesis

After title and abstract screening, all the citations that were deemed relevant to the topic were kept in the scoping review database (S2 Table). All full text articles were obtained once identified as eligible; however, as the intent was not to provide critical review of the articles, they were not catalogued based on the completion of a full text article review. Instead, all articles were kept in the database from the title and abstract screening alone for the categorization process, ensuring that no judgement was placed on traditional medicine topics in keeping with an Indigenous methodological paradigm. Therefore a quality assessment procedure was not performed on the articles included in this scoping review as noted (e.g., Critical appraisal of qualitative research [38]) for a few reasons:

1. The purpose of this review was to map the existing state of the literature on this topic and not to analyze the results of the included articles, and
2. The vast array of formats and methodologies used in the Indigenous traditional medicine literature make the dominant Western metrics of validity simply not applicable to the current research purpose.

All citations found were compiled in a single Microsoft Excel 365 ProPlus spreadsheet. Coding of articles was done based on title and abstract review alone, with an Elder advisor to aid identification of categorical themes. Themes were based and developed by way of traditional knowledge (TK); however, it was noted in the synthesis process that there was often substantial overlap between themes. In these cases, a priority category was given for the ease of database creation which means that the categorical themes cannot be looked at as being black and white. Traditional Indigenous medicine is often very complex in its practice; however, an attempt was done to ease classification by assessing for the most discussed or most focused research topic(s) in each article.

Results

Due to the substantial overlap of search terms used for traditional medicine in other disciplines (i.e., traditional medicine can be the term used from the Indigenous perspective or from the Western perspective), the initial search yielded thousands of articles.

Based on a review of the title and abstracts, 249 articles met the criteria for inclusion (see S2 Table for the full database of articles included). A full article review was conducted when the initial screen left questions about the relevance of the research for inclusion. Broad inclusion was purposeful, as by ensuring a wide capture of the literature was categorized, future research and program needs have a more complete database to pull information from. Articles ranged in date from the earliest year of publication, being in 1888, to the most recent publication, being in 2020 (Fig 1). Sixty two percent of the articles were published prior to 2009 (n = 154) with the average year of publication being 2001.

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Fig 1. Trends in the number of articles identified in the scoping review over time.

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There were five overlapping categorical themes that emerged in the review including: General traditional medicine, integration of traditional and Western medicine systems, ceremonial practice for healing, usage of traditional medicine, and traditional healer perspectives. Fig 2 summarizes the selection process and findings.

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Fig 2. Adapted PRISMA diagram.

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General traditional medicine

There were 126 articles identified for this category with the majority of the publications being from 2009 and earlier (75%, n = 95). Thirty-three of the articles were based in Canada, one was based in both Canada and the US, and the remaining ninety-two were based in the US alone. The publication dates for articles spanned a wide time period between 1888 and 2020 (average year of publication was 1997), with the majority being commentary or qualitative in nature.

In the review of this category, it became clearly evident that the terms or conceptualizations applied to traditional medicine or its variants (i.e., traditional healing, Native American healing, etc.) were very generalized. Specifically, the general research topics ranged from trying to answer the question of what is traditional medicine [13,39–41], to asking questions on the efficacy and acceptance of traditional medicine [42–44], to the applicability of traditional medicine with specific disease states [45–47], in addition to stories of healing by recipients of traditional medicine practice or approaches [48,49].

According to Alvord and Van Pelt, traditional medicine is described in the Navajo culture as a medicine that is performed by a hataalii, which is someone who sees a person not simply as a body, but as a whole being with body, mind, and spirit seen to be connected to other people, to families, to communities, and even to the planet and universe [50]. In helping to clarify the intent and purpose for utilizing a traditional Indigenous medicine approach, Hill describes it as “the journey toward self-awareness, self-knowledge, spiritual attunement and oneness with Creation” and “the lifelong process of understanding one’s gifts from the Creator and the embodiment of life’s teaching that [an] individual has received” [13]. The traditional medicine practitioner’s role in the healing process has been described as their being an instrument, a helper, the worker, the preparer, the doer in the healing process with the work using the “medicines” being slow, careful, respectful, and embodying a sense of humility [51].

Also of note in this section of articles, was the subtle distinction between the terms ‘traditional healing’ compared to the actual using of ‘traditional medicines’. The core of ‘traditional healing’ was said to be or attaining spiritual ‘connectedness’, in which there were many stated ways for developing this in order to have a strong physical body and mind [52]. In essence, this ‘connectedness’ could be with or without the actual use of what we would call a ‘medicine’ in Western terms achieved instead through being in harmony with the natural environment, through fasting, prayer, or meditation, or through the use of actual ‘traditional medicines’ that could include plant- and herb-based medicines [52].

Quantitative data analysis within the general traditional medicine category of articles was rarely performed. When quantitative analysis was performed, it was usually done in a mixed method format that utilized survey tools alongside qualitative approaches (e.g., interviews, focus groups) [53–55]. For example, a mixed methods study by Mainguy et al., found that the level of spiritual transformation achieved through interaction with traditional healers was associated with a subsequent improvement in medical illness in 134 of 155 people (P < .0001), and that this association exhibited a dose-response relationship [55]. In another mixed-methods study by Marsh et al., a 13-week intervention with “Indigenous Healing and Seeking Safety” in 17 participants demonstrated improvement in trauma symptoms, as measured by the TSC-40, with a mean decrease of 23.9 (SD = 6.4, p = 0.001) points, representing a 55% improvement from baseline [53]. Furthermore, in this study all six TSC-40 subscales demonstrated a significant decrease (i.e., anxiety, depression, sexual abuse trauma index, sleep disturbance, dissociation, and sexual problems) [53].

It was clear from the review of articles in this category that a large number of the articles were written from an observational or commentary perspective by non-Indigenous scholars (e.g., anthropologic perspectives) [42,56]. Those written more than twenty years ago often had titles or content that would not be considered culturally appropriate in today’s scholarly work. For example, an article by Walter Vanast from 1992 was titled, “‘Ignorant of any Rational Method’: European Assessments of Indigenous Healing Practices in the North American Arctic” [57]. Considerations for the issue of quality and accuracy in this body of literature will be addressed in the discussion section of this paper.

Integration of traditional and Western medicine systems

A total of 61 articles in this category were reviewed, with publication dates ranging from the year 1974 to the year 2019 (average year of publication was 2006). Sixteen percent (n = 10) of these articles were from nursing journals, and 39% (n = 24) were articles from mental health and/or substance abuse journals. Of the total number of articles in this section, 61% (n = 37) were based in the US, with the remaining being from Canada (n = 24).

Articles in this category fell into overlapping subsets within the overarching theme of the integration of traditional Indigenous medicine systems with Western medicine systems. There were articles specifically calling for physicians and other healthcare providers to better collaborate with traditional healers [58,59], and also calls for health “systems” to better coordinate and work with Indigenous medicine systems and associated practitioners [60–62]. Some of the articles focused on cultural accommodations, and awareness and attitudes in medical settings towards traditional medicine and healers [63–65]. Lastly, a number of articles reviewed existing medical environments, practitioners, and facilities that had either piloted or fully integrated traditional and Western medical care under the same roof or practice [24,66–69].

The integration of traditional medicine into existing medical education environments was showcased through a residency training program as described by Kessler et al. [70]. In 2011, the University of New Mexico Public Health department and their General Preventive Medicine Residency Program in the United States started to integrate traditional healing into the resident training curriculum with full implementation completed by 2015. An innovative approach was used in the teaching delivery by utilizing a compendium of training methods, which included learning directly from traditional healers and direct participation in healing practices by residents [70]. The “incorporation of this residency curriculum resulted in a means to produce physicians well trained in approaching patient care and population health with knowledge of culturally based health practices in order to facilitate healthy patients and communities” [70].

Other articles in this section described the role of nurses in advocating for Indigenous healing programs and treatment. In research by Hunter et al., healing holistically can be said to match the time-honored values seen in the nursing profession: caring, sharing, and empowering clients [71]. Participant observations demonstrated that health centers could support progression along a cultural path by providing traditional healing with transcultural nurses acting as lobbyists for culturally sensitive health programs directed by Indigenous peoples [71]. This need for advocacy and awareness building on traditional ways of healing were emphasized throughout this category of articles.

According to Joseph Gone, “Lakota doctoring [traditional healing] remains highly relevant for wellness interventions and healthcare services even though it is not amenable in principle to scientific evaluation” [72]. In reference to Indigenous healing practices in general, Gone states that in Indigenous settings “we already know what works in our communities” and this claim seems “to reflect the vaunted authority of personal experience within Indigenous knowledge systems [72].

Some scholars noted the potential harms of not moving towards a respectful dialogue between the two systems of medicine (i.e., Western and Indigenous). A noted article by David Baines, an Indigenous physician from the Tlingit/Tsimshian tribe in Southeast Alaska, describes one of his patients who had metastatic lung cancer [73]. The patient had an oncologist but also went to a traditional healer to help deal with the pain she was having [73]. When the patient told the oncologist she was seeing a traditional healer, the oncologist got angry and wanted to know why she wanted to see a “witch doctor” [73]. The patient was offended and angry and refused to go back to the oncologist. She ended up dying a very painful death. Dr. Baines noted that it is important to remember we have the same goal—a healthy patient [73].

Ceremonial practice for healing

Thirty articles were identified for this category. Important sub-categories became apparent in the review, including sweat lodge ceremonies (n = 15), traditional tobacco ceremonies and use (n = 6), birth and birthplace as a ceremony (n = 2), puberty ceremonies (n = 4), and using ceremony as a model for healing from a relative’s death or from trauma (n = 3). There were only eight Canadian studies published in this category, with the majority being based in the US (n = 22).

Sweat lodge ceremonies (SLC) have been practiced by many Indigenous nations since ancient times. SLCs are used as a process of honoring transformation and healing that is central to many Indigenous traditionalisms [74]. Gossage et al. examined the role of SLCs in the treatment for alcohol use disorder in incarcerated people [75]. The Dine Center for Substance Abuse Treatment staff utilized SLCs as a specific modality for jail-based treatment and analyzed its effect on a number of parameters. Experiential data was collected from 123 inmates after SLCs with several cultural variables showing improvement [75]. Gossage et al. also reported results from a similar prior study that analysed data for 100 inmates who participated in SLCs [75]. The research found that incarceration recidivism rates for those SLC participants was only 7% compared with an estimated 30–40% for other inmates who did not participate in such ceremonies [75]. Another study by Marsh et al., gathered qualitative evidence about the impact of the SLC on participants in a trauma and substance-abuse program and reported an increase in spiritual and emotional well-being that participants said was directly attributable to the ceremony [76].

Much of the existing literature on ceremonial tobacco focuses on either the perception of usage or the usage in general by Indigenous peoples in the region examined. In research done by Struthers and Hodge, six Ojibwe traditional healers and spiritual leaders described the sacred use of tobacco [77]. Interviews with these traditional healers confirmed that “sacred tobacco continues to play a paramount role in the community and provides a foundation for the American Indian Anishinabe or Ojibwe culture. They reiterated that using tobacco in the sacred way is vital for the Anishinabe culture [as] tobacco holds everything together and completes the circle. If tobacco is not used in a sacred manner, the circle is broken and a disconnect occurs in relation to the culture” [77].

The exploration of ceremonies surrounding birth and the relationship that is created through birth practices were outlined in a few studies reviewed for this category [78,79]. Ceremony was referred to in this context as the practice of what can be considered “rituals of healing”, noting that pregnancy itself “is carrying sacred water” [78]. As Rachel Olson points out, “[b]ringing people “back” to practicing ceremonial ways is seen as a healing process from the trauma encountered by First Nations peoples in Canada, as well as a way to both maintain our connection to the land and water, and to keep that same land and water safe for future generations. The implication in this is that by restoring our connection to the land through ceremony, other structural issues will again come into balance” [78].

Usage of traditional medicine

Data collection was completed in reservation and urban Indigenous communities to determine the usage rates of traditional medicine by Indigenous peoples. There was a total of 14 articles published on this topic, which included over 650 participants combined who completed surveys or interviews. Five studies were completed in Canada, and the remaining were completed in the United States (n = 9). Seventy-nine percent of the studies were published prior to 2009 (n = 11). The average year of publication was 2002 with publication dates ranging from 1988 to 2017. Rates of usage of both traditional medicines and traditional healers varied per region. Relevant findings are summarized in Table 1.

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Table 1. Included studies in the category “Usage of traditional medicine”.

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Overall, the perception of traditional medicine amongst Indigenous people were positive. Several studies noted that access was an issue for many respondents who had the stated desire to use traditional medicine or see a traditional healer but did not know where to go for this support or treatment.

Traditional healer perspectives

The viewpoints of traditional healers themselves are an important contribution to this research topic. There were 18 studies that elicited the perspectives from Elders and traditional healers ranging in dates of publication between 1993 and 2019 (average year of publication was 2011). Twelve studies were either fully or partially based in the US, with nine articles published in either nursing or mental health related journals.

Moorehead et al. describe discussions held with a group of traditional healers on the possibilities and challenges of collaboration between Indigenous and conventional biomedical therapeutic approaches [93]. The participants recommended the implementation of cultural programming, the observance of mutuality and respect, the importance of clear and honest communication, and the need for awareness of cultural differences as a unique challenge that must be collaboratively overcome for collaboration [93].

It is not culturally acceptable to alter the words or provide an interpretation of the words of traditional healers. The following are some notable excerpts from traditional healer interviews that occurred in the literature reviewed:

The doctors and nurses at a local hospital asked me to speak to them on natural medicines. So I did. You could tell the doctors have a hard time trying to understand traditional healing and the use of plants to heal…it is hard for them to understand. Some of them got up and left when I started to talk about how you have to develop a relationship with the plant world…They sometimes have a hard time if things are not done their way…I respect the medicine, I just wish Western medical persons would understand [94] …

When we gather medicine…the plant has a spirit in it…and…the spirit of those plants stays in the medicine…Every individual is different…every remedy is different…because specific things work for specific people…We’re made up of four parts…physical, mental, emotional, and spiritual. Sometimes sickness can be caused by imbalance within a person. When we do Indian healing…it goes to the source of the problem…not to the symptoms [94].

It’s a very powerful gift that we’ve been given…I am not a healer…I am only an instrument in that whole process. I am the helper and the worker, the preparer, and the doer. The healing ultimately comes from the Creator…With the lighting of that smudge, holding that eagle feather while we pray…these sacred medicines, these sacred pipes, and everything that we carry in our bundles. That’s where the strength comes from…from those medicines, from Mother Earth, and from the Creator… You are a part of creation, you’re a part of everything…there is this interrelatedness of all things, of all creation, and everything has life…we’re a whole family. And we’re related to all living things and all beings and all people [95].

I’ve been saying it for years. We need more medicine people. We need more Native healers…male and female [96].

It was apparent throughout the articles reviewed for this category that many traditional healers were not opposed to Western medicine; however, many had voiced concerns that Western medicine seemed to not respect them (i.e., didn’t respect their way of thinking or disregarded their knowledge base). Overall, a deep understanding and appreciation for the long-standing colonial injury felt in many Indigenous communities demonstrated through the cumulative effects of trauma ‘snowballing’ across generations [94] has become a platform for much of the traditional healers’ work in their home communities. To work with these present and historical harms, there was a clear advocacy among many of the traditional healers interviewed for ensuring the availability of therapeutic talk within cultural settings in addition to ceremonial participation to help facilitate healing and the revival of traditional spiritual beliefs [97].

Discussion

This scoping review identified 249 articles that were predominately qualitative in nature, pertaining to traditional Indigenous medicine in the North American context. Although there was broad coverage of the topic area, it became apparent that many of the published articles were written from an ‘outsider’ perspective (i.e., observational research by scholars outside of the Indigenous communities themselves). With this, there was a slight shift noted in the type of research that was completed on traditional medicine around the 2000s. Prior to this date, it became apparent by the writing style used by many authors (i.e., they, them, etc.) that the articles were very much written “about” Indigenous people and their traditional medicine practice(s). Although post-2000 there was still quite a large volume of articles written by non-Indigenous scholars, there was an increasing presence of articles authored or co-authored by Indigenous people themselves [13,60,68,72,76]. The significance in this regard is notable as the presentation of Indigenous medicine by outside researchers often misses key cultural nuances, sometimes uses inappropriate or even insulting terminology, has a tendency to make assumptions that are not always correct (implicit bias), and presents an application or integrationist perspective that comes from what is often perceived to be a dominant Western knowledge system. As this type of ‘outsider’ scholarship serves as the foundational academic and clinical knowledge base for many of the current assumptions around traditional medicine, it was important to catalogue where some of the noted bias comes from.

Although it can be culturally inappropriate to assume there are pan-Indigenous ways of looking at traditional medicine and its practice (due to often stark differences in the practice of traditional medicine regionally), similar sentiments were expressed throughout many of the published articles. One was the assumed dominance of conventional medicine over traditional medicine practice, presented sometimes unconsciously through Western providers’ or researchers’ accounts of the subject and the language used. One possible consideration in this respect is that Indigenous-based interventions were often defined by a Western methodological approach and governance structure, which could be said to constrain and change the descriptions or programs themselves into something they were not actually meant to be. One solution to this issue would be to utilize an Indigenous methodological approach, governance structure, and reporting approach for these interventions, and then adapt the Western system to this approach and structure instead [58]. This would better ensure the centering of an Indigenous worldview and knowledge system through a truly self-determined Indigenous model with a potentially higher degree of success.

There is often a misperception that Indigenous peoples are in need of Westernized science in order to ‘legitimize’ our knowledge and healing systems [98]. It was clear from the literature reviewed on traditional healer perspectives that there was great opportunity for Western medicine and providers to learn about other ways of looking at health and disease in a form of respectful cooperation with Elders and Indigenous communities. This is consistent with the work of Berbman in 1973 who tells a story about a psychiatrist who brought some Navajo medicine men into his practice to demonstrate some of the things that he does in his practice [99] (i.e., the psychiatrist’s intent was to teach the medicine men). The psychiatrist demonstrated putting a Navajo woman under hypnosis for the medicine men.

One of the medicine men stated, “I’m not surprised to see something like this happen because we do things like this, but I am surprised that a white man should know anything so worthwhile… they [then] asked that my subject … diagnose something [while under hypnosis]. I objected, saying that neither she nor I knew how to do this and that it was too serious a matter to play with. They insisted that we try, however, and finally we decided that a weather prediction was not too dangerous to attempt. …When my subject was in a deep trance, I instructed her to visualize the weather for the next six months. She predicted light rain within the week, followed by a dry spell of several months and finally by a good rainy season in late summer. I make no claim other than the truthful reporting of facts: She was precisely correct” [99].

It was also evident through the articles reviewed that many Indigenous peoples using traditional medicine do not disclose this use to their Western healthcare providers. This reflects on the importance of developing culturally safe health systems and healthcare providers with strong communication skills for diverse patient settings. The story told by David Baines about the oncologist calling the patient’s traditional healer a “witch doctor” was a clear example of a lack of respect for utilizing a shared decision-making methodology for best outcomes in a clinical setting [73]. Implicit as well as overt bias against medical pluralism in diverse settings needs to be acknowledged and addressed in often authoritarian institutional settings [100,101] for best patient outcomes.

Overall, there has been a recent push with somewhat more acceptance in certain conventional medical settings towards supporting traditional Indigenous medicine interventions as demonstrated in some of the literature in this scoping review; however, the question remains whether or not “these efforts tend to represent political achievements more so than bona fide epistemological reconciliation” [72]. With continuing and significant health disparities existing in Indigenous populations in North America [102], a broader concerted effort needs to be mobilized and operationalized to ensure that Indigenous self-determined ways of knowing in relation to health and delivery of care is prioritized. Initial outcomes are promising in regard to traditional medicine’s benefit for Indigenous peoples in self-determined healthcare environments and settings. This has been clearly demonstrated by some of the literature reviewed here, yet, without more formalized support from all levels of the healthcare system, it will be difficult to expand these benefits and health outcomes to all Indigenous peoples who desire this type of care. This review and database (S2 Table) will hopefully serve as a repository for a portion of the academic literature contributing to practice, policy making, and research on this topic. This effort is aligned with Article 24 of the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP):

Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals, and minerals [1].

Limitations

This scoping review was an attempt to catalogue the literature in the area of traditional Indigenous medicine in the North American context. The use of defined categories may give the impression of distinct traditional medicine themes unrelated to each other; however, due to the wholistic nature of traditional medicine, there will always be substantial overlap between concepts given the interconnected nature of all aspects of Indigenous healing practices. Categorical themes were used to help create some organization of the large body of literature aiding with delineating future research needs as well as for the ease of pulling for programmatic and policy needs.

It is possible, due to the substantial overlapping terminology with other fields, that some articles may have been missed in the search strategy. With this, an effective search strategy in this field would require the searcher to be familiar with how Indigenous medicine terminology is commonly used and applied in academia to be able to correctly select and screen articles from a very large databases of mixed disciplines. Traditional medicine terminology can be complex and can be referenced using other languages or simply geographic location. Due to this, any published articles that used unique ways of referencing traditional medicine or were described using an Indigenous language term could have caused additional articles to be missed; however, due to saturation being reached in the methods review, we feel the literature was well represented in our database. Regardless, this comprehensive database (S2 Table) of the available literature should not be considered exhaustive of all available material on this topic.

From an Indigenous worldview, culture and cultural practices can be looked at and examined as being a form of medicine. Even traditional language can be considered a form of cultural medicine [103]. This review excluded studies to this effect due to the variation in interpretations that are possible in this area; however, this exclusion was not intended to degrade or minimize the importance of culture as a healing strategy in any way. Due to the need to capture one defined area of this topic on traditional medicine and healing as a first step, further research can now build upon this work by evolving the scholarship area to be inclusive of all facets of Indigenous healing.

Traditionally within Indigenous communities, knowledge on traditional healing or the medicines themselves was and is passed down through a strong oral tradition that often involves deep ceremonial practice. As knowledge transmission in the North American context most often does not include a written record, historical and present-day information on community practice in this area is rightfully held within Indigenous communities themselves. This form of knowledge needs to be recognized, honored, and respected in the context of the traditional protocols that the respective community follows under the guidance of their Elders. This knowledge is the true knowledge that is most often not reflected in written academic scholarship. Some Indigenous communities have become more engaged with research as you will have seen throughout this review; however, some choose not to engage in this form of knowledge transmission for a variety of important reasons. This review, although detailed, is therefore only a small snapshot of the vast knowledge that exists within Indigenous communities in North America.

A critical review of the retained full text articles was not completed as the intent was to provide a representative and complete database on this topic. In addition, the vast array of formats and methodologies used in the Indigenous traditional medicine literature make the dominant Western metrics of validity simply not applicable to the current research purpose. Because it is not culturally acceptable to critique traditional Indigenous medicine, an Indigenous methodology was honored. Using an inclusive framework for this topic, several articles that were not written by Indigenous peoples or communities were included, which in some cases portrayed gross stereotypes from ‘outside’ observations of traditional medicine practice(s). The reader is therefore advised to exercise caution when utilizing information from ‘outside’ observational and older studies that may not be reflective of actual and current Indigenous community perspectives on the topic discussed. To this end, we highly recommend prioritizing the respectful engagement of Indigenous scholars and/or their scholarship, community members, and local knowledge holders to better ensure the concepts and resources presented here will be grounded and relevant within any local or cultural context.

Conclusion

This scoping review identified 249 articles pertaining to traditional Indigenous medicine in the North American context with the following categorical themes being identified: General Traditional Medicine, Integration of Traditional and Western Medicine Systems, Ceremonial Practice for Healing, Usage of Traditional Medicine, and Traditional Healer Perspectives.

Although effort has been made to better accommodate Indigenous ways of knowing and healing into healthcare settings and delivery models, self-determined options for traditional Indigenous healing are still lacking in Western institutions. This scoping review underscores the crucial need to further examine the dynamics of healthcare relations in a post-colonial context, with more open spaces for dialogue surrounding the use of Indigenous traditional healing often desired in racially diverse medical settings. The prerequisite to move closer to transformative practice in this area involves prioritizing further research and communication on this topic with a focus on applied self-determined interventions and programming.

Supporting information

Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist.

RESEARCHARTICLE
Self-reported negative outcomes of psilocybin
users: A quantitative textual analysis
Bheatrix Bienemann
1
, Nina StamatoRuschel
Aure ´lio Negreiros
1
, Daniel C. Mograbi
1
, Maria Luiza Campos
1
ID1,2*
, Marco
1 DepartmentofPsychology,Pontifı ´cia Universidade Cato ´lica, São Paulo, Brazil, 2 Department of
Psychology, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, England,
United Kingdom
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OPENACCESS
Citation: Bienemann B, Ruschel NS, Campos ML,
Negreiros MA, Mograbi DC (2020) Self-reported
negative outcomes of psilocybin users: A
quantitative textual analysis. PLoS ONE 15(2):
e0229067. https://doi.org/10.1371/journal.
pone.0229067
Editor: Giuseppe Carrà, Universita degli Studi di
Milano-Bicocca, ITALY
Received: September 12, 2019
Accepted: January 28, 2020
Published: February 21, 2020
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0229067
Copyright: © 2020 Bienemann et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The article analyses
data already publicly available at www.erowid.org.
Funding: D.C.M. acknowledges funding from the
National Research Council (CNPq ref 312370) and

• [email protected]
  Abstract
  Psilocybin, a substance mainly found in mushrooms of the genus psilocybe, has been his
  torically used for ritualistic, recreational and, more recently, medicinal purposes. The scien
  tific literature suggests low toxicity, low risk of addiction, overdose, or other causes of injury
  commonlycausedbysubstances ofabuse,withgrowing interest in the use of this substance
  for conditions such as treatment-resistant depression. However, the presence of negative
  outcomes linked to psilocybin use is not clear yet. The objective of this study is to investigate
  the negative effects of psilocybin consumption, according to the users’ own perception
  through self-reports extracted from an online platform. 346 reports were analyzed with the
  assistance of the IRAMUTEQ textual analysis software, adopting the procedures of
  Descending Hierarchical Classification, Correspondence Factor Analysis and Specificities
  Analysis. The text segments were grouped in 4 main clusters, describing thinking distor
  tions, emergencies, perceptual alterations and the administration of the substance. Bad
  trips were more frequent in female users, being associated with thinking distortions. The use
  of multiple doses of psilocybin in the same session or its combination with other substances
  waslinked to the occurrence of long-term negative outcomes, while the use of mushrooms
  in single high doses was linked to medical emergencies. These results can be useful for a
  better understanding of the effects of psilocybin use, guiding harm-reduction initiatives.
  Introduction
  The growing use of psychedelic substances has been prominent in epidemiological research.
  According to the United Nations Office on Drugs and Crimes 2019 World Drug Report, there
  is an upward trend in recent years on quantities of hallucinogenic substances seized all over
  the world. This is in agreement with reported qualitative information on increasing use of this
  class of substances recently [1, but see 2]. Data from the 2019 Global Drug Survey indicates
  that among the 20 drugs used most prominently over the past year, 6 were psychedelic drugs
  [3]. From 2017 to 2019, “magic mushrooms” (mushrooms from the genus psilocybe) in partic
  ular had increases in lifetime use from 24.4% to 34.2% and use in the last 12 months from
  10.4% to 14.8% [3, 4]. These increases are mirrored by the growth of the new psychoactive
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  1/ 14
  Self-reported negative outcomes of psilocybin users
  the Carlos Chagas Filho Research Support
  Foundation (FAPERJ ref 226501). The funders had
  no role in study design, data collection and
  analysis, decision to publish, or preparation of the
  manuscript.
  Competing interests: The authors have declared
  that no competing interests exist.
  substances (NPS) market in Europe in the last years [2], with some NPS attempting to mimic
  the effects of classic psychedelics.
  Psilocybin (4-phosphoryloxy-N,N-dimethyltryptamine), the active ingredient in “magic
  mushrooms”, has been investigated in relation to its medicinal properties, in particular for
  conditions such as treatment-resistant depression (TRD) [5], with suggestions that psychedelic
  research may lead to a paradigm shift in psychiatry [6, 7]. Psilocybin has also shown potential
  clinical benefits for depression and anxiety in end-stage cancer [8], possibly with reductions in
  death anxiety underpinning its therapeutic effects [9]. Although psilocybin is considered a
  toxicologically safe substance [10–12], there is no scientific consensus on the risks that the use
  of psilocybin may bring [13].
  In a recent study by Carbonaro et al. [14], 10.7% of users reported that, under psilocybin,
  they placed themselves or others at risk of physical damage; 2.6% reported being violent or
  physically aggressive with themselves or others, and 2.7% reported having sought help in a hos
  pital or emergency room. Regarding mental health outcomes, significant associations between
  the consumption of hallucinogens throughout life and mood, anxiety, personality, eating and
  substance abuse disorders were found in an epidemiological study [15]. This is in agreement
  with anecdotal evidence indicating persistent anxiety disorder after consumption of mush
  rooms containing psilocybin [16].
  However, there are divergences relative to these findings. In a populational study by Krebs
  and Johansen [17], no negative mental health outcomes related to the use of classical psyche
  delics [LSD (lysergic acid diethylamide), psilocybin, mescaline or peyote (Lophophora wil
  liamsi)] were found. In fact, the authors reported findings indicated that the use of
  psychedelics was associated with decreased mental health problems. Similarly, another large
  epidemiological study found no relationship between psychedelic use and incidence of psycho
  sis [18]. In addition, some recent studies have demonstrated the potential for psilocybin to
  treat or alleviate symptoms present in different clinical conditions [e.g. 6,19–21].
  The analysis of self-reported user data is a method often neglected in the scientific litera
  ture. There are sites exclusively devoted to the storage and dissemination of information about
  psychoactive substances, with users visiting these sites to informally publish and share reports
  of their own experiences with different substances and the outcomes they cause. In addition to
  serving, potentially, to harm reduction purposes, providing access to information for users,
  these sites create an opportunity for real-time evaluation of emerging drug trends [e.g. 22].
  Psilocybin is capable of promoting intense perceptual changes that include hallucinations,
  synesthesia, and alterations in temporal perception, as well as changes in emotion and
  thoughts, which may lead to risk of harmful use [23]. In addition, healthy individuals may
  experience episodes of bad trips–negative experiences, which may involve mental confusion,
  agitation, extreme anxiety, fear and psychotic episodes–including bizarre and frightening
  images, severe paranoia, and loss of sense of reality [24]. The relationship between bad trip epi
  sodes and certain mental states and/or physical settings is also relevant to consider subjective
  aspects as important triggers of anxiogenic outcomes related to the use of psychedelic sub
  stances. Understanding the specific circumstances in which psilocybin may lead to negative
  outcomes may have important implications for the future clinical use of this substance, also
  providing relevant information for harm reduction initiatives.
  Considering this, as well as the scarcity of quantitative analyses of self-reported user data,
  the aim of this work was to investigate negative effects resulting from the consumption of psi
  locybin, according to the perception of users themselves. Specifically, we sought to investigate
  the occurrence of health problems caused by the consumption of the substance, negative acute
  effects and contextual details of the experiences and possible relationships with the negative
  outcomes.
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  Self-reported negative outcomes of psilocybin users
  Methods
  Extraction of data and construction of textual corpus
  The textual data were obtained from reports manually extracted from the EROWID website
  (www.erowid.org), a database dedicated to reporting on psychoactive substances and docu
  menting actual reports of users. The reports are reviewed before being published and authors
  are asked to fulfill certain criteria, such as: description of the context in which the experience
  was performed and of their previous mental states, details of the preparations made for the
  use, dosage and time information, observations on possible other medications, herbs or sup
  plements used and a description of the physical and mental effects experienced.
  The reports are published anonymously, freely accessible and available on the website in
  several categories [see 25]. In this research we selected the reports of the subcategories “health
  problems”, “bad trips”, “train wreck & trip disasters”, present in the category described as
  Mushrooms (Magic Mushrooms; Psilocybin-containing Fungi). Reports describing the use of
  mushrooms with substances other than psilocybin as the main active ingredient (e.g. Amanita
  muscaria) were not included. The texts (n = 346) were transcribed manually and any grammar
  or typing errors were corrected. In addition, some symbols were deleted or replaced (e.g.,
  dashes, quotation marks, indents) to enable analysis by the software. The average length of the
  reports was 1319.5 words.
  In addition, the reports were also categorized according to the following variables: the three
  subcategories mentioned above (“health problems”, “bad trips”, “train wreck & trip disasters”),
  presence of other substances besides mushrooms, dosage, route of administration, form of
  consumption (dried, tea or fresh and pure) and gender of user (one of the few socio-demo
  graphic variables consistently available from the reports). For dosage, a binary variable (doses
  below and above 5g) was created for the analyses, considering what has been described as a
  high dose with qualitatively different experiences [26]. Missing values in the variables were
  classified as null and classifications different from the ones mentioned above were classified as
  other. To determine the reliability of the analysis, inter-rater reliability was calculated for all
  categories that have not been previously provided by the website (i.e., presence of other sub
  stances besides mushrooms, dosage, route of administration, form of consumption, and gen
  der of user; see S1 Fig for a model of report). Total agreement between raters was 92.3%, with a
  kappa of .85 (p < .001).
  Data analysis
  The participants’ answers were initially analyzed qualitatively and freely, in order to generate
  familiarity with the content. During this stage, the reports were read in detail, one by one, by
  two members of the research team. Subsequently, the texts were analyzed quantitatively
  through IRaMuTeQ 0.7 alpha 2 [27] and R3.1.2. [28]. The analysis was carried out in the tex
  tual corpus constructed from the reports and their categorizations, using text segments (TS).
  TSare divisions of the text, defining the context in which words appear. TS are automatically
  sized according to the corpus extension; in this study we used the default division provided
  by Iramuteq (40 words per text segment; please see S1 Fig). We used the procedures of the
  Descending Hierarchical Analysis (DHA, Reinert Method); Specificities and Correspon
  dence Factor Analysis (CFA). DHA seeks to obtain textual content clusters with specific
  meanings, resulting from the similarity, association and frequency of their vocabularies.
  CFAresults in a graphical visualization of the proximities, oppositions and tendencies of the
  text segments (TS) or corpora classes; locating these elements in a Cartesian graph with fac
  tors generated from their classifications and allowing graphical visualization of the co
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  Self-reported negative outcomes of psilocybin users
  occurrence between words and the possible communities in which they coalesce [29]. Speci
  ficities analysis indicates the index of co-occurrence between the words, i.e. the relationship
  of the words between them and the communities formed by groups composed of the words
  that are most associated.
  The criteria for inclusion of both words and categories in their respective classes by DHA
  are a frequency greater than the mean of occurrences in the corpus and a chi-square value with
  the cluster greater than 3.84. The words of interest (active forms) selected for analysis were
  adjectives, nouns, pronouns, verbs, adverbs and forms not recognized by the IRaMuTeQ dic
  tionary. In addition, when words presented with other associated forms (e.g., test, testing,
  tested), the most frequent form was chosen for graphic representation. The chi-square test val
  ues indicate how strongly words and categories are associated with their clusters [29]. We also
  reported Cramer’s V, a measure of effect size for the association [30]. To avoid inflation of
  type I error, α was set at .01.
  Ethical issues
  All materials were anonymized, preventing identification of subjects. Considering that data
  was public, in agreement with national ethics regulation [31], application for ethics committee
  approval was dispensed [31; p. 2].
  Results
  Descending hierarchical analysis
  The analysis by DHA retained 98.4% of the total corpus, a percentage indicated as acceptable
  for the corpus to be considered for this type of analysis [29]. The corpus was divided into
  12,215 TS, of which 12,414 (98.4%) were retained, relating 15,788 words that occurred 453,711
  times (mean of occurrence for TS = 33.55). Of these, the active forms formed 11,239 words,
  with 2,637 words with frequency greater than six. As can be seen in dendrogram form (Fig 1),
  DHAresulted in four clusters of words. Initially, the clusters were grouped into two distinct
  branches, one composed only of cluster 4 (28.1% of total forms classified) and the other com
  posed of another branch with cluster 3 (20.1%) in one of the extremities and a grouping of
  clusters 1 (30.5%) and 2 (21.4%) in the other. For the association between words and clusters
  (degrees of freedom = 3), considering that the 25 words with highest association in each cluster
  are reported, Cramer’s V indicated medium and, particularly in Clusters 3 and 4, large effect
  sizes [30].
  Correspondence factor analysis
  2
  The CFAcarried out in order to visualize the relation between the clusters indicated that the
  clusters are divided mainly in three large areas, with cluster 1 and class 2 being strongly related
  to each other (Fig 2). In relation to the previous categories of the reports and other variables of
  interest, it is observed that cluster 1 was significantly associated with the subcategory bad trips
  (χ
  (2) = 53.81; p < .001, V = .39) and more frequently reported by female users (χ
  13.38; p < .001, V = .20); cluster 2 with train wrecks and trip disasters (χ
  .001, V = .67), use of just mushrooms (χ
  2
  2
  2
  (2) =
  (2) = 155.92; p <
  (1) = 15.56; p < .001, V = .21) and single doses (χ
  (4) = 11.72; p < .001, V = .18) and cluster 4 with health problems (χ
  2
  2
  (2) = 67.61; p < .001, V =
  .46), multiple doses in the same session (χ
  other substances besides mushrooms (χ
  2
  2
  (3) = 12.39; p < .001, V = .19) and consumption of
  (1) = 17.22; p < .001, V = .22). Cluster 3 did not relate
  to any category and there were no other significant associations (Fig 3).
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  Self-reported negative outcomes of psilocybin users
  Fig 1. Dendogramwith the 25words with highest χ
  2
  in each cluster. Small (red), medium (blue) and large (green) effect sizes, according to (30).
  https://doi.org/10.1371/journal.pone.0229067.g001
  Specificities analysis
  The specificities analysis, indicating the index of co-occurrence between the words, can be
  seen in Fig 4 (cluster1), Fig 5 (cluster2), Fig 6 (cluster 3) and Fig 7 (cluster 4).
  Discussion
  The objective of this study was to analyze reports of experiences with psychedelics that led to
  negative outcomes, according to the perception of the users themselves. The results indicated
  that the textual corpus was susceptible to this type of analysis. The textual analysis carried out
  by means of the DHAgave rise to four clusters of words, i.e. four main fields with different
  meanings in the participants’ reports.
  Cluster 1, which included 30.5% of TS, has two main axes: “feel” and “think”. Although the
  word “feel” may refer to sensorial experiences, the specificities analysis (Fig 4) indicates that
  these terms were used in reference to mental elucubrations. This is reinforced by the inclusion
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  Self-reported negative outcomes of psilocybin users
  Fig 2. Relationship between clusters and words in each cluster. Red–Cluster 1; green–Cluster 2; blue–Cluster 3; purple–Cluster 4.
  https://doi.org/10.1371/journal.pone.0229067.g002
  in the cluster of words and associations such as insane, crazy, mind-race, mind-lose, death,
  die, fear, among others. The specific contents of this cluster, as well as its association with the
  category bad trips, suggests that short term negative experiences are essentially linked to para
  noia and fear/anxiety responses. This is in agreement with previous literature on negative reac
  tions to psychedelics and highlights how these are driven by distortions at the level of thought,
  co-occurring with anxious states. It suggests that management of anxiety, either by pharmaco
  logical or contextual agents (e.g. setting) is crucial in the administration of psilocybin. This
  cluster was also associated with female users. It is possible that this represents stronger effects
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  Self-reported negative outcomes of psilocybin users
  Fig 3. Wordsrelation by cluster and category associated with each cluster. Words in blue belong to Cluster 1 that relates to category 3 (Bad Trips), words in
  green to Cluster 2 that relates to category 2 (Train Wrecks and Trip Disasters), words in red belong to Cluster 4 that relates to category 1 (Health Problems).
  Cluster 3 did not relate to any category and is not represented in the graph.
  https://doi.org/10.1371/journal.pone.0229067.g003
  in womenwith similar doses of psilocybin, which could be explained by enzymatic, hormonal
  or social differences between men and women.
  Cluster 2, which accounted for 21.4% of TS, has central words linked to action, e.g. walk,
  back, tell, call, car. Examining the specificities analysis of this class (Fig 5), indicate that the
  word associations suggest measures that had to be taken in response to the negative experi
  ences. The presence of words such as ambulance, cop, police, hospital and the significant asso
  ciation of this cluster with the train wrecks and trip disasters subcategory indicate the
  occurrence of emergencies. Such occurrences probably include the need for medical attention,
  detention by the police force, need for parental help, etc, also requiring transportation, as indi
  cated by words that refer to the process of getting ready, leaving some place, means of trans
  portation, among others.
  This cluster was also associated with single doses of psilocybin only. One way to interpret
  this result is considering a trend for an association between this cluster and doses above 5g (χ
  =4.22; p = .040), which was not significant considering the established α of .01. This suggests
  that emergencies were linked to single high doses of psilocybin, which is relevant in terms of
  2
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  Self-reported negative outcomes of psilocybin users
  Fig 4. Co-occurrence and communities for words in cluster 1.
  https://doi.org/10.1371/journal.pone.0229067.g004
  identifying the safety profile of the substance, also establishing a potential benchmark that may
  increase unwanted consequences accompanying consumption.
  It is important to highlight the strong proximity between clusters 1 and 2, as demonstrated
  by the CFA(Fig 2). The association between both types of experiences suggests that subjective
  experiences of bad trips are directly linked to emergencies. The direction of causality, however,
  is not clear. It is possible that emergency procedures were carried out in response to anxiety
  (e.g. a request for medical care due to excessive fear of dying or going crazy). Conversely, nega
  tive emergence outcomes themselves may have contributed further to the occurrence of bad
  trips, which are often strongly influenced by the setting in which the experience occurred
  [13,24,32–35], although this is a less straightforward explanation.
  Cluster 3 was made up of 20.1% of TS, with words such as eye, color, pattern, light, visual,
  vision, stare, referring to visual distortions and sensory-perceptual changes in general, which
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  8/ 14
  Self-reported negative outcomes of psilocybin users
  Fig 5. Co-occurrence and communities for words in cluster 2.
  https://doi.org/10.1371/journal.pone.0229067.g005
  are well known in psychedelic experiments [14,36–38]. The absence of categories significantly
  associated with this cluster (Fig 1 and Fig 6) is probably explained by the fact that such
  described effects are common to psychedelics use as a whole, including benign use.
  Finally, cluster 4 collected 28.05% of TS, and agglutinated words that seem to refer to the
  context of psilocybin use (Fig 7), including preparation of mushrooms (e.g. eat, dry, tea), dos
  age (e.g. dose, gram, bag), use with other substances (e.g. smoke, weed, LSD) and contextual
  details such as date (e.g. weekend, month). This cluster was associated with the concurrent use
  of other substances and use of multiple doses in the same session. In addition, this cluster was
  also associated with the subcategory “health problems”, typically indicative of longer-term
  complications. It is possible that these complications are consequences of use associated with
  PLOSONE|https://doi.org/10.1371/journal.pone.0229067 February 21, 2020
  9/ 14
  Self-reported negative outcomes of psilocybin users
  Fig 6. Co-occurrence and communities for words in cluster 3.
  https://doi.org/10.1371/journal.pone.0229067.g006
  other substances, given the presence of words like weed, pot, marijuana, LSD, acid. This fact
  mayreinforce the findings about negative outcomes that occur more frequently due to the use
  of psilocybin associated with other substances, especially alcohol [13,39], and may explain dis
  crepancies in the literature in relation to the association between psychedelic use and negative
  mental health outcomes.
  Conclusion
  This study aimed to analyze self-reports of negative experiences with psilocybin according to
  the perception of the users themselves. Psilocybin has been used for centuries, with increased
  medical interest in recent decades, but the wealth of experience of users has rarely been investi
  gated with sound methodology in the scientific literature. To the best of our knowledge, this is
  the first study to analyze, using appropriate software, the structure and associations of user
  self-reported experiences. Findings reinforce the need to manage anxiety during psilocybin
  administration [24], indicating that distortions at the level of thought were the main cause for
  bad trips. Additionally, these bad trips were also associated with high doses of psilocybin as
  well as with emergencies. Longer-term health problems were associated with multiple doses
  and concurrent use with other substances, in agreement with existing literature [13, 39]. These
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  10/ 14
  Self-reported negative outcomes of psilocybin users
  Fig 7. Co-occurrence and communities for words in cluster 4.
  https://doi.org/10.1371/journal.pone.0229067.g007
  findings clarify individual and contextual elements that may precipitate negative outcomes
  linked to psilocybin use, assisting in the elaboration of safety guidelines for users and/or
  researchers.
  The study has a number of important limitations, including a large number of missing val
  ues, which prevented the analysis of contextual variables, including setting-specific informa
  tion. Another limitation refers to sampling, with these reports potentially not representing
  fully psilocybin users and even with the effective use of substances not being secured in fact, as
  they only come from reports shared online. This consideration should be done together with
  the issue of self-selection, that can promote a biased sample with non-probability sampling,
  considering only experiences that are reported by the users at the website. Additionally, the
  illegal status of psilocybin is also a potential confounder for results, as the negative outcomes
  maybeconnected to black market influences (e.g. different substance being consumed, lack of
  information about freshness of mushrooms) and not to the substance itself. Nevertheless,
  given that psilocybin remains being consumed illegally, the current findings provide informa
  tion valuable to understand use under current circumstances. Finally, the study is exploratory
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  11/ 14
  Self-reported negative outcomes of psilocybin users
  in nature. In this sense, the current study may be used to generate hypotheses by other
  researchers in the field conducting experimental work, helping to clarify the relationship
  between contextual variables and subjective effects of psychedelic experience, including the
  content of the “trips” reported by the users. Further studies are needed to establish more con
  sistently the long and short term consequences of psilocybin use.
  Supporting information
  S1 Fig.
  (TIF)
  Acknowledgments
  The authors acknowledge the work done by Erowid.org in providing information about the
  use of psychoactive substances and promoting increased awareness on this topic.
  Author Contributions
  Conceptualization: Bheatrix Bienemann, Daniel C. Mograbi.
  Data curation: Bheatrix Bienemann, Nina Stamato Ruschel.
  Formal analysis: Bheatrix Bienemann.
  Investigation: Bheatrix Bienemann, Nina Stamato Ruschel.
  Methodology: Bheatrix Bienemann, Daniel C. Mograbi.
  Resources: Daniel C. Mograbi.
  Supervision: Marco Aure ´lio Negreiros, Daniel C. Mograbi.
  Writing– original draft: Bheatrix Bienemann, Maria Luiza Campos, Daniel C. Mograbi.
  Writing– review & editing: Nina Stamato Ruschel, Marco Aure ´lio Negreiros.
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1

Preferred Reporting Items for Systematic reviews and Meta-

Analyse

s extension for

Scoping Reviews (PRISMA

-ScR) Checklist

SECTION

ITEM

PRISMA

-Sc

R CHECKLIST ITEM

REPORTED

ON PAGE #

TITLE

Title

1

Identify the report as a scoping review.

Page 1

ABSTRACT

Structured

summary

2

Provide a structured summary

that

includ

es

(

as

applicable

): background, objectives, eligibility criteria,

sources of evidence, charting methods, results, and

conclusions that relate to the review

questions and

objectives.

Page 1

INTRODUCTION

Rationale

3

Describe the rationale for the review in the context of

what is already known. Explain why the review

questions/objectives lend themselves to a scoping

review

approach.

Page 5

Objectives

4

Provide an explicit statement of the questions and

objectives being addressed with reference to their

key elements (e.g., population or participants,

concepts, and context) or other relevant key

elements used to conceptualize the review questions

and/or objectives.

Page 5

METHODS

Protocol and

registration

5

Indicate whether a review protocol exists

; state

if and

where it can be accessed (e.g., a

Web address)

; and

if available, provide registration information, including

the registration number.

Page 6

Eligibility criteria

6

Specify characteristics of the sources of evidence

used as el

igibility

criteria (e.g., years considered,

language, and publication status), and provide a

rationale.

Page 6-

7

Information

sources

*

7

Describe all information sources

in the search (e.g.,

databases with dates of coverage and contact with

authors to identify additional sources), as well as the

date the most recent search was executed.

Page 8

Search

8

Present the full electronic search strategy for at least

1 database, including any limits used, such that i

t

could be repeated.

Page 41 as S1

Table

Selection of

sources of

evidence

†

9

State the process for selecting sources of evidence

(i.e., screening and eligibility) included in the scoping

review.

Page 9

Data charting

process

‡

10

Describe the methods of charting data from the

included sources of evidence (e.g., calibrated

forms

or forms that have been tested by the team before

their use, and whether data charting was done

independently

or in duplicate) and any processes

for

obtaining and confirming data from investigators.

Page 9

Data items

11

List and define all variables for which data were

sought and any assumptions and simplifications

made.

Page 7-

9

Critical appraisal of

individual sources

of evidence

§

12

If done, provide a rationale for conducting a critical

appraisal of included sources of evidence; describe

Page 10

2

SECTION

ITEM

PRISMA

-Sc

R CHECKLIST ITEM

REPORTED

ON PAGE #

the methods used and how this information was used

in any data synthesis (if appropriate).

Synthesis of

results

13

Describe the methods of handling and summarizing

the data that were charted.

Page 9-

10

RESULTS

Selection of

sources of

evidence

14

Give numbers of sources of evidence screened,

assessed for eligibility, and included in the review,

with reasons for exclusions at each stage, ideally

using a flow diagram.

Page 11 –

Fig 2.

diagram

Characteristics of

sources of

evidence

15

For each source of evidence, present characteristics

for which data were charted and provide the

citations.

Page

10-

21

Critical appraisal

within sources of

evidence

16

If done, present data on critical appraisal of included

sources of evidence (see item 12).

Page 11-

line

211-

217

Results of

individ

ual sources

of evidence

17

For each included source of evidence, present the

relevant data that were charted

that

relate to the

review questions and objectives.

Page 10-

21

Synthesis of

results

18

Summarize and/or present the

charting results as

they relate to the review questions and objectives.

Page 10

–

21,

F

ig 1

& 2

DISCUSSION

Summary of

evidence

19

Summarize the main results (including an overview

of concepts, themes, and types of evidence

available),

link

to the rev

iew questions and

objectives, and consider the relevance to key groups.

Page

21-

24

Limitations

20

Discuss the limitations of the scoping review process.

P

age 24

–

25

Conclusions

21

Provide a general

interpretation of the results with

respect to the review questions and objectives, as

well as potential implications and/or next steps.

Page 25-

26

FUNDING

Funding

22

Describe sources of funding for the included sources

of evidence, as well as sources of funding for the

scoping review. Describe the role of the funders of

the scoping review.

In

journal

submission

system

questions

JBI = Joanna Briggs Institute; PRISMA

-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analy

ses

extension for Scoping Reviews.

* Where

sources of evidence

(see second footnote) are compiled from, such as bibliographic databases, social media

platforms, and Web sites.

† A more inclusive/heterogeneous term used to account for the different types of

evidence or data sources (e.g.,

quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping

review as opposed to only studies. This is not to be confused with

information sources

(see first footnote).

‡ The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the

process of data extraction in a scoping review as data charting

.

§

The process of systematically examining research evidence to assess its validity, results, and relevance before

using it to inform a decision. This term is used for items 12 and 19 instead of “risk of bias” (which is more applicable

to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used

in a scoping review (e.g., quantitative and/or qualitative research, expert

opinion, and policy document).

From:

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews

(PRISMAScR):

Checklist and Explanation. Ann Intern Med. 2018;169:467–

473.

doi: 10.7326/M18-

0850

.

1 / 3Downloadfigshare

S1 Checklist. Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist.

(PDF)

S1 Table. Sample electronic research database search strategy (PubMed).

(PDF)

S2 Table. Traditional Indigenous medicine in North America article database.

(XLSX)

Acknowledgments

A very heartfelt thank you to all of the Indigenous Elders and communities who have shared their stories and perspectives throughout this body of literature. Special thanks to Margo Greenwood, PhD, at the National Collaborating Center for Indigenous Health (NCCIH) for her helpful guidance on this project in addition to Daisy Goodman, CNM, DNP, MPH, for her ongoing support and helpful recommendations with the writing process. Thank you also to Devon Olson of Library Sciences at the University of North Dakota for aid in the search term development process.

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