Slouching towards engagement: interactions between people using psychedelics naturalistically and their healthcare providers

Psychedelic research has expanded rapidly in recent years, driven by shifting policy landscapes and interest in alternative treatments for psychiatric conditions. Clinical trials have reported promising results for psychedelic-assisted psychotherapy across disorders such as major depression, treatment-resistant depression, cancer-related anxiety and depression, alcohol and tobacco dependence, and post-traumatic stress disorder; other compounds including MDMA, ayahuasca (DMT), ketamine, and LSD have also yielded therapeutic signals. At the same time, psychedelics remain criminalised under federal law in the United States for most compounds, new local decriminalisation initiatives are emerging, and naturalistic self-administration outside formal clinical settings appears to be increasing. Prior surveys suggest many people use psychedelics for mental health reasons but often do not disclose use to healthcare providers because of stigma, legal concerns, or doubts about provider knowledge, raising safety concerns such as contraindicated conditions and drug interactions. Boehnke and colleagues set out to characterise interactions between people who use psychedelics naturalistically and their healthcare providers. The study aimed to quantify disclosure of psychedelic use to primary care providers (PCPs) and psychiatric care providers (PsyCPs), assess participants’ desire for and access to professional support around psychedelic experiences, identify reasons for nondisclosure, and document concurrent use of prescribed psychoactive medications. The authors hypothesised that disclosure would be more common to PsyCPs than PCPs, while confidence in providers’ ability to integrate psychedelics into care would remain low despite a general desire for therapeutic support.

This cross-sectional, anonymous online survey was open from 18 September to 5 November 2022. Recruitment used a convenience sampling strategy: in-person and advertised recruitment at a psychedelics advocacy event in Ann Arbor, Michigan, and online recruitment via email listservs and social media (including Facebook and Reddit). Eligibility required being at least 18 years old, living in the United States, and reporting past psychedelic use. Qualtrics settings were used to prevent duplicate responses. The questionnaire was developed with input from therapists, psychedelic advocacy groups, and academic survey designers. It collected sociodemographic data, past medical and psychiatric diagnoses, psychedelic consumption patterns (frequency, substances, dose levels), and specific items about interactions with PCPs and PsyCPs. Measures included whether participants had disclosed psychedelic use to their PCP or PsyCP, confidence in the provider’s ability to integrate psychedelics into treatment (5-point Likert scale from "Not at all" to "Completely"), reasons for nondisclosure (privacy, legal concerns, stigma, etc.), and whether participants had preparatory, in-session, or integration support. The survey also asked about concurrent use of prescribed psychiatric medications on the same day as psychedelic use, the participant’s belief about risks of combining medications, prior use of psychedelics with trained therapists or healthcare professionals, likelihood of using psychedelics with a licensed or underground therapist if available, and views on whether therapists should have personal psychedelic experience (5-point Likert scale). Analyses were descriptive: categorical variables are reported as n (%) and continuous variables as mean ± SD. Likert-scale measures were analysed continuously; independent-samples t-tests (with Cohen’s d for effect size) compared perceived adequacy of preparation and support between those who did and did not disclose to PCPs or PsyCPs. All analyses used SPSS v27. Ethical approval was granted by the University of Michigan Health and Behavioral Sciences Institutional Review Board; participation was voluntary and uncompensated.

Of 2,151 initiated surveys, 1,287 were completed (59.8% completion); after excluding 66 respondents who reported never using psychedelics, the final sample comprised N = 1,221. Participants were 48% women, predominantly White (85%), with a mean age of 39 ± 12 years, and 59% holding at least a bachelor’s degree. Only 1.4% lived in Oregon, the sole US state with decriminalisation at the time. Most respondents used psychedelics at least twice a year (67.2%), and 23.7% used them monthly or more often; 18.2% had used only once or not within the past five years. Psilocybin mushrooms were the most used substance (93.4%), followed by LSD (66.6%) and MDMA/MDA (57.0%). Smaller proportions reported using ketamine (32.0%), DMT (30.5%), salvia (25.3%), mescaline (19.5%), other synthetic phenethylamines (14.1%), and ayahuasca (13.7%). On average participants had used three different psychedelics (SD = 3), and 23.9% had used six or more. Most (85.7%) had taken moderate or high doses; 14.3% reported only microdosing. Common self-reported past psychiatric diagnoses were depression (62%), anxiety (52%), and ADHD (27%). Regarding disclosure, 22% of participants had discussed psychedelic use with their PCP, whereas among the subset who reported having a PsyCP (n = 274) 58% had discussed use with that provider. Participants reported significantly greater confidence in their PsyCP’s ability to integrate psychedelics into treatment compared with their PCP (mean difference = 0.66, 95% CI: 0.46–0.87, p < 0.001). The most cited reason for not disclosing psychedelic use to either PCPs or PsyCPs was stigma (59% for PCPs; 70% for PsyCPs). Legal concerns and perceived lack of provider knowledge were also common rationales. Concurrent medication use was reported by 23% of participants for psychedelic episodes: among those who took psychiatric medications on the same day as a psychedelic experience, 71% reported antidepressants, 19% stimulants, and 13% anxiolytics. Just over half (54%) of those combining medications and psychedelics believed there were risks to doing so. Despite 81% indicating they would be likely to use psychedelics with a legal/licensed therapist and 71% being open to an underground guide, only 15% had actually consumed psychedelics with a trained therapist or healthcare professional. Common barriers to seeking professional support included not knowing where to find it (51%) and lack of affordability (28%). A majority (approximately 75%–85%) agreed or strongly agreed that therapists supporting psychedelic experiences should have personal experience using psychedelics. Participants’ perceptions of support were mixed: 70% reported always or often having adequate preparation for a psychedelic experience, 51% reported always or often adequate support during the experience, and 48% reported adequate support after the experience. Those who disclosed psychedelic use to their PCP reported higher perceived adequacy of preparation (t(1096) = 3.65, p < 0.001, d = 0.27), support during (t(1095) = 2.89, p = 0.002, d = 0.21), and support after (t(1095) = 3.74, p < 0.001, d = 0.27). By contrast, the extracted text reports no differences in perceived preparation or support associated with disclosure to a PsyCP; the reported test statistics were t(272) = 1.55 (p = 0.001, d = 0.19) for preparation, t(272) = 0.41 (p = 0.679, d = 0.05) for support during, and t(272) = 0.96 (p = 0.340, d = 0.12) for support after. The p-value associated with the first of these PsyCP comparisons appears inconsistent with the t-statistic as presented in the extracted text.

Boehnke and colleagues interpret these data as evidence that naturalistic psychedelic use is largely disconnected from primary and psychiatric clinical care, although disclosure and confidence are higher with PsyCPs than PCPs. The authors note that confidence in providers’ ability to integrate psychedelics was still generally low, and that many participants reported taking psychiatric medications on the same day as psychedelics—a finding that raises safety concerns. In particular, the potential for pharmacologic interactions, blunting of psychedelic effects, and serotonin syndrome (an adverse state of excessive serotonergic activity characterised by autonomic instability, neuromuscular changes, and altered mental status) was highlighted, with MDMA posing comparatively higher risk among commonly used substances. The authors cite systematic review evidence of numerous potential interactions between MDMA and various classes of medications and between psilocybin and antipsychotics or anxiolytics, arguing that clinical conversations could help mitigate risk. While most respondents valued having a trained therapist or healthcare professional present for therapeutic psychedelic use, only a small fraction had accessed such support, primarily because of uncertainty about where to find it and cost barriers. The data also show sizeable openness to underground guides, indicating many are prepared to proceed outside sanctioned medical contexts. The surveyed population’s strong preference that therapists have personal psychedelic experience presents an operational and ethical challenge, the authors argue, because legal and professional constraints limit clinicians’ ability to gain that experience. The authors further suggest that people who disclosed to their PCP reported modestly better preparation and support, implying that clinical communication may improve set and setting. They call for targeted research to define appropriate levels of support for different patient groups, for educational initiatives to improve providers’ competency in discussing psychedelics, and for policy changes—particularly reconsideration of the Schedule I status of most psychedelics—to align regulation with evolving evidence and clinical needs. The authors acknowledge limitations that temper generalisability: the convenience sample recruited via advocacy events and online forums was largely White, middle-aged (mean 39 years), and likely enriched for psychedelic enthusiasts; indigenous and non-Western traditions were not addressed; and provider perspectives were not assessed. Strengths include a large sample size and interrogation of previously underexamined domains such as disclosure to PCPs and PsyCPs, desire for therapist support, and concomitant prescription medication use. The authors identify several priorities for future work, including determining which clinical factors predict adverse versus therapeutic outcomes, clarifying necessary preparatory and integrative care, and understanding patient subgroups that may require additional safeguards.

In this large convenience sample of people who use psychedelics naturalistically, participants commonly used these substances for mental health reasons and expressed a desire for more therapist or clinician support. Disclosure of use was more frequent to psychiatric care providers than to primary care providers, yet confidence in both provider types to integrate psychedelics into treatment remained low. Notably, 23% reported taking psychiatric medications on the same day as psychedelics, including agents that may raise the risk of adverse effects or attenuate psychedelic effects. Access, affordability, provider knowledge, stigma, and legal concerns were important barriers to care. The authors conclude that as psychedelics become more available through changing legal frameworks, there is an urgent need for healthcare provider education, policy reforms that reflect current evidence, and harm-reduction services to support people using these substances.