Abstract
Background and aims
Because psychedelic-assisted therapy (PAT) is likely to be provided by interdisciplinary professional teams comprised of social workers, psychologists, and psychiatrists, understanding the acceptability of this treatment approach among these professional disciplines is essential as the treatment advances through approval processes at the Food and Drug Administration.
Methods
The study includes data from three separate survey studies investigating the attitudes and beliefs about PAT among national samples of social workers (n = 309), psychiatrists (n = 181), and psychologists (n = 366). The combined sample (n = 856) was predominantly female (64.3%), with a mean age of 49 (SD = 16.13), and 17 (SD = 13.56) years of professional experience.
Results
There were no significant differences between groups in confidence that PAT would be effective. However, there were significant between-group differences in psychiatrists' understanding of PAT compared to social workers. Next, psychologists' mean ratings of the acceptability of PAT were significantly greater than social workers' ratings. Mean ratings about believing that PAT was a reasonable treatment approach were higher among psychologists compared to social workers and psychiatrists. Additionally, mean ratings regarding the disadvantages of PAT were significantly greater among social workers compared to psychologists and psychiatrists. Lastly, social workers' ratings that PAT could permanently improve clients' lives were significantly lower than psychiatrists and psychologists.
Conclusions
Findings help elucidate overall impressions of PAT among disciplines likely involved in providing this treatment should it be approved and suggest the need for education and training across professions. However, given the inconsistencies across disciplines, more research is needed to inform successful interdisciplinary training programs and better understand potential barriers to dissemination of this new treatment.
Introduction
Psychedelics (also known as hallucinogens) are a broad class of chemical compounds that overlap in their mechanisms of action (Garcia-Romeu, Kersgaard, & Addy, 2016). These substances share an “ability to occasion temporary but profound alterations of consciousness, involving acute changes in somatic, perceptual, cognitive, and affective processes (p. 6).” Psychedelics can be further subdivided as “classic” (e.g., lysergic acid diethylamide (LSD), psilocybin, ayahuasca) and “non-classic” (e.g., 3,4-methylenedioxymethamphetamine (MDMA). Classic psychedelics act at the serotonin 2A receptor (5-HT2AR) as agonists or partial agonists (Johnson, Hendricks, Barrett, & Griffiths, 2019), and the psychological mechanisms for non-classic psychedelics are varied (Mendez et al., 2022).
In the 1950s and 1960s, research on the clinical effectiveness of combining psychotherapy and psychedelics, known as psychedelic-assisted therapy (PAT), for treating mental health conditions revealed promising results (see Garcia-Romeu et al., 2016 for a review). However, in the 1960s, patterns of abuse began to emerge, which resulted in illicit manufacturing and distribution of psychedelics and unfavorable beliefs among the medical community and politicians (Belouin & Henningfield, 2018). By the 1970s, research dwindled as many psychedelics were banned and classified as Schedule 1 substances (i.e., deemed to have “no currently accepted medical use” and a “high potential for abuse”) by the U.S. Drug Enforcement Administration (DEA; Comprehensive Drug Abuse and Control Act of 1970). By 1985 the DEA banned MDMA leading to a near halt in all research.
Given the DEA's scheduling of these substances, many misconceptions and misunderstandings developed and continue to exist regarding psychedelics, in general, and PAT specifically. First, the prevalence of hallucinogen use disorder among United States adults is one of the rarest substance use disorders, with less than 1% of adults meeting the criteria (American Psychiatric Association, 2013). Additionally, there is no evidence of significant long-term negative effects of psychedelic use in the general population (Krebs & Johansen, 2013) nor long-term adverse effects in clinical trials (Aday, Mitzkovitz, Bloesch, Davoli, & Davis, 2020) despite beliefs that these substances are dangerous (Barnett, Siu, & Pope, 2018). In clinical trials where the therapeutic setting is an important controlled aspect of treatment, the use of psychedelics is associated with improvement in depression (Carhart-Harris et al., 2016; Davis, Agin-Liebes, España, Pilecki, & Luoma, 2021; Davis, Barrett et al., 2021; Ross et al., 2016), post-traumatic stress disorder (PTSD; Mitchell et al., 2021; Mithoefer et al., 2019), anxiety (Griffiths et al., 2016; Ross et al., 2016), and decreases in smoking (Johnson, Garcia-Romeu, & Griffiths, 2017), alcohol use (Bogenschutz et al., 2022; Garcia-Romeu et al., 2019) and social anxiety in adults with autism spectrum disorder (ASD; Danforth et al., 2018). Comparatively, in terms of harm (physical and social) and potential addiction, evidence indicates that alcohol, heroin, and crack cocaine are the most harmful, with psychedelics as the least harmful (Morgan, Muetzelfeldt, Muetzelfeldt, Nutt, & Curran, 2010; Nutt, King, & Phillips, 2010). This evidence, and concerns about the abuse potential of other currently approved medications and legal drugs, leads to questions regarding the scientific justification of U.S. drug policies (Levin et al., 2022; Xin, España, & Davis, 2022). However, there are some risks associated with the use of psychedelics, including the potential for psychologically challenging experiences (Barrett, Bradstreet, Leoutsakos, Johnson, & Griffiths, 2016) as well as the rare and less understood risk of hallucinogen persisting perception disorder (HPPD; Halpern, Lerner, & Passie, 2018), a condition that involves lasting perceptual distortions that may cause distress, or the potential for psychedelics to trigger psychosis (Lebedev et al., 2021).
In the 1990s, researchers began to re-evaluate the potential benefits of psychedelics which was supported by technological advancements in the ability to evaluate brain mechanisms and drug action (Belouin & Henningfield, 2018). There is currently a resurgence of research investigating the clinical effectiveness of PAT. Current research has sought to address limitations common in early investigations (Carhart-Harris & Goodwin, 2017) by including rigorous methodologies such as randomization, blinding, and controls (Mitchell et al., 2021; Mithoefer et al., 2019). As the research progresses, evidence continues to mount regarding the effectiveness of PAT for treating mental disorders (Luoma, Chwyl, Bathje, Davis, & Lancelotta, 2020), leading the FDA to designate breakthrough therapy status to MDMA-assisted psychotherapy for PTSD (Mithoefer, 2017) and psilocybin-assisted psychotherapy for depression (Davis, Agin-Liebes et al., 2021; Davis, Barrett et al., 2021). Despite advances in research and a deeper understanding of PAT, misunderstanding and misinterpretation of these treatments appear widespread within the mental health field and as reported by the news media (Morgan, 2020).
PAT is a treatment provided by an interdisciplinary team, often including psychiatrists, psychologists, and clinical social workers. These professionals have advocated for more research on the effectiveness of PAT, including Hutchison and Bressi (2020), who advise increasing awareness and use of PAT within social work. As research and implementation of PAT continue, front-line clinicians, including psychologists, social workers, and psychiatrists, will need targeted and comprehensive training in delivering this treatment. Before the development of large-scale training programs, an understanding of the current attitudes and beliefs regarding PAT among psychologists, social workers, and psychiatrists could help identify potential barriers to training and enable the creation of targeted educational materials in these disciplines.
In this study, utilizing data from three separate surveys, we sought to explore how attitudes and beliefs about the potential effectiveness of PAT varied among three professions (i.e., psychologists, social workers, and psychiatrists) who will all likely play a vital role in the future as front-line clinicians in PAT (Davis, Agin-Liebes et al., 2021; Davis, Barrett et al., 2021; Levin et al., 2022; Xin et al., 2022). Given misunderstandings, misinterpretations, and the limited awareness of PAT, we hypothesize that psychologists, social workers, and psychiatrists likely have conservative attitudes and beliefs about the effectiveness of PAT.
Methods
This secondary analysis study used data from three separate survey studies that explored attitudes and beliefs related to PAT among professionals from national samples of psychologists, clinical social workers, and psychiatrists (Davis, Agin-Liebes et al., 2021; Davis, Barrett et al., 2021; Levin et al., 2022; Xin et al., 2022). All studies received approval from The Ohio State University Institutional Review Board and data was collected via Qualtrics. The social worker survey study (Xin et al., 2022) recruited participants from the National Association of Social Workers (NASW) using InFocus Marketing between April and May 2020. Two recruitment emails to all NASW members with a substance use primary practice area or work focus (approximately 7,200 NASW members) were sent, and a $15 incentive was provided to 309 participants who completed the full survey. The psychologist survey study (Davis, Agin-Liebes et al., 2021; Davis, Barrett et al., 2021) recruited participants via a database of 27,886 email addresses of psychologists purchased from a marketing firm. Two waves of recruitment emails were sent to participants between July and August 2020 (approximately 12,866 emails were delivered successfully). In total, 366 psychologists completed all questionnaires and were entered into a raffle to win a gift card. The psychiatrist survey study (Levin et al., 2022) recruited participants via two psychiatrist emailing lists purchased from marketing firms, email listservs from the American Psychiatric Association, and personal networks (i.e., snowball sampling) between April to May 2021. In total, 181 psychiatrists completed all questionnaires and were entered into a raffle to win a gift card. Additional details regarding the methodology, inclusion criteria, and recruitment procedure for all three studies, see Davis, Agin-Liebes et al. (2021), Davis, Barrett et al. (2021), Levin et al. (2022), and Xin et al. (2022).
Measures
Background characteristics
Demographic characteristics (e.g., biological sex, age) and years of experience (e.g., years practicing in the profession) were assessed.
Attitudes and beliefs about psychedelic-assisted therapy
A modified Treatment Acceptability Rating Form Revised (TARF-R; Reimers, Wacker, & Cooper, 1991) was included in three survey studies to measure professionals' attitudes and beliefs regarding PAT and included 6 items. The original measure language was changed to specifically assess PAT (e.g., changed the question “How clear is your understanding of this treatment” to a statement question “I have a very clear understanding of psychedelic-assisted therapy”), and response options were updated to fit the newly formatted questions. Participants were asked to report their agreement with each statement (e.g., “I find psychedelic-assisted therapy to be very acceptable”) on a 5-point scale ranging from −2 (Strongly disagree) to 2 (Strongly agree). We reverse-scored ratings for one item (i.e., “I think it is very likely that there might be advantages in psychedelic-assisted therapy”) in the social worker sample so that it would be comparable to the way the item was worded in the psychiatrist and psychologist surveys (i.e., “I think it is very likely that there might be disadvantages in psychedelic-assisted therapy”). Individual items were used in all analyses.
Data analysis
First, we calculated descriptive statistics to examine demographic variables in the overall sample and within the three groups (i.e., professions). Chi-square and ANOVAs were calculated to determine if there were significant differences in demographic characteristics between groups. We then conducted a series of six ANCOVAs to investigate whether there were differences in mean ratings of each attitude and belief item between groups. Next, we conducted an analysis of effect using the partial eta squared statistic to measure the magnitude of differences between groups. According to Cohen (1988) effect sizes are interpreted as small (ηp2 = 0.01), medium (ηp2 = 0.06), and large (ηp2 = 0.14). A p-value of 0.05 was used to determine statistical significance. Last, we conducted a post-hoc test of mean pairwise comparisons (using Bonferroni correction) to determine whether mean ratings in each group were significantly different from one another. All analyses were conducted in SPSS v.28.
Results
The sample was comprised of primarily female (64%) and middle-aged (M = 49, SD = 16.13) adults. Participants reported practicing in their clinical profession for an average of 17 years (SD = 13.56; see Table 1). Chi-square analyses revealed there were significantly more male psychiatrists than male social workers and psychologists. Because the makeup of sex varied by profession, we controlled for this demographic variable in our analyses.
Demographic characteristics of total sample and each profession
| Characteristic | Total Sample | Social Work | Psychiatry | Psychology | X2 or ANOVA | Effect size |
| n = 856 | n = 309 | n = 181 | n = 366 | |||
| M(SD) or % | M(SD) or % | M(SD) or % | M(SD) or % | |||
| Age | 49.1 (16.13) | 48.39 (16.66) | 48.68 (16.15) | 49.87 (15.66) | 0.78 | |
| Sex | 90.43*** | 0.33 | ||||
| Female | 64.3% | 76.1%a | 34.8%b | 68.9%a | ||
| Male | 35.7% | 23.9%a | 65.2%b | 31.1%a | ||
| Experience | 17.01 (13.56) | 17.46 (11.70) | 16.21 (15.27) | 17.03 (14.14) | 0.48 |
*p < 0.05, **p < 0.01, ***p < 0.001
Participant responses to questions about their attitudes and beliefs regarding the acceptability and perceived effectiveness of PAT are in Table 2. Results comparing mean ratings across groups indicated no significant differences in mean ratings that they were “very confident that psychedelic-assisted therapy would be effective” (p = 0.17). However, there were significant between-group differences in mean ratings that they had a “very clear understanding of psychedelic-assisted therapy” (p ≤ 0.001; ηp2 = 0.03). Post-hoc tests revealed that psychiatrists reported significantly more understanding than social workers. There were significant between-group differences in mean ratings of one's attitude that they “find psychedelic-assisted therapy to be very acceptable” (p ≤ 0.01; ηp2 = 0.02). Post-hoc tests revealed that psychologists reported significantly more acceptability than social workers. There were significant between-group differences in mean ratings of one's attitude that they “find psychedelic-assisted therapy to be a very reasonable approach” (p ≤ 0.001; ηp2 = 0.04). Post-hoc tests revealed that psychologists reported significantly more reasonability than social workers and psychiatrists. There were significant between-group differences in mean ratings of one's belief “it is very likely that there might be disadvantages in psychedelic-assisted therapy” (p = 0.004; ηp2 = 0.02). Post-hoc tests revealed that social workers reported significantly more disadvantages than psychologists and psychiatrists. Lastly, there were significant between-group differences in mean ratings of one's belief “that it is very likely that psychedelic-assisted therapy could make permanent improvements in my clients' lives” (p ≤ 0.001; ηp2 = 0.03). Post-hoc tests revealed that psychologists and psychiatrists were more likely to believe that PAT would lead to improvements than social workers.
Analysis of Covariance (ANCOVA) comparing mean ratings of attitudes and beliefs about perceived effectiveness of psychedelic-assisted therapy across professional disciplines controlling for sex
| Item | Total Sample | Social Work | Psychiatry | Psychology | F | ηp2 |
| n = 856 | n = 309 | n = 181 | n = 366 | |||
| M(SD) | M(SD) | M(SD) | M(SD) | |||
| I have a very clear understanding of psychedelic-assisted therapy | −0.12 (1.26) | −0.26 (1.27)b | 0.17 (1.22)a | −0.14 (1.26) | 7.77*** | 0.03 |
| I find psychedelic-assisted therapy to be very acceptable | 0.34 (1.08) | 0.17 (1.08)b | 0.39 (1.13) | 0.45 (1.04)a | 5.04** | 0.02 |
| I find psychedelic-assisted therapy to be a very reasonable approach | −0.05 (1.24) | −0.35 (1.12)b | −0.05 (1.28)b | 0.20 (1.26)a | 12.96*** | 0.04 |
| I think it is very likely that there might be disadvantages in psychedelic-assisted therapy | −0.64 (0.92) | 0.51 (1.08)a | −0.81 (0.81)b | −0.68 (0.81)b | 4.51** | 0.02 |
| I think it is very likely that psychedelic-assisted therapy could make permanent improvements | 0.32 (0.98) | 0.14 (1.03)b | 0.56 (0.95)a | 0.36 (0.91)a | 8.49*** | 0.03 |
| I am very confident that psychedelic-assisted therapy would be effective | −0.11 (1.00) | −0.17 (1.03) | −0.03 (1.06) | −0.08 (0.92) | 1.69 | 0.00 |
*p < 0.05, **p < 0.01, ***p < 0.001
Discussion
To our knowledge, this is the first analysis that directly compares attitudes and beliefs surrounding PAT across professional disciplines that specialize in mental health treatment. Although some interesting differences emerged in this comparison, our overall results reveal a general lack of consistency, both within and between disciplines, as it relates to views of psychedelics and their therapeutic potential. For example, although psychologists rated PAT as more reasonable compared to social workers and psychiatrists, psychiatrists and psychologists were more likely to agree that PAT could make permanent improvements compared to social workers. However, there were no significant differences in the overall ratings of the effectiveness of PAT between professional discipline groups.
These inconsistencies may reflect a general lack of consensus about this novel treatment approach, a hypothesis supported by survey evidence across disciplines. In a recent survey of United Kingdom National Health Service psychiatrists, for example, 77.2% of respondents felt that there should be a role for the therapeutic use of psychedelics, however, a majority of psychiatrists and psychiatry trainees did not feel prepared to participate in the delivery of PAT or to discuss it with patients (Page, Rehman, Syed, Forcer, & Campbell, 2021). In the same survey, 60.2% of participants were not familiar, or only slightly familiar, with the use of psychedelics in therapy, and a thematic analysis identified ‘need for knowledge’ as one of three overarching themes. In a recent survey of psychologists in the United States, a majority reported a lack of understanding of PAT and tended to overestimate the risks associated with psilocybin (Davis, Agin-Liebes et al., 2021; Davis, Barrett et al., 2021). While data on social workers' attitudes is more limited, a recent survey that utilized a semi-structured interview approach found that, although participants generally agreed that PAT aligned with the ethical standards of the social work profession, 87% of participants made statements indicating that the depth of their knowledge related to PAT was limited (Ellow, 2022).
Generally, increased knowledge of psychedelics has been correlated with more favorable views of their therapeutic potential, as well as more realistic assessments of their risk/benefit profiles (Barnett, Parker, & Weleff, 2022; Barnett, Beaussant, King, & Doblin, 2022; Luoma, Pilecki, Davis, & Smith, 2022). In contrast to this finding, although psychiatrists in our survey reported more understanding of PAT relative to social workers, they did not generally have more favorable views of its therapeutic potential. One possible explanation for this is that psychiatrists in our survey overestimated their knowledge of PAT. This is supported by a recent survey in which a self-selected group of psychiatrists at psychedelic didactic presentations demonstrated substantial limitations in objective knowledge related to psychedelics and limited awareness of the status of research surrounding PAT (Barnett, Parker et al., 2022; Barnett, Beaussant et al., 2022).
Another possibility is that psychiatrists' relative lack of confidence in the therapeutic potential of PAT was driven, not by their lack of understanding or doubts about effectiveness, but by their relatively lower ratings of reasonability. Given that the current standard of care in psychiatry centers around the 16-min medication management visit (Miller, 2021), a 6-to-8-h psychedelic treatment may indeed present an unreasonable approach. These concerns seem to be reflected in the above-referenced surveys of psychiatrists, in which participants endorsed concerns about the logistics and time demands of the treatment and were skeptical that the current health structures would support the requirements of delivery (Barnett, Parker et al., 2022; Barnett, Beaussant et al., 2022; Page et al., 2021). These findings might also indicate the presence of stigma or bias based on the more traditional training found in medicine where medical students are more likely to be taught about hallucinogens in the context of drug abuse. Stigma based on misinformation, the DEA's scheduling system that purports that psychedelics have no medical value, and the War on Drugs represent barriers to the dissemination of PAT and support the need for greater education and training efforts among health care disciplines. Further, these policies also prevent NIH funding for psychedelic-assisted therapy research, perpetuating the stigma by contributing to a lack of information about these treatments (Barnett, Parker et al., 2022; Barnett, Beaussant et al., 2022).
Interestingly, social workers' ratings of reasonability mirrored those of psychiatrists in our survey, and, in Ellow's (2022) analysis, social workers highlighted a similar set of logistic and systemic concerns, including costs, insurance company incentives, patient vulnerabilities, and the competence of providers. In contrast, psychologists, who rated the approach as more reasonable than social workers and psychiatrists, have a standard practice environment that may, at present, most easily integrate intensive psychological interventions. Taken together, these concerns about reasonability suggest that the implementation and scaling of PAT will require significant restructuring of current practice and reimbursement environments across disciplines. Indeed, PAT represents a completely novel form of treatment that combines a substance-induced altered state of consciousness with psychotherapy, and therefore does not fit neatly within existing health care systems, and will, to some extent, require a paradigm shift in how various professionals deliver this treatment.
As an analysis of several cross-sectional internet surveys, this study has several limitations. First, all three studies were cross-sectional survey studies which limit the inferences that can be made. Second, it is possible that given the areas of interest of the authors and the items used in the survey of acceptability of PAT, the respondents who participated may have been more likely to view psychedelics favorably than a general population of health care providers. However, the social work sample includes only professionals with a substance use disorder practice/focus area, which may have introduced bias specifically regarding concerns about the addictive potential of psychedelics. Third, given that data were analyzed across three different survey studies with slightly different methodologies, some variables, such as race, were not asked consistently, preventing us from analyzing the impact of some demographic characteristics. Finally, there were a variety of recruitment approaches utilized across all three studies (i.e., snowball sampling, listservs, marketing firms), which may have differentially impacted the professionals we were able to access across studies.
Our findings suggest a general lack of knowledge and preparedness, at both a provider and systemic level, for the likely and expected introduction of PAT into the mental health landscape, which may occur as soon as 2024. For example, the Substance Abuse and Mental Health Services Administration (SAMHSA) is exploring a joint task force with the Biden Administration to oversee a relationship between the public and private sectors' dissemination of PAT (Delphin-Rittmon, 2022). Given the time- and resource-intensive nature of the treatment approach, the rate-limiting step in implementation may be the availability of qualified, trained providers (Nutt & Carhart-Harris, 2021; Phelps, 2017). Thus, the expansion of specialized training programs, as well as cross-disciplinary educational initiatives, is needed to optimize the effectiveness and accessibility of PAT.
Conflict of interest
Alan K. Davis is a board member of Source Research Foundation and lead trainer at Fluence, neither organization was involved in this research. Alan K. Davis is an associate editor of the Journal of Psychedelic Studies. Peer review has been handled without his involvement; hence, he does not have a conflict with the review process.
Acknowledgments
Woo Yul Byun, WooYul.Byun@osumc.edu. This work was supported by Portland Psychotherapy Clinic and Training Center; Drug Enforcement and Policy Center at the Mortiz College of Law at Ohio State University; The Center for Psychedelic and Consciousness Research, funded by Tim Ferriss, Matt Mullenweg, Craig Nerenberg, Blake Mycoskie, and the Steven and Alexandra Cohen Foundation; Center for Psychedelic Drug Research and Education, funded by anonymous private donors.
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