Abstract
Background and aims
Psychedelic-assisted psychotherapy (PAP) is currently being studied as a possible treatment option for multiple disorders. Despite promising safety and efficacy findings, the high costs of the current PAP model makes it questionable if the treatment will be scalable. Non-hallucinogenic psychedelic analogs have been developed as a potential cost-effective alternative, but it is unclear what psychedelic users perceive as a reasonable cost for treatment and whether they would be open to trying a non-hallucinogenic analog.
Methods
We queried a large sample of people using psychedelics naturalistically (N = 1,221) about their attitudes regarding the role of altered states of consciousness in PAP outcomes, costs of treatment, and their openness to trying a non-hallucinogenic psychedelic analog for treating a mental health condition.
Results
We found that most (76%) participants considered altered states of consciousness as very or extremely important to the therapeutic effects of psychedelics. Despite this, most (61%) were also moderately, very, or extremely likely to try a non-hallucinogenic substance if given the chance. Lastly, participants considered approximately $70–80 per hour to be a reasonable cost for various aspects of psychedelic services (e.g., preparation, integration, and dosing sessions).
Conclusions
Participants valued the role of altered states of consciousness in therapeutic changes attributed to psychedelics, but were still open to trying a non-hallucinogenic analog. Notably, the price participants considered to be a reasonable amount for PAP is well below current market projections. Future research is needed to address limitations of the study as well as to identify ways of lowering treatment costs.
Psychedelic drugs such as psilocybin and lysergic acid diethylamide (LSD) as well as related compounds (e.g., 3,4-Methylenedioxymethamphetamine; MDMA) have preliminarily demonstrated a high level of safety and efficacy for treating psychiatric conditions when paired with psychotherapy (Bogenschutz et al., 2022; Davis et al., 2021; Goodwin et al., 2022; Mitchell et al., 2023). As regulatory approval and subsequent clinical implementation of psychedelic-assisted psychotherapy (PAP) becomes increasingly probable, a looming bottleneck for the field is the high cost of treatment, which is largely dependent on the amount of therapist time included (Aday, Carhart-Harris, & Woolley, 2023). The current PAP model used in clinical trials generally includes two therapists who are both present for 6–8 h of preparatory sessions, each 6–8 h dosing session, and multiple follow-up integration sessions (Aday et al., 2022). Altogether, a single dosing session with appropriate preparation and follow-up uses more provider time than most individuals typically use over the course of an entire year of therapy (Aday, Barnett, et al., 2023). Researchers are currently exploring a wide variety of methods for reducing costs, including the use of group therapy (Anderson et al., 2020) and the development of non-hallucinogenic derivatives of psychedelic compounds (Cameron et al., 2021; Olson, 2020), which are hoped to confer the same therapeutic benefits without requiring psychotherapeutic support after drug administration. However, given that aspects of the subjective experience have been related to many of the therapeutic benefits observed with psychedelics (Roseman, Nutt, & Carhart-Harris, 2018), other researchers are skeptical that such pursuits will be successful (Yaden & Griffiths, 2020). Despite the increasing acknowledgement of the current PAP model being unscalable because of its costs, researchers have seemingly overlooked a key question—that is, how do consumers feel regarding these issues? Specifically, what do people using psychedelics perceive to be a reasonable cost for treatment and would they even be open to taking a non-hallucinogenic alternative?
The current brief report was designed to address these simple, but critical, questions by asking a sample of people using psychedelics naturalistically about their attitudes on costs for various aspects of PAP as well as their openness to trying a non-hallucinogenic psychedelic derivative. We hypothesized that what participants perceived as a reasonable cost for PAP would be below current projected costs for treatment and that most would be open to trying a non-hallucinogenic alternative.
Materials and methods
This section was one component of a larger project investigating the naturalistic use of psychedelics. The survey and procedures were approved as an exempt study (IRB #HUM00205639) by the Health Sciences and Behavioral Sciences Institutional Review Board at the University of Michigan. We recruited participants who self-reported using psychedelics from September 18 to November 05, 2022 through posts on social media platforms (e.g., Reddit, Facebook) and email listservs related to psychedelics (83% of participants) as well as a psychedelic advocacy event on September 18, 2022 in Ann Arbor, MI (17% of participants). Participants could stop taking the survey at any time and were not compensated. For further information on survey development, recruitment, and demographics, please see Kruger, Enghoff, Herberholz, Barron, and Boehnke (2023).
In addition to collecting basic sociodemographic information, we asked participants: “How important do you think altered states of consciousness are to the therapeutic effects of psychedelics?” and “How likely would you be to try a non-hallucinogenic substance based on psychedelics to treat mental health conditions as an alternative to psychedelics?” with response options Not at all, Somewhat, Moderately, Very, and Extremely. We asked “What do you think is a reasonable cost for a…” for items “Full day (6–12 h) psychedelic therapy session?”; “2-h ketamine session?”; and “1-h psychedelic therapy preparation or integration session? (not including the use of psychedelics)?”
Results
Most (76%) of the participants thought that altered states of consciousness were very or extremely important to the therapeutic effects of psychedelics (Table 1). Yet, the majority of participants (61%) stated that they would be moderately, very, or extremely likely to try a non-hallucinogenic substance based on psychedelics to treat mental health conditions as an alternative to psychedelics. Responses to these items were inversely related, (r(1,218) = −0.24, p < 0.001)—that is, the more important participants thought that altered states of consciousness were to therapeutic effects, the less likely they were to try a psychedelic-derived non-hallucinogenic substance. On average, participants considered $70–80 per hour to be reasonable costs for psychedelic services such as full day psychedelic therapy sessions, 2-h ketamine sessions, and 1-h preparation or integration sessions.
Descriptive results (N = 1,221)
| Items and response options | Value |
| Importance of altered states of consciousness | |
| Not at all | 1% |
| Somewhat | 6% |
| Moderately | 16% |
| Very | 35% |
| Extremely | 41% |
| Likelihood of trying a non-hallucinogenic substance | |
| Not at all | 18% |
| Somewhat | 21% |
| Moderately | 23% |
| Very | 21% |
| Extremely | 17% |
| Reasonable costs for… (M, SD, range) in USD | |
| Full day (6–12 h) psychedelic therapy session | 418, 404, 0–3,600 |
| 2-h ketamine session | 168, 331, 0–10,050 |
| 1-h psychedelic therapy preparation or integration session | 78, 68, 0–1,000 |
Discussion
To summarize, this study measured the attitudes of people who use psychedelics regarding the importance of the subjective experience conferred by psychedelics in subsequent therapeutic effects, openness to trying a non-hallucinogenic psychedelic analog, and reasonable costs for various aspects of PAP. Given that various aspects of the subjective state induced by psychedelics (e.g., mystical experiences, awe, insight) have been closely linked to positive therapeutic effects with the drugs (Roseman et al., 2018), we were not surprised to find that most participants reported an altered state of consciousness as being important to therapeutic benefits. What could be considered unintuitive, however, is that most participants were still open to trying an analogous drug that does not alter consciousness. This might be partially explained by previous convergent findings from cross-sectional and clinical trial research indicating increased openness to experience among psychedelic users (Erritzoe et al., 2019; MacLean, Johnson, & Griffiths, 2011) as well as a general need for novel therapeutics in psychiatry. Equally interesting to underscore is the notable proportion (18%) of participants who indicated “not at all” for their interest in taking a non-hallucinogenic psychedelic, even in the context of hypothetical suffering and functional impairment. Speculatively, this may reflect the vehemence that many in the psychedelic community hold regarding the importance of the psychoactive effects of psychedelics.
Most strikingly, the monetary amount that most participants considered to be reasonable costs for treatment was well below current projected costs. Already, some organizations are charging $1,500–$4,000 just to connect customers with underground facilitators (Wilde, 2023), and in Oregon, where supervised psilocybin use has been legalized, a course of psilocybin treatment costs approximately $2,000–$3,000 (Haas, 2023). The high costs seem to be largely driven by the amount of therapist time required for the intervention as well as liability insurance, state licensure, and state-required security systems (Haas, 2023). Indeed, in a model evaluating the cost-effectiveness of MDMA-assisted therapy (Marseille, Kahn, Yazar-Klosinski, & Doblin, 2020), therapist time (e.g., $6,197) accounted for over 80% of the direct intervention costs (e.g., $7,543), and seems to be a barrier to accessing psychotherapy more generally (e.g., costing approximately $100-$200 per session on average; Woods, 2023). Thus, it might be the case that the treatment will be limited in accessibility in the context of current incentive structures in our healthcare system; innovative solutions will be needed in order to drive down costs to be in-line with consumer attitudes and budgets.
Our study has several limitations that should be noted. Our findings are limited by the use of a convenience sampling approach, which makes it unclear if these results are representative of national trends of people using psychedelics. Additionally, it may be the case that non-psychedelic users have differing opinions on costs of treatment as well as openness to trying a non-hallucinogenic psychedelic analog. Another limitation is that feelings regarding what is considered to be a “reasonable” cost for treatment likely varies as a function of socioeconomic status, local cost of living, and may shift depending on insurance coverage for PAP. Lastly, certain terms in the survey (e.g., “based on psychedelics”, “integration”) were not explicitly defined for participants. We assumed those who use psychedelics and are participating in a survey on psychedelic use would understand these, but this is not guaranteed. Future research should include clear definitions for terms that may be considered jargon.
To conclude, the current well-powered study provides novel insight into attitudes of people using psychedelics on key issues for the field. In particular, it appears that participants valued the role of altered states of consciousness in mediating therapeutic effects with psychedelics, are open to non-hallucinogenic analogs, and consider approximately $70–$80 per hour to be a reasonable cost for treatment. As psychedelic therapy is increasingly scaled up and implemented into clinical settings, it is important to continue to gather, consider, and share attitudes from the psychedelic community regarding these important issues.
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