Where have all the therapists gone? Gone to psychedelics, every one.
by Andrew Penn, MS, PMHNP
(originally appearing on Psychology Today)
Maria used to dread going into the clinic, knowing that each day when she turned on her computer, her EHR would show her the 16 patients she was expected to see each day in her psychiatry group practice. In those 20-minute med checks, she would titrate up lamotrigine, change an SSRI, or try to convince a patient that their relationship challenges might be better addressed through therapy instead of medication. In the eight years since she finished residency, she’d watched her enthusiasm for patient care wane as her panel grew to over 700 patients that her HMO-employer expected her to manage.
But a year ago, soon after the FDA approved both psilocybin for depression and MDMA for PTSD, Maria went through a psychedelic therapy training program, and decided to practice psychedelic therapy full time. Now, she provides 3 all-day psychedelic sessions on M/W/F and provides preparatory and integration therapy on Tuesdays and Thursdays. She went from treating 260 patients a month, to just 12. She loves how she really gets to know her patients, and how she’s been able to really see people get better, and not just trying to put out spot fires of symptoms with one medication change after another.
Maria wasn’t the only one who made this career change after the FDA approval of these two psychedelic medicines. Two other psychiatrists in her group practice of 10 also decided to leave and become psychedelic therapists. Unfortunately, the nationwide shortage of psychiatrists has only worsened, and her former HMO employer can’t find anyone to take on the hundreds of patients left behind who still need their Prozac refilled and their lithium adjusted.
COVID has finally taught the world something that we who work in psychiatry have known all along – mental health is essential. Unfortunately, our current mental health workforce is inadequate to meet the swelling demand that over a year of pandemic life has brought about. The pandemic has expanded the hairline cracks in our mental health care system to full-on fractures. Therapists are inundated with calls from new patients, and subspecialty programs for conditions such as eating disorders or intensive outpatient programs have wait lists that stretch for weeks, if not months. I fear that the inability to access mental health care is about to get worse.
The answer may surprise you.
Psychedelics. Psychedelic therapies, including psilocybin for depression and MDMA for PTSD are poised to take psychiatry by storm, winding closer to FDA approval within the next 2-5 years. Unlike conventional psychopharmacology, these medicines will only be given in carefully controlled settings, usually just once or only a handful of times, supervised by one to two therapists. Unlike conventional treatments, which are often targeted towards symptom management and must be taken (and therefore managed) on an ongoing basis, psychedelic therapies appear to offer something that has not been seen in psychiatry – the promise of a cure for some of our most vexing problems.
However, these therapies are labor-intensive. If the FDA were to approve a protocol similar to those being used in clinical studies, treatment of a patient with depression would require two therapists to provide about 20 hours each (40 hours total) for each patient treated with psilocybin. MDMA therapy usually involves about double that amount of time under current protocols. Drug sessions require an entire day of work, with the duration of action for these drugs typically in the 4-6 hour range, with additional preparatory and wrap-up time at the start and end of each session.
The insufficient supply of mental health clinicians is not a new problem. According to a 2016 report by the Health Resources and Service Administration (HRSA), the predicted 2025 mental health care workforce will fall short of meeting expected demand in almost all sectors of the profession, with marked shortages of psychologists, licensed counselors, and psychiatrists (Psychiatric NP’s and PA’s are the only two sectors of the workforce predicted to be in surplus). These models were created with assumptions that extant workloads would continue (e.g. a psychiatrist might see 16 patients per day, a therapist 6-7 patients per day). Also bear in mind that these prognostications were made well before COVID increased the prevalence of anxiety and depression.
What happens to these models if psychedelic treatments lure clinicians away from existing models of care delivery and towards a model in which fewer patients receive a short, but intensive course of treatment enhanced by a psychedelic medicine? If the improvements seen in current phase 2 and phase 3 trials can be replicated in regular practice, there are some patients who may not need ongoing treatment following psychedelic therapy. They are, in a word, cured. The exiting of these individuals from the mental health care system will undoubtedly reduce some demand, but how much will this reduction in demand be offset by the loss of clinicians to lower patient-volume psychedelic practices? Put differently, if a large number of prescribers leave to provide psychedelics, who will refill the Prozac? If a large number of therapists leave to provide psychedelic therapy, who will provide the CBT? Will psychedelic therapies siphon clinicians away from the conventional workforce, thus exacerbating existing challenges with accessing mental health care?
While some clinicians will return to “conventional” service provision upon finding that psychedelic therapies are not well suited to them, many will not, and addressing this challenge will require a creative pivot of the mental health workforce following FDA approval of these medications. However, there are some ways of making sure that patients who need psychedelic therapies can get them while at the same time making sure patients who need conventional treatments can still obtain care.
1) Incentivize more people to go into mental health care careers
Even before COVID and psychedelics potentially increased demand and reduced supply, respectively, the HRSA report predicted a shortage of most mental health providers by 2025. Regardless of if psychedelics become legalized, there will be a need for more mental health providers. Many training programs require that students go into debt >$100,000 for careers that often pay less than that per year, a debt-to-income ratio that many find untenable. To incentivize students to pursue a mental health career, private and governmental funders should consider debt forgiveness programs and work scholarships for those entering mental health training, especially for those who commit to work with underserved populations.
2) Eliminate the two-therapist model of psychedelic therapy.
This model, in which two therapists, historically of different sexes, are present through the entirety of the therapy, in preparatory sessions, the drug dosing day, and for integration therapy, has been a standard of care through all contemporary psychedelic therapy studies. It has been suggested that it protects the therapist and the patient (who is in a non-ordinary state of consciousness) from sexual abuse or the perception of impropriety. Additionally, it was thought to encourage transference by providing both a maternal and paternal figure in the role of therapists. Finally, on a practical level, it allows for the patient to remain under supervision when a therapist needs a bathroom or meal break.
This model, while generous and feasible for a clinical trial, is not only impractical for clinical use not only for reasons of scheduling and logistics, but effectively doubles the labor cost of the therapy. If therapists are concerned about ensuring patient safety, they could offer to videotape sessions for accountability. But really, hundreds of thousands of patient visits occur between clinician and patient behind closed doors each day in psychiatry clinics, even with patients in vulnerable emotional states, almost entirely without incident. Why wouldn’t psychedelic therapists be able to do the same?
3) Consider non-physician and non-doctorally trained therapists as clinicians
Some clinical trial protocols have required a doctorally trained therapist or psychiatrist as a lead therapist. This is unnecessary. Psychiatric Nurse Practitioners and Psychiatric Physician Assistants are the two professions estimated by HRSA to be training clinicians at a rate commensurate with projected need, could easily train to be psychedelic therapists. Nurses, who comprise the largest workforce in all of health care are well suited to delivering psychedelic therapy. Even if the two-therapist model were to be retained, there is no added value to having two doctorally trained therapists or physicians in the therapy room. Some models, such as that used by the Multidisciplinary Association of Psychedelics Studies require that the lead therapist be licensed, but that the second therapist could be a mental health paraprofessional or a trainee with a bachelors degree. This would help to reduce costs.
4) Allow for multiple sessions to be run at once and attended by nurses
In the early days of psychedelic therapy in the middle of the 20th Century, a psychiatrist like Humphrey Osmond might initiate several sessions of LSD psychotherapy with several patients in separate rooms, while a nurses like Kay Parley would attend to the patients as needed throughout the dosing day. While this model might not permit for minute-to-minute monitoring by a therapist, but a floating nurse trained in psychedelic therapy, could attend to patients in need during their sessions and thus reduce personnel needs.
5) Consider psychedelic group therapy
In much of the historic use of psychedelic medicines in other cultures, the use of psychedelic medicine by an individual was unusual. Psychedelic plants, such as ayahuasca or peyote, were used ceremonially and in community. The communitas created by the medicine was part of the healing experience. This practice continues in places such as Peru and Brazil where ayahuasca remains an active part of the culture. Additionally, this is a common practice in North American and European “underground” psychedelic therapy practice. While no contemporary studies have yet used a group dosing model, a study by Anderson, et al treated men with longstanding HIV who were experiencing demoralization with psilocybin in which the preparatory and integration therapy were done in small groups of six with two therapists present. While the dosing of the psilocybin in this study was done in the typical individual model with two therapists in attendance, future studies should consider providing the medicine to the group, not only for purposes of efficiency, but also to potentially enhance the healing experience of the medicine by taking it in community.
6) Respect, honor, and genuinely explore patient’s own personal psychedelic explorations from a benefit maximization/harm reduction stance
Our patients have long taken and continue to take psychedelic medicines in a variety of contexts. Often, these experiences are not shared with mainstream mental health clinicians out of fear of being misunderstood as drug abuse or pathological behavior. Many patients are thoughtfully seeking insights into lives through these self-directed psychedelic experiences. These drugs are used in a variety of settings, some safe and therapeutic, while other settings may pose more risk. As clinicians, we can support these efforts with an open-minded, nonjudgmental stance that seeks to maximize the benefit patients may receive from these experiences and to reduce attendant harms. We should not assume that all substance use is evidence of a substance use disorder, nor should we assume that experiences had in a nonordinary state of consciousness are pathological. If patients trust us enough to tell us that they are going to take a psychedelic, we owe them the respect of asking their intentions for the experience and inquiring about the provisions for their safety when their consciousness is altered. If they tell us about a psychedelic session that has occurred in the past, we can support their desire for self-directed healing by becoming trained in and engaging in integration therapy with our patients.
7) Remove psychedelic therapy from the domain of psychiatry or at the very least, integrate it
My final, and perhaps most controversial suggestion to reduce the potential for psychedelic therapy to siphon off the “conventional” psychiatric workforce is to expand psychedelic therapy beyond the domain of psychiatry and medicine. The legitimization of psychedelics has occurred in the last 20 years, largely by showing them to be effective medicines. However, as medicines, they can only be administered by people who are qualified to prescribe medicines and can only be given to people with an illness. Not only does this model exclude the possibility of what Bob Jesse has called “the betterment of well people,” it severely limits who can provide this treatment, and thus limits access. Medicine and psychotherapy historically have been licensed, protected professions, requiring the completion of specialized training and the passing of exams, to protect the public from charlatans, and to create a mechanism of maintaining accountability through abrogation of a license for malpractice or misdeeds. However, this exclusivity also serves as a kind of guild protection. If only a rarified class of people can provide a service, then costs usually remain high and access is limited. The emergence of unlicensed “life coaches” (read: lay therapists) represent a threat to the hegemony of licensed psychotherapists by providing counseling without purporting to treat mental illnesses. Within psychedelic therapy, future psychedelic retreat centers, such as those that will be allowed under Oregon’s recent psilocybin decriminalization initiative, psychedelic mushrooms could be given to people without a mental health diagnosis from a “psilocybin service facilitator” (qualifications of such a facilitator are currently in discussion during the 2 year implementation period for this new law). These facilitators could conceivably allow access to knowledgeable guides without relocating these services to the domain of the professional class.
Psychedelic therapies are sometimes portrayed by their promoters as replacing current psychiatry as we know it. The reality is likely to be less dramatic. Psychedelic therapies will undoubtedly become an important tool against mental illness, but it is unlikely they will replace all conventional psychiatric treatments. In all likelihood, they will exist in tandem, with many providers continuing to deliver “conventional” treatments, integrated with thoughtfully deployed psychedelic therapies. And this is fine. While we may debate the way that this treatment is delivered and how it is accessed, it is critical that we not lose sight of why we are pursuing this question, and that is to better serve our patients in their fight against mental illness.