A High Price to Cutting Costs in Psychedelic Therapy

– By Brendan Caldwell

As the field of psychedelic-assisted therapy has boomed in the United States, more and more people are gaining access to this promising avenue for healing. One of the biggest barriers for most Americans is the high cost of this treatment. However, as demand surges and large commercial interests begin to enter the market, I have seen a worrying trend rapidly emerging. In order to make services lower cost and more accessible, large companies are focusing their efforts on making the substance itself more accessible while drastically compromising the therapeutic care that clients receive. The likely result is that these lower cost services will have higher adverse events for clients and lower short and long-term therapeutic efficacy.

The evolution of ketamine-assisted psychotherapy (KAP) serves as a cautionary tale for the future of psychedelic therapy more broadly. While there are still many cautious and capable ketamine therapists in Colorado, those providers are having to compete with alternative services that are much more affordable by offering much less care. Preparation, integration and active guidance during the journey are expensive – and therefore they are often the first things to go in the name of cost efficiency. Some clinical settings will leave clients alone in a room with nothing but a panic button to use if they run into trouble. If the client somehow manages to use the panic button while dissociated, the staff member who comes in to support them may or may not have ever taken ketamine themselves.

While many clients can, and do, see benefits from using ketamine this way, more often than not, those who see short-term improvement will require repeated sessions to maintain their gains. If there is no therapeutic support, there is really no feasible end-date to these maintenance sessions. The underlying root cause of their suffering may never be addressed and therefore they will always be chasing symptom relief. From a strictly commercial perspective, this means long-term recurring revenue. These indefinite maintenance sessions have become a part of the business model for some companies in this space.

If clients could stay well forever with this method, maybe there would be more value to this. However, almost everyone on some sort of long-term maintenance schedule starts to lose effectiveness over time. Their providers increase dose and increase frequency to try to hold onto that symptom relief, but at some point that runs out and clients are back to having no solutions. What’s worse, if the ketamine provided really effective relief, clients have likely gained no new coping skills or lifestyle changes to work with their re-emerging mental health issues.

The reason for this loss of efficacy over time is that the brain is really good at adjusting to whatever psychotropic substance it encounters on a regular basis. One of its jobs is to return to its ‘baseline’ no matter what we’re putting in our bodies – this is what tolerance is. Unless you work towards treating the root cause of that person’s suffering, whatever quick-fix you find will inevitably stop working and you’ll be back where you started. If lasting therapeutic outcomes are the top priority, then the goal should clearly be to do whatever is necessary to help clients change in a stable way that does not require ongoing continuous treatment with no end in sight.

In the case of psilocybin-assisted therapy, I see a real risk of this pattern repeating itself. Large companies will come into the space and create accessibility through cutting down on the allotted time for journeyers in session, limiting or eliminating prep and integration, and drastically underpaying and overworking facilitators. At-home services may emerge which will send a facilitator to your house, but without giving the facilitator ample time to understand the client, their appropriateness for psychedelics, or whether the home space is actually secure and safe. Cutting these corners will inevitably reduce therapeutic effectiveness and put the client and facilitator in danger. One can even imagine a future where the most affordable psilocybin clinics will simply put clients in a room alone with 5 grams of mushrooms and a panic button. The room turns over every 4 hours whether you’ve landed or not.

To clarify, I do not believe that everyone needs to take psilocybin in the presence of a trained and licensed professional. There are many people who have absolutely benefited from using psilocybin on their own or with a trusted friend. My contention is that when people who need real therapeutic support find their only affordable option contains little to no actual support, that will be a tragedy. Both for those clients and for the field of psychedelic therapy.

I also recognize that psychedelic therapy is too expensive for most people. Wages are too low and healthcare costs are too high. So many people can’t afford quality mental healthcare of any kind. Clients currently pay many thousands of dollars out-of-pocket to access quality psychedelic therapy. Moreover, the most expensive part of these clinics will always be the humans involved – the facilitators and their support staff. But if we only make it affordable by slashing the quality of care, then we just ensure that most people can only get access to bad psychedelic therapy.

So, what is the path forward? How do we ensure that psychedelic therapy remains both accessible and effective for all who need it? In this, I have very few answers. Some have suggested that getting psilocybin-assisted therapy covered by health insurance is the answer. I am skeptical of this because insurance companies put the exact same pressure on providers to cut costs and reduce therapeutic support whenever feasible. Just as we’ve seen with KAP, the first psilocybin services covered will likely be those that minimize therapeutic support.

Building not-for-profit organizations and increasing the availability of grant funding could be a potential solution. Mission-driven companies could use these grants to subsidize lower income clients. Furthermore, initiatives to support grassroots organizations and community-based approaches to psychedelic therapy should be prioritized. I see immense promise in the possibility of providing psilocybin in groups from community-led organizations.

Ultimately, the future of psychedelic therapy hinges on our collective commitment to prioritizing quality care over profit margins. By investing in the well-being of clients and upholding ethical standards, we can ensure that psychedelic therapy fulfills its promise as a transformative force for healing in this country.