Skin in the Game: Why Psychedelic Therapists Should Share Patient Risks

Plenty of ink has been spilled over whether psychedelic therapists should have their own psychedelic experiences. I’m not going to rehash existing arguments, but sketch an idea that I don’t think has gotten enough attention. I’m not certain it’s even mentioned in peer-reviewed literature.

Much of the discussion hinges on the ‘travel guide’ analogy. In the same way we expect someone leading us through a foreign country to have been there before, we might expect practitioners and guides alike to have first-hand experience with psychedelic or similar experiences. This is important, but not the aspect I want to discuss.

What I’m going to talk about is risk. Specifically, why psychedelic practitioners should be willing to share some of it.

Psychedelic power asymmetry

When a psychedelic assisted therapy (PAT) practitioner prescribes psilocybin or MDMA to a patient, it’s part of their expected ethical & legal practice that they fully inform that patient of the risks involved with that therapy. This is doubly important because, in terms of above-ground approval, these therapies are somewhere between new and outright experimental.

There is always deep power asymmetry between any sort of therapist and their clients. Psychedelics increase this as clients are for more vulnerable during & shortly after dosing. Where a therapy is experimental, or part of a pilot program, the power differential increases again. In that case, not only is the client in a heightened state of vulnerability, they carry the knowledge that their recovery could help bring about broader approval, while an adverse outcome could contribute to the exact opposite. In reality, clients are personally responsible for neither of these things. But the sometimes-evangelical tone of PAT true believers makes it hard to avoid.

Photo by Micaela Parente on Unsplash

Should practitioners share some risk?

All things considered, we should expect practitioners in general to be willing to take the same risks they expect their patients to take. This is a principle of ethical symmetry, where practitioners shouldn’t ask patients to take a risk that they would not take, were they in a similar position.  Where the risks are impractical or too high – cardiac surgery or chemotherapy – we don’t expect them to do this as part of their training.

But we do expect they’d have the same treatments as their patients if they had the same illnesses. It’s minor by cardiothoracic surgery standards, but last year I had to have a biopsy taken from the outside of my lung.  If I asked my surgeon if he’d do the same thing if he were in my shoes, and he’d said ‘no’, I would absolutely reconsider either the procedure or my choice of surgeon (possibly both).

Not all risks are equal, obviously. Some surgical procedures do carry higher risks and are therefore reserved for when the risk of not intervening is higher (though even then, the patient should have the last say on how things proceed.)

But where the risk is relatively low, there is less reason to say that practitioners ought to be excused from sharing it.

Yes, there is a small chance that a psilocybin experience could psychologically ‘one-shot’ a psychiatrist by leading to a deep change in values, exacerbating a latent mental health condition, or causing ongoing issues such as HPPD. But these same risks apply to their clients. If anything, if the practitioner has no physical or mental health contraindications, their risk of an adverse outcome is probably far lower than for their patients.

It’s strange to argue against this. PAT clients are expected to accept a treatment that, according to a 2023 meta analysis, has about a 10% chance of making their depression worse. But if a practitioner has a few percent chance of experiencing ongoing negative effects, that risk is too high? What makes the life of a psychiatrist earning hundreds of thousands a year worth more than a veteran suffering from PTSD or a nurse suffering from treatment resistant depression? It can’t just be the money (can it?)

Call me naïve (or socialist), but I’m pretty sure people are more than their ability to contribute to capitalism.

Visionary alternatives

If we allow that PAT practitioners just need to have mind-altering experiences, and that they don’t necessarily need to take psychedelic drugs to achieve them, the field really opens up.

Where MDMA or psilocybin are contraindicated, there are alternatives. Go to a meditation retreat or cultivate your own deep meditative practice. Heck, go to a rave or EDM festival and dance the night away. Even drug-free, the atmosphere and music can give you the feeling of being part of something bigger.  (I know lots of you will suggest breathwork as a lower-risk alternative. I’d remind you that it has its own contraindications, which are not dissimilar those for psilocybin – so the main risks you’re avoiding are legal.)

Anything that can produce an altered state carries at least some risk, even of just psychological or emotional vulnerability, if nothing else.

Based on the PAT practitioners and other people I know in the field, I’m confident that there would be an acceptable alternative out there for most people who want to work with psychedelics. I’d argue that they’re accessible enough that anyone who refuses all of them isn’t signaling caution, but avoidance. Considering a range of alternatives, the case for sharing some risk or vulnerability is stronger.

Warning: Moral hazard ahead

This might all sound great, but you’re probably asking why there should be any presumption of shared risk. Part of the answer is avoidance of moral hazard. Moral hazard is where one party disproportionally avoids the risk, usually by externalizing it onto someone else, but still reaps the positive rewards. This comes up a lot in finance, e.g., businesses gambling with other people’s money in the stock market. But the principle is the same. If a practitioner can collect significant rewards like wealth, prestige, keynote speaker invites, but it’s the patient who carries much more of the risk of negative outcomes – adverse events, worsening symptoms etc., then we have two problems. One is that it’s just plain unfair and inequitable. The other is that when people can offload the negative consequences of their decision onto others, they make worse decisions and are more likely to act unethically.

In reality, it’s complex. The client has the potential benefit of relief from their depression or PTSD. The practitioner has the spectre of malpractice action and legal sanctions if they really make a mess of things. Where positives and negatives are qualitatively different, we can’t do a neat numerical ranking of the risks they pose.

Nonetheless, if a PAT practitioner has to take the risk associated with having a psychedelic experience, they take on a little of the same sort of risks their patients face, reducing the asymmetry just a little.

Obligation, not option

Does this idea of shared risk enough to justify the idea that psychedelic practitioners must have psychedelic experience if they want to deliver PAT? By itself, maybe not. But in combination with other expectations and the value of lived experience, I feel it’s close. When practitioner asks a client to take on a risk they wouldn’t accept for themselves, they create space for moral hazard.

In this light, psychedelic experience isn’t just a ‘nice to have’ for PAT practitioners. It’s part of the minimum ethical skin in the game.