Why Clients Aren't Telling You About Their Psychedelic Use
8 million Americans used psilocybin last year. Most didn't tell their clinicians. Research on the disclosure gap and what it costs when the silence holds.
Jun 23
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Dr. Peter H. Addy
A colleague described the exchange in our consultation group: her client had mentioned psilocybin use in session three. She’d asked whether he’d “looked into the risks.” He said yes. She moved on. She found out fourteen months later — after he’d stopped using on his own and wanted help processing why — that he’d been using throughout their entire work together. Every session. He’d stopped mentioning it after the first time she responded. She thought she’d handled the disclosure well. By her training, she had. What her training hadn’t given her was an understanding of what it actually took to handle it well in this context.
That gap is not unusual. And the cost of it is not abstract.
That gap is not unusual. And the cost of it is not abstract.
Eight Million Users, Most of Them Invisible to Their Clinicians
A 2026 study by Yang and colleagues in the American Journal of Psychiatry, drawing on the 2024 National Survey on Drug Use and Health, found that approximately 8 million Americans (or 2.8% of the U.S. civilian population) used psilocybin in the past year. The study also found a significant association with major depressive episodes: people experiencing depression were among the more likely to have used. This is not a fringe behavior, and it is not happening outside the population licensed mental health professionals are already treating.
And yet most of those people are not telling their clinicians. A 2023 survey by Boehnke and colleagues in Frontiers in Psychiatry found that among naturalistic psilocybin users with healthcare providers, only 22% had disclosed their use to a primary care provider. Fifty-eight percent had disclosed to a psychiatric care provider. A higher rate, but still a meaningful gap. The majority were silent.
That’s not a patient communication failure. The researchers asked why people didn’t disclose. What came back was stigma, concern about inadequate provider knowledge, and fear of losing access to prescribed medications. Patients were making a rational calculation: they’d learned, or expected, that disclosure carries costs. The silence is a response to something.
And yet most of those people are not telling their clinicians. A 2023 survey by Boehnke and colleagues in Frontiers in Psychiatry found that among naturalistic psilocybin users with healthcare providers, only 22% had disclosed their use to a primary care provider. Fifty-eight percent had disclosed to a psychiatric care provider. A higher rate, but still a meaningful gap. The majority were silent.
That’s not a patient communication failure. The researchers asked why people didn’t disclose. What came back was stigma, concern about inadequate provider knowledge, and fear of losing access to prescribed medications. Patients were making a rational calculation: they’d learned, or expected, that disclosure carries costs. The silence is a response to something.
What Happens When They Do Tell
The data on what happens when patients do disclose is clarifying. A 2024 study by St. Pierre and colleagues in Psychedelic Medicine surveyed patients about their experiences discussing psychedelic use with physicians and other healthcare providers. Fifty-six percent reported less satisfaction communicating about psychedelics compared to other medical topics. Fifty-five percent felt discriminated against by their provider for bringing up the subject.
More than half of the people in that sample walked away from a disclosure feeling penalized. The rational protective response, as the literature frames it, is not to disclose again.
The person in my colleague’s consultation group had made that calculation. He’d tested the waters in session three and gotten back a question about whether he’d looked into the risks. That was enough. He didn’t stop using; he stopped mentioning it.
More than half of the people in that sample walked away from a disclosure feeling penalized. The rational protective response, as the literature frames it, is not to disclose again.
The person in my colleague’s consultation group had made that calculation. He’d tested the waters in session three and gotten back a question about whether he’d looked into the risks. That was enough. He didn’t stop using; he stopped mentioning it.
The Medication Intersection
This matters beyond the therapeutic relationship. The same Boehnke survey found that 23% of naturalistic psilocybin users reported using the substance on the same day as potentially interacting psychiatric medications: anxiolytics, antidepressants, and others. A clinician who doesn’t know about the use cannot screen for that interaction, adjust treatment accordingly, or formulate accurately. The disclosure gap is not only a relational problem. In a significant subset of cases, it is a medication safety problem.
This Is a Training Gap
Here is the structural reality: most licensed clinicians were never trained for the first-contact moment, because that moment didn’t exist as a clinical category when they were trained. The psychedelic-use conversation sits in territory that graduate programs and post-licensure CE requirements have not historically addressed.
The field has responded, but unevenly. What has scaled most visibly is facilitator training: intensive, expensive programs aimed at clinicians who want to administer psychedelic therapy themselves. Many of those programs are rigorous and valuable. Most cost between $5,000 and $15,000. And none of them address what a clinician needs in order to respond competently when a client mentions psilocybin use at minute forty-five of a fifty-minute session. That is a different skill set. It is the one that applies to the vast majority of licensed professionals whose clients are using psychedelics right now.
The silence in my colleague’s consultation group was not her client’s failure. It was a readout of where clinical training has and hasn’t gone.
The field has responded, but unevenly. What has scaled most visibly is facilitator training: intensive, expensive programs aimed at clinicians who want to administer psychedelic therapy themselves. Many of those programs are rigorous and valuable. Most cost between $5,000 and $15,000. And none of them address what a clinician needs in order to respond competently when a client mentions psilocybin use at minute forty-five of a fifty-minute session. That is a different skill set. It is the one that applies to the vast majority of licensed professionals whose clients are using psychedelics right now.
The silence in my colleague’s consultation group was not her client’s failure. It was a readout of where clinical training has and hasn’t gone.
What Changes When the Clinician Is Ready
The first-contact moment is trainable. How to receive a disclosure, what basic history to gather, which safety questions to ask: these are learnable skills. When a clinician has them, the clinical relationship changes. The client doesn’t have to remain silent to protect themselves. The medication screen can happen. The integration support can happen. The formulation can reflect what’s actually going on.
None of this requires becoming a psychedelic therapist. It requires being prepared to respond when the subject comes up. For most licensed clinicians in practice right now, that is the training gap that matters most.
None of this requires becoming a psychedelic therapist. It requires being prepared to respond when the subject comes up. For most licensed clinicians in practice right now, that is the training gap that matters most.
Psychedelics and the Therapeutic Frame: Foundations for Licensed Clinicians is a 3-CE-hour course for licensed mental health professionals seeking a grounded foundation in psychedelic-informed practice, including pharmacology, scope of practice, medication interactions, and first-contact clinical skills the field hasn’t taught. NBCC-approved. $137.
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Peter Addy, PhD, LPC, LMHC, is a Portland-based licensed therapist and the founder of Psychedelic Affirming Education, an NBCC-approved continuing education provider for licensed mental health professionals and Oregon Psilocybin Services facilitators. His research background includes work at Yale School of Medicine on psychedelic substances.
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