**“Activate, adjust, disengage” became a rallying point for freedom. “What a lengthy, peculiar journey it has been” encapsulates our retrospective storytelling of the outcomes. Psychedelic-supported therapy now finds itself situated between these two cultural references: a swiftly formalizing clinical venture and an expanding, loosely governed marketplace of “retreats” promoting healing, insight, and enlightenment.**
The research surrounding psychedelics is more concrete than ever. So too are the dangers. The issue is that public access is outpacing the development of safety infrastructure, standards, and realistic expectations.
A new qualitative research study in JAMA Network Open provides a rare glimpse into publicly promoted psychedelic retreats, and the findings should alarm anyone concerned about patient safety, public health, and the reliability of this developing field.
**Findings from the retreat study: Variability posing as “protocol”**
Representatives from 49 organizations promoting retreats to English-speaking individuals were interviewed. Most were based in the U.S., with only a small fraction identifying as medical.
The substances offered were diverse, frequently including multiple options per retreat. Ayahuasca and psilocybin were the most prevalent. A significant number offered more than one psychedelic substance, and some included several psychedelics in a single retreat schedule. This is important because combining substances and stacking sessions heightens physiological and psychological uncertainty in environments where monitoring may be limited.
Participant screening was present but inconsistent and often relied on self-reporting. All organizations took medical histories; approximately three-quarters disqualified participants with certain conditions, most commonly psychosis and bipolar disorder. However, the study authors point out a key vulnerability: Screening based on self-report can fail, especially when participants are eager for relief from depression, PTSD, or addiction and might downplay symptoms to gain access.
Medication “washout” was nearly universal yet highly inconsistent. Most organizations mandated or suggested ceasing prescription medications, with recommended washout periods spanning from one day to over six weeks. This practice poses risks. Sudden discontinuation of antidepressants is associated with known dangers (withdrawal, relapse, destabilization) and may lead to the very psychiatric vulnerability that increases the likelihood of an adverse psychedelic experience.
Medical presence was common but not guaranteed, and qualifications were not always clear. About two-thirds collaborated with a licensed health professional or someone trained in emergency response, and around two-thirds reported having such a person available at least some of the time. Nevertheless, this still allows for significant potential for disastrous outcomes when “at least some of the time” turns out to be the wrong patient, the wrong weekend, or the wrong complication.
Integration support was universal but frequently informal. Every organization provided some form of integration, yet it varied greatly and was often optional and loosely organized, such as sharing circles or peer-led discussions. In clinical trials, preparation and integration are not mere enhancements; they are fundamental safety and risk-reduction protocols.
Ultimately, the study anchors these concerns in a stark reality. Between 1994 and 2022, at least 58 deaths were reported during ayahuasca retreats, attributed to causes such as homicide, suicide, cardiac events, drowning, and toxic additives—incidents that could plausibly be prevented with stringent screening and medical precautions.
**The broader context: Psilocybin is exiting the clinic faster than the clinic can adapt**
A JAMA Psychiatry review, “Psilocybin Outside the Clinic,” highlights a growing gap between rigorously controlled clinical trials and real-world applications. In trials, risks are reduced through structured preparation, standardized dosing, trained facilitators, and meticulous screening. In non-clinical settings, psychedelic use often coincides with alcohol or cannabis, with adverse-event signals increasingly surfacing in poison control and emergency room data.
Two findings warrant special attention. Firstly, potency in natural products is highly inconsistent. Testing from decriminalized areas reveals more than twentyfold variations in psilocybin content among mushroom samples. Results from trials employing standardized, synthetic psilocybin do not automatically apply to mushrooms cultivated and administered in natural settings.
Secondly, public health monitoring is trailing behind demand. The review advocates for a shift from an exclusive concentration on efficacy trials to research on real-world safety: adverse-event tracking, product testing, harm-reduction tactics, and age-specific risk evaluations.
Infrequent outcomes are also significant as exposure increases. While hallucinogen-persisting perception disorder has not been detected in controlled psilocybin trials, enduring negative psychological effects have been reported outside clinical environments, including cases requiring hospitalization and electroconvulsive therapy.
The takeaway is not that psychedelics are intrinsically hazardous. It is that a culture which frames deterioration as “spiritual resistance” and dissuades medical assistance is itself a safety risk—one that clinicians will inevitably need to address retroactively.
**What responsible integration should entail**
Across recent consensus statements and harm-reduction perspectives, several principles converge. Policymakers and regulators should implement enforceable minimum safety standards for any commercialized psychedelic service, including retreats.