Exploring the Use of Psilocybin Therapy for Existential Distress: A Qualitative Study of Palliative Care Provider Perceptions

Psilocybin is a naturally occurring psychedelic compound that has been used historically for healing and spiritual purposes. Recent clinical research and regulatory developments—such as FDA "breakthrough therapy" designations and state-level changes in legal status—have prompted renewed interest in psilocybin as a therapeutic tool. Within palliative care, existential distress is common among patients with life-limiting illness, is difficult to treat, and can worsen pain, depression, anxiety, demoralisation, feelings of being a burden, and requests for hastened death. Emerging clinical studies suggest that controlled psilocybin therapy (PT)—which typically includes careful screening, preparatory work, supervised dosing with trained guides, and integration sessions—may produce rapid and sustained reductions in existential distress and improvements in meaning, quality of life, and interpersonal relationships. Mayer and colleagues set out to explore a gap in the literature: the perspectives of interdisciplinary palliative care providers about existential distress and the possible use of psilocybin therapy in this population. The study aimed to characterise providers' experiences managing existential concerns, identify barriers to addressing those needs, and document beliefs, attitudes, and uncertainties regarding PT as a potential treatment option should legal and regulatory conditions change. Understanding provider perceptions was framed as important for planning safe, inclusive, and feasible pathways for PT integration into palliative care if it becomes legally accessible.

The investigators conducted a descriptive qualitative study approved by the University of Virginia Social and Behavioral Sciences Institutional Review Board. They used purposive sampling to recruit interdisciplinary clinicians from a single academic medical centre's palliative care team. Inclusion criteria targeted health care professionals who specialise in, or primarily work with, palliative care patients; recruitment was facilitated by a clinical liaison within the hospital's palliative care programme. Data were collected using a semi-structured interview guide developed by the authors in consultation with the University of Virginia Center for Survey Research and informed by the literature and study aims. Prior to each interview, participants viewed a 7-minute video that briefly introduced psilocybin and depicted a patient experience from an existing psilocybin cancer-anxiety study. Interviews were conducted remotely by one investigator via Zoom because of COVID-19 restrictions, lasted about 45 minutes, were audio recorded with permission, and transcribed using Zoom's transcription software. Transcripts were verified against audio files, de-identified, and prepared for analysis. For analysis the study team followed an inductive descriptive qualitative approach. One investigator read the full data corpus and used Dedoose v.8.3.17 to code salient passages about managing existential distress and perceptions of PT; coded excerpts were exported and organised using concept maps in MindMeister. A second investigator independently reviewed transcripts and identified key patterns; the team reached consensus on final themes. The methods emphasised iterative coding, verification against audio, and collaborative theme development.

Five interdisciplinary palliative care professionals participated: two physicians, one nurse, one chaplain, and one pharmacist. Analysis produced four primary themes: (1) multi-level barriers to exploring and addressing existential distress, (2) the duality and power of presence, (3) suffering as an intrinsically subjective phenomenon, and (4) uncertainty about the risks and benefits of psilocybin therapy. Theme 1 — Multi-level barriers: Participants described barriers at cultural, institutional/organisational, relational, and individual levels. Culturally, existential and spiritual care were characterised as taboo within Western medicine and historically delegated to religious institutions. Organisational pressures—productivity demands and a reductionist biomedical model—limited clinician time and capacity to engage existentially. Relational barriers included miscommunication about treatment plans and professional symbols such as the "white coat" that can inhibit human connection. At the individual level, providers reported gaps in knowledge, limited self-reflection about their own existential concerns, and discomfort discussing death and dying. Theme 2 — Duality and power of presence: All participants emphasised presence as central to palliative care. Presence was described as potentially healing when it involves vulnerability, trust, compassion, humility, non-judgement, intention, and, in some cases, therapeutic touch. Conversely, an ungrounded or boundary-crossing presence can exacerbate suffering; time constraints and severe trauma were noted as limitations on the capacity to offer a therapeutic presence. Theme 3 — Suffering as subjective: Providers conceptualised suffering as multi-faceted—universal, collective, interdimensional (biopsychosocial intersecting with existential), transferable (affecting others in the room), and deeply individual. Manifestations associated with existential distress included unexplained or intractable symptoms, incongruent emotions (for example, guilt or survivor's guilt), and requests for hastened death. Participants also articulated that capacity to love and be loved functions as an index of well-being and recovery from suffering; one clinician observed, "In the end suffering is in the eye of the beholder." Theme 4 — Uncertainty about risks and benefits of psilocybin: Views on PT varied across participants. Familiarity ranged from relative unfamiliarity to active interest informed by professional networks. Some clinicians framed psilocybin as a medicalised pharmacological intervention that would require prescription and controlled administration; others viewed it through spiritual or resilience-enhancing lenses akin to meditation. Debates centred on whether PT should be highly protocolised or individualised, who should act as guides (existing disciplines versus a new specialty), and how to integrate PT into mainstream care. Practical concerns included the logistics of lengthy monitored sessions, staffing and training needs, cost and accessibility, and regulatory constraints given psilocybin's Schedule 1 status. Safety concerns emphasised heightened suggestibility, potential for coercion or abuse, and historical misuse in unethical practices. Several participants expressed that PT might be appropriate only for a narrow subset of refractory patients—one physician said, "I would see this as being really, really a last resort for refractory suffering."

Mayer and colleagues interpret their findings as reinforcing the complexity of addressing existential distress in palliative care and highlighting both opportunities and significant uncertainties around psilocybin therapy. Participants recognised limitations of current pharmacological and non-pharmacological options and considered PT a potential adjunct for patients with substantial, refractory existential suffering, but they expressed doubts about feasibility, safety, and equitable access. The discussion situates presence as a core competency for both palliative care providers and prospective psychedelic guides; non-judgemental rapport and trust were described as central to therapeutic outcomes. At the same time, the team emphasised ethical concerns arising from power imbalances and the increased suggestibility associated with psychedelics, noting that these raise risks of coercion or abuse. The authors also note a notable knowledge gap among providers—three of the five participants were unfamiliar with PT—underscoring a need for education as psychedelics become more visible in health care discourse. The investigators draw attention to structural barriers that may impede safe and inclusive PT integration, including time pressures, institutional priorities, lack of diversity among researchers and guides, and the potential for high costs if PT follows a pharmaceutical model. They recommend more diverse and inclusive clinical research and the development of trauma-informed, patient-centred care models. Specific future research directions suggested by the authors include larger and more diverse samples of providers, patients, partners, and caregivers; examination of the provider-as-guide role and its implications for safety; and educational initiatives to prepare clinicians for potential changes in psilocybin availability. Limitations noted by the authors include the small sample size from a single academic institution, limited demographic and disciplinary diversity (sample was primarily male and white, and no social workers were recruited), and recruitment of participants who were willing to discuss PT, which may introduce selection bias. These factors reduce generalisability and the authors recommend cautious interpretation of the findings while advocating for further research to clarify how, and whether, PT might be integrated into palliative care delivery.