Best Practices in Psychedelic-Assisted Group Psychotherapy

Psychedelic-assisted group psychotherapy (PAGP) is an emerging therapeutic approach that harnesses the neurophysiological effects of psychedelic substances within a group setting to address various mental health conditions, including post-traumatic stress disorder (PTSD), substance-use disorders, major depressive disorder, and anxiety disorders. Rooted in centuries-old indigenous practices where they were used as sacred tools for healing, community bonding, and spiritual connection–often under the guidance of shamans or elders– psychedelics are now recognized in clinical settings for their potential to enhance cognitive flexibility, emotional openness, and self-compassion. Group psychotherapy further enriches the therapeutic process by fostering shared experiences, social support, and collective insight (Guimarães dos Santos et al., 2021). While individual psychedelic-assisted therapy has been more commonly studied, the unique advantages and challenges of PAGP remain underexplored. This paper aims to examine the best practices in PAGP, encompassing preparation, safety, ethical integrity, therapeutic guidance, and integration, and to contribute to advancing this promising field within mental health care.

Psychedelics are a class of psychoactive substances known for their profound effects on cognition, perception, mood, and thought (Guimarães dos Santos et al., 2021; Nichols, 2016). Research highlights their promising therapeutic potential with evidence supporting antidepressant, anxiolytic, and anti-addictive properties. Psychedelics have shown particular promise in addressing treatment-resistant depression, major depressive disorder, and mood symptoms in terminal cancer patients, as well as aiding in recovery from alcohol and tobacco dependence. Similarly, MDMA, a kind of psychoactive substance, has gained recognition for its effectiveness in treating post-traumatic stress disorder, further expanding the scope of these substances in therapeutic contexts (Guimarães dos Santos et al., 2021).

Group psychotherapy serves as a dynamic social therapy, fostering meaningful interactions among participants who share similar experiences, aligning closely with the communal and relational effects of psychedelics. In the context of PAGP, combining the use of psychedelics with group dynamics may amplify key therapeutic factors such as trust, self-disclosure, empathy, and acceptance. The altered states induced by psychedelics can facilitate deeper emotional processing and interpersonal connection, creating a unique environment where individuals can support one another. By engaging multiple individuals simultaneously, group therapy not only enhances accessibility and cost efficiency, making psychotherapy available to a broader group, but also reinforces the collective insight and transformation that psychedelics can promote (Yalom & Leszcz, 2020). Its flexibility in structure and approach allows it to be tailored to diverse settings, with particularly strong outcomes observed in homogenous groups where participants share similar conditions, therapeutic goals, and stages of treatment (Ponomarenko et al., 2023). Furthermore, group therapy has been demonstrated to be highly effective across a wide range of psychiatric and behavioral disorders, with efficacy comparable to that of individual therapy (Burlingame et al., 2016).

Preparation – Preparatory Sessions, Group Selection, Safety, and Cultural Considerations

Psychedelic-assisted group psychotherapy integrates best practices from both individual psychedelic psychotherapy and traditional group therapy yet differs by typically involving a single-dose session where group members collectively take a psychedelic under clinical supervision. Unlike standard group therapy, the concepts of set and setting play a central role in creating a safe, supportive environment for therapeutic exploration. As described by Ponomarenko et al. (2023), set refers to patients’ mindset – their beliefs, attitudes, and intentions toward self-reflection within the group. Meanwhile, setting encompasses the external environment, including group atmosphere, physical surroundings, social environment, and the therapist’s role. In the preparation phase, optimizing set and setting are critical, requiring a serene atmosphere, carefully chosen music to guide synchronicity, and safety measures for the intense experience. Curating a controlled, supportive space where individuals can introspect and connect with others is essential (Stauffer et al., 2020). Additionally, Kettner et al. (2021) underscores the importance of a safe, supportive, and structured environment, encouraging members to express session goals and intentions in a sharing circle to foster trust and enhance the therapeutic effect.

Beyond setting the physical and mental environment, PAGP involves preparatory group sessions where clinicians introduce mindfulness practices and guided imagery prior to dosing (Gasser, 2022). During these sessions, group members discuss their intentions and any concerns about the dosing experience, promoting cohesion and rapport. Stauffer and colleagues (2020) emphasize the importance of thorough preparation and rapport building to establish trust and a therapeutic alliance, which can be especially beneficial for those with attachment insecurities. Ponomarenko and colleagues (2023) further stress the need to define the therapist’s roles before the dosing session. This includes their approach to emotional support during intense moments and the establishment of a group contract outlining boundaries, such as whether physical contact will be allowed.

While psychedelic-assisted group therapy can sometimes feel disorienting, safety and ethics are central to best practices (Oehen & Gasser, 2022; Ponomarenko et al., 2023). Contraindications for PAGP include pregnancy, cardiovascular diseases, certain medications, history or presence of psychotic disorders, bipolar disorders, and borderline personality disorder (Ponomarenko et al., 2023). Furthermore, stringent inclusion and exclusion criteria help ensure group safety, underscoring the importance of pre-screening participants (Oehen & Gasser, 2022). Group dynamics are also crucial. Blewett (1971) explained how group size affects interactions; groups of four with one therapist offer intellectual stimulation but may reduce empathy, while dyads or triads can foster intensity yet limit individuals’ ability to withdraw into self-reflection. Some studies have utilized a one-to-one participant to therapist ratio with a lead therapist overseeing the group process and the dyadic connections helping to enhance rapport, safety, and personal exploration (Lewis et al., 2023). Contemporary research studies typically include more than four participants with Swiss PAGP studies included groups of up to 12 subjects with three supporting therapists without breaking into smaller groups, suggesting that larger groups can also be effective (Oehen & Gasser, 2022).

Incorporating culturally sensitive and inclusive approaches is also fundamental to PAGP. Hauskeller and Schwarz (2023) advocate for decolonial and anti-patriarchal approaches, community engagement, equitable collaboration, and interdisciplinary ethics in PAGP. They recommend diverse, culturally sensitive frameworks that prioritize indigenous systems, particularly by emphasizing communitas, a collective sense of unity that can enhance therapeutic outcomes. Drawing on indigenous frameworks that center on ancient communal rituals and experienced facilitators, PAGP can foster community-oriented experiences, deepen social bonds, and enhance connectedness long after the session is over, enriching both individual and collective healing outcomes. The decolonial framework requires disarming past and present power frameworks that perpetuate the hierarchical dualism of subject, who knows and is typically associated with researcher and object. Inherent to a decolonial framework is the ethical embrace of non-hierarchical differences, reviewing identity patterns recognized by the colonized and colonizers, recognizing the needs of others and acknowledging the complexity and diversity of colonizing situations, histories, legacies, and methods (Guimarães dos Santos et al., 2021). Central to acknowledging the indigenous history in psychedelics are eight ethical principles: (1) Reverence for Mother Nature, (2) Respect Indigenous ways of knowing and being, (3) Responsibility for use, benefits, and harms, (4) Relevance of Indigenous knowledges in psychedelic medicine, (5) Regulation of tangible and intangible use of traditional Indigenous medicines, (6) Reparation and sharing of benefits, (7) Restoration of Indigenous authority, and (8) Reconciliation of Indigenous-Western relations (Celidwen et al., 2023). It is important to recognize the critical elements of historically marginalized peoples within Western science and this applies to psychedelic work as well.

Dosing Sessions – Therapeutic Support, Engagement, and Ethics

In the dosing session of PAGP, each participant receives a predetermined psychedelic dose under clinical supervision. Additionally, during the integration sessions, emotional reflections, autobiographical insights, and individual experiences are discussed to deepen the therapeutic process within the group dynamic (Blewett, 1971). Active therapeutic support during the group session is essential for clinical progress, especially through the skilled interpersonal support of trained clinicians. Effective therapists practicing psychedelic-assisted therapy possess key competencies, including a critical understanding of psychedelic effects, strong ethical integrity, spiritual sensitivity, and an ability to build trust and offer an empathetic presence to group members (Ponomarenko et al., 2023). The Multidisciplinary Association for Psychedelic Studies (MAPS) details 12 psychedelic psychotherapy code of ethics principles, including: (1) safety, (2) confidentiality and privacy, (3) transparency, (4) therapeutic alliance and trust, (5) use of touch, (6) sexual boundaries, (7) diversity, (8) special considerations for non-ordinary states of consciousness, (9) finances, (10) competence, (11) relationship to colleagues and the profession, and (12) relationship to self (Carlin & Scheld, 2019). Therapists play a vital and supportive role during intense moments in psychedelic sessions. It’s recommended therapists use minimal verbal interventions and more often employ singing, storytelling, or humming to help participants remain grounded in their experiences (Ponomarenko et al., 2023). Additionally, appropriate physical contact, requiring prior consent, can offer crucial support to participants in distress. It is important to note that in group settings, transference can become more complicated and potentially amplified by the unprofessional behavior of group participants, including unwanted intimacy or sexuality, underscoring the importance of establishing clear and unambiguous group and therapy rules. In PAGP, the involvement of multiple therapists necessitates alignment and discussion of therapeutic styles and collaborative efforts before administration to ensure a cohesive approach. Therapists are encouraged to be flexible and responsive to both collective insights and individual needs (Ponomarenko et al., 2023).

Applying Yalom and Leszczs’ (2020) 11 therapeutic factors in group psychotherapy – instillation of hope, universality, imparting information, altruism, corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors – is recommended in PAGP (Ponomarenko et al., 2023). Though these factors can foster a healing and supportive environment that enhances group member awareness, connection, and meaningful change, further research is essential to understand the unique effectiveness of this approach within psychedelic group dosing sessions.

During the dosing session, group members are guided to focus inward, with minimal interaction amongst themselves (Oehen & Gasser, 2022). Music and a supportive environment foster emotional openness, with therapists closely monitoring and providing individualized support as needed. Group techniques, like guided breathing, music, and intentional eye contact, can foster emotional synchronization and unity among members, enhancing the collective therapeutic effect (Kettner et al., 2021). Though participants are physically together, the focus remains on personal introspection. In the hours after the psychedelic experience, gentle engagement tailored to each participant’s unique process—be it silent reflection, introspection, or sharing insights with other group members—is encouraged to foster integration (Gasser, 2022).

Integration Sessions and Follow-Up

During integration sessions, individuals share their subjective experience of the dosing sessions, allowing for observation and reframing of core processes while focusing on any particular issue a participant might bring up. In PAGP, the focus of the group is typically on the subjective experiences of the psychedelic dosing session, interpreting insights, and integrating psychological processes. In these sessions, mutual support and feedback from peers are essential, and therapists may take on a more peripheral role. Given the diversity of personal insights that may emerge, therapists must adeptly address an individual’s specific experience while also reframing events to resonate with the group’s core processes. As psychedelic experiences are often ineffable, therapists may reassure participants that finding words is not necessary to capture their insights fully. Due to the profound nature of psychedelic experiences, group members may feel isolated from those outside the group who cannot relate, making the integration group invaluable for mutual understanding and insight. Following the dosing experience, members may show heightened social interest, absorption in group interactions, and responsiveness to therapeutic interventions–an ideal moment to utilize the plasticity window associated with the experience (Ponomarenko et al., 2023).

Integration sessions are a crucial aspect of PAGP with prevailing protocols recommending integration sessions the day after the psychedelic group experience where individuals share their own subjective experience with the group (Gasser, 2017; Gasser, 2022; Oehen & Gasser, 2022). The structured approach to psychedelic group therapy in clinical trials in Switzerland underscores the importance of integration and long-term follow-up to maximize therapeutic outcomes (Gasser, 2022) The day following the dosing session, the group should meet for group members to share and collectively process their experiences from the day before. There is significant value in fostering group unity in the integration sessions to significantly enhance individual psychological well-being and social connectedness. Integration sessions help group members incorporate their emotional insights into daily life, supported by additional follow-up sessions to reinforce these insights. Therapists encourage long-term follow-up, post-dosage self-care, and ongoing personal reflection to help individuals solidify and apply their insights into their daily lives (Gasser, 2022).

Conclusion

In conclusion, psychedelic-assisted group therapy is a promising therapeutic model providing a unique setting for individuals dealing with mental health concerns. This paper has explored the current best practices associated with PAGP, including the importance of preparation, safety and ethics, therapeutic support, controlled group dynamics, and thorough integration and follow-up sessions. These structured practices help create a safe, supportive environment where group members can explore their psychological experiences and dynamically work through their experiences. Future research into PAGP should continue to assess both its clinical effectiveness and the nuanced aspects of group dynamics. With adherence to best practices and continued investigation into the mechanisms and outcomes of PAGP, this approach has the potential to expand therapeutic options and improve mental health care.