Best Practices in Psychedelic-Assisted Group Psychotherapy
Gaby Rodriguez
George Washington University
Introduction
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 (Guimarães dos Santos et al., 2021). 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.
Preparation – Preparatory Sessions, Group Selection, Safety, Ethics
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 individuals take a controlled dose of a psychedelic substance under professional guidance as part of structured therapy or research (Blewett, 1971). 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 is 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 and Ros es (2021) underscore the importance of a safe, supportive, and structured environment, encouraging members to share 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. It is emphasized by Stauffer and colleagues (2020) the importance of thorough preparation and rapport-building to establish trust and a therapeutic alliance, especially beneficial for those with attachment insecurities. It is recommended by Ponomarenko and colleagues (2023) to define therapist roles before the dosing session, including their approach to emotional support during intense moments, and to establish 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 (Ponomarenko et al., 2023; Oechen and Gasser, 2022). Contraindications for PAGP include pregnancy, cardiovascular diseases, certain medications, a history of psychotic disorders, bipolar disorder, borderline personality disorder, and poor social skills (Ponomarenko et al., 2023). Furthermore, stringent inclusion and exclusion criteria help ensure group safety, underscoring the importance of pre-screening participants (Oechen and Gasser, 2022). Group dynamics are also crucial. Blewett (1971) explained how group size affects interactions–groups of four 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 1:1 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– Swiss PAGP studies included groups of up to 12 subjects with three supporting therapists, without breaking into smaller groups, suggesting that larger groups can be effective (Oechen and Gasser, 2022).
Incorporating culturally sensitive, inclusive approaches is also fundamental to PAGP. It was Hauskeller and Schwarz (2023) who advocated 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. The decolonial framework requires disarming past and present power frameworks that perpetuate the hierarchical dualism of ‘subject,’ who holds knowledge and is typically associated with researcher, and ‘object,’ who is being studied (Guimarães dos Santos et al., 2021). Drawing on indigenous frameworks that center on ancient communal rituals and experienced facilitators, it is the position of PAGP to foster community-oriented experiences, deepen social bonds, and enhance connectedness long after the session is over, enriching both individual and collective healing outcomes (Hauskeller and Schwarz, 2023). Eight ethical principles have been detailed in reference to using traditional indigenous medicines in Western psychedelic research and practice, including: reverence, respect, responsibility, relevance, regulation, reparation, restoration, and reconciliation (Celidwen et al., 2023).
Dosing Sessions – Therapeutic Support, Engagement
In the dosing session of PAGP, each participant receives a predetermined psychedelic dose under clinical supervision. Additionally during the integration sessions, emotional, autobiographical insights, and 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 (Ponomarenko et al., 2023). Effective psychedelic-assisted therapists possess key competencies, including a critical understanding of psychedelics’ effects, strong ethical integrity, spiritual sensitivity, and an ability to build trust and offer empathetic presence to group members (Ponomarenko et al., 2023). The Multidisciplinary Association for Psychedelic Studies (MAPS) details twelve psychedelic psychotherapy code of ethics principles, including: safety, confidentiality and privacy, transparency, therapeutic alliance and trust, use of touch, sexual boundaries, diversity, special considerations for non-ordinary states of consciousness, finances, competence, relationship to colleagues and the profession, and relationship to self (Carlin and Scheld, 2019).Therapists play a vital supportive role during intense moments in psychedelic sessions, and they are recommended to 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, provided with prior consent, can offer crucial support to patients in distress. Important to note, however, is 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 (Ponomarenko et al., 2023). 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).
During the dosing session, group members are guided to focus inwardly, with minimal interaction among themselves (Oechen and 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 and Rosas, 2021). Though participants are physically together, the focus remains on personal introspection. Hours after the psychedelic experience, gentle engagement with other group members is encouraged to support integration (Gasser, 2022).
Integration Sessions – Follow Up
During integration sessions, individuals share their subjective experiences, allowing for observation and reframing of core processes while focusing on a particular issue any member might bring up. In PAGP, the focus of the group is typically 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 (Ponomarenko et al., 2023). 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, 2022; Gasser, 2017; Oechen and 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 critical importance of preparation, safety and ethics, therapeutic support, controlled group dynamics, and thorough integration and follow-up. 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.
References
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