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Intersubjective Experience During Psychedelic Group Sessions Predicts Enduring Changes in Psychological Wellbeing and Social Connectedness

Background: Recent years have seen a resurgence of research on the potential of psychedelic substances to treat addictive and mood disorders. Historically and contemporarily, psychedelic studies have emphasized the importance of contextual elements (‘set and setting’) in modulating acute drug effects, and ultimately, influencing long-term outcomes. Nevertheless, current small-scale clinical and laboratory studies have tended to bypass a ubiquitous contextual feature of naturalistic psychedelic use: its social dimension. This study introduces and psychometrically validates an adapted Communitas Scale, assessing acute relational experiences of perceived togetherness and shared humanity, in order to investigate psychosocial mechanisms pertinent to psychedelic ceremonies and retreats.

Methods: In this observational, web-based survey study, participants (N = 886) were measured across five successive time-points: 2 weeks before, hours before, and the day after a psychedelic ceremony; as well as the day after, and 4 weeks after leaving the ceremony location. Demographics, psychological traits and state variables were assessed pre-ceremony, in addition to changes in psychological wellbeing and social connectedness from before to after the retreat, as primary outcomes. Using correlational and multiple regression (path) analyses, predictive relationships between psychosocial ‘set and setting’ variables, communitas, and long-term outcomes were explored.

Results: The adapted Communitas Scale demonstrated substantial internal consistency (Cronbach’s alpha = 0.92) and construct validity in comparison with validated measures of intra-subjective (visual, mystical, challenging experiences questionnaires) and inter-subjective (perceived emotional synchrony, identity fusion) experiences. Furthermore, communitas during ceremony was significantly correlated with increases in psychological wellbeing (r = 0.22), social connectedness (r = 0.25), and other salient mental health outcomes. Path analyses revealed that the effect of ceremony-communitas on long-term outcomes was fully mediated by communitas experienced in reference to the retreat overall, and that the extent of personal sharing or ‘self-disclosure’ contributed to this process. A positive relationship between participants and facilitators, and the perceived impact of emotional support, facilitated the emergence of communitas.

Conclusion: Highlighting the importance of intersubjective experience, rapport, and emotional support for long-term outcomes of psychedelic use, this first quantitative examination of psychosocial factors in guided psychedelic settings is a significant step toward evidence-based benefit-maximization guidelines for collective psychedelic use.

Introduction
The ‘biomedical revolution’ of the 1970 and 80s led to an explosive infiltration of pharmaceutical interventions into psychiatric practice and the marginalization of previously favored psychodynamic approaches, consequentially inviting the charge that clinical psychopharmacology offers an atomized and decontextualized approach to mental illness, improving revenues rather than mental health outcomes or stigma (Deacon, 2013; Kleinman, 1988; Kleinman and Cohen, 1991; Peele, 1981). Research on the therapeutic application of psychedelic serotonin 2A receptor agonists (such as LSD or psilocybin) constitutes a curious outlier in this regard, considering the strong emphasis it places on the role of psychological, social, and cultural context of administration–popularly known as ‘set and setting’–for attaining therapeutic success (Leary et al., 1963; Hartogsohn, 2016; Hartogsohn, 2017; Carhart-Harris, 2018; Carhart-Harris et al., 2018b). However, motivated by pragmatic and safety reasons, modern trials of psychedelic-assisted psychotherapy have almost exclusively employed individual, rather than systemic or group therapy approaches–consistent with dominant psychedelic therapy models of the 1950s–70s (Grof, 1980), although modern (Anderson et al., 2019) and historical group-therapy exceptions do exist (see Trope et al., 2019 for a historical review of psychedelic-assisted group therapy research). This focus on individual therapy, delivered in highly engineered clinical and laboratory settings, might partially explain why contemporary psychedelic research has remained largely silent in relation to what might be one of the most prevalent factors impacting psychedelic effects in natura: the social dimension of psychedelic use.

The socially constructive function of psychedelic use has been central in many cultures that developed customary or ritualized forms of consumption (Dobkin de Rios, 1984; Andritzky, 1989; Hunt and Barker, 2001; Winkelman, 2010), and can be deduced even from earliest mentions and anthropological studies of indigenous usage (Villavicencio, 1858; La Barre, 1938). An inherently social function is also reflected in the plethora of approaches to psychedelic use that persists in contemporary Western cultures, ranging from dance-events (“raves”) (Papadimitropoulos, 2009) to religious ceremonies conducted by ayahuasca churches (Tupper, 2008), to the medically supervised administration of ibogaine in underground addiction treatment centres (Alper et al., 2008). The number of people drawing on various types of these naturalistic settings by consuming psychedelic substances on their own behalf is increasing (Palamar and Le, 2018; Yockey et al., 2020), often with self-medicative or self-explorative purposes (Mason and Kuypers, 2018; Kettner et al., 2019b; Hutten et al., 2019). Importantly, naturalistic settings in which psychedelics are taken almost always involve their use as a collective activity, raising the question of how psychedelic substances may acutely affect the experience of intersubjectivity, i.e., human interaction, relation, and collective emotion, and how such psychosocial dynamics might, in turn, act upon the psychological constitution of the individual.

A rapidly growing phenomenon that lends itself particularly well to the study of psychosocial effects of psychedelics can be found in psychedelic retreat settings. In countries where specific psychedelic substances have remained legal, the unmet global demand for structured and safe use of psychedelics has helped create an industry of psychedelic experience-provision, often comprising of multi-day retreat programs, typically consisting of one or more guided psychedelic group sessions, referred to as ‘ceremonies’. Usually, such guided psychedelic sessions are prepared and conducted by one or more individuals who have acquired this skill through formal training or experience in the care for others during psychedelic experiences. These practitioners (e.g. ‘shamans’, ‘ayahuasceros’ or ‘curanderos’ in the context of ayahuasca ceremonies; ‘experience facilitators’, ‘sitters’ or ‘guides’ in Western settings) may carry out or recommend preparatory activities before the session to induce a prepared mind-“set” in the participants (Harris and Gurel, 2012). Additionally, they strive to establish a safe and comfortable environment, often making use of decorative or ritual objects, special lighting, incense or bonfires, and provide emotional support to participants under the influence of the psychedelic (Fadiman, 2011). During the session, facilitators or shamans may interact with participants directly or indirectly, but most often including the medium of music. Rattling, drumming, singing and whistling, sometimes including the group’s active participation, are typical elements in Meso and South American settings of mescaline (i.e. peyote or San Pedro) and ayahuasca use (De Rios and Katz, 1975).

While many psychedelic retreat providers in the West utilize elements discovered to be useful in psychedelic therapy such as tailored playlists for psychedelic sessions (Kaelen et al., 2018), most facilitators also draw from other therapeutic or spiritual traditions. These often include techniques aimed to structure the relational dynamics amongst retreat participants and between participants and facilitators. A prevalent example are ‘sharing-round’ rituals (Fotiou, 2020; Gearin, 2015a; Gearin, 2016b), often held both before and after ceremonies, during which participants are invited to articulate personally salient material, such as intentions for, or experiences during sessions. Controlled self-disclosure of feelings and thoughts, being fundamental for developing social relationships (Derlega and Chaikin, 1977), has been shown to elicit trust and reciprocity especially among ‘passing strangers’ (coming from different locations) (Rubin, 1975) and liking within groups (Collins and Miller, 1994). These ritualized and carefully moderated spaces for exchange may therefore facilitate the creation of intragroup cohesion and alliance with facilitators, the potential importance of which, although not yet investigated empirically, can best be understood in light of group psychotherapy research, where cohesion and therapeutic alliance are among the most powerful predictors of positive treatment-outcomes (Schnur and Montgomery, 2010). On an individual level, apart from rendering facilitators potentially more able to adequately react to difficult material arising during psychedelic sessions, disclosure of deeply personal, especially challenging, narratives or experiences, without others advising or judging, has been shown to improve emotion regulation and enhance self-acceptance (Farber, 2003; Hemenover, 2003; Kahn and Garrison, 2009), suggesting that sharing-rounds in psychedelic retreats might in themselves hold therapeutic value (Aronovich, 2020).

In addition to the relational processes commonly employed in preparation and aftercare of ceremonial psychedelic use, one can also expect the acute psychedelic state itself to be impacted by the presence of others. However, little to no quantitative empirical research exists on the intersubjective phenomenology of psychedelic states, which is striking considering the substantial body of literature indicating a crucial role of the acute psychedelic state mediating the long-term psychological outcomes of psychedelic substance use (MacLean et al., 2011; Uthaug et al., 2018a; Haijen et al., 2018; Roseman et al., 2018; Kettner et al., 2019a; Roseman et al., 2019; Uthaug et al., 2019; Spriggs et al., 2020). Whereas psychedelic research has so far focused largely on individual, i.e., intrasubjective drug effects, entry points into relational or ‘intersubjective’ aspects of shared altered states of consciousness can be found in studies on ritual and collective action. As proposed by Durkheim (1897), an important function of collective dancing, music listening, or music-making (which are commonly also employed in psychedelic group settings) lies in their ability to induce a synchronization of affect and behavior among participants. This phenomenon, originally termed ‘collective effervescence’ (Durkheim, 1912) has been identified as a catalyst for the blurring of self-other boundaries, social affiliation and cooperation (Hove and Risen, 2009; Reddish et al., 2013; Tarr et al., 2014). Specifically, Páez et al. (2015) found increased perception of emotional synchrony in collective gatherings to elicit ‘identity fusion’, a process that implies a change in self-concept from a personal to a collective level. Identity fusion has been described as “a unique form of alignment with a group, one that entails a visceral feeling of oneness with the group” (Swann et al., 2012), which, in concurrence with phenomena of synchrony, may explain how collective rituals often reinforce social connectedness and cohesion (Whitehouse et al., 2014).

The theory of identity fusion is conceptually linked to Victor Turner, (1969) notion of “spontaneous communitas”, defined as an experience of intense togetherness and shared humanity that temporarily transcends social structures. According to Turner, communitas occurs in situations such as rites of passage, where existing relational structures are lifted in order to allow for a transition into a new social configuration, mediated by an anti-structural and often ritualized ‘liminal phase’ of equality among community members. Communitas, thereby, involves a transgression or dissolution of norms that regularly govern structured or institutionalized relationships, placing the group that experiences it temporarily ‘outside’ of society. Unsurprisingly, modern conceptions of communitas thus also include states of spontaneous fellowship during events such as natural disasters, revolutions, countercultural happenings, music or sport events (Turner, 2012), which suspend conventional social structures. Explaining how communitas may generate enduring changes beyond the acute liminal state, Olaveson (2001) discusses how the dialectic of communitas lies in the revitalizing function that this anti-structural state entails, owed to its creative potential: “In liminality, the state in which communitas occurs, culture is analyzed into factors and freely recombined and experimented with (Turner and Turner, 1970) […] Anti-structure can thus be a positive and generative force (Turner, 2018), and is a condition in which myths, symbols, rituals, philosophy, and art are generated, which are templates for the periodical reclassification of reality and man’s relationship to society, nature, and culture.” (Olaveson, 2001, p. 106).

The concept of communitas thereby invokes a fascinating semblance to the transformative potential of psychedelic states, which analogously has been discussed as resulting from a temporary suspension of established hierarchical neurocognitive structures, allowing for less constrained recombination of thoughts, emergence of novel insights, and sometimes radical reorientation of the individuals’ relationship to themselves, others, and reality at large (Carhart-Harris and Friston, 2019). While seeing the psychedelic state as a ‘functional communitas of the brain’ might be an overly stretched analogy, Turner’s concept of spontaneous communitas has indeed been applied to explain transformative collective experiences both in psychedelic rave culture (Tramacchi, 2000), as well as in psychedelic ceremonies (Lewis, 2008; Mantere, 2013; Roseman et al., 2021), although not yet assessed quantitatively in this context. Communitas as a sociopsychological construct has so far only been operationalized in the contexts of sports (McGinnis et al., 2012) and night clubbing (Taheri et al., 2016), finding that communitas as an intersubjective experience was more relevant than the intrasubjective experience of ‘flow’ in the context of night clubbing, but not golfing, for the generation of emotional responses, and enduring involvement, respectively. Of note, both studies showed discriminant validity of their respective measure of Communitas only against intra- but not related intersubjective (e.g., identity fusion, emotional synchrony) constructs.

The current study aimed to address the existing gap of knowledge and research instruments pertaining to relational processes pertinent to psychedelic experiences, providing a first comprehensive, quantitative assessment of psychosocial mechanisms underlying collective psychedelic use. For this purpose, we here leverage the largest prospective sample of psychedelic use reported to date to psychometrically validate an adapted psychedelic Communitas Scale (COMS), a measure of communitas specifically tailored to psychedelic group experiences. Construct and criterion validity are investigated through the COMS′ relationship to: 1) validated measures of intersubjective experience and acute psychedelic effects; 2) ‘set and setting’, specifically its relational elements (identity fusion, self-disclosure, rapport with participants and facilitators) and trait absorption, a well-established predictor of previously studied intrasubjective psychedelic effects (Studerus et al., 2012; Haijen et al., 2018); as well as 3) long-term psychological outcomes, including psychological wellbeing and social connectedness as primary outcomes, and depressive symptoms, trait anxiety, and interpersonal tolerance as secondary outcomes. This was achieved by means of correlational and longitudinal path analyses, the latter approach being able to reveal directed causal dependencies between variables measured at multiple timepoints.

Methods
The current study used web-based data collection from a self-selected opportunistic volunteer sample. Eligibility criteria for participants were being 18 years or older, a good comprehension of the English language, and the intention to participate in a retreat, ceremony, or other guided experience involving the use of a classic psychedelic containing a 5-HT2A receptor agonist (e.g., psilocybin, DMT, mescaline, or LSD). Ethics approval was granted by the Joint Research Compliance Office and the Imperial College Research Ethics Committee (ICREC reference 18IC4346). The online survey platform Surveygizmo was used to create and host the survey.

Participants were recruited following two dissemination strategies: Firstly, advertisements including a link to the study website (www.ceremonystudy.com) were posted and shared on psychedelic-related online for a (Reddit groups, Bluelight, and ayahuasca. nl), email newsletters (MAPS, Chakruna, and psychedelicexperience.net), and social media platforms (Twitter and Facebook). Secondly, retreat centers and facilitators of guided psychedelic experiences were contacted with information about the study, inviting them to advertise the study to their future clients. This mediated outreach strategy was chosen to maximize awareness of the study in the target population, and to facilitate the collective participation of multiple participants from single retreat or ceremony groups.

Study Design and Timepoints
In this prospectively designed study, a minimum of five surveys were completed by participants at different time points. A first baseline measurement took place 2 weeks before the psychedelic experience, followed by a second measurement up to 3 h before. A third measurement took place on the day after the experience, in which subjective drug effects were assessed retrospectively.1 A fourth survey was completed on the day after leaving the ceremony or retreat location. Finally, the fifth, key endpoint survey was completed 4 weeks after the end of the psychedelic retreat or ceremony.

Each survey included a number of existing measures and in some cases self-constructed scales to assess particular constructs of interest for which no previously validated measures could be found. The following section describes the measures that were included in the present analysis.

Measures
Baseline Measurement (Survey 1)
Participant Information
The baseline survey included questions assessing demographic information, including age, gender, nationality, education, employment, income, ethnicity, and marital status, as well as frequency of lifetime psychedelic use.

Experience Details
Next, a number of questions served to specify details of the upcoming experience. These included the type of plant or substance expected to be used (“Psilocybin/magic mushrooms/truffles”; “LSD/1P-LSD”; “Ayahuasca”; “DMT”; “5-MeO-DMT (Bufo)”; “San Pedro”; “Peyote”; “Iboga/Ibogaine”; self-specified option), the duration (in days) and number of psychedelic sessions of the retreat.

Outcome Measures
As primary outcomes, the 14-item Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS) (Tennant et al., 2007) and the 8-item Social Connectedness Scale (SCS) (Lee and Robbins, 1995) were used to assess longitudinal changes in wellbeing and psychosocial health from before to after the psychedelic experience. Of secondary interest, the self-report version of the quick inventory of depressive symptomatology (QIDS-SR-16, hereon referred to as the QIDS) (Rush et al., 2003) and the 6-item short form of the Spielberger Trait-State Anxiety Inventory (STAI) (Fioravanti-Bastos et al., 2011) trait subscale were included to measure changes in depressive symptoms and trait anxiety. Lastly, the Warm Tolerance subscale of the Interpersonal Tolerance Scale (IPTS) (Thomae et al., 2016) was included to measure changes in attitudes and openness toward people who hold different values or beliefs than one’s own.

Psychological Traits
An established trait predictor of psychedelic effects (Haijen et al., 2018; Lifshitz et al., 2019), trait absorption was measured using 25 items of the Modified Tellegen Absorption Scale (MODTAS) (Jamieson, 2005), a previously identified predictor of acute psychedelic drug effects (Studerus et al., 2012; Haijen et al., 2018).

Pre-experience Measurement (Survey 2)
Preparedness—“Set”
The 12-item psychedelic predictor scale (Haijen et al., 2018) was used to assess preparedness for the experience. A sub-score for the social setting pre-ceremony (from hereon referred to as ‘Rapport’) was calculated as a sum of the items “I have a good feeling about my relationship with the group/people who will be with me during the experience” and “I have a good relationship with the main person/people who will look after me during the upcoming experience” from the psychedelic predictor scale. In the present sample, the Pearson correlation coefficient for the two items of this subscale was strong (r = 0.62). Additionally, a single-item pictographic identity fusion scale (IF) (Swann et al., 2009) was included to assess identity fusion with the group shortly before the session.

Post-experience Measurement (Survey 3)
Subjective Psychedelic Experience
To assess subjective drug effects, a combination of validated and self-constructed questionnaires was employed. These included: In order to measure visual perceptual alterations, the three subscales on visual effects of the Altered States of Consciousness Questionnaire (ASC-VE) were included: elementary imagery, complex imagery and audio-visual synaesthesia (Studerus et al., 2010); the 30-item Mystical Experience Questionnaire (MEQ) (Barrett et al., 2015), including four subscales (mystical, positive mood, transcendence of time and space, ineffability); the 25-item Challenging Experience Questionnaire (CEQ) (Barrett et al., 2016) comprising seven subscales (fear, grief, physical distress, insanity, isolation, death, paranoia); and an adapted short 5-item version of the Perceived Emotional Synchrony Scale (PESC) (Páez et al., 2015), assessing feelings of collective emotional entrainment. To further assess the psychosocial dimensions of the experience, the pictographic IF was included retrospectively to assess perceived fusion with the group during the experience (see Appendix). Lastly, an 8-item Communitas Scale (COMS, see Appendix) was adapted based on items previously used in the context of sports (McGinnis et al., 2012) and night clubs (Taheri et al., 2016), rated on a 7-point Likert scale. Specifically, the 5 items used by Taheri et al. (2016) were reworded to apply to psychedelic ceremonies, rather than night clubs. Also, three additional items were constructed to capture aspects of Communitas that were deemed central to the construct based on the primary literature, but not captured in above-mentioned previous operationalisations, i.e., irrelevance of social status, experience of equality, loss of ego.

Two further self-constructed items were added, which assess the connection felt with another participant and with a facilitator during the experience, respectively. In order to assess the impact of emotional support delivered in the ceremonial setting, participants rated one further self-constructed item “To what extent did the presence of emotionally supportive individuals influence the overall quality of your experience?” on a 1–100 VAS.

Post-retreat (Survey 4)
Retreat Experience
On the day after the retreat, an adopted version of the COMS and pictographic IF scale were included, measuring both constructs in reference to the retreat as a whole, rather than just the duration of a single psychedelic ceremony. Additionally, the revised self-disclosure scale (RSDS) (Wheeless and Grotz, 1976) was used to measure self-perceived self-disclosure across six components (intended disclosure, positiveness, honesty, amount, relevance, and depth of disclosure), using a total of 18 items rated on a 7-point Likert scale which are summed into a total self-disclosure score.

Key Endpoint (Survey 5)
Outcome Measures
In order to assess changes on primary and secondary outcomes, measures assessing psychological wellbeing (WEMWBS), social connectedness (SCS), depressive symptoms (QIDS), trait anxiety (STAI), and interpersonal tolerance (IPTS) were repeated at the key endpoint, 4 weeks post-experience.

Statistical Analysis
Data from all time points was imported and merged using the Statistics Toolbox or Matlab (release 2019b) and were then exported for further analysis into RStudio (v1.2). Several heuristics were employed to first verify the factor structure and internal consistency among the eight items of the COMS. Since, in accordance with its previous versions (McGinnis et al., 2012; Taheri et al., 2016), we hypothesized the COMS to be unidimensional, a confirmatory factor analysis was carried out after verifying the number of latent factors, as recommended by Matsunaga (2010). Visual examination of the scree plot and the Kaiser, (1960), which accepts as reliable factors those whose corresponding eigenvalue is larger than one, were applied. Complementary analyses included, optimal coordinate and acceleration factor tests in order to identify an appropriate number of factors via non-graphical solutions (Raîche et al., 2013). The scale reliability was assessed via Cronbach’s alpha and composite reliability—the latter being less prone to over- or underestimations of reliability at a population level (Raykov, 1998).

Construct Validity
To assess construct validity, bivariate Pearson correlations were calculated between COMS scores, self-constructed items on participant and facilitator-connectedness, and the subscales of validated subjective experience measures taken at each ceremony (IF, PESC, MEQ, CEQ, ASC-VE).

Criterion Validity
To test the primary hypothesis—that communitas experienced during ceremony would be predictive of changes in the primary outcomes wellbeing (WEMWBS) and social connectedness (SCS)—Pearson-correlations were calculated between SCS, WEMWBS and COMS scores. For participants who reported multiple ceremonies, the analyses considered the highest COMS score reported. Additionally, two-sided pairwise t-tests were conducted for SCS and WEMWBS to assess significance of changes from baseline to the key endpoint at 4 weeks post-retreat. The same procedure was repeated for the secondary outcomes trait anxiety (STAI), depression severity (QIDS), and interpersonal tolerance (IPTS).

Path Analysis
In order to further explore the causal structure of the assessed psychosocial factors and examine the concurrent, pre- and postdictive criterion validity of the COMS, a longitudinal path analysis was conducted across the five collected timepoints, including individuals who partook in no more than one ceremony over the course of a retreat (N in analysis = 631). As a first step, an initial model was constructed considering the following variables: 1) Psychological trait absorption and demographics (age, gender) measured at baseline; 2) Identity fusion and rapport assessed hours before the psychedelic session; 3) Perceived emotional synchrony, communitas, identity fusion and ‘perceived emotional support’ during the session, assessed on the following day; 4) Self-disclosure, communitas and identity fusion in relation to the retreat as a whole, measured on the day after leaving the ceremony location; and 5) Psychological well-being and social connectedness as long-term psychological outcome variables, assessed 4 weeks later and controlled for baseline variables. In this initial model (represented in Figure 1), regression paths were set so that each variable at time point t would predict each variable at time points t + 1 and t + 2, thereby accounting for uncaptured delayed effects. Additionally, theoretically motivated concurrent regression paths were allowed within timepoints 3) and 4) from ‘perceived emotional support’ and ‘self-disclosure’ to the remaining variables within the respective timepoint.

As a second step, an iterative model pruning process was employed that removed the following elements: 1) Non-significant paths, and 2) Variables that exhibited no significant direct or indirect effects on either communitas or any of the outcome measures, psychological wellbeing (WEMWBS) and social connectedness (SCS), were dropped from the model, until all remaining effects were significant at p < 0.05. Estimation methods were adjusted during the pruning process, using weighted least squares (WLS) estimation where endogenous non-continuous variables were present, and robust maximum likelihood estimation (MLR) when all endogenous variables were continuous. As recommended by Kline (2015), several indicators of overall fit are reported for the initial and final model, including the model Chi-Square, Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), and Standardized Root Mean Square Residual (SRMR). Cut-off values for determining fit quality (presented in Table 1) were based on previous literature (Hooper et al., 2008; Hair et al., 2010; Awang, 2012).

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