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There is emerging evidence that psychedelic-assisted therapies perform relatively well compared with placebo trials. Indeed, findings from meta-analysis indicate that effect sizes associated with these therapies are larger than those associated with typical psychopharmacological or psychotherapy interventions for a range of mental health conditions1. This is particularly evident in meta-analyses that have looked at the effects of psychedelic-assisted treatment to address (1) anxiety and depression in the context of life-threatening illness, (2) anxiety in autistic adults, and (3) post-traumatic stress disorder (PTSD) and suicidality1,2,3,4,5,6,7. These analyses also find little evidence of post-acute adverse effects. In turn, this evidence has stimulated considerable investment in psychedelics from both corporate and non-corporate sectors. For example, in 2021 the Australian Federal Government launched plans to invest AU$15 million in trials of psychedelic treatments for mental illness8.

Yet, although there is growing evidence to support psychedelic use and of their robust, relatively low-risk safety profile9, as things stand, psychedelics are typically delivered in individualized therapeutic settings. By contrast, other successful therapies increasingly use group-based delivery to accentuate positive outcomes10,11,12,13.

The contentious nature of psychedelic therapies appears to be the primary cause of this reluctance14. In particular, legal barriers and fears of being seen as ‘radical’ dampen practitioners’, researchers’, and funders’ willingness to embrace innovative psychedelic practice. Psilocybin or ayahuasca-based retreats are therefore legal in only a minority of countries, and national frameworks that support legal psychedelic-assisted therapies rarely incorporate a group approach. In addition, while licensing boards have the power to determine the boundaries of professional practice, it is nevertheless the case that risks of criminal prosecution, litigation for malpractice, and harm to one’s professional reputation all weigh heavily on clinicians’ decisions to engage (or not engage) with psychedelic interventions. These same factors also affect their enthusiasm for group-based delivery of these treatments, as do negative representations of mass psychedelic use in the 1960s15. It is also the case that licensing boards can be risk-averse and rule against clinicians in the event of a negative client experience or if there is a perceived risk of reputational harm to the profession. So while there can be ‘safety in numbers’ for more traditional therapies, the opposite tends to be true when it comes to psychedelic treatments.

Other barriers to incorporating a group component into clinical trials relate to the (over)simplification that the biomedical model requires. Psychedelics are researched through the apparatus of randomized controlled trials, which is the gold standard in biological psychiatry. In that paradigm, any contextual elements are often treated as superfluous when it comes to isolating a substance’s ‘pure’ effect and considered additive to the treatment effect rather than bound up with it16. Accordingly, a group component might be seen to add ‘noise’ to the data, in ways that make conclusions less clear and less ‘scientific’. Studying treatment effects in groups also increases statistical complexity because the individuals in a trial cannot be treated as independent.

In this Perspective, we argue that there are several reasons why the sociocultural and scientific barriers to researching psychedelic treatment in group settings may be problematic. This is primarily because there is now a large body of research informed by the social identity approach to health (also referred to as the social cure model) that points to—and explains—the potential benefits of delivering therapeutic interventions in groups and that more generally indicates that group and identity processes are implicated in a range of positive health outcomes. As we will explain, the social cure model hinges on the importance of people coming to identify with a group, rather than merely having contact with other people in a group setting. In particular, it argues that it is social identification with a group that allows individuals to access the social and psychological resources that the group provides (for example, support, agency, and meaning) in ways that are beneficial for mental health17. It is worth noting that optimizing ways of delivering psychedelic therapies to groups of participants would also provide a cost-effective alternative to the individualized treatment plans that currently predominate in the field. Given the length of time that therapists are required to support participants (for example, 9 hours or more for LSD administration and/or months of psychotherapy for integration), this is a non-trivial consideration. On top of the social and psychological imperatives, there are thus economic reasons for wanting to put the social cure (back) into psychedelic treatments.

At the same time, this body of work alerts us to problems that group delivery can create and how these might be avoided. These insights align with those that emerge from Indigenous cultures and communities where the use of psychedelics is generally rooted in what can be conceptualized as a group-based social cure.

We develop these arguments by first reviewing the status of psychedelics research and therapies. We then draw on the social cure model to account for some of the effects and challenges of these therapies. On this basis, we go on to outline the practical implications of this approach for therapeutic practice and propose how to put the social cure (back) into psychedelic treatments. This includes steps to integrate social cure research into psychedelic practice with a view to increasing therapeutic effectiveness. Importantly, these also provide a framework for a much-needed program of scientific research. We conclude by identifying priorities for this research program and by reflecting more generally on the enormous potential that such research holds, while also considering some of the key challenges that this research confronts.

Psychedelics and the group

Recent research has found that psychedelics can enhance feelings of empathy18,19, group bonding20, connectedness21, social cognition22, social functioning23 and even sociality with nature in the form of animism24. Furthermore, a recent study showed that psychedelics can enhance metaplasticity and reopen the social learning critical period in adult mice25. Critically, however, this research also suggests that these outcomes are heavily dependent on features of both the therapeutic set and setting26. More specifically, there is evidence that efficacy varies as a function of where the therapy takes place, who administers it, who receives it, as well as the interactions between these various elements.

In practical terms, this means that positive therapeutic psychedelic experiences are dependent on there being trust and rapport within the therapeutic environment, with the therapist27, the facilitator20 or the ritual group with which the therapy is associated28. Trust and rapport have themselves also been shown to be contingent on such things as music29,30 and other identity-related sociocultural factors, including shared heritage and shared beliefs31,32.

More generally, there is clearly a bidirectional relationship between psychedelic use and psychosocial states. Just as psychedelics can create certain orientations and emotions, so too their impact is contingent on the psychological state of the user33. Indeed, so pronounced is this inter-relationship that some have argued that psychedelic consumption during the Paleolithic era may have led to biological adaptation in response to 5-HT2 mechanisms in areas as diverse as serotonin, stress responses, and visual systems34,35. Yet despite this, in the context of the resurgence of psychedelic research and treatment, opportunities to increase the efficacy of psychedelic-assisted therapies by attending to their social contextual dimensions have received relatively little attention36,37,38. In particular, there have been very few (if any) attempts to capitalize on the proven capacity for group life and related identity dynamics to deliver a social cure (for reviews, see refs. 39,40) Given the origins of psychedelic use in the practices of diverse cultural groups and Indigenous communities, this is surprising to say the least41.

At the same time, it is important to note that the ritualistic use of psychedelics is not limited to ‘traditional’ or Indigenous cultures. In the Northern Hemisphere, and indeed much of the industrialized world, neo-shamanic or neo-tribal practices abound, whether underground or legally sanctioned42,43,44. Moreover, when psychedelics are used recreationally, this is often in a group setting, and therapeutic gatherings often have a group dimension. In these contexts too, the group bonds and emotional sharing that often accompany psychedelic experiences have been observed to contribute to long-term changes in a person’s sense of social connection and, through this, their mental health45,46. For example, this pattern has been observed (1) in longitudinal studies of guided retreats and ceremonies where wellbeing is enhanced by the sense of connection that these create20, (2) in structural equation model analyses of illegal ‘raves’ in theUK where both psychedelically induced transformative experiences and cooperation are enhanced by a sense of identity fusion such that individuals perceive a sense of oneness with the group47, and (3) in multiple field studies of festivals in the UK and the USA where psychedelic consumption improves affect only to the extent that it is accompanied by a sense of personal transformation48. A common thread in all this research is that while participants are typically seeking personal healing through their participation in these various activities, they quickly realize that it is the social and relational aspects of their experiences that are the real medicine.

Beyond the ritual sphere, psychedelic group therapy is also common as an underground practice, and it is evident that here, too, group life has a crucial therapeutic role49,50. Indeed, this was the conclusion of psychedelic group therapists in the 1960s38, and mindful of this, modern psychedelic studies sometimes include group therapy sessions between psychedelic sessions36,51. Although these are rarely integrated into the psychedelic session itself, the addition of such group activities appears to have encouraging results. In particular, advocates point to the capacity for therapy groups to create a positive sense of social cohesion and belonging, which promotes feelings of safety and thereby helps participants to process and deal with trauma52.

Perhaps the most promising case of modern psychedelic group therapy comes from a practice in Switzerland where a 3-day course of LSD (lysergic acid diethylamide) and MDMA (3,4-methylenedioxymethamphetamine) group-assisted therapy has been found to ameliorate treatment-resistant trauma-related disorders, depression, and anxiety in groups of between 5 and 13 people53. Here, treatment is delivered without the eyeshades or headphones that are commonplace in many psychedelic-assisted therapies. In this way, rather than being a socially isolating experience, the treatment is socially immersive in so far as participants share their experiences with others—and indeed openly discuss their experiences together on the third day of treatment. Through this sharing process, participants come to work collectively on their challenges as a group, and this group subsequently becomes a resource for healing53. Moreover, because participants in the program have four collective experiences with psychedelics over a 12-month period, there is opportunity for their sense of group connectedness to strengthen over time. Similarly, patients with cancer receiving group-based psilocybin-assisted psychotherapy have been found to have reduced depression 2 and 26 weeks after intervention54.

This Swiss treatment is a legal form of psychedelic therapy that is delivered by licensed therapists, but it is permissible only when clients are resistant to standard treatments37,53. However, the effectiveness of the group elements that it includes has not yet been formally evaluated. Together with the aforementioned caution around psychedelic treatments, the absence of definitive evidence has prevented such practices from being taken up within the medical system. Nevertheless, alongside the renewed interest in psychedelic-assisted group psychotherapy, this case points to the fact that psychedelic treatment can have a group component and that this has the potential to be beneficial. Importantly, however, as with all other work in this area, the extant literature does not offer a framework for understanding the influence of group processes on treatment outcomes. This, however, is something that we can derive from the social cure model and the social identity approach to health more generally.

Social identity and the social cure

The social identity approach to health provides an integrated theoretical framework for understanding precisely how group dynamics and associated social identities can shape the health outcomes of psychedelic use. Social identity refers to the subjective sense of self that people derive from their membership in social groups—whether they be family, community, or treatment groups39. To the extent that people identify with a given group (so that the group defines their sense of self in a given context), social identities have been observed to play a critical role in shaping their values, attitudes, and behaviors in different situations55,56. For example, if a person identifies as a supporter of a particular football club, then their thoughts and emotions will be heavily structured by this group membership so that, among other things, their mood will vary as a function of the changing fortunes of their team57,58.

At the same time, social identities provide people with tangible psychological resources that they can draw on when experiencing challenge or adversity39. In particular, they are the basis for social support and a sense of control, self-esteem, and meaning and purpose in life. For example, the fan who identifies highly with their team can turn to other fans of that team for support if their team is defeated, and their collective struggles give them a sense of control, agency, and purpose (in a way that is not true for those who do not identify with the team59.

More generally, the social identity approach to health provides an integrated theoretical framework from which a series of hypotheses can be generated concerning the importance of social identities for people’s physical and mental health60,61. As observed in ref. 62, health does not occur in a social vacuum. Where social groups are recognized and embraced as a vehicle for change, this can promote improved mental health and wellbeing in the form of a social cure. Meta-analysis shows that clinical interventions that build social identification have a moderate to strong positive impact on participants’ health63. Social connectedness to both relational groups (for example, friends or family) and more extended groups (for example, one’s country or even all of humanity) have also been found to predict better mental health and wellbeing in large, global samples64.

We outline some of the synergetic relations between psychedelics and the social cure that can lead to improved health and wellbeing in Fig. 1. The key idea is that on the one hand, different elements of the psychedelic experience can support and help to build a sense of shared social identity, such as ego dissolution65,66, shared experience and associated bonding20,27,33,47,67, sensitivity to culture and neural plasticity25,34, and enhanced self-disclosure. On the other hand, different aspects of the social cure provide a platform for a safe and effective psychedelic experience, which is known to be context-dependent26—pivoting around, for example, trust and belonging27,28, meaning and purpose17,60, and agency or self-efficacy61. Overall, then, psychedelics and the social cure are hypothesized to interact with each other to make psychedelic-assisted therapies more effective.

Fig. 1: Hypothesized pathways to improved mental health and wellbeing via psychedelic-assisted therapies in synergy with the social cure.
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Elements that can support and help to build a sense of shared social identity include ego dissolution and a flexible identity structure, which can lead to a reconfiguration of identities; the emotional intensity of the shared psychedelic mystical and cathartic experiences, which can lead to identity fusion by a similar mechanism to other rituals with intense emotional experience; enhanced connectedness and communitas, which can improve relations and enhance identification between group members; increased sensitivity to cultural elements such as music and ritual, which can enhance sociality and belonging; the opening of a plasticity window, which can lead to social (re-)learning; and enhanced self-disclosure during integration sessions, which can increase belonging, intimacy, and a sense of being seen. In return, different aspects of the social cure provide a platform for a safe and effective psychedelic experience, including a sense of shared social identity that provides a basis for a sense of mutual social support, belonging, and trust; meaning and purpose; and agency and self-efficacy—all of which increase the likelihood of participants having a meaningful and safe psychedelic experience.

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The social cure approach differs from other approaches to group therapy in emphasizing the crucial contribution that group-based social identities make to the therapeutic process, and to health more generally. Key here is the difference between simply ‘showing up’ at social activities, making a single friend or having one-on-one contact, and internalizing a given group as part of one’s social identity so that the group is a subjectively meaningful point of self-reference and understanding17. Beyond group therapy sessions that merely facilitate group contact, the social cure approach suggests that, above all else, participants must identify with any group they join to realize the benefits of group membership. It is this social identification that is therefore hypothesized to be the active ingredient in any group-based approach to psychedelic-assisted therapy and to be critical for unlocking the potential of that therapy.

In the past two decades, studies around the world have confirmed that social cure processes have a positive impact on such things as depression, physical health, cognitive health, and wellbeing60. Indeed, these effects have been reported in over 25 countries and all populated continents68. The capacity for social cure research to inform practice has also been confirmed by a range of intervention studies. This is perhaps most clearly evidenced through clinical trials of the Groups 4 Health (G4H) program, in which efforts to build and consolidate social identity among members of vulnerable groups have been shown to ameliorate social anxiety, loneliness, and depression (relative to treatment-as-usual and gold-standard treatments including cognitive–behavior therapy11,53.

At the same time, there can be challenges associated with giving people access to this social cure—not least because it is at odds with hegemonic medical models that focus on the individual as a preferred unit of treatment69. Nevertheless, despite (or perhaps partly because of) this, the social identity model appears well suited to the challenges of improving the efficacy of psychedelic-assisted therapies. With this in mind, in what follows we offer suggestions as to how researchers and practitioners of psychedelic-assisted therapies might draw on the lessons learned from social cure research to increase the efficacy of their psychedelic treatments. We also reflect further on the challenges that a social cure approach to psychedelic-assisted therapies is likely to present.

Future directions for group-based psychedelic treatment

On the basis of the extensive research and applied practice that supports the social identity approach to health, we propose that the social cure can be (re-)injected into psychedelic-assisted therapies, largely via integrating social cure research into psychedelic practices and aligning with future psychedelics research. These are summarized and expanded on in the Supplementary Information. It is perhaps worth noting at the outset that the idea of harnessing groups to build identity in psychedelic therapies may seem counterintuitive since it is at odds with the idea that psychedelically induced states involve the dissolution of identity70.

Here, however, we note that the social identity approach is centered on the claim that identity can be, and often is, defined at multiple levels of abstraction71. Accordingly, the loss of identity at one level (the individual-based and personal) can be associated with the gain of identity at another (the group-based and social). This idea is captured in Table 1, and we hope this will be a catalyst for future research that explores these issues in the context of psychedelic treatments. Indeed, we suggest that it is precisely this capacity for the self to be redefined by social context that is at the heart of many people’s experience with psychedelics. This is seen, for example, in Michael Pollan’s reflections: “[I]n order to make sense of the divide that had opened up in my perspective, I would need a whole new first-person pronoun … In fact I hesitate to use the ‘I’ to denote my presiding awareness, it was so different from my usual first person,”72.

Table 1 The hierarchical structure of the self, based on self-categorization theory
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Pollan’s quote speaks to the fact that there are many examples of psychedelic therapists, researchers, and patients who have informally identified the relevance—and benefits—of group identities and social connections in the context of psychedelic experiences. Our sense, then, is that the social identity approach affords the potential to formalize such insights in ways that ground psychedelic-assisted therapies in evidence-based theory. As the proposed steps demonstrate, this in turn can provide a structured framework to guide both future research and optimal therapeutic practice.

Potential challenges and limitations

Elsewhere, extensive literature has already examined the controversial ethical terrain surrounding medicalized use of psychedelics. This speaks to issues of informed consent (for example, relating to the challenges of opting out of treatment once it has begun, unrealistic expectations due to media coverage, and consequences for high-risk groups) as well as concerns about the ‘underground’ use of psychedelics, commercialization, and regulation/legalization73. The use of psychedelics in group settings presents additional challenges, not least because of the need to work with many clients at the same time. Nevertheless, we believe that practitioners’ capacity to navigate these can be enhanced by learning from group treatments that have been informed by the social cure model and have been found to be both practical and effective63,74.

More specifically, this research suggests that there are three major ethical issues that arise in the context of group-based psychedelic-assisted therapies. The first of these is that under certain circumstances, participants who take part in group-based psychedelic treatments may be adversely affected by group dynamics and internalize others’ negative emotions and experiences75. This is particularly likely where the group is divided or where it has (or develops) problematic norms62,76. Similarly, there are potential dangers in group therapy that may be more pronounced and ethically sensitive in the psychedelic arena, including the risk of certain individuals being excluded from the group’s bond, the enhanced influence of facilitators and ensuing unhealthy power dynamics, and the increased suggestibility of participants, which can be abused by facilitators or other group members either knowingly or subconsciously.

Accordingly, therapists need to be trained to lead such sessions in ways that enable them to manage these dynamics constructively, notably by developing skills of identity leadership that help the group to build and promote a positive sense of shared social identity within a given therapeutic group77.

Second, a core premise of the social cure is that if participants identify with a target group and come to trust it, they will be more likely to bond with the group and to benefit from the resources that it provides78. However, if the group itself is defined in opposition to, or is at odds with, the world at large—as can sometimes be the case with groups that use psychedelics—this may be a source of ‘social curse’79 because the group feels devalued and disparaged by the broader community and hence is unable to benefit from the resources that this larger group might provide. This means, for example, that stigmatizing media portrayals of psychedelic counterculture have the capacity to be harmful for vulnerable participants who strongly identify with a psychedelic treatment group. Under such circumstances, therapists and facilitators need to provide safeguards to minimize this potential for harm, and again they can do this through strategies of identity leadership that are recognized as a basis for collective resilience and growth.

Finally, third, there are challenges associated with cultural adaptations of psychedelic therapies that practitioners need to be sensitive to if they are planning to apply the social cure model globally. In this regard, the lack of cultural sensitivity in adaptations of other psychological therapies is something of an object lesson—showing, as it does, how therapeutic treatments that emerge in the Global North tend still to be tailored (only) to the needs and perspective of white clients. As antidote to this, recent research in which psychedelic doses of ketamine were given to a small group of First Nations people sought first to engage closely with these Indigenous people’s voices and traditions, for example, through a focus on between-participant relationships36.

In the case of psychedelic treatments, there is also the reverse problem that the practices of groups and cultures outside the Global North can be appropriated in ways that are both insensitive and problematic. In this regard, we would note that the applications of the social identity approach to health need always to be sensitive to the identity-related concerns of groups who both develop and receive psychedelic treatment. Among other things, this means that practitioners need to be attuned to the potential importance of identities that have been shown to be important by advocates of the ‘Address’ approach (identities associated with age, developmental and acquired disabilities, religion, ethnicity, socioeconomic status, sexual orientation, Indigenous heritage, Native origin, and gender)80. This is a complex task in all forms of group therapy81, but it is also one that can be supported by a process of social identity mapping that seeks both to understand the nature and diversity of the groups and identities that people bring to a therapeutic context and to draw upon these in productive ways82.

More generally, however, it is important to recognize that while social groups are a constant across all human cultures, their social identities differ markedly. Accordingly, rather than simply adapting therapies for different cultures, it is important to ensure that clinicians, facilitators, and therapists are well trained in cultural competency and sensitivity so that they can tune into these different identities and work with them rather than against them36.

Conclusion

“For working purposes, you might separate the personal, the community, and the planet, but within the vision, the cosmology of Indigenous communities of the Amazon rainforest, you do not separate the individual from the community from the planet, that’s fictitious. Individual health is collective health, collective health includes the territory. We’re talking about one ecosystem which is inseparable and it’s very important to view it as one,” (Miguel Evanjuanoy, human and Indigenous rights leader of the Inga people).

With mental health providers reaching a crisis point in many nations, the need for innovative solutions to support individuals and their families and communities has never been greater. The new wave of psychedelic-assisted therapies may help to meet some of these needs, but unlike most other medical treatments, psychedelics are extensively self-prescribed and used recreationally in diverse ways. Their uses range from micro-dosing to week-long transformative, endurance-like experiences at events such as Burning Man in the Nevada desert. In contrast to the relatively robust safety profile of therapeutic psychedelics, the risks associated with underground use can be considerable, and they are increasing due to an ever-growing population of non-medicalized psychedelic users' psychiatric support to make sense of often intense experiences that can occur in challenging or unsafe environments. These risks relate to such things as unknown or incorrect dosing, contaminated drugs, poorly understood risk factors (for example, history or family history of psychosis), and lack of appropriate medical and psychosocial support.

Against this complex backdrop, the need to find safe ways for researchers and clinicians to explore and harness the benefits of group-based psychedelic therapies and integration practices is clear. Yet it is something of an understatement to observe that this need has not yet been met by clinical research. Indeed, the surface of possibilities has barely been scratched. Our hope, however, is that the strategies and directions that we have proposed here can pave the way to a more unified, theoretically coherent approach to group-focused psychedelic research and practice. This approach should be beneficial not only for researchers and clinicians but also for those who seek therapy to improve their physical and mental health, as well as for their families and wider communities.

In this Perspective, we have made the case that the social cure model is highly applicable to psychedelic therapies. Alongside the general observations we have made on the basis of previous theory and research informed by the social identity approach to health, for us this raises the possibility that without other people to bond with during the experience, psychedelic treatments are selling themselves short. But whether this is the case, and to what extent, is currently unknown. Substantial work is thus needed both to establish an evidence base that would explore this possibility and to test our various claims. In addition, we need to work with relevant professional bodies to inform and train therapists who can contribute to this effort and potentially also leverage the social cure in their own practice.

Despite the ethical and practical challenges it presents, we believe that this work is manifestly practical and worthwhile. By integrating psychology’s well-evidenced social cure model with insights from anthropological and sociological research that has identified important lessons from traditional and Indigenous practices as well as contemporary underground use, there are very good prospects for the substantial advances recently made in psychedelic-assisted therapies to be further amplified via feelings of identity-based belonging. Our confidence in these prospects is increased by the fact that the social cure model has previously worked well as a basis for interventions that have successfully tackled a wide range of health conditions in a wide range of health contexts. However, in line with the observations of Miguel Evanjuanoy, the model would seem to be peculiarly well suited to the task of improving psychedelic treatments—given that opportunities to explore and benefit from the social dimensions of self are a core part of what such treatments offer. In short, there are grounds for believing that, at their best, psychedelic treatments are a social cure. It is time to realize the full meaning and the full potential of this observation.