Integrating Psychedelics into Groupwork: A Culturally Responsive Model for the Counseling Profession

Abstract

Psychedelics, combined with talk therapy, indicate promise with challenging clients, such as those struggling with PTSD. Furthermore, groupwork, with the emphasis on social connections, can be an effective modality. There appears, however, little movement with integrating psychedelics with professional counseling and even less in groupwork. Societal perceptions of psychedelics and the concern of practicing outside one’s scope may cause practitioners to hesitate. This article provides a brief overview for the lack of progression in implementing psychedelics in group counseling. I explain what potentially inhibits the utilization of psychedelics, then offer a resolution to these issues by advocating for a psychedelic-assisted groupwork (PAG) model. The argument is that psychedelic approaches can be an innovative and transformative method for group facilitators. I conclude with an overview depicting what a PAG with an interdisciplinary team could entail, including recruitment, screening, selection, therapeutic processes, and termination.

1. Integrating Psychedelics into Groupwork: A Culturally Responsive Model for the Counseling Profession

A popular podcast held an episode where the title bombastically declared the future was your brain on drugs [1]. The premise of the talk was that psychedelics provide mass benefits, such as increased creativity and relief from addiction, depression, and trauma [2,3,4]. The problem arises in that societal indoctrination and misinformation have contributed to people holding a distorted view of psychedelics [5]. For example, common misconceptions of these substances are that they are simply party drugs and damage cognition when used frequently [6]. Cultural norms notwithstanding, current psychedelic research appears to indicate a myriad of benefits that contradict these negative images [7,8]. Of critical importance is the emphasis on improving clients’ mental health conditions [9,10,11]. Psychedelics, combined with traditional talk therapy, indicate promise with clients, such as those struggling with suicidal ideation and social anxiety [9,12]. While the research continues to build, there appears to be, however, a slow progression to accept psychedelics in counseling, which includes groupwork [10,11,13].

Group counseling has long been at the forefront of the helping profession as one of the most powerful modalities for therapeutic change [14,15,16], yet the onset of COVID-19 and recent racial unrest in the U.S. revealed the profession’s shortcomings in regards to addressing systemic inequality [17,18]. Included in this revelation was the fact that helping fields assisted in maintaining institutional racism by diminishing people of color’s scholarly contributions [19]. This acknowledgment of complicity has, ironically, benefited the field, as much more culturally responsive groupwork emphasizing multiculturalism has increased [20,21]. Moreover, there is now a renewed focus on social diversity and liberatory approaches as a requirement for acceptance into scholarly journals [22]. Even with these excellent modifications and course corrections, there are aspects of group counseling that continue to need enhancing and improvement [23]. Although cultural responsiveness still needs to advance, there are other relevant facets groupwork can include, such as improving integrative approaches [24]. Integrating psychedelics with groupwork could be a potential solution to improving both these areas (i.e., cultural responsiveness/liberatory approaches and integrative approaches) [6,25,26]. On this surface, this combination may seem to be an odd choice, but upon further scrutiny, a connection does exist. The following paragraphs explain this nexus in more detail.

2. Psychedelic-Assisted Group Work as a Culturally Responsive and Integrative Approach

2.1. Psychedelic-Assisted Group Work as a Culturally Responsive Approach

While psychedelic research may appear novel, many Black, Indigenous, and People of Color (BIPOC) populations already valued the use of these substances for medicinal purposes [27]. Resembling groupwork, many BIPOC societies had communal ceremonies with therapeutic actions that mirrored groupwork principals [27,28]. There was an empathetic understanding, catharsis, instillation of hope, cohesion, universality, and altruism [29]. When initially observed through the lens of Western research, many scholars discarded the practices and labeled them as useless cultural rituals [30]. Unfortunately, a common behavior amongst these academics was to take the essence of the rituals but reject the culture it originated from [31]. What emerged was an appropriated and reductionistic view of psychedelics devoid of their originating cultures [29]. Combatting this sordid historical perspective is a contemporary push to legitimize indigenous practices [6,32]. Psychedelics for curative purposes do have a long history within BIPOC populaces and is at the heart of many cultures. This knowledge/expertise existed for centuries and is now receiving the acknowledgment as a culturally responsive approach [7,31]. What makes this modality appealing for group workers is the emphasis of it being a communal experience [6,13,26]. Having the opportunity to share cathartic experiences with others who can relate assists in holistically creating bonds through spiritual, emotional, cognitive, and biological means [33]. Psychedelics can help to amplify the group experience and augment it to a higher therapeutic level [26].

Even with the above-mentioned positive attributes, problems still exist. The major issue is that contemporary systemic racist policies disproportionally targeting BIPOC people (i.e., war on drugs) has made using the substances taboo [27]. While this concern can be commonplace among all people, there is a real fear and alarm for BIPOC people [29]. Not only can societal norms label their behavior as criminal, they could incur harsher legal penalties if they use psychedelics. Resultingly, many BIPOC populations may avoid utilizing these substances due to fears of stereotyping or being associated as deviant. [34]. That said, there has been a renaissance of contemporary researchers attempting to dismantle these stereotypes. Accordingly, these scholars are advocating for psychedelics as a liberatory approach to decolonizing therapy [7,27,28,31]. Instead of viewing psychedelic-assisted groups (PAG) as new, the focus is, instead, to conceptualize it as a return to indigenous practices. This method helps in honoring the culture by acknowledging its roots [6,29]. The idea is to create a place of safety by using an approach that values the person as a unique, holistic entity [35,36,37]. With an emphasis on diversity, personalizing the meaning behind rituals, and exploring the self through communal experiences, a PAG can be a culturally responsive method.

2.2. Psychedelic-Assisted Groups as an Integrative Approach

Due to the cathartic principles groupwork provides, many facilitators rely on traditional methods of practice when providing services to clients struggling with severe issues [6]. These methods can range from eye movement desensitization and reprocessing (EMDR), trauma-focused group treatment to group cognitive behavioral therapy [38]. While these modalities have empirical support, many force clients to relive their traumatic pasts in a manner that elicits strong affective responses. These reactions can, unfortunately, cause a person to become re-traumatized [38]. To circumvent these issues, facilitators need a method that mitigates the anxiety produced when clients discuss their trauma. Groupworkers should utilize an integrative approach that addresses people’s spiritual, psychological, emotional, biological, and social needs concurrently [24]. PAGs can be this integrative, therapeutic tool that allocates to the group counselor a means to work with clients holistically. Operationally defined, integrative approaches incorporate empirically-supported modalities with rigorously researched alternative therapies [39]. The overarching goal is to have a treatment that connects the various aspects of a person as a unique entity. PAGs encompass mental health, biological mechanisms, social ties, and cultural/spiritual aspects that researchers deem necessary for integrative methods [13,24]. The promise of these groups is that they can offer a viable alternative to traditional means that may not be as effective with contemporary clients.

Taking the proceeding information into consideration, other helping professions (e.g., psychiatry) appear to be more receptive and open towards these novel/innovative methods [4,8,12,40,41]. Thus, a concern begins to emerge within the counseling profession [6]. The alarm is that the field may lag if PAGs continue to progress and go mainstream. This stagnation within the profession could be due to lack of cultural awareness and societal factors mentioned beforehand or additional reasons. For example, other causes could be unfamiliarity or trepidation of practicing outside one’s scope [10,30].

Factoring in these issues above may cause practitioners to hesitate. While conceivable misgivings may exist, psychedelics do, however, offer tremendous promise for clients [4,9,10,13]. A PAG has the capacity to be an innovative and transformative group method for clients. For this to occur, however, there needs to be a deeper exploration on how group counselors can utilize the method. To illustrate the futility of a PAG, this commentary provides a concise overview depicting the overall process of implementation. Included in this description are recommendations on how counselors can execute a PAG with an interdisciplinary team of health professionals. The following sections will address recruitment, screening, selection, multicultural and social justice aspects, and the termination of a PAG. Though not exhaustive, the proceeding passages assist in depicting the role of counselors in PAGs.

3. Implementation of PAGs

One of the qualms counselors have when contemplating utilizing psychedelics with clients is that of practicing outside of one’s expertise [10]. While it is not within the scope of this article to delve deep into the different phases of psychedelic therapy, other research describes the diverse stages [10]. They are as follows: preparation/integration and integration. For succinctness, the former entails when a client is taking psychedelics concurrently with therapy (i.e., ingesting before a session). The latter occurs after a person took (ingested) psychedelics in the past (not concurrently or immediately before receiving counseling). For a more robust understanding of what each method involves, various counseling literature provides numerous resources, tools, and education [6,10]. It does need noting the procedures describe above are for individual therapy, but the stages also can be suitable for PAGs.

Currently, however, most counselors involved with PAGs do not dispense substances and instead work with a treatment team of professions. In the U.S., these groups are usually in an integrated behavioral health setting that provides services for clients’ social, emotional, and mental needs. Situated within these facilities are counselors, psychiatrists, and social workers who offer a wide array of services, such as therapy, medication, home services, and clinical assessment [6,10]. Although not normally thought of as a venue for counselors, integrated settings are becoming a more common location for group counselors to practice [42]. In these locations, group facilitators provide therapy, and a trained psychiatrist/medical consultant dispenses psychedelics [43]. Additional duties the counselor has are to develop the structure of the group, beginning with recruitment, screening, and selection.

4. Recruitment, Screening, and Selection

Due to the fact that most PAGs currently occur in integrative behavioral health settings, the following paragraphs will denote how to operate in those locations. That said, psychedelics are growing in usage and may soon be in other therapeutic milieus [6,9]. Regarding recruitment, group counselors can take a four-pronged approach by contacting previous clients, asking colleagues for referrals, placing fliers in the integrated behavioral health setting, or utilizing the facility’s social media/website. This method has its pros and cons. Taking a personal approach allows facilitators to contact clients they already worked with and know. Thus, this strategy builds off an established therapeutic alliance, which may convince more members to join. Conversely, the individual method may produce a limited range of possible candidates, and there is a possible preference in the selection of applicants. Taking referrals from other clinicians partly removes the personal bias, yet this method still has similar pitfalls. For example, there is a limit to the counselors he knows, has tangential links with, or feels comfortable approaching. As such, predispositions may still exist. Placing fliers, while eliminating potential partialities, has confines in regards to money required for copies and available space to post documents. Advertising on social media is extremely helpful in reaching large numbers of people [44] and reduces subjectivity, financial restrictions, and physical restrictions. However, this approach brings up other issues, such as accessibility (i.e., no internet access) and having too many people apply. As mentioned beforehand, each has its strengths and drawbacks. The hope is, however, that employing multiple sources of recruitment will produce a robust potential PAG population.

Screening entails looking for characteristics that are broadly related to what a group facilitator deems is necessary for potential candidates. These aspects can range from demographics to clinical considerations. Research indicates the typical psychedelic user is young, male, Indigenous, multi-racial, or White and has experienced trauma [45]. That said, the facilitator and the team ultimately decide what group traits are appropriate. With these qualities loosely defined, the process can now shift to selection. The selection process comprises three categories, which are demographics, medical concerns, and mental concerns [43,46]. Keeping with multicultural and social justice precepts, it may be beneficial to have a robust group, with members representing various identities and backgrounds [33]. The next step, medical concerns, should be a joint endeavor for the entire team. While a psychiatrist normally can manage this specific aspect, it may behoove the group counselor to remain engaged. The next steps are to assess general risk factors that include familial genealogy [46]. Family history encompasses clinical disorders (e.g., psychosis, bipolar I disorder) and medical issues such as high blood pressure or a history of stroke [10]. These considerations are critically important, as these risk factors can complicate the PAG process [6]. Finally, in regards to the psychedelic approach, with it being in an integrated setting, the most logical method would be to utilize preparation/integration.

Prescription medication and dietary restrictions that can cause adverse interactions are the next consideration [47]. For instance, monoamine oxidase inhibitors (MOIs) can trigger potential life-threatening situations when taken with psychedelics. Throughout the process, group facilitators must collaborate with psychiatrists/medical staff to stay within their scope of practice [10]. An additional medical consideration is to have potential members undergo drug tests [46]. A recommended, but not mandatory, concluding step of the selection process entails evaluating candidates to see if they have PTSD. Trauma is difficult to define and can range from person to person. For example, the recent pandemics (COVID-19 and racial unrest) impacted society in a myriad of negative ways [33]. Thus, it befits counselors to assess potential members to determine the extent of issues they may have. Assessments can be costly, but some free/low-cost appraisals exist, specifically one endorsed by the U.S. National Center for PTSD in conjunction with the Veteran’s Association. The Center offers a no-cost assessment, labeled as the Brief Trauma Questionnaire (BTQ), that has strong psychometric properties [48].

5. Therapeutic Processes

After completing the necessary group structural aspects, therapy can begin. Currently, one of the most popular therapeutic models is by the multidisciplinary association for psychedelic studies/MAPS [49]. Utilizing a humanistic approach, the precepts of this model deem it necessary for facilitators to clearly explain for members the concepts of set and setting. Operationally defined, set refers to clients’ mental states (i.e., what cognitive condition they are in), and setting refers to the surrounding physical environment of people [50]. Taking a multicultural and social justice perspective, group counselors must consider the cultural environment of members when discussing set and setting. For instance, many members may come from communities with distorted perceptions of psychedelics. Research indicates some BIPOC populations harbor self-stigma that combines with negative societal biases, which perpetuates shaming oneself for using psychedelics [27]. These vital cultural components impact members greatly, yet many existing PAGs ignore these principles [51]. A culturally responsive facilitator must fully engage members to speak freely about not only their concerns but also what cultural views they may have and how it impacts them [52].

An additional cultural concern is to discuss with members the origins of psychedelics coupled with their indigenous roots [6]. Mirroring land acknowledgments [53] crediting Indigenous people who previously inhabited the land, the facilitator takes a similar approach. The idea is for the group counselor to provide education explaining what modern science is revealing but what numerous native populations already knew and practiced [28]. For example, many BIPOC communities believed ingesting psychedelics allowed one to speak to the inner self, free of impediments [51]. Psychoactive research verifies this statement, as ketamine is a dissociative analgesic that people report makes them separate from their bodies and hold conversations with imaginary people (43,50]. Further, psychedelics can stimulate a mystical experience, which people state connects them to their ancestors and past lives [10,29,31]. When addressing the group, the facilitator needs to make sure to address these possibilities and inform members this process could connect them to their forgotten cultural lineages.

While it may appear that after members ingest psychedelics, a group counselor will have an uptick in therapeutic responsibilities, evidence exists stating otherwise [46,49]. If a mental health professional creates a proper foundation (i.e., establishes rules and prepares members well), barring any adverse reactions, members take on more of the processing during the post-ingestion phase [41,43]. Most of what the facilitator will do is employ empathetic understanding coupled with active listening and non-directive communication. Thus, research suggests the counselor truly facilitates; asks questions, such as “what did this experience reveal to you”; and encourages members to share their revelations and connect with one another [7,26,54,55]. Due to the communal/indigenous aspects of PAGs, peer support is critical, and counselors must take steps to use it to enhance cohesion, trust, and hope [6]. An example of peer support is the counselor encouraging members to share their psychedelic experiences with one another, which may include spiritual journeys [10].

6. Termination

The final stage (termination) includes critical aspects, such as ensuring the group ends properly and providing any referrals or therapeutic recommendations to members [56]. Due to the intensity of sessions, PAGs normally only require one to three sessions [13]. Whilst this may seem minuscule, research indicates the intensity of the experience and cathartic release amplify when utilizing psychedelics [41]. As a result, there are less sessions needed. However, due to the short duration, some members may still require other therapeutic services afterwards. If this occurs, the facilitator needs to arrange to have regular meetings with the group to discuss any after-effects of the experience. Thus, the group counselor can continue the PAG (minus the ingestion) for three to four additional sessions (i.e., integration approach). Depending on if members will take services again, a possibility could be for them to keep in contact with one another, as PAGs tend to create intense bonds afterwards [49]. Coupled with the preceding information, the facilitator can encourage members to keep notes after the group concludes. Further, a common behavior of members is the need to engage in expressive techniques (i.e., art), as many participants report wanting to participate in artistic activities [49]. During the entire termination process, the facilitator encourages members to express themselves and state to one another what the group meant for them.

7. Conclusions and Future Directions

In conclusion, while there still needs to be more research conducted to substantiate the utility of psychedelics in groupwork, what does exist is promising. Furthermore, a PAG potentially allows group facilitators to truly consider the biological, cultural, and spiritual aspects of clients. For example, research indicates that psychedelic existentialist–humanistic therapy could be fundamental in understanding mystical/spiritual experiences [10]. Although not explicitly stated, this literature implies how an altered state of consciousness (ASOC) develops through a cultural spiritual journey that assists in increasing personal unity and stabilization. Resultingly, a PAG incorporates these tenets and places members into an ASOC. With the emphasis on mental health, biological mechanisms, and cultural/spiritual aspects, PAGs have the potential to be a powerful factor in the future of groupwork.