Using a large international survey (n=6,877), the study found that ceremony and ritual characteristics, additional support practices and drinkers’ motivations are significantly associated with acute spiritual/insight experiences and longer-term mental health and wellbeing outcomes, with mediation by intermediate variables such as personal insights and spiritual experience. Generalised structural equation modelling indicates these set-and-setting factors can be optimised in naturalistic and clinical contexts to enhance therapeutic benefits.
Ayahuasca is a traditional plant decoction containing N,N-dimethyltryptamine (DMT) and various β-carbolines including harmine, harmaline, and tetrahydroharmine, which has been used ceremonially by Amazonian Indigenous groups for healing and spiritual purposes. Use of the brew has now spread far beyond its original context of consumption to North America, Europe, and Australia in neo-shamanic settings as well as Christian syncretic churches. While these groups have established their own rituals and protocols to guide use, it remains unknown the extent to which the use of traditional or non-traditional practices may affect drinkers’ acute experiences, and longer term wellbeing and mental health outcomes. Hence, this study aimed to provide the first detailed assessment of associations between ceremony/ritual characteristics, additional support practices, motivations for drinking, and mental health and wellbeing outcomes. The paper uses data from a large cross-sectional study of ayahuasca drinkers in more than 40 countries who had used ayahuasca in various contexts (n= 6,877). It captured detailed information about participant demographics, patterns and history of ayahuasca drinking, the setting of consumption, and ritualistic practices employed. Current mental health status was captured via the Kessler 10 psychological distress scale and the mental health component score of the SF-12 Health Questionnaire, while reported change in prior clinically diagnosed anxiety or depression (n= 1276) was evaluated using a (PGIC) Patient Global Impression of Change tool. Various intermediate outcomes were also assessed including perceived change in psychological wellbeing, number of personal self-insights attained, and subjective spiritual experience measured via the spirituality dimension of the Persisting Effects Questionnaire (PEQ) and Short Index of Mystical Orientation. Regression models identified a range of significant associations between set and setting variables, and intermediate and final mental health and wellbeing outcomes. A generalized structural equation model (GSEM) was then used to verify relationships and associations between endogenous, mediating and final outcome variables concurrently. The present study sheds new light on the influence of ceremonial practices, additional supports and motivations on the therapeutic effects of ayahuasca for mental health and wellbeing, and ways in which such factors can be optimized in naturalistic settings and clinical studies.
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Ayahuasca is a traditional Amazonian plant decoction containing DMT and harmala alkaloids that can induce intense alterations in consciousness. Perkins and colleagues note growing scientific interest in ayahuasca's potential for treating psychiatric and substance use disorders, as well as for promoting psychological and spiritual wellbeing in healthy users. Use of the brew has spread from Indigenous and Brazilian syncretic religious contexts into neo‑shamanic and tourism settings worldwide, creating substantial variation in ceremonial elements, supports and cultural framing. Earlier work has established the importance of "set and setting" for psychedelic experiences, but there has been no large dataset able to compare how specific ceremonial practices, supports and drinker motivations relate to acute experience and longer‑term mental health and wellbeing outcomes across contexts. This study sets out to examine associations between micro‑ and macro‑level set and setting factors (ceremonial characteristics, additional supports, motivations, and whether drinking occurred in traditional ayahuasca countries) and both intermediate outcomes of the acute experience (mystical/spiritual intensity, self‑insights, extreme fear, integration difficulties, community connectedness) and final mental health and wellbeing measures. Using a large international cross‑sectional dataset of ayahuasca drinkers, the investigators aim to identify direct and indirect pathways linking context, set, and supports to perceived growth in psychological wellbeing and current mental health status.
The analysis used cross‑sectional, self‑report survey data collected online between 2017 and 2019, with the questionnaire translated into Portuguese, Spanish, German, Italian and Czech. Eligibility required participants to be at least 18 years old and to have used ayahuasca at least once. Because the population is hidden or legally ambiguous in many countries, a non‑random recruitment strategy was adopted; promotion occurred via organisations, retreat centres, churches, online groups, social media and conference flyers. From an initial sample of 10,836 respondents, the present analyses were restricted to participants who had consumed ayahuasca with two or fewer groups (n = 6,877). The study received University of Melbourne ethics approval. The investigators collected demographics, lifetime mental health diagnoses, detailed ayahuasca drinking history (times drunk, time since last use, country where most drinking occurred), context of last consumption (traditional shamanic ceremony, ayahuasca church, or "other"), motivations for drinking (15 checkbox items), ceremony characteristics (checkbox list), and additional supports provided at the drinking site (eg, preparation activities, religious/spiritual counselling, psychologist sessions, yoga/tai‑chi, fasting). They derived several derived variables: a count of self‑insights from seven listed items (internal consistency α = 0.80), a single 0–10 item for extreme fear/panic during session, and an ordinal measure of community closeness. The authors also created a binary indicator of drinking mostly in traditional ayahuasca countries (Peru, Colombia, Ecuador, Bolivia, Venezuela; Brazil excluded). Standardised outcome instruments included the SF‑12 mental component score (MCS) for current mental health, the Kessler‑10 (K10) for psychological distress, the Psychological Wellbeing‑Post‑Traumatic Changes Questionnaire for perceived growth in wellbeing (PWG), the spirituality subscale of the Persisting Effects Questionnaire (PEQ‑S), the Short Index of Mystical Orientation (SIMO) for mystical experience intensity, and a patient Global Impression of Change (PGIC) for perceived change in prior diagnosed anxiety or depression. Integration difficulties used PHQ‑4 items plus five additional items. Statistical methods comprised chi‑square and one‑way ANOVA for bivariate comparisons, linear regression for continuous outcomes and stereotype logistic regression for ordinal outcomes, implemented in STATA 16. To handle missing data in multivariate models the team used multiple imputation by chained equations with m = 20 imputations. Exploratory factor analysis (principal‑component, varimax rotation) reduced motivation, ceremony characteristic and support items into factors (three motivation factors: therapeutic, self‑knowledge, experiential; two ceremony characteristic factors: traditional and non‑traditional; plus support/preparation dimensions). Finally, generalized structural equation modelling (GSEM) was used to estimate a network of direct and indirect pathways linking motivations, ceremony characteristics, supports, intermediate outcomes and final wellbeing/mental health outcomes; GSEM combines generalised linear models and structural equation modelling to permit simultaneous estimation of multiple linked relationships.
Sample composition varied by last reported context of consumption: 52.1% (n = 3,553) last drank with an ayahuasca church, 19.6% (n = 1,338) in a traditional context, and 28.3% (n = 1,926) in other contexts. Mean age was approximately 40 in church and traditional groups and slightly lower in other contexts; gender distribution was roughly balanced and over 60% of respondents in all groups reported university‑level education. The ayahuasca church subgroup was more likely to reside in Brazil, less likely to report any lifetime mental health diagnosis, and had a higher number of lifetime uses. Exploratory factor analysis yielded interpretable factors for motivations (therapeutic, self‑knowledge, experiential), ceremony characteristics (traditional, non‑traditional) and support/preparation dimensions. Multivariate regression models showed consistent associations between motivations, ceremony characteristics and support activities and the six intermediate outcomes (SIMO, PEQ‑S, self‑insights, extreme fear, integration difficulties, and community closeness). Therapeutic motivation was most consistently linked to outcomes: it predicted a greater number of self‑insights and higher PEQ‑S scores but was also associated with more integration difficulties, greater likelihood of extreme fear during ceremony, higher reported growth in psychological wellbeing (PWG), and paradoxically poorer current mental health (lower SF‑12 MCS and higher K10), a pattern the authors attribute to therapeutic drinkers having worse baseline mental health. Self‑knowledge motivation correlated with more self‑insights, stronger spiritual/mystical experiences on both PEQ‑S and SIMO, closer community ties, higher PWG and better current mental health (lower K10). Experiential motivation was negatively associated with spiritual experience (PEQ‑S), with lower PWG and with poorer current mental health (higher K10 and lower SF‑12 MCS) and with lower PGIC improvement for prior anxiety/depression. Ceremony support and safety ratings were beneficial across almost all intermediate and final outcomes, predicting more self‑insights, stronger spiritual experience, closer community, and reduced extreme fear and integration difficulties, and were associated with better PWG and current mental health. Non‑traditional ceremony characteristics were linked to increased self‑insights and higher SIMO scores but also to a small increase in integration difficulties and extreme fear; these practices did not show detectable effects on final mental health measures. Traditional ceremony characteristics were associated with higher PEQ‑S spirituality ratings but also with increased extreme fear, lower community closeness, poorer current mental health (higher K10), and greater PGIC‑reported improvement in prior anxiety/depression. Drinking mainly in a traditional ayahuasca country was associated with lower K10 scores (reduced distress). Among additional support activities, higher preparation activity scores showed robust beneficial associations with nearly all intermediate and final outcomes (greater self‑insights, stronger spiritual experience, closer community, fewer integration difficulties, higher PWG, better SF‑12 MCS and lower K10, and improved PGIC). Religious/spiritual counselling was positively associated with PWG and SF‑12 MCS, psychologist/psychotherapist sessions were associated with better current mental health (SF‑12 MCS and lower K10), and yoga/tai‑chi correlated with higher spiritual/mystical scores, greater PWG and better current mental health. Fasting showed some positive associations (reported with SIMO score in one set of models and with PWG in another). The GSEM‑derived model positioned number of self‑insights, mystical experience strength (SIMO), integration difficulties, extreme fear, and community closeness as mediators that strongly predicted reported growth in psychological wellbeing (PWG); PWG in turn strongly predicted current mental health (SF‑12 MCS and K10). Integration difficulties had a direct negative effect on current mental health. Most shown paths were highly significant (many p < 0.001) with a smaller number at p < 0.01 or p < 0.05 as noted in the paper.
Perkins and colleagues interpret their findings as evidence that aspects of set (drinkers' motivations) and setting (ceremonial practices and additional supports) influence both the acute ayahuasca experience and longer‑term wellbeing and mental health, with effects operating via measurable intermediate outcomes. An overarching observation is the fluidity of ceremonial elements across contexts: traditional practices appear in non‑traditional settings and vice versa, while ayahuasca churches tend to display distinct patterns (for example, greater use of hymns and higher perceived safety/support). Multivariate and GSEM results indicate that therapeutic motivation predicts stronger spiritual experiences and perceived wellbeing growth but is also associated with greater acute distress and poorer current mental health, which the authors suggest may reflect baseline vulnerability among people seeking therapeutic benefit. A central finding is the consistent positive role of perceived support and safety during ceremonies and of preparatory activities. These "tangible and intangible supports"—emotional, structural, moral, spiritual and interpersonal forms of support—were associated with better acute outcomes (more self‑insights, stronger spiritual experience, reduced fear and integration difficulties) and with improved PWG and current mental health. The authors therefore highlight preparation and a supportive ceremonial environment as potentially critical for optimising outcomes in both naturalistic and clinical contexts. Body‑focused practices such as yoga or tai‑chi were also linked to stronger spiritual experiences and better mental health, which the investigators note could relate to ayahuasca‑related activation of interoceptive neural systems and may support somatic integration. The discussion positions the study within prior work on set and setting while acknowledging that effect sizes for individual variables were often modest. The GSEM pathway analyses emphasise that acute mystical/spiritual experiences, self‑insights and post‑session integration difficulties are key mediators of downstream wellbeing gains. Community and social connectedness emerged as an important and separable contributor to wellbeing, influenced in turn by ceremony features and supports. Several limitations are acknowledged. The sample was non‑random and self‑selected, which may bias results towards those reporting positive effects. All data were self‑reported; some items required retrospective recall, and the cross‑sectional design precludes assessment of pre‑existing mental health status. The investigators used number of lifetime mental health diagnoses as a crude proxy for baseline mental health but concede this is imperfect. Important variables were not available, notably quantitative data on ayahuasca dose, composition and purity; the authors note that stronger subjective spiritual scores might partially reflect higher dose. Their measures of "set" were limited to motivations and did not capture other psychological state variables known to influence psychedelic outcomes. Finally, the binary indicator for drinking in traditional countries was an imperfect proxy for facilitator skill and ceremony authenticity, since tourist‑focused centres and travelling shamans add heterogeneity. On balance, the authors conclude there is limited evidence favouring one single set of ceremonial practices; rather, perceived safety/support and adequate preparation consistently relate to better acute and longer‑term outcomes. They suggest these elements merit careful attention when designing naturalistic and clinical protocols for ayahuasca and possibly for other psychedelics with a pronounced spiritual dimension, and they point to the value of integrating psychospiritual and somatic support approaches in future research and practice.
Pearson's χ2 test and one-way ANOVA tests were used to assess differences between categorical and continuous variables. Multivariate models utilized linear regressions for continuous and stereotype logistic regressions for ordinal outcomes, performed using STATA 16. A particular advantage of the stereotype model is that effects of each predictor are not assumed to be identical across the ordinal categories. There was no evidence of To minimize potential bias associated with participants not completing certain questions/sections within the survey we utilized multiple imputation for the imputation of missing data for all variables in multivariate models. We used the mi impute chained command in STATA 16 with imputations undertaken using the regress command for continuous variables, the ologit command for ordinal variables, and logit command for categorical variables with 20 datasets (m 20) imputed for the analysis. The GSEM (generalized structural equation modelling) function in STATA 16 was used to identify a final model reflecting a network of causal relationships between motivations, ceremony characteristics, additional supports, wellbeing, and mental health outcomes. GSEM combines generalized linear models and structural equation modeling, to enable simultaneous consideration of direct and indirect effects of interacting factors resulting in a high predictive ability. The model was selected by iteratively adding or removing links to an initial model based on linear model results, theoretical justification, path coefficients significance and minimum information criteria. Exploratory Factor Analyses (EFA) using the principalcomponent factor method and varimax rotation were undertaken to identify relevant dimensions of respondent motivations, ceremony characteristics, and support activities (see Table). Three motivations factors were yielded for use in further analysis (therapeutic, self-knowledge and experientialsee Table), along with two ceremony characteristic factors (traditional and non-traditional). The traditional characteristics are consistent with those documented in Amazonian countries (see. Two factors relating to preparation safety and support were obtained. All displayed a good level of internal. The created motivation and ceremony characteristics variable items were summed to identify the total number of motivations or characteristics selected, while the "safety and support" and "preparation activities" variables used the mean rating (1-4) for each of the included items.
The global spread of the traditional Amazonian psychoactive brew ayahuasca raises questions regarding the role of accompanying cultural and ceremonial practices in ensuring a safe and therapeutic experience for drinkers. Unlike other psychedelic substances currently being investigated for potential clinical application (such as psilocybin), the use of ayahuasca in naturalistic settings almost always takes place as part of a facilitated ceremony or ritual and commonly with a therapeutic intent. However, differing effects of different ceremonial practices have not been previously explored. Our sample of 6,877 ayahuasca drinkers in more than 40 countries who have consumed ayahuasca in religious, traditional and nontraditional settings provides a unique opportunity to investigate such associations. An interesting higher level finding from our data is that there is considerable fluidity in ceremonial practices across reported contexts of use, with our group of "traditional" characteristics commonly reported in non-traditional contexts, and in countries outside South America. Similarly, our "non-traditional" ceremony practices were relatively common in traditional contexts, although neither group of practices was commonly reported in ayahuasca churches. Such a result is consistent with other research that has highlighted the incorporation of Christian and other spiritual practices and symbols by both traditional indigenous and Mestizo ayahuasca practitioners in South America, as well as the transportation and incorporation of indigenous "shamanic" South American practices and perspectives in ayahuasca healing ceremonies in Western countries. Multivariate models confirmed associations between ceremonial practices, additional supports, and individual motivations with the six intermediate outcomes considered (self-insights, SIMO score, PEQ-S, integration difficulties, extreme fear, and reporting a close ayahuasca community) and final mental health outcomes (psychological wellbeing growth, SF-12 MCS, K10, and PGIC). Although, in many cases the size of such effects were relatively small individually. Therapeutic motivation was the most consistently associated of the motivation variables, including with a greater number of self-insights, stronger subjective spiritual experience, and higher PWG, but also increased integration difficulties, likelihood of experiencing extreme fear during an ayahuasca ceremony, and poorer current mental health. We believe these latter associations may reflect the nature of this group, with a higher number of therapeutic motivations being a proxy for poorer initial mental/emotional health. Among ceremony characteristics the support and safety score was the only variable significantly associated with all intermediate and mental health outcomes (and in a therapeutically beneficial direction) other than PGIC, highlighting the importance of a ceremony/ritual process that can provide this experience regardless of the type of other practices used (religious/ traditional/non-traditional). As the support and safety score is a rating of participants' experience of these things during a ceremony, it appears to be identifying passive or active "intangible supports," defined byas emotional, structural, moral, spiritual, or other interpersonal forms of encouragement or support. These appear to play a crucial role in optimizing drinkers experience and outcomes. Non-traditional practices were also associated with intermediate benefits in-terms of self-insights, spiritual experience, and ayahuasca community, but also a slight increase in integration difficulties, with no detectable effects on final mental health outcomes. Traditional practices were associated with a higher rated spiritual experience (PEQ-S), but also increased extreme fear, and reduced community connection (likely because people who travel to South America to use ayahuasca usually spend only a limited time in a retreat center), poorer current mental health (SF-12 MCS and K10), but greater PGIC reported improvement. Religious characteristics were not significantly associated with any mental health outcomes. Of the additional support practices considered, the importance of adequate preparation activities was highlighted via the significant (beneficial) associations between this item and all intermediate and final mental health outcomes (other than extreme fear). A similar but somewhat less consistent benefit was observed for religious or spiritual counselling, while effects of a session with a psychologist or psychotherapist were apparent only for final outcomes, better current mental health (lower K10 and higher SF-12 MCS). The broad apparent benefit of religious or spiritual counselling is an interesting finding and not surprising given the profound and often life changing spiritual content commonly present within ayahuasca experiences. It also raises a question about whether a psychospiritual framework, such as Internal Family Systems therapy, may improve therapeutic outcomes, compared with standard Western psychotherapeutic approaches. This may also apply to the clinical use of related substances such as psilocybin that have a similarly powerful spiritual dimension. The use of body therapies such as yoga/tai-chi was positively associated with both spirituality measures, greater psychological wellbeing growth, and better current mental health (SF-12 MCS and K10), and in this regard we note experimental research with ayahuasca that has identified significant activation of neural systems involved with interoception (particularly frontal and paralimbic areas). It seems feasible that); Relig/spir couns., religious or spiritual counseling; Times drunk, number of times ayahuasca has been drunk; Trad. country, all Amazonian countries where ayahuasca has been used traditionally by indigenous groups except Brazil (Peru, Ecuador, Colombia, Bolivia, and Venezuela). Black color is positively associated, and gray color is negatively associated. All paths shown are significant at p < 0.001, other than "Self-knowledge → Community," "Experiential → Community," "Relig/spir couns → Integ diffs," "Therapeutic → SIMO," "Religious → SIMO," "Fasting → SIMO," and "Yoga/tai-chi etc → SIMO," all p < 0.01; and "Fasting → Self-insight," "Support and safety → Self-insight," "Nontraditional → Integ diffs" and "Times drunk → Integ diffs" all p < 0.05. "Religious → Integ diffs," and "Non-traditional → Community" was not significant. physical therapies such as yoga or tai-chi, which support somatic awarenessmay work synergistically by allowing greater connection to bodily sensations and subtle messages during the acute ayahuasca experience, and possibly post-ceremony during the integration of emotional and psychological material. A notable aspect of our study is to illuminate the pathways by which ceremonial practices, additional supports and individuals motivations affect the mental health and wellbeing of ayahuasca drinkers, and the key mediating role of aspects of the acute experience (spiritual experience, self-insights, extreme fear) and, integration difficulties in the weeks or months after drinking ayahuasca. These factors are all strong predictors of perceived growth in psychological wellbeing, which in turn was highly predictive of current mental health status. Moreover, unlike previous studies, we are also able to identify and consider separately the sizable wellbeing and mental health benefits associated with the social and community aspects of ayahuasca drinking, on which ceremony practices, additional support, and drinkers motivations also have an influence. Our study has a number of important strengths, including a large sample size, international cross-cultural sampling frame, and inclusion of ayahuasca drinkers from a range of different contexts of consumption. However, several limitations are also important to note. In particular, the use of a non-random, selfselected sample that risks bias towards drinkers experiencing positive effects, who are motivated to spend time completing a survey, compared with those who had negative or neutral experiences, who may feel lower impetus for involvement. The data collection instrument was entirely self-report, and several items involved retrospective assessments, although this did not apply to the mental health measures SF-12 MCS and K10. The cross-sectional study design also means that we do not have data relating to the mental health status of respondents prior to their consumption of ayahuasca, and there is a possibility that individuals with better mental health were more likely to report improved psychological wellbeing, and hence that better current mental health status may simply be associated with better past mental health. We have included number of lifetime mental health diagnoses as a proxy for mental wellbeing, to adjust for such effects, however this may not be a completely satisfactory substitute. Additionally, we do not have data regarding the composition, purity, and dose (concentration and quantity) of the ayahuasca being consumed, and hence potential influence of these factors. However, we would expect a higher dose to be reflected in higher subjective spiritual experience scores. It is also important to note that while specific practices may influence the experiences and mental health and wellbeing outcomes of ayahuasca drinkers, there are potentially other aspects of the ceremony and additional supports that are of equal or greater importance. Our inclusion of a variable identifying ayahuasca consumption in countries for which ayahuasca has been traditionally used by indigenous groups was intended to capture ayahuasca use that was more likely to involve shaman/facilitators with a higher level of experience, knowledge and skill; although this is not always the case as some tourist focused centers use shaman with little training, and some people in western countries attend ceremonies hosted by traditional Amazonian shaman "touring" in their country. In addition, our data regarding set was limited to only the motivations of drinkers, while research with other psychedelics such as psilocybin identifies various aspects of an individual's mental state at the time of ingestion as being predictive of both mystical and adverse experiences during the acute phase as well as longer term mental health outcomes. It would be of benefit for future research to attempt to incorporate such elements, as well as obtaining greater specificity in areas we have identified as being important, such as support and safety. In conclusion, we identify that aspects of setting (ceremonial practices and additional supports) and set (individual motivations) appear to have significant effects on drinkers' acute experiences, likelihood of experiencing difficulties with integration, and longer term wellbeing and mental health outcomes. Noting the complexity in attempting to quantify and measure the multifactorial inputs relating to the consumption of ayahuasca in ceremonial contexts, we identify limited evidence for the superiority of one specific set of practices. However, tangible and intangible supports that provide a sense of safety and support in the ceremonial context, and preparation activities were found to be particularly important. Figureprovides a summary of key findings of potential interest for the therapeutic use of ayahuasca in naturalistic and clinical settings.
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