This online survey (n=1,867) found that therapeutic-like context and support helped buffer the negative effects of life stress on challenging psychedelic experiences, and also moderated how those challenging experiences affected psychological outcomes such as well-being and coping.
Research has established that life stress may elevate the likelihood of challenging experiences with psychedelics, which may be linked to poorer outcomes from psychedelic use. Studies have highlighted the importance of therapeutic support, but questions remain about the type of effective support and its specific contribution. We examined the contribution of therapeutic-like contexts and support on the relationship between life stress and challenging psychedelic experiences and between challenging experiences and psychological outcomes. An online survey was conducted in an international sample (N = 1,867) of psychedelic users. Statistical analyses were conducted to examine the moderating roles of therapeutic-like context and support on presumed links between life stress and challenging psychedelic experiences and between challenging experiences and outcomes. Data generally supported theorized associations among stressful life events, challenging psychedelic experiences, therapeutic-like context/support, and psychological outcomes. Therapeutic-like context mitigated the association of stressful life events with challenging experiences and the association of challenging experiences with coping, but not other associations. Interaction effects indicated that the degree of therapeutic-like support moderated the association of challenging experiences with valence, impact on coping, and impact on well-being. In other regression models, therapeutic-like support maintained significant independent effects, but interaction effects were not found. Therapeutic-like context and support were found to moderate links between life stress and challenging psychedelic experiences and between challenging experiences and outcomes. These findings may be relevant to clinical uses of psychedelics in therapeutic contexts and harm reduction practices in naturalistic contexts.
Papers cited by this study that are also in Blossom
Aday, J. S., Mitzkovitz, C. M., Bloesch, E. K. et al. · Neuroscience and Biobehavioral Reviews (2020)
Barrett, F. S., Bradstreet, M. P., Leoutsakos, J. M. S. et al. · Journal of Psychopharmacology (2016)
Basedow, L. A., Kuitunen-Paul, S. · Drug and Alcohol Review (2022)
Breeksema, J. J., Niemeijer, A. R., Krediet, E. et al. · Scientific Reports (2024)
Classic psychedelics have attracted interest for their acute subjective effects and potential to produce enduring psychological change. Clinical research has shown that measured administration of psychedelics in contained environments with varying degrees of therapeutic support can augment treatment for mental disorders, and observational studies in naturalistic contexts report reductions in depression and anxiety and gains in well‑being and psychological flexibility. However, outcomes are strongly shaped by extrapharmacological factors — notably the sociopsychological context, life circumstances and immediate ‘‘set and setting’’ — and the role of life stress and relational support in moderating the links between challenging acute experiences and later psychological outcomes remains incompletely characterised. This study investigated whether therapeutic‑type contexts and perceived therapeutic‑like relational support moderate two key links: (1) the association between cumulative stressful life events and the occurrence of challenging psychedelic experiences, and (2) the association between challenging experiences and subsequent psychological outcomes (both proximal appraisals of the episode and distal general psychopathology). The authors framed therapeutic‑like relationships as perceived safe, supportive, growth‑oriented interactions that share features with formal therapy (empathy, trust, non‑judgemental acceptance) without implying professional psychotherapeutic delivery, and tested hypotheses in a large multinational sample of recent users of longer‑acting classical psychedelics.
Design and recruitment: Cherniak and colleagues conducted an anonymous, retrospective online survey of English‑ and German‑speaking volunteers between August 2021 and April 2023. The study received Institutional Review Board approval at Technische Universität Dresden. Eligible participants were aged 23+ at the time of participation (and at least 18 at the time of the reported psychedelic experience), fluent in their preferred language, and reported at least one experience with a classical longer‑acting psychedelic (LSD, psilocybin, mescaline or ayahuasca) within the past five years that produced perceptual effects. Reported experience and measures: Participants selected one specific memorable psychedelic experience that had occurred between one month and five years prior and answered questions about substance, route, dose strength, time since the event, concomitant substance use (other than caffeine and nicotine), memory clarity and prior psychedelic history. Life stress was assessed with an adapted checklist of 36 adverse events experienced in the previous five years; the total count served as a continuous cumulative life adversity score. Challenging acute experiences were measured with the 26‑item Challenging Experience Questionnaire (CEQ; total scale used; reliability α/ω = .95). Therapeutic‑like context and support: Therapeutic‑type context was coded from a binary self‑report item asking whether the setting was designed or prepared with a therapeutic objective. When a supportive other was present, participants completed the five‑item Therapeutic Relationship subscale from the General Change Mechanism Questionnaire (GCMQ; non‑clinical version), rated 0–5 and showing excellent reliability (α/ω = .91). The authors treated therapeutic support both as a categorical context variable (therapeutic‑like setting vs non‑therapeutic) and as a continuous measure of perceived relational support in regression analyses. Outcomes: Proximal outcomes were participants’ retrospective appraisal of the valence of the experience (single item, 1 = very negative to 5 = very positive) and two single‑item measures (0–100) of perceived impact of the episode on coping with stressful life events and on general mental well‑being. A distal outcome was current general psychopathology assessed with the Symptom‑Checklist‑K‑9 (SCL‑K‑9; 9 items; α/ω = .84). Analysis approach: The researchers compared descriptive characteristics between the therapeutic‑like context and non‑therapeutic groups, examined bivariate correlations, and tested moderation hypotheses using hierarchical regression models. In each regression the dependent variable was regressed on the main predictor (e.g., life stress or CEQ score), the therapeutic‑like support variable (continuous GCMQ score), and their interaction term. Interaction terms test whether the association between two variables differs depending on levels of the moderator. The authors also reported subgroup correlations within the therapeutic‑like and non‑therapeutic context groups. The extracted text notes quality control/exclusion criteria for invalid responses (e.g., duplicate responding, multiple psychedelics used, non‑oral routes, poor recollection) though not all procedural details were reproduced in the extract.
Sample and bivariate associations: The final analysed sample comprised 1,867 participants. The therapeutic‑like context group included 250 participants (13.4%). Bivariate correlations showed that cumulative life stress was positively associated with challenging psychedelic experiences and with psychopathology, while also showing a positive association with perceived impact of the psychedelic experience on coping. Challenging experiences correlated positively with life stress and psychopathology and inversely with therapeutic‑like support and the three proximal outcomes (valence, impact on coping, impact on well‑being). Therapeutic‑like support was positively associated with the proximal outcomes and inversely with psychopathology. Positive valence of the episode correlated positively with perceived impact on coping and well‑being and inversely with psychopathology. Life stress → challenging experiences: Within the therapeutic‑like setting subgroup there was no significant association between life stress and challenging experiences (r = 0.03, not significant). In the non‑therapeutic subgroup the association was positive (r = 0.13, p < .001); a z‑test comparing correlations yielded z = -1.578, p = .057 (borderline). In hierarchical regression using the continuous therapeutic‑support measure, both life stress (positive predictor) and therapeutic‑like support (inverse predictor) were significant contributors to CEQ scores, but the interaction term (stress × support) was not significant. The authors interpret this as indicating independent contributions of stress and support to challenging experiences rather than a conditional effect. Proximal outcome — valence: Challenging experiences were inversely associated with retrospective valence in both groups (therapeutic: r = -0.28, p < .001; non‑therapeutic: r = -0.40, p < .001). The non‑therapeutic association was significantly stronger (z = 1.971, p < .05). Regression models showed negative main effects of CEQ and positive main effects of therapeutic‑like support on valence, and a significant interaction: the adverse association between challenging experiences and positive valence was evident for participants reporting low perceived support but was negligible at higher support levels. This suggests support attenuates the negative impact of challenging experiences on how positively the episode is appraised. Proximal outcome — impact on coping: In the therapeutic‑like context group challenging experiences were not significantly related to perceived impact on coping (r = -0.09, ns), whereas in the non‑therapeutic group an inverse association was reported (r = -0.09, p < .001; the extract reports a between‑group z = -0.03, ns). In hierarchical regression perceived therapeutic‑like support had a significant positive main effect on impact on coping; after including support, CEQ scores were no longer significantly associated with coping. The interaction was significant: at high levels of perceived support, higher CEQ scores were associated with greater perceived improvement in coping, whereas at low support higher CEQ scores were associated with worse perceived impact on coping. Proximal outcome — impact on well‑being: Challenging experiences were inversely associated with perceived impact on mental well‑being in both groups (therapeutic: r = -0.16, p = .010; non‑therapeutic: r = -0.19, p < .001). In regression models both therapeutic‑like support (positive) and CEQ (negative) were significant predictors and their interaction was significant: at higher levels of perceived support challenging experiences were positively associated with impact on well‑being, while at lower levels of support challenging experiences predicted less positive impact on well‑being. Distal outcome — psychopathology: CEQ scores were positively associated with current psychopathology in both groups (therapeutic: r = 0.24, p < .001; non‑therapeutic: r = 0.14, p < .05), with the z‑test comparing correlations yielding z = -1.552, p = .06. In hierarchical regression both challenging experiences (positive predictor) and therapeutic‑like support (inverse predictor) were significantly associated with psychopathology when entered together, but their interaction term was not significant. Across analyses the authors note some mixed patterns: therapeutic‑like context alone attenuated some associations (for example, life stress to CEQ and CEQ to impact on coping were non‑significant within the therapeutic setting), whereas certain associations (CEQ with valence, well‑being impact and psychopathology) persisted even in therapeutic contexts. The extract also notes that, per supplementary materials, settings designed for therapeutic use outperformed mere presence of a supportive other.
The authors interpret the findings as supportive of a contextual‑experiential model in which therapeutic‑type contexts and perceived relational support play a dual role: they can reduce the influence of preceding life stress on the occurrence of challenging acute psychedelic experiences, and they can mitigate the extent to which such challenging experiences lead to less favourable proximal and distal psychological outcomes. Overall, higher perceived therapeutic‑like support was associated with more positive appraisals of the episode, greater perceived benefit for coping and well‑being, and lower general psychopathology. However, effects were mixed. Within settings explicitly designed to be therapeutic, the link between life stress and challenging experiences and the link between challenging experiences and perceived impact on coping were not significant, yet associations between challenging experiences and retrospective valence, impact on well‑being and current psychopathology remained present. The authors suggest several possible explanations: therapeutic‑type settings often include preparatory work and environmental controls that may shift attention away from life stressors and reduce physiological arousal; relational support may aid meaning‑making and processing of distressing material even when the experience is subjectively unpleasant; and corrective or problem‑actuation experiences can be therapeutically useful despite being aversive. They caution that ‘‘insight’’ arising in such contexts could have iatrogenic aspects and emphasise the need to translate experiences into actionable coping strategies. The researchers note that interaction effects were not uniformly observed. Some models indicated that support moderates the adverse impact of challenging experiences, while other models showed main effects of support without significant moderation. The authors infer that therapeutic‑type support is beneficial across life‑stress levels and may not always prevent the subjective distress of challenging experiences but can help in their integration. Limitations acknowledged by the authors include reliance on an anonymous retrospective online survey susceptible to selection and response biases (including possible duplicate responses), non‑representativeness of psychedelic users, reliance on single‑item proximal outcome measures, uneven and partially missing background data (e.g. on antecedent psychedelic use, concurrent substances, psychiatric medication), and a self‑reported and potentially heterogeneous definition of ‘‘therapeutic‑like’’ context. The cross‑sectional, retrospective design precludes determination of causal direction and alternative explanations. Psychiatric medications were excluded from analyses due to variability in reporting, and the focus on longer‑acting classical psychedelics limits generalisability to shorter‑acting or atypical compounds. The authors call for longitudinal studies, clinical samples, clinician‑rated outcomes, and research that distinguishes between challenging experiences driven primarily by drug effects versus those that reflect underlying psychological difficulties, since these may require different clinical responses.
Cherniak and colleagues conclude that in a large multinational sample of recent users of longer‑acting classical psychedelics, both being in a setting designed for therapeutic use and perceiving higher degrees of therapeutic‑like relational support were associated with attenuated links between life stress and challenging psychedelic experiences and between challenging experiences and less favourable psychological outcomes. The authors note that settings explicitly designed for therapeutic purposes appeared to outperform the mere presence of a supportive other, illustrating how relational and contextual factors can shape psychedelic experiences and their subsequent effects in both clinical‑type and naturalistic settings.
Experiences with psychedelics and outcomes are dependent on contextual, extrapharmacological factors, including factors in the immediate context (i.e., "set and setting") and superordinate context (i.e., life circumstances; Hartogsohn 2017). The sociopsychological context is particularly important. People who use psychedelics may be more likely to come from difficult life circumstances, 1 and life circumstances can have a nonnegligible influence on psychedelic-related outcomes, whether stressors relate to the present contextor adverse childhood experiences. Stress is also often present in the immediate context of psychedelic use. Among other motives, individuals frequently report using psychedelics in relation to difficult life experiences. For example, people often report using psychedelics with specific therapeutic/self-medicating intent (e.g., "to treat psychological problems," or "confront difficult feelings") or escapist intention/avoidancemotivated recreational use ("to distract myself from my problems," or "escape from difficult feelings"; see Basedow and Kuitunen-Paul 2022 for a review). Life stress may contribute to a "preoccupied" state of mind that prevents people from being fully present on top of the uncertainty, distress, and anxiety that may accompany subjective effects and may yield less favorable outcomes. Difficulty navigating the onset of psychedelics' effects and challenging psychedelic experiences often arise due to a perceived lack of psychological support or disagreeable social environment. Challenging experiences with psychedelics can disrupt therapeutic processes. Psychological distress intensifies basic needs and motivates attempts to re-attain feelings of safety and security, for example, by seeking proximity to supportive others or activating more maladaptive patterns of affect regulation strategies. Feelings of insecurity are linked to maladaptive regulatory strategies, which may undermine efforts to navigate psychedelics' effectsand interfere with therapeutic processes (e.g., avoidance-free exposure;. By contrast, therapeutic support may make feelings of safety and security contextually salient, even amidst high levels of dispositional insecurity, and lead to more favorable outcomes.
Clinical and naturalistic studies have examined factors that promote feelings of safety and security as a mechanism of therapeutic and salutogenic effects. Clinical studies have examined constructs like therapeutic alliance to assess patients' perceived emotional bond with their therapists. For example, in two clinical trials of psilocybin-assisted therapy for depression, therapeutic alliance predicted postsession symptom severity and symptom reduction. 2 Naturalistic studies have investigated feelings of connectedness to a range of relational targets. For example, in a prospective online survey,found that "communitas" predicted positive changes in psychological wellbeing.found that social connectedness mediated the moodenhancing effects of psychedelic use in naturalistic settings across a series of field studies. Connectednessrelated constructs feature prominently in qualitative studies tooand are integral to the history of psychedelics within indigenous communities. Therapeutic support and connectedness may contribute to better outcomes by facilitating effective emotion regulation. Insecurity and distress, stemming from both life stress and aversive internal experiences, may hamper emotion regulation either by reinforcing distress upregulation or by eliciting experiential avoidance, including the tendency to suppress emotions and inhibit direct contact with painful memories and thoughts. By contrast, dispositional or contextually salient feelings of security have positive consequences for emotion regulation, including by fostering openness to experience, acceptance, mindfulness, and overall effective coping with undesirable physiological and psychological states. Whether in formal psychotherapy or in other settings, facilitator qualities and environmental characteristics that engender interpersonal trust, connectedness, and support reinforce feelings of safety and security and promote therapeutic processes of change. For psychedelics, therapeutic support may be particularly important since favorable experiences are associated with acceptance-related responses toward aversive internal stimuli rather than avoidant responses. The contextual-experiential model of psychedelic effects) posits that the provision of support has a dual role in enabling therapeutic processes with psychedelics. First, therapeutic support may buffer the potentially detrimental effect of a maladaptive set or life circumstances on the acute psychedelic experience. Second, therapeutic support may help mitigate the potentially harmful influence of challenging psychedelic experiences on longer-term psychological outcomes.
Previous research into psychedelics has established the influence of context on the effects of psychedelics and related outcomes. Specifically, therapeutic or therapeuticlike contexts for psychedelic use may help attenuate the influence of ongoing life stress on the individual's psychological state, mitigate the impact of distress related to the onset of drug effects, and facilitate experiences that serve intended beneficial effects. By contrast, using psychedelics in a non-therapeutic context may render psychedelics' effects less beneficial or even increase the risk of adverse experiences. In this study, we examined the role of therapeutic-type contexts and support in moderating the association between stressful life circumstances and challenging psychedelic experiences, and the association between these experiences and a variety of outcome measures. A visual depiction of the hypothesized dual function of therapeutictype context and support on psychedelics' effects and related outcomes is presented in Figure. In this article, we use the term therapeutic-type relationship to refer to a relationship that is perceived as safe, supportive, and growth-oriented, and that shares key characteristics with formal therapeutic relationships (e.g., empathy, active listening, trust, and non-judgmental acceptance;, without implying a professional psychotherapeutic setting.
The study and its sample have been fully described in. The study was approved by the Institutional Review Board of Technische Universität Dresden (SR-EK-147032021). From August 2021 until April 2023, English-and German-speaking volunteers were recruited online to participate in a survey study about experiences with psychedelics. Eligible and consenting participants were invited to participate. Inclusion criteria included: age of 23+ (at least 18 at time of psychedelic experience described), fluency in preferred language, and at least one experience in the past 5 years with a classical psychedelic 3 involving perceptual effects.
Participants were asked to provide demographic information including their age, gender, and country of residence. Participants were asked whether they had ever been diagnosed with a mental disorder and, if so, to specify the type of the given disorder(s).
To assess life stress, we used a procedure adapted fromwhere participants indicate whether and how they experienced 36 adverse events in the past five years. The list included various types of events, including illness, injury, violence, discrimination, bereavement, and social/environmental stress. The total number of events that participants indicated that they experienced was treated as a continuous variable reflecting a cumulative stressful life events score as an index of general life adversity. For a complete list of events and descriptive statistics, see.
Participants were asked to select and report on one specific memorable experience that occurred up until at least one month ago and no more than five years ago. Participants were asked about the substance used, method of consumption, time since the experience, concomitant use of other psychoactive substances besides caffeine and nicotine, subjective clarity of their memory of the experience, subjective strength of the dose, and approximate number of antecedent psychedelic experiences. To assess aversive and psychologically challenging experiences with psychedelics, we administered the Challenging Experience Questionnaire (CEQ;. The CEQ consists of 26 items on seven subscales (Fear, Grief, Physical Distress, Insanity, Isolation, Death, and Paranoia) rated on a 6-point scale (ranging from 0 = No, not at all, to 5 = Extreme, more than ever before in my life). We used the total scale, as is commonly done (α and ω = .95).
Therapeutic-like support was assessed in two ways. First, for therapeutic-like context, participants were asked ("Yes" or "No) whether "the setting [was] designed and/or prepared with a therapeutic objective in mind." Second, participants who had a supportive other present were administered the five-item Therapeutic Relationship subscale from the General Change Mechanism Questionnaire (GCMQ;, which measures the degree of therapeuticlike/relational support experienced during the psychedelic experience (e.g., "I felt safe with the person(s) I was with," "I could trust the person(s) I was with"). The non-clinical version of the scale was used here. Items are rated from 0 (not at all) to 5 (extremely), and the scale had excellent reliability (α and ω = .91).
Notwithstanding the cross-sectional nature of the study, we assessed both proximal and distal outcomes related to participants' psychedelic experiences.
We assessed participants' appraisal of the valence of their psychedelic experience with a single-item -"In retrospect, how do you evaluate the experience you had by taking the substance?" -on a 5-point scale from 1 (Very negative) to 5 (Very positive). Higher scores reflect more positive appraisals. Two additional items assessed the impact participants believed their psychedelic experience had on (1) how they "deal with stressful life events" (henceforth "coping") and () their "general mental well-being" (henceforth "well-being"), each rated from 0 (Very negative) to 100 (Very positive).
We also assessed mental health to obtain outcome data without reference to -and farther removed from -the psychedelic experience. Participants were administered the Symptom-Checklist-K-9 (SCL-K-9; Klaghofer and Brähler 2001), a 9-item screener for nine psychopathological dimensions, 4 which yields a measure of general psychopathology. Items were rated on a 5-point scale ranging from 0 (Not at all) to 4 (Extremely). Higher scores reflect greater severity of psychopathology (α and ω = .84).
We summarized the characteristics of the included participants and their reported psychedelic experiences and compared the therapeutic-like context group and nontherapeutic-like context group. Then, we examined the role of contexts designed to be therapeutic-like (vs. other settings) by comparing the strength of correlations between study variables between the two groups. Second, we included the continuous measure of the degree of therapeutic-like/relational support in a series of hierarchical regression models examining the hypothesized effects of therapeutic-like support on the association of stressful life events with challenging psychedelic experiences and of challenging experiences with the psychological outcome variables. In each model, dependent variables were regressed on each respective predictor variable, the therapeutic-like support variable, and the interaction term between the former and latter. We assessed therapeutic-like/relational support not only in the therapeutic-like context group but also in the group that had a supportive other present because a) the GCMQ subscale for the therapeutic relationship was validated for a range of research scenarios, including clinical and non-clinical studies, b) studies have shown that naturalistic psychedelic use may, under certain circumstances, have some therapeutic benefit (even if the intention or setting is not explicitly therapeutic), as reviewed above, and c) relational factors are highly involved in therapeutic processes and favorable outcomes in both clinical and naturalistic contexts.
The sample has been fully described in5 Characteristics of the final sample of 1867 participants and their reported psychedelic experiences are presented in Table(additional details in Supplementary Materials, Table), including comparisons between the therapeuticlike context group ("the setting [was] designed and/or prepared with a therapeutic-like objective in mind"; 250, 13.4%) and the non-therapeutic-like context group. Bivariate correlations between study variables are displayed in Table. Associations for life stress were mixed. On the one hand, life stress was positively associated with challenging psychedelic experiences and psychopathology. On the other hand, life stress was also positively associated with perceived impact of the psychedelic experience on coping with stress. Challenging experiences were associated with all other variables in theorized directions -positive associations with life stress and psychopathology; inverse associations with therapeutic-like support and the three proximal outcomes (positive valence of the psychedelic experience, impact of the experience on coping, and its impact on wellbeing). Therapeutic-like support was positively associated with the three proximal outcomes and inversely with psychopathology. Similarly, positive valence of the psychedelic experience was positively associated with positive impact of this experience on coping and well-being and inversely associated with psychopathology.
In the therapeutic-like setting group, there was no association between life stress and challenging experiences (r = 0.03, ns), but in the non-therapeutic-like setting group there was a positive association (r = 0.13, p = <.001; z = -1.578, p = .057). The hierarchical regression with the continuous measure of therapeutic support indicated that both stressful life effects (positively) and therapeutic-like support (inversely) significantly contributed to challenging psychedelic experiences. The interaction term was not significant (Table), suggesting that these experiences may be affected by both life stress and therapeutic-like support and that these effects do not necessarily depend on each other (i.e., support predicts reduced challenging experiences in the context of either high or low degrees of life stress). Note. CEQ = Challenging Experience Questionnaire; GCMQ RE = General Change Mechanisms Questionnaire Relationship; SCL-K-9 = Symptom-Checklist-K-9.
There was an inverse association between challenging experiences and valence of the psychedelic experience in both the therapeutic-like setting group (r = -0.28, p = <.001) and non-therapeutic setting group (r = -0.40, p = <.001). The latter association was significantly stronger (z = 1.971, p < .05). The hierarchical regression with the continuous measure of therapeutic-like support showed that both challenging psychedelic experiences (inversely) and therapeutic-like support (positively) were significantly associated with the reported valence of the psychedelic episode. The interaction term was also significant (Table). The inverse association of challenging experiences with positive valence was significant for those who reported feeling less support, while negligible at higher levels of therapeutic-like support (Figure). In other words, therapeutic-like support may attenuate the adverse impact of challenging experiences on the perceived valence of the psychedelic episode.
Coping with stress. Challenging experiences were not significantly associated with the perceived impact of the psychedelic episode on coping in the therapeutic-like context group (r = -0.09, ns). However, there was a significant inverse association in the non-therapeutic setting group (r = -0.09, p = <.001; z = -0.03, ns). In the hierarchical regression model, therapeutic-like support had a significant positive association with impact on coping. Once therapeutic-like support was included in the regression, challenging experiences were no longer associated with impact on coping. The interaction term was significant (Table). At high levels of therapeutic-like support, challenging psychedelic experiences were associated positively with perceived impact on coping. However, at low levels of therapeutic-like support, the association was inverted (Figure). Though overall there was an inverse association between challenging experiences and the perceived impact of the psychedelic episode on coping, these experiences may facilitate coping in the context of high therapeutic-like support.
There was a significant inverse association between challenging experiences and perceived impact of the psychedelic episode on mental well-being in both the therapeutic-like setting group (r = -0.16, p = .010) and non-therapeutic-like setting group (r = -0.19, p = <.001; z = .484, ns). In the hierarchical regression, both therapeutic-like support (positively) and challenging experiences (inversely) were significantly associated with the perceived impact of the psychedelic episode on well-being. The interaction term was also significant (Table, Figure). At high levels of therapeutic-like support, challenging experiences were positively associated with impact on wellbeing. However, at low levels of therapeutic-like support, challenging experiences were associated with less positive impact on well-being (Figure).
Psychopathology. There were significant associations between challenging psychedelic experiences and psychopathology in both the therapeutic-like context group (r = .24, p = <.001) and the non-therapeutic-like context group (r = .14, p < .05; z = -1.552, p = .06). The hierarchical regression (Table) showed that both challenging experiences (positively) and therapeutic-like support (inversely) were significantly associated with psychopathology when the two variables were entered together. The interaction term was not significant (see Table).
This study examined the dual role of a therapeutic-like context and therapeutic-like support as hypothesized by a contextual-experiential model of psychedelics' effects. Our findings support the notion that life stress may elevate the risk of challenging psychedelic experiences and that these experiences may increase subsequent mental health problems. Moreover, our findings highlight the influence of the therapeutic-like context and the experience of therapeutic-like support, which can enhance positive responses to psychedelics and mediate the processes of effective psychedelic-assisted psychotherapy. Therapeutic-like contexts and feelings of support appear to decrease the impact of stressful life circumstances on challenging psychedelic experiences and their impact on outcomes. 6 There were mixed results for differences between therapeutic-like and non-therapeutic-like contexts. For therapeutic-like settings, associations between life stress and challenging psychedelic experiences or between these experiences and perceived impact of the psychedelic episode on coping were not significant, but associations of challenging experiences with perceived valence of the psychedelic experience, impact on well-being, and psychopathology severity remained significant. One explanation may be the specific role of therapeutic-like context. Therapeutic-like contexts often involve preparation sessions and efforts to establish a safe environment, which may help lower individuals' physiological arousal and move their attention from their stressful life circumstances to the experience at hand and specific instructions for managing the acute effects of the substance. Moreover, though challenging psychedelic experiences may cause distress, therapeutic-like context and support can help individuals make meaning of those experiences, process difficult emotions, and feel agency in coping. However, this support may not prevent individuals from appraising challenging experiences as negatively valenced, just as corrective experiences in psychotherapy may be beneficial, though unpleasant. Importantly, though therapeutic-like support may help individuals explore the potential meaning of their challenging experiences, the ostensible "insight" may have iatrogenic effects. Furthermore, therapeutic progress may be dependent upon translating experiences and insights into actionable coping strategies. The hierarchical regression models were also mixed for the degree of therapeutic-like support. Though, as an independent predictor, therapeutic-like support was uniformly linked with more favorable outcomes, interaction effects were not as consistent. On the one hand, significant interactions align with previous research indicating that therapeutic-like support may assist in the reappraisal of challenging experiences such that their blow is softened, both in terms of valence and outcomes. In two cases, there were no interaction effects -the effect of therapeuticlike support on challenging experiences (with high or low life stress), and the effect of challenging experiences on psychopathology (with high or low therapeutic-like support). These findings may indicate that therapeuticlike support, albeit perhaps of different types, is called for regardless of individuals' life circumstances to prepare them for psychedelics' effects, and therapeutic-like support may not necessarily prevent challenging experiences from being distressing. Though some studies link challenging experiences to worse mental health outcomes, suggesting that they may be counter-therapeutic and perhaps even iatrogenic, life stress or clinical symptoms do not necessarily predispose psychedelic users to harmful psychedelic experiences or preclude the possibility of effective psychotherapy. Several studies have found that "psychedelic preparedness" can help stave off the impact of life stress on psychedelic experiences in naturalistic contexts) and even clinical studies with minimalist models for therapeutic support may cultivate sufficient preparedness. Moreover, challenging experiences can be integrated, for example, by reappraising challenges as part of the therapeutic journey. Some studies even report challenging experiences co-occurring with subjective effects viewed as putative therapeutic mechanisms like mystical experiences, ego dissolution, psychedelic insights, and emotional breakthroughs. Moreover, though challenging experiences may be related solely to drug effects, distress may arise in connection with problematic aspects of mental and relational functioning. All psychotherapeutic approaches posit, in one way or another, that, for patients to overcome their problems, they must directly experience their problems and associated negative emotions, whatcalled problem actuation. Problem actuation experiences are not always distressing, for example, if the individual navigates them with acceptance rather than avoidance) and if the experiences help in understanding previously automatic maladaptive behaviors). Thus, not only do challenging experiences not necessarily preclude therapeutic experiences, but they are also a core aspect of "corrective experiences". Future studies ought to distinguish between challenging experiences related to drug effects per se, which may call for therapeutic support as a balm to help patients regulate themselves, and distress related to psychological difficulties, which may require more skilled therapeutic interventions. To make problem actuation experiences opportunities for therapeutic growth, clinicians may help individuals activate personal resources, clarify the meaning of experiences or behavior, or attain feelings of mastery of new coping skills. We have used the term therapeutic-like support to refer to the perceived relational qualities of the person who supported the respondent during their psychedelic experience). As explained above, in examining "supportive figures," we defined therapeuticlike support broadly, including non-clinical, naturalistic contexts. Thus, we intend "therapeutic-like" to refer to the sociopsychological function of the support rather than a strict "psychotherapy" label. However, therapeutic-type support as examined here constitutes more than social support as generally studied in psychological, health, and medical research (see Chronister, 2019, for a review of social support research). Psychedelics have been described as "psychotherapeutic drugs"that may act as "catalysts" of psychotherapeutic processes (e.g.,in clinical or other settings.
The study had several limitations. Data was collected through an anonymous online survey. We cannot rule out problematic response patterns (e.g., duplicate responding), selection effects (e.g., accessibility, digital competency). Psychedelic users are not representative of the general population. The single-item outcome measures (coping and well-being) are somewhat limited, though most research published on single-item measures indicates they are often as valid and reliable as their multi-item counterparts. Data on some background characteristics assessed (e.g., antecedent psychedelic experiences, concurrent drug use, psychiatric medication) were uneven across groups and had some missing data, which limited inclusion in analyses. In addition, the category of therapeutic-like context was based on self-report, which may have been interpreted in different ways. Notably, people may seek out divergent contexts for psychedelic use because of different use motives or other predispositions. The GCMQ subscale for therapeutic support was developed for both nonclinical and clinical psychedelic research, however the current study assessed non-clinical samples in varied therapeuticlike settings. Future research is needed to examine clinical samples and more directly compare therapeutic and nontherapeutic settings. In addition, most participants reported at least a moderately positive relationship. Though researchers have less control when studying naturalistic use, some survey studies have shown that naturalistic psychedelic experiences may also provide some benefit. Naturalistic studies may more accurately reflect people's lived experiences. The current research is also limited by its retrospective, cross-sectional study design, which cannot determine process direction or rule out alternative interpretations. Additional studies using longitudinal designs and clinician ratings are required. Due to variability in reporting on medication and tapering practices, psychiatric medications were excluded from analyses. Lastly, this study focused on longer-acting classical psychedelics rather than atypical psychedelics and shorteracting classical psychedelics. While the exclusion of these substances limits the generalizability of the findings, survey studies of naturalistic use may reflect the substance-context-experience matrix more than strict psychopharmacological effects. Notwithstanding these limitations, this study represents an initial step in examining the influence of relational support as experienced during a psychedelic experience, rather than beforehand or afterward, and its dual impact on the link between life stress, difficult psychedelic experiences, and outcomes.
The current study examined the influence of therapeutic-like context and support on psychedelic experiences and their effects in a large multinational study of people who had recently used psychedelics in a variety of settings. First, we found support for the capacity of therapeutic-like context and degree of therapeutic-like support to attenuate links between life stress and challenging psychedelic experiences as well as between these experiences and less favorable outcomes for mental health. Findings indicate that settings designed for the therapeutic use of psychedelics outperformed mere presence of a supportive other (Supplementary Materials). These findings exemplify how supportive figures can influence experiences with psychedelics and their effects in therapeutic and naturalistic contexts.
1. Up to 42% of users of illegal drugs had been diagnosed beforehand with a mental disorder unrelated to substance use). 2. Similarly, in a clinical trial of 3,4-methylenedioxymethamphetamine (MDMA) -assisted psychotherapy (MDMA-AP) to treat posttraumatic stress disorder (PTSD), therapeutic alliance predicted post-session PTSD severity. Though MDMA is classified as an atypical psychedelic and not a classic psychedelic, they are often grouped together because they share two central features -their rapid onset subjective effects and persistent effects on behavior. 3. Specifically, LSD, psilocybin or psilocybin-containing mushrooms, mescaline or mescaline-containing cacti, or ayahuasca. The decision to focus on the most commonly used longer-acting classical psychedelics rather than shorter-acting classical psychedelics (e.g., inhaled N,N-dimethyltryptamine [DMT]) or atypical psychedelics (e.g., ketamine or MDMA) was to obtain a considerable proportion of respondents who would report experiences that took place in therapeutic contexts (i.e., with therapeutic intentions and in settings designed for therapeutic purposes). 4. Somatic symptoms, interpersonal sensitivity, obsessive -compulsive behaviors, anxiety and depressive symptoms, hostility, phobic symptoms, paranoid tendencies, and psychoticism. 5. Including excluded participants, comparisons between completers versus non-completers, and comparisons between the English and German samples. Reasons for invalidating responses include: (1) speeding, (2) reported using multiple psychedelics during the reported experience, (3) unusual (non-oral) route of consumption (i.e., smoked, inhaled, insufflated, injected, or other), (4) responses to the request for feedback at the end of the survey in ways that cast doubt on the validity of reports, (5) choices of an experience from over five years ago, or (6) self-reports of poor recollections of the reported experience. 6. Being in a therapeutic-like context appeared to have more of an impact than merely having a supportive other (e.g., a trip sitter) present (see Supplementary Materials).
No potential conflict of interest was reported by the author(s).
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