(Dis)connectedness, Suicidality and Group Psychedelic Therapies
by Rosalind McAlpine & George Blackburne
This article by UCL-based researchers Rosalind McAlpine and George Blackburne first appeared in the Psychedelic Press journal, issue XXXIX (summer, 2023). Find out more about their work at The Understanding Neuroplasticity Induced by Tryptamines (UNITy) Project.
I was speaking to a massive mushroom. I asked the mushroom for healing for me and everyone in the circle, and it said there was nothing to fix because we are not broken. We are made as we are meant to be. The ceremony left me with the message that we are never truly alone. We are a part of something so much bigger than ourselves.
- Psilocybin retreat participant [suicidal ideation >4 years]
Discourse on suicide has traced a serpentine path over the history of thought. While philosophical discussions continue to grapple with the intrinsic nature of suicide - such as whether it represents the ultimate assertion (Amery) or rejection (Camus) of freedom - there remains a glaring set of pragmatic and empirical questions: what motivates individuals towards suicidal thoughts or behaviours (STBs), and which interventions are effective in preventing suicide attempts?
Across all age groups, social disconnectedness—a multifaceted social concept that includes structural elements (e.g., size of social networks, marital status, living situation, social isolation), functional aspects (e.g., received and perceived social support, loneliness), and quality-related components (e.g., satisfaction with relationships, conflict)—has been identified as a significant risk factor for STBs.
The large volume of research describing the impact of social (dis)connectedness within this population [1,2] has prompted both local and global efforts to address it [3-6]. Despite these efforts, few effective tools are currently available to rapidly and sustainably improve social connectedness [7], and the growing prevalence of STBs highlights an urgent need for new approaches.
In the midst of a planetary mental health crisis and well-documented ‘deaths of despair’ [8-9], renewed investigations are taking place on the use of psychedelic substances for treating illnesses such as addiction, depression, anxiety, and post-traumatic stress disorder (PTSD). The ability of these substances to increase connectedness transdiagnostically [10,11] could have important implications for suicide prevention. Currently, however, no clinical trials have specifically explored the impact of psychedelic therapy on STBs. Existing (and upcoming) clinical trials typically exclude participants with high suicide risk [12].
The reasons for this are obvious; the relationship between (clinical and non-clinical) psychedelic use and suicidality is a sensitive topic, and the findings inconsistent. While some studies suggest that psychedelic use may reduce suicidal ideation [13-17], others have found no significant association [18], and a few even suggest an increase in STBs [19, 20]. However, the cited studies all report on suicidality as an incidental outcome.
Psychosocial theories of suicide
Research into the relationship between interpersonal constructs [1,2] and suicidality is by no means novel; theorists for more than a century have been discussing these ideas, with Emile Durkheim providing seminal contributions in his late 19th century classic, Le Suicide (1887). Indeed, one of the main strengths of Durkheim’s theory is its contextualization of individual deaths within the wider society in which one lives.
While Durkheim’s theory continues to have a lasting impact throughout contemporary suicide research, its emphasis on social structures fails to account for the difference between objective and perceived indicators of connectedness. Modern research has shown that the latter has a stronger impact on suicide attempts and ideation [3], yet few studies have delved into the specific mechanisms by which perceived connectedness influences the risk of suicide and other mental health outcomes.
One prominent model, Joiner’s Interpersonal Theory of Suicide (ITS) [4, 21], addresses these mechanistic concerns by suggesting that suicidal ideation is driven by perceptions of ‘thwarted belongingness’ paired with ‘perceived burdensomeness’, and that suicidal intent is driven by the additional capacity for lethality. Both belongingness and burdensomeness stem from perceptions of (lack of) social affiliation and have both an intrapersonal aspect (involving individual thoughts and emotions that shape the perception and interpretation of social interactions) and an interpersonal aspect (whereby individuals and systems outside of the self play a role in reinforcing intrapersonal cognition and emotions through exchange). Joiner further postulates that it is these perceived (rather than objective) indicators of isolation that are the core mechanisms by which social disconnectedness influences suicidality.
Suicide research has also highlighted the crucial role of perceived social support, which appears to offer greater protection against STBs in individuals with psychiatric conditions compared to objective measures of social support, such as the number of social connections [22]. For example, in a sample of patients with PTSD symptoms, Panaioti et al., found that those who reported high levels of perceived social support were less likely to experience suicidal behaviour, even at the highest severity of the PTSD symptoms [23].
Interestingly, both receiving and providing social support seem to have a significant impact on reducing STBs [24]. As such, peer-led suicide prevention groups—with a focus on reducing suicidality in individuals and supporting recovery from suicidality through group-based social support initiatives [25,26]—have steadily grown in both community and service settings, and evidence for their effectiveness has started to emerge [27]. However, there exists a limited number of evaluated group-based therapies for suicide treatment, with only 14 published studies identified in a recent scoping review [28]. This is concerning as peer- and group-based therapies likely offer a distinctive opportunity to promote social connectedness and foster collaborative relationships between members [29-31].
Group-based psychedelic therapies.
The potential for psychedelics to enhance feelings of connection to self, others, and the wider world has been noted in individual therapeutic settings [10,11,32]. When considered in a group therapy context, it’s conceivable that these feelings of interconnectedness could be amplified. In such a collective space, an amplified sense of connection has the potential to not only awaken a renewed awareness of social support but also to establish a sturdy framework of communal care, rooted in the group experience itself. In alignment with Joiner’s ITS, these hypothetical benefits of group-based psychedelic therapy hold promise in addressing crucial factors contributing to suicidality.
‘Thwarted belongingness’, characterised by feelings of isolation and detachment from a larger community, may be alleviated as participants experience a profound sense of unity during the psychedelic journey and the subsequent shared integration of those experiences. Likewise, the perception of being a ‘perceived burden’ to others can be challenged and reframed through the mutual support and empathetic understanding cultivated in the group therapy setting. Hence, the convergence of group-based therapies and the catalytic power of psychedelics could offer a potent synergy, impacting perceptions of social affiliation and opening novel avenues for invaluable social support.
Importantly, the potential social enhancements resulting from psychedelic-assisted group therapy may be beneficial not only during the psychedelic experience itself, but also in the preparation and integration phases of treatment, in which the recursive dynamics of group therapy could provide an opportunity for achieving insights that are grounded within the structural, functional, and quality-related aspects of the patients’ social world [33].
It is vital, however, to recognise that while these potential benefits align with Joiner’s theory, they remain predominantly theoretical, underscoring the need for further empirical research to validate these concepts and explore the nuanced impacts they may have on mitigating suicidality.
Although research has begun to investigate the impact of intersubjective experiences in naturalistic studies, and has demonstrated the ability of psychedelics to promote feelings of togetherness and shared humanity (i.e., ‘communitas’)—which are independent predictors of long-term mental well-being [34]—modern trials have almost exclusively employed an individual-based therapeutic approach. Prior to the rescheduling of these compounds in the 1970s, however, several group-based psychedelic studies were conducted, employing a range of treatment modalities.
Moreover, employment of psychedelics in communal settings aligns with the historical norm for their use. Indeed, we see this with the use of psilocybe mushrooms in velada by Mazatec communities [35], ayahuasca by members of the Shipibo group [36], yakoana by the Yanomami people [37], Kambo by the Mayorunas [38], and iboga by the Bwiti [39].
Without the communal buoyancy and sustained practice of these group rituals, the global North would never have had the honour of knowing about these psychopharmacological agents of connection. Despite evidence supporting the safety and efficacy of group administration of psychedelics within these ritualised frameworks [36,40], contemporary psychedelic research has yet to focus on group dynamics, and this theoretically important ‘communal’ factor seems to be lacking from most modern trials of psychedelic therapies.
In our quest to delve into the impact of group dynamics on psychedelic experiences, we partnered with multiple psychedelic retreat centres situated across Europe and South America. These retreats frequently employ strategies like sharing-round rituals to guide interpersonal interactions.