Effects of Setting on Psychedelic Experiences, Therapies, and Outcomes: A Rapid Scoping Review of the Literature

This review (2022) explores the role and value of the setting in the psychedelic experience and the subsequent therapeutic outcomes. It was found that while the importance of setting is emphasized in the literature, there is yet to be any consistent and rigorous testing of setting and its complexities. There is yet to be a shared consensus on the effects setting has and the mechanism by which it affects outcomes as a result.

Abstract

“The health and well-being impacts of art and aesthetic experiences have been rigorously studied by a range of disciplines, including cognitive neuroscience, psychiatry, public health, and translational clinical research. These experiences, encompassed in the concepts of set and setting, have long been claimed to be pivotal in determining the acute and enduring effects of psychedelic experiences. Responding to the field’s longstanding emphasis on the role and value of the setting, a rapid scoping review was undertaken to identify the extent to which effects of setting and aesthetics on psychedelic experiences and therapies have been explicitly studied. It offers an analysis of the strengths and limitations of the extant literature and discusses evidentiary gaps as well as evidentiary opportunities for the field. The 43 included studies indicate apparent consensus regarding the importance of setting in psychedelic therapies, as well as consistent interest in theorizing about these effects. However, this consensus has yet to generate consistent, prospective, rigorous tests of setting and its complexities. As a result, the field continues to lack understanding or agreement regarding the effects of various specific elements of setting, the mechanisms by which they affect outcomes, for whom these effects occur, under what circumstances, given what conditions, and other critical factors. Further studies of setting and aesthetics in the context of psychedelic therapies are likely to not only improve these therapies and their delivery but also inform considerations of setting and aesthetics for non-psychedelic interventions.”

Authors: Tasha L. Golden, Susan Magsamen, Clara C. Sandu, Shuyang Lin, Grace M. Roebuck, Kathy M. Shi & Frederick S. Barrett

Summary

A rapid scoping review was undertaken to identify the extent to which effects of setting and aesthetics on psychedelic experiences and therapies have been explicitly studied. It found that there is apparent consensus regarding the importance of setting in psychedelic therapies, but no consistent, prospective, rigorous tests of setting.

1.1 Setting, Aesthetics, and Health

Arts and aesthetic experiences have played key roles in humans’ physical, social, and spiritual health for millennia. In 25,000 BC, carved figurines promoted fertility, and thousands of years later, the Atharvaveda medical text encouraged people to “enjoy soft sounds, pleasant sights, and tastes” after eating to aid digestion.

In the last two decades, research has shown that art and aesthetic experiences can improve health and well-being. This includes decreasing negative emotions, improving social connections and self-worth, and reducing pain and anxiety. Numerous studies have demonstrated the effects of aesthetics and the built environment on health, and the World Health Organization has published a scoping review regarding the roles of art in addressing individual, community, and population health.

1.2 Applications in Psychedelic Experiences and Psychedelic Therapies

The setting of psychedelic experiences and therapies is crucial in determining outcomes. Traditional shamanistic rituals to enhance the healing experience of psychedelic medicines contain such setting manipulations as “icaros (ritual songs), whistles, smoke blowing, and sucking”.

The extensive attention given to setting in psychedelic therapy has generated clinical guidance for therapy settings, including recommendations for warm rooms with pleasing artwork and a sofa to recline on. However, the extent to which effects of setting have been empirically tested remains unclear.

1.3 Scoping Review

A rapid scoping review was conducted to identify the extent to which effects of setting on psychedelic experiences and therapies have been explicitly studied.

2.1 Design

Completion of this review followed the Joanna Briggs Institute’s Methodology for JBI Scoping Reviews. Scoping reviews are similar to systematic reviews in that they employ systematic literature searches and rigorous screening and data extraction processes.

This review searched for similar reviews or protocols using several databases, but did not find any that gathered all published evidence related specifically or exclusively to setting and psychedelics.

2.2 Protocol Registration and Reporting

A protocol for this review was registered with the Open Science Foundation and has been completed in accordance with PRISMA-ScR reporting guidelines.

2.4 Inclusion and Exclusion Criteria

This review includes studies on the effects of setting on psychedelic experiences and therapies, including randomized controlled trials, within-subjects designs, qualitative studies, case reports, systematic reviews with and without meta-analyses, etc.

2.5 Literature Search

Comprehensive literature searches were conducted in PubMed, PsychINFO, and Embase by an experienced health sciences librarian, and the results were uploaded to the Covidence platform for screening by the research team.

2.6 Data Collection and Analysis

Blinded pairs of research team members conducted title and abstract screening and full-text screening, and a shared document was utilized to collect data.

3.1 Summary

This review identified 1,160 articles for potential inclusion, of which 43 met the inclusion criteria. Of these, 29 reported primary empirical data, with 14 of these reports representing data from controlled laboratory studies, 8 reports representing large-scale online surveys with retrospective ratings, and 7 studies reporting on observational data from naturalistic settings.

3.2 Study Dates and Locations

Studies on psilocybin have been conducted in 10 countries, including the U.S., Brazil, Australia, Israel, Palestine, the Netherlands, the U.K., Argentina, Denmark, and Switzerland.

3.3 Populations

Among all of the 43 identified articles, healthy volunteers comprised the most common study population, followed by patients with a mental health diagnosis and/or receiving therapy. Other populations included individuals with a history of using psychedelics, participants in religious rituals, and individuals currently using substances.

Of 29 primary empirical studies, 62% did not report participants’ sex, and 72.4%) were coded as “mixed group,” indicating that the study involved both males and females. Race and ethnicity were inconsistently reported.

3.4 Sample Sizes and Study Designs

Twenty eight of the twenty nine primary studies reported sample sizes, and the mean sample size was 395.7, with a median sample size of 31.5. Five studies were randomized controlled trials, four were within-subjects studies, and five were coded as “other”.

3.5 Study Purposes

The included studies considered effects of setting or aesthetics on the psychedelic experience. These effects included religious, ritual, or ceremonial settings, contextual factors on expectancy and psychedelic outcomes, naturalistic or recreational settings vs. clinical or laboratory environments, and effects of music.

While some studies specifically sought to explore or test the effects of setting on subjective aspects of the psychedelic experience, others aimed to understand the mechanisms by which psychedelic therapies work.

3.6 Psychedelics Under Study

Across all 43 included studies, LSD was the most studied psychedelic compound, followed by psilocybin and ayahuasca. Six studies involved DMT, five involved peyote, and three involved mescaline.

3.7 Drug Comparators

In studies involving psychedelics, 9 studies included the comparison of different drug conditions within the study. No studies involved a systematic comparison of the interaction between drug condition and setting conditions.

3.8 Settings and Aesthetics Addressed

Across 43 studies, music was the most studied or discussed setting or aesthetic, followed by articles that addressed multiple setting components, religious or ritual settings, “other” setting elements, and physical environment.

3.8.1 Comparators

Many primary studies documented effects of a single setting, using qualitative, quasi-experimental, or survey approaches. Few studies included setting comparators.

3.9 Facilitators

The authors have used the term “facilitator” to refer to the individual administering the drug and its experience.

3.10 Outcomes

Across primary studies, subjective effects were the most common outcome measure, followed by psychiatric outcomes and well-being/quality of life, with few studies reporting on outcomes related to acute effects on emotion, spiritual outcomes, personality, or other self-report behaviors.

3.10.1 Outcome Measures/Instruments

Across 29 primary studies, 90 unique measures or instruments were used, with the most prominent type being Standardized Questionnaires/Scales.

3.11 Associations Between Setting and Psychedelic Experiences

The relationship between setting and psychedelic experiences is widely debated, with some studies confirming the hypothesis that setting affects psychedelic experiences, while others assuming that the hypothesis is true.

3.11.1 General Settings

In studies using music, photographs of loved ones, reflections in a mirror, and art therapy, participants reported having a positive psychedelic experience. However, these studies did not provide empirical controls or rigorous tests of the hypotheses that elements of setting had any influence on psychedelic experiences.

3.11.2 Social/Cultural Settings

Positive social relationships and interactions, as well as one’s perception of support and safety during psychedelic use, have been suggested to increase the likelihood of positive experiences and beneficial effects. However, these studies did not provide empirical controls or rigorous testing of these hypotheses.

3.11.3 Ritual or Ceremonial Settings

A controlled trial suggests that a shared ceremonial environment may evoke psychotropic effects without psychedelic consumption, and a survey study suggests that elements of the ritual environment may support intended outcomes.

An observational study investigated the experiences of two separate ceremonial groups, the Santo Daime and Uniao do Vegetal, and found that participants experienced different degrees of awe, peace, and psychological insight. The social and group context of psychedelic use may be important, and may improve the enduring positive outcomes. However, anonymous psychedelic trip reports suggest that social interaction is less important than the experience of individual pleasure gained from various activities during psychedelic experiences.

Sources such as survey studies and anonymous trip reports can yield rich and seemingly compelling information, but must be approached with caution.

A study of psychedelic drug use found that setting an intention before using the drug predicted the degree of the participants’ mystical experience, though questions related directly to “setting” did not correlate with subjective or neurobiological measures.

Psilocybin effects in long-term meditators have been reported, but there was no direct comparison condition within the study or within the given population for the meditation retreat context.

3.11.4 Music as Setting

Several studies have examined the effects of music on psychedelic experiences and associated brain function. However, these studies were not well-controlled, and the effects of familiarity and thematic content were not systematically manipulated.

Qualitative interviews of patients who had undergone psilocybin therapy for depression indicated that the type of music they liked, resonated with, and were open to during therapy sessions predicted therapeutic outcomes.

A small-sample, open-label pilot study showed no drawback to using a playlist primarily constructed over overtone music for psychedelic experiences, and a survey study found some common acoustic and music-theoretical features of musical stimuli that seemed consistent across therapist recommendations.

Functional neuroimaging studies have provided evidence that music has a biological basis for its effects on psychedelic experiences, including increasing meaning making, engaging vivid subjective experiences, and engaging personally-relevant content during a psychedelic experience.

4.1 Summary

This scoping review found that effects of setting on classic psychedelic therapies and experiences have been studied in multiple countries since 1958, among varied populations.

4.2 Evidentiary Gaps

This scoping review found that although setting is widely recognized as an important aspect of psychedelic experiences, there are very few studies that rigorously test hypotheses regarding the interaction between setting and either acute or enduring effects of psychedelics.

While many studies have investigated the effects of music on psychedelic experiences, few have investigated the effects of pleasant, safe physical environments.

Many included articles make claims regarding the effects of social settings, physical environments, music, festivals, general naturalistic contexts, and more on psychedelic experiences. However, study designs and variations in reporting often preclude a full exploration or understanding of these effects.

Researchers have claimed for some time that the “black box” of setting contributes to psychedelic experiences, but the existing evidence base does not provide enough insight into these phenomena to inform the establishment of evidence-based best practices.

4.3 Evidentiary Opportunities

This scoping review does reveal that music/sound, religious and ritual contexts, group vs. individual experiences, socio-cultural expectations or norms, and the physical environment may be important aspects of setting that influence psychedelic experiences.

The existing literature suggests that settings, including music and environment, can influence psychedelic experiences. Further research is needed to determine the specifics of setting optimization, including consideration of extraclinical environments.

Setting is an important variable in psychedelic research, but standard approaches to pharmacological research neglect or exclude it. However, additional approaches are necessary to inform improved understanding and delivery of psychedelic therapies.

In addition to existing models and practices, more specific setting variables could improve future outcomes. Testing hypotheses regarding the optimization of setting may be difficult to sell.

Psychedelic research provides a significant model for the larger health care field regarding the importance of setting in treatment and delivery of care. This model may have application in the design of wellness and retreat centers, as well as public, private, corporate, government, education, and other institutional settings.

4.4 Reporting

This scoping review identified gaps in reporting that limit the synthesis of evidence across studies and thereby put limits on continued improvements in research and practice. Greater use of reporting guidelines may help ensure that evidence can be synthesized and applied over time for the optimization of treatment and care.

Psychedelics research may consider new guidelines to address the issue of underreporting critical information in research, including subject selection, researcher expectations, subject expectation, preparation, and physical setting. The EQUATOR Network offers an extensive yet accessible toolkit to assist in this effort.

4.5 Theory to Practice

This scoping review illuminates the prominence of theoretical articles in literature related to setting and psychedelic therapies, and suggests rich opportunities to develop empirical studies that test existing theories, generate translational research, and propel continued improvement.

5 Limitations

This review limited results to those available through the identified databases and precluded hand-searches of the literature. It is possible that additional empirical studies of setting have been conducted but were inaccessible via the selected databases, and that studies in other languages may have offered new information.

6 Conclusion

This scoping review was designed to support the field’s understanding of the effects of setting on psychedelic therapies by gathering and organizing existing evidence regarding these effects. It indicates apparent consensus regarding the importance of setting, but lacks consistent, rigorous tests of setting.

This review illuminated that current practice is disproportionately derived from clinical practice and guidance rather than empirical study. Further theory-driven, practice-based research is needed to support evidence-based practice.

Setting and aesthetics have been recognized as critical aspects of human experience throughout human history. Psychedelic therapies have underscored the importance of extra-drug variables in research and practice.