Facing Mortality Together: A Constructivist Grounded Theory Analysis of Group Psilocybin Therapy Among Older Long-Term AIDS Survivor Gay Men

Study design

The present analysis deploys a qualitative constructivist grounded theory (CGT) methodology to explore how group PAT may impact ED and DA in older long-term AIDS survivors (OLTAS) who also have a history of a co-occurring cancer diagnosis. These individuals, all cisgender gay-identified men aged 50 or older, had previously participated in an open-label group psilocybin trial at the University of California, San Francisco (UCSF). ³⁰ The parent trial was a single-arm, open-label pilot study to evaluate the safety, feasibility, and potential efficacy of a seven-week psilocybin-assisted group therapy program-including group and individual psychotherapy plus a single psilocybin session-for demoralization in OLTAS gay men. ³⁰ Eligibility required a HIV diagnosis predating the advent of protease inhibitors (pre-1996) and moderate-to-severe demoralization.

PAT in the parent trial comprised one individual psilocybin session complemented by extensive group therapy: four to six group meetings predosing and an equal number postdosing. This structure fostered connection and created space for reflection, integration, and shared meaning-making.

CGT was chosen for its capacity to capture rich narrative data in ambiguous, subjective contexts, particularly salient when examining highly individualized psychedelic experiences.^31,32 Knowledge and reality are constructed in dialogue between participants and researchers and are profoundly shaped by social interaction, which includes facilitated group therapy visits.^33,34

Ethical approval, consent, and reporting guidelines

Qualitative methods were reported using the Consolidated Criteria for Reporting Qualitative Research, a 32-item checklist developed to help researchers improve rigor, transparency, and comprehensiveness in reporting qualitative studies (see Supplementary Data). ²¹ This checklist is particularly useful in studies involving interviews and focus groups. ²¹ The parent study was approved by the UCSF Institutional Review Board (CHR#15-17825). All participants provided informed consent prior to participation in the parent study.

Participants and data collection

For this secondary analysis, we purposively selected completed audio and video interview transcripts from the parent study, identifying six participants with confirmed diagnoses of both AIDS and a history of co-occurring cancer (renal carcinoma, Kaposi sarcoma, bladder cancer, or anorectal cancer) who had participated in group PAT, to explore how this intervention may impact ED and DA in this underrepresented population. All six participants completed individual, one- to two-hour interviews during postdosing integration sessions the day after psilocybin administration, with three also completing follow-up interviews at three months. The dataset comprised nine verbatim transcripts of semistructured interviews that explored participants’ attitudes toward illness, death, and the emotional impact of PAT. The transcripts were de-identified, and the analyst had no direct interaction with participants.

Data analysis

Transcripts were imported into Atlas.ti, a computer-assisted qualitative data analysis software, and used for coding and analysis. The primary author conducted all data coding, with coauthors reviewing the resulting codes and themes for accuracy and consensus. Themes were not identified in advance but were inductively derived from the data using the CGT methodology. The process began with open coding, progressing to axial and selective coding, grouping key ideas into categories such as difficult feelings, illness, impermanence, positive feelings, social support, and spirituality. Although the dataset comprised six participants (nine transcripts), the sample was information-rich, purposively selected, and demonstrated recurring thematic patterns, indicating sufficient depth for exploratory grounded theory analysis. Given the small, homogeneous sample, these findings should be interpreted as exploratory, providing a conceptual foundation for future, broader investigations. No substantially new themes emerged in the final interviews, suggesting that thematic saturation was reasonably achieved within this purposively selected, information-rich sample. Theoretical memos tracked evolving ideas, and findings were discussed with the coauthors and the primary investigator of the parent trial to triangulate and enhance the credibility of the research.

Acceptance of death, dying, or impermanence

The theme of acceptance of death, dying, or impermanence emerged from 18 co-occurrences between the code of acceptance and the group code of impermanence, the highest number found throughout the analysis. A “co-occurrence” in the context of utilizing Atlas.ti software for CGT analysis refers to instances where two or more codes or group codes appear simultaneously in the data, often appearing in the same or overlapping quotations. ²² These co-occurrences can help identify relationships between codes and support the development of the emerging conceptual framework^22,23 (see Fig. 3 for a list of acceptance co-occurrences).

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FIG. 3.

Acceptance co-occurrences. Explanation: The left column contains the codes (or group codes) in descending order with the highest ranking of groundedness throughout all transcripts, identified by the number of quotations associated with each code. The far-right column, highlighted in shades of blue/green, shows the rate of co-occurrences between the code “acceptance” and the listed codes (or group codes), which help develop the emergent conceptual framework.

Participants described encounters with mortality during and after the psilocybin session. Many reflected on losses (friends, partners), near-death experiences, and the prospect of their own death, often speaking of new equanimity, reduced fear, and a sense of peace. One participant, diagnosed with a recurrence of cancer during the study, reported, “Since the experience (psilocybin dosing), it’s made it easier, more peaceful… the experience was almost like death… totally peaceful.” Several noted survival amid the devastation wrought by the early AIDS epidemic, describing themselves as “the last one standing” and grappling with survivor’s guilt. Recollections of a deceased partner or witnessing a friend’s gentle passage into hospice illuminated the capacity to hold grief and love simultaneously. The day after dosing, one participant described:

Participants were aware that speaking openly about death is uncommon, yet vital.

Said one, “I’ve sat with a lot of dying people… I mention this to very few because the response is, ‘That’s so creepy,’ but to me, it’s just real.” By the three-month follow-up, acceptance of mortality persisted or deepened, often co-occurring with renewed appreciation for life and community.

Acceptance of illness

The co-occurrence of the codes “acceptance” and “illness” had the second-highest frequency in the analysis. This theme spanned cancer, HIV/AIDS, and disability. While reflecting on the psilocybin dosing day, one participant stated, “I didn’t dwell on being HIV positive. I didn’t dwell on, like, poverty existence… I have everything I need.” Another said simply, “It just is what it is,” acknowledging his concurrent cancer diagnosis. Several emphasized the universality of illness, noting that “everyone’s body is going to break down at some point,” normalizing their own suffering in the broader human context. A third participant transformed earlier self-doubt and perceived loss into acceptance, seeing other opportunities rise in place of those stolen by illness.

Embracing emotional complexity

The theme of embracing emotional complexity emerged from the high co-occurrence rates between the codes of acceptance and positive feelings, as well as between acceptance and difficult feelings (see Fig. 3 for codes co-occurring with acceptance). Participants reported learning to hold conflicting emotions, such as hope, sadness, love, anger, and gratitude, without avoiding or judging them. One described a “bubbling over” of joy during dosing, which allowed a new compassion for his long-held anger or rage. Another mused, “You’ve got to have the sadness to have the joy, and they’re all beautiful to just let that feeling happen without judgment.”

Several minor themes emerged in tandem with the major themes generated. Many reported increased mindfulness and a more positive relationship to self, sharing statements like, “There’s moments I like myself more than I ever have” and “I just want to be good enough for myself, and that extends to others.”

Themes identified in the analysis were consistently supported by participant data, with illustrative quotations directly underpinning the study’s findings. These thematic outcomes frequently overlapped across interviews conducted on the day after dosing and at the three-month follow-up, suggesting both immediate and lasting changes.

Comparison to existing literature

Contemporary systematic reviews and meta-analyses validate these findings, documenting significant, sustained reductions in depression, anxiety, and ED in terminally ill or seriously ill individuals after PAT. ²⁸ A recent scoping review indicates that DA was a major recurring theme in patients with cancer treated with psilocybin across both quantitative and qualitative studies. ³⁵ Additionally, a 2017 qualitative study at Imperial College of London identified acceptance of difficult emotions as a key process underlying therapeutic benefit from psilocybin for treatment-resistant depression. ³⁶ Although participants’ individual religious or spiritual orientations were not formally assessed, several described experiences of interconnectedness, peace, and acceptance, suggesting a shared psychospiritual dimension consistent with prior findings on psilocybin-facilitated meaning-making and spiritual well-being.

Other qualitative studies, including those on MDMA-assisted (3,4-methylenedioxymethamphetamine) therapy for people with life-threatening illness, consistently report increased coping, improved quality of life, and explicit acceptance as outcomes. ³³ These effects appear stronger in individuals with psychedelic experience than after nondrug-related near-death events, particularly for meaning, insight, and reduced fear. ³⁴ The OLTAS community faces compounded stigma and unique layers of social isolation and existential suffering compared to broader cancer or HIV populations, with survivor’s guilt highlighting further clinical nuances. ²⁴

Proposed mechanisms of therapeutic change

Insight, impermanence, and mystical experience. Almost all participants described psychological insight into their illness relationships, contributing to less fear and greater acceptance of adversity and mortality. Alongside these insights, themes of impermanence- drawn from both Western and Eastern philosophies-were prominent, with participants reporting increased present-moment awareness and acceptance of change, reflecting the study’s mindfulness meditation component. While classical mystical-type experiences, such as transcendence, unity, or ego dissolution, were less common in this group compared to prior research, some individuals did describe feelings of interconnectedness and a broader, “cosmic” perspective.

Psychological flexibility. Core study themes echo the psychological flexibility model, which emphasizes present-moment awareness, acceptance, self-as-context, and clarification of personal values. ³⁷ Recent research demonstrates that improved psychological flexibility is strongly associated with reduced depression and existential anxiety.^36,37 Our findings suggest that enhanced psychological flexibility help participants integrate fears around mortality and impermanence, supporting the central theme of acceptance and offering direction for future standardized clinical protocols.

Group therapy dynamics

The group therapy format provided social support, shared identity, and emotional safety, allowing frank discussion of death, stigma, illness, and aging with rare openness. This protective group belonging mitigates loneliness and related health risks. ²⁵ Positive social connection in psychedelic group settings further enhances well-being and outcomes.^38,39 The parent trial’s group model strengthened rapport, emotional validation, and increased psychological insight beyond standard individual approaches.

Clinical implications

Group PAT represents a promising intervention for older adults with serious illness, particularly those at the nexus of multiple stigmas or facing compounded isolation. PAT can deliver rapid and durable improvements in depression, demoralization, ED, and overall quality of life, supporting both meaning-making and practical coping.^18,40 All participants of the parent trial underwent cognitive screening to rule out baseline impairment, and no evidence of delirium or cognitive decompensation was observed during dosing or follow-up, consistent with psilocybin’s favorable safety profile in palliative settings.^41,42 Integration of psychospiritual care and a broadened appreciation for nondogmatic spirituality, manifesting as self-acceptance, connectedness, and mindfulness, may further enhance patient outcomes. For clinical teams, integrating PAT within HPC, oncology, and geriatric services, ideally in group settings, may address unmet needs in patient psychosocial–spiritual care while fostering meaning and an expanded perspective on facing illness, advancing age, and death. Translating PAT into HPC will require addressing regulatory barriers, ensuring interprofessional training for nurses, social workers, and chaplains, and establishing ethical and safety frameworks to support multidisciplinary delivery.^41,43

Challenges and limitations

Methodological limitations include the small and homogeneous sample size, as well as the lack of researcher–participant interaction in this secondary analysis, which may constrain the emergence of novel insights and limit generalizability.

Analysis of preexisting transcripts also precluded dynamic theoretical sampling and limited flexibility in refining interview prompts. Potential bias from the original study’s design and research questions may have influenced the kinds of themes and experiences discussed. Nonetheless, critical steps such as triangulation, analytic memoing, and systematic coding enhanced the rigor and credibility of findings, and the unique intersectionality of participants’ experiences offers novel contributions to the field.

Future research directions

Future directions should extend qualitative analysis to larger, more diverse, and heterogeneous samples, including racially and ethnically diverse groups, as well as younger and female participants facing complex, serious illness. Comparative and longitudinal studies are needed to examine the persistence and variation of PAT’s effects and to distill which elements (pharmacologic, psychotherapeutic, social) are most influential in different contexts. Further work to integrate HPC nurses into research teams could enhance care models and facilitate the broader dissemination of findings. Lastly, exploring the application of group PAT for other marginalized or psychologically at-risk populations (e.g., LGBTQ+ youth, individuals with chronic pain, and caregivers) would increase generalizability and inform more inclusive, responsive clinical interventions.