Ayahuasca ceremony leaders' perspectives on special considerations for eating disorders

Eating disorders (EDs) are complex, often chronic conditions with high relapse and treatment dropout rates, motivating investigation of novel therapies. Recent psychedelic research has included trials of psilocybin and MDMA for ED-related conditions, and ayahuasca—a traditional Amazonian brew containing DMT plus MAOIs—has drawn interest because its acute effects (including vivid imagery, strong emotions and somatic phenomena such as vomiting) and ceremonial practices (notably preparatory dietary restrictions and in‑ceremony purging) overlap in some respects with behaviours and rituals familiar in EDs. These overlaps raise specific questions about safety, suitability, and the meaning of such experiences for people with EDs. Williams and colleagues set out to explore these questions from the viewpoint of ayahuasca ceremony leaders. The study aimed to characterise leaders' experiences and beliefs about screening, risks, behavioural overlap (purging and diets), and potential complementarities between ceremonial ayahuasca use and conventional ED treatments, with a view to informing safer participation and future research directions.

Fifteen ayahuasca ceremony leaders were recruited using purposive, convenience, and snowball sampling. Inclusion criteria required self‑identification as a ceremony leader, age 18+, having led ceremonies attended by people with EDs, and conversational English fluency; leaders affiliated solely with ayahuasca churches (e.g., Santo Daime) were excluded because those settings differ substantially from ceremonial contexts. The sample sought heterogeneity in experience and gender identity; the majority reported training under an experienced leader in South America (n = 12), none identified as Indigenous or Mestizo, most were from Western/Global North contexts, and nine disclosed a personal history of disordered eating or an ED (one reporting a formal diagnosis). Data were collected via ~90‑minute telephone semi‑structured interviews after written informed consent; interviewers had graduate mental‑health training and used an adapted protocol to explore therapeutic utility, screening and support practices, views on conventional ED treatments, and the roles of dietary restriction and purging. Laurentian University provided ethics approval. Interviews were audio‑recorded, transcribed, anonymised, and fidelity‑checked. Analysis followed an inductive Qualitative Content Analysis (QCA) approach, focused on manifest content within a constructivist‑interpretivist epistemology. Two analysts independently extracted meaning units and iteratively developed categories, using memoing, reflexivity, and team discussion to refine coding and resolve disagreements. Dedoose software managed the data. The team drew on standard QCA trustworthiness criteria (credibility, transferability, dependability, confirmability, authenticity).

Four primary analytic categories emerged: screening for EDs; purging and dietary restrictions; potential risks and dangers; and complementarity with conventional ED treatment. Screening for eating disorders: Leaders most commonly identified EDs when participants self‑disclosed during intake or post‑ceremony conversations. A minority had explicit ED questions on application materials or intake, and another minority did not screen at all. Several leaders emphasised difficulty detecting EDs because participants may conceal symptoms out of shame, fear of exclusion, or stigma. One leader reflected that disclosure often occurred only after a ceremony when participants reported benefit. Purging and dietary restrictions: Approximately one‑half of leaders reported observing participants who used ceremony attendance to engage in ED behaviours (for example, fasting under the mantle of spiritual practice), while others had not observed this or were uncertain. Two‑thirds of leaders characterised in‑ceremony purging as qualitatively different from ED‑related purging, describing it as an ‘‘energetic’’ or cleansing release linked to processing trauma or blockages. Preparatory diets were framed by many leaders as enhancing safety (e.g., avoiding tyramine interactions), receptivity to the medicine, and commitment to the ceremonial process; however, prior participant reports and some leaders indicated that diet protocols could ‘‘stir up’’ ED thoughts or behaviours for some individuals. Potential risks and dangers: One‑third of leaders named specific contraindications for ayahuasca among people with EDs, including very low body weight, severe ongoing ED behaviours, electrolyte imbalance, dehydration, cardiovascular issues, and esophageal or stomach injuries. Several leaders noted the physical demands of ceremony (vomiting, diarrhoea, elevated heart rate) and the need for a baseline level of physical strength or medical stability. Emotional destabilisation and exacerbation of psychiatric comorbidities (e.g., bipolar I disorder, borderline personality disorder) were also raised as concerns. Some leaders suggested that people with EDs might require multiple ceremonies and tailored retreats, and proposed accommodations such as very low dosing, topical application instead of ingestion, or use of a ‘‘master plant dieta’’ as alternatives or adjuncts. Complementarity with conventional ED treatment: Nearly two‑thirds of leaders reported limited knowledge of conventional ED treatments and felt the worldviews could differ markedly. Nonetheless, about one‑half envisaged potential synergy: conventional treatments could help with renourishment, integration of ayahuasca experiences, and relapse prevention, while ayahuasca might increase post‑ceremony receptivity to psychotherapy. Leaders emphasised that the skills of ED clinicians could assist safe integration and sustainment of any post‑ceremony gains.

Williams and colleagues interpret their findings as extending earlier, limited work on ayahuasca and EDs by foregrounding ceremony leaders' perspectives on special considerations. Leaders identified physiological, psychiatric, and behavioural contraindications that align with broader safety concerns in the ayahuasca literature, while generally believing that, when indicated and conducted in supportive settings, ceremony participation can be safe. Screening practices were highly variable across leaders, from no formal screening to physician‑involved comprehensive intake, suggesting inconsistency in how suitability is assessed. The investigators note practical implications raised by leaders, including the potential value of requiring medical assessments of vitals (height, weight, heart rate, electrolytes, blood pressure) to inform decisions and to determine whether accommodations (lower doses, non‑ingestion options) are appropriate. Ethical tensions were highlighted: for some people with severe, treatment‑refractory EDs the risks and benefits of participation may be weighed differently, and deliberate or inadvertent non‑disclosure of ED symptoms by participants complicates risk management. Leaders advocated for sensitive, non‑judgemental intake conversations to facilitate disclosure. On the topic of purging and diets, leaders largely viewed ceremony‑related purging as distinct from ED‑motivated purging, often experienced by participants as healing rather than compensatory. Nevertheless, the authors caution that preparatory diets or purging could potentially ‘‘recruit’’ ED processes in subtle ways, and that some leaders had observed participants using retreats to continue ED behaviours. Consequently, they recommend further research to clarify the impacts of diets and purging on ED symptoms and to develop supports—such as ED‑informed dietary guidance and collaborative consultation between ceremony staff and ED treatment teams—to reduce harms while not unduly excluding potentially benefiting individuals. The discussion places these findings within a broader argument for collaborative, culturally respectful work between Indigenous/Mestizo practitioners and Western ED researchers and clinicians. Leaders posited potential complementarities: ayahuasca might catalyse emotional processing and neuroplasticity that conventional therapies could harness to enhance renourishment, psychotherapy, and relapse prevention. The authors emphasise that Indigenous epistemologies should be engaged respectfully and bidirectionally in research and practice. Limitations reported by the investigators include modest sample size based on convenience sampling, English‑only interviews limiting cultural diversity, potential under‑reporting due to legal constraints, interview dynamics shaping content, and possible self‑selection bias given that many leaders disclosed personal disordered‑eating histories. These constraints limit transferability beyond Western ceremonial contexts. The authors call for further qualitative and quantitative research on efficacy, safety, the effects of preparatory diets and purging, empirically derived decision aids for participation, studies of post‑ceremony neuroplasticity and receptivity to conventional treatment, and inclusion of other key informants (participants with EDs, family members, clinicians). They also recommend consulting Indigenous and Mestizo knowledge holders in future work.