This review (2024) scrutinizes the role of psychotherapy in psychedelic-assisted psychotherapy (PAP/PAT) for mental health conditions. It underscores a significant research gap in understanding the psychotherapeutic elements within PAT, despite its assumed importance for safety and efficacy. The paper calls for a transdisciplinary approach in future research to optimize PAT clinical outcomes and inform federal guidelines.
Rationale
Psychedelic-assisted psychotherapy (PAP) has emerged as a potential treatment for a variety of mental health conditions, including substance use disorders and depression. Current models of PAP emphasize the importance of psychotherapeutic support before, during, and after ingestion of a psychedelic to maximize safety and clinical benefit. Despite this ubiquitous assumption, there has been surprisingly little empirical investigation of the “psychotherapy” in PAP, leaving critical questions about the necessary and sufficient components of PAP unanswered.
Objectives
As clinical trials for psychedelic compounds continue the transition from safety- and feasibility-testing to evaluating efficacy, the role of the accompanying psychotherapy must be better understood to enhance scientific understanding of the mechanisms underlying therapeutic change, optimize clinical outcomes, and inform cost-effectiveness.
Results
The present paper first reviews the current status of psychotherapy in the PAP literature, starting with recent debates regarding “psychotherapy” versus “psychological support” and then overviewing published clinical trial psychotherapy models and putative models informed by theory. We then delineate lessons that PAP researchers can leverage from traditional psychotherapy research regarding standardizing treatments (e.g., publish treatment manuals, establish eligibility criteria for providers), identifying mechanisms of change (e.g., measure established mechanisms in psychotherapy), and optimizing clinical trial designs (e.g., consider dismantling studies, comparative efficacy trials, and cross-lagged panel designs). Throughout this review, the need for increased research into the psychotherapeutic components of treatment in PAP is underscored.
Conclusions
PAP is a distinct, integrative, and transdisciplinary intervention. Future research designs should consider transdisciplinary research methodologies to identify best practices and inform federal guidelines for PAP administration.
Papers cited by this study that are also in Blossom
Aday, J. S., Heifets, B. D., Pratscher, S. D. et al. · Psychopharmacology (2021)
Aday, J. S., Skiles, Z., Eaton, N. et al. · Psychedelic Medicine (2023)
Aday, J. S., Davoli, C. C., Bloesch, E. K. · Therapeutic Advances in Psychopharmacology (2020)
Barba, T., Buehler, S., Kettner, H. et al. · BJPsych Open (2022)
High-dose administration of classic psychedelics paired with psychotherapeutic support before, during, and after dosing sessions is increasingly being studied as a potential treatment for several psychiatric conditions. Aday and colleagues describe two principal rationales for combining drug and psychotherapy: safety (therapeutic support is thought to reduce the acute risks of giving a psychedelic) and efficacy (psychedelics may transiently relax prior beliefs, increase suggestibility, and promote neuroplasticity in ways that could augment psychotherapeutic processes). The authors emphasise that this context sensitivity makes it important to understand which psychotherapeutic elements are necessary or sufficient for clinical benefit. The paper sets out to review the current status of psychotherapy within psychedelic-assisted psychotherapy (PAP), summarising psychotherapeutic models used in published clinical trials and putative models proposed in the literature. It also aims to draw lessons from decades of traditional psychotherapy research about standardising treatments, identifying mechanisms of change, and optimising trial design, with the overarching goal of highlighting gaps and priorities for empirical study of the psychotherapeutic component of PAP.
Aday and colleagues present a narrative, conceptual review rather than a formal systematic review or meta-analysis. The authors synthesise existing clinical trial reports, historical models from mid-twentieth century research (for example psychedelic peak therapy and psycholytic approaches), contemporary trial practices, and theoretical proposals about mechanisms and therapy modalities that might be synergistic with psychedelics. They also draw on methodological literature from traditional psychotherapy research to suggest study designs and standards that could be applied to PAP. The extracted text does not report a specific search strategy, databases searched, inclusion/exclusion criteria, dates of coverage, or a formal risk-of-bias assessment for included trials. Instead, the paper organises material thematically across topics such as current PAP practice (preparation, dosing, integration), varieties of psychotherapeutic approaches used or proposed, putative mechanisms of change, issues with treatment description and standardisation, and methodological tools from psychotherapy research (for example dismantling studies, comparative efficacy trials, and cross-lagged panel models). The authors integrate examples from individual trials where relevant, and discuss empirical gaps and design considerations for future research.
The review finds that contemporary PAP trials commonly follow a three-stage sequence: preparation (psychoeducation, expectation-setting, goal identification, establishment of therapeutic relationship), dosing (typically multi-hour sessions in a controlled environment with music and therapist support), and integration (sessions aimed at meaning-making and applying insights to daily life). Modern trials are heavily influenced by the psychedelic peak therapy model, which uses high doses to induce transformative states and typically adopts a non-directive, supportive stance during dosing. Mid-twentieth-century variants such as psycholytic therapy (lower doses combined with ongoing psychotherapy) have been largely sidelined in contemporary protocols. A wide range of psychotherapeutic modalities have been used or proposed alongside psychedelics, including cognitive behavioural therapy (CBT), CBT combined with motivational interviewing, Acceptance and Commitment Therapy (ACT), Internal Family Systems Therapy, EMDR, existential and psychodynamic approaches, mindfulness, psychoanalysis, group therapy, virtual reality adjuncts, and common-factors or novel therapies. The authors report that putative mechanisms of change identified in PAP work include awe, mystical-type experiences, increased acceptance, reduced rumination, greater cognitive flexibility, and therapeutic alliance, but empirical measurement of many of these constructs has been limited. A key empirical finding highlighted by the authors is the scarcity of trials that manipulate the psychotherapeutic component. The only trial noted to directly vary aspects of psychotherapeutic support randomised 75 healthy participants into three groups: very low-dose with standard support (LD-SS), high-dose with standard support (HD-SS), and high-dose with high support for spiritual practice (HD-HS). At six months, both high-dose groups showed large positive changes on measures such as interpersonal closeness, gratitude, meaning/purpose, and spiritual/religious measures compared with LD-SS. Differences between the two high-dose groups were generally small, suggesting dose had a larger impact than the manipulated contextual support in that study. The review documents shortcomings in treatment reporting: psychotherapy content and intensity are often minimised in methods sections, manuals are infrequently published, and provider eligibility (training, licensure) is not consistently defined. Mechanism measurement is also uneven: expectations are rarely measured despite being considered important, therapeutic alliance is predictive of some outcomes but often unmeasured in trials, and constructs such as corrective experiences or ongoing reality testing have not been specifically examined in PAP. The authors note methodological challenges inherited from psychotherapy research—most notably the so-called "Dodo Bird Verdict," whereby common factors across therapies reduce detectable differences between approaches in RCTs. They propose that designs such as dismantling studies, comparative efficacy/non-inferiority trials, and cross-lagged panel models could be informative, while acknowledging practical constraints (larger sample sizes, ethical issues, and the relatively small number of sessions in PAP compared with traditional psychotherapy). Finally, the paper flags policy and implementation issues: patchwork legalisation across jurisdictions, the imperative for clear licensure and training standards given participants' heightened vulnerability and suggestibility, and the limited federal funding that has channelled research resources towards drug development rather than psychotherapeutic innovation.
Aday and colleagues interpret the literature as showing early therapeutic promise for PAP but also a marked paucity of empirical work on the psychotherapeutic component. They argue that the field needs to move beyond trial-and-error traditions and community practices by more precisely defining and reporting what psychotherapy entails in PAP, measuring putative mechanisms, and empirically testing which psychotherapeutic components contribute to safety and clinical benefit. The authors position these recommendations within broader psychotherapy research, noting that established practices—such as publishing treatment manuals, specifying provider qualifications, and using designs that can isolate active ingredients—are applicable to PAP. They caution, however, that some standard approaches (for example dismantling designs that remove supportive elements) raise ethical and safety concerns when applied to PAP, and such trials would need to be conducted iteratively with risk mitigation in mind. Cross-lagged panel models and other within-subject longitudinal methods are proposed as complementary strategies to improve causal inference about mechanisms, though the limited number of PAP sessions and the potential for rapid, non-linear change constitute practical hurdles. Key limitations acknowledged include the inconsistent reporting of psychotherapeutic procedures across trials, the scarcity of trials that experimentally manipulate psychotherapeutic variables, and constraints on funding and incentives—industry funding tends to favour drug-focused work because psychotherapy is harder to monetise. Implications discussed by the authors include the need for transdisciplinary research efforts, clearer standards for therapist training and licensure to mitigate risks arising from participant suggestibility, and targeted investment (including public funding) to support rigorous study of the psychotherapeutic elements of PAP so that clinical guidelines and regulatory policies can be evidence-based.
Recent clinical trials of PAP have demonstrated preliminary therapeutic benefits for several health conditions, but there remains considerable ambiguity and limited empirical investigation regarding the psychotherapeutic component of these interventions. Given the sensitivity of psychedelic effects to context and the potential safety and efficacy implications of psychotherapy, the authors conclude that more research is needed to identify best practices, leverage methodological advances from traditional psychotherapy research, and inform regulation and clinical guidelines. They argue that state approvals for PAP and calls from funding bodies to clarify mechanisms of change increase the urgency for investment and innovation in psychotherapy research within the psychedelic field to reduce adverse effects, optimise outcomes, and improve comparability of study findings.
"There is considerable variation in dosage and method of managing patients while they are under the influence of. Further, there is no uniformity in views expressed as to how the drug facilitates psychotherapy. This is inevitable, since there is no universally accepted theoretical basis for psychotherapy, and each psychotherapist develops techniques of management of patients under the drug in accordance with the principles of his general psychotherapy.. High-dose administration of a classic psychedelic (e.g., psilocybin or LSD) paired with psychotherapeutic support before, during, and after dosing sessions is increasingly being studied as a potential therapeutic intervention for multiple disorders. This tight combination of pharmacological and psychological treatments is arguably unlike anything else in psychiatry and represents a potential paradigm shift for the field). There are two major rationales for this unusual, combined approach: (1) Safety. Giving high-dose psychedelics to individuals on their own can confer acute risks that are thought to be reduced with psychotherapeutic support; and (2) Efficacy. Psychedelics appear to transiently relax prior beliefs, increase suggestibility, and promote neuroplasticity, which when combined with psychotherapy, may facilitate changes in behavior and self-concept. This increased sensitivity to context (i.e., non-pharmacological variables) means that a nuanced understanding of the optimal types of psychotherapeutic treatment to pair with the drugs is needed. One fundamental challenge dating back to early psychedelic research is the lack of empirical investigation into, and operationalized definition of, the "psychotherapeutic support" paired with psychedelic dosing. Current approaches to psychotherapy in psychedelic-assisted psychotherapy (PAP) are largely the product of trial-and-error from early psychedelic researchers and contemporary community or "underground" psychedelic practitioners. Although these sources of knowledge have been incredibly valuable for the field, systematic study of the psychotherapy associated with psychedelics has been lacking. Indeed, although the drug component in trials has frequently been manipulated (e.g., by comparing different dosages of the same psychedelic or by using active or inert placebos), studies have rarely systematically manipulated the non-pharmacological aspects of treatment, including psychotherapy (see: Griffiths and colleagues' 2018 study for a notable exception). Similarly, the wide variety of terms used to describe individuals supporting patients through psychedelic experiences, such as "guide", "sitter") "monitor", "facilitator", and "psychedelic therapist"outcomes. These guidelines go on to suggest that researchers provide separate psychotherapists for various stages of PAP, despite a lack of evidence suggesting this is a safe or efficacious approach. Furthermore, a recent publication from Goodwin and colleagues (2023) asks whether psychotherapy is even a necessary component of the intervention, suggesting "the effects observed thus far in the best controlled studies of psychedelic treatment must be attributed to the drug itself and not to psychotherapy". These recent publications underscore an immediate need to determine the necessity and sufficiency of psychotherapy in PAP in order to inform considerations for safety, cost-effectiveness, and clinical efficacy. The underlying complexity of this question was succinctly summarized by Dr. Matthew: "Psychedelic therapy is more psychotherapy than most pharma companies & neuroscientists know how to deal with, and more pharmacology than most psychotherapists know how to deal with." The challenge of parsing psychotherapy effects versus pharmacological effects in the overall combined 'package' of PAP remains a contentious area of debate. Moreover, there is much the field has yet to leverage from decades of non-psychedelic psychotherapy research to optimize the psychotherapeutic aspect of treatment. Here, we outline psychotherapeutic models that have been utilized and proposed to be synergistic with psychedelics as well as delineate how these approaches can leverage important lessons from traditional psychotherapy research. Throughout this review, we underscore the need for increased research to determine the content and intensity with which psychotherapy should be embedded within psychedelic treatments, as well as the role it may play in clinical mechanisms and outcomes.
Contemporary clinical trials of PAP often include the same general sequence for the intervention, comprising three stages: preparation, dosing, and integration. Preparation sessions are largely intended to provide psychoeducation, set expectations, and identify goals for treatment, while establishing a therapeutic relationship between participant and therapists. The length of dosing sessions can vary by drug, but are typically at least six hours, in which the psychedelic is administered in a relaxing environment with music and "psychotherapeutic support" from the therapists. Subsequent integration sessions assist participants in making meaning of their experiences and exploring ways of potentially generalizing insights from the dosing session to improve their daily lives. Modern psychedelic literature often cites a foundational paper written bytitled "Human Hallucinogenic Research: Guidelines for Safety." These early guidelines provided the broad framework of preparation, dosing, and integration for PAP trials to examine the potential clinical benefits of PAP across a variety of psychiatric conditions, including cancer-related anxiety and distress, substance use disorders, and major depressive disorder.draw heavily from a model described as "psychedelic peak therapy," which was designed specifically to induce peak, transformative, and altered states of consciousness with high doses of psychedelics, typically LSD. Notably, psychedelic peak therapy was one of many therapeutic approaches utilized in the mid-twentieth century, among other approaches such as psycholytic therapy, which involves the use of low doses of psychedelics in combination with ongoing psychotherapy. Nonetheless, the psychedelic peak therapy model has been ubiquitously applied to modern PAP research-across various psychedelic drugs, research groups, and clinical diagnoses. The psychedelic peak therapy model includes a "non-directive supportive" approach to treatment, in which therapists support, but do not guide, the participants during the dosing experience. Trials also mentioned utilizing other modalities of psychotherapy along with this "non-directive" approach, including cognitive behavioral therapy, combined CBT and motivational interviewing, and an eclectic treatment drawing from existential, psychodynamic, and CBT models. The list of approaches that have been proposed to be synergistic with PAP cascades into a myriad of psychotherapies, including Acceptance and Commitment Therapy, Internal Family Systems Therapy (IFST;, Eye Movement Desensitization and Reprocessing Therapy (EMDR; Rose & Raine-Smith 2023), existential psychology, mindfulness, psychoanalysis, group psychotherapy, virtual reality therapy, a common factors approach (Gukasyan and Nayak 2022), and even novel psychotherapies. Similarly, it should be noted that a range of putative psychological mechanisms of change have been identified in PAP, such as awe, mystical-type experiences, acceptance, decreased rumination, cognitive flexibility, and therapeutic alliance). Thus, views regarding best psychotherapeutic practices for PAP vary widely beyond the standard psychedelic peak therapy framework that includes "non-directive support", and there has been very limited empirical investigation to date of these diverse approaches in the context of PAP).
Given the large body of literature developed over the last century on standardizing protocols, identifying mechanisms of change, and assessing the efficacy of competing approaches in traditional psychotherapy research, not leveraging these methodological advancements to improve upon current PAP research and therapy models may represent an important missed opportunity (Table).
First, in order for best practices to be established in PAP, it is evident that greater emphasis is needed on the specific content and intensity of the psychotherapy in psychedelic research papers, as description of the psychotherapy has typically been minimized). Speculatively, this may be because many of the researchers in this area are not psychotherapists themselves and that manualizing interpersonal interactions can be intrinsically challenging. Nonetheless, the field does not need to generate novel standards for description of treatment components, as this has been an issue that has been addressed in traditional psychotherapy research to standardize treatments. Indeed, an international group of psychotherapy researchers published recommendations to improve rigor in psychotherapy trials. Regarding description of treatment components, the authors highlighted that all potential treatment ingredients should be listed in method sections, including the order of administration. Ideally, including a published manual or supplement outlining important details of the therapy (e.g., how many hours were provided, principles of treatment, etc.) would improve replicability as well. Defining the eligibility criteria for care providers (e.g., training, licensure, etc.) may also promote consistency of intervention delivery and mitigate risks for boundary violations.
There are also specific psychotherapeutic mechanisms of change that have been established as fundamental to effective psychotherapy but have been as of yet under-examined in PAP research. Identification of relevant mechanisms in any form of health treatment is important for improving treatment efficacy as well as targeting populations most likely to benefit from the intervention.recently surveyed a large number of psychotherapy clinicians and researchers (N = 1,998) from a variety of theoretical orientations regarding principles of change that guide routine psychotherapy practice. They found that there was consensus regarding five principles: 1) fostering hope, positive expectations, and motivation, 2) facilitating the therapeutic alliance, 3) increasing awareness and insight, 4) encouraging corrective experiences, and 5) emphasizing ongoing reality testing. There is variability regarding the extent to which researchers have assessed these principles in the context of PAP. Certainly, fostering hope, positive expectations, and motivations prior to dosing in PAP is considered to be integral to facilitating positive and therapeutic experiences with psychedelics, but researchers have rarely measured expectations. Similarly, therapeutic alliance strength in PAP predicts greater emotional breakthrough, mystical-type experiences, and decreases in depression), but has most often not been measured. Regarding insight, there is emerging evidence that experiences of insight facilitated with psychedelics predict persisting clinical benefits,although further research is needed.theorized that the state of belief relaxation conferred by psychedelics may facilitate corrective experiences, but no PAP studies to-date have specifically examined corrective experiences. Lastly, to the best of our knowledge, emphasis of ongoing reality testing has not been incorporated as a fundamental aspect of PAP nor measured in any trials. Beyond these transtheoretical principles, there may be additional mechanisms of change derived from traditional psychotherapy (e.g., experiential avoidance;that are applicable to PAP, and it should also be highlighted that PAP may involve unique mechanisms that traditional psychotherapeutic frameworks do not typically consider (e.g., mystical-type experiences).
Another opportunity to leverage lessons from traditional psychotherapy research regards assessing differences in treatment efficacy, including the direct head-to-head empirical evaluation of psychotherapeutic approaches or techniques within a single trial. However, to that end, non-psychedelic psychotherapy research suggests that there is reason to doubt that traditional randomized controlled trials (RCTs) are sensitive to detecting such differences. Indeed, this has been a simmering issue for the field of psychotherapy for almost a century. That is, the high number of "common factors" among different psychotherapeutic techniques often makes it difficult to identify outcome differences among approaches when directly compared in a clinical trial, a phenomenon referred to as "The Dodo Bird Verdict". This notion seems to have preliminary support from the only psychedelic study to-date that has manipulated aspects of the "psychotherapeutic support" between conditions. In this trial, 75 healthy participants were randomized among three groups: (1) very low-dose (1 mg/70 kg on sessions 1 and 2) with moderate-level ("standard") support for spiritual-practice (LD-SS); (2) high-dose (20 and 30 mg/70 kg on sessions 1 and 2, respectively) with the same "standard" support (HD-SS); and (3) high-dose (20 and 30 mg/70kg on sessions 1 and 2, respectively) with high support for spiritual practice (HD-HS). At the six-month follow-up, compared with LD-SS, both high-dose groups showed large positive changes on longitudinal measures of interpersonal closeness, gratitude, life meaning/purpose, forgiveness, death transcendence, daily spiritual experiences, religious faith and coping, and community observer ratings. Although there were a small number of differences in the trial between the high-dose groups (e.g., increased ratings of spiritual experiences in the group with high support for spiritual practice as expected), there were generally more similarities than differences-suggesting that drug dose was a more pertinent factor in trial outcomes than the contextual factors that were manipulated. To date, this is the only psychedelic trial we are aware of to directly study aspects of the surrounding psychotherapeutic intervention, beyond music, which is ubiquitously thought to be crucial to clinical outcomes. Psychotherapy researchers have attempted to address issues like the Dodo Bird Verdict with innovative study designs, such as dismantling studies, comparative efficacy trials, and cross-lagged panel models (CLPMs). A dismantling study design typically involves comparing a full treatment protocol to a "dismantled" control condition, where one or more components of the treatment thought to be an active mechanism(s) of action are removed. All other aspects of the study design and implementation are held constant between conditions, and attempts are made to ensure equivalence across nonspecific aspects of care that might influence outcomes. The rationale is that if the removed portion of the treatment is an important "ingredient" in the overall treatment package, subsequent group comparisons should demonstrate reductions in clinically significant change in the dismantled group as compared to the group that received the complete treatment. For example, narrative reformulation is an assumed active ingredient of cognitive analytic therapy (CAT) in treating depression.compared typical CAT with a dismantled control condition that removed narrative reformulation. They found that narrative reformulation did not enhance the efficacy of CAT for depression, suggesting that it may be a redundant portion of the treatment that can be removed while maintaining treatment efficacy. Certainly, in the context of PAP, there are possible safety concerns regarding removing aspects of the psychotherapeutic support, but if done iteratively, risks may be minimized. Similarly, comparative efficacy and non-inferiority trials compare two active forms of treatment for the purposes of assessing treatment superiority after a treatment has demonstrated efficacy against an inactive control. Such designs could be systematically deployed to identify aspects of PAP that account for clinical change and inform best practices for the field. Although, it should be noted that they are limited by the need for larger sample sizes and higher costs. Psychotherapy researchers have similarly acknowledged the drawbacks of dismantling designs and potential ethical limitations of withholding aspects of treatment. As an alternative, cross-lagged panel models have been put forth as a means for identifying mechanisms of change in psychotherapy. In a CLPM, two variables (X and Y) are repeatedly measured throughout treatment, which makes it possible to track session-by-session changes and focus on within-patient associations between predictors and outcomes. The primary advantage of CLPMs compared to traditional cross-sectional correlational analyses is accounting for temporality, a primary criterion for causal inference. Although this design allows for greater confidence in causal inference, it is still limited by the potential for confounding variables and requires a large number of within-subject observations. This may be a particularly relevant hurdle for PAP, given that the treatment involves a limited number of sessions relative to traditional psychotherapy and can be characterized by periods of rapid, non-linear change in some cases. Nonetheless, CLPMs represent another untapped resource provided by traditional psychotherapy researchers that has been as of yet underutilized by PAP researchers.
As patchwork legalization of PAP begins to unfold across the world, standards for psychotherapy will undoubtedly vary by jurisdiction, as has already been seen in Oregon, Colorado, and Australia. The effects of these inconsistent standards on treatment outcomes remain mostly unknown. Given the heightened state of vulnerability and sensitivity to context conferred by psychedelics, it is critical for researchers to begin systematically studying the role of the surrounding psychotherapeutic component of treatment. Relatedly, the importance of establishing clear guidelines and standards for appropriate licensure and training of psychedelic therapists is of the utmost importance. Licensure and training are requirements for all psychotherapy clinicians, designed to ensure clinicians are appropriately trained and qualified to practice psychotherapy. Moreover, licensure is intended to mitigate risks for boundary violations and requires therapists to adhere to an oath to "do no harm." Such considerations are paramount for PAP, as participants are given suggestibility-enhancing substances that may increase their vulnerability to therapist coercion and malpractice. As previously outlined, the psychedelic peak therapy model could likely be better mechanistically understood and clinically optimized by leveraging the techniques developed in the context of traditional psychotherapy, and it may be the case that certain psychotherapeutic approaches may be more suitable for specific doses or conditions. A critical issue to consider, however, is the paucity of federal funding for psychedelic studies, which has forced researchers to primarily rely on philanthropic and industry support for trials. Due to the difficulty of patenting and monetizing psychotherapy approaches, companies in the psychedelic industry are incentivized to focus on drug discovery and development
Recent clinical trials of PAP have shown early therapeutic promise for a variety of health conditions. However, to date, there has been considerable ambiguity and a lack of empirical investigation regarding the PSYCHEDELIC-ASSISTED PSYCHOTHERAPY 12 psychotherapeutic component of treatment. Given the crucial role of context, including psychotherapy, in PAP outcomes, more research is needed to identify best practices associated with the treatment, and there are valuable advancements developed in the context of traditional psychotherapy that PAP has yet to fully leverage. Recent state approvals for the clinical use of PAP, coupled with calls from the NIH to better understand the mechanisms underlying changes induced by PAP, necessitate investment and innovation into this research to reduce the risk of adverse effects, optimize clinical outcomes, and enhance generalizability and comparability of study findings.
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