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Cited by 29Psychedelics and Drug StudiesPsychotherapy Techniques and ApplicationsReligion, Spirituality, and Psychology

Psychedelics assisting therapy, or therapy assisting psychedelics? The importance of psychotherapy in psychedelic-assisted therapy

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Zamaria, Joseph A., Fernandes-Osterhold, Gisele, Shedler, Jonathan, Yehuda, Rachel·2025·Frontiers in Psychology
DOI 10.3389/fpsyg.2025.1505894PMC PMC11835864
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Abstract

There is notable controversy about the role of psychotherapy in clinical trials of psychedelic-assisted therapy (PAT). This heated and perpetually evolving debate informs questions such as how much therapy should accompany a psychedelic intervention (Marseille et al., 2022), what type of therapy most effectively complements psychedelic administration (Cavarra et al., 2022;Yaden et al., 2022), and even whether psychotherapy should always be included (Goodwin et al., 2023;Earleywine et al., 2024;Schenberg, 2024). Recent events, namely the rejection by the Food and Drug Administration (FDA) of Lykos Therapeutics' application to approve MDMA-assisted therapy (MDMA-AT) as a treatment for PTSD, has brought forth some of the intricacies within this debate. That governing body's role is to approve pharmacological agents, not psychotherapies. The FDA was likely unfamiliar with the complication of including therapy with MDMA-AT, rather than evaluating the administration of MDMA as a standalone pharmacological intervention. This highlights the novelty of PAT in medicalized settings, and underscores the controversy of including bona fide psychotherapy as a necessary component of psychedelic drug administration.From our perspective, PAT is a unique psychiatric intervention in that it is genuinely a combined treatment, involving the administration of a psychedelic substance such as psilocybin or MDMA within the context of psychotherapy. Thus, PAT synergizes elements of pharmacological enhancement along with psychological and relational learning and healing. The application of psychedelics seems to potentiate cognitive, emotional, and behavioral change and help psychotherapy to be more effective (Cavarra et al., 2022;Grunder et al., 2024;Nayak & Johnson, 2021). Additionally, like most psychotherapies, PAT is a relational intervention. There is emerging evidence, consistent with the body of evidence in the psychotherapy literature, suggesting that the quality of the relationship between PAT therapists and patients is critically important for the success of the treatment (Levin et al., 2024;Murphy et al., 2022;Zeifman et al., 2024). The emotional impact of the real relationship developed between therapists and patients is crucial to the patient's healing, not a perfunctory safety protocol nor a peripheral afterthought.We champion the essential role of psychotherapy within the arc of PAT in helping patients attain meaningful relief from their psychological distress, and we encourage a rigorous scientific examination of which types and doses of therapy may optimize the delivery of PAT.Commented [JZ1]: This word was erroneously included in the title of the article, as it was "auto-read" as being part of the title. I am deleting it here and it should not be included in the title of the paper.While some researchers support the necessary inclusion of psychotherapy within PAT (Cavarra et al., 2022;Deckel et al., 2024;Earleywine et al., 2024;Schenberg et al., 2024), others have made a case for not including psychotherapy as a component of psychedelic administration. Goodwin et al. (2023) advance this argument, stating that there is minimal evidence to confirm the belief that PAT is a truly combined treatment and a form of enhanced or catalyzed psychotherapy. They suggest that psychedelic administration, with some psychological support for safety, is often all that is necessary to produce meaningful change for many patients suffering from serious mental health conditions, and this configuration should be the general context in which we study the effects of psychedelic administration on psychosocial health.They first claim the type of psychotherapy used in some PAT trials has been nondirective counseling, and that nondirective counseling is not an evidence-based treatment for conditions targeted by PAT, including treatment-resistant depression, PTSD, and substance use disorders. Our perspective is that PAT is not an la carte platter, in which the "best" treatment is constructed by extracting elements of other effective non-psychedelic treatments (like evidence-based psychotherapies) and forcing them into the framework of PAT. Rather than cobbling together specific ingredients to produce an evidence-based treatment package, we advocate for the examination of which therapies are most efficacious when delivered in concert with psychedelic administration and applied in a PAT setting. If there is preliminary evidence that administration of psychedelics with psychological support could help treat a psychiatric condition, how might it further improve the outcome of psychedelic administration to pair it with thoughtfully-selected psychotherapy approaches, principles, or techniques that are understood to be efficacious? We will not know unless we study this phenomenon. As stated by Earleywine et al. (2024), "only data can answer this question. A clinical trial could compare groups with and without extensive preparation and integration." The s

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  • Psychedelics enhance psychotherapeutic outcomes by facilitating cognitive, emotional, and behavioral transformations.

    “Psychedelics have been shown to enhance psychotherapeutic outcomes by facilitating cognitive, emotional, and behavioral transformations (103, 106, 127).”

    From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [103]

    The Introduction says psychedelic use “seems to potentiate cognitive, emotional, and behavioral change” and help psychotherapy become more effective. That supports the proposed mechanism and outcome, but the citing sentence’s “have been shown” states the conclusion more firmly than this passage does. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • The flexibility of psychoanalytic therapy makes it particularly compatible with psychedelics, whose effects are often unpredictable and require therapists to adapt to patients' evolving processes.

    “This flexibility makes it particularly compatible with psychedelics, whose effects are often unpredictable and require therapists to adapt to patients’ evolving processes (103).”

    From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [103]

    In “What type of therapy should accompany PAT?” (page unavailable), the paper says psychedelic sessions are often difficult to predict and therapists must remain open to patients’ processes. It describes flexibility as important in psychotherapy generally, but does not specifically identify psychoanalytic therapy as particularly compatible with psychedelics. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • The role of psychotherapy in psychedelic treatment remains a subject of debate.

    “The role of psychotherapy in psychedelic treatment remains a subject of debate (103).”

    From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [103]

  • PAT is inherently relational, in keeping with psychoanalytic therapy's emphasis on therapist-patient dynamic.

    “Zamaria et al. (103) describe PAT as inherently relational, which is in keeping with the contemporary ethos of psychoanalytic therapy, where the importance of the therapist-patient dynamic helps facilitate change.”

    From Psychoanalytically informed MDMA-assisted therapy for pathological narcissism: a novel theoretical approach (2025) · cites this paper as [103]

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Research works printed but not linked: 1

  1. Lambert, 2013, “The efficacy and effectiveness of psychotherapy,”, 169

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Authors
Zamaria, J. A., Fernandes-Osterhold, G., Shedler, J., & Yehuda, R.
Affiliations
  • University of California, San Francisco (US)
  • Icahn School of Medicine at Mount Sinai (US)
Corresponding author
Zamaria, Joseph A.
ORCID
Venue
Frontiers in Psychology
Publisher
Frontiers Media SA
Published
2025-02-05
Volume
16
Pages
1505894-1505894
ISSN
1664-1078 (ISSN-L)
DOI
10.3389/fpsyg.2025.1505894
PMC
PMC11835864
OpenAlex
W4407181198
Semantic Scholar
7ef361af345c4d2f4daff8f02ced34004ff09bf0
Cited by
29
References
23
Citations by year
2026: 20 · 2025: 9
FWCI
26.45
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Psychology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Psychedelics and Drug Studies
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Health › Religion, Spirituality, and Psychology
Keywords
psychedelic therapy, psychotherapy, MDMA-assisted psychotherapy, psilocybin-assisted therapy, therapeutic relationship, combined psychotherapy and pharmacotherapy

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