Psychedelic medicines are well known to catalyze profound encounters with mystical or spiritual content (Griffiths et al., 2006; Breeksema et al., 2020; Podrebarac et al., 2021) and existential concerns, such as mortality (Swift et al., 2017), alienation (Watts et al., 2017), or questions of life meaning (Ross et al., 2016, 2021; Belser et al., 2017). This is perhaps not surprising, given the historical and current use of psychedelic plants and fungi in the religious practices of many cultures worldwide (Schultes et al., 2001). Several PAP clinical trials have found that participants often report profound experiences of an existential or spiritual nature (Johnson et al., 2014; Bogenschutz et al., 2015; Belser et al., 2017; Podrebarac et al., 2021) that may hold enduring significance for them (Griffiths et al., 2006). The potency of participants’ mystical experiences has been found to correlate with a range of treatment benefits, including reductions in symptoms of depression (Davis et al., 2021) and treatment-resistant depression (Roseman et al., 2018), increased motivation to stop problematic cocaine use (Dakwar et al., 2014), decreases in cancer-related depression and anxiety (Griffiths et al., 2016; Ross et al., 2016), greater success in nicotine cessation (Johnson et al., 2014), and other positive changes in psychological functioning (Griffiths et al., 2018). Despite calls for further elucidation of specific therapeutic mechanisms in this domain (Roseman et al., 2018; Breeksema and van Elk, 2021; Jylkkä, 2021; Sanders and Zijlmans, 2021), existential and spiritual elements of PAP warrant recognition as potential sources of treatment benefit (Johnson et al., 2019).

The current state of our knowledge suggests that anti-depressive outcomes may be facilitated simply by having a mystical experience during a medicine session (Roseman et al., 2018; Davis et al., 2021). However, providing support for a participant’s post-medicine spiritual self-development may contribute additional benefit, as suggested by prior PAP research (Griffiths et al., 2018; Lafrance et al., 2021) and non-psychedelic findings of negative correlations between spirituality and depressive symptoms (Koenig, 2009; Bonelli et al., 2012). The role of EMBARK therapists treating MDD by way of this domain is thus to create the conditions for mystical or spiritual phenomena to potentially arise and to support participants in using them as an impetus for spiritual growth. In the preparation phase, therapists assess for any intrinsic motivation a participant may have to bring existential-spiritual elements into their treatment and work with them in developing this motivation into their intentions for the medicine session. For the medicine session, therapists prepare the physical treatment space in a way that demonstrates respect for the subjective sense of sacredness that may arise for the participant and open the session with a brief, collaboratively designed ritual. If phenomena in this domain arise during the medicine session, therapists are invited to use supportive psychotherapy or evidence-based interventions of their preference during the integration phase to explore the participant’s experience, support them in developing a sense of what actions it could motivate, and co-create plans for life changes and/or further spiritual self-development. Examples of approaches with evidentiary bases to use in this process include meaning-oriented psychotherapies (Vos et al., 2015), Logotherapy (Thir and Batthyány, 2016), or Spiritual Guidance (Miller et al., 2008), which is derived from the evidence-based approach of MI (Riper et al., 2014), despite not being an EBT itself. Throughout all phases, therapists are taught to attend to their own biases and beliefs in order to avoid imposing their own understanding or interpretation on a participant’s experience in this domain.

This domain refers to treatment events that result in the participant becoming more capable of recognizing symptomatic internal states and responding to them with a greater capacity for self-compassion and self-regulation. Mindfulness in EMBARK has significant conceptual overlap with the notion of “psychological flexibility” that the ACE Model (Watts and Luoma, 2020) derives from ACT. In previous PAP trials, participants have often experienced various forms of disruption of their habitual self (Belser et al., 2017; Roseman et al., 2018), a sense of “mental freedom” (Watts and Luoma, 2020, p. 95), or an increased feeling of sovereignty in how one relates to the workings of their own mind (Bogenschutz et al., 2018). Overall, the “M” domain represents a place in EMBARK for preparing the participant to attend to their thoughts and feelings with compassion during a medicine session and for working with increases in psychological flexibility and other metacognitive shifts during integration.

In the treatment of MDD, mindfulness has been found helpful in disrupting ruminative thought patterns (Watkins, 2016), enabling more cognitive flexibility (Kohtala et al., 2018; Shapero et al., 2018), and fostering a more compassionate stance toward oneself (Segal et al., 2012). To support these outcomes, EMBARK therapists begin a course of PAP treatment for MDD by teaching basic mindfulness skills to the participant. This teaching is only meant to ensure that the participant knows how to attend to their internal experience during the medicine session, which is when a more enduringly increased capacity for mindfulness may arise. During the integration phase, therapists help to anchor whatever aspect of mindfulness arose for the participant through the use of indication-specific mindfulness practices. Therapists may also help the participant integrate a new feeling of self-compassion or support them in using the momentary abatement of ruminative thoughts as an opportunity to develop mindfulness-based skills that may prevent a recurrence. Therapists can use their own mindfulness-based interventions within the bounds of the guidelines provided, or they can use suggested interventions drawn from Rumination-Focused CBT (RF-CBT; Watkins, 2016) and Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2012) included in the treatment manual. At all times, therapists are taught to work with the participant in this domain within a trauma-informed approach to mindfulness and to avoid imposing one’s own beliefs or biases onto the participant’s experience.

As discussed earlier, PAP participants have reported that embodied phenomena are a notable part of their experience of a medicine session. There are few EBTs that provide support in conceptualizing or responding to these phenomena, though innovative somatic psychotherapy approaches have offered suggestions (Levine, 1997; Grabbe and Miller-Karas, 2017). EMBARK therapists are prepared to respond to embodied treatment events using the most widely accepted elements of these novel somatic approaches, such as “pendulation,” or the process of helping a participant alternate between active, embodied engagement with trauma material and self-soothing (Grabbe and Miller-Karas, 2017). EMBARK also encourages integration of somatic elements from more established EBTs, such as somatic awareness training exercises and self-regulation skills from MBRP or Dialectical Behavioral Therapy (DBT; Linehan, 2014) to support therapeutic outcomes in this domain.

Importantly, the techniques used by EMBARK therapists in this domain do not require them to work with the body in an intensive, hands-on way and are thus not prohibitively far beyond their standard psychotherapeutic training. In preparation, therapists train the participant in basic somatic awareness so that they can attend to and thereby facilitate pro-therapeutic bodily phenomena during the medicine session. Once the medicine is administered, the therapists’ role is to guide the participant back toward an awareness of their body when clinically indicated and help them remain within their zone of optimal arousal through the use of the self-soothing interventions discussed earlier or therapist-participant touch-based interventions.

While some have asserted the importance of therapist-participant touch in PAP (Mithoefer et al., 2017; McLane et al., 2021) based on historical assertions by authorities in the field (e.g., Martin, 1957; Eisner, 1967), others have noted that there remains a lack of knowledge or consensus around the efficacy, safety, or necessity of therapist-participant touch in PAP (Devenot et al., 2022). EMBARK therapists are thus instructed to prioritize non-touch interventions and limit their touch-based interventions to basic supportive touch that minimizes points of contact between parties, like handholding or placing a hand on a participant’s shoulder to convey support or offer grounding. More intensive forms of touch (e.g., full-body embraces) are omitted until further research establishes them as safe, effective interventions. Therapists also rigorously assess for the participant’s consent to touch-based interventions during preparation and proactively give participants a chance to reject any form of touch during preparation, immediately before the provision of touch in the medicine session, and at any time during the touch, so as not to move beyond the participant’s espoused level of comfort.

Since most interventions in this domain involve supporting the participant in mindfully attending to their body, the “B” domain shares some practical overlap with the “M” domain. The primary distinction between the Body aware and Mindfulness domains is found less in their associated interventions than in participants’ subjective experiences of how benefits arise and the integration goals that best support these benefits. Body aware treatment goals follow from medicine session events that a participant locates in their body (e.g., “I saw the [pain in my chest] […] then I felt so much lighter, like something had been released,” Watts and Luoma, 2020, p. 95) and involve integration practices that work with shifts in somatic awareness. Treatment goals in the Mindfulness domain involve benefits that adhere more closely to the core concepts of psychological flexibility and other metacognitive shifts (“I got a wider perspective […] that there’s a lot more going on than just the minor things that were going on in my head,” Watts and Luoma, 2020, p. 96) and are sustained with practices that build upon a participant’s revised relationship with the contents of their mind.

In the treatment of MDD, somatic phenomena are hypothesized to contribute to therapeutic outcomes in two ways. Depressive symptoms are notable for their disturbance of embodiment (e.g., fatigue or energy loss, disruptions of sleep and appetite, weight gain or loss). It has been suggested (Ratcliffe, 2015; Doerr-Zegers et al., 2017; Rønberg, 2019) that disruptions of one’s lived experience of their body are the most fundamental and cross-culturally consistent MDD phenomena. As such, the experiences of enlivenment and sensory embodiment that some PAP participants describe (Watts et al., 2017) may form the basis for a relationship with one’s body that opposes the recurrence of depressive symptoms. If such an experience arises for a participant, therapists may work with them to build and strengthen this new relationship.

Additionally, it is likely that treating MDD will often involve working with trauma. The comorbidity and symptomology of MDD and trauma has been posited as evidence that many cases of MDD can be meaningfully thought of as a subtype of PTSD characterized by an internalizing response to trauma (Flory and Yehuda, 2015). Although classic psychedelics have not yet been used to address trauma in a completed clinical trial, it has been suggested (Bird et al., 2021) that the disinhibiting effect of psilocybin on frontal-limbic neural circuits of emotional regulation are similar to those of MDMA, which has more established efficacy in treating trauma (Bahji et al., 2020; Illingworth et al., 2021; Smith et al., 2022). Classic psychedelics may thus have facility in trauma treatment by way of similar disinhibitory mechanisms. It is likely that PAP treatment of MDD with a classic psychedelic will sometimes facilitate the appearance of trauma symptoms, possibly in the form of the somatic phenomena described earlier (nausea, shaking, etc.). When this occurs, a skillful therapeutic response may facilitate lasting resolution.

During a medicine session, some PAP participants experience dramatic shifts in their emotions and cognition. Participants have often reported that they experience a degree of emotionality that is ordinarily unavailable to them, including feelings of bliss, love, despair, fear, and grief, often in the context of a healing catharsis (Belser et al., 2017; Watts et al., 2017; Breeksema et al., 2020). They may also find themselves confronting maladaptive self-beliefs with a directness they would normally avoid (Bogenschutz et al., 2018). Engaging non-defensively with these emotions and beliefs during a medicine session has become a widely accepted practice among PAP models. This practice mirrors that found in several non-psychedelic EBTs, such as ACT’s emphasis on acceptance (Hayes et al., 2012) and Emotion-Focused Therapy’s (EFT; Greenberg and Watson, 2006) emphasis on entering into maladaptive states in service of transformation. This domain serves as a space within EMBARK for incorporating approach-oriented practices for working with emotions and self-beliefs in way that best addresses the indication being studied.

For example, the EMBARK approach to MDD in this domain begins with the notion that many depressed individuals have developed a habitual response to challenging feelings that entails dimming their awareness of them through a kind of automatic, unconscious avoidance and characteristic depressive experience of feeling numb and withdrawn (Tull et al., 2004). Participants in PAP medicine sessions have often experienced a greater facility in reconnecting with this avoided material and have implicated these experiences in their positive treatment outcomes (Gasser et al., 2015; Watts et al., 2017; Bogenschutz et al., 2018; Watts and Luoma, 2020). In the preparation phase of MDD treatment, EMBARK therapists are tasked with helping participants understand the importance of adopting an approach orientation during the medicine session. They also help the participants develop one or more self-soothing techniques. During the medicine session, the therapists’ role is to remind the participant to welcome challenging content if needed and to help them utilize the previously learned self-soothing techniques when necessary. To integrate these experiences, EMBARK therapists help participants use experiences of approaching challenging material as the basis for updating maladaptive core beliefs about oneself or the world and cultivating an enduring attitude of greater acceptance in their emotional life. All of these interventions are taught and employed in a way that is respectful of participant autonomy, the principles of trauma-informed care, and cultural differences in relating to and expressing one’s emotions.

As noted earlier, practitioner-participant interactions are often significant events in medicine sessions that have yet to be adequately characterized by other PAP models. These interactions may be home to amplified versions of dynamics that are typically found in any relational form of psychotherapy, including transferences, projection, or reenactments of traumatizing dynamics or events. As in talk therapy, the appearance of these phenomena represents an opportunity for clinical gain if handled skillfully or rupture and harm if handled poorly. EMBARK therapists are thus trained to work ethically and efficaciously in this domain through the didactic and experiential processes discussed later under the Ethically rigorous care cornerstone.

In the treatment of MDD, these relational events are framed as potential moments of relational repatterning that may reduce depressive symptoms. A core element of depression is social isolation, both actual and felt (Meltzer et al., 2013; Morrison and Smith, 2018). This isolation may derive from patterns or beliefs learned in early life relationships, such as a sense that one is unacceptable, deserves to be alone, or may lose love if they express themselves freely in the presence of another person. The altered relational dynamics of a PAP medicine session may provide opportunities for relational repatterning that supplants these maladaptive beliefs. EMBARK therapists are also prepared to support relational benefits that may arise for the participant outside of their interactions with the therapists, such as an internally felt sense of social connectedness or emotional empathy (Pokorny et al., 2017; Carhart-Harris et al., 2018b) or an autobiographical review process that examines past and present relationships in the participant’s life (Belser et al., 2017; Watts et al., 2017). If these shifts in social cognition occur and are skillfully worked with in the integration phase, a depressed participant can be helped to use them as the grounds for a less isolative social life.

A course of PAP treatment is brief, and its most enduring benefits have been conceptualized as those that continue to unfold well beyond the final session (Mithoefer et al., 2017; Dölen and Briggs, 2021). PAP participants often emerge from a medicine session with a sharp uptick in the sense of motivation, self-efficacy, and commitment to making pro-therapeutic changes to their behavior or life context (Bogenschutz et al., 2018; Griffiths et al., 2018; Nielson et al., 2018). Some may also develop a clarified sense of their deeply held values, which may form the basis for beneficial post-treatment actions (Watts and Luoma, 2020). At the neural level, it has been suggested that the plasticity brought about by many psychedelic medicines may signal the reopening of a social reward critical learning period for weeks after administration, suggesting that pro-therapeutic changes may take root during a time period that extends beyond the end of what is typically considered integration (Nardou et al., 2019; Dölen, 2021; Dölen and Briggs, 2021; Lepow et al., 2021). The EMBARK approach recognizes this unique opportunity. Therapists are trained to support a participant’s movement from the setting of intentions to the planning of concrete actions by attending to importance of post-treatment changes throughout all stages of PAP treatment.

For MDD or any other indication under study, these changes are expected to look very different for each participant. EMBARK therapists are trained to apply a broad lens to what helpful post-treatment change might look like. For some participants, the most supportive change may be at the level of personal behaviors, such as problem drinking or procrastination. For others, change may be warranted in their personal contexts, such as relationships or work environments. Some participants may find additional benefit in taking aim at collective concerns that have a bearing on their life, such as structural racism or exploitative work conditions, through participation in collective organizing. The EMBARK approach recognizes the potential of both individual and collective forms of change in the service of enhancing a participant’s psychological, spiritual, and social wellbeing.

This cornerstone reflects a recognition of the prevalence of trauma likely to be found in PAP clinical trial participants. Moreover, it marks the need for greater attentiveness to the unique and sensitive ways that trauma may manifest in PAP medicine sessions and the potential for retraumatization that may occur in the absence of adequate training. Therapists trained in the EMBARK approach are provided with psychedelic-specific training in how to identify and respond to trauma when it arises, ways to avoid re-traumatization, and strategies for maintaining their own wellbeing in service of sustainably supporting participants.

Marcela Ot’alora G., MA, LPC, contributed her approach to trauma-informed care to the EMBARK training program. Her training materials applied the Substance Abuse and Mental Health Services Administration’s (2014) SAMHSA six key principles of trauma-informed care (safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; cultural, historical, and gender issues) to PAP treatment, along with the additional principles of choice and autonomy. These principles were discussed in conjunction with important practical considerations and attention to ways in which therapists may unwittingly cause harm to participants who carry trauma. EMBARK manuals emphasize these principles and considerations throughout treatment, with particular attention paid to ensuring that any exercises that invite the participant to focus inwards (e.g., mindfulness, somatic awareness) are conducted in a way that is sensitive to the needs of those with trauma.

The field of mental health has reached a consensus that the ability to provide care to those who differ from their therapist in terms of race, culture, gender, sexual orientation, or class is an essential part of delivering effective treatment (American Psychological Association, 2017). However, training therapists to consider these factors when treating those who are culturally different has often lagged behind this realization. This has been particularly true in clinical PAP trials, which have received much scrutiny for not recognizing the importance of cultural considerations (Herzberg and Butler, 2019; George et al., 2020; Williams et al., 2020; Fogg et al., 2021). While an appropriate response to these concerns would entail structural and cultural changes in the field of PAP research that go beyond therapist training, EMBARK training was designed to minimize iatrogenic harm by helping therapists to engage in culturally humble and attuned ways that avoid replicating oppressive dynamics in the therapist-participant relationship.

NiCole T. Buchanan, Ph.D., has led the training module on this cornerstone. She has provided materials for therapists on a variety of areas pertaining to cultural competence in clinical work: privilege, power, implicit bias, awareness of one’s social position, concerns around language and non-verbal communication, cultural influences on the expression of emotions and disclosure of struggles, norms around touch and relationships, use of the DSM-V Cultural Formulation Interview (American Psychiatric Association, 2013), the adoption of an anti-oppressive advocacy approach to the role of therapist (Ali and Lees, 2013), and more. Psychedelic-specific topics that she addressed in this module include the influence of the War on Drugs on People of Color seeking psychedelic treatment, responding competently to intergenerational and collective content that arises in medicine sessions (e.g., cultural grief), and considering cultural appropriation in music selection. Attentiveness to these topics have been incorporated into EMBARK manuals’ approaches to PAP treatment.

As noted earlier, PAP treatment presents unique ethical challenges that, if mishandled, could lead to boundary transgressions that do considerable harm to participants. EMBARK responds to this heightened potential for relational harm by interweaving ethical considerations and training into many aspects of its approach, including the guidelines it offers for therapist interventions. EMBARK therapists are also supported in their own ethical self-reflection and growth through ongoing supervision, participation in peer consultation groups, and other practices that aim to enhance their ethicality, as therapists’ own self-reflection and growth is central to their capacity to engage with participants in ethically grounded ways. The model also recognizes the importance of organization-wide commitments to preventing and responding to boundary transgressions with integrity and encourages those who employ EMBARK to adopt such commitments.

Kylea Taylor, MS, LMFT, has taught this module in the EMBARK training. She presented therapists with techniques for attending to how their personal material may be activated by the unique demands of PAP work. Her didactics touched on considerations around touch, multiple relationship, power differentials, suggestibility, and other psychedelic-relevant topics not adequately covered by therapists’ standard ethical training. Attentiveness to these elements is also written into EMBARK manuals’ instructions on setting relational boundaries, being mindful of and proactively discussing relational dynamics with participants, assessing consent for touch, and other ethical practices. Suggested practices for continued ethical development are discussed in an appendix found in all manuals as well.

The underlying causes of the struggles and symptoms that bring PAP participants into treatment are not always entirely locatable in the personal and biological conditions of their lives. The fields of medicine and psychology have become increasingly attentive to the fact that the micro-level conditions they treat are heavily influenced by the macro-level or structural conditions of the society in which participants live (Ali and Sichel, 2014). These societal factors include discrimination built into governing institutions (e.g., legal systems, policing), inequities in access to resources (e.g., housing, medical care, work, social services), structural deficits in community cohesion and mutual support, and systemic inattentiveness to those with increased needs (e.g., those with disabilities, the elderly). EMBARK therapists are trained to attend to structural factors in their work and are offered recommendations on how they can broaden their sense of their role and become more holistic advocates for the participants they have committed to serve. Additionally, the model recognizes that much of the onus for collective care falls upon the organizations that employ it and thus encourages any groups who use EMBARK to commit resources to addressing structural concerns relevant to the populations they serve.

Florie St. Aime, LCSW, led the EMBARK training in this cornerstone. She facilitated an exploration of psychotherapy and PAP’s situatedness within deeply engrained systems of domination, anthropocentrism, and historical inequities, with a focus on the implications this has for how suffering is treated in PAP clinical trials. Her presentation also focused on historical and ancestral dimensions that may arise in PAP and what it would mean to respond to them with more collective notions of care. In the EMBARK manuals, this cornerstone shows up most notably in the integration phase, which holds that pro-therapeutic, post-treatment change at the personal level can be most supportive to participants when it occurs in conjunction with changes to the broader structural context of their lives.

All EMBARK protocols developed so far have included three preparation sessions leading up to each medicine session, though this may change if called for by the indication under study. The therapists’ general aims for this phase have included building rapport and trust, learning about the participant’s experience of their mental health challenges, explaining basic elements of PAP treatment and what to expect from the medicine session, providing preparatory instructions about diet and aftercare, and responding to participant questions about PAP treatment.

Therapists are also given domain-specific tasks in the preparation phase (see Figure 1), which may vary across protocols in response to the specific proposed mechanisms of change for the clinical indication under study. These tasks lay the groundwork for the participant to receive benefit within whichever of the six domains become important for them during the medicine and integration phases. It is considered important to prepare every participant for potential benefit across all six domains because EMBARK therapists make no determination before the medicine session about which domains may or may not become relevant later in treatment, despite any prediction or wish held by them or the participant during this phase. Even if a participant frames their MDD in, for example, primarily spiritual terms and expresses a desire to address their symptoms within a spiritual framing, it is still very possible that treatment benefits will occur for them in other domains, in addition to or instead of the “E” domain, if they are properly prepared. During preparation, the participant’s lived experience of their symptoms and their functional significance are assessed, but no attempt is made by therapists to use this information to focus the participant’s treatment on a specific subset of psychedelic-induced phenomena during the medicine session. However, this information is taken into consideration later during the integration phase when deciding what integration goals would be most supportive.

Since it is unknown during the preparation phase which domains and domain-associated mechanisms of change will be most relevant to the specific participant, therapists’ role in this phase tends to be more standardized than it is in later phases. However, while preparation tasks are fixed in their intent, therapists are invited to bring in interventions from their preferred clinical orientation(s), as long as they conform to the guidelines that ensure that the intended utility of each task is conferred to the participant. For example, therapists tasked with teaching basic mindfulness skills to a participant may do so using mindfulness-based tools from ACT, DBT, other mindfulness-based EBTs, or a meditative spiritual tradition, provided that the tool meets the following criteria set forth in the EMBARK manual: (1) it invites the participant to cultivate a receptive, attentive state, (2) does not contain elements that could potentially clash with a participant’s religious beliefs, (3) and abides by trauma-informed practices detailed in the manual. The manual also provides example interventions for therapists who do not have relevant expertise to bring in for any given task.

Ethical considerations based on the four care cornerstones are woven throughout the guidelines set forth for therapist interventions. For example, the guidelines for the discussion of therapist-participant dynamics requires that it include an exploration of cultural dynamics, in line with the cornerstone of culturally competent care.

At the outset of a medicine session, the therapists maintain an agnosticism about which benefits and which domains will ultimately become most salient for a participant, much as they did in the preparation phase. The pre-dosing therapist tasks (see Figure 1) thus serve a similar purpose to the tasks in the preparation phase in that they set the stage for phenomena in any domain to arise and bring the potential for benefit. These stage-setting tasks are woven together into a suggested pre-dosing agenda for the medicine phase that includes a collaborative ritual (E), a check-in about intentions (K), and a brief somatic awareness practice (B). The six EMBARK domains thus continue to serve therapists as a conceptual frame for laying the groundwork for a broad variety of pro-therapeutic outcomes.

However, once a psychedelic medicine is administered, the therapists’ role becomes more responsive to the specific situation and less about a domain-agnostic approach to preparation. At this point, the course of a participant’s treatment starts to come into focus, and specific EMBARK domains present themselves as more pertinent to the participant’s experience of the medicine. EMBARK’s six-domain framework comes to serve therapists in a new way as a practical rubric for helping them to characterize in-session events and determine what domain-specific interventions these events might call for. For example, if they observe the participant experiencing what they identify as a somatic trauma process, they can recall the training they received in the Body aware domain, and apply the interventions associated with it. Support in identifying and responding to these events is provided in the EMBARK training program (see later section) and in each indication-specific EMBARK manual.

The value of organizing the preparation work by domains becomes clear during this phase, as many of the responsive interventions applied in a particular domain will draw upon work that was conducted with the participant during the preparation phase in that same domain. For example, a reminder to “move toward” challenging emotional material will draw from preparatory psychoeducation provided in the Affective-cognitive domain, or a reminder to use a somatic self-soothing technique in response to intense somatic events will rely on what was taught during preparation in the Body aware domain. Therapists’ incorporation of their own favored interventions during the preparation phase also ensures that they will be working squarely within their competence during this more unpredictable phase as well.

At this point, the therapists and participant are likely to have a strong sense of the most beneficial direction for a participant’s continued therapeutic progress. During the first debrief session, all parties collaboratively determine what treatment goals might be best to work toward in integration. This process entails (1) debriefing and supporting the participant’s sense of what transpired in the medicine session, (2) relating material that arose in the medicine session to their symptoms and treatment goals, (3) collaboratively identifying new attitudes, beliefs, behaviors, values, or other subjective shifts that may contribute to symptom reduction, and (4) planning post-treatment changes that may support and sustain this outcome.

A set of suggested integration goals are provided in each indication-specific manual, along with guidelines and suggestions for working toward each of these goals. These goals are organized by domain to provide continuity with events that arose in the medicine session. Together, therapists and participants choose a subset of these goals, or develop their own, as long as they are based on a clear clinical rationale. This selection process is guided primarily by what transpired in the medicine session using a tool provided in each EMBARK manual (see Figure 3). For instance, a participant who had an experience that they identify as spiritual may benefit from support in advancing their spiritual self-development or spiritual practices (E), or a participant who had a strong emotional opening might be best served by continued processing and reflection that may lead to revised core beliefs or a sustained movement away from emotional avoidance (A). However, the selection process is also informed by the participant’s previously stated intentions for treatment and the functional meanings of their symptoms. For instance, if a depressed participant initially framed their suffering in terms of loneliness and set an intention of understanding their isolation, it might benefit them to consider goals in the Relational domain, even if nothing observable transpired in that domain during the medicine session.

All integration goals are framed in terms of three possible spheres of change: individual behavior, personal context, and broader context. Individual behavior changes may include stopping a maladaptive behavior, changing an old behavior, or adopting a new practice. Personal context changes may include updates to social, vocational, or physical contexts that support treatment benefit, such as moving away from a social circle that encourages problem drinking or moving into a vocational field more congruent with one’s revised personal values. The broader context refers to structural, cultural, or economic conditions that have real, mental health consequences for the individual. Participants who decide that change at this level would be supportive for them may benefit from taking collective action (e.g., community activism, labor organizing) that addresses broader conditions in a way that feels congruent with their revised values or sense of self and/or serve as a form of socialization or behavioral activation. This may have acute benefit for them (Fang et al., 2018; Hayhurst et al., 2019; Hui et al., 2020) while also contributing to the amelioration the conditions that had engendered or exacerbated their distress in the first place (e.g., exploitative work conditions). Participants and therapists determine together which of the three spheres might be appropriate foci for post-treatment changes that support participant wellbeing.

The number of integration sessions is left to the discretion of the group employing EMBARK, though all EMBARK manuals written to date have included a standard of three integration sessions per medicine session. It is suggested that, whatever the intended number may be, therapists and participants both use their judgment to determine if additional sessions would be supportive of the participant’s wellbeing and to undergo these sessions whenever possible. Otherwise, therapists working within the EMBARK approach are required to be prepared to make appropriate outside referrals if a participant requires ongoing therapeutic support. While EMBARK was designed to support short-term PAP interventions in clinical trial settings, its authors recognize the crucial importance of aftercare (Watts, 2022) and urge any organization adopting the EMBARK model to recognize the intensive nature of PAP treatment and ensure that participants’ wellbeing is properly supported after their participation in the trial.