Classic psychedelics, such as 5-HT2a partial agonist psilocybin, are being tested for their potential therapeutic effects. Psilocybin is well-tolerated in clinical settings in which precautions have been taken to screen out participants who might have medical or psychological contraindications and where clinicians are available to provide support (Johnson et al., 2008). In general, the risks of toxicity and addiction are comparatively low with psilocybin compared to other recreational psychoactive substances (Johnson et al., 2008; Nichols, 2016), though there are risks to psychedelic use in general which are increased in recreational settings (Carbonaro et al., 2016). Clinical trials have demonstrated the therapeutic potential of psilocybin on both mood (Carhart-Harris et al., 2016, 2021; Griffiths et al., 2016; Ross et al., 2016; Davis et al., 2021) and substance use disorders (Johnson et al., 2014; Bogenschutz et al., 2015). Further safety and effectiveness trials are needed (Yaden et al., 2021d), but it is possible that psilocybin (and perhaps other classic psychedelics) will be approved for clinical use in the next few years. While current psychotherapeutic and pharmacological treatments are effective, additional treatment options are needed for those suffering from mood and substance use disorders.

Classic psychedelics present a number of challenges and opportunities in terms of their clinical application. Importantly, the acute subjective effects of classic psychedelics such as psilocybin are highly responsive to one’s expectations and physical/social surroundings (referred to as “set and setting”; Hartogsohn, 2016). This raises the question—-what psychotherapeutic paradigm(s) should most inform the administration of classic psychedelics such as psilocybin?

In this article, we review several historical, sociological influences on the development of contemporary classic psychedelic administration in mainstream healthcare and clinical research settings in European and American cultural contexts. Specifically, we briefly review indigenous practices, new age spirituality, psychodynamic/psychoanalytic approaches, and cognitive-behavioral approaches. After succinctly evaluating each of these and pointing to several issues with each (although extensive analyses of these paradigms goes beyond the scope of the present article), we focus on cognitive-behavioral therapy (CBT) approaches in more detail (also see Walsh and Thiessen, 2018; Luoma et al., 2019) and suggest that these approaches have the most evidence and rationale for serving as a default therapeutic paradigm to combine with psychedelic treatments in contemporary healthcare contexts. While much of what we discuss will apply to other psychoactive substances (e.g., MDMA, ketamine, DMT, etc.), we focus our discussion on classic psychedelics such as LSD and psilocybin. Lastly, we provide a sampling of concepts from CBT approaches, particularly from so-called “third wave” CBT, that we think can usefully inform the preparation, session, and integration phases of psychedelic-assisted psychotherapy.

Historically, psychedelics appear to have been ingested in a number of regions across a wide range of cultures for hundreds or even thousands of years (Schultes, 1969; Miller, 2019). The available archeological and anthropological evidence suggests that psychedelics have often been used in ritual settings (and they still are, as discussed below), generally accompanied by the invocation of a society’s religious worldviews by a religious leader (e.g., see Miller, 2019). We refer to this approach as “indigenous practices” as this is the term that has been used most by others in contemporary discourse, although we acknowledge that some may object to the use of the term indigenous term in this context. There are a number of contemporary religious traditions, such as the Peyote Church, in which psychedelic substances are ritually ingested. People who engage in these religious practices have a history of being oppressed by colonialists and in more recent eras by prohibition (e.g., see George et al., 2020).

Some have called for more integration of indigenous practices in contemporary, mainstream psychotherapeutic settings using psychedelics (e.g., Winkelman, 2007). The rationale for this view is that some religious practices may have been honed for many decades in order to maximize the beneficial effects of psychedelics. Proponents of this view might suggest that we ignore practices that have been developed over generations at our peril, as such practices could perhaps benefit participants and patients in contemporary healthcare settings.

We agree that such indigenous contexts should be studied, but we see problems with the view that such practices should be incorporated in secular clinical settings. First and foremost, it could be offensive to decontextualize certain kinds of religious practices and transplant them into secular clinical settings. These practices are usually overseen by elders and traditional healers (Portman and Garrett, 2006) and an abundance of literature urges mental health practitioners to partner with these members of indigenous tribes and nations (Dufrene and Coleman, 1992; King, 2008; Gone, 2010; Trimble, 2010). This could be regarded as a case of cultural appropriation, as there is a power differential and potential to profit from adopting such practices in secular healthcare settings. Thus, there are important moral considerations that would seem to largely or entirely prevent drawing from indigenous practices and requisitioning them for use in contemporary healthcare settings. Additionally, such practices have not been empirically evaluated in clinical settings, so their safety and effectiveness are mostly unknown, particularly for individuals who do not share in the worldview associated with such practices. Therefore, applying such practices with the bulk of participants likely to receive treatment in mainstream clinical settings could put participants and patients at increased risk.

Of course, if a participant or patient already held these beliefs and chose to interpret their personal experience accordingly (see Graziosi et al., 2021), the therapist should accept this as the patient’s worldview and support this participant without disagreeing or suggesting other metaphysical belief systems. As we will reiterate, therapists should not be promoting their own metaphysical belief system to patients (Moreira-Almeida et al., 2016; Johnson, 2020; Koenig et al., 2020; Yaden et al., in press, 2021a). Overall, we believe that treatment should be adapted to the cultural contexts and identities of those seeking treatment but that directly borrowing from indigenous traditions is not an appropriate means to do so for most patients or practitioners.

Before the current so-called “renaissance” of psychedelic research in the last decade or so, psychedelics were largely associated in the public and even among researchers with the 1960s (e.g., Pollan, 2019). During this period, psychedelics emerged from the laboratory and were adopted by various sub-cultures, including what has been called “new age spirituality” (e.g., Luhrmann, 2012). New age spirituality is a syncretism of various religions, perhaps especially Hinduism and Vedanta, and involves a set of flexibly defined highly personal beliefs. Such beliefs generally (but not necessarily) involve a divinity of some kind and persistence of consciousness after death (Yaden et al., 2021b). While there was a great deal of research conducted on psychedelics in laboratories all over the US during this period of time, the most high-profile research was conducted at Harvard by professors who were later fired or contract not renewed—Timothy Leary and Richard Alpert (Baumeister and Placidi, 1983). These two researchers explicitly mixed new age spiritual ideals into the therapeutic context in the hopes of enhancing the therapeutic effects of psychedelics (Lattin, 2010).

Some have called for more integration of new age spirituality in contemporary psychotherapeutic settings (e.g., Roberts, 2020). The rationale for this view is that beliefs involving a benevolent all-encompassing divinity that one might encounter and/or connect with appears intuitively likely to reduce the chance for a negative experience and could enhance the beneficial effects of psychedelics. There is in fact good evidence that people report experiences of this kind spontaneously (Yaden et al., 2017b; Griffiths et al., 2019; Davis et al., 2020b). However, the extent to which such experiences are the result of the intrinsic effects of psychedelic substances interacting with innate cognitive/perceptual systems or are culturally constructed from available beliefs and expectations is unknown (see Yaden et al., 2017a). To be clear, we see great potential in studying the interaction of psychedelics with beliefs and practices broadly construed as “spiritual.”

However, we see problems with integrating spiritual worldviews into psychedelic psychotherapy in clinical settings. First, there are serious ethical issues with a therapist imposing their own particular worldview (religious, spiritual, atheistic, or otherwise) on a participant or patient (see Johnson, 2020 for a discussion). Psychedelic substances appear to create a suggestable state (Carhart-Harris et al., 2015), which could put participants and patients in a vulnerable position (Johnson, 2020). Additionally, there has been little research on actively encouraging a spiritual framing of psychedelic experiences in therapeutic settings, which means that adopting such a therapeutic frame has unknown risks (see Johnson, 2020). From a secular clinical perspective, we simply have no expertise or knowledge of ground truth regarding metaphysical or religious questions, and the imposition of such content could be considered an epistemological harm (Letheby, 2021). As in the previous section, if a participant or patient holds such beliefs, choosing to engage with them before, during, or after their experience is entirely appropriate and is not the topic under discussion. This does not include the provision of knowledge or expertise but rather taking the patients lead and, for example, using reflective listening to help them process their thoughts and feelings. Here again we emphatically discourage the imposition of a belief-based therapeutic paradigm adopted by researchers and clinicians onto patients or study participants (see Moreira-Almeida et al., 2016; Koenig et al., 2020; Yaden et al., in press).

Psychedelics were generally not commented upon by the founders of the psychoanalytic movement (Sigmund Freud etc.—although Jung has a brief letter on this topic, see Jaffe, 2015), so the typical strategy of referencing and interpreting historical texts that often occurs in psychoanalytic circles is not as possible in this case. In general, psychoanalytic approaches postulate the existence of active unconscious forces or dynamics. Some contemporary researchers and clinicians have promoted the value of the psychoanalytic perspective in understanding psychedelic experience. For example, Carhart-Harris et al. (2014), claim that “scientific research with psychedelics has considerable potential for developing aspects of psychoanalytic theory.” Psychedelics are sometimes thought to reveal primary processes (unconscious functioning) in the same way that dreams do, which can then be interpreted by the analyst. Carhart-Harris et al. (2014) also quote Grof in saying: “The phenomenology of the psychodynamic experiences in LSD sessions is to a large extent in agreement with the basic concepts of classical psychoanalysis… Observations from LSD psychotherapy could be considered laboratory proof of the basic Freudian premises” (Grof, 1982).

Psychodynamic approaches generally involve less specific unconscious processes than psychoanalysis and refer to a wider range and more eclectic set of approaches than psychoanalysis (Wells, 1963; Eagle, 1984). Many forms of psychodynamic psychotherapy are commonly practiced in contemporary settings, and although their quality is highly variable, there is evidence for the effectiveness of many such approaches (Leichsenring and Steinert, 2017). In terms of psychedelic applications, the most prominent psychodynamic approach is that promoted by Grof (1977, 1980, 1982), which claims that the acute subjective effects of psychedelic substances can best be understood as a figurative and perhaps literal memory of being born (a view with Freudian roots). This “peri-natal theory” of psychedelic experience came to inform his preferred psychotherapeutic framing of psychedelic treatments and was highly influential in underground (i.e., illegal) psychedelic psychotherapy contexts.

At the present time, psychodynamic theory may be the most commonly utilized theory utilized by therapists conducting psychedelic psychotherapy, perhaps because it was ascendant at the time psychedelic therapy was developed and before research essentially stopped in the 1970s.

Furthermore, contemporary psychodynamic approaches conceptualize psychopathology in developmental, cultural, and temporal contexts in which a “persistent personality” navigates conflict and struggles via emotion-laden psychological defenses—understanding these dynamics is ultimately in the service of behavioral change (Fulmer, 2018). These defense mechanisms have been defined as “mental processes that operate unconsciously to reduce some painful emotion” (Paulhus et al., 1997, p. 543). This conceptualization may have been/be useful in approaching psychedelic experience, especially given the flexibility that this conceptualization provides and the intuitive nature of working with an “unconscious.” While sharing a context and goal with psychodynamic approaches, rather than unconscious processes, CBTs target empirically derived processes which are linked (through empirical evidence) to outcomes. As psychedelic therapy emerges from this period of relative quiescence, some have advocated for psychodynamic/psychoanalytic approaches to continue (see Harris, 2021). Psychedelics certainly offer interesting psychological content to try to understand using these perspectives.

However, there are reasons to question this approach. First, psychoanalytic/psychodynamic approaches have fallen largely out of synch with psychological research and cognitive science in general over the past several decades. Psychoanalytic/psychodynamic approaches were criticized decades ago as failing to keep pace with empirical research (e.g., Eysenck and Wilson, 1973; Beck, 1979). Psychoanalytic/psychodynamic approaches are largely separate from scientific research in general, and were used as a paradigm example of an unfalsifiable form of pseudoscience (Popper, 1983). For example, it is generally agreed that there is no way to falsify through a test the proposition of the id/ego/superego structure of the mind. Psychoanalytic/psychodynamic forms of therapy have been generally surpassed by cognitive approaches in terms of empirical support (Beck and Beck, 2011; Beck, 2019), which is discussed in the next section.

The cognitive revolution in psychology built on earlier established empirically based behavioral principles and marked a shift away from the unfalsifiable psychoanalytic understandings of the mind (Miller, 2003). The most prominent pioneer of CBT was psychiatrist Aaron T. Beck, who de-emphasized unfalsifiable theories involving birth memories, early sexual conflicts, and supposed structures of the psyche. Instead, Beck’s view took a more empirical approach to psychotherapy development and treatment, focusing more on observable and reportable processes such as beliefs and emotions that could be empirically studied, in theory. In response to critiques that the cognitive approach is too superficial, Beck (2019, p. 17) famously said: “There’s more to the surface than meets the eye.” By this, Beck appears to mean that there are plenty of reportable beliefs, interpretations, emotions, and behaviors to work with in a psychotherapeutic setting without needing to postulate additional unconscious processes and forces.

Cognitive-behavioral approaches (including traditional CBT, DBT, and ACT, described below) are considered gold-standard forms of evidence-based psychotherapy for many psychological disorders by the American Psychological Association (APA) due to the substantial evidence supporting their efficacy (APA Presidential Task Force on Evidence-Based Practice, 2006; David et al., 2018). Over time, CBT has become more specifically described, articulated, and adapted to various populations and disorders.

Of the cognitive-behavioral approaches, traditional cognitive-behavioral therapy (CBT) involves a systematic assessment of thinking and behavior related to dysfunction and then intentional action is taken to help the client learn more adaptive thoughts and behaviors. Typically, clients are asked to fill out assessment measures specific to their presenting problems, and to self-monitor their own experience; therapists form their case conceptualizations based on these data (Persons, 2008). Sessions are structured to promote efficiency, and clients are guided by therapists to collaboratively evaluate and question their thoughts and beliefs (McGinn and Sanderson, 2001). There are many approaches within CBT to teach adaptive behavior which are both person- and pathology-specific. This traditional CBT approach has empirical support for its utility in treating a wide range of psychological disorders (APA Presidential Task Force on Evidence-Based Practice, 2006; David et al., 2018).

More recent versions of cognitive-behavioral approaches (such as DBT and ACT, described below) are often referred to as “third-wave” cognitive behavioral therapies (Hayes and Hofmann, 2017). Hayes and Hoffman highlight this third wave of cognitive-behavioral approaches as “a set of new behavioral and cognitive approaches… Third wave methods emphasized such issues as mindfulness, emotions, acceptance, the relationship, values, goals, and meta-cognition” (p. 245).

One widely practiced third-wave therapy is dialectical behavior therapy (DBT) created by Linehan (2020). It is now used to target a variety of mental health disorders where emotional dysregulation features prominently (Ritschel et al., 2018). DBT elaborates on traditional CBT in a number of ways. First is the central importance of mindfulness skills, which is one of four skills modules (the others are distress tolerance, emotion regulation, and interpersonal effectiveness; Rathus and Miller, 2015). Second, DBT has both an individual therapy and group component which work together to promote symptom reduction and skills use (Linehan, 2015). Third, DBT asks clients to call their individual therapists in crisis situations in order to be coached through effective skills use (phone coaching; Oliveira and Rizvi, 2018). These strategies are intended to teach adaptive behavior and ensure that it generalizes to situations in which it is most needed.

Another third-wave therapy is Acceptance and Commitment Therapy (ACT; pronounced “act”) the development of which was led by Steven Hayes. Like traditional CBT and DBT, in ACT there is an emphasis on developing awareness of thoughts, feelings, and sensations (Harris, 2006). Like DBT, ACT incorporates mindfulness techniques and promotes acceptance, however, unlike these approaches, ACT doesn’t directly target the reduction of dysfunctional thinking or difficult emotions, postulating instead that efforts to control or avoid these experiences contribute to suffering. The ACT approach targets six processes that promote psychological flexibility, defined as “contacting the present moment as a conscious human being, fully…and persisting with or changing a behavior in the service of chosen values” (Hayes et al., 2012, p. 96–97).

Finally, there are several notable ways cognitive-behavioral approaches may benefit from the partnering with psychedelic administration. First, psychedelics have an impact on processes, notably psychological flexibility (Close et al., 2020; Davis et al., 2020a) and outcomes (e.g., depression and anxiety, Davis et al., 2021; suicidal ideation; Zeifman et al., 2020) explicitly targeted by cognitive-behavioral approaches. Therefore, empirically understanding the psychedelic experience may provide insight into cognitive-behavioral approaches (and vice versa). This is exemplified by recent work exploring the overlap between psychedelic experience and the sense of self in ACT (Hayes et al., 2020). The authors make explicit that this overlap is an opportunity both for ACT to guide future research in psychedelic science and “learn more about flexibility processes” (p. 36). Second, nesting psychedelic administration in cognitive-behavioral-based preparation and integration sessions may amplify the therapeutic effects (and generalization) of these processes and outcomes. Ultimately, consistent with the scientific values of cognitive-behavioral approaches, these sorts of potential synergies must be explicitly tested.

Taken together, traditional CBT, DBT, and ACT (we refer to these three together as cognitive-behavioral approaches) have the merits of more empirically testable claims, theoretical assumptions more linked to contemporary psychological science, and a large base of empirical support for their safety and efficacy. We therefore believe these cognitive approaches ought to be the default psychotherapeutic paradigm paired with psychedelic treatments.

We have encountered some resistance to the view that cognitive-behavioral approaches (CBT, DBT, and ACT) should be the default approach to psychedelic psychotherapy in contemporary healthcare and research settings. Some common objections to this view include issues related to (1) the high prevalence of participants’ reports of religious/spiritual/unconscious material, which do not feature prominently in cognitive-behavioral approaches (2) lack of studies pairing CBT with psychedelics, (3) concerns that cognitive-behavioral approaches are often rigidly manualized treatments that unduly restrict patient and clinician choice; and (4) unfamiliarity with concepts from cognitive-behavioral approaches that are relevant to psychedelic treatments.

Regarding objection one, the prevalence of participant reports of content related to religious, spiritual, and unconscious processes, we admit that such reports are prevalent and important to acknowledge. We reiterate our view that participants and patients are free to bring their own beliefs and ideologies into psychedelic treatments–as should be the case in all medical and psychotherapeutic treatments (see Peteet et al., 2011). In other words, we are not commenting on the frame that participants and patients ought to bring, but rather that used by researchers/clinicians (see Johnson, 2020). In addition, there is much writing to guide how spiritual/religious content can be incorporated into CBT treatments (e.g., Nieuwsma et al., 2016) and ACT, specifically, has a robust theory that addresses typical spiritual experiences that occur in psychedelic-assisted therapy (Luoma et al., 2019) such as mystical experiences that involve self-transcendence (Yaden et al., 2017a) or feelings of interconnection with others or the universe (Watts and Luoma, 2020).

Regarding objection two, the lack of studies pairing CBT with psychedelics: The objection is sometimes made that because psychedelic treatments are so novel, there is a paucity of research on all psychotherapeutic pairings—and, therefore, they should all be tried and no particular approach should be assumed the default. While we agree that research is on-going and relevant approaches should be tested, we do not agree that all approaches are equally reasonable candidates. We argue that we have good reasons to choose approaches that fit best with contemporary scientific research, are suited to secular treatment contexts, carry less risk of being culturally offensive, and have more evidence of safety and effectiveness. We believe that CBT represents the strongest family of approaches in each of these regards. Lastly, and crucially, there have already been successful pairings of cognitive-behavioral approaches with psychedelic treatments. Specifically, Johnson et al. (2014) combined traditional CBT with psilocybin in a tobacco use disorder trial. Also, ACT has been combined with psilocybin in the treatment of depression (Carhart-Harris et al., 2016; Sloshower et al., 2020).

Regarding objection three, that cognitive-behavioral approaches leads to overly restrictive manualized treatment, we wish to emphasize that we are not advocating for the strict application of a particular manualized process in each psychedelic study/treatment, nor for particular interventions to be used in specific sessions. The idea that CBT is an approach that is inherently restrictive of clinician flexibility, creativity, and responsiveness is a straw man. Of course, cognitive-behavioral approaches will need to be adapted to the context of use, for example alongside psychedelic substances (there are numerous examples of doing this for particular diagnoses, patient populations, and other contextual factors; e.g., see Wenzel et al., 2012). Furthermore, any approach can be rigidly applied, including non-cognitive-behavioral approaches. In summary, we believe that cognitive-behavioral approaches should not be used without adaptation to this unique therapeutic context and to the individual patient/participant, but this concern applies to other theoretical approaches as well.

Regarding objection four, unfamiliarity with concepts from cognitive-behavioral approaches that are relevant to psychedelic treatments, we acknowledge that not all researchers and clinicians have had exposure to cognitive-behavioral approaches (e.g., CBT, DBT, ACT) and particularly how cognitive-behavioral approaches are capable of addressing the unique characteristics involved in psychedelic assisted psychotherapy, such as spiritual experiences (see Luoma et al., 2020). Furthermore, we recognize that there are a great number of popular books and articles advocating for the pairing of psychedelic treatments with indigenous practices, new age spirituality, and psychodynamic approaches—-and that there is a relative paucity of such resources for cognitive-behavioral approaches in the domain of psychedelic treatments. This simply speaks to the need for more work to disseminate cognitive-behavioral approaches that address issues which commonly occur during psychedelic states. One advantage of utilizing cognitive-behavioral approaches with psychedelic administration is that there is a long tradition and much expertise in learning how to rigorously adapt and test cognitive-behavioral principles in a wide variety of clinical contexts.

To be clear, our view that cognitive-behavioral approaches should be considered default for psychedelic treatments rests upon the context in which psychedelic administration is being delivered. We do not posit that all psychedelic use everywhere should be grounded in cognitive-behavioral approaches. However, in the current clinical research context, psychedelic-psychotherapy research programs are targeting outcomes for which cognitive-behavioral approaches have been shown to be effective for in experimental studies (e.g., depression and anxiety, Davis et al., 2021; suicidal ideation, Zeifman et al., 2020). Not only are cognitive-behavioral approaches effective for these outcomes, but they are also currently the gold standard of evidence-based care (APA Presidential Task Force on Evidence-Based Practice, 2006; David et al., 2018). Reiterating the synergy mentioned above regarding the overlap between the effects of psychedelic experience and processes and outcomes targeted in cognitive-behavioral approaches, these approaches are the best fit empirically and ethically.

The next section represents an overview of several concepts and techniques from cognitive-behavioral approaches that appear highly relevant to psychedelic psychotherapy (see Table 1).

There are a number of concepts from cognitive-behavioral approaches that appear to be highly relevant to psychedelic treatments. In this section, we provide concepts from cognitive-behavioral approaches to inform each step of psychedelic treatments, which can usefully be divided into (1) preparation, (2) dosing sessions, and (3) integration. In the following, we describe these three broad stages of this process (as described in, for example, Johnson et al., 2008, 2019) and then list concepts from CBT, DBT, and ACT that are relevant with a brief explanation of each. Again, this is not meant to be a comprehensive list—and there is overlap in concepts across CBT/DBT/ACT (i.e., each concept is not necessarily unique to each framework), so this should be considered a starting place to show the rich set of concepts to draw from in these psychotherapeutic paradigms. Note that we use the terms patients (but the terms clients and participants can also be used interchangeably) and therapist (but the terms guides, monitors, facilitators, and clinicians can also be used interchangeably).

We have provided a review of historical, sociological influences on contemporary psychedelic psychotherapy as it is practiced largely in clinical healthcare research settings and have argued that cognitive-behavioral frameworks (i.e., CBT, DBT, and ACT) should be considered the default. That said, to the degree that some investigators choose to use other approaches, we should evaluate outcomes, and ultimately, research randomizing individuals to different therapeutic approaches (within ethical limits), as this would provide the most importance evidence on this topic, at least regarding safety and efficacy. We provided rationale largely resting on more empirically founded and testable theory, stronger connection to the evidence base of contemporary science, reduced potential to cause offense, and large amount of safety and efficacy data across a number of treatment contexts.

There are other frameworks that we have not discussed in great detail here but deserve mention and some discussion, these include motivational interviewing, emotion-focused therapy, and supportive psychotherapy. Motivational interviewing (MI) emerged from the research on addiction and is defined as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (Miller and Rollnick, 2012, p. 12). Rather than targeting change processes, MI seeks to prepare clients for change by guiding a conversation that ultimately encourages clients to be engaged, empowered, open, and understood (Miller and Rollnick, 2012). MI has been used in at least one clinical trial with psilocybin (Bogenschutz et al., 2015). We believe motivational interviewing could be used as an adjunct intervention. However, we do not believe motivational interviewing is broad enough to be a comprehensive treatment approach for many disorders or difficulties that present as part of psychedelic assisted therapy.

Emotion-focused therapy is a therapy approach emerging from the humanistic tradition that views emotions as centrally important in the experience of the self, in maintaining both adaptive and maladaptive functioning, and in the therapeutic change process (Greenberg, 2011). It has been empirically studied for depression, social anxiety, complex trauma, generalized anxiety, and eating disorders (Goldman, 2019), but the evidence base for this approach is not nearly as extensive as for CBT, including specifically in the context of psychedelics.

The default paradigm currently used in clinical trials with psychedelics is overtly something like supportive psychotherapy, as it is generally characterized as empathetic in a non-directive manner (e.g., Winston et al., 2004). Arguably, this should not change. However, we believe that supportive psychotherapy consists of a set of clinical practices into which concepts from other frameworks invariably slip in. In other words, we believe that many of the clinicians, guides, and monitors who are overtly providing supportive psychotherapy in psychedelic contexts are drawing from an eclectic blend of the other influences on psychedelic psychotherapy that we have already reviewed. To the extent that this is the case, we argue that drawing more explicitly from concepts from cognitive-behavioral approaches (e.g., CBT/DBT/ACT) is advisable.

We have argued that CBT approaches have the strongest rationale to be the default option for a psychotherapeutic paradigm to pair with psychedelic treatments in mainstream American and European clinical research contexts. We examined some common alternatives and found that they each have problems that are absent or substantially reduced in CBT approaches. We have also provided a substantial number of concepts from CBT, DBT, and ACT that appear relevant to psychedelic treatments. While we believe cognitive-behavioral approaches should be the default in psychedelic psychotherapy, we are open to and supportive of additional scholarship and research on the other approaches considered here as well as others. Furthermore, the CBT/DBT/ACT concepts listed are provided for illustrative purposes and are not meant to be comprehensive and should be subjected to further research. Overall, we believe participant and patient safety and efficacy should be paramount considerations in psychedelic treatments and we believe cognitive-behavioral approaches currently best fulfill these criteria.

DY conceived the project and wrote the manuscript. DE and MG conducted literature reviews and provided writing. DF-W provided writing and edits. JL and MJ provided writing and edits. All authors contributed to the article and approved the submitted version.

MJ was an advisor to the following organizations regarding the medical development of psychedelics and related compounds: AJNA Labs LLC, AWAKN Life Sciences Inc., Beckley Psychedelic Ltd., Entheon Biomedical Corp., Field Trip Psychedelics Inc., Mind Medicine Inc., and Otsuka Pharmaceutical Development & Commercialization Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.