Over the past few years, research and public interest in psychedelic agents – such as psilocybin and 3,4-methylenedioxymethamphetamine (MDMA) – for mental health purposes has skyrocketed. The therapeutic approach to the use of these agents involves three components: preparation, drug administration, and integration. This bundled treatment has been termed psychedelic-assisted therapy (PAT). The basic assumptions and methods of PAT, however, have remained unchanged since the 1950s, despite notable advances in the treatment of mental disorders.

The preparation phase involves building rapport between the patient and therapist(s), providing education about the psychedelic experience, and establishing a therapeutic intention (i.e., a set of goals) for the drug session. These practices are thought to facilitate a positive response to the drug and reduce the likelihood of adverse events (e.g., a “bad trip”). In the empirical literature, preparation has been described with consistent practices but wide-ranging durations, from two to eight hours over one to three sessions¹.

The drug administration session has been the most consistent practice in empirical studies. The participant is monitored by two clinicians with little interruption for 6-8 hours. During this interval, patients lay on a couch with eyeshades, listen through headphones to a pre-determined playlist of classical music, and are encouraged to be as introspective as possible. These sessions typically entail minimal involvement from the therapists, except to provide emotional support, safety monitoring and, when appropriate, therapeutic touch.

The most inconsistent offering within PAT has been the integration phase, which has ranged from an individual telephone call to nine psychotherapy sessions¹. Integration sessions have traditionally involved various forms of non-directive, unstructured psychosocial support. The theoretical basis behind this approach is that the psychedelic drug assists patients in identifying what they need to heal. The integration sessions have been culled from various traditions, including classic psychoanalysis, Rogerian person-centered therapy, Maslow's theory of self-actualization, and inner healing intelligence².

Many questions remain about how the psychotherapy components of PAT produce meaningful benefits above and beyond the drug itself. Some experts claim that the current integration practices contribute little (if any) value beyond the drug's immediate psychiatric benefits, whereas others claim that it is the therapy enhanced by the drug that leads to psychiatric change^{1, 3}. While the psychedelic drugs have received the bulk of the attention, the psychosocial treatment components of PAT have not been studied to measure their relative benefits for symptomatic and functional improvements.

To advance the field further, it is important that the psychotherapy adjunct be updated and optimized from its 1950s origins through rigorous scientific testing. We recommend testing the efficacy of adjunctive psychosocial treatments with a strong evidence base for the psychiatric indication of interest. Cognitive-behavioral therapies (CBTs) have robust empirical bases across the core emotional disorders being approached with psychedelics (i.e., mood, anxiety and stress-related disorders). CBTs are most notable for their enduring effects in terms of symptom improvement and relapse prevention⁴. Importantly, these treatments are manualized, reducing the variability in treatment delivery and making the testing of treatment fidelity possible. Additionally, CBT can be disseminated safely and effectively by community clinicians, as shown by the Improving Access to Psychological Therapies (IAPT) programme in the UK⁵.

Examining the comparative contributions of the drug and the accompanying psychotherapy is also critical to our understanding of the mechanisms of psychedelic treatment. The core emotional disorders have shared etiologies and psychological processes, including poor emotion regulation that leads to emotional and behavioral avoidance of negative stimuli. Psychedelics have a range of acute effects on consciousness, including sensory and physical experiences; sense of self, time and space; and emotions and cognitions⁶. The changes in an individual's emotions and cognition help to foster greater social connectedness and self-esteem and may clarify priorities and values. Additionally, psychedelics appear to reduce patients’ emotional sensitivity and cognitive rigidity in reaction to emotionally-laden stimuli, allowing them to approach emotional and cognitive content that they would otherwise avoid. For example, a patient can feel more able to undergo imaginal exposure to a previously avoided trauma. This can also be facilitated by the effects of the drug on the individual's perception of time and space through what can feel like actual movement through a trip or journey. Thus, psychedelics can help patients regulate their emotional sensitivity, appraise and approach stressful situations more flexibly, and connect to their social environment.

Structured empirically-based psychotherapies seek to modify these same psychological mechanisms of emotional regulation, cognitive flexibility, and prosocial engagement. Changes in cognition and behavior can also be tested as mediators of the impact of CBTs on symptomatic or functional outcomes. When combined with psychedelics, we expect psychosocial treatments to work synergistically with the drug to catalyze immediate and longer-term changes in thinking, feeling and behavior⁷.

PAT has had varying lengths of treatment response, ranging in major depression from as little as a few weeks to as long as one year^{8, 9}. Helping patients make sense of the cognitive, affective and physiological changes produced by the drug through CBTs may instill longer-lasting benefits. Further, working with patients to concretely apply these insights into real-world cognitive and behavioral changes seems critical to producing deep-seated, durable improvement. For example, the effects of psychedelics on feelings of social connectedness may serve as catalysts for changes in thoughts and behaviors that foster social engagement. While the drug may motivate change initially, working with the patient to create behavioral activation plans, holding him/her accountable in making these changes, and solving problems that arise in the implementation of these plans may prolong the duration of the drugs’ benefits.

To examine the effects of structured psychotherapy on psychedelics (and vice versa), it will be important to vary doses of the therapy in the preparation and integration phases. What is the minimal number of preparation sessions that are necessary to safely administer a psychedelic? Does a longer preparation phase magnify the psychedelic experience, facilitate therapeutic alliance, or increase opportunities to practice newly acquired skills (such as cognitive restructuring)? Would preparation be different for psychedelic-naïve participants compared to those who have prior experience with the drug? Do integration sessions gradually improve psychiatric outcomes and functioning, or are the majority of clinical benefits apparent shortly after drug administration? How many integration sessions are optimal? Seeking to identify the treatment ingredients necessary for effective and safe delivery of psychedelics can help to update therapeutic practices. Furthermore, determining whether more than one participant can be served at one time (be it in a group setting or in adjoining rooms), and how the addition of other co-patients affects the delivery of adjunctive psychotherapy, are questions ripe for investigation.

In our ongoing trial of a psilocybin-assisted CBT for patients with major depression⁷, we are already impressed by the synergy between the psychotherapy and drug treatments. Our preliminary observations are that CBT skills can be leveraged during the drug experience and can increase the individual's accountability for behavioral change following the drug administration. Additionally, the psychedelic appears to increase prosocial emotions and cognitions to help enact behavioral change following the drug session.

The next generation of studies on psychedelics should consider the impact of the psychotherapeutic context of drug administration, which may prove to be as important for clinical change as the drug itself.

在过去的几年里，用于精神健康目的的致幻剂（例如裸盖菇素和 3,4-亚甲二氧基甲基苯丙胺 (MDMA)）的研究和公众兴趣猛增。使用这些药物的治疗方法涉及三个组成部分：准备、给药和整合。这种捆绑治疗被称为迷幻辅助治疗（PAT）。然而，尽管精神障碍的治疗取得了显着进展，但 PAT 的基本假设和方法自 20 世纪 50 年代以来一直没有改变。

准备阶段包括在患者和治疗师之间建立融洽关系，提供有关迷幻体验的教育，并为药物治疗建立治疗意图（即一组目标）。这些做法被认为有助于促进对药物的积极反应并减少不良事件（例如“糟糕的旅行”）的可能性。在实证文献中，准备工作被描述为采用一致的做法，但持续时间范围很广，从两到八个小时，一到三个疗程¹。

给药环节是实证研究中最一致的做法。参与者由两名临床医生不间断地进行 6-8 小时的监测。在此期间，患者躺在带眼罩的沙发上，通过耳机收听预先确定的古典音乐播放列表，并鼓励患者尽可能进行内省。这些治疗通常需要治疗师的最少参与，除了提供情感支持、安全监测以及在适当的情况下进行治疗性触摸。

PAT 中最不一致的服务是整合阶段，该阶段的范围从单独的电话到九次心理治疗疗程¹。传统上，整合课程涉及各种形式的非指导性、非结构化的社会心理支持。这种方法背后的理论基础是迷幻药物可以帮助患者确定他们需要治愈什么。整合课程从各种传统中精选出来，包括经典精神分析、罗杰斯以人为中心的疗法、马斯洛的自我实现理论和内在治愈智能²。

关于 PAT 的心理治疗成分如何产生超越药物本身的有意义的益处，仍然存在许多问题。一些专家声称，当前的整合实践除了药物的直接精神益处之外几乎没有贡献（如果有的话）价值，而其他专家则声称正是药物增强的治疗导致了精神变化^{1, 3}。虽然迷幻药物受到了大部分关注，但 PAT 的心理社会治疗成分尚未被研究来衡量其对症状和功能改善的相对益处。

为了进一步推动这一领域的发展，重要的是通过严格的科学测试对 20 世纪 50 年代的心理治疗辅助手段进行更新和优化。我们建议通过针对感兴趣的精神病学指征的强有力的证据基础来测试辅助心理社会治疗的功效。认知行为疗法（CBT）在致幻剂治疗的核心情绪障碍（即情绪、焦虑和压力相关障碍）中拥有坚实的经验基础。CBT 最引人注目的是其在改善症状和预防复发方面的持久效果⁴。重要的是，这些治疗是手动的，减少了治疗实施的可变性，并使治疗保真度的测试成为可能。此外，正如英国改善心理治疗的可及性 (IAPT) 计划所示，社区临床医生可以安全有效地传播 CBT ⁵。

检查药物和伴随的心理治疗的相对贡献对于我们理解迷幻治疗的机制也至关重要。核心情绪障碍具有共同的病因和心理过程，包括情绪调节不良导致情绪和行为上回避负面刺激。迷幻药对意识有一系列急性影响，包括感官和身体体验；自我感、时间感和空间感；以及情绪和认知⁶．个人情绪和认知的变化有助于培养更大的社会联系和自尊，并可能澄清优先事项和价值观。此外，迷幻药似乎可以降低患者对充满情绪的刺激的情绪敏感性和认知僵化，使他们能够接近他们本来会避免的情绪和认知内容。例如，患者可能会感觉更有能力经历想象中的暴露于先前避免的创伤。药物对个人对时间和空间的感知的影响也可以促进这一点，这种感觉就像在一次旅行或旅程中的实际运动一样。因此，迷幻药可以帮助患者调节情绪敏感性，更灵活地评估和处理压力情况，并与他们的社会环境建立联系。

基于经验的结构化心理治疗试图改变这些相同的情绪调节、认知灵活性和亲社会参与的心理机制。认知和行为的变化也可以作为 CBT 对症状或功能结果影响的中介因素进行测试。当与致幻剂结合使用时，我们期望心理社会治疗能够与药物协同作用，从而促进思维、感觉和行为的即时和长期变化⁷。

PAT 的治疗反应时间长短不一，重度抑郁症的治疗反应短则几周，长则一年^{8, 9}。通过 CBT 帮助患者理解药物产生的认知、情感和生理变化可能会带来更持久的益处。此外，与患者合作，将这些见解具体应用到现实世界的认知和行为变化中，对于产生深层次、持久的改善似乎至关重要。例如，迷幻药对社会联系感的影响可能会成为促进社会参与的思想和行为变化的催化剂。虽然药物最初可能会激发改变，但与患者合作制定行为激活计划，让他/她负责做出这些改变，并解决实施这些计划时出现的问题可能会延长药物益处的持续时间。

为了检查结构化心理治疗对迷幻药的影响（反之亦然），在准备和整合阶段改变治疗剂量非常重要。安全使用迷幻药所需的最少准备时间是多少？较长的准备阶段是否会放大迷幻体验，促进治疗联盟，或增加练习新获得的技能（例如认知重建）的机会？与那些有过使用迷幻药经验的参与者相比，未接触过致幻剂的参与者的准备工作是否会有所不同？整合课程是否会逐渐改善精神结局和功能，或者大多数临床益处是否在给药后不久就显现出来？最佳集成会话次数是多少？寻求确定有效和安全地输送迷幻药所需的治疗成分有助于更新治疗实践。此外，确定是否可以同时为一名以上的参与者提供服务（无论是在团体环境中还是在相邻的房间中），以及其他共同患者的增加如何影响辅助心理治疗的实施，这些都是需要研究的问题。

在我们正在进行的针对重度抑郁症患者的裸盖菇素辅助 CBT 试验中⁷，我们已经对心理治疗和药物治疗之间的协同作用印象深刻。我们的初步观察结果是，CBT 技能可以在吸毒过程中得到利用，并且可以增加个人对吸毒后行为改变的责任感。此外，迷幻药似乎会增加亲社会情绪和认知，有助于在用药后改变行为。

下一代关于致幻剂的研究应该考虑药物管理的心理治疗背景的影响，这可能被证明与药物本身一样对临床变化同样重要。