Psychedelic-assisted CBT and motivational enhancement

1. Introduction

Version followed: the core is the Bogenschutz and Forcehimes (2017) two-therapist model for psilocybin-assisted treatment of alcohol dependence. It pairs a Motivational Enhancement and Taking Action (META) therapist with a psilocybin preparation and integration (PSI) therapist, as used in the UNM and NYU trials (pilot: Bogenschutz et al. 2015; RCT: Bogenschutz et al. 2022, NCT02061293). The guide adds the Johns Hopkins psilocybin plus CBT smoking-cessation protocol (Johnson et al. 2014 pilot; Johnson et al. 2026 randomised pilot vs nicotine patch). The Dakwar et al. (2020) ketamine plus MET protocol for alcohol use disorder appears where it differs. [source: Bogenschutz & Forcehimes 2017; Johnson et al. 2014; Johnson et al. 2026; Dakwar et al. 2020]

What it is. "Psychedelic-assisted CBT and motivational enhancement" is not one named therapy. It is a family of research protocols in which a standard addiction psychotherapy is the main treatment. That therapy is either Motivational Enhancement Therapy (MET) or manualised CBT for smoking cessation or alcohol use, and it brackets a small number of supervised psychedelic sessions run by a trained team. The authors chose "a fairly typical outpatient alcoholism therapy model" because it should help on its own, and because the mechanisms of psychedelic treatment are poorly understood. [source: Bogenschutz & Forcehimes 2017]

Core idea of change. The proposed sequence has three steps. Motivational work before the session sets a clear change intention, which is part of the "set". The psychedelic experience may then bring insight, reconnection with values, and a temporary drop in craving and rise in self-efficacy. Debriefing and continuing MET/CBT then turn that experience into change talk, commitment and a concrete behavioural plan, which relapse-prevention skills sustain. The authors call the proposed synergies (MI preparing intention, CBT using a window of plasticity, mindfulness and 12-step work supporting spiritual aspects) "pure conjecture" still to be tested. [source: Bogenschutz & Forcehimes 2017; Nielson et al. 2018; Bogenschutz et al. 2015]

Who this guide is for. In 2026 these protocols are delivered lawfully only inside approved research or regulated programmes. A therapist outside such a programme can use the MET/CBT and integration components with clients. For clients who use psychedelics elsewhere, the therapist's role is harm reduction and integration (section 5), never facilitation. [synthesis]

Legal and regulatory status (as of the sources' dates).

USA, federal: psilocybin is a Schedule I controlled substance, and research requires FDA authorisation; the FDA granted a Breakthrough Therapy designation for psilocybin in major depressive disorder in 2019 [source: ASTHO 2023]. Whether any psilocybin product had full FDA approval by late 2026 was not verified [uncertain].
US states: Oregon runs licensed service centres with state-trained, licensed facilitators; licensing began in 2023, clients must be 21 or older, and no medical referral is required. Colorado runs a Regulated Natural Medicine Access Program with licensed healing centres. New Mexico passed a Medical Psilocybin Act in 2025. Utah has run a hospital-based pilot since 2024. Washington has a University of Washington pilot. [source: ASTHO 2023; Drug Science 2026]
Australia: since 1 July 2023, psychiatrists approved under the TGA Authorised Prescriber scheme may prescribe psilocybin for treatment-resistant depression and MDMA for PTSD. Addiction is not a listed indication. [source: TGA]
Europe and elsewhere: the Czech Republic has allowed specialist prescribing of psilocybin for certain mental disorders since 1 January 2026. Germany has had a compassionate-use programme for treatment-resistant depression since 2025. Switzerland grants individual exemptions to physicians. New Zealand approved its first prescriber in June 2025. Canada allows only exceptional access. [source: Drug Science 2026]
UK status and ketamine's regulatory status for addiction indications are [uncertain].

2. Framework

[source: Bogenschutz & Forcehimes 2017; Nielson et al. 2018; Bogenschutz et al. 2022 via Blossom summary; Johnson et al. 2014; Johnson et al. 2026; Dakwar et al. 2020]

Team format (alcohol model). Two therapists form a dyad.

The META therapist delivers the alcohol-focused MET/CBT content.
The PSI therapist delivers preparation, attends medication sessions and leads debriefing.
Where possible the two are of opposite genders, and neither shares the patient's gender.
Both attend medication sessions. Either may run their own non-drug sessions alone. A substitute may cover a medication session only after at least two prior meetings with the participant.
In the RCT, one of the two attending therapists was a psychiatrist. A physician must be immediately available if neither therapist is one.
In practice both therapists contribute to both components.

Team format (smoking model). Two or three staff per medication session, including at least one doctoral-level psychologist, with a physician on call. In the 2026 trial the facilitator pair was a doctoral- or master's-level psychologist and a research coordinator.

Phase A: Assessment and screening.

Goal: confirm the diagnosis, motivation and medical and psychiatric safety.
Format: structured clinical interview, medical examination, ECG, blood and urine tests.
Published exclusions across the protocols:
- current or past psychotic disorder or bipolar disorder (in some protocols, also a family history)
- other drug dependence (in the smoking trials, alcohol or drug dependence)
- hallucinogen use (alcohol RCT)
- severe major depression within the past five years (smoking RCT)
- cardiovascular conditions such as uncontrolled hypertension
- pregnancy
- medical conditions or current medications that contraindicate the study drug
- current other treatment for the target disorder (alcohol RCT)
Inclusion: a diagnosed disorder plus a current desire to change. The smoking trials also required several prior failed quit attempts.
Moving on: the medical team clears the patient, and consent is given after the study rationale is explained.

Phase B: Motivation and preparation (before the first medication session).

Alcohol model: META sessions (MI, personalised feedback, values card sort) run alongside PSI preparation sessions (life review, expectations, handling difficult states, choice of meaningful objects, ground rules). In the RCT, four of the twelve sessions came before the first medication session.
Smoking model: four weekly meetings of about 90 minutes, each roughly half CBT and half preparation. A quit contract, a smoking diary and a motivational statement are built in this phase.
Moving on: rapport and trust are established, a change goal and intention are articulated, the patient understands the range of possible experiences, and a safety plan for the day is agreed.

Phase C: Medication session(s).

Day-long sessions in a calm, homelike room, with eyeshades and a standardised music programme through headphones.
Therapists support but do not deliver directive therapy. In the smoking protocol, no smoking-specific content is delivered during the session.
Medical monitoring is the responsibility of medical staff.
At the end of the session, a mental status check is done and the patient is released to a briefed friend or relative who stays overnight.
In the smoking protocol, the target quit date is anchored to the first medication session. In the ketamine protocol, the session falls on a predesignated quit day.
The number and spacing of medication sessions is set by each protocol and not described here.

Phase D: Debriefing (next day).

About an hour, with both therapists where possible.
A mental status examination and adverse-event follow-up come first, then an open narrative of the experience and its meaning, linked to drinking or smoking.
In the ketamine protocol, an extra MET session is held about a day after the session.

Phase E: Integration, action and maintenance.

Alcohol model: further sessions build a STORC-based change plan and add individualised modules, revisiting the plan each session. In the RCT, twelve manualised MET/CBT sessions were spread across the 12-week course.
Smoking model: weekly support meetings of about 45 minutes, plus brief daily phone contact in the first one to two weeks after the quit date. In the 2026 trial, visits were weekly to week 7 and then every two weeks to week 13.
Preparation is repeated and revised before any later medication session.
Follow-up runs to 6 or 12 months. In the smoking trials, abstinence was verified with breath carbon monoxide and urine cotinine.

Typical totals.

Alcohol RCT: 12 psychotherapy sessions over 12 weeks, plus the medication and debriefing days.
Smoking pilot: 19 in-person meetings over 15 weeks.
Ketamine protocol: six MET sessions over five weeks.

Criteria for moving between phases. The sources give no formal criteria beyond medical clearance and session schedules. The following readiness markers are [synthesis]:

Moving to the medication session: a stated change goal, a written intention or motivational statement, a trusted relationship with both therapists, an agreed plan for difficult states, and a support person arranged.
Moving to maintenance: a stable mental status at debriefing, and the experience translated into at least one concrete behavioural commitment.

3. Guiding principles

[source: Bogenschutz & Forcehimes 2017 unless marked]

The psychotherapy is the treatment, and the medication session is embedded in it. In practice: deliver a complete MET or CBT course that would be credible without the drug.
Intention shapes the experience. In practice: use MI to strengthen the patient's own reasons for change before the session, so they go into it with a change intention.
Set and setting matter. In practice: manage expectancy, the relationship and the physical room deliberately (calm, homelike, music, eyeshades).
Safety comes first. In practice: careful selection, several hours of preparation, a supportive team, an available physician and structured debriefing.
Each therapist needs expertise in their own domain. In practice: the META therapist needs MI/MET fidelity, and the PSI therapist needs training in preparation and integration. Both are manualised and supervised to fidelity.
Be non-directive in the session. In practice: offer reassurance, support, grounding and redirection, not therapy content; let the patient's own process lead [source: also Johnson et al. 2014].
Encourage openness, and don't force surrender. In practice: invite the patient to "trust, let go, and be open", and never push them into what they do not feel ready for [source: also Nielson et al. 2018].
Don't predict the experience. In practice: describe the full range (sensory, autobiographical, symbolic, mystical-type) without saying which will occur.
Integration creates the lasting change. In practice: the meaning the patient makes of the experience is the working material, and it unfolds over weeks to months.
Elicit change talk and commitment. In practice: listen for desire, reasons and confidence, and actively invite explicit statements of a plan or intention [source: Nielson et al. 2018].
Link values to behaviour. In practice: use the discrepancy between stated values and drinking or smoking as the motivational lever.
The therapists are a temporary support network. In practice: patients often have no peers who share the experience, so the team holds that role and helps them build lasting supports [source: Nielson et al. 2018].
Keep the plan flexible. In practice: revisit and revise the change plan every session, and address barriers rather than restating the plan.
The therapist's own psychedelic experience is not required. In practice: don't assume your experiences resemble the patient's. The authors treat this as an empirical question.
Be humble about the model. In practice: the authors make "no claims as to the superiority of this model", so stay open to adapting it within protocol limits.

4. Intervention inventory

The source protocols are not publicly available as manuals. The steps below follow the published descriptions; detail beyond those descriptions is marked [synthesis]. All therapist wording is illustrative unless quoted.

Part A: Motivational Enhancement and Taking Action (META therapist, alcohol model)

A1. Open motivational interviewing to elicit intrinsic motivation (META session 1)

Purpose: draw out the patient's own reasons for change before any medication session, so they enter it with a change intention. [source: Bogenschutz & Forcehimes 2017]
Steps:
1. Open with open questions about drinking and what brought them.
2. Reflect ambivalence on both sides.
3. Selectively reflect and summarise change talk: desire, ability, reasons, need. [source: Nielson et al. 2018 for change-talk definition; sequencing is synthesis]
4. End with a summary of the patient's own reasons. [synthesis]
Example language (illustrative): "What would you like to be different about drinking a year from now?" / "Part of you values how it helps you unwind, and part of you is worried about what it is costing you at home."
Watch for: sustain talk dominating, or righting-reflex arguing by the therapist. It is working when the patient's ratio of change talk to sustain talk rises. [synthesis]

A2. Personalised feedback from baseline assessment

Purpose: give non-confrontational, personalised information that builds discrepancy. [source: Bogenschutz & Forcehimes 2017]
Steps:
1. Prepare a feedback report from the baseline measures, covering drinking compared with population norms, consequences experienced, and motivation measures.
2. Ask permission, present each item, and elicit the patient's reaction before moving on (elicit-provide-elicit). [synthesis: standard MET practice]
3. Reflect surprise or concern; don't interpret for them.
Example language (illustrative): "Would it be OK to look at how your drinking compares with other adults? ... What do you make of that?"
Watch for: defensiveness. If it appears, back off, emphasise autonomy, and return to the patient's own concerns. [synthesis]

A3. Values card sort and values–behaviour discrepancy (META session 2)

Purpose: identify core values and use the gap between values and drinking as motivation. These values are referenced again after the medication session. [source: Bogenschutz & Forcehimes 2017]
Steps:
1. The patient sorts a deck of value cards by importance (the specific card set used is not named in the source [uncertain]).
2. Explore the top few: what each means and how they live it.
3. Ask how drinking fits or conflicts with each one.
4. Record the top values for use in later sessions and in the debriefing.
Example language (illustrative): "You put 'being a dependable father' near the top. How does drinking fit with that right now?"
Watch for: values chosen to please the therapist, and guilt spirals. Reflect strengths as well as gaps. [synthesis]

A4. Eliciting change talk and commitment language

Purpose: strengthen statements of desire, reasons and confidence, and actively invite explicit commitment (a direct statement of a plan or intention), especially after medication sessions. [source: Nielson et al. 2018]
Steps:
1. Listen for change talk and reflect it.
2. Ask evocative questions ("why", "how", "what next").
3. When readiness appears, ask key questions inviting commitment.
4. Summarise any commitment in the patient's own words. [steps 2–4: synthesis]
Example language (illustrative): "Given what you saw in that session, what do you intend to do about drinking this week?"
Watch for: commitments that run ahead of a concrete plan; follow with A5. It is working when the language shifts from "I should" to "I will". [synthesis]

A5. STORC change plan with a strategy menu (META sessions 3–4 onwards)

Purpose: turn change goals, often sharpened after the first medication session, into a concrete treatment plan. [source: Bogenschutz & Forcehimes 2017]
Steps:
1. Review change goals and the patient's experience of the first medication session, linked to their values.
2. Use the STORC framework (Situations, Thoughts, Organic patterns, Responses, Consequences) to map typical drinking episodes.
3. For each domain, choose strategies from the workbook menu, for example monitoring urges, sleep hygiene and asking others for help.
4. Write the plan down.
5. Revisit and revise it every session.
Example language (illustrative): "Let's take last Friday. Where were you, what went through your mind, how was your body, what did you do, and what came of it?"
Watch for: plans that are too broad. One or two strategies per high-risk situation is more workable. [synthesis] The workbook itself is not drawn on here [uncertain].

A6. Individualised pull-out modules

Purpose: add skills matched to the patient's plan in later sessions. [source: Bogenschutz & Forcehimes 2017; the RCT combined MET with CBT for AUD, per the Bogenschutz et al. 2022 summary]
Modules named in the source:
- 12-step or other self-help facilitation
- mindfulness
- exercise
- changing the social network
- developing alternative positive reinforcers
- referral for further formal alcohol treatment
Steps: choose a module with the patient, teach the skill in session, set a between-session practice, and review it next session. [synthesis]
Example language (illustrative): "You said you felt connected in that session. Would looking at a mutual-help meeting or another sober community fit with that?"
Watch for: the module content is not published in detail [uncertain]. Use your standard CBT-for-AUD and MI materials and label them as your adaptation. [synthesis]

A7. Re-engagement and barrier work

Purpose: keep patients in treatment and address obstacles to the plan. [source: Bogenschutz & Forcehimes 2017]
Steps:
1. Review what happened since the last session without judgement.
2. Identify the barrier.
3. Revise the plan.
4. Reaffirm the link to values. [steps: synthesis]
Example language (illustrative): "It sounds like the plan didn't hold up at the work party. What got in the way, and what would you change?"

Part B: Preparation, session conduct and debriefing (PSI therapist)

B1. Overview, rationale and detailed life review (preparation session 1)

Purpose: build rapport and trust, and give the therapists a full picture of the person, which is a prerequisite for safety in the session. [source: Bogenschutz & Forcehimes 2017; Johnson et al. 2014 for discussing childhood, relationships, work and hobbies, and spiritual or philosophical worldview]
Steps:
1. Explain the study or programme rationale.
2. Take a life review covering history, current situation, personality, relationships, goals, and philosophical or spiritual outlook.
3. Invite questions.
Example language (illustrative): "I'd like to get to know you well before the session day: your story, the people who matter, and what you hope for."
Watch for: unprocessed trauma or current crises that may need attention before the session. [synthesis]

B2. Psychoeducation on effects and the range of experiences (preparation session 2)

Purpose: set realistic, open expectancies and encourage positive expectancy. [source: Bogenschutz & Forcehimes 2017; Johnson et al. 2026]
Steps:
1. Review motivation and expectations.
2. Describe possible physical and psychological effects in general terms.
3. Describe the range of experiences (sensory, autobiographical, symbolic, mystical-type) without predicting which will occur.
4. Frame the session as a chance to reflect on the role of alcohol or smoking in their life.
5. Address hopes and fears.
Example language (illustrative): "People's experiences vary a lot: some are mostly visual or emotional, some revisit memories, and some feel deeply meaningful. We can't predict yours."
Watch for: over-high expectations of a cure, and catastrophic fears. Reflect both and normalise uncertainty. [synthesis]

B3. Coaching for difficult experiences

Purpose: equip the patient to meet fear or dysphoria during the session. [source: Bogenschutz & Forcehimes 2017; Nielson et al. 2018]
Steps:
1. Explain that dysphoric moments can occur.
2. Teach breath awareness as an anchor.
3. Encourage meeting difficulty with curiosity and openness rather than resistance.
4. Agree how the patient will signal for support.
5. Emphasise that letting go cannot be forced. [step 4: synthesis]
Example language (illustrative): "If something frightening comes up, come back to your breath. You can turn towards it with curiosity, and we'll be right here. Nobody is asking you to force anything."
Watch for: a patient who hears "surrender" as a demand. Nielson et al. report a therapist cautioning against pushing a patient beyond readiness.

B4. Meaningful objects, ground rules and plan for the day

Purpose: personalise the setting and secure a safety framework. [source: Bogenschutz & Forcehimes 2017]
Steps:
1. Invite the patient to bring personally meaningful items, such as photographs or religious objects.
2. Agree ground rules. The specific rules are not listed in the source [uncertain]; typical items include staying in the room, no harm to self or others, and the team staying throughout [synthesis].
3. Confirm a briefed friend or relative will take them home and stay overnight.
4. Agree that they will write an account that evening.
Example language (illustrative): "Is there a photo or object you'd like to have with you on the day?"
Note on touch: no touch policy is described in the sources [uncertain]. If you work in a regulated programme, follow its written policy, and agree any supportive touch, such as a hand to hold, in advance with explicit, revocable consent. [synthesis]

B5. Motivational statement and intention (smoking model; adaptable)

Purpose: carry a condensed personal reason for change into the session. [source: Johnson et al. 2014; Bogenschutz & Forcehimes 2017 on intention]
Steps:
1. From the reasons-to-quit work (C3), the patient condenses their most important reasons into a brief statement.
2. They recite it immediately before each medication session.
Example language (illustrative): "Read it aloud once more, slowly, as you would like to carry it with you today."
Watch for: a statement written for others rather than for themselves. [synthesis]

B6. Booster preparation before later sessions

Purpose: update the plan using what the previous session taught. [source: Bogenschutz & Forcehimes 2017]
Steps: revisit each preparation topic, revise intentions and plans in light of the prior session, and finalise the plan for the coming session.
Example language (illustrative): "Last time you were surprised by how much came up about your brother. How would you like to approach the next session?"

B7. Therapist conduct during the medication session

Purpose: help the patient use the session productively. [source: Bogenschutz & Forcehimes 2017; Johnson et al. 2014; Johnson et al. 2026]
Steps:
1. Provide a calm, homelike room; the patient lies down with eyeshades and a standardised music programme on headphones for most of the session.
2. Encourage an inward focus.
3. Offer non-directive support, reassurance, grounding and redirection as needed, and no therapy content. In the smoking protocol, no smoking-specific content was delivered; one protocol added a short guided imagery at the end of the first session (see C10).
4. Do brief check-ins on mental state. Medical staff handle physiological monitoring.
5. When acute effects subside, allow open conversation about the experience.
6. At the end, carry out a mental status check and hand over to the support person.
Example language (illustrative): "You're safe. We're right here. Breathe and let it move through you." / "Would you like to go back under the eyeshades?"
Watch for: episodes of fear or feeling trapped. These occurred in 6 of 15 smoking-pilot participants and resolved with interpersonal support. Rare escalation, such as severe anxiety or dangerous blood pressure, is managed by medical staff under protocol. [source: Johnson et al. 2014; Bogenschutz et al. 2022 summary]

B8. Next-day debriefing

Purpose: check safety and begin integration. [source: Nielson et al. 2018; Bogenschutz & Forcehimes 2017]
Steps:
1. Carry out a mental status examination (thought process, content, perception, orientation), with safety screening and adverse-event follow-up.
2. Invite a detailed open-ended account of the experience, using the written narrative if available.
3. Explore its significance: changes in views of self, relationships, values and spirituality.
4. Ask about lasting positive or negative effects.
5. Ask how it relates to drinking or smoking.
6. Where useful, remind the patient of things they said during the session. No formal recall technique was used.
Example language (illustrative): "Take me through it from the beginning, in whatever order it comes." / "Where, if anywhere, did alcohol show up in all this?"
Watch for: difficulty putting the experience into words, and worry that others won't understand. Normalise this and avoid imposing interpretations. [source: Nielson et al. 2018]

B9. MI-linked integration

Purpose: turn insights into motivation and commitment. [source: Bogenschutz & Forcehimes 2017; Nielson et al. 2018]
Steps:
1. Use MI to explore how the session changed the patient's relationship to alcohol and their desire to change.
2. Reflect change talk.
3. Link insights to the values from A3.
4. Invite commitment.
5. Feed the result into the STORC plan (A5).
Example language (illustrative): "You said you saw yourself from your daughter's eyes. What does that tell you about what comes next?"
Watch for: frightening content left without meaning. Participants valued dysphoric moments once these were given meaning afterward. [source: Nielson et al. 2018]

B10. Extended integration

Purpose: consolidate change over weeks to months. [source: Bogenschutz & Forcehimes 2017]
Steps: across later sessions, help the patient form new understanding of their symptoms, experience cravings differently, set new intentions and make behavioural changes. Return to the experience whenever it is relevant to current struggles.
Example language (illustrative): "How is what you learned in that session showing up this week, especially on the hard evenings?"

Part C: CBT for smoking cessation (Johns Hopkins protocol)

The protocol is a manualised CBT largely based on the Quit For Life programme, delivered in four preparation meetings (about half CBT, half preparation) and then support meetings. Components below are as named in Johnson et al. (2014). The 2026 trial lists a diary, reasons to quit versus continue, health and financial drawbacks, and craving and withdrawal strategies. Session-by-session wording was not published. [source: Johnson et al. 2014; Johnson et al. 2026]

C1. Quit contract and target quit date

Purpose: formalise commitment and fix a quit date. In this protocol the date is anchored to the first medication session. [source: Johnson et al. 2014]
Steps:
1. At the first meeting, explain the quit-date logic.
2. The patient signs a written commitment to quit on that date.
3. Ask them not to use other cessation aids during the study. [source: Johnson et al. 2014; outside a trial, discuss evidence-based aids openly: synthesis]
Example language (illustrative): "This contract is a promise to yourself. Let's write the date in together."

C2. Smoking diary and timeline follow-back

Purpose: self-monitoring to reveal patterns and triggers. [source: Johnson et al. 2014]
Steps:
1. Introduce a daily diary at meeting 1, recording each cigarette with time, situation and mood. [fields: synthesis]
2. Review it at every meeting.
3. Complete a timeline follow-back of use since the last visit.
Example language (illustrative): "Looking at your diary, the after-dinner and phone-call cigarettes stand out. What's happening then?"
Watch for: missing entries. Simplify the format rather than criticise. [synthesis]

C3. Reasons to quit versus reasons to continue, condensed into a motivational statement

Purpose: decisional work that ends in a short personal statement carried into the session (see B5). [source: Johnson et al. 2014; Johnson et al. 2026]
Steps:
1. List reasons to quit and reasons to keep smoking.
2. Weigh them.
3. Pick the most important reasons to quit.
4. Condense them into a brief statement in the patient's own words.
Example language (illustrative): "Of everything on the 'quit' side, which two or three would you most want to remember on a hard day?"

C4. Health, cost and weight information, and review of past quit attempts

Purpose: inform the patient, address weight-gain concerns, and learn from what helped or failed before. [source: Johnson et al. 2014; Johnson et al. 2026]
Steps:
1. Discuss health and financial drawbacks in the patient's terms.
2. Address weight concerns without setting weight targets.
3. Review each prior attempt: what helped, what triggered relapse.
Example language (illustrative): "Last time you lasted three weeks. What was working before the slip?"

C5. Reframing withdrawal as recovery

Purpose: reinterpret withdrawal symptoms as signs of the body recovering. [source: Johnson et al. 2014]
Steps: describe common withdrawal symptoms, frame them as time-limited recovery, and plan coping for each. [coping plan: synthesis]
Example language (illustrative): "That irritability is your system recalibrating. It's a sign of recovery, and it passes."

C6. Trigger-awareness card ("pause, think, deprogram")

Purpose: interrupt automatic smoking by noticing the urge and naming its trigger. [source: Johnson et al. 2014]
Steps:
1. Give the patient a pocket card that prompts them to notice the urge and ask what triggered it.
2. They pause, think, and "deprogram" the link.
3. Review card use from the diary.
Example language (illustrative): "When you reach for one, take the card out first. What set it off?"

C7. Post-cigarette card

Purpose: before the quit date, weaken the reward value of each cigarette. [source: Johnson et al. 2014]
Steps:
1. After each cigarette, the patient reads a card reinforcing how unsatisfying it was and their waning desire to smoke.
2. Review their reactions at the next meeting.
Example language (illustrative): "Right after that cigarette, how satisfying was it, honestly, out of ten?"

C8. Urge management after the quit date

Purpose: cope with cravings without smoking. [source: Johnson et al. 2014; Johnson et al. 2026]
Steps: build a list of urge strategies: delay, distraction, breathing, a change of setting, calling support, and the scent cue (C11). Rehearse them in session and review use. [specific strategies: synthesis]
Example language (illustrative): "Cravings peak and fall within minutes. What will you do for those few minutes?"

C9. Brief mindfulness (body scan)

Purpose: build present-moment awareness for urge surfing and for meeting the session experience. [source: Johnson et al. 2014]
Steps: open each preparation and support meeting with a body-scan meditation of under ten minutes, then briefly debrief it.
Example language (illustrative): "Let your attention rest on your feet... now your legs... noticing, without needing to change anything."
Watch for: distress during interoceptive focus in trauma survivors. Offer eyes-open practice and external anchors. [synthesis]

C10. Guided imagery

Purpose: rehearse life as a non-smoker and strengthen motivation. [source: Johnson et al. 2014]
Steps: use brief imagery exercises (under ten minutes) in preparation and support meetings, plus one near the end of the first medication session, once acute effects have eased. The imagery content was not published [uncertain]; a typical theme is coping successfully in a trigger situation [synthesis].
Example language (illustrative): "Picture yourself next month, after dinner, coffee in hand, at ease without a cigarette. Notice how that feels."

C11. Scent cue

Purpose: a portable conditioned cue for calm and commitment. [source: Johnson et al. 2014]
Steps:
1. The patient smells a chosen scented oil during meetings.
2. They receive a supply at the quit date.
3. They use it whenever craving arises.
Example language (illustrative): "Each time you smell this, let it bring back why you chose to quit."

C12. Post-session journaling

Purpose: capture the experience while it is fresh, to use in debriefing. [source: Johnson et al. 2014; Bogenschutz & Forcehimes 2017]
Steps: the evening after each session, the patient writes an open-ended narrative, which is discussed the next day (B8).
Example language (illustrative): "Write it however it comes: images, feelings, fragments. Bring it tomorrow."

C13. Brief daily contact after the quit date

Purpose: close support in the highest-risk days. [source: Johnson et al. 2014; Johnson et al. 2026]
Steps: make short daily phone or text check-ins (under five minutes) for one to two weeks after the quit date, covering status, one encouragement and one coping reminder. [content: synthesis]
Example language (illustrative): "Day three. How are you doing, and what's the plan for tonight?"

C14. Support meetings and relapse prevention

Purpose: sustain abstinence, review CBT techniques, integrate the experience and give encouragement. [source: Johnson et al. 2014; Johnson et al. 2026]
Steps:
1. Open with a body scan.
2. Review the diary and verification result.
3. Discuss the session experience as relevant.
4. Problem-solve high-risk situations.
5. Close with imagery.
- If a lapse occurs, treat it as a learning event and re-plan (standard relapse-prevention practice). [synthesis]
Example language (illustrative): "One cigarette doesn't erase the weeks you've done. What led up to it?"

C15. Biological verification

Purpose: objective feedback and outcome measurement. [source: Johnson et al. 2014]
Steps: measure breath carbon monoxide (roughly the last day of smoking) and urine cotinine (roughly the last week) at intake, at each intervention week and at follow-up, using protocol cut-offs. Share results with the patient as feedback. [feedback use: synthesis]

Part D: Ketamine plus MET (Dakwar et al. 2020; research protocol)

D1. MET built around a ketamine session

Purpose: use a short-lived window of increased motivation after the session. [source: Dakwar et al. 2020 via Blossom summary]
Steps:
1. Hold a goal-setting MET session.
2. Continue weekly MET.
3. The ketamine session takes place on a predesignated quit day, with relaxation and mindfulness exercises before and during it; medical staff monitor and cover the patient afterwards.
4. Hold an extra MET session about a day after the session to build on any motivational change.
5. Continue weekly MET to the end.
- Participants were told they might receive one of several psychoactive compounds, to reduce expectancy effects.
Example language (illustrative): "Yesterday was your quit day. Looking back on it now, what feels different about drinking, if anything?"
Watch for: transient dissociation and mild agitation after the session; sedation and headache were common in both arms. How the experience itself was used in therapy is not described [uncertain].

Part E: Applications outside trials [synthesis]

E1. Harm-reduction and integration support for clients using psychedelics outside clinics

Purpose: keep clients safer and help them integrate experiences. This is not facilitation of illegal use. [synthesis, informed by the screening and integration elements above]
Steps:
1. Ask non-judgementally about any planned or past use.
2. Screen for the risk factors the trials excluded: personal or family history of psychosis or bipolar disorder, cardiovascular disease, pregnancy, other substance dependence, and current medications.
3. Explain in general terms that these raise risk and that drug interactions exist. Advise a medical review; do not give dosing information.
4. Discuss the elements the trials used for safety: a trusted sober support person, a safe setting, and a plan for distress and for getting home.
5. Explain the legal risks.
6. Offer referral to a regulated programme or clinical trial where one exists.
7. Afterwards, use the debriefing and integration steps (B8–B10) and the MET/CBT plan.
Example language (illustrative): "I won't help you plan the drug use itself, but I do want you safe, and I'm glad to help you make sense of whatever happens."
Watch for: new psychotic or manic symptoms, persistent perceptual changes or suicidality. Assess urgently and refer to medical or psychiatric care.

5. Handling problems

Low or fluctuating motivation before the medication session.

The sources prescribe MI to heighten motivation and values-discrepancy work. [source: Bogenschutz & Forcehimes 2017]
Return to the feedback report and values sort, and reflect ambivalence rather than pushing. [synthesis]
If a patient wants the drug session but not behaviour change, explore that openly. Within a programme, discuss with the team whether the session should go ahead. [synthesis]

Fear, panic or feeling trapped during the session.

These occurred in 40% of smoking-pilot participants and resolved with interpersonal support. [source: Johnson et al. 2014]
Respond with reassurance, grounding (breath, voice, the reminder that the effects are time-limited), and redirection inwards or back under the eyeshades if the patient wishes. [source: Bogenschutz & Forcehimes 2017; Nielson et al. 2018]
Don't push surrender.
If distress escalates beyond support, or blood pressure or psychotic symptoms become dangerous, medical staff manage it under protocol. Rescue medication was used for anxiety in two RCT participants and once for hypertension in the 2026 trial. [source: Bogenschutz et al. 2022 summary; Johnson et al. 2026]

Suicidal thoughts.

One RCT participant had brief passive suicidal ideation during a session, which resolved without consequences. [source: Bogenschutz et al. 2022 summary]
Assess at the post-session mental status examination and at every debriefing using standard risk assessment. Update the safety plan, and escalate to psychiatric care if risk is present. [synthesis]

Overwhelm or destabilisation afterwards.

Debriefings include a mental status examination and follow-up of adverse events. [source: Bogenschutz & Forcehimes 2017]
Watch for persisting anxiety, perceptual changes, insomnia, derealisation or emerging mania or psychosis. None persisted in the RCT. [source: Bogenschutz et al. 2022 summary]
Offer extra contact, grounding skills and medical review. [synthesis]
Headache after the session was common and should be anticipated and normalised. [source: Johnson et al. 2014; Bogenschutz et al. 2022 summary]

Difficult or meaningless-seeming experiences.

Participants valued dysphoric moments once these were given meaning afterward. [source: Nielson et al. 2018]
Work collaboratively on meaning in later sessions. Don't impose interpretations.
If a patient reports "nothing happened", treat that as information, and keep the MET/CBT plan as the main treatment. [synthesis]

Difficulty putting the experience into words, isolation and stigma.

Participants struggled to describe the experience and faced stigma around both addiction and psychedelics, and some kept the experience private. The team acts as a temporary support network. [source: Nielson et al. 2018]
Help the patient decide what to share and with whom. Build alternative supports, such as mutual-help groups and sober networks (module A6). [synthesis]

Over-reliance on the drug experience ("I'm cured").

Reinforce that the psychotherapy and the behaviour plan carry the change. Schedule lapse planning even when motivation is high. [synthesis]

Lapse or relapse.

The alcohol model has no specific relapse protocol beyond revisiting and revising the plan and addressing barriers. [source: Bogenschutz & Forcehimes 2017]
Use a standard relapse-prevention analysis: chain of events, coping gaps, and a revised plan. Avoid the abstinence-violation effect. [synthesis]

Non-adherence (missed sessions, no diary, plan not used).

Re-engagement is a named META task. [source: Bogenschutz & Forcehimes 2017]
Simplify homework and explore barriers without blame. Offer phone sessions; some sessions in the pilot were held by phone. [source: Nielson et al. 2018; rest synthesis]

Ruptures.

The sources do not address ruptures directly. [synthesis throughout]
With two therapists, check that the patient trusts both; triangulation or a preference for one is common.
Name any strain directly and invite feedback.
After a medication session, a patient may feel exposed or ashamed about what they said or did. Acknowledge this and reaffirm confidentiality and boundaries.
If trust with one team member is broken, discuss changing the team before a further medication session; recall that a substitute needs at least two prior meetings.

Boundary and touch issues.

The sources state no touch policy. [uncertain]
The team composition (a mixed-gender dyad, a support person present at discharge) reflects safeguarding aims. [source: Bogenschutz & Forcehimes 2017]
Agree any touch in advance with explicit, revocable consent and document it. Never sexualised contact; report any concern under your professional code. [synthesis]

Expectancy and blinding.

In the RCT, participants and therapists guessed the assigned condition in more than 90% of sessions. [source: Bogenschutz et al. 2022 summary]
In practice, expect patients to know what they received, and manage expectancy openly in preparation. [synthesis]

Clients seeking or using psychedelics outside legal programmes.

Follow E1. Do not source, supervise or plan use. Document a harm-reduction rationale. Check your licensing board's and insurer's position. In jurisdictions such as Oregon or Colorado, clarify the difference between your psychotherapy role and licensed facilitation. [synthesis; regulatory frame from ASTHO 2023]

Ineligible clients.

People with psychotic or bipolar disorders, cardiovascular disease, pregnancy or other contraindications were excluded from these protocols. Offer them evidence-based MET/CBT without the drug component, which is the core of these models. [source: exclusion lists as above; synthesis]

Sources

Sources: