In recent years, much attention has been focused on studies involving psychedelics, including MDMA. The debate concerns not only the substance itself, but also, and perhaps more importantly, what happens surrounding the session. A recent systematic review poses a seemingly simple but important question: is the “psychological support” in psychedelic trials primarily a safety framework, or does that support usually function as psychotherapy in practice?
That question is more than a matter of definition. How we name guidance has implications for educational requirements, ethics, study design, and potentially later for how care is organized. Below, we explain what the review investigated, what the findings mean for MDMA trials, and how to understand the difference between psychotherapy and a harm reduction framework. In doing so, we explicitly distinguish between research findings and practical interpretation.
What exactly is the review about?
The review at issue here describes no new outcomes for patients, nor does it compare which guidance “works best.” Instead, the authors analyze how psychological support is described and structured in existing clinical trials with psilocybin, MDMA, and LSD. The core question is: does that support meet standard criteria to count as psychotherapy?
The researchers conducted a systematic review according to PRISMA guidelines. They searched PubMed and PsycINFO for clinical studies that explicitly described participants receiving psychological support. Subsequently, they assessed the interventions using a so-called “common factors framework” with four criteria that frequently appear in definitions of psychotherapy. These include elements such as a structured working relationship, a psychological model or rationale, a goal-oriented approach, and techniques aimed at change.
You can find more background on this review in the source: Psychological support in psychedelic trials is usually only psychotherapy..
What did the authors think (and what didn't)?
The authors screened 224 records, assessed 52 full texts, and ultimately included 29 clinical studies with a total of 449 participants. Of these 29 studies, 69 percent met all four criteria of the Common Factors Framework. In other words, in the majority of the described trials, the support appears to qualify as psychotherapy based on the trial description.
The difference between studies that do and do not label themselves as psychotherapy is striking. Of the 19 studies with a psychotherapy label, 84 percent met all four factors. However, even in studies that did not call it that, 40 percent still met all criteria. The suggestion is that psychotherapeutic elements are often present, even when researchers prefer to frame the guidance more neutrally as “support” or “psychological support”.
It is important to add nuance: this says nothing definitive about effectiveness. The review does not show that “more psychotherapy” automatically leads to better or safer outcomes. It concerns the classification of what actually happens in trials, based on what researchers write down. Therefore, if descriptions are incomplete, they may contain an underestimation or overestimation.
Why the distinction matters in MDMA trials
In MDMA research, set and setting have long been a central theme: how someone feels, what expectations exist, and how the environment and guidance are structured. If that guidance has psychotherapeutic characteristics in practice, this has consequences for how we interpret the results.
Suppose a trial shows positive outcomes. Then the question is: what contributed to this? The pharmacological effects of MDMA, the psychotherapeutic interventions, the combination, or also factors such as participant selection and intensive screening? If we describe guidance “merely” as a safety framework, there is a risk that we underestimate the active role of the therapeutic relationship and interventions.
Conversely, viewing guidance as psychotherapy raises questions regarding education and competencies. Psychotherapy is a field with its own standards, boundaries, and ethical responsibilities. The review therefore emphasizes implications for the training of counselors, the time investment surrounding sessions, and the careful acknowledgment of the complexity of the intervention.
Psychotherapy versus harm reduction: two frameworks, sometimes with overlap
In discussions about MDMA, you encounter roughly two perspectives: a psychotherapeutic framework and a harm reduction framework. In practice, these can overlap, but the starting point is different.
Within a psychotherapeutic framework, the emphasis lies on the treatment of psychological complaints with an explicit goal of change. This may mean that a therapeutic model is used, that work is done with themes from a person's life, and that there is a process involving preparation and integration. The therapeutic relationship is then an active part of the intervention.
In a harm reduction framework, the emphasis lies on risk mitigation and safety. This involves, for example, risk screening, agreements regarding the setting, sober support, and practical guidance during difficult moments. The goal is not necessarily “treatment,” but rather reducing the risk of harm and supporting someone to navigate an intense experience as safely as possible.
The review makes clear that many trials contain elements that go beyond mere safety monitoring. This does not mean that harm reduction is unimportant, but rather that the word “support” sometimes obscures the number of therapeutic components included in the protocol.
What does this mean for study design and interpretation of results?
If support in trials is usually psychotherapy, it becomes methodologically more difficult to isolate the specific contribution of MDMA. This is not necessarily a problem, as long as it is acknowledged and carefully documented. However, it does call for transparency: which sessions are conducted, how long does the process last, which interventions are permitted, and how are therapists trained and supervised?
The authors also point out an ethical dimension. When a trial is a complex intervention involving a strong therapeutic relationship and intensive guidance, this must be taken seriously in informed consent, expectation management, and aftercare. Here, “complex” does not automatically mean “better” or “worse,” but rather that multiple active and risk-determining factors are at play simultaneously.
Finally, the source mentions an interesting idea: to better understand the effects of psychedelics, one could also design trials with minimal psychotherapeutic support. At the same time, this raises tension, because less support might also entail other risks or ethical questions. There is no simple consensus on this yet, and that is precisely why this debate is important.
Practical context: what is and isn't allowed outside of research?
In the Netherlands, it is important to remain factual regarding the context in which MDMA sessions are discussed. Currently, MDMA sessions can only be discussed within scientific research or in clinical practice within a harm reduction context. This means that “therapy” in the everyday sense does not simply equate to a clinical treatment trajectory such as in trials, with fixed protocols, medical screening, and research structures.
Anyone exploring their options would do well to critically examine the language used. Is there talk of treatment and psychotherapy, or of guidance and safety? How concrete is the discussion regarding preparation, during-session support, and post-session integration? And what boundaries are set regarding what is and is not promised? It is wise to look for providers who are transparent about their framework and who do not offer guarantees regarding outcomes.
If you would like to know more about the possibilities for a guided session within a harm reduction framework, you can explore your options via sign up for an MDMA session. View this as practical information and not as individual medical advice.
Conclusion
The review discussed shows that psychological support in many psychedelic trials, including studies involving MDMA, often exhibits characteristics of psychotherapy in practice, even when not always labeled as such. This insight helps to interpret research results more realistically and underscores the importance of clear training, ethics, and transparency regarding exactly what guidance entails. For those orienting themselves outside of research, it is particularly relevant to understand the distinction between a psychotherapeutic treatment model and a harm reduction framework, and to keep expectations realistic and factual.
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