A Perspective for Enhancing the Supervision of Psychedelic-Assisted Therapy: Motivational-Interviewing-Enhanced Integration Supervision (MIE-IS)
Round 1
Reviewer 1 Report
Comments and Suggestions for Authorssee attached.
Comments for author File: 
Comments.pdf
Author Response
Comments 1:
Major Concerns:
Background Needed – Guidelines:
I did a Google search of "psychedelic assisted treatment guidelines" and found several papers/reviews. Is there a single accepted set of “guidelines” for psychedelic-assisted treatments? If there is a “holy grail” set of guidelines, the authors should describe that in brief. If not, the authors should note that and describe in brief the various guidelines, where they agree and where they disagree. Then perhaps the authors could explain how this paper fits into the context of existing suggested guidelines?
Response 1:
We sincerely thank the reviewer for this thoughtful and constructive suggestion. The fact that we have no gold standard is, indeed, part of the problem. We are asserting that trying to have a model of all of the PAT supervision process might be too ambitious. We agree that contextualizing our proposed model within the broader landscape of psychedelic-assisted therapy (PAT) guidelines strengthens the manuscript. In the revised draft, we now make it clear that while multiple frameworks exist, no universally accepted set of guidelines currently governs training, practice, or supervision in PAT.
On page 2, paragraph 2, lines 66-68 of the manuscript, we write:
Previous work has already provided thorough, detailed models for training therapists in PAT [6-7], but markedly fewer publications address the role of clinical supervision specific to this field.
To help orient the reader, we also acknowledge the scope of our work on page 2, paragraph 1, lines 57-62 as we mentioned above:
Given the breadth of both the psychedelic psychotherapy literature and the supervision literature more broadly, a comprehensive review of either is beyond the scope of this paper. Instead, we aim to highlight key themes most relevant to the unique supervisory needs of psychedelic-assisted therapy and propose a targeted model that may help guide future training and research.
We further emphasize the tentative, generative nature of our proposal on page 5, paragraph 1, lines 202-204.
We have invented this approach in hope of generating relevant discourse, empirical work, and action rather than proclaim it as the definitive framework.
Finally, to clarify how our model builds upon and complements existing practices, we include a new side-by-side comparison on page 5 in Table 1: Key features of stereotypical traditional clinical supervision and additional elements proposed in the MIE-IS model. This addition directly addresses the reviewer’s request by distinguishing what is shared across models and what MIE-IS adds—particularly in the realm of integration, MI-consistent process elements, and attention to therapist values and meaning-making.
We are grateful for the reviewer’s guidance in helping us strengthen this foundational context.
Comment 2:
Definition of terms and roles:
- Supervisor
- Trainee
- Client
- Therapist
- Integration
Response 2: The reviewer then turns to definitions of terms and roles, echoing the previous reviewer’s concerns. We mentioned several of these above but reiterate here for a thorough response:
Supervisor
Page 2, paragraph 2, lines 68-70
Clinical supervision is a structured, collaborative process in which a more experienced clinician (the supervisor) helps develop the skills, insight, and ethical practice of a clinician-in-training or peer (the trainee).
Trainee
See above, on page 2, paragraph 2, lines 68-70
Clinical supervision is a structured, collaborative process in which a more experienced clinician (the supervisor) helps develop the skills, insight, and ethical practice of a clinician-in-training or peer (the trainee).
Page 2, paragraph 2, lines 70-71
Supervision typically aims to promote client welfare, build trainee competence, and ensure ethical fidelity.
(Also referenced throughout as the recipient of psychedelic-assisted therapy, particularly in contrast to the therapist or trainee.)
Therapist
Page 2, paragraph 2, lines 76-78
In PAT, the therapist’s role often shifts across phases—sometimes offering structure and containment, and other times allowing space for clients to lead with their own meaning-making.
Integration
Page 1, paragraph 1, lines 52-54, with the clearest definition on page 1.
Integration sessions, which focus on helping clients process and apply insights from their psychedelic experiences, are especially crucial for achieving lasting therapeutic benefits [6].
Comment 3:
Supervisor-Trainee-Client Triad?The significance of framing the process of treatment in the context of the triad of supervisors, trainers, and clients is unclear to me. From my own admitted ignorance, I have the following question: does other, i.e., non-PAT, treatment in psychiatry have this supervisor, trainee, client triad, or is this approach unique to PAT? If this is the norm in psychiatry and psychological counseling, please say that. If it is unique to PAT, please say that. And then say, why does it exist?
Response 3:
We can’t thank this reviewer enough for bringing up the functioning of the triad, which has helped us reframe the whole paper. On page 6, paragraph 1, lines 235 - 237.
In a sense, our unit of analysis is the triad of supervisor, therapist, and client. Enhancing the functioning of this triad becomes the goal of the supervision.
Table 1 further highlights some of these disparities as well. We appreciate this opportunity to clarify the manuscript’s emphasis. Comment 4: Evidence that Supervision Needs Improvement?
The title of the article suggests that current supervision of PAT is somehow lacking. Please explain why supervision needs enhancing. Response 4:
We thank the reviewer for this important comment. We appreciate the opportunity to clarify these points and recognize that they would benefit from additional emphasis. We fully agree that clarifying the rationale for enhancing supervision is essential. As described in Section 1.1 of the revised manuscript, we aim to build from a foundation that acknowledges both the promise and limitations of existing supervision practices in general psychotherapy and how these concerns apply to the emerging field of psychedelic-assisted therapy (PAT).
As noted on page 2, paragraph 2, lines 71- 80.
“supervision is ubiquitous in traditional psychotherapy training… the lack of established models focused specifically on PAT supervision leaves a significant gap in the field, potentially affecting both trainee development and client outcomes.”
On page 3, paragraph 2, lines 116-125 we begin a detailed review of the broader supervision literature, emphasizing how little supervision seems to contribute to outcomes.
Despite widespread enthusiasm, research that evaluates supervision’s impact on client outcomes has produced, at best, mixed results. While studies suggest that supervision improves therapist confidence and self-efficacy [17-18], the direct effect on client treatment outcomes remains unclear. A study using a reliable measure of client progress [19] found that supervision accounted for only 0.04% of the variance in client outcomes [20]. A replication study in university counseling centers found that the impact of supervision on client outcomes was not only statistically insignificant but accounted for literally 0.00% of the variance in outcome [21]. These findings, supported by data from thousands of clients and hundreds of therapists, raise concerns about whether supervision, as traditionally practiced, meaningfully enhances therapy effectiveness.
We acknowledge that this concern extends beyond PAT. In fact, page 3, paragraph 3, lines 128-142 read:
These two findings that disconfirm the efficacy of supervision on treatment outcomes are not anomalies. Despite heartfelt enthusiasm among supervisors and trainees, multiple reviews over many decades consistently note small effects of supervision on outcomes [18, 22]. One review identified common supervision elements recommended across multiple professional associations, such as goal setting and formal evaluation [23]. Although some elements significantly improved measures of client impressions of treatment, methodo-logical shortcomings weakened causal arguments. While supervision improved trainee competence, alliance, and self-efficacy, the link between supervision and client outcomes remained unclear or exceedingly small [18]. A review specific to cognitive behavioral therapy supervision reports that only one of five studies documented a positive impact of supervision on treatment outcomes [24]. A meta-review of 20 previous reviews empha-sized the weak empirical evidence for supervision’s impact on outcomes as well [18]. If supervision has a direct effect on outcome, we have yet to identify it. PAT provides a novel opportunity to enhance supervision and supervision research because of the novel vulnerabilities associated with the effects of psychedelics.
Nevertheless, we argue that this gap creates a strong rationale for intervention-specific models such as the one we propose. PAT provides a novel opportunity to strengthen supervision (and supervision research) for the whole field. Page 4, paragraph 1, lines 169-178 attempts to drive these points home:
Considering these concerns, a tailored model of supervision that focuses on how to improve both trainee and client outcomes during a specific treatment phase within a specific intervention might yield stronger empirical support. In the context of PAT, supervision focused on enhancing a critical phase of treatment (integration) offers a direct path to improved outcomes. Integration often solidifies the therapeutic work that clients perform during PAT [25]. Supervision that strives to enhance therapists’ ability to facilitate the integration process could effectively bridge the gap between psychedelic experiences and lasting psychological growth. With refined supervision practices that target specific therapeutic processes within an intervention, the field can move beyond the notion that a supervisor’s years of experience alone leads to trainee competency and client well-being.
Integration?
Define “integration” in the context of PAT. Is this code for having supervisors and trainers who have had direct experience with psychedelics and can therefore better assist patients to “integrate” their psychedelic experiences into their personal situations? If that is not what you mean by “integration,” what do you mean? Can a trainer assist the patient with “integration” if he/she has no past personal experience with psychedelic use? Is that the point?
Consider, for example, that many substance use disorder counselors are recovering addicts (to use the old term), and some would argue that their past experience with drug abuse makes them better counselors. Is there a comparable situation with PAT? That is, what is the literature on the value—if any—associated with having supervisors and trainers who have personally used psychedelic agents? Does this fit into the “increased integration” concept, or is that something entirely different?
Response 5:We are eager to sidestep some of these issues because they have generated so much trouble in published work as well. We go into detail about the definition of integration on page 1, as mentioned above, on page 2, paragraph 1, lines 52-54.
Integration sessions, which focus on helping clients process and apply insights from their psychedelic experiences, are especially crucial for achieving lasting therapeutic benefits [6].
But as this reviewer has emphasized, the meta-message seems to be that “integration” might require personal use. Another publication addresses this issue in detail [30] and we cite that paper extensively. We elaborate on this issue in a new section, on page 7, paragraph 4, lines 285-298.
The issues of small improvements that can accumulate over time does suggest some key hypotheses about personal use of psychedelics among therapists and supervisors. Although the topic appears in detail elsewhere [30], we note that data suggest that the majority of relevant trainees already have relevant personal experience [31]. Potential clients genuinely think that personal use is important for those who assist with psychedelic interventions [32]. Although randomly assigning trainees to receive a psychedelic raises ethical concerns, even the logistics of answering such an empirical question are humbling. Based on effect size estimates from other therapist research, power analyses reveal that an experiment with 80–160 participants could offer meaningful data. An ideal design would require 80 therapists treating 30 clients each [30]. We note that few studies on psychedelics or supervision have received adequate funding for such a project. We do not mean to imply that personal use is essential to the therapy or supervision process, as no data have linked personal use to client outcomes, and adequate statistical power for addressing the issue would make gathering relevant, definitive data extremely challenging.
Training the Trainer:
In general, this paper argues for a “training the trainer” approach, which makes sense, but is that unique to PAT? What, if anything, does it have to do with PAT as opposed to any other therapy?
We wholeheartedly agree. Psychotherapy supervision researchers, however, apparently do not.
We assert that PAT provides a novel opportunity for “training the trainer” given the unique vulnerabilities associated with the acute effects of the psychoactive molecules. We DO now emphasize that, should these data look compelling, perhaps investigators will provide broader attention throughout psychotherapy supervision research. We attempt to be straightforward about these facts at the start of the paper. page 2, paragraph 1, lines 56-57 now reads:
Supervising trainees so they can master these skills presents numerous challenges, some unique to PAT and some that overlap with general psychotherapy supervision.
We also underscore these points on page 12, paragraph 1, lines 543-546 as we detail how comparable work could benefit all of psychotherapy supervision research.
We do note that comparable research on psychotherapy supervision in the absence of a psychoactive molecule would undoubtedly benefit from a comparable approach, especially given the small effects supervision appears to have on client outcomes.
Comment 7:
MIE-IS: Motivational-Interviewing-Enhanced Integration-Specific:What does that mean beyond having a good supervisor leads to better outcomes? Put another way, are the authors simply saying that the better the supervisor, the better the outcome for patients? If this is the argument, this does not seem to be unique to PAT; good supervisors would be expected to make for better operations further down the chain for many situations.
Response 7:
We appreciate the opportunity to emphasize this key point earlier in the paper. We first emphasized in section 1.1 that the field has no data suggesting that supervision alters client outcomes directly. In general psychotherapy, Goldberg’s data suggest that supervision accounts for literally 0% of the variance in outcomes. As we assert, part of the problem might be that current models of supervision are attempting to do too much. We emphasize this idea early. Page 1, lines 11-13 now read:
Current data suggest that, despite supervisor reports or the enthusiasm of trainees, supervision accounts for extraordinarily little variance in treatment outcome.And on page 2, paragraph 1, lines 62-65:
We note that our new model focuses exclusively on integration. Other models of supervision account for little variance in outcome, as we detail below. We assert that those models might be too ambitious for PAT, and encourage a more focused approach. Comment 8: To go back to an earlier point, in my naive mind, perhaps the single most important difference between PAT and any other interview/conversational therapy is that the psychedelic drug experience is something that therapists might—or might not—have any experience with, even outside the practice situation. Has the question of whether a therapist has—or has not—ever had a psychedelic drug experience been considered a relevant factor? If this has been addressed already, I did not see it referenced in the paper. And this is a clear “do-able” goal if there is evidence that such “hands-on” experience helps the therapist be a better therapist… Response 8:Again, we could not agree more. We thank the reviewer for “calling the room” on this issue and hope that this new paragraph can point readers in the right direction. We do note that the ethics behind such a do-able goal have generated a lot of conversation, as proving that a simple intervention like providing a therapist with a relevant psychedelic experience has tied North American trainees in some rather uncomfortable knots. As mentioned above, on page 7, paragraph 4, lines 285-298:
The issues of small improvements that can accumulate over time does suggest some key hypotheses about personal use of psychedelics among therapists and supervisors. Although the topic appears in detail elsewhere [30], we note that data suggest that the majority of relevant trainees already have relevant personal experience [31]. Potential clients genuinely think that personal use is important for those who assist with psychedelic interventions [32]. Although randomly assigning trainees to receive a psychedelic raises ethical concerns, even the logistics of answering such an empirical question are humbling. Based on effect size estimates from other therapist research, power analyses reveal that an experiment with 80–160 participants could offer meaningful data. An ideal design would require 80 therapists treating 30 clients each [30]. We note that few studies on psychedelics or supervision have received adequate funding for such a project. We do not mean to imply that personal use is essential to the therapy or supervision process, as no data have linked personal use to client outcomes, and adequate statistical power for addressing the issue would make gathering relevant, definitive data extremely challenging.
We believe that these changes have strengthened the paper dramatically. We appreciate the chance to make these revisions and hope to hear from you soon. We’re very excited about seeing how this work might appeal to your readers.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe article is devoted to the prospect of introducing a new supervision method for psychedelic-assisted therapy (PAT). The article is devoted to an interesting topic that has not been much covered by the literature before. The material of the article is structured and corresponds to the manuscript type ‘perspective’.
The Introduction chapter explains why specific supervision is appropriate in the case of PAT, but it is interesting to see the authors' views on whether specific supervision is needed for each of the existing psychedelics or whether the choice of drug is not important. The use of different drugs would probably require different supervision.
It would be useful for readers if the authors would describe how widely PAT is currently used and in which countries this type of therapy is allowed. Without this, the scope of the topic is not clear.
The type of article perspective assumes a wide readership and therefore requires precise definitions for all terms. It is important to provide a detailed definition of PAT and where it applies. It is also important to provide a definition of supervision and a more detailed definition of MI. Without this it is not clear what variations the authors are considering.
Chapter 1.2 is entitled «The Role of Motivational Interviewing in PAT Supervision». I was expecting to see research describing the impact of current supervision methods in PAT. However, the section describes a new method proposed by the authors. Perhaps the title of the chapter could be adjusted.
The authors suggest the use of ‘Motivational Interviewing Enhanced Integration Specific (MIE-IS)’, but I was unable to find a description of this term in the literature. The authors should note that MIE-IS is their original idea, which has not been described previously, if this is the case.
Figure 1 shows a schematic of the MI-Enhanced Integration Supervision, but it is not clear how this differs from the previously used models. If the authors add a schematic of the old model for comparison, it would improve the clarity of the article.
The scheme also shows the link between the supervisor and the client, does this mean that the supervisor should interact with the patient without therapist?
In general, it is not clear what new elements should be part of supervision according to the authors. The authors should provide a list of mandatory elements of their approach that have not been used before. This is important to demonstrate the novelty of the idea and its key features. Moreover, if the authors give a brief example of a session with MIE-IS, it will make the authors' position clearer.
I recommend adding the name of the new method (MIE-IS) to the Abstract and possibly to the title of the manuscript. This will make the literature search easier for researchers.
In conclusion the authors can give an example of an experiment model that will demonstrate the positive impact of MIE-IS. This will help other researchers to verify the performance of the method. If the authors describe which key parameters of therapy will be improved after the implementation of their method and how these parameters can be controlled, it will be easier for researchers to verify their approach.
The general idea of the authors is clear to me, but I recommend the authors to improve their manuscript and make the description of their method and the possibility of its verification more unambiguous.
Author Response
Comment 1:
The Introduction chapter explains why specific supervision is appropriate in the case of PAT, but it is interesting to see the authors' views on whether specific supervision is needed for each of the existing psychedelics or whether the choice of drug is not important. The use of different drugs would probably require different supervision.Response 1:
We appreciated these ideas and added to page 11, paragraph 3, lines 507-513 which emphasizes that supervision with different drugs would have incredible potential, as the reviewer emphasizes:
Although we developed our model to support integration across a range of psychedelic-assisted therapies, different psychedelics might eventually warrant unique supervisory considerations. For example, the extended duration and intensity of ibogaine sessions [39], the empathogenic effects of MDMA (K-B & B), or the rapid arc of ketamine experiences might require tailored approaches. Future work could examine whether substance-specific adaptations to supervision protocols improve outcomes for trainees and clients alike.
Comment 2:
It would be useful for readers if the authors would describe how widely PAT is currently used and in which countries this type of therapy is allowed. Without this, the scope of the topic is not clear.
Response 2:
Good point! We added this information right up front so page 1, paragraph 1, lines 36-43 read:
Psychedelic-assisted therapy (PAT) is gaining continued attention as a promising approach for treating a variety of mental health conditions. Clinicians legally use keta-mine off-label for mental health treatment in the U.S., Canada, the U.K., and Australia [1-4]. North American countries permit clinical trials for other psychedelics. Oregon and Colorado have legalized regulated psilocybin services; Canada permits psychedelic therapy under its Special Access Program. Several European countries, including Switzerland and the Netherlands, allow limited supervised use as well [1, 5].Comment 3:
The type of article perspective assumes a wide readership and therefore requires precise definitions for all terms. It is important to provide a detailed definition of PAT and where it applies. It is also important to provide a definition of supervision and a more detailed definition of MI. Without this it is not clear what variations the authors are considering.Response 3:
These issues required providing more detail about each of these terms, so the changes appear in several separate places. We didn’t want to list a bunch of definitions, so we define and describe PAT right up front, in the second paragraph of the whole paper. (The other reviewer had comparable concerns that we will mention later.)
We define supervision in more detail on page 2, paragraph 2, lines 68-70
Clinical supervision is a structured, collaborative process in which a more experienced clinician (the supervisor) helps develop the skills, insight, and ethical practice of a clinician-in-training or peer (the trainee).
The elaborations on Motivational Interviewing are throughout, but a formal definition appears on page 5, paragraph 1, lines 208-213:
Motivational Interviewing is a collaborative, client-centered approach that helps individuals explore and resolve ambivalence to support behavior change in line with their values. In this case, the target behaviors involve the functioning of the triad of supervisor, trainee, and client. Successful outcomes will include not only improved functioning in the client but also enhanced skills in the trainees and supervisors, with self-care remaining appropriate for all three people.
Comment 4:
Chapter 1.2 is entitled «The Role of Motivational Interviewing in PAT Supervision». I was expecting to see research describing the impact of current supervision methods in PAT. However, the section describes a new method proposed by the authors. Perhaps the title of the chapter could be adjusted.
Response 4:
We now call this section on page 4, paragraph 2, line 182: “Proposing a MI-Enhanced Supervision Strategy for PAT.”
Comment 5:
The authors suggest the use of ‘Motivational Interviewing Enhanced Integration Specific (MIE-IS)’, but I was unable to find a description of this term in the literature. The authors should note that MIE-IS is their original idea, which has not been described previously, if this is the case.Response 5:
We were eager to point out our original idea but wanted to avoid sounding as if we overstating our contribution. Page 5, paragraph 1, lines 202-210 now reads:
We propose building from these characteristics of supervision to generate an innovative approach. Unlike traditional supervision models, which can rely on directive feedback, hierarchical oversight, or undocumented expertise, the Motivational-Interviewing-Enhanced Integration-Specific (MIE-IS or pronounced “my is”) model integrates Motivational Interviewing (MI) techniques directly into the supervisory process. We have invented this approach in hope of generating relevant discourse, empirical work, and action rather than proclaim it as the definitive framework. Motivational Interviewing is a collaborative, client-centered approach that helps individuals explore and resolve ambivalence to support behavior change in line with their values…
Comment 6:
Figure 1 shows a schematic of the MI-Enhanced Integration Supervision, but it is not clear how this differs from the previously used models. If the authors add a schematic of the old model for comparison, it would improve the clarity of the article.
Response 6:
This comment inspired Table 1, which now emphasizes multiple facets of supervision as currently practiced. We first mention the table and the relevant topics on page 4, paragraph 2, lines 183-192. Table 1 is on page 5.
Given these challenges, a new supervision model must address both the need for structured guidance in PAT and the lack of empirical support for existing supervision frameworks. Summarizing all of clinical supervision would require multiple volumes, but we highlight key components in Table 1, including primary goals, supervisor stance, trainee development, client representation, content focus, session process, theory integration, outcome orientation, and attention to therapist and supervisor experience. The traditional, or at least stereotypical models, tend to align with the topics described [12]. We are not asserting that all clinical supervision ends up exactly as we describe here, but relevant manuals and data suggest that a great deal of clinical supervision contains some of these components.
We then go into much more detail about clinical supervision as currently practiced within the table.
Comment 7:
The scheme also shows the link between the supervisor and the client, does this mean that the supervisor should interact with the patient without therapist?
Response 7:
We appreciate the chance to clarify this point! On page 5, paragraph 1, lines 233-235 we’ve added:
We note that although supervisors would rarely, if ever, speak directly to clients, their actions would impact client outcomes both directly and indirectly via changes in therapist behaviors.
Comment 8:
In general, it is not clear what new elements should be part of supervision according to the authors. The authors should provide a list of mandatory elements of their approach that have not been used before. This is important to demonstrate the novelty of the idea and its key features. Moreover, if the authors give a brief example of a session with MIE-IS, it will make the authors' position clearer.Response 8:
We were unable to fully address this without substantially lengthening the manuscript, potentially impacting readability and overall accessibility. We sincerely hope that Table 1 will provide a clearer idea of key features. We did, however, point readers toward a compelling article that provides a review of how to assess competence more broadly [40]. On page 12, paragraph 2, lines 539-543 we note:
Generally, MI-consistent behaviors in supervision sessions should predict comparable actions in therapy sessions, increased targeted integration actions in clients and trainees (and, ideally, in supervisors), decreased burnout, and client improvements. Strategies for assessing these competencies in both the supervisor and the trainee appear to have extensive empirical support [40].
Comment 9:
I recommend adding the name of the new method (MIE-IS) to the Abstract and possibly to the title of the manuscript. This will make the literature search easier for researchers.Response 9:
We’ve added these terms in both places. The new title now reads:
A Perspective for Enhancing Supervision of Psychedelic-
Assisted Therapy: Motivational-Interviewing-Enhanced Integration Supervision (MIE-IS)
The abstract on page 1, lines 15-21 reads:
Thus, we propose a model of supervision that rests on key Motivational Interviewing (MI) principles and supports the integration process—a pivotal phase of PAT where clients translate psychedelic-induced insights into meaningful behavioral change. This Motivational-Interviewing-Enhanced Integration Supervision (MIE-IS) model bridges the gap between psychedelic experiences and personal growth by ensuring supervisors can effectively encourage trainees to support their clients through this crucial integration process.
Comment 10:
In conclusion the authors can give an example of an experiment model that will demonstrate the positive impact of MIE-IS. This will help other researchers to verify the performance of the method. If the authors describe which key parameters of therapy will be improved after the implementation of their method and how these parameters can be controlled, it will be easier for researchers to verify their approach.
The general idea of the authors is clear to me, but I recommend the authors to improve their manuscript and make the description of their method and the possibility of its verification more unambiguous.
Response 10:
We now address verification of the supervision model in considerably more detail, though we were eager to avoid making the paper unduly long. The most dramatic changes appear in Section 1.6 Conclusion and the Clarion Call for Research on page 11, paragraph 2, lines 491-506:
To verify the MIE-IS model empirically, future researchers could conduct a randomized controlled trial comparing it to traditional supervision approaches. In an ideal version, researchers would randomly assign trainees to MIE-IS or supervision-as-usual, then assess changes in client integration behaviors, therapeutic outcomes, and alliance ratings. Researchers could code recorded supervision and therapy sessions for MI-consistent behaviors and measure outcomes such as client symptom reduction, reflective and application-based integration behaviors (e.g., via the IES and EIS), and ratings of supervisory and therapeutic alliance. On the provider side, they could track changes in trainee and supervisor functioning, including MI skill adoption, professional development, and self-care behaviors, as well as potential reductions in burnout (e.g., [29]). In a more pragmatic design, researchers might employ a quasi-experimental pre/post framework within clinics adopting MIE-IS, measuring changes in client-reported outcomes and therapist-reported burnout, professional satisfaction, and use of integration-promoting strategies. Across both models, key supervisory processes such as modeling, evocation, and autonomy support should covary with changes in relevant outcomes, allowing for verification and refinement of the approach.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsI have read and reviewed the revised manuscript by Earleywine and Olivia entitled “A perspective for enhancing supervision of psychedelic-assisted therapy: Motivation-Interviewing-Enhanced Integration Supervision (MEI-IS)’. This is an interesting paper on a very interesting topic. The manuscript reads a bit like a well-written ‘Background and Rationale’ section from a grant application, with the exception that there is no preliminary data provided. Although the manuscript is very well-written in terms of text editor issues, I still found the manuscript lacking in several areas. As I indicated earlier, I would guess that the authors intend for this paper to be read by a relatively wide audience. For these reasons I still cannot support publication without major revision.
Major Concerns:
Definition of Terms and Roles:
The authors adequately defined supervisor, trainee and client, thank you.
Integration:
Upon reading the revision, I now believe that the authors are talking about integration BOTH (1) in the absence of psychedelic drug use and (2) in the context of psychedelic drug use. If this is indeed the case, I think the authors need to be more clear regarding the type of integration they are writing about in various sections of the manuscript. Maybe a second term like ‘integration of drug experiences’ needs to be used? Also, if it’s true that the BIG QUESTION (the elephant in the room, if you will) is whether effective integration in the context of PAT might require psychedelic drug experience on the part of the trainee (therapist?), why do the authors avoid discussing this question/concern?
Figure 1: For readers to better see what you are doing with your model, perhaps you should show the more traditional model as well.
Page 7, lines 243-245: The authors talk about qualitative data that suggests “...integration bridges the psychedelic experience with everyday life and promotes lasting behavioral change….” They cite their own work on this. But is it really integration that does it? Griffiths et al (Psychopharmacology 2006) have shown that psychedelic use (presumably without much ‘integration’) produces profound and long-lasting life-changing experiences in human volunteers.
More MINOR Concerns (in order of their appearance in the manuscript):
Page 2, line 49: I would suggest “sitter, defined as someone who is experienced regarding the effects of psychedelics,”
Page 3, lines 116-117: Why do the authors”...have no reason to believe that PAT might face comparable challenges….”?
Page 3, lines 131-133: Specifically what about PAT “...provides a novel opportunity to enhance supervision and supervision research….”? I don’t see how “...the novel vulnerabilities associated with psychedelics…” is something that provides an opportunity.
Page 4, lines 144-145: Why do you think “...Research on PAT supervision could do markedly better….”?
Table 1. Should the term be ‘Stereotypical’ or ‘Typical’ ?
Figure 1: For readers to better see what you are doing with your model, perhaps you should show the more traditional model as well.
Page 6, lines 202-203: Is it really true that “...supervisiors would rarely, if ever speak directly to clients….”?
Page 7, lines 227-238: I see this as an argument for the benefits of MI in general, but I don’t see each of the three points that you raised as being uniquely connected to psychedelic drug use.
Page 11, lines 421-424: “...Supervisions might increase their impact by beginning with ample praise for what the trainees have done well. Supervisors can buttress trainee confidence by highlighting their strengths, knowledge, and past successes….” Is that not good advice for supervisors in any setting, with or without MIE-ES?
Page 11, lines 439-460: I do not see how this added text increases the value or understanding of the rest of the manuscript. I would recommend deleting this section.
Page 12, lines 476-487: This is not about PAT so much as MI in general. Again, consider deleting.
Also, should the term patients be used rather than clients? Again, maybe this is just me being a bit of an outsider to the field.
Author Response
Comment 1: I have read and reviewed the revised manuscript by Earleywine and Olivia entitled “A perspective for enhancing supervision of psychedelic-assisted therapy: Motivation-Interviewing-Enhanced Integration Supervision (MEI-IS)’. This is an interesting paper on a very interesting topic. The manuscript reads a bit like a well-written ‘Background and Rationale’ section from a grant application, with the exception that there is no preliminary data provided. Although the manuscript is very well-written in terms of text editor issues, I still found the manuscript lacking in several areas. As I indicated earlier, I would guess that the authors intend for this paper to be read by a relatively wide audience. For these reasons I still cannot support publication without major revision.
Response 1: We were grateful for the praise about the revisions and now turn to the concerns as listed.
Comment 2: Major Concerns: Definition of Terms and Roles: The authors adequately defined supervisor, trainee and client, thank you.
Response 2: Again, we were grateful for the praise. We agree that the new clarity has advantages.
Comment 3: Integration: Upon reading the revision, I now believe that the authors are talking about integration BOTH (1) in the absence of psychedelic drug use and (2) in the context of psychedelic drug use. If this is indeed the case, I think the authors need to be more clear regarding the type of integration they are writing about in various sections of the manuscript. Maybe a second term like ‘integration of drug experiences’ needs to be used?
Response 3: In response to this concern, we have now clarified this distinction early in the manuscript. We explicitly define psychedelic integration as the process of reflecting on and making meaning from psychedelic experiences and contrast it with the more general use of integration in psychotherapy. (As the reviewer notes, it might refer either to an eclectic blending of therapeutic techniques or to the synthesis of disparate aspects of a client's other experiences or identity.) We've also taken care to ensure that later uses of the term “integration” refer consistently to psychedelic contexts unless otherwise specified.
Thus, we have added the following to page 2, paragraph 1, lines 63-70:
We discuss integration here as the process of reflecting on, making sense of, and applying insights gained from acute psychedelic reactions to relevant molecules in ways that support psychological growth and well-being. This usage is distinct from other meanings of “integration” in psychology, such as the integration of therapeutic modalities (i.e., combining techniques from different schools of therapy) or the integration of the self (i.e., synthesizing disparate aspects of personality or life events). While these meanings share a thematic emphasis on synthesis and coherence, our focus remains on integration related to interpretations of acute psychedelic reactions in adaptive ways.
Comment 4: Also, if it’s true that the BIG QUESTION (the elephant in the room, if you will) is whether effective integration in the context of PAT might require psychedelic drug experience on the part of the trainee (therapist?), why do the authors avoid discussing this question/concern?
Response 4: We did devote a whole paragraph to this issue in the last revision but we were happy to elaborate beginning on page 7, paragraph 5, lines 296-355:
Small, experience-based improvements that accumulate over time raise important hypotheses about the role of personal psychedelic use among therapists and supervisors. Prior work has examined this issue in more detail [30], but relevant data suggest that most PAT therapists already report personal psychedelic experience [31]. Many training programs encourage experiential work as a part of the development of relevant competencies [7]. Potential clients report that a therapist’s personal experience matters to them, often as much or more as the therapist’s gender, ethnicity, and previous symptoms [32]. These findings might reflect assumptions about the value of experiential learning, especially in contexts where verbal instruction cannot fully capture the nature of the work. Acute reactions to psychedelics often resist easy description. Clients might feel more understood when therapists possess firsthand knowledge of similar states. Shared experience can also lead to more fluent communication. When both therapist and client have encountered similar altered states, they might find it easier to exchange meaning around otherwise ineffable moments.
Nevertheless, critics of the idea of required personal experience emphasize that therapists can acquire relevant skills through structured training, observation, and supervision. Alternative approaches to altering consciousness, including hypnosis, meditation, breath work, and sensory deprivation might provide parallel experiences. Procedural learning like this often develops through guided practice and repetition, even when direct personal experience remains absent. Testing the effects of personal psychedelic use with a randomized design would require considerable resources and might raise ethical challenges. A fully powered study would involve at least 80 therapists, each treating 30 clients, to detect differences in outcomes related to personal psychedelic use [30]. No existing trial in this area has met that standard. This paper does not argue that personal use must occur for effective therapy or supervision. Instead, we aim to outline the complexity of the issue and clarify the current limits of the available evidence. Given the potential impact of personal psychedelic use on communication between therapist and client, however, we must emphasize that the same issues apply to relevant communication between supervisor and trainee.
Comment 5: Figure 1: For readers to better see what you are doing with your model, perhaps you should show the more traditional model as well.
Response 5: We were concerned about making the figure unwieldy and difficult for readers to interpret. As an alternative, we have added the following to page 6, paragraph 1, lines 219-222:
Please note that this model contrasts with many forms of supervision that simply rely upon a supervisor providing information to a trainee who then adds relevant psychoeducation in a session with the client. This new approach emphasizes creating therapeutic experiences rather than providing information.
Comment 6: Page 7, lines 243-245: The authors talk about qualitative data that suggests “...integration bridges the psychedelic experience with everyday life and promotes lasting behavioral change….” They cite their own work on this. But is it really integration that does it? Griffiths et al (Psychopharmacology 2006) have shown that psychedelic use (presumably without much ‘integration’) produces profound and long-lasting life-changing experiences in human volunteers.
Response 6: We are big fans of paper! Note that although the term “psychedelic integration” had not entered the relevant research literature by 2006, the experimenters did have multiple, meetings devoted to this task. Quotations from that paper (Griffiths et al., 2006) reveal:
“Each participant met with his or her primary monitor on four occasions (~4 h total) before the first session, four times before the second session, and four times (~4 h total) after each session.”
(p. 269)
“These meetings served to develop rapport and prepare participants for the session and to provide support and allow discussion of experiences after the session.”
(p. 269)
We realize that making this distinction, however, seems important or the reviewer would not have mentioned the issue. That specific location did not seem ideal for getting these points across, so on page 2, paragraph 2, lines 71-80 we added several sentences, so the relevant portion now reads:
Although initial investigations of PAT often labeled these sessions as “debriefing” rather than “integration,” most training models stress the import of these sessions for optimizing outcomes [6,7]. Other findings emphasize that the absence of these integration sessions and their associated enhancement of self-care likely minimize aversive or challenging responses after drug administration [8,9]. Other models of supervision account for little variance in outcome, as we detail below. We assert that those models might be too ambitious for PAT and encourage a more focused approach. For these reasons, we emphasize supervision of integrations sessions here and stress that relevant models for preparation and administration might require considerably more information devoted to the specifics of those stages of the intervention.
Comment 7: Page 2, line 49: I would suggest “sitter, defined as someone who is experienced regarding the effects of psychedelics,”
Response 7: We added the following information on page 2, paragraph 1, lines 49-52:
Drug administration includes a sitter who remains present to provide emotional and physical support throughout the acute effects. Sitters typically have experience with psychedelic-assisted therapy that includes training to encourage use of eyeshades and music rather than active discussion during the session itself.
Comment 8: Page 3, lines 116-117: Why do the authors”...have no reason to believe that PAT might face comparable challenges….”?
Response 8: We apologize and appreciate the reviewer pointing out our error. This sentence on page 3, paragraph 3, lines 139-141 now reads:
We believe that PAT supervision might face comparable challenges, suggesting that a focused, detailed model of supervision for one component (integration) might provide novel benefits.
Comment 9: Page 3, lines 131-133: Specifically what about PAT “...provides a novel opportunity to enhance supervision and supervision research….”? I don’t see how “...the novel vulnerabilities associated with psychedelics…” is something that provides an opportunity.
Response 9: Thank you for this comment, we appreciate the insight! We have omitted this sentence from the manuscript.
Comment 10: Page 4, lines 144-145: Why do you think “...Research on PAT supervision could do markedly better….”?
Response 10: We elaborate on that sentence now. Page 4, paragraph 2, lines 166-170 now read:
Research on PAT supervision could improve dramatically by incorporating these methodological recommendations, including the use of multiple independent raters, random assignment of trainees to supervisors when feasible, longitudinal designs, and more focused supervision models tailored to specific therapeutic modalities and client concerns.
Comment 11: Table 1. Should the term be ‘Stereotypical’ or ‘Typical’ ?
Response 11: We are eager to sidestep some critiques from supervisors who frequently assert that “no therapy, and therefore no supervision, is typical.” We appreciate that the reviewer has the optimism to make this suggestion, but we would really prefer to go with “stereotypical.”
Comment 12: Figure 1: For readers to better see what you are doing with your model, perhaps you should show the more traditional model as well.
Response 12: We mention in response 5 that we were concerned about making the figure unwieldy. As an alternative, we have added the following to page 6, paragraph 1, lines 219-222:
Please note that this model contrasts with many forms of supervision that simply rely upon a supervisor providing information to a trainee who then adds relevant psychoeducation in a session with the client. This new approach emphasizes creating therapeutic experiences rather than providing information.
Comment 13: Page 6, lines 202-203: Is it really true that “...supervisiors would rarely, if ever speak directly to clients….”?
Response 13: In a word, yes. A great deal of supervision is asynchronous, with supervisors watching sessions long after they have ended. Rarely, a supervisor might reach out to a client in the middle of a session that has gone terribly awry while addressing suicidal ideation, but these discussions are the exception rather than the rule.
Comment 14: Page 7, lines 227-238: I see this as an argument for the benefits of MI in general, but I don’t see each of the three points that you raised as being uniquely connected to psychedelic drug use.
Response 14: We agree that the principles of Motivational Interviewing (MI) are broadly applicable to many forms of psychotherapy and not exclusively unique to psychedelic-assisted treatment (PAT). However, we see the alignment between MI and PAT as especially apt for several reasons, which we now clarify in the revised text. Page 7, paragraph 2, lines 263-280 now read:
Several key elements of MI are especially relevant to PAT supervision, though they make good practice in most any supervisory relationship. Psychedelic experiences often evoke deeply personal, emotionally intense, and hard-to-verbalize content. MI’s emphasis on reflective listening and evocation can help supervisors guide trainees in supporting clients as they process these ineffable experiences. The client-centered approach can allow them to provide this guidance without imposing interpretations or prematurely structuring meaning. This restraint is especially crucial in PAT, where psychedelics have the potential to increase suggestibility, and client autonomy in meaning-making is a core ethical concern.
Further, MI’s collaborative, non-hierarchical stance aligns well with the unique demands of PAT supervision, where strict protocol adherence must often balance with intuitive responsiveness. Supervisors who model this collaborative spirit can help trainees navigate the nuanced relational dynamics that arise in altered states of consciousness, which might challenge conventional therapeutic roles. Finally, MI’s focus on supporting practitioner self-efficacy and values-consistent behavior becomes particularly salient in PAT, where therapists might carry increased emotional weight due to the intensity of client experiences. The capacity to model and foster self-care within supervision can help sustain therapist resilience and preserve ethical sensitivity over time.
We have revised the paragraph to better articulate these distinctions and appreciate the opportunity to clarify. Please let us know if additional refinement would be helpful.
Comment 15: Page 11, lines 421-424: “...Supervisions might increase their impact by beginning with ample praise for what the trainees have done well. Supervisors can buttress trainee confidence by highlighting their strengths, knowledge, and past successes….” Is that not good advice for supervisors in any setting, with or without MIE-ES?
Response 15: This line of comments is very helpful. We agree that the practice of affirming trainee strengths and highlighting past successes represents good supervisory practice across many settings. However, we believe this guidance is particularly relevant in the context of MI-enhanced supervision (MIE-ES) within PAT. We welcome the chance to underscore these practices, as many supervisors seem to need to hear these ideas again. Page 11, paragraph 3, lines 539-551 now reads:
This approach supports self-efficacy, a core construct in Motivational Interviewing, for both trainees and clients. Supervisors can encourage trainees to recognize and build upon client strengths, reinforcing their belief in their ability to guide integration activities skillfully. At the same time, supervisors can highlight the trainee’s own strengths, fostering confidence and reinforcing past successes. Beginning supervision with specific praise for what trainees have done well can set a collaborative tone and increase openness to feedback. Emphasizing strengths, knowledge, and prior accomplishments might offer particular benefit in the context of psychedelic-assisted treatment, where trainees often face unusual client content and heightened ambiguity. A strong sense of competence can help them maintain presence without needing to impose interpretation. This kind of support might also increase supervisors’ own satisfaction by focusing attention on the developmental growth they help facilitate. Prior work offers complementary guidance for strength-based supervision practices [38].
Comment 16: Page 11, lines 439-460: I do not see how this added text increases the value or understanding of the rest of the manuscript. I would recommend deleting this section.
Response 16: The reviewer recommends deletion, which we were happy to do! Thank you for the suggestion to enhance our manuscript.
Comment 17: Page 12, lines 476-487: This is not about PAT so much as MI in general. Again, consider deleting.
Response 17: Thank you again for this suggestion to delete extraneous sections. We omitted this section from our manuscript.
Comment 18: Also, should the term patients be used rather than clients? Again, maybe this is just me being a bit of an outsider to the field.
Response 18: Conventions within PAT refer to the individual receiving treatment as “client”, thus we prefer to retain this term rather than “patient”.
Thank you again for your helpful comments, we agree that they enhanced the clarity and readability of our manuscript.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe article has been improved since the last revision. The authors have made most of the suggested changes, including changing the title of the manuscript. The new title better reflects the essence of the article. The authors improved the description of their method and added a table. The authors proposed their own version of verification of the new method, which also improves the quality of the article.
This article corresponds to the manuscript type “perspective” and can be published.
Author Response
Comment 1:
The article has been improved since the last revision. The authors have made most of the suggested changes, including changing the title of the manuscript. The new title better reflects the essence of the article. The authors improved the description of their method and added a table. The authors proposed their own version of verification of the new method, which also improves the quality of the article. This article corresponds to the manuscript type “perspective” and can be published.
Response 1: Thank you for your response! We appreciate your feedback in the first round of revisions, too.
