Preliminary evidence for the importance of therapeutic alliance in MDMA-assisted psychotherapy for posttraumatic stress disorder

Abstract

Background: MDMA-assisted psychotherapy (MDMA-AP) is a combined psychotherapeutic and pharmacologic intervention that shows promise in the treatment of posttraumatic stress disorder (PTSD). Although therapeutic alliance has been established as a key predictor across psychotherapies and is emphasised within MDMA-AP treatment manuals, research has not yet examined the relationship between therapeutic alliance and MDMA-AP treatment outcomes.Objective: Examine whether therapeutic alliance predicts changes in PTSD symptoms following MDMA-AP.Method: Twenty-three individuals with chronic PTSD participated in a MDMA-AP clinical trial that included a randomised (MDMA vs. placebo) and open-label phase. The present analyses focused on participants who were administered MDMA over the course of the randomised and open-label phases (n = 22). Therapeutic alliance was assessed using the Working Alliance Inventory at sessions baseline (pre-session 3) and sessions 4 and 9. PTSD symptoms were assessed using the Clinician Administered PTSD Scale and the Impact of Events Scale-Revised.Results: Controlling for baseline clinician-assessed PTSD severity, therapeutic alliance at sessions 4 and 9 (but not baseline) significantly predicted post-MDMA-AP clinician-assessed PTSD severity. Controlling for baseline self-reported PTSD severity, therapeutic alliance at baseline (although this did not survive correction for multiple comparisons) and sessions 4 and 9 predicted post-MDMA-AP self-reported PTSD severity.Conclusions: The present results provide the first preliminary evidence for the relationship between the therapeutic alliance and treatment outcomes within MDMA-AP for PTSD. These findings highlight the important role of psychotherapy, and common psychotherapeutic factors, within MDMA-AP. Replication in studies with larger and more diverse clinical samples remain necessary.Trial registration: ClinicalTrials.gov identifier: NCT00090064.

Keywords: MDMA; MDMA-assisted psychotherapy; Posttraumatic stress disorder; Psicoterapia asistida por MDMA; Trastorno de estrés postraumático; alianza terapéutica; mecanismos de cambio; mechanism of change; therapeutic alliance.

Figure 1.

Study flow for the present analyses.

Figure 2.

A timeline of patient progression through study procedures. Note: CAPS: Clinician Administered PTSD Scale; IES: Impact of Event Scale-Revised; WAI: Working Alliance Inventory. Grey dashed lines () indicates that not all patients entered Stage 2. The solid double line () indicates a visit with assessments but no therapy sessions occurred. Sessions with striped backgrounds () represent those added following protocol amendments. *Supplemental half doses were available after a protocol amendment, and the final nine participants enrolled were allowed this supplement. Four patients in the MDMA group and four in the placebo group received supplemental doses. #A protocol amendment allowed four participants initially in the placebo condition and five participants initially in the MDMA condition to receive an additional (i.e. a third) MDMA session and three integration sessions.