Therapeutic Alliance and Rapport Modulate Responses to Psilocybin Assisted Therapy for Depression

Abstract

Background: Across psychotherapeutic frameworks, the strength of the therapeutic alliance has been found to correlate with treatment outcomes; however, its role has never been formally assessed in a trial of psychedelic-assisted therapy. We aimed to investigate the relationships between therapeutic alliance and rapport, the quality of the acute psychedelic experience and treatment outcomes.Methods: This 2-arm double-blind randomized controlled trial compared escitalopram with psychedelic-assisted therapy for moderate-severe depressive disorder (N = 59). This analysis focused on the psilocybin condition (n = 30), who received two oral doses of 25 mg psilocybin, 3-weeks apart, with psychological preparation, in-session support, and integration therapy. A new psychedelic therapy model, called “Accept-Connect-Embody” (ACE), was developed in this trial. The primary outcome was depression severity 6 weeks post treatment (Quick Inventory of Depressive Symptomatology, QIDS-SR-16). Path analyses tested the hypothesis that therapeutic alliance (Scale To Assess the Therapeutic Relationship Patient Version, STAR-P) would predict depression outcomes via its influence on the acute psychedelic experience, specifically emotional-breakthrough (EBI) and mystical-type experiences (MEQ). The same analysis was performed on the escitalopram arm to test specificity.Results: The strength of therapeutic alliance predicted pre-session rapport, greater emotional-breakthrough and mystical-type experience (maximum EBI and MEQ scores across the two psilocybin sessions) and final QIDS scores (β = −0.22, R2 = 0.42 for EBIMax; β = −0.19, R2 = 0.32 for MEQMax). Exploratory path models revealed that final depression outcomes were more strongly affected by emotional breakthrough during the first, and mystical experience during the second session. Emotional breakthrough, but not mystical experience, during the first session had a positive effect on therapeutic alliance ahead of the second session (β = 0.79, p < 0.0001). Therapeutic alliance ahead of the second session had a direct impact on final depression scores, not mediated by the acute experience, with a weaker alliance ahead of the second psilocybin session predicting higher absolute depression scores at endpoint (β = −0.49, p < 0.001)Discussion: Future research could consider therapist training and characteristics; specific participant factors, e.g., attachment style or interpersonal trauma, which may underlie the quality of the therapeutic relationship, the psychedelic experience and clinical outcomes; and consider how therapeutic approaches might adapt in cases of weaker therapeutic alliance.Clinical Trial Registration: This trial is registered at http://clinicaltrials.gov, identifier (NCT03429075).

Models of Psychedelic-Assisted Psychotherapy: A Contemporary Assessment and an Introduction to EMBARK, a Transdiagnostic, Trans-Drug Model

“…In support of this notion, a recent survey study found that individuals who attended group psychedelic ceremonies and felt they had a positive relationship with the ceremony facilitators self-reported greater improvements in wellbeing than those who did not ( Kettner et al, 2021 ). Additionally, Murphy et al (2022) recently found that the strength of the therapeutic relationship in the preparation phase of a course of psilocybin-assisted treatment for depression predicted greater emotional-breakthrough and mystical-type experience in the medicine session, which in turn led to greater reductions in depressive symptoms. The lack of attention paid by most current PAP models to relational aspects of treatment may represent another under-characterized avenue of therapeutic benefit in PAP and a missed opportunity for therapist training.…”

Pattern Breaking: A Complex Systems Approach to Psychedelic Medicine

“…One can draw parallels between critical slowing in CST and sensitivity to perturbation. In psychedelic therapy, greater sensitivity to perturbation could be related to the strongly hypothesised exaggerated influence of context on outcomes , some concrete examples of which include sensitivity to the therapeutic alliance (Murphy et al 2022), suggestibility (Carhart-Harris et al, 2015 and the music played during the dosing session (Kaelen et al, 2018). If the contextual conditions are adverse, however, one can imagine how small perturbations could cause spiralling ruminative 'loops' that are difficult to break out of.…”

From Relaxed Beliefs Under Psychedelics (REBUS) to Revised Beliefs After Psychedelics (REBAS): Preliminary Development of the RElaxed Beliefs Questionnaire (REB-Q)

“…While specific manipulations of the context (e.g., administering a psychedelic in an adverse or unsupportive environment) may be ethically problematic, measurement of individual's perception of the context (e.g., their relationship with their guides/therapists; Murphy et al, 2022), grading the extent of environmental support (e.g., from low to very high), and naturalistic research, may aid in understanding the effects of context on belief relaxation and revision (Carhart-Harris et al, 2018c).…”