Therapeutic Relationship Plays Key Role in Psychedelic Treatment

A strong therapeutic relationship between the therapist and patient can help improve outcomes during treatment with the psychedelic psilocybin, according to research published in the journal PLoS One.¹ Investigators say the findings suggest that psilocybin administration might work best when there has been a therapist-patient relationship established over time.

Research into the potential therapeutic benefits of psychedelics has re-emerged recently after a long hiatus due to the 1970 Controlled Substances Act. Investigators are now looking into many compounds—including MDMA, psilocybin, and LSD—for the treatment of various mental health conditions. However, very few studies on psychedelic medicine have looked into the role of the therapist-patient relationship, which is a key component of treatment.

“This concept is not novel,” Alan Davis, senior author on the study, said in a release.² “What is novel is that very few people have explored this concept as part of psychedelic-assisted therapy. This data suggests that psychedelic-assisted therapy relies heavily on the therapeutic alliance, just like any other treatment.”

Investigators from Ohio State University conducted an analysis to determine if the relationship between patients and intervention facilitators in a psilocybin-assisted therapy trial changed over time. The study also assessed whether the therapist-patient relationship was associated with acute psilocybin experiences and depression outcomes.

READ MORE: The Psychedelic Pharmacy: A Paradigm Shift in Mental Health Treatment

The study analyzed data from a randomized, waiting list-controlled clinical trial that investigated acute and persisting effects of psilocybin on depressive symptoms. The study cohort included 24 adult patients with moderate to severe major depressive disorder (MDD) who received either 2 immediate or delayed oral doses of psilocybin in conjunction with 11 hours of psychotherapy.

To assess the therapeutic alliance—defined as the sense of collaboration between a patient and clinician—investigators used the 12-item, participant-rated, Working Alliance Inventory-Short Revised (WAI-SR) questionnaire. Depression severity was measured by the GRID-Hamilton Depression Rating Scale (GRID-HAMD) and acute psilocybin effects were measured with the Mystical Experience Questionnaire (MEQ30).

The study found that a higher patient-rated therapeutic alliance was linked with improvements in depression outcomes up to 1 year later. A strong therapeutic alliance in the final preparatory session also was associated with higher peak mystical experiences during psilocybin therapy, which were correlated with improvements in depression.

“The mystical experience, which is something that is most often reported as related to outcome, was not related to the depression scores at 12 months,” Davis said in a release.² “We’re not saying this means acute effects aren’t important—psychological insight was still predictive of improvement in the long term. But this does start to situate the importance and meaning of the therapeutic alliance alongside these more well-established effects that people talk about.”

Study limitations include the use of a single item measure for insight, that participants may have been more susceptible to expectancy bias due to being self-referred, an inability to control for participant, therapist, or treatment setting influences, and that findings may not be applicable to more diverse populations due to most participants being White, female, and heterosexual. The authors noted that future studies should seek to replicate the findings in different therapeutic settings and approaches.

“This isn’t a case where we should try to fit psychedelics into the existing psychiatric paradigm—I think the paradigm should expand to include what we’re learning from psychedelics,” Adam Levin, lead author on the study, said in a release.² “Our concern is that any effort to minimize therapeutic support could lead to safety concerns or adverse events. And what we showed in this study is evidence for the importance of the alliance in not just preventing those types of events, but also in optimizing therapeutic outcomes.”

READ MORE: Mental and Behavioral Health Resource Center

References

1. Levin AW, Lancelotta R, Sepeda ND, et al. (2024) The therapeutic alliance between study participants and intervention facilitators is associated with acute effects and clinical outcomes in a psilocybin-assisted therapy trial for major depressive disorder. PLoS ONE 19(3): e0300501. https://doi.org/10.1371/journal.pone.0300501

2. Caldwell, E. In psychedelic therapy, clinician-patient bond may matter most. News Release. Ohio State University. April 22, 2024. Accessed April 22, 2024. https://news.osu.edu/in-psychedelic-therapy-clinician-patient-bond-may-matter-most