Therapeutic Alliance and Trust in Psychedelic-Assisted Therapy

After decades of prohibition—even in tightly-controlled research settings—psychedelics are finally being explored in research institutions and clinical settings around the world. Research suggests that psychedelic compounds like MDMA and psilocybin, in combination with psychotherapeutic support, can cause transformative experiences for patients and potentially reduce symptomatology among people with mental health and substance use disorders. As this new modality of therapy speeds toward clinical adoption, we must examine its current model, specifically, the role therapists play in the treatment.  

Psychedelics can cause a wide range of responses and reactions in patients. These compounds affect the brain’s neurochemistry and have the capacity to alter patients’ consciousness, perception, and mood. These shifts can cause patients to feel considerably more vulnerable and open than usual, which is why psychedelic-assisted therapy is conducted under the supervision of a highly skilled therapist. From the first day of treatment to the last, psychedelic therapists act as an anchor for patients, there to maintain a safe space and ensure that the treatment elicits the best therapeutic outcome possible. As patients look inward during medication sessions, it is paramount that they feel comfortable embarking on the psychedelic experience in the presence of their therapist.  

One of the most important skills a psychedelic-assisted therapist can possess is the ability to build trust and rapport with their patients. Many experts believe it is impossible to overstate the role that rapport between therapist and patient plays in this treatment. One of the most significant predictors of outcomes in psychedelic-assisted therapy is the working relationship between therapist and patient, also known as the therapeutic alliance (Murphy et al., 2022).  

When patients trust their therapist, they are more likely to trust in themselves and their capacity to make meaning from the psychedelic experience, which is arguably one of the most transformative parts of the treatment. In an article on developing competencies and guidelines for psychedelic therapists, Janis Phelps, Ph.D. claims that “the trust-enhancing therapist is competent in helping the participant cultivate multifocal viewpoints for making sense of what may reveal itself as meaningful during psychedelic-assisted therapy” (2017). In the integration stage of treatment, therapists help patients process and reconcile meaningful parts of their medication session.  

Research also shows that “enhanced meaning making and relevance attributions were the most highly weighted subjective variables in a path analysis of outcome” in patients who underwent psychedelic-assisted therapy (Preller et al., 2017). Though these may be subjective variables, there is no denying how critical they are to patient outcomes. Psychedelic medications are one piece of the puzzle that allows patients to access altered states that promote healing, but it is trust-enhancing therapists who empower patients to put the puzzle together themselves.  

There is growing evidence that the therapeutic alliance is essential to the psychedelic-assisted therapy model. Just this year, researchers found “evidence of an effect of therapeutic alliance and rapport on the quality of the psychedelic experience, which in turn was associated with changes in depressive symptom severity six weeks later” (Murphy et al., 2022). This supports what experts in the psychedelic therapy field have asserted for years: high-quality, psychedelic-assisted therapy isn’t just a reaction to a psychedelic compound but a careful dance between patient, therapist, and the trust and rapport they have built. 

To learn more about the core elements of psychedelic-assisted therapy and the critical role that therapists play in the process, please check out our latest report: An Expert-Informed Introduction to the Elements of Psychedelic-Assisted Therapy. We consulted with 22 experts in the field to understand the current state of practice and where the field might be going next. If you’re pressed for time, please check out our two-page summary on psychedelic-assisted therapy and our mini-brief on the future of psychedelic medicine. BrainFutures thanks you for your support.  

References 

Murphy, R., Kettner, H., Zeifman, R., Giribaldi, B., Kartner, L., Martell, J., Read, T., Murphy-Beiner, A., Baker-Jones, M., Nutt, D., Errizoe, D., Watts, R., & Carhart Harris, R. (2022). Therapeutic alliance and rapport modulate responses to psilocybin-assisted therapy for depression. Frontiers in Pharmacology, Article 3819. https://doi.org/10.3389/fphar.2021.788155 

Phelps, J. (2017). Developing guidelines and competencies for the training of psychedelic therapists. Journal of Humanistic Psychology, 57(5). https://doi.org/10.1177/0022167817711304 

Preller, K. H., Herdener, M., Pokorny, T., Planzer, A., Kraehenmann, R., Stämpfli, P., Liechti, M. E., Seifritz, E., & Vollenweider, F. X. (2017). The fabric of meaning and subjective effects in LSD-induced states depend on serotonin 2A receptor activation. Current Biology, 27(3), 451–457. https://doi.org/10.1016/j.cub.2016.12.030