Therapeutic Alliance and Perceived Closeness in MDMA-Assisted Therapy for Social Anxiety Disorder

Abstract

The therapeutic relationship is considered central to psychedelic-assisted therapy, yet little empirical research has examined how it changes during 3,4-methylenedioxymethamphetamine-assisted therapy (MDMA-AT) or relates to acute MDMA experiences and clinical outcomes, particularly for social anxiety disorder (SAD). This preregistered secondary analysis examined therapeutic alliance and perceived closeness during an open-label pilot trial of MDMA-AT for SAD (N = 20; NCT-redacted-for-anonymous-review). Participants completed three preparation sessions, two MDMA dosing sessions, and six integration sessions. Therapeutic alliance and therapist closeness were assessed before and after each MDMA session using the Agnew Relationship Measure and Inclusion of Other in the Self Scale, respectively. Social anxiety severity was assessed with the Liebowitz Social Anxiety Scale at baseline and post-treatment, and self-transcendent experiences were assessed following MDMA sessions. Alliance was high after preparation and increased significantly following the first MDMA session, with evidence of ceiling effects later in treatment. Closeness increased significantly during each MDMA session and decreased during the subsequent nondrug interval. Greater MDMA-session closeness predicted lower post-treatment social anxiety, including after adjustment for corresponding pre-MDMA closeness. Self-transcendent emotions and connection-related experiences were associated with greater MDMA-session closeness, and pre-dosing closeness predicted greater self-transcendent emotions during the subsequent MDMA session. These findings distinguish more stable therapeutic alliance from more dynamic felt interpersonal closeness and suggest that closeness may be a particularly sensitive relational process in MDMA-AT for SAD.