Combining Cognitive-Behavioral Conjoint Therapy for PTSD with 3,4-Methylenedioxymethamphetamine (MDMA): A Case Example

This case study (n=2) describes the treatment methodology of MDMA (112.5mg) -assisted Cognitive-Behavioral Conjoint Therapy administered to a PTSD patient in conjunction with his romantic partner. Through the therapeutic context, set, and setting that entailed multiple days of participant engagement and the empathy-inducing effects of the MDMA, the procedure created strong therapeutic bonds between the couple and the therapists and facilitated the resolution of PTSD symptoms and improvement in relationship satisfaction.

Abstract

“Introduction: Treatments for posttraumatic stress disorder (PTSD) have evolved significantly in the past 35 years. From what was historically viewed as a pervasive, intractable condition have emerged multiple evidence-based intervention options. These treatments, predominantly cognitive behavioral in orientation, provide significant symptom improvement in 50–60% of recipients. The treatment of PTSD with MDMA-assisted psychotherapy using a supportive, non-directive approach has yielded promising results. It is unknown, however, how different therapeutic modalities could impact or improve outcomes.

Methods: Therefore, to capitalize on the strengths of both approaches, Cognitive Behavioral Conjoint Therapy for PTSD (CBCT) was combined with MDMA in a small pilot trial.

Results: The current article provides a case study of one couple involved in the trial, chosen to provide a demographically representative example of the study participants and a case with a severe trauma history, to offer a detailed account of the methodology and choices made to integrate CBCT and MDMA, as well as an account of their experience through the treatment and their treatment gains.

Discussion: This article offers a description of the combination of CBCT for PTSD and MDMA, and demonstrates that it can produce reductions in PTSD symptoms and improvements in relationship satisfaction.“

Authors: Anne C. Wagner, Michael C. Mithoefer, Ann T. Mithoefer & Candice M. Monson

Summary

Treatments for posttraumatic stress disorder (PTSD) have evolved significantly in the past 35 years. A small pilot trial combining Cognitive Behavioral Conjoint Therapy for PTSD and MDMA produced significant symptom improvement in 50 – 60% of recipients, and improved relationship satisfaction.

ARTICLE HISTORY

The field of PTSD treatment has made enormous strides in the past 30 years. Cognitive-behavioral interventions are now considered an effective treatment option. Cognitive-behavioral interventions for PTSD have been found effective in meta-analyses, adopted throughout healthcare systems, and thousands of clinicians have been trained through ongoing dissemination efforts. However, many people with PTSD do not respond adequately to existing treatments.

PTSD has been conceptualized as an interpersonal disorder, and CBCT for PTSD makes use of this interpersonal dynamic to treat PTSD symptoms and relationship satisfaction by increasing understanding of PTSD within the context of the relationship, dyadic skills, behavioral approach tasks, and cognitive restructuring of thoughts that are preventing recovery.

Because of the avoidance of PTSD, stigma, and concern regarding treatment, involving close others in PTSD treatment may be useful. CBCT has been found to be effective with distressed and non-distressed dyads.

MDMA, an atypical psychedelic compound, has been shown to be effective in the treatment of PTSD when coupled with non-directive, supportive psychotherapy. This is likely due to the compound’s neurobiological effects, which include activation of the prefrontal cortex and dampening of activity in the amygdala.

The experimental expectancy effect of taking a psychedelic compound, as well as the “special” nature of therapy, may allow for optimal treatment gains. The sense of empathy produced extends to therapists, partners, and also the client.

CBCT protocol and session flow

CBCT is a 15-module, three-phase, protocol-based, dyadic treatment for PTSD. It consists of psychoeducation about PTSD, development of communication and problem-solving skills, and cognitive work to address stuck thoughts related to the trauma.

In this case study, two full-day MDMA sessions were added to the CBCT protocol, one after module 5 and the other after module 9. The MDMA sessions were placed to facilitate trauma processing and prime the participants with self-referential, trauma-related content.

The first three modules of CBCT were delivered in one day, and the second two modules were delivered in person the day before the second MDMA session. The final four modules of CBCT were delivered weekly over videoconference after the second MDMA session.

MDMA sessions

The design of CBCT + MDMA includes a team of two therapists, with no specification as to the gender of the therapist. The participants alternated time “inside” and “outside” during the MDMA sessions, and their subjective units of distress were recorded.

Participants stayed overnight at the study facility with a night attendant, met with the therapists the following morning to debrief and assign out-of-session assignments, and then took 75 mg or 100 mg of MDMA for the first session, with a supplemental half-dose offered at 90 minutes post-administration to elongate the session.

Assessment and inclusion

PTSD symptoms and relationship satisfaction scores were assessed at baseline, post-treatment, three-month follow-up, and six-month follow-up. The Clinician-Administered PTSD Scale-5 (CAPS-5) and Structured Clinical Interview for the DSM-5 (SCID-5) were used to determine eligibility.

Participants had to be over 18 and have a diagnosis of PTSD. They were also required to taper off of all psychiatric medications.

Case background, assessment, and therapists

Stuart and Josie were recruited as part of a pilot study of CBCT + MDMA. Stuart had been attending therapy for several years to address his trauma-related symptoms, but had not previously received a cognitive-behavioral treatment for PTSD.

Stuart’s CAPS-5 score was 43, his PCL-5 score was 66, and his relationship satisfaction was 3 at baseline. He did not have any current comorbid disorders, and Josie’s relationship satisfaction was 3.

The therapists were one female, early-career clinician and one male, late-career clinician. They both underwent training in the other modality.

Stuart’s traumatic event was repeated sexual assault in childhood by his father and his father’s work colleagues. Stuart’s confusion about his early sexual experiences resulted in an unwanted focus on being submissive.

Course of treatment and outcomes

In phase one of CBCT, Josie and Stuart identified that emotional numbing and irritability were symptoms of PTSD. They worked through Josie’s concerns about hearing traumatic information.

Stuart and Josie developed skills to express strong emotions, and were prompted to use those skills during their first MDMA session.

Stuart, unprompted, went chronologically through his traumatic experiences during the first MDMA session, and experienced strong emotional reactions, such as crying and grief. He also experienced strong visceral reactions, including muscle tightening and sweating.

Josie was able to discuss her challenges with Stuart’s PTSD in the MDMA sessions, and reported strong positive experiences and the sensation of finally being able to relax.

Stuart and Josie were religiously devout and used religious symbolism in their MDMA sessions.

Stuart reported feeling fatigued, but emotionally and psychologically lighter following the first MDMA session.

Stuart and Josie completed behavioral approach tasks in the three weeks between the two MDMA sessions, and worked through stuck thoughts related to themes of blame, trust, and control for Stuart, and related to emotional intimacy for Josie.

Stuart’s symptoms were almost non-existent following the second MDMA session, and remained so through follow-up. Josie and Stuart rated their relationship satisfaction as 5, and these gains were maintained at three- and six-month follow-ups.

Discussion

For this couple, CBCT + MDMA had the intended effect of resolution of PTSD symptoms and improvement in relationship satisfaction. The intensive nature of the treatment facilitated participant engagement and commitment.

Stuart’s reduction in symptoms was attributed to a better understanding of the events that occurred, and acceptance of both the events and himself. He and Josie felt bonded for having gone through the therapy together, and that their recovery was meaningful.

Stuart’s CBCT + MDMA experience allowed him to make sense of his traumatic experiences and unlocked the cycle of PTSD symptoms. He now lives his life with hope where despair ruled before.

Josie experienced relief from anxiety and tension after the CBCT + MDMA experience, and was able to share her experience of Stuart’s traumatic memories with Stuart.

This case example demonstrates that CBCT + MDMA can be used effectively for PTSD, and that CBCT can be delivered via videotherapy. Additionally, MDMA can be used in combination with an evidence-based stand-alone treatment for PTSD.

The therapeutic use of MDMA in a trauma-focused PTSD intervention is based on the principles outlined in the early psychedelic-assisted psychotherapy literature. However, further research is needed to explore whether this treatment will be helpful for other couples.