This open-label study (n=12, 6 couples) examines the secondary outcomes (up to 6 months later) of Cognitive Behavioral Conjoint Therapy (CBCT) where one partner was suffering from PTSD. There were improvements for both partners on post-traumatic growth, relational support, social intimacy, empathic concern, and less conflict.
“Healing from trauma occurs in a relational context, and the impacts of traumatic experiences that result in post-traumatic stress disorder (PTSD) go beyond the diagnosis itself. To fully understand a treatment for PTSD, understanding its impact on interpersonal, relational, and growth outcomes yields a more fulsome picture of the effects of the treatment. The current paper examines these secondary outcomes of a pilot trial of Cognitive Behavioral Conjoint Therapy (CBCT) for PTSD with MDMA. Six romantic dyads, where one partner had PTSD, undertook a course of treatment combining CBCT for PTSD with two MDMA psychotherapy sessions. Outcomes were assessed at mid-treatment, post-treatment, and 3- and 6-month follow-up. Both partners reported improvements in post-traumatic growth, relational support, and social intimacy. Partners reported reduced behavioral accommodation and conflict in the relationship, and patients with PTSD reported improved psychosocial functioning and empathic concern. These improvements were maintained throughout the follow-up period. These findings suggest that CBCT for PTSD with MDMA has significant effect on relational and growth outcomes in this pilot sample. Improvements in these domains is central to a holistic recovery from traumatic experiences, and lends support to the utility of treating PTSD dyadically.”
This paper investigated secondary measures from Monson and colleagues (2020).
Traumatic events impact relationships, and healing from trauma occurs in a relational context. A pilot trial of Cognitive Behavioral Conjoint Therapy for PTSD with MDMA examined the relational and growth outcomes.
Interpersonal functioning is often negatively impacted by PTSD, and vice versa. This is important to address given the fundamental role interpersonal functioning plays in developing and maintaining relationships over time, attachment, parenting, reducing secondary traumatization, and satisfaction and security in life.
Post-traumatic growth is a construct consisting of relations to others, perceptions of new possibilities in life, perceived personal strength, spiritual change, and an appreciation of life. It is positively associated with resiliency.
The loved ones of individuals with PTSD often experience their own struggles, including their own mental health and well-being, quality of life, and relationship satisfaction with the person with PTSD. However, behavioral accommodation may inadvertently reinforce the presence of these symptoms.
Treating PTSD in a relational framework, such as a couple format, has shown significant positive impact on both patient and partner mental health and well-being.
MDMA has been used in couple therapy since the 1970s to facilitate individuals’ ability to maintain an optimal window of tolerance, which can be particularly useful in addressing couple-based distress and communication.
In a pilot study of Cognitive Behavioral Conjoint Therapy for PTSD with MDMA, patients and partners reported improvements in psychosocial functioning, relationship satisfaction, and post-traumatic growth. The treatment gains continued to improve by 6-month follow-up.
Six dyads participated in an uncontrolled pilot trial, in which one partner had PTSD and the other did not. They were required to taper off all psychiatric medications, and were medically screened.
All participants were White, had experienced multiple traumatic events, and were in mixed gender partnerships. Two were female, all had co-morbid psychological diagnoses, and all had received prior psychological and pharmacological PTSD treatments.
Relationship Aggression Outcomes
The Revised Conflict Tactics Scale (CTS-2) contains 39 methods of managing conflict, and contains five subscales: negotiation, psychological aggression, physical assault, sexual coercion, and physical injury. The baseline levels of aggression were low, and the treatment did not worsen aggression over time.
The Post-Traumatic Growth Inventory (PTGI) was completed by both members of the dyad, and scores were given on a 6-point scale.
The Significant Others’ Responses to Trauma Scale is a 14-item measure completed only by the partner of the person with PTSD. It assesses relationship problems and distress associated with behaviors meant to accommodate PTSD symptoms.
Relationship Quality Outcomes
The Quality of Relationships Inventory (QRI) is a 25-item self-report measure that assesses perceived support from a chosen relationship, the amount of conflict within this relationship, and the perception of the relationship as deep and secure.
The Inventory of Psychosocial Functioning (IPF) is an 80-item self-report measure developed to assess functioning across domains of romantic relationships, family, work, friendships, parenting, education, and self-care.
Miller Social Intimacy Scale is a 17-item self-report measure designed to assess current social intimacy experienced across relationships. It has demonstrated strong internal consistency.
A 28-item self-report scale measuring empathic tendencies, the Interpersonal Reactivity Index (IRI) has demonstrated good internal consistency ( = 0.71 – 0.77).
Participants received a course of CBCT for PTSD with the addition of 2 full-day MDMA sessions. The protocol was delivered over a total of 7 weeks.
CBCT for PTSD consists of three phases: safety-building, shared communication skills, and cognitive work to address meaning-making of the trauma. Both members of the dyad engage in all components of the therapy, including MDMA sessions.
MDMA sessions consisted of the administration of 75 mg of MDMA during the first session, and 100 mg of MDMA during the second session. Participants were in reclining armchairs with eyeshades and headphones available.
Analyses were conducted in SPSS Version 26 using growth curve models, and a chi-square difference test was conducted to compare the nested models using the log-likelihood based goodness of fit statistic. Within-group effect sizes were calculated using estimated means and raw pooled standard deviations.
Based on the Chi-square difference test, a model with random intercepts and slopes was the best fit to the data for the majority of outcomes, but did not converge in the majority of cases.
Safety Outcomes Relationship Aggression
There were improvements on minor psychological aggression, minor physical assault, minor sexual coercion and minor injury for patients, but no significant change on emotional or cognitive negotiation strategies.
Trauma-Related Outcomes: Post-Traumatic Growth and Behavioral Accommodation
Both patients and partners showed significant improvement in post-traumatic growth and decreased accommodating behavior over the course of treatment.
Relationship Quality Outcomes
There were significant improvements in relationship quality as rated by both patients and partners, but no significant improvements were found in patient-reported conflict. Both patients and partners reported significant increases in intimacy.
Psychosocial Functioning Outcomes
Patients rated improved overall psychosocial functioning and showed significant improvements in empathic concern, while partners did not. There were no significant changes in personal distress, fantasy, or perspective taking.
In this study, couples who received CBCT and MDMA for PTSD experienced significant gains in relational functioning, post-traumatic growth, and behavioral accommodation. They also exhibited gains in or maintenance of strong interpersonal and psychosocial functioning, suggesting that the intervention is safe and does not increase a risk of relational or interpersonal harm.
Participants reported feeling greater connection to others during MDMA-assisted sessions that lasted beyond the therapeutic intervention. Additionally, partners demonstrated high baseline levels of empathic concern that remained stable over the course of therapy, demonstrating that expressions of empathy can remain stable and improve while engaging in trauma-focused work.
The results of this study demonstrate significant improvements in couple functioning, but the study sample was very small and the study was uncontrolled. A larger, controlled study of CBCT + MDMA is warranted to explore the relational outcomes of the intervention.
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Authors associated with this publication with profiles on BlossomAnne Wagner
Anne Wagner is the Founder of Remedy, a clinical psychologist and treatment development researcher based in Toronto.
Michael Mithoefer is a psychiatrist and a Clinical Investigator and acting Medical Director of MAPS Public Benefit Corporation.
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This open-label study (n=12, 6 couples) describes the safety, tolerability, and efficacy of MDMA in combination with cognitive-behavioral conjoint therapy (CBCT) where one half of the couple was battling with PTSD.