It’s no longer a novelty that psychedelic drugs can play a role in medical treatments. Controversial substances, including psilocybin, LSD, and MDMA, are now recognized for their potential therapeutic benefits. Clinical trials have revealed promising outcomes in the treatment of mental health disorders such as depression, PTSD, and anxiety.

But it’s not just about the drug. According to a new study, what really matters in this type of therapy is a strong relationship between the therapist and study participant.

The researchers started by analyzing data from a 2021 clinical trial. The trial concluded that psilocybin (magic mushrooms) combined with psychotherapy was effective at treating major depressive disorder. 

But now, the team wanted to go even deeper. They wanted to see why the treatment worked when it did. What they found was that the most significant parameter that defined whether the treatment worked was the relationship between the clinician and the patient.

The therapeutic alliance

The therapeutic alliance, also known as the working alliance, is a crucial element in psychotherapy, representing the collaborative and trusting relationship between a therapist and a client. Research consistently shows that a strong therapeutic alliance can significantly influence the effectiveness of therapy, enhancing client engagement and increasing the likelihood of positive outcomes.

Apparently, therapy including psychedelic treatments is no exception.

“What persisted the most was the connection between the therapeutic alliance and long-term outcomes, which indicates the importance of a strong relationship,” said lead author Adam Levin, a psychiatry and behavioral health resident in The Ohio State University College of Medicine.

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

Researchers also analyzed different components, like the mystical experience, which often includes profound feelings of connectedness and transcendence. Although these experiences are influential, the study indicates that the lasting effects of therapy were not impacted by this.

In other words, it didn’t matter how spiritual people found the psychedelic effect. Treatment outcomes hinged much more on the therapeutic alliance.

“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. “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.” 

Studying the importance of trust

This was still a small-scale study involving 24 participants experiencing depression. The participants received two doses of psilocybin and 11 hours of psychotherapy. Then, they completed questionnaires to assess the therapeutic alliance and various other parameters.

Participants completed questionnaires regarding mystical and insightful experiences during drug treatment sessions and had their depression symptoms evaluated at various intervals up to one year post-trial. The analysis indicated that a stronger therapeutic alliance correlated with more profound mystical and insightful experiences during treatment. While these acute effects were associated with reduced depression symptoms at the four-week mark, they did not predict long-term improvement in depression outcomes one year after the trial.

However, designing and conducting larger-scale studies is difficult because of the stigma associated with psychedelic research and use. Despite these challenges, the importance of a well-established therapeutic relationship continues to be a central theme in achieving successful outcomes.

“That’s why I think the relationship has been shown to be impactful in this analysis — because, really, the whole intervention is designed for us to establish the trust and rapport that’s needed for someone to go into an alternative consciousness safely,” Davis said. 

Still a lot to learn

In this case, researchers emphasize, the clinician-patient bond matters most. Consequently, training therapists to build strong, empathetic alliances might be as crucial as the pharmacological aspects of the therapy, potentially reshaping future approaches to mental health treatment.

“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,” Levin said. “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.” 

The study was published in the journal PLOS ONE.