Rating Adherence and Training Therapists in MDMA-Assisted Psychotherapy for PTSD Research
For MDMA-assisted psychotherapy to reemerge as a legal treatment for PTSD and potentially other psychiatric disorders, the method we use to demonstrate our results has to be sound, scientific, reproducible, polished, and refined. It must have certain checks and balances, with the therapists conducting the experimental sessions needing to demonstrate adherence to the protocol and treatment method (and, of course, a high level of proficiency) even though they are utilizing a relatively non-directive approach. This is where we, the Adherence Raters, come in.
MDMA-assisted psychotherapy is an organic, ever-evolving treatment, and the work and observations done by the Adherence Raters help the process along. It’s a meticulous and sometimes grueling process, but it has important implications for the research.
Therapeutic quality control
Performing adherence ratings helps ensure that the therapists demonstrate competency and adhere to the Manual for MDMA-Assisted Psychotherapy in the Treatment of Posttraumatic Stress Disorder [available at maps.org/treatmentmanual], which makes sure that the treatment was applied as it was intended and that it improves the quality of the data, strengthening the validity of the study. Through a kind of therapeutic quality control, we provide useful feedback to the therapists with the intention to improve the quality of treatment for the participants and aid in the training of new generations of psychedelic psychotherapists. Also, since there are multiple studies going on around the world, establishing adherence may aid in pooling all of the data together into a meta-analysis. Adherence Raters even help find ways of improving the rating process itself.
As Adherence Raters for ongoing studies, our job consists of watching videos of study sessions and monitoring how well the therapists follow the study protocol. At the same time, we rate how effectively they work as a therapeutic team with the participants. We pay special attention to how well the therapists communicate with study subjects, the strength of the rapport between the therapists and subjects, and the strength of the therapeutic alliance. We also monitor how well the therapists make the subjects feel safety and complete support during the process, while themselves maintaining a strong empathic presence; that they are well timed and complete at acquiring all the relevant information; and that they are attending to any questions or needs the subjects may have.
The therapists need to demonstrate these qualities while utilizing a very non-directive approach at the same time. In addition, while watching the study sessions, Adherence Raters review several checklists, making sure the therapists address all of pertinent points of the protocol. Importantly, we also have to show that we have “inter-rater reliability:” that is, we have to make sure that we are consistent amongst each other, that between us we are using the same “yardstick” to measure therapist adherence.
The Therapist Adherence and Competence Rating Manual [available at maps.org/treatmentmanual] has been considered a living document since its inception in the Spring of 2010, built in the general spirit of assuring quality and safety in the standard of care provided to participants in MAPS-sponsored studies. That year, Michael Mithoefer, M.D., and his wife and co-therapist Annie Mithoefer, B.S.N., led an intensive MDMA-assisted psychotherapy training in Charleston, South Carolina, for the research team for the (later rejected) Jordanian study as well as those who became the original four members of the Adherence Team (Ray Worthy, Blu Cohen, Zhenya Gelfand, and Evan Sola). After that first training, the Mithoefers began some initial attempts to organize their thoughts regarding what MDMA-assisted psychotherapy should look like. These meetings became the first Adherence Rater trainings.
The initial outline of Adherence Items echoed major ideas set forth in the Treatment Manual, with theoretical scaffolding largely generated from the work of Stan Grof. Already inherent in this document when the original team of raters coalesced was the notion of an “inner healing intelligence,” and the importance of a non-directive approach to engaging participants. The core of this work, from the beginning, seemed to be about allowing the “inner healer” to do its work by setting up a safe environment, and then simply staying out of the way. The idea is that the medicine will catalyze the emergence of this inner intelligence, and the role of the therapists is to actively watch and listen, ready to engage the participant when needed, otherwise poised in reverie. This philosophical base, as well as the protection of a therapeutic approach that can allow participants to maximize their sense of safety and support before entering into narratives and states of awareness that might feel unsafe, has remained the common denominator between among the many (often shifting) Adherence Items.
The Adherence Manual further emphasizes the importance of bringing the insights that are revealed in experimental sessions into the everyday lives of participants. The important work of revisiting the path that had been cleared by MDMA-assisted psychotherapy, later experienced from an ordinary state of consciousness, is what therapists call integration. Integration is a concept referenced often in the entheogenic (psychedelic) community, but usually with little elaboration on what exactly it entails; thus the Adherence Team has been faced with the challenge of bringing form to something that is amorphous, and yet hugely important. We have tried to provide a standard that is comprehensive and available for others in the field, as well as for curious explorers in the lay community. The importance of integration sessions is clear in the therapeutic protocol: for every one experimental session, participants receive three integration sessions. Other work focusing on mind-body integration is suggested for use in between MDMA-assisted psychotherapy sessions, including ongoing, long-term psychotherapy with an alternate therapist.
As Adherence Raters, we consciously strive to maintain the attitude known as “beginner’s mind.” We hope to bring this attitude of openness both to the therapeutic approach for which we provide feedback and to our regular amendments to the Adherence Manual. In introductory and experimental sessions, Dr. Mithoefer has often helped facilitate this attitude by reminding participants of the importance of allowing a process that shifts, and exemplifying an attitude of availability to whatever emerges, including feelings of being stuck and discomfort. This approach is an integral part of MDMA-assisted psychotherapy that has inspired the Adherence Team to stay open to what we notice and are inspired by in the therapy. We keep our eyes and ears open to what heals; and to what opens dialogue, intimacy, and catharsis.
Training a new generation of researchers and therapists
The importance of training the next generation of Adherence Raters with this attitude is apparent in how many revisions we made to the Adherence Items after each of our recent trainings in Boulder and San Francisco. Each new group trained brings a slightly new perspective on how we might improve or reconceptualize our work. Adherence Raters are trained to become critical of the therapy MAPS-sponsored researchers provide, and not simply to follow an already established protocol.
The training of the next wave of raters is a major priority for Adherence Raters, since we will require many new teams in order to meet the rating needs of Phase 3 MDMA-assisted psychotherapy for PTSD studies. Phase 3 will be conducted in multisite fashion—many sites consisting of multiple studies with different therapist configurations. Hopefully, this gives a sense of the need for a multitude of trainees, as well as a sense of the expansion of this research, and the growing number of participants in the experimental therapy.
Due to the level of success and impact MAPS’ MDMA-assisted psychotherapy has had in previous studies and on the broader culture, we decided itwas important to maintain a high level of training. We require a standard for Adherence Rater trainees to have professional experience in the mental health field. We also require them to have direct experience resolving ethical dilemmas, a clear understanding of the imperative of self-care, and relationships with other professionals demonstrating ongoing consultation and supervision. This movement to meet Phase 3 research needs has brought on a need for new positions within the Adherence Rater Group, mainly dedicated to conceptualizing Adherence Rater training within the context of the Treatment Manual.
Since Adherence Raters become the standard for inter-rater reliability, and thus the backbone for understanding the results of the study, the original Adherence team members have taken on new positions to help ensure a smooth transition, including the management and training of new raters. Another level of general oversight of adherence issues, especially as they relate to reliability and validity, will be provided by Ingmar Gorman, who recently joined the Adherence Rater team, with experience in the field coming from his work at the New School for Social Research, as well as his current on the role of the therapeutic alliance in MDMA-assisted psychotherapy. Other original members have moved on, being groomed for inclusion as therapists in upcoming studies. Ultimately, the position of Adherence Rater is a major stepping-stone in becoming a therapist in MAPS-sponsored research.
Q: Why do you work as an Adherence Rater in MAPS’ MDMA-assisted psychotherapy research?
Zhenya: There are several reasons why I personally work on adherence for MDMA-assisted psychotherapy. Primarily, I believe in the cause of psychedelic research to the vey core, and I feel honored and privileged to have the opportunity to contribute to its reemergence. I am also hoping to some day be part of a therapy team working with psychedelic-assisted psychotherapy both in a research setting and—hopefully—in my psychiatric and wellness practice. Being part of the Adherence Rater team serves as a gateway into this promising and fascinating field and adds immensely to my experience and understanding. Hopefully, that can someday manifest into my aspiration of practicing psychedelic psychotherapy and bringing healing and wellness into the lives of my clients in a way that conventional medicine simply cannot.
Evan: Since the first session video I watched in 2010, I was struck by the deep listening of both participants and therapists that reflected the level of healing experienced, beyond what could be explained by the medicine alone. I was blown away by the stories, the raw and genuine emotive force of a life-shattering narrative now being held delicately in the hands of two bodhisattva-like therapists: wounded individuals and the illuminated space between them all greatly enhanced by the medicine. I remember audibly sobbing the night after watching those first sessions.
While serving as Night Attendant for the study, on the nights when I wasn’t sitting with participants until dawn, I woke up from sleep grasping, with what might have been my unconscious mind, the importance of the work being done. Again, a bursting forth of tears, accompanied by images and memories of my own hurt places. My dreams were piecing together something difficult to hold in my waking life. The release I felt in my chest was, I believe, permitted by what I had observed (and felt!) while watching the cathartic surrenders of participants in those difficult hours of experimental sessions.
Since the work first drew me in, I had to learn when to shut the laptop and go for a walk, run, do yoga, talk, etc. I learned how important social support was to counteract the isolation felt by those holding in emotional turmoil. The participants and therapists were teaching me something about emotional development and mature responsibility in caring for the wounded and impressionable parts of the psyche. The work has delivered inspiration for me in so many personal ways that I made it the focus of my dissertation, “Phenomenology of surrender: The complex mission of the combat veteran in MDMA/PTSD psychotherapy.”