MDMA with cognitive-behavioural conjoint therapy

1. Introduction

Version followed: MAPS study MPVA-1 ("MDMA-Assisted Cognitive-Behavioral Conjoint Therapy in Dyads in which 1 Member has Chronic PTSD", Phase 1/2 open-label protocol, Amendment 4 v1, 8 May 2017; clinical investigator Michael Mithoefer, sub-investigator Candice Monson), as delivered and reported by Monson et al. (2020) and Wagner et al. (2019, 2021), in which both partners take part in the MDMA sessions ("dual-dosing" model). CBCT content follows the 15-session, three-phase structure of Monson & Fredman (2012); phase and session titles below were checked against the publisher's table of contents (Guilford), and session content against Monson's own training slides. A later single-partner variant (MDMA for the PTSD partner only, with the 8-session brief CBCT; Morland et al., 2024 pilot) exists and is noted in section 2 but not followed [source: Guilford contents page; Morland et al., 2026]. The MDMA-session therapist stance follows the MAPS teaching manual (Ruse, Mithoefer et al., revised draft Oct 2010; the protocol cites a later manual version that is not drawn on here [uncertain]).

MDMA-facilitated cognitive-behavioural conjoint therapy (CBCT + MDMA) is a research protocol, not an approved treatment. It combines CBCT for PTSD, a manualised couple/dyadic therapy (Candice Monson, Steffany Fredman), with two day-long MDMA-assisted sessions run in the non-directive MAPS style (Michael and Annie Mithoefer), in which both members of the dyad are participants. Anne Wagner co-developed and reported the combination. CBCT's model of change: PTSD and relationship distress maintain each other (avoidance, accommodation, conflict, trauma-related beliefs), so treating the couple as a unit, improving communication, jointly approaching avoided situations and jointly re-examining trauma appraisals reduces PTSD and improves the relationship. The added rationale for MDMA is its reported empathogenic effect (felt closeness, reduced fear), with the MDMA sessions "placed strategically in sections of the CBCT protocol we wanted to amplify" (Wagner et al., 2021) [source: MPVA-1 protocol; Monson et al., 2020 abstract; Wagner et al., 2021; PsyPost 2021].

Legal and regulatory status (as of sources). MDMA is a controlled substance in essentially all jurisdictions; MDMA-assisted therapy is available only inside approved research or, where permitted, specially authorised medical frameworks. USA: MDMA "is currently a Schedule I drug in the United States" and not clinically available for any medical use, including PTSD; clinical use would require both FDA approval and DEA rescheduling [source: Morland et al., 2026, J Trauma Stress, p. 181]. The FDA declined to approve Lykos Therapeutics' MDMA-assisted therapy for PTSD in August 2024 (Complete Response Letter made public Sept 2025), citing trial-design, durability and prior-MDMA-use concerns; the developer rebranded as Resilient Pharmaceuticals in 2025 [source: Psychiatric Times, 5 Sept 2025; Morland et al., 2026]. Australia: since 1 July 2023 MDMA is in Schedule 8 (controlled drug) of the Poisons Standard for PTSD only, prescribable only by psychiatrists approved under the TGA Authorised Prescriber scheme after Human Research Ethics Committee approval; other uses remain Schedule 9 (research only). No MDMA product is registered on the ARTG or evaluated by the TGA. States add their own requirements: in NSW, for example, a separate state authority, an import licence and permit, treatment in a supervised healthcare setting with monitoring and emergency capability, and treatment and adverse-event reporting at 3, 6 and 12 months [source: NSW Health, Psilocybine and MDMA, current at 2 Sept 2025; TGA webinar listing, 2023]. Other jurisdictions (Canada special access, EU) were not verified [uncertain]. Trial status: no randomised (Phase 2) trial of MDMA + CBCT has published results [uncertain]. Wagner described a planned larger randomised trial of CBCT + MDMA, with a CPT + MDMA pilot to come first (interview published 2021, updated 2023) [source: Psychedelic Support]; a separate open-label pilot of MDMA with brief CBCT in which only the PTSD partner receives MDMA (Morland et al., 2024 protocol) was described as "nearing completion" in a 2026 review [source: Morland et al., 2026]. Current status of the randomised dual-dosing trial is [uncertain]. A practising therapist cannot "start using" the MDMA component outside a regulated trial or authorised programme; what you can use now is (a) CBCT itself, (b) the preparation/integration and safety frame for couples in regulated programmes, and (c) harm-reduction and integration support for clients using MDMA elsewhere (see 4.32) [synthesis].

2. Framework

Format. Dyads in which one member has chronic PTSD (the "PTSD+" partner) and the other is a concerned significant other (CSO; romantic or non-romantic in the protocol; all six completers were romantic, heterosexual couples). Both are clients, not helpers. Co-therapy team: one therapist trained in MDMA-assisted therapy and one trained in CBCT, ideally both trained in both. CBCT sessions are about 75 minutes; the MDMA sessions are full days followed by an on-site overnight stay [source: MPVA-1 protocol; Wagner et al., 2021].

Standard CBCT phases (15 sessions; titles as in the published manual) [source: Guilford table of contents for Monson & Fredman, 2012; Monson CBCT slides; Schumm CBCT handouts]:

Phase 1 – Rationale for treatment and education about PTSD and relationships (sessions 1–2). Goal: shared model of PTSD as impeded recovery in an interpersonal context, treatment contract, reduction of risk of aggression. S1 Introduction to treatment; S2 Safety building.
Phase 2 – Satisfaction enhancement and undermining avoidance (sessions 3–7). Goal: communication skills and dyadic in vivo approach of avoided situations. S3 Listening and approaching; S4 Sharing thoughts and feelings: emphasis on feelings; S5 Sharing thoughts and feelings: emphasis on thoughts; S6 Getting U.N.S.T.U.C.K.; S7 Problem solving to shrink PTSD.
Phase 3 – Making meaning of the trauma(s) and end of therapy (sessions 8–15). Goal: dyadic cognitive work on trauma-related themes. S8 Acceptance; S9 Blame; S10 Trust; S11 Control; S12 Emotional closeness; S13 Physical closeness; S14 Posttraumatic growth; S15 Review and reinforcement of treatment gains.
Each Phase 2–3 session: review out-of-session assignments (OOSA), trauma-relevant in-session practice, couple-level in vivo planning, new OOSA, check-out [source: Monson slides; Schumm handouts].
The manual is published with session outlines, therapist scripts and about 50 reproducible handouts and forms; these are not reproduced or paraphrased here [source: Guilford book summary page].

MPVA-1 sequence [source: MPVA-1 protocol; Wagner et al., 2021]:

Screening/baseline for both partners (structured diagnostic interview, CAPS-5 for PTSD+, medical work-up by medical staff), separate consent for each partner.
Preparatory sessions (one by telemedicine, one in clinic), delivering early CBCT content and MDMA-session preparation.
MDMA-assisted Experimental Session 1 (day-long, CBCT content condensed into the session), overnight stay, integrative session next morning.
Further CBCT sessions in the interval (several by phone/video), midpoint evaluation and preparation visit.
Experimental Session 2 (same structure), overnight stay, next-day integrative session.
Remaining CBCT sessions weekly, then primary assessment (blind-rated CAPS-5) about a month after the last CBCT session; remote follow-up at 3 and 6 months. Total participation about 8 months.

As delivered (Wagner et al., 2021): five CBCT modules before the first MDMA session (i.e., after communication skills were introduced), six between the two MDMA sessions (two of them the day before the second), four after it (i.e., second MDMA session in the middle of the Phase 3 trauma-meaning work); whole course condensed to about seven weeks, with intensive in-clinic blocks. Wagner describes the communication skills as giving the couple "a language" and "a template" to take into the first MDMA session, and the second as timed to the heart of trauma processing [source: Psychedelic Support interview]. A 2026 review summarises the same study as 15 CBCT sessions over 7 weeks, two of them delivered on the morning of each MDMA session, with two 90-minute next-morning integration sessions [source: Morland et al., 2026, Table 1]. The protocol amendment text gives yet other module splits [uncertain: the three accounts differ on where the two in-clinic CBCT sessions fall; the Wagner et al. (2021) account is followed here].
Single-partner variant (not followed here): Morland et al. (2024) set out a VA pilot protocol (8 veterans with PTSD and their partners) in which only the veteran receives MDMA. Brief CBCT has eight 75-minute sessions in two phases (relational safety; then relationship satisfaction and PTSD-related distress); sessions 1–3 and 4–5 are each combined into one longer session and sessions 6–8 are weekly. A 90-minute preparation session after the combined sessions covers what to expect, how to respond to memories that emerge and how the non-dosed partner takes part (the 2026 review describes two preparation sessions [uncertain]). Each full-day MDMA session is run by two co-therapists in a non-directive way, with optional eyeshades and music; the partner may join for part of it, usually towards the end, when therapists can help the couple use bCBCT communication skills, and one therapist can support the partner privately. There is no overnight stay: the veteran leaves after about eight hours with a prearranged driver. A 90-minute emotion-focused couple integration session follows the next day (4.33). Exclusions include psychotic and bipolar disorders, serious current suicide risk, intimate partner violence or severe psychological aggression above the study's thresholds, and significant cardiovascular or other medical risk. The authors present the model for settings where only one partner can be dosed for regulatory reasons (e.g. the VA) or where medical issues rule out the other partner. [source: Morland et al., 2024; Morland et al., 2026] Pilot results were reported in the Journal of Traumatic Stress in 2026: PTSD and relationship satisfaction improved by the end of treatment, with partial rebound at follow-up and no serious adverse events, in an uncontrolled pilot. [source: PsyPost, 14 Sept 2026]

Criteria for moving between phases. The sources found give a fixed session sequence, not mastery criteria [uncertain]. Protocol gates are: eligibility confirmed before preparation; next-day stability (agreed by team and participants) before leaving the clinic; midpoint evaluation before the second MDMA session; any continuation decision after a severe adverse reaction made on next-day assessment [source: MPVA-1 protocol; MAPS manual 2010]. Clinically sensible additional gates: no new aggression since S2 before trauma-focused Phase 3; time-out/time-in being used; both partners able to do the listener role before an MDMA session [synthesis].

Eligibility and exclusions (as published for MPVA-1) [source: MPVA-1 protocol]:

PTSD+ partner: adult; DSM-5 PTSD of at least 6 months, CAPS-confirmed, at least moderate severity; in a significant ongoing relationship; willing to stay overnight, accept transport arrangements, contraception/pregnancy testing and pre-session restrictions; provides an emergency contact for suicidality; English-proficient; not in another interventional trial.
CSO: adult; relationship distress related to the partner's PTSD (V62.89 code); no current PTSD.
Both excluded for: pregnancy/nursing or no effective contraception; primary psychotic disorder, bipolar I, dissociative identity disorder; major depression with psychotic features; personality disorders (protocol lists clusters A, B and C); significant cardiovascular, cerebrovascular, hepatic, renal, endocrine, haematological, pulmonary, gastrointestinal, immunological or neurological disease including seizures; hypertension; history of hyponatraemia or hyperthermia; low body weight; current serious suicide risk or risk to others (past attempts not exclusionary); substance use disorder in the previous 60 days; active purging eating disorder; extensive lifetime or any recent ecstasy use; ongoing psychiatric medication (with narrow listed exceptions; medication decisions are the prescriber's); inability to consent.
CBCT-specific exclusions: current severe relationship violence; minimal commitment to the relationship [source: Monson CBCT slides].

3. Guiding principles

[source: Monson CBCT slides; Schumm handouts; MAPS manual 2010; MPVA-1 protocol; inferences marked]

PTSD lives in a relationship system. Treat symptom–relationship fit (accommodation, conflict, withdrawal), not just the individual. Practice: every intervention is aimed at both partners and their interaction.
Both partners are clients. The CSO's own distress and accommodation are treatment targets, measured separately. Practice: give the CSO equal airtime, assessment and consent; never use them as a co-therapist or informant only.
Trauma-focused but not imaginal exposure. Trauma is addressed through disclosure at the couple's pace, joint approach and joint meaning-making, not prolonged retelling. Practice: do not require a detailed trauma narrative to the partner.
Avoidance maintains PTSD and erodes the relationship. Practice: every session links skills to something the couple has been avoiding together.
Safety first. Aggression is assessed and contained before deeper work. Practice: screen each partner alone for violence; build time-out/time-in in session 2.
Collaborative, non-judgemental, curious. Practice: frame the couple as a team against PTSD, never one partner against the other.
Skills over insight; practise in session. Practice: coach live exchanges between partners rather than talking to each in turn.
Cognitive work is a shared process, not a worksheet. Practice: the partner helps test appraisals; worksheets support, not replace, the conversation.
Out-of-session practice carries the change. Practice: assign, then always review OOSA first.
Inner healing capacity (MAPS). The manual holds that healing comes from the participant's own capacity, with the drug as a catalyst. Practice: in MDMA sessions follow rather than lead.
Non-directive presence in MDMA sessions, structure around them. Practice: during the session offer CBCT skills as options, not tasks; directive skills work happens in preparation and integration [synthesis on the balance; the protocol says therapists may use judgement within the tenor of both methods].
Alternate inward focus and dialogue. Practice: in MDMA sessions, periods with eyeshades/music alternate with talk with therapists and partner.
Optimal arousal. Practice: help both partners stay engaged with emotion without numbing or flooding; ground when needed.
Do not push trauma; agree how it will be raised. Practice: agree in preparation that therapists may gently raise it if it does not arise.
Consent-based touch and strict boundaries. Practice: touch only as agreed in advance, stoppable at any time, never sexual.
Medical safety is the medical team's job. Practice: therapists recognise and escalate; vital-sign and medical monitoring sit with medical staff.
Dual-partner safety. Two people are in an altered state at once, with shared history and possible conflict [synthesis]. Practice: the co-therapy team keeps both partners in view and can attend to each separately.

4. Intervention inventory

Source note: the three phases and all 15 session titles follow the publisher's table of contents for Monson & Fredman (2012); session titles, OOSA names, the U.N.S.T.U.C.K. steps and the MDMA-session frame come from the Monson training slides, the Schumm workshop handouts, the MPVA-1 protocol, the MAPS manual (2010) and Wagner et al. (2021). The book's session-by-session text, therapist scripts and handouts are not publicly available, so step-by-step detail inside each session is the writer's reconstruction from those outlines and is marked [synthesis]. All example wording is illustrative. Part A is CBCT (usable today on its own); Part B is the MDMA-session frame (only inside a regulated trial or authorised programme).

Part A – CBCT components

4.1 Conjoint and individual assessment, treatment contracting

Purpose / when: Before session 1; establish PTSD diagnosis, comorbidity, relationship functioning and safety; decide whether conjoint work is appropriate [source: Schumm handouts; Monson slides].
Steps: (1) Assess the PTSD+ partner (clinician interview, self-report and partner-report of PTSD) and comorbid conditions. (2) Assess the relationship: satisfaction and conflict areas, violence and felt safety (each partner alone), intimacy and emotional expression, sexual functioning, infidelity, and a short observed communication sample. (3) Apply exclusions: current severe violence, minimal commitment. (4) Use Monson's decision guide on CSO participation: is another trauma-focused treatment under way, can the trauma focus sit in the dyad, how much distress/accommodation is there, should the CSO be seen alone or conjointly (participation from none to maximal). (5) Contract: 15 sessions, attendance by both, OOSA, confidentiality and no-secrets rules [synthesis on the no-secrets policy].
Example language (illustrative): "I'll see each of you on your own for part of today. That's routine, and it's where I ask everyone about safety at home."
Watch for: fear in one partner when seen alone; one partner coerced into attending; active substance misuse or suicidality needing priority [synthesis].

4.2 Psychoeducation and treatment rationale (Session 1)

Purpose / when: Session 1; give a shared model of PTSD as impeded natural recovery that plays out in the relationship [source: Monson slides; Schumm handouts].
Steps: (1) Describe PTSD symptom clusters and how each shows up between partners (re-experiencing, hyperarousal, avoidance, emotional numbing as a cycle). (2) Explain recovery as approaching rather than avoiding, and making balanced meaning. (3) Ask each partner how PTSD has shown up in daily life together. (4) Link avoidance and accommodation to maintenance. (5) Contract for treatment; assign OOSA (4.3, 4.4).
Example language (illustrative): "PTSD isn't just inside one of you; it has moved into the relationship. Our job is to shrink the space it takes up, together."
Watch for: the CSO framed as the cause or the cure; the PTSD+ partner feeling blamed. Working: both use shared language ("when PTSD shows up") [synthesis].

4.3 Catch Each Other Doing Something Nice (OOSA)

Purpose / when: Assigned in sessions 1–2; build positive attention and counter negative tracking [source: Monson slides; Schumm handouts; purpose wording synthesis].
Steps [synthesis]: each partner notices and notes small positive acts by the other during the week; in the next session each reads one or two out and the receiver acknowledges them.
Example language (illustrative): "Tell her directly what you noticed, and what it meant to you."
Watch for: sarcastic or backhanded examples; one partner producing none (explore, don't scold).

4.4 Trauma Impact Questions (OOSA)

Purpose / when: Assigned in session 1; each partner reflects on how the trauma has affected them, the other, and the relationship, laying ground for meaning work [source: Monson slides; Schumm handouts; the exact questions are in the manual and not reproduced here – uncertain].
Steps [synthesis]: each partner writes privately; in session 2 the therapist reviews them, choosing what is shared conjointly at a safe pace.
Example language (illustrative): "Write in your own words how what happened has changed how you see yourself, each other and the world."
Watch for: avoidance of the task (an early marker of avoidance to work with); themes that point to Phase 3 modules (blame, trust, control).

4.5 Safety building (Session 2)

Purpose / when: Session 2; reduce risk of aggression and create safety for trauma work [source: Monson slides; Schumm handouts].
Steps: (1) Discuss trauma disclosure: how much and when the PTSD+ partner chooses to share, without pressure. (2) Identify negative behaviours (aggression, intimidation, verbal attacks). (3) Primary prevention: recognise early signs and lower arousal before conflict escalates. (4) Secondary prevention: what each does once escalation starts (4.7). (5) Assign 4.6 and 4.7 [steps 3–4 operationalised: synthesis].
Example language (illustrative): "Nothing we do here works if either of you feels unsafe at home, so we'll build a plan for when tempers rise."
Watch for: minimisation of aggression; any disclosure of fear or injury → stop conjoint trauma work and assess (section 5).

4.6 Learning About My Anger (OOSA)

Purpose / when: Assigned in session 2; each partner learns their own anger cues and triggers [source: Monson slides; Schumm handouts].
Steps [synthesis]: each partner tracks situations, body signs, thoughts and actions when angry during the week; reviewed in session 3 to personalise time-out cues.
Example language (illustrative): "Notice the first signs in your body, before the words come out."
Watch for: tracking only the other partner's anger.

4.7 Time-out and Time-in

Purpose / when: From session 2; interrupt escalating conflict and return to the topic safely [source: Monson slides; Schumm handouts].
Steps [synthesis]: (1) Agree a neutral time-out signal either partner can use. (2) On the signal, both separate for an agreed period and use calming strategies, not rumination or substances. (3) Time-in: return at an agreed time and either resume with the skills or schedule the discussion. (4) Rehearse in session.
Example language (illustrative): "A time-out is a promise to come back, not a door slam."
Watch for: time-out used to avoid all difficult conversations (no time-in); a partner blocking the other from leaving → safety concern.

4.8 Listening skills (Session 3)

Purpose / when: Session 3; build the listener role so the speaker feels understood [source: Monson slides; step detail synthesis].
Steps [synthesis]: speaker shares briefly; listener attends without interrupting, then paraphrases content and feeling; speaker confirms or corrects; swap. Start with low-stakes topics, then trauma-relevant ones.
Example language (illustrative): "Before you respond, tell him what you heard him say, and check you got it right."
Watch for: rebuttals disguised as summaries; therapist doing the talking instead of coaching the dyad.

4.9 Dyadic in vivo approach assignments

Purpose / when: Introduced in session 3 and continued in every later session; reduce shared avoidance that maintains PTSD [source: Monson slides; Schumm handouts].
Steps: (1) Ask the couple what they would stop avoiding if PTSD took up less space in the relationship (a prompt from the slides, paraphrased). (2) List shared avoided activities (crowded places, social events, intimacy, discussing the trauma). (3) Choose one manageable activity to do together before the next session [ordering by difficulty: synthesis]. (4) Plan support and coping. (5) Review experience and learning next session.
Example language (illustrative): "What's one thing you used to enjoy together that PTSD has taken off the calendar?"
Watch for: the CSO doing the task for the PTSD+ partner (accommodation); safety behaviours; skipped assignments (section 5). Working: wider shared activity, less accommodation reported by the CSO.

4.10 Sharing thoughts and feelings – emphasis on feelings (Session 4)

Purpose / when: Session 4; counter emotional numbing and avoidance of emotional expression [source: Monson slides].
Steps [synthesis]: introduce a feelings vocabulary; speaker names a feeling and its context in short "I" statements; listener uses 4.8; practise first on everyday events, then on trauma-related ones.
Example language (illustrative): "Try: 'When the door slammed, I felt scared, and then ashamed of being scared.'"
Watch for: only anger expressed (explore softer feelings underneath); flooding.

4.11 Sharing thoughts and feelings – emphasis on thoughts (Session 5)

Purpose / when: Session 5; help each partner notice and voice the thoughts behind feelings, preparing for cognitive work [source: Monson slides; Schumm handouts].
Steps [synthesis]: link situation, thought and feeling; each partner shares a recent thought about the trauma or relationship; listener paraphrases without challenging yet.
Example language (illustrative): "What went through your mind just before you felt that?"
Watch for: thoughts stated as facts ("you don't care") – flag them as material for 4.12.

4.12 Getting U.N.S.T.U.C.K. (Session 6, used through Phase 3)

Purpose / when: Introduced in session 6; the couple's joint reality-testing process for everyday and trauma-related appraisals [source: Monson slides; Schumm handouts].
Steps (the acronym, paraphrased): U – approach the thought united, as a team and with curiosity rather than blame; N – notice and share the thoughts and feelings, checking you are on the same page; S – brainstorm alternative ways of seeing it, including unlikely ones; T – test each alternative against the evidence; U – use the most balanced thought for a trial period; C – check for changes in emotions and behaviours; K – keep practising. The slides use a "big picture" sheet and a "noticed thought" sheet as aids.
Example language (illustrative): "Let's treat that thought as a hypothesis the two of you test together, not a verdict."
Watch for: the partner arguing the PTSD+ partner out of the thought (shift to joint curiosity); the worksheet replacing dialogue. Working: alternatives generated by the couple, change in feeling reported.

4.13 Problem solving to shrink PTSD (Session 7)

Purpose / when: Session 7; joint, structured handling of practical problems linked to PTSD and the relationship [source: Monson slides; step detail synthesis].
Steps [synthesis]: define the problem specifically and jointly; brainstorm without evaluating; weigh options; pick one and plan who does what by when; review next session.
Example language (illustrative): "Let's define the problem in one sentence you both agree with before trying to solve it."
Watch for: solving before both feel heard (return to 4.8); repeated deadlock on a topic loaded with trauma meaning (move it into 4.12).

4.14 Phase 3 dyadic cognitive modules – shared format (Sessions 8–14)

Purpose / when: Sessions 8–14; apply U.N.S.T.U.C.K. to one trauma-related theme per session while in vivo approach continues [source: Monson slides; Schumm handouts].
Steps [synthesis on order]: review OOSA and approach task; introduce the theme and how PTSD typically distorts it; each partner identifies a related thought (about self, partner, world); work one thought through 4.12 jointly in session; set a theme-linked OOSA and approach task; check out.
Watch for: the CSO's own appraisals are also targets, not only the PTSD+ partner's.

4.15 Acceptance (Session 8)

Purpose / when: Address non-acceptance of the trauma having happened, and its effects, which keeps recovery stuck [source: session title from Monson slides; content synthesis].
Steps [synthesis]: identify "it shouldn't have happened / I should be over it" type thoughts in either partner; test them together; balance acceptance of what happened with responsibility for the present.
Example language (illustrative): "Accepting that it happened isn't saying it was okay."
Watch for: acceptance heard as resignation.

4.16 Blame (Session 9)

Purpose / when: Work on misplaced self-blame or partner-blame about the trauma or its aftermath [source: session title from Monson slides; the Schumm handouts give a self-blame worked example].
Steps [synthesis]: separate intent, foreseeability and responsibility from outcome; test hindsight-based blame jointly; address the CSO blaming themselves for the partner's symptoms.
Example language (illustrative): "What did you actually know at the time, rather than what you know now?"
Watch for: genuine responsibility (e.g., harm done) being argued away rather than acknowledged [synthesis].

4.17 Trust (Session 10)

Purpose / when: Rebalance over- or under-trust in self, partner and others [source: session title from Monson slides; content synthesis].
Steps [synthesis]: identify extreme trust beliefs; distinguish trust in different domains; plan graded trust-building actions as approach tasks.
Example language (illustrative): "Trust doesn't have to be all or nothing. What could he trust you with this week?"

4.18 Control (Session 11)

Purpose / when: Address over-control (rigidity, controlling the partner or environment) and helplessness linked to trauma [source: session title "Control" from the Guilford table of contents and Monson slides; the Schumm handouts use a control-and-surprises example].
Steps [synthesis]: identify control-related thoughts and the behaviours they drive in the couple; test them; agree experiments that share control or tolerate small surprises.
Watch for: control behaviours that amount to coercive control → safety reassessment (section 5).

4.19 Emotional closeness (Session 12)

Purpose / when: Rebuild emotional intimacy blocked by numbing and avoidance [source: session title from Monson slides; content synthesis].
Steps [synthesis]: identify beliefs about closeness ("if I let her in she'll see I'm broken"); test them; plan sharing and approach tasks for closeness.

4.20 Physical closeness (Session 13)

Purpose / when: Address trauma-related changes in physical affection and sexuality [source: session title "Physical Closeness" from the Guilford table of contents and Monson slides; content synthesis].
Steps [synthesis]: discuss non-sexual and sexual touch separately; identify triggering contexts and related thoughts; agree consent-based, graded steps the PTSD+ partner controls; refer to sex therapy or medical review where needed.
Watch for: pressure or obligation; sexual-trauma triggers – go slowly, check consent explicitly.

4.21 Posttraumatic growth (Session 14)

Purpose / when: Identify positive changes and values that have emerged individually and as a couple [source: session title from Monson slides; PTGI used as an outcome in MPVA-1 – Wagner et al., 2021].
Steps [synthesis]: each partner names changes in relationships, priorities, strengths, possibilities; link to future plans; avoid forcing growth.
Example language (illustrative): "Without minimising what it cost, has anything grown in either of you or between you?"

4.22 Review and reinforcement of treatment gains (Session 15)

Purpose / when: Final session; consolidate skills and plan maintenance [source: Monson slides].
Steps [synthesis]: review change on measures and in daily life; each partner names the most useful skills; identify likely triggers and early warning signs; plan continued approach and U.N.S.T.U.C.K. practice; arrange follow-up.

4.23 Standard session structure: OOSA review and check-out

Purpose / when: Every session from 3 on [source: Monson slides; Schumm handouts].
Steps: review OOSA (praise attempts, problem-solve barriers); trauma-relevant in-session practice of the session's skill; plan the next couple-level in vivo task; assign new OOSA; check out with each partner on how the session felt [check-out content: synthesis].

Part B – MDMA-assisted session frame (regulated trial or authorised programme only)

Risk flag for all of Part B: two partners in an altered state at once raises the stakes for conflict, disclosure regret and boundary problems; medical monitoring and any medication decisions belong to the medical team and are not described here [synthesis].

4.24 Informed consent and preparation of the dyad

Purpose / when: Before the first MDMA session; both partners consent separately and are prepared for the experience [source: MPVA-1 protocol; MAPS manual 2010].
Steps: (1) Separate consent for each partner covering the investigational status, risks, recording, overnight stays and restrictions. (2) Build alliance and take histories. (3) Explain what the MDMA session involves: inner-focused periods with eyeshades and music alternating with conversation; therapists non-directive. (4) Teach breathing (slow breathing for early anxiety; breathing into intense feelings). (5) Agree how trauma will be approached, including permission for therapists to raise it gently if it doesn't arise. (6) Agree the touch policy (4.28). (7) Safety agreements: no harm to self or others, staying on site, leaving only when the team agrees. (8) Plan support and transport. In MPVA-1 the preparation sessions also delivered early CBCT content.
Example language (illustrative): "There's no right way for this day to go. Some of it you'll spend inward with music, some talking with us and with each other."
Watch for: one partner consenting under pressure from the other – confirm consent alone [synthesis]; high expectations of a breakthrough.

4.25 Set and setting

Purpose / when: The day of each MDMA session [source: MAPS manual 2010; Wagner et al., 2021].
Steps: a private, quiet, living-room-like room; reclining chairs (Wagner et al. describe reclining armchairs for both partners), blankets, controllable temperature; eyeshades and headphones available; pre-chosen instrumental music without lyrics; silence on request; headphones and eyeshades off for conversation; medical emergency access arranged by medical staff.
Watch for: one partner's needs (e.g., silence) clashing with the other's (talk) – negotiate, or let one stay inward while the other talks with a therapist [synthesis].

4.26 Therapist conduct during the MDMA session: alternation and condensed CBCT

Purpose / when: Throughout the session; support each partner's process and the dyad's work [source: MPVA-1 protocol; MAPS manual 2010; Wagner et al., 2021].
Steps: (1) Keep empathic presence during inward periods; check in after a stretch of silence. (2) Alternate inward time and conversation, roughly balanced but flexible. (3) Follow rather than lead; offer options rather than instructions. (4) Gently redirect inward when talk becomes intellectualising. (5) Accept unusual or transpersonal content without pathologising (manual's stance). (6) In the conjoint protocol, condensed CBCT content is brought into the session and partners talk with each other as well as the therapists; therapists may use judgement as long as interventions fit the tenor of both methods. The first session followed the communication-skills sessions (natural use: listening and sharing), the second sat within trauma-meaning work (natural use: approach and U.N.S.T.U.C.K.-style reflection) [placement from Wagner et al., 2021; what to bring in each: synthesis].
Example language (illustrative): "Would you like to tell him what you just noticed? He can just listen, the way you practised."
Watch for: pressure to perform skills; one partner dominating the session; hostile or blaming exchanges, which call for slowing down and returning to the listener role [synthesis].

4.27 Breathing and somatic support for difficult experiences

Purpose / when: When fear, distress or dissociation arises in either partner [source: MAPS manual 2010].
Steps: stepwise: ask what is happening in the body; encourage breathing into it; offer touch only with permission; explore content that emerges; return the participant inward; only then consider focused bodywork (described in the MAPS manual's appendix, not summarised here [uncertain]). Normalise dissociation and ground via body and breath. Aim for the optimal arousal zone.
Example language (illustrative): "Stay with your breath. Where in your body is this strongest?"
Watch for: escalating panic or disorganisation – involve the medical team per protocol.

4.28 Touch policy

Purpose / when: Agreed in preparation; applied in sessions [source: MAPS manual 2010].
Steps: discuss nurturing touch (e.g., hand-holding) in advance; use only with consent; participant can say "stop" at any time and therapists comply except where needed for safety; ask about preferred seating distance; sexual contact strictly prohibited. In the conjoint setting also agree, in advance, what touch between partners is welcome [synthesis].
Watch for: touch that is not clearly wanted; any sexualised dynamic; sessions are recorded in the trial, which supports accountability.

4.29 Overnight stay, attendant and next-day integrative session

Purpose / when: After each MDMA session [source: MPVA-1 protocol; MAPS manual 2010].
Steps: participants remain on site overnight; a trained attendant (an RN in the manual) offers quiet company, food and drink, listens without interpreting and calls therapists if distress arises; next morning an integrative session with both partners; discharge only when team and participants agree they are stable; prearranged transport.
Watch for: partners processing a conflict overnight without support [synthesis].

4.30 Post-session contact and safety monitoring

Purpose / when: Days after each MDMA session [source: MPVA-1 protocol; MAPS manual 2010].
Steps: daily phone or video contact for about a week; general wellbeing checks and suicidality screening (C-SSRS) on set days; subjective distress ratings; adverse events recorded and followed to resolution; therapists reachable between sessions; if severe destabilisation persists, daily check-ins until stable, hospitalisation as a last resort.

4.31 Integration through remaining CBCT sessions

Purpose / when: After each MDMA session [source: MPVA-1 protocol; Wagner et al., 2021].
Steps: both partners attend; link what emerged in the session to the current CBCT skill or theme; turn insights into approach tasks and U.N.S.T.U.C.K. practice; encourage journalling, art or dream notes (MAPS manual); advise discretion about sharing the experience with others.
Example language (illustrative): "You said you felt close for the first time in years. What would one small step towards that look like this week?"
Watch for: the glow fading and being read as failure; disclosures that now need careful handling.

4.32 Harm reduction and integration support for clients using MDMA outside regulated settings [synthesis]

Purpose / when: A couple tells you they are using, or plan to use, MDMA privately or at a retreat. Not facilitation.
Steps: assess both partners (PTSD, psychiatric and medical history, cardiac issues, medications, substance use, relationship safety); explain in general terms the known risks (cardiovascular strain, overheating, low blood sodium, interactions with psychiatric and other medications, unknown purity) and that the protocol exclusions above exist for safety; encourage medical review and research trial options; do not give or advise on use; safety-plan for conflict or crisis; offer integration using CBCT skills; refer for substance-use treatment where indicated; document carefully.
Watch for: coercion of one partner by the other; using drug sessions to avoid working on violence.

4.33 Emotion-focused couple integration session (single-partner variant)

Purpose / when: In the single-partner brief-CBCT protocol, a 90-minute session with both partners on the day after each MDMA session, to deepen mutual understanding and rebuild a secure bond; up to three further integration sessions may be added before the 3-month follow-up [source: Morland et al., 2024].
Steps: (1) Invite each partner to describe what emerged: the veteran from the MDMA session, the partner from their part of the day. (2) Empathic joining: help each partner voice the vulnerable feelings (sadness, fear, shame, guilt) beneath surface reactions, and help the other partner hear them. (3) Unified detachment: describe problem patterns as driven by PTSD, a shared problem outside both of them, while validating each partner's natural emotional reactions. (4) Help the partners validate each other. (5) Link what emerged to the bCBCT skills and the remaining sessions. [source: Morland et al., 2024, drawing on Integrative Behavioral Couple Therapy; the order of steps is synthesis]
Example language (illustrative): "When you hear the fear underneath the anger, what happens for you?" / "This sounds like PTSD pulling you both apart, not either of you failing."
Watch for: the non-dosed partner feeling shut out of the experience; blame returning once the closeness fades; disclosures that call for a safety check [synthesis].

5. Handling problems

The published sources give little explicit troubleshooting; except where a source is tagged, the guidance below is [synthesis].

Violence or fear disclosed at any point. Current severe violence excludes CBCT [source: Monson slides]. Respond: see each partner alone, assess risk and coercive control, pause conjoint trauma work, safety-plan with the at-risk partner, refer to individual treatment and domestic-violence services; resume conjoint work only if safety is re-established. In a trial, report as the protocol requires.
Uncertain CSO participation. Use Monson's decision guide (other trauma-focused treatment under way? trauma focus workable in the dyad? level of distress/accommodation? see CSO alone or conjointly?) to set CSO involvement from none to maximal [source: Monson slides; Schumm handouts].
OOSA not done (non-adherence). Review first, every session; explore barriers as possible avoidance; shrink the task; do part of it in session; ask the CSO how they can support without taking over.
Accommodation persists. Name it kindly as PTSD's "helper"; plan approach tasks where the CSO steps back gradually; track CSO accommodation (the trial measured it) [measurement: source MPVA-1 protocol].
Stuck in blame between partners. Return to the "united" step of U.N.S.T.U.C.K.; reframe the problem as PTSD versus the couple; slow to listener skills [source for the step: Monson slides].
One partner dominates or the other withdraws. Structure turns tightly; coach the quieter partner; check privately whether withdrawal reflects fear.
Overwhelm or flooding in session. Pause, use time-out/time-in in the room, slow breathing, grounding; return to a less loaded topic; titrate trauma disclosure (CBCT is not exposure-based) [source: Monson slides for non-exposure; rest synthesis].
Disclosure regret, especially after an MDMA session. Revisit in the next-day integrative session; separate the content from the decision about further sharing; remind both of the agreement that the PTSD+ partner controls disclosure.
Partners' MDMA experiences diverge (one euphoric and connected, one anxious or untouched). Normalise; give each individual time with a therapist; avoid comparing; integrate separately and together.
Conflict during or after an MDMA session. Slow down, separate partners if needed with one therapist each, apply time-out agreements, avoid working through major grievances in the altered state; process in integration.
Anxiety, panic, re-experiencing or dissociation in an MDMA session. Reassurance, breathing, grounding, staying present; touch only with consent; medical staff decide on any medical response; decisions about a further session after severe panic are made after next-day assessment [source: MAPS manual 2010].
Resistance in MDMA sessions. Accept and follow it rather than challenge; explore repeated avoidance gently later [source: MAPS manual 2010].
Post-session destabilisation or suicidality. Daily contact, C-SSRS screening, the safety plan agreed at screening and the emergency contact; daily check-ins until stable; hospitalisation as a last resort [source: MPVA-1 protocol; MAPS manual 2010]. Follow standard risk-assessment practice; lethal-means counselling limited to secure storage and removal.
Afterglow then drop. Prepare both partners that mood may dip in the days after; frame the work as continuing through CBCT.
Boundary and touch problems. Use only pre-agreed touch; stop on request; no sexual contact; co-therapy and recording support accountability; report any violation [source: MAPS manual 2010; recording from MPVA-1 protocol].
Rupture with a therapist. Name it; ask each partner what felt wrong; repair before going on; watch for triangulation (one partner allying with one therapist).
Expectation the drug will "fix" the relationship. Address in consent and preparation: the sessions amplify CBCT work, they don't replace it.
Couples asking you to guide private MDMA use. Decline facilitation; offer assessment, general risk education, medical referral, trial information, integration and harm-reduction support (4.32).
Limits of the evidence for generalising. Pilot samples were small, all romantic and heterosexual and white; adapt with care for same-sex, non-romantic and culturally diverse dyads [sample: PsyPost 2021; adaptation advice synthesis].

Sources

Sources used:

Further sources:

Also cited:

Monson, C. M., & Fredman, S. J. (2012). Cognitive-Behavioral Conjoint Therapy for PTSD: Harnessing the Healing Power of Relationships. Guilford Press. (used through the publisher's table of contents and description)
Monson, C. M., Wagner, A. C., Mithoefer, A. T., et al. (2020). MDMA-facilitated cognitive-behavioural conjoint therapy for posttraumatic stress disorder: an uncontrolled trial. European Journal of Psychotraumatology, 11(1), 1840123. (abstract)
Wagner, A. C., Mithoefer, M. C., Mithoefer, A. T., & Monson, C. M. (2019). Combining cognitive-behavioral conjoint therapy for PTSD with MDMA: a case example. Journal of Psychoactive Drugs, 51(2), 166–173. (via the OPEN Foundation summary)
Morland, L. A., Perivoliotis, D., Wachsman, T. R., et al. (2024). MDMA-assisted brief cognitive behavioral conjoint therapy for PTSD: study protocol for a pilot study. Contemporary Clinical Trials Communications , 40, 101314 (eScholarship, University of California )
PsyPost (14 Sept 2026): MDMA-enhanced couples therapy shows promise for treating PTSD and relationship distress (summary of Morland et al., Journal of Traumatic Stress)

Remaining [uncertain] points: the CBCT book's in-session scripts and handouts; later MAPS manual versions; the status of the randomised dual-dosing trial; regulation outside the USA and Australia.

← Previous · VII-057MDMA-assisted therapy for PTSD Next · VII-059 →MDMA-assisted therapy with mindfulness skills