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A Gift to be Alive:  MDMA ('ecstasy') in Psychotherapy

 

From "PIHKAL":

[We] took 120 mg of MDMA in the early afternoon[...] At about the half-hour point, the usual "awareness" time, 'Janice' gave no indication of effects, nor were there any changes at the 40 minute, nor at the 50 minute point. A few off-hand comments were offered:

     "My throat is dry."

     "I'll get you a glass of water." Which I did. It did no good.

     "I'm having trouble breathing."

     "So, breathe as best you can." I noticed by the reflection in the window where we were, at the back of the house, that she had no difficulty breathing when I wasn't watching her.

     We walked up the hill, to an area I had leased out to the condominium builders on the neighboring land for the storage of lumber. There were several 'no smoking' signs around as fire warnings.

     "Do you think I smoke too much?"

     "Do you think you smoke too much?"

     "I don't think so."

     "Then the answer is: probably not."

     It was now an hour into the experiment, and still no acknowledgement of any activity from the MDMA. Then came the unexpected question, the "off the wall" question.

    "Is it all right to be alive?"

    "You bet your sweet ass it's all right to be alive! It's a grace to be alive!"

    That was it. She plunged into the MDMA state, and started running down the hill, calling out that it was all right to be alive. All the greens became living greens and all the sticks and stones became vital sticks and stones. I caught up with her and her face was radiant. She told me some of her personal history which she knew well, and which I knew well, but with which she had never come to peace.

     She had come into the world by an unexpected Caesarean section and her mother had died during the delivery. And for fifty years she had lived in the guilt of having had her life given at the cost of her mother's life. She had been in therapy with her family physician for about three years, largely addressing this problem, and apparently what she needed was the acknowledgement that it was all right to be alive.

     I didn't hear from her for a couple of months. When she did call, she volunteered that she still felt very much at peace, and had discontinued her therapy.

[End Quote.]

 

     This story represents one of the earliest reports of MDMA having therapeutic benefits. In spite of the striking, almost mystical qualities of the case, such responses to MDMA are not unusual. What would eventually become "ecstasy" first entered the medical community's awareness not as a new kick for the weekend, but as a powerful new tool for personal growth. For people familiar with psychedelic drugs the idea of drugs as a catalyst for growth hardly seems surprising, but to a general public who's idea of recreational drugs means the drooling stupidity of alcohol abuse the idea takes some explaining.

      What does MDMA do that could be beneficial to a patient? First, it powerfully suppresses emotional fear, to such an extent that people under the influence are often able to openly discuss deeply traumatic events, such as rape, suicide attempts, etc. MDMA produces complete emotional honesty with yourself. Second, it is a moderately powerful stimulant, not simply allowing the patient to sit there indifferently, but prodding them to examine and discuss their lives. Animal experiments also indicate that MDMA enhances learning, allowing what is discovered and experienced during the MDMA state to strongly affect and stay with the patient long after the session.

     The net result is a patient who, for a few hours, is almost perfectly primed to grow as a person. Their fears are gone. They feel strong, at peace, and able to handle almost anything emotionally. They're also hyperactive and extremely talkative, eager to explore ideas and issues and share their thoughts. The 'hyper-focused' MDMA state can also allow the therapist to steer the conversation into otherwise highly charged topics...they don't have to tease the story out of them; the patient is truly ready to talk about what's on their mind. And finally, the experience seems to allow a high degree of incorporation of what they learn about themselves back into their normal lives.

     Many classic elements of a cathartic MDMA experience appear in the above case, including Janice's anxiety/difficulty in letting go and embracing the experience. Once she entered the MDMA state, she became euphoric, talkative, and emotionally open, bringing herself to face what was truly bothering her. Equally important, however, was that the experience stayed with her. She didn't simply revert to her prior emotional state upon sobering up. Although her long-term prognosis is unknown, several months of relief from a few hours of treatment is nothing to sneeze at.

     Granted, an anecdote is not proof of efficacy. But when the anecdotes become as striking, as numerous, and as tantalizing in their promise as those surrounding MDMA are, it becomes difficult to discount them all as placebo effects or sudden improvements for unrelated reasons. The thousands of therapists that originally spread the use of MDMA certainly believed their patients were benefiting. The scientists that fought tooth and nail against its prohibition certainly thought it had value. The therapists that have continued to use it after it was outlawed, risking prison in order to be able to provide this form of treatment to suffering patients certainly believe. And indeed, the US government is sufficiently intrigued by the evidence that the FDA has given permission to test MDMA under controlled circumstances in the treatment of people with post-traumatic stress disorder. This research (overseen by MAPS) should begin in 2004.

     Only the research can say how useful MDMA will be in objective terms, but there is no doubt in my mind that there will, in fact, be a significant and measurable benefit to the experimental patients. Where we go from there is the real unknown. MAPS intends to seek full FDA approval, which would allow doctors to have (legal) access to MDMA again. (That would hardly make it easily available; methamphetamine is available by prescription as well, but good luck getting any that way.) However, it is likely that there will be mortal opposition to gaining FDA approval, since it would mean admitting what the science has already proven: That all things considered, the demon-drug "ecstasy" is actually fairly safe. Granting MDMA prescription status would also be seen as a threat to another piece of prohibitionist dogma: That no good can come from psychedelic experiences. In part I think this latter conviction stems from a perceived cultural threat; the law didn't really go after psychedelics until they became associated with the Hippie/anti-war/socialist movements of the sixties and seventies. Regardless of the specific motivation, however, there is likely to be a long and bitter battle over getting full FDA approval as the dark forces of politics rise up to oppose science and medicine once more.

     Some explanation of the exact role of psychedelics in therapy is needed. These drugs do not solve problems per say. Getting high isn't inherently going to make your life better or make sense. Rather, drugs offer us a change in perspective that can allow us to better understand and come to terms with ourselves. What MDMA has to offer is the chance to examine your own life with complete honesty and compassion for yourself. It's an emotional moment of grace; a chance to forgive yourself for your own mistakes and pain. In the MDMA state, you can stop repressing issues and face them. Ultimately, what MDMA offers is a chance for closure...to pour out everything that is weighing on your soul, face it...and give yourself permission to let it go.

     Pharmacologically, therapeutic use of MDMA probably works because the drug provides a rather exotic mix of stimulant, anxiolytic, and dopaminergic effects. The massive serotonin release neutralizes anxiety and emotional defense mechanisms. The large noradrenaline release prods the patient to high levels of mental activity, thinking about themselves and their lives (instead of simply sitting on the couch feeling cheerfully indifferent as would occur with other anxiolytics.)  The dopamine release enhances conditioning/reinforcement.  This mechanism appears to be central to drug addiction, but in this context it has a much more interesting role:  It allows the patient to essentially re-write their conditioning, over-riding the initial memory of trauma and fear (such as from a violent crime) with a newer memory of being able to calmly examine, cope with and move past the experience.   The net result is an extremely promising tool for the treatment of psychological trauma of all sorts.  MDMA assisted psychotherapy is not some sort of mystical Hippie mumbo-jumbo.  It is very real science, with perfectly rational neurological mechanisms behind its effects.

     Although the current research on MDMA in psychotherapy targets Post Traumatic Stress Disorder (victims of sexual assault and other violent events) the drug also seems to have a great deal of potential for couples therapy, since it can break down the defensiveness and lack of trust that prevent open, honest and compassionate communication between many couples. If MDMA is approved for PTSD, doctors will be able to use it for other forms of therapy as well ("off-label use"); although the FDA issues approval of drugs for specific conditions, long tradition (and court rulings) have established that once a drug is approved, doctors may prescribe it for other conditions that they believe it may help.

 

Guidelines for MDMA use in therapy:

     Just as there are considerations of company, environment, etc. for recreational use of MDMA, there are guidelines for safe and effective therapeutic use. In the course of pursuing human MDMA research, MAPS has prepared a detailed treatment manual. It was written by medical doctors, psychiatrists and therapists experienced in using MDMA to treat patients.

• Read the MAPS Treatment Manual for MDMA-Assisted Psychotherapy

 

     The MAPS protocol is extremely conservative, as is only appropriate for human research. This document doesn't specify a dosage of MDMA to be used; I believe a dose of about 1.5-1.7 mg/kg would be appropriate (about 120-135 mg for a 175 pound person.) A person who is relatively uncomfortable with the idea of altering their state of mind may prefer a lower dose (1 mg/kg) for their first time, although it would be considereably less effective in my opinion.