On the Analyst's Couch With Ecstasy
Sitting on a couch is Melissa, a woman in her mid-20s who has just taken 125 mg of methyllenedioxymethamphetamine (MDMA), or ecstasy, in a glass of juice. Sitting in a rocking chair to the left of Melissa is licensed psychotherapist Dr. Jane, who will work intensely with her patient over the next few hours, as Melissa's brain bathes in the surplus neurochemicals brought on by the MDMA.
Melissa and her therapist aren't part of any currently approved research. They consider themselves to be conscientious, law-abiding citizens, but have decided to augment traditional psychotherapy with what the U.S. Drug Enforcement Agency currently classifies as a Schedule I substance – an illegal drug.
But, illegal or not, Dr. Jane (not her real name) has a rationale for using this drug with her patient: MDMA eases anxiety surrounding traumatic events, allowing them to be recalled with extensive clarity, then amplified by a desire to discuss them, perhaps for the first time in the patient's life.
Dr. Jane is one of an informal network of a half dozen or so psychologists – licensed social workers and psychiatrists practicing in Utah – with the experience and willingness to work with patients who choose to use MDMA in conjunction with other drug-free therapy sessions.
She and her underground clinical colleagues aren't doing anything new. Long before its popularity blossomed under the moniker "Ecstasy" in dance clubs and warehouses across Europe and North America, and long after its first patent by German pharmaceutical company Merck in 1914, MDMA was used by scores of psychotherapists during the 1970s and halfway through the 1980s.
With its relatively minimal side effects, therapists classified the drug as an empathogen for its ability to open the heart, increase awareness and foster sensations of self-love and acceptance. In addition, the drug has the added benefit of keeping the patient firmly grounded and in control, rather than orbiting Pluto as occurs with stronger drugs. From the perspective of the analyst's chair, these are all very desirable traits.
From its ingestion, MDMA takes about 45 minutes to take effect. During this time, Melissa nods her head in affirmation, as Dr. Jane reads aloud the goals for this session and the safety contract, both of which have been developed and agreed upon during six earlier preparation sessions.
It is now 60 minutes past the point when Melissa unwrapped a small triangle of tin foil, emptied the white, powdered contents into a glass of juice and drank it down in one long gulp. Her earlier, tense posture has given way to a more relaxed position on the doctor's leather couch. The pillow she had been clutching nervously in her lap is now resting under her right leg, and her head rests gently on the back of the sofa. Melissa is both alert, and noticeably relaxed, as she talks openly about abuse that occurred early in her childhood. Dr. Jane listens intently, only occasionally asking questions that probe lightly into progressively deeper layers of her memories.
Now two hours into her session, tears fall from Melissa's face and into a white Kleenex she holds in her hand as she recounts one particularly strong memory. Using a succession of questions, Dr. Jane assists Melissa in understanding how her earlier trauma caused her to project certain beliefs into her present relationships – beliefs that are creating some problems.
Toward the end of her session Melissa says: "Reliving this incident helped me free up my emotions in a number of ways. ... I know that I have a lot more to do, but I know now that I molded my views about the world – that I now know are not true – because that one incident caused me to distrust my parents."
Melissa, who works as a computer programmer, seems visibly relieved, and hopeful. Weeks after the sessions, she sent a promised e-mail describing the sum of her three MDMA-assisted therapy sessions: "I was able to dump my file ... the medicine cleared my channels ... insights and memories poured through me ... fragments and pieces of the puzzle all came together. I had a cloud of trauma that had seemed in front of me ... that for almost my whole life had been distorting my beliefs about myself ... it seems behind me now, and I've gotten a new sense of who I am."
Don't rush out to your local psychotherapist for sessions on the couch with this "love drug" just yet, though.
First of all, these renegade therapists will allow only certain patients to use the drug, and only after a careful screening and analysis process of several therapy sessions in advance of taking the drug. The drug's therapeutic effects have been found especially beneficial to those suffering from post-traumatic stress disorder (PTSD).
Second, don't go thinking that your time on the couch will amount to some sort of drug-crazed party of one. Most patients take MDMA during therapy twice at least, maybe three times at most. Perhaps most discouraging of all is the fact that you will have to score the drug yourself. Patients who desire this type of therapy assume all the responsibility in obtaining, possessing and ingesting the drug. Finding authentic MDMA, free of adulterants and of known strength, takes some work, but is not difficult.
Dr. Jane cautions any prospective MDMA patient against running down to the local warehouse or club to buy a hit from a raver sporting an X on his shirt. You're more likely to end up with a fake drug or sometimes-harmful counterfeit. Some have had luck procuring legitimate samples from undergraduate chemistry students who've figured out that MDMA is not all that difficult to synthesize.
Once the patient procures the drug, Dr. Jane provides guidance on determining potency of the MDMA, and assists with dosing. Preparation sessions are crucial. Not only are patients given information on the risks and benefits of therapy using the drug, they also establish goals for the session, discuss expectations, and how information yielded during the MDMA session will be integrated in the patient's life. Dr. Jane follows a safety protocol that involves having a trusted friend or relative assume charge for the patient after the session, among other things.
In short, MDMA-assisted psychotherapy is serious business, not the dance party for which it's commonly used. Those who take the drug recreationally to enhance the repetitive beat of dance music and feel closer to other people at a party will gain a few pleasant hours with little or no insight into themselves. An MDMA session in the confines of an office and under the guidance of an experienced professional is something else entirely.
Before the drug was criminalized in 1985, Rick Doblin, an expert on the therapeutic and medical uses of marijuana and psychedelics who earned his doctorate from Harvard University's Kennedy School of Government, was witness to MDMA's effects on patients during psychotherapy. "I saw first-hand just how helpful it was for certain patients," he said during a telephone interview from his Boston home.
But as the drug gained more and more publicity for its pleasurable qualities at dance and club parties, as opposed to its less sensational benefits during psychotherapy, the DEA moved to ban the drug under Schedule I classification. Therapists protested, suing the government in court. An administrative law judge agreed that the drug shouldn't be classified as such but could only make a recommendation to the DEA. The agency said, in effect, "Thanks, but no thanks."
As if to buttress the DEA's position, the scientific community released study after study questioning the drug's safety and long-term effects. The most damning studies by Johns Hopkins University researcher Dr. George A. Ricaurte concluded that MDMA use led to permanent brain damage in primates and damaged the brain's dopamine neurons. Upping the fear factor, the doctor also concluded that use of the drug could lead to Parkinson's disease in humans.
But in a stunning reversal, Ricaurte himself put those findings to rest September 2003 when he admitted in Science magazine that his researchers had not given primates used in his studies MDMA, but another drug entirely. However, even some of Ricaurte's detractors say his earlier studies demonstrating the drug's neurotoxic qualities may have merit. Debate about the drug's long-term effects continues, but many hope that with Ricaurte's primate study now invalidated, a new era of study surrounding the drug's benefits will soon dawn. About time, too, they say.
Doblin founded the Multi-Disciplinary Association for Psychedelic Studies (MAPS) in 1986 with just that goal in mind. Based in Sarasota, Fla., his organization works to advance the study of MDMA's therapeutic value through legitimate scientific studies. The United States isn't the only nation with resistance to studying the drug's therapeutic uses. Spain hosted the first scientific study of MDMA in the world, testing its therapeutic value on women survivors of sexual assault. The study seemed to be advancing quite well according to media reports. Then the International Narcotic Control Board shut it down.
Although there is considerable anecdotal evidence about the benefits of MDMA-assisted therapy, scientific confirmation of its effectiveness is admittedly minimal. The most notable of the few studies originate from a group of Swiss psychiatrists who used MDMA in conjunction with psychotherapy from 1988 to 1993. During this six-year period, 121 patients underwent a total of 818 sessions. More than 90 percent of the patients described themselves as "significantly improved." During the course of the study, there were no adverse incidents, no suicides, no psychiatric hospitalizations and no negative reactions.
Doblin's MAPS is working hard to change the drug's research landscape. It launched a "$5 million, five-year Clinical Plan" to one day see MDMA made into a prescription drug for the treatment of post-traumatic stress disorder. The organization is also trying to secure funding for research at Harvard University, where the drug might be tested on advanced cancer patients to help mitigate their fear of death and other anxieties, Doblin said. But the truly big news among MDMA's proponents was the FDA's November 2001 green light for a study of the drug's effects on people with PTSD. Early this year, in February, the proposed study also earned necessary regulatory approval from the DEA. Together, both approvals mark the first time since the drug was criminalized that it will officially be studied for therapeutic value.
For Doblin, this kind of approval for scientific study of MDMA makes the perfect bookmark to 1963, when Timothy Leary got the boot from Harvard University for his studies regarding LSD.
"The Israelites, so to speak, have been wandering in the desert for 40 years. Researchers have been locked out of the lab, wandering the wilderness for that long. It's really the first time in decades that we've had any research on these substances at all," he said. "The quest for verification and scientific research is totally appropriate. What's fundamentally problematic is that it's taken us so long to even get to that point. It's especially difficult to gain traditional funding sources for this kind of research, too. The drug is just too controversial for them to even touch it."
All this is extremely important news for therapists like Dr. Jane, too. A practicing psychotherapist in Salt Lake City for years, one of the degrees on her wall boasts the blue and white accents of a relatively conservative Utah school. Displayed on the wall just below that degree is a license issued by the Utah Department of Occupational Licensing to practice as a clinical psychologist. She's gravely aware that her license and livelihood could be in jeopardy each time a patient of hers takes MDMA under her supervision. One patient with one bad reaction is about all that separates her from a bee's nest of legal problems, investigators, and a trip (no pun intended) in front of the licensing board.
Nevertheless, she is resolute. "I would rather tender my license and make widgets than turn a blind, fearful eye away from an avenue of treatment that may help someone," she said. "MDMA has a fantastic ability to scan through the unconscious, lock onto areas of emotional tension, and then allow the patient to talk about themselves in spite of any defensive walls they've created."
Like her patient Melissa, the Utah doctor has her own description of MDMA-assisted therapy: "Feelings of self-love and self-acceptance suffuse the session and, frequently, they can endure long after the drug has left the body," she said.
And any good psychotherapist knows that any long-lasting behavioral change has its roots in feelings of genuine self-love.
"People ask me all the time if I can refer them to therapists [using MDMA], and I cannot. I know it's going on, but I don't know exactly who's doing it. I know they're out there," says Julie Holland, M.D.
A New York University psychiatry professor and psychiatrist in practice at Greenwich Village, Holland is widely considered the most celebrated authority regarding MDMA's therapeutic value. And with Ricaurte's studies discredited, her comments are no longer seen as those of the naïve proponent. Just ask Newsweek, and other publications in which her words have gotten a forum. Taking a break from vacation in Massachusetts to speak by phone, her voice is measured and assured, even if occasionally surprised.
"You found some underground therapists? That's great, and it's not easy to do," she said.
Anyone who's ever heard of Prozac or lithium knows that the marriage of drugs and therapy is nothing new. That's one of the reasons Holland has no qualms about entertaining the use of MDMA with patients on the couch. She seems shocked that anyone would consider its use such a radical departure. In addition to authoring an exhaustive research paper on the drug, she edited articles by 21 of the world's most noted MDMA experts, compiled in 2001 under the title "Ecstasy: The Complete Guide."
One of Holland's favorite quotes from an article included in her book comes from George Greer, a therapist who prescribed the drug for patients while it was legal, only to find himself forced to stop using it. "I felt like an artist who'd just discovered oil paints, but had to put them away and start using charcoal again because people were sniffing the oil paint," Greer wrote.
Holland sympathizes with any physician forced to put effective medicine aside. And she believes MDMA can be especially beneficial, not just for people with PTSD, but also with adults who were physically or sexually abused as children. "Psychiatry doesn't really have many good tools in its armament when you get right down to it. This is a really good tool," she said. "And it's very possible that if the government said this was a good drug for therapy, fewer people would be enticed by its illegal status."
The irony of recent FDA and DEA decisions to approve preliminary studies of the drug, however, is that now government seems to have taken the lead where universities and private companies haven't taken the trouble. Universities, of course, are cautious to do anything that smacks of illegality. But the reason why corporations never took MDMA's case before the FDA or DEA is clear, Holland believes.
"No pharmaceutical company has gotten behind this because [MDMA's] patent is expired, and it's a drug that the average patient will take once or twice during therapy, and that's it. There's no profit margin in it," she said.
But that doesn't mean there's no connection between current favorites such as Prozac and MDMA. Both drugs work to release serotonin, which brings on a general sense of openness, energy and well being. But where Prozac merely stops the recycling of serotonin, so that it backs up in the brain to make more available for the synapses, MDMA, on the other hand, floods the brain with serotonin. In addition, like Prozac, it also stops the recycling, or uptake, of serotonin as well.
"It's a very subtle experience. For most people it's about as subtle as having one or two glasses of wine," Holland said. "It's not as big of a break from normal consciousness as people might think it is. But give it a name like Ecstasy and people have a lot of assumptions about it.
"It's similar to anesthesia during surgery. It's not that you're pain-free, but you are very much more relaxed. You have to really peel through layers of defenses to get to core therapy. People are pretty much laid out, and you're much more likely to get to the malignant core of what's going on. It allows you to more readily examine it, and potentially excise it or remove it. It makes therapy much more efficient and effective. You don't have to spend three years building an alliance with your therapist. It really strengthens that alliance, which is really important for future sessions."
And unlike alcohol or other sedatives that would result in blurry disinhibition, MDMA has the added benefit of letting a patient recall the experience of what was discussed. That's due to the drug's amphetamine base, which gives patients greater ability to remember what's happened. And when an issue is recalled and remembered, there's no need to talk about it over and over. Taken once or twice during therapy, Holland said, MDMA can reap multiple benefits in future sessions.
Doblin concurs. "In a way, MDMA is the anti-drug, because Prozac and Zoloft are drugs people have to take every day, and when people stop taking them their problems come back," he points out. "MDMA in therapy is taken only a few times. In the PTSD study, people take it only twice. It was never intended to be a regular daily drug in a therapeutic setting, and was never intended to be a take-home drug."
Concern over the drug's current status as an illegal substance is that it may sit forever in the recreational realm, where it's most often used incorrectly. Used in the context of a dance party, users frequently experience dehydration, overheating or elevated blood pressure. Used in psychotherapy and under professional supervision, those conditions are much less likely to occur.
"Millions of people around the world are using it recreationally; it gets more popular every year," Holland said. "But people who could really benefit from it, can't. It's a real tragedy and a real shame."
Even though Mike (not his real name) has been apprised in advance of steps that will be taken to protect his anonymity, he's understandably guarded in talking about MDMA and his psychotherapy practice. A clinical social worker, he brings hand to chin when asked about his initial reasons for using MDMA with select patients.
"There was no big 'eureka' moment or anything," he said. "To me, the decision to add it to my psychotherapy practice was just common sense ... consider a therapist with a strong Jungian orientation. Well, using Jungian therapeutic techniques doesn't work with every client and so, unless you're neurotically rigid, you use some cognitive behavioral therapy or some other modality that is going to make a difference. It was kind of like that. I never struggled with it as an ethical question. The greater moral wrong seemed to be in denying relief to a human being seeking it."
He estimates that in the years he's maintained a practice in Utah, he has treated about 30 people using different psychedelics. He prefers MDMA for much the same reasons as other therapists do, but has used psilocybin, ayahuasca, and the research chemicals 2ct2 and 2ct7 – all with good results.
Mike believes that MDMA's area of greatest promise is in couples or marital counseling. "MDMA, with or without couples counseling, has salvaged a handful of marital relationships I had considered doomed," he said.
As evidence, he furnished a written account by one of his MDMA patients, who initially presented relationship problems: "During my session I could see clearly for the first time in my life ... many of the patterns or cycles of conflict I had been having with [my wife] I realized were responsible for our separation, and that my continued happiness in my relationship with her depended on me stopping those behaviors completely. I saw that she was a caring and loving person, and let old anger and grudges fall away. I made a commitment to myself to give up those behavioral patterns ... I would never again focus on our differences or pretend to ignore them. I learned that they are necessary, and that I would celebrate them ... at that moment, and now, even five months later I found it was no longer necessary for her to change in order for me to be happy in the relationship."
Mike, for one, is hopeful that the attitudes of the authorities will change regarding his type of work as a psychotherapist. He's well aware of MAPS' work in this regard.
Concern by Mike and Dr. Jane for their anonymity is not difficult to understand. Being present, much less having a participatory role in the use of MDMA, clearly violates a handful of laws and licensing rules. The Utah State Department of Occupational and Professional Licensing (DOPL) has not been ambiguous about therapists practicing in this manner. Providing MDMA-assisted psychotherapy is one of only a handful of major infractions that would result in the revocation of a license, as opposed to other lesser sanctions.
However, it's fair to say that MDMA, like every other medication, is not completely safe, as well as not completely understood in its mechanism of action. Chalk that up, again, to its status as an illegal, Schedule I drug. As a result, there is not an abundance of research directed at answering questions about the drug's mechanism of action and, unfortunately, most of the few studies completed to date have focused only on its tendency to release the brain chemical serotonin. It's hoped that MDMA's unhindered study will be a significant turning point in assembling a comprehensive picture of its very unique pharmacological functions. Experts know that questions about MDMA having a neurotoxic effect, or a depleting effect on the brain's supply of serotonin, need further study.
But in consideration of the universal side effects described by the millions of people who've used the drug, MDMA's major risks to any individual appear to be the very real possibility of being arrested and jailed.
Still, even proponents such as Doblin know the importance of research, whether that be to prove the drug's effectiveness, or demonstrate its risks. "That's one of the lessons we learned from the '60s," Doblin said. "You can't downplay the risks or emphasize the benefits."
Mike and Dr. Jane in no way perceive themselves as divergent warriors on the frontlines in the effort to legitimize MDMA. However, as the resurgence of therapeutic research on MDMA begins, it's therapists such as they who may one day be in a position to teach other mental health professionals the techniques of harnessing the drug's potential.
For his part, Doblin roots for any psychotherapist brave enough to blaze such a trail while the drug remains illegal. "I feel a lot of sympathy and pride that there are two people in Utah who care enough about their patients that they're willing to risk their freedom and licenses," he said. "That creates a lot of inspiration and responsibility in me to work even harder to see this through."