Destigmatizing MDMA-Assisted Therapy: Unlocking Why Legal PTSD Treatments Do Not Always Work

By: Victoria Donkin

Approximately 76% of individuals in Canada experience or witness a traumatic event in their lifetime.¹ Of those individuals, approximately 10% will be diagnosed with posttraumatic stress disorder (PTSD).¹ Individuals diagnosed with PTSD often avoid thoughts and feelings related to their trauma; however, despite this avoidance, the traumatic event is often re-experienced through nightmares, flashbacks, and intrusive recollections.⁵ This can be highly debilitating for the individual, impairing every day activities such as sleep and work and can lead to harmful coping strategies such as isolating oneself, addiction, and self-harming behaviours.²

Therefore, receiving treatment is critical! However, of the individuals that are able to receive treatment, only 32% of patients actually recover from their PTSD and demonstrate healthy functioning.^{3 4 5}  Due to the low amounts of treatment success, researchers aim to identify new treatment methods to alleviate PTSD symptoms for individuals who do not respond well to traditional treatment. This includes the assistance of MDMA.

What are traditional treatments used to treat PTSD?

1. Medication 

Although specific medication for PTSD does not exist, some psychologists recommend PTSD patients to take antidepressants to target certain mood symptoms associated with PTSD; however, this method of treatment shows low to modest effects in helping the overall disorder. Therefore, evidence-based psychotherapies are often the first-line of treatment.⁶

2. Evidence Based Therapy (EBT) 

There are several evidence based treatment methods used to alleviate PTSD severity, predominantly: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), Cognitive-Behavioural Conjoint Therapy (CBCT) and Prolonged Exposure Therapy (PE). 

Limitations to Current Treatment Methods 

Although the aforementioned treatments can be effective for many individuals with PTSD, the dropout rates from these treatments are fairly high, averaging to about 30% of patients. However, some patients may not even be able to obtain treatment due to high costs, inaccessibility, or stigmatization. Of the individuals able to obtain treatment, approximately 58%  still have diagnosable levels of PTSD after going through with their treatment.^{2 4 5}  

Although many treatment options exist in treating PTSD, they often require a long-term commitment to attend multiple sessions, which can be financially costly, and difficult to maintain alongside family and work-related commitments. Additionally, to be able to engage in this healing process, patients need to be able to retrieve the emotions, thoughts, and memories central to their traumatic event; however, not all patients have the emotional ability to handle the distress that comes with treating PTSD. This distress can cause patients to resist treatment, distrust their clinician, or quit altogether. ⁷  

Therefore, clinicians have now begun to explore alternative treatment methods, such as MDMA assisted therapy, to help patients feel safe, open and trusting to the treatment process. 

What is MDMA and how does it work? 

MDMA is a monoamine releaser that promotes the release of serotonin (stabilizes mood and feelings), dopamine (pleasure), noradrenaline (regulates arousal and vigilance), and oxytocin (encourages social-bonding and connection). Therefore, the bodily effects of MDMA allow patients to enter an “optimal arousal zone” where their distress and anxiety are mitigated, and they can better respond to therapy by feeling more open to trusting their therapist and partner if engaging in conjoint therapy.⁸

By including MDMA in psychotherapy treatment, patients can decrease their fear response without blocking their accessibility to trauma-related memories so that they can engage in the process of identifying their emotions and thoughts without feeling distressed by them. This is because MDMA has also shown to decrease activity in the fear processing system of our brain  (where PTSD individuals have increased levels), and an increase in areas responsible for processing information.⁸ However, it is essential to clarify that MDMA-assisted therapy is not for ALL patients with PTSD. It is ONLY recommended for those that are physically, emotionally, and mentally unable to process their trauma in regular treatment.⁶

How was MDMA introduced into the therapeutic setting? 

MDMA was combined with therapy starting from the 1970s, where psychotherapists acknowledged its ability to allow patients to have insight into their own problematic patterns, heightening their self-reflection. However, the euphoric, pro-social feelings that MDMA provides garnered traction as a recreational substance within night-club settings rather than a therapeutic one. This became problematic, as the drug itself can moderately increase body temperature and blood pressure, which, combined with other substances and the warm atmosphere of dance clubs, led to several heatstroke deaths. This contracted some concern leading to its criminalization in 1985. However, many physicians, clinicians, and researchers protested and testified in favour of using MDMA in a therapeutic setting, gaining special permission and regulation to use MDMA for research purposes within the last 15 years for clinical testing.⁹

What is MDMA assisted therapy? 

MDMA assisted therapy incorporates the substance “3,4- methylenedioxymethamphetamine” (also known as MDMA) into regular evidence-based psychotherapies.¹⁰  For example in CBCT there are 15 sessions in total that enable a traumatized individual and their close other to engage in cognitive work to address what thoughts are central to their trauma, and develop skills to communicate effectively with one another. 

When performing MDMA-assisted CBCT, two additional MDMA sessions are added to the original protocol. The protocol guidelines of MDMA assisted sessions are regulated broadly across all research.⁸ In these sessions participants are given 75 mg of MDMA, and are offered an option half-dose (37.5 mg) after 90 minutes of the first dose (the approximated time that the first-dose takes to display full effects) due to potential differences in substance tolerances. 

Participants are then seated in reclinable lounge chairs, where they are encouraged to spend time alternating from independent “inside” time (with headphones playing pre-selected music and eyeshades) and “outside” time where their headphones and eye shades are taken off and they converse with their partner and or therapists. The alternations between “inside” and “outside” time are six hours long. Their feelings of distress and blood pressure/temperature are checked to ensure safety during substance consumption. The participants then stay overnight during the night of the MDMA-assisted session, where they are checked on by a night assistant to ensure continuous safety. They then are debriefed and assigned out-of-session assignments by their two therapists, that continue to work on the skills taught in the CBCT sessions. The second MDMA session follows the same protocol, but participants are offered a choice between 75mg or 100mg to start, and once again, an additional half-dose after 90 minutes.¹¹ 

Is MDMA safe to use alongside treatment?

MDMA-assisted therapy is carefully controlled and has been shown to be safe in the therapeutic setting. Particularly, because MDMA is typically only used in 2-3 sessions, health concerns are constantly monitored when taking the substance. Additionally, several studies have used drug screens after treatment to test whether the use of MDMA within a few sessions could cause dependence or recreational use outside of treatment. It was found that no participants used MDMA following treatment or during treatment. ^{8 12 13}

How Has MDMA Shown To Be Successful in Treating PTSD? 

In a study by Mithoefer and colleagues (2013), 74% of the participants who underwent MDMA-assisted therapy demonstrated long-lasting relief of PTSD symptoms. 89% of the participants also had continued self-awareness and understanding post-treatment, 68% had increased emotional ability, and 58% of the participants had improved relationships with their close others. Mithoefer and colleagues (2018) continued their MDMA-assisted therapy research, examining veteran and first responder patients. 85% of the participants treated with 75 mg of MDMA no longer met PTSD diagnoses at the end of treatment. Two-thirds of those participants had continued remission after one full year.⁸

Of those participants, an individual identified as Lubecky provided his thoughts on how the therapy helped him. Lubecky expressed that his suicidal ideation disappeared after treatment, and his depression was now almost 70% gone, whereas his PTSD reduced by 50%. He states that he feels like a better father, son, and husband to his family. The treatment allowed him to function in his everyday life, enabling him to return to work. His goal post-treatment is that everyone with PTSD knows that this MDMA-assisted treatment is coming and that there is hope, and that others don’t get to the point that he was, where he wanted to take his own life.¹⁴

There are some barriers preventing wider use of assisted therapy:

If MDMA-assisted therapy is so beneficial, why is it not widely used? 

1.The criminalization of MDMA makes funding for research difficult, which can serve as a barrier to making MDMA-assisted therapy accessible!

2. Stigmatizing myths that perpetuate criminalization misinform the public on the effects of MDMA, further creating barriers to making this treatment widely available!

Common Misconceptions about MDMA

1. Researchers examining the effects of MDMA-assisted therapy are NOT attempting to pass MDMA as a sole PTSD medicinal treatment. If MDMA becomes approved for general clinical practice, it would not be something prescribed to patients to pick up independently at the pharmacy, it would be given to specialized clinics under supervision.⁸ Therefore it should always be referred to as MDMA-assisted therapy, as MDMA itself is not the treatment. 

2. MDMA is NOT “ecstasy” or “molly.” When MDMA-assisted therapy research entered mainstream media, individuals were using MDMA and ecstasy interchangeably. Street substances sold under the name ecstasy, molly, or even MDMA, often do not contain pure MDMA and are made from unknown and dangerous components. In research utilizing MDMA, a purified substance is used, where small to moderate doses are given. The doses given are scientifically measured to be of safe human consumption. Media suggesting that MDMA-assisted therapy utilizes ecstasy, undermines the success of these treatments, and makes it harder to decriminalize the substance for clinical use. ⁶

3. The use of MDMA in clinical settings does NOT cause substance-abuse post-treatment. Several studies utilizing drug-tests have examined if MDMA-assisted therapy enables other recreational drug use, and they have all shown that it does not. ^{8 12 13}

Limitations of MDMA-Assisted Therapy 

Much research has identified that trauma and PTSD disproportionately affect BIPOC individuals as well as low-income communities. However, these populations also demonstrate higher rates of comorbid substance use disorder with their PTSD diagnoses. Due to these dual disorders, it is unlikely that these populations were used in MDMA-assisted therapy research trials. Individuals with active-substance use disorders were excluded from research to date as the effects of MDMA causing addiction post-treatment had not been examined. However, by decriminalizing MDMA from clinical settings, more funding for research can be provided to better support marginalized communities through this treatment method. ^{15 16 17 18}

Future Steps

1. Help legalize the use of MDMA in clinical settings to provide more accessibility to marginalized communities. Clinicians must advocate for this form of treatment and support novel research that demonstrates a significant alleviation of PTSD severity.

2. Train various forms of “therapists” to administer MDMA-assisted therapy to reach different communities. Different mental health practitioners such as social workers, psychotherapists, psychiatric nurses, clinical psychologists, and psychiatrists reach diverse populations with varying incomes. By training various professionals, more populations will be able to receive this treatment.  

3. Be vocal to local administrators and government representatives on the necessity of a diverse range of treatments! Having a “one treatment fits all” mentality actually worsens society’s mental health; by educating the public on different modes of treatment and how they benefit their target recipient, we can de-stigmatize treatment and mental illness! 

References

1. Van Ameringen, M., Mancini, C., Patterson, B., & Boyle, M. H. (2008). Post‐traumatic stress disorder in Canada. CNS neuroscience & therapeutics, 14(3), 171-181.

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

3. Bisson, J. I., Cosgrove, S., Lewis, C., & Roberts, N. P. (2015). Post-traumatic stress disorder. Bmj, 351.

4.  Cloitre, M. (2009). Effective psychotherapies for posttraumatic stress disorder: a review and critique. CNS spectrums, 14(1), 32-43.

5. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2010). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press.

6. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

7. Zepinic, V. (2015). Treatment resistant symptoms of complex PTSD caused by torture during war. Canadian Social Science, 11(9), 26-32.

8. Lawrence, J. (2018). Like a hug from everyone who loves you- how MDMA could help patients with trauma. The Pharmaceutical Journal. Doi: 10.1211/PJ.2018.20205586

9. Hutchison, C. A., & Bressi, S. K. (2018). MDMA-Assisted psychotherapy for posttraumatic stress disorder: Implications for social work practice and research. Clinical Social Work Journal, 1-10.

10. Danforth, A. L., Struble, C. M., Yazar-Klosinski, B., & Grob, C. S. (2016). MDMA-assisted therapy: a new treatment model for social anxiety in autistic adults. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 64, 237-249.

11. Wagner, A. C., Mithoefer, M. C., Mithoefer, A. T., & Monson, C. M. (2019). Combining cognitive-behavioral conjoint therapy for PTSD with 3, 4-methylenedioxymethamphetamine (MDMA): A case example. Journal of psychoactive drugs, 51(2), 166-173.

12. Lawrence, J. (2021, February 12). ‘Like a hug from everyone who Loves you’ – How MDMA could help patients with trauma. https://pharmaceutical-journal.com/article/feature/like-a-hug-from-everyone-who-loves-you-how-mdma-could-help-patients-with-trauma. 
13. Feduccia, A. A., Holland, J., & Mithoefer, M. C. (2018). Progress and promise for the MDMA drug development program. Psychopharmacology, 235(2), 561-571.

14. Mithoefer, M. C., Mithoefer, A. T., Feduccia, A. A., Jerome, L., Wagner, M., Wymer, J.,… & Doblin, R. (2018). 3, 4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post-traumatic stress disorder in military veterans, firefighters, and police officers: a randomised, double-blind, dose-response, phase 2 clinical trial. The Lancet Psychiatry, 5(6), 486-497.

15. Slopen, N., Shonkoff, J. P., Albert, M. A., Yoshikawa, H., Jacobs, A., Stoltz, R., & Williams, D. R. (2016). Racial disparities in child adversity in the US: Interactions with family immigration history and income. American journal of preventive medicine, 50(1), 47-56.

16. Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological medicine, 41(1), 71.

17. McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs, 27(2), 393-403.

18. Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2012). Physical health conditions associated with posttraumatic stress disorder in US older adults: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of the American Geriatrics Society, 60(2), 296-303.

Image References

Conner, C. (2020). [The Mind on MDMA]. The New York Times. https://www.nytimes.com/2020/07/25/fashion/weddings/me-my-relationship-and-ptsd.html

Horton, A. (2016). [Patient During “Inside Time”]. Stars and Stripes. https://www.stripes.com/feel-good-drug-ecstasy-one-step-closer-to-approval-as-ptsd-treatment-1.445361

MAPS Europe. (n.d.). [MDMA-Assisted Therapy Session]. MAPS Europe. https://mapseurope.eu/

PTSD Health (2020). [BIPOC Representation]. Health Magazine. https://www.health.com/condition/ptsd/relationship-ptsd