Highlights from Training for Therapists Involved in Phase 3 Clinical Trials of MDMA-Assisted Therapy for PTSD
“Crushing truths perish from being acknowledged.”
In April 2016, I was one of a group of therapists, researchers, and others who convened in Fort Collins, Colorado, for our first in-person training for individuals who will be working on Phase 3 trials of MDMA-assisted psychotherapy for posttraumatic stress disorder (PTSD) sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS). I am a Registered Clinical Counsellor in Vancouver, Canada, working in the field of mental health and substance use, and I was fortunate to be among those invited to participate from across Canada and the U.S.
The course was led by Michael Mithoefer, M.D., Annie Mithoefer, B.S.N., and Marcela Ot’alora, L.P.C., who are also the Principal Investigators for MAPS’ Phase 2 trial sites in South Carolina and Colorado. They brought a wealth of knowledge and great generosity in the sharing of their work, which set the tone for an inclusive and productive week.
The training consisted of viewing videos of MDMA-assisted psychotherapy sessions from Phase 2 PTSD trials, with lively discussions about what we were seeing, questions about the therapists’ interventions, and the sharing of our own therapist backgrounds. Some of the recorded sessions were intense; I was periodically distressed by what I saw and others reported the same. I found myself wanting to lash out at those who had perpetrated the traumas, but there were no enemies present, just my own old grievances that were surprisingly activated by watching the videos. Trauma has this effect, moving scattershot amongst those that it touches. This proved to be an in vivo inoculation for the work ahead.
The videos were rounded out by introductions to the Internal Family Systems (IFS) approach to therapy and Holotropic Breathwork™, modalities that inform MAPS’ approach to MDMA-assisted psychotherapy for PTSD. IFS is a model of psychotherapy, developed by Richard C. Schwartz, that posits that our minds are comprised of sub-personalities, or parts. According to IFS, under conditions of duress these sub-personalities keep traumatic memories compartmentalized, sometimes outside of conscious memory. This compartmentalization is helpful for survival of the organism while the trauma is happening, but later on it can also interfere with our ability to comprehend events and our ability to take responsibility for healing them—leading to the feeling that when we feel bad, it must be because we are bad. Due to the compartmentalization, we fail to see the larger picture and the impossible positions we have experienced. One of the goals of IFS is to encourage these separate parts to communicate and work together. I have used IFS concepts in my own work with clients, and have found it helpful in de-pathologizing their internal experience of distress.
Holotropic Breathwork™ (HB) was developed by Stanislav Grof, M.D., Ph.D., and Christina Grof, Ph.D., out of their desire to continue working with the healing potential of non-ordinary states of consciousness after therapy with psychedelic substances became illegal. HB works from the premise that we all have an “inner healing intelligence” which, when given the right conditions, will naturally evoke the emotional material needed for healing. I spent two weeks in an immersive HB retreat in February, and I can attest to the power of the set and setting created. Through the use of specific breathing rhythms and evocative music, I was able to access non-verbal experiences that transcended my logical mind. I felt into deep wells of sadness and grief of which I was not previously aware—apparently, I (like many people) have been a very effective suppresser of emotional distress. In that experience, I got a small taste of what psychoanalyst D.W. Winnicott called primal agony. When pockets of grief are allowed to come into consciousness, it becomes possible to integrate them, providing a measure of control over how we feel about events that gave rise to that grief.
Unresolved trauma has a way of manifesting in the present. Without making trauma present and digestible, its symptoms emerge, unbidden, in myriad forms: flashbacks, nightmares, triggers, fear, and circumscribed lives. Individual potential is thus curtailed. Without the ability to bring traumatic memories into the light where they can be integrated, symptoms will continue to recur.
MDMA decreases activation in the amygdala, or fear center, and releases the bonding hormone oxytocin. These properties allow people to feel safe and connected, perhaps for the first time in their lives. MDMA’s stimulant effect provides the stamina required to stay with difficult emotional material for longer periods of time. In combination, these effects create the conditions for traumatic memories to emerge and be spoken.
Harvard psychiatrist Judith Lewis Herman, M.D., posits that there are three necessary phases in successful PTSD treatment: (1) developing a safe relationship; (2) remembering and processing the trauma; and (3) reconnecting with others after the process. MDMA-assisted psychotherapy seems to allow for the establishment of sufficient safety within the experimental (active dose) session, which without the MDMA could take months or years, or in some cases may never develop. Further, this safety creates the container within which exiled memories and experiences can be brought to the surface for processing. The treatment process includes follow-up sessions and check-ins, allowing for further integration and reconnection.
Self-care for therapists
As with any work involving trauma processing, providing MDMA-assisted psychotherapy requires a commitment to self-care and integrity on the part of the therapist. During the training week, we discussed the importance of attending to ourselves. Sitting with subjects who are metabolizing trauma requires presence and transparency. In order to effectively support another in giving voice to the unspeakable, the therapists’ instrument—which is the self—needs to be as robust and intact as possible. As Laura Huxley, psychotherapist and widow of Aldous Huxley observed:
A person in a psychedelic state can perceive much more in other human beings than he can when he is in his everyday mind. Anyone who is a companion must give up any attempt at self-hiding. Not only is it useless, but it creates a fatiguing and distracting tension for both.
In therapy, pretending or performing by the therapist will be perceived for what they are: disingenuous and therefore not safe. It is incumbent on therapists, then, to attend to our own lives with integrity so as not to cloud or detract from the process. This includes our physical selves. Attending to our physical bodies before, during, and after sessions is essential. I see preparing for this study akin to training for a marathon: I need regular exercise, stretching, meditation, good nutrition, and sleep. During our week together, our group
spent our non-training time participating in yoga, early morning hikes, meditation, drumming, singing, laughing, socializing, and dancing. The expressed spirit of the training was to nurture non-competitive relationships, which the extracurricular activities helped develop and deepen.
My highlights of the training included witnessing, in the session videos, Michael, Annie, and Marcela providing loving corrective experiences to subjects who were receptive and available to their wisdom and care. Another highlight was our final dance party on Saturday night, where we discharged the tensions of the training week and proved that therapists can DJ an inspired set. Both the videos and the celebration were a great privilege to experience.
Fifty years ago, in This Timeless Moment, Laura Huxley asked questions about the necessary checks and balances required for the safe and ethical administration of psychedelic therapy: “How should the psychedelics be administered? Under which circumstances, with what kind of preparation and follow up? These are questions that must be answered empirically, by large scale experiments.” Now, 50 years later, we are at the point where these large-scale experiments are at hand, and we will soon have the empirical data required to answer these questions. In early 2017, my cohort will meet with the other therapist groups in training for Phase 3 trials for a final in-person training before Phase 3 trials begin recruiting participants.
This is an exciting time, and one that calls for some sober reflection. Many have come before us and have made this research possible. I want to express gratitude to our teachers, Michael and Annie Mithoefer and Marcela Ot’alora, and of course to Rick Doblin and MAPS who have built this foundation, allowing us to gather data with the express goal of making this a legal prescription treatment and thereby offering relief to individuals and families who have not found healing through currently available treatments. I have worked with many individuals in my own practice, and have felt helpless when I cannot offer more concrete relief to their suffering. MDMA-assisted psychotherapy may offer a potential for healing that many have not been able to access through talk therapy alone. I will continue working with MDMA in therapy outside of research contexts when it can be legally prescribed.
Huxley, Laura (1968) This Timeless Moment. New York, New York: Ballantine Books.
Charlotte Jackson is a Registered Clinical Counsellor working in Mental Health and Substance Use for over 15 years in Vancouver, BC. She works from a harm reduction, strengths based, trauma informed perspective, as well as from an anti-oppression framework. She works with individuals and couples addressing trauma, anxiety, depression and life transitions. Charlotte is currently in training with the Multidisciplinary Association of Psychedelic Studies (MAPS) to be a therapist in the Phase III study using MDMA-assisted psychotherapy for individuals with treatment resistant PTSD. Her mentor is Andrew Feldmar, social phenomenologist and radical psychotherapist. Charlotte believes in each individual’s innate capacity to move towards wholeness and healing given the right conditions. She can be reached at firstname.lastname@example.org.