MAPS Bulletin Spring 2014 Vol. 24, No. 1 – Psychedelics and Education
I admit at the outset that I am much more comfortable reporting on correlation coefficients and treatment fidelity than writing in the first person about my own experiences—but isn’t this the essence of our hopes for MDMA-assisted psychotherapy: to encourage our clients to move outside the limited and limiting zone of comfort they have demarked for themselves in order to cope with their PTSD; to experience and embrace the thoughts, emotions, sensations, and behaviors they have cloistered themselves from for fear of being overwhelmed and losing the tenuous control they have maintained since their traumatic experience.
When I think about what motivated me to become a subject in MAPS’ therapist training study, I remember an event many years ago when I first began training as an amateur singer. My teacher suggested that I adopt a model, a singer whose voice I admired, to listen to often and form a mental representation that could guide me from the inside as my teacher guided me from the outside. When I told her of my choice, she responded, “Oh, anyone but Dietrich Fischer-Dieskau!” His sonorous baritone, articulation, dramatic sensitivities, and range of color and expression defied modeling and would only, she said, cause me much frustration.
I approached the MDMA therapist training trial in which I was to participate in the same spirit. I had by then already been through a training workshop to become one of the therapist investigators in MAPS’ Israeli study of MDMA-assisted psychotherapy for PTSD, but still, I wanted a model to internalize which would help me carry out a type of therapy quite different than I was used to. It could well be that I chose the “Fischer-Dieskau team” of MDMA-assisted therapists for my model, but nonetheless, I travelled to South Carolina in hopeful anticipation of bringing a bit of Michael and Annie Mithoefer with me back to Beer Yaakov.
I approached my own experience with a mix of trepidation and excitement. Michael and Annie had long since won my confidence and I knew I wanted to make this journey in their company. They jumped right in to hear and validate my doubts, fears and hesitations, never for a moment implying “there’s no turning back now”—even after two transatlantic trips separated by 11 months. Their calm and gentle encouragement helped me to truly look forward to what was to come. In just one evening at their home in South Carolina, I had already learned a whole lot about MDMA-assisted treatment that was not to be found in any practice manual.
The morning of my first experiential session arrived, and it wasn’t long before I had another observation to be jotted down for my future sessions on the other side of the couch: I found taking MDMA in pill form somewhat unsettling. For me, a pill as the medium of delivery seemed to be an abrupt, all or nothing affair: take the dose, then wait for onset (or not, in the case of a placebo). Nevertheless I took it, and we settled in for the day’s journey.
As it turned out, my first experience was a placebo. This made it easy to be in the dual role of trainee and participant. I largely succeeded in maintaining a “participant observer” stance—learning about the treatment while not squandering the rare opportunity for my own introspection and healing in the company of expert guides. The placebo day turned out to be a magnificent one of learning and observation. Had the trial ended here I would already have been the better for it. But now I knew that the real thing awaited.
My MDMA experience was absorbing to the point of mocking any conceit of “participant observation.” I experienced onset anxiety, but at the ever-wise suggestion and encouragement of Annie and Michael, rather than trying to repel it, I met it, breathed into it, and embraced it. At one point I became concerned with deliberating over whether or not to accept the offer of a top-up dose. I clearly remember the moment I realized I was frittering away a precious opportunity by being less inside the experience. The anxiety yielded to an exhilarating sensation that at the time I likened to hydroplaning—water has always been for me the element of freedom and flow. This experience sensitized me to the possibility that my future clinical trial patients might face the same choice.
Since my MDMA session, I have reflected a lot on how I used the session and how I would try to do so were another opportunity to come along. My complete immersion in the session allowed me to walk away with a clearer image of how to be present with and for a client during their experience, and I felt more prepared to respond to what I would encounter as a therapist in an MDMA study.
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Back in Israel, I awaited my opportunity to make the transition to “the other side of the couch.” For me, there are two elements of the treatment protocol that are notably different from the way in which I usually give treatment. First, the treatment calls for the involvement of two therapists, rather than one. My experience doing psychological treatment has largely been limited to single rather than co-therapy, though I sometimes do co-lead mind-body skills groups. This was no small shift in modus operandi to be sure, and I was truly happy for the chance to work alongside a colleague who shares my passion for pushing the therapeutic envelope, one who would bring with them skills and attitudes complementary to those that I would be bringing to the treatment.
The treatment protocol is also built upon a “less directive approach” than that to which I am accustomed. As a fairly structured cognitive behavioral therapy (CBT) therapist, I initially felt somewhat pushed out of my strike zone. In the process of trying to understand what this really meant in practice, I found Dr. Michael Mithoefer’s excellent analysis, “MDMA-Assisted Therapy: How Different is it from Other Psychotherapy?” (2013).
At first glance, MDMA-assisted psychotherapy looks very different from any conventional treatment: Participants lying on a futon, sometimes with eyeshades and headphones listening to music with male and female therapists sitting on either side for at least eight hours.
In his analysis, Dr. Mithoefer explains the seven elements which together create a treatment that is “stimulating access to the individual’s innate, universal healing capacity” (which I hope would be an axiom for anyone in therapeutic endeavors). Some of these elements made sense to me already upon beginning the therapist training, such as Cognitive Restructuring, Anxiety Management, and Exposure Therapy. Others I had to work more to understand, such as Working with the Multiplicity of the Psyche. As I entered my first experience as an MDMA-assisted psychotherapist, it’s clear to me that both my active participation and my internal efforts to integrate the therapeutic philosophy into my own vernacular prepared me well for what I was about to do.
My MDMA experience emphasized a truth that I aspire to both in therapy sessions and in the rest of my life: Trust the process. In MDMA-assisted treatment, trusting the process is absolutely critical. Trying to force or overly direct the content or unfolding of a therapy session violates a cardinal principle of this type of therapy: that healing must be self-directed. Yes, we can facilitate the process, but in the end the healing guides itself
. In this sense, MDMA-assisted treatment reminds me of Eye Movement Desensitization and Reprocessing (EMDR), a psychotherapy technique that heals while allowing the client’s brain to go where it needs to go. So, too, with MDMA-assisted treatment. Drawing this parallel to the non-directedness of MDMA-assisted psychotherapy was very helpful as I began administering MDMA-assisted psychotherapy.
Another therapeutic realization that was driven home during my own MDMA-assisted experience was the importance of trust, security, and a sense of partnership in the therapeutic context. Particularly important in the context of PTSD treatment, this is a model of interpersonal interaction that needs to be (re)learned by the PTSD sufferer. A hallmark of the chronic post trauma victim is the belief that the world and much of what and who occupies it are dangerous. One of the first difficulties therapists encounter when treating PTSD sufferers is winning their trust, helping them let their guard down, and finding a safe place in their world—even if that safe place is only imaginary at first.
Co-therapy, as it is built into the MDMA-assisted protocol, can greatly enhance this therapeutic element, however its ability to do so cannot be taken for granted. Treatment teams must be carefully chosen, and they must be given ample time to become greater than the sum of their parts.
It was a stroke of great fortune to have been assigned to work with Keren Tzarfaty as my co-therapist. It was clear to me very quickly that in Keren I had someone who was secure enough in her therapeutic skin to dance the co-therapist two-step with grace and style, and to do so in the best interest of our client. Like a Bach fugue our vocal lines support each other: now as melody, now as accompaniment, always in harmony.
At the time of this writing, we have just completed our first treatment, which turned out to be a placebo. As in my own placebo experience, we ventured to create a therapeutic experience which was in every other way identical to the full dose MDMA treatment. The full post-trial evaluation still awaits, but there is no doubt to me that the subject walked away from this stage with certain improvements, certain realizations about his own healing capacities, certain hopes that he now dares to entertain. A bond between us—both between the therapists and the subject, and between the therapists—has been created that will soon be reinvested in a full-dose trial, one that I believe will facilitate a much deeper healing and learning.
References
Mithoefer, M. (2013). MDMA-Assisted Therapy: How Different is it from Other Psychotherapy? MAPS Bulletin, 23(1).
Naftali Halberstadt, Ph.D., earned his Ph.D. in Cognitive Psychology from the Hebrew University of Jerusalem. He is a senior CBT therapist and supervisor at the Hadassah University Medical Center in Jerusalem and directs a CBT training program for therapists from the ultra-orthodox sector in Jerusalem. His work in CBT, and as a Mental Health Officer in the Israel Defense Forces, motivated him to develop a Psycho-Trauma Response Program for The American Jewish Joint Distribution Committee (AJJDC) in Israel, which he directed from 2002–2008. This nation-wide initiative provided individual and community-based services and professional training. From 2008–2012 he was director of the Training Center for Mind-Body Skills, closely associated with the U.S-based Center for Mind-Body Medicine (CMBM). Naftali is a member of the CMBM International Training Faculty. International humanitarian relief is central to Naftali’s professional identity. He has been part of a team of trauma experts sent to train professionals in Sri Lanka in the aftermath of the Tsunami disaster, provided consultation to professionals in Louisiana in the aftermath of hurricane Katrina, and was part of a team of mental health experts sent to train professionals in Haiti. Since 2012, Naftali has been the lead psychologist for a USAID-funded, AJJDC project to develop psycho-social disaster readiness in Indonesia. Naftali lives in Jerusalem with his wife and children. He can be reached at nhalberstadt@gmail.com.
MAPS Bulletin Spring 2014 Vol. 24, No. 1 – Psychedelics and Education