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A Review of Clinical Issues in MDMA-Assisted Psychotherapy

Drs. Juraj and Styk

A talk given at the Conference on the Clinical Utility of MDMA and MDE - Israel, 1999

Back to the 1999 MAPS MDMA Conference Page
See also Structuring Psychotherapy Sessions with MDMA in a Research Context
by George Greer, M.D.

Juraj and Sonja Styk are members of the Swiss Society of Physicians for Psycholytic Therapy, a group of therapists which in 1988 was granted special permission to work with MDMA in private practice. Permission to work with MDMA lasted until the end of 1993, when all psychedelic therapy in Switzerland was forbidden. For information about the renewal of research in Switzerland, see the MDMA Research in Switzerland Page

When I was working as a young resident in a progressive psychiatric hospital in the then Czechoslovakia, my boss received Delysid (trade name of LSD) ampoules from the Sandoz Scientific Office in Prague. I was assigned the task of accompanying trial volunteers and was fascinated by the effect of LSD. I was soon able to make my first self-experience. Although my boss was more interested in research into experimental psychosis, I noticed that I was affected above all by unexpected and usually very sudden memories of suppressed events from my childhood.

My first LSD experience - although carried out in an unfavourable clinical setting - opened the door to an undiscovered facet of my soul. In my withdrawn state I felt separated from the sitter and was unable to speak. Instead of speaking I was acutely aware of what was happening inside and around me: truth and lies, genuineness and falseness. I felt that I could see through the enigmatic character of my companion.

Painful images of incidents during the years of the war and persecution came to my mind; threatening situations with Nazis and their Slovak allies, living in hiding, my mother being attacked by a Russian soldier. Subsequently, I experienced the feelings of helplessness, anxiety and distrust and also remembered shameful situations from my early childhood. The experience gained from humanistic-existentially oriented groups and from body therapy in the seventies and eighties was in-dispensable for our group sessions with MDMA. The insights obtained from my own therapy provided a reliable basis enabling me to recognize my tendency to grandiosity which appeared in some sequences of the session. The feelings of warmheartedness, humour, self-irony, empathy on the one hand, and my becoming familiar with different cultural and political systems on the other, gave me a solid grounding. The memories of one's own painful experiences are very valuable in relationships with others. Groups sessions teach one a great deal about human frailty, vanity and power struggles, but also about to-erance, the creative power of teamwork with a male and a female therapist and mutual support. Everybody who receives the gifts of entactogens has an opportunity to discover a new meditative path. The experience he gains along this path can change his attitudes and he can pass this legacy on to others.

You may be asking yourselves how we work in our practice:
In the introductory phase we use ecclectic psychotherapy to assess the patient's suitability for psycholytic therapy and to get to know his/her personal circumstances. We need to find out:

a) whether the patient is capable of establishing a working alliance and a trustful relationship;
b) whether he/she can cope with strong emotions and how his/her defence is organized;
c) how understanding and reliable his/her partner is (jealousy re-actions have threatened our work in the past).

Sometimes we check these these points by means of a breathing session in the group or on an individual trip.
In addition to its use in psychiatric indications (anxiety disorders, depression, PTSD, eating disorders, psychosomatic disease, personality disorders) , consciousness training can be helpful by creating new perspectives during or after life crises. Moreover, the use of MDMA is of importance for religious and spiritual experiences, for the enhancement of creativity and for accompanying the dying process.

The principal prerequisites for a psycholytic therapist are: 1) his/her psychotherapeutic training in which he/she has learned to understand his/her reactions and to control countertransference, and 2) specialized psycholytic training which teaches him/her to handle the subtle changes in the altered state of consciousness and to experience the body work. The subconscious facets of the personality of therapist's personality can be hazardous or even harmful, namely:

1. The urge to dominate and indoctrinate
2. Omnipotence fantasies       -     narcissistic

3. Inability to withstand feelings of powerlessness    -    depressive

4. Impatience when there is no progress    -    obsessive- compulsive

5. The hedonistic use of substances    -    addictive

6. Excessive zeal    -    fanatical

7. Lack of experience hand in hand with overconfidence
8. Insufficient contact with colleagues       -     schizoid

The therapeutic relationship can be jeopardized by poor motivation, an unstable alliance, unclarified power relationship (i.e. when working with friends, clients of other therapists) and addictive attitude. A good setting calls for responsibility and discretion. All participants promise to avoid aggressive behaviour and sex during the ritual. It is essential to express one's questions and one's intention and willingness to cooperate. The fundamental aspect of the psycholytic therapy process is the integration work. We have found that it is very moving and productive if this work takes place in the circle of the next and individually on the following days. The participants have to keep a journal. Integration work is imperative, otherwise a large part of the experience will be forgotten and suppressed anew.

Example: Therese is a nurse, unmarried, and the younger of two children of a chemist. The mother gave up her profession on marrying and subsequently lived practically only through her children, who were expected to satisfy all her unfulfilled wishes and desires. In order to achieve their mother's ambitions, the children should be successful. However, at the same time - and completely unconsciously - she passed on her own anxiety and insecurity to her children. She did her best, but how could she give her children support without having any inner stability of her own (the true self, in Winnicott's words)? Therese felt ignored by her father, who had a very demanding job, although she constantly tried to attract his attention. She also loved her brother, but he soon went his own way and did not take much notice of his little sister. Therese experienced her confirmation as a glimpse of light on an otherwise clouded horizon. When the subject of university came up after she had completed her final school exams, she had less confidence in her own abilities than her equally gifted schoolfriends. While her friends married and had children, she was in an unsatisfying relationship with a married colleague who was rather fond of a drop too much. During therapy Therese began to rediscover the wide range of her talents and worked with sound, movement and imagination. She found her energies and learned to channel them and to work them off. But the question of the meaning of life remained unanswered and thus her loneliness persisted.

Excerpt from her journal:
"The start is difficult, accompanied by nausea and a lot of fear. Alternate waves of heat and cold go through my body. I can clearly feel the familiar blockades in my diaphragm and throat. Tormenting negative thoughts and ideas go round and round in my head. I keep trying to concentrate on my breathing and my body, and this helps for a moment. I feel imprisoned in my energies and struggle to get free by shouting and kicking, but nothing helps. I know very well that I'm cutting myself off from my life-force by putting up a fence of prohibitions, and this only makes me feel even more desparate. I'm scared that in this state of being cut off I will lose touch with myself and others and won't find the way out. I perceive my negative thoughts as energy lines which converge in my body and reinforce the blockades. I am working with Sonja, experience myself in the birth canal. The movements are normal, but labour never ends, everything starts all over again. At some point an inner voice tells me that perhaps I needn't discharge my energies outwards, but can direct them inwards. You're blocked now, so look what's possible within this confinement. I look outwards and see light in the room, soft, bright and shining. Energy spreads throughout my body, I'm aware of my breathing, calm and peaceful. I am filled with profound peace and my solar plexus is calm. At the same time I become intensely aware of the circle. I sit and look and am united with every member of the circle. I am filled with deep love and thankfulness. I am part of a large whole, can be myself, polarities and judgments have vanished. The feeling is so intense that tears run down my cheeks. I sit and cry with happiness. The peace and harmony last the whole evening. I am very grateful."

The yearning for one's own centre out of which we act, the direct for authenticity, uniformity, the feeling that what I say is right, is genuine, is direct and unfeigned, is one of the central healing experiences on the way towards developing the true self as defined by Winnitcott. Many of our patients complain of inner contradictions, excessive willingness to adapt, lack of authenticity, lack of defined borders, a wavering to and fro between hunger for life and death wish, peculiarity and banality, superiority and inferiority, poor relationship to one's own body, anxiety, excess or lack of control.

The main topic for most psychotherapists today is no longer the treatment of symptoms, but the kind of relationship they can build up with clients suffering from a personality disorder in which narcissistic, depressive and compulsive components are interwoven. Formerly, psychoanalysts concentrated a great deal on the analysis of resistance and the function of abstinence; today, however, in working with altered consciousness we are primarily concerned with the many different manifestations of anxiety when the conventional mask of defence no longer functions. Tim Leary described this poetically as follows: "He who returns to this eternal law is enlightened. Being enlightened he is serene. Serene he is open-hearted. Open-hearted he is beyond social games. Being beyond social games he is in tune with seed. In tune with seed he endures. Until the end of his life he is not in peril."

When the protective defence mechanisms against anxiety no longer act in the usual way, unexpected drives break through. When masks and armour crumble, anxiety and shame arise in widely varying forms. Caring and sympathetic attention, a competent therapeutic presence and a pre-existing stable relationship with the therapist are crucial in order to avoid a horror trip. In such circumstances regression takes place, providing enormous healing possibilities. Here is an example from the journal of a depressive patient with sexual and dependence problems:

"A CD sounding to me like church music was played and made me feel restless and ill at ease. I got up on my knees, Sonja came. When she held me, desire welled up in me and I held her tightly and felt extremely tense and exhausted at the same time. My bottom and thighs turned hard and stiff. It took a while before I could give in to this exhaustion, let myself fall and relax my muscles. I sank deeper and deeper and noticed that I was approaching death. I felt a wall of fear in me, the same fear as before the desire. I realized that life and death are inseparable and that life cannot be lived without the acceptance of death. Death, life and desire belong together. I was very scared and knew that I couldn't escape this fact, that I had to face up to it. I had the feeling that I should let myself drop into the unconscious and let myself flow into it, but how could I do so, without knowing what was coming. I knew that I had to find somebody I could trust. I think that this is the key to death as well, trust in a higher power. At some point I also realized that there's no gentle detachment. Ties have to be cut. Maybe something new will come out of it, but there is no gradual or gentle solution. Pain cannot be avoided."

The group psychotherapy (a 3-hour session once a week) is generally attended by the workshop participants. The resulting contacts form a basis of confidence for the workshop participants. The workshops are held every quarter of a year in a suitable and carefully selected and secluded house. The group process intensifies on Friday evening. We combine bioenergetic exercises with clarifying discussions and meditation phases. There arises a feeling of community in which, admittedly, the former pathological communication patterns may occur, but it also provides a "new beginning" as described by Balint, in contrast to repetition compulsion, as well as the willingness to help and to respect others. In keeping with our inner attitude that "It is not just a matter of self- realization but also of opening our hearts for the good of the community and our planet" we begin the circle ritual on Saturday, after having relaxed or meditated in nature. Each of the 8-10 participants, the 2-4 sitters and the 2 therapists has his/her own place in the circle. The mats are arranged like petals around a centre containing flowers, candles, rattles and Tibetan meditation bowls. A talking stick is passed from one participant to the next and whoever holds it is allowed to speak. The participants promise to assume responsibility for themselves and for the circle, to exercise discretion, to follow the rules and not to be aggressive towards themselves or others. They talk about what they have learnt from the preceding meditation. It mostly concerns their wishes to heal specific emotional wounds, to break down energy blockades, to find answers to specific questions, to acquire knowledge, to develop visions, to withstand anxiety and to experience an ecstatic state. After ritual ingestion of the medication, mantras are sung, short texts or poems are read out and peaceful music is played. The participants may then lie down. Eyeshades are used. From normal daytime consciousness they pass to other worlds; the fundamental elements, the cardinal points, the leaders' voices, sometimes holding hands with the sitters play an important role in the opening phase, like a landmark or an anchor. When the effect reaches its maximum, specific body work - depending on the individual's state - is carried out. The participant is also encouraged to go through given themes, e.g. being in the birth canal, painful childhood memories, visions, without trying to understand, pass judgment or evaluate. Once the fears have been overcome, the grace of deep peace persists.

In the closing phase the participants sit in a circle, the talking stick is passed round, they maintain eye contact without speaking, or a note is sung. One hour later, in the second round, maybe a syllable, a word or a sentence is spoken. The group concentrates on each individual and confirms his/her statement. Meanwhile, 8 hours have passed since the ritual was started, and after the third round the participants can go for a walk or visit the thermal baths. Moving and being held in warm water enables the subject to re- experience the regressive state. Supper together is followed by the first integration round, writing up journals and painting. The next day the trip is discussed in detail.

The sitters play a very important role; they have had several experiences themselves and know that they must not force anything or overwhelm the tripper with unsolicited help. They are encouraged to be present, to be attentive to the partner even if they do not know which stage of the trip he/she has reached at the actual moment. Here is an example given by a sitter:

"State in the week before the workshop. I have seldom felt so mentally and physically drained. There are the usual fears and feelings of uselessness, and sorrow that it's always like this. Again and again the problem of how to tackle my inadequacy? I'm afraid that I'll dissolve into self-pity at the workshop and won't be to contribute anything. The group and the meditation in the Friday session help me to calm down, to reach a quiet spot inside myself. Then there's always this fear of being hurt, when I open up. Saturday is a great gift for me. Thanks to Sylvia and Eva, whom I feel safe with, I've regained my self- confidence. It's alright, I can join in and let go without losing myself. The others feel and listen into me, give and take. It's a new pleasure for me to be able to permit so much close physical contact, and to enjoy it even. I experience Rolf as brother, child, lover in turn, without the old fear of being somehow sexually involved. It is simple. With Ingrid and later on with Marcel I manage to keep my escape reflexes, my fear of getting stuck and being sucked into fear, at bay and to withstand them for longer than usual. I can control my fear of suffocation by breathing deeply down to my abdomen and trying to be with myself and the others at the same time. I feel a lot of joy, love, tenderness, gratitude, peace and harmony, oh man! Sometimes I feel a great deal of energy flowing towards and away from me, like alternating current. Again and again, intense, clear and without protecting me. I feel my closeness to Sylvia and Eva. Ruth, whom I love for her sensuality and a lot more. Renate, in whom I recognize my self-hate and...and...and.. in all of them a bit of me. It's fascinating, my thera pist's search for new ways in therapy. I attended my first workshop in 1987. A lot has changed since then. It's exciting. Today it's back to the everyday routine again, work, obligations. At the moment I can see this as part of my life as well, as part of a larger whole. I hope it will stay like this!"

We use verbal approaches for preparation and for integration work. The essential part takes place mostly during the integrating group sessions on the day after the trip and in the following sessions. Integrating what has been experienced corresponds to Freudian working-through. During the work in an altered state of consciousness the therapist creates the supportive framework. He makes use of a good therapeutic relationship and employs a technique, such as breathing, meditation, evocative music and a psychedelic drug, with which the unconscious can be activated. Under these conditions existing personality traits and pathological signs may become more pronounced and may provoke other underlying latent symptoms. Grof believes in the autonomy and spontaneity of the healing process. We feel that the continuity of the therapeutic process has a greater chance than sporadic peak experiences. If a wound is to heal cleanly, it needs not only a dressing but also competent care and rehabilitation.

The therapist is a fellow adventurer on the trip, learning something new during each session and no longer interpreting the resulting material in terms of a closed theoretical system. Nevertheless, it is he who, by virtue of his personal experience, assumes the function of a tour courier, a mountain guide or a diving instructor even when in an altered state of consciousness.

The peak experiences, as Maslow has formulated them, the fleeting moments without self, that is, in the language of spiritual development, letting go, crossing borders, sensing supernatural powers, the absence of logic, space, time, causality, non-attachment, is an overwhelming personal experience. When it is not embedded in a process accompanied by a spiritual teacher or a therapist, there is a risk that, in the best case, normally functioning defence mechanisms will gain the upper hand, and in the worst case, that a disintegration crisis may occur.

One repeatedly encounters onself on all spiritual paths towards enlightenment. The psychedelic peak experience (of unity, happiness and grace) can only be attained in an atmosphere of tolerance and love. Mature mystical development is influenced by a psychotherapeutic process which is based on the mystical experiences in psychedelic sessions. It lives and integrates what became visible during the experience in an altered state of consciousness, namely the sense of autonomy towards old models of dependence, confrontation with truthfulness and openness.

I have attempted to show that the peak experience which ushers in a new spiritual development is best achieved by means of a therapeutic process. We have repeatedly observed that the lasting integration of transpersonal experience can only succeed once dramatic events in the subject's life history have been worked through in previous sessions. The experience of a hitherto unknown intensity of awareness, the intense feeling of love and peace with oneself, with others and with the universe make up the special features of psycholytic psychotherapy. The progress observed in the follow-up evaluation comprises:

1) Better self-acceptance
2) Improved self-esteem
3) Reduction in anxiety and psychosomatic symptoms

Strictly scientific thinking is sceptical towards the results of the follow-up study, and this all the more so as our study does actually exhibit a few shortcomings. However, we know that we have helped a lot of patients with our method. MDMA or other psycholytics are used to establish an unique therapeutic atmosphere, in which a special experience in an altered state of consciousness is achieved by the overcoming of distrust, anxiety, shame, inhibition etc.

We need an open and critical attitude towards our own ideas, but we must avoid rationalization, relativation and scepsis. But what is most important is not to lose heart. And we must also be able to take decisions and be prepared to defend our convictions. We know that - in spite of the many difficulties and setbacks - the psychedelic experiences of the past thirty years have been a significant, meaningful and productive period in our development.

See also Structuring Psychotherapy Sessions with MDMA in a Research Context
by George Greer, M.D.