by Saj Razvi, Director of Education at Innate Path
Many readers of this Bulletin may already know or have heard how powerful the MDMA experience can be. To use the phrase “game-changer” in describing how MDMA-assisted psychotherapy will alter the field of mental health is not hyperbole; it is backed by the quantitative data as well as the qualitative reports we have seen in the clinical research trials sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS). These Phase 2 results are impressive and show a high degree of promise. Accordingly, we can expect strong interest from therapy consumers that will necessitate an equally strong, game-changing shift in the training of therapists, the modalities we use, and the economics of mental health.
As a clinical sub-investigator in the Boulder, Colorado, Phase 2 MDMA-assisted psychotherapy for posttraumatic stress disorder (PTSD) trial and also the Executive Director of Trauma Dynamics, a psychotherapy training that focuses on trauma and the body, I was asked by MAPS to write about how Food and Drug Administration (FDA) approval for MDMA will alter the field of mental health. This question has been on my mind since sitting with my first study participant a few years ago and seeing what is possible when psychedelics meet psychotherapy.
Trauma Dynamics training at the University of Colorado Anschutz Medical Campus, Spring 2014.
One significant shift that will take place in the field of mental health post-FDA approval is the need for therapists to become, at the very least, informed about MDMA. Clinicians who work at hospitals, addiction treatment centers, private practice settings, the Department of Veterans Affairs, or public mental health agencies stand a good chance of working with someone who either wants the treatment, someone who has had the treatment, or someone who ought to receive the treatment as an evidence-based best practice for the condition of PTSD.
Becoming MDMA-informed can mean a number of different things. Generally speaking, therapists will need to alter the theoretical lens through which they understand their clients’ experience. This is no easy task. If therapists have not had their own experience with MDMA or other psychedelics, they may have difficulty connecting with the world their clients are trying to convey and the experiential processing that is integral to this type of healing. We are leaving Kansas in a significant way when it comes to how unique progress and processing can look with psychedelics.
On the occasions when I’ve given presentations to therapists about processing trauma and the topic of MDMA-assisted psychotherapy has come up, I find that many clinicians simply don’t have a category in their mind in which to put it. They often do not believe the results coming out of the trials because the findings are so out of the norm. There is a lot of clinical experience showing that chronic, treatment-resistant patients have a much longer, weaker arc of improvement with psychotherapy, if they improve at all. Psychotherapy often appropriately aims for symptom management in these cases and not a true resolution of a condition, and so the durable remission we are seeing with many study participants in a relatively short span of time is difficult to comprehend.
Another key part of becoming an MDMA-informed therapist is to distinguish between psychedelic medicines and psychiatric medications that are aimed at symptom management like Zoloft, Xanax, or the heroin substitute Suboxone. Current medical education has few reference points for drugs that actually help people engage with themselves more deeply, feel more fully, and work through very difficult states. Furthermore, many people’s only experience with a chemically altered state of consciousness is with alcohol or cannabis and so they will understandably reference these as a way to try to understand MDMA. Entering into a psychedelic process is very different from becoming high or intoxicated. Quite the opposite, MDMA is a highly associative experience.
For therapists who want to train and work with psychedelic medicines, there will be changes beyond simply becoming MDMA-informed. We get hints of how trainings for MDMA-assisted therapy may eventually look from the Therapist Training Program MAPS is already developing to prepare clinicians for Phase 3 MDMA trials (maps.org). They note:
The Therapist Training Program is a four-module training, 1) a 10-hour online course about MDMA and study design, 2) 7½ day in-person training with lead MDMA therapists, 3) home study assignment to include a workshop or experiential training of therapist’s choice 4) a second week-long in-person gathering bringing all training groups together.
A notable element about training of future MDMA therapists is that MAPS is leaving room for modalities that the therapist may already be trained in or is interested in learning as part of their larger training to work with psychedelics. This is because MDMA has many different pathways for effecting change. There are simply too many variables between individuals (their needs, their biology, their history, their defense structure) to limit the therapeutic pathways this medicine will take. We have seen participants spontaneously engaging in cognitive restructuring during one part of the day, working with disintegrated self states (parts work) at another time and engaging in deep autonomic processing at yet another point. What is clear is that MDMA is significantly expanding the ways in which we are able to process. While some participants can have a linear, talk therapy focused MDMA session, many do not. Participants can enter a far more visceral reality that may not operate on the same principles as does the rational mind. People report a vivid re-experiencing and renegotiation of memory in a deeply supportive, embodied and often highly relational space.
There is one general rule of thumb that we can say about therapeutic interventions as people enter non-ordinary states of consciousness for processing. No longer is it appropriate to approach healing from structured therapy protocols. As a client’s inherent sanity leads the way, approaches to trauma that follow a step by step structure will not fit with the fluid nature of the mind and body while under the effects of MDMA. As noted by the Principle Investigator for the Boulder Phase 2 trial, Marcela Ot’alora, the MDMA therapist will need to be a well-informed, non-directive, yet highly engaged "guide who follows".
There are a few early adopter programs working to meet the needs created by this mixing of psychedelics and psychotherapy. The Center for Optimal Living offers a harm reduction model of approaching psychedelics by offering psychotherapy and psycho-educational resources for individuals who have had or wish to have psychedelic experiences (psychedelicprogram.com). Clinicians can also turn to this program to learn how to best work with patients who have a history of psychedelic use. While not actually facilitating psychedelic sessions, the goal is to mitigate the potential risks involved and to incorporate the valuable insights from these experiences into psychotherapy.
Scheduled to launch later this year is the Certificate in Psychedelic-Assisted Therapies and Research program at the California Institute of Integral Studies (CIIS) for licensed and pre-licensed professionals and clergy (ciis.edu). This program has roots in transpersonal psychology, consciousness studies, psychoanalysis, comparative mysticism, and anthropology. Impressive is the group of foundational thinkers and researchers in the field of psychedelic studies that have served as advisors to this program. To be clear, CIIS notes that its certificate course "…serves a growing need for the training of skilled therapist researchers who will ideally seek advanced training for future FDA-approved psychedelic-assisted and entactogen-assisted psychotherapy research." While there is no guarantee that clinicians who complete the certificate program will be given research positions in future FDA trials of psychedelics, CIIS reports a robust level of interest from therapists and one can easily imagine this program as a kernel for a full-fledged masters or Ph.D. track once MDMA is approved.
Lastly, there is the Trauma Dynamics training, which I direct at the University of Denver (traumadynamics.com). While the skill sets and interventions of Trauma Dynamics or other somatic modalities were developed without the consideration of medication or psychedelics, there is no doubt that the body-oriented, entactogenic ("touching within") nature of MDMA greatly enhances and supports the processing of trauma that occurs within the autonomic nervous system. As we approach legal medical use (whether that is the expanded access status that MAPS will apply for in the 2018 time frame or full FDA approval around 2021), there is a