The piece is interesting as much for what it doesn’t say, as for what it does, and for how it ties into the history of psychological treatments for posttraumatic stress disorder or PTSD.
The trial is testing whether MDMA can assist in psychological treatment for the condition, in which a traumatic event leads to a sense of current threat and intrusive sensory impressions that are maintained by a pattern of avoiding reminders.
The most effective tried-and-tested treatments for the condition are types of therapy that are ‘trauma-focused’ that involve, among other things, a mental revisiting of the traumatic memories to ‘take the sting out of their tail’.
But this is exactly what most people who arrive in psychologists’ offices don’t want to do. This makes sense from the perspective of someone who is troubled by these memories and wants to stop thinking about them, but the avoidance actually helps maintain the problem.
This is, in part, because the person never learns to adjust to the anxiety (they don’t habituate in technical terms) and the memories remain as fragmented impressions that don’t fit into a coherent narrative, making them more likely to intrude into the conscious mind.
In other words, most people with PTSD initially arrive for treatment wanting a better form of avoidance because their current methods simply aren’t working. The mental health professional has the unenviable task of explaining that treatment involves exactly the opposite and reliving the event and experiencing the anxiety will be key.
It is so key, in fact, that anti-anxiety drugs like benzodiazapines (e.g. vallium) may reduce the effectiveness of treatment because they dull the experience of stress that the person needs to adjust to.
The MDMA trial is interesting in this regard, because ecstasy is, for many, a remarkably effective anti-anxiety drug.
So how does the drug facilitate the psychotherapy? Here’s the description from the article:
MDMA’s effects typically manifest themselves 30-45 minutes after ingestion, so it doesn’t take long for rhythms to develop in Charleston. Sessions at the clinic oscillate between stretches of silent, inward focus, where the patient is left alone to process his trauma, and unfiltered dialogue with the co-therapists. “It’s a very non-directed approach,” Michael Mithoefer told me. This allows subjects to help steer the flow of their trip. They are as much the pilots of this therapy as their overseers. “Once they get the hang of it,” Mithoefer explained, “sometimes people will talk to us for a while and then say, ‘OK, time to go back inside. I’ll come report when I’m ready.’”
That said, patients understand that if no traumas emerge, the Mithoefer’s must coax them out. But they’ve never had to. The traumas always emerge, and by now there have been over 60 sessions between an initial, smaller Phase 2 study and the present trials. Horrors are bubbling up naturally, patient after patient.
This harks back to a more psychoanalytic or Freudian-inspired idea of trauma and treatment. The goal of the therapy is to understand the inner self while the drug is intended to help us overcome psychological defences that prevent us from seeing things as they really are. In fact, this is a central assumption of the therapy.
This approach is not new. ‘Narcoanalysis’ was used widely in mid-20th Century where a range of drugs, from ether to sodium pentathal, were applied to patients with ‘war neurosis’ for exactly this purpose. Unfortunately, it was unsuccessful and abandoned.
So this is why the MDMA treatment is a gamble. All known effective psychological treatments for PTSD involve not only confronting the memories of what happened to make sense of them, but also re-experiencing the associated anxiety. A treatment with a drug that removes anxiety will, by current predictions, have limited effectiveness.
But this is also why the approach is interesting, because if it is shown to be genuinely effective, we might have to rethink our ideas about PTSD and its treatment.
Link to Mother Board article on the MDMA PTSD trial.