MDMA, the love elixir
The FDA-designated Breakthrough Therapy spearheading psychedelic research will soon be legally available across the US
“You’re so beautiful. You’re the most beautiful woman in the world. I’m sorry I don’t tell you more often.” My boyfriend looked me straight in the eyes, unable to hide a hint of awe. “I promise I’ll work on it and tell you more often. Because I think it all the time.”
For the past year, I’d been waiting to hear these words. They’d help me overcome my lingering self-esteem issues and body dysmorphia for good, I believed. Until my therapist gave me some tough love. “You’re in a relationship with someone who doesn’t naturally articulate validation in the ways you’d wish. Maybe that’s in your favor. It will require you to develop the validation yourself.”
While his words gave me butterflies, the reality was that I no longer needed to hear them. Did they mean any less because, two hours prior, we’d ingested a substantial dose of pure, clinical-grade MDMA?
Not to me. I could tell that these words had been on the tip of his tongue for a while, but there was just something in the way. Now that something was gone, and over the next few hours, he would proceed to express all the things I’d been craving to hear.
Despite my enthusiasm for psychedelics, MDMA remained on the back burner for several years, for several reasons.
MDMA is first in line to become a legal, nationally prescribed psychedelic-assisted mental health treatment. As such, much of my daily work revolves around it. While MDMA is technically not a psychedelic, it is often grouped as such for better or for worse.
Among recreational drugs, psychedelic or not, MDMA is an undefeated fan favorite. Everybody loves MDMA, as I’ve come to learn. And yet, it’s taken me years to seek it out.
I had an unpleasant experience with it a few years ago, before my psychedelic healing era, that I don’t count. While my friends were rolling their faces off at a day rave in Amsterdam, I was curled up in the corner, nauseous and miserable all day. It was not fun. Now that I have more insight into the workings of this medicine, I’m grateful for how things went down (more on this shortly).
My curiosity was further limited because I (wrongfully) dismissed MDMA as the “placeholder psychedelic”. The medicine that would be instrumental in building a new care infrastructure for other psychedelic treatments. Those other treatments, whether it be psilocybin or ibogaine, were the real deal, or so I thought.
My beliefs shifted as I witnessed people close to me transform through guided MDMA journeys. I learned that the gentler approach that MDMA provides can sometimes be more impactful than forceful medicines such as Ayahuasca.
MDMA: Therapy or Rave Drug?
While MDMA was originally first synthesized in 1912 by a pharmaceutical company, it gained popularity in the 70s and 80s among psychiatrists who used the medicine to enhance their therapy sessions. It did not take long for MDMA to make its way from doctor’s offices into the streets, where it quickly became a raver favorite. The DEA scheduled the substance in 1985 in the same category as LSD, psilocybin, cocaine, and heroin — no (proven) medical benefit, high risk for abuse.
Nevertheless, MDMA maintained its beloved position in rave culture. It was increasingly cut with stimulants such as speed to create drugs such as ecstasy. In parallel, many therapists continued to use pure MDMA to enhance their sessions.
Change was around the corner when a stubborn Harvard graduate, who wrote his PhD on the legalization of psychedelics and cannabis, embarked on an ambitious quest. Rick Doblin wanted to become a psychedelic therapist, but, as the federal prohibition made his desired career illegal, he shifted his focus toward drug policy reform. He vowed that one day, he’d be able to become a legal, psychedelic therapist.
Doblin laid out a strategy that now, over 35 years after its inception, is finally bearing fruit. He chose MDMA as the substance to head the movement to legalize psychedelics, and PTSD as the first indication to tackle.
Why MDMA? Well, everybody loves MDMA. It’s also much less likely to produce adverse reactions compared to other medicines such as LSD, which made it clinically (and politically) more attractive.
Why PTSD? PTSD patients generally elicit more sympathy than most mental health conditions. As such, it presented a promising gateway to policy reform. In addition, a key patient population among PTSD patients is veterans, and veteran mental health is one of the few remaining bi-partisan, national interests.
MDMA therapy for PTSD became Doblin’s trojan horse.
The Clinical Research on MDMA-Assisted Therapy
MAPS made waves when it published its first Phase 3 trial results in May 2021, which landed on the front page of the NYT. At this point, MAPS had already amassed a loyal fanbase of hundreds of thousands on social media, and thousands of conference participants. If the psychedelic community were a cult (which I promise it’s not) and it had a leader (which it doesn’t), it would be Rick Doblin.
MAPS’ research was intriguing not only because it was a novel model of care using a stigmatized Schedule 1 substance, but also because it was more effective than any other PTSD treatment we know of. Already back in 2017, MAPS received the Breakthrough Therapy designation from the FDA for its research.
In the initial Phase 3 trials, nearly 90% of participants had a clinically meaningful response to MDMA therapy, and a whopping 67% no longer qualified for a PTSD diagnosis after the 3.5 months of treatment. The study was composed of 90 patients, all with severe, treatment-resistant PTSD, suffering on average for well over a decade. Years and years of PTSD, sometimes a lifetime, reversed within a few months. Results of the confirmatory Phase 3 trial published in September further substantiated efficacy. This study treated patients both with severe and moderate PTSD, and the share of patients who lost their diagnoses increased to 71%.
The myth of “no medical benefit” that justifies Schedule 1 categorization has been debunked. The FDA is expected to approve the treatment as soon as early next year, as a result of which MDMA will be rescheduled, likely into Schedule 2.
Despite the praise, the ride has not been smooth for MAPS, which received plenty of criticism for its study ethics and practice. Many of those issues surfaced through a podcast called Cover Story: A Power Trip, produced by the New York Magazine. The podcast exposed some of the misconduct that occurred during the clinical trials — realities I found heartbreaking, yet sadly not surprising. It’s a well-known concern in the world of psychedelic therapy that the risk for abuse and transference is amplified.
MAPS and others have since started further trials to investigate MDMA therapy for alcohol use disorder, eating disorders, anxiety disorders, and couples therapy. (Here’s an interesting NYT piece that explores the couple’s angle.)
Why Is MDMA Therapy So Effective?
MDMA differs from other psychedelic therapies in two main ways:
Mechanism of Action (MOA). MDMA is not considered a classical psychedelic but rather an entactogen or empathogen. It does not produce the severe changes in perception psychedelics are known for. Rather, MDMA down-regulates the fear response and increases feelings of empathy, euphoria, and compassion. People love MDMA because MDMA makes them feel love. That’s why rolling at a rave with friends is such a peak experience. Now in a therapy setting, all the love and empathy have nowhere to go but inward, which makes this medicine so profound. One can revisit traumas that previously were attached to too much shame or fear, and process them with love and compassion. MDMA is quite literally the antithesis of the “flight or freeze” trauma response.
Therapeutic relationship. Most psychedelic treatments are not technically psychedelic-assisted therapies because it’s mainly the psychedelic that does the therapy. The provider’s role in classical psychedelic therapy is to provide the container that allows for the teaching, guiding, and healing through the psychedelic to occur. MDMA therapy is different because it relies on (outside) therapeutic guidance. There is no plant or fungus spirit that drives the journey, and while MDMA therapy is still inner-directed, the conversational component is critical to the therapeutic impact. Internal Family Systems is a therapy model that particularly complements MDMA well (I wrote about it previously here).
If one believes the thesis that trauma underlies most mental health conditions, then this breakthrough treatment is meaningful not only for those with a formal PTSD diagnosis. While legal access may be limited to PTSD patients initially, new indications will likely be approved over time (and underground guides will continue to provide MDMA therapy regardless of the diagnosis).
The documentary “Trip of Compassion”, which stars victims of a sexual assault (the biggest patient population within PTSD patients) along with veterans, provides a moving account of the healing journey with MDMA.
I once heard someone say that psychedelics sometimes make you nauseous or physically ill when you’re not ready for the journey you need to have. I have no doubt that’s why MDMA made me sick all these years ago, a time when most of my trauma memories were suppressed. Hence, I feel grateful for how things went down. I’d rather feel sick than have suppressed trauma memories surface at a festival without the proper setting and support to process them. However, I’ve come across interesting survey data showing that if traumatic memories do come up during an MDMA trip, how one processes the experience makes all the difference. Those who received care from a friend, for example, and were able to work through the experience with love and support still had a therapeutic experience — even if it occurred at a festival. (I’ve not been able to dig this research up since, but if you’re keen let me know and I’ll look some more).
Then there are promising anecdotes such as that of the white supremacist who underwent MDMA therapy and drastically changed his belief system as a result. Maybe there’s hope for humanity, after all.
Should You Try MDMA?
Aside from rolling at parties, here are your options for the setting:
Individual MDMA-assisted therapy
Joint journey with a partner (with or without the support of a guide)
If you’re in the process of healing severe trauma, I urge you to seek out professional support. If you can’t wait until FDA approval next year, you could look into finding an underground practitioner. If you happen to be in Australia, MDMA-AT is already legal.
If you want to deepen your relationship with your partner, I cannot recommend this experience highly enough. I first heard about MDMA as a relationship enhancer in Ayelet Waldman’s “A Really Good Day”, which chronicles the LSD microdosing experiment of the mother of four. Semi-regular MDMA journeys have been instrumental in her marriage, Ayelet argues. Experiencing MDMA in the company of my partner made it so special I’m reluctant to attempt to articulate it. Imagine that, for a few hours, you bathe in sheer love for another, knowing that this force is stronger than whichever struggles you’ve been facing in the relationship. You feel open and expressive. There’s a mutual understanding that love is all that matters. Your ability to empathize expands, making it easier to lay aside your ego and understand your partner’s needs. One MDMA journey was enough to deepen my relationship in a way that I’m confident will last and compound over time.
However, for all MDMA use, whether of recreational or therapeutic nature (which also doesn’t have to be mutually exclusive), there are two critical caveats:
MDMA is a neurotoxic chemical and should not be taken frequently. It will cause serious neurological damage, and there are many sad stories of those who now suffer permanent damage. A minimum of three months in between experiences is highly recommended if you want to keep your brain healthy.
Be prepared to have a low day after your MDMA journey. The MDMA comedown is notoriously bad. Your serotonin is completely depleted, and you can feel it. Be prepared to write the day off, remind yourself that any depressive thoughts are a direct cause of this temporary neurological imbalance, and pamper yourself with a good TV show and some comfort food. It sucks, but in my books, an intentional MDMA experience is so beneficial that one shitty day after is well worth it.
If you have any questions about any of this, feel free to reach out or drop me a comment here. If you’ve experienced MDMA alone or with a partner, I’d also love to hear about your experience and the impact it had on your life.
Thanks so much for this well written piece!
In my personal experience, MDMA has been extremely insightful and helpful. During the course of a weekend, I did multiple doses in a forest, with friends. In that one experience, I managed to defeat catastrophic ideas and harsh self judgement, especially by perceiving how my entourage loved me and supported me in my endeavors. I've never felt lonely again! My experience with MDMA lead me to a jungle, years later, for an Ayahuasca ceremony. This has been just as eye-opening... Other points: zero addiction or withdrawal symptoms (I've only done sporadic, spaced apart sessions), zero anxiety and even less need to drink or even eat junk food.
It's really revolutionary.