Von Prof. Dr. Torsten Passie
3,4-Methylenedioxymethamphetamine (MDMA), also known as ecstasy, was first synthesized in 1912 but first reached widespread popularity as a legal alternative after the much sought-after recreational drug 3,4-methylenedioxy-amphetamine (MDA) was made illegal in 1970. Because of its benign, feeling-enhancing, and nonhallucinatory properties, MDMA was used by a few dozen psychotherapists in the United States between 1977 and 1985, when it was still legal. This article looks into the contexts and practices of its psychotherapeutic use during these years. Some of the guidelines, recommendations, and precautions developed then are similar to those that apply to psychedelic drugs, but others are specific for MDMA. It is evident from this review that the therapists pioneering the use of MDMA were able to develop techniques (and indications/counterindications) for individual and group therapy that laid the groundwork for the use of MDMA in later scientific studies. In retrospect, it appears that the perceived beneficial effects of MDMA supported a revival of psycholytic/psychedelic therapy on an international scale.
This article provides an overview about the early use of MDMA ('Ecstasy') in psychotherapy in the United States during the years 1977-1985, before MDMA became scheduled under the Controlled Substances Act (CSA) in 1985. MDMA was considered a useful drug by some professional psychotherapists which worked with it during the 1977-1985 period (cf. Eisner, 1989). After its scheduling, efforts were made to conduct clinical studies, but most applications failed. Since the 2000s, rigorous placebo-controlled studies have proven the safety and efficacy of MDMA-assisted psychotherapy for treatment-resistant Post Traumatic Stress Disorder (PTSD) (Mithoefer et al., 2011; Oehen et al., 2013).As it appears now, in 2017 Phase 3 trials will be started to establish MDMA as a prescription medicine fort he use in psychotherapy (Philipps, 2016).
The article describes the historical context and the appproaches, techniques and precautions which developed for the therapeutic use of MDMA in the early period of its use.
A prehistory of MDMA in psychotherapy
Mescaline and some of its derivatives were researched for their hallucinatory activity since the beginning of the 20h century (Passie, 1992/1993). It was the Californian pharmacologist Gordon A. Alles who first came across the specific psychopharmacological effects of the mescaline derivative Methylenedioxy-amphetamine or MDA, which did not induce as much hallucinatory activity and cognitive alteration, but a state of intensified emotions (Alles, 1959). For this reason MDA was tested since the early 1960s as an agent to facilitate psychotherapy by Chilean psychiatrist Claudio Naranjo (Naranjo et al., 1967, Naranjo, 1973). In their continuing search for a "psychotherapeutic drug", Naranjo and his associate, the American chemist Alexander T. Shulgin, studied derivatives of the essential oils of nutmeg (Shulgin et al., 1969 + ethnopharm). In 1962, Shulgin synthesized the derivative MMDA, which had an even lower hallucinogenic activity than MDA and appeared to be a promising therapeutic drug (Shulgin et al., 1973, Naranjo, 1973). MDA, but not MMDA, became the drug of choice of some underground psychotherapists from the mid-1960s onwards (e.g. Stolaroff, 2004). Psychologist Leo Zeff Ph.D., a central figure of the psychedelic therapy underground, was a proselytiser of MDA (Sargent, 2013). MDA had not as much sensory and cognitive effects and its major effect was to open up the person and to intensify emotions, to give access to suppressed memories and to furthering insight. MDA was also used in the last studies of drug-assisted psychotherapy (Turek et al. ,1974, Yensen et al., 1976). Nevertheless, in the mid-1970s, Zeff stumbled over MDA’s toxicity (cf. Naranjo, 1973, Richards, 1972) and stopped his work with MDA (Greer, 2015). But a short while later, in 1977, Shulgin introduced Zeff to MDMA, which was then a virtually unknown compound, which appeared to be much less toxic than MDA (Benzenhöfer and Passie, 2010).
The „Boston group“ and the therapeutic use of MDMA
A certain impact on the therapeutic use of MDMA has to be attributed to the "Boston group". In 1976, this group began distributing MDMA on a small scale in the Boston area. The group consisted of a chemist and a some people interested in spiritual devlopment and psychotherapy. Most of those were associated with the MIT’s Artificial Intelligence Lab (Harlow, 2013). They periodically synthesized MDMA and distributed it in the Boston area. They were interested in bettering themselves and the world through self-knowledge by exploring their psyche and behavior (Harlow, 2013). According to Beck and Rosenbaum (1994: 18/19), “… this group had a 'therapeutic' perspective". „They periodically made some MDMA and gave it to a few people. They cared about the experience and how people made use of it“ (Harlow, 2013: 1). It seems reasonable to presume that the Boston group has furthered some early interest in the therapeutic use of MDMA. For example, early MDMA therapist Rick Ingrasci Ph.D. got his MDMA from the Boston group (Ingrasci, 2016).
Leo Zeff – the secret chief
Psychotherapist Leo Zeff Ph.D. became interested in the therapeutic use of psychedelics in 1961 (Zeff in Stolaroff, 2004: 37). After using LSD in psychotherapy, he became very much convinced of its therapeutic potential. In the mid-1960s he came across MDA through Shulgin’s research associate Tony Sargent (Sargent, 2013). After LSD became illegal in 1966, he continued his work underground. During the 1970s, Zeff became a major figure of an informal underground network of therapist using psychedelics. He developed many useful procedures and shared them with other aquainted therapists. For this role he was later named „the secret chief“ (Stolaroff, 2004).
After Shulgin introduced Zeff to MDMA in 1977. Zeff responded enthusiastically and started therapeutic work. During the next 12 years Zeff administered MDMA to about 4000 people, and trained more than 150 therapists (Stolaroff, 2004: 86).
Zeff conducted sessions for personal and spiritual development. His groups always had a consistent format. Participants were sitting in a talking circle on Friday night. One by one, they were telling what was going on in their lives. Following this, Zeff would review the instructions and agreements. These include that is prohibited to leave the room without permission and to do anything harmful. The final agreement was, ‚If I should tell you to stop something that you are doing, you will’ (Stolaroff, 2004: 137). Zeff found it to be most effective to focus the clients toward their own inner experiences by using eyeshades and headphones. „We dont want anybody to talk. Sometimes ... people like to get up and do some hugging and then we set them right back down" (Zeff in Stolaroff, 2004: 81). „Lay down and stay down. No wandering around, because as soon as you start to be functional you detract. You’ve got to get into your ego to be functional. Lay down and have your whole trip and when you’re all the way down, really coming down, then you can getup and walk around“ (Zeff in Stolaroff, 2004: 92). His instructions for the session itself were these: „If you don’t know what to do and your mind wanders, then listen to the music. If you go into heavy judgements against yourself, then listen to the music.“ In the evenings, after the daytime drug sessions were finished, a meal was prepared. On sunday morning a ritualized circle for integration of the experiences was conducted, where every participant spoek about his personal experiences and insights (Andrew, 2004: 138).
The Association for the Responsible Use of Psychedelic Agents (ARUPA)
The Name ARUPA was coined by Richard Price, one of the founders of the famous Esalen Institute at Big Sur (California), which was a center for the development of new psychotherapeutic techniques during the 1970s and 1980s (Kripal, 2008). The term Arupa originated from Sanskrit and denominates a "formless" network. ARUPA had no formal structure. Its main activity was to organize some by invitation-only conference-like meetings at the Esalen Institute in Big Sur, California during the 1978-1984 period to discuss the therapeutic use of psychedelics (Forte, 2014). During the ARUPA meetings in the early to mid-1980s, MDMA became a major topic. Participant lists reads like a list of the psychedelic luminaries at the time (e.g. David Nichols, Rick Doblin, Jack Downing, Stan Grof, Oscar Janiger, Rick Ingrasci, Sasha Shulgin, Myron Stolaroff, Rick Strassman, Ralph Metzner, Leo Zeff) (Greer, 2014). It was at at an ARUPA meeting in December 1984, when psychedelic researcher Terence McKenna said about MDMA „we don’t know anything about it“. Doblin reacted promptly: „I put up a thousand Dollars for a study – and Dick Price said: I put up a thousand Dollars“. This spontaneous approach lead to the first psychophysiological MDMA study in 1984, which will be described later (Doblin, 2013).
The next meeting (co-organized by ARUPA), was a „MDMA Educational Workshop“ in February 1985 at Esalen. The printed program included presentations by George Greer and Rick Ingrasci about MDMA therapy, with Richard Yensen outlining the differences between MDMA and MDA. The evening was devoted to discussions about MDMA and procedures for facilitating MDMA experiences. On day three, half of those interested in experiencing MDMA began their first MDMA session while the others assisted them. On Day five discussions were held about scientifically valid research designs and the possible integration of MDMA into psychiatry. During early 1985, it became obvious that illegalization was inevetible. In view of this, another conference was held, titled „MDMA in Psychotherapy“ at Esalen in March 1985. Among the 35 participants were veterans of psychedelic research (Grof, Naranjo, Yensen, Lynch, DiLeo), and four psychotherapists using MDMA in their offices (Greer, Downing, Wolfson, Ingrasci). Greer concluded in a conference report: „The reports on the benefits of MDMA, although anecdotal, were uniformly positive. ... The drug reduced defensiveness and fear of emotional injury, thereby facilitating more direct expression of feelings and opinions, and enabling people to recieve both praise and criticism with more acceptance than usual. ... Many subjects experienced the classic retrieval of lost traumatic memories, followed by the relief of emotional symptoms ...“ (Greer, 1985: p. 58).
Ann Shulgin’s therapeutic work with MDMA
Around 1980, Ann Shulgin, the wife of chemist Alexander Shulgin and a lay therapist, began to help friends to have a MDMA experience for helping "sort out some personal problems". In some cases she took MDMA together with the patients, but soon recognized that this was counterproductive (Shulgin and Shulgin, 2005: 75). During that time she was instructed by Leo Zeff and partnered with a licensed psychotherapist. The therapist would select patients with whom she had already been working for at least six months. For these Patients, a MDMA session under the guidance of Ann Shulgin would be offered. In the beginning of the MDMA session the patients had to affirme the following "four agreements": 1. not to allow any hostile feelings to be expressed in aggressive action; 2. no sexual activity during the session; 3. that the client not voluntarily allow their consciousness to abandon their body in such a manner that would cause physical death; 4. not leaving until the end of the session. In respect to the therapist attitude and doings, he is mainly supposed to activate the internal healing abilities of the patients. An important requirement to do this is a caring and trustful relationship in the therapeutic dyade. The usual dose was 125 mg MDMA per os, sometimes followed by a dose of 40 mg 90 minutes later (Shulgin, 2013).
Ann Shulgin extensively discusses an aspect she was very concerned with in her therapeutic work. This is the „dark side of humans“, also called the "Shadow" by prominent psychoanalyst Carl Gustav Jung (1875-1961). These forces are aspects of the psyche which are usually suppressed and excluded from consciousness - to protect the conscious self against „inacceptable“ inner tendencies and/or fantasies. Before taking MDMA, clients should be prepared that they may encounter aspects of this darker side of themselves. She recommends that these issues should be discussed before starting a session, in relation to the patients biography and actual situations. "One of the problems that most humans beings suffer from is the suspicion that the core essence of who they are deep down is a monster. There is terrible fear ... when you get down to it ... MDMA removes that fear" (Shulgin and Shulgin, 1995: 131). "During psychedelic therapy, ... what we do is we go into it and look through its eyes, so that we become it. But we're all afraid that we got stuck with the demon. ... Once you get inside the demon, the first thing you expereince is a lack of fear, and then you begin to recognize that this is also the survivor aspect of yourself. There's a part that takes care of you. Then it begins to transform, and you recognize its quality of total selfishness - it's going to take care of you and nobody else, right? - but it's your ally. And then you begin to recognize its positive aspects" (Shulgin and Shulgin, 1995: 135/6).
>>> PICTURE IMPLEMENTATION here: Ann Shulgin Bild „Discussing the shaow in MDMA psychotherapy with the author in 1993 (cortesy of Thomas Metzinger)
At last the shadow aspects of the psyche can be integrated and the shadow will take its place where it functions as a devoted ally and protector. To confront and learn to know the shadow can take more than one session, but the transformative power of this encounter is claimed to be enormous. Ann Shulgin's Jungian interpretion of MDMA psychotherapy was inspired by her first husband, John Perry, who was one of the last therapists trained by Jung himself (Perry 1974).
Ann Shulgin's active therapeutic work spans just a few years (Shulgin and Shulgin 2005: 76), but she was influential for other early psychotherapists and authored an early guideline for the therapeutic use of MDMA (Anonymous, 1984, Greer, 1984). She also appears to have been instrumental in discovering the combination of MDMA with the mescaline derivative 2-CB (first synthesized by her husband), which unfolds a specific therapeutic synergy when taken at the tail end of a dose of MDMA (Anonymous 1984).
Interestingly, Ann Shulgin does not only mention successes with her patients, but she points to a few cases in which the clients were not able to make positive uses of the MDMA-assisted psychotherapy sessions (cf. Shulgin and Shulgin, 2005: 75-77).
The study of Kueny 1980
In 1979, Alexander Shulgin initiated an exploratory study about the psychotherapeutic use of MDMA at the Pacific Graduate School of Psychology (San Francisco, California). Psychologist Sallie Kueny (1980) administered MDMA to nine persons in a „non-clinical setting“ to evaluate its use in psychotherapy, especially in respect to the „therapeutic alliance“ between patient and therapist. The report on the (unpublished) study includes a research protocol, a synopsis of the MDMA sessions and a follow-up after nine months. Originally it was planned to administer MDMA at three occasions to each client. But the project was stopped for technical reasons after each client got just one MDMA session.
No negative effects were registered during or after the sessions. All subjects reported positive experiences free of usual anxieties. Kueny concluded: „... that this brief experiment yields enough provocative data to justify further research on that issue. Although the sessions in this study were not defined as therapeutic encounters, even without the facilitating intervention of a clinician, the participants experienced what may be termed therapeutic changes. ... MDMA allows ordinary defenses against communication and closeness to relax, and permits those involved in its effects to deal with substantive issues. The researcher believes that the implications for using this agent in the therapeutic setting are enormous" (Kueny, 1980: 8, 16).
Claudio Naranjo – early researcher in drug-assisted psychotherapy
Claudio Naranjo, M.D., a chilean psychiatrist, was periodically visiting the U.S., when he was on different scholarships during the 1960s. Naranjo describes himself as having „a life shaped by the study of music, philosophy, ad medicine, and by the pursuit of the philosophers’ stone. I had been an ‚eternal student’ ... wanting to reach beyond boundaries ...“ (Naranjo, 1973: XV). When he finished his education he was a research psychiatrist at the Centro de Estudios de Antropologia Medica in Santiago de Chile. In 1962, Naranjo became an associate of the American psychedelic chemist Alexander T. Shulgin (Naranjo, 2001: 209). Their cooperation lead to testing of MDA and MMDA in 1965/66 at Naranjo's research facility in Chile (Shulgin et al., 1969, 1973, Naranjo et al., 1967). In 1973, Naranjo published a classic book on drug-assisted psychotherapy. In one subchapter he gave specific advice for „Handling the states of feeling enhancement“ during the effects of MDA and MMDA (Naranjo, 1973: 97-115).
In the late 1970s, when MDMA became apparent, Naranjo was a major figure in spiritual teaching programs in California and became the most scientifcally educated among the early MDMA therapists. Naranjo had known Zeff since the 1970s, and inspired him to use ibogaine and MDA in his work (Naranjo, 2015). Naranjo participated in some ARUPA-meetings at Esalen. By 1984, he had used MDMA with more than 30 patients. To Naranjo MDMA differs from MDA being not hallucinogenic, less toxic and having very mild side-effects (Naranjo in Eisner, 1989: 58). Because MDMA reduces natural defenses and opens the user to trust relationships‚ he calls MDMA experiences "artifical sanity, a temporary anesthesia of the neurotic self". In respect to clinical practice he stated: „I use MDMA once or twice with patients. I mostly use MDMA as an ‚opener’ at some point in psychotherapy, not only for the wealth of the material gained during the session but for how it facilitates therapeutic work in the aftermath“ (Shafer, 1985: 69). Naranjo was eager to differentiate his approach from others in the field. „... Most people I know have used MDMA with a model borrowed from the use of LSD – that of listening to music through headphones while blindfolded. Much can be gained from that alone, but essentially the feeling enhancers have to do with the the world of relationship and with the enhancement of the sense of ‚I’ and the sense of ‚you’. ... I see verbal interaction as an invaluable vehicle for guiding people and helping them to go deeper ...“ (Naranjo, 2001: 216). Consequently, his main interest became its use MDMA "... within groups of people who had ongoing relationships with one another ... to ‚clearing away the garbage’ so as to keep the relationship healthy“ (Naranjo, 2001: 216). His appraoch „... is one in which I have intervened little, except in the preparation of the group and in the course of the session of retrospective sharing and group feedback. I not only coordinate and share my own perceptions but also assist toward further elaboration of the experience“ (Naranjo, 2001: 216). Especially in group therapy, he found a feeling-based intensification of interpersonal trust and empathy for others. This can be furthered by creating „... an atmopshere of surrender and spontaneity within the boundaries of a simple structure that limits movement away from the group but allows for withdrawal, protecting everynone’s expereince from invasion“ (Naranjo, 2001: 217). Form his expereinces, group therapy with MDMA does not produce confucion or chaos. „Again and again I have had the impression that as the result of the catalytic effects of MDMA upon the participants, the group becomes a spontaneously organizing system, for the good of all“ (Naranjo, 2001: 217). A greater role is also given to the smooth (non-sexual) body touch which often occurs spontaneously, and furthers the dimunition of emotional blocks and enhances openess and trust (Naranjo, 1986: 168).
Naranjo usually worked with groups of 12-16 people. He does individual interviews with those group members he has not met before. A group session at the first day of a weekend workshop is "... devoted to personal information, for sharing the expression of interpersonal emotions and for the clarification of individual expectations. 3. group rules and general indications - of which the most important are: 3.1. Seeking a balance between spontaneity and non-interference. 3.2. No sexual intercourse during the psychedelic session and the night after. 3.3. waiting for the effects of MDMA in an attitude of self-observation and goalless restful effortlessness. 3.4. Seeking not to establish contact with other group members before a sufficient time devoted to "self immersion" (Naranjo, 1989: 107/108). An integrative session is conducted on the following day for sharing experiences, group feedback and therapeutic interventions. Naranjo points explicitely to the necessary work after the sessions to integrate the emerged material.
Not much is known about if Naranjo continued his work during the 1980s and 1990s, but druing the late 1990s he trained the Spanish team for a study using MDMA-assisted therapy for victims of rape and violence (Doblin in Naranjo Festchrift 2012: 145?? + Bouso et al., 2008).
Joseph Downing and the Exuma Island Institute
Joseph J. Downing, M.D., became interested in the effects of drugs on the mind in 1954. As director of the Mental Health Division of San Mateo County he treated alcoholics with LSD therapy from 1961 until the mid-1960s (Downing, 1968; Seymour, 1986: 67). Downing was associate professor at Stanford University, a scholar-in-residence at the Esalen Institute, and president of the Gestalt Institute of San Francisco (Downing, 1986a).
Downing began using MDMA in psychotherapy around 1984 in eight patients (Downing 1985). He describes its effects as different from the hallucinogens, because „the site of action is primarily in heart and emotions. ... It produces no images or hallucinations. It does produce a general sense of well-being. ... Feelings of fear and anxiety lift. One feels that one can examine both one’s motives and actions, and those of others, calmly and objectively, with acceptance and compassion. ... Depending on the material contained in the unconscious, the patient will deal with any situation, from childhood traumas, to long-felt adult insecurities, to deeply repressed emotions" (Downing, 1985: ??).
At the occasion of the hearings about the scheduling of MDMA, he presents a case story of a patient who was a victim of a crime in which she was abducted, tied up and tortured for several hours. The patient had undergone psychotherapy, but still suffered from terrible flashbacks, nightmares and suicidal thoughts. Here are the patients conclusions from the MDMA sessions: „I’ve taken it several times, and each time I felt a little less fearful. For the first time I was able to face the experience, go back and piece together what had happened. By facing it, instead of always burying it, I was able to sort of slowly discharge a lot of horror. The drug helped me regain some measure of serenity and peace of mind and enabled me to begin living a more normal live again“ (Tamm in Eisner, 1989: 59).
In 1986, Downing decided to make productive use of the so-called „Grinspoon window“, a period of a few months when MDMA was made legal again because of a legal appeal against its illegalization by Harvard professor Lester Grinspoon. Consequently, he founded the Exuma Island Institute on the Bahamas. This offshore MDMA stress-relaxation clinic was situated in the most scenic beach resort on the small tropical island named Exuma. The goal of the program was to help people remove as much stress as possible. The „psychocatalytic" program of the institute included MDMA sessions devoted to personal introspection and interpersonal communication. After some initial support, the government of the Bahamas suddenly became uncooperative, and after some months of activity the Institute was forced to close.
A manual (written by Downing) elaborated on the intentions and activities of the Institute. It described candidate selection, the psychocatalytic experiences, follow-up, and advanced training. The participants were grouped into 10-person "Life Groups", originally intended to be a month-long program with two MDMA sessions. During the initial period, participants were instructed what to expect, how they would be supported when encountering negative emotions, and encouraged to surrender to the experience. The preparation emphasized the incorporation of new insights into everyday life after the sessions. MDMA was understood as providing a powerful learning experience with life-changing benefits. Sessions were conducted in a comfortable setting under the supervision of two staff members. In order to integrate the experiences the accompanying exercises emphasized mental concentration, proper breathing, and stretching yoga movements (Downing, 1986a).
George Greer’s work with MDMA in psychotherapy
George Greer M.D. became interest in psychedelics during his college years in the mid-1970s. He attended workshops with former LSD-therapist Stan Grof at the Esalen Institute and opened a private practice in San Francisco in 1979. In 1980, Greer heard that underground psychedelic therapist Leo Zeff gave MDMA for therapy. Greer asked Zeff to learn about MDMA and had some training sessions with him (Greer, 2015). Greer quickly realized that the therapeutic use of MDMA by a physican was legal. „I .read the regulations and found that if I synthesized it myself, I could prescribe and administer it to my own patients if I had peer review and informed consent“ (Greer, 2001: 223). Consequently, he synthesized 100 gram in Shulgin’s lab and started to work with it in his office. During the 1980-1985 period, Greer, together with his wife Requa Tolbert, a registered psychiatric nurse, treated over 80 patients with MDMA-assisted psychotherapy (Greer, 2015). The work proceeded in stillness. „It wasn’t secret, but we did not tell people, we didn’t publisize it“ (Greer, 2015). The subjects were typically referred by conventional psychotherapists for having a MDMA session. After an examination and informed consent, the sessions were usually held in the subjects' homes. During individual sessions, the subject listened to instrumental music, usually with headphones and eyeshades, to facilitate internal exploration. During interpersonal sessions, anothe rformat which was used, music was played in the background.
Greer and Tolbert had some rules for their patients: 1. to agree to remain at the site until it was determined to be safe for them to leave, 2. to refrain from any destructive and/or sexual activity, 2. to follow any instructions from the therapists, a final question and answer session to be held prior to adminsitering the dose (Seymour, 1986: 42).
It was in 1982, when Greer heard that MDMA was used at Parties in New York City and realized that will not take long for MDMA to be scheduled (Greer, 2001: 227). Therefore he decided to write up his results. In 1983, two scientific papers about his work with MDMA were self-published. These were circulated only among interested psychotherapists to avoid the promotion of MDMA as a recreational drug.
One of these papers gives a follow-up of 29 patients treated with 75-150 mg MDMA per os, plus a 50mg booster offered around two hours after ingestion. Individual and group sessions were conducted. No serious side-effects or after-effects were found. The most common benefits were enhancement of communication and intimacy during the sessions, improvement in interpersonal relationships, self-esteem, mood, and a decrease of consumption of addicting substances (Greer, 1983a). 23 subjects reported positive changes in attitude lasting from a week to a follow-up time of 2 years. From his clinical experience the authors conclude that „... the single best use of MDMA is to facilitate more direct communication between people involved in a significant relationship. Not only is communication enhanced during the session, but afterward as well. Once a therapeutically motivated person has experienced the lack of true risk involved in direct and open communication, it can be practiced without the assistance of MDMA. ... Regardless of the mechanism, most subjects expressed a greater ease in relating to their partners, friends, and co-workers for days to months after their sessions“ (Greer and Tolbert 1986: ??). In respect to the mechanism of action, Greer concluded that a massive decrease of activity in the neurophysiological fear networks promoted inspection of traumatic memories, self-acceptance and the development of trust. „The insights obtained during the MDMA induced state can be quite valid, but that therapeutic change and development require follow through with regular practice or therapy ...“ (Greer 1983a:??).
Revised versions of these early papers were later published in established scientific journals and became classics in the field (Greer and Tolbert, 1986, 1998). One of these describes „A method of conducting therapeutic sessions with MDMA“ (Greer and Tolbert 1998). The client's psychological preparation and goal-directed motivation were posited as the most important factors in determining productive outcome. To facilitate internal exploration, clients were encouraged to recline and to wear eyeshades and headphones. It is recommended that the client should not have any obligations for at least the following day. It is necessary that very facilitator should be trained by someone who has given many MDMA sessions and should ideally have had the MDMA experience himself at different dosages. Follow-up contact with the patient is recommended as needed, but a facilitator should be available on a 24-hour basis for the following 3 days (Greer in BB I: 193).
Greer’s interest in the therapeutic use of psychedelics never subsided. In 1998, he became the Medical Director of the Heffter Research Institute, an association of scientists to further studies with psychedelics.
Rick Ingrasci, M.D.: MDMA in couples and patients with life-threatening illnesses
During the early 1980s, Rick Ingrasci M.D. owned a psychotherapeutic office in Watertown, MA. and acted as president of the Association for Humanistic Psychology (AHP). Ingrasci was interested in psychedelic psychotherapy since the late 1960s. Since LSD was banned, Ingrasci was looking ot for possible legal alternatives. He worked for some years with ketamine to treat people with anxiety associated with a life-threatening disease (Ingrasci, 2000: 2). In the late 1970s, he became excited when he heard about MDMA as a benign and still legal psychedelic drug with therapeutic potential. After some treatment sessions, Ingrasci was pretty convinced about MDMA's therapeutic potential: „... if anything was going to redeem psychedelic psychotherapy that MDMA could do it because it wasn’t a hallucinogen, and when used correctly it was remarkably predictable and safe ...“ (Ingrasci, 2000: 2). Ingrasci has treated 100 patients with around 150 sessions from 1980 to 1985. One third of the sessions were with couples (Ingrasci, 1986: 1).
Using a careful medical examination (excluding patients with epilepsias and cardiovascular diseases), Ingrasci never came across a physical complication. The usual dose was 135 mg per os. „After the onset of action of the drug (usually 45-60 minutes after ingestion), I encourage the patient or couple to talk about what they are thinking and feeling in the present moment. This gentle, non-directive process continues for the next two hours. ... Following the formal therapeutic sessions with me, I have the patient spend the next two hours with their spouse and/or family members, or with a close friend, someone with whom the patient would like to talk in an open, intimate way. Please note I only use MDMA once or twice in the context of an ongoing individual or couple psychotherapeutic process“ (Ingrasci 1985). Ingrasci describes MDMA’s effects: „It puts a person in an unbelievable open frame of mind ... the expanded capacity for self-awareness, the expanded sensitivity, the increased ability to share feelings. All that’s attributable ... to the lowered fear and anxiety induced by this drug“ (Ingrasci in Gertz, 1985: 56).
In couples therapy, MDMA worked as a catalyst for dissolving encrusted communication blocks. „To sit with a couple ... as they kind of opened up and you facilitate the process a bit, but, quite frankly, once things get rolling, it’s like, they just kind of go where they need to go. ... MDMA ... what it does is, actually remove the fear of being real, of being authentic with yourself and with other people. ... And afterwards ... you don’t need to take MDMA in order to experience authenticity“ (Ingrasci, 2000: 4). In this state of uplifted neurotic fears, the couples were able to communicate in very direct, honest and compassionate ways. „I have seen MDMA help many couples break through long-standing communication blocks because of the safety that emerges in the session as a result of the drug“ (Ingrasci 1985: 3). And because of the very alert and well-functioning cognitive state there is a good chance that these insights can be transferred into everyday life. MDMA-assisted therapy can be also useful for „a deeper bonding process to take place in relationships where for some reason the natural bonding process has been prevented from occuring. ... MDMA holds promise of allowing a healing to take place on those primary feeling levels“ (Ingrasci in Eisner, 1989: 41).
Ingrasci has given MDMA to eleven cancer patients. Ingrasci's work was presented at the popular Phil Donahue TV show in 1985, when some of his patients were invited to speak for themselves. One of his patients was a 40 years old lawyer with terminal liver cancer. At the begining of the therapy she was very contained emotionally and it was virtually impossible for her to open up for her inner feelings about the situation. After months of psychotherapy, she had a session with MDMA. When the effects came on „...she became more relaxed than she had ever felt in her entire life. She opened up emotionally and was able to discuss her feelings about dying in a deeply-felt, meaningful way. Even more significant was the discussion that took place with her husband, mother and her daughter following the therapy session itself. ... Many unresolved feelings and family issues were dealt with openly and honestly in one evening’“ (Ingrasci in Seymour, 1986: 70/71). In conclusion, Ingrasci feels that MDMA „... has helped some of these patients put their impeding death in perspective and releases some of the pain that hey are feeling. It may also help in communication of their feeling and needs to loved ones“ (Seymour, 1986: 45).
In summary, Ingrasci there are many people who can benefit from the use of MDMA in psychotherapy, especially when their defense mechanism include splitting, isolation, and projection of negative feelings. MDMA helps people to reconnect with these split off emotional parts of themselves“ (Ingrasci, 1985: 4). Ingrasci reports not much about his rules in therapy, but he asked his patients to do a written report on their experiences afterwards. H elaos implies that he typically uses MDMA just once or twice in the context of an ongoing individual or couple psychotherapy (Ingrasci 1985).
Phil Wolfson's work with patients and their families in psychotic crisis
Wolfson is a psychiatrist in California. He was the only psychiatrist who has worked with individuals and their families experiencing a psychotic crisis. He has graduated at New York University and has ran an alternative psychiatric inpatient clinic, which was family centered and used little or no medication in dealing with people going through a madness experience.
Psychotic illness of a family member comes with a family dilemma. The strangeness of the disease, the disagreement over labeling, treatment choices and prognosis, and the tendency to blame parents or to eliminate them from the treatment process - all that contributes to a complex interpersonal situations and significant suffering. A psychotherapeutically guided MDMA session in such a situation can provide a context in which defensiveness and character armor would diminish in favor of frank communication and sensitvity to the other's perspectives and feelings. Diminution of negativity and reduction in paranoia and distrust are other important aspects.
Wolfson presents a case vignette to illustrate the issue. He describes a 27 years old male with a psychotic illness beginning two years earlier. The psychosis was characterized by hallucinations, paranoia, delusions and negativism. After being hospitalized a few times, he was under treatment on an outpatient basis. Unfortunately, his psychotic behavior prevented positive relationships that could reduce symptoms by increased trust. To treat this condition, several MDMA sessions with various configurations of family members were interspersed throughout a year of family therapy. The first MDMA session "... was profound in the change in this individual's sense of of self. Connections of an affectional nature were made with his parents and myself and the openings of trust experience began. For the first time in two years, he experienced a glimpse of a positive self-image and loving feelings that did not panic him. The afterglow of this session lasted several days with intensity, but recognition of that positive self-image has lasted permanently" (Wolfson in Eisner, 1989: 66). Despite short-term gains in intimacy and understanding, often periods of closeness were followed by painful rebounds into isolation and alienation. Wolfson clearly realized the limits of these deep-reaching interventions, because "growth and change occur over time with ebb and flow. ... and significant shifts in attitude and behavior require singular effort and understanding on everyone's part". But he also sees the possibilities of such an approach. "In the warm afterglow of an MDMA session, new possibilities for love, relationships and self-appreciation emerge. To achieve these possibilities, the forgiving, less judgmental, reduced defensive state that MDMA provides has to be learned, at least partially, as an everyday way of life" (Wolfson, 1986: 331).
To Wolfson, MDMA offers the possibility for a rapid and significant break with defensive structures that are product of cumulative trauma and communicational disqualification. In a lot of his patients he saw a shift from autism and isolation to interpersonal contact and intimacy. From this experience he gives a glimpse intoa possible future of such an approach: "Imagine a setting in which individuals and their families would ... be in psychotherapy for a psychotic crisis and in which MDMA might be used. It would be in a secure outpatient environment or in the home. ... MDMA would be used on a once per five-day basis, with psychotherapy continuing daily. There would be space and time for dedifferentiation and privacy. Exploration of anger, distance and negativity would be possible ... A family focus would enable exploration of the communication matrix and embedded injustice in the structure" (Wolfson, 1986: 333). Wolfson thinks, that embedded in an overall program of skilled psychotherapy, MDMA could be a new means to help those in torment (Wolfson, 1985: 13-14). Wolfson’s approach was not followed up until now. In 2014, Wolfson became the principal investigatzor of a study using MDMA in psychoptherapy with end-stage cancer patients (Wolfson, 2014).
Psychologist Ralph Metzner Ph.D. was part of the Harvard-based research team which came across psilocybin and LSD in their search for creativity and personality change during the early 1960s. Another member of this team, psychologist Timothy Leary, later became a prominent figure in the 1960s psychedelic drug movement (Dass et al., 2010). During the late 1960s, Leary was in prison and Metzner reluctant about psychedelics, studying Yoga and eastern spiritual traditions. In 1983, Metzner first heard about the new drug MDMA. He met with Leo Zeff Ph.D. at an ARUPA meeting in Esalen, and had some MDMA sessions under his guidance (Metzner 1998, 2013). Metzner also had sessions with John Downing and they treated some patients together. Zeff used a very permissive approach with minimal therapeutic intervention („I just give it to them and they do the therapy themselves“) (Metzner, 2013), but Metzner preferred to be more directive. During the years 1983-1985, Metzner gathered a lot of experience with MDMA. In 1985, together with psychologist Padma Catell, he published a collection of first-hand descriptions of MDMA experiences (Adamson, 1985a). The book included the first comprehesive guide for the use of MDMA in psychotherapy and spiritual exploration. The guidelines were distillied from the experiences of about two dozens of therapists (Adamson, 1985b). They describe intention or purpose as the most important factors for a beneficial experience. Questions about self, personal life and others should be put forward and in writing in advance. Because MDMA induces a „state of extraordinarily heightened emotional intimacy“ it is not advisable to initiate an ordinary sexual encounter, when barriers to „access to fears, concerns and frustrations in the area of intimacy“ are lowered. But it may be important to „... agree that the physical touch of a hand on the heart, the shoulder, the head or the hand, can be an important source of support and encouragement ...“ (Adamson, 1985b: 183). Meditation or relaxation practices during the time immediately before a session were recommended. They also mention the combination of MDMA with the mescaline derivative 2-CB (4-bromo-2,5-dimethoxyphenethylamine) given two hours after MDMA (Adamson, 1985b: 186). As counter-indications severe heart disease, high blood pressure, history of psychosis, diabetes, epilepsia and pregnancy were mentioned (Adamson, 1985b: 187). As the preferred mode for therapeutic sessions a serene and comfortable room was recommended. In respect to music, he found „fast or highly complex music irritating and too difficult to follow. Therfore he prefers „inner space“ music, a serene, peaceful and meditative music during the sessions. Metzner thinks that “no therapist should consider ... guiding a session with these substances who has not had personal experiences with those“ (Adamson, 1985b: 189). The therapist should „suggest to the voyager to go first as far and deeply within as they can, to the core or ground of being ... From this place of total centeredness, compassion and insight, one can review and analyze the usual problems and questions of one’s life“ (Adamson, 1985: 190). It was found that „during the state of heightened though balanced, emotional awareness, one can think clearly about the various options available, without the usual distortions caused by our emotional attractions and aversions“ (Adamson 1985: 190). In respect to group sessions, Metzner characterizes two kinds: one without interaction of its members, which are expected to concentrate and follow their intrapsychic processes, and second, groups were some interaction and communication is allowed during the drug action (Adamson, 1985b: 192). The number of experiences necessary in most cases is given as one to five sessions.
In respect to working mechanisms, MDMA helps „... facilitating a significant opening of relationship communication and helping in the healing of disabling trauma“ (Metzner, 1997/98: 287). The case of a traumatized Vietnam veteran, treated by Metzner in 1984, provides an impressive example (Metzner, 2011). In a 1988 publication on MDMA-assisted psychotherapy, Metzner and Catell described as their primary thesis „... that the empathogenic substances induce an experience that has the potential for dissolving the defensive intrapsychic separation between spirit, mind, and body, and that therefore physical healing, psychological problem solving and spiritual awareness ... ususally do co-occur in the same experience ... thus, instinctual awareness, as well as mental, emotional, and sensory awareness, can all function together, rather than being the focus at the expense of the other“ (Adamson and Metzner, 1988: 59/60). The most important therapeutic implications of the MDMA induced state is that „... [patients] have empathy and compassion for themselves, for their ordinary, neurotic, childish, struggling persona or ego“ (Adamson and Metzner, 1988: 60). In addition, „the psychological problem solving that occurs is also most frequently a shift in perspective, a reframing of the belief that may also be healing ...“ (Adamson and Metzner, 1988: 59). And „individuals are able, if their intention in taking the substance is is serious and therapeutic, to use the state to resolve long-standing intrapsychic concflicts ot interpersonal problems in relationships“ (Adamson and Metzner, 1988: 59).
Since 1985, Metzner was instrumental in bringing the knowledge of therapeutic MDMA use to Europe (Styk, 2012). Based on his extensive knowledge, Metzner later developed „hybrid shamanic therapeutic rituals“, combining features of shamanism and western psychotherapy for therapeutic sessions with MDMA and other psychedelics (Metzner, 1998b).
The Earth Metabolic Design Laboratories, Inc. (EMDL)
EMDL was set up in 1984 as a formal organization to support and coordinate the opposition against the proposed scheduling of MDMA. It was „a group of self-described physicans, researchers and lawyers“ participating in the preparation of data and provide funding for the hearing and to initiate studies in humans and toxicological animal studies (Earth Metabolic Design Laboratories, 1984a: 2). Directors were Rick Doblin, Alise Agar and Deborah Harlow. The Board of Advisors included James Bakalar, Francesco Di Leo, Jack Downing, George Greer, Stanislav Grof, Stanley Krippner Richard Price, Tom Roberts, Alexander und Ann Shulgin, Richard Yensen und Leo Zeff (Earth Metabolic Design Laboratories, 1984b). EMDL intended to gather more than $100.000 to fund six human studies investigating: „A. ... routes of metabolism and physiological effects of MDMA in humans. B. ... survey those physicans and therapists who use MDMA in their practice ... C. a pilot study designed to evaluate the use of MDMA as a training tool for the education of ... mental health professionals. D. a study designed to evaluate the use of MDMA in the treatment of psychological distress in cancer patients. E. a study designed to evaluate the effects of MDMA in a controlled double-blind study. F. ... a study investigating the effects of MDMA on insight and empathy within a psychotherapeutic context“ (Earth Metabolic Design Laboratories, 1984b: 2). EMDL played a significant role in the successful preparation of the hearings and the organization of some meetings promoting the use of MDMA in psychotherapy. It existed just two years and dissolved shortly after the hearings in 1986. Following this, Doblin founded a somewhat equivalent organization, the Multidisciplinary Association for Psychedelic Studies (MAPS) in 1986, which served successfully up to today to gather funding for clinical studies with MDMA (Emerson et al., 2014).
A survey of MDMA therapists
Deborah Harlow, an educated psychotherapist, administered MDMA-assisted psychotherapy to more than 200 clients before 1985 (Harlow, 1994). In 1984, Harlow conducted an exploratory survey for ARUPA of 16 therapists „... who have either worked with MDMA or are well acquainted with its therapeutic use through colleagues’ research“ (ARUPA 1984: 362 = BB I: 362). The therapists were asked to valuate their experiences with MDMA with different kinds of psychiatric complaints. They found betterment in most of their patients, with especially good results in depression, phobias, alexithymia and PTSD. 15 of 16 therapists valued the worth of MDMA as an aid in psychotherapy as very effective. In respect to specific psychological changes therapsist mentioned less projection and rigidity, being less defensive and more accepting, and increased ego-strenght. One therapist reported that he found his own significance reduced by "the work MDMA does with the patient" (Harlow, 1997: 173). Harlow concluded that MDMA was especially useful to "re-structure early object relationships", e.g. to transform early imprints on later behavioral patterns. She also thinks that MDMA could be a good "introduction" to other psychedelics, because it enables people to trust an altered state (Harlow, 1994: 220).
All of the therapists interviewed claimed that complications with the clinical use of MDMA were neglient and that it had no „high potential for abuse“, because „... (a) it is not physiologically addictive, (b) it produces very little effect if taken frequently, and (c) it lacks the hallucinatory or narcotic effects sought by escape seekers.“ (ARUPA, 1984: 363 = BB I: 363??). Harlow's survey was used as evidence during the hearings held about a possible prohibition of MDMA in late 1985.
The first psychophysiological MDMA study
In 1984, a clinical study on the psychological and physiological effects of MDMA was conducted in secrecy at a private house in Stinson Beach, CA, initiated by EMDL and associated MDMA therapists. It was originally planned to be started before the U.S. Drug Enforcement Administration (DEA) will announce its intention to schedule MDMA (in July 1984). In fact, the study started on October 20, 1984. It was intended to gain objective data on MDMA’s clinical effects before it will be scheduled and research severely hindered. The study did neither have F.D.A. approval (which wasn’t necessary) nor IRB approval, which some found would be appropriate, but which has been avoided for less publicity.
The study was conducted under the auspices of Leo Zeff at the private house of John Downing M.D., who was also the study’s clinical coordinator (Doblin, 2001: 374). Phil Wolfson M.D. directed the neurobehavioral substudy. All 21 participants had previous personal experience with MDMA and were found healthy by a physical examination.
The oral dose was in the range 0,8-1,9 mg per kg bodyweight. Blood pickings and cardiovascular parameters were taken from every subject, but ECG's just from a subgroup. With ten participants neurological and neuropsychological tests were performed during the 24 hours after ingestion. All participants were asked to write a protocol about their experiences. The dose-dependent rise of blood pressure was 20-40 mm Hg. Blood analyses and neurobehavioral tests showed only very small changes. Many participants reported euphoria and a subjective increase of physical and psychic energy. There were no grave sensory alterations, e.g. pseudohallucinations. Some particpants reported mild to moderate mood lifting for up to 24 hours. No complications or negative after-effects were found. Neuropsychological testing showed no alterations in memory, but deficits with mathematical performance during the acute effects. The authors concluded that MDMA "... has remarkably consistent and predictable psychological effects that are transient and free of clinically apparent major toxicity“ (Downing, 1986: 339). But they appropriately mentioned that „... any drug that causes ataxia, elevates blodd pressure and pulse is potentially unsafe. ... safety must exclude long-term toxicity. Not enough is known about MDMA’s long-range effects“ (Downing, 1986: 339). Results of the study were used to support the therapeutic viewpoint during the hearings on the scheduling of MDMA and published in 1986 (Downing, 1986b).
The EMDL Conference at Esalen 1985
The first publication on the therapeutic use of MDMA appeared under the title „Using MDMA in Psychotherapy“ in the Journal Advances in 1985. The paper reports on a conference held at the Esalen Institute on March 13-15, 1985 under the auspices of EMDL and ARUPA. According to Greer, a lot of the participants had experience in treating patients with MDMA and „... the combined clinical experience in using MDMA during the past several years totaled over a thousand sessions ...“ (Greer, 1985: 58).
Within the 35 participants were 5 veteran psychedelic researchers from the 1960s (F. DiLeo, S. Grof, R. Lynch, C. Naranjo und R. Yensen) and 4 psychiatrists. Lectures showed that compared to LSD, MDMA was much easier to handle clinically. Reasons for that were virtually no cognitive and sensory alterations (e.g. hallucinations) and intact self-control. Beside some mild sympathomimetic effects the side-effects were limited to temporary anxiety in some cases, which were easy to manage. All participants agreed that „the drug reduced defensiveness and fear of emotional injury, thereby facilitating more direct expression of feelings and opinions, and enabling people to receive both praise and criticism with more acceptance than usual“ (Greer, 1985: 58). From the experiences gained, it appeared obvious that especially severly traumatized patients could profit enormously by enabling them to open up for positive communication and relationship experiences. It was agreed upon the participants that „Integrating MDMA sessions within a format of psychotherapy, family support, or conjoint therapy were deemed essential components of the healing process“ (Greer, 1985: 58).
Physical abuse in MDMA-assisted psychotherapy
Having sexual contact with patients is a violation of professional ethics. In Massachusettes and some other U.S. states it was a crime in the 1980s only if rape, indecent assault or unlawful drug use was involved. However, medical experts said that sexual contact (as opposed to rape) may be considered a crime because people in therapy or under a doctor's care are too vulnerable and dependent to give informed consent. „There can be a feeling of extreme guilt because, unlike rape, the patient may not protest vehemently“, said Kathleen Mogul, a psychiatrist of the American Psychiatric Association’s ethics board. Nevertheless, in a national survey of psychiatrists, more than five percent admitted that they had had sexual relations patients (Diesenhouse, 1989).
In respect to the early therapeutic use of MDMA, two cases became known. The case of Rick Ingrasci M.D. from Masachussettes and Francesco DiLeo Ph.D. from Baltimore. Both had their patients in therapy for a while, when they found that some therapeutic hindrances could be solved by using MDMA. In both cases, the therapists initiated intimate body contact, sexual touch and intercourse during the MDMA sessions. In both cases lawsuits against the therapists were filed and they both lost their licenses.
To illstrate what happened, a short outline of one case is given. The patient of Dr. DiLeo began psychotherapy sessions in 1981, twice per week. In summer of 1985 „a therapeutic impasse“ was reached, because the patient was „unable to to verbalize feelings she has for her therapist“. DiLeo asked her if a MDMA session would be benefical to her. In late 1985 he initiated the session and they „lay down on a mat together, and [DiLeo] began caressing and fondling her“. In the third drug session, the therapist initiated sexual intercourse. After the sessions, the patient immediately terminated treatment. Shortly thereafter, she suffered from panic attacks and had difficulties functioning. Her physican diagnosed PTSD and anxiety neuroses. The court involved later found this treatment „totally unacceptable, counter-therapeutic, and forbidden by the American Psychiatric Association“ and awarded the patient $200.000 for medical expenses and $500.000 for non-economical damage (Court of Special Appeals of Maryland, 1991).
Beside the general problem of possible intimate/sexual relationships between therapist and patient, which occasionally occurs in psychotherapy, this may represent a special problem of drug-assisted psychotherapy, where the client has lower defenses aas well as altered emotions and cognition and may unable to decide what he wants and what not.
Deborah Harlow had interviewed 20 psychotherapists using MDMA in the 1980-1985 timeframe. She has called the Ingrasci case „a huge wake-up call“, which has to be encountered by the antidote of „really stringent rules“ (Harlow, 2013: 33). Of special interest is what one therapist told her about the situation at risk: „You know the person you’re sitting with ... and they’ve suffered so much and they’ve been very closed down and then you see that person open up [on MDMA] and for the first time it’s like they become really beautiful to you and it’s like you see them in a sense they’re the best like they can be and in some cases you may actually fall in love with that person ...“ (Harlow, 2013: 35). The other way around is that patients given MDMA may project their good feelings on the therapists: „Oh, this is about you, you gave me this, oh you are a goddess“ (Harlow, 2013: 35). She also found that some people may feel tempted to use MDMA because they are not very well prepared to work with conventional psychotherapeutic methods (Harlow, 2013: 35). According to Harlow (2013), it was the case of Ingrasci, which lead to the installation of a male and female co-therapist team as a rule in later scientific studies (Mithoefer et al., 2010, Oehen et al., 2013).
Therapists opposed the scheduling of MDMA in 1985
On July 27, 1984, the DEA recommended to place MDMA in Schedule 1 of the Controlled Substances Act. On August 27, 1984, EMDL, in cooperation with a group of physicans, researchers and therapists, requested that the DEA grant a hearing on the proposed scheduling of MDMA. The intention of this was to have MDMA unscheduled or placed in a Schedule other than 1, so that research could continue (Cotton, 1985). The DEA was quite astonished about this. Their top chemist Frank Sapienza said „we had no idea pyschiatrists were using it“ (Sapienza in Adler 1985: 96).Such hearings have to be held if there is resistsance against a proposed scheduling of a substance, which can also be a prescription drug. The hearings were held in 1985. After he heard witnesses from the DEA side as well as from the opponent’s side, the DEA’s Adminsitrative Law Judge, who lead the hearings, concluded that MDMA does not have to be put in Schedule 1. He argued that MDMA had proven therapeutic potential, can be handled without grave dangers in medically supervised settings, has no high potential for abuse and found no appropriate data for a significant toxicity in humans. Nevertheless, the DEA decided overrule the judges decision. EMDL and Lester Grinspoon, a Harvard Professor of Psychiatry and psychedelic drug expert, prepared for an appeal, which came out negative, but lead to the so-called „Grinspoon window“, when the DEA’s placement of MDMA in Schedule 1 was made invalid because of inappropriate handling of some issues through the DEA.
MDMA therapy goes underground
Since the late 1970s, a few people experienced in MDMA-assisted therapy from the U.S. came to Germany and other European countries to teach their work. Ann Shulgin, somewhat at the center of an international network of psychedelic therapists through her husband Alexander Shulgin, claimed that, „... there were some psychotherapists and psychologists who used MDMA in the seventies, and when MDMA became illegal ... many of them didn’t stop using it; its use went underground. ... In both Europe and the United States, there has been a great deal of continuing work ... (Shulgin and Shulgin, 2001). Some evidence for this can be found in the books of British MDMA researcher Nicholas Saunders, who interviewed some underground therapists (cf. Saunders, 1997).
One of those is known under the pseudonym Andrew. This psychotherapist from California was interested in LSD and learned to know Leo Zeff and MDMA in the late 1970s. He hosted his first MDMA group session in 1980. Closely connected to a network of Gestalt therapists in Europe, he came into contact with interested therapists throughout Europe for giving instructive MDMA sessions. Andrew and a few associates „were doing this regularily, primarily in Germany, but also Austria, Switzerland, Holland, Hungary, and Czechoslovakia. We started gradually in 1981. By the next year it really got going. ... We sat for about twenty groups of twenty people per year. ... Psychologists from different cities became interested in starting their own groups“ (Andrew, 2004: 141).
In early 1985, American MDMA therapist George Greer published his short „MDMA users manual“ which gave instructions and precautions for its use in the first German booklet on MDMA (Greer 1985 in Rippchen). In mid-1985, when MDMA was still legal in Europe, a major „new age consciousness“ conference with more than 500 participants was held in Todtmoos, a remote location in the Black forest of Germany. At this occasion MDMA became known to a broader public. For example, American MDMA therapist Ralph Metzner held a day-long workshop, including a MDMA session. This workshop ignited further interest among German psychotherapists, which were inspired to start psycholytic work again with the, in comparison to LSD, much more beneficial and easy to manage „empathogenic“ MDMA.
A year later, some of those therapists founded two now legendary entities. One was the „European College for the Study of Consciousness (ECSC)“ lead by Professor Hanscarl Leuner, a leading European authority on psychedelics, and Albert Hifmann, the discoverer of LSD. The ECSC worked successfully to bring scientists together interested in the therapeutic use of psychoactive substances and altered states of consciousness (Scharfetter, 1994). The other entity was the „Swiss Physicans Society for Psycholytic Therapy (SAEPT)“, whith five of their members given permission to use MDMA and LSD in psychotherapy during the 1988-1993 period (Styk, 1994; Gasser, 1993). It is worth mentioning that until the mid-1990s MDMA wasn’t use broadly, as later in the context of the Rave dance movement (cf. Collin, 1998).
Obviously, it can’t reliably estimated how much MDMA was used in underground psychotherapeutic work. Our informants gave evidence that less then a few hundred therapists worldwide have ever used it underground. If it is assumed that in the ten largest European countries, 5-10 therapists per country were giving 10 weekend workshops (the usual format) with group averaging 12-15 patients it sums up to 10.000 sessions per year. If the average number of sessions per patient is assumed to be five, this (probably conservative) estimate would suggests that more than 2.000 patients may have been treated each year. Over a 30-year period, it can be calculated that 60.000 patients may have been treated underground with MDMA.
When MDMA became known a s useful adjunct to psychotherapy since 1978, a lot of psychotherapists were inspired by its power and efficacy. But obviously, not as much were really working with MDMA when it was still legal. Our best estimates from the vastly different data in the literature and from our informants is that a few dozen therapists were working with MDMA in a psychotherapeutic fashion during the 1978-1985 timeframe. The major part of these was located on the West Coast of the U.S., primarily in California.
MDMA was not an FDA-approved prescription drug nor was it a DEA-specified controlled substance. In California it was completely legal to use MDMA in a physicans practice, if the substance was synthesized by the physican and he gave elaborate informed consent to the patient and was discussing the new treatment with other physicans. „The physican must also have peer review and some supporting scientific literature justifying the use of MDMA with the patient. No special permission is necessary ... (Greer, 1985/1983??: BB I: 190) Greer G (1985?? Original 1983??) Recommended protocol for MDMA sessions. In: Earth Metabolic Design Laboratories (ed.) (1985) Reports from the medical, scientific, and regulatory communities. Lafayette, CA: EMD, p. 190-195
It is known that physicans Zeff, Greer and Wolfson were getting help of Alexander Shulgin to synthesize their own batches of MDMA in Shulgins lab (Wolfson, 1985; Greer, 2015; Baggott, 2016??). A recent article by MDMA researcher Matthew Baggott tried to elucidate the significance Zeff and Shulgin in respect to the early distribution of MDMA therapy. Zeff is focused by ususal literature, but this underestimates Shulgins role. Zeffs MDMA came from Shulgin, and he helped others to synthesize it to stay legal with their therapeutic work (Baggott, 2016??).
>>> Interestign that it appears today that MDMA was created by underground chemists to circumvent the prohibition of MDA as a legal MDA. Ifo ne looks at the psychotherapueitc use, it appears that MDMA followed the more toxic MDA (Passie and Benzenhoefer, 2016).
Because it appears that MDMA was a rather unknown substance until the early 1980s, the therapits were eager to avoid media attenton which had already lead to the prohibition of the psychedelics like LSD and psilocybin. MDMA has been detected by DEA laboratories since 1970, but its use did not signifanclty increase during the 1970s For example, the U.S. Drug Abuse Warning Network (DAWN) had reported only eight emergency room visits related to MDMA in the 1977-1981 period, and none in the 1982-1984 period (Passie and Benzenhoefer, 2016). Shulgin obviously was cooperative with this strategy by not mentioning MDMA in his pulications during the 1978-1983 period (cf. Shulgin, 1981; Shulgin, 1983). On the part of the therapists „... many of the psychotherapists attempted to control the dissemination of information about this drug ... They hoped that enough informed research could be done before it became public ...“ (Eisner, 1989: 2). „Despite their belief in MDMA’s efficacy, therapists were reluctant to publish any prelimnary findings, fearing that such efforts would only hasten the criminalization of this still-legal ‚psychedelic’ and block further research“ (Beck und Rosenbaum, 1994: 15).
MDMA wasn’t as much distributed in the 1976 to 1982 timeframe. It was estimated that around 30,000 doses per month were being used in the United States during the early 1980s (Doblin 1985: 227). Since 1983, it became more widely distributed, especially in some Texas cities (Passie and Benzenhoefer 2016). Activists of the EMDL stated in 1984: „Within the last few years the use of MDMA has spread outside the therapeutic circles. An estimated million 100 mg dosage units have been consumed to this point“ (Earth Metabolic Design Laboratories 1984a: 5). However, MDMA wasn’t mass produced at the time. The Forensic Sciences Division of the D.E.A. reviewed their search on 751 detected illegal labs during 1978-1981. None had produced MDMA, but 16 produced MDA and had the appropriate chemicals available to produce MDMA, but did not do so (Frank 1982: 29).
Doblin attests some success of this strategy when claiming that „for several years ... Sasha [A.T. Shulgin] and others had been able to dissuade the media from reporting on MDMA ...“ (Doblin 2001: 376). For this reason, results of the study conducted by Greer and Tolbert were not published until 1983, when they were self-published and distributed exclusively „seriously interested psychotherapists“ (Seymour 1986: 40).
It was an offshot of the Boston group, named Michael Clegg, who was distributing MDMA since 1983 on a larger scale in some Texan cities. In 1984, these activities inspired the DEA to schedule MDMA. The last „secret“ action in respect to the therapeutic MDMA use was the psychophysiological study October 1984. In April 1985, after the initial media hype on MDMA, the therapists somewhat reoriented themselves by using the media, e.g. an article documenting MDMA-assisted psychotherapy by Greer and Tolbert in Newsweek magazine (Adler, 1985), which galvanized media attention. A short later, a popular TV show (Phil Donahue Show), presented therapist Rick Ingrasci and some of his patients, which made enthusiastic statements about their experiences with the drug.
As mentioned above, when it became obvious that the DEA will initiate the scheduling of MDMA in 1984, some physicans opposed the scheduling. However, the DEA Judges decision in favor putting MDMA in Schedule III (which would allow further research) was overruled by the DEA. Anyhow, the proponents of MDMA therapy reached their goal partially by making their views on the potential of MDMA-assisted psychotherapy known to the public. Some articles positive on the therapeutic use of MDMA appeared in the press. They also were backed by a statement of the World Health Organization’s Expert Committee on Drug Depencence (which illegalized MDMA internationally in late 1985): „It should be noted that the Expert Committee held extensive discussions concerning the reported therapeutic usefulness of 3,4-methylenedioxymethamphetamine. While the Expert Committee found the reports intriguing, it felt that the studies lacked the appropriate methodological design necessary to ascertain the reliability of the observations. There was, however, sufficient interest expressed to recommend that investigations be encouraged to follow up these prelimnary findings. To that end, the Expert Committee urged countries to use the provisions of article 7 of the Convention on Psychotropic Substances to facilitate research on this interesting substance (World Health Organization, 1985).
Immediately after its scheduling, five research protocols for clincial studies with MDMA were introduced to the FDA. ---- Later approaches to be discussed: SÄPT, nicaragua, Bouso in respect to trauma) and Grobs approach to terminal patietns (later changed into hispsilcybin trial) and Wolfson trial w terminal patients, Passie approached for a couple therapy study, but was hindered by new regulatory ...
Ricks follwing action, separation from EMDL after scheduling for doing animal studies and else
WHO statement as an outcome of the hearings clinical practice of early therapists and the efforts to resist the illegalization of MDMA before no urther research was done.
In late 1985, five research protocols for studies in humans were introduced to IRBs or the F.D.A. to examine the clinical potential and risks of MDMA therapy (Grob?, Strassman, Buffum and Wesson, Reese T. Jones at San Francisco ...), but all these attempts failed to get permission. Just the protocol of Dr. Charles Grob at the University of California Los Angeles to treat existe tial anxiety in end-sagte cancer patients was putted on a long-term track. It was evaluated by a subsection of the FDa and rejected in 1992. But the advice was given to introduce a experiemntal prootocl for a study ib healthy volunteers to get more safety data for a later study in patients. Grob aplied for such a study and was able to start in 1992 to conduct the first MDMA study in humans since the Downing study in late 1984. Nevertheless, in 1988 a few psychiatrists from the Swiss Physican Society for Psycholytic Therapy got permission to use MDMA and LSD in psychotherapy until 1993. In 1993, Doblin started working with the military psychiatrist of the Army in Nicaragua and some treatments were conducted with traumatized soldiers, but the project not completed. In 2002, a study to treat tramatized victims of violence was initiated in Spain. This dose-response study was started and some patients were treated , but tne study was stopped for political reasons. The next study was a study with patients suffering from treatment-resistant Post Tramatic Stress Disorder (PTSD). In 2014 a study in terminal cancer patients was started by Phil Wolfson, an early MDMA therapist. As one looks at the indications favored for MDMA therapy by the early MDMA therapists, it can be stated that most therapeutic modalitues and indications later intended to be used in clinical studies were touched tested by the early therapists (traumatized patients, end of life anxiety, couples therapy, psychosmatic diseases etc.
In respect to working mechanisms of MDMA in therapy, the therapists made some empirical clinical findings. Psychotherapy in general rests on a trustful therapeutic alliiance wich enables the patient to uncover hidden causes of distress and recognize them and accept their existance, so that the problem can be dealt with. In regular therapies. This process can take years. The use of MDMA may shorten the development of the alliance and trust. This is reflected in the study by psychologist Kueny to examine the effects of MDMA on the therapeutic alliance. If it is assumed that much of the neurotic problems depends on parts of the psyche splitted-off the everyday personality, „MDMA can help people reconnect with these spli-off parts of themselves ... it seems to generate a sense of wholeness and well being that is not quickly forgotten“ (Seymour 1986: 45/46). While LSD-like psychedelics act on cognitive strucures that consitute the underpinnings of the ego, the ‚ego death’ is induced by a ‚blowing of the mind’. This is why Naranjo calls them „head drugs“, in contrast to the „heart drugs“ like MDA, MMDA and MDMA, which elicit an expansion of emotional awareness without interfering with cognition and sensory perception. Their effects do not take the subject away from the ordinary world, but seemed rather specific for the „processing of unfinshed businesses in the interpersonal world“ (Naranjo, 2001). Naranjo found their application mainly with relationship issues, e.g. couples. His focus in this is also reflected in his therapeutic approach which allows for interpersonal experiences.
For example, In respect to working mechanisms, Greer described MDMA’s unique action as that of „cutting through the neurophysiological mechanisms of fear“. He believed that this enbables people to think about and communicate ideas, memories, beliefs, opinions and attitudes about themselves and others that are normally repressed. In addition, under the influence of MDMA, feelings about this repressed material may be retranslated into physical symptoms, such as bodily pain, nausea, or vomiting. Subjects don’t ususally feel threatened by these symptoms and can experience them and allow them to subside“ (Seymour, 1986: 69). In fact, the early clincial researcher have described therapeutic mechanisms of MDMA therapy, which were proven later by neuroimaging studies. These found as its major mechanism of action the de-activation of the (left) amygdala, the center of the brains fear network (Gouzoulis-Mayfrank et al. 1999; Gamma et al., 2000; Carhart-Harris et al., 2015).
One important specialty was made explicit by therapist Ann Shulgins approach. She implicates a serious cultural bias in respect to our views at the psyche. Western culture „basically treats the unconscious as the enemy, as if only an ax murderer will be found in there! ‚For gods sake, let’s repress it!’“ (Shulgin and Shulgin, 2005: 135). This is, as it seems, different within the community of the psychedelic therapists. They found during the 1960s with psycholytic and psychedelic therapy that the psyche is only opens access to material which is within the capacity of the inidividual to cope with (e.g. Grof, 1975; Caldwell, 1968; Leuner, 1981). Another insight gained was that at the core of a person is love and compassion, not just instincts and aggression (e.g. Richards, 2016). This approach takes the unconscious and its force and more as a frined amd associate than as a potentially evil enemy. This paradigm implies that one can generally trst the unconscious and that it (potentially) enables the psyche to head twoards healing by confronting and handlung apprpriately the unconscious. This is quite congruent with the psychoanalytically inspired theories of Swiss psychologist Carl Gustav Jung.
In respect to the guidelines on how to conduct MDMDA sessions, as far as they can be reconstructed by their writings, the following can be said. Incomparison the recommendations or guidelines for MDMA-assisted therapy show obvious similarties and differences (table) when compared to typical underground work as known and typical for therapeutic woirk of SÄPT and Passie (Contemporary psychedelic therapy).
It appears that, presumably through the impact of MDMA effects on communication and interpersonal behavior, the use of MDMA in groups became more an more favored. This is contrast to covetional psychedelic and psycholytic work, where the patients were treated in individual settings (e.g. Caldwell, 1968; Grof, 1980). Starting their official work with MDMA-assisted psychotherapy in 1988, the members of the Swiss SAEPT Society als used a specific group therapy approach. Their structured but permissive settings also allow for interpersonal contacts as recommended by Naranjo.
The setting guidelines which can be extracted from their work reflect much of the work of the early MDMA work explicated in this article (cf. Passie Contemporary, Passie 2012). These were also established in the same fashion by a lot of therapists working underground (Passie, 2007).
It appears in retrospect that MDMA ignited a new phase of the use of psychoactive substances in psychotherapy. From my personal view, this was mainly caused by its much more easy to handle clinical effects (as compared to LSD) and its specific anxiety-reducing effects, and just minimal effects on sensory perception and cognition. In the early 1980s, at least in Europe, was a low tide in respect to research (and therapy) with psychedelics. It was when Ronald Reagan was President of the U.S., when the irrationality of the war on drugs reached at its heights??. When MDMA hitted in the psychotherapy community in the early 1980s it immediately became the drug of choice of the psychedelic therapists left. In addition, a lot of therapists were being inspired by the profound effects of MDMA and started using it with their clients.
SIDE EFFECTS Most of the early MDMA therapists were physicans. As it seems, they immediately realized that the main danger may come from MDMA’s sympathomimetic effects. Therefore patients with cardiovascular diseases, epilepsia as well as those with severe liver and kidney problems were excluded from treatment. Another approach to handle these side effects was recommended by Greer and Tolbert, which gave some of their subjects „... 5 mg of diazepam (Valium®) at the start of the session. Others had 20 mg to 40 mg propanaolol (Inderal®) every three and a half to four hours to reduce muscle tension“ (Seymour, 1986: 43). However, the side effects of MDMA were found to be mild and safe from a clinical point of view. „There are only minor side effects such as mild nausea, dizziness, increased heart rate, and transient anxiety. Nystagmus and blurred vision are very rare in this dose range. I know of no allergic reactions nor other adverse reactions ... because of the slight increase in heart rate and blood pressure“ (Ingrasci 1985: ??). Driving home after the sessions generally wasn’t allowed, but some therapists did allow driving home some hours after the session, when the subjects driving abilities was carefully assessed (Seymour, 1986: 43).
Preparation of the patient is usually done in preparatory individual sessions
While MDMA was used in the beginning mainly in individual sessions (like LSD), it became quickly obvious to most therapists that it can be easily used in group settings. It apparently offered specific advantages for group settings because of its capacity to open up people and to free them from interpersonal distrust and communication blocks. And it does not interfere with cognition. Two approaches to group therapy were establshed. One is with instructing the participants to focus on themselves and to go inside as the major purpose of the session. The other approach, representet by Naranjo and Metzner, does allow for more interpersonal contact and experience during the session and looks at this as a major feature of the therapeutic process.
The guidelines and instructions for the sessions can be summarized as follows. As a prerequisite, “no therapist should consider ... guiding a session with these substances who has not had personal experiences with those“ (Adamson, 1985b: 189). However, approaches to take the MDMA woth the patient together were soon abandoned and found coounterproductive (cf. Ann Shulgin). In the course of a year-long psychodynmamic psychotherapy 1-5 MDMA sessions are usually enough to further healing. A quiet, comfortable and protected environment with a living room atmosphere was recommended. It is reommended to have more than one therapist available, if group therapy is conducted.
In respect to body contact, no sexual contact was allowed while being in a vulnerable state (and without appropriate ability to decide about intimacy). However, some smooth body contact had been allowed, if agreed on before.
For the session itself the patient should be prepared by a Vergegenwärtigung, an outspoken about his actual state and where he is at this pont in his live and how that relates to his individual biographical dispositions. If possible acute and chronic issues of his live as well as questions he has about these issues should be considered before the begining of the session. This can be done in preparatory individual sessions,but also in a group session. When the session starts, the therapist should „suggest to the voyager to go first as far and deeply within as they can, to the core or ground of being ... From this place of total centeredness, compassion and insight, one can review and analyze the usual problems and questions of one’s life. It was found that „during the state of heightened though balanced, emotional awareness, one can think clearly about the various options available, without the usual distortions caused by our emotional attractions and aversions“ (Adamson, 1985b: 190). After the acute effects are over, the patient still needs (and can make use of) a quiet and protected place. He usually stays where the session was conducted for the following night. On the next day an „integration session“ with the possiblity to elaborate in retrospect on the experience should be conducted. Interestingly, this general format was also established as a typical format by a lot of underground therapists (Passie, 2007, 2012).
In retrospect, it looks like MDMA has lead to another wave of the use of psychoactive substances in therapy, which began in the early eighties. This came after therapeutic work with LSD and psilocybin was left alone after much research during the 1960 (cf. Passie, 1997). Interestingly the latest official studies done with hallucinogen-assisted psychotherapy used MDA a substance closely related to MDMA. As mentioned above, MDA was also a favorite drug used in underground psychedelic therapy since the mid 1960s. Given this, it appears somewhat logical that a related substance with even less cognitive and sensory distortion may be the next step for psychedelic-assisted psychotherapy. The generally begnin effects made MDMA a drug of choice for psychiatrists. Harvard professor of psychiatry, Lester Grinspoon called it a „gentle invitation to insight - the mirror image of paranoia. ... It may well prove to be the first pharmacological agent that actually gives a patient the capacity for insight. It enhances positive feelings of love and trust and seems to facilitate the retrieval of early memories" (Grinspoon in Perlman D:). Since the early 1980s a line can be seen which lead from the MDMA hearings to the work of the Swiss SAEPT therapists in the late 1980s to the congresses and scientific studies oinitiated by the ECSC in the 1985-2000 period to the first placebo-controlled studies with MDMA therapy in the U.S. since 2004 up to now.
As reflected in the statement of the WHO’s Expert Committee, the question of methodologically sound research was critical. Sidney Cohen, a former LSD researcher suggested: „If scientists want to study it, let them file an Investigational New Drug application with the Food and Drug Administration“ (Cohen in Shafer 1985: 69). This sounds easy, but all research with psychedelics was stopped at this point for more than ten years worldwide. There was also the threatening realization that if MDMA would be scheduled, virtually any research would be stopped. However, there is no way to deny the necessity of appropriate scientific research. But in retrospect, these fears were proven to be realistic. All five protocols submitted for therapeutic MDMA studies duirng the eithies were rejected. It wasn’t until 1992, that the first MDMA study in healthy volunteers was started by Charles Grob at the University of California Los Angeles (Grob et al. ??). However, the notorius MDMA proponent Rick Doblin was eager to initiate the animal toxicological studies, a necessary requirement for any studies in humans. These were realized in 1985 and lead to the establishment of a F.D.A. master file for MDMA, which is used until today (Emerson et al. 2014). After a marathon run through different Institutional Review Boards, the F.D.A., the D.E.A. and a million dollar investment, Doblin and Mithoefer were able to realize the first therapeutic study in 2004. Their results were published in 2011 and lead to further successful Phase II trials and a hope for MDMA becoming a prescription medicine in the context of psychotherapy (Philipps, 2016). This contradicts the statement of the D.E.A. leading chemist Frank Sapienza, the DEA’s hwo claimed the early therapists to be irresponsible. „They pass it out, but they`re not willing to do the research.” (Sapienza in Burns S 1985).
On number of therapists
Greer estimates: 100-200 nationwide; Ingrasci estimates 35-50 (Leavy J: Ecstasy: the lure and the peril [Washington Post? is mentioned on the title]< from MAPS media history website)
Although the drug has never received FDA approval, a handful of psychiatrists – about 30, according to one authority – either make it themselves or have it custome-manufactured within their own states. (Adler J (1985) Getting High on `Ecstasy`. Newsweek Magazine by, April 15, 1985)
Harlow: "I mean I probably knew twenty therapists who worked with it ..." (Harlow-Interview, p. 24).
Description of effects
… „What happens is, the drug takes away all your neuroses. It takes away the fear response. You feel open, clear, loving. I can`t imagine anyone being angry under its influence, or feeling selfish or mean or even defensive. You have a lot of insights into yourself, real insights that stay with you after the experience is over. It doesn`t give you anything that isn`t already there. It`s not a trip. You don`t lose touch with the world.“ (Klein J (1985) The New Drug They Call „Ecstasy“ by Joe Klein, New York Magazine, May 20, 1985).
Greer on MDMA's effects in PT and the carry-over into everyday life
On translation of insights and Experiences druing MDMA into later life: "I think the carry-over effect is due to the fact it doesn't alter state of mind very much. Cognition is normal. The state of mind so closely resembles normal state that the insights learned still apply ..." (Leavy J: Ecstasy: the lure and the peril [Washington Post? is mentioned on the title]< from MAPS media history website).
R.B Seymour on early uses in trauma therapy
"... in cases where MDMA has been used to ease traumatic immediacies and unravel painful mental blocks the process may be hastened and long-term psychic pain ameliorated. Therapists have used MDMA with patients who suffered childhood sexual molestation or more recent rape trauma to get at suppressed emotions“ (Richard B. Seymour: MDMA: Another View of Ecstasy. PharmChem Newsletter May-Jue 1985)