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This present study will analyze audio and video recordings of therapy
sessions from the ongoing MDMA-assisted psychotherapy study in the
treatment of clients with post-traumatic stress disorder (PTSD) from
the site of MAPS-sponsored research conducted by Michael Mithoefer,
M.D. in South Carolina. The dataset that Dr. Mithoefer and MAPS have
generously made available provides an invaluable opportunity to study
the MDMA-assisted psychotherapeutic process in depth. This pilot project
will be conducted at the Norwegian University of Science and Technology
(NTNU) in close cooperation with MAPS President Rick Doblin, Ph.D.,
Dr. Mithoefer, and John Halpern, M.D. The objective of this study
is to provide empirical evidence on how MDMA influences behavior in
the context of psychotherapy, to understand how MDMA might facilitate
the therapeutic process, and finally to empirically inform the development
of a standardized treatment manual for MDMA-assisted psychotherapy.
Defenses are coping strategies, often unconscious, that diffuse
conflict and minimize stress. As an example, in the less adaptive
defensive behavior of dissociation, which we expect to be frequent
among the PTSD patients, both the uncomfortable idea and the associated
emotion are kept out of awareness but are expressed by an alteration
in consciousness. The subject usually comments that something “weird”
or unusual takes place at such times. In the therapy session dissociation
might be occuring when the client frequently expresses clouding of
consciousness in response to talking about emotional trauma, e.g.
“I suddenly feel confused and can’t think.”
A person’s characteristic defensive behaviors are more enduring
and trait-like than many of the more state- or mood-dependent psychiatric
self-report tests. Longitudinal studies have shown that people continue
to use the same pattern of defenses over decades. Thus any change
in defensive behavior during treatment is likely to indicate lasting
change in a PTSD patient beyond the remission of the current episode
of distress.
Experiential avoidance occurs when a person is unwilling to
remain in contact with particular experiences in the form of bodily
sensations, emotions, thoughts, memories, or behavioral dispositions.
Experiential avoidance manifests itself in the therapy session as
defensive behavior. The converse of experiential avoidance is emotional
experiencing, something that MDMA is reported to increase. Experiential
avoidance is recognized as an important concept in all the major systems
of psychotherapy. Exposure to emotional experiences or memories is
a central therapeutic intervention, particularly for anxiety disorders
and PTSD.
In this pilot study we will quantitatively measure the frequency
and relative adaptivity of defensive behavior and the degree of emotional
experiencing. Defensive behavior and emotional experiencing are closely
related and have previously been linked to therapy outcome. Change
in defensive behavior is also regularly found to predict symptomatic
change for anxiety, depressive, and personality disorders.
Anecdotal accounts, reports of subjective effects of MDMA in Phase
I studies, and results of neuropsychological studies all suggest that
MDMA belongs to a new class of psychoactive agents called entactogens
that produce feelings of closeness to others, empathy, well-being,
and insightfulness, with little perceived loss of control, and increased
recall of emotional material. These findings are consistent with reports
of decreased defensive behavior and increased emotional experiencing
in previous accounts of MDMA-assisted psychotherapy.
The Defense Mechanism Rating Scales (DMRS), 5th edition, developed
by Christopher Perry, M.D. at Cambridge Hospital (1990) provides an
observer-rated system for measuring defensive behavior. The DMRS is
a manual for quantitatively identifying the use of 28 specific defensive
behaviors, similar to the proposed Defense Axis in Appendix B of the
Diagnostic and Statistical Manual IV by the American Psychiatric Association,
1994.
The DMRS groups defenses into a hierarchical structure of seven
levels (mature, obsessional, other neurotic, minor image-distorting,
disavowal, major image distorting, and action defenses) that has been
consistently empirically validated. Overall defensive functioning
(ODF) is a weighted average of the observed defenses, ranging from
1 (least adaptive) to 7 (most adaptive). Trained coders can achieve
high reliability. Inter-rater reliability for the ODF has yielded
a high median intra-class R of .875 (range from .83 to .90) across
seven studies. One of the investigators of this study has had extensive
experience in the identification of defensive behavior, has received
supervision by the author of the DMRS scale at the Austin Riggs Center,
and is a co-investigator at the current defense mechanism project
at the Harvard Study of Adult Development. When using the DMRS, coders
individually mark each defense with a timecode, a clinical vignette,
and a reason for each rating.
Of relevance for the current study, the DMRS scale also includes
defensive behavior characteristic of highly adaptive and optimally
functioning people. Some highly adaptive defenses we expect to be
more frequent during the MDMA experimental sessions and the sessions
following include: humor, sublimation, anticipation, self-observation,
self-assertion, and affiliation. We expect the change toward a more
adaptive defensive style under and following the MDMA experimental
sessions will be accompanied by more intense, better modulated, and
more integrated emotional expression.
The emotional experiencing sub-scale of the Assimilation of Therapeutic
Objectives Scale (ATOS), developed by Leigh McCullough, Ph.D. at the
Harvard Psychotherapy Research Program, provides a system for quantitatively
measuring experiential avoidance. In the present study, the peak expression
of anger and sadness in each ten minute segment from the therapy sessions
will be rated, according to the ATOS, on a 1–100 scale based
on the intensity, duration, and modulation of the emotional expression.
The ATOS has undergone five reliability studies and has been clarified
and improved with each successive examination.
We plan to analyze at least 40 minutes from each of sessions 3, 5,
8, 11, and 14 from all of the 20 subjects (for a total of 100 sessions)
across the range of outcomes in both the MDMA and the placebo conditions.
Sessions 5 and 11 are the experimental (MDMA or placebo) sessions.
Eight to ten graduate students in the clinical program at the Norwegian
University of Science and Technology will participate in the coding
process.
We expect that the MDMA will facilitate a bearable re-experiencing
of the trauma while increasing the relative adaptivity of defensive
behaviors and enabling a more effective emotional processing of the
trauma. Based on the previous empirical evidence from multidisciplinary
research into MDMA and clinical research into experiential avoidance,
we will examine the role of defensive behavior and emotional experiencing
with the following main hypotheses:
- Overall Defensive Functioning (ODF) score will increase to a
more adaptive level from pre-treatment to therapy session 14, in
both the MDMA and the placebo therapy conditions.
- There will be both a higher relative ODF score and a higher degree
of emotional experiencing in the MDMA compared to the placebo condition.
- The change in ODF and emotional experiencing separately and in
combination will predict outcome in both conditions, both at the
end of treatment and at the three month follow-up.
This pilot study is unique since it is the first well-controlled
study of how MDMA influences behavior within psychotherapy. It will
evaluate the degree to which MDMA facilitates emotional experiencing
through a relative increase in Overall Defensive Functioning, and
it will examine if this predicts outcome. We are well aware of the
limitations of our quantitative approach, so we hope to be able to
supplement our results with illustrative and indepth qualitative case
studies.
Our long-term goal is to extend this study to the other MDMA-assisted
studies that are starting up through MAPS and also to examine the
effects of specific therapist interventions on specific defense mechanisms.
Since defensive behavior is discrete and relatively frequent within
therapy sessions (about 20–80 defensive behaviors are recorded
in each session), they are well suited for quantitative studies of
interactions with therapist interventions. Our hope is that, in cooperation
with other psychotherapy process researchers, we can examine the effects
of specific psychotherapy interventions before and after the defensive
behaviors, and before and after the peaks of emotional experiencing,
to see whether they lead to emotional processing. For instance, should
therapists ignore, clarify, confront or validate defenses? By identifying
interventions that lead to emotional experiencing and more adaptive
overall defensive functioning we can supplement clinical experience
and develop empirically informed training tools, treatment manuals,
and systems for monitoring therapist adherence and competence for
MDMA-assisted psychotherapy, and thus pave the way for well-controlled
larger multi-site studies down the road.
We are grateful that MAPS has provided $5000 for this pilot study
to fund graduate student coders and project acquisition. However we
are in urgent need of further support in this initial stage of the
study. Please contact MAPS if you would like to contribute funds toward
this
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