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Structuring Psychotherapy Sessions with MDMA in a Research Context

George Greer, MD

A talk given at the Conference on the Clinical Utility of MDMA and MDE - Israel, 1999

Back to the 1999 MAPS MDMA Conference Page
See also the talk by Juraj Styk given at the same conference and Subjective Reports of the Effects of MDMA in a Clinical Setting by George Greer, M.D. & Requa Tolbert, R.N., M.S.N.

The three categories of factors involved in conducting MDMA enhanced psychotherapy are:
  1. The drug and dose
  2. The physical setting of the session
  3. The mental set of the patient and therapist

Each research team will determine the first two variables based on their particular situation. The mental set of the patient will be determined by the screening and preparation before the session. These are covered in the article, "A Method of Conducting Therapeutic Sessions with MDMA." The patient questionnaire and informed consent document used in our work with MDMA also provide more specific information.

The mental set of the therapist has not been discussed in depth in the paper, and will be addressed here, organized around several key points.

  1. You or your co-therapist should have taken MDMA in a similar setting and procedure. This ensures that the you understands the variety of altered states that can be facilitated by MDMA and how they can affect the psychological processes of healing in the patient. Furthermore, telling the patient about your experience helps provide a more secure sense about the session and the therapeutic alliance.

  2. We always told patients our personal histories of how and why we had come to work with MDMA, including important ways we felt that MDMA and psychedelic drugs in general had benefited us in the past. This is an important way to establish a therapeutic relationship that is different from the normal non-self disclosure of traditional psychotherapy. When the patient knows everything about you that interests them, they can avoid projecting fantasies of transference onto you, and can feel more secure in knowing realistically who you are and what you know and believe. Because the method we used did not involve verbal interaction and healing through transference, as in psychoanalytic therapy, we felt this more equal disclosure of information between therapist and patient took away expectations of an uneven power relationship in which the therapist had some healing effect on the patient, rather than the healing power coming from the patient's own internal resources. We were more in the role of a psychological support team supporting the patient through a healing experience than the people administering the healing.

  3. Provide plenty of time and attention to all the details of screening and preparation for the session, so that you and the patient are pointed in the right direction when the MDMA is taken, then allow the process to proceed unhindered by expectations or preconceptions, because it is usually the preconceptions that have been preventing the patient from getting well in the first place.

  4. During the screening and preparation phase, have the patient describe to you as clearly and specifically as possible their general purpose and any specific goals they have for the MDMA session, along with their expectations about what will happen during it. It is important that the patient knows that you understand and support the their purpose during the session so there is minimal conflict and opposition between you.

  5. Make sure the patient has a healthy intention and purpose for taking MDMA, and is willing to have the most unpleasant and difficult experience in their life in order to fulfill their purpose. It is almost impossible for a session not to be helpful if the patient has this level of commitment to MDMA therapy, or to any psychotherapy.

  6. Know explicitly what the patient's and your beliefs are about the psychological healing process with MDMA. Is it the shifting patterns of firing and neurotransmitter release among neurons that is the critical factor in reducing symptoms? Does MDMA reduce psychological defenses and allow the recovery of repressed memories along with an ability to process and release them with a linking of their cognitive and emotional aspects? Or does MDMA facilitate the patient's access to their essential holistic spiritual nature which is healing in itself? There are many theories about healing, and it is important that you be conscious of the ones that form your parameters for healing, and be open to other explanations if the patient gets better but the theory does not fit. One effective belief to have is that there is an inherent tendency toward health in the patient, and that MDMA can help them utilize it by reducing the fear that promotes neurotic defenses.

  7. Be prepared to allow the patient to make personal discoveries and go through experiences that neither could have imagined, much less anticipated that do not fit into either of your belief systems. In the film, "The Ideal Husband," Cate Blanchett portrays a wife leading a comfortable but somewhat superficial upper class life in late 19th century England. She surprises herself in awakening to the deep thrill of forgiving her husband for fraudulently gaining all his wealth, something she had always believed to be an unforgivable sin, and of telling him that she had lied to him, which she had also believed to be unforgivable. Her marriage is saved by these revelations. These surprises of discovery and changes in beliefs are very common with MDMA, and are often life transforming. One reason to be fully conscious of one's belief system is that it is easier to set it aside when the therapeutic process takes on a healing life of its own, rather than to try to steer the process on a predetermined path to a preconceived outcome. We hardly know anything about how MDMA can be helpful in therapy, and we need to discover more. Be prepared for the patient to have experiences of themselves that lead to changes in their core beliefs about who and what they are, as well as changes in their religious beliefs. These experiences are rare, and can include the giving up of neurotic beliefs of unworthiness or victim status as well as the acquisition of a more spiritual identity with a greater sense of unity and security of the identified self. At least two of my 80 patients described communication with a divine presence during their sessions, and it was extremely beneficial to both.

  8. During the session, you should maintain an attitude generally supportive toward the patient making progress toward their chosen therapeutic goal. You should be comfortable with all manner of extreme emotions and other experiences the patient might have, without judging or evaluating the significance of any of them until after the session is over, and perhaps not even then. It is the result in the patient's everyday experience in life and their functioning in their relationships at work and at play that are most important, not what happened along the way there.

  9. Understand that psychotherapy with MDMA does not necessarily require any therapeutic intervention at all in order to be successful. The patient might spend the whole time in silence, or perhaps experiencing a variety of emotions without interacting with you, and have an excellent result. Like insight-oriented psychotherapy, the more the patient does it for themselves, the better the result is for their sense of personal competence and self-sufficiency. Therapeutic interventions may be either helpful or distracting, so you should be fully confident of you intention and plan before initiating any communication with the patient during the session. The processing that goes on inside the patient is so fast, that it will usually be a hindrance for the patient to try and describe it to you in a way that can be understood, and for you to process that information and come up with a useful response before the patient has already progressed to the next step. However, if the patient asks for help, then respond simply, briefly and somewhat intuitively, communicating your understanding of their purpose for the session. It is usually after the peak MDMA effect has worn off, around three hours or more after ingestion, that verbal interactions can be most helpful in integrating the experiences and transitioning back to a fully functional mental state. I tried both interacting the entire time and having the patient use headphones and eyeshades, and they felt the verbal interaction was less useful.

  10. It is important for MDMA therapists to have some personal spiritual practice that is satisfying to avoid the temptation to overuse or abuse MDMA as a form of personal therapy or growth. The problem of therapists and scientists abusing the drugs they are studying is a major one, and is one of the reasons why it has been so difficult for researchers to get governmental permission to do the research. The euphoria, which is similar in quality to the feeling immediately after a sexual climax, and flood of personal insight with MDMA can be compelling, and without another means to find peace and happiness in one's life in a relatively dependable way, one can start to rely on MDMA as an apparent answer to life's difficulties, which it is not. One can also become somewhat obsessed and Messianic about it as a panacea, which it also is not. It is important to keep in mind that virtually all the psychotherapeutic benefits of MDMA are potentially available without it, and that MDMA is not absolutely necessary for any condition, regardless of how much or how often therapeutic changes occur with its use in therapy.

See also Subjective Reports of the Effects of MDMA in a Clinical Setting
by George Greer, M.D. & Requa Tolbert, R.N., M.S.N.