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Combining Cognitive-Behavioral Conjoint Therapy for PTSD with 3,4-Methylenedioxymethamphetamine (MDMA): A Case Example



Treatments for posttraumatic stress disorder (PTSD) have evolved significantly in the past 35 years. From what was historically viewed as a pervasive, intractable condition have emerged multiple evidence-based intervention options. These treatments, predominantly cognitive behavioral in orientation, provide significant symptom improvement in 50–60% of recipients. The treatment of PTSD with MDMA-assisted psychotherapy using a supportive, non-directive approach has yielded promising results. It is unknown, however, how different therapeutic modalities could impact or improve outcomes. Therefore, to capitalize on the strengths of both approaches, Cognitive Behavioral Conjoint Therapy for PTSD (CBCT) was combined with MDMA in a small pilot trial. The current article provides a case study of one couple involved in the trial, chosen to provide a demographically representative example of the study participants and a case with a severe trauma history, to offer a detailed account of the methodology and choices made to integrate CBCT and MDMA, as well as an account of their experience through the treatment and their treatment gains. This article offers a description of the combination of CBCT for PTSD and MDMA, and demonstrates that it can produce reductions in PTSD symptoms and improvements in relationship satisfaction.
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Journal of Psychoactive Drugs
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Combining Cognitive-Behavioral
Conjoint Therapy for PTSD with 3,4-
Methylenedioxymethamphetamine (MDMA): A
Case Example
Anne C. Wagner, Michael C. Mithoefer, Ann T. Mithoefer & Candice M.
To cite this article: Anne C. Wagner, Michael C. Mithoefer, Ann T. Mithoefer & Candice
M. Monson (2019): Combining Cognitive-Behavioral Conjoint Therapy for PTSD with 3,4-
Methylenedioxymethamphetamine (MDMA): A Case Example, Journal of Psychoactive Drugs, DOI:
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Combining Cognitive-Behavioral Conjoint Therapy for PTSD with
3,4-Methylenedioxymethamphetamine (MDMA): A Case Example
Anne C. Wagner
, Michael C. Mithoefer
, Ann T. Mithoefer
, and Candice M. Monson
Department of Psychology, Ryerson University, Toronto, Canada;
Remedy, Toronto, Canada;
Private Practice, Charleston, SC, USA
Treatments for posttraumatic stress disorder (PTSD) have evolved significantly in the past 35 years.
From what was historically viewed as a pervasive, intractable condition have emerged multiple
evidence-based intervention options. These treatments, predominantly cognitive behavioral in
orientation, provide significant symptom improvement in 5060% of recipients. The treatment of
PTSD with MDMA-assisted psychotherapy using a supportive, non-directive approach has yielded
promising results. It is unknown, however, how different therapeutic modalities could impact or
improve outcomes. Therefore, to capitalize on the strengths of both approaches, Cognitive
Behavioral Conjoint Therapy for PTSD (CBCT) was combined with MDMA in a small pilot trial.
The current article provides a case study of one couple involved in the trial, chosen to provide
a demographically representative example of the study participants and a case with a severe
trauma history, to offer a detailed account of the methodology and choices made to integrate
CBCT and MDMA, as well as an account of their experience through the treatment and their
treatment gains. This article offers a description of the combination of CBCT for PTSD and MDMA,
and demonstrates that it can produce reductions in PTSD symptoms and improvements in
relationship satisfaction.
Received 30 November 2018
Accepted 21 February 2019
MDMA; couples; CBT;
couples; MDMA; PTSD
The field has made enormous strides in the treatment
of PTSD in the past 30 years. From what was once
viewed as a pernicious, intractable disorder deserving
a palliative treatment course, PTSD is now considered
a treatable condition with various evidence-based inter-
vention options. The majority of these interventions are
cognitive-behavioral in approach (e.g., Cognitive
Processing Therapy, Resick, Monson, and Chard 2016;
Prolonged Exposure, Foa, Hembree, and Rothbaum
2007; Cognitive Behavioral Conjoint Therapy (CBCT)
for PTSD, Monson and Fredman 2012). Cognitive-
behavioral interventions for PTSD have been found
effective in meta-analyses (e.g., Watts et al. 2013),
adopted throughout healthcare systems (e.g., Karlin
et al. 2010), and thousands of clinicians have been
trained through ongoing dissemination efforts (e.g.,
Chard et al. 2012; Foa, Gillihan, and Bryant 2013;
Monson et al. 2018). Cognitive Processing Therapy
(CPT) and Prolonged Exposure (PE) have received
support as strongly recommended in treatment guide-
lines (e.g., APA 2017; ISTSS 2018).
These treatments, however, do not work for all of
those who receive them. For example, 5060% of
people no longer meet criteria for PTSD in the most
successful treatment trials (Foa et al. 2005; Monson
et al. 2006; Resick et al. 2002), yet this leaves millions
of people every year who do not respond adequately to
existing treatments. Additionally, the current model of
individual weekly or biweekly psychotherapy does not
fit the needs of all individuals with PTSD. Alternative
approaches are needed, both to improve treatment out-
comes and to address participant interest in alternative
modes of treatment administration. The current study,
illustrated through the use of a case example, combines
CBCT for PTSD with MDMA, a medication with grow-
ing evidence for its efficacy for treating PTSD.
PTSD has been conceptualized as an interpersonal dis-
order, given the impact it has on interpersonal relation-
ships, and also the interpersonal nature of meaning making
post-trauma that occurs when PTSD is present (Monson,
Fredman, and Dekel 2010). Cognitive-Behavioral
Interpersonal Theory (C-BIT) outlines the relationship
between PTSD symptoms for an individual and for close
others in their psychosocial system (Monson, Fredman,
and Dekel 2010). PTSD impacts the functioning of not
only the individual with PTSD, but also their relationships.
CONTACT Anne C. Wagner Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, Ontario,
M5B 2K3, Canada
Color versions of one or more of the figures in the article can be found online at
© 2019 Taylor & Francis Group, LLC
Conversely, the functioning of close others and relation-
ship functioning impact PTSD (e.g., Bradley et al. 2005;
Lambertetal.2012;Shnaideretal.2014). CBCT for PTSD
makes use of this interpersonal dynamic in the treatment of
PTSD, and notably addresses the desire for close others to
be involved in treatment. CBCT for PTSD targets both
PTSD symptoms and relationship satisfaction by increas-
ing understanding of PTSD within the context of the
relationship, dyadic skills (e.g., communication, problem
solving, and conflict management), behavioral approach
tasks, and dyadic cognitive restructuring of thoughts that
are preventing recovery (Monson and Fredman 2012).
Because of the nature of avoidance with PTSD, along
with stigma regarding seeking mental health care and
concern regarding treatment (e.g., Stecker et al. 2013),
involving close others in PTSD treatment can be useful.
There may be strong investment in engaging in care for
the sake of the relationship, if not only for the indivi-
dual (e.g., Meis et al. 2013). There is growing evidence
for the effectiveness of CBCT, with strong outcomes for
the reduction of PTSD symptoms, as well as improve-
ments in partner functioning and in relationship func-
tioning (Monson and Fredman 2012; Monson et al.
2004; Shnaider et al. 2014). CBCT has been found to
be effective with distressed and non-distressed dyads
(Monson and Fredman 2012; Shnaider et al. 2014).
MDMA, an atypical psychedelic compound, was used as
a therapy-facilitating tool before it was placed in Schedule 1
in the United States (Greer and Tolbert 1986;Passie2018;
Passie and Benzenhofer 2016; Riedlinger and Riedlinger
1994). MDMA has shown promise in the treatment of
PTSD when coupled with non-directive, supportive psy-
chotherapy (Mithoefer et al. 2011,2013,2018b). MDMAs
neurobiological effect includes activation of the prefrontal
cortex and dampening of activity in the amygdala, as well
as release of neurotransmitters such as serotonin, dopa-
mine, norepinephrine, and hormones such as oxytocin,
cortisol, vasopressin, and prolactin (Carhart-Harris et al.
2015; de la Torre et al. 2000;Dumontetal.2009; Emanuele,
Arra, and Pesenti 2006; Feduccia and Mithoefer 2018).
Coupled with the intentional creation of a therapeutic con-
text, set, and setting, this neurobiological effect enables
what has been theorized as an optimal zone of arousal, as
well as possibly allowing for a type of fear extinction
(Feduccia and Mithoefer 2018).Wepositthattheneuro-
transmitter release and changes in brain activity may also
allow for flexibility in cognition, given the altered affective
and sensory state, as well as increased feelings of empathy
(Kuypers et al. 2014), positive or clear affect (Green et al.
2003), openness (Gamma et al. 2000), and less constrained
cognitive processing (Carhart-Harris et al. 2015), which
may address elements of trauma reappraisal targeted in
cognitive therapies. Additionally, it is posited that the
experimental expectancy effect of taking a psychedelic
compound, as well as the specialnature of the context
of therapy (massed dosing, full-day sessions, significant
pre-treatment discussion and consent, contact with thera-
pists daily following MDMA sessions), may allow for opti-
mal treatment gains. The sense of empathy produced
extends to therapists, partners, and also to the client, allow-
ing for more thorough examination of thoughts and emo-
tions with a sense of care and understanding, as opposed to
fear. The MDMA session experience may create a salient
example of what it may feel like to no longer have PTSD,
and therefore offer a scaffold on which to continue to
a detailed account of the methodology and choices made to
experience through the treatment and their treatment
CBCT protocol and session flow
CBCT is a 15-module, three-phase, protocol-based, dya-
dic treatment for PTSD (Monson and Fredman 2012).
Each module is typically delivered in a 75-minute psy-
chotherapy session. The relationship between the mem-
bers of the dyad is considered the client in therapy, and
all interventions are designed to address both people.
Phase one of the treatment (two modules) includes psy-
choeducation about PTSD and addresses barriers to
safety, including understanding and working with
anger and irritability. Phase two (five modules) empha-
sizes the development of communication and problem-
solving skills, and introduces behavioral approach tasks
aimed at reducing avoidance. Phase three (eight mod-
ules) consists of dyadic cognitive work to address stuck
thoughts related to the trauma, including areas related to
acceptance and blame, trust, power, control, emotional
intimacy, physical intimacy, and posttraumatic growth.
Out-of-session assignments are used to practice skills
and techniques learned in session.
In this case study, two full-day MDMA sessions were
added to the CBCT protocol, during which both mem-
bers of the dyad were given MDMA. The first MDMA
session was placed after module 5 of CBCT, which is
mid-way through phase two (see Figure 1). This place-
ment was selected in order to place the MDMA session
directly after the couple had learned and practiced
communication skills, as we wanted the couple to
have these skills in order to share their experiences
and be able to communicate effectively during their
MDMA session and afterwards. The second MDMA
session took place after module 9 of the CBCT proto-
col, which is near the beginning of phase three of the
protocol, and in the heart of the trauma processing
around themes of acceptance and blame. The rationale
for placing the second MDMA session there was to
facilitate trauma processing and to prime the partici-
pants with self-referential, trauma-related content.
The first three modules of CBCT were delivered in
one day (see Figure 1), with time during breaks for the
couple to complete homework exercises. This procedure
was both feasible and acceptable to the participants.
Subsequently, two modules of CBCT were condensed
the next morning prior to the first MDMA administra-
tion. Four modules of CBCT were delivered over video-
conference over the following three weeks, and then two
modules of CBCT were conducted in person the day
before the second MDMA session. The final four mod-
ules of CBCT were delivered weekly over videoconfer-
ence after the second MDMA session. The CBCT
modules that were delivered over videoconference were
done so due to pragmatic considerations; the couples and
therapists often did not live in the same city and all would
travel to meet for the in-person sessions. CBCT has been
demonstrated to be effective when delivered over video-
conference (Morland et al. 2018).
MDMA sessions
The design of CBCT + MDMA includes a team of two
therapists, with no specification as to the gender of the
therapist, deviating from the norms of a male and female
therapist dyad used with MDMA-assisted non-directive,
supportive psychotherapy (Mithoefer et al. 2018a). The
therapists were present with the dyad throughout all
components of the therapy. During the MDMA sessions,
the participants, who were seated in reclining lounge
chairs, were encouraged to spend time inside(e.g.,
with headphones on with pre-selected instrumental
music playing and with eyeshades). This time inside
alternated with time outside(e.g., headphones and
eyeshades off, speaking with the partner and therapists).
The alternating pattern of time spent inside and outside
lasted for approximately six hours, during which time
hourly subjective units of distress (SUDS) ratings were
recorded and blood pressure and temperature were
checked per the safety protocol.
Participants stayed overnight at the study facility the
night of the MDMA session with a night attendant, and
then met with the therapists the following morning to
debrief and assign out-of-session assignments. Daily
phone check-ins ensued for seven days to maintain
supportive contact and check in on any adverse reac-
tions to the medication. The second MDMA session
followed the same procedure as the first.
Participants were given 75 mg of MDMA for the first
session, with an optional supplemental half-dose
(37.5 mg) offered at 90 minutes post-administration to
elongate the session (the participants in this case study
both took the supplemental half-dose). Ninety minutes
post-administration was chosen as this is the time where
the MDMA has reached full effect for the majority of
participants. For the second MDMA session, participants
were offered the choice of 75 mg or 100 mg as their initial
dose of MDMA (in the case described here, both mem-
bers of the dyad chose 100 mg), and therefore the supple-
mental half-dose was 50 mg. The choice to offer an
increase in dose was done based on the option to create
a stronger felt effect of the MDMA, as 75 mg is the lowest
and Consent
(Before Day
Modules 1-3
of CBCT, in
(Day 1)
Modules 4+5
of CBCT +
(Day 2)
(Day 3)
Modules 6-9
of CBCT over
4 telehealth
(Over 3
10+11 of
CBCT, in
(Day 22)
(Day 23)
(Day 24)
Modules 12-
15 of CBCT
over 4
(Over 4
(One month
after last
Figure 1. CBCT+MDMA Treatment Flow.
dose used in other studies of MDMA for the treatment of
PTSD (e.g., Mithoefer et al. 2018b). All MDMA doses
were administered via oral capsule. Participants were
required to refrain from eating from midnight the night
before the MDMA session, and the MDMA was adminis-
tered by 11 AM on the day of the session.
Assessment and inclusion
Ethics approval was obtained from the Copernicus Group
in the US and Ryerson University in Canada, and written
informed consent was obtained from participants. The
study took place in a private practice facility in the
Southern United States. Assessments were conducted by
an independent rater pool. Participants completed assess-
ments at baseline, post-treatment, three-month follow-up,
and six-month follow-up, and completed the PTSD
Checklist (PCL-5, patient or partner version; Weathers
et al. 2013b) and a one-item rating of relationship satisfac-
tion (Couples Satisfaction Index, CSI; Funk and Rogge
2007) at every session. Participants were assessed on the
Clinician-Administered PTSD Scale-5 (CAPS-5; Weathers
et al. 2013a) at each assessment time point, and the
Structured Clinical Interview for the DSM-5 (SCID-5;
First et al. 2015) at baseline to determine eligibility. PTSD
symptoms and relationship satisfaction scores are consid-
ered the primary study outcomes.
Participants had to be over 18 years of age, and one
member of the couple had to have a diagnosis of PTSD.
The partner could not have a diagnosis of PTSD. Current
substance use disorder, active suicidal planning or intent,
mania, and psychosis were psychiatric exclusionary cri-
teria for both partners. Severe partner aggression was also
an exclusionary criterion. Participants were medically
screened for safe inclusion, including of heart rate, car-
diac functioning, blood pressure, and any major medical
condition, and participants were required to taper off of
all psychiatric medications.
Case example
Case background, assessment, and therapists
The participants, Stuart and Josie,
were recruited as part
of a pilot study of CBCT + MDMA. They were referred
to the study by Stuartsindividualtherapist.Stuarthad
been attending therapy for several years to address his
trauma-related symptoms. While he had experienced
periods of symptom abatement, the symptoms returned
and, within the past three years, they had become
increasingly problematic for him and for his relationship
with his wife, Josie, and their three grown children.
Stuart and Josie were both in their mid-50s at the time
of treatment. They were both Caucasian and were
employed full-time. Stuart had not previously received
a cognitive-behavioral treatment for PTSD. He had
received a course of Eye-Movement Desensitization
and Reprocessing (EMDR; Shapiro 2001). Stuart had
not shared much regarding his traumatic experiences
with Josie, because Josie reported being concerned
about the effect they might have on her if she should
hear them.
At baseline, Stuarts CAPS-5 score was 43 (range 0 to
80; Weathers et al. 2013a), his PCL-5 score was 66 (all
versions range 0 to 80; Weathers et al. 2013b), and his
baseline relationship satisfaction on the one-item CSI
measure was 3 (on a scale of 0 to 6, with 0 being
Extremely Unhappy and 6 being Perfect). He did not
have any current comorbid disorders on the SCID-5,
and met criteria for past Major Depressive Disorder and
past Alcohol Use Disorder. Josie had no psychiatric diag-
noses per the SCID-5, and rated Stuarts posttraumatic
symptoms as a 53 on the PCL-5. Her relationship satisfac-
tion was a 3.
The therapists consisted of one female, early-career
clinician who took the role of CBCT expert, and one
male, late-career clinician who had extensive experience
with MDMA-assisted psychotherapy. Both clinicians
underwent training in the other modality in order to
facilitate treatment development and create a common
understanding of the administration of MDMA in
Stuarts traumatic event was repeated sexual assault
in childhood by his father and his fathers work collea-
gues. Through the course of therapy, Stuart came to
realize that he had been groomed by his fathers friends,
and that his father had been coerced and blackmailed
into sexual acts with Stuart by his friends. Stuart
reported immense guilt and shame surrounding the
events, particularly because he recalled always wanting
to go to work with his father, and desperately wanting
his fathers approval. Stuarts confusion about his early
sexual experiences resulted in what he described as an
unwanted focus on being submissive and seeking out
sexual scenarios consistent with that experience. This
created strain in the relationship with Josie, because
this was not a dynamic she enjoyed.
Course of treatment and outcomes
In phase one of CBCT, Josie and Stuart identified that
emotional numbing and irritability, as symptoms of
PTSD, had impacted their relationship. They were able
to identify how the different symptom clusters interplayed
together to maintain PTSD, and noted particularly how
avoidance of emotion fed that cycle. Work was done early
on in the treatment to work through Josies concerns
about hearing traumatic information, based on the under-
standing that how the information is shared in therapy
would not be traumatizing for her and that she would be
supported in responding to Stuart.
In phase two of CBCT, Stuart and Josie worked to
develop skills such as paraphrasing. They were also taught
skills to express specific thoughts and feelings related to
PTSD that created strong emotion for them both. The
development of those skills was used to prime the couple
before their first MDMA session, and the couple was
prompted to use the skills during the session when they
wanted to share thoughts and emotional experiences.
Prior to the first MDMA session, both partners
expressed anxiety, having never used any type of
non-ordinary state of consciousness-inducing medi-
cation before, and not knowing what the experience
would bring up cognitively and emotionally. During
the first MDMA session, Stuart, unprompted, went
chronologically through his traumatic experiences.
He reported staying with the memories and sensory
details, much of which he had previously avoided.
Stuart experienced strong emotional reactions, such
as crying and grief in the sessions, and did not try
to stop or escape those experiences. Stuart also had
strong visceral reactions in the MDMA session,
including muscle tightening and sweating as he
reviewed traumatic memories while inside.
Following this session, Stuart reflected, Theresno
easy fixI need to work through the darkness.
Josie was able to discuss her challenges in coping with
Stuarts PTSD and the impact on their relationship, her
mental wellness, and their family more generally, in the
MDMA sessions. She reported strong positive experi-
ences and the sensation of finally being able to relax,
which she reported as being atypical for her. Josie
reported that I just have overall inner peaceitsamaz-
ing. There is no price anyone can pay for that.
Stuart and Josie are religiously devout, and cited their
faith as a key ingredient in their individual lives and
relationship. Religious symbolism was rife throughout
their MDMA sessions, including Josie reporting that
she felt as if Jesus is holding my hand and walking
with me.Stuart and Josie used this type of referent
frequently in therapy, although the sensation appeared
heightened and comforting in the MDMA sessions.
Following the first MDMA session, neither Stuart
nor Josie reported significant emotional or physiologi-
cal challenges in the subsequent days. Stuart reported
feeling fatigued, but emotionally and psychologically
much lighter. Stuarts self-reported PTSD symptoms
reduced markedly following the first MDMA-
facilitated session; he attributed this to a new under-
standing of the traumatic experiences and acceptance.
Josie and Stuart completed behavioral approach
tasks in the three weeks between the two MDMA
sessions, such as organizing to spend time with
Stuarts sister and having conversations about emo-
tions. Moving into phase three of the treatment,
Stuart and Josie tackled stuck thoughts, which are
dysfunctional cognitions that maintain the cognitive
loop that contributes to the cycle of PTSD symp-
toms. They worked through stuck thoughts related
to themes of blame, trust, and control for Stuart
(such as Ididnt do enough to stop what happened.
It was my fault,which resulted in the alternative
thought It wasnt my fault, I know that now. I was
a little kid and I didnt have a choice), and related
to emotional intimacy for Josie (such as We cant
let other people into our lives,which resulted in
the alternative thought I can learn to let other
people in and become close to them).
The second MDMA session closely resembled the
first, although Stuart did have some time of peace and
gentle pleasurable experience by the end of his second
session. Josie continued to have a supportive, relaxing,
and engaged experience during the second session.
Following the second session, Stuarts symptoms were
almost non-existent, and remained so through follow-
up, with several waves of strong emotions over the
months that he attributed to paying attention to differ-
ent memories from his childhood that he had avoided
previously. At post-treatment, Stuarts CAPS-5 score
was 1, and his PCL-5 score was 4. Josies PCL-5 score
of Stuarts symptoms was 1. They both rated their
relationship satisfaction as 5. These gains were main-
tained at three- and six-month follow-ups.
For this couple, CBCT + MDMA had the intended effect
resolution of PTSD symptoms and improvement in
relationship satisfaction. The intensive nature of the treat-
ment facilitated participant engagement and commit-
ment, and it can be posited that the context, set, and
setting of multiple full days together, as well as the empa-
thy-inducing effects of the MDMA, created strong ther-
apeutic bonds between the couple and the therapists. The
issue of homework completion early in treatment was
mitigated by condensing modules together and having
breaks within the therapy session itself to do homework.
Stuart attributed much of his reduction in symptoms
to a better, clearer understanding of the events that
occurred, and acceptance of both the events and himself.
This understanding allowed the struggle around the
memories and experiences to cease, which resulted in
less numbing, avoidance, and irritability. Memories of
the traumatic events that entered his mind following the
therapy were often described as being examined with
curiosity and interest, as opposed to fear and displeasure.
Stuart and Josie both described feeling a strong sense of
this (the trauma, their journey together, this treatment,
Stuarts recovery) having happened for a reason,and
felt bonded for having gone through the therapy together.
The salient, shared experience of the intervention, as well
as experiencing what it felt like not to have the overlay of
PTSD present during the MDMA sessions, created
a lasting impression for Stuart and Josie that they were
able to integrate and move forward.
For Stuart, the CBCT + MDMA experience offered
a new template to make sense of his traumatic experi-
ences, and allowed him the space to think and experi-
ence through the memories and assumptions he had
made about the event without the overlay of fear and
anxiety. That ability to take a nuanced look allowed
Stuart the opportunity to make meaning of the events
in a way that felt helpful to him, and unlocked the cycle
of PTSD symptoms. I have my life back and for the first
time in my life I look forward to a renewed future.
I live my life now with hope where despair ruled before.
That is a pretty huge realization for me.Its like a light
has been shined into the darkness of my soul(Stuart, 11
months post-treatment in an email to the clinicians).
For Josie, the CBCT + MDMA experience allowed her
the opportunity to no longer feel she had to walk on
eggshells,and to experience relief from anxiety and
tension. Together, Stuart and Josie were able to share
the experience of Stuarts traumatic memories, and face
them in a united and accepting manner. They both cited
having the template of the skills offered in CBCT, such as
the skills of paraphrasing and the tools of behavioral
approach and challenging thoughts, as helpful in creating
a common language and roadmap for them.
This case example demonstrates that the combina-
tion of CBCT + MDMA was feasible, effective for this
case, and well-tolerated by the couple. They were able
to follow the protocol as designed, and were engaged in
out-of-session work and all therapy sessions. This case
also demonstrates that the delivery of CBCT can be
condensed (e.g., having the course of therapy delivered
in two months as opposed to four to five months; see
also Fredman et al. 2018), elements can be delivered
effectively via videotherapy, and that the addition of
MDMA was viewed as useful to the clients.
Additionally, this case demonstrates that the use of an
evidence-based stand-alone treatment for PTSD can be
combined effectively with MDMA, as previous studies
of MDMA-assisted psychotherapy for PTSD have used
non-directive, supportive psychotherapy, which alone is
not considered an evidence-based PTSD treatment.
The specific setting created for the therapeutic use of
MDMA (a comfortable room, the ability to lie down,
the use of music and eyeshades) and set (the presenta-
tion of this medication as an adjunct that could help
facilitate therapy), as well as context (in the midst of
a trauma-focused PTSD intervention), are key elements
that need to be considered. The context prepares the
clients for engaging with trauma-related content in the
sessions. The set and setting are following principles
outlined in the early psychedelic-assisted psychotherapy
literature (Greer 1985; Grof 2001), and described in
a treatment manual used in recent MDMA clinical
trials (Mithoefer et al. 2018a). While appealing and
standardized in this context, their individual effect
and necessity is not yet known.
Although the findings from this case are positive, addi-
tional research is needed to explore whether this treatment
will be helpful for other couples presenting for treatment.
1. Names have been changed. Some identifying charac-
teristics have been changed in order to protect partici-
pant confidentiality, although all data are accurate.
This work was supported by the Multidisciplinary
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... MDMA has also been found to increase attention to positive emotional cues (Bershad et al., 2019). In therapeutic contexts, MDMA allows for the experiencing of challenging emotions, as well as increased compassion and decreased defensiveness (e.g., Metzner and Adamson, 2001;Stolaroff, 2004;Feduccia and Mithoefer, 2018;Wagner et al., 2019). MDMA has also demonstrated a reduction in anxiety in therapeutic contexts (e.g., Danforth et al., 2018). ...
... MDMA has also been shown to increase cooperation (Gabay et al., 2019). Therapeutically, MDMA can create a reduction in experiential avoidance and engagement in challenging content (emotional and cognitive) without disorientation, including a desire to communicate (Feduccia and Mithoefer, 2018;Wagner et al., 2019). Increased openness to experience, which can facilitate greater engagement and risk-taking in vulnerability in interpersonal relationships, has been shown to increase following MDMA-assisted psychotherapy (Wagner et al., 2017). ...
... Increased openness to experience, which can facilitate greater engagement and risk-taking in vulnerability in interpersonal relationships, has been shown to increase following MDMA-assisted psychotherapy (Wagner et al., 2017). Reports of increased introspection and improved communication collectively create a behaviorally rich opportunity for relational processing and engagement for the couple (e.g., Metzner and Adamson, 2001;Stolaroff, 2004;Wagner et al., 2019). ...
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MDMA's first identified potential as a therapeutic catalyst was for couple therapy. Early work in the 1970s and 1980s explored its potential amongst seasoned psychotherapists and their clients. With the completion of the first pilot trial of MDMA-assisted psychotherapy with couples for PTSD, and as the possibility of conducting MDMA-assisted psychotherapy trials expands due to new regulatory frameworks, we have an opportunity to explore and investigate how and why MDMA-assisted couples therapy works. This theoretical paper will explore the neurobiological and neurochemical effects of MDMA in a relational context, the emotional, behavioral, cognitive and somatic effects within a dyadic frame, and how empathy, communication, perception of social connection/support, non-avoidance, openness, attachment/safety, bonding/social intimacy and relationship satisfaction, are all impacted by MDMA, and can be harnessed to facilitate systems-level and interpersonal healing and growth. A model to support MDMA-assisted couple therapy is introduced, and future directions, including implications for intervention development and delivery, will be elucidated.
... Most contemporary clinical trials employ a mixed-gender co-therapist team throughout all stages of the therapeutic process (Bogenschutz and Forcehimes, 2017;Garcia-Romeu and Richards, 2018;Johnson et al., 2008;Mithoefer, 2017). There are exceptions with no considerations of gender specifications of the therapists (see Wagner et al., 2019). Roles and responsibilities for different aspects of the therapy can be divided between the therapists and, as was reported in first-wave psychedelic research, some sessions have been conducted by a single highly experienced therapist (Grof and Halifax, 1977;Grof, 1980;Kurland, 1985;Eisner, 1997;Johnson et al., 2008;Bogenschutz and Forcehimes, 2017;Watts, 2021). ...
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Background: Clinical trials are currently investigating the potential of substance-assisted psychotherapy (SAPT) as treatment for several psychiatric conditions. The potential therapeutic effects of SAPT may be influenced by contextual factors including preparation prior to and integration after the substance-assisted therapy sessions. Aims: This systematized review outlines recommendations for current practice in preparatory sessions in SAPT including safety measures and screening procedures, preparation of set and setting, session contents, methods, and roles, prerequisites, and appropriate conduct of therapists. Methods: A systematized review of the literature was conducted based on PRISMA guidelines. MEDLINE (OVID), PsycINFO (OVID), and Cochrane Library were searched and clinical trials, treatment manuals, study protocols, case studies, qualitative studies, descriptive studies, theoretical papers, reviews, book chapters, and conference proceedings published until February 1, 2022 were retrieved. Results: The final synthesis included k = 83 sources. Information about safety measures including screening of participants, set and setting, contextual-, physiological-, and psychological preparation, roles, competencies, prerequisites, and characteristics of the therapists, and the establishment of a therapeutic relationship were summarized and discussed. Conclusion: It is concluded that there is a consensus in the literature about the importance of adequate preparation before the administration of psychoactive substances in SAPT. However, the extent and approaches for these sessions vary across different models and there is a need for timelier and more rigorous qualitative and quantitative investigations assessing different approaches and techniques for the optimal preparation of clients in SAPT.
... In all, 16 studies were selected, including one qualitative study (total N = 266 patients treated). In total, 10 publications described MDMA-assisted treatment of PTSD (total N = 214 patients): seven RCTs (Mitchell et al., 2021;Mithoefer et al., 2011;2013b, 2018, 2019Oehen et al., 2013;Ot'alora et al., 2018), one openlabel trial (Jardim et al., 2020), one case series (Monson et al., 2020;Wagner et al., 2019), and one qualitative study (Barone et al., 2019). Other RCTs reported on the treatment of end-of-life anxiety (EOLA) (Wolfson et al., 2020), social anxiety in adults with autism (Danforth et al., 2018), and tinnitus (Searchfield et al., 2020); one open-label study focused on alcohol use disorder (AUD) (Sessa et al., 2019;2021b). ...
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Introduction Small-scale clinical studies with psychedelic drugs have shown promising results for the treatment of several mental disorders. Before psychedelics become registered medicines, it is important to know the full range of adverse events (AEs) for making balanced treatment decisions. Objective To systematically review the presence of AEs during and after administration of serotonergic psychedelics and 3,4-methyenedioxymethamphetamine (MDMA) in clinical studies. Methods We systematically searched PubMed, PsycINFO, Embase, and for clinical trials with psychedelics since 2000 describing the results of quantitative and qualitative studies. Results We included 44 articles (34 quantitative + 10 qualitative), describing treatments with MDMA and serotonergic psychedelics (psilocybin, lysergic acid diethylamide, and ayahuasca) in 598 unique patients. In many studies, AEs were not systematically assessed. Despite this limitation, treatments seemed to be overall well tolerated. Nausea, headaches, and anxiety were commonly reported acute AEs across diagnoses and compounds. Late AEs included headaches (psilocybin, MDMA), fatigue, low mood, and anxiety (MDMA). One serious AE occurred during MDMA administration (increase in premature ventricular contractions requiring brief hospitalization); no other AEs required medical intervention. Qualitative studies suggested that psychologically challenging experiences may also be therapeutically beneficial. Except for ayahuasca, a large proportion of patients had prior experience with psychedelic drugs before entering studies. Conclusions AEs are poorly defined in the context of psychedelic treatments and are probably underreported in the literature due to study design (lack of systematic assessment of AEs) and sample selection. Acute challenging experiences may be therapeutically meaningful, but a better understanding of AEs in the context of psychedelic treatments requires systematic and detailed reporting.
... Some subsequent treatment efforts combined the psychedelic experience with empirically validated psychotherapies. For example, researchers have paired psychedelic experiences with mindfulness training (e.g., Payne et al., 2021), or conjoint couples therapy (Wagner et al., 2019). Other research groups point out how psychedelics might decrease the severity of symptoms via the same mechanisms known to underlie empirically supported treatments. ...
Integration therapy, an integral part of psychedelic-assisted treatment, usually includes sessions devoted to making meaning of relevant psychedelic experiences after subjective effects have subsided. As the psychedelic renaissance continues, offers for this integration therapy have proliferated. In the present project, semi-structured interviews with 30 integration therapists focused on definitions of integration as well as challenges and concerns that they associated with the practice. A mixed-methods approach revealed 19 themes that coders identified reliably. Prevalent themes included expressing concern about nonresponsive clients, defining integration as a bridge between the psychedelic experience and daily life, and apprehensions about the commercialization of psychedelic psychotherapy. Interviewees viewed integration as a process that begins prior to the administration of substances, never ends, makes sense of the psychoactive experience, creates behavioral change, is personalized, and makes the individual whole. Most participants also discussed issues related to client resistance, unrealistic expectations of psychedelic psychotherapy, problems associated with power differentials, the importance of an integration therapist’s connection to other service providers, and the need for self-care. These data might help the standardization of integration therapy, inform lay impressions of the process, and help generate hypotheses for continued research on this aspect of psychedelic-assisted treatment. These data also suggest that psychedelic integration practitioners would appreciate regular support from a community of like-minded colleagues.
... There are reported exceptions to this approach. In a study by Wagner et al. (2019) clients alternated between spending time focused inside and time focused outside without headphones and eyeshades spend in conversation with their partner or therapists. In theory, all models for SAPT may allow for an incorporation of a variety of different schools of psychotherapy. ...
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The present narrative review is the first in a series of reviews about the appropriate conduct in substance-assisted psychotherapy (SAPT). It outlines a current perspective onpreconditions and theoretical knowledge that have been identified as valuable in the literaturefor appropriate therapeutic conduct in SAPT. In this context, considerations regarding ethics and the spiritual emphasis of the therapeutic approaches are discussed. Further, current methods, models, and concepts of psychological mechanism of action and therapeutic effects of SAPT are summarized, and similarities between models, approaches, and potential mediators for therapeutic effects are outlined. It is argued that a critical assessment of the literature might indicate that the therapeutic effect of SAPT may be mediated by intra- and interpersonal variables within the therapeutic context rather than specific therapeutic models per se. The review provides a basis for the development and adaptation of future investigations, therapeutic models, training programs for therapists, and those interested in the therapeutic potential of SAPT. Limitations and future directions for research are discussed.
Posttraumatic stress disorder (PTSD) can develop after exposure to a traumatic event and impacts roughly 5–8% of trauma-exposed individuals. Individuals with PTSD develop distressing intrusions, trauma-related avoidance, alterations in mood and cognition, and hyperarousal. There are both social and neurobiological factors that appear to confer risk for PTSD. There are high rates of psychiatric comorbidity, particularly with respect to mood disorders and substance use disorders. PTSD is associated with significant functional impairment and is likely to persist when untreated. Cognitive-behavioral psychotherapies, specifically prolonged exposure and cognitive processing therapy, have the most research supporting their use as frontline treatments for PTSD. Although effect sizes are not as robust as with psychotherapy, some of the selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) medications are associated with benefits. Psychological debriefing methods are not recommended for the treatment of PTSD. With successful treatment, PTSD can remit, and individuals return to their premorbid level of functioning.KeywordsPosttraumatic stress disorderTraumaCognitive-behavioral therapyProlonged exposureCognitive processing therapy
In this thesis, the author investigates the therapeutic potential of psychedelics through literature analysis. First, he places psychedelics in a historical context and presents the current legal regime. Through the presentation of the psychedelic experience through aspects of safety, physiological effects, neurobiological effects and psychological effects, the author answers the question of how, if at all, psychedelics work in combination with psychotherapy. In the discussion, the author notes that psychedelics: (a) create new connections between different centers in the brain; (b) release high-level beliefs of the default brain network, (c) reduce normal ego functions, (d) enhance feelings of connection with others, nature and self and lead from avoidance of emotions to acceptance; (e) affect the personality structure.
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Modern clinical research on psychedelics is generating interesting outcomes in a wide array of clinical conditions when psychedelic-assisted psychotherapy is delivered to appropriately screened participants and in controlled settings. Still, a number of patients relapse or are less responsive to such treatments. Individual and contextual factors (i.e., set and setting) seem to play a role in shaping the psychedelic experience and in determining clinical outcomes. These findings, coupled with data from literature on the effectiveness of psychotherapy, frame the therapeutic context as a potential moderator of clinical efficacy, highlighting the need to investigate how to functionally employ environmental and relational factors. In this review, we performed a structured search through two databases (i.e., PubMed/Medline and Scopus) to identify records of clinical studies on psychedelics which used and described a structured associated psychotherapeutic intervention. The aim is to construct a picture of what models of psychedelic-assisted psychotherapy are currently adopted in clinical research and to report on their clinical outcomes. Ad-hoc and adapted therapeutic methods were identified. Common principles, points of divergence and future directions are highlighted and discussed with special attention toward therapeutic stance, degree of directiveness and the potential suggestive effects of information provided to patients.
MDMA (±3,4-methylenedioxymethamphetamine)-assisted therapy (MDMA-AT) was shown in previous clinical trials to have promising efficacy and safety for alleviating treatment-resistant posttraumatic stress disorder (PTSD). However, due to low ethnoracial diversity, the question remains as to whether ethnoracial minority participants would benefit similarly. Thus, a mixed-methods case study was conducted on a participant of color from an open-label trial of MDMA-AT for PTSD to provide a culturally informed lens on symptom recovery with this treatment approach. An additional aim was to elucidate mechanisms of change underlying this treatment for the participant. A case profile was provided, documenting quantitative improvement in PTSD symptoms. This was followed by an interpretative phenomenological analysis (IPA) of effects and mechanisms of action for this participant, based on integration session transcripts. Results of IPA indicated recurrent themes related to psychological mechanisms of symptom change, reduced PTSD symptoms, and additional effects (positive and negative) beyond PTSD symptom reduction. These themes were discussed and recommendations for attuning to culturally relevant material during MDMA-AT were provided.
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Background: Post-traumatic stress disorder (PTSD) is prevalent in military personnel and first responders, many of whom do not respond to currently available treatments. This study aimed to assess the efficacy and safety of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for treating chronic PTSD in this population. Methods: We did a randomised, double-blind, dose-response, phase 2 trial at an outpatient psychiatric clinic in the USA. We included service personnel who were 18 years or older, with chronic PTSD duration of 6 months or more, and who had a Clinician-Administered PTSD Scale (CAPS-IV) total score of 50 or greater. Using a web-based randomisation system, we randomly assigned participants (1:1:2) to three different dose groups of MDMA plus psychotherapy: 30 mg (active control), 75 mg, or 125 mg. We masked investigators, independent outcome raters, and participants until after the primary endpoint. MDMA was administered orally in two 8-h sessions with concomitant manualised psychotherapy. The primary outcome was mean change in CAPS-IV total score from baseline to 1 month after the second experimental session. Participants in the 30 mg and 75 mg groups subsequently underwent three 100-125 mg MDMA-assisted psychotherapy sessions in an open-label crossover, and all participants were assessed 12 months after the last MDMA session. Safety was monitored through adverse events, spontaneously reported expected reactions, vital signs, and suicidal ideation and behaviour. This study is registered with, number NCT01211405. Findings: Between Nov 10, 2010, and Jan 29, 2015, 26 veterans and first responders met eligibility criteria and were randomly assigned to receive 30 mg (n=7), 75 mg (n=7), or 125 mg (n=12) of MDMA plus psychotherapy. At the primary endpoint, the 75 mg and 125 mg groups had significantly greater decreases in PTSD symptom severity (mean change CAPS-IV total scores of -58·3 [SD 9·8] and -44·3 [28·7]; p=0·001) than the 30 mg group (-11·4 [12·7]). Compared with the 30 mg group, Cohen's d effect sizes were large: 2·8 (95% CI 1·19-4·39) for the 75 mg group and 1·1 (0·04-2·08) for the 125 mg group. In the open-label crossover with full-dose MDMA (100-125 mg), PTSD symptom severity significantly decreased in the group that had previously received 30 mg (p=0·01), whereas no further significant decreases were observed in the group that previously achieved a large response after 75 mg doses in the blinded segment (p=0·81). PTSD symptoms were significantly reduced at the 12-month follow-up compared with baseline after all groups had full-dose MDMA (mean CAPS-IV total score of 38·8 [SD 28·1] vs 87·1 [16·1]; p<0·0001). 85 adverse events were reported by 20 participants. Of these adverse events, four (5%) were serious: three were deemed unrelated and one possibly related to study drug treatment. Interpretation: Active doses (75 mg and 125 mg) of MDMA with adjunctive psychotherapy in a controlled setting were effective and well tolerated in reducing PTSD symptoms in veterans and first responders. Funding: Multidisciplinary Association for Psychedelic Studies.
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MDMA-assisted psychotherapy for treatment of PTSD has recently progressed to Phase 3 clinical trials and received Breakthrough Therapy designation by the FDA. MDMA used as an adjunct during psychotherapy sessions has demonstrated effectiveness and acceptable safety in reducing PTSD symptoms in Phase 2 trials, with durable remission of PTSD diagnosis in 68% of participants. The underlying psychological and neurological mechanisms for the robust effects in mitigating PTSD are being investigated in animal models and in studies of healthy volunteers. This review explores the potential role of memory reconsolidation and fear extinction during MDMA-assisted psychotherapy. MDMA enhances release of monoamines (serotonin, norepinephrine, dopamine), hormones (oxytocin, cortisol), and other downstream signaling molecules (BDNF) to dynamically modulate emotional memory circuits. By reducing activation in brain regions implicated in the expression of fear- and anxiety-related behaviors, namely the amygdala and insula, and increasing connectivity between the amygdala and hippocampus, MDMA may allow for reprocessing of traumatic memories and emotional engagement with therapeutic processes. Based on the pharmacology of MDMA and the available translational literature of memory reconsolidation, fear learning, and PTSD, this review suggests a neurobiological rationale to explain, at least in part, the large effect sizes demonstrated for MDMA in treating PTSD.
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Associations between PTSD and difficulties in intimate relationships have prompted national calls for partner-involvement in treatment for PTSD. However, research is limited evaluating patient preferences for the format of these services or predictors of these preferences. Such information is vital to shaping services so they are relevant to those most interested in them and to those with greatest need. To address these gaps, we surveyed 185 coupled veterans as they presented for mental health appointments at a VA PTSD treatment clinic. We assessed broad interest in greater partner-involvement, specific interest in couple therapy, and potential predictors of these interests, including family concerns, relationship satisfaction, PTSD symptom severity, and combat era. We found unique positive associations between interest in partner-involvement and both family concerns and relationship satisfaction, suggesting those most interested in partner-involvement are likely those experiencing the greatest family concerns and the most satisfied in their intimate relationships. Associations between interest and PTSD severity were nonsignificant. Interest in couple therapy was significantly greater among returning veterans than Vietnam/Korean War Veterans. However, these two groups did not vary significantly in their interest in greater partner-involvement more broadly. Discussion of findings considers the roles of both insight into PTSD-related family problems and relationship satisfaction in motivating interest in partner-involvement in care, the potential need to address motivation for partner-involvement among veterans in distressed relationships, and the importance of alternative methods of partner-involvement to full courses of couple therapy, particularly for Vietnam/Korean War era veterans. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
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The present study aimed at investigating the effect of MDMA on measures of empathy and social interaction, and the roles of oxytocin and the 5-HT1A receptor in these effects. The design was placebo-controlled within-subject with 4 treatment conditions: MDMA (75 mg), with or without pindolol (20 mg), oxytocin nasal spray (40 IU+16 IU) or placebo. Participants were 20 healthy poly-drug MDMA users, aged between 18–26 years. Cognitive and emotional empathy were assessed by means of the Reading the Mind in the Eyes Test and the Multifaceted Empathy Test. Social interaction, defined as trust and reciprocity, was assessed by means of a Trust Game and a Social Ball Tossing Game. Results showed that MDMA selectively affected emotional empathy and left cognitive empathy, trust and reciprocity unaffected. When combined with pindolol, these effects remained unchanged. Oxytocin did not affect measures of empathy and social interaction. Changes in emotional empathy were not related to oxytocin plasma levels. It was concluded that MDMA (75 mg) selectively enhances emotional empathy in humans. While the underlying neurobiological mechanism is still unknown, it is suggested that peripheral oxytocin does not seem to be the main actor in this; potential candidates are the serotonin 2A and the vasopressin 1A receptors. Trial Registration MDMA & PSB NTR 2636
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A number of studies have documented that posttraumatic stress disorder (PTSD) symptoms in “one” partner are negatively associated with their intimate partner's psychological functioning. The present study investigated intimate partners’ mental health outcomes (i.e., depression, anxiety, and anger) in a sample of 40 partners of individuals with PTSD within a randomized waitlist controlled trial of cognitive–behavioral conjoint therapy for PTSD (Monson & Fredman, ). There were no significant differences between active treatment and waitlist in intimate partners’ psychological functioning at posttreatment. Subgroup analyses, however, of partners exhibiting clinical levels of distress at pretreatment on several measures showed reliable and clinically significant improvements in their psychological functioning at posttreatment and no evidence of worsening. Results suggest that cognitive–behavioral conjoint therapy for PTSD may have additional benefits for partners presenting with psychological distress.
This randomized controlled hybrid implementation/effectiveness trial aimed to compare the impact of three different models of training and consultation by examining the PTSD treatment outcomes achieved by therapists who were learning a front-line recommended psychotherapy for posttraumatic stress disorder (PTSD), Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017). Therapists (N = 134) were randomized into one of three conditions after attending a standard CPT training workshop: No Consultation with delayed feedback on CPT fidelity, Standard Consultation involving discussion and conceptualization of cases without session audio review, and Consultation Including Audio Review, which included a review of segments of audiorecorded CPT sessions. Across all training conditions, the patients treated by these therapists (N = 188) evidenced statistically significant reductions in PTSD symptoms, (d = -0.95 to -1.78), comorbid symptoms and functioning (d = -0.27 to -0.51). However, patients of therapists in the Standard Consultation condition (ΔPTSD = - 19.64, d = -1.78) experienced significantly greater improvement than those in the No Consultation condition (ΔPTSD = - 10.54, d = -0.95, ΔDEV = 6.30, ΔParms = 2, p = .043). This study demonstrates that patients who receive evidence-based psychotherapy for PTSD in routine care settings can experience significant symptom improvement. Our findings also suggest that to maximize patient benefit, therapist training should include consultation, but that audio review of sessions during consultation may not be necessary, at least for structured protocols. Implications for implementation, including the reduction of burden and cost of post-workshop support, are discussed.
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.
MDMA (3,4-methylenedioxy-methylamphetamine, a.k.a. "ecstasy") was first synthesized in 1912 and resynthesized more than once for pharmaceutical reasons before it became a popular recreational drug. Partially based on previously overlooked U.S. government documentation, this article reconstructs the early history of MDMA as a recreational drug in the U.S. from 1960 to 1979. According to the literature, MDMA was introduced as a street drug at the end of the 1960s. The first forensic detection of MDMA "on the street" was reported in 1970 in Chicago. It appears that MDMA was first synthesized by underground chemists in search of "legal alternatives" for the closely related and highly sought-after drug MDA, which was scheduled under the Controlled Substances Act (CSA) in 1970. Until 1974, nearly all MDMA street samples seized came from the U.S. Midwest, the first "hot region" of MDMA use. In Canada, MDMA was first detected in 1974 and scheduled in 1976. From 1975 to 1979, MDMA was found in street samples in more than 10 U.S. states, the West Coast becoming the major "hot region" of MDMA use. Recreational use of MDMA spread across the U.S. in the early 1980s, and in 1985 it was scheduled under the CSA.
The following values have no corresponding Zotero field: ID - 47