MDMA therapy: certain things you might want to know
an unofficial primer on risks, protocols, and some other stuff
When it goes well, MDMA therapy can go extremely well. Those who benefit from it tend to go screaming from the rooftops about how it changed their entire life. I am, fortunately, a member of this population, and, indeed, I’ve written about it a few times.
Since writing these articles, I’ve started getting a lot of questions about MDMA therapy. Questions like: what exactly does one do while on MDMA, and how should you prepare? And what are the risks?
And I haven’t found a document that adequately covers these questions. Specifically, I have trouble with the fact that most resources seem to skew relentlessly positive, or mostly negative—they tout MDMA as a perfect drug or vilify it as dangerous. Both of these perspectives are incomplete.
The truth is that MDMA can provide revelatory experiences, but it can also traumatize you. It’s less harmful than many drugs our society ingests, but it’s still not harmless. It can be incredibly effective therapeutically, but the wrong setting or the wrong protocol can make it unproductive, or even counterproductive.
So I decided to write this document myself.
The below text is drawn from discussions with a few therapists/guides who work with MDMA, many anecdotes I’ve read, literature on psychedelic therapy, and my own personal experience. So it’s not just my unsubstantiated blabbering. But please note that I’m not a therapist or a doctor myself. This is intended to be the beginning of your research or a supplement to it—certainly not the only thing you should read. You should do a lot of reading about any new drug before you decide to do it, and, for the love of God, test your stuff.
I write a paragraph like the previous one in everything I write about MDMA, and some people seem not to read it. Make sure that you read it.
Also, note that this guide doesn’t cover MDMA couples therapy, or group experiences—I don’t have as much experience with those facets, and judged them to exceed the scope of this post.
Finally: this is not medical advice or an endorsement of illegal activity. MDMA will be decriminalized/legal soon, but it isn’t as of press time.
For the sake of deflating the hype and establishing realistic expectations, let’s talk about the risks first, and then I’ll move on to advice about preparatory work and protocols.
What can go wrong
Neurotoxicity and psychosis
MDMA, like alcohol, is somewhat neurotoxic, and, very rarely, causes psychosis. Let’s talk about neurotoxicity first.
I am not an expert on MDMA neurotoxicity. If you want the expert opinion, see this document, and, for a general take on harm reduction, this is a solid resource.
The basic high-level take is that it can be hard on the system. Subjectively, one can feel this: after an MDMA trip, you are typically physically and mentally somewhat taxed, even if the trip has gone fantastically. (Some people report feeling few-to-no physical effects if they get good sleep, take supplements, and eat healthily—I, myself, find these steps mitigate the comedown, but don’t stop it from happening entirely.)
What’s not clear is whether occasional therapeutic use is likely to cause any real damage, like, more damage than an occasional night of drinking. One person I know who I consider an expert on this—and who places an unusual emphasis on retaining all of his IQ points—has said that he wouldn’t recommend doing more than three MDMA trips in a year, and probably wouldn’t do more than twenty in a lifetime.
Complicating this further: there appears to be a great deal of individual variance here. Observation reveals that MDMA is much physically harder on some people than others, and, at present, there’s no way to predict this in advance.
Now, for the psychosis part. Very rarely, people who take MDMA have psychotic symptoms. These can last for hours, or months.
That’s about all I can tell you. I would like to give you more detail on exactly what “very rarely” means, but this data is really hard to get—it’s rare enough that it hasn’t really occurred in clinical trials, and there aren’t enough documented cases to get a sense of what the risk factors are. This 2001 paper, for example, claims that there were twelve documented cases of acute psychosis in the medical literature at that time—which, given how many people do MDMA, seems minuscule. But how many cases go undocumented? Out of how many users exactly? Is there a particular dose at which psychosis is more likely? We do not know these things.
It is even possible, given the rarity of these episodes, and MDMA’s promising clinical results, that MDMA is protective against psychosis, while at the same time occasionally triggering it in those especially vulnerable. (Thank you to Milan Cvitkovic for pointing this out.) After all, the prevalence of lifetime psychotic experiences in the general American population seems to be around 5.8%, making it more common than you'd think. Additionally, there has been some evidence that MDMA can be used to treat the negative symptoms of schizophrenia.
Perhaps the precautions that apply to most psychedelics apply here: it is plausible that MDMA is riskier if you are currently mentally unstable, or your family has a history of instability. But there’s not enough evidence to fully support even that minimal hypothesis.
More sensitization than healing
MDMA inclines you towards a state of love, openness, and forgiveness. This does two things at once. First, it allows you to look at parts of your life and personality that are usually too painful or awkward to consider. Second, it allows you to heal those painful aspects of your history by “painting” them with this positive, loving energy.
However, sometimes, the “surfacing” part can outpace the “healing” part. Sometimes you dig up painful memories that are so unexpected, and so powerful, that they overwhelm the positive energy. Or the volume of surfaced memories is such that you end the trip still grappling with baffling data that you haven’t had time to process.
What this looks like: in the midst of the joy of the trip, you are suddenly wracked with sorrow, and are confused about why this lovey-dovey wonderdrug is making you feel awful. Or: you emerge from the trip feeling alright, but, subsequently, you are suddenly buried under an avalanche of previously dormant material.
This isn’t necessarily a failure mode, long term. Such harrowing instances can serve as openings, leading to productive healing processes.
Where this can go wrong is if you expect MDMA to heal you instantly, and don’t plan for prolonged work. Also, significant pain can be caused if you end an MDMA trip in a vulnerable state, in need of care, and you’ve done it in a container that can’t provide this for you. (See the section on containers, below, for more on this.)
One therapist I spoke to, for this reason, never plans for just one MDMA session. They have clients plan for at least two sessions, sometimes interspersed with regular talk therapy sessions for integration purposes, sometimes interspersed with sessions featuring other psychedelic medicines, like psilocybin. It’s worth noting that there is currently no established protocol for using MDMA with other substances; this is an art and not a science, although there are some interesting notes here. (Thank you to Quintin Frerichs for pointing this out and for the link.)
If you judge your trauma to be severe and complex, pay special attention to this—note that one MDMA session can open the wound without closing it, which could have highly disruptive effects on your life, especially in the short term.
In my own work with MDMA, the highest impact came from two sessions separated by a week, using the second to revisit what had come up in the first.
The wrong container
Some people do MDMA with a guide, some people do it solo. In both cases, engineering the right circumstances is necessary for a positive experience.
Let’s talk about guides first.
Recently, one of my Twitter followers posted about a horrifically bad experience they’d had with MDMA, which left them suffering with depression and anxiety for a year. I inquired about this more, and it turned out that they attributed much of it to the guide they worked with, a guide who left at least one other client—that this person knew about—in a state of prolonged distress.
This is a healthy reminder that the psychedelic scene is still the wild west. There are a lot of unskilled “practitioners” out there. And MDMA is a drug that produces a highly plastic and sensitive state, in which much damage can be caused by an unskilled person.
When you evaluate a potential MDMA guide, you should evaluate very carefully. Collect many testimonials. Ask them about their education and protocols. If you get a bad feeling, listen to that. The best person to go with is probably someone with a high level of therapeutic education, official or unofficial.
Sometimes, a friend can serve as an excellent guide. However, if you go this route, make sure that the friend is someone emotionally skilled, who truly has your best interests at heart. Also, be prepared for the possibility that you will tell them a lot of stuff. People on MDMA do not have secrets. (However, Dor Konforty reminds me that this can be a feature, not a bug. Exposing what you thought was a shameful secret or a limiting belief, like “I’m not smart enough to do great work,” or “I’m too messy to receive love,” on MDMA, and receiving love in return, can be exceptionally potent.)
Know, too, that you might feel an unprecedented amount of love for your guide, uncorrelated with their actions, in a way that goes far beyond the usual admiration you might feel for a therapist. This will likely subside after the trip.
As for solo containers: if you choose to do it on your own, I would recommend not actually doing it on your own. Have someone nearby who you trust, either to intervene during the trip if you become distressed or to debrief with afterward. MDMA often gives people the powerful urge to express love, and this combined with complete solitude can be lonely. Also, if you finish the trip in a difficult place, some nonjudgemental consolation can make all the difference. Trauma research has shown that a primary component of traumatization is feeling alone during, or after, the potentially traumatic experience.
One last thing: solo experiences tend to go better in tranquil settings which allow focus. Remove distractions, put your devices away, and clean up. (More on this later.) If you have the means, consider finding a beautiful natural setting for your session. Note, also, that MDMA tends to induce ADHD and a sudden appreciation for the beauty of ambient surroundings—rather than going within, you might be suddenly possessed by the urge to, say, feel every texture in your vicinity. Gently resisting this tendency, and staying with the inner landscape, can result in a much more productive experience.
Underdosing or overdosing
Too small a dose and MDMA will just make you feel uncomfortably high without producing much emotional well-being. Too big a dose and MDMA will be too “druggy” an experience to enable introspection, complete with lockjaw and shaky eyes. Neither is necessarily disastrous, but a too-high dose is probably more destructive, given that higher doses are more physiologically taxing.
It might be worth experimenting with a dose that’s on the low-to-medium end for your body weight, and, if it’s not feeling emotionally protective, skipping the therapy and subsequently trying a slightly higher dose.
For dosing information, see here for a rough guide, and here for the MAPS (Multidisciplinary Association for Psychedelic Studies) dosing protocol.
Find healing techniques that work for you beforehand
One reason that my MDMA therapy went spectacularly well, I think, is because I was already equipped with a number of self-therapy tools. I had done months of loving-kindness meditation, as well as self-dialogue in the mode of Internal Family Systems. After this work, I felt equipped with a blend of techniques for dealing with difficult emotions and memories, and I knew what it felt like when I was making progress, and this all helped during my MDMA experience.
This is not necessarily an endorsement of loving-kindness or Internal Family Systems as the go-to MDMA tricks, although they’re worth investigating. Throughout my informal research into MDMA, I’ve encountered a huge number of healing modalities that have worked for people.
Visualizing themselves, or imagining themselves, comforting a younger version of themselves in difficult previous circumstances (as in this account of a guided session)
Replaying difficult conversations from their life and “annotating” them with MDMA-mind
Core Transformation, a fascinating modality that generates positive feelings with the assistance of scared parts of the self
Attempting to forgive people that had caused them pain, and trying to see their perspective (here is a nice meditation script)
Simply talking to themselves about their life narrative and why they relate to the world as they do
Projecting vast amounts of the felt sense of love inwards with loving-kindness meditation, or visualizing themselves in a loving way
Specifically for attachment issues, Ideal Parent Figure protocol, in which you imagine the loving guidance of an ideal caregiver
The diversity of this list should indicate that many options are possible. Now, it is plausible that some protocols are more effective than others, period. But, unfortunately, it is really hard to run MDMA trials right now from a legal perspective, so there’s not as much data about relative efficacy as there should be.
The category of “healing techniques” also includes peer-to-peer techniques. If you have a therapist or coach who’s worked wonders in your life, consider asking them if they’d supervise an MDMA session—I know a few mental health professionals who don’t offer psychedelic interventions but will sit in on them upon discreet request.
For a couple of people I’ve talked to, MDMA has “driven itself,” which is to say, the drug provoked a sudden intuitive understanding of how to go about the self-healing process. This seems to be a fortunate occurrence that predicts positive outcomes. However, this doesn’t mean you shouldn’t prepare; in my case, and in many other cases I’m aware of, diligent preparation has led to the best results.
Prepare to be surprised
MDMA therapy sessions often go in unexpected directions. It’s almost as if the drug wants you to look at memories you might have forgotten about entirely, or dismissed as unimportant. This is surprising when it happens, but not all that surprising as a phenomenon, if you think about it. One of the effects of MDMA is to loosen our hangups, and our hangups are a part of our ego structure, and our ego structure determines which memories we deem important. (Thank you to Mark Estefanos for this insight.)
For example, during my most pivotal session, a lot of the memories I revisited took place in a weird part of my 20s that I didn’t think of as traumatic stuff—but it turns out that revisiting this era was highly important. (An important component of repression is unconsciously dismissing the importance of impactful memories.)
Another example: someone I know got huge therapeutic benefits from revisiting a brief memory of being mocked for telling an ill-timed joke—and this is a person who had been through a lot worse, in absolute terms.
One weird thing about the human psyche is that, sometimes, memories of small struggles can become inner exemplars of much broader personal issues. For example, a memory of someone mocking your physical appearance can become an anchor for years of body insecurity. This creates a therapeutic opportunity: those memories can serve as threads to pull on, revealing the buried material underneath.
So, while preparation and agenda are important, it’s also important to be open-minded. Have an intention, but hold it lightly. Try not to dismiss any part of your personal history that comes up.
Moderate your expectations and mindset
I’ve noticed something in common among a few acquaintances who have had challenging experiences. They went in with a mindset of “this will cure me instantly and then I’ll never have to deal with my shit again.” This mindset is naive, but that’s not the biggest problem with it. The biggest problem is that this is a form of self-contempt.
Consider two ways you could view a person in distress.
They just need to get over it! Haven’t they hurt themselves enough? It’s obvious what their issues are, can’t they just snap out of it, or do more drugs to resolve it?
Healing takes time. I hope this person gets over their shit quickly, but if they don’t, that’s okay––personal issues are complicated and multilayered, often built deep into the structure of who we are, and inseparable from our virtues. Moreover, the healing process can be an enriching part of life, something to explore for its own sake.
The latter is much more compassionate, flexible, and nuanced. Now, I am aware that not a problem-free viewpoint: a few people develop what could be called a “healing addiction,” where their identity becomes anchored in the notion that they will inevitably suffer. But I think this is rarer than the other problem, which is viewing the less happy parts of you like obstinate children who just won’t do their homework.
Additionally, an “it’s time to cure myself instantly” attitude will probably lead you to approach the session hurriedly, rather than with an open, exploratory mindset. Remember that even on MDMA, confronting every single one of your agonies in an afternoon is unlikely to be pleasant or productive.
Be intentional about your container
I went into this in some detail above, but this really bears repeating. Get your container right, and remember that “right” is whatever makes you comfortable, however strange or silly that might seem to someone else. Devote some time and resources to this. Your return on investment here could be the difference between a “meh” experience, and a life-changing experience.
Solo, or not solo?
I expected that the therapists I spoke to would all advocate supervised work. I was wrong! They unanimously opined that both can be great and are best viewed as fundamentally different experiences, rather than rival options.
Here are two incomplete lists of what I see as the benefits of these two approaches.
A good guide can:
Stop you from taking on too much trauma too quickly
Provide steerage and guidance to maximize the experience
Serve as an outlet for feelings of love and exuberance
Take thorough notes on the session and provide perspective, ensuring the experience has enduring worth
Doing it alone can:
Lead to more comprehensive results, given the depth and speed of communication enabled by self-to-self telepathy
Be freer of distraction, allowing more space to travel to deeper inner waters
Be a more potent conduit for transcendent/spiritual experience, given the psychoactive potential of solitude
Only you can decide which is appropriate. However, personally, I think it’s plausible that if you’re not experienced with MDMA, guidance will be especially helpful, whereas if you have experience with self-therapy and inner work and have already done MDMA, solo or semi-solo experiences are likelier to be of maximum benefit. But your mileage may, of course, vary.
Make notes and recordings, but stay off devices
A common side effect of MDMA is that it will make you want to hop on your phone and text everyone that you love them. Another common side effect is that it will make you want to listen to all of your favorite music, or discover that European techno finally makes sense. And, while a well-chosen song can have potent therapeutic power, and a well-curated playlist can be a great accompaniment for some people, it’s probably the case that spending all your time clicking around on Spotify will have diminishing returns.
Thus, it’s prudent to avoid digital distractions. At the same time, many people find that their memory is inhibited during MDMA use, so it’s good to make notes—I’d just recommend keeping them analog, or, if using a device, pre-committing to staying offline. A sticky note on your laptop saying “you’re high, stay off the internet” could be a boon.
Don’t make life decisions or sudden confessions
I have encountered MDMA enthusiasts who regard being on MDMA as synonymous with being enlightened. And it is true that, when a trip is going well, the state of mind induced can be lovely. However, you’re unfortunately going to have to spend most of your life in a less radically affectionate state of mind, and so is everyone else.
So: don’t make commitments or unusual communicative decisions in this highly abnormal state. This might seem like the time to buy plane tickets to Morocco, or quit your awful job, or tell your ex-girlfriend about why you valued her so much. You might be right, but if so, that will probably still be clear when you revisit these opinions in a week.
Treat yourself gently after
It is rumored that the day after MDMA always sucks, is always bleak and depressing. But the truth is that aftereffects are varied, and dependent on personality, genetics, context, dose, and probably a dozen other factors.
Personally, I’ve had some day-afters that were enjoyable and some that were crushingly difficult. After my most successful trip, I felt unburdened, clear, and overjoyed, although a little exhausted. Meanwhile, the day after an ill-advised MDMA experience, I temporarily stopped being able to experience human faces as beautiful, and I have no idea why this was.
In saying that, there are some outcomes that are general enough to be remarked upon here.
The day after is typically less thrilling than the trip and is typically a time of sensitivity. Plan to take care of yourself, and to not be “on it” socially or career-wise. This might be a time for journaling and reflection, but also, a time for a cheesy feel-good movie, or a satisfying, heavy meal, or the least demanding human company you can find. (Or animal company: a friendly cat will probably have a good sense of what you need.)
This isn’t just for the sake of your near-term happiness. Anecdotally, it seems that the plasticity induced by MDMA (and other psychedelics) extends beyond the high itself. The integration starts right away, and a successful integration can either make a great experience stick or make a difficult experience more easily processed.
One acquaintance of mine who has had great results with MDMA opines that 25% of the results come from the preparation, 50% come from the trip itself, and 25% come from the integration period, and that people get inferior results because they think that the trip itself is everything.
I think it’s most helpful and realistic to view MDMA as an incredibly powerful tool with significant flaws and limitations. If you struggle with depression, self-constriction, self-contempt, or anxiety, it can be an important component of a complete healing process. However, it is not necessarily the best tool for you in particular, and it may be strongly contraindicated by your circumstances.
Remember that many people have healed their misery without MDMA: don’t think that this drug is your one opportunity to be okay again.
It’s also worth knowing that better times are coming. When MDMA is legalized/decriminalized, greater frequency of use will lead to more knowledge about how to apply this drug well, and it will be easier to access both MDMA and therapists who work with it.
Excitingly, a number of people I know are working on MDMA equivalents with fewer side effects, less neurotoxicity, et cetera. Based on information I’ve collected from them directly, these drugs are already quite promising, and will likely hit the market within a decade. If you’re nervous about the downsides of MDMA, know that this is reasonable, and also know that an even better drug could be available soon.
Thank you to Nick Cammarata, Quintin Frerichs, Dor Konforty, and Mark Estefanos for your help with this piece.
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Thanks for sharing Sasha.
One thing that gets missed or, at best, glossed over in most of the research and literature on therapeutic use of psychedelics/MDMA is that the folks who need it most are often on really powerful psychoactive drugs - usually SSRIs. These drugs of course cause major neurochemical adaptations that mess with the mechanisms of psilocybin, LSD, MDMA, etc, which renders a lot of the research and anecdotal accounts on therapeutic modalities and outcomes irrelevant. As someone who has been on SSRIs for a long time, I've noticed that I end up ignoring most discussions around these kinds of therapies because I feel like I'm 'ineligible'.
With all that said: have you read or heard anything about long-term SSRI users and MDMA therapy?
One of the best long-form things I've ever read on MDMA. Bravo, Sasha!!! I'm still working on finding the "best" interweaving of IFS and MDMA for myself and for others. It's a lovely space to be in, with so much potential.