Thanks to the success of modern medicine, more people are surviving life threatening illnesses (LTIs) than ever before. This also means more people are living with trauma that results from surviving these conditions. Join Dr. Phil Wolfson as he explores the results of an MDMA-assisted clinical trial for people with life threatening illnesses, and how psychedelic therapy could help treat, and even prevent, PTSD-LTI.
Modern medicine is producing a vast and rapidly increasing population of survivors of life threatening illnesses (LTIs) due to its successes. Unfortunately, for many the cost of survival may well be trauma to mind as well as body. From its difficult commencement, the impact on patients may well be harmful–with the shock and life change of diagnosis, the ensuing treatment which may well be arduous and diminishing of capacities both physical and mental, through often long term treatment, and then recovery. The nature of the traumas induced vary in depth, and symptomatology, on spirit and relationships.
Our experience with 18 subjects with life-threatening illnesses who enrolled in an MDMA-assisted clinical trial led us to the conviction that it is essential for prevention of this trauma that beginning with diagnosis of the LTI there be implementation of psychosocial strategies. Support for patients and their dear ones during the course of the illness and its medical treatment extending through the recovery period needs to be provided.
It is just not enough to focus our medical skills on interventions for illness and to leave on the sidelines the impact on the human experience. Our study delineated the breadth and variety of the traumatic reactions which we have defined as a new Post Traumatic Stress Disorder—PTSD-LTI. Delineation of the plethora of symptoms that make for this diagnosis has been described as well as criteria for diagnosis (available from the author).
…we with our subjects were able to have significant impact on their traumatic residues, their fears for relapse and death…
MAPS sponsored our unique Phase 2 study of anxiety as the primary marker for those with LTIs and a life expectancy of at least one year. Based on what may well be the most intensive psychotherapy with subjects who have trauma from life-threatening illnesses (LTI), with MDMA experiences as a fundamental part of the process, we with our subjects were able to have significant impact on their traumatic residues, their fears for relapse and death, and their struggle to make recoveries with full resumption of lives that had moved on—morphed from before their diagnosis and the sudden threat of protracted illnesses and death itself.
MDMA-assisted psychotherapy is a reciprocal process and as much as our subjects responded and changed, so did we as practitioners. In fact, we experienced profound changes in our awareness of illnesses multiplicity of manifestations, the causation and breadth of trauma and our own self concepts.
Over the course of the three years of this intensive and intense study, we experienced a progressive revelation of the traumatic nature of this diagnosis and its aftermath, and its various manifestations in cognition, motivation, affect, spirit, meaning, relationships, and view of self. Exposed to our subjects’ suffering and impacted ways of being and to their tension with potential recurrence of illness and death, we grew to be a unit for exploration and healing.
So many of our sessions were marked by strong emotions and we often experienced a unity with our subjects’ suffering and liberation from it. For the mind, heart and spirit are inseparable and the MDMA experience carries this at its center. There is joy in this work, meaning and connection that is far more possible to achieve in the long and deep sessions of MDMA work.
MDMA-assisted psychotherapy is a reciprocal process and as much as our subjects responded and changed, so did we as practitioners.
While anxiety was our primary marker for enrollment in our program and for measuring its outcome, trauma in its impact on our subjects, was the predominant cause of the suffering they experienced. And while our focus was on the specific causation of the LTI and its aftermath, earlier trauma also was an inevitable part of the work.
We used the STAI Trait measure in conformity with other studies of psychedelic-assisted psychotherapy. But if I were to do it again, and we are in the process of preparing a ketamine-assisted psychotherapy study of LTIs, I would and will pursue using assessments of trauma as the primary measure.
In the best sense of developing clarity about suffering with LTIs (and other forms of suffering) coming to the PTSD-LTI designation continues the expansion of psychology’s reclamation of trauma to its true status as the overwhelming cause of human distress and dysfunction. Sadly, that realization remains incomplete.
Near attitudinal blindness continues to the effects of traumas to humans caused by prejudice and culturally embedded formats–such as racism, sexism, caste, and class that are forms of domination; to war; refugee displacement; poverty and to illness. That myopia remains and limits our evolving view. Prevention of trauma remains the abiding issue for developing a healthy population instead of a wounded population—as per the World Health Organization.
Prevention of trauma remains the abiding issue for developing a healthy population instead of a wounded population.
Our view of trauma from within psychiatric diagnostic categories such as those for depression and anxiety tends to be only partially reflective of lives lived and affected by past and ongoing trauma. Focusing on limiting clusters of symptoms, diagnoses can be constraining conceptual structures that prevent clear views of the complex matrix of existence and the fullness of the expressions of suffering in their myriad aspects.
It is essential to turn to a comprehensive and phenomenological view of suffering–its prolongation beyond the intruding traumas that are immediately afflictive; an awareness of prolonged traumatization; developmental trauma; its diverse expression in diverse beings.
This enables the therapeutic conversations that give forth recognition and validation to trauma victims in need of understanding themselves and for being understood. This does and will engender the conscious connections that are healing in themselves and lead to the alleviation of suffering–to the extent we are able; and to the prospect for better caring of those who have been afflicted with traumas (See Van der Kolk for a full explication of this-–The Body Keeps the Score 2016).
What makes this so appealing has been the demonstration of efficacy in small Phase 2 studies with MDMA in PTSD; with psilocybin for LTIs, and now, ours, the first to test MDMA as a treatment for this indication.
While attention to the experience of those facing death from LTIs has become a more prominent part of palliative care and hospice consciousness and there have come to bear a variety of psychotherapies, it is only in recent years that it has been possible for a resumption of clinical interest in the potential for psychedelic medicines–provided in an assisted psychotherapy format-to address PTSD-LTIs.
What makes this so appealing has been the demonstration of efficacy in small Phase 2 studies with MDMA in PTSD; with psilocybin for LTIs, and now, ours, the first to test MDMA as a treatment for this indication. Prior studies with psilocybin have demonstrated the value of peak experiences on PTSD-LTIs and reduction of anxiety and depression. MDMA as less of a hallucinogen and operating through a variety of means to promote empathic connection to oneself and others, offers a different modality for psychotherapy.
With its wide variety of manifestations, the treatment of PTSD-LTI is an individualized matter. Yet, clusters of concerns emerge from personality, family, history, morality, religiosity, culture, gender, class, ethnicity and more. ‘Taking stock’ as life is threatened is one common path. So too is ‘denial’, even until the very end. So too is the great fear of cessation and non-being. As well as: who we are; who we feel ourselves to have been; peace or dissatisfaction; love or rage; or the mishmash of it all. Confusion is common to us and it comes and goes.
The compassionate non-judgmental work of being a therapist in such a crucible is many sided—moving, frustrating, loving, opening, patient, persevering, available, self-reflective, resonant, orchestrating, social working, family system conscious, and above all respectful of the differentiation of each of us. It relies on assisting in the access to each of our own desires for healing, connection, and realization.
In essence, for PTSD-LTI patients, there is a relatively specific set of treatment outcomes that are desirable and are relevant to the diagnosis. These can be clustered as follows with ratings provided subjectively:
- Did your experience help you with recovery from the emotional effects of being diagnosed and treated for a life-threatening illness?
- Do you feel more vital?
- Are you able to feel more pleasure?
- Do you have a greater sense of peace?
- Did your experience help you to connect and integrate with the important others in your life?
- Did your experience help you with your fears of death and dying?
- Did your experience help you think about and plan for what you consider your remaining life span?
- Have you been able to find and give meaning to your remaining life?
- Do you feel you have made peace with the possibility of having a limited future?
- Have you been held by or found a spiritual or religious path?
- Have you been helped in planning for future treatment options and for your ultimate death?
- Do people in your life notice a difference in you in these ways and other ways?
While the improvements as expressed by the assessment measures used in our study certainly indicate these issues being addressed, it was in the therapeutic work with our subjects over the many days of contact in which these concerns were delineated and assistance rendered. Our study highlights the need for more sensitive measures that reflect the manifestations of PTSD-LTI and allow for assessment of the benefits of treatments for this difficult state.
It also supports the benefit of an intensive psychotherapeutic approach applied within a brief therapy context. The six-month follow-up assessment and psychotherapy session validated the continuing impact of our MDMA-assisted psychotherapy and is in contrast to the usual 8-week evaluative period for antidepressant trials. It argues for the intensity of contact between therapists and subjects as a cost-effective process.
It argues for the intensity of contact between therapists and subjects as a cost-effective process.
MDMA-assisted psychotherapy provides a unique approach to conscious work with patients. With the prolonged sessions that last 6-8 hours, therapists are more available to patients and must present as human beings in greater fullness than in conventional work. Trained to be cautions of countertransference and working dyadically, interaction is more alive and fruitful. The therapeutic crucible is based on the reality testing that is forthcoming from this contact.
Under MDMA’s particular influence, an open mind ensues with the possibility of letting go of persistent traumatic embedded attitudes caused by the LTI impact. While MDMA is not significantly hallucinogenic, it is powerfully trance and reverie inducing.
Mind moves in both recollection and imagination and is freed from its usual constraints and inhibitions. It opens the floodgate of compassion for self and others and suffering is realized, contextualized and expressed. By reducing the alarm system’s traumatically induced hypervigilance and self-protective mechanisms, MDMA balanced with the presence of therapists and the nest that has been constructed with its down lining of the assurance of safety—unlocks the fear-shut awareness of suffering and its causes. The ensuing rush of the spring waters of healing and balancing anew gush forth.
Each person, in their particular idiosyncratic fashion, may well experience the restructuring of self and an awakening of view leading down new paths and resulting in the ripening of the fruit of new life. As if there has been an inherent internal force awaiting its liberation, its resumption of being the guide to life lived ethically and passionately, creatively and in connection.
Rarely do psychiatrists and therapists write or speak of the exhilaration of having the opportunity to work intensively with their patients. The success of our study is reflected in the deeply moving experience of working with our subjects as well as in the outcome measures.
To succeed in psychotherapy, therapists must find compassion, respect and understanding for their patients—at least to some extent. MDMA-assisted psychotherapy brought us into intimate contact with the deepest of life’s struggles. While maintaining a therapeutic stance, we also participated in the intimacy of a shared human experience that touches us all.
MDMA-assisted psychotherapy has this particular nature to it. It does not work in this manner for everyone—no therapy is universally successful or applicable to all the ways in which humans are dilemma-d. So, as we build the psychedelic psychotherapy toolbox, our potential for administering a broader range of experiences adds to our hopeful success rate in alleviating and ameliorating suffering.
The work with psilocybin for LTIs has demonstrated its utility in providing a hallucinogenic experience that benefits those suffering with PTSD-LTI. This occurs with a different therapeutic construction that is deeply experiential in its inner liberation, and not primarily of a psycholytic nature as is the case with MDMA. The nest is built, the therapeutic relationship is supportive and the experience/experiencer interaction does the liberating rectification relying on the ‘mystical experience’ of the journey. This is the elegantly performed process initiated decades ago with mushrooms and LSD.
Ketamine-assisted psychotherapy available as presently the only legal psychedelic is of yet another nature. It can be psycholytically applied at low doses that reduce defensiveness and create access somewhat in the same vein as MDMA, or with more robust doses creating a time-out from ordinary mind, ego dissolution and access to realities of new construction.
Freed from obsessions, daily concerns and debilitating moods, the journey is liberating and on return enables a reconstruction of self and the recognition that not all is suffering, despair and inevitable. Ketamine is a profound hallucinogen which when embedded in its particular format for therapeutic work is beneficial for all sorts of human predicaments. And marijuana deserves its place and the practice of marijuana-assisted psychotherapy is growing and as it is legal now in most states can be amalgamated with ketamine or stand on its own.
All psychedelics tend to move a person into a spaciousness of mind that is meditative in nature given our separation from constraints, usual attitudes and prejudices.
The intent of all psychedelic psychotherapies is to result in a reduction of out mental attachments and enable freedom to explore our lives without being so encumbered. All psychedelics tend to move a person into a spaciousness of mind that is meditative in nature given our separation from constraints, usual attitudes and prejudices.
Psychedelic experiences tend to enhance one’s ability to imagine, be fresh and creative. Integrated with daily practices and the active realization of our connectedness to all things and all beings, they tend to bring a person closer to each other and ourselves for lives lived in gratitude, sharing, love and community. It is up to us to realize their potential as we build our practices and learn the potentialities for the therapeutic application of psychedelic medicines.
In the psychedelic gladiator’s arena, confusion arises. A tendency to extol the virtues and superiority of one medicine over another conforms to the ‘ownership’ of the psychedelic pharma development of their uses for prescription. Money, fame, and first to the finish line motivation all create mystification.
In fact, all psychedelic medicines have potential for broad effects and broad applications. Head-to-head studies may occur but seem frivolous. The realms for the therapeutic applications of our medicines as they become available are nurtured by our understanding of our patients, their particularities, personalities and struggles and our knowledge of the best practices and the therapeutic prospects emerging form our work together. This is the best way to proceed!