PSYCHEDELIC ASSISTED COUPLE THERAPY: �A JOURNEY TO DEEPER INTIMACY AND HEALING�ALAN GROVEMAN, PH.D., ABPP��

LEARNING OBJECTIVES

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1) Describe three areas of the brain that MDMA impacts.�2) Discuss four recent research articles that support MDMA for psychedelic assisted couple therapy�3) List six risks that need to be addressed when using MDMA in psychedelic assisted couple therapy�

Psychedelics and Couple Therapy

Ketamine (legal)

• Ketamine’s precise mechanisms are still being explored, but theories suggest it increases neuroplasticity, dopamine, and serotonin, and alters brain connectivity (Aleksandrova & Phillips, 2021) to promote more flexible thinking, greater perspective taking, empathy, openness to experience, and reduced avoidance. These cognitive, emotional, and behavioral shifts are important for moving through relationship pain, creating new patterns, and building healthy connections. Indeed, across different couple therapy approaches, the primary goals typically include identifying harmful patterns, increasing understanding and empathy, and improving communication in order to build closer and more fulfilling intimate connections.

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PSYCHEDELICS AND COUPLE THERAPY

Psilocybin (legal) Oregon and Colorado

• One preliminary theme that has been found in many of these studies is that psilocybin can increase the user’s empathy and acceptance (Griffiths et al., 2011; Grob et al., 2011; Lerner & Lyvers, 2004; Lerner & Lyvers, 2006; Lyvers & Meester, 2012; Maclean et al., 2011). Both empathy and acceptance have also been found to be key features of relationship satisfaction.

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MDMA – Not legal in any state

One of the common problems that couples identify is Lack of Communication.

We will examine how MDMA impacts empathy, communication, perceptions of social connection and support, non-avoidance, openness, attachment and safety.

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History of MDMA

• One of the most common misconceptions is that in 1912 the substance was synthesized with the goal of creating an anorectic but was not marketed by Merck because of side effects. 
• The man responsible for the modern research of MDMA is Alexander Shulgin, who after graduating from the University of California at Berkeley with a Ph.D. in Biochemistry landed a job as a research chemist with Dow Chemicals. Among his many achievements for Dow Chemicals were one profitable insecticide and several controversial patents for what were to become popular street drugs. Dow was happy with the insecticide, but Shulgin’s other projects created a parting of the way between the biochemist and the chemical company. Alexander Shulgin is also the first reported human to use MDMA and is often referred to as the Godfather of Psychedelics

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History of MDMA

• 1990 Shulgin and his wife, Ann published PHKAL - “Phenethylamines I Have Known and Loved”
• The book has two parts
• a) Love Story - Fictional love story
• b) Chemical Story - Detailed instructions for, and effects of, the synthesis of 179 psychedelic phenethylamines, which were mostly discovered by Shulgin himself. For each substance there is information on its synthesis, suggested effective dosage, duration, and detailed commentary on the subjective effects that were experienced.

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MDMA AND THE BRAIN

1. MDMA (3,4-methylenedioxymethamphetamine) increases the release and prevents reuptake of serotonin, norepinephrine, and dopamine (Liechti and Vollenweider, 2001; Farré et al., 2004; Hysek et al., 2011; Bershad et al., 2016).

2. MDMA elevates serum oxytocin (Wolff et al., 2006; Dumont et al., 2009) and vasopressin (Bershad et al., 2016) Both men and women naturally produce vasopressin. It has an important impact on sexual function for both genders, according to research, although men may experience its effects more strongly because of how it interacts with the male sex hormone testosterone.

3. MDMA causes a decrease in cerebral blood flow to the amygdala and hippocampus, an increase in activity in the prefrontal cortex, action in the occipital cortex and insula, and a decrease in functional connectivity between the hippocampus and prefrontal cortex, and an increase between the hippocampus and amygdala (Gamma et al., 2000; Phelps et al.,

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MDMA AND THE BRAIN

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MDMA AND THE BRAIN

Because of its empathogenic properties, MDMA is a great option to be used as a 

psychotherapy adjunct. 

The brain regions most affected by love are the amygdala (registering threat, 

and fear), prefrontal cortex (related to reasoning), hippocampus

 (engagement with thoughts and memories), caudate nucleus (registering love),

 and hypothalamus (registering lust). The hormones and neurotransmitters 

most closely associated with the experience of love are oxytocin and 

vasopressin (linking to attachment and bonding), dopamine, and serotonin (causing 

pleasure and positive mood) (e.g., Zeki, 2007; Fisher et al., 2010).

MDMA AND THE BRAIN

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MDMA - Psychological Effects

• Acceptance of self and others.
• Empathy.
• Tolerance of emotionally upsetting materials- Ability to address upsetting material without extreme disorientation·
• Ease of cognition

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Protocol for MDMA Assisted Couple Therapy

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Active doses of MDMA (75–125 mg)

Informed Consent

How Long Does MDMA Stay in Your System?

• Onset: After taking ecstasy, effects can begin to be felt within 30 minutes to an hour
• Peak: The peak of the experience, where the effects are most intense, typically occurs around 2 to 3 hours after taking the drug
• Duration: In general, the effects can last for about 4 to 6 hours. However, this can vary widely between individuals
• Afterglow: After the peak effects wear off, users may continue to feel positive and sociable for several hours, but these effects gradually subside

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MDMA and creating the couple bubble

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Case Study

• We Took Ecstasy Together In A Clinical Trial. It Saved Our Marriage.
• https://www.huffpost.com/entry/mdma-therapy-treatment-marriage-cancer_n_6423337be4b049e21e2eafb9

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Case Study

• Set and Setting
• At the clinic, we meet our therapists, Sue and Tom. They explain their role as facilitators. We will have a total of six talk therapy sessions before and after two daylong MDMA dosing sessions. Neither they nor the medicine will be doing the work — Laura and I will. Research shows that MDMA shuts off the fight, flight or freeze responses that hijack a person’s nervous system. This allows the brain to rewire itself. We might want to address a specific issue, but the mind will bring up whatever it needs in order to heal.

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Case Study

• When we arrive for our first dosing session, Laura and I are led to separate rooms by our therapists. A sunrise seascape hangs on the wall above a futon bed in my room. They encouraged us to bring items to make the room more conducive to the experience, so I unpack and place around the room pictures of Laura and my daughters, a colorful Mexican blanket, fossils, crystals, a bell, and mementos of Algeria and Italy, where I taught English as a second language as my first job out of grad school.
• I lie down. Tom spreads a weighted blanket over me, then fits me for headphones and an eye mask to shut out visual stimuli. He reviews the protocol — stay with the emotions and feel where they appear in my body. If I invite him, he will hold my hand or touch my arm or shoulder, only for support — no hugs.

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Case Study

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Case Study

• After about 30 minutes, vivid memories start coming. I am a boy of 8. My father and I are in a funeral home. He has brought me to view a friend’s son who had died. Dad leads me to the casket, where we kneel to pray. Looking in the coffin, I freeze in terror: The boy is my age. Suddenly I feel a presence. I say out loud, “Death is here.”
• Now I see this is what starts my lifelong dread of dying, which gets triggered by every CT scan. I am angry at my father for bringing me here and then leaving me alone in the back seat of the car as we drive home in silence. But I’m not scared anymore. Instead, I say, “Dad, why ever did you take me there?” He apologizes and says he wanted to support his friend, and it scared him too. He says he loves me and he never wants anything bad to happen to me.
• I realize MDMA has just allowed me to rewrite the script of a major traumatic life experience. Death suddenly loses its sting.

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Case Study

• For our second session, Laura and are in the same room. We lie on our beds in opposite directions so we can see each other. Tom and Sue sit between us, close by our heads. We laugh when they remind us that we can hold hands but not hug. Are they afraid we’ll get too frisky?
• About an hour after dosing, I am transported to a decade of intense suffering and I watch my first marriage unravel. For the first time, I acknowledge the part I play. My hand shoots from under the covers in search of Tom’s. He grasps mine firmly, and I weep over the stress the divorce causes my daughters. When the grief subsides, I tell Tom how I vowed to make amends and am happy and proud that they are now back in school working on advanced degrees.

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Case Study

• Laura, too, has a history of trauma being sexually molested in her Brooklyn neighborhood by a playmate’s grandfather when she was 4.
• Her mother, who survived Auschwitz, offered her no comfort at the time. “What do you expect?” she had said. “That’s what men are like. Stay away from him.”

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Case Study

• Soon, both Laura and I are sitting up in our beds. We gaze lovingly into each other’s eyes and express our undying love. We acknowledge the pain of the last four years and vow to support each other as we grow old together.
• “Will this last?” we ask. They remind us that we will continue to integrate the lessons of the session over the next few days and perhaps weeks and months.

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Case Study

• They urge us to use the tools they taught us. So, since then, when we feel overwhelmed by unhelpful emotions, we practice breathing and other relaxation techniques. At any sign of conflict, we use a healthy communication model they showed us. We take weekly walks in nature to get out of our heads and into our bodies. After finding their playlist on Spotify, we listen again to particular pieces that brought profound insights.

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Couple Therapy

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MDMA prior to Schedule one designation

MDMA-assisted couple therapy was conducted prior to MDMA being made illegal in the mid-1980s. Greer and Tolbert (1986, 1998) conducted a series of cases of MDMA-assisted psychotherapy, including with couples, that demonstrated improvements in fear of emotional hurt and improved communication and introspection. Reports by Sasha and Ann Shulgin describe MDMA’s therapeutic use with couples shortly

after it was re-synthesized in the mid-1970s (e.g., Holland, 2001), and that it is an excellent tool for communication and to navigate relational issues.

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Legal and medical Issues

• MDMA is illegal. Since 1985 MDMA has been a Schedule I substance under the Controlled Substances Act. Schedule I substances, which include heroin and LSD, have a high potential for abuse and serve no legitimate medical purpose.
• https://www.justice.gov/archive/ndic/pubs3/3494/index.htm#illegal

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Legal and Medical Issues �https://www.dea.gov/sites/default/files/2023-03/Ecstasy-MDMA%202022%20Drug%20Fact%20Sheet.pdf�

• Although MDMA is known among users as ecstasy, researchers have determined that many tablets sold as ecstasy may not contain any MDMA, or may contain MDMA in combination to other harmful drugs, such as: Methamphetamine, ketamine, cocaine, cathinones*, and caffeine In addition, other drugs similar to MDMA, such as 3,4-methylenedioxyamphetamine (MDA) or paramethoxyamphetamine (PMA), are often sold as ecstasy, which can lead to overdose and death when the user takes additional doses to obtain the desired effect
• *Cathinone (/ˈkæθɪnoʊn/; also known as benzoylethanamine, or β-keto-amphetamine) is a monoamine alkaloid found in the shrub Catha edulis (khat) and is chemically similar to ephedrine, cathine, methcathinone and other amphetamines..

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Legal and Medical Issues

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Common street names include: • Adam, Beans, Clarity, Disco Biscuit, E, Ecstasy, Eve, Go, Hug Drug, Lover’s Speed, MDMA, Peace, STP, X, and XTC

Legal and Medical Issues

• MDMA use mainly involves swallowing tablets (50- 150 mg), which are sometimes crushed and snorted, occasionally smoked, but rarely injected. MDMA is also available as a powder. Users may take MDMA by “stacking” (taking three or more tablets at once) or by “piggy-backing” (taking a series of tablets over a short period of time) tablets. One trend among young adults is referred to as “candy flipping,” which is the co-abuse of MDMA and LSD. MDMA is considered a “party drug” or “club drug” As with many other drugs of abuse, MDMA is rarely used alone. It is common for users to mix MDMA with other substances, such as alcohol and marijuana.

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Legal and Medical Issues

• Clinical Relevance: MDMA’s shows great potential for accelerating PTSD recovery
• Short-term MDMA therapy has demonstrated transformative effects, offering new possibilities for effective and efficient treatment of PTSD.
• Positive clinical trial results could lead to FDA approval for MDMA therapy within a year, researchers said.
• When combined with psychotherapy, the drug has shown remarkable results in reducing PTSD symptoms and improving overall well-being.

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Recent Controversy

• An independent advisory panel to the U.S. Food and Drug Administration (FDA) voted overwhelmingly against the use of MDMA – or ecstasy – to treat post-traumatic stress disorder (PTSD) survivors

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• The specific treatment in question included a Lykos Therapeutics pharmaceutical midomafetamine variant along with psychological intervention.

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• In a 9-2 vote, the Psychopharmacologic Drugs Advisory Committee rejected Lykos’s claim that recent drug trials showed that the hybrid treatment is effective. The committee also shared doubts about the risks involved.

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Recent Controversy

• The committee pored over the data from a pair of double-blind, placebo-controlled, Phase 3 studies that Lykos published in the journal Nature Medicine. What the panelists saw raised some doubts.

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• During the meeting, committee members posed questions about the findings, raised concerns over abuse (and a lack of safeguards to prevent it), and the efficacy of the psychology behind the follow-up therapy sessions.

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Recent Controversy

• The regulators wrote that about 90 percent of those assigned MDMA and 75 percent of those who received a placebo accurately figured out which group they were in.
• Concerns have been raised by some that therapists encouraged favorable reports by patients and discouraged negative reports by patients including discouraging reports of substantial harms, potentially biasing the recording of benefits and harms

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Precaution

• Recent use of selective serotonin reuptake inhibitors (SSRIs) may reduce the treatment response to 3,4-methylenedioxymethamphetamine (MDMA)–assisted psychotherapy for posttraumatic stress disorder (PTSD), even if patients are no longer taking SSRIs.
• Pooled data from four phase 2 trials reveal that patients with recent SSRI exposure were significantly more likely to continue to meet PTSD diagnostic criteria after MDMA-assisted psychotherapy than their peers who had not recently taken SSRIs.

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Precaution

• Taking antidepressants and Ecstasy together, especially in high doses,
• increases the risk of Serotonin Syndrome which can be fatal.
• Signs of serotonin syndrome include:
• Tiredness
• Nausea
• Muscle cramps
• Confusion
• Restlessness
• Fast heartbeat
• Overheating
• Dehydration
• Dilated (wide) pupils
• More serious cases can progress to coma, fits and death

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THANK YOU

Alan Groveman, Ph.D., ABPP

njpsych@gmail.com

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