In May 2013, Richard
Shrubb reported for Therapy Today, on controversial trials that use Class A drugs such as LSD and
ecstasy to treat depression and post-traumatic stress disorder.
A small
number of pioneering psychiatrists, psychologists and psychotherapists are
researching how certain Class A drugs can be used with very positive effect to
help people with severe, chronic psychological and emotional health problems.
Despite
the practical and legal difficulties, pilot trials are currently under way into
the use of LSD, pure MDMA (ecstasy) and psilocybin (magic mushrooms) as an
adjunct to conventional talking therapies for the treatment of post-traumatic
stress disorder (PTSD) and in end-of-life care.
The
therapeutic use of banned drugs has featured in the UK national media headlines
in recent months, thanks to the outspoken David Nutt, Professor of
Neuropsychopharmacology at Imperial College London and former Chair of the
Government’s Advisory Council on the Misuse of Drugs. He was sacked from the
Advisory Council in 2009 after declaring that ecstasy was less dangerous than
horse riding (in terms of adverse incidents per use). In a subsequent paper he
classified drugs according to the harm they caused; alcohol and tobacco emerged
as more harmful than ecstasy and cannabis.
In
September last year, he, with Val Curran, professor of psychology at University
College London, joined forces with Channel 4 to film some of the participants
(including the novelist Lionel Shriver) in a study that used fMRI imaging to
examine the effects of MDMA on the brain. In April this year, in his
presentation to the British Neuroscience Association’s biennial conference, he
roundly condemned the British Government for blocking attempts to develop more effective
treatments for depression with what he says are its ‘irrational’ drugs
laws.
Nutt
wants to research the use of the chemical psilocybin, the psychedelic
ingredient in magic mushrooms, which he says can suppress activity in the parts
of the brain that are overactive in severely depressed people. But, because
magic mushrooms are a Class A drug, their active chemical ingredient cannot be
manufactured without a special licence. Despite a grant of £550,000 from the
Medical Research Council to begin a three-year project to test the drug on
people with depression, Nutt and his team have been unable to progress because
they can’t get the comparatively small amount of the drug needed to conduct
their trials. It isn’t easy to find companies who can manufacture the drug and
are prepared to stump up the estimated £100,000 and go through all the bureaucratic
hoops to get a licence.
Nutt’s
research has already established that psilocybin appears to switch off the
ruminative parts of the brain that are overactive in people with depression.
‘We badly need more types of treatment [for depression] but we cannot pursue
these because the Government is denying scientists access to powerful tools
that could help people in need,’ Nutt told the conference. ‘The whole field is
so bedevilled by primitive old-fashioned attitudes. Even if you have a good
idea, you may never get it into the clinic, it seems.’
MDMA
and PTSD
Post-traumatic
stress disorder (PTSD) is notoriously difficult to treat, and a condition for
which almost no drugs are being developed. Psychotherapy is generally regarded
as the treatment of choice for the condition. NICE guidance recommends: ‘All
people with PTSD should be offered a course of trauma-focused psychological
treatment (trauma-focused CBT or EMDR)’.
At the
heart of PTSD is the issue of avoidance: the patient finds the experience too
difficult to face and is therefore unable to process it. Clinical trials are
being conducted in Israel, the US, Canada and Switzerland into the use of
MDMA-assisted psychotherapy to treat PTSD. The trials are funded fully or in
part by the US-based charity Multidisciplinary Association for Psychedelic
Studies (MAPS), a research and educational organisation dedicated to promoting
use of psychedelics and marijuana for therapeutic purposes.
South
Carolina-based psychotherapist Michael Mithoefer is leading one of the trials.
Mithoefer, a psychiatrist by training, believes that MDMA can open doors in the
mind, whether the person wants it or not. The MDMA-assisted therapy sessions
are eight hours long, with two therapists present – generally a male and a female
so the client can talk to either, as they prefer. Though an apparently intense
session – 45 minutes can be a lot for most patients in traditional non-drug
psychotherapy – it is designed to be completely relaxed and without pressure.
It
takes place in a non-clinical setting and, as the drug takes effect and the
session progresses, the client finds him/herself talking naturally about the
stressor that is causing them so much trouble. ‘We have an agreement with the
client that if nothing comes up during the session at a certain point, the
therapist can engage them. This has never happened yet,’ Mithoefer says. Few of
the clients found taking MDMA an ‘ecstatic experience’, according to Mithoefer,
and all have been able to both face the trauma and not be traumatised by doing
so.
Outcomes
to date indicate that MDMA-assisted psychotherapy is achieving results.1, 2
Twenty patients with chronic PTSD that had not responded to other forms of
psychotherapy and drug treatment were randomly assigned to psychotherapy with
MDMA or a placebo. The participants had suffered PTSD for an average of 19
years. Most of those who underwent the MDMA-assisted therapy had not relapsed
3.5 years later. Four out of five of the MDMA treatment group improved,
compared with just one in four of those in the placebo group. The study found
no evidence of drug-related serious side effects or adverse neurocognitive
effects and concluded that MDMA can be given safely to people with PTSD, and
may be particularly useful for those who have not responded to other
treatments.2
Stephen
Joseph, Professor of Psychology, Health and Social Care at the University of
Nottingham, is sceptical. He has pioneered psychological techniques to treat
PTSD and is the author of What Doesn’t Kill Us: a guide to moving forward and
overcoming adversity, on post-traumatic growth. He argues: ‘In a nurturing,
supportive environment, people can let go. If you rush them they will become
more avoidant. You have to build up the client’s trust over a couple of
months.’ Indeed, ‘it is important to spend a lot of time not talking about
their trauma’. Joseph is concerned about the use of any kind of drug to treat
PTSD: ‘PTSD is not a psychiatric disorder – it is more of a bereavement. You
cannot medicate an existential crisis.’ But he is prepared to be convinced:
‘I’d be interested to see where we are when the research is complete in 10
years. I may well be surprised.’
MDMA
and social anxiety
The US
Food and Drug Administration (FDA) is currently considering an application from
MAPS to conduct an MDMA-assisted psychotherapy trial for social anxiety among
autistic adults.
Dr
Berra Yazar-Klosinski, Lead Clinical Research Assistant at MAPS, says there is
a lot of anecdotal data suggesting that MDMA can help with social anxiety, ‘although
there is little hard science on the subject’.
Put
very simply, MAPS is arguing that MDMA can address social anxiety by reducing
the individual’s reactions to negative social interactions and enhancing the
feel-good effect of positive interactions. The treatments are once or twice
only, several weeks apart. There is no suggestion that people should be
regularly dosed with MDMA, like an antidepressant or antipsychotic. The theory
is that MDMA is a ‘teacher’, not a ‘helper’.
Julian,
a Londoner who has Asperger’s, has taken MDMA at raves and confirms this
effect: ‘It seems to help filter out the signals you normally get, teaching you
how others see social interaction.’
To help
design the pilot study, MAPS brought in Nick Walker, who has autism and has
taken MDMA recreationally. A teacher on the Interdisciplinary Studies programme
at California Institute of Integral Studies in San Francisco, Walker says:
‘Though MDMA is empathogenic for most who take it, the theory that autistic
people lack empathy is complete rubbish.’ He feels that social anxiety results
from the power imbalance imposed on the autistic by ‘neurotypical’ mainstream
society. ‘Autistic people are generally bullied at school and misunderstood as
children. By their adolescence and adulthood they are traumatised from being
taught they are somehow wrong. MDMA makes you warm and welcoming. It helps you
get involved in others’ interests. How do you share your interests? By getting
over your social fear.’
LSD-assisted
therapy
Dr
Peter Gasser was able to practise psychedelic assisted psychotherapy in the
1990s under licence in Switzerland, as a member of the Swiss Association of
Psychedelic Therapists. The licence was revoked when LSD and other psychedelics
were banned even for medical use in 1993, but Gasser has since been given a
licence to run a clinical trial into its use in end-of-life psychotherapy,
partly sponsored by MAPS.3 The results have yet to be published.
Taking
LSD is a very intense and transformative, almost religious experience,
according to research assistant Katharina Kirchner, who worked with Gasser and
wrote her Master’s thesis on LSD-assisted end-of-life psychotherapy.
Many
writers over the years have likened the experience of taking LSD to Eastern
mystic religious experiences. Kirchner challenges this: ‘Those who have the
language of the Eastern mystic experience speak of an LSD trip on those terms.
An ordinary person from a village in Switzerland or Germany doesn’t have that
language to use, so describes their experience on the terms they have for
reference.’
Kirchner
practises meditation and describes the LSD experience as like ‘taking a train
to a peak meditative experience. You arrive in under an hour where through
learning meditation it sometimes takes years to achieve that destination – not
unlike walking’. One participant had a horrifying experience in the first trip,
which they described as ‘… really black, the black side. I was afraid, was
shaking [...] Really it was a total strain, no way out, no escaping.’ They had
reservations about taking the next trip but this proved more positive:
‘Suddenly there came a phase of relaxation. Completely detached. It became
bright. Everything was light. It is a pleasant feeling, a warm feeling. No
pain. Almost like floating, like being carried, and together with the music…
really wonderful…’
The
protocol for the Gasser clinical trial explains that psychotherapy will take
place before, during and after the LSD session. During the experience, ‘as
appropriate, the investigators will engage with the participant to support and
encourage emotional processing and resolution of whatever psychological
material is emerging. The investigators will also encourage periods of time in
which the participant remains silent with eyes closed and with attention
focused introspectively on his or her sense of self and life history in order
to increase the psychological insights mediated by the LSD treatment’.
Very
simply, there are two forms of experience, depending on the dose of LSD. A low
dose is known as ‘psycholytic’ – it is still intense and transformative, but
the client doesn’t ‘leave the planet’ or hallucinate bright lights, for
instance. The other dose is a ‘psychedelic’ experience and will result in
complete release from reality. Kirchner says 300 microgrammes in most cases
will bring about a psycholytic experience, depending on the person’s body
weight, health and stage of illness; 400mcg is the minimum needed to achieve a
peak psychedelic experience in a healthy adult of a typical weight.
The
therapy environment itself is similar to that for MDMA-assisted therapy: a
calm, relaxing and non-clinical setting. The patient wears a blindfold and can
choose to listen to music. They are given the LSD under the supervision of two
therapists. Kirchner says: ‘Therapists are there to guide you through the
experience and help along the way.’ After the trip has worn off, the client
goes to bed and is left to sleep overnight – although a therapist is there for
them to speak to if they wish at any time. Kirchner explains: ‘Patients often
just need time to process their experience and understand what they have seen
and felt.’ They receive talking therapy the next day, but again in a
non-traditional way – the therapist is there simply to listen and help the
person articulate what they felt, heard and saw, not to interpret or analyse
it.
In her
thesis Kirchner argues that LSD opens the individual’s mind to a different
viewpoint and way of thinking while they remain conscious, so they gain a
different perspective on the seemingly intractable issue (for example, their
impending death) facing them. Brad Burge, Director of Communications at MAPS,
puts it more simply: ‘With end of life therapy one comes to the understanding
that “I do not end where my body ends”.’
As the
end-of-life research progresses, the hope is that enough scientific evidence
will be gathered to break through the social and legal barriers that are
currently blocking the therapeutic application of these and other so-called recreational
drugs.
Case
study: ‘By letting go I regained my mind’
Mikee
(not his real name) was a Forward Air Controller for the US Army during the
Surge in Iraq in 2006-07. He had to get artillery and air strikes signed off by
officers. ‘There were so many career officers in it for themselves that would
not sign off strikes when I deemed them necessary that I had to sit by while 20
men were killed in six months whose lives I could have saved.’
PTSD is
severely stigmatised in the US Army, particularly among elite soldiers like
Mikee. Until he was medically discharged with a broken back, and his behaviour
in civilian life forced his hand, he wouldn’t admit his problems.
‘As a
soldier your mind controls everything. You live in the next five seconds in a
structure that controls everything you do. In civilian life there is no control
of your life,’ says Mikee. He became violent on several occasions and had
difficulty reintegrating with civilian life.
For
Mikee, taking MDMA allowed him to let go of the control, which allowed him to
understand what was going on for him. ‘The feeling initially was extreme
anxiety as I was about to come up on the drug, but when I became high I was
only anxious when I had a thought about my past and didn’t talk about it. When
I talked about the thing, in my head I relaxed. By letting go and no longer
being in control, I regained my mind.’
Asked
how he has changed, Mikee says: ‘I feel as if I have grown as a person. What
doesn’t kill you makes you stronger!’
Mikee
is now going to medical school to learn to be a doctor. He wants to study
psychedelics as part of therapy and help his former buddies cope with civilian
life when they too leave the Armed Forces.
Link to original article: http://www.therapytoday.net/article/show/3703/
Related video: HORIZONS Psychedelics Forum: Treating PTSD with MDMA-assisted therapy
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