Where Ecstasy Meets Power: The Unique Risks of MDMA Therapy

mdma therapy risks

Several clinical trials have concluded that MDMA-assisted psychotherapy – utilised for the treatment of PTSD – is safe (as well as highly effective). But this doesn’t necessarily mean the treatment is risk-free. 

MDMA therapy entails unique risks, and here I don’t mean concerns about possible neurotoxicity. The subject of MDMA’s neurotoxicity is complicated; while some research finds that repeated exposure to MDMA can damage serotonin receptors, leading to long-term emotional and cognitive problems, this is seen in mice and primates given high doses or in heavy users. High doses, frequent use, and hot environments like poorly ventilated clubs (also thought to contribute to neurotoxicity) do not match the way MDMA is provided in a clinical setting (one or two sessions, using moderate doses). 

However, it is not the potential negative effects of MDMA on the brain that I want to draw attention to (although these are worth exploring, especially if some clients seek out regular MDMA therapy). The unique risks of this form of psychotherapy relate to the subjective effects of MDMA and the way these interact with the psychotherapeutic component, with the therapist(s) present during the session. Abuses of power are always a risk when vulnerable individuals seek out psychotherapy, but this risk is especially pronounced when it comes to MDMA therapy, perhaps even more so compared to psychedelic-assisted therapy using psilocybin, for instance. 

Evidence and awareness of this are now emerging, and these dangers need to be addressed and mitigated, particularly since MDMA therapy for PTSD is on track to be approved by the FDA by 2023. When this treatment is legalised, it will be accessible to large numbers of people, which is why those in the psychedelic space are sounding the alarm about abuse in MDMA therapy ever more loudly.

In Cover Story: Power Trip, an investigative podcast from New York Magazine covering the dark side of psychedelic therapy, we find that several participants in MAPS-sponsored MDMA trials were negatively affected by the treatment. These participants describe experiencing worsened mental health after the trial ended, with some even feeling suicidal. 

One such participant, Leah, said “I was one of the people who looked cured on paper.” David Nickles, one of the hosts of the podcast and managing editor at Psymposia, stated that no participants who had difficult experiences in the trials “could find those experiences represented in the published papers.” The trial data – and, in turn, the media reporting of the trials – gives the impression that no major issues occurred. 

Beyond the distressing experiences and worsened mental health experienced by some participants, the Cover Story podcast – also hosted by Lily Kay Ross of Psymposia – detailed the inappropriate actions of two therapists involved in one MAPS-sponsored clinical trial using MDMA. 

Video footage shows psychiatrist Dr Donna Dryer and unlicensed therapist Richard Yensen crossing physical boundaries with one participant, Meaghan Buisson, who has struggled with PTSD related to sexual abuse and assault. The therapists can be seen cuddling, spooning, blindfolding, and pinning down Buisson, going beyond the kind of touch that MAPS has said is appropriate in its manual for MDMA-assisted therapy. This is especially problematic given that many patients, such as Buisson, have trauma related to sexual assault.

Yensen also admitted to having sex with Buisson after the experimental sessions ended but while she was still enrolled in the trial. Buisson alleged this was sexual assault, while MAPS issued a statement acknowledging that Yensen had an “inappropriate and unethical” sexual relationship with her.

The problem of crossing boundaries and sexual abuse exists in psychotherapy more generally, but the risks are higher in psychedelic therapy, in which the patient is in a much more vulnerable state. Since MDMA in particular can create feelings of sexual arousal, emotional intimacy, trust, and disinhibition, it is possible that some therapists will exploit these effects. In a Medium post, The Complainers – a multidisciplinary psychedelic ethics research group – write:

The potential for harm resulting from a potentiation of/synergy with poor, misguided, or ill-intended psychotherapy practices, combined with drugs that lower inhibition and increase suggestibility, cannot be ignored.

We believe this novel combination approach to treatment dramatically increases the risk of iatrogenic harm as compared to traditional psychotherapy or drug treatments alone, which necessitates novel approaches to regulation and oversight.

While both MDMA and classic psychedelics can increase suggestibility, the former seems especially prone to lower inhibitions, which – alongside increased sexual arousal, emotional intimacy, and trust – may lead to a heightened risk of sexual abuse compared to the classic psychedelics. This is why we need to think seriously about ways to prevent sexual transgressions from occurring in MDMA therapy (as well as in psychedelic therapy more generally, of course). 

The power imbalance between a therapist and patient is already significant, but when you throw in powerful mind-altering chemicals into the mix, this imbalance only becomes bigger. Hence, the self-awareness and integrity of psychedelic therapists – as well as training and regulations – need to go far beyond what is expected in conventional psychotherapy. Higher and distinct standards should apply, but there are concerns that these standards are not being adequately set and followed.

Fortunately, some providers of psychedelics for therapeutic use are heeding the call for clear ethical guidelines in psychedelic therapy. The Synthesis Institute, whose Advisory Board includes Rosalind Watts (former clinical lead for Imperial College London’s psilocybin for depression trial), has developed an 18-month professional certification programme (the first of its kind). This helps to set the standard for practitioners to safely, ethically, and effectively support people using truffles containing psilocybin. 

Celebrating the life-changing successes of MDMA therapy and working to destigmatise this substance should not come at the cost of ignoring or downplaying the risks involved. Falling prey to the latter will increase the chances of abuses of power actually taking place, which will only worsen people’s mental health, as well as provide motivation (for the media and the wider public) to demonise the treatment wholesale. The excitement surrounding MDMA- and psychedelic-assisted therapy is certainly justified, but the sort of hype that excludes caution and balance is not.

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