Psychedelic drugs that have been considered recreational for decades—and classified as drugs of abuse by the FDA—are showing major promise as potential solutions for hard-to-treat disorders and illnesses (see this goop piece on ibogaine and addiction, as well as this one on ayahuasca). Usually associated with the street names ecstasy or molly (although it’s not actually the same), the drug MDMA is in new clinical trials to treat PTSD and anxiety; other possible therapeutic applications are being explored, too.

Emily Williams, M.D. is a resident psychiatrist at UCSF and trained MDMA-assisted psychotherapist working with MAPS (Multidisciplinary Association for Psychedelic Studies), a non-profit pharmaceutical research organization leading the way on MDMA research. In Williams’ current work, she has patients take MDMA while undergoing tailored psychotherapy sessions. MDMA is thought to enhance the efficacy of psychotherapy by reducing the fear response, and strengthening the sense of the trust between patient and therapist. “MDMA seems to bring about an internal awareness that even painful feelings that arise are important to the therapeutic process,” says Williams. “Many people describe the experience of MDMA-assisted psychotherapy as ‘years of therapy in one day.’”

Below, Williams tells us how MDMA might change the future of various therapy modalities, as well as how we think about psychedelics.

A Q&A with Dr. Emily Williams

Q Can you explain what MDMA is? A MDMA is not the same as ecstasy or molly, which may contain MDMA, but frequently also contain unknown and/or dangerous adulterants. (It’s important to note that in clinical research trials, the MDMA used is created in a strictly regulated lab setting and monitored by both the FDA and DEA.) In technical terms, MDMA (3, 4-methelynedioxymethamphetamine) is a monoamine releaser and re-uptake inhibitor that affects serotonin, prolactin, and oxytocin. This means that it causes an increase in serotonin and other neurotransmitters in the body, and also allows for increased serotonin activity at certain receptors in the brain. MDMA was first synthesized in 1912 by Merck in an effort to develop a compound to stop abnormal bleeding. It wasn’t thought to have a medical benefit until it was rediscovered by Alexander Shulgin, Ph.D. in Northern California in 1976 and spread by psychiatrists and psychologists who reported seeing benefits to its use as an adjunct to psychotherapy in individuals and couples.

Q What does MDMA-assisted psychotherapy entail, and who is it meant for? A Clinical trials have primarily investigated MDMA as treatment for PTSD, but there have also been studies on MDMA-assisted psychotherapy for social anxiety in autistic adults, anxiety related to life-threatening illness, as well as in couples therapy. (As mentioned above, in the late 1970’s and early 80’s, before MDMA was reclassified as a drug of abuse, it was used with anecdotal success in individual and couples therapy.) In MAPS’ clinical research trials, a course of MDMA-assisted psychotherapy begins with a series of psychotherapy sessions, sans drugs, to establish the therapeutic relationship and safe space for processing. This preparatory phase is followed by a series of MDMA psychotherapy sessions: Each one lasts about six to eight hours and consists of the patient orally ingesting MDMA and resting in a comfortable position with eyes closed or wearing an eye mask, while listening to music that’s initially relaxing and then emotionally evocative. Throughout these experimental MDMA sessions, periods of patient introspection alternate organically with periods of conversation with the therapists, largely determined by the desire of the patient. The MDMA sessions are followed by integration sessions (no drugs involved) that last about 90 minutes, where the patient and therapist talk about insights gained during the experimental sessions, and how they relate to the trauma or other issues that were brought up during the preparatory phases.

Q Can you tell us about the results so far? A The combined results from the PTSD studies are very promising: After just two sessions of MDMA-assisted psychotherapy for PTSD, 52.7% of 74 study participants no longer met criteria for PTSD, versus 22.6% of the placebo group. Among all study participants who received active dose MDMA-assisted psychotherapy, 67.4% of 86 participants no longer met criteria for PTSD at the twelve-month follow up. This shows that not only is MDMA-assisted psychotherapy effective for treating PTSD, its benefits are long-lasting. No other psychiatric medications or therapies currently available are comparable.

Q What’s the treatment like for the patient? A The MDMA experience itself has been described as having an enhanced mood, heightened sense of openness, sense of closeness with others, and increased connection with one’s intuition or what we refer to as “inner healing intelligence.” A large majority of patients in the clinical trials have reported that their course of MDMA-assisted psychotherapy was profound and life-changing. Many describe it as “years of therapy in one day.”

Q Would MDMA be effective on its own, without the therapy session, or does it work because of the interaction of the two? A MDMA’s effectiveness is reliant on the accompanying psychotherapy. It is thought that MDMA increases trust and strengthens the therapeutic alliance (the relationship between patient and therapist)—that relationship is actually the number-one factor determining the efficacy of psychotherapy. MDMA is thought to catalyze the healing process, which is further supported by highly trained MDMA therapists. MDMA seems to bring about an internal awareness that even painful feelings that arise are important to the therapeutic process. The MDMA and psychotherapy complement each other to foster a clearer perspective, helping the patient understand that the trauma is an event from the past, and to see the support and safety that exists for them in the present moment. This process also relies on concepts of “set” and “setting”: Set is the intention of the patient, the preparations they have made, as well as their mental and physical characteristics. The setting is the physical/interpersonal environment that can contribute to a person’s altered state of consciousness. The psychotherapeutic frame of MDMA-assisted therapy is so important; the preparatory process works towards establishing an optimal set and setting for the MDMA experience. It is also important to stress that there are medical risks associated with MDMA use, including hyperthermia, cardiac complications, as well as a potentially fatal complication called Serotonin Syndrome, so close supervision by a physician is critical.

Q How is MDMA/psychotherapy treatment thought to decrease the fear response in patients? A MDMA can reduce a patient’s perceived threat to their emotional integrity; it can also decrease defensiveness without blocking access to memories, or preventing a deep and genuine experience of emotion. Eliminating your conditioned fear responses can lead to more open, comfortable communication about past traumatic events and give you greater access to information about those events. Some studies show a decrease in communication between the amygdala (the fear-processing area of the brain) and hippocampus (memory storage) with MDMA compared to a placebo, however the actual mechanism of action remains unknown, which is why further research is crucial in this growing field.

Q Could MDMA be used for other applications/to treat other conditions? A MDMA-psychotherapy has the potential to be used to supplement more traditional therapy modalities, such as psychodynamic or cognitive behavioral therapies, as a way to explore personal growth and overall wellbeing.

Q Besides MDMA, which psychedelic drugs do you think are most promising in terms of potential therapeutic applications? A There are a number of different psychedelics being studied currently for a variety of disorders, ranging from depression to addiction and tobacco cessation. At this moment, I would say that psilocybin (the active compound in psychedelic “magic” mushrooms) is also very promising in terms of becoming legalized for clinical use. The Amazonian brew, ayahuasca is also showing benefit in some recent research studies for a variety of disorders, including trauma and depression.

Q MAPS’ work is all privately funded; do you see federal funding (or FDA approval) on the horizon? A The Multidisciplinary Association for Psychedelic Studies (MAPS) is undertaking a roughly $25-million effort to make MDMA into an FDA-approved prescription medication by 2021; it’s currently the only organization in the world that’s funding clinical trials on MDMA-assisted psychotherapy. We’re closer than ever before to seeing federal research funding awards to projects focusing on MDMA-assisted psychotherapy. We are experiencing a societal, cultural shift in how psychedelics are perceived and I hope that as more people express interest, the funding will follow.