The Mithoefers describe MDMA as “inner directive therapy.” The point isn’t to express the altered state outwardly, but to use the state to confront and explore one’s emotions. Michael Mithoefer explains that avoiding such confrontations is what keeps PTSD going. Many substances numb the fear that leads to avoidance — alcohol is an obvious example. But, says Sessa, they also numb other responses, making the overall effect unconstructive. “MDMA selectively removes fear,” says Sessa. “All the other faculties are there, but things are not scary.”

In November 2018, psychotherapist Veronika Gold traveled to South Carolina for her sessions. Gold had become interested in psychedelics while she was still living in the Czech Republic and wondered if MDMA might offer help to people coping with memories of child abuse and rape. She had relocated to San Francisco for graduate school and entered private practice. After hearing the Mithoefers speak about their MDMA research in 2004, she applied to be a therapist on a MAPS clinical trial. Five years later, they invited her to be a therapist on a study of MDMA for PTSD. “It was my dream,” she says. In 2018, she decided to participate in the therapist study. “I felt it was a crucial part of training and work to have that experience,” says Gold, “to better understand and support the people I will be working with.”

Sessa enrolled in the MDMA clinical trial for therapists in 2016. His session began with a pill made of either sugar or 125 milligrams of MDMA. He lay on a bed, chatty but not obviously in an altered state. He was chilly, so his guides — the Mithoefers — offered him extra blankets. They put on music, checked his pulse periodically, and asked how he was feeling. Eventually, his conversation and behavior made his MDMA-induced state obvious. At about two hours into the session, they offered Sessa a booster dose of 62.5 mg, part of the study design, which he accepted. He talked with his guides. He felt fidgety even though he was relatively still. Music continued to play in the background. At some point, his guides offered him an eye mask and encouraged him to “go inside.”

In the days following Sessa’s session, he began to see therapeutic MDMA as distinct from recreational ecstasy. With the latter, he notes, users tend to party, dance, have sex. In a clinical setting, all that energy goes toward sorting through pain, a process that he found revelatory. Unlike LSD and mushrooms, recreational ecstasy isn’t usually taken for a spiritual awakening. “If more people took MDMA in dark silence,” says Sessa, “I think we’d get higher reports of psychospiritual experiences.”

Gold’s experience was similar. She was at ease with a wider range of emotions than usual, she says. “There was this beautiful healing from inside out happening,” says Gold. And she felt connected to her guides, an aspect of the treatment that she believes will benefit patients. Both she and Sessa also note the importance of the counseling sessions before and after, which Sessa calls “the real strength” of MDMA therapy — and where inexperienced guides offering psychedelics fall short. “Things are left unintegrated,” he says. “It’s not just about taking the drug.”