The Impact of MDMA on PTSD and Self-Experience

"Yes, It's Trippy," from the visual journals of Cathy Malchiodi, PhD

Source: ©2023 Cathy Malchiodi PhD, shared with permission.

Self-experience is arguably at the center of all approaches to psychotherapy. It is generally defined as an experience of the self that we have reflected upon, can articulate, and make conscious. Others refer to this as the “sense of self,” the capacity to communicate emotional states, reflect on experiences, and identify “who am I” as a person.

From a neurobiology point of view, self-experience or the sense of self takes place in the area of brain along the midline referred to as the default mode network (DMN). The DMN is active during self-reference and access of autobiographical memory. Self-reference and autobiographical memory are thought to make up the foundation for a well-established sense of self that we can access to reflect and express our thoughts and feelings.

But what happens when we are not able to self-reflect and communicate our self-experiences? Many of us who work with individuals with posttraumatic stress often encounter this in the course of psychotherapy. We repeatedly hear statements like, “I feel emotionally dead inside,” “I no longer know who I am,” “I feel myself floating outside my body,” or “I will never be able to forgive myself for what happened.” For many reasons, individuals in treatment may struggle with a lack of ability to articulate emotions (alexithymia) or an inability to feel compassion for oneself, resulting in guilt, shame, or moral injury. These experiences highlight how cognitive and somatosensory disturbances not only alter the sense of self, but also impact an individual’s capacity to perceive “who am I” in the aftermath of trauma.

This is why a current study (van der Kolk et al, 2024) in the field of trauma on the inclusion of psychedelics within the context of psychotherapy interests me. As an expressive arts therapist, my work focuses on supporting individuals in accessing their interoceptive sensations, one way to reflect and articulate self-experience. Interoception by some definitions is the “felt sense” and is an implicit, often wordless perception of the self. For some individuals, this way of self-experiencing via movement, sound, image making, and imagination is reparative and leads to meaning making and restorative narratives. But others with tenacious posttraumatic stress continue to struggle with alexithymia, disembodiment, and the ability to regulate. Meaning making and restoration eludes them even when I can offer them what are accepted and effective psychotherapy practices for trauma.

MDMA-Assisted Therapy and PTSD

A recent study examined the effects of MDMA-assisted therapy for posttraumatic stress disorder (PTSD) and self-experience. MDMA is a psychoactive drug that stimulates and heightens the senses and enhances emotions and empathy. In previous studies, researchers have found that when people with PTSD are given specific amounts of MDMA in a clinical setting, it helps them to more effectively process traumatic events. In this current study, half the participants received 36 hours of psychotherapy from a team of qualified therapists. The other half received the same treatment, but with the inclusion of three 8 hour sessions on the psychedelic MDMA. In brief, those participants did poorly with psychotherapy alone with problems such as lack of self-compassion, alexithymia, and lack of emotional regulation. In contrast, the inclusion of MDMA had a positive effect on self-experience, with sharp increases in self-compassion, self-awareness, and measures of emotion regulation.

The authors underscore that improved self-experience resulted in participants in the MDMA group benefitting from the overall treatment, and thus decreasing their PTSD symptoms. Psychotherapy alone had only a small effect on negative self-judgment and self-awareness, while the addition of MDMA to the protocol produced significant improvements.

Implications for Addressing PTSD

The importance of effectively supporting individuals in exploring a sense of self, in all its dimensions, is at the core of psychotherapy. Self-experiences determine who we are and who we perceive we are; they form the internal compass that guide us throughout our life span. In cases of posttraumatic stress, we may not only lose this internal sense of direction, we also experience an alteration in the sense of self. This altered sense of self is mostly clearly identified through recent studies of the functionality of the DMN and the impact of posttraumatic stress on that functionality (Lanius et al, 2020).

For therapists who work with trauma, supporting individuals who struggle with disturbing reactions is a continuing challenge. What is significant about the inclusion of MDMA within a structured psychotherapy protocol is how it may open up pathways to support those with the most tenacious reactions when psychotherapy alone cannot. For me, it also underscores how alterations in self-experience are at the core of trauma-related outcomes, such as alexithymia, disembodiment, and even moral injury where self-compassion is impossible. This is an important takeaway for all psychotherapists working with trauma to consider, whether a psychedelic-trained practitioner or not.

Despite the significant outcomes in this study, remember there is one more important point about the inclusion of psychedelics in any psychotherapeutic treatment. At this point in time MDMA still is not a legally available substance, but other mind-altering treatments, such as ketamine, are already available. The authors of this current study underscore that it is critical that these substances only are used for therapeutic purposes with well-trained and experienced therapeutic guides.