PTSD, Meet MDMA
Date Published: December 29, 2020
Rachel Yehuda, PhD, has been at the forefront of trauma research and treatment for three decades. Her pioneering work with populations including military veterans and Holocaust survivors has illuminated the biology of post-traumatic stress disorder (PTSD). But despite scientific advances, PTSD remains famously difficult to treat. Even “gold standard” cognitive-behavior approaches have been largely ineffective. In this interview, Dr. Yehuda talks about the therapeutic potential of psychedelic-assisted psychotherapy and describes her journey from skeptic to advocate for more research.
Dr. Yehuda is Professor of Psychiatry and Neuroscience, and Director of The Center for Psychedelic Psychotherapy and Trauma Research at the Icahn School of Medicine at Mount Sinai. She is also the Vice Chair for Veterans Affairs in the Department of Psychiatry as well as Director of the Traumatic Stress Studies Division.
From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm Jon Earle. My guest today is Dr. Rachel Yehuda. She's a professor of psychiatry and neuroscience at the Icahn School of Medicine at Mount Sinai. Dr. Yehuda has been at the forefront of trauma research for 30 years. Her work has illuminated the underlying biology of PTSD and trauma, including its intergenerational effects. But as Dr. Yehuda says to me in our interview, even though the science has progressed, treatment for PTSD remains woefully inadequate. Even the gold standard cognitive behavioral therapy is not as effective as we want it to be. And so a few years ago, Dr. Yehuda became interested in psychedelic-assisted psychotherapy. And even though there's a lot more research that needs to be done, the initial results are very promising. So promising in fact that Dr. Yehuda spearheaded the creation of a new center at the Icahn school of Medicine at Mount Sinai, it's called the Center for Psychedelic Psychotherapy and Trauma Research. And she's the director. So one of the psychedelics that Dr. Yehuda is excited about is MDMA, commonly known as ecstasy. So that's the one that we're going to be talking about today in the context of MDMA-assisted psychotherapy for PTSD. So here is Dr. Rachel Yehuda. Hope you enjoy it. Dr. Yehuda, welcome to Road to Resilience.
Dr. Rachel Yehuda: 01:25
I know there's so much popular interest right now in psychedelics and psychedelic-assisted psychotherapy. And I think people would be surprised to know that this isn't a new field of research per se. Psychotherapists were experimenting with LSD in the 1950s and that research continued until the government put a stop to it in the seventies and eighties. My question to you, Dr. Yehuda, is that when you were beginning your career in the mid-eighties if I'm not mistaken, what had you heard about that research, if anything?
Dr. Rachel Yehuda: 01:56
I had heard nothing about that research. The rather nuanced message that I got--but I think many of us did--was stay away from all drugs. Any drugs that have the potential of altering your mind are probably drugs you don't want to have anything to do with. You remember that commercial, this is your brain with the egg, and this is your brain on drugs. So certainly when I was in graduate school, that was a message. And when my career started evolving into more of a clinical domain and started doing clinical research, when we asked patients about drug abuse, if they expressed taking any kind of illegal drug, that was a cause for concern, true concern about the potential harm that they might be experiencing. And we can include cannabis in that mix. We can include opiates in that mix. And LSD somehow had a very scary feeling about the most harmful, the King of all drugs that made you the most out of control. So these were just the impressions that I had as someone who really didn't know better.
Yeah. The scientific community, it sounds like, was very much getting the message, "bad, bad, bad," which is the same message the public was getting, that these substances are unequivocally bad in all circumstances, period.
Dr. Rachel Yehuda: 03:24
That's a message that you would get if you were not in the culture where you were taking these drugs and deciding for yourself. Yeah. I wasn't part of that.
So MDMA is your focus right now. So given that we're going to be talking about MDMA, I was wondering if you could just give us a primer on what it is?
Dr. Rachel Yehuda: 03:45
Yeah. MDMA was first synthesized in 1912 by Merck, and they didn't really know what it was going to be used for. It was patented a few years later and it was found to have psychoactive properties that were studied in the fifties. Therapists began using it in the sixties and seventies as a way to help people open up their heart and talk about things that were difficult to talk about. And MDMA is not actually considered to be a classic psychedelic. It's an entactogen. It's a drug that promotes empathy and promotes introspection and interpersonal trust. And all of those qualities that make people feel very comfortable and less afraid to confront things that are painful. It's not really associated with visual hallucinations or ego dissolution, like other kinds of psychedelics like psilocybin or LSD. So it's more of a gentle experience. The street name for MDMA is ecstasy, which gives you an idea of how some people feel when they take it. But when it's used in the context of therapy, it really is more of a heart opener. It's just medicine that gets you to face things that are usually more difficult to face.
If we had spoken three years ago, you would have been a skeptic about the potential for MDMA. Why is that?
Dr. Rachel Yehuda: 05:14
Yeah, but I would have been a skeptic about the current treatments that we have also. I've been someone that has tried to voice concern about the fact that the cognitive behavioral approaches and the medication approaches that are the gold standard in our field might be the best we have, but aren't good enough. They don't really bring the kind of recovery that people with PTSD need to have so that they can get their lives back. In discussions with people who have healed from PTSD, it's very clear that the way that people do heal is that they create a new narrative about themselves. They're somehow able to see what happened to them in a different light. Getting them to see something in a different light though is really not as easy as it sounds because the way that you accomplish that is by looking at what happened to you without being flooded by the usual feelings of fear or shame or guilt. And self-recrimination that usually distorts your understanding of your own experience. So if you can kind of put a mute button on all that negative stuff, you might be able to have a change, a change in your perspective. So yeah, if you would've met me a few years ago, I would have told you that. I would have told you my experience in talking to people that once had PTSD, but no longer do, but I wouldn't have been able to tell you exactly how that is accomplished in a reliable way.
I guess this leads us back to where trauma and PTSD meets MDMA. So let's talk about that. Let's talk about where MDMA figures into this? How does it help to clear a path to healing or to enable a person's innate healing ability?
Dr. Rachel Yehuda: 07:16
So what's really important to understand about that question is that it's not that the MDMA is going to heal someone, but the MDMA is going to create an opportunity for a certain kind of introspection that is then going to allow somebody to make a change in the way they see things. And with MDMA, you get to mute some of the negative symptoms or the negative feelings that you're usually flooded with when you talk about the trauma. So if you talk about something terrible in a state where you have maximum self-compassion, for example, and minimal self-criticism, then you might actually get somewhere with how you see the event. It's the immutable narrative of trauma that means that you're just seeing the same thing in the same way each time.
And you know, sometimes I like to use the metaphor of the difference between looking in a one-way mirror and a three-way mirror. If you only look at a one-way mirror, maybe from the neck up, you will have one view of yourself. But if you can look from the back and look from the side and look from the top and look from the bottom, you may actually see yourself in a different way. I mean, what a lot of trauma survivors might reflect on when they're in an MDMA psychotherapy session is maybe how young and small they were at a time when somebody much bigger abused them. And they'll say, "Wow, I'm so little." But that might not be the normal way that they look at this. The normal way they look at this might be, "Why didn't I stop it?" As if they were equal to the perpetrator. Because the perpetrator may have told them that they can never tell anyone the secret and made them feel powerful that they had the ability to ruin someone's life with information. But in an MDMA journey, you might say, "Wow, I was five. I was 10." And you might really give yourself a break. You might actually be able to come out of that in a very different way that is informed by a real truth of something that you saw. And once you see it, you don't unsee it. You don't have to keep taking psychedelics once you see what you need to see. And that is the beauty of the therapy.
You've been trained in MDMA-assisted psychotherapy. And I think I want to underline the distinction that you've been making, that this is very different from the recreational use of MDMA. I was wondering if you could just kind of briefly talk us through what the course of treatment actually looks like. It's very intensive, isn't it?
Dr. Rachel Yehuda: 10:08
Yeah. It's not a quick fix at all. The protocol that has been designed for MDMA-assisted psychotherapy involves meeting with the patient for preparation at least three times for three 90-minute sessions, which has a lot of prep work. And during that prep work of the therapist establishing a relationship, there's two therapists as a co-therapy model, which is also very unusual. But the therapists establish a relationship with the patient, try to get to know the patient, figure out what the likely traumatic materials are. And they explain that unlike previous therapies that the patient might have had, they're not going to be directing the person to talk about their trauma. They're going to be following the person's process. They're going to be supporting the person in what they're going through. And you have to prepare people for the fact that that may feel unpleasant at times and may be difficult at times, but that they won't be alone. And that they're going to be assisted. And patients are going to be encouraged to kind of trust the medicine and trust their inner healer. And then there are actually three or two experimental sessions that are about eight hours long. A patient is given the MDMA at nine in the morning. There may be an opportunity for booster dose. And then the patient is with the therapist, lying down comfortably, there are eye shades, there's music. And the patient goes where the patient's going to go. And usually it involves some things that are not surprising, like just talking about the traumatic experiences that are known to the patient and the therapists at this time. But a lot of times there are surprises. The patient goes somewhere else, maybe earlier, maybe to childhood, maybe some experience that hasn't been thought of in a long time. And then the next morning, the first of three integration sessions occur where the patient and the therapist talk about what happened. The therapist usually takes notes. Patient absolutely remembers what happened during the session. And sometimes patients don't talk much. Sometimes they talk a lot, but it's all discussed. And then you can kind of start it all over again with another session and more integration.
So the two interesting features here is that an intention is set in the preparation work. What is the intention of taking the medicine? Well it's to explore something difficult. And then there is also the integration, which is talking about what happened in the altered state of consciousness. That's what makes it different from recreational use. In recreational use, even if it's real MDMA, or real whatever, the intention is different. The intention is recreational and there isn't the opportunity to do the integration. You're taking it for a completely different reason. And so it will have a different effect. But when you take this with a certain intention and a very specific follow-up of integrating the experience, then the healing occurs. They've done studies at John Hopkins that have shown that when you take a psychedelic in a therapeutic context with the right intention and integration, it ends up being one of the most profound experiences of your life. People rate doing this kind of work way up there with major life events. So it can be very, very powerful.
And what are the studies showing so far about the effectiveness and the long-lasting nature of that effect?
Dr. Rachel Yehuda: 13:55
So far the results of the phase two trials of MDMA--there've been six of them--have been so good that the FDA has designated MDMA as a breakthrough therapy, which it doesn't do very often. And what happens is that patients show a profound change, an average of a 50 point decline in symptom severity of PTSD with this medicine. And just to give you an idea of the scale, most patients start out, let's say about a 70 or 80 on a PTSD symptom severity scale. To go down 50 points means you're down in the 20 range. And in a 20 range, you don't have PTSD. With cognitive behavioral therapies, the clinically meaningful response is considered a 12 point reduction on some of these scales. So we're talking orders of magnitude different in terms of the kind of response you can achieve. And about 68 percent of people no longer have PTSD, even at follow-up about a year later. Again, that makes sense to me because you're not reducing symptoms, you're not doing something that addresses the symptoms. You're giving someone a new way to look at it. And once they look at it that way they don't go back. It's a completely different model. You don't have to worry. You know, when you give a medication that suppresses something, maybe a medication that allows you to sleep or medication that suppresses your dysphoria or your anxiety, you're not even claiming that this is going to be a permanent fix. You're claiming that you're suppressing it as long as it can be suppressed.
I saw a picture of you in the Black Rock Desert at Burning Man. It's a giant festival in the desert in Nevada, and it's often associated with psychedelic drug use and self-exploration. So what got you to Burning Man? And what did you find there?
Dr. Rachel Yehuda: 15:57
Yeah, good question. What made me go to Burning Man initially was curiosity, something that I do with my husband and some friends. It was a real novelty for me because there is a lot of psychedelic drug use there, and I was not ready to do that. I had never done it. And you don't need to do drugs at Burning Man to have a good time. There's just so much happening there. But one of the things that I learned when I went there is that there are efforts that are sponsored by MAPS to do harm reduction.
What is MAPS?
Dr. Rachel Yehuda: 16:36
MAPS is the Multidisciplinary Association for Psychedelic Studies. And I heard about the fact that they were looking for people to do harm reduction. And in fact, that is what I found myself naturally doing the first year that I was there, kind of talking to people who needed somebody to talk to. It can be a very overstimulating environment, especially if you're more of an introvert. And I thought, "Oh, this is how I can make myself useful." And that's when I learned about the efforts in MDMA in PTSD. I had heard about them before, but I had kind of dismissed them as, you know, the latest healed quick ideas in our field. But meeting some of the people that were involved in doing this work really made an impression on me. And also just seeing what the effects of psychedelics are even recreationally was very intriguing. And it really dispelled a lot of biases that I had about what it means to take a psychedelic drug. And so that kind of began getting me to think about whether maybe this psychedelic movement in psychiatry, I need to learn a little bit more about it. I needed to just not dismiss it. And so, a few months later I went to the next training to become a psychedelic psychotherapist. And it's very difficult to walk out of a seven day training where you're watching videos of people being completely transformed after the psychedelic-assisted psychotherapy, to not be more curious about it.
You also got to play the role of a patient taking MDMA with therapists.
Dr. Rachel Yehuda: 18:25
Yeah. I want to clarify that that's not part of the training. And that therapists trained without taking any psychedelics. That's not part of the training. But there was an FDA-approved protocol. I think it's maybe still ongoing that was actually designed as a safety study in normal volunteers, but was doubling as a protocol that would give therapist's experience with understanding what it is like to take MDMA under therapeutic conditions. And I was very fortunate that I was able to have that experience because it really taught me a lot about psychotherapy. It just taught me about the power of an altered state of consciousness and helping identify things that we usually just don't allow to come to the surface. Things that we all bury because we don't think any good will come of bringing them up. And the power of being in a room with two therapists who are helping hold your process and helping you understand and make connections between various events in your life. I mean, to me, it felt like in eight hours what one might do in the course of 10 years in psychotherapy.
Dr. Rachel Yehuda: 19:46
But it happens quickly. And then the integration afterwards is very powerful. So most of all, what I understood is that this is safe. That was the biggest take home for me. That this is not a scary thing to be putting patients through. It's an extremely gentle thing. And in some ways it's much more gentle then having people talk about their trauma without the help of a medicine that is promoting self-compassion and taking away fear of a bad memory. So I learned about that and I also understood the difference between processing something in a 50 minute or 90 minute increment, and then going home and really sticking with it for eight hours.
You know, what I said afterwards was that it's like being in labor, having a baby where you're building up contractions and you got your labor coaches with you, and it comes to a very natural end. And at the end you feel like you did something. And for women that have had contractions, I mean, they're not necessarily fun. And in fact, they're often very, very painful, but you're doing it because you know that you're doing it for a really important purpose. And after you hold the baby, in your hand, you don't think about how horrible the contractions were. I mean, you kind of have that sense, but that's not what stays. What stays is the baby. And so, to me, it was a beautiful, profound experience. And I came out of there, wishing everyone could have such an experience. I mean, this is something that was deeply meaningful to me.
And psychedelics also have this ability to make you feel connected to the world, to mankind, to the universe. For people that have suffered trauma, they feel so alienated. They feel that the world isn't their world anymore. They don't belong here. That's why maybe so many of them take their own lives because this world is not meant for me. What psychedelics do is they kind of make you feel that you have as much right to be here as the sun and the moon and the trees and the earth and any other person. And that you're part of all of that. So these are not experiences that most of us have or many of us seek through yoga and meditation or being mindful or through spiritual practice or through religion, we're seeking ways of connection. And this can be another one of those tools, particularly for people that are having significant mental health challenges.
What would you say this work has taught you about the mind itself?
Dr. Rachel Yehuda: 22:41
That there's way more to it than we're aware of. That the mind is a very big place and stores a lot of our secrets and a lot of information about who we are. I've been very interested in intergenerational trauma. And one of the things that is really true is that psychedelics actually can put you in touch, not only with your own events, but it really makes you reflect on experiences that your parents or ancestors may have also had so that there is this connector between you and the people that came before you. And in my case, certainly my children and people that are coming after me. There's a lot in your mind. There's a lot in your consciousness. And the ability to kind of look at some of that stuff that you don't usually get to see can be a profound privilege, but certainly a meaningful and life-changing experience.
Do you have any sense or are you at all willing to speculate about where you might be in a few years? Do you think that this MDMA-assisted psychotherapy could be approved by the FDA or under wider use in a few years?
Dr. Rachel Yehuda: 24:00
Yeah. I mean, look, it's on track to be approved in 2021. That's next year. If all goes well, sometimes things take a little longer than planned and with the pandemic, the FDA probably has a lot of things that it's trying to do right now, but yeah, this is happening in the near future. This is happening and I'm not advocating psychedelic use in psychiatry right now because things are not approved and we haven't done the work. I'm merely explaining to you why I'm so excited about doing it. I mean, what excites me most about the potential use of psychedelics in the future is how to apply it beyond PTSD into other forms of trauma. And I include in this mix, racial trauma and the kind of chronic systemic microaggressions that people have suffered for a long time. Intergenerational traumas and many of those kinds of experiences. And, you know, we're taping this podcast during a global pandemic that is really creating, I think, a very big mental health pandemic. And there's a lot of trauma now in our society. And we just have to make sure that we have the right tools and the right approaches. And when the FDA does approve this for the treatment of PTSD, we want to be able to do the research that will help us understand what other indications that are trauma related. Who could this help? Do you have to have a full blown PTSD? Are there other psychedelics that might also be helpful? Not just MDMA. We want to be armed with the right information so that we can guide the field.
That's all for this episode of Road to Resilience. Thank you again, Dr. Yehuda for taking the time to talk. If you want to learn more about her work and the work of the Center, check out the links in the show notes. Road to Resilience is a production of the Mount Sinai Health System in New York City. It's made by Katie Ullman, Nicci Cheatham, and me Jon Earle. Lucia Lee is our executive producer. One side note here. This is Katie Ullman's last episode of Road to Resilience. And I just want to take a moment to give her a shout out. She's been with the show since the very beginning two and a half years ago. She is the behind the scenes wizard that makes sure everything happens. She gets guests booked, episodes edited and published, she makes promo videos, she does social media posts. There is literally nothing that Katie Ullman can't do. And if she doesn't know how to do something, she learns how to do it. So, Katie, thank you so much. We're so proud of you and excited for what's next. As always, if you enjoyed this episode, please head over to Apple Podcasts, leave us a five-star rating and a nice review. We really appreciate it. And it helps other people find the show. From all of us at Mount Sinai, we wish you a Happy New Year and resilience in 2021. We'll see you there.