Mechanism of Action

“PTSD, posttraumatic stress disorder, changes people’s brains. What it does is it increases activity in the amygdala, which is the fear processing part of the brain, so that fearful memories are always not far from the surface and there’s all sorts of triggers and reminders that people have. And people, to cope with it, they become emotionally numb or they become hyperreactive. PTSD also changes the brain in terms of the prefrontal cortex, where we think logically, put things in association. It reduces activity in the prefrontal cortex with people with PTSD, so that they’re more emotionally fearfully reactive and they’re less logical about things.

“MDMA does exactly the opposite. MDMA reduces activity in the amygdala, so that emotions that are fearful, that are linked to memories of trauma, once people can look at them, once they think about them, they can do it from a more peaceful place. And they can, in some ways, release the fears and anxieties that when the trauma happened, they had to suppress, because they had to focus on survival, and yet the fears stay with them. MDMA also increases activity in the prefrontal cortex, so people are able to think more logically. Every person who is in a red hat, if they were attacked by somebody in a red hat, every time they see a red hat they get fearful. So in their prefrontal cortex, they’re able to separate out that that’s not always a signal of danger.

“MDMA also releases hormones of oxytocin and prolactin, which are the hormones of nursing mothers, of love. It helps people feel connection and trust, and it helps build the therapeutic alliance. And then MDMA also increases connectivity between the hippocampus and the amygdala, where emotions are moved more into long-term storage, where the hippocampus is connected to memory. So people are able to take these emotions that have been trapped, in a sense, in short-term memory because they’re so fearful, and are able to process them into long-term memories. And then MDMA also stimulates activity in serotonin, dopamine, and norepinephrine. Which has a cascade of different effects but also in some mysterious ways, we’re not exactly sure how, contributes to this [feeling] like you’ve tapped into a well to the unconscious, and emotions emerge and thoughts and feelings emerge into awareness that have been suppressed. We find that under the influence of MDMA, people’s memory for the trauma is enhanced, that they actually can recall a lot more of what happened to them from a position of safety and awareness that it’s not happening right now.

“So all of those factors combine to create MDMA as the ideal drug for PTSD, and I should add that MDMA acts fundamentally differently than the classic psychedelics. When you say mechanism of action for psilocybin or LSD or mescaline from peyote or ayahuasca, what is being discovered through modern brain scan research is that there is a resting state ego awareness. It’s called the default mode network of the brain. It’s the part of the brain that’s when you’re scanning the horizon or just thinking about things, you’ve got no particular agenda. It’s your ego, it’s your self, it’s sort of looking at what you need from the world, who you are. It’s the anchor of us in time and space.

“What the classic psychedelics do is they don’t really do what I described with MDMA with the amygdala or the prefrontal cortex, but what they do is, they reduce activity in the default mode network, which acts as a filter. So the filter of incoming information to what’s relevant to us in our human life from birth to death, what are our needs, that filter is weakened, and we get flooded with all sorts of perceptions, including emotional material that we’ve tried not to see, that we’ve suppressed, but that’s highly charged. Stan Grof has talked about LSD as a nonspecific amplifier of the unconscious, and that’s a good way to understand how modern neuroscience is looking at the effect of these psychedelics on the default mode network. MDMA is not so nonspecific, in the sense that it’s more filled with emotions of self-love, self-acceptance, of connection, of reduction of fear. So that’s what we understand about mechanisms.”

Harm Reduction Model: 4 Key Principles

“So the first thing is, create a safe space, help people feel that they’re not going to be arrested, they’re not going to be taken away, that they’re not going to be attacked. Their attention is directed inward, into what’s happening with them, and so they are, in a sense, in a real genuine sense, defenseless from people from the outside, so you have to protect them and help them feel safe, and also that means that they’re safe with the emotional content, that you’re not reactive yourself. If they start talking about a rape and you’ve been raped and you don’t want to think about it and they start talking about it and then you are like, “Don’t go there,” or you communicate your own anxieties, that’s part of not creating a safe space.

“So you create a safe space. Once you’ve done that, and we teach about all the different ways that you do that, and we have medical supervision also to check people out to make sure they’re not having physical problems, then the next thing is that we teach, it’s called sitting, not guiding. The key aspect of that is that we are not the guide, we meaning the people sitting with, the therapists, the support people. The guide is the person’s own unconscious, and things emerge in a way that is unique to each individual, and our job is to help people process that, but not to direct that. We don’t know the goal. We don’t know where they need to be. We don’t know what they need to feel. We don’t know the order. We just are supporting.

“So we are sitting in kind of a meditative way with people and then… A lot of times, people will have their eyes closed, listening to music, going inward. But when they come out and they want to talk, then we will sort of sit with them and help them process whatever they’re processing. So it’s a key aspect of the attitude of the sitters, that they’re… It’s arrogant in a way to say you’re the guide and you know where people need to go. It’s not like being a wilderness guide where you’ve been out on the trails before and the mountain is an exterior mountain. These are interior mountains of people’s unconscious and their own history, and the symbols mean different things to different people. So sitting, not guiding.

“Then the third part that we teach, it’s called talk through, not talk down. What that means basically is that you don’t try to distract people to talk them down from what they’re feeling, like, “OK, you’re on a drug, it’s going to get over in a few hours. Think about things that are beautiful. Here’s a flower. You know, think about this, think about that. Don’t worry about the trauma that you’re trying to tell us. That’s only in the past.”

“So we don’t talk people down. We’re not trying to take people away from their experience. We’re trying to help them face it and look at it, and so we talk through. So it’s, “What is it that’s scaring you? You see a vision of a skull. Tell me about it. What’s behind that? Accept that. You feel that you’re dying. Well, OK, you’re not physically dying, we have medical staff here, but it’s like an ego death or emotional death. Let it happen. Go through it. These fears that are coming up that you don’t want to face, you’re better off facing them because they influence your life even more when they’re unconscious than when they’re conscious.” So we try to direct people’s attention towards what they’re worried about, rather than talk them down.

“And then the fourth principle, which in some ways I think is the most important to help people really frame this in their own minds, is that difficult is not the same as bad.”

Difficult is not the Same as Bad

“Many people are trained or they believe that once things start getting difficult, once a psychedelic trip starts getting difficult, then they’re going to have what we all know is called a bad trip. What makes a bad trip bad is not the content, but it’s the resistance to the content. It’s the unwillingness to explore it and to feel it. I mean, one time when I was having a terrible LSD trip early on in my late teenage years, I was so resisting the feelings that I felt like my brain was an electric wire but that things were blocked and my brain was just heating up and it was going to be melting because of the resistance. I actually felt like a nasal drip and I thought, “Oh, my brain is coming out my nose.” It was terrible.

“So it’s the resistance that’s the problem, and so when we say difficult is not the same as bad, what that means is this may be painful, this may be very, very difficult. Some of the PTSD patients have said, “I don’t know why they call this ecstasy,” because when they’re actually releasing the trauma, they’re experiencing a lot of the trauma for the first time because they had to shut down when it was happening and focus on survival. Once people understand that it’s OK to have a difficult experience, there is a way to emerge from it stronger, then I think people are really fully ready to work through difficult experiences.”