MDMA-Assisted Therapy for Posttraumatic Stress Disorder: A Mixed-Methods Case Study of a Participant of Color From an Open-Label Trial

Trauma Reprocessing

After the first dosing, Kenneth shared his experiences revisiting his index trauma without being overwhelmed:

The challenging part was just diving into those memories. But I wasn’t crying. In fact, I was able to sometimes laugh at some things. I was able to really dive into my own mind. It’s like, “I’m gonna go for it.” And I just went in and did it, you know?

He also shared the experience of organizing his trauma memories neatly as folders in the filing cabinet that is his mind, and which are now voluntarily accessible:

Now, I can remember if I want to, and I don’t have to remember if I don’t want to. Now, they’re all there, so that’s really nice. It almost felt like I was going through files yesterday. Like, “Hmm, where is the hidden file?” Now, I have access to the memories. It’s all there.

Kenneth also described metaphorical experiences of revisiting his sexual abuse rapidly as different “planets of experiences,” as a way to process them quickly and efficiently. He also described assuming a persona that allowed him to survey his “planets of experiences”:

Each of my memories was its own planet, and I landed on each one. It was awesome really diving into and revisiting each of those memories. While all that was happening, I also remember becoming Galactus, a giant cosmic character in the Marvel Universe. So, I was just looking around, being him, and watching myself revisiting these memories.

Kenneth reported that in the first dosing session, he experienced the symbolic merging of his pretrauma, posttrauma, and ideal selves. In doing so, he removed the “mask” that he had put up to navigate life after his sexual trauma and reemerged as his authentic self. Kenneth utilized references to pop culture and his Hindu heritage in describing this integration of parts of himself:

There was the innocent child, angsty teenager, and the adult God form. The innocent child is the one that existed before any of the abuse. The angsty teenager’s right after that, and the God is the final form. Now the innocent child’s happiness and pureness is mixing with that God-like form. I feel like now there’s no reason to be that angsty teenager anymore. The angsty teenager feels like a fallen soldier almost. You have done your service, go and rest. Let go of the pain. The pain the angsty teenager endured is still valid, he’s just not in the main picture anymore. It’s like when a Jedi dies. They don’t actually die, they just become a part of the Force. It’s also kind of like a Hinduism thing. In the Baghavad Gita, Krishna can be at times a baby. It can also be the chariot driver for Arjuna, and it can also have an all-powerful universal form too, you know? It’s kind of like all these things mixed together. Now, all of the parts of myself can work well together. And it’s really nice, because it’s easier to show up fully in all of my interactions and not have to hide or mask myself in different relationships.

Cognitive Change

After the first dosing, Kenneth expressed the insight that while his need for achievement and perfectionism was means of coping with the sexual trauma, these maladaptive patterns of thinking paradoxically served to maintain his difficulties in functioning. As a result of this newfound awareness, Kenneth reported being better able to challenge his thinking patterns in ways that he was not able to previously:

Michael Phelps didn’t win a perfect 28 gold medals; he got a few silver and bronze medals on the way. That’s still an amazing achievement. In the past, I was striving to achieve, but I was never satisfied. Now, I’m satisfied. Instead of being negative or critical with myself, I’m more constructive with myself in a lot of ways.

He also accurately recognized that he was older now and less physically vulnerable, which made him less fearful about trauma-related cues and reminders:

I’m grown now. There’s no real need to protect myself or be as fearful anymore. There’s no real danger anymore.

After the third dosing, Kenneth described a sense of self-efficacy in facing future stressors because (a) he believed that he was prepared to handle them, (b) he trusted that others (e.g., any therapist he might see in the future) would help him out, and (c) his PTSD symptoms were very much improved:

I think there’s just a lot fewer things bothering me right now. I’m just ready to take things on. Everything just feels stable. Even with bad things happening in the future, I’ll be able to take care of myself. And if not, I’ll just ask others for help.

Emotional Awareness and Regulation

Kenneth reported experiencing emotions in their fullness during the first dosing session, which he discussed as different than his usual mode of “bottling things up.” He reported being able to release the anger—emotionally, verbally, and somatically—which he had attempted to suppress throughout his early teenage years after the sexual trauma. Kenneth also used motivational lyrics in rap music to bring forth positive emotions during the first overnight stay:

This time I didn’t want to bottle it up. It’s not going back in my muscles. That’s not happening. Also, after the session, I put some Lil Uzi Vert on and I realized, Lil Uzi is so happy. There’s a song where he is like, “I can do what I want, I’m better now.” I was like, “Damn, that’s relatable.”

After the first dosing session, Kenneth reported successfully de-escalating arguments with his parents through affectionate behaviors (e.g., hugging them) or compromises, contrary to his behaviors pre-MDMA-AT. He attributed this change to an increased awareness of how negative emotions can worsen interpersonal conflicts:

Every time they yell at me, I was just able to bring the situation back down. If I just calm myself down and give my mother a hug, she’ll relax and won’t freak out on me. It’s working pretty well.

Kenneth reported meditating regularly after the first dosing to practice calming down, to sustain feelings of calmness he experienced during that session. Meditation was also helpful in managing trauma-related anger and paranoia, to the extent that he was much less affected even in the presence of trauma triggers:

I now like to meditate for brief periods because it helps me calm down. You know how some people describe being angry as holding on to something hot? That’s what it feels like to me when I’m meditating, like dropping a hot object. I also feel a lot less tense and paranoid.

After the second dosing, Kenneth also reported doing full-body stretches regularly, which he endorsed as a somatic strategy to release trauma-related muscle tension:

I feel like I can breathe more, because I’m constantly like, stretching out. So much tension has been relieved from my body because of that.

After the first dosing, Kenneth described having a softer, more compassionate inner voice whenever he introspected about his current problems. He likened it to a “mature God voice,” one which was not so hard on himself, as opposed to his earlier “angsty teenager voice.” Furthermore, Kenneth was also able to experience compassion toward his perpetrator, as well as other sexual perpetrators. He described being able to see their pain and the reasons why they might have committed the crimes that they did:

I don’t think anyone does anything bad because they’re inherently evil. I think they do it because they’re in some sort of pain, and this is what comes from that pain.

Reduced Intrusions

Kenneth denied experiencing any flashbacks after the first two dosing sessions, which made it easier for him to focus on academic tasks. He expressed surprise at how his flashbacks were absent even just after the first dosing, even in the presence of trauma reminders. Furthermore, he described the function of flashbacks as his brain’s way of helping him fill in gaps in his index trauma memory, a function which was now unnecessary due to now having complete memory about his sexual abuse:

A lot of times whenever I was doing anything, especially when I was working on things, sometimes I’d have flashbacks, and that would bother me a lot. I’d almost dissociate. I wouldn’t remember where I am, and then I’d have to recalibrate, because I’m distracted. Now I don’t have any flashbacks at all.

After the first two dosing sessions, Kenneth also denied experiencing trauma-related nightmares, which made it easier for him to “get on” with his day after waking in the morning:

Now, when I have dreams at night, they’re normal. They’re not like the usual trauma nightmares. These days, I haven’t woken up in a cold sweat at all.

Reduced Avoidance

After the first dosing session, Kenneth reported mindfully approaching his trauma-related memories, which have decreased in frequency and intensity. He viewed them now as nonintrusive and was not distressed or overwhelmed by them:

Now I just let those memories play through. I can easily deal with those experiences now. I don’t have to avoid them or distract myself.

Similarly, after the first dosing session, Kenneth reported mindfully approaching trauma-related reminders as well; in the past, he would engage in immediate avoidance to prevent the onset of distressing flashbacks:

There was news on NPR about the Harvey Weinstein case, and I just let it play. I can now kind of deal with those experiences that remind me of the trauma, and not avoid them.

Improved Cognitions and Mood

After the first dosing session, through the use of the filing cabinet metaphor, Kenneth endorsed being able to remember everything about his sexual trauma. He believed that this was the reason why he no longer experienced flashbacks or other intrusive symptoms:

Whenever I got the flashbacks, it felt like they were missing pieces that pop up, and were just another thing that I have to make sense of. It was one of those things that really bothered me. Like, how can I not remember something so big that happened to me as a kid? I think these pieces were just always buried in my brain, and my brain was constantly trying to remember the whole sequence of events. Now, I don’t need to keep searching, it’s just all there. Now, I remember everything.

After the first dosing session, Kenneth described being able to accept the sexual trauma as part of his life history, and being able to resolve his thoughts and feelings about his sexual trauma on a profound level. This was a stark contrast from his previous perseverative self-blame for not having been able to defend himself against the perpetrator. Due to improved PTSD symptoms, Kenneth also reported experiencing greater clarity, focus, and problem-solving ability, even with persisting inattention symptoms:

I was going through the trauma in my head during the session. Just accepting it once again, affirming it, like, “Yes. It happened. But I’m alright now.” You know how when you have a problem and you deal with it and feel content afterwards because you handled the problem? It feels a lot like that, but on a deeper level. Things are a lot clearer, and I feel like I’ve just gotten so good at figuring out problems, that I don’t need to go to others for advice. It’s like archery, and I’m aiming for the bullseye, and I’m rapid firing, and I keep splitting the bows in half every time because it just keeps working.

Kenneth further reported that during the second dosing session, he was able to move beyond accepting to internally resolving his residual trauma-related feelings of paranoia, anger, and irritability:

I was like, “Alright, I still have a few symptoms, let me go dive into those.” And I just went for it. There was a time when I sat up and I was repeating the symptoms that were bothering me. The paranoia, the irritability, the anger, I just kept naming them out loud over and over again until I started having that dialogue with these feelings, and then I was able to handle them. They don’t bother me now.

Finally, after the third dosing session, Kenneth articulated a deep sense of liberation from his trauma and wanted to metaphorically “charge forward into the unknown” that was his future and embrace it, instead of being afraid of it:

It feels like I’m finally moving forward. It feels like the trauma has been taken care of. I’m figuring out what to do going forward. It’s really freeing. Now it’s time to charge forward into the unknown and see how things come out, and embrace what comes next.

After the first two dosing sessions, Kenneth also described experiencing sustainable feelings of happiness and optimism, increased motivation to accomplish things, and the belief that he can readily confront future challenges. These improvements were consistent with his pre–post session reduction in BDI-II scores (Figure 2):

I just feel like my motors are running a lot quicker because there’s less gunk. Less sadness gunking up everything. It won’t even be a sunny and cheery day, and I would be like, “Let’s go do some work. Let’s get to it.” I’m smiling a lot more, and I feel a lot happier, in a sustainable way.

Reduced Vigilance and Arousal

After the first two dosing sessions, Kenneth described significantly reduced vigilance for signs of physical danger in his surroundings:

In the past, I would have checked way more for safety. But last night after I closed my bedroom door and shut the blinds, I went right to sleep. It was interesting because I wasn’t worried, you know? I didn’t have to distract myself from thoughts about danger or anything.

After three dosing sessions, Kenneth described experiencing progressive somatic relaxation, being less “tensed up,” less physiologically aroused, and less jumpy, “on edge,” or irritable. For example, after the third dosing session, he said,

It felt more physical than mental this time in terms of the experience. I was so relaxed. It just felt like I was sinking into the couch.

Kenneth also reported improved sleep quality, with significantly reduced waking during the night after the first two dosing sessions:

It’s been really nice to get some solid sleep, to sleep soundly without waking from nightmares. With the MDMA, in my head, I’d just be like, “Take me.” And when I’m in bed, I just do the same thing. I just think to myself, “Take me,” and I fall asleep so easily.

Reduced Suicidality

During the first dosing session, Kenneth saw himself living life as a 60-year-old, which he interpreted as needing to abandon any distorted, suicidal ideation that may arise moving forward. He described the effects of MDMA as propelling him forward in time, so that he could envision life as his future self, with several strong reasons to continue living:

The MDMA definitely helped me zoom forward, like seeing past the age 40. That was always the arbitrary number. It’s so much easier to believe you’ll live past that age if you can see past that age. It’s really hard to say you’re gonna die at 40 when you see yourself at 60. I just couldn’t hold onto that belief anymore. I’m done with thinking that way.

As a result of this insight, Kenneth experienced rapid reductions in the frequency and intensity of his suicidal thoughts. He described these thoughts as being much less egosyntonic and was able to easily and quickly control, dismiss, or ignore these thoughts with minimal distress. In addition, when his suicidal thoughts would occur, he reported being able to attend to activities that he would be engaging in, instead of being distracted by those thoughts. These changes were consistent with his reductions in suicidality on the C-SSRS:

I had a suicidal thought just once. That was on Saturday. But I’d also like to point out that it was a lot different than before. It felt much more surface-level than actually, genuinely wanting to do it. And it was also much less intense. Before all this, it would feel like an 8 or a 9 out of 10, but now it’s at most 2 at the worst. I would say after a minute or two I was able to control and dismiss it pretty solidly.

Reduced Illicit Substance Use

Kenneth also expressed deep appreciation of how MDMA and other psychedelics purportedly catalyzed creativity in public figures whom he admired. At the same time, he was also cognizant that these substances should not be used recklessly and, after three dosing sessions, expressed no desire to engage in psychedelic use:

I can now see why Steve Jobs did so much after taking psychedelics. In his biography or in the movie, they talk about how he wouldn’t have been who he was if he didn’t have those experiences that allowed him to think ahead of his time.

After the first two dosing sessions, Kenneth also expressed less desire or need for marijuana as a way to cope with his PTSD symptoms:

I have much less need or want for weed now, since that was mostly to help with the PTSD. My friends brought me more weed for my birthday, and I was like, “I don’t want that, you know?” I cannot smoke while I’m in this study. I also just don’t want to smoke, you know? I don’t need to.

Pursuing Priorities

After the third dosing session, Kenneth reported feeling “hypermotivated” to accomplish multiple goals. He described this motivation as “laying dormant” prior to MDMA-AT and “reignited” due to the treatment. At the same time, although he was cognizant that he would need adequate sleep to have enough energy to pursue his goals, he reported being unsure as to how to achieve a “balance” between the two:

I think one way to achieve something is if I work hard on it for a long time. If I get used to doing that, then that becomes my natural state. But I also know that for problem-solving and learning, sleep is very necessary. The problem is that there’s so much schoolwork. Add to that the important causes that I want to support that I sometimes forget about the fact that sleep is very necessary. I just have to figure out a way to find a balance.

One of Kenneth’s many priorities, besides mental health initiatives, was to create restorative justice initiatives targeting sexual misconduct on campus. To do so, he had to access and read complaints provided by the institution. Notably, this was another indication of nonavoidance of trauma reminders. He described feeling motivated to get implicated organizations on campus shut down, so that others would not be subjected to the sexual violations that these organizations seemed to perpetrate:

If I pursue these cases and get these organizations shut down, or get an investigation into the system going and call people out and fix policy and get people removed, that’s a change that matters. Because that means that there would not be any people suffering in the future. And as long as I can do something about it, I’m going to do something about it.

Negative Effects

Kenneth experienced significant sleep deprivation after the third dosing, due to the start of the academic semester and Kenneth’s desire to accomplish multiple goals. Kenneth reported staying up most nights to complete schoolwork and work on his initiatives and, as a result, did not get sufficient sleep. He reported that his sleep debt, as well as his occasional overuse of his ADHD medication, had led to transient side effects such as mild visual blurring:

I sleep very sporadically. During the week, there will be around two days where I just won’t sleep and then the weekend is when I catch up a lot on it, which is not healthy. And if I don’t sleep for a couple days, some things, like lines and colors, tend to blur, but it’s not very bad or noticeable. But like, how else does one get all of this work done?