Posttraumatic stress reactions, most often captured by the clinical construct of posttraumatic stress disorder (PTSD), are a significant global mental health problem, with a lifetime prevalence rate estimated at 3.64 to 3.9 % worldwide (Illingworth et al., 2021). PTSD is especially prevalent in conflict-affected populations, including refugee populations (Illingworth et al., 2021). Among refugees, torture survivors are especially vulnerable to developing posttraumatic reactions in addition to co-occurring symptom profiles congruent with depressive and anxiety disorders (Campbell, 2007; Daud et al., 2005; Hárdi et al., 2011; McColl et al., 2010). Among refugees and torture survivors, congruent with strengths-based and non-pathological therapeutic frameworks, these reactions are best conceived as normal responses to abnormal circumstances, including circumstances of co-occurring geo-political violence, social injustice, and the gross violation of human rights.
There are many types of psychotherapies used to both manage and resolve posttraumatic reactions, including but not limited to expressive arts therapy (EXA) (McNiff, 1992), somatic experiencing (SE) (Levine, 2010), sensorimotor psychotherapy (SP) (Ogden et al., 2006), exposure therapies, trauma-focused cognitive behavioural therapy (TF-CBT); interpersonal therapy (IPT), and eye-movement desensitization and reprocessing (EMDR) (Mithoefer et al., 2010). In terms of psychopharmacology, selective serotonin reuptake inhibitors (SSRIs), as well as the serotonin-norepinephrine reuptake inhibitor (SNRI), Venlafaxine, appear to be most effective at treating trauma-related symptomatology (Mithoefer et al., 2010).
Despite good evidence for the efficacy of several psychotherapeutic approaches in the therapeutic remediation of trauma-related reactions, a significant portion of trauma survivors – estimated at 30-60% – do not achieve symptom remission regardless of the psychotherapeutic or psychopharmacological approach used (Illingworth et al., 2021; Mithoefer et al., 2010). Also, research suggests that the prevalence of posttraumatic stress disorder (TR-PTSD) may be over-represented among torture survivors (Baker, 1992; Hárdi et al., 2011; Miller, 1992; Sapporta et al., 1992; Somnier et al., 1992).
Given the prevalence of TR-PTSD among torture survivors, there is a pressing need to explore and validate efficacious and potentially novel treatments to better support this population.
3,4-methylenedioxymethamphetamine (MDMA) is a monoamine releaser with a signature pharmacodynamic profile that, when administered in conjunction with psychotherapy, appears to increase the tolerability and effectiveness of psychotherapeutic treatment (Jerome et al., 2020). The operant psycho-physiological mechanisms associated with these treatment gains appear to be associated with MDMA’s effects on serotonin, serum oxytocin, prolactin, reduced amygdalar activity, reductions in neural activation associated with fear and negative emotionality, as well as with subjectively perceived increases in empathy, extroversion, and confidence (Jerome et al., 2020; Mithoefer et al., 2010). The non-clinical phenomenological effects of MDMA administration include both complex and sometimes paradoxically and heterogeneously pleasant and unpleasant somatic, sensory, social, and transpersonal experiences (Wagner et al., 2017). Somatically, these experiences can range from muscle tension to muscle relaxation, increased yawning, coldness and/or extremely pleasant waves of euphoria. Sensorily, tactile sensations may appear richer, and colour often appears more vibrant and brighter. The perception of music can become extremely pleasant and engrossing. Emotionally, these experiences may include anxiety or deep calmness, felt security, pure contentment, or extreme pleasure. These feelings are often accompanied by the generally felt sense of being able to see the world more clearly. Socially, there is an increased pleasure in sharing feelings and ideas with others and with a marked absence of social anxiety. Transpersonally, there may be a felt sense of ultra-connection to all living beings, persons, and things. There may be a marked fascination and wonderment with existence, a felt sense of being 100% complete of the world being perfect just the way it is. There can also be the felt-sense-cognition that the present moment is all you will ever need (Lifey Health, 2023; Psyched Substance, 2023; Wagner et al., 2017).
Clinical populations undergoing trials of MDMA-assisted psychotherapy (MA-PT) have experienced significant and lasting gains in the reduction of posttraumatic symptomatology. MA-PT has also shown promising results on measures of well-being and psychological growth not captured by the Clinical Administered PTSD Scale (CAPS), which serves as the primary measure in evaluating PTSD in clinical trials (Barone et al., 2019). In addition to significant PTSD symptom reduction, participants in MA-PT have reported significant and lasting improvements in self-awareness, relationships, social skills, occupational functioning, substance abuse problems, openness to continued therapy, reduced medication use, enhanced spiritual life, increased empathy and self-compassion, as well as increased “openness to experience,” which may itself represent a deep-rooted personality transformation (Barone et al., 2019; Jerome et al., 2020).
To date, MA-PT trials have focused on trauma survivors with TR-PTSD of diverse traumatic backgrounds, including but not limited to combat veterans, first responders, and sexual abuse and sexual assault victims. MA-PT has yet to be shown to be an effective therapeutic adjunct to the rehabilitation of torture survivors. This paper intends to critically explore and discuss both seminal and current research regarding the therapeutic efficacy of MA-PT, as well as its relevance as a novel treatment modality in the rehabilitation of torture survivors. This paper also proposes a common factors model to better understand the therapeutic mechanisms of MA-PT, as well as important directions for future research.
Common Themes and Problems: MA-PT and Torture Rehabilitation
Common themes and problems researchers must address in exploring the intersection between MA-PT and the rehabilitation of torture survivors include addressing complex and confounding research participant variables. These include, but are not limited to, variables associated with settlement factors and stressors, ethno-racial and socio-cultural factors, factors associated with the complex clinical interplay between organic tissue damage, tissue scarring, acute and complex pain (de C. Williams et al., 2010; Liedl et al., 2011; McColl et al., 2010), as well as factors associated with the phenomenological anxiogenic experience of perceived lack of control secondary to MDMA administration (Psyched Substance, 2023). In this regard, the administration of a potentially anxiogenic substance could be re-traumatizing – especially if the survivor’s torture experience included the forced administration of drugs or other noxious or psychoactive substances. Other potential research considerations include ethical-religious factors pertaining to the prohibition of ingesting “intoxicants,” as well as the determination process to decide which psychotherapeutic approach/modality to augment vis-à-vis MDMA administration.
Clinical Literature Review – Seminal and Current Research
Since the criminalization of MDMA in Canada in 1968 and in the United States in 1985, Mithoefer et al. (2010) conducted and reported on the first clinical trial evaluating MDMA as a therapeutic adjunct to psychotherapy in the treatment of TR-PTSD.
Twenty participants (N=20) with TR-PTSD were enrolled in the study. Subjects were between 21 and 70 years old, with a mean age of approximately 40 years old. Average PTSD duration was estimated at 19+ years. The sample was predominantly white, female, and self-reported sexualized violence in either childhood or adulthood.
Eligible participants (N=20) were randomized, double-blind, to receive two experimental sessions of either MA-PT or the same psychotherapy with active placebo. Several outcome measures were employed in this study, including the CAPS to assess PTSD symptoms at baseline, after each experimental-MDMA session, as well as at 2-month follow-up.
Following analysis, it was found that the MA-PT group had significantly greater improvements in PTSD symptoms than controls. A significant portion of the treatment group (10/12 subjects) no longer met DSM-IV criteria for PTSD. All three participants who reported significant occupational impairment returned to work.
Mithoefer et al. (2010) concluded that with monitoring and support, MA-PT can be used with short-lived and acceptable side effects in a carefully screened group of individuals with TR-PTSD. They concluded that MA-PT resulted in clinically significant reductions in PTSD symptomatology not only at 2-month follow-up but at 17+ month’s follow-up as well (Mithoefer et al., 2013).
In this seminal study, Mithoefer et al. (2010) demonstrate the efficacy of MA-PT in the treatment of TR-PTSD. This study also provides preliminary evidence for the limited side effects and neurocognitive risks of this treatment intervention. However, although sexualized violence may be a common and significant contributor to the overall trauma presentation among torture survivors (Hárdi & Kroó, 2011), the results cannot be readily generalized since many displaced persons, including torture survivors, experience complex stressors and traumas (i.e., which may or may not include sexualized violence). Moreover, most torture survivors who survive to access rehabilitation services oftentimes become racialized BIPOC minorities in their host countries. In this regard, this preliminary study fails to account for complex identity intersections in treatment outcomes.
Lastly, a significant theoretical bias in this study is the authors’ focus on the bio-psychoactive response of MDMA administration instead of the therapeutic impact of the phenomenological experience of MDMA administration itself. MDMA produces potent phenomenological alterations to present-moment conscious experience. Perhaps the phenomenological impact of the treatment, as much as the bioactive response, is responsible for these promising clinical outcomes.
To better understand the long-term qualitative impact of MA-PT, Barone et al. (2019) conducted a follow-up study of a clinical trial of MA-PT for a sample of individuals with TR-PTSD (N=19). Research participants included combat veterans, police officers, and firefighters with a confirmed diagnosis of moderate to severe TR-PTSD. Most eligible participants identified as male and as combat veterans (13/19). Nearly all participants identified as white (18/19).
At one year follow-up, participants of this MA-PT phase II clinical trial completed a long-term follow-up (LTFU) questionnaire and interview. Interviews were recorded, transcribed, and underwent Interpretive Phenomenological Analysis (IPA). IPA is an approach that is especially relevant for evaluating novel treatment modalities since it illuminates the meaning that participants make of their experiences in clinical trials.
Results indicate that most participants reported improvements in friendship (11/19), family relationships (12/19), substance abuse problems (13/19), as well as openness to further therapy (14/19). Furthermore, at one-year follow-up, all participants (19/19) reported improved self-awareness, engagement in new activities, enhanced quality of life, and reduction in PTSD symptoms. Participants perceived that the therapy sessions, in conjunction with the therapeutic benefits of MDMA, as well as the strong rapport with the therapy team, significantly contributed to these sustained long-term therapeutic gains.
According to the study authors, these results indicate that MA-PT can positively and sustainably impact a range of psychosocial functions and improve the overall quality of life, regardless of changes to PTSD symptoms or status.
These clinical findings are particularly useful since all the participants in this study, as is often the case with survivors of torture, specifically experienced adult-onset traumas. The results of this study may be further generalized to survivors of torture, as far as many survivors have also experienced the ongoing stress and terror of war. However, the generalizability of this study suffers from the homogeneity of the predominantly male and white study sample. Generalize to torture survivors who were tortured as a “consequence” of their perceived role in social service or social justice work (i.e., as human rights advocates).
In a more recent effort to summarize clinical findings, Illingworth et al. (2021) conducted a review of the extant clinical literature exploring the use of MA-PT in the treatment of TR-PTSD. A meta-analysis was performed on four clinical trials employing a moderate-sized sample (N=85). All four trials were double-blind, randomized, and compared MA-PT to psychotherapy and placebo. Primarily, outcome measures included scores on the CAPS as well as the Beck Depression Inventory (BDI). Secondary outcomes included measures for physically adverse and neurocognitive effects.
When compared to placebo, treatment groups administered 75mg and 125 mg (but not 100 mg) with psychotherapy (PT) had significant decreases in CAPS scores. A significant decrease in BDI was only observed at 75 mg of MDMA administration. In addition, treatment groups were found to experience minimally adverse physical and neurocognitive side effects. Illingworth et al. (2021) also highlighted that according to this review of treatment efficacy, combat veterans, as well as survivors of domestic violence, may be especially amenable to MA-PT.
These unique indications in terms of treatment amenability may generalize to some torture survivors since the experience of torture is often confounded with war stress and terror, as well as by interpersonal entrapment. With this said, however, neither gender, ethno-racialization, nor cultural characteristics were reported regarding this aggregate sample. Additionally, as the study was biased toward psychometric measures of clinical impairment, it lacked a framework to discuss the surprising inconsistencies within the study. If this study had included alternate psycho-clinical frameworks, for example, the zone of workability from CBT, One significant omission in the study is a discussion of the potential role that perceived social service and benevolent self-sacrifice can have on the onset, persistence, and remediation of trauma-related symptomatology. For example, there may be under-explored common factors within this study population that may (Mithoefer et al., 2010) Or the window of tolerance from SP (Ogden et al., 2006), then perhaps some of these paradoxical findings, including over-activation of the autonomic nervous system (ANS) at higher doses of MDMA, might be better explained.
To explore the maintenance of these positive treatment outcomes at long-term follow-up, Jerome et al. (2020) conducted a longitudinal pooled analysis of six (6) randomly assigned, double-blind, controlled phase 2 trials of MA-PT compared to active placebo for TR-PTSD. Eligible participants (N=107) of heterogeneous trauma etiologies received MA-PT or PT with active placebo. PTSD symptoms were assessed using the CAPS at baseline, 1-2 months after the last active MDMA session, and at least 12 months at long-term follow-up (LTFU). Treatment benefits at LTFU were also assessed using a questionnaire.
CAPS scores were shown to decrease from treatment exit to LTFU. Additionally, the number of participants who no longer met positive diagnostic criteria for PTSD increased from treatment exit to follow-up (56-67%). At treatment exit, 82% of participants (88/107) exhibited clinically significant improvement, with symptom improvements sustained from 1 to 3.8 years post-treatment. Jerome et al. (2020) also found that positive long-term impacts of the treatment included “enhanced spiritual life,” “increased self-awareness and understanding,” “increased empathy”, and “greater involvement in the community” (p. 2494). Taken together and consistent with non-clinical findings (Wagner et al., 2017), the authors suggest that MA-PT may result in changes in facets of personality, such as openness to experience, which may be considered a deep-rooted therapeutic transformation. This change may represent a broad re-orientation of the central nervous system (CNS) from a general experiential physio-emotional-psycho-social pattern of constriction, risk aversion, and social disconnection to a nervous system more broadly characterized by patterns of curiosity, exploration, and sociability (Courtois et al., 2009).
These findings may be of special clinical importance to the rehabilitation of torture survivors since, in addition to TR-PTSD, many authors have described a constriction of personality as a long-term consequence of the torture experience (Baker, 1992; Hárdi et al., 2011; Miller, 1992; Sapporta et al., 1992; Somnier et al., 1992). However, like previous studies, this pooled analysis fails to assess the impact of gender, ethnic-racial, and cultural variables on treatment response. Lastly, this study fails to account for the phenomenological impact of the treatment experience on treatment outcomes. For example, there may be common factors to MA-PT, as well as to other experiential psychotherapies (e.g., EXA, SE, SP, and Accelerated Experiential Dynamic Psychotherapy [AEDP]) that privilege novel and pleasurable experiences of transformance as a primary mechanism of psychotherapeutic change.
As previous research on the efficacy of MA-PT was mostly limited to non-Hispanic, white samples, Ching et al. (2022) conducted a pooled analysis to assess whether MA-PT is also an effective treatment for Black, Indigenous, and other racialized populations (i.e., BIPOC populations). Secondary analysis was conducted on two phase 2 open-labelled trials and a phase 3 randomized, blinded and placebo-controlled trial to compare MA-PT for PTSD between sub-groups of BIPOC (N=37) and non-Hispanic white (N=90) participants. The primary measure was the CAPS score at baseline and at the primary end-point post-treatment. No significant ethno-racial differences were found in terms of CAPS score pre-and post-treatment. These findings provide preliminary evidence for the efficacy of MA-PT for the treatment of PTSD across diverse ethno-racial groups.
These findings are significant in rehabilitating torture survivors since many torture survivors become racialized as BIPOC individuals within predominantly white host countries. However, ethno-racial diversity cannot be conflated with cultural diversity. Nor can contextual factors, such as unmet settlement needs, be ignored in any discussion of the potential efficacy of treatment on symptom reduction. Future studies on the efficacy of MA-PT across ethno-racially diverse sub-groups should include sub-populations with diverse migration statuses to determine if positive MA-PT treatment will also generalize to displaced persons with complex psychosocial needs.
Discussion and Clinical Implications
Preliminary, as well as phase 2 and phase 3 clinical trials have found that MA-PT is an effective treatment for TR-PTSD. The treatment efficacy of MA-PT appears to target not only PTSD symptoms but also broader areas of psychosocial functioning. Treatment gains can be observed at treatment exit, as well as at long-term follow-up. Among some treatment samples, these treatment gains appear to reflect deep-rooted and adaptive changes in personality. Treatment gains have been observed across diverse trauma etiologies in both childhood and adulthood. The treatment gains of MA-PT were observed, in most cases, with limited and tolerable side-effects and minimal risk in terms of substance abuse or other neurocognitive effects.
This body of research indicates that MA-PT may be a viable treatment option in the rehabilitation of torture survivors with presenting TR-PTSD symptoms. However, more research is needed, with diverse migrant samples, to better assess the viability of this novel treatment modality. Treatment participants report that close therapeutic support with their clinical teams was an important contributing variable in the perceived benefit of MA-PT treatment (Barone et al., 2019). In this regard, future trials of MA-PT in the rehabilitation of torture survivors would benefit from in-house wrap-around approaches of care and psychosocial support already present in many torture rehabilitation centers worldwide.
MA-PT highlights phenomenological aspects of psychotherapeutic transformance that are common to many forms of psychotherapy. These common phenomenological aspects of transforming may account for the clinical impact of the treatment beyond the specific administration and psychoactive effects of MDMA. Common phenomenological factors associated with MA-PT may include generalizable, in-session experiences of transformants, which, in addition to the extinction of fear conditioning in the trauma response, may themselves inform the mechanisms of change and personality expansion beyond any remediation of PTSD symptomatology. Common phenomenological/psychotherapeutic factors in trauma-focused treatment modalities (i.e., EXA, SE, AEDP, SP, and MA-PT (Ruse et al., 2008) include:
- Inviting the client to stay present with their own inner experience.
- Fostering willingness to explore new and unexpected perceptions.
- The therapist’s attention to the client’s account of their inner experience.
- The therapist’s capacity to observe a delicate balance between focusing on inner experience while at the same time exploring it in an open-ended way.
- The creation of a therapeutic space where the therapist and client can surrender to the process without controlling or over-determining its outcome.
- Both therapist and client recognize that therapy is a non-linear process that may shift and resolve in unexpected ways.
- The foundational principle is that a human being’s inner healing intelligence, in conjunction with medicine, will bring forth whatever experiences are needed for healing and growth so that anything that arises is viewed as part of the healing process.
- The therapist’s role is often to follow rather than guide.
- Facing painful experiences is a path toward healing. (Ruse et al., 2008)
To better understand the interplay between common factors in trauma-informed and trauma-focused therapies of phenomenological expansion and transformation, future studies exploring the differential subgroup treatment outcomes of MDMA-assisted expressive arts therapy (MA-EXA), MDMA-assisted somatic experiencing (MA-SE), or MDMA-assisted sensorimotor psychotherapy (MA-SP), may shed light on the specific therapeutic mechanisms of change in any MDMA-assisted psychotherapeutic approach.
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