MDMA-assisted Psychotherapy: An interview with Ivar Goksøyr

MDMA, principle ingredient in the illegal drug ‘ecstasy’, may soon be legally administered as part of a radical new psychotherapy. We caught up with Ivar Goksøyr, clinical psychologist at Psykologvirke and board member of the Norsk Forening for Psykedelisk Vitenskap, to find out more.

tekst: Dominic Munton, Psykologi profesjon

Can you tell us a little about yourself and your professional career?

I finished my studies at the University of Oslo in 2009 and I’ve been working as a psychologist since then. I specialised in clinical psychlogy with the Norsk Psykologforening. I started working in mental health public care services, and for the last five years I’ve been working in private practice. I’m also affiliated with a unit at Sykehuset Østfold called Psykforsk, which researches into innovative treament modalities. Technically, I’m specialised in an intensive form of psychoanalysis called ISTDP, intensive short-term dynamic psychotherapy, but I also do general psychotherapy work with adults.

Foto: Ivar Goksøyr

How did you first hear about MDMA as a therapeutic tool?

My first relationship to MDMA was, like anyone else, through its identity in the media as a dangerous party drug. What opened my eyes to MDMA’s other identity, was listening to the histories of patients who had experienced its therapeutic effects. Once I started digging into the science of it, I was shocked to discover that MDMA and other psychedelics had a history of therapeutic use that no-one ever talks about.

I’ve always been interested in trying to reach the deeper levels of the psyche. Depth psychology is fascinating, and yet at the same time it is so difficult to really get access to the deep unconscious material of the mind. Throughout my career, I’ve become steadily better at working with these dimensions, and I do succeed in reaching people by conventional methods, but some patients are still really difficult to help, especially those who have been stuck for a long time or from a very early age. When I read in the literature that there were agents that could help us more readily access this unconscious material, I was more than interested.

“MDMA is like a pharmacological bridge to deep psychological landscapes which are otherwise difficult to access”

Existing medications tend to blunt or supress not only anxiety or depression, but also other feelings too. It seems like MDMA and the psychedelics offer the potential to work from the opposite direction, opening up and revealing instead of disconnecting. I really like that! This is the way that I like to work because I believe that it has the potential to yield deeper healing and more longlasting effects.

Most of us are used to hearing about MDMA or ‘ecstasy’ in the framework of recreational drug use and abuse. How did we get from potential therapeutic tool to illegal drug and now back again?

In the late 1970s, MDMA was initially used therapeutically, not in night clubs. Early use was primarily oriented towards healing and self-development; an estimated half million doses were used in this context. It wasn’t until later that MDMA was commercialised as ‘ecstasy’ and distributed as a party drug.

Up until the mid-1980s, there were dozens of therapists using MDMA together with psychotherapy in some several thousand sessions. There were no controlled scientific studies at this time, but there were some uncontrolled studies and many reports which gave indications of MDMA’s potential therapeutic value, at least within certain populations.

“Psychedelic science has moved from stigma to cutting edge within the last five years”

Then, in 1985 the US regulated against MDMA. The next year, the World Health Organisation regulated in line with US wishes for corresponding controls at a UN level. Despite classifying MDMA as a schedule I drug, the WHO noted that MDMA was of potential scientific significance and encouraged member states to continue researching into its therapeutic properties. However, since then it has been very difficult to do research, due both to difficulties in financing and in getting protocols approved. In the early 2000s one study was approved, but it was forced to shut down after only six patients had been treated due to political pressure.

2011 saw the publication of the first well controlled study on MDMA. Although the study demonstrated highly promising results, its findings were inconclusive due to its small size (twelve participants). Since then much more research has been carried out, especially into the use of MDMA-assisted psychotherapy to treat PTSD (Post Traumatic Stress Disorder). So far, 107 patients have been treated in randomized, double-blind, placebo-controlled trials, and the effect size looks good. Furthermore, remission rates in long-term follow-ups are looking very good, especially in difficult to treat populations. Right now, the evidence looks highly promising, but we still need much more of it. This means that it is not currently possible to draw further conclusions about MDMA’s therapeutic value in terms of rigorous scientific standards. That said, most clinicians and patients who have experience of the drug agree that it demonstrates potential.

How does MDMA-assisted psychotherapy compare to other treatments for PTSD?

As of today, there are other good treatments for PTSD, but many patients still respond suboptimally and there is a lot of suffering. There is a general consensus that we need to improve clinical implementation of scientifically-validated treatments, but we also know that no single modality is effective for all patients at all points on their healing journeys. This means that we need a bouquet of different methods with which we can reach different people at different stages in their development.

In recent years, other medical disciplines have shown significant improvements in their treatment methods: people are dying less, and new treatments and even cures are being developed. In contrast, mental health has developed into a largely palliative discipline where treatment focuses on symptoms, not root causes of illness. There are clear indications that MDMA and other psychedelic therapies have the potential to work with core psychological issues, not just symptoms; hopefully the data will confirm these early observations.

Furthermore, although many people respond well to existing treatments, these treatments also have a high dropout rate because treatment is extremely psychologically challenging. Patients must confront their deepest fears in order to heal, and it is easy to become overwhelmed. The closer a patient gets to their trauma, the higher the risk that they dissociate or become overwhelmed.

MDMA seems to work by reducing activity in the amygdala, the brain’s fear centre, and stimulating the release of oxytocin, the ‘love hormone’. This means that patients get additional resources that increase their chances of successfully engaging with their trauma. During an MDMA-assisted therapy session, the patient can process their trauma and help their body re-experience and integrate their traumatic experiences. Once the drug effect has worn off, fear and avoidance of traumatic issues are still lessened. MDMA is like a pharmacological bridge to deep psychological landscapes which are otherwise difficult to access.

“Therapists Marcela Ot’alora and Bruce Poulter conduct MDMA-assisted psychotherapy in Boulder, Colorado.” Courtesy of the Multidisciplinary Association for Psychedelic Studies (www.maps.org)

Do you experience stigma in your professional life as a result of your interest in MDMA-assisted therapy?

Not anymore. I would say that these days, people read their journals, and they see for themselves that this is a legitimate and important area for research. We are not in a position where we can simply dismiss any promising modality on the basis of our preconceptions. In fact, I have the impression that psychedelic science has moved from stigma to cutting edge within the last five years.Nowadays, I get a lot of recognition and a big thumbs-up. Personally, I find it unethical that anyone be fundamentally against conducting research. And what we’re saying right now is not that psychedelics are ready for use in clinical practice, and certainly not in recreational settings, but that more research is called for.

With increasing media focus on the therapeutic use of psychedelics, do you think there is a risk that people will get confused ideas about what these substances are and how they can be used?

Yeah, I think that there is a potential for that. What we need to do is to avoid underestimating the risks, but also avoid overestimating them. We should also be careful not to idealise these modalities as therapeutic agents. Most people that have tried psychedelics would probably agree that whilst they experienced some benefit from them, they were not a magic bullet that resolved everything. Therefore, it is important that we take care to communicate both potential benefits and risks. I want to underscore that the clinical use of MDMA or other psychedelics is clearly different from recreational use. In the clinic, we know exactly what the compound is, exactly what dose we are using, and we can control the circumstances to create a safe environment. On both MDMA and psychedelics, individuals can potentially get in touch with deep and frightening aspects of the unconscious. This can lead to destabilization, which in rare cases could be dangerous outside of a safe container.

What are the differences between the different kinds of psychedelic therapy?

Classical psychedelics such as LSD, psilocybin-containing mushrooms, mescaline and ayahuasca work by dis-integrating the brain’s standard information processing networks. When this happens, there is less of an “I” through which information is processed, and we experience less attachment to our habitual ways of perceiving ourselves and the world. Classical psychedelics could be likened to a fresh snowfall on a winter’s day: prior to the snowfall, the old snow is patterned with movements and footfalls that reflect our everyday mental behaviours. When fresh snow falls, everything is fresh and new. We can find new patterns, and we don’t fall into old ones so readily.

“I want to underscore that the clinical use of MDMA or other psychedelics is clearly different from recreational use”

However, classical psychedelics are not anxiety regulating, so whilst they can give rise to therapeutic experiences, they can also be really frightening. In recreational settings, such challenging experiences can potentially become a ‘bad trip’. In a clinical setting, such experiences need not escalate to the same extent, but there can still be a lot of anxiety to work through.

In this sense, classical psychedelics could be described as ‘mind opening’, whilst MDMA would be a ‘heart opener’, as the patient feels much less anxiety under its influence. The state of consciousness experienced on MDMA is actually not so different from what we experience every day, apart from including a greater sense of safety, love, empathy and compassion towards oneself and others. Psychotherapeutically, this is a really good state to work with.

In addition to your clinical work, you are also on the board of directors for the Norsk Forening for Psykedelisk Vitenskap (NFPV). Could you tell us a little about this organisation and its work?

We work to promote the scientific exploration of psychedelic substances because we believe that past censorship and stigma has made it difficult to do research with them. We’ve been running for about a year now. We find that there is plenty of academic interest in this area from multiple disciplines, but that researchers are often isolated. We serve primarily as a networking point so that academics can get in touch with each other, share research ideas and get their projects up and running. We also inform our colleagues and the public about the current status of psychedelic science and hope to encourage those who might be interested in a career in the field. So far, we’ve held a variety of lectures and seminars, and we have a conference planned in the near future.

We offer a significantly reduced membership fee for students who wish to participate. I would really encourage students to get involved because, due to past restrictions on research, this is an almost untouched field. Today, the field is really opening up, and there will be a lot to do over the coming years. For students interested in psychedelic science, joining the forening is a great way to start networking and get the ball rolling on a future career.

How do you see the future of psychedelic science in Norway over the next five years?

Sykehuset i Østfold just received approval for Norway’s first-ever study on the treatment of PTSD with MDMA-assisted psychotherapy; research and recruitment will start this October. Treatment of depression with ketamine is also part of this movement, and implementation in clinical practice has just begun, for example at Sykehuset i Østfold. There are more and more international psychedelic research centres popping up and psychedelic publication rates are at an alltime high, so we can expect to see many more articles over the coming years. As far as clincal use is concerned, we hope to have MDMA-assisted psychotherapy approved for clinical use here in 2024: the US is heading towards approval in 2022, and current phase 3 clinical trials in Europe are only a few years behind. Assuming that current research continues to follow the same positive trend, we can expect to see MDMA-assisted psychotherapy rolled out in Norway within five years.

Millions worldwide do not respond to standard treatments and are still suffering. We owe it to them to clarify the therapeutic potential of these agents as soon as possible, no matter what the science ultimately tells us. ■

Psykologvirke – http://www.oslopsykologvirke.no/

Norsk Forening for Psykedelisk Vitenskap – http://www.nfpv.no/

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