DAVID E. NICHOLS, PHD
GEORGE R. GREER, MD
MARK A. GEYER, PHD
ROLAND R. GRIFFITHS, PHD
CHARLES S. GROB, MD
DENNIS J. MCKENNA, PHD
STEPHEN ROSS, M.D.
FRANZ X. VOLLENWEIDER, MD
ROBERT J. BARNHART
ELIZABETH GORDON
WILLIAM A. LINTON
RICHARD M. WOLFE
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LYNETTE HERRING

Subjective Reports of the Effects of MDMA in a Clinical Setting

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Reprinted from the Journal of Psychoactive Drugs Vol. 18(4):319-327 (October-December, 1986). Copyright 1986 by the Journal of Psychoactive Drugs. All rights reserved. Unless authorized in writing by Haight-Ashbury Publications, 612 Clayton St, San Francisco CA 94117, no part of this article may be reproduced or used in a manner inconsistent with the publisher's copyright. This prohibition applies to unauthorized use or reproductions in any form, including electronic media. (Thanks to the Journal of Psychoactive Drugs for allowing reproduction of this article on the Web.)

George Greer, M.D. & Requa Tolbert, R.N., M.S.N.

(email: george@newmexico.com)

The psychological effects of MDMA were first reported in 1978 by Shulgin and Nichols (Shulgin & Nichols, 1978). Because it had originally been patented in Germany in 1914 and was no longer patentable, no pharmaceutical manufacturer could be found who was interested in sponsoring an Investigational New Drug Application with the Food and Drug Administration or in supporting research (Shulgin, 1980). In 1980, it was learned that, in California at least, drugs that were not yet available commercially could be used within a physician's practice if they were manufactured by the physician or by a pharmacist (Younger, 1978). The State medical board recommended that there be peer review, informed consent and supporting scientific literature when conducting experimental work (California Board of Medical Quality Assurance, 1980). This article is a summary report of data gathered from the first 29 people administered MDMA in a clinical setting.

Because the primary purpose of the project was to assist the subjects in achieving their particular and varied goals for having the sessions, the data available for analysis is limited. Only phenomenological descriptions were obtained of the therapists' observations and of the subjects' experiences before, during and after the sessions. Psychological evaluations by independent observers with testing before and after sessions, placebo control group data with double-blind assessment, vital signs during sessions (except in 2 subjects), and pre- and post-session laboratory testing of organ and metabolic functions, were not conducted.

Method

The MDMA used in this study was synthesized in the laboratory of Alexander Shulgin, Ph.D., who had collaborated in writing the only published papers on its synthesis ( Shulgin & Nichols, 1980; Braun, Shulgin & Braun, 1980). Dr. Shulgin was present during the entire procedure for consultation and assistance. Identity was verified primarily by infrared spectrophotometry.

All sessions were conducted in San Francisco, California and Santa Fe, New Mexico between 1980 and 1983. All guidelines specified by the California Board of Medical Quality Assurance and the New Mexico Board of Medical Examiners for experimental medical practice were followed. All subjects were referred by psychotherapists or friends specifically for the purpose of having an MDMA session, and none were referred from the author's (Greer) private psychiatric practice. The co-authors, a Board-certified psychiatrist, usually accompanied by a Masters-level psychiatric nurse, were the psychotherapists for all sessions. A questionnaire designed for screening and preparing the subjects for MDMA sessions was filled out, and lengthy informed consent information was explained both verbally and in writing. (Information regarding "Informed Consent for MDMA Session" is available from the authors.) Parenthetically, 5 subjects (#'s 25-29) who were well-known to the investigator filled out the questionnaire retrospectively at the time of follow-up.

In the preparatory process, the possible side effects that could occur (resulting primarily from MDMA's sympathomimetic effects) were described in detail. Subjects were also told that they should not take MDMA unless they were certain that they were willing to deal with any disturbing experience they might have, including (but not limited to) previous psychological difficulties.

The following medical conditions were criteria for exclusion from the study: hypertension, heart disease, hyperthyroidism, diabetes mellitus, hypoglycemia, seizure disorder, and glaucoma (all because of MDMA's sympathomimetic effects); diminished liver function from any cause (to avoid prolonged metabolism); and actual or possible pregnancy. In addition, subjects with a history of a socially or vocationally disabling psychological condition--other than alcohol or drug intoxication--were excluded. Subject #19 was an exception because the disability was not known until after the session.

The following agreements were made with the therapists before the session to ensure an atmosphere of psychological security and physical safety during the session: 1) Everyone agreed to remain on the premises until the session was over, and the therapists determined that it was safe to leave; 2) The subjects agreed to refrain from any destructive activity to self, others, or property; 3) All agreed that there would be no sexual activity between the therapists and the subjects; and 4) The subjects agreed to follow any instructions given by a therapist when explicitly stated as part of the structure of the session.

Most sessions were held in the subjects' homes. A 6-hour fast was instituted to ensure rapid absorption of the MDMA and to prevent nausea. Before the dose was administered there was time to re-establish contact with the therapists and answer questions. A dose of 75-150 mg of MDMA was then given by mouth. (Subject #7 received higher doses, which are discussed below.) Lower doses were used in interpersonal sessions, and higher doses were given to heavier people. During individual sessions, the subject listened to instrumental music--with or without headphones and/or eyeshades--to facilitate an internal experience. During interpersonal sessions, music was usually played in the background. The therapists were attentive and available to respond to requests or needs, to receive and record communications, and to interact with subjects as was deemed appropriate.

When subjects noticed that the effect of MDMA was beginning to subside--usually before 2 hours--they were offered a second dose of 50 mg or, rarely, 75 mg. The purpose of the second dose was to prolong the session and to provide a more gradual return to their usual state of consciousness. Some subjects were offered diazepam, 5 mg, at the beginning of the session, or propranolol, 20-40 mg, every 3-1/2 to 4 hours to reduce unwanted sympathomimetic side-effects. Others received l-tryptophan, 500 mg, to reduce discomforts occurring late in the sessions.

When the sessions were over, the subjects' ability to drive was assessed before they were allowed to drive a car. The usual duration of sessions was 5-8 hours, depending on the dosage and setting. Follow-up was conducted both verbally, soon after the session, and much later by written questionnaire. DSM-III psychiatric diagnoses were made retrospectively.

Results

The data gathered are presented in narrative form. (These data are available from the authors in tabular form.) The findings are presented in the categories of the questions asked, though the actual answers summarized may have been given in response to other questions. Much information was gathered on the pre-session questionnaires, but most was for screening purposes or for comparison with the follow-up questionnaires. The only items from that questionnaire mentioned here are pre-existing physical or psychological problems and the subjects' purposes for having the session.

5 couples took MDMA together, and 6 sessions involved groups of 3-6 mutual friends. 8 subjects, including 2 of the couples, had 2 sessions each; and 3 subjects had 3 sessions each. 4 subjects reported they had taken MDMA from 5 to 14 times in addition to the sessions supervised by the investigator.

14 of the 29 subjects reported psychological problems, none of a severe nature. 6 reported a dissatisfaction with themselves (fear of rejection, perfectionism, lack of self-confidence, etc.). Mild depression was reported by 4, anxiety by 2, hate or sadness at being alone by 2, "normal" existential despair or "angst" by 2, and difficulty making major life choices by 1. (Subjects with DSM III psychiatric diagnoses are discussed below.)

2 subjects had significant health problems: subject #4 had essential hypertension that was well-controlled with medication, and subject #7 had chronic macula edema in one eye with an ocular implant.

Follow-up questionnaires were completed by 28 subjects from 2 months to 2 years after the last session, and most were around 9 months. The other subject (#22) responded with a letter over 2 years later instead of filling out the questionnaire.

Benefits during sessions

Every subject experienced some benefit from MDMA during his or her session. 27 felt closer and more intimate with anyone present. (The other 2 had solo sessions.) All 21 subjects who had sessions in couples or groups experienced more closeness and/or enhanced communication, and 2 found it easier to receive compliments or criticism.

All 29 subjects reported positive changes in their attitudes or feelings. 16 felt more warm, fresh, alive, euphoric or loving feelings. 10 subjects mentioned greater self-confidence or self-acceptance, and 10 felt their defenses were lowered. 2 of these and 5 others reported undergoing a therapeutic emotional process. 5 subjects said they had a transcendent experience. 5 noticed having less negative thoughts or feelings. 3 felt more self-aware or self-grounded, and 2 reported feeling blessed or at peace.

22 subjects reported some cognitive benefit: an expanded mental perspective, insight into personal patterns or problems, improved self-examination or "intrapsychic communication" skills, or "issue resolution." 5 subjects used a low dose (50 mg) to facilitate their creative writing abilities--4 in a group session and 1 alone. All found it quite useful. 5 subjects reported clear cognition or enhanced presence of mind.

1 subject reported an enhanced sense of touch; and 1 felt pleasantly warm, which was unusual for her.

Undesirable effects

All subjects reported some undesirable experience during or after their sessions. The longest that any of these symptoms persisted was 1 week, except in 2 subjects. Subject #14 experienced a week of increased appetite and rapid weight gain over a few weeks. He enjoyed eating more for a few months and then lost 10 pounds. No other subjects reported increased appetite. Subject #19 had difficulty coping with work, friends, and relatives a few weeks later. He then had anxiety attacks which caused him to miss 7 days of work. Work had been a major life stress both before and after the session, and had led to similar episodes of disabling anxiety in the past. He was "not receptive to the sensation" of MDMA and "stress[ed] that the session itself was not the anxiety-inducing catalyst. Rather, I think it served to open up some tightly controlled emotions that spilled out in a frightening way." He entered long-term, semi-weekly psychotherapy for the first time. A year later he said, "It probably was a good thing. It speeded up processes that needed to happen."

Every subject reported some undesirable physical symptom and 1 subject (#7) had many more physical symptoms than any other. She was by far the oldest (74 years) though in good general physical health, except for her macula edema. She took, in two separate sessions, a much higher single dose (200 mg) and total dose (350 mg) than any other subject. The side effects she reported during sessions were: nausea, a small amount of vomiting, jaw tension, ataxia, urinary urgency, blurred vision, sweating, brief short-term memory loss, and brief distortion in depth perception with a brief hallucination. During the evening after the sessions, she experienced loss of appetite, a little vomiting, less taste for alcohol, a strong body odor, blurred vision, urinary urgency, a mild hearing impairment, difficulty opening her jaws very wide, insomnia, and the biting of her cheek in her sleep. Her jaw opening difficulty continued for several days, along with 2 days of fatigue and hoarseness; 1 day of feeling uncertain of her feet; and a brief visual illusion the second night, lasting only until she turned on the light. She also reported a pleasant 2 day relief from her usual light sensitivity in an eye with chronic macula edema.

22 subjects reported jaw tension or shaking, or teeth clenching, during the session. 2 of these and 1 other also reported it for the day after. Diazepam, 5 mg, clearly relieved this effect in 2 subjects, and propranolol, 40 mg, also relieved it in 2. 1 subject (#12) who had propranolol at the start of his session reported more jaw tension than he had had in an earlier, identical-dose session without it. He wondered if it was due to his purposefully more cognitive orientation during the second session. None of the other 8 subjects who used propranolol during their sessions complained of jaw or other muscle tension after taking it.

23 subjects reported fatigue from a few hours to a few days after the session; for 16 this lasted 2 days or less. 4 of the 23 felt sleepy or tired during the session, though 1 had also taken diazepam, 5 mg, to prevent the jaw clenching she had experienced with MDMA in the past. 1 other subject felt tired late in the session.

11 subjects reported some insomnia the night after the session, though 3 subjects reported sleeping better. 8 subjects experienced muscle aches or tightness--6 during the sessions and 4 afterward for a day or less. 6 of the 8 also had jaw tension.

All but 1of the subjects lost their appetites during sessions--though none found it unpleasant--and all had fasted overnight, or for a few hours before. 7 subjects felt nauseous during sessions, most for about 5-30 minutes. 2 reported stomach upsets for the next 1-2 days and 1 subject (#17) lost her appetite for 3 days and was mildly constipated for a few days. During the session she related her nausea to thoughts and feelings about her parents when they were in German concentration camps. After an unsuccessful attempt at vomiting, the nausea and negative feelings stopped. 2 subjects felt mildly nauseated during the evening after the session day and 1 other subject was constipated for a day.

3 subjects reported difficulty walking during the session. 2 reported feeling cold during sessions. Many others mentioned coldness early in the sessions, though not as a problem; and it usually lasted for less than 30 minutes. 2 other subjects mentioned sweating during sessions; it, too, was a common occurrence that was only mentioned in passing.

The following undesirable physical symptoms were reported by only 1 subject each: jittery vision early in the session; lip swelling, shakiness, and numb hands and face, all during sessions; headache late in the session; fainting the evening of the session (subject #16, who thought it was psychosomatic because she was thinking about her difficult relationship with her boyfriend at the time); anorgasmia the day after; and decreased sexual desire for 1-2 days.

Pulse and blood pressure were measured in 2 subjects. Subject #10 had a baseline pulse of 60 and blood pressure of 90/50. During the session, the maximum pulse recorded was 112, and maximum blood pressure was 128/70. Subject #11 had a baseline pulse of 64 and blood pressure of 110/78. His pulse reached 100, and his blood pressure went up to 154/88. Readings were taken 35 minutes after ingestion, when subjects reported the first sensations of MDMA, and after 1 hour and 20 minutes, when side-effects were felt the strongest.

16 subjects reported undesirable emotional symptoms. 5 reported anxiety or nervousness during the session, including subject #19. 2 subjects reported mild depression the day after. 1 subject reported mental fatigue, and 1 reported mild emotional inflation. 1 subject reported feeling lonely or sad for brief periods during his session. 1 other (#8) felt 1-3 minutes of fear and paranoia early in his session, and then a flattened affect later in the evening. 1 (#18) described waves of physical and emotional "crud" during his session and over the next few days. He believed it had built up over previous few days and felt he was "letting go" of it during the session. 1 subject reported feeling simply more emotional after her session; and subject #17 felt more emotionally vulnerable and off center for 3-4 days, including a few hours of non-specific anger 2 days after her session.

4 subjects described undesirable cognitive symptoms. 1 had a "racing mind," and 1 reported confusion, both during the evening of their sessions. Subject #6 said it was hard to work the next day because there was "too much going on" inside her mind, and she felt confused about her relationship with her boyfriend for 2 days. 1 reported 5-7 days of "negative self-talk."

Realization of the session's purpose

All but 1 subject had some purpose or goal, other than curiosity, for having a session and most had multiple reasons. 16 of these felt their purpose was completely realized, 4 reported significant progress made toward all their goals, and 7 felt that some goals were realized while others were not. 1 reported that his curiosity was satisfied, but that no new learning about himself occurred.

9 subjects implied they wanted more cognitive understanding of themselves and expressed it in several ways: self-analysis; rational self-examination; learning about themselves; understanding losses, fears, or attitudes; gaining insight into life patterns; objectivity with insights into feelings and behavior; clarifying thinking; etc. 3 of these felt this goal was fully achieved; 1 said progress was made; 1 was less than satisfied with the results; and 4 reported no results at all in this area.

Of the 8 subjects who wanted a peak-experience of a visionary or mystical state--or a sense of wholeness, connectedness, or enlightenment--6 felt they realized such a goal and 2 felt they did not. 2 of the 6 and 3 others desired personal or spiritual growth or self-exploration, and all 5 felt this purpose was fully realized.

6 subjects desired increased communication with someone (often their spouse) taking MDMA with them; 5 felt this occurred while 1 was less than satisfied. 1 of the 5 also desired to have more open communication with people after the session and reported possible progress. 3 other subjects desired closeness with their mates during the session, and all said they achieved it.

As mentioned above, 5 subjects had low-dose (50 mg) sessions specifically for the purpose of facilitating their creative writing, and all were very satisfied with the results.

4 subjects mentioned fun or enjoyment as a goal. 1 of these and 2 others wanted increased awareness. All 6 said these goals were attained.

3 subjects wanted to change their personality or behavior patterns in some lasting way. 2 reported progress and 1 was less satisfied than he wanted or expected to be. 1 of the 2, and 2 others, wanted to work or move through emotional blocks, and all 3 said they made significant progress. 1 subject sought to resolve inner conflicts regarding her husband, from whom she was separated, and she also made progress.

2 subjects wanted to experience a different state of consciousness, and 2 others desired more awareness of their feelings. All 4 felt they realized these goals. 1 subject desired psychotherapy for sadness at being alone, and 1 other wanted to lessen his fear of rejection during a session with friends. Both reported fully reaching these goals.

Changes in psychiatric disorders

All 9 subjects with Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association, 1980) diagnoses reported significant relief from their problems. 2 subjects reported full and lasting remissions: subject #17 with a dysthymic disorder (follow-up after 9 months) and subject #23 with a simple phobia of sexuality and possible pregnancy after an abortion. All 3 subjects had atypical or mixed personality disorders (#'s 5, 9, and 13) all reported improvement, as did the 4 subjects with depressive disorders (adjustment disorders with depressed mood in #'s 6 and 22, dysthymic disorder in #7, and atypical depression in #16).

Mood changes

18 subjects described positive changes in their mood or emotional state, lasting from several hours to several weeks, and averaging about 1 week. 14 reported having more good feelings. 5 of these specifically mentioned euphoria or improved mood, and 4 mentioned an increase in energy. 11 reported feeling more relaxed, calm, detached, serene, and/or less anxious or agitated. 2 reported increased alertness for at least a few weeks (1 had just begun a leave of absence from work), and 2 others felt more amorous or sexual after their sessions. In addition, 1 subject felt more physical relaxation after his session.

Attitude changes

23 subjects reported positive changes in attitude lasting from a week to a follow-up time of 2 years. Again, the average duration was roughly a week. 11 of these specifically mentioned increased self-esteem. 10 subjects said they felt more acceptance of negative experiences or more patient in some way, 4 of these in relation to achieving their life goals. 4 subjects reported simply feeling more positive. 3 mentioned feeling less guilty; 3 reported having a more spiritual orientation in their lives; and 2 felt more powerful. 1 subject each reported an increase in the following characteristics: self-awareness; hopefulness; satisfaction; lucky to have her position in life with her husband and friends; and flexibility, openness to change, self-discipline, and commitment. 1 subject described a clear and brisk feeling with a sense that there is more love in the world. 1 felt less self-defeating, 1 felt less self-conscious and inhibited, and 1 felt less needy.

Some attitude changes were more interpersonal in nature and will be described below. Negative changes reported by 7 subjects were previously discussed, but 4 of these also had some of the positive changes mentioned above.

5 subjects reported changes in their attitudes toward death since their sessions. 2 now see death as a change and not an end. 2 others feel less fear of their own or their parents' deaths. 1 subject found he thought more about death, though his feelings about it were no different.

Belief changes

16 subjects reported belief changes, but rarely did two report the same specific change. All changes resulted in a more positive belief about themselves, individually, or in relation to others or the world. 6 subjects reported greater self-acceptance, self-confidence, independence, self-control, or appreciation of being alive. 4 expressed more interest or ability in pursuing spiritual growth; and 3 others reported a sense of unity with people, with the world, or with "being." 4 perceived an increased willingness to love, a greater appreciation of others, or a greater capacity for interpersonal warmth. 4 learned new ways to deal with psychological problems. 2 said their beliefs in their limited possibilities were diminished. 1 reported that his beliefs about himself and the universe were strengthened and deepened.

Relationship changes

Only 2 subjects reported negative changes in their interpersonal relationships after their sessions. 1 (#22) felt more guilt around men for "a while." She thought it resulted from an insight gained during the session concerning the childhood death of her brother. She also proceeded with a divorce, having separated from her husband before the session. The other (#19) has been mentioned above.

Every subject except #25 reported positive changes in their relationships after sessions, and he said, "It is possible that I have become more capable of expressing my self without having as much hesitation about how people will respond to my openness." The closeness and enhanced communication present during sessions continued for a few days to 2 years (at follow-up) in 3 of the 5 couples. In the 2 couples who had prior difficulties, they resolved significant conflicts after the session. 3 subjects whose spouses were present, but not using MDMA, also reported more closeness and/or improved communication with them--2 briefly, but the other still at follow-up after 10-1/2 months. In addition to the 3 couples, 14 subjects reported the same changes with people other than their mates. In 6 of these, the changes were still present at follow-up between 4 and 24 months later, and in 3 others they lasted from one to several weeks.

10 subjects reported that soon after their sessions they resolved conflicts with others, and for 5 of these people the conflicts concerned partners who did not have a session with them. 2 of the latter (one being married) and 2 others (whose partners were also not present for the session) reported the continued decline and eventual termination of their primary romantic relationships that were already failing before the sessions. On the other hand, 2 subjects who both had solo sessions subsequently got married (not to each other).

An increase in the interpersonal expression of feelings after sessions was reported by 7 subjects. An increase in acceptance and/or tolerance of others afterward was reported by 6 subjects. 3 said they now avoid superficial social interactions, 2 specifically mentioning cocktail parties. 3 subjects reported seeing others as more autonomous and less in terms of their own needs and/or projections. 2 said they found it easier to ask for help or make demands. 1 couple reported enhanced sexual enjoyment afterward-- partly due to delayed orgasm--and 1 couple gained more awareness of their prior sexual problems.

Subject #17 reported feeling closer to her mother, seeking out people like herself more often (while avoiding egotistical people), and being able to state her beliefs to others more easily. All other relationship changes were reported by 1 subject each and include the following: feeling more compassionate; having greater freedom to have friends, and a willingness to risk more with them; actually making more close friends; feeling more forgiveness toward others, along with receiving feedback from friends about "positive changes in the heart; "feeling comfort and rightness with wife; having a more confident and comfortable attitude toward wife without fear (with more confident and direct social behavior); experiencing an increased awareness of wife and others, with more empathy; having greater interest in others; recognizing how he distances others while wanting to be close; and understanding better the relationships with friends who shared the session.

Occupation changes

16 subjects reported positive changes in their work since their sessions. 6 felt better on the job in some way: less driven, compulsive, tense, stressed, temperamental, or burned-out; more patient and tolerant; or reported having more fun working or having more energy to do their work. 4 had improved work relationships with more patience and tolerance, connectedness, acceptance, or just getting along better with others. Most subjects did not say how long these changes lasted, but those who did indicated a range of 1-10 days.

3 subjects reported an increase in income since their sessions. 1 had changed jobs; 1 had graduated from school and begun her professional career; and 1 had switched from the technical side of his work to the management side, where he enjoys spending more time with people. 1 subject (#19) reported increased job satisfaction, while another reported a decrease, but neither attributed the change to their sessions. 1 subject said he had become more active since his sessions. 1 subject said he had become more active in his independent professional work.

2 subjects reported negative changes: Subject #6 found it harder to work the day after a session, and subject #7 found it harder to deal with demands and was less interested in her work, but did not say for how long.

Activity changes

6 subjects reported changes in their involvement with activities other than their work. 2 subjects joined groups for spiritual growth. 1 noticed an improvement in his creative writing abilities during the months after his session, when he was on a leave of absence from work to complete a book of poetry. 1 subject (#21) was able to resume golf (his lifetime sport) after years of back pain, which had required multiple surgeries, ceased. Subject #19 took up woodworking for the first time, and 1 subject said he enjoyed his hobbies more. 1 reported a decrease in political activity but did not attribute it to the session.

Spiritual and physical practice changes

14 subjects reported positive changes in their regular practices for improving their spiritual or physical well-being. 6 subjects began some sort of meditation or spiritual practice after their sessions. 2 of these described MDMA-like states occurring during meditation, and 1 other said her meditation improved. 1 subject, who continued a previous practice, felt meditation was more important and meditated more often with clearer goals in mind. 1 subject (#12) reported looking at Buddhism (which he practiced) more analytically than emotionally or spiritually, but placed no value judgment on the change.

3 subjects had started new exercise programs by the time of follow-up while 1 had stopped a previous one. 2 others increased prior exercise routines, though 1 said it was due more to advancing age than to his session. 1 subject became more interested in health foods and improved his diet.

Substance use changes

14 of the 28 subjects who answered follow-up questionnaires reported a decrease in the use of mind- or mood-altering substances, and 3 reported increases. 6 reported a decrease in alcohol intake: 2 continued to drink less at follow-up, with 1 reporting a marked decrease in his inclination to do so; 2 stopped drinking completely; and 1 of the remaining 2 said the decrease lasted 2-4 weeks. 1 subject reported an increase in consumption from 3 to 5 beers a week. 1 other subject did not feel like drinking alcohol, coffee or tea (as was her custom) after her sessions, but did not mention changes in long-term use.

6 subjects decreased their marijuana intake: 1 for only 2-4 weeks, but the rest continuing to use less at follow-up 4 to 18 months later. 1 stopped entirely, and another reported a decrease in his desire for marijuana. 1 of the 6 said marijuana enhanced the sensations she remembered from MDMA sessions, even though her actual use decreased significantly. 1 subject had increased his marijuana use by follow-up time at 9 months.

5 subjects reported a decreased caffeine intake. In 4 the change lasted, with 1 stopping entirely. In the 1 remaining subject, the decrease lasted several days. 1 subject who drank 6-8 cups of coffee a day also stopped completely, but he does not relate it to his MDMA sessions. 1 non-coffee drinker now drinks it 2-3 times a week, and 1 other increased his use, but not soon after his session.

2 subjects continue to smoke less tobacco, but 1 other reported a greater urge to smoke after sessions.

1 subject has continued to refrain from cocaine use for the 4-1/2 months between his session and follow-up. Another reported a decreased desire for cocaine, without mentioning a change in use. These were the only 2 frequent users of cocaine in this study.

1 subject reported less LSD use, 1 said he desired all psychedelics less, while 1 said he desired them more. 1 subject had a much more introspective psychedelic experience, and 1 had a more enhanced experience than usual, after MDMA sessions. 1 subject said she would be interested only in MDMA to alter her state of mind in the future because she "learned from it."

Changes in life goals

15 subjects changed some of their life goals after sessions, all implying that they were positive. 5 said they felt more commitment to the same goals; or felt their goals were closer, or more intense or "emergent." 4 others reported a change toward seeking more self-awareness, personal growth and/or well-being. Another 4 had given up pursuing goals that were not being achieved, or were trying less hard to reach their goals. 2 subjects' goals had shifted away from concerns with money and financial security. Individuals reported the following varied changes: a shift from avoiding the negative to seeking the positive in life; a greater desire to communicate and bond with husband; having a new goal of understanding relationships; becoming more active in work; and a greater interest in intellectual activities.

Changes in experiences sought out

9 subjects reported changes in the kinds of experiences they seek out in life. 4 sought more trust, honesty, openness, closeness, or direct communication in their relationships--in addition to actual changes in their relationships described above. 1 subject now wants to be with more spiritually oriented people, and 1 other seeks to offer more loving service to people.

2 subjects sought both to experience more love and openheartedness, as well as more freedom to be creative and/or artistic. Another 2 reported now having a more spiritual orientation in their lives, while 2 others found themselves more amorous or sexual after their sessions. Subject #19 sought intensive psychotherapy.

Changes in experiences avoided

9 subjects described changes in the kinds of experiences they avoid in life. 3 now avoid superficial socializing (2 mentioning cocktail parties). 1 other avoids egotistical people, and 1 now avoids habitually taking care of others in her relationships.

2 subjects now avoid "sloth" or boring things. 1 reports accepting negative experiences more (less avoidance of them), and 1 other (#19) chooses to face problems rather than avoid them. The latter is also avoiding all psychoactive drugs. 1 subject is trying to avoid "negative karma" for herself and others.

Changes in attributes preventing self-actualization

13 subjects reported changes in this area, all for the better. 7 reported gaining lasting insight into psychological problems during their sessions. 3 said they experience less guilt, such as over enjoying small pleasures. 2 reported a decrease in limiting beliefs about their possibilities. 1 of these also now feels less self-defeating and recognizes how he distances others while he wants to be close. 1 subject feels less defensive and compulsive; 1 sees that she can change her defenses; and 1 feels less impatient and rebellious. 1 reported feeling less that emotions should not be expressed, 1 feels less self-conscious and inhibited, and 1 less bound by anxiety. Subject #17 said she "literally got rid of a lot of negative material I had carried around with me forever," and now takes more risks in life. Nine months after her session she said, "I'm continually getting better, brighter, happier, clearer and more grounded." 1 subject reported dissolving "useless structures within the mind," and 1 said her sessions accelerated her psychotherapy.

Discussion

MDMA was apparently physically safe for all 29 subjects of this study. No side effects were serious, and only one subject had a side effect last more than a week. Vital signs recorded in 2 subjects revealed some increase in blood pressure and heart rate. These increases would be safe in a healthy person, but not in anyone with vascular disease. Other contraindications are standard for any sympathomimetic drug.

Only 1 subject (#19) experienced post-session psychological difficulties that were disabling, or of more than a few days duration. He had been briefly disabled by the same symptoms of anxiety a few years earlier. During the session, he became afraid that he would become overwhelmed by unwanted emotions. He worked at preventing this from happening and became intermittently anxious in the process. He felt that other events in his life were the causes of his post-session anxiety. A year later, he even felt that his session was probably beneficial. Subject #17 also had a past history of disabling anxiety attacks, but she had already received a long course of psychotherapy for them. In any case, there is an indication that MDMA may predispose people to a recurrence of previous psychological disabilities.

In future studies, informing subjects in detail of the possible risks of taking MDMA, and emphasizing them, is mandatory and will appropriately discourage some prospective subjects. Exclusion of those with a prior psychological disability--or an inability or unwillingness to have any disturbing experience that might occur, during or after the session--should result in a safe population for clinical trials. It is also recommended that people who want MDMA to cure their problems should be excluded, whereas people who want to use it to learn about themselves should make good candidates.

In regard to the efficacy of MDMA for treating psychiatric disorders, all 9 subjects with DSM III diagnoses reported significant benefit, with 2 reporting lasting remissions. A trend also exists toward relieving low self-esteem and increasing self-acceptance and self-confidence. One subject (#21) reported relief of back pain from which he had suffered for a few years. It is most likely that the psychosomatic component in this disorder was relieved, as opposed to any anatomic abnormality. MDMA might be useful in other medical conditions involving a psychological factor, though there is no other supporting evidence from this study.

In general, it is reasonable to conclude that the single best use of MDMA is to facilitate more direct communication between people involved in a significant relationship. Not only is communication enhanced during the session, but afterward as well. Once a therapeutically motivated person has experienced the lack of true risk involved in direct and open communication, it can be practiced without the assistance of MDMA. This ability can not only help resolve existing conflicts but can also prevent future ones from occurring due to unexpressed fears or misunderstandings. Regardless of the mechanism, most subjects expressed a greater ease in relating to their partners, friends, and co-workers for days to months after their sessions.

MDMA's use as an adjunct to insight-oriented psychotherapy was specifically recommended by 6 subjects. Many felt that MDMA enhanced self-understanding and was useful in their personal and spiritual growth.

A value in treating at least mild alcohol and other drug abuse is indicated by the decreased use (reported by 14 subjects) of substances that have psychological dependence potential. Some subjects mentioned that these substances seemed less appealing after experiencing MDMA. The ability not only to feel free of conflict--which can be provided by many drugs of abuse--but to learn how to prevent conflicts in everyday life seems unique to MDMA as a therapeutic adjunct.

In addition, MDMA's diminished pleasurable effects and markedly increased side-effects when taken in either larger doses (subject #7) or with greater frequency distinguish it from most drugs of abuse. Subjects #3 and #11 took four 50 mg supplements after their initial dose and found the fourth to cause only more agitation and confusion without any pleasant effects at all. Some subjects reported using MDMA on their own, but only #22 used it twice in the same week. The second experience was therapeutically useful but left her depressed and exhausted for about two days. Therefore, both the positive experience of MDMA, and the impracticality of using it frequently, can motivate people to find other ways to achieve a desirable state of mind in everyday life. 16 subjects began or increased their meditation practices or exercise programs, supporting this conclusion.

Providing the reports of these 29 subjects' experiences will hopefully encourage further research into the beneficial effects of MDMA. Presenting evidence establishing the limits of its usefulness should discourage any movement to promote it as a social or psychological panacea.

[The authors wish to thank Jack Downing, M.D., Stanislav Grof, M.D., Robert Hausner, M.D., Rodney Houghton, M.D., Will MacHendrie, M.D., Ralph Metzner, Ph.D., and John Perry, M.D. for serving as the peer-review committee for this project; Alexander Shulgin, Ph.D. and Ann Shulgin for their support and instruction; and Mary Greer and Ron Romanik, M.D. for editorial assistance.]

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California Board of Medical Quality Assurance. 1980. Personal communication.

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Shulgin, A.T. & Nichols, D.E. 1978. Characterization of three new psychotomimetics. In Stillman. R.C. & Willette, R.E. (Eds.). The Psychopharmacology of Hallucinogens. New York: Pergamon Press, pp. 76-77.

Younger E. J. 1978. Opinion of Evelle J. Younger, Attorney General, State of California on questions from the State Board of Pharmacy, May 2. (Reference Nos. CV 76/212 & CV 77/236).