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(applause)

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3,4-Methylenedioxymethamphetamine: MDMA.

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Now you're probably heard of this compound
in the context of the recreational drug Ecstasy.

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But today I want to talk about MDMA not 
as a recreational drug,

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but as a potential new treatment in medicine.

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And then very important treatment 
for psychiatry because MDMA could offer us

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in psychiatry for the first time the
opportunity to tackle trauma.

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And psychological trauma particularly that
caused by child abuse and maltreatment

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is at the heart of all or most psychiatric
disorders due to anxiety and addictions.

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Psychiatry is in need of this 
innovative approach,

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because current treatments 
are failing patients.

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Hi, my name's Ben Sessa. I'm a child and
adolescent psychiatrist.

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Now that means I trained as a medical doctor,

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then specialized in mental health

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and then specialized in child 
and adolescent mental health.

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But for the last five years I've 
been working with adults with

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mental health disorders and addictions
due to misuse of drugs.

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And that developmental pathway 
of my own,

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from working with child abuse into adults

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with mental disorders and addictions has
brought me to the door of MDMA.

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And I'm gonna propose today 
that MDMA could be

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important for the future of psychiatry
as the discovery of antibiotics was

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for general medicine a hundred years ago.

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So when we think about child abuse we think
about physical abuse, mental abuse,

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emotional abuse, sexual abuse and neglect.

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And we think about noxious environments.

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We think about parents with mental disorder. 


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We think about parents
who are addicted to drugs.

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And social issues like poverty and
poor housing, poor education.

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Now I'm going to illustrate my talk
today with a patient

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and I'm going to call her Claire.

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Now Claire was no single particular
patient of mine.

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Rather she's an amalgamation
of many different people

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I've met in the last 18 years working
as a medical doctor.

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She's certainly not the worst.

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Now what was Claire's environment like 
when she was growing up?

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Well, her mother was depressed.

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Now unfortunately the family
doctor didn't have time to accurately

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diagnose and treat depression, rather,

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Claire's mother was put onto one
antidepressant after another,

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never really got therapy.

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Claire's mother also had a lot of aches and pains

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typical what we call 
psychosomatic symptoms in depression,

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and as a result the family doctor 
put her on to opiate based painkillers

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which she promptly became addicted to.

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Now Claire's father, now he was alcoholic and he was often

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not around in and out of prison.

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Which is just as well because when he was
there

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he was physically abusive to Claire
and her mother.

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Okay so what does this kind

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of chaotic, frightening environment do

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to the developing child brain?

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I'm going to give you a brief
neurophysiology lesson if I may.

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There's a part of the brain called the amygdala.

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Now the amygdala is a very
ancient part of the mammalian brain

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and many other animals other than humans
have an amygdala.

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The amygdala lights up when stimulated by

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fear in the environment,
by a frightening stimulus.

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It lights up and it says:
fight-or-flight, get out!

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Now there's another part of the brain
much more sophisticated part,

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called the prefrontal cortex and it's
right here at the front above the eyes.

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Now the prefrontal cortex only humans have.

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And it's in the prefrontal cortex
where we use logic and reasoning to

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rationalize the situation and we can use

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our prefrontal cortex to overcome that

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instinctive fear response from the amygdala.

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Now when Claire was growing up

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she never knew from one moment to the next

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whether the adult coming into the room,
were they going to give her a kiss

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or a cuddle or do a jigsaw with her,

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or were they going to punch her or kick her

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or burn her with their cigarette.

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Or were they going to rape her.

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Because throughout her childhood
Claire was also subjected to sexual abuse.

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Now, there's a group of disorders
called the anxiety disorders,

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and one of the most important

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is what we call
post-traumatic stress disorder or PTSD.

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Now PTSD, some of the core features:

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very low mood, anxiety,
high levels of anxiety,

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what we call hyper vigilance:

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this edginess, this jumpiness.

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Exactly how Claire felt 
throughout her childhood and adolescence.

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Never knowing whether
the next assailant or assault

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was around the corner.

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Another core feature of PTSD,
what we call re-experiencing phenomena.

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Flashbacks, when the patient has sudden
remembrances of painful traumatic memories.

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They can just pop into the head

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at any time, triggered by
some cue in the environment.

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And when they have those experiences,
those daytime flashbacks,

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they relive the trauma in all the
sensory modalities and this results in

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them freezing or dissociating
to try and block out the pain.

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Claire experienced all of this
as she was growing up.

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High levels of self-harm and suicide
are associated with PTSD.

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Claire would cut her thighs and her breasts.

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Pretty common form of cutting in
children who've been sexually abused.

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She was being sexually abused
by her mother's clients,

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because her mother had moved on
from the addiction to painkillers and

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was using street heroin
when Claire was a teenager.

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Because of the way the war on drugs has
set up that reduces access to treatment

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for people with opiate dependence,
she had to pay for her

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heroin using sex work and the clients
would sexually abuse Claire.

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It's very hard to treat PTSD and it has a high treatment resistance,

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50% of people do not respond to the traditional treatments.

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How do we treat it?

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We can treat it with medications. We can treat it with psychotherapies.

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And the medications we use:
there's a broad range of drugs.

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No single drug, and this is very important,
no single drug cures PTSD.

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Rather we treat the disorder symptomatically:

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If the patient's depressed
give them an antidepressant.

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If their mood fluctuates give them a mood stabilizer.

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If they can't sleep give them a hypnotic.

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And if that edginess and that fear 
spills over into paranoia and psychosis,

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give the patient an anti-psychotic drug.

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And they have to take these drugs
day in day out for weeks, months, decades.

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They have to keep taking them because
the drugs we use to treat trauma when it's

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due to this level of severity do not attack the root cause of trauma.

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They paper over the cracks.

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A good analogy would be taking aspirin
or ibuprofen when you have a fever.

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A fever is caused by an infection, by a microorganism.

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Sure, you can take paracetamol or ibuprofen
and this will lower the temperature

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and make you feel a bit better but it doesn't attack the root cause.

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And that's what we do when we give these patients these daily SSRI drugs.

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We paper over the cracks.

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We maintain the symptoms at a manageable level.

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We also use psychotherapies to treat PTSD, and there's

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again a broad range of these: DBT, CBT,
EMDR, trauma focused psychotherapy,

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CAT, APT... Now all of them have a pretty

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similar approach which actually is an old wives tales which is:

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a problem shared is a problem halved.

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"Let's talk about your trauma.
Claire tell me about your rape."

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Now that's fine for 50% of patients but for
a significant half they just cannot do that.

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As soon as Claire is asked to talk about her rape she freezes,

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she flees, she drops out of treatment.

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By the time she was 15 Claire had been
removed from the family home and she was

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brought up in a succession of foster
placements and children's houses and

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hostels where the abuse continued.

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She was self-harm cutting and
she started drinking and

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by the time she was 18,
she was using heroin as well.

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Sometimes working in psychiatry can feel
pretty desperate, can feel pretty hopeless.

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Sometimes it feels as if psychiatry is a palliative care profession.

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And this is the truth because

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the treatments we use do not get to the

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root cause of the problem, the trauma.

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They paper over the cracks. And I think

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the pharma industry know this and they

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queue up and they

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provide us with product after product to

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give to our patients that doesn't quite

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cure them but it gets them slightly

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better to function. And they have to keep

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taking them. Indeed I would say that we

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are in psychiatry today where we were in

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general medicine 100 years ago. Now 100

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years ago in general medicine, humanity

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was losing the battle to the infectious

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diseases. Oh we were very good at

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classifying and diagnosing them. We knew

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who got smallpox. We knew people died of

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post-operative surgery. We knew there

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were microorganisms but we didn't have a

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treatment. And then at the beginning of

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the 20th century we discovered the

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antibiotics. Not symptomatic treatment

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but treatment that goes to the core of

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the cause and we started getting on top

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of infectious disease. Now psychiatry

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today is in a similar place. We're very

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good at classifying and diagnosing. Our

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epidemiology is superb. We write these

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thick diagnostic manuals. We know who

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gets depression. We know who gets anxiety.

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We even know the cause: trauma, child

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abuse, maltreatment, poor social

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conditions. But our treatments are lousy.

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And I'm quite shocked the way the empathy

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switch and our understanding of these

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patients seems to be switched off. We

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have lots of gushing sentimentality for

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the little five and six year old who's

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being abused and we throw money at our

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television sets on these campaigns to

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improve the lives of these poor little

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innocent victims. Well, let me tell you

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what happens to that little five or six

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year old when they're 11 or 12. On goes

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the hood, start smoking weed. By the time

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they're 16 they're buying and selling

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amphetamine and by the time they're

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Claire's age in their mid-20s, they're

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addicted to heroin and alcohol. And

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suddenly we have lost our empathy. These

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people are public enemy number one. "It's

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your fault Claire. You brought this upon

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yourself. It's your lifestyle choice." And

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I'm quite shocked and having worked in

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pediatrics and seen the developmental

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trajectory that is so inevitable from

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early trauma into adolescent and then

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adult mental health and addictions, we

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have to hold on to that sense of

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compassion and evidence-based

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understanding

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about the developmental trajectory there.

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So it does sound desperate, but all is

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not lost.

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MDMA. MDMA has some fascinating qualities.

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Indeed I would suggest that if you were

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to invent a hypothetical drug to treat

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trauma, it would be MDMA. The way it works

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in terms of its receptors and its

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subjective psychological effects ticks

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all the right boxes. At one level of

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receptors it causes a increased positive

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mood. Lowering of depression, lowering of

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anxiety. At another group of receptors it

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speeds the patient up, mild stimulation

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which motivates them to engage in

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therapy. At another level it relaxes

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the patient paradoxically at the same

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time as the stimulation and this puts

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the patient into the optimal arousal

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zone where they can engage in

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psychotherapy. But perhaps the most

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important thing about MDMA and the most

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important clinical tool is its ability

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to provide a sense of empathy and

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understanding and emotional security. It

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can hold the patient in a place where

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they can think about and access their

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trauma like they've never been able to

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do before. One of the ways in which MDMA

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works is it increases the release of a

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hormone called oxytocin. Now oxytocin is

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released from the brains of

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breastfeeding mothers. It's a hormone

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that engenders a sense of attachment and

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bonding. And that's what's happening in

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the patient who takes MDMA. And also it

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acts directly on the amygdala to reduce

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that fear response whilst at the same

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time boosting the prefrontal response,

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allowing the patient to see things in a

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new light. A positive light. So let's go

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back to Claire. She's 40 now. She's been

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in and out of psychiatric hospitals,

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having tried to take her own life and

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the inception. She's been on all the

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antipsychotic and antidepressant mood

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stabiliser drugs. She's tried all the

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psychotherapies but she cannot engage

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because she will not talk about her

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feelings. So she comes into a course of

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MDMA-assisted psychotherapy.

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Wwhat does it look like? Well,

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it's weekly sessions, maybe eight, ten,

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twelve weeks long. The two therapists,

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male-female pair. You do not take MDMA

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everyday, you do not take it every

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week. Over that course of 12 sessions

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you'll take the MDMA three times and the

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other sessions you talk about the

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material that's released on the MDMA

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session. So what does Claire actually

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feel when she takes this MDMA? What she

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feels is a sense of warmth and

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understanding and a sense of containment

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within that relationship she's having

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with the therapist. MDMA is like it's

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like a lifejacket like a bulletproof

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vest to wear to go into battle with your

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trauma. This is not ecstasy! She's not

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enjoying some raver's euphoric ecstasy

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delight. This is still trauma focused

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psychotherapy and it is still hard and

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distressing for her, but she can just

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about do it with MDMA on board. So when

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the therapist says: "Claire, tell me about

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your rape". Now in the past just the word

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rape and she'd be out the door, but on

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MDMA she says: "yeah, I can talk about that!

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I can see him now coming into the room. I

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can smell the whiskey on his breath and

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I can feel the stubble on his face as

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he's raping me". And she talks about it

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and she explores it and she reflects

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upon it and she can begin the process of

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healing. And from here she can start her

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journey. She can attack the root cause of

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her problems. Not just maintain the

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symptoms at a level. So, does it work? Well

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we've known about MDMA for very long

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time and indeed we've used MDMA in

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underground therapy for 30 or 40 years.

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And there are thousands of positive

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anecdotal cases. I get five emails a week

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from all over the world: "Dr. Sessa, I've

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had PTSD for years. I've tried everything

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and now I tried MDMA and I'm starting to

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make a breakthrough!"

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Now, anecdotal reports like that are

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interesting but they're not science so

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we've done the science. And some

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important studies in recent years.

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Big study in the States

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showed that a single course of MDMA

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therapy, 16-week course, patient takes

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MDMA three times tested against a

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placebo. At the end of that course 85% of

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the people no longer met the diagnostic

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criteria for PTSD. Not just a relief of

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symptoms, they didn't have PTSD!

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Now that cohort were then followed up

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three years later, the same no PTSD. Many

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of those people had come off their daily

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medications. They were cured! We don't use

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the word "cure" in psychiatry. We've become

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learned helplessness position of-- This is

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the truth! If you're diagnosed with a

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severe mental disorder like anxiety or

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depression in your 20s and the

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developmental route of that disorder is

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severe child abuse, there's a pretty good

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chance, and I'm sorry to say this, there's

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a pretty good chance you will still be

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going to psychiatric clinics in your 60s

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and 70s. Now that is not good enough and

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we're in this position because we're not

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tackling trauma. So, it works but is it

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safe? Well, when we talk about safety of

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clinical MDMA, what we must not do is

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look at the risks of recreational

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ecstasy. I don't even know what ecstasy

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is anymore!

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Ecstasy is over here, what is ecstasy?

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Some dodgy pill bought in some dodgy

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club of some dodgy geezer, that may or

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may not contain MDMA plus or minus

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whatever far more toxic substance. And

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indeed when you hear about the very

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high-profile deaths of people who take

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ecstasy, it invariably is not MDMA. So,

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let's not look at ecstasy as a measure

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of MDMA. Let's look at clinical MDMA. Now,

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when you use clinical MDMA, you take

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it under medical supervision. It is pure.

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The MDMA that I'm using in my studies is

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99.98% pure! Very expensive! 
(laughter)

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We do it under medical supervision with

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a doctor and a nurse and a psychologist.

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And under those conditions the risks are

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reduced to a absolute minimum. Indeed

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after 40 years of MDMA research, there

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has not been a single serious adverse

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drug reaction, not one! And certainly no

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deaths. So, we need to do this research

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and we need to do this research in an

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evidence-based, compassionate way. Looking

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at the data. We need to ignore the

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socio-political agenda that says any

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drug that's being used recreationally

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must also be very bad and dangerous. That

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sort of attitude hampers research. And we

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need scientists to drive this. It works,

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it's safe. And it offers patients like

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Claire for the first time in their life

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an opportunity to break through from

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that trauma and not become a lifelong

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chronic PTSD sufferer. So where were we

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going with MDMA research? Well, we've had

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some studies, we've got more coming here.

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I'm doing a study in Cardiff with

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neuroimaging in which we're going to

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give patients with PTSD MDMA and placebo

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and we're going to look at

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that relationship between the

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amygdala and the prefrontal cortex. We're

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also doing a study here in Bristol

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giving patients with alcohol use

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disorder MDMA, because underlying the

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root of this addiction is trauma. So this

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is an exciting time. Now people say: "This

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is controversial!" And indeed, I was

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introduced as a controversial speaker.

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I'm not controversial, I'm a very boring

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conservative doctor. I like data.

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I like evidence-based data that helps my

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patients. I'll tell you what's

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controversial! What's controversial is

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that more people have died returning

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from Afghanistan and Iraq because

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they've committed suicide because of

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their untreated PTSD then ever died in

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the conflict out there. That is

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controversial and that is unethical! So

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this is a important time for science.

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MDMA could be the antibiotic that

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psychiatry has been waiting for. We owe

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that population of patients who are

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being failed,

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we owe them this research! We owe this

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Claire! Thank you.
(applause)