Is MDMA psychiatry’s antibiotic? | Ben Sessa | TEDxUniversityofBristol

This TEDx talk will explores the practice of MDMA Psychotherapy, illustrated with the life-story of a fictional typical patient. We owe it to this population of vulnerable, untreated patients with unremitting mental disorders due to psychological trauma, to explore MDMA Therapy as potential new treatment for the future of psychiatric medicine.

Ben Sessa is a consultant psychiatrist in adult addictions, working part-time at Addaction in Weston-Super-Mare and is senior research fellow at Bristol, Cardiff and Imperial College London Universities, where he is currently taking part of his time away from clinical medical practice to study towards a PhD in MDMA Psychotherapy. He is the author of two books exploring psychedelic medicine; The Psychedelic Renaissance (2012) and To Fathom Hell or Soar Angelic (2015) and is currently conducting research with Imperial College London and Cardiff universities studying the potential role for MDMA-assisted therapy for the treatment of PTSD and alcohol dependence syndrome. Dr Sessa is outspoken on lobbying for change in the current system by which drugs are classified in the UK, believing a more progressive policy of regulation would reduce the harms of recreational drug use. He is a co-founder and director of the UK’s premier international psychedelic conference, Breaking Convention.

This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at http://ted.com/tedx

3,4-Methylenedioxymethamphetamine: MDMA.

Now you've probably heard

of this compound in the context
of the recreational drug Ecstasy.

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

but as a potential
new treatment in medicine,

and then a very important
treatment for psychiatry

because MDMA could offer us,
in psychiatry, for the first time,

the opportunity to tackle trauma.

And psychological trauma,

particularly that caused
by child abuse and maltreatment,

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

Psychiatry is in need
of this innovative approach

because current treatments
are failing patients.

Hi, my name's Ben Sessa.

I'm a child and adolescent psychiatrist.

Now that means
I trained as a medical doctor,

then specialized in mental health,

and then specialized
in child and adolescent mental health.

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

with mental health disorders
and addictions due to misuse of drugs.

And that developmental
pathway of my own,

from working with child abuse into adults
with mental disorders and addictions

has brought me to the door of MDMA.

And I'm going to propose today
that MDMA could be [as] important

for the future of psychiatry
as the discovery of antibiotics was

for general medicine a hundred years ago.

So when we think about child abuse,

we think about physical abuse,
mental abuse, emotional abuse,

sexual abuse, and neglect.

And we think about noxious environments.

We think about parents
with mental disorders,

we think about parents
who are addicted to drugs,

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

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

and I'm going to call her Claire.

Now, Claire was no single
particular patient of mine.

Rather, she's an amalgamation
of many different people

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

She's certainly not the worst.

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

Well, her mother was depressed.

Unfortunately, the family doctor
didn't have time

to accurately diagnose
and treat depression,

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

never really got therapy.

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

typical of what we call
psychosomatic symptoms in depression,

and, as a result, the family doctor
put her onto opiate based painkillers

which she promptly became addicted to.

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

not around, in and out of prison,

which is just as well
because when he was there,

he was physically abusive
to Claire and her mother.

Okay, so what does this kind

of chaotic, frightening environment
do to the developing child brain?

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

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

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

and many other animals
other than humans have an amygdala.

The amygdala lights up when stimulated

by fear in the environment,
by a frightening stimulus.

It lights up and it says,
"Fight or flight, get out!"

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

called the prefrontal cortex,

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

Now the prefrontal cortex,
only humans have,

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

to rationalize the situation
and we can use

our prefrontal cortex to overcome

that instinctive fear response
from the amygdala.

Now when Claire was growing up,

she never knew,
one moment to the next,

whether the adult coming into the room
was going to give her a kiss

or a cuddle or do a jigsaw with her,

or were they going
to punch her, or kick her,

or burn her with their cigarette.

Or were they going to rape her.

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

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

and one of the most important
is what we call

posttraumatic
stress disorder, or PTSD.

Now PTSD, some of the core features:

very low mood, anxiety,
high levels of anxiety,

what we call hypervigilance -

this edginess, this jumpiness.

Exactly how Claire felt,
throughout her childhood and adolescence.

Never knowing whether
the next assailant or assault

was around the corner.

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

Flashbacks, in which the patient

has sudden remembrances
of painful traumatic memories.

They could've popped
into the head, at any time,

triggered by some cue
n the environment.

And when they have those experiences,
those daytime flashbacks,

they relive the trauma in all the
sensory modalities,

and this results in them
freezing or dissociating

to try and block out the pain.

Now, Claire experienced all of this
as she was growing up.

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

Claire would cut her thighs
and her breasts.

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

She was being sexually abused
by her mother's clients

because her mother had moved on
from the addiction to painkillers

and was using street heroin
when Claire was a teenager.

And because of the way
the war on drugs has set up

that reduces access to treatment
for people with opiate dependence,

she had to pay for her heroin
using sex work,

and the clients
would sexually abuse Claire.

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

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

How do we treat it?

Well, we can treat it with medications.

We can treat it with psychotherapies.

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

No single drug,
and this is very important,

no single drug cures PTSD.

Rather, we treat
the disorder symptomatically.

If the patient's depressed,
give them an antidepressant.

If their mood fluctuates,
give them a mood stabilizer.

If they can't sleep, give them a hypnotic.

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

give the patient an anti-psychotic drug.

And they have to take
these drugs day in, day out,

for weeks, months, decades.

They have to keep taking them
because the drugs we use to treat trauma,

when it's due to this level of severity,
do not attack the root cause of trauma.

They paper over the cracks.

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

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

Sure, you can take
paracetamol or ibuprofen,

and this will lower the temperature

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

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

We paper over the cracks.

We maintain the symptoms
at a manageable level.

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

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

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

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

a problem shared is a problem halved.

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

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

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

she flees, she drops out of treatment.

Now, by the time she was 15 Claire had been
removed from the family home and she was

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

hostels where the abuse continued.

She would self-harm cutting and
she started drinking and

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

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

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

And this is the truth because
the treatments we use do not get to the

root cause of the problem, the trauma.

They paper over the cracks.

And I think the pharma industry know this
and they queue up and they

provide us with product after product to
give to our patients that doesn't quite

cure them but it gets them
slightly better to function.

And they have to keep taking them.

Indeed I would say that we're in psychiatry today where
we were in general medicine 100 years ago.

100 years ago in general medicine,

humanity was losing the battle
to the infectious diseases.

Oh we were very good at classifying
and diagnosing them.

We knew who got smallpox.

We knew people died of post-operative surgery.

We knew there were microorganisms
but we didn't have a treatment.

And then at the beginning of the 20th
century we discovered the antibiotics.

Not symptomatic treatment but treatment
that goes to the core of the cause

and we started getting on top
of infectious disease.

Now, Psychiatry today is in a similar place.

We're very good at classifying and diagnosing.

Our epidemiology is superb.

We write these thick diagnostic manuals.

We know who gets depression.

We know who gets anxiety.

We even know the cause: trauma, child abuse,
maltreatment, poor social conditions.

But our treatments are lousy.

And I'm quite shocked the way the empathy

switch and our understanding of these
patients seems to be switched off.

We have lots of gushing sentimentality for
the little five and six year old who's

being abused and we throw money at our
television sets on these campaigns to

improve the lives of these
poor little innocent victims.

But let me tell you what happens to
that little five or six year old,

when they're 11 or 12.

On goes the hood, start smoking weed.

By the time they're 16 they're
buying and selling amphetamine

and by the time they're Claire's age
in their mid-20s,

they're addicted to heroin and alcohol.

And suddenly we have lost our empathy.

These people are public enemy number one.

"It's your fault Claire. You brought this
upon yourself. It's your lifestyle choice."

And I'm quite shocked and having worked in
pediatrics and seen the developmental

trajectory that is so inevitable from
early trauma into adolescent and then

adult mental health and addictions, we have
to hold on to that sense of compassion

and evidence-based understanding
about the developmental trajectory there.

So it does sound desperate,
but all is not lost.

MDMA. MDMA has some fascinating qualities.

Indeed, I would suggest that if you were to invent
a hypothetical drug to treat trauma,

it would be MDMA.

The way it works in terms of its receptors
and its subjective psychological effects

ticks all the right boxes.

At one level of receptors it causes
an increased positive mood.

Lowering of depression, lowering of anxiety.

At another group of receptors it speeds
the patient up,

mild stimulation which motivates them
to engage in therapy.

At another level it relaxes
the patient paradoxically

at the same time as the stimulation and this
puts the patient into the optimal arousal

zone where they can engage in psychotherapy.

But perhaps the most important thing about
MDMA and the most important clinical tool

is its ability to provide a sense of empathy
and understanding and emotional security.

It can hold the patient in a place where
they can think about and access their trauma

like they've never been able to do before.

One of the ways in which MDMA works is

is it increases the release of a
hormone called oxytocin.

Oxytocin is released from the brains of
breastfeeding mothers.

It's a hormone that engenders a sense of
attachment and bonding.

And that's what's happening in the
patient who takes MDMA.

And also it acts directly on
the amygdala to reduce

that fear response whilst at the same
time boosting the prefrontal response,

allowing the patient to see things in a new light.

A positive light.

So let's go back to Claire.

She's 40 now.

She's been in and out of psychiatric hospitals,

having tried to take her own life
in the inception.

She's been on all the antipsychotic and
antidepressant mood stabiliser drugs.

She's tried all the psychotherapies
but she cannot engage

because she will not talk about her feelings.

So she comes into a course of
MDMA-assisted psychotherapy.

What does it look like?

It's weekly sessions, maybe eight, ten,
twelve weeks long.

There're two therapists, male-female pair.

You do not take MDMA everyday,
you do not take it every week.

Over that course of 12 sessions you'll
take the MDMA three times and the

other sessions you talk about the material
that's released on the MDMA session.

So what does Claire actually feel
when she takes this MDMA?

What she feels is a sense of warmth and
understanding and a sense of containment

within that relationship she's having
with the therapist.

MDMA is like a lifejacket like
a bulletproof vest

to wear to go into battle with your trauma.

This is not ecstasy!

She's not enjoying some raver's euphoric
ecstasy delight.

This is still trauma focused psychotherapy
and it's still hard and distressing for her,

but she can just about do it with
MDMA on board.

So when the therapist says:
"Claire, tell me about your rape".

In the past just the word rape
and she'd be out the door,

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

I can see him now coming into the room.
I can smell the whiskey on his breath and

I can feel the stubble on his face
as he's raping me".

And she talks about it and she explores it
and she reflects upon it

and she can begin the process of healing.

And from here she can start her journey.

She can attack the root cause of her problems.

Not just maintain the symptoms at a level.

So, does it work?

Well, we've known about MDMA
for a very long time

and indeed we've used MDMA in
underground therapy for 30 or 40 years.

And there are thousands of
positive anecdotal cases.

I get five emails a week from all over the
world: "Dr. Sessa, I've had PTSD for years.

I've tried everything and now I tried MDMA
and I'm starting to make a breakthrough!"

Now, anecdotal reports like that are
interesting but they're not science so

we've done the science.

And some important studies in recent years.

Big study in the States showed that a single
course of MDMA therapy, 16-week course,

patient takes MDMA three times
tested against a placebo.

At the end of that course 85% of the people no
longer met the diagnostic criteria for PTSD.

Not just a relief of symptoms,
they didn't have PTSD!

Now that cohort were then followed up
three years later, the same no PTSD.

Many of those people had come of
their daily medications.

They were cured! We don't use
the "cure" word in psychiatry.

We've become learned helplessness
position of--This is the truth!

If you're diagnosed with a severe
mental disorder like anxiety or depression

in your 20s, and the developmental route
of that disorder is severe child abuse,

there's a pretty good chance--
and I'm sorry to say this--

there's a pretty good chance you
will still be going to

psychiatric clinics in your 60s and 70s.

Now that is not good enough and we're in this
position because we're not tackling trauma.

So, it works but is it safe?

When we talk about safety of
clinical MDMA, what we must not do is

look at the risks of recreational ecstasy.

I don't even know what ecstasy is anymore!

Ecstasy is over here, what is ecstasy?

Some dodgy pill bought in some
dodgy club of some dodgy geezer,

that may or may not contain MDMA plus or
minus whatever far more toxic substance.

And indeed, when you hear about the very high-profile
deaths of people who take ecstasy,

it invariably is not MDMA.

So, let's not look at ecstasy as a
measure of MDMA.

Let's look at clinical MDMA.

When you use clinical MDMA, you take it
under medical supervision. It is pure.

The MDMA that I'm using in
my studies is 99.98% pure!

Very expensive!
(laughter)

We do it under medical supervision with
a doctor and a nurse and a psychologist.

And under those conditions the risks are
reduced to an absolute minimum.

Indeed, after 40 years of MDMA research,

there has not been a single serious
adverse drug reaction, not one!

And certainly no deaths.

So, we need to do this research and

we need to do this research in
an evidence-based, compassionate way.

Looking at the data.

We need to ignore the socio-political
agenda that says any drug

that's being used recreationally must
also be very bad and dangerous.

That sort of attitude hampers research.

And we need scientists to drive this.

It works, it's safe.

And it offers patients like Claire for the
first time in their life an opportunity

to break through from that trauma and not
become a lifelong chronic PTSD sufferer.

So, where were we going with MDMA research?

Well, we've had some studies,
we've got more coming here.

I'm doing a study in Cardiff with neuroimaging
in which we're going to give patients

with PTSD, MDMA and placebo and
we're going to look at that relationship

between the amygdala and the
prefrontal cortex.

We're also doing a study here in Bristol giving
MDMA to patients with alcohol use disorder

because underlying the root
of this addiction is trauma.

This is an exciting time.

Now people say: "This is controversial!"

And indeed, I was introduced
as a controversial speaker.

I'm not controversial, I'm a very boring
conservative doctor.

I like data.

I like evidence-based data that
helps my patients.

I'll tell you what's controversial!

What's controversial is that more people
have died returning from Afghanistan and Iraq

because they've committed suicide
because of their untreated PTSD

then ever died in the conflict out there.

That is controversial and that is unethical!

So, this is an important time for science.

MDMA could be the antibiotic that
psychiatry has been waiting for.

We owe that population of patients
who are being failed,

we owe them this research!

We owe this to Claire!

Thank you.
(applause)