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

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

Now, Claire's father, 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,
a 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,
from 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 assaulter was around the corner.

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

flashbacks,

in which the patient
has sudden remembrances

of these painful traumatic memories.

They can just pop
into the head at any time,

triggered by some cue in 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 clients of her mother

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
use in sex work,

and the clients
would sexually abuse Claire.

Now, 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.

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

Sure, you can take
paracetamol or ibuprofen,

and this will lower the temperature,
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' tale

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,

and paper over the cracks.

And I think the pharma industry
knows 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.

I would say that we're
in psychiatry, today,

where we were in general
medicine 100 years ago.

Now 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.

When they're 16, they're
buying and selling amphetamine,

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 seeing 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 receptors

and 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 it increases the release
of a hormone called oxytocin.

Now, 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,

while, 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 stabilizer 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 the 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
off 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, off 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 are 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 patients with alcohol
use disorder, MDMA,

because underlying the root
of this addiction is trauma.

So, 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

than 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)