E for Ecstasy by Nicholas Saunders
Appendix 1: Reference Section

99 Ecstasy: the clinical, pharmacological and neurotoxicological effects of the drug MDMA (book), edited by Stephen Peroutka, published by Kluwer Academic Publishers 1990

This is the classic serious work on MDMA but costs about #100. The book includes essays by a range of experts in the field: The History of MDMA by Shulgin; Therapeutic Use by Greer; Testing Psychotherapeutic Use by Bakalar and Grinspoon; Recreational Use by Peroutka; Toxicity by Dowling.

There are 13 chapters in all.

MDMA is unique among recreational drugs in that taking larger or more frequent doses reduces the pleasant effects and increases the bad effects. It is also unique in that the effects change with successive doses, the first being the most pleasant while further uses produce more uncomfortable side effects. [This view is challenged in a more recent report.26]

Therapeutic use

"MDMA seems to decrease the fear response to a perceived threat to a patient's emotional integrity, leading to a corrective emotional experience that probably diminishes the pathological effects of previous traumatic experiences," Greer says. Double-blind comparisons are not feasible in clinical settings because the MDMA state is easily perceived by both the patient and the therapist. Suggested therapeutic uses include family relationships and drug addiction.

The effect of MDMA was seen as secondary by the therapists: the drug assisted rather than caused the desired outcome. The goal of developing a more compassionate attitude towards oneself and others was easily achieved in MDMA-assisted therapy. Of paramount importance was the quality of the relationship between the client and therapist: enabling the client to feel safe to open up fully was seen as more important than the dose of MDMA taken. It was considered essential that the therapists tell the client that the client's MDMA trip had been helpful to them, in order to reassure the client. For therapists, "The experience of fearless communication and spontaneous forgiveness, or letting go of resentments, was particularly important in understanding how MDMA can be used effectively."

The screening of prospective clients is very important. Those with heart problems; those using psychoactive medication; epileptics; hyperthyroids; diabetics; hypoglycemics; hypersensitive people and those with liver disease or other risks of morbidity should be excluded. Although the drug was considered useful for those with psychiatric problems, therapists worked only with relatively well-adjusted people. They excluded those who aroused uneasiness on interview. Patients were warned about the possible adverse side effects, and this resulted in several opting out.

The therapists preferred to work as 'sitters' or assistants to patients who were exploring themselves rather than to become involved in a long term therapeutic relationship. Patients could ask for anything they wanted during sessions. [Agreements given under Greer.28]

Discussing unwelcome effects of MDMA, therapists mentioned the pain of unfinished grief or trauma associated with forgotten memories or repressed feelings, which often resulted in depression and/or anxiety. This was usually experienced as difficult but useful, and seldom lasted more than a few days. They had not heard of long-term problems resulting from such feelings.

Since the outcome of MDMA sessions cannot be predicted, patients were warned to be prepared to experience anything that might arise during or after their session. They had to have a conscious desire to be open to the most painful experience of their past so as to be able to work through it. "You are consciously taking a medicine to open yourself to whatever teachings you may need at this time. Neither you nor we know what these teachings are or how they may occur. We will provide a safe place for your explorations and be available to assist you with any difficulties, but all that you learn that is real comes from yourself or from the Divine that is within you - not from us or the medicine itself," one therapist would say. Preparation was seen as important. It was felt to be useful for clients to have clear expectations, which made it easier for them to let go. Clients were advised not to take alcohol and other drugs for the preceding few days, as this is thought to reduce the effect of MDMA, and to eat no food for the preceding few hours.

Patients were asked whether they wanted a low, medium or high dose. For men, this was 100 to 150; for women 75 to 125 - women were thought to be more sensitive to the drug, perhaps due to their lower body weight. Higher doses were advised for those focusing on themselves; lower doses for couples wanting to communicate with each other. The therapists' main role was to provide for physical needs and to offer interpretations as required. Dr. Greer advises clients to relate their experience afterwards, rather than have their therapist record the trip in process. If a monologue occurred, he suggested the use of a tape recorder to focus attention inward, rather than towards the therapist. After the drug wore off, patients usually sat up and talked about what had happened. Therapists did not routinely offer to interpret clients' experiences, but tried to facilitate a smooth transition back to normal.

About 90% of the clients had powerful and generally positive and useful experiences under MDMA. A third of these had had one session; another third, two and the rest, three or more.

The book also includes a report of a survey of Ecstasy use among students at Stanford University. 39% of students had used MDMA. 100 completed a questionnaire while under the influence. The results were unsurprising: 90% reported increased closeness with others.

Also included is a report of Ecstasy-related deaths involving heart failure and asthma that have been investigated in the US.