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Four years ago, Hannah was 35 and raising a 3-year-old daughter with her husband Jacob. Then, that October, she was diagnosed with breast cancer. Amidst the strain of the ongoing pandemic, she underwent a year of treatments. But even after finishing them, she was wracked by anxiety and depression, paralyzed by fears of recurrence, debilitation, and of their daughter growing up without her. She experienced bouts of dissociation and was diagnosed with post-traumatic stress disorder. Jacob felt crushed under the weight of it all. Their marriage was unraveling.
The couple sought out anything that might help reknit the threads of their relationship. Antidepressant medications didn’t work, and their side effects made things worse. Individual therapists trained in cognitive behavioral therapy, mindfulness, and eye-movement desensitization and reprocessing couldn’t ease their distress either. Neither of two different couples therapists helped.
So, on the cusp of turning 40, with most other options exhausted, Hannah and Jacob (whose names have been changed to protect their privacy) tried one more new thing to salvage their relationship: MDMA.
The drug—short for 3,4-methylenedioxymethamphetamine, also known as ecstasy and molly—was first synthesized in a Merck lab in 1912. It waited until the 1980s, though, to rise to prominence as a subject of curiosity among some psychotherapists and the drug of choice in many dance clubs around the world, where it was prized for the sense of elation and connection it offered.
Rather than as part of a night out or experiment at home, however, Hannah and Jacob took the drug one spring day this year at Sunstone Therapies, a clinic on the sunny third floor of an Adventist HealthCare Medical Center, in Rockville, Maryland. They were part of a clinical trial exploring the potential of MDMA-assisted therapy to help partners with a cancer diagnosis and adjustment disorder restore connection to their impaired relationships. Their experience, and those of the other couples in the trial, hints at the promise of this approach—even when the drug’s effects don’t go as expected.
MDMA was banned in the United States by the Drug Enforcement Agency in 1985. But as psychedelics have re-entered the mainstream over the past decade, researchers have begun to study whether these mind-altering drugs can help people overcome trauma, among a host of other mental health challenges. In 2017, MDMA was granted breakthrough therapy status, expediting investigations into its potential to substantially improve the treatment of post-traumatic stress disorder; the Food and Drug Administration in August rejected an application to approve MDMA for that purpose, but efforts to legalize its therapeutic use are ongoing.
In the vast majority of psychedelic therapy trials—often involving ketamine, LSD, or psilocybin—individuals are treated alone, their partners absent for an experience that often ranks among life’s most profound.
Hannah and Jacob tried one more new thing to salvage their relationship: MDMA.
But MDMA, which is known for facilitating communication and pro-social behavior, offers researchers a differently shaped tool to explore whether a psychedelic can also accelerate the therapeutic process in a relational setting. It has long been used in couples therapy—both before it was made illegal and, since, in the underground.
With its breakthrough status, however, researchers can continue to test its efficacy in the clinic. A 2021 pilot study found that MDMA-assisted couples therapy led to significant decreases in PTSD symptoms and reductions in relationship conflict, offering early evidence of the treatment’s potential in relational work. Three new trials are now further investigating its efficacy in tandem with more traditional cognitive-behavioral therapeutic treatment—exploring psychedelic-assisted couples therapy in a clinical setting for the first time since the class of drugs was made illegal.
Of course, relationships are messy, with myriad forms of conflict and disconnection, stemming from all types of sources, making this sort of research tricky to approach scientifically. But a cancer diagnosis offers a specific and common source of relational strain. “Cancer doesn’t affect just the person with cancer,” says Manish Agrawal, an oncologist who is the principal investigator of the study Hannah and Jacob took part in and co-founder and CEO of Sunstone Therapies. “It affects an entire family system.”
So, Agrawal says, just as cancer should be treated within the broader context of a patient’s life, its emotional fallout should be as well. Psychedelic therapy can be most effective when shared between two people, so studying MDMA’s potential in couples therapy allows for a social view, rather than an isolationist one, he says.
After experiencing the breakdown cancer can cause, Hannah and Jacob—and the other 20 couples in Agrawal’s trial—turned to MDMA therapy in hopes of putting the pieces back together.
For many couples, the pain of living with cancer becomes a “gorilla in the room,” an unwelcome and destructive guest that simply can’t be ignored, says Mark Bates, a soft-spoken therapist who came to Sunstone following a career as a military psychologist. And Jacob, a professor of social and personality psychology, and Hannah, an executive career coach, struggled to adjust to the havoc it caused.
The trial they enrolled in focused on couples in which a cancer diagnosis had caused adjustment disorder, which is classified alongside PTSD and acute stress disorder, part of a continuum of responses to an overwhelming stressor that can result in severe distress and trouble with daily functioning. The two other ongoing studies examining the use of MDMA in couples therapy are focused on partners in which one member has PTSD.
With a range of consciousness-altering drugs currently being deployed in therapeutic trials, however, these researchers are intrigued by MDMA’s particular modes of action for addressing relational distress. The dissociative anesthetic ketamine is being investigated—and already, in some cases, used—as a treatment for depression, owing to its apparent short-term impact on neuroplasticity. And “classic” psychedelics, including LSD and psilocybin, powerfully alter consciousness and induce mystical experiences in ways that MDMA doesn’t; they also contribute to ego dissolution that may be valuable in individual therapies but less so when focusing on a relationship. Whereas LSD, for example, can inspire introversion, MDMA leads to extraversion, which researchers say is central to its benefits for couples.
The drug can help couples approach one another with openness, understanding, and empathy.
MDMA prompts the release of the neurotransmitters serotonin, dopamine, and norepinephrine in the brain—and inhibits their reuptake—delivering short-term improvements in mood, energy, and alertness while enhancing pleasure and sensation. At the same time, the drug decreases activity in the amygdala and the hippocampus, which are associated with fear response and memory processing, respectively. It also decreases connection between those parts of the brain, allowing access to traumatic memories without the stress-related symptoms that often accompany them, offering an opportunity for people to revisit and recontextualize pain that otherwise interferes with their daily lives. “It softens that rigidity where trauma is stored, so you’re able to address those things that are pushed down and held way back,” says Betsy Jenkins, a therapist on the Sunstone trial.
Amidst all of these shifts in the brain, MDMA is reported to increase openness and improve compassion for oneself and others. And it releases a surge of oxytocin, which is associated with trust and relationship building. The drug conjures a feeling of “comfort and safety,” Bates says, creating a setting in which couples can approach one another with openness, understanding, and empathy as they work through trauma and disconnection together.
In the 2021 pilot study, Anne Wagner, a psychologist and founder of Toronto mental health clinic Remedy Centre, gave couples MDMA in conjunction with cognitive behavioral conjoint therapy (CBCT), a couples-therapy program focused on education about PTSD and developing behavioral tools to navigate stressors together. The combined therapy reduced PTSD symptoms and improved relationship functioning. She’s now enrolling participants in an expanded trial that will address some of the pilot’s limitations, including its small size.
MDMA’s ability to engender empathy—both for oneself and others—makes it particularly useful in a couples setting, Wagner says, and especially for those with PTSD who can feel destabilized by accessing their emotions. It helps couples “share and communicate in an open and vulnerable way and experience all the emotions that go along with that without getting overwhelmed,” she says. “That creates a relational opportunity that’s important and potentially really fruitful.”
A third ongoing study, led by Leslie Morland, a clinical psychologist and senior researcher in the VA National Center for PTSD, will give veterans with PTSD and their respective partners eight sessions of CBCT and two MDMA sessions with both individuals present. But only the veteran will receive MDMA. (Morland’s pilot expands on earlier research in which she found that CBCT—without MDMA—helped improve veterans’ symptoms; it had the same impact on relationship functioning and satisfaction as a more basic, education-based control group.)
While researchers investigate the therapeutic potential of MDMA in a clinical setting, the drug continues to be used by many couples without the guidance of a therapist. Last year, therapist Robert Colbert and Shannon Hughes, an associate professor in social work at Colorado State University, published a paper describing eight couples’ private use of MDMA as a tool for improving their relationships. For most couples, taking MDMA together serves as “a general tune-up” for a relationship in need of closer attention, rather than a full engine rebuild, Colbert says. Their small-scale study suggests MDMA may have relational benefits for couples well beyond those with a cancer or PTSD diagnosis.
Even outside of a relational context, there are no perfect treatments for those with PTSD or adjustment disorder, and more options are needed, says Katy Dondanville, associate professor and a licensed clinical psychologist at the University of Texas Health Science Center at San Antonio who specializes in PTSD and suicide prevention. The burgeoning research on MDMA-assisted couples therapy is promising, she says, but the dozens of participants in the ongoing trials pale in comparison to the thousands who have been studied for the leading PTSD treatments, such as cognitive processing therapy and prolonged exposure therapy, leaving plenty to still be learned.
Beyond the very small study sizes—which pose a challenge in applying conclusions to the broader population—these studies are difficult to conduct in a double-blind manner, in which neither the participant nor the people they interact with in the study know whether they are receiving an active treatment or a placebo, which is required for the most rigorous clinical pharmaceutical trials.
She felt “empowered and spacious,” and her depression lifted in the days that followed.
This limitation raises a bit of a red flag for Jonathan Abramowitz, director of clinical training in the University of North Carolina at Chapel Hill’s Anxiety Lab, which studies anxiety within couples and families. He notes that participants can easily deduce whether they’ve been given MDMA or a placebo. To that end, Wagner’s expanded study will randomize participants in an attempt to tease out the impact of the drug without a placebo. She aims to treat 15 couples using MDMA-assisted therapy and 15 using couples therapy alone.
The hype about psychedelics also makes it difficult to trust participants’ subjective responses about the effectiveness of treatment—and opens the door to enthusiastic therapists influencing the experience, Abramowitz says. He worries that psychedelics may have the same “15 minutes of fame” as other pharmaceuticals without becoming the “game-changer” many want them to be. The very internal, subjective experience of these consciousness-altering drugs also complicates the process of gathering data. “The problem with some of the things psychedelics are thought to bring about is it’s hard to verify them,” Abramowitz says.
And although MDMA is widely viewed as being on the safer end of the psychedelic spectrum, it carries serious potential health risks. As an amphetamine, it increases heart rate and blood pressure, and in rare cases it can cause hyperthermia and seizures. Bates and Jenkins note that participants are carefully screened to ensure they have no contraindications. And as with any consciousness-altering drug, it comes with the risk of “bad trips,” in which those under the influence have an overwhelmingly negative experience.
Even when things go well, MDMA can’t address PTSD or relational distress on its own, researchers say. Anecdotally, couples tend to reflect on the drug as a significant part of the equation, Jenkins says, but remark that, “I never would have gotten where I am without the therapist.” Bates describes MDMA as “a catalyst, not a replacement” for therapy, whose addition to the process may help accelerate individual and relational healing.
“You can invite those experiences and sometimes they arise [in couples therapy], but it appears to me that it’s much more profound with the medicine,” he says.
In psychedelic therapy, as in life, things sometimes do not go as planned, as Hannah and Jacob discovered.
Their study’s plan was for couples to undertake two MDMA sessions. First, each partner would take the drug at the same time but in separate rooms and with separate therapists. Later, they would undergo a trip together, also with their respective therapists present. During the first of the two planned doses at Sunstone, Hannah saw how lonely she and Jacob had become since they married in 2015—all the ways they were growing apart, distanced by their distresses. With previous therapists, she had always hit a wall, but under the influence of MDMA, she told me she was able to push through to understand what lay behind it.
Hannah says she realized, “There was a growing misunderstanding, a growing desire for both of us to be seen and heard in the relationship. And just within the first hour of the MDMA, I was able to see him in a way that I’ve never been able to see him before.”
She felt “empowered and spacious,” and her depression lifted in the days that followed, she says. She found herself more capable of staying emotionally regulated and in touch with her husband.
Jacob, meanwhile, felt something more like a “bad high” during his individual dosing session, he says. He anticipated a sense of euphoria and deep feelings of love that never came. Instead, he found himself unnerved by the eye mask he was asked to wear and the ethereal music in his ears. He knew he was in a safe space and his therapist helped guide him to a better mental state by the end of the session, but it was more like a continuation of past suffering than a rupture from it.
After a week of discussion, the couple decided to forgo the second dosing session, in which they would have taken MDMA together, and leave the study.
Still, it was profoundly beneficial for their marriage, they both told me. As Hannah’s symptoms lightened, she could see the vast caretaking burden Jacob had assumed. He finally felt understood. The fight-or-flight instinct that had reared up in Hannah whenever tension arose dissipated, and they began solving problems together.
Their experience won’t factor into the trial’s results, but they believe it demonstrates the therapy’s potential—even when the drug didn’t work as expected for both partners. “I used to think maybe I didn’t marry right,” Hannah says. “Now, I’m so happy that I have him—that we are together.” Despite his challenging experience, Jacob agrees the drug altered the foundation of their relationship for the better. “It’s night and day from before,” he says. 
Lead image: Jorm Sangsorn / Shutterstock
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