Open MDMA: An Evidence-Based Synthesis, Theory, and Manual for MDMA Therapy Based on Memory Reconsolidation, Complex Systems, and the Defense Cascade

MDMA therapy is not approved by most medical regulators. But underground use is popular despite a severe lack of adequate practical guidance. Thus, I provide comprehensive practical guidance for solo and guided MDMA therapy based on critical literature synthesis, personal experience, community reports, and a mechanistic framework. I primarily address the individual doing or seeking MDMA therapy while also discussing certain aspects mostly of interest to practitioners and researchers. With this manual I aim to improve the appeal, safety, and efficacy of MDMA therapy through scientific rigor, comprehensiveness, transparency, and respect for autonomy.

These ideas are grounded in a theoretical model based on frameworks of memory reconsolidation, predictive processing, complex system dynamics, and the defense cascade model of autonomic nervous system threat responses. I use this to explain how many mental illnesses work, how MDMA therapy works, why destabilization exists, and how to navigate the long-term healing process. I argue that MDMA therapy durably improves many mental illnesses and stuck emotional reactions and beliefs through the unlearning, or reconsolidation, of inaccurate mental models. It reconsolidates most or all stuck mental models that are activated—and which you stay present with—during the session.

Practical guidance contains evidence-based discussion of safety, session preparation, the session itself, troubleshooting, between-session healing, and how that all fits into the longer-term healing journey. I also extend MDMA therapy beyond clinical mental illness to mental models that inhibit healthy community relationships, cognitive flexibility, and ethical reasoning. The tradeoffs between practitioner- versus self-guidance and instructions on how to find skilled, ethical, and well-matched practitioners are included.

This is the only MDMA/psychedelic therapy manual to explain and justify its recommendations based on a mechanistic theory of mental illness and healing while providing reasons for both confidence and skepticism of its claims.

This book doesn’t offer personalized medical/therapeutic advice, guarantee healing, assure the prevention of negative (possibly severe) outcomes, or prevent legal problems if used in a place where MDMA is illegal. Instead, this book is my framework for increasing the efficacy and safety of MDMA therapy, grounded in research, community insights, and author experiences. I spent considerable effort trying to make the best book I can, but could be wrong about some important things. Please cross-check my references with other high-quality sources of information if you question something I say or are considering doing something potentially risky. Possessing MDMA is a felony in many jurisdictions. Licensed mental health professionals might risk their licenses by offering MDMA therapy in contexts where it isn’t legal.

While this book has universal aspects, it doesn’t cover all frameworks for doing MDMA therapy. Although MDMA therapy has been practiced for 50 years, comprehensive scientific study is relatively recent, leaving many aspects unexplored or unformalized. I think my model is a formalized version of what many MDMA therapists have already been practicing for decades. However, that formalization, integrating complex systems dynamics, memory reconsolidation, attention, and the defense cascade, appears novel despite each piece, and some combinations of the pieces, being fairly well-established. Novel frameworks are usually incorrect to some degree even when their authors find them convincing. Additionally, as an interdisciplinary work, I am surely getting some nuances of the individual frameworks I draw from wrong.

The purpose of the book is reducing suffering. As part of that goal, several sections apply MDMA therapy to topics not typically considered part of therapy.

There’s now an ebook version at github.com/groeneveld/mdma-guide/blob/main/Open MDMA.epub. There a few minor formatting issues that I haven’t figured out how to fix, including section headings in the Table of Contents not displaying at the right level and missing Appendix and Bibliography headings. There’s also an html version at groeneveld.github.io/mdma-guide/.

Substantively edited / rewrote almost everything for clarity, logical flow, and rigor. Also fixed almost all the grammar and spelling issues. Added the Feeling Like You are Going Crazy troubleshooting subsection. Added Alternatives to MDMA. Removed Our Pitch because it didn’t fit in well and was redundant. Removed Psychoeducation and Self Determination Theory because they were also redundant. Removed Making Sense of the Experience and distributed its content to Precautions and Uncertain Memory. Reorganized Between Sessions. Shuffled a few other sections around. Condensed Making Positive Life Changes to a small subsection at the end of Life Changes Associated with Improved Mental Health. Moved T.H. from an author to an acknowledged contributor since they’re no longer a part of the project.

Removed the two Beyond Therapy sections and Organizing Community Care because they were overly influenced by my own stuck schemas. Added Mechanism of Action Hypotheses, The Arc of Healing, How Schemas Update (Or Don’t), the Sessions Become Less Effective Over Time troubleshooting subsection, Plain Language Summary, the Psychosis troubleshooting subsection, and the subsection Reasons to be Skeptical to Methodology. Rewrote Somatic Symptoms, Session Frequency, and the Safety section bullet point on psychosis. Split Epistemic Status into Core Assumptions and Approach Mental Health Research and Practice With Skepticism. Shuffled around various sections into different chapters or renamed them. Bumped up the risk assessment of frequent higher-dose sessions due to Coray¹. Also made a lot of little changes here and there.

Preface

This is, admittedly, an odd book that doesn’t fit traditional categories. I combined the tasks of reviewing and theorizing, all in the packaging of a practical manual. It includes a significant amount of personal experience with the practices described here. I aim to democratize access to high-quality MDMA therapy by mixing scientific rigor, comprehensive practical guidance, high ethical standards, and transparency about my biases and what is known and not known in the field.

The book started as my attempt to figure out what was actually happening during my MDMA therapy journey, which I started after getting no help from almost every treatment licensed mental health professionals can offer. I had a very difficult time figuring out what mental illness is,¹ what MDMA therapy does, and how to optimize MDMA therapy for efficacy and safety. As I learned, rigorous answers to these questions have only started to appear in the 2000s and 2010s and haven’t yet widely diffused down from academia. This knowledge base is also widely distributed in the literature and as far as I can tell hasn’t been put together in one place before. This is unfortunate because many people are desperate for mental health treatment and are attempting MDMA therapy with inadequate information. I thought a manual could help with these problems.

Since MDMA therapy was almost my last option, knowing how to do it right was critical to my health. I created this book because I felt my life was at stake. I felt that creating this unique set of actionable but accurate knowledge was my only option for survival in a world of untrustworthy and poor-quality mental health information.² Making the best of non-optimal situations in ways the medical system doesn’t approve of has been a critical survival tool for me. The book is my version of Where There Is No Doctor, but made for a world in which even mental health practitioners need far better information than they currently have.

My deepest desire is that this book aids the well-being and cooperation of all beings through the unlearning of stuck reactions and beliefs. However, I have wide and deep-seated stuck beliefs (severely disorganized attachment in my case) and have certainly projected them into this book in unhelpful ways despite attempting to avoid that. I’ve tried to be critical of the things I’m enthusiastic about, but inevitably my biases have pushed me to be overly critical of some things and credulous about others.

Likewise, I try to strike a balance between practical applicability and scientific robustness but recognize this balance means the book is optimally adapted to neither case. In addition, the scope of this book presents some issues. I have thorough experience with some aspects of MDMA therapy and have excellent broad knowledge of the research but am not an expert on any of the individual theoretical frameworks I use. Hence, while I have done my best to critically evaluate the evidence and references, I certainly have missed some nuances only visible to certain subject-matter experts. My core assumptions, my reasons for believing each, and my confidence in them are laid out in Appendix A. The core ideas of the book are likely solid; however, I have probably made some errors in extrapolating those core ideas into the framework I use. Some of my citations will also inevitably not reproduce in further experiments. Reproducible science is difficult to do or identify.

The strength and novelty of this book lie in the synthesis of multiple theoretical frameworks for describing MDMA therapy, in this case memory reconsolidation, predictive processing, complex systems, and the defense cascade model of autonomic threat response. It is also valuable as a comprehensive review and guide for most aspects of MDMA therapy that is accessible to solo users, clients, and practitioners. I’m not aware of any other work that rigorously covers most of the knowledge required for successful MDMA therapy. Its rigorous, mechanistic, science-based approach will also appeal to readers disinterested in the New Age and shamanic beliefs that pervade psychedelic spaces. Simultaneously, it avoids the neurobabble³ that is endemic in popular and clinical discourse of mental health.

I think my recursive approach produced a higher-quality and better-grounded book than if I worked from either theory or personal experience alone. Personal experience informed theory, which then informed interpretation of personal experience, which further informed theory, etc.

Finally, I would like to thank the scientists and therapists who developed this body of knowledge and practice; Jessica Sojorne Libere; my partner for encouragement, support, and editing; r/mdmatherapy for numerous case examples and feedback; the researchers who answered my questions; one primary care physician for feedback on Chapter 4; Claude for a few things listed below, and several users on dharmaoverground.org for feedback on Subsection 8.4.12. Thomas Harper (T.H.) also provided major contributions.

Project Contributions:

Thomas Harper (T.H.) wrote [unedited] How to Find a Practitioner, most of Navigating Uncertain Memories, and minor parts other sections. M.G. was responsible for everything else. M.G. also copyedited all of T.H.’s sections and changed some terms to match the rest of the book. T.H. also provided early feedback on many of M.G.’s sections.

AI Disclosure

With the exception of Table 7.1 and T.H.’s writing, I authored all content. In the occasinal instances where I accepted Claude’s rephrasing of an existing sentence or paragraph, I exercised complete editorial control and my original meaning remained intact. All AI responses were also verified against original sources and treated as one input among many—not as authoritative.

Biases, Conflicts of Interest, and Background:

Summary

Biases, conflicts of interest, and backgrounds.
M.G.	T.H.
• Disorganized attachment to MDMA therapy.	• Attached to their identity and work as a therapist.
• Scored 14.5/40 (not at all a cultist) on Evans’ Are You a Psychedelic Cultist quiz³.	• Scored 11.5/40 (not at all a cultist) on Evans’ Are You a Psychedelic Cultist quiz³.
• Used MDMA therapy to successfully treat their own severely disorganized attachment and childhood sexual abuse. Started with 3 practitioner guided sessions and then did about 25 solo sessions. Has been through many ups and downs throughout the process.	• Hasn’t used MDMA or guided any MDMA therapy sessions. Is a therapist and has two decades of experience in community organizing around mental health.
• Thoroughly familiar with the broad, interdisciplinary set of MDMA therapy research.	• Deeply familiar with the professional practice of therapy, therapy best practices, and the failures of the mental health industry.
• No financial stake other than one $500 unsolicited donation to the project from a friend unaffiliated with the psychedelic field.	• No financial stake than a future share of the donations and M.G. paying them an hourly rate for writing and editing.

MDMA facilitates extraordinary feelings of compassion, connection, and safety.⁴ This state of mind is highly effective for processing difficult or unhelpful emotions, memories, and reactions. However, there are no quick fixes for all but the simplest issues. Even in optimal conditions, intensive MDMA therapy can take multiple years to heal the most severe mental illness.

There is moderate-quality clinical trial evidence that a limited course of MDMA therapy is highly effective for durably resolving PTSD, not just managing its symptoms. However, I think there are good theoretical reasons and ample anecdotal reports indicating that MDMA therapy can also resolve the psychological part of most mental illnesses and emotional issues. This includes CPTSD, non-secure attachment (which 41% of the US population has⁴), anxiety, addiction, alexithymia, obsessions, eating disorders, ADHD, depression, somatic symptom disorders, personality disorders, dissociation, panic, and more. Some instances of these issues may have biological components that MDMA therapy does not address.

Many self-reports of successful MDMA therapy can be found on the top posts on reddit.com/r/mdmatherapy. The top posts mostly describe productive sessions that don’t contain intense dissociation, avoidance, or symptom worsening. You can see occasional descriptions of less productive or more disruptive sessions by sorting by new. Godes⁵ also reports how therapy clients describe how they felt MDMA therapy worked during their sessions: staying with what “is”; decreased reactivity; insight, reflection, linking; mental clarity; recovery of traumatic memories; disentangling trauma from self; reuniting lost affects and parts; self-acceptance; joy, happiness, gratitude; hope and empowerment; relaxation, calmness, peace; comfort; gratitude, compassion, empathy; union, wider perspective; inner healing intelligence [the therapeutic framework used in this study]; accessibility to emotions; and mind-body connection.

As of 2026, MDMA has not been approved by most medical regulators. There is disagreement over whether existing clinical trials were sufficient to approve MDMA for medical use. The US FDA thought the existing evidence was insufficient and requested one more trial, but the Dutch State Commission on MDMA determined that “Scientific research has shown that MDMA-AT [assisted therapy] is an effective and safe treatment method. … The State Commission deems it desirable that this treatment method becomes available in the Netherlands as soon as possible.” ⁶. Possession of MDMA is a felony in many jurisdictions, though it often isn’t an enforcement priority. The vast majority of MDMA therapy in 2026 is done underground, though there are clinical trials and special access programs in certain countries.

How Trauma and Insecurity Affect Us

Our brains continually learn beliefs (e.g., “I can’t do anything right,” “I am bad”), emotional reactions, and behavioral patterns to move through the world and thrive. Different therapeutic frameworks group these components into units called schemas, parts, trauma reactions, priors, etc., because the components seem to act as an integrated whole rather than separate things. Occasionally, the schemas we learn to survive in one context become maladaptive in another context. This often starts when we learn particularly deep, pervasive, negative, and resilient schemas about ourselves, other people, and relationships to survive emotional or physical insecurity or trauma. Once we shift out of that context, like when we become adults, a wide variety of circumstances trigger those old schemas, resulting in fear, anxiety, anger, depression, panic, etc. in situations where those reactions are no longer helpful.

Strong schemas of imminent threat and powerlessness also cause our nervous systems to activate the defensive states of arousal, flight-or-fight, freeze, and tonic/collapsed immobility. The latter is often called dissociation.

Our brains have an updating process called memory reconsolidation, that, in normal circumstances, modifies schemas to become adaptive to different situations. Unfortunately, some things can inhibit this process, like flight-or-fight, tonic/collapsed immobility, avoidance (often unnoticed), and lack of time or emotional capacity. Exceptionally strong schemas also seem resistant to updating, perhaps because they are too overwhelming to be present with. For example, in PTSD, there is an exceptionally strong belief of imminent danger that doesn’t update when the danger passes.

How MDMA Therapy Works

MDMA starts the previously blocked update process for any stuck schema you activate or trigger during the session and then stay present with. Thinking, writing, or talking about your issue is often sufficient to do this. After the schema updates, it will not reactivate after the session is over, though complex schemas have numerous parts that you have to individually update. Dissociation and flight-or-fight also resolve once you update the underlying schemas.

This is a powerful process but is not a quick fix except for simple issues. People typically need to do a lot of between-session therapy-like work as well as multiple sessions. Resolving the most severe issues will take years of hard work.

Temporary symptom worsening is likely the most significant downside. It is a common and probably often unavoidable phase of therapy for those with severe trauma. Unfortunately, people are sometimes not explicitly aware they have gone through severe trauma. This may happen if that trauma takes the form of disorganized attachment (assess with attachmentproject.com), the abuse is explained away as cultural tradition or “how things are,” the trauma took place in the period of childhood amnesia, or it is not remembered for some reason. Diagnosis of mental illness indicates higher risk as well.

Symptom worsening is occasionally long and overwhelming and can cause major problems when poorly managed or entered into at an inappropriate moment in your life. It may also, on rare occasion, exacerbate or activate dangerous symptoms like psychosis or suicide attempts. In Robinson⁷, people with prolonged post-psychedelic symptoms reported these activities as helpful, in order of most to least commonly reported, and excluding those reported by less than 10% of participants: peers and community support; professional therapeutic or coaching assistance; meditation and prayer; reading for self education; physical exercise; journaling; breathing strategies; embodied contemplative practices; time in nature; and acceptance and surrender.

MDMA-assisted therapy tends to speed up both healing and symptom worsening. Additional MDMA sessions and regular therapy often help work through the latter.

Symptom worsening is sometimes caused by experiences that feel like remembering apparently forgotten memories. Unfortunately, there is no way to determine how accurate these memories are other than independent corroboration. See psychedelicsandrecoveredmemories.com for more information.

The MDMA Therapy Session

A standard, safe dose is 100 mg for body masses less than 60 kg (132 lb) and 125 mg for more. People over 75 years old also start with 100 mg. These doses can be adjusted later to fit individual circumstances. Low doses generally don’t work. Too high of a dose might be so blissful that you can’t engage with your trauma reactions.

Booster doses half the strength of the initial dose are sometimes taken 1.5–2.5 hours later to extend the session length. This has worked well in large clinical trials with no obvious, reported adverse effects. However, there is a lower degree of certainty that these higher total doses are safe for more than a handful of sessions. I think booster doses are fine to start off with, but that once people have established a reliably therapeutic routine, they gradually reduce their dose to find their minimum effective dose.

The general strategy during the session is emotionally activating (triggering) your anxieties, depression, panic, etc., then staying with that feeling, regardless of what it is. If you have the right dose of MDMA and aren’t dissociating, the schema should gradually dissipate. That’s the updating process at work.

For dissociation, Razvi⁸ recommends “bringing blankness, flat affect, nothingness, boredom, sleepiness, or sobriety [the subjective feelings of dissociation] into focus.” Then, “it might take staying with it from minutes to a full day-long session, but it will crack.” A skilled, ethical, and well-matched practitioner may also be especially helpful here.

People often need the whole following day to recover, and aftereffects may last a few days. It’s also important to spend significant amounts of time in the following days and weeks attending to your emotional changes.

It’s common to experience moderately increased psychological turmoil and adverse symptoms for days to weeks after a session. MDMA helps us confront distressing feelings that we have been avoiding, and our minds can feel distressed about that until we process those feelings and reactions. It’s often worthwhile developing a set of healthy coping practices to help you through this period.

The Fireside Project offers a hotline to help people through challenging psychedelic experiences at +1 (623) 473-7433 in the USA. tripsit.me/webchat is a chatroom available anywhere.

There is almost no data on how frequently it is safe to do sessions, though many people have strong opinions on the subject. In the absence of better data, the 6 week spacing used in the clinical trials might be a reasonable minimum.

Working with a Mental Health Practitioner

It’s helpful to start MDMA therapy with a skilled, ethical, and well-matched practitioner, at least to learn the basics. Some people have success starting off solo, but it can be more difficult and riskier. A trip sitter who is trusted, experienced, empathetic, and emotionally non-reactive can also be helpful.

There are a few important factors when working with a guide, therapist, or other mental health practitioner:

Medical, Psychological, and Drug Interaction Risks

A limited course of MDMA therapy is generally well-tolerated, but there are dangerous drug/supplement/herb interactions, medical contraindications, side effects, and psychological risks:

Always Avoid (significant risk of death or irreversible damage)

Use Caution With

Take Precaution:

Introduction

How to Read this Book

This book addresses a broad audience but is organized for, and talks to, a client or solo user, since that is my background. Mental health practitioners will benefit from reading the entire book as well as the supplementary material for them in Appendix B.

I aim to provide most of the “full stack” of knowledge needed to successfully do MDMA therapy, though I don’t include much about the fundamentals of being a good mental health practitioner. Aspiring practitioners can’t rely on this book alone to teach themselves to be an MDMA therapy guide. This book contains a mix of theory, checklists, instructions, and tools. Simple instructions work well in some areas, but MDMA therapy’s complexity means they don’t cover every aspect of the process. The theory is included so that you can adapt the tools to your own unique situation.

The book is lengthy and somewhat technical. I prioritized rigor over accessibility because there is little consensus on many of topics explored here and thus showing my work is important to back up my claims. Feel free to skip or skim non-critical sections. I think the most important sections include:

The book is structured for front-to-back reading, but is also designed as a reference. Sections extensively cross-reference each other to facilitate that style of reading. In the PDF version, many terms are colored red, and clicking them takes you to the relevant glossary definition.⁵ The glossary is just before the appendices. I use some terms differently from some other authors, and the glossary describes my choices.

For help understanding the book, you can also upload it to a Claude LLM (large language model) model and ask it to explain the book to you. It can also respond in your language of choice. I tested it with other major LLMs but they had unacceptable amounts of hallucinations. Paste in the following text and let it read the book. Then ask your first question in a second message.

Approach Mental Health Research and Practice With Skepticism

Robust scientific models are, as the science bloggers Slime Mold Time Mold¹¹ argue, “a proposal for a set of entities, their features, and the rules by which they interact, that gives rise to the phenomena we observe.” They also make a wide variety of accurate predictions in the area of their relevance. Physics exemplifies this standard; it has such a complete model of atoms that their behavior can be predicted to many decimal points of precision. It also has a highly detailed and precise list of the particles and forces involved and the rules by which they interact. Few fields can match that level of completeness. Psychological models don’t have convincing lists of well-defined parts and mechanisms and generally have no plausible connection to what cells are doing in the brain. The political scientist argues on their blog that the social sciences, including psychology, mostly use models that occasionally make good predictions in a narrow area but rarely over a wide area¹² (see also Briggs¹³).

Working with these ungrounded abstractions may be a helpful first step to figuring out the set of mechanistic rules that govern a particular system. However, a number of these abstractions turn out to be false or meaningless. That’s ok in the process of science, but these provisional models have taken on a great deal of undeserved prominence in popular culture and clinical practice. These problems aren’t limited to the social sciences either. The neuroscientist synthesizes papers on their blog to argue that even neuroscience is beset by severe systemic issues¹⁴.

I am not implying that all psychiatric drugs are useless or that therapy doesn’t work. Instead, I aim to calibrate expectations. Approach any model of brain function or mental health with considerable caution unless its components have been experimentally verified by multiple labs and it mechanistically explains a wide range of phenomena. Exceedingly few models of mental illness meet those criteria. That includes almost everything from psychology and psychiatry, much of neuroscience—and many parts of this book. Where my framework relies on memory reconsolidation, predictive processing, complex systems, and defense cascade models, it inherits whatever mechanistic grounding those models have—which is more than most alternatives, but less than I would like.

Methodology

I wrote this book by synthesizing information from four categories of sources. First, papers, books, and blogs on the topic. Second, my own experience using MDMA therapy to treat my complex trauma. Third, T.H.’s personal experience with community mental health and professional experience as a therapist. Fourth, trip reports (largely from reddit.com/r/mdmatherapy) and discussions with people who have done MDMA therapy, henceforth called anecdotal reports. There was a loop of personal experience and discussions informing theory, which then informed interpretation of personal experience, which then further informed theory, etc. This loop continued until there were no major remaining disagreements, though obviously I may be mistaken about some pieces.

Throughout the book, I always clearly distinguish between more established science and educated guesswork by marking opinions as “I think,” “I believe,” etc. Of course, I’m also making judgements about what is established science that others disagree with.

I didn’t cite any neuroimaging studies because neuroimaging is a minefield of poor statistical methods, low statistical power, and mistaking correlation for causation¹⁴. It has provided little meaningful information about any specific mental illness²³. Some psychedelics also change the coupling between brain activity and blood flow (the thing that fMRI measures), though it’s not clear if MDMA also has that effect²¹.

Reference Validity Checks

I applied these checks on the validity of my references while writing this book:

Major Unresolved Issues

Any pharmaceutical or therapeutic intervention relies on a multitude of choices that have not been rigorously studied. In this case they might include questions like 1.6 mg/kg vs. 1.4 mg/kg of MDMA; non-directive vs. minimally directive therapy; and which type of therapist training is best. Any manual or practice, including mine, thus inherently depends on a lot of educated guesswork to fill in the gaps between the main support beams of validated theory and practice. Beyond that general caveat, three uncertainties are particularly important to flag:

Reasons to be Confident

Reasons to be Skeptical

I know of the following reasons to be skeptical of this book while acknowledging that I could be avoiding explicit awareness of the book’s real weak points²⁸. I regard this disclosure as a basic practice of truth-seeking epistemology.

Efficacy of MDMA Therapy

MDMA therapy showed excellent results for PTSD in clinical trials^10,29. However, the FDA requested one additional phase III trial be conducted to fill in some missing data before they could approve MDMA³⁰. Psychedelic Alpha³¹ analyzes this request in detail. Schenberg³² also discusses why a Dutch government commission came to the opposite conclusion⁶ and decided there actually was enough evidence of efficacy and safety to roll out MDMA therapy to the public.⁹ While the FDA’s requests are mostly helpful and would certainly result in better quality evidence, I largely agree with the Dutch State Commission’s overall assessment. They better incorporate secondary sources of information about the risks of MDMA. I also lay out additional reasons I think MDMA therapy is effective in the third bullet point of the Memory-Reconsolidation/Predictive-Processing section of Appendix A.

Mustafa³⁴ pooled both MAPS phase III MDMA therapy trials together (194 total participants) and calculated the average effect sizes¹⁰ of three sessions of MDMA with therapy compared to placebo with therapy, though these calculations don’t include some potential systematic biases. It is between 0.49–1.1 (small–large) for PTSD symptoms, with the most likely value being 0.80 (large), and between 0.17–0.66 (very small–medium) for functional impairment, with the most likely value being 0.42 (medium). Actual effects were larger since those numbers just compare the difference between MDMA and placebo; both involved therapy that likely had its own positive effect. Those reported ranges are confidence intervals (CI); roughly speaking, there is a 95% chance that the true average effect is within that range.¹¹ Confidence intervals convey the statistical precision of studies. Individuals will also have a range of responses surrounding the true average, which is itself specific to the population of participants in each study and the characteristics of the study.

The greater effect on PTSD symptoms than on functional impairment may reflect the fact that most participants had multiple traumas or mental illnesses^10,29. PTSD symptoms were measured using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) that measures symptoms related to a single traumatic event. Table 2.1 breaks the CAPS-5 results into clinically relevant labelled bins. Functional impairment was measured using the Sheehan Disability Scale (SDS), which may better represent the entirety of an individual’s issues. Logically, there would be more progress on the issue participants picked to focus on. More therapy focused on the other issues might further continue the decrease in functional impairment.

Mean outcomes from the first and second phase III clinical trials derived by averaging Fig. 3 in Mitchell²⁹ and Fig. 3 in Mitchell¹⁰. *Clinically meaningful response,* *loss of diagnosis,* and *remission* are labels applied to escalating degrees of improvement.
	MDMA w/ Therapy	Placebo w/ Therapy
No Response	13 %	31 %
Clinically Meaningful Response	87 %	65 %
Loss of Diagnosis	69 %	40 %
Remission	40 %	13 %

Each session added durable benefits on top of the benefits persisting from previous sessions^10,29. The benefits persisted at least to the end of the study, which was two months after the last session. Preliminary evidence additionally shows that the improvements persist longer^35,36.This strongly suggests that more sessions beyond the three in the trials would further improve symptoms for individuals who need it. The three-session schedule was likely chosen to balance efficacy with cost and time constraints in the drug development process, and clinical use should be tailored to individual needs.

Only 5% of participants in the MDMA groups discontinued treatment (mostly for reasons unrelated to adverse effects from MDMA therapy), compared to 16% in the placebo groups^10,29. MDMA therapy worked across severity of symptoms and presence of other mental illnesses.

There are differences between MDMA therapy in clinical practice and in clinical trials that may affect efficacy:

MDMA Therapy Generalizes Beyond PTSD

MDMA therapy has historically been used for a wide variety of conditions, not just PTSD³⁷. I have been able to find some evidence that a limited course of MDMA therapy may also be effective for durably improving

These findings raise the question of why MDMA therapy might work across such different conditions. The prevailing model of mental illness is called the biopsychosocial model⁴¹. It describes how most mental illnesses arise through complex interactions between biology (e.g., genetics, medical history, defense cascade activation, sleep quality), psychology (e.g., schemas, attention, emotions, thoughts), and social context (e.g., social models of how to respond to trauma, support networks, living situation, work situation). However, it doesn’t actually say anything about the details of how this might work, how much each element contributes to a given mental illness, or how to categorize mental illnesses.

Three lines of reasoning suggest MDMA therapy durably resolves the psychological component of many mental illnesses. The first, as detailed above, is its apparent broad spectrum of effect in clinical trials and historical practice.

The second is based on the HiTOP (Hierarchical Taxonomy of Psychopathology) model, a leading model of mental illness classification. It was built from the ground up on statistical associations between symptoms and categorizes them in a hierarchy of clusters¹⁵. At the subfactor level, the symptoms that are associated with PTSD, major depressive disorder, dysthymia, borderline personality disorder, and generalized anxiety disorder are clustered together. This suggests that those disorders are varying presentations of the same phenomenon. At higher levels of the hierarchy, even more symptoms cluster together. If the clustering reflects shared underlying processes rather than coincidental symptom overlap, then the evidence for MDMA therapy for PTSD should generalize to the other clustered disorders.

Third, Ecker⁴² describes how psychosocial factors cause many mental illnesses and how psychotherapy can durably resolve these illnesses through the single psychological mechanism of memory reconsolidation. Appendix A argues that MDMA therapy also facilitates memory reconsolidation when a stuck schema is activated and stayed present with.

I think that the psychological component is substantial for most mental illnesses, and in my understanding, no evidence rules this out for more than a few mental illnesses. Vanishingly few biomarkers have been established as significant causes of mental illness rather than as symptoms or unclear associations⁴³. Genetics increases the risk of mental illness, but in my reading of Aftab⁴⁴, Alexander⁴⁵, and Alexander⁴⁶, even high heritability doesn’t establish that genes are the primary or only cause in any individual case. Heritability describes how much of the differences between people can be attributed to genetic differences in a given environment and population—it doesn’t tell you how much genes versus environment shaped any particular person’s illness. Psychosocial components may still play large roles.

In the face of this uncertainty and the prevalence of psychological components, I think it’s worth trying MDMA therapy to see if it works. As discussed in Chapter 4, it is safe for most people. MDMA therapy is likely not worth trying for disorders with established biological causes, like thyroid dysfunction, neurosyphilis, and anti-NMDA receptor encephalitis.

Theoretical Model

The Defense Cascade

The sympathetic and parasympathetic nervous systems govern a wide variety of involuntary bodily functions, such as heart rate and digestion⁴⁷. In one of their roles, they activate a defense cascade, a sequence of responses, to shield us from threats. Increasing levels of perceived threat, threat imminence, powerlessness, and somatic sensory input activate these responses, though the order of activation also depends on individual variability and past experience.

Assessments of threat and power are relative to your ability to deal with the threat; children activate easily because the threshold at which a threat becomes life-threatening is much lower for them than it is for securely attached adults. Lack of parental support, attention, or attunement (see Therapevo⁴⁸) can be life-threatening situations for children. Here is the defense cascade:¹²

The defense cascade activates during immediate physical attacks like a predator biting you, but it also is activated by stimuli (sounds, thoughts, sensations, places, etc.) associated with threats⁴⁷. In the rest of the book I call these associations schemas. These associative activations are ideally adaptive; activation of flight-or-fight when you see a wolf running toward you will give you more time to run than if activation only occurs when the wolf bites you.

Unfortunately, associative activations can also be maladaptive⁴⁷. Think of the soldier who goes into flight-or-fight in response to loud noises even after the war is over. Maladaptive defense cascade activation is implicated in many mental illnesses. As described in subsequent sections, MDMA therapy can unlearn maladaptive associations between stimuli and activation.

There is considerable uncertainty over which mental and physical states are mediated by endogenous (self-produced) opioids. Immobility and freeze may be the ones best physiologically characterized. However, other states, like some types of non-immobile derealization and depersonalization, are plausibly included. I call all opioid-mediated states opioid dampening to mechanistically differentiate them from other phenomena. The term dissociation is often used; it is an “involuntary disruption or discontinuity in the normal integration of one or more of the following: identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, or behaviour” ^{50, sec. Dissociative
disorders}. Moreover, other phenomena, like unnoticed avoidance, also produce dissociation, making the term etiologically imprecise.

The complexity of opioid dampening may depend on which opioids (e.g., enkephalins, endorphins, dynorphins) are interacting with different opioid receptors (μ, κ, δ, and their subtypes; conceivably also nociceptin and its subtypes) and what other chemicals (e.g., endocannabinoids, noradrenaline, adrenaline) are also present⁵¹. Additionally, chronic immobility induces opioid tolerance, which may further alter these effects.

See Fear and the Defense Cascade: Clinical Implications and Management by Kasia Kozlowska et al.⁴⁷ for further discussion of the defense cascade. As the paper itself notes, the descriptive part is more solid than the Clinical Interventions part. I also advise caution regarding some proposed mechanisms of action because the paper cites polyvagal theory². While many people find therapeutic interventions associated with polyvagal theory helpful, the theory’s foundation in specific neuroanatomical and evolutionary claims has not held up to empirical scrutiny.

Refer to Table 3.1 for a thorough comparison of the signs of intensified arousal, immobility, and probably also the schemas that activate them.

Trauma, Insecurity, and their Effects

Comparison of hyperarousal and dissociation [opioid dampening] signs. Britton⁵² compiled this from Ogden⁵³, Magyari⁵⁴, and Treleaven⁵⁵. Reprinted with permission. I think that these are likely the signs of hyperarousal, opioid dampening, and the schemas that activate those states, not just signs of hyperarousal and opioid dampening themselves.
Signs of Hyperarousal	Signs of Dissociation
Body/Somatic	Body/Somatic
Agitation, difficulty relaxing Psychomotor hyperactivity Tingling Twitching Hyperventilation, difficulty breathing Exaggerated startle Increased heart rate Hot flashes, flushing Sweating Cold hands + feet Muscle tension Chronic pain Insomnia	Flaccid muscle tone Extremely still (frozen) Pale skin tone Fixed gaze (“thousand yard stare”), glassy eyes
Cognitive	Cognitive
Racing, repetitive, obsessive, intrusive thoughts Worry, rumination Rapid or disorganized speech; Jumping from topic to topic Executive dysfunction (memory, planning, decisions)	Few thoughts, “mind is blank” “Can’t think” Concept loss Slow responses Difficulty evaluating surroundings Executive dysfunction (memory, planning, decisions) Slowed/slurred or disorganized speech “Spacey,” “ungrounded” Hypernowness, no past or future
	Self
	Disconnected from body, emotions, thoughts Outside body or at distance Disownership Don’t exist, not here
Emotion	Emotion/Motivation
Emotional volatility, mood swings Euphoria, mania, grandiosity Anxiety, panic Reports of flashbacks, nightmares Irritability, anger	Affective flattening, blunted emotions, loss of emotion Normal emotions but “can’t feel them” or “not mine” Apathy, feel dead, nothing matters Lack of meaning, motivation
Conative/Motivational
Excessive, obsessive striving/effort Scrupulosity/perfectionism Apathy/withdrawal
Perception	Perception
Perceptual hypersensitivity Sounds too loud Light sensitivity	World appears unreal or dreamlike Objects appear flat/2-dimensional; “cartoon-like” Distance distortions Visual hyper-clarity or fog
Social	Social + Occupational
Social engagement dysregulated Inhibition/withdrawal (also disinhibition, disruptive, interrupting) Inability to make eye contact during interviews/interactions	Social engagement system offline Not seeking social support Withdrawn/avoidant Eye contact difficulty
	Dissociation vs. Meditative Calm
	Disconnected from thoughts, body, emotions, world, others “Not here” Immobility; frozen quality Sudden resolution of distress “Feel fine” “Nothing going on”

Our brains continually learn models of the world, other people, our bodies, and our minds for the purpose of fulfilling our innate needs, like bodily integrity, social connection, and reproduction⁵⁶. We typically model threats in an appropriate and unproblematic manner and don’t ruminate about falling off cliffs until we are near a cliff edge. Then the closer to the edge we go, the more alert and cautious we become. This alertness or fear is healthy because the response is situationally appropriate.

Not all responses are situationally appropriate⁴². The brain’s learning process doesn’t necessarily build true models of the world; it builds models (an individual model is called a schema) that are true enough (a heuristic) to work mostly well in the contexts they develop in. These heuristics are sometimes inaccurate or don’t work very well outside the context in which they form, like a soldier who goes into fight mode in response to loud noises even after the war is over.

We can define trauma as events that create schemas that impair functioning or well-being either now or in the future. Standing near cliffs is not typically traumatic because the situation is under our control, and we manage it to stay safe. If nothing surprising or threatening occurs, our models of what happens around cliffs don’t change much.

Conversely, threatening situations outside our control create strong signals for updating our models because your survival may depend on avoiding or managing that situation in the future. Maybe someone attacks you near the cliff edge and you almost fall off. You may learn that cliffs, the combination of cliffs and other people, or the combination of cliffs and just that particular person are much more dangerous than you previously thought. You may feel alertness or fear from much farther away from the edge than you did before. If the attack was overwhelming enough, you may learn that everything about cliffs is dangerous, even the thought of them or pictures of them.¹³ I think “high caution around that particular person” or “that person is dangerous and unpredictable” is the adaptive response in this scenario. Unfortunately, the other responses, such as fear at the thought of cliffs, sometimes occur and can cause problems for you or others.

I call these types of responses stuck schemas throughout this book. I call them stuck because they are significantly inaccurate, cause difficulties for you and others, and resist updating to a more accurate form. Maladaptive is another common term, but some people think it is invalidating⁴². Even a partially maladaptive schema might have been the best they could do at the time.

Children, because of their limited life experience, frequently learn inaccurate schemas about trauma and insecurity. For instance, if their parents emotionally neglect them, they might learn “I am unlovable” instead of the more accurate schema “My parents don’t know how to parent.” If a dog attacks them, they may learn “dogs are dangerous” instead of “big angry dogs are dangerous.”

When schemas are stuck, these outputs become problems: stuck schemas push us to overreact, deny the truth, misjudge significant trade-offs, say hurtful things, etc. We may seek the connection and safety we desperately need in dysfunctional ways⁵⁷, or we may get too distracted by our distress to pay attention to the needs of those we love.

Here’s another example of a schema that became stuck. As a young child, Amy was frequently ridiculed by her peers whenever she spoke up in class or shared her opinions. She then learned “my opinions are shameful,” experiences fear at the thought of speaking up, and has a behavioral inhibition to speaking up. This schema guides Amy’s behaviors and beliefs. Even when Amy is old enough to reflect on the schema explicitly, she may not think about it or realize it isn’t accurate.

Schemas can be particularly confusing when we don’t know what events created them. This can happen if you were too young to form long-term episodic memories that persist into adulthood or when we don’t explicitly recognize the link between an event and the schemas it created. People often develop inaccurate stories about stuck schemas to fill the explanatory gap. As Resmaa Menakem says in Tippett⁵⁸:

Some of these are transmitted intergenerationally or culturally via chains of stuck schemas creating harmful behavior that then causes other people to learn stuck schemas, etc. Think of people who beat their child whenever the child does something slightly wrong. The child learns to stop trying to do anything at all. When they grow up they inadvertently neglect their own children if they’re still operating under the “don’t do anything or I’ll get hurt” schema.

Many traumas, especially chronic ones experienced during childhood, create complex networks of stuck schemas around things like your sense of self, relationships, body, etc. These are frequently disabling because the schemas are intense and are activated by either a wide variety of stimuli or a few particularly pervasive stimuli (e.g., being alive).

Some people have schemas that predict pervasive threat or classify ambiguous signals as threatening⁶⁰. These may have developed in situations where noticing and reacting quickly to potential threats was more important than taking the time to accurately decide if something really is a threat or not. These schemas can easily create new stuck schemas. Thus, severely traumatized people can more easily acquire more stuck schemas.

Some people have mental illness. However, many more people have sub-clinical stuck schemas. For example, one study found that 41% of the US population has non-secure attachment⁴. It’s not a matter of having them or not; virtually everyone has some stuck schemas, even if they are mild or rarely activated.

For more information, I highly recommend Unlocking the Emotional Brain: Memory Reconsolidation and the Psychotherapy of Transformational Change by Bruce Ecker et al.⁴². Scott Alexander’s review (Alexander⁶¹) of Surfing Uncertainty: Prediction, Action, and the Embodied Mind by Andy Clark⁵⁶ is also an excellent introduction to the general theory of predictions/schemas in the brain. See the Heidi Priebe YouTube channel for a wealth of information on the types of schemas that trauma causes⁶².

How Schemas Update (Or Don’t)

A contradiction between an old schema and another source of information creates prediction error, a difference between expected and actual reality⁴². That information can be sensory (sight, sound, smell, touch, taste, internal bodily senses, and observed thoughts and emotions) or come from another schema. When the magnitude of difference is within certain bounds (not too small; not too large), it triggers an updating process that changes the old schema.¹⁴ This process works well in everyday life but often fails for schemas formed under trauma, for reasons we’ll see below.

When schemas are first created, they are consolidated (i.e., integrated) into long-term memory⁴². Thereafter, whenever prediction error is within the updating boundaries, the schema enters a state of plasticity where it can be changed again. That prediction error updates the schema to account for the contradictory information you’re experiencing. When that is finished, the memory is re-consolidated, re-entering a stable state where it can no longer be changed without another experience of sufficient prediction error. Throughout this book I use reconsolidate in a slightly different way to concisely denote the entire process of schema deconsolidation, updating, and reconsolidation.

For instance, you might learn “Brussels sprouts taste bad” after only eating boiled Brussels sprouts. That belief consolidates in long-term memory after your first experience. At a later point you eat Brussels sprouts pan-browned with Parmesan. This tastes great, which strongly contradicts the old “Brussels sprouts taste bad” belief. That contradiction, or prediction error, makes the old belief enter a plastic state where it might then update to “Brussels sprouts taste delicious when cooked right but bad when boiled.” After the updating, the belief reconsolidates and is again no longer changeable.

Contradictory information can come from a few different sources. Conventional therapy sometimes juxtaposes two contradictory schemas next to each other to facilitate reconsolidation⁴². Incoming sensory information also strongly contradicts many stuck schemas. Some stuck schemas erroneously predict immediate threat, like someone hurting you if you refuse a request. Saying no to a normal, non-abusive person in a conversation provides contradictory sensory information indicating that they are not actually hurting you. As with the Brussels sprouts example, contradictory information in daily life naturally reconsolidates schemas all the time without any deliberate process.

However, prediction error is often too small or too large to start the update process for schemas created in traumatic situations. This happens for a few reasons:

The first three items in the list above are forms of schema-driven attention control⁵⁶. Attention control may be physical, like orienting the eyes and head to certain objects, or internal, like ruminating on certain things or not thinking about certain uncomfortable thoughts, emotions, or sensations. Attention control is flexible and can avoid specific abstract concepts in addition to broader categories of information or sensory input. Many symptoms and disorders look like internal avoidance from this attentional perspective. PTSD from assault frequently causes people to feel disconnected from their bodies⁶⁴. Alexithymia is basically disconnection from emotions⁶⁵.

The above list might explain why mentally healthy and securely attached people are resilient to events that would traumatize others^66,67. They generally don’t avoid much, feel comfortable attending to their feelings and body, lack preexisting opioid dampening, and don’t carry schemas predicting pervasive threat.

For more information, I highly recommend Book Summary: Unlocking the Emotional Brain by Kaj Sotala⁶⁸ for a description of memory reconsolidation. It describes the fundamental process of reconsolidation better than any other resource I am aware of, short of the book they are reviewing. I also recommend Scott Alexander’s summary (Alexander⁶³) of Better Safe Than Sorry: A Common Signature of General Vulnerability for Psychopathology by Omer VandenBergh et al.⁶⁰ for further information about attention, which the article calls precision.

How MDMA Helps Update Schemas

Personal experience and anecdotal reports suggest that MDMA facilitates sufficient prediction error to reconsolidate most, if not all, stuck schemas that you activate and stay present with during a session. It’s not clear why it does this, though I list several hypotheses in Appendix D.

I posit that there are at least three ways of using MDMA to aid memory reconsolidation. More than one of these may occur during a particular MDMA therapy session:

These processes are conceptually simple but can be practically complex. People’s stuck schemas are frequently intense and may require multiple, or numerous, sessions to fully reconsolidate.¹⁵ They may also have multiple stuck schemas. People typically only have a partial understanding of the schemas causing their problems, so they frequently end up needing to work on schemas they weren’t initially aware of. The simplest issues may easily be resolved in a single session, but my rough estimate is that the most severe mental illnesses require thousands of hours of reconsolidation to resolve.

The payoff is worth the effort though. Ecker⁴² describes the following signs of a completely reconsolidated schema:

Reconsolidation is the mechanism of updating stuck schemas, but it is not the only part of healing. Learning healthy habits and emotional skills is also important for some people. Throughout this book I occasionally mention resources for this, but it is not my focus.

Somatic Symptoms

Many people with stuck schemas also have what different medical and therapeutic fields call medically unexplained symptoms, psychosomatic symptoms, functional symptoms, subjective health complaints, somatization, somatic symptom distress, or bodily distress⁶⁹.

VandenBergh⁶⁹ makes a convincing case that many of these issues are inaccurate perceptions (e.g., pain) or functional impairments (e.g., inability to move a certain way) created by stuck mental models, or schemas in this book’s language. This appears to work similarly to how the schemas I have already discussed create inaccurate perceptions of threat and inaccurate abstract beliefs of how the world works. These symptoms can exist despite a total lack of current organ dysfunction or tissue damage. They seem real because perceived reality is an abstract internal representation of the world, where there is no fundamental difference between accurate and inaccurate perceptions⁵⁶. These stuck schemas are typically learned and reinforced through a combination of the following:

These factors prevent your mental model from updating by inhibiting the contradictory information that would normally update it. Updating the mental model, and thereby resolving these issues, requires some combination of two things. First, reconsolidating¹⁶ the stuck schemas creating these symptoms. This might take a while if your schemas are intense or complex.

Second, (a) disconfirming experiences, where a touch or movement is feared to produce symptom perception but doesn’t, and (b) learning more finely grained categories of sensation, which increases the certainty of contradictory evidence⁶⁹. Controlled research on somatic therapies for schema-produced symptoms is limited, but the mechanism predicts they should help by providing safe and detailed sensory input, and some anecdotal reports are consistent with this. For instance, Kolk⁶⁴ contains many anecdotes of practices like yoga, massage, and acupuncture resolving people’s stuck schemas.

My own experience with schema-driven somatic symptoms illustrates how several of these factors can compound. I had chronic itching. It checked off at least the first three causes in the list above: it followed an encounter with bedbugs, I had severe pre-existing stuck schemas predicting pervasive threat, and I had a hard time paying attention to my body. The initial bedbug situation was deeply anxious for me, and like many people being bitten by insects, I often imagined I was being bitten when I wasn’t. Some ambiguous sensory information, like being poked by a feather from a comforter, would easily activate the “I’m being bitten” perception. This developed into chronic, anxiety-filled itching that lasted for years after the bedbug situation was over. It didn’t resolve until I started working on that schema with the technique I describe in Appendix C. Roughly 5 hours of that reconsolidation technique unlearned most of the itching. The only complication was that I had to reconsolidate many other schemas first before this one was accessible.

Not all health issues associated with mental illness are inaccurate perceptions. Inaccurate predictions of symptom existence can also coexist with tissue damage or organ dysfunction⁶⁹. In these cases, symptoms are perceived as stronger or more pervasive than what the organ dysfunction or tissue damage is physically causing. The previously mentioned fixes may reduce symptom perception by aligning it with physiological reality.

A common belief is that stuck schemas indirectly cause organ dysfunction via chronic stress. However, VandenBergh⁶⁹ finds the evidence for this pathway weak. The account offered above provides a more parsimonious explanation: many symptoms can be fully accounted for by inaccurate mental models without needing to invoke stress-mediated tissue damage or organ dysfunction.

Stuck schemas can also cause physical issues through driving harmful coping behavior or impairing your access to healthy activities. For instance, escapist schemas can take the form of alcoholism and “if I move I’ll die” schemas inhibit exercise.

For further reading on the topic, I recommend Symptoms and the Body: Taking the Inferential Leap by Omer VandenBergh et al.⁶⁹.

Complex Systems: Symptoms Can Get Worse Before They Get Better

The framework I’ve laid out explains the process of therapy for simple issues. However, it is common knowledge in therapy that many people with intense or complex sets of stuck schemas go through a series of symptom ups and downs during therapy. As described below, this can happen when we start feeling or doing things that we were previously avoiding, whether consciously or unconsciously. These can activate more of our stuck schemas. For a period of time we may even feel worse than we did before we started.

One of the conscious or unconscious behaviors that schemas control is where you direct your attention—toward or away from particular experiences. In severely traumatized people, many bodily sensations, feelings, and certain aspects of memories are systematically kept out of awareness. This avoidance means that there can be latent states of worse mental health in the brain that become accessible when avoidance decreases.¹⁷ I think that complex systems theory provides the right conceptual vocabulary for this phenomenon even though it doesn’t predict the details of any individual’s situation.

In the complex systems formulation, your mental state is like a ball that can be at the bottom of a deep valley of mental illness⁷⁰. Conversely, good mental health is a landscape of shallow valleys that the ball goes in and out of as needed, depending on the context. In complex systems, valleys are called attractor states. In my model, attractor states, or attractors, are composed of schemas and avoidance that continually push the ball back to the bottom of the attractor. Other factors play roles too, but I limit this discussion to schemas and avoidance because I think they’re usually the most influential and adding more factors makes the model too complex to use.¹⁸

I think there are at least three kinds of symptom worsening, though the lines between these are fuzzy. By symptoms, I mean the aspects of schemas: emotions, thoughts, behaviors, and somatic sensations⁴². Those can further activate the defense cascade, depending on their content and intensity⁴⁷.

Symptom worsening is certainly difficult, but it isn’t necessarily bad⁷⁰. I suspect it is also not always avoidable in the process of healing. The worse attractor might have more intense symptoms but fewer self-reinforcing features that make the attractor persist over long periods of time. I think you would also have needed to access and reconsolidate the newly-active stuck schemas composing the attractor at some point. Continuing to avoid them indefinitely tends to come with its own costs.

Of course, symptom worsening can also be a net negative experience. This can happen when it occurs at a point in your life when you don’t have the slack to work through it, it seriously harms you or someone else, or you and your practitioner don’t know how to get out of it.

I don’t know any reliable way to reconsolidate complex or fragile stuck schema networks without ever falling into a worse attractor for a while. You may need to reconsolidate numerous stuck schemas over a long period of time to gradually shift the network from fragility, with multiple maladaptive attractors, to resilience, with few or no maladaptive attractors. In other words, you have to individually fill in most or all of the mental illness valleys in the mind’s landscape that the ball of your mental state can fall into. This can be compared to standing up. Sitting and standing are both stable positions. If you want to walk around and access a wider range of adaptive attractors, you have to stand up. The transition between the two is unstable, but that’s the cost of being able to walk (healing).

In practice, symptom improvement appears to typically outweigh symptom worsening, given that the MDMA therapy clinical trials showed significant average decreases in disability and functional impairment over the course of three sessions^10,29.

Healing as a Complex Change

Since the components of highly complex systems tangle together, it’s often unclear which category an intervention fits in. Therapeutic interventions also frequently combine multiple approaches.

Those with complex issues may both transition through and gradually disassemble many attractors. As previously discussed, this comes with ups and downs that tend toward adaptiveness over the long-term course of therapy.

In practice, reconsolidation is often sufficient to resolve many issues⁴². Furthermore, by disassembling the maladaptive attractor, relapse is possible only to the extent that the maladaptive attractor still exists⁷⁰. The other processes leave the maladaptive attractor intact, whether its active or not. Relapse occurs when the right circumstances either reactivate the inactive attractor or makes an active one worse.

See Mental Mountains by Scott Alexander⁷² for more information. Also reference A Complex Systems Approach to the Study of Change in Psychotherapy by AdeleM Hayes and LeighA Andrews⁷⁰, the main citation for this section.

The Limitations of My Model and the Complex Systems Approach

While complex systems dynamics qualitatively describes important parts of therapy and stuck schemas, it currently offers few detailed predictions⁷⁰. Complex systems are difficult to model; the brain’s architecture is unknown and might be significantly different for every individual, the architecture dynamically reorganizes all the time, and almost all the parameters of the model are extremely difficult or impossible to measure. Furthermore, the state space these attractors exist in isn’t just a simple one- or two-dimensional landscape of valleys and hills that the “ball” of mental health rolls around in; it has as many dimensions as there are schemas, behaviors, and environmental elements. That number is essentially infinite. Even the number of practically significant dimensions in any particular case could easily be enough that it’s frequently too complicated for any human to comprehend and possibly too complex for any computer to model, even with perfect information.

It’s unclear who will worsen, when they will worsen, and how long the worsening will last⁷⁰. No one knows for sure what avoided, distressing material you may or may not uncover, or how reconsolidating certain schemas will cause complex nonlinear shifts in schema networks. It may also be the case that skilled therapists have developed useful heuristics for navigating the complex landscape, but I am not sure.

Safety

MDMA is often considered a risky substance due to its illegality, adulterants, and association with occasional harm in recreational contexts. However, the vast majority of these risks are caused by overheating, overhydration, and mixing drugs at raves⁷³. They are easily avoided by taking the right precautions or not doing MDMA therapy if you have certain risk factors. On rare occasion, some adverse effects may occur despite precautions. This section covers the significant drug interactions, medical contraindications, and psychological risks. Here is a summary of how to avoid or prepare for the most significant risks (in therapeutic contexts) discussed in the literature, which are detailed later:

Always Avoid (significant risk of death or irreversible damage)

Use Caution With (continue reading for further assessment)

Take Precaution:

This section aims to provide basic information, usable dosing and testing recommendations, and an overview of the most practically relevant effects and risks. It does not cover less common or less serious interactions between MDMA and drugs or medical conditions. I encourage consultation with a doctor or pharmacist for most individual questions about safety and list appropriate papers to bring with you to a consultation, since a clinician likely won’t understand MDMA well.

Aside from the issues discussed later, combining unusual states of consciousness, the physiological effects of MDMA, intense trauma reactions, activation or deactivation of defense cascade states, and psychogenic illness may unpredictably affect a wide variety of health conditions.

Basic Pharmacology

MDMA is a serotonergic (releases serotonin) amphetamine with both sympathomimetic (stimulant) and connectogenic properties, whose structure is shown in Figure 4.1. Stocker⁷⁴ coined the term connectogen for MDMA’s class of drugs. These drugs facilitate profound connection to self, body, senses, and others. The sense of self is maintained and hallucinations are minimal, unlike with the classic psychedelics or hallucinogens.

MDMA is typically taken by mouth. It’s produced in hydrochloride (HCl) salt form as a white to off-white crystalline powder, and all stated masses are masses of the HCl form.²¹ The average half-life is 9 hours in healthy individuals⁷⁶. On average, subjective effects become strong around minute 45, reach a maximum around hour 1.5–2, but only last until hour 5⁷⁶ because of rapidly developed tolerance⁷⁷.

Storage of MDMA is simple because it is stable in water, though this has only been tested up to 20 °C (68 °F)⁷⁸. Drugs are typically much more stable in dry form.

Acute Effects

Liechti⁷⁹ measured side effects during a session and 24 hours afterward that I list in Table 4.1. Some of them can last up to 3 days. Free access to water during sessions commonly causes mild hyponatremia, and this may have exacerbated some side effects⁸⁰. Colcott⁸¹ additionally reported non-cardiac chest pain/discomfort.

Studerus⁸² analyzed acute alterations in consciousness that I report in Figure 4.2. I compare it to ketamine and psilocybin to provide useful reference points to people who understand those experiences.

Both of these studies used participants who were not mentally ill, though some individuals could have been engaging with intense stuck schemas that wouldn’t be classified as mental illness. Therefore, these symptoms are likely due to the MDMA itself rather than defense cascade activation or stuck schemas. Using MDMA in therapy to confront schemas of intense fear may additionally activate states of agitation, panic, opioid dampening and their associated symptoms (see Section 3.1). Large amounts of reconsolidation also cause a period of exhaustion called a therapy hangover. There is no data on the phenomenon, but common knowledge is that it lasts anywhere from a few hours to a couple days.

I am not aware of these effects causing major problems in therapeutic contexts, though it’s common to feel fatigued and low-mood enough that you need to spend the whole following day or two resting.

Testing and Measurement

Side effects of 1.35–1.8 mg/kg of MDMA, adapted from Table 3 of Liechti⁷⁹. Values indicate the percent of participants reporting that symptom. Placebo values are in parentheses. MDMA increased all effects except the ones marked by ↓ or –.
Symptom	Acute %	24 Hours %
Difficulty concentrating	59 (15)	28 (8)
Jaw clenching	58 (0)	20 (0)
Lack of appetite	54 (4)	39 (3)
Dry mouth/thirst	53 (3)	34 (4)
Impaired balance	49 (0)	7 (0)
Restless legs	41 (1)	11 (1)
Sensitivity to cold	41 (11)	12 (3)
Dizziness	38 (1)	7 (0)
Palpitations	35 (1)	7 (0)
Restlessness	34 (1)	12 (1)
Being cold	34 (7)	9 (3)
Sweating/sweaty palms	31 (0)	12 (0)
Forgetfulness	28 (1)	11 (1)
Heavy legs	27 (1)	12 (0)
Fatigue	26 (47) ↓	41 (26)
Weakness	26 (1)	24 (1)
Hot flushes	24 (3)	15 (1)
Tremor	23 (0)	8 (0)
Paresthesia (tingling sensation)	22 (9)	1 (8) ↓
Inner tension	20 (5)	8 (5)
Brooding	16 (3)	18 (1)
Nausea	15 (3)	1 (0) –
Lack of energy	15 (8)	24 (4)
Exhaustibility	15 (4)	19 (1)
Frequent urge to urinate	14 (5)	15 (5)
Headache	12 (12) –	27 (7)
Insomnia		24 (0)
Anxiety	11 (1)	1 (1) –
Irritability	8 (1)	5 (0)
Increased appetite	4 (7) ↓	1 (3) ↓
Muscle Aches	1 (3) ↓	4 (3) –
Bad dreams		7 (3)

Assessing dose, impurities, and adulterants is important for safety and efficacy and requires testing if you don’t get your MDMA from a legal, regulated source. Always use a reagent kit to test for the presence of MDMA and many common adulterants unless you know that the batch has already been tested. /r/ReagentTesting⁸³ maintains a list of reagent kit suppliers. Lab testing provides a much higher quality analysis, reporting the quantity of all ingredients. /r/ReagentTesting⁸⁴ maintains a list of drug testing laboratories.

MDMA is sold in two forms, loose crystals/powder and pills. In underground MDMA therapy, it is common to buy crystals/powder loose or prepackaged into capsules. The purity of this varies, but is, to my knowledge, typically good enough if it comes from a trusted supplier, is white to off-white, and passes the reagent tests.²² The effective dose range of MDMA provides enough wiggle room to accommodate small amounts of impurities remaining from the manufacturing process.

Unregulated pills are more of a challenge because they’re always mixed with unknown quantities of fillers and binders. The amount of MDMA they contain can only be assessed with lab testing.²³

You will also need a calibrated milligram scale to verify your supply or measure precise amounts of MDMA into empty capsules unless you trust that your supplier has accurately measured your capsules. They are inexpensive and easy to find on the internet.

Illegally sourced MDMA crystals have usually absorbed small amounts of water from the air and production process even though the crystals still appear dry⁷⁵. To my knowledge, sellers market MDMA by the mass of the MDMA + water, so a given amount of illegal MDMA is slightly less potent than legal MDMA, where a pill or capsule contains exactly how much MDMA HCl it advertises. This effect, in addition to impurities, is small enough to not be worth considering for most people.²⁴

You can also use volumetric dosing to divide your sample into doses appropriate for therapy. I suggest aiming for a simple-to-remember 1 mg/ml solution of MDMA in water.²⁵ Dissolve your measured amount of MDMA (in mg) in the same number of mL of water. It is much easier to measure one mL of liquid, whose mass is also 1 gram, than one mg of powder. Tripsit⁸⁹ also offers a volumetric dosing calculator.

Do not purchase or store MDMA dissolved in liquid unless you know your country or state’s drug laws are based on the mass of the drug itself rather than the total mass of the mixture. In jurisdictions where the law is based on total mass (typically English speaking countries), dissolving 1 g of MDMA in 1 L of water allows a prosecutor to upgrade possession charges to distribution charges with mandatory minimum prison sentences because you now legally possess 1 kg of MDMA. This principle also favors purchasing pure crystals/powder over pills, which contain fillers and binders that increase the total mass.

Dosing

Accurate dosing is important for avoiding unnecessary side effects and optimizing effectiveness. The effects of MDMA primarily depend on dose, body mass, and, to a much lesser extent, how active your CYP2D6 enzymes that metabolize MDMA are⁹⁰.

MDMA therapy only works within a certain range of doses. A dose of 0.75 mg/kg, for instance, doesn’t provide any significant increase in the effects that I associate with therapeutic benefit⁹¹. Anecdotal reports also indicate that too high a dose can cause the session to be so blissful that you aren’t able to productively engage with and reconsolidate stuck schemas.

The two primary risks of higher doses are oxidative damage in the serotonin system and conceivably long-term cognitive impairment⁹². I discuss these further in Section 4.7. The first has been measured in animal experiments but hasn’t yet been clearly linked to any clinically relevant impacts. The latter has most clearly been seen only in recreational users who use lots of MDMA over long periods of time, often in unsafe ways (drug mixing, overdose, overhydration, heat illness). It’s not clear how relevant either are for less frequent, moderate doses in MDMA therapy, so I make precautionary recommendations here until there is better data.

This section describes two sets of dosing recommendations for different individual circumstances and risk tolerances, along with my recommendations.

The First Set

These doses are more conservative and based on a body of evidence suggesting that these doses do not cause measurable oxidative damage in the serotonin system⁹³.

Liechti⁹⁴ recommends a standard single dose of 100 mg for body mass less than 60 kg (132 lb) and 125 mg for higher body mass, though up to 200 mg can be used for the highest body masses.²⁶ The 100 mg dose also applies to everyone over 75 years old. This is roughly similar to the 2 mg/kg threshold that Baggott⁹³ discourages exceeding.

CYP2D6 poor metabolizers have stronger reactions to MDMA⁹⁵. People aware they have this should use up to a 25% lower dose, though it’s not essential⁹⁴. Various drugs, like bupropion, also affect dose.

Adjusting the dose in subsequent sessions might be necessary to match the effect of the medicine to the strength of your schemas or to deal with avoidance or opioid dampening. The peak plasma concentration and likely oxidative stress²⁷ increase much faster than linearly above 125 mg in the $>$60 kg group⁹⁶. For instance, increasing from 125 mg to 150 mg doubles the peak concentration. For the $<$60 kg group, this faster increase presumably starts at a lower dose; I speculate 100 mg based on initial dose recommendations . Therefore, I suggest increasing or decreasing your total dose in smaller increments than you would expect when you’re above the total doses recommended by Liechti⁹⁴. I think a 10–15% increase or decrease per session when above the standard dose is reasonable .

Accurate data on the upper limit of safe doses is unfortunately absent due to difficulties translating the results of animal testing to humans and confounding factors muddying the study of harmful effects in recreational use³⁷.

The Second Set

These doses have been successfully used in large clinical trials without any obvious, lasting adverse effects⁹⁷, but there is lower certainty that they do not cause small amounts of oxidative damage.

Two sessions using doses of 125 + 62.5 mg, where the second dose was taken 2–2.5 hours after the initial to extend the productive duration of the session, did not cause any statistically significant, lasting cognitive issues in one clinical trial⁹⁷. They did not measure oxidative damage.

Because effects depend on body mass⁹⁰, I don’t recommend the fixed dosing these trials used. Adding a 50% strength booster dose to the first set of recommendations from Liechti⁹⁴ is a better option for those using booster doses.

My Recommendations

I think either set of doses are reasonable starting points; a handful of higher-dose sessions is not likely to have significant negative effects, and the mental health benefits can be large^10,29. Longer-term higher-dose use may also occasionally be worthwhile for individuals for whom lower doses and other therapeutic modalities do not work well.

As a general principle for everyone, especially those planning more than a handful of sessions at the higher total doses, I strongly recommend finding your personal minimum effective dose. First, establish an effective MDMA therapy routine and gain a good sense of how your sessions feel and produce durable therapeutic improvement. Then you might reduce your total dose by 10% each session until you notice sessions becoming less helpful. Judge this a few weeks after the session, after the afterglow is finished and you have stabilized to a new baseline. This small reduction is unlikely to waste a valuable session by making it completely ineffective. You can also always return to your previous dose in the current session with an additional booster of the right amount.

You could also start by cutting the booster dose and then continuing with a 10% decrease on the single remaining dose on subsequent sessions. In my experience, a single initial dose often provides enough working time to get me to the therapy hangover limit. If therapy hangover is the limiting factor, then a higher dose or booster dose may not add much benefit.²⁸

There are a few other preventative measures for oxidative stress that some people use. Most of these have not been tested in humans, and therefore the dose and practical utility are unclear. I recommend primarily focusing on reducing your MDMA dose in the face of these uncertainties, though people doing more than a handful of higher-dose sessions could consider trying some of these.

Session Frequency

Specific recommendations for session spacing are difficult because individuals have different risk/reward tradeoffs and neurological responses to MDMA. There are two main limitations relevant for minimizing risk^92,102. First, the brain’s antioxidant capacity needs time to replenish after a session. MDMA causes oxidative stress, but the brain’s antioxidant buffer is normally capable of neutralizing this for the doses of MDMA recommended for therapy. However, using more MDMA before it has recovered may cause oxidative damage in the brain.²⁹ To my knowledge, no human studies, including the clinical trials, have measured this time span.

Three expert panels independently ranked MDMA, or substances sold as MDMA, among the least harmful drugs on their scales, including on criteria that would plausibly capture neurotoxic effects if those were producing clinically apparent outcomes^103–105. While their criteria are oriented toward observable clinical effects rather than subclinical neural changes, the absence of any signal strong enough to elevate MDMA in these rankings is consistent with oxidative damage from typical non-therapeutic use patterns being, at most, a minor contributor to population-level harm. The typical therapeutic protocol—low-to-moderate dose, proper hydration, infrequent administration, no hyperthermia, no drug mixing—would be expected to produce even less.

That being said, even mild-to-moderate amounts of harm are worth minimizing when possible. Occasionally, people may also need to do many MDMA sessions to treat severe CPTSD, and gradually cumulative effects may become more noticeable. To myour understanding, there are no public estimates on how long it takes for the human antioxidant buffer to recover after using MDMA. In the absence of any better line of reasoning, I used the research function of the Claude 4.7 Opus LLM model to find and read scientific papers on the topic and then generate a span of likely values.³⁰ Its semi-educated guess was that it takes 2–10 days to replenish the antioxidant buffer after complete depletion, and there is some evidence that total doses under 2 mg/kg are unlikely to exceed the buffer⁹³. I tentatively propose using twice³¹ the upper end of that range as a “don’t go below” spacing for oxidative stress, while noting that it is likely inaccurate due to the nature of LLM agents and the limited evidence available.

The second main limitation is downregulation of the serotonin system during an MDMA session, which causes short-term tolerance^92,102. Using MDMA again before tolerance has returned to baseline will result in lower efficacy. Using higher doses to overcome that will increase the risk of oxidative damage if the dose becomes too large for the antioxidant buffer to handle. Neither the time required for tolerance to return to baseline nor the limits of the antioxidant buffer are known, so I strongly recommend spacing sessions far enough apart that you don’t notice any lessening of effect. I don’t think anyone has measured how long short-term tolerance lasts, though the six-week spacing of the phase III trials¹⁰ produced progressively increasing benefit after each session, suggesting that this time span may be sufficient.

Doing sessions more frequently than those limits may also risk long-term tolerance, sometimes called “losing the magic”^92,102.

I think the six-week spacing used in the phase III trials¹⁰ is likely a reasonable spacing to start at, though longer is always ok too.³² From there, I recommend establishing an effective MDMA therapy routine and gaining a good sense of how your sessions feel and produce durable therapeutic improvement. Then, if you feel that a shorter spacing would benefit you, you might reduce your spacing by one week every one or two sessions until you notice sessions becoming less helpful. Judge this a few weeks after the session, after the afterglow is finished (see Section 8.5), and you have stabilized to a new baseline. This reduction is unlikely to waste a valuable session by making it completely ineffective.

That procedure only measures short-term tolerance. You may not be able to notice when you go below your antioxidant system recovery timespan, and thus I recommend the two-week spacing as an absolute minimum.

See Mechanisms of MDMA Tolerance and Loss of Magic by Matthew Baggott¹⁰² for further discussion of tolerance and oxidative stress.

Additional Downsides of Frequent Sessions:

Benefits of Frequent Sessions:

Drug Interactions

MDMA has dangerous or undesirable interactions with various drugs, supplements, and herbs. If you regularly take another drug, I suggest consulting Liechti⁹⁴ and Malcolm¹¹¹ (more accessible) or Sarparast¹¹² (more technical) for recommendations on whether you should continue or discontinue it during MDMA therapy, avoid MDMA, or modify the MDMA dose. If your medicine is essential for your health, I strongly recommend consulting your doctor or pharmacist for help managing this. They will likely not understand the effects of MDMA, so you may need to provide Sarparast¹¹² to them. That paper discusses pharmacokinetics, pharmacodynamics, and psychiatric drug interactions.

If you can’t access a doctor or pharmacist, pausing a drug for 3 half-lives³⁴ before the MDMA dose and 24 hours (3 MDMA half-lives) after might work, provided a few conditions are met. The drug shouldn’t be critical for your health, isn’t one of the few high-risk interactions discussed in the section summary, and can be paused with tolerable effects. This doesn’t work as well for drugs whose MDMA-relevant effects persist after the drug itself has been flushed out, like SSRIs and irreversible MAOIs. Certain health conditions also affect half-lives.

In this section I list a couple of classes of interaction, then the most risky specific interactions and a few other selected interactions that frequently appear in therapeutic contexts. Combining MDMA with other prescription psychiatric or psychoactive drugs causes various changes to the intensity or duration of different effects, including changes to the efficacy of MDMA therapy¹¹².

The most risky classes of interactions:

Specific drug interactions, starting with the most risky:

Medical Risks

MDMA’s interactions with certain serious health conditions are not well understood. As of 2026, MAPS clinical trial exclusion criteria are commonly regarded as the baseline for what medical conditions are incompatible with MDMA. However, clinical trial exclusion criteria are conservative and designed to reduce unknown variables, regulatory scrutiny, and actual, if uncertain, harm. I think the exclusion criteria indicate that additional caution should be taken but are not all absolute contraindications. In the phase III trials (Mitchell^{10,
Supplementary Information; p. 5}) “any medical condition that could make receiving a sympathomimetic drug harmful due to increased blood pressure and heart rate” was cause for exclusion, along with additional details for cardiovascular conditions discussed below. Please consult your doctor if there is any question about whether that applies to you. It would be useful to review the MAPS pharmaceutical investigator’s brochure¹²⁰ with your doctor.

The trial inclusion criteria did regard some serious medical conditions as compatible with MDMA therapy¹⁰. Mitchell^{10,
Supplementary Information; p. 5} said that “individuals with medical conditions such as hypertension, asymptomatic hepatitis C virus, diabetes mellitus, hyperthyroidism, and glaucoma were eligible, providing the condition was well managed and mild.” They couldn’t have assessed every type of serious medical condition, so some conditions not on that list are presumably also compatible with MDMA therapy.

Preexisting health conditions:

Acute adverse effects:

Chronic adverse effects:

Higher risk groups:

Psychological Risks

There is uncertainty about which psychological disorders are compatible with MDMA therapy. These are the exclusion criteria for the phase III trials ^{10,
Supplementary Information; p. 5}:

Clinical trial exclusion criteria are conservative and designed to reduce unknown variables, regulatory scrutiny, and actual, if uncertain, harm. I don’t know their reasoning for each item, but have some informed speculation. MDMA therapy induces psychotic episodes on rare occasion, though risk is likely higher in those with a personal history. Amphetamines are a known risk factor for manic episodes. Personality disorders make forming a healthy relationship between a client and therapist difficult to achieve. MDMA therapy might produce overwhelming symptom worsening in people with dissociative identity disorder if it facilitates abrupt confrontation of extremely distressing dissociated schemas. The trial environment and staff were likely not equipped to cope with some of these conditions, even if they are addressable with MDMA therapy.

Mental illness treatment is highly individualized. Therefore, I don’t think most of these conditions are absolute contraindications. Rather, each case should be assessed on an individual basis for its expected reward/risk ratio. Individual practitioners have different capacities for which symptoms they can support in their clients. Client factors include the amount of symptom worsening they can cope with at a particular point in their life, how capable they are at managing dysregulation, how much their basic functionality depends on avoiding certain feelings or memories, and how much healthy external support they have.

I know that some people have enough resources, skill, and slack to use solo MDMA therapy to successfully treat debilitating mental illness. Many more people can use solo MDMA therapy to reconsolidate relatively minor issues. Skilled, ethical, and well-matched support is especially desirable for people with significant risk factors for dangerous conditions like psychosis and mania. However, I recognize that people sometimes have to make the best of bad situations. Solo MDMA with risk factors is sometimes a better option than the available alternatives, though this is highly individualized and I can’t make any specific recommendations.

Practitioners should be able to accurately identify each of the following conditions and have a plan to either manage them or get the client to an appropriate higher level of care. I rank these according to my impression of risk, starting from the most significant. See Chapter 9 for management recommendations and when and where to seek additional care.

When to Seek Emergency Care

Most of the interactions that cause severe acute harm are known and can be avoided with proper precautions or by not using MDMA^73,113. However, individuals may not always follow proper precautions or may have undiagnosed health conditions. The direct causes of severe acute damage involving MDMA are almost always high body temperature, hyponatremia, or serotonin syndrome. Cardiovascular events may also rarely occur in people with pre-existing cardiovascular issues, especially when MDMA is combined with other drugs associated with cardiac function abnormalities¹⁶⁶.

Many typical symptoms of heat illness, hyponatremia, serotonin syndrome, and cardiac events are also therapeutically appropriate symptoms of MDMA, flight-or-fight, freeze, tonic/collapsed immobility, and confronting extreme fear or anger. Thus, recommendations specific to MDMA therapy are important. Malcolm¹¹⁷ recommends seeking emergency care for any of these symptoms of psychedelic/MDMA-facilitated serotonin syndrome: myoclonic seizures, fever greater than 38.5 °C (101.3 °F), fluctuating or unstable blood pressure and heart rate, delirium or coma, and muscle rigidity.³⁹ To my knowledge, that recommendation also covers severe hyponatremia, which is only possible with very high fluid consumption, and forms of severe heat illness not caused by serotonin syndrome.

In the absence of MDMA-specific advice, one cardiologist offers this general advice for what type of chest pain you should go to the emergency room for¹⁶⁹:

Common Concerns

The Arc of Healing

As described in Section 3.3, healing is fundamentally a process of aligning stuck schemas with current reality and integrating previously-avoided information.

MDMA-facilitated reconsolidation may cause a straightforward decrease in symptoms and increase in mental health for those with simple issues. However, as described in Section 3.6, those with disorganized attachment or other forms of severe complex trauma face a long process of unpredictable ups and downs that gradually tends upward. MDMA and reconsolidation help you confront previously avoided sensations and emotions. Confronting them may then activate other stuck schemas, producing new fear, anger, sadness, grief, dysfunction, etc. You then have to reconsolidate these newly activated stuck schemas, which might surface still more previously-avoided information. This cycle of reconsolidation → decreased avoidance → reaction → reconsolidation → decreased avoidance → reaction continues until there are no more major avoided information and stuck schemas. Note that even this cycle is a simplification of an even more complex and inscrutable process described in Section 3.6.

The simplest issues may be resolved in a single session, but my rough estimate is that the most severe mental illnesses require thousands of hours of reconsolidation to resolve. This process is necessarily spread out over a long period of time for those with complex trauma because therapy hangover limits active reconsolidation to 2 hours/day in my experience.

MDMA is a moderately scarce resource because of the unclear risk that frequent or high-dose sessions may cause long-term tolerance^77,174, long-term cognitive impact¹, and valvular heart disease¹²⁸. Thus, I suggest achieving the bulk of reconsolidation with sober reconsolidation exercises like those described in Section 9.1 if possible.

If you want to progress as quickly as possible, I recommend maxing out on reconsolidation exercises whenever you have the time. There are two difficulties to consider, though. First, while you might be able to achieve 2 hours of active reconsolidation a day, that will also create multiple additional hours of therapy hangover. Second, reconsolidation exercises typically require some additional time for the overhead of figuring out what your stuck schemas are and finding mismatches, not to mention all the other tasks involved in practitioner-guided therapy.

If you can, try to develop techniques that require less overhead, like the first one in Appendix C. I’ve also noticed in my practice and that of one person I know that you don’t have to experience a therapy hangover for as long when you reconsolidate right before going to sleep. The therapy hangover resolves while you sleep.

Unnoticed avoidance makes it difficult to assess how much material you need to work through. You could fill out the Buchanan¹⁷⁵ at least once to get a rough inventory of your stuck schemas, though it’s not essential. It’s the broadest scale I’m aware of and should catch a wide variety of common stuck schemas. You can fill out the scale again every few months to track your therapeutic progress. The scale is long, so it may be worth finding and using a shorter, more specific scale if your stuck schemas are limited to certain areas. That will save you time if you’re filling it out frequently.

Unnoticed avoidance and lack of understanding about what improvements are possible also make it difficult to assess when you are done with the process. If you get to the point of thinking you are done or close enough, I suggest working through every item in Chapter 7 during MDMA sessions. Filling out Buchanan¹⁷⁵ may also help. These will help you uncover, understand, and reconsolidate many of the stuck schemas that even mentally healthy people typically avoid dealing with or thinking about. I think it’s worth working through most of the items in those sections; just getting to a point of good-enough mental health leaves a great deal of individual improvement and capacity for connection and compassion on the table.

I recommend the following resources for guidance on the long-term process of healing:

When to Schedule Sessions

It may be especially productive to schedule sessions when you have a few hours of available time most days for the next 1–3 weeks. Some people report that reconsolidation exercises like therapy are more productive than normal in this period of afterglow (see Section 8.5). Spending a few hours a day paying attention to the emotions that came up during the session may also be particularly useful (see Section 9.1 (Increasing Attention)). I list some ideas for when to schedule sessions in Table 5.1.

Working With or Without a Practitioner

Practitioner Guidance vs. Self-Guidance

Example decision matrix for when to schedule MDMA therapy sessions, based on available time and session cost. This represents my informed thoughts and is not based on any rigorous research process. Individuals will need to consider other factors as well.
	Low Session Cost	High Session Cost
Lots of Time	Whenever you want, within the safety constraints of Chapter 4. Experiment with different frequencies to see how they affect therapeutic progress.	When you have enough time to max out on post-session reconsolidation every day.
Little Time	Ideally, when you can make time for post-session reconsolidation, but sessions may still be very helpful without that.	When you have the most time in your schedule for post-session reconsolidation.

MDMA therapy can be safe and effective in a wide variety of contexts, including therapist-guided sessions with pre- and post-session support^10,29, do-it-yourself couples therapy¹⁷⁷, and solo therapy¹⁷⁸. Unfortunately, to my knowledge, there is almost no evidence regarding what level of support is appropriate in any particular case. I rely on my experience and anecdotal evidence for the following information and recommendations. I start out discussing factors that favor either practitioner or self-guidance then make a set of recommendations.

Factors Favoring Practitioner Guidance

Factors Favoring Self-Guidance

As discussed in Section 6.3, finding a skilled, ethical, affordable, and well-matched practitioner is difficult.

Practitioner guidance is expensive when it’s not covered by insurance. In 2026, in the US, a guided psychedelic therapy session including pre- and post-session support costs in the low $1000s^179–181. MDMA itself only costs 6–50 Euros per gram (in Europe in 2022), which is enough for 5–10 sessions¹⁷².

Scheduling is an obvious advantage of self-guidance; you don’t need to find a day when your practitioner is also available.

Self-guidance may be the only option for those who have been traumatized by mental health practitioners or who don’t trust them.

I suspect that access to a high-quality trip sitter improves the risk and efficacy of MDMA therapy in many cases. Sitters aren’t replacements for practitioners, but could make effective solo sessions significantly more accessible. The sitter should be trustworthy, empathetic, and emotionally non-reactive¹⁸².

As discussed in Section 6.2, some licensed practitioners may call the cops on you if they think you are at high risk of imminent suicide, hurting someone, or are so psychotic that you might do one of the former accidentally. Involuntary commitment can be traumatizing and often actually increases the risk of suicide and hurting other people.

Practitioners who are ethical and skilled but whose style or personality are not a good match for you should be easy to approach about this mismatch. They might even recommend any colleagues who they think would be a better match. The risks inherent in working with an ethical and skilled practitioner who you don’t match well with mostly involve wasted time and money. However, the risks of unethical or unskilled practitioners can include

Recommended Models

I don’t recommend self-guiding without high-quality reference material and an understanding of the nuances of safe and effective healing. The lack of an accurate framework to contextualize the variety of experiences in MDMA therapy impairs safety, efficacy, and your ability to fully access the possible benefits.

Involuntary Commitment

Licensed mental health providers are usually legally obligated to call the police on you if they think you are at high risk of imminent suicide, hurting someone, or are so psychotic that you might do one of the former accidentally¹⁸⁴. In practice, it depends on their interpretation of local laws that they may not understand, how much they fear being sued or losing their license if someone is hurt, and how much they believe involuntary hospitalization will help you. If you are suicidal or fantasize about hurting your abuser, I strongly suggest asking your provider to elaborate on their decision criteria before you open up to them. Then you can decide if you can cope with the level of self-censorship necessary to not cross their boundary. Or, you may trust your provider enough that you can be completely open with them because you know they will only tell you to go to the hospital if you really need it. In that case you could write up a crisis plan involving which hospital you want to go to, which family members or friends you want notified, etc. If your provider does call the police on you, know that police typically have little training in mental health and will likely take your provider’s word over yours. There is also a good chance that the police dragging you away against your will to a place you can’t leave—where medical staff may do various invasive and non-consensual things to you—will traumatize you. Even worse, Emanuel¹⁸⁵ found that (at least in Allegheny County) involuntary hospitalization actually significantly increases the chance of a patient killing themselves or hurting someone else over the 6 months following admittance in cases where clinicians might disagree about admitting a patient (43% of evaluations in this study). It’s not clear how well these results apply to situations where multiple clinicians would all agree on admitting a patient. Alexander¹⁸⁴ is a good guide for navigating/avoiding the inpatient mental health system.

[unedited] How to Find a Practitioner

M.G.’s note: /r/mdmatherapy maintains a list of practitioner directories and referral services in the sidebar (on the new Reddit; not old.reddit.com). I have not vetted most of them. You may also be able to find practitioner by talking to people at psychedelic meetups. Also, in addition to the information in this section, Psychedelic Safety Flags by Leia Friedwoman et al.⁹ is a list of green/yellow/orange/red flags to look for in practitioners.

Which therapist you work with matters a lot. For instance, in a large study done by Firth¹⁸⁶, after adjusting for demographic factors like symptom severity, the best 3.9% of clinicians had 77.2% of their clients recover; the recovery rate for therapists in the average range was 58%; and the 3.9% of clinicians who had the worst outcomes only saw 41.4% of their clients recover. Note that a significant percentage of people recover even without therapy, so the worst therapists might have a negative influence on their clients.

T.H. hopes that the following recommendations, which largely emerge from personal and clinical experience,⁴⁰ can make finding a therapist less overwhelming and more hopeful for those who are struggling with the search.

Even under optimal circumstances, accessing mental healthcare can turn out to be a slog. These challenges are common knowledge for people who provide community mental health services or who have accessed them repeatedly: the financial and administrative costs are often daunting. Interacting with licensed mental healthcare professionals is inherently vulnerable for many, especially those who have witnessed or experienced carceral hospitalization or forced medication. Intake interviews frequently demand intimate details of your finances, sexuality, and medical and mental health. All of this is the price of accessing a clinical relationship that may or may not be very helpful. If it isn’t, clients may feel they need to stick with it because they do need help, and finding someone else to help them seems like more than they can take on. That doesn’t necessarily mean the clinician will stick around, especially if they are students whose clinical internships end only a few months after starting to work together. Online services, which have endeavored to bridge the gap between what is needed and what is easily available, are plagued by serious ethical and product-quality concerns^187–190.

The good news is that there are excellent clinicians out there, and not all of them are late in their careers. Early career therapists, like those who tend to staff more affordable clinics, provide just as good of care as their more experienced counterparts¹⁹¹. Here are T.H.’s recommendations on how to find one that’s right for you.

Bad Therapy is Worse than no Therapy

Remember that really bad therapy can really hurt you¹⁹², and as such it is worse than no therapy. Bad therapy can leave you stagnant for a long time with the impression that no real help for you exists. It can make your symptoms worse without subsequently improving them. In the worst scenario, it can leave you with additional trauma. See Section 6.3 (MDMA-Specific Complications in Obtaining Practitioner Care) for a discussion of the particular challenges of avoiding negative and damaging clinical experiences in the realm of MDMA therapy.

Good therapy is often very uncomfortable⁴². However, you should feel a sense of mutual trust, respect, collaboration, and consent regarding the goals you are working towards and the methods you use to get there¹³¹. T.H. thinks a skilled and well-matched clinician will take the time to help you develop trust commensurate with the discomfort of what they are asking you to undertake. They should do this even if you don’t understand the methods your clinician is using to help you.

Although T.H. cannot speak to the specific trade-offs of your situation, in general T.H. recommends continuing to search until you can access good therapy.

Trust Your Personal Experience

Trust your perceptions, because your personal experience of your clinician impacts the efficacy of your treatment¹⁹³. You don’t just need a good provider, but a good provider who is also a good fit with you. T.H. strongly recommends using the BR-WAI¹³¹, an empirically validated tool for understanding how you and your therapist are connecting and what might be required to improve that connection.

In T.H.’s experience, it’s a good idea to look for someone it feels like you could say anything to. If you cut your arm, any skilled emergency physician will be able to competently stitch you up. The same is not true with a comparable degree of psychiatric injury¹⁸⁶. In mental healthcare, the bedside manner is part of the intervention, and the same bedside manner doesn’t work for everyone. Although the most skilled mental healthcare providers connect well with an extremely broad spectrum of clients, it is unrealistic to expect every provider to click with every client. Many excellent mental healthcare providers ultimately focus narrowly on particular populations of interest to them. If you aren’t connecting with a particular clinician, it doesn’t mean anything is wrong with them, and it doesn’t mean anything is wrong with you.

Feedback

Good therapists love feedback and direction. It is likely that many therapists who could do great work with you if you are expressive about what you need and want would, in contrast, be bad therapists for you if you aren’t expressive about those things^194–197. If you can, T.H. recommends asking clearly for what you want and talking clearly about how things feel. Additionally, there are several instruments that have been developed to help therapists measure and improve their performance. Examples include the BR-WAI, the ORS-SRS, the Core-OM, or the QR-45.2. If your therapist asks you to participate in one of these formal feedback mechanisms, T.H. recommends doing so, even if it feels awkward. These measures really appear to help therapists provide better services.

I’ve observed that it is sometimes helpful to imagine what therapy would be like if it went as well as you could possibly imagine and to share this, and your fears about the process, with your clinician. You can also ask if your ideal hopes align with their experience of their methodology, which may help you set expectations for your treatment. You can use the list above (of what a skilled therapist can provide) to identify ways you would like your therapist to support you. It may be helpful to identify which forms of support you are interested in receiving and to spend some of your initial sessions learning how your clinician feels about providing support in those particular ways.

If you have been working with a particular clinician for a while and your issues are within their main practice area, you are well within your rights to ask them to learn or implement a new-to-them intervention. An accredited therapist is required to complete continuing education hours anyway. There are many legitimate reasons they may say no, like cost, time, and accessibility of additional training, and that’s OK too, but please don’t be afraid to ask.

Sometimes things don’t work out even after you’ve made some effort to recruit your clinician’s help in fixing the situation. As a final service, they may be willing to spend some of your final few sessions helping you find and connect with someone who is a better fit.

Boundaries

Good therapists have good boundaries. Clients often come to therapy without an understanding of what healthy therapeutic boundaries are and why they might be important. That’s OK; it is the clinician’s job to have this knowledge, to share it with the client, and to assert boundaries as needed.

One of the most critical reasons boundaries are crucial in therapy is a phenomenon called adverse idealizing transference (AIT)^192,198. Idealizing transference is a phenomenon in which clients develop strong positive feelings towards their therapist. This can be totally healthy and extremely helpful to the course of therapy, supporting clients in their sense of safety and their ability to sustain focus and effort through the sometimes severe discomfort of healing. However, in some cases, it is possible for these positive feelings to be so strong and misdirected that they cause considerable harm, causing lasting distraction and disruption in the client’s life, potentially continuing for decades. This situation creates a severe vulnerability that the therapist, if they are unscrupulous or unskilled, may exploit (intentionally or not) for emotional, sexual, or financial gain, creating severe trauma for the client and sometimes impacting others as well. In these cases, idealizing transference has become adverse idealizing transference. Just as helpful drugs sometimes have side effects for a small percentage of the people who use them, a small percentage of therapy consumers experience AIT.

AIT can happen even when a clinician is doing everything right¹⁹⁸. However, both the emotions of AIT and the harm created by them can be greatly amplified when therapists fail to communicate and follow through on healthy boundaries. Here are some commonly recognized healthy professional boundaries for therapists:

Therapists are, unfortunately, not explicitly educated on AIT at this time. T.H. strongly recommends that all clinicians read the two reference articles for this section. That said, therapists in all the major licensure categories should be familiar with and generally compliant with the boundaries listed above; understanding the importance of boundaries and respecting the vulnerability of clients are important topics in their clinical training.

Per item 3 on this list, if you are a client with a high number of risk factors for AIT^192,198, T.H. recommends discussing preventative measures with your clinician. You might also heavily weigh boundary practices in your assessment of clinicians’ fit for you. Note that these risk factors are not required to develop AIT, nor do they guarantee AIT. They simply correlate with an increased risk. The risk factors include

A final recommendation on boundaries and the prevention of AIT: although confidentiality is a critical therapeutic boundary, T.H. feels it is an excellent sign if your clinician seeks regular supervision and consultation as needed. They need to disclose some details to their supervisor or consultant, but it should only be the minimal amount necessary. Neither you nor your clinician should feel that anything is happening in the therapy room that they would be ashamed or embarrassed to disclose to a trusted friend in your case or a trusted HIPAA-compliant colleague in theirs. Therapy should feel private, but if it starts to feel like a secret, something may be off.

Targeted Therapy

In T.H.’s experience, in some circumstances it is important to seek therapy that is targeted to the challenges you are experiencing. One of the most common and arguably benign forms of bad therapy happens when clinicians offer a generally empathetic and supportive environment without bringing clients into a space of productive discomfort. This often results in therapy that feels pleasant but not very helpful and which perpetuates the damaging myth that working with a skilled mental healthcare provider is interchangeable with, but pricier than, having an empathetic friend.

Although the current diagnostic system is substantively flawed^199,200, T.H. recommends that a best practice for seeking effective mental healthcare is first obtaining one or more accurate diagnoses. Second, research the most evidence-supported treatments for your diagnoses. Then, seek clinicians who are trained and experienced with those specific treatments and ideally, who are experienced using those specific treatments to address those specific diagnoses. According to T.H.’s experience and Thomas Insel, MD²⁰¹, this leads to radically better outcomes than a less targeted search for mental health treatment.

A less medicalized approach to this process recommended by a colleague²⁰² is to identify what kind of change you would like to make with the help of a practitioner. Then, do some research on how people seem to be working towards that change in various contexts and seek a practitioner who has a good reputation or training in that method. This may be especially appropriate if the help you are seeking is not specifically oriented around mental illness.

This whole sequence may or may not feel accessible to you. However, T.H. recommends that if you are experiencing therapy that feels pleasant but not as helpful as you need it to be, it is worth discussing it with your therapist. You can ask what specific interventions and modalities they are employing and what might work better. Often, in this situation, you as a client require a treatment method that will push you more.

Finding a Therapist Can Be a Long-Term Project

If you feel daunted by the process of finding a good therapist, T.H. strongly encourages you to recruit some support and treat finding a therapist as a long-haul effort. For example, if you have a supportive friend or partner, you could ask them to commit to providing you with your favorite takeout every time you complete ten or fifteen actions on your therapist search. These actions might include getting a list of clinicians your insurance covers, messaging therapists to see if they are taking clients, completing an intake interview, scheduling a session, and completing a session. Alternately, you might start a text thread with your closest supporters, where you can report your efforts and be rewarded with GIFs and emojis. A perspective shift that may be helpful when searching for a therapist is to regard each failure or action as an intermediate step towards finding the help you need and worth celebrating.

T.H. recommends completing three or more sessions with a given therapist before committing to giving treatment with them a try. If you luck out and find a great fit on your first or second try, the BR-WAI will help you have confidence that you’ve really found what you’re looking for. If a particular clinician (or a string of clinicians) is not a fit for you, that’s OK too; that doesn’t mean you have anything to apologize for. It’s good to trust the process and expect that it may take some time.

Accreditation and Safety

T.H. would feel remiss not to acknowledge that unlicensed⁴¹ or minimally accredited mental healthcare providers are common²⁰³, often billed as coaches, guides, shamans, pastors, or simply healers. In this era when a mass-scale mental health crisis is met with a healthcare affordability crisis in the USA, individuals in need of healing seek assistance wherever they can. Indeed, talk therapy and psychiatry are modern inventions, and both common sense and through personal experience suggest that skilled and ethical healers of mental and emotional distress exist across many contexts and training levels.

That said, it can be extremely difficult to verify whether the individual you are considering working with is ethical and skilled, and working with an unskilled or unethical provider can be extremely harmful^192,204. Although the protection offered by working with a licensed counselor is imperfect, T.H. feels it is a critical consideration, especially when working with MDMA, as described in Section 6.3 (MDMA-Specific Complications in Obtaining Practitioner Care).

T.H. perceives significant risks associated with using an unlicensed mental healthcare provider. They may

The protections provided by working with a licensed professional are mediocre. For instance, the field of mental health talk therapy is still relatively young, and it is widely accepted that talk therapy is as much art as science. T.H. has observed that most fully licensed professionals center their practices on interventions that could be covered by insurance, and this may provide some probabilistic guardrails against interventions that have no empirical support at all. However, even among fully licensed practitioners, there is little enforcement that compels clinicians to focus on the most empirically validated interventions or delivery methods. There is also little enforcement for matching a client’s particular situation to the most empirically validated treatment for that specific situation. If these practices are important to you, T.H. recommends asking many detailed questions about them when you are searching for a well-matched therapist.

Additionally, T.H. has observed that various systems of power and oppression can and do play out in the therapy room if clinicians are not actively, vulnerably, and skillfully working to avoid this outcome. The prestige and respect generally afforded to therapists can sometimes foster hierarchical and non-collaborative dynamics. Therapists sometimes say extremely inappropriate, dismissive, harmful, or stigmatizing things. That can be even more harmful than normal because those statements were made by a therapist, someone who they perceive to be an expert and who is supposed to have the answers. Licensure does little or nothing to protect against or prevent these forms of harm.

Although cultural acceptance is improving, mental illness is still very stigmatized, and there are many reports of clinicians who turn on their clients, abusively labeling them “borderline” or simply crazy if those clients file a complaint against them¹⁹². The privacy of the therapy room, the power of stigmatized diagnoses, and the prestige of the therapist role mean that in “he said, she said” adjudications, a client is unlikely to be listened to. The situation is further complicated by the reality that clinicians really are misrepresented and attacked occasionally^205,206. This can emerge out of clients’ profound attachment wounds, overwhelming trauma, and at times delusions, hallucinations, and paranoia. It is inherently very difficult to tell from the outside, and sometimes from the inside too, what has really gone on. As such, many therapists may be more likely to empathize with their peers¹⁹² than wronged clients when they hear about misconduct by colleagues. This unfortunately creates a robust haven for a minority of unethical clinicians,⁴² extremely incompetent, negligent, or predatory.

Despite these shortcomings, T.H. feels it is important to highlight the advantages of working with a licensed clinician and encourage you to weigh the risks carefully. Some certificates for coaching or counseling can be obtained in a few weeks to a month for less than a thousand dollars. These kinds of certifications do not bring significant professional accountability. The loss of such a certification doesn’t usually create significant occupational impairment, and certifications this small are not typically backed up by a licensure organization with sufficient resources to keep track of practitioner misconduct or enforce consequences²⁰⁸. Obtaining independent licensure as a mental health clinician demands years of study, additional years of supervision, and an often six-figure financial investment in education and accreditation. If a fully licensed professional practices therapy while they are impaired, crosses sexual boundaries with a client, or exploits clients for financial gain, the client can file a complaint with the clinician’s licensure board^209,210. If the clinician is then found to have committed the harm described in the complaint, they may, depending on their particular license and jurisdiction

Independently licensed clinicians must typically pass a criminal background check to become accredited²¹¹. They may also lose their accreditation if they are found guilty of a felony in other areas of their lives²¹⁰. This is an important safeguard because a pattern of exploitation across various domains of their life is one of the earmarks of a genuinely predatory individual²¹². These consequences are not always commensurate with the harm caused, but at least one study indicated that the process of filing a board complaint against a harmful clinician tends to be a positive experience for survivors²⁰⁹.

To check whether your clinician is licensed or accredited in some way, try asking them for their license number and then looking it up on the website of their professional association. There are also several professional directories (e.g., Psychology Today in the United States) that will only list clinicians after verifying their credentials. In the United States, there are many qualifications and certifications that allow a practitioner to legally provide mental health counseling.

To further add to the confusion, T.H. has observed that even within the same license, training can vary widely. If you are committed to working with a licensed professional, T.H. recommends searching for providers based on the professional’s experience, preferred client demographic, or treatment modalities, and then verifying their license. You can attain a clearer understanding of the details of a particular clinician’s background with the particular issues you are having or the particular modalities and interventions you are interested in being treated with by asking them detailed questions. For example, how many clients have you worked with who have x diagnosis? What is your training and background in y intervention? They might answer with details including trainings or continuing education units they have completed, books they have read, classes that were part of their degree, relevant experience with those populations before they became a therapist, and much more. All these details are highly variable between individual practitioners, but the baseline safety protections that come from working with a licensed professional are always attached to the specific license they hold. Finally, please note that the fields of life coaching, guiding, or other unlicensed practitioner support often serve as havens for individuals who have lost a license due to misconduct.

If you choose to work with unlicensed practitioners, T.H. recommends exclusively working with practitioners who are very clear about their scope of care, participate in accountability and transparency practices like accountability pods⁴³ and publicly post their business ethics (as exemplified in Sinback²¹⁴). Indeed, T.H. feels these practices, though imperfect, are a green flag from providers of any licensure level. T.H. hopes they will become normalized across mental healthcare, along with providers routinely seeking appropriate supervision and consultation and being transparent with clients about who is supervising or consulting with them. Finally, many of the suggestions from Section 6.3 may be adapted to reduce your risk profile, even if you are not working with MDMA. The caveats T.H. placed on that list apply here as well. No matter who you work with, if they choose to harm you through their behavior, that is not your fault.

To understand the scope of care when you are considering working with an unlicensed practitioner, it may help to ask detailed questions about which services they provide and how and where they learned the skills to provide those services. Unlicensed practitioners are forbidden by law from diagnosing or treating mental illness^203,215. However, many of the interventions that are used to treat mental illness can be appropriately implemented by unlicensed practitioners and have many legitimate uses outside mental illness treatment. For instance, some coaches teach reconsolidation, thought records, mindfulness practices (see Brach²¹⁶), or myriad other skills and strategies that constitute legitimate mental illness interventions. These skills are not exclusively relevant to mental illness; a reasonable person might learn them simply to enrich their life and increase their personal growth. When unlicensed practitioners deploy them, they are also not doing so (or legally should not be doing so) in the context of a treatment plan wherein a therapeutic relationship is constructed and interventions are performed that will specifically address a specific mental illness. As such, it can reasonably fall within the domain of unlicensed care to teach these skills and to help folks identify some circumstances where it is helpful to use them. These kinds of services may significantly help you self-manage or self-treat your mental illness, especially (as is often the case) if you are unable to access high-quality licensed mental healthcare.

On top of this, T.H has observed that unlicensed practitioners are frequently helpful for bridging a gap between the needs of people with mental illness and the necessary level of support (often, more than meeting with a clinician once a week) that would allow them to achieve a significantly better quality of life. For example, a coach might call you several times a week when you are most vulnerable, to help you accomplish task initiation or avoid doom-scrolling, a service a therapist is unlikely to provide. Unlicensed practitioners might help you with more practical, seemingly superficial, yet crucial aspects of changing your life for the better: sitting with you while you fill out job applications, or declutter your house, or practice eating mindfully. Some unlicensed practitioners can help you learn and apply healthy relationship skills that will radically improve your life.

In contrast, T.H. believes the very best mental health practitioners can complete a detailed biopsychosocial assessment of your situation, accurately diagnose you, and offer you mental health interventions that are well-suited to you. They offer a deep understanding of how various constellations of symptoms tend to show up and some awareness of pitfalls you are likely to encounter along the way based on that. They will have an understanding of what level of care is appropriate to your situation, and if they do not have the particular expertise appropriate to your condition, they will help you find a provider who does. They may know much sooner than you do if it is urgently important for you to receive a higher level of care. For instance, early intervention for a first psychotic episode has a massively positive impact on the lifelong trajectory of individuals with psychotic spectrum disorders, and timely intensive treatment for eating disorders or substance use disorders can be lifesaving. Particularly if you do not have a case manager to take on this role, a mental health practitioner may help you work through what is stopping you and learn the skills to recruit and coordinate care from many sources. Examples include

Although reconsolidation may ultimately heal most or all of your mental illness in a deep and durable way, meanwhile you must live with your symptoms and build the best life you can, despite your symptoms. The best mental healthcare providers are experts not only in addressing the root causes of mental illness but also in helping you reduce the incidence of your symptoms and in helping reduce the impact of your symptoms on your life.

MDMA-Specific Complications in Obtaining Practitioner Care

Finding practitioner support for MDMA therapy carries challenges over and above the challenges of finding mainstream mental healthcare. The specific nature of MDMA therapy amplifies the vulnerability of seeking psychiatric care, including (T.H. surmises) vulnerability to AITs²¹⁷. Some of these challenges emerge from the legal status of MDMA therapy. Finally, these factors have combined to create an existing culture of underground MDMA therapy that can be painfully exploitative²¹⁸. An effective process for securing practitioner support must take all of these challenges into account.

Challenges caused by the vulnerability of seeking psychiatric care

As discussed in Section 6.3 (Accreditation and Safety), there is a severe power imbalance between providers and consumers of mental healthcare. When a fully licensed professional enacts behavior that is clearly abusive, it creates the case in which T.H. would expect the maximum possible structural support for accountability within conventional criminal-legal and administrative systems. However, even in these cases, proving misconduct and enforcing appropriate consequences for it is not always possible²¹⁹. On top of this, I’ve observed that many individuals consuming mental health care feel that they must put up with a certain degree of discomfort to access care they may desperately need. T.H. finds they are often understandably unskilled at detecting the difference between the healthy discomfort of effective treatment⁴² and discomfort related to mistreatment or misconduct.

Challenges caused by the nature of MDMA

As detailed below, MDMA can increase client vulnerability. MDMA can create experiences of great mental and sometimes physical intensity, of much longer duration than a traditional therapy session. Long sessions, sometimes a risk factor or red flag for harmful boundary violations²²⁰, are necessary in MDMA therapy. MDMA can generate sexual feelings²²¹, and T.H. thinks the same enhanced empathy and openness to experience that make them such a fantastic aid to reconsolidation work may mean they leave individuals who take them more susceptible to persuasion. Altered states of consciousness also impair the ability to be appropriately cautious and thoughtful about risk. These factors make it even harder for clients to tell when providers are behaving inappropriately. Additionally, a significant subset of MDMA clients are having one of the peak experiences of their life, or even the peak experience of their life. T.H. thinks this could cause practitioners who routinely facilitate this therapy to feel godlike. Even excellent practitioners may need to work very hard, when administering MDMA-assisted therapy, to maintain appropriate boundaries, humility, and client-centered care. This dynamic can undermine even good clinicians’ ability to provide quality care. . Although there is no data on the topic, T.H. feels this dynamic almost certainly increases the risk of AITs with MDMA therapy, particularly with providers who are not scrupulous regarding boundaries or thoughtful about preventing this specific risk. All of these aspects of MDMA amplify the already formidable power dynamics between a therapist and a client, regardless of legal status or other factors.

Challenges caused by legal status

The legal status of MDMA creates additional risk for those seeking practitioner support for Psychedelic-assisted therapy (PAT) in several ways:

Existing culture of exploitation in psychedelic therapy

Taken together, the above factors render it unsurprising that exploitation, spiritual bypass, and cultic dynamics seem to have been woven into the culture of underground psychedelic therapy^223,224. MDMA facilitates suggestibility and profound experiences. Providers face challenges in staying humble and client-centered when providing these interventions and have deep shelter from any legal threat about malpractice that is created when it is all illegal. These all play a role in a culture of guides, healers, shamans, and therapists who can harm with impunity. Multiple accounts have surfaced of the need to develop a better framework of accountability in these underground, unregulated communities.

If you are interested in learning more about this topic, T.H. recommends the following resources:

Individual Actions to Improve Safety of MDMA Care

In this era of regulation, many people with mental illness are driven to work with unlicensed providers due to mistrust of the mainstream mental health system or the financial or logistical inaccessibility of high-quality licensed care²⁰³. Additionally, while the system of licensed providers presumably prevents many of the most egregious violations, some serious harm can and does slip through, as evidenced by the whistleblower reports from the MAPS trials³⁴. In this context, T.H. believes there are steps some individuals may be able to take to increase their safety when seeking MDMA therapies.

T.H. wants to emphasize that even if you do nothing on this list, any care provider who violates the sacred trust you have put in them as a healer by mistreating you is fully responsible for their actions. Those who are most badly in need of psychiatric care are often under-resourced and likely to find it challenging or impossible to carry out the degree of vetting or preparation they might have ideally preferred. T.H. provides these suggestions not to cast blame or create additional responsibilities for care-seekers, but as a resource with which those who are able may be able to improve the risk profile of their healing endeavors.

License and Certification

Research their license and certifications carefully. See Section 6.3 (Accreditation and Safety) about accreditation and the protections it provides. Remember that practitioners may claim a license they don’t have, or they may have some sort of certification that does not carry enough weight in their professional life to enforce any kind of accountability. T.H. particularly recommends taking other precautions if your clinician does not belong to a licensing body that publishes the names of clinicians who are found to have violated its ethical code.

Evaluate Fit

Follow the advice above (see Section 6.3) about finding a clinician who is a good fit for you, including working with them for at least three sessions (preferably five or more) before making any decisions about using their assistance for medicine work. During this time, observe their boundaries carefully, and have frank discussions about their qualifications, your needs and expectations, and the modalities that would be employed during the medicine work.

Methodology and Expertise

Research their therapeutic methodology and expertise. It is T.H.’s hope that the evidence-based theoretical framework offered in this book, positing that the primary mode of healing MDMA offers is memory reconsolidation, can assist some clients in assessing whether they are interested in engaging with various therapeutic methodologies. Accordingly, T.H. particularly recommends seeking clinicians who have a strong background in addressing dissociation and panic, in dealing with trauma generally, and in assisting their clients in working through somatic manifestations of trauma/somatic release.

Although they may be particularly effective for activating some important schemas, T.H. strongly recommends avoiding methodologies that involve physical touch, particularly those that involve physical touch during the actual medicine work. The client may be unable to consent or make unbiased decisions about whether to continue or stop a particular therapeutic interaction in this state.

If you are interested in somatic methodologies that involve touch, T.H. recommends alternatives such as therapeutic use of restorative yoga postures. In this practice, a clinician can provide support through various bolsters and pillows, along with verbal instruction, so that there is never any need to touch you in any significant way. If for some reason you do choose to pursue a methodology that involves touch, T.H. recommends undertaking precautions to increase your sense of volition and improve the safety of the endeavor, including

T.H. agrees with the assertion of the American Association of Sex Educators, Counselors, and Therapists when they suggest that there is no circumstance where sexual touch is appropriate to the therapeutic relationship²²⁵.

M.G.’s note: Clients sometimes feel that therapy helped them remember traumatic events they weren’t previously aware of²²⁶. These may or may not be accurate recollections of historic events, and I am not aware of any reliable method of distinguishing a memory’s accuracy other than independent corroboration. To avoid incorrect interpretation of perceptions during the session, practitioners should categorically avoid suggesting a memory is either true or false and shouldn’t even suggest that a specific individual has avoided memories they can recover²²⁷.⁴⁴

Background Check

Get a background check on the guide and possibly on others who recommend them or who have trained them. In some cases, significant networks of recommenders or well-regarded trainers may all be invested in unsubstantiated or potentially harmful therapeutic modalities²¹⁸. Historically, lineage of training has been an important way that healers are credentialed in the absence of licensure systems; if your guide has trained under someone who promotes potentially harmful therapeutic modalities, like breaking people down, or if they have been mentored by people who have a history of boundary violations against clients, T.H. recommends proceeding with extreme caution if at all. If a guide with these red flags seems like an otherwise excellent match, T.H. recommends having detailed conversations about how they relate to those practices and approaches, and taking the other safety considerations listed here especially seriously. Finally, as noted in the accreditation section, if a prospective practitioner has a history of fraud or abuse in other areas of their life, this is also worth taking into consideration, even though it may appear unrelated, because this may be a warning sign for truly predatory behavior.

Accountability

Look for external accountability in the clinician’s ethical structure, both philosophically and practically. One of the concerns cited by²²⁸ regarding safety in PAT is that there seems to be a cultural norm in underground psychedelic therapy of identifying the truth-including the truth about situations in which clients allege their clinicians have harmed them-as something that comes from inside each person. In contrast, healthy accountability practices require us to listen with openness to outside information which can make us feel downright terrible on the inside. T.H. recommends seeking providers who maintain active relationships with supervisors, mentors, or accountability pods²¹³ who can help them receive the report appropriately if a client has a bad experience in their care. Additionally, T.H. recommends seeking clinicians who can provide you with a clearly articulated set of written ethical standards they endeavor to adhere to, whether those standards come from a professional organization or personal soul-searching.

Flight Plan

Create a “flight plan” and a safety plan collaboratively with your provider/s while sober, and review/update it before each medicine experience. Birth plans have become popular tool that birthing parents can use to (a) educate themselves about the many choices that may emerge during labor and delivery, and (b) communicate strategically with providers about their needs and preferences; T.H. feels that structured advance planning for PAT sessions could provide similar benefits²²⁹. Here are some considerations you may wish to include in your flight plan if you feel you are at particularly high risk for AIT (link to assessment questions in section above), or otherwise have significant safety concerns:

Cultishness

Keep an eye out for cultic group structures or dynamics. Accounts from the underground PAT world have described closed systems centered around charismatic leaders, exploitation of the labor of group members, and abundant use of what cult scholars call thought terminating clichés²¹⁸thoughtTerminating. Thought terminating clichés are phrases used to address cognitive dissonance while shutting down inquiry into the framework that produced that dissonance. For instance: one client said they were being told that their abuse-induced “downward spiral was just some personal failure of my own. To get over my crisis I needed only surrender, let go, and have unquestioning faith in psychedelics—and him.” In other words, survivors were told to stop considering the choices and volition of the human beings who betrayed them, and instead to focus on their own complicity and potential growth that might emerge from their abuse. In contrast, in a non-cultic framework, people are allowed to ask questions and investigate what is under these thought terminating clichés. They are allowed to disagree. They are not taught to believe they are dependent on just one source for healing.

Prompts for Activating Stuck Schemas

Schema activation does not always happen spontaneously during a session, and when it does, it may not cover all the stuck schemas that are worth reconsolidating in your life. This section helps you deliberately activate and reconsolidate common stuck schemas that you may not be aware of. Working through these prompts builds more resilience and equanimity than the default of just doing enough MDMA therapy to make your primary issue feel manageable.

These are going to feel uncomfortable, but that’s part of the process. Start with the easiest ones and work your way up to the harder ones over time.

I also strongly suggest keeping a list of subtle (or not) discomforts that you notice in daily life. Some of these might be valuable reconsolidation targets.

Personal Schemas

See Table 7.1 for a list of prompts designed to activate many mental illness, developmental, and attachment-related stuck schemas that people commonly have. It may help to imagine a concrete scenario for each item. Feel free to skip sections you feel totally comfortable with.

Habit Mapping

Schema Activation Prompts inspired by A Comprehensive Questionnaire for Schemas Related to Psychopathology: The Maladaptive Schema Scale - Version 1.4 (MSSv1.4) by B. Buchanan et al.¹⁷⁵. I used Claude to transform the items in the original scale from their diagnostic forms into schema-activating forms, each framed as a scenario the schema is built to defend against.
Activation Prompt	Schema Domain


-Someone you love is about to leave you without warning	Abandonment
-The person closest to you is wavering on their commitment
-You desperately need someone and no one is coming
-The person you depend on most is leaving
-You have no choice but to let someone else take care of you	Excessive Self-Reliance
-Someone is getting very close to you
-You are completely dependent on another person right now
-You need to ask someone for help with something painful
-You’re struggling and there’s no one to turn to	Emotional Deprivation
-You’re in trouble right now and there’s no one you can call
-The people around you don’t care how you feel
-You need emotional support and no one is offering it
-Someone is being kind to you but you can’t see their real motive	Mistrust of Others
-You have to trust someone completely right now
-Someone is telling you something important and you can’t verify it
-You just realized the people around you have been lying to you
-You just saw clearly how selfish the people around you really are	Others are Dangerous
-You’re watching someone suffer and no one is stepping in to help
-The person in front of you could become violent at any moment
-Someone just revealed who they really are underneath
-You walked into a room and immediately felt you don’t belong here	Social Isolation
-You’re trying to explain something important and no one understands
-You’re surrounded by people and none of them can see you
-You are completely on the outside looking in
-The people closest to you can finally see who you really are	Defectiveness / Shame
-Someone just looked at you and saw what’s broken
-The people you love can’t love you because of what’s wrong with you
-You are exposed and there are real reasons to feel ashamed
-You’ve stepped outside your safe zone and bad things are closing in	Vulnerability
-You just realized you’re exposed and nothing is protecting you
-Everything is falling apart and catastrophe is coming
-The world is hostile and it’s coming for you

-You are alone and must take care of yourself with no help	Dependence
-You have to manage everything today entirely on your own
-A major decision is in front of you and no one can advise you
-You must choose and there is no one to confirm you’re right
-Everyone around you has accomplished more than you	Failure / Inferiority
-You’re looking at what you’ve done with your life and it’s not enough
-Someone you know just succeeded at something you failed at
-You’re being compared to others and you’re falling short
-A hard problem is in front of you and you probably can’t solve it	Low Self-Efficacy
-You’re stuck and you can’t think of any way forward
-Something unexpected just happened and you have to handle it alone
-The problems you’re facing are beyond your ability to manage
-Something important is being decided about your life and you can’t influence it	Fatalism
-A critical moment is coming and nothing you do will change the outcome
-You’re watching your future be decided by things completely beyond you
-You just realized you’ve never really been steering your own life
-Someone you love is in pain and it’s your job to carry it	Enmeshment
-You can’t tell where your feelings end and someone else’s begin
-You are dissolving into another person—you can’t find yourself
-Someone else’s needs are consuming everything you have

-Someone is telling you what to do and they know better than you	Subjugation
-You must obey even though you disagree
-Someone else is deciding what’s best for you
-Another person is taking control and you have to let them
-Someone needs you and you must put them first no matter what	Self-Sacrifice
-Someone is bringing you their pain and it’s your duty to hold it
-You need something right now but someone else needs more
-You’ve given everything you have and it’s still not enough
-You have to choose between what you want and what others approve of	Approval-Seeking
-Someone disagrees with you and you feel the pull to agree with them
-Someone you don’t even care for doesn’t like you, and it’s eating at you
-You need to decide but you don’t know what anyone else thinks
-Strong emotions are pushing up and they won’t stay contained much longer	Emotional Inhibition
-Your emotions are taking over and they’re going to cause damage
-You’re about to cry in front of people who can’t handle it
-Your emotions are dangerously intense right now

-Something is about to go wrong, as it always does	Pessimism
-You’re facing uncertainty and there’s no reason to hope
-You’re waiting for the bad news you know is coming
-You’re looking ahead and you can’t see anything good coming
-You just made a mistake and you can’t let it go	Unrelenting Standards
-You have to choose between being happy and meeting your standards
-You performed well but not perfectly and it’s not enough
-You fell short and that is not okay
-You just made a mistake and you don’t deserve compassion for it	Punitiveness (Self)
-Something went wrong and you shouldn’t get away with it
-You failed and now you deserve what’s coming
-A small thing just went wrong and you must pay for it
-Someone made a mistake and they don’t deserve your compassion	Punitiveness (Others)
-Someone failed and they should be held accountable
-Someone let you down and they deserve consequences
-Someone did something wrong and letting it go would be wrong

-Someone just told you no	Entitlement
-You have to follow the same rules as everyone else
-No one around you recognizes how special you are
-You’re being treated like everyone else and you deserve more
-Something has gone wrong and you should have been able to prevent it	Full Control
-Something is happening that you cannot control or influence
-Willpower alone cannot change this situation
-Something has been left to chance and you can’t intervene
-Your gut says one thing but the evidence says another	Over-Reliance on Emotions
-You’re making an important decision based only on how you feel
-Your emotional reaction feels like the truth even though it might not be
-A problem is in front of you and thinking won’t help—only feeling

-You just experienced something unjust and no one is going to fix it	Unfairness
-You are being treated unfairly and no one sees it
-Something bad happened to you and you didn’t deserve it
-Good things keep happening to other people but never to you
-You’re looking at your life and nothing in it seems to matter	Meaninglessness
-You’ve been trying to find meaning and coming up empty
-You can see now that everything you’ve worked for will be forgotten
-You’re watching people strive and none of it will have meant anything
-You don’t know who you are right now	Lack of Coherent Identity
-Your interests and beliefs feel like they belong to someone else
-You are watching yourself from the outside, disconnected
-The person you were yesterday is not the person you are today

If you hope to unlearn old habits or to reconnect to a project that you’ve been feeling too overwhelmed to engage with, habit mapping (see The Habit Mapper by Jud Brewer²³⁰) can help. This consists of identifying behaviors you are hoping to adjust, identifying what triggers lead you to engage in those behaviors, and identifying the results after you engage in the behavior. For example, you might identify that you would like to adjust the habit of scrolling through social media on your phone for three to five hours every day as soon as you get off work.

Identifying triggers might involve exploring: what are the feelings that precede your going online? What are the stories you tell yourself? What physical and social environment are you experiencing that supports this behavior? Are you triggered by loneliness, by a desire to be free of demands for a period of time, or by a feeling of boredom/desire for stimulation, or all of the above? What happens when you work the second half of your workday in a communal space vs. when you work alone? What happens when you lock the phone in the glove compartment of your car during your lunch break and don’t revisit it until you’ve walked outside to the parking lot?

The last stage of habit mapping involves checking in with yourself and taking time to feel all the consequences of enacting the habit. You might feel stiff and sedentary, which feels bad in your body; you might find yourself feeling anxious or tired or lonelier than when you started scrolling, or that you get caught up in cycles of self-judgment or shame about the behavior. Maybe you feel frustrated and wish you had more time for other things. Or perhaps you feel some of these things and also feel delighted and inspired by the content you are consuming. The goal of habit mapping is to observe and record each habit as it plays out in your life and to open yourself to deeply understanding whether the choices you are making are the choices that are best for you. Sitting with what you feel an intense need to numb—and with the consequences you’re willing to pay for that numbing—may prime you to face those feelings during the session.

To activate the relevant schemas during a session, you can repeat this activity or just read over the notes you made when you did it sober.

Social Schemas

Imagine, as vividly as possible, being a member of a different group of people. Then, imagine how you and your friends, family, coworkers, and community would react to you. Go toward any fear, disgust, or shame and stay with that feeling. Race, gender, disability, class, political affiliation, wealth, education, attractiveness, and religion are all good attributes to consider. Add any other categories relevant to your situation. Choosing the lowest status group for each category may activate the strongest stuck schemas.

Existential Schemas

Imagine permanent disconnection from health, material comfort, sensory pleasures, relationships, belonging, status, order, certainty, meaning, being a good person, life, and existence (including any afterlife). Additionally, consider the possibility that your fundamental assumptions about life, meaning, existence, and self might not actually be true. To my understanding, reconsolidating these stuck schemas leads to equanimity, not the loss of healthy protective behaviors or basic attachments.

Attaining persistent non-attachment and non-duality/unity requires considerably more work than using the prompts just mentioned to reconsolidate stuck schemas during MDMA therapy. Subsection 8.4.12 lists a few starting points.

Cognitive Flexibility and Truth-Seeking

While each of the parts in this section logically follows from the rest of the book, applying them to this class of stuck schemas is partially speculative.

I think that cognitive flexibility is both highly important and lower than it should be for most people in the modern world. Tribalistic instincts are a major contributor. While we need to form coalitions (family, work, friendships, etc.) to accomplish almost anything, our tribal tendency seems disproportionate for life in modern nation-states. This creates all sorts of problems, such as poor governmental policy because people vote based on identity²³¹, being shunned for believing or doing things that are markers of belonging to a rival group, etc.

It is common to perceive obviously false beliefs in the out-group. But how do you know they are mistaken and you aren’t? The human capacity for self-deception must be strong enough to make at least one of you wrong about a supposedly obvious fact, and we have no foolproof meta-reason to believe it is them instead of us. You may think “ah, but I’m right because I’ve done x, y, and z to make sure”, but the other person may feel they have also made sure. Confidence can easily coexist with delusion.

As the psychologist says on their blog about self-deception being a core aspect of tribalism²³²:

Trapped Priors as a Basic Problem of Rationality by Scott Alexander²³³ discusses another mechanism for how emotionally charged, false beliefs become entrenched. It proposes, based on VandenBergh⁶⁰, that when another group or another group’s beliefs are perceived as highly threatening, the brain dials down the relative certainty of all incoming sensory information, including information that indicates you aren’t really in danger in the moment. Thus, the false belief never reconsolidates unless the contradictory information is extremely strong and unignorable, or the contradictory information is introduced very gradually, like in exposure therapy.

Self-deception relies on a constellation of schemas that serve to justify your belief or deny the validity or existence of contradictory information. I propose that MDMA therapy can help you reconsolidate some of these stuck schemas. During a session you might consider a hated or feared political, religious, national, or cultural group—or a faction of your group if you want an easier starting point—being correct about an important point of contention. Imagine believing that point yourself. How does that feel? Imagine expressing your new belief to your friends, family, or community. How would they react? How would you feel about that? I suggest primarily focusing on noticing and staying with any fear, anger, grief, etc. that you feel during this process rather than spending all of your energy on intellectual thought. This will reconsolidate any associated stuck schemas. Intellectual engagement with the subject will work better after reconsolidation anyway, so save it for after the session. Working through Section 7.2 will also help.

The point of the exercise isn’t necessarily acquiring more accurate beliefs about the specific topic you imagine during the session. Rather, the point is activating and reconsolidating any stuck schemas potentially interfering with your thought processes, which improves your general, long-term ability to acquire accurate beliefs. You could actually pick an idea that you don’t think is worth considering the truth of at all, like the Earth being flat. Using that as a prompt might activate and reconsolidate a stuck fear of being like those people, which makes you discount all beliefs that you and your social circle consider odd, but some of which are certainly true.

The world is full of pervasive threats, fear-based messaging, and out-group dehumanization that may reconstitute some stuck schemas over time. I suspect additional strategies beyond reconsolidation and avoidance-reduction are necessary to maintain cognitive flexibility and compassion in the long run. I recommend the following:

Authentic Engagement with Empathy, Ethical Reasoning, and Ethical Action

While each of the parts in this section logically follows from the rest of the book, applying them to this class of stuck schemas is partially speculative.

Our innate empathy and learned schemas interact to form our actions, moral beliefs, and circle of moral consideration. As they do in other areas, stuck schemas can interfere with coherent and empathetic ethical reasoning and ethical action.

People sometimes hurt other beings, usually without deliberate intent or full awareness of the impact of our actions. This typically involves some combination of (a) a driver—fear, anger, perceived insecurity, desire, or simply a default cultural behavior—and (b) a constellation of schemas that justify the harm, deny the harm, deny the other being’s worth, or prevent the harm from becoming salient in the first place. Non-salience is especially strong when harm is incentivized through intermediaries like markets, elections, or culture; consumers creating demand for cheap fish, for instance, rarely confront the conditions of extreme suffering in fish farms that fulfill it²³⁶.

This dynamic implies a conundrum for those interested in acting in congruence with their values: how do you know if you’re significantly and unnecessarily hurting someone if the act of hurting others is frequently obscured by a cloud of subtle avoidance, denial, and justification strong enough that the vast majority of people have historically been fooled?

Avoidance, denial, and justification in large part function to shield us from information that feels threatening (see Section 3.3). MDMA notably increases tolerance of discomfort, and I suspect it is useful for bringing attention to other beings, contemplating their worth, and reconsolidating any stuck schemas those actions activate. During a session I suggest two practices.

The first is for situations where the driver is desire or default cultural behavior. Look at photos or real-life examples of other beings and contemplate in detail what you share with them, what their life might be like, what causes them to suffer or thrive, what they deserve, how you have hurt or neglected to help them, and what obligations you may have to them. You may have to investigate what their lives are like; I provide suggestions in the list below.

The second is for situations where the driver is a perceived solution to fear, anger, or insecurity in a conflict. Try the prompts in Section 7.2.

Focus on noticing and staying with any fear, anger, or other distress you feel during this process rather than getting completely distracted by intellectual thought. This should reconsolidate any associated stuck schemas, and intellectual questions can be considered after the session is over, when there are fewer stuck schemas getting in the way. The next question is who to bring into this contemplation.

Analytically determining what beings have inherent worth is difficult; it depends on solving multiple open problems in philosophy of mind and moral philosophy, like metaethics and the hard problem of consciousness^237,238. Since there are no broadly agreed-upon solutions to these, I take a pragmatic approach that centers uncertainty and the precautionary principle. This involves thinking about what features of humans are associated with having positive and negative internal experiences and then looking at what other beings possess those features. I recommend the short video The Science of Animal Sentience: Sentience and the Precautionary Principle by Jonathan Birch²³⁹ for an introduction to this approach.

I propose considering beings that some major groups of people think have inherent worth, if only to check whether you’re missing something others have noticed. Here are the categories that seem worth considering to me. You might disagree about where to draw the line of who to consider. I’ve included references for further reading that take positions of uncertainty in edge cases (e.g., AI) and compassion in stronger cases (e.g., mammals and birds).

This procedure will likely be uncomfortable, but that’s part of the process. Discomfort, avoidance, and automatic discounting of worth are strong indicators that there are stuck schemas. Stay with that feeling until it reconsolidates.

Connection with Nature

This exercise will help you connect to nature and reconsolidate any stuck schemas inhibiting that. I hope that this will facilitate nature being a source of peace and enjoyment for you.⁴⁶

First, if you’re going anywhere more remote than a back yard, get acquainted with how MDMA and MDMA therapy affect you before adding the nature complication to your session.

If you’re new to spending time alone outdoors, start somewhere safe, like a back yard. You can also ask a nature-experienced friend to come with you.

During the session, engage all your senses—press your bare feet into the soil, look closely at plants and insects, feel bark textures, crush and smell leaves, and listen to the wind and water. Don’t taste anything unless you’re absolutely sure it’s safe. As with the previous exercises, prioritize noticing, going toward, and staying with any feelings of distress to reconsolidate the associated stuck schemas.

Beyond MDMA Therapy

Psilocybin sessions might durably increase feelings of nature-connectedness²⁴⁵. Psilocybin creates a more dramatically altered state of mind, is significantly more unpredictable than MDMA, and doesn’t necessarily buffer difficult experiences with feelings of safety. I strongly suggest starting with low doses, like 0.5 g dried mushrooms.

If you are interested in doing more to help preserve natural areas, I highly recommend Not the End of the World: How We Can Be the First Generation to Build a Sustainable Planet by Hannah Ritchie²⁴⁶. It presents rigorous, high-impact, evidence-based solutions that an individual can do and is neither overly optimistic nor pessimistic.

Pre- to Post-Session

Pre-Session Checklist

MDMA is not inherently therapeutic; the effects of a session depend on your mindset and the external setting. Many people also use MDMA for escapism²⁴⁷ or fun and social connection²⁴⁸. This section describes mindsets and settings that facilitate reconsolidation. I also discuss tools for the session and preparation for the post-session.

Mindset

Setting

Tools

Preparation for the Post-Session

Opioid Dampening and Avoidance During the Session

Avoidance and opioid dampening are difficult to deal with because they impede reconsolidation, including reconsolidation of the very schemas that create avoidance and opioid dampening. This section focuses on techniques that loosen this self-reinforcing state of stuckness. I group avoidance and opioid dampening together because they both inhibit conscious experiences of contradiction, a requirement for reconsolidation, they are dealt with similarly, and it may not always be clear which one is present.

Razvi⁸ reports that successful experiences of engaging with stuck schemas (my interpretation) in the presence of dissociation (an effect of opioid dampening and avoidance) make the process much easier in subsequent sessions. I think it is a skill primarily learned through experience. Therefore, this section is mostly focused on facilitating successful experiences and building this skill.

I define avoidance in this context as consciously or unconsciously diverting attention away from stuck schemas. Uncertainty about the process of tuning in to stuck schemas might also play a similar role. As described in Section 3.1, schemas predicting imminent threat and powerlessness produce opioid dampening.

The spectrums of avoidance and opioid dampening are not well understood, and it may not always be clear which one you are in. For instance, Razvi⁸ reports a state sometimes encountered during MDMA therapy where a person “may have very little or no response to substances as powerful as MDMA or psilocybin. They will feel sober, or bored or sleepy as if they could get up and go about their day. If a therapist wasn’t in the room, they might fall asleep during the height of an MDMA session.” Soberness and boredom are neither effects of immobility nor MDMA. This suggests there might be at least one more poorly understood form of avoidance, opioid dampening, or some other phenomenon. These reports may also reflect the interaction between MDMA and avoidance or opioid dampening.

I group the interventions listed here into two categories: deactivating the schemas that produce avoidance and opioid dampening by increasing feelings of safety, and paying better attention to stuck schemas in the face of avoidance and opioid dampening. This grouping is done for organizational simplicity even though the attractor state is naturally circular. For instance, increasing safety leads to decreased avoidance and opioid dampening, which facilitates reconsolidation of the stuck schemas producing avoidance and opioid dampening, which makes further reconsolidation easier, etc. Alternatively, starting with increased attention can lead to reconsolidation, which then reduces avoidance and opioid dampening, etc.

MDMA combined with deliberate therapeutic introspection is often sufficient to deactivate avoidance and opioid dampening or reconsolidate the schemas that produce avoidance and opioid dampening if they aren’t too strong⁸. The threat and powerlessness schemas causing opioid dampening are already highly activated, so you probably can just try to feel whatever is already present rather than trying to reconsolidate specific schemas. You might notice schemas like “I’m dying right now,” for instance.

Resolving opioid dampening can immediately lead to flight-or-fight⁴⁷, which in my understanding, is easier to deal with on MDMA.

Increasing Safety

Paying Attention

The goal of these items is emotional engagement with stuck schemas. This is a requirement for therapeutic reconsolidation¹⁷³. Intellectual or abstract thinking about the schemas isn’t sufficient.

Other Options

MDMA therapy may not always be able to resolve dissociation. Saj Razvi, founder of the Psychedelic Somatic Institute, recommends that people with strong dissociation will find MDMA therapy more productive if they start with three sessions of cannabis-assisted PSIP (Personal communication, Saj Razvi, Jan. 2, 2026). They find that cannabis is a particularly good complement for selective inhibition, possibly because it impairs voluntary control of the experience, though that factor also makes the process more difficult to do solo⁸. The maintains a directory of therapists²⁵³.

The Therapeutic MDMA Session

The effects of a single MDMA dose are generally noticeable 30 minutes after taking the medicine, peak an hour after that, and then last a further 3 hours before gradually dissipating¹⁵⁷. Those with genetically or pharmacologically low CYP2D6 metabolic capacity peak earlier and higher, though any differences disappear by hour 3–4⁹⁵. Food delays the onset of effects²⁵⁴.

A half-strength booster dose taken around hour 2 is often used to extend the productive duration of the session¹⁰. Besides the booster dose, anecdotal reports indicate that people sometimes take more MDMA than they were originally planning to because of anxiety about the session not being what they expected or feeling like the medicine isn’t working. I think taking additional medicine is most justified if

The upper safe limit of MDMA is unknown, so I advise caution above total doses of 3 mg/kg (roughly the amount used in Mitchell¹⁰) or 200 mg⁹⁴, whichever is lowest for you. It is difficult to accurately measure the right amount of MDMA while you’re panicking or in an altered state of consciousness, so you could prepare the additional dose, and the regular booster dose, in advance.

Many first-hand reports of successful MDMA therapy can be found on the top posts on reddit.com/r/mdmatherapy. The top posts mostly describe productive sessions that don’t contain strong opioid dampening, avoidance, or poorly handled symptom worsening. You can see descriptions of less productive or more disruptive sessions by sorting by new.⁵⁰

Session Timeline

Come-up

The effects of MDMA become noticeable, but you are not yet deeply engaging with stuck schemas. Some users experience anxiety¹⁷⁸. This might be misinterpretating MDMA’s stimulant effects as anxiety, early engagement with distressing schemas, or fears about the session.

Peak

Reconsolidation is possible here. Connection and safety become pronounced, though this may be unnoticeable if distressing schemas are also present, you are avoiding the experience, or you are in opioid dampening. In my experience, MDMA therapy can work even if you do not feel MDMA’s classic love⁵¹ and safety. See Section 4.2 for a list of physiological and some subjective effects.

Anecdotal reports indicate that people frequently experience mind’s-eye images of therapeutically relevant content.

Comedown

You may still feel high, but engaging with painful emotions is more difficult, and reconsolidation may no longer be achievable. Personal experience and anecdotal reports indicate that people can be disappointed by how hard it is to be present with and reconsolidate difficult feelings again.

After-effects

See Table 4.1 for how side effects change as the drug wears off. Some of them can persist up to 3 days⁷⁹.

Therapeutic Technique

First, if you’re experiencing ok-ness and self-love for the first time or are seeing how trauma shapes the world, I recommend engaging with that and not trying to refocus on engaging with distressing schemas. This experience can be a preview of the end goal of therapy and can be a great motivator for staying on the healing journey long-term through challenges. The peace and compassion may not last long after this first session, but you will gradually get some of it back as you reconsolidate various stuck schemas over the long term. Regular life is rarely total bliss, but reconsolidation does gradually improve life over the long run. If you find yourself repeating these blissful experiences on subsequent sessions, I recommend refocusing on your stuck schemas. Repeat exposure likely has declining marginal return even if the love and ok-ness feel wonderful.

In my model, the first main activity in this phase is emotional activation of stuck schemas,⁵² a prerequisite for reconsolidation⁴². You’re “triggering” yourself. You can do this through

Often, a stuck schema is already activated. I think this is the case if you feel any anxiety, fear, anger, sadness, or grief, or are immobile.

The second main activity is staying present with, and leaning into, that distress. Personal experience, observations, and many anecdotal reports suggest that once you’re emotionally engaged and aren’t distracted, the MDMA usually reconsolidates the schema without any further action. Because of this, I think that therapeutic exercises that facilitate reconsolidation, like coherence therapy and acceptance and commitment therapy, likely won’t help beyond their function of activating or engaging with stuck schemas. Abstract thinking can also be a distraction unless your stuck schema remains emotionally activated and you are at least partially focused on it.

In my experience, people with complex trauma may spend the whole session quickly transitioning from one stuck schema to the next as each one reconsolidates.

As discussed in Chapter 3, stuck schemas are primarily composed of a belief like “if I move I will die” and an emotion like fear, anger, or sadness. Bodily expressions of that emotion may also be present, like bared teeth in rage. Episodic memories of related events are also often recalled. Schemas can also generate inaccurate perceptions of bodily sensations (e.g., pain, itching) and movement ability (e.g., an inability to make a certain movement when your body is physically capable of it).

You can notice a stuck schema is activated by the presence of one or more of these components. Since the stuck schemas addressed in therapy typically involve intense distress, you will also notice your attention focusing on the perceived threat. This may take the form of rumination or looking for the perceived threat.

Insightful thoughts about yourself, how trauma impacted you, and the human condition may arise. Spend time on them if they feel cathartic or important, particularly if you feel emotionally engaged rather than just intellectually interested. Otherwise, leave them until after the session.

Sometimes people shake, move in other ways, or vocally express intense fear/anger/sadness/etc. I don’t know what the shaking fundamentally is. It might be a flight-or-fight activated by putting attention on previously avoided sensations or memories. It might also be whatever is happening when people shake while crying in regular life. Unusual vocal expressions of intense emotion might be the natural expression of those emotions that comes out when people don’t try to suppress it or make it more socially palatable. Maintaining emotional engagement with the underlying schema should reconsolidate the schema and resolve any reactions it is causing.

Anecdotal reports indicate that some sessions focus primarily on somatic sensations without significant emotional engagement. Our framework does not clearly explain these sessions. People varyingly report them as helpful or unhelpful.

Barriers to Reconsolidation

You may feel what is called resistance. This could be simple avoidance of emotional pain because it is uncomfortable or schemas that say confronting/unlearning some schema is dangerous. While the protective function of these schemas may have been important at one point, they are now an impediment. I suggest focusing on the resistance schemas first if you can. Reconsolidating these will make the rest of your therapeutic efforts much easier, as you won’t have to fight against a part of your mind telling you to stop what you’re doing.

It is well-known that over-attachment to a specific therapeutic goal can impede progress. This might happen because reconsolidating certain schemas often depends on reconsolidating some other schema, sometimes one you are unaware of, first. People also frequently have inaccurate beliefs about what their issues are. Because of this, I recommend that if you don’t feel like you are making significant progress on your target issue, try noticing and focusing on any fear, anger, grief, anxiety, discomfort, or tension in your body or field of awareness. Reconsolidating that distress may be an “access point” to the whole knot of stuck schemas in your life.

Spiritual bypass is a trap people occasionally fall into. As Cashwell^{255, sec.
Spirituality and spiritual bypass defined} states, spiritual bypass “occurs when a person attempts to heal psychological wounds at the spiritual level only and avoids the important (albeit often difficult and painful) work at the other levels, including the cognitive, physical, emotional, and interpersonal.” For instance, you might feel that MDMA has allowed you to transcend your emotional limitations and that reconsolidation is no longer relevant. While genuine spiritual attainments seem possible²⁵⁶, and MDMA may occasionally facilitate them¹³⁷, Ingram²⁵⁶ doubts that transcending emotional limitations is possible. I suggest treating such beliefs as a sophisticated form of avoidance. Look for subtle feelings of fear while considering the possibility that your transcendence is not what you imagine it is.

Some people also feel that they are receiving a message from the medicine (e.g., “the medicine has done all it can do for me, and now I need to focus on some specific practical aspect of my life”)²⁵⁷. Many life changes are important for mental health. However, it may be difficult to distinguish whether such messages are a form of avoidance vs. actually needing to shift focus from reconsolidation to other changes. I suggest spending one more session looking for stuck schemas to see if MDMA really has done all it can for you.

If you feel “blankness, flat affect, nothingness, boredom, sleepiness, or sobriety,” you are likely dissociating (either unnoticed avoidance or opioid dampening in my opinion), according to Razvi⁸. Refer to Section 8.2 for more information.

Crisis Management

If you panic or are planning to imminently hurt someone or yourself, leaning into and staying present with those schemas as much as you can manage can reconsolidate them like it would for any stuck schema. If those schemas are too overwhelming to stay present with, more MDMA or another source of comfort, like holding the hand of a loved one or therapist, may help.

You can also call the Fireside Project hotline at +1 (623) 473-7433 if you require help and live in the United States, though they can’t support people considering suicide and presumably violent intent²⁵¹.⁵³ You could also use tripsit.me/webchat, a chatroom available anywhere.

You might also ask for help from your sitter or practitioner to keep yourself safe. Note that if the person with you is a licensed medical professional, they might call the police on you if you tell them about intense acute suicidal or violent desires. See Section 6.2 for more discussion of this. Involuntary hospitalization and police involvement carry a high risk of traumatizing you further and may actually significantly increase the medium-term risk of suicide and hurting someone else¹⁸⁵.

Therapy Hangover

People can only do so much reconsolidation in a day before they become emotionally exhausted. This is commonly called a therapy hangover, though a therapy hangover on MDMA may not feel like a regular psychotherapy hangover because the drug effects are also present. To my knowledge, the phenomenon hasn’t been formally studied. Personal experience and anecdotal reports suggest that it dissipates within a few hours to a couple of days. It can be the limiting factor for session length.

Personal experience suggests that higher doses facilitate faster reconsolidation and faster therapy hangover than lower doses. If you feel exhausted, I recommend staying with that feeling for as long as possible, since it may be difficult to distinguish between therapy hangover and opioid dampening. Furthermore, MDMA sometimes gives people a “second wind” of reconsolidation after a period of therapy hangover.

A Precaution Against Life-Altering Decisions

MDMA therapy can highlight aspects of your life that you want to change. However, immediately post-session, this new view can be unbalanced by other considerations. Your insight is very new, possibly not fully fleshed out, and you may be in afterglow, an altered state of consciousness. I suggest waiting at least until the afterglow ends so that you have had time to think it through and are back in your normal state of consciousness.

Troubleshooting

Numbness, Immobility, Heaviness, or Sleepiness

These are likely tonic/collapsed immobility. See Table 3.1 for a list of other symptoms and Section 8.2 for recommendations.

It’s also conceivable that some people have atypical reactions to MDMA, though I suggest working through the immobility recommendations first even if you suspect an atypical reaction. Feeling convinced that MDMA therapy doesn’t work for you is also a sign of immobility (presumably the schemas causing immobility rather than the immobility itself)²⁵⁷.

Note that emotional processing often stops after a few hours due to exhaustion (a therapy hangover). This isn’t a concern; it’s a sign of success. If you’re unsure whether you’re experiencing a therapy hangover vs. immobility, I recommend working through the immobility recommendations.

Soberness, Boredom, or No Emotional Processing

Distress is too Overwhelming to Stay Present with or Reconsolidate

Additional sources of safety may help. See the Increasing Safety list in Section 8.2.

Feeling too Blissful to Engage with Stuck Schemas

Adverse Effects Lasting up to Three Days

Adverse Effects Lasting More than Three Days

Not Getting to the Issue, Schema, or Memory You Want to Address

Symptoms Come Back After a Few Weeks

Still High More than 24 Hours Later

Feeling Like You are Going Crazy

These fears or anxieties are commonly stuck schemas rather than psychosis or mania, perhaps ones about self-control, altered states of consciousness, or drugs. I suggest focusing on those schemas to reconsolidate them.

There are almost no credible reports of a single standard-dose MDMA trip causing mania without major exacerbating circumstances (e.g., overdose, multi-drug abuse, back-to-back sessions) despite tens of millions of people using it over half a century (see Chapter 4). When it does happen, people usually have pre-existing bipolar disorder. Since delusion and poor self-awareness are inherent aspects of mania, the presence of fear or anxiety about being manic is strong evidence that you are not manic. The exception is some people with bipolar disorder who have learned their early-warning signs of manic episodes.

A single standard-dose MDMA therapy session can induce psychosis, but this is rare, especially for people without a personal history of psychosis or exacerbating circumstances like overdose, multi-drug abuse, or back-to-back sessions (see Chapter 4). If you think you are psychotic, or are unsure, and don’t have a skilled practitioner, I recommend calling the Fireside Project hotline at +1 (623) 473-7433 for a second opinion if you live in the United States²⁵¹.⁵⁴ You could also use tripsit.me/webchat, a chatroom available anywhere.

Substance-induced psychosis and mania usually dissipate without treatment, but occasionally don’t. If the symptoms are bearable, not worsening, and you retain intact reality testing, I suggest getting a few good nights’ sleep (with sleep aids if necessary) and then assessing again.

Sessions Feel Like They’re Becoming Less Effective Over Time

Insight into Selfhood, Existence, Reality, Suffering, or Spirituality

Some experiences—particularly meditation, psychedelics, and MDMA—can facilitate a particular set of durable, uncommon, experiential shifts^137,256. Many contemplative traditions (traditionally religious groups, but increasingly secular) frame these shifts—especially unity with God or non-duality, impermanence, and unsatisfactoriness—as important, positive, and potentially destabilizing²⁵⁶.⁵⁵ These traditions have established practices, largely different forms of meditation, for facilitating these shifts for those who want to walk that path and achieve contemplative attainments. People who inadvertently find themselves on that path face additional challenges since they have to figure out what’s happening and how to deal with it.

Those traditions often frame some challenging experiences as temporary (when properly handled) but legitimate periods in the longer path of contemplative development. Some other challenging experiences may not be considered part of the process; Lindahl²⁶⁰ discusses which are which. As Lindahl²⁶¹ discusses, “what is categorized as ‘progress’ versus ‘pathology’ may differ across traditions, lineages, or even teachers.” If your existentially disruptive experience reflects your most honest perceptions of yourself and the world, I suspect you will not be able to fully return to your prior state. Deliberate attention to the insight and its implications in daily life will facilitate high levels of integration of the new insight, whereas avoidance will tend to keep the insight poorly integrated. I also think that, as in healthy therapeutic relationships, your practice of integration should align with your goals, expectations, and autonomy. This alignment is a predictor of whether you will see challenging experiences as positive or negative²⁶¹.

Regardless of how you proceed, the most important thing is stabilization of adverse symptoms if they are overwhelming or preventing you from accomplishing critically important tasks in your life. Cheetah House²⁶³ specializes in helping people through this stabilization process. In addition, many practices aiming toward high levels of integration involve processing large amounts of existential distress²⁵⁶ that can be destabilizing, especially when done without proper practice or supportive teachers that respect your autonomy and goals²⁶¹. This may be difficult when mixed with mental illness, or it may be that existential distress is already intertwined with your mental illness in such a way that they can only be processed at the same time. Trauma-Sensitive Mindfulness: Practices for Safe and Transformative Healing by DavidA Treleaven⁵⁵ focuses heavily on ways of engaging with mindfulness practices that are fully respectful of autonomy, and I recommend it.

Below is a set of resources for dealing with spiritual emergencies that I have seen others endorse but have mostly not verified myself:

Here are several resources for integrating these existential insights; I have not read most of them but know they are well-regarded by a range of practitioners:

Non-Buddhist-inspired works are less common, and you may have to do some searching or find a teacher. There is the Christian movement of Centering Prayer, Sufi dhikr and muraqaba, Ecstatic/Prophetic Kabbalah and hitbonenut in Judaism, Jainism, zuowang and possibly neidan in Taoism, Rāja yoga, and Advaita Vedanta.

Afterglow

Some people experience an afterglow for days to weeks after some psychedelic sessions, characterized by well-being, positive mood, mindfulness, positive behaviors, and less mental illness²⁷².⁵⁶ Anecdotal reports indicate that MDMA therapy sometimes also induces a 1–2 week afterglow period and that conventional therapy is easier or more effective during afterglow.

Anecdotal reports also indicate that people sometimes chase afterglow with more frequent doses because they feel better during this period. I don’t recommend this because afterglow doesn’t reliably occur, and frequent use of MDMA may cause a few different problems described in Chapter 4. If you find yourself doing this, I suggest focusing on reconsolidation instead; it produces more durable effects.

Afterglow can occasionally be strong enough that it feels like a low dose of MDMA, as myself and one person I know have experienced. Both instances occurred after particularly profound initial MDMA experiences.

Assessing Whether the Session Worked

It’s not always clear whether a session was productive. There are a few ways to assess this:

Between Sessions

Transitioning from a state of mental illness to a state of mental health using reconsolidation often requires going through a series of in-between ups and downs (see Section 3.6). The intensity of this can be difficult for those with severe stuck schemas. This chapter covers tools to help manage this: grounding techniques, peer and professional support, and lifestyle changes associated with improved mental health. It also covers tools for additional reconsolidation. The chapter doesn’t suggest when you use these tools; that is left for you to figure out on your own for your unique situation.

Implicitly woven throughout this chapter is the process of making sense of your experience. Severe trauma and insecurity often create lifelong confusion about your symptoms, thoughts, sense of self, and childhood. Discovering the narrative of your experiences can help resolve this. Engaging with the activities in this section will help you gradually construct that narrative. The individuals in Robinson⁷ also recommended journaling about your experiences and reading educational material. This includes topics like trauma responses, attachment theory, the defense cascade, and schemas.

The suggestions in this chapter also support you in developing expertise on your mind, body, and healing through experimentation and self-education.

Reconsolidation Tools

Here are various practices and medicines I think are particularly useful.⁵⁷ These vary in how difficult they are to learn on your own without expert assistance.

LLM Therapy

People commonly use LLMs as therapists, trip sitters, or patient listeners. There is almost no research investigating how specific combinations of models and prompts compare to the quality and ethics spectrum of human therapists.⁵⁸ I suggest using something like the following prompt I developed based on quotes from^42,131. It performed well during the small amount of testing I did, but I haven’t thoroughly evaluated it in all scenarios it may be used in. You can swap out coherence therapy in the last paragraph for your preferred therapeutic framework, like acceptance and commitment, cognitive behavioral, or ideal parent figure method.

Please check your LLM provider’s data and privacy policies; it is almost certainly not as private as licensed human therapy conversations are, though they don’t have harmful mandatory reporting obligations for suicide (see Section 6.2). The “garbage in, garbage out” principle also applies to current LLMs. Thus, because LLM training data (most of the internet and most books) is full of inaccurate information about MDMA, LLMs tend to also output inaccurate information about MDMA. If you want to discuss MDMA therapy or its side effects, I suggest uploading this book to your LLM along with a prompt I developed in Section 2.1. That ensures the LLM has a high-quality base to work from.

Grounding Tools

Grounding brings attention to present-moment sensory experiences, which can connect you to your body and environment. Psychedelic practitioners²⁸⁰ and individuals experiencing prolonged post-psychedelic difficulties⁷ both recommend grounding as helpful in the healing process.

Among individuals experiencing prolonged post-psychedelic difficulties in Robinson⁷, the most reported helpful practices that I classify as grounding tools (each reported by $>10\%$ of participants), ranked by frequency, were

I suspect that grounding can either be immediately calming or facilitate reconsolidation depending on how it’s used. Using grounding to deactivate a stuck schema would be calming, whereas using grounding to juxtapose present-moment awareness with a stuck schema facilitates reconsolidation. It’s not clear how the participants in Robinson⁷ were using each technique. Each use delivers different outcomes. Calming helps you relax or sleep, which can be important, but don’t unlearn stuck schemas. Reconsolidation is difficult and tiring, but does unlearn stuck schemas.

Peer and Community Support

Peer and community support is highly recommended by both psychedelic therapy practitioners and individuals who have experienced prolonged post-psychedelic difficulties^7,280. When receiving emotional support, participants in Robinson⁷ most commonly reported the following aspects of support as helpful: talking and feeling heard, acceptance and validation, and sharing similar experiences.

The following support communities will likely understand what you are going through:

Local psychedelic and mental illness support groups are also available in many places. You might have to exercise caution about which friends, family, and mental illness support groups you open up to; hostility toward and misunderstanding of MDMA are widespread.

Medical/Psychiatric Support

Some individuals experiencing prolonged post-psychedelic difficulties in Robinson⁷ reported that psychiatric drugs were helpful. However, that recommendation did not meet the 10% reporting threshold that I’ve used to identify helpful tools in this chapter. Psychedelic therapy practitioners also sometimes recommend psychiatric drugs²⁸⁰.

Psychiatric medication is complex and largely outside the scope of this document.⁶¹ However, my view is that, for schema- and defense-cascade-based symptom worsening, conventional psychiatric medication’s clearest indication is short-term crisis management or occasional, as-needed support. For instance, sleep aids may be an important tool for reducing the risk of a manic episode after MDMA therapy for people with bipolar disorder if they can’t sleep.

Read Alexander¹⁸⁴ before seeking any psychiatric treatment; it discusses how voluntary hospitalization can easily turn into involuntary hospitalization and when discussing suicidal ideation or violent intent with a psychiatrist might be dangerous. As discussed in Section 6.2, involuntary commitment for suicidality or violent intent appears to increase the risk of suicide and violence¹⁸⁵. Because of that risk, cost, and the potential for traumatization in involuntary commitment, a psychiatrist’s office or mental health urgent care center is preferred over hospitalization if one is available.

I highly recommend specialist services over non-specialists who likely won’t understand MDMA therapy and what you’re going through, and who may misdiagnose you. Unfortunately, I only know of two specialized clinics (I haven’t vetted them), though you may be able to find individual physicians with the right skills and knowledge:

If you seek medical assessment from providers who don’t specialize in psychedelics, it is important to at least find a medical professional who understands the physical and psychological symptoms of trauma. It is ideal to find a medical professional who will anticipate and accommodate your trauma-related safety needs or at least be willing to listen and adapt. Unfortunately, many medical systems are severely overstressed. Medical professionals are frequently both undertrained on these topics and lacking the resources to effectively implement the understanding they do have. Additionally, many under-supported healthcare professionals are undergoing extended workplace trauma themselves, which does not necessarily lend itself to optimal participant care. As such, T.H. recommends taking a posture of firmly compassionate self-advocacy wherever possible. You deserve safe and trauma-informed care; whether you receive this care or not is not a reflection of what you deserve. You may wish to take notes about the symptoms you are experiencing or collect information (like Chapter 4) about the safety of MDMA to bring with you to your medical appointment; these measures can help you support your healthcare professionals in giving you the best quality of care possible.

Finally, check whether your medication is compatible with MDMA before doing another session (see Chapter 4).

Navigating Uncertain Memories

During MDMA therapy, you may feel you remembered traumatic events you weren’t previously aware of²²⁶. These may or may not be accurate recollections of historical events, and I am not aware of any reliable method of distinguishing a memory’s accuracy other than independent corroboration. To avoid incorrect interpretation of perceptions during the session, practitioners should categorically avoid suggesting a memory is either true or false and shouldn’t even suggest that you have memories that you can recover²²⁷.⁶² I recommend The Psychedelics and Recovered Memories Project²²⁶ for a nuanced guide on psychedelics and remembering previously forgotten memories.

Relatedly, stuck schemas not clearly related to specific remembered events often form in the period of childhood amnesia. While you may or may not eventually be able to understand where these schemas came from, they can be reconsolidated like any other.

T.H. thinks that Western culture prioritizes a continuous and linear narrative understanding of ourselves and our place in the world. This can further disempower survivors of trauma, especially childhood abuse, since the nature of memory often precludes clear and objective understandings of what exactly happened in our childhoods. The shame and taboo surrounding discussion of abuse—and the fact that many cultures condone some forms of child abuse (e.g. spanking)—further obscure what happened. In cases where abuse is extensively documented, survivors may face aggressive gaslighting and extended abuse in response to speaking up about their initial experiences. Even documented certainty about the actual events that happened is not always enough to endow survivors’ suffering with the legitimacy they are frequently seeking when they focus on the accuracy or inaccuracy of recovered memories.

So, given that you can never know for sure what actually happened, then what? And “what,” as it turns out, is that you still deserve compassion and healing. It can be reassuring to gather as much objective evidence as you can about your history. This can be a way of reclaiming what you can of your broken narrative, of knowing what is possible to know, and at least laying hold of it. And you may need to grieve a great deal, because frequently the evidence is very thin, and knowledge of your history is one of the things that was stolen from you. But your deservingness of healing does not depend on someone coming along and saying, “I have a video of you suffering a legitimate kind of suffering, so your pain is valid now.”

It may be helpful to explore the following questions, either by journaling on your own or by talking them through with a trusted/emotionally skilled friend or a clinician: What does it mean to me if X actually happened? What does it mean if Y happened instead, or Z? What does that say about my identity, my needs, how I perceive myself, and how others perceive me? What does it say about my future? What does it say about what I deserve?

Please be compassionate with yourself, as much as you possibly can. That your suffering is real and matters is a different question from what to do about it. Your pain is trustworthy, even if your memories are not. If you feel like you are suffering, that is real, and it matters.

Life Changes Associated with Improved Mental Health

Considerable low-quality evidence indicates that various changes in your daily life improve mental health. Most of this research was not adequately blinded and controlled, so the reported effects may be inaccurate. However, they are generally low-risk and have other positive effects. All of these items are part of the biopsychosocial complex system of mental health discussed in Section 3.6. That means that a certain intervention will have different effects for every individual and possibly different effects during different stages of the healing process.

Many of these topics are difficult to engage with for people with trauma and mental illness. Approach them as much as you feel comfortable.⁶³ I am not aware of any of these being necessary additions to MDMA therapy for improved mental health.

Health Habits and Practices

Relationships

While the effect of most of these items on mental health has not been rigorously studied, I think they are clearly good ideas.

Making Changes

Making healthy changes can be difficult for many reasons: stuck schemas, physical dependence on chemicals, easy access to unhealthy behaviors and substances, peer pressure, lack of community/family support for healthy habits, and poor access to better alternatives. None of these imply that there is anything fundamentally wrong with you.

Implementing and sticking with these changes can be a difficult but worthwhile long-term process with many ups and downs.

Core Assumptions

The following assumptions are the foundation of this book as I understand them. I list them as one step on the road of epistemic legibility and cooperation described by Nostrand³¹². My list might be missing some important assumptions that I either haven’t noticed or haven’t identified as critical. Note that I don’t have the deep expertise to fully evaluate the mechanism of action of these phenomena, instead relying on other researchers’ summaries, and different people will have significantly different assessments of how likely each of these assumptions is. I detail the evidence for each assumption here so that the relevant sections can focus on readable, practical explanations, and readers can see all my core assumptions in one place.

Complex Systems

The brain is a complex adaptive system whose most important elements include, but are not limited to, priors/schemas, attention, behavior, emotions, defense cascade activation, drugs, medical history, environment, genes, and sleep quality.

Most of the dysfunctional attractor states known as mental illness are largely caused by stuck priors/schemas, attention/avoidance, and defense cascade activation.

Complex system dynamics largely explain features of therapy like symptom worsening, sudden unforeseen improvement or worsening, and how mental illness is sometimes a stable state that doesn’t naturally resolve. Additionally, symptom worsening is usually part of the healthy process of therapy when managed well.

Sufficient further reconsolidation resolves symptom worsening (symptom fluctuation and stable symptom worsening), though the timeline is difficult to predict and there are unpredictable ups and downs.

Memory-Reconsolidation/Predictive-Processing

Reconsolidation is the updating of a set of priors encoded in long-term memory. Prediction error in memory research and predictive processing are a single phenomenon or different aspects of a single phenomenon.

Predictive processing priors, also known in therapeutic contexts as schemas in memory research, are the primary psychological elements of mental illness.

MDMA often facilitates memory reconsolidation when a stuck schema is emotionally activated and paid attention to.

MDMA doesn’t reconsolidate schemas that are fundamentally adaptive to the person’s current environment, though symptom worsening may impair important functioning.

Defense Cascade and Safety

Learned predictions or schemas can cause the sympathetic and parasympathetic nervous systems to activate arousal, flight-or-fight, freeze, and immobility, though the categorization of these states is up for debate and there are unexplained complexities.

Adverse symptoms persisting after the post-acute period are largely caused by shifts in the landscape of stuck schemas and defense cascade activation.

Acute physical injury from MDMA is almost always caused by mixing it with dangerous activities, certain other drugs, or certain medical conditions.

MDMA has a low risk of long-term physical problems when the precautions in Chapter 4 are followed.

MDMA does not directly cause significant post-acute cognitive issues with 2–3 mg/kg doses in therapeutic contexts.

Information for Practitioners

This section is a collection of things particularly relevant to therapists and guides that I’ve come across while writing this book. Note that this book does not substitute for high-quality training.

Skills

It is important for practitioners to effectively help their clients through various difficult experiences. Bender³²¹ surveyed psychedelic (not just MDMA) therapy practitioners about the most challenging experiences they have managed in clients across all types of psychedelics. These were, from most to least common and excluding categories only reported by a single respondent to ensure they represented at least somewhat of a consensus:

It’s important for practitioners to be proficient in identifying and successfully working with opioid dampening and panic during MDMA sessions (see Section 3.1 and Section 8.2).

Ethics

Maintaining especially high ethical boundaries is critical because MDMA can create intense feelings of trust and connection. Idealizing transference may also be intense (see Section 6.3 (Boundaries)). A number of practitioners have used psychedelics to abuse their clients^218,322.

Treatment

Evidence does not support phased treatment (a stabilization/resourcing phase preceeding reconsolidation)^323–325. Starting with reconsolidation is just as effective. It’s conceivable, but not established, that there are exceptions for cases of extreme dissociation.

Experience

Poulter³²⁶ recommends that personal experience with MDMA therapy is helpful but not necessary for therapists. Clients want to know that their practitioner understands what they will experience and how the process works. I think learning that via first-person experience is much more thorough and grounded than learning it secondhand. In my view, personal experience with MDMA-facilitated reconsolidation is also more helpful than experience with MDMA in other contexts.

Recommended Reading

Reports of Internalized MDMA Therapy

This next report is my informal interview with Anonymous (A). The interviewee explicitly consented to their answers being published in this book.

Mechanism of Action Hypotheses

I’ve developed several informal hypotheses for MDMA therapy’s mechanism of action and how some people internalize the process of MDMA therapy. The evidence I list is anecdotal and phenomenological; I am not aware of any experiments that convincingly inform these ideas.

In this section I switch from memory reconsolidation terminology to predictive processing terminology for precision. The predictive processing terms here are used as conceptual vocabulary rather than mathematically precise definitions. Hopefully these hypotheses are helpful for prompting more formalized investigation. A prior or collection of priors is roughly equivalent to a schema in this context. The precision of a prior or sensory information refers to its certainty, and updating is essentially reconsolidation in this context. Updating becomes significant when contradictory information is more precise than the prior.

I think any proposed mechanism of action needs to explain these facets of MDMA therapy:

With those constraints in mind, I propose the following hypotheses. The supporting and contradictory evidence only lists what initially came to mind. It is not comprehensive.

It’s not clear which of these are causes and which are effects. Perhaps they all combine to form a complex causal structure where cause and effect are not separable. They may also be just poorly understood conceptions of a single unified mechanism of action.

As described in Appendix C, people sometimes internalize the process of MDMA therapy. Sufficient exposure to the state, whichever mechanism is correct, creates a model of the experience or perception through a new set of priors. Individuals sometimes reactivate the new model they learned, typically via associative cues (e.g., music, meditation, tactile sensations) present during the MDMA therapy session. The cues don’t have to be physically present; high-fidelity imagination of the cues was sufficient in one case. If they realize what is happening, the individual may now know how to control the process.

Some people report using this state to update away stuck priors in the same way MDMA therapy can, though less intensely. Notably, one person reports that this process updates any stuck prior with none of the “overhead” associated with memory reconsolidation in conventional therapy. It also worked just as well in the presence of panic or dissociation, unlike traditional therapy. This is essentially the same process as MDMA therapy. Notably, for both individuals, the capacity for internalized MDMA therapy does not dissipate over time, like one might expect if it was a simple conditioned response.

I think the stillness⁷⁴ and “everything is ok just how it is” (anecdotal reports) that MDMA can facilitate are also strikingly reminiscent of the absence of Duḥkha, a Buddhist concept meaning unsatisfactoriness. In that model, a subtle identification with craving (a pull toward pleasant sensations) and aversion (a push away from unpleasant sensations), rather than mere preferences, creates a baseline level of suffering/Duḥkha. The involvement of identification also circles back to the Deidentification hypothesis. Perhaps MDMA can not only deidentify people from specific stuck schemas, but from craving and aversion themselves. See Subsection 8.4.12 for further discussion. Ingram¹³⁷ has also noticed a related link.

Alternatives to MDMA

Other drugs in the same class as MDMA may also be useful for therapy. The following are the most promising candidates that I’m aware of, though none have gone through as much safety and efficacy testing as MDMA.

Suggested Avenues of Future Research

I think the following research questions are particularly interesting or relevant to the practice of MDMA therapy.

Bibliography

Coray, R. C. et al. Memory deficits of MDMA users are linked to cortical thinning related to 5-HT receptor densities. Brain awaf391 (2025) doi:10.1093/brain/awaf391.

Luck, A. Polyvagal theory: A critical appraisal. https://alyssaluck.com/polyvagal-theory-a-critical-appraisal/ (2023).

Evans, J. Are you a psychedelic cultist? Ecstatic Integration https://www.ecstaticintegration.org/p/are-you-a-psychedelic-cultist (2025).

Mickelson, K. D., Kessler, R. C. & Shaver, P. R. Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology 73, 1092 (1997).

Godes, M., Lucas, J. & Vermetten, E. Perceived key change phenomena of MDMA-assisted psychotherapy for the treatment of severe PTSD: An interpretative phenomenological analysis of clinical integration sessions. Frontiers in Psychiatry 14, (2023).

Toebes, B. et al. MDMA. Beyond the Ecstasy. https://www.government.nl/site/binaries/site-content/collections/documents/2024/05/31/mdma-beyond-ecstasy/MDMA+Beyond+Ecstasy.pdf (2024).

Robinson, O. C. et al. Coming back together: A qualitative survey study of coping and support strategies used by people to cope with extended difficulties after the use of psychedelic drugs. Frontiers in Psychology 15, (2024).

Razvi, S. & Elfrink, S. The PSIP model. An introduction to a novel method of therapy: Psychedelic somatic interactional psychotherapy. Journal of Psychedelic Psychiatry 2, 1–24 (2020).

Friedwoman, L. et al. Psychedelic safety flags. https://docs.google.com/document/d/1lK2Rif24BAmJqqsLfUSkAVCO48IFNrGdysS2nI1EjZA (2025).

10.

Mitchell, J. M. et al. MDMA-assisted therapy for moderate to severe PTSD: A randomized, placebo-controlled phase 3 trial. Nature Medicine https://doi.org/10.1038/s41591-023-02565-4 (2023) doi:10.1038/s41591-023-02565-4.

11.

Slime Mold Time Mold. The mind in the wheel - prologue: Everybody wants a rock. Slime Mold Time Mold https://slimemoldtimemold.com/2025/02/06/the-mind-in-the-wheel-prologue-everybody-wants-a-rock/ (2025).

12.

Klaas, B. The crisis of zombie social science. The Garden of Forking Paths https://www.forkingpaths.co/p/the-crisis-of-zombie-social-science (2025).

13.

Briggs, R. Can we trust social science yet? Asterisk https://asteriskmag.com/issues/10/can-we-trust-social-science-yet (2025).

14.

Hoel, E. Neuroscience is pre-paradigmatic. Consciousness is why. The Intrinsic Perspective https://doi.org/10.32388/substack.2mwu0v (2024) doi:10.32388/substack.2mwu0v.

15.

Kotov, R. et al. The hierarchical taxonomy of psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology 126, 454 (2017).

16.

Leucht, S., Hierl, S., Kissling, W., Dold, M. & Davis, J. M. Putting the efficacy of psychiatric and general medicine medication into perspective: Review of meta-analyses. British Journal of Psychiatry 200, 97–106 (2012).

17.

Sørensen, A. Crossing Zero: The Art and Science of Coming Off — and Staying Off — Psychiatric Drugs. (Anders Sørensen, 2025).

18.

Jonas, E. & Kording, K. P. Could a neuroscientist understand a microprocessor? PLOS Computational Biology 13, e1005268 (2017).

19.

de-Wit, L., Alexander, D., Ekroll, V. & Wagemans, J. Is neuroimaging measuring information in the brain? Psychonomic Bulletin & Review 23, 1415–1428 (2016).

20.

Aliko, S., Wang, B., Small, S. L. & Skipper, J. I. The entire brain, more or less, is at work: ‘Language regions’ are artefacts of averaging. (2025) doi:10.1101/2023.09.01.555886.

21.

Padawer-Curry, J. A. et al. Psychedelic ${5-HT}_{2A}$ receptor agonism alters neurovascular coupling and differentially affects neuronal and hemodynamic measures of brain function. Nature Neuroscience 1–14 (2025) doi:10.1038/s41593-025-02069-z.

22.

Tackett, J. L., Brandes, C. M., King, K. M. & Markon, K. E. Psychology’s replication crisis and clinical psychological science. Annual Review of Clinical Psychology 15, 579–604 (2019).

23.

Etkin, A. A reckoning and research agenda for neuroimaging in psychiatry. American Journal of Psychiatry 176, 507–511 (2019).

24.

Feduccia, A. A., Jerome, L., Mithoefer, M. C. & Holland, J. RETRACTED ARTICLE: Discontinuation of medications classified as reuptake inhibitors affects treatment response of MDMA-assisted psychotherapy. Psychopharmacology 238, 581–588 (2021).

25.

Feduccia, A. A., Jerome, L., Mithoefer, M. C. & Holland, J. Retraction note: Discontinuation of medications classified as reuptake inhibitors affects treatment response of MDMA-assisted psychotherapy. Psychopharmacology vol. 241 2403 (2024).

26.

Jacobs, A. Three studies of MDMA treatment retracted by scientific journal. The New York Times https://www.nytimes.com/2024/08/12/health/mdma-ptsd-retractions.html (2024).

27.

Jacobs, A. & Nuwer, R. How a leftist activist group helped torpedo a psychedelic therapy. The New York Times https://www.nytimes.com/2025/02/04/health/fda-mdma-psychedelic-therapy-psymposia.html (2025).

28.

Yudkowsky, E. Avoiding your belief’s real weak points. https://www.lesswrong.com/posts/dHQkDNMhj692ayx78/avoiding-your-belief-s-real-weak-points (2007).

29.

Mitchell, J. M. et al. MDMA-assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine 27, 1025–1033 (2021).

30.

Author Redacted. Lykos Complete Response Letter. https://psychedelicalpha.com/wp-content/uploads/2025/09/CRL_NDA215455_20240808.pdf (2024).

31.

Psychedelic Alpha. Unpacking FDA’s MDMA rejection letter and the road ahead for lykos. Psychedelic Alpha https://psychedelicalpha.com/news/unpacking-fdas-mdma-rejection-letter-and-the-road-ahead-for-lykos (2025).

32.

Schenberg, E. Evidence-based medicine is inadequate to develop evidence-based psychedelic therapies. (2024) doi:10.31234/osf.io/rzdpm.

33.

Toebes, B. et al. MDMA state commission reports to Dutch parliament. (2024).

34.

Mustafa, R. et al. MDMA-Assisted Psychotherapy for Post-Traumatic Stress Disorder: Effectiveness and Value; Final Evidence Report. https://icer.org/assessment/ptsd-2024/#overview (2024).

35.

Yazar-Klosinski, B. Midomafetamine-assisted therapy (MDMA-AT) for treatment of post-traumatic stress disorder (PTSD). (2024).

36.

Liknaitzky, P. MDMA-assisted therapy for PTSD in veterans and first responders: Safety and efficacy in randomized, waitlist-controlled clinical trial. (2026).

37.

Passie, T. The History of MDMA. (Oxford University Press, 2023).

38.

Højlund, M. et al. Efficacy, all-cause discontinuation, and safety of serotonergic psychedelics and MDMA to treat mental disorders: A living systematic review with meta-analysis. European Neuropsychopharmacology 101, 41–55 (2025).

39.

Kolk, B. A. van der et al. Effects of MDMA-assisted therapy for PTSD on self-experience. PLOS One 19, e0295926 (2024).

40.

Liechti, M. Swiss limited use program. (2025).

41.

Engel, G. L. The need for a new medical model: A challenge for biomedicine. Science 196, 129–136 (1977).

42.

Ecker, B., Ticic, R. & Hulley, L. Unlocking the Emotional Brain: Memory Reconsolidation and the Psychotherapy of Transformational Change. (Taylor & Francis, 2024). doi:10.4324/9781003231431.

43.

Carvalho, A. F. et al. Evidence-based umbrella review of 162 peripheral biomarkers for major mental disorders. Translational Psychiatry 10, 152 (2020).

44.

Aftab, A. Psychiatric genetics. Psychiatry at the Margins https://www.psychiatrymargins.com/p/psychiatric-genetics (2025).

45.

Alexander, S. Missing heritability: Much more than you wanted to know. Astral Codex Ten https://www.astralcodexten.com/p/missing-heritability-much-more-than (2025).

46.

Alexander, S. The good news is that one side has definitively won the missing heritability debate. Astral Codex Ten https://www.astralcodexten.com/p/the-good-news-is-that-one-side-has (2025).

47.

Kozlowska, K., Walker, P., McLean, L. & Carrive, P. Fear and the defense cascade: Clinical implications and management. Harvard Review of Psychiatry 23, 263 (2015).

48.

Therapevo. The 5 pillars of attachment. https://therapevo.com/podcasts/the-5-pillars-of-attachment/ (2020).

49.

Lanius, R. A. et al. A review of the neurobiological basis of trauma-related dissociation and its relation to cannabinoid-and opioid-mediated stress response: A transdiagnostic, translational approach. Current Psychiatry Reports 20, (2018).

50.

World Health Organization. International classification of diseases, eleventh revision (ICD-11). https://icd.who.int/browse11 (2019).

51.

Lanius, U. F. in Neurobiology and treatment of traumatic dissociation: Towards an embodied self (eds Ulrich F. Lanius, S. L. P. & Corrigan, F. M.) (Springer Publishing Company, 2014).

52.

Britton, W. Dissociation and hyperarousal. https://www.cheetahhouse.org/hyperarousal-and-dissociation (2018).

53.

Ogden, P., Pain, C. & Fisher, J. A sensorimotor approach to the treatment of trauma and dissociation. Psychiatric Clinics 29, 263–279 (2006).

54.

Magyari, T. Teaching individuals with traumatic stress. in Resources for teaching mindfulness: An international handbook (eds McCown, D., Reibel, D. & Micozzi, M. S.) 339–358 (Springer, 2016). doi:10.1007/978-3-319-30100-6_18.

55.

Treleaven, D. A. Trauma-Sensitive Mindfulness: Practices for Safe and Transformative Healing. (WW Norton & Company, 2018).

56.

Clark, A. Surfing Uncertainty: Prediction, Action, and the Embodied Mind. (Oxford University Press, 2015).

57.

Brown, D. P. & Elliott, D. S. Attachment Disturbances in Adults: Treatment for Comprehensive Repair. (WW Norton & Company, 2016).

58.

Tippett, K. ‘Notice the rage; notice the silence’: Interview with Resmaa Menakem. On Being With Krista Tippett (2020).

59.

Ronca, K. E. The impact of complex post-traumatic stress disorder and structural violence on children in impoverished urban communities. (Temple University, 2018).

60.

Van den Bergh, O., Brosschot, J., Critchley, H., Thayer, J. F. & Ottaviani, C. Better safe than sorry: A common signature of general vulnerability for psychopathology. Perspectives on Psychological Science 16, 225–246 (2021).

61.

Alexander, S. Book review: Surfing uncertainty. Slate Star Codex https://slatestarcodex.com/2017/09/05/book-review-surfing-uncertainty (2017).

62.

Heidi priebe. Heidi Priebe https://www.youtube.com/@heidipriebe1 (2025).

63.

Alexander, S. The precision of sensory evidence. Slate Star Codex https://www.astralcodexten.com/p/the-precision-of-sensory-evidence (2021).

64.

Kolk, B. van der. The Body Keeps the Score. (Penguin Books, 2015).

65.

Hogeveen, J. & Grafman, J. Chapter 3 - alexithymia. in Disorders of emotion in neurologic disease (eds Heilman, K. M. & Nadeau, S. E.) vol. 183 47–62 (Elsevier, 2021).

66.

Woodhouse, S., Ayers, S. & Field, A. P. The relationship between adult attachment style and post-traumatic stress symptoms: A meta-analysis. Journal of Anxiety Disorders 35, 103–117 (2015).

67.

Bonanno, G. A. Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? Psychological Trauma: Theory, Research, Practice, and Policy https://doi.org/10.1037/1942-9681.S.1.101 (2008) doi:10.1037/1942-9681.S.1.101.

68.

Sotala, K. Book summary: Unlocking the emotional brain. https://www.lesswrong.com/posts/i9xyZBS3qzA8nFXNQ/book-summary-unlocking-the-emotional-brain (2019).

69.

Van den Bergh, O., Witthöft, M., Petersen, S. & Brown, R. J. Symptoms and the body: Taking the inferential leap. Neuroscience & Biobehavioral Reviews 74, 185–203 (2017).

70.

Hayes, A. M. & Andrews, L. A. A complex systems approach to the study of change in psychotherapy. BMC Medicine 18, (2020).

71.

Olthof, M. et al. Destabilization in self-ratings of the psychotherapeutic process is associated with better treatment outcome in patients with mood disorders. Psychotherapy Research 30, 520–531 (2020).

72.

Alexander, S. Mental mountains. Slate Star Codex https://slatestarcodex.com/2019/11/26/mental-mountains/ (2019).

73.

Rigg, K. K. & Sharp, A. Deaths related to MDMA (Ecstasy/Molly): Prevalence, root causes, and harm reduction interventions. Journal of Substance Use 23, 345–352 (2018).

74.

Stocker, K. & Liechti, M. E. Methylenedioxymethamphetamine is a connectogen with empathogenic, entactogenic, and still further connective properties: It is time to reconcile ‘the great entactogen—empathogen debate’. Journal of Psychopharmacology 38, 685–689 (2024).

75.

Kranenburg, R. F. et al. The influence of water of crystallization in NIR-based MDMA·HCl detection. Forensic Chemistry 32, 100464 (2023).

76.

Straumann, I. et al. Acute effects of R-MDMA, S-MDMA, and racemic MDMA in a randomized double-blind cross-over trial in healthy participants. Neuropsychopharmacology 50, 362–371 (2024).

77.

Farré, M. et al. Human pharmacology of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) after repeated doses taken 4 h apart human pharmacology of MDMA after repeated doses taken 4 h apart. European Neuropsychopharmacology 25, 1637–1649 (2015).

78.

Clauwaert, K. M., Van Bocxlaer, J. F. & De Leenheer, A. P. Stability study of the designer drugs ‘MDA, MDMA and MDEA’ in water, serum, whole blood, and urine under various storage temperatures. Forensic Science International 124, 36–42 (2001).

79.

Liechti, M. E., Gamma, A. & Vollenweider, F. X. Gender differences in the subjective effects of MDMA. Psychopharmacology 154, 161–168 (2001).

80.

Atila, C. et al. Oxytocin and the role of fluid restriction in MDMA-induced hyponatremia: A secondary analysis of 4 randomized clinical trials. JAMA Network Open 7, e2445278–e2445278 (2024).

81.

Colcott, J., Guerin, A. A., Carter, O., Meikle, S. & Bedi, G. Side-effects of MDMA-assisted psychotherapy: A systematic review and meta-analysis. Neuropsychopharmacology 49, 1208–1226 (2024).

82.

Studerus, E., Gamma, A. & Vollenweider, F. X. Psychometric evaluation of the altered states of consciousness rating scale (OAV). PLOS One 5, e12412 (2010).

83.

/r/ReagentTesting. Test kit suppliers. https://www.reddit.com/r/ReagentTesting/wiki/test_kit_suppliers (2025).

84.

/r/ReagentTesting. Testing labs. https://www.reddit.com/r/ReagentTesting/wiki/labs (2025).

85.

Borax. How to run an ‘acetone wash’ on MDMA to remove caffeine, leftover precursors and some other impurities. https://www.reddit.com/r/Borax/comments/pxccet/how_to_run_an_acetone_wash_on_mdma_to_remove/ (2022).

86.

feilong420. A user friendly purification guide - turn brown oily MDMA into beautiful white crystals! https://www.reddit.com/r/MDMA/comments/4a48iq/a_user_friendly_purification_guide_turn_brown/ (2016).

87.

Nair, J. B., Hakes, L., Yazar-Klosinski, B. & Paisner, K. Fully validated, multi-kilogram cGMP synthesis of MDMA. ACS Omega 7, 900–907 (2022).

88.

Miličević, M. P. et al. Volumetric properties, viscosity and taste behavior of MDMA-HCl in aqueous binary and (water+ D-lactose) ternary mixtures at different temperatures. The Journal of Chemical Thermodynamics 142, 106027 (2020).

89.

Tripsit. Volumetric dosing tool. https://volume.tripsit.me (2025).

90.

Studerus, E., Vizeli, P., Harder, S., Ley, L. & Liechti, M. E. Prediction of MDMA response in healthy humans: A pooled analysis of placebo-controlled studies. Journal of Psychopharmacology 35, 556–565 (2021).

91.

Bedi, G., Hyman, D. & Wit, H. de. Is ecstacy an ‘empathogen?’ Effects of 3,4-methylenedioxymethamphetamine on prosocial feelings and identification of emotional states in others. Biological Psychiatry 68, 1134–1140 (2010).

92.

Baggott, M. & Mendelson, J. Does MDMA cause brain damage? in Ecstasy: The complete guide (ed. Holland, J.) (Park Street Press, 2001).

93.

Baggott, M. Thoughts on taking supplements with MDMA. https://www.reddit.com/r/MDMA/comments/3r09sg/thoughts_on_taking_supplements_with_mdma/ (2015).

94.

Liechti, M. & Schmid, Y. Interactions with psychedelics and MDMA. https://saept.ch/wp-content/uploads/2026/03/interactions-with-Psychedelics-and-MDMA-V8-23.03.2026.pdf (2026).

95.

Schmid, Y. et al. CYP2D6 function moderates the pharmacokinetics and pharmacodynamics of 3,4-methylenedioxymethamphetamine in a controlled study in healthy individuals. Pharmacogenetics and Genomics 26, 397–401 (2016).

96.

De La Torre, R. et al. Non-linear pharmacokinetics of MDMA (‘ecstacy’) in humans. British Journal of Clinical Pharmacology 49, 104–109 (2000).

97.

Mithoefer, M. C., Wagner, M. T., Mithoefer, A. T., Jerome, L. & Doblin, R. The safety and efficacy of ±3,4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: The first randomized controlled pilot study. Journal of Psychopharmacology 25, 439–452 (2011).

98.

Vanattou-Saifoudine, N., McNamara, R. & Harkin, A. Caffeine provokes adverse interactions with 3,4-methylenedioxymethamphetamine (MDMA,‘ecstacy’) and related psychostimulants: Mechanisms and mediators. British Journal of Pharmacology 167, 946–959 (2012).

99.

Aguirre, N., Barrionuevo, M., Ramírez, M. J., Del Río, J. & Lasheras, B. Α-lipoic acid prevents 3,4-methylenedioxy-methamphetamine (MDMA)-induced neurotoxicity. Neuroreport 10, 3675–3680 (1999).

100.

Shankaran, M., Yamamoto, B. K. & Gudelsky, G. A. Ascorbic acid prevents 3,4-methylenedioxymethamphetamine (MDMA)-induced hydroxyl radical formation and the behavioral and neurochemical consequences of the depletion of brain 5-HT. Synapse 40, 55–64 (2001).

101.

Alves, E. et al. Acetyl-l-carnitine provides effective in vivo neuroprotection over 3,4-methylenedioximethamphetamine-induced mitochondrial neurotoxicity in the adolescent rat brain. Neuroscience 158, 514–523 (2009).

102.

Baggott, M. Mechanisms of MDMA tolerance and loss of magic. https://reddit.com/r/MDMA/comments/4wyjd9/mechanisms_of_mdma_tolerance_and_loss_of_magic/ (2016).

103.

Nutt, D., King, L. & Phillips, L. Drug harms in the UK: A multi-criterion decision analysis. Lancet 376, 1558–1565 (2010).

104.

Bonomo, Y. et al. The Australian drug harms ranking study. Journal of Psychopharmacology 33, 759–768 (2019).

105.

Crossin, R. et al. The New Zealand drug harms ranking study: A multi-criteria decision analysis. Journal of Psychopharmacology 37, 891–903 (2023).

106.

Jomova, K. et al. Several lines of antioxidant defense against oxidative stress: Antioxidant enzymes, nanomaterials with multiple enzyme-mimicking activities, and low-molecular-weight antioxidants. Archives of Toxicology 98, 1323–1367 (2024).

107.

Fiorentini, A. et al. Substance-induced psychoses: An updated literature review. Frontiers in Psychiatry 12, (2021).

108.

Dell, L. et al. Massed v. Standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial. Psychological Medicine 53, 7070–7077 (2023).

109.

Ehlers, A. et al. A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry 171, 294–304 (2014).

110.

Foa, E. B. et al. Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. JAMA 319, 354–364 (2018).

111.

Malcolm, B. Spirit pharmacist member resource and support program. https://www.spiritpharmacist.com (2025).

112.

Sarparast, A., Thomas, K., Malcolm, B. & Stauffer, C. S. Drug-drug interactions between psychiatric medications and MDMA or psilocybin: A systematic review. Psychopharmacology 239, 1945–1976 (2022).

113.

Malcolm, B. & Thomas, K. Serotonin toxicity of serotonergic psychedelics. Psychopharmacology 239, 1881–1891 (2022).

114.

O’Mathúna, B. et al. The consequences of 3,4-methylenedioxymethamphetamine induced CYP2D6 inhibition in humans. Journal of Clinical Psychopharmacology 28, 523–529 (2008).

115.

Flockhard, D. Drug interactions Flockhart table. https://drug-interactions.medicine.iu.edu/MainTable.aspx (2025).

116.

Edinoff, A. N. et al. Clinically relevant drug interactions with monoamine oxidase inhibitors. Health Psychology Research 10, (2022).

117.

Malcolm, B. Ayahuasca and drug interaction: The good, the bad, and the soul. https://pharmacy.uconn.edu/wp-content/uploads/sites/2740/2022/01/HO-2-slides-per-page-Ayahuosca-1.pdf (2023).

118.

Bracchi, M. et al. Increasing use of ‘party drugs’ in people living with HIV on antiretrovirals: A concern for patient safety. Aids 29, 1585–1592 (2015).

119.

Malcolm, B. Antidepressant and Psychedelic Drug Interaction and Taper Planning Guide. (2025).

120.

Multidisciplinary Association for Psychedelic Studies. MDMA Investigator’s Brochure. https://maps.org/wp-content/uploads/2022/03/MDMA-IB-14th-Edition-FINAL-18MAR2022.pdf (2022).

121.

Kraus, E. et al. Case report: Well-tolerated MDMA-assisted therapy in a 32-year old female patient with advanced alcohol-induced liver cirrhosis. Psychiatry Research Case Reports 4, 100252 (2025).

122.

Shokry, I. et al. Individuals with hyperthyroidism are more susceptible to having a serious serotonin syndrome following MDMA (Ecstasy) administration. Annals of Forensic Research and Analysis 5, 1052 (2018).

123.

Baggott, M. J. et al. MDMA impairs response to water intake in healthy volunteers. Advances in Pharmacological and Pharmaceutical Sciences 2016, 2175896 (2016).

124.

Valtin, H. and. ‘Drink at least eight glasses of water a day.’ Really? Is there scientific evidence for ‘8 x 8’? American Journal of Physiology-Regulatory, Integrative and Comparative Physiology 283, R993–R1004 (2002).

125.

Hew-Butler, T. et al. Statement of the second international exercise-associated hyponatremia consensus development conference, New Zealand, 2007. Clinical Journal of Sport Medicine 18, 111–121 (2008).

126.

Amsterdam, J. van, Brunt, T. M., Pierce, M. & Brink, W. van den. Hard boiled: Alcohol use as a risk factor for MDMA-induced hyperthermia: A systematic review. Neurotoxicity Research 39, 2120–2133 (2021).

127.

Freidel, N. et al. Psychedelics, epilepsy, and seizures: A review. Frontiers in Pharmacology 14, (2024).

128.

Droogmans, S. et al. Possible association between 3,4-methylenedioxymethamphetamine abuse and valvular heart disease. The American Journal of Cardiology 100, 1442–1445 (2007).

129.

Tagen, M. et al. The risk of chronic psychedelic and MDMA microdosing for valvular heart disease. Journal of Psychopharmacology 37, 876–890 (2023).

130.

Bartu, A., Dusci, L. J. & Ilett, K. F. Transfer of methylamphetamine and amphetamine into breast milk following recreational use of methylamphetamine. British Journal of Clinical Pharmacology 67, 455–459 (2009).

131.

Greenspace. Brief revised working alliance inventory. https://greenspacehealth.com/en-us/br-wai (2023).

132.

Flückiger, C., Del Re, A. C., Wampold, B. E. & Horvath, A. O. The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy 55, 316 (2018).

133.

Evans, J. et al. Extended difficulties following the use of psychedelic drugs: A mixed methods study. PLOS One 18, e0293349 (2023).

134.

Calder, A. E., Diehl, V. J. & Hasler, G. Traumatic psychedelic experiences. in Current topics in behavioral neurosciences (Springer Berlin Heidelberg, 2025). doi:10.1007/7854_2025_579.

135.

Evans, J. Can MDMA lead to extended difficulties? Ecstatic Integration https://www.ecstaticintegration.org/p/can-mdma-lead-to-extended-difficulties (2024).

136.

Holze, F. et al. Distinct acute effects of LSD, MDMA, and D-amphetamine in healthy subjects. Neuropsychopharmacology 45, 462–471 (2020).

137.

Ingram, D. https://www.ecstaticintegration.org/p/can-mdma-lead-to-extended-difficulties/comment/56645807 (2024).

138.

Martin, D. The ones who dream of tigers. in Breaking open (eds Evans, J. & Read, T.) (Aeon Books, 2020).

139.

Sitko, K., Bewick, B. M., Owens, D. & Masterson, C. Meta-analysis and meta-regression of cognitive behavioral therapy for psychosis (CBTp) across time: The effectiveness of CBTp has improved for delusions. Schizophrenia Bulletin Open 1, sgaa023 (2020).

140.

Goodman, D. A. MDMA in a severely disturbed man with psychosis, administered by his brother. https://maps.org/research-archive/mdma/edsstory.html (2003).

141.

/r/mdmatherapy. Can meditation ever be safe again after psychosis? https://reddit.com/r/mdmatherapy/comments/1mw061y/can_meditation_ever_be_safe_again_after_psychosis/ (2025).

142.

/r/mdmatherapy. Has anyone else had a psychotic break after using MDMA? https://reddit.com/r/mdmatherapy/comments/1n1pqw9/has_anyone_else_had_a_psychotic_break_after_using/ (2025).

143.

Winkel, R. van, Stefanis, N. C. & Myin-Germeys, I. Psychosocial stress and psychosis. A review of the neurobiological mechanisms and the evidence for gene-stress interaction. Schizophrenia Bulletin 34, 1095–1105 (2008).

144.

Sulstarova, A. et al. Treatment approaches and efficacy in psychedelic-induced psychosis: A systematic review. Asian Journal of Psychiatry 104604 (2025) doi:10.1016/j.ajp.2025.104604.

145.

Arnovitz, M. D. et al. MDMA for the treatment of negative symptoms in schizophrenia. Journal of Clinical Medicine 11, 3255 (2022).

146.

McGuire, P. & Fahy, T. Chronic paranoid psychosis after misuse of MDMA (‘ecstasy’). BMJ: British Medical Journal 302, 697 (1991).

147.

Patel, A. et al. Persistent psychosis after a single ingestion of ‘ecstasy’(MDMA). The Primary Care Companion for CNS Disorders 13, 27095 (2011).

148.

Vaiva, G. et al. An ‘accidental’ acute psychosis with ecstacy use. Journal of Psychoactive Drugs 33, 95 (2001).

149.

Sabé, M. et al. Reconsidering evidence for psychedelic-induced psychosis: An overview of reviews, a systematic review, and meta-analysis of human studies. Molecular Psychiatry 30, 1223–1255 (2025).

150.

Moncrieff, J. Does antipsychotic withdrawal provoke psychosis? Review of the literature on rapid onset psychosis (supersensitivity psychosis) and withdrawal-related relapse. Acta Psychiatrica Scandinavica 114, 3–13 (2006).

151.

Robledo, P., Balerio, G., Berrendero, F. & Maldonado, R. Study of the behavioural responses related to the potential addictive properties of MDMA in mice. Naunyn-Schmiedeberg’s Archives of Pharmacology 369, 338–349 (2004).

152.

Erowid. MDMA (also Ecstasy; Molly; adam; E; X) reports - addiction & habituation. https://www.erowid.org/experiences/subs/exp_MDMA_Addiction_Habituation.shtml (2024).

153.

Nutt, D. J., Lingford-Hughes, A., Erritzoe, D. & Stokes, P. R. The dopamine theory of addiction: 40 years of highs and lows. Nature Reviews Neuroscience 16, 305–312 (2015).

154.

Nicholas, C. R. et al. The effects of MDMA-assisted therapy on alcohol and substance use in a phase 3 trial for treatment of severe PTSD. Drug and Alcohol Dependence 233, 109356 (2022).

155.

Psychedelics in Recovery. Psychedelics in recovery. https://www.psychedelicsinrecovery.org (2025).

156.

Halpern, J. H., Lerner, A. G. & Passie, T. A review of hallucinogen persisting perception disorder (HPPD) and an exploratory study of subjects claiming symptoms of HPPD. in Behavioral neurobiology of psychedelic drugs (eds Halberstadt, A. L., Vollenweider, F. X. & Nichols, D. E.) 333–360 (Springer Berlin Heidelberg, Berlin, Heidelberg, 2018). doi:10.1007/7854_2016_457.

157.

Vizeli, P. & Liechti, M. E. Safety pharmacology of acute MDMA administration in healthy subjects. Journal of Psychopharmacology 31, 576–588 (2017).

158.

Litjens, R., Brunt, T., Alderliefste, G.-J. & Westerink, R. Hallucinogen persisting perception disorder and the serotonergic system: A comprehensive review including new MDMA-related clinical cases. European Neuropsychopharmacology 24, 1309–1323 (2014).

159.

Carhart-Harris, R. L. & Nutt, D. J. User perceptions of the benefits and harms of hallucinogenic drug use: A web-based questionnaire study. Journal of Substance Use 15, 283–300 (2010).

160.

Salvadore, G. et al. The neurobiology of the switch process in bipolar disorder: A review. The Journal of Clinical Psychiatry 71, 12633 (2010).

161.

KankaanpÄÄ, A., Meririnne, E., Lillsunde, P. & SeppÄlÄ, T. The acute effects of amphetamine derivatives on extracellular serotonin and dopamine levels in rat nucleus accumbens. Pharmacology Biochemistry and Behavior 59, 1003–1009 (1998).

162.

Bengt. Bipolar reaction: An experience with MDMA (Ecstasy) (Exp39866). https://erowid.org/exp/39866 (2006).

163.

Girl, B. Combined with psych meds: An experience with Ecstasy (MDMA), divalproex, venlaxafine, & risperidone (Exp27915). https://erowid.org/exp/27915 (2004).

164.

I<3Hallucinogens. https://www.bluelight.org/community/threads/mdma-and-bipolar-2-mood-disorder-nos.675952/#post-11552378 (2013).

165.

Lara, D. R. Caffeine, mental health, and psychiatric disorders. Journal of Alzheimer’s Disease 20, S239–S248 (2010).

166.

Makunts, T., Dahill, D., Jerome, L., Boer, A. de & Abagyan, R. Concomitant medications associated with ischemic, hypertensive, and arrhythmic events in MDMA users in FDA adverse event reporting system. Frontiers in Psychiatry 14, (2023).

167.

Malcolm, B. Healing states or serotonin toxicity? (2024).

168.

Liechti, M. E. Effects of MDMA on body temperature in humans. Temperature 1, 192–200 (2014).

169.

Fromson, N. When chest pain isn’t a heart attack. Health Lab https://www.michiganmedicine.org/health-lab/when-chest-pain-isnt-heart-attack (2023).

170.

Ruggeri, A. Natural doesn’t always mean better: How to spot if someone is trying to convince you with an ‘appeal to nature’. British Broadcasting Corporation https://www.bbc.com/future/article/20250210-the-appeal-to-nature-fallacy-why-natural-doesnt-always-mean-better (2025).

171.

United Nations Office on Drugs and Crime. World Drug Report. https://www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf (2014).

172.

European Union Drugs Agency. EU Drug Market: MDMA — in-Depth Analysis. https://www.euda.europa.eu/publications/eu-drug-markets/mdma_en (2025).

173.

Ecker, B. Memory reconsolidation understood and misunderstood. International Journal of Neuropsychotherapy 3, 2–46 (2015).

174.

Parrott, A. Chronic tolerance to recreational MDMA (3,4-methylenedioxymethamphetamine) or Ecstasy. Journal of Psychopharmacology 19, 71–83 (2005).

175.

Buchanan, B., Bartholomew, E., Smyth, C. & Hegarty, D. A comprehensive questionnaire for schemas related to psychopathology: The maladaptive schema scale - version 1.4 (MSSv1.4). https://novopsych.com.au/assessments/formulation/maladaptive-schema-scale-mss (2024) doi:10.17605/OSF.IO/C3UPR.

176.

Kaspian, P. MDMA Solo. (2024).

177.

Colbert, R. & Hughes, S. Evenings with Molly: Adult couples’ use of MDMA for relationship enhancement. Culture, Medicine, and Psychiatry 47, 252–270 (2023).

178.

Hills, J. Phenomenology of MDMA solo sessions. (Antioch University, 2023).

179.

TheraPsil. Understanding costs. https://therapsil.ca/understanding-costs/ (2026).

180.

Althea. How much does a legal psilocybin journey cost? And is it worth it? https://withalthea.com/2025/02/27/how-much-does-a-legal-psilocybin-journey-cost/ (2025).

181.

Psychedelic Passage. Mushrooms macrodose program. https://www.psychedelicpassage.com/macrodosing/ (2026).

182.

Thal, S., Engel, L. B. & Bright, S. J. Presence, trust, and empathy: Preferred characteristics of psychedelic carers. Journal of Humanistic Psychology https://doi.org/10.1177/00221678221081380 (2022) doi:10.1177/00221678221081380.

183.

Scoboria, A. et al. A mega-analysis of memory reports from eight peer-reviewed false memory implantation studies. Memory 25, 146–163 (2017).

184.

Alexander, S. Navigating and/or avoiding the inpatient mental health system. Slate Star Codex https://slatestarcodex.com/2018/03/22/navigating-and-or-avoiding-the-inpatient-mental-health-system/ (2018).

185.

Emanuel, N., Welle, P. & Bolotnyy, V. A Danger to Self and Others: Health and Criminal Consequences of Involuntary Hospitalization. https://www.newyorkfed.org/medialibrary/media/research/staff_reports/sr1158.pdf?sc_lang=en (2025).

186.

Firth, N., Saxon, D., Stiles, W. B. & Barkham, M. Therapist and clinic effects in psychotherapy: A three-level model of outcome variability. Journal of Consulting and Clinical Psychology 87, 345 (2019).

187.

Bartov, S. L. BetterHelp patients furious at ‘sketchy’ therapists. Newsweek https://www.newsweek.com/betterhelp-patients-tell-sketchy-therapists-1762849 (2023).

188.

Foisy, N. Is BetterHelp a scam? Unpacking the truth. (2024).

189.

Better Business Bureau. Customer reviews for Talkspace. https://www.bbb.org/us/ny/new-york/profile/mental-health-services/talkspace-0121-149740/customer-reviews (2024).

190.

Arshad, M. Struggling telehealth company exploited Adderall sales for profit, prosecutors say. USA Today https://www.usatoday.com/story/news/nation/2024/06/13/telehealth-execs-arrested-100-million-fraud-adhd/74091441007 (2024).

191.

Goldberg, S. B. et al. Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology 63, 1–11 (2016).

192.

Hook, J. & Devereux, D. Boundary violations in therapy: The patient’s experience of harm. BJPsych Advances 24, 366–373 (2018).

193.

Horvath, A. O., Del Re, A., Flückiger, C. & Symonds, D. Alliance in individual psychotherapy. Psychotherapy 48, 9 (2011).

194.

Macdonald, J. & Mellor-Clark, J. Correcting psychotherapists’ blindsidedness: Formal feedback as a means of overcoming the natural limitations of therapists. Clinical Psychology & Psychotherapy 22, 249–257 (2015).

195.

Delgadillo, J. et al. Progress feedback narrows the gap between more and less effective therapists: A therapist effects meta-analysis of clinical trials. Journal of Consulting and Clinical Psychology 90, 559 (2022).

196.

Lambert, M. J. et al. The effects of providing therapists with feedback on patient progress during psychotherapy: Are outcomes enhanced? Psychotherapy Research 11, 49–68 (2001).

197.

Oanes, C. J., Anderssen, N., Karlsson, B. & Borg, M. How do therapists respond to client feedback? A critical review of the research literature. Scandinavian Psychologist 2, (2015).

198.

Devereux, D. Transference love and harm. Therapy Today https://web.archive.org/web/20250408183730/https://www.bacp.co.uk/bacp-journals/therapy-today/2016/september/transference-love-and-harm/ (2016).

199.

Cohen, B. M. & Öngür, D. The need for evidence-based updating of ICD and DSM models of psychotic and mood disorders. Molecular Psychiatry 28, 1836–1838 (2023).

200.

Eaton, N. R. et al. A review of approaches and models in psychopathology conceptualization research. Nature Reviews Psychology 2, 622–636 (2023).

201.

Klein, E. A top mental health expert on where America went wrong. The Ezra Klein Show https://podcasts.apple.com/us/podcast/a-top-mental-health-expert-on-where-america-went-wrong/id1548604447 (2021).

202.

Sinback, L. How to get help. Making Polyamory Work https://www.makingpolyamorywork.com/episodes/how-to-get-help (2024).

203.

Aboujaoude, E. Where life coaching ends and therapy begins: Toward a less confusing treatment landscape. Perspectives on Psychological Science 15, 973–977 (2020).

204.

Miller, J. When therapists lose their licenses, some turn to the unregulated life coaching industry instead. Propublica https://www.propublica.org/article/utah-therapists-life-coaches-regulation (2024).

205.

Gutheil, T. G. Patients involved in sexual misconduct with therapists: Is a victim profile possible? Psychiatric Annals 21, 661–667 (1991).

206.

Williams, M. H. Victimized by victims: A taxonomy of antecedents of false complaints against psychotherapists. Professional Psychology: Research and Practice 31, 75 (2000).

207.

Celenza, A. Sexual boundary violations. https://www.andreacelenza.com/sexual-boundary-violations (2024).

208.

Carr, R. The end of coaching as we knew it. https://www.linkedin.com/pulse/end-coaching-we-knew-rey-carr (2011).

209.

Vinson, J. S. Use of complaint procedures in cases of therapist-patient sexual contact. Professional Psychology: Research and Practice 18, 159 (1987).

210.

Barsky, A. E. & Spadola, C. E. Licensing investigations: Suggestions from social workers who received sanctions. Social Work Research 47, 135–148 (2023).

211.

Dunlap, B., Basye, A. & Skillman, S. M. Background Checks and the Health Workforce: Practices, Policies and Equity. https://familymedicine.uw.edu/chws/wp-content/uploads/sites/5/2021/11/Background-Checks-FR-2021.pdf (2021).

212.

Cooke, D. J. & Michie, C. Refining the construct of psychopathy: Towards a hierarchical model. Psychological Assessment 13, 171 (2001).

213.

Mingus, M. Pods and pod mapping worksheet. https://batjc.wordpress.com/resources/pods-and-pod-mapping-worksheet (2016).

214.

Sinback, L. Business values. https://www.libbysinback.com/values (2024).

215.

Joseph, J. The role of coaching in mental health. https://www.healthygamer.gg/blog/the-role-of-coaching-in-mental-health (2022).

216.

Brach, T. Feeling overwhelmed? Try the RAIN meditation. https://www.mindful.org/tara-brach-rain-mindfulness-practice (2023).

217.

Meikle, S., Carter, O. & Bedi, G. Psychedelic-assisted psychotherapy, patient vulnerability and abuses of power. Australian & New Zealand Journal of Psychiatry 58, 104–106 (2024).

218.

Hall, W. Ending the silence around psychedelic therapy abuse. Mad in America https://www.madinamerica.com/2021/09/ending-silence-psychedelic-therapy-abuse/ (2021).

219.

Biaggio, M., Duffy, R. & Staffelbach, D. F. Obstacles to addressing professional misconduct. Clinical Psychology Review 18, 273–285 (1998).

220.

Strom-Gottfried, K. Professional boundaries: An analysis of violations by social workers. Families in Society 80, 439–449 (1999).

221.

McElrath, K. MDMA and sexual behavior: Ecstasy users’ perceptions about sexuality and sexual risk. Substance Use & Misuse 40, 1461–1477 (2005).

222.

Liknaitzky, P. Mental health professionals’ views and experiences. (2024).

223.

Quinn, D., Martinez, R., Cuentas, C., Hernandez-Wolfe, P. & Fine, C. Addressing abuse and repair: An open letter to the psychedelic community. https://psychedeliccommunity.medium.com/addressing-abuse-and-repair-an-open-letter-to-the-psychedelic-community-ccf677dd92b9 (2021).

224.

Brown, J. Ethical transgressions and boundary violations in ayahuasca healing contexts: A mixed methods study. (California Institute of Integral Studies, 2020).

225.

American Association of Sex Educators, Counselors, and Therapists. Code of conduct for AASECT certified members. (2020).

226.

The Psychedelics and Recovered Memories Project. The psychedelics and recovered memories project. https://psychedelicsandrecoveredmemories.com (2024).

227.

Otgaar, H., Mangiulli, I., Li, C., Jelicic, M. & Muris, P. The recovery and retraction of memories of abuse: A scoping review. Frontiers in Psychology 16, (2025).

228.

Power trip. Cover Story https://www.thecut.com/2021/11/cover-story-podcast-goes-into-world-of-psychedelic-therapy.html (2021).

229.

The Bump Editors. What is a birth plan and why is it important? https://www.thebump.com/a/tool-birth-plan#3 (2023).

230.

Brewer, J. The habit mapper. https://drjud.com/wp-content/uploads/2021/03/Unwinding-Anxiety-Habit-Mapper-from-DrJud-1-1.pdf (2024).

231.

Klein, E. Why We’re Polarized. (Simon; Schuster, 2020).

232.

Pinsof, D. The truth about self-deception. Optimally Irrational https://www.optimallyirrational.com/p/the-truth-about-self-deception (2024).

233.

Alexander, S. Trapped priors as a basic problem of rationality. Slate Star Codex https://www.astralcodexten.com/p/trapped-priors-as-a-basic-problem (2021).

234.

Galef, J. The Scout Mindset. (Penguin, 2021).

235.

McRaney, D. How Minds Change: The Surprising Science of Belief, Opinion, and Persuasion. (Portfolio, 2022).

236.

Singer, P. Animal Liberation: The Definitive Classic Renewed. (HarperCollins, 2023).

237.

Weisberg, J. The hard problem of consciousness. The Internet Encyclopedia of Philosophy https://iep.utm.edu/hard-problem-of-conciousness (2024).

238.

Sayre-McCord, G. Metaethics. in The Stanford encyclopedia of philosophy (eds Zalta, E. N. & Nodelman, U.) (Metaphysics Research Lab, Stanford University, 2023).

239.

Birch, J. The science of animal sentience: Sentience and the precautionary principle. (2021).

240.

Singer, P. Famine, affluence, and morality. in Applied ethics, a multicultural approach (ed. May, L.) 132–142 (Routledge, 2017).

241.

Andrews, K., Birch, J., Sebo, J. & Sims, T. Background to the New York declaration on animal consciousness. (2024).

242.

Scully, M. Dominion: The Power of Man, the Suffering of Animals, and the Call to Mercy. (macmillan, 2003).

243.

Birch, J. The Edge of Sentience: Risk and Precaution in Humans, Other Animals, and AI. (Oxford Academic, 2024).

244.

Rodriguez, L. & Harris, K. Jonathan Birch on the edge cases of sentience and why they matter. 80,000 Hours Podcast https://80000hours.org/podcast/episodes/jonathan-birch-edge-sentience-uncertainty/ (2024).

245.

Forstmann, M. et al. Among psychedelic-experienced users, only past use of psilocybin reliably predicts nature relatedness. Journal of Psychopharmacology 37, 93–106 (2023).

246.

Ritchie, H. Not the End of the World: How We Can Be the First Generation to Build a Sustainable Planet. (Hachette UK, 2024).

247.

Moonzwe, L. S., Schensul, J. J. & Kostick, K. M. The role of MDMA (Ecstasy) in coping with negative life situations among urban young adults. Journal of Psychoactive Drugs 43, 199–210 (2011).

248.

Hunt, G. P. & Evans, K. ‘The great unmentionable’: Exploring the pleasures and benefits of Ecstasy from the perspectives of drug users. Drugs: Education, Prevention and Policy 15, 329–349 (2008).

249.

Berro, L. F. et al. Acute effects of 3,4-methylenedioxymethamphetamine (MDMA) and R(-) MDMA on actigraphy-based daytime activity and sleep parameters in rhesus monkeys. Experimental and Clinical Psychopharmacology 26, 410 (2018).

250.

Emde, K. MDMA (Ecstasy) in the emergency department. Journal of Emergency Nursing 29, 440–443 (2003).

251.

Fireside Project. The psychedelic peer support line provides emotional support during and after psychedelic experiences. https://firesideproject.org (2023).

252.

Smookler, E. Beginner’s body scan meditation. https://www.mindful.org/beginners-body-scan-meditation (2023).

253.

Psychedelic Somatic Institute. PSIP therapist directory. https://www.psychedelicsomatic.org/find-a-psychedelic-therapist (2024).

254.

Mithoefer, M. & Mithoefer, A. MDMA. in Handbook of medical hallucinogens (eds Grob, C. S. & Grigsby, J.) 233–263 (The Guilford Press, 2021).

255.

Cashwell, C. S., Bentley, P. B. & Yarborough, J. P. The only way out is through: The peril of spiritual bypass. Counseling and Values 51, 139–148 (2007).

256.

Ingram, D. Mastering the Core Teachings of the Buddha: An Unusually Hardcore Dharma Book-Revised and Expanded Edition. (Red Wheel/Weiser, 2018).

257.

Razvi, S. Why MDMA & other psychedelic therapy may not work for you (part 1). https://www.psychedelicsomatic.org/post/why-mdma-psychedelic-therapy-may-not-work-for-you (2024).

258.

Yeager-Cordial, E., Ison, J., Becker, R., Boyd, C. & Weinstock, M. Psychiatric manifestations of organic disease: Don’t get fooled! Journal of Urgent Care Medicine 16, 11–15 (2022).

259.

First, M. B. Medical assessment of the patient with psychiatric symptoms. in Merck manual professional version (2026).

260.

Lindahl, J. R., Cooper, D. J., Fisher, N. E., Kirmayer, L. J. & Britton, W. B. Progress or pathology? Differential diagnosis and intervention criteria for meditation-related challenges: Perspectives from Buddhist meditation teachers and practitioners. Frontiers in Psychology 11, (2020).

261.

Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K. & Britton, W. B. The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in western Buddhists. PLOS One 12, e0176239 (2017).

262.

Canby, N. K. et al. The teacher matters: The role and impact of meditation teachers in the trajectories of Western Buddhist meditators experiencing meditation-related challenges. Contemporary Buddhism 25, 9–53 (2025).

263.

Cheetah House. Resources and support for adverse meditative experiences. https://www.cheetahhouse.org (2024).

264.

Lutkajtis, A. The Dark Side of Dharma: Meditation, Madness and Other Maladies on the Contemplative Path. (Aeon Books, 2021).

265.

Spiritual Emergence Network. Spiritual emergence network. https://www.spiritualemergence.org (2025).

266.

Integrative Mental Health University. Integrative mental health university. https://imhu.org (2025).

267.

American Center for the Integration of Spiritually Transformative Experiences. American center for the integration of spiritually transformative experiences. https://aciste.org (2025).

268.

Barford, D. Coping with mental health challenges on retreat. https://firekasina.org/2019/05/02/mental-health/ (2019).

269.

Kornfield, J. A Path with Heart: A Guide Through the Perils and Promises of Spiritual Life. (Bantam, 1993).

270.

Burbea, R. Seeing That Frees: Meditations on Emptiness and Dependent Arising: 10th Anniversary Edition. (Hermes Amāra Publications, 2025).

271.

Sayadaw, M. Manual of Insight. (Wisdom Publications, 2016).

272.

Evens, R., Schmidt, M. E., Majić, T. & Schmidt, T. T. The psychedelic afterglow phenomenon: A systematic review of subacute effects of classic serotonergic psychedelics. Therapeutic Advances in Psychopharmacology 13, 20451253231172254 (2023).

273.

Calder, A. E. & Hasler, G. Towards an understanding of psychedelic-induced neuroplasticity. Neuropsychopharmacology 48, 104–112 (2023).

274.

Nardou, R. et al. Oxytocin-dependent reopening of a social reward learning critical period with MDMA. Nature 569, 116–120 (2019).

275.

Lu, O. D. et al. A multi-institutional investigation of psilocybin’s effects on mouse behavior. (2025) doi:10.1101/2025.04.08.647810.

276.

The International Center for Ethnobotanical Education, Research, and Service. Assistance with challenging experiences. https://www.iceers.org/support-center-2 (2024).

277.

PsyAware. Need support? https://www.psyaware.org/need-support (2024).

278.

The Psychedelic Experience Clinic. Psychoanalytic psychotherapy after psychedelic experiences. https://www.thepsychedelicexperienceclinic.co.uk (2024).

279.

Coherence Psychology Institute. Coherence psychology institute referral directory. https://coherencetherapy.org/prac/directory-terms.php (2024).

280.

Argyri, E. K. et al. Practitioner perspectives on extended difficulties and optimal support strategies following psychedelic experiences: A qualitative analysis. Harm Reduction Journal https://doi.org/10.1186/s12954-025-01347-0 (2025) doi:10.1186/s12954-025-01347-0.

281.

Mithoefer, M. A Manual for MDMA-Assisted Psychotherapy in the Treatment of Posttraumatic Stress Disorder. (Multidisciplinary Association for Psychedelic Studies, 2017).

282.

Greater Good Science Center. Walking meditation. https://ggia.berkeley.edu/practice/walking_meditation (2025).

283.

Kabat-Zinn, J. This loving-kindness meditation is a radical act of love. https://www.mindful.org/this-loving-kindness-meditation-is-a-radical-act-of-love (2023).

284.

SHINE Collective. Support resources. https://www.shinesupport.org (2026).

285.

The Challenging Psychedelic Experiences Project. Online peer support group. https://challengingpsychedelicexperiences.com (2024).

286.

Huneke, N. T. M., Fusetto Veronesi, G., Garner, M., Baldwin, D. S. & Cortese, S. Expectancy effects, failure of blinding integrity, and placebo response in trials of treatments for psychiatric disorders: A narrative review. JAMA Psychiatry https://doi.org/10.1001/jamapsychiatry.2025.0085 (2025) doi:10.1001/jamapsychiatry.2025.0085.

287.

John Hopkins Medicine. Personalized psychiatry. https://www.hopkinsmedicine.org/personalized-care/personalized-psychiatry (2024).

288.

Alexianer St. Hedwig Hospital. The psychedelic substance outpatient clinic. https://www.alexianer-berlin-hedwigkliniken.de/st-hedwig-krankenhaus/leistungen/ambulante-behandlung/ambulanz-psychedelische-substanzen (2024).

289.

Rosenbaum, S., Tiedemann, A., Sherrington, C., Curtis, J. & Ward, P. B. Physical activity interventions for people with mental illness: A systematic review and meta-analysis. The Journal of Clinical Psychiatry 75, 14465 (2014).

290.

Lieberman, D. Exercised: Why Something We Never Evolved to Do Is Healthy and Rewarding. (Vintage, 2021).

291.

Lauersen, J. B., Bertelsen, D. M. & Andersen, L. B. The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine 48, 871–877 (2014).

292.

Low, S. R/bodyweightfitness recommended routine. https://www.reddit.com/r/bodyweightfitness/wiki/kb/recommended_routine (2023).

293.

Scott, A. J., Webb, T. L., Martyn-St James, M., Rowse, G. & Weich, S. Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials. Sleep Medicine Reviews 60, 101556 (2021).

294.

Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M. & Cunnington, D. Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine 163, 191–204 (2015).

295.

Stanford Medicine. Cognitive behavioral therapy for insomnia. https://stanfordhealthcare.org/medical-treatments/c/cognitive-behavioral-therapy-insomnia/procedures.html (2024).

296.

Moon, E., Kim, K., Partonen, T. & Linnaranta, O. Role of melatonin in the management of sleep and circadian disorders in the context of psychiatric illness. Current Psychiatry Reports 24, 623–634 (2022).

297.

Siskind, S. Melatonin. https://lorienpsych.com/2020/12/20/melatonin/ (2020).

298.

Dominski, F. H. et al. Effects of air pollution on health: A mapping review of systematic reviews and meta-analyses. Environmental Research 201, 111487 (2021).

299.

Clean Air Kits. Sizing guide. https://www.cleanairkits.com/pages/sizing (2025).

300.

Clean Air Kits. Did CleanAirKits just break EnergyStar for room air cleaners? https://www.cleanairkits.com/blogs/news/did-cleanairkits-just-break-energystar-for-room-air-cleaners (2025).

301.

Grajek, M. et al. Nutrition and mental health: A review of current knowledge about the impact of diet on mental health. Frontiers in Nutrition 9, (2022).

302.

Willett, W. et al. Food in the anthropocene: The EAT-Lancet commission on healthy diets from sustainable food systems. Lancet 393, 447–492 (2019).

303.

Goyal, M. et al. Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Internal Medicine 174, 357–368 (2014).

304.

Gottman, J. M. The Science of Trust: Emotional Attunement for Couples. (WW Norton & Company, 2011).

305.

Rosenberg, M. Nonviolent Communication: A Language of Life. (Puddledancer, 2015).

306.

Mingus, M. The four parts of accountability & how to give a genuine apology. Leaving Evidence https://leavingevidence.wordpress.com/2019/12/18/how-to-give-a-good-apology-part-1-the-four-parts-of-accountability (2019).

307.

Barnard Center for Research on Women. Building accountable communities. https://bcrw.barnard.edu/building-accountable-communities (2020).

308.

Grenny, J., Patterson, K., McMillan, R., Switzler, A. & Gregory, E. Crucial Conversations: Tools for Talking When Stakes Are High. (McGraw Hill, 2022).

309.

Kennedy, B. Good Inside: A Guide to Becoming the Parent You Want to Be. (HarperCollins, 2022).

310.

Kondo, M. What is the KonMari method? https://konmari.com/about-the-konmari-method (2026).

311.

Mattick, R., Breen, C., Kimber, J. & Davoli, M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews https://doi.org/10.1002/14651858.CD002207.pub4 (2014) doi:10.1002/14651858.CD002207.pub4.

312.

Nostrand, E. V. Epistemic legibility. https://www.lesswrong.com/posts/jbE85wCkRr9z7tqmD/epistemic-legibility (2022).

313.

Aizenbud, I. et al. Neural mechanisms of predictive processing: A collaborative community experiment through the OpenScope program. (2026) doi:10.48550/arXiv.2504.09614.

314.

Clark, J. E., Watson, S. & Friston, K. J. What is mood? A computational perspective. Psychological Medicine 48, 2277–2284 (2018).

315.

Lane, R. D., Ryan, L., Nadel, L. & Greenberg, L. Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science. Behavioral and Brain Sciences 38, e1 (2015).

316.

Elsey, J. W., Ast, V. A. van & Kindt, M. Human memory reconsolidation: A guiding framework and critical review of the evidence. Psychological Bulletin 144, 797 (2018).

317.

Feduccia, A. A. & Mithoefer, M. C. MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? Progress in Neuro-Psychopharmacology and Biological Psychiatry 84, 221–228 (2018).

318.

Hunt, G. P. & Evans, K. ‘The great unmentionable’: Exploring the pleasures and benefits of ecstacy from the perspectives of drug users. Drugs: Education, Prevention and Policy 15, 329–349 (2008).

319.

Wolfgang, A. S. et al. MDMA and MDMA-assisted therapy. American Journal of Psychiatry 182, 79–103 (2025).

320.

Halpern, J. H. et al. Residual neurocognitive features of long-term Ecstasy users with minimal exposure to other drugs. Addiction 106, 777–786 (2011).

321.

Bender, D. A. et al. Provider perspectives on challenges in treatment during psychedelic therapy. Psychopharmacology 1–8 (2025) doi:10.1007/s00213-025-06907-7.

322.

Davidson, T. & Plesa, P. Break on through: Betty Eisner’s problematic use of psychedelics, groups, and control for integrative experiences. Journal of the History of the Behavioral Sciences 61, e70027 (2025).

323.

Sele, P., Hoffart, A., Cloitre, M., Hembree, E. & Øktedalen, T. Comparing phase-based treatment, prolonged exposure, and skills-training for complex posttraumatic stress disorder: A randomized controlled trial. Journal of Anxiety Disorders 100, 102786 (2023).

324.

Oprel, D. A. C. et al. Effect of prolonged exposure, intensified prolonged exposure and STAIR+prolonged exposure in patients with PTSD related to childhood abuse: A randomized controlled trial. European Journal of Psychotraumatology 12, 1851511 (2021).

325.

Vliet, N. I. van et al. Phase-based treatment versus immediate trauma-focused treatment for post-traumatic stress disorder due to childhood abuse: Randomised clinical trial. BJPsych Open 7, e211 (2021).

326.

Poulter, B. & Ot’Alora, M. The art of simmering in MDMA-assisted therapy. (2023).

327.

Carhart-Harris, R. L. & Friston, K. J. REBUS and the anarchic brain: Toward a unified model of the brain action of psychedelics. Pharmacological Reviews 71, 316–344 (2019).

328.

Emilsson, A. G. The phenomenology of MDMA: Self-honesty, authenticity, & the unraveling of gnarly knots in the field. Andrés Gómez Emilsson https://www.youtube.com/watch?v=86nyhA5Fsh0 (2023).

329.

Jones, A. et al. Efficacy and safety of the neuroplastogen TSND-201 for the treatment of PTSD: A randomized clinical trial. JAMA Psychiatry https://doi.org/10.1001/jamapsychiatry.2025.4625 (2026) doi:10.1001/jamapsychiatry.2025.4625.

330.

Baggott, M. Beyond Ecstasy: Progress in developing and understanding a novel class of therapeutic medicine. (2023).

331.

Erowid. 5-MAPB dose. https://erowid.org/chemicals/5-mapb/5-mapb_dose.shtml (2026).

332.

Borax. The MDMA experience can be replicated with less neurotoxicity using unscheduled compounds. Here’s how. https://www.reddit.com/r/Drugs/comments/224llv/the_mdma_experience_can_be_replicated_with_less/ (2014).

Strong, unnoticed avoidance of my emotions was also part of the reason I didn’t understand my mental illness.↩︎
Much of my motivation was attachment issues and CPTSD, but these schemas can occasionally be redirected to productive uses.↩︎
Babble is a term for explanations that are superficially scientific but actually poorly supported, like polyvagal theory². They often serve the function of illness myths that justify subjective suffering in a way that is congruent with a culture’s beliefs about what illnesses are valid and which aren’t.↩︎
Positive emotions may not be noticeable during the session if strong fear, anger, other distressing emotions, avoidance, or opioid dampening are also present. This isn’t necessarily an issue; the process can still work well in these instances.↩︎
I used a script to automatically link the first occurrences of glossary terms in each section to the glossary. This process may have resulted in an occasional, inappropriately linked term.↩︎
The page range instruction excludes the gossary, appendices, and bibliography. Reducing the file size improves LLM output quality and gives you more responses before hitting usage limits.↩︎
I added the warning against conventional wisdom because without it Claude would constantly mix in poor-quality information it picked up from the internet and mainstream mental health resources that haven’t the slightest clue how MDMA therapy works. I don’t want to discourage you from using other high-quality resources.↩︎
I still cite the retracted study Feduccia²⁴. The journal claims it was retracted because of three reasons^25,26. The first was that the authors did not remove one participant’s data from the data set despite one of the therapists sexually abusing them. The second is that the authors did not inform the journal of the abuse. The third reason appears to be that the authors listed their conflicts of interest under the Funding section instead of a dedicated Conflicts of Interest section.

I still cite the paper because removing one data point out of 50 would not significantly affect the results, and the third issue appears to be a negligible formatting mistake. I don’t know the significance of the second. The retraction was also part of a highly contested set of events reported by Jacobs²⁷. It’s unclear why the paper was retracted instead of corrected.↩︎
The Dutch State Commission maintained their position even after the FDA’s non-approval³³.↩︎
Cohen’s d↩︎
That definition of confidence intervals is a simplification. The technically accurate definitions are unintuitive and complicated.↩︎
I use the taxonomy of Kozlowska⁴⁷. Other sources categorize the states differently, but the general pattern of an active, sympathetic state; a passive, parasympathetic state; and a mixed state is similar.↩︎
This decription of trauma is a simplification of why something is traumatic for one person but not for another. The next section covers this topic more thoroughly.↩︎
Memory reconsolidation researchers and predictive processing researchers formally define prediction error differently. To my knowledge, no one has formally shown that they are the same thing despite the plain-language descriptions of both phenomena being nearly indistinguishable. I assume in this book that reconsolidation is the updating of a set of priors encoded in long-term memory. See Appendix A for further discussion.↩︎
It’s not clear to me whether intense schemas needing multiple sessions are actually one schema or multiple closely related schemas. The difference is theoretically interesting but not practically important, in my opinion.↩︎
For consistency, I use the term reconsolidation instead of prior updating that VandenBergh⁶⁹ prefers. As discussed in Appendix A, I think reconsolidation is one type of prior updating.↩︎
Deep avoidance also creates dissociation, the “involuntary disruption or discontinuity in the normal integration of one or more of the following: identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, or behaviour” ^{50, sec. Dissociative
disorders}.↩︎
I treat priors/schemas as critical elements of the complex system of mental illness, on the following reasoning. First, conceptualizing mental health and illness as complex adaptive system attractor states is increasingly well established⁷⁰. Second, individual schemas/priors are core components of many mental illnesses⁴². Therefore, schemas/priors are core elements of that complex system. Another component, avoidance, is widely recognized in clinical practice as central to the maintenance of mental illness.↩︎
The number 240 is extremely imprecise, but as described below, there isn’t any better data.↩︎
I use the terms psychosis and mania in this article rather than terms like schizophrenia and bipolar on the assumption that they are closer to natural kinds, and more predictive of risk, than DSM/ICD diagnoses.↩︎
MDMA HCl crystals are also usually hydrated; they absorb small amounts of water from the air and production process⁷⁵. In my understanding, illegal MDMA is measured based on the hydrated mass instead of the pure MDMA HCl mass.↩︎
Borax⁸⁵ recommends that lower quality MDMA with more impurities can frequently be salvaged by washing out the impurities with acetone if the crystals/powder “have an obvious brown colour, appear wet and sticky, under 80% concentration of MDMA hydrochloride or have a strong smell.” See Borax⁸⁵ for instructions.↩︎
You can also filter out the insoluble fillers and binders while the MDMA is dissolved in hot anhydrous isopropyl alcohol. See feilong420⁸⁶.↩︎
Kranenburg⁷⁵ and Nair⁸⁷ tentatively suggest that most of this hydrated MDMA has 1 water molecule per MDMA molecule. You would increase your dose by 8% to correct for this. You can also dry your MDMA in an oven set to 100 °C (212 °F) for a few hours and then measure out a dose immediately afterward. The second method is more precise, since not all MDMA may have a 1:1 molecular ratio.↩︎
MDMA is extremely bitter⁸⁸. It may be nice to chase it with fruit.↩︎
M. Liechti, personal communication, December 11, 2025, clarified that 200 mg is the maximum total dose, not a maximum initial dose. It also only applies to individuals with higher body masses, though specifics weren’t mentioned.↩︎
I think oxidative stress is likely related to the area under curve (AUC) rather than peak concentration.↩︎
It’s conceivable that a booster dose could push someone through their single-dose therapy hangover limit, but that would also result in even higher levels of post-session therapy hangover.↩︎
I don’t think using antioxidant supplements to do more frequent sessions is wise because the oral dose of antioxidants humans need to prevent oxidative damage is unknown⁹³. It’s not even established that it’s possible or safe to get antioxidant plasma concentrations high enough using oral dosing. The studies demonstrating antioxidant protection injected rats with massive doses, though that was to protect against similarly massive doses of MDMA.↩︎
I used this prompt:

Give me two 95% confidence intervals for how long the brain’s antioxidant buffer takes to replenish after a single dose of MDMA, assuming no hyperthermia. The first CI is for a dose large enough to use up all the buffer but not any more. The second CI is for doses that exceed the buffer. The research on MDMA oxidation is scarce, so you’ll have to extrapolate some from other research. I’ve attached a primer [Jomova¹⁰⁶] on the endogenous antioxidant system as a reliable starting place.

The report is available here.

It reported 0.5–7 days for full replenishment after complete buffer depletion and 3 days to 8 weeks to recover from buffer-exceeding doses that cause damage. The latter interval doesn’t necessarily imply that all damage has been reversed, just that the antioxidant buffers have been restored. Furthermore, Claude bumped up the first interval to 2–10 days when I asked it to investigate the differences between the Opus 4.6 and 4.7 reports.

These are not real confidence intervals; they are the LLM’s guesstimates. I did try a few different prompts with the research functions of five different LLMs (Gemini 3.0 thinking, Claude 4.5/4.6/4.7 Opus thinking, and ChatGPT 5.2 prompted to think hard). All the reports suggested spans from a few days to a few weeks. The numbers reported above came from the run that I judged was the most rigorous.↩︎
Using twice the upper end adds protection for people with exacerbating circumstances, like poor CYP2D6 metabolic capacity, other interfering drugs, and poor nutrition.↩︎
The sparsity of data means that well-informed people with different risk tolerances and starting assumptions will disagree on what a reasonable starting spacing is.↩︎
The Precision of Sensory Evidence by Scott Alexander⁶³ provides a more accessible summary of VandenBergh⁶⁰.↩︎
One half-life is the time it takes for a drug’s concentration in your body to decrease by half. Each drug has a different half-life, which can be found on DrugBank under Pharmacology → Metabolism. So the concentration would be 50% after one half-life, 25% after two, etc.↩︎
Blood pressure and heart rate are averaged values from the 2nd and 3rd sessions. I excluded the 1st session because it used a different dose.↩︎
I suspect that benign premature ventricular or atrial contractions are compatible since ~50% of people have them but I haven’t been able to confirm this.↩︎
The addiction pharmacology of these substances might share enough similarities with MDMA to warrant caution¹⁵³. Other classes of addictive substances have different addiction pathways.↩︎
I searched for the terms “manic” and “mania” on reddit.com/r/mdma, reddit.com/r/mdmatherapy, erowid.org, and bluelight.org and read every result, or in the case of bluelight.org, read every search result snippet. There were a few additional reports on bluelight.org where people said that MDMA worsened their manic-depressive symptoms, but it wasn’t clear that the manic symptoms in particular were worsened.↩︎
Malcolm¹⁶⁷ further discusses these criteria, but the author lists a lower temperature threshold in this document for unexplained reasons. The 100 °F threshold of danger is implausibly low; a moderate dose of MDMA alone can raise body temperature that high, and it is not dangerous¹⁶⁸.↩︎
T.H.’s experience includes some common knowledge of professional norms among the licensed mental health professions, much of which can be found in the ethics codes of the major licensed mental health professions. These include codes of ethics from the National Association of Social Workers, American Psychological Association, American Counseling Association code of ethics, American Association for Marriage and Family Therapy, etc.↩︎
For the purposes of this section, unlicensed does not referring to pre-professionals and pre-licensed professionals who are operating under the license of an independently licensed professional as part of their training progression. Examples would include a resident counselor or psychologist. In terms of accountability and ethics enforcement, T.H. feels comfortable recommending this class of providers at the same level as independently licensed professionals.↩︎
“Studies generally show remarkable consistency in age, gender, and practice characteristics in that the typical transgressor [of sexual relationships with clients] is a middle-aged male therapist in solo private practice who engages in a sexual dual relationship with one female patient” (Celenza²⁰⁷).↩︎
Accountability pods are a practice developed by the Bay Area Transformative Justice Collective. See Mingus²¹³.↩︎
People who retract claims of recovering accurate memories of abuse overwhelmingly blame their therapist for improperly influencing them²²⁷.↩︎
Conscious experience means having subjective experience, not necessarily having self-reflection.↩︎
The previous prompts were designed to activate stuck schemas that almost always have negative consequences. This section is different; not everyone may have a fundamental need to connect to nature. If you don’t, any stuck schemas preventing you from connecting with it may not have negative consequences.↩︎
MDMA seems to deactivate cravings, so you’re left with the actual present-moment sensations of eating, which are unpleasant for many foods.↩︎
Razvi⁸ doesn’t frame the process in terms of reconsolidation, but I think it is clearly facilitating reconsolidation.↩︎
I speculate that each wave is the activation and reconsolidation of an individual schema that produces opioid dampening.↩︎
Godes⁵ also lists common self-reported experiences of MDMA therapy clients: staying with what “is”; decreased reactivity; insight, reflection, linking; mental clarity; recovery of traumatic memories; disentangling trauma from self; reuniting lost affects and parts; self-acceptance; joy, happiness, gratitude; hope and empowerment; relaxation, calmness, peace; comfort; gratitude, compassion, empathy; union, wider perspective; inner healing intelligence [the therapeutic framework used in this study]; accessibility to emotions; and mind-body connection.↩︎
MDMA is known for exceptional feelings of love, and I suggest refraining from telling anyone how much you love them unless that is an established norm in your relationship.↩︎
Some people think insight is the primary goal during MDMA therapy, but I disagree. Insight is important for conventional psychotherapy, where it’s often helpful to know what the schema is before you reconsolidate it⁴². I don’t think this is critical in MDMA therapy, where you can skip straight to reconsolidation without knowing what the schema is first. In my experience, insight can be gained through post-session reflection. This reserves scarce session time for difficult reconsolidation.↩︎
I couldn’t find any services similar to²⁵¹ in other countries.↩︎
I couldn’t find any services similar to²⁵¹ in other countries.↩︎
The fact that multiple traditions describe similar paths of contemplative development suggests that there is an overlapping set of underlying changes²⁵⁶. This presumably consists of major changes to networks of schemas that model self, agency, permanence, consciousness, and how those all relate to perception and reality. Each tradition then interprets these changes within their own religious framework.↩︎
Psychedelics induce periods of post-session neuroplasticity that may explain this phenomenon, though this remains untested for MDMA²⁷³. Nardou²⁷⁴ measured a certain type of increased neuroplasticity following MDMA dosing in mice. However, that lab’s similar results with psilocybin failed to replicate in a large multi-site replication effort, calling their MDMA results into question as well²⁷⁵.↩︎
I’ve noticed in my practice that you don’t have to experience a therapy hangover for very long if you reconsolidate right before going to sleep. It’s gone by the morning.↩︎
My understanding is that as of 2026, Anthropic (who makes Claude), leads other frontier LLM developers in prioritizing ethics and safety and avoiding incentives to enshittify their product.↩︎
Different types of meditation serve different functions. I also listed meditation under Reconsolidation Tools.↩︎
I am a moderator on /r/mdmatherapy.↩︎
While many people benefit from psychiatric medication, several aspects are typically not discussed: there is little high-quality evidence on long-term efficacy¹⁶. Even short-term benefits are often overstated since the effects of psychiatric drugs are usually noticeable and therefore difficult to truly randomize in trials, and trials rarely use active placebos to control for this²⁸⁶. Many psychiatric drugs can also cause physical dependence after chronic use and may be difficult to quit¹⁷. Increased adverse symptoms when tapering or quitting a psychiatric medication may be a symptom of withdrawal rather than a sign that the medication is still providing a valuable benefit.↩︎
People who retract claims of recovering accurate memories of abuse overwhelmingly blame their therapist for improperly influencing them²²⁷.↩︎
The discomfort with certain habits and practices may also serve as a valuable indicator of stuck schemas.↩︎
Grajek³⁰¹ also lists fish, but I cannot conscientiously include that recommendation. Almost all farmed fish live in torturous conditions, and extreme suffering is part of the catch or killing processes of fish from any source²³⁶.↩︎
The lack of control might actually be a benefit. Many people drastically underestimate the benefits of reconsolidation, and the lack of control will keep the process going through any periods where I might be too depressed to manually activate reconsolidation.↩︎