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 some 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 or incomplete to some degree.

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.

Added Issue Comes Back After What Feels Like Successful Reconsolidation, Not Accessing Any Memories of Traumatic Events, and Casual Observations About MDMA Therapy. Partially rewrote .

Removed the rest of Thomas Harper’s content. I replaced their major section, How to Find a Practitioner, with a few paragraphs that link out to equivalent information written by other people.

Substantively edited almost everything for clarity, logical flow, and rigor. This meant rewriting about a third of the content. 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 Thomas Harper 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 book combines 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.

I try to strike a balance between practical applicability and scientific robustness. My core assumptions, my reasons for believing each, and my confidence in them are laid out in Appendix A.

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 Jessica Sojorne Libere for much MDMA therapy guidance; the scientists and therapists who developed this body of knowledge and practice; 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 8.4.14. Thomas Harper provided early feedback on many sections.

AI Disclosure

With the exception of Table 7.1, I authored all content. In the occasional 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

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 [episodic] 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 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 create internal models to move through the world and thrive. These models create our thoughts/beliefs (e.g., “I can’t do anything right,” “I am bad”), emotional reactions, and behavioral patterns. Different therapeutic frameworks call these models schemas, parts, priors, etc. Occasionally, the schemas we learn to survive in one context become maladaptive or inaccurate 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 memory⁵ 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 create emotions that 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. Staying present means focusing on it and allowing it to be felt in the body and mind without acting to end, alter, escape, or explain it away. It can also include investigatively feeling, feeling how the feelings change as you move or as your thoughts and triggers change or as the schema reconsolidates. 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 Robinson⁸, 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 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 events. 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 significantly lower degree of certainty that these higher total doses are safe for more than a handful of sessions. Booster doses might be fine to start off with, but once you have established a reliably therapeutic routine, gradually reduce your dose to find your 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 creating these feelings should gradually dissipate. That’s the updating process at work.

For dissociation, Razvi⁹ 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 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 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 (some of these are best guesses based on sparse evidence):

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 the 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.⁶ 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 Mold¹² 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 area¹³ (see also Briggs¹⁴).

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 issues¹⁵.

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 three categories of sources. First, papers, books, and blogs on the topic. Second, my own experience using MDMA therapy to treat my complex trauma. Third, 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 obvious disagreements.

Throughout the book, I 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 fMRI studies because it is a minefield of poor statistical methods, low statistical power, and mistaking correlation for causation¹⁵ and I don’t have the expertise to sort out what is correct. It has also provided little meaningful information about any specific mental illness²⁴. 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 effect²².

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, these 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 missing the book’s real weak points³⁰. 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^11,32. However, the FDA requested one additional phase III trial be conducted to fill in some missing data before they could approve MDMA³¹. Psychedelic Alpha³³ analyzes this request in detail. Schenberg³⁴ 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.¹⁰ 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.

Mustafa³⁶ pooled both MAPS phase III MDMA therapy trials together (194 total participants) and calculated the average effect sizes¹¹ 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 arms of the experiment involved therapy that likely had its own positive effect, not to mention the benefits many people get from the placebo effect. Those reported ranges are confidence intervals (CI); roughly speaking, there is a 95% chance that the true average effect is within that range.¹² 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^11,32. 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 Mitchell³² and Fig. 3 in Mitchell¹¹. *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^11,32. 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^37,38. 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^11,32. 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 PTSD³⁹. 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 these conditions. The prevailing model of mental illness is called the biopsychosocial model⁴³. 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 clusters¹⁶. 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 and associated disorders 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, Ecker⁷ 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 associations⁴⁴. Genetics increases the risk of mental illness, but in my reading of Aftab⁴⁵, Alexander⁴⁶, and Alexander⁴⁷, 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 digestion⁴⁸. 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 Therapevo⁴⁹) can be life-threatening situations for children. Here is the defense cascade:¹³

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 threats⁴⁸. 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 maladaptive⁴⁸. 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” ^{51, 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 present⁵². 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.⁴⁸ 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. Britton⁵³ compiled this from Ogden⁵⁴, Magyari⁵⁵, and Treleaven⁵⁶. 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.
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 mental 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 reproduction⁵⁷. We typically model threats in an appropriate and unproblematic manner and don’t feel fear and 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 appropriate⁷. 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. In some cases they might not even have worked well in the original context.

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.¹⁴ 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 invalidating⁷. Learning that schema might have been the best you 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” or “My parents are not capable of parenting.” If a dog attacks them, they may learn “dogs are dangerous” instead of “big angry dogs are dangerous.”

These symptoms are not the schema/model itself, just its outputs⁷. ¹⁵ Some of these symptoms may also not be noticed or noticeable. For example, I’ve had many experiences in MDMA therapy where I notice the emotion first, and the belief only becomes clear after some amount of reconsolidation.

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 ways⁵⁸, 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 Tippett⁵⁹:

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 threatening⁶¹. 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 about this and other sections in this chapter, I highly recommend these reviews of Ecker⁷: Book Summary: Unlocking the Emotional Brain by Kaj Sotala⁶² and Mental Mountains by Scott Alexander⁶³. I suggest reading them after finishing this chapter. Scott Alexander’s review (Alexander⁶⁴) of Surfing Uncertainty: Prediction, Action, and the Embodied Mind by Andy Clark⁵⁷ is also an excellent introduction to the general theory of predictions/schemas in the brain.

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 reality⁷. That information can be sensory or created by 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.¹⁶ 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 memory⁷. 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. The type of memory described here is implicit memory, not explicit memory of events and facts⁷. Implicit memory is our often unconscious model of the world and self.

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 sprinkled on top. 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 reconsolidation⁷. Incoming sensory information also strongly contradicts many stuck schemas. Some stuck schemas erroneously predict immediate threat, like someone hurting you if you refuse a request¹⁷. 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 (this list is likely incomplete):

The first three items in the list above are forms of schema-driven attention control⁵⁷. 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 bodies⁶⁶. Alexithymia is basically disconnection from emotions⁶⁷.

The above list might explain why mentally healthy and securely attached people are resilient to events that would traumatize others^68,69. 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.

I recommend Scott Alexander’s summary (Alexander⁶⁵) of Better Safe than Sorry: A Common Signature of General Vulnerability for Psychopathology by Omer VandenBergh et al.⁶¹ for further information about attention, which the article calls precision. They also call schemas priors.

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 propose 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.¹⁸ 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. Ecker⁷ 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, learning emotional skills, and resolving conflict are also important for some people. Throughout this book I occasionally mention resources for these, 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 distress⁷⁰.

VandenBergh⁷⁰ 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 perceptions⁵⁷. 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, reconsolidating¹⁹ 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 evidence⁷⁰. 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, Kolk⁶⁶ 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 a significant part of the itching and anxiety. The only complications were that I had to reconsolidate many other schemas first before this one was accessible, and I think that considerably more reconsolidation will be necessary to resolve the rest of it.

Not all health issues associated with mental illness are inaccurate perceptions. Inaccurate predictions of symptom existence can also coexist with tissue damage or organ dysfunction⁷⁰. 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 position is that stuck schemas indirectly cause organ dysfunction via chronic stress. VandenBergh⁷⁰ thinks that the evidence for this pathway weak, but I am not sure.

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

For further (technical) reading on the topic, I recommend Symptoms and the Body: Taking the Inferential Leap by Omer VandenBergh et al.⁷⁰.

Complex Systems: Symptoms Can Get Worse Before They Get Better

The framework I’ve laid out explains the process of therapy well 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 the process of healing. As described below, this can happen when we start feeling or doing things that were previously blocked by stuck schemas. These feelings, thoughts, and behaviors can activate even more of our stuck schemas. For a period of time, we may even feel worse than we did before we started. I think that complex systems theory provides the right conceptual vocabulary for this phenomenon even though it doesn’t predict the details of any particular individual’s situation.

In the complex systems formulation, your mental state is like a ball that can be stuck at the bottom of a deep valley of mental illness⁷¹. Conversely, in good mental health, the ball is in a different part of the landscape where there are no deep valleys, only shallow valleys that the ball rolls in and out of as needed, depending on the context. One shallow valley may be your mental state at work, another your state at home, etc.²⁰

In complex systems, valleys are called attractor states. In the model discussed here, maladaptive attractor states, or maladaptive attractors, are created by two factors: stuck schemas and low attention to contradictory information. The schema generates the symptoms. The low attention prevents the schema from updating and thus prevents the symptoms from dissipating. In long-term anxiety, for instance, the ball stays at the bottom of the anxiety attractor because (a) the stuck schema predicting imminent threat is activated by a pervasive trigger, and (b) low attention to contradictory information keeps that schema stuck.

Other factors play roles too, but I limit this discussion to schemas and low attention. I think they’re usually the most influential for the types of issues described in this book, and adding more factors makes the model too complex to use. Certain mental illnesses likely critically depend on other factors.

To recap, the landscape of attractors and the “mountains” between them is created by the interactions of schemas and attention. It changes slowly through learning and reconsolidation, though I think that MDMA can also temporarily reshape it. Your current mental state is the current position of the ball, which can roll through the landscape on a short timescale when nudged by internal or external events. Its trajectory is determined by the shape of the landscape and the nudges it receives.

Symptom Worsening

Symptom worsening (symptoms being emotions, thoughts, behaviors, and somatic sensations⁷) is typically temporary but can be stable, at least without further intervention⁷². I think it occurs when something, like MDMA therapy, opens up or pushes you onto previously unavilable trajectories in the landscape²¹. Your mental state is then free to go to these new areas, where your schemas then create an array of (potentially distressing and maladaptive) emotions, thoughts, behaviors, and possibly defense cascade activations. In practice, this might look like

Whether newly accessible maladaptive attractors are temporary or stable would depend on how much attention there is to contradictory evidence. You might stay in one of these attractors. Low attention to contradictory information would make one of these attractors stable, whereas moderate or high attention would make it self-limiting. High attention mixed with mild stuck schemas may just feel like a minor dip on your way to somewhere else in the landscape.

Symptom worsening can be a severely harmful experience if it occurs at a time 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 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 reactivity, with many stuck schemas, to resilience, with few or no stuck schemas. In other words, you may 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 price of being able to walk.

In practice, symptom improvement seems 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^11,32.

Healing in Complex Systems

Therapeutic interventions may combine multiple of these 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 issues⁷. Furthermore, by disassembling the maladaptive attractor, relapse is possible only to the extent that the maladaptive attractor still exists⁷¹. The other processes leave the maladaptive attractor intact, whether your mental state is currently in it or not. Relapse occurs when the right circumstances nudge your state back into the attractor.

The Limitations of My Model and the Complex Systems Approach

While complex systems theory qualitatively describes important parts of mental illness, therapy, and stuck schemas, it currently offers few detailed predictions⁷¹. Complex systems are difficult to model; the architecture of mental models is unknown and might be significantly different for every individual, 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; it has at least as many dimensions as there are schemas and symptoms. The number of practically significant dimensions in any particular case could easily be enough that it’s too complicated to comprehend.

It’s unclear to me who will worsen, when they will worsen, and how long the worsening will last⁷¹. No one knows for sure what avoided, distressing material or reactions you may or may not uncover, or how reconsolidating certain schemas will cause complex cascades of schema activations. It may also be the case that skilled therapists have developed useful heuristics for estimating these and navigating the complex landscape, though 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 raves⁷⁴. They are largely 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 (some of these are best guesses based on sparse evidence):

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 connecting properties, whose structure is shown in Figure 4.1. Stocker⁷⁵ 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.²⁴ The average half-life is 9 hours in healthy individuals⁷⁷. On average, subjective effects become strong around minute 45, reach a maximum around hour 1.5–2, but only last until hour 5⁷⁷ because of rapidly developed tolerance⁷⁸.

Storage of MDMA is simple because it is stable in water, though this has only been tested up to 20 °C (68 °F)⁷⁹. Drugs are typically much more stable in dry form.

Acute Effects

Liechti⁸⁰ 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 effects⁸¹. Colcott⁸² additionally reported non-cardiac chest pain/discomfort.

Studerus⁸³ 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 Liechti⁸⁰. 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/ReagentTesting⁸⁴ maintains a list of reagent kit suppliers. Lab testing provides a much higher quality analysis, reporting the quantity of all ingredients. /r/ReagentTesting⁸⁵ 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.²⁵ 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.²⁶

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 dry⁷⁶. 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.²⁷

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.²⁸ 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. Tripsit⁹⁰ 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 positive and negative of MDMA primarily depend on dose, body mass, and, to a much lesser extent, how active your CYP2D6 enzymes that metabolize MDMA are⁹¹.

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 benefit⁹². Anecdotal reports also indicate that too high a dose can cause the session to be so blissful that you aren’t able to productively activate and reconsolidate stuck schemas.

The two primary risks of higher doses are oxidative damage in serotonin neurons and possibly long-term cognitive impairment⁹³. 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 the recommendations here are cautious until there is better data. This section describes two sets of dosing recommendations for different circumstances and risk tolerances, along with my recommendations.

The First Set

These doses are more conservative and based on some evidence suggesting that they do not cause measurable oxidative damage in the serotonin system⁹⁴.

Liechti⁹⁵ 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.²⁹ The 100 mg dose also applies to everyone over 75 years old. This is roughly similar to the 2 mg/kg threshold that Baggott⁹⁴ discourages exceeding.

CYP2D6 poor metabolizers have stronger reactions to MDMA⁹⁶. People aware they have this should use up to a 25% lower dose, though it’s not essential⁹⁵. 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. 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 use³⁹.

The Second Set

Doses up to 125+65 mg have been successfully used in clinical trials without any obvious, lasting adverse effects²⁶, but there is significantly less certainty that they do not cause small amounts of oxidative damage.

Because effects depend on body mass⁹¹, I don’t recommend the fixed dosing these trials used. Adding a 50% strength booster dose to the first set of recommendations from Liechti⁹⁵ 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^11,32. 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, I strongly recommend finding your 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.³⁰

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

Making specific recommendations for session spacing is difficult because individuals have different risk/reward tradeoffs and neurological responses to MDMA, and safe spacing strongly depends on dose. There are two main limitations relevant for minimizing risk^93,101. First, the brain’s antioxidant capacity may need time to replenish after a session. MDMA causes oxidative stress, but the brain’s antioxidant buffer is normally capable of neutralizing this, likely at least for doses under 2.0 mg/kg⁹⁴. However, using more MDMA before it has recovered may cause oxidative damage in the brain. 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^102–104. 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–moderate contributor to population-level harm. The typical therapeutic protocol—2–3 mg/kg total 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. People may also need to do many MDMA sessions to treat severe CPTSD, and gradually cumulative effects may become more noticeable. I know of four lines of indirect evidence that tentatively suggest that the 4 week spacing used in the phase III trials is ok when using total doses under 1.5 mg/kg:

The second main limitation is downregulation of the serotonin system during an MDMA session, which causes short-term tolerance^93,101. 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. 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 four-week spacing of the phase III trials³² produced progressively increasing therapeutic benefit after each session, suggesting that this time span may be sufficient for many people.

Doing sessions more frequently than those limits may also risk long-term tolerance, sometimes called “losing the magic”^93,101.

The four-week spacing used in the phase III trials³² might be 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, and you’re already above 4-week spacing, 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 4 week spacing as an minimum. Some people might decide to risk shorter spacing if they think the tradeoffs of their particular situation are worth it.

See Mechanisms of MDMA Tolerance and Loss of Magic by Matthew Baggott¹⁰¹ 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 Liechti⁹⁵ and Malcolm¹¹⁰ (more accessible) or Sarparast¹¹¹ (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 Sarparast¹¹¹ 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 therapy¹¹¹.

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^{11,
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 select parts of the MAPS pharmaceutical investigator’s brochure¹¹⁹ with your doctor.

The trial inclusion criteria did regard some serious medical conditions as compatible with MDMA therapy¹¹. Mitchell^{11,
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 ^{11,
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 feelings and perceptions. 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. High quality 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 and Subsection 8.4.11 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^74,112. 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 abnormalities¹⁶⁴.

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. Malcolm¹¹⁶ 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.⁴⁰ 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 for¹⁶⁷:

Additionally, the American College of Cardiology and American Heart Association say that chest pain that is left-sided, dull, aching, central, squeezing, gripping, behind the sternum, or feels like pressure, heaviness, or tightness indicates a high likelihood of cardiac ischemia (inadequate blood supply, often caused by blocked or broken blood vessels)¹⁶⁸. Stabbing pain is a moderate risk. Pain that is right-sided, tearing, ripping, burning, sharp, fleeting, shifting, dependent on your posture, or related to breathing indicates a low likelihood of ischemia. Of course, ripping or tearing sensations may indicate other severe problems.

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^78,173, long-term cognitive impact¹, and valvular heart disease¹²⁷. 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 before you wake up.

Unnoticed avoidance makes it difficult to assess how much material you need to work through. You could fill out the Buchanan¹⁷⁴ 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 Buchanan¹⁷⁴ 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^11,32, do-it-yourself couples therapy¹⁷⁶, and solo therapy¹⁷⁷. 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 6.2, 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^178–180. MDMA itself only costs 6–50 Euros per gram (in Europe in 2022), which is enough for 5–10 sessions¹⁷¹.

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-reactive¹⁸¹.

As discussed in Section 6.3, 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.

How to Find a Practitioner

Practitioners vary widely in skill, ethical behavior, and how good of a fit they are to your needs. Choose one carefully; many practitioners have appeared in the news for harming their clients¹⁸³. Some are even members of groups that practice organized abuse. I strongly recomment using Psychedelic Safety Flags by Leia Friedwoman et al.¹⁰ to evaluate the practitioners you are considering working with. I also strongly recommend using Brief Revised Working Alliance Inventory by Greenspace¹³¹ to evaluate the quality of your therapeutic relationship. This quality has a moderate impact on the effectiveness of therapy¹³².

Licensure may offer a mediocre amount of protection against harm and incompetence. Licensed clinicians have usually had background checks, a couple of years of typically so-so education, and a few years of pre-licensure clinical experience. There are also subject to formal complaint processes.

/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 practitioners by talking to people at psychedelic meetups.

See the following for further information about harm in the psychedelic community:

Involuntary Commitment

Licensed practitioners are often legally obligated to call the police on you if they think you are at high risk of hurting someone or are so psychotic that you might do so accidentally. They might also coerce you into going to hospital yourself under explicit or implicit threat of calling the police on you. In practice, what the practitioner does 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. Practitioners may also call the police on you, or threaten to do so, for suicidal ideation or planning. 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 yours¹⁸⁶. 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, Emanuel¹⁸⁷ found that (at least in Allegheny County) involuntary hospitalization actually significantly increases the chance of a patient dying by suicide or overdose or being charged with a violent crime over the 3 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.

Alexander¹⁸⁶ is a good guide for navigating/avoiding the inpatient mental health system.

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. Reconsolidating the stuck schemas that these prompts activate build more resilience and equanimity than the default of just doing enough MDMA therapy to make your primary issue feel manageable.

Using these prompts to trigger yourself is going to feel uncomfortable, but that’s an inherent part of reconsolidation. 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.

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.

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.¹⁷⁴. 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

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 8.4.14 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 identity¹⁸⁸, 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 tribalism¹⁸⁹:

Trapped Priors as a Basic Problem of Rationality by Scott Alexander¹⁹⁰ discusses another mechanism for how emotionally charged, false beliefs become entrenched. It proposes, based on VandenBergh⁶¹, 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 it¹⁹³.

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^194,195. 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 Birch¹⁹⁶ 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.⁴²

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-connectedness²⁰². 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 Ritchie²⁰³. 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 escapism²⁰⁴ or fun and social connection²⁰⁵. 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.

Razvi⁹ 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, Razvi⁹ 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 strong⁹. 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-fight⁴⁸, 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 reconsolidation¹⁷². 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 solo⁹. The maintains a directory of therapists²¹¹.

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 dissipating¹⁵⁵. Those with genetically or pharmacologically low CYP2D6 metabolic capacity peak earlier and higher, though any differences disappear by hour 3–4⁹⁶. Food delays the onset of effects²¹².

A half-strength booster dose taken around 1.5–2.5 hours after the first is often used to extend the productive duration of the session (by about one hour²¹³)¹¹. 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. As described in Section 4.4, I advise caution above using total doses of 2 mg/kg for more than a handful of sessions. 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.⁴⁶

Session Timeline

Come-up

The effects of MDMA become noticeable, but you are not yet deeply engaging with stuck schemas. Some users experience anxiety¹⁷⁷. This might be misinterpretating MDMA’s stimulant effects as anxiety, early engagement with schemas that generate distress, or fears about the session.

Peak

Reconsolidation is possible here. Connection and safety become pronounced, though this may be unnoticeable if schemas creating distress are also active, 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 love⁴⁷ 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 days⁸⁰.

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 negative emotions created by stuck 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.

The first main activity is emotional activation of stuck schemas,⁴⁸ a prerequisite for reconsolidation⁷. In other words, 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. You may nor may not also notice other symptoms of the schema at this point. I’ve had many experiences in MDMA therapy where I notice the emotion first, and the belief component only becomes clear after some amount of reconsolidation.

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 is a distraction unless your stuck schema remains emotionally activated and you are at least partially focused on it.

You might also investigatively feel how the schemas and symptoms change as you move, as your thoughts and triggers change, or as the schema reconsolidates.

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

As discussed in Chapter 3, stuck schemas generate beliefs like “if I move I will die” and emotions 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 sometimes also recalled at the same time, though this isn’t necessary for reconsolidation. 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 is an impulse to avoid/resist the therapeutic process because some schema predicts that it is dangerous. While the protective function of these schemas may have been important at one point, they are likely 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 or what is causing their issues. 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 the schemas driving this 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^{214, 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 possible²¹⁵, and MDMA may occasionally facilitate them¹³⁵, Ingram²¹⁵ 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”)²¹⁶. 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 Razvi⁹. 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 feelings (without acting upon them) as much as you can manage can reconsolidate the underlying schema 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 intent²⁰⁹.⁴⁹ 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 6.3 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 else¹⁸⁷.

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 before making major decisions 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 reported as a common sign of immobility (presumably the schemas causing immobility rather than the immobility itself)²¹⁶.

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.

Not Accessing Any Memories of Traumatic Events

Recalling episodic memories of traumatic events is not necessary for reconsolidation, and that kind of memory can be unreliable. The “memory” of memory reconsolidation means implicit memory, your brain’s model of how the world and self function.

Focus on staying present with any fear, anger, sadness, etc. that you notice. That is likely a symptom of a stuck schema that can start reconsolidating once you “sink into” its symptoms.

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. Developing your capacity to focus while distressed may also help. See the Paying Attention list in Section 8.2.

Feeling too Blissful to Engage with Stuck Schemas

Issue Comes Back After What Feels Like Successful Reconsolidation

Intense stuck schemas might need multiple sessions of reconsolidation to fully resolve. Complex networks of stuck schemas might need to be activated with a number of different cues and contexts to fully resolve.

Because of this, I suggest only concluding that MDMA therapy doesn’t work for you if multiple sessions don’t deliver any persistent improvements.

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 created by stuck schemas rather than psychosis or mania, perhaps ones about self-control, altered states of consciousness, or drugs. In rare cases it might be actual psychosis.

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, poor self-awareness, and feeling good are typical aspects of mania, the presence of fear or anxiety about being manic weighs against being manic. The exceptions are partial mania and 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 States²⁰⁹.⁵⁰ You could also use tripsit.me/webchat, a chatroom available anywhere.

If your perception of being manic or psychotic does not dissipate at the end of the session, I strongly suggest getting assistance, since if you are manic or psychotic, it may be impossible to accurately self-assess your state. I would recommend, in order of preference,

Substance-induced psychosis and mania usually dissipate without treatment, but occasionally don’t. If your practitioner or responsible friend thinks that your symptoms are bearable, not worsening, and you retain intact reality testing, getting a few good nights’ sleep (with sleep aids if necessary) may be sufficient to resolve the issue.

Sessions Feel Like They’re Becoming Less Effective Over Time

Remembering Previously Forgotten Events

During MDMA therapy, you may feel you remembered traumatic events you weren’t previously aware of²¹⁹. These may or may not be accurate recollections of historical events, and I am not aware of any reliable method of distinguishing an episodic memory’s accuracy other than independent corroboration. To avoid incorrect interpretation of perceptions during the session, practitioners should categorically avoid suggesting an episodic memory is either true or false and shouldn’t even suggest that you have episodic memories that you can recover²²⁰.⁵¹

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 stuck schema.

Whether or not you can corroborate an episodic memory, I suggest focusing on any fear, anger, sadness, etc. about the memory itself or its implications for your life. The schemas creating these feelings can be reconsolidated like any other stuck schema.

I highly recommend The Psychedelics and Recovered Memories Project²¹⁹ for a nuanced guide on psychedelics and remembering previously forgotten events.

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^135,215. Many contemplative traditions (traditionally religious groups, but increasingly secular) frame these shifts—especially non-duality or unity with God, impermanence, and unsatisfactoriness—as important, positive, and potentially destabilizing²¹⁵.⁵² 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; Lindahl²²¹ discusses which are which. As Lindahl²²² discusses, “what is categorized as ‘progress’ versus ‘pathology’ may differ across traditions, lineages, or even teachers.”

As in therapeutic relationships, it’s important that your contemplative practices and teacher are well-matched to your needs²²³. You might even use the Greenspace¹³¹ to evaluate your alignment with your teacher. Canby^{223, sec. Abstract} reported that when working with a teacher:

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 House²²⁴ specializes in helping people through this stabilization process. In addition, many practices aiming toward high levels of integration involve processing large amounts of existential distress²¹⁵ that can be destabilizing, especially when done without proper practice or supportive teachers that respect your goals²²². Stuck schemas may or may not be intertwined with these experiential shifts, so different people may need to either delay contemplative work until their mental health is improved or work on both projects at once.

Below is a set of resources for dealing with these difficulties 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 illness²³³.⁵³ 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 Robinson⁸ 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.⁵⁴ 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.⁵⁵ I suggest using something like the following prompt I developed based on quotes from^7,131. 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 6.3). 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 practitioners²³⁹ and individuals experiencing prolonged post-psychedelic difficulties⁸ both recommend grounding as helpful in the healing process.

Among individuals experiencing prolonged post-psychedelic difficulties in Robinson⁸, 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 Robinson⁸ 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 uncomfortable 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^8,239. When receiving emotional support, participants in Robinson⁸ 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 may understand what you are going through, though I have not vetted some of them:

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 Robinson⁸ 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 drugs²³⁹.

Psychiatric medication is complex and largely outside the scope of this document.⁵⁸ 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 Alexander¹⁸⁶ 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 lead to involuntary hospitalization. As discussed in Section 6.3, involuntary commitment appears to increase the risk of suicide and being charged with violent crimes¹⁸⁷. 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 can’t find a medical provider who understands psychedelics, try to find one who at least understands trauma. They will be much more helpful than the average provider who doesn’t understand anything about what you’re going through.

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

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.⁵⁹ 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 Nostrand²⁷⁰. 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 activated and the emotions it creates are 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. Bender²⁷⁹ 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 also 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. A number of practitioners have used psychedelics to abuse their clients^183,280.

Treatment

Evidence does not support phased treatment (a stabilization/resourcing phase preceding reconsolidation)^281–283. Starting with reconsolidation is just as effective. It’s conceivable, but not established, that there are exceptions for cases of extreme dissociation.

Experience

Poulter²⁸⁴ 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 stillness⁷⁵ 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 8.4.14 for further discussion. Ingram¹³⁵ 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.

Casual Observations About MDMA Therapy

I have observations about MDMA therapy may be true or useful but which I don’t know how to formalize or back up:

Suggested Avenues of Future Research

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

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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 or dissociation are also present. This isn’t necessarily an issue; the process can still work well in these instances.↩︎
In this case, memory refers to implicit memory, not explicit memory of events and facts⁷. Implicit memory is our often unconscious model of the world and self.↩︎
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 glossary, 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 studies Feduccia²⁵ and Mithoefer²⁶. The journal claims they were retracted because of three reasons^27,28. 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 Jacobs²⁹. It’s unclear why the paper was retracted instead of corrected.↩︎
The Dutch State Commission maintained their position even after the FDA’s non-approval³⁵.↩︎
Cohen’s d↩︎
That definition of confidence intervals is a simplification. The technically accurate definitions are unintuitive and complicated.↩︎
I use the taxonomy of Kozlowska⁴⁸. 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.↩︎
Brains and mental models are complicated and poorly understood. However, we can often gain a decent understanding of how a particular schema developed, works, and influences us⁷. Practices in therapy can help us observe the structure of the schema itself instead of just a poorly understood collection of symptoms. In the example of Richard from Ecker⁷, he starts at noticing fear and a thought of "they hate me" when he thinks about confidently speaking up in meetings. Through therapy he gains awareness of the structure of the schema, which takes the form of a verbalized thought, “Having a feeling of confidence as you speak turns you into an arrogant asshole, like Dad.” It’s accompanied by deep sense of feeling that the explanation is right. In my experience, MDMA also facilitates access to a verbalized structure of a schema, either immediately or after some reconsolidation.↩︎
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.↩︎
Critically, an intellectual understanding that a stuck schema is inaccurate is not sufficient to reconsolidate many schemas⁷. The contradictory information has to be deeply felt as real.↩︎
It’s not clear to me whether intense schemas needing multiple sessions are actually one schema or multiple closely related schemas.↩︎
For consistency, I use the term reconsolidation instead of prior updating that VandenBergh⁷⁰ prefers. As discussed in Appendix A, I think reconsolidation is one type of prior updating.↩︎
This is only a crude illustration. Real mental landscapes are far more complicated, and it’s not clear how they’re organized. For instance, there may be loops, which are not possible in a 2D landscape.↩︎
Hallucinogens like ayahuasca also have the possibility of just creating new stuck schemas from traumatizing experiences. E.g., you feel that a demon is possessing you, and this is deeply ingrained in your mental model during the trip. I’m not aware of this type of problem happening with MDMA.↩︎
The number 200 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 process⁷⁶. In my understanding, illegal MDMA is measured based on the hydrated mass instead of the pure MDMA HCl mass.↩︎
Borax⁸⁶ 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 Borax⁸⁶ for instructions.↩︎
You can also filter out the insoluble fillers and binders while the MDMA is dissolved in hot anhydrous isopropyl alcohol. See feilong420⁸⁷.↩︎
Kranenburg⁷⁶ and Nair⁸⁸ 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 bitter⁸⁹. 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.↩︎
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.↩︎
Ten percent of participants declined the second optional dose. Their total dose would have only been 75–125 mg.↩︎
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 Alexander⁶⁵ provides a more accessible summary of VandenBergh⁶¹.↩︎
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.↩︎
I chose six hours as the restriction period since Figure 2A of Atila⁸¹ suggest that the worst risks of unrestricted water have passed by then.↩︎
The addiction pharmacology of these substances might share enough similarities with MDMA to warrant caution¹⁵¹. 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.↩︎
Malcolm¹⁶⁵ further discusses these criteria, but the author lists a lower temperature threshold in this document for unexplained reasons. The 100 °F threshold of danger cited there is implausibly low; a moderate dose of MDMA alone can raise body temperature that high, and it is not dangerous¹⁶⁶.↩︎
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.↩︎
Razvi⁹ 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 [episodic] 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 it⁷. 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 to²⁰⁹ in other countries.↩︎
I couldn’t find any services similar to²⁰⁹ in other countries.↩︎
People who retract claims of recovering accurate memories of abuse overwhelmingly blame their therapist for improperly influencing them²²⁰.↩︎
The fact that multiple traditions describe similar paths of contemplative development suggests that there is an overlapping set of underlying changes²¹⁵. 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 this common set of changes through their existing religious beliefs.↩︎
Psychedelics induce periods of post-session neuroplasticity that may explain this phenomenon, though this remains poorly tested for MDMA²³⁴.↩︎
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 efficacy¹⁷. 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 this²⁴⁵. Many psychiatric drugs can also cause physical dependence after chronic use and may be difficult to quit¹⁸. 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.↩︎
The discomfort with certain habits and practices may also serve as a valuable indicator of stuck schemas.↩︎
Grajek²⁶⁰ 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 source¹⁹³.↩︎
The lack of control might actually be a benefit. Many people drastically underestimate the benefits of reconsolidation, and the lack of control kept the process going through any periods where I might have been too depressed to manually reconsolidate.↩︎