Bad Touch! Saving MDMA: Part V
What will medical boards think about therapeutic touch baked into a FDA-labeled therapy?
The Frontier Psychiatrists sometimes tackles difficult issues. The most rigorously addressed problem is how can I possibly write something almost every day?! Writing something else is usually the answer. Every once in a while, I have a larger story to tell, and it takes a couple of parts, and this story has been a while in the making. I've been thinking about psychedelic medicine for a long time.
I’ve been writing about the problems with MDMA-AT for several days in a row. I’ll begin today with a quote from the MDMA-AT manual:
The psychic material that has revealed itself during the first MDMA-assisted session and the therapeutic work occurring in the follow-up non-drug sessions may help the participant trust the process more deeply this next time. Given a stronger sense of trust and familiarity, the participant is likely to move even further beyond her/his defenses.
Today, we will address the role of boundary violations and the, frankly, chilling implications of MDMA-AT, as proposed to the FDA by Lykos, were it to be deployed at scale. Here is what their therapy manual says about “focused bodywork” in just one part of the text:
Focused bodywork catalyzes the healing process by providing a safe way to express intense emotions and impulses in order to release tensions that may be contributing to somatic complaints and blocking energy flow within the body. Focused bodywork catalyzes the healing process by providing a safe way to express intense emotions and impulses in order to release tensions that may be contributing to somatic complaints and blocking energy flow within the body.
Page 49 of 69
Leaving aside the adolescent guffaws available if one notes the therapy manual is all of 69 pages in length, the manual continues:
Focused bodywork is only done with participant permission and is immediately discontinued if the participant requests that it stop. Although focused bodywork may be an important part of the follow-up integrative sessions for some participants, it should not be used prematurely if challenging emotions or their somatic manifestations are being adequately experienced, processed, and expressed spontaneously. The focused bodywork is most appropriate in situations in which emotional or somatic symptoms are not resolving because their full experience and expression appears to be blocked.
Such promotion of physical touch in the fraught milieu of psychotherapy for trauma is deeply problematic. It is more mendacious when combined with a powerful drug, creating a sense of mystical connection like MDMA. Sexual assault in therapy starts by breaking down the boundaries between patient and therapist behavior. As the MDMA-AT manual puts it:
The therapeutic work occurring in the follow-up non-drug sessions may help the participant trust the process more deeply this next time.
Trust is a double-edged sword. Boundry violations, allegedly, were rife in the MAPS MDMA-AT trials (quoting Lily Kay Ross & David Nickles’ open comment to the FDA):
They have pointed out the heightened suggestibility that accompanies these drugs, and how the drugs can enhance the consequences of poorly administered psychotherapy and clinical errors.
Heightened suggestibility.
The manual continues to encourage therapists—using a dizzying array of unclear words—to encourage handsy behavior (MDMA-AT manual, p. 49)
Other forms of training or background that include mindful use of touch, somatic oriented therapies and focused bodywork can provide important therapeutic tools that are compatible with this treatment method and can facilitate energy movement and release of body tensions.
That sounds like a happy ending. The manual also encourages:
Therapeutic techniques should be available to address somatic manifestations of trauma that arise. These may include one or more approaches such as nurturing touch, focused bodywork, breathing techniques, or other approaches to somatosensory processing.
“Other approaches,” which ended up including sex with study subjects:
Meaghan Buisson… the woman who had the courage to publish footage of her therapists abusing her during the MAPS Phase 2 clinical trial. Long before that, she unearthed a litany of methodological and ethical issues in the MAPS clinical trials.
She found these issues because while she was in the trial, her trial therapists made her their trial coordinator.
She released the video of what happened to her to the press. You can watch it here. It’s disturbing. This is a screenshot:
After the video for the clinical trial was made, and the cameras were off?
Buisson moved to a small island where Yensen and Dryer lived and continued to do therapy with them. During that time, Yensen started what he called a consensual “intimate and sexual relationship” with her. Buisson later reported him to various authorities, including the police, for sexual assault and therapy abuse. You could say getting the videos were part of her search for the origin point.
This is beyond the bodywork of somatic experiencing therapy or the healing of surgery or physical therapy. It’s beyond what is safe or acceptable in psychotherapy:
Sexual behavior in therapy creates a severe rupture in which the healing aspects of the relationship become compromised and tainted, creating a situation in which any therapist is now inherently suspect, and it is extremely difficult for trust to be re-established in a subsequent treatment relationship.1
Boundaries are important.
Therapy is dangerous, complicated, and life-saving work. Different models of therapy and different patients will respond differently. It's not just talking. I think psychotherapy is often the highest-level intervention we have available in psychiatry. If I need more, more than electroconvulsive therapy, more than neurosurgery, I'm going to reach for intensive psychotherapy. This is not a mild intervention. It is a potent medicine for serious problems. If the problems are really bad, we might add family therapy or even, heaven help us, group therapy.
If I had only one tool at my disposal, it might be psychotherapy. When I say dangerous, I don't just mean for the patients. I mean for the therapist also. We are exposed to the pain, hurt, and trauma of individuals coming to us, and our connection with them allows us to heal. Therapy lets you change your mind and, in some cases, change your life. This happens when we build trust; we can talk about what we have been thinking to ourselves, which can be very traumatic—not just for the patient but the therapist—hearing, even secondhand, about the brutality of humans against each other. This is the severe thing that scars human souls. Confronting hopelessness, week after week, this is difficult. MDMA and other psychedelics hold the promise to break through to hope. However, caution is warranted.
There's a good reason why we don't add physical touch to that relationship. As a physician, sometimes physical touch happens while providing medical care. Sometimes I have to take a blood pressure. Sometimes I have to check your joints for inflammation. All of these things require physical touch. But what about adding manualized cuddling with patients? That crosses vital boundaries. Professional boundaries. It makes the therapy we're doing— a peculiar form of human interaction—more dangerous for all involved.
Surgery cuts you open, and it can save your life. That's a physical and dangerous touch; sometimes, that danger is worth it. Sometimes, you need a hug. Other times, sexual contact can be deeply fulfilling. Those are not the same jobs for the same person. None of those jobs are the kind of things that someone doing the challenging work of psychotherapy can be involved in without endangering the underlying set of tools we need to do our work. It's not that physical touch can't be healing—it just can't be done safely by psychotherapists. The therapist talks to you so that you can go out and get physical touch from someone else, not with them. It's a limit. To suggest that breaching that limit is safe is foolish, but it's also an indication that whoever made that suggestion isn't a serious therapist. “Now touch me” should remain the domain of lovers, friends, massage therapists, EMTs, and anyone who hasn't set up, as part of the frame of what will and will not occur, hands off.
I'll quote guidance from the State of California next:
Therapists are trusted and respected by their clients, and it is not uncommon for clients to admire and feel attracted to them. However, a therapist who accepts or encourages the expression of these feelings through sexual behavior with the client—or tells a client that sexual involvement is part of therapy—violates the therapeutic relationship, and engages in conduct that may be illegal and unethical. This kind of abusive behavior can cause harmful, long-lasting, emotional, and psychological effects to the client.
Finding good data on the rate of sexual assault happening in the context of therapy is very difficult—the majority of cases would not be reported. These transgressions are harmful to patients. They can also destroy the careers of health professionals who perpetrate them. This is not to weep about perps but to note that it would have been better for all involved if the slippery slope that led to the violation had not started. Data on sexual assault in therapy is scant. However, some literature exists:
Method: Data informing the analysis are derived from assessments of 40 women who experienced sexual abuse in therapy. These women had mostly presented with depression, 68% had a history of childhood abuse, and one half were themselves helping professionals.
In this study, half of those violated were themselves healers. The damage doesn't stop there:
Results: The majority were seriously damaged by the abusive therapy. Offenders were chiefly male (90%) and most were senior, well-qualified therapists of high status: some were charismatic leaders or teachers. Such a group cannot be dismissed as marginal, deviant, or Ill-informed; a more systemic analysis is necessary to understand how the professions spawn and some- times protect offenders.2
The problem with abuse by therapists goes beyond abuser and abused—it creates mistrust in healing and therapy for myriad others. The more abuse that occurs in therapy? That makes any allegation more believable—even when baseless. I should know—I have been harassed for years with allegations so preposterous they include puppy murder:
The absurd nature of the allegations didn't stop me from needing to spend years in frustrating legal matters—yes, they are ongoing—I had to file a defamation suit. This is despite a dismissal with prejudice of the initial medical malpractice lawsuit and the remarkably prompt clearance by my medical board. No one could believe such a thing, one might say. Except, people very much can believe it, when boundary violations are rampant.
I am far from alone—25% of psychiatrists will be the victims of stalking. For those of us not assaulting patients, a more permissive culture around this risk gives rise to more plausible allegations. I have documented one such case previosuly on my podcast. This adds yet more injury to our colleagues and patients who have been abused. Those victims don't disappear into thin air—they still need help. That help is rendered endlessly harder by the abuse at the hands of colleagues. The therapists with excellent boundaries? Those working with patients to clean up the mess after predictable boundary violations? These dyads and teams have tremendously difficult and draining work ahead of them. No victim wants to be victimized, and as a victim of harassment myself, leading to my PTSD, the legal redress is a slow and re-traumatizing process itself.
I beg—don't bring therapeutic touch, rebranded cuddling, or “other somatosensory methods” one iota closer to the mainstream of practice. The following is what the MAPS MDMA-AT code of ethics says about the use of touch:
When touch is part of our practice, we discuss consent for touch during intake, detailing the purpose of therapeutic touch, how and when touch might be used and where on the body, the potential risks and benefits of therapeutic touch, and that there will be no sexual touch.
We obtain consent for touch prior to the participant ingesting medicine, as well as in the therapeutic moment. Aside from protecting a person’s body from imminent harm, such as catching them from falling, the use of touch is always optional, according to the consent of the participant.
We discuss in advance simple and specific words and gestures the participant is willing to use to communicate about touch during therapy sessions. For example, participants may use the word “stop,” or a hand gesture indicating stop, and touch will stop.
We practice discernment with touch, using clinical judgment and assessing our own motivation when considering if touching a participant is appropriate.
When a therapy code of ethics reads like a junior varsity BDSM guide to safe words, there is a conceptual problem. Because, despite the protestations of the above “code of ethics,” sexual touch did happen in at least one case with a trial participant. Let’s draw out the implications of this at a larger scale. At least in BDSM contexts, “stop” is rarely deemed sufficient. Even in non-professional contexts, consent is not renegotiated “in the moment,” as it is in MAPS’ official guide to ethical conduct.
If there is only one ever determined to be one sexual boundary violation in the MAPS phase III sample ( two studies with an n = 150), can we take that as the rate of likely sexual assault in MDMA-AT exposed individuals? Even that 0.66% rate, at the scale of 1,000,000 patients treated, would be…
6,600 additional sexually assaulted patients—by their therapists
As MAPS would have it, two at a time. This is just too much horrific trauma caused to already vulnerable people to stomach for this author. When Rick Doblin talked about “net-zero” trauma, is this very risk what he was glibly referring to? Who's caught in your net—zero or otherwise— matters when we are discussing trauma treatment. I will remind us that physicians take an oath with a stern invocation against such interventions:
Medicine isn’t a “Net-Zero” culture. We strive not to add harm. It’s not perfect, but it’s a starting place different from the “the difference rounds out in the end” utilitarian (or effective altruist) worlds of John Stuart Mill and Sam Bankman-Fried. What can we do to avoid these risks and still let healing that is both desperately needed and perhaps remarkably potent, with psychedelic medicine, proceed through an appropriate regulatory process?
That is what we will address in part VI.
Prior articles in the series include:
Now, Everyone Is Interested in Drug Development
Should MDMA-AT Be Saved, Part III
Other closely related articles include:
How Big of A Deal Are Psychedelic Medicines Likely to Be?
Open Comment Periods about Psychedelic Medicines
The FDA Bad Ad Program and Psychedelic Medicines
Dear Psychedelic Exceptionalism
William Osler, M.D. for Psychedelic Key Opinion Leader
Bailey, T. D., & Brown, L. S. (2021). Treating clients who have been sexually abused by a therapist. In A. (L.) Steinberg, J. L. Alpert, & C. A. Courtois (Eds.), Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct (pp. 319–341). American Psychological Association. https://doi.org/10.1037/0000247-01
Quadrio, C. (1996). Sexual abuse in therapy: gender issues. Australian and New Zealand Journal of Psychiatry, 30(1), 124–131. https://doi.org/10.3109/00048679609076080
More musings on the choice of and need for safe words in certain treatment contexts: in working with a patient with complex PTSD with dissociation, sometimes this person becomes overwhelmed by their Transcranial Magnetic Stimulation protocol and to avoid any ambiguities and because verbal expression can be challenging when flooded with emotions , we have red/yellow/green flags. They hold onto the green flag but can easily pick up the others if needed. I would recommend this for anyone doing more intense work in trauma therapy. Relying on “stop” while in these states is woefully inadequate with a high potential for misunderstanding.