Additional Chapter: Clinical Experience with MDMA
An Interview with Rick Ingrasci, MD, MPh
JH There are really just a handful of people who had clinical experience giving MDMA to patients, but you are one of those people, so I was anxious to speak with you.
RI There are lots of people who have had clinical experience with MDMA but won't talk about it, and I was one of the people who was publicly involved with trying to get the Federal courts not to put it into Schedule I.
JH I remember first coming across your name in 1985 when I had heard about the DEA emergently scheduling MDMA and your being one of the people... I remember having some sympathy for you because you had a private practice based largely on using MDMA, and I felt badly that you were losing that.
RI Well, it didn't affect my business on that level, but it was such an effective tool. To lose that... I mean, as you know in psychotherapy, there are not always effective things you can do for lots of people. I used MDMA a lot with dying patients and cancer patients, couples, it was just wonderful.
JH It was pretty much my perception in 1985 that it was a potent, sort of a power-tool, if not a little bit magical, and to take something you'd been using, and to put it up on the shelf and say, "okay you can't use this anymore," it seems like that would be really frustrating.
RI Yeah. It was. I wasn't happy. I wasn't surprised either, but I wasn't happy.
JH When you say you weren't surprised, had you been using it in your practice for a while before the DEA got involved?
RI About five years.
JH How did you first hear about the drug?
RI Well, I've been interested in psychedelic psychotherapy for many years. When I initially went to medical school, I had gone specifically to go into psychiatry and to do psychedelic psychotherapy. With my own novice experiences as a college student, and as someone interested in consciousness and spirituality, it was clear that there was some healing potential here. Of course, back in those days, in the sixties, Spring Grove and Stan Grof's work and things like that were kind of demonstrating the potential. But then, of course, I went to medical school in 1969 and that's just before Nixon banned everything, if you remember.
JH Right. That must have been an interesting time, where were you then?
RI I went to Cornell in New York City.
JH So, how did you first hear about MDMA? When was it?
RI Well, I had heard about it in the seventies from other psychotherapists, and because I was a part of that network, when they banned LSD I had looked for alternative molecules that might be useful in a therapeutic setting, and I had been working for many years with ketamine hydrochloride. When Sasha Shulgin began to talk to us about MDMA, let's just say that I was amenable. I was wanting to try it both personally and therapeutically.
JH And had you worked with LSD with patients or no?
RI Only with myself.
JH So you were giving ketamine to people and I assume that you were looking for other options.
RI That's right. You see, in my practice I focused on working with people with life threatening illnesses, cancer, etc. and I used to call ketamine "a preview of coming attractions."
JH That sounds like a very good idea. I know a lot of people describe near death experiences with higher doses. And how did that manifest itself? What sort of responses did you get when you gave ketamine to people who were terminal?
RI The most striking thing, in terms of symptoms and emotional states was a lowering of anxiety around death. The fear of death was lowered; and that's exactly what we were looking for. We were looking for both a lowering of anxiety and of fear, and also "an opening" in terms of the ability to or the desire to communicate what was going on in the process. A little ego death can go a long way; it really opens you up to be more authentic.
JH So, take me through the process of first, learning about MDMA, and then how you introduced it to your patients. How did that go?
RI Well, I began experimenting with it myself, and with colleagues and friends in the late seventies, and by 1980 I was pretty convinced that "we had a winner here." That this was a molecule... that if anything was going to redeem psychedelic psychotherapy that MDMA could do it because it wasn't a hallucinogen, and when used correctly it was remarkably predictable and safe, despite what you read in the popular press. Most people today are not using it responsibly, they're using it for parties. And there are risks with any drug.
JH With any effective medicine there are recommended doses, indications, contraindications...
RI It just seemed to me that if you fully disclosed to your patients, "here's the potential benefits and here's the downside"... I always evaluated people for histories of cardiac disease or high blood pressure or stroke. That seemed to me to be the biggest medical risk. If someone was severely hypertensive, I don't think I ever would have given it to them.
JH What sort of risks and benefits would you convey to a patient?
RI Well, my understanding, and again this was in the early eighties, was that it seemed to heal fear. And that it seemed to give people an opportunity to open up emotionally, and to communicate their inner life and their inner feelings in ways that were really useful. And again, when you use it in the context of a cancer patient who may or may not be dying, having this kind of experience, and I always used to invite the family to come in a few hours, to be...
JH To join into the session, when work had already been done individually?
RI Exactly. And, uh... it was just remarkable.
JH I bet...
RI So, basically I was asking people to take the risk, of, you know, I mean the substance wasn't illegal, but it was in that quasi-limbo place, and of course if you have a therapeutic alliance with people, they'll listen to you, and they'll make their own choice. I wasn't a zealot, if you know what I mean, it wasn't like this was the cure-all for everything from A to Z.
JH What sort of risks would you outline?
RI Well, the physical risks seem minimal at the proper dosage; I was using about a hundred and twenty-five milligrams.
JH And did you use a booster?
RI Not usually. A little later on I started to experiment with that.
JH Because it seems like the side-effects really increase with a booster dose.
RI Well they do. There's no question. Having taken high doses a couple of times myself, just in the spirit of experimentation. The bruxism and the nystagmus...it's definitely... I mean this is what cracked me up about the government. It met none of the criteria for a Schedule I substance. Especially the potential for high abuse, because if you took more of it you felt lousy!
JH It really does seem to be an interesting drug that way, in that it has a little bit of a self-limitation to it. So, what other patient populations did you work with? Did you work with individuals, couples...
RI Well, quite frankly, I gave it to several hundred patients. I worked with all kinds of people, but the main focus, it seemed to me, since I was concerned about the legality issue. We wanted to be able to make a case for medical research, that would validate the use of mind-altering substances in a therapeutic context. And life-threatening illness, dying patients, people like that, where it's like, they want to take the risks, you know? It seemed to me to be the way to go. But yeah, I gave it to individuals, I tried it with all kinds of psychopathology, not in any depth. I didn't find it, some people found it useful with psychosis. My borderline people and psychotic people, they had a good experience, but it didn't change the overall dynamic, if you know what I'm saying...
JH Do you think it exacerbated any tendency towards any underlying psychosis?
JH Did you happen to work with anybody who had a history of mania or schizophrenia?
RI No. I didn't see anybody, and in terms of the network of therapists I was working with, stating unequivocally that it had precipitated a psychotic break with anyone.
JH I have yet to find anybody who has really had a lot of experience using MDMA in schizophrenia. I have had contact with four people with schizophrenia that have had some good experiences with MDMA, but I am always looking for more data.
anyway, I have some more questions on my list here. What were your goals when you were using MDMA in private practice? What were you after?
RI Well, healing was my goal, and, depending on what the situation was, when it came to, for instance, couples therapy, it was a remarkable catalyst. To sit with a couple for three or four hours as they kind of opened up and you facilitate the process a bit, but , quite frankly, once things get rolling, it's like, they just kind of go where they need to go. I used to frame it as "look, imagine that your true self is kind of hidden under a layer of fear, and imagine that the MDMA, what it does, is actually remove the fear of being real, of being authentic with yourself and with other people. And that you can create a space to be this way, both during the experience, and afterwards, because quite frankly, you don't need to take MDMA in order to experience authenticity. Most people understood what I was talking about, and then, of course, after they had the experience, they definitely understood what I was talking about. Because, it was a fairly predictable kind of euphoric experience for people to be unshackled from that level of ego fear and anxiety.
JH What do you mean by ego fear?
RI Well, you know the kind of inner voices that are essentially rooted in fear, the ones that say "something's wrong, something's dangerous, you're no good" you know, the self-deprecation, the kind of sub-personalities that are rooted in fear. And it, uh, my experiences, and I'm not trying to say that it was the be-all and end-all and it would completely transform a person's personality, but it definitely opened a channel into what's underneath the fear. It was very striking.
JH And, how did that work in terms of the terminal patients, or them with their families... uncovering the fear?
RI Oh, did you ever see the Phil Donahue show where did the public debate on this?
JH No, no. I've heard about it but never saw a tape of it.
RI I refused to participate in the show unless I could bring several patients with me to sit in the audience and essentially be interviewed by Donahue about what their experience actually was. In other words, instead of just having a bunch of opinions up there on the panel, let's see what people actually experienced. And they agreed to do that. And, one of the people who agreed to come with me was a lawyer from West Germany. She was originally from Missouri, but she was living there, and she was the straightest looking lady. She had terminal liver cancer, but she had this Southern accent, she was about forty years old, she had a sixteen year old daughter, and her husband, but she was very contained emotionally, put it that way. I had been working with her for many months, in psychotherapy, trying to get her to open up. She agreed to do MDMA. I gave it to her, and she blossomed like a flower, you might say. Really started talking, first to me, and then I brought in her husband and her daughter, and they spent the next twenty-four hours just, in a kind of emotional download. Let's just say that a door opened and it never closed for that family, and she didn't want to go on national television for any reason, but she was willing to do this... Anyway, she came across as so down-to-earth and sane, like your normal... she wasn't some flaky person who was on drugs, and after Donahue heard her, he went from hammering at me to hammering at the DEA, the reason being is that he saw... what he said to her is "Well, how often do you have to take the medication?" And she said "I only took it once, and I'd really like after I die if my daughter would take it, so it can help her to grieve." And you know how sometimes he dropped the microphone and his jaw drops? And he looked at me and said "Oh, I see!"
JH That sounds great... So, one of the things that I want to try to get at in the book is that there's really a connection between a person's emotional state and their physical state, and that, when someone is chronically ill or they're dying, to have a lysis of that fear and of that anxiety can really affect how they're doing physically, especially in terms of how much pain they're experiencing. Could you comment on that?
RI I found that pain has a subjective component to it. A lot of the patients I was working with were experiencing a lot of pain due to their cancer. What I found was that people would be in pain, they might even be writhing in pain, but they experienced it in a whole new way, from a state of equanimity. It reminds me of what John Kevinson has been able to accomplish with Nepasana meditation and yoga. The kind of pain reduction work they do at University of Massachusetts medical center.
JH In that they would still experience it but their perception of it would be altered? Was it more that they would accept it and not fight it? Were they less afraid of it?
RI You know, it was hard to say, because I didn't tend to get them to focus on the pain. My tendency was to ask them to go deeper inside their psyche. If you think of the pain as being a more superficial experience, or state, it's like you could both have that, and actually, it would be like looking at a pond, and then looking into the bottom of the pond.
JH And the pain is the algae, floating at the top...
RI I don't want to make any wild claims about, as a matter of fact, with MDMA or any other substance, we shouldn't make claims, we should do clinical studies and find out. There are all kinds of ways to measure its effects.
JH You know, one of the messages in this book is that, it's the bottom line that we need to be allowed to do research. It should be encouraged, and it should be easier to perform. Both because it is a potent tool that should be explored, and also because literally millions of people are taking this drug around the world, and we should know what it does.
RI Yeah, there's a new book out called the Love Drug, by Richard Cohen, which is a pop version, stating the case for at least looking at the facts, here, and I think he's done the general public a service there, by saying, here's what it is, here's what happened. He even spends a chapter talking about the battles we had...
JH With the DEA, yeah. that was one of the better parts of the book for me. But, getting back to the pain issue, did you find that MDMA was somewhat of an analgesic?
RI Yes. For whatever reason. If you're asking me to describe the mechanism, I really can't.
JH No, I'm more asking you to describe the phenomenon you witnessed.
RI From the point of view of the symptom of high levels of pain, people either tended to focus on it less or could cope with it better.
JH I think it was George Greer who described a patient with myeloma who had chronic pain, and whenever he would have a session, he was pain free on that session.
RI Yeah. George was the one other psychiatrist who used it in his private practice, in the way that I did. He and his wife, Requa.
JH Tell me more about the scheduling. Were you in Washington D.C., and going to the trials?
JH What were they like?
RI Well, the judge was actually quite good, Francis Young. He listened to everything, and based on what was presented, he said it met none of the criteria for a Schedule I substance, and that it did seem to have a medically acceptable use, and that it should be studied, and that was his recommendation.
JH The judge made a recommendation for Schedule III. How did you feel at that time?
RI We felt vindicated.
JH Right. I did too. I was following the whole thing - I was in college - and I was really pleased. And then how soon after that did the DEA just overturn judge Young's recommendation and place it in Schedule I.
RI Almost immediately. And then, what Cohen left out of the book was that we appealed, in Federal District Court, where they have a three judge panel, to review all the evidence, without more testimony. That was up in New England. And that panel of judges reviewed all the data and came to the same conclusion as judge Young, saying basically Schedule III sounds right. You know what? It doesn't make a damn bit of difference, because the FDA and the DEA already knew what they were going to do.
JH So they overturned both an initial ruling, and an appellate ruling.
RI Yeah. Yeah.
JH The DEA just went ahead and did...
RI Exactly. We were scratching out heads. Wondering, well, why did we bother to do this?
JH That just sounds immensely frustrating.
RI Oh, and then, there was all this hysteria around so-called "Designer Drugs." And this crazy law was passed that basically said that any drug that even resembles, from the point of view of the experience, like if for example if aspirin gets you high, it can be put into the illicit drug scheduling. And it was like the craziest piece of legislature, and we lobbied and we had Frank Mankowitz's lobby group work with us on this, and that law passed! It was the craziest, most unformed piece of crap legislation. It just shows you how irrational and hysterical our country, and our government in particular, is around this subject. It hasn't changed a whole lot, take marijuana for instance...
JH And again, this administrative law judge, Francis Young, when he reviewed all the medical marijuana data, also made a recommendation that it should be in Schedule III, and that also was not heeded.
RI No surprise, there, but the good news to me was, here was a judge who was actually being fair. He was looking at the evidence dispassionately, and was saying this is what I hear, this is what makes sense. Our government is not being rational about this.
JH No. Our nation' drug policy is anything but rational, and I think the most glaring inconsistency, is the fact that cigarettes and alcohol do meet the criteria for Schedule I, so, I think we have a ways to go in terms of having some sort of uniform scheduling that makes some sense. So, how did the DEA's decision change your practice or your course of actions?
RI I stopped using it. First of all, I was in the spotlight, so it's not a good idea to continue to use it in my practice.
JH And how long had you been performing MDMA-Assisted Psychotherapy before you had to stop?
RI In terms of my practice, it was like four-and-a-half to five years. Again, recognize that I also found, we haven't talked about this, but in terms of small group process, it's a fabulous facilitator.
JH What sorts of groups?
RI Well these were more just groups of creative individuals, friends or colleagues wanting to have a transformational experience. You could say it was more of a spiritual focus, because I've always used psychedelics in a sacred context. To me, that's what half of the battle is, the set and setting You want to create the kind of context, where, it's what I call, the non-trivial use of a powerful mind-altering substance. And when you do that, in other words, when people are there for the right reasons, and the right intentions, good things happen. And MDMA was just, a very benign, that's the thing, it's so benign when it's used correctly.
JH When it is used judiciously in single oral doses.
RI So, with small groups, if you're encouraging people to be themselves, in the best sense, you find that people sing songs for the first time. They sing their own song, or they'll play music together, or ... I never... there are some people who say it increases sensuality. That was not my experience. Sensual meaning people want to have sex or whatever. It certainly never had that effect on me.
JH Well, it's a really interesting phenomenon. I don't know if it's just this culture or every culture, but anytime there's a new drug, it is ascribed the property of an aphrodisiac. Any new drug gets dubbed the "love drug" or the "date rape drug." It's always about sex. People are like "Oh, ecstasy. Yeah, isn't that the drug that makes you want to have sex?" And I'd have to say, "No, that really isn't one of its properties, as a rule."
RI No, we meant it as "the love drug" in a more spiritual sense! Not the sex drug. Opening the heart, that was another way we used to talk about it, the effect. But with small groups, and again, I don't want to get down on people who use it for partying and things like that, but I do consider that somewhat of a trivial application. It just seems to me regarding the raves, I can see how it energizes a certain kind of...
JH On the other hand, though, I think that it does help to foster this tremendous kind of tribal unity, and sense of community, which may be, on some level, therapeutic. And if it's not individually therapeutic, then maybe just towards society... to help encourage tolerance, for instance.
RI Again, that's why I don't want to judge. I haven't gone to any raves...
JH But it's not the focus of the book. If I have one cause I am going to get behind, it is not that everyone should be raving. I'd like to stick more with the issue of MDMA-assisted psychotherapy and research.
RI Well, you see, I could see from a social healing application, used in that way, I would say in a more restricted context. But the kids tend to take more than just MDMA, they drink alcohol, they smoke dope...
JH And also, I think that they really are getting overheated, and that's where you run into trouble medically, when people are getting hyperthermic and dehydrated, and they're taking more than a single oral dose and they're not just sitting still and talking and sharing, they're sort of bouncing off the walls.
RI Anyway, I'm sure you're familiar with the Heffter Institute. If all goes well, they're going to get some major funding, and hopefully they'll be in a position to do some MDMA research.
JH Well, I did want to let you know that this is a non-profit project, in that all proceeds from book sales are going to help fund clinical MDMA research, and whether the money gets administratively handled by Heffter, MAPS, or myself, I haven't yet figured out. I have no idea how much money a book like this will generate, to tell you the truth.
RI Well, as long as you have that intention, and you know... the pendulum is going to swing sooner or later, because, basically, you just can't hold an irrational position as an adaptive posture, culturally. Have you ever been to Amsterdam?
JH Are you kidding me? They have the best social policy I have seen on the planet. It is very rational. It is a sort of sane harm reduction, with the attitude that "look, people are gonna do this, they might as well do it safely."