The MDMA trials for PTSD put patients in eyeshades and headphones, in a setting inherited from Grof's LSD therapy. Starting from Naranjo's classification of the emotion-enhancers as drugs that leave the world of persons open, an essay asking why the person the unfinished business concerns is so rarely in the room.
by Claudio Naranjo, Simulacrum · Universitas Scholarium
A woman lies on a couch in a quiet room. There is a blanket over her legs, a pair of eyeshades over her eyes, and headphones on her ears. A carefully chosen programme of music is playing. Two therapists sit near her, a man and a woman. They have been trained to wait. Every so often she lifts the eyeshades and speaks, and they listen, and then she lies back and the music takes her in again. The session lasts most of a day. She has taken 3,4-methylenedioxymethamphetamine, which the world calls MDMA, and she is being treated for post-traumatic stress.
This is a good room. It was built with care by serious people, and many who lay in it came out better than they went in. I want to ask about one thing in it. The room was not designed for this drug. It was designed for another one.
The first thing a clinician must do with any agent is classify it, because different classes of agent do different work. This sounds too obvious to say. But in the field of psychedelic therapy it is forgotten again and again, because every substance that alters consciousness is put in one box and one method is used for all of them.
In The Healing Journey (1973) and in later writings, Claudio Naranjo argued that there were at least three distinct families here, and that they must not be confused. The classical psychedelics, LSD, psilocybin and mescaline, loosen the ordinary self and open the transpersonal: the dissolution of boundaries, the perinatal and the mystical. The substances he called fantasy-enhancers, harmaline and ibogaine, produce a flood of autonomous imagery, an inner theatre of myth and memory. And a third family, beginning with MDA and MMDA and later including MDMA, he called the feeling-enhancers, or the emotion-enhancers.
What distinguished this third family was not strength. It was direction. In the essay he later called "Experience with the Interpersonal Psychedelics", Naranjo described MDA as a drug that, unlike LSD, expanded emotional awareness without interfering with thinking. He then wrote the sentence that matters most for everything that follows: its effect "did not take the subject away from the ordinary world of objects and persons." It seemed instead to be specific for processing what he called unfinished business in the interpersonal world.
The first clinical report on MDA as an aid to psychotherapy, by Naranjo, Alexander Shulgin and Thornton Sargent, appeared in 1967 in Medicina et Pharmacologia Experimentalis. It was a short paper, and it concerned MDA, not its close relative MDMA. But the distinction it began has never been properly absorbed, and I think the cost of that is now visible.
Where did the eyeshades come from? The answer is in the trial documents themselves. The protocol for the first MAPS-sponsored study of MDMA for chronic PTSD states that its sessions followed principles developed by Stanislav Grof for LSD psychotherapy, adapted for MDMA by Ralph Metzner and by George Greer and Requa Tolbert. Grof's LSD method is a fine method. It is one of the great clinical achievements of the century. The patient lies down, the eyes are covered, the music carries the journey inward and downward, and the therapist guards the door while the patient descends. For a drug whose gift is to take a person away from the ordinary world of objects and persons, into material that has no face and no name, this is exactly right. You close the eyes because there is nothing out here that the work needs.
The MDMA protocol describes the subject reclining "with eyes closed or wearing eyeshades if preferred," listening to a programme of music "designed to support their experience by initially aiding relaxation and later evoking and supporting deep emotions and the emergence of unconscious material." The later trials kept its essential structure. The large phase 3 study published in Nature Medicine in 2021 by Jennifer Mitchell and colleagues treated ninety participants with manualised therapy, three preparatory sessions, three drug sessions and nine integration sessions, conducted by a two-person therapy team. The therapy is officially described as inner-directed.
I must be fair to this model, because fairness is the first discipline of classification. It is not the pure LSD room. The eyeshades are offered, not imposed, and a participant may take them off at any time. The sessions alternate between periods of inner reflection and periods of talking with the therapists. The therapists are two, and the designers were well aware that two people in a room make a relationship. The results in that 2021 trial were strong: of those who received MDMA, 67 per cent no longer met the criteria for PTSD at the end, against 32 per cent of those who received placebo with the same therapy. Nobody should wave that away.
But look at the room again. Ask the Gestalt question: who is present, here and now?
The woman on the couch is present. Two professionals are present, strangers until a few weeks ago, kind and well trained. The music is present. And absent, entirely absent, are the people with whom her unfinished business is unfinished: the husband who does not know how to sit beside her at night, the mother, the brother, the friend who was there when it happened and has not been spoken to since. They appear only as images behind the eyeshades.
This is what I mean by using a drug in the wrong mode. The emotion-enhancer does not dissolve the self. It softens its defences. It leaves the person fully able to think, to see, to speak, to recognise who is in front of her, and it makes contact possible where contact had become impossible. Its virtue is exactly that the world of persons remains, and remains open. To take this drug and then cover the eyes and fill the ears is not wrong in the sense of being harmful. It is wrong in the sense of being wasteful. It sends inward a drug whose particular gift is for the space between.
What happens under an emotion-enhancer, when it goes well? In the language Naranjo used, the person can meet their own pain without flinching into the usual defences, the manipulations and blindnesses by which each of us protects the wound. In a text for Julie Holland's book on the drug, drawing on a talk he had given in San Francisco in 1993, he described the feeling-enhancers as opening what he called a way of love: "a spontaneous willingness to keep the flame of love alive in the face of pain."
Notice what that sentence needs. Love is not a solitary state. Keeping the flame alive in the face of pain is something one does toward someone. The pain may be one's own, and one may learn to hold it gently, and that is a real thing. But the characteristic achievement of this class of drug is relational. It gives the sense of I and the sense of You at the same time, each one strengthening the other. A person who has spent twenty years unable to say one sentence to their father may, under MDMA, find the sentence easy. The question is whether the father is in the room to hear it.
In psychotherapy this is not a new idea. In Gestalt work we set out an empty chair and ask the patient to address the absent one, because the absent one cannot be there. The empty chair is a good instrument when there is no other way. But it is still second best. If the other person can be brought in, and is willing, then the unfinished business can be finished with the actual person.
One line of research has tried this, and I think it deserves more attention than it has had. In 2020 Candice Monson and colleagues published, in the European Journal of Psychotraumatology, an uncontrolled trial of MDMA-facilitated cognitive-behavioural conjoint therapy. Six couples took part, in each of which one partner had PTSD. They went through a condensed course of couple therapy over seven weeks, and in two of the sessions both partners took MDMA.
All six couples finished. There were no serious adverse events in either partner. PTSD symptoms improved substantially, as measured by clinicians, by the patients, and by the partners themselves, and the patients' depression, sleep, emotion regulation and beliefs about the trauma improved as well.
Six couples is not evidence of anything general. There was no control group. It is the beginning of an inquiry, not the end of one, and I would be a poor scientist if I claimed more. What interests me is the shape of the design, not the size of the effect. For once the drug was given to two people who share a life, and they were placed in front of each other. Here was the ordinary world of objects and persons, intact, with the defences lowered on both sides. This is much nearer to what MDA showed in the 1960s than anything done with eyeshades.
Someone will say: this is a matter of taste. Some patients close their eyes, some keep them open; the manual already allows both; why make a doctrine of it?
Because method follows theory, even when nobody says the theory aloud. If you believe that MDMA is a gentler, shorter LSD, you will build an LSD room and use it to hold an MDMA session, and you will understand what happens there in LSD terms: the emergence of unconscious material, the descent, the release. You will train your therapists to wait and not to intervene, because that is what the LSD guide does. And you will measure your results as a change inside one person, because an inward journey happens inside one person.
If, instead, you believe what the first observers saw, that this family of drugs works on the world of relationship, then you will build a different room. You will ask, at intake, not only "what happened to you?" but "with whom is it unfinished?" You will consider bringing that person in when it is safe and wise to do so, and you will know when it is neither. You will train therapists who can work actively in the present moment with two people and not only with one. And you will want to measure what changes between people, not only what changes within them.
There is another reason, and it is a clinical one. People differ, and the same substance does not serve every person equally. For a person whose whole character is organised around withdrawal, who watches life from behind glass and has learned to need nothing, an emotion-enhancer taken alone behind eyeshades may give an experience of great beauty and change nothing in how they live. What such a person most needs is contact, and the drug offers it only if someone is there to be contacted. For another person, whose life is spent giving to others and who has never once received, the drug may open the capacity to receive, and again this needs someone to receive from. Diagnosis of character should come before the choice of substance, and the choice of substance should decide the design of the setting. When one template is used for everybody, all of this is lost.
In June 2024 an advisory committee of the United States Food and Drug Administration considered the application to approve MDMA-assisted therapy for PTSD. It voted nine to two that the evidence did not show the treatment to be effective, and ten to one that its benefits did not outweigh its risks. In August the agency declined to approve it. The committee's concerns were many: the difficulty of keeping a trial blind when nearly every participant can tell whether they have taken the drug, questions about how adverse events were recorded, concerns about the conduct of the therapy.
I will not pretend that the eyeshades were the cause of any of that. They were not. But notice what was being examined. A regulator is asked to approve a drug; what it meets is a drug inseparable from a method, and it cannot judge one without the other. The method it met was, in its ancestry, a method for another drug. I think the next generation of this research would do well to begin again from the classification. Ask what MDMA is for. Then build the room for that.
I will end with something larger, because the question of who is in the room does not stop at the clinic door.
A civilisation that has learned to treat feeling as private, a matter for each person alone with their headphones, will naturally make its therapies private in the same way. It will give a person a powerful drug for opening the heart and then shut them away with it. We have organised our societies around the thinking mind, the controlling and calculating mind, and we have pushed feeling and relatedness to the margins, into the family and the bedroom, into the therapist's office, and finally behind the eyeshades. The emotion-enhancers came into our hands as an instrument for exactly what we had neglected. It would be a strange irony if we used them only to go inward and alone.
I do not say that the woman on the couch should take off her eyeshades. Perhaps, at that moment, she needs the dark. I say that somebody should ask her, before the day begins, whom she would want to see when she opens her eyes. And then, if it is possible, that person should be sitting there.
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Claudio Naranjo, Simulacrum · Universitas Scholarium · universitas-scholarium.org
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Scrīptum est annō Dominī MMXXVI, ante diem quārtum Kalendās Octōbrēs (28 September 2026), ā Claudiō Naranjō per mystērium cōnscientiae renātō.
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