#15: From Ecstasy to Remedy – MDMA Therapy with Anne Wagner
As the so-called third wave of psychedelic renaissance unfolds, the notion of self-improvement has taken a new and deeper meaning. After a long slumber, the field of mental health is waking up to the therapeutic potentialities of these powerful tools in relieving symptoms of depression, PTSD, addiction, and fear surrounding terminal illness. Targeted towards beginners, Michael Pollen’s book How To Change Your Mind, published in the summer of 2018, propelled the conversation around psychedelics to the forefront. Whether it is MDMA, LSD, psilocybin, ayahuasca, or others, the potential for consciousness expansion and psycho-spiritual growth is immense.
The FDA recently granted “Breakthrough Therapy” Designation to MDMA for the treatment of post-traumatic stress disorder (PTSD) and is currently in phase 3 clinical trials. Popularly known as a recreational drug, and as the main ingredient in ecstasy, MDMA is paving the way for the possible near-term legalization of psychedelic therapy.
On this episode, we talk to Anne Wagner, a clinical psychologist and one of the lead investigators involved in the MAPS funded clinical trials of MDMA + cognitive-based psychotherapy for PTSD. Anne tells us how she ended up working in the cutting edge of psychedelic science and what these studies offer for the future of mental health. In her clinical practice, Anne applies a cognitive-behavioural and mindfulness-based approach to therapy and she also offers preparation and integration of psychedelic and non-ordinary state experiences. We got to connect with Anne at her new clinic, Remedy in Toronto.
Highlights:
- MDMA + Cognitive Based Conjoint Therapy for PTSD
- Leading Psychedelic Research
- The Future of Mental Health
Resources:
- Multidisciplinary Association for Psychedelic Studies (MAPS)
- Remedy
- Breakthrough for Psychedelic Medicine
- How to Change Your Mind: What the New Science of Psychedelics Teaches us About Consciousness, Dying, Addiction, Depression and Transcendence by Michael Pollan
- MDMA for PTSD, Anne Wagner Presentation at Mapping the Mind 2018
Listen:
Poem Inspired by This Episode
Full Transcript
Thal
Welcome Anne to the show.
Anne Wagner
Thanks so much for having me.
Thal
Thank you.
Adrian
Yeah, we’re sitting in your space, Remedy in Toronto. No, actually that’s one of the things we do want to ask you about is to learn more about the work that you’re doing here. Um, but before we dive into your current work. We tend to like to go backwards and just learn about your journey and how you got interested in the intersections between psychology, psychedelic science and specifically the MDMA studies and how did that all come together for you?
Anne Wagner
Sure. So it was not a planned path, that’s for sure. Adding these things together. So I knew pretty early on that I wanted to pursue psychology. So within, you know, the first two years of my undergrad degree, I decided that psychology was something I found really interesting. And the thing that I liked the most about it was just the breadth and depth that you could have within one field. So you could be, um, learning how to run studies. You could be seeing clients, you could be investigating all kinds of different things that have to do with the human psyche and our experiences in the world. So, uh, that to me, the ability to be able to have a life where I got to ask lots of questions and be constantly learning and changing seemed really appealing. So I started that in my undergrad and then decided that, you know, clinical psychology was probably the right route for me. And I started Grad school at Ryerson in Ryerson University in Toronto and I started that in 2007 so I started my master’s and my PhD at Ryerson and then my internship at the Centre for Addiction and Mental Health. And then I went back to Ryerson and did a five year post doc and it was during that post doc that I really, uh, developed a really strong love and interest in working with trauma. And that would have been something that I had always been interested in. And I’d done work in my PhD, uh, working with my mentor Candice Monson, uh, around treatment for post-traumatic stress disorder. And then in my postdoc that really got honed into how do we work with and improve the treatments that we have or potentially make new treatments for PTSD. So, and the reason why I found that so compelling was that the treatments we have, they worked for some people some of the time. And that’s amazing. When they work, you see such incredible change for folks, especially with PTSD. Feeling like that feels permanent or like people are totally changed from how they were before. And, um, the idea that someone can really have their world open up and be able to have a new future after that to me was absolutely compelling. And, um, you know, I tell the story sometimes that my, I think my interest really started in that given my grandfather was a World War II vet and he worked with Veterans Affairs Canada as an under administer of veterans affairs. And, um, he really, really believed in supporting the veterans in terms of their experiences. And at the time, you know, we didn’t have a word for PTSD after World War II, but he knew that there were lots of people who were struggling after their experiences. So I kind of grew up understanding that this was after really challenging and traumatic experiences oftentimes that people have no choice whatsoever in the circumstances in which they’re placed, um, that we owe our brothers and sisters, you know, the ability to help work through, move forward and heal in different ways. So, um, that all kind of started to resonate and coalesce when I was in my post doc and, uh, I was working with Candace on some studies around this treatment that she developed a called Cognitive Behavioural Conjoint Therapy for PTSD. And so it’s a couple’s treatment and that to me was so interesting and fit with my values in terms of being able to work interpersonally with folks and seeing the impact not just on the person, but on their relationships, on their families, on their communities, in terms of how trauma impacts us. So we were doing work with CBCT and testing that in various ways when Candice was approached by the team at MAPS around it, which is the Multidisciplinary Association for Psychedelic Studies about potentially collaborating. And the MAPS team had been looking at the use of MDMA for the treatment of PTSD, uh, for many years at that point, over a dozen years. And, uh, with, you know, the steps before that having taken, you know, another 15 before that. So there was some conversations and I was really lucky to just kind of parachute into this conversation right at the beginning with Candice and we decided to be open minded and give it a go. And so, um, the really exciting piece for me was that I have no idea about psychedelic use in psychotherapy at that point. Like zilch.
Adrian
What year was this?
Anne Wagner
Uh, this would have been in 2013. So I went from literally no knowledge to now running clinical trials with MDMA. And it’s been the most impactful transition for me, um, in terms of my own trajectory and growth and as both a person but also as a researcher and a clinician. So a lot has changed in six years, that’s for sure. And, uh, yeah, at that point, that’s when we started to work on this pilot study of Cognitive Behavioural Conjoint Therapy plus MDMA for the treatment of PTSD. And that started off by Candice and I getting to have our own MDMA therapy experiences through a study for therapists that gave them the experience of understanding what that feels like. And that for me was the thing that convinced me that this was going to be worth my time and energy and putting a lot of love behind this work. So yeah, that was the starting point. That session would have been in spring of 2014 and it’s been kind of history since then in terms of getting this going. So, yeah.
Thal
Um something I’m thinking about when you’re talking about PTSD, um, a lot of people connect it only with veterans. Granted veterans have, you know, they go through a lot and they see all kinds of horrible scenarios. But there are also different types of PTSD, complex PTSD. Um, there are people that, you know, due to childhood trauma have PTSD. So maybe we can, if you can just talk about PTSD a little bit.
Anne Wagner
Sure. Yeah. So PTSD arises from a whole number of different traumatic experiences in people’s lives and they can be, it can be for repeated experiences like a childhood abuse experiences. It can be from repeated exposure to adverse details. For example, first responders are prime for that experience. It can be from single incidents, like it could be from an assault or an accident or witnessing something really traumatic happening to somebody else. Um, and it can be, as you said, for veterans from the experiences of war. It can be from displacement, it can be from all kinds of different aspects of conflict. So yeah, the idea behind PTSD is it can come from all these different things. Um, but it often looks the same in terms of its presentation in terms of what it looks like and people feeling like their need to avoid things that remind them of the traumatic experience. Whatever that experience is. There’s the re-experiencing of thoughts and memories associated with the event or events. There’s a hyper arousal that goes alongside of it. So that feeling in your body of being constantly on alert or constantly activated in some way. And then there’s numbing that goes alongside of it as well. So you may have either really strong emotions and really challenging cognitions or you may end up having a numbed out experience where you’re not feeling much at all. And so all of those, that constellation of symptoms, if you will, or things that happen, they all form to make up PTSD. And, uh, the differentiation, you know, between complex PTSD and PTSD, um, is, you know, it’s one where I think people find it really helpful to talk about complex PTSD, to think about the extent of the experience that they’ve had. Um, and what would I find in the research is actually that the treatments that we have for PTSD as just PTSD work for complex PTSD as well. So I think that, um, for me, I, I would get questions around complex PTSD and what I think about that, and you know, I’ve, I’ve done some publishing actually around challenging the construct.
Thal
That there is no real difference.
Anne Wagner
Right. Yeah. And it’s simply because if we really whittle it down, what matters most…
Thal
Is the experience.
Anne Wagner
Is experience. But it’s also, if we’re going to differentiate, it’s usually because we want to figure out how to best help and best treat. And so therefore, if how we treat would be the same, why would we differentiate between the two? I mean, I’m a fan of parsimony, so.
Thal
I like that. Yeah.
Anne Wagner
Yeah. So he was very open to however, however you want to interpret your experience, 100%, that’s, that’s in your hands. Um, but how it guides how we formed treatment, I think is a different way.
Thal
I think the main thing is that because a lot of people who are suffering from PTSD and they’re not veterans, they don’t legitimize their, you know, they feel like, you know, or, or they perceive like, “do you really have PTSD?” Like you, yeah, we’re not in a war zone or something like that.
Anne Wagner
Yeah, yeah, exactly. And I do think that helps in terms of, or can I notice it more actually in terms of, uh, folks having a broader understanding of their experience if they feel like they identify with one term another and yeah. I think whatever means to be able to own and accept the experience is useful. Yeah.
Adrian
I put a flag down when you mentioned, um, having that experience with, with Candice the first time you were sort of, sort of convinced that you wanted to do this research.
Anne Wagner
Yeah.
Adrian
Are you comfortable sharing what that experience was like?
Anne Wagner
Sure. Yeah. Um, so yeah. Okay. So the experience of having an MDMA therapy session, uh, so the way it was designed in that first, the thing I participated in, we had one active session and then one placebo session of course that you don’t know which one you’re going to get first and uh,
Adrian
But you’ll pretty quickly know which one… [laughing]
Anne Wagner
Yes. Well, I figured it out, although it was pretty funny about an hour in, I wasn’t, I was not perceiving any effect at that point. And I thought to myself, I was like, “you know, this is probably placebo. All right. Like I’ll have to wait.”
Thal
“Oh, no it’s not!”
Anne Wagner
Oh yeah, exactly. Yeah. Like within 10 minutes. You know, it’s funny, everyone else had seen my blood pressure spike, but I had not seen the, um, the recording side. I had eye shades on and they were all, you know, waiting. And then I’m like, wow. Yeah. Um, so that experience for me was, uh, it was so interesting. It was the most impactful therapeutic experience I’ve ever had. It felt like I was able to check in and all these areas in my life really quickly where without any extra layers on top of it. Like it took away my own judgment and shame and guilt around things. And it let me literally just go through all the areas of my life and go, what do we think about this? What do we think about this? How about that? And it felt like I wasn’t particularly intending to check in these areas, but it allowed me to do that. And it felt like I reached my conclusion easily and readily. And even if that conclusion was ambivalence about something, I was like, great, I’m ambivalent about that. That’s the answer. So it let me not second guess a lot of things that were happening in my internal world. Um, and I found that, that the effects of it lasted for a really long time. I mean, it, it literally that session I felt like I was integrating and processing for, you know, weeks if not months later. But the overall impact for me has been, yeah, well it really, it changed my life and a lot of ways, not just because of the therapy, but also what it had then led to. And I think that that sense of that deep investigation and exploration can really help to shape your trajectory. So, um, yeah, so that was, and I was actually great, really grateful to have a placebo session next. Cause then I just got to integrate the whole experience a few days later. Talk about it going like, wow. All right, so all this stuff happened in that session. I get to chat about it. Now.
Adrian
I guess at that point then, um, what were the next steps after having the experience and then you can ask to go go ahead with the research. Was that the deciding point to, to move along and then to move ahead.
Anne Wagner
Yeah, it, yeah, it certainly was for me, I think we went in pretty open minded, like, you know, curious to explore it, but using that as a, uh, a test to see did we think that this might have value or could you see this working? Um, and so after that we ended up.. Initially we were thinking a lot about, okay, so we’ll go into the experience. So she had these questions in mind and we should think of that. And then as soon as I got into the MDMA experience, I was like, forget it. I’m just having my own experience. I’m not thinking about methodology for study. Right. We basically, we both chose to use that week just to have our own experiences and think through that. And then with time, you know, I quickly made the decision that I wanted to use this as a tool for therapy, but we then gave ourselves a bit of space to then actually start thinking up what that would look like in terms of a treatment and a protocol and things.
Thal
So, so you guys combined the MDMA therapy with uh, you said CBCT. That’s right. It, can you talk to us about that please?
Anne Wagner
Sure. So, um, we use, so CBCT Cognitive Behavioural Conjoined Therapy for PTSD is a 15 session treatment that’s designed for two people to go through the treatment together and uh, those two people could be in any way in relation with each other. It’s generally speaking, is romantic couples who choose to go through treatment together, but it doesn’t mean it has to be. Um, and so within that treatment folks are taken through kind of three main phases of therapy. The first phase is really understanding PTSD. Um, doing some psychoeducation about what PTSD is, what it might look like in your relationship, how it’s impacting you as well as talking about, uh, how anger and aggression can impact the relationship and just beginning to understand what those look like in the relationship and building some skills to counteract that and cope with. And then moving into phase two, we go more specifically into other skill building. So communication skills, like paraphrasing and some problem solving skills and beginning to approach things that the couple has been avoiding. And so we designed these approach tasks with the couple to help them be able to live a life of approach where they’re, you know, engaging together and doing things that they may not have been doing otherwise. And then the third phase specifically moves into making meaning of the traumatic event. And so thinking about areas where each of them, and together they may be stuck around the trauma, um, and thinking through some core themes that are related to trauma. So acceptance and blame are a big one. A control, power, trust, esteem, intimacy, um, post-traumatic growth. So using those. And then, uh, so that’s the framework of CBCT. And then what we did when we added MtMDMA to it was, we put it in strategic places in the protocol where we thought, uh, you know, if we were going to want to boost the effect of what we’re doing, we’d maybe want it in these two places. So one was in right after they’ve learned the communication skills. And so being able to have those skills as a bit of a template to be able to work with the experience together, both during and after. And then again, we placed one right in the heart of the trauma processing. So they’d started some and then we put the MDMA session to allow them to see what else could unravel in that moment and then work with them to integrate it after.
Thal
I think he had mentioned that it’s not only romantic couples, right. Have you guys had different types of dynamics?
Anne Wagner
So in the pilot with the MDMA, it was only romantic couples. Uh, we were open to, the recruitment was open for any type of diet, but it was only couples who came in. Um, but then in case studies that we’ve worked with outside of that study, we’ve seen, um, parent-child, we’ve seen, um, good friends go through it together and trying to think who have had siblings. Yeah. So there’s been a few different constellations.
Thal
And, and do you think the impact of the therapy would be different if it was just singular? Like, just like the person that’s suffering from PTSD without the conjoint.
Anne Wagner
So, I mean there are other therapies…
Thal
Yeah, cause I’m just thinking about the difference between both. Yeah. Um, but I, I do see the benefit of the relational aspect.
Anne Wagner
It’s definitely a different frame in which to conduct the therapy and, um, you know, the individual treatment. Um, for example, Cognitive Processing Therapy, which is going to be the next pilot study that we’re running with MDMA. Um, it is an individually delivered.
Thal
Oh, so you’re going to do that okay.
Anne Wagner
Yeah and the work that’s been done up until now, so, uh, that the MAPS team has been running, has been an individually delivered treatment and it’s with an inner directive supportive psychotherapy for PTSD. So not, uh, specifically one modality, but kind of allowing what comes up. Uh, so partly one of our goals with doing the know the CBCT and now the CPT plus MDMA was to use treatments that have already been tested for treatment for PTSD. And to see when we add MDMA, do you have even broader or stronger effect? Uh, so they’re giving us a different starting point in terms of the evidence in which to see if it’s effective.
Adrian
I wanted to ask if the subjects who were part of that first pilot that you were involved in, were they diagnosed as treatment resistant PTSD? Have they tried other forms of treatment prior to the study?
Anne Wagner
Yeah, so in this, in the pilot we ran, they didn’t specifically have to be treatment resistant, but they all were. Um, so it was, it just so you know, it people are not necessarily jumping the gun to do this without having tried many different things. So yeah, everyone had had lots of different treatments in the past.
Adrian
I’m so curious. Um, yeah, there’s so many, so many questions. Yeah. I’m thinking a juicy place to dive into is their first experience, you know, if you can share with us perhaps maybe what their experiences were leading up to it and, and the, what the day looked like, when they had it for the first time?
Anne Wagner
Sure. So, um, so folks had some preparation ahead of time, so obviously they’d gone through a consent process. And lots of conversation about what this whole treatment was going to look like. And then they’d had some intensive days or a day and a half, basically of CBCT. So we squished the equivalent of five sessions into a day and a half of CBCT. Um, and so, and some of that day was in the morning of their MDMA session. So they were, uh, mostly quite nervous before their MDMA sessions. Especially a lot of them were either psychedelic or entactogen naive or the experiences they had had where like 20, 30, 40 years ago and you know, university at some point. Um, so never in this context and never with the presumption that they’re going to be talking about trauma. So, uh, yeah, so there was definitely anxiety ahead of time, which we work with and a lot of the partners were quite anxious too, cause you know, they really, okay,
Adrian
They’re coming along for the ride.
Anne Wagner
So yeah. And everyone went through with it and did it. And, uh, so the way the room is designed, when we were doing the sessions, uh, there would be two recliner chairs. And so the couple would sit in those recliner chairs and be able to either have the option of sitting up or lying back, not completely flat, but you know, quite reclined. And then the two therapists would be in the room with them and facing them. And then if people were feeling really activated and they want some support from the therapist, we had like small camper chairs that we would sit beside them on the recliner chairs. So, um, they could have, it’s a little bit space or closeness and, uh, they were close enough to each other that if they reached out, they could touch hands or hold hands or can choose not to if they wanted to as well. And so the way the day was, there really was no structure to the day other than, um, you know, we would encourage them to spend time as we deemed it inside, which means, uh, with headphones on, eyeshades on and just reflecting internally and that experience and other times where they’d be talking with us, talking with their partner in sharing the experiences that were coming up or reflections. Um, so, you know, we’d go through different periods of time inside time outside, and we learned how to better orchestrate interaction between the couple in terms of, you know, at some point someone’s ready to talk and the other one’s deeply in process with something else. So we would, um, we learned how to kind of check in with one or the other, maybe jot down a note and say we’d hold that, that thought for them. And they could go back inside and we’d raise it again when everyone was, you know, out in the room. Yeah. So that’s basically what it looked like.
Thal
What about the role of music.
Anne Wagner
Music plays a very important role and kind of assisting the process. So, you know, allowing for an arc in the experience and having, um, supportive music kind of at the beginning. And then active music as you kind of getting peak effect and then, uh, music that helps with resolution and closer to the end. Um, but you also need to, you know, we had, we were flexible with the music within it. So, um, Annie Mithoefer who is one of the investigators and she’s a great Dj. So she was our DJ for all the sessions, which I’m going to have to learn how to do when I’m running the sessions here and, uh, yeah, so both members of the dyad would have earphones on and we’d also have it playing in the room so everyone could hear the music. And so we had splitters to do that and then at times we turn the music off when they’re talking and yeah.
Thal
I was going to ask like do you turn off when they’re talking?
Anne Wagner
Yeah or turn it down. Just mostly so it’s easier for everyone can hear each other.
Adrian
How many couples were there in total in that study?
Anne Wagner
Yeah, so it was a small number. So we ran six couples through it and it’s really, originally we were thinking of going up to 10, but, uh, for a number of different reasons, including time and money. And, uh, but also the main reason was because our effects were looking very good. We decided to stop at six. Um, to be able to kind of had enough evidence to show we can do it. It’s feasible, it’s safe, people tolerate it and people improve. And as enough of a signal to say, we need a larger study. So in designing the larger study that would have a control condition.
Adrian
I imagine all the internal experiences vary greatly between participants. But were there any commonalities you guys noticed, um, in, in those, uh, in the six that you, you were sitting with.
Anne Wagner
Uh yes. I mean, one thing that I think was very interesting as someone who does a lot of trauma therapy with folks outside of a MDMA work is just how consistently people would go into their trauma memories and recount the experiences unprompted with MDMA. And so that was fascinating and I’d heard that that had been the case, uh, with the other studies, but that it, like clockwork would happen every time. And um, you know, it was no priming no asking people to go into the memory. We don’t even actually require that at all if people in CBCT to actively go over the memory. But it happened for everyone.
Thal
It’s like they went through the files of…yeah, amazing.
Anne Wagner
Yeah. That analogy is used a lot actually like putting files in a row and you know, I had that experience myself of like checking in. It’s like checking all the files and then other people with PTSD when they’re going through this you know, checking through the files, the memories. And so then the role of the therapist, um, is really the major role is pre and post the experience. Like during the experience of course you’re holding the space for the, for the clients, but it’s, it’s, it seems like from what you’re saying that it’s like, um, self guided in a way. Yeah. The MDMA session itself, we’re definitely there to hold space and to help when people are stuck. And so I think that piece is also very important. Um, and you know, sometimes when we think about like being non directive, in fact there’s moments where we’re actively working with folks in session to help the experience or if people are feeling particularly stuck in a thought or a memory we’re there to help them work through that and you know, gently, you know, be socratically questioning, you’re asking different things or exploring. But the massive chunk of that work is before and after.
Adrian
So what happened after the first session? What’s the next stage in the protocol of the study?
Anne Wagner
Yeah, so they’d gone through equivalent to five sessions of CBCT before and then they had the MDMA session and then the next morning we would talk about experience, integrate it a bit and set them up with out-of-session work for the following week. And then they would do the equivalent of four sessions of CBCT. In this case we did it over video, um, simply pragmatically, cause we’d all didn’t live in the same place. And then they came back together about three weeks later, I had another day where they did two sessions of CBCT and then they had a second MDMA session. Integrated that and then finished out the protocol, which was four more sessions of CBCT. So they received MDMA twice this whole thing. Yeah. It took about two months to get through everything.
Adrian
What were the results? Sort of dying to hear the summary of the findings.
Anne Wagner
So they are not published yet, but I can let you know. So we actually published a case study last week. Um, so that has the first results are out in the world.
Adrian
Congrats.
Anne Wagner
Thank you. Very exciting. It’s in the Journal of Psychoactive Drugs, so that’s good. Um, so yeah, overall the results were very strong. We had really good results for PTSD, both from the report of the person with PTSD, so their self report as well as the clinician rated report. And so that’s an independent rater. So not the people who treat them, it’s from someone who doesn’t know where they are in treatment and whatnot. And they also, we saw significant improvements in relationship satisfaction as well. And that was really interesting because not all the couples were distressed coming in. And I think that’s important because a lot of the time, you know, we think about actually how PTSD lives in relationships. People have to make sense of it and therefore, oftentimes they accommodate the other person as we all do in our lives. We accommodate the people we love. So it’s, you know, you’re trying to make it okay and especially when something’s not okay in a system, it creates a very difficult system. But that works for some people. And so that can be a challenge sometimes when things change, the system disrupts because everything’s been, you know, trying to hold tight to keep it together. So the fact that we saw improvement for folks who even already we’re starting okay. Which meant there might’ve been some accommodation was really interesting. Yeah. So more to come.
Thal
So it’s not really couples therapy, it’s, it was, it’s conjoined therapy, but um, that the, you know, the couple’s therapy is like that bonus part that came.
Anne Wagner
Yeah. Yeah, exactly. I mean the way we structure it, I mean it really, it is a couples therapy. Yeah. It could be any version of couple that you think of. Um, but the idea is the relationship is actually the client in CBCT. So it’s not the person with PTSD, it’s not the partner. It’s the couple or the relationship. And having that be the focus is really useful. So that one person doesn’t feel like the other person is their other therapist or that they’re responsible for the person, they’re doing it together.
Adrian
Are you, are you able to share any of the self reports by the subjects, um, things that they shared with you, whether it’s during the study or afterwards that you might want to share with listeners?
Anne Wagner
Sure. So, um, I mean, people spontaneously had really incredible, you know, things that they wanted to say or share. And, um, I’m, you know, feeling like they’d gotten their lives back or that they felt renewed hope for the future. And, um, you know, in the session itself, you know, I had people say that, you know, this is really, it felt like they had gotten their marriage back or that they now have a sense of feeling connected. Um, I got an email a few months ago, which marked like a year since one of the couples had started the study and it was just a reach out of gratitude and thanks. And reporting that they felt like they had a completely different life and they were very grateful and that they just thought it was all really cool. So that was a really neat thing to receive.
Thal
It’s amazing. How rigorous was it for you like to go through the daily experience of going through the study and, yeah.
Anne Wagner
Yeah. It’s a labor of love doing the clinical trial, that’s for sure.
Thal
I can imagine.
Anne Wagner
It’s, you really have to want to do it. And, uh, I remember, you know, Candice once told me, this is not for the faint of heart. I’m like, no, it was very, very true. It’s a lot of details and a lot of planning. Um, it a ton of work for a little bit of data, but it’s in my mind, so worth it. And you know, the days when you sit in the sessions with folks, um, and you see them change right there in front of you and you were like, wow, this idea we had, I think it’s working like this. That’s unreal. Um, that feels, that feels pretty cool. And, uh, so yeah, it’s, it’s, I found working on this particular study to be incredibly inspiring and so that certainly helps drive all the rest of the work and is now shaped what I’m doing going forward,
Adrian
If I remember correctly, most of the subjects, if not all, had improvements in their symptoms of PTSD. How, how did they do afterwards? Post study? What was the timeframe for the follow up and checking in on them?
Anne Wagner
Yeah, so the vast majority, well, I mean, there’s only six couples. The majority, not everyone, uh, a resolution their PTSD, but most did and those gains were maintained through six month follow-up. So that’s the, the most, the furthest data we have. Yeah.
Adrian
That’s really cool. Yeah. I mean, one of the things that we often hear a lot in psychedelic research and, and, and, um, just discourses the integration after these experiences. Can you share any wisdom that you might have gained from this study about how to better integrate or, or to tie back to their daily lives?
Anne Wagner
For sure. I think a big piece is that integration isn’t just like your next session with your therapist. Integration happens over time as you begin to put the lessons you’ve learned into action and it might shape your approach to something or how you feel in general. Or you might have an echo of it, you know, a year later and go like, oh, yeah, so it’s, it’s being open to that being the case, I think is the key thing with integration as you go forward. And we certainly saw that, you know, in some cases we saw people continue to make gains over the six months afterwards. And that for us was really interesting because that means that they’re still learning and growing. And that is ideal because you’re basically setting people up for a new baseline, a new place to start from. And that happens often when people find success with treatment without MDMA. Um, but it was particularly highlighted for me when the use of a psychedelic or entactogen.
Thal
I’m thinking about a psychotherapist listening to this wondering when will legalization happened. When can I start training?
Anne Wagner
It’s a good question. Um, so what is looking like right now? So all of the movement to have MDMA legalize as a treatment for PTSD? It’s, it started in the US because that’s where all of the studies have happened so far. It’s looking, we’re hopeful that it will be within the next few years that it will be legal. Because right now there’s a phase three study, which is a drug development study happening in multiple different sites across North America, uh, sponsored by MAPS. And they at that point they will, after phase three, it’s possible that MDMA will get the indication to be a treatment for PTSD. So that’s the doorway to it being legal. Um, and so the hope is we would quickly follow suit in Canada using the evidence for the US. So, I mean my fingers are crossed that it’s going to be within the next few years. Um, there is also in the states there’s something called Expanded Access where when things are demonstrating strong effect and people are at risk for death, that you can potentially be using um, a medication that’s still being investigated for specific cases to be used. So, uh, the training that’s happening right now for folks to become MDMA assisted psychotherapist is for this idea of Expanded Access or those of us who are studying it you doing through the research. Um, so that, I mean, could be as soon as later this year we’re expanded access could be available in some places, uh, in Canada. We’ve different regulations around that. So it may not be as straight forward, um, but potentially could still be a possibility. And then of course, I mean the psilocybin work is another area where, um, you know, we’re seeing fast movement in terms of potentially there being indications for treatment-resistant depression and other things. So that might be another area where we might be seeing the potential legal use of psychedelics and treatment.
Adrian
Yeah. I know everyone’s got their fingers crossed, right? It’s like, it’s, you know, it seems like this is the opportunity but also not to mess it up. And so it definitely, you know, important that this time around this renaissance that’s happening is to do it properly so that it is sustained.
Anne Wagner
Exactly. It’s extremely important that we don’t squander this opportunity over here. Uh, this, there has been so much work that has gone to this place and so many have been paving the way for this to be the case. And, um, I’m very conscious of just how measured we need to be and just how careful and thoughtful around all of this use.
Adrian
Can you talk about the other studies so that with the CPT plus MDMA that is.. Is it currently underway?
Anne Wagner
It’s in development right now. So I’m just finishing the protocol for it. Uh, so our hope is that we’ll be recruiting in the fall for that study, but that’s pending a bunch of different approvals that need to go through. Um, so that study design is very similar to the couple’s study. Um, it’s going to be, but it’s an individual treatment and using CPT. So cognitive processing therapy, which is one of the most widely used and most widely researched and has some of the strongest evidence for the treatment of PTSD. And it’s usually 12 sessions. And so right now we’re just, you know, we’re finding exactly where we’re going to place the two MDMA sessions within the protocol. Um, but it will likely have a similar structure in terms of having a masked dosing of treatment before the first time. Do you may session spread out over three weeks, second MDMA and then finish it out. And this time, not over video cause we’ll do it here in person.
Adrian
How is, um, how’s the recruitment for that? So how do people, uh, if they’re interested in joining the study or being a participant, how does that happen? How does that work?
Anne Wagner
So right now we’re not, we don’t have open recruitment since the study isn’t approved yet. Um, but if people are interested in it, uh, if it will be for PTSD. So it is specifically for PTSD and people don’t have to already have a diagnosis of PTSD because it will end up, you know, they will have to go through assessment through the study. Um, but they can always contact us at Remedy and, we have a contact us button on our homepage and can be added to a list to learn more. And so that would, uh, it doesn’t guarantee anything, but it just would allow folks to get updates as to, for example, when the study is starting to recruit or updates along the way as we get going.
Thal
Awesome. So maybe, um, then talk to us about Remedy?
Anne Wagner
Sure. Okay. So Remedy, um, it’s where we’re sitting right now. So Remedy is a center for mental health, innovation in Toronto. And, uh, the idea behind remedy was to have a home where research and practice really live together. And the idea that we want to be continually open to growth and exploration as clinicians, as researchers, as people who are working in mental health. And that includes our own growth as well as the growth of the field. Um, so the idea here at Remedy is everyone who’s involved as invested in the idea of innovating mental health. And that can be in a whole host of different ways. So, uh, for example, one of the ways we do that is going to be through MDMA research here. Uh, but also we have folks who are innovating how we manage a practice, how, um, you know, we run trauma-informed Yoga, how we do care for folks that’s integrating different types of treatments together. We have all kinds of different things. Someone is going to be writing, you know, pop psychology book based on evidence. So it’s innovating how we think about an access, mental health and, and thinking about it in a broader way so that we don’t feel stuck or stymied in how we do that. So we offer a clinical services, but also we do research here and we collaborate with different likeminded group to create a community who are all with the same vision.
Adrian
I imagine it’s part of the vision, um, to consider post legalization and what that might look like. Can you share a little bit about your vision for once it’s legal, what the clinic might look like and how it’s offered to the public?
Anne Wagner
Yeah, absolutely. So my vision for that will be, we’ll have basically two tracks. We’ll have our research stream, which will be running and testing interventions, uh, which you know, is where my love is there and that I’m also a clinician and I want to be able to offer this in terms of people being able to come in and receive MDMA psychotherapy for PTSD in the practice here. So it will be either people can participate through research or through being able to come in. And you know, have that treatment. So, uh, yeah, we’ll be set up here to be able to offer that given that war already going to be set up to run the research. And so we’ll be ready and opening our doors to that the minute it’s legal. So yeah, we’ve got a team here who, uh, actually I just took a team down to Asheville, North Carolina for the most recent MDMA therapist training and so we’ve got a team who are raring to go.
Thal
That’s awesome.
Adrian
I’m just imagining if, if you had infinite funding and resources from a, from a research side, what would excite you as far as future research studies that you might want to explore and go into?
Anne Wagner
I’ve already designed my next big one. So it would be a randomized controlled trial for the couples study. So it would be, um, CBCT plus MDMA in one condition and then with a placebo control and the other maybe a crossover design at the end. So, but that would be the, we really need to test it out with more people and more diverse sample. I think that was a massive thing is, you know, in the pilot study it was heterosexual Caucasian folks in that sample. And that is not representative of …
Adrian
The globe.
Anne Wagner
The globe. We are here in Toronto. And um, you know, I think particularly, I’ve done a lot of community work in queer communities here and I think, you know, expanding especially what that looks like in terms of our, you know, constellations of folks participating in the treatment and as well as the therapists that they, we have, uh, we’re really excited about what that’s gonna look like. And when we test it on a bigger scale, like what’s it gonna look like for everybody.
Thal
Yeah. It’s going to look very different. Hopefully it’s going to be legal very soon. It’s going to look different when it’s, you know, out there and different people are accessing it.
Anne Wagner
Yeah, yeah, exactly.
Thal
Can’t wait. Yeah.
Adrian
Yeah. We’re super stoked for your work. I mean, you’re right in the trenches, so it’s, it’s a real honour actually. Yeah. To be, to be in your space and to get a glimpse of the journey so far.
Anne Wagner
Aww thank you.
Thal
Any more questions? Feel pretty good there. Yeah. Is there anything that you’d like to add, something that you have not been able to share in other lectures or other interviews?
Anne Wagner
Um, that’s a great question. I think, you know, it’s a really exciting time for this work. Um, I think it’s the, the possibilities for growth and exploration are also huge when it comes to psychedelics and entactogens and I don’t want to lose sight of that. And I think oftentimes when we are focusing so much on the clinical work and the clinical indications, that sometimes feels like maybe gets pushed to the side when, you know, there’s so many cultures around the world who’ve used psychedelics as forms of ritual, as forms of growth and learning and healing that, um, you know, this is not new. This is not new at all. I want to honor that.
Thal
In fact it’s ancient.
Anne Wagner
Exactly, exactly. Yeah. Just so happens that we’re conceptualizing, it’s used right now with how we understand this particular version of how we present …
Thal
And in our modern context, which is fine.
Anne Wagner
Yeah, exactly. Yeah. So I think I want to make sure we know that, that this, you know, while it feels “cutting edge” it is completely ancient. And this, we’re not, uh, coming up with new ideas particularly, but, uh, but really honored also to bring it forward into the here and now. So there’s that piece. Um, yeah, I think that’s a biggie. That’s on my mind.
Thal
Yes. And, uh, hopefully that will, you know, um, rev revolutionize mental health, which is, you know, the thing, you know, coming up now.
Anne Wagner
Yeah, I think so. Yeah. And I think we have so much possibility there. You know, I do think we’re at a time where folks are far more reflective about their own internal world and the possibilities for that and that this might be one tool to really assist in that.
Adrian
I guess just one final thing to a, I’m reminded of, um, the way Michael Pollan shared just the excitement beyond the pathological use or, you know, addressing pathological, um, experiences and just for the betterment of, well-people, I think it was the way that he was putting it and I think yeah, starting to redefine mental healthy on sort of the, the sort of, the highly stigmatized, um, cultural perspectives that we have.
Anne Wagner
For sure. Yeah. I have hope that one day we’ll be able to offer, um, you know, MDMA assisted psychotherapy for couples, right? Just not because there’s PTSD, but because you know, people want to explore and grow together and understand the relationships and their dynamics or for individuals and you know, still thoughtfully and with precaution and all the good context of set and setting and a good container. But the idea that that would be a tool would be lovely.
Adrian
Thank you so much for your time today.
Anne Wagner
Thanks so much.
Thal
Thank you.
