MDMA-AT as facilitated communication for the "inner healing intelligence"
On my new bioethics commentary in the American Journal of Bioethics.
A quick thank you to everyone who has sent me kind messages since my last update! I’ve been so grateful for them.
For this post, I’m sharing my new commentary article that was just published in the American Journal of Bioethics. As I was piecing together the analysis for this commentary over the summer, I realized that bioethicists did not understand the full risks of MAPS/Lykos’ MDMA-assisted therapy (MDMA-AT), which MAPS had couched in euphemisms.
Since these euphemisms were so successful at diverting attention from MAPS’s full (undisclosed) protocol, the highest-risk applications of touch in MDMA-AT had never even been discussed in the bioethics literature on psychedelic therapy. I felt a moral and professional responsibility to call attention to the these omissions, and to their implications for the psychedelic research field.
I’d been in the process of looking for journals that publish bioethics commentaries, most of which require advance topic approval or — commonly — a direct invitation from the journal’s editors. I received this email from AJOB just as I was preparing a proposal for this topic:
“We would like to invite you to write a commentary for an upcoming Special Issue on Psychedelic Ethics in the American Journal of Bioethics, featuring articles from Glenn Cohen & Mason Marks, Katherine Cheung et al., Logan Neitzke-Spruill et al., and Tahlia Harrison et al. (all attached). You may either respond to specific article(s) or write on the topic as a whole.
“These Open Peer Commentaries are among the most cited articles in bioethics, and offer you an opportunity to highlight, in brief comment, your own work and disciplinary perspective on an issue where your own expertise is widely recognized.”
The full articles in this special issue — which discuss topics including the ethics of touch in psychedelic therapy, and the risks of deviating from bioethical guardrails based on “psychedelic exceptionalism” — provided a fitting context for what I had to say.
Before the publication of this issue, I shared the details of my commentary with journalist Hannah Harris Green, who referred to it in an article for The Guardian at the end of November:
“Neşe Devenot, a bioethics researcher affiliated with Johns Hopkins University and the psychedelic harm reduction non-profit Psymposia, organized opposition to Lykos’s treatment. Their research, which has not yet been published, found “the therapy component was based on pseudoscience very similar to Facilitated Communication,” a discredited technique ostensibly intended to help disabled people communicate, that actually gives their “facilitator” power to speak for them.
“[Robert F Kennedy Jr] boosted claims that Devenot’s opposition stemmed from hatred toward veterans, and blasted the FDA’s decision, suggesting it illustrated collusion with the pharmaceutical industry.”
Since the commentary is behind a paywall, I’m including the text below, after a short introduction:
Some preliminary context
Around the time I was in graduate school, I became fascinated by “facilitated communication” (FC) — a technique that claims to help nonverbal individuals express their thoughts with assistance from a facilitator, who physically supports the individual’s arm as they type messages on a keyboard. Despite widespread belief in the accuracy and validity of these messages among FC’s facilitators, extensive research has attributed authorship to the facilitators themselves. FC ultimately results in unintentional ventriloquism, and yet a global industry of “true believers” continues to promote its authenticity — at the expense of the vulnerable people that FC purports to serve.
It wasn’t until this past year — a decade later — that I realized MAPS’s model of MDMA-assisted therapy (MDMA-AT) is vulnerable to the same biases that mislead FC’s facilitators to falsely attribute authorship to their clients.
Effectively, MDMA-AT’s “focused bodywork” is facilitated communication for the “inner healing intelligence.” The risk of harm from therapists who have been trained to amplify traumatic symptoms by touching their clients with undue confidence — based on the therapist’s subjective attunement to “what the inner healer is trying to express” — is unacceptable. These pseudoscientific foundations of MDMA-AT are incompatible with any evidence-based treatment for PTSD.
I first encountered FC from reading about the case of Anna Stubblefield, which has received renewed attention due to a recent documentary on Netflix, Tell Them You Love Me. Although Stubblefield was a professor of philosophy at Rutgers University with expertise in disability studies, FC’s ability to produce the feeling of genuine attunement led Stubblefield into delusion. Believing that she was developing an intimate, consensual relationship with her client, Stubblefield used FC to inform the client’s family that the pair had initiated sexual contact. Stubblefield was criminally charged, and she ultimately pleaded guilty to “third-degree aggravated criminal sexual contact.”
With both FC and MDMA-AT, the majority of facilitators do not sexually abuse their clients, but such abuse is a predictable result of these flawed methodologies.
To reiterate what I’ve said in previous posts: not all MAPS therapists were trained in Grofian focused bodywork, but this was a core feature of MAPS’s therapy model, and MAPS specifically hired Grofian therapists who were familiar with focused bodywork and “nurturing touch.” As I mentioned previously, MAPS co-PI Casey Paleos acknowledged that MAPS discouraged its clinicians from looking into the somatic elements of its therapy model if they weren’t already trained in it:
Casey Paleos: We were taught [by MAPS that] if you're already certified in one of these somatic-oriented psychotherapies, or somatic therapies...for trauma that involve touch, and you have proficiency in doing that, and that's part of your scope of practice, that's okay. Then you can use that. […] You already know how to do that ethically, and you’re doing it already in your practice. Then we were instructed that it's okay to incorporate that into the work that you're doing [in the clinical trials].
Hamilton Morris: And what might that entail?
Casey Paleos: I don't know, because I'm not a somatic therapist. (Laughs) But for those of us who weren't trained a somatic therapist, what we were taught is you shouldn't be trying to learn a new skill around touch therapy to be a part of this clinical trial. That was — we were explicitly told not to do that, because this is not the right circumstance for you to be learning this from scratch.
From other sources (some of which I cite in my previous substack post), it’s clear that many MAPS therapists were trained in Grofian “touch therapy,” and that they used this approach in the MDMA clinical trials.
By sanctioning therapists to use (Grofian) focused bodywork with clients, MDMA-AT created conditions where therapists could easily mistake their own projections as authentic telepathy about their client’s best interests. And since MAPS’s model of MDMA-AT promoted an environment characterized by intimacy, where therapists’ physical expressions of love were framed as healing, the therapy created an acute risk of harm. As I mention in my commentary, the therapy model conditioned therapists to project their own desires onto the “inner healing intelligence,” and to frame submission to those desires as inherently therapeutic.
This specific pattern of abuse is endemic to the psychedelic underground, where MAPS’s therapy model was initially developed. (Kayla Greenstien and Will Hall discussed this mostly unacknowledged pattern of psychedelic therapy abuse in a recent essay on Mad in America, which I encourage everyone who works in the field to read.) This exact pattern of abuse also matches the case of sexual assault that occurred during MAPS’s Phase 2 clinical trial in Vancouver.
By reading the research literature on facilitated communication alongside the “undisclosed” aspects of MAPS’s therapy model — especially the elements on Grofian touch, which were only known to insiders — it becomes clear that MAPS’s dangerous, pseudoscientific methodology created the conditions for the abuse that occurred during Phase 2.
I have much more to say about these connections, and my evidence extends far beyond what I was able to share here. This commentary is a start.
Note: The Version of Record of the following manuscript has been published and is available in American Journal of Bioethics, 13 Jan 2025, https://doi.org/10.1080/15265161.2024.2433416
My AJOB commentary, “Focused Bodywork as Facilitated Communication: Cautionary Perspectives on Touch in Psychedelic Therapy”
On August 9, 2024, the FDA declined to approve Lykos Therapeutics’ application for MDMA-assisted therapy (MDMA-AT), in alignment with the recommendation of its independent advisory committee. In its decision, the FDA requested a new Phase 3 clinical trial to collect additional data on the drug’s safety and efficacy. Although Lykos (formerly MAPS PBC) has not released the FDA’s Complete Response Letter, employees familiar with the letter shared that the FDA sought to impose significant new requirements for any future clinical trials (Hardman 2024). The FDA’s decision led to significant debates among researchers, clinicians, and bioethicists about the role of psychotherapy in psychedelic clinical trials, with many interpreting this as a signal to remove psychotherapeutic adjuncts from psychedelic trials altogether. So far, these debates have overlooked the most significant ethical issues with the psychotherapy component employed in Lykos’ clinical trials, MDMA-AT. While some discussions have examined the ethics of supportive touch (e.g., a reassuring hand on the patient’s shoulder), there has been no open discussion of the serious risks involved in MDMA-AT’s focused bodywork, which is foundational to the therapy model.
MDMA-AT was developed by illicit, “underground” practitioners during the decades since prohibition, when MDMA was more acutely stigmatized. Due to the stigma associated with these practices, descriptions of MDMA-AT employed euphemistic language (like “non-directive”) that presented a misleading picture of the intervention. Although Lykos replaced “non-directive” with “inner-directed” after the initiation of its Phase 3 trials, Lykos’ protocols still included incomplete descriptions of the uses of touch in MDMA-AT. These omissions have resulted in significant misunderstandings about the intervention among researchers and clinicians trained in conventional psychiatry and therapy. This impact is particularly evident in the bioethics literature, which has yet to critically engage with the highest-risk applications of touch in MDMA-AT.
To begin this conversation, it is necessary to move beyond the euphemisms and critically examine the underlying conceptual framework of the therapy model. According to MAPS Founder Rick Doblin, “the entire therapeutic approach that we have in the MDMA studies” was based on Stanislav Grof’s transpersonal teachings (Doblin 2015, 109). According to a 2012 article published in the MAPS Bulletin, Grof developed the guidelines for applying touch as “focused bodywork” in MAPS’s treatment manual (Richardson 2012, 18). Since “the essence of the [MDMA-AT] treatment approach” was the “death-rebirth” process that is also facilitated by Grof’s holotropic breathwork (HB), MAPS recruited therapists who had been trained by Grof in HB (Doblin 2015, 109). Lykos therapists who were familiar with HB (and with the underground context where HB was popularized) would understand that MDMA-AT was euphemistically described as “non-directive” in reference to the Grofian “inner healing intelligence,” which diverges substantially from the “colloquial” interpretation that psychedelic ethicists had commonly assumed.
Grof’s adherents believe that MDMA facilitates a “holotropic” state, wherein the ego’s normal boundaries and defenses “soften” like a dilating cervix. Once liberated from its habitual restrictions, the participant’s “inner healing intelligence” begins processing embedded trauma imprints, which may spontaneously emerge—in the order that is most accessible for processing by consciousness—through a series of symbolically charged scenes. This can include “vivid reenactments of traumatic…memories” that may progress to “psychodramatic enactment of struggle” with a therapist via focused bodywork (Grof 1980, 64, 120). This can involve therapists using touch to “amplify” distressing symptoms, since emerging trauma imprints must be “fully experienc[ed] and express[ed]” for healing to occur, according to the model (Mithoefer et al. 2015, 27).
Phase 3 clinical trial therapist Veronika Gold acknowledged using “the same [focused] bodywork as Stan [Grof] taught in holotropic breathwork” within “the MDMA clinical trials,” which involved “connecting with the symptoms [of trauma] in the body, and…making them stronger” to facilitate their processing (Psychedelics Today 2019, 39:45). In a case study describing this use of focused bodywork in her ketamine practice, Gold acknowledged pushing against a patient’s hands during a struggle that escalated over several minutes, as the patient shouted: “Go away! Get your fucking hands away from me!” (Butler, Herzberg, and Miller 2024, 116). Since the patient did not say a preestablished “safe word,” Gold determined that the patient’s demand was directed at the patient’s inner experience of a traumatic perpetrator, which ensured that Gold should continue applying physical resistance.
This reliance on a “safe word” to moderate therapist touch during a “psychodramatic enactment of struggle” was already present in MAPS’s 2015 MDMA-AT manual: “This convention will avoid confusion between communications that are meant to be directed to the therapists and statements that are expressions of the participant’s inner experience” (Mithoefer et al. 2015, 16). This version of “focused bodywork” was a central feature of the on-camera physical and sexual assault that occurred during MAPS’s Phase 2 clinical trial in Vancouver (Rosin 2022). In 2021, the victim-survivor submitted a personal impact statement to the FDA, which called for an investigation into MDMA-AT’s practices to protect the safety of future patients: “Abusive practices were normalized within the clinical framework, as therapeutic and necessary. As video evidence reflects, this included my being blindfolded, gagged, pinned and violated even as I screamed and fought; begging my therapists to stop.” Lykos has never acknowledged that this assault was facilitated by MDMA-AT’s reliance on Grofian bodywork, which has no empirical support for its use (Devenot et al. 2022).
Because of Lykos’ reliance on euphemisms like “non-directive,” there has been no meaningful ethical discussion of the risks of relying on “safe words” to moderate “psychodramatic enactment of struggle” in psychedelic therapy, which is exacerbated by bodywork’s reliance on therapist intuition. At its core, MDMA-AT taught that therapists can telepathically “attune” to their patients’ needs through the “relational field,” which enables therapists to sense when patients’ distress is within an acceptable “window of tolerance” and conducive to healing: “Skillful therapists in the Phase 3 trials cultivated awareness of, and dynamically responded to, whatever was unfolding in that field, tracking the participant’s—and their own—internal (i.e., cognitive, emotional, interoceptive, somatic), interpersonal, and transpersonal experiences as they emerged in a moment-to-moment way” (O’Donnell et al. 2024, 9). Grofian therapists with underground experience were acculturated to believe that self-reflection on the purity of their intentions could ensure the accuracy of such attunements and serve as a safeguard against ethical violations: “Practitioners spoke of self-awareness in terms of keeping an eye on one’s personal comfort levels…. They felt that this form of self-awareness and being honest about one’s inner state could be preventive of ethical lapses” (Brennan 2022, 125). This is a scientifically discredited premise that increases the risk of boundary violations, however.
Due to “psychedelic exceptionalism” and transparency deficits in public-facing accounts of MDMA-AT, psychedelic bioethics has not yet reckoned with this model’s methodological similarities to facilitated communication (FC)—a scientifically discredited technique that purports to enable nonverbal individuals to express their thoughts. By relying on intuitive “attunement” to an external agency that has been physiologically blocked (in this case, by trauma), MDMA-AT risks amounting to facilitated communication for the client’s “inner healing intelligence.” Despite strong belief in the fidelity of messages among FC facilitators, scientific testing has demonstrated that messages originate from the facilitator rather than the client. In controlled studies where facilitators and clients were shown different images, the typed output reflected the facilitator’s image every time (Simmons, Boynton, and Landman 2021, 148). Decades of research have conclusively revealed that while FC facilitation produces an intuitive sensation of the client’s external agency, the methodology actually results in ventriloquism, influenced by a complex interplay of factors including ideomotor effects and confirmation bias (Simmons, Boynton, and Landman 2021, 155–58).
There is a significant risk that these biases will foster undue confidence in the use of touch in MDMA-AT, while patient vulnerability is intensified by MDMA's pharmacological effects in a context marked by power imbalances (McNamee, Devenot, and Buisson 2023). Michael Mithoefer—a trial therapist and lead designer of Lykos’ therapy protocols—believed that Lykos therapists could sense what participants’ inner healing intelligence was expressing, “even when [the participants] can’t see it themselves” (The Psychedelic Guide 2024, 13:43). In a 2005 version of the MDMA-AT Teaching Manual, therapists were instructed to inform participants that focused bodywork amplifies what the participant’s inner healing intelligence is communicating, even if the participant perceives the action as originating with the therapist: “The therapist must be careful to take his or her cues about touch from the experience of the participant and to help the participant avoid the misconception that the therapist is the source, rather than the facilitator, of his or her therapeutic experience” (Ruse et al. 2005, 48).
These shared features of FC and MDMA-AT amount to pseudoscience, and they have already subjected vulnerable individuals to harm, including sexual abuse. In one prominent case, FC influenced a Rutgers University professor to believe she had developed a consensual relationship with her disabled client, resulting in a criminal charge of “aggravated criminal sexual contact” (Simmons, Boynton, and Landman 2021, 158–59). Within MDMA-AT—which promotes an environment characterized by intimacy, where therapists’ expressions of love are framed as healing (Brennan 2022, 229–30)—there is a high risk that therapists may project their own needs and assumptions onto the patient’s “inner healing intelligence,” and subsequently frame submission to those assumptions as inherently therapeutic. Even in well-intentioned cases, focused bodywork’s reliance on intuitive touch creates a vector for bias, which is likely to disproportionately impact the most vulnerable demographics.
In a recent commentary on FC that is equally applicable to MDMA-AT, the authors—Amy S.F. Lutz and psychedelic ethicist Dominic Sisti—articulate a mandate for bioethicists to speak up against pseudoscientific practices when the welfare of vulnerable groups is at stake: “As a field, bioethics has an explicit obligation to defend vulnerable populations from abuse and exploitation…. We understand why it is tempting to avoid this debate—in an era that privileges lived experience, those who challenge the authenticity of…FC are often attacked as ‘ableist’ perpetrators of ‘epistemological violence’. But there is too much at stake to be intimidated…. We who work in bioethics…should be guided by scientific fact and publicly reject pseudoscience, no matter how hopeful or affirming” (Lutz and Sisti 2024). From this stance, psychedelic ethics should move beyond exceptionalism to expect greater transparency and accountability in psychedelic therapy protocols, which is a precondition for developing safer psychedelic therapies. Simultaneously, we must commit to supporting—and protecting—those who are working to identify systemic issues, before patterns of harm are allowed to scale.
Terrific writing, as always, Neşe! Do you think pseudoscientific artifacts of MAPS’ treatment approach will be intentionally/unintentionally incorporated into treatment protocols for the new phase three trials, assuming they launch?
I used to practice facilitated communication when I was in grade school…with my friends and a Ouija board. Great article Nese.