Two hands exchanging a pill.

Let Go and Surrender: Considerations on MDMA Couples Therapy and Coercive Control

Note from Susannah Baruch, Petrie-Flom Center: Following this recent post in the Critical Psychedelic Studies symposium on the Bill of Health blog, two sets of researchers whose studies were described in the post expressed concerns that the post contained inaccuracies. As the Executive Director of the Petrie-Flom Center, which publishes Bill of Health, I made the decision to temporarily remove the original post to look at the issues carefully and to give the author and researchers more time and space for discussion. The original post is now back up [below] with an addendum from the author. My thanks to everyone involved for being helpful and patient while we gathered more information.

By Kayla Greenstien

From 2016 – 2022, I worked in client-facing community support work, focusing on domestic abuse and sexual assault. Throughout this time, I regularly witnessed how the mental health system struggled to respond to non-physical violence in the form of coercive control — an insidious form of abuse that involves intimidation, threats, and manipulation to restrict the autonomy of another person. On countless occasions, I saw coercive and controlling behavior entirely attributed to mental illness, resulting in missed opportunities and devastating injustices. Outside of work, I also started to notice how little of the content in my psychology coursework discussed domestic abuse. Little (if any) content focused on the psychology of people who engage in abuse and coercive control. Despite more open discourse on domestic abuse, it seemed like the mental health system was still deeply reticent to talk about power and control.  

At the same time, a new wave of research on psychedelic and MDMA therapy was underway. In 2021, I signed up for a psychedelic therapist training program, and the next year I started a PhD in Australia, studying the theoretical underpinnings of psychedelic therapies. I saw psychedelic therapy as a “paradigm shift” in mental health care. I wanted to believe psychedelics could get rid of the patriarchy, just like Ben Sessa said it did at raves in the 1980s. (Sessa is now facing medical practitioners’ tribunal in the U.K. for an alleged relationship with a patient.) But as I learned more about the theories and practices accompanying clinical trials of psychedelics and MDMA, I found misogyny, queerphobia, and alt-right New Age spirituality woven throughout. When multiple reports of sexual abuse emerged from underground, ceremonial, and clinical trial settings, I heard the same tropes that are used to discredit women in court: “It was a consensual relationship…She has BPD and manipulated him…This is all about a scorned woman seeking and revenge…”. Slowly, I started to see how historic and contemporary discussions on psychedelic and MDMA research largely ignored theories on power, control, and abusive interpersonal relationships, particularly in couples therapy.   

The first wave of MDMA couples therapy (1977 – 1985)  

Since the 1980s, MDMA has been associated with connectedness, empathy, and love, making it a (seemingly) natural fit for couples therapy. While still technically legal in the early 1980s, a few dozen clinicians began offering MDMA to their psychotherapy patients as a way to open up the therapeutic process. Many of these clinicians were involved with the Human Potential Movement, Neo-Freudian theory, and other New Age orientations associated with the 1950s-60s LSD boom. Based on personal and professional experimentation, some clinicians theorized that by increasing empathy, connectedness, and reducing defensiveness, MDMA would uniquely enhance communication between couples.  

Therapists and husband and wife duo George Greer and Requa Tolbert described “the single best use of MDMA” as facilitating “more direct communication between people involved in a significant emotional relationship”. Greer and Tolbert came to this conclusion after conducting MDMA therapy with 29 people, including 5 couples, from 1980-1983. Three out of the five couples experienced increased intimacy and improved communication lasting from a few days up to two years. To my knowledge, no information was supplied about the two couples who did not experience lasting benefits. 

 It is also unknown whether domestic abuse was a factor in any of the couples who participated in 1980s MDMA therapy, though it is statistically very likely.  Mental health professionals’ responses to domestic abuse at the time were later critiqued for focusing on shared responsibility for violence. A 1991 study of 362 family therapists found 40% failed to identify domestic abuse in real case studies with clear signs of coercive control in accompanying court records. It is possible that couples were thoroughly screened for domestic abuse prior to MDMA therapy in the 1980s, but the dearth of information on the topic suggests this is unlikely.  

During this period, the absence of rigorous clinical trials left assessment of safety and efficacy up to the interpretation of the clinician. Among the most experienced clinicians delivering MDMA therapy, Rick Ingrasci—a former physician—conducted around 50 MDMA dosing sessions with couples before 1985. Ingrasci lauded MDMA for enhancing safety in sessions: “I have seen MDMA help many couples break through long-standing communication blocks because of the safety that emerges in the session as a result of the drug,’’ Ingrasci said. However, in a troubling twist, Ingrasci himself exploited the subjective feeling of safety created by MDMA. In the late 1980s, Ingrasci resigned his medical license after being sued for sexually abusing patients during MDMA sessions, claiming to at least one patient that sexual contact would help heal them of cancer. Despite cases of abuse like Ingrasci and others, the experienced psychedelics researchers who led the resurgence of MDMA therapy in the 2010s were not able to prevent extremely similar cases of clinician boundary violations and gender-based violence in clinical trials in at least two countries. The staggering failure to monitor trial therapists and adequately assess their therapeutic practices highlights ongoing challenges in ensuring ethical practice within the realm of MDMA-assisted therapy. 

The First Clinical Trial of MDMA Couples Therapy  

When research into MDMA couples therapy resurfaced in the 2010s, much of the underlying therapeutic theory remained unchanged from the 1980s, including the notable omission of attention to domestic abuse and coercive control. Such omission is evident in the first clinical trial of MDMA couples therapy,  which was published in 2020 and explored the efficacy of alleviating PTSD symptoms. Six couples, each with one partner who had a PTSD diagnosis, underwent two MDMA dosing sessions and 15 sessions of conjoint therapy. Researchers screened couples for severe physical aggression and sexual coercion. Although domestic abuse is more common in couples seeking therapy (and more common again in people with PTSD), the researchers did not screen for other forms of domestic abuse, including coercive control. 

This study’s novel approaches to conjoint therapy also may have contributed to or exacerbated coercive dynamics. As part of the conjoint therapy, partners of participants with PTSD were encouraged to use fewer accommodating behaviors, like “reducing noise, limiting the responsibilities of the person with PTSD, [and] excusing aggressive behavior”. The idea of accommodating PTSD as a barrier to recovery is similar to the theory that family members might enable alcohol dependence by acting in ways that cause the addiction to continue. That idea gained popularity in the 1980s alongside “tough love” theories on treating addiction, which pathologized allowing the addiction (and oftentimes, subsequent domestic abuse) to happen. Feminist critiques derided the theory as failing to recognize the complexity of family dynamics and caring responsibilities in the home. Leaving a relationship or asserting firm boundaries are not always feasible or safe – in many cases, risk of harm is highest when a controlling partner loses some of their power. It’s not clear how loss of power was addressed in the study.    

Working to reduce accommodating behaviors in the non-PTSD affected partner is a relatively new approach, and it is still unclear what impact this has on relationships. Reducing accommodating behaviors was first written about by two of the co-authors of the 2020 MDMA couples therapy study, who also co-authored a scale to measure accommodating PTSD behavior . Items on the scale, such as “tiptoe around a partner so as not to anger him/her” or “give up control to their partner because of his/her desire to be in charge,” may be indicative of accommodating behaviors; however, they also mirror common descriptions of being in an abusive relationship. Similarly, a “desire to be in charge” is not a symptom of PTSD and suggests a conflation of PTSD symptoms and controlling behavior. In the study of MDMA couples therapy, PTSD symptoms decreased, yet incidents of “minor physical assault” reported by partners of people with PTSD did not significantly decrease. It is possible that the continued presence of minor physical assault suggests that there are abusive behaviors that remained unexplored within the couples. 

Going forward… 

Coercive control is also absent from the media discourse on MDMA couples therapy and emerging MDMA research. In a thesis from the California Institute of Integral Studies (a school known for teaching New Age therapies) on couples who take MDMA illegally at home to improve their relationship, there are no mentions of coercive control or domestic violence. There is, however, brief mention of a participant being arrested for a “domestic disturbance” after taking what he thought was MDMA with his partner. The man explains that as he was sitting in jail, he realized the MDMA was likely contaminated and later found out it contained a novel psychedelic similar to LSD. There is no other information provided about the incident. Reading this account immediately reminded me of the stories I would hear from people trying to minimize and justify abuse they experienced or committed. Without coercive control as part of the theoretical frame for the researchers’ analysis, a potentially serious safety incident was left unexplored.   

More clinical trials of MDMA couples therapy are underway. Of the protocols that I have reviewed, none include mention of coercive control. One trial that is currently recruiting veterans with PTSD for MDMA couples therapy even relaxed screening requirements, and will accept couples who score several points over an established threshold for the presence of intimate partner violence. Despite including couples with domestic violence in the relationship, there do not appear to be any additional safety measures in place around interpersonal violence. In contrast, contemporary domestic abuse behavior change programs require individual support and robust safety consultations with the non-offending partner as part of minimum standards. Research suggests that contact with the non-offending partner is crucial to establishing how behaviors are (or are not) changing. MDMA couples therapy should incorporate this research from existing behavior change programs as a safety consideration.     

Safety in relation to coercive control is not a hypothetical concern — there are already cases where coercive control and psychedelics intersect. A notable public case recently emerged involving a tech-millionaire who allegedly exploited his ex-partner’s MDMA-induced vulnerability to “unduly influence” her to sign a separation agreement. Couples may soon have access to MDMA therapy in the US and in Australia; MDMA therapy is already accessible to patients with PTSD (though it is not clear when MDMA couples therapy will be available). There is an imminent need for broader discussion of safety in relation to psychedelics, domestic abuse, and power. Examining the relationship between MDMA, abusive behavior, and coercive control will also be crucial for maximizing the potential benefits of MDMA therapy. It is possible MDMA could reduce abusive and controlling behaviors in a partner. However, unless coercive control is understood and measured as distinct to PTSD and other conditions, it will remain impossible to know the answers. 

Kayla Greenstien is a PhD researcher at the University of Sydney and Students for Sensible Drug Policy Australia.

Author’s Note: In response to unsubstantiated claims, this post was taken down for an extended period. The article was not found to contain any factual errors. Nevertheless, this addendum provides further context for my statement that the trial of MDMA couples therapy that is currently recruiting has “relaxed screening requirements and will accept couples who score several points over an established threshold for the presence of intimate partner violence.” This statement is based on the trial’s inclusion and exclusion criteria. The trial excludes couples who score 10 or higher on the E-HITS (Extended-Hurt, Insulted, Threaten, Scream) measure of domestic violence. A score of 7 or higher is widely considered the cut-off point for domestic violence. Thus, based on the cut-off score for the E-HITS listed by the study (10 or above), couples with domestic violence are eligible for inclusion in the study. Whereas a similar earlier study of MDMA couples therapy screens for the “presence of severe aggression in the sexual coercion or physical aggression subscales,” the currently recruiting study only screens for severe aggression on the psychological aggression scale. This makes it less restrictive. This article uses discursive analysis, a well-established research methodology, which focuses on assessing “language in context.” All arguments in this article are substantiated with evidence from publicly available trial information.

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.