This case study paper (n=3) examines cultural themes and clinical applications from the one-time use of MDMA for three African American female therapists. Included is a discussion of the importance of facilitator training to make the best use of emerging material when it includes cultural, racial, and spiritual themes.
Abstract
“Psychedelic medicine is an emerging field of research and practice that examines the psychotherapeutic effects of substances classified as hallucinogens on the human mind, body, and spirit. Current research explores the safety and efficacy of these substances for mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although current studies explore psychotherapeutic effects from a biomedical perspective, gaps in awareness around cultural issues in the therapeutic process are prominent. African Americans have been absent from psychedelic research as both participants and researchers, and little attention has been paid to the potential of psychedelics to address traumas caused by racialization. This paper examines cultural themes and clinical applications from the one-time use of 3,4-methylenedioxymethamphetamine (MDMA) as part of an US Food and Drug Administration (FDA)-approved clinical trial and training exercise for three African American female therapists. The primary themes that emerged across the varied experiences centered on strength, safety, connection, and managing oppression/racialization. The participants’ experiences were found to be personally meaningful and instructive for how Western models of psychedelic-assisted psychotherapy could be more effective and accessible to the Black community. Included is a discussion of the importance of facilitator training to make best use of emerging material when it includes cultural, racial, and spiritual themes. A lack of knowledge and epistemic humility can create barriers to treatment for underserved populations. Implications for future research and practice for marginalized cultural groups are also discussed, including consideration of Functional Analytic Psychotherapy (FAP) as an adjunct to the psychedelic-therapy approaches currently advanced. As women of color are among the most stigmatized groups of people, it is essential to incorporate their perspectives into the literature to expand conversations about health equity.“
Authors: Monnica T. Williams, Sara Reed & Jamilah George
Summary
Psychedelic medicine examines the psychotherapeutic effects of substances classified as hallucinogens on the human mind, body, and spirit. Three African American female therapists used MDMA as part of a US Food and Drug Administration (FDA)-approved clinical trial and training exercise.
Introduction
Psychedelics in Western medicine
Psychedelics have been used in indigenous contexts for centuries for emotional health, spiritual purposes, and personal growth. Recent clinical research has explored the use of psychedelics for mental health disorders, but little research has focused on people of color.
Western clinical paradigms have used psychedelic substances in combination with traditional psychotherapy to treat mental health disorders and opiate dependence. These treatments have shown promise, but more research is needed to evaluate their effectiveness cross-culturally.
Indigenous practices
The existing literature on psychedelic therapy is from a Eurocentric, medicalized perspective, and often omits indigenous use or discusses its origins in a detached historical manner.
Cultural groups around the world make use of psychedelic healing traditions, which provide important guidelines relevant to Western applications of these substances in medicine and therapy.
Psychedelics have been used across cultures and eras, including ancient Indian (Vedic) religiosity, Biblical times, and African culture and traditions. In Ethiopia, all plants are believed to possess some degree of medicinal usefulness, including important psychoactive plant medicines for psychological problems and psycho-spiritual problems.
Iboga, a shrub from West Africa, is used in healing ceremonies and cultural rites. It is also the source of ibogaine, a powerful psychoactive alkaloid that can be used to treat opiate addiction.
In southern Africa, ubulawu is used as psychoactive spiritual medicine by many communities to communicate with their ancestral spirits and to treat mental disturbances. Further, Bantu traditional healers use ubulawu as part of their ritual initiation process and as a training tool for their shamanic work.
There are many psychedelic medicinal traditions in Africa, but most are not yet sufficiently researched to enable Westerners to fully understand them.
Stigma surrounding psychedelics in Black communities
Despite great public interest in the use of psychedelics for mental health, people of color in the US have shown less enthusiasm for this repopularized modality, and false stereotypes about African American drug use causes many to have increased fears about even considering psychedelics as a mode for healing and growth.
The Black Church aligned itself with the Reagan-era “War on Drugs” to find solutions to the crack epidemic, but the War on Drugs became an excuse for long and harsh sentencing of Black Americans found guilty of drug infractions, and US prisons became filled with Black and Brown bodies.
There is no scientific literature on African Americans and psychedelics, but the limited research on MDMA among Black youth indicates that the drug has gained some popularity.
African American racial and cultural trauma
Historical trauma refers to the cumulative emotional harm caused by a profound traumatic experience or event. Black people in the United States have experienced historical trauma due to slavery, Jim Crow laws, and the unequal application of the criminal justice system.
A lot of African American women have experienced trauma, including being raped, sexually assaulted, stalked, having a life threatening illness, and having a child with a life threatening illness. This trauma has changed their future identity in fundamental and irreversible ways.
Dr. Joy DeGury (2007) has termed the combination of historical and cultural trauma in African Americans “Post Traumatic Slave Syndrome”. Racial trauma can indeed result in stress, traumatization, and PTSD.
African Americans and medical research
African Americans also have traumas surrounding medical research, including psychedelic research. Inequities are evident when comparing the treatment received by White research subjects to what was experienced by people of color.
One study compared two groups that received LSD, one that was incarcerated African American males and the other that was professional White people living freely. The two groups had very different experiences.
Over 500 published studies were conducted at ARC from 1935 to 1975, testing the limits of human tolerance for psychedelics, opiates, and amphetamines on prisoners. These studies violated well-established guidelines for the ethical conduct of biomedical research.
Psychedelic experiences for training of therapists
Psychedelic-assisted psychotherapy involves the use of a psychedelic compound in conjunction with a specified sequence of therapy sessions that are intended to inform, shape, and support the psychedelic experience.
Therapists and researchers who work with psychedelics are often questioned regarding their own use of psychedelics, but the Multidisciplinary Association for Psychedelic Studies received FDA approval to conduct a study for healthy volunteers in which they were able to receive one dose of MDMA along with psychotherapy.
Methoods
Participants and study procedures
Our team at UConn participated in a Phase 2 open-label study on MDMA-assisted psychotherapy for PTSD, which focused on culturally-sensitive treatment approaches.
At the UConn site, most study clinicians participated in a separate study to further their clinical training, “Phase I Placebo-Controlled, Double-Blind Crossover Study to Assess Psychological Effects of MDMA when Administered to Healthy Volunteers” (MT-1). Three of the study’s participants were Black women.
Methodology
An iterative thematic analysis process was utilized to identify critical themes in a study of a cultural phenomenon. The participants themselves created the themes by reading the accounts and revising the final list until there was agreement.
Psychedelic experiences
Therapist 1 was a study therapist for psilocybin-assisted psychotherapy for Major Depressive Disorder at Yale University and served as a sub-investigator and study coordinator for MAPS0 Phase 2 MDMA PTSD at UConn.
Therapist 2 is a board-certified licensed clinical psychologist and academic researcher who provides supervision and training to clinicians for empirically-supported cognitive-behavioral treatments. She feels passionate about improving cultural competence in the delivery of mental health care services.
Therapist 3 is a psychiatric researcher who is passionate about making treatment available to underserved populations. She obtained her Bachelor’s degree from the University of Michigan and her Master of Divinity degree from Yale University.
Results
Major themes
Three Black women experienced MDMA-assisted experiences that included cultural themes relevant to the experience of Black women in America. The main theme from Therapist 1 focused on healing deep, racialized intergenerational wounds.
The themes from Therapist 2 focused on the paradoxical need for human connection and dependence, in contrast to the perceived need to be strong, efficient, and self-sufficient.
The themes from Therapist 3 included transcendence, situating herself simultaneously within her ancestral community and her current African American experience, and a lack of safety.
The primary themes across the varied experiences included strength, safety, connection, and managing oppression/ racialization. Challenges with vulnerability were also prominent.
Experience as a training exercise
All three therapist participants found the process of having an MDMA-assisted therapy session helpful for better understanding the research protocol and the client experience. Two therapists made statements that were culturally insensitive or microaggressive during the MDMA session, which negatively impacted two of the three Black therapist participants.
Discussion
Psychedelic-assisted therapy for Black women
The material from the MDMA-assisted psychotherapy sessions was filled with themes that are particularly salient for Black women in America, such as cultural trauma, spiritual connection to ancestors, care for community, and the Strong Black Woman archetype.
Cultures have different ways of understanding the self, with North American cultures emphasizing individualism and African cultures emphasizing ancestors, spirits, or larger cosmic forces.
African cultures have a spiritual and relational-oriented perspective of the self, in which an individual manifests personhood through connections to God, ancestors, and spirits, the family, the clan, and the community, and self-agency.
Black women experience oppression by being both Black and a woman, and may not be able to separate these two facets into distinct pieces.
Dangers of culturally uninformed therapy
When therapists are unable to make use of cultural material, they can cause harm through micro-aggressions or other harmful actions or inactions. People of color are often expected to maintain White comfort by remaining silent about past and present experiences of racial oppression. The heart-opening properties of MDMA may make clients who are seeking healing from racial traumas particularly vulnerable to further emotional injury.
Training for therapists and guides
Due to the extreme vulnerability of patients during psychedelic-assisted psychotherapy, all therapy providers and supervisors should have basic competencies in working ethically and skillfully with people of color.
FAP is a therapeutic approach rooted in the contextual behavioral tradition that promotes intrapersonal awareness as well as interpersonal awareness between the client and therapist. This approach encourages clients to engage in courageous self-expression in order to improve connections with others.
Inadvertent insensitivities and micro-aggressions committed by therapists present a barrier to fundamental and necessary intimate, trusting, and safe transactions with people of color. FAP is particularly well-suited for culturally-sensitive practice because of its focus on the relationship as a primary change mechanism.
MAPS has made efforts to improve the cultural competence of its therapists, including a series of trainings for independent raters, but important gaps remain. For example, there are almost no approved supervisors able to provide culturally-informed oversight to new therapists.
Addressing misgivings
Some people may be concerned that exposing people to psychedelics in a clinical setting may be simply introducing a new approach for escaping from problems. However, the data indicate that psychedelics are generally safe, with low addiction potential, and even recreational use is correlated to few negative outcomes.
Reclaiming our cultural birthright
Two participants have started providing culturally-informed psychedelic-assisted psychotherapy as a means of treating racial trauma in an outpatient mental health clinic. They believe that African Americans deserve the same access to psychedelic medicines that their ancestors have benefitted from.
Limitations and future directions
This study focused on the voices of African American women, and cannot be assumed to generalize to other racial and ethnic groups. More research is needed to better understand psychedelic experiences cross-culturally.
Conclusion
People of color have the same mental health needs as White people, but there are barriers to safe and effective psychedelic care, including a lack of clinicians who are able to navigate challenging racial material in a non-violent matter.
Psychedelics have not always been safe for Black Americans, but as they become legal medicines, Black people may be able to reclaim psychedelic healing for themselves.
The authors wish to thank Marcela Ot’alora for her therapeutic support and guidance, and the Multidisciplinary Association for Psychedelic Studies for funding this study.