Dr. Julie Holland on the Risks of Ecstasy and What MDMA Therapy Looks Like

When people ask me about Ecstasy, the trouble usually starts with the fact that nobody knows what's actually in the pill. Substitution is the biggest hazard: you think you're taking one thing and it turns out to be something else entirely. That uncertainty alone accounts for a huge share of the harm.

After that, I'd put over-hydration near the top of the list. Somewhere along the way the idea took hold that if you take MDMA you're obligated to drink gallons of water. What you actually want is to replace the fluid you're losing through sweat, nothing more. Drink too much and you throw off the balance between water and salt in your body. The result can be too much water in the body, in the brain, in the lungs, and that can kill you. Some of the best-known Ecstasy deaths involved tiny doses of the drug and enormous quantities of water, which tipped people into water intoxication, then seizures, coma, and death.

Set aside the hydration problem and overheating is the next danger. People dance for hours without stopping, often packed into a hot, crowded room, and MDMA itself nudges you a little further toward heat stroke. Stay on the floor long enough in those conditions without a break and the risk becomes real.

Compare that to the clinical setting. You're on a therapist's couch, not dancing. There's no crowd, no heat, no pressure to pound water. Take away the dancing, the overheating, and the over-hydration and most of what makes the recreational version dangerous simply isn't present.

Erik: That's great. For people curious about what MDMA-assisted psychotherapy actually involves, what are you doing in Boulder right now? What does one of these sessions look like?

Dr. Holland: There's work going on in South Carolina, in Boulder, and in a growing number of places elsewhere. If you look at Maps.org you'll see research underway in Canada, Spain, and in places like Syria, Jordan, and Israel. The Middle East side of this work fascinates me. The protocol usually front-loads a lot of sessions before any MDMA is given. You spend considerable time preparing: talking through what the experience will feel like, what to expect, and beginning to map out which issues you'll want to open up once the medicine session arrives. A great deal of the work happens before the drug is ever involved.