The Challenge and Promise of MDMA-Assisted Psychotherapy MONNICA WILLIAMS, PH.D

MAPS Bulletin Special Edition

Race-Based Trauma: The Challenge and Promise of MDMA-Assisted Psychotherapy MONNICA WILLIAMS, PH.D. CHRIS LEINS, M.A.

Monnica Williams, Ph.D. Chris Leins, M.A.

CURRENT RESEARCH SHOWS PROMISE FOR a new intervention race (i.e., racial harassment). He began to sufer from symptoms for posttraumatic stress disorder (PTSD) known as methylene- of depression, generalized anxiety, low self-esteem, and feel- dioxymethamphetamine (MDMA)–assisted psychotherapy. This ings of humiliation. After fling a complaint, he was threatened paper explicates the present state of research into clinical trauma by his boss and then fred. Allen’s symptoms worsened and his related to the experience of racism in America, and the poten- interpersonal relationships became strained. He had intrusive tial contribution MDMA-assisted psychotherapy might make to thoughts, fashbacks, difculty concentrating, irritability, and the efcacy of present interventions. jumpiness—all hallmarks of PTSD. Allen was found to be suffering from race-based trauma (from Carter & Forsyth, 2009). POSTTRAUMATIC STRESS PTSD is a severe and chronic condition that may occur DISORDER IN MINORITIES in response to any traumatic event. The National Survey of Allen was a young African American man working at a retail American Life (NSAL) found that African Americans show a store. Although he enjoyed and valued his job, he struggled with prevalence rate of 9.1% for PTSD versus 6.8% in non-Hispanic the way he was treated by his employer. He was frequently de- Whites, indicating a notable mental health disparity (Himle et meaned, given menial tasks, and even required to track African al., 2009). Increased rates of PTSD have been found in other American customers in the store to make sure they weren’t groups as well, including Hispanic Americans, Native Ameri- stealing. His work experiences consisted mostly of hostile ac- cans, Pacifc Islander Americans, and Southeast Asian refugees tions intended to communicate his inferior status due to his (Pole et al., 2008). Furthermore, PTSD may be more disabling

32 Spring 2016 for minorities; for example, African Americans with PTSD ex- may respond with disbelief, shock, or dissociation, which can perience signifcantly more impairment at work and carrying prevent them from responding to the incident in a healthy out everyday activities (Himle, et al. 2009). manner. The victim may then feel shame and self-blame because they were unable to respond or defend themselves, which may CHANGES IN THE DSM-5 lead to low self-concept and self-destructive behaviors. In the Changes to PTSD criteria in the DSM-5 have been made to same study, a parallel was drawn between race-based trauma vic- improve diagnostic accuracy in light of current research (APA, tims and victims of domestic violence. Both survivors are made 2013; Friedman et al., 2011). Previously, a person was required to feel shame over allowing themselves to be victimized. For to have directly experienced a discrete traumatic event for a instance, someone who has experienced a racist incident may diagnosis. Under the new criteria, if a person has learned about be told that if they are polite, work hard, and/or dress in a cer- a traumatic event involving a close friend or family member, tain way, they will not encounter racism. When these rules are or if a person is repeatedly exposed to details about trauma, followed yet racism persists, powerlessness, hyper vigilance, and they may now be eligible for a PTSD diagnosis. These changes other symptoms associated with PTSD may develop or worsen were made to include those exposed in (Bryant-Davis & Ocampo, 2005). their occupational felds, such as police Many clinicians only recognize ofcers or emergency medical techni- Racism continues to be racism as trauma when an individual cians. However, this could be applicable experiences a discrete racist event, such to those sufering from the cumulative a daily part of American as a violent hate crime. This is limit- efects of racism as well. culture, and racial barriers ing given that many minorities experi- The diagnostic requirement of ence cumulative experiences of racism responding to the event with intense have an overwhelming as traumatic, with perhaps a minor event fear, helplessness, or horror has been re- impact on the oppressed. acting as “the last straw” in triggering moved in the new version of the DSM. trauma reactions (Carter, 2007). Thus, It was found that in many cases, such the conceptualization of trauma as a as soldiers trained in combat, emotional responses are only felt discrete event may be inadequate for diverse populations. Fur- afterward, once removed from the traumatic setting. The criteria thermore, minorities may be reluctant to volunteer experiences have changed from a three-factor to a four-factor model. The of racism to White clinicians, who comprise the majority of proposed factors are now (a) intrusion symptoms, (b) persis- mental health care providers. Patients may worry that the clini- tent avoidance, (c) alterations in cognition and mood, and (d) cian will not understand, become defensive, or express disbelief. hyperarousal/reactivity symptoms. Three new symptoms have Additionally, minority patients may not link current PTSD also been added: persistent distorted blame of self or others, per- symptoms to cumulative experiences of discrimination if que- sistent negative emotional state, and reckless or self-destructive ried about a single event. behavior. These symptoms may be also seen in those victimized by race-based trauma. IMPLICATIONS FOR TREATMENT Racism is not typically considered traumatic by mental health RACISM AND PTSD care providers. Psychological difculties attributed to racist in- One key factor in understanding PTSD in ethnoracial mi- cidents are often questioned or minimized, a response that only norities is the impact of racism on psychological well-being. perpetuates the victim’s anxieties. Thus, patients who seek out Racism continues to be a daily part of American culture, and mental healthcare to address race-based trauma may be further racial barriers have an overwhelming impact on the oppressed. traumatized by micro-aggressions—subtle racist slights—from Research has documented that both implicit and explicit rac- their own clinicians when they encounter disbelief or avoidance ism create barriers to health care (Penner, Blair, Albrecht, & of racially charged material (Sue et al., 2007). Dovidio, 2014). Much research has been conducted on the Clinicians assessing ethnoracial minorities are encouraged social, economic, and political efects of racism, but less research to directly inquire about the patient’s experiences of racism recognizes the psychological efects of racism on people of color when determining trauma history. Some forms of race-based (Carter, 2007). Chou, Asnaani, and Hofmann (2012) found that trauma may include racial harassment, discrimination, witness- perceived racial discrimination was associated with increased ing ethnoviolence or discrimination of another person, histori- mental disorders in African Americans, Hispanic Americans, cal or personal memory of racism, institutional racism, micro- and Asian Americans, suggesting that racism may in itself be a aggressions, and the constant threat of racial discrimination traumatic experience. (Helms et al., 2012). The more subtle forms of racism may be Bryant-Davis and Ocampo (2005) noted similar courses of commonplace, leading to constant vigilance, or “cultural para- psychopathology between rape victims and victims of racism. noia,” which may be a protective mechanism against racist inci- Both events are an assault on the personhood and integrity of dents (Whaley, 2001). However subtle, the culmination of dif- the victim. Similar to rape victims, race-based trauma victims ferent forms of racism may nonetheless result in traumatization.

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Unfortunately, many clinicians are unprepared to address ally, compensating participants may encourage the involvement cultural issues due to social taboos surrounding racism, dis- of those who would otherwise be made to take time of of crimination, and White privilege. This will in turn prevent open work, and would thus be unable to participate. dialogue with patients about potentially relevant trauma-related Developing therapeutic approaches to the treatment of experiences. Thus it is important that all clinicians are well race-based trauma is an important research goal. Cultural trained in the delivery of culturally competent care to enable knowledge and sensitivity by the clinician are essential pieces in them to properly serve diverse patients (Miller et al., 2015). the understanding and efective treatment of race-based trauma (Chapman et al., 2014; Williams et al., 2014). Indeed, several IMPLICATIONS FOR studies have shown that a strong positive ethnic identity is cor- STUDY RECRUITMENT related with higher self-esteem, the development of efective Identifying the specifc aspects of racism that tend to be psy- coping skills, the experience of optimism, and fewer psycho- chopathogenic for individuals is difcult in light of individuals’ logical symptoms (Smith et al., 1999; Williams, Chapman, Wong, tendency to vary in their reactivity to stress and perceptions & Turkheimer, 2012). However, individuals with a strong sense of racism (Williams et al., of belonging to their native 2014). Thus some of the cultural identity are more complexities facing modern likely to experience signif- psychological research and cant distress in the face of practice include both limit- racism (Yip, Gee, & Takeu- ing the misidentifcation of chi, 2008). Thus, cultivat- race-based stress and trauma ing familiarity with clients’ and continuing research ethnic heritage and dem- toward the effective and onstrating respect for and culturally authentic treat- sensitivity to their cultural ment of trauma reactions background is an essential stemming from the experi- part of adapting evidence- ence of racism (Helms et based treatments to meet al., 2010). their needs. Additional complexi- Although the clinical ties pertain to ongoing re- efficacy of pharmacologi- search and the gathering cal and psychotherapeutic of new data. Several studies Monnica Williams and a group of her students at the Anxiety interventions for PTSD is and Depression Association of America conference in Chicago, have chronicled the success- well established (Foa et al., March 2014. The group presented their research and Monnica ful recruitment of members participated in a symposium on cultural competency in research 2009), the literature reveals of minority groups into on anxiety and depressive disorders. deficiencies in modern clinical trials (e.g., Williams, treatment capacity for psy- Tellawi, Wetterneck, & Champman, 2013); these studies high- chological trauma (Cloitre, 2009). Such defciencies include a light the signifcant underrepresentation of minority group- tendency for persons who enroll in clinical trials to prematurely members involved in current research studies. The importance discontinue treatment at an alarmingly high rate (Hembree et and clinical necessity of cross-cultural involvement in current al., 2003), and dropout rates for minorities may be higher yet. research cannot be overstated. Data gleaned from culturally ex- For example, Lester and colleagues (2010) found that African clusive research studies may reduce treatment success for certain Americans were 1.5 times more likely to drop out and three ethnic groups, including African Americans (Williams et al., times more likely not to initiate PTSD treatment, despite being 2014). However, conducting culturally inclusive studies involves more hopeful about treatment benefts prior to therapy. The intensive recruitment phases which are complicated by the per- study authors attribute fndings to potentially faster improve- ception among many minorities that the American healthcare ment among African Americans, stigma related to treatment, system, including psychological researchers and practitioners and lack of cultural sensitivity in the assessment and treatment within that system, is a racist institution, favoring Whites and process. The latter two attributions are more likely, given the perhaps even causing minorities deliberate harm (Suite et al., literature surrounding treatment issues and African Americans. 2007). Such signifcant defciencies in existing approaches to efective In light of this, barriers to recruiting minorities for research treatment raise questions of alternative interventions. Often, the studies are evident. Williams et al. (2013) found that successful experience of emotional intensity in relationship to traumatic recruitment of minorities often involves building personal con- memories precludes the efcacy of psychotherapeutic interven- nections with members and leaders of local communities, and tion for trauma symptoms (Jaycox & Foa, 1999). using multiple culturally specifc advertising venues. Addition-

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THE PROMISE OF durable as evidenced by CAPS scores at two-month follow-up MDMA-ASSISTED PSYCHOTHERAPY and up to 74.3 months following treatment. Thus preliminary Methylenedioxymethamphetamine (MDMA) is a psychoactive data demonstrates that MDMA-assisted psychotherapy can be drug historically used in conjunction with psychotherapeutic an efective intervention for successfully treating PTSD and intervention. Although MDMA was classifed as a Schedule maintaining therapeutic gains over time. 1 controlled substance in 1985, several comparatively recent One of the major challenges facing research on MDMA- studies have found that the administration of MDMA for the assisted psychotherapy for the treatment of PTSD is the scant purpose of trauma-related psychotherapy correlated with posi- amount of data demonstrating its efcacy in ethnic minority tive outcomes. Individuals whom were administered MDMA patients. That is, among the published studies involving this ex- experienced an increase in oxytocin, a hormone implicated in perimental treatment for PTSD no participants were ethnic or trust and emotional perception (Domes et al., 2007; Kirsch et racial minorities. In recently completed Phase 2 trials, minority al., 2005). Also, Dumont et al. (2009) inclusion was improved but still low found that elevated oxytocin was as- (15.2%). Further, Mithoefer et al. sociated with greater sociability. That (2013) did not specifcally address is, the administration of MDMA the implication of MDMA-assisted may help with building human con- psychotherapy for the treatment of nection, including rapport within race-based trauma. Thus, the degree the context of psychotherapeutic to which MDMA-assisted psycho- interventions. therapy can be helpful for race-based Additionally, MDMA produces trauma has not yet been empirically temporary modifcations in neuro- demonstrated. To further explicate logical activity. Liechti (2000) found the dilemma, successfully conduct- that volunteers who were adminis- ing cross-cultural research toward tered MDMA had increases in activ- culturally authentic treatments is ity in the ventromedial frontal and compounded by the history of rac- occipital cortexes, and decreases in ism in the American healthcare sys- the left amygdala. Such neurological tem, making stigmatized minorities modifcations were associated with reluctant to volunteer for clinical a reduced sense of fear as it per- trials (Suite et al., 2007; Williams et tained to trauma-related memories. al., 2013). Thus, the administration of MDMA While there is apparent promise in conjunction with psychotherapy, implicit in the above data, there is Monnica Williams met with state legislators to Mithoefer et al. (2011) postulated in also signifcant challenges inherent advocate for mental health reform and increased a recent study, may specifcally allow access as a Diversity Delegate from Kentucky in the present research: We are not for efective processing of traumatic at the American Psychological Association State certain as to how relevant existing material. That study comprised two Leadership Conference on March 1, 2016. data is to the non-White population, randomized groups, MDMA (n = including those sufering from race- 12) and placebo (n = 8). The onset of MDMA-efects was based trauma. Additionally, researchers need to employ cultur- concurrent with psychotherapy for each volunteer. Thus, the re- ally specifc—and sometimes extensive—strategies to ensure search study included both 125 mg of MDMA (or placebo) and stigmatized minorities are included in clinical trials. two, eight-hour psychotherapy sessions. The primary outcome measure was the Clinician-Administered PTSD Scale (CAPS; SUMMARY Blake et al., 1990), a gold-standard assessment of PTSD used Although changes to the DSM increase the potential for bet- by the military. Clinical response was defned as a greater than ter recognition of race-based trauma, more awareness is needed 30% reduction in baseline of symptom severity as measured by among clinicians to properly identify it. More research is needed the CAPS. to develop a culturally competent model of PTSD to address A clear divergence emerged between the two groups. how culture may diferentially infuence trauma experiences 83.3% of those in the MDMA group showed clinical response of stigmatized minorities. In the meantime, clinicians must be to treatment, versus 25% of those in the placebo group. Addi- educated about the impact of racism in lives of their ethnic tionally, the ten subjects in the MDMA group no longer met minority patients, specifcally the connection between racist diagnostic criteria for PTSD. Thus, MDMA-assisted psycho- experiences and trauma. To that end, interventions to increase therapy was demonstrated to be an efective intervention for awareness and improve clinical dialogue should have the same PTSD in these participants. In a follow-up study, Mithoefer value as other aspects of medical training (Penner, Blair, Al- et al., (2012) found that therapeutic gains were longitudinally brecht, & Dovido, 2014).

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There is an urgent need to develop empirically supported Mayo, M. S., & Resnicow, K. (2002). Successful recruitment interventions for those sufering the efects of race-based trau- of minorities into clinical trials: The Kick It at Swope project. ma, and MDMA-assisted psychotherapy may be an important Nicotine and Tobacco Research, 5, 575–584. next step. Prior research focused on treatment of stigmatized Helms, J., Nicolas, G., & Green, C. (2012). Racism and minorities sufers from low inclusion and high dropout rates, ethnoviolence as trauma: Enhancing professional training. Trau- although minorities sufer from disproportionately high rates of matology, 16(4), 53-62. PTSD. As a compassionate society, we must fnd or make ways Hembree, E., Foa, E., Dorfan, N., Street, G., Kowalski, J., & to reach all segments of our society with promising new treat- Tu, X. (2003). 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T. (2012). Perceived racism and mental health among Black Bahojb-Nouri, L. V., & Leavell Bruce, S. (2014). Cultural Adap- American adults: A meta-analytic review. Journal of Counseling tations of Prolonged Exposure Therapy for Treatment and Pre- Psychology, 59(1), 1-9. vention of Posttraumatic Stress Disorder in African Americans. Pole, N., Gone, J., & Kulkarni (2008). Posttraumatic stress Journal of Behavioral Sciences, 4(2), 102-124. disorder among ethnoracial minorities in the United States. Williams, M., Tellawi, G., Wetterneck, C., & Champman, L. Clinical Psychology: Science and Practice, 15(1), 35-61. (2013). Recruitment of ethnoracial minorities for mental health Scurfeld, R., & Mackey, D. (2001). Racism, trauma, and research. The Behavior Therapist, 36(6), 151-156. positive aspects of exposure race-related experiences: Assess- Yip, T., Gee, G., Takeuchi, D. (2008). Racial discrimination ment and treatment implications. Journal of Ethnic and Cultural and psychological distress: The impact of ethnic identity and age Diversity in Social Work, 10, 23-47. among immigrant and United States-born Asian adults. Develop- Smith, E., Walker, K., Fields, L., Brookins, C., & Seay, mental Psychology, 44(3), 787-800. R. (1999). Ethnic identity and its relationship to self-esteem, perceived efcacy, and prosocial attitudes in early adolescence. Monnica T. Williams, Ph.D., is a clinical psychologist and Associ- Journal of Adolescence, 22, 867-880. ate Professor at the University of Louisville in Psychological and Brain Sue, D.W., Capodilupo, C.M., Torino, G.C., Bucceri, J.M., Sciences, where she serves as the Director for the Center for Mental Holder, A.M.B., Nadal, K.L. & Esquilin, M. (2007). Racial Mi- Health Disparities. She completed her undergraduate studies at MIT croaggressions in everyday life: Implications for clinical practice. and UCLA and received her doctoral degree from the University of American Psychologist, 62(4), 271-286. Virginia. Dr. Williams has published over 60 peer-reviewed articles and Suite, D. H., La Bril, R., Primm, A., & Harrison-Ross, P. book chapters, focused on psychopathology and cultural diferences. Her (2007). Beyond misdiagnosis, misunderstanding and mistrust: work has been featured in several major media outlets, including NPR relevance of the historical perspective in the medical and men- and the New York Times. She is currently an associate editor of The tal health treatment of people of color. J Natl Med Assoc., 99(8), Behavior Therapist. She can be contacted through her website, mon- 879–885. nicawilliams.com. Whaley, A. (2001). Cultural Mistrust: An Important Psy- chological Construct for Diagnosis and Treatment of African Chris Leins, M.A., is a clinical counselor with the Louisville OCD Americans. Professional Psychology: Research and Practice, 32(6), Clinic, where he treats people with mental disorders and specializes in 555-562. treating religious scrupulosity. Chris was trained at Eastern University, Williams, M. T., Chapman, L. K., Wong, J., & Turkheimer, attaining a Master of Arts degree in Clinical Counseling. Chris is pres- E. (2012). The Role of Ethnic Identity in Symptoms of Anxiety ently pursuing a Master of Divinity degree at the Southern Baptist and Depression in African Americans. Psychiatry Research, 199, Theological Seminary. Chris’ research passion is working to combine 31-36. doi: 10.1016/j.psychres.2012.03.049 evidence-based treatments with biblical teaching, with a focus on diverse Williams, M. T., Malcoun, E., Sawyer, B., Davis, D. M., populations. He can be reached at [email protected].

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