Q&A with Dr. Tiffany Sauls, psychiatrist providing psychedelic-assisted psychotherapy

Medical school did not teach Dr. Tiffany Sauls anything about psychedelics. “Not at all, other than to stay away,” she says with a laugh.

But as she moved into her career as a psychiatrist, Sauls began to wonder about effective alternatives to exclusively treating mental health symptoms with pharmaceuticals. Over time, she became interested in the possibilities of psychedelic-assisted treatments.

Today, Sauls provides ketamine-assisted psychotherapy at her integrative psychiatry practice in Asheville. The federal Department of Justice’s Drug Enforcement Administration describes the drug as “a dissociative anesthetic that has some hallucinogenic effects.” Researchers in the early 2000s found the drug works quickly to reduce symptoms of depression without any side effects. (Pharmaceutical antidepressants can take days or weeks to begin working and may have unpleasant side effects.)

Sauls is also trained to provide therapy with MDMA — sometimes used recreationally as ecstasy or molly — for treatment-resistant post-traumatic stress disorder through the Multidisciplinary Association for Psychedelic Studies. She is the co-principal investigator at a site in Waynesville that will soon treat two patients with MDMA, among the first in the United States to do so legally.

Sauls spoke with Xpress about research on MDMA, what happens during a ketamine-assisted psychotherapy session and how she explains her work to her children.

This interview has been condensed and lightly edited.

Researchers are exploring how MDMA, which promotes the release of dopamine and serotonin, can treat people with PTSD. It’s been used to increase relaxation and decrease fear in patients working through painful memories. What can you share about the MDMA-assisted psychotherapy research that you’re leading?

The expanded access site that I am a co-principal investigator at is the first site in the country, in Waynesville. We are only OKed to start seeing two clients at this point, because our group is still completing training. Two clients from Western North Carolina will be able to access that. Then, maybe in the future, we’ll be able to open up and start seeing some more.

What does “expanded access” mean?

If a drug shows such promise that it’s going to be effective for the population, then in phase 2 or phase 3 clinical trials, the [federal Food and Drug Administration] can approve its “compassionate use” — if not allowing it to be used would be even more harmful than the risk of its use before full approval by the FDA. It’s kind of a gray zone of “No, MDMA is not rescheduled [removed from the federal list of dangerous drugs with no medical use] yet. But we see that it’s effective and healing for so many people with PTSD, so it would be a shame not to offer it if we can.” And we are still collecting safety data. We’re still really focused on the safety of it.

What’s the difference between pharmaceutical-grade MDMA and the ecstasy or molly that someone might use recreationally?  

MDMA used in a research setting is pure MDMA. When you’re getting ecstasy or molly, [3,4-methylenedioxymethamphetamine] could be a component of what you’re receiving, but a lot of times things can be mixed with other drugs.

What sparked your interest in psychedelic-assisted psychotherapy? 

I was working in residential treatment here in Asheville and I worked with adolescents, the majority of whom had some form of trauma. I was seeing the research about MDMA-assisted psychotherapy [in adults] and how around 70% of participants who went through the studies were coming out no longer having PTSD.

It was curative, and that’s unheard of in psychiatry. We don’t have cures; we have symptom management with medications and things that might help people cope. It just was kind of astonishing. I was like, “Whoa, I need to learn more about MDMA.” And then I started looking into the whole field of psychedelic-assisted therapies, which includes ketamine and psilocybin [the active ingredient in psychedelic mushrooms].

Are there common misunderstandings you hear about psychedelic-assisted psychotherapies?

No, I haven’t come across that too often. I feel like Michael Pollan really opened the door with the book How to Change Your Mind. So many people have read that book and have some understanding about psychedelic-assisted therapies. And it’s just been in the news so much lately. There is a buzz about, “Hey, this is really effective and can be really helpful and healing.”

I feel like there’s a big opportunity to educate our community, specifically rural areas, around this. There’s a lot of veterans, first responders and victims of trauma in rural areas that don’t have any idea what I’m talking about.

Your practice provides ketamine-assisted psychotherapy. Patients prepare by connecting with nature, then receive oral ketamine and are guided by the psychotherapist through the hallucinogenic experience. What is that like for the patient?

With psychedelic therapies, for the most part, people are lying down with eye shades on and listening to music, either on headphones or just in the room. In general, you don’t want people moving around, because they can be unstable or unsteady. So it’s a lying-on-the-couch kind of thing. A therapist sits with them, takes notes and is there to guide and make sure the person is safe, and to prompt like an explorer if things come up.

What are the common therapeutic goals for ketamine-assisted psychotherapy?

Treatment-resistant depression is one, as well as anxiety, trauma, life transition, obsessive-compulsive disorder. Improvement in their level of functioning, reduction of symptoms or resolution of those symptoms would be the ultimate goal.

What excites you about the future of clinical research on psychedelics?

The work with MDMA right now is still with adults, 18 and up. I’ve spent most of my career in child and adolescent psychiatry. I am excited to be able to do research with adolescents who have either severe trauma or attachment issues related to adoption and using MDMA to address those issues. I can see preventing years of distress from those issues if you can treat them while they’re still in adolescence.

How do you explain your job to your 8-year-old and 13-year-old?

I talk openly about this, and they’re pretty up to speed on what I do. I think they understand that we’re using new medicines to really help people feel, and feel better.