This open-label study (n=20) suggests that the effects of compassionate imagery and MDMA may be additive in regards to self-compassion and emotional empathy.
3,4-Methylenedioxymethylamphetamine (MDMA;‘ecstasy’) produces prosocial subjective effects that may extend to affiliative feelings towards the self. Behavioural techniques can produce similar self-directed affiliation. For example, compassionate imagery (CI) and ecstasy reduce self-criticism and increase self-compassion to a similar extent, with the effects of CI enhanced in the presence of ecstasy. Here, we examine self-compassion and self-criticism in recreational users who consumed chemically verified MDMA in a within-subjects crossover study. In a naturalistic setting, polydrug-using participants performed a self-focused CI exercise on two occasions separated by ≥6 days: once having consumed self-sourced MDMA and once not. Effects on state self-criticism, self-compassion and emotional empathy were assessed before and after MDMA use (or over an extended baseline period on the occasion that MDMA was not consumed) and reassessed after CI. In participants (n = 20; 8 women) whose ecstasy contained MDMA and no other drug, CI and MDMA appeared to separately increase emotional empathy (to critical facial expressions) and self-compassion. The effects of CI and MDMA on self-compassion also appeared to be additive. Establishing the observed effects in controlled studies will be critical for determining the combined utility of these approaches in fostering adaptive self-attitudes in a therapeutic context.
Ecstasy (street MDMA) is widely used recreationally and has well-documented prosocial subjective effects, including heightened interpersonal understanding and compassion. Controlled laboratory work with MDMA has reported increases in emotional empathy and reductions in some aspects of cognitive empathy, and a number of neurobiological mechanisms have been proposed to explain these effects, notably MDMA-induced increases in central oxytocin. Behavioural strategies aimed at increasing self-directed affiliation, such as compassionate imagery (CI) drawn from compassion-focused therapy, can produce similar changes in self-attitudes, but individual differences (for example, fear of compassion or insecure attachment) can limit their effectiveness. Kamboj and colleagues note prior naturalistic findings suggesting that ecstasy and CI can both increase state self-compassion and that their effects may summate, but emphasise that earlier work did not chemically verify ecstasy composition and so could have been influenced by adulterants or by uncontrolled aspects of "set and setting". This study set out to replicate and extend previous naturalistic findings while chemically verifying participants' self-sourced ecstasy. The main hypotheses were that recreational MDMA use and CI would each increase state self-compassion and reduce self-criticism, and that combined administration (MDMA + CI) would produce additive effects on these self-attitudes. A secondary prediction was that MDMA would enhance emotional arousal in response to compassionate facial expressions, assessed using an emotional empathy task with both basic (anger, happiness) and complex (criticism, compassion) facial stimuli. The investigators emphasised that confirming MDMA content of participants' tablets would allow clearer attribution of observed effects to MDMA itself.
Papers cited by this study that are also in Blossom
Kamboj, S. K., Kilford, E. J., Minchin, S. et al. · Journal of Psychopharmacology (2015)
Grob, C. S., Mithoefer, M. C., Brewerton, T. D. · Lancet Psychiatry (2016)
Bershad, A. K., Weafer, J. J., Kirkpatrick, M. G. et al. · Social Neuroscience (2016)
Danforth, A. L., Struble, C., Yazar-Klosinski, B. et al. · Progress in Neuro-Psychopharmacology and Biological Psychiatry (2016)
Recreational ecstasy users were recruited by word-of-mouth and screened by telephone; those with serious ongoing medical or psychiatric illness, pregnant or breastfeeding women were excluded. Twenty-five participants began and completed the protocol; chemical analysis retained data from 20 participants (12 men, 8 women) whose samples contained only MDMA (n = 18) or MDMA plus ≤ 33% glucose (n = 2). Participants were predominantly polydrug users and reported prior regular MDMA experience (median 4 years; median frequency 1/month). Sixteen participants were smokers and most (n = 17) did not practice meditation. Participants received £30 for participation. A naturalistic, within-subjects crossover design was used. Each participant completed two home-based testing sessions 6–14 days apart: one session in which they consumed their usual self-sourced ecstasy dose ~1 hour before a standardised guided compassionate imagery (CI) exercise (MDMA + CI session), and one session in which no drug was taken prior to CI (CI-only session). Session order was approximately balanced (9 of the 20 completed MDMA + CI first). Assessments occurred at three time points: T1 (baseline), T2 (~1 h after T1; on the MDMA + CI session this corresponded to near-peak drug effect) and T3 (~20 min after T2, i.e. after CI). Between T1 and T2 participants read or listened to music; CI was delivered after T2 via standardised audio instructions including rhythmic breathing and imagery of an ideal compassionate being. Primary psychometric outcomes were state self-compassion and self-criticism measured by the scenario-based Self-Compassion and Criticism Scale (SCCS). Secondary measures included the Types of Positive Affect Scale (TPAS), Beck Depression Inventory-II (BDI-II), the Revised Adult Attachment Scale (AAS), and an emotional empathy task (EAT-SAM) that recorded subjective arousal and valence in response to images of basic emotions (anger, happiness drawn from NimStim) and custom-generated complex interpersonal expressions (criticism, compassion). Physiological assessment comprised ambulatory ECG-derived heart rate. Urine drug screens and breathalyser tests documented recent substance use. Chemical verification of ecstasy samples (~10 mg retained prior to consumption) was performed using 1H NMR spectroscopy and, when needed, additional 13C and 2D NMR and ESI-MS to identify constituents. Statistical analyses used repeated-measures ANOVAs (Time × Session) for subjective and SCCS outcomes and three-way ANOVAs (Time × Session × Emotion) for EAT-SAM arousal, with separate analyses for basic and complex emotion pairs. ANCOVAs tested moderation by attachment subscales (AAS closeness and dependence). Data were checked for normality and outliers; parametric tests were applied. Effect sizes reported included partial eta-squared for ANOVAs and Cohen's d (adjusted for paired observations) for planned contrasts. Key analyses were re-run excluding an outlier who consumed 0.25 g MDMA and excluding the three participants who insufflated their dose; results were reported as robust to these exclusions.
Twenty participants contributed chemically verified MDMA-only data (mean age 28.45 ± 6.16 years; mean BDI-II 9.50 ± 6.53). Urine drug screens showed some positive results across sessions (e.g. THC, cocaine, occasional MDMA), reflecting recent drug use in this polydrug sample; breathalyser readings were 0.00% on both sessions. Visual analogue mood and symptom scales showed multiple Time × Session interactions consistent with expected MDMA effects (increases in energetic, jaw clenching, muscle tension, sensitivity to colour, 'high' and alertness, and a decrease in hunger) between T1 and T2/T3 on the MDMA + CI session. Heart rate increased significantly in the MDMA + CI session relative to the CI-only session, by 14.15 ± 18.93 beats/min at T2 and 14.63 ± 19.39 beats/min at T3 (Session × Time interaction F(1.4, 23.5) = 9.034, p = 0.003, ηp2 = 0.347). On the SCCS self-criticism subscale there were main effects of Time (F(2,38) = 26.745, p < 0.001, ηp2 = 0.585) and Session (F(1,19) = 6.881, p = 0.017, ηp2 = 0.266) but the Time × Session interaction did not reach significance (F(2,38) = 2.584, p = 0.089). By contrast, the SCCS self-compassion subscale showed main effects of Time (F(1.5,28.1) = 10.285, p = 0.001, ηp2 = 0.351) and Session (F(1,19) = 6.592, p = 0.019, ηp2 = 0.258) that were subsumed by a significant Time × Session interaction (F(2,38) = 5.794, p = 0.006, ηp2 = 0.351). Follow-up contrasts indicated: on the CI-only session there was no change from T1 to T2 (extended baseline) but a modest increase in self-compassion from T2 to T3 after CI (p = 0.023, d = 0.355). On the MDMA + CI session self-compassion increased significantly from T1 to T2 (post-MDMA; p = 0.008, d = 0.396) and showed a further small increase from T2 to T3 (post-CI; p = 0.015, d = 0.191). Scores at T1 did not differ between sessions, but at T3 state self-compassion was higher on the MDMA + CI session than on the CI-only session (p = 0.003, d = 0.301). No Session × Time interactions emerged for the TPAS positive-affect subscales (active, relaxed, content/warm), suggesting specificity of effects to self-compassion rather than broad increases in positive affect. Analyses testing attachment moderation found no significant Time × Session × AAS-closeness effect; using AAS-dependence as a covariate produced a trend-level Time × Session × Attachment interaction (F(2,36) = 3.039, p = 0.06, ηp2 = 0.144), with descriptive evidence that higher dependence scores were associated with larger self-compassion increases. On the EAT-SAM, basic emotions showed only main effects of Emotion (arousal: anger > happiness; valence: happiness > anger) with no Session or Time effects. For the complex emotion pair there was a Time × Session × Emotion interaction on arousal (F(1,19) = 5.155, p = 0.035, ηp2 = 0.213). Subsequent tests revealed a strong Time × Session interaction for critical faces (F(1,19) = 16.429, p = 0.001, ηp2 = 0.464): at T2 arousal to critical faces was higher on the MDMA + CI session relative to the CI-only extended baseline (p < 0.001, d = 0.768), and on the CI-only session arousal to critical faces increased from T2 to T3 after CI (p = 0.019, d = 0.391). There was no evidence of an additive increase in arousal to critical faces between T2 and T3 on the MDMA + CI session. No significant correlations were found between EAT-SAM ratings to critical faces and concurrent self-compassion or self-criticism scores.
Kamboj and colleagues interpret these results as an extension of earlier naturalistic observations: both recreational MDMA use and a brief guided compassionate imagery exercise produced small-to-medium increases in state self-compassion when administered separately, and the combination yielded a further, statistically significant but modest, increase. The authors highlight that the current study's chemical verification of participants' ecstasy strengthens the attribution of these effects to MDMA itself, relative to prior work where tablet composition was unknown. They note that changes in self-compassion occurred without parallel Session × Time effects on three distinct types of positive affect, suggesting the effects were not merely a generalised mood increase or demand artefact. In terms of interpersonal processing, the study found that emotional arousal in response to critical faces increased following MDMA (at T2) and following CI (T2 to T3 on the CI-only session), whereas no MDMA- or CI-related enhancement of arousal to compassionate faces was observed. This pattern departs from some previous experimental reports that emphasised MDMA-related increases in empathy to positive stimuli; the investigators suggest methodological differences (use of facial rather than situational stimuli, and novel critical-face stimuli) may explain the divergence. Mechanistically, the authors propose the oxytocinergic system as a plausible shared substrate for the observed increases in self-compassion, given oxytocin's role in affiliation and its hyperstimulation by MDMA, but acknowledge autonomic pathways differ for MDMA (sympathetic activation) versus compassion practices (parasympathetic engagement), so a single autonomic explanation is unlikely. The authors are cautious about therapeutic implications. They stress that the findings are preliminary, derived from a naturalistic, non-placebo-controlled design, and that generalisability to MDMA-naive individuals or clinical populations is unknown. Key limitations discussed include the naturalistic setting and attendant expectancy effects, inability to blind participants, variability in self-chosen MDMA doses (one outlier at 0.25 g), presence of recent other drug use detectable in urine screens, and absence of additional control conditions (for example an MDMA-only session or an active control behavioural task). Kamboj and colleagues therefore recommend that future work employ randomised, double-blind, controlled laboratory designs to test whether MDMA combined with compassion-oriented psychosocial strategies can produce lasting therapeutic gains, and to clarify mechanisms and boundary conditions for potential clinical application.
Recreational ecstasy users were recruited by word-ofmouth and snowballing from the local community (note that we use the term 'ecstasy' when referring to the recreational drug when its composition is unknown and 'MDMA' in situations in which this constituent is known to be present). Interested participants were asked to contact the research team for information about the study. Those expressing an interest in participating were telephone-screened. Those disclosing a history of serious mental health problem or physical illness (i.e. requiring ongoing medical/psychiatric treatment), as well as women who were pregnant or likely to become pregnant or who were breast-feeding, were excluded. Since our aim was to only include participants confirmed to have consumed MDMA, we over-recruited relative to our previous study, anticipating the exclusion of some volunteers. Twenty-five participants began and completed the study (14 men; 11 women). Data from 20 participants (12 men; 8 women) was retained as their ecstasy contained only MDMA (n = 18) or MDMA plus ≤ 33% glucose (n = 2). These participants had previous regular experience with MDMA (median length of experience, 4 years; median regularity of use, 1/month). Excluded participants' ecstasy contained 50% MDMA plus 50% cocaine (n = 1), 67% MDMA plus 33% mephedrone/sucrose (n = 1), > 99% glucose plus undetermined impurities (n = 1), and < 50% MDMA plus > 50% sucrose plus solvent plus undetermined impurities (n = 2). The majority (n = 15) of participants used MDMA < 2 times/month (n = 5 used it ≥ 2 times/month). All participants also regularly (≥twice/month) consumed other drugs or alcohol: alcohol (n = 20), cocaine (n = 9), cannabis (n = 14), mephedrone (n = 6), amphetamine (n = 1), or other illicit drug (n = 3) and hence, are best characterised as polydrug users. Sixteen were smokers. Of the women participants, five used hormone-based contraception, and three were 'regularly cycling'. The majority of participants (n = 17) did not practice any form of meditation. Participants received £30 for participating.
The Statistical Package for Social Sciences (SPSS, version 24, IBM) was used to perform all statistical analyses. Data was examined graphically and statistically for normality and outliers. Shapiro-Wilk tests were non-significant (all p values > 0.1) and no studentised residuals exceeded ± 3 on the outcomes. Parametric statistical analyses were therefore applied. Two-way Time × Session repeated measures ANOVAs, with Session (CI-only or MDMA + CI) and Time (T1, T2 and T3) as within-subject factors, were used to analyse positive/ negative mood states and state self-compassion and self-criticism. Three-way (Time × Session × Emotion) ANOVAs were used to analyse the EAT-SAM arousal responses. For the latter, the Time factor had only two levels (T2, T3) and separate analyses were conducted for basic (angry; happy) and complex emotions (critical; compassionate) because these pairs of stimuli were drawn from different sources. As such, the Emotion factor also had two levels (angry and happy or critical and compassionate). Additional ANCOVAs were used to assess moderation by attachment security of the effects of MDMA and CI on self-compassion. Specifically, indices of dispositional avoidant attachment (closeness and dependence scores on the AAS) were entered as covariates. Planned comparisons were used to follow up the main analyses on self-compassion and self-criticism. All other post-hoc analyses of significant ANOVA effects were Bonferroni-corrected. Pearson's correlations were used to explore association between variables. All reported statistics are two-tailed and values are presented as means ± standard deviations unless otherwise indicated (in figures). As reflected in the reported dfs, the analyses were based on complete data, except for heart rate, which, due to technical difficulties, was missing at one or more time points for two participants. ANOVA effect sizes (η p 2 ) were calculated in SPSS, and individual effect sizes (Cohen's d) included an adjustment for the correlation between paired observations where appropriate. Key analyses were repeated excluding the participant with the outlying MDMA dose (0.25 g). Similarly, reanalyses was conducted by excluding the three participants who insufflated their MDMA. The patterns of means, effect sizes and statistical significance (i.e. < 0.05) were retained despite data removal, and as such, all the 20 cases were retained in the analyses.
In this report, we extend previous findings on the effects of recreational ecstasy and compassionate imagery (CI) on selfattitudes. The broad qualitative pattern of individual effects of MDMA and CI reported previouslywere also found here, although the statistical pattern of interactions diverged. In particular, in our previous study, we found clearer evidence of additive effects of MDMA and CI on selfcriticism (here, the Time × Session interaction was suggestive but not statistically significant). Critically, in the current study, we only used data from participants whose ecstasy was confirmed to contain only MDMA (plus ≤ 33% glucose in two samples). The broadly similar pattern of effects across both studies supports the validity of those previous findings, although the confirmed sole presence of MDMA in participants' ecstasy in this study lends it more weight. The primary findings in the current study were that MDMA and CI appeared to produce similar (small to medium) increases in self-compassion when administered separately. Note however that these effects were not based on placebocontrolled comparisons and must therefore be considered provisional. When the CI instructions occurred in the presence of MDMA, there was a small but significant further increase in self-compassion, that the effects of CI can be potentiated in the presence of MDMA. In addition, emotional empathy in response to critical faces appeared to increase following CI (the small within-session increase in EAT-SAM arousal between T2 and T3 on the CI-only session) and following MDMA (the medium to large between-session difference in EAT-SAM arousal at T2). The effects on self-compassion were found in the absence of interactions on three relevant and psychometrically distinct types of positive affect (relaxation, contentment/warmth and activation). It has been suggested that arousal ratings in tasks such as the EAT-SAM represent an implicit index of emotional empathy). As such, our main findings are not entirely consistent with a simple generalised enhancement of positive affect or demand characteristics. In contrast to these effects on self-compassion, the effects of CI ± MDMA were less clear-cut for self-criticism. Examination of Figureshows that there was an unexpected reduction in self-criticism in the absence of, which may explain the lack of a Time × Session interaction (p = 0.089; cf.. Although previous studies have also examined the effects of MDMA on emotional empathy, these have tended to use situational rather than facial stimuli (reviewed byand have not specifically examined compassion and criticism. Unlike these previous studies, we did not find a generalised increase in emotional empathy or the more specific hypothesised increase in response to compassionate expressions in the presence of MDMA (cf. Instead, while there was no effect on EAT-SAM arousal to basic emotion or compassionate facial expressions in response to CI ± MDMA, critical faces elicited enhanced arousal following MDMA at T2 relative to the extended baseline time point (T2) on the CI-only session. In addition, CI also appeared to increase arousal to critical faces (from T2 to T3 on the CI-only session). The specific effects of MDMA on critical (i.e. negative) expressions diverged from previous studies, which have not tended to show such enhancement of emotional empathy in response to negatively valenced stimuli. This divergence may relate to our use of facial (rather than situational) affective stimuli generally or critical facial expressions in particular, which have not been used in previous studies. The apparently similar effects of CI and MDMA (on state self-compassion rather than positive affect more generally, and on arousal to critical facial stimuli, rather than other emotion expressions) might suggest a common biopsychological mechanism through which some behavioural and pharmacological strategies increase aspects of self-affiliation and emotional empathy. However, given the distinct effects of MDMA on the sympathetic systemand compassion-oriented practices on the parasympathetic system, it seems unlikely that the qualitatively similar effects of CI and MDMA observed here are due to common effects on the autonomic nervous system. Alternatively, given its ostensible role in (self-) affiliation) and its hyperstimulation by MDMA), the oxytocinergic system seems to be a mechanistically plausible substrate for the common effects observed here, at least for self-compassion. Our current and previous) findings complement the existing biobehavioural methods used in the neuroscientific study of contemplative practices). MDMA's effects are particularly relevant to contemplative neuroscience in terms of mimicking or augmenting the effects of compassion-oriented practices (e.g. loving kindness meditation or compassion-focused therapy) through a biologically plausible (oxytocinergic) pathway. Whether the observations reported here have therapeutic relevance, however, remains an open question and would need to be the subject of separate careful study. A primary concern in such studies would be to determine if lasting beneficial effects (on selfattitudes) would be observed after a small number of doses of MDMA in combination with a compassion-oriented psychosocial strategy (such as CI). If so, this would be in line with
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King, C., Nichols, D. E. · Nature Reviews Neuroscience (2013)
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