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In the days and weeks after her two MDMA sessions, Sarah didn't think in terms of magic: The effects of her therapy were less cosmic, more workaday. But drop by drop, she says, these effects radically transformed her life. Suddenly she could sleep through the night, with the windows closed and the doors locked. Her cholesterol went from 260 to 165, and stayed there. She attended spin class faithfully, drank less caffeine, ate better. "I didn't learn from the therapy that chips and cheese puffs are bad—I knew that," says Sarah, who's now in her mid-40s. "But I lost my interest in self-sabotage. I wanted to take care of myself." Her relationships with her close friends and young son subtly changed. "I was able to be present with them rather than feeling obligated to be the court jester, making jokes all the time to deflect my anxiety. I was so much calmer. The paranoia went away—the fear that I wasn't good enough, smart enough, or pretty enough to interact with them.

"There's part of me that would have wanted the classic psychedelic journey, the great shamanic experience in the Amazonian rainforest or whatever," she says. "This therapy didn't do that. It taught me to eat well, to wear my seat belt. The little things in life, so I can get through the day or sometimes just get through the minute."

Some minutes are easier to get through than others. Sarah's father died two years ago, and "he was mean to the end," she says with a rueful laugh. "But I had forgiven him at that point, and I just wanted to be there for him. Because of the therapy, I was able to feel empathy." A year later, Sarah lost her job as a social worker; after many months of looking for work, she found a position as a substitute teacher. Money has been tight. She has started smoking again—though nothing like before, just a few sneaks a day.

"I do think one more MDMA session would have helped me integrate what I learned into my daily life better," Sarah says. She wishes therapeutic MDMA were legal, but says she'd never take it underground. "I'm too well to go that far."

Yet despite the decades of bad publicity, illegal MDMA therapy—to treat PTSD and just about anything else—remains in quiet demand. It's especially popular in pockets of northern California, where, judging by anecdotes from the clinicians and patients with whom I spoke for this article, an MDMA journey or two is virtually a rite of passage in many upscale, well-educated circles.

"I have lawyers, appellate court judges, doctors and surgeons, teachers, Stanford graduates, Harvard graduates," says a West Coast therapist whom I'll call Beth. "I've had rabbis and priests. I had a 75-year-old nun. It's not just the hippies. It's often people high up in their fields, very centered professionals who have come to a place in their lives where they're stuck." When a fellow MDMA therapist suspected that a patient's spouse was about to report his work to authorities, Beth reached out to a lawyer for advice. "Here's this mainstream criminal attorney, and he says, 'I need to tell you something: My wife and I did that in couples therapy. It saved our marriage.'"

But even the drug's fiercest advocates will say that for MDMA to save a marriage, it has to be a marriage worth saving—the substance can unearth buried love, but it can't create love from scratch. It can't implant an empathy chip in a sociopath or strip the egotism from a narcissist. "I don't think MDMA can give you access to an emotional experience that's not already within you," Ot'alora says. "It's not a miracle drug."

Of her patients, Beth says, "My work is to allow them to empower themselves to take charge of their own lives. It's not up to me and it's certainly not up to the drug." She has "zero tolerance," she adds, for recreational use of MDMA.

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