Alexa Albert has been a practicing psychoanalyst and psychiatrist since 2008, holding a clinical instructor position at the University of Washington and at the Seattle Psychoanalytic Society and Institute. Over the course of her career, she’s seen patients with many mental health issues, but in her private practice, she specializes in working with people with pathological narcissism.

When Michael Pollan’s book How to Change Your Mind came out in 2018, her husband — an entrepreneur — suggested she look into psychedelics, because it seemed likely her patients might eventually ask her about it. Albert took her husband’s advice, and applied to a psychedelics certificate program through the California Institute of Integral Studies. There, she first learned about the therapeutic potential of MDMA, a substance she’d previously only known about as a party drug. She was struck by the descriptions she read of people’s experiences of it — how it helped people take others’ perspectives, and feel more empathy. She thought to herself: this is exactly what my narcissistic patients could use.

Earlier this year, Albert began a pilot clinical trial in which she’s using MDMA-assisted psychotherapy with people who have narcissistic personality disorder or pathological narcissism. The Microdose spoke with her about why MDMA might help people with narcissism, and the details of the study.

The term "narcissism" is having a moment in popular culture right now — it’s become a common armchair diagnosis for anyone we don’t like. What’s the clinical definition of narcissism?

There are different schools of thought about this, but generally speaking, I prefer using the term “pathological narcissism” because it encompasses people who may fit the DSM-5 definition of narcissism — which really emphasizes people’s tendency towards grandiosity — but also people who oscillate between the poles of grandiosity and vulnerability or low self-esteem.

Often, these patients are coming in depressed or anxious; perhaps a family member has given them an ultimatum, or they’ve lost another job, and they feel a void inside. They often have difficulty with self-regulation, and have fluctuating self-esteem. On the one hand they may feel smug and arrogant, resentful that the world doesn’t appreciate their greatness, but then they will also feel impotent and powerless when they’re unable to finish school or move out of their parents’ home. You also have superagentic people: they may have achieved a lot, running companies and gaining power, but inside, they don’t feel good enough. They seek success after success, but that still doesn't fill the void they feel.

Many have not been formerly diagnosed with a personality disorder; many schools of mental health training have discouraged clinicians from giving people those diagnoses because there haven’t been many effective treatments, and also, it’s terribly stigmatizing. There may be concerns about billing and coding in people’s patient charts. So often we tend to defer diagnosis and instead focus on the symptoms.

What’s the typical treatment for people with a type of pathological narcissism?

Often people end up seeing a therapist, but that doesn’t necessarily address the underlying personality disorder. Common therapy modalities like Dialectical Behavior Therapy (DBT) focus on helping people gain emotional skills, and can provide feedback, empathy and support, but I call it “moving the furniture” — it doesn’t get at the underlying structural problem. Many people also seek out psychoanalysts to explore their early relational trauma. The gold standard in many circles is psychoanalytic therapy; people are currently studying its efficacy. But there’s never been a psychopharmacological agent found to be helpful, though people will treat the symptoms — for example, mood stabilizers for depression or anxiety.

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Why do you theorize MDMA might help people with pathological narcissism?

It’s often said that people with narcissism don’t have empathy, but it’s really that they have impaired empathy. A better way of putting it is that they have cognitive empathy: they can intellectually imagine what someone might feel like if something terrible happens to someone else, but they don’t actually feel what other people may be feeling. They don’t feel moved by it. Often people with pathological narcissism didn’t feel attended to as children, or experienced childhood neglect; we learn through being seen, so people with parents who were not available or never feel seen or known by their parents don’t learn how to reflect that back to people. It’s also quite common for people to blame themselves for the way their parents treated them.

Meanwhile, MDMA influences people’s ability for self compassion and empathy. Some people who have tried MDMA after being in combat report that they’re able to see their memories differently — they’re able to review what happened, and have empathy for themselves, realizing they couldn’t have done things any differently, or they might see others’ actions differently.

It can invite deeper insight and reflection, and to consider someone else’s mind. It also seems to affect the amygdala, the brain’s fear center, and reduce the fear element in attending to negative or difficult emotions, the type of emotions that people with pathological narcissism often can’t regulate well. They tend to harbor rage, envy, longing, and neediness, but struggle to really feel those things — it’s like a membrane they can’t cross. But my hope is that MDMA invites them to tolerate exploring feelings that have been too scary to explore before.

What’s the design of this study?

This is the first contemporary study of any psychedelic being used in a clinical trial for personality disorder. Just like MAPS’s PTSD study, we’re doing three preparation sessions, three dosing sessions, and three integration sessions — and the therapy model we’re using is a psychoanalytically informed therapy. We’re following up a week after the last integration session, then again 3, 6, and 9 months after their first MDMA dose.

Our primary measure is a standard questionnaire called the Brief Pathological Narcissism Inventory, which we’re giving participants pre- and post-study, and we’re also asking a family member or someone close to the participant as well as their personal therapist to fill out that inventory as well, so we can have their input on what changes they see. Since narcissists aren’t always able to see themselves and often lack the ability to reflect on themselves, having outside eyes to report on what they see is important. We’re also using other measures to assess their ability to mentalize, regulate emotions, and their cognitive and affective empathy.

You’ve just started this study. How is it going so far, and are you finding any challenges?

This is a pilot study, so we’ll be working with 12 patients. So far, we’ve enrolled three participants: two have had their second dosing session, and one has had their first dose. We anticipate enrolling new patients into 2026.

MDMA is a Schedule I drug, and it’s been frustrating to see first hand how that has impeded researchers’ ability to study them. In late 2022, we had an agreement for this study to be an investigator-initiated trial with MAPS Public Benefit Corporation, which meant we could get MDMA from them. But by the time we got approval from the University of Washington’s Institutional Review Board in spring 2024, MAPS PBC had became Lykos — and shortly after that, the FDA did not approve the company’s application to use MDMA in the treatment of PTSD, and then the company contracted. In short, we needed to find another source for pharmaceutical-grade MDMA and basically there was no other source in the U.S., so we found a company in Canada from which to purchase it. But that required getting approval from Health Canada, and that was all happening just as Trump’s tariffs were going into place. Of course, none of this is news to people who do research on these substances but it’s staggering.

This interview has been edited and condensed for clarity and length.