For the purposes of this manual we will use the term "bodywork" to refer to touch, (usually in the form of giving resistance for the subject to push against) which is aimed at intensifying and thereby releasing tensions or pains in the body that arise during therapy. "Touch" will be used as a broader term including both "bodywork" and nurturing touch such as hand holding or hugging. The subject of touch in psychotherapy is complex and is discussed in more detail in Appendix A.

The subject of touch in psychotherapy is complex and, in some circles, controversial. There are psychiatrists and other therapists who believe that any physical contact with a client is contraindicated. On the other hand, there are numerous practitioners of various methods of "body centered psychotherapy" who consider the appropriate use of touch to be an essential part of the therapeutic process. (references) What follows is a description of our approach to the use of touch in MDMA-assisted psychotherapy. We believe that mindful use of touch can be an important catalyst to healing during both the MDMA sessions and the follow-up therapy. It must always be used with a high level of attention and care, with proper preparation and communication, and with great respect for the subject's needs and vulnerabilities. It is certainly clear that touch which has sexual connotations or which is driven by the therapist's, rather than the client's, needs has no place in therapy, and can be counter-therapeutic or even abusive. By the same token, withholding nurturing or therapeutic touch when it is indicated can be counter-therapeutic and, especially in therapy involving non-ordinary states of consciousness, may even be perceived by the client as abuse by neglect. (reference)

Some of the pitfalls related to touch which the therapist must be attentive to:

1. Touch could be motivated by the therapist's own sexual desires or needs for physical contact.
2. The patient may misinterpret touch as being sexual or exploitative when it is not.
3. Touch may distract the patient from his or her inner experience. While touch has the potential to help a client move through and resolve difficult emotional experience, there is the danger that either the client or the therapist may unconsciously use touch it as a means of avoiding or moving attention away from an experience that is uncomfortable.
4. The act of intervening with bodywork may give the patient the unspoken message that something from outside him/her is required for healing. An important principal of MDMA-assisted psychotherapy is that the healing experience is guided by an intelligence from within the clients own psyche and body. The therapist must be careful to take his or her cues about touch from the experience of the patient and to help the patient avoid the misconception that the therapist is the source, rather than the facilitator, of his or her therapeutic experience.
5. The therapist may use touch to satisfy his or her own need to do something in the role of therapist. Not only can this lead to an unwelcome distraction from the client's experience, it runs counter to an important principle; healing often comes as a result of bringing conscious attention to difficult feelings or memories, and staying present in this challenging experience without doing anything to change or escape it. At the same time, the patient can learn to recognize and understand in a deep and enduring way when the feelings and associated thought patterns they are experiencing are the result of old experience, and do not apply to their present situation in life. Part of preparing someone for MDMA-assisted psychotherapy is teaching them the value of this approach.
6. Bodywork can be used prematurely in an attempt to resolve challenging emotions or their somatic manifestations before they have been adequately experienced, emotionally processed and expressed. It is important to convey to clients that the experiences catalyzed by MDMA-assisted therapy will likely continue to unfold and resolve over days or even weeks following the MDMA sessions. Therapists must exercise judgment about when bodywork is indicated to help move the therapeutic process forward, and when it is preferable to allow the process to proceed at its own pace.

Principles of bodywork and nurturing touch:

In considering the possible pitfalls listed above and the specific principles described below, it is important to understand that, in most cases, little or no bodywork will be required in the MDMA sessions themselves. It is more likely that bodywork will be indicated in the integrative follow-up sessions as a means of working with unresolved emotional and somatic difficulties.

Despite the fact that MDMA-assisted psychotherapy is likely to involve less bodywork than LSD psychotherapy, the principles underlying this approach are those developed by Stanislov Grof, MD in his LSD psychotherapy research. He points out that, At the time when the effect of the drug is decreasing it is important to engage in verbal exchange with the subject, to get detailed feedback on his or her emotional and psychosomatic condition. If at this time he or she is experiencing discomfort, such as depression, anxiety, blocked aggression, feelings of guilt, circular thinking, headaches, nausea, muscular pains, intestinal cramps, or difficulties in breathing, this is the time to suggest active intervention. The possibility of this happening should have been discussed during the preparation period. The first step is to find out exactly what type of experience is involved....It is also important to encourage the subject to scan his or her body for signs of physical pain, tension or other forms of distress indicating energy blockage. There is, in general, no emotional distress or disturbing and incomplete psychological gestalt that does not show specific somatic manifestations. These concomitant psychosomatic symptoms then become the entry points for...intervention. (Grof, 2001, p. 144)

In preparation for the session the subject should be asked to use the work "stop" if there is ever any touch he or she does not want. He or she should be told that this command will always be obeyed by the therapists unless what they are doing is necessary to protect the subject from physical harm. This will avoid confusion between communications that are meant to be directed to the therapists and things the subject may say that are part of his or her inner experience.

There are specific measures for the therapists to take in the event that the patient is experiencing emotional distress that they are not able to process and move through spontaneously. In most cases, these steps should be taken sequentially, proceeding to the next step only if necessary:

1. Ask, "What are you aware of in your body?" This will help the patient become conscious of the link between distressing emotions and any somatic manifestations. Making this link and making the suggestion to, "Breathe into that area and allow your experience to unfold", may be the only intervention that is needed at that point.
2. Encourage the patient to "Use your breath to help you stay as present as you can with this experience. Go inside to allow your inner healing intelligence to work with this." If it is during the MDMA session add, "The medicine will help that to happen."
3. If the patient is quite anxious (anxious affect, moving on the mat, opening eyes) it may be helpful to hold his or her hand, or for the therapist to put a hand gently on the subjects arm, chest or back, or on an area where he or she is experiencing pain, tension or other physical symptoms. This can be reassuring and help refocus attention on inner experience. This should only be done with the patient's permission.
4. If this does not lead to resolution of the distress, ask, "Is there content (specific images, memories or thoughts) that's coming up with these feelings?" If so it may be helpful to talk about it. The opportunity to put the experience into words may in itself be therapeutic, especially in this safe setting and with the tendency of the MDMA to decrease judgment and fear and to increase trust. This will also be an opportunity for the therapists to help the patient explore connections between symptoms and past traumatic experiences, and to put these experiences into perspective in his/her current lives.
5. After this period of talking, and periodically throughout the session, encourage the patient to "go back inside", to focus on his/her own inner experience.
6. If there continues to be unresolved emotional distress or somatic tension or pain, again ask, "What do you notice happening in your body?" (Pain or tension caused directly by the MDMA will be treated somewhat differently and will be discussed below). If there is tension or pains in the body ask, "Would you like to work with it?" If so, start with gentle massage in the identified area. This alone may bring resolution or may allow the experience to unfold further (e.g., further awareness and expression of feelings, connections to other experiences or patterns of thought and behavior, spiritual awareness).
7. If, during the massage, the patient's body responds spontaneously by pushing against the therapist's hand, the therapist should give resistance for the patient to push against and should encourage him/her to allow the body to move in whatever way it is inclined to. Encouragement should also be given to allow expression of any words or sounds that may accompany the experience.
8. If the massage itself does not either resolve the symptoms or lead to spontaneous pushing against the therapists' resistance, then the therapists should apply resistance to the affected area (which may be either a very specific point or a broad area) and invite the subject to, "take a few breaths into this area. Then when you're ready push against me with all your power, hold it as long as you can, and express yourself in whatever way you can ­ with sounds, words or body movements." This process should be repeated (moving the location as needed, following the patient's instructions about where the tension is) until the patient has a sense or release and relief or until he/she decides to stop, or in the therapists' judgment needs to rest.

The above steps should be offered to patients as possible ways of working with their symptoms if they choose to. Patients should never be pressured to do body work or to be touched in any way, and any use of touch should be determined by the patient's choices. Patients should be encouraged to ask for whatever they feel they need even if it is quite different from what they or the therapists would have predicted.