Establishing a Therapeutic Alliance
The first stage of the Preparation phase provides adequate time in non-drug therapy sessions for establishing a safe and positive therapeutic alliance. The therapeutic alliance is a prerequisite for treatment (Johnson, 1996). Development of trust and understanding between the therapists and participant is essential. A safe and positive therapeutic alliance is one in which the participant feels assured that his/her well-being will be attended to with utmost care. The therapists introduce themselves and share how they became interested in this work as well as their experience in healing PTSD. This may help to assure the participant of the therapists' experience and commitment to support the patient throughout the process. Greer and Tolbert (1998) note that self- disclosure on the part of the therapist created a context for collaboration, intimacy, and trust. Additionally, appropriate self-disclosure from the therapists gives the participant a sense of shared identification with the therapists. Shared identification may also have the benefit of increasing personal comfort as the participant enters a state of heightened vulnerability. Participant: "With all the PTSD that's got to be out there ... I was so afraid to admit how I feel. I felt like I was the only one."

Therapist: "You are not in that position any more."

Participant: "No one really listened to how I was feeling. They just wanted to give me another prescription."

Therapist: "Anything else that comes up for you, thoughts ... feelings?"

Participant: "I've been feeling nervous, anxious, not sleeping well. I know a part of it is being free of the antidepressant. I am agitated short-tempered." (Sniffing)

Therapist: "Let's practice the abdominal breathing. This is one method to help you be with your feelings and let them inform you of what is going on inside of you."

Participant: Inhalation/ Exhalation

Therapist: "In some ways the process begins before we actually begin. It's like it begins ahead of time, as you set the intention to do it. And as you get closer, these feelings are a natural thing. It is not easy. In some ways your psyche is already making use of what you decided to do."

Participant: "It helps to understand. I am willing to try anything. Hell, I was in therapy every week for a whole year and we never really addressed my symptoms."

Gathering Information
The therapists-participant interaction includes sharing mutually relevant information. The therapists ask open-ended questions, provide some feedback to the participant about the results of his/her psychological testing and medical evaluation, and encourage the participant to share what he/she believes is personally significant information.

Therapist: "We don't have all the results from your tests, but we spoke with the doctor and all of the results tell us that you meet the criteria for this treatment. Let's start with any thoughts or questions that may have come up for you."

Participant: "The session with Dr. Wagner was good. I can see where it is starting to open up a can of worms. I can see where the process is already starting with me. Part of me is very excited and part is very skeptical, like `uh oh, is this really what I need to be focusing on.' There was a question on the PTSD scale. Dr. Wagner asked if I had dreams. I said `no', then, it dawned on me. I don't have dreams about my father actually doing whatever he did, but I have dreams about my mother. Just the other night I had a dream about how we were talking on the phone. It was very light and we were talking on the phone and she was going off, because she never really worried about what he was doing or how he was abusing us or how he was abusing her. She would worry whether the fall-out from Chernobyl got into my Mars candy bar and I got nuclear poisoning. She worries about things that are completely out of control. And she goes on and on in our conversations and we are "close." But I realize that I do dream about her. And in this particular dream the light was white and she went into her normal, `I'm worried about this, I'm worried about where you are living, without actually helping, cuz she wants to help, but my father won't let her help even though she makes all the money. And, um, the phone just came unplugged from the wall and I thought it was really interesting that ... and then my first instinct was to plug it back in and call her back. And so I started thinking about that because it was right after the testing."

Therapist: MMMmmm.

Participant: "And I said, `No, I don't have dreams about this and then continuously how I have dreams about her. He's not in the dreams, but she's in the dreams. And how she's not this kind, compassionate mother like she used to be. How's she's changed. It's really interesting. I've tried to resolve my anger towards her. And I think it is harder now that I have a child. To think, `I don't care who you are or how much I love you or how dependent I am on you, I'm going to take my child away from you. You know I wouldn't even let my child in the room with people who even think like that, except that I do let him go with my father knowing ... so it's kind of a ... so it's interesting that the process is already starting to work even though I haven't had any therapy. (laughs)

Therapist: "Well that is typical."

Therapist: "Yeah, the screening does tend to stir things up for a lot of people. And also as you were saying, the intention to do this work also sets your psyche in motion about it, from the time that you decide that you are going to do it. I think it is an important question that you bring up ... `Is this the time that I can be focusing on this or do I need to focus on day to day life?' What's your feeling about that now?

Participant: "Well, I vacillate on that, but I figure that my day to day and this is an opportunity for my day to day life to get better ... or not. At least it's an opportunity that doesn't come across your path every day. I mean it's an opportunity to do that and because of my profession, because I tend to be a school counselor by profession, I'm in no state to actually be a school counselor. So I consciously or subconsciously can not go and pursue jobs because I know there are things I need to work on my self. So I think this is the time to do it ... even if it is hard. I mean it can not be easy."

The therapists guide these interviews to gather information about the participant's present symptoms, event(s) that caused the PTSD, previous treatment and outcome, other psychiatric history, and medical, social and family history.

Therapist: "We'd like to talk in more detail about the sessions and we'd also like to hear more detail about your history and the trauma in particular. We can do that in any order you want. Do you feel like talking more about your self and your trauma now or would you like to hear about the sessions."

The therapists also inquire about and discuss with the participant his/her previous experiences with MDMA, psychedelic drug use, or other non-ordinary states of consciousness. During this interaction the therapists should make sure they have gathered sufficient information and established a sound understanding of the participant. This interaction is an opportunity for the therapists to inquire about and address any concerns the participant may have about his/her treatment.

Participant Orientation
In this stage, the therapists orient the participant to the therapeutic process. The therapists begin a dialogue with the participant about the scope of the MDMA session. They discuss the participant's expectations, motivations, purpose, and intentions for the therapy sessions. The therapists may liken the effect of the MDMA to an opportunity to step inside a safe container in which it will be easier to remain present with his/her intrapsychic material. The participant should be encouraged to cultivate an attitude of trust in the wisdom and timing of their own healing process as is catalyzed by this approach.

The participant is advised to include experiencing, understanding, and achieving relief from his/her PTSD symptoms and the underlying trauma as part of the therapeutic goal. Here the therapists want to clarify the participant's expectations and intentions and encourage an attitude of openness toward the MDMA-facilitated experience in whatever way it unfolds. The therapists explain that often the deepest, most effective healing experiences take a course that is quite different from the one predicted by the participant's rational mind. Participants are encouraged to welcome difficult emotions rather than to suppress them, in order to better resolve deep-seated patterns of fear and powerlessness.

The therapists emphasize their commitment to help the participant cope with and recover from all the emotional material that may arise during the drug session. This commitment from the therapist is explicitly discussed. They agree to provide support, safety, and guidance for the participant in working with whatever emotions and memories arise within the session.

Therapist: "We want to emphasize our commitment to you and to be available for you. It is a privilege to support you as you do this work."

Therapist: "If you decide you need to be on an antidepressant you can do that. You are always free to change your mind. What's most important is your well being."

Participant: "I think after experiencing 4 of 5 life stressors, like losing my job, typically I would say I need to go on an antidepressant. But because of the study, I am excited because I am also faced with working through this without being on anything. I think that I am cognitively aware enough to know that if I really feel like I'm slipping I would be able to let you know or ask for it."

It is sine qua non for the therapists to use clinical judgment and personal awareness regarding when it is best to facilitate the participant's process and when it is best to silently witness the participant's experience. (This will be discussed at greater length in stage three of this phase of treatment). The participant is encouraged to feel free to ask for support from the therapists during times of intense emotion or painful memories. They may ask to be touched or held, ask for reassurance, or simply to talk about what they are experiencing.

Therapist: "We want to reaffirm our commitment to be present for you. We will make this a safe place for you to have whatever experience comes up. The approach is if difficult things come up to stay with them and fully experience them and use your breath to move into them. And ask us for anything you need. We'll weave alternating periods of going inside, using eye shades, listening to music if you want to and then talking to us when you feel like it.

Therapist: "Sometimes if we've been talking for a while we may suggest you bring your attention inside or you may just get the sense that you need to do this."

During the second introductory session the participant will be introduced to the attendant who will accompany him or her during their overnight stay at the clinic. While this may not always, be possible, a meeting with the attendant will help the participants feel more comfortable and familiar with the attendant. If necessary, the participant will meet the attendant on the day of the MDMA session.

The attendant will be a registered nurse (RN), and will always be of the same sex as the participant with whom he or she will be staying. The RNs will be trained by the therapist in how to appropriately fill this role. These nurses will be selected for their ability to act as reliable and compassionate attendants, and to recognize when to call the therapists in the event that the participant is experiencing physical or emotional distress during the night following an experimental session. A necessary quality for these individuals will be the ability to tolerate being in the presence of other people's emotions without becoming emotionally reactive themselves. Attendants will be taught to be attentive to the participant's need for food or liquids, and to offer companionship by sitting with them or taking a walk according to the participant's desires. They will be instructed to listen compassionately if the participant wants to talk, but not to attempt to interpret the participant's experiences or otherwise act as therapists. The emphasis will be on listening rather than talking and being quietly present. The attendant will be taught to avoid initiating long conversations with the participant or being intrusive in any way on the participant's experience, other than to inquire about their comfort or their physical or emotional needs.