Follow-up and Integration Sessions

The initial ninety minute Follow-up treatment session is scheduled for the day after the MDMA session and is designed to initiate the integration process. The therapists and participant begin the process of understanding the lessons and experiences of the previous day. The therapists schedule two to four additional sessions, generally one week apart, before the second MDMA session. These sessions are designed to assist the participant with integrating the events of the MDMA session through exploring the participant's psychological and physical response. Follow-up sessions scheduled after the first MDMA session will also prepare the participant for the second MDMA session. The therapists engage in an active dialogue and elicit detailed disclosure as a means to accomplish the following:

Examining the events of the MDMA-assisted treatment session and exploring what is occurring for the participant on a psychological and physical level.
Ensuring that the participant understands that the experience catalyzed by the MDMA-session will likely unfold and resolve over days or even weeks following the treatment session. MDMA Manual 33
Introducing bodywork into the therapy in the event that the participant is experiencing emotional distress that he/she is not able to move through spontaneously or with talk therapy.
Assessing how the participant tolerated the MDMA session and processing content of the MDMA session. Processing includes discussing effects on PTSD symptoms, re-evaluating goals and discussing integration of insight and new perceptions gained from the MDMA session.
To assess any possible contraindications for the second MDMA-assisted treatment session.

The therapist will remind the participant that they have two options for dealing with upsetting thoughts, memories or feelings lingering after the MDMA session, or unfolding over the course of time. One is to set aside time to experience them as fully as possible; feeling free to call the therapists for support if necessary. An important basis of this approach is the perspective that waves of difficult experience may recur for some time as a part of the healing process. A second option is to perform the relaxation and centering techniques, such as diaphragmatic breathing. This option may be chosen if the situation does not allow for the first approach. These exercises may be especially important immediately after each MDMA session, as the anxiolytic effects of MDMA decline while some upsetting memories, thoughts or feelings brought forth during the session remain. Information on the utility of bodywork and breathing exercises can be reinforced in this session in preparation for the next MDMA session.

Content from the MDMA session will cue the therapists to the likelihood of the participant requiring (or requesting) bodywork to assist in working with the physical areas in which there might be tension and pain. This work catalyzes the healing process by releasing any emotions that may be contributing to somatic complaints and otherwise keeping emotional energy blocked within the body. Bodywork is only done under the condition of participant permission and is immediately discontinued if the participant requests "Stop." Although bodywork may be an important part of the follow-up and integration sessions for some participants, it should not be used prematurely in an attempt to resolve challenging emotions or their somatic manifestations if they are spontaneously being adequately experienced, emotionally processed and expressed. The bodywork is most appropriate in situations in which emotional or somatic symptoms are not resolving because their full experience and expression appears to be blocked.

An example of bodywork in an Integration Session:

Therapist: "How are you today?"

Participant: "Much better today than yesterday. But you know it was, this morning, it was the same feeling I had yesterday morning. When my eyes popped open, when the alarm went off, the dread hit me right in the gut. You know, that, `I don't want to get out of bed. I don't want to do this day.' Just like I had a bad case of the "don't want tos." I just didn't feel like I had the strength to get up and face another day. I mean it was just, the minute my eyes popped open, it was dread, knot in my stomach, the anxiety. I mean it was just like automatic last night. I slept really well, about 9 hours of sleep. I didn't have any bad dreams. It was like flipping on a switch, my eyes popped open and here it came. Just felt, it makes me feel sick in my stomach, that kind of fear. You know, that you feel nauseated, just like you want to throw-up. That's been pretty much the theme today. I haven't had any other emotional outbursts. I didn't cry at all today, haven't felt angry, just that dread, that lump in my gut."

Therapist: "So it is like yesterday but on a lower level."

Participant: "Much lower. I think a lot of it is my mind set too. I felt so much better after leaving her last night, realizing if it does happen again, I will live through it. It's probably going to happen again, but I feel more prepared. It didn't become overwhelming at all today."

Therapist: MMMmmm MMMmmm.

Participant: "Dread and fear were there for so long. You get so used to it you don't know what it is anymore, especially after having the anxiety disappear. It feels like a whole new wound. It wasn't the same. It just felt dreadful."

Therapist: "Would you be willing to explore that or work with that a little bit today? See what you may discover. Do you feel like you'd do some body work with that lump in your stomach?"

Participant: "Yeah. It is time to try some of that too."

Therapist: "It might be a good way to work with it since you know where it is in your body."

Participant: "I can envision this croquet ball made out of metal. That's what is in my mind and that's how it feels, like a metal croquet ball just sitting right there and it is cold."

Therapist: "And that is what you talked about in your sessions, a cold metal feeling in your stomach."

Therapist: "So maybe just use your breath and breathe into that feeling in your stomach. I encourage you to remain present with whatever comes up and if your body wants to express it in any way, stand, move, or you want some resistance from us." As the Bodywork was done, the participant breathed into it and experienced a deep sobbing.

Participant: "Thank you. I feel a lot lighter. I wonder what that was. I want to know what that was. Just this tightness, this ball, I don't know what it was. I mean it was like fear and anger and everything in one ... started going up and went back down and now it is gone. So is that funny feeling in my stomach and now it is gone."

Therapist: This may be what you already processed in your sessions and this is what is left in your body, those emotions."

Participant: "This is cool. It is cool for it to be gone." The therapists must exercise judgment about when body work is indicated to help facilitate the therapeutic process and when it is preferable to allow the process to proceed at its own pace.

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 ultimate goal of MDMA-assisted psychotherapy is the elimination of symptoms and attainment of an improved level of functioning. This is accomplished by the participant's weaving all aspects of therapy into a new relationship with self, others, and with his/her traumatic history. This phase of treatment brings these elements together, in a cohesive, harmonious way. Paradoxically, in some sense, integration begins during introductory therapy sessions, when the participant and therapists discuss the participant's intentions for therapy. Integration involves the ability to access and apply to daily life the lessons, insights, changes in perception, awareness of bodily sensations, and whatever else was revealed during MDMA sessions.

The therapists and participant use several strategies to bring the lessons gleaned from the non- ordinary state of consciousness over the bridge to the ordinary state of consciousness. This is done during the integrative follow-up sessions as the participant works with the therapists to understand and accept the changes he/she has undergone. It involves giving meaning to the memories, thoughts, feelings, and insights experienced during the MDMA and integrative follow-up sessions and determining how this new meaning will be manifested in daily living.

The therapists encourage the participant to record and examine material from the MDMA sessions. They will suggest ways to facilitate this, such as: listening to music from the sessions, listening to the voice-recordings from the MDMA sessions, practicing breathing techniques, or drawing, singing, dance, exercise, painting, or other forms of creative expression. The use of creative endeavors for recalling and retaining MDMA-session related memories, thoughts, feelings or insights may provide the participant with a new set of coping skills with which to restructure anxiogenic cognitions and trauma-related environmental cues and triggers. The therapists skillfully support these activities that allow the restructuring to emerge from the participant's own thinking and exploration.

Each integrative follow-up session should begin with an invitation for the participant to talk about whatever is on his/her mind. This is to make sure that the participant's experience rather than the therapists' agenda will direct the session. After allowing sufficient time for this open-ended discussion and exploration, the therapists should consider directing the session into other potentially useful areas. The therapists may use a variation of the following comments always in the spirit of offering something for the participant to consider, and with respect for the fact that it may or may not apply to any given individual:

"Sometimes one of the challenges of this kind of therapy is that the MDMA experience may cause significant changes in a person's point of view or belief systems. It can sometimes be hard to reconcile these changes in thinking with old beliefs or with the attitudes of other people in your life or with the society in general. Is this something you've noticed?
"Since the MDMA experience is quite unique it can be hard to explain to other people, and it can be painful if such an important experience is misunderstood or judged by other people in your life. It may be important to exercise judgment about how and when you talk about your experience."
"Often people have very valuable insights and corrective emotional experiences with the help of MDMA that aid in decreasing fear and judgmental thinking. Sometimes the next day the judging mind can get active again and start doubting the truth of these experiences, or sometimes people can have emotional reactions the next day that are different from those they had during the MDMA session. This can sometimes be confusing or upsetting. It's really helpful to acknowledge and talk about it if you're having any experiences like this."
"It is very common for the MDMA experience to continue to unfold for days after the session. Often it unfolds in an easy, reassuring way, but sometimes it can be more difficult. Sometimes working with traumatic experiences in any therapy, including MDMA assisted therapy, can stir things up so that symptoms may temporarily get worse. This may come in waves of emotion or memories. When this happens it is part of the healing process and we're here to help you work with anything that comes up for you after the MDMA sessions. It's important to let us, ("and your other therapist" if they have one) know about it if you have any difficulties like this.
"It may be helpful to write about your MDMA experience and your thoughts and feelings since then. It's best to write this for yourself without the thought doing it for anyone else, but if you want to bring it in to share with us that could be useful. It may also be helpful you to listen to the audio-tape of the session in connection with this assignment."
"It can be helpful to write down your dreams and bring them in to discuss with us. For some people MDMA makes dreams more vivid and meaningful." MDMA Manual 37
"There are some books we can recommend that address some of the experiences you've been talking about."
"Drawing, painting, collage, working with clay can all be helpful, nonverbal, ways of expressing and further exploring your experience."
"If a lot of feelings or images are coming up for you after the MDMA session it's good to allow them to unfold and explore them when you have time and energy to do so, but it can also be important to set them aside when you have other obligations or when you need a break. It may be helpful to write a sentence or two about what you are setting aside and acknowledge that you will attend to it later, either in the therapy or when you have the time and energy. Hot baths, walks in nature, physical exercise, working in the garden, cleaning the house, nourishing food, playing with a pet are all activities that can help to ground you in the present."
"If there are tensions left over in the body, yoga or a massage can be helpful."

During the integrative follow-up therapy sessions, the participant continues the process of accessing and interpreting the other levels consciousness experienced during the MDMA sessions. This expansion in consciousness may lead to a personal paradigm shift. The shift in self and other- related cognition and emotion is then applied to subsequent experiences that trigger unwanted and habitual patterns of thought or emotion. For instance, a lack of trust in the safety of the environment or the trustworthiness of others can be countered by accessing the sense of safety and closeness to others first experienced during the MDMA-assisted session. With the therapists' help, the participant develops a bridge between ordinary consciousness and his/her experiences in non- ordinary states of consciousness, so that these states are experienced more as a continuum than as separate realms. For example, the patient is able to readily access two of the most noted therapeutic aspects of the MDMA experience, "inhibiting the subjective fear response to an emotional threat" (Greer & Tolbert, 1998, p. 371) and increasing the range of positive emotions toward self and others (Adamson, 1985; Cami et al, 2000; Grinspoon & Bakalar, 1986) at times when he/she may be confronted with cues of the traumatic event(s). This allows the participant to maintain a sense of calm security in the face of these anxiogenic stimuli. The ability to expand consciousness assists the participant with restoring a sense of intrapersonal safety while gaining mastery over the debilitating symptoms of PTSD.

Participant: (Crying)

Therapist: "Oh my, what's going on?"

Participant: "I'm just not holding it together very well. I've been like this all day long. (Crying, sniffling) It took everything I had to get out of bed this morning."

Therapist: "What feelings are you having?"

Participant: "Right now I am just pissed. (Crying) I'm very angry. (Sniffling) I was scared that I was just going to lose it. You know, I just couldn't hold myself together. As busy as I tried to stay at work, you know, I didn't even want to go to work this morning."

Therapist: "Where you angry when you woke up this morning?"

Participant: "No, I wasn't angry. I was more hopeless this morning." Therapist: "You know, Tamra, I know this really hard, especially hard to do this and go to work at your job. As hard as it is, I think this is really valuable what is coming up for you. You said you saw the feelings one time and the second time you had the feeling and the feelings are still coming. The fact that they are still coming this strongly is much more than just a superficial kind of moving through them. You are really moving through them in a deep way.

Participant: "I know. It's so bad. I don't want my life to be like this and I'm just pissed off that I have to go through all of this. (Sobbing) I'm afraid it is never going to go away. I'm gonna be stuck like this forever."

Therapist: "You know, we've seen this so many times in Breath Work, that when this kind of thing happens, especially when you're feeling it all n your body, it's not a sign that you are getting worse or you're going to be this way. It's a sign that you're really dealing with this stuff that you've been carrying around all this time."

Participant: "It's so overwhelming though. I'm afraid I'm just going to crack up. You know I'm afraid I'm just going to lose it. I'm afraid I can't handle it."

Therapist: "I can understand that. Did the Lorazepam help?"

Participant: "I stooped shaking, but that's as far as it went. I actually took one, then I waited about an hour and a half and I took another one."

Therapist: MMMmmm

Participant: Big breath.

Therapist: "So maybe, this is so different from the way you keep it together. As you talked about... `OK that's done, it's behind me and it's time to move on' and the cost of that has been to be cut off from your feelings, being anxious and experiencing derealization. So now your psyche is not letting you do that any more."

Participant: "But the derealization has been so bad. It's just been off the charts last night and this morning. I was just sitting there and Tom got up to make coffee and I was just, I didn't think I was going to make it. It was past surreal. It was past anything that's ever been."

Therapist: "Often what happens is both things intensify. You start to have the feelings you've been having this defense against and they intensify and so the defense intensifies."

Participant: "That makes sense. (Calmer now). I hadn't thought about that. All I could think of is O know it is going to get worse before it gets better. But am I going to be able to live through the worst part?"

Therapist: "Remember the last time, you're first day back at work was hard for you."

Participant: "Yeah."

Therapist: "And it has been different this weekend than the last time, but your first day back at work you had some anxiety. It was hard, it wasn't like today. That's been my experience with MDMA, a few days after and it hits me like that, the anxiety and it scares the death out of me � the panic attacks and it usually goes away."

Participant: (Big breath, sigh) I told Tom this morning, `What's gonna happen if I get so incapacitated that I can't work?"

Therapist: "So far you have been able to work and hold it together. You've been doing great. It was just a few days couple of days this weekend and you had a very powerful session."

Participant: It's so strong. It's not like the sadness in my chest. It isn't localized, something I can put my finger on. I think that worries me too. I think it should be a certain way and it's not. You know I just flat out think I'm losing it. I'm going crazy."

Therapist: "It's really hard to just surrender to trusting that your process is unfolding the way it needs to. When you're in the middle of it, it's really hard to have that perspective. I think the more you can set aside your judgment about whether it is going the right way or the wrong way, and just follow it and let us support you in it you'll see that it's leading you in the direction of healing."

Participant: "I'm sure it is too. It's just so dang scary. It's so overwhelming."

Therapist: "One thing that can happen is the session � may feel like you are having those feelings, but you may not really have the emotions until after. It's very common that you are going to present like this � having these emotions � that kind of lag behind is common." The therapists recognize that the information revealed during the MDMA and integrative follow- up sessions serves as a starting point for enhancing the participant's emotional and behavioral repertoire in response to the PTSD symptoms. As the days between the MDMA sessions and integrative follow-up sessions unfold, the participant is instructed to be mindful of any changes in his/her perceptions thoughts, feelings, interactions, and other experiences. When confronting emotionally threatening material he/she is encouraged to return to or reactivate the feelings of intimacy and closeness to others and the reduced fear originally experienced during the MDMA treatment sessions. Teaching the participant to do this between MDMA sessions involves cueing him/her to recall the accepting attitude experienced during the MDMA session and to ask him/herself, "How can I best use my new knowledge in this situation?" The therapists will validate the participant's use of this technique.

MDMA-assisted psychotherapy utilizes the effects of MDMA administered within a therapeutic setting to help people gain insights into their symptoms and adopt new, more effective means of coping with these symptoms. The newly constructed meanings that the participant has arrived at through MDMA sessions and integration of this material afterwards can serve as a template for coping with a variety of PTSD symptoms, including those related to anxiety and those related to interpersonal relationships. The participant should feel less fearful, with a greater sense of self- control or insight when confronted with trauma-related triggers or memories.

Participant: "Basically more than the trust I have in other people, it hits the trust I have in myself. The ability to know my inner strengths and I know they are there. It's just when it shakes you to the core you can't help but second guess ad question. It's feels like it's bombarding me from different directions and you don't know which way to go or what to do."

Therapist: "In a way it is shaking to the core. In a way that is what you asked for."

Participant: (Laughs). "That's what I got, it wasn't in the brochure.

Therapist: We didn't have those terms exactly, but I think shaking you to the core is going to involve releasing the old ways of having to keep that false sense of control."

Participant: (Sighs) Does the derealization ever go away?

Therapist: "Yeah"

Participant: "I'm trying to train my brain to enjoy it. I have all these tools I just need to remember to use them."

Strengthened interpersonal trust will allow the participant to further develop his or her social network. Greater insight into the whole range of thoughts and feelings about the trauma give the participant confidence in confronting his or her emotions and reduce the likelihood of emotional numbing. Maintaining and nurturing the participant's social network may also be made easier when an individual has gained a sense of mastery over feelings of terror or shame and when he or she is better acquainted with these feelings. Relying on the new perspectives gained from the MDMA session, the participant can confront anxiety-producing situations with more confidence and may be more comfortable with asking for assistance from his/her supportive network.