This section discusses the three steps in the Phase II: MDMA sessions: initiating therapy, first MDMA-assisted therapy session, and second MDMA-assisted therapy session. The overall goal of an MDMA-assisted session is to reduce the symptoms of PTSD and improve overall functioning and quality of life. This is accomplished by gaining new perspectives about life experiences and clearing emotional and somatic blocks resulting from past trauma as the participant confronts trauma-related memories, thoughts, and feelings within a designated "safe space" provided by the therapeutic set and setting and the effects of the MDMA. The MDMA-assisted treatment sessions are discussed below in four sections. As the therapists prepare the participant for ingesting the medication, they take time to talk with the participant and familiarize him/her with the MDMA experience (Section 4.1). The next step involves working with the acute and sub-acute effects of the medication (Section 4.2). The role of the therapists throughout the treatment session is discussed separately in Section 4.3.
At the beginning of the MDMA session, the therapists and participant review the participant's goals for the session, the range of experiences that can occur during the session, and any concerns the participant might have. This encourages the participant to disclose his/her feelings about the process and provides the therapists with the opportunity to reassure, and guide the participant towards maintaining a therapeutic intention.
Participant: "I have this thing about the unknown. It just doesn't sit well with me. I don't do well with it. When I know what to expect it's OK. Not knowing and having unanswered questions, I just don't do well with. Like the idea of possibly having flashbacks ... and I don't know, worst case scenario."
Therapist: "It's really natural to be anxious about that. One of the challenges of this approach is being willing to go into it and work with whatever comes up. Your reactions are common. I think it is helpful to remember nothing is going to come up that is not already there. Whatever comes up is something you are walking around with already but not conscious of. It's scary. The paradox is although it could stir memories or even flashbacks, temporarily, it allows you to move through them in a way so that you are actually more apt to be free of them and less likely to have them be a problem for you in the long run. It's possible you could have more symptoms temporarily, like we talked about."
Participant: "Yeah right. Is this one of those things where you won't remember what happened? Like being under sedation?"
Therapist: "You'll remember this. One of the qualities of MDMA is that it makes it easier to face memories and not be overwhelmed, and actually work through them and the painful emotions in a way that is healing rather than re-traumatizing. In everyday life flashbacks and memories can come up spontaneously and overwhelm you. We are trying to change this by inviting whatever comes up to come up in a safe setting, with the medicine helping you approach it without being overwhelmed. The idea is to approach your memories with less fear and less defensiveness.
Participant: (Sigh) "If that can happen ..."
Therapist: "We're here to help you stay with what you're experiencing and encourage you not to judge whether it's the right thing or the wrong thing, but experience it as fully as possible."
Participant: "Uh huh."
Therapist: "Ask for support in whatever way you need, if you want us to hold your hand or hold you or if you want to talk to us. All that we talked about. It's really good to ask for support if you feel you can. I know a lot of your tendency can be to tough your way through ..."
Participant: "Suck it up."
Therapist: "Today is an invitation and encouragement to let go of as much of that as possible. This is a whole day for you to have all the support you need, all the support you are able to accept, and allow yourself to feel and work with whatever comes up rather than pushing it away or sucking it up."
As the therapists give the medicine to the participant they explain that MDMA is known to increase feelings of intimacy or closeness to others and to reduce fear when confronting emotionally threatening material (Adamson 1985; Cami et al. 2000; Downing 1985; Greer and Tolbert 1998; 1986; Grinspoon and Bakalar 1986; Grob et al. 1996; Harris et al. 2002; Tancer et al. 2001; Vollenweider et al. 1998). They remind the participant that in the context of psychotherapy, a combination of drug effects may all serve to facilitate the therapeutic process and bring the participant closer to his/her treatment goals. These effects include enhanced positive mood, changed thoughts about meaning, increased access to distressing thoughts and memories, reduced anxiety and increased feelings of empathy or closeness to others, and decreased self-blame and judgment. This combination of drug effects should allow the participant to confront and examine memories of traumatic events and the effects these memories and related thoughts and feelings have had on his/her life without being overwhelmed by fear, anger, or shame. The participant is guided towards a relaxed state, encouraged to focus his/her attention on abdominal breathing and to set aside any expectations about what might happen during the session.
4.2 MDMA-Assisted Therapy Sessions
4.2.1 First MDMA-Assisted Therapy Session
Onset of subjective and physiological effects begins 30 to 60 minutes after oral administration.
During this period the participant is in a comfortable position and may find it helpful to focus on
his/her breathing. The participant has the option to use eye shades and listen to the music
selected for the session. At the beginning of the session participants have been reminded of their
intentions, as mentioned above in Step 1. During this stage it is important that neither the
participant nor the therapists be forceful about directing attention toward these goals. It is more
useful at this point to be open to whatever unfolds and trust the innate healing capacity of the
participant's psyche. The participant may talk to the therapists at any time.
Therapist: "You mentioned that you're worried that this stuff with your dad may come up and it is fine for this type of material to arise."
Participant: "OK. I feel good about that."
Therapist: "We don't want to direct this nearly as much as we want to follow and support the way it unfolds for you. So we trust that your own inner healing mechanism will bring up whatever needs to come up. As we talked about before, we would like to have an agreement that at some point if nothing about the trauma has come up spontaneously we'll bring that up in some way so that we can work with it. But we will let your own unfolding of the process take the lead."
In some cases the participant may become anxious at the onset of the MDMA.
Participant: "I feel really weird. My arms and legs feel heavy and tingly"
Therapist: "I want to remind you that you're in a safe place, and we're paying close attention to how your body is reacting. Use your breath. What you're experiencing is a normal reaction to the MDMA effect starting. By using your breath like we practiced you can stay with the energy in your body."
Participant: (Begins breathing. Music is soft and melodic.)
Therapist: (After a long silence) "It's very common to have a lot of energy. One thing is to breathe into it and experience it, maybe savor it and also if your body wants to move, just let your body express itself."
Participant: "I need direction. I'm just going every which way. I need something to focus on. I need something to think about ... too many thoughts."
Therapist: "Try to see what direction the medication gives you. Instead of trying to control your thoughts, trust the medicine will unravel these knots in some way and take on direction. I know there is an abundance of energy in your body, so you do not have to make your body relax, just let your thoughts float by."
Peak effects typically occur 70 to 90 minutes after drug administration (Harris et al, 2002; Tancer & Johanson 2003; Liechti & Vollenweider, 2001), and persist for 1 to 1.5 hours. The therapists check in with the participant after 60 minutes if the participant has not talked since the administration of the medication. This check reminds the participant of the therapists' presence and provides the therapists with a cue as to the participant's inner status. After this brief interaction, the therapists encourage the participant to return to an inner focus.
To check in with the participant at 60 minutes one of the therapists may put a hand gently on the participant's shoulder (if the participant has previously given permission to be touched in this way ) and ask softly,
Therapist: "It's been an hour and we're just checking in to see how you're doing."
Participant: "I don't remember so much about my childhood. It's hard for me to imagine that I can heal this stuff if I don't remember what it is. I just want to dig it out."
Therapist: "So what I encourage you to do right now, as much as possible, is to stay with all of that, including the feelings of frustration and concerns about your not being able to remember. Let yourself just go into feeling all of it and let go of worrying about whether you can remember or not remember. Let go of worrying about how you are going to heal. Breathe into the process and trust your own healing intelligence with the help of the medicine. It will help it unfold the way it needs to."
Most of the MDMA-treatment session consists of the participant attending to his/her intrapsychic experience and the therapists maintaining a clear empathic presence to support the process of the MDMA-treatment session. As the session progresses, the participant is likely to experience a positive mood and a sense of trust for both self and others, along with facilitated recall, which can result in the emergence of difficult and painful emotions and memories. Ideally the effects of the MDMA and the therapeutic set and setting will lead to catharsis and improvement.
Therapist: "You were beginning to sense the fear."
Participant: "It changed from fear to `I'm really mad at myself for allowing it to happen.'"
Therapist: "Is that easier to feel than the fear?'
Participant: "I guess so."
Therapist: "Because you were experiencing that and the fear began to come up and I invited you to go inside and feel the fear. How long before it switched to the anger?"
Participant: "Not long at all."
Therapist: "Your mind does that to distract you from the feeling of fear."
Participant: "That's possible. After the initial, `What the hell is going on,' my mind clicked into `This is not happening. This is just too absurd to be happening" ... all the way back to when I was little ... I never felt protected, really. There's never been any support. I wasn't free to be me ... just what the situation called for. I had to do it then too, be what the situation called for." (Long silence.)
Participant: "I feel like a lot of this baggage I've been carrying around I put onto myself either disappointment in myself or self blame. Don't get me wrong, I don't think I deserved it or asked for it or did something to bring that on. I don't feel that way at all. It's like your baseline and you've got your self-doubt, desperation on top of that and before you know it you've got a 7- layer burrito. I can feel every one of them. I don't know how to express it or articulate it but I can feel every one of them. It's not the "Yuck" that I used to describe. They're stacked one on top of the other. I guess I have just done it for so long that when the rape happened it was the straw that broke the camel's back. I just left. My mind said that's enough, no more."
The MDMA-assisted psychotherapy helps the participant face the traumatic memories and associated thoughts and emotions. With more self-acceptance and less self-criticism, the participant gains self-confidence, a sense of self-efficacy and control over unfolding memories, thoughts or feelings. A sense of inner calm, rather than extreme arousal, on confronting trauma- related material is expected to help the participant examine memories and thoughts more closely and objectively, while at the same time allowing the powerful emotions to surface. The sense of safety and facilitated recall may work in concert to facilitate deeper or more intense exploration of the trauma-related events and/or their effects on relationships and other aspects of the participant's life.
Participant: "Fear is the only emotion I've ever really known that well ... afraid of this, afraid of that. That's all I remember feeling for as far as I can remember. Heart stopping, gut-wrenching fear."
Therapist: "Hmmm" (Long silence/soft piano music)
Participant: "I've kept all this inside for so long. It feels so heavy, these emotions ... it's like I was trained this way ever since I can remember. Children were to be seen and not heard. From that point on I sought to make myself as insignificant as possible. Then after the rape happened, I was headline news. I knew everyone at the hospital. I was ashamed, like I had a scarlet letter."
Therapist: "I think it's important for you to experience these feelings of fear and shame. You've been holding on to these emotions for so long, and also the belief that you have to be a certain way. It is a really powerful thing to feel, just the realization of it."
Participant: "And it all ties into how I handled my adult relationships, `cuz I was always afraid to be myself because nobody would like me as myself. Then Tom comes along and I don't have to be a certain way. Now I have someone I can lean on and somebody that is there for me and doesn't judge me. It's a great feeling."
As the participant experiences a greater sense of closeness to others, with more trust and intimacy, she/he may also feel empathy and forgiveness for the self and others. Ideally this progression leads the participant to feel worthy despite the shame or distress caused by the traumatic event or events.
Participant: "I felt that interconnection between me and Tom. I haven't felt it for a long time and that's what makes me feel so much better, knowing that it is still there. It's been a big stressor for me."
Such insights may also help the participant develop greater trust with the therapists and make it easier to talk about his/her inner experience. The participant may also be more likely to comply with any instructions intended to improve the therapeutic experience or to help the participant experience fully a particular element of the experience, such as a difficult memory, insight or feeling.
Participant: "It sucks to just live. Y'all are really a godsend. It is so nice to have someone who understands. For so long it's been take this pill, take that pill. The night that I was raped, the first thing that popped into my mind was they are not going to believe me because of the T-shirt I was wearing. I really thought nobody would believe me. And here you are. Just throughout the years, everyone said take this and take that. Nobody's really bothered to dig down to the symptoms and help me figure out what's causing this."
As the therapists listen and talk with the participant, they are also assessing whether such verbal interaction is indicated or whether it may be an attempt to defend against difficult or painful emotional material. If the participant seems to be intellectualizing, then the inner experience is probably not resolved and needs more time to unfold. This is sometimes referred to as the participant "getting ahead of the internal emotional experience." In this situation, it is necessary for the therapists to intervene and guide the participant back to his/her internal experience.
Therapist: "It may be helpful to really get into a comfortable position and allow your body to sink into the mattress."
Participant: "I feel so crooked. Are you going to be able to walk me through any of the traumatic experiences to kind of help me focus?"
Therapist: "Absolutely. If it feels like it's the time to do that now, we can help you do that, but it might be better at this point to go inside and relax. Sometimes talking can get in the way of the experience. We can talk more later." (This response was based on the therapist's sense that the participant was trying to force the experience and was looking for outer direction at the expense of inner awareness.)
Participant: "I feel really restless."
Therapist: "Just attempt to go with the flow with that energy for a little while."
Therapist: "I think you should lie down, sink into the mattress and let your body get comfortable with that movement if you need to. Try and let your breath take you through the confusion and let the medicine work as you breathe and take you through it."
Participant: "If you don't mind, could you remind me to breathe into it? Just give me a little sign to breathe."
Therapist: "How about if I just touch your shoulder to remind you? Remember the words, `Don't get ahead of the medicine. Let the medicine take you where you need to go."
The therapists must recognize and work with both the participant's underlying psychological processes and the experience produced by the medicine. This involves simultaneously supporting the participant in experiencing the negative effects of the trauma and experiencing the softening effects of MDMA. The therapists' presence and the effects of the medicine provide a feeling of safety as the participant's barriers to perception open to allow increased access to memories, thoughts and emotions.
Participant: "Sometimes I am so detached from my family. Sometimes I don't even feel like I'm Aileen's mom. There's just not that ... I don't know."
Therapist: "Your derealization takes all of your attention."
Participant: "My perception is off."
Therapist: "This is a safe time to notice your own experience more. Try to focus on your experience rather than have it outer directed or having to just make it through. It appears to be unfolding today that there are these layers connected not only with the rape, but the experiences before. First, the top layer is the depersonalization when that veil came down, then there is self- pride and under there is fear and anger. It is finally safe to revisit that."
Participant: (Breathing softly.)
The therapists continually create a safe space for the participant as he or she experiences increased access to memories or thoughts. The medicine may also produce in some participants a feeling of loss of control. The therapists work with the participant to embrace these feelings and move through them as the participant is encouraged to surrender control and open to inner emotions which may previously have been too fearful to encounter.
Increased sensitivity to interpersonal relationships and intimacy issues may allow participants to consider ways in which their symptoms have altered or impaired their relationships with others. With this perspective, participants are more able to view their interpersonal relationships realistically, without judging themselves or others too harshly.
Participant: "Did you tell Tom that I love him?"
Therapist: "No. Sorry I missed that but I can call him back. Is that something you are experiencing deeply now?"
Participant: "Yes, on a deep level, a deep feeling for all the love and understanding what I am going through and not knowing how to help. He's my soul mate. I don't know what I`d do without him. That deep love I feel right now. I haven't felt that for so long."
The increased focus on interpersonal relationships may benefit participants who have distanced themselves from others as a way of coping with the trauma or PTSD symptoms. Feelings of interpersonal trust may also help participants who have experienced a lack of support from significant others after traumatic events. The therapists and participant may explicitly seek to explore these areas during part of the MDMA session.
During the MDMA session, the participant may experience strong negative emotional reactions, including a feeling of loss of control. When the therapists see that the participant's distress is interfering with his/her ability to focus on the inner experience, they intervene, encouraging the participant to stay with deeper levels of emotion, and to trust that it is safe to face the experience. This may take the form of introducing the previously practiced breathing exercises, (e.g., "use your breath to stay with the experience, breathe into it"); verbal statements assuring the participant that he/she is in a safe place, orienting the participant to the "here and now"; encouraging the participant to talk about his/her emotions; holding the participant's hand; or providing other nurturing touch. In this way, the therapists help the participant to stay with and move through his/her emotional experience, (i.e., the participant stays with the fear, anxiety, shame, guilt, etc.), and acknowledge this as a natural progression of the therapeutic process. At this point in the session, the therapists and participant may engage in some level of focused bodywork (Appendix B).
An example of helping the participant with a difficult experience:
Participant: (deep breaths) "Fear."
Therapist: "Fear. Where do you feel it in your body?"
Participant: "In my chest. It's hard to breathe, kind of a suffocating kind of fear."
Therapist: "Any images or content associated with it?"
Participant: "No, just deep seated fear. Just that wrong feeling. It's just wrong. I don't know how to explain it. It's like that `take the wind out of your sails ... that overwhelming suffocating fear, terror, just out of control helpless fear." (Crying)
Therapist: "I would understand this is something you've been carrying around and it is now coming up to be expressed and for healing."
Participant: "It's weird. My body, I know I'm safe, but my mind just doesn't want to know it. It's a weird combination of my mind is telling my body one thing and my body is going `NO' but my mind is just that, just that ... it's like someone is throwing a wet blanket on me. It's just that suffocating; you know you can't catch your breath ... just fear."
Therapist: "Remember your breathing. We are right here with you. " As the effects of the MDMA subside, the therapists may communicate with the participant more extensively about what she or he experienced during the session. The therapists ask if the participant would like to give more detailed feedback on his/her emotional and psychosomatic status (Grof, 2001). However, there should be no pressure to do so at this point, and much of this may be left for follow-up sessions.
Therapist: "There is no pressure to talk now, but we might want to give you the opportunity to share more detail if that feels right. Sometimes people have the sense that it is best to hold the experience in silence until the next day and others find it useful to talk about it at this point." The therapists encourage the participant to reflect on and accept the experience, and to consider any newly experienced insights. If the participant indicates physical pain, tension, anxiety, or other signs of distress, the therapists may use focused bodywork at this point (Appendix B).
To prepare for focused bodywork the participant is reminded to use the word "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 such touch 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 expressions that are part of the participant's inner experience. When the participant's emotional distress is impeding a participants experience to they point where they are not able to process and move through spontaneously, the following steps may be helpful. In most cases, these steps should be taken sequentially, proceeding to the next step only if necessary:
As the MDMA session draws to a close, the participant may invite a significant other into the consultation room to assist with re-entry and join the participant in his/her recovery process. The participant and therapists explain the participant's present condition to the visitor, and the therapists encourage the significant other to share any concerns or questions he/she may have. The therapists may explain some of the after-effects of the MDMA experience, and together the group may discuss what might be expected over the course of time as the healing process unfolds. The participant remains overnight in the treatment setting, accompanied by a trained attendant, and the participant may be given the option for his/her significant other to stay as well. Both the participant and significant other (with the participant's permission) are given a means to contact the therapists. The therapists are available to speak with the participant during this time and they can also rapidly return to the clinic if requested by the participant or the attendant.
The therapists examine physiological measures (blood pressure, pulse, and temperature) and self- reported distress and mental state to make a clinical judgment concerning the participant's stability and the strength of drug effects. When the drug effects are no longer apparent and the participant is judged to be emotionally and medically stable, the therapists may leave the clinic. Any place where MDMA-assisted therapy is performed should be equipped with rooms that can house the participant, an attendant, and a selected significant other. A kitchen and eating space should also be available, and good quality food should be on hand. Art supplies can be especially useful at this point, and the participant can be encouraged to continue his/her process symbolically with the art materials.
The participant spends the rest of the evening and night in a comfortable private room in the clinic or offices of the therapists. The attendant is on duty during this time and has a separate room in which to rest. The attendant can function as an impartial and empathic listener, if necessary but primarily serves as a supportive caretaker and monitors the mental and physical state of the subject. The attendant contacts the therapists if at any time the participant seems to be experiencing undue distress.
The participant may spend time indoors or outdoors, so long as the attendant is nearby. However, the participant is encouraged rest, reflect on and integrate the recent experience a quiet atmosphere. The participant may also spend time with the selected friend, family member, partner or spouse as mentioned earlier.
A follow-up session occurs on the morning following each MDMA session, as explained in Section 5.2.
4.2.2 Second MDMA-Assisted Therapy Session
The participant and therapists integrate the progress and experience from the previous session to
set intentions for the second MDMA session. The participant and therapists review the
participant's goals at the outset of the session, and the participant is reminded to follow his or her
inner experience throughout the session. As previously described, the therapists guide and
support the participant throughout this process. The second MDMA-assisted therapy session is
conducted in a manner identical to the first session, and typically occurs about three to four
weeks later.
Participant: "I felt so good after the first session and my whole outlook had changed. I guess for the most part it still has."
Therapist: "The last time you said you wanted to more specifically address talking about the trauma. Do you still feel that way?"
Participant: "Oh yeah. I think that's what's got me so nervous."
Therapist: "So as far as the way we approach bringing up the trauma ... Do you have any thoughts about how you want that to happen?"
Participant: "All I can really tell you is that I'm not the `beat around the bush' type of person.
Therapist: (Laughs)
Participant: "Bluntness is usually the best thing. I can't think of a really good way to approach it. I mean, um, I don't know, whatever you think."
Therapist: "I hear you about beating around the bush. I like that about you. I think it's useful to strike a balance between giving the experience a chance to come up the way it is naturally going to come up for you, if it does, and us gently guiding you in that direction in accordance with your intention, if we need to. So probably, like the last time, we'll wait for a while and if you haven't checked in with us after an hour, we'll check in with you."
Participant: "Sure" The second MDMA session can facilitate a deeper emotional experience, due to several factors: an already established therapeutic alliance, familiarity with the structure and nature of the MDMA session, experience with the effects of MDMA, and an increased openness to further exploration. The psychic material that has revealed itself during the first MDMA session and the therapeutic work occurring in the follow-up non-drug sessions may help the participant trust the process more deeply this next time. Given this stronger sense of trust and familiarity, the participant is likely to move even further beyond his/her defenses.
4.3 Role of the Therapist During MDMA-Assisted Therapy Sessions (Phase II)
A primary role of the therapist in MDMA-assisted therapy is to create and maintain a safe
therapeutic alliance with the participant. The therapists' own self-awareness is a crucial
requirement. They must be fully present during the participant's processing of trauma and at the
same time, maintain healthy, appropriate boundaries. In so doing, the therapists encourage
theparticipant to stay present with his/her inner experience and facilitate the participant's
willingness to explore new and unexpected perceptions which may arise during the healing
process.
Thus the strength of the therapeutic experience relies heavily on the therapists' ability, their level of comfort with intense emotions, and their skill in remaining empathically present and open to a range of emotional experiences the participant undergoes. The therapists maintain an awareness of the participant's intentions for the session while allowing for additional psychic material to emerge. They also consider the psychological factors influencing the participant, including the participant's expectations of the therapists (Widmer, 1997).
To maintain the delicate balance between focusing on the inner experience and providing a safe space for exploring this experience, the therapists must respect the natural healing mechanisms of the participant's own psyche and body. This involves skillfully interweaving interaction with the participant and periods of silent witnessing.
Participant: "When my brother left there was just no contact for me. I really felt abandoned. He was a rock for me. I could feel safe. He was a really good brother, and then he went to California, and he was gone."
Therapist: "Do you think it would be a good time to go inside and work with those feelings?"
Participant: "Yeah"
Therapist: (After a long silence). "How is it going in there?"
Participant: "It is really crazy. And not all of what I was expecting. ... I don't know if I can even verbalize it. Some of it is really dark and some of it is not. It is kind of anxiety-provoking. It's like stuff I had no idea was in me. I am OK being there. It's not realistic at all. I am not really trying to connect it with anything. It is kind of like I want to get out of my skin. I kept wanting to stop and then stay. I'll stop if it gets too weird."
Therapist: "It isn't necessary to feel as though you have to verbalize it right at this point."
Participant: "OK"
During the MDMA treatment session, the therapists act both as guides and supportive figures. As guides, the therapists facilitate the healing process and encourage the participant to focus on his/her goals when appropriate. This role may require therapists to redirectbehavior, as when participants are requested to discontinue talking if the communication seems to represent either defensive avoidance or a distraction from the opportunity to experience and benefit from the unique effects of the medicine. These MDMA effects can lead to important insights and healing that arise through a non-linear process. This process is enhanced by allowing the medicine to bring forth experiences instead of intervening -- a posture of acceptance rather than analysis. In this vein, the therapists may need to follow the participant as he/she explores new and unexpected perceptions, even if they appear to be leading away from the primary agenda.
At other times, participants may describe experiences of exhilaration, joy, resolution or self-affirmation. The therapists, as guides, provide room for these expressions and encourage the participant to accept and perhaps further explore these experiences. The therapists may inquire as to how the participant experiences these feelings as part of his/her healing process. These experiences may serve to soften or reduce the intensity of distressing memories, thoughts or feelings and may provide a life-affirming perspective for the participant.
Participant: "This is such a fun way to spend the day. I am really having a lot of fun. I was thinking that I hope you guys are having as much fun as I am. (Laughs).
Therapist: "We are. Thank you."
Participant: "This is what I love about this work. It is, like so beautiful on one level. I feel like every one should have the experience of what the collective unconscious is and about how full we are. It is just really lovely. Some of it is painful and creepy too, but a lot of it for me is just so, I am going `Wow I can't believe I have this in my head. I can't believe it is in me.' It is really a neat experience. It is very reassuring because even when it gets dark and kind of uncomfortable, I am like, I feel very clear that it is just part of what I am made of and it is OK." As supportive figures, the therapists provide comfort and reassurance to the participant and assist him/her in facing overwhelming and upsetting thoughts, memories or feelings. The therapists encourage the participant to reach new perceptions or insights by empathic listening, questions or observations that may help amplify the experience, verbal and physical comfort on request, and techniques to help the participant relax and gain a sense of security in the face of trauma related feelings.
The role of the therapists is clarified and strengthened by agreements concerning appropriate behavior during the treatment session. Any sexual behavior between therapists and participant is absolutely prohibited, and this agreement assures participants that their heightened vulnerability will not be exploited, while simultaneously fostering a safe environment for offering physical comfort during the treatment session. Everyone also agrees that the participant will remain within the confines of the treatment area until completion of the sessions. This agreement helps ensure the participant's safety and reassures the participant that the therapists will not allow him or her to leave the safe space until they are ready to do so.
The therapists provide verbal and physical comfort upon request. They may remind participant of their presence and encourage the participant to use breathing exercises or request focused bodywork if needed. The therapists also maintain a safe space through the immediate discontinuation of any action, including verbal or physical contact, when the participant says "Stop." Support is also offered by reminding the participant of his or her own strengths and the tools that he or she possesses, such as new insights or self-soothing skills that can be used in the face of intense emotional experience.
In conducting MDMA-assisted treatment sessions, therapists must attend to balancing their responsibilities as facilitators and as noninvasive observers. This may prove challenging at times, particularly when the therapists must decide when it is desirable for the participant to explore and confront his/her inner experience and when interaction with the therapists is appropriate to facilitate a particular avenue of experience.
The therapists may also help the participant examine and negotiate ambivalent feelings toward the appropriateness of emotions or thoughts he or she is experiencing during the MDMA session. For example, the participant may experience cognitive dissonance between newfound feelings of self-forgiveness and self-acceptance and habitual thoughts of self-blame and self-loathing related to the traumatic experience(s). Here the therapists must determine whether or not to intervene. In either case, the therapists seek to maximize the potential benefits of the MDMA-facilitated inner experience while at the same time ensuring that participant is safe and is not re-traumatized by the internal conflict. Maintaining this balance requires a focus on the verbal and nonverbal communications of the participant, and an understanding of any potential difficulties the participant might be facing as a part of his/her healing process.
Toward the end of the session as the participant is emerging from the effects of the MDMA, the therapists assess the participant's emotional stability, alertness to ascertain whether the participant continues to experience altered perception. This assessment is made by using the methods described above for the first MDMA session. The therapists allow the MDMA session to end only when they conclude that the participant is stable and alert. If the participant is experiencing residual emotional distress, the therapists use clinical judgment to asses the apparent intensity of distress and to gauge what interventions should be employed. In most cases, the proper intervention will be to allow the participant to express his/her feelings, and to help him/her understand the importance of these feelings in the overall healing process. The therapists will only depart from the clinic when they have concluded that the participant is emotionally stable and that most MDMA effects have subsided.
The participant should be informed that, though the acute effects of the MDMA have worn off, the effects of the MDMA session inevitably continue to unfold over the hours and days following the session. The participant is also assured that the therapists will continue to provide support and help in working through and resolving any difficulties. At this point in time and before leaving, the therapists may wish to review and assist the participant in practicing relaxation and self-soothing techniques that were taught in the introductory sessions. If the participant's distress is not sufficiently decreased by the above measures, the therapists should consider focused bodywork as described in Appendix B. As mentioned above, a "rescue medication" may be administered if extreme anxiety persists and all other interventions have failed to reduce anxiety to a tolerable level.
If all means of reducing the participant's distress have failed and the participant remains severely anxious, agitated or in danger of self harm or suicide, or is otherwise psychologically unstable at the end of this two-hour stabilization period, the therapists may decide between one of two options: (1) the therapists may then meet with the participant daily until the period of destabilization has passed; or (2) the participant may be hospitalized until she or he is in a stable condition. All participants will be aware of these possibilities when consenting to undergo MDMA-assisted psychotherapy. The therapists are only likely to use these options under extreme conditions, and all other options will be tried before hospitalization.
As described above, the principal therapist is responsible for disqualifying any participant who has had a sufficiently adverse physiological or emotional response to MDMA during the first session to indicate that he/she would be at risk during a second MDMA session. All participants eligible for a second MDMA session should discuss their thoughts and feelings about undergoing the second session. The consequences of continuing MDMA-assisted therapy and the consequences of discontinuation will be frankly discussed. The participant's decision about what he or she would prefer is respected unless the therapists have an overriding reason for excluding the participant on grounds of safety.
At the end of the MDMA session or upon departing on the night of the session, the therapists may provide the participant with specific suggestions to write about his/her thoughts, feelings, and experiences of the day, and to bring this writing to the follow-up session. The participant will also be encouraged to pay close attention to his/her dreams and work with expressive art materials.
In early and pilot studies, the therapists will contact the participant for a week after each MDMA session to assess the psychological well-being during this time period.