The integrative follow-up sessions occurs the day after each MDMA session, each week between the two MDMA sessions and the week after the second and final MDMA session. The following section describes three steps involved in conducting the integrative follow-up sessions. The first step involves implementing a "safety net;" step two addresses the structure, nature, and goals of the follow-up sessions; and step three considers the therapists' role during the integrative follow-up therapy sessions.

Safety Net
The therapists provide a sixty-minute follow-up session the day after each MDMA session. There are several aspects of the integrative follow-up session that contribute to the patient's felt sense of safety after his/her experimental (MDMA) session. These include, but are not limited to, the following:

1. Knowing that he/she has access to the therapists at any time through their pager as well as during the scheduled appointment the day after the experience may reduce any anxiogenic thoughts the patient may have about his/her experience.
2. Knowing that he/she will participate in a non-drug therapy session less than 24 hours after each MDMA session for an opportunity to debrief and understand the intensity of his/her experience.
3. Strengthening of the therapeutic alliance.
4. Knowing that the therapists may have had an opportunity to work with or speak with members of the patient's support system, including the support person, if one was present.
5. Knowing that the therapists may have had the opportunity to dialogue with patient's primary therapist if the patient is in therapy. MDMA-Assisted Psychotherapy Treatment Manual 31
6. Knowing it is an opportunity to connect with the therapists and process any experience they may have of a heightened state of vulnerability.

Follow-up and Integration Sessions
The initial Follow-up session is scheduled for the day after the first MDMA session and is designed to begin the integration process. The therapists and patient begin the process of understanding the lessons and experiences of the previous day. These sessions are designed to assist the patient with integrating the events of the MDMA session through exploring the patient's psychological and physical response and to prepare him/her for the second MDMA session. The therapists engage in an active dialogue and elicit detailed disclosure as a means to accomplish the following:

1. To examine the events of the MDMA-assisted treatment session and explore what is occurring for the patient on a psychological and physical level.
2. To ensure that the patient understands that the experience catalyzed by MDMA-assisted therapy will likely unfold and resolve over days or even weeks following the MDMA session.
3. To assess how the patient tolerated the MDMA session and process content of the MDMA session. Based on this process, the therapists discuss effects on anxiety symptoms, re- evaluate goals and discuss integration of insight and new perceptions gained from the MDMA session.
4. To assess any possible contraindications for the second MDMA-assisted therapy session.

In response to distress or upsetting thoughts, memories or feelings lingering after the MDMA session and those that may unfold over the course of time, the patient is reminded to perform the relaxation and centering techniques such as diaphragmatic breathing. 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 may remain. Information on the utility of breathing exercises can be reinforced in this session in preparation for the next MDMA session. Review of the videotaped treatment session may also similarly aide the patient in the days following the MDMA session, and patients will be encouraged to view their copy of the videotape.

The primary goal of MDMA-assisted psychotherapy is the elimination of symptoms of anxiety and a return to an improved level of functioning and quality of life. This is accomplished by the patient's weaving all aspects of therapy into a new relationship with self, others, and with his/her anxiety related to having advanced stage cancer. The integration phase of treatment brings these elements together, in a cohesive, harmonious way. 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 to the patient during his/her treatment experiences.

The therapists and patient 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 patient 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 patient to record and examine MDMA session material, refer to the music listened to during the sessions, watch and listen to the videotape recording of the MDMA session, practice breathing techniques, or drawing, singing, dance, exercise, painting, or other forms of creative expression. The use of creative endeavors in recalling and retaining MDMA-session related memories, thoughts, feelings or insights may provide the patient with a new set of coping skills with which to restructure anxiogenic cognitions. The therapists skillfully support these activities that allow the restructuring to emerge from the patient's own thinking and exploration. Each integrative follow-up session should begin with an invitation for the patient to talk about whatever is on his/her mind. This is so the session will be directed primarily by the patient's experience rather than the agenda of the therapists. 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 patient 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 which aids 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 anxiety 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 videotape 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."

"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 a 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 patient continues the process of accessing and interpreting the other levels of 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.

With the therapists' help, the patient 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; Came et al, 2000; Grinspoon & Bakalar, 1986) at times when he/she may be confronted with cues and realities of reduced ability to perform everyday functions, increased pain, and impending death. This allows the patient to maintain a sense of calm security in the face of these anxiogenic stimuli. The ability to expand consciousness assists the patient with restoring a sense of intrapersonal safety while gaining mastery over the debilitating symptoms of anxiety.

The therapists recognize that the information revealed during the MDMA and integrative follow-up sessions serves as a starting point for enhancing the patient's emotional, behavioral, and spiritual well-being. As the days between the MDMA sessions and integrative follow-up sessions unfold, the patient 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-assisted therapy sessions. Teaching the patient to do this between 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 validate the patient's use of this technique.

MDMA-assisted psychotherapy utilizes the effects of MDMA administered within a therapeutic setting to help patients gain insights into their symptoms and adopt new, more effective means of coping with these symptoms. The MDMA-assisted treatment sessions provide the basis for constructing new meanings about self, others and his/her world. In turn, these newly constructed meanings can serve as a template for coping with the variety of ways in which the anxiety may manifest. The patient should feel less fearful, with a greater sense of self-control or insight when confronted with anxiogenic situations. Strengthened interpersonal trust will allow the patient to further develop his or her social network. Greater insight into the whole range of thoughts and feelings about having advanced-stage cancer give the patient confidence in confronting his or her emotions and reduce the likelihood of continued or increasing anxiety. Maintaining and nurturing the social network may also be made easier when an individual has gained a sense of mastery over feelings of anxiety and fear and when he or she is better acquainted with these feelings. Relying on the new perspectives gained from the MDMA sessions, the patient can confront anxiety-producing situations with more confidence and may be more comfortable with asking for assistance from his/her supportive network.