Let me be clear, we strongly support the current revolution in mental health that is psychedelic psychotherapy. We have been involved in MDMA research, we provide psychedelic therapy at our clinics in the US as well as in Amsterdam, and we know what it means to work with these medicines in mental health compared to how long, difficult, and at times impossible healing can be without them. This does not, however, mean a positive outcome is guaranteed. One of the most significant and yet invisible factors in a person’s psychedelic therapy session is their capacity for dissociation.
What is Dissociation?
Dissociation is a biological reaction we all have to overwhelming threat. It is an involuntary emotional and physical numbing response that is caused by the release of natural, endogenous opioids within the brain and nervous system. In a landmark paper on the topic, PTSD researcher Dr. Bessel van der Kolk notes:
“…two decades after the original trauma, opioid-mediated analgesia developed in subjects with PTSD in response to a stimulus resembling the traumatic stressor, which we correlated with a secretion of endogenous opioids equivalent to 8 mg of morphine” .
Van der Kolk is referring to Vietnam veterans who 20 years after their trauma were re-exposed to some echo of the war (sounds, images, smells). These vets had the same numbing response that can be produced with an injection of 8 mg of morphine. Lesser doses of opioids are used in hospitals to treat severe breakthrough pain. This means that our internal pharmacy is secreting powerful opioids to physically, emotionally and psychologically numb us out even decades after a trauma has taken place. This is true for war veterans; this is true for adults who grow up in stressful, neglectful, chaotic or abusive families as children. Dissociation is not mild, it’s not invented, it’s not a placebo. It is a very real neuro-chemical shift in the brain that can be measured.
To comprehend the central role of dissociation in mental health, we turn back to van der Kolk who notes:
“…A vast literature on combat trauma, crimes, rape, kidnapping, natural disasters, accidents, and imprisonment has shown that the trauma response is bimodal:…hyper-reactivity to stimuli, and traumatic re-experiencing coexist with psychic numbing, avoidance, amnesia, and anhedonia. These responses to extreme experiences are so consistent across the different forms of traumatic stimuli that this bimodal reaction appears to be the normative response to any overwhelming and uncontrollable experience” .
Van der Kolk is saying that this combination of sympathetic nervous system fear, stress, anxiety, and panic mixed with an opioid-based, parasympathetic, dissociative numbing response is utterly common. We see it in research, and we see it every day in the trenches of mental health work.
These two sides are the hallmark of trauma, but the surprising fact is that there are no widely practiced modalities that effectively treat dissociation. You can see and feel stress; it is much more challenging to see and feel blankness. Neither your own mind nor your therapist is trained to notice, much less successfully engage dissociation.
Trauma-focused Therapies and Dissociation
The EMDR protocol, for example, advises the clinician to back away from the processing phase and return to resourcing if the client begins to dissociate. Arguably one of the most well-known modalities for treating trauma was never designed to treat dissociation. Consider that any self-report measure of distress such as the ‘how bad do you feel on a scale of 0 to 10’ on the Subject Units of Distress (SUDs) assessment will completely miss and underrate significant trauma events involving dissociation versus much less severe stress events involving no dissociation, which will rate higher.
Common talk therapy or CBT is very limited in what it can do with symptoms emanating from dissociated material. This is because we talk about what the mind can see. We talk about what is upsetting and can be felt. We don’t talk about or even look for what should be there but is oddly missing, especially if the numbing blankness has been in a person’s life since childhood and is the water they swim in. Dissociation is the central dilemma at the heart of mental health. We don’t have good metrics for even noticing it, engaging with it and in our opinion, it is the central cause behind depression and treatment resistance.
Most people have some level of dissociation. This is almost certainly true of people considering psychedelic therapy to resolve their more treatment-resistant symptoms. It’s more a question of how much and how deep the dissociation runs.
Is the client coming in for a single event trauma, like an assault or a car accident, where they dissociated during just that one event or is there prolonged, repeated, childhood neglect or abuse that happened in their family of origin? Both will create dissociation, but the latter person will likely have lived significant parts of their childhood in a dissociative state. They will typically not remember their childhood with actual specific concrete events but will have vague, abstract, generalized recollections of a ‘fine, happy’ childhood. This person will encounter much more profound dissociation during their psychedelic therapy session.
MDMA and other psychedelics do not, by their own nature, crack dissociation.
Most clients in the first scenario, people with a relatively stable childhood who experienced a traumatic event later in life, are typically not driven by suffering from treatment resistant symptoms. These are clients for whom talk therapy, EMDR or standard treatment has worked or who may not have even needed to enter into therapy in the first place.
At least for now, the psychedelic therapy client is more likely to be the complex PTSD, early childhood, developmental trauma patient with a significant amount of dissociation in their system. First, when used skillfully they can lead to peak or mystical experiences in which the boundaries of the individual ego dissolve and one knows that they are intimately connected through love to everything and everyone else on the planet. After having had such an experience most people find that it is much more difficult do things that are harmful to anything or anyone. This is one of the more generic outcomes of mental health research on psychedelics that shows they may be very therapeutic in treating depression, anxiety, addictions, and a variety of other mental health conditions.
MDMA and other psychedelics do not, by their own nature, crack dissociation. They can significantly accelerate the clearing of it, but the process needs to be focused, to be guided, in order to go beyond this dissociative defense structure. Consider this scenario: you will be taking a powerful psychedelic medicine to address the pain in your life, and at the same time, your neurobiology is going to release a large dose of numbing heroine-like opioids specifically to protect you from your traumatic memory. Your system has been doing this for years (perhaps even as far back as infancy), it’s good at it, and it’s not going to stop today. Consider what might happen when a psychedelic response runs straight into an opioid response. This is where we get some variation in people’s experience.
Here is what we have seen specifically with MDMA, but these observations apply to other psychedelics as well (which we will focus on in part 2 of this article): clients frequently feel completely sober even at the high point of a session. People will think that they received a placebo, or it’s just not working for whatever reason. They will feel like nothing is going on. They’ll feel bored and that they can get up and go about their day. They will simply feel unaltered.
Another possibility is that they may just become sleepy. If a therapist was not in the room, they might well fall asleep for a few hours on MDMA which may be hard to fathom if you are familiar with this drug in a recreational setting. In a therapy session, however, where dissociation is given room to emerge because we are focusing on traumatic memory, sleepiness is common. Just like antipsychotic medication will prevent a psychedelic response, our endogenous opioids also have the power to shut things down.
The conscious, storytelling, meaning-making mind being what it is, we will often ascribe meaning to this experience such as ‘I knew nothing would ever work for me’ or ‘The medicine is telling me…’. There are all sorts of conceptual stories we can generate on top of what is happening, but the core experience is one of ‘nothing much is going on’.
The trick to working with dissociation is not to ignore the gold that is boredom in favor of other juicy bits that are more interesting to the mind. The client and the therapist will have an impulse to provide something evocative to get the session going, but the trick is to bring the nothingness, the blank, flat, sobriety, or sleepiness into focus. Have the client notice all the details of boredom. Doing so will take a lot of trust; just know the blankness is incredibly valuable.
The seeming non-response is the access point to go deeper. One of the gifts of many psychedelics, and certainly of both cannabis and MDMA, is that they generate a profoundly embodied, visceral, ‘here and now’ experiences. In this case, the very real ‘here and now’ reality that the medicine is bringing up is dissociation; it is a blanked out, unfeeling state. Our recommendation is to stay with that experience even though it does not fit the client’s idea of how the session should be. Again, easier said than done when the psychedelic therapy client has so much hope and expectation that this treatment will work and be the one thing that helps.
The seeming non-response is the access point to go deeper.
Eventually, the blank boredom will crack. It might take staying with it for 30 minutes, it might take 2 hours, or the entire session, but it will crack. When it does, there is an entire universe underneath that was being hidden from awareness by the dissociation. This is the material that can now be engaged with since it has become visible. Remember, the reason why the dissociation became active in the first place was that overwhelming experiences were taking place. These overwhelming and impossible experiences are what the client fully believes they couldn’t survive when they were happening. Certainly, they were not digestible, integratable experiences at the time and were partitioned off.
Your mind is very well organized not to see dissociation. You will have developed all sorts of interesting, often repeating distractions that will keep looping you around in the session(s). These can be an even a more exaggerated form of the defensive looping that we see in non-psychedelic therapy. There is a lot of other material and channels to focus on that will seem interesting to you, but these are mostly just a distracting puppet show put on by your mind to keep the dissociation in place.
The other possibility is that dissociation doesn’t appear because most people who have traumatic events residing in dissociation also have many other more surface events that are appropriately available to be worked with. Events that were not so overwhelming that they generate an opioid response but instead, these events were milder and thus create disturbing anxiety and fear responses that are visible to awareness.
Essentially, many clients are in a target-rich environment for both dissociation as well as garden-variety stress events. Ketamine, MDMA, and cannabis are very effective at clearing out these more available-to-consciousness surface experiences. PTSD scores generally will go down, and clients will feel a lot better for some significant period of months or years. However, the work and, unfortunately, the symptoms are typically not done yet. There is a lot of short-term benefit, but the material that was hanging out in dissociation will begin to bubble to the surface because you are ultimately more healthy, resourced, and trusting of the process.
In this condition, where your entire system is less compromised and more trusting, it may be weeks or months later but at some point, previously dissociated material will begin to emerge. It is not a sign that your previous psychedelic sessions failed. Quite the opposite, it is a sign of a person’s innate health that their system wants to keep excavating and processing until they are actually done.
In part 2 of this article, we’ll talk about how dissociation interacts with psilocybin (psychedelic mushrooms) assisted therapy. We reference our experience in our Amsterdam program as well as interviews with clinicians who are part of the Psychedelic Society of the Netherlands who regularly use psilocybin in their therapy practice.
- van der Kolk, B. A. (1994). The Body keeps the score: Memory and evolving psychobiology of PTSD. Harvard Review of Psychiatry, 1, 253-265.