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by Saj Razvi, Director of Education and Founder at Psychedelic Somatic Institute
Even though there is large and growing body of research and practice based evidence for how useful psychedelic medicines can be in mental health, this does not in any way guarantee a positive outcome. One of the most significant and yet invisible factors that can frustrate healing in the psychedelic therapy session is our foundational, involuntary, autonomic nervous system defensive capacity for dissociation.
What is dissociation?
Dissociation is a biological reaction we all have to overwhelming threat. It is a passive defensive response initiated by the autonomic nervous system (ANS), specifically the parasympathetic branch of the ANS, when all active attempts at survival have failed. The biological mechanism that generates dissociation is a release of endogenous, naturally occurring opioids within the brain and nervous system. None of this activity is under our volitional control, it is an involuntary, bottom-up, psychobiological response. Under conditions of threat, the parasympathetic nervous system produces symptoms ranging from depression, lethargy, collapse, hopelessness, sleepiness, tonic immobility, and flaccid immobility all the way to a much more thorough physical and emotional numbing. These deeper states of dissociation can be experienced as depersonalization, emptiness, weightlessness or a sense that one’s body is made of non-living material such as plastic or metal.
Remarkably, these deeper states of dissociation don’t lead to catatonia but instead lead to a disembodied cognitive existence that is unencumbered by sensation and feeling. It’s a functional state but one lacking in varying levels of sensate and affective experience. Many people with PTSD find dissociation to be a respite, freeing them from the vulnerability and suffering they experienced in more associated states. Many people who have grown up in threatening circumstances may have lived an entire childhood in dissociation and may not have ever experienced a sense of safe, calm, associated embodiment.
In a landmark paper on the topic, traumatologist Dr. Bessel van der Kolk notes:
"…2 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 morphine are used in hospital settings to treat severe breakthrough pain. This means that our internal pharmacy is secreting powerful opioids to physically, emotionally and psychologically numb us out many years after a trauma has taken place. The dissociate response in Van der Kolk’s veterans was alive and active even two decades after the threats they experienced were long gone. This is true for war veterans, this is true for adults who grew up in stressful, neglectful or chaotic families as children. Dissociation is a very real, neuron-chemical response effecting mind and body.
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."
This mix of fear, stress, anxiety or panic along with an opioid-based dissociative numbing response is utterly common. We see it in research, and we see it every day in the trenches of mental health work. This does not mean the mental health field has been effective at treating it however. You can see and feel stress, fear, panic, and anxiety. You can engage this type of material because it is visible to consciousness. It is much more challenging to see and feel blankness, to see and feel things that are supposed to be there but are simply missing. People aught to be able to feel their body but they don’t, people aught to be able to feel emotions but they don’t, people aught to be able to feel relationship but they don’t. The mind is not designed to notice it’s own dissociation.
Most people have some level of dissociation. This is almost certainly true of the mental health population and perhaps even more true of individuals seeking psychedelic therapy for whom more traditional first line mental health treatments have not worked.
The question is, how much dissociation does someone have. How deep does it run? Is the client coming in for a single event trauma like a car accident or a one time assault where they dissociated during that particular event or did they spend their formative, developmentally sensitive childhood with prolonged, repeated, childhood neglect or abuse that took place at the hands of a family member? Both will create dissociation, but the later scenario will necessitate and thus create a much more profound state of blankness. A state of numbing that will weave itself into development and even identity. Individuals who grow up in threat will typically not remember their childhood with actual specific concrete events but will have vague, abstract, generalized recollections. This person will encounter much more dissociation during their psychedelic therapy session, and their healing path will be far more complicated requiring more skill on the part of their therapist.
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, CBT, EMDR or other standard treatment have worked. The psychedelic therapy client is much more likely to be the complex PTSD, early childhood, developmental trauma patient with a significant amount of dissociation in their system.
Psychedelics do not by their own nature resolve dissociation. Yes, they tend to evoke more dissociated memory than is available to ordinary consciousness but even then, if the process is not specifically focused to engage the emptiness, the the numb heart of the trauma will remain inaccessible. However, if paired with a modality that specifically targets dissociation at the felt sense, autonomic level at which its created, these medicines greatly accelerate the clearing of it.
Consider this scenario: your client will be taking a powerful psychedelic medicine to access and work with the traumatic episodes in their life. At the same time, their neurobiology will be releasing a large dose of numbing heroine like opioids. Their system has been doing this for years, it’s effective at it, and it's not going to stop just because a psychedelic is in the mix. Consider what might happen when a psychedelic response runs head-on 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: clients frequently feel sober even at the high point of a session. In the MAPS trials, participants would think that they got a placebo, or the medicine is simply not working for them 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, the participant might well fall asleep for a few hours on MDMA which may be hard to fathom given the amphetamine molecule that is part of that medicine. Just as antipsychotic medication will prevent a psychedelic response, our endogenous opioids also have the power to shut things down.
The mind being what it is, will often ascribe meaning to this experience such as ‘I knew nothing would ever work for me’ or ‘The medicine is telling me that I should not seek a psychedelic solution for this, I need to handle this on my own'. There are all sorts of conceptual stories we can generate on top of what is happening, but the core experience can be one of sobriety, sleepiness or boredom.
The trick to working with dissociation is not to ignore the gold that is underneath the 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 direct experience of sobriety, boredom or sleepiness into focus. Doing so will take a lot of trust on your part; just know the blankness is incredibly valuable. The seeming non-response is the access point to an entire universe that lays hidden in your client’s unconscious mind.
One of the gifts of certain embodiment supporting psychedelics, such as cannabis and MDMA, is that they generate a profoundly visceral, ‘here and now' experience. When there is a lot of blankness, sobriety or boredom in a session, the very real ‘here and now' reality that these medicines are evoking is the direct, felt sense experience of dissociation. The emptiness is not nothing, it is a very pregnant something. Our recommendation is to stay with that experience even though it does not fit the client's idea of how the session should be. This is much easier said than done, of course.
Eventually, the blank boredom will crack. It might take staying with it for 30 minutes, or it might take hours, but it will crack. What you will find waiting for you are the events, the memories, the relationships, the nightmare that caused the client to need to dissociate in the first place.
If dissociation is manifesting in the session, the client's mind is very well organized to escape the emerging reality underneath the numbing. The client will have developed all sorts of avoidance, management, coping strategies, both conscious and unconscious, that can keep them looping around in the session(s). There is a lot of other material and channels to focus on, such as psychedelic imagery, that will seem interesting to your client but are mostly just a distractive puppet show put on by their mind to keep the dissociation in place.
In the PSIP model, we continually direct the client’s focus back to their direct, felt sense experience. If they see an image, we’ll ask if they can feel the image. If they can, we’ll have the client move towards the felt sense aspect which very often will lead to an autonomic process. If they can’t connect to a direct, felt sense experience, the stimuli is most likely a distraction of the mind that will only continue the looping. We suggest running an experiment with the psychedelic imagery that often arises in the session. Does following it lead to deeper connection or association with material, does it lead to a deepening of the process, or does the image just continue to morph into an infinite display that don’t lead anywhere?
In summary, dissociation is a hardwired element of our psychobiology. It is the heart of trauma, and if we are to heal, it cannot be ignored. We cannot pretend that it does not exist. We cannot ally with a client’s dissociation by agreeing that it does not exist. It must be engaged on it’s own visceral terms. Emptiness is not nothing, it is a very pregnant something.