by Saj Razvi, Director of Education at Innate Path & MDMA Phase 2 Clinical Investigator
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 drugs 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 a done deal. As someone who has been part of hundreds of hours of MDMA assisted psychotherapy sessions and taught PTSD studies at the university level, I can tell you that one of the most significant and yet invisible factors in a person’s psychedelic psychotherapy session is their capacity for dissociation.
What is dissociation?
Dissociation is a biological reaction we all have to trauma. It is an involuntary emotional and physical numbing response that is caused by the release of our own natural, endogenous opioids within the brain and nervous system. In a landmark paper on the topic, PTSD researcher 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." (1)
What is van der Kolk talking about here? He’s 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 and their nervous systems did this two decades after the original trauma. Smaller doses of morphine 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 many years after a trauma has taken place. This is true for war veterans, this is true for adults who grew up in stressful, neglectful or chaotic 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." (2)
Van der Kolk is saying that this mix of fear, stress, anxiety or panic with an opioid based dissociative numbing response is utterly common. We see it in research and we see it everyday in the trenches of mental health work. These two sides are the hallmark of trauma but the surprising fact is that we don’t have modalities that know how to deal with dissociation. You can see and feel stress, it is much more difficult to see and feel blankness. Neither your own mind nor your therapist are trained to notice much less successfully engage dissociation (3). We typically look for what is distressing, what is upsetting and can be seen and felt. We are not trained to sit there and look for what should be there but is oddly missing.
So what does this have to do with you and your psychedelic psychotherapy session? Well, you have dissociation as well. We all do. It’s just a question of how much and how deep it runs. Are we talking about a single event trauma like a car accident where you dissociated during just that one event or are we talking about prolonged, repeated, childhood neglect or abuse that happened in your family? Both will create dissociation but the later 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. They will have much more dissociation that needs to be processed during their psychedelic therapy session.
If you were someone in the first scenario, someone with a relatively stable childhood who experienced a gnarly event later in life, you probably would not need to take a deep dive into your subconscious mind looking for healing. You probably would not even be reading this article. You would be someone for whom talk therapy, EMDR or standard treatment has worked. No, if you are coming to psychedelics to help with your suffering or if you are treatment resistant, you likely have a significant amount of dissociation in your system.
MDMA and other psychedelics do not by their own nature crack dissociation. They can greatly accelerate the clearing of it but the process needs to be focused, to be guided, in order to go beyond the dissociative defense structure. Think about it, 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 dump a big dose of numbing heroine like opioids into your system specifically to protect you from your traumatic memory. Your system has been doing this for years, it’s good at it and it’s not going to stop today. What do you think might happen when a psychedelic response meets an opioid response? Great question and this is where we get some variation in people’s experience.
Here is what I’ve seen specifically with MDMA: people feel flat-out sober even at the high point of the session. People will think that they got 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. Just like antipsychotic medication will prevent a psychedelic response, our endogenous opioids also have the power to shut things down.
The mind being what it is, we will often ascribe meaning to this experience such as “I knew nothing would ever work for me” or ‘I’m being told by the medicine that I should not seek a psychedelic solution for this, I need to handle this on my own’. There is all sorts of conceptual story we can generate on top of what is happening but the core experience is one of ‘nothing much is going on’.
The trick with this is to not ignore the gold that is boredom in favor of other things 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. This 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 go deeper. One of the gifts of MDMA is that it provides a profoundly embodied, visceral, ‘here and now’ experience. The very real ‘here and now’ experience that the medicine is bringing up in these sessions is dissociation, it’s blankness. Do yourself a favor and stay with that channel even though it doesn’t fit your idea of what the session should be like. This is much easier said than done.
Eventually, the blank boredom will crack. It might take staying with it for 30 minutes, it might take 2 hours but it will crack. When it does, there is an entire universe that was being hidden from your consciousness by the dissociation that will begin to emerge. Remember, the reason why the dissociation became active in the first place was because overwhelming experiences (deep grief, fear, abandonment) were taking place. These overwhelming places, the impossible experiences, that you fully believed you couldn’t survive when they were taking place and where your core symptoms are coming from are getting ready to emerge.
What happens if you don’t do this, if you don’t focus the session to crack dissociation? There will tend to be two paths here. The first is that dissociation won’t be seen for what it is. Blankness is seen as random and your mind or the therapist’s unease give you other more exciting content to focus on. Remember, if you have dissociation, your mind is pretty well organized to not see it. You will have developed all sorts of interesting, often repeating, distractions that will keep looping you around in the session(s). There is a lot of other material and channels to focus on that will seem interesting to you but are essentially just a distractive puppet show keeping the dissociation in place.
The other possibility is that dissociation doesn’t present itself because most people who have traumatic events residing in dissociation also have many other more surface events that are appropriately available to be worked. 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 your system is allowing you to see and feel. Your MDMA and psychedelic sessions will be very effective at clearing out these more available-to-consciousness surface experiences. Your PTSD scores will go down, you’ll feel a lot better for some significant period of months or years. However, the work and unfortunately the symptoms are typically not done yet. You might be better off for the short term but the material that was hanging out in dissociation will begin to bubble to the surface because there is room for it, or rather, there is a trust for it to emerge and not destroy you.
In this condition where your entire system is less burdened and more trusting, this is when you will find material that previously had to be locked away in dissociation will begin to be felt. It may be weeks or months later but at some point, this material will begin to emerge. It is not a sign that your previous psychedelic sessions failed. Quite the opposite, it is a sign of how trusting, resourced and safe you are that these previously hidden memories are knocking at your door. It is a sign of your innate health that your system wants to keep excavating and processing until you 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.
Saj Razvi is the Director of Education at Innate Path, a psychedelic psychotherapy training, research and therapy organization that provides clinical services. He was also a clinical researcher for the MAPS Phase 2 study of MDMA-assisted psychotherapy for treatment resistant PTSD.
(1) van der Kolk, BA: (1994) The Body Keeps the Score: Memory and Evolving Psychobiology of Posttraumatic Stress. Harvard Rev Psychiatry. Volume 1, Number 5
(2) van der Kolk, BA: (1994) The Body Keeps the Score: Memory and Evolving Psychobiology of Posttraumatic Stress. Harvard Rev Psychiatry. Volume 1, Number 5
(3) The protocol for EMDR, for example, requires that clinicians end the process if their client begins to dissociate.