Why MDMA & Other Psychedelic Therapy May Not Work for You (Part 1)
Updated: Oct 22, 2019
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.
van der Kolk, BA (1994)
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 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 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.
van der Kolk, BA (1994)
Van der Kolk is saying that this mix of fear, stress, anxiety and panic 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. These two sides are the hallmark of trauma, but the surprising fact is that we don't have 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. Again, the bias is to look for what is distressing, what is upsetting and can be seen and felt. We are not trained to look for what should be there but is oddly missing.
Most people have some level of dissociation. This is almost certainly true of people considering psychedelic therapy to resolve their more treatment resistant symptoms. Its more a question of how much and how deep the dissociation runs. Is the client coming in for a single event trauma like 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 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. This person will encounter much more profound dissociation during their psychedelic therapy session.
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. 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.
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: your client will be taking a powerful psychedelic medicine to address the pain in their life, and at the same time, their neurobiology is going to release a large dose of numbing heroine like opioids specifically to protect them from their traumatic memory. Their system has been doing this for years (perhaps even infancy), it's good at it, and it's not going to stop today. Consider what might happen when a psychedelic response runs strait 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 completely sober even at the high point of a 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 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, story-telling, meaning making 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...'. 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. 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 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' experience. The very real ‘here and now' reality that the medicine is bringing up in these sessions is dissociation; it is blankness. 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 client and you have so much hope and expectation that this work will help them.
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 will begin to emerge to be processed. 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, integratible experiences at the time and were partitioned off.
The client's mind is very well organized not to see dissociation. They will have developed all sorts of interesting, often repeating, distractions that will keep looping them around in the session(s). These can be an even a more exaggerated form of the looping than we discussed in chapter 5. There is a lot of other material and channels to focus on that will seem interesting to your client but these are mostly just a distractive puppet show put on by their 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. 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 a target-rich environment for both dissociation as well as garden variety state 1 and 2 sympathetic stress events. Ketamine, MDMA and cannabis are very effective at clearing out these more available-to-consciousness surface experiences. PTSD scores 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 the client is ultimately more healthy, resourced, and trusting of the process.
In this condition, where a client's 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 their 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.
van der Kolk, BA: (1994) The Body Keeps the Score: Memory and Evolving Psychobiology of Posttraumatic Stress. Harvard Rev Psychiatry. Volume 1, Number 5
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.