Dissociation Therapy: Ketamine for Depression and the Psychedelic Revolution
The dissociative experience of ketamine is often described as a side effect. For me, it’s experiential psychotherapy.
This is not medical advice, and I’m not a physician. Do not do what I did, as described below.
An afternoon in eternity
Even as an experienced psychonaut, nothing could have prepared me for the dissociative drug experience.
When I took my first few doses of legally prescribed oral ketamine, written off-label via telehealth and shipped discreetly to my doorstoop, I was often alone in my living room. During the early treatments, with my dog tucked under the couch I splayed upon, listening to my favorite Aphex Twin playlist, I’d sometimes feel as if I had died or was a god becoming self-aware. Suddenly, my entire concept of Self–the structure of my suffering–spaghettified, atomizing into what I perceived to be a single photon, a molecule of light now trapped in fiber-optic cable. Bouncing back and forth, stuck in a violent loop, it felt like the physical manifestation of an ancient Zen riddle, a koan: “When the many are reduced to one, to what is the one reduced?”
As I traversed the global internet at such a terrifying clip, a little dot of light punished to toil binary, I became aware of enormous Forces at work under our feet and in the sky, in the cables laid brute force on the bottom of our mighty oceans, and I panicked in a kind of awkward awareness because I finally felt, was forced to feel, the Seriousness and the weight, the raw composition of this world in which I was so miserable.
This sensation, this level of dissociation, is, in fact, tidily described by clinicians. According to a University of South Flordia research publication on ketamine-assisted psychotherapy, my adventure would be categorized as a near-death experience (NDE), in which their summary includes the “Experience [of] being a single point of consciousness simply aware of itself.”
Their version sounds vastly more peaceful than mine actually was, but it’s a clean way to put it, the uniquely bizarre feeling of utterly forgetting your personhood while still being awake through the experience.
The term neuroplasticity is often used when brain scientists describe why ketamine is so effective for treatment-resistant depression (TRD). Roughly speaking, chronic depression makes your brain rigid and stubborn in how it processes and remembers information, and ketamine can help dislodge things. There’s even evidence suggesting chronic stress and depression literally shrink your brain. And a big part of me suspects the dissociative experience of ketamine, the K hole if you will, is a kind of manifestation of this plasticizing effect on my sad, shriveled brain.
Indeed, dissociation might be an integral part of the therapeutic process, further enforcing ketamine’s anti-depressant effects, while others disagree or aren’t sure. And while I’m merely a lab rat in this scenario and have zero medical credentials, I’m increasingly inclined to believe that dissociation is a key ingredient in the rapid response to my treatment.
“Dissociation therapy” and the importance of forgetting yourself
When describing the experience of being on sub-anesthetic doses of ketamine, the term “psychedelic therapy,” I think, is a bit of a misnomer. Of course, I can see why it’s used, and something like “dissociative therapy” wouldn’t have the same marketing allure.
I think “depersonalization therapy,” or even better, “derealization therapy,” actually approaches a description of my ketamine experience. Again, the term isn’t great for exaggerated headlines in research papers or for pop science journalists looking to hype and chart the trends in a “psychedelic revolution.” Nor would the phrase gain the approval of marketing directors at increasingly venture-capital-backed ketamine clinics and telehealth startups.
Understandably, the ketamine therapy industry would rather sell you a warmer, cozier idea: open a felt-covered box, swallow some MDMA-looking tablets, sit cozy in your pajamas; all you gotta do is just vibe.
In contrast, “dissociative therapy” is work. Sometimes, I think the bravest thing I’ve ever done for my mental health was take a ketamine trip when I really didn’t feel like it, like dragging myself to the office on a cold and rainy Monday — or at the least the therapist’s office. Because while ketamine isn’t a magic bullet, it is a magical tool that’s miraculously helped me shovel a lot of shit out of my cave.
I feel I should say at this point that ketamine for TRD may only work on about 50% of the population, and some researchers suggest traditional psychedelics like LSD or psilocybin may be more effective on a larger population. But the fact remains: people who respond positively to ketamine therapy seem to respond strongly.
In my experience, using ketamine for my mental health has a much more visceral effect on my particular neuroses–the things that make up my understanding of why I’m so depressed and anxious. I can take four dried grams of psychoactive magic mushrooms and experience a sense of weight-lifting, a gentle easing of the rumination within my default-mode network (DMN, the “Dark Matter of Clinical Science”). Or I can take a single dose of ketamine which (sometimes violently) will, within hours, knock my melancholic depression on its ass, stopping in its tracks the endless rumination and suicidal ideation–with my generalized anxiety effectively halved.
What I’m trying to say is that no matter how good or bad my experiences with mushrooms have been, there’s almost always a me that experiences them. And I think there’s something valuable in the act of forgetting myself. Of course, serotonergic psychedelics are often unpredictable, and you may experience ego death. But LSD and psilocybin trips are marathons, and most people don’t want (or need) an 8-hour-long near-death experience. It’s far too much! 45 mins, though? That’s workable.
Looking under the hood: some clumsy neuroscience
Pharmacologically speaking, the basic method of action for traditional psychedelics like LSD and psilocybin is they interact primarily with serotonin, targeting the 5-HT receptor. In contrast, ketamine works mainly with the glutamate neurotransmitter, targeting the NMDA receptor.
This is important because it means the psychoactive experience of serotonergic and glutamatergic drugs, while both largely defined by hallucinations, differ drastically. And I think when you’ve taken LSD or psilocybin once, you can more or less predict how future trips will play out, while with ketamine, I can hardly assume the places I’ll go with nearly each and every treatment.
Also, unless you’re taking massive doses, an LSD or psilocybin trip is incomparable with the kinds of hallucinations a sub-anesthetic dose of ketamine may induce. I’ve taken psilocybin about as many times as I’ve taken ketamine (as of writing, roughly 15 times), and frankly, a lot of my memories of being on mushrooms have blended together. But I reckon I can remember at least 120% of the ketamine trips I’ve taken alone in my living room.
Ketamine’s bad wrap and the spiritual question
Culturally, ketamine has had a reputational problem ever since the 70s. Largely associated with club and dance culture, by 1999, it became a federally-scheduled narcotic. I think most people lump ketamine, as a drug class, with cocaine and alcohol–a purely hedonistic psychotropic–containing none of the “spiritual” properties of a baby boomer’s substance of choice. But even if ketamine is often confoundingly dissociative compared with traditional psychedelics, I believe it can still offer a spiritual experience.
There’s a recurring theme towards the end of my ketamine sessions, where if I time things just right, the music changes in a momentous way. A powerful vibe shift, it’s the moment I begin re-atomizing back into my Self–or the previously remembered version of my Self. Suddenly, I’m recalling my Patterns, and I feel insanely self-conscious, like God has peeled my eyes open so wide they’re stretched out, forming into a 3rd eye, and awareness–identity–is pouring back into me like a broken dam.
Grabbing the back of my head, he forces my face into the stream of consciousness, and I’m garbling and gasping, squirming and trying to remember all my usual Copes and pattern-believing, my neuroses flashing back in horrific recognition. Indeed, this is all therapy for me. And sometimes, I’ll find myself grinning, reorienting myself to collective reality, let’s call it, and the landlord I was stressed about making rent is smiling above up in the clouds or some other stressor manifestation now laughing with me. And I’m still meek but proud to be a human being, doing whatever this is, with a bunch of other human beings, whoever they are.
Getting better
Moving forward, I find I’m accomplishing things that still seem unfathomable. This is progress, of course, but it’s stubborn. In early treatment I find myself compelled to do the basic life tasks I dread so much, but the compulsion fights a still-frigid soul, and breaking the ice is never a warm and gushy feeling. Sweep the floor, windbreaker on the rack, sort the grey socks from the whites– it’s Mister Rogers shit, but for sad adults.
In quotidian life, I’ll have these flashes of recognition where I’ll realize just an hour before I was grappling with the idea of simply combing my hair. Suddenly, I’m aware I’m outside walking my dog, having not only combed my hair but clipped my nails and turned on the water, got in the shower, washed and rinsed my body, even stretched my limbs and toweled off in a slightly chilly room while covered in cold water. I’m wearing clean clothes and moisturizer with sunscreen and I’m in my lane and hey this song sounds amazing and the strangers I pass, I just wanna reach out and connect and–well, you get the idea.
Again, the literature discusses this phenomenon. My belief-updating biases, the way I categorize and alter my beliefs when presented with new evidence, have become increasingly unrealistic and optimistically biased.
You see, not only are the darks not so dark anymore, better able to ignore what would usually send me spiraling, but the brights have illuminated a pathway. And it’s one I’m compelled to follow.
