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Integrative Psychiatry

Psychedelics, Ego Dissolution, Fragmentation and the Role of Integration by Keith Kurlander, MA, LPC and Will Van Derveer, MD

By November 22, 2021No Comments

The correlation between psychedelic use and “psychological flexibility” has been recently explored in research by Robin Carhart-Harris [link HERE to article]. One of the potential benefits of psychedelics is to support increased psychological flexibility, potentially useful even to prevent psychological disorders. In theoretical discussion and research, ego dissolving experiences are a mechanism to loosen psychologically rigidity to promote ego structures that lend to more flexibility such as behavior change in accordance with personal values, remaining present to higher degrees of stimuli and emotional bandwidth, and the ability to adapt more often and quicker to new situations in one’s life.

Ego dissolution can be experienced as both blissful and relieving, as well as overwhelming and terrifying. Typically overwhelm and terror occur when there is an experience of the Self fragmenting from a sense of cohesion, and the self in disparate parts are trying to maintain a sense of identity as if it still exists. This experience of fighting for control and a normal reality can flood an individual in fear. 

With ketamine in particular, ego dissolution can reliably occur at higher doses. An experience of a fragmented, disturbing ego dissolution can happen in healthy individuals; however, it’s not common for these experiences to not return to a cohesive self within days with post integration sessions. However, clients with serious mental illness tend to be more prone to these more difficult experiences, partly due to having a less flexible self structure, which, in theory, can shatter into fragments when the boundary between self and other is loosened by a psychedelic experience. Therefore, clients that have more difficult mental health concerns will likely require more integration to return to seeing this as a positive, growth oriented experience.

Although this is not an experience to strive for with a client, it’s also not recommended to try and avoid at all costs. The benefits of altering a very rigid psychological structure after decades of other interventions not working can promote much greater healing with proper integration, if that were to occur. 

The question, “What is an ego dissolution state?” has yielded many opinions and is very relevant to working as a psychedelic therapist. Over the past 70 years of clinicians and researchers writing about the impacts that psychedelics appear to have on the self, many models have emerged for understanding ego dissolution states and the fragmented experiences of the clients that sometimes follow. 

A developmentally oriented therapist might understand a fragmented state as a pre-egoic state – akin to the concept that psychosis could be understood as a state similar to how an infant experiences reality. A parts-oriented therapist might consider the fragmented ego as an opportunity to integrate shards of a shattered self. A traumatologist might think of these as dissociative states as a response to, or recapitulating, a traumatic event. For example, states of fragmentation which repeatedly occurred during a (complex) traumatic early childhood, and which were suppressed over time, can and do re-emerge from behind the veil of ego defenses. A psychodynamic therapist might conceive of ego fragmentation as a primitive dissociative ego defense. 

Whatever the orientation, the first step when a client presents in a fragmented state after a psychedelic experience is psychological first aid to support a coalescence of the self-structure that has been temporarily lost. A variety of supportive approaches can be very helpful to clients during these times.

Relational support (versus isolation) is critical. It’s important to do in person integration sessions for these clients whenever possible. Calm, relaxed presence of another person can make all the difference. There is a delicate balance for someone who is severely fragmented between not talking about it too often throughout the day as that can exacerbate the experience, yet not feeling alone and knowing they share about it when they need to. More frequent follow-ups may be necessary as well. Therapeutic touch can be very helpful for grounding in such states, but as always should be approached with care and caution, without assuming anything and asking first. 

Another element of support is to diminish the risk of further overstimulation. The therapist should assume that many stimuli experienced by the client in such a state can feel overwhelming. This is especially true of the senses (e.g. sensory inputs are typically very heightened). This may include directing the client and caregivers toward lowering lighting, decreasing the exposure to chaotic or loud public environments, mindfulness around the type of music they are listening to, and slowing the pace of life as much as possible. 

Impulsivity is often heightened in these states, and clinicians would do well to anticipate such experiences and inquire directly about what impulses are arising for these clients. Big life decisions should be postponed. Clients can make rash life decisions during a period of a fragmented sense of self, only to realize when they return to a regulated, cohesive sense of self that big life changes were not necessary or even resulted in relational, financial, or personal self harm. The question of competency should be considered or even directly challenged with a client who plans to make an impulsive decision and refuses to wait until they are more whole again.

Foods that are perceived as supportive can be explored. Teaching the client mindfulness exercises can be very comforting. Nature is a powerful intervention during these times, such as lying flat on the earth and feeling the grounding energy. Returning to routine behaviors such as exercise, reading, etc. can also help coalesce the ego quicker from the familiarity. Weighted blankets, massage, yoga are also very effective at “grounding” individuals and helping them reintegrate into their bodies. Alternating hot and cold compresses on the back of the neck – a tool borrowed from dialectical behavioral therapy (DBT) – can also help. Because fragmentation blocks access to some of these resourcing strategies, a wide range of them should be proposed and discussed to personalize the integration process, as well as serving as a temporary external regulator with accountability check-ins and support.

Equally important is psychoeducation about what is likely occurring. Without a framework about what has happened, the client can remain extremely disoriented and terrified that this experience will never change. Many clients will wonder whether they have “broken their mind permanently” or “gone crazy.” It is important to educate the client from a theoretical perspective about what is occurring, why this isn’t a mistake or something that shouldn’t have happened, and how this temporary “loosening” of the mind can lead to a greater sense of flexibility and health in the cohesiveness that will arise on the other side. Reassuring the client that such states gradually resolve with integration or even sharing examples of other clients or yourself going through similar states can also feel deeply reassuring.

Written By:
Keith Kurlander MA, LPC
Will Van Derveer, MD

Frederick Barrett is a cognitive neuroscientist with training in behavioral pharmacology, and the Associate Director of the Johns Hopkins Center for Psychedelic and Consciousness Research. Dr. Barrett has been conducting psychedelic research at Johns Hopkins University since 2013, and his research in healthy participants and in patients with mood and substance use disorders focuses on the psychological and neurological mechanisms underlying the enduring therapeutic and other effects of psychedelic drugs. In 2017, he received an NIH “R03” grant as Principal Investigator to investigate biological mechanisms of psilocybin effects, the first federally funded research since the 1970s administering a classic psychedelic to people with psychedelic effects as the primary focus. He has developed measures of subjective effects of psychedelic drugs, and has also published first-in-human studies characterizing the acute and enduring effects of psilocybin on the brain. He is currently leading clinical trials to investigate the use of psilocybin to treat patients with major depressive disorder and co-occurring alcohol use disorder, and he is leading a number of ongoing studies aimed at better understanding the psychological, biological, and neural mechanisms underlying therapeutic efficacy of psychedelic drugs.

Will Van Derveer, MD is co-founder of Integrative Psychiatry Institute (IPI), along with friend and colleague Keith Kurlander, MA. He co-created IPI as an expression of what he stands for. First, that anyone can heal, and second that we medical providers must embrace our own healing journeys in order to fully command our potency as healers.

Dr. Van Derveer spent the last 20 years innovating and testing a comprehensive approach to addressing psychiatric challenges which transcends the conventional model he learned in medical school at Vanderbilt University and residency at University of Colorado, while deeply engaging his own healing path.

He founded the Integrative Psychiatric Healing Center in in 2001 in Boulder, CO, where he currently practices. Dr. Van Derveer regards unresolved emotional trauma as the most significant root cause of psychiatric symptoms in integrative psychiatry practice, along with gut issues, hormone imbalances, inflammation, mitochondrial dysfunction, and other functional medicine challenges. He is trained in Somatic Experiencing, EMDR, Internal Family Systems, and other psychotherapy techniques. His current clinical passion is psychedelic-assisted psychotherapy, which he mentors interested doctors in providing. An avid meditator, he has been a meditation instructor since 2004.

For the past several years Dr. Van Derveer has taught psychiatrists and other psychiatric providers integrative psychiatry in a number of settings, including course directing the CU psychiatry residents’ course as well as with Scott Shannon and Janet Settle at the Psychiatry MasterClass. In addition to his clinical work and teaching, he was co-investigator in 2016 a Phase II randomized clinical trial, sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS). He continues to support this protocol, now in a Phase III clinical trial under break-through designation by FDA.

Dr. Van Derveer is a diplomate of the American Board of Integrative and Holistic Medicine (ABoIHM) since 2013, and he was board certified in the first wave of diplomates of the new American Board of Integrative Medicine (ABIM) in 2016.