In the modern clinic, we often operate under an unstated a priori assumption that if a phenomenon is real, its primary explanation must be molecular. As a psychiatrist, I find this reductionist bias increasingly apparent in how we conceptualize “breakthrough” treatments like ketamine therapy for depression or chronic pain. When we discuss how ketamine works, the conversation almost instantly gravitates toward the neurotransmitter system, synaptic plasticity, glutamate surges, and the stimulation of BDNF. We treat the patient’s subjective experience of dissociation as a mere side effect, a pharmacological noise to be managed or bypassed. But in doing so, we may be ignoring the very mechanism of healing.
The “Hard Problem” of consciousness asks how objective neuronal activity gives rise to subjective experience. While often dismissed as the domain of philosophers, this question sits in the room with us every time we see a patient. We have become accustomed to assuming that health and healing must be explained at the micro-level, yet this materialistic bias often fails to account for the macro-level primacy of the mind. Consider a different hypothesis for both depression and chronic pain. Perhaps the dissociative process serves as a functional suspension of a rigid, suffering-laden reality. By temporarily decoupling the conscious self from the heavy, ruminative weight of the ego or the relentless signal of a pain circuit, the patient’s awareness is granted a “view from nowhere.”
This suspension allows the mind to recalibrate its measurement of the social and psychological factors that fuel these conditions. It is a psychological reset that occurs at the level of meaning. While the micro view focuses on synaptogenesis, the macro view suggests that ketamine suspends the ego-filter, allowing the mind to re-evaluate its relationship to trauma and physical sensation without the interference of ingrained, maladaptive schemas. There are many instances in medicine where we assume a molecular level of explanation is the “true” one, treating the psychological or social levels as secondary. However, the human experience of health is inherently holistic. If we view the brain only as a chemical soup, we risk treating our patients as biological machines to be tuned rather than conscious agents in need of perspective. As physicians, we must be careful not to let our quest for objective measurement blind us to the reality of the patient’s internal world. We must ask ourselves if we are healing the brain to fix the mind, or if the mind, once liberated, is the force healing the brain. It is time for medicine to stop treating the primacy of mind as a philosophical nuisance and start treating it as a clinical reality.
Farid Sabet-Sharghi is a psychiatrist.
