Episode Transcript
[00:00:03] Speaker A: Welcome to Unburdening, a mountainorth Podcast, where we unburden mental health topics from stigma with the gusto of an unblocked particle of glutamate coursing through the bloodstream.
So if you're listening to this, you may not know what glutamate is or understand yet its relevance to healing. But by the end of this episode, you'll have some idea of the role this neurotransmitter plays in our ability to move past the kind of emotional stuck points often labeled as depression, PTSD or other mental health diagnoses.
Our topic today is Ketamine assisted psychotherapy.
I know that many listeners out there likely already have some awareness of this treatment because it's actually been in the news for some time now. The New York Times started publishing consistent articles on the benefits and risks of this therapy starting around 2021, a few years after Spravato, a form of esketamine, or synthetic ketamine, was approved by the FDA as a medication for treatment resistant depression in 2019.
That said, the use of ketamine as a tool to augment treatment has been a topic of conversation in medical and therapeutic circles for decades. Before this point, in the year 2000, Yale University published a study that tested intravenous ketamine, that's IV ketamine, in a small group of depressed patients and found it produced rapid antidepressant effects.
This was followed up in 2006 when the National Institute of Mental Health conducted a randomized controlled trial which they published in the Archives of General Psychiatry.
And this double blind, placebo controlled crossover study really demonstrated some definitive evidence.
It showed that a single IV infusion of ketamine significantly reduced treatment resistant depression within 110 minutes, with effects lasting up to a week.
And if you are someone who has ever struggled with the inner numbness or hopelessness that is often labeled as treatment resistant depression, you'll understand how big this is.
Treatment resistant depression can feel like a persistent lack of vitality or meaning that just keeps coming back.
It's constant fatigue, constant brain fog, a feeling of persistent separation from the person that you want to be. It's like you're a flower that stays pale and dry no matter how much you water yourself, no matter how often you try to turn towards the sun.
So to be given this slip of hope, a chance to feel the rain, the sun, the wind, to grow in the world again, that's a big deal.
It's why I wanted to spend a whole episode diving deep into the potential of this treatment.
So to get back to our timeline of ketamine assisted therapy, even before the early 2000s, there were practitioners and scientists who saw the promise in this treatment.
However, for a very long time in the United States, it was extremely difficult, if not impossible, to secure funding or institutional backing for studies exploring science psychedelic assisted therapies.
There are reasons for this, most of which boil down to moral panic, fear and greed. And that history could be its own episode. So I'm not going to spend much time on it here.
Today I'm going to give only a brief overview of the context of ketamine assisted therapy. We'll talk about the benefits of this treatment and how it differs from recreational ketamine, what you might do at a club or party, and what you can expect should you want to explore this treatment for yourself.
After this introduction, I'm excited to share with you guys an interview with Katie Bikane, one of my colleagues here at Mount north, who is trained in ketamine assisted therapy. That's K A P or CAP for short.
Throughout this episode, you'll hear us use that acronym to describe the treatment as saying the full thing can be a bit of a mouthful sometimes.
In that interview, Katie does a really good job of explaining the science of cap, the literal mechanism of action and process for this treatment.
So in my intro here, I'm going to focus more on the phenomenology that is the personal experience or meaning that behind this therapy, as well as just give a little context for the long tradition of psychedelic assisted therapies in general.
So let's get into it.
There's a quote by Bob Samples I can't get out of my mind.
In the 70s, Bob wrote a book called the Metamorphic Mind, in which he explores the balance between rational scientific thinking and intuitive creative consciousness.
Citing Albert Einstein's views on consciousness, Bob says the intuitive mind is a sacred gift and the rational mind is a faithful servant.
We have created a society that honors the servant but has forgotten the gift.
It is my belief that psychedelic assisted therapy can facilitate an individual's process of remembering the gift of their intuitive mind.
Now, there is some debate in the field about whether ketamine is a true psychedelic, such as psilocybin or acid, for example.
And I know some people prefer to label it as an anesthetic, but personally I like to use the word psychedelic for this medicine because to me that's what feels most true to the experience of therapeutic ketamine.
Recreational ketamine might be more of an upper or even a downer, depending on the dosage, how it's used or what else it's mixed with, if you got it off the street.
And while I think many people use recreational ketamine with the hope of feeling something that makes them feel more or better than their current reality, that experience is fundamentally different from therapeutic ketamine, which is more ritualized and boundaried and just all around more safe.
Used in a therapeutic setting with the guidance of a practitioner, ketamine can for some people, truly fit the meaning of the word psychedelic.
This word was coined by Humphrey Osmond, who was a British researcher. Osmond coined the word from the Greek term psyche, meaning soul, and another Greek term delein, meaning to manifest.
Hence psychedelic is an adjective and means soul manifesting.
I know the word soul can feel very unscientific, but on a human level, this is very often the part of ourselves we feel separated from when we are consumed by a treatment resistant depression.
On a physical level, psychedelics like ketamine do a few things.
They are non specific expanders. They amplify our senses as well as certain aspects of our internal world.
They can cause some distortion of stimuli, external or internal stimuli. So sound or light might feel different and even our experience of time may feel altered. Time can feel more gelatinous, more four dimensional, as opposed to a strict line from point A to point B.
It can alter our thought, content or process.
So it can change the way we think.
It can alter self referential thought and autobiographical memory.
And what that means is that it can really shift the role of the ego, the part of us that tells us who we are and what to think.
When used therapeutically, ketamine can help quiet or shift the voice inside of us that keeps us stuck.
And I think you know what I mean when I say the voice.
It's that inner critic, that part of us that is constantly judging, constantly analyzing, always having something negative to say when we're depressed or suicidal. This voice becomes like a relentless internal social media comment section aimed entirely at criticizing us or other people or even life itself.
Any therapy that helps us work through treatment resistant depression is going to have to deal with this voice in some way, either by addressing it intellectually or through the ego, or by appealing to our bodies and souls instead of our thinking minds. And this appeal to the body and soul is what ketamine can facilitate.
Ketamine is what we call a bottom up treatment. It works with the body first.
Specifically, it expands the body's experience of itself so the ego can step back and the rest of us can step forward and begin to heal.
And once that process begins, sometimes our ego, that inner voice, can start to soften to get on board with the idea of healing. I know this was the case for me, and I think it's the case for many people who like to think deeply and analyze and intellectualize our experiences.
Our minds are so powerful, we can literally think our way into hating life.
And the evidence we gather for that hatred can be very convincing because, again, we are skilled in presenting an argument, skilled in rationalizing.
It can be really hard for people like us to see how this, too is a form of self deception.
So experiential therapies like ketamine can be helpful for people like me or other people who tend to intellectualize their pain. That said, ketamine isn't the only experiential therapy out there.
Any process that appeals to your body or spirit, like equine assisted therapy, where you work with a horse who mirrors your emotions, or art or music therapy, where you let go of the thinking voice to intuit your way through sound or images, those can be great.
So if you're someone who is maybe put off by the idea of taking ketamine, just know that there are other treatments out there that can help you access the parts of you that ketamine therapy does. And it's hard to quantify the value of an experiential therapy to put it into language, because the very nature of it resists language. It's like trying to describe the texture of velvet to someone who has never felt velvet.
You need to feel it for yourself.
To know that kind of softness is possible, to know it on a molecular level.
And that kind of feeling is, I think, one of the most healing parts of ketamine assisted psychotherapy. It exposes you to a feeling of hope and possibility that you can then look back on and recall when you need it.
You know, when you're in a place of trauma, you're getting negative flashbacks. These swift feelings of fear or pain that can be accompanied by just the cruelest thoughts about yourself or other people.
This therapy can create a positive flashback. It's a swift feeling of warmth, joy, or openness that can come on at random moments.
Sometimes, to me, it happens when I'm listening to music.
It's a reminder that even when you're at your worst and all hope seems lost, another way is possible.
So at this point, I'm going to shift over to the interview part of the show and let Katie give you guys a deeper perspective on the potential of this therapy.
I Hope you enjoy our conversation because I really enjoyed recording it. And as you're listening, keep in mind what we talked about here and notice if any parts of you open or close during this conversation. And feel, feel free to share those moments in the comments.
As always, keep in mind that nothing here is medical advice. It's just information for you to use however you like on your path to healing or meaning.
So without any further ado, here's Katie.
So welcome, Katie, to the podcast.
[00:14:43] Speaker B: Hi. Thank you.
[00:14:44] Speaker A: Can you just give our listeners a general introduction, introduce yourself, your name, specialty and clinic clinical background.
[00:14:53] Speaker B: So my name is Katie McEnany. I am by title a psychiatric mental health nurse practitioner, which is a mouthful.
I have been working in psychiatry for well over a decade, probably closer to 12 years now. It was my only specialty that I worked in as soon as I graduated from nursing school. I have several years experience inpatient and then transitioned into the outpatient setting probably six years ago. I don't know if I have a specialty per se. I do have definite populations that I'm quite passionate about and find really fulfilling. One is the adolescent, kind of transitional youth age. I really appreciate treating specific diagnoses and helping individuals kind of find their true authentic self. I also really enjoy working with ADHD population.
And then I think I have two sort of trainings that are unique that I tend to use a lot of functional medicine, psychiatry. So like holistic type methods, supplements, vitamins, behavioral changes, and then what we'll be talking about today. I'm really quite passionate about interventional psychiatry options. So treatment methods that aren't traditional, pharmacotherapy, which ketamine is one of those.
[00:16:08] Speaker A: So you have a diverse background here. You have the nursing training, the psychiatry training, the functional medicine training, which I think is great because people benefit from different treatments and it's nice to have a variety.
So what drew you to the healing professions?
[00:16:29] Speaker B: I think I've always been drawn to serving others, but I think what drew me to nursing and mental health, psychiatry in general is I see the profound impact with like common humanity and kind of shared suffering, shared joy, and how just sitting with one another and shared experiences can be incredibly impactful. Healthcare in general is really beautiful, but the mental health aspect, you can have the most physically healthy body, but if you're not mentally healthy, there's not a, there's not a journey in wellness that can happen.
[00:17:06] Speaker A: Yeah. And as you're talking, I'm thinking about how the original root definition of psychology, it comes from Greek psycho, meaning soul.
And it's healing the soul in some way as well as the body. When did you become interested in ketamine assisted therapy? And what interests you about this modality?
[00:17:29] Speaker B: This question we could honestly belabor for hours. It's just so lovely. But truthfully, I've had a mentor. His name's Dr. Greg Thorkelson. I've had a mentor. He's been a mentor of mine for over a decade. I went to work with him in a practice in Pittsburgh called the Nexus Group, and he's incredibly well known for his functional psychiatry approaches, in interventional psychiatry approaches. And when I started working for his practice, I guess around Covid, so about six years ago, ketamine assisted psychotherapy was already service that was offered in the clinic. To be completely candid, I was a little bit apprehensive about being trained in it, even providing the service, because it does have a lot of negative connotations, which we can obviously talk about later. But I had an open mind and was trained in it. And then I also was afforded the ability to have experiential training. So I experienced ketamine as like, assisted psychotherapy myself. The impact was so incredibly beautiful and profound that it's something like you just want to tell the whole world about it.
[00:18:34] Speaker A: Let's maybe talk about what literally this modality is. Right.
Can you explain for our listeners what therapeutic ketamine is and how it differs from the variants that might be used for anesthesia or for recreational use?
[00:18:53] Speaker B: And we could even diversify that a bit more, because even ketamine is used in psychiatry in two different ways, really.
But you're absolutely right. By classification, ketamine is what we call a dissociative anesthetic.
So it's most commonly used and FDA approved to be used as, like, in emergency settings and surgical settings.
It has a very short half life, so it is used well in pediatric settings even.
So it blocks pain receptors so people don't feel pain and they have this dissociative property. So people can kind of distance themselves from their self. Right. That's how it's used in anesthesia. In recreational use, it tends to be abused, and we can talk about the risks associated with that. And then in psychiatry, ketamine is used in actually two different ways. One is like a medical model where there are treatments like IV Ketamine, where you can go and sit and follow a protocol.
And ketamine is used to treat depressive symptoms. Right. And it can actually be really helpful and work as antidepressant properties. There's also an intranasal form called esketamine, which is similar compound, just very highly concentrated, and that's marketed as bravado. Also a medical model. There's no therapy involved. It's purely using the medication to treat depressive symptoms, which can be really helpful.
What I've had training in, most training in, and what we're hoping to bring on board here is ketamine assisted psychotherapy, which is not a medical model, it's really a therapeutic model. The ketamine is just part of the tools that we get to allow people to open up and feel safe and in the healing space.
So that is an incredibly powerful treatment, but one that is maybe not one size fits all.
[00:20:50] Speaker A: I'm curious, how does therapeutic ketamine literally impact our body and brains? I heard you say it's a dissociative. Can you paint a picture of what's literally happening inside our brain or our bodies when we partake in this substance?
[00:21:06] Speaker B: Yes. I love this question.
So probably most people who are listening to this have had some exposure to the medications that are prescribed in psychiatry. SSRIs, stimulants, things like that. Typically, we're targeting neurotransmitters like serotonin, dopamine, norepinephrine. Ketamine is in its own world really, and it does something that works on the NDMA receptors, which really is a receptor that binds to a neurotransmitter called glutamate.
Glutamate we don't talk about too much in psychiatry 10, 15 years ago, but it's actually the most abundant neurotransmitter in the brain.
It's an excitatory neurotransmitter.
It is like, known as like one of the workhorses of the brain because it. It's involved in pretty much everything. Memory, communication, emotion regulation.
All the. What we found is that because the receptors allow glutamate to be so profound, we have something called a downregulation in the default mode network. I don't know if this is something that you've heard about, Claire, but the default mode network is a dysfunctional one. Leads to a lot of ruminations, leads to a lot of compulsory thoughts and actions. And so it's related to a lot of mental health diagnoses. With the downregulation of the default mode network, we're actually just increasing neuroplasticity.
Neuroplasticity is probably, if I would want somebody to remember anything out of this conversation, is that ketamine can increase neuroplasticity in the Brain
[00:22:48] Speaker A: default mode network.
Is this what people might call nervous system or.
[00:22:55] Speaker B: Yeah, that's a really good way of putting it. It's actually. It's specific parts of the brain. The frontal lobe, the parietal lobe. A lot of the things that we target in psychiatry, it's all of those systems put together. A lot of resilience and flexibility and things like that are associated with the default mode network.
[00:23:13] Speaker A: Right. And I'm thinking about how, you know, when someone experiences trauma, how that trauma response can become their default. So when you have an experiential therapy like this, where someone's doing something a little different they haven't done before, it maybe interrupts that default
[00:23:33] Speaker B: and
[00:23:34] Speaker A: allows them to do something differently.
So you mentioned neuroplasticity. Can you tell us just a little bit more about that?
[00:23:43] Speaker B: So neuroplasticity, I think the core concept of where the evolution of psychiatry is going or has gone, to be honest, even 15 years ago, when I first started working in this specialty, I would sit around in treatment teams and we would talk about chemical imbalances, and we had to optimize serotonin or, you know, decrease dopamine because they're psychotic, which is not untrue. But now the specialty is zoomed out a bit, and it's not just about the neurotransmitters and the imbalance, but really reformatting the neurocircuitry of the brain.
In fact, a psychiatrist just not long ago won a Nobel prize about this, that we're looking at whole neurocircuitry. Neuroplasticity is really the brain's ability to adapt, recognize change in response to some sort of experience. Right? And we've kind of experienced. Experienced this probably in everyday life, if you go to a new city, you're automatically realizing, I don't. I have no idea where I am. I don't know what direction I'm going in, am I safe? All these sorts of things, the situations like that really depends on the neuroplasticity of your brain. If you have zero plasticity, it will make you feel stuck, right? And if you have the ability to adapt, feel resilient, change, be flexible, any challenge will become maybe not easier, but you feel equipped to navigate it.
So some people like, okay, this sounds like hocus pocus, but there's actual research. Ketamine does this. If you do something called an fmri, which is a functional MRI of the brain post ketamine administration, you can look at a neuron and see not just strengthening dendrites which are like the legs that speak out and attach to other neurons, but there's actually new dendrite growth, which is just amazing. So I like liken it to. I just said this to a patient the other day that, you know, if you're walking in the woods and it's dark, you have like one flashlight and you just go in the forward direction because you have no idea if there's other trails in other ways. So you just keep going.
And then it's like the sun rises and you look and there's like six different trails you could go. And you just had zero awareness and you felt safest going in this direction, so you just kept going. It's just beautiful that it translates into like decreased hyper vigilance, more flexibility, more adaptability, ability to think in new and different ways and have new perspectives, more hope. It's really quite beautiful.
[00:26:25] Speaker A: Wow, I love all this neuroscience that you're sharing. While we're on this topic of neuroplasticity, something I'm thinking about. There's a difference between a healthy dissociative treatment and an automatic trauma dissociative response. And it's so interesting how it's almost like the cure is in a little bit of the sickness with this. A lot of folks when we're stuck in trauma, we go numb inside, we dissociate.
But when we do that, we make our world smaller. This is a way of having a little bit of dissociation on the right parts of the brain. It sounds like that actually helps other parts step forward.
It sounds like it helps the guards move away.
[00:27:11] Speaker B: You absolutely hit the nail on the head. Because truthfully, when you and I diagnose major depressive disorder, even a dissociation, and sometimes as is a symptom, and if people say they dissociate, that kind of is a red flag that we need to explore that more. Is there trauma involved? What's going on here? And then it seems like counterintuitive to say, like, we'd like to get you into a dissociative state to feel better. But I think you hit the nail on the head that it's not really the state that's helping, it's how it's working in the brain. If I can kind of go on a little bit of a tangent, it really helps with the history of how this came about in the first place. Because ketamine is actually fairly old medicine. I think it became a part of healthcare in like the 60s purely for like its anesthetic purposes.
It was Even used in the Vietnam War, medics would carry ketamine around.
If they saw somebody who was wounded, they would inject them with ketamine and get them in this proverbial K hole until they could get help, get them to safety. But this person would then at least not feel any pain.
So how did this get into the psychiatry world? It's exactly what we've been talking about is that, unfortunately, they were animal studies that were started, but it was this concept of learned helplessness that individuals were trying to explore, that, you know, if you're swimming in water and you feel like you have zero ability, animals would just give up.
Right. And not see that there were stairs on the other side or somebody to grab their hand. I'm just like, literally using a huge analogy now. But it was a test about learned helplessness and depression.
Quite quickly, researchers realized that using ketamine A, animals would swim much longer.
And also they saw, like, a sense of hope, even just in the fact that they would continue to try these things. And some people would look at that and say, this is, like, too much, too philosophical.
We're just exploring different medicines to see how it helps depression. But thank goodness we had a small cohort of researchers that were like, I want to dive into this.
So this was like, early 2000s, I think it was maybe the year 2000, the first paper was actually published, because then they took that data and used a really small subset of depressed individuals, I think it was like six or seven. And used ketamine to see if they had improvement in depressive symptoms. I honestly think that we benefited from those people who kind of took the risk and went off the beaten path, because this was not the intent of why ketamine came into place in the first place. And the research continues.
[00:30:01] Speaker A: Yeah. And I'm thinking about, as you're describing this, how when someone has a dissociative trauma response, it's not their choice, it's automatic.
Right. But when they go through the journey of this treatment with someone who is looking out for them, with a professional, it's a choice that they are facing proactively. It reminds me a little bit of exposure therapy where, you know, not to overwhelm someone. Right. But to give them that healthy challenge of experiencing the full range of their feelings again.
[00:30:40] Speaker B: Sure.
[00:30:41] Speaker A: Right. Including joy. Right. Which a lot of people might be numbed out
[00:30:46] Speaker B: from,
[00:30:47] Speaker A: you know, when they first come in.
And it has a long history, and I know it has a long history of recreational use as a party drug. A lot of people using it There it seems like what they are seeking a lot of the time is that feeling of connection, right? Or even to be spiritual transcendence, you know, which is historically why humans have used substances for thousands of years in ritual and things like that.
But getting it on the street, so many risks, that experience doesn't really have a container to hold it. And so there's just a lot of variables that can destabilize someone. And I think anytime we are seeking something, it's like we want to have that strong container to hold that experience.
Otherwise we could wind up in a really dark place. Our psyche can become fragmented.
I wanted to say that because I think a lot of us, like, if we seek a recreational drug, what is being sought is actually, paradoxically, sometimes a healing instinct. I want to connect, but it's just that the setting is working against someone, right?
[00:32:00] Speaker B: 100%.
And it's interesting because ketamine, the majority, not always, but the majority of time, does get people in a sort of euphoric, dissociative state. So there is joy and happiness that happens. And I think people are also seeking that simultaneously. If using the substance with somebody else, you do feel this sense of connection, right? The setting is so important during the use of the, like, I don't even call it a medication then, but like the ketamine.
But also, this is something that continues to have impact long after the medication is no longer in your system or the ketamine's no longer in your system. So. And it's important, even from a therapeutic aspect, but so much so, if it's being abused or misused, that you might have this wonderful, exciting journey or trip, right? But then go back into an abusive environment, an unhealthy environment, something like that, and your brain has all these new neural pathways without a safety or a sense of self, and that can be really damaging.
[00:33:13] Speaker A: Yeah, definitely.
That integration step of how do I translate this healing modality into the rest of my life? After my initial experience, I think that's where a lot of people get stuck, not just with ketamine, but with any psychedelic experience or even, even sometimes standard psychiatric medications too, right? How do I.
How do I translate this into the rest of my life? Right? Because, you know, sometimes we do something once and we get that glow, but how do we.
How do we pay forward the wisdom of that in daily life?
So from start to finish, just so listeners get a clear picture of what they could expect if they were to seek out this type of treatment from a professional, can you explain how a typical course of treatment goes. And I know it could vary a lot, maybe depending on the person. Right. But if you had your ideal course of treatment for trauma or maybe depression, what would that look like for someone?
[00:34:24] Speaker B: And I'm really only going to talk about cap, which is ketamine assisted psychotherapy. I do have a experience in spravato and things like that, but that's kind of a different course of treatment. I think in my ideal setting, the most important thing is to have a patient established in a clinic that they feel safe in, even if they're working with a team of different individuals. I would be hesitant for somebody to come in a first time with an intake with you or me and say all I want is ketamine assisted psychotherapy.
Because I think one of the most important aspects is having a healthy trusting relationship with the person who is sitting with you or the practice that is sitting with you. Right. So I think establishing a healthy environment is probably step one.
Then after some work, maybe some other medications, what have you. If it sounds like something that together we agree we need to explain, explore, probably the first step in the CAP process would be like what we call the evaluation, which would be with a psychiatric provider like myself, which would really be one, maybe two one hour sessions of a full psychiatric evaluation, history, physical, talking about medications. You're on a significant timeline of medication trials, things like that, to make sure that this is an appropriate and safe treatment modality for you. Discussing risks and benefits and then going over consents and things like that. In this space too is where I would prescribe medications to help with any adverse side effects that ketamine sometimes does cause. So usually an antiemetic or like anti nausea medicine is prescribed, an anti hypertensive because ketamine can sometimes raise blood pressure. Those things are prescribed, discussed things like that before we even start the treatment. So that would probably be step one.
Then after, if it's still something that the client wants to do, we think it's a safe medicine, then we could probably start figuring out the sessions. I have seen impact in one to three sessions, but in an ideal world I would think it would be a course of about nine, 10 sessions the first few weeks, maybe two sessions a week, and then weekly thereafter. And then there's typically some maintenance and those sessions are typically around three hours.
So the first part you would come in, we would do some discussing, set an intention, make sure the setting's appropriate, which we can get into. Then there's the journey part. And then afterwards a bit of integration and then hopefully continuing Forward with a therapist or myself. With continued integration throughout the weeks too.
[00:37:18] Speaker A: Yeah. This sounds like a intentional process that takes steps to counteract what has been called the rush to healing.
When we have been struggling for so long, sometimes we just want something to make us better. Right. Because we've just been in our pain and there's no really magic fixed. And if we rush through any treatment, you know, not just ketamine assisted.
[00:37:49] Speaker B: Sure.
[00:37:50] Speaker A: Psychotherapy, but anything, you know, it could be like putting a band aid on a wound without going in there and really resetting the bone. To your point, research shows the strongest indicator of client outcomes is their relationship to that therapist.
And.
Right. It's kind of fascinating how this is true modality to modality. Right. There has to be trust and there has to be connection. You know, this goes deeper than the surface level. Do I like my therapist? Do I not? You know, I've been in therapy. My therapist has told me things I don't like, but they increased my trust for him because he was being direct. Right. Directness can increase trust with kindness. Right.
And part of the healing aspect of the ketamine treatment. But any therapy is practicing that trust and building that trust in yourself, in other people, and in the process.
Okay, so who are the people who tend to benefit the most from ketamine assisted therapy?
[00:39:00] Speaker B: Yeah, I'm glad you asked this, because it actually ties to the point that you were just making, because one of the most attractive things about ketamine treatment, therapy, or even the medical model is that it does tend to have very rapid effects versus if we use an antidepressant like an SSRI, SNRI. Typically, it takes 2, 4, 6 weeks for any sort of improvement, which can be incredibly frustrating for somebody who is at their worst. Right. And feeling so depressed and stuck like what we've talked about. So it's an incredibly attractive thing to say. We'll get you feeling at least a little bit better within an hour or two.
So I think what we call, like, the bullseye target of ketamine is what we call treatment resistant depression, which is really signifies anybody who's had two or more failed medication trials, which is actually not that uncommon to have two or more failed medication trials and then acute suicidality. So somebody who is suicidal, very much at risk.
Years ago, we didn't have any immediate treatment other than let's get them in the hospital and make sure that they stay safe. And now that narrative has changed a bit. That comes with risks. Right. But those are kind of the targets. But there's Also incredible data. And I've seen help with PTSD veterans or even people who have dealt with some chronic abuse, ocd, substance abuse. That purview has really expanded over the past few years. But I think our bullseye right now and the most data is in this treatment resistant depressive category
[00:40:47] Speaker A: with all those things people can struggle with.
Suicidality, trauma, depression.
I'm thinking about it from a internal family systems lens, which is a type of therapy. How in a lot of people struggling with that, we have a part of ourselves that is a protective manager, that it sounds counterintuitive to say that my protector part is suicidal. But if you think about what a lot of suicidality is, it is protecting a person from pain, disappointment, fear of the unknown. And an OCD can be like that too. It's very protective. It's an anxious response. Trauma has a lot of avoidance behaviors that are protective.
And how this treatment seems to help that protector step back so other parts of the person can step forward.
And I just think that's. That's great because it's really tough to get that protector to step back. And what helps with that?
Trust, what we were talking about earlier and self trust. You know, on the other hand, what are some of the contraindications for this therapy? So when should someone strongly consider that it may not help them or even set them back in their journey?
[00:42:12] Speaker B: I think probably the most obvious is somebody that does have a history of substance abuse or recreationally abusing medications. Because there's a really awesome psychiatrist, her name is Dr. Anna Lemke. She said like you can get addicted to really anything because of the dopaminergic pathways. Ketamine isn't really addictive per se in the way that we think of like an addiction opioid like heroin or something. But you can continue want to crave that euphoric feeling. Right. So I think somebody who has history of substance abuse would be really need to be taken into consideration and probably not the right treatment for them. Also, data suggests that ketamine does tend to increase blood pressure by several points. So somebody who has a history of uncontrolled hypertension would probably not be appropriate for this treatment or some major like cerebrovascular accident that could be related to that. Those are probably the biggest ones or certain cardiovascular concerns. Like most medications. There's not a ton of data on the perinatal or our pregnant population, so we tend to avoid that. And then another big one is that it's not appropriate, like we've said, for all psychiatric Disorders.
So individuals who have a history of psychosis, mania, schizophrenia, schizoaffective, bipolar 1 would likely be activated. Right. Because we're really adapting and enhancing glutamate here and we don't want to get them into another psychotic state. So that's where the thorough and appropriate psychiatric evaluation is so important. Because I'm sure that you and I have seen, maybe not purposefully, but there have been misdiagnoses throughout somebody's treatment and maybe a bipolar disorder has been missed. And in fact somebody who has not responded to several antidepressant trials sometimes is a little bit of a flag saying, like, what's going on here?
So maybe we're not even thinking in the right diagnosis. Those would probably be my, my like key, like red flags or like even orange flags that we need to keep discussing to see if this is appropriate or not.
[00:44:31] Speaker A: Yeah, I, I like that term, orange flag.
Right. Because you know, it really does depend on, on the person.
I think too, if you're someone listening to this and you have like struggled with addictive behaviors or things like that, this is like one of those things where you get to practice that self wisdom of knowing your limit, that there's just some things that are my mortal limit. Right. Or if you have a history of psychosis or mania. Right.
Coming out the other side of that, you get this understanding. And there are plenty of other treatments that might be better suited to your brain. Right. If that's the case. I'm curious, when it comes to age range for this medication, what are we looking at most? Typically
[00:45:18] Speaker B: it's the healthy adult, however, I mean, I have had training in an organization called Proddy, which a psychiatrist by the name of Scott Shannon in Colorado kind of spearheaded. But I've sat in discussion groups where teens and even children have been benefiting from ketamine assisted psychotherapy. And I guess this is now good a time as any to talk about like, how is this even happening? Because it seems like we're doing a lot of like off label things and we absolutely are. But I want to highlight that ketamine assisted psychotherapy is legal, 100% legal. It's just not FDA approved.
So we can. I prescribe things off label all the time, even just general psychiatric medicine. So we can treat things off label and make sure that the patient is making an informed decision and understanding the risks and benefits. But unfortunately being FDA approved means that it's not covered by insurance. That's the biggest.
And we'll probably get to barriers at some point, but as we're talking about this because it does sound so individualized and I probably wouldn't feel comfortable treating an adolescent for quite some time with it, but it has happened and the same with the geriatric population. The most recent training I've had, some people have had really, really wonderful outcomes with, with even elderly people. But then you have to a consider medical, like hypertension contraindications. But also do they have obstructive sleep apnea? And what if they fall asleep during treatment and then have too many apneic episodes or difficulty breathing in general?
Because sometimes communicating concerns, does not that come that easily when, when you're under the influence of ketamine?
[00:47:07] Speaker A: And to clarify and correct me if I'm wrong, ketamine assisted psychotherapy not covered by insurance, not FDA approved.
Sometimes I.
And again, I'm not sure if you know, but sometimes I've seen the holdup. There is a copyright thing. I don't know, there's some interesting restrictions within the FDA when it comes to that. But the Spravato, that can be covered by insurance in places, correct?
[00:47:35] Speaker B: Yeah,
[00:47:35] Speaker A: right.
[00:47:36] Speaker B: Spravato came about in about 2019. And I've worked with Spravato quite a bit in the Pittsburgh Clinic I'm still affiliated with. It's now FDA approved for a monotherapy, meaning we used to have a psychiatric medication prescribed along with the Spravato. Now people can just solely be on Spravato and get Spravato treatments too, and insurance will pay for that.
That's typically covered by insurance as long as you meet that treatment resistant depressive category. Same with IV Ketamine. The medical model of going in several times a week and having intravenous ketamine, that's typically also covered by insurance. And people have profound symptom improvement. But like I think your band aid analogy is perfect. We're absolutely putting a lovely band aid, beautiful band aid on these depressive symptoms. But the psychotherapy part I think is where really the deep work and true path to mental wellness can happen.
[00:48:35] Speaker A: I'd a hundred percent agree with that. So what does the research say are the overall benefits of this kind of treatment? And what benefits have you seen yourself in your own clinical experience?
[00:48:49] Speaker B: So when CAP was first introduced to me, somebody told me it was shaking up the snow globe in the brain. And I had trouble wrapping my head around it for a bit. But then if you picture a snow globe and it's just sitting there, all the beautiful snow is just kind of resting at the bottom. There might be music Playing it actually still might be turning on its axis, but it's still just sitting there. Right? But if somebody physically picks it up and shakes it in a way that snow starts to fly and find new different pathways, people often say it's like jump starting your car battery. And I don't love that analogy. But I do love the snow globe one, because the snow globe itself looks beautiful, but it's kind of stuck. But then if you start shaking it up and the snow spreads everywhere, that's where a lot of the beauty is. And I think that's what I've probably like, if I zoom out, that's probably the most profound impact I've seen in really anybody. I think, like the most powerful, noteworthy things that I've seen is somebody who comes in acutely suicidal and then two days later will say something along the lines of like, I have hope again, or I can find some joy in living again. And like, it makes me emotional just thinking about it.
But also from personal experience and my experiential training, we would sit with people and then we would trade places. Right. Often individuals feel tethered by something. So like attached to something, abuse, or maybe they didn't have great attachment to a parent or substances that they feel tethered by. And I have seen a lot of really incredible beauty in just having a journey, exploring your mind, seeing different perspectives, and then waking up and saying, I don't have to feel tethered to this anymore and giving yourself permission to do that. So that's probably the most powerful impacts that I've seen.
I think when somebody asks me and if I'm like sitting in a consultation, probably this increased cognitive ability to be emotionally flexible is really profound and something that most people can expect in one way or another. And also just kind of a decreased hypervigilance or decreased vigilance in general.
Just being present in the moment and not anticipating or feeling anxious.
[00:51:21] Speaker A: I'm hearing this treatment can help a person with stuck points.
And for those who are unaware of cognitive processing therapy for trauma, a stuck point is exactly what it sounds like. It's a belief we have about ourselves, other people, or the world that is just driving our thinking and our feeling and our behavior.
Right. And it can be kind of sneaky, these things. We can be totally at the mercy of one of our stuck points and not realize it for a while. Just to give an example of some stuck points, you know, it's, if I open up, my vulnerability will be used against me. Right. That's one a lot of folks who have interpersonal trauma from family or past relationships might have.
Right. Or if I stop my hyper vigilant checking behavior, if I step back, I will be hurt or something terrible will happen. I'm thinking of a lot of folks I've worked with who are first responders or veterans who are scanning the road for danger, scanning each room for the exits, you know, and there's an aspect of that training that's automatic, but there's also our relationship to that automatic response. Right. And that's where we can have some change. We can get unstuck from that. So it's not controlling our daily life so much or impacting us or keeping us away from the things we want to do and the person we want to be. So when I did my training for ketamine assisted therapy, two things that the trainers were really driving home and that just in personal experience I've seen to be really important is set and mindset. Right. So set being the environment in which you are receiving this treatment in the therapeutic office, but also your environment, your family environment when you go home, your community environment, and then your mindset, which is your state of mind. Can you tell our listeners what they can expect in terms of priming for mindset and setting?
[00:53:35] Speaker B: And I actually think it even boils down to there are actually different methods of administration we can utilize. In cap, ketamine comes in all sorts of forms, but in cap, typically it's used in a sublingual method, so under your tongue, we call it like troches or lozenges that sometimes switched around and for about 15, 20 minutes and then ingested, which feels really personal for people, but also can be triggering based on certain traumas to ingest something. So we need to take that into consideration.
But conversely, the other option is an intramuscular injection that would typically goes in the arm and that works pretty quickly, but again can be triggering for certain reasons. So just even deciding what is most appropriate for the client and what feels safest for the client is huge.
And once that's decided, it is about the setting of the therapeutic environment, like what you've talked about. So it absolutely needs to be a safe place physically, mentally, but also a place that's conducive to healing. It's all about comfort and ability to be vulnerable. So I always tell people, people to make sure that they're in comfortable clothing, come in PJs, if you want to bring a comfortable blanket or a stuffed animal.
Most often than not, individuals choose to lay on like a cot or mattress on the floor because they feel quite grounded. But most facilities we do here have recliners available too, if that feels better.
Some people like to feel cocooned in and have weight on them. Some people like to feel free, right? And that's all dependent on the individual. And also could vary from treatment to treatment depending. You want to have dim lights, low lights, really low sensory, anything with the exception of music.
But even then, the music's so important, it needs to be unfamiliar. It needs to not have lyrics. I have kind of my own playlist that I like to use.
It's important that we don't get stuck on lyrics or anything like that.
And even the artwork in a room can be really, really influential.
Because even though while you are journeying, you will be wearing a blindfold, things that you see and things that you experience right beforehand are incredibly important too.
So that's important. Then the first part of the session, which sometimes can be rushed, is the like setting the intention.
So sometimes it's the honoring of the medicine, sometimes it's.
You almost always need to have some sort of intention. Whether it's, I just want to see what my mind has to say, I want to explore. Sometimes it is, I want to get unstuck with this specific concept. But also managing the expectation that that might not be what your mind decides to reveal for you, but having some sort of attention getting in the space. I often like to read some sort of poem or something beforehand to get people feeling in a really safe space. And then dosing also matters, depending on what they want to work on, what's appropriate, that's all individualized. So low doses get people in like a really empathic state, which often is really a lot of where the talking is doing, because this is psychotherapy still, so you're still talking with the clinician.
And then the higher doses get into the trans, like ego dissolving type state, which is probably what we're all like in society think of as like these trips, which can have beautiful and profound impact.
And usually the responsibility of the clinician then is to support, be safe, not even necessarily guide. But if somebody needs a hand to hold, you're there. If somebody needs a blanket, you're there. Because regardless of the state, typically individuals have an awareness of where they are. And it's not uncommon for somebody to say like, are you still there? Am I still here? Yes, you're here, you're safe.
And then you're absolutely right about the setting afterwards. I always think of like fresh fallen snow.
And if you wake up the morning it's quite beautiful and peaceful. And that's kind of what it is like in this container that you're talking about whenever you have this lovely journey with an individual you trust, but then the world is outside.
So what do you do with this fresh fallen snow? You can take a nice hike in it and appreciate its beauty or, you know, you can throw mud on it and dirt on it and then it disrupts it all.
So it's just so huge. And that could be a contraindication like we talked about. If they don't have a supportive, stable home environment.
I would not feel safe doing this type of therapy with somebody and then putting them in a potentially vulnerable or unsafe environment.
[00:58:21] Speaker A: Yeah, I think everything you brought up is so important. And to your last point, ketamine therapy increases neuroplasticity.
So if you have this lovely experience in the therapist's office, but you go home to an abusive partner who says something really nasty to you that could get extra stuck in your head, Right?
[00:58:45] Speaker B: Absolutely.
[00:58:47] Speaker A: So it's important to treat this treatment with some sense of sanctity.
When you do that, you can take that to everything else in your life.
And I think that's one of the benefits here.
I like that you went into detail about the music and the art and how those choices, again, they help that protector part, that anxious protector, step back. Because protectors love literal thinking. They love an over analysis. They love language itself. Right.
So just having that ego part, protector part again come back. I have one more question for you. Do you think the general public has any misconceptions about this treatment? And if so, do you have any information that might be helpful for them?
[00:59:39] Speaker B: Yes, I think is my short answer. I absolutely think that the general public has some misconceptions. And I actually see this kind of like in a polarity. One is, I think in our industry, and you've maybe heard something like this, you've alluded to this, that it's almost viewed as like a miracle cure and it can be really impactful. I've seen some really beautiful outcomes, but it's certainly not one size fits all. And it's not the cure. It can put people in remission like many of the treatments we use, but coming in with the expectation that all will be well again is.
Is not managing things appropriately.
And then conversely, it's that it's a very unsafe, highly abused, risky medicine which has a lot of negative connotation and then creates some distrust with the clinician. If you find out that's something that's being provided or even offered to people in that practice. And so with that, I.
I actually want people to be concerned and vigilant. And I think it's important that we make sure that the medicine is monitored, administered, that you feel safe. But also recognizing that abuse can happen with any medicine, particularly with medicines that we prescribe in psychiatry and in pain, like pain management.
But it's something that, unfortunately, has been a part of the narrative and in the media, even as of in the past few weeks, because of that tragic sexual abuse case at Cornell University. Right.
And we know of many celebrities who abuse or misuse ketamine, and that's often in the media.
So that's a misconception that it is a bad thing, because there's a lot of beauty in it, too.
[01:01:36] Speaker A: What you're saying, it reminds me that these treatments are like tools.
And, you know, just like you can use a knife to make a beautiful meal for yourself, a kitchen knife, and to share that with other people and to nourish yourself, you can also use a knife to harm yourself or other people.
And this is true not just with ketamine assisted therapy, but any therapy, even cognitive therapies. If you think about it, doing, for example, CBT with a clinician you trust with informed consent can be very healing. Trying to do CBT on your spouse against their will can be manipulative and emotionally abusive.
[01:02:22] Speaker B: Wow. Yeah.
[01:02:24] Speaker A: So it's really, again, comes back to that sanctity of setting and with the awareness that this is a powerful tool. And, you know, anytime we're using a powerful tool, we want to take the time to get to know it, know what it's capable of, you know, and where our limits are with it.
Well, I know we're just at time here, you know, before we wrap up, you know, is there anything else, you know, that you'd want to mention that we didn't get to or any closing remarks?
[01:02:53] Speaker B: I want to hone in on the fact that there is not a specialized treatment model for really anybody. The more individualized a treatment plan is, I think, the better the outcome.
So I think adding CAP as an option for some people can have incredible outcomes, but making sure that people understand that it's. That it might not be appropriate at this time. But that doesn't mean that there aren't other options out there,
[01:03:24] Speaker A: because timing is really important with something like this. That is increasing neuroplasticity. We want to make sure that we maximize those gains.
Right. But we also want to make sure that someone isn't coming along and just like leaving footprints in your fresh snow.
Foreign.
My lovely listeners, thank you for joining us for another episode of Unburdening.
If you have anything you want to share about this episode, feel free to leave us a comment and we'll see you next month. As a reminder, we drop episodes every first Monday of the month and and you can find those on any streaming platform, Spotify, Amazon, Apple, whatever you like.
So until next time, take care of yourselves, take care of each other, and be well.
