WEBVTT 00:00:10.530 --> 00:00:16.009 - Okay. All right. Welcome, everyone. Thank you so much for joining us after lunch. My name is Melanie. 00:00:16.009 --> 00:00:21.381 - If we haven't met before, I'm with the Youth Services Bureau, but also in this hat, I'm part of the 00:00:21.381 --> 00:00:27.129 - SUDAC Recovery Summit Planning Team. And I am super excited to have Kara Baerch over here as our presenter 00:00:27.129 --> 00:00:29.278 - for her second session, an introduction 00:00:29.474 --> 00:00:34.908 - introduction to ketamine-assisted psychotherapy. So just a quick housekeeping thing. You've heard it 00:00:34.908 --> 00:00:40.341 - already before, probably. If you are here to receive continuing education credits, do make sure that 00:00:40.341 --> 00:00:45.721 - you sign in on any of the sheets that are in on your table. Make sure that you sign out. And at the 00:00:45.721 --> 00:00:51.209 - very end of the session, there's going to be a QR code at the screen. Make sure that you scan that QR 00:00:51.209 --> 00:00:56.696 - code. Write down the six-digit ID. It is specific to the session. And then if you have any challenges 00:00:56.696 --> 00:00:57.342 - with the C, 00:00:57.506 --> 00:01:04.276 - the QR code, come find me, I can scan it for you or something or send you a link. Okay, with that, out 00:01:04.276 --> 00:01:11.111 - of the way, Kara, take it away. All right, hi everyone, can you all hear me okay? Great, on my clicker, 00:01:11.111 --> 00:01:17.749 - great. So welcome and thanks for joining us after lunch. I'll try to keep you awake, but if you need 00:01:17.749 --> 00:01:24.387 - to get up, move your body around, please feel free to do that. Make yourself comfortable in whatever 00:01:24.387 --> 00:01:26.622 - way. It won't distract me at all. 00:01:27.234 --> 00:01:33.921 - So if you want to stand, stretch, do yoga in the back of the room, whatever. Because I know that after 00:01:33.921 --> 00:01:40.024 - lunch can be a little bit of a difficult haul. So welcome. So today we're going to talk about 00:01:40.024 --> 00:01:46.712 - ketamine-assisted psychotherapy, or you'll hear it referred to as CAP. And I'll tell you just a little 00:01:46.712 --> 00:01:53.789 - bit about my journey, what led me to decide that CAP was something that I wanted to get into professionally. 00:01:53.789 --> 00:01:56.126 - So I have always been a fan of what 00:01:56.226 --> 00:02:03.091 - I call the subcortical therapies. And so these are the therapies that are looking at more than the thinking 00:02:03.091 --> 00:02:09.575 - part of the brain, more than that prefrontal cortex, really looking at the nervous system, looking at 00:02:09.575 --> 00:02:15.932 - somatic presentations, what's happening in the body that is sort of fueling whatever disturbance or 00:02:15.932 --> 00:02:22.479 - distress that the person is experiencing, because I really feel like what is happening on a deep level 00:02:22.479 --> 00:02:24.958 - needs to be addressed on a deep level. 00:02:25.090 --> 00:02:31.677 - There's immense value and healing value in being able to sit and tell your story. That is absolutely 00:02:31.677 --> 00:02:38.655 - true. And I will never deny it. And also when we're talking about things that are going on in your nervous 00:02:38.655 --> 00:02:45.633 - system, in the wiring of your brain, your polyvagal tone, all of those things that are not being addressed 00:02:45.633 --> 00:02:48.894 - in therapy, I kind of feel like there's something 00:02:49.026 --> 00:02:56.231 - missing there. So I started my foray into subcortical psychotherapies with EMDR, moved into looking 00:02:56.231 --> 00:03:03.436 - at other somatic approaches, HACOMI, somatic experiencing, internal family systems, which I view as 00:03:03.436 --> 00:03:10.786 - a subcortical therapy when done in that way. And heard about, started hearing about ketamine assisted 00:03:10.786 --> 00:03:16.478 - psychotherapy, you know, probably maybe during COVID is when I started sort of 00:03:16.642 --> 00:03:24.231 - You know, I was bored, so I was reading stuff. And I always had this kind of like, oh, that's interesting 00:03:24.231 --> 00:03:31.462 - kind of approach. And then in 2023, I got an opportunity to do an introductory training retreat with 00:03:31.462 --> 00:03:38.837 - a program out of Asheville, North Carolina, the Asheville area. And really, it was a huge game changer 00:03:38.837 --> 00:03:42.846 - for me, both personally and professionally. And so just 00:03:43.042 --> 00:03:50.652 - kind of continued down that path. And so that's what brings me here to stand in front of you today. 00:03:50.652 --> 00:03:58.489 - Like I said, I started that training in 2023, completed certification at the Living Medicine Institute 00:03:58.489 --> 00:04:06.327 - in 2024, certification with Skylight Psychedelics in 2024 too, I think, and most recently, Integrative 00:04:06.327 --> 00:04:11.806 - Psychiatry Institute. So I'm very, very much dedicated to increasing my 00:04:12.002 --> 00:04:18.643 - my knowledge, my skills, my experience, my understanding with psychedelic assisted psychotherapies, 00:04:18.643 --> 00:04:25.285 - because as Talcott mentioned this morning, it is the future, shall we say, or the next cutting edge 00:04:25.285 --> 00:04:31.992 - of mental health treatment. That having been said, before I even move into the slides, I am going to 00:04:31.992 --> 00:04:38.833 - say, and I say this to my clients all the time, ketamine is a catalyst, not a cure. So anything that's 00:04:38.833 --> 00:04:40.958 - new, anything that's, you know, 00:04:41.954 --> 00:04:47.987 - cutting edge, anything that feels kind of sexy or out there or edgy, people get really excited about 00:04:47.987 --> 00:04:54.318 - and then they decide it's the silver bullet and they decide that this is the thing that's going to change 00:04:54.318 --> 00:05:00.888 - everything and this is the thing and there's no thing. And I just say that to sort of temper our expectations 00:05:00.888 --> 00:05:05.726 - and understand that ketamine and psychedelics in general are an amazing, amazing 00:05:06.114 --> 00:05:13.541 - It's a tool or set of tools and provide opportunities for healing that many people maybe would not experience 00:05:13.541 --> 00:05:20.428 - without them. And also, I just want you to take those words with you, the catalyst, not the cure. And 00:05:20.428 --> 00:05:27.247 - that is why I'm actually here talking about ketamine-assisted psychotherapy. So what are we gonna do 00:05:27.247 --> 00:05:33.054 - today? We're gonna talk about how ketamine is used in various settings and understand 00:05:33.282 --> 00:05:39.644 - different routes of administration, like how the medicine gets on board. We're gonna talk about the 00:05:39.644 --> 00:05:46.006 - difference between different doses of ketamine administration that produce different experiences in 00:05:46.006 --> 00:05:52.369 - different types of states, psychedelic, psychedelic. We'll talk about common subjective experiences 00:05:52.369 --> 00:05:58.731 - of ketamine and how set and setting factors affect these experiences for better or for worse. We'll 00:05:58.731 --> 00:06:00.894 - talk about the difference between 00:06:02.018 --> 00:06:08.911 - psychedelic or ketamine-assisted psychotherapy versus what people refer to sometimes as antidepressant 00:06:08.911 --> 00:06:15.871 - treatment or just ketamine infusion. And we'll talk about the importance of preparation and integration 00:06:15.871 --> 00:06:22.430 - for ketamine-assisted psychotherapy. It's not just about the drug. Okay, so what does chemist do? 00:06:22.530 --> 00:06:29.949 - Ketamine is a compound that was developed in the 60s by some guy in Detroit. And its first use was as 00:06:29.949 --> 00:06:37.222 - an anesthetic in hospitals and medical settings. Veterinary hospitals have historically, ever since 00:06:37.222 --> 00:06:44.495 - Ketamine's development, used it quite extensively. It's actually used a lot in ERs and in emergency 00:06:44.495 --> 00:06:52.496 - medical response because it's got a pretty high safety profile and can get the results that we're looking for 00:06:52.496 --> 00:06:59.300 - pretty quickly, meaning a calm, relaxed effect. And it is also an analgesic, so if somebody dislocates 00:06:59.300 --> 00:07:06.038 - their shoulder and they're screaming, they're excruciating pain, it can be really useful, and it does 00:07:06.038 --> 00:07:13.502 - have a fairly high safety profile. I will say, and this is an important disclaimer, I am not a medical provider. 00:07:13.730 --> 00:07:19.569 - I am not a medical prescriber. So when I talk about ketamine, it is from the position of a mental health 00:07:19.569 --> 00:07:25.131 - clinician who has gotten a lot of training and done a lot of research and reading on her own, not a 00:07:25.131 --> 00:07:30.803 - medical provider. So I just want to make sure that, you know, as I'm talking about that, that you are 00:07:30.803 --> 00:07:36.364 - not hearing me say, oh, ketamine's got a high safety profile. And I know that because I went to med 00:07:36.364 --> 00:07:40.702 - school. I know that because smart people who went to med school told me that. 00:07:41.218 --> 00:07:51.959 - And I'll make a point of letting you know when I have information from one of my collaborating prescribers. 00:07:51.959 --> 00:07:54.942 - So ketamine is the only legal 00:07:55.234 --> 00:08:01.229 - psychedelic in the US. Now there's also fights about what is a psychedelic and what is not a psychedelic, 00:08:01.229 --> 00:08:07.449 - but I will say that ketamine, when used at psychedelic doses, shares enough characteristics with psychedelics 00:08:07.449 --> 00:08:13.387 - that we can call it that. And it's the only one that is legal in the entire United States, meaning there 00:08:13.387 --> 00:08:19.382 - are no states in the United States where ketamine is not a legal substance. It is a controlled substance, 00:08:19.382 --> 00:08:25.150 - as it should be, but there are no states that it is not legal to use with a physician's prescription. 00:08:25.346 --> 00:08:33.806 - It is used off-label for depression, treatment-resistant depression, specifically responds quite well 00:08:33.806 --> 00:08:42.847 - to ketamine, PTSD, anxiety, addictions, other mental health diagnoses, so it's being used, again, off-label, 00:08:42.847 --> 00:08:45.086 - and when we say off-label, 00:08:45.250 --> 00:08:52.900 - Again, as I said, it's still certainly legitimate for a medical professional to prescribe. But according 00:08:52.900 --> 00:09:00.404 - to the FDA, it's not like this has been approved for this use. So that's why we call it off-label. And 00:09:00.404 --> 00:09:07.689 - a lot of medications are used off-label. There are anti-seizure medications that are used off-label 00:09:07.689 --> 00:09:09.438 - for migraine disorders. 00:09:10.210 --> 00:09:16.958 - 5N is used off-label for appetite control. So there are a lot of different types of off-label medical 00:09:16.958 --> 00:09:23.905 - use. And so ketamine, when it is used for PTSD, depression, anxiety, addictions, and other mental health 00:09:23.905 --> 00:09:30.521 - diagnoses, we call it use off-label. And unfortunately, it has high abuse potential. It's been used 00:09:30.521 --> 00:09:32.638 - recreationally back probably up 00:09:32.866 --> 00:09:39.520 - all the way back until the 70s. It does have high abuse potential. I cannot think of something that 00:09:39.520 --> 00:09:46.307 - sounds more horrible for myself than experiencing ketamine in a club. Part of my draining is I've had 00:09:46.307 --> 00:09:52.030 - multiple ketamine experiences with almost all the different routes of administration. 00:09:52.354 --> 00:09:58.815 - didn't feel like I needed to try suppositories, I'm okay there, but all the other out to administration 00:09:58.815 --> 00:10:05.276 - I have experience with with ketamine, and trying it in a club sounds horrible to me, but again, it does 00:10:05.276 --> 00:10:11.489 - have a high abuse potential and is frequently abused. And as Tall Cop said this morning, that's the 00:10:11.489 --> 00:10:16.894 - rub, right? Those of us in the mental health field who are seeing positive effects and 00:10:17.154 --> 00:10:23.692 - that sometimes even feel near miraculous with psychedelics are like, oh God, thank you, we can use these. 00:10:23.692 --> 00:10:29.860 - And the people that are treating the abuse and that are responsible for law enforcement and whatnot 00:10:29.860 --> 00:10:36.274 - are like, oh God, here we go. So there's two sides to that coin. I think it's important to acknowledge. 00:10:36.274 --> 00:10:42.935 - Okay, so I was just talking about routes of administration, right? And the typical routes of administration 00:10:42.935 --> 00:10:47.006 - that you'll see out there, an IV infusion, an intramuscular shot, 00:10:48.002 --> 00:10:54.826 - an oral lozenge, or sometimes you'll hear them called trochies, nasal spray, and suppositories. 00:10:54.826 --> 00:11:02.219 - Nasal spray, you'll hear people talk about Spravato. Spravato, and that's actually misspelled. I should 00:11:02.219 --> 00:11:10.110 - have a T, I believe. Spravato is a designer ketamine. It was developed by Johnson & Johnson. They like changed 00:11:10.210 --> 00:11:16.463 - one thing in the molecule or something, I don't know how they do those things, to create spravato. And 00:11:16.463 --> 00:11:22.473 - spravato actually is considered unlabeled for treatment of, yeah, treatment of treatment-resistant 00:11:22.473 --> 00:11:28.544 - depression. But you can also, a provider can also prescribe compounded ketamine nasal spray. So all 00:11:28.544 --> 00:11:34.979 - different routes of administration, and they'll give you some slightly different experience. IV infusion, 00:11:34.979 --> 00:11:36.254 - onset is very quick, 00:11:36.354 --> 00:11:42.111 - It's a very steady experience. And then as you're coming out of the medicine, it's also fairly quick 00:11:42.111 --> 00:11:47.925 - because again, you know, with IV, we're going directly into the bloodstream. Intramuscular shots will 00:11:47.925 --> 00:11:53.796 - give you like a sort of a launch you up into the stratosphere sort of effect and then you kind of come 00:11:53.796 --> 00:11:56.190 - down from there. So it's a different arc. 00:11:56.962 --> 00:12:04.505 - An oral lozenge has a much slower onset. We hold them under the tongue or sublingually in the mouth. 00:12:04.505 --> 00:12:12.198 - They absorb through the mucous membrane and so it's a much more gradual onset. Also tends to be a more 00:12:12.198 --> 00:12:19.741 - gradual leaving the system. Nasal spray, pretty similar to the oral lozenge because it is also being 00:12:19.741 --> 00:12:24.446 - absorbed through the mucous membranes. Nasal spray tends to be 00:12:24.802 --> 00:12:31.944 - a little bit shorter. The experience tends to be a little bit shorter than with the lozenges. And suppository 00:12:31.944 --> 00:12:38.631 - is very similar to lozenges. Again, all are relatively short acting. It says one to three hours, about 00:12:38.631 --> 00:12:45.124 - 45 minutes of the real altered state. But again, there is sort of the movement into that state. And 00:12:45.124 --> 00:12:51.422 - then there's what we call the landing, which can be gradual. So one to three hours for the whole 00:12:51.554 --> 00:12:58.133 - journey, sometimes we refer to it. And dosage matters a lot, a lot. As you can imagine, because this 00:12:58.133 --> 00:13:04.647 - is a substance that is actually used as a general anesthetic at high enough doses. So the dosage is 00:13:04.647 --> 00:13:11.357 - gonna make a really big difference in terms of the experience. I talked about psycholytic doses, which 00:13:11.357 --> 00:13:17.936 - are very low doses. It's not that there's nothing altered about the experience, but you're certainly 00:13:17.936 --> 00:13:18.718 - not feeling 00:13:18.882 --> 00:13:26.639 - in a really highly altered state, all the way up to psychedelic doses where you're potentially having 00:13:26.639 --> 00:13:34.473 - visuals, having a sense of altered reality, ego dissolution, things like that. So dosage is definitely 00:13:34.473 --> 00:13:41.470 - a major factor, not the only factor, but a major factor in your experience with a medicine. 00:13:42.146 --> 00:13:49.762 - So dosing, and this information is from Julie Addis, who's an NP in South Bend that I worked pretty 00:13:49.762 --> 00:13:57.911 - closely with during my training. But you'll also see this like other, my training program, Living Medicine 00:13:57.911 --> 00:14:05.603 - Institute. You'll see these figures fairly commonly bandied about 0.5 milligrams per kilogram. Tends 00:14:05.603 --> 00:14:10.782 - to be like a starting dose, where we'll start for the dose finding. 00:14:11.010 --> 00:14:19.031 - Psycholytic doses are lower. In a psycholytic state, you're still able to track the room very well. 00:14:19.031 --> 00:14:27.052 - In an observing state, you're able to get up and go to the bathroom without assistance. It's a very 00:14:27.052 --> 00:14:35.153 - mild experience. Psychedelic doses, again, higher doses. A lot of the time, there's a lot more focus 00:14:35.153 --> 00:14:40.126 - on your inward experience, almost like what's outside of you. 00:14:40.418 --> 00:14:47.367 - in your environment almost doesn't even register anymore. Altered states of consciousness, non-ordinary 00:14:47.367 --> 00:14:54.115 - states of consciousness, which when we talk about non-ordinary states of consciousness, you know, we 00:14:54.115 --> 00:15:00.997 - might be looking at, you know, depending on one's psychospiritual sort of framework or whatnot, I have 00:15:00.997 --> 00:15:08.414 - clients who've had conversations with God in their ketamine experiences. I've had clients who've had ancestral 00:15:08.642 --> 00:15:15.833 - communication, like visits with ancestor guides. I have clients that have experience with other types 00:15:15.833 --> 00:15:22.954 - of, you know, they're angelic or other, you know, spiritual figures or guides. And, you know, for me 00:15:22.954 --> 00:15:30.216 - and for most people that are working in the psychedelic space, openness to what that means for you and 00:15:30.216 --> 00:15:36.702 - how that helps you is essential. But at the same time, everybody's experience is their own. 00:15:37.186 --> 00:15:44.145 - And so, you know, as a provider, I'm not gonna like jump on board and be like, all right, you talk to 00:15:44.145 --> 00:15:51.514 - God, what'd she say? And I'm also not, but I'm also not gonna, you know, kind of shy away from the client's 00:15:51.514 --> 00:15:58.474 - spiritual experience or psychospiritual experience that they may have had in that non-ordinary state. 00:15:58.474 --> 00:16:04.478 - So, again, just being really client-centered on that, which we really should be anyway. 00:16:05.634 --> 00:16:12.780 - All right. So what does ketamine do in the brain? So this is important. And again, this is provided 00:16:12.780 --> 00:16:20.141 - to me by Julie Addis. Again, it has a high safety profile. It can be used with many other medications, 00:16:20.141 --> 00:16:27.359 - including many psychiatric meds. So a lot of the time when people talk about psychedelics like MDMA, 00:16:27.359 --> 00:16:28.574 - like psilocybin, 00:16:28.674 --> 00:16:36.974 - DMT, F5MeO DMT, IOSCA, like a lot of the plant medicines, they are not compatible with SSRIs. They will 00:16:36.974 --> 00:16:45.115 - at the very least have significantly diminished effects. At the worst, looking at serotonin syndrome, 00:16:45.115 --> 00:16:53.175 - so they are not compatible. Ketamine is compatible with SSRIs, which is one of the reasons that it's 00:16:53.175 --> 00:16:57.086 - really accessible for a client who realistically 00:16:57.186 --> 00:17:04.250 - going off their SSRI would be putting them at risk of significantly increased suicidal ideation and 00:17:04.250 --> 00:17:11.738 - other really risky things. They can still experience the benefits from ketamine. So it's not serotonergic 00:17:11.738 --> 00:17:12.798 - in that sense. 00:17:13.378 --> 00:17:20.108 - And there are some meds that will lower the effects of the ketamine, but in terms of safety, it's a 00:17:20.108 --> 00:17:27.041 - high safety profile. Works on NADMA receptors, increasing neurotransmitter communication, specifically 00:17:27.041 --> 00:17:33.838 - with glutamate and GABA, which you don't really need to know all that much about, except saying that 00:17:33.838 --> 00:17:40.569 - it's increasing the brain's ability to communicate through neurotransmitters, increases neurofiring 00:17:40.569 --> 00:17:41.982 - and neuroplasticity. 00:17:42.242 --> 00:17:49.215 - So the ability to make adaptive changes relating to the structure and the function of the nervous system, 00:17:49.215 --> 00:17:56.057 - which is what I was talking about before, the importance of understanding effects on the nervous system 00:17:56.057 --> 00:18:02.701 - and how talking about it doesn't always get down there. So it does increase that neuronal firing and 00:18:02.701 --> 00:18:09.345 - increases neuroplasticity and increases brain-derived neurotrophic factor, brain growth hormone, and 00:18:09.345 --> 00:18:10.398 - helps to create 00:18:10.946 --> 00:18:19.259 - new neurons, which, of course, is also part of that neuroplasticity. So it's doing stuff in the brain 00:18:19.259 --> 00:18:27.491 - is what we're saying. And it's really doing some very specific things in the brain. Actually, before 00:18:27.491 --> 00:18:34.174 - we leave this one, there are some other aspects of it that are not necessarily as 00:18:35.618 --> 00:18:44.182 - specific as this neurotransmitter, this, this, this. But there's also a system within our brain that's 00:18:44.182 --> 00:18:53.246 - called the default mode network. Okay, default mode network, DMN. And this system in our brain is essential, 00:18:53.246 --> 00:19:01.560 - kind of what it sounds like. It enables us to sort of have a default mode where we can kind of move 00:19:01.560 --> 00:19:02.974 - through our day, 00:19:03.362 --> 00:19:11.773 - We can sort of have a sense of identity, who we are, where we're going, what we're doing. The default 00:19:11.773 --> 00:19:20.431 - mode network is really important. In certain diagnoses, especially treatment-resistant depression, major 00:19:20.431 --> 00:19:29.502 - depression, severe anxiety, and PTSD, the default mode network can become problematic. Any guesses as to why? 00:19:32.802 --> 00:19:42.427 - Again, the default mode network is sort of a default mode that tells us who we are, what we're doing, 00:19:42.427 --> 00:19:52.146 - et cetera, et cetera. Any ideas why an overactive default mode network might become problematic, maybe 00:19:52.146 --> 00:20:00.638 - with depression? Yeah, so if you struggle with depersonalization, like not really feeling 00:20:00.770 --> 00:20:07.606 - yourself as a person, the default mode network is just going to amplify that or continue that, exactly. 00:20:07.606 --> 00:20:14.376 - If you think about negative beliefs that we hold about ourselves, rumination, the default mode network 00:20:14.376 --> 00:20:21.080 - is gonna keep, you're a piece of shit, you're a piece of shit, you're a piece of shit. So you can see 00:20:21.080 --> 00:20:27.390 - how the default mode network, while essential for our functioning, when it goes into overdrive, 00:20:27.586 --> 00:20:36.239 - can cause things like rumination, intense inward self-focus, which we actually know for depression is 00:20:36.239 --> 00:20:44.891 - a terrible thing. You don't want to get stuck in there for too long. And so really needing to sort of 00:20:44.891 --> 00:20:53.374 - understand how an overactive default mode network can exacerbate our mental health symptoms through 00:20:53.506 --> 00:21:01.266 - rumination through rigid thought structures and beliefs. And ketamine actually, psychedelics in general, 00:21:01.266 --> 00:21:08.952 - help disrupt that default mode network, just kind of set that aside for a period of time. And that also 00:21:08.952 --> 00:21:16.638 - is part of that neuroplasticity. All right. So subjective effects of ketamine. So it is a dissociative. 00:21:16.930 --> 00:21:24.230 - It's also different than some of the other psychedelics. Certainly some other psychedelics are dissociatives. 00:21:24.230 --> 00:21:30.932 - But when you're looking at psilocybin, MDMA, some of those that have been highly studied with trauma 00:21:30.932 --> 00:21:37.568 - and depression, ketamine is very different in that it is a dissociative. So there can be a sense of 00:21:37.568 --> 00:21:43.806 - disembodiment of not being in your body. For many people, that's actually a pleasant feeling. 00:21:44.002 --> 00:21:53.100 - I've had many clients say to me, this is so weird, I feel heavy and light at the same time. They feel 00:21:53.100 --> 00:22:02.198 - heavy and yet floating, and it's a positive feeling. So people can experience euphoria in that state. 00:22:02.198 --> 00:22:11.385 - Ketamine will create changes in perceptions, the way we think about things. Visuals, people frequently 00:22:11.385 --> 00:22:12.990 - will see visuals, 00:22:13.922 --> 00:22:19.764 - Ketamine, whether it's ketamine assisted psychotherapy or ketamine therapy, we tend to use an eye mask 00:22:19.764 --> 00:22:25.549 - to assist the person with sort of a more inward focus, and so there can be very vivid visuals in that 00:22:25.549 --> 00:22:31.278 - experience, although it's not the case for everybody. There's no everybody, or there's no normal for 00:22:31.278 --> 00:22:31.902 - everybody. 00:22:32.130 --> 00:22:38.953 - some of my clients that don't really have very many visuals, but they have like lots of somatic sensations, 00:22:38.953 --> 00:22:45.270 - even though I know I just said that it kind of can disembodied, not for everybody. For some people, 00:22:45.270 --> 00:22:51.966 - it can really heighten an awareness of somatic sensations. So again, these are kind of subjective effects 00:22:51.966 --> 00:22:58.663 - that nobody's gonna experience all of these. Changes in mood, again, you know, euphoria is not an unusual 00:22:58.663 --> 00:23:01.758 - feeling. Increased auditory awareness, increased 00:23:02.178 --> 00:23:08.007 - awareness of sensory stimuli in general can happen. A transcendence of time and space. When I'm doing 00:23:08.007 --> 00:23:13.778 - a cap session, I'm with my client anywhere from two to three hours. And sometimes for them, it feels 00:23:13.778 --> 00:23:19.721 - like I went by in the blink of an eye. And other times, I feel like it was like 1,000 years. I actually 00:23:19.721 --> 00:23:25.493 - had a client say to me, like, you're not going to bill me for 1,000 years, are you? I was like, nah. 00:23:25.493 --> 00:23:31.550 - But this transcendence of time, transcendence of space. You can have a real sense of being somewhere else 00:23:32.546 --> 00:23:40.790 - a sense of awe and wonder. And awe moments are actually super beneficial for mental health. And so, 00:23:40.790 --> 00:23:49.117 - you know, experiences of awe can really help with shifts in perspective and things like that. We see 00:23:49.117 --> 00:23:54.558 - birth and death themes, again, mystical or spiritual experiences. 00:23:55.554 --> 00:24:05.228 - Sometimes the re-experiencing of trauma memories, re-living, re-experiencing, but with space, with distance, 00:24:05.228 --> 00:24:14.814 - with observer mind. So it's really kind of an interesting phenomenon because it's almost like, well, it can 00:24:14.978 --> 00:24:21.291 - occur a few different ways, but it can almost be like a re-experiencing, but sometimes I'll say like 00:24:21.291 --> 00:24:27.978 - kind of like your emotions get wrapped in cotton wool so that they're a little fuzzier or a little further 00:24:27.978 --> 00:24:34.353 - away. Sometimes it can be a re-experiencing, but re-experiencing it from a third person place instead 00:24:34.353 --> 00:24:40.666 - of it happening to me. Lots of different things can happen there. Grief can show up and frequently a 00:24:40.666 --> 00:24:43.166 - sense of a deceased person being there. 00:24:44.290 --> 00:24:52.394 - Again, imagery, hallucinations, visual distortion, impressions. Ego dissolution, high enough doses can 00:24:52.394 --> 00:25:00.970 - happen, and this is, ego dissolution is an experience where, you know, there's, and not all ego dissolutions 00:25:00.970 --> 00:25:08.916 - are the same, but I would describe my experience with ego dissolution as no longer being a separate, 00:25:08.916 --> 00:25:11.198 - you know, person with my own 00:25:11.394 --> 00:25:19.713 - personhood and whatnot, but rather being a part of the cosmos, if you will. But anyone who has an experience 00:25:19.713 --> 00:25:27.344 - of ego dissolution will have a different experience. And so I don't think it's for us to define for 00:25:27.344 --> 00:25:35.052 - them. Muscle relaxation and relief from pain. So actually, a number of my clients have chronic pain. 00:25:35.052 --> 00:25:39.326 - And there's an experience of not being in pain for this 00:25:42.882 --> 00:25:49.795 - 90 minutes or so, and then sometimes a return of the pain, but even being able to look at that in a 00:25:49.795 --> 00:25:56.847 - different way. So yeah, so these are all subjective effects that people can have when they experience 00:25:56.847 --> 00:26:02.654 - ketamine. Any questions about any of that? That's a lot of stuff that might happen. 00:26:13.314 --> 00:26:33.662 - Yeah. Absolutely. Yeah. 00:26:36.994 --> 00:26:42.606 - That's a great question. And actually, I'm going to address both parts of that, because the first part, 00:26:42.606 --> 00:26:48.056 - I think, was so important. When you were asking about having that experience, if you're watching the 00:26:48.056 --> 00:26:53.668 - trauma, if you will, from the third person, can people have the experience of speaking up for the child 00:26:53.668 --> 00:26:59.281 - self? Absolutely, yeah. And there are a lot of different things that can happen in that way. The second 00:26:59.281 --> 00:27:04.839 - question was about bad trips. And we're going to get to the importance of set and setting and how that 00:27:04.839 --> 00:27:05.918 - can help with that. 00:27:08.642 --> 00:27:11.198 - All right, before we get to that, we'll stick on the... 00:27:57.666 --> 00:28:05.493 - Yeah, great question. So somebody who's been on opioids for a long period of time to manage pretty severe 00:28:05.493 --> 00:28:13.099 - chronic pain, would they be a candidate for ketamine? As a therapist who has training in this, I would 00:28:13.099 --> 00:28:20.926 - say absolutely, at the discretion of the medical provider. Now, that having been said, ketamine infusions 00:28:20.926 --> 00:28:23.806 - are prescribed to manage chronic pain. 00:28:24.002 --> 00:28:32.520 - And so that's actually something that is already happening. And it's actually easier to get that covered 00:28:32.520 --> 00:28:40.956 - by insurance than ketamine for other diagnoses. And so ketamine is used for management of chronic pain. 00:28:40.956 --> 00:28:49.150 - And it's really gonna be at the discretion of the prescriber in terms of what feels safe, what feels 00:28:49.150 --> 00:28:52.638 - appropriate with that. But in terms of the 00:28:52.898 --> 00:28:59.661 - the subjective feelings that come with it. Yes, they would have potentially any of those same experiences. 00:28:59.661 --> 00:29:06.109 - And in fact, I've had a few consultees that are like, okay, so one of my clients is actually going to 00:29:06.109 --> 00:29:08.574 - be having ketamine infusions for pain. 00:29:09.122 --> 00:29:15.088 - Can we use that? And I'm like, yes, double dip, because insurance is paying for that for pain. And if 00:29:15.088 --> 00:29:21.230 - she comes to you, first of all, if you do some really good preparation, which we're going to talk about, 00:29:21.230 --> 00:29:27.372 - and then she comes to you for therapy the day after her infusion, you're going to see her therapy really 00:29:27.372 --> 00:29:33.280 - take off. So absolutely, it can be used for both of those things. But again, it really comes down to 00:29:33.280 --> 00:29:37.374 - the prescriber's evaluation as to whether this person is appropriate. 00:29:53.506 --> 00:30:01.726 - Great question. So if you are paying out of pocket, it can be expensive. It can be quite expensive. 00:30:01.726 --> 00:30:10.029 - If you are experiencing chronic pain, I think my first step would be talk to your pain specialist. I 00:30:10.029 --> 00:30:16.030 - know that there are providers here in Bloomington that provide ketamine. 00:30:16.674 --> 00:30:22.653 - for pain, I believe through the hospital. I believe it's through IU Health. There's one new ketamine 00:30:22.653 --> 00:30:29.047 - infusion clinic in Bloomington. I don't know if they take insurance or not. It's True Bloom out of Vanished 00:30:29.047 --> 00:30:35.027 - Aesthetics. They're the first one that's come that's sort of open to the public, so to speak. But my 00:30:35.027 --> 00:30:35.678 - first step 00:30:35.778 --> 00:30:41.860 - would be talking to your primary care doctor and talking to your pain specialist to see what the options 00:30:41.860 --> 00:30:47.827 - are. There are some ketamine infusion clinics in Greenwood that have been in operation for a while and 00:30:47.827 --> 00:30:53.677 - pretty well established. So yeah, but the first step for me would be talking to the PCP and the pain 00:30:53.677 --> 00:30:57.790 - specialist because they'll be able to help you navigate those systems. 00:31:16.930 --> 00:31:25.099 - So I guess it depends on really the route of administration and how that's being managed. Because ketamine 00:31:25.099 --> 00:31:32.811 - in general, is ketamine as a substance expensive? No, it's been around since the 70s. So medication, 00:31:32.811 --> 00:31:40.827 - the longer they've been around, the cheaper they are, right? However, infusion clinic services are quite 00:31:40.827 --> 00:31:45.790 - expensive. The prescriber that I collaborate with to provide CAP 00:31:45.922 --> 00:31:53.306 - He will only prescribe ketamine lozenges for people that are going to be with a licensed provider who's 00:31:53.306 --> 00:32:00.690 - trained in CAP the entire time. That gets expensive. So I would say it's really more the infrastructure 00:32:00.690 --> 00:32:04.382 - involved than the medicine itself that's expensive. 00:32:19.650 --> 00:32:26.130 - That is possible, yeah, and it really depends on insurance company PAs. I know a number of people that 00:32:26.130 --> 00:32:30.974 - have been able to navigate that system, but it depends so much on insurance. 00:32:40.514 --> 00:32:46.645 - So the question was, if you're on those treatments for months and months, what does tolerance buildup 00:32:46.645 --> 00:32:52.776 - look like? And again, I would leave that more to a medical provider to really comment on. What I will 00:32:52.776 --> 00:32:58.846 - say is that it really depends on what we're talking about in terms of the use of the ketamine. So if 00:32:58.846 --> 00:33:00.830 - we're talking about ketamine for 00:33:01.346 --> 00:33:10.814 - for chronic pain. I'm not qualified to speak on that because that's not what I do when it comes to 00:33:11.426 --> 00:33:17.454 - use of ketamine within the mental health sphere, what I do, when it's used appropriately, and I'll talk 00:33:17.454 --> 00:33:23.308 - about what appropriately looks like in just a moment, when it's used appropriately, we're really not 00:33:23.308 --> 00:33:29.220 - looking at developing a tolerance because we're not using enough of it frequently enough, long enough 00:33:29.220 --> 00:33:35.422 - to develop a tolerance. But I won't speak for the pain management side of things because it's not my area. 00:33:38.498 --> 00:33:47.812 - So my prescriber, his name is Adam Pruitt. He's with Taconic Psychiatry and he is in Vermont. He's licensed 00:33:47.812 --> 00:33:56.782 - in Indiana, but yeah. All right, so back to the effects. We talked about the subjective effects, right, 00:33:56.782 --> 00:34:05.838 - of some, you know, feelings that people might have. Now we're going to talk about possible side effects, 00:34:05.838 --> 00:34:07.390 - physical effects. 00:34:07.554 --> 00:34:14.490 - All right, the most common one is nausea. It's not something that everybody experiences, but it's not 00:34:14.490 --> 00:34:21.494 - uncommon. A lot of prescribers will prescribe like Zofran to go with the ketamine to manage the nausea 00:34:21.494 --> 00:34:28.362 - if it's there. Dizziness, yes, if you have enough of a dose to sort of be entering into that kind of 00:34:28.362 --> 00:34:35.774 - psychedelic space. Dizziness, impaired or blurry or double vision, that's while you're in the altered state. 00:34:36.674 --> 00:34:44.528 - Increased heart rate and blood pressure. That will happen. Dysphoria or confusion can happen. Dysphoria 00:34:44.528 --> 00:34:52.382 - means feeling bad, right? And confusion can happen. A loss of a sense of control and paranoia and fear. 00:34:52.382 --> 00:35:00.387 - These are all things that can happen. So coming back to that question of a bad trip, it is the provider's 00:35:00.387 --> 00:35:01.822 - job to reduce any, 00:35:01.922 --> 00:35:09.250 - any factors that we have control over that could contribute to distress in a non-productive way, and 00:35:09.250 --> 00:35:16.651 - to assist the client in navigating any distress that comes up in a productive way. And I'll talk more 00:35:16.651 --> 00:35:23.979 - about what I mean by productive distress in a moment. But yeah, so these are the basic side effects. 00:35:23.979 --> 00:35:29.566 - And again, the clinician, or sorry, the medical provider would be the one to 00:35:29.666 --> 00:35:36.072 - discuss the risks of side effects, management of side effects. Certainly because they temporarily increased 00:35:36.072 --> 00:35:42.537 - heart rate and blood pressure, anyone who has uncontrolled high blood pressure would not be a good candidate 00:35:42.537 --> 00:35:47.934 - for ketamine, but that's the medical prescriber's job to take care of that side of things. 00:35:50.434 --> 00:35:57.722 - All right, so, okay, contraindication, severe cardiac disease, preeclampsia, eclampsia, hypertension, 00:35:57.722 --> 00:36:04.653 - stroke, so all this stuff has to do with high blood pressure and dangers of high blood pressure. 00:36:04.653 --> 00:36:12.012 - Schizophrenia. Schizophrenia and bipolar I are also contraindications because psychedelics can trigger 00:36:12.012 --> 00:36:14.942 - psychotic episodes. We know that, right? 00:36:15.842 --> 00:36:23.506 - Again, ketamine has a very high safety profile in general, but for somebody who has schizophrenia or 00:36:23.506 --> 00:36:31.094 - has bipolar I, likely ketamine's not gonna be a good choice for them. People who are actively using 00:36:31.094 --> 00:36:38.683 - other drugs, because again, we don't wanna be mixing things for one thing, and then also there's an 00:36:38.683 --> 00:36:44.222 - abuse potential with ketamine. And then children under the age of three, 00:36:44.994 --> 00:36:51.786 - Most medications are not for use with children under the age of three. So again, that's provided by 00:36:51.786 --> 00:36:58.918 - my NP that helped me out with a lot of my training. So those are our basic contraindications. And again, 00:36:58.918 --> 00:37:05.779 - why it's so important to have a prescriber that you have a really good relationship with if you're a 00:37:05.779 --> 00:37:06.526 - clinician. 00:37:06.690 --> 00:37:11.854 - Whoever you're prescribing or whoever is doing your prescribing, having a really good relationship, 00:37:11.854 --> 00:37:17.121 - being able to talk through whatever needs to happen. I had one client who became really upset because 00:37:17.121 --> 00:37:22.439 - she wasn't a good candidate for ketamine because of some blood pressure issues and whatnot. And it was 00:37:22.439 --> 00:37:27.655 - really important for the prescriber and I to be able to kind of be on a united front on this because 00:37:27.655 --> 00:37:32.870 - she just wanted it really badly. And so having that kind of relationship and making sure there's not 00:37:32.870 --> 00:37:35.710 - like a triangulation effect there is really important. 00:37:37.090 --> 00:37:44.112 - So the subjective effects we were talking about, what do they depend on? Well, we already talked about 00:37:44.112 --> 00:37:50.998 - dosage as being very important, right? Set and setting as being very important, and then therapy. Is 00:37:50.998 --> 00:37:57.815 - therapy involved or not? And it might not necessarily be during, but is it before, is it after? And 00:37:57.815 --> 00:38:04.837 - so these are the things that will really determine a person's subjective experience of ketamine is the 00:38:04.837 --> 00:38:06.814 - dosage, the set and setting, 00:38:07.202 --> 00:38:15.096 - whether or not therapy is provided. So first thing that we're gonna address is whether or not therapy 00:38:15.096 --> 00:38:22.836 - is provided. So we'll start with the last first. And these are different models of ketamine use. So 00:38:22.836 --> 00:38:30.653 - psychedelic use, which happens in, or which we are typically using when we're doing CAP, psychedelic 00:38:30.653 --> 00:38:35.838 - use is where we're kind of getting into those higher doses, right? 00:38:36.098 --> 00:38:44.513 - and can very much enhance psychotherapy work, having those experiences. Frequency becomes less important. 00:38:44.513 --> 00:38:52.769 - The therapist is present and engaged with the client during that experience. Engaged in a very specific 00:38:52.769 --> 00:39:01.342 - way that we'll talk about in a moment, but present and engaged. And the goal is psychotherapeutic progress. 00:39:03.842 --> 00:39:10.546 - Antidepressant use, or sometimes you'll hear people talk about going to the infusion clinic for their 00:39:10.546 --> 00:39:17.250 - induction series. They tend to be lower doses. That's not to say that you will not have a psychedelic 00:39:17.250 --> 00:39:24.085 - experience, because it's really so specific on how the medicine affects your system. You can still have 00:39:24.085 --> 00:39:28.094 - a psychedelic experience, but it's not as much of the focus. 00:39:28.226 --> 00:39:33.737 - So there tend to be a little bit of lower doses, especially if we're talking about spravato, significantly 00:39:33.737 --> 00:39:38.425 - lower. The dose schedule frequency matters, right? So if somebody says, I'm doing ketamine 00:39:38.425 --> 00:39:43.679 - for treatment-resistant depression, and I'm going to the ketamine clinic, they're going to want to do 00:39:43.679 --> 00:39:48.881 - three sessions a week for two weeks, or like two sessions a week for three weeks. The idea is to get 00:39:48.881 --> 00:39:52.126 - them kind of close together, and that's based on the research. 00:39:52.290 --> 00:40:00.724 - So the dose schedule, the frequency does matter. And it's going to generally be happening in an ketamine 00:40:00.724 --> 00:40:08.997 - clinic. It's gonna be usually IV or spravato, potentially maybe IM. And the goal is symptom reduction. 00:40:08.997 --> 00:40:17.190 - The goal is symptom reduction. I will also say, and I need to add this to the slide, that I will also 00:40:17.190 --> 00:40:19.198 - do CAP with low doses of 00:40:19.298 --> 00:40:25.372 - ketamine sometimes, where the person is in like, again, what we call that psycholytic state. It's not 00:40:25.372 --> 00:40:31.328 - really an altered state, but they have sort of enough on board, so to speak, that there's sort of a 00:40:31.328 --> 00:40:37.640 - loosening of protective systems and defense mechanisms. There's like a more of an openness. We're getting 00:40:37.640 --> 00:40:43.417 - more of that neuroplasticity on board. So that is another way that we can use ketamine with CAP. 00:40:43.417 --> 00:40:48.062 - But again, I kind of talk about like CAP, ketamine assisted psychotherapy, or 00:40:48.418 --> 00:40:59.039 - Ketamine therapy without the psychotherapy added as sort of the main distinction between those two. 00:40:59.039 --> 00:41:09.342 - Great question. How many times do you have to do this process to actually see symptom reduction? 00:41:09.442 --> 00:41:15.619 - Well, the therapist's favorite answer is it depends. But in general, pretty significant relief after 00:41:15.619 --> 00:41:22.347 - the first session, depending on what the symptoms are and how severe they are. In general, pretty significant 00:41:22.347 --> 00:41:28.525 - relief after the first session. And again, six sessions when you're talking about antidepressant use 00:41:28.525 --> 00:41:35.008 - for treatment-resistant depression. Six sessions over the course of two or three weeks is pretty typical. 00:41:35.008 --> 00:41:38.494 - And so certainly by the end of that. But I will say that 00:41:39.650 --> 00:41:47.317 - the majority of people, even after the first session, are experiencing some pretty significant symptom 00:41:47.317 --> 00:41:55.356 - reduction. What else do I want to say about that? So can even one experience have a big effect? Absolutely. 00:41:55.356 --> 00:42:03.320 - Absolutely. And if you want to think about it this way. So traditional SSRIs, which has been the treatment 00:42:03.320 --> 00:42:08.382 - of choice for depression for a really long time, traditional SSRIs, 00:42:08.802 --> 00:42:18.445 - are effective about 50% of the time. Ketamine, for people who have treatment resistant depression, meaning 00:42:18.445 --> 00:42:27.548 - depression that SSRIs don't work for, so it's like the 50% of people that the SSRIs didn't work for, 00:42:27.548 --> 00:42:37.822 - ketamine is effective for that population for 50 to 80% of those people. So, as I said at the beginning, there is 00:42:37.922 --> 00:42:44.484 - no magic bullet, there is no simply take this and everything will be great. But we do see that ketamine 00:42:44.484 --> 00:42:50.857 - does have a significant sort of edge, shall we say, over traditional SSRIs in general, and certainly 00:42:50.857 --> 00:42:57.672 - for those people that traditional SSRIs are not doing anything for. Because there's also a middle category, 00:42:57.672 --> 00:43:00.638 - like SSRIs help, but they're still not enough. 00:43:00.834 --> 00:43:07.157 - And ketamine really helps that population as well. Now in terms of frequency, how long do you do this 00:43:07.157 --> 00:43:13.542 - and whatnot? I have clients, I do sort of plan for a six session series. It doesn't have to be smushed 00:43:13.542 --> 00:43:19.865 - all together, although if I have a client with treatment resistant depression, we'll probably try and 00:43:19.865 --> 00:43:26.127 - do them a little closer together than a client who's looking at other symptomology. But we generally 00:43:26.127 --> 00:43:30.590 - do a six session series. After that, I have some clients that are like, 00:43:30.722 --> 00:43:37.713 - that they're good to go and that they just kind of feel like that did the job. I'll have others that 00:43:37.713 --> 00:43:45.051 - we might do a booster session after a month and a half or a couple months or something along those lines. 00:43:45.051 --> 00:43:52.734 - I've had, I think, one client where we did a series. They were great for about a year and a half and something 00:43:52.866 --> 00:43:58.918 - really big and impactful in a negative way happen in their life, and I really threw them for a loop, 00:43:58.918 --> 00:44:05.209 - and so we did another one. Sometimes psychedelics can get this reputation of the fix and then everything 00:44:05.209 --> 00:44:11.260 - was great forever, and I really like to temper those expectations. It's not the fact that it's gonna 00:44:11.260 --> 00:44:15.934 - fix everything and everything will be great forever, because a lot of things. 00:44:16.034 --> 00:44:23.844 - because life, because our changing circumstances, because our changing bodies, because of adversity, 00:44:23.844 --> 00:44:31.808 - because of loss and grief, we may come to a place where we're feeling really depressed again. But what 00:44:31.808 --> 00:44:39.927 - we're seeing, and especially with ketamine-assisted psychotherapy, and this is an important distinction, 00:44:39.927 --> 00:44:45.726 - what the research is showing is that in the short term, in the short term, 00:44:46.018 --> 00:44:52.959 - there's very similar symptom reduction, whether you're using CAP, ketamine-assisted psychotherapy, or 00:44:52.959 --> 00:45:00.172 - just ketamine, where there's not a therapist involved. In the short term, symptom reduction, specifically 00:45:00.172 --> 00:45:07.181 - depression, suicidal ideation. In the long term, those gains are much more likely to stay with therapy 00:45:07.181 --> 00:45:14.462 - involved versus not. Yeah. Does it seem like it's easier to tear down the wall when you're doing it? Yeah. 00:45:23.362 --> 00:45:29.429 - That's a good question. Does it make it easier to establish that rapport between the therapist and the 00:45:29.429 --> 00:45:35.438 - client in the Ketamine state? What I would say is that the relationship between the therapist and the 00:45:35.438 --> 00:45:41.564 - client has to be trusting in order to move into the medicine work. I would not provide CAP for somebody 00:45:41.564 --> 00:45:47.573 - that did not feel safe with me because I don't think that that would be appropriate. What it does do, 00:45:47.573 --> 00:45:48.574 - though, is helps 00:45:48.770 --> 00:45:56.119 - protectors soften back. And when I talk about protectors, we're talking about defense mechanisms that 00:45:56.119 --> 00:46:03.685 - come up like, I don't want to talk about it. That's a protector right there. I don't want to think about 00:46:03.685 --> 00:46:11.251 - it. That's a protector right there. You know, avoidance is a huge part of any trauma disorder, including 00:46:11.251 --> 00:46:15.646 - substance use disorder. And it can really sort of reduce the 00:46:15.842 --> 00:46:23.959 - the defense mechanisms around protectiveness and closed off and avoiding and everything. So it can be 00:46:23.959 --> 00:46:32.235 - really useful for that. So again, with CAP, where the therapist is involved in the treatment, the gains 00:46:32.235 --> 00:46:34.622 - tend to last much longer with 00:46:34.754 --> 00:46:42.950 - you know, with ketamine infusions or ketamine therapy that does not include psychotherapy, the symptom 00:46:42.950 --> 00:46:51.067 - reduction is pretty immediate and pretty quick if it's gonna work. But in terms of lasting change, we 00:46:51.067 --> 00:46:53.534 - don't really see that so much. 00:47:07.682 --> 00:47:13.745 - So in the mental health field, ketamine is used for depression, it's used for severe anxiety, it's used 00:47:13.745 --> 00:47:20.042 - for trauma-related disorders, which are most disorders. And there are also people who engage in appropriate 00:47:20.042 --> 00:47:26.105 - use of ketamine for, like what I would refer to as psychospiritual growth. Now that's a very privileged 00:47:26.105 --> 00:47:32.284 - thing to be able to do, but I'm just gonna say that that is also something that happens. So in the mental 00:47:32.284 --> 00:47:37.648 - health field, like I'd say those probably, those would be the big E's, depression, anxiety, 00:47:37.648 --> 00:47:45.727 - trauma-related disorders, and also I would say in the mental health field, find me a disorder that's 00:47:45.727 --> 00:47:54.286 - not complicated by anxiety, depression, or trauma-related material. Yeah. No, ketamine was first developed 00:47:54.286 --> 00:47:57.726 - as an anesthetic, yeah, back in the 1960s. 00:48:11.362 --> 00:48:18.556 - That's a great question. For somebody who's still being triggered by their environment, would this be 00:48:18.556 --> 00:48:26.033 - effective? I would say that along with, again, the other modes of subcortical therapy, yes, it absolutely 00:48:26.033 --> 00:48:32.733 - can be effective. However, it's not going to fix the situation. So when I say that, it's like, 00:48:32.733 --> 00:48:36.542 - first of all, if the environment itself is unhealthy, 00:48:36.770 --> 00:48:42.575 - the person is going to feel anxiety and distress and disturbance about that, and they should, right? 00:48:42.575 --> 00:48:48.437 - Again, well, I shouldn't say again, because that was my morning topic, but it's important to remember 00:48:48.437 --> 00:48:54.241 - that our survival instinct and our emotions all are centered in the amygdala, the same place, right? 00:48:54.241 --> 00:49:00.103 - And so if survival is saying, you're not safe here, you're not going to feel safe, and anxiety is not 00:49:00.103 --> 00:49:01.310 - feeling safe, right? 00:49:01.826 --> 00:49:07.984 - What can happen, whether we're using ketamine-assisted psychotherapy, EMDR, somatic approaches, whatnot, 00:49:07.984 --> 00:49:14.142 - is that we can help this client, or we can provide the circumstances for the client to be able to access 00:49:14.142 --> 00:49:20.300 - their inner healing knowledge that can help them to recognize how can I get out of this situation. Yeah, 00:49:20.300 --> 00:49:26.282 - so it can absolutely be helpful, but it's not gonna be helpful in the sense of like, oh, you can stay 00:49:26.282 --> 00:49:28.862 - in that shitty situation and feel good now. 00:49:29.186 --> 00:49:35.442 - It's not going to be helpful like that. But it could be helpful like, I don't deserve this anymore. 00:49:35.442 --> 00:49:41.762 - I'm strong enough to do something about this. I can, yeah, so in that sense. Good question. Yeah. So 00:49:41.762 --> 00:49:48.143 - when we're talking about ketamine-assisted psychotherapy, as opposed to just ketamine therapy without 00:49:48.143 --> 00:49:54.400 - the psychotherapy involved, we are looking at a three-stage model. Those of you who were around for 00:49:54.400 --> 00:49:58.654 - me this morning know I love me my three-stage trauma therapy model. 00:49:58.850 --> 00:50:05.249 - There's preparation, there's the actual medicine experience, and then there's the integration. 00:50:05.249 --> 00:50:11.581 - And preparation and integration are key, right? Coming back to that question about bad trips, 00:50:11.581 --> 00:50:13.534 - bad experiences, preparation 00:50:13.698 --> 00:50:21.733 - is so key for that and to help support somebody in having the most helpful experience they can have. 00:50:21.733 --> 00:50:30.006 - And integration is also really important to support people in dealing with challenging experiences that 00:50:30.006 --> 00:50:37.086 - they have. So I keep referring to set and setting. So I think I'm going to take a moment 00:50:38.722 --> 00:50:45.283 - Oh, not yet. Okay. In a little bit, I'm going to take a moment to really delve into what set and setting 00:50:45.283 --> 00:50:51.843 - is. But when we talk about the importance of preparation, right? Preparation is about knowing, not going 00:50:51.843 --> 00:50:58.279 - into a situation not knowing what could happen, but it's also about going to a situation with openness 00:50:58.279 --> 00:51:01.278 - to allow whatever is going to happen to happen. 00:51:02.114 --> 00:51:08.214 - So preparation is really important. And preparation is directly related to the mindset as the client 00:51:08.214 --> 00:51:14.253 - is going in. So talking through all of those subjective experience possibilities so that the client 00:51:14.253 --> 00:51:20.533 - understands. Even when I still remember one of my training programs, they were like, make sure and tell 00:51:20.533 --> 00:51:26.693 - your clients it's gonna feel weird. And I'm like, well, duh, it's gonna feel weird. But they're like, 00:51:26.693 --> 00:51:31.102 - no, no, no, no. People can have experiences where they do not understand 00:51:31.554 --> 00:51:37.991 - that an altered state is gonna feel weird. And so if they don't know that, that could be really like, 00:51:37.991 --> 00:51:44.301 - oh shoot, is there something wrong? What's going on here? I don't like this, this isn't for me. And 00:51:44.301 --> 00:51:50.864 - kind of bring up a whole lot of distress that's not necessary. We just let them know this is gonna feel 00:51:50.864 --> 00:51:57.616 - weird, right? So making sure that they're aware of that. Making sure that they understand what the process 00:51:57.616 --> 00:51:58.878 - is gonna look like. 00:51:59.106 --> 00:52:06.329 - Talking them through what to expect and everything. But also, preparation also includes talking about 00:52:06.329 --> 00:52:13.481 - the mindset they're going into it with. I won't talk about ketamine as a cure. It's a catalyst. It's 00:52:13.481 --> 00:52:20.350 - something that's here to help you. But it's not just going to fix everything without other work. 00:52:20.450 --> 00:52:26.256 - And just being really open to what the experience has to show you, we can find lessons, we can find 00:52:26.256 --> 00:52:32.119 - relief, we can find challenging material, we can find opportunities to work through stuff that we're 00:52:32.119 --> 00:52:37.983 - kind of stuffing down. We can find a lot of opportunities there. And as the client, or I'm sorry, as 00:52:37.983 --> 00:52:43.904 - the clinician, I am here to help you navigate that in the way that's gonna be most supportive to you, 00:52:43.904 --> 00:52:47.678 - right? But to really make sure that they sort of understand what 00:52:48.418 --> 00:52:55.745 - what to expect without knowing what's going to happen. And again, it's very non-directive. The therapeutic 00:52:55.745 --> 00:53:02.866 - approach is very non-directive because again, the idea is all of our clients have within them what they 00:53:02.866 --> 00:53:09.714 - need to access in order to heal, right? And the ketamine or the psychedelic space can allow them to 00:53:09.714 --> 00:53:13.822 - sort of soften enough to be able to get in touch with that. 00:53:15.682 --> 00:53:20.745 - Um, again, CAP is different than anti-depression protocols. Um, and super important. This is kind of 00:53:20.745 --> 00:53:25.959 - like, I feel like a death statement, but we're not going to treat conditions with CAP that you wouldn't 00:53:25.959 --> 00:53:31.022 - treat without the medicine. So I would say this with any kind of form of therapy that I train people 00:53:31.022 --> 00:53:36.085 - in, like if you weren't already, if you didn't already have experience with dissociation, you're not 00:53:36.085 --> 00:53:40.446 - going to like now go do EMDR with dissociation. If you didn't already have experience, 00:53:40.546 --> 00:53:47.938 - working with children, you're not gonna go do IFS with kids because you learned how to do IFS. You need 00:53:47.938 --> 00:53:55.116 - to have experience with the populations that you're treating. And of course, you need to have really 00:53:55.116 --> 00:54:02.224 - good, thorough training and experience with the medicine yourself. All right, so again, what are we 00:54:02.224 --> 00:54:08.478 - talking about for preparation? We talk about ketamine's effects, right? We talk through 00:54:08.578 --> 00:54:15.122 - what the client might expect in terms of what that experience will be like. We talk about the goals 00:54:15.122 --> 00:54:21.273 - for therapy. What do you want to be different? What do you want to see that's different after 00:54:21.273 --> 00:54:28.078 - this experience? What are we looking for? We talk about consent for touch or distance. And when we talk 00:54:28.078 --> 00:54:33.182 - about consent for touch, we'll talk about that a little bit more in a moment. 00:54:33.826 --> 00:54:40.101 - But there are some forms of touch that we would use just for grounding and to help the client have an 00:54:40.101 --> 00:54:46.500 - increased sense of safety. And there's also touch for safety itself. We'll talk in a moment. We'll talk 00:54:46.500 --> 00:54:52.775 - about music, what forms of music. Music is frequently used with psychedelic assisted psychotherapy as 00:54:52.775 --> 00:54:59.358 - sort of a container to sort of hold the space. And sometimes the music ends up playing a very active role. 00:54:59.874 --> 00:55:05.017 - And really basics like you can't drive afterwards and other restrictions. My paperwork says you're not 00:55:05.017 --> 00:55:10.159 - going to drive for the rest of the day. We're going to have a safe person to drive you home. We're not 00:55:10.159 --> 00:55:15.202 - going to do Uber or the bus or anything like that. Your safe person is going to be there to take you 00:55:15.202 --> 00:55:20.195 - home. You're not going to be solely responsible for the care of small children. You're not going to 00:55:20.195 --> 00:55:22.142 - get into a hot tub or a swimming pool. 00:55:22.562 --> 00:55:31.640 - All of these things that the client really understands about the safety. Then also, what are the things 00:55:31.640 --> 00:55:40.631 - they can do to support themselves after this experience? We're going to talk about that as well. Those 00:55:40.631 --> 00:55:49.534 - are the basic components of our preparation. Now we're going to get more deeply into set and setting. 00:55:49.730 --> 00:55:56.136 - is the mindset of the client going into the ketamine session, right? The mindset of the client. So this 00:55:56.136 --> 00:56:02.357 - is where it's really important that we talk about what, you know, what are you wanting to get out of 00:56:02.357 --> 00:56:08.824 - this? And sometimes there's managing expectations around that, like what do you want to get out of this? 00:56:08.824 --> 00:56:14.860 - You know, what would you like to see different? What would you like to be different, right? Also, 00:56:14.860 --> 00:56:18.494 - you know, part of mindset is like, is there fear involved? 00:56:18.594 --> 00:56:25.823 - Is the client anxious about it? And how do we work with that? Another aspect of mindset is control, 00:56:25.823 --> 00:56:33.052 - about control and our relationship with control. I had one client who came in and he said, well, in 00:56:33.052 --> 00:56:40.353 - the first session, I want to deal with this thing that happened to me when I was five. In the second 00:56:40.353 --> 00:56:47.582 - session, I want to heal the relationship with my mother. In the third session, I'm just like, whoa. 00:56:48.546 --> 00:56:55.896 - Sounds great. No, we do not have that kind of control. And so really just relaxing and being open to 00:56:55.896 --> 00:57:03.392 - the experience. I will encourage the client to have trust, trust in the medicine, trust in their inner 00:57:03.392 --> 00:57:10.961 - healing wisdom, trust that their body and their mind will bring up what needs to be healed. And if that 00:57:10.961 --> 00:57:18.238 - feels like too big of an ask for the client, then I'll just say, what about openness and curiosity? 00:57:18.850 --> 00:57:30.964 - It's just openness and curiosity. And we, anything that comes up for you in this space, we can, through 00:57:30.964 --> 00:57:42.612 - psychotherapy, work through that material in a way that is gonna benefit you, right? Yeah. Oh yeah. 00:57:42.612 --> 00:57:47.038 - There's always respect for the, yeah. 00:57:47.394 --> 00:57:56.158 - Great question. Yeah, so how does window of tolerance fit into all this? In general, window of tolerance 00:57:56.158 --> 00:58:04.756 - in ketamine is expanded. Yeah. In general, again, there's like a sense of, I've had clients say things 00:58:04.756 --> 00:58:13.854 - like I was able to be with my pain without being engulfed by my pain, right? I was able to be with the grief 00:58:14.050 --> 00:58:21.942 - instead of drowning in the grief. So ketamine really actually can assist with window of tolerance issues 00:58:21.942 --> 00:58:29.534 - in a really positive way. And if somebody does become overwhelmed in the medicine experience, that's 00:58:29.534 --> 00:58:37.051 - where it's the clinician's job to help them manage that window of tolerance, yeah. So it's always a 00:58:37.051 --> 00:58:40.734 - consideration, yeah, where it's never just like, 00:58:40.962 --> 00:58:48.775 - Let's get you high and see what happens. Yeah, but it's a great question because yes, all of the things 00:58:48.775 --> 00:58:56.363 - that apply and all of the other forms of therapy apply with CAP as well. What else about mindset? So 00:58:56.363 --> 00:59:04.101 - intention setting. Setting an intention for the session. I really encourage intentions like just being 00:59:04.101 --> 00:59:08.158 - open and curious to what the medicine has to show me. 00:59:08.258 --> 00:59:14.342 - sometimes clients will have something really specific like I want to open my heart to healing or I want 00:59:14.342 --> 00:59:20.191 - to open my heart to love or I want to increase compassion for the child parts of me or you know but 00:59:20.191 --> 00:59:26.216 - having some kind of intention and then super important holding that intention loosely because medicine 00:59:26.216 --> 00:59:32.358 - is going to do as medicine is going to do right and for me that's part of the trusting the process right 00:59:32.358 --> 00:59:35.166 - trusting the process that your inner healing is 00:59:35.266 --> 00:59:44.146 - Wisdom knows what needs to be healed. The medicine helps to create the conditions and the space for 00:59:44.146 --> 00:59:53.026 - it. And we just, you know, we sort of just follow that process along. I think that's, any questions 00:59:53.026 --> 01:00:01.996 - about set, about mindset, the client's mindset going into it? All right, then we're gonna talk about 01:00:01.996 --> 01:00:04.926 - setting. So setting is the space 01:00:05.378 --> 01:00:11.831 - where the ketamine will be administered. And I include in setting any person that they are going to 01:00:11.831 --> 01:00:18.413 - encounter in that space. So if you work in a practice that has a receptionist, a front desk person or 01:00:18.413 --> 01:00:24.994 - whatnot, that person is part of the setting. If you work in an infusion clinic, the person that comes 01:00:24.994 --> 01:00:31.512 - in to put your IV in, that person is part of the setting. So anything that you're gonna encounter in 01:00:31.512 --> 01:00:32.286 - this space. 01:00:32.514 --> 01:00:39.977 - where the ketamine's gonna be administered. Again, music is very common, music or background noises 01:00:39.977 --> 01:00:47.439 - of some sort. I don't use white noise, I just use music. I use music in a container holding kind of 01:00:47.439 --> 01:00:55.051 - way, but sometimes if a client is wanting to explore a certain style of music or type of music, we'll 01:00:55.051 --> 01:00:59.006 - create a playlist that's a little bit more evocative 01:00:59.202 --> 01:01:05.031 - for them or sometimes I'll just kind of follow my intuition of like sort of what emotionally is happening 01:01:05.031 --> 01:01:10.641 - in the room and sort of what the felt sense is and I might kind of mix up the music a little bit. But 01:01:10.641 --> 01:01:16.470 - it is important to understand that music does have a really deep role and can be supportive and container 01:01:16.470 --> 01:01:22.300 - holding but it can also be evocative and so I never use music with English words like words that a person 01:01:22.300 --> 01:01:27.854 - can understand because that to me feels directive really. It's kind of like I'm wanting them to feel 01:01:27.854 --> 01:01:28.734 - a certain thing 01:01:28.994 --> 01:01:36.088 - So, music is really important. Even just the comfort of the space, making sure, you know, I have like 01:01:36.088 --> 01:01:43.252 - a big, fairly wide couch that the clients can recline on. A lot of people who do a lot of catwalk have 01:01:43.252 --> 01:01:50.555 - like an actual recliner in their office. My office is not big enough for both, so, but I have the couch. 01:01:50.555 --> 01:01:56.606 - Making sure that it feels warm, feels inviting, feels safe, it's all really important. 01:01:57.282 --> 01:02:03.263 - if clients want to have a person, like I will sometimes have a client ask if their loved one can come 01:02:03.263 --> 01:02:09.419 - into the session, like halfway through, their person's waiting out in the waiting area and they're like, 01:02:09.419 --> 01:02:15.283 - can so-and-so come in? Yeah, absolutely. As long as we've kind of talked about it ahead of time and 01:02:15.283 --> 01:02:21.263 - that all feels safer for everyone, that the person is welcome to, or feels comfortable to come in. So 01:02:21.263 --> 01:02:23.550 - that's super important as well, right? 01:02:38.626 --> 01:02:46.107 - For me, it's part of holding the intention loosely. So the question is, if somebody comes in with an 01:02:46.107 --> 01:02:54.033 - intention, why wouldn't we not use music to boost that intention? Yeah, for me, that becomes about holding 01:02:54.033 --> 01:03:01.440 - the intention loosely. And for me, having trust in how the medicine is going to sort of deliver the 01:03:01.440 --> 01:03:07.070 - intention. So what I will do sometimes is send people home with some music. 01:03:07.234 --> 01:03:15.849 - I'll send a Spotify link to them or something with music that has lyrics that spoke to what they were 01:03:15.849 --> 01:03:24.296 - telling me during the session. But during the session, I want it to be coming out of them. And then 01:03:24.296 --> 01:03:28.350 - what they tell me might inspire me to send them 01:03:28.482 --> 01:03:34.929 - a link to a song that has some of those, yeah. So it's not that we can't use music in that way, but 01:03:34.929 --> 01:03:41.441 - during the session, I really want to not use music with words that might plant, like we had a agenda 01:03:41.441 --> 01:03:45.374 - here. That's what we want to avoid, we want to avoid agenda. 01:04:13.314 --> 01:04:19.990 - That's a good question. I don't ask for the client to tell me what music they want. I tell them that 01:04:19.990 --> 01:04:26.601 - if there's something they don't like about the music, to let me know. But I am selecting the music, 01:04:26.601 --> 01:04:33.476 - what's playing. And then if they don't like it, I will switch to something else. Very, very rarely have 01:04:33.476 --> 01:04:40.218 - I had that happen. But in general, I don't have the client tell me what music they want to listen to. 01:04:40.218 --> 01:04:41.342 - Yeah, over here. 01:04:56.386 --> 01:05:05.957 - So mind bloom, right? Yeah, that's a thing. And I'm not saying that it can't be useful. For me, it would 01:05:05.957 --> 01:05:15.163 - really depend so much on the client presentations. The question is about home use with a sitter that 01:05:15.163 --> 01:05:24.734 - will kind of keep you safe, but they're not a trained professional that would be doing therapy with you. 01:05:25.602 --> 01:05:32.430 - To me, that's not really too much different than going to a ketamine clinic where they're keeping you 01:05:32.430 --> 01:05:39.258 - safe, but they're not providing you therapy or whatnot. Almost always for the general public, I would 01:05:39.258 --> 01:05:46.019 - not recommend that. For the general public, and the reason I say for the general public is I've done 01:05:46.019 --> 01:05:48.830 - self-guided medicine sessions for myself. 01:05:49.186 --> 01:05:56.845 - after getting trained in CAP. And I have a therapist that I can do integration with after that. But 01:05:56.845 --> 01:06:05.117 - in terms of the lay person, I probably wouldn't recommend it without a lot of conversation with a therapist 01:06:05.117 --> 01:06:11.934 - about what could be the benefits of it. All right. Other questions about set or setting? 01:06:32.354 --> 01:07:00.894 - That leads to your earlier question about people who have bad trips. Almost all of the time, 01:07:01.378 --> 01:07:08.405 - people who have what we call a bad trip, set and setting was not established in a healthy way. Now that 01:07:08.405 --> 01:07:15.566 - doesn't mean that you're never gonna have dysphoric state sessions, meaning a session where uncomfortable 01:07:15.566 --> 01:07:22.458 - feelings like anger, like sadness, like grief, like shame, like embarrassment, like humiliation, like 01:07:22.458 --> 01:07:29.281 - any of those terror, panic. It's not to say that you're not ever gonna encounter any of that in your 01:07:29.281 --> 01:07:31.038 - medicine experiences, but 01:07:31.234 --> 01:07:36.867 - When you have good set and setting and safety with the clinician, there's a navigating through that 01:07:36.867 --> 01:07:42.501 - that is actually part of the healing process. So when challenging material comes up, and I say this 01:07:42.501 --> 01:07:48.303 - to some of my consultees who are just getting into CAP, when challenging material comes up and there's 01:07:48.303 --> 01:07:54.050 - like this really intense negative emotion or uncomfortable emotion happening, that's not a bad thing. 01:07:54.050 --> 01:08:00.190 - It's not like, oh, it didn't work. It's like, okay, now we're present with this and how can we work with it? 01:08:01.154 --> 01:08:09.624 - So set and setting isn't about never having dysphoric or uncomfortable feelings or distressing feelings 01:08:09.624 --> 01:08:18.013 - in the space. It's being able to work through them for healing. Yeah. Yes. And that would be like that 01:08:18.013 --> 01:08:26.238 - would definitely be for the prescriber to address. But in terms of like when you say it has a fairly 01:08:26.238 --> 01:08:28.926 - high safety profile there aren't 01:08:29.026 --> 01:08:35.876 - that many but and so you know a number a lot of the contraindications are really more like it's just 01:08:35.876 --> 01:08:42.659 - not going to work as well but it is a sedative so if somebody was on opioids if somebody was on had 01:08:42.659 --> 01:08:49.713 - alcohol in their system like anything that's a depressant is going to interact negatively and so that's 01:08:49.713 --> 01:08:56.495 - you know that would you know certainly be like if somebody showed up to my office and they you know 01:08:56.495 --> 01:08:58.462 - clearly were already on some 01:08:58.562 --> 01:09:03.764 - type of central nervous system depressant. Well, we're not gonna do medicine work, but we're also actually 01:09:03.764 --> 01:09:08.286 - not gonna do anything besides manage this situation that's right there in front of me, yeah. 01:09:26.114 --> 01:09:34.421 - Yeah, so yeah, definitely abstinence-based. All of my paperwork says, while we're doing this, I'm not 01:09:34.421 --> 01:09:43.135 - gonna be doing these other substances and whatnot. And depending on where the person is in their recovery, 01:09:43.135 --> 01:09:51.524 - I've had people say, I have treatment-resistant depression, I've been sober for 19 years, do you think 01:09:51.524 --> 01:09:52.990 - it would be okay? 01:09:53.282 --> 01:10:00.054 - And I'm like, yeah, I think it would be okay. If somebody is, and when I say that, I don't mean to make 01:10:00.054 --> 01:10:06.565 - light of it, but this is a person who's very well established in their sobriety. They have a really 01:10:06.565 --> 01:10:13.272 - good support system. They've learned other coping skills and resourcing and things like that. And have 01:10:13.272 --> 01:10:20.239 - a respect for how we're, that's the biggest thing. Have a respect for how we're going to use the medicine. 01:10:20.239 --> 01:10:22.974 - If there is a respect for this substance, 01:10:23.074 --> 01:10:29.050 - and the therapeutic and the healing benefits and qualities of it. And they understand that this is just 01:10:29.050 --> 01:10:34.910 - not just about feeling good. It's not just about getting a feeling of euphoria and whatnot. I'm going 01:10:34.910 --> 01:10:40.943 - to feel a lot more comfortable moving forward with medical clearance, of course, you know, than somebody 01:10:40.943 --> 01:10:46.746 - who's like, oh, yeah, I can't wait to feel euphoria or whatever. It's like, you know, so really like 01:10:46.746 --> 01:10:50.366 - looking at, like, what is that relationship with the medicine? 01:11:04.194 --> 01:11:11.050 - That's a good question. So if somebody were concerned about like, I'm concerned that even the euphoria 01:11:11.050 --> 01:11:18.105 - of it could trigger me, I'd say well then we'll do psycholytic dosing. We're not gonna do a dosage that's 01:11:18.105 --> 01:11:24.894 - gonna let you feel euphoric. Yeah, yeah, that would be my, and again, anything that I talk about that 01:11:24.894 --> 01:11:31.550 - has to do with adjusting dosage and everything is always my prescriber's call, right? I also don't. 01:11:32.034 --> 01:11:37.781 - I've never had him say like, you should do more. Why are you doing such low doses? I've never had him 01:11:37.781 --> 01:11:43.698 - say that. But whenever I talk about adjusting dosage, that's always me communicating with the prescriber 01:11:43.698 --> 01:11:49.332 - and him saying this, right? But yeah, if there's a concern that a feeling of euphoria could trigger 01:11:49.332 --> 01:11:54.967 - relapse or trigger behaviors moving towards relapse, we just won't let you feel the euphoria. We'll 01:11:54.967 --> 01:11:58.686 - do like a low dose that's like that cyclical range that still has 01:11:58.978 --> 01:12:05.961 - according to the research, those antidepressant qualities, but not the feeling of euphoria or the altered 01:12:05.961 --> 01:12:12.680 - state. Yeah. I don't know. I guess we probably wouldn't want to do it. But if somebody did have a bad 01:12:12.680 --> 01:12:19.530 - trip or whatever, and they're scared of that situation, do you think this would be something that could 01:12:19.530 --> 01:12:26.184 - help them do that? So if somebody actually had incurred a trauma through a bad trip, could this help 01:12:26.184 --> 01:12:26.974 - them? Yeah. 01:12:45.794 --> 01:12:53.945 - So yeah, what I will say is if somebody has an experience with a drug that is traumatizing to them, 01:12:53.945 --> 01:13:02.096 - which a bad trip can be traumatizing, could this help heal from that experience? My short answer is 01:13:02.096 --> 01:13:10.248 - yes. My longer answer is that would entail a lot of preparation work, of really good rapport with a 01:13:10.248 --> 01:13:13.182 - really experienced provider of CAP. 01:13:13.282 --> 01:13:25.518 - So really that comes down to like the case by case basis of how we would handle that. Yeah. Yeah, 01:13:25.518 --> 01:13:38.003 - for sure. Yeah, when somebody has a traumatic experience, regardless of the nature of the traumatic 01:13:38.003 --> 01:13:41.374 - experience, it's a lasting 01:13:41.954 --> 01:13:49.293 - you know, suffering that can come from that. And yes, this would be something to consider. And also, 01:13:49.293 --> 01:13:56.778 - like I said, it would be a very, very careful approach. Yeah. All right. The last thing here. And when 01:13:56.778 --> 01:14:04.044 - I talk about holding the intention loosely, holding the intention that the healing is inside us and 01:14:04.044 --> 01:14:10.366 - the medicine allows it. So whatever I decide my intention is going to be, knowing that 01:14:10.722 --> 01:14:18.225 - The healing is inside. Again, I use the term inner healing wisdom, right? The medicine is what allows 01:14:18.225 --> 01:14:25.727 - it. Sometimes we talk about like the triad of the client, the clinician, and the medicine as creating 01:14:25.727 --> 01:14:33.303 - this space to be able to access that inner healing wisdom. All right. So let's talk about what therapy 01:14:33.303 --> 01:14:37.790 - looks like when we're doing ketamine-assisted psychotherapy. 01:14:38.306 --> 01:14:45.044 - I'm sorry, remind me, 10 minutes. Thank you, ladies. All right. So during medicine session, it's very 01:14:45.044 --> 01:14:51.716 - non-directive. Mirroring, tracking prompts if needed, parts work. Sometimes parts will spontaneously 01:14:51.716 --> 01:14:58.785 - emerge. So those of you that are familiar with internal family system or other ego state forms of therapy, 01:14:58.785 --> 01:15:05.787 - parts work, navigating choice points. Curious inquiry only if needed. What that means is that in general, 01:15:05.787 --> 01:15:06.910 - I'm just sort of 01:15:07.746 --> 01:15:15.183 - responding in a very non-directive way to things that my client says. I only am going to ask questions 01:15:15.183 --> 01:15:22.404 - if it feels like the client might be a little lost or stuck, right? And that's curious inquiry. And 01:15:22.404 --> 01:15:29.913 - possible touch and or somatic practices of consent is given if needed. We talked about discussing touch 01:15:29.913 --> 01:15:34.462 - and how touch can be used frequently. Touch isn't used at all. 01:15:34.754 --> 01:15:41.468 - So it's not like, oh, if you're going to have ketamine-assisted psychotherapy, your therapist is going 01:15:41.468 --> 01:15:48.117 - to touch you. But there are things that we discuss ahead of time. So for instance, if you are feeling 01:15:48.117 --> 01:15:54.635 - really overwhelmed, sometimes having a caring hand on your arm or your shoulder or somebody to hold 01:15:54.635 --> 01:16:01.414 - your hand during a really intense grief experience can be very, very therapeutic. So we talk about that 01:16:01.414 --> 01:16:02.718 - during preparation. 01:16:03.938 --> 01:16:11.418 - We talk really, really in depth about what would feel supportive, what would not, always during preparation. 01:16:11.418 --> 01:16:18.350 - Now, when I am in the middle of a CAP session with a client, when I'm in the middle of a CAP session 01:16:18.350 --> 01:16:25.281 - with a client, and they're seeming to be maybe, again, engulfed in grief or something like that, and 01:16:25.281 --> 01:16:32.350 - I might kind of wonder if they want me to put my hand on their arm or to hold their hand or something. 01:16:32.514 --> 01:16:39.034 - I will always ask first. Just because they gave me consent last week in a preparation session doesn't 01:16:39.034 --> 01:16:45.618 - mean that I'm not gonna ask before I touch them. But if I don't have, here's what I'll say, if I don't 01:16:45.618 --> 01:16:52.330 - have sober consent, I don't have consent. Just like in any other area of our lives, if there's not sober 01:16:52.330 --> 01:16:59.106 - consent, there's no consent. So if they have agreed to a hand on the arm, a hand on the shoulder, holding 01:16:59.106 --> 01:17:02.174 - hands in a sober state, and then I'm wondering, 01:17:03.138 --> 01:17:09.220 - Might this be helpful for them? I will still offer. I will ask. I'll say, would you like me to hold 01:17:09.220 --> 01:17:15.363 - your hand? Would you like me to put my hand on your arm? And if they don't want me to, obviously I'm 01:17:15.363 --> 01:17:21.566 - not going to. But if they told me in a sober state that, I don't really think I want you to touch me, 01:17:21.566 --> 01:17:27.709 - and then in the medicine session they're asking me to, I am not going to, right? Because if I didn't 01:17:27.709 --> 01:17:31.358 - get consent sober, I didn't get consent. But what I can do, 01:17:31.714 --> 01:17:37.762 - is maybe take a pillow and sort of push it against their arm. So they're feeling a little bit of pressure 01:17:37.762 --> 01:17:43.525 - from that, but it's not me touching them. There are other somatic practices that can be part of CAP, 01:17:43.525 --> 01:17:49.574 - but only for clinicians who are trained in the use of touch and somatic practice. So that's not something 01:17:49.574 --> 01:17:55.394 - that you're just going to be like, oh, I'm an academy provider now. You want me to push on your feet? 01:17:55.394 --> 01:18:01.214 - There needs to be appropriate training for this and discussion so that the client is prepared for it. 01:18:02.818 --> 01:18:10.264 - That's probably all I've got to say about touch. So again, during medicine session, very non-directive, 01:18:10.264 --> 01:18:18.140 - very minimal. After the medicine session, this is where we call integration. I always schedule an integration 01:18:18.140 --> 01:18:23.582 - session 24 to 48 hours after the medicine session to make good use of that. 01:18:23.714 --> 01:18:30.547 - 48-hour window of increased neuroplasticity. It's what the research Galdolin out of Israel is showing 01:18:30.547 --> 01:18:37.380 - the research that that there's about a 48-hour window of increased neuroplasticity. So we're going to 01:18:37.380 --> 01:18:42.270 - do an integration session and we're going to capitalize on that openness 01:18:42.786 --> 01:18:48.679 - that increased neuroplasticity. We're gonna bring medicine session themes into the therapeutic session. 01:18:48.679 --> 01:18:54.345 - Maybe there was a theme of surrender. Maybe there was a theme of letting go of control. Maybe there 01:18:54.345 --> 01:19:00.181 - was a theme of self-acceptance. Maybe there was a theme of self-love or compassion, right? So bringing 01:19:00.181 --> 01:19:05.054 - the theme from the medicine session in. And how is it relating to the client's goals? 01:19:05.282 --> 01:19:12.519 - Right, we can use embodiment, like some somatic interventions to anchor in some of these feelings. Discussion 01:19:12.519 --> 01:19:19.164 - of how to carry forward the effects and themes. Sometimes during integration, I'm using EMDR or IFS, 01:19:19.164 --> 01:19:25.940 - again, to capitalize on that increased neuroplasticity. But the integration session after the medicine 01:19:25.940 --> 01:19:31.006 - session is gonna feel a lot more like a normal therapy session, if you will. 01:19:31.170 --> 01:19:38.907 - Whereas during the medicine session, it looks very different. All right, so what are the psychological 01:19:38.907 --> 01:19:46.645 - mechanisms here? Altered state, feeling something that's different than usual. So if you have somebody 01:19:46.645 --> 01:19:54.232 - who's always armored up, always braced, always waiting for the bad thing to happen, notice that your 01:19:54.232 --> 01:20:00.542 - body knows how to feel safe when you are safe. That actually can be really, really, 01:20:00.674 --> 01:20:07.138 - significant and profound for people. It can be pleasurable. Softening aspects of control, letting go, 01:20:07.138 --> 01:20:13.538 - don't need to worry about that. Providing some psychological distance. This is where we, again, talk 01:20:13.538 --> 01:20:19.874 - about that observer mind. Being able to see yourself thinking what you're thinking without being so 01:20:19.874 --> 01:20:26.465 - invested and meshed and grossed in it that there's no possibility for anything else to be true. Ability 01:20:26.465 --> 01:20:29.950 - to face challenging thoughts or memories in a new way. 01:20:30.914 --> 01:20:37.391 - Again, it turns down the volume on emotional and physical pain. And again, that increased neuroplasticity. 01:20:37.391 --> 01:20:43.504 - So these are all of the psychological mechanisms at play here. Integration, I talked about after the 01:20:43.504 --> 01:20:49.859 - medicine, ideally within 48 hours. What did the medicine teach you or show you? What did that experience 01:20:49.859 --> 01:20:55.912 - teach you or show you? How can we anchor that in? How do you want to carry that forward? Is there a 01:20:55.912 --> 01:20:58.878 - practice? Is there a ritual? Is there, you know, 01:21:01.570 --> 01:21:06.970 - going to go buy myself a bracelet. And when I look at the bracelet, I'm going to remember, hey, retail 01:21:06.970 --> 01:21:12.266 - therapy. Great. But if that's a visual reminder of something from your medicine session, then that's 01:21:12.266 --> 01:21:17.561 - going to help you to have sort of a more adaptive approach. Yes, Ashley? Five minutes. Five minutes. 01:21:17.561 --> 01:21:23.119 - Oh, OK. I thought you were waving at me. Like, yeah. All right. And so again, preparation and integration 01:21:23.119 --> 01:21:28.729 - are essential, are absolutely essential. People always think what's happening while you're in the medicine 01:21:28.729 --> 01:21:30.302 - is the most interesting part. 01:21:31.202 --> 01:21:37.829 - Maybe it is, but if you don't have good preparation and good integration, it's not going to have the 01:21:37.829 --> 01:21:44.390 - effects that we want longer term. All right. There's lots of research out there on ketamine. Not as 01:21:44.390 --> 01:21:46.686 - much on cap, but it is increasing. 01:21:46.818 --> 01:21:53.441 - Randomized control trial, first one on depression was in 2000. In 2017, JAMA, the Journal of American 01:21:53.441 --> 01:21:59.934 - Medicine Medical Association, published a consensus statement that six treatments over two to three 01:21:59.934 --> 01:22:06.557 - weeks is optimal for treatment-resistant depression. Yeah, okay, that's about all I have on research. 01:22:06.557 --> 01:22:13.310 - There's actually been a lot of research, especially in 2025, looking more at the difference between CAP 01:22:13.698 --> 01:22:19.474 - and ketamine therapy alone, and that's where I was drawing from when I was talking about how ketamine 01:22:19.474 --> 01:22:25.194 - therapy alone has similar effects in the short term as CAP, but it's not as long lasting. All right, 01:22:25.194 --> 01:22:30.971 - what questions do you have? Oh, take a picture of this if you think you might wanna get in touch with 01:22:30.971 --> 01:22:36.747 - me. I'm gonna leave it up there for five seconds, and then I'm gonna switch to the QR code that y'all 01:22:36.747 --> 01:22:42.014 - gotta scan to get your CEs. So if you want a picture of that, take it now. Four, three, two, 01:22:43.682 --> 01:22:55.260 - All right, so there's your QR code. Any other questions in the last four minutes that we have? Yes. 01:22:55.260 --> 01:23:06.722 - Oh, good question. I am never in possession of their academy and I don't ever touch it. There's a, 01:23:06.722 --> 01:23:08.574 - you know, most, 01:23:08.738 --> 01:23:14.024 - Providers use like a mail order pharmacy. You can get it compounded here in town. I've had people pick 01:23:14.024 --> 01:23:19.515 - it up at Williams Brothers. But most of them go through mail order compounding pharmacy. It comes straight 01:23:19.515 --> 01:23:25.160 - to them. They are in possession of it. I know how much they have. They know how much they have. My prescriber 01:23:25.160 --> 01:23:30.549 - knows how much they have. And we all keep track of it together. And if anything goes missing, then we're 01:23:30.549 --> 01:23:35.937 - kind of done with CAP. Yeah, good question. But yes, as the therapist, I am never in possession of their 01:23:35.937 --> 01:23:37.374 - medicine. I don't touch it. 01:23:39.746 --> 01:23:54.443 - Correct. Other questions? Yes. Great question. So MDMA is used for trauma. It's been extensively studied. 01:23:54.443 --> 01:24:09.694 - It went up for some FDA trials. Unfortunately, it was not approved last year, but it's only a matter of time. 01:24:10.402 --> 01:24:19.007 - Yes, they resubmitted. It's going to happen. But they're very different. I guess in a nutshell, I'll 01:24:19.007 --> 01:24:26.334 - say they're very different. MDMA is a stimulant medication. Ketamine is a depressant. 01:24:26.466 --> 01:24:34.321 - The felt experience, felt-sense experience is very different. The arc of the journey is very different. 01:24:34.321 --> 01:24:42.402 - Ketamine is short-lasting. MDMA, the way the MAPS trials set it up for the FDA trials is about a five-hour 01:24:42.402 --> 01:24:50.634 - arc with a booster about an hour to an hour and a half in, somewhere around there. So they're very different 01:24:50.634 --> 01:24:55.166 - substances. Ketamine has a higher safety profile than MDMA. 01:24:56.386 --> 01:25:02.662 - Ketamine is not serotonergic, meaning that you don't have to worry about your SSRIs. MDMA is serotonergic, 01:25:02.662 --> 01:25:08.527 - so lots of differences, yep. All right, I think that's our time. Thank you all, this has been super 01:25:08.527 --> 01:25:12.926 - fun, and don't hesitate to reach out if you have any additional questions.