Okay. All right. Welcome, everyone. Thank you so much for joining us after lunch. My name is Melanie.
If we haven't met before, I'm with the Youth Services Bureau, but also in this hat, I'm part of the
SUDAC Recovery Summit Planning Team. And I am super excited to have Kara Baerch over here as our presenter
for her second session, an introduction
introduction to ketamine-assisted psychotherapy. So just a quick housekeeping thing. You've heard it
already before, probably. If you are here to receive continuing education credits, do make sure that
you sign in on any of the sheets that are in on your table. Make sure that you sign out. And at the
very end of the session, there's going to be a QR code at the screen. Make sure that you scan that QR
code. Write down the six-digit ID. It is specific to the session. And then if you have any challenges
with the C,
the QR code, come find me, I can scan it for you or something or send you a link. Okay, with that, out
of the way, Kara, take it away. All right, hi everyone, can you all hear me okay? Great, on my clicker,
great. So welcome and thanks for joining us after lunch. I'll try to keep you awake, but if you need
to get up, move your body around, please feel free to do that. Make yourself comfortable in whatever
way. It won't distract me at all.
So if you want to stand, stretch, do yoga in the back of the room, whatever. Because I know that after
lunch can be a little bit of a difficult haul. So welcome. So today we're going to talk about
ketamine-assisted psychotherapy, or you'll hear it referred to as CAP. And I'll tell you just a little
bit about my journey, what led me to decide that CAP was something that I wanted to get into professionally.
So I have always been a fan of what
I call the subcortical therapies. And so these are the therapies that are looking at more than the thinking
part of the brain, more than that prefrontal cortex, really looking at the nervous system, looking at
somatic presentations, what's happening in the body that is sort of fueling whatever disturbance or
distress that the person is experiencing, because I really feel like what is happening on a deep level
needs to be addressed on a deep level.
There's immense value and healing value in being able to sit and tell your story. That is absolutely
true. And I will never deny it. And also when we're talking about things that are going on in your nervous
system, in the wiring of your brain, your polyvagal tone, all of those things that are not being addressed
in therapy, I kind of feel like there's something
missing there. So I started my foray into subcortical psychotherapies with EMDR, moved into looking
at other somatic approaches, HACOMI, somatic experiencing, internal family systems, which I view as
a subcortical therapy when done in that way. And heard about, started hearing about ketamine assisted
psychotherapy, you know, probably maybe during COVID is when I started sort of
You know, I was bored, so I was reading stuff. And I always had this kind of like, oh, that's interesting
kind of approach. And then in 2023, I got an opportunity to do an introductory training retreat with
a program out of Asheville, North Carolina, the Asheville area. And really, it was a huge game changer
for me, both personally and professionally. And so just
kind of continued down that path. And so that's what brings me here to stand in front of you today.
Like I said, I started that training in 2023, completed certification at the Living Medicine Institute
in 2024, certification with Skylight Psychedelics in 2024 too, I think, and most recently, Integrative
Psychiatry Institute. So I'm very, very much dedicated to increasing my
my knowledge, my skills, my experience, my understanding with psychedelic assisted psychotherapies,
because as Talcott mentioned this morning, it is the future, shall we say, or the next cutting edge
of mental health treatment. That having been said, before I even move into the slides, I am going to
say, and I say this to my clients all the time, ketamine is a catalyst, not a cure. So anything that's
new, anything that's, you know,
cutting edge, anything that feels kind of sexy or out there or edgy, people get really excited about
and then they decide it's the silver bullet and they decide that this is the thing that's going to change
everything and this is the thing and there's no thing. And I just say that to sort of temper our expectations
and understand that ketamine and psychedelics in general are an amazing, amazing
It's a tool or set of tools and provide opportunities for healing that many people maybe would not experience
without them. And also, I just want you to take those words with you, the catalyst, not the cure. And
that is why I'm actually here talking about ketamine-assisted psychotherapy. So what are we gonna do
today? We're gonna talk about how ketamine is used in various settings and understand
different routes of administration, like how the medicine gets on board. We're gonna talk about the
difference between different doses of ketamine administration that produce different experiences in
different types of states, psychedelic, psychedelic. We'll talk about common subjective experiences
of ketamine and how set and setting factors affect these experiences for better or for worse. We'll
talk about the difference between
psychedelic or ketamine-assisted psychotherapy versus what people refer to sometimes as antidepressant
treatment or just ketamine infusion. And we'll talk about the importance of preparation and integration
for ketamine-assisted psychotherapy. It's not just about the drug. Okay, so what does chemist do?
Ketamine is a compound that was developed in the 60s by some guy in Detroit. And its first use was as
an anesthetic in hospitals and medical settings. Veterinary hospitals have historically, ever since
Ketamine's development, used it quite extensively. It's actually used a lot in ERs and in emergency
medical response because it's got a pretty high safety profile and can get the results that we're looking for
pretty quickly, meaning a calm, relaxed effect. And it is also an analgesic, so if somebody dislocates
their shoulder and they're screaming, they're excruciating pain, it can be really useful, and it does
have a fairly high safety profile. I will say, and this is an important disclaimer, I am not a medical provider.
I am not a medical prescriber. So when I talk about ketamine, it is from the position of a mental health
clinician who has gotten a lot of training and done a lot of research and reading on her own, not a
medical provider. So I just want to make sure that, you know, as I'm talking about that, that you are
not hearing me say, oh, ketamine's got a high safety profile. And I know that because I went to med
school. I know that because smart people who went to med school told me that.
And I'll make a point of letting you know when I have information from one of my collaborating prescribers.
So ketamine is the only legal
psychedelic in the US. Now there's also fights about what is a psychedelic and what is not a psychedelic,
but I will say that ketamine, when used at psychedelic doses, shares enough characteristics with psychedelics
that we can call it that. And it's the only one that is legal in the entire United States, meaning there
are no states in the United States where ketamine is not a legal substance. It is a controlled substance,
as it should be, but there are no states that it is not legal to use with a physician's prescription.
It is used off-label for depression, treatment-resistant depression, specifically responds quite well
to ketamine, PTSD, anxiety, addictions, other mental health diagnoses, so it's being used, again, off-label,
and when we say off-label,
Again, as I said, it's still certainly legitimate for a medical professional to prescribe. But according
to the FDA, it's not like this has been approved for this use. So that's why we call it off-label. And
a lot of medications are used off-label. There are anti-seizure medications that are used off-label
for migraine disorders.
5N is used off-label for appetite control. So there are a lot of different types of off-label medical
use. And so ketamine, when it is used for PTSD, depression, anxiety, addictions, and other mental health
diagnoses, we call it use off-label. And unfortunately, it has high abuse potential. It's been used
recreationally back probably up
all the way back until the 70s. It does have high abuse potential. I cannot think of something that
sounds more horrible for myself than experiencing ketamine in a club. Part of my draining is I've had
multiple ketamine experiences with almost all the different routes of administration.
didn't feel like I needed to try suppositories, I'm okay there, but all the other out to administration
I have experience with with ketamine, and trying it in a club sounds horrible to me, but again, it does
have a high abuse potential and is frequently abused. And as Tall Cop said this morning, that's the
rub, right? Those of us in the mental health field who are seeing positive effects and
that sometimes even feel near miraculous with psychedelics are like, oh God, thank you, we can use these.
And the people that are treating the abuse and that are responsible for law enforcement and whatnot
are like, oh God, here we go. So there's two sides to that coin. I think it's important to acknowledge.
Okay, so I was just talking about routes of administration, right? And the typical routes of administration
that you'll see out there, an IV infusion, an intramuscular shot,
an oral lozenge, or sometimes you'll hear them called trochies, nasal spray, and suppositories.
Nasal spray, you'll hear people talk about Spravato. Spravato, and that's actually misspelled. I should
have a T, I believe. Spravato is a designer ketamine. It was developed by Johnson & Johnson. They like changed
one thing in the molecule or something, I don't know how they do those things, to create spravato. And
spravato actually is considered unlabeled for treatment of, yeah, treatment of treatment-resistant
depression. But you can also, a provider can also prescribe compounded ketamine nasal spray. So all
different routes of administration, and they'll give you some slightly different experience. IV infusion,
onset is very quick,
It's a very steady experience. And then as you're coming out of the medicine, it's also fairly quick
because again, you know, with IV, we're going directly into the bloodstream. Intramuscular shots will
give you like a sort of a launch you up into the stratosphere sort of effect and then you kind of come
down from there. So it's a different arc.
An oral lozenge has a much slower onset. We hold them under the tongue or sublingually in the mouth.
They absorb through the mucous membrane and so it's a much more gradual onset. Also tends to be a more
gradual leaving the system. Nasal spray, pretty similar to the oral lozenge because it is also being
absorbed through the mucous membranes. Nasal spray tends to be
a little bit shorter. The experience tends to be a little bit shorter than with the lozenges. And suppository
is very similar to lozenges. Again, all are relatively short acting. It says one to three hours, about
45 minutes of the real altered state. But again, there is sort of the movement into that state. And
then there's what we call the landing, which can be gradual. So one to three hours for the whole
journey, sometimes we refer to it. And dosage matters a lot, a lot. As you can imagine, because this
is a substance that is actually used as a general anesthetic at high enough doses. So the dosage is
gonna make a really big difference in terms of the experience. I talked about psycholytic doses, which
are very low doses. It's not that there's nothing altered about the experience, but you're certainly
not feeling
in a really highly altered state, all the way up to psychedelic doses where you're potentially having
visuals, having a sense of altered reality, ego dissolution, things like that. So dosage is definitely
a major factor, not the only factor, but a major factor in your experience with a medicine.
So dosing, and this information is from Julie Addis, who's an NP in South Bend that I worked pretty
closely with during my training. But you'll also see this like other, my training program, Living Medicine
Institute. You'll see these figures fairly commonly bandied about 0.5 milligrams per kilogram. Tends
to be like a starting dose, where we'll start for the dose finding.
Psycholytic doses are lower. In a psycholytic state, you're still able to track the room very well.
In an observing state, you're able to get up and go to the bathroom without assistance. It's a very
mild experience. Psychedelic doses, again, higher doses. A lot of the time, there's a lot more focus
on your inward experience, almost like what's outside of you.
in your environment almost doesn't even register anymore. Altered states of consciousness, non-ordinary
states of consciousness, which when we talk about non-ordinary states of consciousness, you know, we
might be looking at, you know, depending on one's psychospiritual sort of framework or whatnot, I have
clients who've had conversations with God in their ketamine experiences. I've had clients who've had ancestral
communication, like visits with ancestor guides. I have clients that have experience with other types
of, you know, they're angelic or other, you know, spiritual figures or guides. And, you know, for me
and for most people that are working in the psychedelic space, openness to what that means for you and
how that helps you is essential. But at the same time, everybody's experience is their own.
And so, you know, as a provider, I'm not gonna like jump on board and be like, all right, you talk to
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
spiritual experience or psychospiritual experience that they may have had in that non-ordinary state.
So, again, just being really client-centered on that, which we really should be anyway.
All right. So what does ketamine do in the brain? So this is important. And again, this is provided
to me by Julie Addis. Again, it has a high safety profile. It can be used with many other medications,
including many psychiatric meds. So a lot of the time when people talk about psychedelics like MDMA,
like psilocybin,
DMT, F5MeO DMT, IOSCA, like a lot of the plant medicines, they are not compatible with SSRIs. They will
at the very least have significantly diminished effects. At the worst, looking at serotonin syndrome,
so they are not compatible. Ketamine is compatible with SSRIs, which is one of the reasons that it's
really accessible for a client who realistically
going off their SSRI would be putting them at risk of significantly increased suicidal ideation and
other really risky things. They can still experience the benefits from ketamine. So it's not serotonergic
in that sense.
And there are some meds that will lower the effects of the ketamine, but in terms of safety, it's a
high safety profile. Works on NADMA receptors, increasing neurotransmitter communication, specifically
with glutamate and GABA, which you don't really need to know all that much about, except saying that
it's increasing the brain's ability to communicate through neurotransmitters, increases neurofiring
and neuroplasticity.
So the ability to make adaptive changes relating to the structure and the function of the nervous system,
which is what I was talking about before, the importance of understanding effects on the nervous system
and how talking about it doesn't always get down there. So it does increase that neuronal firing and
increases neuroplasticity and increases brain-derived neurotrophic factor, brain growth hormone, and
helps to create
new neurons, which, of course, is also part of that neuroplasticity. So it's doing stuff in the brain
is what we're saying. And it's really doing some very specific things in the brain. Actually, before
we leave this one, there are some other aspects of it that are not necessarily as
specific as this neurotransmitter, this, this, this. But there's also a system within our brain that's
called the default mode network. Okay, default mode network, DMN. And this system in our brain is essential,
kind of what it sounds like. It enables us to sort of have a default mode where we can kind of move
through our day,
We can sort of have a sense of identity, who we are, where we're going, what we're doing. The default
mode network is really important. In certain diagnoses, especially treatment-resistant depression, major
depression, severe anxiety, and PTSD, the default mode network can become problematic. Any guesses as to why?
Again, the default mode network is sort of a default mode that tells us who we are, what we're doing,
et cetera, et cetera. Any ideas why an overactive default mode network might become problematic, maybe
with depression? Yeah, so if you struggle with depersonalization, like not really feeling
yourself as a person, the default mode network is just going to amplify that or continue that, exactly.
If you think about negative beliefs that we hold about ourselves, rumination, the default mode network
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
how the default mode network, while essential for our functioning, when it goes into overdrive,
can cause things like rumination, intense inward self-focus, which we actually know for depression is
a terrible thing. You don't want to get stuck in there for too long. And so really needing to sort of
understand how an overactive default mode network can exacerbate our mental health symptoms through
rumination through rigid thought structures and beliefs. And ketamine actually, psychedelics in general,
help disrupt that default mode network, just kind of set that aside for a period of time. And that also
is part of that neuroplasticity. All right. So subjective effects of ketamine. So it is a dissociative.
It's also different than some of the other psychedelics. Certainly some other psychedelics are dissociatives.
But when you're looking at psilocybin, MDMA, some of those that have been highly studied with trauma
and depression, ketamine is very different in that it is a dissociative. So there can be a sense of
disembodiment of not being in your body. For many people, that's actually a pleasant feeling.
I've had many clients say to me, this is so weird, I feel heavy and light at the same time. They feel
heavy and yet floating, and it's a positive feeling. So people can experience euphoria in that state.
Ketamine will create changes in perceptions, the way we think about things. Visuals, people frequently
will see visuals,
Ketamine, whether it's ketamine assisted psychotherapy or ketamine therapy, we tend to use an eye mask
to assist the person with sort of a more inward focus, and so there can be very vivid visuals in that
experience, although it's not the case for everybody. There's no everybody, or there's no normal for
everybody.
some of my clients that don't really have very many visuals, but they have like lots of somatic sensations,
even though I know I just said that it kind of can disembodied, not for everybody. For some people,
it can really heighten an awareness of somatic sensations. So again, these are kind of subjective effects
that nobody's gonna experience all of these. Changes in mood, again, you know, euphoria is not an unusual
feeling. Increased auditory awareness, increased
awareness of sensory stimuli in general can happen. A transcendence of time and space. When I'm doing
a cap session, I'm with my client anywhere from two to three hours. And sometimes for them, it feels
like I went by in the blink of an eye. And other times, I feel like it was like 1,000 years. I actually
had a client say to me, like, you're not going to bill me for 1,000 years, are you? I was like, nah.
But this transcendence of time, transcendence of space. You can have a real sense of being somewhere else
a sense of awe and wonder. And awe moments are actually super beneficial for mental health. And so,
you know, experiences of awe can really help with shifts in perspective and things like that. We see
birth and death themes, again, mystical or spiritual experiences.
Sometimes the re-experiencing of trauma memories, re-living, re-experiencing, but with space, with distance,
with observer mind. So it's really kind of an interesting phenomenon because it's almost like, well, it can
occur a few different ways, but it can almost be like a re-experiencing, but sometimes I'll say like
kind of like your emotions get wrapped in cotton wool so that they're a little fuzzier or a little further
away. Sometimes it can be a re-experiencing, but re-experiencing it from a third person place instead
of it happening to me. Lots of different things can happen there. Grief can show up and frequently a
sense of a deceased person being there.
Again, imagery, hallucinations, visual distortion, impressions. Ego dissolution, high enough doses can
happen, and this is, ego dissolution is an experience where, you know, there's, and not all ego dissolutions
are the same, but I would describe my experience with ego dissolution as no longer being a separate,
you know, person with my own
personhood and whatnot, but rather being a part of the cosmos, if you will. But anyone who has an experience
of ego dissolution will have a different experience. And so I don't think it's for us to define for
them. Muscle relaxation and relief from pain. So actually, a number of my clients have chronic pain.
And there's an experience of not being in pain for this
90 minutes or so, and then sometimes a return of the pain, but even being able to look at that in a
different way. So yeah, so these are all subjective effects that people can have when they experience
ketamine. Any questions about any of that? That's a lot of stuff that might happen.
Yeah. Absolutely. Yeah.
That's a great question. And actually, I'm going to address both parts of that, because the first part,
I think, was so important. When you were asking about having that experience, if you're watching the
trauma, if you will, from the third person, can people have the experience of speaking up for the child
self? Absolutely, yeah. And there are a lot of different things that can happen in that way. The second
question was about bad trips. And we're going to get to the importance of set and setting and how that
can help with that.
All right, before we get to that, we'll stick on the...
Yeah, great question. So somebody who's been on opioids for a long period of time to manage pretty severe
chronic pain, would they be a candidate for ketamine? As a therapist who has training in this, I would
say absolutely, at the discretion of the medical provider. Now, that having been said, ketamine infusions
are prescribed to manage chronic pain.
And so that's actually something that is already happening. And it's actually easier to get that covered
by insurance than ketamine for other diagnoses. And so ketamine is used for management of chronic pain.
And it's really gonna be at the discretion of the prescriber in terms of what feels safe, what feels
appropriate with that. But in terms of the
the subjective feelings that come with it. Yes, they would have potentially any of those same experiences.
And in fact, I've had a few consultees that are like, okay, so one of my clients is actually going to
be having ketamine infusions for pain.
Can we use that? And I'm like, yes, double dip, because insurance is paying for that for pain. And if
she comes to you, first of all, if you do some really good preparation, which we're going to talk about,
and then she comes to you for therapy the day after her infusion, you're going to see her therapy really
take off. So absolutely, it can be used for both of those things. But again, it really comes down to
the prescriber's evaluation as to whether this person is appropriate.
Great question. So if you are paying out of pocket, it can be expensive. It can be quite expensive.
If you are experiencing chronic pain, I think my first step would be talk to your pain specialist. I
know that there are providers here in Bloomington that provide ketamine.
for pain, I believe through the hospital. I believe it's through IU Health. There's one new ketamine
infusion clinic in Bloomington. I don't know if they take insurance or not. It's True Bloom out of Vanished
Aesthetics. They're the first one that's come that's sort of open to the public, so to speak. But my
first step
would be talking to your primary care doctor and talking to your pain specialist to see what the options
are. There are some ketamine infusion clinics in Greenwood that have been in operation for a while and
pretty well established. So yeah, but the first step for me would be talking to the PCP and the pain
specialist because they'll be able to help you navigate those systems.
So I guess it depends on really the route of administration and how that's being managed. Because ketamine
in general, is ketamine as a substance expensive? No, it's been around since the 70s. So medication,
the longer they've been around, the cheaper they are, right? However, infusion clinic services are quite
expensive. The prescriber that I collaborate with to provide CAP
He will only prescribe ketamine lozenges for people that are going to be with a licensed provider who's
trained in CAP the entire time. That gets expensive. So I would say it's really more the infrastructure
involved than the medicine itself that's expensive.
That is possible, yeah, and it really depends on insurance company PAs. I know a number of people that
have been able to navigate that system, but it depends so much on insurance.
So the question was, if you're on those treatments for months and months, what does tolerance buildup
look like? And again, I would leave that more to a medical provider to really comment on. What I will
say is that it really depends on what we're talking about in terms of the use of the ketamine. So if
we're talking about ketamine for
for chronic pain. I'm not qualified to speak on that because that's not what I do when it comes to
use of ketamine within the mental health sphere, what I do, when it's used appropriately, and I'll talk
about what appropriately looks like in just a moment, when it's used appropriately, we're really not
looking at developing a tolerance because we're not using enough of it frequently enough, long enough
to develop a tolerance. But I won't speak for the pain management side of things because it's not my area.
So my prescriber, his name is Adam Pruitt. He's with Taconic Psychiatry and he is in Vermont. He's licensed
in Indiana, but yeah. All right, so back to the effects. We talked about the subjective effects, right,
of some, you know, feelings that people might have. Now we're going to talk about possible side effects,
physical effects.
All right, the most common one is nausea. It's not something that everybody experiences, but it's not
uncommon. A lot of prescribers will prescribe like Zofran to go with the ketamine to manage the nausea
if it's there. Dizziness, yes, if you have enough of a dose to sort of be entering into that kind of
psychedelic space. Dizziness, impaired or blurry or double vision, that's while you're in the altered state.
Increased heart rate and blood pressure. That will happen. Dysphoria or confusion can happen. Dysphoria
means feeling bad, right? And confusion can happen. A loss of a sense of control and paranoia and fear.
These are all things that can happen. So coming back to that question of a bad trip, it is the provider's
job to reduce any,
any factors that we have control over that could contribute to distress in a non-productive way, and
to assist the client in navigating any distress that comes up in a productive way. And I'll talk more
about what I mean by productive distress in a moment. But yeah, so these are the basic side effects.
And again, the clinician, or sorry, the medical provider would be the one to
discuss the risks of side effects, management of side effects. Certainly because they temporarily increased
heart rate and blood pressure, anyone who has uncontrolled high blood pressure would not be a good candidate
for ketamine, but that's the medical prescriber's job to take care of that side of things.
All right, so, okay, contraindication, severe cardiac disease, preeclampsia, eclampsia, hypertension,
stroke, so all this stuff has to do with high blood pressure and dangers of high blood pressure.
Schizophrenia. Schizophrenia and bipolar I are also contraindications because psychedelics can trigger
psychotic episodes. We know that, right?
Again, ketamine has a very high safety profile in general, but for somebody who has schizophrenia or
has bipolar I, likely ketamine's not gonna be a good choice for them. People who are actively using
other drugs, because again, we don't wanna be mixing things for one thing, and then also there's an
abuse potential with ketamine. And then children under the age of three,
Most medications are not for use with children under the age of three. So again, that's provided by
my NP that helped me out with a lot of my training. So those are our basic contraindications. And again,
why it's so important to have a prescriber that you have a really good relationship with if you're a
clinician.
Whoever you're prescribing or whoever is doing your prescribing, having a really good relationship,
being able to talk through whatever needs to happen. I had one client who became really upset because
she wasn't a good candidate for ketamine because of some blood pressure issues and whatnot. And it was
really important for the prescriber and I to be able to kind of be on a united front on this because
she just wanted it really badly. And so having that kind of relationship and making sure there's not
like a triangulation effect there is really important.
So the subjective effects we were talking about, what do they depend on? Well, we already talked about
dosage as being very important, right? Set and setting as being very important, and then therapy. Is
therapy involved or not? And it might not necessarily be during, but is it before, is it after? And
so these are the things that will really determine a person's subjective experience of ketamine is the
dosage, the set and setting,
whether or not therapy is provided. So first thing that we're gonna address is whether or not therapy
is provided. So we'll start with the last first. And these are different models of ketamine use. So
psychedelic use, which happens in, or which we are typically using when we're doing CAP, psychedelic
use is where we're kind of getting into those higher doses, right?
and can very much enhance psychotherapy work, having those experiences. Frequency becomes less important.
The therapist is present and engaged with the client during that experience. Engaged in a very specific
way that we'll talk about in a moment, but present and engaged. And the goal is psychotherapeutic progress.
Antidepressant use, or sometimes you'll hear people talk about going to the infusion clinic for their
induction series. They tend to be lower doses. That's not to say that you will not have a psychedelic
experience, because it's really so specific on how the medicine affects your system. You can still have
a psychedelic experience, but it's not as much of the focus.
So there tend to be a little bit of lower doses, especially if we're talking about spravato, significantly
lower. The dose schedule frequency matters, right? So if somebody says, I'm doing ketamine
for treatment-resistant depression, and I'm going to the ketamine clinic, they're going to want to do
three sessions a week for two weeks, or like two sessions a week for three weeks. The idea is to get
them kind of close together, and that's based on the research.
So the dose schedule, the frequency does matter. And it's going to generally be happening in an ketamine
clinic. It's gonna be usually IV or spravato, potentially maybe IM. And the goal is symptom reduction.
The goal is symptom reduction. I will also say, and I need to add this to the slide, that I will also
do CAP with low doses of
ketamine sometimes, where the person is in like, again, what we call that psycholytic state. It's not
really an altered state, but they have sort of enough on board, so to speak, that there's sort of a
loosening of protective systems and defense mechanisms. There's like a more of an openness. We're getting
more of that neuroplasticity on board. So that is another way that we can use ketamine with CAP.
But again, I kind of talk about like CAP, ketamine assisted psychotherapy, or
Ketamine therapy without the psychotherapy added as sort of the main distinction between those two.
Great question. How many times do you have to do this process to actually see symptom reduction?
Well, the therapist's favorite answer is it depends. But in general, pretty significant relief after
the first session, depending on what the symptoms are and how severe they are. In general, pretty significant
relief after the first session. And again, six sessions when you're talking about antidepressant use
for treatment-resistant depression. Six sessions over the course of two or three weeks is pretty typical.
And so certainly by the end of that. But I will say that
the majority of people, even after the first session, are experiencing some pretty significant symptom
reduction. What else do I want to say about that? So can even one experience have a big effect? Absolutely.
Absolutely. And if you want to think about it this way. So traditional SSRIs, which has been the treatment
of choice for depression for a really long time, traditional SSRIs,
are effective about 50% of the time. Ketamine, for people who have treatment resistant depression, meaning
depression that SSRIs don't work for, so it's like the 50% of people that the SSRIs didn't work for,
ketamine is effective for that population for 50 to 80% of those people. So, as I said at the beginning, there is
no magic bullet, there is no simply take this and everything will be great. But we do see that ketamine
does have a significant sort of edge, shall we say, over traditional SSRIs in general, and certainly
for those people that traditional SSRIs are not doing anything for. Because there's also a middle category,
like SSRIs help, but they're still not enough.
And ketamine really helps that population as well. Now in terms of frequency, how long do you do this
and whatnot? I have clients, I do sort of plan for a six session series. It doesn't have to be smushed
all together, although if I have a client with treatment resistant depression, we'll probably try and
do them a little closer together than a client who's looking at other symptomology. But we generally
do a six session series. After that, I have some clients that are like,
that they're good to go and that they just kind of feel like that did the job. I'll have others that
we might do a booster session after a month and a half or a couple months or something along those lines.
I've had, I think, one client where we did a series. They were great for about a year and a half and something
really big and impactful in a negative way happen in their life, and I really threw them for a loop,
and so we did another one. Sometimes psychedelics can get this reputation of the fix and then everything
was great forever, and I really like to temper those expectations. It's not the fact that it's gonna
fix everything and everything will be great forever, because a lot of things.
because life, because our changing circumstances, because our changing bodies, because of adversity,
because of loss and grief, we may come to a place where we're feeling really depressed again. But what
we're seeing, and especially with ketamine-assisted psychotherapy, and this is an important distinction,
what the research is showing is that in the short term, in the short term,
there's very similar symptom reduction, whether you're using CAP, ketamine-assisted psychotherapy, or
just ketamine, where there's not a therapist involved. In the short term, symptom reduction, specifically
depression, suicidal ideation. In the long term, those gains are much more likely to stay with therapy
involved versus not. Yeah. Does it seem like it's easier to tear down the wall when you're doing it? Yeah.
That's a good question. Does it make it easier to establish that rapport between the therapist and the
client in the Ketamine state? What I would say is that the relationship between the therapist and the
client has to be trusting in order to move into the medicine work. I would not provide CAP for somebody
that did not feel safe with me because I don't think that that would be appropriate. What it does do,
though, is helps
protectors soften back. And when I talk about protectors, we're talking about defense mechanisms that
come up like, I don't want to talk about it. That's a protector right there. I don't want to think about
it. That's a protector right there. You know, avoidance is a huge part of any trauma disorder, including
substance use disorder. And it can really sort of reduce the
the defense mechanisms around protectiveness and closed off and avoiding and everything. So it can be
really useful for that. So again, with CAP, where the therapist is involved in the treatment, the gains
tend to last much longer with
you know, with ketamine infusions or ketamine therapy that does not include psychotherapy, the symptom
reduction is pretty immediate and pretty quick if it's gonna work. But in terms of lasting change, we
don't really see that so much.
So in the mental health field, ketamine is used for depression, it's used for severe anxiety, it's used
for trauma-related disorders, which are most disorders. And there are also people who engage in appropriate
use of ketamine for, like what I would refer to as psychospiritual growth. Now that's a very privileged
thing to be able to do, but I'm just gonna say that that is also something that happens. So in the mental
health field, like I'd say those probably, those would be the big E's, depression, anxiety,
trauma-related disorders, and also I would say in the mental health field, find me a disorder that's
not complicated by anxiety, depression, or trauma-related material. Yeah. No, ketamine was first developed
as an anesthetic, yeah, back in the 1960s.
That's a great question. For somebody who's still being triggered by their environment, would this be
effective? I would say that along with, again, the other modes of subcortical therapy, yes, it absolutely
can be effective. However, it's not going to fix the situation. So when I say that, it's like,
first of all, if the environment itself is unhealthy,
the person is going to feel anxiety and distress and disturbance about that, and they should, right?
Again, well, I shouldn't say again, because that was my morning topic, but it's important to remember
that our survival instinct and our emotions all are centered in the amygdala, the same place, right?
And so if survival is saying, you're not safe here, you're not going to feel safe, and anxiety is not
feeling safe, right?
What can happen, whether we're using ketamine-assisted psychotherapy, EMDR, somatic approaches, whatnot,
is that we can help this client, or we can provide the circumstances for the client to be able to access
their inner healing knowledge that can help them to recognize how can I get out of this situation. Yeah,
so it can absolutely be helpful, but it's not gonna be helpful in the sense of like, oh, you can stay
in that shitty situation and feel good now.
It's not going to be helpful like that. But it could be helpful like, I don't deserve this anymore.
I'm strong enough to do something about this. I can, yeah, so in that sense. Good question. Yeah. So
when we're talking about ketamine-assisted psychotherapy, as opposed to just ketamine therapy without
the psychotherapy involved, we are looking at a three-stage model. Those of you who were around for
me this morning know I love me my three-stage trauma therapy model.
There's preparation, there's the actual medicine experience, and then there's the integration.
And preparation and integration are key, right? Coming back to that question about bad trips,
bad experiences, preparation
is so key for that and to help support somebody in having the most helpful experience they can have.
And integration is also really important to support people in dealing with challenging experiences that
they have. So I keep referring to set and setting. So I think I'm going to take a moment
Oh, not yet. Okay. In a little bit, I'm going to take a moment to really delve into what set and setting
is. But when we talk about the importance of preparation, right? Preparation is about knowing, not going
into a situation not knowing what could happen, but it's also about going to a situation with openness
to allow whatever is going to happen to happen.
So preparation is really important. And preparation is directly related to the mindset as the client
is going in. So talking through all of those subjective experience possibilities so that the client
understands. Even when I still remember one of my training programs, they were like, make sure and tell
your clients it's gonna feel weird. And I'm like, well, duh, it's gonna feel weird. But they're like,
no, no, no, no. People can have experiences where they do not understand
that an altered state is gonna feel weird. And so if they don't know that, that could be really like,
oh shoot, is there something wrong? What's going on here? I don't like this, this isn't for me. And
kind of bring up a whole lot of distress that's not necessary. We just let them know this is gonna feel
weird, right? So making sure that they're aware of that. Making sure that they understand what the process
is gonna look like.
Talking them through what to expect and everything. But also, preparation also includes talking about
the mindset they're going into it with. I won't talk about ketamine as a cure. It's a catalyst. It's
something that's here to help you. But it's not just going to fix everything without other work.
And just being really open to what the experience has to show you, we can find lessons, we can find
relief, we can find challenging material, we can find opportunities to work through stuff that we're
kind of stuffing down. We can find a lot of opportunities there. And as the client, or I'm sorry, as
the clinician, I am here to help you navigate that in the way that's gonna be most supportive to you,
right? But to really make sure that they sort of understand what
what to expect without knowing what's going to happen. And again, it's very non-directive. The therapeutic
approach is very non-directive because again, the idea is all of our clients have within them what they
need to access in order to heal, right? And the ketamine or the psychedelic space can allow them to
sort of soften enough to be able to get in touch with that.
Um, again, CAP is different than anti-depression protocols. Um, and super important. This is kind of
like, I feel like a death statement, but we're not going to treat conditions with CAP that you wouldn't
treat without the medicine. So I would say this with any kind of form of therapy that I train people
in, like if you weren't already, if you didn't already have experience with dissociation, you're not
going to like now go do EMDR with dissociation. If you didn't already have experience,
working with children, you're not gonna go do IFS with kids because you learned how to do IFS. You need
to have experience with the populations that you're treating. And of course, you need to have really
good, thorough training and experience with the medicine yourself. All right, so again, what are we
talking about for preparation? We talk about ketamine's effects, right? We talk through
what the client might expect in terms of what that experience will be like. We talk about the goals
for therapy. What do you want to be different? What do you want to see that's different after
this experience? What are we looking for? We talk about consent for touch or distance. And when we talk
about consent for touch, we'll talk about that a little bit more in a moment.
But there are some forms of touch that we would use just for grounding and to help the client have an
increased sense of safety. And there's also touch for safety itself. We'll talk in a moment. We'll talk
about music, what forms of music. Music is frequently used with psychedelic assisted psychotherapy as
sort of a container to sort of hold the space. And sometimes the music ends up playing a very active role.
And really basics like you can't drive afterwards and other restrictions. My paperwork says you're not
going to drive for the rest of the day. We're going to have a safe person to drive you home. We're not
going to do Uber or the bus or anything like that. Your safe person is going to be there to take you
home. You're not going to be solely responsible for the care of small children. You're not going to
get into a hot tub or a swimming pool.
All of these things that the client really understands about the safety. Then also, what are the things
they can do to support themselves after this experience? We're going to talk about that as well. Those
are the basic components of our preparation. Now we're going to get more deeply into set and setting.
is the mindset of the client going into the ketamine session, right? The mindset of the client. So this
is where it's really important that we talk about what, you know, what are you wanting to get out of
this? And sometimes there's managing expectations around that, like what do you want to get out of this?
You know, what would you like to see different? What would you like to be different, right? Also,
you know, part of mindset is like, is there fear involved?
Is the client anxious about it? And how do we work with that? Another aspect of mindset is control,
about control and our relationship with control. I had one client who came in and he said, well, in
the first session, I want to deal with this thing that happened to me when I was five. In the second
session, I want to heal the relationship with my mother. In the third session, I'm just like, whoa.
Sounds great. No, we do not have that kind of control. And so really just relaxing and being open to
the experience. I will encourage the client to have trust, trust in the medicine, trust in their inner
healing wisdom, trust that their body and their mind will bring up what needs to be healed. And if that
feels like too big of an ask for the client, then I'll just say, what about openness and curiosity?
It's just openness and curiosity. And we, anything that comes up for you in this space, we can, through
psychotherapy, work through that material in a way that is gonna benefit you, right? Yeah. Oh yeah.
There's always respect for the, yeah.
Great question. Yeah, so how does window of tolerance fit into all this? In general, window of tolerance
in ketamine is expanded. Yeah. In general, again, there's like a sense of, I've had clients say things
like I was able to be with my pain without being engulfed by my pain, right? I was able to be with the grief
instead of drowning in the grief. So ketamine really actually can assist with window of tolerance issues
in a really positive way. And if somebody does become overwhelmed in the medicine experience, that's
where it's the clinician's job to help them manage that window of tolerance, yeah. So it's always a
consideration, yeah, where it's never just like,
Let's get you high and see what happens. Yeah, but it's a great question because yes, all of the things
that apply and all of the other forms of therapy apply with CAP as well. What else about mindset? So
intention setting. Setting an intention for the session. I really encourage intentions like just being
open and curious to what the medicine has to show me.
sometimes clients will have something really specific like I want to open my heart to healing or I want
to open my heart to love or I want to increase compassion for the child parts of me or you know but
having some kind of intention and then super important holding that intention loosely because medicine
is going to do as medicine is going to do right and for me that's part of the trusting the process right
trusting the process that your inner healing is
Wisdom knows what needs to be healed. The medicine helps to create the conditions and the space for
it. And we just, you know, we sort of just follow that process along. I think that's, any questions
about set, about mindset, the client's mindset going into it? All right, then we're gonna talk about
setting. So setting is the space
where the ketamine will be administered. And I include in setting any person that they are going to
encounter in that space. So if you work in a practice that has a receptionist, a front desk person or
whatnot, that person is part of the setting. If you work in an infusion clinic, the person that comes
in to put your IV in, that person is part of the setting. So anything that you're gonna encounter in
this space.
where the ketamine's gonna be administered. Again, music is very common, music or background noises
of some sort. I don't use white noise, I just use music. I use music in a container holding kind of
way, but sometimes if a client is wanting to explore a certain style of music or type of music, we'll
create a playlist that's a little bit more evocative
for them or sometimes I'll just kind of follow my intuition of like sort of what emotionally is happening
in the room and sort of what the felt sense is and I might kind of mix up the music a little bit. But
it is important to understand that music does have a really deep role and can be supportive and container
holding but it can also be evocative and so I never use music with English words like words that a person
can understand because that to me feels directive really. It's kind of like I'm wanting them to feel
a certain thing
So, music is really important. Even just the comfort of the space, making sure, you know, I have like
a big, fairly wide couch that the clients can recline on. A lot of people who do a lot of catwalk have
like an actual recliner in their office. My office is not big enough for both, so, but I have the couch.
Making sure that it feels warm, feels inviting, feels safe, it's all really important.
if clients want to have a person, like I will sometimes have a client ask if their loved one can come
into the session, like halfway through, their person's waiting out in the waiting area and they're like,
can so-and-so come in? Yeah, absolutely. As long as we've kind of talked about it ahead of time and
that all feels safer for everyone, that the person is welcome to, or feels comfortable to come in. So
that's super important as well, right?
For me, it's part of holding the intention loosely. So the question is, if somebody comes in with an
intention, why wouldn't we not use music to boost that intention? Yeah, for me, that becomes about holding
the intention loosely. And for me, having trust in how the medicine is going to sort of deliver the
intention. So what I will do sometimes is send people home with some music.
I'll send a Spotify link to them or something with music that has lyrics that spoke to what they were
telling me during the session. But during the session, I want it to be coming out of them. And then
what they tell me might inspire me to send them
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
during the session, I really want to not use music with words that might plant, like we had a agenda
here. That's what we want to avoid, we want to avoid agenda.
That's a good question. I don't ask for the client to tell me what music they want. I tell them that
if there's something they don't like about the music, to let me know. But I am selecting the music,
what's playing. And then if they don't like it, I will switch to something else. Very, very rarely have
I had that happen. But in general, I don't have the client tell me what music they want to listen to.
Yeah, over here.
So mind bloom, right? Yeah, that's a thing. And I'm not saying that it can't be useful. For me, it would
really depend so much on the client presentations. The question is about home use with a sitter that
will kind of keep you safe, but they're not a trained professional that would be doing therapy with you.
To me, that's not really too much different than going to a ketamine clinic where they're keeping you
safe, but they're not providing you therapy or whatnot. Almost always for the general public, I would
not recommend that. For the general public, and the reason I say for the general public is I've done
self-guided medicine sessions for myself.
after getting trained in CAP. And I have a therapist that I can do integration with after that. But
in terms of the lay person, I probably wouldn't recommend it without a lot of conversation with a therapist
about what could be the benefits of it. All right. Other questions about set or setting?
That leads to your earlier question about people who have bad trips. Almost all of the time,
people who have what we call a bad trip, set and setting was not established in a healthy way. Now that
doesn't mean that you're never gonna have dysphoric state sessions, meaning a session where uncomfortable
feelings like anger, like sadness, like grief, like shame, like embarrassment, like humiliation, like
any of those terror, panic. It's not to say that you're not ever gonna encounter any of that in your
medicine experiences, but
When you have good set and setting and safety with the clinician, there's a navigating through that
that is actually part of the healing process. So when challenging material comes up, and I say this
to some of my consultees who are just getting into CAP, when challenging material comes up and there's
like this really intense negative emotion or uncomfortable emotion happening, that's not a bad thing.
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?
So set and setting isn't about never having dysphoric or uncomfortable feelings or distressing feelings
in the space. It's being able to work through them for healing. Yeah. Yes. And that would be like that
would definitely be for the prescriber to address. But in terms of like when you say it has a fairly
high safety profile there aren't
that many but and so you know a number a lot of the contraindications are really more like it's just
not going to work as well but it is a sedative so if somebody was on opioids if somebody was on had
alcohol in their system like anything that's a depressant is going to interact negatively and so that's
you know that would you know certainly be like if somebody showed up to my office and they you know
clearly were already on some
type of central nervous system depressant. Well, we're not gonna do medicine work, but we're also actually
not gonna do anything besides manage this situation that's right there in front of me, yeah.
Yeah, so yeah, definitely abstinence-based. All of my paperwork says, while we're doing this, I'm not
gonna be doing these other substances and whatnot. And depending on where the person is in their recovery,
I've had people say, I have treatment-resistant depression, I've been sober for 19 years, do you think
it would be okay?
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
light of it, but this is a person who's very well established in their sobriety. They have a really
good support system. They've learned other coping skills and resourcing and things like that. And have
a respect for how we're, that's the biggest thing. Have a respect for how we're going to use the medicine.
If there is a respect for this substance,
and the therapeutic and the healing benefits and qualities of it. And they understand that this is just
not just about feeling good. It's not just about getting a feeling of euphoria and whatnot. I'm going
to feel a lot more comfortable moving forward with medical clearance, of course, you know, than somebody
who's like, oh, yeah, I can't wait to feel euphoria or whatever. It's like, you know, so really like
looking at, like, what is that relationship with the medicine?
That's a good question. So if somebody were concerned about like, I'm concerned that even the euphoria
of it could trigger me, I'd say well then we'll do psycholytic dosing. We're not gonna do a dosage that's
gonna let you feel euphoric. Yeah, yeah, that would be my, and again, anything that I talk about that
has to do with adjusting dosage and everything is always my prescriber's call, right? I also don't.
I've never had him say like, you should do more. Why are you doing such low doses? I've never had him
say that. But whenever I talk about adjusting dosage, that's always me communicating with the prescriber
and him saying this, right? But yeah, if there's a concern that a feeling of euphoria could trigger
relapse or trigger behaviors moving towards relapse, we just won't let you feel the euphoria. We'll
do like a low dose that's like that cyclical range that still has
according to the research, those antidepressant qualities, but not the feeling of euphoria or the altered
state. Yeah. I don't know. I guess we probably wouldn't want to do it. But if somebody did have a bad
trip or whatever, and they're scared of that situation, do you think this would be something that could
help them do that? So if somebody actually had incurred a trauma through a bad trip, could this help
them? Yeah.
So yeah, what I will say is if somebody has an experience with a drug that is traumatizing to them,
which a bad trip can be traumatizing, could this help heal from that experience? My short answer is
yes. My longer answer is that would entail a lot of preparation work, of really good rapport with a
really experienced provider of CAP.
So really that comes down to like the case by case basis of how we would handle that. Yeah. Yeah,
for sure. Yeah, when somebody has a traumatic experience, regardless of the nature of the traumatic
experience, it's a lasting
you know, suffering that can come from that. And yes, this would be something to consider. And also,
like I said, it would be a very, very careful approach. Yeah. All right. The last thing here. And when
I talk about holding the intention loosely, holding the intention that the healing is inside us and
the medicine allows it. So whatever I decide my intention is going to be, knowing that
The healing is inside. Again, I use the term inner healing wisdom, right? The medicine is what allows
it. Sometimes we talk about like the triad of the client, the clinician, and the medicine as creating
this space to be able to access that inner healing wisdom. All right. So let's talk about what therapy
looks like when we're doing ketamine-assisted psychotherapy.
I'm sorry, remind me, 10 minutes. Thank you, ladies. All right. So during medicine session, it's very
non-directive. Mirroring, tracking prompts if needed, parts work. Sometimes parts will spontaneously
emerge. So those of you that are familiar with internal family system or other ego state forms of therapy,
parts work, navigating choice points. Curious inquiry only if needed. What that means is that in general,
I'm just sort of
responding in a very non-directive way to things that my client says. I only am going to ask questions
if it feels like the client might be a little lost or stuck, right? And that's curious inquiry. And
possible touch and or somatic practices of consent is given if needed. We talked about discussing touch
and how touch can be used frequently. Touch isn't used at all.
So it's not like, oh, if you're going to have ketamine-assisted psychotherapy, your therapist is going
to touch you. But there are things that we discuss ahead of time. So for instance, if you are feeling
really overwhelmed, sometimes having a caring hand on your arm or your shoulder or somebody to hold
your hand during a really intense grief experience can be very, very therapeutic. So we talk about that
during preparation.
We talk really, really in depth about what would feel supportive, what would not, always during preparation.
Now, when I am in the middle of a CAP session with a client, when I'm in the middle of a CAP session
with a client, and they're seeming to be maybe, again, engulfed in grief or something like that, and
I might kind of wonder if they want me to put my hand on their arm or to hold their hand or something.
I will always ask first. Just because they gave me consent last week in a preparation session doesn't
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
have sober consent, I don't have consent. Just like in any other area of our lives, if there's not sober
consent, there's no consent. So if they have agreed to a hand on the arm, a hand on the shoulder, holding
hands in a sober state, and then I'm wondering,
Might this be helpful for them? I will still offer. I will ask. I'll say, would you like me to hold
your hand? Would you like me to put my hand on your arm? And if they don't want me to, obviously I'm
not going to. But if they told me in a sober state that, I don't really think I want you to touch me,
and then in the medicine session they're asking me to, I am not going to, right? Because if I didn't
get consent sober, I didn't get consent. But what I can do,
is maybe take a pillow and sort of push it against their arm. So they're feeling a little bit of pressure
from that, but it's not me touching them. There are other somatic practices that can be part of CAP,
but only for clinicians who are trained in the use of touch and somatic practice. So that's not something
that you're just going to be like, oh, I'm an academy provider now. You want me to push on your feet?
There needs to be appropriate training for this and discussion so that the client is prepared for it.
That's probably all I've got to say about touch. So again, during medicine session, very non-directive,
very minimal. After the medicine session, this is where we call integration. I always schedule an integration
session 24 to 48 hours after the medicine session to make good use of that.
48-hour window of increased neuroplasticity. It's what the research Galdolin out of Israel is showing
the research that that there's about a 48-hour window of increased neuroplasticity. So we're going to
do an integration session and we're going to capitalize on that openness
that increased neuroplasticity. We're gonna bring medicine session themes into the therapeutic session.
Maybe there was a theme of surrender. Maybe there was a theme of letting go of control. Maybe there
was a theme of self-acceptance. Maybe there was a theme of self-love or compassion, right? So bringing
the theme from the medicine session in. And how is it relating to the client's goals?
Right, we can use embodiment, like some somatic interventions to anchor in some of these feelings. Discussion
of how to carry forward the effects and themes. Sometimes during integration, I'm using EMDR or IFS,
again, to capitalize on that increased neuroplasticity. But the integration session after the medicine
session is gonna feel a lot more like a normal therapy session, if you will.
Whereas during the medicine session, it looks very different. All right, so what are the psychological
mechanisms here? Altered state, feeling something that's different than usual. So if you have somebody
who's always armored up, always braced, always waiting for the bad thing to happen, notice that your
body knows how to feel safe when you are safe. That actually can be really, really,
significant and profound for people. It can be pleasurable. Softening aspects of control, letting go,
don't need to worry about that. Providing some psychological distance. This is where we, again, talk
about that observer mind. Being able to see yourself thinking what you're thinking without being so
invested and meshed and grossed in it that there's no possibility for anything else to be true. Ability
to face challenging thoughts or memories in a new way.
Again, it turns down the volume on emotional and physical pain. And again, that increased neuroplasticity.
So these are all of the psychological mechanisms at play here. Integration, I talked about after the
medicine, ideally within 48 hours. What did the medicine teach you or show you? What did that experience
teach you or show you? How can we anchor that in? How do you want to carry that forward? Is there a
practice? Is there a ritual? Is there, you know,
going to go buy myself a bracelet. And when I look at the bracelet, I'm going to remember, hey, retail
therapy. Great. But if that's a visual reminder of something from your medicine session, then that's
going to help you to have sort of a more adaptive approach. Yes, Ashley? Five minutes. Five minutes.
Oh, OK. I thought you were waving at me. Like, yeah. All right. And so again, preparation and integration
are essential, are absolutely essential. People always think what's happening while you're in the medicine
is the most interesting part.
Maybe it is, but if you don't have good preparation and good integration, it's not going to have the
effects that we want longer term. All right. There's lots of research out there on ketamine. Not as
much on cap, but it is increasing.
Randomized control trial, first one on depression was in 2000. In 2017, JAMA, the Journal of American
Medicine Medical Association, published a consensus statement that six treatments over two to three
weeks is optimal for treatment-resistant depression. Yeah, okay, that's about all I have on research.
There's actually been a lot of research, especially in 2025, looking more at the difference between CAP
and ketamine therapy alone, and that's where I was drawing from when I was talking about how ketamine
therapy alone has similar effects in the short term as CAP, but it's not as long lasting. All right,
what questions do you have? Oh, take a picture of this if you think you might wanna get in touch with
me. I'm gonna leave it up there for five seconds, and then I'm gonna switch to the QR code that y'all
gotta scan to get your CEs. So if you want a picture of that, take it now. Four, three, two,
All right, so there's your QR code. Any other questions in the last four minutes that we have? Yes.
Oh, good question. I am never in possession of their academy and I don't ever touch it. There's a,
you know, most,
Providers use like a mail order pharmacy. You can get it compounded here in town. I've had people pick
it up at Williams Brothers. But most of them go through mail order compounding pharmacy. It comes straight
to them. They are in possession of it. I know how much they have. They know how much they have. My prescriber
knows how much they have. And we all keep track of it together. And if anything goes missing, then we're
kind of done with CAP. Yeah, good question. But yes, as the therapist, I am never in possession of their
medicine. I don't touch it.
Correct. Other questions? Yes. Great question. So MDMA is used for trauma. It's been extensively studied.
It went up for some FDA trials. Unfortunately, it was not approved last year, but it's only a matter of time.
Yes, they resubmitted. It's going to happen. But they're very different. I guess in a nutshell, I'll
say they're very different. MDMA is a stimulant medication. Ketamine is a depressant.
The felt experience, felt-sense experience is very different. The arc of the journey is very different.
Ketamine is short-lasting. MDMA, the way the MAPS trials set it up for the FDA trials is about a five-hour
arc with a booster about an hour to an hour and a half in, somewhere around there. So they're very different
substances. Ketamine has a higher safety profile than MDMA.
Ketamine is not serotonergic, meaning that you don't have to worry about your SSRIs. MDMA is serotonergic,
so lots of differences, yep. All right, I think that's our time. Thank you all, this has been super
fun, and don't hesitate to reach out if you have any additional questions.