Tatyana is a Psychiatric Nurse Practitioner on Faculty at UT Austin with the Psych Nurse Practitioner program. She also has a private practice where she treats mental health using a combination of meds and psychotherapy. She has recently added...
Tatyana is a Psychiatric Nurse Practitioner on Faculty at UT Austin with the Psych Nurse Practitioner program. She also has a private practice where she treats mental health using a combination of meds and psychotherapy. She has recently added ketamine treatment to her private practice and came to the show to share her insights and thoughts on the subject.
She comes to the table with a wealth of knowledge, experience, and skill for explaining the current state of mental health treatment, spending nearly two hours digging into the benefits and ways that ketamine can be used in conjunction with existing tools. Tatyana is an eloquent speaker, all around friendly person, and was a joy to have this conversation with.
Welcome back to another episode of The Mind State podcast. This week, my guest is Tatyana Gustafson. She is a psychiatric nurse practitioner on faculty at UT with a psych nurse practitioner program. She also has a private practice here in Austin, where she treats mental health illness using a combination of meds and psychotherapy, and is his most recently added ketamine treatment to that private practice, which is a big part of what we're going to dig into today. So first of all, Tatyana thank you for being here.
Thank you for having me.
I've been looking forward to this conversation for a while. So I'm excited to jump right in, let's take the standard route. And like get an idea. Let listeners know where you are coming from how you ended up here in front of me today and got into mental health. And I'll let you take it from there.
Okay. Yeah. That that's a long story.
I'm actually from a family of mental health providers, I don't think I had a choice really, as far as this is a profession. And I'm pretty sure my daughters are destined to do it as well. But I completed my psychiatric nurse practitioner certification, oh, 12 ,14 years ago. And it's I mean, it's been a great profession. Mostly what I've done is teaching, teaching at UT. I really liked teaching, but also, I've been in private practice, treating people with medication and psychotherapy and a combination of that. And I, it's, it's been a great profession for me, and interesting ly enough. It was really in preparing a lecture about three years ago for UT students on PTSD. And I was really looking at the pharmacology that we have available to us for treating PTSD. And it's, it's really bad.
Yeah, it's somewhat limited and effective,
Really limited, really ineffective. And not only did I you know, see that played out in the research as I was updating my lecture, but I also see it in my private practice every day. And I actually in this, really stumbled across the research on MDMA.
In the treatment of PTSD. And I ended up down an internet rabbit hole. And just the it was really just the data that was incredible.
in a very compelling,
it's very compelling,
like the numbers are, they don't show up in research very often, which is why I think a lot of people like what is happening here?
No, I mean, in psychiatry, we just get used to research that looks not that great. And we accept it and we celebrate it because at some point in the research, our medication separates from placebo, and we're just excited, but it separates from placebo.
Yeah, for sure.
And so to see something that separates really significantly, and, you know, MDMA is not legal, and I, but kind of in that I ended up really looking into getting certified as an MDMA psychotherapist, for what it was approved.
I have to admit, at that time, I had some judgments about ketamine. I have had a few patients that had gone to some ketamine clinics probably about five years ago that had opened up around town had had some less than desirable experiences
And I was just really skeptical about the whole space. Really the whole
like the whole psychedelic therapy space. Okay.
Yeah. And, and specifically ketamine, it seemed as though there were a lot of medical providers, er specialists anesthesiologist that were really jumping into this space and providing ketamine infusions with no back
without like the psychotherapy backgrounds,
right? No background in psychiatry, or mental health care at all. So I really kind of felt like this. This space was not safe for most of the patients that I treated. But as I signed up for more trainings in the psychedelic space, ketamine kept coming up and I kept saying not come on people is ketamine even a psychedelic? are we really talking about the same thing and it Turns out that they're all very different. MDMA, ketamine, psilocybin, Ayahuasca, they're all very different. But But yes, I would say at this point in time and in my training and my experience and my treatment of patients that ketamine can stand up as its own, as a psychedelic with a lot of similar benefits.
for for patients, and it's legal.
That's what I always, like, perhaps one of the most beneficial ones right now is that
want to exist within the confines of law can participate,
It's also as I understand it, and we'll kind of hopefully dig into these more, but let's talk about how should we approach this, maybe if you could provide some context of what a typical ketamine treatment looks like. So that we know and like about duration and experience and cetera?
Sure, it really a very important question, because one of the things about ketamine is that the duration of action also makes it very usable,
So it typically the non ordinary state of consciousness that that ketamine induces lasts for most people about 45 minutes.
So it, it makes it usable, makes it slightly less expensive than in comparison, something like MDMA, which is about an eight hour session.
Yeah. Because you need the medical facility for that, booked for that timeframe.
Exactly. We pay a therapist time for eight,
and you gotta paid labor on
exactly. And, and, again, they're different, I don't think we can necessarily replace one for the other. But it does mean that within the current model of mental health care, where you come in, you know, once a week, and you see a therapist, instead of seeing me for an hour for a ketamine session, we're looking at more like two or three hours,
but that's a lot more, that's an easy stretch.
It's do able, people can get off work for an afternoon to do that. the finances of it are vastly different than eight hours. And yeah, right. So there's the duration of action, and the legalities of it, which make it very accessible. And I predict that even with the approval of MDMA, and possibly psilocybin, you know, five years or something, ketamine will still be used quite frequently, because of its efficacy, but also just the logistics
around what a session looks like.
And what is the I mean, I know, especially really, with any psychedelics, they're often characterized by how different the experience can be for an individual. But if there was a pattern that you see in ketamine treatment, do you see a pattern at all? And like, what's the general felt experience for the patient?
Right? Of course, it has to be said, everybody has a different experience.
And when people come to me for ketamine treatment, I don't know and they don't know exactly what their tolerance is going to be for a dose of ketamine. So when we begin these series, which are usually somewhere between, you know, three to six sessions, when we begin, especially the first session, I usually start at a low dose to kind of test
some people at a very low dose have a really profound, intense, both visually psychedelic, but sort of emotionally deep response. Some people don't at that low dose, and then I kind of can adjust it as we go. But I would say that the common threads that usually people talk about after a ketamine experience is that it is very much of a dreamlike state. So a way that it really differs from psilocybin is that most people on psilocybin see things clearly, the stories are more clear, the visions are more clear. Ketamine is really more dreamlike pieces colors, swirling, the visual experience is not as intense. And it's usually kind of just finding meaning in these dreamlike messages. But then there is also the component of the emotional experience that people have during these sessions.
that I think are some of the most profound work
that people do. In a ketamine space,
what, perhaps we should have talked about this too, but what What are the symptoms that a typical patient is experiencing that would bring them to ketamine treatment in the first place?
I have been really working on narrowing down the answer to that question. And I think I've come up with a good one. But it is really the concept of ruminations. I think sometimes in psychiatry, we do spend a lot of time parsing out, you know, what is the difference between depression, depressive disorders and anxiety disorders versus trauma disorders? There's good reason to parse those out. On the other hand, I think that one of the ways that I often link them all together is the idea that these are all internalizing disorders and what I mean by that is the symptoms the struggle are all coming from these negative ruminations. Whether it's depression, whether it's anxiety or whether it's trauma, it's someone's brain chewing on thoughts that are highly negative,
And as much as their you know, frontal lobe or the brain that they feel like they have more control over, tries to tell themselves right to stop chewing on that doesn't matter. The more the brain kind of fights with itself, and the more those ruminations begin to cause insomnia, cause self doubt, cause self loathing that ketamine space is a good space to begin to separate yourself from your ruminations.
so and I do find that in that the deep dive into the subconscious that can be done with psychedelics, but specifically here ketamine, people start to find meaning answers to these ruminations.
Yeah, in one sense, are they? Are they able to sort of observe the rumination is almost like are they witnessing them and being like, what am I doing this for? Or is it just, I am sure, it's a variety of things, but
it's it is a variety of things. I think after practicing psychiatry for a while I, there's just there's just themes themes on these negative ruminations. And they usually are around a concept of trusting and loving oneself. And through that process, trusting and loving the world. So those are two things that dance actually incredibly closely together. So most ruminations, when we kind of boil them down, they are around self judgment, self loathing, a lack of self love, lack of self acceptance.
So in the ketamine psychedelic space, there can be a number of different experiences that people can have that can bring them to an understanding of that conflict within themselves. Sometimes the experiences can be difficult,
difficult. People feel afraid. People see an intense darkness. And it's not always good, fluffy, you know, floating on clouds experience, sometimes that happens. But even in that, even in that difficult space, they often have visions or ideas of how irrational that difficult space is. And they can come out of it. And again, kind of create a meaningful story of why those maybe those difficult spaces have taken over their mind, and how that's not necessary. That they don't have to be gripped by those fears, or those worries or those concerns.
It's funny that I've been continually just sort of shocked at how powerfully psychedelics tend to be able to cut in and just get right to that. And just, I guess more than anything, create an environment where the Insight is more likely to happen, digging into the ketamine a little bit. So I've had one ketamine experience, and it was not legal. Was it in the context of a clinical setting or anything like that? And it was actually bizarre in a couple of ways. So my understanding is that, like we have all these classic case in sort of psychedelics, and as I understand it, ketamine is a dissociative, which would, which, like, prior to experiencing it, I was like, what does that really mean? And my friend was explaining it to me. And he's saying, it's like, I remember telling my friend, I don't even feel like I can sit down and I was like, What are you talking about? That doesn't make sense, you know? And then I had went through the experience and that just made so much sense to me. Like I, I was looking at myself and wondering, like, how am I sitting here? Where am I in like, that dreamlike state is definitely a good way to describe it, because I, I really struggled. Like later in the evening, one of our friends was trying to tell us a story. And I just, I couldn't understand it, I felt I felt stupid. Like, I was like, this must be like, what really dumb people feel like like I couldn't. I couldn't understand. Like, I would start to think about it. And I'd almost like lose track like it felt like, like, I had a software problem in my head, like something wasn't working. And ultimately, my reflection on that particular experience was like, usually I do psychedelics to feel smart. And that was not. That wasn't how I felt this time. So what I'm driving towards, aside from just trying to talk about how I like to do drugs, is what are there some ways that say like, you know, the street usage of ketamine, which is like a powder and you snort it, compared to intramuscular and or IV injections, how does the spectrum of ketamine differ? And finally, I've heard that there's kind of like a more psychedelic version and then, like, a more tranquilizer version? If you could give us like, a little bit more of the details on like, what's going on there? And then
sure, sure, yeah. So ketamine, as you know, has been used as an anesthetic in Oh, RS and ers. And it really, it found it some place in modern medicine during the Vietnam War, okay, being used actually on the battlefield. And you can give ketamine in high enough dose, you know, 10 milligrams per kilogram, it's usually dosed by weight, you know, in a clinical setting,
not gonna rave setting. You can give it at such high doses that you could cut somebody's leg off, and they wouldn't want feel, they wouldn't be so dissociated from their body. They wouldn't even feel the sensations, whoa. And so and, but it doesn't cause respiratory depression, which a lot of other things that we use in the operating room, to put people under can cause respiratory depression. So ketamine is an amazing compound in modern medicine, for the fact that we can, given these high doses works really fast. And I am injection, what they call a dart in the ER, you know, works within five minutes,
So if you have to do a painful procedure, if you have to, you know, put somebody's shoulder back in its socket and er, you just give a dose of ketamine couple minutes later, you can do that pain free and then 45 minutes later, they are out of the experience.
so an amazing medication. Now, at that dose, there are no psychedelic properties.
You are gone.
you are out of your mind and you're out of your body. And you come back into it. Having really no idea what happened in that,
what's the difference? It's like, is it an order of magnitude higher dose, or roughly like how much more
there are darts that are usually used mostly in the ER, but are usually around four milligrams per kilogram to 710 times per kilogram. So then if we take ketamine out of that space and move it into the mental health space, which really started to be researched in early 2000s, was really when this began. We started using ketamine at point five milligrams per kilogram,
tiny doses as
roughly attempt depending on Okay,
yeah. And the first doses of ketamine that were given to treat severe suicidality. This is how ketamine came into psychiatry is people really in acute stages of suicidality. But it all comes back to that ruminative thinking people that are intensely suicidal are ruminating intensely. And so these low doses of ketamine were given IV. Specifically for this research, it was given at a non psychedelic dose in psychiatry, we've been trying to avoid anything psychedelic.
Just because of all the cultural baggage.
Absolutely. That the idea is we don't want to induce any kind of hallucinatory state. We're trying to treat people out of hallucinatory right.
so really the dose that was given at point five milligrams per kilogram was chosen to be sub psychedelic.
And for some people, I have to say, point five milligrams has some psychedelic properties, but not most, not most. And really, when people get a very small dose of an IV infusion, what we are really attributing their improvement in depression to is purely the effects of ketamine on the receptors of your brain.
Okay, so it's purely physiological, not so much. Okay, and how does that work
completely? Well, ketamine modulates glutamate,
it's a chemical in our brain that very few medications modulate, to be honest, it's a we are typically modulating serotonin, dopamine, norepinephrine, and that's really where psychiatry has been for 50 plus years.
And so ketamine is really one of the few medications that really stimulates glutamate production and taking up the brain. But it also has effects on a little bit on serotonin, a little bit on dopamine. But very specifically, it also seems to affect a hormone in our brain that we call BDNF, but this chemical in our brain causes neuronal growth. So mostly in in rodent studies, we know that ketamine causes neuronal growth, I eat little branches of neurons are spreading out for about three days after a dose.
your neurons are grown, specifically in the hippocampus is where most of the neuronal growth goes on hippocampus does a lot of things but it modulates learning and memory.
so when those three days after a ketamine dose, your brain is ripe to learn a different story.
if those ruminations are your story, you have ketamine gives you a window, where I think this is where psychotherapy can really come in the ketamine in and of itself is going to do this for you. And most people experience a relief in their negative thinking, just from the ketamine alone, but to not add some psychotherapy component in those several days, post ketamine or hours post ketamine, you're really you're I mean, you're losing a window of opportunity that I think is lost a lot in the party scene.
Well, in what for risk? Yeah, what risk is there then that if somebody were to take a ketamine dose, and then for whatever reason, be triggered in such a way that their ruminations become more intense? Is that where we start to see like negative outcomes or, because like, they're driving those like patterns deeper into their mind or,
you know, theoretically could be possible,
but you don't see that
they don't see
because it has the psychedelic properties. This is the beauty of psychedelics is we feel more self love,
and more connection to the world around us under this psychedelic state, so it is almost and that's probably probably this is very theoretical, due to the serotonin activities and the glutamate activities, that a lot of those good feeling neurotransmitters are increased. And then you bring in this BDNF component and the neurons growing, and you're really just creating a space to write a story of more positivity towards yourself, and towards others, it would be hard.
you could do it if you really wanted to. But your brain is ripe for having a little more patience and softness towards yourself in the world.
So we set the stage for that likelihood of self love. And it's followed up by a few days of neurogenesis. And especially if we add a psychotherapy component, then we're in really good shape to start to rewrite our story.
Can we talk a little bit more about glutamate for a second, because obviously everybody's heard of dopamine and serotonin, probably as much so but glutamate is less Comment as you pointed out, so and I'm also curious to know more about it?
Sure. So, glutamate actually is the most abundant neurotransmitter of our nervous system, the nervous system that we call the sympathetic nervous system. So that's the cranked up nervous system. One of the things that we've tried to do in psychiatry somewhat unsuccessfully is to block glutamate in schizophrenia. Because we do know that dopamine is not the only reason that people with schizophrenia have hallucinations. We know we know glutamates playing a part. We just haven't figured out how to target that with a medicine. Now, ketamine boosts glutamate. One of the reasons why at this point in time, and I don't think ever that ketamine is really going to be studied in people that have a history of schizophrenia,
because of that boosting effect, right? Okay,
we know it boosts glutamate, but that is the place where the visions come in. And so there is this psychoactive property to ketamine. So very different than being given a infusion of a benzodiazepine. For instance, a lot of the studies that were initially done on ketamine, the control group was given an infusion of a benzodiazepine.
So they feel some psychoactive effects, and not okay,
so their state of consciousness has changed. It's a good state of consciousness is relaxed, it's almost sleep, like ketamine is not going to give you a sleep like state. Even though when you see people after an injection of ketamine, they might look like they're sleeping, their brain has a lot of glutamate. And therefore, it is very active thinking it's jumping around from topic to topic, probably one of the reasons where you kind of felt like you couldn't stay focus on these conversations. And what people were saying is because your brain was actually having many thoughts, kind of at the same time,
yeah, it it did feel like it was hard to as I would be like, okay, thought locked in, and then I'd hear the next part of the story. And I'm like, what was that? And then I'm like, oh, no, I missed this one. And now I'm lost. And why are we talking about this?
Right. And I think that under an injection of ketamine and intramuscular injection, but also an oral dose of ketamine, can, you know if it's high enough, can also bring up that state? Where you're lots going on in your brain? I think this is,
is that like too high of a dose? Or is it not really linked to dosage?
I, you know, this is the million dollar question that us in the ketamine space, we are constantly discussing this as as a protocol for treatment, right? How do we come up with the right algorithm that can meet most people's needs? And we're going to try to come up with it, but it's kind of it's gonna be hard to nail down. Because it kind of depends on what people need. People in an in a severe suicidal state might just need an IV dose of ketamine at a low dose to just get them out of that thinking to get them safe.
right. We don't have anything like that in psychiatry we never have. And so that component of it is, it's huge in this profession. It's typically short lived. That's the sad part is that, you know, most people feel proximately 70% of people feel an immediate relief from their depressive or suicidal thoughts. But a month later, they no longer are experiencing the benefits of it. And almost all of that research was done without any therapy. Just really looking at
How does ketamine affect the brain? You know, that, that I would say is the first way that we use ketamine in psychiatry. The second way can really be at low sublingual doses. So that's an oral dose, you really can't swallow ketamine once it gets into the GI tract that the acidic nature of your stomach will kill it. So you have to hold a lozenge in your mouth.
Swish, swish, swish it, it's really kind of weird but 15 minutes of swishing and you don't want to swallow and your body this is a it's a very non exact way, sure, to the body because your body the Buechel mucosa is only probably taking up maybe 20 to 30%
on who could really swish around for 15 minutes without swallowing a little bit.
whyy, why would somebody go sub or sublingual or lozenge as opposed to intramuscular
That space, a lighter dose. But usually the way to use that is in the confines of a psychotherapy relationship. So I've seen this patient, I've worked with this patient for a while. And I really feel like this would be a good way for them to begin to explore things that it's very hard for them to talk about painful memories, painful relationships, people that think their nervous system just gets really activated if they ever talk about their mom. So we can't ever really talking about the pain that they have with
the source of the hole.
Exactly, So you know, you can get to that in psychotherapy. And I would say using a sublingual dose is just a way to kind of fast forward that psychotherapy work. Yeah. And so in a state of a light dose, but here it is your brain swirling and kind of glutamate and serotonin. And then people are able to talk about difficult things in this concept of kind of, I love myself and I trust myself, and it really is that self trust that allows people to talk about their mom. And actually even it's, it's so beautiful when I see people be able to take a person that has caused them a huge amount of pain. And in that kind of ketamine psychotherapy space, really say, you know, my mom was a really flawed person and a lot of pain,
to see that. It wasn't just directed at them that they were also experiencing
rise up above that victim story, if you will, and see that there's, there's just a lot of pain. And in that ketamine lubricated space, they can explore these ideas without it being threatening without their nervous system, shutting them down.
Right. It seems like it it's also this, I like that phrase ketamine lubricated space, it sort of cuts through this shame, like,
shame, it's a shame
seems to get in the way of like, that's what would hold me back from talking about things like because I'm ashamed of them, you know, and but for whatever reason, the substances can like pull those inhibitions away. And yeah, it's like that self love, like, why would I be embarrassed about this?
Why am I blaming myself when trauma follows you around in a ruminative kind of way? I believe that at the core, there is some still child brain activity that I should have done something else to avoid having been in this situation.
And even if it's not a conscious thought, there is a way that in that space, people can forgive themselves and others for that pain.
Yeah. What about man I had a thought from
let me tell you because I have not so then there is because there's really three ways that I'm starting to look at using ketamine. So in contact about the IV, low dose suicidality,
so psychedelic and then we have the kind of lubricant for psychotherapy, people talk about things in that state. And then there is the third, which is really kind of the psychedelic paradigm,
which I think can be achieved best with an injection, the intramuscular injection, because that is just the, your body's going to absorb 95% of that ketamine,
quickly. So within five minutes of an injection, somebody is in a really different state of consciousness than where they started. And it is in that psychedelic space that again, a lot of psychotherapy happens, a lot of emotions come up. However, most people because of that disassociated space, they're not talking, right. It's not something that you're talking through with your therapist. You're in another plane of consciousness. Ideally, I believe it's good to have a therapist there, because sometimes you enter difficult spaces. Music is a huge part of this third paradigm of psychedelics. Ketamine doesn't work very well as a psychedelic without music.
The brain kind of gets stuck.
Yeah. Music sort of like kind of gives it a boat to float in, in a sense.
Absolutely. Usually the experience can change based on the music
that sure like if it gets kind of sad it may draw you towards motions
may draw you also towards sort of some of the darkness sometimes if you know, if you play music that has a little bit of a darker feel people can feel that in that psychedelic space, you're you really are even though disassociated from your body, your mind is really taking in what is going on around you. And music is the second therapist in the room Absolutely. Like you. And I often am changing the music I'm using, based on what I'm seeing in a person, like their breath rate, if they seem like they're getting tense, I may change the music to loosen that up interesting. Also, I base it a lot on their intention, I always ask people to come in with an intention for their psychedelic work. That doesn't mean that what happens in the psychedelic space actually comes back to that intention. But getting your mind ready to, you know, blast off into its deeper self, that prep work. Really important for it to be the most therapeutic experience that it can be.
Yeah. I feel like we've done a relatively good job of covering some of the physiological and just like practical aspects. Or let's talk more about like, what you were just going to there the prep work. So say you're taking on a new client, and maybe they haven't been a client of yours. So they're new to your practice. Let's talk about like, what the intake looks like the questions you're asking, like, how you're trying to judge what makes sense for them? And what that prep work looks like?
Yeah, yeah. Ideally, these people are coming usually from a therapist, who feels like they can benefit from again, kind of an intensive therapy experience of ketamine. That's not always the case. But typically, they're being referred to us by either another psychiatrist and other psychiatric nurse practitioner or a therapist. So first off, I like to have a phone call with that referring person to kind of find out, you know, where are we stuck, their work is stuck. The work that they've been doing with this person has gone only so far, and they kind of feel like there's more work to be done. So we start with that our intake, of course, goes through safety. I have to reiterate, ketamine is a very safe medication, but it can increase your blood pressure. Not only can it it will, it will people will even laying down on a couch with this great meditative music, their blood pressure is going to go up because of ketamine.
So people do need to have their blood pressure, well controlled, if they have hypertension. So we do kind of just a medical screening workup, people with history of aneurysms, heart attacks, kind of depending on their history. But so there is a safety workup that we do. And then the prep work that I like to do with people really is based in the work of a man by the name of Dick Schwartz, who came up with something called the internal family system. It's an approach to psychotherapy, that is long and complicated, I'll make it kind of as brief as I can. But it's the idea that there is a core self in all of us. And he uses the concept of self, capital S, capital S self, we can think of that as the soul. We can think of that as the inner child. And there's a lot of different ways that we can refer to it, but the capitalist self is compassionate, clear. Loving, connected. And the idea is that that core self exists in everyone. And life is hard. It's hard, Danny, let's face it. And so throughout, starting in childhood, as we start to recognize life is hard. We begin to develop parts of ourself that protect that more capital S self. And these Pete these are what he termed protectors, managers, exiles, and I think the important thing to just know about this is that these ruminative thinking patterns are or protectors, you develop them as a young child to protect your core self. For a lot of reasons, kids are generally feel like their worlds and their worlds are out of control. They're dependent on adults, they are not in control. And so kids have various ways of trying to exert control over their environment. And one of the ways that they do this is to exert a lot of negative thinking about themselves, because it's all they can control.
Oh, wow. Okay.
So just for instance, like divorce, many children will always feel like a split in their parents is their fault.
that right and it's terrible? And many parents will say it's not your fault? No, of course not. But in a way, it makes sense. That's the only way that a child can try to figure out how to control an environment that they are not in control,
because if it's their fault, they elicit some control.
Exactly. Exactly. And then we hold on to this, this concept that was originally meant to protect us. And I think in some ways it does,
But then we get older teenagers, adults, and it's no longer serving us, and can't get rid of it. And ifs is the I the idea of kind of beginning to have compassion for those protector parts. And understanding that they're not really needed, and believing in this core capital S self. So a lot of the prep work that I do with people is kind of around embracing the idea of general self compassion, right? These ruminations are not serving you anymore, but actually, your brain came up with them to try to protect you, you're not an enemy of yourself. It's just a matter of opening up that space. No ifs is done all the time without any psychedelic.
However, it applies really nicely to the psychedelic space, even though I think Dr. Schwartz came up with it in the 80s.
And maybe less than proponent of psychedelics. himself.
No, he is now.
Yes. And it turns out his theory is great for this because it really the idea that psychedelics can introduce you to that capitalist self,
in some sense, is this also helpful just to give some people a bit of a framework to hang these ideas on right, to start to have a mental model of how to even think about this stuff?
Right, right. And I think that having starting to introduce these frameworks to people allows them to create meaning from their psychedelic experience.
Human beings are smart, fascinating mammals. But we are trying constantly to make meaning. Yeah, out of everything. One could certainly make the argument that this is completely unnecessary, but it doesn't really matter. Humans are going to do it.
we're trying to create meaning. And, you know, we're writing stories to create that meaning. And so, psychedelic use in a non therapy state, at a rave party, it's all fun, it's good. But most people are not entering it with the idea of creating, meeting creating, just like you said, a framework for how to internalize that experience. So psychedelics or ketamine, for improvement in mental health, you need a framework to hang the meaning on.
Alright, so use ifs as part of the intake. On the one hand, it gives them a framework to hang these new ideas upon and prepares them for creating meaning. What about if, what if somebody just finds you I was gonna say in the phonebook, like, I'm sure there's people listening? I haven't even heard of that. Somebody finds you on the internet, and they call you up and they're like, you know, they're the I listened to a podcast, I did all this research. I think ketamine is for me. Somebody coming to you without a referral. What does that look like as opposed to? Because you can't call their therapist?
Right? I would do more prep work, okay. I feel strongly for my practice, that I want to be a psychotherapy-centered experience. You know, psychedelic medicine is not cheap,
It insurance doesn't cover it.
We try to get around that. And sometimes we do win. Sometimes we don't, you know, it's an interesting dance that we're doing with insurance. But I, I hope that by creating more of a psychotherapy framework for people, they're getting more out of this instead of paying the least amount of money for the least amount of visits,
That really, probably what you're getting out of that is going to be just the, you know, the, the ketamine neuronal growth and those kinds of improvements. Nothing wrong with that. And it kind of all depends on why you're looking for help. Are you just fascinated, right? Are you just fascinated, I'm okay with that. Somebody that really comes in, they haven't really had previous mental health treatment, and they really just kind of want to see what happens if they expand, like
looking to optimize type of people.
that that's okay, too. And I do think that there's a way that you can add some psychotherapy a little bit to those experiences, that can absolutely help people go out and just be a little bit more optimized.
Sure, right, definitely.
If you're a person, though, with a history of mental health struggles, and unfortunately, there are many people that have had bad experiences with psychiatric treatment, or with therapists, and they're really just not interested, they really just, you know, would like to try ketamine, there are places you can go to do that, I'm not sure I want that necessarily to be a part of my practice. I don't feel like it's doing all that it can do for a person. And there is a way that trying to hide from yourself continuing to try to hide from yourself isn't probably going to work very well, in a psychedelic space, the whole idea is not
kind of the point,
right anymore. And sometimes people need a few sessions to let go of that control. Some people get a little distressed with the that ketamine that the I am injeinjectingh into this world that you are not in control of kind of like what you described,
so they have to kind of get comfortable with like, Okay, I know, I'm going to lose control. And after a few sessions, they can anticipate that and not be so terrified by it, perhaps
right, because that being terrified, will bring up a little more of a terrifying experience.
Right. So there is a way that you got to trust me, you know, you've got to this is a lot about trust, trusting yourself. trusting me trusting the world.
if if we can kind of make any headway on in that landscape, people are going to have improvements in their mental health,
for sure. At the risk of going like making the most out of this, I still am curious about this cost insurance aspect of it all. Because, like you said, insurance often isn't going to cover these types of things. And like for myself, personally, I I just recently like, purposely declined health insurance because I'm like, I don't, I don't need it. I literally do not want it. So as a cache customer, what does that look like? What are the costs typically range, etc,
right? You'll Well, there's a lot of different prices out there the the method with which you get the ketamine in your body.
It's the first one
definitely matters IV ketamine, which has is the most studied. So that's where you get an IV put in your arm, you're hooked up to a ketamine drip. And that is the most expensive way to receive ketamine mostly because it requires that you start an IV. It requires more intensive monitoring. I don't believe that's necessary, but that is just because IV ketamine was always being used in operating rooms.
you have to monitor people as you would in an operating room.
And it's probably not necessarily legally you have to do it. So that's going to be the most expensive and one of the main reasons that I'm not offering IV ketamine, it's a labor intensive and and I find that kind of that psychedelic space of I am ketamine that injection. There. There's so much work to be done in that there's something a little more subtle about IV ketamine, you have a little more control over that though. You can increase or decrease that Um, so from an insurance standpoint, insurance is just generally a problem. But in the mental health space, it's an enormous problem. And we are constantly in conversations about what are the ethics of accepting insurance, right, accepting kind of being ragdoll, by insurance companies? You know, what are the ethics and not in terms of, you know, kind of being true to your craft and your profession? And then what are what are the ethics that we owe to patients who pay high premiums, towards their insurance policies. And then when they need mental health care, all they can find are psychiatrists and therapists that don't take insurance.
Interesting. Yeah, let's dig into that. So when you say the X, the ethics of this, what you mean is that it's a hassle for you to accept insurance, and you get screwed over left and right. Yet, the patient that you want to help, if you don't accept insurance, like you said, I mean, insurance is not cheap. And it rarely covers anything that I want done. So now I'm paying all this money for insurance, and you just decide not to accept it.
So I see you're saying now at the ethics of that, what, uh, let's just shit on the insurance industry a little bit like, why is it so difficult as a private practice to accept insurance? What are some of the main obstacles you encounter?
Well, first of all, you have to hire people, you can't possibly I could not possibly I can't speak for other people. But most people I couldn't possibly deal with all of the hoops that you have to deal with in insurance, and then also have time to practice.
So you need like a full time person just
Do the insurance stuff,
simply more than one?
kind of, depending on what how many policies that you take, you know, so now you're paying salaries, you're at the whim of insurance companies, you know, just denying coverage for whatever reason, you're kind of at the whim of them asking to audit your charts to ensure that you are doing what they want you to do. So the ethics of practicing psychiatry to the insurance company standards are feels bad, right? I mean, we all know insurance companies are not doing this for any good other than the insurance companies themselves. I personally, I mean, my bias on this is that there have to be mental health care providers that accept insurance. There have to and Austin is very affluent city, and affluent cities tend to really go more towards not accepting insurance. So enough people with
enough customers that can pay.
Yeah, so our clinic accepts insurance and we accept a whole bunch of insurance panels and we are constantly frustrated with the ins and outs of insurance companies, but just as an ethic, I just feel like that's the right way to go. So we manage it. So we have salaries, we have four front desk, people that kind of help us manage this whole other part of our business. Now ketamine becomes problematic because insurance companies don't really want to pay more than one hour a week. Give that for mental health care whatever you want to do in that hour
and that might be up to you and however, you want to manage that person
can you likedo two hours every two weeks or something?
No. for rare circumstances if you have like a crisis situation, but you can't have a crisis situation like every week so
then how do you continue build like for one hour and charge cash for the second hour? So that's what you have to do
that's what we have come up with okay. There's arguments to say that we're not even you know that that insurance company once you have a contract with an insurance company, you're really can't charge people out of pocket if they're the carry that insurance,
We've just decided to not worry about it. So right now what we're doing is exactly that billing for the first hour to their insurance companies and then the second hour they pay out of pocket
I would say that two hours are is good enough for most people. However, there are some people that have you know, what we kind of call the tail end of ketamine is a little long.
and that tail end is usually some dizziness. All right,
it's to drive safe,
right? You can't just kick people out. Well, good point, Danny because you can't can't drive you got to get a ride. You got to get a ride to your ketamine appointments and a ride home or Uber. There's a business opportunity out there for somebody to start a Drive service for ketamine where you know, like not to talk. You're picking up somebody from ketamine appointments and they actually don't want to change
is gonna be a checkbox on it. Bernau like they have a don't talk to me checkbox, which is interesting.
No, yes. So there, but you know how it's hard to hustle people out. So sometimes these two hour appointments, which I we only charge two hours at this point, but there are just some people who, you know, need to recover for another 30 minutes.
before we walk them out. And you know, that's something that I know of. I've had several patients who have just kind of been ushered out of IV ketamine clinics, they're not feeling good. They're still feeling really weird, but their time is up, and they call you an Uber and they send you out
just hanging out in the waiting room are interesting. What about so then what are the what are those costs look like? So say it as a cash customer? Is there a rough range for like, I guess you can speak on the your facility? I know, there's probably a broad range.
Right, right. But yeah, I would say they probably range between two to 500 an hour.
Is I think what I've typically seen,
and usually you're committing to at least three sessions, so it's kind of a package deal, or
it's kind of so the, again, the the initial research we do we try, we I want to have a research based practice.
it's a little hard in this space. But the initial research that was done introducing ketamine to the psychiatric world, was done with six infusions.
two a week for three weeks.
Now, again, that's in that modality of just looking at treatment-resistant depression, extreme suicidality. There's been much less research in those other spaces of kind of psychotherapy, lubricant versus psychedelic therapy, right? Those two spaces, there's a lot less research. And I, those six sessions every three to four days, give you a lot of good neurogenesis work,
Think about it, you're coming in every three to four days. First,
as it's wearing off, you're reappearing like so you're getting that like three weeks to rewrite the story.
Right? So you're getting a good chunk of time to really experience all the benefits that ketamine has to offer. I do not by any means think that that is the only way to do it. And I certainly it is cost-prohibitive six sessions in three weeks, or it's gonna get expensive first,
I mean, what's that gonna run me? Like? Six grands?
Okay, cut? Yeah?
And what about on the copay of your insurance? What I mean, just straight up cash, like, what is it
straight up cash? Well, so that would probably be hourly. So you're probably looking at something like 200 to 500 an hour. And then we're
going to four hours a week. So it can be 2000 a week at the high end. So 6k Right, to change my life.
Right. Could be worth it
sort of, you know, as we're starting to look at the approval of MDMA, which again, is eight hours.
Yeah, no kidding,
three, eight-hour sessions. But really, the research that is going through the FDA is really showing that one year, two years out. Many of the people in these map studies have severe PTSD, they actually on purpose, enrolled people with severe PTSD symptoms. You know, one year 18 months out, we're symptom-free.
Isn't that? Just bananas? It's, it's amazing. It's like a miracle.
It is. It's, it's a miracle. And so if you look at it like that, you're actually probably saving money. Will insurance companies begin to look at it that way? I don't maybe they're about saving money.
I mean, that's what I like. What confuses me is it seems like so pharmaceutical companies, presumably, you know, this is I'm making too much stuff up. But like I'm saying that the narrative they want lifetime customers, like pharmaceutical companies don't want to cure you. They want to subscribe you. And I would think that insurance companies would prefer to cure you. And yet, it seems like they're often so aligned as the insurance company just getting screwed on this. Like, they're the worst negotiator than the pharmaceutical company. What's going on?
It's like the mafia. I don't even know I you know, I do sometimes feel like when I am prescribing patients medications that are not generic, and they are very expensive medications. And I, the patient is understandably very worried about this. But we have a lot of really good new medications. And they're new and they're roughly about $1,000 a month. If you were to pay out of pocket. Nobody does that. And so just that, that space of where, you know, I get on the phone to the pharmaceutical representative that visits our office and brings us a lot of good food and I get on the phone with them and I say how can I do this? You know, and they
They, they give me all these coupon codes, and then they give me some pharmacy that they specifically work with. So then I send the prescription to that pharmacy. And then the patient now is getting this medication for $1,000 a month and they're getting it for free, cheaper than the generic generic medication. And the patient I do I feel like I'm in the mafia, as I'm explaining to them,
how I can get this medication for them for very minimal cost. And, and it works, but there's corruption in there and I'm dancing with it.
Just as a part of my job, in a sense,
part of the job to navigate that and even if you don't take insurance, you can't get away from that navigation. Ketamine, I think it's important to point out is really inexpensive,
like as a just a drug
as a medication. It's been around,
it's really what you're paying for is like, the, the hourly wage of the psychotherapist and like the facility.
But the medicine itself is
medicine itself is very cheap.
We got that going for it.
Right. Right. I mean, that is a good thing. Now, the the, I mean, this statistics are so good on ketamine that, you know, pharmaceutical companies needed to get on board and Johnson and Johnson tried many ways to you can't patent ketamine because it's already there.
can't do it. So they were really trying to come up with a different
ketamine X for
that they could patent
But they did. They eventually developed a very expensive filtration process
that is patented. And so now there is spravato. So spravato is an FDA approved brand medication, and it is intranasal ketamine. But what they did is they just filtered out the mirror images of ketamine. So you're only getting the left handed ketamine molecule and spravato There's nothing magical about the left handed ketamine
does it work is the same interest
seems to be roughly the same couple of head to head trials do show that the mixed ketamine which is what's cheap,
might be a tad bit more effective. But really, those numbers are so small, I think it's irrelevant.
so really, the left hand ketamine is perfectly effective, but it's roughly about $1,000 a month, and it's only in the intranasal form,
but for some that might be like, the delivery system can be a big part of these treatments, too. Because for example, if, say you have a traditional psychotherapists office, they probably don't want to just like put a needle in you.
but the lozenge or
specifically designed, I mean, Johnson and Johnson could have and maybe is making an intramuscular injection of s ketamine, but they really wanted to introduce this as the one of the least addictive, least psychedelic again, that the the
They really wanted kept that package
medical model is not trying to induce psychedelic experiences so intranasal low doses. And right now, the pharmaceutical company that is sponsoring spravato, is giving it out for free. So and I do this with a lot of my patients, patients that cannot afford to pay for the ketamine services that I offer, you can refer them to spravato clinics that are right now being covered almost 100% $10 is typically right now what they're being charged for spravato.
Novartis, the pharmaceutical company is just paying for people to get spravato for two years they've committed to to this. So it's really actually a very good option for people who are financially under the gun and spravato is it's an eight week treatment.
Twice a week of intranasal ketamine, no therapy, you're just going to therapy and yeah,
I guess I keep the cheap, right.
It keeps it cheap. And and what are
the results? Like are people having similar outcomes? Obviously, I would argue that and I think you would do that if there were a psychotherapy component that they would maybe have elevated results.
And I think the important thing is might they have better sustained result?
That's the key right?
Because ketamine in that way it can boost people's mood. So well, within hours
Of using this medication. You just can go back into the same ruminative depressed, chemical wash that your brain was in previously.
there is a lot of work to be done to try had to change that story. But that is not to say that there isn't some real benefits that people can experience.
Yeah, I mean, if the two options are nothing or eight weeks this bravado without therapy, then go for option B. Right, hands down.
What about? So my understanding before we got to sit down and talk more today was that ketamine was largely focused on treating anxiety? So can you talk about how it is used for that and like, what the outcomes are there? And and when you talk about these ideas of the ruminating thoughts, that makes me think of like anxiety of like, somebody who's just like always, like, worried, worried and always goes to the worst case scenario, and like, I'll just leave it to you like so let's, let's hear what you got to say.
It's a good point. And I think that I actually think that ketamine can absolutely be used for anxiety, depression, anxiety, trauma, right. That's kind of what I think about those internalizing ruminative disorders. Depression is it's a little less, less risky, I'll say. So the depression is a low. It's a low down disorder, right? I mean, if I say that, it's, it's a lot of, I can't get motivated, I have no energy. You know, I think of kind of er, when either,
that is sort of a good visual picture of what depression can be for people, a lot of times their anxiety is mixed in with that. But that glutamate pump, from ketamine, good for depression. Good anxiety, I think, takes a little more of a careful approach. It kind of depends on the flavor of the anxiety, how debilitating is the anxiety, but I approach patients who really suffer almost exclusively from anxiety type symptoms. I absolutely think ketamine can be really helpful, really helpful. But approaching it a little more carefully. Maybe starting with, I like to do like half sublingual dose and a half injection dose
and just see how things like if they're already experiencing high glutamate requires
putting them in a state and activated sympathetic nervous system state is a good idea.
it tends to be a good idea. I just think there's a way to do it. That is a little bit slower. Sure, trauma is the same way. So trauma has a lot of disassociation with it, people get triggered with traumatic memories, and they naturally can kind of dissociate, which is for most people with trauma, very unsettling experience. So again, if you're attempting to treat trauma with ketamine, which can be really effective, especially those relational traumas, right, but really, when you're talking about the mom, a lot of trauma around those intense interpersonal relationships, ketamine can be really good for that. But you just approach it a little more step by step, right? The music is a little lighter, it's a little fluffier, that I use, right? It's kind of and then maybe as we go on, and I see how things go,
so there's a little bit of a different approach based on what's going on depression, you can kind of have a little more confidence and let's just let's just jump in here.
Interesting. I would have thought that that'd be the one you'd have to be more careful with. And as it turns out, that's that's a safe one.
Right? Right. That's half a little more standard.
Well, that's good to hear that I mean, because for anybody experiencing depression, it's a brutally law
right right. And call it full of so much self blame full of so much. Just negativity that that can definitely be rewritten. I had a I had a patient describe to me this really interesting thing and her experience of she just saw this kind of balloon if you will, sucking up blackness and as it was sucking up blackness, it was creating this colorful balloon,
and I mean, that was just such a good metaphor for her depression. And And again, in that in that work in that vision, the meaning that she could apply to it is that you know, my depression is part of me and I can use it. Color
If I can, so it's it's trying to integrate all the parts of yourself
rather than something you have to get rid of.
Wow. Let's see. Okay, this one's out of left field. Actually, in the beginning, you had mentioned that you kind of just, were destined to be in mental health. And you think your daughters are going the same way. So I have daughters, too. And as soon as you said that word just made me think let's talk about them. So tell me about your daughters.
Right? Yeah. So I have a 17 year old have a 14 year old and an eight year old.
all girls. And why are they destined? They told me they're not going to mental health least teenagers.
hey, my little one wants to be a chiropractor. I think she knows any chiropractors, she loves cracking her fingers. And she, that's what she wants to be. There's a lot of mental health in that too. But, but my older daughter is telling me they do not want to go into mental health. But I think it's just a similar thing. My husband is not in mental health. He's he's high tech. He's an artist. So there might be some room for them to make different decisions in my house. My father was a psychiatrist. My mother was a hospice nurse. And so we just sat around and talked about just being alive, being sad, being anxious and other people. We talked about family and human dynamics. We still do. Yeah, there's five of us in my family. I'm the youngest. Two of my sisters are therapists.
Oh, wow. It must be like quite the Thanksgiving
it. Yeah, no other people come, it all seems normal to me that we all just sit around analyzing dynamics. But and there was just so much of that. I realized when I when I when I talked to my girls. That's just what we're talking about.
And they're, they're really interested, I have to say it's been it's been interesting to me to have them be aware of the fact that I am running a ketamine practice,
right? Because it's a bit edgy, and it's
a bit edgy. And I am not actually a huge proponent of drugs.
I've been in psychiatry a long time, I've seen a lot of, again, relational trauma, secondary to substance use.
You know, alcohol and cannabis both have they're really good points, they really do. But if used an excess, they they lead to relational distance, they lead to a break down of connection. And that's never what I want for my patients.
So I am coming to this field pretty uptight about drugs, I have to admit. So it's been a while. So my, my goal for my children is that they don't get caught up in any kind of drug use, that's going to hinder their ability to connect.
Yeah, at least abuse.
It's hard. It's a very thin line to walk.
It's a thin line. And there's a lot of really functional people out there that have relational struggles
that are way past the line.
Yeah. They're functional.
Yeah, that's what's interesting, like Amanda, who introduced us, when her and I spoke, leading up to it and during and a little before and after, she highlighted to me that it's not even considered substance abuse unless it's creating problems in your life. Like, right, the technical definition. I'm like, that is bananas like that. You have to actually be messing up for it to be
And it's hard to measure that. I mean, it really is. So yeah, I've been I've decided though, that I really need to I think it's best for my daughters for them to really know about this know about it in a really clinical approach,
the the approach that I'm taking and really understand it and they are like most people really fascinated by it. Their friends are fascinated by it.
It's so in that that fascination is there's a beauty in that fascination because it is a beautiful thing to me that people that we are we inherently feel like we need to always know ourselves better.
that is our work. And I can see it in my teenagers. They even understand that work.
So there's a beauty in the fact that this work is kind of laying out that concept right in front of us. This is what we need to do. Um, but I do think ketamine, the beauty of ketamine therapy is a wonderful thing that I celebrate in the psychiatric field. I also know that that means that we are going to see more street ketamine abuse,
just because of like the word being more commonly used and so people are gonna hear about it and then
exactly, and it'll be available.
Yeah, so I'll talk about that more like the difference. So there's, you know, intramuscular, which is presumably like, you know, comes in a liquid form, it's injected, and then how do you get is like, the street ketamine that's just a powder is that like dissolved in solution,
so Well, it's an absolutely be snorted. And then there's also sublingual,
ketamine that can be used in high doses you can achieve a psychedelic state is up do a lot. You're gonna do swishing but but we all know about, you know, street drug drug dealers, our willingness to good right, and drug dealers know how to deliver what their patrons want. So there is up until this point in time in the US, we have had very minimal St. Ketamine abuse, minimal. And I we're going to see more of it.
we're already seeing just in the last year, more high schoolers
using recreational ketamine that doesn't mean abuse, using recreational ketamine in a way that five years ago high schoolers didn't never thought about ketamine. So it's, it's out there. And I do think it's just a natural side effect of it just being around and there, there will be probably a, I believe a very small subset of patients that will go from therapeutic use of ketamine feel like that was really such a lifesaver and moving into, you know, overusing it or straight use of ketamine. I believe that, as professionals, we we can mitigate that.
I believe that we can,
what are some ways that we can like that that can be mitigated?
Well, good selection, right. I mean,
just for patients,
So somebody comes in, and they're just like, trying to get high? Probably,
it's really it's not hard to parse that out.
sure. It's not. But I think one of the best ways we can do this is with just kind of ongoing, open, trusting relationships. I think that the way ketamine could go from therapeutic to detrimental would be somebody that is really leaving the mental health profession. They don't they're not accessing that anymore. And they're hitting struggles again.
They know somebody who can get it
But they can't afford the six grand for another three week,
right? And then you end up in a lot of that addictive process of shame around it, and then leading to more use.
And so building trusting relationships with people where when they start to struggle, they also trust that they can come back to you. They're not letting you down.
sometimes people don't want to go back because they feel like it. It's a failure on them. It's a failure on you. And it just sort of feels messy. And so really leaving space open where we can get, you know, get to people, even if we use it again, therapeutically.
That could really help.
To not move into an addictive or detrimental space.
All right. So you approach in your clinic with ketamine, it's a very clinical research based like, approach is my impression. And then we have these other psychedelic assisted therapies that have more of this sort of ritualistic tone to them. What is your take on that? Like, if any, and if that plays any role in a ketamine or if you have even encountered other clinics that do have a more ritualistic approach?
Right, right. I think that this is probably one of the most exciting crossroads in psychiatry, in my opinion. Psychiatry and mental health care in general has always been designed to avoid the spiritual
right. We've always thought that was a strong point of our scientific work. that for people, their spiritual lives are dealt with over there or not dealt with at all. It's kind of up to you, your spiritual life is up to you. And improving your mental health symptoms are up to me, right? It's very didactic, secular.
idea. I would say that for the most part, I embraced that idea. I was educated in this western medicine world, and I never questioned that. And I, it's been very interesting for me to have my own psychedelic journeys and my own ketamine journeys, to really get comfortable and embracing that in my own practice. It I have to say at first it was really uncomfortable for me, and I'm, I'm it's growing on me though, and really growing on me. So I would say that. So currently, right now I have it two separate offices. I have one office where I do kind of mid management, the old silent and then I have a separate ketamine office.
And the the ketamine office is really different. Like, it's really different. And I have a lot of different crystals that I use in session with people Interesting,
Based on kind of what's going on with them, or if they need grounding, sometimes being outside of one's body is not a good experience. And you can see especially like if you have trauma and disassociation and finding like grounding crystals, explaining it to people, they can hear my voice, right.
I mean, it doesn't matter how psychedelic Your journey is, you can always hear the music, you can hear what I'm saying. And I find people are really open, even people that don't have a strong spiritual life.
really open in that ketamine space to the concept of just spirituality.
So tapping into things that maybe they're not even into crystals. Maybe that's not maybe they think that's crazy. But in that ketamine space, though, that crystal, they'll hold that Garnet, if I tell them, that it'll route their chakras, and they'll, you know, and they take it, and they make it a part of their experience. And most people come out of that feeling really connected to the introduction of things that don't make sense.
Yeah, that's what like, because even listening to talk about that, when you said the world crystals, I'm like, bullshit, like, there's this like, voice in my head. And then there's this part of me that knows like, that, I think, too, is almost like, a shame thing. Like, I'm afraid that I'll be judged by like, Oh, what an idiot. You know, like, that doesn't make any sense. But then that's just like me worrying too much what other people think about me like, I don't think I actually personally have anything against crystals.
Oh, they're pretty but
yeah, they're pretty impressive, like, think rocks. I don't know, not really going anywhere with that. But
I think it's really true. And I think what, what we're trying to do is, is create things that people can also hold on to i i Burn, Palo Santo, in all my ketamine sessions, and I really take the time to explain to them, you know, what, what the palo santo is and why I'm burning it and what is it
I have any MLU
so Palo Santo, you've probably seen it. The sticks, they just look like bark.
right. And they and they burn and they're, they're good because they don't smell sweet. It's not a sweet smell at all. So in a way wouldn't bother people that are sort of sensitive
smells. Palo Santo is an ancient tradition. And you know, almost all I mean, Native Americans, South Americans mean palo santo is thought to really cure negative energies, very similar to sage on the stage.
I just prefer the smell of Palo Santo. And when I went through a whole process of getting becoming a psychedelic certified psychotherapist, we actually there were a group of Native Americans that came in and they really informed us that as long as we're using sort of Native American traditions and understanding where they come from, you know, they really feel like that's a cultural celebration, not cultural appropriation, and that really makes sense to me. And so I do find that that palo santo smells are important and when people kind of go back to those ruminative states six months later, and just kind of burning In some Palo Santo, maybe you have a garnet crystal, whatever you've assigned meaning in a non ordinary state of consciousness to those things, I've asked you to assign me to it really, because I want you to have something to hold on to, to remember the non ordinary state of consciousness where you found
where you found that people have to be reminded of that space.
Yeah. And smell is such a powerful reminder of things.
The I'm glad you reminded me of this, the certification to be to provide this sort of therapy. So, you know, there's so many different levels, and you come to the table with an actual background as a psychiatric nurse practitioner. So let's talk about first, what certification you went through what that looks like. And then I also want to ask about if there's a path for people that don't have that medical background to take to, like play some role in this space in a way that you think is, you know, ethical,
right? Yeah, yeah. Okay. Well, so I completed psychedelic psychotherapy certification is a year long program out of a clinic in Boulder,
They were called the integrative psychiatric institute. It was, it was a really good program. Part of that program was going out and having a ketamine experience. And they, I think, are really the first certification body to force you to have an ketamine is legal.
So it's a lot easier to foresee.
Right. But so they covered three domains that covered ketamine, MDMA and psilocybin.
which was what was covered in this program, and then the psychotherapy that goes throughout, which doesn't change all that much, really, it's really more just staying. We've got, you know, four to six hours of psilocybin, eight hours of MDMA hour of ketamine. Right. So, that was that program, there is no standard Pro.
At this point. They're working on that. Maps. I don't know if you've heard of maps maps is the multidisciplinary action on Psychedelic Studies, no maps, but John Hopkins is doing a lot of maps.
Are they not related?
Oh, no. But they're doing a lot of the same work, all doing good work and all very supportive of each other. But maps right now is focusing on MDMA.
so Johns Hopkins is doing mostly psilocybin end of life. end of life care is a big part of what's coming out of Johns Hopkins.
Yeah. And that, I mean, that research is equally as good and fascinating. But so maps is the closest thing we have to a certain
body of foundation. Okay. Yes.
And so maps actually did get approved in the fall that they could administer MDMA to the therapists. The therapists would have to have an MDMA experience in order to be certified. So the FDA approved that,
that's amazing. Yeah. And it seems so logical, like it would, it'd be hard to really, I would think that most therapists probably would go and do it. Just like not talk about it, you know,
But it's cool that it's, like, fair and expected and legal and like, they can be vocal about it and share their experience and
right, and that, and that has been, it's been a healing thing. Even for me, I, again, was educated in the idea that I only share so much of myself,
of course, with patients.
You know, that's okay. There's good reason for that. But I do find that when I can talk to patients about my ketamine experience, even though there will be different than mine. The fact that I trust this medication enough and I and I trusted my ability to go deep into my psyche, psyche does kind of set me up I think is a little more credible to help them explore their so
yeah, in a sense, like, it just occurred to me that I'm like, of course, they should do MDMA, if they're going to be teaching them like, it's not like we make doctors do all the other drugs they prescribe. So this is unique, in a sense, almost like I can know, my doctor did this.
As a matter of fact, we are very much trained in psychiatry that if we have ever had our own experiences with Prozac or Abilify, or whatever, we really need to not bring that really into the space because that was us or our family member or whatever our personal experience is. You know, we really have to be compartmentalize.
Because this person in front of us may not have the same experience with taking floxie Tina's as we did. But it was interesting how before psychedelics, we kind of almost felt like it might have been a weakness
yeah to have said that you had taken it
right to say to somebody Oh, when I took Prozac
and they might almost distressed you like why is this pitch taking Prozac? Is my doctor
gonna judge me?
here we are trying to say it's okay to take Prozac like notion.
Wow. So fascinating
So the idea that with ketamine therapy or psychedelic therapy, but it's, it's okay, like, it's okay. Not only is it okay, it's it's such an intense experience that you actually want a Sherpa?
has been, at least in this weird, dreamlike state. My dreamlike state is not going to be like yours, but at least I kind of know there. There is this this word in the psychedelic world called ineffable. It's not a word I ever used before. But ineffable is means you just can't describe it can't put words to it. And I find that when patients come out of their ketamine experience, and I'm usually spending, you know, 30 to 45 minutes with them. And in that moment, in that time period, I hope that some of this solidifies into beginning of meaning,
Beginning they're still kind of in a little bit of an altered state. And so usually, I asked them to keep their eyes closed, but at least start to kind of verbalize. But it's hard it finding words for it is hard. So then just just the idea that I know when they they're trying to describe an experience or describing how they felt in that experience. I don't need the word like I kind of get that.
Yeah, you don't need to, like get it,
I get it. But as we try to apply meaning to things, putting words to things as much as we can, is important.
Yeah, it's a part of the process. So then, what about this side of the coin of people wanting to be able to assist in all of this work and do integrative post work, whether it may be or even guide people through sessions, but don't come to the table with a medical backgrounds? What's your perspective on that?
I mean, I think that, that, you know, we control so many things through licensure, um, there's good and bad ways. You know, there's good and bad outcomes to that. I think there are people that don't need a background in psychotherapy, they don't need an education in western medicine and They could absolutely guide people through psychedelic spaces really well, in a really therapeutic way, I have no doubt that that's possible. I think that we do have a desire to streamline these things, to try to make sure that the ethics of it are withheld. The ethics of sexual relationships between clients or patients and provider of psychedelics has been the Achilles heel of psychedelics ever since. Well, ever since it was really, really come up with Oh, Lord, unfortunately. Yeah, yeah. Because I think there is a vulnerability there.
And a connection that can happen in that space. That doesn't typically happen.
For a tip for like, practitioners with a medical background, right, or Sony drilled in?
Well, no, no, no, that the people that I'm talking about are all people that were were trained,
and ended up having sex with their patients.
And getting caught is really bad. I mean, maps is dealing with this right now they had, they had a couple up in Canada, a psychiatrist and his wife and
I heard something about this.
Who Are y'all one of the one of the patients that went through that has come out, and she had a sexual relationship with him. And this happens outside of the psychedelic space. But at least when you have a license,
there's a risk that you could lose it.
Yes. There is a qualifying body that will come after you. And
will that stop everybody? No, unfortunately, not. But there is a way to regulate the ethics of the treatment. If we're talking about people that have you know, no regulation. might that happen? A little more? Maybe? I don't know. It would make me a little nervous, because I am sort of in the space of understanding the ethics of my profession, and how to stay within those boundaries.
And, you know, there are, there are people that will argue that sex and psychedelics have been used therapeutically for 1000s and 1000s. of years. And so, is this really an ethical breach? Right?
I mean, you know, there's gonna be like one and 100 people who can walk that line, ethically, I think,
but if you don't have a regulating body,
you can tell yourself whatever story exactly right?
Like I'm healing people
can be your story.
And he's sneaking a little barbituates into the mix. And I'm just hooking up with everybody.
one of the things that I think will decrease the cost of, of psychedelics. And I've even kind of thought about, I've thought about it more in the use of students in the psych NP program, is to, you know, since sitting with people, when they're in a non ordinary state of consciousness is expensive, and requires some interaction, but often not a lot, that we could make it cheaper to have a sitter or a guide.
somebody that is sort of trained. So
there's sort of like the, the master and then the apprentice type of situation, so that I can't just open my own practice, but like, maybe somebody could play a role when there is at least a licensed professional,
Right, right. And I think that especially as MDMA gets approved, and we're talking about long sessions,
there's gonna be a lot more space for what we're going to call psychedelic guides.
Yeah, for sure.
And I'm sure somebody will come along that will create a certifying body to become a psychedelic guide. I mean, I think and, you know, that will be a whole different person that doesn't really exist right now.
It will be like the dentist office where the the dentist just goes around and checks on everybody and the assistants are doing a lot of the heavy lifting
besides the dose and then
and then that eight hours and that'll make it more affordable. You know, you win some you lose some
thanks sometimes in that space, but
I think that'll that'll definitely be a profession.
Yeah, that particular detail never crossed my mind about the risk of the sexual relationships. And that should probably maybe be a part of the integration certification, like sort of a module on
Oh, it's the act about constantly Yes, we and I do think you know, those of us that have really kind of moved into seeing the potential for psychedelics and healing you know, feel like we do it it is our lot to try to protect this space.
Yeah, it's gonna it's there's some sense of like, really wanting to not mess This up like so just takes a couple of scandals to get everybody like right now we're really lucky in that psychedelics are kind of like cool again and like there's a lot of social support for them, but a couple of bad stories, and it could really turn the direction of things.
Right. Right. Right. It could and we do have, we had an interesting intersection of things. We have kind of the introduction of ketamine that then coincided with quarantine.
so right, as a lot of ketamine clinics, were just getting started spending a lot of money.
getting up and running. And then quarantine happened. And people were such good problem solvers. So there were a lot of people that said, you know, instead of letting this dream die, I'm going to start offering this in a virtual space.
So that has led to huge corporate funded clinics of ketamine being mailed to people. We're doing zoom sessions, so sublingual, ketamine, uh huh. being mailed to people and then you do zoom sessions. With a therapist. This is controversial within the field. But it's out there. And there is an idea of you know, most of the professionals that I'm surrounded with, feel very worried about that space, feel very worried about this virtual ketamine that I mean, it went from almost unheard of,
massive because of Corona. We just couldn't have predicted that without quarantine, there would have been kind of a slow movement.
Yeah. What it is like no way not gonna happen. But yeah, that that was the catalyst.
And then in in the quarantine space, all regulations were thrown out. Right, because everybody had to get health care virtually.
And mental health especially
Right. So these, these ketamine clinics could really operate without any regulation really fast, which I would have not happened without court,
as people would have introduced the idea of virtual ketamine. There would have been, it would just would have been a very different process. But you know, here we are.
here we are. And we'll have to kind of deal with that.
Yeah. Well, we're, we're ready. We're nearing our end here. Before we get there. Is there anything that you sort of hoped we would talk about or some message that you personally want to share and make sure it gets out? Who
Well, um, I guess I hope in that same vein, of, of, you know, protecting this space. I hope that with the excitement of psychedelics, and I and I am very excited about it. And, but but I do hope that we, I keep a kind of a, a sacred ritual around it. I think it's important for keeping we'll just say ketamine, keeping ketamine as a molecule that we can use to help people and we've never in a way that we've never been able to help people before. And, but I do think some of that spirituality, some of that ritual, you know, if you had told me two years ago that I was going to be reading poetry to my patients
and burning incense,
right, I would have been like, but I feel as I move into this space, I really have been able to let go of some of my weirdness around that. And I think it's been, I think it's been really helpful. It's not the only way to practice ketamine therapy. There's a lot of work and energy that goes into it. But a holding some respect for it and some sacredness for the fact that these molecules in and of themselves, would have already saved the world, if just the molecule itself was all we needed.
But it's not there's a lot of work that patients who have successful ketamine journeys, a lot of work they put into it beforehand. There's work that goes into it afterwards. And when you look at that space, there's a lot of beauty and it's something that the mental health profession has just never really seen before. And so I just I hope that that we all hold on to that.
Yeah. And don't just overly clinical fight and lose all of that.
And we can in mental health, we often fall back on on cost and access,
right? Well, I'm not going to do it that way, because people can't afford it, or people need access. And those are also good arguments. That's why this is a complicated space.
Because both arguments are equal. But it just it, you know, it's gonna, I think it might water down what we can do with this,
and ketamine is quite safe. And I really do feel like there there, there will be something to booster sessions, go through three sessions, and then a year later, life is hard. Let's face it kind of comes at you fast. And you find you go back into those ruminations and then you do one or two booster sessions. And, you know, if we can keep it in that space, I think it can actually really help people long term, even if they have some setbacks.
And even like, you know, you probably, with so much of your work being with mental health, and people that are struggling, tend to look at it through that lens. And I see it more to is I, I see a whole nother part of the sector of the population that is just looking for people that are actually things are pretty good. And they just sort of like, things look like they could be better. You know, it's like, so like, just people more seeking optimization or, and sometimes like and to be fair, I often find myself thinking that that's me. And then what I realized, as I've done some work is that there's more mental health work to be done than I realized, and I'm maybe I'm just functionally that stuff or whatever. But anyways,
we all struggle,
right, we, there's just no way through through this life. Without periods of negative rumination. They're just, there's no way and there is strength in that, right. If you take any kind of the Buddhist perspective is, I mean, life is suffering, life is struggle, and there's no way we're gonna optimize our way out
of that when it would be just utterly boring. If there was nothing to just struggle
with the depth and the connection, right. At the end of the day, I really want to help people, you know, keep connected to the world around them, people around them. And I think that there is something in the struggle that allows us empathy and connection. But I think that using ketamine or psychedelics, however, to optimize, I'm doing well, right, I don't have dysfunction in my life. I have some struggle.
doing pretty well. But I want to know myself better. Excellent.
Yeah, it's like you could always know yourself a little better,
you could always you always have a subconscious that you are not exploring. And psychedelics aren't the only way to explore that, right? I mean, there's Holotropic breathwork. There's certainly people in fitness that are aware that you push yourself hard enough, you can achieve non ordinary states of consciousness. And there's a lot of good that comes out of those states. So by no means do psychedelics, you know, own that world. On the other hand, it's pretty easy. It's easier than running a marathon.
And like Sam Harris puts it, you know, like, yes, there are all these other ways that we can achieve transcendental states of mind. But the thing about psychedelics is you're sort of guaranteed, you know, where it's like, maybe if you join a monastery and meditate for 25 years, like you'll reach some special things, but like, if you take a sufficient dose of psilocybin, ketamine, MDMA, LSD, Ibogaine, you're gonna have something, something's gonna happen,
Right? And the beauty of it is that whatever happens, your brain is also going to be awash with the idea that that's what should happen, right? It's just a beautiful thing that we make meaning out of whatever we explore.
And so yeah, so psychedelics are an excellent way to do it. So yeah, my my approach is sort of a mental health approach, but I definitely support the optimizing approach.
Cool. Two more questions. Sure. Number one, trying to think of the order to do this and let's go like this. If you want to, can you tell us about your clinic and how people here in Austin er who want to come visit could find you and how to look you up on the internet, get into your system and like experiencing this whether it's for mental health or optimization,
right, excellent. So we I work at a clinic called Greater Austin psychiatry and wellness. It was the first nurse practitioner run clinic opened in Austin. There is no a bunch of us we really like to think of ourselves as kind of a nurse practitioner Haven. And how many are there's probably 10 Nurse Practitioners are probably the busiest psychiatric practice in Austin, Texas.
At this point in time. Now there's three of us that have moved into this ketamine space become certified. And so right now we are sort of, I'm taking patients that I've worked with for years and treating them with ketamine. We're taking referrals from other nurse practitioners within our office for ketamine treatment, and that's keeping us quite busy. But if there's anybody out there that wants to look into it, it's Greater Austin psychiatry and wellness. It's it's me, it's Tatianna. And then Laurie Fox and Jessica Fernandez are the three nurse practitioners there that are really moving our clinic, not in a different direction will always continue to provide the services that we provide. But adding this additional service to it.
Yeah. Excellent. Is there I guess if anybody Google's the name, Greater Austin, psychiatry and wellness, okay, that's, that's how we'll track it down. Okay, this last question it this might be the last time I asked this, because I'm thinking about rewriting it. But let's, let's do it anyway, if you could snap your fingers or push a button, and everybody on planet Earth tomorrow would wake up with a new belief, not just like, a new piece of information, but like they would wake up believing something new tomorrow. What would it be? And why?
Oh, well, it would absolutely be the concept of self love. The concept as as I've, it's, I've been, as I've been saying it to my husband a lot in this training of just sort of moving people more towards self love. And he interpreted that as like, how do I I just be a better friend to myself. And I also thought that was a great way to say it and quite as flaky. I'm getting really flaky, but but a way that people can really see like, I don't actually treat myself the way that I treat my friends. I don't give myself that kind of space. And how do we embrace a feeling more than a thought? A feeling of what it's like to hold ourselves in that light? Yeah. And especially when we feel ourselves distressed, activated by the world, you know, insecure, or whatever the world sort of brings us and our reaction is to feel negatively about ourselves. Now, if we can start to feel the idea of what is it like to hug ourselves, what is it like to be a friend and to love ourselves? We would react to these difficult situations in a much smoother manner.
Yeah. I think that's a great way to put it, it reminds me I think my wife is kind of mentioned this similar idea to me that, like if, if a friend treated us the way we treat ourselves, sometimes how long would they be our friends? Like? And the answer is like,
no, no, we only put
might even punch them in the face.
We could fight over it.
Right? Exactly. And when when people say that to me, after ketamine sessions of just kind of like, wow, I just like I'm okay. My anxiety I had, I had a person who did experience what we call in the psychedelic world kind of an ego death. And it was it was a very difficult experience of not knowing who he was. And not happy about it. Most of us most are not happy when we completely lose all of our boundaries and our sense of self. But the meaning that he derived from that of like, wow, when I really lost my anxiety, I didn't know who I was. And that was really the meaning that he attached to that. So then as as we've worked on that since then, his anxiety is lower, but almost because he gave himself permission to experience it when it comes up. Not to fight it.
it's like this is actually a part of me, and I can love myself anyway, like this is this is all part of my capital S self.
And when you put it in that space, you can move through it
like that. So the main takeaway Then as we all got to love ourselves some more,
a little bit more.
And if we want a little pharmacological help, we should look into ketamine.
Right? To find that relationship with yourself. We can help you. Yeah.
All right, Tatiana, thank you so much. This is a blast.
Yeah, this is great. Thanks, Danny.
Thank you, everybody for listening. We'll see you next week.