034 - Tatyana Gustafson on Ketamine Treatment for Depression, Anxiety, Suicidality, and Optimization

Danny Mulvihill  0:15  
Welcome back to another episode of The MindState 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 has 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.

Tatyana Gustafson  0:47  
Thank you for having me.

Danny Mulvihill  0:48  
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.

Tatyana Gustafson  1:06  
Okay. Yeah. That that's a long story. 

Danny Mulvihill  1:11  
Sure. 

Tatyana Gustafson  1:12  
I'm actually from a family of mental health providers, I don't think I had a choice really

Okay

As far as this as 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.. 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 like 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 interestingly 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.

Danny Mulvihill  2:24  
Yeah, it's somewhat limited and ineffective

Tatyana Gustafson  2:26  
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. 

Danny Mulvihill  2:47  
Yeah

Tatyana Gustafson  2:48  
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

Danny Mulvihill  2:58  
It's very compelling

Tatyana Gustafson  2:59  
It's very compelling

Danny Mulvihill  3:01  
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?

Tatyana Gustafson  3:08  
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, that it separates from placebo. 

Danny Mulvihill  3:23  
Yeah, for sure. 

Tatyana Gustafson  3:25  
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. 

Danny Mulvihill  3:45  
Yeah. 

Tatyana Gustafson  3:46  
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 

Danny Mulvihill  4:04  
Interesting. 

Tatyana Gustafson  4:05  
And I was just really skeptical about the whole space. 

Danny Mulvihill  4:09  
Yeah

Tatyana Gustafson  4:09  
Really the whole 

Danny Mulvihill  4:10  
Like the whole psychedelic therapy space. 

Tatyana Gustafson  4:12  
Like the whole ethics of it. 

Danny Mulvihill  4:12  
Okay. 

Tatyana Gustafson  4:12  
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 

Danny Mulvihill  4:28  
Without like the psychotherapy backgrounds

Tatyana Gustafson  4:30  
Right? No background in psychiatry

Danny Mulvihill  4:32  
Sure

Tatyana Gustafson  4:33  
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 now, 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. 

Danny Mulvihill  5:21  
Yeah 

Tatyana Gustafson  5:22  
For, for patients, and it's legal.

Danny Mulvihill  5:25  
That's what I was gonna -- like, perhaps one of the most

Tatyana Gustafson  5:28  
Yeah

Danny Mulvihill  5:28  
Beneficial ones right now is that 

Tatyana Gustafson  5:30  
It's accessible 

Danny Mulvihill  5:31  
People who want to exist within the confines of law can participate

Tatyana Gustafson  5:37  
Right? 

Danny Mulvihill  5:37  
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 etcetera?

Tatyana Gustafson  5:57  
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 

Danny Mulvihill  6:08  
Right. 

Tatyana Gustafson  6:09  
So it typically the non ordinary state of consciousness that that ketamine induces lasts for most people about 45 minutes. 

Danny Mulvihill  6:20  
Okay. 

Tatyana Gustafson  6:21  
So it, it makes it usable, makes it slightly less expensive than in comparison, something like MDMA, which is about an eight hour session.

Danny Mulvihill  6:31  
Yeah. Because you need the medical facility for that, booked for that timeframe.

Tatyana Gustafson  6:35  
Exactly. We need to pay a therapist's time for eight hours

Danny Mulvihill  6:38  
And you gotta paid labor on it

Tatyana Gustafson  6:40  
Exactly. And, and, again, they're different, I don't think we can necessarily 

Danny Mulvihill  6:46  
Sure

Tatyana Gustafson  6:46  
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

Danny Mulvihill  7:03  
Yeah

Tatyana Gustafson  7:03  
to three hours

Danny Mulvihill  7:04  
but that's a lot more, that's an easy stretch.

Tatyana Gustafson  7:07  
It's doable, 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, in you know, five years or something. Ketamine will still be used quite frequently, because of its efficacy, but also just the logistics

Danny Mulvihill  7:41  
Right 

Tatyana Gustafson  7:41  
Around what a session looks like.

Danny Mulvihill  7:44  
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?

Tatyana Gustafson  8:03  
Right. Of course, it has to be said, everybody has a different experience. Sure. 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 

Danny Mulvihill  8:36  
Sure 

Tatyana Gustafson  8:37  
Some people at a very low dose have a really profound, intense, both visually psychedelic, but sort of emotionally deep

Danny Mulvihill  8:47  
Yeah

Tatyana Gustafson  8:48  
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 threats 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

Danny Mulvihill  9:18  
Yeah 

Tatyana Gustafson  9:18  
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. 

Danny Mulvihill  9:47  
Yeah

Tatyana Gustafson  9:47  
That I think are some of the most profound work 

Danny Mulvihill  9:51  
Totally 

Tatyana Gustafson  9:51  
That people do in a ketamine space

Danny Mulvihill  9:56  
What, perhaps we should have talked about this too, but what are the symptoms that a typical patient is experiencing that would bring them to ketamine treatment in the first place?

Tatyana Gustafson  10:07  
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, 

Danny Mulvihill  11:06  
Right. 

Tatyana Gustafson  11:08  
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 'does it 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.. the ketamine space is a good space to begin to separate yourself from your ruminations. 

Danny Mulvihill  11:43  
Okay

Tatyana Gustafson  11:44  
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.

Danny Mulvihill  12:04  
Yeah, in one sense, are they.. are they able to sort of observe the ruminations 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

Tatyana Gustafson  12:19  
It's, it is a variety of things. I think after practicing psychiatry for a while I, there's just there's just themes. 

Danny Mulvihill  12:29  
Yeah

Tatyana Gustafson  12:29  
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. 

Danny Mulvihill  13:03  
Yeah. 

Tatyana Gustafson  13:04  
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

Danny Mulvihill  13:24  
Yeah, okay

Tatyana Gustafson  13:24  
Difficult. People feel afraid. People see an intense darkness. And it's not always a 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.

Danny Mulvihill  14:23  
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. It wasn't 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 classifications, sort of, of psychedelics, and as I understand it, ketamine is a dissociative, 

Tatyana Gustafson  15:04  
Yeah

Danny Mulvihill  15:05  
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

Tatyana Gustafson  17:02  
Sure, sure, yeah. So ketamine, as you know, has been used as an anesthetic

Danny Mulvihill  17:09  
Right

Tatyana Gustafson  17:10  
In ORs 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 a high enough dose, you know, 10 milligrams per kilogram, it's usually dosed by weight, you know, in a clinical setting

Danny Mulvihill  17:32  
Sure

Tatyana Gustafson  17:32  
Not in a rave setting. You can give it at such high doses that you could cut somebody's leg off, and they wouldn't even feel it.

Danny Mulvihill  17:39  
They wouldn't even feel it.

Tatyana Gustafson  17:40  
They wouldn't be so dissociated from their body. They wouldn't even feel the sensations

Danny Mulvihill  17:47  
Whoa. 

Tatyana Gustafson  17:48  
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

Danny Mulvihill  18:11  
Okay

Tatyana Gustafson  18:11  
You know, works within five minutes, right? 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

Danny Mulvihill  18:25  
Wow

Tatyana Gustafson  18:25  
And then 45 minutes later, they are out of the experience. 

Danny Mulvihill  18:30  
Yeah

Tatyana Gustafson  18:31  
So an amazing medication. Now, at that dose, there are no psychedelic properties. 

Danny Mulvihill  18:36  
Interesting. 

Tatyana Gustafson  18:37  
You are gone. 

Danny Mulvihill  18:39  
Yeah

Tatyana Gustafson  18:39  
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

Danny Mulvihill  18:49  
What's the difference? It's like, is it an order of magnitude higher dose, or roughly like how much more

Tatyana Gustafson  18:56  
There are darts that are usually used mostly in the ER, but are usually around four milligrams per kilogram to 7, 10 milligrams

Danny Mulvihill  19:06  
Okay

Tatyana Gustafson  19:07  
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

Danny Mulvihill  19:16  
Okay

Tatyana Gustafson  19:16  
Was really when this began. We started using ketamine at point five milligrams 

Danny Mulvihill  19:24  
Per kilogram?

Tatyana Gustafson  19:25  
Per kilogram. 

Danny Mulvihill  19:26  
Okay. 

Tatyana Gustafson  19:27  
Ti ny doses

Danny Mulvihill  19:29  
Roughly a tenth.. depending on

Tatyana Gustafson  19:31  
Yup

Danny Mulvihill  19:31  
Okay

Tatyana Gustafson  19:32  
Yeah and the first doses of ketamine that were given to treat severe suicidality. This is how ketamine came into psychiatry

Danny Mulvihill  19:44  
Yeah

Tatyana Gustafson  19:45  
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.

Danny Mulvihill  19:57  
Yeah

Tatyana Gustafson  19:57  
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.

Danny Mulvihill  20:13  
Just because of all the cultural baggage. 

Tatyana Gustafson  20:15  
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 state, right? 

Danny Mulvihill  20:29  
Yeah

Tatyana Gustafson  20:29  
So really the dose that was given at point five milligrams per kilogram was chosen to be sub psychedelic. 

Danny Mulvihill  20:36  
Okay.

Tatyana Gustafson  20:37  
And for some people, I have to say, point five milligrams has some psychedelic properties, but not most

Danny Mulvihill  20:42  
Okay

Tatyana Gustafson  20:42  
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.

Danny Mulvihill  21:00  
Okay, so it's purely physiological, not so much

Tatyana Gustafson  21:03  
Purely

Danny Mulvihill  21:03  
Okay, and how does that work 

Tatyana Gustafson  21:05  
Completely. Well, ketamine modulates glutamate

Danny Mulvihill  21:10  
Okay

Tatyana Gustafson  21:10  
It's a chemical in our brain that very few medications modulate, to be honest, it's a we are typically modulating serotonin, dopamine

Danny Mulvihill  21:18  
Sure

Tatyana Gustafson  21:18  
Norepinephrine, and that's really where psychiatry has been for 50 plus years. 

Danny Mulvihill  21:24  
Okay. 

Tatyana Gustafson  21:24  
And so ketamine is really one of the few medications that really stimulates glutamate production and taking up

Danny Mulvihill  21:33  
Yeah

Tatyana Gustafson  21:33  
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.e. little branches of neurons

Danny Mulvihill  22:02  
Yeah

Tatyana Gustafson  22:02  
Are spreading out for about three days after a dose. 

Danny Mulvihill  22:07  
Interesting

Tatyana Gustafson  22:08  
Your neurons are growing, 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. 

Okay

So in those three days after a ketamine dose, your brain is ripe to learn a different story. Yeah, 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.

Danny Mulvihill  23:06  
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,

Tatyana Gustafson  23:29  
You know, theoretically could be possible

Danny Mulvihill  23:31  
But you don't see that?

Tatyana Gustafson  23:33  
But you don't see it.

Danny Mulvihill  23:34  
Interesting, okay, 

Tatyana Gustafson  23:35  
Because it has the psychedelic properties. This is the beauty of psychedelics is we feel more self love

Danny Mulvihill  23:43  
Yeah

Tatyana Gustafson  23:43  
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 

Danny Mulvihill  24:19  
Yeah

Tatyana Gustafson  24:19  
Towards yourself, and towards others, it would be hard. 

Danny Mulvihill  24:22  
Yeah

Tatyana Gustafson  24:23  
You could do it if you really wanted to.

Danny Mulvihill  24:25  
Sure

Tatyana Gustafson  24:25  
But your brain is ripe for having a little more patience and softness towards yourself in the world. 

Danny Mulvihill  24:33  
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. 

Tatyana Gustafson  24:48  
Right, exactly. 

Danny Mulvihill  24:49  
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.. common as you pointed out, so and I'm also curious to know more about it

Tatyana Gustafson  25:03  
Sure. So, glutamate actually is the most abundant neurotransmitter of our nervous system, the nervous system that we call the sympathetic nervous system.

Danny Mulvihill  25:17  
Okay

Tatyana Gustafson  25:17  
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 glutamate's 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,

Danny Mulvihill  25:53  
Because of that boosting effect?

Tatyana Gustafson  25:55  
Right? 

Danny Mulvihill  25:55  
Okay

Tatyana Gustafson  25:55  
Cause 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.

Danny Mulvihill  26:23  
So they feel some psychoactive effects, and not -- okay

Tatyana Gustafson  26:26  
So their state of consciousness has changed. It's a good state of consciousness

Danny Mulvihill  26:30  
Sure

Tatyana Gustafson  26:30  
It's relaxed, it's almost sleep-like 

Danny Mulvihill  26:33  
Yeah

Tatyana Gustafson  26:34  
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 focused

Danny Mulvihill  26:56  
Yeah

Tatyana Gustafson  26:57  
On these conversations. And what people were saying is because your brain was actually having many thoughts

Danny Mulvihill  27:03  
Yeah

Tatyana Gustafson  27:04  
Kind of all at the same time

Danny Mulvihill  27:06  
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 oh fuck, what was that thought? And then I'm like, oh, no, I missed this one. And now I'm lost.

Tatyana Gustafson  27:18  
Yes

Danny Mulvihill  27:18  
And why are we talking about this?

Tatyana Gustafson  27:21  
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

Danny Mulvihill  27:39  
Is that like too high of a dose? Or is it not really linked to dosage?

Tatyana Gustafson  27:45  
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

Danny Mulvihill  27:59  
Yeah

Tatyana Gustafson  27:59  
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.

Danny Mulvihill  28:07  
Yeah

Tatyana Gustafson  28:08  
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. 

Danny Mulvihill  28:24  
Yeah

Tatyana Gustafson  28:25  
Right. We don't have anything like that in psychiatry we never have. And so that component of it is, it's huge

Danny Mulvihill  28:32  
Yeah

Tatyana Gustafson  28:32  
In this profession. It's typically short lived. That's the sad part is that, you know, most people feel -- approximately 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 

Danny Mulvihill  29:00  
Purely physiological. 

Tatyana Gustafson  29:01  
Right. 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. 

Danny Mulvihill  29:27  
Gotcha. 

Tatyana Gustafson  29:27  
Swish it, swish it, 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

Danny Mulvihill  29:39  
Sure

Tatyana Gustafson  29:39  
Of getting ketamine to the body because your body the Buechel mucosa is only probably taking up maybe 20 to 30%

Danny Mulvihill  29:47  
Well and who could really swish around for 15 minutes without swallowing a little bit. 

Tatyana Gustafson  29:51  
It's hard

Danny Mulvihill  29:51  
Sure, I bet 

Tatyana Gustafson  29:52  
It's uncomfortable

Danny Mulvihill  29:54  
Why would somebody go sub or sublingual or lozenge as opposed to intramuscular?

Tatyana Gustafson  29:59  
So in 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 they -- their nervous system just gets really activated if they ever talk about their mom. So we can't ever really talk about the pain that they have with their mother.

Danny Mulvihill  30:38  
And that's the source of the whole fucking problem.

Tatyana Gustafson  30:40  
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. 

Danny Mulvihill  30:50  
Yeah. 

Tatyana Gustafson  30:51  
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

Danny Mulvihill  31:03  
Yeah

Tatyana Gustafson  31:04  
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 in a lot of pain

Danny Mulvihill  31:34  
To see that it wasn't just directed at them that they were also experiencing 

Tatyana Gustafson  31:39  
Yeah, to kind of 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.

Danny Mulvihill  31:59  
Right. It seems like it.. it's also this, I like that phrase ketamine lubricated space, it sort of cuts through this shame, like

Tatyana Gustafson  32:12  
Shame

Danny Mulvihill  32:14  
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?

Tatyana Gustafson  32:32  
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.. some still child brain activity that I should have done something else to avoid having been in this situation. 

Danny Mulvihill  32:52  
Yeah. 

Tatyana Gustafson  32:53  
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.

Danny Mulvihill  33:06  
Yeah. What about.. man, I had a thought from

Tatyana Gustafson  33:13  
Oh, let me tell you because I have not so then there is because there's really three ways that I'm starting to

Danny Mulvihill  33:17  
Okay

Tatyana Gustafson  33:17  
Look at using ketamine so we kinda talked about the IV, low dose suicidality? 

Danny Mulvihill  33:22  
Yeah 

Tatyana Gustafson  33:22  
Sub 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

Danny Mulvihill  33:35  
Okay

Tatyana Gustafson  33:36  
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,

Danny Mulvihill  33:52  
Right

Tatyana Gustafson  33:52  
Quickly. So within five minutes of an injection, somebody is in a really different state of consciousness 

Danny Mulvihill  34:00  
Yeah

Tatyana Gustafson  34:00  
Than where they started. And it is in that that psychedelic space that again, a lot of psychotherapy happens, a lot of emotions come up. However, most people because of that dissociative 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

Danny Mulvihill  34:42  
Yeah

Tatyana Gustafson  34:42  
Of psychedelics. Ketamine doesn't work very well as a psychedelic without music.

Danny Mulvihill  34:48  
Interesting.

Tatyana Gustafson  34:49  
 Yeah. The brain kind of gets stuck.

Danny Mulvihill  34:53  
Yeah. So the music sort of like kind of gives it a boat to float in, in a sense.

Tatyana Gustafson  34:59  
Absolutely. Usually and and the experience can change based on the music that you're playing

Danny Mulvihill  35:05  
Sure, like if it gets kind of sad it may draw you towards those emotions 

Tatyana Gustafson  35:09  
It 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

Danny Mulvihill  35:21  
Yeah

Tatyana Gustafson  35:21  
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 

Danny Mulvihill  35:52  
Interesting. 

Tatyana Gustafson  35:53  
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.

Danny Mulvihill  36:09  
Right

Tatyana Gustafson  36:09  
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.

Danny Mulvihill  36:27  
Yeah. I feel like we've done a relatively good job of covering some of the physiological and just like practical aspects. 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?

Tatyana Gustafson  37:01  
Yeah, yeah. Ideally, these people are coming usually from a therapist

Danny Mulvihill  37:08  
Okay

Tatyana Gustafson  37:09  
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

Danny Mulvihill  37:41  
Yeah

Tatyana Gustafson  37:41  
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. Although, 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. 

Danny Mulvihill  38:11  
Yeah. 

Tatyana Gustafson  38:12  
So people do need to have their blood pressure well controlled, if they have hypertension. You know, 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.

Danny Mulvihill  38:34  
Yeah

Tatyana Gustafson  38:36  
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 internal family system.

Danny Mulvihill  38:47  
Okay

Tatyana Gustafson  38:48  
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 capital S 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.

Danny Mulvihill  39:44  
Okay

Tatyana Gustafson  39:45  
And these, these are what what he termed protectors, managers, exiles, and I think the important thing to just know about this is that these ruminative thinking patterns are protectors, you developed 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

Danny Mulvihill  40:30  
And how does that

Tatyana Gustafson  40:30  
Can control. 

Danny Mulvihill  40:31  
Oh, wow. Okay. 

Tatyana Gustafson  40:33  
So just for instance, like divorce, many children will always feel like a split in their parents is their fault. 

Danny Mulvihill  40:41  
So sad 

Tatyana Gustafson  40:42  
But 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

Danny Mulvihill  40:57  
Because if it's their fault, they elicit some control. 

Tatyana Gustafson  41:00  
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

Danny Mulvihill  41:12  
Sure. 

Tatyana Gustafson  41:14  
But then we get older teenagers, adults, and it's no longer serving us. And we can't get rid of it. And IFS is the.. 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

Danny Mulvihill  41:49  
Yeah

Tatyana Gustafson  41:50  
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. Now IFS is done all the time without any psychedelic. 

Danny Mulvihill  42:09  
Sure. 

Tatyana Gustafson  42:10  
However, it applies really nicely to the psychedelic space, even though I think Dr. Schwartz came up with it in the 80s.

Danny Mulvihill  42:18  
And maybe was some proponent of psychedelic therapy himself.

Tatyana Gustafson  42:21  
No, no, he is now. 

Danny Mulvihill  42:22  
Oh, nice. Good for him. 

Tatyana Gustafson  42:23  
Yes. And it turns out his theory is great for this because it really -- the idea that psychedelics can introduce you to that capital S self.

Danny Mulvihill  42:38  
In some sense, is this also helpful just to give some people a bit of a framework to hang these ideas on 

Tatyana Gustafson  42:44  
Right

Danny Mulvihill  42:45  
To start to have a mental model of how to even think about this stuff?

Tatyana Gustafson  42:49  
Right, right. And I think that having starting to introduce these frameworks to people allows them to create meaning from their psychedelic experience.

Danny Mulvihill  43:03  
Ah, yeah 

Tatyana Gustafson  43:04  
Human beings are smart, fascinating mammals, but we are trying constantly to make meaning 

Danny Mulvihill  43:12  
Yeah

Tatyana Gustafson  43:13  
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. 

Danny Mulvihill  43:20  
Yeah

Tatyana Gustafson  43:21  
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 meaning, 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.

Danny Mulvihill  44:02  
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 that 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 listen 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?

Tatyana Gustafson  44:38  
Right. I would do more prep work

Danny Mulvihill  44:42  
Okay. 

Tatyana Gustafson  44:43  
I feel strongly for my practice, that I want this to be a psychotherapy centered experience. You know, psychedelic medicine is not cheap

Danny Mulvihill  44:59  
Right

Tatyana Gustafson  45:00  
Insurance doesn't cover it. 

Danny Mulvihill  45:01  
Yeah. 

Tatyana Gustafson  45:03  
We try to get around that. And sometimes we do and sometimes we don't you know, it's.. it's an interesting dance

Danny Mulvihill  45:11  
Yeah

Tatyana Gustafson  45:11  
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, yeah. 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. 

Danny Mulvihill  45:51  
Sure

Tatyana Gustafson  45:51  
Are you just fascinated

Danny Mulvihill  45:53  
Yeah

Tatyana Gustafson  45:53  
Right? Are you just fascinated, I'm okay with that. Somebody that really comes in, they haven't really had previous mental health treatment

Danny Mulvihill  45:59  
Right

Tatyana Gustafson  45:59  
And they really just kind of want to see what happens if they expand

Danny Mulvihill  46:02  
Like looking to optimize type of people. 

Tatyana Gustafson  46:04  
Right, right. 

Danny Mulvihill  46:05  
Yeah

Tatyana Gustafson  46:05  
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, and that can absolutely help people go out and just be a little bit more optimized. 

Danny Mulvihill  46:19  
Sure

Tatyana Gustafson  46:20  
Right

Danny Mulvihill  46:20  
Definitely. 

Tatyana Gustafson  46:21  
If you are 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, you're not kind of the point hide 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 IM injection woosh into this world that you are not in control of kind of like what you described

Danny Mulvihill  47:30  
So they have to kind of get comfortable with like, Okay, I know, I'm going to lose control. 

Tatyana Gustafson  47:34  
Right

Danny Mulvihill  47:34  
And after a few sessions, they can anticipate that and not be so terrified by it, perhaps 

Tatyana Gustafson  47:39  
Right because that being terrified, will bring up a little more of a terrifying experience. 

Danny Mulvihill  47:44  
Sure. 

Tatyana Gustafson  47:45  
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. 

Danny Mulvihill  47:55  
Yeah

Tatyana Gustafson  47:55  
If we can kind of make any headway on in that landscape. People are, are going to have improvements in their mental health

Danny Mulvihill  48:07  
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.

Tatyana Gustafson  48:19  
Yes

Danny Mulvihill  48:19  
Because, like you said, insurance often isn't going to cover these types of things. And like for myself, personally, 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 cash customer, what does that look like? What are the costs typically range, etc, right?

Tatyana Gustafson  48:43  
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. 

Danny Mulvihill  48:54  
Ah, It's the first one 

Tatyana Gustafson  48:55  
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. 

Danny Mulvihill  49:24  
Yeah

Tatyana Gustafson  49:24  
You have to monitor people as you would in an operating room. 

Danny Mulvihill  49:28  
Yeah, okay. 

Tatyana Gustafson  49:29  
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 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. 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 ragdolled, by insurance companies? You know, what are the ethics in that 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.

Danny Mulvihill  50:46  
Interesting. Yeah, let's dig into that. So when you say 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.

Tatyana Gustafson  51:07  
Yup

Danny Mulvihill  51:07  
And it rarely covers anything that I want done.

Tatyana Gustafson  51:09  
Right

Danny Mulvihill  51:09  
So now I'm paying all this money for insurance, and you just decide not to accept it. Right? 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? 

Tatyana Gustafson  51:30  
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. 

Danny Mulvihill  51:44  
So you need like a full time person just 

Tatyana Gustafson  51:45  
Absolutely. 

Danny Mulvihill  51:46  
To do the insurance stuff

Tatyana Gustafson  51:47  
Possibly more than one

Danny Mulvihill  51:48  
Yeah

Tatyana Gustafson  51:48  
Kind of depending on how many policies that you take, you know, so now you're paying salaries

Danny Mulvihill  51:54  
Sure

Tatyana Gustafson  51:55  
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's standards  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.

Danny Mulvihill  52:35  
Yeah

Tatyana Gustafson  52:35  
There have to and Austin is very affluent city, and affluent cities tend to really go more towards the not accepting insurance. So enough people with enough money

Danny Mulvihill  52:45  
Cause enough customers that can pay 

Tatyana Gustafson  52:47  
Yeah, 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

Danny Mulvihill  53:31  
Yeah

Tatyana Gustafson  53:32  
And that might be up to you and however you want to manage that person 

Danny Mulvihill  53:36  
Can you like do two hours every two weeks or something? 

Tatyana Gustafson  53:39  
No

Danny Mulvihill  53:39  
Really?

Tatyana Gustafson  53:40  
No. For rare circumstances if you have like a crisis situation, but you can't have a crisis situation like every week. Insurance companies will stop paying for that. 

Danny Mulvihill  53:48  
So then how does that look? Do you.. can you bill like for one hour and charge cash for the second hour? 

Tatyana Gustafson  53:53  
Right

Danny Mulvihill  53:54  
So that's what you have to do.

Tatyana Gustafson  53:55  
That's what we have come up with okay. I.. there's arguments to say that we're not even you know that insurance companies once you have a contract with an insurance company, you're really can't charge people out of pocket if they carry that insurance, right. We've just decided to not, not worry about it. So right now what we're doing Yeah, it's exactly that billing for the first hour to their insurance companies. And then the second hour they pay out of pocket 

Danny Mulvihill  54:21  
Gotcha. 

Tatyana Gustafson  54:22  
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. 

Danny Mulvihill  54:30  
Yeah

Tatyana Gustafson  54:31  
And that tail end is usually some dizziness

Danny Mulvihill  54:36  
You can't just be 

Tatyana Gustafson  54:36  
Maybe some nausea

Danny Mulvihill  54:37  
Like alright, drive safe 

Tatyana Gustafson  54:38  
Right? You can't just kick people out. Well, good point, Danny because you can't can't drive you gotta get a ride. You gotta 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 chat

Danny Mulvihill  54:58  
There's gonna be a checkbox on Uber now.. like they have a don't talk to me checkbox, which is interesting. 

Tatyana Gustafson  55:04  
I know, yes. So there, but you know, 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. Yeah, before we walk them out. And you know, that's something that I know.. 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

Danny Mulvihill  55:38  
You can't just hang out in the waiting room or.. interesting. What about, so then what are the.. what do 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.

Tatyana Gustafson  55:55  
Right, right. But yeah, I would say they probably range between two to 500 an hour. 

Danny Mulvihill  56:00  
Okay. 

Tatyana Gustafson  56:01  
Is I think what I've typically seen

Danny Mulvihill  56:03  
And usually you're committing to at least three sessions, so it's kind of a package deal, or?

Tatyana Gustafson  56:08  
It's kind of -- so again, the initial research we do we try, we, I want to have a research based practice. 

Danny Mulvihill  56:17  
Yeah,

Tatyana Gustafson  56:17  
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. 

Danny Mulvihill  56:27  
Okay

Tatyana Gustafson  56:28  
Two a week for three weeks. 

Danny Mulvihill  56:29  
Gotcha. 

Tatyana Gustafson  56:32  
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

Danny Mulvihill  56:55  
Right

Tatyana Gustafson  56:56  
Think about it, you know you're coming in every three to four days. First few weeks.

Danny Mulvihill  57:00  
So as it's wearing off, you're re-upping like so you're

Tatyana Gustafson  57:02  
Right

Danny Mulvihill  57:02  
Getting that like three weeks to rewrite the story.

Tatyana Gustafson  57:06  
Righ. 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.

Danny Mulvihill  57:18  
Sure

Tatyana Gustafson  57:18  
And I certainly it is cost prohibitive six sessions in three weeks, or it's gonna get expensive for some people.

Danny Mulvihill  57:26  
Yeah, I mean, what's that going to run me like six grands? Okay

Tatyana Gustafson  57:31  
It could. Yeah. 

Danny Mulvihill  57:32  
Yeah. And what about 

Tatyana Gustafson  57:34  
It kind of depends on the copay of your insurance

Danny Mulvihill  57:36  
What I mean, just straight up cash, like, what is it 

Tatyana Gustafson  57:38  
Straight up cash? Well, so that would probably be hourly. So you're probably looking at something like 200 to 500 an hour.

Danny Mulvihill  57:45  
And then looking at four hours a week. So it can be 2000 a week at the high end. So 6k, right, to change my life. 

Tatyana Gustafson  57:52  
Right. Could be worth it 

Danny Mulvihill  57:55  
Could be.

Tatyana Gustafson  57:55  
Sort of, you know, as we're starting to look at the approval of MDMA, which again, is eight hours. 

Danny Mulvihill  58:01  
Yeah, no kidding

Tatyana Gustafson  58:02  
Three, eight hour sessions. But really, the research that 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, 1 year 18 months out, we're symptom free.

Danny Mulvihill  58:27  
Isn't that.. just bananas? 

Tatyana Gustafson  58:29  
It's amazing.

Danny Mulvihill  58:30  
It's like a miracle.

Tatyana Gustafson  58:31  
It is. It's, it's a miracle. And so if you look at it like that, you're actually probably saving money. Will 

Danny Mulvihill  58:38  
Sure 

Tatyana Gustafson  58:38  
Insurance companies begin to look at it that way? I don't -- maybe they're they're about saving money.

Danny Mulvihill  58:43  
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 much of this 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 is the insurance company just getting screwed on this. Like, they're just a worst negotiator than the pharmaceutical company. What's going on?

Tatyana Gustafson  59:18  
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.

Danny Mulvihill  59:35  
Yeah

Tatyana Gustafson  59:36  
But we have a lot of really good new medications. And they're new and they're roughly about $1,000 a month.

Danny Mulvihill  59:42  
Geez

Tatyana Gustafson  59:42  
If you were to pay out of pocket. Nobody does.

Danny Mulvihill  59:46  
Pays that. 

Tatyana Gustafson  59:47  
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 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, yeah, 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.

Danny Mulvihill  1:00:32  
It's just as a part of the job, in a sense.

Tatyana Gustafson  1:00:34  
Yup. 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

Danny Mulvihill  1:00:47  
Like, as a.. just a drug 

Tatyana Gustafson  1:00:48  
As a medication. It's been around 

Danny Mulvihill  1:00:50  
It's really what you're paying for is like, the, the hourly wage of the psychotherapist and like the facility.

Tatyana Gustafson  1:00:57  
Exactly. 

Danny Mulvihill  1:00:57  
But the medicine itself is 

Tatyana Gustafson  1:00:58  
Medicine itself is very cheap. 

Danny Mulvihill  1:01:00  
That's good.

Tatyana Gustafson  1:01:01  
Very cheap

Danny Mulvihill  1:01:01  
At least we got that going for it. 

Tatyana Gustafson  1:01:02  
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. 

Danny Mulvihill  1:01:21  
Yeah

Tatyana Gustafson  1:01:22  
Can't do it. So they were really trying to come up with a different molecule

Danny Mulvihill  1:01:26  
Ketamine X-4 or some shit

Tatyana Gustafson  1:01:27  
Exactly. That they could patent 

Danny Mulvihill  1:01:30  
Those bastards. 

Tatyana Gustafson  1:01:31  
But they did. They eventually developed a very expensive filtration process 

Danny Mulvihill  1:01:36  
That's patented

Tatyana Gustafson  1:01:37  
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 it the same? 

Yeah

Danny Mulvihill  1:01:47  
Interesting 

Tatyana Gustafson  1:01:51  
Seems to be roughly the same couple of head to head trials do show that the mixed ketamine which is what's cheap

Danny Mulvihill  1:02:14  
Yeah

Tatyana Gustafson  1:02:14  
Might be a tad bit more effective. But really, those numbers are so small, I think it's irrelevant. 

Danny Mulvihill  1:02:20  
Yeah

Tatyana Gustafson  1:02:21  
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

Danny Mulvihill  1:02:33  
But for some that might be like, the delivery system can be a big part of these treatments, too. 

Tatyana Gustafson  1:02:37  
Yeah

Danny Mulvihill  1:02:38  
Because for example, if, say you have a traditional psychotherapists office, they probably don't want to just like put a needle in you. 

Tatyana Gustafson  1:02:44  
Right

Danny Mulvihill  1:02:44  
But the lozenge or 

Tatyana Gustafson  1:02:46  
The intranasal was

Danny Mulvihill  1:02:46  
The intranasal

Tatyana Gustafson  1:02:48  
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.. 

Danny Mulvihill  1:03:05  
They really wanna cut that baggage out of it

Tatyana Gustafson  1:03:06  
A 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. 

Danny Mulvihill  1:03:43  
Wow. 

Tatyana Gustafson  1:03:43  
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

Danny Mulvihill  1:03:53  
Sure

Tatyana Gustafson  1:03:54  
For people who are financially under the gun and spravato is it's an eight week treatment. 

Danny Mulvihill  1:04:01  
Okay

Tatyana Gustafson  1:04:02  
Twice a week of intranasal ketamine, no therapy, you're just going in

Danny Mulvihill  1:04:06  
No therapy? 

Tatyana Gustafson  1:04:06  
And yeah,

Danny Mulvihill  1:04:07  
I guess that keeps it cheap

Tatyana Gustafson  1:04:08  
Right. It keeps it cheap and, and.. 

Danny Mulvihill  1:04:13  
What are the results? Like are people having similar outcomes? Obviously, I would argue that and I think you would too that if there were a psychotherapy component that they would maybe have elevated results.

Tatyana Gustafson  1:04:24  
And I think the important thing is might they have better sustained result 

Danny Mulvihill  1:04:29  
That's the key, right?

Tatyana Gustafson  1:04:30  
Cause ketamine in that way it can boost people's mood so well, within hours 

Danny Mulvihill  1:04:40  
Yeah

Tatyana Gustafson  1:04:40  
Of using this medication. You just can go back into this same ruminative depressed, chemical wash that your brain was in previously. 

Danny Mulvihill  1:04:55  
Yeah

Tatyana Gustafson  1:04:55  
There is a lot of work to be done to try to change that story. But that is not to say that there isn't some real benefits that people can experience on Spravato.

Danny Mulvihill  1:05:08  
Yeah, I mean, if the two options are nothing or eight weeks with spravato, without therapy, then go for option B. 

Tatyana Gustafson  1:05:15  
Right

Danny Mulvihill  1:05:15  
Hands down. 

Tatyana Gustafson  1:05:16  
Right. 

Danny Mulvihill  1:05:17  
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.. like, somebody who's just like always, like, worried worried, or it 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.

Tatyana Gustafson  1:05:48  
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 Eeyore, Winnie the Pooh, right, 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

Danny Mulvihill  1:07:25  
And just see how, like, if they're already experiencing high glutamate prior to this

Tatyana Gustafson  1:07:32  
Right, you're putting them in a state, an activated sympathetic nervous system state is a good idea. 

Danny Mulvihill  1:07:41  
Yeah

Tatyana Gustafson  1:07:41  
It tends to be a good idea. I just think there's a way to do it. That is a little bit slower. 

Danny Mulvihill  1:07:48  
Sure

Tatyana Gustafson  1:07:49  
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

Danny Mulvihill  1:08:15  
Right, okay

Tatyana Gustafson  1:08:15  
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

Danny Mulvihill  1:08:40  
Yeah

Tatyana Gustafson  1:08:40  
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.

Danny Mulvihill  1:08:49  
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.

Tatyana Gustafson  1:08:55  
Right, right. That's, has a little more standard.

Danny Mulvihill  1:08:58  
Well, that's good to hear that I mean, because for anybody experiencing depression, it's a brutally law

Tatyana Gustafson  1:09:05  
Right, right. And fill it full of so much e 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

Danny Mulvihill  1:09:37  
Okay

Tatyana Gustafson  1:09:38  
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. to create color.

Danny Mulvihill  1:09:59  
Wow

Tatyana Gustafson  1:09:59  
Right. So I can.. so it's, it's trying to integrate all the parts of yourself

Danny Mulvihill  1:10:05  
Rather than something you have to get rid of. 

Tatyana Gustafson  1:10:08  
Right

Danny Mulvihill  1:10:08  
Sure. 

Tatyana Gustafson  1:10:09  
Right. 

Danny Mulvihill  1:10:10  
That's cool. 

Tatyana Gustafson  1:10:12  
Yes. 

Danny Mulvihill  1:10:12  
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.

Tatyana Gustafson  1:10:36  
Right, yeah. So I have a 17 year old, I have a 14 year old and an 8 year old. 

Danny Mulvihill  1:10:41  
Okay

Tatyana Gustafson  1:10:41  
All girls. And why are they destined? They told me they're not going to mental health, at least teenagers. 

Danny Mulvihill  1:10:50  
Yeah

Tatyana Gustafson  1:10:51  
My little one wants to be a chiropractor. I don't think she knows any chiropractors, she loves cracking her fingers.

Danny Mulvihill  1:10:59  
Aw, that's the best.

Tatyana Gustafson  1:11:00  
And she, that's what she wants to be. There's a lot of mental health in that too. But, but at anyway, my older daughters tell me they do not want to go into mental health. But I think it's just a similar thing. Now, 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

Danny Mulvihill  1:11:11  
Yeah

Tatyana Gustafson  1:11:34  
Being anxious and other people. We talked about family and human dynamics. We still do. 

Danny Mulvihill  1:11:43  
Yeah

Tatyana Gustafson  1:11:44  
There's five of us in my family. I'm the youngest. Two of my sisters are therapists.

Danny Mulvihill  1:11:49  
Oh, wow. It must be like quite the Thanksgiving

Tatyana Gustafson  1:11:53  
It is. 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. Yeah. 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

Danny Mulvihill  1:12:21  
Right? Because it's a bit edgy

Tatyana Gustafson  1:12:24  
It's a bit edgy. And I am not actually a huge proponent of drugs. 

Danny Mulvihill  1:12:30  
Sure. 

Tatyana Gustafson  1:12:30  
I've been in psychiatry a long time, I've seen a lot of, again, relational trauma, secondary to substance use. 

Danny Mulvihill  1:12:40  
Yeah. 

Tatyana Gustafson  1:12:42  
You know, alcohol and cannabis both have they're really good points, they really do. But if used in 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. Right. 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. 

Danny Mulvihill  1:13:17  
Yeah, at least abuse. 

Tatyana Gustafson  1:13:18  
Right. 

Danny Mulvihill  1:13:19  
It's hard. It's a very thin line to walk. 

Tatyana Gustafson  1:13:22  
It's a thin line. And there's a lot of really functional people out there that have relational struggles that I think are

Danny Mulvihill  1:13:30  
Way past the line. 

Tatyana Gustafson  1:13:31  
Yeah, right. They're functional. 

Danny Mulvihill  1:13:33  
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 a problem.

Tatyana Gustafson  1:13:57  
Measurable messing. 

Danny Mulvihill  1:13:58  
Yeah. 

Tatyana Gustafson  1:13:59  
And it's hard to measure that.

Danny Mulvihill  1:14:02  
Right.

Tatyana Gustafson  1:14:03  
I mean, it 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

Danny Mulvihill  1:14:20  
Yeah

Tatyana Gustafson  1:14:20  
Right, 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. 

Danny Mulvihill  1:14:31  
Yeah. 

Tatyana Gustafson  1:14:32  
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. 

Danny Mulvihill  1:14:45  
Yeah 

Tatyana Gustafson  1:14:46  
That is our work and I can see it in my teenagers. They even understand that work. 

Danny Mulvihill  1:14:50  
Yeah. 

Tatyana Gustafson  1:14:51  
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.. 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

Danny Mulvihill  1:15:18  
Just because of like the word being more commonly used and so people are gonna hear about it and then abuse it

Tatyana Gustafson  1:15:24  
Exactly, and it'll be available. 

Danny Mulvihill  1:15:26  
Yeah, so let's 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

Tatyana Gustafson  1:15:35  
Right

Danny Mulvihill  1:15:35  
And then how do you get is like, the street ketamine that's just a powder is that like dissolved in solution, so

Tatyana Gustafson  1:15:45  
Well, it can absolutely be snorted. And then there's also sublingual 

Danny Mulvihill  1:15:50  
Right 

Tatyana Gustafson  1:15:51  
Ketamine that can be used in high doses you can achieve a psychedelic state, you just have to do a lot. 

Danny Mulvihill  1:15:57  
Yeah

Tatyana Gustafson  1:15:57  
You're gonna do swishing, but but we all know about, you know, street drug drug dealers

Danny Mulvihill  1:16:01  
And people's willingness to 

Tatyana Gustafson  1:16:02  
Good, right

Danny Mulvihill  1:16:03  
Yeah

Tatyana Gustafson  1:16:03  
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 street Ketamine abuse, minimal. And I -- we're going to see more of it. 

Danny Mulvihill  1:16:22  
Yeah

Tatyana Gustafson  1:16:23  
We're already seeing just in the last year, more high schoolers really 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 and 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. 

Danny Mulvihill  1:17:14  
Okay. 

Tatyana Gustafson  1:17:15  
I believe that we can

Danny Mulvihill  1:17:16  
What are some ways that we can like that that can be mitigated? 

Tatyana Gustafson  1:17:21  
Well, good selection, right. I mean

Danny Mulvihill  1:17:23  
Not for patients

Tatyana Gustafson  1:17:24  
Right.

Danny Mulvihill  1:17:24  
Yeah. 

Tatyana Gustafson  1:17:25  
Picking, picking -- 

Danny Mulvihill  1:17:26  
So somebody comes in, and they're just like, trying to get high, probably

Tatyana Gustafson  1:17:30  
It's really, it's not hard to parse that out. 

Danny Mulvihill  1:17:34  
Yeah, sure. 

Tatyana Gustafson  1:17:35  
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.

Danny Mulvihill  1:18:01  
Yeah

Tatyana Gustafson  1:18:02  
Right. 

Danny Mulvihill  1:18:02  
They know somebody who can get it 

Tatyana Gustafson  1:18:04  
Right. 

Danny Mulvihill  1:18:05  
But they can't afford the six grand for another three week go.

Tatyana Gustafson  1:18:08  
Right. And then you end up in a lot of that addictive process of shame around it, and then leading to more use. 

Danny Mulvihill  1:18:16  
Yeah. 

Tatyana Gustafson  1:18:17  
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. 

Danny Mulvihill  1:18:29  
Right, yeah

Tatyana Gustafson  1:18:29  
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.

Danny Mulvihill  1:18:38  
Sure.

Tatyana Gustafson  1:18:39  
And so really leaving space open where we can get, you know, get to people, even if we use it again, therapeutically. 

Danny Mulvihill  1:18:47  
Yeah. 

Tatyana Gustafson  1:18:49  
That could really help. 

Danny Mulvihill  1:18:51  
Yeah. 

Tatyana Gustafson  1:18:52  
To not move into an addictive or detrimental space.

Danny Mulvihill  1:18:56  
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 ketamine, or if you have even encountered other clinics that do have a more ritualistic approach? 

Tatyana Gustafson  1:19:29  
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 

Danny Mulvihill  1:19:50  
Yeah

Tatyana Gustafson  1:19:50  
Right. We've always thought that was a strong point of our scientific work. 

Danny Mulvihill  1:19:58  
Yeah

Tatyana Gustafson  1:19:59  
Um, 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?

Danny Mulvihill  1:20:12  
Yeah

Tatyana Gustafson  1:20:12  
It's very didactic, secular

Danny Mulvihill  1:20:16  
Yeah. 

Tatyana Gustafson  1:20:17  
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 in embracing that in my own practice. It I have to say at first it was really uncomfortable

Danny Mulvihill  1:20:48  
Yeah

Tatyana Gustafson  1:20:49  
For me, and I'm, I'm it's growing on me though

Danny Mulvihill  1:20:53  
Interesting

Tatyana Gustafson  1:20:53  
It's really growing on me. So I would say that. So currently, right now I have two separate offices. I have one office where I do kind of mid management, the old style one and then I have a separate ketamine office. 

Danny Mulvihill  1:21:08  
Okay.

Tatyana Gustafson  1:21:09  
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 

Danny Mulvihill  1:21:22  
Interesting, okay. 

Tatyana Gustafson  1:21:24  
Based on kind of what's going on with them

Danny Mulvihill  1:21:27  
Yeah

Tatyana Gustafson  1:21:27  
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. 

Danny Mulvihill  1:21:41  
Yeah 

Tatyana Gustafson  1:21:42  
I mean, it doesn't matter how psychedelic your journey is

Danny Mulvihill  1:21:45  
Yeah

Tatyana Gustafson  1:21:45  
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. 

Danny Mulvihill  1:21:55  
Yeah

Tatyana Gustafson  1:21:56  
Really open in that ketamine space to the concept of just spirituality. 

Danny Mulvihill  1:22:03  
Yeah. 

Tatyana Gustafson  1:22:03  
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.

Danny Mulvihill  1:22:33  
Yeah, that's what like, because even listening to talk about that, when you said the word 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'm glad to share it.

Tatyana Gustafson  1:23:16  
No 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 

Danny Mulvihill  1:23:42  
What is it? I don't have any -- I'm not familiar

Tatyana Gustafson  1:23:44  
So Palo Santo, you've probably seen it. 

Danny Mulvihill  1:23:46  
Okay

Tatyana Gustafson  1:23:46  
It's the sticks, they just look like bark. 

Danny Mulvihill  1:23:48  
Okay

Tatyana Gustafson  1:23:49  
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 

Danny Mulvihill  1:23:58  
To smell

Tatyana Gustafson  1:23:59  
To smells. 

Danny Mulvihill  1:23:59  
Yeah

Tatyana Gustafson  1:24:00  
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

Danny Mulvihill  1:24:14  
Yeah, sure

Tatyana Gustafson  1:24:14  
Without burning sage. 

Danny Mulvihill  1:24:15  
Yup. 

Tatyana Gustafson  1:24:16  
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 Some Palo Santo, maybe you have a garnet crystal, whatever you've assigned meaning

Danny Mulvihill  1:25:07  
Yeah

Tatyana Gustafson  1:25:07  
In a non ordinary state of consciousness to those things, I've asked you to assign me

Danny Mulvihill  1:25:13  
Yeah

Tatyana Gustafson  1:25:13  
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 self love where you found that people have to be reminded of that space.

Danny Mulvihill  1:25:29  
Yeah. And smell is such a powerful reminder of things. 

Tatyana Gustafson  1:25:32  
Right. Right. 

Danny Mulvihill  1:25:34  
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 looked 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,

Tatyana Gustafson  1:26:09  
Right. Yeah, yeah. Okay. Well, so I completed psychedelic psychotherapy certification is a year long program out of a clinic in Boulder, okay. 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 -- ketamine is legal. 

Danny Mulvihill  1:26:46  
So it's a lot easier to force you to 

Tatyana Gustafson  1:26:49  
Right. But so they covered three domains that covered ketamine, MDMA and psilocybin. 

Danny Mulvihill  1:26:54  
Okay

Tatyana Gustafson  1:26:55  
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

Danny Mulvihill  1:27:07  
Yeah

Tatyana Gustafson  1:27:07  
Of MDMA hour of ketamine. Right

Danny Mulvihill  1:27:09  
Sure. 

Tatyana Gustafson  1:27:10  
So, that was that program, there is no standard Pro. 

Danny Mulvihill  1:27:17  
Yeah, right. 

Tatyana Gustafson  1:27:18  
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 work

Danny Mulvihill  1:27:29  
They sponsor maps or are they not related to maps? 

Tatyana Gustafson  1:27:31  
Oh, no. But they're doing a lot of the same work

Danny Mulvihill  1:27:34  
Okay

Tatyana Gustafson  1:27:34  
All doing good work and all very supportive of each other. But maps right now is focusing on MDMA. 

Danny Mulvihill  1:27:42  
Okay

Tatyana Gustafson  1:27:43  
So John Hopkins is doing mostly psilocybin end of life. 

Danny Mulvihill  1:27:47  
Ah, okay

Tatyana Gustafson  1:27:47  
End of life care is a big part of what's coming out of Johns Hopkins. 

Danny Mulvihill  1:27:51  
Huge, yeah. 

Tatyana Gustafson  1:27:51  
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

Danny Mulvihill  1:28:01  
Like a body of foundation. Okay. 

Tatyana Gustafson  1:28:04  
Yes. Because they are getting MDMA through the FDA

Danny Mulvihill  1:28:09  
Right

Tatyana Gustafson  1:28:09  
Which is unbelievable. 

Danny Mulvihill  1:28:10  
Yeah

Tatyana Gustafson  1:28:11  
I mean, they maps and the leader who started maps, really, they will be the first ever probably to have a drug make it through the FDA, with no pharmaceutical company sponsoring it. 

Danny Mulvihill  1:28:25  
Oh, wow. 

Tatyana Gustafson  1:28:27  
So from a from a business regulatory standpoint, what they're doing is amazing.

Danny Mulvihill  1:28:34  
Well that.. wow. So then there's not going to be this business at the end of the study, or the end of the process that is ready to make trillions of dollars? 

Tatyana Gustafson  1:28:47  
No

Danny Mulvihill  1:28:47  
It's just maps

Tatyana Gustafson  1:28:48  
Right, MDMA will not be patented

Danny Mulvihill  1:28:51  
Right. 

Tatyana Gustafson  1:28:51  
So any lab 

Danny Mulvihill  1:28:55  
Can make it?

Tatyana Gustafson  1:28:56  
Can make it.

Danny Mulvihill  1:28:56  
Oh, that's good.

Tatyana Gustafson  1:28:57  
So it's still generic. 

Danny Mulvihill  1:28:58  
Yeah. 

Tatyana Gustafson  1:28:58  
So it's still relatively inexpensive. The medication,

Danny Mulvihill  1:29:02  
Yeah, the therapy and the treatment in the facility.

Tatyana Gustafson  1:29:06  
But so Maps has created a protocol for MDMA, which involves psychotherapy, right? So it won't be the kind of thing that I will just prescribe people to take MDMA at home. 

Danny Mulvihill  1:29:18  
Have fun on Saturday

Tatyana Gustafson  1:29:19  
Right. You just go pick it up and do whatever you want with it

Danny Mulvihill  1:29:21  
Yeah

Tatyana Gustafson  1:29:21  
It will have to be prescribed within the confines of this protocol. But so that means it maps has been working very hard to crank out certified therapists.

Danny Mulvihill  1:29:33  
Yes, I've heard that there's this impending like, vacuum, of like, we're gonna finally get things legalized and then we're just not going to have enough therapists to handle it.

Tatyana Gustafson  1:29:43  
Right, yeah. Because it is very, it's a really different approach to therapy

Yeah, that too.

You really need additional training. I don't care how experienced you were in IFS or in psychodynamics, or whatever it was. Moving into this space requires a really different approach. 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.

Danny Mulvihill  
That's amazing

Tatyana Gustafson  
Yeah

Danny Mulvihill  
And it seems so logical. Like, 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? 

Tatyana Gustafson  
Right, right. 

Danny Mulvihill  
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 

Tatyana Gustafson  
Right

Danny Mulvihill  
On that. 

Tatyana Gustafson  
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 

Danny Mulvihill  
Of course, yeah. With patients 

Tatyana Gustafson  
And, you know, that's okay. There's a good reason for that. But I do find that when I can talk to patients about my ketamine experience, even though theirs will be different than mine. The fact that I trust this medication enough and I trusted my ability to go deep into my psyche does kind of set me up I think is a little more credible to help them explore their 

Danny Mulvihill  
Well 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 prescribed. So this is unique in a sense, almost like I can know my doctor did this. 

Tatyana Gustafson  
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 

Danny Mulvihill  
Really?

Tatyana Gustafson  
Into the space because that was us or our family member or whatever our personal experience is. You know, we really have to be compartmentalized. 

Danny Mulvihill  
Yeah. 

Tatyana Gustafson  
Because this person in front of us may not have the same experience with fluoxetine as we did. But it was interesting how before psychedelics, we kind of almost felt like it might have been a weakness. 

Danny Mulvihill  
Yeah to have said that you had taken it.

Tatyana Gustafson  
Yeah, to say to somebody "Oh, when I took Prozac.." 

Danny Mulvihill  
And they might almost distrust you like "Why is this bitch taking Prozac?"

Tatyana Gustafson  
Right

Danny Mulvihill  
She's my doctor.

Tatyana Gustafson  
They're gonna judge me! 

Danny Mulvihill  
Yes

Tatyana Gustafson  
Yet, here we are trying to say it's okay to take Prozac like no shame in that.

Danny Mulvihill  
Wow, this is so fascinating.

Tatyana Gustafson  
And then you have all this shame

Danny Mulvihill  
Yeah

Tatyana Gustafson  
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. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
Who 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 just 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 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.

Danny Mulvihill  
Yeah

Tatyana Gustafson  
The 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. 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. 

Danny Mulvihill  
Yeah, you don't need to

Tatyana Gustafson  
Like I get it, I get it.

Danny Mulvihill  
Sure

Tatyana Gustafson  
As we try to apply meanings to things putting words to things as much as we can, is important. 

Danny Mulvihill  
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 medical backgrounds? What's your perspective on that?

Tatyana Gustafson  
I mean, I think that you know, we control so many things through licensure. 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 providers of psychedelics has been the Achilles heel of psychedelics ever since. Well, ever since it was really

Danny Mulvihill  
Really?

Tatyana Gustafson  
Come up with. Oh, Lord, unfortunately. Yeah, yeah. I think there is a vulnerability there. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
And the connection that can happen in that space that doesn't typically happen. 

Danny Mulvihill  
For like practitioners with a medical background. 

Tatyana Gustafson  
Right. 

Danny Mulvihill  
So drilled in

Tatyana Gustafson  
Well, no, no, no, that the people that I'm talking about are all people that were were trained, okay, and ended up having sex with their patients

Danny Mulvihill  
Wow

Tatyana Gustafson  
And getting caught. That's 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

Danny Mulvihill  
Oh, I think I heard stuff about this

Tatyana Gustafson  
Who are.. yeah, 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. 

Danny Mulvihill  
True

Tatyana Gustafson  
But at least when you have a license

Danny Mulvihill  
Ah, there's a risk that you could lose it. 

Tatyana Gustafson  
Yes. There is a qualifying body that will come after you. And 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
Will that stop everybody? 

Danny Mulvihill  
No

Tatyana Gustafson  
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

Danny Mulvihill  
Yeah

Tatyana Gustafson  
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. 

Danny Mulvihill  
Yeah. 

Tatyana Gustafson  
And there are, there are people that will argue that sex and psychedelics have been used therapeutically for thousands and thousands of years. And so is this really an ethical breach? Right? 

Danny Mulvihill  
I mean, you know, there's gonna be like one and 100 people who can walk that line ethically, I think.

Tatyana Gustafson  
Right, right. But if you don't have a regulating body 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
You can tell yourself whatever story you want 

Danny Mulvihill  
Exactly, right, like I'm healing people.

Tatyana Gustafson  
It can be your story and you 

Danny Mulvihill  
Sneak a little barbituates into the mix and I'm just hooking up with everybody. 

Tatyana Gustafson  
Right 

Danny Mulvihill  
Yeah. That's dangerous.

Tatyana Gustafson  
One of the things that I think will decrease the cost 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. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
Somebody that is sort of trained. 

Danny Mulvihill  
So there's sort of like the, the master and then the apprentice type of situation so that

Tatyana Gustafson  
Exactly

Danny Mulvihill  
I can't just open my own practice, but like maybe somebody could play a role when there is at least a licensed professional 

Tatyana Gustafson  
Right

Danny Mulvihill  
I see. 

Tatyana Gustafson  
Right, right. And I think that especially as MDMA gets approved, and we're talking about long sessions,

Danny Mulvihill  
Right

Tatyana Gustafson  
There's gonna be a lot more space for what we're going to call psychedelic guide. 

Danny Mulvihill  
Yeah, for sure. 

Tatyana Gustafson  
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 proffesion that doesn't really exist right now. 

Danny Mulvihill  
It'll be like the dentist office where the dentist just goes around and checks on everybody and the

Tatyana Gustafson  
Exactly

Danny Mulvihill  
Assistants are doing a lot of the heavy lifting 

Tatyana Gustafson  
Decides the dose and then right and then that eight hours and that'll make it more affordable. You know, you win some you lose some 

Danny Mulvihill  
Sure 

Tatyana Gustafson  
I think sometimes in that space, but 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
I think that'll, that'll definitely be a profession. 

Danny Mulvihill  
Yeah, that particularly detailed 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 

Tatyana Gustafson  
Oh, it's talked about constantly. 

Danny Mulvihill  
Okay.

Tatyana Gustafson  
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 to this space 

Danny Mulvihill  
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. 

Tatyana Gustafson  
Right

Danny Mulvihill  
But a couple of bad stories, and it could really turn the direction of things. 

Tatyana Gustafson  
Right. Right, right. It could and we do have, we had an interesting intersection of things. We have kind of the introduction of ketamine then coincided with quarantine. 

Danny Mulvihill  
Oh, right. 

Tatyana Gustafson  
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. 

Danny Mulvihill  
Right. 

Tatyana Gustafson  
So that has led to huge corporate funded clinics of ketamine being mailed to people 

Danny Mulvihill  
What?

Tatyana Gustafson  
And doing zoom sessions. So sublingual ketamine is mailed to people and then you do zoom sessions with a therapist. This is controversial within the field. But it's out there

Danny Mulvihill  
Yeah

Tatyana Gustafson  
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, to..

Danny Mulvihill  
Massive

Tatyana Gustafson  
Massive because of Corona 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
And we just couldn't have predicted that without quarantine, there would have been some kind of a slow movement. 

Danny Mulvihill  
Yeah, it would have just been like, no way not gonna happen. But yeah, that.. that was the catalyst for sure

Tatyana Gustafson  
And in, in the quarantine space, all regulations were thrown out.

Danny Mulvihill  
Right

Tatyana Gustafson  
Because everybody had to get health care virtually. 

Danny Mulvihill  
And mental health especially 

Tatyana Gustafson  
Right. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
Right. So these, these ketamine clinics could really operate without any regulation really fast, which I don't -- would have not happened without court. 

Danny Mulvihill  
No way

Tatyana Gustafson  
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. 

Danny Mulvihill  
Sure

Tatyana Gustafson  
Here we are, and we'll have to kind of deal with that. 

Danny Mulvihill  
Yeah. Well, we're, we're wrapped, 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?

Tatyana Gustafson  
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.. keep a kind of 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.

Danny Mulvihill  
Yeah

Tatyana Gustafson  
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, 

Danny Mulvihill  
And burning incense

Tatyana Gustafson  
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 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. 

Danny Mulvihill  
Sure. Yeah. 

Tatyana Gustafson  
But it's not. There was 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 one thing that the mental health profession has just never really seen before.

Danny Mulvihill  
Yeah

Tatyana Gustafson  
And so I just, I hope that.. that we all hold on to that. 

Danny Mulvihill  
Yeah, and don't just overly clinical-fy and lose all of that. 

Tatyana Gustafson  
And we can in mental health, we often fall back on cost and access. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
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

Danny Mulvihill  
Sure

Tatyana Gustafson  
And ketamine is quite safe, and I really do feel like there, there will be something to booster sessions.

Danny Mulvihill  
Sure

Tatyana Gustafson  
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. 

Danny Mulvihill  
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.. as 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 that look like they could be better, you know? 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 is.. 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 messed up or whatever. But I anyways

Tatyana Gustafson  
We all struggle

Danny Mulvihill  
Yeah

Tatyana Gustafson  
Right. There's just no way through.. through this life. Without periods of negative rumination. There's just, there's no way and there is strength in that, right. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
If you take any kind of the Buddhist perspective, I mean, life is suffering, life is struggle. And there's no way we're gonna optimize our way out 

Danny Mulvihill  
And it would be just utterly boring. If there was nothing to struggle with.

Tatyana Gustafson  
The depth and the connection, right?

Danny Mulvihill  
Sure

Tatyana Gustafson  
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. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
Doing pretty well. But I want to know myself better. Excellent. 

Danny Mulvihill  
Yeah. It's like you could always know yourself a little better. 

Tatyana Gustafson  
You could always you always have a subconscious that you are not exploring and psychedelics aren't the only way to explore that

Danny Mulvihill  
Sure

Tatyana Gustafson  
Right? I mean, there's Holotropic breathwork.

Danny Mulvihill  
Yeah

Tatyana Gustafson  
There's certainly people in fitness that are aware that if 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, own that world, on the other hand, is pretty easy. It's easier than running a marathon.

Danny Mulvihill  
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, whereas 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

Tatyana Gustafson  
Right. 

Danny Mulvihill  
Guaranteed

Tatyana Gustafson  
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. 

Danny Mulvihill  
Yeah. 

Tatyana Gustafson  
And so yeah, so psychedelics are an excellent way to do it. So

Danny Mulvihill  
Love it

Tatyana Gustafson  
My.. my approach is sort of a mental health approach, but I definitely support the optimizing approach. 

Danny Mulvihill  
Cool. Two more questions.

Tatyana Gustafson  
Sure

Danny Mulvihill  
Number one, trying to think of the order to do this in.. let's go like this. If you want to, can you tell us about your clinic and how people here in Austin or who want to come visit could find you and how to look you up on the internet, get into your system and like experience on this whether it's for mental health or optimization

Tatyana Gustafson  
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. 

Danny Mulvihill  
Nice

Tatyana Gustafson  
There's now a bunch of us. We really like to think of ourselves as kind of a nurse practitioner haven and how many arms there's probably 10 Nurse Practitioners 

Danny Mulvihill  
Wow, nice

Tatyana Gustafson  
We are probably the busiest psychiatric practice in Austin, Texas. 

Danny Mulvihill  
Wow

Tatyana Gustafson  
At this point in time. Now, there's three of us that have moved into this ketamine space and 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 me, it's Tatyana. And then Laurie Fox and Jessica Hernandez are the three nurse practitioners there that are really moving our clinic, not in a different direction, we'll always continue to provide the services that we provide. But adding this additional service to it. 

Danny Mulvihill  
Yeah. Excellent. Is there I guess if anybody Google's the name, Greater Austin, Psychiatry and Wellness, okay, that's how we'll track it down. 

Tatyana Gustafson  
Right

Danny Mulvihill  
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?

Tatyana Gustafson  
Oh, well, it would absolutely be the concept of self love. The concept as, as 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 just be a better friend to myself? And I also thought that was a great way to say it quite as flaky right? 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. 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. 

Danny Mulvihill  
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, 

Tatyana Gustafson  
No, no, we only put up with them 

Danny Mulvihill  
I might even punch them in the face. We could fight over it. 

Tatyana Gustafson  
Right. Exactly. And when, when people say that to me after ketamine sessions, just the kind of like, wow, I just.. like I'm okay. My anxiety I had, I had a person who did experience what we call the psychedelic world kind of an ego death. It was a very difficult experience of not knowing who he was.

Danny Mulvihill  
Wow

Tatyana Gustafson  
And not happy about it. Most of us 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. 

Danny Mulvihill  
Yeah

Tatyana Gustafson  
It's like this is actually a part of me and I can love myself anyway, this is this is all part of my capital S self. 

Danny Mulvihill  
Yeah. 

Tatyana Gustafson  
And when you put it in that space, You can move through it.

Danny Mulvihill  
I like that. So the main takeaway then is, we all got to love ourselves some more, 

Tatyana Gustafson  
Little bit more. 

Danny Mulvihill  
And if we want a little pharmacological help, we should look into ketamine

Tatyana Gustafson  
Right, to find that relationship with yourself. We can help you. 

Danny Mulvihill  
Alright, Tatyana, thank you so much. This was a blast. 

Tatyana Gustafson  
Yeah, this is great. Thanks Danny.