CIIS Public Programs Podcast

transcript

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This is the CIIS Public Programs Podcast, featuring talks and conversations recorded live by the Public Programs department of California Institute of Integral Studies, a non-profit university located in San Francisco on unceded Ramaytush Ohlone Land. Through our programming, we strive to amplify the voices of those who have historically been under-represented. To find out more about CIIS and public programs like this one, visit our website ciis.edu and connect with us on social media @ciispubprograms.  
 
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Gisele: Good evening, everybody. It's wonderful to be here with you Raquel, tonight and to open up the Spring Series on Psychedelic-Assisted Psychotherapy. Such an important conversation, such a hot topic these days with a lot of movement towards decriminalization and legalization of the medical use of psychedelics with psychotherapy. And welcome, so glad to have you here.  

Raquel: I’m delighted to be here. Thank you so much for inviting me. 

Gisele: Yeah! So, Ketamine has been classified with psychedelic drugs, even though it's not a classical psychedelic, like psilocybin, LSD, or DMT. Can you define what ketamine is?  

Raquel: Sure, happy to do that. Ketamine is a medicine that was first synthesized as a surgical anesthetic for humans, it's actually a derivative of PCP, or angel dust. Ketamine has some properties in common with classical psychedelics in that ketamine can produce an altered state of consciousness that gives people an enhanced sense of connection to other people and, potentially, to the whole universe. This can also help bring material that is buried in the psyche, help bring it to the surface.  

So, in that sense, it's similar, but ketamine is quite different from the other psychedelics that you mentioned, the classical psychedelics. It seems to be primarily active in the glutamate pathway, as opposed to the other medicines that have a lot of activity in the serotonin pathway. Ketamine is dissociative, so it quiets the signals from one's body and it has pain modulating properties, but it's also quite a bit flatter. I think it has a much flatter experience than the other classical psychedelics. The other medicines tend to amplify people's experience of their own body and of their emotions. And ketamine does exactly the opposite. It quiets the experience of your own body, and it tends to quiet your own, or kind of compress, your emotional range, and that's quite useful for some of the therapeutic applications. 

Gisele: Yeah, so ketamine historically has been used in the medical field as an anesthetic and it also has had a history of a fun drug, right? A party drug. But now we're here tonight to discuss a different way in which ketamine is used, which is as an adjunct to psychotherapy. Would you like to speak a little bit about that in terms of how is this legal substance that has been used in different settings now beginning to be used for psychotherapy? It is present in many clinics and there's a wide variety of ways in which this work is being developed.  

Raquel: Yeah, I would love to talk about this. Thank you for asking. Ketamine is a flexible tool, and it can be used in a variety of ways, specifically in psychiatry and psychotherapy and for psycho-spiritual exploration. All of them are valid and all of them are useful some of the time. So let me outline this for your listeners.  

Let's see, one way of thinking about ketamine for a mood disorder or a psychological exploration is as a pharmaceutical alone, focusing on what ketamine does at a biochemical level. There's no doubt that ketamine does something at a chemical level, at an organic level, that seems to be helpful for people with severe and refractory, and recurrent depressive disorders. For people who have obsessional thought patterns or something on the OCD spectrum, and for a couple of other disorders, it definitely does something chemical. That's not the whole story with ketamine, that's only part of it.  

Another way of thinking about ketamine is to use it as a lubricant for psychotherapy in a way that's similar to what MAPS is studying now with respect to MDMA and the treatment of PTSD. So, in this other way of thinking about ketamine, we’re using it as a lubricant. Ketamine is a catalyst for exploration in the psychotherapy process. That's more of a psychological approach to working with ketamine where it's doing something at a chemical level also, but where accessing and verbally processing emotional and psychological material is really the focus of that kind of work.  

There's a third way also of using ketamine, which is to use it to fully induce psychedelic journeys or fully dissociative experiences. In that case, you're inviting in as a provider and as a team, the provider and the client. You're actually on purpose, inducing dissociative and psychedelic experience with the intent of inviting visions. Inviting non-ordinary visions to come into the patient's body and mind with the idea that those visions are potentially useful. So, in that case, you're working in a fully psychedelic range.  

That's the thing when we talk about ketamine treatment, we should be clear about whether we're conceptualizing the conversation at a biological level, at a psychological and relational level, or at a psychedelic and shamanic level. In reality, they all interact with each other. There's interplay there, but I think it's important to start from that point in having this conversation. 

Gisele: Wonderful. Thank you for being so clear and differentiating these different therapeutic approaches with ketamine use. I'm understanding there are different models of healing and different protocols, depending on the therapeutic effect that one might want to have for the patient and depending on the patient too, right? We will throughout this conversation talk about some of the indications and contraindications, some of the ways of the training, some of the ways in which these three different models, whether it is the biological use, the chemical use of ketamine, the lubricant for psychotherapy, more in a catalyst relational way, or in a psychedelic way.  

When we look at these three different models and three different paradigms of healing, would you say something about the ways in which these effects get produced in the body? So, there's something about those and intake and so just to get the audience a little bit clued in of how come the same medicine can provide such different effects? 

Raquel: Yeah. That's a great question. The effects are overlapping, that's the thing. They're all sort of happening at the same time. But, on a chemical level, ketamine produces an antidepressant effect for people with certain kinds of depression, not every kind of depression, that lasts probably about two weeks. When it's done correctly, the effect is more prominent for about seven days and then a little bit more subtle for another seven days. Probably, the chemical effect lasts about two weeks, but it's really hard to measure how long the effect lasts or how durable it is when people are untangling knots on the inside. When people have a chance to express material that has been troubling them or that feels locked up and they move through that or release that or have a new insight about that, that can potentially exert a benefit, a therapeutic effect, something that feels helpful for months or years, decades, sometimes. We're just beginning to see that, and we don't have great data because we haven't been asking the right questions about that. But clearly, we're hearing from patients and former patients that sometimes, they get something that they need out of ketamine facilitated psychotherapy that has an enduring effect.  

And similarly with psychedelic ketamine, which I think of as a sort of a separate, distinct phenomenon from ketamine facilitated psychotherapy. People sometimes have visions that they describe as some of the most meaningful and some of the most information-rich and some of the most enjoyable experiences of their entire lives. So, what do you do with that when people are still chewing on their experience, still deriving benefit from the meaning or the direction of those visions, and decades later they're still talking about it and still finding it informative and helpful. One could say that the psychedelic journeys that they had when they're held in a tender and beautiful way, that they exert an effect that lasts an immeasurable amount of time. So, I think this is a really interesting question for research, is to begin to do longitudinal studies to begin to have better data about this phenomenon. 

Gisele: Yeah. So, what you're saying is when viewed through a psychedelic paradigm, the ketamine can bring people into a non-ordinary state of consciousness, and in that, it will potentially disrupt their mental structures and reorient them to their self-narratives and perhaps, bring personal meaningful experiences that are long-lasting. 

Raquel: In some cases, and in other cases, when people are not adequately prepared or it's not the right medicine at the right time or it's not the right dose or the setting isn't optimal, then people sometimes have an experience that's very frightening and psychologically distressing. So that's possible too. We don't see that so much in therapeutic ketamine when it's administered by a team of medical and mental health professionals, but certainly, people have reported that particularly when they're doing psychedelic exploration on their own.  

Gisele: Okay. So let's thread slowly through all these different subjects here. So, to start, right, if somebody is interested in ketamine work, what are the...for who is ketamine indicated for? 

Raquel: That's a good question. So according to the academic research literature, ketamine is clinically indicated for people who have five possible diagnoses. Those are called the Big Five in ketamine treatment. Let me say what those are. Those are people who have severe and refractory depressive disorders that are recurrence or people who have bipolar depression or people who have physical pain with depression. That's a pretty common combination. People who have been diagnosed with true OCD or people who have what's called ruminative suicidal ideation.  

And I just want to make a quick note about that: ruminative suicidal ideation is actually not suicidal ideation in response to a clear stressor, but rather it has a ruminative and obsessive quality to it so that people are hearing a thought in their mind that's telling them to hurt themselves and they find that distressing. And very often people don't share that with other people, that they're not threatening to kill themselves, but rather, they're having an experience that often gets revealed in psychotherapy treatment. And that particular kind of ruminative self-harm thought is very responsive to ketamine treatment.  

Anyway, because there's so much literature on these five indications, there's been so much research on it, that it's pretty darn safe as a clinician to administer ketamine for one of those indications. You're on solid legal ground. There's a couple of other things that we're looking at as possible indications for ketamine treatment. Those are considered the investigational indications. That means that we think it probably works or where we think that ketamine is probably helpful, but where there's not a lot of literature yet. But let me say what some of those are. That list would include probably some kinds of disordered eating, probably depression in older adults, probably depression in adolescence, severe, you know, refractory depression, probably pretty useful in hospice or when people are contemplating their own deaths, probably useful in treating severe postpartum depression in women. So, there are new articles and new research coming out on these things. So that's really exciting and I think we're going to see more about that.  

Then there are a couple of places where clinicians are using ketamine where I think they should be using a lot of caution. So, on that list of things where ketamine might be useful, but you got to do it carefully. A couple things that might include PTSD or trauma. That might include substance use disorders. And it would probably include anxiety disorders or a lot of anxiety. Probably ketamine is not the optimal tool for some of those things but it's what we have available now and so you just got to make the most of what you got. 

Gisele: Yeah. Go ahead. 

Raquel: Just to add, you know, really the core question here. The key thing: is it legal and is it useful for people to use ketamine in their own personal exploration or their psycho-spiritual exploration in the absence of psychiatric symptoms? What if you don't have a psychiatric diagnosis; is ketamine still useful?  

And I think that all the clinicians who have been working with this for many years, as I have, would say that it's probably pretty useful. But the question is: is it legal? Are you allowed as a prescriber or as a therapist to offer or suggest or prescribe ketamine treatment for someone who doesn't have a refractory disorder? And this is a tricky area. Right now, you’re allowed to give ketamine when it's clearly clinically indicated and you know, who decides what that means? That's a very loaded and culturally embedded concept. So anyway, what needs to happen in this field as we need to have more research and literature that documents the helpfulness and effectiveness of ketamine for people wanting to do psychological work and psycho-spiritual exploration. We need that written down, we need case reports, and we need studies on this and that's what's going to move the field forward to make it possible to have this treatment more accessible to more people who want it.  

Gisele: Yeah, so a couple of comments there. When I think about the clinical indications for ketamine use and you're talking about the five most common and documented and researched indications, but also some other ways in which ketamine is now being used and in looking at our local centers here in the Bay Area: The Polaris Insight Center, Healing Realms, The Center for Transformational Psychotherapy, Temenos, Sage Integrative Health, and SAGE Institute. All of those have, as part of their website and their offerings, to work with PTSD. And so, it's an area that you are here saying that hasn't been as well researched, but it's something that can be explored, and I am reading Resmaa Menakem’s book, My Grandmother's Hands. And so beautiful, the way in which he contextualized trauma as part of everybody's lives, especially if you look into racial trauma in this country. And so, you know the idea that we're all traumatized and that we're all in some way, in a healing journey, then it puts trauma on this different way of conceptualizing and leads me into asking you the next question because I think a lot of what you're saying is based on the safety and integrity of using the medicine in the best way possible for best outcomes.  

So, do you want to talk a little bit? Let's perhaps zoom in a little bit on the model. That would be either a relational model, where ketamine can be used as an adjunct to psychotherapy, or a psychedelic journey. In both senses, we’re talking about a model of treatment where there is a clinician involved, a psychotherapist or a psychologist, as well as a medical professional, being a doctor or a nurse or a psychiatrist. And so, it's a multidisciplinary team. It happens at a clinic and there's a process in which this work happens. Do you want to highlight a few of the elements that you think are important for the best successful treatment? 

Raquel: Well sure. It's clear to me that optimal treatment looks like having somebody with a medical background, some sort of medical professional, who can be attentive to the patient's medical and physical safety during this whole process. So, a medical professional who is assessing the patient before receiving ketamine. The same person who's available in case there's something adverse that happened during the ketamine administration and someone available to follow up with the patient, who's working in collaboration with a psychotherapist who's responsible for diagnosing the patient, thinking about an integrative treatment plan before you start ketamine, but thinking about what that patient really needs. Who's also available to be with the patient and provide psychological support if needed during the actual ketamine administration and then who's available to do the really, essential work, psychological work the after the medicine administration, sometimes called integration or follow-up care.  

So, this is not unique to ketamine. This is, I think, applicable to all of these powerful psychoactive visionary medicines. But anyway, I just wrote about this. I wrote a document called The Ethical Guidelines for Ketamine Clinicians that outlines the roles and responsibilities of the different kinds of professionals, but ideally, people are working together. Medical and mental health professionals are working together to make sure that this is both medically and psychologically safe for patients. There's a lot to know but it's…anyway, that would be a starting place, that document. 

Gisele: Yeah, so we are here discussing a model where the patient is in psychotherapy and ketamine is a part of their treatment and either that psychotherapy is done within the center that they will get their treatment, or they have a psychotherapist, and that psychotherapist works in conjunction with the center and the clinical staff and doctors in which the patient will get that treatment. And so, psychotherapy is always a part of the intervention because we're talking about a concept of healing that is a little bit broader than just injecting medicine and feeling chemically better. We're talking about a concept of healing that includes preparation for entering deeper realms of one’s psyche, of perhaps getting in touch with wounds with developing more trust, relationally, of being able to open up to areas that one hasn't been able to access perhaps, in their healing journey and that takes time and takes space and takes preparation. And then you have the journey itself, which may have elements of a psychedelic journey. And then there is the aftermath of what does one do with this material that got evoked with these visions that maybe someone saw, or with these memories that one might have revisited, and it's in the process of integration and processing and talking about it that the healing comes together.  

Raquel: Well said, well said. That's the thing too, is that ketamine makes learning more potent, we think, and that's not a surprise because glutamate which is one of the neurotransmitters involved here, is essential in other kinds of learning and memory processing. But anyway, the presence of ketamine opens people up to a special kind of learning and so there's a unique opportunity there to do some psychological rewiring I think and so, you know, that's the thing, is that ultimately the goal of treatment, in my opinion, is to help people learn new psychological skills or add to their tool kit such that they can help themselves going forward. What we don't need is a whole bunch of people who need more drugs, chemicals, and medications ongoing; a small fraction of people will need that but not everybody needs that. And so, the thing is how do people acquire new skills? Well, they have to be taught. And so, I think that's why pairing ketamine with psychotherapy is so potent. In addition to that, so much of the pain in this life comes from relationships and having the opportunity to revisit the dead or work through that with another person who is well trained and open-hearted, and receptive; that's a really valuable opportunity. And so, there's something there that I think makes ketamine treatment optimal with a therapist or guide. 

Gisele: Wonderful. So, we're on the same page. However, there are some models and I just want you to shine some light on that because in case people look at the research, they will see that on a chemical level and a biological level, a lot of clinics and doctors have worked with these six sessions, right? Six injections for a certain number of times, a certain period of time, and have gotten a certain result, a clinical result that is both very effective for suicidality and treatment-resistant depression. And so, could you mention that a little bit? It's a different paradigm. But since we're looking at the medicine, yeah. 

Raquel: Yeah. I think you're referring to the Diamond and McShane protocol of the six infusions in two or three weeks. I think that's what you're talking about. [Gisele: Mhm, yes] And okay. So, let's look at this from a historical perspective. The thing is, is that there was some evidence, probably 30 years ago, that ketamine might have some mood modulating properties, but everybody was afraid of it because it had psychedelic properties also. And in the research, in the early research, the fact that ketamine might induce a non-ordinary state of consciousness, might induce visions or make people feel twinkly or far out; that was considered a bad thing, a problematic side effect. They called it psychotomimetic. That means that they thought that that state mimicked psychosis, which of course it doesn't. Don't even get me started on that because that's a whole another…let's not go down that rabbit hole.  

But anyway, what happened was mental health professionals wanted to work with ketamine, but they weren't that familiar with this tool, the people who got the most training were anesthesiologists and ER docs and other people who work in that part of the medical field. So, they borrow from anesthesiology and these early researchers came up with a protocol of giving 0.5 milligrams per kilogram of body weight of ketamine to a patient on infusion, on a 40-minute infusion. There's nothing magical about 40 minutes. They did that for the researcher’s convenience, and they say that outright so that they could change patients on the hour. So that's where the 40 minutes came from. But anyway, they were giving these patients these low doses of ketamine for mood modulation or for treating depression, specifically with the explicit intent that psychedelic or psychotomimetic experience was bad. It was a problematic side effect to be avoided and so the way they avoided it was either to dose under the psychedelic effect or to medicate it if it occurred. To give benzodiazepines to prevent the visions. Because there was a fundamental bias against psycho-spiritual experience.  

So anyway, they came up with this low dose protocol and it works okay for some folks. The problem is that the dose is a little on the low side and it wasn't very durable. The effect didn't last long enough. So anyway, eventually somebody came up with the idea of packing six sessions close together. Originally, it was Monday, Wednesday, Friday for two weeks. So, giving six low-dose infusions in a cumulative series. The idea was, the concept here was to get enough medication, enough ketamine, into the patient's body to do the magic thing that ketamine does but while trying to avoid psychedelic experience in any individual session. That was the premise of this treatment.  

And...okay, if you do a clustered series like that, you might get up to a couple of months of symptom relief for severe and refractory depression. But here's the problem. There are two problems with this model, there are a number of problems with this model. So, problem number one is that the patient is rendered passive. They're not called upon to do anything to participate in their own treatment. The patient in this conceptually is a passive recipient of the medication and all they do is show up for the appointment. And this kind of passivity, the patient sort of doing nothing on their behalf, is a great model for certain kinds of medical interventions like surgery, but we have to wonder if that's a great model for someone who's having a chronic mental health difficulty. I think that empowering people to be as active as possible in their treatment is a good thing.  

But the other problem is that the effect is temporary and you're just sort of band-aiding over it. It's kind of like if you have weeds on your lawn, do you want to just keep mowing the grass or do you want a more durable solution where you pull the weeds up by the roots, which I think is more analogous to ketamine facilitated psychotherapy where you begin to deal with the roots of the problem with an attempt to try to resolve it. Anyway, all of that to say that the passive position of the patient and the effect is temporary. Those are some of the limitations of this medical model that has been so heavily researched.  

That said, there are some advantages to it. The main one is that that makes ketamine treatment accessible for people who are medically complicated. So, I wanted to just be clear that we do refer people out for low-dose ketamine infusion when it's necessary, there's a place for that but I would be very concerned. I would be wary of clinicians who want to sell you this model and don't mention the fact that integrative treatment is needed, that other kinds of interventions are needed, and that there's another way of doing it, namely ketamine facilitated therapy or psychedelic ketamine.  

And here's the problem. Some providers, some ketamine infusion providers, are coming from a beautiful place in their hearts where they really want to be helpful, and I can see that. But for other providers, we have to not fool ourselves. We have to be honest about the fact that it's financially beneficial to someone who's an infusion provider, to provide these infusions ongoing. If the patient needs the treatment for a long period of time, the clinician benefits economically. And so that's a conflict of interest that I think has to be named when we assess these different treatments and their efficacy. And so anyway the ketamine infusion is usually devoted to symptom reduction or symptom management and ketamine facilitated psychotherapy has a slightly different goal, as I said, to get more to the roots of the issue.  

Gisele: So yeah, so here what you're saying is that providers should be familiar with the different strategies that they can consider in relation to the client diagnosis and what's most clinically indicated. And in these different models, there are also different concepts of healing embedded in these different models, right? And you're mentioning IV and I think a lot of people may be afraid of that like, “I don't want to inject” and so there are different ways to get ketamine into the body. Would you say a little bit more about that in terms of the different ways that the ketamine can get to the body and the doses? 

Raquel: Yeah, I’m happy to answer that question. I also want to highlight something that you just said, which is the premise of KRIYA Institute and KRIYA Conference. The premise is, you know, the bottom line is that I believe that ketamine clinicians and ketamine providers should be familiar with all of the dosing strategies for ketamine and all of the different routes of administration, and they should take the time to explain to each patient why they're choosing the route and the dose that they're choosing or what they're recommending. They should be making referrals out if the patient needs something different than what they can provide, et cetera. But yeah, I think all clinicians should be familiar with, should consider taking some training, and be familiar with the whole spectrum of ketamine services.  

So, with respect to route, ketamine is a little teeny tiny molecule that easily crosses the blood-brain barrier. So that means that you can get into your body in a whole lot of ways. The most efficient way to get ketamine into your body is to have an infusion where the ketamine is put into a bag that's fed into a needle that's placed in a vein and then the next most efficient way of working with ketamine is as an injection put into a big muscle. So, in both of those cases, more than 90% of the ketamine makes it to the patient's brain to do the job that it was intended to do but not everybody has access to that for a variety of reasons. And so, there are some other ways that you can work with ketamine. You can insufflate it or put it into your nose. That's how the S-ketamine product is delivered. You can have it compounded, have it made into a lozenge. It's essentially a medicated piece of candy that you would hold in your mouth and the absorption is called transbuccal. It goes through the membranes of your mouth and into the capillaries and then into the circulatory system. It can be swallowed, which is very inefficient. It can be applied to the skin, also very inefficient. It can be compounded into a suppository. Also, highly variable.  

The problem is that all these routes that I just mentioned are less than 50% bioavailable. What I mean is less than 50% of the medicine makes it to the person's brain, and the effect is variable. That means that it varies from day to day and hour to hour and person to person. So, this is really a clinical problem. It's somewhat undesirable. I mean again, if this is all you've got, then you make it work, but people should be aware that different routes of administration for ketamine have different effects and again, ideally, we would match the route and the treatment to each patient based on what they need.  

Gisele: And in an overall sense, broadly speaking, Raquel, with these different routes of administration. How would the person feel better? When would they feel better? Is there some research that indicates that you know, there's a certain effect right away or the next day or how long does it last; could you talk a little bit about that?  

Raquel: Those are some big questions. I'll tell you what I've observed. When people are exposed to ketamine and they have certain kinds of organic symptoms. So that's a small subsection of people. They usually feel better right away, you know within the first 10 minutes of ketamine exposure, there's a little bit of improvement or lift. And then people tend to feel another energetic uplift a couple of hours after ketamine administration so, you know with injectable ketamine which is what we use the most in my practice, that's typically four to six hours post-injection. And then there's another blossoming of ketamine. There's another kind of like solidification of the effect probably two to three days after ketamine treatment. It takes that amount of time for the effect to fully blossom and then that can last, as I said, 7 to 14 days from a single ketamine exposure.  

Our best guess at this point is that these different intervals that I've just mentioned probably correspond to things happening in different chemical pathways. So probably the serotonin pathway, the dopamine pathway, the glutamate pathway, and the opioid pathway are probably involved, and the effect is probably kind of taking hold at different times and I'm excited for when the neuroscience catches up with us and can better explain that. But there's a couple of really important things that we can extract from these observations. First thing is that people probably don't need, if the dose is optimal and the setting is optimal. Okay. So, when those conditions are met, people probably don't need ketamine treatment more than twice a month, at the most. So, people who are doing ketamine more frequently than that, either something's not right with the dosing or something's not right with the setup, or something else is going on there that needs to get looked at. So that's one thing to notice. Another thing is how can you possibly assess ketamine's effect if you haven't waited the full two or three days to see what it's going to do. So, the idea of taking ketamine every day makes no sense to me, clinically. And so, I want to draw some attention to that question.  

Just want to say one more thing, which is that when people are first getting treatment for depression, they need ketamine more frequently. It's called the induction phase. At first, it takes more to lift someone out of depression than it does to kind of keep them on the road. In other words, if the truck goes off the road and into the mud it takes more energy to get it back on the road than it does to keep the truck on the road in the first place if that makes any sense. All that to say is that if someone is severely depressed for a long period, they might need ketamine, you know, probably twice a week for a couple of weeks and then they should move into a maintenance phase of ketamine. You don't stay at that high frequency forever. That's… something's not right there if that's what's happening.  

But rather in a maintenance phase, people come back for ketamine treatment for a booster. Sometimes, they want to come back once a year. So annually, sometimes they want to come back quarterly, a couple of times a year. Some people need to come back monthly. So, you know once a month for more ketamine. You know, occasionally we have people that need to be seen more frequently than that, but I just want to put that out there so that people can be you know, thinking about what they're getting and what they need and do they need to make a change to the regimen so that it's closer to optimal. 

Gisele: And for some patients, if they are under another regimen of medication that would be combined with ketamine treatment? 

Raquel: Like conventional oral medication?  

Gisele: Yes, antidepressants, for example. 

Raquel: Yeah, so it depends on the medicine and it depends on the patient and it depends on the provider. Ketamine plays well with a lot of psychiatric medications but not all of them. So, most of the time, people can continue on their regular oral meds as needed. But again, that would have to be decided on a case-by-case basis and I wanted to point out that that's one of the advantages of ketamine treatment as compared with something like an MDMA or psilocybin where the patient might have to go off their SSRIs. I think that's still being debated but ketamine plays okay with most SSRIs. Rather, they don't have a negative interaction. So, people can stay on their meds during ketamine treatment and that's a real plus for a lot of people in this population.  

Gisele: So, since you're comparing ketamine with these other psychoactive medicines, it also distinguishes it from classical psychedelics. Please correct me if I'm wrong, that ketamine doesn't bring up so much anxiety and the fear and that intensity of life and death as you go through the journey. It's a little bit more gentle medicine and it has a shorter half-life and also a quicker onset. So how do you see these elements of ketamine for example in combination with the psychotherapy is perhaps a little bit easier to work with or you know more adaptable to certain populations or to conditions? Can you say something about that?  

Raquel: Sure. Let's see here. God, there's a lot in there, a lot of interesting points. I am not sure that I would agree that ketamine is gentler than other medicines. The experience of being disconnected from your own body and the fully dissociative psychedelic experience of ketamine can potentially be very intense, very intense, and often mimics…often causes people to think that they're dying or that they have died which can be very intense and/or distressing if people are not adequately prepared for that or not feeling adequately supported.  

It's true, ketamine has a little bit less chaos. I think you know; I sort of think of psilocybin and LSD as being kind of swirly into the chaos. Ketamine is maybe, not doesn't exactly have that property for most people. But anyway, the effect is dose-dependent. But ketamine is ideally suited for lots of therapeutic applications. It works well. As I said for primary organic depression, but what's good about it is that it's rapid-acting and it wears off fairly quickly. So that can be used in a therapy session that lasts you know, a couple of hours whereas MDMA or psilocybin or LSD kind of takes the whole day, you know, it's hard to fit that into a single or double psychotherapy session. So, the rapid-acting nature of ketamine makes it a good adjunct for psychotherapy. 

Gisele: I want to just emphasize here what you just said that the experiences induced by ketamine that are similar to those produced by psychedelics, you know, the sense of the luminous, the out of the body experience, the ego dissolution. Those can be very scary, and the key here is the right set and setting, the careful preparation, a safe relationship with the provider. And so, these experiences that are, very, can be very precious and very transformative are not creating traumatic responses, but rather healing opportunities. 

Raquel: Agreed. Yeah, there is so much to say about that and to add to that, you know, the fact that ketamine is so rapid-acting and can be such an intense experience packed into such a short period. I think that's one of the reasons why it's used in an unsupervised way. I hate the word recreational, but you know what I mean, and why it can be a drug of abuse because you can you know, sort of fit into a short slot and I think that's one of the appeals of this medicine and so, you know, it's a double-edged sword, right, the thing that makes it incredibly powerful and useful is also something that leads people down a bad road sometimes. 

Gisele: Do you want to say more about that, about either addiction or challenges of using ketamine unsupervised? 

Raquel: Sure. This is such an interesting question. Do I think that ketamine is inherently addictive? Does it pull for addiction? I don't think that it does. There's so much evidence that it's been used for literally millions of people for medical and psychotherapeutic applications where the people, where the clients expressed no interest in using ketamine, you know, in between their medical sessions, so I don't know that it's inherently addictive but certainly people do become addicted and that can be, that can be difficult. Some people get addicted to or you know are attracted to or become obsessed with being disconnected from their struggles of everyday life or whatever physical or psychological pain that they're experiencing. So, I think all these very powerful tools can potentially…people can be in an addictive relationship with them.  

And then on top of that, COVID certainly has amplified and exacerbated all of this in some concerning ways. I, you know, I've been doing this for 19 years and I was not aware of/have not heard of so much ketamine addiction until pretty recently. So, it's hard to sort of parse out what is situational and what is, you know, a property of the chemical. So, I think we'll have to figure that out as we go forward. In the meantime, I hope that people who are struggling with ketamine addiction have access to care and compassion.  

I just want to point out that there are a couple of things that we need to be worried about. Ketamine is an incredibly useful and beautiful medicine and an ally of mine, but when it's used incorrectly, several things can go wrong. Let's just take a second to talk about that. Accidents. People can fall down the stairs or injure themselves. Using ketamine, driving under the influence of ketamine could lead to a very serious bad outcome for the user or other people in the community. People have drowned under the influence of unsupervised ketamine, so injuries and death are something that we should be talking about. Tolerance. If you use ketamine too frequently, you need more and more to get the same effect. So, you don't see that in supervised ketamine use but I hear about it quite a bit from people who are using it unsupervised. So, tolerance is a problem we should be concerned about. Diversion is a problem that we should be concerned about. That means when the ketamine ends up in the hands of somebody for whom it was not prescribed and where it might be dangerous for that person diverted medically or psychologically, that's a concern here. And finally, functional damage. Too much ketamine exposure puts people at a high risk for cystitis, which is the medical term for damage to the kidneys or bladder and that can be a very painful problem, a urinary problem with a lot of suffering. And hard-to-treat. So, we want to be careful about that, people need to think about their overall ketamine exposure so that they are staying healthy and safe. 

Gisele: Yeah, thank you for bringing up these adverse outcomes with ketamine use and some of the safety that is important to consider here and you're highlighting the challenges in people's mental health with the pandemic and something about using ketamine unsupervised and it's less ideal and it doesn't pertain to this model that we're discussing here.  

So, in the best-case scenario, there is psychotherapy happening, there are providers that are helping the patient be prepared. Not only for the ketamine session but also for the process as a whole, as we've been talking about here. Ways of healing depression or anxiety or trauma are not, cannot be condensed to just a chemical intake or a few chemical intakes but rather a whole investigation and a holding and supportive container for the unfoldment in the healing process. 

But you know, what comes up a lot of times is how accessible is this, right? So, if we're talking about you know, why we'll have a therapist, I'll have a doctor who's going to oversee you. There will be a psychiatrist or a nurse. Is this going to be in the clinic, there will be several sessions before, during, and after for the time that the experience is happening. There is a holding environment with music, with attunement. This is expensive, right? So, can we talk a little bit about cultural considerations around ketamine treatment and accessibility? 

Raquel: Yeah, I'm glad you brought that up. Let's talk a little bit about increasing accessibility. Let's start with that. Several things need to happen to make ketamine treatment more broadly available and more accessible to people who need it. So here are some things that we can do right now. People can request racemic, generic ketamine. It's dirt cheap. It's broadly available as a medical supply in most medical facilities. We should be using that and not the expensive patented S-ketamine product. It's insane to up-pay more for something that doesn't work better. So, requesting racemic ketamine number 1. Number 2, requesting injectable ketamine as much as possible. That's by far the fastest, cheapest, and easiest way of doing it. So, cost savings there. Putting people into groups for group work when it's clinically appropriate. So, some folks need the individual attention of a therapist particularly if they're working on traumatic material. But other folks do well in groups, and it's beneficial to them, socially beneficial to be in a group. So that dramatically decreases the cost of ketamine treatment and makes it more accessible. So, we should be thinking about that.  

And finally, you know, what needs to happen is we need for providers to be working together to collect enough data to get insurance coverage and FDA approval for generic ketamine for psychiatric indication because when we get FDA approval for this, then more medical insurances will cover this treatment and that'll drop the price dramatically and that's a good starting place for getting this medicine to more people. So, there's a lot that we can do.  

Then there's a separate issue, a related issue that you mentioned which is making this medicine more accessible specifically to people who have been locked out of mental health treatments and research. So, this is an area that we need to be paying attention to. First of all, the medicine amplifies anything that could be happening in the room. And so, if there's a power differential in the room between the clinical team and the client; if they're different in any access of identity the medicine may amplify all the meanings of that. So, if they're different in terms of ethnicity or race, sexual orientation, gender, and religion, a lot of other things, it's really important that the clinical team is tuned in to what the meanings might be for the client because all that could be amplified by the medicine. Let me give a better example of that. If I go for ketamine treatment, which by the way, I do, when I go to the clinician’s office and they close the door behind me and lock it, I just don't think anything of that. It makes me feel safe and I think it's appropriate and it's like, it didn't occur to me that that would be an issue except that some colleagues of mine who identify as people of color, pointed out that for someone who identifies as a person of color, if they're in a room with a clinician who identifies as white and the white clinician goes and locks the door and tells the client that they're going to, they're going to be there in a situation where the client is potentially immobilized and vulnerable and they're not allowed to leave. What does that mean? And again, for some clients, it's going to be a non-issue and for other clients, it's going to be highly evocative and significant and all of that needs to get addressed before introducing a powerful amplifier like ketamine. So that's what I mean when I talk about the power differential. And issues related to that.  

And then you know, Gisele, you and I were having a conversation the other day that I've been thinking, about how different groups and people of different identities have been historically underserved in this country by the clinical community and by the research community. I was affected by what you said: we have to do better. We have to find ways to make all the treatments, all medical care, all psychological care, and psychedelic care in particular. How to make that available particularly to the people who have been overlooked or neglected so that's a conversation I would like to have. 

Gisele: Yeah and I was thinking about, you know, the power differential, the differences in racial, gender, sexuality, age; so many elements of identities that come into play when we're talking about healing and how essential it is for healing to be able to have all parts of you present and if a part of you is not feeling safe, even if it's  just one element of your identity, how that is going to influence the ability to open up and heal. I was talking to Rick Tarnas - he and Stan Grof. He was, in face of this conversation, he was telling me about some stories about Esalen in the 70s, that there was this psychiatrist who lived there, Doctor, what was his name...Craig Enright that was exploring ketamine with Stan Grof and Rick Tarnas and they were doing injections and they were mostly interested in extraordinary states of consciousness and a trans dimensional exploration as the 70s brought that about.  

But even back then they had this kind of utopian vision of the future that someday, there could be some special centers, kind of part clinic part healing center, where individuals could come and they could be interviewed, they could be counseled, they could be taken into where they were at and then be guided and be given options to deep exploration and healing, whether that would be breathwork or bodywork or in this case, with what they were exploring, MDMA, ketamine, psilocybin, mescaline, LSD; just have a whole spectrum, but that counseling would be a key element in that and as well as in their vision and I find that beautiful. An astrological archetypal consultation. And so here we have some ideas of you know, okay, you know Stan Grof as being one of the grandfathers of the transpersonal field and somebody who created a lot of validity to the transpersonal territory in terms of the psychedelic experience. And then we see where are we at today, right?  

So, if we think about this vision from them in the 70s at Esalen, something so unique, so, so privileged in so many ways, right? How do we then bring this vision forth in a way that's serving the communities of the city, of the people who need access to this kind of healing and this kind of medicine that doesn't stay only with the privilege or those who can have access to it, in a very expensive way? 

Raquel: Yeah, that's the problem. But I think people also have to take a step back and appreciate a little bit of, take a little bit of a historical perspective. I appreciate what you're…yes, we need to make it more accessible, and we will get there and when I wrote my dissertation about this, I was writing in 2012 and I published it in 2014. I can tell you. I can tell you that the number of people on Earth who would admit to being interested in this topic, the use of ketamine in psychotherapy, and the number of people who had any experience with it on the entire planet Earth is this many people: 5.  

And then the following that was…so that's 2014, and then I had the first KRIYA conference which was supposed to be a lunch that turned into an international event and you know, we could barely get two dozen people into the room. I mean that was all the people that we could find. Or that I could find. And then you know the next year, it was maybe 50 people who came and then the next year was nearly a hundred people who came and now every year I get thousands of inquiries.  

So, I say that to say that we're on a trajectory, a growth trajectory, that started with a small group of people who have been working hard to bring this forward, to bring forward the idea that ketamine is pretty safe when it's supervised, that it's quite effective in treating certain disorders. And part of my agenda and part of our workgroup was to help people appreciate that the visions are potentially beneficial, may be central to the healing process, and that they're not something to be afraid of. So, all of that has happened in less than 7 years. So, I think it's useful to look back at the history to say, “Wow, look at how far we've come” in a short period and to be hopeful about how far we're going to get in the next, you know, the next couple of years. So yes, there's still work to be done and things are changing very rapidly and in many ways changing for the better. So, we're going to get there. 

Gisele: Yes, and so see us here today, talking about this and knowing that you are both a practitioner in this modality as well as a patient in this modality and how profound it is that you can come here and with a wide audience and speak about your experience and talk about that. So, we've come a long way. Right? Is there something else about that, about your experience from being on both sides of this experience, both as a patient and as a therapist that you would like to highlight? 

Raquel: Sure, sure. Well, just to say that my interest in this topic is personal. I first encountered ketamine in 2002. So, 19 years ago, in my own quest to find something to help me with my own severe and refractory depressive disorder that I've had most of my life and all of my adult life and I tried a variety of things underground, not so helpful, and then I bumped into ketamine and became friends with her and that was life-changing for me. And I, you know, I thought somebody really ought to study this. It seemed to me at the time that it had rapid-acting antidepressant or mood modulating effects as I said, this was 19 years ago and there was essentially nothing written about that.  

And so, I set out upon a quest to learn everything that I possibly could and to talk to people, all the while continuing ketamine treatment for myself. And by the way, I discussed this in great detail my whole, the whole colorful backstory. I described it in an interview that I did with Mike Margolies a couple of years ago. And so, we can put up the link for that and people can check it out if they want to hear exactly what happened. But anyway, the importance of all this is that I wanted to say that most of what I know, much of what I know, and much of what I teach to other clinicians and what I'm trying to put out in the world actually was informed by my experience as the patient and I'm still a ketamine patient. I can say more about that in a second but to that end, I think it's really valuable for clinicians who are interested in this space to have experiential training to the degree that it is legal. So, if it's accessible to them, it's really useful to have an experience as the client in learning how to navigate these vulnerable altered states that getting ketamine, you know, I don't know that I did a great job of explaining it at the beginning but so many people have an encounter with God. They spontaneously describe that they have an encounter of the divine or something sacred when they're working in the psychedelic range of ketamine and when that's being held beautifully and it's really hard to describe, it's ineffable. And I think there's real value in people having in clinicians, in particular, having direct experience of these kinds of states in preparation for providing those experiences to clients. I think it makes them more compassionate and more sensitive. And frankly more effective.  

I wanted to say one other thing that popped in my head, as we head towards wrapping up here, but just to say that I, that I openly myself, I get ketamine regularly with a significant interval of time in between each journey, and I do that mostly for symptom reduction and symptom management reasons, but also because it's really meaningful and I wanted to throw out the idea that for some people, it's possible to use ketamine or use a psychedelic medicine like ketamine in a spiritual practice that's closer to meditation or closer to yoga in the sense that it's, that for me, working with ketamine is a practice that unfolds over time and I keep returning to it and the experience keeps deepening. And even though I've done it hundreds of times, literally hundreds of times, in the last two decades, I feel like I'm always learning something new, and I have no desire whatsoever to use ketamine. Even when I'm stressed, in between my scheduled appointments; that for me that would ruin the sacredness of my relationship with it. So, I don't use it casually, but just to say that it is possible to have a long relationship with these medicines that I don't think constitutes substance use disorder, but rather as something else because I and other people like me are approaching it with reverence and respect. So, I think that's a really important part of being in relationship to one of these sacred medicines. 

Gisele: I love to hear that. It's the process of a permanent transformation of consciousness. Not necessarily just a peak experience. So, the mystical consciousness here is about an engagement of advancing the work. Not only with temporary states but with an advanced transformation and I think that's what you're talking about. And in some way, this is very timing because we are on the brink of a profound spiritual awakening, collectively and individually. So, it's a wonderful tool and you’ve just explained it in a beautiful way in which you are engaging with that. Thank you. It was wonderful to have this time today here with you and to engage in conversation and I look forward to many more opportunities to do that as the field continues to evolve and we continue to expand the access and include different ways of providing the treatment and evolving in what has been already worked with. Anything you would like to add as we come to the end of our time today? 

Raquel: These are exciting times. I just, I can't believe how rapidly the field is changing and I can't wait to see where we're at in a couple of years from now and welcome to everybody in the field who's coming in, who's interested. We're excited to meet you and work with you.  

Gisele: Thank you for being here tonight, Raquel, and thank you for all your work. 

Raquel: It's a pleasure. Thank you so much for having me.  

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Thank you for listening to the CIIS Public Programs Podcast. Our talks and conversations are presented live in San Francisco, California. We recognize that our university’s building in San Francisco occupies traditional, unceded Ramaytush Ohlone lands. If you are interested in learning more about native lands, languages, and territories, the website native-land.ca is a helpful resource for you to learn about and acknowledge the Indigenous land where you live. 
 
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