Ketamine-Assisted Psychotherapy

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Nick Angelis: Welcome to the Ascend Health Show. I’m Nick Angelis. I’m one of the Owners of Ascend Health Center and I’m a nurse anesthetist. And today I’m with Adriana Markov, and we’re going to talk about Ketamine-Assisted Psychotherapy, which is one of those terms that whenever I describe it to someone, they nod, they smile, their eyes glaze over just a little bit and often that’s the end of the conversation. So can you explain to us what exactly that is? And this may take us a while, that’s perfectly fine.

Adriana Markov: Yeah. So ketamine-assisted psychotherapy is a really unique form of psychotherapy. Um, we’re blending your background and my background, um, in therapy to offer for people to, um, go through deep therapeutic processing, um, in different experiences, whether their dose is lower, and allows some more psychoanalytic processing and kind of softening of defenses, or in high doses, um, people can experience somewhat of a psychedelic experience.

Nick Angelis: Okay. And I think the softening of defenses is important, because while we were waiting to start this show, as you notice, and as the rest of you have no clue whatsoever, there’s about a 10-minute fire drill, where we heard this mechanical voice telling us, leave the building, you’re not safe, don’t congregate in the entrance ways. And there are strobe lights fashion — uh, flashing. And we’re trying to think — we’re trying to talk during, okay. Here’s how we’ll plan this show, because by my nature, I haven’t planned the show and this is our only planning time. And as we were discussing what we might talk about, this voice keeps droning overhead at 60 decibels and the strobe lights keep flashing, and we realize this-this isn’t happening, we can’t really plan something with this loud voice, with this flashing.

Adriana Markov: Yeah. Yeah. So when you think of whether it’s depression, um, or effects of trauma or anxiety, these are kind of experience that are continuously felt. Um, people are dissociating, um, everything except being able to be present and uh, be mindful. So I think people are in need of these treatments more now than ever before. And, um, ketamine-assisted psychotherapy is one of those modalities that are accessible right now, and people are getting benefits from it.

Nick Angelis: Right. And I think it takes some of the pressure off people too. A lot of times, uh, I have patients that are so distraught that they’re depressed or so discouraged because they’re anxious. But if we use that same analogy of this morning of — we’re trying our best, and there’s this voice that keeps talking to us and we don’t want to listen, and there’s these strobe lights that keep on distracting us.

Then it makes a bit more sense that, well, maybe you shouldn’t be discouraged that you’re having relationship problems or that this is going wrong in your life. Because for anyone dealing with that at the same time as they’re trying to live their life as a normal person, there comes a point when we have to think, okay, my willpower can only get me so far, just gritting my teeth and bearing it.

Um, one of the examples I use is because as a nurse anesthetist, I’m in surgeries all the time. If your ankle is broken, there’s not a point when you’re like, you know what, just got to tough it out, just limp around, my left foot works, this will be fine, I’m sure it’ll repair itself. No, you have to stop, you have to do whatever you need to do to fix it, because otherwise you can’t move forward. Well, you can move forward, but it’ll be hobbling. So, I don’t think that counts.

Adriana Markov: Yeah. And it takes a lot of strength and courage to come to a full stop and be able to — and allow for your body and your psyche to kind of access, um, deeper psychological processing. And I feel like that, um, is-is over the long term net ease. And that shift that happens for people is what people really need to move forward with, you know, feeling better from treatment resistant depression or, um, complex trauma occurring throughout their lives.

Nick Angelis: Sure. So you’re saying that the ketamine-assisted psychotherapy is almost like a container or a safe space, a pause from whatever else is going on in their lives?

Adriana Markov: Yeah, totally. Um, it’s really a supportive relationship, um, with people undergoing these treatments to feel supported and, um, to have the trust and the safety to kind of approach different experiences with intent and, um, you know, empathetic understanding. And that’s all what my relationship is in that process.

Nick Angelis: Okay. So if I can play devil’s advocate, which I guess considering my red black outfit and my beard today, it won’t be too difficult. How-how is that different from when people tell us like, well, you know, the only time I really feel safe or the only time I can escape my problems is when I drink alcohol or when I shoot up drugs or when I play video games. How can we make this different than just the escape, where people feel better, but the process of the escape, the addiction, the gambling, whatever it is actually makes your life a lot worse? Because I mean, that’s all a lot of people want and just want a break from my stress, but is that even healthy since that’s what all sorts of people do with alcohol drugs, cigarettes, pornography, you name it?

Adriana Markov: Right. And that’s a really good question. Um, because here we are advocating for something new, something that you have to take. Um, I think there’s fundamental differences, one of them being, um, how the compound and ketamine actually, um, helps within your body and some of the neuroplasticities and the amino amines — amines compared to a traditional pharmaceutical medications, that the intention is to be able to use them, um, over a shorter period of time to experience effects, um, as well as the relationship of a therapist, um, whether your theoretical orientation is something like DBT or CBT, um, working with someone through a person centered approach, you’re meeting them with empathetic understanding in that space. And that goes along with psychedelics too, where you’re allowing for the conditions for someone to feel heard and listened to, and be met with congruence that facilitates this emergence of, um, you know, the inherent self that we all have within us.

Nick Angelis: So you’re saying you’re walking with intention with someone else. So that helps prevent any sort of a quick fix basically?

Adriana Markov: Yeah.

Nick Angelis: With Ketamine I used to tell people a lot about how it stimulates brain-derived neurotrophic factor, which is true. But then I did some more research, I said, well, so does cocaine; don’t see any clinics just offering a line of coke for their patients. And as you can probably tell from this show, I don’t have the linguistic capacity to be both nuanced and polished and have a live show. So, uh, at no point in this show am I anything other than very blunt with whatever comes to mind, which I probably should use a disclaimer in that we do have an actual show that is a disclaimer. The entire show spent several minutes explain how, whatever I say, you should not go do, you should consult your medical practitioner, make an appointment with us at Ascend Health Center.

A lot of substances we’re talking about today are schedule one, meaning that from outside of narrow research, you cannot access them for medical purposes. And we’re also talking about the cutting edge research much of which is not available for public use. So at our clinic, we do use ketamine-assisted psychotherapy and ketamine infusions. But again, these are by prescription. After you see a psychiatrist, after your therapist clears you, after I’m okay with it as a nurse anesthetist, uh, because many times patients will say, well, my insurance says they’ll pay completely for the infusions and I have to respond, well, yes, they may pay for the medicine, they will not pay for me as a nurse anesthetist to supervise you. It’s similar to Delta giving a free flight, but saying, you know what, can’t really, uh, can’t really include the pilot on this free flight. Here’s some controls, if we watch the YouTube, you’ll be fine.

Adriana Markov: Yeah. I think safety is, um, in my work and I know your work as well as like the-the foundation that leads and guides our work. Um, I have a really, I would guess harm reduction approach to using substances, um, that these are substances, whether it’s alcohol or, um, psychedelics or ketamine that there’s other factors, um, like protective factors that relate to socioeconomic, um, class and, um, trauma in their lives that really predict whether someone forms a harmful relationship with substances.

So if we’re educating them, if we’re screening them and providing services that are most appropriate for them, I think, um, that plays hand-in-hand with, um, their experiences with the substances.

Nick Angelis: Mm-hmm. And I think a lot of times for the research, if we dig a little deeper to think, well, who’s behind this. And there was a new research study that came out a few weeks ago, and I did read the article at first because I thought it was a quick debate. It said that there’s no, uh, particular safe use of alcohol. Meaning that, it can harm your brain at any level, which I’ve never heard before, because there’s so much research on the benefits of wine, the benefits of dark chocolate. And then I thought, well, obviously there’s a lot of really large companies that would do really well if there’s this research saying that their harmful product is great for you.

Adriana Markov: Yeah.

Nick Angelis: So I think we kind of have to think of it in those steps, because even with psychedelics and ketamine isn’t technically a psychedelic, but they’re in a similar class.

Adriana Markov: Yeah.

Nick Angelis: A lot of times they do work better than psychiatric drugs. And most of our patients at Ascend, they just get their psychiatric medication and that’s the end of it. That’s the only minority that need the ketamine infusions or the TMS or things of that nature. Uh, but still we have to realize, well, this is a competitor to huge classes of drugs and billions and billions of dollars. So there is sort of that tug and pull of what is best for the patient, what does the research show, and where can we find unbiased research?

Adriana Markov: Yeah, totally.

Nick Angelis: But I did want to go back to, you had mentioned CBT and DBT and, uh, because my mind is mostly with molecules and receptor sites. And I already mentioned once about how, when I start talking, many people nod and smile. And I think we’re having a conversation, but they’re probably just thinking, okay, I don’t know what he’s talking about. How can I get out of this conversation? So to keep it simpler, what is psychotherapy itself? And can you define some of the — I almost said the word modalities, but that’s not going to work with me trying to simplify it. How does talking to people work and make them feel better? That’s-that’s probably a better way to work.

Adriana Markov: Yeah. And I’ll try to stay on track too, because I’m really big on psycho education and-

Nick Angelis: Um, and I’m really big on tangents, so yes, try your best.

Adriana Markov: Okay. So psychotherapy, I seem to think of it as meeting in a, um, dual, um, ethical, supportive egalitarian relationship with someone, where you’re working with them to meet them wherever they are, with whatever they want to work through whether that’s career related or, um, reprocessing of trauma, looking for help, as far as medication management, when they are put on any type of, um, psychotherapeutic drug. But there’s tons and tons of theoretical orientations that you can have. Um, whether it’s CBT, like you mentioned, where, um, it’s looking at cognitive processes that are taking place that influence behaviors and people are experiencing like maladaptive effects.

Nick Angelis: Mm-hmm.

Adriana Markov: Um, and then DBT is a therapeutic approach that is based on mindfulness and a lot of Eastern practices that allow for individuals to experience, um, kind of duality you know, yes, I experienced pain, but life is also can be without pain. And in that inherent difference is I think radical acceptance that both can exist. And, um, finding yourself throughout that process, whether, you know, you’re experiencing something like depression or any type of phobia.

Nick Angelis: Sure. So the CBT or cognitive behavioral therapy is more of using your mind to access your heart, than trying to use, okay, let me — and I’ve read the other day, where it said, the mind runs but the heart walks, meaning that you can know something in your head for it to actually affect your feelings and your actions is a much slower process.

So, at least you’re starting the process of, okay, here’s what my brain knows, and even if my feelings don’t quite match up with that, I can kind of do this diagnostic evaluation. And then DBT takes that a step further, where you’re creating space for all sorts of ambivalence and the regular, using a big word again, where you’re creating a space for contrasting emotions of, I’m sad about this and I’m excited about that. And by accepting all of that, you can kind of pick and choose, okay, here’s where I want to move forward.

Adriana Markov: Totally. Yeah.

Nick Angelis: Because one thing I’m really big at in my clinic is I have patients sometimes who, they’re feeling great and everyone around them is still suffering as they’re feeling great. So it’s similar to the opioid crisis, where you’re not in pain, but you are on your couch and you’re not doing anything. So how does that work? Where, okay, now maybe the therapist, patient relationship is great, but it’s still not to the point where the person is making less selfish decisions.

Um, and this is my own bias, I’m not really into the whole self-help thing that makes a person feel great and everyone else just sort of, whether it’s under their personality or their actions. Maybe that’s where the ketamine-assisted psychotherapy comes in, because that’s how these medicines work. They’re just associative. You get a bird’s eye view of yourself and how you really are instead of the facade of how you’re pretending to.

Adriana Markov: Totally. Like this-this experience that also allows for insight into those core conditions that have been playing, you know, by help with our default mode networks over and over again. So it allows for something new to happen, a new experience, new emotions, new memories.

Nick Angelis: So-so in that way, it allows us to get advice from others. So often it’s challenging, because if someone tells us, here’s what I think you should do, it’s hard to know, do they know what they’re talking about, are they having insight? What is their own motivation that you’re saying through ketamine-assisted psychotherapy, because you have a better insight of who you are and you can ground yourself better. You can now obviously with a therapist, but even those around you, you can get better advice or insights. You don’t have to be scared that, well, maybe I’ll take their advice too much and so it’s not authentic.

Adriana Markov: Yeah. And I think if anyone is in a position where they’re thinking about, you know, getting, um, psychotherapy services or working with a life coach or really anyone, um, go by the feeling that you have, you know, is this person authentic, do I feel supportive, because in these roles, we’re not playing, you know, subject matter experts. Our clients are the experts in their own life and we’re really there to support them. And I think that’s the misconception and stigma around seeking mental health services through a psychotherapeutic relationship is that, you know, I-I don’t know what to do, so I kind of need someone’s expert opinion. Um, in my practice, it’s really not giving advice at all, it’s really supporting someone, and, um, yeah.

Nick Angelis: No, that makes sense. And of course the reason I brought you on the show is because you are doing these classes on ketamine-assisted psychotherapy. So I’m well familiar with the modality. I’m not a therapist, as you can probably tell by my lack of therapeutic language, even when I’m talking to you. I do tend to keep things very much in the open whatever comes to mind.

But is there anything that you’ve really learned through that process, because again, right now you’re at the cutting edge of this. Um, a lot of my learning has been from the anesthesia standpoint, meaning I’ve worked with ketamine for over a decade. But it’s still, here’s a molecule, here is the receptor side, here’s the dopamine, the serotonin, the glutamate, all the ways it affects the endocannabinoid system. So, what other new insights do you have either in that space or even with the emerging research on MDMA and some of these other substances?

Adriana Markov: Yeah, that’s an amazing question. Um, the first thing that comes to mind is trust. You know, trusting individuals in their organic healing intelligence, um, that we all have. And um, showing up, if you are looking to seek this form of treatment, um, you know, forming trust within yourself that whatever comes up is there to come up and to heal. And that, um, there are people out there to support you, um, whether it’s, you know, through a ketamine-assisted psychotherapy relationship, where you’re doing this work with a therapist, or if those are sources inside of your community or your, um, your church, um, meetup group that I do believe healing happens in relationship. So finding that support and, um, building your resources around you goes a long way.

Nick Angelis: Right. It’s interesting that you mentioned church and relationship too, because with today’s technology and also throughout the pandemic, there was this idea that I can get everything I need spiritually through podcasts or Zoom church or, and the — no, no, you can’t. Many times the way we express our faith is how we treat others. I can’t say I’m so close to Jesus. He and I just love each other so much.

And then the gospels are filled with examples of, no, if you love me, you’ll obey my command to love each other. They’ll demonstrate itself very quickly. And I think that is what honestly scares people about substances like ketamine, where these are truth tellers. These go into your soul and reveal what’s there and so there’s no façade, there’s no, uh, trying to convince yourself of this is what I’m really like.

I’m not really this selfish. It was my environment, or this is a reason that especially with the psychotherapy, it strips away everything, and you have to face who you are and what you are, and you have to make that choice. Am I going to change or am I going to walk away from this, and some patients do walk away. But at least now they have the knowledge of who they are, what they are, and what they need to change this dynamic.

Adriana Markov: Yeah. And I think like all those things that come up, you know, that you just mentioned, um, they continue to happen after an experience. Um, it’s continually integrated in your life. Um, it takes place over time, it happens in relationships too. And I think that the more people are educated on what, you know, the benefits and the outcomes of these experiences, they can plan, um, more carefully to have them.

Nick Angelis: Right, and to go full circle, this is a difference, uh, ketamine, or even some of the other psychedelics, uh, the difference between them and an experience, for example, in anesthesia, sometimes patients feel euphoric and they say — they say, oh, I want some of this to take home. And I say, no, no, you can’t. That’s not how this works. But for them it’s that experience for the psychedelics.

It’s a brief experience. But then it starts a natural chain reaction in your brain that continues. So I actually encourage people, well, so you did enjoy that experience. It was hard, it was intense. That’s perfectly fine, that’s only a small part of it and that’s the way it should be. Because if everything was how do I feel in this moment, then we’re back to the American healthcare system, where it’s all about symptom management. I want to feel better and I don’t have any long-term goals other than right now this moment I need to feel good.

And no matter what the substance is, if you have that philosophy, you’re going to abuse it, you’re going to chase that. When we first started, uh, I tried to make us almost like an urgent care for mental health, and I realized, no, it can’t be available for everyone, that’s unhealthy. There are times when you have to go inside yourself and find what you need in that moment. You’ve got 24/7 therapists or someone other than yourself isn’t really healthy, because at the end of the day, we do have ourselves and have a support system around us. But we also have to be comfortable with ourselves and our own abilities to cope and deal with stress and just that whole situation.

Adriana Markov: Yeah. That’s really amazing how you sum that up. I think there’s a lot of meaning to be made out of challenging experience; a lot of healing and medicine. Um, that might be a little bit uncomfortable especially hearing that. But over time when you give yourself the space, um, to kind of create a new possibility around some of those challenging experiences or thoughts, I think that is the way towards really living like more wholesome.

Nick Angelis: Right. And it simplifies what you need. So at Ascend Health Center, we have transcranial magnetic stimulation. We’ve obviously been talking about ketamine with this bravado, which, uh, Medicaid pays for it too, which helps with that dynamic, where a lot of these substances historically have only been used by indigenous people or white people with a lot of money. So that helps level the playing field. But the simpler we can make this, the easier it is for people to realize, well, maybe I don’t need psychiatric medications. Maybe I don’t need these cutting edge therapies for treatment resistant anxiety and depression, bipolar, or even pain.

Maybe I just need to talk to someone. Uh, some of the best stories I’ve seen at our clinic have just been a good relationship between a patient and a therapist, all the symptoms sort of melted away as a person learned themselves better.

Adriana Markov: Yeah. It’s amazing what happens inside your body when that’s, you know, listening and empathy is modeled to you, um, through — like mirror neurons and you feel heard and supported, and that’s a felt experience in your body too.

Nick Angelis: Right.

Adriana Markov: Um, people go a really long time without ever feeling that. And that’s what happens when you enter into a relationship like that.

Nick Angelis: Right, because your body does want to talk to you. And if you won’t listen to it, it will express itself through pain, maybe physical, maybe emotional. And that’s the key drilling down to that root cause of what’s really going on here.

Adriana Markov: Yeah, Um, being willing to see that relationship between our minds and our bodies, which I think is something new in our, um, medical system, you know, there’s more integrative practices that are popping up. But I think that really is at the root of people finding treatments that look at the body and the mind, and look for wholeness between the two.

Nick Angelis: Right. And I agree with you, the simpler, we can do this easier. Do you have any closing thoughts as we-?

Adriana Markov: I just want to say thank you. Um, this has really been wonderful for me to talk about ketamine-assisted psychotherapy and the work I’m doing at alleviant, have a wonderful day.

Nick Angelis: Yeah, absolutely. So again, Ascend Health Center is our website, uh, 754-4844 is our phone number. Uh, and we welcome clients who have other therapists and psychiatrists. We work well with pain management, with other places you don’t have to abandon what is working for you to try some of our more cutting edge services.

And that’s an important part about mental health, that it should be everyone working together. You, your family, your therapist, your psychiatrist if need be, uh, we won’t — we don’t need to take care of every single part of you. We love working in partnership with other providers. But it really comes down to that relationship.

Adriana Markov: Totally.

Nick Angelis: That’s beyond any chemical molecules and receptor sites and the way that people just love hearing about the latest and greatest in mental health. Sometimes all you need is a therapeutic relationship, all the pieces fall into place. And you can learn to trust not only your therapist, but also just the people in your life. That’s a big part of healing is being able to trust again.

Adriana Markov: Yeah and yourself too.

Nick Angelis: Absolutely. Well, thanks for watching.

Adriana Markov: Thank you.

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