Duration: 23 minutes, 38 seconds

KELLIE NEWSOME: In our final installment, Dr. Greenway shares the challenges that arise while doing ketamine assisted therapy.

CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. We continue our conversation with Dr. Greenway on ketamine assisted therapy in this final installment of the series.

CHRIS AIKEN: We delve more into the how-to of Ketamine Assisted Therapy with Dr. Kyle Greenway. I'm getting the sense the active treatment induction session is very non-directive. I'm imagining the therapist might ask some questions like, what are you experiencing? What happens after that in the following sessions?  

KYLE GREENWAY: Well, we're still always kind of coming back to our goals. And this is from our own experience, if you read the psilocybin literature and even treatment-resistant depression, there's sort of this idea that if you have a mystical experience, you will be more or less cured, or at least you'll be well for a number of months. And I think that has kind of an intuitive logic when you think about somebody with a terminal cancer, for example. The major issue for them, psychologically, is probably their mortality. Or the fear that the cancer will return. And so, a mystical experience, I mean, I can see why that would be heavily therapeutic, and maybe permanently therapeutic. But with treatment assisted depression, at least with the people, that we treat, a mystical experience, it's not, it's not obvious to me how that will help someone stay free of depression or recover from a severe episode of TRD. Our work psychotherapeutically is essentially summed up by, teaching patients to feel their emotions, to diffuse their thoughts, and to change their behavior. 

CHRIS AIKEN: So diffuse thoughts, can you tell us more what that means? 

KYLE GREENWAY: This is a, yeah, this is a little bit of jargon from acceptance and commitment therapy based on the idea that if we're not aware, a lot of us are constantly fusing with our thoughts. So we are either consciously or unconsciously kind of Walking around with the idea that we are our thoughts. Our thoughts are reality. The trouble with this is we get swept up in our thoughts. We find ourselves out of the present moment. Or if we have this idea that for example, a depressive, depressogenic idea, like we are bad, or we've done a bad thing, the more we think about it, the more it feels true. If you think about depressive ruminations, that's kind of the classic example of people who are stuck in their thoughts, or even just one recurring thought. And so the idea from Acceptance Commitment Therapy that I love and that I think is very intuitive, as a pairing with ketamine is that we're not our thoughts, we can have all sorts of wacky thoughts, we can have all sorts of beautiful thoughts, there's really nothing that constrains our ability to think and we shouldn't, therefore, take our thoughts too seriously or mistake them for reality. Thought diffusion is a lot about- in Acceptance Commitment Therapy, you might ask somebody to just to sing their recurrent depressive thought in a way that makes it clear that this is not reality.

CHRIS AIKEN: What are some techniques you use to help people feel their feelings, as you said?

KYLE GREENWAY: So this is where I think, I love the English word feeling. It's better than the French word because it has the word feel right in it. Feelings are, are phenomena that we are, are physically aware of. Whether we're, we notice or not. And so we often ask people to just inspect them, their body with their eyes closed and find traces of shame or anger or whatever feelings are really calling their attention, or even if it's pain. And then we coach people in trying to avoid telling complicated stories about what those, those sensations mean, and instead just return to the actual phenomena. And this is sometimes called somatic processing or interoception. There's many words, I think trauma-focused therapy uses techniques like this a lot.That work is, is very much preparation for then the ketamine treatments, where their body might become, they might feel like it's become a million miles long, or it's disappeared, or it's shrunk. Their feelings might feel like they've been magnified, that their whole body is, is anger. All sorts of wacky things happen. It's a great opportunity to practice just being curious about it. Avoiding telling complicated stories about what's happening and just observe the phenomena. Because that same skill allows you then, when in sober life, to deal with your heart racing with anxiety, or your gut feeling like it's full of shame, etc. It's essentially feel your emotions, diffuse your thoughts, and change your behavior. And the behavior-I actually, it's funny to me because behavioral therapy obviously has really fallen out of vague, but behavioral activation therapy is probably equivalent to CBT in terms of outcomes for almost everything, especially depression. And the more I've done this work and the more severe popular patients I've worked with, the more I've become interested in behavior of the triangle of emotions, thoughts, and behavior. Emotions we can't control. Thoughts we can't control. But behavior, at least in theory, we can actively do something about. We can actively change. 

CHRIS AIKEN: Along this route, do you work on values to help connect values to new behaviors? 

KYLE GREENWAY: So that's, that's a wonderful question because that's an intrinsic part of acceptance and commitment therapy. I have to say, I think values are very, very important, but when we're dealing with people that are severely, stuck in a depressive episode, I think often their values are less accessible to them than a more mild population. And so often we return to stuff that I just know from the research is going to be beneficial. Brushing your teeth at the same time every day is going to help you organize your life a bit. 

CHRIS AIKEN: Yeah. I agree with you, you can make a lot of difference just with the basics that are generically good for everybody.

KYLE GREENWAY: Totally. Sleep hygiene practices are, like, 90 percent of Americans don't do it well. Almost nobody gets, even a moderate amount of exercise, let alone the recommended quantities. 

CHRIS AIKEN: And I wonder if there is a value there, which is the value of taking care of yourself.

KYLE GREENWAY: A hundred percent. And I really think, these kind of activities build people's self-esteem. And they also de-psychiatrize them a bit if they've been stuck in the idea that their, their problems are totally due to a chemical imbalance and out of their control. When you start with a routine in your life, and you start to leave the house every day, and then eventually maybe walking a little bit every day, et cetera, you build momentum, and that momentum, I think can continue for a long time in people. 

CHRIS AIKEN: I wonder if that's the partnership that you're looking for before you give ketamine. In other words, to some, you might be saying, buddy, you don't care about yourself enough right now to receive ketamine. You're not doing anything good for yourself. 

KYLE GREENWAY: This is absolutely the implicit message. Like, ketamine won't fix you, and that eventually, ketamine can help, and care providers like myself can help, but eventually you're going to have to fix you. And that is a hard message to deliver, and it takes a lot of kindness, it takes a lot of trust, and it's, it's often better left to be sort of a message that is implicit in the process, than in an explicit confrontation. And so by talking about goals, by saying like, okay, what can we do? Can we find three, small changes in your life that we can work on together. By talking about that stuff, you're implicitly engaging people and trying to make change in their life without shaming them for spending their days in bed, watching movies all night long in their, in their bedroom, et cetera.  

CHRIS AIKEN: To back up, it sounds like you're doing acceptance and commitment therapy that's medication-enhanced. 

KYLE GREENWAY: Yeah. That’s a good way to put it. I would say as we talked about, I think it's a little less than the commitment, a little less value-centered and a little bit more behavioral. 

CHRIS AIKEN: Okay. So I'm thinking, well, I'll just give lithium or aripiprazole and that'll enhance and then I'll do it. What is unique about ketamine that enhances this acceptance and commitment therapy?  

KYLE GREENWAY: Yeah, I think ketamine is, in my mind, it would be hard to design a drug that was better for this sort of work. So, I mean, ketamine obviously produces robust antidepressant effects. We have very good evidence about this. Ketamine is also very helpful for addressing the cognitive impairments of depression. And ketamine is also very helpful in addressing suicidality. And it can do all these three things very quickly. Which is remarkable, and it has good evidence in real life treatment-resistant depression patients that, honestly, would probably be screened out of most studies, even on Abilify. 

CHRIS AIKEN: To our readers who aren't familiar with acceptance and commitment, just to remind them, what is the connection there? 

KYLE GREENWAY: Yeah, absolutely. So that's it. So I think those are the symptoms that I think pairs ketamine well with any therapy, but to your question about why acceptance and commitment therapy specifically the ketamine state, because it's so strange for most people, there's bodily distortions, your thoughts moving in different patterns, there's often emotional or bizarre sort of visual hallucinations that come, all of that stuff is wonderful for teaching people to not take their thoughts so seriously, for example, that if you can experience an entirely different way of being or relating to the world for an hour, when you come back, Inevitably, I think you'll hold your view of the world with a little less rigidity. 

KELLIE NEWSOME: And now for the CME quiz for this episode. Earn CME through the link in the show notes.  

What special challenge does ketamine assisted therapy with PTSD bring?  

1. Ketamine may interfere with experiential learning.
2.  Ketamine needs to be dosed 24 hours before exposure sessions.
3. Ketamine may cause traumatic memories to surface.
4.  Ketamine is more likely to cause dissociative symptoms in patients with PTSD. 

CHRIS AIKEN: What are some of the challenges of doing ketamine assisted therapy, particularly in working with the client and getting them on board?  

KYLE GREENWAY: First of all, it's, it's bizarre, it really is different for most people compared to what they know from psychiatry. And so people have to have a certain tolerance of the weirdness that ketamine can bestow. 

CHRIS AIKEN: The experience of ketamine is bizarre. You mean? 

KYLE GREENWAY: Yeah, that's it. Okay. And even just, not just the actual content of what ketamine might produce in someone, but sitting in a room, being injected with ketamine while someone sits with you, and it either provides music or talks to you about what's going on, that is not a familiar treatment setup for most people. You need to have a certain level, again, of trust, but also openness to try something different, and I have to say, I think that people are surprisingly open to this. Most of the people we meet are just so desperate for something that'll help that they really will try anything.  

CHRIS AIKEN: The challenge might be if the patient doesn't have any altered experience. 

KYLE GREENWAY: Yeah, absolutely. Absolutely. You know? Or if they find that their experience didn't match their expectations. A big thing, as I referred to earlier, that we are very mindful of is expectations, because even though I try to temper people from feeling that ketamine will give them a mystical experience or rewire their brain, inevitably people will come with this idea that they're going to have a very powerful experience of their emotions or mysticism, et cetera, and yeah, as you say, if they don't have that, there's a lot of disappointment that might need to be debriefed. 

CHRIS AIKEN: Is another challenge, though, that they might have such a good experience on ketamine that they start to see psychotherapy as useless and as ketamine as everything?  

KYLE GREENWAY: So, there, I think the ketamine assisted psychotherapy models win compared to the biomedical model. So, if you've reinforced to people that this is a treatment that will hopefully help them for biological reasons, but also by bestowing therapeutic experiences, then, I think at the end of the day, when they're feeling bad again, or they're comparing different treatment options, they're going to seek out therapeutic experiences. In a sense, and if you compare that to if people have understood that ketamine works only biologically to correct some kind of internal deficit, when they're feeling bad again, they're going to seek out more ketamine.  

CHRIS AIKEN: I’m imagining about 10 or 14 days after their last treatment, they might start to feel bad again. I'm just imagining. Is that realistic?  

KYLE GREENWAY: It varies. It really, it's quite remarkable. In this study that we are currently writing up, what we saw is that four weeks after our treatment course finished, there's not even a numeric difference in people's symptoms from the end of the trial. So people remained exactly where they were, which is very atypical for the ketamine world.

CHRIS AIKEN: Okay, so you're not dealing with these major dips and, oh my god, I need more ketamine, where can I get it, kind of things after their last dose. 

KYLE GREENWAY: Definitely not after one month, no. There are certainly cases where two or three months later, people start to feel all those familiar patterns acting up. And that's where I would say that the attention we spend on the explanatory model and the behavioral changes and the psychological work really pays off. Because we've already told people almost at day one that ketamine is not the answer. It's not there, I don't think it's a good solution to receive a dose of ketamine once a week for the rest of your life. Ketamine is a catalyst to make changes. And if people crash, or I shouldn't say crash, if people are feeling worse three months later we will speak with them and we will try to reinforce that the thing that was going to keep you well was not ketamine, right? It was the behavioral activities, the psychotherapy. Where are we on those fronts?  

CHRIS AIKEN: Okay, I think earlier you said something about six months. You might try ketamine again. Did I hear you right?  

KYLE GREENWAY: Yeah, that's right I think between four to six months for some patients and we will consider a one-off boost A single dose, and that's kind of aligned with psychotherapy, right? Like after a course of 12 or 18 sessions of CBT, if people are doing well, but have sort of a little bit of new stressors, or they're regressing a little bit they might receive one or two psychotherapy sessions as a sort of a boost model six months or a year later. That's the way we see SORT Academy, again, it's there for the psychological impacts, and that's why even a one-off six months later might be enough to bring people right back to where they were after that acute treatment. 

CHRIS AIKEN: Your model sounds like would fit someone who works with third-wave behavioral or acceptance and commitment therapies. Can you speak to therapists who might come from a more CBT perspective or others how they might work with ketamine clients?  

KYLE GREENWAY: Great question, and I think that speaks to the transcendent power of behavior. All psychotherapies can be described to some degree as interpersonal interactions that add some kind of explanation to people for their suffering and push for behavioral changes. Or at least positive steps forward, that’s from the common factor model of psychotherapy. And so behavior is kind of consistent, I think with even psychodynamics, let alone CBT, encouraging people to try to make behavioral changes is something that is intrinsic to any kind of psychotherapeutic setting. Then when it comes to the specifics, we've, we've worked closely with therapists who come from all sorts of lenses, internal family systems. Dialectical behavioral therapy, cognitive behavioral therapy, and I think the only way that ketamine doesn't fit is with CBT's idea that our thoughts are kind of reality in a sense that in cognitive behavioral therapy, when we engage in thought catalogs, If we don't do it correctly, I think, we often kind of reinforce the message that we're suffering because we're illogical, we're suffering because we're committing cognitive errors, and the way to fix that is to identify those errors and correct them. And I think ketamine is, is a little weirder than that. I don't think that's a coherent fit with a drug that generally just introduces a lot of uncertainty to people. And that's where I think the acceptance commitment therapy lens, which is, we're just not going to take thoughts as seriously. I think it is a more coherent sort of model. 

CHRIS AIKEN: Although I read the paper on using CBT to prevent depression after ketamine, and I believe they emphasize that ketamine makes people more cognitively flexible, so they're more amenable to cognitive change.  

KYLE GREENWAY: There's an excellent article from experts at Hopkins in, in psilocybin therapy, arguing that CBT makes a lot of sense for even psilocybin work. And that's based on the idea of experiential avoidance. And that ketamine treatments, psilocybin treatments, pretty much all psychedelic experiences are kind of famous for bringing up probably exactly the content that you were trying to avoid. And CBT does a great job of engaging in avoidance, asking people to do exposure work, for example. And psychodynamic does a great job, too, in helping people understand that content better as a way to tolerate it more. Acceptance and commitment therapy does a great job, I think in practicing understanding that those, that that content, that internal content is not reality. And so therefore it's easier to tolerate. So I think there's a certain logic with any psychotherapy that fits with engaging in less avoidance and more exposure and that fits nicely with any psychedelic.  

CHRIS AIKEN: How does the treatment process look different for people who've experienced a lot of trauma?  

KYLE GREENWAY: Wonderful question. In a sample of ours, we found 30 or 40 percent of our patients came with a diagnosis of PTSD from their referring psychiatrists, and that varies, of course, from the more complex childhood trauma or repetitive trauma sort of PTSD from the acute incident, the acute violent trauma, often combat PTSD. And I would say that one, people with PTSD often struggle to form therapeutic and trusting alliances with care providers for a variety of reasons. And that is something that can be a major obstacle to doing this work safely. Two, I would say that people with PTSD, like almost a hallmark is patterns of avoidance either with substances or with different behaviors, like avoiding a certain area, avoiding certain people, et cetera. They should be prepared for a psychedelic drug like ketamine, doing the opposite of that, doing, like, inevitably bringing up probably the index trauma that they've been trying to avoid. 

CHRIS AIKEN: So we might, in the preparatory session, prepare them for the idea that traumatic experiences could flood their mind during the ketamine infusion. Is that right? 

KYLE GREENWAY: Absolutely. And it's something that- the many different things we discussed in preparation, that is definitely 1 of them. They're kind of a little too many to just to recall right off to name kind of sequentially. But I would say preparing people for challenging experiences, traumatic. Traumatic memories to resurface is an excellent step early on in the process. There was a patient that we treated that had a traumatic event related to ketamine. They had a pain crisis that was badly managed in a surgical situation, and they received ketamine for that, and they forever created this association that ketamine equals their pain crisis. And so they actually had a reliving, they had a pain crisis while receiving ketamine in our hands, which is ketamine is an excellent treatment of pain normally. So you can see, I mean, how important it is to understand, different people's different experiences. And indeed, a lot of the most emotionally powerful ones will pop up with the psychedelic treatment model. 

CHRIS AIKEN: It sounds like the guides in the room are sometimes helping them to process difficult experiences actively during the treatment.  

KYLE GREENWAY: Exactly. And that's, and that's where we landed on doing some sessions with music and some sessions without it. When you do a session with music, if people are able to immerse themselves in music, it's a little bit like having an interpersonal relationship with somebody who's not going to make you angry. So what I mean is that anybody in a psychiatric setting probably has friction with other human beings in one way or the other, like interpersonal deficits are almost guaranteed. And if you're just in the room with a therapist, even say a kind therapist, still, there's going to be a bit of clash, I think at some moment, a conflict that will show up in the ketamine experience. Whereas nobody has a conflict with Beethoven, I think it's much easier to relate to Beethoven or Bach or just world music or whatever it is kind of in an interpersonal way, but it doesn't evoke the same sort of counter the same sort of transference that a therapist will. 

CHRIS AIKEN: And it centers them. I guess it keeps them from drifting. 

KYLE GREENWAY: Yeah, it provides structure. It provides an arc as we talked about. There's this idea of kind of building intensity and yet centers structures and it's reassuring. And music is powerful at evoking emotions. Much better than I think I am as a therapist. So if a patient's The primary problem, for example, is that they have a fear of intense emotions, then music might be really powerful at kind of allowing them to do some exposure work to their own emotions. Or if the opposite problem, a patient who's just struggling severely with anhedonia, having a powerful experience with music can be just therapeutic in its own right because it reminds them what it is to feel joy or happiness. Whereas I think if, if patient's problems, in our model, if we conceptualize our patient's problem as being more to do with, say, difficulty in letting go or interpersonal difficulties, sometimes the music just feels a little bit more like you're engaging in avoidance. You're just giving people kind of a fun moment, and you're not really addressing the core issues that are better addressed with more of our non-music approach.  

CHRIS AIKEN: All right. Thank you, Kyle. I've been very generous with your wisdom today. I appreciate it. 

KYLE GREENWAY: Hey, it's been a pleasure. 

CHRIS AIKEN: Kyle Greenway is an Assistant Professor of Psychiatry at McGill University and the Director of the Ketamine Assisted Therapy Program at Jewish General Hospital in Montreal, Canada. You can find his full interview in our online edition for June of 2024. 

KELLIE NEWSOME: The July edition of Carlat Psychiatry News is out, featuring a new batch of randomized controlled trials on lumateperone, cariprazine, antidepressants, clonidine, lavender, and varenicline. Tune in on the Carlat Youtube Channel or find us under webinars at the Carlat Report.com.

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.