What We’re Missing in Adolescent Mental Health

Introduction to Psychedelic Healing 0:00

Probably the dangers of psychedelics, I would say, is that you start to feel too much. You start feel it all. And if we don't have a community, if you don�t have language, a framing, or a trusted understanding of like, �Okay, why am I so dysregulated? I did psychedelic. I thought it was supposed to solve everything.� Actually, what it's solving is maybe our disconnection. and actually getting connected with where we're at can be disruptive to the patterns that we've been used to. With the wisdom from holistic, alternative and these conventional medicines, we are here to challenge the status quo.

We're curious about the connectivity and complexity between diverse fields of knowledge as it relates to consciousness, chronic illness, mental health, resilience and beyond. Learning more about art and science of healing, or listening to stories of extraordinary healing. You're in the right place. Let's dive in. So welcome to another episode of Voices in Health and Wellness. This is the podcast where we sit down with health and wellness innovators who are redefining what care looks like. I'm your host, Dr.

Andrew Greenland, and today's guest is someone whose work truly sits at the cutting edge of what's possible in mental health care. Dr Soraya Raman is a board certified pediatric hospitalist, the medical director of our own integrative practice and a co-founder of IACAP, a community and consultation group pioneering the use of ketamine assisted psychotherapy for adolescents. And so, I'd like to welcome you to the show, and thank you so much for joining me today. Thank you. And I will just correct that it's actually IACAP, A-Y-A-K-AP.

I would correct, but thank very much. So, could we start a little bit with your journey and how you moved from being a pediatric hospitalist into this integrative and now psychedelic focused work? Yeah, yeah. As one of my friends says, you can't get here from there. There's no clear one path, clear path through. However, I think as a physician, lifelong learning is always the way through, looking at the problems that are in front of us, seeing more deeply into the solutions that aren't there for the problem that may be in plain sight, but may underutilized.

And then bringing in the experiential aspect of being a You know, a physician's journey is lifelong. It's a different profession from any other and it continues to evolve. So, you know both my parents were physicians and growing up I saw that it's who you are, it is a perspective that you walk into into the world and people really trust a Physician to be the one that says, yeah there's something wrong here and yes we can do something about it. And so, all that has always been kind of the motivating factor behind, you know, stepping into, for example, hospitalist medicine itself.

You know pediatric outpatient is where I started and then I went into hospitalists medicine because I wanted to work with the higher acuity kids, the kids that had more chronic illnesses and I saw a lot of trauma. So, I think that trauma informed lens really help to understand that we are under treating mental health conditions in pediatrics specifically. We just don't have the resources in the United States at least. we have a lot of patients who end up in emergency rooms sometimes for days awaiting placement because the only higher level of care that can provide is hospitalization and we just dont have enough beds.

to actually deal with the number of patients that are coming through. So one of the kind of realizations as I was training in moderate sedation, so for about the last 10 years, In a trauma center,

From Pediatrics to Ketamine Therapy 3:48

I've been providing moderate sedation services, you know, just like an anesthesiologist would, but it was being handed over to the pediatric hospitalist because the studies show that we can do just as good and just a safe of a job because we know our patients better, too, and we're much more aligned with the paediatric physiology. So using it for painful procedures, long procedures and becoming familiar with a medication that's ketamine. And at that time before the pandemic, i really didn't have a consciousness about ketamines and psychedelics.

None of us are taught about that. We're just taught that there's an emergence reaction that occurs mainly in adults after you've given them ketamine for a painful procedure and that that's just something that we can chemically or physically restrain for. Not understanding that, there is an internal experience happening and what happens on the outside the set and setting how a person is prepared for that experience can really make the difference. And so it really was kind of like a penny drop moment where it was like, wow, this is real.

You know, the ketamine is a very ubiquitous medication in the emergency room and an inpatient and the procedural suite. However, it took me two years to really convince myself that this is a real psychedelic and that psychedelics medicine in and of itself is creating a different paradigm for mental health. So, those two things really drove, I think, the impetus to change lanes and to do so over the last three to four years. And what sparked the pivot to start using ketamine with adolescents specifically?

Yeah, I was just in a meeting of our group, ICAP, which is the Adolescent and Young Adult Ketamine Assisted Psychotherapy Group. We started about two and a half years ago. and we are physicians and psychotherapists and other professionals who meet around this exact question. It's like, okay, so if we say that, you know, in the adults, we're seeing a lot of results with treatment-resistant depression, with PTSD, anxiety, eating disorders, and OCD, how does this now relate into the adolescent population, what do we have to be aware of?

What are some of the pitfalls? what are the best practices? So even just thinking about it in that way has revealed to us that there is a population of patients for whom the risk benefit analysis makes sense. As in, you have a patient who's catatonic and in the hospital for 100 days, just this morning, a physician was giving me that story. I mean, we're hospitalists, so we see these patients every single day. We try everything. It's a multidisciplinary effort. It's a lifelong trajectory for this patient.

And they were talking about how they used ketamine in a lumbar puncture situation. So they needed to see if this person had high pressure, their brain and spinal cord, and they use ketamine as a medication to just sedate during that procedure. What they noticed is that over the next three to four days, the catatonia disappeared. the patient started to be more verbal, actually remembered the doctor's name, had never spoken before. The whole team was just astounded, and at the time, they didn't know what to attribute it to.

There was not even a question of, could this have been the ketamine? And now, three to four years later, as we're looking back at some of our most difficult cases, we see that there's a cohort of patients who do suffer with long-term treatment-resistant conditions, for example, OCD, eating disorders, that can absolutely create a high degree of morbidity as well as mortality. And to have a medication that's kind of ubiquitous, well-known, used for the last 60 to 70 years has an amazing safety profile.

you know, we can use it down to neonates, but also comes with this kind of cultural stigma that's been attached to it, has been a really interesting dilemma, and that is why our group exists to parse that through. It's like, who are the patients for whom this is a good idea? Another example is patients who have had treatment resistant depression, for example, maybe on three to four to five medications. That is very common scenario in adolescent depression. And so, using a rapid antidepressant like ketamine, not all the time, as an intensification induction and then as a maintenance phase, we can really think of it as procedural, interventional, you know, mental health treatment that can allow better functionality.

decrease medication use, improve developmental milestones. That's the other piece that's really important when we talk about adolescence is we're not just talking about the mental health diagnosis. We're talking an entire lifetime of low functionality, which may reflect in their relationships and their ability to learn, to hold down a job. And so, I think this is a real under-recognized gap And so, we're really excited to talk about it, to bring more people to understand that, yes, there may be caveats and all of that.

But the bang for your buck that you get is pretty astounding, and that's the piece that I think comes with psychedelics and the potential for transformation that we see. So, here I was scratching my head going, ìNo one is going to allow me to do this within the hospital situation. Iím going break into private practice.î I really took that seriously. I said, alright, Iím putting myself out there as this pediatrician. It was kind of like, all right, Iíll just put out an intention and see what occurs.

And I think I might have mentioned this to you. Applied to I was like, okay, there's a conference coming in about 18 months I'll you know, it's in my consciousness if I do have a patient I would love to present it there and Lo and behold there was a person who reached out to me a parent and as we kind of proceeded through the intake of It was positive, it made sense, they were really motivated. They had already experienced psychedelic healing and so, there were a really good container for this. And so there was a certain sense of, okay, we're doing this and we are trusting the relationship, the therapeutic relationship that's building here.

Why Ketamine for Adolescents 10:07

I did a lot of psychoeducation, I do a lots of consenting around This is a non-ordinary state of consciousness. We were very clear about what we're here to do and what were not here do. A lot of harm reduction as well. And it was really challenging. It was challenging in the way that it's not just the medication. You know, it is not the medicine. The medicine opens a door. And in each opening, there is an opportunity. There's an opportunities that arises whether in a memory that is clear and is coming up for exploration or relating.

there's opportunity for withstanding the kind of difficulty or discomfort that may come with really disturbing OCD thoughts. In this case, specifically, it was thoughts of pedophilia that can occur. and suicidal thoughts, thoughts of ending their life. And really, the opportunity is to understand your thoughts. So I really leaned heavily on my knowledge and practice of meditation, contemplative practices, narrative medicine, yoga, somatic, breathwork, all of that just to bring the nervous system regulation is part and parcel of this treatment.

What I learned was it's very intensive. It needs a lot of support, it needs regularity, and it takes time. It actually takes a much longer timeline than what people might be reading about. You know, the popular press might talk about, well, yeah, you do successions and you're a different person and its transformational. And for some people, yes, that it can be that transformional, but what the stories aren't revealing is that that person did a lots of work beforehand that was an investment into what became available in this transformational field.

So it is not one size fits all. It's really contextual. it has an opening and availability, but it's absolutely wonderful to see those assessments, you know, the PHQ-9, GAD-7, PCL. depression, anxiety, PTSD scores going down and staying down, and the opportunity that that brings out. You know, if you're feeling better every day, you are feeling a little bit more of your motivation, that's the opportunities for coaching that we get to engage in, which is, okay, your feeling is better, what do you want to do with this extra energy that is showing up for you?

that you've really not been able to access. One of the biggest pieces of feedback I got from the parents was, we're afraid to breathe. We don't know if this is going to stay. When the changes first started to show up, they couldn't believe it. It was kind of like a, is this a new reality we're stepping into? Can we trust it? You know, Is this going to go away? Like the patient themselves had a lot of, you know anxiety about, okay, now I'm better. But just like any other time I felt better because of psychotherapy or medications, this also going away.

And so really getting the person to recognize, look at the pattern. So I do a of actually looking at objective data. It's fantastic. After six weeks or so, they'll come back and their story may be, yeah, it worked, but I'm still not feeling better, and then you show them the objective data. Oh, I didn't know. We use a lot of trackers, sleep track, mood track and heart rate variability track. Hypertension goes down. That's one of the interesting things I see. Ketamine is such an interesting medicine.

If a patient comes with anxiety, they've got high blood pressure, and they're on medication for high pressure. Four to six weeks later, we've done some ketamine treatments. their stress and their anxiety levels are down. Their blood pressures are normalizing and sometimes they actually have to wean off of some of their blood pressure medications. So that's also an interesting phenomenon we see. Really just getting at the root cause of these things has been really interesting. Thank you. What were some early responses you got from colleagues and parents when you started exploring this space?

Oh, goodness. Yeah, yeah, absolutely. I call it my coming out of the psychedelic closet. We all joke about it. There's a great number of neuroscientists and physicians and therapists who are all going through this process that I remember going I was burning out, I in a pediatric trauma center, and I realized that I had to heal myself. There was this personal impetus. I think that is probably the most common reason why people become involved or see this kind of healing, because it's affected them.

or somebody else around them in a very transformative manner. And so we see this again and again is when you have experienced it, you kind of become a believer in it because it's the evidence of your eyes. So there was this kind like, yes, this is the truth and this real, but I'm taking on a lot of courier jeopardy. I don't know how this is going to end. Am I going be known as the ketamine pediatrician? And always. It was like a dual world perspective because I would go for my trainings. I'd go to places like Berkeley and Colorado for psychedelic training.

And within that community, there would be this welcoming of like, oh my gosh, thank you, we need more pediatricians. We really need to address this childhood abuse that's underlying. We're talking about complex PTSD that masks as a major depressive disorder, and we try medications and psychotherapy, but you can't get at the non-verbal trauma. With psychotheraphy, you could only get it at verbal. You can really get the developmental and some of the relational trauma that happens in childhood, you know, in complex PTSD.

And so, I see that in my, uh, pediatric world. I've really tried, given grand rounds, presented at the American Academy of Child and Adolescent Psychiatry. Within those spaces, what you'll see is that the general leadership will be very skeptical because they'll be carrying attitudes that are more from the you know, boomer generation and Gen X attitudes. And then there'll be a younger cohort of physicians, scientists, and therapists and ED physicians who are looking at the crisis that's in their emergency rooms and they're like, oh my gosh, tell me more.

How do I do this better? So it's really a dichotomy that we're facing here. So yeah, it is a range of attitudes, so I've learned that You know, not to take it personally, to be more grounded. And I think the community aspect has really helped is we talk to the parents as psychedelics become more mainline. There's also a awareness amongst parents, you know. In the United States, at least, for example, Non-profits like Moms on Mushrooms talk about how microdosing psilocybin safely has helped them be more emotionally focused on their children.

Doing their own trauma healing has actually helped to be better parents in a lot of these you know, intentional ways.

Early Cases, Outcomes, and Parent Reactions 17:28

So, I'm also aware that as a pediatrician and pediatrics, you now, especially integrative pediatrics. Pediatrists that practice within the context of the family, their intergenerational trauma, the trauma burden overall. the awareness that family systems can really respond to the trauma unconsciously, you know, in the scapegoating, and the narcissistic kind of, patterns of relationships. And so we're becoming aware, I think, as pediatric professionals of how trauma is working in a family system around the patients that we take care of.

For example, now, if I see a patient with anxiety, And so, we don't really do that work. We don�t really turn to the parents and say, �How are you dealing with what's going on? How is your anxiety? And do you realize that you are one nervous system when you're with your child, and that that matters?� So really turning that lens of integrative practice has really helped as well. So there's definitely a growing attention on the mental health crisis amongst adolescents. Can you speak to that and can you sort of see how ketamine assisted therapy might fit into that wider conversation?

Oh, what a big conversation. I mean, we're talking about a time, you know, where in the context of our time right now, great transformation, disruption, disaster, violence in The United States is an uptick. And I'm a parent of two teenage young adult kids, and I remember the times where I would have to drop them off to school having just heard about the school shooting that happened maybe two counties down. So, that's the reality of a child's life in some countries. And so, what we're seeing in the pediatric population is an uptick in when a children goes to school and the school is not supportive of who they are and what they need.

The bullying, we're talking about bullying. We're not being met. This cohort of students who really mask, who just kind of tolerate what their life is, and it comes out in different ways. Within that, you talk about the climate crisis. We're talking about a food supply system that is more processed than non-processed. And I'm talking when you look at the general population. If we look very resource kids, they have a different set of problems that do also come out of mental health disorders. But if we're taking about the population, our air quality, water quality or the quality of our food, it all kind of comes into the picture.

for how, let's say, a mental health condition can really become ingrained, become identity, you know, oh, this is who I am now, instead of this what's happening to me, right? And only later, as adults, when we have safety and we that mature way of looking at things, can we kind of look back and recognize like, Oh, wow, that wasn't me. That was what was happening around me and that was the label given to it. Or, I couldn't even have language for what was happening to me. A lot of childhood trauma is kind of just pre-verbal, as we talked about.

And so, when we talk about adolescent mental health, we're talking about the future adult mental-health crisis. We're talking about the roots of what's happening to everybody. And so the way it shows up here is in a higher degree of disability applications that are happening within younger groups. So more and more young people are actually applying for more disabilities. that trend that we're seeing. We're seen a greater awareness maybe and diagnosis of neurodivergence and autism in adults and this concept of masked autism.

You know, so, you know near divergent adults who have higher than normal intelligence and never really fit in and basically developed a way of relating to reality that was very much about not being their authentic self and how a lifetime of doing that can really lead to a sense of disconnection and all the things that follow from disconnections, depression, anxiety, addiction, and things like that. So, we are learning that the adolescent mental health crisis has a trauma aspect, has neurodivergence aspect.

It has kind of like a, oh, were feeling disconnected from our bodies. Were feeling disconnective from nature. We're feeling disconnected from our role on this planet as human beings. When you talk about neurodivergent young adults, they have a high sense of justice. They have high truth-telling, which can be really problematic in a polite society. Nobody wants to hear it. And so we kind of take our population that may be the canary in the coal mine in a situation and we go ahead and then shut them out, you know, and maybe those are the voices we actually need to hear more and bring into awareness more because I think what they're calling us back to is a reorientation of our relationship to being human.

And I think that's where it fits into the overall piece of psychedelics, because what psychedelic have been shown to do, like across the board, any psychedeli you talk about is it increases people's awareness of their nature-relatedness. So there's kind of like a burgeoning, like an uncapping of our ability to connect with nature, to feel like we're part of nature and actually be healed in that kind very elemental way by the patterns of Nature. So one of the things that we talk about after psychedelics is Go and integrate, meaning go feel like yourself out in nature.

What we're talking about are the diseases of the ego. We're taking about when we become so entrenched in the idea that we are superior to what we were embedded in. and then we can maybe have a little bit of a reset as to our proportionality. It's like when you look at a 500-year-old redwood and you really look and feel with it and see the majesty and the impact of it, and just what it represents, then you see forest fires that are taking them away. You know, the sense of just despair that we feel right now, that is one of the kind of probably the dangers of psychedelics,

Mental Health Crisis and Trauma in Youth 24:18

I would say, is that you start to feel too much. You start feel it all. And if we don't have a community, if you don�t have language, we do not have framing, If we have trusted understanding of like, okay, why am I so dysregulated? I did psychedelic. I thought it was supposed to solve everything. It's like actually what it's solving is maybe our disconnection. and actually getting connected with where we're at can be disruptive to the patterns that we've been used to. You know, my treatment-resistant disorder diagnosis patients, one of the first things they say as they're starting to feel better is that I feel a lot of grief.

I fell better, but I felt a grief, and what is the grief? It's like, oh, I spent a whole lifetime. not knowing that I could connect, that this was possible. That I'm not meant to be this. I am actually more than what I've been led to believe. And so there's 70 year olds mourning. a lifetime of living with diagnoses they didn't have to. So I think we're going to see more and more of that as psychedelics become more mainstream, more compounds are coming out that are going be easier to administer. At this point in time, it's a bit of a wild west.

When you talk about dosing, there's no way of ensuring that you're doing any kind of dosage that's weight-based or person- based, you're kind of like doing it and see what happens. Whereas I think with ketamine, we have a lot more of that piece sorted out. We have decades of data on how to dose well, what's a low dose, a medium dose or a high dose. A lot of different ways to administer it, and so to do it safely. So it's really interesting place to be at, at the tension of these two things. The psychedelics are really coming online, but they're really coarse and they may not be ready yet for another few years or so, and practices that are there are going to really be constrained and kind of very basic and coarse.

And then you have just the ketamine, which we're a lot more familiar with as emergency room physicians. and hospitalists, and to know that there's a benefit to it. There's benefit that waiting on the classic psychedelics to hit the market, we're possibly leaving a 10-year gap in some people's lives of treatment. So that's on my mind, too. Great. Thank you for that. You're building a network that spans North America, South Central America and Australia. What's different about how this work is being adopted internationally?

Great question. We just had a wonderful check-in with our Australian counterpart, one of the therapists who has a treatment facility for eating disorders. They've been in their rollout for about two to three years now in Australia, and it was just fascinating to hear how different it is. You know, they have a much more clinical protocol, there's not a lot of this Wild West underground that they're involved in. They're able to use MDMA, psilocybin, and ketamine in treatment centers for eating disorders in the above 18 age group.

You know, so that's how that working in South America. I'd say that there's a greater emphasis on ayahuasca and psilocybin just because of the familiarity and the constructs there. And I think South and Central America definitely have their own culturally you know, aligned ways of doing medicine. And what you'll see is it's kind of like the medical model and the indigenous model, and variations that are kind at the intersection of the two, you now. So the Medical model very much based on patient selection, criteria that they're being used, our patients who are very well into their psychotherapy, kind-of journey, are resistant to standard treatment, and then have the ability to engage in a very rigid, protocolized way of doing it.

And they're following the MAPS protocol. So if anybody is curious about what the protocols are around it, MAHPS, which is the Multidisciplinary Association of Psychedelic Studies based here in the United States, has trained the largest number of the MDMA therapists worldwide. I know that they are working in other places. like the Middle East. They've actually done work in between Israel and Palestine as well, so really focusing on these conflict areas. And in North America, actually, the VA, you know, The Department of Defense, a lot of work is being done in PTSD in the veteran population, because in a veteran's population you have such a high degree of recidivism.

and chronic functional impairment that the VA has really understood that ketamine therapy is a really good tool that can be used and now they're actually paying for clinics that cover that. So, there's a wide range. It really depends on who's pushing for which population. The vets are definitely having an opening happening around, for example, ibogaine as well. Texas and other states are funding ibogaene treatment. Ibogane is a psychedelic that comes out of West Africa, out from Gabon, based on the Iboga plant.

And so, that is very powerful psychedelics. So, I'll kind of end with saying, you know, when you're thinking about psychedelcs, it helps to think about length of action, duration of the action. because that actually correlates to that critical period that's open of increased neuroplasticity and flexibility. And so ketamine is the one that has about 48 hours of neuro plasticity flexibility because its duration of action is about one to two hours if you use it psychedelically. Then ibogaine has the longest duration neuro plasticities.

So its impacts last for weeks. It's being investigated in not just PTSD but also traumatic brain injury. spinal cord issues, just things where we're trying to rehabilitate actual neuronal growth is a fascinating place. So, all that to say that there is quite a difference and uptake based on the culture of the place, the context, and the populations that are being made more aware and are advocating and actually finding their own funding.

Nature, Integration, and the Risks of Psychedelics 30:48

At the end of the day, it's who wants to fund what. For example, in San Diego, we just had a protocol that had been approved to use ketamine-assisted psychotherapy in youth in a halfway house situation where they would be there for three to four weeks. It was initially approved and now the approval has been taken away. The barriers that are there, some are visible and some aren't. And so we're just trying to work within these paradigms, but it's really wonderful to have an international global awareness because trauma is global.

what's happening in all these different ways. Thank you. I was going to ask you, are we ready clinically and culturally for this kind of model of care? I guess you are, so it would be yes, but I'll ask anyway. Oh, actually, it's more nuanced. Absolutely. It's very much more nuance. You know, I will admit to the fact that the deeper one goes into the psychedelic world, the more distorted our lens becomes. I would say I couch that with when I'm in Colorado and I am talking to a physician who is working with psilocybin and ketamine and seeing things, I feel like I�m in the future.

It's been done in a really beautiful way. But I also really aware that there's always this narrative, especially in United States, of the quick fix. of the thing that's going to solve everything, and the ways in which our culture responds to the idea of a quick fix. you know, of rapid adoption, but not really in the way that would lead to good clinical outcomes. And so, I think that's where my caution lies, is that it's not for everybody. What we're learning is it really about preparation. It's really the trust in relational aspect of the healing, meaning is this therapist that you're working with or this container that your working in, really able to hold the kind of experience that you might end up having.

So it's a very experiential container, meaning that we got to know what's there. And sometimes we don't, and we still have to kind of, we might find ourselves in the middle of a treatment protocol going, wow, this is new information we did not have. And even this person didn't have, so I'm reminded of the Joe Harry window, the things that you know, you don�t know. Sometimes, for some people, that window of I don´t what I do not know? That's the box we open. So if we end up opening that box and don' t have the relational container, if don''t have safety, what have we just done, you know, but re-traumatized, what made somebody feel alone again, like disconnection and loneliness is the hallmark of mental illness.

And so, if we can keep our sights on what is it that we're really doing with psychedelics? What became clear to me is, it is about the container, the community. The ways that kind of worked with that is I think clinics like ours have understood that we're here not just to be a medical clinic, we are actually here to provide the structure and the healing resources and that may be yoga class, that maybe breath work, regular events where people can just connect with other people who are going through similar things, similar aspects of this healing journey, and to really feel that that heals.

I would say the culture is ready in some places. It's very well developed in Silicon Valley. However, as we know, Silicon valley can be like the jet fuel to anything, right? And so what we're seeing is also distortions of culture. There's a story within our human condition that's about, I'm broken. I'm beyond help, and I need to be fixed. That's one story. And I love how physicians like Gabor Mate and others talk about, actually, you are experiencing the result of what happened to you, whether you were a child or you're an adolescent, or an adult.

If we can think of it that way, we really source a lot of compassion, a lots of awareness a lot of forgiveness, which is really at the basis of true healing and acceptance and moving on. So people are able to, and this is where the other piece that we work with is narrative healing, here's the story that needs me to be this broken person in the midst of this story. And I've been telling it to myself for so long and other people have told it me for long that it's become what I live. I don't even know what's outside of it.

And slowly over time, this awareness that that was a story, but I could rewrite the parts of the story that aren't functioning, that are actually real, and what does that look like is a much larger time-intensive moment. If we can, as a culture, connect with each other in that way, what we might be talking about is culture change, and a lot of people talk about that in the psychedelic world. With greater awareness, we're really changing the paradigms of psychiatry. I can't speak to that. I'll let somebody much more erudite and learned in the psychiatric field talk about that.

I go back to the Father of Psychiatry, William James, who did nitrous oxide in early 1900s and talked about the varieties of experience that lie just beyond our awareness, and how if we are to have a complete psychiatry we can't leave those out. So, I'll just end with that awareness that psychiatry itself is a young profession, and human beings as well are young species. So what does your typical week look like at the moment? You do various things. You're involved in clinical care and education.

Just give us some sense of what a typical weeks looks like for you. I'm guessing no week is typical. Typical week, I'm a mother. As part of my own healing, it was really important to me to pay attention to what my physiology and my nervous system needs because this work is really taxing. It's emotionally taxed. You have to be present completely. Heart work and we get really involved so being aware that this is a very different pace of work So I may see up to two to four patients a day and that's

International Adoption and Clinical Readiness 37:18

about it And that would be the max would for one individual person who's in the room for two hours at a time really supporting a patient through the situation, through their treatment plan. There's a lot of phone calls, there's talking to psychiatrists, therapists, medical evaluations, preparation. We do a lots of integration, so between getting people ready to go into the space, making sure that they are keeping in track with their integration. There's a lot of checking in and a a of making sure that we're getting the objective data.

I really believe in the qualitative piece of it, so I'm taking copious notes about what's happening in this session, what is happening afterwards, and what are some words and phrases that people are using, because sometimes That is the piece that really turns the key in how this healing is going on is what really happened, what came through, and what you need to make meaning of. So, it's a lot of real intensive and I love that. I like looking at subtexts, I look at language, so it is kind of like I joke that I came into medicine, went into pediatrics, really went in to medical education, but I think psychedelics are also a learning tool.

went into narrative medicine and now all of that is here in like a practical, you know, kind of therapeutic way. So typically these are long days. I'm doing a lot of social media. talking, educating, talking to therapists who might be reaching out going, hey, I've got a patient who's doing ketamine therapy. I'd like to really understand what's happening. So, lots of education. We invite therapists. You know, at times where I have to take a break from it going, oh wow, this is overwhelming because I become about this, and I don't want to become this.

This is my work, but it can't be what I've become. So, there's been a real rebalancing of understanding like, okay, we're doing this work. It's really intense. We really believe in it. But how do we hold that objective perspective as well? How do know when we're not supposed to do this? Who are the patients for whom this is not a good idea? And being really discerning about that. So there's a lot of discussions, a consultations. One other thing that I do is be part of a consultation group where I can take my patient stories and be heard by a group of people who are much more experienced, are looking at it through the ethical lens of, you know, There's a wonderful resource called The Ethics of Caring by Kylia Taylor, which is kind of like the gold standard book for any psychedelic healer who's going into this because the ethics of this is really interesting, situational, challenging, because it is interpersonal.

It is in that space where you're in it as much as the patient, and so a greater amount of And so, that brings with it some of those stories that you might have heard of inappropriate conduct. And just this last week, I had a patient who I have done consent with before for a handhold. Within the journey, the patient says, ìOh, can you put your hand on my chest?î And I said, while this person was in ketamine and we were still able to talk, and I say, Iím sorry, but I can. you know, work with you to put your own hand there.

I can offer you a cushion that you can hold to give you that pressure, but I did not take consent from you for that before I put you under the medicine and I cannot allow you change it, and that's on me. That's me for not having gone through that and we talked about that. We talked how that situation actually recreated the situation for this patient where a young part of themselves came out and recognized that I remember what it's like not to be met. I remembered what's it like to know I need a hug or know that i need comfort and not get it.

And we were able to really connect in that level to say that yeah, and there was anger behind that. You know, there's a discharge there and I had to not really get involved in the anger. I had to recognize it for what it was, which was a much younger part, needing someone else to be there, to the adult, a resource caring from and not having had it. So, those are some situations where we talk about closing the loop, having this, we call it, the word is just escaping me, but being met in that way.

being met in that way, completing the trauma cycle, co-regulation, things like that. So yeah, I hope that answered the question, but it's challenging. It does. Obviously, your clinic is a business, and I'm just curious to know what's working particularly well for you as a businessman. Also, what are some of the challenges and bottlenecks in running the business that you have? Great question, great question. I think the insurance uptake of this business is the biggest barrier, and it depends on what kind of structure a business wants to have.

So clinics that have integration of sprovato, which is Johnson & Johnson product of the S-ketamine, ketamine is a racemic product isomers and so the esketamine

Running a Ketamine Clinic 43:00

is one isomer and that has been now you know kind of taken up by a lot of psychiatry clinics where the ketamine has administered as a nasal spray and the patient is given about 15 minutes of kind It's taken off. Johnson & Johnson has made upwards of a billion dollars on this for the last couple of years. So, they're not wrong. There's a market for it. However, what we've noticed is that because patients are being left alone in these treatment rooms, their online. They're on Amazon. Their shopping while they are on ketamine and they call it ketamin prime day.

So let's talk about uptake and safety, right? So insurance is a big challenge. Psychotherapy, the psychotherapy part of it can be reimbursed, however the ketamine part will not. you know, and if you do get reimbursed. So, the best place to be re-imbursed for it now, right now in the United States, is the VA pipeline. The Veterans Administration, because it has really run forward with psychedelic treatment, VA tends to ahead in some of these ways because they have such a body of research and such great population need.

that they are actually paying for the treatment, so they'll pay for a bundled treatment protocol. But our clinic, we have had to be really agile. We've had think about, okay, patients who come to us, they're usually coming to... We happen to live in California, which is the fourth largest economy in the world. So, it's not like it is a population that is very constrained by resource. So we do have the people who can afford it, who are coming through and can offer the $4,000 to $5, 000 and the time and energy and resources that it would take.

They are not being left out of the psychedelic renaissance. It's the insurance for their treatment. And so what we are learning is that that first initial intense period of four to six sessions, if we do those through an IV, you know, method with this intensive, kind of protocolized, a lot of support, and a of integration, commitment from the patient, we get them to a different baseline. And then, it's a matter of keeping them on a maintenance of some sort. And we're finding that maintenance can be once a month, once every two weeks, depending on the patient.

So, the way my clinic does it is we start everybody off on an IV version, and then we actually transition them to intramuscular, which is easier to administer, a lot less cost and time resource. You can do it in group settings. We actually have formulated a way where our patients can engage in the maintenance part using the group therapy model, and that is a lower cost. So we've been able to decrease the cost even more because we're doing a group. That's one of the things we are seeing also in places like Vancouver, Roots to Thrive is the gold standard here by Prem Krishkao, who is physician, also a previous firefighter who's really worked at bringing ketamine-assisted psychotherapy to the insurance system.

in Canada, and it's being covered there as group therapy. And so, really, we're trying to make it work. We're integrating it with other modalities. So, sound healing is another modality in which really combining psychedelic therapy, especially for somatic conditions like pain, and somatic activation, those can help combining with acupuncture, yoga. So we're investigating how to expand the offerings and how people can access them. Trying to increase access to it and using the ketamine as a tool and not the be all and end all.

I think my clinic, we've been now in operation for two and a half years, we were really affected by the fires that occurred in Altadena that really led to a dampening. There's been a greater diversification of, you know, ketamine providers as well. So I think we are learning from season to season, year to year, that this is a very dynamic space, and we're not at the final model of it. I thinks the models are going to evolve based on what it looks like. I think countries like Australia with universal health care where the payment system is, and the UK where, the payer system, is much more streamlined.

Once you get buy-in, I thinks those countries will run ahead. And the countries that don't have a good way of paying for it, what will happen is the people who are much resourced and able to afford it, we'll be able access it as they are, and then we're going to have to cobble together. There's all these different funds, there's patient funds. People are coming up with different ideas of how to do it. But I just think it is a symptom of the overall health care here in this country that if you happen to be on insurance, you're probably not going get access to a lot of these integrative therapies.

It's going be delayed. If I gave you a magic wand, And you could fix any one thing in your work, whether it's clinical, operational, educational, what would that be? Nobody's asked me this question. There's so much power in this magic wand. Oh, I think the breaking down of these silos, the breakdown of this informational silos is critical path, because depending on where you are in the silo and what information you're being fed, you either are very scared of anything to do with psychedelics, or you�re all the way out front.

And I think that speaks to just how divergent our population has become when it comes to issues of control and openness. I would say. So I think magic wand, more community, grassroots involvement, and more funding given towards places where people can go to access a whole host of integrative therapies, not just psychedelic therapies but relational therapy, somatic therapy. acupuncture, nutrition, exercise, just this awareness of how much there's a dearth of it and how access plays into it, into our general well-being is probably

Future Plans and Closing Reflections 49:30

where I'll leave it. But thank you for asking that question. And finally, what's next for you in terms of the next 6-12 months? Any particular plans or projects or things you're working on or directions you are looking to take? Absolutely, absolutely. With IACAP, we're really bringing together the experts in this field to talk more about it, to share their experiences. These are still experiences based in qualitative data. When we put together quantitative large-scale trials, by the time we've put these trials together, you've got to know what it is that we are treating.

You know, if you have a mixed bag in your quantitative trial, you're gonna get mixed results. We're not discerning as we're going into the trial. So I feel like we are still in the discernment mode. work, bringing this education and awareness through the couple of platforms we have. So we've got a podcast called The Two Curious MDs Podcast where we talk to patients who are going through their healing as well as practitioners. We've had really wonderful You know, it's been a great resource to give to people to be like, OK, how do you understand what's happening and really reaching people at where they're at?

So our being much, I think, smarter about how we reach out to the pockets of the populations where we can really have a big bang for our buck. So instead of looking at the psychedelic field as one big thing, we're kind of really focusing down on the populations for whom will move the needle the most and have the best outcomes. And I think whenever you're dealing with something like as complicated as this, maybe that's the way to do it, is the discernment piece. Personally speaking, I completed the Berkeley psychedelic certification this year.

There's been a lot of excitement about doing more group work, especially for healers, so other physicians, you know, this burnout epidemic in The physician and nursing population and frontline workers, firefighters, police, law enforcement is huge. And this is one of the most innovative tools that we have to treat a lot of people really quickly. So I think reaching out and encouraging And I'm really mentoring. I think that's the other piece as we educate, we're educating for professionalization.

So mentoring the different people who are coming into this field. The neuroscientists, there's a slew of research happening. in psychedelics and so there's a great number of young neuroscientists who are coming in, MD-PhDs, who were really curious about how this is working and then the real-life experience. So really being a translator, I think that's where I'm at in the transitions, putting more language to it. I vow to do more writing this year is probably what comes forth. With that, Surya, thank you so much for joining me this afternoon.

It's been a really fascinating conversation, such deep insights, lovely to hear about your journey, great information, and great education. And we're not just talking about psychedelics, we really talk about rethinking systems around the care of young people, families and healing. So it's being such a fascinating Oh, thank you, Andrew. This was wonderful. Thank you. Very wonderful questions. Thanks for joining us on the Two Curious MD podcast. We hope today's episode inspired you to ask new questions and explore fresh perspectives.

post or comment with a question or curious inquiry that you have and seek to explore or learn with us. Stay curious and we'll see you next time.