DG: What are the kind of psychiatric diagnosis that lend themselves well to the use of psychedelics?
GV: A lot of the research has been looking at, initially, end of life cancer and anxiety and depression. When you have cancer, end of life anxiety, depression, thoughts for life threatening illnesses. But since then there's been so much research looking at treatment resistant depression, major depression. They've done a lot of addiction studies, PTSD, which is post-traumatic stress disorder. So there's been a variety of indications. But I think the most exciting thing about psychedelics, even though in psychiatry we like to think of different diagnosis, is there’s an idea that has emerged that perhaps psychedelics have a trans diagnostic potential. And what that really translates to, psychedelics can actually, really instead of us thinking of different diagnosis, can get to some of the underpinnings of what lies behind all of these diagnoses. So you can actually get to the building blocks, which make the diagnosis system a little bit deconstructed, to actually help with the, really with people's underpinnings or the building blocks of character or foundational deficits which might lie behind these diagnoses. So in some ways, maybe psychedelics can help with, like, attachment wounds, character deficits, and could be helpful across the board.
DG: You mentioned treatment resistant depression.
GV: Yes.
DG: I'm just wondering, what does that mean, treatment resistant depression? Is there a definition of treatment resistant depression?
GV: Yes. When someone has been diagnosed with depression, which essentially means they've been struggling for a long duration of time with depression of significant severity that really impairs one’s functioning and well-being, when they have not responded to several courses of different treatments with antidepressants, which is unfortunately all too often, they get started with a class of medications, don't really necessarily have a robust response, get switched to another group of medicines, and if they fail a third, then, unfortunately, we have to say they’re treatment resistant because the conventional treatments are not really serving them.
DG: And some of the research has shown that in the treatment resistant depression, that the use of psychedelics has been supportive in helping people?
GV: Yes. It's been really interesting. I work, I'm a ketamine expert, so I work with ketamine, which is really the medicine that's widely available now and is not regulated so it's no way the first psychedelic, and it's shown to be really effective and rapid acting in treatment resistant depression. There's also been another study which is really interesting, which was in the New England Journal of Medicine, which compared citalopram, which is a very leading antidepressant we use, with psilocybin. And it's quite interesting because they really matched head to head with one dose of psilocybin being comparable. It was a really interesting study. So you don't have to take the medicines on a daily basis, but I found it to be as effective as the leading, in a way, one of the leading antidepressants. And what was even more interesting, I think, was the secondary data, where aside from, you know, a checklist of feeling better, it's helped with some of the, you know, self states, the way one felt about themself, compassion to themself. So in some ways there was some wellness measures which were improved, which typically don't get addressed with conventional antidepressants. And of course, the tolerance for side effects is much better if you don't have to be taking them on a daily basis. Because, sadly, a lot of our conventional agents, even when they work, come along with a fair amount of side effects, which can disrupt also the benefit overall.
DG: Do you see a time in the future where psychedelics actually become a conventional medication and they become like a first line psychiatric tool?
GV: I do hope for that. I do hope for that, and I am looking forward to that possibility. I would say, like everything, you know, everything is about much, much more complicated than it appears. So there has been so much excitement about psychedelics. And psychedelics are not the magic bullet. So I think there's also going to be some disappointments, we had that with Prozac in the ‘80s. When it came out we thought we had the answer, the biological fix. And it wasn't quite as it was hoped to be. And I think with psychedelics, we're going to see there's a settling out some disappointment because actually I think psychedelics themselves are really strong, robust new treatments for depression, anxiety and all these conditions. But one of the applications that I think is more exciting is when it is used as a catalyst, not just for its biological effects, but a catalyst to really allow other therapies to work in unison with the psychedelics. Psychotherapies, you know, we talked about how psychiatry, sometimes we lean towards psychological therapies and move towards biological.I think when you integrate the two, that's where you have a much more robust, mechanism of action. And it's not surprising because you're really working on two systems rather than one.
DG: Can you tell me a bit more about that integration? Psychedelic psychotherapy, are the two things taking place at the same time? So does the client or the patient take the psychedelic and the psychotherapy is applied while they're feeling the effects, or is it done afterwards?
GV: Yes, it's a good question. It actually goes in three stages. So we break it down to three different components. There's the preparation for the session, which is a really important aspect of the psychotherapy itself. The therapeutic relation, building rapport, helping the patient feel safe, educating the patient. And I think the most exciting thing and very unique thing about psychedelics is there really aren’t too many drugs where when you take a drug the mindset you enter into the session is going to influence the experience. Like, I can give you Prozac anywhere in the world. Any time you can be sad, you can be happy, doesn't make a difference, you're more or less going to have the same pharmacological effect. With psychedelics, your mindset, how you're feeling, what you expect to feel, how safe you feel, how unsafe you feel can actually alter the course of the experience itself. So it makes preparation a valuable aspect of the experience where we set intentions and really prepare a person for their experience. And as the session itself, the dosing session, when the therapy is happening during the experience, and that has all sorts of components as well. And the third phase is after the session, because the session effects is over but there's still an unfolding and a processing that can occur for many days, sometimes even several weeks after the session. And during that period support is also really helpful to enhance and really take advantage of that period. So it's an extensive, extensive course.
DG: Conventional psychiatric medication is usually prescribed over a term, you know, maybe people take a medication every day. What about with psychedelics? Is it a one off event or are people taking a course of treatment? How does it work?
GV: I would say it's both, but usually it's a sequence. Usually, most of the studies and most of the experience I've had is, usually it's initiating a process, an opening, and you can really train people's minds and bodies to learn how to move out of fear and patterns of conditioning. Most of us live in a habitual conditioning, really the patterns that we've established in our early life, which we keep on employing, which is why we're recognisable to our families and friends. And that becomes, you know, our safety zone, but also a little bit of a restriction in our everyday life. And a lot of our gifts are really limited because we're doing the same moves, over and over again. And I think we see this in people, we tend to not be quite as expansive as children, as adults. Right? We see how we become narrower, more restricted, more rigid, generally speaking, and we suddenly notice the individuals who, as they get older, are still free and open and have new ideas. The psychedelics really allow us to open ourselves up, to move beyond those limiting structures, to harness more of our creativity and our imagination, and have more of a child's mind of seeing things differently, not being so locked into perspectives.
DG: Okay, I really like what you said about having a more rational approach to the the impact of psychedelics, that they're not a magic bullet, they're not going to cure mental health across the world. Are there a particular set of clients that psychedelics are going to work better for? And are there a particular group of clients that maybe should avoid psychedelic treatment?
GV: I think there's many different applications. So I think it does cover a broad terrain of people who could be eligible or who could benefit. But I think also you're pointing to careful screening, that even though there are different applications, and I'll give you an example, someone might come into my office who is deeply unstable and struggling with tremendous depression and suicidality, and they would benefit from maybe I.V. ketamine, which is a very rapid acting antidepressant where people can really not feel suicidal immediately. It's the leading anti suicidal drug. And even without therapy, it can be used as a rapid acting pharmacological agent to interrupt the stream of negative thoughts and have someone feel better right away. It's a cumulative response, so you have to have a few treatments. It's not going to be one shot fix it, but one shot can break that cycle and then you need a sequence to continue it. But when the person is actually stable, maybe several weeks or several months out and they actually are feeling more comfortable and stable, then sometimes they will shift to less frequent sessions, but more therapy with the ketamine to move into psychedelic psychotherapy, to try and get to within the deeper reasons that actually maybe threw them into that crisis to begin with. So there's many different ways of going about it. I also work with people who have, you know, maybe just find me a generalised anxiety, and are perhaps less plagued by symptoms but still suffering tremendously. And I found that they can get maybe even off their conventional psychotherapy agents that they’d used for a long time, such as some of the classical psychedelics, I'm sorry, antidepressants, and shift over to less frequent treatment with support to get to some of the root causes and build resilience to what might have led them to having these symptoms or distress in the first place. But there are people who should avoid them, and that really requires very careful clinical evaluation. People who have unstable medical conditions. There are some medical contraindications. So you want someone to be in genuinely good health and not have some underlying medical conditions, such as unstable high blood pressure, which should be treated anyway, but certainly extreme fluctuations in blood pressure, if you already have high blood pressure it could be a medical risk. So you want to make sure someone is stable. But also from a psychological point of view, you want to make sure there aren't any conditions on board that could make someone's condition get worse. If someone has psychosis, active psychosis, giving them a psychedelic could throw them into an even deeper, more disoriented state. So it's, these are very strong medicines and given the right conditions and the right support, they can be marvellous. But they're not for everybody. They're not candy. I've seen a lot of people brought in by family, actually, who have, you know, read all the research and jumped towards taking it without realising that they had a strong family history of schizophrenia and then got into a real jam. And it's hard sometimes when you bring these conditions that were lying in our, in our cards out, it's not so easy to treat them. So I really would, you know, really advocate caution and not being quick to jump into trying this or doing this yourself at home.
DG: Okay. I want to, like, ask a question, but about the difference between somebody taking a psychedelic in a recreational setting and, in a, in a clinical setting. Like, are people that are taking psychedelics at raves, are they curing their own trauma?
GV: It's a really interesting question, Right? I think that, you know, connecting socially can be very therapeutic. I think we know that when we're disconnected and lonely, oftentimes we can feel, you know, less good, more suffering. Although I think that's a very tricky thing, because there are a lot of people who feel tremendous disconnection and loneliness, even within communities or within families. So it's not so easy on the outside to gauge that. But of course, I think there is some bonding aspect that could be deemed valuable. And psychedelics in community, even in, you know, research which is, you know, not done in labs but just collected through reports, there does seem to be some value. Although I would say in general, even talking to, you know, individuals I work with who used a lot of recreational drugs in college or at Burning Man, I'm not sure as a group I see them as mentally healthier or more enlightened. But you know, that doesn't mean to say there can't be some therapeutic value. Some of it depends on the intention, and some of it actually depends on, I think, you know, the set and setting and the direction. You know, I have worked with individuals who have used psychedelic drugs in party scenes and raves, and they're shocked when they come to my office because the experience, even if they're taking the same drug, is vastly different. Some of that, of course, is you never know what you're getting when you're doing a recreational drug and you're getting it on the street. You don't know if you're actually getting the active substance. And some of it is also when you actually have to go into your own process, individuals have noticed it's not just peace and love and having a good time, It's actually meeting yourself. Which can be a very beautiful experience, but can also bring up a lot of feelings that haven't been processed, which are beautiful to have a situation to work through them, but can be a lot of work emotionally because this is, after all, psychotherapy and there is a benefit to that. But it's a deeply different process.
DG: Okay. Is there some clinical value to people that are using these drugs recreationally?
GV: I would say I do notice a difference because I think at least people who have tried psychedelics have a level of comfort with them. So there's less fear, there's less anxiety. Usually, I think all of us, if we've not done any of these new substances, particularly when you read about them, they're pretty intense, I think we come in with a fear of ‘what if I have a bad reaction?’ Or ‘what if I lose my mind?’ I think these are normal fears. These were fears that I had in anticipation of, you know, hearing about psychedelics, or before I had done a psychedelic, I thought, well, what if I have a bad reaction? What if I lose my mind? What if it doesn't work for me? And these are very loaded subjects for individuals who are struggling. So I think someone who has done a psychedelic and has had some experience, has a sense what an unordinary state is, has a sense of how they come on, how they come out. They trust their mind. So there's a preparedness. And if they haven't had that, then just that whole phase of preparation becomes even more important.
DG: Okay. I have one question now that I want to ask that I think might be useful. So there’s several psychedelics that are being researched. So, for example, there's ketamine, there’s MDMA.
GV: Correct.
DG: There’s LSD, there’s psilocybin, several others.
GV: Right.
DG: Is the impact of all of these psychedelics similar or are they very diverse in, are they very diverse in the end result?
GV: That’s a really good question. I would say, well, first of all, I think they're quite diverse sometimes in the way in which they act in the body, the receptors they hit. MDMA works very differently than ketamine, which works very differently than LSD. They even work on different neuro receptors in the brain. So their mechanism of action is very different. And then the experience itself can be vastly different with the different medicines. You know, MDMA will allow people to feel very safe in a very hot, open space. Less in their thinking mind, more in their emotional mind. And in that field of safety, they can really go into comfortably dark, traumatic memories, which comes up almost spontaneously, to be looked at, processed and healed. So it's a very different experience during the MDMA session, which is quite long, lasts 3 to 6 hours. And that's quite in contrast to something like LSD, which is a very long experience, sits 12 hours in duration. Quite intense, It comes on at a peak and then it slowly, over the course of the remaining 11 hours, is still quite persistent, sometimes in rolling waves. But it's a highly, highly activated state where you have a lot of sensory impressions, a lot of information coming from inside and outside, visual distortions, and a lot of knowledge coming through these different modes of experience. So sometimes people will learn about themselves through visual imagery seen around them or when they close their eyes or through different sensual realms, even like downloads of information through music or through reflection or through somatic experience. So it's quite you know, we call that synesthesia, where all of this mixing of different sensations, which is so different than ketamine, which is short acting, it really only lasts about 40 minutes when you give it by injection. And during that duration, the experience is quite meditative depending on the dose. It's called a dissociative. A dissociative anaesthetic actually. But in the lower doses you almost distil out the components of the self. You see the mind, you see the emotional stream, the somatic stream, and you have a platform to witness how you're built architecturally. So you can imagine the experience itself is quite different. And the downstream effects also can be quite different too. But I like to use the analogy, It's almost like you can learn about yourself or grow yourself through different experiences, very much like, you know, I think we all grow and learn about ourselves through travel to different countries. You can go to India and learn about yourself or go to Europe and have a different experience of yourself. And for some people, I could see you, meet you, talk to you and say, no, no, no, you should go to, don't go to India. You’re going to be a bit freaked out. Why don't you start off and go to America first, and then from there you'll learn about yourself. And so that's like how I like to think about medicines, cause you can really have a sense, based on the individual, about what would be a nice way for them to explore themselves. Someone who's really traumatised and has a really difficult time being alone, to start with MDMA might be a good place because that'll allow them to open into safety and not be disconnected. Whereas someone who's a bit of a controlling type, to stay safe, is very obsessive, that might be a good start, but something even shorter acting where they don't have to lose control for more than 20 to 40 minutes, like low dose ketamine, might be a better starting point. So you can really become sophisticated and skilled in trying to assess, you know, sadly, at this moment, some of the choices are restricted by legality because a lot of these medicines are only available during research protocols. But in the future, hopefully we'll have more sophisticated ways of assessing why one drug might be preferable for a person versus another.
DG: So in your own clinical practice, how have you experienced the difference between clients presenting with trauma or PTSD, the difference between those clients that use psychedelic psychotherapy and traditional psychotherapy?
GV: Well, I would say the process is really different, and I'll give you an example, just so you can get a flavour, perhaps, of what it looks like in a session. I did treat this, actually very intelligent, very, creative young woman who was a college student. And she came to me because she had actually been doing quite well, but she still struggled with PTSD symptoms, in spite of a lot of treatment that had helped her and she had suffered the experience of, two experiences of being raped. And one was more recent, so it had reactivated the early, earlier trauma and injury, and during her session, and this was actually her first session with ketamine, she had this visual experience of seeing a tapestry, which was very intricate, with a lot of detail and a lot of beauty, and she saw this as a symbolic representation of herself and her whole life. And she was marvelling at the, actually the texture and the beauty and the intricacy of it. She also noticed a big stain on it in one particular area, and she immediately understood, in the psychedelic encounter, that that represented and symbolised this kind of horrible rape experience she had experienced, and how much she saw that was capturing her sense of who she was, almost became her centre of gravity. And she, real time, was describing to me and actually laughing at it, how she was much bigger and vaster than that. And why was that her centre of gravity as opposed to the whole richness of the tapestry? And there was a really a delinking of that experience that had hijacked her, which is unfortunately what trauma does, and a liberation, really from that moment on, that was sustained in her having really herself back and having a much deeper expansive sense of herself and identity and a freedom from not having so much of a force over her, an influence. I think that gives you a sense of how different the process is as well as how rapid acting it can be. And more importantly, I think the creativity, which is really from the subject themselves, very much like dreams. We all, sometimes we don't think of ourselves as creative, but we all, when we remember our dreams, can be astounded at the, really at the imaginative capacity. It's really like there's another person inside us who is inventing these, sometimes these strange coming together of different components. But that's really our psyche.
DG: Do you see a point in the future, It sounds a little bit like, almost like a tool for personal development and a tool to build resilience.
GV: I think it does actually get into self-actualisation and self-development, which actually I think is not unrelated to mental suffering, because I think that a lot of our stuck places, a lot of our trauma limits us from actualising our full capacity. So when you deal with those blocks and traumas, actually, self-actualisation and self-development ensues.
DG: So I want to ask you about the training of professionals that are going to be involved in the dosing application psychotherapy. Is there development in the training? Is it in parallel to the research?
GV: Yes. There are a lot of training programmes right now which are being built out really for psychedelic psychotherapy. And it's a bit of a tricky thing because we're training therapists with some of these tools that we're training them for are not fully available, but there is a large, extensive training to even become an MDMA, PTSD psychotherapist. So you have to go into your own training, watch a lot and learn a lot about the approach. Back in the day when I did it, we also had the chance of actually taking MDMA and experiencing what MDMA as a therapist is like, so we have that knowledge within us. Now they've shifted that. So, you know, we do still offer within that training programme a non ordinary state experience from holotropic breathwork. Certainly with ketamine, a lot of the ketamine training centres, one in which I'm familiar with and affiliated with, the ketamine training centre, we offer an experiential retreat where therapists experience themselves in non ordinary states through ketamine, low dose and high dose. So there's a lot of different ways in which people are getting trained. Most training programmes are for modules of training. I'm actually the international clinical director for the psychedelics psychotherapy training course Mind Medicine on Australia. Australia's very exciting because they’ve jumped ahead because they're the first country which has approved for, you know, in terms of their regulations, both MDMA and psilocybin. So the therapists there and the psychiatrists there are very keen to learn how to work with these medicines. And we have a very long course where we have a lot of didactics, but also retreats where people can have a non ordinary dosage experience. We're using holotropic breathwork, which is, for those who don't know, It's a, it's actually a technique that was developed by Stanislav Graf. He's a psychiatrist from the Czech Republic who really was a pioneer in LSD psychotherapy. And he, when these restrictions came up with LSD, cultivated a different approach through actual rapid breathing, which is in a way, has been used for millennia in different cultures. But he developed an approach with breathing and loud music, really, with oxygen and shifting levels in the metabolism to access non ordinary states. Because what we forget is this capacity, once again, it's in our, we're hardwired for these states and there are different ways to really hijack that capacity. Psychedelics is one, there are other approaches too, like meditation or sensory deprivation or breathwork. It does take a lot more work and time and effort and discipline, but these have been employed for millennia.
DG: Maybe Wim Hof and his ice barrels is another.
GV: Another one. Absolutely.
DG: Yeah. Okay.
GV: A lot colder.
DG: And will we, are we moving to a place where, the reason I'm asking you about the professionals is, I want to know if we're going to get to a place where there's going to be some uniform accreditation?
GV: I would hope so. I think there really needs to be much more standards of practice, standards of care. And I think that's, that's where we're very early in this field. You have to be very careful about who are you seeing, how are they trained, and do they have credentials that would give, you know, consumers confidence that the therapist is really up to snuff.
DG: Doctor Gita, it's been fantastic talking to you today. You've got so much knowledge and experience and I've really learned a lot. And thank you for spending some time with me and with The Kusnacht Practice and sharing your knowledge with us.
GV: Thank you for having me. It's been a pleasure being here.
