PT222 - Dr. Thomas of Clarity Psychiatry

Hey, everybody. Welcome back to Psychedelics Today. This is Joe Moore coming at you again from Breckenridge, Colorado. Today on the show, we have Dr. Thomas out of Boulder, Colorado. Dr. Thomas has a integrative psychiatry practice and also does a bunch of work with his clients with ketamine. And I think that's the bulk of the conversation here. It's been a bit since we recorded, but it was a really fun conversation. I'm really appreciating getting to know Dr. Thomas. The gentleman who helps us out here, Rob, with our audio, pointed him out to us recently and immediately reached out. And it turns out he's been a great connection so far. So thank you, Rob. Thank you, Dr. Thomas, for your time. This is a really fun episode to record. And yeah, you actually even helped me get on a really interesting panel conversation affiliated to a much larger conference recently. So that was really great of you. So thanks for including me on that. And I think that's it for the intro. I actually, earlier today, just had my first intermuscular ketamine injection, so I'm a little tired. But that was a really interesting experience. So expect a little bit more on that soon. I wouldn't be surprised if we do kind of like an experience roundup, Kyle and I, on the next Friday episode. But we'll see what we can make happen there. And yeah, I think that's it for Dr. Thomas. And reminder that we have a CE-approved class called Navigating Psychedelics for Clinicians and Therapists. That's a live supported class with a whole mess. We have pre-recorded material that you can work through outside of class, and you come to class to discuss it. It's been an amazing project for Kyle and I so far, and we are really excited about this January edition. So if you're inclined, check it out at psychedeliceducationcenter.com. And I think that's it. We'll see you on the other side. Hi, everybody. Today on the show, we have a special guest. I'm Dr. Thomas from Clarity Psychiatry in Boulder, Colorado. And Dr. Thomas, you do ketamine-assisted psychotherapy in Boulder. Is that right? I do. I do. Is that the majority of your practice at this point? Or are you doing other stuff? No, I would actually. It's the majority of the fun in my practice. Yeah, right. So you're still doing kind of like traditional psychiatry? Yeah. I'm actually a mix. If I take a guess. I do about probably, let's say, 50%-ish, 60% conventional psychiatry, medication management. And then I do about maybe, let's say, another 25%-ish, what I call holistic or integrative psychiatry, which is a different kind of worldview or paradigm of mental health treatment. And then the last piece is the. Is the psychedelic work with the ketamine-assisted psychotherapy. Cool. I want to dig in just a little briefly on this integrative psychiatry concept or holistic angle. So yeah, typically, we look at symptom reduction, I think, not necessarily always root cause. And it's not always financially reasonable for people to engage in something that's like, why am I having this? Sometimes it's really expensive. I completely. Completely agree. And I'm to those issues. Yeah. So it's an interesting problem to address. Will you typically start with a conventional approach? And then as stuff doesn't really sort out, you might look at nutrition and lifestyle, stuff like that? That's such a good question. And before I even answer that question, I really want to make it clear, I am not denigrating in any way my allopathic psychiatric colleagues. I was that guy for many years. And I think. And I think it did people a lot of good. I think the issue that I see is just, it's really about if the resources are available, how do we tailor treatment to what they really want, to what somebody really wants? So now that brings us to the issue of how do I decide, right? Somebody comes to me. Okay, let's put it this way. Joe, nobody's coming to me generally because they're feeling so great and they want to feel even better, right? I would, but I hear you. Okay, maybe with the exception of you. Pretty much everybody that's coming to me in some way, shape, or form is suffering. And they want relief. And that's a very understandable human need. I would want the same. Okay. So the short answer, Joe, is what. My approach is largely going to be based, driven by what the person's. Looking for and what they're specifically asking for. So let me give you an example, right? So somebody comes. Somebody comes to me, unfortunately, deeply depressed. That's a very common presentation. All right. So in general, the person who's deeply depressed, they want out of it. They want their life back. So they want to function again. So I'm generally. I'm a very pragmatic clinician. I just. I want them to get better. We need their symptom burden to at least ease if we have any chance of meaningful recovery. And even potentially having the conversation at some point of how do we do things more naturally. So the more severe the case, the more likely it is we're going to sort of lead with meds, right? Even if the person's preference is that we don't do meds. I mean, I'll respect that if I can. But if things get too bad, I'm just going to tell them that it's not. I don't think it's in their best interest to completely avoid meds initially. Totally. Yeah. We totally talk about that. For acute need, it's great. Let's get you manageable. Yeah. Nothing wrong with it. Absolutely nothing wrong with it. Okay. So. But let's say that same person had very strong opinions, which many of my patients do. You know, Doc, I really don't want to be on this stuff forever. And I've tried, you know, other doctors in the past, they haven't really wanted to take me off. And so I'm going to be much. I'd like to think I'd be much more open to having that conversation saying, yes, I would love that for you too. You know, and let's see what we can do to build a solid foundation of health, build a strong house so that we can get away with removing those meds down the road. And, you know, and actually have the person, you know, function, you know, just as well, if not better than they did, you know, with the meds on board, you know, and there's so many details, Joe, so many contingencies. In some cases, that's just not ethical, you know, to even like promise people the possibility of going off meds. Right. You know, for example, like somebody has really severe bipolar disorder, schizophrenia, it's just not a wise thing to do to plant hope that we're going to get rid of it. Right. Get the med free. It's not likely to happen. I think the more realistic hope is maybe can we reduce? Can we get somebody on fewer meds, lower doses, lower side effects by doing more and more natural approaches supporting the system? Yeah. With other things and emphasizing to people that they're all there in the driver's seat, that especially as they get better, we're going to put more and more responsibility on them to take charge of their health by doing some of the lifestyle changes that could really support their health. For example, simple things like, you know, eating a cleaner diet, a more whole foods based diet, if possible, you know, engaging in centering grounding activities, whether it's yoga, meditation, hitting the ski slopes like you do, whatever, you know, you know, getting your body moving. These are just a few examples of lifestyle changes that I really like to emphasize. Yeah. Cool. Yeah. So that, so that's, that's a, I could certainly go on more, but that, that's, that's just one way of approaching things. And, and what I also like to do is I really like to start out with most people. Uh, if they haven't had a complete blood work panel, I really like to, to order a blood work panel because I mean, one, one interesting paradox about in America is that nutritionally we're starving in a sea of plenty. Oh yeah. Yeah. Right. Um, calories abound, but yet nutrition, real nutrition paradoxically can be hard to find. Right. So what kind of things in a panel like, uh, D Omega's and I start, I start generally with a very simple panel that, that I'm pretty confident people's insurances are going to pay for. Yeah. So I'm going to start with the same that a lot of doctors might start with. Yeah. So I'm going to start with the same that a lot of doctors might start with, uh, a, we call it a basic chemistry panel. Um, looking for things like their sodium potassium potassium, their liver enzymes, things like that. They're a blood count to see if they're anemic or maybe have an active infection. I will typically, on almost everybody, I'm going to order a vitamin D level because it's just so epidemic in our country that vitamin D levels are low and it really does cost the body and brain, but that's true. Iron panels, I'm usually going to order thyroid panels. I'm going to check people's B12 and folate. From a functional or holistic point of view, this is really low-lying fruit. This is easy stuff in general that's remarkably easy to treat. From my point of view, it's kind of like I don't want to be the guy that misses that low-lying fruit because we can really help people by just giving their brain the absolute best. Joe, other people come to me from a different stance. They're on meds, they want to be off of them, and they haven't been able to get away with it. If it's appropriate, I may guide them in that direction or at the very least moving towards reduction. For us holistic psychiatrists, our mantra is generally, when it comes to meds, less is best. In general, there are exceptions, but that's the. Yeah, as little of the drug as possible to get the job done. Yeah, we've heard that a lot on the show from others. I think that's a really great advice. Let's not really just put you on the standard dose. Start light. Yeah. Also, to encourage people to really check in with what the medicine is doing for them and really emphasize that it's their body and their choice with very few exceptions. I tell my patients, if the medicine I'm giving. Is causing you to feel zombified or out of it or just not yourself, that's where we either got you on the wrong medicine or the wrong dose. Because the whole point of pharmacotherapy is to help somebody to become a better version of themselves. And I think that should be true of any therapy. Yeah. Yeah. It's a big deal. Vitamin D3, by the way, did you see Fauci just came out about it helping with symptomology for COVID? Yeah, I think that's a really good advice. Yeah. Yeah. Yeah. I'm glad you said it and I didn't. Yeah. He can't take my license away. Right. Right. Yeah. And there are some. And that's a separate conversation. So there's a couple other really low-lying fruits that really for. I'm taking every day that most that could really decrease our risk of. Of COVID transmission or if we got it, we can have a much milder version. And why not? Let me just mention them. The biggies that are super easy for immune support, vitamin D, we already talked about it. Vitamin C, usually around the range of minimum 500 milligrams twice a day. For many people, twice that. I probably would take three times that. And the other one that's to thinking about is zinc. Really? Yeah. I think that's a powerful immune booster that really doesn't, in my opinion, and those of many of my tribe, doesn't get a lot of press. What kind of dosage with zinc would you think is the lower end? I don't know how sufficient somebody is, but as a general. For somebody who is not really. We're not suspicious of true deficiency, 30 milligrams should be plenty. A good multivitamin, like the one that I use myself, has about that. If I've got reason to think that somebody is deficient, I'm usually aiming more towards 50 to 60 milligrams. But it can be really, really profound in terms of the benefit on the immune system and on the brain. Almost everybody that I see, Joe, I recommend that they take a multivitamin, like a really good multivitamin. And as you know, out here in Boulder, we're vitamin snobs. Right. So you don't want the three. Three-dollar bottle that lasts you two months. You want something that's like 50 a month or something like that? It means there's any King Soopers representatives out there, but I don't want the King Soopers brand. Right. Yeah. I hear you. Yeah. But on the other hand, I don't want people getting ripped off. So there's happy mediums. So I usually tell people, I send people a link to the same multi that I take and make sure they get a good deal on it. Nice. Don't get about it. And the reasoning for that is that I know whatever medication I choose, if we're giving the brain more of the building blocks of what it needs, we're going to get more mileage. Maybe I don't have to be in the position of like constantly increasing doses or adding more and more medicines because the other ones weren't enough that we can just help this exquisite brain of ours that's been honed through millennia to work really well and trusted that it knows what it's doing if we give it what it needs. Right. Yeah. So it's a weird conversation to have, right? Like this seems to me like it should be really common sense, but in our kind of like McDonald's Walmart culture, we don't really think about basic building blocks too often. Yeah. Yeah. I totally agree. And so very selfish perspective, I'll put people on it just because I know it's going to make my life easier. And then, you know, from an unselfish perspective, I know it's going to make their life easier, generally. Right. Absolutely. Like super low risk. Yeah. Super low risk. Okay. So I don't want to let there's, you want to know this, I'll give you my, my triad that almost pretty much almost anybody that comes to see me is going to get a recommendation for this triad of ones. All right. Number one, high quality, broad spectrum, multi, you know, multivitamin that has a good dose of zinc and a good dose of methylfolate. All right. The brand that I tend to recommend is called Pure Encapsulations. Pure Genomics, Pure Encapsulations. You can get it off Amazon or if they see me, I'll give them a deal. Right. I'll put almost, I'll suggest almost everybody take extra high quality absorbable magnesium. Why? Because magnesium is also typically low in the American diet. Most Americans are deficient if you use high standards. And if you use actually a good magnesium that gets absorbed, it can do wonders for the brain. You know, it tends to, once again, boost the effects of, of, of any medication, uh, specifically for mood or anxiety tends to have an, an independent anti-anxiety, anti-stress effect tends to improve memory and concentration and tends to, to naturally promote better sleep quality. Sounds like a good deal, huh? Yeah. Bargain. Yeah. Yeah. And, uh, yeah. So the, the, you know, I, I typically recommend there's so many good ones out there, but it's also, there's so much junk out there too. It's full of the details important. I usually recommend a brand. Uh, uh, designs for health, magnesium malate. And then the last thing I recommend almost everybody, unless they're a vegetarian is fish oil, minimum 3000 milligrams of high quality, uh, fish oil a day with a meal. Just the omega threes are so good for the brain. Um, just over time promote brighter moods, lower anxiety, better heart health. Oh, and the ladies love it because they get shinier hair, skin, and nails. I, uh, I have some family members that went vegan recently, and I've been concerned about that. And I found some decent brand names with some vegan options for DHA, EPA, which is kind of cool too. I never try to convert people. I want to respect their, we can work with it. We can work with it. If you're going to be a vegan, I just want them to be a smart vegan. Ideology is not that important to health. Well, sometimes it is. All right, Dr. Thomas, you want to start jumping into the really fun topic? Yeah, let's do it. Cool. So. Ketamine assisted psychotherapy, been a huge topic lately for us at Psychedelics today. Right. We're seeing a lot of kind of, I hate to say it this way, but pump and dump clinics. It's just like, all right, cool. Like, yeah, here's your Xanax. Here's your injection of ketamine. Uh, you can get out of here, drive yourself home in three hours or something like something crazy like that. I'm going to put on my politically correct hat. Go for it. And in my, in my, I know a lot of those clinics and I really do think on the whole, they do good work. I've got really good friends and colleagues who do that work. And I think it can be done very well. And I think it's doing honestly a service to the society as a whole. And, and, and just for the audience, let me, let me give them a little background. So let's say somebody, a typical person who might be interested in going to an ketamine infusion clinic is let's say the person with very severe depression, this unfortunate, this, this poor person, they, they tried all these meds, nothing's working. They're trying, they're getting desperate. They're thinking about electroconvulsive therapy. So instead they go off to a, to an infusion clinic. And, you know, typically what's going to happen is they're going to enter like a very medicalized setting, you know, often with other, other clients in the room, they're going to, they're going to get hooked up to an IV there. You know, there's going to be a nurse who diligently checks on them and checks their, their blood pressure and their other vital signs and their oxygenation levels. And, you know, they're going to get dripped for about, you know, at a conservative, extremely conservative dose for their, first one 0.5 milligrams per kilogram body weight uh and it's going to happen over 40 minutes and then they're going to have a 20 minutes to kind of recover so in terms of what they experience they're generally going to experience kind of an effect maybe similar to that of having a drink or two right a little loose a little little swimmy a little dreamy and if they're really lucky repeat that process four to five times at 500 at minimum a pop and their depression is you know getting a lot better totally and and and that's great because they may have they may get their life back with that so and what that's speaking to is the power of the the chemical molecule of ketamine it's an incredibly powerful molecule and that model that worldview exploits that to to great i think to to really you socially beneficial ends the challenge i have with that the problem i don't say problem but the the kind of the issue that i think comes up in that model is there's a couple okay number one the person who tends to do really well in that model almost always needs to be maintained if they want to stay well and the ketamine is the only thing that's keep it getting them well they need to stay on the ketamine to keep them well so they need to keep coming in at intervals i mean if they're lucky they can slow it down maybe once every two weeks three weeks four weeks whatever but they're going to keep coming back so they are you know they're kind of now dependent on ketamine and there's nothing wrong with that i think there's you can make an argument that it may be there may be some it may be better to be on ketamine than some other agents i don't know i'm not i don't want to you know speak kind of you know unilaterally across the board on that but some people might have might agree with that you know that statement but one of the other challenge with with potential challenge with that model is for the sensitive patient okay the the patient who their system is just really really sensitive and the same low dose that for another person might get them a second dose they had a drink or two for the sensitive person it can send them to true psychedelic space and the challenge is many of these clinics are not you know are they're not run by people who are necessarily have training and in guiding people safely through some version of a psychedelic experience i'm not blaming them it's not just not their training and and there's often i what i hear from many patients who've done the the iv infusion method is they did they felt they were unsupported here they were so you know so let's say we you know you know we hooked you up to an iv you were a really sensitive guy no one told you that you could be entering a profound psychedelic state yet here you are and you're in a medical suite there's beeping you know there's this blood pressure cuff that's that's you know that's going off it can be very disorienting and and unfortunately in many cases those people who have this experiences there's no real support for them even after they go home they're like what the heck just happened to me i'm not going to be able to do this again it just happens and maybe some of their stuff came their shadow material came up and uh and yeah i i tend to hear from some of those of those people that that that that model of ketamine could theoretically be um somewhat traumatizing to them all right not all the time i don't want to make a unilateral statement like that it can be life-saving all right so the third kind of you know potential issue with that model is the issue of let's call it the missed opportunity yeah what do i mean um so in if my understanding of the of the conventional you know allopathic approach the iv and ketamine experience it's that the altered state that ketamine can induce like so many other uh agents with psychedelic properties uh is in in mainstream you know in the mainstream world view can be considered basically an annoying side effect right it has to be tolerated because that's part of the package but at the very least what we you know it can be reduced by clever dosing and you know my the main problem with that in in the view the world view my world view and the people who train me was that that's missing such an opportunity because if you gave that same medication you know you're not going to be able to do it again you're not going to be able to do it again in a safe contained um environment you know preferably as non-medicalized as possible like a comfy office with cozy couches and nice pictures and soothing color tones they you know and they enter into some degree of a psychedelic or expanded state there can be such tremendous learning that happens because one of the other because with the the conventional model is often not a lot of learning that happens the learning that happens is you feel bad you show up you get dripped you eventually feel better i mean that's an oversimplification and pardon me if my my iv infusion colleagues are listening to me but that's my opinion but with with the what they call the transformational approach we can we can have people really tap into this gold mine where we are giving full reign to their inner healing intelligence it's not me as the doctor that's really doing it it's not me as the doctor that's really doing it it's not me as the doctor that's really doing it a lot it's it's the medicine is facilitating but it's their it's their own in my world view that their own inner healing intelligence that now gets the mic it gets to say wow finally i'm going to take advantage of the opportunity i'm going to i'm going to communicate what this person needs to know um and they can people can have tremendous insights into their life they can have tremendous alignment with what's most important to them you know whether it's their higher power as they see it whether it's to their core values whether it's to the people they love whatever they can really get tuned in and tuned up and in in the world view of the way i was trained the whole point of ketamine therapy is not to get somebody hooked on ketamine for the rest of their life it's to give them enough corrective expanded experiences of healing and of their own inherent wholeness that they don't need the ketamine that whatever was off balance is coming right so that's i mean you know and i'm not i'm not and i'm not even though it's pretty clear that i've got a strong opinion on this uh you know it's not a either or but both can be helpful but i i just think that that this this way of working with the ketamine with with with a very psychotherapeutic focus you know using this experience as a chance for people to learn more about themselves and to self correct to self-correct and in under the guidance of a warm-hearted loving you know guide who knows what they're doing and knows how to you know help people navigate this very special experience and i think we're just really really lucky that we have this tool available to us and it's legal and it's legal i often have to like remind people like i say just just wanted to remind you here uh what you just experienced that that that amazing wonderland that you of yourself that you just entered that was legal yeah let that sink in yeah in our classes we people are always i can't wait for psychedelic psychotherapy to be legal and kyle and i always have to remind folks it's here now it's legal now yeah yeah it's true and it's just that you know for various reasons you know the word is not completely out that said that ketamine is a true psychedelic agent and i'd like to humbly make the assertion that it it absolutely is and a lot of the magic of the you know the the expanded states experience a lot of it has to do with dosing in in some ways ketamine you can think of ketamine a little bit like a chameleon right a chameleon can change colors uh depending upon what environment it's found in ketamine is similar and but instead of changing colors the experience can vastly change depending upon the dosing environments what do i mean you know ketamine at very low doses uh can be marvelous for treating um physical pain often pain that's resistant to to high dose you know opiate treatment it can be a wonderful alternative uh ketamine at low doses can be a tremendous uh anxiety reducing agent you know it was it was originally developed in the 60s that it cut its teeth in the vietnam war i tell people if you were a soldier and you took fire and nam you really really hoped your buddy had some ketamine in his pack to give you you know while you're while you're being uh feely backed out so that was kind of the fentanyl equivalent for the military back then yeah yeah and then i don't want to go into it but there's a lot of reasons that ketamine is one of the safest medications in the world it's considered an essential medicine and virtually every hospital around the world regardless of economic status okay yeah like it's an extremely durable hardy medicine that does that doesn't doesn't need a lot of it doesn't have a lot of requirements doesn't have to be refrigerated um so there's a lot of benefits uh in using it so darn safe right that i don't want to imply that it that there's you know there are always things safety factors we have to consider but it's extremely safe medication yeah so let me go out back to the analogy okay so what are the other colors for the chameleon let's start going a little higher and now you can get into what we call the psycholytic experience are you familiar with that term or should i explain that we like to call that kind of a lower dose psychedelic experience paired with like a more talk therapy as opposed to like the deeper full psychedelic assisted psychotherapy which is kind of like more medium high dose i think that's that yeah that that's that's a i think that's a that's a good working introduction i mean understanding of it another way of thinking of it is lysis what's lysis it's dissolving so what we're trying to do is just dissolve or soften some of the typical ego defenses okay one of the challenges that any good conventional you know uh therapist no matter how talented they are is that they're gonna the human psyche has defenses everything we do there's a reason why we do it whether it's things that are functional things that are dysfunctional and so if we can even temporarily soften some of those defenses um i think that's in part how we can explain some of the tremendous efficacy the tremendous results we can achieve with any agent or technique that can soften those ego defenses so i don't want to pretend that psychedelics are the only game in town they're not yeah tremendous value and yes in that you know let's call it a trance state a lower level trance state um somebody's ego is still there you know but it's softer maybe more flowing maybe more receptive maybe more intuitive um and yes you can do very very powerful talk therapy when somebody's in that state because they have access to information insights that they wouldn't otherwise so now let's let's move on to another color the chameleon now let's start getting to the to the quote psychedelic dose you know psychedelic you know psique mind you know delos manifesting manifesting mind are we manifesting small mind no we're manifesting big mind right so what are we doing with psychedelic dosing we're we're taking that ego softening to the next level now we're getting it really whisper quiet right and that's when people can experience the more intense varieties of the expanded states people can have experiences that you know some might some might describe as quote mystical but just experiences of what what it's like to have access to a psychic space where the ego is really really quiet and many people find that downright magical people are not usually doing a lot of talking in that state right it's not a to to ask them about their childhood it'll be some likely some version of mumble and so yeah now let's go up the scale okay so now we go even higher um now we're maybe getting to the light you know to the anesthetic range ketamine was initially designed designed as an anesthesia agent to help people uh undergo medical procedures even surgeries um to this day around the world um it's used for that purpose so at lighter doses it can help you know uh help people tolerate a potentially painful procedure that might be traumatizing otherwise at extremely high doses the ketamine alone can put somebody can completely obliterate temporarily their conscious awareness and now they're in a in in a true state of anesthesia so that's kind of the spectrum of of the you know the of the chameleon we had somebody so this is a really far out non-medical application that we had somebody on the show talk about a while ago he actually uh insufflated i think half gram or a full gram in each nostril at one go um lasts about six eight hours and it's an interesting like this this idea of like high dose ketamine is really interesting because at the same time there's nothing happening there still seems to be something happening and i don't totally understand what that is we talk about it as like a full dissociated state where there's no body it's simply mind seemingly and this is on the psychic aspect nothing to do with like what's going on in the body or medically with the ketamine have you have you seen those high dose kind of like k-holes i guess in the popular parlance absolutely what you know another way of thinking of the quote k-hole it's it's it's someone really entering a dissociative space so i think i'd like to take a few moments to describe the term dissociation please because because ketamine in in terms of classification medically it's a quote dissociative anesthetic any other use of ketamine is off label with the one exception of the recently branded spravato which indicated it's a ketamine analog that is indicated as a uh not necessarily as a standalone treatment but as an adjunct treatment for major depressive disorder okay but that that that's a that's a very new addition to the saga yeah uh to the history but the term dissociative so in mental health circles in many cases my opinion that the word dissociative gets kind of a bad rap it's like stop dissociating you know deal with your issues etc etc like we need to treat this dissociation and i can i can see that i can i can see that um uh but i i'd like to maybe reframe the word dissociative like you know with ketamine chemically we are in in the ketamine state we are becoming less and less in tune with outside sensory input we are disassociating with ourselves as a body temporarily to some degree and we are associating with ourselves as something other than body and there's some real you know i'm just going to go ahead and use the word there's some real magic in that possibly um there's some real healing potential to give even to people to give people even a a short temporary glance a felt experience not an idea felt experience of what is it like to really be a human being that is something other than body you know and what terms people use i'm going to let them have the terms that they're most comfortable with soul spirit you know whatever but something mind something other than body and it's often very very healing so i i look at it as an opportunity because how many of us have that opportunity in our day-to-day lives okay sure if you're a you know you're a 30-year meditator you're you're a you know you're at a in a monastery in thailand for the last 20 years you might you might have experiences with that on a regular basis i don't know perhaps yeah i don't know about you that's not generally how i'm spending my normal days yeah for sure uh so so yeah so there's just i i try to reframe it as a positive as a as a positive as an opportunity and what and what that can do is it can give people a really needed break from ordinary mind um because one of the challenges i mean the human mind is an incredible incredible instrument you know and if used for the right purposes it can it can accomplish you know incredible things and has you know look at our the modern wonders of our life and what we're able to send men to the moon or women to the moon etc etc but as many of people have discovered who who struggle with mental health issues and mental illness is that that same mind can can be a torture chamber oh yeah yeah yeah and that's just that's just the nature of being human and and in in my opinion any medication or technique or change in perception that can temporarily disrupt that you A rigid what called it you know the rigid egoic self the rigid self narrative that perpetuates um kind of a negative you know view of oneself in the world can have tremendous value tremendous value in terms of healing and finding balance and wellness yeah it just so happens that ketamine is a very efficient and effective mental and mental and legal you know way of doing that and accepting what do i mean by accepting there are many or at least several agents that have been used as in agents uh in in some traditional cultures which are equally if you know um helpful in in potentially in in promoting a healing response but you know some of these agents like for example let's just let's name it like ayahuasca you know you know used uh in many parts of the amazonian basin um for millennia if not more they don't it's a very challenging medicine to use chemically there are so many reasons why you can't do ayahuasca safely a lot so even if it was available legal today it's not like i would be prescribing ayahuasca to most people it's just not an we don't you know it wouldn't even be ethical because you know for somebody to tolerate that they'd have to go off of their antidepressant and that's that's just a really uh project that's a whole project and you know and telling somebody who's really suffering oh by the way we're gonna just actually strip you off of your antidepressants so and just kind of please you know just suck it up for a month while we do that and then maybe you'll have this great healing experience and you'll have to stay off of it for another you know another three weeks by the way that's just not going to be a conversation i'm going to really want to have with a lot of people so what's my point ketamine there's very few reasons why i couldn't safely use ketamine there are a couple but there's there's not nearly as many and people can absolutely be on their antidepressants and maybe we're going to even be using the ketamine to try to eventually wean them off of their antidepressant right so that's that that's a beautiful use of this medicine so anyway i don't know if i've kind of gone off in the tangent and what we did really good we covered a lot of territory by me not interrupting you for a bit there sure i want to backtrack and say that my comment about pump and dump ketamine clinics might be a little harsh because i do know i i do know they help a lot of people i just i i think the best use is ketamine-assisted psychotherapy largely but not everybody's ready for that i i agree and it's also tailoring the medicine to where the person is at yeah if if for whatever reason if somebody is just you know they're all talked out and they just they're not really in a space where they where they want to they just want symptom relief there's nothing wrong with that um there's absolutely nothing right and maybe down the road maybe they'll be open to the the ketamine-assisted psychotherapy approach because they're ready for it you know as a general we want to get people the treatments they need when they're ready for it i am of the opinion that you know that that as human beings i'd like to think that you know the healing that we need will become available when we are ready for it yeah we could see that internally and like uh more um like um i'm happy to know that there's great developments happening in orthopedic medicine joint replacement i'm glad that's out there for when i need it like i don't want to rush to have it now but when i'm ready i'm glad it's there absolutely and let me just put in one little point just in case we don't do it later so joe let's do a thought experiment sure i'll do a thought experiment so what if the the dea representative came to me and said dr thomas for the rest of your career you only get one legal medication that can be used for for psychedelic-assisted psychotherapy you can have any one you want but you better pick because you're not going to get another so if i was put in that position the one that i'm going to choose is ketamine yeah for various reasons um that's not to say that it's necessarily superior in its healing uh possibility to other agents it really needs to be customized one person may do wonderfully on ketamine the next person might might do better on psilocybin when that comes on board but given its its its properties and its nature ketamine is an incredible ally in the field of psychedelic therapy and and seems to to me to deliver a very incredible balance between efficacy how well it works safety and costs and access to care you know and and we can even we can touch on that later if if if that would be a point of interest for your for your listeners because i i i'm a i feel passionately that access to care is is a i'm going to be alive to those issues is really important um it's such a big topic it's not an easy discussion either the larger society and the collective healing of the just the collective suffering and it's just yeah just over time myself and and many of my my medical tribe and and just psychedelic tribe in general we we really feel passionately about offering offering this medicine to people who need it as much as we can and finding ways to be creative about making that happen so i'll leave it at that unless you know you want to you know go into that more um you know this is something that could take days to unpack but i kind of want to do it so psychiatry therapy not exactly cheap if you if you're making like seven seven to ten bucks an hour somewhere like how can you really afford it so like in we ramp it up with like drug assisted psychotherapy it becomes even more expensive the weird thing about ketamine relative to a lot of these other drugs correct me if i'm wrong but for like a cap session we're looking at like a dollar a dose like uh roughly but i know there's other costs added to that yeah if that yeah so like we're looking at you know an amazingly cheap drug a super safe drug but then when we have to pair it with like psychiatry or like a therapist sitter like that might be where the situation is but but i think there's new exciting models we could explore like people get some mindfulness training and a little bit of sitter training and we could really lower that cost where do you go with that access discussion so so joe i i'm i'm kind of a centrist i take a middle ground so i'd like to maybe present as much without judgment just the spectrum of ketamine assisted psychotherapy as i'm aware of it in my community okay so there are on the one end of the spectrum is the most conservative approach so that's the that's the approach that that that states that a physician a prescribing ketamine physician needs to be on site at all times uh if a patient is undergoing ketamine assisted psychotherapy and and that's a good approach that there's there's the wonderful thing about that there's lots of safety that's built in to to that approach and lots of you know there's opportunities to tweak things to change the dose to address side effects however it also by definition is going to be the most costly variant of the service spectrum and so it's likely to you know the the Those who can access it are going to be, you know, generally very resourced or honestly very desperate individuals who can find a way somehow by hook or by crook to, you know, to leverage those resources. So that's a good way to do it. It's very it's it's on the conservative side. Also, legally, that's a that's a conservative way to approach it from a risk management standpoint, from the practice. Yeah, the the perhaps the most, shall we say, liberal approach that I'm aware of in ketamine assisted psychotherapy is perhaps the approach where, you know, a client saw a psychiatrist who prescribes this. You know, they they gave them a ample supply of the medication and perhaps the the client is is is told that they can. Simply use it at home. They can have a psycholytic or psychedelic experience, essentially unsupervised. That'd be the most liberal, you know, and there there's there's a huge middle ground in between. OK, what's a little bit more conservative than that? Maybe you mandate that they that they have to do their sessions in the presence of a of a trained psychedelic therapist. OK, that's a little bit more supervision. Maybe we we give a little bit less medication at a given time. So that's a little bit more conservative. So, you know, my my current approach, once again, I'm the scent. I like to try to be a centrist. So I like to I'm building a network of talented, ethical and really kind hearted psychedelic therapists who do this work. And what I what I like to do is I like to follow the gold standard of co-therapy, if at all possible, at least in the initial session. So I'm going to be there. I'm going to be there, preferably for the entire session, beginning and managing any needs that come up. They're going to have their therapist there as well. Therapist is largely going to be running the show in terms of the actual process, the the content of the experience where. And well, I'll get into what a session is like a little bit later, because I think you're there, you're you're you're listeners might be interested in that. But but, yeah, I'm. See him through beginning to end and I'm going to keep my antenna out and I'm going to get I'm going to be paying attention to some very specific information. Like one of the main questions I need to answer to myself is how sensitive are they? Right. Yeah. What kind of dosing do I need to be aiming to get them into an optimal psychic space? And there's both an art and a science to this. Just so listeners can get a sense of my worldview, I usually have a very simple way of approaching it. There'll be a time after I dose somebody with their medicine that I'll come back and I'll check in on them. And I'll ask them, are they light, medium, or deep? And as a general rule, I'm aiming for the medium territory. Enough of a dose so they have a legitimate experience that's markedly different from their experience of ordinary mind. Yet, on the other hand, I'm not going kind of overboard. I really don't think I'm doing most people. I'm doing most people a favor by pushing them off of a psychedelic cliff, especially on a first session. I don't know if that person will come back to me. Yeah. Yeah. And more importantly, I don't know if they'll get, you know, if they're scared off, they're not getting the healing experience that they need. So there's a balance to be had. So I like to think that I'm conservative in the sense that I want to be safe and be gentle and give. But on the other hand. And I, you know, I don't want people to go home with their hands empty. Like, you know, empty-handed. They came for an experience. I want to give them that. Right. So anyway, so that's the first session, at least trying to get them into the medium territory. And, you know, we can talk dosing a little later, you know, in terms of what that means. And then as long as it's with a therapist that, you know, that I am, you know, very confident, comfortable with their work, I may choose to. Yeah. Allow the client to prescribe a small supply of ketamine tablets, specifically with the instructions to only be used when supervised by their psychedelic therapist. And if the tablets are used outside of a setting, that's a breach of contract. And I'm not obligated to prescribe anymore. Right. I think that's a great approach. And they can have. You know, they can have a certain number of sessions with their therapist, and then eventually they're going to have to check in with me again. So is it cheap? No. But, you know, whenever, you know, whenever you limit MD time, there's going to be an overall net cost savings to the patient. And I trust that the therapists I work with, they're going to let me know if there's any safety concerns in any, you know, in any of the number of realms that that could emerge. You know, medically, psychologically, et cetera, et cetera. Yeah. And then, you know, and the person, if they choose, at some point they can get me involved. And I'll often travel to the therapist's office, and I have the option of, you know, administering an injection, you know, which is a deeper. And allow for the possibility of the more. Yeah. Yeah. Yeah. Yeah. Potentially the more psychedelic type experiences. So it's what I call a hybrid. There's a back and forth. And I'd like to think that it's a good blend of safety, efficacy, and, you know, and access. And there's certainly much more that we can do, you know, to improve the access even further. But I don't know, I feel good about that right now. So are you largely. Are you largely doing lozenge for clients? Largely. Yeah, largely. Typically, what I'm going to do for the first session, you know, I'm going to. I want to also make sure, because if the person's going to have the possibility of working with a lozenge session, you know, with their therapist, I want to see for myself that their body can handle it, or if there's anything that I need to be aware of to give them a safer, more productive experience. Like, for example, managing side effects, like a common one from ketamine is nausea. So in many people, I've got to come up with an anti-nausea plan. Right. And so what I'll typically do is, you know, give at least one lozenge in the first session. And then what I'm increasingly moving more towards now is then, you know, not expecting that first lozenge to really take them to the depth, the optimal depth, but to then either give them another lozenge and or allow the opportunity for a very low dose. I am booster so they can have at least a taste of that experience, you know, knowing full well, that's a very different experience than the high dose. I am experience. That's cool. It's kind of like a calibration session. Yeah. And I'm moving towards that model. It seems to be working well. People are usually very appreciative and seem to be, I seem to be getting really good feedback from it. It's it there's time efficiency built into that model. Because Joe, one of the things about, I think, psychedelics. Therapy in general is that there are exceptions, but by and large, the medicine is not the the choke point in terms of cost, the ketamine, as you mentioned, dirt cheap, the costliness and the therapy is paying for professionals time, right? And ketamine, I don't see it getting any less expensive than ketamine, because it's theoretically possible to do a ketamine session from beginning to end in two hours. There are, you know, many people out there who prefer more time and we'll, you know, we'll, we'll charge for that appropriately, but it is possible to do a, you know, to do a session in that timeframe. Think of an MDMA session, right? How long is that? Hours, hours, eight hours, you know, with, with two professionals involved, it's incredible medicine. I think it's such a wonderful thing, but you can see how the cost basis is going to be different. Imagine when psilocybin comes online and we're talking minimum of five to. Six hour experience for most people. Right. Yeah. So there, there's, there's, there's a, yeah, that, that I think it's an issue, but so ketamine and that's in part backing up my previous assertion that ketamine would be my choice if I only had one agent forever. Yeah. It makes a lot of sense. It's just practical, cheap time. Time is not anywhere close to the traditional time. We think of. Psychedelic psychotherapy and you get to still do a lot of great work. Absolutely. Well, another thing that maybe the listeners might want to hear about is that one of the wonderful things about working with ketamine is that it carries a paradox. And one of the, and the paradoxes I see it is the medicine is simultaneously powerful and gentle. So if you think about some of the traditional entheogens, things like ayahuasca and some other iboga, et cetera, et cetera, powerful. Yes. Gentle. Right. Depends on who you ask, but many people would, would, would, would, might not corroborate the gentle part. Right. So in my opinion, and then many of those that I work with in this professional space, there's a gentleness. There's a gentleness. Even when, even if I'm going high dose, I am experienced. There's, there's thought that there's a gentleness that seems to be one of the signature traits of this medicine, which, which makes it a really valuable clinical ally. Totally. Yeah. So here's a question about ketamine in, in, in kind of a lozenge form and circling back a little bit to this idea of the smaller, the amount of medicine, typically the better. So from, from your, you know, medical perspective, like how, how much safer is I am versus lozenge? Like, do you think the risk profile to like, I, I don't really know what the terminology is, but when it hurts, when you pee or something, when you're have, have ketamine in your system. Yeah, that's a great question. And, you know, and let me just preface it. I'm not a, I mean, I've, I've read, you know, some of the research in this area. I am not a researcher and I don't want to pretend to be something I'm not. So if any of my colleagues are listening to this and have a comment on it, I'd be definitely open to, to their, to their feedback. But let's just say from my current understanding, ketamine is safe, regardless of its form, you know, whether it's oral, intermuscular, injection, some people are using it. We're creatively like, like sub, subcutaneous below the skin, whatever, it's still a safe molecule, regardless of that being said, in terms of possibility of side effects, you know, I do think that you probably generally likely to, if you're going to have a, you know, a significant side effect from ketamine, let's say, you know, the side effect of, of being a stimulant to the person. and increasing their cardiovascular load yeah sure you're probably going to get more of that with a high dose injection or a high dose intravenous session than you are from a low dose uh lozenge right lower dose generally equals lower side effects and there is an exception to that and that that exception is nausea you're actually much more likely to get nausea with the oral the tablet version than you are uh or lozenge version than you are with either the injection or the uh intramuscular in terms of safety the intravenous is is is uh i think arguably the quote safest version of ketamine simply because you can turn it off at any time you're infusing for a period of time and let's say that we we were doing a session on you we noticed you know your blood pressure was spiking you're breathing a little fast i could turn off that drip and reasonably quickly that that medication the medication levels are going to start to drop and that whatever issue came up is going to is going to start getting better uh probably quicker than if we were doing an injection because an injection once it's in it's in it's going to run its course right have peak effect for about you know 45 to 60 minutes and you know we can hold your hand we can we can comfort you but the medicine's in in my opinion i don't you know i guess in my practice i don't i don't have access to an ivy suite uh so i don't know what it's really like to administer that that route um my patients have generally done great with the you know with the injections um especially if i'm trying to buy aim on the side of caution uh in the dosing it's a safe medicine no matter how you slice it but there are i suppose different gradations and levels of safety yeah yeah well it's good to know and on that topic just just there's no like just from the spectrum of how people use this medicine i've got some very well respected colleagues in the greater boulder denver area that are using they're actually doing true ketamine assisted psychotherapy with iv infusion and having marvelous results and so it's yeah so it's a it's it that that route can be very very powerful it's an amazing way to titrate the experience like okay like cool you're in there for five minutes and you're chilling now let's ramp it up a little bit more and a little bit more yeah it's like sure like uh like a dj almost versus like yeah you just turn on and off here wants to wants to donate an iv suite with uh with a resident nurse or emt i'm open to it perfect let's talk yeah yeah there's so much room in this ketamine space for more people to come on and more more options like you don't have to hold on to for maps to finally accept you to the training right um and then to wait a couple more years for it to become prescribable right this is here now exactly and that and that's that's one of the the the real beauties is medicines here now i love that yeah absolutely really briefly because i i probably only have about five more minutes to hang out but um i'm i'm curious uh about your perspective on breathwork as an integration tool something like holotropic breathwork yeah yeah i am a big proponent of holotropic breathwork um one of the um it seems like one of the final common pathways shall we say of any medicine or technique that that can induce a non-ordinary state is temporarily softening uh uh the ruminative negative self-narrative that's so characteristic of human suffering and mental illness okay so that can be and and how you achieve that state in some ways is you know potentially not even that of a mental illness but it's a state that's so characteristic of human illness okay so that can be and and how you achieve that state in some ways is you know important that may that that may be an overstatement but but what's my point holotropic breathwork or what i call journey breathwork in any of its forms absolutely can can soften that egoic function and give people access to the parts of themselves that are bigger than that negative self-narrative and just to bask in the juiciness of what's possible when that happens so it's in my opinion um the use of journey breathwork you know intentional deep breathwork that induces a a a trance state it i think it can be a tremendous integration tool after a psychedelic session because it can really get people in their bodies and also teach them that they don't need to have a chemical to always achieve that state incredible healing can happen you know just with the air that they're breathing in and they're breathing in and they're breathing in and they're breathing in and the lungs that are taking it and i i think from a pragmatic standpoint if we were to use uh breath work as a interim integration tools between sessions could we get away with maybe slightly decreasing the frequency of the psychedelic the more expensive psychedelic sessions how might there be societal value in that while still retaining the you know the efficacy and the and the self-learning and the insight and all the good stuff that goes along with that who no one studied it at least no then i'm aware of there's some clinical data on holotropic breathwork but it's largely done outside the states like russia did a whole bunch right but specifically holotropic breathwork as an as an integration tool oh near zero yeah if if any yeah yeah yeah please tell me because i found a way if you're aware because i'm not i would love to know it i would love to actually run that trial so if anybody wants to fund me let's go and i don't mind telling the audience i have had some amazing experiences with uh with that with the journey breathwork myself and i've just seen just the value and the healing in my own life and i and i'd love for the word to get out and you know groups like yours who can promote that work you know i love it yeah yeah it's so cool like i i love that for the most part it's safe for anybody like i'm able to screen people comfortably um myself and it can be done almost anywhere it's unbelievable i think i think only the yeah in france there's some uh weird uh things about breathwork i think the government flagged holotropic breathwork as a cult a while back nowhere else in the world just there and it was during a cult mania i'll tell the listener and you're gonna know more about this topic than i will but the one thing i'll caution the listeners is please don't dismiss breathwork uh and i'll caution the listeners is please don't dismiss breathwork as you know as a lesser it it can really bring out people's stuff in ways that that that use the audience you might find fascinating and amazing and it's just the releases of trauma and pain there that are possible i mean it could really feel like somebody is in you know that there's a whole group of people who are in the throngs of a deep psychedelic medicine yet there's not a chemical in their body right that's being you know it's not a chemical in their body put in yeah yeah absolutely like um stan groff along with my um mentor lenny said the thing that really convinced them about holotropic breathwork was that the experience was identical to high dose lsd sessions this is not every time but this is on occasion this can happen i i i you know yeah yeah i can see that yeah yeah cool well um dr thomas i think i've got a run but let's give you a moment to talk a little bit about what you're doing and what you're doing in the practice where people can learn more about you and so yeah yeah let me just kind of keep this brief um so my practice uh is called clarity integrative psychiatry uh if you guys wanted to google clarity psychiatry boulder or call it so clarity psychiatry colorado you're going to come up with a website and uh if you happen to be in the greater boulder area or willing to drive here you know we absolutely you know could consider you know if if audience members need some help and uh if we could be of service and it's possible yeah let's let's talk um they would you know they would likely interface with my very capable and competent what i call the high my high priestess of scheduling katia and she'll take good care of them excellent and i'm gonna leave it at that you know i'm i'm you know i there's a lot of really trusted that are doing this work and i considered i consider myself to be lucky enough to be part of a movement yeah it's not about me and my practice this is a movement of healing and self-empowerment let's do this absolutely well dr thomas i really appreciate you coming on the show and um yeah i hope we can link up in person in the future i'd love that i'd love next time i'm in breck i'll look you up and there you have it dr thomas i hope you all liked it it's a really fun episode and um i think you will be hearing more from dr thomas and i in the future so i'm hoping to meet dr Thomas in the next few months, but we haven't really talked about it. And I, yeah, just really grateful for him spreading this knowledge and working in the field. It is a, you know, a field with a lot of problems and a lot of risky avenues. And I'm just grateful that Dr. Thomas felt comfortable enough to move into this kind of psychedelic ketamine integrative angle on psychiatry. You know, how often do you hear a doctor actually talk about supplements and mean it, you know, honestly, but yeah, like there's, there's a lot of factors that go into health and mental health and to ignore big portions of them as a mistake. So I guess that's it right now. I hope you liked that. And a reminder that we do have an eight week program coming up in January for clinicians, therapists, coaches, whoever, whoever's interested, really, but just know that we're coming at it from a really high level. This is not, you know, for, for somebody in high school, really like this is for people who are planning to go into medicine or coaching or, or are in medicine or coaching. And we have a lot of depth here, a lot of masterclasses from expert people from around the world in their sub aspect specialty in psychedelics. And yeah, it's just an amazing eight week program. A lot of live support from, from us and a Slack group. You get to build your network around the world too, over the course of the class. And there's two time slots, I think noon and five mountain time, two and seven Eastern US time. So, and everything's recorded. So if you miss a class, it's not a problem. There's no pressure to attend every class unless you're shooting for CEs. And if you're shooting for CEs, you do need to be there. If you have any questions, hit us up psychedelicstodayemail at gmail.com. If you want to learn more about the class, check it out at psychedeliceducationcenter.com. And I think that's it for now. I hope you all have a great rest of your day and we will see you on the next episode. Joe Moore signing off. Bye-bye. Bye-bye. Bye-bye.