At IPI, within a mental health framework, we talk about humans in four core areas of spirituality, body, mind, and lifestyle. These four areas in alignment and harmony provide optimal mental health, or, conversely when out of balance, mental illness. In the body, an interdependent complex networks of biological and physiological factors contribute to mental health.
In the integrative model of mental health, many factors are considered in the category of body well beyond the conventional approach of mainly talking about neurotransmitters. The gut/brain connection is important. The immune system plays a significant role. Hormones and other signals are involved. Detoxification pathways and genetic vulnerabilities can be involved.
The mind is more difficult to define. For simplicity, the mind includes the social-emotional-cognitive perceptions of the human experience.
Spirituality includes the relationship to interconnectedness, non-ordinary states, essence, and the connection to the natural world.
And, lifestyle includes the behavioral choices we make such as diet, exercise, addictive behaviors, and sleep.
Ketamine-Assisted Psychotherapy clients are primarily people with chronic depression and/or severe PTSD. More often than not these clients have elements of their lifestyle and behaviors that are not supportive of optimal mental health. Insights which often occur at a rapid speed with ketamine-assisted psychotherapy can easily become overshadowed within days or weeks by “old” behaviors that aren’t adapting to this rapid change in meaning and sense of self.
One purpose of integration sessions is to bridge this gap between the internal shift that has occurred and the external changes that need to happen in order to transform their life and not relapse. Additionally, ketamine offers an immediate anti-inflammatory effect and a shift in the default mode network which provides a brief window of increased neuroplasticity. This window is an opportune time to help clients translate insights into actions and shift behaviors that have been entrenched sometimes for decades.
We have found that creating an inventory of targets for behavioral change with clients in the preparation phase of treatment, prior to psychedelic therapy sessions themselves, can contribute to a highly effective integration process. Setting accurate expectations about results is very important. Clients with chronic emotional suffering naturally want a ‘silver bullet.’ But the reality of the healing process, even with psychedelics, is that it requires hard work to turn the effects of psychedelic therapy sessions into lasting affirmative behavioral change. This is why prepping the client about the work ahead during integration is essential for the client to fully engage in the process.
When utilizing integration as a bridge to taking insights into action there are typical lifestyle issues within the ketamine assisted psychotherapy client population. Physical activity is often inadequate to reset the immune system. Food choices are typically injuring gut functioning, microbiome population, and metabolic and immune processes. Sleep quality is diminished which doesn’t allow for the brain to effectively restore. Unexamined habits are rampant that often present as substance use or other addictions. Relationships are often experienced as unfulfilling or overwhelming.
It’s important to have a general understanding of each area to help generate solution-focused interventions that will help the client create new behaviors that will anchor the profound internal shifts they are experiencing.
Inadequate physical activity is not compatible with wellness. Although there are individual differences in how much exercise a person needs, and what kind of exercise, medical studies have shown that exercising for less than thirty (30) minutes three days a week correlates with higher rates of depression. Thirty (30) minutes a day provides even more protection from depression. In our KAP medical consults, we discuss exercise with physically inactive clients as a behavioral target. There are also some interesting studies showing that the antidepressant effects of minimum activity are comparable to the effects of SSRI medication. Clients who are less active have less lymphatic drainage of waste products and are more prone to inflammation. Less activity can also diminish the peristalsis of the intestines impacting absorption of nutrition and excretion of wastes. Such individuals may oxygenate themselves less effectively due to the shallower breaths of sedentary lifestyles. Typically they stay inside more, with more risk of breathing air that is less fresh. There are many other physiological aspects such as less endogenous endorphins but this is a short list of pathways to be familiar with when discussing the role of activity in the integration process.
Fast food, highly processed foods, genetically modified foods, and non-organic foods are all examples of challenges to healthy mood and long-lasting well-being. There are a number of large studies and meta-analyses that have connected these kinds of food choices with depression and anxiety. On top of these challenges, the micronutrient content of non-organic and organic plants has diminished over time through the use of pesticides and depletion of soil from non-regenerative farming practices. This can significantly impact the gut microbiome. It sounds a bit bleak; however, there are a number of choices we can make to correct this and improve and sustain mood.
Baby steps with food choices are often far more effective than dieting: the turtle beats the hare in this situation. Many people spend much of their lives in diet and non-diet cycles. Starting with addressing overconsumption of sugar in the form of sodas and sugary drinks can be a huge win. Overconsumption of sugar impacts several physiological pathways including stoking the fire of inflammation, further challenging insulin production and potentiating insulin resistance, tilting the gut microbiome toward dysbiosis and candidiasis, and destabilizing attention and mood through marked supraphysiological excursions into hyperglycemic and the ensuing hypoglycemic states.
Swings between hyperglycemia and hypoglycemia in children can present as ADHD symptoms. In adults, the hypoglycemic periods are much more likely to produce symptoms than the hyperglycemic periods, often showing up as irritability, depressed mood, loss of focus, headaches, and in severe cases, delirium. Brain health deteriorates in direct relationship with impaired regulation of blood glucose due to overconsumption of sugar, so much so that Alzheimer’s Disease has been dubbed ”type three diabetes” by neuroscientists.
After reducing sugar intake, tackling a more global nutritional issue can be a good next step. Introduce the concept of focusing on shopping around the edges of the supermarket where the food looks like something that was recently alive as Michael Pollan famously recommended in The Omnivore’s Dilemma. If you want to get more specific, there are food plans (diets) that have demonstrated to support mental health.
Adherence to the mediterranean diet is strongly inversely correlated with depression. This diet is neither a fad nor a particularly restrictive diet. It’s been practiced by humans in large numbers for thousands of years. There’s no need to go further into the nuances of specific diets unless the basics (e.g. the mediterranean diet) fail to produce results. Less is more when introducing further nuances of food recommendations and far too many patients get stuck in the minutiae of diet choices due to practitioners introducing too many topics too quickly. It’s also worthwhile to bear in mind that some people are vulnerable to orthorexia, or becoming obsessive about avoiding any and all foods that may contain toxins.
Vegetarian diets present pros and cons which also need to be addressed. Regarding mood, there are specific nutritional deficiencies associated with depression which can be avoided with careful attention to the right choices of plant food sources for vegans. Micronutrient deficiencies impacting mood are very common, such as deficiencies of B6 and B12, Zinc, folate, and magnesium, to name a few, and correcting them primarily from actual food choices can be very impactful. Taking a higher quality daily multivitamin is also useful, but should not be understood as a replacement for the dietary choices necessary for sustained health.
It is important to note that while there are some dietary factors that are negative for almost everyone (such as lots of unrefined sugar, pesticides or other poisons, processed foods severely lacking in nutritional content) there is considerable variation in both compatibility of certain diets and the individual tolerances to specific diets and to specific toxins. In other words, personalized recommendations are sometimes necessary to address needs that are not adequately covered by general recommendations. Without supporting and challenging our clients to look at the way nutrition impacts mood, sustaining the benefits achieved with psychedelic therapy is much harder.
Good quality sleep is essential for health. Adequate duration of sleep, and with healthy amounts of the 4 phases of normal sleep in the right sequence and ratios, is essential. Sleep deprivation in rodent studies kills rodents quickly. Many physiological events necessary to feel well occur during sleep. Hormone levels are reset. Cellular garbage is cleared from extracellular spaces and removed from brain tissue. The body relaxes and restores itself for the next period of wakeful activity. The mind integrates the events of the day and learning is reinforced. The evidence shows that Americans in particular are very sleep deprived.
Recent cultural developments such as mobile devices being used by most people, even children, creates a scenario of brain stimulation often too close to bedtime which interferes with sleep onset and is associated with disturbances in sleep architecture. The light emitted by smartphones, laptops, tablets etc. stimulate the reticular activating system in the brain stem of humans, altering the natural relaxation response which precedes natural initiation of sleep.
The effects of less sleep, interrupted sleep, and disturbed sleep architecture all add up to challenges to maintaining a bright, open, curious, and inspired mood. Many people try to solve their issues with sleep by grabbing an over the counter sleep aid or relying indefinitely on a pharmaceutical. Although a short course of natural sleep supplements is likely less detrimental to sleep architecture than pharmaceutical sleep aids, both are not answers to attaining long lasting efficient sleep.
Sleep hygiene practices are essential in order to re-establish our body’s natural ability to sleep. This includes turning off devices and televisions at least 2 hours before bed, reading books in bed rather than reading on a screen (unless the screen does not emit standard spectrum light), winding down activity, exercising too vigorously for most, and not working right before bedtime.
Basic sleep hygiene interventions can go a long way. More subtle interventions might involve looking at the temperature of the sleeping environment, noise in the room such as snoring, or movements of bed partners or pets. Clinicians are also encouraging the use of wearable technology such as the Oura ring or Fitbit to get more precise in sleep hygiene interventions.
A very simple assessment called the Epworth Sleepiness Scale may point toward the need for a referral to a medical doctor who specializes in assessment of sleep disorders. Obstructive sleep apnea (OSA) is common and under diagnosed, with current research showing rates of 25% in adult men and 10% in adult women! This is an insidious, silent epidemic except when a bed partner complains of the noise of snoring or gasping overnight.
Psychedelic therapy is currently under investigation at many centers and promising results are being published to address frank substance addiction (see the published work of Elias Dakwar, Matthew Johnson, Evgeny Krupitsky, Peter Hendricks, and others).
Clients with moderate to severe addictions are trapped in a cycle of seeking high degrees of pleasure in the short-term to avoid pain and discomfort, only to discover that pain and discomfort returns over and over in the long-term until it’s addressed.
It’s human nature to want more comfort, routine, familiarity, and pleasure and to escape from challenge, suffering, and pain. However, addictions are on the extreme end of this spectrum and it’s very difficult to maintain progress from psychedelic therapy when an addiction is at play. This might involve a referral to an addiction specialist, or many integration sessions focused on addiction resolution.
Due to the nature of ketamine a brief window of increased neuroplasticity occurs following KAP sessions. This is a great opportunity to help clients initiate more adaptive and generative behaviors, and address entrenched, addictive and destructive behaviors that clients normally avoid discussing or even defend against. Initiating conversations about lifestyle changes during integration sessions can go a long way in promoting remission and helping clients optimize their mental health.
Keith Kurlander MA, LPC
Will Van Derveer, MD