The Business of Psychedelic Therapy – Keith Kurlander & Will Van Derveer – HPP 139

Keith Kurlander  00:10 

Thank you for joining us for the higher practice Podcast. I’m Keith Calandra, with Dr. Wolf Vanderveer. And this is the Podcast where we explore what it takes to achieve optimal mental health. 

 

Keith Kurlander  00:26 

Hey there, everybody, welcome back again, to the show. Today, we are going to dive into the business of psychedelic therapy, we haven’t done an episode, really going into the business of psychedelic therapy. And it’s a good moment in time for us to talk about this because if you’re in this space, you’re paying attention to the media news. And there’s some companies that have fallen in recent weeks, months in the psychedelic therapy space. So it’s just a good time to be discussing psychedelic therapy and the nuances of the business of it, and how it’s gonna play out over time, but also like, what can we do right now. And what’s available. And also another part of the conversation is, you know, going deep into yourself as a provider, and we’re going to talk about what if you’re considering this or you’re already involved, how he wants to look, in your practice. And what are the things that you need to know about and watch out for. And we’re also doing this episode, because we just released a new course, that is about helping people with their psychedelic therapy practices. It’s a bit like a business school for psychedelic therapy. And we did that because a lot of people have a lot of questions. And it’s such a different space, in terms of a traditional therapy practice and then offering psychedelic therapy and regulations are changing over time. And a lot of people want to know what kind of forms do I even need to think about? And how are things different operationally from traditional practices? So we got that horse out now, which is exciting. So that’s something if you want to take advantage of it’s still on sale right now. So you can definitely keep your eyes out for emails around that. So why don’t we dive in? Well, you and I have been in the business of psychedelic therapy and trying to understand it, and make it accessible to people now for many years. And so we have a lot to kind of think and say about here, maybe a good start is a broader thing for people who are maybe just getting interested in psychedelic therapy, people who are kind of new to it, but they’re getting curious, I think maybe a good starting point for us is just discuss, like, Well, why is it important to consider psychedelic therapy at this point? And we’ll talk about the different medicines and what’s available now. But why don’t we just start with why is it important to consider that? 

 

Dr. Will Van Derveer  02:55 

Yeah, that’s a good place to start. So for folks who haven’t been following the emergence of psychedelic therapy, I think for me as a clinician, you could speak to your own perspective, Keith, if you have a different one. But as a psychiatrist and clinician, over more than 20 years, I’ve seen way too many people not get better from traditional treatments for the common things. And I think for the sake of conversation today, maybe we limit it to depression and PTSD because this is where psychedelics are really emerging. The numbers are pretty scary, globally, 320 million people with depression. And about a third of those according to big, well designed studies independently funded government funded studies show that about a third of those people with major depression are not going to respond to conventional FDA approved treatments, medications and therapy. So when you think about globally more than 100 million people with a condition, it’s kind of hard to wrap your mind around that. So the global mental health pandemic is huge, and it’s a huge driver for someone like me to look for other ways to help people get well, we could talk about getting well versus staying well, we’ve talked about that on other episodes, who will really get into that. But what we’re seeing with PTSD is also a serious lack of effectiveness for currently approved treatments. So we really only have two medications for PTSD approved: Paxil and Zoloft. And some people respond and it’s great, but way too many people don’t respond. And so what we’re beginning to see now, and depression and PTSD, psychedelic research is that we have a very promising early data to look at in both conditions with different medicines. So with PTSD, we’re seeing two thirds of people who undergo an MDMA therapy protocol. And I’ve been involved in some of this research in the past that is not meeting criteria for PTSD anymore after suffering for decades, chronic symptoms resolving within a five month protocol with three MDMA sessions. And then with depression, we’re seeing really encouraging early results with psilocybin. And there are other medicines and other conditions under review. But to summarize it, it’s really about right now. It’s about psilocybin assisted therapy for depression, and also MDMA assisted therapy for PTSD. 

 

Keith Kurlander  05:38 

Yeah, and then there’s sort of this, we’re using ketamine, now, doing assisted therapy, and there’s no data on that actual therapy. But there’s data on ketamine. So we’ll talk about that, too. Yeah, I think for me, too, one thing to add about why psychedelic therapy, and we’ve talked a lot about this, I don’t see psychedelic therapy as a panacea, and it’s just like the beyond all this. You do three sessions, and you’re done. And you’re moving on with your life and never need it again. Like, it’s just, that’s not how I view it. But one thing I would throw out is like, Could you imagine if we started with psychedelic assisted therapy instead of antidepressants? Like that’s where we started 100 years ago, 50 years ago, whenever it was that we really started bringing some things to market, different psychotropics, and but we started with a medicine that instigates therapy right with therapy. It’s like, where will we be right now? Would we be better off? I think so. I think we really would be, I think that we would have seen a different curve here. If it really went global and mainstream, and that there was sort of a different philosophical stance from the beginning of like, well, let’s try and discover medicine that actually are used medicines that were already around that actually and research them and then use them to actually do deep healing. It would have been a very different conversation that we’re in. I don’t know what it would have been. But it’d be a very interesting thing to think about. 

 

Dr. Will Van Derveer  07:13 

Thank you for saying that. Because the other thing that I failed to mention, in summarizing the research, is that what we’re seeing with MDMA therapy, and the data that’s available thus far, is that the benefits, the resolution of PTSD is extremely durable. Okay, so this is what, what I want for my patients with a lot of people seeking mental health care. One is they want a durable change in their condition, they don’t want to take medicine for the rest of their lives. Same thing with psilocybin assisted therapy for depression, we’re seeing very long term benefits lasting for six months, 12 months beyond that. So this is another huge promise of the possibility of psychedelic therapy is actually, for some people, putting mental health care behind you, doesn’t mean you’re done. As you said, Life is an obstacle course that has a lot of surprises in it. And there’s always something to face and deal with. But to be able to put severe depression or PTSD behind you, and then work on other challenges is incredibly optimistic. 

 

Keith Kurlander  08:19 

So why psychedelic therapy? We’re in a time where we see rising mental health rates, staggering numbers, we have sort of an epidemic of loneliness, where people are getting more disconnected from each other, more connected, in some ways more disconnected physically, in other ways. We need some new tools, or old tools that are new tools to deal with. And so, and there’s a lot of promising research now that these new tools are very different from the tools we’ve been using in mental health care. And that something to really pay attention to, I think, at this point, like if you’re a mental health care provider, you got to go find out what this is all about. Because whether or not you get involved with it, you need to know about it, because we need to know about anything that’s innovative right now, that could help the situation. So that’s why now and of course, another reason why now would be because there’s now a good amount of research. We’re getting further along. And we’ve got multiple medicines now in FDA trials. And so it’s a great, very exciting time with MDMA. And we’ll go into the medicines a little more specifically, just to give the people exactly where everything is in a minute, but we’ve got MDMA and face ending phase three. Psilocybin entering phase three, it’s pretty basic, and hopefully these things, the efficacy stays strong and they come to market and we’re ready to help people and think twice. So it’s an exciting time. But why now? Why would you want to know about psychedelic therapy and understanding, sort of the business of psychedelic therapy because it’s not as straightforward as just like, it’s not the same thing as, you go get your education. And then if you want to start a practice, let’s say, and you just have to learn to start your practice. There’s more nuance there because now we’re involved in medicine and missile practice. 

 

Dr. Will Van Derveer  10:24 

And I guess the other thing to mention, aside from the efficacy data, is the safety data. So we’re seeing very reassuring levels of risk and, and side effects. And I’m knocking on wood over here, because hopefully we won’t see surprises. And in phase three, or towards the end of Phase Three surprises do happen in phase three. And there are plenty of medicines that went through FDA processes and got into Phase Three and didn’t make it. So that’s a common thing. But to be able to offer somebody an intervention that’s potentially having long lasting benefits, and also comes with a really low risk profile is pretty exciting. 

 

Keith Kurlander  11:10 

Yeah definitely. Well, let’s talk a little bit about what it’s like to be a psychedelic therapist, and many people, maybe they aren’t doing this work already. But more so of like, okay, you’ve got these different medicines. Ketamine is available, again, we’re going to talk about that. But what is this going to look like in practice? This is the person that they’re in there doing six hours a day of sessions, five days a week of psychedelic therapy, what would that be like, let’s just talk about the practical of as this more and more becomes mainstream of a modality. What does it look like to be a psychedelic therapist? And what do you need to know about yourself as a therapist to craft how you want to work, if you want to work and how you want to work with these medicines as they become available?  

 

Dr. Will Van Derveer  12:04 

Sure, well ,one right off the battle say that one of the nice things about psychedelic therapy is there’s plenty of room for therapists who have a basis in a particular way, let’s say, internal family systems, or somatic therapies or various approaches that people have been practicing to weave that into their psychedelic therapy, and even cognitive behavioral therapy, which might not be perfect as a fit for the deepest part of the altered consciousness that happens in a psychedelic session can be super helpful for preparation and integration and working through insights that people get. So that’s exciting that it’s not like a completely different set of tools that you have to go get. But there are differences, big differences in terms of what you need to know about how to really be effective as a psychedelic therapist, which is why we train people over a year and over 200 hours of education, but I will say that, from my experience, practicing ketamine assisted therapy, and also in MDMA therapy, clinical trials, that the gratification of practicing psychedelic therapy is way different from meeting with people week in and week out one hour at a time over monster years. And I’ve done both a lot. And being a psychedelic therapist is a little bit like watching therapy on fast forward. Or another way to say it maybe is getting to see all the highlights of this is a little bit of a corny metaphor. But I’m a sports fan and watching the highlights of a game rather than watching a four hour football game, seeing everything that is important about what happened over that four hour period in about 10 minutes or so, seeing the insights, and the changes happen dramatically. And sometimes at a deeper level than you could ever get to in ordinary therapy is really exciting to get to be a part of that. But it also can be tiring and exhausting, where with MDMA therapy, you’re looking at a or psilocybin six, or maybe even eight hours of being with your client. And that can get tiring, it can be boring, sometimes it takes really good skills of self regulation and meditation and other things to not sort of fade out or succumb to the temptation to jump on your phone and check your email while somebody’s deep on their journey, that kind of thing.  

 

Keith Kurlander  14:43 

Adapt because like in reality, if this were one thing, let’s say it really becomes mainstream, like I just had a picture, there’s going to be a number of practitioners who are just sitting there on their phone for hours when people are silent and that’s why the training is so important. because there is an attentiveness and connection to the process that is a part of the process, even when someone is in a deep space that’s silent. 

 

Dr. Will Van Derveer  15:09 

100% and again, having been through a clinical trial with MDMA, as a therapist, I can tell you firsthand that it is tempting to do that when it gets boring, and someone’s been inside with eye shades and headphones on for an hour or two at a time even. But when you’re paying attention to someone who is inside of their experience, and pretty quiet, you do see things and you feel things that are actually really important for the process. So there’s all of that and then there’s all of this business side of things that we are here to talk about today that present different kinds of challenges from ordinary therapy. 

 

Keith Kurlander  15:51 

Yeah, and I think that a part of the business conversation is for therapists to be asking themselves for medical providers that they want to get involved with? Is this actually who they are? Because it’s an important question. It’s not everyone, for sure, it’s actually probably a smaller minority of people, actually, that will get involved over time than the majority of practitioners in the world, it’s a modality and no modality is taken over an entire field. So there’s no reason to think this well, but it’s not right for everybody. I mean, it’s, this altered state of psychedelics is a very, it’s like, you sort of have to have some connection to altered states to want to work in that way you do need to, and that there’s a mystical aspect to going into an altered state that isn’t describable unless you can connect to that in some way. And so there’s got to be some we’re immerging things here into psychotherapy, when we introduce psychedelics really have to have that kind of longing to dance in that space with your client to help them there. And, again, like you said, this, the highlight reel often, like you’re getting these downloads that sometimes you don’t even wouldn’t like, you would just be like, oh, I would never have thought of that in ordinary consciousness. And it, but it makes perfect sense. I mean, that statement is said all the time, like I wanted our thought, was not medicine. But that makes perfect sense. It’s so accurate. So yeah, so there’s magic here, there’s a mystical component in a certain way. And it’s not for everyone, but a lot of people are getting interested, they want to know more. So if you’re that person that wants to know more, or you’re already like, ready you’re starting to get trained, really, the business of psychotherapy of psychedelic psychotherapy would be someone who’s got some training behind them. They’re like ready to get in there. So let’s dive a little more into it. So why don’t we just talk about the first piece, I think something important is to just ask a big question of like, well, what’s really the demand right now, just so you kind of understand, like, if you’re just starting your training, and you’re, you’re wanting to help clients, like, well, how many people are out there that are ready for this? So I think to answer that question, we should start with just talking about ketamine as a medicine since then we could talk about MDMA and psilocybin but right now, ketamine is the only widely available medicine in the United States to use for psychedelic therapy. Let’s talk a little bit about where we are at with ketamine and how it’s being used. And then we could talk about, well, what’s the demand for ketamine? 

 

Dr. Will Van Derveer  18:31 

So, ketamine was developed as an anesthetic. In the late 60s, it was approved in 1970. So we know a lot about what the side effects are and what the risks are, and what happens to a person when they take ketamine. So that’s useful compared to these newer bodies of research that we don’t know a whole lot about yet. It’s used in mental health and is only about 20 years old, since around the turn of the century. And what ketamine has in its favor is a very rapid and robust antidepressant effect, and particularly specifically anti suicidal thinking effect that can be seen in hours or days. Ketamine is different from the psychedelics we’ve been talking about as well in that it only lasts for about an hour after you administer a dose in terms of the acute effect of it. You wouldn’t want to drive a car for the rest of your day after ketamine, but it’s a much shorter session for a therapist. There are different routes of administration for ketamine for therapy. What’s been studied the most is IV ketamine, you can also give a shot in the arm, which is the intramuscular ketamine and then there’s sublingual ketamine, all of these routes of administration are being used quite a bit currently in the US. And the other thing to say is that I think it was Johnson, Johnson and Johnson who developed the left-handed version of ketamine into a new drug called spravato. And this is on patent. It’s a nasal spray, and it requires the client to be in the office for two hours after the, for the dosing. So, in general, the preponderance of ketamine therapy is being done with sublingual, and some intramuscular. dosing with psychotherapy. There are unusual clinics like the one we run where we do IV ketamine, because IV is the route that’s most studied for efficacy, along with psychotherapy. 

 

Keith Kurlander  20:42 

Yeah, so it’s good to, thanks for saying all that, I think it’s good to tease out something for somebody who’s new to the conversation, which is that the studies are really not about therapy. Generally speaking, they’re not, they’re not looking at how effective the therapy is, or using psychedelic therapy with ketamine. They’re not looking at therapy versus no therapy with ketamine. These studies are looking at the effectiveness of ketamine, the medication being administered. So there’s not a lot of data out there to say like ketamine therapy does something specific. And that’s not bad or good. I mean, obviously, putting a therapist in a room when a psychedelic experience is already happening is going to feel more supportive to a person than if there’s no one there. And probably a lot more can come out of the process. So there’s just a nuance to understand there that a lot of people are using ketamine in medical practice for mental health without therapists. That’s what the data actually is showing that that’s supportive for treatment resistant depression. But we also know that we see here and there’s this is very known in this space, like you’ll hear a lot of people say that that was sort of traumatizing for me, I felt alone, I was having a psychedelic, no one even told me, I was gonna have a psychedelic experience. They told me I have a side effect of dissociation, whatever that is and then they get scared, and they don’t use the benefit of being a psychedelic. So it’s just a nuance to kind of tease out. And then the other nuance that you talked about, which is that there is spravato, which actually has an indication by the FDA. But for psychedelic therapy, that’s not what almost anyone’s using. Most people are using generic ketamine off label for treatment, resistant depression, or maybe some PTSD. And you could speak a little thought about, if you want to just why off label usage is a common practice in medicine. And we have research to support the off label use and that kind of thing. 

 

Dr. Will Van Derveer  22:46 

Yeah, I definitely will use it and in the mental health field it is extremely common. And one of the reasons for that is that the conditions that we treat in psychiatry or mental health care, don’t have enough highly effective tools that are FDA approved to cover the territory for folks who are suffering with these conditions. So it didn’t make sense. If you’ve tried XY and Z, FDA approved treatment, and all of these treatment attempts failed, that you would then go to another option. Anybody who’s listening who’s been through the henna depressant kind of carousel, the merry go round of, okay, first, I tried Prozac. And then I went to Effexor, and then I went to lithium, or some other drug. I know that it’s hit and miss with medications. So, unfortunately, the sad reality is that the more trials of antidepressant medication you undergo for depression, the lower your likelihood is to get a good treatment response at third, fourth, fifth, sixth attempt and medication is incredibly discouraging for people who are suffering so severely. 

 

Keith Kurlander  24:00 

So, right now, yes, we get to the demand question, the medicine outside of research that is being used for psychedelic therapy. And the indication is, generally speaking, depression that has been used for ketamine. And then there’s a lot of nuance about how it’s being used in the business of it, meaning like, how can you make this work and do this as a therapist and things we’ll get into that. And so the demand is the next thing to just sort of disgust for someone just starting to see clients and things like that. And so what we’ve seen in the last handful of years, and particularly probably the last two to three years is you see ketamine therapy, entering the media a lot more. 

 

Keith Kurlander  24:54 

If you Google ketamine therapy, I guarantee a major publication has written an article on it. A major new source has written an article on it within the last week or two, that’s how much publicity is happening. So that’s amazing. We see this level of attention it’s getting, I think on the ground, though, it’s important to know that it’s still a small portion of clients that would ever seek that out on their own. Some might get referred and say, hey, have you thought about this, but the awareness is not like a cultural phenomenon yet, in terms of like, therapy is right therapy is a cultural phenomenon, you can ask anyone in the United States, and they’re gonna know what psychotherapy is, generally speaking, they’re gonna there’s a kind of knowledge of it. That’s not the case yet, with psychedelic therapy, or ketamine therapy. So there are clients out there, all over the country. Now a lot of people are starting to get kind of in therapy, and it’s so much mainstream. And we will hopefully see that more as FDA approved, medicines come to market, where it’s like, this is an approved treatment, psychedelic therapy. And people still care about that, in terms of that process, that happens, and it creates a cultural movement in our country, for better or worse. 

 

Dr. Will Van Derveer  26:18 

It’s true, the legitimacy of a treatment is very much defined by FDA approval, we do have these off label uses, like you said, but in general, in this culture, and in the United States, FDA approval is the seal of approval for people to embrace something. And not only that, but for payers like insurance to begin paying for that type of care, generic ketamine is often not covered by insurance, because it is off label, as you said. 

 

Keith Kurlander  26:51 

Right. So as you’re thinking of getting involved, or you are involved in you’re like, I’ve got clients, I’ve even got multiple clients a week, but I don’t have as many as I want. I think learning more about marketing a practice and how to do that helps a lot. And we’re at the beginning. And it’s really important to just be patient and know that the beginning and the middle might not be far away. The middle could be just a few years away, we’re like, now we’re in the middle, like people really taking this on in a big way. So you have to be a little patient, but it is the time to get involved. It’s a great time to get involved right now, because it’s a great time to get trained. If you’re not trained, it’s a great time to start seeing people. Because we may only be a few years away before, there’s a lot of demand, and not enough practitioners. And that’s where we’re headed, we’re going to be headed into a moment, assuming some of these medicines do come to market and get approved, we’re going to be in a situation where there’s a lot of demand and not enough providers that didn’t set up the practice, they didn’t get their marketing, they didn’t get trained. And that’s going to happen, we’re not going to have enough supply of the therapy for the demand.  

 

Dr. Will Van Derveer  28:03 

I agree, there’s going to be a problem with access to care based on how many therapists are already trained and ready to go the timeframe to be more specific, we were expecting the FDA to review the MDMA dataset from Phase Three in May of next year. That’s very soon, it’s like almost just a little over a year from now. So if a training that you take takes a year of your time, it’s time to do right now, if if you’re wanting to work with MDMA therapy, 

 

Keith Kurlander  28:38 

Let’s talk about access to care. A lot of providers are going to be wondering about that. And what is the cost and how does this work? And I think again, let’s start with ketamine. And then we can kind of highlight what it might look like since we don’t know what the other medicines are as we go along here. But I think Access to care is a big conversation and the complexity of the question of access to care, and cost, specifically, around access to care if we look at the cost issue or an Access to care is that it’s not expensive to provide the treatment, because there’s a lot involved. So we talked about ketamine, you have to see a medical provider who’s going to get you ketamine, depending on how you’re doing it. If you’re doing IV, you’re talking about a very big staff to hold an IV clinic setup. If you’re working with a psychotherapist individually, and I think there’s a lot of psychotherapists wondering how do I work with ketamine in my practice? There’s a model developing now over many years where clients are bringing sublingual ketamine from their medical provider to the therapist office to have a session there. And but that’s costly, so they have to do their medical appointment and they have to get evaluated. They have to get the Medicine which they have to pay for, often out of pocket, but it’s not that expensive. But then they also have to pay for a number of hours of therapy to make this work. So Access to care is a big question of how do we, how do we help people here. Get Access, especially when we’re just talking about access to care and cost, there’s other issues of access to care. 

 

Dr. Will Van Derveer  30:23 

Absolutely, and another element of access to care, which arguably, maybe should be under a different heading, but since we’re speaking to people who might be interested in getting in the game of providing psychedelic therapy is who is qualified to provide psychedelic therapy, who, who’s in a position based on their prior professional decisions and passions and choices. And what kind of training a person has is actually important. You mentioned that a lot of ketamine, IV ketamine, in particular is being provided in clinics that are owned and operated by people without a mental health background in their training at all. And the danger you mentioned, of going on to a psychedelic with no psychological support in your environment. So people who are excited about the opening up of psychedelic therapy in this culture, also, I think, need to hear the message to appreciate that there’s a foundational level of education that puts you in a position to be able to deal with the psychological intensity and sometimes psychological emergencies that can happen inside the room with a psychedelic therapy session. And as a physician, I can say that there might be physicians listening, where that’s not something they want to hear, because there are a lot of physicians who would like to be a psychedelic therapist, and which is great. But if you don’t have a basic training or understanding and psychotherapy, you really need the position that we’ve taken in order to get this more advanced psychotherapy training, that psychedelic therapy training.  

 

Keith Kurlander  32:15 

Right. I think that’s key that training is so important, which brings me to scope of practice a little bit here in terms of psychedelic therapy, and we’re in a new modality, that the scope of practice is not been dealt with yet, at the state association level that much in terms of like when you think of psychotherapy boards, psychotherapy associations, even medical boards, like the psychedelic therapy piece, the scope of practice there, it hasn’t been argued through that often haven’t been attached to enough cases and these kinds of things. So states are just starting to take some positions here. So then, the next piece is like you’re thinking of getting involved with psychedelic therapy, is it in your scope of practice to let’s say, You’re a psychotherapist, let’s just take the model that you want to be able to work with sublingual ketamine, in your office client brings it to your office, you want to be able to hold space for that person, and there’s not a medical provider on site. Is that within your scope of practice? I mean, I think the answer to that is, well, you need your state’s board to answer that question. Because they will either say to you, we haven’t taken a position on that, we have taken a position on that. Or they’ll just say, just make sure you’re within your scope of practice and put it back on, as confusing as that is. It’s a reality. But what’s important, I think, for a psychotherapist getting involved with, with a medicine is that with this medicine, is that on one level, it’s an amazing medicine to get involved with, because it’s basically a two hour session. And when you think of access to care, you’re going to have a higher level of access to care, especially if there’s no insurance involved with any of these medicines, you’re going to have a higher level of access to care, because it’s a two hour session, it’s way less labor. It’s also sometimes less exhausting for the therapist, they can throw in a two hour session one day and another than another day. And it’s just like a double session, versus six sessions in a row. So and it’s reliably a very powerful psychedelic, reliably a very powerful psychedelic experience can happen on ketamine. So it’s an amazing medicine to get involved with. It’s got great data for depression. And then there’s this whole question of scope of practice and like, is it okay for you? If someone’s bringing their sublingual from their doctor and they’re sitting in your space and I think the things to consider as it can be okay, as long as you are the medical providers creating those safety protocols, not you. That’s key, and you need to be aligned with those safety. protocols, if you don’t agree with them, you don’t need to be doing it with them. But they’re the one prescribing medicine. So whatever protocol they’re requiring their patient to have at home with sublingual medicine, it’s very important that you hear about their protocols and you feel good about them. And then you need to have some basic protocols. If someone’s going to bring a medicine like that into your practice. And you do need some safety in terms of you need to know which the medical provider should be communicating like someone can’t drive after that. If you’re sort of colluding with someone driving after that, you could be held responsible for that. I don’t know if you want to go to an incident that hurt your well, but if there’s anything else you want to say about this, I think a lot of people have questions about this, obviously, who is first getting involved? 

 

Dr. Will Van Derveer  35:48 

Well, I think what we’re talking about is another aspect of psychedelic therapy that is different from ordinary therapy is that it requires you to be in close collaboration with a medical provider. And most therapists are not used to having to do that. And so that’s a different arrangement. And the reason you need to be in close collaboration is that you need to stay in your lane, you need to stay in your scope of practice as a therapist, and you need to not be in a situation where your client comes back, after having a difficult experience and accuses you of practicing medicine without a license. And so that involves, like you said, Keith, following the safety protocol that the medical provider told the client to follow, making medical recommendations or decisions, not having conversations about doses that the person should take and your clients not going to, we’re getting a little deep in the rabbit hole here. But there’s a whole aspect of ethics and staying in your lane that it’s really important to understand. I would also say in addition to checking with your local licensing board, to make sure that your malpractice insurer is going to insure you for psychedelic therapy, some companies that provide professional liability insurance are eager to cover people to do this different form of therapy. Others want to see that you’ve completed a training program. And then others are just outright denying therapists coverage for that specific type of therapy. So you want to make sure you’re covered for what you’re doing. 

 

Keith Kurlander  37:20 

Right. And we’re seeing some data out there that is positive in terms of there’s a lot of people being prescribed home medication at this point at home ketamine without a medical provider, they’re sublingual, specifically. And it does appear to be safe, if the protocols are followed properly. There’s obviously a risk with ketamine being a powerful medication, there are risks that people need to be aware of. So, but we’re seeing people do this. Now. There’s a lot of therapists having this collaborative relationship with medical providers, and clients are coming to them with sublingual ketamine for sessions, and it’s going well, it’s a system that can work. Mine bloom put out my Bloom is a larger company that is doing at home ketamine, they put out a paper of like 1200 of their patients, and it appeared very safe, the data in there with good results. So I’m not advocating necessarily that someone’s alone doing ketamine without a therapist there with them or something. I think, again, it’s always better to have a therapist if you can, when you’re on a psychedelic, when you have a mental health issue, specifically, but it’s looking good. This is a promising model for people who want to get involved now. It’s a strong model, it’s promising and it’s a good time to get involved. There’s a lot of access right now to it. 

 

Dr. Will Van Derveer  37:20 

Yeah, and I think another dimension of what you’re saying is, the more you alluded to this, but the more complex the delivery care system is, the more expensive it is for patients and clients. So coming into an IV ketamine clinic that provides psychotherapy is pretty intense overhead for that clinic to pay all of its team members, and do and break even and be able to survive. And when the cost is high, you want to be able to see a reasonable return on the investment for the client. They want if it’s an expensive treatment, you want to see really powerful benefits. So one of the access to care issues around cost is what is the minimum amount of involvement from the medical team and the therapy team to be able to offer someone really powerful benefits. And I think it’s also important when we’re talking about SR cares to talk about risks. We haven’t really talked about downsides of ketamine today. But I think it’s important to mention that ketamine uniquely and differently from other psychedelics does carry a risk of addiction. And the reason I’m mentioning this is that in these at home models, you can mitigate the risk of addiction by not giving people too much ketamine and not giving them refills on the ketamine. So it’s not necessarily a deal breaker that people are taking a drug that could be addictive at home. People take Ativan, they take Valium, they take Klonopin, there’s all kinds of commonly prescribed medications and mental health care that can carry that risk. And there are ways to mitigate it. The other thing about ketamine, that’s just I think it needs to be mentioned, is that with long term use, there can be a bladder issue that can become very problematic for people. But it’s extremely rare. If you’re not taking ketamine long term, and especially if you’re keeping it, the dose is relatively low. So because we’ve talked about the benefits, I think, just to be fair, I think it’s important to mention those downsides or drawbacks. 

 

Keith Kurlander  41:13 

Yeah, I think I’m glad you mentioned that. And also from sort of, again, the business of psychedelic therapy, from what we’re talking about, we are not and this is not necessarily wrong, but we’re not talking about maintenance therapy with ketamine, or any psychedelic medicine in this moment where someone is on it every single day. And often regularly, like these models of psychedelic therapy that are being researched. And what we’re speaking to these are, you know, three sessions, six sessions, maybe there’s another session in six months, one and a year, like, a lot of the problems that you’re talking about well, which are very real, is where people are looking at it more as a medication, like you would prescribe an antidepressant. And its regular use and problems with those. And you can have big problems with this one because it’s got the addictive component, like you said, Ativan. And a lot of people have problems with Ativan, right over a lot of people have serious problems with painkillers. And it was prescribed for a week for their injury. And now they’re five years old with a low level of pain. So there’s a lot out there and a lot of complexity to that. So I think as a practice of psychedelic therapy, short term intervention, and as a psychotherapist that’s want to get involved. Ketamine, psychedelic therapy is an incredible place to start. It’s amazing. It has a lot of great research behind it. There are ways to get connected with medical providers to feel safe. And of course, you’ve got to do your homework around how you’re going to feel you’re in your scope of practice and feeling safe, but it’s a great place to start. I think we should transition to a couple of other medicines, and just some people don’t know this and more about what might be coming. And then just some highlights there. And psilocybin has some nuances there, because it’s maybe in Colorado gonna be here in a couple years, not maybe. So why don’t we go to MDMA? Where are we at? And what that model might look like for a psychotherapist out there?  

 

Dr. Will Van Derveer  43:22 

Sounds great. So what’s currently happening with MDMA therapy is the research by the Multidisciplinary Association for Psychedelic Studies is at a point where my understanding is that all of the phase three data for efficacy has been collected. And what that means is, in a phase three study you generally do research on hundreds of people, you randomize people to either get the active treatment or the placebo. And then you collect data on the differences between the two groups, for however long the protocol takes to get everyone through it. And then, in the case of MDMA therapy, people who were assigned to the placebo group, during the efficacy part of the trial get the opportunity to cross over, it’s called the crossover or the unblinded phase of the trial to move over to receive the protocol with actual MDMA therapy, not placebo. And the data collected in the second part of the trial is important because it helps establish more evidence for what the risks are of MDMA therapy. So it’s more of a safety data phase, collection phase. So we’re going, we’re moving into all the, I would say beautiful souls suffering beings to endure the placebo phase of that study, they went off their medications, they stopped a lot of things to get through that And now they’re being given the opportunity to have MDMA therapy. So that data is expected to be complete by the spring of next year. So this is very thin. This is like a year away. Should I talk about psilocybin too? 

 

Keith Kurlander  45:19 

Yeah, I think the only other thing to say about MDMA is that, let’s say assuming the data holds, everything’s going well. Maybe it could be as early as the end of 2024, that there’s approvals and rescheduling, and that kind of thing, and then we start seeing it come to market, maybe 2025. And then how that’s going to look, no one knows in terms of what are the protocols? It seems like it’s two therapists in a room, six hours of therapy, it’s a very different model. And ketamine, I think it’s just the point to get across. And we don’t know all those details yet. But it’s an exciting time with MDMA, because we’re closing in here on the final results, basically.  

 

Dr. Will Van Derveer  46:09 

I will say that there is a challenge in I guess the business term would be commercializing this treatment. Or another way to say it is helping people gain access to this treatment, because inside of the protocol that’s been studied up to this point, it’s 42 hours of therapist time for the entire protocol. And the 42 hours is with two therapists, actually. So it’s more like 80 hours total of therapy time. And when you think about 80 hours of therapists time, it’s expensive, and time consuming. So one big question is whether the FDA is going to approve the protocol as is, or try to make some modifications that are reasonable based on access to care. So it’s good there’s a lot of questions there.  

 

Keith Kurlander  46:59 

Yeah. And what we’re even seeing with ketamine is that, if you go look, you’ll see that there’s a lot of companies that tried to be larger, multi clinics, ketamine companies, 1020 clinics, maybe more. And they haven’t done that well yet. Maybe there’s a few doing fine. But you see, a lot of them sort of, they end up going bankrupt, or they are closing sites. And the reason I think, just from our experience, is twofold. It’s very expensive to do a clinic model, the psychedelic therapy, I think the larger reason is we’re still in the early adopter phase. And the demand is not high enough, and then insurance isn’t paying for it. Right, which also decreases demand. So in the name of an X Karis, you’re so I think what the message here is like starting a small clinic in your town can be great. Having huge aspirations that you’re going to be doing great with 10 clinics. It’s not the norm right now, having a single psychotherapy practice for ketamine is so our session can work great for you. And then we’ll see what happens with MDMA. We’re facing even harder questions, because now you’re talking about a full day session. So now we’re talking about more challenging, complicated questions about how to get that available. But hopefully, there’ll be insurance for MDMA, if it gets approved. So let’s go to psilocybin briefly. It’s yeah, you want me to start? You want to start?  

 

Dr. Will Van Derveer  48:32 

Sure. Go ahead.  

 

Keith Kurlander  48:33 

Yeah. So psilocybin we, it seems like the people farthest along this compass pathways they have, they’re waiting for phase three trial to get started, hopefully, within the next number of months. They were saying that late fall, last year, early winter, I should say. So hopefully, we’ll see that phase three go through soon. And there’s speculation that it could be as early as 2025, 2026 to get an approval if phase three data looks good, which we don’t know yet. It hasn’t started. So there’s not like early indications of that. So, psilocybin is not far away at all, in terms of it, the possibility of it being a medicine that’s widely available. And then the nuance with psilocybin, which is very interesting as you have state led initiatives for psilocybin. So we have Oregon’s that is now bringing psilocybin services accessible within the next few months, the rule sets are all established, people are trying to get applications right now. But that is not a mental health treatment. That is a personal development treatment is the best way to say it. But yeah, we will see that hopefully in the next few months being available in Oregon, but it’s still a schedule one substance, it’s federally illegal, but at the state level, it would be illegal for that service. And then we have Colorado that passed their bill in the last election, which is going to be a mental health treatment, if it keeps falling the way the bill was written, once the rule sets are established, so that’s very interesting, that will be the first state level initiative that comes to market so to speak, that’s a mental health treatment for psilocybin at the state level. That could be a couple of years from now, once all those rules were written, and it’s in play and everything. So psilocybin, then there’s some other states trying to do some initiatives. So psilocybin is getting the attention. We didn’t talk about breakthrough designation for MDMA or psilocybin. We don’t need to talk about that right now. But it’s getting attention. It’s also not far away from being accessible, hopefully. So it’s exciting. But then there’s complexities like MDMA in terms of what it’s gonna look like, is it one therapist? Is it two therapists? So long a session? How’s that going to feel for people? Is there going to be insurance involved? So those are the different medicines, there’s obviously other psychedelics available, that we could go through and think about, and there’s some under research even. And I think those are the main ones to keep your eye on if you’re getting involved, as a psychedelic therapist right now. Between those three medicines, in four years from now, it is a possibility you’re working with all three medicines in your practice. I mean, it’s amazing to even think that four years is around the corner, will play out that way. Who knows. But if that’s true, and it’s, it looks very possible at this point, that that’s actually going to be within just a small handful of years, we’re going to be there, three to five years, multiple medicines, it’s great time to learn the business of psychotherapy and get trained if you haven’t started that. Anything else you want to say about that? Will? 

 

Dr. Will Van Derveer  51:53 

I think that we haven’t talked a whole lot about how to go out and find clients. But there aren’t that many. You did mention that there are not that many clients out there to go out and find right now. 

 

Keith Kurlander  52:05 

Yeah, well, let’s talk about that. Yeah, I mean, we have a busy clinic. So there’s clients, right. But it’s not the same as getting your psychotherapy clients in your general practice. So why don’t we spend a little time on how to go find clients for ketamine therapy. So there are a few ways Google Ads goes a long way. And there’s nuances there if you want to do Google ads, because you need special certifications, if you want to actually market this practice. But Google ads are always a great way to get therapy clients and psychedelic therapy clients. And that has not stopped here. That is a big way. But I think the strongest way is the same way you’re getting regular clients, which is that there’s a lot of people who are not practicing ketamine therapy. 99% of the practitioners or not more probably are not practicing psychedelic therapy is probably 99.5% of practitioners are not practicing psychedelic therapy, which means even though there’s a smaller client pool, is a very small practitioner pool. So the best way to go get therapy clients is to go to other therapists, the nice thing is you’re not competing with them. If they’re not offering it, there’s no competition. So because you’re going to just see their client for whatever a month, to get them through the process, whatever it is six weeks, so you’re not competing with them. Therapists are getting more and more interested in helping some of their clients that aren’t getting better to think about this. So it’s that way, it’s actually very marketable and easy to get clients if you’re willing to keep meeting with referral sources, educating referral sources on the benefits as you learn about them. That way, there’s a lot of room here right now. And in a certain way, even though there’s not a huge client pool, it’s like a very wide open market to get involved, because there’s not a lot of us doing it, very few. When you look at the number of providers in the country, or even globally, and the amount that’s doing ketamine therapy, we’re talking about an extremely small amount, still, it’s a great time to get involved. That will change 10 years from now, hopefully it changes. Right now is a good time to get involved because of that. 

 

Dr. Will Van Derveer  54:22 

And I just want to underline that, because there’s not many people doing it. What we found is that for therapists who go and do the work of meeting with referral sources, it’s not that hard to become the person in your community who people trust to provide this really niche treatment. And, as Keith said, Google doesn’t, doesn’t like people advertising controlled substances on Google. So Google ads for this are difficult to do. And I think a lot of therapists don’t really think about having a marketing budget and they’re busy. As for their work, it’s always worked really well for me to just meet with people. And it’s such a personal experience to be a therapist and to offer therapy. And there’s so much about who you are as a personality, I think these face to face meetings really matter whether they’re over zoom or in person, for people to get to know you and trust you. So a lot of impact can happen from just investing your time and your energy into building relationships. 

 

Keith Kurlander  55:30 

Yeah, and as we wrap up the, let’s say you are already psychedelic therapy curious, but, and let’s see even taking some trainings, or some kind of training and you’re like, you’re hesitating and going to get clients, but you really want to get your practice moved over there, or you’re wanting to just start a practice a small practice. You’re doing other work. It’s a good time, we’ve got this new business school program that’s on sale right now go check it out, if that’s what you’re looking for. It’s psychiatry. institute.com, forward slash b dash school. So B School B dash school, half off for another couple of days. Check it out, if you’re wanting to get involved right now. And it’s a good program to really just get an overview of how you transition or practice or start a new one, to get involved with psychedelic therapy? What are the different forms and all that kind of stuff that you need for psychedelic therapy that you need to know about? We really just wanted to simplify it. We don’t want to make a 100 hour program that you’re not going to get through. We wanted to make a program that just simplified the process so you can get out there. A lot of people are hungry to get out there. But they’re just a little hesitant and don’t know where to start. But we need people to get out there. People need help. So feel free to check that out. And we look forward to talking with you again soon on the next episode. Thanks, Will.  

 

Dr. Will Van Derveer  56:58 

Thanks, Keith.  

 

Keith Kurlander  57:03 

We look forward to connecting with you again on the next episode of the hire practice Podcast where we explore what it takes to achieve optimal mental health.