Dear Future” is a monthly column that explores the rise of transformative entertainment and how it can be a foundational pillar, alongside psychedelics, in the field of mental health and wellness.
Nick Brüss and I met in LA and immediately dove deep into the future of ketamine and mental health. He has been practicing an Internal Family Systems approach to ketamine-assisted therapy since 2017. As a young and forward-thinking psychedelic-assisted therapist, researcher, and therapist trainer, he was able to shed light on the emerging field with a well-rounded, grounded approach. Brüss focuses on innovative new models of care, moving legislation forward, and serving as a voice for the safety, efficacy, and accessibility of these emerging treatments.
Lyle Maxson: What’s your take on the landscape of remote psychedelic treatment, ranging from the highly personalized high-touch treatment that you provide, versus almost zero-touch ketamine delivery services that started to scale during the pandemic?
Nick Brüss: Psychedelics are going to have a huge impact in the mental health space. The ketamine landscape shows a lot of people are being helped. Some people are getting their lives back from debilitating issues. And some people are having negative experiences, ineffective or worse, while others are seemingly swapping in ketamine for alcohol to numb out.
There’s a big difference between ketamine-assisted psychotherapy and ketamine therapy. A lot of people don’t know that when they hear about ketamine treatments and there’s a lot of confusion about what they’re actually getting.
We can call anything therapy. I’ve got a pen here – I could give you a pen and call it pen therapy. Hope that helped, have a nice day. But ketamine-assisted psychotherapy, or KAP, means that there’s a trained licensed clinician involved who has gotten to know you, leads preparation, and is present in real time during medicine sessions and during integration sessions. They are licensed therapists, which means they have training in ethics, developmental psychology, and multiple modalities along with years of documented experience and have been vetted by a state accrediting board.
Whereas with “ketamine therapy” you’ll have a guide, coach or sitter. While I’m sure they are well-meaning, they may just get in-house training, which could consist of watching a few videos, doing a couple of practice client sessions. And you have a fraction of real time contact.
There’s a big difference in how we can approach this. We can pump ketamine out to a lot of people, and it could help a great number of people. But my focus is on safety and optimization. The vast majority of people have not had any psychedelic experience, so ketamine may be an induction for tens of millions to these novel experiences. But the way they get introduced is substantial.
What I do is highly personalized, high-contact KAP that involves a medical assessment by an integrative psychiatrist, multiple prep sessions to establish a therapeutic alliance and get rich childhood information, and a cohesive understanding of current life patterns and goals. It requires being present in real time during ketamine-assisted sessions and the following integration sessions. I think nearly any person will get the most out of this model of treatment. That’s a lot of well-trained contact, and yes,comes with a not-small price tag. This obviously limits access greatly.
I also consulted for a few national ketamine treatment companies early on and continue to follow what they’re doing. They’re relatively very low-touch ketamine delivery services. These companies prescribe ketamine for home use with minimal direct interaction with healthcare professionals before, during or after. They suggest protocols and guidelines to be followed. Some services provide remote check-ins or integration support with guides or coaches through video or messaging platforms.
These groups prioritize convenience and accessibility. Successfully. Those are strengths: eliminating barriers and substantially lowering costs. Though you’re getting a vastly different level of care. Some of these companies are skipping vital pieces because they don’t scale well.
I consider some of them ketamine dispensary mills. Some are clearly prioritizing profit and sacrificing quality of care. Minimal preparation, lack of containment, huge doses, inadequate support and integration. I have heard many stories of things going sideways. Quite frequently I have people reaching out for repair of some psychedelic experiences that have gone poorly, and invariably there was not the proper preparation or container setup.
Are there any larger companies with strategies centered around a more high-touch experience that are trying to do it at scale?
Often, ketamine can be an acute treatment by itself. But it doesn’t heal depression, anxiety or trauma by itself. It may provide some relief. Hallelujah for that. But healing requires work, often revisiting and untangling past limited narratives about oneself. That work is most efficiently done in relationship with a trained clinician. Ketamine by itself may help you feel better for a day, week or weeks, but that’s temporary. Ketamine plus psychotherapy can be a process that yields durable healing. That’s what we’re really going for.
So to your question, for trauma-informed mental healthcare, more personalized treatment requires more personnel. Outside of that, a couple of things come to mind.
Esther Perel gave an interesting talk at SXSW this year that got into AI. It was mostly about another AI, “Artificial Intimacy.” AI therapists are coming. No doubt this will be paired with and without medicines for scalability.
Perhaps the most useful way to elevate a lower-touch model is shifting to a group format. A well-held group is a powerful thing. Some of the preparation work and integration sessions could be done in groups. And if the actual medicine sessions were held in a group and clinicians were present, this would bring the costs down and the accessibility up.
Is there a specific number of patients that’s optimal for group therapy? What is the ideal number for holding a container that is still high-touch and personalized for each individual?
I have participated in groups during my own training and as a trainer, and am developing group retreats for later this year and next. I have worked with couples and with groups up to twelve. Most important is the ratio of clinicians to participants. I do think there is an upper ceiling on that. What that might be would depend on the medicine and the dose, and also the set and setting.
There are ketamine clinics where people come in and get an infusion of ketamine, maybe a nurse comes in the room and out, but there’s no psychological intervention. Afterwards they hang out in the waiting room, then they leave and f don’t even get a phone call to check in. Whereas some of some great psychotherapeutic work can happen with low dose sublingual lozenges. The means of administration and the dose plays an important role in maximizing benefits and minimizing risks.
The ability to prescribe ketamine digitally is going to be revoked this year, so you’ll have to meet with a clinician in person for a prescription. Do you feel like this is a good shift for the industry?
You’re referring to the Ryan Haight Act from 2008, which put safeguards in place on prescribing controlled substances online without an in-person medical intake. During Covid, that law was temporarily suspended or adjusted. In May the DEA announced that this adjustment will be shifted so that people can receive a prescription, but only a 30-day supply without an in-person visit. So after the first 30 days, they have to visit their provider in-person for more. The DEA has since announced that they are extending the Covid adjustment until November 2024.
I do think this shift is a good thing, because it slows down these ketamine dispensary mills that are just putting out ketamine without the proper safe container for clients. It shifts the focus back to partnering with these medicines with preparation, dosing sessions, and integration. The real juice of this psychedelic work is in what we do after psychedelic medicine sessions, and how we prepare for them. I think this shifts some of the focus back to that. It also leaves open the option for ketamine to be delivered to psychedelic naive people who are first time users, with minimal instruction and care.
I’m curious if there’s an educational resource for people that would help them with preparation, integration, and general guidelines per substance.
As psychedelic medicines are becoming decriminalized and legalization is approaching, we need much more education around different medicines. About dose, particulars of set and setting, and preparation.
Psychedelic.Support is a solid educational resource particularly around safety and ethics.
The Aware Project has a rich collection of resources. It also helps potential journeyers prepare by listing questions to ask yourself, questions to ask the potential facilitator, and questions that a facilitator should be asking you. One other is NEST. They offer trauma-informed harm reduction training. And Bunk Police – test your drugs everyone! They sell several types of drug test kits.
In addition to training more therapists to facilitate this medicine, we also need supportive technologies. Anything from preparation and integration tools to meditation apps to patient tracking and analytics. There’s a whole new category of digital therapeutics called Digital Phenotyping, which could track things like the gyroscope on your phone to see if you’re lying in bed all day, and having a depressive streak. Then there’s things like I’ve been working on which are substitutes or enhancements for psychedelic substances, such as SoundSelf. Where do you see the biggest need for patients and therapists?
I think that tracking outcomes is really important. The day of or day after a psychedelic experience is often called one of the most impactful moments of one’s life. We should follow that up and learn how people integrate that, what changes that makes in their relationships, how it impacts the way that they speak with themselves. Are they more compassionate, more expressed, better at self-regulating or feeling their emotions?
I’m a big supporter of anything that helps people take what came up during medicine experiences into their daily lives. For example, there are a lot of meditation apps to support developing your relationship with your mind, body, nervous system and emotions. This is vital. The one that you actually use is the best one. Any technology that helps people practice meditation, to help one know even a little bit more of the landscape of their mind before adding the rocket fuel of psychedelics to it, that’s in the category of maximizing benefits and minimizing harms. Some of the biggest changes show up in personal lifestyle changes too, like exercise, eating, rest, creativity, friendships, intimacy.
I use a habit tracking app with clients for accountability and to follow up on practices throughout the week. For example, in a KAP session a client connects with a five-year old version of themself who had some needs go unmet as a kid. My client might choose to meet with that five-year old in a meditation for five minutes a day.
What’s Happening in Transtech
Opus – Companies like this are starting to pop up across the start-up space. A couple of months ago, this video made waves across Twitter. The ability to generate worlds and video games by simply typing (or speaking) them into existence will create a massive wave of new content, letting benevolent technology ideas flourish from creatives without coding skills. All I can say is wow. This emergence of generative AI in the right hands will be groundbreaking for developing games for spreading good at scale.
Takelo – A massive need in the tech space is for impact-driven organizations to find impact-driven developers. There are impact-focused developers out there looking for aligned companies, working in silos that begrudgingly have to take a big tech job to pay the bills. Simultaneously, there are amazing organizations that are hiring developers based on talent alone, without any cultural alignment. Bridging this gap is critical for the movement.
Endeavor OTC – Akili Interactive has been spearheading video games as medicine and looking for new innovative solutions to deploy their ADHD digital therapeutic to the masses. From partnering with one of the biggest gaming companies on the planet, Roblox, to now offering an over-the-counter version of their experience through the app store, they continue to be the company to watch as the digital therapeutics movement gets off the ground.