Of the many things I value about being a clinician who helps persons with eating disorders and their families, the one I perhaps hold most dear is that the clients themselves have been some of my best teachers. I believe in keeping an open mind and being ready to change. A shift that has been happening recently is the use of psychedelic medicines to help with a variety of mental health challenges. Many of these medicines are not legal yet, but the Food and Drug Administration (FDA) has approved trials for them with specific disorders, including a Multi-Site Study for MDMA Assisted Psychotherapy with Eating Disorders.
The Use of Ketamine for Mental Health Challenges
One medicine that is linked to psychedelics that is legal is ketamine, a schedule III medication that is not technically a psychedelic but a dissociative anesthetic known for its psychedelic effects at low doses and when emerging from anesthesia.(1) It is used off-label for the treatment of several mental health challenges, including depression, anxiety, substance use, post-traumatic stress disorder, obsessive compulsive disorder, and suicidality.
My clients and families began asking about ketamine. When I was working at a world-class eating disorders treatment program, my psychiatric colleagues also began using ketamine for eating disorder cases with treatment-resistant depression. At first, I was skeptical, as ketamine is also known as a club drug with potential for abuse. But from listening to my clients and my observation of their recovery journeys, I could see it was helping them.
There is now emerging data and interest in research for the use of ketamine for the treatment of eating disorders.(2) I began to wonder about how to do psychotherapy with the medicine and discovered there was a whole world of ketamine-assisted psychotherapy as well as a very lovely practice of intentional preparation, setting, guided experience, and integration of the medicine experience. Leading the way in this space are Dr. Phil Wolfson, co-author of The Ketamine Papers: Science, Therapy, and Transformation, and his team with Julane Andries at The Center for Transformational Psychotherapy in San Anselmo, CA, where I went to add to my own experiential learning.
They describe how ketamine works using the language below:
“Ketamine, when taken in a psychotherapy session, can be beneficial. The medication can stabilize patients with severe depression swiftly. Scientists from the University of Texas (UT) have identified the key protein that helps activate the rapid antidepressant effects of ketamine in the brain. Their study, published in the journal Nature, revealed that ketamine inhibits a protein responsible for an array of normal brain functions. The medication blocks the N-methyl-D-aspartate (NMDA) receptor, an ion channel protein and glutamate receptor found in nerve cells. Inhibiting NMDA produces an initial antidepressant reaction. A metabolite found in ketamine is responsible for prolonging the effect’s duration.
Stabilization is not the only effect of ketamine depression therapy. The blocking of the NMDA receptor also induces the hallucinogenic responses of ketamine. When taken with proper care, however, the drug may help severely suicidal or depressed patients get effective and fast treatment.”
KRIYA Ketamine Research Institute also has a nice reading list here for more learning.
Ketamine in Eating Disorder Treatment
Because so many of my clients with eating disorders also struggle with co-occurring conditions and the data on ketamine therapy is very compelling, I decided to get training through Polaris Insight Center and offer ketamine-assisted psychotherapy to my treatment of eating disorders. Also notable is that the founder who trained me in Emotion Focused Family Therapy (EFFT), Dr. Adele Lafrance, has developed Emotion Focused Ketamine Assisted Psychotherapy (EFKAP) with Reid Robison, MD. Of course, I was in the first training cohort!
Some of the things I find advantageous about ketamine for eating disorder treatment is that, while other psychedelics may last 6 to 8 hours, ketamine effects range from roughly 45 minutes to 2 hours. I also find it to be a gentle, loving medicine that allows for some respite from deeply-entrenched eating disorder thoughts and access to emotions and the heart space that is often difficult for someone with an eating disorder to reach. Combined with psychotherapy, there is a huge opportunity to get into contact with who and what is important to you and set some goals on how to move in those directions. And, thanks to the EFKAP model, there is inclusion of support persons to learn about the process and assist in at-home dosing.
So that is a long introduction into announcing that Eating Disorder Intervention will now be offering ketamine-assisted psychotherapy in-person in Golden. If you are interested in this therapy for yourself or a loved one, the first step is to reach out to me and discuss the process. Ketamine has some medical and psychiatric contraindications and is not for everyone. We will need to work with a prescribing provider to do an assessment to determine if the medicine would be an option for your situation. If ketamine is a possibility for you, we will take it slow and get to know each other so that you can build a sense of trust and safety to prepare you for what may be a wonderfully transformative experience.
Check out my website or reach out to me via my contact page. I offer free, 30-minute consultations to new clients.
1 Andrew T. Bowdle, Allen D. Radant, Deborah S. Cowley, Evan D. Kharasch, Rick J. Strassman, Peter P. Roy-Byrne; Psychedelic Effects of Ketamine in Healthy Volunteers : Relationship to Steady-state Plasma Concentrations. Anesthesiology 1998; 88:82–88 doi: https://doi.org/10.1097/00000542-199801000-00015
David S. Mathai, MD , Sanjay J. Mathew, MD , Eric A. Storch, PhD , Thomas R. Kosten, MD. Revisiting the Hallucinogenic Potential of Ketamine. June 25, 2018. Psychiatric Times, Vol 35, Issue 6, Volume 35, Issue 6
2 Daniel F. Hermens, Gabrielle Simcock, Megan Dutton, Ana P. Bouças, Adem T. Can, Chris Lilley, Jim Lagopoulos. Anorexia nervosa, zinc deficiency and the glutamate system: The ketamine option. Progress in Neuro-Psychopharmacology and Biological Psychiatry. Volume 101, 2020; 109921, ISSN 0278-5846. https://doi.org/10.1016/j.pnpbp.2020.109921.Esther Dechant, Brian Boyle, Rachel A Ross. Ketamine in a Patient with Comorbid Anorexia and MDD. Journal of Women’s Health and Development 3 (2020): 373-375
Schwartz T, Trunko ME, Feifel D, et al. A longitudinal case series of IM ketamine for patients with severe and enduring eating disorders and comorbid treatment-resistant depression. Clin Case Rep. 2021;9:e03869. https://doi. org/10.1002/ccr3.3869
As we spend the next few weeks in Mental Health Awareness Month, I invite you to consider how you can change your relationship with the thoughts inside your mind. While many of us would like to delete some of our thought content from time to time, it turns out that trying to not think about something or trying to suppress it may have the paradoxical effect of increasing the thought.(1)
That Song in Your Head
I like to think of this idea as having a song in your head that you don’t want in your head. I bet you’ve had one, annoyingly looping around your thoughts. Maybe it’s a jingle from a commercial, the echoes of your kids’ favorite program, or just a song from a random space in time that plays in the background of your mind much longer than you want. How do you get rid of it? Can you just tell your mind, “Stop thinking about that song”? Can you grit your teeth, plug your ears, and force it out? Or maybe you try to give it away and tell your buddy, “Hey, remember that annoying song?” Now you’ve just doubled the pain. You might try to listen to another song...and then, it dubs its way into the original song!
So how do you get rid of that song in your head? The more we pay attention to the song, the louder, stronger, faster it may present itself and the more likely we are to experience the urgency of wanting to do something about it. The answer is that you change your relationship to it and stop attending to it or trying to force yourself not to have it. You accept that it is there and that it is annoying, and you go about your day. Once it’s gone, you may realize you got rid of it — and there it is again!
Acceptance and Commitment Therapy
Now, I’d like you to think about the song in your head as similar to the thoughts you may have about yourself that are hurtful or painful. Maybe you have a thought that you are “too much” or “not enough.” Or that you will never succeed or that things are hopeless. Acceptance and Commitment Therapy (ACT) teaches us to just notice those thoughts or stories about ourselves, to make some space for them to just be thoughts without necessarily being the definition of who we are and what is important to us.
Debating with yourself and others about whether they are true or not may paradoxically increase the feeling that they are. The more airplay you give to the thought, the more you will be spending time with it, and the louder and stronger it may seem. There is also no need to shame yourself for having a thought you don’t want. We don’t blame ourselves about a song being there, right? Judging ourselves for having thoughts we don’t want is adding pain on top of pain — what ACT calls “dirty pain.”
So for a mental reset in this month of mental health awareness, I encourage you to notice a thought that cycles around like a song in your head and just let it be that: a song that will fade away as you attend to other things. Change your relationship from trying to fight with it to giving it some space to be there and drift away without judging yourself for having it. As Steven Hayes, the founder of ACT, shares in his TEDx talk, this approach will allow you to make space to focus in the direction of who and what is important to you and how you can bring what you love and joy into the world and share it with others.
Check out my website or reach out to me via my contact page. I offer free, 30-minute consultations to new clients.
1 Wegner, Daniel M.,Schneider, David J.,Carter, Samuel R.,White, Teri L. Paradoxical effects of thought suppression.Journal of Personality and Social Psychology, Vol 53(1), Jul 1987, 5-13
I recently watched an interview with Brené Brown during which she shared many incredible thoughts. The one that stuck most with me was that “joy is the most vulnerable emotion” and that, for many persons, the experience of joy triggers a “dress rehearsal for tragedy.” This idea means that, for some people, what brings them joy also elicits thoughts about loss or not having joy. Part of this connotation may have to do with how we learn early in life to organize our mental world in opposites (e.g. hot and cold, light and dark, or on and off). For those in recovery, it is the very experience of joy that may help lead them into the reason to recover in the first place. Joy, like love, lets us know how to move toward who and what is important to us. Joy is an emotion we want to share and use to connect with others. So if joy triggers a “dress rehearsal for tragedy,” how do we help persons with eating disorders experience it and not cause more pain in the process?
Understanding Harm Avoidance and Self-Directedness
One thing that has helped me understand persons with eating disorders over the years is the temperament trait of Harm Avoidance and the character trait of Self-Directedness, as assessed by the Temperament and Character Inventory developed by C. R. Cloninger and applied to the study of eating disorders. Persons with eating disorders, both recovering and recovered, tend to have elevated scores in Harm Avoidance and lower scores in Self-Directedness.
Harm Avoidance is a trait of wanting to be prepared for the future, making sure the details are all sorted out, and not wanting to break the rules or get in trouble. There is a tendency towards worrying and anxiety. The higher you are in Harm Avoidance, the more prone you are to be fantastic at planning and details and the more likely you are to worry about the future and want to follow the “rules.” Persons with higher Harm Avoidance may also tend to excel in professions where they need to pay attention and remember that instructions and details will mitigate risk. You want a good dose of Harm Avoidance in your surgeon, your CPA, your engineer, and your architect, for example!
Self-Directedness is a changeable character trait that describes the ability to direct one’s behavior towards who and what is important to them as well as their own values and goals. Persons with eating disorders tend to score lower on Self-Directedness. When making decisions about what to do or what choice to make, they will make those decisions to avoid harm, relieve problems and pain, and not break the rules rather than do what feels like the best decision for them. Persons with low Self-Directedness may people-please or be compliant because they don’t want conflict or for people to be mad at them. There is nothing wrong with this strategy in and of itself; we all need to make decisions to avoid problems and pain. However, things become problematic when you are too focused in that direction and are not making decisions based on what you need and what you value. When you seek to increase Self-Directedness, you can override the temperament trait of Harm Avoidance and choose, with intention, to move in a direction that feels right for you and what you believe in.
The good news is that you can change Self-Directedness and also manage your temperament trait of Harm Avoidance. Steven Hayes, founder of Acceptance and Commitment Therapy, has studied the processes by which people get well and states that doing what you love and sharing that with others is the secret to moving out of psychological problems. Watch his TEDx talk for a more in-depth look at psychological flexibility.
Five Ways to Practice Joy
Back to the experience of joy. It is not surprising to me that joy elicits a “dress rehearsal for tragedy,” especially for Harm Avoidant persons with lower Self-Directedness. Joy may feel risky, undeserved, and/or not appropriate because not all the problems have been solved yet. It may be a reminder that good things are transient and will not last, that it’s best to get ahead of the game and plan for the inevitable. Yet it is the experience of joy and sharing it with others that will help lead the way out of psychological difficulties. There is the double problem with eating disorders in that this way out requires one to feel emotions with the body -- the very thing that is so hard to be present in -- to even access the experience of joy.
If you are struggling to experience joy yourself, I feel for you. No doubt it will be hard and may not feel okay or natural at first. I promise that I have seen persons in that same space transform when they begin to allow those small moments. If you are supporting someone with an eating disorder, giving permission and helping to create moments of joy can be perhaps some of the most important supports you give.
Here are five ways you can practice or help someone else practice the experience of joy:
This blog is dedicated to all the wonderful attendees at the support group for persons 50+ with eating disorders facilitated by therapist Lauren Jouzapatais and me through The Eating Disorder Foundation. You all are a very important part of my experience of joy each Tuesday. I am so grateful for you all.
For more information, check out my website or reach out to me via my contact page. I offer free, 30-minute consultations to new clients.
1 Cloninger, C. R., Przybeck, T. R., Svrakic, D. M., & Wetzel, R. D. (1994). The temperament and character inventory (TCI): A guide to its development and use. St. Louis: Washington University Center for Psychobiology of Personality.
2 KLUMP, K., STROBER, M., BULIK, C., THORNTON, L., JOHNSON, C., DEVLIN, B., . . . KAYE, W. (2004). Personality characteristics of women before and after recovery from an eating disorder. Psychological Medicine, 34(8), 1407-1418. doi:10.1017/S0033291704002442
3 Fassino, S., Abbate‐Daga, G., Amianto, F., Leombruni, P., Boggio, S. and Rovera, G.G. (2002), Temperament and character profile of eating disorders: A controlled study with the Temperament and Character Inventory. Int. J. Eat. Disord., 32: 412-425. https://doi.org/10.1002/eat.10099