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6/22/20

Ketamine and Mental Health: Part II

~This blog series is about my approach to mental health and the integration of ketamine therapy with a psychodynamic and affective neuroscientific lens~

Psychotherapy

The reconstruction of old narratives is a common goal in psychotherapy, particularly in psychodynamic therapy. And when I say ‘old narratives’, I mean old episodes within the story-like layout that we use to organize life events. However, one of the troubling issues with classical psychoanalysis lies in its reliance on autobiographical memory from before the ages where semantic and episodic memory are even reliable. In addition, there is little emphasis placed on psychological development in later life stages beyond just childhood, leaving out many affectively-rich life events that contribute to personality development. Importantly, as the neocortical thinking cap develops, so do the affective ‘gifts’ of the subcortical midline structures. This is best conceptualized with the “nested hierarchies” idea seen in figure 1 below. So even though affective systems are primarily built during early years, they are still influenced by the secondary and tertiary processing of the limbic and lateral cortical regions. It is a very circular process that is updated continuously along development.

Another important point when discussing early life experience is that there is a large gradient for trauma, and that not all trauma is negative. The definition of trauma is actually pretty vague, so defining it through an individual lens will be helpful. To me, trauma is a stressful event that surpasses an individuals’ coping threshold. But, with a decent support group and constructive evaluation, the event can be integrated and perceived in a way that causes growth. Without supportive scaffolding or real friends, the trauma is less likely to be integrated and more likely to negatively impact mental health. It should be emphasized that throughout adolescence there is no shortage of opportunity to experience stress, social defeat, and interrupted goal progression. Such experiences are completely capable of being traumatic, even if the harm isn’t verbal or physical. Accordingly, in my opinion, the therapeutic approach should take all levels of analysis across the lifespan into account – the cognitive-behavioral, the gradual exposure and voluntary facing of fears, and the reorganization of sensitized affective systems by straightening out the past.

Fig1 Mental Health and Ketamine Pt2.png

Philosophical Grounds

A necessary question to ask in the space of mental health is the contribution of value and belief systems to the development of moral and ethical behavior, which by and large involves the field of psychology. Apart from the neuroscientific and biological basis of mental health, the psychological aspects appeal to a deeper, evolutionary level of analysis – one that in fact ties itself to a restless question – as individual beings given the ability to act in the world, how does one act in the world? How should we act? Is there an optimal way of acting?

From an evolutionary perspective, the unconscious mind is built from ancestral memory, bootstrapped from primitive reflexive behaviors. Of these, primary process emotions – the systems discussed in part I – are stimulated and experienced in response to environmental cues that form the basis of learning and motivation. What seems to separate us from animals that share similar affective systems is the tertiary processing and modification of primitive behavior that is normally geared only toward self-preservation and immediate gratification. Humans, as social beings, are constrained by culture and molded into good citizens according to societal values, ethics, and morals. This constraint begins in childhood, as everyone knows a toddler has no ability to think unselfishly. Instead, they are ruled and possessed by their affective systems. As Jean Piaget championed, the development of mimicry and play are the beginnings of a proto-ethic, out of which reciprocity and fair-play concepts emerge. Literature on rough and tumble play, frontal lobe development, and ADHD also supports the idea that play is crucial in the psycho-socio-neural development of children. However, in our society today it seems as though there is much less emphasis on PLAY and more on scholastic and competitive-athletic achievement. As such, many individuals grow up with beliefs, values and ideas of success that are not their own, while delaying or forgoing the necessary interpersonal skills needed to succeed across many games – not just one or two. When prefrontal development reaches maturity this can become challenging, especially if the individual finds his or herself ‘successful’ based on false assumptions or axioms. Unfortunately, it is a challenge that is difficult to overcome when the formative years have been spent integrating such fundamental structures with their ‘self’ concept. It can be psychologically traumatizing to find out one has lived out another’s narrative, but it can also be quite a frustration to be unaware of such a scenario. This philosophical perspective is in line with what occurs on a network level, which will be discussed in part III.

My approach places a large initial emphasis on individual involvement and ‘buy-in’. Not everyone is a fan, as it takes a decent amount of time to complete the prerequisites prior to receiving ketamine. However, it is very important to me to know the individual is serious about uprooting dysfunction and integrating the past into the present, thus shaping the future. There are plenty of ketamine clinics that offer infusion therapy that aren’t interested in the phenomenology of mental illness and just hope for symptom resolution, which is what I used to do, but that isn’t solely what I’m after anymore. Ketamine is an amazing drug, and its effects on neurochemistry, cell signaling, and neuronal networking have very good mechanistic evidence for positively impacting mental health and resiliency, but achieving these goals is still hit-and-miss, and the process often requires repeated infusions to maintain benefit. Using ketamine as an adjunctive agent with the dualistic cognitive-behavioral/psychodynamic method will speed the process of individuation and understanding of the Self, which should translate to greater psychological resiliency and fewer ‘abnormalities’.

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