Imagine that the conventional approach to treating mental illness was a snow globe. More than a century ago, Sigmund Freud gave the globe a vigorous shake when he developed his psychoanalytic theory. A flurry of theories about the treatment of people struggling with their mental health followed, some later to be proved harmful and dangerous, others found to be helpful.
Since the introduction of SSRI antidepressant medications in the mid-1980s, there has been little significant change in the treatment of mental illness, said Manoj Doss DO, co-founder of the Institute for Integrative Therapies (IIT), a Twin Cites-based clinic that offers psychedelics as a part of mental health treatment. To Doss and his colleagues at IIT, it seems like the contents of the snow globe have for too long been settled on the bottom — and need to be shaken up again.
“If you compare psychiatry to every other field of medicine, there really haven’t been many breakthroughs in the last several years,” said Doss, who is certified in occupational and general medicine. “We’ve hit a wall on what’s been really effective for patients. Maybe we need to re-examine how we treat mental illness.”
Kyle Keller, LICSW, IIT co-founder, said that he and his colleagues try to approach mental health treatment from a different perspective. While mainstream treatments like talk therapy and psychotropic medications have helped millions of people worldwide, they also have their limitations, he believes.
Keller said that at IIT, an offshoot of Ellie Family Services, staff members see the use of psychedelic medication as a new and promising way to help patients move beyond blockages in their mental health and take further steps toward recovery.
“We try to do things that are cutting edge and unconventional,” he said. “We want to get to the next level of mental health care, and help people find progress where they haven’t been able to before.”
When combined with psychotherapy, Keller said, psychedelics can help patients “treat their mental health and process trauma. They tend to evoke something that’s more spiritual or beyond the traditional therapeutic approach.”
For now, IIT offers ketamine treatment for patients. The drug, a commonly used anesthetic also known as the party drug Special K, has shown promise in treating severe depression and is being offered at clinics and infusion centers nationwide. Depending on FDA approval, Doss and Keller would like to expand IIT’s treatment options to other psychedelics, including MDMA, popularly known as ecstasy or Molly, and psilocybin mushrooms. Both drugs have shown promise in the treatment of common mental illnesses, Keller said, including depression, anxiety, and PTSD.
“We’re laying the foundation to provide additional psychedelic-assisted therapies as they become available,” Keller said.
In June 2020, IIT started accepting patients with a “soft opening,” Keller said. As many as 40 patients have been treated since then; the institute’s official opening is scheduled for May 1.
Keller said that patients well suited to psychedelic therapy include “someone who might feel a sense of meaninglessness or nihilism, like nothing matters. Many times, psychedelics help create a profound sense of meaning for individuals that lingers with them and that can carry forward in their lives.”
Another type of patient that has been shown to benefit from psychedelic therapy is, Keller said, “people with a terminal diagnosis. These kinds of patients report profound, transformative experiences where they come away no longer fearing their own mortality.”
Keller, who grew up in a strict religious background and struggled with the impact of this upbringing, tried psychedelic drugs when he was in college. “It was the most significant experience of my transitioning-into-adulthood period that helped with the processing of the religious piece,” he said.
After learning more about the history of academic research into the use of psychedelics in the treatment of mental health disorders, he was inspired to learn more, completing a yearlong certification in psychedelic assisted therapy at the California Institute for Integral Studies.
Keller said that he has found that psychedelic drugs “work on an unconscious level. They allow things to surface that may be repressed. A psychedelic experience is a disruptive thing. Of someone is caught in a pattern and they can’t get out of it, a psychedelic can interrupt that reoccurring cycle that happens in someone’s life.”
How psychedelic treatment works
Keller explained that staff at IIT take a multipronged approach to psychedelic treatment for mental illness, combining the use of psychedelic medications with traditional psychotherapy and medical monitoring. “We follow a pretty standard structure,” he said. “It’s a model that is used by Johns Hopkins or NYU for doing psychedelic-assisted therapy.”
Keller said that IIT’s treatment process has four parts: first, an evaluation session to assess if this form of therapy is suitable for the patient, followed by a medical exam (conducted by Doss) that determines if the patient has any preexisting conditions that would make this form of therapy unsafe; then a preparation session (or sessions) that prepare the client for the psychedelic experience.
Conditions that restrict a person from undergoing psychedelic treatment include a number of relatively common diagnoses, Doss said: “I’ve turned people away for things like uncontrolled hypertension, uncontrolled or undiagnosed hyperthyroidism, uncontrolled diabetes or coronary heart disease or a history of stroke or cerebral tumor or glaucoma.”
The third step in the process, Keller explained, is a treatment session, which takes place in a specially designed room in IIT’s St. Paul office.
“Our focus is on optimizing the setting,” he said. “It is important that the environment is in all ways conducive to the process, including music.” Once settled in the treatment room, the patient puts on eye shades and headphones and rests in a lounge chair.
Music is projected through the headphones, Keller explained: “We curate playlists for them that evoke relevant emotional content and follow the trajectory of the ketamine.”
During treatment — which can last, depending on the method of ketamine delivery, anywhere from an hour and a half to three hours — the patient is closely monitored by a therapist and a physician.
Beyond tracking physical reactions to the drug, the observation is mostly hands-off. “We follow their lead and let them tell us what they need,” Keller said.
The institute administers ketamine orally or through intramuscular (IM) injection. “The oral route is more gentle and takes more time to take effect,” Keller said. “The IM is a more psychedelic experience. People tell us they go on journeys, feeling like they’re leaving the room.”
Doss administers the medications. During IM treatments, he stays in the room with the therapist, monitoring the patient’s condition. “I’m there to witness that they are tolerating it well,” he explained. For sublingual treatments, he said he’s usually in and out of the room every 15 minutes: “But I’m just down the hall if they need me.”
The fourth part of psychedelic treatment at IIT is called integration and generally takes place on the day after treatment. “It’s the most important part of the therapy,” Keller said. “We’re watering the seeds that were planted during the therapy itself.” This part can take place in person or by a video conferencing call.
Further follow-up sessions are scheduled as needed, he added: “We can also do a few sessions afterward focusing on taking the lessons and insights and putting them into practice in the experience.”
Doss said that for most patients, ketamine isn’t a once-and-done treatment.
“The effects of ketamine can be short-lived, on average two to four weeks,” he said. But he said that he and Keller believe that carefully targeted therapy can extend the drug’s impact: “I think that the best approach would be if someone needs to do it every three to six months. As the effects wear off, you might need a ‘reset.’ That’s what the therapy session would add to it.”
Psychedelic treatment sessions are not covered by insurance and can cost as much as $850 for a single treatment. Most patients’ insurance covers the assessment and follow-up therapy sessions, Keller said. He explained that the clinic is working to address financial barriers to treatment.
“Accessibility is the No. 1 obstacle. We’re always looking at creative ways to bring costs down.”
Promise and potential
Because they see such potential in the ability of psychedelics to take mental health treatment to the next level, Doss and Keller are committed to building a practice that can quickly expand treatment options to patients as new options are approved for use.
“We’re excited to someday offer MDMA (Molly) and psilocybin mushrooms,” Keller said. ‘We’re at the inflection point where things are going to happen very rapidly in the next year.”
Doss said he sees IIT as it is structured now as a template for future expansion. “Essentially, what we’re doing is setting up the infrastructure,” he said. “Ketamine is a great drug for depression, but there are limits on what it can do. We want to be able to offer other options for our patients.”
Well publicized research on the positive impact of psychedelics in the treatment of a range of mental illnesses combined with significant progress toward FDA approval for their use makes Doss feel confident that he and Keller are on the right track.
“It’s coming,” Doss said of eventual FDA approval for MDMA and mushrooms. Because of this eventuality, he said, “We need to have good actors out there. There are going to be some bad actors that show up, but if we start this clinic and we become the standard of care, hopefully, anybody else that comes into this field will use us a model of how things should be done.”
Rory Remmel, professor in the department of medicinal chemistry at the University of Minnesota’s College Pharmacy, said that he sees the potential of psychedelics for treating a range of mental illnesses. “I think it’s really quite promising,” he said. “MDMA especially has been really successful in treating post-traumatic stress disorders. It just seems to work with one or two doses typically. It allows people to access their memories in a non-threatening atmosphere.”
Have any of IIT’s patients ever had negative experiences with psychedelic treatment? Their website’s FAQ section addresses the issue in this manner: “It’s our belief that ‘bad trips’ can be avoided, with attention to set and setting and through trusting relationships with your therapist. For some people, the ketamine therapy experience can still be challenging … but, it’s often the challenging experiences that are the most rewarding.”
Doss recalled a patient who had a “pretty difficult emotional experience” during a treatment session. In the end, he said, processing the negative experience added to the long-term impact of her follow-up therapy sessions: “She came out of it describing more openness. She described a decrease in rumination, which was not something she’d expected with how she was feeling immediately after the session.” The impact of psychedelic therapy goes far beyond the actual time in the treatment room, he explained: “It’s not just the medicine. It is the work afterward.”
As for potentially dangerous physical side effects of psychedelic treatment, Doss said, all drugs IIT proposes to one day offer to patients are safe when administered by a medical professional.
Almost any drug can be dangerous if used in the wrong setting, Doss said: “Fentanyl has a horrible rap, but it has also done wonders in the operating room. In a controlled setting, it is completely safe. The same can be said about psychedelics. If you are using the drug in a safe setting, then you’re using it in the right setting.”
But people are being addicted to ketamine, Remmel said. It isn’t as large of an issue in the United States, but in the UK and some European countries, there is, he explained, a subculture of people “who use ketamine all the time. They get tolerant of it, just like an opiate. They keep having to use higher doses.”
Keller said that when administered safely, the deeper benefits of psychedelics far outweigh the risks.
“A term used in psychedelics is an ‘inner feeling’ or an ‘inner intelligence,’” he said. “Many people believe that the higher self is always striving toward wholeness and healing.” Psychedelic drugs can help user access the higher self, he believes: “Wherever it goes is where you’re meant to be. Trusting that there is a part of yourself that knows what you need to experience is part of the journey they are on.”
C. Sophia Albott, M.D., assistant professor in the University of Minnesota’s Department of Psychiatry and Behavioral Sciences, said she doesn’t endorse the theory that a psychedelic journey can cure severe mental illness. “Clinically I’m not entirely certain what a mystical experience can do in terms of vegetative depression,” she said. “I have to wonder how this type of experience is relative to being so depressed that you aren’t able to get out of bed. To me, it feels like you’re not actually treating the depression at its core — even if people are having meaningful experiences.”
‘Follow the science’
While key medical advances can come from experimentation, it’s important to not jump too quickly on the psychedelics-for-mental-illness bandwagon, said Joseph Lee M.D., president and CEO designate of the Hazelden Betty Ford Foundation.
“In today’s age of hype,” Lee said, “we have to be careful. While there is some promising data about hallucinogens and depression, sometimes we can be a little premature and jump the gun. When you are a hammer everything is a nail.”
With this hammer-nail comparison, Lee cautions that practitioners should take a measured approach to the use of psychedelics in the treatment of mental illness. He is concerned by what he sees as an emerging overenthusiasm for this treatment approach.
Hallucinogens, Lee said, may have efficacy in the treatment of some conditions, but he cautions that they may not work equally for all. “I think we want to follow the science. What we mean by that is, ‘Follow the science fully.’”
Following the science means waiting for more robust research that proves psychedelics’ effectiveness in the treatment of mental illness, Albott said. “I have a lot of ambivalence about it, to be honest,” she said. “I think the research is still very much its infancy. There aren’t even any randomized controlled trials of the combination of ketamine with psychotherapy. There isn’t evidence supporting that.”
While Lee said that he understands that even the most addictive substances can be helpful to patients in controlled settings and he resists the impulse to “grant moral properties to substances,” he still remains concerned about the potential negative impact of psychedelics in the treatment of mental illness.
“We’ve seen the downsides of psychedelics,” he said, “everything from psychosis to people bypassing the rapid tolerance they get and using levels that aren’t safe.” In his experience as a child and adolescent psychiatrist, he said, “I have not had a number of young people come up to me and say, ‘Because of my experience with hallucinogens, I’ve thought differently about x, y, z.’ Maybe a handful — but not a significant amount.”
The same goes for patients addicted to other substances, Lee added: “The only people who came into my office talking about the benefits of alcohol for their health were people who drank too much.”
Regarding potential addiction, Doss said, “People who aren’t aware of the process and the medication automatically go toward addiction or abuse. Any drug can be abused. I don’t prescribe these drugs [directly to patients]. They are administered in a controlled setting in the correct manner. Patients don’t have access to them after they leave the facility.”
Albott also takes objection to the idea that there have been no significant effective treatments for mental illness introduced in the last several years.
“I think there has been substantial development in the treatment of depression,” Albott said, listing what she sees as significant advances in psychotherapy and other hands-on approaches. And new, non-pharmaceutical tools are being developed, she added: “I am part of a group that does interventional psychiatry using transcranial magnetic stimulation (TMS), which has very few side effects and can be very effective for people. I wouldn’t say that we haven’t made any progress.”
Keller argues that at IIT he and Doss are focused on progress. Their goal is to help patients take the next step in the healing process: They see psychedelics as a key tool that can break patterns that have been blocking people from recovery.
To illustrate what he sees as the power of psychedelics in the treatment of mental illness, Keller describes a passage in Michael Pollan’s best-selling book, “How to Change Your Mind”: “He compares using psychedelics to going snow skiing: If you’re always heading downhill in the same tracks, eventually you’re going to create deep grooves in the snow. By the 500th time down, you’re stuck in the tracks you’ve established.”
All too often, Keller said, traditional mental health treatment follows the same well-worn grooves. He wants to help his patients forge a new path: “A psychedelic creates a new snowfall,” he continued. With the hill covered in fresh snow, “The tracks grab you less.”