Dr Andrew Greenland: 0:00

So welcome to another episode of Voices in Health and Wellness. This is the podcast where we sit down with health and wellness innovators who are redefining what care looks like. I'm your host, Dr. Andrew Greenland, and today's guest is someone whose work truly sits at the cutting edge of what's possible in mental health care. Dr. Saraya Rahman is a board-certified pediatric hospitalist, the medical director of our own integrative practice, and a co-founder of AYAKAP, a community and consultation group pioneering the use of ketamine-assisted psychotherapy for adolescents. So with that, so I'd like to welcome you to the show and thank you so much for joining me today.

Dr Andrew Greenland: 0:42

So could we start a little bit with your journey and how you move from being a pediatric hospitalist into this integrative and now psychedelic focused work?

Dr Saraiya Rahman: 0:55

Yeah, yeah. As one of my friends says, you can't get here from there. There's no clear one path, you know, clear path through. However, I think as a physician, you know, lifelong learning is always the way through, uh, looking at the problems that are in front of us, um, seeing more deeply into the solutions that are there for the problems that may be in plain sight, but maybe underutilized. Um, and then bringing in the experiential aspect of being a physician, a physician, you know, uh a physician's journey is lifelong. It's a different profession from any other, and it continues to evolve. So, you know, both my parents were physicians, and growing up, I saw that uh it's it's who you are, it's you know, a perspective that you walk into into the world, and people, you know, um really trust a physician to be the um you know the one that says, yeah, there's something wrong here, and yes, we can do something about it. And so uh all that has always been kind of the motivating factor behind um, you know, stepping into, for example, hospitalist medicine itself, you know, pediatric outpatient is where I started, and then I went into hospitalist medicine because I wanted to work with the higher acuity kids, the kids that had more chronic illnesses, um, and I saw a lot of trauma. So I think that trauma-informed lens really helped to understand that we are under treating mental health conditions in pediatrics specifically. We just don't have the resources in the United States at least. We have a lot of patients who end up in the emergency room, sometimes for days, uh, awaiting placement because the only higher level of care that we can provide is, you know, and um hospitalization, and we just don't have enough beds to actually deal with the number of patients that are coming through. So, one of the kind of realizations uh as I was training in moderate sedation, so for about the last 10 years in a trauma center, I've been providing moderate sedation services, um, you know, just like an anesthesiologist would, but it was being handed over to the pediatric hospitalist because the studies show that we can do just as good and just as safe of a job because we know our patients better too, and we're much more aligned with the pediatric physiology. So using it for painful procedures, long procedures, and becoming familiar with the medication that's ketamine, right? And um, at that time before the pandemic, I really didn't have a consciousness about ketamine and psychedelics. Um, none of us are taught about that. We're just taught that there's an emergence reaction that occurs mainly in adults after you've given them ketamine for a painful procedure, and that that's just something that we can chemically or physically restrain for. Not understanding that there's an internal experience happening and that what happens on the outside, the set and setting, um, how a person is prepared for that experience can really make the difference. Um, and so it really was kind of like a penny drop moment where it was like, wow, this is real. This is, you know, this ketamine is a very ubiquitous medication in the emergency room and in the inpatient and the procedural suite. However, um, it took me two years to really convince myself that um this is a real psychedelic and that psychedelic medicine uh in and of itself is uh creating um a different paradigm for mental health. So those two things really uh drove, I think, the impetus to change lanes and to do so over the last three to four years. Yeah.

Dr Andrew Greenland: 4:37

And what was the um what sparked the pivot to start using ketamine with adolescents specifically?

Dr Saraiya Rahman: 4:43

Yeah, yeah, you know, we I was just in a meeting of our group uh IACAP, which is the adolescent and young adult ketamine-assisted psychotherapy group, we started about two and a half years ago, and we are physicians and psychotherapists and other professionals who meet around this exact question. It's like, okay, so if we say that, you know, in the adults, we're seeing a lot of results with treatment-resistant depression, with uh PTSD, with anxiety, with eating disorders and OCD, how does this now relate into the adolescent population? What do we have to be aware of? What are some of the um you know pitfalls? What are what are the best practices? So even just thinking about it in that way has revealed to us that there is a um a population of patients for whom the risk-benefit analysis makes sense. As in, you have a patient who's catatonic and in the hospital for a hundred days, you know. Just this morning, a physician was giving me that uh story. I mean, we're hospitalists, so we see these patients every single day. You know, we try everything, it's a multidisciplinary effort, it's a lifelong trajectory for this patient. And they were talking about how they used ketamine in a lumbar puncture situation. So they they needed to see if this patient had high, you know, um, pressure around their brain and spinal cord, and they used ketamine as a medication to just sedate during that procedure. And what they noticed is that over the next three to four days the catatonia disappeared. The the patient started to be more verbal, actually remembered the doctor's name, had never spoken before. The whole, you know, the whole um team was just um astounded. And and um at the time they didn't know what to attribute it to. There was not even a question of could this have been the ketamine, you know, and now three to four years later, you know, as we're looking back at some of our most difficult cases, you know, we see that there are there's a cohort of patients who do suffer with long-term treatment-resistant um conditions, for example, OCD, um, you know, eating disorders, that can absolutely create a high degree of morbidity as well as mortality. And to, you know, have a medication that's kind of ubiquitous, well known, uh, used for the last 60 to 70 years, has a amazing safety profile. You know, we can use it down to neonates, um, but also comes with this kind of uh cultural stigma that's that's been attached to it, has been a really interesting dilemma, and that's why our our um you know our group exists to parse that through. It's like who are who are the patients for whom this is a good idea? Another example is patients who have had uh treatment-resistant depression, for example, and maybe on three to four to five medications. That is a very common scenario in adolescent depression. And so using a rapid antidepressant like ketamine, um, not all the time, um, you know, as an intensification induction, and then as a maintenance phase, we can really think of it as a procedural interventional, you know, mental health treatment that can allow better functionality, decreased medication use, improved, you know, um developmental milestones. That's the other piece that's really important when we talk about adolescence, is we're not just talking about the mental health diagnosis, we're talking about an entire lifetime of low functionality, which may reflect in their relationships, in their you know, ability to learn, um, to hold down a job. And so, you know, I think this is a real under recognized gap. And so we're we're really um excited to talk about it, to bring more people to understand that yes, there may be caveats and and all of that, but the bang for your buck that you get is pretty astounding, and that's the piece that um I think uh comes with psychedelics and that potential for transformation that we see.

Dr Andrew Greenland: 8:50

Amazing. Can you you remember that the very first time you used it in this context? Was it was it that was one well that first patient that really made you think, okay, there's really something in this? Oh my gosh.

Dr Saraiya Rahman: 9:04

So here I was, you know, scratching my head, going, nobody's gonna allow me to do this within the hospital situation. I'm gonna break into private practice. And you know, I really uh took that seriously. I was like, all right, I'm I'm putting myself out there as this pediatrician. And it was kind of like uh, all right, I'll just put out an intention and see what occurs. And I think I I might have mentioned this to you. I I applied to uh I was like, okay, there's a conference coming in about 18 months. I'll, you know, it's in my it's in my consciousness. If I do have a patient, I would love to present it there. And lo and behold, um, there was a patient who reached out to me, um, a parent, um, and uh as we kind of proceeded through the intake, it was positive, it meant it made sense, they were really motivated, um, they had already experienced psychedelic healing, and so they were a really um good um container for for this. And so uh there was a there was a uh a certain sense of okay, we're doing this and we're trusting the relationship, um, the therapeutic relationship that's building here. Um I did a lot of psychoeducation, I did a lot of um consenting around, you know, this is a non-ordinary state of consciousness. Um, you know, we were not here, you know, we we were very clear about what we're here to do and what we're not here to do, a lot of harm reduction as well. Um, and it was really challenging. It was challenging in the way that it's not just the medication, you know, it's not the medicine. The medicine opens a door, and in each opening, there is an opportunity. There's an opportunity that arises whether in a memory that um is clear and is coming up for um you know exploration or relating. Um there's an opportunity for withstanding um the kind of difficulty or discomfort that may come with uh really disturbing OCD thoughts. In this case, uh specifically, it was um thoughts of pedophilia, you know, that can occur, and and um suicidal thoughts, you know, thoughts of um ending their life, and kind of really the opportunity is to understand your thoughts, you know. So I really leaned heavily on my medic, my my uh knowledge and practice of meditation, um, you know, contemplative practices, narrative medicine, um, you know, yoga, somatic, breath work, all of that just to bring, you know, the the nervous system regulation is part and parcel of this treatment. So it is what I learned was it's very intensive, um, it needs a lot of support, it needs a lot of regularity, and it takes time. It actually takes a much longer timeline than what uh people might be reading about, you know, the the popular press might be talking about, well, yeah, you do successions and you're a different person and it's transformational. And for some people, yes, that it can be that transformational, but what the stories aren't revealing is that that person did a lot of work beforehand that um was an investment into what became available in this transformational field. So it is um not one size fits all, it's really contextual, um, it has an opening and and um and uh availability, but it is absolutely wonderful to see those um assessments, you know, the PHQ 9, the GAD 7, the PCL, so uh depression, anxiety, PTSD scores going down and staying down, and the opportunity that that brings out, you know, if you're feeling better every day, you're feeling a little bit more of your motivation, that's the opportunity for coaching that we get to engage in, which is okay, you're feeling better. What do you want to do with this extra energy that's showing up for you that you've really um not been able to access? And then how do we hold that? How do we let the person actually, you know, one of the biggest um I think um feedback, one of the biggest pieces of feedback I got from the parents was we're afraid to breathe. We don't know if this is going to stay. You know, when the changes first started to show up, they couldn't believe it. It was kind of like a, is this is this a new reality we're stepping into? Can we trust it? Um, you know, is this gonna go away? Like the patient themselves had a lot of you know anxiety about okay, now I'm better. But just like any other time I felt better because of psychotherapy or medications, is this also going to go away? And so really um getting the person to recognize, look at the pattern. So I do a lot of actually looking at the objective data, you know, and it's fantastic after six weeks or so, you'll um, you know, and I'm talking about now my adult patients, after six weeks or so, they'll come back and their story may be, yeah, it worked, but I'm still not feeling, you know, better. And then you show them the objective data, they're like, oh, oh, I didn't know. You know, so we use a lot of trackers, you know, sleep trackers, mood trackers, heart rate variability trackers, hypertension goes down. That's one of the interesting things I see. You know, ketamine is such an interesting medicine. Okay, a patient comes with anxiety, they've got you know high blood pressure, they're on a medication for high blood pressure. Four to six weeks later, we've done some ketamine treatments, their stress and their anxiety levels are down, um, their blood pressures are normalizing, and sometimes they actually have to wean off of some of their blood pressure medications. So that's also an interesting phenomenon we see. So, really just getting at the root cause of some of these things has been really interesting.

Dr Andrew Greenland: 15:00

Thank you. And what were some of the early responses you got from colleagues and parents when you started exploring this space?

Dr Saraiya Rahman: 15:06

Oh, goodness, yeah, yeah, absolutely. Um, I I call it my coming out. Um, the psych coming out of the psychedelic closet. Uh, we all joke about it. There's a growing number of neuroscientists and physicians and and therapists who are all going through this process of that I remember going through in 2022. You know, I was burning out, I was um in a pediatric trauma center. Um, I was really realizing that um I had to heal myself or or, you know, so there was this personal impetus. And I think that is probably the most common reason why people become involved or see this kind of healing because it's affected them or somebody else around them in a very um you know transformative manner. And so we see this again and again is when you have experienced it, you kind of become a believer in it because it's it's the evidence of your eyes. And so there was this kind of like, yes, this is the truth and this is real, but I'm taking on a lot of career jeopardy. I don't know how this is gonna end. Am I gonna be known as the ketamine, you know, pediatrician? And and always it was, you know, um, and it was a it was like a it was like a dual-world um uh perspective because I would go for my trainings, I would go to you know, places like Berkeley and and Colorado for for my psychedelic training. And within that community, there would be like this welcoming of like, oh my gosh, thank you. We need more pediatricians, you know, we really need to address this childhood epidemic, you know, childhood abuse that's underlying um, you know, we're talking about complex PTSD that masks as uh you know a major depressive disorder, and we try medications and psychotherapy, but you can't get at the nonverbal trauma. With psychotherapy, you can only get at the verbal. You can't really get at the developmental and and some of the relational trauma that happens in uh childhood, you know, and complex PTSD. And so I see that, and then um in my uh you know, pediatric uh, you know, uh world, uh I've really tried. I've given ground grand rounds, I've presented at the American Academy of Child and Adolescent uh psychiatry, and within those spaces, what you'll see is that the general, you know, kind of leadership will be very skeptical because they'll be carrying attitudes that are more kind of from the uh you know boomer generation and and Gen X attitudes, and then there'll be a younger cohort of physician scientists and uh therapists and and ED physicians, you know, who are you know looking at the crisis that's in their emergency rooms and they're like, oh my gosh, tell me more. You know, how do I do this better? So it's really a dichotomy that we're facing here. And um, so yeah, it's a range of attitudes. So I've I've learned that um, you know, not to take it personally to be more grounded. And I think the community aspect has really helped is we talk to the parents, you know, there's a as psychedelics become more mainline, there's also a uh awareness amongst parents. You know, there's uh in in the United States at least, uh, for example, um, nonprofits like moms on mushrooms talk about how microdosing uh you know psilocybin safely has helped them be more emotionally focused on their pay on their uh children, you know, doing their own trauma healing has actually helped them to uh be better parents in in a lot of these you know intentional ways. So um I'm also aware that as a pediatrician uh and and pediatrics, you know, we're we're uh especially integrative pediatrics, the pediatrics that's uh uh you know um uh kind of uh practiced within the context of the family, their intergenerational trauma, their trauma burden overall, um, the the uh awareness that family systems can really respond to the trauma and conscious consciously, you know, in the scapegoating, in the narcissistic kind of um, you know, patterns of relational uh of relationships. And so uh we're becoming aware, I think, as pediatric professionals, of how trauma is working in the in the family systems around the patients that we take care of. For example, now if I see a patient with anxiety, I know for a fact that it's a hundred percent within the family system. And so we don't really do that work, we don't really turn to the parents and say, How are you dealing with what's going on? How is your anxiety? And do you realize that you are one nervous system when you're with your child and that that matters? And how can we, you know, so so really turning that lens of integrative practice has really helped as well.

Dr Andrew Greenland: 20:00

Thank you. So there's definitely a growing attention on the mental health crisis amongst adolescents. Can you speak to that and can you sort of see how ketamine assisted therapy might fit into that wider conversation?

Dr Saraiya Rahman: 20:11

Oh, what a big conversation. I mean, um we're talking about a a time, you know, we're in the context of our time right now. Great transformation, disruption, disaster, uh, you know, violence in the United States is an uptick. I mean, I'm a uh parent of two teenage young adult kids. And I remember the times where I would um, you know, have to drop them off to school, having just heard about a school shooting that happened maybe, you know, two counties down, right? So that's the reality of a child's life in some countries, you know, and so um what we're seeing in the pediatric population is an uptick in uh, you know, when when a when a child goes to school and the school is not supportive of who they are and what they're you know, what they need, um, the bullying, you know, we're talking about bullying, we're talking about um not being met, uh, we're talking about this um cohort of students who really mask, you know, who really just kind of tolerate what what their life is, and uh it comes out in different ways. So we're we're within that, and then you talk about the climate crisis, you know, we're we're talking about uh a food supply system that uh is more processed than non-processed. And I'm talking about, you know, when you look at the general population, if we look at very resourced kids, you know, there have they have a different set of problems that do also come out of mental health disorders. But if we're talking about the general population, our air quality, our water quality, our the quality of our food, the quality of, you know, it all kind of comes into the picture for um how let's say a mental health condition can really become um ingrained, become identity, you know, oh this is who I am now, you know, instead of this is what's happening to me, right? And only later as adults, when we have safety and we have that mature way of looking at things, can we kind of look back and recognize, like, oh wow, that wasn't me, that was what was happening around me, and that was the label given to it. Or I couldn't even have language for what was happening to me, you know. A lot of childhood trauma is kind of just pre-verbal, as we talked about. And so when we talk about adolescent mental health, we're talking about the future adult mental health crisis, you know, we're talking about the roots of what's happening to everybody, and so um the way it shows up here is in a higher degree of disability applications that are happening within younger groups. So more and more young people are actually applying for more disability. So there's that trend that we're seeing. Um, we're seeing a uh greater awareness, maybe, and diagnosis of neurodivergence and autism in adults and this concept of masked autism, you know. So um, you know, neurodivergent adults who um have higher than normal intelligence and never really fit in, and basically uh developed a way of relating to reality that was very much about not being their authentic self and how a lifetime of doing that can really lead to a sense of disconnection, you know, um, and all the things that follow from disconnection, right? Depression, anxiety, addiction, and and things like that. So we are um learning that the the adolescent mental health crisis has a trauma aspect, has a neurodivergence aspect, has kind of like a oh, we're feeling disconnected from our bodies, we're feeling disconnected from nature, we're feeling disconnected from our role on this planet as human beings, you know. Like um when you talk about uh neurodivergent uh young adults, they have a high sense of justice, you know, they have a high sense of truth-telling, which can be really problematic in in uh you know polite society. Nobody wants to hear it, you know, and so we we kind of take our the population that maybe the canary in the coal mine in a situation, and we go ahead and just shut them out, you know, and and maybe those are the voices we actually need to hear more and bring into awareness more because I think what they're calling us back to is a reorientation of our relationship to being human, you know. I I think we really are at this kind of, and I think that's where it fits into the overall, you know, piece of psychedelics. Because what psychedelics have been shown to do, like across the board, any psychedelic you uh talk about is it increases people's awareness of their nature-relatedness. So there's kind of like a burgeoning, like an uncapping of our ability to connect with nature, to feel like we're part of nature, and actually be healed in in that kind of very um elemental way by the patterns of nature. So one of the things that we talk about after psychedelics is, you know, go and integrate, meaning go feel like yourself out in nature, you know, and and just that feeling of, you know, even and and and we're what we're talking about are the diseases of the ego, right? We're we're talking about when we feel, you know, when we become so entrenched in the idea that uh we're better or we're more we're superior to uh what we're embedded in, and then we can maybe have a little bit of a reset as to our proportionalities. Like when you look at a 500-year-old redwood and you really look at it, and you really feel with it, and you see the majesty and the impact of it, and just what it represents, and then you see the the forest fires that are taking them away, you know, the sense of um just despair that we feel right now, that is one of the kind of probably the dangers of psychedelics, I would say, is that you start to feel too much. You start to feel it all. And if we don't have a community, if we don't have language, if we don't have a framing, if we don't have trusted uh, you know, understanding of like, okay, why am I so dysregulated? I did psychedelics, I thought it was supposed to solve everything. It's like actually what it's solving is maybe our disconnection and actually getting connected with where we're at can be disruptive to the patterns that we've been used to. You know, on my treatment-resistant disorder uh diagnosis patients, one of the first things they say as they're starting to feel better is that I feel a lot of grief. I feel better, but I feel a lot of grief. And what is that grief? It's like, oh, I spent a whole lifetime not knowing that I could connect, that this was possible, that I'm not meant to be this. I am actually more than what I've been led to believe. And so there's, you know, there's 70-year-olds mourning a lifetime of living with diagnoses, they didn't have to. So I think we're gonna see more and more of that as psychedelics become more mainline, you know, um mainstream, more and more compounds are coming out that are gonna be easier to administer. I mean, at this point in time, it's a bit of a wild west, you know, when you talk about dosing, there's no way of ensuring that, you know, you're doing any kind of dosing that's weight-based or or person-based, you're kind of like doing it and see what happens, you know. Whereas I think with ketamine, we have a a lot more of that piece sorted out. We have, you know, uh decades of data on how to dose well, what's a low dose, what's a medium dose, what's a high dose, um, a lot of different ways to administer it and so to do it safely. So it's a really interesting um place to be at, at the tension of these two things. You know, the psychedelics are really coming online, but they're really coarse and they may not be ready yet for another few years or or or so, and uh the practices that are there are going to be really constrained and kind of very basic and coarse. Um, and then you have, you know, just uh the the ketamine, which um we're a lot more familiar with as the emergency room physicians and and um hospitalists, and uh to know that there's a benefit to it. There's a benefit to it, that uh waiting on the uh classic psychedelics to hit the market, uh we're we're possibly leaving um a 10-year gap in some people's lives of treatment, you know. So that's that's um on my mind too.

Dr Andrew Greenland: 29:08

Great insights, thank you for that. So you're building a network that spans North America, South Central America, and Australia. What's different about how this work is being adopted internationally?

Dr Saraiya Rahman: 29:19

Great question. We just had a wonderful check-in with our Australian counterpart, um, one of the uh therapists who has a uh treatment facility for eating disorders. And uh they've been in their rollout for about two to three years now in Australia, and uh it was just fascinating to hear how different it is, you know. Um they um have a much more clinical um, you know, protocol. There's not a lot of this Wild West, you know, underground that they're uh you know involved in. It's uh they're they're able to use MDMA, psilocybin, and ketamine in treatment centers for eating disorders uh in the above 18 age group. And one of, you know, so that's that's how that's uh working in South America. I'd say that there's a greater emphasis on ayahuasca and psilocybin, uh, just because of the familiarity and the constructs there. And I think uh South and Central America definitely have their own culturally um you know aligned uh ways of doing medicine. And what you'll see is it's kind of like um the medical model and the indigenous model and the variations that are kind of at the intersection of the two, you know. So the medical model, uh very much based on patient selection, um, criteria that are being used, our patients who are very well, you know, in into their psychotherapy, you know, kind of um journey, um, are resistant to standard treatment, and then have the ability to engage in a very rigid, protocolized way of doing it, and they're following the MAPS protocol. So if anybody is curious about what the protocols are around it, MAPS, which is the multidisciplinary association of psychedelic studies based here in the United States, um, has uh trained uh the largest number number of the MDMA therapists worldwide. And I know that they're working in other places like the Middle East. Um, they've actually done work in uh between Israel and Palestine as well. So really focusing on these conflict areas. Um, and in North America, actually, the um VA, you know, the Department of Defense, um, a lot of work is being done in PTSD in the veteran population, because in the veteran population you have um such a high degree of recidive recidivism, recidivism, and um chronic uh, you know, kind of just um uh functional impairment that um the VA has really understood that ketamine therapy is a really good tool that can be used, and and now they're actually paying for clinics that that cover that. So there's a wide range. It really depends on you know who's pushing for which population. So the vets are definitely having um an opening happening around, for example, ibogaine as well. Um Texas and other states are funding Ibogaine treatment. Ibogaine is a psychedelic that comes out of West Africa, out of Gabon, um, based on the Yuboga plant. And so um that is a very powerful psychedelic. So I'll kind of end with saying, you know, when you're thinking about psychedelics, it helps to think about length of uh action, duration of action, uh, because that actually correlates to that critical period that's open of increased neuroplasticity and flexibility. And so ketamine is the one that has about 48 hours of uh neuroplasticity and flexibility because its duration of action is about one to two hours if you if you um use it psychedelically. And then ibogaine has the longest duration of neuroplasticity, so its impacts last for weeks. Um, and so it's being investigated in uh not just uh PTSD but also traumatic brain injury, um, you know, spinal cord issues, you know, just just things where we're trying to rehabilitate actual neuronal growth is a fascinating place. So um all that to say that there is a quite a difference in uptake based on the culture of the place, the context, the populations that are being made more aware and are advocating and actually finding their own funding. Um, you know, at the end of the day, it's who wants to fund what. Um, for example, we just in San Diego, we just had a um uh protocol that had been approved and uh to use ketamine-assisted psychotherapy in um youth in a you know kind of halfway house situation where they would be there for uh three to four weeks. And uh it was initially approved and now has been uh you know, the approval has been taken away. So um we're really uh, you know, the barriers that are there, some are visible and some are not. And uh so we're we're just trying to work within these these paradigms, but it's really wonderful to have an international global uh awareness because trauma is global, trauma's happening um in all these different ways.

Dr Andrew Greenland: 34:31

Thank you. I was gonna ask you, are we ready clinically and culturally for this kind of model of care? I guess you answer will be yes, but I'll ask you anyway.

Dr Saraiya Rahman: 34:39

Oh, ooh, actually, the the it's more nuanced. Absolutely, it's very much more nuanced. I feel like um, you know, uh, I will admit to the fact that the deeper one goes into the psychedelic world, the more distorted our lens becomes. So, you know, I would say I would I would couch that with um, you know, when I'm in Colorado and I'm talking to a physician who is um working with psilocybin and ketamine and seeing things, I feel like I'm in the future. You know, it's been done in a really beautiful way. And and uh, but I'm also really aware that you know, there's always this um this narrative, especially in the United States, of the quick fix, you know, of the thing that's gonna solve everything, you know, um, and and the ways in which our culture responds to the idea of the quick fix, you know, of of rapid adoption, but not really in the way that um would lead to good clinical outcomes. And so I think that's where the um my caution lies is that it's not for everybody. What we're learning is it's really about preparation, it's really about the trust in the relational aspect of the healing, meaning, is this therapist that you're working with or this container that you're working with really able to hold the kind of experience that you might end up having, you know, and so it's a very experiential container, meaning that we got to know what's there, you know, and sometimes we don't, and we still have to kind of, you know, we might find ourselves in the middle of a treatment protocol going, wow, this is new information we did not have, and even this person didn't have. So I'm reminded of the Joe Harry window, you know, the things that you know you know, and the things that you know you don't know. And sometimes for some people, that window of I don't know what I don't know can be the, you know, that's that's the box we open. And so if we end up opening that box and we don't have the relational container, if we don't have safety, what have we just done? You know, but re-traumatized, but made somebody feel alone again, you know, like um disconnection and um loneliness is one of the is is a hallmark of mental illness. And so if we can keep our our sights on what is it that we're really doing with psychedelics, um, you know, what became clear to me is it is about you know, the container, the community. So the way the the ways that we've kind of worked with that is I think clinics like ours have uh understood that we're here not just to be a medical clinic, we're actually here to provide the structure and the healing resources. And that may be a yoga class, that may be breathwork, that may be uh regular events where people can just connect with other people who are going through the similar things, you know, similar aspects of this healing journey, and to really feel that that heals, you know. So so I would say the culture is ready in some places, it's very well developed in Silicon Valley. Um, however, as we know, uh Silicon Valley can be like the jet fuel uh to anything, right? And so what we're seeing is also distorted distortions of culture, you know, distortions of um, I think um, you know, there there's a story within our our human condition that's about I'm broken. I'm broken, I'm beyond hell, and I need to be fixed, right? That that's one story. And I love how you know physicians like Gabor Mate, you know, um and others um talk about actually you're experiencing the result of what happened to you, whether you were a child, whether you're adolescent, where you're whether you were an adult. And if we can think of it that way, we really source a lot of compassion, a lot of uh awareness, a lot of forgiveness, which is really at the you know, kind of basis of healing, true healing, and acceptance and moving on, you know. So people are able to, and this is where uh the other piece that we work with is narrative, you know, healing, which is here's the story, here's the story that needs me to be this broken person in the midst of this story, and I've been telling it to myself for so long, and other people have told it to me for so long that it's it's become what I live. I don't even know what's outside of it. And slowly over time, this awareness that that was a story, but I could rewrite the parts of the story that aren't functioning, that aren't actually real, that aren't actually honest, you know, or authentic. And what does that look like? Is a much larger, I think, time intensive, you know, moment. And I think if we can as a culture uh connect with each other in that way, I think um what we might be talking about is culture change, and a lot of people talk about that in the psychedelic world is um with greater awareness. We're really changing the paradigms of psychiatry. You know, and that's yeah, I can't speak to that. Let somebody much more um erudite and learned in the psychiatric fields talk about that. You know, I go back to the father of um psychiatry, William James, who, you know, did nitrous oxide in the 1900s, early 1900s, and talked about the varieties of experience that lie just beyond our awareness, and how if we are to have a complete psychiatry, we can't leave those out. So I'll just end with uh, you know, kind of that awareness that psychiatry itself is a young um profession, um, and human beings as as well are are are young species.

Dr Andrew Greenland: 40:44

So, what does your typical week look like at the moment? You you do various things, I think you're involved in clinical care and education advocacy. Just give us some sense of what a typical week looks like to you.

Dr Saraiya Rahman: 40:55

I'm guessing no week is typical, but typical week, you know, I'm I'm a mother. I I in as part of my own healing, it was really important to me to uh uh pay attention to what my own physiology and my nervous system needs, because this work is really taxing. It's emotionally taxing. You have to be present completely. It's not just head work, it's actually heart work, and we get really involved. So being aware that this is a very different pace of work. So I may see up to two to four patients a day, and that's about it. And that would be the max, you know, uh it would be for one individual person who's in the room for two hours at a time, uh, really supporting a patient through this situation, uh, through their treatment plan. Um, there's a lot of phone calls, there's a lot of talking to psychiatrists, therapists, um, medical evaluations, preparation. Uh, we do a lot of integration. So between getting people ready to go into this, uh into the space, uh, you know, uh making sure that they are uh keeping in track with their integration, um, there's a lot of a lot of checking in and a lot of you know making sure that uh we're getting the objective data. We're you know, I I really believe in the qualitative piece of it. So I'm taking copious notes about what's happening in the session, what's happening afterwards, what are some words and and phrases that people are using, because sometimes that is the piece that really turns, you know, um uh turns turns the kind of key in in how this healing is going on is what really happened, what came through, and what do you need to make meaning of? So it's a lot of real intensive, and I love that. I I love looking at subtext, I love looking at language and you know what what's kind what that what that is. So it's kind of like I I joke that you know I I came into medicine, went into pediatrics, really went into medical education, um, and I think psychedelics are also a learning tool, uh, went into narrative medicine, and now all of that is here in like a practical um, you know, kind of therapeutic uh way. So uh typically these are long days. I'm doing a lot of social media, I'm doing a lot of um talking, educating, um, talking to therapists who might be reaching out, going, hey, I've I've got a patient who's doing ketamine therapy, I'd like to really understand what's happening. So lots of education. We invite therapists, we we do talks, we um put out information because it is different. It is different. So um yeah, uh I there there's times at the end of the day, or or you know, um at times where I have to take a break from it going, oh wow, this is overwhelming because I become about this, and I don't want to become about this. I want to, you know, this is my this is my work, but it can't be what I become about. So there's been a real rebalancing of understanding, like, okay, um, we're doing this work, it's really intense, we really believe in it, but how do we hold that objective uh perspective as well? How do we know when we're when we're not supposed to do this? When who are the patients for whom this is not a good idea, you know, and being really discerning about that? So uh there's a lot of discussions, a lot of communication, a lot of teamwork, a lot of consultations. Um, you know, one other thing that I do is uh be part of a consultation group where I can take my patient stories and be heard by a group of um uh people who are much more experienced, are looking at it through the ethical lens of, you know, um, there's a wonderful uh resource called The Ethics of Caring by Kylia Taylor, which is kind of like the gold standard book for uh any psychedelic healer who's going into this, because the ethics of this is really interesting, um uh situational, challenging, uh, because it is interpersonal. It is it is in that in that space where you're in it as much as the patient. And so a greater amount of contact occurs. And and so that brings with it some of those stories that you might have heard of you know inappropriate conduct. And um, you know, just this last week I had a patient who I had done consent with before for a handhold, and within this within the um within the journey, the patient says, Oh, can you put your hand on my chest? And I had to say, while this person was in ketamine and we were still able to talk, and I had to say, I'm sorry, I can't, but I can, you know, work with you to put your own hand there. I can offer you a cushion that you can hold to give you that pressure, but I did not take consent from you for that before I put you under the medicine, and I can't allow you to change it, and that's on me, you know, that's on me for not having gone through that. And we talked about that. We talked about how um that situation um actually recreated the situation for this patient where they were a very a young part of themselves came out and recognized that I remember what it's like not to be met. I remember what it's like to know I need a hug or know I need comfort and not get it. And we were able to really connect in that level to say that yeah, and there was anger behind that, you know, there was there was a discharge there, and I had to really not get involved in the anger. I had to recognize it for what it was, which was a much younger part, needing someone else to be there, to be the adult, to resource caring from and not having had it. So those are some situations where we talk about, you know, closing the loop, you know, um having this um we call it, I the the word is just escaping me, but um being um, you know, um met in that way, being met in that way, completing the trauma cycle, um, co-regulation, things like that. So, so yeah, um I hope that answered the question, but it's it's challenging.

Dr Andrew Greenland: 47:23

It does. So obviously your clinic is a business, and I'm just curious to know what's working particularly well for you as a business, and also some of the what are some of the challenges and bottlenecks in running the business that you have.

Dr Saraiya Rahman: 47:36

Great question. Great question. Um, I think uh insurance uptake of this business is the biggest um you know uh barrier. Um, you know, if it and it depends on what kind of um structure a person, you know, a business wants to have. So clinics that have integration of sprovado, which is the uh Johnson ⁇ Johnson product of the S-ketamine, um, which ketamine is a racemic product of two isomers, and so the S-ketamine is one isomer, and that has been now uh, you know, kind of taken up by a lot of um uh psychiatry clinics where the ketamine is administered as a nasal spray, and the patient is given about 15 minutes of kind of um you know accompaniment. Um, but that that uh and it's taken off, you know. Johnson ⁇ Johnson has made upwards of a billion dollars on this uh over the last couple of years. Yeah, yeah. So so they're not wrong. There is a market for it. However, what we've noticed is that because patients are being left alone in these treatment um rooms, they're online, they're on Amazon, they're shopping while they're on ketamine and they're calling it ketamine prime day. So, so let's talk about uptake and safety, right? Um, so insurance uh is is a is a big challenge. Um psychotherapy, the psychotherapy part of it can be reimbursed, however, the ketamine part of it will not, um, you know, and if you do get reimbursed, so the best place to be reimbursed for it now, right now in the United States, is the VA pipeline. So the Veterans Administration, um, because it has uh really run forward with psychedelic treatment, um, and the and the VA tends to be ahead in some of these ways because they have such a body of research and such a great populational need, um, that they are actually paying for the treatment. So they'll pay for a bundled treatment, you know, protocol. Um, but our clinic, we have had to be really agile. We've had to think about, okay, you know, patients who come to us, they are usually coming to us. Um, you know, we happen to live in the in California, which is the fourth largest, you know, economy in the world. So, um, so in the world. Um, so it's not like it's a population that's a lot very constrained by um, you know, resource. So we do have the people who can afford it, who are coming through and can afford the you know, four to five thousand dollars and the time and the energy and the resources that it would take. So they're not being left out of the psychedelic renaissance, it's the people who are dependent on insurance uh for their treatment. And so what we are learning is that that first initial uh intense period of four to six sessions, if we do those through an IV, you know, method, uh with this intensive, you know, kind of protocolized, a lot of support, a lot of integration, a lot of commitment from the patient, we get them to a different baseline. And then it's a matter of keeping them on a maintenance of some sort. And we're we're finding that maintenance can be once a month, once every two weeks, you know, depending on the patient. And so the way my clinic does it is we start everybody off on the IV version, and then we actually transition them to intramuscular, which is easier to administer, a lot less cost and time uh resource, and you can do it in group settings. So we actually have formulated a way where our patients can uh engage in the maintenance part uh using the group therapy model, and that is a lower cost. So we've been able to decrease the cost even more because we're doing a group. So that's one of the things we're seeing also in places like Vancouver, Roots to Thrive, is um uh you know, the kind of gold standard here uh by Pram Chrisgow, um, who is a um physician, also previous firefighter, who's really worked at bringing ketamine-assisted psychotherapy to the insurance system in Canada, and it's being covered there as group therapy. And so, really, um, you know, we're we're trying to make it work, we're integrating it with other modalities. So sound healing is another modality in which um you're really combining psychedelic therapy, especially for uh somatic, you know, conditions like pain um and um you know somatic activation, those can help. Uh, we're combining it with acupuncture, yoga. So we're we're investigating how to you know kind of expand the um the the offerings and how people can you know access them. So trying to increase access to it and using the ketamine as a tool and not the be all and end all. The you know, so um really um I think uh my clinic, um we've been now in um operation for two and a half years. We were really affected by the fires that occurred in Altadena. Um that really led to a dampening. Um, there's been a greater diversification of you know, ketamine providers as well. So I think we're learning from season to season, year to year, that this is a very dynamic space, you know. And there's we're not at the final um, you know, uh model of it. I think the models are going to evolve based on what it looks like. Uh, I think countries like Australia with universal health care, where the payment um, you know, system is uh and and the UK where um the payer system is uh much more streamlined, once you get buy-in, I think those countries will run ahead. Um and the countries that um don't have a good way of paying for it, uh, what'll happen is the people who are much more resourced and uh able to afford it will be able to access it as they are. Um, and then we're gonna have to cobble together, you know, there's all these different funds, there's um, you know, uh patient funds, people are coming up with different ideas of how to do it, but um I just I just think you know it is a symptom of the overall health care here in this country that if you happen to be on insurance, you're you're probably not gonna get um access to a lot of these integrative therapies. Um, it's gonna be delayed.

Dr Andrew Greenland: 54:04

Yeah. Um if I gave you a magic wand and you could fix any one thing in your work, whether it's clinical, operational, educational, what would that be?

Dr Saraiya Rahman: 54:16

Nobody's asked me this question. There's so much power in this magic wand. Oh um I think the breaking down of these silos, the breaking down of these informational silos um is is critical path, um, because depending on where you are in the silo and what your what information you're being fed, um you're either very scared of anything to do with psychedelics, or you're all the way out front. And and I think that speaks to just how divergent our population has become when it comes to you know um issues of control and openness, I would say. So I I think um magic wand, more community, more grassroots involvement, more funding uh given towards um, you know, uh places where people can go to um access a whole host of integrative therapies, not just psychedelic therapies, but relational therapy, somatic therapy, acupuncture, nutrition, exercise, just this awareness of of how um much there's a dearth of it and how access plays into it and uh into our our general well-being is is probably where I'll leave it. But thank you for asking that question.

Dr Andrew Greenland: 55:50

And finally, what's what's next for you in terms of the next six, 12 months? What are you any particular plans or projects or things you're working on or directions you're looking to take?

Dr Saraiya Rahman: 55:58

Absolutely, absolutely. With AyaCap, you know, we're really uh bringing together the experts in this field to talk more about it, to share their experiences. Uh, these are still experiences based in qualitative data, you know. Um, when we put together quantitative, um, you know, large-scale um trials, by the time we put together these trials, we've got to know what it is that we're treating. You know, if you have a mixed bag uh in your qual in your quantitative trial, you're gonna get mixed results. You know, if you're we're not discerning as we're going into the trial. So I feel like we're still in the discernment mode. We're still in the mode of we're still learning, you know. So I really think in this next year, stepping back, um, bringing this uh education and awareness through the couple of platforms we have. So we've got a uh podcast called the Two Curious MDs Podcast, where we talk to patients who are going through their healing as well as practitioners. Um, so we've had really wonderful, you know, uh it's been a great resource to give to people to be like, okay, how do you understand what's happening? Um, and uh really reaching people at where they're at. So uh are being much um, I think, smarter about how we reach out to the pockets of you know, the populations where we can really have a big bang for our buck. So um instead of looking at the psychedelic field as one big thing, we're kind of really focusing down on the populations for whom uh will will move the needle the most and have the best outcomes. And I think whenever you're dealing with something like as complicated as this, maybe that's that's uh that's uh the best way to do it is um that discernment piece. Um, and um personally speaking, um, you know, I completed the Berkeley uh psychedelic certification um this year. There's been a lot of um excitement about doing more group work, especially for healers, so other physicians, you know, this burnout epidemic in the physician and nursing population and frontline workers, um, you know, firefighters, police, uh, you know, law enforcement is huge. And this is one of the most uh I think innovative tools that we have to treat a lot of people really quickly. So I think reaching out and encouraging and and and really mentoring. I think that's the other piece as we educate, we're educating for professionalization. So mentoring the different people who are coming into this field. I mean, the neuroscientists, you know, there's a um a slew of of research happening in psychedelics, and so there's a there's a great number of young neuroscientists who are coming in, MD PhDs, um, who are really curious about how this is working and then the real life experience. So really being a translator, I think you know, that's that's that's uh where I'm at in the transitions, um putting more language to it. I I vow to do more writing this year is probably what comes forth.

Dr Andrew Greenland: 59:11

With that, Suria, thank you so much for joining me this afternoon. It's been a really fascinating conversation, such deep insights, lovely to hear about your journey, um, great information, great education. And we're not just talking about psychedelics, we've been really think talking about rethinking systems around the care of young people, families, and healing. So it's been such a fascinating conversation. I'm so grateful that you were able to join me.

Dr Saraiya Rahman: 59:34

Oh, thank you, Andrew. This was wonderful. Um, thank you for your wonderful questions.