Ketamine’s Culture In Psychiatry

Ketamine’s Culture In Psychiatry

Psychiatry (noun): the study and treatment of mental illness, emotional disturbance and abnormal behaviour

 

(This piece was originally commissioned for Reality Sandwhich)

 

Lithium, Zoloft, Prozac, Clozapine and Risperidone – modern medicine mainly views psychiatric conditions as organic diseases to be treated by molecular means. There is no doubt that popping pills saves lives. Countless people have been successfully treated by such methods, but given that these practices often come with some pretty weighty side effects, is it time for more sustainable and integrative solutions?

We know that everything is more than just the sum of its parts, and mental health is no different. The emotional, behavioural and cultural ties to states of mental distress are often treated as an adjunct to an organic foundation. Most pharmaceutical methods target levels of neurotransmitters in the brain.

However, the emergence of psychedelic approaches and their potential to shake up the medical model in its entirety, could be leading us towards a new paradigm that bridges the gaps between quantifiable Hippocratic (biochemical) and intangible Asclepian (emotional) dimensions [1].

We are creatures of our environments. It’s becoming increasingly clear that interdisciplinary approaches to health should not be limited to secular scientific departments or take an overly reductionist approach. A truly bio-psycho-social model also extends an arm into the humanities and the existential.

With the debate still open as to whether many psychiatric diagnoses are truly universal, or relative to the prevailing culture, psychedelics help us to better question what it really means to live the human experience, across a spectrum that does not respect the borders of the binary.

 

 

Clinical Culture

Culture influences our behaviours in diverse ways. It consists of the social ethics, principles or morals seen in society, and manifests as a way of living that encompasses beliefs, values, customs, language and traditions. This is important because it provides the lens necessary for understanding how mind, mental illness, abnormal behaviour are studied differently in varying cultural contexts.

Within the medical sphere, there are 3 main components to consider: the culture of the patient, the physician and the medical culture within which treatment is practiced. This can affect all of diagnosis, prognosis, treatment expectations, compliance, and presentation.

Studies show that placebo (mind) and drug (body) are not separate, psychological and physical processes, rather they are part of a highly complex interaction between consciousness, genetics, environment, and the types of substances being used. [2]

An illustrative example of this is ‘culture-bound’ syndromes – which often have a special relationship with their setting. Culture-bound syndromes show no objective biochemical or structural alterations of organs or functions, but are a mix of behavioural and somatic symptoms. Examples include Hwabyeong and Ghost Sickness.

Hwabyeong is a Korean somatization disorder (mental illness) that occurs when people are unable to confront their anger as a result of conditions which they perceive to be unfair. It’s also known as ‘depression anger illness’ with symptoms including palpitations, anorexia, insomnia and being easily agitated.

Ghost Sickness is a term used among the Navajo of North America to describe a preoccupation with the deceased. This manifests as loss of appetite, suffocation, recurring nightmares, and anxiety; culturally it may be attributed to ghosts or witches.

Alternative views have an effect on treatment. In Creek culture, purification rituals for mourning focus on moving an energy called ‘Ibofanga’ which is supposedly obstructed between mind, body and spirit – causing prolonged emotional and physical drain.

There are a variety of mainstream psychological theories about ‘ghosts’ and ‘spirits’ – emotional energies which may be viewed as being directly or indirectly related to the cause of an event, accident or illness. What this shows is that culture is the container framing the entire experience of mental health for both the patient and clinician – moulding the interpretations of thoughts, emotions and behaviours that rise to the level of symptoms.

Culture and language equally set the standards for how we define abnormality – as a set of socially acceptable norms about expected ways of behaving according to the majority. A good example of the disconnect this can create is that of Schizophrenia, which may be considered a culture-bound illness.

Whereas Western societies view Schizophrenia as a medical issue, there are still many Eastern cultures that treat this as a ‘spiritual’ or ‘supernatural’ phenomenon. In an age where we are seeing the demonstratable benefits of spiritual practices such as meditation on mental health, to simply disregard such a lens as primitive would clearly be a mistake.

 

 

Special K

Enter the integrative psychedelic lens. Clinically, trials for dosing and administration in the psychedelic sphere are still limited and require personalisation. However, there is already promising data showing significant improvements in mental health issues such as depression and anxiety using ketamine, with effects lasting for months after the first dose [3].

Ketamine has been described as a breakthrough in psychiatric medicine because its action on the neurotransmitter system is entirely distinct from the pathways which conventional SSRIs act on using serotonin, norepinephrine and dopamine. It works on the glutamate level – a crucial excitatory neurotransmitter with a role in neurodevelopment, memory, and nerve growth function.

It has been found that depressed patients have elevated levels of glutamate in their blood and cerebrospinal fluid compared to healthy controls: changes which can be reversed. Under ketamine therapy, a patient receives 1-5 infusions, calibrated according to their receptivity [4].

Despite it being inexpensive compared to traditional methods, the side effect of psychosis is something that many clinicians and patients find difficult to manage. However, there is reason to suspect that this aspect is not necessarily something to be rejected.

While many practitioners see the glutamate hypothesis as a reason to isolate ketamine’s effects, the role of the emergent, transpersonal or mystical experience seems to pull its own weight. ‘No study to date, has demonstrated that, absent some degree of psycho-activity, there is an antidepressant effect [5].

A holistic systems science of the nervous system therefore, is inclusive of cognition and consciousness; replacing the monolithic concept of psyche with an integrated systems operation of information, mind, self and life [6].

 

 

A Shamanic Science

The off-label use of ketamine for depression in India is a prime case study for looking at the implications of combining medical, historical, existential and cultural models in practice.

It is in the home of the Taj Mahal that mental health and the psyche have been an area of exploration for centuries. This dates back to the Vedic period, where the human mind is described in relation to consciousness and the dynamics of human behaviour. In other words, ‘abnormalities’ were often seen to be associated with beneficial psychic changes [6].

While Ketamine is much more likely to be leveraged here, psychedelics are not considered standalone treatments. Delivery takes a more holistic approach and the process of change may be allowed to run free within an existential context described as the ‘guru-chela relationship’ [7]. This relationship is similar to the container provided by a psychotherapist.

Taken literally, the word ‘dissociative’ means ‘detached from reality’, occasionally leading to out of body phenomena, dream-like states or trances. These are experiences that patients may find hard to make sense of on their own, and an unstructured or chaotic approach to management has the potential to re-enforce existing trauma.

The reason talk therapy is additive to this process is because, as high neuroplasticity primes the brain for change, psychological guidance ensures that any novel wiring is structurally engineered to lead to positive destinations. The culture of the guide and participant therefore need to be aligned for the best outcome to be reached.

Spiritual experiences can occasionally be organic, and are not always instigated by psychedelic use. The term ‘spiritual emergence’ was first coined by psychiatrist Stanislav Grof, because such experiences often presented a chance to ‘emerge’ with a higher level of spiritual and psychological awareness – if correctly supported, instead of being suppressed. [8]

Ketamine is also not a panacea and comes with its own bag of risks. However, this need must be weighed up against the potential bio-psycho-social harms caused by untreated mental health issues like chronic depression.

Yet to avoid becoming just another thing on the conveyer belt of routinised care feeding a ‘magic pill’ approach, the ceremonial history of psychedelic medicine-use and its focus on environment and cultural context must be brought to the fore.

Such experiences have the potential to loosen up our usual filters and judgments, and open our hearts to deeper and more authentic ways of relating to both others and ourselves. It is becoming increasingly evident that it is one element to be clinically cured, and another to be holistically healed.

 

 

References

[1] Morris, David (August 2007) Un-forgetting Asclepius: an erotics of illness. Retrieved from https://muse.jhu.edu/article/225315

[2] Wager, Tor (July 2015) The neuroscience of placebo effects: connecting context, learning and health. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6013051/

[3] Mandal, Suprio (September 2019) Efficacy of ketamine therapy in the treatment of depression. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767816/

[4] Sanacora, Gerard (January 2012) Towards a glutamate hypothesis of depression. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3205453/

[5] Dore, Jennifer (Feb 15, 2019) Ketamine Assisted Psychotherapy (KAP): Patient Demographics, Clinical Data and Outcomes in Three Large Practices Administering Ketamine with Psychotherapy. Retrieved from https://www.tandfonline.com/doi/full/10.1080/02791072.2019.1587556

[6] Mukhopadhyay, AK (November 2015) Neural Fabrics of The Mind: Systems Neuroscience, Systems psychology and consciousness. Retrieved from https://www.jscimedcentral.com/Psychiatry/psychiatry-3-1049.pdf

[7] Neki, JS (1973) Guru-chela relationship: the possibility of a therapeutic paradigm. Retrieved from https://doi.apa.org/record/2013-41581-009?doi=1

[8] Holotropic Association (August 2020) Retrieved from https://holotropic-association.eu/what-is-spiritual-emergency

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