Hello, friends! Super happy to bring you this question and answer episode. You’ll have to excuse my congestion. The plague continues in the Duff household. If you’d like to get a 4th bonus question, check out my patreon.
Thank you for your eagerness to spread the word about ketamine as a potentially life-saving solution to the conundrum of treatment-resistant depression. I appreciated the interview with Dr. Mandel but am a bit wary because his pitch was for ketamine as well as his clinic, which is certainly understandable, as he is offering help and a for-profit service. If I lived in Los Angeles, I might just high tail it over to him, but I see that there are other clinics around the country, including one run out of Columbia University Medical Center in New York, near my office.
I guess my question to you, as someone invested in seeing people get help in this possibly revolutionary way, is whether, given the delicate nature of such a treatment (the prospect of cognitive side effects especially gives me pause), I should 1- flock to the person profiled in your podcast, who may indeed be the class of the field, does have excellent Yelp reviews and other distinctions (first practice in the country, only one with a certain organization’s recognition), but who is also one practitioner among many and one as keen on selling his practice as he is on selling ketamine itself, 2- save myself the cost of traveling and spending two weeks in LA for the initial course of infusions and try the one at the ostensibly reputable Columbia Med clinic, at the risk of not having as good an experience as I might at Dr. Mandel’s practice, and having spent money and placed my mental health at risk. I suppose this will be a risk, whatever clinic I choose, especially with a treatment that is so new and that works by altering brain chemistry.
What is your sense of the potential for things going wrong cognitively and the long-term impact (which it’s probably too early to know much about) of sustained use? Also, is this drug being hailed as so miraculous because the initial course of infusions suffices to help the patient overcome something (in my case I’m grappling with healing from developmental, “small t” trauma over years) and then does not require regular use, with the attendant risks, over time?
First off – this is not medical advice. Talk to your doctor about this. Therefore, I’m just going to provide observations.
One of the most amazing things about the use of Ketamine infusions for TRD is how quickly it works. In many cases, a single infusion is sufficient to bring someone from suicidal to hopeful. That is a massive thing. When you are considering any potentials cons of the treatment, you must weigh it against that. This is something that could potentially immediately save someone’s life. You can’t have side effects if you are dead.
Now when it comes to maintaining the antidepressant effect of Ketamine, it seems that, for some people, repeated infusions after the initial treatments are necessary. But you also need to remember that Ketamine shouldn’t be your only treatment. Therapy therapy therapy. Ideally, Ketamine gives you the relief and the hope that you need to work through the stickiest parts of your treatment-resistant mental illness and affords you the clarity to make some of the changes that need to happen in therapy to keep you going.
The side effects of Ketamine
When it comes to the side effects, most of them are mild. Feeling out of it or woozy, grogginess, dizziness, or mild nausea. You also can feel dissociated, which many people list as a negative side effect. However, as we discussed in the podcast episode, that may actually be one of the things that makes Ketamine treatment effective in treating trauma. The dissociation combined with the fact that Ketamine is affecting Glutamate seems to allow people to work through trauma in a way that feels safer, but is still active. So that “side effect” may actually be the therapeutic effect in some cases. Now regarding the more serious side effects, there are numerous rare ones. This is the case for almost any medication. Rare means rare though. You are very unlikely to have them. I’m not going to go into all of them here, but you can look them up.
The cognitive one you talked about is concerning though. Essentially it sounds like you are worried that this may affect your memory or something like that. I had not heard of this potential side effect, so I looked into the research a bit. I think what’s going on here is a little bit of overextension. One thing that you need to realize is that research studies, especially summaries and meta-analyses, are not perfect. There is a problematic thing that happens where someone makes a claim and then cites another study to back it up, but when you look at that other study, it doesn’t exactly back up what they are implying. In this case, I found a paper that was exploring and summarizing the current safety of Ketamine called Controversies of the Effect of Ketamine on cognition by Zhang and Ho, 2016 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809869/. They make the statement that “although studies have shown that serial infusions of ketamine in the short term (of 4 weeks) does not result in cognitive impairments, other studies have demonstrated that the administration of ketamine chronically would lead to memory impairments.” In support of that statement, they cite a study called Long-Term Heavy Ketamine Use is Associated with Spatial Memory Impairment and Altered Hippocampal Activation. by Morgan and colleagues – https://www.ncbi.nlm.nih.gov/pubmed/25538631.
The problem is the article they are referencing isn’t talking about using Ketamine for depression. They are looking at chronic recreational use of Ketamine as a party drug. The dose that is used when doing a Ketamine infusion for depression is lower than what you would use for anesthesia in surgery. When abusing the drug as a recreational substance, you use WAY more of it than you do for the therapeutic purpose we are talking about here. So their claim that chronic administration of Ketamine would lead to memory impairment is just straight up unfounded. Chronic high dose recreational use might lead to spatial memory impairment though, so don’t be dumb.
Finding a provider
In terms of whether to go with your local clinic or make the trip out to LA, I would say the best course would be to set up a consultation at your local place and see how they strike you. I agree that Dr. Mandel is a skilled practitioner and has a great program, but he doesn’t have the ONLY one. Since you listened to the podcast, you have a bit of a point of comparison though. The follow-up episode that I did with Jamie about her experiences with Ketamine infusions was from a different clinical altogether and she had a great experience. If you feel like they are approaching things the right way and you get a good feel from your local clinic, then go there. Your positive expectations will also play a role in how well the treatment works.
But overall, I think you are right to be cautious, but could be overestimating the risk both of ketamine itself and the risk of choosing the wrong place. So take the information that I’ve provided here, mull it over, continue to do your own research, then talk to your doctor and make a decision.
Watch out for a follow up interview with Dr. Mandel coming up on a future episode where we talk more about ketamine, particularly esketamine.
I love my mom but her hoarding is tearing apart our family and I don’t know how to help her.
For as long as I can remember my mom has had an excessive amount of stuff that lies around and is never touched again. It started out with just the basement and random areas throughout the house being completely filled with “storage” items that are never touched again. But I am 22 years old now and the accumulation of useless stuff has tremendously increased over the years to the point where just about every room is being used to store junk. The garage, basement, closets, multiple bedrooms (including their own), and just any free space in the house is barely navigable due to the piles and piles of things stacked to the ceilings.
My dad, my older sister and I have noticed the collection of things getting worse each year and it has always caused a lot of tension and resentment towards my mom because anytime we bring up the issue, touch her stuff, or try to offer help with cleaning it up, she has a meltdown where she cries and screams and makes it seem like we are intentionally trying to hurt her feelings.
We cannot get rid of ANYTHING.
I’ve tried to approach the situation from different angles to see if I could get a more positive and cooperative reaction from her but it always ends in a meltdown and then I feel terrible for making my mom cry. I think she may have some form of OCD but she has never seen a doctor about it and if I even mentioned something like that to her I feel like she would lose it.
Its suffocating to live in this type of environment and the inability to address the situation is not only extremely frustrating, but is damaging our relationship as a family. We love her and want to help her but have no idea how to go about doing that without making her so upset.
Do you have any advice on how to deal with this?
Thank you for writing this in. I don’t think that I have discussed hoarding on here, so I’m happy for the opportunity.
Hoarding is really really hard. And anyone that has lived with someone that has a legitimate hoarding disorder can probably see a lot of their own experiences in what you have written here. By nature, hoarding disorders are very difficult because people that hoard are very resistant to change and very defensive of their hoarding. It can also be dangerous because things like walking areas, food areas, bathrooms, and other areas become so cluttered that they are not usable. I have seen a lot of hoarding in my professional work during house calls and often there are concerns about fire hazards or methods of escape in emergency situations. Lastly, hoarding also causes disruption in family relationships and the person’s mood.
It’s very interesting that you said your mother probably has some form of OCD because until this most recent edition of the DSM, hoarding was classified as a type of obsessive-compulsive disorder. There are many similarities. However, due to some differences like the fact that hoarding is often less ritualistic and there are more positive associations to keeping items rather than intrusive negative thoughts, it has been broken out into its own disorder, but within the OCD and related disorders category.
Here are the current DSM criteria:
- persistent difficulty discarding or parting with possessions regardless of their actual value
- difficulty is due to perceived need to save items and to distress associated with discarding them
- difficulty discarding possessions results in accumulation of possessions that congest and clutter active living areas and substantially compromises their use. If living areas are uncluttered, it’s only because of the intervention of third parties
- Hoarding causes significant distress, impairment in social, occupational, or other functioning
- Hoarding not attributable to a medical condition
- Hoarding not better explained by other mental disorders.
There are a few important things to consider here. First, forced cleaning doesn’t typically work. It gets the house clean, which is sometimes necessary. In cases where a house has been tagged as unsafe by the city, this may need to happen regardless. But it won’t change the behavior moving forward. Most people that have their houses uncluttered and cleaned against their will go right back to the hoarding behavior. The other important thing to consider is that while it is considered a disorder in it’s own right, it’s often helpful to think of the hoarding as a symptom of other issues. It is very often the case that there are other mental health issues such as anxiety and trauma that are feeding the behavior. You will also want to consider the person’s background. Is there a reason that they learned early on to adopt a scarcity mindset and hold onto things just in case? Perhaps they grew up in poverty or in an immigrant family?
Unfortunately, as you have experienced, it is really hard to intervene with someone who has hoarding disorder. It is common that they lack insight into the issue and take things very personally when you suggest or try to get rid of things. In terms of what makes a difference, often the individual will need to receive psychological intervention. CBT is one of the most common forms of treatment. In CBT, the therapist will work to help them challenge their beliefs related to acquisition. In other words, trying to stop the behavior before the stuff is accumulated and avoiding the primary problem of accumulation.
The person with the disorder is inevitably going to have some unique ways of thinking about items that get them into trouble. This could be used as a tool, this would make a good gift for someone, this might be worth money later on, etc. But these intentions are almost never followed through with. So CBT can help the person recognize and challenge those thoughts. It can also help the person build awareness of their behaviors or habits that lead to hoarding. Like going to garage sales, aimlessly walking through target, spending time on FB market place, or watching infomercials etc.
You are going to want to make sure it is someone that has experience in working with hoarding disorder because the approach is a bit different than typical anxiety treatment, although there may be a lot of straight-up anxiety coping strategies, and even diving into the past to see where these beliefs and behaviors came from. But a skilled provider is also going to recognize that there is sort of an information processing component to the disorder. That it’s hard for the person to organize and evaluate the importance (or lack thereof) of items. They can help build systems and use exercises to help the person gain skills that will help the decluttering process. Therapy for hoarding disorder is best done in the home of the person. However, it can sometimes be hard to find therapists or psychologists that are willing to do that. Do lots of research. Another option to bridge the gap could be online therapy. You can find some info and my advice on finding a therapist at duffthepsych.com/findatherapist/.
Family involvement is essential
The other aspect that is essential to treating hoarding disorder is family involvement. Again, you can’t just go and force clean the whole place and effect change. But they may need to be confronted by the family as a whole in order to urge them to get therapy and acknowledge that their behavior is hurting other people. I don’t want to underestimate how tough this can be. But it’s important to not pretend like it isn’t an issue just to avoid upsetting her. As a family, you can also work to change aspects of the environment to cut the behavior off before it happens. Things that I mentioned before like not turning on the shopping channel, limiting the use of credit cards, not facilitating trips to garage sales or stores, canceling subscriptions etc. You ARE going to get push backs and it WILL be painful to make changes. That’s one of the reasons that it goes untreated so often.
I think the first step for you guys is trying to find a way to get through to her that this can’t go on and is having an impact on herself and on others. This looks different for everyone, but it could be a sit-down intervention or someone that she trusts implicitly that sits her down. Sometimes a rock bottom or wake up call is also necessary, such as the house getting red-tagged or the person becoming distressed enough to be hospitalized. My hope is that it doesn’t go that far, but in order for change to occur there may need to be some pain and inconvenience first.
Sorry for not sugar coating it, but hoarding is a hard one. I do hope that these comments have been helpful to you though and give you some ideas for moving forward.
Hello, I started listening to your podcast about a month ago and am loving it. You have a great way of communicating and I can sense your compassion. I’m a 42 year old male from Utah. I’ve battled depression and anxiety since I was a teenager. And I’ve been through a lot of therapy. My main question I wanted to ask is what are your thoughts on CBT and ACT (Acceptance and Commitment therapy). I’ve done a lot of CBT and it helped, but when I went to see a psychologist for counseling, here introduced me to ACT. For me, ACT made more sense and put things into perspective, leaving me the “commitment” or responsibility to follow through for the therapy to work. I don’t hear a lot about ACT, and wanted your ideas on it. One of the biggest helps to me has been a book written by Dr. Russ Harris entitled, “The Happiness Trap”. This seemed to speak directly to me and has helped more than any other form of therapy. The book is also a no BS approach, stating life isn’t going to be all rainbows and Unicorn farts. Anyway, I know you can’t reading to everyone but thought I’d try. Thanks for what you’ve given the world. The power to people to find resources and education so they can help themselves
Great question! You definitely don’t hear about ACT as much as CBT these days. In my opinion, they really go hand in hand and I would consider some of my approach to be influenced by ACT, even though a lot of the exercises that I do are straight up CBT.
CBT v ACT
CBT and ACT are both theoretical frameworks for therapy. This means that they have a theory about why people develop problems and how people change, which guides the techniques a therapist uses to try to help out. CBT is very much focused on thoughts, feelings, and behaviors. Namely, how your thoughts, interpretations, and assumptions influence the way that you feel, which in turn causes you to behave a certain way. The theory behind ACT is that it often doesn’t work to try to suppress and control negative emotions because the act of pushing them away leads to more distress. Instead, you are encouraged to engage in mindfulness, pay attention to your personal values, and commit to action.
If you are a student in my online course, some of this might sound familiar. We talk about exercises to find your values because those are the things that fuel you and help to clarify the decisions you can make. If you are able to have the compass of your values to guide you, it is easier to be less influenced by the immediate suffering that you might feel. Mindfulness is also, in my opinion, a vital component for most people’s mental health journey. I’ve harped on about mindfulness in many forms, but it is essentially the practice of becoming less judgmental about your own experience. Rather than labeling everything that you think or feel as bad or good, you are trying to simply acknowledge what’s there and let it be. Rather than running away or fighting back directly, sometimes it makes sense to just acknowledge what intrusive thoughts or feelings are there, and then just move forward with what you would like to focus on (possibly inspired by your values).
There is a metaphor of the annoying party guest that is often used in ACT therapy:
Imagine you’re having a party and you’ve invited a bunch of friends over. It’s going well and you’re having fun when suddenly somebody comes in who you didn’t invite – John. You didn’t invite John…in fact, you hate John. You really don’t like hanging out with him. He comes in and starts acting up and bugging all your other guests and you really don’t like it and start to get stressed about it. So instead of paying attention to your party, you get worried about John being there, to the point that you end up asking him to leave. You get back to the party and all seems good! Then suddenly, John comes in again. You have it out with again and ask him to leave. This ends up happening a few times…you get more and more wound up and stressed. But then you realize people are starting to leave…you’re missing you’re own party because of getting so worked up about John. You were so focused on him that you lost sight of your awesome party!
It’s a great metaphor as it demonstrates what can happen when you directly push back on some of these things and give them too much recognition. The other way of going about dealing with the annoying party guess is to just let them be there. It’s not ideal and you don’t want John there, but at the same time, he can be there and not be the whole focal point of the party. You can focus on other guests and just let him be in the background. In doing so you can get backing to enjoying the party and you might even notice some positive things about John. So in ACT you’re encouraged to not always push back directly against the thing, but instead acknowledge that it’s there and focus on what you want to focus on. Allowing it to be in the background lets it become less of an issue. This YouTube video also demonstrates the metaphor in action. But a lot of ACT is about avoiding denial. Being real about what the situation is. You can’t ignore or pretend that things aren’t the way they are. You have to accept what is there and make a commitment to the actions that will make the situation better for you.
Overall, I really like ACT as an approach. I don’t think that it is at odds with CBT in any way. I will say that I’m not a full-fledged ACT practitioner, but as I said, I integrate elements of it into my practice the same way that I integrate aspects of psychodynamic therapy. If you’ve already had a lot of CBT in the past, I think you are in a great position to work with an ACT practitioner. You can use the skills from CBT as part of those committed actions and the other pieces of mindfulness, values, etc is like extra fuel that will give you the stability and push you need.
Bonus Patreon question:
I was hoping you’d have some advice you could discuss anxiety and closed spaces. I don’t consider myself claustrophobic but lately I’ve noticed when my anxiety is getting the best of me that closed spaces can really send me into a full panic attack. I’m talking things such as the kitchen getting cluttered and not having enough counter space to set things down suddenly feels like I’m locked in a straight jacket. If my dog is standing is in the hallway and I don’t have room to walk around I feel like the walls suddenly close in and I’m trapped. This causes me to want to flee, and sometimes I do. This is a very new symptom to my anxiety and I’m not sure what to do about it. I don’t know if others experience this kind of thing or if I’m alone in this feeling. Thank you.
If you would like to hear my advice on this week’s bonus question, check out my patreon!
This episode of Hardcore Self Help is sponsored by BetterHelp.
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