A Trauma Expert's View on Psychedelic Medicine with Steven Berkowitz, MD

Journal of Clinical Psychiatry

Publisher of peer-reviewed research discussed in this episode.

Dr. Steven Berkowitz – LinkedIn

https://www.linkedin.com/in/stevenberkowitz/

CU Anschutz START Center

https://www.cuanschutz.edu/home

Dr. Berkowitz’s family-centered, lifespan trauma research and treatment center.

Child and Family Traumatic Stress Intervention (CFTSI)

https://www.nctsn.org/interventions/child-and-family-traumatic-stress-intervention

Brief early intervention model for children and caregivers discussed in this episode.

Steven Berkowitz, MD, is Professor of Psychiatry at the University of Colorado School of Medicine and Director of the Stress, Trauma, and Adversity Research and Treatment (START) Center at CU Anschutz. He previously spent nearly a decade at Penn directing the Center for Youth and Family Traumatic Stress Recovery and more than a decade at the Yale Child Study Center, where he developed CFTSI, a model designed to intervene in the days and weeks following a traumatic event.

Ben Everett, PhD, is the creator and host of The JCP Podcast, a series that brings together leading voices in psychiatry to explore the latest research and its clinical implications. Everett earned his PhD in Biochemistry with an emphasis in Neuroscience from the University of Tennessee Health Science Center. Over a two-decade career spanning academia, publishing, and the pharmaceutical industry, he has helped launch more than a dozen new treatments across psychiatry, neurology, and cardiometabolic medicine. His current work focuses on translating complex scientific advances into accessible, evidence-based insights that inform clinical practice and foster meaningful dialogue among mental health professionals.

This transcript has been auto-generated and may contain errors. Please refer to the original audio recording for full accuracy.

00:00 – Introducing Dr. Steven Berkowitz

Dr. Ben Everett: Hello, and welcome to the “JCP Podcast.” I’m your host, Dr. Ben Everett. On the podcast, we sit down with leading clinicians, researchers, and educators to explore the science shaping mental health care today with a focus on the insights that matter most in clinical practice.

Today I’m joined by Dr. Steven Berkowitz, a psychiatrist and researcher whose career is focused on one of the most difficult problems in child and adolescent mental health, trauma. Dr. Berkowitz is Professor of Psychiatry at the University of Colorado School of Medicine and Director of the Stress, Trauma, and Adversity Research and Treatment, or START center at CU Anschutz. Before coming to Colorado, he spent nearly a decade at Penn directing the Center for Youth and Family Traumatic Stress Recovery, and more than a decade before that at the Yale Child Study Center. At Yale, he developed the Child and Family Traumatic Stress Inventory, or CFTSI, a model designed to intervene in the days and weeks following a traumatic event before PTSD becomes established. Talk about why that early window may be so important, what makes trauma different in children and adolescents, and how the field’s understanding of developmental and chronic trauma has evolved. Also get into some of the harder questions around diagnoses, including the debate over whether conventional PTSD adequately captures the effects of chronic childhood adversity, as well as trauma in autistic youth and adolescents dealing with other psychiatric comorbidities. Is the first of two conversations with Dr. Berkowitz. In this episode, we’re staying focused on his career and expertise in pediatric and adolescent trauma. In the second episode, we’ll shift gears and look at his work with psychedelic research at CU. With that, Dr. Berkowitz, welcome to the podcast.

Dr. Steven Berkowitz: Why, thank you very much. It’s a pleasure to be here.

01:30 – Forensic Expert Work and Delayed-Onset PTSD

Dr. Ben Everett: All right. Look, we got a lot we’re gonna talk about today. I’m really excited for this episode. But I wanna start with something that your CV doesn’t really capture. Since 2010, you’ve also worked as a consultant for the Federal Defenders Association, where you provide psychiatric expertise in death penalty cases.

You’ve been qualified as an expert witness for a bunch of states, like nine, 10 states now. I’m curious how you ended up doing that kind of work and, has it changed the way you think about trauma or your, psychiatric clinical practice at all?

Dr. Steven Berkowitz: All right that’s a long story, so I’ll try to keep it short. When I moved to Philadelphia to University of Pennsylvania I was asked to write a chapter in a textbook, forensic textbook, about evaluating child abuse, maltreatment, early childhood trauma as a mitigating factor in death penalty cases. And so I did that and then I gave a talk at the Bar Association of Philadelphia about it at their request. And then about, don’t know, a week or 10 days later were the Haiti earthquakes. And so I was on the local NPR station talking about that. And I get a call the next day from an attorney said he went to my lecture, he heard me on NPR, and he had never heard anybody talk about trauma in this developmental way. And that he represented a number of clergy abuse cases, and he would want me to be the expert.

Dr. Ben Everett: Nice.

Dr. Steven Berkowitz: I just couldn’t say no,

Dr. Ben Everett: Yeah.

Dr. Steven Berkowitz: And so that’s how this all started. And I never thought I’d be doing that. What I will say is I think I have made more impact on policy th- these civil cases than I have in all my policy work over the years. Clergy abuse, Boy Scouts, other such things that really did change how they operate. We had some– actually had some bills in the consent decree in Chicago. There’s been… I-it’s just been fascinating. And I take– I actually take these cases ’cause I think they can change how, how the protocols and organizations operate. One of the things that it did for me to recognize importance of a lifespan approach. That so many people don’t come forward for a range of reasons and that sometimes they’re, managing well, and then something happens, and they fall apart. So one of the things that, I definitely experienced was, this idea of the, delayed onset PTSD. A lot of that, particularly in the clergy abuse cases. And so that really, I think, ha– influenced how I think about the program I developed here, which is lifespan. Primarily because I believe that and I-I think the data supports it, that you have to be able to treat parents in order for kids to get better. In our program, I’d say fifty percent of the adults are parents. The others are, come through. We also have a, a intensive outpatient program that we developed for adults. All of them had child maltreatment. Just, the other thing I will say that, with with particularly, again, with the sort of early clergy abuse cases was how much dissociation I was seeing in this group of people.

05:00 – Prevention and the Neurobiology of Childhood Trauma

Dr. Ben Everett: Really interesting. I tell you, that really resonates. I know just in my brief stint in doing trauma research it came up over and over again in the adults we were treating with MDMA-AT was even if they didn’t know it or didn’t recall it when they were in the dosing sessions and then when they were doing their reconciliation therapy sessions after the dosing was, I, I had no idea that I had, this, this issue lingering from childhood.

And, we’re learning more and more about the neurobiology now and the developmental course of the neurobiology, but it really fits with why some people might be more susceptible to, to PTSD in a subsequent ev- event. You know what, fully one-third, just over one-third of, our men and women that served in the 20-year wars qualified for a diagnosis of PTSD.

That doesn’t mean that over one-third actually received that diagnosis, so a different thing. All right. Look let’s get into your own kind of career development. You were at Yale at the Child Study Center for over a decade, and then as you mentioned at Penn, directing their Center for Youth and Family Traumatic Stress and Recovery.

Now you’ve been at CU for nearly a decade. What drew you really to focus specifically on childhood trauma and adolescent trauma, rather than adults? Was it something about working with the pediatric population that really drew you in?

Dr. Steven Berkowitz: So I’ve always loved working with kids. I was, camp counselor. I ran a couple camps. And I just– I enjoy kids. I enjoy the imagination. So I was always thinking about working with kids. What really made it happen for me was when I was a resident I did my third year outpatient at the v– local VA, West Haven VA connected to Yale. And I had a peripheral involvement in a study that was trying to evaluate what was the, predictors of PTSD in combat vets, and the answer was child abuse. So I’ve always thought about working with kids as preventative that if we can get them to be, back on a regular developmental trajectory, they’re gonna do better as adults than adolescents. And so to me that’s what we need to do and what we should be doing. I really believe in prevention, and I think unfortunately, given our current set of circumstances, we’re never gonna treat our way out of what is a mental health crisis in this country. We’re chasing our tails, and so I believe focusing on pr– prevention is really our best approach and nothing like– there’s nothing like trauma to demonstrate that, right? My soapbox, right? We know seventy percent of people in a- adults in outpatient care have a history of child trauma. So that, that’s who we’re seeing. I– psychiatry as it’s become, more open to thinking about this, it’s a tra– stress and trauma field by and large. With, people who have neuropsychiatric diagnoses, many of them over sixty percent have a history of some childhood trauma.

Dr. Ben Everett: Yeah. I tell you, that’s why so many of these people end up joining the military at 18 out of high school. It’s, for some it’s certainly a call to service or something else, but a lot of people are just like, “Man, I gotta get out of this environment. I need some structure. I need a paycheck.”

And it really is pretty, pretty terrible. I do think the field is doing better. When I had Jennifer Ballard on from NIH a couple of weeks ago, and she’s done a lot of the screening tools that are used. And I had my annual visit the other day with my doctor. I had to do a PHQ-9 online before, so I think that’s great.

That’s pretty new with this practice. I’ve been seeing the guy– we, we were fraternity brothers in college he’s– since he finished residency, he’s been my doctor. And in the pediatric setting or in the emergency room department setting, every kid that they see, they have nurses doing these really quick, three to five question surveys, because we’re just trying to capture some of these people before it escalates.

So I think that’s a step in the right direction. But yeah, I couldn’t agree more. We’ve really got some problems with child trauma. So I mentioned the neurobiology and how it can impact adult diagnosis of PTSD. Let– can you give us just a snapshot of what we’ve learned about the neurobiology and maybe how childhood trauma can predispose someone to subsequent full-blown PTSD diagnosis after 18?

Dr. Steven Berkowitz: Yes. Some of the best work in that area has been done by Marty Teicher, who’s at Harvard, who did an enormous amount of looking at brain imaging studies and trying to consolidate them. I, I think what we know and, is that early childhood maltreatment trauma really sculpts the brain to what is a stressful, overwhelming environment. And so we see, focus on on areas of the brain that are reactive, that threat sensors and a pruning down of the more cognitive more judgment areas of the brain, of the prefrontal cortex and whatnot, because that is preparing you, for a harsh environment. Fails, of course when you quote enter civilization like school or things like that. These kids are already vulnerable to s- to threat sensor. They see threat everywhere, and they react. And so when they encounter, a criterion event, they’re much more prone to survival mode.

And, PTSD in many ways is an overreaction to create survival. And so this is all evolutionary. It’s survival-oriented and directed, it makes all the sense when you think about it, that’s what happens. The problem, of course, is that it’s maladaptive after the moment, after that time.

11:00 – Developing the CFTSI Early Intervention Model

Dr. Ben Everett: Yeah, the whole conditioned response versus unconditioned response and all that stuff.

All right let’s get back to early career at Yale. You helped develop the Child and Family Traumatic Stress Inventory, or CFTSI, which has become a very widely used model. Can you walk us through maybe the study development and, where it is now and how widely it’s been adapted?

Dr. Steven Berkowitz: Really grew out of what was the Child Development Community Policing Program which may arguably could have been the first co-responder program in the country. And it was focused on kids and families who were victimized by crime. With the idea of early intervention, getting there, working with police to support them would interrupt the pathway to psychiatric issues related to stress and trauma. One of the things that we were really, trying to f-figure out is what was a short intervention that would be helpful to these kids and families? So CFTSI really grew out of that. The, the model is really pretty simple. We take s- standard screening scales, and we ask the child and the caregiver or caregivers basically to comp… to fill out these scales, and then we compare. And we have a discussion about, “Oh, you’re you may be, minimizing that. We’re seeing this. What do you think?” And, we provide s- basic skills, the, the classic ones that everybody knows about. And we do that iteratively over t- over about five or six sessions. We also, really do evaluate the caregiver to make sure they’re capable, ’cause many of them are pretty traumatized themselves. And, in our first and only RCT, I wish there was funding for more RCTs we reduced PTSD by sixty-three percent which is pretty impressive. And, one of the things in later studies was that reduction in symptomatology correlated with on the scales between the, the parents and the child so this is a, w- it’s focused on social support, but you have to be able to communicate to get that. So they’re getting familial support, and we know that, s- familial support and efficacy are the two most important, things to focus on.

E-efficacy in kids is easy, right? They’re in school. So we can promote, them going to school and doing better in school and demonstrating that’s effective. Where it’s really taken off, interesting enough, is in child advocacy centers. They have the setting, and they, they’re required to provide treatment. And so at last count, I think we’re in about 100, 120 child advocacy centers around the country. I have had very minimal ability to do the work out of EDs. Complex systems not really prepared for that. CACs are the perfect, kind of place. They see kids early. They have a setting.

We’re supportive, lots of support for kids. They do treatment. So that’s really been where we’re seeing the best uptake.

Dr. Ben Everett: That’s great. And despite only one RCT, which, hey, if it’s enough. You had a robust, what? Sixty-three percent reduction in PTSD. That’s very robust, especially with PTSD, where it’s very difficult to get people to remit or remission. Yeah, I think that’s great. And 120 centers is great.

I’m sure you’d like to see it be more, but, it’s a good place to be right now, and, anything we can do to try and grow that number would be great.

Dr. Steven Berkowitz: No complaints. I would like EDs adopted. I think there’s a, th- that’s an opportunity that we should be really thinking about.

Dr. Ben Everett: Yeah. And it goes back to, if, a kid might not be there for trauma per se that, it could be, okay, we don’t have insurance. They’ve got a real high fever or broken arm riding a bike or whatever. But yeah, if you can have a nurse ask three to five quick questions, identify somebody.

But yeah, it can be a problem in the ED. It’s okay, we think you need a psych consult, or we want a social worker to see you. Do you have those resources there? And then because so much– so often ED, the, the model is just we’re gonna patch you up well enough and tell you to follow up with this person, your primary or this specialist or whatever.

And yeah, we know that there’s a big, a, a big pause in that, and a lot of people don’t get the follow-up. They think they feel better now.

Dr. Steven Berkowitz: So.

16:00 – Developmental Trauma, Complex PTSD, and the Limits of the DSM

Dr. Ben Everett: There’s been a long-running debate in the field about whether, chronic Complex childhood trauma is adequately captured by standard PTSD diagnoses or whether it should have its own diagnostic category.

Bessel van der Kolk and others published a developmental trauma disorder diagnosis in DSM-5. It was not widely adopted through the ICD 10 and 11 process, which is a whole disconnect between DSM-5 and actual diagnosis and billing and all that sort of stuff. And then this idea of complex PTSD is in and of itself controversial, right?

It’s not in DSM-5. Some people say, “Oh, okay, PTSD can just get complex. We don’t need a separate disorder,” diagnosis. Where do you sit with that whole debate?

Dr. Steven Berkowitz: Oh, boy. Quite the question. Look, the DSM is inadequate and I think we all know that, right? It’s really categorical. It’s a symptom, observational approach. We use self-report which is very subjective to, make our diagnoses. The DSM certainly has not captured impact of childhood trauma on various symptomatology and diagnoses. I actually was part of that– the developmental trauma study. I did the– one of the field trials in Philadelphia. My feeling is actually that we should be doing is saying “This is major depressive disorder that is stress-induced or trauma-induced. This is a anxiety disorder that’s stress-induced or trauma-induced. This is behavioral issues or disorders that are related to trauma and stress.” I think that fits the DSM way of approaching things better than developmental trauma disorder, which is a very complex set of symptoms and observations. I think if we did that, we would capture much of what Bessel and others were trying to do, which is say, “Hey, this is kinda different.

It has multiple outcomes multiple presentations, and that we should– you know, we need to capture them.” As a side note I’m working with a startup, I won’t name them here, but who is using an phone app to make diagnoses using eye metrics. It started with PTSD and so far the data’s pretty good. I’m hoping that we’ll have a physiologic, more objective measure certain– at least certain psychiatric diagnoses in the future. Everybody’s looking for biomarkers. We’re not gonna draw blood on everybody but I think physiologic approaches may actually be a much better, more objective approach.

Dr. Ben Everett: I agree, and I think the, the evidence on digital therapeutics that I’ve seen in a number of different disease areas is promising. The adoption has been hard in the United States because of reimbursement. It’s doing better in Europe and rest of world. But yeah, everybody’s got a phone.

It’s not like we don’t have access to phones, and it’s not like kids are not looking at their phones. And yeah I think some of that data looked really good, and I think it could b- go a long way to help addressing some of these access and adequate diagnosis issues. So yeah I’ll be following that.

Thanks.

Dr. Steven Berkowitz: Primary care, right? Look at your phone. It would be perfect, so.

19:30 – How Trauma Presents in Autistic Youth

Dr. Ben Everett: Yeah, exactly. All right let’s focus on some of your more recent work. You’ve looked at traumatic stress symptoms and coping specifically in autistic youth. What’s different about how trauma presents and how it should be assessed and treated in autistic children and adolescents compared with neurotypical kids?

Dr. Steven Berkowitz: Being autistic in itself is just stressful in and of itself, right? Perceive the world differently than most of the others. It’s hard to communicate how you’re experiencing the world. There’s a lot of just baseline stress. One of the interesting things when you talk to autistic individuals, the first haircut was very disturbing, as an example, right? I don’t remember my first haircut, they do. So it’s really about the, the different way they perceive experience. And we don’t really have a good idea given that baseline, difference,

What’s traumatic, what causes them to, become even more impaired. And so was a study that was, really run by Connor Kearns. And we learned a lot about, how they just perceive things differently. How– what’s traumatic to them. Often it was being hospitalized just in and of itself and not understanding any of it, right? And it presents just differently, right? Yes, they may develop PTSD, and we certainly see that, often we see just, the standard autistic problems just are exacerbated greatly.

Dr. Ben Everett: Yeah.

Dr. Steven Berkowitz: So the treatment, it really has to be very individualized, really understanding who this child, adult is with autism ’cause there’s, it’s on such a wide spectrum, as we know. So standard approaches can work but often we…

And we’re doing more of this in general, more sensory approaches are useful. So it really is, you have to do a really good assessment in general, but particularly with individuals with autism.

Dr. Ben Everett: So it’s interesting. So I’m actually getting a haircut later today, and it’s– I, I had to go to a new guy. My lady retired and and when I got… And he’s– it’s the Bloody Irish Barber and Tattoo Parlor, so it’s a little edgy. And so the first time I went there he’s got black paint all over the wall, and you can tell kids have just been drawing on it with the neon markers and whatnot.

And I was like: “This is different.” I was like: “What’s this?” And he said: “Oh my wife and I, we’re both certified.” There’s a special certification that barbers can get. He said: “We’re actually certified to cut hair on autistic children, as well as children with Down syndrome and other, neurodevelopmental things.

We have a, a great nonprofit in central Mississippi called The Mustard Seed.” And he said: “Yeah, we go to The Mustard Seed once a month, and we cut hair for free.” They do all this great stuff. But it never occurred to me how traumatic that could be for somebody. And, it’s make sure they’re comfortable, and they talk them through the whole thing.

But yeah pretty cool that, barbers can get a special certification in that to try and make the experience more a, a little bit easier for these for these autistic kids. And I thought that was really wonderful. I’m gonna take a little side note here because I, a couple of things that I think are interesting in autism and, I believe in the psychedelic hypothesis.

That’s how we originally met. You know what there’s one Phase 2 study that looked at, anxiety in autistic adults with MDMA-AT. Looked really good. They just did the one Phase 2 study, and I believe Definium is gonna do a single-dose LSD study looking at the same thing. So it’ll be interesting to, to see how that falls out as well.

All right. So back to the original thing. I’m sorry I’m talking way more than normal.

Dr. Steven Berkowitz: That’s.

23:30 – Sequencing Treatment for Substance Use, Comorbidities, and Sleep

Dr. Ben Everett: Also you’ve also published on comorbid trauma and substance use in adolescents and antidepressant response in childhood PTSD that can be complicated by ADHD. ADHD can be a multiplier for so many of these i-issues in, in children and adolescents.

I’ve seen it in my own kids. So what comorbidities like that change, how you might approach the treatment? Do you start with the depression or the anxiety? Do you do both at the same time? Is there a sequencing of this, or is it all very just patient individual?

Dr. Steven Berkowitz: We don’t have a standard approach, and that probably would be inappropriate. Substance abuse is a great example, right? One of the things about substance abuse that we– is, from recreational you enjoy the, the, the, the high, whatever it is, but then what happens is now you’re trying to catch up. You use substances actually to mitigate side effects or withdrawal effects. And so when that’s the case, we really promote, “Let’s focus on the substance abuse first.” otherwise, you’re probably not gonna really engage in treatment. So and, it’s very important that… and I really don’t like the term trauma-informed but it’s very important that substance use programs understand that it’s often childhood stress trauma that leads to substance abuse, and so you have to really engage with that in mind. Now if it’s minimal substance abuse, yeah, we’ll treat for whatever psychiatric diagnosis they have. It comes to depression, anxiety if it’s trauma-related, which is what we often see, then we’ll treat it as a trauma-related disorder. Now, we use m-medications certainly SSRIs for anxiety and mood.

We frequently use, Trauma psychiatry in many ways is about sleep psychiatry. The goal is to get people sleeping. Nightmares and ruminations and intrusive thoughts at nighttime are very impairing. And, I often wonder how people who are not sleeping can actually do any therapy. Therapy’s hard. So that’s really often a focus. Let’s get these kids, let’s get these, folks at least sleeping, and then we can figure out what else we have to do. When it comes to PTSD, SSRIs are nice. They take– they may take the edge off, but they’re not a treatment. So but we actually have seen, people symptomatology really reduce when we get them sleeping.

26:30 – The START Center, Sensory Processing, and the “Trauma-Informed” Debate

Dr. Ben Everett: Yeah. That’s amazing. Yeah, sleep seems really compound another, it’s another thing that really compounds a number of these psychiatric disorders. All right, so let’s move on to where you are now. So you’re, you’ve been at CU for, about eight years, and you’ve been instrumental or, you might have developed it all in the CU START Center, and that’s the Stress, Trauma, Adversity, Research, and Treatment Center at CU.

Can you tell us about how that got started, and then what are you working on right now there?

Dr. Steven Berkowitz: Okay, this– the full disclosure, we were recruited because my wife is chair of our department. What was interesting is they are already saying, we don’t really have a trauma section in psychiatry.” And so it was good timing that, they both– they wanted both of us. So the START Center we just started here in, in psychiatry when I arrived. Now, not surprisingly, there are here and there that were doing trauma work, but not in any coherent, organized manner. So we, we basically started saying we’re gonna focus… It’s a family-centered approach. We’ve, firmly believe, and I think again, data supports that regardless of age, that your support system has to be involved in order to maintain gains. When they don’t understand, when they don’t get it, people often don’t really improve. So that’s one, I think, essential difference in how we approach things. We use a range of evidence-based treatments. You name it, we do it. And we also, as I mentioned, started a intensive outpatient program. It’s about a year old. This is for adults. And our focus on that is really around mind-body work particularly focused on interoception. The– there’s a lot of in-interesting data growing around that pr- in traumatized people, particularly those with maltreatment. So related to that a couple years ago, we started a program called TASK, a Treatment Sensitive Evaluation for Kids Assessment for Kids, sorry. And this was really focused on three to twelve-year-olds touching the child welfare system. So had significant histories of often substance exposure in utero. We just published a paper in Child Abuse and Neglect with a new finding that hadn’t come out before of a high correlation. Eighty percent of the– I think it was eighty-five percent of these kids had sensory processing deficits, which of course makes sense when you think about early maltreatment and the impact on sensory is-sensory parts of the brain and connections. We found a point seven one correlation. That’s point seven one, which is of. I’ve never seen it before. Was very funny, the larger the sample size, the higher the correlation got with executive functioning pro-

Dr. Ben Everett: Yeah.

Dr. Steven Berkowitz: Many of these kids can’t do treatment. They can’t sit still for five seconds, right?

And, our traditional, more cognitively based treatments don’t work for them. So based on that, we’re we have a occupational therapist who does a trauma-specific OT, and we’re evaluating its e-efficacy in these kids. Further analysis actually showed a very high correlation interoceptive issues, and behavioral dyscontrol. One of the big dropout often from parents and caregivers is even an impact to behavior. And so we think that there’s a phased approach where we get people, kids in particular, stable, able to, use their sensory apparatus more effectively and then, if necessary, go into trauma-s-specific treatment.

Dr. Ben Everett: That’s really interesting. You mentioned earlier you didn’t like the term trauma-informed. Do you think that, those types of therapies that are trauma-informed are– i- is that more aspirational i- in youth? Or, what is it particular that you think is failing or not right with that term or that colloquialism, whatever you wanna call it?

Dr. Steven Berkowitz: I think, when we’re talking about traumatic stress symptomatology, y- the treatments are, trauma-focused or trauma-specific. There’s a range of effective treatments more or less. Is, this sort of idea of everybody should be trauma-informed.

There should be this broad approach. It’s not about trauma. About respect. It’s about being a human being, working with your patients or whomever, and recognizing that people have experiences that impact how they receive support, help, and treatment. I don’t think that’s about trauma per se. I think that’s about being a good clinician and, understanding how to be a human. I think it just bring– diverts people from being what I think should just be, standard clinical practice. It’s not about trauma, right?

32:00 – PTSD Pharmacotherapy and Psychedelic Research in Youth

Dr. Ben Everett: It sounds like it’s about compassion, which– a-and I’ve, and I’ve– the best definition of compassion I ever read was that compassion is empathy in action, and and I like that. That’s great. So in PTSD in particular, we have not had a new medication in over 20 years. We’ve tried with adults with the MDMA-AT as well as with brexpiprazole in addition to sertraline, I believe was what they used in the Otsuka studies.

And for various reasons, with the two different programs, neither was able to get through the FDA advisory committee. And it’s a shame because, we haven’t had a new medication with an indication. Certainly, a lot of things are used off-label. It gets even harder in children and adolescents, especially when we’re talking about things like psycho- psychedelics.

So curious where you look at, the potential to do psychedelic research in children or adolescents with PTSD. We talked about MDMA-AT. I think Compass is looking at PTSD with psilocybin. Definium is looking at PTSD with LSD very early in those other ones. We’ve talked about how psychedelic research in general is very difficult, and we’re gonna get into this more later today.

That’s with adults. I can only imagine how complex and more difficult it could potentially be with children and adolescents. So I’m curious kind of your thoughts on this and, where would you start? Let’s say you had unlimited budget and access to all the drugs or whatever you wanted to do, interventions.

H-how would you start at this in, in, in doing it in the most, ethical and robust way to try and get a clinically meaningful outcome that benefited the patient in a safe and effective manner? I know that’s complicated, right? But that’s kind of why– this is philosophical.

This is why I wanted you on to talk about this.

Dr. Steven Berkowitz: Okay. It is complicated. First, we’re not gonna do studies in adolescents probably until the medications are FDA approved in adults. And I have a general rule that I use around new medications, which is I don’t prescribe them until they’re on the market for two years. The amount of what we learn in the general population when we use these medications and the side effects and that don’t come up in the drug trials yeah, we all know it’s fairly robust, and we need to pay attention to those. Another kind of factor, that you probably more about than I do is, do we need to hallucinate in order for these medications to be effective?

We don’t know the answer to that, right? There are certainly trials, one that was done here in, rodent models where non-hallucinogenic, medications impacted substance use greatly, really diminished it. Is that gonna be the same for depression or PTSD? I don’t think we know. I’m al– I’m very interested in some of the findings that the– having a spiritual experience using, these medications somehow ha- to being more effective, which fascinating and interesting of itself.

With kids and yeah, you, you do remember I started this with Lykos talking about this. There’s got to be a lot more preparatory work with kids. There has to be a lot of preparatory work with families. So all of a sudden you got a lot more going on than you do with an adult other thing and, we’ve talked about this is, should there be psychotherapy as part of this? With kids, feeling is it’s not even a question. We should absolutely be doing psychotherapy in these sessions as well as before and after. What kind of psychotherapy is a fascinating question, right? Do we need an evidence-based practice? Is there something else that we should be doing because we’re using psychedelics or MDMA or ketamine?

Those are really interesting and important questions. In general and again we talked about this a little bit before I wanna know if we need to do psychotherapy, it– do we have better outcomes? Are gains sustained? Because we know that, we see often a huge drop-off after several months. So I think these are all questions but these are things that for kids will have to happen. And I imagine that very few pharmaceutical companies wanna, invest in that complexity.

Dr. Ben Everett: Yeah, I couldn’t agree more. I think the hallucination versus non-hallucination question is an excellent one, and frankly, we just don’t have enough evidence at this point in time. The field is very split. I know a lot of people feel very strongly one way versus the other. Yeah, and I think it’ll be really interesting to see as more of these non-hallucinogenic neuroplastogens make their way into clinical research.

Is it the same effect? The only study I am aware of was in adults on high-dose ketamine while they were anesthetized versus those that were not given ketamine while they were anesthetized. And of course, ketamine’s not really a psychedelic, it’s associative. So it’s a little bit different, but that’s the only study that I’m aware of that really was trying to get at this idea of consciousness and what, what is the difference that you can see afterwards.

So that’s interesting. Yeah, and a lot to unpack there. Look, this has been a, a fascinating conversation today, really talking about, child and adolescent trauma, family-focused interventions.

I’ve learned a lot. I think this has been very helpful. Hopefully our listeners, I feel certain our listeners are gonna really enjoy this episode. We’re gonna bring you back here, and we’re gonna get into the psychedelic program that’s going on at CU, some of the research that y’all are doing.

But really wanna thank you for the insights, all the work that you’ve done in this area over your career, and yeah, thanks for being our guest today.

Dr. Steven Berkowitz: Appreciate the opportunity, and thank you for listening to me.

Dr. Ben Everett: Absolutely. This has been the JCP Podcast. Insightful, evidence-based, human-centered.