Rachel Stein
LPC-S, LCDC · Founder of Atomic Souls
TL;DR - Melanie Cotter has spent twenty years treating substance abuse, and now spends two hours a week doing something she never expected to need: ketamine therapy for a very specific kind of depression. This issue is about what's actually doing the work in that chair, and in her experience it has almost nothing to do with the drug itself.
Hi everyone,
My friend Melanie Cotter has spent twenty years treating substance abuse, and during this conversation she told me about something she never expected to need: twice a week she sits in a comfortable chair behind a curtain, takes a dose of Spravato, the FDA approved ketamine nasal spray, and stays there for two hours with a little fan running and her own music playing. She walks through the whole two hours in the episode itself.
What surprised her most was realizing the chemistry only opened a door, and it was the two hours of forced stillness that actually walked her through the work.
Think about how a phone eventually has to power all the way down, not just lock the screen, before whatever got stuck running in the background finally clears. Most of us never give ourselves that, we take five minutes between meetings and mistake it for rest. Melanie's two hours in that chair, phone away and nothing left to fix, is closer to a real shutdown than anything she's built into her week in years, and the spray was just the excuse she needed to finally sit still long enough to let it happen.
Neurovegetative, not everything. Melanie's psychiatrist gave her a specific term for what Spravato targets: neurovegetative symptoms, the fatigue and mental fog that stop responding to standard antidepressants. It's a narrow diagnosis, and she's careful to separate it from the deeper work of therapy and recovery that mended her relationships and processed her trauma instead. She breaks the distinction down herself far better than I can secondhand.
Who it's actually for. Melanie's rule, earned from twenty years of watching people relapse while chasing shortcuts, is that ketamine only belongs at the end of a long line of more foundational work, never as a replacement for it. She won't recommend it to anyone with less than two or three years of stable recovery, since someone hoping a treatment will be the easier, softer way is walking in for exactly the wrong reason.
The leg up isn't the climb. Melanie made a comparison to GLP-1 drugs that applies just as well to her own treatment: they give people a real chance for exercise to actually work, not a substitute for doing it. Every version of that same trade gives someone a leg up out of the hole they're in, but none of them do the climbing.
What Melanie keeps coming back to has less to do with the spray or the neuroscience behind it than with the simple fact that her life finally got quiet enough, twice a week, for something to land, and for once she had permission to stop producing.
You're the kind of high performer who only stops when your body finally forces the issue. What would it take to build two unreachable hours into your week before it comes to that?
-Rachel
You can hear the full conversation with Melanie Cotter, including why AA might be losing ground with the generation that needs it most and how the 12 steps map almost exactly onto CBT. New episodes drop every week
Apparently I'm doing another thing… running for vice president of Austin TAAP.
If you've known me more than five minutes, this isn't a shock. I have never once successfully sat on the sidelines. Building things. Hosting community events. Turning into a professional squeaky wheel when something matters. Basically my love language.
I'd love to bring that same energy to Austin TAAP. Supporting our community. Making real connections. Helping push things forward.
Anyone can vote, no membership required. I would be so grateful for yours!
Vote HERE.
My Reads of the Week
Esketamine nasal spray shows rapid, durable effectiveness in treatment-resistant depression A real-world study of 570 patients across Europe and Israel found esketamine produced steady, clinically meaningful symptom reduction through 48 weeks of treatment, and depression scores stayed largely stable for six months after patients stopped. It's one of the first looks at what happens after people leave the chair for good.
Ketamine for substance use disorders: a systematic review and meta-analysis A meta-analysis of fifteen randomized trials found ketamine improved abstinence in the first month of treatment, but that edge mostly disappeared by the six-month mark. The authors call it a real but short-lived signal, not proof the drug changes long-term outcomes on its own.
New study explores the transformative power of deep rest UCSF researchers coined the term "deep rest" for a restorative state distinct from ordinary relaxation, one where cells actively repair themselves rather than just idle. Getting there requires specific safety cues to the nervous system, like slowed breathing and real stillness, not just time off a to-do list.
Wisdom Nugget
This post breaks down what the body actually goes through in early recovery, and none of it is subtle. It opens with withdrawal, and the case for enlisting a doctor or detox specialist instead of white-knuckling it alone. From there it gets into nutrition and hydration as literal fuel for repair, and movement as a rebellion against the lethargy addiction leaves behind. Sleep gets its own section too, framed as the unglamorous work of actually recharging rather than optional downtime. The whole piece lands on a simple point: recovery isn't a straight line, and a rough day is still part of the rebuild, not proof it isn't working.
Hot Takes
The lunch break is sacred (YouTube)
Don't pursue happiness, chase after purpose (YouTube)
How do you handle conflict? (YouTube)
Writing from my desk at
The essence of our mission at Atomic Souls transcends the realms of recovery and stability; it's about igniting the flame of purpose and passion within each soul we encounter. Join us.
Thanks for reading,
Rachel
p.s. If this is our first introduction, hi, I’m Rachel, founder and CEO of Atomic Souls Counseling. I’m a Licensed Professional Counselor Supervisor (LPC-S) and a Licensed Chemical Dependency Counselor (LCDC). After years in the trenches as a clinician, I discovered that my real passion isn’t just helping clients heal; it’s helping therapists thrive.
I’ve built Atomic Souls into more than a counseling practice; it’s a place where healing and business intelligence meet. I work with therapists, counselors, and practice owners to help them build sustainable, ethical, and profitable practices. Together, we focus on strategy, systems, and the economics of growth the behind-the-scenes work that allows you to keep showing up fully for your clients without burning out.
My approach blends clinical wisdom with business strategy. I coach on everything from pricing models and team structure to marketing, leadership, and scaling, all while maintaining your integrity and purpose. I believe you can be both a gifted clinician and a confident entrepreneur; those two identities don’t have to compete.
Through Atomic Souls, I’ve built a community where mental health professionals support one another, share resources, and turn purpose into sustainable success. Whether you’re just starting out or ready to expand, I’m here to help you build a practice that aligns with your values and fuels your life, not drains it.
If you’re a therapist ready to step into the next chapter of your career with clarity and confidence, let’s connect.
I write about the business of healing: strategy, systems, and soul for therapists who want to build thriving, values-driven practices on my blog.
Your clients are doing the work. Is your business?
Take the free Therapy Practice Health Check and see where things are solid and where support is overdue.
Until next time,
Rachel