INTRODUCTION
Ketamine was approved by the Food and Drug Administration (FDA) as an anesthetic agent in 1970 and is classified by the Drug Enforcement Agency (DEA) as a Schedule III medication. In 2019, the FDA also approved it for treatment-resistant depression, as an intranasal spray under brand name Spravato. In addition, ketamine is often used “off-label” to treat pain, depression, alcohol use disorder, substance use, PTSD, OCD, and other psychiatric diagnoses. For psychiatric conditions, ketamine can be especially effective when combined in a particular way with psychotherapy, in a treatment called Ketamine-Assisted Psychotherapy (KAP), which I describe further below.
The psychiatric use of ketamine has been promoted by researchers at the National Institute of Mental Health (NIMH) and has become relatively widespread in recent years. The neurochemical basis for its effects is not fully understood, but we do know that ketamine blocks NMDA (N-methyl-D-aspartate) receptors in the brain, thereby increasing concentrations of the neurotransmitter glutamate. The particular bursting patterns of glutamine release alter neural circuits in the brain in ways that increases neuroplasticity, meaning that the brain becomes more easily modified by new experiences, including new experiences during and after ketamine sessions.
OVERVIEW OF KETAMINE-ASSISTED PSYCHOTHERAPY
Ketamine-assisted psychotherapy (KAP) involves “Preparation”, “Medicine”, and “Integration” sessions.
If I determine that someone is eligible for treatment with ketamine, and if we decide to proceed with it, we have several Preparation sessions. During these sessions, we discuss more about the process, develop intentions for the Medicine session, and answer any further questions about KAP.
In Medicine sessions, ketamine facilitates the therapy process by increasing access to unconscious material that can be later explored during Integration sessions. Under the effect of ketamine, participants are likely to be aware of the flow of their thoughts and explore their inner world. During this time, participants are able to interact with me as they wish to.
Once the medicine’s effects wear off, participants might forget details of their personal exploration, as if they had been dreaming. However, they will be able to recall and explore many details with my assistance as well as their optional audio recording during Integration sessions. Recollection and exploration allow participants to integrate the material from the Medicine session into their daily life. Under the effects of ketamine, many participants describe a release from habitual concerns, accompanied by a positive change in outlook. These effects may last several days, allowing follow-up Integration sessions to be more effective, so the changes in thought patterns and outlook may be sustained over time.
The length of a ketamine Medicine session is typically 3 hours, including some final preparation, the ketamine experience itself, and some time as the acute effects wear off. As the acute effects wear off, I continue to monitor and provide support, and we might also use this time to begin to integrate the experience. The acute ketamine effects typically last about 60 to 90 minutes. Participants mostly focus internally for the first 30 to 60 minutes or possibly longer and continue to remain under ketamine’s influence to some degree for at least another hour.
As a dissociative anesthetic, ketamine tends to cause some degree of dissociation even at doses used during KAP. Dissociation refers to a sense of disconnection from one’s body and usual self. There is some evidence that psychedelic-induced dissociative experiences help catalyze deep change. Working through any challenging experiences arising with KAP can lead to profound healing and growth. At the dose(s) I provide, participants may experience mild anesthetic, anxiolytic (anti-anxiety), anti-depressant, and psychedelic effects. Transpersonal (“transcendental”, “mystical”, “spiritual”, “religious”) peak experiences may also occur. I closely track shifts in physical and psychological states during ketamine sessions, including monitoring vital signs. I also remain in close touch in the days following the Medicine session.
In the days and weeks following the Medicine session, we have several Integration sessions. In these sessions, I support participants in making their experiences understandable, meaningful, and beneficial to them. These Integration sessions can also serve as Preparation sessions for subsequent Medicine sessions.
POTENTIAL BENEFITS
Some participants experience an antidepressant response to low dosages of ketamine. The antidepressant effect tends to be more sustained with repeated dosing, meaning it can have a cumulative effect. Ketamine, by increasing neuroplasticity, can lead to short-term, medium-term, and long-term improvements in mood and well-being.
Participants often experience important changes in personality, mood, and cognition/thoughts from KAP. Individual responses vary widely but, in general, KAP can increase feelings of safety, soften defenses against painful emotions, increase access to emotions and traumatic memories, decrease rigid attachment to old narratives, increase formation of new narratives, and improve creativity and growth.
KAP can involve experiencing uncomfortable feelings, engaging in difficult interactions, and/or being challenged to see the world in new and different ways. It is not uncommon for participants to experience painful memories or be confronted with new images of themselves. Occasionally, in the process of working through issues, depression or anxiety can temporarily increase before improvement is seen. The ketamine experience itself is designed to enable participants’ own internal healing wisdom (“inner healing intelligence”), an innate tendency to move toward greater awareness, integration, and health, to be accessed and of benefit to them. I support participants in making their experience(s) understandable, meaningful, and beneficial to them.
I am unable to make any guarantees as to the benefits of KAP. While it is not uncommon to feel positive results after one or two sessions, it sometimes takes three, four, or more sessions before positive benefits become apparent.
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