KETAMINE ASSISTED PSYCHOTHERAPY
Ketamine is an extremely safe medicine with many applications. It was designed as an anesthetic and is commonly used in medical settings, including children's hospitals, to put patients under for various procedures. In lower/non-anesthetic doses, it's also been shown to provide remarkable benefit around many mental health conditions: depression, anxiety, OCD, PTSD, addiction, eating disorders, existential concerns, relationship patterns, and more.
To simplify this complex medicine, there are two basic ways to apply it for mental health.
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1. As a chemical to re-balance the brain.
2. As an accelerant to therapeutic progress, and a tool to break out of feeling stuck.
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NOTE: My approach to Ketamine Assisted Psychotherapy is developing rapidly. While much of the information here is relevant in better understanding Ketamine, more current updates are available on Facebook.
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CHEMICAL BALANCE
Tweaking the brain's chemistry is the most common view of ketamine's usefulness in mental health. While most anti-depressants target the serotonin system, ketamine works differently— a current hypothesis supports its action on NMDA receptors and the glutamate system. Therefore, those who haven't responded to traditional anti-depressants often find relief with ketamine.
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What's also cool is that ketamine works rapidly. It's effective for approximately 70% of people, and those who respond to it notice effects immediately or within 24-72 hours. For anyone in a dark, dark place who can't tolerate six weeks for a pill to kick in, this is a fast-acting alternative. Ketamine is also neat because it's safe to use with most medications. Accordingly, it could be applied to someone who's waiting for an anti-depressant to set in. It could even be used as a tool to help ween someone off of other psychiatric medications.
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If someone is dangerously suicidal, this is a much-needed tool for quick relief. With the guidance of a professional team and support network, this could be utilized as an alternative to hospital admission. This study shows that a single ketamine infusion produced significant benefit in acutely suicidal patients: Wilkinson et al., The Effect of a Single Dose of IV Ketamine on Suicidal Ideation, 2018.
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When approached as something to balance the brain, most IV ketamine clinics will recommend 6-8 infusions over 2-3 weeks to fill the synapses with ketamine, and then to return every so often for maintenance infusions. Research indicates no difference between 2 or 3 infusions a week, but it does support this front-loaded approach for managing psychiatric symptoms.
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Not to state the obvious, but IV infusions aren't widely affordable. To address this, one psychiatrist, Dr. Stephen J. Hyde, wrote a book called Ketamine for Depression that summarizes the ketamine literature and explains how he arrived as his solution: to prescribe very low doses of ketamine that clients can take at home (basically 'microdosing'). While this may be one cost-effective option that offers comparable effects, there are concerns about the consequences of longterm use, including bladder damage. One ketamine physician also suggested to me that the research on this approach is 'outdated.' Furthermore, most Alabama doctors likely won't prescribe this due to liability.
IV or Nasal Spray, Longterm
6-8 infusions over 2-3 weeks. Plus maintenance infusions every so often (variable frequency for each person). Nasal spray has similar protocols.
Suicidality
Research suggests a single infusion can offer fast-acting relief for someone experiencing acute suicidal ideation.
Low Dose at Home
It is possible to take ketamine in low doses at home to achieve these effects, but it's difficult to find prescribers. Black market ketamine should be avoided.
Ketamine Assisted Psychotherapy
'KAP's effectiveness lies in several factors. Depending upon dose, ketamine promotes a time-out from ordinary, usual mind, relief from negativity, and an openness to the expansiveness of mind with access to self in the larger sense. These effects enhance a patient’s ability to engage in meaningful psychotherapy during and after administration.'
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THERAPY
In a therapeutic light, ketamine helps in a few ways. First, it can offer a window of relief that can allow enough momentum and clear-headedness to make positive life changes. Like turning on the lights to rearrange furniture, the ketamine will wear off, but one's life can look different when these adjustments are sustained. Second, it increases neuroplasticity, which is the fancy way of saying that with ketamine, the brain can make connections more easily than usual. Insights might 'click' a little better, and habits might be easier to change. Therefore, it's useful to have therapy the next day to solidify anything you may be working on. You could also engage in a host of other therapeutic activities to process the experience, like spending the day journaling, meditating, painting, or discussing your experience with a supportive person who understands altered states of consciousness.
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That's the most 'normal' way to understand how ketamine can help.
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Ketamine's additional therapeutic value has to do with its psychedelic properties. The word, 'psychedelic,' means 'mind-manifesting' or 'mind-revealing.' That's exactly what ketamine does. It lowers one's psychological defenses and produces a variety of effects that come from within. Some of the many possible outcomes could involve feelings of joy or relief, access to old memories, having a completely safe 'near-death' or spiritual experience, or an ability to see one's life in a new light.
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An example could involve someone saying, 'Wow, I feel like I'm out of my body right now. I feel like I can see my depression, my anxiety, and my trauma as if they're way over there! I know this sounds weird, but for the first time, I realize like I am NOT my depression, my anxiety, or my trauma.'
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The goal of Ketamine Assisted Psychotherapy (KAP) is basically to create a therapeutic context around the medicine; essentially preparing you for what might come up and taking the time to process the experience afterwards with effort and intention.
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To explain, let's take the movie Star Wars. Imagine watching it on your phone in the middle of a crowded subway while some kid throws candy corn at your face the whole time. Cool movie, probably, but did you really see it? Now pretend you're buying a ticket two months out to see the same film on opening night, in the best theater in town, dressed as your favorite Jedi. Not only are you mentally preparing for this event, you're also in an energized room with the sort of super fans who understand how profound this occasion might be. Plus, you coordinated all your best friends to see this with you, and you even set aside two hours afterwards to process every twist and turn.
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Both times you technically watched Star Wars.
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But one of these experiences was potentially life-changing.
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This is the difference between 'taking ketamine' and engaging in Ketamine Assisted Psychotherapy.
(Comedy aside, it's all about approaching it respectfully, and knowledgeably, to get the most out of it.)
Normal Therapy
Ketamine makes the brain more flexible. It's essential to have therapy, or intentionally work on self-growth, within 24 hours.
Psychedelic Therapy
You'll get more out of this if you're prepared for the 'psychedelic' experiences that might come up, and if you process their content (like interpreting a waking dream).
Psychedelic Harm Reduction
For anyone considering other psychedelics, Ketamine Assisted Psychotherapy is a very safe/legal entry point into the therapeutic use of altered states of consciousness.
TYPES OF SESSIONS
In the world of medicine-assisted therapy, there are two buzzwords for session types.
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Psycholytic therapy and psychedelic therapy.
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Lower doses can generate 'psycholytic' experiences. The word, 'lyse' means breaking through the walls, and 'psycho' means relating to to the mind. So basically, it means doing therapy when your defenses have been lowered. We could talk the whole time during a psycholytic session, and this could help overcome psychological blocks.
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At higher doses, we enter into the psychedelic space. These experiences are less about talking and more about allowing yourself to go on a journey with infinite possibilities of what might unfold.
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Several studies suggest better longterm outcomes for those who have experiences that involve 'leaving the body' or having a mystical, spiritual, or near-death encounter. Therefore, it's often suggested to gradually increase the dose of ketamine to achieve this goal. However, I've also talked with providers who have seen the most therapeutic progress on lower doses.
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Everyone's journey is different.
COST
Please read THIS LETTER for more information on the cost of this treatment.
FREQUENCY
With the goal of chemical balance, it's recommended to engage in 6-8 infusions over 2-3 weeks, and then to return every so often for maintenance treatments.
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Approaching this as an aide to therapy, however, there are fewer guidelines on frequency. Clients generally find the most benefit between 3 and 10 KAP sessions. Doing them close together could be a way to make a lot of progress in a short time. Alternatively, spacing them out can allow for more time to integrate the experiences; in other words, to explore the content of the ketamine sessions and make practical life changes. Figuring out the timing that works best for you would be an individual decision based on your needs and goals.
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I get most excited about using ketamine as a therapy boost, because it offers the potential to make life changes and therapeutic insights that will outlast the effects of the medicine itself. Different things work for different people, however, and these approaches can also be combined: using ketamine both for its chemical and therapeutic benefits.
RESEARCH
I've been studying all available research on this to ensure that I'm providing the most informed and effective treatment possible. Because using ketamine for mental health is a new approach, there are not a lot of standardized practices. Most clinicians utilize ketamine in slightly different ways. I'm happy to share more resources on this, but to avoid the boring business bogging you down with too much, I've whittled it down to one article and two videos. These will give you a better idea of what's going on.
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Dr. Steve Levine is a ketamine specialist who has an easy-to-understand way of explaining the basics of ketamine and alleviating worries before a first appointment.
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This article explores how several KAP clinics have treated a variety of conditions, and it indicates that of the many ailments that showed progress, those suffering from complex PTSD received an additional added benefit.
If you'd like further reading or videos, please let me know.
ADMINISTRATION ROUTES
There are many different ways to take ketamine, but you're essentially receiving the same medication every way. The main difference is 'bioavailability,' or how much of the actual ketamine your body is absorbing. IV ketamine is 99% bioavailable, which means that you're absorbing all of it.
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For a short while, I thought that to effectivley engage in Ketamine Assisted Psychothearpy (KAP), it would require a lozenge or an intramuscular injection. But after learning more – from medical providers, KAP clinicians, from clients who have tried every form of ketamine, and from having an IV infusion myself – and after exploring the financial barriers to these other administration routes (namely the need for a psychiatrist and nurse to be on-site simultaneously), I have arrived at the conclusion that IV ketamine is the most practical, affordable, and effective option at this time.
SPRAVATO / ESKETAMINE
Ketamine is a whole molecule. If you split it in half, there's a left and a right side. These two halves are called r-ketamine and s-ketamine. S-ketamine or esketamine is also called Spravato.
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Because ketamine (the whole molecule) is off-patent, no pharmaceutical company can profit from it. Therefore, there's no incentive for any major company to spend the time and money to push for FDA approval. However, since there was no patent on s-ketamine/Spravato, Johnson & Johnson claimed ownership. It is now FDA approved for treatment resistant depression and very well marketed. Accordingly, there is more flexibility for doctors to prescribe it and for insurance to cover it.
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If you mention ketamine to a doctor, they might likely mention Spravato.
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While it has shown some benefit for treatment-resistant depression, and many report that it has saved their lives, the research indicates that it barely outperformed a placebo in the largest clinical trial. In a meta-analysis that looked at all available studies to compare s-ketamine and ketamine, the conclusion is that ketamine is a superior medicine (Bahji et al., 2021). Furthermore, S-ketamine/Spravato doesn't offer as much of a dissociative or psychedelic effect as ketamine. Some doctors consider the 'psychedelic effect' to be a negative side effect, but research has shown that the greater the dissociative/psychedelic effect, the better the outcomes. We also know that there is immense value in processing these 'psychedelic experiences' for their therapeutic content and internal wisdom.
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Spravato treatments might be most effectively utilized if your insurance covers Spravato but will not cover ketamine. Or if your doctor will prescribe Spravato but not ketamine. If you're choosing between out-of-pocket with either medicine, Spravato is more expensive and potentially less effective.
MANAGED EXPECTATIONS
Ketamine is best looked at as a boost to make constructive life changes, or arrive at useful therapeutic insights, and not a remedy in and of itself. It works most effectively when clients take it seriously. It is not a cure. And unfortunately, it may not work at all. 30% of people don't respond to ketamine, and many who do respond relapse afterwards. It cannot be understated how important it is to manage expectations for this treatment to avoid any despair on the backend.
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If it doesn't work, there are other options. There's TMS, ECT, and a host of alternative treatment modalities. There's EMDR, ACT, DBT, CBT, IFS, neurofeedback, polyvagal theory, meditation, brainspotting, reiki, energy healing, acupuncture, biofield tuning, float tank therapy, dark meditation retreats, somatic experiencing, holotropic breathwork, The Tapping Solution, The Wim Hof Method, Vision Quest, Muse Alchemy, sensorimotor psychotherapy, the Hakomi method, psychic mediumship, hypnosis, regression therapy, holistic yoga, Qi Gong, Tai Chi, wilderness therapy, forest bathing, salt rooms, sweat lodges, herbal remedies, anti-psychotic medication, and so on. New drugs and treatments are being developed daily. There are also legal ways to pursue other psychedelic medicines (psilocybin retreats, ayahuasca retreats, entheogen churches, MDMA assisted psychotherapy, cannabis assisted psychotherapy, etc.), and many avenues to explore other non-chemical practices to find some relief.
CONCLUSION
While I've done my best to summarize, this is a lot to take in. I'm happy to answer any questions you may have, and if this feels like the right fit for you, I would love to support you through it!