What is Ketamine?
Ketamine is in a category of medications called dissociative anesthetics. It has been used since 1970 by anesthesiologists to help keep patients, usually children, asleep and free of pain in surgery. More recently, however, it was discovered that depressed patients who were given ketamine during surgery would find their depression symptoms rapidly improved. This prompted a series of scientific studies supporting the use of ketamine for rapid treatment of severe depression, especially those with suicidal urges. In doses used to treat depression, it is neither dissociative nor anesthetic.
At slightly higher doses, ketamine produces a light trance-like state where anxiety is lowered. Our defenses, the protective character armor that we have developed over our lives, can be slipped off for a while, allowing us to feel connected to emotions and memories for 30 to 40 minutes. For many patients, this experience can act as a rapid and powerful catalyst for change and insight that might otherwise take months or years to access and work through.
At higher doses, but still much lower than those used commonly in anaesthesia, ketamine can bring psychedelic effects. Psychedelic literally means “mind manifesting”; or, as psychiatrist and pioneer in psychedelic psychotherapy Stanislav Grof stated it, as a “nonspecific amplifier of the unconscious process.” At these slightly higher doses people can have deep, meaningful experiences beyond the boundaries of one’s personal identity (often referred to as “transpersonal” experiences).
Ketamine is very safe and has been used for decades with medically fragile patients, soldiers in the battle field, and children.
We use ketamine in several ways: as an oral lozenge, an intramuscular injection, and sometimes intranasal. We do not use it intravenously but that does not seem to be necessary for effects.
What is Psychedelic Assisted Psychotherapy?
Firstly, let’s describe the mental and emotional suffering that we hope to address with psychedelic assisted psychotherapy. Mental and emotional suffering may come from external triggers (such as past trauma and present life conditions) and also, importantly, from how we perceive and respond to those triggers. Our perceptions and responses are determined by deep beliefs and behavioral patterns, influenced by genetics, and shaped through early and later experiences – both positive and negative. We are only sometimes aware of these processes that shape how we perceive and respond to our life challenges.
All psychotherapy attempts to improve how we perceive and respond to past and present life challenges. When memories emotions and experiences arise which we feel powerless to respond to effectively, or are otherwise unbearable, they arouse anxiety and our defenses kick in so we can cope. Therapy helps us bear these emotions, feel safe with another person, and soften maladaptive defenses so that we can act more effectively. Such change takes time because anxiety can be overwhelming and protective defenses are entrenched and habitual.
We develop a rigid pattern of defenses and a perception of ourselves that is based on these rigid patterns. Neuroimaging reveals a system of interrelated brain structures – called the ‘default mode network’ – that operates when we are actively monitoring and making decisions based on these limited patterns, and our limited sense of self.
Psychedelics seem to temporarily relax this default mode network through acting on the serotonin 5HT-2A receptors in the cortex and layer 5 pyramidal neurons. This releases the constraints on the raw here-and-now data coming in from our senses. As the psychedelic experience recedes this information is re-integrated in surprising ways that challenge our rigid patterns. We can rewrite our sense of ourselves and the World in profound and lasting ways.
We can make the most of this opportunity with careful preparation: setting a clear intention, ensuring an experience of curiosity and openness to new learning and integrating the insights into new knowledge. The intense connected experience provided by the combination of medicine and therapist can provide a corrective emotional experience, changing a previously frightening or avoided emotional memory into one infused with compassion and hope. Deliberate psychotherapy can result in deep and lasting change, sometimes far more rapidly than with psychotherapy or use of psychedelics alone.
What is Ketamine Assisted Psychotherapy?
Ketamine works slightly differently but has many of the same results as classical psychedelics such as psilocybin or LSD. Ketamine targets NMDA glutamate receptors, which are crucial to memory and synaptic plasticity. One set of actions may deactivate the anti-reward center, and restore the connections between the default mode network and the lower brain structures active in processing feelings. People once again feel a capacity for pleasure, and are able to experience emotions and associated memories without the constraining habits from a lifetime of trauma and other painful experiences. There is less of the visual hallucinations and patterns common in traditional psychedelics as ketamine is less active in the visual cortex; but there can be deep emotional experiences that open us to connection, memory and meaning.
The NMDA action of ketamine may bring a special capacity for relearning and rewiring. Memories, once open and activated, become malleable. Ketamine prolongs this reconsolidation window so that new memories can solidify. With careful evocation of painful memories or cravings for drug and alcohol use, followed by ketamine administration, new and flexible knowledge and habits can be established.
Ketamine-Assisted Psychotherapy is a practice that allows participants to gain access to the “felt-sense” of emotional content and difficult unconscious material in a rapid and powerful way, allowing the participant to open up a doorway to allow that content to be accessed, worked with, and processed with the assistance of a highly-trained therapist. Ketamine is a powerful catalyst to allow inner access to difficult and often “stuck” material and emotions, and the psychotherapy allows the participant to actively examine, work with, and effectively process that material for long-lasting change, often far more quickly than traditional talk-oriented psychotherapies. It may have additional roles in the treatment of addictions, where stuck memories can be softened and replaced.
What is a KAP session like?
A KAP session generally lasts three hours, consisting of:
1. The participant and therapist discussing goals, intentions, concerns, and any leftover material from previous sessions. These may include specific drug and alcohol cues in the treatment of addictions.
2. The ketamine medicine experience (by oral lozenge or intramuscular injection)
3. The participant and therapist processing the material and emotions which have arisen during the experience as the participants emerges from the ketamine experience.
Initially a participant will meet with clinic staff, including a physician, for a medical and psychological evaluation and an exploration of the participants issues, concerns, intentions, and goals. Once a course of treatment is agreed upon and the participant is evaluated as a good candidate for KAP, the participant will meet with a clinician trained in ketamine-assisted psychotherapy for one or more psychotherapy sessions to prepare for the ketamine experience.
The treatment then consists of a combination of psychotherapy/integration sessions, in-office ketamine-assisted psychotherapy sessions using lozenge or intramuscular injection, and possibly at-home lozenge ketamine sessions.
During a ketamine-assisted psychotherapy session using lozenges, participants will allow the ketamine lozenge to dissolve in their mouth, without swallowing, for between 10-15 minutes. Participants generally lie down and wear an eye-mask while music is playing. Generally after those 10-15 minutes participants experience body-tingling sensations and a sense of relaxation. Over the next 20 minutes or so most participants enter more deeply into a trance state where they will often experience old memories or stored emotions, and many report experiencing images arising and passing through the mind.
Participants remain lying down and attending to their inner experience for approximately an hour. Some feel moved to relate some of what is happening to their therapist, and many prefer to keep their focus internal. After the main impacts of the ketamine experience ends the participant and therapist discuss and work with what arose.
Intramuscular injection (in the upper arm) tends to bring a more intense experience that comes on within a few minutes, lasts 40 minutes or so and resolves cleanly. The volume used is very small so people do not tend to feel any soreness afterwards.
Oftentimes, the time directly after the main ketamine experience the participant has regained the ability to think and speak normally but has also retained the deep and relaxed access to emotions and emotional material without the interference of everyday and often rigid defense mechanisms. That processing continues in the non-ketamine psychotherapy integration sessions, which are an important part of leveraging the sometimes powerful and dramatic ketamine experiences into long-lasting change in one’s life.
Is Ketamine-Assisted Psychotherapy Safe? What are the risks?
Ketamine is quite safe even at high anesthesia doses. It is not toxic to the heart or brain and is not addictive. Some people have a small increase in blood pressure during the procedure. Some people who have misused massive doses of ketamine for a significant period can develop a cystitis. Our clinical ketamine doses are from 20-30x times less than anesthetic doses. They are quite tolerable, resulting in sensations of time and thinking distortion that usually lasts around 30-45 minutes. At Psych Garden, the first dose and dose increases will always be monitored by us to ensure you can safely tolerate the doses we prescribe. We require that for in-office KAP sessions that you must have a confirmed ride home as it is not safe for you to drive for several hours after dosing.
Is it Effective?
Ketamine has been and continues to be studied but there are now numerous double-blind placebo-controlled studies showing it to be safe and effective, rapidly improving depression symptoms, and especially suicidality, in the short term. There are other studies in alcohol and cocaine addiction showing marked benefits after even one administration. Because this drug is cheap and readily available, there is no reason a pharmaceutical company will finance a study of effectiveness, so studies are being done at academic centers. The vast majority of research thus far has been done with intravenous ketamine. Research on intranasal, intramuscular or sublingual dosing is much scarcer.
What if I Have an Addiction?
There is no evidence that using ketamine for depression causes or worsens addiction symptoms. Perhaps because it does not directly stimulate dopamine pathways like most other addictive substances, ketamine use rarely becomes compulsive. To the contrary, ketamine is being studied for the treatment of addictions, with some promising results. More clinical trials will be needed to know with certainty that it is helpful for addictions. At this point, we do not see addiction as a contra-indication for ketamine, and treat these clients on a case-by-case basis depending on what their addiction patterns are, monitoring use, misuse, and benefits. We are experienced experts in the treatment of addictions and take risks seriously. We will look after you.
What next if I want Ketamine Assisted Psychotherapy at Psych Garden?
The Ketamine Assisted Psychotherapy program at Psych Garden involves a comprehensive approach tailored to your unique situation. After a brief telephone screening you will be set up for a psychological and medical evaluation. This will take 90-minutes and will be with both a psychotherapist a psychopharmacologist. We will assess your situation thoughtfully and so our recommendations may include approaches other than just KAP. We are interested in your wellbeing, not simply ketamine treatment.
Next, you’ll meet with your therapist to articulate goals and the blocks in your life you want to address, as well as any worries. Your first dose will be administered and you’ll spend a 3-hour session with your therapist journeying and processing your experience. This integration will continue in a further therapy session after each ketamine session. We hope you will have at least three sessions to get the most from your experience. Some people will have intramuscular higher dose experiences and some lower dose oral (sublingual) doses,depending on the work met in the journey.
Some people will receive lozenges to take at home in order to get a frequency of administration that is more effective for major depression. Your therapist will prepare you for this part of the work, and ensure that you will be safe at home. During these times you can call us for guidance if needed.
We will review your progress in regular appointments with the psychopharmacologist, and any dose changes will first be given in our facility. We will work with you and adjust the treatment until you have arrived where you need to be.