Ketamine Assisted Psychotherapy
Ketamine Assisted Psychotherapy (KAP) is a safe, effective way to enhance traditional psychotherapy by increasing your brain's capacity to create new pathways. It is considered a form of psychedelic assisted therapy; it is fully legal when used with a licensed provider, closely regulated for quality and safety, and its use is supported by decades of robust research. Let's get into what KAP is, the history of its development, how it is used, and what to expect from a KAP session.
What is Ketamine? Ketamine is classified as a dissociative anesthetic and is used widely in the medical field, including emergency medicine, dentistry, pediatrics, and veterinary medicine. It has very few drug-drug interactions, is non habit-forming, and does not interfere with a person's breathing and swallowing reflexes, meaning that the patient does not need to be as closely monitored as they would under the effects of alternate anesthetics. The World Health Organization classifies Ketamine as an essential medicine, on par with penicillin, and considers it one of the safest drugs available. In low doses it has psychedelic properties, often imparting a dreamlike state that may include powerful visual and narrative elements. In microdoses it creates a relaxed and expansive experience where the defenses of the mind are loosened and distress is lessened.
History. Ketamine was originally approved for anesthetic use in the 1970s and shortly afterwards its use was expanded into psychological care when patients treated with Ketamine reported marked improvements in their mental health. Notably, patients saw a spontaneous improvement in conditions like treatment-resistant depression and had significantly lower rates of PTSD from traumatic injury compared to those treated with opiates or other anesthetics. Ketamine has also been widely used as a recreational drug; people find its lightly dissociative, pain- and anxiety-reducing properties pleasant.
Use. It has been used as an adjunctive care tool in psychology for decades but is just now becoming widely available to the public due to current social and political climates, specifically the growing excitement and acceptance around the burgeoning field of psychedelic assisted medicine. It can be administered via intravenous (IV) infusion, intramuscular (IM) injection, or as a lozenge/troche that a patient can hold in their mouth for a set period of time, allowing the medication to be absorbed by the mucous membranes within the mouth. The lozenge is the way I use Ketamine in my practice - the lack of needles means that administration can happen within a therapy office setting instead of requiring a medical clinic and staff, cutting the cost of treatment significantly and allowing for increased access to care. There are two distinct methods of application within a psychotherapeutic model - the psycholytic dose is a very low dose that does not produce marked differences in states of consciousness but still offers many benefits that I will outline below, and the other is the psychedelic or dissociative dose that does produce a non-ordinary state of consciousness.
What to expect from a KAP session. I will explain how I structure KAP sessions within my own practice; providers vary widely in their preferences and training and I can only attest to what works well for myself and my clients. As I am not a prescriber, my potential KAP clients are referred to Journey Clinical, the organization that I partner with in order to provide KAP. Journey Clinical is responsible for the psychological intake and assessment. Medical assessment must be completed by an in-person medical professional; the client's preexisting primary care provider is usually a great choice for this. If clients are approved for treatment, Journey Clinical will prescribe and ship the medication to them directly.
I only offer KAP to ongoing psychotherapy clients, as research has shown the therapeutic relationship to be a critical part of the treatment process. I require new potential KAP clients to have several sessions leading up to the dosing session so that we can establish a strong therapeutic alliance and I can be familiar with the client's motivation, goals, and needs within the context of KAP. The actual dosing sessions are 3 hours long and include three phases. The first phase is the preparation, where we explore how the client is showing up to session that day, any fears or excitements that need attention, and any intentions that they would like me to hold with them. Within the second phase, clients will take their blood pressure to make sure that they are within a safe range to proceed, and if so, they will then self-administer the medication, holding the rapid-dissolving lozenge in their mouth for 10-15 minutes, swishing regularly, before spitting the remaining liquid into a provided vessel. The medication is not to be swallowed*. Usually at this point the client will lay back and apply an eye mask and headphones with a curated playlist to support them in their journey. Clients are still conscious during this period and can sit up and speak, but the world will feel a bit 'boaty' or off-balance. The psychedelic experience seems to be heightened if a client is able to relax their mind and 'surrender' to where their journey wants to take them. After 45 minutes to an hour we transition into stage three: as they begin to come more fully back into their bodies we will process what happened for them, have a small snack and tea to encourage grounding into the here and now, and prepare for their chaperone to come pick them up from session. I like to have anywhere from 1-3 integration sessions between each dosing session. Depending on the client's needs, a client will usually have a series of 2-8 dosing sessions, usually one dosing session every two weeks until the course of treatment is complete. Many clients feel complete after a single series, whereas other clients require occasional 'booster' sessions to maintain results.
How does it work? The psychedelic experience does absolutely have a number of healing benefits including experiences of spiritual connection and awakening. I certainly don't mean to downplay the incredible benefits of psychedelics. However, the fascinating thing about Ketamine is that is restructures the brain itself. When a brain experiences chronic stress, including anxiety, depression, OCD, and PTSD, the brain is bathed in chemicals that degrade neural connections - that is part of why it is so hard to change habits, thought patterns, and behaviors when we are unwell. Within hours of taking Ketamine the brain is bathed in Brain Derived Neurotropic Factor (BDNF) which is a hormone that creates an extreme state of neuroplasticity. Imagine a stressed neuron like a spindly stick attaching two distant points in space; within hours of dosing that same neuron is like a lush tree with branches connecting it to everything in its vicinity - suddenly things that were impossible just hours before are now readily available. Change is suddenly within reach.
At the same time, we have a system called the Default Mode Network. This is the system that is responsible for daydreaming, self-reflection, identity, etc., and is hyperactive in people with conditions like depression and anxiety. Ketamine takes that network offline for anywhere from a few hours to a few days, so instead of reflexively seeing yourself, your relationships, and your world through painful, maladaptive lenses, you can see yourself and your connections with new eyes. You are still aware of your old stories and narratives, but they do not rule you anymore. People report deep relief from harrowing self-criticism, feelings of safety and connectedness, and a sense of control and autonomy.
This is where it gets interesting: these neuroplastic biological changes only last for a few days to a few weeks, so if one does not actively do the work within that window to repattern their brains and strengthen those new connections they will likely revert right back to where they were in the first place. This is why regular psychotherapy is key to making this compound as useful as possible in effecting healing and growth.
Who is a good fit for KAP? If you are someone who has experienced trauma, anxiety, depression, suicidal ideation or attempts, obsessive and or compulsive thoughts and behaviors including but not limited to addiction, you may be a solid candidate for this course of treatment. Things that would disqualify someone from this course of treatment are things like uncontrolled hypertension (Ketamine does raise blood pressure slightly), or a history of dissociative disorders (e.g. schizophrenia, schizoaffective disorder).
If you are curious and would like to explore whether or not this would be a good fit for you, reach out for a complimentary 20 minute consultation. I'd be happy to share what I know and provide you with several options moving forward.
*Swallowing the medication is not dangerous but it can be uncomfortable: when Ketamine is processed through the liver it is converted into Norketamine which has a much longer duration, heightened risk for uncomfortable side effects like nausea and anxiety, and anecdotally a much 'darker' experience.